Gaps in understanding about how cardiovascular disease affects women are putting lives at risk, say experts, who have called for greater action and investment to improve access, quality and equity in women’s heart health.
In a presidential advisory issued by the American Heart Association, leading heart doctors argued that women continued to be underrepresented in research for cardiovascular disease – the number one killer of women in the US and UK – and that greater emphasis needed to be placed on prevention and education. They suggested heart health programmes should begin as early as primary school, to engage girls and empower families to take greater control over their health.
“We are losing ground on key indicators of cardiovascular health among women, including blood pressure control, weight management and diabetes,” said Dr Véronique Roger, the advisory committee’s corresponding author and a senior investigator at the National Heart, Lung, and Blood Institute in Bethesda, Maryland.
According to research funded by the British Heart Foundation, more than 8,000 women died between 2002 and 2013 in England and Wales because they did not receive the same standard of care as men. Inequalities at every stage lead to women being diagnosed late and not getting the prompt treatment and aftercare they need to survive a heart attack.
Roger added there needed to be a cultural shift in how cardiovascular data was presented in research studies, if health equity for women was to be achieved.
“Comparing data from women with data from men inherently positions data from men as the gold standard,” said Roger. “For example, the belief that women having a heart attack will present more often with atypical symptoms carries an undertone that women present in the ‘wrong way’.”
Instead, researchers should focus on recruiting more women to clinical trials, and analyse their data in a more objective way, she said.
The advisory, which was published in the journal Circulation, outlined a roadmap divided into four key areas requiring attention and investment: epidemiology and prevention; awareness; access and delivery of equitable health care; and involvement of health care professionals, researchers and communities.
In particular, women and their doctors should be educated about certain female-specific factors that increase the risk of heart disease, such as starting menstruating before the age of 11; early menopause (before age 40); hormone imbalances that result in irregular ovulation, eg polycystic ovary syndrome (PCOS), or having unpredictable cycles.
Other risk factors include suffering from inflammatory and autoimmune disorders, such as lupus, rheumatoid arthritis and scleroderma, or depression and anxiety – all of which women are disproportionately affected by – and risks related to oral contraceptive use and hormone replacement therapy, or treatment for various cancers that are more prevalent in women, such as breast, uterine or ovarian cancer, some of which may harm the heart.
Of particular concern is heart health among women considering pregnancy, where high blood pressure or diabetes could increase the risk of pre-term delivery, or delivering a baby that is significantly above or below the average birthweight, with potential long-term consequences for that child’s health.
“We recommend cardiologists, primary care physicians and obstetricians and gynaecologists work together to quantify and reduce the risks of cardiovascular disease throughout a woman’s life. These interdisciplinary partnerships are crucial to developing and implementing the best approaches that will yield improvements in women’s overall health,” said Nanette Wenger, an emeritus professor of medicine at Emory University School of Medicine, who chaired the advisory group.
“We need to help women develop a ‘lifetime approach’ to their health, where they are empowered to proactively manage their heart disease risk in every life stage.”
Prof Sir Nilesh Samani, the medical director at the British Heart Foundation, said: “Women are disadvantaged at so many stages in their heart journey – they are underdiagnosed, undertreated and underrepresented in research. There’s now an urgent need for more research to close this health gap in cardiovascular diseases seen in women across the UK and globally.
“It’s vital that we tackle the fundamental problems – to understand sex-specific risk factors for cardiovascular diseases, to improve participation of women in clinical trials so the evidence generated is equally applicable to them, and to guard against the unconscious biases which lead to women with heart disease receiving worse care than men.”
Helen Wilson, the head of research at Heart Research UK, said: “We are in complete agreement with the American Heart Association that research into women’s heart health needs more investment to reduce the number of women living with and dying from cardiovascular disease, and to improve their chances of surviving a heart attack.”
