This editorial, “What Women (and Clinicians) Don’t Know Hurts Them“, originally appeared in the Journal of the American College of Cardiology. As a woman with heart disease, I wanted to immediately read it to find out what might be hurting me.
But as is common practice in most medical journals, this editorial was behind a paywall, so it was not available for heart patients like me, or anybody else who wasn’t a subscriber to the journal.
I could pay a fee of $35 for the privilege of reading this one article, but the reality is that I can’t afford to pay for articles that aren’t being published in what’s known as an open access journal.*
So I’d like to thank the editorial’s author, University of Iowa cardiologist Dr. Jennifer Robinson, for granting my direct request to her for access to a paper that seems important for all women to read. Here it is:
What Women (and Clinicians) Don’t Know Hurts Them
by Jennifer G. Robinson, MD, MPH
The decline in cardiovascular disease (CVD) mortality has plateaued, keeping CVD the leading cause of death among women (1).
Women have experienced slower declines in CVD than men, and recently, premature mortality from coronary heart disease began increasing in U.S. women over 50 years of age (2). Few women have ideal cardiovascular health, and risk factor treatment remains sub-optimal (1), with substantial disparities in risk factor control in women compared to men, and in African-American women compared to white women (3).
By 2035, almost 45% of women will be living with some form of CVD, with projected direct and indirect costs of almost $500 billion per year (4).
In response to these alarming statistics, the Women’s Heart Alliance undertook nationwide surveys of CVD awareness in women age 25 years to 60 years, primary care physicians, and cardiologists (5).
As presented in this issue of the Journal, they found that although 74% of women reported having one or more CVD risk factors, women had only modest levels of CVD awareness.
Women reported more often being told to lose weight rather than having their CVD risk factors addressed. An unfortunate consequence was that 45% of women cancelled or postponed a physician appointment until losing weight.
The majority of cardiologists (82%) believed that they were well-prepared to assess women’s CVD risk, a rate somewhat higher than primary care physicians (64%) who deliver the majority of care for women in this age group.
Nonetheless, both groups of physicians infrequently implemented all eight American Heart Associations guidelines for risk assessment (16% and 22% respectively).
On the bright side, both women and physicians were receptive to awareness and education campaigns, and supported more research in women’s CVD health.
Decades of cardiovascular prevention research have clearly identified the lifestyle habits and risk factors that cause CVD (1).
Lifestyle is the foundation of cardiovascular disease risk reduction efforts, and developing healthy lifestyle habits early in life will pay dividends over a lifetime (6).
Helping women overcome barriers to increasing physical activity and healthier eating habits may avoid the stigma of focusing on weight loss. Women are often the gatekeepers for family meals, activities, and health care, and a focus on healthy lifestyle habits may also encourage primordial prevention in the family as a whole.
Clinical trials have also established that controlling risk factors reduces CVD risk in women and men (7,8).
Preventive drug therapy plays an increasingly important role in women with advancing age, especially if a woman has been unable to maintain healthy lifestyle habits.
Efforts to increase use of evidence-based preventive medication will have the greatest measureable impact on reducing incident CVD events in higher risk women and recurrent events in women living with CVD.
Primary prevention statin and aspirin therapy requires estimation of 10-year atherosclerotic cardiovascular disease (ASCVD) risk (7,9). The (ACC)/American Heart Association ASCVD calculator performs quite well in both white and African American women in the general U.S. population (10,11).
Statins reduce the risk of stroke as well as coronary heart disease in women, with similar reductions in overall CVD risk in women and men (7). The remarkable safety record for statins in properly selected patients must be empha- sized to overcome public- and to some extent provider-hostility toward statin therapy.
Updated hypertension guidelines are in progress, but the general expert consensus is that repeated elevations in systolic blood pressure >140 mm Hg, or diastolic blood pressure >90 mm Hg after dietary modification should be treated with drug therapy (12).
Women have the unique opportunity to receive regular CVD health evaluations during their annual gynecologic examinations.
Pregnancy as a stress testcan help identify women at higher risk of developing CVD (8). It is essential to increase the comfort of obstetrician-gynecologists with performing CVD risk assessment and lifestyle counseling, accompanied by establishing referral pathways to other primary care providers or cardiologists committed to prevention, who also need to address reproductive safety issues with preventive drug therapies (7,13).
The national awareness campaign planned by the Women’s Heart Alliance will no doubt build on the rich information obtained in these surveys. But to successfully improve risk factor control, awareness efforts must be coupled with quality clinician education and implementation programs (14). Team-based approaches and non-physician–led prevention programs have been shown to improve risk factor control. It will be essential to partner with a range of professional organizations to have evidence-based continuing medical education programs in place when the public awareness campaigns begin.
Research into the most effective governmental, community, workplace, and health care system interventions and technological innovations should guide efforts to increase access and implement risk factor control programs (15).
NOTES FROM CAROLYN:
1. * Other than a direct request to the author of a paper (who are almost always very agreeable), I’ve found a few ways to access journal articles hidden behind paywalls: try The Open Access Button or Sci Hub.
2. I wrote much more about addressing cardiac risk factors in my book A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press, 2017). You can ask for this book at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (use their code HTWN to save 20% off the list price when you order).
Q: Have you ever had a medical issue that was displaced by advice to lose weight?
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