Heart Disease in Women
Heart disease is the leading cause of death among women. In comparison with men, women have greater cardiovascular mortality, report more morbidity, and have greater reductions in quality of life. Furthermore, sex disparities in cardiovascular health exist among women of all ages, socioeconomic backgrounds, and racial subgroups, which likely reflect both lingering diagnostic and treatment disparities, and underlying biological sex differences, as well. For example, there is a largely female predominance of stress-induced (Takotsubo) cardiomyopathy after menopause, a greater occurrence of heart failure with preserved ejection fraction, particularly in elderly women, and a higher incidence of rheumatic mitral stenosis among women in developing countries. In addition, after 55 years of age, hypertension is more prevalent in women than in men, particularly in black women. Clinical outcomes also differ by sex. Women with atrial fibrillation have a higher risk of thromboembolic events in comparison with men, and, among individuals younger than 55 years of age, the rate of acute myocardial infarction in the past decade has declined in men, but not in women. As the importance and impact of cardiovascular disease in women is increasingly recognized, we are learning how heart disease is distinct between the sexes, both in its pathophysiology and in our ability to diagnose and treat women.
To better understand and appreciate sex differences in cardiovascular disease, there needs to be a compilation of current knowledge and an accessible tool that increases awareness of these differences. Heart Disease in Women, by Drs Navin Nanda and Nurgul Keser, is that clinical tool and an excellent resource for all providers of women’s health. Heart Disease in Women brings greater awareness to sex-specific differences in heart disease and emphasizes the unique features of cardiovascular disease in women. The book consists of 34 chapters organized into 8 sections covering prevention and risk factors, coronary heart disease, noninvasive testing, heart failure and cardiomyopathies, arrhythmias, valvular heart disease, heart disease in pregnancy, and a final segment on largely underrecognized issues in women, including peripheral arterial disease, cardio-oncology, and the current status of evidence-based medicine for the treatment of heart disease in women. Many of the chapters are written by leaders in the field of women’s cardiovascular health who have been instrumental in bringing attention to the sex-specific nature of heart disease pathophysiology and sex disparities that exist in cardiac care.
It would be of great benefit to any practitioner to read this book cover to cover, but unfortunately time often dictates a more abbreviated approach to acquiring new knowledge. The following are particularly noteworthy chapters to be read if time precludes an extensive review of this topic. Chapter 3, by Sanne Peters and colleagues, provides a very well-articulated overview of the current literature on sex differences in conventional cardiovascular risk factors and their association with heart disease and stroke in women and men. Chapters 10 and 11 address the nontraditional, and often overlooked, risk factors of psychosocial stress and autoimmune disease, respectively, which can contribute to the development of cardiovascular disease in women. Dr Nanette Wenger and colleagues author the well-written and very comprehensive chapter on stable ischemic heart disease in women, expertly highlighting the sex-specific differences in treatment. Chapters 18 and 19 provide a thorough review of the literature on noninvasive stress testing in women with clinically relevant and useful guidance that would be an asset to any medical practitioner. The management of women with heart failure is expertly reviewed in Chapter 20 by Dr Ileana Pina and colleagues. This chapter incorporates supporting data from many contemporary trials, both completed and ongoing; however, a noticeable omission was the lack of emphasis on heart failure with preserved ejection fraction that is considerably more prevalent among women than men. Chapter 21 provides an interesting discussion about sex hormones, immunity, and myocarditis, and compliments the following chapter, a well-written overview on Takotsubo Cardiomyopathy. Dr Anne Curtis and Deepika Narasimha eloquently explore the sex-specific differences in cardiac electrophysiology in Chapter 23. Chapter 28 summarizes cardiac hemodynamics during pregnancy and the frequently encountered cardiac conditions in pregnant women including both preexisting and acquired heart disease; however, a discussion on spontaneous coronary artery dissection, a condition with increased incidence in the peripartum period, is noticeably absent. Dr Reema Chugh authored the chapter entitled, “Management of Heart Disease in Pregnancy: A Clinician’s Approach,” which provides extremely helpful clinical recommendations on a multitude of cardiac issues that can arise during pregnancy and emphasizes the importance of a multispecialty team to optimize the health of both mother and child during the peripartum period.
Speculative statements occasionally punctuate the text, but likely reflect the lack of rigorous study data on sex-specific differences in certain areas of cardiovascular disease and treatment. Knowledge of heart disease in women is constantly evolving and data are emerging that female-specific risk factors, such as complications of pregnancy (preeclampsia, gestational diabetes, and pregnancy-induced hypertension), are predictors for the development of heart disease later in life. Greater emphasis on these nontraditional risk factors and a discussion of risk scores for women (eg, Reynolds risk score) would have further complimented the current content. This text was published after the most recent updates to the evidence-based guidelines on the management of hyperlipidemia and high blood pressure in adults (Eighth Joint National Committee). These new guidelines are referenced in Chapter 2, which discusses the prevention of heart disease in women, but unfortunately are not included in the dedicated chapters on Dyslipidemia in Women (Chapter 4) or Hypertension in Women (Chapter 7). Additionally, there is some redundancy, overlap, and, at times, even contradictions in the content, but this text largely reflects our contemporary understanding of heart disease in women and demonstrates that, although much has been learned, knowledge gaps in women’s cardiovascular health still remain and are in need of further study.
The combination of expert contributions to Heart Disease in Women results in an indispensable resource for all medical professionals, but particularly those in cardiology, internal medicine, and obstetrics and gynecology. For the busy practitioner, this text can be used as a single point of reference for a spectrum of women’s cardiac issues ranging from anticoagulation management during pregnancy to the recommended diagnostic strategy for women presenting with suspected ischemic heart disease. The text appropriately emphasizes the importance of cardiovascular prevention in women, and details the current recommendations for sex-specific disease management when such data exist. In addition, the sex disparities that are further pronounced in elderly patients, among minorities, and in women in developing countries are discussed and highlight the need for further study in these particularly vulnerable populations of women.
There is an increasing awareness of the impact and importance of cardiovascular disease in women; however, the sex-specific differences that currently exist are often underappreciated by medical practitioners. Heart Disease in Women effectively details the ways that sex affects the pathophysiology and expression of heart disease and provides useful clinical guidance to improve the management of women with or at risk for heart disease.
Pamela S. Douglas, MD
Melissa A. Daubert, MD
- © 2015 American Heart Association, Inc.