Women and cardiovascular disease: I was fit and healthy - and had a heart attack at 46

Nichola Wilson-Miller, who had a heart attack at 46

Nichola Wilson-Miller, a 48-year-old business coach and mother from Dunmanway in Cork, was 46 years old when she had a heart attack in 2020. Having joined the Royal Navy after school and spent her life being fit and active, she could not believe what was happening to her.

"I worked out four or five times a week and had a fit and healthy body that could keep going all day," she says. "How could I have a heart attack? Such things didn't happen to people like me."

 Wilson-Miller certainly didn't conform to the stereotypical candidate for cardiovascular disease (CVD), the general term for conditions that affect the heart, blood vessels, and circulation. She was young, slim, and, significantly, not a man.

"About one-third of all women in Ireland die from CVD," says Dr Angie Brown, medical director of the Irish Heart Foundation and a consultant cardiologist. "But many still view it as a man's problem. This isn't true. CVD – which includes heart attacks and strokes – affects so many women."

CVD is the leading cause of death in women globally and women in Ireland are at almost as much risk as men. According to the CSO, of the 8,744 deaths from heart disease and stroke in Ireland in 2020, 4,612 were men and 4,132 were women.

Most women worry more about breast cancer than they do about heart health. Yet they are six times more likely to die of the latter than the former.

Why is there such a disconnect between the risk and women's perception of the risk? Brown suggests that it may be because CVD tends to present in women at an older age. On average, symptoms present in men from their early to mid-60s. "In women, it's about seven to ten years later," she says.

By the age of 50, many women know other women who have had breast cancer. They may also know men who have been diagnosed with CVD. But they are not likely to know many women with CVD.

"This may be why they don't realise the risk," says Dr Crochán O'Sullivan, a consultant cardiologist in the Bon Secours Hospital, Cork. "Pre-menopausal women have higher levels of oestrogen which seems to give them some protection from the early onset of CVD. But they do catch up, and post-menopause, when their oestrogen levels have fallen, they are affected by CVD at the same rate as men."

The significant gender bias in research may also have skewed the public and the medical profession's understanding of CVD.

"Historically, there were far fewer women than men included in trials looking at the effects of drugs or interventions to treat heart disease," says Brown.

The Harvard Physicians' Health Study carried out in the 1980s is one such example. It recommended that aspirin be used to prevent heart attacks, yet of its 22,000 participants, not one was a woman.

Though a leading cause of death among females, cardiovascular disease is still seen mainly as a male health issue. The lack of awareness means women can delay seeking help 

Women's biology too complicated to research

The reasons cited for women's exclusion from such studies include congenital disabilities that resulted from foetal exposure to certain drugs in trials that had previously involved women of childbearing age, and women's fluctuating hormone levels.

Women's bodies were treated like men's because their biology was deemed too complicated to research. This approach persisted despite women's physiology being demonstrably different and their bodies not always presenting with the same symptoms or reacting in the same way to drugs.

This male-centred approach has had serious consequences. A 2016 University of Leeds study found that women presenting with a heart attack were 50% more likely to be misdiagnosed than men. As someone who is initially misdiagnosed has a 70% higher chance of death after 30 days than someone who gets the correct diagnosis straight away, such mistakes can be lethal.

Furthermore, US data published in 2018 reported that women with heart attack symptoms were less likely than men to receive aspirin, be resuscitated, or be transported to hospital in ambulances using lights and sirens.

These factors may explain why globally, more women than men die from CVD, as proven by a 2018 University of Ottawa study that looked at data from more than 90,000 patients.

If this is to change, women need to understand the risk of CVD and know the symptoms. This is particularly true of older women, according to our cardiologists.

"After menopause, CVD risk increases, particularly if there are additional risk factors," says Brown. "Falling oestrogen levels can lead to increased levels of bad cholesterol and stiffening of the arteries, raising the risk of heart disease."

Additional risk factors include smoking, diabetes, having high levels of cholesterol in the blood (hypercholesterolemia), and a family history of premature coronary disease. "A sedentary lifestyle, obesity, and a high alcohol intake contribute too," says Brown.

Some CVD risk factors are specific to women, says O'Sullivan. "These include premature menopause, polycystic ovarian syndrome, and adverse pregnancy outcomes such as pre-eclampsia, gestational diabetes mellitus, preterm birth, pregnancy loss, and intrauterine growth restriction. Prior pregnancy loss, such as miscarriage or stillbirth, increases a woman's risk of high blood pressure, stroke, or heart attack two-fold."

Autoimmune diseases such as rheumatoid arthritis are another risk factor. "They are highly prevalent in women and associated with accelerated coronary artery disease," says O'Sullivan.

Wilson-Miller didn't know it at the time, but she had some of these risk factors. "I'd gone through premature menopause," she says. "I was under a lot of stress at work. After my heart attack, I was shocked to find out I had CVD."

CVD can strike a woman at any age. "The process starts when we are teenagers, progressing as we age," says Brown. "But things like high blood pressure, high cholesterol, diabetes, smoking, or a family history of premature heart disease means the process occurs more rapidly. It is therefore important to diagnose and treat any of these risk factors early to hopefully prevent or delay disease."

I felt as if I'd pulled a muscle in my chest

Like risk factors, symptoms can also be different in women. "They may be more subtle," says Brown. "Women might experience breathlessness, pain in the upper abdomen immediately below the ribs, upper back pain, nausea, sweating, vomiting, or fatigue. Then there's the classic symptom of central chest pain, pain in the left arm, or pain in the neck, jaw, or throat. All of these symptoms are warning signs that a heart check-up is needed."

Wilson-Miller's first symptom was a tightness in her chest. "It was the Saturday of the October bank holiday weekend 2020 and I was cleaning carpets when I felt as if I'd pulled a muscle in my chest," she says. "That was early afternoon and by evening, I'd begun to feel lightheaded and woozy."

She never suspected a heart problem. "I thought I'd inhaled carpet cleaner, so I lay down on the sofa watching TV before going to bed," she says.

By the next morning, she had pain in her left arm. "Why I didn't call my GP then, I'll never know," she says.  Brown says this is typical of many women. "They think there's no point worrying anyone," she says. "This can mean they lose valuable time for necessary treatment."

According to the Irish Heart Foundation, 80% of premature heart disease and stroke are preventable. There are steps we can take to minimise our risk. (See sidebar.) Wilson-Miller is now doing some of those things. "I walk four kilometres a day and no longer smoke or drink," she says. "I eat more fresh fruit and vegetables and less processed foods than I used to."

Efforts are being made to raise awareness and improve health outcomes for women. The Irish Heart Foundation has a campaign called Go Red for Women, and Croí, the heart and stroke charity, has one called Women at Heart. Both aim to educate and empower women to make their heart health a priority.

More attention is being paid to gender equality in research too, with some interesting results. One example is a 2021 University of Exeter study of 88,000 people, which showed that going to sleep at 10pm or shortly afterwards was associated with a lower risk of CVD than falling asleep earlier or later. This effect was more pronounced in women than men.

But more such research needs to be done. An Amsterdam University review of 740 cardiovascular clinical trials completed between 2010 and 2017 found that even though an attempt had been made to include more women, they only accounted for 38% of total participants.

Brown hopes for more progress. "It's only in the last 15 years or so that more women are being included in studies," she says. "Our knowledge base is slowly improving, and this will help us to understand and treat CVD in women much better in the future."

Wilson-Miller may not have seemed a stereotypical candidate for a heart attack but in many ways, she was typical of women who suffer from CVD. She was unaware of her risk. She didn't recognise the symptoms and she delayed seeking help in what proved to be a cardiovascular emergency. 

She doesn't want other women going through what she did. "I learned the hard way that women are at risk of heart attack and hope other women won't have to," she says. "I urge them to inform themselves of the risk factors and symptoms and, most importantly, to see their GP if they feel something isn't right. Time is vitally important when it comes to your heart."