women and heart disease: missed opportunities

10
Women and Heart Disease: Missed Opportunities Angela D. Banks, RN, PhD One woman dies of cardiovascular disease (CVD) every minute in the United States. CVD is the primary cause of mortality in US women, substantially affecting the lives of African American women compared to other ethnic groups. In a national survey conducted by the American Heart Association, 87% of women surveyed failed to cite heart disease as a major threat to their health. These misperceptions may lead women to underestimate their risk for CVD, resulting in a delay in seeking medical care, thus increasing their morbidity and mortality rates. Professional association guidelines and Internet resources for women and their health care providers are available to address the risk factors of smoking, diabetes mellitus, obesity, hypertension, hyperlipidemia, and physical inactivity. Unless women are informed and educated about these risk factors, they are unable to modify their lifestyles, be proactive in their health care, or reduce their cardiovascular risks. J Midwifery Womens Health 2008;53:430 – 439 © 2008 by the American College of Nurse-Midwives. keywords: cardiovascular disease, prevention, risk factors, women INTRODUCTION Cardiovascular disease (CVD) is the number one cause of death and disability of women in the United States, disproportionately affecting more African American women than any other ethnic group. 1 More than 459,000 women die of CVD annually. 2 Yet in a national survey conducted by the American Heart Association (AHA), only 13% of women cited heart disease and stroke as their greatest health threat. 2 Most women perceive breast cancer as their greatest health concern. 3 In reality, myocardial infarction (MI), stroke, and related CVDs are responsible for almost twice as many deaths among women than all forms of cancer combined. 2 Younger women and minority women are even less aware of their CVD risks. 2 African Amer- ican and white women have the highest prevalence of CVD compared to Hispanic, Asian, and Pacific Islander women. However, CVD and stroke is also the number one cause of mortality of Hispanic women. 1 In 2006, CVD was responsible for more than 28% of the 122,000 deaths among Hispanic Americans, while Asian and Pacific Islander women are the least affected by cardio- vascular heart disease compared to all other ethnic groups. 1 Health care providers have an essential role in both screening for CVD and raising women’s awareness. This article provides an overview of heart disease in women by reviewing the gender differences in symptoms, diag- nosis, and treatment, and describes strategies for decreas- ing CVD risks in women by making changes in the modifiable risk factors. HEART DISEASE AND WOMEN CVD is a general term used to describe diseases of the heart and the blood vessel system usually related to atherosclerosis (narrowing of the arterial blood vessel wall caused by formation of fatty plaques). 4 Coronary heart disease (CHD), the most common form of heart disease, causes narrowing of the arteries supplying the heart and can cause cardiac ischemia, which results in angina symptoms (chest discomfort and radiating pain). 4 If an artery becomes blocked, it can result in MI (death of a part of the muscle). 4 A cerebrovascular accident occurs if a cerebral artery becomes occluded or ruptures, leading to tissue death. 4 Although the basic facts of CVD are the same for both men and women, there are pronounced gender-based differences in its presentation, recognition, and treatment. Gender Differences in Symptoms of Coronary Heart Disease Most women with CHD present with typical chest pain, but many women also experience atypical symptoms (such as fatigue, shortness of breath, epigastric pressure, nausea, vomiting, numbness of the arms, and/or jaw pain). In contrast, men usually present with severe radiating substernal pressure accompanied by nausea. 5 The quality of the chest pain or discomfort in women is usually less severe or milder compared to men. Mc- Sweeney et al. 5 surveyed 515 women 4 to 6 months after they had an acute MI to determine what symptoms women experienced before the MI (prodromal phase) and what symptoms occurred during the MI (acute phase) that did not resolve until women sought treatment. They found that 57% of women in the study experienced chest pain in the month before the acute attack, but the intensity of the chest pain was mild. The remaining 43% did not experience any pain during the prodromal phase before experiencing an acute MI. Given that chest pain is considered a hallmark of CHD, women who do not experience chest pain may fail to recognize the serious- Address correspondence to Angela D. Banks, RN, PhD, Assistant Profes- sor, Department of Adult Health, University of San Francisco, 2130 Fulton St, Cowell 302, San Francisco, CA 94117-1080. E-mail: adbanks@usfca. edu 430 Volume 53, No. 5, September/October 2008 © 2008 by the American College of Nurse-Midwives 1526-9523/08/$34.00 doi:10.1016/j.jmwh.2008.04.008 Issued by Elsevier Inc.

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Page 1: Women and Heart Disease: Missed Opportunities

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Women and Heart Disease: Missed OpportunitiesAngela D. Banks, RN, PhD

One woman dies of cardiovascular disease (CVD) every minute in the United States. CVD is the primarycause of mortality in US women, substantially affecting the lives of African American women compared toother ethnic groups. In a national survey conducted by the American Heart Association, 87% of womensurveyed failed to cite heart disease as a major threat to their health. These misperceptions may lead womento underestimate their risk for CVD, resulting in a delay in seeking medical care, thus increasing theirmorbidity and mortality rates. Professional association guidelines and Internet resources for women and theirhealth care providers are available to address the risk factors of smoking, diabetes mellitus, obesity,hypertension, hyperlipidemia, and physical inactivity. Unless women are informed and educated about theserisk factors, they are unable to modify their lifestyles, be proactive in their health care, or reduce theircardiovascular risks. J Midwifery Womens Health 2008;53:430–439 © 2008 by the American College ofNurse-Midwives.

keywords: cardiovascular disease, prevention, risk factors, women

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NTRODUCTION

ardiovascular disease (CVD) is the number one causef death and disability of women in the United States,isproportionately affecting more African Americanomen than any other ethnic group.1 More than 459,000omen die of CVD annually.2 Yet in a national survey

onducted by the American Heart Association (AHA),nly 13% of women cited heart disease and stroke asheir greatest health threat.2

Most women perceive breast cancer as their greatestealth concern.3 In reality, myocardial infarction (MI),troke, and related CVDs are responsible for almostwice as many deaths among women than all forms ofancer combined.2 Younger women and minority womenre even less aware of their CVD risks.2 African Amer-can and white women have the highest prevalence ofVD compared to Hispanic, Asian, and Pacific Islanderomen. However, CVD and stroke is also the numberne cause of mortality of Hispanic women.1 In 2006,VD was responsible for more than 28% of the 122,000eaths among Hispanic Americans, while Asian andacific Islander women are the least affected by cardio-ascular heart disease compared to all other ethnicroups.1

Health care providers have an essential role in bothcreening for CVD and raising women’s awareness. Thisrticle provides an overview of heart disease in womeny reviewing the gender differences in symptoms, diag-osis, and treatment, and describes strategies for decreas-ng CVD risks in women by making changes in the

odifiable risk factors.

ddress correspondence to Angela D. Banks, RN, PhD, Assistant Profes-or, Department of Adult Health, University of San Francisco, 2130 Fulton

et, Cowell 302, San Francisco, CA 94117-1080. E-mail: [email protected]

30

2008 by the American College of Nurse-Midwivesssued by Elsevier Inc.

EART DISEASE AND WOMEN

VD is a general term used to describe diseases of theeart and the blood vessel system usually related totherosclerosis (narrowing of the arterial blood vesselall caused by formation of fatty plaques).4 Coronaryeart disease (CHD), the most common form of heartisease, causes narrowing of the arteries supplying theeart and can cause cardiac ischemia, which results inngina symptoms (chest discomfort and radiating pain).4

f an artery becomes blocked, it can result in MI (death of part of the muscle).4 A cerebrovascular accident occursf a cerebral artery becomes occluded or ruptures, leadingo tissue death.4 Although the basic facts of CVD are theame for both men and women, there are pronouncedender-based differences in its presentation, recognition,nd treatment.

ender Differences in Symptoms of Coronary Heart Disease

ost women with CHD present with typical chest pain,ut many women also experience atypical symptomssuch as fatigue, shortness of breath, epigastric pressure,ausea, vomiting, numbness of the arms, and/or jawain). In contrast, men usually present with severeadiating substernal pressure accompanied by nausea.5

he quality of the chest pain or discomfort in women issually less severe or milder compared to men. Mc-weeney et al.5 surveyed 515 women 4 to 6 months after

hey had an acute MI to determine what symptomsomen experienced before the MI (prodromal phase)

nd what symptoms occurred during the MI (acutehase) that did not resolve until women sought treatment.hey found that 57% of women in the study experiencedhest pain in the month before the acute attack, but thentensity of the chest pain was mild. The remaining 43%id not experience any pain during the prodromal phaseefore experiencing an acute MI. Given that chest pain isonsidered a hallmark of CHD, women who do not

xperience chest pain may fail to recognize the serious-

Volume 53, No. 5, September/October 2008

1526-9523/08/$34.00 • doi:10.1016/j.jmwh.2008.04.008

Page 2: Women and Heart Disease: Missed Opportunities

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ess of their symptoms, delay seeking medical treatment,r be misdiagnosed once they arrive at the hospital forreatment.

However, in order to act on atypical symptoms,omen must be aware of the symptoms that can occur,

nd surveys have shown that they are not.6 In 2000,osca et al.6 conducted a national survey of 1000omen to assess their awareness, knowledge, and per-

eption of heart disease and found a lack of awareness ofeart attack warning signals. Although 67% of theomen knew some of the “classic” signals of heart

ttack, such as chest pain, shortness of breath, pain in therm, and tightness in the chest, only 10% were aware ofhe less common signals that women may have such asausea, fatigue, and dizziness, and 7% of the women didot answer the question at all.6

The survey results also revealed that most womenearned about CHD from magazines (43%) and television24%), and less so from their own physician (18%). Thendings suggested that many women (90%) felt comfort-ble discussing CHD prevention with their doctor, yetost of them (70%) did not.6 The lack of provider–

atient discussion about CHD may be related, in part, tohe aforementioned gender-based myths associated withHD. Wenger7 crystallizes the problem of traditionalender bias in heart disease: “. . . The community hasiewed women’s health almost with a ‘bikini’ approach,ooking essentially at the breast and reproductive system,nd almost ignoring the rest of the woman as part ofomen’s health.”Finally, many women interpret their symptoms as

nsignificant,3 further increasing their risk for a heartttack as they devalue (or diminish) their symptoms.omen may also be more preoccupied with high-profile

emale health problems (e.g., breast cancer and osteopo-osis). Clinicians also fail to recognize atypical symp-oms of heart attacks in women.8

In addition to failing to recognize symptoms, manyomen, particularly African American women, oftenelay seeking help for cardiac symptoms. Banks andalone9 found that “African American women experi-

nced trivialization of their complaints by clinicians andfocus on technological procedures over respectfully

ttending to their concerns, which provided further dis-ncentives to seeking care.” African American womenay also experience different symptoms as their primary

omplaint—such as shortness of breath rather than chestain—and interpret these symptoms differently com-ared to members of other groups.10

fngela D. Banks, RN, PhD, is an Assistant Professor in the Department ofdult Health, University of San Francisco, San Francisco, CA.

ournal of Midwifery & Women’s Health • www.jmwh.org

ender Differences in the Evaluation and Diagnosisf Coronary Heart Disease

he starting point of gender-related inequalities in theealth care delivery system could be when women arrivet the emergency room with chest pain indicative ofymptomatic CHD.11 Women diagnosed with CHD areess likely to receive the prompt diagnostic testing andntervention procedures as compared to men.12 In 2005,nand et al.12 conducted a post-hoc analysis of data fromrandomized clinical trial consisting of approximately

800 women and more than 7200 men diagnosed withcute coronary syndromes. An acute coronary syndromes defined as a combination of MI, non-ST elevation MI,T-elevation MI, and unstable angina.12 They found thatomen underwent fewer invasive procedures including

ngiography, angioplasty, and coronary artery bypassraft (CABG) surgery compared to men (47.6% vs.0.5%; P � .0001). While there were no differences ineart attacks, strokes, or deaths, women returned to theospital with persistent complaints of chest pain morerequently than men during the 9-month follow-up pe-iod. If there is lower utilization of noninvasive diagnos-ic testing at the initial point of care, it may translate into

delayed diagnosis, delayed initiation of therapeuticntervention, and ultimately poorer outcomes.11 Lessggressive care of women with CHD can lead to higherates of complications and higher death rates.6

Daly et al.13 studied more than 3700 men and womeniagnosed with angina and found that women were lessikely than men to be referred for cardiac diagnosticrocedures such as exercise electrocardiography andoronary angiography. Women with confirmed CHDere less likely to be revascularized compared to theirale counterparts, and were twice as likely to suffer

eath and a non-fatal MI in the 1-year follow-up period.dditionally, women compared to men in this study were

lso placed in lower CHD risk categories. This failure oflinicians to recognize cardiovascular risk in women waslso found by Mosca et al.14 Their 2005 online study of00 randomly selected physicians of different specialtiessed a standardized questionnaire to evaluate whether orot physicians were aware of and adhering to the currentVD prevention guidelines. The study design presentedase scenarios describing high-, intermediate-, and low-isk patients according to the Framingham risk score,hich estimates the risk of developing CHD within a0-year period.15 Women diagnosed as intermediate-riskere significantly more likely to be assigned to a

ower-risk category by primary care physicians than menith the same risk profiles (P � .0001), and the resultsere similar for physicians in other specialties such asbstetricians/gynecologists and cardiologists.14 In addi-ion, only 20% of the physicians surveyed knew thathere was a higher mortality in women compared to men

rom CVD.14

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McSweeney et al.16 conducted a qualitative study of0 women with CHD and interviewed each woman forpproximately 2 hours. They found that even though theomen experienced many prodromal and acute symp-

oms associated with CHD, there was a significant delayn a cardiac diagnosis despite frequent visits to theirlinicians. In fact, some women experienced a MI beforehey were actually diagnosed with CHD, and otheromen received a non-cardiac diagnosis of indigestion,epression, anxiety, and joint pain. Women who pre-ented with characteristic cardiac symptoms were diag-osed without problems, but women who presented withtypical symptoms experienced a delayed diagnosis.16

onsidering that two-thirds of women who die suddenlyrom heart disease had no previously recognized symp-oms,17 the necessity for early symptom recognition,rompt diagnosis, and immediate treatment is clear.

ender Differences in the Treatment of Coronary Heartisease

2005 study18 of 890 men and women with a confirmedI evaluated outcomes in cardiac treatment and found

hat women who suffer heart attacks not only wait longerompared to men to be seen and assessed, but they alsoxperience differences in treatment.15 Men were assessedithin 20 minutes after arrival to the hospital compared

o women who waited 10 minutes longer. After approx-mately 30 minutes, 95% of men received aspirin toecrease platelet aggregation and clot formation; 92% ofomen received the same treatment but waited 20inutes longer for it. After approximately 50 minutes,

3% of the men received reperfusion therapy to dissolvelood clots in their coronary arteries and restore adequatelood flow to their heart. Women waited considerablyonger (70 minutes), and only 35% of women receivedhe same treatment. Even though outcomes and compli-ations of these delays were not addressed, the authorsoncluded that: “These delays in treating women whouffer heart attacks could expose them to a greater rate ofife-threatening complications and a less favorable out-ome than their male counterparts.”18

In 2007, Hernandez et al.19 examined more than3,000 African American and white men and women tovaluate the use of an implantable cardioverter-defibril-ators for persons suffering from heart failure with leftentricular systolic dysfunction. The data revealed thatess than 40% of eligible patients received this therapy,nd among women and blacks, the incidence was evenower. Only 28.2% of black women, 29.8% of whiteomen, and 33.4% of black men received the defibril-

ators, yet 43.6% of the white men received the defibril-ators.19 Heart failure with left systolic dysfunction is aajor risk factor for sudden death in persons who have

ad a heart attack, so it is disconcerting that so few a

32

ligible patients received this treatment, and that gendernd race disparities were so evident.

ender Differences in Outcomes

here are physiologic differences that may affect cardio-ascular outcomes in women. Women tend to havemaller coronary vessels regardless of their body size;his may cause them to be more prone to coronarycclusion compared to men.20 When revascularization iserformed to reestablish blood flow to occluded arteriesia percutaneous coronary intervention, or coronary ar-ery bypass graft, the luminal diameter of an artery is atrong predictor of restenosis.20 The size of the coronaryessel correlates with long-term graft patency,20 and maye associated with higher perioperative mortality rates inomen after CABG.21 In addition, women tend to belder and have more medical problems because the onsetf clinical manifestations of CHD in women is approxi-ately 10 years later and about 20 years for more serious

roblems such as MI and sudden cardiac death.7

SSESSING WOMEN FOR CORONARY HEART DISEASE

stimating Risk

n order to decrease the likelihood of developing CHD,omen and/or their health care providers must first

ecognize the risk factors (Table 1). Table 2 highlightsecommended lifestyle interventions for CHD preventionnd risk factor reduction in women.

Health care providers can calculate the 10-year abso-ute risk for developing CHD by using the Framinghamisk score for women, which stratifies into 4 categories ofigh, intermediate, low, and optimal risk. The Framing-am risk score calculator uses 5 different factors—age,holesterol, lipid levels, smoking status, and blood pres-ure—to give women an individualized score that acts as

Table 1. Risk Factors for Cardiovascular Disease

Unmodifiable Risk FactorsIncreasing ageGenderRace/ethnicityFamily history of premature cardiovascular disease

Modifiable Risk FactorsObesityUnhealthy eating/nutritionLack of physical activitySmokingHypertensionElevated lipidsType 2 diabetes

dapted from the American Heart Association.1

starting point for an assessment of her risk for CHD

Volume 53, No. 5, September/October 2008

Page 4: Women and Heart Disease: Missed Opportunities

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Table 3). A risk greater than 20% is considered high; aisk of 10% to 20% is intermediate; and a risk of less than0% is low.Based on these categories, interventions can be tai-

ored to meet the needs of each woman according to herndividual categories of risk. The most important thinghat women can do to decrease the risk of CHD,egardless of their base risk category, is to make lifestylehanges.15 The 2007 AHA evidence-based guidelines forVD prevention recommend that all women 20 years ofge and older be screened for CVD by their health careroviders.22 The screening process includes a medicalistory, physical examination (including blood pressure,ody mass index [BMI], and waist circumference), andaboratory values of fasting blood glucose and lipids inddition to conducting the Framingham risk assess-

Table 2. Lifestyle Interventions for Coronary Heart Disease Prevention in

Lifestyle Risk Reduction Goal

besity Maintain a BMI between 18.5–24.9waist circumference �35 in15

utrition Encourage a diet rich in vegetableswhole-grain, and high-fiber foodsfish at least twice weekly.22 Decrintake of saturated fats and tranand foods high in cholesterol.

hysical activity Exercise 30 min or more (moderate-intensity aerobic activity) on mospreferably all days of the week22

essation of smoking Stop smoking and avoid environmento tobacco22

lood pressure control Maintain BP �140/90 mm Hg (optimm Hg). Maintain BP �130/80 mdiabetic.22 Pharmacotherapy is inwhen BP is out of acceptable ran

ipid/lipoprotein management Maintain total cholesterol �200 mg�100 mg/dL; HDL-C �50 mg/dLtriglycerides �150 mg/dL22

iabetes management Maintain fasting blood glucose 65–maintain HbA1c �7%22

MI � body mass index; BP � blood pressure; CHD � coronary heart disease; CVDL � low-density lipoprotein; MI � myocardial infarction.

ent.22 B

ournal of Midwifery & Women’s Health • www.jmwh.org

OUNSELING STRATEGIES TO DECREASE MODIFIABLEORONARY HEART DISEASE RISK FACTORS

he modifiable risk factors associated with CHD arebesity/nutrition, physical activity, smoking, hyperten-ion, elevated lipids, and diabetes. In addition, thencidence of CHD in women increases after menopause.ppendix A offers Internet resources for patients andealth care providers about each of the modifiable riskactors discussed below.

besity/Nutrition

besity has become a major epidemic in the Unitedtates, and over the last 10 years there has been aubstantial increase in the number of adults who arebese.23 According to the National Heart Lung and

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Supporting Data

and a Obesity is an independent risk factor for CVD in women.54

It predisposes or is associated with CHD, heart failure,and sudden death.23 Waist circumference reflects themagnitude of abdomen adipose tissue and total fatmass and is strongly linked to CVD risks.55

lyeacids

Men and women who averaged 8 or more servings offruits and vegetables a day were 30% less likely tohave a heart attack or stroke.56 Fish, especially oilyfish, decreases the risk of CVD, in part because ofomega-3 fatty acids.22 Saturated fats and trans fatsincrease blood cholesterol, and an increased bloodcholesterol leads to heart attack and increased risk ofstroke.42

ous Women who walk briskly for a least 2–3 hours per week–or burn an equivalent amount of energy throughvigorous exercise decrease their risk of CHD by 30%to 40%. 57

osure Risk of CVD is substantially decreased in women within1–2 years after smoking cessation.34 Environmentaltobacco (also known as secondhand smoke) causesheart disease in nonsmoking adults.58 Nonsmokers whoare exposed to secondhand smoke at home or workincrease their risk of developing heart disease by25–30%.58

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The higher the blood pressure, the greater the chances ofMI, heart failure, stroke, and kidney disease.36 Bloodpressure control reduces the risk of CVD amongpersons with diabetes by 33–50%.59 Every 10-mm Hgreduction in systolic BP reduces the risk ofcomplications related to diabetes by 12%.59

L-C CHD risk increases with elevated total and LDL cholesterollevels and decreases with high HDL cholesterol levelsin women and men.42 The role of triglycerides in thedevelopment and progression of CHD in women remainsunclear.42

/dl; The risk of fatal CHD associated with diabetes is 50%higher in women than in men.60

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ndividuals involves three key measures—BMI, waistircumference, and risk factors for diseases and condi-ions associated with obesity. In adults, overweight isefined as a BMI of 25 to 29 kg/m2; obesity is defined asBMI 30 kg/m2 or higher.24 Waist circumference is aeasurement of central obesity and intraabdominal fat

nd provides an independent prediction of disease risk,ecause body fat that accumulates around the stomachends to pose a greater health threat than fat stored in theower half of the body.25 In women, a waist circumfer-nce of more than 35 inches is associated with anncreased risk for type 2 diabetes, hyperlipidemia, hyper-ension, and CVD.25 Obese women are 4 times as likelyo develop these conditions compared to women oformal weight.23 African American women (33%) areearly twice as likely as white women (17%) to bebese.24 Additionally, women who are obese also expe-ience a greater risk of sudden death.23

Improving diet and lifestyle is a critical component ofhe AHA’s strategy for CVD risk reduction.26 In 2006,he AHA issued dietary and lifestyle recommendationshat focus on balancing caloric intake and physicalctivity to achieve and maintain a healthy body weight;onsuming a diet rich in vegetables and fruits; choosinghole-grain, high-fiber foods; and consuming fish, espe-

Table 3. Framingham Point Score Estimate of 10-Year Riskfor Women*

B xoB A xoBy,egArepstnioPstnioPegA

20–34 –7 Total Cholesterol, mg/dl

20–39 40–49 50–59 60–69 70–79

35–39 –3 <160 0 0 0 0 0 40–44 0 160–199 4 3 2 1 1 45–49 3 200–239 8 6 4 2 1 50–54 6 240–279 11 8 5 3 2 55–59 8 ≥280 13 10 7 4 2 60–64 10 65–69 12 Box C 70–74 14 y,egArepstnioP75–79 16 Smoking 20–39 40–49 50–59 60–69 70–79

Nonsmoker 0 0 0 0 0 Smoker 9 7 4 2 1

Box D Box E Box F High-Density Lipoprotein, mg/dl

Points Systolic BP, mm Hg

Untreated Treated PointTotal

10-Year Risk of Developing

Coronary Heart Disease %

>60 –1 <120 0 0 <9 <1 50–59 0 120–129 1 3 9 1 40–49 1 130–139 2 4 10 1 <40 2 140–149 3 5 11 1 ≥160 4 6 12 1 13 2 14 2 15 3 16 4 17 5

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>25 30

20 11

10-Year Risk _________%

Women can find their point score in boxes A through F, and then add up these pointso receive their total points. The point values in box F will provide an estimate of their0-year risk. Adapted from Mosca.40

ially oily fish, at least twice a week. Note, however, that a

34

omen of childbearing age should be aware of theercury content of some fish, including king mackerel,

wordfish, and shark, when increasing dietary omega-3atty acids (in order to reduce the potential risk ofeurologic problems with the fetus).22 Recommendationsnclude limiting intake of saturated fat to less than 7% ofotal calories, trans fat to less than 1% of total calories,nd cholesterol to less than 300 mg/day. This can be doney choosing lean meats and vegetables, fat-free orow-fat dairy products, and minimizing the intake ofartially hydrogenated fats and beverages and foods withdded sugars. Women should also choose and prepareoods with little or no salt and consume alcohol inoderation.26 The risk of developing CVD can be

ubstantially reduced by adhering to these dietary andifestyle recommendations. Akesson et al.27 found thathe daily consumption of vegetables and fruit combinedith whole grains, fish, beans, and half of a glass of wine

ignificantly reduced (by 50% or more) the risk of heartttacks in women.

hysical Activity

ccording to the Centers for Disease Control and Pre-ention, “Physical inactivity contributes to 300,000 pre-entable deaths a year in the United States.”28 A seden-ary lifestyle increases mortality, decreases quality ofife, and is preventable by changes in behavior patterns.28

omen who are sedentary are twice as likely to developHD compared to women who are not sedentary.29 Ineneral, ethnic minority women are less active and lessikely to engage in physical activity compared to whiteomen.30 In 2004, 78.4% of white women, 76% ofsian/Pacific Islander women, 66.1% of black women,

nd 60.1% of Hispanic women were physically active.he ethnic minority women were the least active com-ared to white and Asian/Pacific Islander women. Theost commonly cited reasons for their inactivity were

nsufficient time, lack of child care, and lack of access toafe and secure places to exercise.28

The benefits of physical activity may include: in-reased levels of high-density lipoproteins (HDLs, goodholesterol) and decreased levels of low-density lipopro-eins (LDLs, bad cholesterol), a decrease in mortalityates for women, a decreased risk of developing CHDnd stroke, a reduced chance of developing diabetes, and

reduction in blood pressure. Despite these provenealth benefits of physical activity, more than 60% ofdult women fail to exercise to realize these benefits.31

Women should begin a program of physical activityfter careful evaluation by their health care provider. The007 CVD prevention guidelines for women recommendxercising for 30 minutes of moderate intensity at least 5ays a week, and for women that are overweight oraintaining weight loss, 60 to 90 minutes of moderate

ctivity is recommended.22 Women who have been

Volume 53, No. 5, September/October 2008

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reviously inactive should start slowly, with 5- to 10-inute sessions, and gradually increase their activity

evel.29 Many women may also benefit from short coun-eling sessions during routine office visits that includeoal setting, behavioral interventions, guidance, andupport. In addition, others may need a more individu-lized exercise program to meet their specific needs.32

egardless of the intervention needed, clinicians canave a significant opportunity to assist and support theiratients as they transition into a more active and healthierifestyle.

moking

n 2006, an estimated 46 million adults in the Unitedtates were smokers. Of these, 20 million were women;0% were white women and 17% were African Ameri-an women.33 Smoking is one of the most preventableauses of CVD among women. The risk of CVD in-reases with the number of cigarettes smoked and theuration of time that a woman smokes.34 A woman whomokes is 4 times more likely to die of CVD than aonsmoker.35

The 2007 AHA evidence-based guidelines for CVDrevention in women recommend that women whomoke should stop smoking, and also avoid environmen-al smoke.22 The clinical guidelines and recommenda-ions established by the United States Preventative Ser-ices Task Force (USPSTF) are similar, and recommendhat clinicians screen all women for tobacco use androvide tobacco interventions for those who smoke.32

he guidelines suggest a five-step behavior and counsel-ng framework for engaging women in conversationsbout smoking cessation. The counseling and interven-ion should begin with inquiring about tobacco use, thendvising women to stop if they smoke, assessing theireadiness to stop, assisting them to stop, and finallyrranging support and counseling to help them stop. Foromen that are having difficulty in relinquishing tobaccose, nicotine replacement therapy should be considereds a safe and effective pharmacotherapy in assistingomen to stop. Clinicians should also inquire at eachffice visit about the success of the therapy that has beennitiated.

ypertension

pproximately 50 million people in the United Statesave hypertension, and nearly half are women.36 Womenho have hypertension have a life expectancy that is 5ears shorter compared to women without hyperten-ion.37 Hypertension is defined as a diastolic bloodressure of 90 mm Hg or higher or a systolic pressure of40 mm Hg or higher.36 A 20-pound increase in bodyeight is associated with a 3.0-mm Hg higher systolic

nd a 2.3-mm Hg higher diastolic blood pressure. This l

ournal of Midwifery & Women’s Health • www.jmwh.org

ranslates into an estimated 12% increased risk for CHDnd a 24% increased risk for stroke for persons who areverweight.36 By the age of 50 years, the incidence ofypertension increases significantly in women comparedo men, and the prevalence of hypertension in women isqual to or greater than the prevalence in men. But by thege of 60 years, the highest prevalence of hypertension isreatest among African American women.36

Many people believe that hypertension is a disease thatesults from stressful lifestyles, physical inactivity,moking, and other unhealthy behaviors. However, withhe exception of a few cases, the exact cause of hyper-ension is unknown.37 Many women with hypertensionre undiagnosed.37 This is particularly relevant for Afri-an American women, because they have a higherrevalence of hypertension, an earlier onset, and disturb-ngly higher rates of hypertension-related death fromtroke, heart disease, and end-stage renal disease.38 Theeventh Report of the Joint National Committee onrevention, Detection, Evaluation, and Treatment ofigh Blood Pressure (JNC 7) recommends that all adultsver the age of 18 years be screened for high bloodressure at least every 2 years. During the initial screen-ng, the JNC 7 guidelines recommend that women shoulde sitting quietly in a chair for at least 5 minutes, withheir feet firmly on the floor, and their arm at the level ofheir heart. Before a diagnosis of hypertension is con-rmed, two or more readings on two separate occasionsfew weeks apart should be done. If diagnosed with

rehypertension, a systolic blood pressure between 120nd 139 mm Hg, and a diastolic blood pressure between0 and 89 mm Hg, she should be rechecked within a year,nd if diagnosed with hypertension stage 1, a systoliclood pressure of 140 to 159 mm Hg and a diastolic of 90o 99 mm Hg, her blood pressure should be rechecked in

months and advised to reduce her blood pressure withifestyle modifications. If diagnosed with stage 2 hyper-ension, a systolic blood pressure of 160 mm Hg or morer a diastolic of 100 mm Hg or more, she should beollowed closely, and re-evaluated in a month by herealth care provider.36

levated Lipids

n 2002, the Third Report of the National Cholesterolducation Program (NCEP) Adult Treatment Panel

ATP) III guidelines were released.39 The updated guide-ines focus on reducing the burden of heart disease in thenited States by recommending the need for more

ggressive lowering of the LDL cholesterol levels. LDLholesterol accounts for 60% to 70% of the total choles-erol, and clinical trials show that reducing LDLs is theost effective way to decrease CHD.39 The ATP III

uidelines recommend that the lipoprotein profile shoulde the primary test in screening for elevated cholesterol

evels. The United States Preventive Services Task Force

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USPSTF) recommends that clinicians screen youngomen for abnormal lipids between the ages of 20 and5 years if they have pre-existing risk factors for CHD.dditionally, the USPSTF also recommends screeningomen aged 45 years and older for lipid disorders and

reating women with elevated lipids who are at risk forHD.32 Total cholesterol should be less than 200 mg/dL;DL (bad cholesterol), less than 100 mg/dL; HDL (goodholesterol), more than 50 mg/dL; and triglycerides (aype of fat in the blood), less than 150 mg/dL.40 Researchas shown that high HDL levels tend to offer protectiono persons even if they have elevated total cholesterolevels. An HDL cholesterol level of 60 mg/dL or highers considered a negative risk factor,41 and compared with

en, women have slightly higher HDL cholesterol lev-ls. These levels tend to remain steady throughout life.41

In women, LDL cholesterol and total cholesterol levelsncrease after the age of 55 years and peak between 55nd 65 years of age, which is approximately 10 yearsater compared to the average age that these values peakn men.41 Elevated triglyceride levels appear to increasehe risk of CHD in women.41

When lifestyle approaches such as diet, exercise, andeight control are not enough to lower total cholesterol

nd LDL levels, more aggressive treatment with statins isecommended to achieve the LDL goals.15 However,tatins should not be prescribed for women who are preg-ant or who are trying to get pregnant,42 because statinslock the formation of cholesterol, an essential componentn fetal development. The reduction of cholesterol in preg-ant women can lead to fetal abnormalities.43

iabetes

omen with diabetes have double the risk of developingVD compared to women without diabetes.44 According

o the American Diabetes Association, women 45 yearsf age or older should have a fasting blood sugar drawnvery 3 years. However, earlier and more frequentcreening is advised for women who have a familyistory of diabetes.45

Gestational diabetes mellitus (GDM) is a glucosentolerance that begins or is first detected during preg-ancy,46 and it affects about 7% of all pregnancies.47

omen with GDM have an increased risk of developingiabetes after pregnancy,46 further increasing their riskor CVD. Women who have diabetes are not only at areater risk for CHD, but they also experience poorerutcomes for survival when diagnosed with CVD.Exercise and physical activity greatly diminishes the

isk of developing type 2 diabetes by as much as 30%,48

nd the combination of physical activity and diet canecrease the incidence of type 2 diabetes by 40% to 60%ver 3 to 4 years.49 In 2008, the American Diabetesssociation position statement recommended that all

ndividuals who are overweight or obese exercise mod- a

36

rately at least 30 minutes a day to delay or prevent theevelopment of diabetes. Physical activity increasesnsulin sensitivity, lowers blood glucose levels, and helpsaintain weight loss. Exercise in addition to healthy

utrition also helps to restore normal glucose metabolismnd decreases overall body fat. In turn, decreasing bodyat and modest weight loss has been shown to alsomprove insulin resistance.

Medical nutrition therapy is pivotal in preventing andelaying the onset of type 2 diabetes.50 The 2008osition statement of the American Diabetes Associationecommends three levels of prevention for diabetes care.he first level is primary, which seeks to halt or delay thenset of diabetes, and uses public health measures toecrease the prevalence of individuals that are obese. Theecond level is for individuals with diabetes, and medicalutrition therapy is used to maintain metabolic control.he third level is focused on controlling and managing

he complications associated with diabetes.50

ole of Menopause

efore menopause, women appear to be somewhat pro-ected from CHD, heart attack, and stroke.51 However, asomen age, their risk of heart disease and stroke begins

o rise and continues rising. In women who have under-one early menopause (before 50 years of age) orurgical menopause, the risk of CVD is even higher,specially if other risk factors are present. After meno-ause, CVD becomes more of a risk for women becausef the reduced level of estrogen.51 A reduced level ofstrogen can lead to the formation of atherosclerosis andlot formation in the blood vessels, an increase in LDLevels, and a decrease in HDL levels.

For many years, the prevailing belief has been thatormone therapy (HT) protects the heart. However, theardioprotective effects of HT have been challenged byhe recent studies. The Heart and Estrogen/Progestineplacement Study (HERS)52 was the first large, ran-omized, double-blind, placebo-controlled trial to di-ectly measure whether HT alters cardiac event risk inomen with established heart disease. The researchers

ound that while HT decreased LDL cholesterol levelsnd increased HDL cholesterol levels, the use of HT wasot associated with any change in the incidence of deathrom CHD. The AHA now recommends that women withhistory of CVD refrain from taking HT if the only goal

s to prevent further cardiovascular problems.52

The Women’s Health Initiative (WHI)53—the largestongitudinal study evaluating the use of estrogen plusrogestin therapy in more than 16,000 women withouteart disease—was halted because of an increase indverse health outcomes in the women in the estrogenrm of the study. The findings revealed that there was a6% increase in breast cancer, a 29% increase in heart

ttacks, and a 22% overall increase in total CVD among

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omen receiving the estrogen plus progestin.53 The find-ngs suggest that if a woman has an intact uterus, taking theombination of estrogen and progestin is more of a healthisk than a health benefit. Therefore, health care providersnd clinicians are cautioned against prescribing HT for theole purpose of decreasing heart disease in women.

ONCLUSION

VD is the number one cause of death and disability inll women in the United States.1 However, only 13% ofomen consider heart disease and stroke a personal

hreat to their health.3 Health care providers have aesponsibility to educate and inform women about theirisks for CVD and help them develop strategies forrevention. Screening for risk factors for heart diseasehould be included in the annual physical examinationsf women, and guidelines to address the risk factorshould be incorporated into practice. Clinicians mustispel the misperception that “heart disease” is a man’sisease and that women are not affected.

I would like to thank Dr. Holly Kennedy, CNM, PhD, FACNM, FAAN,Associate Professor at the University of California, San Francisco for hercomments and suggestions on the earlier drafts of this manuscript.

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Appendix A. Clinical Recommendations and Internet Resources

Risk Factors Internet Resources Comments

besity www.obesity.org Addresses cause, health effects, prevention and treatmentof obesity

utrition www.cfsan.fda.gov/�frf/sea-mehg.html Complete list of mercury levels in seafoodhysical activity www.cdc.gov/nccdphp/sgr/women.htm Physical activity and heart of womenmoking www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf Treating tobacco use and dependenceypertension http://hypertension.medicweb.org/special_concerns/women.php Hypertension and womenlevated Lipids http://circ.ahajournals.org/cgi/reprint/106/25/3143.pdf Third Report of the National Cholesterol Education

Program Adult Treatment Panel III (NCEP ATP III)iabetes www.diabetes.org/about-diabetes.jsp Overview of diabetesenopause www.menopause.org/default.htm North American Menopause Society (NAMS)HD risk calculation www.nhlbi.nih.gov/guidelines/cholesterol/index.htm Framingham CHD risk scoring system

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