by Carolyn Thomas   ♥  @HeartSisters

During my Women Heart Science & Leadership patient advocacy training at Mayo Clinic, I learned that until recently, most cardiac research over the past 3-4 decades has been done primarily on (white, middle-aged) males, or with women participating in “statistically insignificant numbers”.  And it may not be because Big Bad Researchers are deliberately refusing to include women in their studies. Although women do volunteer for hormone or breast cancer clinical trials – what we call the ‘bikini approach’ to women’s health research – we do not seem as interested in participating in cardiac research.

Many of us still mistakenly believe that heart disease is only a man’s problem.

At a Canadian Cardiovascular Congress in Toronto, researchers announced that women are still under-represented in heart research. Although 53% of heart disease patients are women, we make up only 25-30% of the subjects in most cardiac studies.

Later, when I attended my first Canadian Cardiovascular Congress conference in person (not in the audience, but with a press pass so I could interview researchers studying women’s heart health), I was shocked to learn that, out of over 700 scientific papers presented at this conference, only four of them focused specifically on women’s heart disease.

Four!   FOUR!?! 

The second time I attended a CCC conference, that number had increased to TWELVE. Whooop-dee-dooo. . .   And that pretty well sums up the current problems in women’s cardiac research.

This doesn’t necessarily mean that treatments aren’t approved for female heart patients (but with so few women represented in clinical trials, it’s difficult to actually claim that what’s good for men will be as good for women).  Researchers know far less about how heart disease develops in women, how diagnostic tests that were researched and developed in (white, middle-aged) men work or don’t work in women, and how women may react to drugs and other treatments.  So when reading research reports, always consider the gender balance in the study methodology.  Good example of this troubling gap: the $100 million ISCHEMIA clinical trial reported at the 2019 American Heart Association Scientific Sessions (listed below).* 

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 ♥  MY BOOK:  I wrote much more about news on women’s heart disease in my book A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press). You can ask for this book at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon.  If you order it directly from Johns Hopkins University Press (use their code HTWN) you can save 30% off the list price.

♥   And here’s how to make sense of medical research studies.

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RECENT RESEARCH UPDATES:

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♥ American Heart Association’s 2023 Heart Disease & Stroke Update:  Cigarette smoking is the most serious risk factor for heart attack. Yet despite consistent decline in cigarette use over the past several years, marginalized populations continue to smoke compared to the general population.

♥ Reflections on patient engagement by patient partners:  how it can go wrong – Academic researchers are encouraged to include the patient perspective in their medical studies by enlisting people with actual lived experience of illness to help inform their project – but these six researchers (including patient partners) reveal how patient partners can be hurt when academics go sideways. (Published in the journal, Research Engagement & Involvement. June 2023.

♥  Surprising Risk Factors May Predict Heart Attacks in Young Women:  Highest risks of acute heart attack in young  women was diabetes, followed by current smoking, depression, hypertension, low household income and family history of cardiac events. Yale University study published in the Journal of the American Medical Association, May 2022.

♥  Call to Action for Cardiovascular Disease in Women:  Report calls out gaps in women’s heart disease research and care, a Presidential Advisory From the American Heart Association,  Circulation. March 2022.

♥   The Lancet ‘Women and Cardiovascular Disease’ Commission:  the first-ever global report on cardiovascular disease in women, published in The British medical journal The Lancet . This report, authored by 17 female cardiac experts from 11 countries,  outlines 10 ambitious new recommendations “to tackle inequities targeting diagnosis, treatment, and prevention to reduce heart disease in women”, May 2021.

♥ Study by Harvard researcher Dr. Catherine Kreatsoulas suggests that women are significantly more likely to underestimate their own cardiac risk, even when already admitted to a hospital’s cardiac unit for treatment. (Journal of General Internal Medicine June 2021.

♥ This international study published in the European Heart Journal found that hospital patients diagnosed with a non-STEMI heart attack who had been admitted by a cardiologist were more likely to receive guideline-directed treatments and had better clinical outcomes compared to patients admitted by other physicians (general medicine, etc). May 2021.

♥ Women with heart disease get better treatment with female doctors:  “Study concludes that women with heart health issues get better treatment if they’re seen by a female cardiologist, suggesting that female doctors may understand female patients better than men do.” Journal of the American College of Cardiology, February 22, 2021.

♥ “Shared decision-making, a dialogue between patients and their care team that includes full disclosure of all testing and treatment options, discussion of the risks and benefits of those options and, importantly, engagement of the patient to express their own goals, is particularly relevant in the management of hypertrophic cardiomyopathy.”  New guidelines on treating this heart condition from the American College of Cardiology. November 2020:  

♥  Awareness that heart disease is the leading cause of death among women DECLINED from 2009 to 2019, particularly among Hispanic and non-Hispanic Black women and in younger women: a shocking report from the American Heart Association’s latest National Survey on women’s declining awareness of heart disease.  See also: my review of this survey’s discouraging results.

♥   Daily aspirin is no longer recommended to protect against cardiovascular events in those who have never had a cardiac event. Heart and Stroke Foundation. March 2020.

♥   *     The $100 million ISCHEMIA clinical trial reported at the 2019 American Heart Association Scientific Sessions suggested that invasive interventions like stents or coronary bypass surgery are not better than cardiac medications and lifestyle improvements in patients with stable angina. Read about it from Shelley Wood in TCTMD.   ♥ CAUTIONARY NOTE FROM CAROLYN: out of over 5,000 participants enrolled in this $100 million study, only 23% were women.

♥ “Patients who took their blood pressure pills at bedtime had a 45% reduction in overall cardiovascular events.” 19,000 patients living with high blood pressure were randomly assigned to take their medications either on waking or at bedtime, and followed for an average of six years.” European Heart Journal, October 2019.

♥ Myocardial Infarction in Young Women: An Unrecognized and Unexplained Epidemic – authors of this study in the cardiology journal Circulation report “a staggering increase”  in the annual incidence of hospitalized heart attack among young women (35–54 years old) but the incidence decreased among men in the same age bracket. February 2019.

♥ Fewer Lights/Sirens When a Woman Heart Patient is in the Ambulance – When women and men with heart attack symptoms called 911 for help, women were less likely to receive aspirin, be resuscitated, or be transported to the hospital in ambulances using flashing lights and loud sirens. (Shocking but TRUE study published in the journal, Women’s Health Issues, December 2018.

♥ Women With Heart Failure: Unheard, Untreated, and Unstudied – Although women with a type of heart failure called “heart failure with reduced ejection fraction” (HFrEF) live longer than men, their additional years of life are of poorer quality, with greater self-reported psychological and physical disability. “The explanation for this different sex-related experience of HFrEF is unknown as is whether physicians recognize it. Women continue to receive suboptimal treatment, compared with men, with no obvious explanation for this shortfall.”  Journal of the American College of Cardiology

♥ Women are more likely to die from heart attacks than men are, but not if they’re treated by female Emergency Department doctors – Proceedings of the National Academy of Sciences, August 2018.

♥ Taking high doses of Biotin (vitamin B7) can lead to false negative blood tests of troponin, a cardiac enzyme that’s used to diagnose heart attacks – some dietary supplements to support hair/skin/nail health are 650 times higher than the recommended daily maximum.

♥ Women are more likely than men to seek care for their cardiac symptoms during the week before hospitalization – but both women and their physicians are less likely to attribute these early symptoms to heart disease compared to men. Pioneer cardiologist Dr. Nanette Wenger weighs in on the VIRGO study. Cardiology, February 2018.

♥ Female heart patients are more likely to be unexpectedly re-admitted to hospital with heart failure compared to men (22.3% of men vs. 29.6% of women). “We don’t know a lot about re-admissions,” said lead author Dr. C. S. Kwok. American Journal of Cardiology, January 2018.   ♥  NOTE FROM CAROLYN:  Maybe it’s about time we DID know more about why heart patients are being unexpectedly re-admitted after hospital discharge.

♥ Fewer Women Would Die of Heart Attacks if Given Same Treatments as Men – After accounting for the expected number of deaths seen in the average population, the researchers studied 180,000 people over 10 years and found that women had an excess mortality of up to three times higher than men’s in the year after having a heart attack. Journal of the American Heart Association, 2018.

♥ Ten-Year Mortality in the WISE Study (Women’s Ischemia Syndrome Evaluation) – An important study to all women whose cardiac symptoms have been dismissed because no coronary blockages were seen. “1 in 3 of the heart-related deaths in this cohort occurred in women without obstructive coronary artery disease, a condition often considered benign and without guideline-recommended treatments.”

♥ Women and Heart Disease: New Data Reaffirms Lack of Awareness By Women and Physicians – While 74% of women reported having at least one risk factor for heart disease, just 16% were told by their doctor that they were at risk. Journal of the American College of Cardiology, June 22, 2017.

♥ Higher Cardiovascular Risk If You’re Taking Calcium Supplements – Dr. Erin Michos of Johns Hopkins University reported that calcium supplements might increase cardiovascular risk, but dietary calcium was associated with a protective effect. Journal of the American Heart Association, October 11, 2016.

♥ Sex Differences in Young Patients with Acute Myocardial Infarction – Researchers in the U.S. and Spain report that young women (under age 55) with AMI represent a distinct, higher-risk population that is different from young male counterparts. This includes lower quality of life, more co-morbidities, higher clinical risk scores, less likely to undergo revascularization procedures like stents during hospitalization, and more delays in seeking emergency medical help. European Heart Journal: Acute Cardiovascular Care. July 2016.

♥  Gender Differences in Coronary Heart Disease – U.K. cardiologist Dr. Ramzi Y Khamis’ comprehensive look at the areas in cardiovascular disease where women are still either under-diagnosed, under-treated even when appropriately diagnosed, or both – published in the journal HEART from the British Medical Journal (2016).  See image below:

♥  “Women’s heart attacks are under-diagnosed and under-treated even when appropriately diagnosed compared to our male counterparts.” (Unofficial translation, thanks to Laura Haywood-Cory: “Sucks to be female. Better luck next life.”   First ever scientific statement IN 92 YEARS (!) on Women and Heart Attacks from the American Heart Association – official AHA press release (2016)

♥  “42% of women present with NO chest pain during heart attack; higher mortality than men”:  Association of Age and Sex With Myocardial Infarction Symptom Presentation and In-Hospital Mortality, Journal of the American Medical Association

♥  Your Diet and Heart Disease: Rethinking Butter, Beef and Bacon: “Available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum (blood) cholesterol”  – from the Scientific Report of the 2015 Dietary Guidelines Advisory Committee

♥  Familial Spontaneous Coronary Artery Dissection: Evidence for Genetic Susceptibility. Journal of the American Medical Association Internal Medicine (NOTE: lead study author Dr. Sharonne Hayes of Mayo Clinic’s patient-inspired research on SCAD)

♥ Sex Bias in Referral of Women to Cardiac Rehabilitation – European Journal of Preventive Cardiology

♥  Heart Disease and Stroke Statistics: 2015 Update – American Heart Association

♥  A Method for Measuring Coronary Artery Blockage in Heart Attack Patients Can Help Over One Fifth Avoid Stents or Surgery – European Heart Journal

♥  Effect of Weight Reduction and Cardiometabolic Risk Factor Management on Symptom Burden and Severity in Patients With Atrial Fibrillation – Journal of the American Medical Association

♥  Endocrinology Group Rejects New AHA/ACC Cardiovascular Disease Treatment Guidelines – Medscape

♥  Angina symptoms increase probability of disability pension and premature exit from the workforce even in the absence of obstructive coronary artery disease – European Heart Journal

♥  FDA warns that popular blood pressure drug can cause severe diarrhea (Benicar in the U.S., Olmetec in EU, Canada and Japan) – Cardiobrief

♥  Calcium in food or supplements increases women’s cardiovascular risk and does not prevent bone fractures – British Medical Journal 

♥  Pregnancy-Related Complications Predict Cardiovascular Disease in Middle Age – American Heart Association

♥  Structural Changes in Hearts of PreTerm Babies – Circulation

♥  Women Who Quit Smoking Do Live Longer– Lancet

♥  Perceived Stress in Myocardial Infarction: Long-Term Mortality and Health Status Outcomes  – Journal of the American College of Cardiology

♥  Taking painkillers increases death risk, second heart attacks in survivors, American Heart Association

♥  Cholesterol particle size: more testing, more therapy doesn’t prevent heart attack, Circulation

♥  FDA adds Diabetes warning to statin drug label, MedPage Today

♥  Breast cancer irradiation tied to coronary stenosis – Journal of Clinical Oncology

♥  Dronedarone (Multaq) for atrial fibrillation “increases risk of serious cardiovascular  events including death”  – FDA

♥   Multaq for atrial fibrillation increases rates of heart failure, stroke, and death in high risk patients  – New England Journal of Medicine

♥  Multaq for atrial fibrillation “unsafe for many patients” –  Therapeutic Initiatives

♥  FDA issues warning for cholesterol drug Trilipix – FDA

♥  EMA recommends restricting anti-arrhythmia drug Multaq – European Medicines Society

♥  Cigarette smoking causes more arterial damage in women than in men – European Society of Cardiology

♥  New research links obesity with atrial fibrillation heart rhythm disorder – University of Adelaide

♥  Cigarette smoking a greater risk for women’s heart health – The Lancet

♥  FDA Approves new anti-clotting bloodthinner for heart attack patients – Wall Street Journal

♥  Stop-smoking drug Chantix/Champix linked to heart risks – Canadian Medical Association Journal

♥  Calcium supplements and heart risk: new fears – British Medical Journal

♥  Common Painkillers Risky For Heart Attack Survivors – Circulation

♥  Warning: PPI drugs for indigestion linked to heart arrhythmias – FDA

♥  New guidelines warn of link between pregnancy complications and heart disease – American Heart Association

♥  Stillbirth and recurrent miscarriage linked to heart disease – Heart

♥  ICD implants “non-evidence-based” in 22.5% of recipients – Journal of the American Medical Association

♥  Noisy workplace may increase heart disease risk – Occupational & Environmental Medicine

♥  Rescue breathing may not be needed for adult CPR – The Lancet

♥  Dental care linked to heart health in older women – Health Economics

♥  Daily coffee consumption reduces stroke risks – MedPage

♥  Religion not associated with better cardiovascular health – Northwestern University

♥  EKG can show false positive results – Henry Ford Hospital

♥  Obesity is poor gauge of detecting high cholesterol in children – University of Michigan

♥  Venous thrombosis risk rises with some birth control pills– Leiden University

♥ Woman gets first wireless-monitor pacemaker implanted – UK Daily Mail

♥  New study endorses heart benefits of fish oil – American College of Cardiology

♥  Cardiac risk factors on the rise in Canada – CMA Journal

♥  Asthma drug Xolair may increase heart disease risks – FDA

♥  No Benefit to Lowering Blood Pressure below 140/90 standard – Cochrane’s

♥  First Stem Cells Injected to Regrow Dead Heart Muscle– Cedars Sinai Heart Institute

♥  Newest Cardiac Tests Explained– WebMD

♥  Portugese Parliament Passes Law to Limit Salt in All Processed Foods – Heartwire

♥  White Bread, Cornflakes Could Increase Heart Disease Risks – Journal of the American College of Cardiology

♥  Ibuprofen (Motrin®, Advil®) May Increase Heart Attack Risks – Circulation

♥  Women with Chest Pain Less Likely To Get Optimal Treatment from Paramedics, Women’s Health Matters

♥  Unhappy Marriage Bad for Women’s Heart Health, Heart & Stroke Foundation

♥  No Evidence That Daily Baby Aspirin Prevents Heart Attacks, Oxford University

♥  Genetic Link Between Gum Disease and Heart Attacks, European Society of Human Genetics

♥  Canadian Women In The Dark About Their Health, Women’s College Hospital

♥  Women Wait Longer for Emergency Angioplasty During Heart Attacks, BMJ

♥  Belly Fat in Women: How To Keep It Off, Mayo Clinic

♥  Women’s Pulse Rate May Predict Heart Attack Risk, British Medical Journal

♥  Gender Differences in Diagnosis & Management of Heart Disease, Women’s Heart Foundation

♥  Study Explores Women’s Rare Blood Pressure Condition,  Heart & Stroke Foundation

♥  Breast Best for Mom’s Heart: “Women who breastfed at least one baby for 7-12 months are significantly less likely to develop cardiovascular disease”, Obstetrics & Gynecology, May 2009

♥  Women More Likely To Miss or Ignore Heart Attack Warning Signs, Yale School of Medicine.

♥  Misdiagnoses Result in Higher Coronary Heart Disease Mortality Rates in Women Than in Men,  Therapeutic Advances in Cardiovascular Disease.

♥  Aspirin Improves Survival in Women with Stable Heart Disease, Women’s Health Initiative

♥  Migraine Raises Risk of Coronary Heart Disease in Women, Mt. Sinai School of Medicine

♥  Menopause Increases Risk of Heart Disease, Canadian Women’s Health Network

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♥  Please consider participating in cardiac research about women’s heart disease.

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