Cardiovascular disease in women

Cardiovascular disease in women
Illustration of coronary artery disease comparing a healthy artery to an artery with atherosclerosis
SpecialtyCardiology
SymptomsChest pain, shortness of breath, nausea, fatigue
Risk factorsTraditional: age, smoking, obesity, hypertension, dyslipidemia, diabetes mellitus; Unique: pregnancy-related syndromes, polycystic ovarian syndrome, autoimmune diseases, premature menopause, depression
Frequency47.8 million (US, 2014)][1]
Deaths8.5 million (worldwide, 2015)[2]

Cardiovascular disease in women is an integral area of research in the ongoing studies of women's health. Cardiovascular disease (CVD) is an umbrella term for a wide range of diseases affecting the heart and blood vessels, including but not limited to, coronary artery disease (CAD), stroke, cardiomyopathy, and aortic aneurysms.[3]

Since the mid-1980s, CVD has been the leading cause of death in women despite being presumed to be a male-specific disease. The risks of CVD were unaccounted for in women due to gender biases, under-representation in clinical trials, and lack of research.[4]

In 1985, the Women’s Health magazine released a report outlining the research gap existing in women’s health. Various institutions and research centers launched initiatives to remedy this. The Take Wellness to Heart campaign (1997) and the Go Red For Women campaign (2004) initiated by the American Heart Association (AHA) acted as notable breakthroughs to build awareness along with outlining guidelines and risk assessment tools.[5]

Women may experience symptoms classically associated with CVD such as chest pain and shortness of breath, but many continue to misidentify the cause of symptoms. Women also experience atypical symptoms such as nausea, fatigue, headaches, and palpitations.[6]

While women have an increased risk of CVD with traditionally associated risk factors such as age, hypertension, smoking, diabetes mellitus, and dyslipidemia, they are also at risk of developing CVD with exposure to unique conditions such as pregnancy-associated disorders, polycystic ovarian syndrome, and certain autoimmune diseases.[7][8]

With increasing awareness, there has been a decline in CVD-related deaths worldwide, but in areas such as the United States and Europe, women continue to make up a greater proportion of deaths from CVD when compared to men. In 2015, over 8.5 million women died from CVD worldwide with CVD-related deaths more common in older populations.[9][10]

History

In the 1980s, women’s health, especially women's heart health, did not account for much research. Despite developing heart disease later in life compared to men, women faced more severe prognoses after surgery.

Institutions such as the National Institutes of Health (NIH) lacked policies on including women in clinical trials. Significant trials on women were approved by the NIH. For example, the Physician's Health Study (1981) studied the effects of aspirin, particularly to reduce the prevalence of myocardial infarction. However, due to the lack of research, its effects on women were unaccounted for.

Food and Drug Administration (FDA) policy prohibited the inclusion of women in both childbearing years and those outside these ages in advanced drug trials. This was done to address concerns of birth defects among infants and changes in estrogen and progesterone in postmenopausal women. Between 1988 and 1991, only 50% of the data analysis from trials that were not designed for women, accounted for the difference in gender. It was assumed that the drugs given to men would work if prescribed to women.[11]

Studies such as the Western Collaborative Group Study (report issued 1975), the Los Angeles Heart Study (published 1964), and the Pooling Project 5 (report issued 1978) included a small population of women in their research but published reports and data of only white males. The Pooling Project 5 consisted of three studies with only males and two with females. These studies showed signs of the high risks women face with CAD but no progress in terms of the treatment course.

The Tecumseh and Framingham studies along with the Rochester Coronary Heart Disease Project were longitudinal studies that included women and provided notable results. In the 1960s, it was reported that hypertension, high cholesterol, and obesity were key risk factors of CAD in women. Reports from the Coronary Artery Surgery Study suggested that chest pain was not an effective indicator of congenital heart disease (CHD) for women.[11]

Awareness of CVD and related heart diseases among women increased from 1997 to 2000. According to a survey conducted by AHA in 2000,[12] women are now more aware of the leading cause of death in women than they were in 1997. Close to 90% of women are now aware that women experience heart disease symptoms gradually in later years and that the initial hours of treatment are critical to reducing damage to the brain and heart. They are also aware of the possibility of resultant strokes.

However, due to infrequent exposure to the concerns and a deficit of personalization, CVD awareness is still lacking among women, especially in the age groups of 25 to 34 years. Nearly 72% of women in this age group consider cancer to be the leading cause of death; however, as age increases, the understanding of heart diseases has also been shown to increase. Women from different ethnicities have also become more aware of their health and related issues. In the 1980s, African American women had double the mortality rates compared to other women between the ages 30 to 39.[11] More recently, about 42% of black women are now more aware through discussions with their doctors of the risks of heart disease or stroke, compared to 34% white women and 32% Hispanic women.

A national survey conducted by AHA in 2012, suggested increased rates of awareness and consciousness. According to the fifteen-year trend report, some of the significant changes are as follows:[13]

  • In 2012 the level of awareness increased in women from different ethnicities with percentages rising up to 65% white, 36% black, and 34% Hispanic.
  • In terms of knowledge of the symptoms of heart attack, 18% of women responded with nausea, while 56% responded with chest pain.
  • In case of experiencing a heart attack, 10% of Hispanic women were reported to initially take aspirin, compared to 22% black and 18% white women.
  • The top 3 health management issues were reported to be exercise (by 49% of women), weight (by 47%), and cholesterol (by 45%).

Analysis of data suggests further improvement in the educational efforts and awareness among women, especially of racial and ethnic minorities, as they face higher mortality rates.

In 2014, provisions created under the Affordable Care Act (ACA) enabled 4.3 million women to have medical coverage by law and close to 48.5 million women to have access and benefits of preventive care, with companies charging women the same premiums as men. The Act also requires Medicare and private health plans to provide preventive care coverage.[5]

Symptoms

CVD is the leading cause of death in American women. Over the years, while death rates have decreased in men, women continue to misidentify the underlying cause of their symptoms. Gender plays a role in the atypical symptoms experienced by the individual. Women do not always experience the same symptoms as men (for example, sharp shooting pains along the left arm). Symptoms of CVD (including heart disease and stroke) in women include:[6]

  1. Pain in chest, shoulders, neck, and arms
  2. Shortness of breath
  3. Nausea and Dizziness
  4. Headaches and fatigue
  5. Sudden and random sweating
  6. Palpitations and faster heartbeats
  7. Numbness and extreme weakness
  8. Sudden loss of vision[12]

Some common symptoms of angina (inaccurately assumed to be heartburn or indigestion) include tightness, pressure, burning.

Risk factors

Traditional risk factors

A number of traditional risk factors for cardiovascular disease have been identified. Age is a non-modifiable risk factor, and the risk of developing cardiovascular disease increases in postmenopausal women due to a reduction in estrogen levels.[7] Modifiable risk factors include smoking, obesity, hypertension, dyslipidemia, and diabetes mellitus.

Smoking

Women smokers face up to a 25% increased risk of developing CAD compared to their male counterparts, with studies showing that reduction in smoking decreased the incidence of CAD in women by 13%.[7]

Obesity

Women make up about 40% of obese adults over the age of 20. Postmenopausal women are more likely to experience fat redistribution to the abdomen and develop metabolic syndrome, resulting in increased susceptibility to obesity.[7]

Hypertension

Estrogen can contribute to maintaining optimal blood pressure in premenopausal women. Consequently, hypertension is frequently seen in older women, especially in black and Hispanic women when compared to white women.[7]Additionally, the prevalence of certain disorders such as fibromuscular dysplasia is increased in premenopausal women and can lead to secondary hypertension. Oral contraceptive use may also be associated with an increase in blood pressure, particularly in individuals already diagnosed with hypertension.[8]

Dyslipidemia

Over 40% of women in the United States have elevated total cholesterol levels, with 30% having elevated LDL levels and 10% of women having low HDL levels. Elevated total cholesterol, elevated LDL, and low HDL have all been implicated in increased CVD risk. Despite the risk of cardiovascular disease, women are less likely to receive appropriate treatment for dyslipidemia.[7]

Diabetes Mellitus

Women with type I diabetes were found to be twice as likely to experience adverse cardiovascular events when compared to men with the same disease and were less likely to receive aggressive treatment to control modifiable risk factors.[7]Women with Type II diabetes are at greater risk than men with the same condition despite similar glycemic control.[14]Studies show an increased risk of cardiovascular disease including myocardial infarction in premenopausal women with diabetes when compared to women without diabetes.[8]

Unique risk factors

In addition to traditional risk factors that contribute to the likelihood of developing cardiovascular disease, women experience additional unique risk factors such as hypertensive diseases of pregnancy, gestational diabetes, and certain autoimmune conditions.

Hypertensive disease of pregnancy

Hypertensive disorders can be seen in 10% of pregnancies, and preeclampsia has been recognized as a risk factor for developing hypertension after pregnancy.[7] Additionally, preeclampsia increases the post-pregnancy risk of ischemic heart disease, stroke, heart failure, and overall mortality.[8]

Gestational diabetes mellitus

Women diagnosed with gestational diabetes are at an increased risk of developing traditional risk factors for CVD such as type 2 diabetes mellitus, and hypertension.[8] Moreover, women diagnosed with gestational diabetes remain at higher risk of developing type 2 diabetes mellitus and cardiovascular disease despite blood sugar metabolism returning to normal post-pregnancy.[7]

Other pregnancy-associated conditions

Women who deliver prior to 37 weeks gestation are at increased risk of developing CVD, with additional risk depending on the number and timing of preterm births. Intrauterine growth restriction (IUGR) in prior pregnancies is associated with an increase in maternal CVD risk. Prior pregnancy loss, including miscarriage and stillbirth, also contributed to a two-fold increase in risk of maternal CVD.[8]

Autoimmune diseases

Certain autoimmune conditions such as rheumatoid arthritis (RA) and systemic lupus erythematous (SLE) are significantly more likely to occur in women. Some populations of women are also more likely to be affected than others. For example, SLE is two to four times more prevalent in black women when compared to white women.[8] Studies have shown that women with SLE are at least nine times more likely to experience a myocardial infarction when compared to the general population, with some estimates showing a 50-fold increase in risk. Similarly, RA increases the risk of death from CVD by 50%.[7][8]

Premature menopause

Menopause is associated with a decrease in estrogen production, and estrogen is thought to be cardioprotective. Premature menopause is defined as menopause prior to the age of 40. Early menopause is correlated with increased CVD risk, although the relationship between the two is complex, and it is unclear whether women experience menopause earlier if they are already at increased risk for CVD.[8]

Polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is an endocrine disorder prevalent in young women that is classically associated with irregular menstruation, androgen excess, and infertility. It is unclear whether PCOS is associated with an increased risk of developing CVD. However, PCOS is associated with multiple traditional risk factors of CVD such as diabetes, obesity, dyslipidemia, and hypertension.[8]

Depression

Women are twice as likely to have depression when compared to men. Studies have shown that women with depression are at greater risk of developing CVD when compared to peers without depression. Depression has also been associated with smoking, a traditional risk factor for CVD.[7]

Prevention

Depending on the risks associated based on age, type of disease, prognosis, pregnancy or menopausal stages, the following primary preventions can be prescribed to women under the guidance and proper consultation with their healthcare provider.[15][8]

Epidemiology

CVD remains the most common cause of death for women, with approximately one-third of deaths worldwide attributed to CVD.[16] In 2015, approximately 8.5 million women died from the disease.[9]

In the United States, approximately 47.8 million women over the age of 20 were diagnosed with CVD between 2011 and 2014, and data from 2015 shows over 400,000 deaths due to CVD in women.[1] While overall deaths from CVD are falling, the decline is slower in women, particular black women.[17] The death rate for women with CVD surpasses that of men from CVD.[18] In Europe, over half of the deaths in women are attributed to CVD.[19] The death rate in some Eastern European countries is high, with over 500 deaths per 100,000 population attributed to CVD. Studies predict that in certain developing countries in Asia and Africa, women will account for a greater percentage of deaths related to CVD by 2040.[10]

Cardiovascular disease is more prevalent in older populations. On average, women develop CVD approximately 10 years after their male counterparts.[18] In the United States, approximately 6% of women over 20 have coronary heart disease.[20] The highest prevalence of CVD is present in adults over the age of 80, and women and men have similar rates of disease after the age of 60.[1]

References

  1. 1 2 3 Benjamin, Emelia J.; Virani, Salim S.; Callaway, Clifton W.; Chamberlain, Alanna M.; Chang, Alexander R.; Cheng, Susan; Chiuve, Stephanie E.; Cushman, Mary; Delling, Francesca N.; Deo, Rajat; de Ferranti, Sarah D. (2018-03-20). "Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association". Circulation. 137 (12). doi:10.1161/CIR.0000000000000558. ISSN 0009-7322.
  2. ↑ Roth, Gregory A.; Johnson, Catherine; Abajobir, Amanuel; et al. (July 2017). "Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015". Journal of the American College of Cardiology. 70 (1): 1–25. doi:10.1016/j.jacc.2017.04.052.
  3. ↑ Know the Differences
  4. ↑ "A History of Women's Heart Health". American College of Cardiology. Retrieved 2020-11-26.{{cite web}}: CS1 maint: url-status (link)
  5. 1 2 Brown N (March 2015). "How the American Heart Association helped change women's heart health". Circulation: Cardiovascular Quality and Outcomes. 8 (2 Suppl 1): S60-2. doi:10.1161/CIRCOUTCOMES.115.001734. PMID 25714819.
  6. 1 2 "Women & Cardiovascular Disease". Cleveland Clinic. Retrieved 2020-11-26.
  7. 1 2 3 4 5 6 7 8 9 10 11 Saeed A, Kampangkaew J, Nambi V (2017). "Prevention of Cardiovascular Disease in Women". Methodist DeBakey Cardiovascular Journal. 13 (4): 185–192. doi:10.14797/mdcj-13-4-185. PMC 5935277. PMID 29744010.
  8. 1 2 3 4 5 6 7 8 9 10 11 Cho L, Davis M, Elgendy I, Epps K, Lindley KJ, Mehta PK, et al. (May 2020). "Summary of Updated Recommendations for Primary Prevention of Cardiovascular Disease in Women: JACC State-of-the-Art Review". Journal of the American College of Cardiology. 75 (20): 2602–2618. doi:10.1016/j.jacc.2020.03.060. PMC 8328156. PMID 32439010.
  9. 1 2 Roth, Gregory A.; Johnson, Catherine; Abajobir, Amanuel; Abd-Allah, Foad; Abera, Semaw Ferede; Abyu, Gebre; Ahmed, Muktar; Aksut, Baran; Alam, Tahiya; Alam, Khurshid; Alla, François (2017). "Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015". Journal of the American College of Cardiology. 70 (1): 1–25. doi:10.1016/j.jacc.2017.04.052. PMC 5491406. PMID 28527533.
  10. 1 2 Gholizadeh, Leila; Davidson, Patricia (2007-12-28). "More Similarities Than Differences: An International Comparison of CVD Mortality and Risk Factors in Women". Health Care for Women International. 29 (1): 3–22. doi:10.1080/07399330701723756. ISSN 0739-9332.
  11. 1 2 3 Thomas JL, Braus PA (February 1998). "Coronary artery disease in women. A historical perspective". Archives of Internal Medicine. 158 (4): 333–7. doi:10.1001/archinte.158.4.333. PMID 9487230.
  12. 1 2 Robertson RM (May 2001). "Women and cardiovascular disease: the risks of misperception and the need for action". Circulation. 103 (19): 2318–20. doi:10.1161/01.CIR.103.19.2318. PMID 11352875.
  13. ↑ Mosca L, Hammond G, Mochari-Greenberger H, Towfighi A, Albert MA (March 2013). "Fifteen-year trends in awareness of heart disease in women: results of a 2012 American Heart Association national survey". Circulation. 127 (11): 1254–63, e1-29. doi:10.1161/CIR.0b013e318287cf2f. PMC 3684065. PMID 23429926.
  14. ↑ Maric C (December 2010). "Risk factors for cardiovascular disease in women with diabetes". Gender Medicine. 7 (6): 551–6. doi:10.1016/j.genm.2010.11.007. PMC 3179621. PMID 21195355.
  15. ↑ Saeed A, Kampangkaew J, Nambi V (2017). "Prevention of Cardiovascular Disease in Women". Methodist DeBakey Cardiovascular Journal. 13 (4): 185–192. doi:10.14797/mdcj-13-4-185. PMC 5935277. PMID 29744010.
  16. ↑ Gholizadeh, Leila; Davidson, Patricia (2007-12-28). "More Similarities Than Differences: An International Comparison of CVD Mortality and Risk Factors in Women". Health Care for Women International. 29 (1): 3–22. doi:10.1080/07399330701723756. ISSN 0739-9332.
  17. ↑ "Cardiovascular Disease: Women's No. 1 Health Threat" (PDF). American Heart Association. March 2018. Archived (PDF) from the original on 2021-07-14. Retrieved 2021-11-17.
  18. 1 2 Zhang, Y. (2010). "Cardiovascular diseases in American women". Nutrition, Metabolism and Cardiovascular Diseases. 20 (6): 386–393. doi:10.1016/j.numecd.2010.02.001. PMC 4039306. PMID 20554179.
  19. ↑ Stramba-Badiale, Marco; Fox, Kim M.; Priori, Silvia G.; Collins, Peter; Daly, Caroline; Graham, Ian; Jonsson, Benct; Schenck-Gustafsson, Karin; Tendera, Michal (2006-04-01). "Cardiovascular diseases in women: a statement from the policy conference of the European Society of Cardiology". European Heart Journal. 27 (8): 994–1005. doi:10.1093/eurheartj/ehi819. ISSN 1522-9645.
  20. ↑ CDC (2020-01-31). "Women and Heart Disease". Centers for Disease Control and Prevention. Retrieved 2021-11-17.

Further reading

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