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Women are less likely to have aortic ruptures, but their symptoms may go unrecognized.

Aortic ruptures can be deadly, but for women, the threat often is unrecognized

When Daniela Crousillat, MD, began practicing cardiology, it struck her how frequently women were already far down the road to cardiovascular disease by the time they were diagnosed.

The revelation would become the heart of her medical research journey.

“Unfortunately, more often than not, we were seeing women who were under-diagnosed, and whose symptoms were potentially under-appreciated,” Dr. Crousillat said.  “I became inspired by a lot of the women I saw – thinking about how we can improve the diagnosis and care for women with cardiovascular disease, and whether the same treatments could also be applied to them?”

Ultimately, trying to understand and better address that inequity led her in 2021 to the University of South Florida, where she became founder and director of the USF Women’s Heart Program in the USF Health Morsani College of Medicine. Dr. Crousillat is an assistant professor of Medicine in the Division of Cardiovascular Science and also in the Department of Obstetrics and Gynecology. 

Now, Dr. Crousillat is the lead author of a recent paper published in the Journal of the American College of Cardiology, entitled “Sex Differences in Thoracic Aortic Disease and Dissection.”

“Despite its higher prevalence among men, women with thoracic aortic aneurysm and dissection (TAAD) have lower rates of treatment and surgical intervention and often have worse outcomes,” write Dr. Crousillat and her co-authors. “A growing number of women with TAAD also desire pregnancy, which can be associated with an increased risk of aortic complications. Understanding sex-specific differences in TAAD has the potential to improve care delivery, reduce disparities in treatment, and optimize outcomes for women with TAAD.”

Before coming to USF Health, Dr. Crousillat completed her residency training in internal medicine at Brigham and Women’s Hospital in Boston, MA, from 2013 to 2016, followed by fellowships in cardiology and advanced echocardiography with a special focus in women’s cardiology and pregnancy heart health at Massachusetts General Hospital from 2016 to 2021.

In Boston, the discrepancy in treatment between the sexes came into sharp focus. Dr. Crousillat came to realize that the disease may manifest differently in women, and that much of the available research and data had revolved around men. 

“For a long time, we’ve been extrapolating what we’ve learned about treatment and procedures from our experience among men, and said, ‘Fine, we’ll do the same for women,’” she said. “But when you look across the board, the number of women included in many cardiovascular trials is actually quite low. We need to do a better job of inclusivity of women in clinical research and in the study of sex differences among even the most common diseases we see as cardiologists.”

The paper explores one key difference, abnormalities in the aorta – including aneurysms or outpouchings (sac-like dilations outside an organ).  These can lead to severe complications, such as a tear or rip of the aorta, also known as an aortic dissection, or an aortic rupture. These complications can be life-threatening medical emergencies. 

“The prevalence of aortic disease is not as common among women,” Dr. Crousillat said. “But when it does occur in women, they tend to do worse. So we need to ask ourselves, what can we do to improve the care of these patients?”

One key difference is that women have thinner aortic walls than men, and research has indicated that hormones may be a factor in initially keeping women protected from aortic issues – specifically in creating greater elasticity in the aorta.

“We think that estrogen, which women have, is helpful in protecting their aorta from not tearing or dilating,” Dr. Crousillat said. “But that can change after menopause, when women lose their estrogen.”

The markers for recommendations of surgery and treatment have typically been geared to male patients – without taking into consideration any differences in body size or the patient’s sex. 

“You can imagine it would be harder for generally smaller women to meet aortic sizes that are large enough to get the green light for surgery, so in part of our paper, we discuss whether we should have different ‘cut points’ for recommending surgery for women,” she said. “But the theme of the paper is should we intervene earlier for women and have different strategies for treating women – not simply extrapolate what we know about men. That may actually help women have better outcomes.”

One of the challenges with TAAD is that there is often no advance warning for men or women, but there are some telltale signs, such as the sudden onset of a sharp chest pain extending to the back. In addition, becoming familiar with one’s family history – knowing whether anyone had an aortic dissection, for instance – could be a helpful guide. And certain underlying conditions, such as Marfan syndrome, which affects the heart and blood vessels, can increase the risk.

The bottom line: Educating women on becoming better aware of possible symptoms is an important part of the equation. 

“They may be busy at work or at home and brush off potential warning signs, which could indicate an impending aortic emergency,” Dr. Crousillat said. “We generally see women seek care more than six to eight hours after the symptoms have started, while we see that men tend to come in earlier. But we also see that women are delayed in getting a diagnosis. Let’s say a woman finally comes into the ER: What is the amount of time it takes for a doctor to suspect that was happening, to get a CT scan and to confirm diagnosis? It’s generally more delayed in women. So, there’s work to do on that end – in educating both the patients and the providers.”

Dr. Crousillat was born and raised in Venezuela. Her parents eventually emigrated to Florida, where she attended the University of Florida, earning her B.S. degree in 2009 and obtaining her medical degree from New York University in 2013. She fell in love with cardiology during her years in Boston, where her path was shaped working in Mass General’s Women’s Heart Center.

“The more time I spent there, the more fascinated I became,” she said. “Half the patients we saw were women and we didn’t really know how best to evaluate them. I thought, ‘This is what I’m going to dedicate my career to.’ ”

Upon finishing her training, Dr. Crousillat decided to return to Florida – her parents live in Bradenton and her husband’s family in Miami. Being from Venezuela, she hoped to find an area with a larger Hispanic population than in Boston. “When I came to USF, I thought, ‘This place is fantastic and fertile ground – the pairing of the prestigious USF Health Morsani College of Medicine and the diversity of the local Tampa community made this the perfect place to grow this program and call my new home,’” she recalled. “The tremendous progress of the university and what Dr. (Charles) Lockwood has accomplished as the dean of the medical school and USF Health is tremendous. For me, it was a marriage of both worlds.”

Joining USF Health also gave Dr. Crousillat the opportunity to bring something to the community that had been missing: “I had been part of an institution that had a Women’s Heart Center for over a decade, and I saw the wonderful work they were doing and the impact they were making, and I thought, ‘Wouldn’t it be fantastic to take what I’ve absorbed in my training there and bring it to Tampa Bay.”

In addition, Dr. Crousillat runs USF Health’s Cardio-Obstetrics Program, treating pregnant women with cardiac disease. In fact, a portion of her recent journal article is devoted to how to provide care for expectant mothers with a history of heart issues. “The risk of aortic dissection is higher during pregnancy and particularly after delivery,” she said.

Dr. Crousillat doesn’t want women to be alarmed by the potential for cardiovascular disease, but creating awareness – before a problem might occur – is essential.

“There are treatments for aortic disease,” she said. “And the earlier a woman or man receives care and the issue is identified, the better the outcome.”

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About Health News

USF Health News highlights the great work of the faculty, staff and students across the four health colleges – Morsani College of Medicine, College of Public Health, College of Nursing and Taneja College of Pharmacy – and the multispecialty physicians group. USF Health, an integral part of the University of South Florida, integrates research, education and health care to reach our shared value - making life better.