Article Archive
September/October 2015

Gender Differences Are Significant in Cardiovascular Disease
By Susan D. Beck, MSN, CNS, RN, and Deb Sanders, RN, PhD, GCNS-BC, CNE
Today's Geriatric Medicine
Vol. 8 No. 5 P. 22

Recognizing gender-specific aspects of cardiovascular disease and providing information to heighten women's awareness of its symptoms and dangers are key to improving women's mortality rates from heart disease.

Heart disease is an escalating problem among women. One-third of adult females have some form of cardiovascular disease (CVD), with at least one death per minute attributed to CVD in 2011.1 This mortality rate is equal to that of female deaths from cancer, diabetes, and chronic lung disease combined. Coronary heart disease (CHD), also known as coronary artery disease, occurs when the heart's blood vessels narrow. Heart disease in women has been underresearched and underrecognized for many years, leading to poorer prognoses for women with CVD when compared with men.2

The Framingham Study, a historic and foundational study that investigated CVD over five decades in a mixed gender general population sample, identified the prevalence, incidence, prognoses, and predisposing risk factors for CVD in women vs men. Initial results found that women outlive men, experience fewer signs of CVD, and experience a later onset by 10 to 20 years in the development of atherosclerotic CVD events vs men. As women age and progress through menopause, however, the gender difference no longer exists, and CVD ultimately becomes the leading cause of death in women as well as men. In the Framingham cohort, the lifetime risk of women experiencing a CHD event was 24% to 36%, compared with the risk of developing breast cancer at 7% to 12.5%.3 The results of this study show there is a definitive need to address the issue of CVD in women.

Gender plays a role in diagnosing CHD. Many providers erroneously believe women have a lower risk of developing CVD, which can lead to a lack of attention to early signs and symptoms. Gender differences are important to note when reviewing symptoms. Typical symptoms experienced by men, such as chest pain with radiation to the jaw and left arm, are often not experienced by women. Atypical symptoms occur more frequently in women, including abdominal pain, dyspnea, nausea, and fatigue.4 These atypical symptoms can hinder early recognition, diagnosis, and intervention in women.

Furthermore, women who have experienced a myocardial infarction (MI) have a higher death rate than men, both in hospital and within the first year post-MI. This trend is particularly true for women over the age of 55 and minority women, who often fare worse than white women of the same age. Moreover, the reinfarction rate in women during the first year post-MI is greater than that in men. Women are more prone to complications post-MI, such as stroke, congestive heart failure, cardiogenic shock, and depression.

The prognoses for women with CVD are dependent upon the severity of the disease and the comorbidities present at diagnosis. Poor prognoses in women can also be attributed to the higher documented rate of depression and worse adjustment to heart disease.2 Findings were consistent with previous research, indicating that women with CVD tend to be older, less educated, less financially secure, more likely to be widowed, and have a greater number of medical and psychiatric comorbidities. The research determined that there are few differences between the genders' functional limitations despite the higher prevalence of depression in female subjects.

Women's perception of cardiovascular risk is particularly important. Awareness is low related to the role of risk factors for developing atherosclerosis and CVD, especially considering the high mortality rate associated with these conditions.5 The risk of CVD increases with the onset of menopause due to the decrease in estrogen, compounded by the proatherogenic changes caused by hyperlipidemia, obesity—especially central adiposity—and hypertension.6 Atherosclerosis is the result of elevated lipids, oxidation, and inflammation. Fatty material forms the center of the plaque, which is covered by a fibrous top. The fibrous cap is uneven, resulting in clot formation and eventual thrombosis, which leads to potential damage from embolization of the thrombosis. The sudden obstruction to blood flow can lead to an MI.7 Despite what is known about such physiologic changes inherent in the aging process that increase the risk of heart disease in women, only one in five American women believes that heart disease presents the greatest threat to her health.

Women who do not perceive their risk of CVD in tandem with providers who do not recognize the risk of disease in their female patients and therefore delay diagnosis and intervention create a potentially deadly combination. Providers must understand the gender differences in CVD and utilize existing guidelines to more effectively assess risk, diagnose, and intervene. Women need to know their risk of CVD and strategies for minimizing risk and become proactive in prevention and lifestyle modification.

Implications for Providers
Although in 1999 the American Heart Association (AHA) proposed gender-specific guidelines for the prevention and treatment of CVD in women and considerable progress has occurred in addressing prevention and treatment, formidable challenges remain in recognizing and treating CVD more than 15 years later. Since MI in women is still underrecognized between 26% and 54% of the time,8 and women are less likely to be evaluated for MI and treated aggressively, providers need to be cognizant of the unique needs and risks of aging women and cardiovascular disease. An aggressive, proactive approach should be employed to address CVD in women.

Providers' use of practice guidelines is foundational to direct best practice in providing care. The AHA's 2020 impact goal details "a 20% improvement in Americans' cardiovascular health while reducing deaths from cardiovascular disease and stroke by 20% by the year 2020,"9 and offers recommendations for implementing this approach in practice. Furthermore, the AHA practice guidelines emphasize an "effectiveness-based" approach to risk reduction, prevention, and treatment.10 This approach means that current recommendations have been updated to reflect therapies that have been "shown to have sufficient evidence of clinical benefit for CVD outcomes".10 Such guidelines should drive care and follow-up for women seen by providers in practice.

Provider education is the critical first step as it subsequently allows providers to educate patients and their families in the prevention and treatment of CVD. Increasing women's knowledge of risk factors and prodromal symptoms of MI and promptly responding to such symptoms can facilitate early recognition and prevent delays in seeking treatment. Women should be well versed in the differences of possible prodromal symptoms of MI vs their male counterparts.11 Suggest that acronyms such as the ones in Table 1 can be viable tools to enhance women's knowledge of the topic.11

Identifying risk factors and risk stratifying in women is essential in raising awareness of and preventing CVD. The AHA offers risk classification levels, including ideal cardiovascular health, at risk, or at high risk, to assist with screening, education, and interventions for better clinical outcomes.10 Women need to be aware of CVD's risk factors and encouraged to collaborate with providers to address modifiable risk factor reduction such as smoking, physical activity, weight control, stress, and diet. In fact, the AHA's effectiveness-based guidelines provide detailed schemata for addressing risk (see Table 2).10

Comprehensive heart health programs can be mechanisms to address the multifactorial components of CVD and promote more long-term adherence to risk reduction and prevention. Such programs, whether hospital- or community-based, can be instrumental in maximizing education, support, follow up, and advocacy for women with CVD. Although modalities such as cardiac rehabilitation programs, which often combine education with exercise, have been associated with decreased mortality in women, fewer women than men receive provider referrals to such programs (39.6% vs 49.4%).12 Interestingly, physicians in busy practices often report a lack of time as a barrier to engaging in education with their women patients.13 Such comprehensive educational programs can complement physician practice and fill in the gaps of necessary patient and family education for best outcomes.

Certainly, there are challenges to maintaining behavioral modifications over time. Interventions aimed at diet, weight control, exercise, and even smoking cessation are complex, and a host of factors can threaten sustaining such long-term behavior changes. However, interprofessional collaboration can foster an integrated, cohesive approach to addressing CVD in women. Professionals with diverse backgrounds and expertise can be complementary for best practice. Nurses, physicians, social workers, psychologists, exercise physiologists, and dietitians, to name a few, can collaborate to unify care, not only among providers, but also with patients and families and across health care systems.14 Additionally, interprofessional team members are in pivotal positions to address complex factors such as culture, race, and socioeconomics to attend to disparate populations at risk. The patient is the beneficiary of all the interprofessional team has to offer for optimal cardiovascular care. Ultimately, the use of the interprofessional team in practice can reach beyond the exam room to positively impact the multiplicity of factors facing women in CVD prevention and care.

— Susan D. Beck, MSN, CNS, RN, is an assistant professor in nursing at Bloomsburg University in Bloomsburg, Pennsylvania, and a doctoral candidate in nursing at Indiana University of Pennsylvania.

— Deb Sanders, RN, PhD, GCNS-BC, CNE, is an assistant professor in nursing at Bloomsburg University, a board-certified gerontology clinical nurse specialist, and codirector of the Center for Healthy Aging at Bloomsburg University.

1. American Heart Association. Statistical fact sheet 2015 update: Women & cardiovascular disease. Updated 2015. Accessed May 21, 2015

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11. Kalman M, Stewart PS, Wells M, Blumkin A, Pribulick M, Rolland R. Education to increase women's knowledge of female myocardial infarction symptoms. J N Y State Nurses Assoc. 2013;43(2):11-16.

12. Colella TJ, Gravely S, Marzolini S, et al . Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis. Eur J Prev Cardiol. 2015;22(4):423-441.

13. Barnhart J, Lewis V, Houghton JL, Charney P. Physician knowledge levels and barriers to coronary risk prevention in women: survey results from the Women and Heart Disease Physician Education Initiative. Womens Health Issues. 2007;17(2):93-100.

14. Légaré F, Stacey D, Pouliot S, et al. Interprofessional and shared decision-making in primary care: a stepwise approach towards a new model. J Interprof Care. 2011;25(1):18-25.