Cardiovascular disease (CVD) is the leading cause of death for both men and women in the United States.1 However, CVD awareness has decreased among women, particularly Black, Hispanic, and Asian women.2

Two surveys from the American Heart Association (AHA), 2019 vs 2009, showed a decrease over 10 years in women’s awareness of CVD as their leading cause of death (43.7% vs 64.8%).2 The reduced awareness poses a risk for women, for example, who may not know that symptoms of myocardial infarction and coronary artery disease are different in women than in men.3,4,5

Beyond a lack of awareness, however, what other factors contribute to CVD as the No. 1 cause of death in US women? In honor of American Heart Month, we spoke with 4 women cardiologists from around the US to hear their different perspectives and patient experiences. They answered 2 questions:

1) Why does CVD remain the leading cause of death for women in the US?
2) What guidance can cardiologists provide to women to protect their heart health?


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Here’s what they had to say:

Anne B. Riley, MD

1) Unfortunately, CVD in women is frequently overlooked or missed for a variety of reasons. Women’s heart health is sometimes at the bottom of their own priority list. I have seen many women over the years who spend so much of their time and energy being the caregivers for other family members (whether children, spouses, or parents), that they push aside symptoms of heart disease until the situation becomes emergent.

Anne B. Riley, MD, is a board-certified cardiologist practicing at Beth Israel Deaconess Medical Center in Massachusetts.

In addition, the general population does not perceive heart disease as a large threat to women in our country, and most are surprised to learn that CVD is the leading cause of death of women in the US. But it is not only the public who needs to be reminded. Many initial pivotal studies of CVD enrolled largely men, and thus results were focused on how men perceived and expressed disease. For many years, symptoms noted by women experiencing heart disease, which are often different from those of men, were deemed “atypical,” because they did not match what men experienced, which was deemed the “typical” experience. Combine these 2 issues, and you create the perfect storm of late/under-detection of CVD in women.

2) Fortunately, national campaigns like the AHA’s “Go Red for Women” movement have begun to move the needle on public awareness of the issues of heart disease in women. It is important for cardiologists to support these public health campaigns to help get the message out about the importance of disease prevention and identification in women. In addition, internal medicine and cardiology training programs have become smarter about teaching differences in symptoms between men and women.

There is also much more research being done on less traditional risk factors, which if present, indicate a higher risk of developing CVD. Most cardiologists now know to ask [about] a history of gestational hypertension, preeclampsia, and gestational diabetes. Similarly, patients with a history of inflammatory disease (like lupus or rheumatoid arthritis), which affect women more than men, also carry a higher risk profile. Finally, as with many things in medicine, the most important tool we have in the identification of disease is a listening ear. Doctors have the best intentions to see the problem, but the rapid-fire environment of health care today can often obstruct our view. Doing what we can to slow down and really hear what the patient is telling us is the best chance we have of picking up CVD in women.

Rachel M. Bond, MD, FACC

Rachel M. Bond, MD, FACC, is a cardiologist with Dignity Health in Arizona.

1) One reason for this is decreasing awareness and limited screening of sex-specific risk factors, such as complications during pregnancy, along with conditions that impact women’s health more, such as chronic stress, anxiety, [or] depression. Beyond that, women are still being under-diagnosed, untreated, and not provided guideline-suggested management highlighting the ongoing unconscious gender bias, which is the primary culprit for these disparities in care.

2) The first step is to listen to the patients and their concerns, as they know their body better than anyone else. With heart disease preventable 80% of the time, we need to encourage our patients to continue to go for their annual well-woman visit, where their “numbers” are checked, including [blood pressure] BP, cholesterol, blood sugar, and body weight, which are common risk factors for heart disease [that] can be controlled. Lastly, we should encourage our patients to continue to live a heart-healthy lifestyle that follows the AHA’s Life’s Simple 7, including maintaining a heart-healthy diet and at least 150 minutes of moderate exercise per week, which may include brisk walking. 

Ritu Thamman, MD, FASE, FACC, is an assistant clinical professor of medicine at the University of Pittsburgh School of Medicine in Pennsylvania.

Ritu Thamman, MD, FASE, FACC

1) Women’s symptoms are not clearly identified as being cardiac by both the physicians and the women. And women wait longer to call for help even if they are experiencing chest pain. Other barriers exist: higher levels of risk for women with [diabetes], obesity, and hypertension, which are not picked up by standard risk assessment tools like the pooled cohort equations.

2) How can cardiologists provide guidance to women to protect their heart health? By asking women patients to know their numbers (BP, weight, sugar, and cholesterol levels) and to exercise in any manner they like!

Nanette Wenger, MD, MACC, MACP, FAHA

1) The fact is that women are not aware that this is their leading cause of death and because they’re not aware, they’re obviously not going to take preventive intervention. Now, back in [2002 and 2004], the National Heart, Lung, and Blood Institute (NHLBI) and the AHA started the awareness campaigns. NHLBI was [the] Heart Truth campaign and AHA was the [Go Red for Women] campaign. And the awareness increased to about 50% from [about 30%]. That did well for a while. But as we examine awareness now, we find that that awareness has dropped. It’s stuck in the [30% to 40% range] again, and the awareness is lowest among young women and women of racial and ethnic minorities.

Nanette Wenger, MD, MACC, MACP, FAHA, is a professor of medicine in cardiology at Emory University, a consultant at Emory Heart and Vascular Center, and founding consultant at Emory Women’s Heart Center in Georgia.

So, what we have to do [is] bring back the awareness in terms of education, because if women are aware that this is their heart problem, they will listen to what their health care providers say about prevention. …[W]e have to increase the awareness that heart disease is [a] major problem [for women] and increase awareness [on] the symptoms of a heart attack [every woman should know].

2) What we have to do is use the AHA’s Life’s Simple 7, and the important thing for the providers … is that all of this information … is on the Web. They can download any of this for their patients. Really, what we are saying is to have good heart health, you need 4 behaviors and 3 numbers—that makes Life’s Simple 7. The 4 behaviors are: no smoking, maintain ideal weight, eat a heart-healthy diet, and be physically active. …And then you have to know 3 numbers: that your total cholesterol is below 200, that your BP is less than 120 over 80, and that fasting blood sugar is under 100. If we teach Life’s Simple 7, then women can [better] address their heart health.

References

  1. Centers for Disease Control and Prevention. Heart Disease in the United States. Updated February 7, 2022. Accessed February 8, 2022. https://www.cdc.gov/heartdisease/facts.htm
  2. Cushman M, Shay CM, Howard VJ, et al. Ten-year differences in women’s awareness related to coronary heart disease: Results of the 2019 American Heart Association National Survey: A special report from the American Heart Association. Circ. 2021;143:e239–e248. doi:10.1161/CIR.0000000000000907
  3. American Heart Association. Heart attack symptoms in women. Updated July 31, 2015. Accessed February 8, 2022. https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack/heart-attack-symptoms-in-women
  4. Cleveland Clinic. 3 Heart attack signs women shouldn’t ignore. Updated October 26, 2021. Accessed February 8, 2022. https://health.clevelandclinic.org/women-dont-ignore-3-subtle-heart-attack-symptoms/
  5. Mayo Clinic. Coronary Artery Disease. Updated June 5, 2020. Accessed February 8, 2022. https://www.mayoclinic.org/diseases-conditions/coronary-artery-disease/symptoms-causes/syc-20350613