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Women and CVD: Assessing sex-specific risk factors can personalize management, treatment
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SAN ANTONIO — At the American Society for Preventive Cardiology Congress on CVD Prevention, Martha Gulati, MD, MS, FACC, FAHA, emphasized the importance of considering sex-specific risk factors for CVD, especially when assessing women who may not present with the same CV symptoms as men.
Differences in mortality, care
While reductions in CVD-related death were observed among men in the 1980s and 1990s, this decrease was not observed in women until about 2001, which was the same year that the Women’s Health Initiative results were released, the American Heart Association’s Go Red for Women movement started and CVD prevention guidelines geared towards women were published, Gulati, who is division chief of cardiology at the University of Arizona College of Medicine – Phoenix , physician executive director for the Banner University Medicine Heart Institute and editor in chief of the ACC’s CardioSmart, said during a presentation here. Since 2001, women had lower rates of CVD mortality compared with men, although this has changed in the last 2 years, with an observed increase in CVD mortality among both women and men.
“We’ll be continuing to watch this, but specifically in younger populations, [which] might be driving this up because that’s where we’re seeing higher mortality,” Gulati said.
Despite various important guidelines and updates that have been published over the years, some physicians do not follow the recommendations equally in women and men, she said. Referencing data from the AHA’s Get With the Guidelines database, women who presented with MI were less likely to receive aspirin or beta-blockers within 24 hours, less likely to undergo any invasive procedure and less likely to meet door-to-balloon or door-to-needle times compared with men who presented with MI. Moreover, data from 2008 and 2018 showed women were more likely to die, especially those presenting with STEMI.
‘Atypical’ symptoms present challenge
One challenge, she said, is that women often present with atypical symptoms of CVD compared with men, Gulati said. Although they may present with more symptoms, women generally often have less obstructive disease than men, she said.
“That term ‘atypical’ has really been translated to mean it’s not heart disease, rather than a different way of presenting,” Gulati said.
In the previously presented VIRGO trial, researchers reported that women were more likely to present with three or more symptoms in addition to chest pain compared with men.
As physicians, “maybe we’re sometimes asking the wrong questions to women or we’re not necessarily listening to them,” Gulati said.
Moreover, when asked, women have said they believed their symptoms were related to anxiety, she said. In VIRGO, women were more likely to have delays in care, but among those who saw a physician before STEMI, many physicians did not attribute their symptoms to CVD.
Another challenge is that “there is a difference even in our perception of women being at risk for heart disease,” Gulati said.
She also noted similar bias in witnessed cardiac arrest, during which men are more likely to be resuscitated, defibrillated and recover compared with women, according to available data, which may be associated with a general fear of touching women or removing their clothing for resuscitation, she said.
Awareness of s ex-specific risk factors
It is important for physicians to consider sex-specific risk factors for CVD in women, such as gestational diabetes, gestational hypertension and pregnancy-related outcomes. However, the ASCVD risk calculator does not take these sex-specific risk factors into account, Gulati said. The most-recent prevention guidelines address these as risk enhancers in women.
Other sex-specific risk factors that should be addressed include pregnancy history and menopause, both of which can increase risk for CVD, she said.
“I do consider pregnancy certainly a time that tells us a lot about a woman’s future cardiovascular risk. Pregnancy is nature’s free stress test to the woman. We can really identify in women that maybe we should be more proactive and more preventative at an earlier stage in their life,” Gulati said.
Breast cancer is another risk factor for CVD. Available evidence has shown that the presence of BRCA1 and BRCA2 genes can increase CVD risk in women.
“We do need to be talking to [women] after the treatment of breast cancer to address risk for cardiovascular disease,” Gulati said.
Another group that warrants increased attention is female veterans, who often have traditional and nontraditional CVD risk factors such as depression and homelessness, according to Gulati.
“[Female veterans are] a group that we need more research on,” Gulati said. “There are a several different trials, including the WARRIOR trial, that are looking at this veteran population specifically for cardiovascular risk, because we do have more women veterans now in service.”
When assessing female patients, Gulati said her approach is to “use the ASCVD risk score to assess risk. I sometimes use the MESA risk score if they have a coronary calcium score, but then I take an inventory of the sex-specific risk factors and female-predominant conditions as well. That’s how I personalize it. No genetics for me at this point because if we’re not even asking the sex-specific things, I don’t need a fancy test. These are things that we can just simply do and simply ask in our women population.” – by Darlene Dobkowski
Reference:
Gulati M. Nanette Wenger Lecture: Women and Cardiovascular Disease: Is There Really a Sex Difference? Presented at: American Society for Preventive Cardiology Congress on CVD Prevention; July 19-21, 2019; San Antonio.
Disclosure: Gulati reports no relevant financial disclosures.