The ACC Corner | Closing the Gender Gap: Women & CV Disease

	JoAnne M. Foody, MD, FACC

Cardiovascular disease (CVD) is the No. 1 killer of women in the U.S., followed closely by stroke at No. 3. Together, they claim nearly half a million lives each year, or one life each minute. Statistically speaking, women are more likely to die from CVD than anything else. They also are more likely to die from CVD than men.

Given these statistics, coupled with the fact that women comprise nearly 50 percent of the U.S. population, one would think that determining optimal treatment of women for CVD would be a given. However, despite medical breakthroughs, cutting-edge science and the increasing ability to prevent heart disease, women (particularly African-American and Hispanic women) are not reaping the rewards of these advances. While there has been a striking reduction in CVD mortality in men over the last 40 years, reductions in women have lagged behind.

What is missing is an understanding of the gender-specific differences in the presentation, manifestation and diagnosis of CVD. Some of the biggest differences are:

• Women have more "atypical" symptoms of CVD compared with men;
• Women have more "silent ischemia," making CVD harder to detect;
• Even when women report symptoms, they show less obstructive CVD compared with men with the same degree of symptoms, suggesting a disease pattern that is different than men and—unfortunately—harder to detect; and
• Once women develop obstructive coronary heart disease, they appear to have more adverse outcomes—including a greater risk of dying—compared with men.

These differences often impact treatment decisions. For example, preventive therapies are less often recommended to women. While women are more likely to be diagnosed and treated for hypertension, they are less likely to reach treatment goals. High-risk women—including diabetic women—are less likely to be on lipid-lowering agents and reach the low levels necessary to stay healthy. Diabetic women also are less likely to reach healthy low levels.

As women grow older, their risk of heart disease and stroke begins to rise. And, like men, women with a family history of heart disease are likely to have heart disease as well. In terms of race, African-American and Asian women have a greater risk of developing CVD (and stroke) than white women. Some of this may be due to a higher prevalence of diabetes among certain ethnicities, as well as economic status and suboptimal access to care.

Previous heart attack also is a key factor, given that women who have had one heart attack have a high risk of experiencing a second one. Statistics show that 43 percent of women surviving an MI who are 40 years or older will die from a second attack or underlying CVD within five years. Other factors, including the use of birth control and hormone therapy, are still being studied, but could play a role (J Am Coll Cardiol 2009;53:221-231 and J Am Coll Cardiol 2001;38:1-7).

The good news is CVD is 90 percent preventable in both men and women. Factors such as smoking, high cholesterol, hypertension, diabetes, physical inactivity, obesity, diet and stress can all be controlled and managed. Over the last decade, research into the treatment of CVD has adapted to include women, with the results providing opportunities to educate providers and patients about the best treatment options. While there is still a long way to go before the gender gap is closed, we are making headway and improving outcomes for women.

Dr. Foody is the new CardioSmart Associate Editor, and medical director of the Cardiovascular Wellness Program at Brigham and Women's Hospital.