Investment, action urged to improve access, quality and equity in women's heart health

Investing in and improving research, awareness and equity in women's heart health are critical for the health and well-being of women, according to a new Presidential Advisory from the American Heart Association, published today in the Association's flagship journal Circulation. The advisory is a call to action to identify and remove barriers to health care access, quality and equity for women. "We are losing ground on key indicators of cardiovascular health among women, including blood pressure control, weight management and diabetes," says Véronique L. Roger, M.D., M.P.H., FAHA, the advisory committee's corresponding author and a senior investigator at the National Heart, Lung, and Blood Institute, a division of the National Institutes of Health.

The advisory also highlights the need for a cultural shift in how cardiovascular health data are presented to achieve health equity for women. "Comparing data from women with data from men inherently positions data from men as the gold standard," said Roger. "For example, the belief that women having a heart attack will present more often with atypical symptoms carries an undertone that women present in the 'wrong way.'" The advisory further suggests that data specific to women that does not label women's symptoms as "atypical" may lead to improved diagnostic or therapeutic choices, helping to increase equitable care. The advisory outlines an actionable roadmap, divided into four key areas that require attention and investment to better address women's heart health: 1) epidemiology and prevention; 2) awareness; 3) access and delivery of equitable health care; and 4) involvement of health care professionals, researchers and communities. "We must urgently address the pervasive gaps in knowledge and health care delivery to reduce gender-based disparities and achieve equity. There is no improving cardiovascular health without achieving health equity," adds co-author of the presidential advisory Nanette K. Wenger, M.D., FAHA, an emeritus professor of medicine in the division of cardiology at Emory University School of Medicine, consultant to the Emory Heart and Vascular Center, founding consultant to the Emory Women's Heart Center and director of the Cardiac Clinics and Ambulatory Electrocardiographic Laboratory at Grady Memorial Hospital in Atlanta.

Epidemiology and Prevention

According to the January 2022 Heart Disease and Stroke Statistical Update, heart disease is the leading cause of death for men and women in the United States, and nearly half (44.4%) of adult women ages 20 years and older between 2015 and 2018 had some form of cardiovascular disease including high blood pressure. The advisory emphasizes that some risk factors for heart disease are specific to women or carry a different risk for CVD events in women than in men. These factors include:

• Risks related to the menstrual cycle: starting young (younger than 11 years of age), early menopause (younger than 40 years of age) or hormone imbalances that result in irregular ovulation (polycystic ovarian syndrome) or unpredictable cycles.
• Risks related to pregnancy and childbirth: hypertension or diabetes during pregnancy, pre-term delivery, and delivering a baby that is under or over average birthweight.
• Risks related to oral contraceptive use and hormone replacement therapy.
• Women are disproportionately affected by inflammatory and autoimmune disorders including lupus, rheumatoid arthritis and scleroderma. These conditions are associated with increased risk of heart inflammation, heart and valve disease, and heart attack.
• Depression and anxiety are associated with heart disease more frequently and at younger ages in women than in men.
• Risks related to treatment for cancers more prevalent in women, such as breast, uterine or ovarian cancer. Some treatments may harm the heart, thus, women may need heart health monitored during and after treatment.

"We need to help women develop a 'lifetime approach' to their health, where they are empowered to proactively manage their heart disease risk in every life stage," said Wenger. Of particular concern to the advisory writers: Heart health is declining among U.S. women who are considering pregnancy, and the heart health of pregnant women is less than optimal. These factors may lead to pregnancy challenges for the mother and later health risks or complications for her and her children. "We recommend cardiologists, primary care physicians and obstetricians and gynecologists work together to quantify and reduce the risks of cardiovascular disease throughout a woman's life. These interdisciplinary partnerships are crucial to developing and implementing the best approaches that will yield improvements in women's overall health," Wenger said.

Awareness

Advocacy and educational campaigns focused on heart disease made great strides in improving knowledge and attitudes among women between 2004 and 2009: awareness of heart disease as the leading cause of death among women jumped from 30% to 56%. However, awareness has slipped, with 44% of women identifying heart disease as their leading cause of death in 2019. Declines in awareness were highest among young women (ages 25-34) and among those who identified themselves as Black or Hispanic. To combat these falling numbers, the advisory committee suggests increasing education for health care professionals. Nearly 7 out of 10 post-graduate medical trainees reported minimal to no training regarding gender-based medical concepts, and only 22% of physicians and 42% of cardiologists feel prepared to adequately assess heart disease specific to women. For nearly 2 decades, the American Heart Association has led initiatives to increase women's heart health awareness, including Go Red for Women in 2004. Under the Go Red umbrella, the Association launched Research Goes Red in 2019 in collaboration with Verily's Project Baseline. Research Goes Red is an online platform that aims to involve more women, especially younger women and women of color, in clinical studies to better understand their specific symptoms, risks, diagnoses and treatments.

Access and Delivery of Equitable Health Care

While several factors affect access to quality cardiovascular care, affordable health insurance coverage and out-of-pocket costs are the two most important factors affecting whether people access health care. The Advisory points out that the Patient Protection and Affordable Care Act (ACA), signed into law in the U.S. in 2010, improved access to health insurance coverage for women between the ages of 19 and 64, the largest coverage gain of any demographic group. In recent years, Medicaid coverage expansion through the ACA has been shown to increase coverage and health care among low-income women of reproductive age, which may lead to improvements in preconception health, pregnancy, cardiovascular health and chronic disease management.

• A 2018 Commonwealth Fund report noted that more than 25% of women spend $2,000 or more per year in out-of-pocket medical costs, and more than one-third skip needed care due to cost.
• The underlying reasons beyond cost for delaying health care are poorly understood. The percentage of women who report delaying medical and dental care and prescription medications has not changed significantly in 30 years.
• The Advisory specifically calls for more effective measurements to address these disparities and affect the most change.

"Our traditional approach to these questions has been to 'look back' at data we have already captured to assess trends. This is useful, however, we need to 'look forward' in real time, or near-real time, to be aware of and to investigate changes as they happen, so we can incorporate new techniques and address gaps and/or barriers quickly," said Roger. To increase access to care for high blood pressure management in communities where it is most prevalent, the American Heart Association, in collaboration with the U.S. Department of Health and Human Services' Office of Minority Health and the Bureau of Primary Health Care, launched the National Hypertension Control Initiative in 2021. The initiative is an evidence-based, community-driven effort to reduce hypertension, which disproportionately affects Black women compared to women of other ethnicities.

Call to Action

The Association and its collaborators are committed to improving the heart health of women across the lifespan. The Presidential Advisory concludes with six specific calls to action for health care professionals, researchers and the public. The advisory urges:

• Creating and implementing heart health-awareness campaigns that are culturally sensitive and appropriate, and emphasize the benefits of prevention and education;
• Optimizing prevention and clinical care through partnerships among cardiology, other specialties such as obstetrics/gynecology and primary care to improve the recognition of heart disease risk factors and ensure tools to calculate risk incorporate factors specific to women;
• Increasing the number of research studies focused on women, especially women from diverse racial and ethnic backgrounds and at younger ages;
• Engaging communities in heart health programs, some beginning in the primary school years, to engage girls and parents and empower families;
• Encouraging advocacy for public policy and legislative interventions that address social determinants of health, which may include access to healthy food, public spaces for physical activity and high-quality prevention and treatment; and
• Surveying and monitoring disease and risk factor data to better capture information that is critical to improving prevention and outcomes and delivering more effective health care.

"Making these advances in research and addressing gaps in and barriers to access health care are fundamental to the American Heart Association's commitment to advancing cardiovascular health for everyone," says Roger. This Presidential Advisory was prepared by the volunteer writing group on behalf of the American Heart Association. American Heart Association presidential advisories promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions and public policy by outlining what is currently known about a topic and suggesting improvements. While presidential advisories inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association's official clinical practice recommendations.