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Commentary

Study Review Highlights How Cardiovascular Disease Affects Women and Current Gaps in Care


March 24, 2021

By Yvette C Terrie, BS Pharm, RPh, consultant pharmacist

Cardiovascular disease (CVD) continues to be the leading cause of death among both men and women in the United States, and globally with CVD contributing to 1 in 3 deaths in women annually.1 According to the CDC, while some progress has been made in expanding awareness about CVD in women, only an estimated 56% of women know that CVD is the leading cause of death among women. 2 Research from a few recent publications have highlighted various aspects of women’s health focusing on cardiovascular disease and women. A review of some of those studies can be found below.

A study recently published in the European Heart Journal- Quality of Care and Clinical Outcomes revealed that mortality rates from cardiovascular disease (CVD) are increasing among women under age 65. The study found that while death rates from cancer declined every year between 1999 and 2018, after an initial decrease, CVD mortality rates have been escalating since 2010.3-5 The study found that across the entire study period, age-adjusted mortality rates diminished for both cancer and CVD disease. But while cancer death rates consistently declined throughout the 19 years, CVD death rates fell initially and then rose between 2010 and 2018. As a result, the absolute mortality gap between cancer and CVD significantly diminished from 32.7 to 23.0 per 100,000/year.3-5

The authors concluded that, “If extreme public health measures are not taken to mitigate cardiovascular risk factors, focusing on high-risk groups, heart disease mortality may supersede cancer to become the leading cause of death in young women.” 3-5 Researchers indicated that the worsening of the diabetes and obesity epidemics are contributing factors.3-5 One of the lead authors, Dr Erin Michos of Johns Hopkins University School of Medicine stated, “Young women in the U.S. are becoming less healthy, which is now reversing prior improvements in heart disease deaths. Women frequently put others’ health and needs before their own, often caring for children and parents and working full-time. But if they have a fatal heart attack, they won’t be there for loved ones. Women must prioritize their own health, especially since heart disease is largely preventable.” 3,5 Another author of the study, Dr Safi Khan of West Virginia University, Morgantown, US stated, “More intensive efforts are needed to prevent and treat heart disease in young women to reverse the upsurge in deaths.” 3,5

Another study published in the journal Circulation indicated that women may be more vulnerable to cardiovascular disease at blood pressures lower than the 120 mg HG threshold.6 In the study, researchers analyzed the blood pressure measurements of 27,542 participants, of whom 14,873 (54%) were women.6 None of the participants had CVD at the outset, but 7424 individuals, of whom 44% were female, developed nonfatal or fatal CVD over the study period, which spanned 4 decades. There were 3405 recorded myocardial infarctions, 4081 cases of heart failure, and 1901 stroke events. Utilizing a gender-specific model approach, the study evaluated which blood pressure measurements corresponded to incidents of CVD among the female participants. Researchers revealed that the blood pressure threshold for expanded risk of CVD may actually be lower in women than in men and the results from their study indicate a call for the need to reevaluate current guidelines for a more precise approach to women’s cardiovascular health.6 They also noted that more research is warranted to confirm their findings. 6

Results from a new meta-analysis from 56 different studies published in the American Journal of Cardiology found that ST-segment elevation myocardial infarction (STEMI) outcomes continue to be reported worldwide and that STEMI outcomes continue to be considerably worse for women than men. 7, 8 The researchers found that women usually experienced lengthier delays to first medical contact and longer door-to-balloon times.7,8 In-hospital rates of mortality, repeat myocardial infarction, stroke and major bleeding events were all also much larger for women. Another major finding from this new meta-analysis is that women received less optimal STEMI therapy during hospitalization. For example, the rates of primary percutaneous coronary intervention (59.5% vs. 68.2%), aspirin use (89.5% vs. 92.1%) and P2Y12 inhibitors use (67.6% vs. 75.4%) were all lower among women when compared to men. They concluded that in spite of advancements in STEMI care, women continue to have in-hospital rates of mortality, repeat MI, stroke, and major bleeding up to 2-fold greater than men. 7 Gender disparities in in-hospital outcomes can generally be explained by age differences at presentation but comorbidities, delays to care and suboptimal treatment experienced by women may add to the gender gap.7,8

Another publication in the Journal of the American College of Cardiology which involved a detailed systematic review of 13 studies explored the patient-physician gender relationship across multiple specialties and its role in the care patients receive.9,10 The researchers found data supporting the idea that a patient's clinical outcome may be positively influenced if they are treated by a physician of the same gender.9,10 The authors indicated that female physicians generally have better patient outcomes compared to their male peers, while female patients are less likely to receive guideline-recommended care when treated by a male physician.9,10 They also indicated that while care disparities can be the result of multiple factors, they may relate, in part, to the variances in how CVD presents in women vs. men, the under representation of female subjects in clinical trials and the lack of women’s health training in U.S. medical education.9,10 They also noted that more research is warranted and there is a need to integrate comprehensive patient centered communication and care into medical education.9,10 The authors also recommended three recommendations to address these findings.

The studies mentioned above illustrate various gaps in care regarding CVD and women. The efforts in identifying and addressing these gaps are ongoing. Through expanding patient education efforts and awareness about CVD, many women may be able to considerably decrease the incidence of CVD by knowing and addressing their risk factors early on including knowing their family history, the warning signs of CVD including atypical signs often observed in women and by being informed about various preventive measures. As frontline health care providers, pharmacists can not only educate patients about the proper use of their medications, but also encourage patients to be proactive about their cardiovascular health by incorporating healthy lifestyle habits such as healthy, balanced diets, losing weight if warranted, exercising and getting adequate rest, obtaining routine health care and by knowing the values of their lipid profiles and keeping track of their blood pressure levels and by discussing their risk factors with their primary health care providers.

References:

  1. American Heart Association. Facts about heart disease in women. American Heart Association website. https://www.goredforwomen.org/en/about-heart-disease-in-women/facts
  2. Centers for Disease Control and Prevention. Women and heart disease. Centers for Disease Control and Prevention website. https://www.cdc.gov/heartdisease/women.htm  Reviewed January 31, 2020. Accessed March 18, 2021.
  3. European Society of Cardiology. Heart disease deaths rising in young women. European Society of Cardiology website. https://www.escardio.org/The-ESC/Press-Office/Press-releases/Heart-disease-deaths-rising-in-young-women. Published February 10, 2021. Accessed March 16, 2021.
  4. Khan SU, Yedlpati SH, Lone AN, et al. A comparative analysis of premature heart disease- and cancer-related mortality in women in the USA, 1999–2018. Eur Heart J Qual Care Clin Outcomes. 2021. doi:10.1093/ehjqcco/qcaa099
  5. Web MD. More Young U.S. Women Are Dying From Heart Disease. WebMD website. https://www.webmd.com/heart-disease/news/20210216/more-young-us-women-are-dying-from-heart-disease. Publsihed February 16, 2021. Accessed March 16, 2021.
  6. Medical News Today. Women’s heart disease risk may be at lower blood pressure thresholds. Medical News Today website. https://www.medicalnewstoday.com/articles/womens-heart-disease-risk-may-be-at-lower-blood-pressure-thresholds. Published February 24, 2021. Accessed March 16, 2021.
  7. Shah T, Haimi I, Yang Y, Gaston S, Taoutel R, Mehta S, Lee HJ, Zambahari R, Baumbach A, Henry TD, Grines CL, Lansky A, Tirziu D. Meta-Analysis of Gender Disparities in In-hospital Care and Outcomes in Patients with ST-Segment Elevation Myocardial Infarction. Am J Cardiol. 2021 Feb 25:S0002-9149(21)00164-8. doi: 10.1016/j.amjcard.2021.02.015. Epub ahead of print. PMID: 33640366.
  8. Walter M. Women consistently experience longer delays in care, worse outcomes following a life-threatening heart attack. Cardiovascular Business website. Published March 4, 2021. Accessed March 22, 2021. https://www.cardiovascularbusiness.com/topics/acute-coronary-syndromes/patient-care-outcomes-women-heart-attacks-stemi 
  9. Lau ES, Hayes SN, Volgman AS, Lindley K, Pepine CJ, Wood MJ; American College of Cardiology Cardiovascular Disease in Women Section. Does Patient-Physician Gender Concordance Influence Patient Perceptions or Outcomes? J Am Coll Cardiol. 2021 Mar 2;77(8):1135-1138. doi: 10.1016/j.jacc.2020.12.031. PMID: 33632488.
  10. American College of Cardiology. Do Female CV Disease Patients With Female Physicians Fare Better? American College of Cardiology website. https://www.acc.org/latest-in-cardiology/articles/2021/02/22/19/50/do-female-cv-disease-patients-with-female-physicians-fare-better. Published February 22, 2021. Accessed March 18, 2021.

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