Welcome to Mayo Clinic podcast. I'm your host, Rich Dietman. Our topic is diagnosing heart disease, what every woman should know.

Heart disease doesn't discriminate. It's the No. 1 killer of men and women worldwide, including the United States. But when it comes to diagnosing heart disease, there's a gender gap. Women are less likely than men to get appropriate testing to diagnose heart disease. To learn more about why that is, we're talking with Dr. Sharonne Hayes. Dr. Hayes is a cardiologist at Mayo Clinic. She's also the director of the Women's Heart Clinic at Mayo, and she serves on the advisory board of WomenHeart, the national coalition for women with heart disease. Dr. Hayes, thanks for being with us.

Dr. Hayes: It's great to be here.

Rich Dietman: Dr. Hayes, what is it about heart disease that makes it harder for women to get diagnosed? Is it physical factors, or do women and their doctors just not take heart disease as seriously?

Dr. Hayes: Well, Rich, it's really both. Because traditionally, we have thought of heart disease as a man's disease, and so it hasn't always been on a woman's radar screen in terms of it being an important health risk for her, or an important factor. And frankly, it's been the same with physicians, who many were taught, that men are the ones who are getting heart disease, or only older women. We know that's not true, and we've known that for a couple of decades, but there's still a little bit of mythology out there.

Rich Dietman: Are there some physical factors too?

Dr. Hayes: There are clearly some physical factors and ones that in the past we sort of ignored. We assumed we could treat women like men, but in fact women are smaller, they have hormones, particularly estrogen, that can change how their electrocardiogram looks, so there are a number of physical factors, some of which have not been fully explored, that probably do impact how we diagnose and how we treat.

Rich Dietman: What tests should a woman ask for if she's concerned that she may have heart disease?

Dr. Hayes: Well, there is no single test. Unlike some other diseases that we can screen for, there's no mammogram or colonoscopy for the heart. On the other hand, every woman should ask her doctor about her risk factors, so she'd know what her numbers are — her blood pressure, her cholesterol — she should know whether her diet is healthy and know about what those things mean, and if they are not normal or optimal, how she can take care of them. In terms of testing, it depends on her age, her risk factors, and whether she has symptoms. There are a variety of tests that she might get, but she can't go in really and ask for a specific test, that's something that needs to come up with all of these things considered, with her physician.

Rich Dietman: Are some tests used to diagnose heart disease less accurate for women than they are for men?

Dr. Hayes: Well, there are a couple of tests that actually are less accurate in women, and we've known that the standard stress electrocardiogram or treadmill test — where they just put the electrocardiogram on — is less accurate in women, giving more false-negatives, meaning that if a woman doesn't exercise as much (the test) may be negative but it's really abnormal, but also more false-positives because of the estrogen effect on the electrocardiogram, so she may be fine but the test comes out positive. I want to preface that by, some tests we have found we need to interpret in a gender-specific manner, meaning we have to know whether it's a man or woman that we're doing the test on, but if we do, it's just as accurate. And in fact, that's the case with most of the tests that are accurate in men; they are accurate in women, such as exercise nuclear test, stress echo and echo, the CT scans, and a variety of things that we are using to diagnose heart disease. Women should be assured that there are good tests for her.

Rich Dietman: So you're saying that it's important for the doctor or doctors reading the test results to know whether the person is a man or a woman.

Dr. Hayes: In some cases it is, and certainly, some of the — what we call "normals" or the range of normals — maybe have to be adjusted whether it's a man or a woman. And some of it is body size.

Rich Dietman: Dr. Hayes, can you give me an example of some of those tests that you're talking about and how they work, what they test for?

Dr. Hayes: Well, a nuclear perfusion scan, and it's called a lot of different things, a sestamibi, or a nuclear scan. We've been using these for years, and what we knew early on is that they were more apt to have this false-positive in women. And we realized that because of breast artifact, the reading, the counts of the radioactive material and women tend to have bigger breasts, which may make the counts less, even when the heart's normal. We can correct for that, and so if we know that that is an issue, we can address that. Stress echo, which is where we use ultrasound waves to look at the heart muscle when it's at rest and pumping, that's equally accurate in men and women, so some have the same accuracy and others we just need to adjust our interpretation to account for gender.

Rich Dietman: Are there things that a woman can do to increase the chance that she'll get the right tests, that she'll get the right diagnosis?

Dr. Hayes: Well, there's no perfect patient or perfect doctor, but in fact there are some things that women can do. One, educate themselves. There are a variety of resources on the Web, from their physician, that they can learn about heart disease and know what their risks are. But they need to bring it up. In a perfect world — this is the No. 1 killer of men and women — their doctor should be bringing it up, but if they don't then they should bring it up: "Am I at risk?" "What tests might I have at my age, or based on my risks?" And if a doctor suggests the tests or consultation, it's perfectly appropriate for a woman to say, "Has that test been validated in women and tested in women?" "Is that the best one?" So I think opening up a dialogue with their physician is probably the best way.

Rich Dietman: You talked about the idea that women may not be referred for heart disease testing as much as men. How can a woman avoid that problem? I suppose it's maybe as simple as just being assertive and saying, don't forget these tests, don't leave these things out.

Dr. Hayes: I think women need to be proactive. And I tell patients that you are your own best advocate, 'cause frankly no one else has as much self-interest as you do. And so, being aware and making sure that your doctor knows more than just the blood tests and the blood pressure — because it will influence me if I know that that woman has a very strong family history, you know, mother and father had heart disease, with the same cholesterol level, same blood pressure. I'm going to be more alert for that woman's risk if she had a family history, or smoked for 30 years, maybe she's a nonsmoker now, so there's other factors that come in. So making your doctor aware that you're concerned is one of the best ways to make sure that you're going to get the adequate care.

Rich Dietman: What about emergency situations? If a woman is having symptoms and she thinks it's a heart attack and she goes to the ER, what tests should she expect, or if it comes to that, insist on?

Dr. Hayes: Well, first of all, the best way if you truly think that you're having a heart attack, you should call 911 and get there by ambulance, which obviously ups the ante on the urgency, and you get, you bypass some of the time syncs in the emergency department. I think it's OK to say, "You know, the reason I called 911 is I thought I was having a heart attack," because that's a clue to whoever is caring for you in the emergency department to check some tests, an electrocardiogram, some cardiac enzymes, such as troponin, and those are very early indicators of heart damage or to help make that diagnosis. If despite that, if you think you're having a heart attack we would, some of the national norms and metrics and expectations are an immediate electrocardiogram and blood work that would tell if there's been heart damage. And then, the evaluation can be leisurely if you've excluded the heart.

Rich Dietman: So it sounds as simple as, say those words.

Dr. Hayes: Yeah, I mean don't cry wolf, but I also think that if the symptoms were concerning enough to a patient to have them activate the emergency medical system, that needs to be conveyed to the treating physicians and nurses.

Rich Dietman: And if a woman doesn't get the kind of testing that she thinks she should, and she's still in the ER but is about to be sent home, because we hear these stories sometimes about women in the ER being misdiagnosed and perhaps already having had, or being well into having a heart attack. What should she do?

Dr. Hayes: Well, I would hope that if they've done these initial tests, that answer would have been made clear. On the other hand, if she says, "I'm having a heart attack," and those basic tests which are important to make a diagnosis of a heart attack have not been done, I think that insisting again, "I'm not leaving." I have a patient who it was they were ready to send her out and she just insisted and said, "I demand an electrocardiogram." Now I would hope it would not come to that, but they did it and she was having a heart attack. So I think that I would not wish that on any patient, that they had to be so assertive to get emergency care, but I also think that patients should feel that they should not be cowered by the medical system and sent out when they are having symptoms that are worrisome to them.

Rich Dietman: You alluded to family history a bit ago. Women often hear that they ought to be cautious if their mothers had breast cancer. Is it the same with heart disease if a mother of a daughter had heart disease or other relatives in the family?

Dr. Hayes: Heart disease is a critically important part of the history that we take when we're looking at cardiovascular risk because any first-degree relative, particularly if they had it prematurely, and that means before age 55 in a man or before age 65 in a woman, had a heart attack or some other cardiovascular event, that's an important piece because that's considered premature coronary artery disease, and that dramatically increases the risk. We know that there are some genetic factors, and we are rapidly expanding those genetic markers. But it probably also is environmental, because if you grew up with a family who didn't eat as healthy or who all smoked, you've got both the nature and the nurture. There are several studies that have shown it's actually more important and riskier if your mother had the heart disease than if you got it from the genes or the influence from your father. And we don't know if that's a stronger genetic influence or the fact that in traditional families a lot of young people spend more time with their mothers and perhaps adopted her bad habits. Whatever it is, your family history is important and if particularly you have multiple relatives and they were nonsmokers or nondiabetic and had early heart disease, it's really important that you let your doctor know. Now the corollary of this, I do have patients who will sometimes come to me and they'll say, "I'm so frightened because everybody in my family had heart disease before they were 50." And the first question I ask, "Were they smokers?" Because smoking is such a powerful risk factor that it can trump a genetic influence, and if that person had all their relatives smoke but they didn't choose to smoke, then they may not have the same risk factors, so the smoking history of the family members is also important.

Rich Dietman: Thanks very much, Dr. Hayes. We've been talking to Dr. Sharonne Hayes, a cardiologist and director of the Women's Heart Clinic at Mayo Clinic. You've been listening to Mayo Clinic podcast. I'm Rich Dietman.

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