CWHHS 2016: What’s Needed to Improve Women’s Heart Health?

In the 1950s, available advice on women and heart health largely consisted of information on how to help husbands recover from their heart attacks. As the famous ad says, we’ve come a long way, baby.

Progress is being made in addressing women’s heart health, progress that was amply demonstrated at the Canadian Women’s Heart Health Summit (CWHHS), held in Ottawa in April. But as delegates also heard, much still remains to be done. No resting on laurels just yet.

Summit participants, presenting research findings and their own clinical experiences, noted areas where more work is required to effectively prevent, diagnose and treat heart disease in all women, whatever their race, ethnicity or socioeconomic status.

Research: Bringing Women into the Picture

Women, traditionally, have been left out of cardiovascular research. But relying on studies conducted primarily in men leaves women at a disadvantage when it comes to their hearts. Women who are ethnic minorities or of lower socioeconomic status are even more disadvantaged.

Summit speakers told attendees that cardiac research needs to change, both in terms of the people and the topics studied.

Nanette Wenger, MD, of Emory University in Atlanta, Georgia, pointed out that not only are women left out of clinical trials, but so are older adults, which disadvantages women further as they tend to live longer than men and get heart disease later than men. However, she pointed out, the 2015 Research for All Act in the United States, which ensures the inclusion of women and minorities in health research, should lead to better applicability of research results to women.

As Dr. Wenger indicated, we need to know more about the impact of factors such as age, hormonal environment, reproductive history, inflammation and psychosocial determinants on cardiovascular risk and disease in women. Other unanswered research questions include:

• The effect of differences in symptoms and access to care on the quality of prevention, diagnostic procedures and rehabilitation
• Cardiovascular disease in young women and in women of racial or ethnic minorities
• The best ways to assess, modify and prevent cardiovascular disease in women
• The biological variables that most influence the development and clinical outcomes of cardiovascular disease in women.
• The increasing incidence of, and death from, heart attacks in younger women is another area requiring further research. Dr. Wenger called these deaths “the leading edge of a brewing storm.”

Epidemiologist Louise Pilote, MD, PhD, of McGill University is currently leading a study of women who have heart attacks before age 55. This study, GENESIS-PRAXY, has found that, among younger women, hormonal changes and pregnancy-related disorders such as preeclampsia are signposts for future heart disease, but not enough is known about the mechanisms of this predisposition.

Further research is only part of the picture, as Sharon Straus, MD, of Toronto’s St. Michael’s Hospital, pointed out. Translating existing knowledge into practice is equally important.

Prevention: Understanding Risk Factors

The biggest challenges for the future, according to Sonia Anand, MD, PhD, of McMaster University, aren’t in in-hospital acute care, but in the periods before diagnosis and after treatment, in encouraging them to make the necessary lifestyle changes and adhere to medications.

Dr. Anand pointed out that the top five risk factors for heart disease—cholesterol, smoking, high blood pressure, diabetes and abdominal obesity—are the same in women and men, but the order of importance differs. (See “What We Know about Women and Heart Disease” for more on risk factors.)

Prevention strategies need to be targeted for each group. She stressed the importance of involving women, particularly those who are particularly disadvantaged by ethnicity or socio-economic status, in designing interventions that will meet their needs.

“We need to treat women and we need to treat women in primary care, before they have their event,” added Beth Abramson, MD, of St. Michael’s Hospital in Toronto. “Small steps can make a big difference.”

Andrew Pipe, MD, of the Ottawa Heart Institute stressed the need for education of primary care providers, who don’t rate themselves highly in their ability to support their female patients. As well, women themselves are often unclear about risk factors for heart disease, with less than half able to identify smoking as a risk factor, and less than a quarter able to identify high blood pressure.

Several participants noted the importance of targeting women who have had pregnancy-related disorders, such as preeclampsia or gestational diabetes, and begin screening them for risk factors early, as there is a clearly demonstrated link between these women and heart disease later in life.

“It’s exciting because we’re identifying them very, very early, but there’s a paucity of evidence to guide us” on how to proceed, said Kara Nerenberg, MD, of the University of Calgary. Nonetheless, she suggested that raising awareness among primary care providers is important, as is educating patients on the importance of follow-up.

Diagnosis and Care: Looking for the Hidden Signs

As detailed in the companion Summit article “What We Know about Women and Heart Disease,” women have quite different symptoms than men. University of British Columbia’s Karin Humphries, DSc, explained that women have much lower levels of troponin, an important biomarker for heart attack. Standard assays to measure troponin often miss indications that a woman has had a heart attack. Dr. Humphries would like to see a high-sensitivity assay used in women to better identify those that have suffered a heart attack. This would lead to more timely treatment and better outcomes.

Sharon Mulvagh, MD, of the Mayo Clinic, said that awareness campaigns focused on recognizing symptoms in women have not been as effective as they could be. She called for physicians to discuss prevention with their female patients and to be more aggressive in assessing their heart health. She wants physicians to be quicker in diagnosing possible problems and ensuring the appropriate tests are done, so that women “get in the door of the cath lab when they need to be there.”

Just as there are differences in diagnosis, so are there differences in care and outcomes. Women are more likely to die in hospital from a heart attack, for instance, said Dr. Abramson. Is that biology, she asked, or bias at work? Either way, it is important for care providers to understand these differences and for care options to be developed that meet the specific needs of women.

Rehabilitation: Making It Work for Women

The evidence is clear: cardiac rehabilitation saves lives, said Sherry Grace, PhD, of York University. Patients who participate in rehabilitation programs have 26% lower mortality from heart disease and 18% lower hospital re-admission rates. Yet fewer women than men are referred to rehabilitation programs, enrol in them and stick with them. The reasons are complex, but lower levels of physician encouragement and lack of awareness of the programs play a role.

Women-only programs have been shown to increase psychological well-being for participants, with reduced levels of anxiety or depression, noted Dr. Grace. She called for more intensive referral processes and programs that are designed to maximize adherence among women.

Public Policy: Moving Beyond the Medical Model

Dr. Pipe took a broader perspective, noting that “there are two causes of disease: pathological and political.”

“If we can create an environment in which the right choices are easy, we can increase life expectancy by 10 to 14 years,” he continued. To accomplish that, “We need to do ordinary things extraordinarily well.”

Dr. Wenger echoed his call to expand the vision of women’s cardiovascular disease beyond the medical model to include beliefs and behaviours; economic and environmental factors; ethical and political aspects, socio-cultural factors and public policy.

Among the measures Dr. Pipe called for are fiscal policy that supports healthy food policies; carefully thought-out recreation and sports policies to support physical activity; and urban planning that builds communities where walking and other forms of active transportation are the easy choice; and new measures to address the rising rate of smoking among young women.

Moving Forward on Women’s Heart Health

The purpose of the Canadian Women’s Heart Health Summit was not merely to share knowledge and experience, but to spearhead a cross-country commitment to action to improve women’s heart health. The day after the Summit, a smaller group of invitees assembled to discuss priorities for action in the areas of research, care, and awareness, training and education.

“It was really exciting,” said Lisa McDonnell, Program Manager of the Canadian Women’s Heart Health Centre at the Ottawa Heart Institute. “We focused on concrete, actionable things we can actually do.”

The results of this planning session will be issued in a report in May. After that, the CWHHC will act as a central organizing body to facilitate progress on these priorities.

“It’s a massive undertaking,” said McDonnell. But annual summits will provide venues for follow up. Once women have their own models for prevention, diagnosis and treatment of heart disease, we will, finally, have truly come a long way.