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Continued focus, greater education may increase awareness of women’s heart health
Women are often underdiagnosed and undertreated for CVD, although heart disease remains the No. 1 risk factor for mortality in the United States. Awareness of heart health is increasing on several levels, but more work must be done to bring this risk factor to the forefront of care for women.
In honor of National Wear Red Day, Cardiology Today spoke with Editorial Board Member Margo B. Minissian, PhD, ACNP, FAHA, a research scientist, clinical lipid specialist and cardiology nurse practitioner at the Barbra Streisand Women’s Heart Center, part of the Smidt Heart Institute at Cedars-Sinai, about the importance of increased awareness of CVD in women.
Question: Why is awareness of women’s heart health so important?
Answer: Awareness is critically important because most women today currently identify their No. 1 risk hazard as breast cancer. Most women in the community are unfamiliar with the idea that heart disease is their leading killer.
There are several initiatives to increase awareness among women. The NHLBI has put together The Heart Truth campaign, for example. This year’s theme from the NHLBI is “Our Hearts Are Healthier Together.” Instead of competitively comparing the risks of heart disease vs. breast cancer, we should think of utilizing the success story of reduced breast cancer mortality as a pathway for us, for women, and heart disease research and outreach to emulate the fundraising, the health policy and the research. The breast cancer field is about 30 years ahead of us. We admire their success and look to further emulate their accomplishments. We continue to push forward to increase awareness among women in the community as well as our legislators.
Q: Why is CVD underrecognized and undertreated in women?
A: Women present differently than men — and their heart disease looks very different. Many times, women with heart disease are difficult to diagnose. Two of the leading symptoms for a woman who is experiencing ischemia are excessive fatigue and shortness of breath. Many women have a difficult time discerning these atypical types of symptoms as opposed to chest pain, which is the primary symptom that many men experience when they are experiencing ischemia-related cardiac symptoms.
Q: The National Wear Red Day campaign is now in its 16 th year. How have initiatives such as this increase d CVD awareness in women? What more needs to be done to increase awareness?
A: The NHLBI has been working to try and increase this outreach. The NIH Heart Truth Red Dress fashion show has been a successful awareness event which includes partnering with Macy’s. These initiatives are examples of creative ideas to increase awareness that CVD is the primary risk in women.
We need to get health care professionals and nonprofit organizations reinvigorated about this topic. We need to increase funding in this area so we can increase data to help provide insight into this area, which is another reason why our CVD reduction rates don’t look as good as we’d like.
Another barrier may be the stigma of heart disease. There are a lot of misnomers, like “I am on medication to treat my high BP, so I don’t have high BP anymore.” I had a female patient this week say, “I had bypass surgery, so my heart is fixed. I don’t have heart disease anymore.” It is hard to believe, but many stigmas and misnomers remain, despite our best efforts. The ultimate goal is to shed light and bring clarity. We do this through research and we do this through outreach, but there also needs to be an increase in support for health policy and an advocacy component.
Q: Once diagnosed, should women be treated differently than men?
A: In many instances, no, they deserve the same care as men. In a recent study (Greenwood BN, et al. Proc Natl Acad Sci U S A. 2018;doi:10.1073/pnas.1800097115), women who went into the emergency room had better outcomes if they were cared for by a female ER physician compared with a male physician. If the male physicians were working alongside female physicians, the women also had better outcomes.
It has to do with equal treatment in certain regards and then personalized medicine for other aspects. It has more to do with having the same ability to have the same access to the same drugs, to have the same access to excellent care and then the personalized medicine comes in with the diagnosis piece and with the treatment piece. For example, we know that if medications are going to have side effects, they typically tend to have more side effects among women than men.
Bernadine Healy, MD, first female director of the NIH, was responsible for increasing the number of women who were required for clinical trials. For many years, women were not a part of clinical trials, so many of the medications that we use today have not been studied in women.
Q: What factors are specific to women that increase their risk for CVD ?
A: The new prevention and lipid guidelines (Grundy SM, et al. Circulation. 2018;doi:10.1161/CIR.0000000000000625) detail a list of risk enhancers. We were happy to see that the guidelines mentioned women who have hypoestrogenemia and those who have an adverse pregnancy outcome, specifically preeclampsia. There are other risk enhancers on that list, and preeclampsia was added, which was wonderful. If you are a woman who has an adverse pregnancy outcome or if you are a woman who goes into menopause too early, you are at increased risk for heart disease. In addition, women who have experienced chemotherapy or radiation due to breast cancer are also at increased risk for heart disease.
There are all certain biases that present challenges. In some cases, women have high BP in the office and are then disregarded by their doctor because they may be fit or thin or look otherwise healthy. Then there are some biases about the way that their BP or cholesterol can be treated in women. The goal is to remove these biases for cardiac risk factors.
Q: What advice should clinicians give their women patients about C V D risk?
A: Women should know their numbers just as men do. They should know what their cholesterol is, what their BP is and they should insist that their physician complete an atherosclerotic CVD risk score on them because the ASCVD risk score is validated in women as well as men, which is great.
If they have a person in their family who has died young from heart disease — for men, younger than 50 years and for women, younger than 60 years — they should strongly consider further risk evaluation with a coronary calcium score looking to see if they have one of those variables such as hypoestrogenemia or a prior adverse pregnancy outcome. Then they can consider coronary calcium scoring or statin treatment.
Q: What additional information can be helpful in identifying women at high risk for C H D ?
A: Women need to keep talking about it. We need to talk to our mothers and talk to our grandmothers and make sure that they understand our families’ pregnancy history. In particular, ask their mothers if they delivered with high BP or if they had babies early. Then, of course, ask them if they have had cholesterol or BP. A lot of what we can find out about ourselves for the future, we have signals coming from the past. It is really helping women inform themselves as well as the other women in their family of these prior health histories. – by Darlene Dobkowski
For more information:
Margo B. Minissian, PhD, ACNP, FAHA, can be reached at margo.minissian@cshs.org; Twitter: @minissianm.
Disclosure: Minissian reports no relevant financial disclosures.