women's access to healthcare - dr. pascha shafer presentation

Cardiovascular Disease in WomenPascha E. Schafer, MD, FACCSenate Women’s Health Study CommitteeOctober 6, 2015

Disclosures• None

Types of Cardiovascular Disease• Coronary (heart) disease

• Heart attack (myocardial infarction, MI)• Angina (chest pain from the heart)• (Congestive) heart failure

• Cerebrovascular (brain) disease• Stroke• TIA (transient ischemic attack, “mini-stroke”)

• Peripheral (body, legs, and arms) artery disease• Claudication (leg/arm pain with walking/activity)• Aortic aneurysm (enlarged aorta, AAA)

Diversity versus Disparity• Diversity

• Race• Geographic origin• Ethnic origin• Age • Language• Culture• Literacy• Disability• Frailty• Socioeconomic status• Occupational status• Religious affiliation

Diversity versus Disparity• Diversity

• Race• Geographic origin• Ethnic origin• Age • Language• Culture• Literacy• Disability• Frailty• Socioeconomic status• Occupational status• Religious affiliation

•Gender

Diversity versus Disparity

• Disparity• Difference in treatment provided to diverse groups that is not

justified by health condition differences or treatment preferences (Institute of Medicine)

• Disparities exist even when controlling for insurance status, socioeconomic status, and comorbidities

• Culturally sensitive care adapts healthcare delivery to meet the needs of a diverse patient population

• Equitable care is not achieved by treating everyone the same

Mosca L et al. Circulation 1997;96:2468-2482

Copyright © American Heart Association

Where did we start?• In 1997, only 7% of women identified cardiovascular disease

as their biggest health risk• Women counseled less often about exercise, nutrition, and

weight reduction• Only 10% of women at goal for LDL cholesterol• Less likely to enroll in cardiac rehabilitation after acute

myocardial infarction

Physician awareness of CVD prevention guidelines by specialty.



Physician incorporation of CVD prevention guidelines by specialty among respondents who stated they were aware of the guideline.



Increasing Awareness

• American Heart Association published guidelines for prevention of cardiovascular disease in women in 1999• Updated in 2004

• Emphasized evidence-based guidelines• Challenged the conventional wisdom that women should be treated

the same as men• Focused on differences in risk and benefit of preventive strategies• Acknowledged unique opportunities to identify women at risk

• Pregnancy• Addressed concerns that women often have more comorbidities and

are older at onset of CHD• Revised again in 2007 and 2011

Increasing Awareness

• Research• CVD research studies

• Women’s Health Initiative • Gender specific analyses

• Public Health Investment

Overall trends in awareness that coronary heart disease is the leading cause of death in women.

Mosca L et al. Circ Cardiovasc Qual Outcomes 2010;3:120-127


Cardiovascular disease mortality trends for males and females (United States: 1979–2007).

Roger V L et al. Circulation 2011;123:e18-e209


Prevalence of cardiovascular disease in adults ≥20 years of age by age and sex (National Health and Nutrition Examination Survey: 2005–2008).



Prevalence of coronary heart disease by age and sex (National Health and Nutrition Examination Survey: 2005–2008).



Prevalence of stroke by age and sex (National Health and Nutrition Examination Survey: 2005–2008).



Barriers for Women• Perception of risk

• 90% of women have one or more risk factor• Differences in symptoms• Role as caretakers

Barriers for Women

• Only 53% of women said they would call 9-1-1 if experiencing the symptoms of a heart attack

• However, 79% said they would call 9-1-1 if someone else was having a heart attack

• For themselves, 46% of women would do something other than call 9-1-1—such as take an aspirin, go to the hospital, or call the doctor

22

Source: Mosca et al. 2010.

Symptoms: Heart Attack• Chest pain

• Most common symptom in women and men• Classically “pressure” or “heaviness”• Women are more likely to have

• Sharp pain• Burning pain• Pain in the neck, jaw, throat, shoulder, upper stomach, or back• Pain in left, right, or both arms

Unique Risk Factors• Pregnancy

• Pre-eclampsia• Hormone replacement therapy• Oral contraceptives• Autoimmune disease• Depression

Pre-eclampsia• May be considered a “failed stress test”

• Unmasks endothelial dysfunction• Women benefit from a postpartum referral to cardiologist or

PCP• Monitoring and control of risk factors

• Providers should take pregnancy history when they encounter women later in life

CV Disease in Georgia• Cardiovascular disease is the leading cause of death• 1/3 Georgians are obese

• 2/3 obese or overweight• Rates continuing to increase

1999

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2010

27Source: CDC

CV Disease in Georgia• Cardiovascular disease is the leading cause of death• 1/3 Georgians are obese

• 2/3 obese or overweight• Rates continuing to increase

• >11% of women diagnosed with diabetes• Many more undiagnosed

• ~15% of women use tobacco products

2011 10Q Report

• Advancing Women’s Heart Health through Improved Research, Diagnosis, and Treatment. • Sponsored by WomenHeart: The National Coalition for Women

and Heart Disease• A consensus by leading experts on the top ten questions in

cardiovascular care for women

2011 10Q Report1. What factors influence or explain disparities in cardiovascular disease

epidemiology and disease outcomes in women?

2. What are the best strategies to assess, modify, and prevent a woman’s risk of heart disease?

3. What are the most accurate and effective approaches to assess and recongnize chest pain and other symptoms suggesting coronary heart disease in women?

4. What role does a woman’s reproductive history and menopausal hormone therapy play in the development of heart disease?

5. What are the risk factors for cardiovascular disease associated with preganancy and how are they best treated?

2011 10Q Report6. What is the best method for studying sex differences in vascular injury

so that cardiovascular therapies may be improved?

7. What are the most effective treatments for diastolic heart failure (heart faikure with preserved ejection fraction) in women?

8. Why are young women more likely than men to die after a heart attack or surgical revascuilarization procedure?

9. How do psychosocial factors affect cardiovascular disease in women?

10. What biological variables are most influential in the development and clinical outcomes of heart disease and what can be done to reduce mortality rates in women?

Conclusions• Cardiovascular disease in women is common and associated with

significant morbidity and mortality• Patients and providers have a growing awareness of CVD risk

factors and treatment goals that are unique to women• Education on lifestyle and other interventions for primary and

secondary prevention are effective• The disparity in healthcare for CVD in women is still present• There are many questions that lack answers regarding

cardiovascular health and prevention in women

• We can promote equitable care through investment in education, prevention, and research to support evidence based practice

Thank You

References• Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, Newby LK, Piña IL, Roger VL, Shaw LJ, Zhao

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