COMMENTARY

Why Women's Cardiovascular Health Needs More Attention

Mamas A. Mamas, BM, BCh, MA, DPhil, FRCP.

Disclosures

February 12, 2019

Hi. Welcome to Medscape UK. My name is Mamas Mamas. I'm professor of cardiology at Keele University and today's focus is going to be around women's cardiovascular health.

February is women's cardiovascular health month. And we know that cardiovascular disease is the number one cause of death in women. Up to 40% of all premature deaths in women before the age of 75 are due to cardiovascular disease, and women are twice as likely to die from cardiovascular disease than they are from breast cancer.

Despite this fact, we know that women's heart disease is often under-recognised, and even if it is, women are less likely to receive evidence-based treatments or receive them in a timely manner. As a result of this the American Heart Association has instituted the Go Red for Women initiative in February and this is what we're celebrating today by drawing awareness to women's cardiovascular health. In this endeavour, I'm helped by some of my friends and close research collaborators who are leading lights in women's cardiovascular health.

In the United Kingdom, over half a million women are living with the after effects of a heart attack. We know that women's cardiovascular care following the heart attack is suboptimal. Dr Purvi Parwani from Loma Linda University in the United States will help us understand why.

Dr Purvi Parwani

Hi, my name is Dr Purvi Parwani and I'm a cardiologist at Loma Linda University Health in Loma Linda, California. Happy Heart Month to all of you. Today I'm going to discuss acute coronary syndrome in women with all of you. Annually around 400,000 women die of cardiovascular disease worldwide. The outcome of women with MI are poorer than in men. So there are significant differences that exist between the two genders in respect to acute myocardial infarction. While the most common presenting symptom of an MI in both the genders is chest pain, women tend to exhibit more atypical symptoms like fatigue, shortness of breath, nausea, dizziness, neck pain, back pain. And part of the reason why this is is because of proposed alternative ACS mechanisms in women, like coronary plaque rupture that is more commonly seen with both genders. But in addition plaque erosion, spontaneous coronary artery dissection, women tend to have normal coronary arteries in spite of having an MI, the subgroup that is known as MINOCA or MI with non-obstructive coronary arteries.

Now, when women present to emergency room, they present later, they are sicker and they are older, they're less likely to get a coronary angiogram and guideline directed medical therapy as well as cardiac rehabilitation. And unfortunately, even when they receive the treatment they are less adherent to the treatment.

Because of all these reasons, the mortality in women in hospital as well as at 1 year is poorer, especially in young woman. They also have poorer mental health. For all these reasons what I'm telling you is women are under-recognised, they are dying more and they are receiving less treatment compared to men. And due to this the presentation of women in clinical trials is of utmost importance.

So what we need is more research, more public health engagement so that we can develop more personalised and specialised primary and secondary prevention models for these women that are at risk of developing acute coronary syndrome. Thank you.

Suboptimal Experiences

Mamas Mamas: Women who experience cardiovascular disease will often seek medical attention and their experiences are often suboptimal.

Here's Erin Michos, professor of cardiology at Johns Hopkins University, to discuss some of her research and to greater understand why this may be the case.

Dr Erin Michos

Hi, I'm Erin Michos. I'm a cardiologist at Johns Hopkins School of Medicine, and I want to thank Dr Mamas and Medscape for having this special Go Red for Women issue. I wanted to talk about one of my recent publications led by Dr Victor Okunrintemi that was published in the Journal of American Heart Association . We used nationally representative data to study 23 million adults living with cardiovascular disease in the United States, 11 million of these were women. And using survey data, we found that 1 in 4 women reported dissatisfaction with their healthcare experience. And in adjusted analysis, even after we took into account age and other comorbidities, we found that women were 25% more likely to report poor communication with their providers. They were 23% more likely to report that their doctor never, or only sometimes, listened to them. And they were 36% more likely to report that their doctors didn't spend enough time with them. And that was patient reported data but we also looked at objective measures such as aspirin and statin use, which should be recommended because this was secondary prevention. And we found that women had lower odds of being on those medications and more likely to have utilised the emergency department. So in other words, women patients weren't getting the same level of care as men, and they feel that way too. So more research is needed to understand these disparities in healthcare communication so that we can ultimately improve outcomes for our women patients. Thank you.

Age & Pregnancy

Mamas Mamas: The increased risk of cardiovascular disease in women may start at a much younger age. We know that certain high-risk pregnancies are associated with increased cardiovascular risk. Dr Martha Gulati, a best-selling author in women's cardiovascular health, and division chief of cardiology at the University of Arizona will tell us why.

Dr Martha Gulati

Happy Heart Month everyone. I am Dr Martha Gulati from the University of Arizona in Phoenix. Of course, in this month, we think about cardiovascular disease in women and some of the things that affect women happened during pregnancy. Things like hypertension during pregnancy, including but not limited to pre-eclampsia or eclampsia, gestational diabetes, and even having a baby early. Particularly having a baby before 37 weeks of gestation. But the risk for cardiovascular disease is even greater if you have a child before 32 weeks gestation. The importance of these risk factors keeps being shown again, again in population models. But the one thing is, is that often these issues resolve after pregnancy. So often our patients will have hypertension during pregnancy, and then it resolves. Same with diabetes, it resolves. And no one talks to our female patients about their future cardiovascular risk. And even when we look at our traditional risk scores, even those don't really include these pregnancy-specific risk factors, which makes it not always a conversation we have. It doesn't always enter into their medical records. So for that reason, we really need to be screening for these adverse pregnancy outcomes when they occur, informing them about their cardiovascular risk. We've also created some videos here at University of Arizona called Heart to Heart and you can use those as resources to educate your patients. Again, knowing that their risk factors is important. The new guidelines have actually called them risk-enhancing factors, and it's important that we ask our female patients about them, but even better if we address them early and address their overall cardiovascular risk.

Inequalities 

Mamas Mamas: The inequalities in the receipt of care of women's cardiovascular health is striking. What can we do about this? Dr Gina Lundberg, director of the Emory Women's Heart Center tells us about the importance of specific institutions that look after women's cardiovascular health and how they can improve outcomes and reduce inequalities

Dr Gina Lundberg

Hello. I'm Gina Lundberg. I'm associate professor of medicine at Emory University and the clinical director of the Emory Women's Heart Center. I'm excited to celebrate Heart Month 2019 with you and talk to you a little bit about women's heart centres, and what we have developed, and what we have accomplished. Woman's heart centres began starting in the late 1990s and early 2000s, long before we had the awareness of Go Red For Women. They were really the pioneering starts for raising awareness about heart disease in women, and how more women were dying every year from heart disease than men. They became the centre for support groups and groups that rallied behind the need for increased funding for education and research in women. And then they advanced to centres of education for training women about sex-specific problems in women with heart disease and launching education for further training. They've also been a focus for research specific to women and have been a strong force behind getting research to always include data on women.

Now, heart centres for women are important for education as well as future research. But in pointing out where we still have gaps and needs in women's care. One thing that we've learned along the way is that women who've had breast cancer have higher risk of cardiovascular disease. And also women with rheumatological disorders, such as rheumatoid arthritis and lupus. Women with HIV have more heart disease. And for some reason, heart disease deaths have not decreased in our young women in America as much as they have in the older women. They're still high-risk groups that need our attention, need research and funding. And the women's heart centres serve as a consolidating point for this awareness, this research, and this future education. I think it's important to continue to have women's heart centres, but we need to extend them to include more male physicians and male providers, and include the primary care women for women, the OBGYNs, the family practice, and even some alternative healthcare physicians.

We need to expand to have a broad base of care for women and we need to be interconnected with other departments in our universities and our healthcare systems. I think there's still an important need for women's heart centres, but I think we've accomplished a lot and I'm very excited about February Heart Month 2019.

Risk Factor Profile

Mamas Mamas: Women often have a worse cardiovascular risk factor profile the men, and this is often under recognised. Dr Annabel Volgman, professor of medicine at the Rush Medical Center in Chicago, will help us understand why.

Dr Annabel Volgman

Cardiovascular disease remains the number one killer of women. This year marks the 15th anniversary of the American Heart Association Go Red For Women campaign, which has led to more research in women.

Women not only present differently compared to men, but women tend to have different forms of heart disease. Some women have microvascular disease instead of obstructive coronary artery disease. This can be seen in women who have positive stress tests, but no obstructive coronary artery disease. Unfortunately, women are told that this is benign and that they had a false positive stress test. Women can be misled and not treated appropriately. They should be treated with medication such as aspirin and statins as well as referred to cardiac rehab which can decrease their symptoms.

Women can have heart attacks triggered by emotional events called stress cardiomyopathy - this needs to be recognised and treated appropriately. Women who have congestive heart failure tend to have normal or preserved ejection fraction, referred to as half path. There is no evidence based treatment for this and more research needs to be done to help these patients.

Know Your Numbers

Mamas Mamas: So thank you for joining us on the Go Red For Women special women's cardiovascular health Medscape video. I'd like to sincerely thank my friends, collaborators, and leaders in women's cardiovascular health, for giving their time so freely in raising this very important issue.

Whilst it's been fun, and it is fun, to talk about women's cardiovascular health in February, this is a problem that affects all of us, and it's a problem that should be addressed all year round. I want to leave you with a final thought. Do you know what the blood pressure or the cholesterol is of your loved one? Whether it be your mother, your sister, your partner or your wife? And if not, why not? And if you don't, I would ask that you really encourage them to go and check it out. Because after all, cardiovascular disease is the number one cause of death in women.

You can follow Mamas Mamas on Twitter

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