Heart disease remains the No. 1 cause of death in women: Why?
Key takeaways:
- Wear Red Day is recognized on the first Friday of February each year.
- Major issues in women’s heart health include pregnancy-related risk factors and underrecognition of heart disease symptoms.
February is American Heart Month, a highlight of which is Wear Red Day, which aims to raise awareness about heart disease in women, on the first Friday of the month.
Heart disease is the No. 1 cause of death in women. Many factors unique to women can raise heart disease risk, including pregnancy-related conditions and hormonal changes related to menopause. While efforts have been made to raise awareness of women’s heart health, many challenges persist: symptoms of heart disease in women are underrecognized and underreported and women are underrepresented in cardiology clinical trials and other research, to name a few.
Healio asked experts in women’s heart health to highlight what they think are some of the most urgent issues related to heart disease in women today. Their responses are below, in no particular order.
Editor's note: If you’d like to share your thoughts on the most important issues in women’s heart health, email the editors at cardiology@healio.com .
Gina P. Lundberg, MD, FACC, FAHA
Being a cardiologist who specializes in women with heart disease, I am at the intersection of women’s heart health and reproductive rights. I personally believe that the greatest threat to women’s health today is the legal deprivation of reproductive autonomy.
Women with underlying cardiovascular risk factors face heightened risks during pregnancy. Pregnancy is extremely high-risk for women with some underlying CV conditions. Preeclampsia, gestational diabetes and other pregnancy-related complications can exacerbate heart disease.
Many CV problems are discovered during pregnancy. These complications can lead to serious long-term health risks. When combined with limited reproductive autonomy, the ability to make informed, personal decisions about pregnancy becomes even more critical. The legal barriers that restrict access to abortion or other reproductive health services can leave women in difficult situations where their health is jeopardized. No woman should die of CV complications during a pregnancy when that death could be prevented if she had the option of terminating the pregnancy before she became gravely ill.
Every pregnancy and personal situation are different. Every woman’s values are unique and different depending on her own religious beliefs, cultural and family values, moral compass and personal goals. Shared decision-making is the foundation of a trusting and sacred doctor-patient relationship. Many women are willing to proceed with a high-risk pregnancy because they want a child more than anything else in their lives. But other women express that they need to have a safe pregnancy because they have other children, a spouse or parents who depend on them and love them.
Physicians and cardiologists need to be able to provide appropriate and effective care to every woman before, during and long after pregnancy without interference from the government or judicial system. These decisions should be between the patient and her doctor and no one else.
Lundberg is professor of medicine at Emory University, clinical director of the Emory Women’s Cardiovascular Health Center and a member of the Healio | Cardiology Today Editorial Board.
Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA
I think there are two issues. No. 1 is underrecognition of heart disease in women. That is partially due to the patients and partially due to the clinicians. For patients, how do you know what angina is until you’ve been told you have heart disease or have had a heart attack? We have to do a better job with our public service announcements to let individuals know if they are having any type of discomfort from the belly button up that doesn’t go away — don’t sleep on it, don’t just think that it’s an ulcer or reflux. We would rather reassure you and let you know it was reflux than find out it was a missed heart attack and now you have heart failure. Tied into that, unfortunately, is that some clinicians still do not recognize when a woman is having angina. If the person does not describe crushing chest pain, she could still be having angina because the symptoms are often different in women. Clinicians need to understand what angina looks like in women, and patients need to be able to advocate for themselves and press them on why they think it is not heart disease. When we start to have more of these conversations, we may be able to diagnose heart disease when it’s present before it leads to more drastic diseases like HF.
The No. 2 most pressing issue for women is the under-studying and underfunding of strategies to improve CVD in women. We know that women are less likely to receive appropriate pharmacologic therapy and less likely to receive nonpharmacologic therapy than men across most of the different types of CVD, including HF, ischemic heart disease and arrhythmia disorders. To overcome this barrier, we have to support and fund studies based on strategies to address these concerns. This includes implementation science, community-based research and clinical trials with appropriate representation.
Breathett is associate professor of medicine at Indiana University, advanced heart failure transplant cardiologist with the Advanced Heart Failure, Mechanical Circulatory Support and Cardiac Transplantation Team at Indiana University Health and a member of the Healio | Cardiology Today Editorial Board.
Leslie Cho, MD
One of the most important issues in women’s heart health is diversity of patients in clinical trials. Over the last 20 to 30 years, there has been an increasing effort to have women participants in clinical trials; however, women are still grossly underrepresented.
If you look at things like participation-prevalence ratio, which is the marker that the FDA uses to determine if participation and prevalence of the disease is on par, women continue to be underrepresented for coronary artery disease, coronary intervention and cholesterol trials.
We know for many drugs, women have different pharmacokinetics, different reactions to medications and to devices. So it’s critically important to have women enrolling in clinical trials.
It’s also important to use sex-specific measurements in guidelines. For example, for things like aortic regurgitation and mitral regurgitation, these guidelines have provided recommendations on when to take patients to surgery, but the indication for that has been sex-neutral. Unfortunately, women’s heart sizes are different from men’s heart sizes. There are numerous studies that have shown that if we send patients to surgery based on sizes that are not sex-specific, women have worse clinical outcome such as death, heart failure rehospitalization, etc. So it’s important to incorporate sex-specific measurements in guidelines. Not just size alone, but in other fundamental aspects of platelet biology, there appears to be sex specific differences. Thus, it is crucial to continue to study sex differences in cardiovascular disease.
Cho is director of the Cleveland Clinic’s Women’s Cardiovascular Center.
Sherry-Ann Brown, MD, PhD, FACC, FAHA
There are approximately 18 million cancer survivors in the U.S. Almost 2 million new cancer diagnoses are made every year, and more than 600,000 new cancer deaths occur. Fortunately, with all of the developments and innovation in oncology, there is a rising number of cancer survivors, and in particular breast cancer survivors. Annually, there are about 300,000 new diagnoses of breast cancer, on top of an existing 4 million breast cancer survivors. Heart-related diseases are the leading cause of death among both male and female cancer survivors, and today I want to focus our discussion on women.
We focus on breast cancer in women, because statistically about one in eight women in the U.S. will develop invasive breast cancer over the course of their lifetime. Among women who survive breast cancer, heart disease then becomes the leading cause of death.
A lot of what we know, how we surveil, and what we do when issues occur is evolving, regarding heart-related morbidity and mortality in cancer care, and in breast cancer in particular.
In cardiology clinics throughout the country, the general trend you will see is that the most common cancer with which people come to see us regarding heart care is breast cancer. It is important for us to recognize how crucial this area is for women.
There are various ways in which we can raise awareness, such as this article, webinars and collaborations between academia and communities.
When there is concern for risk of heart problems during breast cancer treatment, there are ways in which we can do baseline risk assessments. Oncologists and cardiologists partner to do those baseline assessments. If the risk is potentially high, there are ways in which we can prevent heart-related problems, whether that’s with medications, more frequent imaging with closer monitoring and so on.
If, unfortunately, issues occur, there are medications we can use to treat the concern, which is typically HF, and there are also guidelines that now exist for how frequently to monitor and how to manage the heart problems that occur.
One of the things to think about is long-term survivorship. For women who have been treated for breast cancer in the past, the risk for heart-related conditions hasn’t necessarily gone away.
Therefore, we can all continue to raise awareness and be vigilant, so that when we are caring for women, we look more carefully at the past medical history to, for example, see whether they have ever had breast cancer, and realize that their risk for heart-related concerns might be higher than for other women.
Brown is preceptor at the Robert Stempel College of Public Health & Social Work at Florida International University and founder of My Heart Spark P.C.
Lili A. Barouch, MD
Women’s CVD is generally undertreated and underreported due to a multitude of factors. One of the major issues is that much of the research studies and even clinical guidelines have focused on symptoms as they appear in men; however, women often have different symptoms compared with men. Women are not just smaller men; there are a lot of things that are different about women’s bodies and women’s heart health. Additionally, there are many aspects of women’s CVD that are unique to women, for example, hormone-related issues around the time of menopause or pregnancy.
Women presenting with CVD also tend to be underdiagnosed or have a delay in diagnosis. This may be due in part to some women’s own tendency to delay seeking medical attention for symptoms they think are not serious, as well as some physicians’ greater likelihood of failing to recognize symptoms as being heart-related because they may be more “atypical” I female patients.
The classic information that is out there for the public has mainly focused on symptoms that are more typical for men. For example, the classic symptoms for a heart attack that most people would recognize are crushing chest pain that radiates to your left arm. This does happen to some women who are having a heart attack, but other women may only experience shortness of breath, arm pain without chest pain, or nausea together with those other symptoms.
There is also underdiagnosis in women of other cardiac diseases such as HF. The signs of HF in women may be misattributed to deconditioning, anxiety or obesity; thus, there is a higher likelihood of women’s symptoms being underrecognized, either by the woman herself or by her doctor.
There are several major hormonal shifts that happen to women throughout their lives that have cardiac implications that are often not fully recognized at that time. During pregnancy, there are massive hormone changes, and conditions that could predict or increase their risk future heart disease can develop. For example, preeclampsia or pregnancy-induced hypertension to name just two. There are also heart diseases that are unique to pregnancy, such as certain types of HF or cardiomyopathy.
Later in life, women who are going through perimenopause begin to have a significant increase in CV risk that only continues to increase after menopause. Hormone changes at that time may change how women’s symptoms present and also result in higher overall cardiac risk.
There is more awareness now about menopausal changes, in terms of both CVD and general health. We, as doctors, generally know that cardiac risk increases after menopause; however, many physicians have not received sufficient education around systemic effects of those hormone changes on other organ systems, particularly the heart and vasculature.
One thing that I want all women to know is that CVD is the No. 1 killer of women. CVD is the number No. 1 killer for both men and women.
Barouch is director of the Sports Cardiology Program and associate professor of medicine at Johns Hopkins University School of Medicine and a member of the Advanced Heart Failure and Cardiac Transplantation group at Johns Hopkins Hospital .
For more information:
Lili A. Barouch, MD, can be reached at barouch@jhmi.edu; X (Twitter): @LiliBarouch.
Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA, can be reached at kbreath@iu.edu; X (Twitter): @KBreathettMD.
Sherry-Ann Brown, MD, PhD, FACC, FAHA, can be reached at drbrowncares@gmail.com; X (Twitter): @drbrowncares.
Leslie Cho, MD, can be reached at chol@ccf.org.
Gina P. Lundberg, MD, FACC, FAHA, can be reached at gina.lundberg@emory.edu; X (Twitter): @gina_lundberg.
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