Sex Disparities in Prevention of Atherosclerotic Cardiovascular Disease Across the Life Course

Cardiovascular disease is the leading cause of death for both men and women worldwide.¹ Yet, heart disease in women is underrecognized and under-treated across the spectrum of atherosclerotic cardiovascular disease (ASCVD) – from primordial prevention to high-risk secondary prevention. To dismantle the source of these disparities, a life course approach that incorporates consideration of social determinants of health should serve as the framework for interventions (Figure 1). Each stage in the life course is a unique opportunity to intervene to prevent ASCVD and promote cardiovascular health.

Figure 1.

Life course approach to cardiovascular disease prevention in women. Abbreviations: ASCVD, atherosclerotic cardiovascular disease.

Intersectionality describes the various identities that an individual may have that can intersect to compound and reinforce health disparities. For example, a woman from a historically marginalized racial or ethnic group may experience increased risk of ASCVD and adverse outcomes based on the complex interplay of gender, race, and ethnicity. While hypertension is an important risk factor for ASCVD in women, the prevalence of hypertension exceeds 50% among Black women.¹ Young Hispanic women also have high rates of obesity, diabetes, and metabolic syndrome, and these vary by acculturation and country of origin.² Intersectionality should be front of mind when tailoring interventions to improve ASCVD prevention for women and suggests that a one-size-fits all approach is unlikely to be successful across the populations in most need.

Atherosclerosis is an insidious process that begins early in the life course,³ yet ASCVD prevention efforts are rarely started early enough. For example, sex-based disparities in physical activity are prevalent among adolescents and young adults with females reporting much lower rates of physical activity as compared with their male counterparts.⁴ Many young women are unaware of their cardiovascular risk, despite ongoing evidence that young women (particularly Black and Hispanic women) have a high prevalence of ASCVD risk factors. Women also experience less accurate and timely treatment when they experience cardiovascular events and higher in-hospital mortality for acute myocardial infarction. Even with a diagnosis of established ASCVD, women are less likely to receive guideline-directed treatments such as high-intensity statins or referral to cardiac rehabilitation.^1,5

Female-specific cardiovascular risk factors are underrecognized and represent unique opportunities for enhanced ASCVD screening and implementation of intensive prevention strategies. For example, adverse pregnancy outcomes (APOs) such as pre-eclampsia, gestational hypertension, and intrauterine growth restriction occur in an estimated 10-20% of pregnancies and can increase the risk of future ASCVD by up to 4-fold.¹ Early menarche, premature menopause, polycystic ovarian syndrome, and fertility treatments are associated with increased cardiovascular risk. Women are also more likely to have autoimmune disease as compared with men, a risk enhancing factor for ASCVD. Since women remain underrepresented in guideline-informing clinical trials and practice statements, there are few sex-specific recommendations for the prevention and management of ASCVD in women.

There are many potential explanations for the longstanding and persistent disparities in the prevention of ASCVD for women. First, since women on average are diagnosed with heart disease later than men, younger women are unaware of how early behaviors can impact cardiovascular health later in life. Second, women are often the primary caretakers of dependent family members such as children and older adults. As caretakers, women may fail to prioritize their own health over the family needs. Third, targeted ASCVD prevention efforts for women are lacking in research, clinical, and community settings.

What are potential solutions to reduce ASCVD risk for women? Ideally, these efforts begin early in life, consider female-specific risk factors across the life course, and largely take place outside of the healthcare system. Primordial prevention should start in utero by ensuring that mothers experience healthy pregnancies and that adverse childhood experiences are reduced through structural and community-based interventions. The focus should shift from sick, episodic hospital care to health promotion as part of the daily environments in which women live, work, and play. Efforts to improve health in women should not only target living longer, but also need to foster approaches to healthy aging free from morbidity and disability. The American Heart Association has recently outlined a new framework (Life’s Essential 8)³ that focuses on defining and optimizing cardiovascular health through the adoption of 8 simple health components: diet, physical activity, nicotine exposure, sleep, body mass index, blood lipids, and blood glucose. This framework also recognizes that cardiovascular health cannot exist without addressing psychological well-being and social determinants of health.

Healthcare systems should leverage existing infrastructures to harness the power of the electronic health records and data to opportunistically identify women who are at high risk of ASCVD (e.g., those with APOs seen in obstetrics practices) and to identify gaps in guideline-directed treatment (e.g., statins for secondary prevention). Digital health tools can be used to reduce the participation burden for women in ASCVD prevention clinical trials and preventive cardiovascular care. These efforts should be intentional in keeping technology accessible for women across diverse sociodemographic backgrounds and lower health literacy levels to avoid inadvertently widening health disparities. It is paramount that women, including pregnant women, are included in cardiovascular clinical trials to ensure that therapies and approaches to ASCVD prevention are equally efficacious and safe for women.

While women’s heart centers may optimally address ASCVD prevention for women, such programs are not widespread. To scale preventive efforts, partnerships with other healthcare professionals and systems that may be more likely to encounter high-risk women and their families are needed. This includes obstetrics and gynecology professionals, primary care physicians, pediatricians, and institutions such as schools and workplaces. Virtual care models may increase access to preventive cardiology programs and group visits to leverage social support networks, including across diverse race, ethnic, and primary language groups. Not everyone has the same opportunity to be healthy, the underlying factors in the built environment that impede healthy choices must be identified and targeted.

In conclusion, disparities in ASCVD prevention for women begin early in life and disproportionately affect historically marginalized communities. Interventions to reduce these inequities cannot start early enough and should move upstream from the healthcare system to address structural barriers to make cardiovascular health the default choice.