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Cardiovascular Disease and Other Chronic Conditions in Women: Recent Findings

Program Brief

The Agency for Healthcare Research and Quality (AHRQ) supports a vigorous extramural and intramural research program that focuses principally on health care quality, patient safety, and the outcomes of health care services. Findings from AHRQ's current and completed research projects that pertain to cardiovascular disease and other chronic illnesses in women are summarized below.

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Contents

Introduction
AHRQ-Sponsored Research
Cardiovascular Disease
Chronic Illness
Mental/Behavioral Health
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.

In addition to cardiovascular disease, other chronic illnesses affecting women include diabetes, obesity, hypertension, osteoporosis, depression and other mental illness, and HIV/AIDS. AHRQ researchers are seeking ways to help women understand and manage their chronic conditions and achieve a better quality of life.

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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 and other chronic illnesses. 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.

This program brief summarizes findings from AHRQ-supported research on cardiovascular disease and chronic illness in women published from 2005-2008. An asterisk (*) at the end of a summary indicates that reprints of an intramural study or copies of other publications are available from AHRQ.

Go to the end of this program brief to find out how you can get more detailed information on AHRQ's research programs and funding opportunities.

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Cardiovascular Disease

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.

  • Process-of-care variables may explain some of the male-female differences in cardiovascular disease outcomes.
Description: Researchers analyzed seven cardiovascular disease quality of care indicators in a national sample of managed care plans and found inadequate lipid control in both men and women, with a lower rate of control in women. Also, women with diabetes were 19 percent less likely than men to have their LDL cholesterol controlled; women with a history of CVD were 28 percent less likely than men to have their LDL cholesterol controlled. More women than men had their blood pressure controlled, although the difference was small (2 percent).

Source: Chou, Scholle, Weisman, et al., Women's Health Issues 17:120-130, 2007 (AHRQ contract 290-040-018).
  • Commercial health plans show disparities between women and men in cardiovascular care.
Description: Researchers evaluated plan-level performance of seven quality of care measures for CVD and found that over half of the plans showed a disparity of 5 percent or more in favor of men for cholesterol control measures among people with diabetes, a recent CVD procedure, or heart attack. The greatest disparity (9.3 percent in favor of men) was among those with recent acute cardiac events; none of the plans showed disparities in favor of women. Disparities between women and men were even greater among Medicare managed care plans.

Source: Chou, Wong, Weisman, et al., Women's Health Issues 17:139-149, 2007 (AHRQ contract 290-040-018). Refer also to Bird, Fremont, Bierman, et al., Women's Health Issues 17:131-138, 2007 (AHRQ contract 290-00-0012).
  • Among heart disease patients, women are less likely than men to use low-dose aspirin therapy.
Description: Use of a low-dose aspirin regimen reduces the risk of heart attack, stroke, and other vascular events and reduces heart disease deaths. Although daily aspirin is recommended for all patients with cardiovascular disease unless contraindicated, women with heart disease are less likely than men with heart disease to use aspirin regularly, according to this study. Researchers examined data on 1,869 men and women aged 40 or older who reported heart disease prior to a heart attack. After adjusting for demographic, socioeconomic, and clinical characteristics, 62 percent of women reported regular aspirin use, compared with 76 percent of men.

Source: Opotowsky, McWilliams, and Cannon, J Gen Intern Med 22:55-61, 2007 (AHRQ grant T32 HS00020).
  • Women continue to fare worse than men in treatment for heart attack and congestive heart failure.
Description: According to this study of gender disparities among adults age 65 and older, women with acute myocardial infarction (AMI) or congestive heart failure (CHF) do not receive the same care as men. Also, women or men who have other medical conditions associated with AMI or CHF—such as diabetes, hypertension, or end-stage renal disease—do not receive better quality of cardiovascular care than those who have only the heart conditions.

Source: Correa-de-Araujo, Stevens, Moy, et al., Women's Health Issues 16(2):44-55, 2006 (AHRQ Publication No. 06-R042)* (Intramural).
  • Immunosuppression related to transfusion may explain women's increased risk of dying after CABG surgery.
Description: A study of more than 9,000 Michigan Medicare patients found that women undergoing coronary artery bypass graft (CABG) surgery were 3.4 times as likely as men to have received blood transfusions and generally received more units of blood, after accounting for age, coexisting conditions, and other factors. Patients who received a transfusion were more than three times as likely to develop an infection as those who did not, and they were 5.6 times as likely to die within 100 days after surgery. The presence of foreign leukocytes in donor blood may suppress the immune system of the recipient and thus increase the risk of postoperative infection, note the researchers.

Source: Rogers, Blumberg, Saint, et al., Am Heart J 152:1028-1034, 2006 (AHRQ grant HS11540).
  • Women with atherosclerosis and high cholesterol receive less intense cholesterol management than men.
Description: The researchers examined cholesterol management of 243 primary care patients from one academic medical center. The patients had coronary heart disease, cerebrovascular disease, or peripheral vascular disease and high (over 130 mg/dl) low-density (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. Women were 23 percent less likely than men to have their cholesterol managed.

Source: Persell, Maviglia, Bates, and Ayanian, J Gen Intern Med 20:123-130, 2005 (AHRQ grant T32 HS00020).
  • Management of chest pain differs by sex and race.
Description: 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.

Source: Hendrix, Mayhan, Lackland, and Egan, Am J Hypertens 18(8):1026-1032, 2005 (AHRQ grant HS10871).

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Chronic Illness

Chronic illnesses, such as diabetes, obesity, stroke, hypertension, osteoporosis, depression, and HIV/AIDS, usually are long-lasting and affect all aspects of a woman's life.

  • Report describes quality of care and outcomes for women with diabetes.
Description: This report, prepared by AHRQ and the Centers for Disease Control and Prevention, presents measures for quality of care and outcomes for women with diabetes. It highlights where the American health care system excels with regard to diabetes care and where the greatest opportunities for improvement lie. For example, women with diabetes were less likely than women without diabetes to have their blood pressure controlled or to have had a dental visit in the preceding 12 months. Among younger women (64 or younger), women with diabetes were significantly more likely than women without diabetes to have only public health insurance. On the other hand, women with diabetes were much more likely than women without diabetes to have received an annual flu vaccination and to have ever received a vaccination for pneumonia.

Source: Women with Diabetes: Quality of Health Care, 2004-2005 (AHRQ Publication No. 08-0099)* (Intramural).
  • Analysis reveals that many women and men with diabetes are not receiving recommended care.
Description: According to this analysis of 10 quality of care measures—as defined by the National Health Care Quality and Disparities Reports—only 29 percent of women and 34 percent of men with diabetes receive the five care processes recommended for people with diabetes: regular blood sugar measurement, regular eye exams, regular foot exams, flu vaccination each year, and lipid profile every 2 years. Avoidable hospitalizations for diabetes complications decrease as income and education increase among women across all racial and ethnic groups.

Source: Correa-de-Araujo, McDermott, and Moy, Women's Health Issues 16(2):56-65,2006 (AHRQ Publication No. 06-R043)* (Intramural).
  • Having a chronic disease may be a barrier to receipt of recommended preventive care among women.
Description: Researchers used data from three nationally representative surveys to examine the quality of care received by women with diabetes and the impact of socioeconomic factors on receipt of clinical preventive services and screening for diabetes-related conditions. They found that use of diabetes-specific preventive care among women is low, and that women aged 45 and younger and those with low educational levels were the least likely to receive recommended services. Also, women with diabetes were less likely than other women to receive a Pap smear, and those who were poor and minority were less likely than more affluent and white women to receive the pneumonia vaccine.

Source: Owens, Beckles, Ho, et al., J Women's Health 17(9):1415-1423, 2008 (AHRQ Publication No. 09-R018)* (Intramural).
  • Osteoporosis and low bone density affect many postmenopausal women.
Description: Although osteoporosis affects both women and men, it occurs most often in postmenopausal women. It increases bone fragility and susceptibility to fracture; each year in the United States, about 1.5 million people experience a fracture related to osteoporosis. These three documents present information about osteoporosis and low bone density. Comparative Effectiveness of Treatments to Prevent Fractures in Men and Women with Low Bone Density or Osteoporosis presents a review of the evidence comparing the efficacy and safety of agents used to treat low bone density (AHRQ Publication No. 08-EHC008-1). Fracture Prevention Treatments for Postmenopausal Women with Osteoporosis: Clinician's Guide presents information for doctors and other providers on the effectiveness and safety of various treatments for preventing fractures in postmenopausal women (AHRQ Publication No. 08-EHC008-3). Osteoporosis Treatments that Help Prevent Broken Bones: A Guide for Women After Menopause describes the effectiveness, side effects, and costs of the various treatments for low bone density (AHRQ Publication 08-EHC008-2A).*

Source: These publications are also available on the AHRQ Web site at http://effectivehealthcare.ahrq.gov/.
  • Women with HIV receive poorer quality of care than men with HIV.
Description: Critical health care services for women infected with HIV continue to lag behind services for men with HIV, according to this study. Researchers examined data on care provided to more than 9,000 patients at HIV clinics and found that women were less likely than men to receive highly active antiretroviral therapy (78 vs. 82 percent, respectively) or prophylaxis for pneumonia (65 vs. 75 percent, respectively). They also were less likely than men to have been assessed for their hepatitis C virus status (87 vs. 88 percent, respectively).

Source: Hirschhorn, McInnes, Landon, et al., Women's Health Issues 16:104-112, 2006 (AHRQ grants HS10227, HS10408).
  • Management of gout differs for women and men.
Description: About 5 million Americans suffer from gout, a painful inflammation of the joints. According to this study, factors leading to gout, as well as its management, are different in women and men. Researchers examined data on 1.4 million members of seven managed care plans from 1999 to 2003 and identified 6,133 adult members with gout. Women with gout were older than men (mean age of 70 vs. 58), had a greater number of coexisting medical conditions, and received diuretics more often (77 vs. 40 percent), respectively.

Source: Harrold, Yood, Mikuls, et al., Ann Rheum Dis 65:1368-1372, 2006 (AHRQ grants HS10391, HS10389).
  • Study details association between maternal asthma and smoking and bronchiolitis in infants.
Description: Researchers studied hospitalizations for bronchiolitis among infants of 100,000 women enrolled in the Tennessee Medicaid program during 1995-2003. They found that infants of mothers who smoked and had asthma were twice as likely to end up in the emergency department (ED) with bronchiolitis as infants whose mothers had neither problem. Infants whose mothers had only one of the problems had a lower but still significantly elevated risk for ED visits and hospitalizations compared with infants whose mothers had neither problem. Although maternal asthma was the most important of these two risk factors, infants were 50 percent more likely to be hospitalized for bronchiolitis if their mothers had asthma and also smoked.

Source: Carroll, Gebretsadik, and Griffin, Pediatrics 119(6):1104-1112, 2007 (AHRQ grant HS10384).
  • Pregnant minority women with asthma are at increased risk for poor outcomes.
Description: Among pregnant women with asthma, this study found that minority women have significantly higher rates of preterm labor, gestational diabetes, and infection of the amniotic cavity than white women. Black women were the youngest (age 24) and had the highest incidence of preterm labor (5.5 percent) and pregnancy-induced hypertension (5 percent). Asian women had the highest occurrence of gestational diabetes (7.2 percent) and were more than three times as likely as white women to have infection of the amniotic cavity (5.7 vs. 1.8 percent, respectively). Black and Hispanic women also had more infections of the amniotic cavity (3.1 and 2.7 percent, respectively) than white women. Findings are based on examination of 11 adverse outcomes across four ethnic groups of 13,900 pregnant women with asthma who gave birth in 1998 and 1999.

Source: MacMullen, Tymkow, and Shen, Am J Matern Child Nurs 31(4):263-268, 2006 (AHRQ grant HS13506).
  • Many osteoporosis medications prevent fractures, but none has been shown to be best.
Description: According to this report, not enough scientific evidence exists to establish whether bisphosphonates (the most commonly used osteoporosis drugs) are better at preventing fractures than estrogen, calcitonin, or raloxifene. The report also indicates that many osteoporosis patients stop taking their medications as prescribed. Some stop because they do not have osteoporosis symptoms; others stop because of medication side effects or because dosing is too frequent. Not taking medications as prescribed increases the risk of bone fractures.

Source: Comparative Effectiveness of Treatments to Prevent Fractures in Men and Women with Low Bone Density or Osteoporosis, Comparative Effectiveness Review No. 12, 2007; online at http://effectivehealthcare.ahrq.gov (AHRQ contract 290-02-0003).
  • Estrogen therapy with progestin is often discontinued in women who have diabetes or cardiovascular disease.
Description: For this study, researchers examined data from five HMOs on hormone use among nearly 170,000 women aged 40 to 80. They found a greater decline in use of estrogen plus progestin therapy (HRT) by women with diabetes or cardiovascular disease than other women following release of findings in 2002 from the Women's Health Initiative study. According to the WHI study findings, combination estrogen-progestin therapy increased women's risk for breast cancer, stroke, and pulmonary embolism. Discontinuation rates increased nearly seven-fold among women with diabetes and nearly six-fold among women with cardiovascular disease.

Source: Newton, Buist, Miglioretti, et al., J Gen Intern Med 20:350-356, 2005 (AHRQ grant HS11843).

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Mental/Behavioral Health

  • Dysthymia may be a barrier to use of recommended HIV medications by women.
Description: Dysthymia—a chronic, low-level daily depression that lasts at least 2 years—is prevalent among women and minorities with HIV and may be a barrier to their use of highly active antiretroviral therapy (HAART). The feelings of hopelessness, indecision, and mental inflexibility that commonly occur in people with dysthymia could reduce the likelihood that they would be offered or accept HAART, according to this study. Researchers analyzed 1997 data on 1,982 adults with HIV; white men were the most likely to receive HAART (69 percent), while Hispanic women (53 percent) and black women (55 percent) were the least likely to receive this life-saving therapy.

Source: Turner and Fleishman, J Gen Int Med 21:1235-1241, 2006 (AHRQ Publication No. 07-R021)* (Intramural).
  • Nearly half of homeless women are in need of mental health services.
Description: Researchers conducted face-to-face interviews with 821 homeless women in the Los Angeles area, and found that nearly half of the women had a mental distress score indicating the need for further evaluation and possible clinical intervention. Sixty-seven percent of the women were black, 17 percent were Hispanic, and 16 percent were white. Black women reported the lowest overall mental distress scores; nearly twice as many white women as Hispanic or black women reported childhood or recent physical or sexual assault.

Source: Austin, Andersen, and Gelberg, Women's Health Issues 18:26-34, 2008 (AHRQ grant HS08323).
  • Screening new mothers for postpartum depression is particularly important in women of color.
Description: According to this survey of 655 women who were 2 to 6 weeks postpartum, nearly one-half of Hispanic (47 percent) and black (45 percent) mothers reported depressive symptoms, compared with less than one-third (31 percent) of white mothers. Factors associated with postpartum depression—the burden of physical symptoms, lack of social support, and lack of self-confidence in infant care—were the same for all women regardless of race.

Source: Howell, Mora, Horowitz, and Leventhal, Obstet Gynecol 105(6):1442-1450, 2005 (AHRQ grant HS09698).
  • Difficulty sleeping and other problems common during pregnancy may mask symptoms of perinatal depression.
Description: According to this evidence report, depression is as common in women while they are pregnant as it is after childbirth. However, health care providers and patients may not recognize depression during pregnancy because signs of depression like tiredness, inability to sleep, emotional changes, and weight gain may also occur with pregnancy. Factors contributing to depression during or after pregnancy include personal or family history of depression or substance abuse, anxiety about the unborn child, problems with a previous pregnancy or birth, and marital or financial problems. The report also discusses screening for depression, the effectiveness of psychotherapy and antidepressants, and the value of providing psychosocial support to pregnant and postpartum women with depression.

Source: Perinatal Depression: Prevalence, Screening, Accuracy, and Screening Outcomes. Evidence Report No. 119 (AHRQ Publication Nos. 05-E006-1, summary; 05-E006-2, report) (AHRQ contract 290-02-0016).*
  • Study reveals differences between male and female providers in behavioral counseling.
Description: According to this study, female providers are more likely than male providers to counsel depressed patients about anxiety and less likely to provide counseling on alcohol or drug use. Also, female patients are less likely than male patients to be counseled by providers of either sex. Male patients of male providers reported the most counseling, and female patients of female providers reported the least counseling about alcohol or drug use. Rates of depression diagnosis and care were comparable regardless of the provider's sex or whether the provider and patient were of the same sex.

Source: Chan, Bird, Weiss, et al., Women's Health Issues 16:122-132, 2006 (AHRQ grant HS08349).
  • Longitudinal study identifies patterns of tobacco use among young women.
Description: Researchers conducted a study of 443 Midwestern women who smoke, beginning in 1980, with followup in 1987, 1993, and 1999. They identified three subgroups among the women who smoked daily: the first group (48 percent) worked full time, were heavy smokers, and were generally happy. The second group (19 percent) started smoking casually in college and exercised regularly. The third group (33 percent) were mothers who smoked because they were addicted and received a psychological boost from smoking. Identifying these groups may help in tailoring smoking cessation interventions and messages appropriate for reaching them.

Source: Rose, Chassin, Presson, et al., Addiction 102(8):1310-1319, 2007 (AHRQ grant HS14178).

* Items marked with an asterisk are available free from the AHRQ Clearinghouse. To order, contact the clearinghouse at 800-358-9295 or request electronically by sending an E-mail to ahrqpubs@ahrq.hhs.gov. Please use the AHRQ publication number when ordering.

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More Information

For more information on AHRQ initiatives related to women's health, please contact:

Shakeh J. Kaftarian, Ph.D.
Senior Advisor, Women's Health and Gender Research
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
Telephone: 301-427-1550
E-mail: Jackie.Kaftarian@ahrq.hhs.gov

Select for more information about AHRQ's research portfolio and funding opportunities.

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AHRQ Publication No. 09-PB005
(Replaces AHRQ Publication No. 06-P016)
Current as of May 2009

Internet Citation:

Cardiovascular Disease and Other Chronic Conditions in Women: Recent Findings. Program Brief. AHRQ Publication No. 09-PB005, March 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/womheart.htm

 

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