Heart health inequalities remain high for women, who are twice as likely to die of a heart attack than men, but pharmacy teams can raise awareness of this and help to ensure women get the support they need

Many women and girls don’t realise they may be at risk of coronary heart disease, believing it to be a man’s problem. Yet, according to the British Heart Foundation (BHF), 24,000 women die from coronary heart disease in the UK each year, most commonly due to a heart attack – that is an average of 65 women per day. 

Women tend to wait longer before calling 999 after first experiencing heart attack symptoms, and this delay can dramatically reduce their chance of survival. Raising awareness among women and healthcare professionals of the main risk factors may help to close the gender gap.

“Unfortunately, women are twice as likely to develop coronary heart disease than breast cancer,” says Philippa Hobson, senior cardiac nurse at the BHF. “Women go for routine mammograms but don’t get their heart checked in a similar fashion, not realising the risk of developing coronary heart disease is greater. They may think they’re not at risk and don’t take the time to think of their heart health in the same way as men do – or they ‘don’t have time’ to be ill.”

In October 2019, the BHF released a new briefing entitled ‘Bias & Biology’ to paint a picture of how women in the UK are disadvantaged at every stage of having a heart attack, compared to men. Failing to recognise the signs of the condition and delaying seeking help, together with gender inequalities in heart attack care, is costing women’s lives, the briefing found. It also revealed that women tend to arrive at hospital later than men when having a heart attack, women are 50 per cent more likely than men to receive a wrong initial diagnosis and women are less likely than men to receive a number of potentially life-saving treatments in a timely way.

In addition, research at the University of Edinburgh in October 2019, revealed that women still receive poorer heart attack treatment than men, even when rates of diagnosis are the same. In this study, women were about half as likely as men to receive recommended heart attack treatments, including the fitting of stents, dual antiplatelet therapy and preventative treatments including statins.

It is currently unclear why these disparities occur and the BHF says more research is needed to fully understand the root causes.

Some 24,000 women die from coronary heart disease each year in the UK

Highly pressured

The main risk factors for heart disease include high blood pressure, high cholesterol, smoking, obesity, diabetes and a family history of heart disease. Research shows that while these risk factors are the same for men and women, they are often more serious for women. Smoking increases women’s heart attack risk up to twice as much as men’s, high blood pressure increases women’s risk 80 per cent more and type 2 diabetes increases it 50 per cent more.

“Although oestrogen has a protective effect on the body as a woman goes through her reproductive years, the coronary arteries can still start furring up if she smokes or has any of the other risk factors we associate with coronary heart disease,” says Philippa. “It is really important to live a healthy lifestyle and to be aware of the risks whatever age you are.”

Mamas Mamas, professor of cardiology at Keele University, says that younger women have the worst outcomes after a heart attack, so need to be aware of their individual risk. “One reason for this is that the medical profession doesn’t always consider them to be at a high risk of cardiovascular disease, which means they are less likely to get the right tests and treatments,” he says. “It is important to get this information out into the open, reminding women that their long-term health is not just about their risk of cancer but also about cardiovascular disease.”

Symptom check

Many people are under the impression that women experience atypical heart attack symptoms – that there are men’s symptoms and women’s symptoms. However, a research study published in August 2019 and funded by the BHF, showed that there is no key difference between heart attack symptoms, quashing one of the reasons given for women receiving unequal care. The University of Edinburgh researchers found that chest pain, including feelings of tightness, pressure or squeezing, is overwhelmingly the most common symptom in both men and women. A similar percentage of men and women reported pain that radiated to their left arm. More women had pain that radiated to their jaw or back, and women were also more likely to experience nausea in addition to chest pain. Less typical symptoms such as heartburn; back pain; or pain that was burning, stabbing or similar to that of indigestion, were more common in men than in women.

Professor Mamas says that while the symptoms are not different, women may use different language to describe them. “Chest tightness, breathlessness, blackouts and palpitations are all common symptoms of cardiovascular disease that are often overlooked and shouldn’t be ignored,” he says. “These may be seen as being caused by weight gain or getting older, but could indicate a significant problem. Lethargy and ankle swelling should also be assessed. Some people describe a feeling of indigestion when they are having a heart attack, or may experience increased sweating.”

Philippa adds that chest pain may be incorrectly seen as anxiety or a panic attack. “If women get a symptom that goes away, they often brush it off and get on with their day. Pain or discomfort in the collar bone, the back or stomach wouldn’t normally be associated with the heart, would it?” she says. “However, these are all potential signs of a heart attack, which are sometimes dismissed as they aren’t ‘typical’ or what you see on TV when someone clutches their chest and collapses on the floor. Missed opportunities can have devastating consequences if a heart attack is missed or not treated quickly.”

If a woman has any of the symptoms mentioned above, she should call 999 so that a first responder can visit and do an electrocardiogram (ECG). “This may not show a heart attack at this point, but the symptoms need to be taken seriously so they should still be taken to A&E and not be brushed off,” says Philippa. “The person will be assessed and asked about her medical history. This is important as high blood pressure, cholesterol and diabetes may not have been previously identified or diagnosed. A blood test is taken, which measures for a protein called troponin. This is released into the bloodstream during a heart attack. However, women tend to release less of this, so [the condition] may be missed.”

Support from pharmacy

Community pharmacies can help women understand their risk of heart disease by offering health checks, including blood pressure measurement and cholesterol testing. They can also offer relevant products, services and lifestyle advice, such as healthy eating, weight loss and smoking cessation, to help reduce their risk.

Steven Riley, director of consumer sales and marketing at OptiBiotix Health, says that diet is a huge factor in heart health. “Reducing intake of foods high in saturated fats and salt is a great start to lowering overall cholesterol levels,” he says. “Introducing a range of foods rich in beta-glucan or functional dietary fibre can also help to promote heart wellness. On the other hand, changes in diet alone may not be enough for individuals who don’t optimise effectively or innately have high cholesterol. This makes it important to consider incorporating supplements with natural science-backed ingredients.” As there is a wide range of supplements available, pharmacy teams should support customers when choosing which ones to purchase and encourage them to do their research first.

Philippa also says visual communications and campaigns, such as posters, can help to raise awareness of heart disease among pharmacy customers. “Everyone should ‘know their numbers’. Make sure to get NHS health checks for women aged 40 to 74 as high blood pressure and cholesterol don’t usually have symptoms. Blood pressure monitors can be useful devices to use at home,” she says. “Advice on quitting smoking will help women stop smoking, which is the single best thing they can do for their heart.”

Some ethnic groups may be at a higher risk of heart disease – a factor that community pharmacies should take into account when identifying customers at a higher risk. “When it comes to health, there is often a focus on Caucasian populations,” says Professor Mamas. “Southeast Asian people, for example, have a much higher risk of diabetes, while African-Caribbean people may be more prone to high blood pressure. The pharmacy team can become advocates for these communities, who may not be accessing primary care as often as they should be, and patients may identify more closely with their pharmacist who may be from the same community as them.”