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A woman’s worst enemy


She’s a walking time bomb: mid-40s, overweight, sedentary, and a smoker. Yet she thinks her risk of heart disease is low because no one in her family has had it.

She’s wrong. She and millions of women like her are 10 times more likely to develop heart disease than lean, active, nonsmoking women of the same age—regardless of family history.

Her ignorance underscores a serious lack of awareness among both healthcare pro­viders and the general public. Until recently, most people regarded heart disease as a threat mainly to men. Studies show that even physicians believe women are at lower risk than men, and as a result, many of them underuse preventive interventions in women.

But make no mistake: Heart disease and stroke are a wo­man’s #1 disease risk—all the more dangerous because they’re underestimated. Yet women of all educational levels perceive heart disease as less of a threat than breast cancer and other diseases. Only 55% of White wo­men, 38% of Black wo­men, and 34% of Hispanic women know that heart disease is their worst enemy. And too many women of all ethnic backgrounds are unaware of the risk factors. Many first learn about their high risk for cardiovascular disease (CVD) when they suffer a catastrophic event, such as myocardial infarction (MI) or stroke.

To make matters worse, women historically have been—and still are—underrepresented in clinical trials for cardiovascular drugs and other therapies. Most recommendations for heart disease prevention, diagnosis, and treatments are extrapolated from studies conducted predominantly in middle-aged men. Only recently have healthcare experts questioned the validity of applying the results of these studies to women.

Facing the facts for females
One in three women has some form of CVD. According to the American Heart Association (AHA), heart disease and stroke kill approximately 480,000 women every year. That’s more than the total number of CVD-related deaths in men or the next five leading causes of death in women combined. Here are more frightening facts:

• Worldwide, CVD causes 8.6 million deaths among women annually, making it the number #1 killer of women.
• CVD kills nearly 12 times as many American women as breast cancer.
• The CVD rate in women has risen slightly over the last two decades, while it has declined steadily in men.
• CVD causes one in every 2.6 female deaths (compared to 1 in every 30 deaths from breast cancer).
• In 2003, 38 million women had CVD. Of these, 6 million had coronary heart disease (CHD) and 3.1 million suffered stroke.
• CHD accounts for the majority of CVD deaths in women.
• Nearly two-thirds of women who die suddenly from CHD had no previously recognized symptoms.
• Within 6 years of a recognized MI, 35% of women have another MI, 11% have a stroke, and 6% experience sudden cardiac death.

Putting heart disease on the women’s health agenda
Heart disease should be on the international women’s health agenda—but it’s not. Although it kills more women than all types of cancer, HIV/AIDS, malaria, and tuberculosis combined, not a single international aid agency funds programs related to women’s heart disease and stroke.

But not all the news is negative: In developed areas such as North America, Australia, New Zealand, and parts of Europe, the CVD death rate among both sexes has dropped about 60% since 1960. Better nutrition, fitness programs, smoking cessation, improved drug therapy for hypertension and high cholesterol, and more comprehensive medical and surgical care seem to have postponed heart disease and stroke from middle age to the later years in these regions.

Just in time, too. With life expectancy increasing and birth rates stabilizing or declining, the world population is aging. The World Bank projects that the global population of people aged 65 and older will hit 1 billion by 2020. Heart disease and stroke will rank as the principal causes of death in older people and will account for one-third of all disabilities. That gives us just 13 years to address the problem.

Fortunately, heart disease can be prevented. Using new evidence-based guidelines, clinicians can improve prevention, diagnosis, and treatment in women. Studies show that evidence-based cardiovascular interventions have been underused in women; with proper application, these interventions are likely to enhance clinical outcomes.

Mapping out the gender gap
Crucial gender-based differences exist not only in risk awareness but in prevention, clinical presentation, diagnosis, treatment, and patient outcomes.

Lack of risk awareness
A recent survey found that fewer than one in five physicians knew that more women than men die from heart disease and stroke each year. And as the opening scenario suggests, many women are oblivious to their risk. Typically, women place their family’s health above their own, and when they do focus on their own, they don’t view heart disease or stroke as major threats. Thus, they’re less likely to recognize signs and symptoms, get prompt medical attention, or make the lifestyle changes needed to reduce risk. If their signs and symptoms persist or grow more severe, many women seek guidance from friends and family before seeking medical attention.

All women—including nurses—must play the leading role in their own cardiovascular health by becoming aware of and empowered about heart disease and stroke.

Symptom disparities
Low awareness of both risk and sex-based symptom differences poses a major barrier to diagnosis. Heart disease and its major manifestation, MI, tend to cause different signs and symptoms in wo­men than in men. For instance, women may have vague complaints, milder symptoms, and normal or nonspecific electrocardiograms (ECGs).

Yet, most clinicians assume women experience the same symptoms as men before and during an MI—crushing chest pressure with pain and tingling down the left arm, shortness of breath, profuse sweating, and light-headedness. In fact, these classic symptoms are far less common in women. In one study, only 30% of women reported chest pain, and acute chest pain was absent in 43%.

Research shows that unless a woman has classic MI symptoms, clinicians aren’t likely to take her complaints seriously, order cardiac testing, or initiate treatment. Because they lack significant chest pain, many women are misdiagnosed and discharged from emergency departments. In a study of 78 emergency and critical care nurses and physicians, 85% of the nurses and 66% of the physicians said they assessed mainly for chest pain in patients with suspected acute MI; only 35% assessed for atypical symptoms.

In women, the most frequent early warning symptoms of acute MI are unusual fatigue, sleep disturbances, shortness of breath, weakness, indigestion, and anxiety. These complaints commonly are misdiagnosed as indigestion, gallbladder disease, depression, or anxiety. Failure to recognize early MI symptoms may explain, at least in part, why women are more susceptible to sudden cardiac death than men. For many women, a full-blown MI is the first sign of underlying heart disease. Women with MIs, especially those younger than age 50, are more likely than men to die during their hospital stay or in the first year after an initial MI.

Diagnostic differences
Women tend to be diagnosed later in the course of heart disease, probably due to clinicians’ failure to suspect CHD and order appropriate tests. Studies show that women with suspected CHD are less likely than men to undergo indicated diagnostic tests, such as exercise ECGs, or to be referred for cardiac catheterization and coronary angiography. And when coronary angiography is ordered, it tends to be delayed more in women than in men.

Even when clinicians order indicated tests, the same techniques that detect CHD in a man may miss it in a woman. Women have smaller coronary vessels, and these vessels contain more diffuse atherosclerosis; such differences can lead to inaccurate test interpretation. Also, women with an intermediate pretest risk of CHD (based on symptoms and risk factors) are less likely than men to present with ST-segment elevation and are more likely to have false-positive test results.

Researchers at the National Institutes of Health found that the accuracy of diagnostic testing improves when gender differences in cardiovascular physiology and pathology are taken into account.

Treatment discrepancies
Women with CHD tend to receive less intensive treatment than men. Preventive therapies, such as antiplatelet and statin drugs, are significantly underused in women even when CHD has been confirmed. Also, women with confirmed CHD are less likely to undergo revascularization and are twice as likely to die or suffer a nonfatal MI during the 1-year follow-up period after diagnosis and management of stable angina.

Increasing awareness through education
Both as healthcare professionals and as persons at risk, nurses have a major stake in learning as much as they can about heart disease. (About 95% of the 2.9 million U.S. nurses are female, with an average age of 47.) The more educated we become about the risk, clinical presentation, diagnosis, and treatment of heart disease in women, the better prepared we’ll be to lower our own risk and to educate patients, family, and friends to do the same.

Currently, several national initiatives are focusing on improving education, detection, and treatment of heart disease and stroke in women. AHA’s “Go Red for Women” campaign aims to empower women with the knowledge and tools they need to reduce their risk. The campaign is year-round, with the first Friday in February 2007 designated as “Go Red For Women” day. The campaign provides tips on healthy eating, exercise, and risk factor reduction. For more information, visit

An important part of the “Go Red” movement is the HEART for Women Act—landmark legislation cosponsored by AHA, the Association of Black Cardiologists, Society for Women’s Health Research, and WomenHeart: The National Coalition for Women with Heart Disease. This legislation aims to improve heart disease prevention, diagnosis, and treatment by educating women and healthcare providers about the most effective options for women. It also calls for stricter Food and Drug Administration requirements for reporting gender-based data on new and experimental drugs and devices.

Also, the National Heart, Lung, and Blood Institute has partnered with AHA and the Office on Wo­men’s Health (part of the U.S. Department of Health and Human Services) to initiate “The Heart Truth”—a national awareness campaign for women about heart disease. The Office on Women’s Health provides information about maintaining heart health at (For information on related ANA activities and campaigns, see “Issues up close” on page 45.)

As nurses, we’re in an excellent position to increase women’s awareness of their risk and provide education on ways to maximize prevention and improve quality of life. We’re also in a position to urge clinicians to listen to women and take their health concerns seriously. So let’s get the word out about wo­men’s high risk for heart disease. Wo­men everywhere are counting on us.

Selected references
Go Red for Women, 2006. Available at: Accessed September 26, 2006.

Grodstein F, Manson J, Stampfer M. Hormone therapy and coronary heart disease: the role of time since menopause and age at hormone initiation. J Womens Health. 2006;15:35-44.

Heart Disease and Stroke Statistics-2006 update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113:e85. Available at: Accessed November 20, 2006.

For a complete list of selected references, see February 2007 references.

Melissa McIntire Sherrod, PhD, RN, is an Assistant Professor of Nursing at Harris College of Nursing and Health Sciences at Texas Christian University in Ft. Worth. Yvette Albarez, BS, and Angela Brookshire,  BS, are nursing students at Texas Christian University. Dennis J. Cheek, PhD,  RN, FAHA, is the Abell-Hanger Professor of Nursing at Texas Christian  University.

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