The journey to better women's heart health starts with having more data, said Nanette Kass Wenger, MD, MACC, MACP, FAHA, professor of cardiology at Emory University School of Medicine, during the Simon Dack Keynote Lecture, which opened the 67th Scientific Session of the American College of Cardiology.
Years before “Go Red for Women” and the red dress pin became symbols of the campaign to end heart disease and stroke in women, Nanette Kass Wenger, MD, MACC, MACP, FAHA, wasn’t going red. For the Emory University professor of cardiology, it was more like seeing it.
Wenger, founding consultant of the Emory Women’s Heart Center, gave the Simon Dack Keynote Lecture to open the 67th Scientific Session of the American College of Cardiology, and her talk, “Understanding the Journey: the Past, Present, and Future of CVD in Women,” revealed the uncomfortable truth: recent declines in cardiovascular death (CV) for women have been possible because science is finally paying attention to them.
Back in the 1970s, when Wenger began educating the public about women’s vulnerability to heart attacks—and the effects of alcohol, smoking, and some medications—CV disease was seen as “man’s disease.” For example, the first conference for women on coronary heart disease by the Oregon Heart Association in 1964 had been about men, specifically husbands, and what wives could do to keep them healthy.
But the data didn’t lie. Starting in early the 1980s and peaking in 2000, the gap in CV deaths between men and women kept getting wider—as the new millennium started, about 500,000 women died each year, compared with about 440,000 men. Since then, numbers for both have fallen, and in 2013, the death total for women from CV causes fell below that of men, with both below 428,000. “We are delighted to be in second place, and we hope to stay there,” Wenger said.
It took a “paradigm shift,” Wenger said, and it started with the idea that medical research had to include women as research subjects to see if outcomes would be different in women. “This change in mindset—the advent of gender-specific medicine—has had a stunning outcome,” she said. Too often, Wenger said, the only studies specific to women were what she calls “bikini medicine,” those limited to the breast, ovaries, or the female genital area.
Conference Identifies Gaps
A breakthrough came in January 1992, when the National Heart, Lung, and Blood Institute (NHLBI) hosted a conference, “Cardiovascular Health and Disease in Women.” Wenger’s paper in the New England Journal of Medicine1 that summarized the findings was a tour de force of all that was wrong: coronary heart disease was the number 1 killer of women; women had fewer procedures than men, and when they received them, they fared worse; women had not quit smoking in rates on par with men; and most of all, women were missing from studies—women of child-bearing years were excluded, and older women had too many comorbidities.
As Wenger wrote, “Information from a number of sources has identified differences in the frequency of use of invasive cardiovascular procedures between women and men; women undergo fewer invasive procedures, raising the question whether the rate of use is inappropriately low among women or excessively high among men.”
Women’s different expression of symptoms and responses to pain meant signs of trouble were overlooked—thus the flawed assumption that women did not experience heart disease until they were elderly. This prevented optimal care, Wenger said.
2001 IOM Report
The next milestone Wenger covered was the 2001 Institute of Medicine (IOM) report, Exploring the Biological Contributions to Human Health: Does Sex Matter?2 This called for research questions specific to each sex and identified the barriers to gender-specific biomedical research. Wenger said this raised the issue of how gender-specific differences should be translated into clinical practice.
From there, trials began to focus whether therapies were good for women’s overall health. “Menopausal hormone therapies were supposed to be the cure-all for women—for everything from wrinkles to dementia,” Wenger said. Randomized controlled trials helped show that these therapies did not prevent incident or recurrent CVD, and helped refocus attention on established therapies.
The Agency for Healthcare Research and Quality issued a report on the diagnosis and treatment of coronary heart disease in women in 2003, since most existing recommendations were based on studies of middle-aged men. The effort identified fundamental knowledge gaps involving basic biology, clinical manifestations, and management strategies for women.
Go Red and Beyond
The year 2004 brought the red dress as the symbol of heart health—which started with a smaller effort within NHLBI. “This has become a worldwide symbol,” Wenger said, and the level of awareness of women’s vulnerability to heart disease has soared. On the research side, the National Institute of Health (NIH)’s Women’s Health Initiative, started in 1991, and the British Women’s Heart Health Study, have given researchers key insights into differences between men and women. For example, in women, “Aspirin prevents stroke, but not [myocardial infarction]—that is the opposite of men.”
Wenger noted that government has taken the lead in both funding many studies and requiring funding or reporting, including the 2015 mandate by the Government Accountability Office to include data on women and minorities for research in studies at NIH or submitted in drug trials at FDA.
“You need data to treat patients,” Wenger said. In this era of quality improvement, data are more important than ever, and the cardiology field revolves around data. She reviewed studies including women that have led to the removal of ineffective therapies, updates in clinical guidelines, and documentation that women are less likely to receive coronary interventions despite their high-risk status.
Wenger put out a challenge to any journal editors in the audience: don’t accept data that fails to segment out results for women. “We have to expand women’s cardiovascular health and research in the next decade,” she said.
1. Wenger NK, Speroff L, Packard B. Cardiovascular health and disease in women N Engl J Med. 1993; 329:247-256 DOI: 10.1056/NEJM199307223290406.
2. Institute of Medicine. Exploring the Biological Contributions to Human Health: Does Sex Matter? Washington, DC: National Academies Press, 2001.