Understanding Arrhythmias: Clinical Challenges, Treatment Gaps, and Opportunities for Improved Care

Podcast Discussion With Nishtha Sareen, MD, MPH, FACC, FSCAI

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EP LAB DIGEST. 2025;25(4):Ahead of print.

Interview by Jodie Elrod

EP Lab Digest talks with Nishtha Sareen, MD, MPH, FACC, FSCAI, Medical Director, Women’s Heart Clinic, Ascension Medical Group, about challenges in cardiovascular care for women, gaps in knowledge, considerations during pregnancy and menopause, differences in response to medical therapy, and more.

Could you explain some of the key sex differences in the presentation and management of cardiac arrhythmias? How do these differences affect diagnosis and treatment of women with arrhythmias?

I would describe the differences in 3 parts. The first is evaluating the inherent differences in cardiac or electrical makeup in men vs women, including gender differences. Women tend to have a higher heart rate at baseline compared to men. They have a longer QT interval compared to men. They also have a shorter sinus node recovery time, and that is something that is inherently built, which also narrates and directs what kind of arrhythmias will be more common in women and what kind of medications may not be as safe in women compared to men. 

The second important aspect is determining the arrhythmias that are more common in women. The most common are AVNRTs and long QT syndrome. Long QT in men can cause more cardiac death early on, but women tend to live longer. So, women need a longer length of therapy and close follow-up throughout their lives. 

The third important difference is atrial fibrillation (AF). Although it continues to be more common in men, there are studies from Mayo Clinic showing the absolute numbers of people affected by AF are equal in men and women. The reason is that more women make it to more than 75 years of age compared to men. So, if you look at a population at a time, more than 50% are females are affected by AF. What is also interesting about AF in women is that it presents differently. Patients tend to have more symptoms and the symptoms are more difficult to control. In addition, if you look at current data, we are not doing a great job with referring female patients for advanced therapy, catheter ablations, or rhythm control therapy. So, there is a lot of discrepancy when it comes to diagnosis and treatment of arrhythmias among men and women.

In your experience, what are the main challenges when it comes to cardiovascular care for women, particularly in the context of arrhythmias? 

The greatest challenges in treating arrhythmias in women originate at the level of diagnosis. Diagnosing women is more challenging compared to men, and that is true for pretty much all cardiovascular conditions whether it is myocardial infarction, stroke, or arrhythmia. Another challenge is referring women in a timely manner for advanced therapy such as rhythm control therapy, thromboembolic protection therapy, and advanced catheter ablations. We must do a better job. I think the root cause is the data. The data is very deficient in gender-specific material. The reason is underrepresentation of women in clinical trials. At this time, there is a lot of push to have more female representation in our EP trials. A part of it also has to do with community awareness and women being aware of their symptoms and promptly seeking medical attention.

What do you see as the most significant gaps in our knowledge when it comes to sex differences in arrhythmias and cardiovascular disease in women?

Women have different phases in their lives and one of those challenges is pregnancy. During a patient’s pregnancy, it is important to determine which therapies are safe for them. For example, is it safe to give them beta-blockers during therapy, and if so, which therapy is the best? I think that is where one of the biggest gaps still exists. Other questions include what arrhythmias are common during pregnancy, what testing is safe during pregnancy, and how far can we go? Those are areas that continue to be deficient in terms of the data. 

Another gap in our knowledge is in patients with hormonal changes such as menopause and perimenopause, including what therapies work and do not work. Based on the luteal phase and hormone sensitivity, there are patients who will respond better to cardioversion compared to times in their cycle when they are not going to respond well. So, there is some hormonal interrelation as well that must be taken into consideration when treating women for arrhythmias, and at this time, our knowledge base is not as strong for those.

How do hormonal changes during pregnancy and menopause influence the development and management of cardiac arrhythmias in women? What specific considerations should clinicians keep in mind?

In pregnant patients, the most common arrhythmia that we typically see is supraventricular tachycardia (SVT). It is usually benign and we treat based on symptoms. Beta-blockers are typically safe during pregnancy and we are comfortable giving that to our patients. Another arrhythmia that we see in pregnant patients is long QT syndrome. What is interesting is that during pregnancy, patients are more tachycardic, and that is why long QT syndrome is less likely. It is when the woman delivers and her heart rate goes down; the postpartum period becomes critical for long QT syndrome management. We do see some ventricular tachycardia and SVT as well, which is treated similar to the way patients who are not pregnant are treated. Those are the predominant issues regarding pregnancy. 

When it comes to menopause, atrioventricular nodal reentry tachycardia (AVNRT) and SVTs are most common in women during the menopausal and perimenopausal period. Hormonal changes must be taken into consideration, including the phase the patient is in, to determine if the therapy is going to work. One of the issues we also hear from our cardiology colleagues is the safety of certain medications during pregnancy—what medications to give or not give comes up quite a bit.

Are there notable differences in how women respond to various treatments for arrhythmias, such as antiarrhythmic medications or catheter ablation? How do you tailor treatment strategies?

Yes, women tend not to respond as well to therapy when it comes to medications compared to men. We typically see more side effects in medications when they are given to women, especially antiarrhythmics. If we look at the literature on ablation, there tends to be more complications among women, but there is still a lot of bias when it comes to referral for those therapies as well. It should not stop us from providing those therapies to women. In fact, if medication is not well tolerated, perhaps that is an indication of an earlier crossover to more invasive therapy. So, I think there are definite differences. There are less data and we do not know the underlying causes, but again, it comes back to representation of women in clinical trials to be able to understand what truly does work for them and how to do it in a safe manner.

Tell us about the Women's Clinic at Ascension Saint Thomas Heart and the Women's Heart Clinic at Ascension Michigan. 

Women present differently and there are unique factors such as pregnancy, cardio-obstetrics, and menopause, including arrhythmogenic aspects. But there is also a robust cardiovascular aspect when it comes to coronary artery disease, heart attack risk, stroke risk, and microvascular dysfunction, and there are conditions that affect women disproportionately compared to men. In our literature, women historically have not been treated aggressively for those conditions. For example, with microvascular dysfunction in women with chest pain, they are told there is no blockage in the arteries of their heart and they are dismissed. However, it is coming from the small vasculature in the heart and there are ways to test this—it is in our guidelines. We can make these patients feel better and decrease their risk of stroke and heart attack moving forward by treating them adequately. So, there is a definite need. 

That is why the Women’s Heart Clinic was created at Ascension. We started off in Michigan with 1 location, and because of demand, we had 6 more locations within 18 months. So, we have now expanded to 7 locations. At Ascension Saint Thomas Heart, we have locations in Midtown, Rutherford, and Franklin. What this program really does is address female-specific risk factors. As cardiologists, we talk about diabetes and hypertension for all our patients, but how often do we ask our patients about preeclampsia, early menopause, hysterectomy before 40 years of age, or multiparity? All these are recognized cardiovascular risk factors, and we tend to stratify our patients and make sure we take those into consideration as well when we stratify our patients. We know from clinical trials that dietary and lifestyle interventions are more likely to work in women compared to men. So, instead of giving them directions to change their diet and lifestyle, we provide an onsite dietician and nutritionist (for menu plans) to our patients. They have memberships with exercise physiologists. They can take online classes such as chair yoga during their lunch hour and have access to all this as a part of the program. 

Another aspect is being able to treat women for conditions that affect them disproportionately. One of these is microvascular dysfunction, and the others are postural orthostatic tachycardia syndrome (POTS) and dysautonomia, which we talk to our EP colleagues about all the time. The resources are lacking. There is no definite therapeutic plan. A lot of places cannot even correctly diagnose it. That is one of the areas where the Women’s Heart Clinic is really making strides and effectively caring for these patients. As part of this program, we have a network called the Physician Champion Network, meaning it is not just one physician who is taking care of the patient. Once the patient is in the program, they have access to a cardiothoracic surgery champion, a cardiac preventative champion, a behavioral health champion, an EP champion, and a maternal fetal medicine champion. All of them manage the condition for women, because presentation and treatment are complex for each patient. That is what this program is all about—bringing quality evidence-based care to the doorstep of our patients.

From your perspective, what are some key opportunities for improving the diagnosis, treatment, and prevention of cardiac arrhythmias in women? 

There are 5 important aspects. The first is generating awareness and educating our physician community to understand, recognize, and address issues that disproportionately affect women. The second important aspect is communicating with our patients to recognize their symptoms and understand when to seek medical attention. A lot of times, the fault lies in the patients for not being able to recognize their symptoms and seek care, but we must share that blame, because we are perhaps not doing a good enough job educating them. The third is clinical trials. We must make active effort to enroll women and study their response to therapies and medications. We must also understand our resources, including knowing referral patterns and ensuring we refer patients in a timely manner when it is indicated. Finally, the most important thing is advocacy. Whether it is at the level of the patient or physician, patients must advocate for their health, family members must advocate, and physicians must advocate for the health of their patients. 

The transcripts were edited for clarity and length.