Cedars-Sinai Blog

Matters of the Heart: Women's Heart Health

Cedars-Sinai women's heart expert C. Noel Bairey Merz, MD

Leading expert Dr. C. Noel Bairey Merz talks women’s heart health.

We are a half-century behind in our knowledge about optimal screening, diagnosis, and treatment of heart disease in women.

Every day, women pay the price.

Dr. C. Noel Bairey Merz is the director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai, and she’s made it her mission to close what she calls an "unacceptable knowledge gap." She’s doing that through research, healthcare, and programs that teach women and doctors about heart health.

In honor of American Heart Month, she answered some questions about women and heart disease.

Women have paid a huge price for the medical community not knowing about important gender differences in heart disease.

With decades of heart disease research done primarily on men, what problems does this create for proper treatment of women?

When I first became a cardiologist, women were widely viewed as if they were simply smaller versions of men. Women have paid a huge price for the medical community not knowing about important gender differences in heart disease.

We’ve now shown that women’s hearts are physiologically different than men’s, and men and women can develop a different kind of disease.

Women more frequently have major arteries clear of plaque—unlike the classic male pattern—but their smaller coronary blood vessels cease to constrict and dilate properly. We call this microvascular coronary dysfunction.

We even develop different plaque than men. Instead of the lumpy-bumpy, fatty plaque men develop, women are more likely to streamline it onto the wall of the artery, which is invisible to the traditional angiogram. That’s why we are working to develop new diagnostic tools, so we can accurately detect small artery dysfunction.

What is Yentl syndrome?

The name started with an editorial in the New England Journal of Medicine in the 1980s. Dr. Bernadine Healy pointed out that heart disease among women was on the rise, and women were dying of heart disease at a much higher rate than men. She raised the question: Is this because women don’t have the same male-pattern heart disease as men? They don’t fit the heart disease that has been studied in men for 50 years, so the diagnostics and treatments don’t work for them. The name was taken from the movie Yentl starring Barbra Streisand, in which she plays the role of a woman who must disguise herself as a man to get the education she desires.

Dr. Healy went on to become the head of the National Institutes of Health and started the Women’s Health Initiative, which has impacted the health of all women in the US. That initiative led to the National Heart, Lung, and Blood Institute’s Women’s Ischemia Syndrome Evaluation—or WISE study, which I chaired beginning in 1999. These studies have helped us understand the fundamental differences in heart disease in women and in men. We’re finding ways to more readily recognize and treat heart disease in women. We have a much better understanding of microvascular disease. We know now that even without evidence of major heart artery obstructions, women with microvascular angina have a greater risk of heart attacks, strokes, heart failure and death.

What findings from the WISE study do think are the most important?

WISE has made many important findings in women’s heart disease, including female-pattern ischemic heart disease—called coronary microvascular dysfunction. We are now studying that as a precursor to Takotsubo cardiomyopathy—also known as "stress cardiomyopathy" (or "broken heart syndrome")—and female-pattern heart failure.

What current research in heart health are you most excited about? What areas do you think are the most important to study?

In addition to the research mentioned above, we are investigating adverse pregnancy outcomes, including gestational hypertension, pre-eclampsia, eclampsia, and pre-term delivery. These impact 20% of pregnancies and predict early heart disease in younger women.

We’re also studying anovulatory cycling. This is where young women are not having regular menstrual periods and have very low estrogen levels, which can lead to premature heart disease. These areas are important to study because they are prevalent in young women and easily recognized. This means prevention and treatments could be widespread and feasible.

Why is it important for women to become more aware that heart disease is the leading cause of death for men and women?

In a recent study, 47% of women surveyed did not know that heart disease is the leading cause of death in women. Heart disease kills more women at all ages than breast cancer. We need to be as good as the breast cancer awareness campaign to address this crisis. We can all think of someone, even a young woman, who has been impacted by breast cancer. We often cannot think of a young woman who has heart disease. That’s because heart disease kills people, and often very quickly. Half the time it strikes for the first time, it’s sudden cardiac death.

What we’ve learned from our colleagues working in breast cancer is that 40 years of advocacy, research and funding has been incredibly effective and successful. Breast cancer mortality is down to 4%. It’s time we do the same for heart disease.