Looking After HER HEART; Let’s Talk About Women’s Heart Health

The 2023 Heart & Stroke (H&S) report, describe that in half the women who experience a myocardial infarction (MI), symptoms are not recognized, with the sobering outcome that every 16 minutes a woman in Canada dies as a result of heart disease or stroke. 1Heart & Stroke Canada. System failure:Healthcare inequities continue to leave women’s heart and brain health behind, 2023Google Scholar It comes as no surprise then, that cardiovascular disease is the leading cause of premature death in women.1Heart & Stroke Canada. System failure:Healthcare inequities continue to leave women’s heart and brain health behind, 2023Google Scholar These statistics are in part attributed to the lack of public understanding and/or awareness of female specific risks associated with heart health issues, but also as the result of lack of awareness on the part of clinicians labeling women’s symptoms as “atypical” or “low-risk” based on risk stratification models and evidence developed and validated primarily in men. In her book “Doing Harm; The truth about how bad medicine and lazy science leave women dismissed, misdiagnosed and sick”, Maya Dusenbery, editor of the award-winning site feministing.com notes that the myths of heart disease being a “man’s disease” are still prevalent and that when women interact with healthcare providers whose perceptions of women’s risk of heart disease continue to be singularly influenced only by the male paradigm and not viewed through a sex and gender lens, the unfortunate result is that women are less likely to be appropriately diagnosed and treated. 2Dusenbery M. Doing harm: The truth about how bad medicine and lazy science leave women dismissed, misdiagnosed, and sick: HarperCollins; 2018.Google Scholar Furthermore, the considerable body of cardiovascular research, including trials used to create clinical practice guidelines that frame the presentation and symptoms of women with heart health issues within a dominant male paradigm, results in women with lived experience being “stopped at the gate” 3Colella T.J. Hardy M. Hart D. et al.The Canadian Women’s Heart Health Alliance atlas on the epidemiology, diagnosis, and management of cardiovascular disease in women—Chapter 3: patient perspectives.CJC open. 2021; 3: 229-235Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar of accessing care, labelled as having anxiety associated with noncardiac disorders, and turned away from further evaluation and investigations. The reasons for this are multifactorial, from unconscious or conscious bias, through to a lack of education and awareness. These disparities are further compounded in ethnic, racialized and elderly women, where racism and ageism also enter into the intersectional dynamic of failure to access and/or receive appropriate, evidence-based care. Our own recent study reported that women who had experienced a heart health event and were attempting to navigate the health care system were “embarrassed” to the point of hiding the event due to the belief that they were being stigmatized and held responsible for “not taking care of their heart- eating too much of the wrong foods or not exercising enough”. 4Oliphant T, Berry T, Norris CM. ‘In a perfect world doctors and the medical profession would accept people for who they are’: women’s heart health information practices. 2022.Google Scholar Recently, epidemiological evidence has identified that MIs continue to increase in women under 65 years of age, especially those eventually diagnosed with non-obstructive coronary arteries (MINOCA), which is more than twice as prevalent in women compared to men.1Heart & Stroke Canada. System failure:Healthcare inequities continue to leave women’s heart and brain health behind, 2023Google Scholar Similarly, angina, a characteristic symptom of ischemic heart disease (IHD), in women, especially younger women, is more likely to be due to ischemia associated with non-obstructive coronary arteries (INOCA).1Heart & Stroke Canada. System failure:Healthcare inequities continue to leave women’s heart and brain health behind, 2023Google Scholar Moreover coronary artery spasm and coronary microvascular dysfunction represent a major cause of IHD in middle age women5Maas A.H. Rosano G. Cifkova R. et al.Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists.European Heart Journal. 2021; 42: 967-984Crossref PubMed Scopus (110) Google Scholar and these entities are difficult to diagnose, requiring additional specialized testing with limited availability. As well, spontaneous coronary artery dissection (SCAD), a common cause of MI’s in younger women, with 90% of SCAD patients being women,6Saw J. Sedlak T. Ganesh S.K. Isserow S. Mancini G.B.J. Spontaneous Coronary Artery Dissection (SCAD).Circulation. 2015; 131: e3-e5Crossref PubMed Scopus (13) Google Scholar,7Krittanawong C. Saw J. Olin J.W. Updates in spontaneous coronary artery dissection.Current Cardiology Reports. 2020; 22: 1-11Crossref PubMed Scopus (13) Google Scholar was previously thought rare until large registries in North America, and now globally, have demonstrated otherwise. SCAD now accounts for 25% to 30% of all MI’s in women under age 60 years of age, and over 40% of MI’s in women less than 40 years of age,6Saw J. Sedlak T. Ganesh S.K. Isserow S. Mancini G.B.J. Spontaneous Coronary Artery Dissection (SCAD).Circulation. 2015; 131: e3-e5Crossref PubMed Scopus (13) Google Scholar,7Krittanawong C. Saw J. Olin J.W. Updates in spontaneous coronary artery dissection.Current Cardiology Reports. 2020; 22: 1-11Crossref PubMed Scopus (13) Google Scholar and is the most common cause of MI’s in pregnancy and the peripartum.8Hayes S.N. Tweet M.S. Adlam D. et al.Spontaneous coronary artery dissection: JACC state-of-the-art review.Journal of the American College of Cardiology. 2020; 76: 961-984Crossref PubMed Scopus (176) Google Scholar From a life stage perspective, the influences of sex hormones on the regulation of biological and physiological processes has not translated into the development, collection or analyses of data on treatments and outcomes in cardiovascular disease (CVD) management in women. As a result, the gap in understanding the mechanistic relationship between the sex (biological) and gender (psychosociocultural) factors in CVD means that women with heart health issues continue to be under-researched, underdiagnosed, undertreated, under-supported, and under aware. 1Heart & Stroke Canada. System failure:Healthcare inequities continue to leave women’s heart and brain health behind, 2023Google Scholar,9Heart & Stroke Foundation. Ms.Understood. Women’s hearts are victims of a system that is ill-equipped to diagnose, treat and support them: Heart & Stroke 2018 Heart Report, 2018.Google Scholar Henry Ford once said that ‘If everyone is moving forward together then success takes care of itself’ and this CJCO special edition focused on women’s heart health clearly demonstrates that we are truly moving forward in using the evidence available to inform practice as well as using practice to demonstrate the evidence we yet need to inform and treat women’s health. Evidence to Inform Practice In 2018, the Canadian Women’s Heart Health Alliance (CWHHA; website: https://www.cwhha.ca ) was established as a network of experts and advocates to develop and disseminate evidence-informed strategies to transform clinical practice and enhance collaborative action on women’s cardiovascular health in Canada. The ‘superpower’ of the CWHHA is that the membership is inclusive, consisting now of over 200 members from across Canada that includes clinicians, scientists, allied health professionals, program administrators, and patient partners with the goal of improving women’s cardiovascular health across the life span. The mission ‘to support clinicians, scientists, patients and decision-makers in working collaboratively to implement evidence, transform clinical practice and impact public policy related to women’s cardiovascular health” was actioned by establishing four working groups addressing Advocacy, Training and Education, Knowledge Translation and Mobilization (KTM), and Health Systems and Policy (HSP) (website: cwhha.ca). Early on, following the establishment of the CWHHA and development of working group projects, our HSP and KTM working groups (which we, CMN, SLM, each respectively led), perceived the value in collaboration, and sought and received committed support from Dr. Michelle Graham (editor of CJCO) to co-create THE CWHHA ATLAS ON THE EPIDEMIOLOGY, DIAGNOSIS, AND MANAGEMENT OF CARDIOVASCULAR DISEASES IN WOMEN, establishing a special CWHHA Collection Tab (https://www.cjcopen.ca/womens_heart_health_alliance) The CWHHA ATLAS project had its roots in the seminal “State of the Science in Women’s Cardiovascular Disease: A Canadian Perspective on the Influence of Sex and Gender” publication in the Go Red Issue of JAHA in 2020.10Norris C.M. Yip C.Y. Nerenberg K.A. et al.Introducing the Canadian Women’s Heart Health Alliance ATLAS on the epidemiology, diagnosis, and management of cardiovascular diseases in women.CJC open. 2020; 2: 145-150Abstract Full Text Full Text PDF PubMed Google Scholar The CWHHA ATLAS has focused on presenting “deep dives” into the ‘under studied, under diagnosed and under treated’ aspects of women heart health, creating multi-chapter in-depth, contemporary reviews of the current evidence including the epidemiology, diagnosis, and management of CVD to inform practice for women across the lifespan. It is fitting then that the final two chapters of the CWHHA ATLAS, CHP 8: Knowledge Gaps and Status of Existing Research Programs in Canada, and CHP 9 Challenges, Opportunities, and Recommendations, are published in this special CJC Open #HerHeartMatters issue during Heart Month in Canada. These chapters highlight the programs of research being undertaken across Canada and summarize opportunities and recommendations for moving women’s cardiovascular health forward. In addition, this CJCO special issues includes a number of manuscripts that provide state of the science data in areas in CVD diagnosis, and treatments specific to disproportionately female predominant conditions, such as: What’s new in Spontaneous Coronary Artery Dissection (SCAD)?; Pathophysiology of Myocardial Infarction with Non-Obstructive Coronary Artery Disease: A Contemporary Systematic Review; Antithrombotic management and outcomes of anterior STEMI; and Female-specific considerations in aortic health and disease. Sex and gender unique aspects of cardiovascular risk across the lifespan of a woman are also addressed including: Prevalence of Sex-specific Cardiovascular Disease Risk Factors; Medical Risk, and Engagement in Health-Promoting Behaviours in Premenopausal Females; The importance of non-traditional and sex-specific risk factors in young women with vasomotor non-obstructive versus obstructive coronary syndromes (MI, INOCA); Increased Prevalence of Health Outcomes Across the Lifespan in Those Affected by Polycystic Ovary Syndrome: a Canadian Population Cohort Study; and Women’s Heart Health and the Menopausal Transition – Two faces of the same coin. Unique aspects of hypertension in women with renal dysfunction as a CVD risk factor are also explored in: The Awareness of Hypertension in Reproductive-Aged Women Living with Chronic Kidney Disease, and Evidence that Testosterone is Not Associated with Vascular Function in Reproductive-Aged Females with Chronic Kidney Disease, We were also fortunate to be able to include manuscripts that addressed existing clinical practice models of CVD care for women in the context of their perspectives and preferences in care delivery, in order to identify and contribute to development of a successful foundation for clinical practice standards and guidelines These include a spectrum of local, regional, national and global reports, again across a woman’s lifespan: Understanding patient perspectives of specialized, longitudinal postpartum cardiovascular risk reduction clinics; Nutritional interventions for lowering cardiovascular risk after hypertensive disorders of pregnancy; Women-focused cardiac rehabilitation delivery around the world and program enablers to support broader implementation. Finally, we conclude on an optimistic note, with a report on How women’s heart health programs address Knowledge Gaps. In essence, this special #HerHeartMatters Heart Month issue on Women’s Heart Health is celebrating all those who have continued to move the dial on advancing the awareness and evidence on women’s heart health not only in Canada but also internationally11Vogel B. Acevedo M. Appelman Y. et al.The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.The Lancet. 2021; 397: 2385-2438Abstract Full Text Full Text PDF PubMed Scopus (402) Google Scholar. More importantly it is a ‘call to action’ challenging us all to continue the work in identifying, diagnosing, and treating, the sex and gender specific aspects of women’s heart health, as we continue to build the evidence-base, and strive towards guideline-directed sex and gender focused diagnoses and treatments, to improve cardiovascular outcomes for all women. Dr Norris holds the Cavarzan Chair in Mature Women’s Health Research funded in part by WCHRI and the Alberta Women’s Health Foundation. Dr. Mulvagh is a consultant for NovoNordisk and Lantheus Medical.

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