Women and CVD: Getting to the Heart of the Matter

Cardiovascular disease (CVD), which includes coronary artery disease (CAD), hypertension, stroke, and other CVDs, continues to be the leading cause of mortality among both men and women. For women, however, increasing awareness and understanding of how CVD affects them remains a challenge.

Since 1984, the number of deaths in women related to CVD has exceeded that of men.¹ In 2004, 459,⁰⁹6 women's deaths were caused by CVD, representing 52% of all CVD-related deaths.² It is estimated that 42.¹ million women in the United States are currently living with some form of CVD, and even more are at risk of developing it.² CVD is responsible for an estimated 39% of all female deaths in the United States annually; CAD alone accounts for 250,000 deaths.¹,³

According to statistics from the Centers for Disease Control and Prevention, CAD claimed the lives of 233,886 women in 2003, compared with 41,566 deaths due to breast cancer.³ Furthermore, results from the Framingham Heart Study conducted by the National Heart, Lung, and Blood Institute (NHLBI) showed that more women than men die within 1 year after having an initial myocardial infarction (MI).⁴ An estimated 1 in 8 or 9 women in the United States aged 45 to 64 has clinical evidence of CAD, and this increases to 1 in 3 women older than 65.⁵

Women and CVD: Some Key Findings

• A 2005 study by Hendrix et al reported that more men than women receive a definitive diagnosis of angina
• Persell et al reported in 2005 that women with atherosclerosis and hyperlipidemia receive less aggressive management of cholesterol when compared with men
• Yawn et al reported in 2004 that existing CVD is undiagnosed in more than 50% of women who have an initial MI
• Natarajan et al in 2003 reported that diabetes significantly increases a woman's risk of coronary artery disease
• Pope et al published a 2000 report indicating that women and minorities may have atypical symptoms when experiencing angina or an MI Adapted from references 14-18.

In recent years, efforts among health care professionals have been focused on gaining a more thorough understanding of the differences in the pathophysiology, diagnosis, and treatment of heart disease in women, compared with men, as well as promoting an increased awareness about how CVD affects women.¹ In a 2004 survey published in Circulation, researchers explored whether physicians knew that more women than men die of CVD each year. The results showed that only 17% of cardiologists, 13% of obstetrician/gynecologists, and 8% of primary care physicians were aware of this fact.⁶

A growing trend among women in their awareness of CVD has occurred in recent years, however. A 1997 survey conducted by the American Heart Association (AHA) found that only 30% of women perceived CVD as the leading cause of death among women; in 2003, 46% of women did.⁷ More recently, results from a 2006 AHA survey reveal that 57% of women identified CVD as the leading cause of death among women; however, 21% of women aged 25 to 34 still believe that breast cancer is the leading cause of death.^4,8

Gender Differences

Study results indicate that men with CVD are more likely to be diagnosed and treated earlier than women. Most clinical studies regarding CVD have primarily involved men, whereas women have accounted for <30% of study participants.⁹ In addition, although men and women may present with the typical symptoms associated with an MI, an estimated 20% of women present with atypical or unusual symptoms, such as back pain, a burning sensation in the chest, abdominal discomfort, nausea, and/or fatigue.¹⁰

Kudenchuk et al showed that women tend to delay seeking medical care for cardiac-related symptoms and are less likely to enroll in cardiac rehabilitation, when compared with men.¹¹ The results of the study also found that women were less likely to undergo diagnostic and therapeutic cardiac procedures.¹¹

Statistics show that 42% of women die within 1 year of a first MI, compared with 24% of men.¹² Although the reasons for these differences are not fully understood, on average the first signs of CVD may occur 10 years later in women than in men, and MIs may occur as much as 20 years later in women than in men.^4,5 Some studies suggest no evidence of undertreatment of CVD in women, whereas other studies suggest that age and other comorbidities could be leading factors in the differences in mortality rates.¹²

According to the American Diabetes Association, women with diabetes are 10 times more likely to die from CAD.¹³ In addition, other studies suggest that conditions specific to women (ie, early menopause, gestational diabetes, etc) may pose an increased risk of ischemic heart disease later in life.¹²

Clearly, more research on CVD and women is needed. The NHLBI's Women's Ischemia Syndrome Evaluation (WISE) study has enabled researchers to gain a better understanding of evaluating and diagnosing CVD in women. The WISE study found that an estimated 3 million women in the United States have a condition called coronary microvascular syndrome.¹⁹ This condition encourages plaque to accumulate in very small arteries of the heart, causing narrowing and reduced oxygen flow to the heart. As a result, the plaque does not show up when physicians use diagnostic coronary angiography. The tests reveal that these women have "clear" arteries and no blockages, thus incorrectly classifying them as low-risk. Many of these women are actually high- risk and go untreated.¹⁹

Last year, the AHA updated its Guidelines for Preventing Cardiovascular Disease in Women. The guidelines classify women at various risk levels and provide recommendations for lifestyle modifications and drug therapies appropriate for each level.²⁰

Conclusion

As more research is conducted to learn more about CVD in women, health care professionals should continue their efforts to increase public awareness. Women also should be aware of the signs and symptoms associated with CVD and seek immediate medical attention when needed. Pharmacists can encourage women to discuss their potential cardiovascular risks with their primary health care provider and also to incorporate various lifestyle modifications, such as eating a diet low in fat, maintaining a healthy weight, quitting smoking, and establishing a regular exercise routine when warranted.

To increase awareness about CVD among women, please visit the following Web sites:

• Act in Time to Heart Attack Signs: www.nhlbi.nih.gov/actintime
• American Heart Association: www.americanheart.org
• American Heart Association's Go Red for Women: www.goredforwomen.org
• The Heart Truth: A National Awareness Campaign for Women About Heart Disease: www.hearttruth.gov
• National Heart, Lung, and Blood Institute: www.nhlbi.nih.gov
• National Women's Health Information Center, Office on Women's Health, US Department of Health and Human Services: www.4woman.gov
• US Department of Health and Human Services Agency for Healthcare Research and Quality: www.ahrq.gov/research/womheart.htm
• WomenHeart: The National Coalition for Women with Heart Disease: www.womenheart.org

References

• Wenger NK, Shaw LJ, Vaccarino V. Coronary heart disease in women: update 2008. Clin Pharmacol Ther. 2008;83:37-51.
• Women and Cardiovascular Disease Statistics. American Heart Association Web site. www.americanheart.org/presenter.jhtml?identifier=3000941.
• WISEWOMAN-Well-Integrated Screening and Evaluation for Women Across the Nation. Centers for Disease Control and Prevention Web site. www.cdc.gov/wisewoman/index.htm.
• Heart Disease and Stroke Statistics-2006 Update. Circulation. 2006;113:e85-e151. circ.ahajournals.org/cgi/content/full/113/6/e85.
• Wenger NK. Coronary heart disease: an older woman's major health risk. BMJ. 1997;315:1085-1090.
• Mosca L, Lifante A, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510.
• 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.
• Robertson RM. Women and cardiovascular disease: the risks of misperception and the need for action. Circulation. 2001;103:2318-2320. circ.ahajournals.org/cgi/content/full/103/19/2318.
• Mikhail GW. Coronary heart disease in women. BMJ. 2005;331:467-468.
• Mayes G. Do Gender Differences in Heart Disease Reset the Standard of Care? Medscape Web site. www.medscape.com/viewarticle/500667.
• Nau D, Ellis J. Gender and perceived severity of cardiac disease: evidence that women are "tougher." Amer J Med. 2005;118:1256-1261.
• Anderson RD, Pepine CJ. Gender differences in the treatment for acute myocardial infarction: bias or biology? Circulation. 2007;115:823-826.
• Wexler DJ, Grant RW, Meigs JB, Nathan DM, Cagliero E. Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes. Diabetes Care. 2005;28:514-520.
• Hendrix KH, Mayhan S, Lackland DT, Egan BM. Prevalence, treatment, and control of chest pain syndromes and associated risk factors in hypertensive patients. Am J Hypertens. 2005;18:1026-1032.
• Persell SD, Maviglia S, Bates DW, Ayanian JZ. Ambulatory hypercholesterolemia management in patients with atherosclerosis. Gender and race differences in processes and outcomes. J Gen Intern Med. 2005;20:123-130.
• Yawn BP, Wollan PC, Jacobsen SJ, Fryer GE, Roger VL. Identification of women's coronary heart disease and risk factors prior to first myocardial infarction. J Womens Health. 2004;13:1087-1100.
• Natarajan S, Liao Y, Cao G, Lipsitz SR, McGee DL. Sex differences in risk for coronary heart disease mortality associated with diabetes and established coronary heart disease. Arch Intern Med. 2003;163:1735-1740.
• Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163-1170.
• WISE Study of Women and Heart Disease Yields Important Findings On Frequently Undiagnosed Coronary Syndrome. US National Institutes of Health Web site. www.nhlbi.nih.gov/new/press/06-01-31.htm.
• Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 Update. Circulation. 2007;115:1481-1501.