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Expert Perspectives on Improving Cardiovascular Disease Management in Women

  • Authors: Michelle Johnson, MD, MPH, FACC; Rachel M. Bond, MD, FACC
  • CME / ABIM MOC Released: 10/24/2022
  • Valid for credit through: 10/24/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

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Target Audience and Goal Statement

This activity is intended for primary care physicians, cardiologists, and diabetologists/endocrinologists.

The goal of this program is for learners to have a better understanding of strategies to enhance CVD management, including cardioprevention, in women.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Recommendations for the management of heart disease in women


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  • Michelle Johnson, MD, MPH, FACC

    Clinical Director of Cardiology
    Fellowship Director, Cardio-Oncology
    Memorial Sloan Kettering Cancer Center
    New York, New York


    Michelle Johnson, MD, MPH, FACC, has no relevant financial relationships.

  • Rachel M. Bond, MD, FACC

    Assistant Professor
    Department of Internal Medicine
    Creighton University School of Medicine
    System Director
    Women's Heart Health, Dignity Health
    Chandler, Arizona


    Rachel M. Bond, MD, FACC, has no relevant financial relationships.


  • Anne M. Sendaydiego, PharmD

    Medical Education Director, WebMD Global, LLC 


    Anne M. Sendaydiego, PharmD, has no relevant financial relationships.  

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  • Susan L. Smith, MN, PhD

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Susan L. Smith, MN, PhD, has no relevant financial relationships.

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Developed through a partnership between Medscape and the Association of Black Cardiologists.

In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

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Expert Perspectives on Improving Cardiovascular Disease Management in Women

Authors: Michelle Johnson, MD, MPH, FACC; Rachel M. Bond, MD, FACCFaculty and Disclosures

CME / ABIM MOC Released: 10/24/2022

Valid for credit through: 10/24/2023


Activity Transcript

Michelle Johnson, MD, MPH, FACC: Hello, I'm Michelle Johnson, vice chair for health equity, Department of Medicine, and clinical director, Division of Cardiology, at Memorial Sloan Kettering Cancer Center in New York. Welcome to this program titled "Expert Perspectives on Improving Cardiovascular Disease Management in Women." Joining us today is Dr Rachel Bond, women's heart, health, and prevention specialist from Chandler, Arizona. Welcome, Rachel.

Rachel M. Bond, MD, FACC: It's so wonderful to see you. Thank you.

Dr Johnson: Cardiovascular disease (CVD) is a leading cause of death among women in the United States. In this program, we will discuss some key recommendations for the screening, prevention, and treatment of CVD in women. Rachel, can you begin by briefly reviewing the burden of cardiovascular (CV) risk factors in women and say something on how Black women are particularly affected?

Dr Bond: Over the course of several decades, there was a steady up-trend in the number of deaths in women and a steady decrease in the number of deaths in men. A lot of what we have noted was that many of the medications, many of the recommended management, were disproportionately being provided to men and not as aggressively being provided to women.

When we think about the risk factors, even starting off with the risk factors that make heart disease 80% of the time preventable, which are the traditional or modifiable ones like high blood pressure, diabetes, smoking, or even being overweight or obese, those risk factors do disproportionately impact women much greater than they do men.

Many of those risk factors we do know disproportionately impact women of color, specifically the Black community. Blood pressure has a high degree of prevalence in the African American community. We know that 60% of Black women above the age of 20 have some form of CVD, and the greatest driver happens to be hypertension. This really highlights the fact that there are disparities when it comes to sex, as well as race and ethnicity, underlining CVD and the outcomes that we're seeing.

Dr Johnson: Would you like to say a couple words about social determinants of health?

Dr Bond: Absolutely. I think just highlighting the fact that where we stand right now in CVD is that we're seeing that younger and younger people are, unfortunately, not only being diagnosed earlier with CVD but also are dying from it. The greatest burdens are in those communities of color, specifically females coming from those communities of color. I will say that the greatest drivers of health outcomes are those social determinants. Those could be lumped into where one grew up, the ability to have access to medical care, and the ability to have access to education. Health literacy is also included within that. We also know that food and the ability to have healthy food patterns or habits, such as the inability to kind of remove ourselves from food deserts, is also something that really drives forward the fact that social determinants of health can play a role.

I will say that I think the greatest driver when we think as a whole of these social determinants of health include psychosocial stressors. We know that many of those stressors disproportionately impact women of color. As it stands, stress and anxiety, they are not traditional risk factors. They are independent risk factors for CVD. Coupling the misogyny that many women face and then adding to the burden being a woman of color with the potential systemic racism, that is unfortunately leading to premature cognitive as well as CV conditions. It's very important that as clinicians we're taking into account all of these social aspects of one's particular health, because they do play a much greater role in terms of the disparities that we see.

Dr Johnson: Thanks for that. Certainly, we know that women have a higher lifetime risk of burden from cerebrovascular events, both in terms of mortality and disability. Women tend to have cerebrovascular accidents (CVAs) later on in life. Black and Hispanic women are at higher risk, and there is more attributable risk due to the presence of diabetes and hypertension in women who have CVAs when compared with men. There's also the additional impact of obesity, which has a stronger association with CVAs in women. When you look at the potential risk factors of diabetes, hypertension, you look at prevalence of those risk factors amongst women of color, it's easy to understand why it is we have disproportionate incidents of cerebrovascular events in our communities.

Rachel, would you like to speak a little bit more about that or some of the pregnancy-related CV risks to women?

Dr Bond: We know that during the reproductive years, many of the conditions, if a woman decides to have a child, can potentially impact your future CV risks. So, what are these conditions? These include gestational hypertension, chronic hypertension, preeclampsia, premature labor, even having intrauterine growth restriction. All of these are potential risk factors in the immediate future for a CV event. It can start as early as during the pregnancy, but in that postpartum period as well. It could eventually transition from 5 years even up to 20 years after they've had their delivery.

What we are really proposing right now is removing the siloed approach to treating a particular patient and working more in a coordinated approach. We want cardiologists working with obstetricians and also primary care clinicians to optimize the woman’s health, preferably before pregnancy, to ensure that during pregnancy we're screening for these conditions, especially if they are high risk. Most notably, we want to get them into the hands of cardiologists after the delivery, especially if they have these conditions, because what it can do is hopefully prevent a catastrophic event.

Going into your area of expertise, we're seeing a lot of data and information really evolving in the field of cardio-oncology. I'd love, Michelle, if you can touch a little bit upon that and what you're doing within your own practice.

Dr Johnson: We know there are sex and race predilections for, we've mentioned CVD, but that also exists for cancer. We also need to look at what it is we do for the treatment of cancer and whether there is difference by sex and race and ethnicity. Cardio-oncology certainly started to look at this. Anthracyclines are one of the oldest, the cornerstone of treatments for liquid tumors, for solid tumors. They're used in adults, they're used in pediatrics, and they're also used on occasion in breast cancer. We know that patients treated with anthracyclines have a difference in risk of developing cardiomyopathy or left ventricular (LV) dysfunction depending on where along the timeline and life course people are exposed. Peripubertal girls have a higher risk of developing acute cardiotoxicity from anthracyclines. Premenopausal women have a lower risk of developing cardiomyopathy than men do. Postmenopausal women have the same risk as elderly men, so clearly there is something going on perhaps linked to the presence of endogenous estrogen that has something to do with the impact of anthracycline cardiotoxicity. So again, begging the question of what is it that's going on in the internal milieu that would make women more prone to developing LV dysfunction?

About 12% of women will get breast cancer. Any cardiotoxicity will have a disproportionate impact on women as a whole because so many of us are likely to be subject to breast cancer. You point out the wonderful success rates in terms of curing breast cancer. It means that we have to do right by our breast cancer survivors. Accurate surveillance and diligent monitoring of our female breast cancer survivors and our male breast cancer survivors, to be sure that they are screened for accelerated atherosclerosis, which we know is a function of exposure to radiation to the chest, is very important. Also, screening for LV dysfunction, which can happen especially in a setting of having received potentially cardiotoxic drugs, is very important. It really needs to heighten our awareness that our cancer survivors are at increased risk of developing CV issues and so they need to be watched carefully.

Dr Bond: Absolutely. One area that I think would be of relevance is for us to maybe pivot the conversation to talk a little bit about prevention, so screening of CVD, but also how to prevent it. From a preventive perspective, I think the most important would be primordial prevention, to prevent those risk factors from happening altogether, which we can touch upon. But when we think about even primary prevention and optimizing many of those risk factors, what is your specific approach when it comes to CV screening that is very specific to females?

Dr Johnson: I am particularly in tune with patients' lifestyle. I am screening for social determinants of health and paying a lot attention to family history. It's very important to me to know what it is my patients are eating. It's also very important to me to know whether they're moving because so much of this is, as you point out, Rachel, preventable on the front end. You can't change the genes. Well, there's a lot that we can't change. I feel that it is incumbent on us to do an aggressive job of trying to move that needle, it's still the number one killer, and making sure that we are doing right by putting in place all of those therapies that have been shown to be potentially cardioprotective. I also like to engage my patients in a discussion. And so, this is a collaborative exploration, if you will. One patient's tolerance for risk is not the same as the person who will walk in after her. Is that what you find in your experience with patients, Rachel?

Dr Bond: Absolutely. After we screen for those traditional risk factors, it is furthermore important that we look for those sex-specific risk factors in females as well, the ones that we touched upon, the pregnancy-related conditions, and perhaps hormone therapy use. We also know hormone therapy, depending on one's risk, can actually increase their risk of CVD, especially based on the duration of how long they've used it and if they were provided any of those cardiotoxic therapies that you've mentioned due to cancer. Also, we're noticing now focusing in on autoimmune conditions is important too, because when it comes to CVD, it is an inflammatory process.

The other thing that I think is relevant to stress is that we see that the disparities that we see in CVD, the impact and the burden being higher in the Black community, that all gets translated to what we're also seeing with maternal health. As it stands right now, Black women are 2 to 3 times more likely to die during their pregnancy and up to 1 year after they deliver, largely coming from CVD. The greatest driver is actually peripartum cardiomyopathy, which as you know is the weakening of the heart muscle that occurs during pregnancy or even up to 3 to 6 months after delivery.

With that being said, it's important that we highlight that just like CVD is 80% preventable, many of these pregnancy deaths and morbidities are also largely preventable. The Centers for Disease Control and Prevention just resurfaced lots of data to show that 84% of pregnancy-related deaths are preventable. That really highlights and homes in on what we are addressing.

We also know that secondary prevention, many times depending on one's sex, depending on one's race and ethnicity, we may not be as aggressive in managing these particular conditions. For example, getting their cholesterol, their low-density lipoprotein-cholesterol (LDL-C), below a threshold and putting them on alternative medications or possible alternative therapies that we may know will optimize their risk factors.

I'd love for you, Michelle, to maybe touch upon your approach in those particular patient populations—as an example, Black women when it comes to secondary prevention—and is your approach a little different based on their race and ethnicity?

Dr Johnson: I would say that my approach is tied to the burden of risk. My responses are custom tailored and culturally appropriate. I am also very invested in engaging patients in their care. I think it is very important that all patients, but certainly Black women who are now in a secondary prevention category, know their numbers, be checking on their blood pressure, know the last time their lipids were checked, know their glycated hemoglobin (A1C). Without that level of patient involvement, it’s very unlikely, I find, that we're going to be able to know that we've kept people at goal and that the ship is going in the right direction.

I really want to know in my secondary prevention group that this is a collaborative effort and that people understand that what we do in the office is only part of the overall mission of what we need to do to prevent them from having another event. I discuss issues like diet and health literacy. I need to know about financial stressors. I need to know about what resources are available in your community. When I tell you that you must exercise, that is whistling in the wind if those opportunities are not readily available for you. I have to make sure that my messages can resonate and have value in people's particular place of living. I also want to be sure that if you are having side effects from the medication and I don't find out because the pharmacy calls to say, "oh, Mrs Smith hasn't picked up our prescription."

I want it to be a 2-way street because, as you know, no one is served if medications are prescribed but not taken. Smoking, we mentioned before, is a very expensive habit. We refer people to smoking cessation, make sure that they're plugged into psychotherapy if that can help. Those are some of the things that I do which is an even more aggressive push, if you will, in the secondary prevention space because there's just less margin for error. Does that resonate with what you're experiencing in Arizona?

Dr Bond: Yes, definitely. I think you said it so profoundly and I would like to just probably highlight the fact that a cornerstone still needs to go back to the basics of lifestyle. Of course, for secondary prevention more so than primary, we're going to be providing them those pharmacotherapies, those medications that are evidence based that are going to prevent another event from happening or even an incident from occurring altogether. I do think going back to those basic steps of focusing in on healthy eating habits and exercise.

I do want to take a moment to acknowledge that the Association of Black Cardiologists has provided wonderful tools, tools that even I as a clinician tend to provide to my patients, irrespective of their race and ethnicity because I think it actually impacts everyone regardless of where they come from demographically as well.

Dr Johnson: I would also add that I oftentimes find it helpful to try to incorporate the family. We're talking about trying to impact prevention, and we know that he who prepares the meals is going to set the table for the rest of the family. Sometimes it is helpful for busy mothers or busy women who are in the ballpark of secondary prevention to have the support of their family who will sign on for lifestyle changes, who will say, "okay, we're going to walk with you," or "we're going to help you with those devices." There's a lot of stuff out there that I find to be helpful for my patients. I say, "what phone do you have? I want you to do 10,000 steps. Do you know that your phone will count how many steps you do?" Things like that. We're going to get a scale. We want everybody in the family to make sure that they are eating healthily. I try to really make this a collective effort. I find it's helpful to have teamwork and to have a partner in this type of work. I don't know if you use the same type of strategies, but sometimes I ask them to bring someone else in I know if they're having a difficult time selling the rest of the family on making changes to how they eat, for example. It's helpful if everybody's in this together.

Dr Bond: Yes, I couldn't agree more. We know that CVD spans the whole vasculature. So, we do have to be more thoughtful in terms of who we're enrolling in the trials, and when it comes to women, specifically women of color, we know that the rates and percentages of enrollment are much less. I think that ties into also the importance of diversifying our principal investigators and our researchers, but also just our field in general.

Dr Johnson: I couldn't agree more. I think you have to have different voices at the table to ask different research questions. We are seeing more and more in terms of shifts to genetic testing, treatment as focused on genetic composition. We'll not be able to answer those questions if we don't have diverse populations in our clinical trials. We suffer from this acutely in cardio-oncology where clinical trials are not diverse. I think the cancer community is more diverse, certainly in those cancers that have disproportionate impact on people of color, but here is a tremendous amount of work that needs to be done to increase enrollment and increase enrollment in women across their life span because, as we've pointed out here this afternoon, it is clear that vascular issues impact women at various points in time in their life course. We have to be enrolling women at different points of their life course if we're looking to answer these questions.

Dr Bond: Michelle, thank you so much for this great discussion. I definitely learned a lot from what you had to offer and I'm hopeful that the audience has learned as well. I do want to thank those in the audience for participating in this activity. Please continue on to answer the questions that follow and complete the evaluation, and we look forward to seeing you again very soon.

This transcript has been edited for style and clarity.

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