Evaluating and Managing Cardiovascular Disease in Women
Understanding a Woman’s Heart
Despite 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 Problem
In 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.
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.
American Heart Association. Heart and Stroke Facts. Dallas, Tex: American Heart Association; 2005.
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.
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.
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.
Wizemann TM, Pardue M-L, eds. Exploring the Biological Contributions to Human Health: Does Sex Matter? Washington, DC: National Academies Press; 2001.
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.
Johnson P, Manson JA. How to make sure the beat goes on: protecting a woman’s heart. Circulation. 2005; 111: e28–e33.
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.
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.