By Kenzie MacDonald
Cardiovascular disease (CVD) is the leading cause of mortality in women, currently accounting for approximately one-third of deaths in women globally1. Since 1984, the annual CVD mortality rate in women has exceeded that of men, highlighting the particularly lethal nature of CVD in women2. Despite unanimous support of these facts, in many respects CVD continues to be regarded as a male disease2-3. The perception that CVD is a disease of men has greatly contributed to the underrepresentation of women in CVD research and development of inadequate protocols for managing women with cardiac complications2.
Although twenty-five years have passed since the American Heart Association (AHA) released the first scientific statement on CVD in women, females continue to be underrepresented in CVD research3. As reported by the Institute of Medicine, this behavior is not new; the health needs of women have historically been marginalized in medical research2. A systematic review of the AHA’s 2007 guidelines for the prevention of CVD in women revealed that 135 of the 156 studies cited investigated both men and women, while 20 investigated only men, and 1 investigated only women4. With women representing only 30.6% of all participants enrolled in the 156 studies cited, the AHA’s guidelines for women are in fact based on research conducted on a predominantly male population4. As specified by the National Institutes of Health (NIH), NIH-funded trials are required to adhere to the NIH’s standard of equal sex representation5. A review conducted on 69 NIH-funded trials revealed that only 46 studies enrolled both men and women and that on average women represented 37% of the participants in those studies5.
The perception that CVD is predominantly a disease of men is apparent in the management of CVD in women1. Women are cited to receive delayed and less evidence-based treatments than men, resulting in poorer health outcomes for women experiencing acute cardiac complications6-7. It is suspected that under-diagnosis is partially correlated to the presentation of atypical symptoms in women6-7. These symptoms include, but are not limited to, weakness or fatigue, disturbed sleep, nausea, jaw, back, and shoulder pain, shortness of breath, dizziness, and an absence of chest pain6-7. As a result of these atypical symptoms, women are less likely to receive referrals for electrocardiograms or other cardiovascular diagnostic tests, further contributing to the under-diagnosis of CVD in women6-7. Similarly, women presenting atypical symptoms are often under-treated, as symptoms are assumed to be attributed to non-cardiac conditions and incorrect courses of treatment are selected6-7. In addition, women are less likely to be admitted to telemetry floors, treated by a cardiologist, prescribed some form of pharmacotherapy for secondary prevention, or referred for surgical intervention, contributing to the under-treatment of women with CVD6-7. Sex-based disparities in CVD management are also exhibited in referral patterns, treatment, and prognosis1.
As CVD is expected to remain the leading cause of death in women globally, the demand for improved research on CVD in women is imperative. Women possess sex differences of biological origin and gender differences, formed by social, environmental, and community dynamics, which must be acknowledged2. Improved sex-specific understanding of CVD is vital to the successful management of CVD in women.
- Gholizadeh, L., & Davidson, P. (2008). More similarities than differences: An international comparison of CVD mortality and risk factors in women. Health Care for Women International, 29(1), 3-22. doi: 1080/07399330701723756.
- Mehta, L. S., Beckie, T. M., DeVon, H. A., Grines, C. L., Krumholz, H. M., Johnson, M. N., … Wenger, N. K. (2016). Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation, 133(9), 916-947. doi:10.1161/CIR.0000000000000351.
- Mosca, L., Barrett-Connor, E., & Wenger, N. K. (2011). Sex/gender differences in cardiovascular disease prevention: What a difference a decade makes. Circulation, 124(19), 2145-2154. doi:10.1161/CIRCULATIONAHA.110.968792.
- Melloni, C., Berger, J. S., Wang, T. Y., Gunes, F., Stebbings, A., Pieper, K. S., … Newby, L. K. (2010). Representation of women in randomized clinical trials of cardiovascular disease prevention. Circulation-Cardiovascular Quality and Outcomes, 3(2), 135-142. doi:10.1161/CIRCOUTCOMES.110.868307.
- Geller, S. E., Goldstein-Adams, M., & Carnes, M. (2006). Adherence to federal guidelines for reporting of sex and race/ethnicity in clinical trials. Journal of Women’s Health, 15(10), 1123-1131. doi:10.1089/jwh.2006.15.1123.
- Mosca, L., Banka, C. L., Benjamin, E. J., Berra, K., Bushnell, C., Dolor, R. J., … & Oz, M. C. (2007). Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Journal of the American College of Cardiology, 49(11), 1230-1250. doi:10.1016/j.jacc.2007.02.020.
- Lansky, A. J., Hochman, J. S., Ward, P. A., Mintz, G. S., Fabunmi, R., Berger, P. B., … Jacobs, A. K. (2005). Percutaneous coronary intervention and adjunctive pharmacotherapy in women: A statement for healthcare professionals from the American Heart Association. Circulation, 111(7), 940-953. doi:10.1161/01.CIR.0000155337.50423.C9.