Clinical Context

Research and prevention strategies for cardiovascular disease have historically been focused on White men, but the American Heart Association (AHA) has shifted its emphasis to be more inclusive of women and racial/ethnic minorities. The current AHA Scientific Statement recommends the evaluation for a host of cardiovascular risk factors particular to women. These include pregnancy-related disease states such as preeclampsia and gestational diabetes, as well as menstrual cycle history. Early age at menarche is associated with a higher risk for metabolic syndrome and possibly cardiovascular disease, and early menopause is also associated with negative metabolic outcomes.

Polycystic ovarian syndrome affects 5% to 10% of women of reproductive age and is associated with hypertension as well as disorders of lipid and glucose metabolism. Finally, women suffer much higher rates of autoimmune disorders compared with men, and these disorders are associated with higher rates of systemic inflammation that increase the risk for cardiovascular disease.

There are also important differences between women and men in more traditional cardiovascular risk factors, and these differences are most profound in considering women of color. The current scientific statement provides a review of these important distinctions.

Study Synopsis and Perspective

In a new scientific statement, the AHA highlights the importance of incorporating nonbiological risk factors and social determinants of health in cardiovascular disease (CVD) risk assessment for women, particularly women from different racial and ethnic backgrounds.

CVD risk assessment in women is multifaceted and goes well beyond traditional risk factors to include sex-specific biological risk factors, as well as social, behavioral, and environmental factors, the writing group notes.

They say that a greater focus on addressing all CVD risk factors among women from underrepresented races and ethnicities is warranted to avert future CVD.

The scientific statement was published online April 10 in Circulation.

Look Beyond Traditional Risk Factors

“Risk assessment is the first step in preventing heart disease, yet there are many limitations to traditional risk factors and their ability to comprehensively estimate a woman’s risk for cardiovascular disease,” Jennifer H. Mieres, MD, vice chair of the writing group and professor of cardiology at the Zucker School of Medicine at Hofstra Northwell in Hempstead, New York, says in a news release. 

“The delivery of equitable cardiovascular health care for women depends on improving the knowledge and awareness of all members of the healthcare team about the full spectrum of cardiovascular risk factors for women, including female-specific and female-predominant risk factors,” Dr Mieres adds.

Female-specific factors that should be included in CVD risk assessment include pregnancy-related conditions such as preeclampsia, preterm delivery, and gestational diabetes, the writing group says.

Other factors include menstrual cycle history; types of birth control and/or hormone replacement therapy used; polycystic ovarian syndrome, which affects 10% of women of reproductive age and is associated with increased CVD risk; and autoimmune disorders, depression, and posttraumatic stress disorder, all of which are more common in women and are also associated with higher risk for CVD.

The statement also highlights the key role that social determinants of health (SDOH) play in the development of CVD in women, particularly women from diverse racial and ethnic backgrounds. SDOH include education level, economic stability, neighborhood safety, working conditions, environmental hazards, and access to quality health care.

“It is critical that risk assessment be expanded to include [SDOH] as risk factors if we are to improve health outcomes in all women,” Laxmi S. Mehta, MD, chair of the writing group and director of preventative cardiology and women’s cardiovascular health at The Ohio State University Wexner Medical Center in Columbus, says in the news release.

“It is also important for the healthcare team to consider [SDOH] when working with women on shared decisions about cardiovascular disease prevention and treatment,” Dr Mehta notes.

No One-Size-Fits-All Approach

The statement highlights significant differences in CVD risk among women of different racial and ethnic backgrounds and provides detailed CV risk factor profiles for non-Hispanic Black, Hispanic/Latinx, Asian, and American Indian/Alaska Native women.

It notes that language barriers, discrimination, acculturation, and healthcare access disproportionately affect women of underrepresented racial and ethnic groups. These factors result in a higher prevalence of CVD and significant challenges in CVD diagnosis and treatment.

“When customizing CVD prevention and treatment strategies to improve cardiovascular health for women, a one-size-fits-all approach is unlikely to be successful,” Dr Mieres says.

“We must be cognizant of the complex interplay of sex, race and ethnicity, as well as social determinants of health, and how they impact the risk of cardiovascular disease and adverse outcomes in order to avert future CVD morbidity and mortality,” Dr Mieres adds.

Looking ahead, the writing group says that future CVD prevention guidelines could be strengthened by including culturally specific lifestyle recommendations.

They also say that community-based approaches, faith-based community partnerships, and peer support to encourage a healthy lifestyle could play a key role in preventing CVD among all women.

This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association’s Cardiovascular Disease and Stroke in Women and Underrepresented Populations Committee of the Council on Clinical Cardiology, the Council on Cardiovascular and Stroke Nursing, the Council on Hypertension, the Council on Lifelong Congenital Heart Disease and Heart Health in the Young, the Council on Lifestyle and Cardiometabolic Health, the Council on Peripheral Vascular Disease, and the Stroke Council.

Circulation. Published online April 10, 2023.^[1]

Implications for the healthcare team

• Black women in the US have the highest prevalence of hypertension in the world (55.3%). Higher rates of cardiovascular disease promote a 5-year lower difference in life expectancy in comparing Black and White women. Black women have the highest levels of lipoprotein(a) compared with other racial/ethnic groups. American Indian and Hispanic women experience higher rates of diabetes compared with Black women.
• The current statement recommends that thiazide diuretics should be considered first line for women to help prevent osteoporosis. Women suffer much higher rates of autoimmune disorders compared with men, and these disorders should be accounted for in assessing the risk for cardiovascular disease. Women with a history of preeclampsia should have a thorough evaluation for cardiovascular risk factors within 12 months of delivery. Statins should be discontinued 1 to 2 months before pregnancy, when possible, among women at moderate risk for cardiovascular disease, but the continuation of water-soluble statins should be considered among high-risk women during pregnancy.
• The healthcare team should incorporate nonbiological risk factors and social determinants of health in CVD risk assessment for women, particularly women from different racial and ethnic backgrounds.

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