A Specialist’s Perspective on Cardiovascular Disease in Women: C Noel Bairey Merz, MD

Q: What makes the WHA different?

Public messaging and government advocacy regarding sex and gender differences in cardiovascular disease are what makes the WHA different from other organizations.

The WHA is effectively pushing for policy change. For example, it was announced last year at the National Institutes of Health (NIH) if a researcher is doing NIH-funded research in a basic science area before he or she is awarded any money, they have to explain how both male and female animal models will be incorporated.

In addition, in response to advocacy and commitment by congress, the US Food and Drug Administration now has a new website called Snapshot. Any study subjected to this new NIH policy must state whether there were any differences in benefits and side effects among sex, race, and age groups in the testing of a drug or device. In other words, how many people like you were represented in a clinical trial; has this treatment been adequately tested in people like me?

The AHA goes after public health in a more generic sense, which is good (eg, lowering salt intake, anti-smoking campaigns, healthy food in schools for kids). But so often the policies do not include anything specific about women.

For example, in the “Life’s Simple 7” campaign7,  weight management is considered a top priority, but our research shows that is a turn-off issue for women.3,4 Men will be prescribed cholesterol meds, blood pressure meds, etc., while women will be told to lose weight. In fact, many women reported in our survey that they will put off going to the doctor until they have lost weight.3,4

And finally, the AHA strategy seems to suggest that men and women are the same. But women and men are not the same. Weight is not an important risk factor—not exercising or not eating right are more important. In my clinical experience, women do care about what they eat. Women feed families, so food and healthy nutrition speak to them.

None of the validated public and medical tools use weight as a risk factor for cardiovascular disease, including the A-risk score (Atherosclerotic Cardiovascular Disease or ASCVD score), the European Society of Cardiology (ESC) Score, and the Reynolds Risk Score.

The ASCVD risk score incorporates gender, age, race, total cholesterol, HDL-cholesterol, diabetes, hypertension, and smoking statuses8, and the ESC Score also uses similar factors, minus race and diabetes status.9 Reynolds Risk Score calculates a 10-year risk of heart attack based on gender, age, smoking status, blood pressure, total cholesterol, HDL and LDL-cholesterol, high-sensitivity C-reactive protein, and whether or not a patient’s mother or father had a heart attack prior to age 60.10

Using BMI to assess weight is not always effective. For example, a 6-foot tall woman is going to weigh more than a shorter woman. BMI for a tall, thin model could be 17 or 18 while overweight women may have a BMI of 25 or above. But there’s a J shaped curve—with a higher mortality under 18.5 and over 25. The sweet spot is to be right in that middle range, and most “overweight” women are in that range.

In order to reach more of the public, we’re working with various women’s magazines (eg, Women’s Day, Glamour, Ladies Home Journal) to bust the myth of what is considered healthy, and to remove some focus from the weight issue. For example, we encourage them to use models that are of average weight.

Women are evaluated  for their appearance and this extends into healthcare, resulting in an over-emphasis on weight for women, distracting attention from effective treatment. Physicians, nurses, etc. all have some gendered lenses on, but guidelines should help us do the right thing. For example, if you have diabetes, you should be offered a statin, but women are less likely to get this compared to men.

Q: Your colleague, Dr Holly Andersen, pointed out that each year cardiology conferences like AHA have become more focused on prevention. How can the medical community improve upon this?

The medical community should follow existing guidelines. Women’s cardiovascular health would improve if we adhered better to the regular prevention and treatment guidelines. Women are less likely to be seen by a cardiologist with and after a heart attack for unclear referral reasons.11

The results of the VIRGO study, which assessed gender differences in outcomes following myocardial infarction in young men and women, were recently published, and the question surfaced, Why is the incidence of cardiovascular events increasing in young women and decreasing in young men?12

While the study is retrospective, it also asked the patients what types of medications they were on prior to the heart attack and what their doctors had advised them to do. Recall isn’t 100% accurate, but the intakes at the hospitals were very revealing. The electronic medical records showed that men were more likely to be on a statin than women.12

And although the women were more likely to be diabetic, which is a stronger risk factor for cardiovascular disease, they were less likely to be placed on cholesterol-lowering medications. In addition, women were more likely to be told to lose weight even though men were more likely to be more overweight. This signals to me that we have societal objectification of women—men get their cholesterol levels checked and women are told to lose weight.