Highlights from the Presentation
On the Need for Change in the Presentation of Cardiovascular Health Data
Cardiovascular disease remains the leading cause of mortality among both women and men. Over the years, research has identified very important biologic differences between women and men and the way they respond to social, environmental, and behavioral stresses. But sadly, the underrepresentation of women in all aspects of biologic research delayed the translation of these discoveries to women.
If you take but one message away from my presentation, I want it to be this: we need a cultural shift in the way we present cardiovascular health data both to health professionals and to the public because we identify the characteristics in men as the implicit gold standard, and the presentations in women are termed atypical. The fact of the matter is they are typical for half of the world's population.
On Sex-Specific, Sex-Predominant, and Population-Attributable Risk Factors for Women
What I will try to [highlight] today are sex-specific risk factors for women: early menarche before 11 years of age; premature menopause before age 40; polycystic ovarian syndrome; hypothalamic amenorrhea. And then a number of pregnancy related issues: hypertensive disorders of pregnancy, including preeclampsia; gestational diabetes; preterm delivery puts a woman at increased risk; if she has a low- or high-birth weight fetus; uses oral contraceptives; or menopausal hormone therapy. And what we see that is very important for our public health is that when there is low cardiovascular health in pregestational and pregnant women, it increases the likelihood that they will have adverse pregnancy outcomes, […] but it also decreases the cardiovascular health in their children, so it goes on to the next generation.
Then, in addition to the sex-specific risk factors, there are sex-predominant risk factors. If there's systemic inflammation or autoimmune disorders, such as lupus or rheumatoid arthritis, this imparts cardiovascular risk. For example, the woman with lupus will not die of her lupus — she will die of the cardiovascular complications. Depression and anxiety, more frequent in women especially at younger ages, and then obviously the chemotherapies for cancer, especially breast cancer. The tragedy is when I see a woman in my clinic and I say “Congratulations, you survived your breast cancer – but now, as a complication of that therapy, you have heart failure.” This is an area we must address.
And because this is a public health problem, we must examine population-attributable risk factors. This is a metric that we need if we are going to prioritize our public health interventions. For example, among white women, obesity and hypertension are their highest risk factors for the development of heart failure. In black women, what we've seen is a temporal increase in the occurrence of diabetes as a risk factor for heart failure — probably related to sedentary lifestyle and obesity in part. In black women, hypertension and diabetes give them the greatest risk for the development of heart failure.
On Poorer Cardiovascular Health in Young Women and Pregnant Women
In this country, cardiovascular health is poorer in young women overall, particularly during pregnancy. When you compare comparably aged pregnant and non-pregnant women, the pregnant women have lower cardiovascular health, which likely explains both their complications of pregnancy and the transmission of risk to their offspring. Cardiovascular health is particularly poor in non-Hispanic black and Mexican women, and what we see is the woman who develops blood pressure elevation during pregnancy has an increased subsequent risk of coronary disease and heart failure.
On the Need for Cross-Disciplinary, Intersectional Risk Interventions
We have to develop and deploy risk calculators that incorporate sex-specific and sex-predominant risk factors. We need cross-disciplinary research on the social determinants of health because that's necessary to design interventions to address these determinants. We have to define and implement cross-disciplinary interventions, and that means we go outside of the medical community. We go into communities, health systems, business, urban developers, economic researchers, and then we have to implement those risk interventions that embrace this intersectionality and have cultural sensitivities.
On Increasing Awareness and Collaborative Care Among Health Professionals
Education of health professionals is requisite to improve awareness — awareness of the risk factors in women and the course of cardiovascular disease in women. In one study, 70 percent of postgraduate medical trainees reported that they received no or minimal sex-based medical concepts during any of their medical training. And in a study, 22 percent of primary care physicians and almost half of the cardiologists were the only ones who felt well prepared to assess cardiovascular risk in women.
We must address the education of our physician workforce, and we need collaboration between the OBGYN clinicians and the cardiologists because for many ostensibly healthy women, the OBGYNs are their primary care physicians. OBGYNs are in the preventive mode — they recommend mammograms and pap smears — but they're not addressing the major health problem of women, and that is cardiovascular risk. And going the other way, the OGBYN and clinicians must share with the cardiology and internal medicine community the awareness of pregnancy-related cardiovascular risk because that is an ongoing problem.
On Greater Cardiovascular Risk for Women in Rural Areas
Women in rural America have a greater cardiovascular risk compared with women in urban settings and it's [attributed to] less access and less health care system delivery. And what we're seeing is that the life expectancy gap between rural and urban areas is increasing — it used to be half a year, then two years, and now it's more than two years. So the rural group is tremendously disadvantaged [because of ] its hospital and outpatient facility care, its clinician supply, its insurance coverage, [and] its public health infrastructure, which is lesser in rural compared with urban areas.
On Artificial Intelligence and the Need for Standard Nomenclature
Research studies have small numbers of women and even smaller numbers of women for underrepresented groups, so we're probably going to have to group studies to get data. And we must have standard nomenclature of illnesses or problems, etc., because if we have that, there's a greater likelihood that artificial intelligence and machine learning can accelerate our understanding of the factors that regulate cardiovascular risk in women. But the baseline need for the AI to come in and do its thing is standard nomenclature. Then, what we have to do is expand the use of social determinants of health indicators in the electronic health records so that we can understand how external factors, environment, [and] social determinants of health modify risk over a lifetime.
On a Wholistic Approach to Mitigating Cardiovascular Disease in Women
Reducing the risks and burden of cardiovascular disease in women takes a community. We have to raise awareness. We have to optimize prevention and clinical care. We have to support research. We have to engage communities. We have to advocate. And then we have to monitor our progress.
