Women and Cardiovascular Disease: Addressing Disparities in Care

February is American Heart Month. The month was created in order to raise the public’s awareness of cardiovascular disease and its risk factors. Cardiovascular disease is the number one killer of Americans and accounts for nearly 2,500 deaths every single day. As providers of cardiovascular healthcare, this month is an opportunity for us all to pause and take stock in our efforts to prevent and treat serious cardiovascular disease in the U.S. Although we are doing a good job of reducing heart disease and its complications overall, there are still gender-specific differences in treatment. Of particular concern is the continued rise of heart-related illnesses in women. During this month, the American Heart Association’s (AHA) Go Red For Women campaign actively promotes awareness of heart disease in women. 

Sudden cardiac death/cardiovascular disease is the number one killer of women in the U.S. second only to all cancers combined. The prevalence of coronary artery disease (CAD) in women is similar to that in age-matched cohorts of men — yet women tend to be underserved and undertreated. When we look at specific interventions such as percutaneous coronary interventions (PCI or coronary stenting), implantation of implantable cardioverter-defibrillators (ICDs), and advanced devices for congestive heart failure (CHF), we find that men tend to have more access to advanced therapies and are undergoing procedures at two to three times the rate of women. 

Over the last six years, I have developed an educational symposium for healthcare providers to address women and cardiovascular disease, particularly, prevention of sudden cardiac death. This symposium has been well received and produced all over the country. The focus of the event has been to specifically address disparities in care — men are much more likely to receive more advanced, more aggressive and more cutting-edge therapy than women in identical circumstances. As demonstrated in JAMA in 2007, women with identical indications as compared to male cohorts are less likely to receive ICD implants and other advanced and potentially lifesaving therapies. Many hypotheses have been put forward to explain and address these disparities. Some include access to care, patient concerns and education about CV disease, social stereotypes, and patient denial of symptoms or risk. During the development of the symposium, I realized that many women in the U.S. today regularly see OB/GYN physicians as their only healthcare provider. OB/GYN physicians are not always well equipped to provide comprehensive primary care and may have little time to devote to screening for cardiovascular disease — these are highly trained women’s health experts. Most women who see an OB/GYN are more concerned with dying of breast, uterine or ovarian cancer than with CV disease or sudden cardiac death. With the OB/GYN, I saw an opportunity to really impact disparity in care. I began to target OB/GYN physicians and developed a quick and easy office screening tool that can be used to pre-screen patients for CV disease. A simple waiting room questionnaire is filled out by the patient and handed to the nurse at intake. This questionnaire would then prompt a busy OB/GYN provider to more aggressively screen at-risk women. I also produced educational events specifically for OB/GYN physicians and invited cardiologists to attend in the hopes of facilitating interactions between very dichotomous specialties. In some cases this worked well, and OB/GYNs and cardiologists began to develop referral relationships following the event.

However, gender disparities in care continue to exist. Despite our best efforts over the last six years, women with cardiovascular disease continue to be undertreated and underserved. Although we are making significant progress, there is still much work to be done. A review article by McSweeny et al published in July 2012 in Women’s Health examined disparities in CHF and other CV diseases in women. In this review, the authors identified reasons why outcomes in women with CHF are poorer as compared to men. Lack of aggressive treatment of the underlying causes of CHF such as coronary artery disease as well as a lack of adherence to medical therapy, late presentation and multiple comorbidities are identified as significant contributors to these poor outcomes. A complete lack of social support is also labeled as a major factor in the outcome of women with CHF.

In 2012, the Minnesota Women’s Heart Summit was held to address issues surrounding disparities in care. Four major points of emphasis were identified:

1. Community Awareness and Prevention: Women’s knowledge of risk of CV disease is improving but still inadequate. Local events to raise awareness among the general public is an important part of reducing CV deaths in women. We must engage clinicians and healthcare consumers as well as government policymakers in order to make a difference.
2. Symptom Recognition and Delays in Seeking Treatment: Often women present atypically with CV disease, and we must work to educate women. Public service informational campaigns are needed to promote symptom recognition in women as well as the importance of seeking timely treatment. A parallel campaign to educate primary care physicians and ER providers about the atypical nature of symptoms in women with a focus on avoiding therapy delays should be conducted.
3. Closing the Survival Gap: Women are less likely to receive evidence-based therapies such as beta blockers and ACE inhibitors that have been proven to decrease mortality. Women are less likely to have coronary artery bypass surgery, cardiac catheterizations, and revascularization. The goal should be to impact this through advocacy, better training of physicians, and inclusion of more women in research and clinical trials.
4. Patient-Provider Connections: Physicians must strive to develop better relationships and have better communication with patients. Often depression, socioeconomic status, and other issues become barriers to care. By seeing the whole patient and addressing some of these issues, a physician may be able to better partner with female patients and improve care.

Making a Difference in Outcomes

Gender disparity in CV care is a big issue in the U.S. today. We all have a responsibility to create positive changes in this area. So what can we do to get involved and make a difference?

1. Educate women and healthcare providers about the risk factors for cardiovascular disease. Make sure that every woman understands the signs and symptoms of heart attacks and how the symptoms might be different in female patients.
2. Actively screen at-risk women for cardiovascular disease. Ask about risk factors such as hypertension, smoking, high cholesterol, diabetes, and family history of CAD. Aggressively evaluate women with multiple risk factors, even in the absence of classic symptoms. Make sure that female patients understand what the risk factors are and how they can modify those risks.
3. Empower women to take control of their own healthcare. Actively engage women in the prevention of disease. Make sure women understand that they must act quickly when symptoms occur. Denial of symptoms and delay in treatment most often result in much poorer outcomes.

Disparities in care for women continue to exist. It is a significant public health problem today. More women than men die from cardiovascular disease each year. Although many have worked very hard to reduce these disparities, there is much work yet to be done. We must continue to communicate, advocate, and educate in order to improve outcomes in the future. As cardiovascular professionals in electrophysiology, we often see women who are already significantly burdened with disease as they come to the EP lab for their ICD implantation. We must strive to make a difference in our own healthcare systems — both inside and outside of the EP lab. The first step is to commit to making a difference. We must become ambassadors for women’s cardiovascular health during American Heart Month, and continue with education, advocacy efforts, and research such as those sponsored by the AHA’s Go Red For Women campaign in February each year. 

Kevin R. Campbell, MD, FACC is with Wake Heart and Vascular (WHV) in Raleigh, North Carolina. He is also Assistant Professor at UNC Department of Medicine, Division of Cardiology, and Director of Electrophysiology at Johnston Health. In addition, Dr. Campbell is President of K-Roc Consulting, LLC.

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