Research considers cardiac gender differences

Before the 1990s, women were primarily left out of cardiovascular research — and now that they’re included, they’re showing additional risk factors while also getting better overall care.

“Now women have to be included in most clinical trials,” said Dr. Rebecca Lolley, general cardiologist and the director of the cardiac rehabilitation program at Banner Health Northern Colorado. “They still are a vast minority, and I think a lot of it has to do with researchers, primarily men, viewing women as being too variable with hormonal changes throughout life, premenopausal and postmenopausal … as well as there still being this fear of starting new medications on women of childbearing potential, not knowing the effects on a fetus.”

In 1977, the FDA banned most women of childbearing potential from clinical research out of concern that the drugs being tested could cause potential birth defects if the trial participants were to become pregnant. The most notable drug at the time was thalidomide, used in the 1950s and 1960s in Europe to treat nausea in pregnant women, but it was found to cause congenital malformations, resulting in its removal from the market.

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“There’s not much research on it, on how women react to medications and how their risk factors are different,” Lolley said. “We need to do a lot of work in increasing research in women, especially when it comes to heart disease.”

Though the risk factors for heart or cardiovascular disease have some variance among men and women, men and women have relatively similar rates of getting the disease, Lolley said.

Cardiovascular disease is the leading cause of death for men and women in the United States, and one in 20 adults ages 20 and older have coronary artery disease, the most common type of heart disease, according to the CDC. Every year, about 805,000 people have a heart attack and one of five of those are silent, where damage is done, but without awareness, as the CDC states.

Some of the risk factors for men and women are the same, including being overweight, having high blood pressure, having high cholesterol, being physically inactive, having diabetes, smoking and excessively using alcohol. Women carry additional risk factors if they become pregnant that can include gestational diabetes, gestational hypertension, preeclampsia or eclampsia, and preterm labor, plus traditional risk factors such as diabetes and smoking can increase during pregnancy.

Research shows that women also have a higher death rate and bleeding after a heart attack than do men, Lolley said. They’re also at a higher risk of re-hospitalization after a heart attack from sometimes not getting early proper care or treatment, she said. That’s because they’re less likely to receive the recommended goal-directed medications, medical treatments and therapies, such as a cardiac catheterization or surgery, when it comes to certain diseases such as heart disease or failure.

“We definitely need to do more studies to see why that is,” Lolley said, adding that in the past, women may have sought care for a complaint of chest pain and got passed off as being anxious. “A lot of times women are treated as an anxious population.”

Women aren’t getting that label now and generally believe they’re more empowered with their medical care, Lolley said. They’re more likely to advocate for themselves when they don’t feel like they’re being heard by their provider or that their problems aren’t being addressed, she said. They’re also more educated about cardiac risk factors, she said.

“We’re starting to focus our studies on gender differences, not only including women but how they react to medications and how risk factors affect both sexes,” Lolley said.

Lolley specializes in female cardiology and cardiac-obstetrics, the care of women who have cardiac concerns during pregnancy. Cardiac-obstetrics is a relatively new cardiology specialty that focuses on the study and care of women who are pregnant and have cardiac concerns. Several co-morbidities that can occur with pregnancy, such as pre-eclampsia/eclampsia, preterm labor, gestational hypertension and gestational diabetes, can all be risk factors for developing cardiovascular disease later in life. 

“Nobody is doing that in Northern Colorado,” Lolley said. “I was brought on to help expand our cardiac care of women.”

Lolley earned her doctorate in medical education from the Jefferson Medical College, now the Sidney Kimmel Medical College in Philadelphia, Pennsylvania, in 2014. She completed her residency in internal medicine in 2017 and her fellowship in cardiology in 2021. She joined Banner Health in September 2021 and works out of McKee Medical Center in Loveland, North Colorado Medical Center in Greeley and Banner Health Clinic in Fort Collins. 

“I probably see a higher preponderance of women than most of my other partners, because I have a specialty in it,” Lolley said. “Women have a higher preponderance of something called microvascular disease, which is a disease of the smaller blood vessels that supply the heart.”

Typically following a heart attack, patients may require stenting of their arteries or to undergo bypass surgical procedures. The focus typically is solely on the three main large blood vessels of the heart, which can develop blockage, but there also are tiny vessels that deliver blood to heart tissue and can cause chest pain and EKG changes, called microvascular disease. 

This type of disease is much more common in women. Patients used to be told that they didn’t have heart disease since their issues couldn’t be detected, but now specialized invasive coronary reactivity testing can be used to diagnose microvascular disease and get patients the proper care and medications.

“As research improves, we find out what works and what doesn’t,” Lolley said, adding that outcomes are better and hospital stays are shorter. “The advancements in research over the past 10 to 20 years have revolutionized cardiac care, leading to better care and access to education for both genders.”

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