As women actresses walked the red carpet at the Golden Globe awards dressed in black in order to corroborate and validate the #metoo movement, I was touched by the notion that women are increasingly standing up for each other and coming together for the betterment of all women’s lives. As this consolidation of purpose is occurring, I can’t help thinking that we can do even more. What about the fact that heart disease continues to be the number one killer of all women, with statistics continuing to reveal that when women present with symptoms related to heart disease, they are under-diagnosed, provided with less treatment, and have significantly worse outcomes compared to men? How can we continue to ignore this most critical woman’s issue? As long as we are standing up for women, shouldn’t there be a movement as powerful and significant as #metoo, that could shed light on the fact that more women are dying of heart disease than from any other cause, and that this is largely preventable? I believe doctors must get on board with this issue, so let’s look at the cold hard facts.
When reviewing the major trials on women and heart disease, it is clear that the paradigm of women and heart disease has to change. The WISE trial, which elucidated how chest pain in women can be associated with non-obstructive coronary artery disease, and was the first significant research to demonstrate microvascular disease in women and microvascular disease. WISE trial Of course there are the Prevention Guidelines, last written in 2011, which showed the profound impact of hypertension, diabetes and depression on women’s hearts and explained pregnancy as a “metabolic stress test.” Prevention Guidelines There are the American Heart Association Stroke Guidelines, published in 2014, Stroke Guidelines for Women, showing that pregnancy, hormones and migraines all contribute to the risk of stroke. Lastly, the American Heart Association Scientific Statement from 2016 about Acute Myocardial Infarction in Women, shedding light on how women are less frequently referred to lifesaving treatment and are less likely to be prescribed medication to prevent complications, improve quality of life and for secondary prevention of MI.
In spite of these guidelines and recommendations, and the progress made in research, we are still seeing more women dying of heart disease, more than all cancers combined. When outcomes in women with heart disease is worse, I propose we focus on the preventive aspects and women’s heart health, so we can truly combat these statistics and provide strategies for early detection of disease, before there are clinical manifestations. With all that we know now, there are basics that could perhaps change how we approach our women patients when it comes to talking care of their hearts:
- The beginning of heart disease in women is not detected through typical testing, such as a stress test, that looks for blockages 70% or greater. Although the stress test could determine functional capacity, it does not detect the stage at which disease begins, and is most preventable-- endothelial dysfunction. Screening tests looking for plaque in the arteries, such as coronary artery calcium scores or carotid dopplers, can identify those women with pre-clinical disease, who have risk factors or a family history, but it is obvious that our goal--especially when outcomes are so bad—should be to find disease before it starts.
- Understand the huge impact of psychosocial risk factors on women’s hearts and screen for depression and social isolation.
- Screen more aggressively for those women with a family history, and more so for those with multiple risk factors.
- Heart disease in women typically begins with endothelial dysfunction, which can often be detected during pregnancy. Just imagine the ramifications for early detection!
I believe the key to prevention might lie in the AHA 2016 Scientific Statement entitled “The Importance of Assessing Cardiorespiratory Fitness in Clinical Practice: A Case for Fitness as a Clinical Vital Sign”. This guideline describes that a woman’s ability to exercise could be the key to the understanding the health of her heart. In fact, a lack of cardiorespiratory fitness is most likely a stronger predictor of mortality than the traditional major risk factors such as smoking, hypertension, high cholesterol, and type 2 diabetes. A cardiopulmonary exercise test (CPET) is a diagnostic test which can diagnose endothelial dysfunction and microvascular disease, and should be part of standard evaluation of our women patients. Studies have shown that “prescribing” exercise alone, based on the CPET, can change outcomes, as for each 1-MET increase of exercise and cardiorespiratory fitness, there was a 21% lower cardiovascular disease mortality for women (and men) who were less than 60 years old at baseline.
Treatment of women can change to become more effectively preventive. We can beat the number one killer of all women--by diagnosing earlier in the disease process, and implementing lifestyle changes and medications to prevent progression. This goal is multi-fold and necessitates the participation of women patients, doctors, and the medical system in general, but we all need to collaborate on this significant venture. This is the time, as we are already coming together on so many other women’s issues. Let’s use the tools we have to become less reactive in the paradigm, or more proactive in caring for women’s hearts. It’s time to set aside opinions, old ways, and traditional methods in favor of the data, because so far, our opinions have been selling our women patients short. Let’s get on board with a new direction, so we can more actively and vigorously and meaningfully pursue our true mission as doctors: Saving lives.
