When Bernadine Healy became the Director of the National Institutes of Health approximately one decade ago, she instituted a new era in cardiovascular research. She rightly noted that women had been largely ignored in the study of cardiovascular disease, and that needed to change. With this shift in NIH interest (and funding), numerous observations began to emerge. Just as in men, cardiovascular disease is the leading cause of death in women (in fact, a woman is some nine times more likely to die of cardiovascular diseasei.e. heart disease or strokethan of breast cancer). Women are less likely than men to present with a heart attack as their first manifestation of heart disease, but more likely to die from that heart attack if they do. Overall mortality from cardiovascular disease is trending down in men, but up in women. Women represent 61% of all deaths from stroke.
Despite these impressive findings, women are less likely than men to receive diagnostic evaluation for heart disease. Although gender bias initially seemed to be a major factor, it turned out that women treated by women physicians were no more likely to receive an aggressive cardiovascular diagnostic work-up than those being treated by men. It soon became clear that symptoms were somewhat different in men than women, that certain noninvasive tests were less predictive in women, and that women tended to present later in life, when they are more prone to other medical conditions which may mask or confound diagnosis, or complicate treatment strategy.
Once the diagnosis has been established, women appear to be at higher risk for aggressive treatment. Early studies suggested that women had a higher mortality and less favorable long term prognosis following angioplasty than men. With the marked technological and patient care improvements in this field, this discrepancy no longer exists. In the realm of coronary artery bypass surgery, women have been classically observed to suffer approximately twice the mortality as men. Although much of the difference is due to risk factors (advanced age, associated disease conditions), research at the Florida Heart Research Institute several years ago demonstrated that this difference can be eliminated in comparable groups of patients through the use of the internal thoracic artery technique of bypass. Despite these findings, the Society of Thoracic Surgeons national database still demonstrates that a much smaller proportion of women undergoing CABG surgery receive this graft than do men.
The observation that coronary heart disease was relatively rare amongst premenopausal women, but increased in incidence dramatically after menopause, led to the almost obvious conclusion that female hormones were protective. Much retrospective and basic science data therefore strongly supported the use of estrogens to prevent heart disease in post-menopausal women. It seemed so obvious in fact; the only question was one of formulation and dose. Then came a series of large, extremely well-designed and conducted prospective studies demonstrating just the oppositepost-menopausal estrogen use leads to increased cardiovascular death in post-menopausal women, probably through effects on the clotting tendencies of blood.
The mysteries continue to unfold. Aspirin has been well demonstrated to reduce the incidence of heart attack, but not stroke in men. Recent studies in women have demonstrated just the reverseaspirin reduces the risk of stroke but not heart attack in women. A statistical fluke? A failure of study design? Probably notjust one more area for fruitful further study.
Yes, this has been an extremely informative decade, which has raised as many questions as it has answered. For now, the following is very clear:
- Cardiovascular disease is the leading cause of death in women in this country.
- The incidence is increasing rather than decreasing
- The same preventive measures which are so critical in mensmoking cessation, weight reduction, cholesterol and blood pressure management, exerciseare equally important in women.
As for the rest, we still have much to learn.
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