ReviewFocused Cardiovascular Care for Women: The Need and Role in Clinical Practice
Section snippets
Aspects of CV Physiology Unique to Women
The 2010 publication of the Institute of Medicine “Women's Health Research: Progress, Pitfalls, and Promise”11 highlighted the fact that women's health involves both sex- and gender-specific differences. A number of factors contribute to the sex-specific differences in CVD morbidity and mortality, including biological variances due to sex chromosomes and complex effects that sex steroid hormones have on the CV system. These differences result in variations in the prevalence and presentation of
CV Adaptations to Normal Pregnancy: A “Natural Stress Test” for Women
In normal pregnancy, the female body undergoes remarkable physiologic, metabolic, and hemodynamic changes needed to support fetal health. Pregnancy has been described as a natural stress test on the CV system of women.13, 14 Normally, pregnancy-related hemodynamic variations are well tolerated by the mother; however, CVD may be initially manifested during pregnancy because of increased cardiac output demands that either expose the underlying genetic phenotypes or exacerbate minor preexisting
Polycystic Ovary Syndrome: A Metabolic Disorder Specific to Women
Polycystic ovary syndrome is the most common endocrinopathy in women of reproductive age. The prevalence of PCOS has been estimated to be 6% to 10%, depending on which diagnostic criteria are used.33 Classic features of PCOS include anovulatory infertility, menstrual irregularities, and hirsutism. Other important manifestations include metabolic derangements such as insulin resistance, dyslipidemia, low-grade inflammation, and a higher risk of type 2 diabetes; therefore, all women with PCOS
Menopause and the Dilemma of Menopausal Hormone Therapy
Many women seen in Women's Heart Clinics are peri- or postmenopausal, experiencing menopausal symptoms and expressing concerns about the use of MHT and CV risk. The average age of menopause in American women is 51 years.35 Epidemiological data have indicated the onset of coronary artery calcification (CAC) on computed tomography and are, on average, a decade later than in men, coinciding with a “10-year lag time” after menopause.36, 37 Conversely, women with hypoestrogenic states, as seen in
Ischemic Heart Disease in Women
Sex- and gender-specific CVD research has led to a new understanding of the pathophysiology of coronary disease in women, which includes, but is not limited to, our conventional understanding of atherosclerosis. Ischemic heart disease (IHD) in women includes not only atherosclerotic obstructive coronary artery disease (CAD) but also an expanded spectrum of coronary disease, including CMD, endothelial dysfunction, vasomotor abnormalities, SCAD, and stress-induced cardiomyopathy.3
Certainly, there
Peripheral Arterial Disease in Women
Atherosclerotic lower extremity PAD impairs walking performance77 and is associated with not only a reduced quality of life78, 79 but also a markedly increased risk of CVD events and mortality.80 Although male sex was traditionally believed to be a risk factor for PAD, recent studies81, 82 have reported compelling results on the high prevalence of PAD in women. At the extremes of ages <40 and >80 years), women represent a greater estimated population burden of PAD, affecting the lower
Heart Failure
Although heart failure can manifest with reduced or preserved ejection fraction, women are more likely than men to develop heart failure in the setting of preserved left ventricular ejection fraction. Differences in prevalence of comorbidities also exist between men and women with HFpEF. Women are generally older and have a higher likelihood of having diabetes and systemic hypertension.92 Estrogen receptors in the heart modulate hypertrophy and subsequently the progression of HF.93 It is
Disparities in CVD Treatment in Women
Sex-specific differences in underlying physiological mechanisms affect not only manifestations of CVD but also the response to treatment. Treatment of hypertension is generally more effective in women, however, at older ages blood pressure control is more likely to be achieved in men than in women. Thus, stroke risk may not be managed as efficiently in women. Antiarrhythmic drugs have different effects, interactions, and need for dosing adjustments in women than in men.120, 121 Similarly, RCTs
Conclusion
The CV health of women is strongly affected by sex-specific factors, including hormonal and metabolic disorders, pregnancy-related adverse CV outcomes, menopausal status, and associated autoimmune diseases. Women are predisposed to certain types of CVD, including CMD, SCAD, PAD, HFpEF, POTS, and apical ballooning syndrome. Awareness and recognition that women are at a significant risk of CVD is crucial to provide appropriate care and avoid reflexive misattribution of symptoms to noncardiac
Acknowledgments
We thank Patricia J. Best, MD; Heidi Connolly, MD, Lori A. Blauwet, MD, and Susan Wilansky, MD, for their assistance.
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