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Q&A: Nieca Goldberg, MD, discusses strategies to encourage CV awareness
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Many women are not aware of their CV risks, and many clinicians are not prioritizing CV health when they treat their female patients. Nieca Goldberg, MD, clinical associate professor, medical director of the Joan H. Tisch Center for Women’s Health and medical director of the Women’s Heart Program at New York University Langone Medical Center, spoke with Cardiology Today about strategies to make progress in these areas.
Question: What do these findings add to the knowledge base?
Answer: Over the last 15 years, there have been an abundance of education and awareness programs by national organizations geared to women and their doctors, yet CVD is still not a top concern for women or their doctors.
Q: Do the findings have any implications for clinical practice?
A: Women mostly see their primary care doctors. They don’t go to specialists. Just 39% of primary care doctors thought CVD was a top concern, and unfortunately a minority of physicians thought they were equipped to take care of the issue. The problem here is that women and their doctors are still unmoved. There seems to be a lack of understanding amongst women about risk for heart disease.
Q: Beyond social stigma and other health concerns, why else don’t clinicians emphasize heart disease as much in women?
A: It doesn’t seem to be a top concern for primary care doctors, who identified breast health and weight gain as more important. A minority of doctors felt well-prepared to assess women’s risk for CVD, and guidelines to help address these issues were used infrequently.
Q: What further research would you like to see done in this area?
A: We need to understand why the guidelines aren’t reaching the doctors who take care of these women every day.
We need to figure out how we can get women more interested in their heart health. Part of the problem is CVD is a multifactorial-risk disease. It just seems like an overwhelming task to do so many things to reduce your risk, and there’s not one screening test. Maybe we need to address this in practice and come up with prepared sets of questions for doctors to ask women about their heart health that are available to them from the electronic health record. We need to educate better about unique risk factors for women.
For instance, risk factors for CVD cross a lot of different areas in health care. We’re noticing a disease that’s more common in women than men, which is autoimmune disease. It can be that the inflammatory nature of the disease increases a woman’s CV risk. Perhaps the rheumatologists will start the discussion on heart disease risk. Having gestational diabetes, hypertension in pregnancy or preeclampsia is a marker that a woman is at increased risk for type 2 diabetes and CVD in midlife. How do we encourage gynecologists to start the conversation with these new mothers in the post-partum office visit?
We need to develop a better tracking system when those things are identified so women get their health care throughout their life and have their risk assessed at each visit. The electronic health record is a valuable tool to track health and risks for disease.
Q: What other clinical changes need to be addressed?
A: Part of our issue is that in clinical practice, doctors don’t spend as much time with patients. The follow-up visit is 15 or 20 minutes. In primary care, maybe there’s not time to counsel the patient on diet and exercise. Again, the electronic health record can be used to download health information to the after-visit summary or transmit the information through the secure patient portal.
Regarding doctors not using guidelines, maybe the guidelines need to be better written so that they address the needs of doctors who are in clinical practice, because most of the guidelines are written by academic physicians that may not spend as much time in practice as the doctors who are actually taking care of these women.
Q: What else should clinicians be doing?
A: It’s very important when you see a patient that you spend time to get a history when a woman comes in with symptoms. Make sure that you ask for all symptoms, not the typical symptoms, but some of the symptoms that are less typical, but more common in women, like shortness of breath and unexplained fatigue. Use open-ended questions. When you say, ‘Do you have chest discomfort?’ ask them to describe the symptom, because cardiac chest pain really feels like a tightness or pressure. If you say chest pain, the patient may say no. Women need to know it doesn’t matter where in the chest it is, it could be the heart. Some people wait at home because it wasn’t on the left side of their chest.
It would be very valuable for the organizations to consider relooking at how they’re reaching out to women. They need to make their recommendations and awareness programs not only valuable to women over 50 years of age, but also to younger women. – by Darlene Dobkowski
Disclosure: Goldberg reports no relevant financial disclosures.