One of the study authors reports receiving research grants from Abbott, Amgen, AstraZeneca, Bayer, Cytokinetics, Janssen, Medtronic, Merck and Novartis. Wenger reports no relevant financial disclosures.
Clinicians and researchers must address pervasive gaps in knowledge and care delivery to reduce sex-based disparities and achieve equity in cardiology care, according to a presidential advisory from the American Heart Association.
In the advisory, the AHA presents a “roadmap” to implementing a vision for equity for women and their CV health. The statement focuses on epidemiology and prevention, awareness, access and delivery of equitable health care and providing a call to action across multiple disciplines.
“We have lost some of the advantages we had gained over the years for women’s heart health,” Cardiology Today Editorial Board Member Nanette K. Wenger, MD, MACC, MACP, FAHA, FASPC, emeritus professor of medicine (cardiology) at Emory University School of Medicine, consultant at Emory Heart and Vascular Center and founding consultant at Emory Women’s Heart Center, said in an interview. “In 2000, as we began to have sex-specific diagnostic, therapeutic and educational messages, CVD mortality among women dropped dramatically. By 2013, for the first time, fewer women than men died of heart disease. Now, we are seeing an increase in CV mortality both among women and men. Women are less healthy, even young women, and are coming to pregnancy with lower levels of heart health. That is one of the more frightening features. We must address women across the life span, with particular attention paid to young women and women of racial/ethnic minorities.”
Cultural shift needed
Véronique L. Roger
The advisory highlights the need for a cultural shift in how CV health data are presented to achieve health equity for women, according to Véronique L. Roger, MD, MPH, FAHA, a senior investigator at the NHLBI and a co-author of the advisory.
“Labeling the presentation of women as ‘atypical’ or different is a way to imply that their symptoms are somehow out of the norm,” Roger said in an interview. “We need to move away from this normative language and consider looking at how women and men present. We also need to look at how men and women may present differently by race and ethnicity. The intersectionality of CVD is at the crux of this conversation. It is very complex; however, we must accept that complexity, embrace it and start working on it.”
Wenger said women share traditional CV risk factors with men; however, the advisory emphasizes six risk factors that are unique to women or predominate in women:
- early-onset or the early termination of menses, or hormonal imbalances leading to irregular ovulation;
- risks related to pregnancy, such as hypertension, diabetes or preterm delivery;
- risks related to oral contraceptives and hormone replacement therapy;
- inflammatory diseases such as lupus and rheumatoid arthritis;
- depression and anxiety symptoms; and
- risks related to cancer treatment, such as breast, uterine or ovarian cancer.
“When any of these are seen, this identifies a population of women at risk,” Wenger told Healio. “Their entire village, if you will, of health care providers must be precise about control of the traditional risk factors. These women should not be smoking; their BP must be controlled; weight management is important. The traditional Life’s Simple 7 metrics.”
Knowledge gaps, research needs
The authors noted that there are sex-specific research needs to address gaps in knowledge and research related to CVD in women. To address those gaps, the advisory calls for developing and deploying risk calculators that incorporate sex-specific and sex-predominant risk factors, as well as fostering cross-disciplinary research on social determinants of health and adopting and implementing cross-disciplinary risk factor interventions that embrace intersectionality and cultural sensitivity.
“We have to define the characteristics of women across their life cycle for the way they present with disease and realize there are specific issues for women. I am concerned that when we interview medical students, trainees and even physicians, many are uncomfortable addressing heart health of women. We need a system of lifelong learning, so all of these items are now included in the way everyone practices clinical care,” Wenger told Healio.
‘Look forward’ to address gaps
Roger said clinicians and researchers must ”look forward in real time” to be aware of and to investigate changes as they happen, incorporate new techniques and address gaps and barriers quickly.
“This is bigger than cardiologists; primary and primordial prevention is also happening in primary care,” Roger told Healio. “I am fully aware that time spent face-to-face with patients is shrinking in cardiology and in primary care. The right forum to educate these women is debatable, particularly in a culturally sensitive way. During a 10-minute office visit, I am not sure this can happen. Perhaps medical offices need to think about creative ways to dispense medication in way that does not require the time of the actual provider.”
The advisory concludes with six specific calls to action for health care professionals, researchers and the public, including creating and implementing heart health-awareness campaigns that are culturally sensitive and appropriate, optimizing prevention and clinical care through interdisciplinary partnerships; increasing the number of research studies focused on women; engaging communities in heart health programs; encouraging advocacy for public policy and legislative interventions; and surveying and monitoring disease and risk factor data to better capture information that is critical to improving prevention and outcomes.
“The message is the female heart is vulnerable,” Wenger told Healio. “It takes a village to improve access to care, quality of care and equity in women’s heart health. Equity does not mean care must be the same as a man. It has to be specific to women, so the outcomes are as good as they are for men.”
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