The Mounting Crisis in Women’s Heart Health

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Cardiovascular disease (CVD) continues to be misdiagnosed and undertreated in women. Physicians are more likely to assign a lower CVD risk to women compared with their risk-matched male counterparts and underestimate the probability of heart disease. Gender-balanced research is lacking, and sparse implementation of prevention guidelines has resulted in less aggressive intervention for women with CVD and lagging survival rates.

In 2014, researchers from the Women’s Heart Alliance, a collaboration between Barbra Streisand Women’s Heart Center at Cedars-Sinai and Ronald O. Perelman Heart Institute at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, surveyed 1,011 women and collected data from 200 primary care physicians and 100 cardiologists. The findings sounded alarm bells.

Only 40 percent of women reported having a heart health assessment in their annual wellness exams. Of the 74 percent of women who had at least one risk factor for heart disease, just 16 percent were told by their doctor that they were at risk. “It is crucial that primary care providers know that cardiovascular disease is the number 1 risk of death for women and that they discuss this with their female patients,” says Jennifer Haythe, MD,  cardiologist and chair of the annual Heart Disease & Women Summit. “In addition, better education in medical school, nursing school, and residency with a focus on gender discrepancies will help raise awareness.”

Teaching patients to advocate for their own heart health via awareness campaigns is starting to make an impact, but there is much more work to be done on the side of health care professionals. The percentage of women in clinical trials is less than in the disease population, and 75 percent fail to report gender-specific results. The omission leaves physicians unprepared to recognize the differences in clinical presentation of CVD and unaware of gender-specific risks. Only 22 percent of primary care physicians and 42 percent of cardiologists surveyed felt well prepared to assess cardiovascular disease in women.

Nearly half of heart attacks among women do not present with the “typical” symptoms seen in men. Dr. Haythe says “chest pain and pressure are still the main signs of cardiovascular distress for both genders. Yet more women commonly report atypical symptoms of indigestion, nausea, pain that radiates across the back or the entire chest, dizziness, malaise, and shortness of breath.”

Physiological differences are a factor—women’s hearts are two-thirds the size of men's and often have smaller arteries and faster heart rates—but two stages in a woman’s life heighten risk: pregnancy and menopause. “All women should be seen by their primary care provider once a year and begin to have evaluation of cardiac risk factors annually starting at age 18.”

For a woman seeking hormone replacement therapy (HRT) during or after menopause, prescription should only come after cardiac assessment. “HRT is a viable option for women with no cardiac risk factors, but it should be started earlier, not when women are well into their 60’s and 70’s,” says Dr. Haythe.

In addition to established CVD risk factors of hypertension, hyperlipidemia, diabetes, smoking, and obesity, conditions specific to women, like preeclampsia, eclampsia, gestational diabetes, and early onset menopause increase the risk of cardiovascular disease in the future. New studies show early labor and vascular complications during delivery are linked to increased risk of CVD later on in life, yet few younger women are informed of their risks beyond the immediate dangers.

While more research is needed to determine cause, primary care physicians, obstetrician/gynecologists and cardiologists can do a lot to improve the health of women through prevention education and assessment of cardiovascular risks. “Our symposiums focus on the point-of-care contact of OB-GYNs and their patients, and how CV risk can be assessed effectively,” says Dr. Haythe.

Mortality from CVD has been declining overall, with the exception of an increase in death in women under 55 years of age. CVD and stroke are the leading causes of maternal death, and hypertensive disorders in pregnancy have increased 73 percent since 1993. Women of color are disproportionately affected. Pregnancy-related hypertensive disorders are 60 percent more common in black women, and black women are 4 times more likely to die in childbirth in the U.S. than white women.

The confusion among health care providers about risk assessment and treatment of cardiovascular disease in women must be addressed. In that same survey by researchers at Women’s Heart Alliance, guidelines for cardiovascular risk assessment were fully implemented by only 16 percent of primary care physicians and 22 percent of cardiologists.

“We’re working very hard to change all this, says Dr. Haythe. “The key is education, for doctors and patients.”

Columbia’s Heart Disease & Women Summit reviews the most current evidence-based guidelines for prevention of heart disease in women, and provides a clear road map for physicians to use in their daily care of women in general and obstetric practices.

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