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Cardiovascular disease (CVD) is a man’s disease; women die of cancer. Yes/No

Symptoms are different. Yes/No

The healthcare system cares for men and women with CVD the same way.  Yes/No

CVD research is gender blind (a lab mouse is a lab mouse!) Yes/No

A pill is a pill, gender doesn’t impact how well it works in patients of a specific gender. Yes/No

Women are equally represented in clinical trials. Yes/No

Female cells used in experimental trials are equally represented. Yes/No

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Definition:
CVD: Cardiovascular disease (CVD) is the name for the group of disorders of heart and blood vessels, and includes Heart Attack (aka coronary heart disease (CHD) and Stroke (aka cerebrovascular disease), heart failure, and peripheral vascular disease. CHD is also referred to as Ischemic Heart disease (IHD), or Acute Coronary Syndrome (ACS).

Contributing factors:

• Sex: biological attributes of humans and animals, including physical features, chromosomes gene expression, hormones and anatomy

• Gender: socially constructed roles, behaviors, expressions and identities of girls, women, boys, men and gender diverse people (Canadian Institute for Health Research, 2014).

(Source: Canadian Institute for Health Research, 2014)

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From a 1975 Dutch Heart Association meeting statement on how women are important in the recovery of the loved one with CDV to today’s Go Red for Women, and Treat me like a Lady campaigns (DHA, 2019).

1975 Dutch Heart Association meeting:

Translation: "International Year of the Woman 1975. The woman still plays a huge role in the preparation of meals and the raising of young children, she has an important role in  post-care (after myocardial Infarction)".

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Gender is one of the most important considerations in public health research and program implementation. Gender inequality considers issues such as protecting women from violence and upholding their rights to property and equality in access to health care (Low, et. al. 2016). Globally, the average life expectancy gap between men and women is 4.6-10 years with women outliving men in all countries. The global burden of disease disproportionately affects men in terms of disability-adjusted life years, although women are more likely to spend a longer time living with a disability (WHO, 2018). The focus of this padlet is gender inequality in women with regards to Cardiovascular Disease from a Public Health standpoint.

Cardiovascular disease exemplifies the impact of gender differences on health: women are at increased vulnerability than men yet there are significant gaps in knowledge, awareness, prevention, treatment and research that lead to excess female mortality and morbidity.

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CVD is the No. 1 cause of death in American women, claiming over 400,000 lives each year, or one death every 80 seconds. CVD kills approximately the same number of women as all forms of cancer, chronic lower respiratory disease and diabetes combined (American Heart Association, 2018; European Health network, 2017).

Since 1984, more women have died of heart disease than men each year (Giardina, 2000).

Prevalence: 48% in African-American women, 35% in Caucasian women (AHA, 2018).
(Graph Source: European Health network, 2017)

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Gender differences in risk-factors, gender-bias in patients, in the healthcare system and research leaves women still too vulnerable to CVD. Although CVD mortality has declined for the past 3 decades, it is now stagnating (AHA, 2018). Primary prevention has not been able to limit rise in incidence, while it has for men, and the incidence in younger women (35-54 year age range) is rising. (Keteepe-Arachi & Sharma, 2017).

(Graph source: Arora et al. 2019)

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The Healthy life expectancy gap between men and women is a clue: while the life expectancy gap typically amounts to years, looking at healthy life years (the number of years one can expect to live free of health-related limitations), the gaps amount to months. Women are free of limitation for  77 % of their total life expectancy, while men are for 81 % of theirs (Eurostat, 2019).
Economic and social cost: especially for younger women, in whom the incidence is rising strikingly.
(Picture Source: Eurostat, 2019)

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Almost everyone!
Going by general CVD risk factors: 83% of the women were either classified as being “high risk” or “at risk” for CVD and an additional 13% of the women lacked risk factors for CVD but did not adhere to a healthy lifestyle (AHA, 2018).

Why look at risk factors? Because addressing them works! CVD is 75% preventable! Nearly 75% of coronary heart disease cases in women can be prevented with better lifestyle choices, such as not smoking, exercising, and eating a healthy diet (AHA, 2018).

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Women-specific CVD prevention is not part of the prevention agenda

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Women-specific CVD prevention is not part of the prevention agenda

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CVD is not addressed in gender-specific objectives and there is no population level risk factor reduction. In fact, the only objective mentioning women and CVD is the revised objective HDS-15.1 which is: Increase aspirin use as recommended among women aged 55 to 79 years with no history of cardiovascular disease (CDC/Healthy People2020, 2017).

In New Hampshire, the state  Heart Disease & Stroke Prevention Action Plan (State Health Improvement Plan) addresses Cardiovascular health in general, and doesn’t include any women-specific objective (NH DHHS New Hampshire Heart Disease and Stroke Prevention Program 2015).

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Disparities in treatment within the healthcare system:

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Disparities in treatment within the healthcare system:

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Disparities in treatment:
-Women are much more likely to experience delays in care when they go in with heart attack symptoms (Bugiardini 2017).
-Women are less likely to receive potentially beneficial medications such as aspirin and the cholesterol-lowering drugs called statins, or to receive advice about quitting smoking.
-Women are also 1.5 times less likely than men to be referred to cardiac rehabilitation.
-Due to such patient-level barriers as multiple comorbidities, lack of social support, and family responsibilities, women are less likely than men to adhere to prescribed cardiac rehabilitation sessions.
-Among Medicare patients, men are two to three times more likely than women to receive an implantable cardioverter-defibrillator for the prevention of sudden cardiac death (AHA, 2018).

Disparities in survival and long-term health:

-Women are more likely than men to die within 1 or 5 years of suffering a heart attack.
-Women are more likely than men to be diagnosed with heart failure within 5 years of their first heart attack.
-Young women with acute coronary syndrome are more likely than men to have adverse outcomes, including death, heart attack, stroke, or re-hospitalization, even after adjusting for age differences (AHA, 2018).

Why? "Gender-related risk factors have now been identified but there is a lack of clinical application, leading to the misdiagnosis and poor management of women with CVD" (Keteepe-Arachi & Sharma, 2017).

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There are both general and women-specific risk factors.
General Cardiovascular Risk Factors include obesity, smoking, hypertension, dyslipidemia (aka cholesterol) and diabetes.

-Women are significantly less likely than men to meet the Federal Guidelines for Physical Activity. Women are more likely than men to be obese (AHA, 2018)

-Women are put at more risk than men in the presence of the same risk factors: With diabetes, high blood pressure or diabetes, they are more susceptible to developing CVD than men (AHA, 2018). Other examples include:

-Smoking: Women have a 25% increased risk for CVD compared to men

-Diabetes: Women have a 44% increased risk for CVD compared to men (AHA, 2018)

Women-specific risk factors are mostly non-modifiable and associated to reproductive history (Peters, 2018). Women's reproductive factors and incident cardiovascular disease in the UK. (Elias-Smale, 2015). Other examples include:

Migraines, hysterectomy, early menarche, early menopause, previous complications in pregnancy, especially hypertensive disorders of pregnancy and gestational diabetes miscarriage.
(Picture Source: Keteepe-Arachi & Sharma, 2017)

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ECS 2016 female specific risk factors.PNG

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Disparities in Awareness and Primary Prevention

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Disparities in Awareness and Primary Prevention

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Women do not perceive themselves at risk (AHA, 2018).
A 2012 survey conducted by the AHA found that only 56% of women were unaware that heart disease is the leading cause of death among women, although awareness has nearly doubled since 1997.  Furthermore, only 36% of black women and 34% of Hispanic women knew that heart disease is their leading cause of death, compared to 65% of white women. Less than 25% of women can name hypertension and high cholesterol as risk factors for heart disease, and less than 50% know the major symptoms of heart disease. Only 65% of women said the first thing they would do if they thought they were having a heart attack was to call 9- 1-1.

(Video Source: AHA, 2017).

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Elizabeth Banks in "Just a Little Heart Attack"

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Disparities in diagnosis because of different symptoms and disease pattern:

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Disparities in diagnosis because of different symptoms and disease pattern:

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Women are underdiagnosed Cardiovascular disease (CVD) in women remains under-diagnosed “due to the diagnostic challenge it presents, as well as the persisting attitude that CVD predominantly affects men” (Keteepe-Arachi & Sharma, 2017).

Diagnostic challenges due to CVD presenting differently in women than men. Symptoms in women are different (Story, 2018) and women report additional, potentially gender-related, non-specific symptoms, however, such as fatigue and sleep disturbance.(Keteepe-Arachi & Sharma, 2017)

(Source Keteepe-Arachi & Sharma, 2017)

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-Older women typically experience CVD symptoms 5 to 10 years later than men and the first event stroke more often than heart attack (Kavousi 2019).
-Younger women suffer increasingly from new, atypical CVD, with microvasculature involvement and spasm. Further evidence supporting this finding from the National Health and Nutrition Examination Surveys demonstrated an increase in the prevalence of MI’s in women in the 35–54 year age range, while a decline in prevalence was observed in age-matched men (Keteepe-Arachi & Sharma, 2017).

(Graph source: Maas, 2019)

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Leaders have started addressing these 3 dimensions. Major research and funding agencies now require from researchers applying for grants that sex and gender criteria be addressed. The European Commission adopted such policy in 2002, the Canadian Institute for Health Research, in 2010, the American NIH in 2014 (Klinge, 2019).

The Heart for Women Act of 2009 was instrumental in allowing the NIH National Heart, Lung, and Blood Institute (NHLBI) to be a leader in the field of sex and gender sensitive basic CVD research by requiring it to equitably use female cells, tissues, and animals. The act also required the Food and Drug Administration (FDA) to enhance the collection and availability of demographic subgroup data, in particular requiring federal government healthcare data (including clinical trial, pharmaceutical and medical device approval, medical errors, hospital quality, and quality improvement data) to be “stratified by gender, as well as by race and ethnicity” (GovTrack, 2009).

An example of initiative aiming to foster high-quality, sex and gender sensitive research at all three levels of the research process is The Dutch Heart Foundation’s Sex up your Research program (Dutch Heart Association, 2019), an initiative led by young researchers based in the Netherlands, Zimbabwe and New Hampshire (shameless promotion here!) to provide fellow researchers with methodological support in making their research methods sex and gender sensitive.
(Picture source: Dutch Heart Association, 2019)

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The quality of healthcare should be equal for everyone: every individual should have the same opportunities for optimal prevention, diagnostics and treatment. This means that healthcare research should take into account differences that exist between people, including the differences between women and men.

In recent years, attention to sex and gender related aspects of health and healthcare has been growing in research. Nevertheless, outcomes of (pre-)clinical studies performed in a research population consisting of mainly one sex is still too often generalized to both sexes. You can help us realize equal healthcare for both women and men by integrating a sex and gender dimension in all aspects of your research.

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How to sex up your research| Hartstichting

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The quality of healthcare should be equal for everyone: every individual should have the same opportunities for optimal prevention, diagnostics and treatment. This means that healthcare research should take into account differences that exist between people, including the differences between women and men.

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Successful Awareness and Prevention Programs

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Successful Awareness and Prevention Programs

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Much is done by advocacy groups and national Heart Associations like the American Heart Association.

At the state and federal level, policy efforts have aimed at improving awareness and prevention. CDC’s public health efforts related to CVD are the responsibility of its Division for Heart Disease and Stroke Prevention (DHDSP), which leads preventative programs, including sodium reduction interventions in collaboration with the U.S. Department of Health and Human Services (HHS)’s Office on Women’s Health (OWH). A map of available programs can be found here: https://www.cdc.gov/dhdsp/programs/spha/images/PDSB_Funding_Map.jpg

The CDC’s signature program aimed at CVD in women is the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program, which provides free CVD screening and lifestyle counseling to low income uninsured or under-insured women in 21 states. See the following links for more information:
https://www.cdc.gov/wisewoman/index.htm https://www.cdc.gov/wisewoman/locations/index.htm

The CDC, in collaboration with HHS and Center for Medicare and Medicaid Services, leads the Million Hearts program. Million Hearts is a national initiative that aims at supporting the use of evidence-based CVD public health and clinical goals and strategies. In particular it focuses on treatment adherence, guideline fidelity, improving the use of self blood-pressure checks, and the use of heart monitoring technology. https://millionhearts.hhs.go

The heart  for Women Act. 2009 included measures aimed at improving the prevention of CVD.” in particular it authorized the Medicare program to conduct an educational awareness campaign for older women about their risk for heart disease and stroke and authorized the expansion of the WISEWOMAN screening program. (source)

(Picture source: AHA, 2019)

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Examples of 3 Successful Campaign and Communication Strategies

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Examples of 3 Successful Campaign and Communication Strategies

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Successful program are relatable, personal, often based on video/PSA content. They raise awareness, in particular of preventive lifestyle changes and CVD symptoms.

-Examples include:

1.The American Heart Association “Go Red for Women” campaign:

https://www.goredforwomen.org.

2. WomenInc's "Treat me like a lady" campaign in the Netherlands (video with English subtitles)
https://www.youtube.com/watch?v=fjLcLOJhkv8

3.The WomenHeart “this is how we fight” campaign for heart disease. https://www.womenheart.org/womenheart-psa-wins-two-bronze-telly-awards/ including an amazing “How can I manage heart failure as a mom/caregiver?”

(Picture Source: WomenInc, 2016)

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An under-used prevention strategy is using pregnancy as an opportunity to screen and educate women about their life-course risk of CVD, especially in women who develop pregnancy complications. Research has addressed the role of pregnancy complications as a risk factor, but hasn’t been translated into practice yet (Haas, 2019). The American Heart Association is publishing content on this issue, in an effort to raise awareness (AHA, 2019).

Visuals aids could include content about pregnancy being a stress-test and the impact of pregnancy complications on short and long-term cardiovascular health.

(Picture source: Maas, 2019)

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Recognizing a Competent Cultural Approach

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Recognizing a Competent Cultural Approach

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A culturally competent approach in communicating about CVD should focus on diversity and acknowledge the cultural context shaping the perception of sex and gender differences.

Diversity:

Successful campaigns like the WomenHeart's campaigns include representations of women and providers of all races/ethnicities, sizes, ages, etc.

Culture and language:

Language is sometimes politically or culturally fraught. To circumvent gender’s potential political, divisive or controversial connotations, focusing in how CVD presents in particular women, in one’s mother, in one’s friend, or on data (symptoms, treatments) might be strategic. That is what successful campaigns like Go Red for women or WomenHeart campaigns achieve in their content (AHA, 2018; WomenHeart, 2019).

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The research bias and how things are changing right now!

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The research bias and how things are changing right now!

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Research is now uncovering how the research process itself is gendered.

The methods used by researchers to examine the research process are not very different than those previously used to uncover the other gaps in CVD in women. Epidemiological methods consist mostly of  analytical epidemiological studies, in particular observational studies: cohort studies and case-control studies. Meta-analyses and systematic reviews are also frequently used. (Oerfelt-Prigione, 2010).

Bias is present at all of these 3 levels:
-Fundamental research bias in found in the fact that male tissues, cells, cell lines or laboratory animals are predominantly used. Gendered Innovations, a European Commission, the National Science Foundation (NSF) and Stanford University collaboration, provides several examples, in particular with stem cells.

-Bias is also found in the way primary data collection is conducted with human participants: women have been underrepresented in clinical trials, generally making up only about 20% of enrolled patients, even though women represent 40% to 50% of participants in longitudinal studies and registries (AHA, 2018).

-At the level of the analysis of secondary data from human participants, results are rarely stratified by sex and gender (GenderedInnovations, 2018; Canadian Institute for Health Research, 2014).

The 3 dimensions of change in research are necessary for the evolution of the existing gender bias of women and Cardiovascular health by utilizing studies tailored to women. Decreasing gaps in knowledge, awareness, prevention, treatment and research that lead to excess female mortality and morbidity is necessary for a woman's overall health and life expectancy.
The 3 dimensions of change required are listed below.
(Source: Canadian Institute for Health Research, 2014)

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Citations:

AHA (2018) Fact sheet. Cardiovascular disease: women’s NO. 1 health threat. Retrieved Oct. 3rd, 2019 at:https://www.heart.org/-/media/files/about-us/policy-research/fact-sheets/facts-cvd-womens-no-1-health-threat.pdf?la=en&hash=F6AD6FC4FD546ABA0E18D4D6C456C666EE4D5C0F

AHA 2019 https://www.goredforwomen.org/en/news/2019/09/30/first-time-pregnancy-complications-could-mean-high-blood-pressure-later

AHA. (2012). Just a little heart attack. YouTube. Retrieved on October 2, 2019 from https://youtu.be/_JI487DIgTA

Arora, S., Stouffer, G., Kucharska-Newton, A., Qamar A.,Vaduganathan, M., Pandey A., Porterfield, D., Blankstein R. (2019), Twenty Year Trends and Sex Differences in Young Adults Hospitalized With Acute Myocardial Infarction; The ARIC Community Surveillance Study. Circulation. 2019;139:1047–1056

Bugiardini, R., Ricci, B, Cenko, E., Vasiljevic, B., Kedev, S., Davidovic, G., Zdrakovic, M., Milici, D., Dilic, M., Manfrini, O., Koller, A., Badimon, L. (20170 Delayed Care and Mortality Among Women and Men With Myocardial Infarction. J Am Heart Assoc. 2017 Aug; 6(8): e005968.

Canadian Institute for Health research, Institute for Gender and Health. (2014). What is Gender? What is sex? Infographic version. Retrieved Oct 3rd, 2019 at:http://www.cihr-irsc.gc.ca/e/documents/igh_s17_infographic_gender_sex-en.pdf

CDC Office of Disease Prevention and Health Promotion/HealthyPeople2020 (2017) revised. Heart Disease and Stroke objectives. https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke/objectives

European Health Network CVD statistics Report. (2017) Wilkins E, Wilson L, Wickramasinghe K, Bhatnagar P, Leal J, Luengo-Fernandez R, Burns R, Rayner M, Townsend N. (2017). European Cardiovascular Disease Statistics 2017. European Heart Network. Retrieved Oct 3rd, 2019 at: http://www.ehnheart.org/images/CVD-statistics-report-August-2017.pdf

Eurostat (2019). Number of healthy years of life: countries compared. Accessed Oct. 3rd, 2019 at https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20190204-1

Elias Smale, S., Gunal, A., Maas, A. (2015). Gynecardiology: Distinct patterns of ischemic hearth disease in middle-aged women. Maturitas 2015 Jul;81(3):348-52.

Giardina E (2000) Heart disease in women. Int J Fertil Womens Med. 2000 Nov-Dec;45(6):350-7.

Haas, D., Parker, C., Marsh, D., Grobman, W., Ehrenthal, D.,  Greenland, P., Bairey Merz, C., Victoria L. Pemberton, V., Robert M. Silver, R. (2019), Association of Adverse Pregnancy Outcomes With Hypertension 2 to 7 Years Postpartum. Journal of the American Heart Association. 2019;8:e013092

Kavousi, M. (2019) Gender Differences in Cardiovascular Disease. Aug. 20th, 2019 presentation. Workshop Gender and Health. Erasmus Universiteit Rotterdam.

Keteepe-Arachi, T., Sharma, S. (2017) Cardiovascular Disease in Women: Understanding Symptoms and Risk Factors. Eur Cardiol. 2017 Aug; 12(1): 10–13.

Low, W, Binns, C. (2016). Gender Issues and Public Health. Asia Pacific Journal of Public Health. Vol. 28(2) 104-106. Retrieved on October 2, 2019 from https://journals.sageppub.com/doi/pdf/10.1177/1010539516637705

Maas, A. (2019) Ischemic Heart Disease in Women. Aug. 20th, 2019 presentation. Workshop Gender and Health. Erasmus Universiteit Rotterdam

Manandhar, M. Hawkes, S., Buse, K., Nosrati, E., & Magar, V. WHO. (2018). Gender, health and the 2030 agenda for sustainable development. Retrieved on October 1, 2019 from https://who.int/bulletin/volumes/96/9/18-211607/en/

New Hampshire Department of Health and Human Services (2015). New Hampshire Heart Disease & Stroke Prevention Action Plan: 2015 – 2020. Retrieved from http://www.dhhs.state.nh.us/dphs/cdpc/hdsp.htm.

Oertelt-Prigione, S., Parol, R., Krohn, S., Preissner, R., & Regitz-Zagrosek, V. (2010). Analysis of Sex and Gender-Specific Research Reveals a Common Increase in Publications and Marked Differences between Disciplines. BioMed Central Medicine, 8, 70-80.

Peters, S., Bots, S., Woodward, M., (2018). Sex Differences in the Association Between Measures of General and Central Adiposity and the Risk of Myocardial Infarction: Results From the UK Biobank. J Am Heart Assoc. 2018 Feb 28;7 (5).

Story, C. (January 23, 2018). Symptoms of a Heart Attack. Healthline. Retrieved on October 3, 2019 from https://www.healthline.com/health/heart-disease/heart-attack-symptoms

US congress (2009) https://www.govtrack.us/congress/bills/110/hr1014

WomenInc. (2016). Behandel Me als een Dame. Retrieved Oct. 3rd, 2019 at: https://www.womeninc.nl/behandelmealseendame/