Heart disease is the leading cause of death in women, but it’s largely preventable if a woman knows she’s at risk and starts taking action in time to avert a heart attack or stroke.
The problem is that traditional risk calculators may be missing the full picture when it comes to female bodies and heart disease, especially in women from diverse backgrounds.
One survey of doctors found only 22% of primary care physicians and 42% of cardiologists felt “well prepared” to gauge the risk of heart disease in women.
So a wider variety of factors needs to be considered, doctors and nurses write in a new scientific statement from the American Heart Association, published in the journal Circulation this week.
They urge including female-specific risk factors — such as pregnancy complications and types of birth control used; differences by race and ethnicity; and non-biological factors, such as where a patient lives and what schedule she works — when assessing a woman’s risk.
Sex and gender aspects of heart disease have been a focus since the early 2000s when doctors noticed more women were dying than men, says Dr. Jennifer Mieres, a statement co-author and a professor of cardiology at the Zucker School of Medicine at Hofstra Northwell in Hempstead, New York.
“This focused research on women’s cardiovascular health had led to the decline in deaths for women over the past five to six years. But as we hit the COVID pandemic, we noticed that we were losing momentum,” Mieres tells TODAY.com.
“So there was a need to sort of issue a call to action, to say we need to increase awareness … but definitely make it customized to women, especially women of color. The one-size approach didn’t work.”
About 80% of heart disease is preventable, according to the American Heart Association.
Traditional risk factors include diabetes, high blood pressure, high cholesterol, family history of heart disease, smoking, physical inactivity, poor diet and obesity.
It’s a start, but the statement urges other factors to also be considered, including:
Risk factors for heart disease in women
Pregnancy-related risk factors
Complications like preeclampsia, eclampsia, gestational diabetes, gestational hypertension or miscarriage put women at risk for heart disease five to 15 years after giving birth because they can damage the endothelium — a layer of cells that lines all blood vessels, Mieres says. “Pregnancy is sort of a stress test for the heart,” she adds.
Menstrual cycle history
For example, how old the patient was when she began having periods and her age at menopause. “What we have discovered is — and this is why women are not small men — estrogen and the fluctuation in hormonal levels affects the vascular supply,” Mieres says. “The menstrual cycle piece is not fully elucidated, but we know it has to do with hormonal variation and the impact it has on the vascular system.”
Previous research has found the age at which a woman had her first period can impact heart attack risk.
Types of birth control or hormone replacement therapy used
This also impacts hormonal levels. “We are still in our infancy in terms of understanding the unique effect that hormonal treatment and pregnancy and the impact of hormones on the vascular system as it relates to women’s risk,” Mieres explains.
History of chemotherapy or radiation therapy
These treatments can cause damage to the lining of the blood vessels, which accelerates the process of atherosclerosis, Mieres says. Atherosclerosis occurs when fats, cholesterol and other substances accumulate along artery walls, according to Mayo Clinic.
Polycystic ovarian syndrome (PCOS)
PCOS has “deleterious effects” on a woman’s cardiovascular risk profile, the authors write.
Autoimmune disorders
Autoimmune disorders are more common in women than men, with patients predisposed to accelerated hardening of the arteries and increased heart disease risk, according to the statement.
Depression and posttraumatic stress disorder
Depression and PTSD are more common in women and linked with a higher risk of developing heart disease.
Heart disease risk in women can differs by race and ethnicity
For example, Black women have a high incidence of high blood pressure that’s usually undiagnosed, Mieres says. “Some of that could be related to a genetic predisposition,” she adds.
Latina women have a higher prevalence of diabetes, obesity and metabolic syndrome, but their heart disease death rates are 15% to 20% lower than in white women, the statement notes.
In South Asian women, there's also a high rate of low HDL, "which is normally the good cholesterol,” Mieres points out.
Social determinants of health
These factors may include the safety of the neighborhood where a woman lives, whether she has access to health care or heart-healthy foods, her economic stability and education level, the statement notes.
Health care workers need to understand the nuances, but women also need to see their interactions with a doctor as a partnership, Mieres says.
“I always tell my patients, ‘Pretend that you’re going to your accountant at tax time — you come with information,’” she notes. “You need to share information with me as to what has been happening with you.”
Mieres hopes the sex and gender differences of heart disease will become part of the curriculum in medical schools in the next five years so that the next survey of doctors will find 100% of them feel “well prepared” to gauge heart disease risk in women, she says.
