At Issue: Early risk identification, addressing disparities key for women’s heart health
February is American Heart Month, and Feb. 7 is National Wear Red Day, an American Heart Association initiative that aims to raise awareness of heart disease as the leading cause of death for 1 in 3 American women and to serve as a catalyst to improve the health of women across the globe.
The Go Red for Women movement also encourages women to manage modifiable risk factors such as high BP, smoking, high cholesterol, physical activity, diabetes and obesity or overweight, and to increase awareness of the signs and symptoms of MI and stroke, which are often different from those for men.
Numerous challenges remain, however. Healio and Cardiology Today asked leading cardiologists: What is the most important issue in women’s heart health today? – reporting by Scott Buzby, Darlene Dobkowski and Erik Swain
Nieca Goldberg, MD
The most important women’s health issue is heart health. Although awareness has increased amongst women that heart disease is the leading cause of death, many women do not recognize the symptoms of MI. Recent statistics from the AHA show that only 25% of women are considered to be physically active by current guidelines.
Over the last several years, conditions such as preeclampsia, gestational diabetes and autoimmune disease have been found to increase MI risk. These conditions affect young women and put them at risk for heart disease at midlife. If we add them to our traditional risk factor assessment, we can reach many more women who should be monitored for early signs of heart disease and development risk factors and prevention efforts. Since these conditions span many women’s health specialties, it is an opportunity to connect providers and researchers on preventing heart disease in women of all ages.
It is also important to develop culturally appropriate awareness programs so we can reach women of all cultural and ethnic groups.
Goldberg is clinical associate professor of medicine, medical director of the Joan H. Tisch Center for Women’s Health and medical director of the Women’s Heart Program at NYU Langone Health.
Eileen Hsich, MD
According to the AHA Heart Disease and Stroke Statistics 2020 Update, there are 60 million women over the age of 19 years living in the United States with CHD, HF, stroke and hypertension. Based on the most recent statistics, this has resulted in more than 400,000 annual deaths and over $126 billion in health care costs for women alone. CV mortality has risen since 2010 for both women and men despite a decline in hospitalizations, and poses a greater mortality risk in women (418,665 annual deaths in 2017) than cancer (283,961 deaths), diabetes (37,262 deaths) or accidents (60,214 deaths).
To reduce CV mortality in women, we need prompt recognition of symptoms by patients and medical providers, as well as focused research. Achievements in 2019 include more than 880 articles published regarding sex differences in heart disease and conferences on Capitol Hill to review the past to improve the future. For instance, Congresswoman Katherine Clark (D-Massachusetts) sponsored a conference in 2019 on Capitol Hill called Women’s Inclusion in CV Research From the Framingham Heart Study to Today, with presentations from WomenHeart, a patient advocacy group for women with heart disease; NHLBI Director Gary H. Gibbons, MD, and Chief of Staff Nakela L. Cook, MD, MPH; and Marjorie Jenkins, MD, MEdHP, FACP, director of medical initiatives and scientific engagement in the FDA’s Office of Women’s Health. Initiatives like this raise awareness at a federal level, highlight efforts to improve health care and provide hope for the future.
As a cardiologist, researcher, mother of two young girls and participant in patient advocacy groups such as WomenHeart, I am aware that we depend on the progress of this generation to improve our health.
Hsich is director of the Women’s Heart Failure Clinic and associate medical director for the Heart Transplant Program at Cleveland Clinic.
Gina Lundberg, MD
CV health in women has made great progress in the last 2 decades. Today, women are more able to identify CV risk factors as well as symptoms of MI. Promoting February as American Heart Month and Wear Red Day and Go Red for Women have all increased general public awareness of CVD in American women. CV deaths in women have dropped from more than 500,000 to under 400,000 annually. But not all women have benefited the same with these improvements.
African American women and other nonwhite women are not seeing the same health equity compared to white women. Disparities in health equity is the single most important issue facing women’s heart health today. All women need access to affordable health care, but there is more to health care hurdles than access. Women have time constraints, job constraints, childcare issues and other nonmedical obstacles that prevent health equity for all women. Health equity must include personal and culturally appropriate education, diversity in the CV care team, flexible appointments and locations that are convenient. Medical education must embrace sex-specific differences in research, diagnostic testing and personalized treatments. And medical education must set guidelines for including health equity in the strategic plans for a more diverse and healthy future.
Lundberg is clinical director of the Emory Women’s Heart Center and associate professor of medicine at Emory University School of Medicine.
Margo Minissian, PhD, ACNP
In my opinion, the lack of early recognition and identification of women who are at increased risk for heart disease is the most important issue today. Once heart disease is identified, we have excellent treatment options, innovative procedures and medications that work and outcomes to prove it. However, none of this can be implemented if a woman does not know she has heart disease, and she certainly cannot begin to prevent it if she is not aware she’s at increased risk. So, what can be done to help this problem?
The answer is to identify women at increased risk earlier in the life course prior to disease setting in. The earlier, the better. Eighty-seven percent of women will become pregnant in the United States. As cardiac output and blood volume increase during gestation, systemic vascular resistance drops, causing decreases in vascular stiffness and vasodilation, reaching nadir in the second to early third trimester. At the time of delivery, arterial stiffness increases as cardiac output and blood volume decrease to maintain homeostasis. This physiologic phenomenon replicates what occurs to our CV system during an exercise treadmill stress test. Essentially this is “Mother Nature’s first stress test” and it can tell us a lot about a woman’s heart health. Adverse pregnancy outcomes, specifically placental disorders including term preeclampsia, spontaneous preterm delivery and preterm preeclampsia have been associated with later development of maternal atherosclerotic CVD. These women have increased risks for ASCVD reported to be 1.6-fold, twofold and eightfold, respectively. These data suggest that level of future ASCVD risk is associated with the type of adverse pregnancy outcome.
The ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease was presented at the American College of Cardiology Scientific Session in March 2019. Risk-enhancing factors were included to help further define women who are potentially at increased risk, and history of preeclampsia is now identified as a risk factor for women. This is a great first step in the right direction.
Minissian is a nurse scientist, cardiology nurse practitioner and clinical lipid specialist at the Barbra Streisand Women’s Heart Center at the Cedars-Sinai Heart Institute. She is also a member of the Cardiology Today Editorial Board.
Clyde W. Yancy, MD, MSc
Nothing is more important in women’s heart health than empowerment. Empowerment to know your risks, enablement to modify your lifestyle and that of your loved ones and the engagement to adopt proactive interventions. We should no longer deal with women’s heart health as an ancillary issue, even an afterthought; we have allowed gender disparities in CVD to persist; the time for change is now. Women’s heart health is central in our cause to reduce the burden of heart disease, prolong life and amplify quality of life.
I have been struck by the indomitable force of women to make change happen. But it begins with empowerment. I hope that we all “Go Red” for Women this month and that today, Feb. 7, 2020, we especially dress the part and more importantly embrace the relentless force that empowered women represent.
Yancy is vice dean of diversity and inclusion, Magerstadt Professor of Medicine, professor of medical social sciences and chief of the division of cardiology at Northwestern University Feinberg School of Medicine; associate director of Bluhm Cardiovascular Institute at Northwestern Memorial Hospital; and past president of the AHA.
For more information:
Eileen Hsich, MD, can be reached at Cleveland Clinic, Mail Code J3-4, 9500 Euclid Ave., Cleveland, OH 44195; email: email@example.com; Twitter: @dr_eileen_hsich.
Gina Lundberg, MD, can be reached at 137 Johnson Ferry Road, Suite 1200, Marietta, GA 30068; email: firstname.lastname@example.org; Twitter: @gina_lundberg.
Margo Minissian, PhD, ACNP, can be reached at 127 S. San Vicente Blvd., Advanced Health Sciences Pavilion, Third Floor, A3600, Los Angeles, CA 90048; email: email@example.com; @minissianm.
Clyde W. Yancy, MD, MSc, can be reached at 676 N. St. Clair, Suite 600, Chicago, IL 60611; email: firstname.lastname@example.org; Twitter: @nmhheartdoc.
Disclosures: Goldberg reports she received honoraria from Bristol-Myers Squibb. Hsich, Lundberg and Yancy report no relevant financial disclosures. Minissian reports she consults for Amgen and received research funding from the NIH.