Professor Angela Maas will never forget the moment she realised that she was failing her female patients. It was the early Nineties, and she was treating a woman who had typical symptoms of heart disease – shortness of breath, fatigue, sporadic chest pains – but for whom no diagnosis could be found.
Up until that time Prof Maas had been dealing with her female patients as she had been taught during her cardiology training, that is, in exactly the same way as men, even if it was clearly not working.
"I learnt that women sometimes had weird, anomalous symptoms, or that they imagined things, or that they just didn’t take their medication properly," she explains down the line from the University of Radboud Medical Centre in the Netherlands, where she is now based, one of the leading cardiologists of her generation. "Their concerns were dismissed, and if their condition deteriorated it was probably somehow their fault. I accepted that.
"However, one day this patient got really angry with me, shouting that I wasn’t listening or giving her any answers. She woke me up. I was being paid to look after her health and I was failing her."
At the same time, research was beginning to be published propounding the groundbreaking possibility that, when it came to cardiology, women might need to be treated differently. "These papers were saying that cardiologists should discriminate between the sexes," says Prof Maas. "Most of my colleagues thought this was a laughable idea and carried on treating women as ‘mini-men’. But I remembered my patient, so I started to examine this disparity."
What Prof Maas discovered would profoundly change how she practised cardiology. It would also lead to her new book, A Woman’s Heart, currently a bestseller in her native Holland, where she lays bare how the disparity between the sexes impacts on everything from symptoms to diagnoses to outcomes.
Still now, she says, too many women are themselves unaware of the danger of heart disease, often considering it to be a ‘man’s condition’, even though it is by far the biggest killer of older people of both sexes almost everywhere in the world.
"Frankly, cardiology for women and for men are almost two different diseases and they should be treated as such," says Prof Maas, who opened her first female outpatient clinic in 2003.
Thanks to the work of Prof Maas and others, awareness of the ‘gender heart attack gap’ and its impact on health outcomes is improving, but the statistics are still worrying.
A 2019 report by the British Heart Foundation found women were 50 per cent more likely to receive an incorrect diagnosis after a heart attack, and significantly less likely to receive the correct aftercare, resulting in 8,200 needless deaths over a 10-year period.
Recently, research from Florida has shown that women recovering from a heart attack have fewer complications and a lower risk of dying when they are treated by a female cardiologist.
Prof Maas says the differences start at a basic physiological level. As women age, and particularly as oestrogen levels drop, they tend to develop stiffness and diffuse narrowing of the arteries that supply the heart. In men this atherosclerosis occurs in one specific place, as a blockage, whereas in women the damage is more widespread.
Women are more likely to suffer from cardiac spasms, also known as angina, a short-lived pain or discomfort, often described as a heavy ache, in the chest that can spread to the arms, neck, jaw, back or stomach, or a squeezing pressure around the heart.
So while the symptoms of male and female coronary disease can be similar – shortness of breath, spreading pain, nausea, faintness – it is much more challenging to spot in women than men, especially, as Prof Maas drily notes, given the diagnostic process has been developed by and for men.
"Usually if heart disease is suspected the first test will be an exercise test – incidentally, designed to be fitted to a man’s flat chest rather than a rounded female one – which, because it is a snapshot, will probably not witness a spasm," she explains. "Then, a coronary angiogram will spot a blockage in an instant, but rarely arterial spasm and microvessel damage."
Prof Maas believes middle-aged women who complain of upper chest pain should have a completely different initial diagnostic test, such as one to determine calcification in the arteries.
With women under the age of 65 twice as likely to die of a heart attack as men, careful and extensive patient history is also vital.
"With men we look for risk factors such as family history, weight, smoking, high cholesterol, high blood pressure and so on. With women, the doctor must look wider," says Prof Maas.
One risk factor for women that is still poorly recognised is a history of migraines. "It is almost as if the vascular contractions that cause migraines move to the area around the heart, which is of course very dangerous.
"Similarly, a history of early menopause, or high blood pressure, pre-eclampsia and recurrent miscarriages are all warning signals. If the doctor doesn’t ask about these things, then the woman should tell them anyway."
Treatments for heart disease work differently in women, too.
"While an arterial blockage can be opened up with a stent or a balloon you can’t really do the same with arterial damage that you see [in women]," she says. "Women often react badly to medication such as statins, because of differences in the breakdown of drugs in the female body.
"Instead of just stopping their medication, the doctor could consider putting her on a thrice weekly rather than daily regimen.
"My profound hope is that my book informs and empowers women to ask the right questions and to demand the best possible treatment. It is their right and we owe it to them."
Questions every woman should ask their doctor
If you’re concerned about your heart – because of a family history, and/or any symptoms you may be experiencing, Prof Maas recommends keeping a diary of any episodes, including where the pain occurred.
"Make a commitment to recording your key numbers via your pharmacy or home testing – your HbA1c levels, blood pressure, weight and cholesterol levels," she says.
"Ask if your doctor is aware of the differences between male and female heart disease, and if they appear dismissive of the concept, consider asking for a second opinion or being referred elsewhere."
Maas says it’s also vital to make your doctor aware of the following risk factors:
• A history of early menopause, pre-menopause migraines, particularly if they were linked to the menstrual cycle, recurrent miscarriage (more than 2-3), miscarriage or early birth linked to pre-eclampsia, gestational diabetes
• A return of menopause symptoms over the age of 60
• A current inflammatory or auto-immune disorder such as rheumatoid arthritis, lupus
• Insomnia – this can be a sign of high blood pressure
The Daily Telegraph