A presidential advisory from the American Heart Association (AHA) was intended to serve as a call to action for the AHA and other stakeholders worldwide to identify and remove barriers to heath care access and quality for women. The aim of the current presidential advisory for cardiovascular (CV) health and cardiovascular disease (CVD)  in women is to delineate an actionable roadmap to implement its vision for equity among women with respect to their CV health. A concise summary of existing data on the subject was published in the journal Circulation.1

Recognizing that CVD remains the most common cause of death among women in the United States (US) today,2 the advisors sought to review the following key relevant domains: epidemiology and prevention; awareness; access to and delivery of equitable health care; and “to provide a clear and urgent call to action across multiple disciplines, including risk and prevention, access to a delivery of equitable health care, and awareness.”

Traditional CV risk factors, such as hypertension, hyperlipidemia, obesity, smoking, sedentary lifestyle, and diabetes, are highly prevalent among women in the US, with differences noted according to race and ethnicity. In fact, in 2019, smoking and high systolic blood pressure were the first and second leading risk factors, respectively, that contributed to years of life lost in the US.2


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The role played by genetic, molecular, cellular, and physiologic factors, such as sex and gender, social determinants of health (SDOH), behaviors, environments, and policy in women’s health are just now beginning to be understood. Adverse SDOH negatively impacts the prevalence and progression of CVD across all sex, age, race, and ethnicity groups. Although the assessment of health disparities along sex, racial, and socioeconomic lines is inherently complex, embracing this complexity is critical for designing interventions, as well as for providing the resources and modifying policies to achieve equity with respect to economy, education, general well-being, and health prevention and treatment.3

Some of the risk factors for coronary disease are either specific to women or are associated with a different risk for CVD events in women compared with men. Certain pregnancy and reproductive risk factors for CVD in women have been noted, including early menarche (<11 years), premature menopause (<40 years), hormone replacement therapy, use of oral contraceptives, gestational diabetes, preterm delivery, and high- or low-birth weight fetus. In fact, the CV health of pregestational women has declined in the US, with that of pregnant women shown to be suboptimnal and lower than that among age-matched nonpregnant women. This decline in CV health in both pregestational and pregnant women is specifically noted as a call to action.

Women are also disproportionately impacted by systemic inflammatory and autoimmune disorders, such as systemic lupus erythematosus, scleroderma, and rheumatoid arthritis. These risk factors greatly increase the risk for CVD events. Further, depression and anxiety are also associated with an elevated risk for CVD, with adverse CV outcomes in this context more common among women than among men. Optimizing mental health is of key importance in the management of women with CVD.

Increased efforts are also needed to improve the awareness and understanding of sex-based differences in the development, diagnosis, and management of peripheral artery disease (PAD) among women. Once diagnosed with PAD, women are less likely than men to receive treatment with evidence-based therapies.

The accurate estimation of risk for atherosclerotic CVD-related events is the foundation of decision-making in prevention, and “the effective communication about the magnitude of the risk is critical to judicious person-centric interventions among those at higher risk.” Improved understanding of the gaps in knowledge and research needs for CVD in women requires the purposeful adoption of a female-centric approach that is focused on factors unique to women that can affect risk throughout their lifetime.

The delivery of equitable health care for women will depend on improving the knowledge gap, education, and awareness among health care professionals of female-specific and female-predominant risk factors. Further research is needed, particularly among women, in order to understand the effect of both intrinsic and extrinsic risk factors on CV risk and CV outcomes. Additionally, the role played by COVID-19 and other possible infectious diseases, as well as the secondary effects of increased social, family, and economic demands on women during a pandemic, will need to be investigated as well.

This call to action offers a framework for considering research needs and knowledge gaps that are key toward attaining significant progress in the health and well-being of all women.

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

Reference  

1. Wenger NK, Lloyd-Jones DM, Elkind MSV, et al; American Heart Association. Call to action for cardiovascular disease in women: epidemiology, awareness, access, and delivery of equitable health care: a presidential advisory from the American Heart Association. Circulation. Published online May 9, 2022. doi:10.1161/CIR.0000000000001071 

2. Virani SS, Alonso A, Aparicio HJ, et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2021 update: a report from the American Heart Association. Circulation. Published online January 27, 2021. doi:10.1161/CIR.0000000000000950

3. Nayak A, Hicks AJ, Morris AA. Understanding the complexity of heart failure risk and treatment in Black patients. Circ Heart Fail. Published online August 13, 2020. doi:10.1161/CIRCHEARTFAILURE.120.007264