At Issue: Sex-specific risk factors, disparities among women’s heart health concerns
February is American Heart Month. During this time, with National Wear Red Day on Feb. 5 and other initiatives, the cardiology community focuses on raising awareness of the signs and symptoms of heart disease, especially in women.
Heart disease is the leading cause of death in women. It can be challenging for women to recognize the signs and symptoms of MI and stroke because they can present differently in women than in men.
Heart disease will kill approximately 1 in 3 women. The American Heart Association’s Go Red for Women campaign calls attention to modifiable risk factors that women — and men — can manage such as hypertension, smoking, low physical activity, high cholesterol, diabetes and obesity/overweight.
Healio and Cardiology Today asked leading cardiologists: What is the most important issue in women’s heart health today?
Nivee P. Amin, MD, MPH
Early recognition of CVD in women is key to improving long-term outcomes in women. Several sex-specific factors put women at increased risk for cardiac disease and poorer outcomes. For example, pregnancy-related complications, certain therapies for breast and ovarian cancer and different presentation at time of acute cardiac events contribute to the disparities in women’s heart health. Awareness of these, and other unique factors, will allow providers to appropriately modify treatments and preventive strategies. We have witnessed an increase in awareness of women’s heart health, but we still have work to do in our medical societies and communities to educate, conduct research and unify our treatment approaches.
Racial and socioeconomic disparities exist in cardiac health even among women. Not only do women have poorer outcomes than men with regards to heart disease, women from certain ethnic groups and those with less access to care due to social and economic factors experience disparities in care. We need to build programs to help women understand their risk for disease, support their roles in the economy and at home, and allow women to succeed in their heart health journey. This may mean more social programs, education, and improving convenience of care, such as with telehealth.
We need to raise awareness of these issues in the community and among patients, but also among our colleagues down to the medical school level, so we can start changing the culture to better look for and recognize symptoms and to be more aggressive in treatment. While many strides have been made already, we still have further to go.
Women have been underrepresented in clinical trials and research. I’m thrilled that our center recently became a site for the WARRIOR trial, which is a national, multicenter effort to understand optimal treatment of women with symptomatic nonobstructive coronary disease. There is a lot more we can do to help with morbidity and mortality in these patients, and the trial is assessing certain treatments toward that end. Performing a clinical trial with only women and investigating a condition that affects women more than men is very exciting, and I hope that more trials like WARRIOR are launched to understand disease and treatments in women.
Amin is associate director for consultative cardiology and director of the Women's Heart Program and Preventive Cardiology at Weill Cornell Medicine and NewYork-Presbyterian.
Kim A. Eagle, MD, MACC
No. 1, since CVD kills more women than any other disease category, it is long overdue that we dispel the myth that this is a man’s disease.
No. 2, much of the CVD that we see is preventable if a woman will be proactive in understanding her risk factors to develop heart disease, and work with her caregivers to define her risk. This then leads to a game plan for attacking modifiable risk factors that can lower that risk, including smoking, elevated BP, elevated cholesterol, inactivity, weight excess, sleep apnea, poor nutrition, elevated blood sugar and depression.
No. 3, many women manifest an elevated BP and/or elevated blood sugar during pregnancy. We now know that these findings are associated with a much greater likelihood of developing high BP and diabetes later in life. Therefore, we need to work vigorously with young women who experience these tendencies in order to start down a path toward heart health at the youngest possible age that we can.
No. 4, we know that there are differences in the frequencies of CVDs across the spectrum of women depending on race, socioeconomic status, ethnicity and geographic location. Therefore, it is imperative that both caregivers and women work hand in hand to address how these factors can influence risk, proper evaluation, prevention and treatment. Equally important is the notion that both the family history of CVD and the environment that women reside in may have a profound influence not only on their health, but that of their children and grandchildren. I like to think of the notion that when a woman at risk for or with heart disease is under my care, we are often addressing risk factors and educational lessons that may affect care for her children and grandchildren.
Eagle is director of the Samuel and Jean Frankel Cardiovascular Center, the Albion and Walter Hewitt Professor of Medicine and a professor of health management and policy at the University of Michigan.
Sharonne N. Hayes, MD, FACC, FAHA
Heart disease is the No. 1 women’s health issue, even during the COVID-19 pandemic. But the pandemic and race-related societal events have heightened our awareness of the need to recommit to addressing not only gender disparities, but also racial and ethnic disparities in women’s heart health.
We need to take a step back to address the systems of inequity and oppression that led us here. The rates of risk factors — especially hypertension, diabetes and obesity — and maternal CV complications are substantially higher in Black women and Native American women than in white women.
As much as we don’t know enough about heart disease in women, we have even less information about heart disease in Black, Native American and Hispanic women. We have to build up the science. That is going to require those of us in health care to build some cultural competence and increase funding so we can include these populations in studies in adequate numbers. We need to build trust among members of those communities, and increase partnerships via community-based participatory research. To be successful, it means confronting past wrongs that have led to this lack of trust, and increasing the diversity of our health care workforce, particularly those who care for women.
As part of this effort, we must realize that race is not a risk factor for heart disease. It isn’t race, it is racism. Race is a social construct. It is the structural systems of society that are the problem. Black women do not choose to live in poor neighborhoods or eat unhealthy food. Often that happens because of generations of not being able to access appropriate food or to live in safe, walkable neighborhoods. These are issues we in CV health care need to sit with a bit and do our part to address.
Hayes is professor of cardiovascular medicine, former director of the Office of Diversity and Inclusion and founder of the Women’s Heart Clinic at Mayo Clinic College of Medicine.
Nandita Scott, MD
The most important issue in women’s heart health today is our rising maternal mortality, for which CVD is a leading cause. Despite the riches of our country, a pregnant woman in the U.S. is more likely to die than any other industrialized nation. There are many contributing factors to this problem, including older age at pregnancy — thus more underlying chronic conditions — and a rise in multifetal gestations, which pose a greater hemodynamic burden. Additionally, due to advances in care, women with congenital heart disease or those with preexisting structural heart disease may be well enough to consider pregnancy. Further challenges include lack of access to care; inconsistent care quality; variable access to birth control, preventing a pregnancy to be well planned; and medical conditions to be optimized preconception.
Most cardiologists have typically not received training on the management of pregnant women, but are increasingly being asked to care for them. Maternal mortality also demonstrates significant racial disparities, as Black women are at greater risk for dying than their white counterparts, with similar mortality rates to women in Cuba.
Fortunately, this issue has been gaining attention nationally and cardiologists and obstetricians are now working hand in hand to solve this problem. As a team, we can find solutions to address disparities in care, create national protocols to standardize care and increase awareness and education. Ongoing research efforts in this field will also help inform us on best practices for these women moving forward.
Scott is co-director of the Corrigan Women's Heart Health Program and director of the Cardiovascular Medicine Section at Massachusetts General Hospital.
Poulina Uddin, MD
It is well documented that heart disease in women is both underrecognized as well as undertreated due to a number of factors, and that overall mortality of women exceeds that of men treated for similar conditions.
The data used to treat women comes largely from randomized controlled trials comprised largely of white men, and in most instances, women comprise less than 30% of the studied population in clinical trials. The disparity is even greater when women with varying ethnic and racial backgrounds are considered, and importantly, when looking at differing socioeconomic levels.
It is well known that in addition to common risk factors for heart disease such as obesity, dyslipidemia, hypertension, smoking, diabetes and family history, other emerging risk factors can play a significant role. Importantly, women with a history of breast cancer and subsequent radiation and chemotherapy are at extremely high risk for CV disorders, as are women with functional menopause, highlighting the need for further attention on the role and influence of hormonal factors in the development of CVD.
Women also are more prone to vascular complications resulting from hormonal shifts during pregnancy, with substantially increased risk for MI, stroke and HF during pregnancy and the peripartum period. Women with complications during pregnancy, such as preeclampsia, gestational diabetes and preterm labor, appear to be more affected by chronic inflammatory conditions associated with new emerging risk factors for CVD, which significantly increase downstream risk for CVD.
During times like these, with the continuation of the COVID-19 pandemic, it’s especially important that we do our best to take care of our health, both in terms of primary and secondary prevention. We continue to see more evidence that people with underlying health conditions tend to do worse once infected with the coronavirus and can have increasing complications down the road.
Uddin is a cardiologist at Scripps Women’s Heart Center, Scripps Clinic.
Helga van Herle, MD, MS, MHA, FACC
The most important issue in women’s heart health today remains the prevention of heart disease in women, along with the recognition of and appropriate management to treat underlying heart disease in women. The cornerstones to promote heart health in women need to be education and empowerment, not only of women themselves, but of all providers of health care for women, not only cardiologists.
Pregnancy may provide an opportunity for health care providers to guide women toward a heart healthy lifestyle that may benefit them in the long term. Data from the American Heart Association’s Heart Disease and Stroke Statistics — 2021 Update (Virani S, et al. Circulation. 2021;doi:10.1161/CIR.0000000000000950), highlight the impact that adverse complications of pregnancy (preeclampsia, gestational diabetes and gestational hypertension) can have on long-term maternal CV health, as well as maternal mortality during pregnancy. For example, CV is the most common cause of maternal death (28.5%); women who develop hypertension during pregnancy have a 67% greater risk for developing CVD later in life; and preeclampsia during pregnancy is associated with a 75% greater risk for death from CVD. The odds of CVD in women with gestational diabetes is 68% compared with women without gestational diabetes. The incidence of BP-related complications in pregnancy has doubled between 1993 and 2014.
These findings suggest that health care providers should pay close attention to a woman’s CV health during pregnancy and use this as an opportunity to promote heart-healthy habits and lifestyle for the future, as well as educating and empowering their patients to advocate for their heart health beyond their childbearing years.
Van Herle is a cardiologist with Keck Medicine of USC and associate professor of clinical medicine in the division of cardiovascular medicine at the Keck School of Medicine at the University of Southern California.
Janet Wei, MD, FACC, FAHA
Despite significant reductions in CV mortality and continued advances in CV therapies in the past 3 decades, CV mortality has been increasing in women since 2010. This troubling trend is seen in young women younger than 55 years, who are at a particularly high risk for mortality after acute MI.
Studies have suggested that increased prevalence of obesity and diabetes may be contributing to this increasing mortality, but sex-specific biological mechanisms and psychosocial stressors also influence the CV mortality risk in women. For example, typical plaque rupture is responsible for only about half of women with fatal MI, with higher prevalence of plaque erosion, spontaneous coronary artery dissection and vasospasm in young women compared with men. In addition, CVD remains the leading cause of maternal death in the United States. We need to improve CVD risk assessment and CVD recognition in women throughout their lifecycle, from prepregnancy to peripartum to perimenopause to postmenopause.
In 2020, the ACC CVD in Women Committee published updated recommendations for primary prevention of CVD in women, highlighting sex-related risk factors to be included in routine CV risk assessment of women. This was a great step beyond the identification of sex-specific risk enhancers recommended by the 2019 ACC/AHA Guideline on the Primary Prevention of CVD.
Wei is assistant professor at Smidt Heart Institute, Cedars-Sinai.
For more information:
Nivee P. Amin, MD, MPH, can be reached at email@example.com.
Kim A. Eagle, MD, MACC, can be reached at firstname.lastname@example.org.
Sharonne N. Hayes, MD, FACC, FAHA, can be reached at email@example.com.
Nandita Scott, MD, can be reached at firstname.lastname@example.org.
Poulina Uddin, MD, can be reached at Scripps Clinic La Jolla, 9898 Genesee Ave., Floor No. 4, La Jolla, CA 92037.
Helga van Herle, MD, MS, MHA, FACC, can be reached at email@example.com.
Janet Wei, MD, FACC, FAHA, can be reached at firstname.lastname@example.org.