Cardiovascular disease (CVD) is an umbrella term relating to a spectrum of conditions which affect the heart and blood vessels of the body. These vessels include the large vessels supplying the brain, heart and limbs, and the smaller vessels supplying the eyes, kidneys and nerves. Although CVD is recognised to be a condition that affects men more than women overall, this risks underplaying the significant challenges relating to the diagnosis and management of CVD in women.
In this article, we consider the incidence and prevalence of heart disease in women and analyse the role of the general practice nurse (GPN) in recognising and managing cardiovascular conditions in women. By the end of this article readers will be able to:
- Recognise the burden of heart disease in women
- Consider how the diagnosis and management of heart disease may be affected by gender
- Evaluate the role of female hormones on cardiovascular risk
- Reflect on how GPNs can contribute to improvements in the management of CVD in women.
The burden of cardiovascular disease in women
According to statistics from the British Heart Foundation (BHF) there are 830 000 women in the UK living with coronary heart disease (CHD), and around 380 000 women in the UK have survived a heart attack (BHF, 2021). Coronary heart disease is the single biggest killer of women in the UK and kills more than twice as many women as breast cancer (BHF, 2019a).
Around 35 000 women are admitted to hospital following a myocardial infarction each year, averaging at almost 100 women per day, or 4 per hour (BHF, 2019a). Women are also at increased risk of a rare type of myocardial infarction, a phenomenon known as spontaneous coronary artery dissection (SCAD). This condition is seen more frequently in younger women (80% of cases occur in women with an average age of 42 years) and it can also occur in pregnancy (Saw et al, 2016).
Heart failure is a condition which carries a heavy burden of morbidity and mortality. The Framingham study highlighted the link between diabetes and heart failure, and showed that women with diabetes had a 5-fold increased risk of developing heart failure compared with a 2-fold increase in risk in men (Kannel and McGee, 1979). Women tend to live longer than men, and as heart failure prevalence increases with age, this affects the incidence of heart failure in older women. Stroke affects women over 65 years of age more than men and the numbers separate even further in women over 85 years of age. Around one in three strokes is fatal and in 2019, 4861 women aged 85 years and over died of a stroke, compared with 2577 men (Stewart, 2020). The long-term disability associated with stroke also affects women more than men because they are likely to be older and living alone when their strokes occur. Stroke risk is also increased in pregnancy and the post-partum period (Roth and Deck, 2019) and to a much lesser extent, with the use of the combined oral contraceptive pill (Dulicek et al, 2018).
Gender differences in the diagnosis and management of heart disease
Gender differences in CVD express themselves in a range of ways. Women are thought to carry excess risk from the same risk factors as men, including hypertension, dyslipidaemia, smoking and diabetes (Woodward, 2019). They are also less likely to recognise and act on the symptoms of a cardiovascular event, such as a myocardial infarction. Nguyen et al (2010) carried out a systematic review which found that the average delay between the onset of symptoms and arrival at hospital for men ranged between 1 hour 24 minutes and 3 hours 30 minutes, whereas for women the delay ranged between 1 hour 48 minutes and 7 hours 12 minutes. Clinicians are also less likely to suspect a diagnosis of CVD in women even when they present with typical symptoms. Wu et al (2018) found that women are 50% more likely than men to receive the wrong diagnosis when presenting with symptoms of a myocardial infarction, while Woodward (2019) reports that male cardiologists are less likely to diagnose women with CVD when compared to female cardiologists. These anomalies may occur because there is a common misconception that women are at low risk of CVD, so symptoms are more likely to be attributed to causes other than CVD. There is also a belief that women tend to present with atypical symptoms. However, Ferry et al (2019) showed that feelings of tightness, pressure or squeezing in the chest were the most common symptoms of myocardial infarction in both men and women.
As a result of delays in diagnosis, women were less likely to receive appropriate and timely interventions for their heart attack (Bugiardini et al, 2017). Early diagnosis and treatment is essential in myocardial infarction, so these delays and failures will result in greater morbidity and mortality: if a woman has a missed diagnosis of heart attack, she will have a 70% higher risk of death after 30 days compared to someone who receives the correct diagnosis straightaway (Wu et al, 2018).
Management of cardiovascular disease
Even the implementation of evidence-based care for women with CVD is problematic. Research in key aspects of CVD management is skewed towards men, right from the numbers taking part. According to Mentzer and Hsich (2019), female participation in heart failure trials ranged from 0–40% with an average of around 20% of participants being women. Overall, around two-thirds of all research in CVD has been carried out in men, with key difference in numbers taking part in trials looking at heart failure, coronary artery disease and acute coronary syndrome (Saeed et al, 2017). The reasons for this under-representation were not clear, and eligibility was not the issue, but this important concern needs to be addressed, as a failure to gather evidence on gender differences could have important consequences in terms of the diagnosis and management of women with CVD. As an example, troponin levels in women who have had a myocardial infarction are thought to be lower than in men and a high sensitivity test may offer better diagnostic outcomes for women (Shah et al, 2015). Women may also respond differently to some drugs used to treat CVD and heart failure, but a lack of gender-specific research and evidence means that women are treated the same as men, possibly to their detriment (Mentzer and Hsich, 2019; Woodward, 2019).
Notwithstanding this lack of research, there is lower adherence by clinicians and patients to generic evidence-based interventions following myocardial infarction, including in both the acute phase and in long-term management. Women are less likely to have angiography, reperfusion and dual anti-platelet treatment compared with men (BHF, 2019a). Women in the US, England and Wales have also been shown to be less likely to be prescribed statins and beta blockers when leaving hospital following a heart attack (Peters et al, 2018; Wilkinson et al, 2018). Women are also less likely to reach secondary prevention targets for lipid and glucose levels, physical activity, obesity and attendance at cardiac rehabilitation programmes (Zhao et al, 2017; BHF, 2019b). Ethnicity can also affect women's chances of engaging in and benefiting from cardiac rehabilitation, as can carer responsibilities, which are often disproportionately evident in women (BHF, 2019b). The number of women in England accessing cardiac rehabilitation dropped further from an already low level according to the latest BHF audit (BHF, 2019b).
Resources
- Primary Care Cardiovascular Society website – free membership and resources for clinicians at pccsuk.org
- British Heart Foundation – professional resources for primary care nurses https://www.bhf.org.uk/for-professionals/healthcare-professionals/resources-for-your-role/resources-for-primary-care-nurses
Evaluating the role of female hormones on the heart
When reflecting on why women have different levels of CVD compared with men, the obvious area to consider is female hormones. CVD incidence and prevalence are both lower in premenopausal women but increase at the time of the menopause, suggesting a link with oestrogen. There is some evidence that changes in hormone levels can affect CVD risk both pre- and post-menopause. As hormones fluctuate during the menstrual cycle, the perinatal period and during the menopause, so do inflammatory cytokines, which are known to play a part in CVD (Mattina et al, 2019). Pregnancy and a woman's health during the perinatal period may offer warning signs for future CVD risk, as pre-eclampsia, gestational diabetes, pre-term delivery, multiple pregnancies and miscarriage have all been identified as risk factors for developing CVD in later life (Grandi et al, 2019). Supporting women to prepare for a healthy pregnancy through weight management and smoking cessation, then, may offer long-term benefits and GPNs have a key role to play here.
Hormone replacement therapy (HRT) has been mooted as a possible intervention which can reduce CVD risk (Newson, 2018). Newson (2018) states that perimenopausal and menopausal woman should be encouraged to have a CVD risk assessment and that more women should be considered for HRT in order to optimise cardiovascular protection. With respect to the benefits of HRT in CVD, the greatest risk: benefit profile is seen when HRT is started as close to the menopause as possible, especially in younger women (Chester et al, 2018; Newson, 2018). Women who are diagnosed as having a premature menopause have been identified as being at increased risk of CVD (Atsma et al, 2006; Zhu et al, 2019) indicating that the need to start HRT in this group may be even stronger. However, Gunning et al (2020) suggest that more research is needed with regard to premature menopause, CVD risk and HRT. News stories about HRT and breast cancer have discouraged some women from taking HRT for symptom management, and yet the potential benefits of HRT with regard to heart health are too often ignored. It is important that a careful risk: benefit assessment is carried out when considering HRT holistically, and when discussing the emotive topic of breast cancer risk, it is easy to overlook the stark fact that coronary heart disease (CHD) kills more than twice as many women as breast cancer in the UK every year, and is the single biggest killer of women worldwide. If HRT is initiated, transdermal oestrogen is recognised as having improved risk: benefit profile than oral therapies, and this should arguably be the default route of administration (Gordon et al, 2020).
GPNs have an important role to play in advising women of the importance of CVD risk assessments and risk reduction strategies. This may include discussion about the additional benefits of HRT beyond symptom control. At this time, however, HRT is not recommended purely as an intervention for CVD prevention.
Hormone levels are also linked to mood changes and specifically depression. Depressive disorders are associated with changes in inflammatory cytokine and serotonin levels, platelet aggregation and endothelial dysfunction, which are all known to influence CVD risk, even in young women (Bucciarelli et al, 2020). Depression is a known risk factor for CVD and can also worsen CV morbidity and mortality, particularly in CHD, heart failure and stroke, while treatments for depressive disorders also seem to have a positive effect on CVD outcomes (Bucciarelli et al, 2020).
The role of GPNs in the diagnosis and management of CVD in women
As identified in this article, GPNs have an important role to play throughout women's lives in reducing CVD risk. Talking to women about their risk profile and ensuring that any misconceptions are addressed, will help to give women the information they need to make lifestyle choices and engage in CVD risk assessment, aimed at minimising risk. Women need to know that CVD affects them too and that in some cases (stroke and heart failure, for example) they are disproportionately affected. They should be made aware of the classic (and less common) symptoms of CVD and should recognise the importance of getting help if they experience them. The pandemic has already been shown to impact on people seeking care for acute cardiovascular conditions. During the first lockdown there was a significant reduction in people calling for ambulances or attending the emergency department and this was thought to have led to the increase in non-COVID-related deaths during this period (European Society of Cardiology, 2020). Women also need to be aware of the impact that hormones can have on their cardiovascular health, both positively and negatively, and be given clear, evidence-based and individualised advice about managing fertility, pregnancy, the perinatal period and the menopause holistically and with respect to CVD risk.
Conclusion
Cardiovascular conditions may affect men more than women overall, but women are still significantly affected by heart and vascular disease as reflected by the morbidity and mortality statistics which show that coronary heart disease kills more women than any other condition. Women are adversely affected compared to men in terms of diagnosis, acute management and implementation of secondary prevention, and the evidence base for treating women is lacking, due to the low numbers of women included in trials. Hormonal fluctuations throughout a woman's lifetime can also affect CVD risk and there needs to be more research into what can be done to improve women's CVD risk, including assessment of the impact of their menstrual and reproductive history. GPNs are ideally placed to consider the challenges of recognising and addressing CVD risk in women and to support them with engaging in reducing their lifetime risk. They can also ensure that women are aware of their risk and seek urgent help if they suffer symptoms of a cardiovascular event.
Key Points
- Coronary heart disease is the single biggest killer of women in the UK
- Women with diabetes have a 5-fold increase risk of developing heart failure compared with a 2-fold increase in risk in men
- Women are less likely to recognise and act on the symptoms of a myocardial infarction
- Women are underrepresented in cardiovascular disease (CVD) trials resulting in an incomplete evidence base
- Hormonal fluctuations over a woman's lifetime may influence CVD risk
CPD reflective questions
- Why are women less likely to recognise a cardiovascular event?
- What role do hormones play in cardiovascular disease risk?
- How could you help women to improve their cardiovascular risk factors?