In the last few months, we have seen multiple deaths of people from cardiac arrest and heart attack in age groups that are usually not expected to have heart-related ailments. Kannada actor Puneeth Rajkumar (46), died of a heart attack in October 2021, and Mekapati Goutham Reddy (50), who was the Andhra Pradesh Industries and Information Technology Minister, died of cardiac arrest earlier this week. More recently, Radio Mirchi RJ Rachana was only 39 when she passed away after a cardiac arrest on February 22, 2022, in Bengaluru. While doctors had been observing the early onset of cardiovascular diseases (CVD) among younger men for a while now, over the last 5-10 years, many have been seeing the same in women in their 30s and 40s – an age group where this was formerly uncommon.
Dr R Anantharaman, Senior Consultant Cardiologist and Director for Advanced Heart Failure, Cardiomyopathy, Circulatory Support and Transcatheter Heart Valve Therapy (ACCiST Centre) at Kauvery Hospital, Chennai, notes that this increase has been recorded all over the world in the last decade, including India. “Heart attacks have increased in women aged 35-50 years due to several reasons including lifestyle, diet, and stress. The US has recorded a 10-15% increase, the number is similar for India,” he says.
While doctors say that there is a lack of comprehensive data collection to show a holistic graph on the incidence of cardiovascular issues among younger women in India, there is plenty of anecdotal and smaller-scale evidence to corroborate the same, especially in view of world trends. According to a study published in the American Heart Association’s journal, Circulation, in 2019, people between the age group of 35-54 visiting the hospital for heart attacks had gone from 27% in 1995-99 to 32% in 2010-14. There was a 10% increase in admission rates among women than men (3%).
In India, 20-40 year-olds are at a higher risk for developing coronary artery disease (CAD) than other populations. A study published in 2016 found that 50% of the CAD cases recorded were among Indians less than 50 years old. CAD or ischemic heart disease is a common condition caused by cholesterol deposit buildup in the walls of arteries that supply blood to the heart. This results in the arteries getting narrowed over time, creating blockages for the blood flow. Another study conducted in Karnataka over two years from July 2017, by the Sri Jayadeva Institute of Cardiovascular Sciences, noted that out of the 2,200 patients studied, 35% had reported their first cardiac event before the age of 35.
While there are several commonly known factors such as sedentary lifestyle, diet, as well as hypertension and diabetes, experts say that there are some gendered causes that seem to be causing the early onset of CVDs in women.
Dr Divya Fernandez, Consultant and Heart Failure Specialist at Aster RV, Bengaluru, observes that about three to four years earlier, the male to female ratio of early CVDs was 70:30. However, this has nearly equalised, with more women in their late 30s to early 50s reporting to the cardiac OPD. “Many of them come with hypertension; they complain of giddiness, tiredness etc. Getting admitted with heart attacks and heart failure is also on the rise,” she tells TNM.
Further, there has been a notable increase in women presenting with hypertension and blood pressure issues in the last two years, due to factors associated with the COVID-19 pandemic. “We’re seeing the effects of work from home, lack of exercise, and increased anxiety and stress among women due to the combined burden of professional work and domestic labour. When women are at home, they end up having to do more work. If stress, anxiety and depression are left untreated, they can expose the heart to cortisol, the stress hormone. You can have blood pressure issues for a long time without any symptoms, which leads to platelet disorders, which can result in a higher risk of clot formation. All these factors increase vulnerability to CVD and heart attack,” Dr Divya explains.
Both Dr Divya and Dr Anantharaman point out that women, due to the disproportionate caregiving and domestic responsibilities on them compared to men, also tend to ignore their own health by putting other chores and the health of the family first. “Many women don’t take note of their own symptoms because they are busy with their responsibilities,” says Dr Anantharaman. “They don’t even get tested till the symptoms worsen,” adds Dr Divya.
Early menopause along with an increase in Poly-cystic Ovarian Syndrome (PCOS) and other hormonal issues in women has led to a drop in oestrogen levels in women, exposing those in the 35-50 age group to the risk of CVDs. “Earlier CAD was more common in men, and in women only after the age of 55-60, because of the protection provided by oestrogen. But now, many women are attaining menopause in their early 40s,” Dr Divya observes.
Dr Siva Muthukumar, Senior Consultant, Cardiothoracic Surgery as Apollo Specialty Hospitals in Chennai, notes that an increase in early-onset CVDs among men and women pertains to hypertension, blood pressure issues, increased sugar intake and diet, as well as lack of physical activity. “We’re observing across the board these days that if a person who is 40 isn’t taking medicine, it is a big deal,” he says.
Dr Siva and Dr Divya note that another major factor, which doesn’t get advertised as a cause for heart attack as much, is smoking. “Usually, people relate it to lung cancer, but it is a huge factor in CVDs and heart attacks also. And we are seeing an increase in smoking among younger women as well,” Dr Divya says. She adds that weight gain, from certain medications, including contraceptive pills, leads to a host of issues if unchecked that could also increase the risk of CVDs.
While regulating diet and exercising for 30-40 minutes regularly is important to maintain health, Dr Anantharaman also points out that intense workouts could be bad. “A cardiac arrest happens when the heart stops – there is no pumping of blood to the brain, which causes it to shut down. This can be caused by Cardiomyopathy, a condition where the heart muscle becomes hard, making it difficult for the heart to pump blood to the rest of your body. Undiagnosed Cardiomyopathy is a significant cause for sudden cardiac death reported in media among celebrities and people who do extreme workouts,” he says.
Too much vigorous exercise and workouts can also lead to arrhythmia, where the heart beats with an irregular pattern and can cause cardiac arrest. A cardiac arrest is different from a heart attack – in the latter, usually one of the coronary arteries presents with a blockage, leading to the heart muscle not getting blood supply over time, and deteriorating. Often, the first sign of CAD is a heart attack. “Because the focus is on heart attacks in India, issues like arrhythmia get ignored. But with better diagnostics, we are now able to identify more people at risk of sudden cardiac arrest and cardiac death, and by treating them with a special defibrillator pacemaker, prevent it,” Dr Anantharaman says.
The doctors also point out that there could be a heredity factor putting some young people at higher risk – Dr Anantharaman advises that if there is a known history of the sudden death of a direct relative under 40, once an individual turn 16, they should have a screening test with ECG, echo and, if indicated, genetic testing. People who do vigorous exercise should get an annual health check-up done including an electrocardiogram (ECG, which checks the heart’s rhythm and electrical activity) and Echo (which checks how the heart’s chambers and valves are functioning to pump blood through the heart).
Dr Divya says that women often present with atypical symptoms of a heart attack. This, combined with a lesser focus on women’s health prevents timely diagnosis. “Symptoms like chest pain are better known. But women often present with giddiness, extreme fatigue, and shortness of breath. For instance, if you’re having shortness of breath after climbing one flight of stairs, and this is a recent development, you should get a medical check-up.”
Dr Siva also mentions that young people especially brush off symptoms like chest pain and dizziness as gastric trouble. “You may even have pain in the neck or right shoulder. It is not necessarily the classic symptom of pain in the left arm that shows up. So when these happen, you should not dismiss heart disease as a cause. Further, if you’re, say in your 40s, have a family history of heart disease, or smoke and have a certain lifestyle, don’t hesitate to get check-ups done regularly to catch symptoms early,” he suggests.
Dr Divya also notes that because of societal pressures to look and behave a certain way and the responsibilities of raising and caring for a family, women often tend to discontinue medications for hypertension and cholesterol. “Many of them feel hesitant to take medication or try to postpone it by 4-5 years because they aren’t able to come to terms with being young and having these issues. But they won’t do that in the case of their fathers and husbands. They should be encouraged to treat their own health with the same regard,” she states.
Doctors strongly suggest having a full health check-up including Echo and ECG every year after the age of 40 (if you don’t have a family history), and at least once every two years if you are over 35.