In their landmark review, Canadian heart researchers Dr. Karin Humphries and Dr. Louise Pilote answered this important question(1):
“Why are we examining women’s cardiovascular health in this issue of the Canadian Journal of Cardiology?” . .
Why indeed? Some of their answers may surprise you. . . .
1. Because it is a problem: “Although some studies have shown improvements for women over the past two decades, marked disparities in the diagnosis, treatment, and outcomes between the sexes still exist. Several studies, in fact, suggest that among younger women (under age 55), the incidence of heart attack is rising and outcomes are worsening.” *
2. Because women don’t know how dangerous heart disease is: Awareness of women’s cardiovascular disease (CVD) is still too low, despite initiatives like the Heart Truth campaign and Go Red for Women. Women’s awareness of CVD as their leading cause of death has increased in the United States from 30 per cent in 1997 to 56 per cent in 2012. However, the level of awareness varies by race, with black and Hispanic women’s awareness reaching just 36 per cent and 34 per cent, respectively. But there are no similar data available in Canada yet.
3. Because lack of awareness of women’s heart disease is also seen among health care professionals: A recent survey of Canadian physicians found that only 26 per cent of primary care providers (PCPs) believed that they were able to effectively support their female patients in understanding either cardiac risk factors or how to prevent and manage CVD. (2)
4. Because physicians believe more men than women die of CVD (38 per cent of PCPs and 32 per cent of cardiologists believe this, when in fact the numbers are roughly equal, and CVD is the major cause of death in both sexes).
5. Because physicians don’t know how to identify women’s cardiac risk factors: The Canadian survey authors concluded that there is a clear need to educate physicians about heart disease in women with a focus on prevention, risk factors and management. These findings are not limited to Canada. A recent survey of American physicians by cardiologist Dr. Noel Bairey Merz reported astonishing results:(3) fewer than half of U.S. cardiologists believed that they were “extremely well prepared” to assess cardiovascular disease risk in women.
Side question from Carolyn: if fewer than half of medical specialists – whose sole professional focus is on heart disease – do NOT feel “extremely well prepared”, who should women trust to assess our cardiac risks?
6. Because some physicians are not concerned enough about our biggest health threat: Cardiovascular disease was rated as the top concern of their female patients by just 39 per cent of PCPs (after body weight and breast health). So not surprisingly, only 16 per cent had implemented guidelines for cardiac risk assessment in their female patients. Guideline-based risk assessment among cardiologists was only marginally better, at 22 per cent.
7: Because too many women don’t know their heart disease symptoms and risk factors – for example, risk factors like smoking, high LDL (bad) cholesterol, diabetes, high blood pressure). In fact, fewer than half of women studied could identify smoking as a cardiac risk factor, and less than one quarter were able to name the other leading risk factors.
8. Because cardiac researchers are still not planning for sex-specific reporting of their studies: In Canada, researchers applying for funding from the Canadian Institutes of Health Research (the major federal agency that funds health and medical research in our country) must indicate whether sex or gender, or both, are being considered in projects they’re seeking funding for (for example, including sex-specific data fields like hormonal status or a history of pregnancy disorders). But although this guideline was implemented in 2010, follow-up review has found that 84 per cent of basic biomedical research and 44 per cent of clinical research failed to take sex or gender into account.
Side questions from Carolyn: Why are my tax dollars continuing to fund ANY cardiac research that fails to plan for specific outcomes in women? And why aren’t we following the U.S. model, where sex/gender inclusion is a regulation (not just a feeble guideline that’s being widely ignored here without consequence?) By comparison, in 2015 the National Institutes of Health in the U.S. added the requirement that sex be considered in ALL research applications for funding. Proposals that examine “only one sex” cannot be submitted for funding unless the researchers provide “strong justification” for deliberate exclusion (e.g. prostate cancer studies).
9. Because drugs prescribed for female heart patients have been developed and tested predominantly in white middle-aged men: The drug industry must include women in all phases of drug development to determine the effectiveness and safety of the cardiac medications we are told to take. Even when women are included, however, their participation numbers are too low, so whether a drug is ineffective or even potentially harmful for women cannot be accurately predicted by the drug company that manufactures it (and typically funds research that leads to drug approvals, by the way). Current guidelines on CVD recommend treating men and women similarly, but the truth is that we lack proper evidence to support these recommendations.
What IS working?
Despite some of these grim findings, all may not be as bleak as first imagined. Authors Drs. Humphries and Pilote do celebrate some recent gains for women in cardiology. For example, cardiology experts have added pregnancy complications like preeclampsia as a known cardiac risk factor.
We’re also seeing increasing recognition by physicians of heart conditions that mostly affect women, such as coronary microvascular dysfunction (my own diagnosis – which I’ve written about here, here and here, for example), spontaneous coronary artery dissection (SCAD) and Takotsubo cardiomyopathy, also known as Broken Heart Syndrome. Yet, as I wrote about here, not all physicians are created equal (e.g. my Heart Sisters blog reader who was told by her own physician: “I don’t believe in coronary microvascular disease”.
As if they had been discussing the freakin’ Tooth Fairy…
We’re also seeing some promising improvements in diagnostic tools (again, most of our standard cardiac diagnostics for decades have been developed in studies on white, middle-aged men). Now, however we have high-sensitivity blood tests for cardiac enzymes, used to help diagnose heart attack in the Emergency Department; we know that the concentrations of these cardiac troponin biomarkers can vary significantly by sex.
What needs to happen next?
The authors acknowledge that progress in some areas has indeed been made, but also list what they call the following strategic directions that must be undertaken if we are to bridge the current gender gap in cardiology, including:
- embracing shared decision-making among patients, caregivers, and health care professionals
- embedding sex and gender at the core of precision medicine research and practice
- revising the medical curriculum in medical school to emphasize sex-specific and sex-dependent critical thinking about effective care for women with CVD
- ensuring that clinical practice guidelines incorporate sex/gender differences as appropriate
Meanwhile, I’m personally thrilled that cardiac researchers like Drs. Humphries and Pilote continue to work tirelessly on our behalf to ensure that women’s cardiac research, diagnostic tools, treatments and outcomes will one day become equal to men’s.
1. Humphries, Karin H. and Pilote, Louise. “Research in Women’s Cardiovascular Health—Progress at Last?” Canadian Journal of Cardiology, April 2018.Volume 34, Issue 4, 349 – 353
2. McDonnell, L.A., Turek, M., Coutinho, T. et al. “Women’s heart health: knowledge, beliefs, and practices of Canadian physicians.” J Women’s Health (Larchmt). 2018; 27: 72–82
3. Bairey Merz, C.N. et al. “Knowledge, attitudes, and beliefs regarding cardiovascular disease in women: the Women’s Heart Alliance.” J Am Coll Cardiol. 2017; 70: 123–132
* For a complete list of all journal references noted for each of the findings reported here, please see the original paper published in the CJC.
Q: How optimistic are you that the recommendations of Dr. Humphries and Dr. Pilote will be adopted by women, physicians and researchers?