Cardiovascular Disease and the Female Disadvantage

Abstract

Age-standardised rates of cardiovascular disease (CVD) are substantially higher in men than women. This explains why CVD has traditionally been seen as a "man's problem". However, CVD is the leading cause of death in women, worldwide, and is one of the most common causes of disability-adjusted life-years lost. In general, this is under-recognised and, in several ways, women are disadvantaged in terms of CVD. Both in primary and secondary prevention, there is evidence that women are undertreated, compared to men. Women often experience heart disease in a different way compared to men, and lack of recognition of this has been shown to have adverse consequences. Female patients of male cardiac physicians have been found to have worse outcomes than their male counterparts, with no such gender differential for female cardiologists. Clinical trials in CVD primarily recruit male patients, yet, it is well recognised that some drugs act differently in women and men. Diabetes and smoking, and perhaps other risk factors, confer a greater proportional excess cardiovascular risk to women than to men, whilst adverse pregnancies and factors concerned with the female reproductive cycle give women added vulnerability to CVD. However, women's health research is skewed towards mother and child health, an area where, arguably, the greatest public health gains have already been made, and breast cancer. Hence there is a need to redefine what is meant by "women's health" to encompass the whole lifecycle, with a stronger emphasis on CVD and other non-communicable diseases. Sex-specific analyses of research data should be the norm, whenever feasible.

Keywords: cardiovascular disease; sex differences; women.

Figure 1

Mortality rates for coronary heart disease in the USA in 2000, by sex; Global Burden of Disease study data.

Figure 2

Incidence rates for myocardial infarction amongst people with specific risk factors and overall, in the UK Biobank, by sex, adjusted for age and other CVD risk factors. The study population was 471,988 people without a history of CVD followed up for 7 years [3].

Figure 3

Types of female disadvantage in cardiovascular disease.

Figure 4

Probability of survival from cardiac treatment in Florida emergency departments, 1991–2010, showing results separately according to the sex of the physician attending and the sex of the patient. This figure was drawn using approximate results derived from the source paper [15].

Figure 5

Percentage of myocardial infarction (MI) patients experiencing a recurrent event and percentage of patients dying within one year after discharge from New South Wales hospitals, 2004–2014, by sex (n = 89,529).

Figure 6

Women-to-men ratios of relative risks (RRRs) for coronary heart disease: pooled results from meta-analyses of numerous individual studies. Total cholesterol, body mass index and blood pressure were all measured continuously (i.e., the relative risks (RRs) are per unit increase); smoking signifies current versus not current; low social status is compared to high social status; diabetes and atrial fibrillation compare yes to no.

Figure 7

Women-to-men RRRs for stroke: pooled results from meta-analyses. Conventions as in Figure 6.