Female CV mortality lags behind male mortality; lifetime risk assessment, not 10-year risk, is a better estimation tool for women
Recent surveys of American women reveal that approximately half still do not identify heart disease as the No. 1 cause of death among women. While mortality among men from cardiovascular disease (CVD) has declined steadily as a result of increased screening and detection and effective treatment, the rate among women lags dangerously behind. Paradoxically, the standard tools for 10-year CVD risk stratification have in the past misclassified women who are at intermediate risk, leaving them vulnerable in a time when excellent preventive measures are available.
In this podcast, renowned preventive cardiologist and women’s heart health expert Dr. C. Noel Bairey Merz speaks directly to these and other critical issues in advancing CVD detection and prevention in women and offers concrete ideas to help primary care physicians take action in daily clinical care.
Women and Heart Disease: Incidence, Prevalence, Progress, and the Future
Links to Resources Mentioned in this Podcast
Fifteen-Year Trends in Awareness of Heart Disease in Women: Results of a 2012 American Heart Association National Survey
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women 2011 Update : A Guideline From the American Heart Association
Framingham Risk Score Calculator
Framingham Risk Score Calculator SI Units
Prevention of Heart Disease in Women: Pearls for Primary Care
1. Although heart disease remains the leading killer of women, women themselves continue to believe that breast cancer poses the greater mortality threat. Awareness is improving, however, as 53% of women in 2012 identified heart disease as the primary threat, compared with less than 20% two decades ago.
2. Female CV mortality has fallen along with overall mortality from heart disease. Nonetheless, there is still a gender gap as reduction in mortality from heart disease among men exceeds the rate of reduction among women.
3. Women face unique CV risks that primary care physicians need to account for when assessing and managing prevention of CVD in women:
o Risk factors unique to women: pregnancy related complication (hypertension, gestational diabetes, eclampsia/pre-eclampsia), autoimmune disease (eg, systemic lupus erythema, rheumatoid arthritis)
o Risk assessment scores: Framingham and Reynolds Risk Scores incorporate gender but may still underestimate the 10-year risk in women, especially since they do not incorporate risk factors unique to women. As stated in the AHA guidelines for the prevention of CVD in women, lifetime risk is a better tool for CVD risk assessment for women
o Hypertension: pregnancy-related hypertensive syndromes (as above) confer a higher CV risk to women.
o Every woman with known heart failure should be on optimal medication management (“Magic 4 pills”): aspirin, beta-blocker, statin, ace-inhibitor
4. Hyperlipidemia, statins and prevention: Treatment of hyperlipidemia is inconsistent among women and primarily varies with age. Data from NHANES suggest that primary care physicians are excellent at controlling and treating elevated cholesterol in the older female population (age 65+ years). These data show, however, that middle-aged and younger women remain undertreated. This may be an artifact of an unexplained reluctance among PCPs to prescribe statins to younger women, which may perhaps be linked to concerns about statin use and pregnancy or potential pregnancy.
• Primary prevention: For some time there was debate about the efficacy of statin therapy for women in primary prevention. This was largely because most statin trials were performed primarily in men and so data on women was underpowered. The JUPITER trial was the first study to provide unequivocal evidence that statins are effective in primary prevention in women and should be used.
• Secondary Prevention: All women who have had a previous cardiac event, or have established coronary artery disease should be treated with a statin.
5. Statins should be avoided in women who are pregnant or planning to become pregnant.