Heart Disease in Women – Part 1
- Article previously published in the Hudson Valley Pilot – see link below
This is the first of a 2 part series
With red hearts everywhere, we are flooded this month with reminders to think of those we love. Whether you are romantically involved or not, this Hallmark holiday does provide a nice backdrop for American Heart Month, a time for us all to think about our own hearts, and the heart health of those we love. Historically, cardiovascular disease (CVD) has largely been considered a disease of men. And while it is still their # 1 killer, most people don’t realize that it is the leading cause of death in women as well, and that a woman’s chances of dying from heart disease is higher than the likelihood of death for all types of cancer combined. While it is only recently that the medical community has begun to recognize this, many women, and the people who love them, do not understand this coronary threat, nor what to do to prevent it..
Understanding the disease
Our cardiovascular system is a network of 60,000 miles worth of blood vessels, connected to the heart, which acts as a pump to move blood to the lungs to pick up oxygen, and then around the body to supply oxygen and nutrition to, and remove waste from, our cells. CVD, also known as heart disease, is caused by atherosclerosis, which occurs when plaque builds up in the walls of the arteries, causing narrowing, and eventually if a blood clot forms, there can be complete blockage. When this occurs in the small arteries that supply the working muscle of the heart we call that a heart attack, and when it occurs in the brain it is a stroke. Additionally, we can develop narrowing in arteries that supply our legs and arms causing peripheral vascular disease, or congestive heart failure, where the heart muscle underperforms and is unable to keep up with the body’s need for blood and oxygen, caused by either a previous heart attack, or just continued increased strain on the heart muscle from elevated blood pressure and narrowing of the blood vessels.
Historical scope of heart disease in America
According to a report published in the American Journal of Medicine, heart disease was an uncommon cause of death in the beginning of the 20th century, but peaked in the 1960s. It was at this time that President Lyndon B Johnson,who himself had suffered a near fatal heart attack at the age of 46, created the first American Heart Month in February 1964. At the time, doctors were still wrapping their heads around heart disease and its causes – they didn’t even know that atherosclerosis and blood clots were what caused a heart attack or that smoking, an unhealthy diet or lack of exercise were risk factors.
Since that time, there has been tremendous research and public education, leading to a significant decrease in the rate of death overall due to heart disease, but the decrease is less for women than men and less for African-American women than white women. A report from Nutrition, Metabolism and Cardiovascular Diseases in 2010 states that since 1984 the number of deaths attributable to heart disease in women has exceeded those for men; women represented 52.6% of CVD deaths. In addition, the Centers for Disease Control and Prevention list that currently 51.9% of deaths due to high blood pressure, and 57.5% of total stroke deaths are in women.
Why are there differences
Some of this gender disparity may be explained by taking a look at the timeline for the medical community to recognize the disease in women and the lack of evaluating women separately in research. Although women’s rates of death from heart disease surpassed men’s in the mid 1980s, it wasn’t until 1992 that the American Heart Association (AHA) published its first scientific statement on women and CVD, which occurred contemporaneously with the NIH Revitalization Act in 1993, a congressional act that mandated the exploration of potential differences in outcome between the 2 sexes in all research funded by the NIH moving forward. More simply put, the overwhelming majority of research on CVD in this country done before 1993 was done on men, and once a medication was approved for use, it was available to both men and women with the assumption that the dosage and outcomes would be the same. It wasn’t until 2004 that the AHA put out the first evidence – based guidelines for prevention of CVD in women and launched the Go Red for Women campaign, marked on the first Friday in February, as a national day to promote heart health awareness for women.
Despite this outreach and the recent inclusion of women into medical research in CVD, considerable challenges remain to understand what contributes to the different outcomes of heart disease in women. Most women themselves don’t recognize the severity of the problem, and although typically the gate-keepers of health for the family, women are often the last to recognize warning signs in themselves. A study published in 2021 showed that compared to 2009, women across the US in 2019 were more likely to incorrectly identify breast cancer as the leading cause of death, and awareness of heart attack symptoms also declined. These changes in educational knowledge were true for all women under age 65, and most striking in women of younger ages and women of color. Additionally in this study, “younger women were less likely to report leading a heart-healthy lifestyle and were more likely to identify multiple barriers, including lack of time, stress, and lack of confidence”. Put another way, according to the Effectiveness-Based Guidelines for the Prevention of CVD in Women published by the American Heart Association in 2011 “ In the USA, one woman dies from CVD every minute of every day and, in 2007, almost half a million female lives were lost as a direct result of CVD. This figure was higher than that for deaths from cancer, respiratory disease, Alzheimer disease, and accidents combined. Worryingly, cardiovascular mortality among women aged 35–54 years actually seems to be increasing”.
What we all need to know
Men and women share several traditional risk factors, but we are just beginning to unpack the physiology that modifies these risks, as well as to recognize the risks that are unique to women’s bodies, as well as the socio-economic features that may contribute to some non-traditional risk factors that are more common in women, especially women of color.
It has been well established that elevated cholesterol levels, smoking, obesity, sedentary lifestyle, high blood pressure, and diabetes are all modifiable risk factors associated with an increased risk for heart disease in both sexes. And while women traditionally developed CVD about 10 y later than men, due in part to the changes that occur at menopause, there is increasing concern about the shift to higher rates of heart disease in younger women. Frightening statistics from the AHA indicate that “among females 20 years and older, nearly 45% are living with some form of cardiovascular disease and less than 50% of women entering pregnancy in the United States have good heart health”. A study published in the Journal Circulation in 2018 found that the overall rate of heart attack in young patients increased from 27% in 1995-1999 to 32% in 2010-2014, with the largest increase observed in young women. They also found increased rates of hypertension (59% to 73%) and diabetes mellitus (25% to 35%) among young heart attack patients, and compared to young men, young women presenting with a heart attack were more often black and had greater rates of these underlying disease risk factors.
Beyond the conventional risk factors, there is new evidence to suggest that women have additional sex-specific risks, and some of these may begin to manifest in young women as adverse pregnancy outcomes, including hypertensive disorders, gestational diabetes, and premature delivery. While an in depth look at these is beyond the scope of this article, data from the AHA confirms as many as “10% to 20% of women will have a health issue during pregnancy, and high blood pressure, preeclampsia and gestational diabetes during pregnancy greatly increase a woman’s risk for developing cardiovascular disease later in life.” As an Ob/Gyn for many years in the Hudson Valley, I can personally speak to the significantly increased rates of these complications we are seeing right here in our community.
And while many of the risks we have been discussing have a direct association with rates of excess weight gain in women, where the weight is distributed on our bodies seems to matter more than the actual pounds on the scale. One of the hallmark risks is the development of visceral fat which is belly fat found deep within your abdominal cavity. It surrounds important organs, including your stomach, liver and intestines, and it is different than subcutaneous fat, which is accumulated just below your skin. While we are learning that visceral fat, identifiable as a waist circumference greater than 35 inches for women and 40 inches for men, is far more dangerous to our health, advising women of the specifics of this risk falls short. An alarming study in the Journal of the American College of Cardiology found that “26% of women find CVD embarrassing”, assuming risk is solely tied to their weight and “45% of women in their study were likely to cancel or postpone a physician appointment until they had a chance to lose more weight”. Additionally, “women reported more often being told to lose weight rather than having their CVD risk factors addressed”. As a physician taking care of women, I am not only disheartened, but embarrassed on behalf of the medical community. There is dramatic room for improvement in our society as a whole in educating and empowering women to understand their risks, and to live in a space where making healthy lifestyle choices factors in more heavily than weight shaming. And the evidence is striking that we need to be doing this long before women are already at risk for their first CVD event in their 5th decade.
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