Program Brief
Experts estimate that one in two women will die of heart disease or stroke, and statistics reveal significant differences between men and women in survival following a heart attack. Research shows that women may not be diagnosed or treated as aggressively as men, and their symptoms may be very different from those of men having a heart attack.
Findings from current research projects of the Agency for Healthcare Research and Quality (AHRQ) focusing on cardiovascular disease in women are summarized here.
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Introduction | AHRQ-Sponsored Research | More Information
Introduction
Cardiovascular disease (CVD) is the
number one killer of women in the
United States. Long thought of as
primarily affecting men, we now know
that CVD—including heart disease,
hypertension, and stroke—also affects a
substantial number of women. Experts
estimate that one in two women will
die of heart disease or stroke, compared
with one in 25 women who will die of
breast cancer.
Recent statistics show significant
differences between men and women in
survival following a heart attack. For
example, 42 percent of women who
have heart attacks die within 1 year
compared with 24 percent of men. The
reasons for these differences are not well
understood. We know that women
tend to get heart disease about 10 years
later in life than men, and they are
more likely to have coexisting chronic
conditions. Research also has shown
that women may not be diagnosed or
treated as aggressively as men, and their
symptoms may be very different from
those of men who are having a heart
attack.
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AHRQ-Sponsored Research
The Agency for Healthcare Research
and Quality (AHRQ) supports a
vigorous women's health research
program, including research focused on
CVD in women. AHRQ-supported
projects are addressing women's access
to quality health care services, accurate
diagnoses, appropriate referrals for
procedures, and optimal use of proven
therapies.
- Management of chest pain differs by
sex and race.
Researchers analyzed the care of 72,508
people with hypertension who were
treated at about 50 primary care
practices in the Southeastern United
States. More men than women received
definitive diagnoses of angina, while
more women than men were diagnosed
with vague chest pain. Also, women
and blacks received fewer cardiovascular
medications than men and whites.
Hendrix, Mayhan, Lackland, Egan, Am J Hypertens 2005;18(8):1026-32
(AHRQ grant HS10871).
- Women with atherosclerosis and high
cholesterol receive less intense
cholesterol management than men.
The researchers examined cholesterol
management of 243 primary care
patients from one academic medical
center. The patients had coronary heart
disease (CHD), cerebrovascular disease,
or peripheral vascular disease and high
LDL (bad) cholesterol. Cholesterol
management by either medication
adjustments or LDL monitoring
occurred at 31.2 percent of women's
visits and 38.5 percent of men's visits.
Persell, Maviglia, Bates, Ayanian, J
Gen Intern Med 2005;20:123-30 (AHRQ grant T32 HS00020).
- Existing heart disease is undiagnosed
in half of women who have a first
heart attack.
The researchers reviewed medical
records of 150 women in one
Minnesota county who suffered a heart
attack between 1996 and 2001. Over
the 10 years preceding their first heart
attack, the women made a total of
8,732 outpatient visits and had 457
hospitalizations, but only 52 percent of
the women had been diagnosed with
heart disease. About 80 percent of
women with high blood pressure were
treated with antihypertensive
medications, but only 28 percent of
women were prescribed drug therapy
for high cholesterol or lipid levels.
Yawn, Wollan, Jacobsen, et al., J
Women's Health 2004;13(10):1087-1100 (AHRQ grant HS10239).
- Younger women with heart failure
have worse quality of life than men
and older women.
Shortness of breath, fatigue, and
emotional problems caused by heart
failure lead to reduced quality of life,
which negatively affects younger
women with heart failure more than
elderly women or men of any age.
However, women younger than 65 in
this study had more improvement in
fatigue over time than older women
and more improvement in emotional
symptoms over time than men age 65
or older.
Hou, Chui, Eckert, et al., Am
J Crit Care 2004;13(2):153-61 (AHRQ grant HS09822).
- Treatment of high cholesterol in
women should be based on all risk
factors for heart disease.
For women who don't have
cardiovascular disease, use of
cholesterol-lowering drugs to treat high
cholesterol does not affect rates of death
due to CHD or total death rates. In
women with known cardiovascular
disease, lipid-lowering therapy can
reduce CHD-related death, heart
attack, and heart surgery, but it does
not affect total mortality.
Walsh, Pignone, JAMA 2004;291(18):2243-52 (AHRQ contract 290-97-0013).
- Women and men with cardiovascular
disease and high cholesterol may
receive different levels of treatment.
This study found that among people
with cardiovascular disease, men have
their cholesterol measured more often,
are treated more aggressively (e.g., with
statin drugs), and have lower levels of
so-called “bad” cholesterol or LDL-C
than women.
Kim, Hofer, Kerr, J Gen Intern Med 2003;18:854-63
(AHRQ grant HS11540).
- Diabetes increases a woman's risk of
death from coronary heart disease.
These researchers found that compared
with women who had neither diabetes
nor CHD, women with only CHD had
nearly double the risk of CHD-related
death, while women with only diabetes
had nearly four times the risk of CHD-related
death. Those who had both
CHD and diabetes were at greatest risk
for CHD-related death.
Natarajan, Liao, Cao, et al., Arch Intern Med 2003;163:1735-40
(AHRQ grant HS10871).
- Researchers find male-female
differences in receipt of recommended
cardiovascular care.
These researchers evaluated differences
between men and women in rates of
receipt of recommended cardiovascular
and diabetes care for enrollees in 10
commercial and 9 Medicare plans. In
commercial plans, an average of 73.6
percent of men and 63.8 percent of
women without a contraindication were
prescribed a beta-blocker after a heart
attack. Among the three plans with
significant male-female differences, all
favored men, ranging from an
advantage of 23.4 to 40 percentage
points.
Bird, Fremont, Wickstrom, et
al., Women's Health Issues 2003;13:150-7 (AHRQ contract 290-00-0012).
- Lack of studies on women limits
usefulness of research on coronary
heart disease.
Although CHD causes more than
250,000 deaths in women each year,
much of the research on CHD in the
last 20 years has either excluded women
or included very few women. As a
result, many of the tests and therapies
used to treat women for CHD are
based on studies conducted
predominantly in men, according to
two evidence reviews done by AHRQ's
Evidence-based Practice Center (EPC)
at the University of California, San
Francisco/Stanford.
The reviews
examined the usefulness of beta-blockers,
aspirin, and ACE inhibitors in
reducing risk among women with
known heart disease; the use of exercise
EKG and exercise thallium testing for
CHD in women; the efficacy of nitrates
to reduce risk for CHD events in
women with known heart disease; the
role of high cholesterol, diabetes, and
high homocystine levels as risk factors
for CHD in women; and other related
topics.
Copies of the two reports,
Results of a Systematic Review of Research
on Diagnosis and Treatment of Coronary
Heart Disease in Women, Evidence
Report/Technology Assessment No. 80
(AHRQ Publication No. 03-E035 full
report; 03-E034 summary)* and
Diagnosis and Treatment of Coronary
Heart Disease in Women: Systematic
Reviews of Evidence on Selected Topics,
Evidence Report/Technology
Assessment No. 81 (AHRQ Publication
No. 03-E037 full report; 03-E036
summary) are available from AHRQ
(contract 290-97-0013).*
- Women with symptomatic heart
failure benefit when treated with
ACE inhibitors and/or beta-blockers.
Researchers at AHRQ's Southern
California EPC examined evidence on
pharmacologic management of heart
failure and found that treatment with
ACE inhibitors was beneficial in
women, but it did not reduce mortality
in women with asymptomatic left
ventricular systolic dysfunction. They
also found that both women and men
with symptomatic heart failure have
reduced mortality when treated with
beta-blockers.
Copies of Evidence
Report/Technology Assessment No. 82,
Pharmacologic Management of Heart
Failure and Left Ventricular Systolic
Dysfunction: Effect in Female, Black,
and Diabetic Patients, and Cost-Effectiveness (AHRQ Publication No.
03-E044 summary; 03-E045 full
report) are available from AHRQ
(contract 290-97-0001).*
- Insurance status does not explain the
disparity in heart attack survival.
An analysis of data on 327,040 men
and women enrolled in a national
registry of patients revealed that women
were less likely to receive aspirin, beta-blockers,
intravenous heparin, or nitrate
therapies within the first 24 hours of
hospital admission for heart attack.
They also were less likely to undergo
coronary angiography, angioplasty, or
bypass surgery, but they were more
likely to die in the hospital.
Canto, Rogers, Chandra, et
al., Arch Intern Med 2002;162:587-93
(AHRQ grant HS08843).
- Women have a higher prevalence of
white-coat hypertension than men.
Researchers at the Johns Hopkins
Evidence-based Practice Center
examined evidence on the utility of
blood pressure (BP) monitoring outside
of the clinic setting. Although they
found some support for the use of
ambulatory BP monitoring, in general,
the evidence was insufficient to
compare clinic BP monitoring with BP
monitoring elsewhere. Evidence on BP
monitoring among population
subgroups was rarely stratified by race
or sex. The only notable subgroup
finding was a higher prevalence of
white-coat hypertension in women.
Copies of Evidence Report/Technology
Assessment No. 63, Utility of Blood
Pressure Monitoring Outside of the Clinic
Setting (AHRQ Publication No. 03-
E003 summary; 03-E004 full report)
are available from AHRQ (contract
290-97-0006).*
- Study finds an association between age
and heart attack outcomes.
In an editorial accompanying study
findings on male and female mortality
rates after heart attack, this researcher
notes that the interaction of age and sex
remains a significant predictor of heart
attack-related death, even after
adjustment for demographic factors,
clinical characteristics, and inpatient
cardiac care. The study reported an 11
percent 2-year mortality rate for
women before age 60 (versus 7 percent for
men) and a lower mortality rate for
women after age 79 (46 versus 51 percent
for men).
Ayanian, Ann Intern Med
2001;134(3):239-41 (AHRQ grant
HS09718).
- Women and minorities may have
atypical symptoms when suffering a
heart attack or angina.
ER doctors miss diagnosing about 2
percent of patients with heart attacks or
unstable angina because they do not
have symptoms typically associated
with a heart attack. When these
patients are mistakenly sent home from
the ER, they are twice as likely to die
from their heart problems as similar
patients who are admitted to the
hospital. Misdiagnosed patients tended
to be women under the age of 55 or
minorities who reported shortness of
breath as their chief symptom, instead
of chest pain, and/or to have apparently
normal electrocardiograms.
Pope, Aufderheide, Ruthazer,
et al., New Engl J Med 2000;342(16):1163-70
(AHRQ grant HS07360).
- Black women are not as likely as
others to receive life-saving therapies
for heart attacks.
Most of the 1 million U.S. patients
who suffer a heart attack each year are
candidates for reperfusion therapy,
either thrombolytic (clot-busting) drugs
or primary angioplasty. In a study of
nearly 27,000 Medicare beneficiaries
who met the strict criteria for
reperfusion therapy between February
1994 and July 1995, only 44 percent of
eligible black women received the
treatment, compared with 59 percent
of white men, 50 percent of black men,
and 56 percent of white women.
Canto, Allison, Kiefe, et al., New Engl J
Med 2000;342(15):1094-100
(AHRQ grants HS08843 and
HS09446).
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E-mail: ahrqpubs@ahrq.hhs.gov. Please use the AHRQ publication number when ordering.
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AHRQ Publication No. 06-P016
(Replaces AHRQ Publication No. 04-P003)
Current as of June 2006
Internet Citation:
Research on Cardiovascular Disease in Women. Program Brief. AHRQ Publication No. 06-P016, June 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/womheart.htm
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