08 Mar 2025
International Women's Day 2025: Raising awareness of aortic stenosis in women: - a silent killer
On the occasion of International Women’s Day, Julia Grapsa shares why women need better access to information about their own heart health #AccelerateAction
It was a day in October last year when I had a meeting with patients’ group in UK. At the time, I needed to discuss with them why a registry on valvular heart disease and sex disparities is needed. The camaraderie was incredible and the discussion never-ending. Interestingly enough, almost all the patients had a female friend or relative who reached the hospital late, who were diagnosed with delay, misdiagnosed or even treated with delay. Think about it: we all have a female friend or relative who delayed getting an echocardiogram, or a CT scan or their concerns were not listened to.
I was stunned to hear those signs such as dizziness, shortness of breath or reduction in exercise capacity was commonly perceived as signs of ageing or menopause, and then the patient would get a delayed diagnosis of debilitating valvular lesion. It was striking to me when a member of the panel burst into tears when he remembered that a neighbour of his had died suddenly at home because of undiagnosed aortic stenosis. It was then when I thought: its not enough to have revised guidelines, its not enough to come up with sex specific cut off values, but a good start would be appropriate education of patients and general practitioners or allied health professionals.
Aortic stenosis in women
It is now a fact that women are underdiagnosed and undertreated. Only very recently we have 2 dedicated randomised clinical trials where the largest percentage of participants are women: SMART and RHEIA trials. The outcomes provide more information around the different anatomy and physiology, as well as complications that take place in female patients with smaller annuli. We are now changing the way we are preparing our patients for TAVR vs SAVR and the potential durability of certain devices.
Julia Grapsa
The evidence around sex differences in valvular heart disease, and especially aortic stenosis, has helped us form our physical examination and questions addressed to the patients, differently. It is now well known that both work-up time and procedural waiting time is longer in women and that this is the reason why women have 10% lower relative survival at 5 years, when compared to men. With regards to clinical presentation, women present differently, most commonly with shortness of breath, dizziness or syncope, and with more advanced heart failure symptoms. Women are also more likely to get low flow low gradient aortic stenosis.
Aortic stenosis in women presents differently: Pathophysiology
To add to the different presentation and heart failure symptoms, many physicians are not aware that women have different cut-off values for echocardiography and computed tomography, indexed to their small annuli and chamber/valve dimensions. As we are waiting for the next ESC valvular heart disease guidelines, it is imperative that these sex specific values will be implemented and will add tremendously into the awareness of early diagnosis of aortic stenosis.
Introducing PCR aortic stenosis booklets
This patient forum I mentioned, was the beginning of work that took place together with exceptional colleagues such as Omar Chehab and Bernard Prendergast and Didier Tchetche, of writing two short booklets, one for patients in lay language (in collaboration with Global Heart Hub the International Alliance of Heart Patient Organisations) and one for physicians such as general practitioners or allied health professionals. We hope that both booklets will be applicable to every one around the world, and will contribute to the early diagnosis and management of aortic stenosis.
A powerful way to celebrate International Women’s Day is by truly listening to women, addressing their concerns, and advocating for their heart health. By raising awareness of valvular heart disease in women and ensuring their voices are heard, we can #AccelerateAction toward better care and outcomes
