Evaluating and Managing Cardiovascular Disease in Women

Abstract

HomeCirculationVol. 111, No. 4Evaluating and Managing Cardiovascular Disease in Women Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBEvaluating and Managing Cardiovascular Disease in WomenUnderstanding a Woman’s Heart Alice K. Jacobs, MD and Robert H. Eckel, MD Alice K. JacobsAlice K. Jacobs From the Boston University School of Medicine, Boston, Mass (A.K.J.), and the University of Colorado Health Sciences Center, Denver (R.H.E.). Search for more papers by this author and Robert H. EckelRobert H. Eckel From the Boston University School of Medicine, Boston, Mass (A.K.J.), and the University of Colorado Health Sciences Center, Denver (R.H.E.). Search for more papers by this author Originally published1 Feb 2005https://doi.org/10.1161/01.CIR.0000155289.62829.0FCirculation. 2005;111:383–384Despite the efforts of investigators, public health and private caregivers, voluntary health organizations, and policymakers, heart disease continues to be the leading cause of death in women, both in the United States and throughout most of the world.1,2 A number of issues contribute to these disappointing statistics.Many women lack the basic awareness that cardiovascular disease is the leading cause of death among women. The American Heart Association’s (AHA) 2004 survey of women’s attitudes and knowledge showed that, when asked what they thought was the leading cause of death among women, >50% of women answered this question incorrectly.3 Even more important, only 13% of women personalized this information and answered that their own personal greatest health threat was heart disease. Although this level has increased from 7% since the initial survey 6 years ago, it is still far too low. Furthermore, because coronary disease becomes clinically evident in women about a decade later than it does in men, women commonly believe that preventing heart disease can be postponed. They may believe that they can begin to focus on it in their 50s, after other priorities such as childbearing, child rearing, and caring for their families no longer need their full attention. They miss the fact so well demonstrated by the Pathobiological Determinants of Atherosclerosis in Youth studies that atherosclerosis is often evident in women in their 20s, that it is related to classical cardiovascular risk factors, and that preventing it must start in childhood.4,5 Publication of the AHA survey mentioned earlier,3 as well as incorporation of the data in the efforts toward increased public awareness of the AHA’s Go Red for Women campaign, launched in 2004, served to highlight this reality.Healthcare professionals also may be unaware of women’s risk for cardiovascular disease, and even if they are aware, they may not have the information needed for the most effective prevention and treatment. Publication of the first evidence-based guidelines for cardiovascular disease prevention in women in February 20046 and distribution of toolkits based on these guidelines to 80 000 physicians during 2004 through the Go Red for Women campaign was an attempt to address this need. In addition, although it has been recognized that research that is directly relevant to women is insufficient, this fact became even more apparent during the development of these guidelines. As the 2001 Institute of Medicine report Exploring the Biological Contributions to Human Health: Does Sex Matter? noted,7 women have been underrepresented in clinical research studies, although the major funders of research in cardiovascular disease, the National Institutes of Health and the AHA, have had guidelines in place since the early 1990s to help improve this situation.Current Approaches to the ProblemIn this issue of Circulation, the AHA continues its focus on understanding a woman’s heart. We have included an important survey assessing physicians’ comfort levels with and expertise in the prevention of heart disease in women.8 What we learned suggests that educational efforts must be prioritized and they must begin early, be incorporated into medical school curricula, and be continued while in clinical practice. To help women who are aware of the risks and want to reduce them, Manson and Johnson9 have contributed a Cardiology Patient Page that women can copy or print out and show to their healthcare professional. This page will help both patient and clinician to assess the woman’s risk and decide the best approach to cardiovascular disease prevention. We also have included 2 new AHA Scientific Statements that will provide healthcare professionals with the most up-to-date information about noninvasive testing10 and interventional procedures11 in women with coronary artery disease (CAD).The statement on noninvasive testing10 addresses the lack of recognition and diagnosis of CAD in women and the fact that both have been implicated in women’s higher mortality rates. Therefore, accurate diagnostic and prognostic testing has the potential to improve outcomes. The higher prevalence of nonobstructive CAD and single-vessel disease in women as compared with age-matched men, which decreases the diagnostic accuracy of conventional noninvasive testing, coupled with the fewer number of women participating in studies of these tests, limit the evidence base. However, the writing group suggests that women with suspected CAD can be accurately diagnosed and risk stratified with contemporary cardiac imaging techniques and recommends that local expertise and availability guide the choice of test. Future studies will be needed, however, to evaluate the importance of traditional as well as emerging markers of risk, in addition to the influence of hormonal, endothelial, and microvascular function on the interpretation of noninvasive test results.As in studies of noninvasive testing, women most often represent less than one third of the population in studies evaluating treatment with percutaneous coronary intervention (PCI). The statement on PCI in women11 is interesting in that although women who undergo contemporary PCI are older and have more comorbid disease and a higher prevalence of risk factors as compared with men generally and with women who previously underwent balloon angioplasty, outcomes in women have improved and the gender difference in mortality has decreased. Because women have a higher incidence of bleeding and vascular complications, however, a careful assessment of the risk–benefit ratio of an invasive strategy must be undertaken, particularly because the benefit in women with acute coronary syndromes may be limited to high-risk women (ie, women with elevated troponin values). It is clear that studies must mandate the increased recruitment of women and include sex-specific results, particularly in trials of new devices.All of the studies and statements mentioned above are based on a disturbing fact: Although women develop the manifestations of coronary disease later than do men, inadequate prevention and the aging of the US population results in the cardiovascular disease-related deaths of >500 000 US women every year. To be effective, prevention must begin early. Thus, the AHA continues to aggressively address these issues with its Go Red for Women campaign. The goal of the campaign is to raise awareness among women and healthcare professionals that cardiovascular disease is the greatest threat to women’s health. This year, the campaign will create a rallying cry for improved prevention and treatment of heart disease in women. The campaign will be highly visible in the media, both on television and in print, and numerous national monuments will “go red” and many cities will mount “Go Red” statues inspired by actors and actresses Melanie Griffith, Antonio Banderas, Geena Davis, Hector Elizondo, Jacklyn Zeman, Rita Moreno, James Woods, and Valerie Harper; the cast of the daytime drama Passions; model Daisy Fuentes; singer Toni Braxton; fashion designer Dana Buchman and other designers featured at Macy’s; comedian Bill Cosby; musician Dave Koz; former NBC Today anchor Jane Pauley; celebrity chefs Rachael Ray and B. Smith; WNBA players Lisa Lesley and Sheryl Swoops; and Univision’s Aqui y Ahora coanchor Teresa Rodríguez. Critical additional elements of the initiative will provide help for the healthcare professional. We hope that Go Red for Women will encourage women, working with healthcare professionals, to take control of their heart health and live longer, stronger lives. Watch for the campaign, and take its messages to heart.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.FootnotesCorrespondence to Dr Alice K. Jacobs, Department of Cardiology, Boston Medical Center, 88 E Newton St, Boston, MA 02118. E-mail [email protected] References 1 Mullis RM, Blair SN, Aronne LJ, Bier DM, Denke MA, Dietz W, Donato KA, Drewnowski A, French SA, Howard BV, Robinson TN, Swinburn B, Wechsler H. Prevention Conference VII: obesity, a worldwide epidemic related to heart disease and stroke: group IV: prevention/treatment. Circulation. 2004; 110: e484–e488.LinkGoogle Scholar2 American Heart Association. Heart and Stroke Facts. Dallas, Tex: American Heart Association; 2005.Google Scholar3 Mosca L, Ferris A, Fabunmi R, Robertson RM. Tracking women’s awareness of heart disease: an American Heart Association national study. Circulation. 2004; 109: 573–579.LinkGoogle Scholar4 McGill HC Jr, McMahan CA. Determinants of atherosclerosis in the young. Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Am J Cardiol. 1998; 82: 30T–36T.CrossrefMedlineGoogle Scholar5 McGill HC Jr, McMahan CA, Herderick EE, Tracy RE, Malcom GT, Zieske AW, Strong JP. Effects of coronary heart disease risk factors on atherosclerosis of selected regions of the aorta and right coronary artery. PDAY Research Group. Pathobiological Determinants of Atherosclerosis in Youth. Arterioscler Thromb Vasc Biol. 2000; 20: 836–845.CrossrefMedlineGoogle Scholar6 Mosca L, Appel LJ, Benjamin EJ, Berra K, Chandra-Strobos N, Fabunmi RP, Grady D, Haan CK, Hayes SN, Judelson DR, Keenan NL, McBride P, Oparil S, Ouyang P, Oz MC, Mendelsohn ME, Pasternak RC, Pinn VW, Robertson RM, Schenck-Gustafsson K, Sila CA, Smith SC Jr, Sopko G, Taylor AL, Walsh BW, Wenger NK, Williams CL. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2004; 109: 672–693.LinkGoogle Scholar7 Wizemann TM, Pardue M-L, eds. Exploring the Biological Contributions to Human Health: Does Sex Matter? Washington, DC: National Academies Press; 2001.Google Scholar8 Mosca L, Linfante AH, Benjamin EJ, Berra K, Hayes SN, Walsh B, Fabunmi RP, Kwan J, Mills T, Simpson SL. Physician awareness and adherence to cardiovascular disease prevention guidelines in the United States. Circulation. 2005; 111: 499–510.LinkGoogle Scholar9 Johnson P, Manson JA. How to make sure the beat goes on: protecting a woman’s heart. Circulation. 2005; 111: e28–e33.LinkGoogle Scholar10 Mieres JH, Shaw LJ, Arai A, Budoff MJ, Flamm SD, Hundley G, Marwick TH, Mosca L, Patel AR, Quinones MA, Redberg RF, Taubert KA, Taylor AJ, Thomas GS, Wenger NK; Cardiac Imaging Committee, Council on Clinical Cardiology, Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention. The role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease. Circulation. In press.Google Scholar11 Lansky AJ, Hochman JS, Ward PA, Mintz GS, Fabunmi R, Berger PB, New G, Grines CL, Pietras CG, Kern MJ, Leon MB, Mehran R, White C, Mieres JH, Moses JW, Stone GW, Jacobs AK. Percutaneous coronary intervention and adjunctive pharmacotherapy in women: a statement for healthcare professionals from the American Heart Association. Circulation. In press.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Morais R, Bernardes S and Verdonk P (2022) What is gender awareness in health? A scoping review of the concept, its operationalization, and its relation to health outcomes, Women & Health, 10.1080/03630242.2022.2041150, 62:3, (181-204), Online publication date: 16-Mar-2022. Visser V, Hermes W, Twisk J, Franx A, van Pampus M, Koopmans C, Mol B and de Groot C (2017) Prognostic model for chronic hypertension in women with a history of hypertensive pregnancy disorders at term, Pregnancy Hypertension, 10.1016/j.preghy.2017.07.141, 10, (118-123), Online publication date: 1-Oct-2017. Abheiden C, Thijs A, de Vries J and de Boer M (2016) Cardiovascular risk factors in women with inheritable thrombophilia a decade after single or recurrent hypertensive disorder of pregnancy, Hypertension in Pregnancy, 10.1080/10641955.2016.1183674, 35:4, (461-469), Online publication date: 1-Oct-2016. van Kesteren F, Visser S, Hermes W, Teunissen P, Franx A, van Pampus M, Mol B and de Groot C (2016) Counselling and management of cardiovascular risk factors after preeclampsia, Hypertension in Pregnancy, 10.3109/10641955.2015.1100311, 35:1, (55-61), Online publication date: 2-Jan-2016. Mol B, Roberts C, Thangaratinam S, Magee L, de Groot C and Hofmeyr G (2016) Pre-eclampsia, The Lancet, 10.1016/S0140-6736(15)00070-7, 387:10022, (999-1011), Online publication date: 1-Mar-2016. Hermes W, Koopmans C, van Pampus M, Franx A, Bloemenkamp K, van der Post J, Porath M, Tamsma J, Mol B and de Groot C (2013) Induction of labour or expectant monitoring in hypertensive pregnancy disorders at term: do women's postpartum cardiovascular risk factors differ between the two strategies?, European Journal of Obstetrics & Gynecology and Reproductive Biology, 10.1016/j.ejogrb.2013.08.006, 171:1, (30-34), Online publication date: 1-Nov-2013. Hermes W, Franx A, van Pampus M, Bloemenkamp K, Bots M, van der Post J, Porath M, Ponjee G, Tamsma J, Mol B and de Groot C (2013) Cardiovascular risk factors in women who had hypertensive disorders late in pregnancy: a cohort study, American Journal of Obstetrics and Gynecology, 10.1016/j.ajog.2013.02.016, 208:6, (474.e1-474.e8), Online publication date: 1-Jun-2013. Hermes W, Tamsma J, Grootendorst D, Franx A, van der Post J, van Pampus M, Bloemenkamp K, Porath M, Mol B and de Groot C (2013) Cardiovascular risk estimation in women with a history of hypertensive pregnancy disorders at term: a longitudinal follow-up study, BMC Pregnancy and Childbirth, 10.1186/1471-2393-13-126, 13:1, Online publication date: 1-Dec-2013. Sabbadini G, Travan L and Toigo G (2012) Elderly women with heart failure: unseen, unheard or simply forgotten?, Aging Health, 10.2217/ahe.12.10, 8:2, (191-204), Online publication date: 1-Apr-2012. Banner D, Miers M, Clarke B and Albarran J (2011) Women’s experiences of undergoing coronary artery bypass graft surgery, Journal of Advanced Nursing, 10.1111/j.1365-2648.2011.05799.x, 68:4, (919-930), Online publication date: 1-Apr-2012. Moore C, Miller I, Andersen R, Arndt S, Haynes W and Moser D (2010) Gender differences in neuropsychological performance in individuals with atherosclerosis: Impact of vascular function, Journal of Clinical and Experimental Neuropsychology, 10.1080/13803391003757841, 33:1, (9-16), Online publication date: 5-Jan-2011. Banner D (2010) Becoming a coronary artery bypass graft surgery patient: a grounded theory study of women’s experiences, Journal of Clinical Nursing, 10.1111/j.1365-2702.2010.03424.x, 19:21-22, (3123-3133), Online publication date: 1-Nov-2010. Miracle V (2010) Coronary Artery Disease in Women, Dimensions of Critical Care Nursing, 10.1097/DCC.0b013e3181ec3731, 29:5, (215-221), Online publication date: 1-Sep-2010. Jacobs A (2009) Coronary Intervention in 2009, Circulation: Cardiovascular Interventions, 2:1, (69-78), Online publication date: 1-Feb-2009. Gopalakrishnan P, Ragland M and Tak T (2015) Gender Differences in Coronary Artery Disease: Review of Diagnostic Challenges and Current Treatment, Postgraduate Medicine, 10.3810/pgm.2009.03.1977, 121:2, (60-68), Online publication date: 1-Mar-2009. Edlow A, Srinivas S and Elovitz M (2009) Investigating the risk of hypertension shortly after pregnancies complicated by preeclampsia, American Journal of Obstetrics and Gynecology, 10.1016/j.ajog.2008.10.012, 200:5, (e60-e62), Online publication date: 1-May-2009. Sigvant B, Wiberg-Hedman K, Bergqvist D, Rolandsson O and Wahlberg E (2009) Risk factor profiles and use of cardiovascular drug prevention in women and men with peripheral arterial disease, European Journal of Cardiovascular Prevention & Rehabilitation, 10.1097/HJR.0b013e32831c1383, 16:1, (39-46), Online publication date: 1-Feb-2009. Cherradi R, Ouldzein H, Zouaoui W, Elbaz M, Puel J and Carrié D (2008) Clinical and angiographic results of angioplasty with a paclitaxel-eluting stent for unprotected left main coronary artery disease (a study of 101 consecutive patients), Archives of Cardiovascular Diseases, 10.1016/S1875-2136(08)70249-3, 101:1, (11-17), Online publication date: 1-Jan-2008. Jiménez-Navarro M and Anguita-Sánchez M (2008) Insuficiencia cardiaca en la mujer. Diferencias de sexo en España, Revista Española de Cardiología Suplementos, 10.1016/S1131-3587(08)73561-1, 8:4, (23D-29D), Online publication date: 1-Jan-2008. Dijkstra A, Verdonk P and Lagro-Janssen A (2008) Gender bias in medical textbooks: examples from coronary heart disease, depression, alcohol abuse and pharmacology, Medical Education, 10.1111/j.1365-2923.2008.03150.x, 42:10, (1021-1028), Online publication date: 1-Oct-2008. DiGiacomo M, Davidson P, Vanderpluym A, Snell R and Worrall-Carter L (2007) Depression, anxiety and stress in women following acute coronary syndrome: Implications for secondary prevention, Australian Critical Care, 10.1016/j.aucc.2007.03.002, 20:2, (69-76), Online publication date: 1-May-2007. Krentz A, von Mühlen D and Barrett-Connor E (2007) Searching for polycystic ovary syndrome in postmenopausal women, Menopause, 10.1097/GME.0b013e31802cc7ab, 14:2, (284-292), Online publication date: 1-Mar-2007. KHAN M (2006) Women and Heart Disease Encyclopedia of Heart Diseases, 10.1016/B978-012406061-6/50093-X, (609-615), . Miracle V (2006) Coronary Artery Disease in Women, Dimensions of Critical Care Nursing, 10.1097/00003465-200609000-00005, 25:5, (209-215), Online publication date: 1-Sep-2006. Rutledge T, Reis S, Olson M, Owens J, Kelsey S, Pepine C, Mankad S, Rogers W, Sopko G, Cornell C, Sharaf B and Merz C (2006) Depression Is Associated With Cardiac Symptoms, Mortality Risk, and Hospitalization Among Women With Suspected Coronary Disease: The NHLBI-Sponsored WISE Study, Psychosomatic Medicine, 10.1097/01.psy.0000195751.94998.e3, 68:2, (217-223), Online publication date: 1-Mar-2006. Blaauw J, van Pampus M, Van Doormaal J, Fokkema M, Fidler V, Smit A and Aarnoudse J (2006) Increased Intima-Media Thickness After Early-Onset Preeclampsia, Obstetrics & Gynecology, 10.1097/01.AOG.0000218097.22464.b4, 107:6, (1345-1351), Online publication date: 1-Jun-2006. Grohé C (2005) ‘Tib the balance’: the search for the optimal hormone replacement therapyThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology., European Heart Journal, 10.1093/eurheartj/ehi354, 26:14, (1345-1346), Online publication date: 1-Jul-2005. February 1, 2005Vol 111, Issue 4 Advertisement Article InformationMetrics https://doi.org/10.1161/01.CIR.0000155289.62829.0FPMID: 15687121 Originally publishedFebruary 1, 2005 KeywordspreventionEditorialswomencoronary diseasePDF download Advertisement SubjectsAcute Coronary SyndromesChronic Ischemic Heart DiseaseExercise TestingPrimary PreventionStent