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Identification of women with heart disease: a missed opportunity Sharonne N Hayes
SN Hayes is Director of the Mayo Clinic Women’s Heart Clinic, and Associate Professor of Medicine and a consultant at the Division of Cardiovascular Diseases and Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
Correspondence Mayo Clinic College of Medicine 200 First Street SW Rochester MN 55905 USA
[email protected] Received 17 March 2006 Accepted 2 August 2006 www.nature.com/clinicalpractice doi:10.1038/ncpcardio0678
Heart disease should top the list of women’s health concerns; unfortunately, it doesn’t even come close. Many women have a disproportionate fear of breast cancer, and dutifully present for annual mammography while remaining oblivious to their risk of cardiovascular disease. Where is the demand by women and the medical community for an urgent agenda for heart disease in women? Cardiovascular disease—that is coronary heart disease, stroke, and other heart and blood vessel diseases—has been the number one cause of mortality in women in the developed world for decades. In the US, cardiovascular disease has killed more women than men each year since 1984—approximately 250,000 women die annually from myocardial infarction (MI) alone— and over 6 million women are currently living with coronary heart disease.1 Women with heart disease have higher morbidity and mortality and are more likely to be misdiagnosed or diagnosed later in the course of their illness than men.2 Cardiovascular risk in women is systematically underestimated by physicians. Once diagnosed, women receive less-intensive therapy at all levels and are less likely than men to receive interventions for primary and secondary prevention.3 These documented, sex-based disparities in preventive, diagnostic and therapeutic interventions are at least partially responsible for the higher cardiovascular-related total mortality in women than in men.2,4 The etiology of the observed differences in treatment and poorer outcomes in women is multifactorial and the solutions are complex. The causes include societal and individual misconceptions about cardiovascular risk and what a heart patient ‘looks like’, inadequate sex-specific research data, later diagnosis and lower-intensity therapy in women than in men, and biological sex differences in cardiovascular disease. For instance, women younger than 50 years of age presenting with MI have a twofold higher mortality compared with agematched men, but this mortality gap gradually shrinks, disappearing at around 70 years of age.5
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Is this observation caused by a biological difference or disadvantage among premenopausal women, or might worse outcomes in women be due entirely to treatment disparities? Available data suggest that both issues are important. In the 1960s, assertions that heart disease was a ‘man’s disease’ were widely promulgated to physicians and the public; however, these findings were based on a faulty and subsequently revised interpretation of the Framingham data.6,7 Initial data suggested that women with angina were much less likely than men to develop or die from more advanced forms of heart disease.6 This underestimation of risk in women led to research almost exclusively focused on cardiovascular disease in men. Many cardiovascular trials initiated in the 1970s and 1980s routinely excluded women or made no effort to enroll women in sufficient numbers to draw sex-based conclusions. Investigators justified these design decisions on the basis of several erroneous assumptions, including that women were at an inherently low risk of heart disease, and that heart disease etiology in men and women was the same and therefore male-only results could simply be applied to women. The lack of relevant research in women has resulted in a substantial and persistent sex-based knowledge deficit about everything from the ‘typical’ heart attack symptoms in women, to the risks and benefits of commonly used diagnostic tests and therapies. Differences in cardiovascular care for women are caused by physician practice and referral patterns. Many women in the US receive all or most of their medical care from specialists in obstetrics and gynecology. Traditionally, there has been a greater focus on reproductive and breast health in women than on other health risks, and a lower awareness among obstetrics and gynecology specialists about early cardiovascular risk identification and treatment. Even after a diagnosis of heart disease is made, sex-based differences in provision of care are present. Women hospitalized following MI are more likely than men to be managed by generalists, rather than cardiologists, and are less likely to be
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transferred from community hospitals to tertiary medical centers for advanced care. Both factors are associated with poorer short-term outcomes. There is also growing evidence of important biological sex differences in heart disease that could impact clinical practice. Aside from the obvious differences caused by gonadal hormones, differences in disease natural history, symptoms, accuracy of diagnostic tests, response to therapy, prevalence and relative risk of cardiovascular risk factors, and social and behavioral issues have all been identified. It is not always apparent, however, whether these differences warrant a variation in established practice. In the absence of data, some clinicians advocate providing identical care to women and men, while others advise that any treatment that has not been specifically proven efficacious in women be withheld from female patients. Either approach puts women at potential risk for overtreatment or undertreatment. What can we do to improve the identification and care of women with and at risk of heart disease? It is important to counteract the widely held belief that women do not develop heart disease except at advanced ages and raise physicians’ ‘index of suspicion’ for cardiovascular disease in women. Continued education of women and health-care providers about women’s cardiovascular risks, symptoms and the use of appropriate diagnostic tests and therapies is critical. While women’s symptoms can sometimes be challenging to address, both women and their physicians should not be too quick to attribute potential manifestations of cardiac disease to menopause or aging. The rise in cardiovascular risk-factor prevalence in younger women, especially smoking, obesity and diabetes, has led to a growing number of highrisk individuals who do not look like ‘typical’ heart disease patients. Research has shown that simply being aware of preconceptions allows health-care providers to actively monitor the behavior of high-risk individuals. These professionals can then ensure that for a given condition or risk level, the most appropriate diagnostic tests, risk-lowering interventions and treatments are being offered, in the same way, to all patients. Wider dissemination and implementation of the American Heart Association evidence-based cardiovascular disease prevention guidelines8 for women would further reduce the burden of disease. Simply taking what we already know works, and applying it more widely to women, will improve care and clinical outcomes.9
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Furthermore, physicians and patients need more sex-specific results if they are to improve, and be confident in, their management of women with cardiovascular disease. Clinical trials must include women in adequate numbers, and data must be analyzed by sex, and reported. Women currently make up only 20–30% of participants in cardiovascular clinical trials. Notably, only a quarter of recent cardiovascular trial results published in major US internal medicine and cardiology journals reported sex-specific outcomes.10 When sex differences are found, further studies must be done to determine the significance and implications of the findings so that diagnosis and treatment can be optimized for both sexes. Cardiovascular disease kills more women than any other condition. It is crucial that effective strategies be developed for optimum risk modification, diagnostic testing and disease management in women. The first step in bridging the gap in cardiovascular care is making the medical community and the women they care for aware that heart disease is a vitally important issue in women’s health.
Competing interests The author declared she has no competing interests.
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