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 3^rd, 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. 20^th, 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. 20^th, 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. 3^rd, 2019 at: https://www.womeninc.nl/behandelmealseendame/

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

• 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)

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)

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)".

-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)

 (Video Source: AHA, 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).

(Graph source: Maas, 2019)

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)

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)

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)

-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)

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).

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).

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)

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)