It’s inspiring to see State Street adorned with American
Heart Association flags in celebration of American Heart Month. For a
cardiologist, every month should be heart health month, but it does help our
cause to intensify the message once a year.
February is also the month when we celebrate the Go Red for
Women campaign, a remarkably successful cause campaign launched in 2003 aiming
to raise awareness about cardiovascular diseases in women. I remember when I
was first captivated by the emerging story surrounding women and cardiovascular
diseases. It was at the turn of this century, and there was no denying the
data. It had been the most common cause of mortality in the United States for
more than 50 years, but it wasn’t till two decades ago that we noted a
disturbing trend — one that could no longer be ignored.
Each year, the American Heart Association updates heart
disease and stroke statistics in the United States. It is a comprehensive and
exhaustive evaluation of the impact of cardiovascular diseases on the U.S. population
as a whole. The document is rich with
data on everything from mortality trends to survey results regarding all the
known risk factors that drive these diseases. It breaks down data by type — six
different diagnoses make up cardiovascular diseases, of which coronary heart
disease and stroke are the two most prevalent — sex, age, and race.
The figure I remember most vividly was one that compared the
disease-related mortality in men and women over time. Starting in 1979, with
the help of research improving our understanding of these diseases and
development of advances in drug therapy and mechanical treatment of coronary
heart disease, men derived a drastic and steep decline in mortality. The trend was
good reason to celebrate.
In complete contrast, the mortality trend among women was
climbing; it reached its peak in 2000. The mortality gap in cardiovascular
diseases between men and women was widening and caught us, the medical
community, completely off guard. We would spend the next two decades first
deconstructing the possible explanations for this trend and then using the
power of science, education, and social media, among other things, to construct
solutions.
The Campaign
The Go Red for Women campaign became the microphone through
which we would spend the next two decades disseminating the message about the
under-recognized risks of cardiovascular diseases in women. In addition to
spreading the word about the risk, the campaign has had immense impact through
various other avenues.
Advocacy efforts led to passage of the congressional Heart
Disease Education, Analysis, Research, and Treatment (HEART) for Women Act in
2011 mandating that there be adequate representation of women and racial and
ethnic minorities in clinical studies, that studies be powered to examine sex-specific
outcomes, and that quality and access of care for women with such diseases be
reported.
This act was much needed given that majority of groundbreaking
trials, which led to approval of many of the lifesaving treatments, extrapolates
data from predominantly white male cohorts to apply to females and minorities.
What has become clear is that women are not small white men and that sex-based
differences do play a role in determining the impact of treatments.
Improving representation of women in trials is now a mandate
by the FDA. This directive has and should continue to help us better understand
sex-specific differences in the treatment of cardiovascular diseases. Thanks to
the campaign, messaging remains strong, now existing in over 50 countries, and
continues to help to shape the cause.
The Differences
Over the last two decades, we have uncovered many striking
differences in the diseases that are specific to women. First, it didn’t take a
deep dive to realize that part of the explanation for the worrisome mortality
trends was related to perception. Women did not perceive themselves at risk for
cardiovascular diseases, and furthermore, providers did not think women were at
risk for cardiovascular diseases, in particular heart disease. Women who were
at risk were unaware. Even when they had more pressing symptoms, they were more
likely to present late in the course of what often was a heart attack.
Second, there was concern that women did not have classic
symptoms of what is infamously known as the “Hollywood heart attack” — a man
clutching his chest and falling to the ground. Thanks to detailed study on sex
differences in symptoms, we now know that women are more likely to have
atypical symptoms, but the vast majority actually do have more classic symptoms
at the time of their heart attack. Women need to pay attention to symptoms that
are not usual for them and occur with exertion or stress.
Third, we have discovered that women are not only at risk
for what is considered a traditional heart attack where there is atherosclerosis
resulting in visible narrowing of the heart arteries. They are also having
heart attacks with open arteries. Women can have chest pain symptoms with
testing suggesting impaired blood flow to the heart muscle without narrowing of
the main heart arteries. These two entities, “myocardial infarction with open
arteries” and “microvascular angina,” are almost always seen in women. The
observation has led to the hypothesis that there are sex differences in how
atherosclerosis effects blood vessels — women may be more likely to have
diffuse disease of the major heart arteries and are more likely to have
problems with the small microvessels. This becomes important when considering
treatment options, as medical and lifestyle therapy plays a larger role in
treating these entities.
In addition, we have uncovered two fascinating diagnoses that
are not new but have been underappreciated until recently. Both are almost
exclusively seen in women. First, the “Broken Heart Syndrome” (also known as Takotsubo
Syndrome) has been described now in thousands of cases. It is a heart attack
usually triggered by an emotional event. The usual presentation is a woman
presenting with classic signs and symptoms of a heart attack after experiencing
something emotional and or tragic. The heart arteries have no blockages but the
heart muscle appears to be stunned. Most patients are treated supportively and
make a full recovery.
The other is known as Spontaneous Coronary Artery Dissection
or SCAD. SCAD occurs in younger women and presents like a heart attack. When
the heart arteries are evaluated, there appears to be a spontaneous tear of one
of the heart arteries. Though the exact cause of SCAD is not confirmed, we have
learned through large patient registries that conservative treatment is
preferred over mechanical treatment and safest.
Lastly, as the treatment armamentarium — or medicines, equipment,
and techniques — has expanded for women presenting with a heart attacks, we
started to notice sex-specific risks of treatments. For example, women
undergoing invasive treatments such as heart catheterizations and stent
placement were noted to have increased risk of procedural bleeding and with it
were having worse outcomes. This sex-specific risk is thought to be multifactorial
and possibly related to anatomical differences in arteries and in the effects
of blood thinners and their metabolism in women. In an attempt to mitigate the
bleeding risk, current practice has evolved away from using drugs that are
associated with increased bleeding. Most importantly, we have transitioned to
using the smaller, safer artery in the wrist (radial artery) as the default
site for procedural access. This has had enormous impact on bleeding
complications and has preferentially improved outcomes among women given their
predisposition.
These are just a few of the many lessons we have learned
trying to navigate our way to answers about women and cardiovascular diseases
in the 21st century. With 20/20 hindsight in the year 2020, it is
remarkable to see where we were and how far we have come in two decades. The
colossal team effort speaks to the power of science, community, advocacy, and unwavering
commitment to ensure that we study and treat all at risk for cardiovascular
diseases, especially women and minorities. Though much more work is needed,
there is no doubt that our heart is in the right place when it comes to women
and these diseases.