Women and CVD: Getting to the Heart of the Matter

Ms. Terrie is a clinical pharmacy writerbased in Haymarket, Virginia.

Cardiovascular disease (CVD),which includes coronary arterydisease (CAD), hypertension,stroke, and other CVDs, continues to bethe leading cause of mortality amongboth men and women. For women, however,increasing awareness and understandingof how CVD affects themremains a challenge.

Since 1984, the number of deaths inwomen related to CVD has exceededthat of men.¹ In 2004, 459,⁰⁹6 women'sdeaths were caused by CVD, representing52% of all CVD-related deaths.² It isestimated that 42.¹ million women in theUnited States are currently living withsome form of CVD, and even more are atrisk of developing it.² CVD is responsiblefor an estimated 39% of all female deathsin the United States annually; CAD aloneaccounts for 250,000 deaths.¹,³

According to statistics from the Centersfor Disease Control and Prevention,CAD claimed the lives of 233,886 womenin 2003, compared with 41,566 deathsdue to breast cancer.³ Furthermore,results from the Framingham HeartStudy conducted by the National Heart,Lung, and Blood Institute (NHLBI) showedthat more women than men die within 1year after having an initial myocardialinfarction (MI).⁴ An estimated 1 in 8 or 9women in the United States aged 45 to64 has clinical evidence of CAD, and thisincreases to 1 in 3 women older than 65.⁵

Women and CVD: Some Key Findings

• A 2005 study byHendrix et al reportedthat more menthan women receivea definitive diagnosis ofangina
• Persell et al reported in 2005 thatwomen with atherosclerosis and hyperlipidemiareceive less aggressive managementof cholesterol when comparedwith men
• Yawn et al reported in 2004 that existingCVD is undiagnosed in more than 50% ofwomen who have an initial MI
• Natarajan et al in 2003 reported that diabetessignificantly increases a woman'srisk of coronary artery disease
• Pope et al published a 2000 report indicatingthat women and minorities mayhave atypical symptoms when experiencingangina or an MI

Adapted from references 14-18.

In recent years, efforts among healthcare professionals have been focused ongaining a more thorough understandingof the differences in the pathophysiology,diagnosis, and treatment of heart diseasein women, compared with men, as wellas promoting an increased awarenessabout how CVD affects women.¹ In a2004 survey published in Circulation,researchers explored whether physiciansknew that more women than mendie of CVD each year. The results showedthat only 17% of cardiologists, 13% ofobstetrician/gynecologists, and 8% of primarycare physicians were aware of thisfact.⁶

A growing trend among women intheir awareness of CVD has occurred inrecent years, however. A 1997 surveyconducted by the American HeartAssociation (AHA) found that only 30% ofwomen perceived CVD as the leadingcause of death among women; in 2003,46% of women did.⁷ More recently,results from a 2006 AHA survey revealthat 57% of women identified CVD asthe leading cause of death amongwomen; however, 21% of womenaged 25 to 34 still believe that breastcancer is the leading cause ofdeath.^4,8

Gender Differences

Study results indicate that menwith CVD are more likely to bediagnosed and treated earlierthan women. Most clinicalstudies regarding CVD haveprimarily involved men,whereas women haveaccounted for <30% ofstudy participants.⁹ In addition,although men andwomen may present with thetypical symptoms associatedwith an MI, an estimated 20% ofwomen present with atypical orunusual symptoms, such as back pain,a burning sensation in the chest,abdominal discomfort, nausea, and/orfatigue.¹⁰

Kudenchuk et al showed that womentend to delay seeking medical care forcardiac-related symptoms and are lesslikely to enroll in cardiac rehabilitation,when compared with men.¹¹ The resultsof the study also found that women wereless likely to undergo diagnostic andtherapeutic cardiac procedures.¹¹

Statistics show that 42% of women diewithin 1 year of a first MI, compared with24% of men.¹² Although the reasons forthese differences are not fully understood,on average the first signs of CVDmay occur 10 years later in women thanin men, and MIs may occur as much as20 years later in women than in men.^4,5Some studies suggest no evidence ofundertreatment of CVD in women,whereas other studies suggest that ageand other comorbiditiescould be leadingfactors in the differencesin mortalityrates.¹²

According tothe AmericanDiabetesAssociation, women with diabetes are 10times more likely to die from CAD.¹³ Inaddition, other studies suggest that conditionsspecific to women (ie, earlymenopause, gestational diabetes, etc)may pose an increased risk of ischemicheart disease later in life.¹²

Clearly, more research on CVD andwomen is needed. The NHLBI's Women'sIschemia Syndrome Evaluation (WISE)study has enabled researchers to gain abetter understanding of evaluating anddiagnosing CVD in women. The WISEstudy found that an estimated 3 millionwomen in the United States have a conditioncalled coronary microvascular syndrome.¹⁹ This condition encouragesplaque to accumulate in very small arteriesof the heart, causing narrowing andreduced oxygen flow to the heart. As aresult, the plaque does not show upwhen physicians use diagnostic coronaryangiography. The tests reveal that thesewomen have "clear" arteries and noblockages, thus incorrectly classifyingthem as low-risk. Many of these womenare actually high- risk and go untreated.¹⁹

Last year, the AHA updated itsGuidelines for Preventing CardiovascularDisease in Women. The guidelines classifywomen at various risk levels and providerecommendations for lifestyle modificationsand drug therapies appropriatefor each level.²⁰

Conclusion

As more research is conducted tolearn more about CVD in women, healthcare professionals should continue theirefforts to increase public awareness.Women also should be aware of thesigns and symptoms associated withCVD and seek immediate medical attentionwhen needed. Pharmacists canencourage women to discuss theirpotential cardiovascular risks with theirprimary health care provider and also toincorporate various lifestyle modifications,such as eating a diet low in fat,maintaining a healthy weight, quittingsmoking, and establishing a regular exerciseroutine when warranted.

To increase awareness about CVD among women, pleasevisit the following Web sites:

• Act in Time to Heart Attack Signs: www.nhlbi.nih.gov/actintime
• American Heart Association: www.americanheart.org
• American Heart Association's Go Red for Women: www.goredforwomen.org
• The Heart Truth: A National Awareness Campaign for Women About Heart Disease: www.hearttruth.gov
• National Heart, Lung, and Blood Institute: www.nhlbi.nih.gov
• National Women's Health Information Center, Office on Women's Health, US Department of Health and Human Services: www.4woman.gov
• US Department of Health and Human Services Agency for Healthcare Research and Quality: www.ahrq.gov/research/womheart.htm
• WomenHeart: The National Coalition for Women with Heart Disease: www.womenheart.org

References

• Wenger NK, Shaw LJ, Vaccarino V. Coronary heart disease in women: update 2008. Clin Pharmacol Ther. 2008;83:37-51.
• Women and Cardiovascular Disease Statistics. American Heart Association Web site. www.americanheart.org/presenter.jhtml?identifier=3000941.
• WISEWOMAN-Well-Integrated Screening and Evaluation for Women Across the Nation. Centers for Disease Control and Prevention Web site. www.cdc.gov/wisewoman/index.htm.
• Heart Disease and Stroke Statistics-2006 Update. Circulation. 2006;113:e85-e151. circ.ahajournals.org/cgi/content/full/113/6/e85.
• Wenger NK. Coronary heart disease: an older woman's major health risk. BMJ. 1997;315:1085-1090.
• Mosca L, Lifante A, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510.
• Mosca L, Ferris A, Fabunmi R, Robertson RM. Tracking women's awareness of heart disease: an American Heart Association national study. Circulation. 2004;109:573-579.
• Robertson RM. Women and cardiovascular disease: the risks of misperception and the need for action. Circulation. 2001;103:2318-2320. circ.ahajournals.org/cgi/content/full/103/19/2318.
• Mikhail GW. Coronary heart disease in women. BMJ. 2005;331:467-468.
• Mayes G. Do Gender Differences in Heart Disease Reset the Standard of Care? Medscape Web site. www.medscape.com/viewarticle/500667.
• Nau D, Ellis J. Gender and perceived severity of cardiac disease: evidence that women are "tougher." Amer J Med. 2005;118:1256-1261.
• Anderson RD, Pepine CJ. Gender differences in the treatment for acute myocardial infarction: bias or biology? Circulation. 2007;115:823-826.
• Wexler DJ, Grant RW, Meigs JB, Nathan DM, Cagliero E. Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes. Diabetes Care. 2005;28:514-520.
• Hendrix KH, Mayhan S, Lackland DT, Egan BM. Prevalence, treatment, and control of chest pain syndromes and associated risk factors in hypertensive patients. Am J Hypertens. 2005;18:1026-1032.
• Persell SD, Maviglia S, Bates DW, Ayanian JZ. Ambulatory hypercholesterolemia management in patients with atherosclerosis. Gender and race differences in processes and outcomes. J Gen Intern Med. 2005;20:123-130.
• Yawn BP, Wollan PC, Jacobsen SJ, Fryer GE, Roger VL. Identification of women's coronary heart disease and risk factors prior to first myocardial infarction. J Womens Health. 2004;13:1087-1100.
• Natarajan S, Liao Y, Cao G, Lipsitz SR, McGee DL. Sex differences in risk for coronary heart disease mortality associated with diabetes and established coronary heart disease. Arch Intern Med. 2003;163:1735-1740.
• Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163-1170.
• WISE Study of Women and Heart Disease Yields Important Findings On Frequently Undiagnosed Coronary Syndrome. US National Institutes of Health Web site. www.nhlbi.nih.gov/new/press/06-01-31.htm.
• Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 Update. Circulation. 2007;115:1481-1501.