Health: The heart works twice as hard during pregnancy, with risks five times higher among those over 35.

Women's hearts can be fragile at any age and at any stage of life. During pregnancy, it's much more fragile than men's because it has to work twice as hard. As the third trimester approaches, blood volume increases by up to 60%, forcing the heart to work harder, accelerating the heart rate. While most women manage these changes without problems, those with pre-existing heart conditions or a predisposition may be at increased risk.

According to a study conducted by the NYU School of Medicine and published in the journal Mayo Clinic Proceedings, the risk is up to five times higher among women aged 35 to 39, while it is 10 times higher among women over 40. Yet, women's cardiovascular health remains understudied, both in clinical settings and in research laboratories. These are some of the topics that specialists will address at GISE Women, the event organized by the Italian Society of Interventional Cardiology (GISE), which opens today in Salerno. The event will also address other gender-related issues in interventional cardiology and present key developments in the field regarding new diagnostic and therapeutic approaches, coronary atherosclerosis, ischemic heart disease, and valvular heart disease, as well as the highly topical issue of cardiac problems associated with oncological diseases and treatments (a specific branch of medicine known as Cardioncology).

"GISE Women represents an important opportunity to share skills, experiences, and gender perspectives in cardiology clinical practice," explains Francesco Saia, GISE president and director of the Interventional Cardiology SSD at the IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant'Orsola. "Our goal is to shine a spotlight on gender inequalities that place women at a significant disadvantage compared to men. Indeed, the female population tends to be underdiagnosed and undertreated in clinics, and underrepresented in clinical trials." In Italy, every 5 minutes a woman is struck by a heart attack or other cardiovascular disease, for a total of 124,000 cases per year, according to a GISE statement. Coronary heart disease affects 1 in 9 women between the ages of 45 and 64 and 1 in 3 over the age of 65, with a 31% risk of death, higher than breast cancer.

During pregnancy, the cardiovascular system undergoes significant adjustments to support the growing fetus: blood flow, heart rate, and cardiac output increase. "When these changes proceed smoothly, they represent a remarkable example of resilience," explains Alfredo Marchese, president-elect of GISE. "However, the heart may not be able to keep pace due to pre-existing conditions or complications related to conditions such as peripartum cardiomyopathy, preeclampsia, and eclampsia, which jeopardize both maternal and fetal health." The risk is especially high in women over 35, as highlighted by a study conducted by the NYU School of Medicine, which analyzed nearly 50 million births in the United States between 2002 and 2014. "The study showed that the risk of heart attack during and after pregnancy is increasing, partly due to the tendency to postpone childbearing due to the increased likelihood of concomitant cardiovascular diseases developing over the years," comments Tiziana Attisano, GISE Women coordinator and head of the Hemodynamics Unit at the University of Salerno. "The cardiology community has strongly felt this need, so much so that it has drawn up new guidelines on the clinical and therapeutic management of cardiovascular disease during pregnancy, including all its peculiarities and pitfalls. These guidelines were presented at the recent European Society of Cardiology (ESC) congress held in Madrid and will be a hot topic at the GISE Women congress."

The fragility of women's hearts isn't limited to pregnancy; it also depends on our inability to "listen" to its signs of distress. This is why women are at higher risk of both "ischemia or angina without obstructive coronary artery disease" (Inoca-Anoca) and "myocardial infarction without coronary obstruction" (Minoca). Many women with cardiac chest pain and ischemia or heart attack do not have significant stenosis in the coronary arteries, but rather a mild narrowing, dysfunction, or spasm of the small vessels, which are often missed in the initial diagnosis,” explains Simona Pierini, GISE Women coordinator and director of the Cardiology and Coronary Unit at the Asst Nord Milano. “Fifty to seventy percent of those with nonspecific symptoms and coronary artery disease not significant on angiography are women. Furthermore, women are more likely to have non-classic cardiovascular risk factors, often aggravated by stress, mood disorders, smoking, autoimmune diseases, or as a consequence of menopause. Yet awareness of women's cardiovascular risk is low. Heart attacks occur 10 years later in women than in men, but mortality is higher, as are complications, 90% of which affect women.” Spontaneous coronary artery dissections (SCADs) are equally dangerous and insidious. They are part of a systemic disease affecting the layers of the vessel wall. Young women are the patients most affected by this disease, which can present as acute coronary syndrome, unstable angina, or even sudden death.

Valvular heart disease is also often underestimated, with significant differences compared to men in terms of type, diagnosis, and treatment. Fewer women undergo corrective surgery, which also presents specific technical challenges due to their smaller anatomy. Furthermore, symptoms in women tend to be more subtle and nonspecific, resulting in delayed diagnosis. "Patients often present at the doctor's office in an advanced stage, with rapid progression and a worse prognosis," emphasize Attisano and Pierini. "It is therefore essential to raise awareness of the specificities of female heart disease, both among the general public and medical professionals, to ensure early diagnosis, timely treatment, and improved long-term management," conclude Saia and Marchese. "Addressing these disparities is a public health priority, and GISE is committed to continuing its work in this area, including through specialized events like GISE Women."