A comprehensive view of sex-specific issues related to cardiovascular disease

Abstract

Cardiovascular disease (CVD) is the leading cause of mortality in women. In fact, CVD is responsible for a third of all deaths of women worldwide and half of all deaths of women over 50 years of age in developing countries. The prevalence of CVD risk factor precursors is increasing in children. Retrospective analyses suggest that there are some clinically relevant differences between women and men in terms of prevalence, presentation, management and outcomes of the disease, but little is known about why CVD affects women and men differently. For instance, women with diabetes have a significantly higher CVD mortality rate than men with diabetes. Similarly, women with atrial fibrillation are at greater risk of stroke than men with atrial fibrillation. Historically, women have been underrepresented in clinical trials. The lack of good trial evidence concerning sex-specific outcomes has led to assumptions about CVD treatment in women, which in turn may have resulted in inadequate diagnoses and suboptimal management, greatly affecting outcomes. This knowledge gap may also explain why cardiovascular health in women is not improving as fast as that of men. Over the last decades, mortality rates in men have steadily declined, while those in women remained stable. It is also becoming increasingly evident that gender differences in cultural, behavioural, psychosocial and socioeconomic status are responsible, to various degrees, for the observed differences between women and men. However, the interaction between sex-and gender-related factors and CVD outcomes in women remains largely unknown.

Fig. 1: Changes in rates of death from cardiovascular disease among men and women aged 35–74 years between 1990 and 2000 in selected countries. Reproduced with permission from the World Health Organization.

Fig. 2: Trends in age-standardized (world population) cardiovascular disease mortality among men and women in the European Union, Eastern Europe (Bulgaria, Czech Republic, Hungary, Poland, Romania and Slovakia), the United States and Japan from 1965 to 1972. Reproduced with permission from BMJ Publishing Group (Heart 2002;88:119-24).

Fig. 3: American National Hospital Discharge Survey data on annual hospital admissions because of heart failure among adults 35 years and older, 1990–2000. Reproduced with permission from Elsevier (Am Heart J 2004;147:74-8).

Fig. 4: Trends in body mass of Canadian boys and girls. Source: Adapted from Tremblay and Willms.

Fig. 5: Trends in systolic and diastolic blood pressure among children and adolescents in the United States. Source: Adapted from Muntner et al.

Fig. 6: Trends in current-smoker prevalence among Canadian adolescents, 15–19 years of age. Source: Adapted from Gilmore.

Fig. 7: Trends in mean daily caloric intake among children and adolescents. Source: Adapted from Troiano et al.

Fig. 8: Trends in leisure-time physical activity among Canadian adolescents. Proportion active are those with an average daily energy expenditure of at least 3.0 kcal/kg. Source: Adapted from Statistics Canada.

Fig. 9: Prevalence of current smoking by age and sex, 2003. Source: Adapted from Canadian Tobacco Use Monitoring Survey.

Fig. 10: In-hospital and late mortality rates among women versus men after primary percutaneous coronary intervention for acute myocardial infarction. Note: ACC–NCDR = American College of Cardiology National Cardiovascular Data Registry; CARS = Coumadin Aspirin Reinfarction Study; CADILLAC = Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications; OR = odds ratio; CI = confidence interval. Reproduced with permission from the American Heart Association (Circulation 2005;111:940-53).