Cardiovascular Disease in Women: A review of statements and positions

J Atherosclerosis Prev Treat. 2024 Jan-Apr;15(1):25-30| doi:10.53590/japt.02.1059

REVIEW ARTICLE

Venetia Notara1, Stamatia Kokkou1, Demosthenes Panagiotakos2

1Department of Public and Community Health, School of Public Health, University of West Attica, Athens, Greece
2Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, Athens, Greece

 

 


Abstract

Cardiovascular diseases (CVDs) remain one of the most crucial burdens for public health. Specifically, for women, CVDs have a devastating effect on prognosis and mortality, which tends to become more severe, due to lack of knowledge and low awareness by healthcare professionals and general populations. Position statements by organizations and regulatory bodies recognize the fact that women have worse outcomes when it comes to their cardiovascular health, compared to men, and emphasize the urgent need that this issue needs to be addressed. Even though, general guidelines and recommendations have been launched, gender-specific ones are scarce, due to the very low number of women participants in clinical trials and scientific research. The present work aims to display a summary of position statements of official and scientific organizations concerning the cardiovascular diseases’ impact on women’s health, as well as existing guidelines and proposed future initiatives.

Key words: Cardiovascular, CVD, women, prevention, treatment

Corresponding author: Venetia Notara, Associate Professor, Department of Public and Community Health, Laboratory of Hygiene and Epidemiology, School of Public Health, University of West Attica, Athens, Greece, Tel.: +30 213 2010127, E-mail: vnotara@uniwa.gr

Submission: 18.12.2023, Acceptance: 16.04.2024


INTRODUCTION

Cardiovascular diseases (CVDs) are one of the most burdening public health issues, nowadays. According to the World Health Organization (WHO), almost 18 million deaths occur every year, with around 30% of those happening to people under 70 years of age, and more than 80% of them being the result of either a stroke or a heart attack.1 Specifically, for women, more than one out of three deaths worldwide are due to cardiovascular disease, which is more than the cumulative result of all cancers, consisting the second leading cause of death.2,3 Elaborating this fact with numbers, recent data pointed out that CVDs account for about 20% of deaths in women in the United States,4 29% in Australia,5 and 43% in the European Union,6 while being the leading cause of death for women in all but two of all European countries.7 These data highlight the urgent need to address the issue more effectively and establish better prevention strategies.

Another issue that should be mentioned is the differences between sex and gender regarding CVD outcomes. Specifically, sex refers to biological characteristics such as sex-defining chromosomes and hormones, along with genitals and gonads, whereas gender refers to factors mostly constructing sociocultural roles and corresponding behaviour.8 Sex-related factors play mostly a protective role against CVDs for women in comparison to men, mainly during the premenopausal period.8 On the other hand, gender-related characteristics and aspects of life, such as stress, anxiety, problematic communication with healthcare professionals and poor understanding of CVD manifestations in women, as well as lack of representativeness in research and clinical trials, negatively affect CVD prevention and management.8

In this paper a collection of position statements and scientific opinions by health Organizations and regulatory bodies are presented and discussed. The goal was to raise awareness about the specific role of women in CVD prevention strategies, and policies.

POSITION STATEMENTS AND OPINIONS

World Health Organization (WHO)

The WHO recognizes a variety of disorders negatively impacting cardiovascular health as CVDs, such as coronary heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, and deep vein thrombosis and pulmonary embolism.9 Due to the diversity of the blood vessels, and thus the organ systems, being affected by the existence of each of those disorders, there is an additional differentiation in the expected incidents. However, the most common ones, being responsible for more than fifteen million deaths globally in 2019, were heart attacks and stroke.9 WHO provides a list of symptoms for each of those incidents, to underscore the differences between CVD occurrence in men and women. Regarding heart attacks, WHO introduces the most common symptoms to be “pain or discomfort in the center of the chest; and/or pain or discomfort in the arms, the left shoulder, elbows, jaw, or back.”, however it is emphasized that women may present different symptoms compared to men when a heart attack occurs. Specifically, women are more likely to experience breathing difficulties, feeling nauseous and/or vomiting, as well as feeling pain or discomfort in their back and jaw.9 The symptomatology of stroke occurrence, according to WHO, is not diverse among the two genders.9

The chronic nature of those disorders is a key point for both prevention and management. According to WHO, certain lifestyle factors play a significant role in both of these aspects, specifically dietary patterns, lack of regular exercise, smoking and excessive alcohol consumption.9 Those determinants, being modifiable, may assist in the amelioration of one’s health and overall quality of life, concerning CVDs. Moreover, the existence of non-modifiable factors, such as genetics, should always be taken into account. Nevertheless, there are some factors that additionally affect how a chronic disease progresses. Specifically, socio-economic parameters9 admittedly tend to vary between genders, thus leading to diverse health outcomes in women and men.

World Heart Federation (WHF)

According to the WHF, due to both general populations and health professionals not being fully aware about certain elements regarding the presence of CVDs in women, female patients are often not being diagnosed and/or treated for those diseases.2 Due to this fact, female patients of young age are more likely to suffer fatal heart attacks than their male counterparts.2 Moreover, the issue emanated mostly from the limited representation of women in both cardiovascular research and clinical trials, caused partially due to the misconception that women are less affected by CVDs than men, thus leading to incomplete data about main symptoms and manifestations, and finally making them more susceptible. It is worth mentioning that the WHF admits that on many occasions women’s symptoms of heart disease are “dismissed as anxiety-related».2

The main risk factor for CVDs in women is elevated blood pressure. Other risk factors are common for both genders, such as physical inactivity, unhealthy dietary patterns, increased adiposity and hypercholesterolemia, however a variety of other factors seem to play a gender-specific role in the development of CVDs. Those include the presence of type II diabetes mellitus, elevated stress levels, current smoking, as well as menopause and pregnancy complications i.e., high blood pressure and/or gestational diabetes mellitus.2 While prevention and treatment may be achieved through the same pathways for men and women, namely maintaining a healthy weight, having a balanced diet, exercising regularly, and avoiding use of tobacco and alcohol overuse, women are less likely to receive adequate care. More specifically, whereas treatment for CVDs includes lifestyle changes, as well as medications and medical procedures, female patients have lower probability of receiving medications such as statins and aspirin, go through coronary bypass surgery, and are less likely to be referred for cardiac rehabilitation as means of treatment and prevention for future incidents, despite scientific evidence supporting their use.2 Finally, younger women are more susceptible to CVDs than younger men, possibly due to the diverse symptomatology in which those diseases manifest themselves. The WHF agrees with the WHO about the symptoms in women, and in addition it points out the fact that women, before a heart attack, might experience an inexplicable feeling of tiredness, which in occasions is dismissed by healthcare professionals, thus restraining diagnosis.2

American Heart Association (AHA): The “Go-Red-for-Women” action

The AHA also confirms that CVDs are almost equally prevailed in both men and women, however, women have a worse prognosis, especially when age and race are taken into account.10 Suggesting the lack of awareness as one of the root causes for the burdening effect of CVDs in women’s health, in 2004 the AHA introduced the “Go Red for Women” initiative, to assist general populations, as well as healthcare professionals, focusing on women’s cardiovascular health.11 Aligned with the WHO and the WHF, it is agreed that female patients’ treatment is inferior to the males’, while prevention lags too. This is attributed partially to the underrepresentation of women in medical research, as well as in other scientific fields.3 Additionally, gender-specific factors, such as menarche, pregnancy, miscarriage, and menopause, play a key role in cardiovascular health.10 Specifically, in addition to the fact that elevated blood pressure and diabetes mellitus place women in greater risk for CVDs than men,10 the occurrence of preeclampsia and gestational diabetes mellitus, which are unfortunately not so rare during pregnancy, furtherly increase the risk for CVDs later in life.3 Moreover, even though menopause (and early menopause) is not a direct risk factor for CVDs, approaching this stage of life negatively affects women’s cardiovascular health and prognosis.3 Finally, unfortunately for women, there is a lower probability of receiving cardiopulmonary resuscitation (CPR) by a bystander, because potential rescuers are afraid that they will be blamed of causing harm, but also of sexual assault and inappropriate touching, therefore leaving them unassisted.3

The “Go Red for Women” action is a prevention program that aims to raise awareness, educate, clarify misconceptions about CVDs among women, but also to promote lifestyle changes to improve health. Furthermore, it funds research on women’s cardiovascular health and seeks ways to eliminate barriers and discrimination for all women and establish equal treatment for female patients in clinical research and practice.11 In terms of general population, the program helps to explicate the root causes of CVDs, debunk myths, elucidate associations with everyday life factors and nurture healthy habits.3

European Society of Cardiology (ESC)

The ESC emphasizes the importance of reforming CVDs’ management in every aspect and filling the gender gap that evidently exists.12 The ESC recognizes the tremendous differences in both the manifestation of CVDs in women, and the false perceptions of healthcare professionals and general populations that women are less at risk than men for the development of the diseases, and thus being more protected.13 To address the issue of the diverse disease management, depending on gender, an effort was made to gather European-wide evidence, recognize gaps and misconceptions in scientific evidence and provide strategic interventions to improve CVD’s management among women.13 It points out that heart attacks account for about 30% of all-cause mortality in women worldwide, when at the same time treatment for the same incident in men leads to better outcomes and greatest surviving rates.12 The etiology behind the gender gap, but mainly the overall issue of misdiagnosis/underdiagnosis and dismissal of symptoms in female CVD patients has its roots in the fact that women are not well represented in clinical trials and cardiovascular research. Specifically, according to recent data, women enrolled in clinical trials regarding CVDs accounted for less than one third of all participants, in both the US.A. and the European Union.12 Furthermore, response and treatment provided by healthcare professionals varies, depending on the geographical position, as it has been shown that among European countries, the level of proper management for female patients is diverse, but always worse compared to males.12

To address the issue and provide better healthcare in female patients with CVDs, the ESC has proposed a holistic approach. Specifically, it stresses the need to gather scientific evidence from the European region, to evaluate prevalence in female populations and also, how each country responds in terms of diagnosis, treatment and future prognosis.12 Furthermore, it has proposed an initiative to better understand potential obstacles that prevent the inclusion of greater numbers of women in clinical trials, and handling those in order to increase participation. Additionally, for the same purpose, it indicates the need for better funding and overall investment in research for women’s cardiovascular health.12 Moreover, increasing knowledge on women’s cardiovascular health by educating and providing up to date scientific evidence to healthcare professionals, as well as raising awareness in general population, is suggested as the cornerstone of improved prevention, effective diagnosis, and quality treatment.12 Finally, the ESC suggests that greater enrollment of women in the cardiology profession would much benefit the scientific community and would help bridge the gender gap in cardiovascular health management.12

THE GREEK CARDIOLOGY COMMUNITY

Hellenic Heart Foundation (ELIKAR)

Regarding the matter of CVDs in women, the Greek cardiology community has also stated some facts and proposed ways to improve prevention and management. The Hellenic Heart Foundation (ELIKAR) points out the fact that the female heart is more vulnerable to CVDs and women need to know as much as possible about heart disease and how to prevent it.14 It states that they are at greater risk as they approach the onset of menopause, as a consequence of higher levels of lipids and cholesterol, resulting in a greater risk of a heart attack.14 It also supports that throughout their life, but much more at the menopause stage, it is imperative to stop smoking, increase physical activity, ameliorate diet, monitor and control body weight, hypertension and cholesterol, because these are the key prevention factors of CVDs.14 The ELIKAR actively participates in the “WOMEN’S HURDLES” European Program, which develops, implements and disseminates innovative practices to enhance the systematic participation of women in physical activity, with the aim of taking effective actions to eliminate the factors that prevent this participation, especially for women balancing between work life and family.15

Hellenic Society of Cardiology (HCS)

Furthermore, the Hellenic Society of Cardiology (HCS) shares the impression that women considered as low cardiovascular risk population needs to be revised, since cardiovascular disease in women has a higher mortality rate than in men, and approximately 50% of women of reproductive age already has poor cardiovascular health. It stresses the need for greater awareness of the importance of prevention, diagnosis and treatment of life-threatening cardiovascular risk factors.16 It also emphasizes on the risk factors among young women – such as special conditions during pregnancy (hypertension, diabetes mellitus, adverse outcome), hormonal factors (taking contraceptive drugs, polycystic ovary syndrome, early menopause), cardiotoxic chemotherapy or radiation therapy, and immunological diseases (more often in women – lupus erythematosus, rheumatoid arthritis).16 In 2019, the HCS created the Action Group of Female Cardiologists for Women, whose main goal was the early awareness of the female population in the CVD diagnosis and treatment. The support of the female patient by the female doctor, who understands the peculiarities of gender (neurohormonal changes, increased social and family obligations, anatomical differences) in a society of high demands, competitive pace and economic crisis is of major importance.17

Hellenic Atherosclerosis Society (HAS)

According to the most recent position statement of the HAS, diagnosis and treatment specifically for dyslipidemias, pregnancy- and menopause-related health conditions should be taken into account when evaluating cardiovascular risk.18 Additionally, therapeutic approach with the use of statins should be considered for the primary and secondary prevention of atherosclerotic cardiovascular disease, following the same recommendations for both sexes.18

Recommendations and guidelines.

Aiming to reinforce primary prevention for CVDs, the AHA developed a Clinical Practice Guideline document in 2019,19 which offers additional recommendations for general populations, that are in accordance with guidelines and recommendations provided by other scientific organizations and regulatory bodies. Among those, the most notable refer to:

1. Establishing/maintaining a healthy lifestyle for general populations, such as:
a. Maintain a healthy body weight.
b. Follow a healthy dietary pattern, with a great variety of fruit, vegetables, nuts and whole grain products, protein derived mostly from plant foods, lean cuts of meat and fish, and minimum amounts of foods rich in trans fats, such as processed and red meats, sugars and refined carbohydrates, such as those in beverages and sweets.
c. Exercise regularly, by either engaging in at least 150 minutes of moderate intensity or at least 75 minutes of vigorous intensity exercise per week, or any combination of those.
d. Avoid tobacco use or seize use, if already engaged.
2. Guidelines for healthcare professionals:
a. Evaluation of social determinants of health that might impact individuals and conclude accordingly to treatment decisions.
b. Assess the risk for the 10-year atherosclerotic cardiovascular disease (ASCVD) and promote a healthy lifestyle, before contemplating treatment with medications.
c. Stress the need for healthier habits in all populations, but emphasize on patients with hypertension, type II diabetes mellitus, preeclampsia and/or gestational diabetes during pregnancy, hypercholesterolemia or any other condition affecting cardiovascular health.
d. If necessary, use of metformin as first-line therapy for type II diabetes mellitus, considering the use of sodium-glucose cotransporter 2 inhibitors (SGLT2 inhibitors) or glucagonlike peptide-1 receptor agonists (GLP-1 receptor agonists).
e. If necessary, use of statins as first-line therapy for hypercholesterolemia caused by high levels of low-density lipoprotein (LDL) cholesterol.
f. No use of medications for elevated blood pressure, but rather achieving target levels with lifestyle interventions.
3. Additional recommendations by the CDC,4 specifically addressed to women:
a. Το know any about risk factors, associated with pregnancy and reproductive health, that might increase the risk for CVDs, including early menarche/menopause, polycystic ovary syndrome (PCOS), gestational diabetes mellitus in any pregnancy, preterm labor, birth of infant with abnormal body weight (either very high or very low), and/or abnormal blood pressure in pregnancy, such as preeclampsia.
b. To talk with their doctor about blood pressure, diabetes mellitus, hypercholesterolemia and hypertriglyceridemia. Get checked regularly.
c. To limit alcohol consumption, with a maximum of one drink per day, and completely avoid it during pregnancy.
d. To seek help regarding stress management, engage in activities that help you release tension.

CONCLUSION

Cardiovascular diseases are the silent killers of the last decades. It is unanimously admitted by scientific organizations that women have the worst outcomes and prognosis. What is recognized is the urgent need to increase gender-specific cardiovascular research, by recruiting more female participants in clinical trials, reconstructing protocols, detecting, and overcoming barriers, and creating interventions and health promotion strategies based on gender-specific scientific evidence. Moreover, guidelines and recommendations should be inclusive for men and women, however additional information should be added, to overcome the gender gap in cardiovascular prevention, but also in diagnosis and treatment. Finally, more female professionals should be involved in scientific and medical fields, as a step towards equality in every aspect of healthcare.

Funding

None to declare.

Conflict of Interest

None to declare.

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