The slowly evolving truth about heart disease and women
By Laura Williamson, American Heart Association News
A century ago, so little was known about heart disease that people who had it resigned themselves to years of bed rest or, worse, an early death. Even less was known about how heart disease affected women – because nobody thought it did.
Heart disease was considered a man's disease. If women had a role to play, it was in taking care of the men in their lives. 甚至美国心脏协会也在20世纪60年代举办了一次会议，主题是“我如何帮助我的丈夫应对心脏病”?" and published a nutrition pamphlet titled "The Way to a Man's Heart."
That attitude persisted throughout the 20th century, a time when questions about a woman's health were centered on the parts of her body under her bikini, said Dr. Gina Lundberg, clinical director of the Emory Woman's Heart Center and a professor at Emory University School of Medicine in Atlanta.
"It was, 'Get a pap smear and a mammogram and you're good,'" she said. "We left out all the things we were checking men for, like diabetes and cardiovascular disease. But between a woman's breasts and her reproductive organs is her heart."
人们认为，女性在更年期激素水平下降之前，对心脏病有一定的天然保护作用, Lundberg said. After menopause, it was believed that hormone replacement therapy could prolong that protection, a premise since amended to apply only to women who take it during the early stages of this transition.
It wasn't until the turn of the century neared that evidence began to slowly emerge that women, as well as men, faced a substantial risk from heart disease, beginning at a much earlier stage in life and with sometimes differing symptoms than men.
Left out of the research
It wasn't until the mid-1980s when anyone began looking at how heart disease might affect women.
That's when the Framingham Heart Study, the first in-depth, long-term cardiovascular investigation in the U.S., began reporting sex-specific patterns of heart disease, questioning whether the magnitude of this condition in women was being overlooked. The researchers noted that heart attacks were less likely to be recognized in women than in men.
他们还指出，之前的调查未能充分评估心脏病的性别差异，因为参与研究的女性人数不足. Since heart disease was thought to predominantly affect men, only men were being studied.
This started to change in the 1990s, after Atlanta cardiologist Dr. 纳内特·温格(Nanette Wenger)和其他人领导了一项运动，旨在推动女性平等参与美国国立卫生研究院(National Institutes of health)资助的研究. Doing so became NIH policy in 1989 and was written into law in 1993. But Wenger later said the legislation amounted to little more than a directive, falling short of achieving parity. "It had no teeth," she recently told The Fuller Project.
Meanwhile, 女性心脏病的预防和治疗是基于主要针对中年男性的研究, said Dr. Jennifer Mieres, 他是亨普斯特德霍夫斯特拉/诺斯韦尔祖克医学院的心脏病学教授和教务副院长, New York.
"We thought that you could treat men and women the same," said Mieres, who was the first woman to be a full-time faculty cardiologist at Northwell Health's North Shore University Hospital. "We had great advances in treatment strategies, but we were applying a one-size-fits-all approach and clearly that wasn't working."
A landmark 2001 report from the Institute of Medicine, a nonprofit policy research organization now known as the National Academy of Medicine, highlighted the underrepresentation of women in clinical trials and sex biases in medicine, calling for a better understanding of differences in how men and women were affected by disease.
Mieres说，女性经常无法达到临床试验的标准，因为她们的体征和症状与构成心血管风险的假设不符. "Our research criteria were customized to men as the gold standard."
This realization led to a push for sex-specific clinical trials, allowing researchers to focus exclusively on how cardiovascular disease develops in women, she said. 这导致人们发现，由心脏动脉狭窄引起的心脏病更为复杂，在女性身上的表现也与男性不同.
Beyond the bikini: A new picture of women's health
One of the biggest questions driving the push for more research was why, despite developing heart disease about 10 years later than men, more women were dying from it. And why were women under 65 twice as likely to die from a heart attack as their male peers?
As researchers began to dig, a new picture of women's health emerged.
One problem was health care professionals were doing less to protect women from heart disease, according to a 1999 report from the AHA and American College of Cardiology, the first women-specific clinical recommendations for the prevention of heart disease.
For example, women were less likely to be counseled by health care professionals to reduce their cardiovascular risk factors, such as by losing weight, eating a healthier diet or becoming more physically active. 她们在心脏病发作或心脏搭桥手术后接受心脏康复治疗的可能性也低于男性.
Mieres说，很明显，女性需要更好的信息，这样她们才能控制自己的健康决定. So, the AHA established Go Red for Women, 一项全国性的运动，旨在提高人们对心脏病和中风作为妇女主要杀手的认识，并推进关于心脏病性别差异的科学研究. It also joined forces with the National Heart, Lung, and Blood Institute, which was developing its own campaign, The Heart Truth. The two campaigns were launched back-to-back in 2003 and 2004.
The Heart Truth went first, unveiling the Red Dress as the national symbol for women and heart disease. That same year, the cover of Time magazine told women they were wrong to think breast cancer was their biggest worry and proclaimed, "ONE OUT OF THREE women will die of heart disease."
A year later, the AHA launched Go Red for Women, along with women-specific, evidence-based heart disease prevention guidelines. The report emphasized that despite significant gains in the treatment of heart disease, it remained the leading killer of women in the U.S.
Mieres, a member of AHA's national board of directors during Go Red's formative years, 她说，开展媒体宣传活动的想法在很大程度上受到了美国心脏病协会发起的一项调查的影响，该调查显示，女性更倾向于从媒体而不是医生那里获取健康信息.
"To me, that was an 'aha' moment," she said. “那时我们意识到，向女性传达准确的科学知识并鼓励女性成为心脏健康知识的方法是通过这些伙伴关系，这些伙伴关系可以提供真正开始心脏沙巴足球体育平台之旅所需的工具和信息。. We used the power of storytelling. We produced public service announcements and documentaries. We wanted women to know that heart disease could be prevented by making lifestyle changes."
And for a while, it worked. The number of women recognizing heart disease as a major health risk nearly doubled, from 7% in 1997 to 13% in 2003. By 2009, 65% of women understood heart disease was their leading cause of death. Mortality from cardiovascular disease began to decline in women, though at a slower rate than it did in men.
But those gains did not last. By 2019, only 44% of women recognized heart disease as their No. 1 killer, and a majority failed to recognize the signs and symptoms of a heart attack. Young women and Hispanic and Black women experienced the greatest drop in awareness.
Among health care professionals, Lundberg said awareness of how big a risk heart disease is for women remains poor, even a decade after a survey found 当初级保健医生被问及他们对病人各种健康问题的关注程度时，体重问题和乳房健康排在心脏健康之前.
And a staggering 70% of physician trainees report they aren't getting enough, if any, education in gender-based medical concepts during postgraduate medical training. In a nationwide survey, 只有22%的初级保健医生和42%的心脏病专家表示，他们对评估女性心血管风险做好了充分的准备.
"We are lagging in implementing risk prevention guidelines for women," Lundberg said. "A lot of women are being told to just watch their cholesterol levels and see their doctor in a year. That's a year of delayed care."
It may be costing women their lives.
Heart attack hospitalization rates among women under 55 have increased, as rates among men of the same age have dropped, one study found. And recent studies show women are more likely to die after having heart attack.
Research shows women continue to be undertreated for cardiovascular problems compared to men. They are less likely to be treated for high cholesterol with statins, which have been shown to lower the risk for heart attacks and strokes. 与男性相比，她们也不太可能被处方血液稀释药物来预防或治疗房颤的血栓, or AFib.
"Statins have helped us make huge improvements in cardiovascular health, but women still aren't getting all the benefit," Lundberg said.
Although they are more likely to have heart failure, women also are substantially less likely than men to receive lifesaving treatments for it, including heart transplants. They are less likely to receive guideline-directed treatment after a heart attack or unstable angina, or to receive treatment in a timely fashion. They are less likely to undergo procedures to restore blood flow to the heart, such as bypass surgery or inserting stents to open blocked arteries.
Unique risks to women's heart health
While gains in awareness may have backslid, progress toward understanding the unique cardiovascular risks women face has surged in recent decades.
Over the past 20 years, there have been significant strides in showing how menopause contributes to heart health. For example, menopause symptoms such as hot flashes and night sweats have been linked to an increased risk for high blood pressure, a major risk factor for cardiovascular disease.
过去十年最大的发现之一是妊娠并发症与心脏病和中风风险之间的联系, Lundberg said.
"Now we know that if a woman has gestational diabetes, hypertension, preeclampsia or eclampsia, they are at increased risk for cardiovascular disease later in life," she said.
Research has also shown that having high blood pressure before becoming pregnant might double a woman's risk of developing cardiovascular disease within a decade of giving birth.
其他已被发现的与性别有关的风险因素包括40岁前开始更年期，患有子宫内膜异位症或多囊卵巢综合征, a hormonal disorder that affects the ovaries. Women also are more likely to have autoimmune disorders, such as rheumatoid arthritis or lupus, that cause plaque to build up faster in their arteries and lead to worse outcomes following a heart attack or stroke.
As for better understanding differences in the ways heart disease develops in men and women, 现在我们知道，动脉粥样硬化——导致心脏病发作和中风的动脉斑块积聚——在斑块的大小上是不同的, where it is found and how vulnerable it may be to rupture. Women are more likely than men to have a heart attack caused by plaque erosion, spontaneous coronary artery dissection and problems other than an obstruction, while men are more likely to have heart attacks caused by rupturing plaque in their arteries.
What we still don't know
Many knowledge gaps remain, Lundberg said, especially in the ways heart disease disproportionately affects women from different racial and ethnic groups. Compared to other women in the U.S., Black women have the highest rates of high blood pressure, stroke, heart failure and coronary artery disease. They also have been less likely to be included in clinical studies.
A growing body of evidence suggests structural racism and other social determinants of health play a role, 例如，获得卫生保健服务和健康食品的机会较少，或者语言障碍和文化适应带来的挑战. Many of these conditions likely add to their stress, Lundberg said, which in turn can contribute to higher cardiovascular risks.
"We know that stressful things in these women's lives cause heart disease, but we don't know exactly how or how to prevent it," she said.
Too few women in cardiology
对于患有心脏病的女性来说，最大的问题之一可能是找到一位能够理解她们正在经历的医生, said Lundberg, who also chairs the Women in Cardiology section of the American College of Cardiology.
"There are not enough women and especially not enough women of color who are entering the field of cardiology," she said. "If you're a male taking care of a female, you may have a bias that women are more dramatic about pain or don't have as big a heart problem. But if you are a woman taking care of a woman, you may listen differently."
The entire medical community, including the AHA and ACC, have been pushing to expand the medical workforce to include more women, especially those from diverse racial and ethnic backgrounds, Mieres said.
"The medical workforce should reflect the diverse population being served," she said. "If a medical team member looks like the person they are treating, there's more trust. The patient will share more and is more likely to stick to a treatment plan."
Change takes time, so start early
Mieres说，她相信唯一能让女性心脏健康发生持久变化的方法就是在年轻时就养成良好的习惯，包括定期的体育锻炼和健康饮食的重要性.
"People need to be better educated about health in general," she said. "I'm a big believer that it should start in kindergarten."
If nothing else has been learned over the past century, it's that change may take time, but it's possible, Mieres said.
"It has been a slow evolution," she said. "And we need to do more."