Ramping up the battle against cardiovascular disease in women represents a golden opportunity to move the mortality needle.
By their own admission, physicians are often treading water when it comes to accurately diagnosing and treating women with cardiovascular disease (CVD). Consider how a community hospital in California recently handled a 78-year-old female patient with a history of angina and nonobstructive coronary artery disease consistent with microvascular dysfunction. Admitted for an incarcerated hernia that needed urgent repair, the woman was taken off her heart medications and suffered a heart attack two days after surgery. A stress test was found to be abnormal, but the woman’s treating physician considered the results a false positive since her coronary arteries weren’t blocked. Consequently, the woman was sent home from the acute care facility without any orders to restart her heart medications.
Helping to frame the oft-leveled charge of a gender gap are 2014 findings from The Women’s Heart Alliance that only 22 percent of primary care physicians and 42 percent of cardiologists felt extremely prepared to assess CVD risks in women, and even fewer of these professionals reported implementing industry guidelines for risk assessment (J Am Coll Cardiol 2017;70:123-32).
“The female pattern of ischemic heart disease is not recognized up to a third of the time by either physicians or traditional testing,” says C. Noel Bairey Merz, MD, director of the Barbra Streisand Women’s Heart Center in the Smidt Heart Institute at Cedars-Sinai in Los Angeles, which partnered with the Ronald O. Perelman Heart Institute at New York-Presbyterian Hospital/Weill Cornell Medical Center to found the Women’s Heart Alliance.
Sharonne Hayes, MD, professor of cardiovascular medicine at the Mayo Clinic and researcher of conditions that uniquely affect women, minces even fewer words in discussing what physicians often miss. “Some women with microvascular disease who complain of angina feel they must be crazy and should see a psychiatrist because their doctor says there is nothing wrong with them,” she says. “It reaches a point where they’re not just undertreated but under-believed.”
Statistically, coronary heart disease afflicts 6.6 million women annually in the U.S., more each year than all cancers combined. Nearly two-thirds of women who die suddenly reported no previous symptoms. Within the first year of a first heart attack, more women than men will die (26 percent vs. 19 percent). And despite their substantial CVD burden, women comprise only about 20 percent of enrolled patients in clinical trials, according to the American Heart Association (AHA).
Other numbers, however, paint a sunnier picture of progress made over the past decade thanks to greater awareness, education and advocacy around cardiovascular health in women. For the first time since 1984, for example, CVD mortality rates were slightly lower in females than in men in 2013, though the rate for both sexes rose in the following two years, according to “Heart Centers for Women” a white paper published in Circulation (2018;138:1155-65).
Percutaneous coronary interventions (PCIs) also have produced dramatically better outcomes for women as technology enables clinicians to respond earlier to bleeding and safety issues with smaller catheters and more judicious use of blood thinners and contrast agents (though women continue to experience almost twice the rate of bleeding as men after PCI). And despite a higher upfront risk of complications, women have a better long-term survival rate after transcatheter aortic valve replacement than men (JACC Cardiovasc Interv 2018;11:24-35).
CARDIAC REHAB OPPORTUNITIES
These gains may seem small to some given the uphill battle ahead to gain clinical and research parity with men. But to other advocates for women’s cardiovascular health, they highlight the vast opportunities that exist to meaningfully move the mortality needle and improve quality of life for a cohort that includes almost 50 percent of the world’s population.
To Laxmi Mehta, MD, associate professor of medicine at Ohio State University’s Wexner Medical Center and director of its Women’s Cardiovascular Health Program, those overarching goals are well within reach but will first require a greater awareness not just of CVD, but of its post-event outcomes. “Women fare far worse than men after myocardial infarction,” she notes, “so how we reduce that statistic will be critical in terms of improving cardiovascular health.” Her prescription: a much greater focus on secondary prevention of heart disease, particularly cardiac rehabilitation (CR).
There’s no shortage of room for improvement. According to an AHA scientific statement on acute myocardial infarction (AMI) in women, “although referral to CR is designated as a performance measure of healthcare quality after AMI, CR has failed to reach more than 80 percent of eligible women in the last three decades” (Circulation 2016;133:916-47). Among patients’ barriers to participation: lack of encouragement or actual referral by physicians, unwillingness to commit the time, feeling that the program is not right for them, lack of insurance and competing work or family obligations.
CR is “one of the most effective and cost-efficient interventions we can do to keep people out of the hospital and keep them from dying,” Hayes says. “If instead of 20 percent of eligible women attending cardiac rehab the number was 50 or 60 percent, the impact on secondary prevention and on women’s mental health, physical health and general well-being would be tremendous. Unfortunately, that message is not getting across.”
Mehta says CR “is not just exercising, but learning from nurses and physical trainers about cardiovascular disease awareness, compliance with medications, mental fitness and other forms of secondary prevention. In many ways it’s an extension of the physician’s office.”
DRAWING WOMEN TO CARDIOLOGY
Another way to close the gender gap would be to give women a greater voice and physical presence in the field of cardiology. The “Heart Centers for Women” white paper reported that females currently represent just 13.2 percent of all practicing cardiologists and 21 percent of all fellows-in-training in the U.S. Bolstering the case for more women in the field are the results of a study of 582,000 women who suffered heart attacks over 19 years (Proc Natl Acad Sci USA 2018;115:8569-74). The study showed that women had higher mortality when treated by male physicians and that gender concordance increased a patient’s probability of survival.
“I’m working very hard to better understand why more than half of the medical school graduating class today is composed of women and yet such a small percentage ends up in cardiology and interventional cardiology,” says Roxana Mehran, MD, professor of medicine, cardiology and population health science and policy at the Icahn School of Medicine at Mount Sinai in New York. As for underlying reasons, she adds, “It’s profoundly demeaning for women as cardiologists not to have the same opportunities for leadership, promotion and pay. Our male colleagues are getting a lot of the recognition, and we need to make sure the same stage is set for women. When that happens, I can’t imagine why we wouldn’t be able to attract more women into cardiology.”
Turning cardiology into an alluring career choice for women will be no easy task. “The big drop-off comes from residency into fellowship,” Mehta says. “Some of that is due to the perception that cardiology is a very difficult field that’s not very family friendly. We’re trying to dispel that because many of us have been successful female cardiologists with fulfilling family lives.”
Professional societies have taken up the challenge, particularly the American College of Cardiology (ACC) through its Diversity and Inclusion Task Force and Women in Cardiology Section. The latter has more than 25 chapters around the country working toward parity for women through professional development, mentoring and networking programs. “We’re changing the culture within cardiology as a profession to be more inclusive, professional and equitable,” says Pamela S. Douglas, MD, professor of research in cardiovascular diseases at Duke University, chair of the ACC’s Diversity and Inclusion Task Force and a past ACC president.
NEED FOR ENHANCED TRAINING
If practicing physicians are ill prepared to recognize conditions like spontaneous coronary artery dissection (SCAD), coronary microvascular dysfunction, Takotsubo cardiomyopathy and fibromuscular dysplasia in women, then greatly enhanced training is often proffered as the cure. Proponents of reform say the effort must be driven by academic medical centers that train medical, nursing and health science students and by heart centers for women, which began emerging in the 1990s in response to the unmet needs of women and today are an integral part of many large healthcare centers and academic cardiology programs.
“Heart centers for women continue to provide front-line care for our patients,” emphasizes Mehta, who is associate program director for education at Ohio State’s Center for Women’s Health, “but they also need to be heavily involved in providing cardiovascular education for medical students up to completed trainees to develop clinical competencies where there are still few, if any, sex-specific guidelines and best practices.”
The “Heart Centers for Women” report, which Mehta co-authored, calls for an even bolder step. It would expand the professional training of medical schools in tandem with women’s heart centers to practicing physicians, nurses and advanced practice providers, and would include continuing education around sex- and gender-based differences in care, assessment of cardiovascular risk, treatment and outcomes in women.
CASE FOR PATIENT INVOLVEMENT
The need to disseminate more practice information and knowledge to physicians—a linchpin of the movement to retool cardiovascular practice around women—could just as easily apply to patients. Germane to this argument is a growing body of evidence showing that most women still only give lip service to CVD.
The 2014 Women’s Heart Alliance survey revealed “that one out of two women still don’t know that heart disease is the leading killer of women and that one out of five even thought it was relevant to them,” Bairey Merz notes. “Women continue to avoid talking about this subject to their healthcare providers, often because they think it’s about being overweight.” Instead, she adds, “they should be going to their doctor to get their cholesterol, blood pressure and blood sugar checked and to have a discussion on exercise and eating right. The average woman on the street still doesn’t know about this story.”
Bairey Merz sees a number of pathways for women to not just achieve parity with but eventually surpass men in terms of cardiovascular health. One way is better cardiovascular screening, and one offshoot could be to piggyback on the routine mammogram. Embedded in breast imaging exams are radiographic patterns that allow for an additional assessment and detection of cardiovascular risk, according to Bairey Merz. “If the physician in charge, the radiologist and the woman’s primary care doctor all looked at the results and noticed you were at high risk, they could say, ‘Let’s get you going on some preventive therapies.’”
Another pathway to earlier detection could be getting into the hands of the treating physician any patient history of hypertension or preeclampsia at the time of pregnancy—a task Bairey Merz believes could be handled through electronic health records. These adverse conditions can increase by five- to tenfold the risk of premature CVD later in life.
MOVING TOWARD PARITY IN RESEARCH
The sex disparity is glaring—and the chance for gains expansive—in clinical cardiovascular research. Even when women are included in studies, the data often are not disaggregated by sex, limiting the evidence-based information available to clinicians and patients. “We need more data and better tools, and we need them now,” declares Hayes, who in 1998 founded the Mayo Clinic’s women’s heart clinic that is dedicated to ensuring women and minorities are included in research aimed at better understanding sex and gender differences in conditions like SCAD, heart failure with preserved ejection fraction and microvascular disease.
Concern over the imbalance in clinical trials prompted the National Institutes of Health in 1993 to require that all of the studies it funds include female subjects and be equipped to perform sex-specific analyses. And while distaff participation has improved since then, there is still room for improvement.
Turning the tide will require intense training of women to take on leadership roles in cardiovascular clinical trials, a challenge that Douglas says the ACC’s Diversity and Inclusion Task Force is undertaking in partnership with industry, which funds many of those studies. “If we can give junior and mid-career women all the didactic learning and hands-on experience they need to become leaders in clinical trials as site [principal investigators] or on steering committees or data safety monitoring boards,” she maintains, “that would be a very powerful step forward.”