Cardiovascular Disease: The Female Heart Is Vulnerable

Abstract

February was Heart Month. Clinical Cardiology has embraced the opportunity to share with clinicians and scientists the major adverse impact of cardiovascular disease in women, identifying actionable items derived from recent research studies and highlighting gaps in our knowledge that require investigation. © 2012 Wiley Periodicals, Inc.

The invited expert clinician/scientists in this issue of Clinical Cardiology, Drs. Noel Bairey Merz, Pamela Ouyang, Leslee Shaw, and Nanette Wenger, are members of the Society for Women's Health Research, Interdisciplinary Studies In Sex‐differences (ISIS) Network on Cardiovascular Disease.

The author has no funding, financial relationships, or conflicts of interest to disclose.

It is well known that cardiovascular disease is the leading cause of mortality for women in the United States, claiming more women's lives annually than the next 7 causes of mortality (including cancer deaths) combined.1 It is noteworthy that since 2000, cardiovascular mortality among women has decreased even more abruptly than for men. This has been attributed both to increased application of preventive strategies and to improved therapies for established cardiovascular disease, including secondary prevention. But warning signs of a reversal of this favorable trend loom on the horizon. The cardiovascular mortality rate for younger women (age 35–54 years) is increasing, likely a reflection of our national epidemic of obesity and sedentary lifestyle, and an increased occurrence of diabetes, hypertension, and the metabolic syndrome.2 Despite the enhanced awareness of cardiovascular risk among women due to widespread educational campaigns,3 with awareness increasing from 30% in 1997 to 54% in 2009 surveys, almost half of US women currently fail to recognize cardiovascular disease as their major health problem and fail to partner with their healthcare providers to adopt heart‐healthy lifestyles.

Emerging research data highlight compelling evidence of sex/gender differences in the basic biology, pathophysiology, preventive strategies, diagnostic procedures, medical and interventional therapies, and clinical outcomes of cardiovascular problems.4 Recognition of these differences requires communication of this information to women and their healthcare providers, enabling translation of such differences into clinical practice.

Much remains to be ascertained to appropriately inform clinical care. A 2003 systematic review of research regarding the diagnosis and treatment of coronary heart disease in women concluded that most contemporary recommendations for the prevention, diagnostic testing, and medical and surgical treatments of coronary heart disease in women are extrapolated from studies conducted predominantly in middle‐aged men.5, 6 This has resulted in fundamental unanswered questions regarding the biology, clinical manifestations, and optimal management strategies for women.

The 10Q Report,7 published in 2011 by WomenHeart, the National Coalition for Women with Heart Disease, and the Society for Women's Health Research is a consensus document by leading cardiovascular experts and represents a call to action. It is emphasized therein that underrepresentation of women in trials of cardiovascular clinical procedures and therapies, and when enrolled, inadequate provision of gender‐specific analyses, limit the ability to define the specific benefits and risks experienced by women. The 10Q Report displays the following prominent evidence gaps regarding the causation, prevention, recognition, and management of cardiovascular disease in women:

• What factors influence or explain disparities in cardiovascular disease epidemiology and disease outcomes between men and women?

• What are the best strategies to assess, modify, and prevent a woman's risk of heart disease?

• What are the most accurate and effective approaches to assess and recognize chest pain and other symptoms suggesting coronary heart disease in women?

• What role does a woman's reproductive history and menopausal hormone therapy play in the development of heart disease?

• What are the risk factors for cardiovascular disorders associated with pregnancy and how are they best treated?

• What is the best method for studying sex differences in vascular injury so that cardiovascular repair therapies may be improved?

• What are the most effective treatments for diastolic heart failure (heart failure with preserved pumping function of the heart) in women?

• Why are young women more likely than men to die after a heart attack or after surgical revascularization procedure?

• How do psychosocial factors affect cardiovascular disease in women?

• What biological variables are most influential in the development and clinical outcomes of heart disease and what can be done to reduce mortality rates in women?

As cited in the 10Q Report, the population of US women is far from monolithic, with prominent disparities in awareness, access to information and care, application of evidence‐based therapies, and consequent adverse outcomes among subpopulations of women who are socially disadvantaged owing to race or ethnicity, income level or educational attainment, medical literacy, and/or cultural issues. Population subgroups have disparities in cardiovascular health, underscoring the need for heightened preventive efforts in these subpopulations of women.

Lack of awareness of coronary heart disease as a health threat is persistently most prominent among the highest risk subpopulations, African American (38%) and Mexican American (42%) women. This compares with the white respondents to a survey, with 62% of white women having some degree of awareness of cardiovascular disease as their leading cause of death.

The 10Q Report thus focuses and underscores challenges to science, public policy, and education that require concerted responses by healthcare providers, research scientists, members of the US Congress, administration officials, and women and their families.

The scholarly manuscripts by invited expert clinicians/scientists in this issue of Clinical Cardiology explore several of the topics highlighted in the 10Q Report.