Leticia Fernández-Friera, cardiologist: "With an annual injection, we can control cholesterol, blood pressure, and glucose levels."

Cardiologist Leticia Fernández-Friera is determined to change the statistics. These figures in Spain show how cardiovascular disease (heart attacks, strokes, etc.) has become the leading cause of death in women. It is ten times more lethal than breast cancer , although there is no early detection campaign to prevent it. Her battle began at Massachusetts General Hospital in Boston (USA), where she completed her residency, and now in Spain with her "Women's Heart" initiative and the CIEC, the Comprehensive Center for Cardiovascular Diseases she directs within the HM Hospitales group. "Women are diagnosed late, and when they are, their prognosis is worse than that of men," she says.

What's wrong? Are patients not going to the doctor, or are the doctors themselves hard of believing that a woman could have a heart attack?

Both. Cardiovascular disease is the leading cause of death, and this is unknown to both society and some professionals. There is still much awareness, education, and research to be done. Raising awareness of cardiovascular disease in women is a challenge we must all work together on. Professionals must learn and train so that the therapeutic approach is the same for women and men, without underestimating their vulnerability. And women must know the symptoms of a heart attack so they can go to the emergency room without delaying diagnosis. I see it every day. I remember a young patient who came to my office because she always felt tired. She had seen other doctors before, who simply told her she was fragile and weak. That weakness was actually a heart condition she was born with. Basically, she had a hole in her heart that caused her clean blood to mix with the dirty blood. We operated on her, and she was no longer tired.

Is there a man's heart and a woman's heart?

The heart is the same in both sexes, although there are nuances, such as size. But we have the same components and can get sick in the same way.

They're the same, but some symptoms are different in women. Does this delay early diagnosis?

It's important to note that the most common symptom of a heart attack in both sexes is chest pain, or pressure in the chest. It's true that women may experience other, different symptoms that aren't as closely associated with ischemic heart disease and can be confused with other problems such as an anxiety attack, digestive problems, or general weakness. It's also reported in the literature that women report symptoms differently than men, and this can be misleading.

Are we telling it so differently?

An example is chest pain, which is one of the most common symptoms. We have a higher pain threshold, we endure it longer, and it takes us longer to go to the emergency room because we prioritize other tasks in our daily lives, and when we do, we don't mention that we notice pressure or pain. Sometimes women begin reporting other symptoms that can be confusing, such as feeling very tired, feeling unwell, or having a racing heart.

Is that why the prognosis for a first heart attack in a woman is 20% worse than the prognosis in a man?

There are many factors that influence these figures. From prevention programs that traditionally focus more on men, to the awareness of women who don't feel vulnerable and can endure more. Treatments are also targeted differently by gender. For example, women are 30% less likely to be prescribed statins for cholesterol than men with the same cholesterol level.

Women do understand that starting at age 40, they should have a mammogram and a gynecological checkup. Should cardiologists partner with gynecologists?

Absolutely. The gynecologist sometimes becomes a woman's primary care physician and would be a good gateway to a cardiologist. This way, we could treat patients we find difficult to reach. European guidelines for cardiovascular prevention establish that, starting at age 50, it's necessary to begin examining a woman's heart.

If I don't smoke and I'm not overweight, is that enough to feel safe?

No.

That is a resounding answer.

Our doctor must determine our cardiovascular risk, assessing the whole picture, not just two risk factors. Our genetic makeup (whether our parents had a cardiovascular problem before), our specific "bad" cholesterol level, whether we have diabetes, or how our glycemic index or blood pressure has changed during menopause all play a role. Tobacco is important, but so are other toxins like alcohol. Whether we exercise and how many hours a day, our stress level, how we sleep... It's all much more complex, which is why we talk about an individual risk profile. Algorithm scales aren't precise enough to determine a patient's condition, especially if they're a woman. We must also use imaging to directly see how we feel inside, how our arteries are doing. Only then can we anticipate a heart attack, which is when the artery closes.

What is the most appropriate imaging diagnosis for this prevention work?

With a coronary CT scan, we can see the condition of the heart's arteries in five minutes and anticipate a possible heart attack. With this image and the risk profile, we can now more accurately determine the true risk. Vascular ultrasounds, which don't emit radiation and don't require contrast, can also be used to provide a more general estimate of the condition of the arteries in the rest of the body: the carotid arteries that go to the brain, the aorta in the abdomen, or the femoral arteries.

Will Ozempic and similar weight-loss drugs be the magic bullet that reduces cardiovascular burden?

Sure. They combat obesity, a disease associated with many cardiovascular risk factors: diabetes, high blood pressure, cholesterol, inflammation... Obesity isn't aesthetic; it's a serious health problem. New drugs are also emerging, for example, to treat cholesterol, where two injections a year can control levels. There will come a time when we'll get an injection every six months or every year and we won't have high blood pressure, cholesterol, or high blood sugar.

Are you referring to a more or less near future or to a treatment already in development?

There are already approved drugs that do this individually, such as PCSK9 inhibitors, which, when administered subcutaneously twice a year, keep cholesterol at bay. Others are in trials to control blood pressure with monthly injections. This is yet to come.

We then need a three-in-one to control blood pressure, cholesterol and glucose levels.

It will arrive like Valentín Fuster's polypill, but instead of in a pill form, in an injection. And if we can't get it together in a single drug, we could schedule a patient for a day to get their medication, without fear of forgetting the pills.