(Circulation. 2001;103:2318.)
© 2001 American Heart Association, Inc.
Editorials |
Women and Cardiovascular Disease
The Risks of Misperception and the Need for Action
From Vanderbilt University Medical Center, Nashville, Tenn.
Correspondence to Rose Marie Robertson, MD, President, American Heart Association, Professor of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37236.
Key Words: Editorials • heart diseases • women • risk factors • prevention
A new American Heart Association survey1 raises serious concerns about our effectiveness in the critical first step in preventing heart disease in women—the challenge of raising awareness among women about their No. 1 health threat. The survey, which included 1004 women and updated data from a 1997 survey, reached across all ages and ethnic groups and brought to light important information on how women perceive their health risks, how much they worry about them, and where and how they are receiving information about heart disease and stroke. Most women (62%) still believe cancer is the greatest health threat for women, and the younger generation is even more convinced of this. At a distant second, <10% of women overall perceive heart disease as their greatest threat.
This belief is in direct contrast to the facts. In 1998, cardiovascular disease claimed the lives of 503 927 women and cancer caused 259 467 deaths; thus, cardiovascular disease killed nearly twice as many women.2
However, there have been notable changes in women’s understanding of cardiovascular disease since 1997. The majority of these changes are in a positive direction. The number of women who consider themselves either very well or well informed about heart disease and stroke has risen since 1997, although it is still <50%. Knowledge of heart disease increased from 34% to 40%. Knowledge of stroke increased from 28% to 35%.
In many other ways, women’s understanding is still high. Most women (92%) know heart disease develops gradually and can go undetected, and they know (86%) that some forms of heart and vascular disease may result in a stroke. A majority of women (86%) also know that certain treatments in the first few hours after the onset of heart attack or stroke symptoms can break up blood clots to reduce damage to the heart or brain.
Although we are making some progress in increasing women’s awareness of heart disease, there are still important issues to address. Data from this survey suggest that women often hear messages about heart disease, but they are not hearing them frequently enough in the right context (ie, from their doctors). In addition, they don’t seem to be personalizing the seriousness of the disease—they don’t believe heart disease can really affect them. In addition, if women do believe heart disease is a threat, they view it as something to worry about later in life, which effectively undermines prevention efforts.
Women need to understand that heart disease is a "now" problem, and that "later" may be too late. Among women aged 25 to 34 years, a key audience for prevention messages, nearly two-thirds believed cancer was their greatest health threat and just 4% regarded heart disease as a danger. Epidemiological evidence suggests that half of these women will die of cardiovascular disease,2 yet the survey indicates that women’s health priorities lie elsewhere.
This devastating lack of awareness in women needs to be seen as a call to action not only for women themselves, but also for healthcare professionals. All of us, not only those specifically involved in women’s health centers, must take advantage of every opportunity to increase awareness and encourage action to prevent heart disease. Without this crucial step, we will clearly fail in our attempts to reduce the incidence of cardiovascular disease for both women and men.
Women Are Concerned About Their Health
Women are clearly more concerned about their health than they were in 1997. There have been significant increases in the number of women who worry about having a stroke (69% versus 58% in 1997) or getting osteoporosis (64% versus 51% in 1997), diabetes (55% versus 42% in 1997), or Alzheimer’s (58% versus 48% in 1997). Hispanic women in particular seem more worried about having a stroke: 80% of Hispanic women today, compared with 64% in 1997, mention worrying about it either a lot or a little. Across all ethnic groups, the number of women who worry about their health has increased for almost all of the health conditions mentioned. Our job as healthcare providers is to focus this concern and motivate women to help prevent heart disease and stroke at a younger age, when the health benefits of lifestyle changes and other modalities of risk prevention could be most substantial.
Heart Disease Still Low Priority: Young Women Are Missing the Message
In 1997, 60% of women between the ages of 25 and 34 years considered cancer the top health problem facing women. In 2000, that number jumped to 72%. Nearly 3 of 4 young women have this mistaken impression, despite the fact that women say they are aware of heart disease and they feel well informed about it.
The number of women who have seen, heard, or read information about heart disease in the past 12 months has remained relatively the same since 1997 among all age groups. However, women aged 25 to 34 continue to be less aware of this information (63%) than women aged 35 to 44 (73%).
Young women are even more focused on cancer, particularly breast cancer, than older women are. Once women reach middle age, they become slightly more aware of heart disease and stroke as the greater risk. The survey shows that 20% of all women aged 25 to 34 believe heart disease is the leading cause of death for all women today, and 21% say it’s breast cancer. Among women aged 45 to 64, 46% say heart disease/heart attack is the leading cause of death for women, while 13% said breast cancer.
Encouraging Patients to Take Action
According to the survey, the majority of women (86%) feel there is something they can do to prevent getting heart disease. They correctly identified 7 activities that can prevent or reduce the risk of heart disease: exercising, losing weight, reducing stress, quitting smoking, reducing dietary cholesterol intake, reducing sodium in the diet, and reducing animal products in the diet.
This information begs the question: If they are hearing the messages, why aren’t they taking action?
We must look for ways to encourage women to take action against heart disease by tailoring messages for specific patient populations and then following-up to make sure the message hit its mark.
The American Heart Association has developed a number of programs and activities geared specifically toward women to meet these needs. One of these programs, Choose to Move, is a 12-week program that helps busy women learn how to increase their daily physical activity level in practical and innovative ways. For more information, visit www.choosetomove.org or call 1-888-MY-HEART.
Symptoms and Risk Factors
We have clearly had an impact in communicating gender differences in the symptoms of myocardial infarction. Many women (65%) now recognize that women can have atypical symptoms for heart attack, such as unexplained fatigue or dyspnea. However, many still do not recognize classic symptoms such as chest pain; pain that spreads to the shoulders, neck or arms; shortness of breath; and tightness in the chest. This is a serious problem because the majority of women who have a heart attack actually experience typical symptoms.
There have been improvements in increasing the awareness of stroke symptoms, even though they are still far less familiar than those of a heart attack. The number of women who associated stroke with trouble talking or understanding speech increased from 15% in 1997 to 22% in 2000. Women’s awareness of other warning signs associated with stroke remained steady: sudden weakness/numbness of the face or limb on one side (36% in both survey years); sudden, severe headache (19% in 2000, 17% in 1997); sudden dimness/loss of vision, often in one eye (17% in both survey years); and unexplained dizziness (16% in 2000, 14% in 1997).
In addition, there are significant gaps in the understanding of risk factors. According to this survey, women most frequently cite obesity as a major cause of heart disease. Although obesity is certainly a major risk factor, physicians and healthcare professionals must be sure that women are aware of all of the major risk factors, which are diabetes, smoking, hypertension, high cholesterol, lack of physical activity, and obesity. We must also be sure that these factors are evaluated and that we are providing tools to help women manage their risk factors. Women often learn about risk factors in places other than the doctor’s office. When they attend community health fairs or other screening activities to have their blood pressure checked, they are often astonished to discover they have high blood pressure and surprised that it has caused no symptoms.
It is clearly important for women to know their blood pressure and cholesterol numbers if they are to be motivated to take effective action. However, just 6 of 10 women today report having had their cholesterol checked in the past 18 months; this number was the same in 1997. When women were asked if they know their HDL and LDL levels, 76% reported that they did not know. Now we also need them to become aware of their triglyceride level, which has a particular impact on a woman’s risk of heart disease.
Minorities
It seems that information about the increased risk of heart disease in blacks, Hispanics, and other ethnic groups is beginning to reach target populations. However, again, there is still much work to be done.
More black women (42%) report that their doctors have discussed heart disease with them when talking about their health than any other ethnic group. This is great news. Among Hispanic women, 34% report discussing heart disease with their doctors. More Hispanic women today also report being knowledgeable about stroke compared with other groups (39% Hispanic, 37% black, 34% white). However, Hispanic women are the least informed about heart disease, with only 32% considering themselves very well or well informed.
Increasingly, more black women (68%) know that they are more likely to die from a heart attack or stroke than white women (up from 62% in 1997). However, more than half of black women (52%) incorrectly associate heart disease with sudden death. This is a significant increase over 43% in 1997.
This brings to light some inequities in the basic understanding of heart disease. Our aim is for universal understanding. The matter is more urgent in black and Hispanic women because they have a higher prevalence of cardiovascular disease and risk factors for cardiovascular disease than their white counterparts.2
Delivering the Message: Go Where the Patients Are
Do you know where most of your patients receive their health information? According to the survey, 43% of women receive heart disease information from magazines. Although it is true that popular magazines are an effective way to get the message out, healthcare workers must also reinforce these messages. The survey shows that 8% more physicians are talking to their female patients about heart disease now than in 1997, but the total number is still only 38%. In addition, only 20% of women in the survey reported that they received heart disease information from a healthcare professional in the 12 months before the survey. This will clearly require more than just pamphlets in the waiting room. In a time-pressured environment, we need to find ways to make sure the message of heart disease prevention is heard. Physicians and other clinicians should have not only standards of care, but standards of prevention for all of their patients.
There is a need to make women part of the treatment team. We
need to set treatment goals for women with hypertension or
hyperlipidemia. There is a mistaken sense that the
solution to a problem such as high blood pressure is simply taking
medication, regardless of the actual effect. According to American
Heart Association
statistics,2 26.2% of people
with hypertension are taking medication for it but their levels are
still not controlled to goal, and nearly half of all adult women (49%;
53.1 million) have total cholesterol levels 
200
mg/dL.
Although most women know that heart disease develops gradually, two-thirds of them believe they are most likely to begin to develop heart disease after the age of 35. We now have solid evidence that the process of atherosclerosis begins even in the very young.3 4 5 If women wait until they are 35 to "prevent" heart disease, they may not receive the maximum benefit from their efforts. Our message of prevention is missing a critical audience. We need to step up efforts to get younger women in the loop.
Issues for Physicians: Closing the Awareness Gap
There are lessons from the inpatient side of our practices. We have comprehensive discharge guidelines for secondary prevention, lipid-lowering, smoking cessation, ß-blocker therapy, and other treatments after a heart attack or other cardiovascular event resulting in hospital admission. Studies show that without such guidelines, doctors are 20% to 80% effective in administering the appropriate treatments eligible individuals. With discharge protocols, this variability in success is limited, and virtually every patient can leave the hospital on the right medicine and prescription for health. Physician judgment is still critical, and these systems preserve it.
A recent study published in the American Journal of Cardiology highlights a hospital-based program for patients with heart disease that called for initiating treatments to prevent recurrent heart attack before individuals were discharged from the hospital.6 These treatments included ß-blockers, ACE inhibitors, aspirin, statins, and other drugs that are generally given at standard follow-up visits after a person is sent home. Nearly half of the participants (41%) in this program were women. Aspirin use at discharge improved from 68% before the program to 92% after it was implemented. ß-Blocker use improved from 12% to 62%, ACE inhibitor use went from 6% to 58%, and statin use increased from 6% to 8%. At the 1-year follow-up, compliance was up, 52% more patients had achieved LDL cholesterol levels <100 mg/dL, and there were fewer recurrent heart attacks, repeat hospitalizations, and deaths. These are the kind of results we like to see and, according to the report, they came at no extra cost to the hospital. The American Heart Association is launching a similar program, called Get With The Guidelines, in acute care hospitals. We plan to have the program implemented in >15 major metropolitan areas in the coming months. Similar approaches in the outpatient arena must follow.
The awareness and treatment gaps documented above are the cause of much of the preventable heart disease and stroke in women in this country. At a time when we have detailed and solid evidence about what to do, translating it into the real world still remains a problem. In 1999, the American Heart Association, the American College of Cardiology, and other professional health organizations released a "Guide to Preventive Cardiology for Women"7 that provided recommendations for closing the wide gap between what is known to prevent heart disease in women and what is actually being done. With these in hand and with systems that support their use, we can make it possible for all of us to implement these guidelines to improve the health of all our patients.
Footnotes
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
References
-
Women
and Heart Disease: A Study Tracking Women’s Awareness of and Attitudes
Toward Heart Disease and Stroke. Dallas, Tex: American Heart
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Heart and Stroke Statistical Update. Dallas, Tex: American
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