American College of Physicians: Internal Medicine — Doctors for Adults ®

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Taking the pulse of women's heart health

Despite heart disease's toll on women, many fail to heed early warning signs

From the January-February ACP Observer, copyright © 2006 by the American College of Physicians.

By Deborah Gesensway

Jacqueline W. Fincher, FACP, a general internist in Thomson, Ga., vividly recalls one of the first myocardial infarction (MI) patients she encountered in residency 20 years ago.

What sticks in her mind is that the patient—a black woman in her early 50s—didn't look the way male patients did during a heart attack. While the patient complained of sharp chest pain and shortness of breath, she was, unlike most men, very upset.

"She had risk factors—she was overweight and had high blood pressure—but what prompted the acute MI was a massive argument she had just had with her daughter," Dr. Fincher said.

Often, she added, physicians underestimate the physical effects of stress on women—and minimize women patients' symptoms.

"Women come in the office more frequently and talk about a lot of different things," she said. "They tend to have more somatic complaints—and sometimes it's hard to ferret out what's significant."

It all adds up, she said, to both physicians and patients not having a low enough index of suspicion. The fact that women don't really think they are candidates for heart disease—at least until they are much older than they are now, no matter what their age—is why, she said, so many of her patients discount worrisome symptoms.

It also explains, at least partially, why women, much more frequently than men, opt not to take medications or make lifestyle changes that could significantly reduce cardiac risk. (Dr. Fincher also pointed out that economic issues "are just huge for women" when it comes to compliance.) (See "Heart disease risk: men vs. women.")

And the lack of a low enough index of suspicion is also, Dr. Fincher suspects, the reason physicians may refrain from recommending—as forcefully as they do for men—treatments or preventive therapies that could help female patients stave off a heart attack or congestive heart failure.

According to experts, the biggest barrier to better cardiac care for women is not overt discrimination. Instead, it is a much subtler form of bias shared by physicians, patients and the population at large that heart disease is just a bigger deal for men than women.

Next month, the American Heart Association (AHA) will launch its third annual "Go Red for Women" campaign, designed to raise awareness among women about their risk for heart disease. At the same time, researchers are increasingly gathering data about how physicians may treat women differently than men for heart disease and prevention—a potentially deadly bias, but one that's easily rectified.

Changing public perceptions

Dr. Fincher's observations—that women's heart disease risks or symptoms may get lost in the noise of other complaints—are backed by scientific research.

Although physicians assume they treat women and men equally when it comes to cardiac risk factors, that isn't the case, according to national studies. Researchers find that women with the same risk as men for developing heart disease in 10 years, as determined by their Framingham Risk Score, are overwhelmingly perceived by primary care physicians as being at lower risk than comparable men.

"We found that only one in five physicians knows that more women die of heart disease every year than men," said Lori Mosca, ACP Member, director of the preventive cardiology program at New York-Presbyterian Hospital in New York. Dr. Mosca is also lead author of a study published in the Feb.1, 2005, issue of Circulation that found gender disparities in physicians' awareness of and adherence to cardiovascular disease prevention guidelines.

"There is still a misperception that heart disease is a man's disease," Dr. Mosca said. "We don't know why that is, but it is a provocative finding."

Advocacy organizations want to change that misperception, at least among women. Throughout the month of February, the public will be bombarded with AHA's "Go Red for Women" public service announcements and ads urging women to "know their numbers," meaning their cholesterol and blood pressure levels and body mass index (BMI). The campaign will also urge women to ask their physicians for help in reducing any "numbers" that are too high.

Changes in public awareness are sorely needed, said Isabel V. Hoverman, MACP, a general internist in Austin, Texas, and a former ACP Regent. "A lot of people feel they are not old enough to have problems or not sick enough," Dr. Hoverman said. "The disease is significant in women, but you don't hear people say, 'My mother died of a heart attack when she was 45.' " The view that only older women are at risk, she said, influences how women respond to their symptoms and how physicians prescribe preventive medications, particularly for middle-aged women.

Contrary to conventional wisdom, even among physicians, heart disease is not just a problem for older women. Although heart disease in women tends to manifest itself 10 years later than it does in men, it is still the No. 1 killer of women.

Moreover, 10,000 reproductive-age women in the U.S. have a myocardial infarction every year, said Janet P. Pregler, FACP, associate clinical professor of medicine and director of the Iris Cantor-UCLA Women's Health Education & Resource Center in Los Angeles.

The AHA's crusade for better public awareness will also get help from the federal government's National Heart, Lung and Blood Institute (NHLBI). Its "Heart Truth" campaign, which since 2003 has included a consumer-oriented initiative called the "Red Dress Project," is rolling out a professional education campaign this year aimed at primary care physicians, obstetricians-gynecologists and other health professionals. (See "New 'Heart Truth' site now offers CME.") The goal is to familiarize providers with new guidelines about cardiovascular disease prevention in women. (Also see, "Heart-healthy goals for women.")

"The critical message the NHLBI is trying to get out there is that heart disease is primarily a disease of risk factors, and we've got to look at them early," explained Dr. Pregler, principal investigator for the "Heart Truth" professional education campaign. The initiative also aims to convince physicians to counsel women patients more forcefully about a healthy diet, exercise and weight.

Clinical gaps

When it comes to women's heart health, physicians used to point to the lack of good evidence about the best way to treat, diagnose and prevent heart disease in women. But that excuse no longer holds water.

In 2004, the AHA was able to publish guidelines for cardiovascular disease prevention in women because preventive cardiology experts felt there was—for the first time—enough high-quality evidence to show what did and didn't work for women.

The guidelines stress preventive measures for each risk category, including lifestyle counseling; disease prevention interventions, including control of hypertension, lipid abnormalities and diabetes; and prescribing aspirin, statins, ACE inhibitors or beta-blockers when appropriate for all women with coronary artery disease. (The guidelines also say physicians should steer patients clear of therapies that have no cardiovascular benefits, including antioxidant supplements and menopausal hormone therapy.)

But "risk category" is the key. The guidelines make it clear that the first thing doctors should do for female patients is calculate patients' risk of having a coronary event in 10 years according to the Framingham Risk Score for women. The guidelines state that women should be assigned to a category of optimal, lower, intermediate or high risk.

Without that calculation, physicians tend to err and consider women to be at lower risk than men—and offer fewer preventive services, according to New York's Dr. Mosca. The Feb. 1, 2005, Circulation study she co-authored found that physicians were "significantly less likely" to assign a woman at intermediate risk of developing heart disease (according to the Adult Treatment Panel III Framingham risk categories) to a higher-risk category than men with a similar risk profile.

"There is a great message in this," Dr. Mosca explained. "If doctors can learn to appropriately assign the risk level, they are more likely to adhere to the guidelines."

To help assign risk, Dr. Fincher in Georgia has loaded the Framingham risk calculator on her PDA. She uses it to convince patients to take heart disease risk seriously and to follow through on lifestyle changes.

"I find it extremely helpful in terms of getting a patient to accept treatment," she said. "I plug their numbers into that program and show them their risk. Then I say, 'Let's say we got your cholesterol down 30 points and you quit smoking,' and then I recalculate it." When patients see they could drop their risk by 10%, she said, "that gets their attention."

Along with women not being assigned to an appropriate risk category, a growing body of evidence indicates that other gaps exist between knowledge and clinical practice.

In Dr. Mosca's Feb. 1, 2005, Circulation study physicians overwhelmingly reported that they did not think "the results of clinical research to determine optimal risk-reducing interventions in men generalize to women."

Another study by Dr. Mosca published in the same issue of Circulation found that high-risk women benefit as much as men from lipid-lowering therapy—but that only one-third of women receive recommended drug therapy. (The study did not look at the treatment of men.) Study results presented at last fall's AHA meeting confirmed those findings. After adjusting for age and risk factors, researchers at Kaiser Permanente found that women with coronary artery disease were more likely to have higher LDL levels and were less likely to be treated to reach optimal cholesterol levels than men.

Other recent studies have found that, contrary to previous thinking, women do just as well as men during percutaneous coronary interventions, including stenting and balloon angioplasty. Nonetheless, according to a statement published in the Feb. 1, 2005, issue of Circulation, only 35% of those procedures are performed on women each year.

A problem with compliance

Dr. Mosca urged primary care physicians to address another finding head-on: Women are less likely than men to comply with medical recommendations for blood pressure and cholesterol management. Physicians should create a simple tracking sheet, she said, to make sure they ask at every visit about compliance with lifestyle and medication recommendations. (See "Tracking form makes a difference, but is no magic bullet.")

Her current research is trying to tease out why women tend to be less compliant. Is it the fact that they're older than men when they develop symptoms and are already taking more medications? Are financial or access issues at play? Or don't women believe the problem is serious enough to warrant significant lifestyle changes and interventions?

Research has shown that the "strength of the recommendation from the doctor is important in adherence in general," Dr. Mosca said. "Doctors may not be as definitive when they are giving preventive medications to women." Asking about compliance at every visit, she added, "reinforces to the patient that you think it is important."

Some important gaps in knowledge remain. According to Dr. Pregler, doctors lack good evidence about the risks and benefits of preventive medications for "old" women, particularly those over age 80.

And there is very little data, Dr. Mosca said, on what preventive measures work for women—as compared to men—at intermediate risk of developing cardiac disease.

That underscores the importance of including women in prevention studies to increase adoption of evidence-based guidelines, she said. In the meantime, physicians need to know that "in fact, we have a lot of great evidence in high-risk women to support preventive recommendations—and we know lifestyle should be emphasized to all women."

Deborah Gesensway is a freelance health care writer in Toronto.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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Heart-healthy goals for women

The American Heart Association has published target heart-healthy goals for women, which include:

  • Total cholesterol: less than 200 mg/dL
  • LDL cholesterol: less than 100 mg/dL (for those at high risk for heart disease); less than 130 mg/dL (for those at intermediate risk); less than 160 mg/dL (for those at low risk)
  • HDL cholesterol: 50 mg/dL or higher
  • Triglycerides: less than 150 mg/dL
  • Blood pressure: less than 120/80 mm/Hg
  • Fasting glucose: less than 100 mg/dL
  • Body mass index (BMI): less than 25
  • Waist circumference: less than 35 inches
  • Exercise: at least 30 minutes on most days
  • Don't smoke

Source: American Heart Association, 2005

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Tracking form makes a difference, but is no magic bullet

Can a tracking form help physicians practice more effective preventive cardiology? Although the formal analysis of a pilot program conducted by New York's ACP Chapter is unfinished, the physicians who tested the form reported good results—and mixed feelings.

For three months last year, three practices in New York state—two internal medicine and one ob/gyn—used a tracking form in the charts of female patients. The forms were designed to help physicians identify and manage hypertension and associated risk factors, and to allow for better documentation of counseling about smoking cessation, weight loss, diet, exercise and alcohol use. Practices also received specific patient counseling handouts.

The results are now being evaluated, said Pamela Charney, FACP, internal medicine program director at Norwalk Hospital in Norwalk, Conn., and co-chair of the New York project, "but it looked like these interventions made a difference in controlling blood pressure." Dr. Charney was also editor of ACP's "Coronary Artery Disease in Women," published in 2000.

The chapter decided to focus on practical application following its "Women and Heart Disease Physician Education Initiative," funded by an initial state grant of $500,000 in 2001 and conducted with the state's chapter of the American College of Obstetricians and Gynecologists (ACOG).

The first year of funding led to a series of grand round presentations across the state and a toolkit containing guidelines and patient education handouts. (Toolkit materials are also available for free download at the New York chapter Web site. Click on the "What's New" link to locate the materials.)

Kathleen M. McCabe, ACP Member, a general internist in New Hyde Park, N.Y., was one of the physicians who used the tracking form. Although she found it helped her pay closer attention to patients' blood pressure and to counseling them at every visit about lifestyle changes, it was no magic bullet.

"The plus was that it helped overcome clinical inertia because it put blood pressure right in your face," she said. The downside was that having a separate form to fill out for every female patient was "a time-loser," such that all the doctors in the group "stopped filling it out as soon as the study period ended."

Even though the tracking form itself may not have survived the end of the study, Dr. McCabe said that participating in the experiment woke her up to the need to practice preventive cardiology. In particular, she now pays closer attention to her female patients' weight.

"When their pressure is a little bit up, I weigh them and tell them, 'Your pressure is probably up because your weight is up. You have to get back on the exercise track,' " said Dr. McCabe. She also now has a body mass index chart on the wall of each of her exam rooms and refers to it regularly.

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New 'Heart Truth' site now offers CME

As part of a new National Institutes of Health national awareness campaign on heart disease in women, physicians can now access a new Web site with continuing medical education (CME) resources on cardiovascular health issues for women.

Called "Heart Truth," the campaign and Web site are designed to raise awareness of female heart disease among physicians and patients. In addition to free CME modules for physicians and nurses, the Web site also includes downloadable patient education tools.

Physicians can use the site to access interactive case-based modules on

  • risk assessment and primary prevention in low-risk women
  • metabolic syndrome and coronary heart disease (CHD) in women
  • secondary CHD prevention in women
  • heart disease diagnosis in women

Other materials on the site include slide sets about cardiovascular disease in women. More information is online.

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Heart disease risk: men vs. women

According to the American Heart Association, the following are some key differences between women and men that affect their risk of developing heart disease:

  • High blood pressure. More women than men have high blood pressure, with particular problems among black and Mexican-Americans.

  • Cholesterol. Beginning at age 45, a higher percentage of women than men has total blood cholesterol levels of 200 mg/dL or higher, and the disparity is most pronounced in African-Americans.

  • Smoking. More adult men than women smoke, but 20% of American women over age 18 smoke.

  • Exercise. More American women than women are physically inactive, with the biggest problem again among African-American women.

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