Are women undertreated for heart disease?

The incidence of cardiovascular disease (CVD) in the United States outranks all other causes of morbidity and mortality. However, the perception still persists that CVD affects primarily men, and that women are somehow protected from it. The reality is a little more sobering. Nearly half a million women in the United States die from CVD every year, and in the year 2000, 41% of all female deaths were attributed to CVD.

One in three women over the age of 65 has clinical evidence of coronary heart disease. Heart attacks, for a number of reasons, also appear to be more lethal in women. While 25% of men will die within one year following a heart attack, that number rises to 40% in women. Overall, heart attacks are responsible for the death of more than a quarter of a million women annually, more than six times the number who die from breast cancer.

Despite the prevalence of heart disease, numerous studies and surveys reveal that many women underestimate their risk for heart disease and overestimate their risk for cancer. They mistakenly see cancer—and in particular, breast cancer—as their biggest health risk. When asked in a 2002 survey commissioned by the Society for Women's Health Research which disease they feared most, the No. 1 response was breast cancer. Only 6% of respondents even mentioned heart disease as a health concern, although more American women die from coronary artery disease alone, than from all types of cancer combined.

There has been a significant rise in heart disease in women and it's a multifaceted issue, according to Emma Meagher, M.D., associate director, Cardiovascular Risk Intervention Program at the University of Pennsylvania Health System. "There's no question that the incidence of heart disease in women has grown disproportionately to that in men," she said. "And while death from CVD has been declining for both genders, the decrease has been far less for women."

Cancer awareness is the result of successful public education and campaigns geared specifically toward women. The media response has been tremendous, but unfortunately, the same has not held true for CVD. Unlike breast cancer, there are no pink ribbons, no 4K runs, and few celebrities lending their name to advertisements and campaigns. Efforts are now being made by the American Heart Association (AHA) and other groups to drum up awareness, but most women still do not perceive heart disease as being a substantial health concern and are not well informed about their risk.

Recent studies also suggest that primary care physicians may not be discussing the risks of CVD with their female patients. In one survey of more than 1,000 women, less than 30% said that their physicians had ever discussed heart disease with them during the course of an office visit. Results also showed that the younger a woman was, the less likely heart disease would be discussed, and 90% reported that they would like to discuss heart disease or risk reduction with their physicians.

A previous survey, conducted among 1,002 women by researchers from Columbia University College of Physicians & Surgeons and published in the Journal of Women's Health in April 1997, found that more than 45% of women 60 years or older also reported that they had not discussed heart disease with their physicians. Data analyzed from the Centers for Disease Control & Prevention's National Ambulatory Medical Care Survey showed that in nearly 30,000 routine visits to physicians, only a minor proportion of women were counseled about physical activity, diet, and weight reduction—lifestyle modifications that reduce CVD risk factors.

"There have been surveys looking at primary care physicians and their awareness of heart disease in women, and it clearly isn't where it should be," said Sharonne Hayes, M.D., director of Mayo Clinic Women's Heart Clinic. "And we also have to remember that many women use their OB/GYN for primary care, and that's a group of physicians whose concerns are different, so it may not be on top of the list. We need to get heart disease on top of the list."

Treated differently from men?

Even though women are more likely to die from heart disease then men, data suggest that they may be undertreated. According to statistics compiled by AHA, women are recipients of only: 33% of angioplasties, stents, and bypass surgeries; 28% of implantable defibrillators; and 36% of open-heart surgeries.

Michael Shlipak, M.D., of the University of California at San Francisco, and colleagues found that women who had suffered a heart attack were not getting adequate treatment. Beta-blockers were used by only a third of the women who should have been taking them, and only half of the women who may have benefited from cholesterol-lowering pharmaceuticals were using them. All of the women should have been taking aspirin as well, but only 80% were doing so.

"Our findings were consistent with other studies, in that, overall, both men and women receive less adequate therapy than they should," explained Shlipak. "Our study included only women so we can't compare it with men. But overall, they were receiving less aggressive treatment than the guidelines recommended for people with heart disease."

Shlipak added that the reasons for less aggressive treatment were not clear. "We don't know what the women spoke to their doctors about, how many of the cases were because the doctor never offered it or the woman refused it—that part we can't say. But it is consistent with other studies, at least in the United States, that not enough patients with heart disease are taking the drugs they need," he said.

A national survey of female heart patients found that 52% were dissatisfied with some aspect of their health care, particularly physician communication styles. More than half of them stated that they had suffered a mental illness as a result of their CVD, with 38% reporting clinical depression, 17% anxiety, and 21% both. Many of the respondents expressed feelings of being socially isolated or not having sufficient support in dealing with their illness. The survey included 204 women. It appeared in the January/February edition of Women's Health Issues. The researchers were from WomenHeart: The National Coalition for Women with Heart Disease, Washington, D.C.; Cardiology Associates, PC, Washington, D.C.; Mayo Clinic Women's Heart Clinic, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic.

"The high percentage of women who had some type of mental illness, particularly depression, should be a take-home message for us," said Hayes, who was lead author of the study. "We can do better at screening and treating these women," she said.

In his experience, Joseph Saseen, Pharm.D., assistant professor of pharmacy at the University of Colorado, hasn't found that women are treated differently from men. But they may need to have messages communicated differently by their providers, he pointed out. And many patients will always be unhappy with their care to some extent.

"This stems from many things—direct-to-consumer marketing, misconceptions of what they should expect, and so on—and is worsened by the inappropriate interpretation of medical information to the public through the media," Saseen said. "For example, many women now think that hormone replacement therapy is always harmful, when this simply is not always true when put in a medical perspective."

Diagnosis

Women with heart disease also tend to be underdiagnosed, and this may be partly due to a difference in presenting symptoms. They typically do not present with the classic crushing chest pain that men have, and often a woman's description of her pain is much less specific. This may be particularly problematic in a younger, premenopausal woman. There is a higher threshold for physicians to consider that a younger woman is having a coronary event because it is less common, and she may be treated for another disorder.

Women may also not get care immediately, which can ultimately delay a diagnosis and treatment. "Gender was found to be an independent predictor of delay in getting care," said Judy Hsiah, M.D., director of the Lipid Research Clinic at George Washington University, referring to a recent study. "Some of the women knew that they were having a heart attack, but did not go immediately to the hospital or call an ambulance."

Hsiah speculated that the women may have had atypical symptoms or were in denial, and that many women still don't think of themselves as having coronary disease. Many may also not have access to health care, and women are often the last member of the family to gain access.

As with men, cholesterol levels can help predict the risk of CVD. However, what is especially important for women is knowledge of the HDL level. A normal total cholesterol level does not mean that the risk of dying from CVD is normal, explained Meagher, but the HDL is predictive of future events. Levels of triglycerides and Lp(a), which consists of a particle of low-density lipoprotein cholesterol linked by a disulfide bond to a large glycoprotein, can also be predictive of future cardiovascular events in women. Lp(a) levels above 30 mg/dl are generally considered elevated, and this number is exceeded by approximately 25% of the general population.

As a result of the data released by the Women's Health Initiative study, several women have decided to stop usage of hormone replacement therapy (HRT). The outcome of this may be that abnormal lipid profiles are being unmasked. Some of the women were taking hormones for menopausal symptoms, said Meagher, and were unaware of abnormalities in their lipid profiles. Others may have been using HRT to manage risk factors, including lipids. "At any rate," she said, "these women are coming off therapy, and their lipid parameters are worsening."

Metabolic syndrome, also known as syndrome X, is a cluster of risk factors that puts individuals at a significantly increased risk of Type 2 diabetes and CVD. The four major risk factors are central obesity (waist circumference > 102 cm for men and > 88 cm for women), impaired fasting glucose, dyslipidemia (HDL cholesterol < 45 mg/dl for women and < 35 mg/dl for men, or triglycerides > 150 mg/dl), and hypertension. Compared with women of the same age without diabetes, those with the disease face a risk of heart disease that is between three and seven times higher, as well as an increased risk of stroke. The addition of obesity, hypertension, and hyperlipidemia greatly increases the risk. The presence of diabetes will double the risk of a second heart attack in women but not in men.

This is an area that needs a lot of attention, explained Jean Nappi, Pharm.D., professor of pharmacy at the Medical University of South Carolina. "Women with Type 2 diabetes need to understand that they should be receiving the same type of attention as someone who has heart disease. They need to be treated aggressively because of the higher risk."

Treatment

Treating women with pharmaceutical agents has been trickier than treating men, since women have been underrepresented in clinical trials and still comprise only 25% of participants in all heart-related research studies.

Statins, for example, have been found to be safe in studies, but less than 20% of trial participants have been women. The question was raised as to whether statins might have a negative effect on reproductive hormones, thus reducing fertility, particularly in women. Since premenopausal women had been underrepresented in clinical trials of these drugs, some doctors hesitated to routinely prescribe statins to this population. However, a recent trial has found that statins do not exert an adverse effect on female reproductive hormone levels.

Digoxin, long used to treat heart failure, was found last year to increase a woman's risk of death by about 23%. The same does not appear to be true in men. This finding was regarded by many as very surprising, since digoxin and other drugs in the digitalis group are some of the oldest drugs in common usage for patients with heart failure. But beta-blockers have been found to provide the same benefits to both men and women, according to results of one of the largest studies to examine gender differences in treating heart failure, and adverse events appear to be the same for both sexes.

There needs to be a concerted effort to remind all clinicians that all patients with cardiovascular needs, independent of their sex, must be treated appropriately, said Saseen. "This can be done by implementing programs that increase the utilization of appropriate medications, and also by having pharmacists participate in the care of patients in the emergency room and in the hospital."

Nappi agreed that pharmacists have a strong role to play in the community as well, especially by identifying diabetes patients who may not be aware of their risk for CVD. "Pharmacists need to look at their patient profiles. If a pharmacist has a patient who is taking either an oral hypoglycemic agent or insulin, then the pharmacist needs to see whether that patient is also taking aspirin, a statin, or an ACE inhibitor," she said. "If not, the pharmacist needs to ask the patient whether she knows her cholesterol level or her blood pressure or whether she's aware of the risk factors for coronary artery disease."

Blood pressure measurements and cholesterol panels can often be done right at the pharmacy, but if not, then the pharmacist can encourage the woman to speak with her primary care physician.

Roxanne Nelson

The author is a writer based in Seattle.

 

Roxanne Nelson. Are women undertreated for heart disease?. Drug Topics Women's Health Supplement;147:29s.