Though the US has enjoyed an overall reduction in the death rate resulting from cardiovascular disease (CVD) in the last few decades, the rate of decline has been less for women than it has been for men. Moreover, as the population ages, the absolute number of deaths due to CVD in women has been increasing. Some experts have suggested that gender differences in mortality related to CVD no longer exist after adjustment for differences in age, risk factors, and medical interventions. But from the perspective of public health, the fact remains that women have a worse prognosis and die more often than men, in the short term, after a heart attack.1
Clearly, there needs to be an increased awareness of CVD as a major public health threat for women. Just as clearly, healthcare providers need to be sensitive to gender differences in presentation, prognosis, and responsiveness to CVD treatment.
Lack of Awareness
A particular problem among women is failure to appreciate the gravity of the health threat. In a major study conducted a few years back, only 8% of women surveyed thought heart disease or stroke presented the greatest threat to their health. Instead, women worry more about cancer,2 even though they’re almost twice as likely as men to die within a year after an acute myocardial infarction.3
Women are largely unaware of this risk because they tend to ignore both prodromal and acute symptoms. One reason for this is that little is known about prodromal symptoms of heart attack in women. Furthermore, symptoms of acute myocardial infarction derive mostly from research involving male patients.
A 1994 national study of nurses caring for heart attack patients in hospitals4 found a need to update care and treatment of those suffering acute myocardial infarction. A review of the literature revealed classical symptoms of mycardial infarction – though from studies of mostly of men. Interestingly, the women participating in the 1994 study largely failed to identify chest pain as an important symptom.
In the Mosca et al. coronary artery surgery study,1 half of all women undergoing arteriography for suspected CVD had no significant obstruction. Despite the limited prognostic value of chest pain, it remains a common initial manifestation of CVD in women, though women with myocardial infarction were more likely than men to experience fatigue, nausea and vomiting, sweating, dyspnea, presyncope, or palpitations in place of chest pain.
The literature also indicates that women are more likely to feel angina at rest and during sleep. Pain may appear in areas other than the anterior chest -and that includes the teeth and lower jaw, both arms and shoulders, the back, and the epigastrium. They also experience more silent heart attacks, with nearly one-half of all myocardial infarctions going unrecognized.5
Since decades of study of the treatment of heart attack have focused on men, prevention efforts become even more important in women. Studies have shown that aspirin reduces subsequent cardiovascular events and vascular mortality in both men and women with a history of CVD. Women have experienced significant benefits with aspirin therapy, and those who ingest one to six aspirin tablets weekly appear to have a 25% lower risk of heart attack.6
Stress reduction, relaxation, and psychosocial support also show promise in reducing vascular events in women with established coronary disease.1
A recent secondary prevention consensus panel of the American Heart Association found compelling evidence that comprehensive risk-factor interventions in patients with coronary heart disease extend overall survival, improve quality of life, decrease the need for interventional procedures, and reduce the incidence of subsequent heart attack. Cardiac rehabilitation is also a key step in reducing risk and restoring functional capacity after a myocardial infarction.7 It has become an established treatment and includes exercise training, risk factor modification, and psychosocial and vocational counseling. Available data also show that women fare worse than men only in the short term – after the first year, they display an improved survival rate compared with men.8
Health educators have a duty to inform women of the major risk factors for CVD: smoking, hypertension, diabetes, obesity, sedentary lifestyle, and poor nutrition. A multifaceted approach is clearly needed to advance medicine and cardiovascular science for the betterment of women’s health.
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1. Mosca L, Manson J, Sutherland S, Langer R, Manolio T, Barrett-Conner E. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association. Circ. 1997;96:2468-2482.
2. Adler T. Many women are in the dark about affairs of the heart. Heart Information Network. Available at: www.heart info.org/news97/womcad91797.htm. Accessed May 7, 2001.
3. McSweeney JC, Crane PB. Challenging the rules: women’s prodromal and acute symptoms of myocardial infarction. Res Nurs Health. 2000;23:135-146.
4. Riegel B, Thomason T, Carlson B. Nursing care of patients with acute myocardial infarction: results of a national survey. Crit Care Nurs. 1997;17(5);23-32.
5. Graboys T, Blatt C. Women and coronary artery disease. Angina Pectoris: Management Strategies and Guide to Interventions. Available at: www.medscape.com/PCI/angina/ angina.ch25/angina.ch25.html.
6. Aspirin in the treatment and prevention of cardiovascular disease. Available at: www.powerpak.com/CE/aspirin cardio_nurses/lesson.cfm. Accessed 2001.
7. Tindall W. Cardiac rehab: movement and medication. Business and Health. 1998;2:28-29.
8. Vaccarino V. Sexual differences in mortality after myocardial infarction. Is there evidence for increased risk in women? Circ. 1995;1867-1871.