Heart disease remains the number one killer of women in the United States; and the rate of decline in heart disease has been less prevalent among women.(1) Approximately one woman dies every minute from heart disease in this country. Every year since 1984 more women have died of heart disease than men yet many women are still unaware of their biggest health threat. The National Heart Lung and Blood Institute’s Red Dress/Heart Truth campaign which began in 2001 and the American Heart Association’s Go Red campaign which began in 2004 were both developed to educate and increase women’s awareness of heart disease. How well are we doing? The American Heart Association conducted random surveys in 1997, 2000, and 2003 asking women to identify their leading cause of death. The percentage answering correctly was 30%, 34%, and 46%, respectively.(2) The most recent Lifetime Women’s Pulse Poll released in February 2006 found that only 54% of the women surveyed were able to correctly identify heart disease as their leading cause of death. Among those who correctly identified heart disease as the leading cause of death, the majority still perceived cancer as their greatest health risk. Even though awareness overall among women has significantly increased, there is still a large population of women who are unaware of their risk and women who are not personalizing this information.

Lack of Awareness Among Physicians

In February of 2004 the American Heart Association published for the first time specific guidelines for cardiovascular disease prevention in women.(3) A random national study of primary care physicians (PCP), OB-GYN physicians, and cardiologists was conducted in November of 2004 to evaluate physician awareness and adherence to these gender specific guidelines. Approximately 60% of the PCPs and OB-GYNs, and 80% of the cardiologists stated they were aware of the women’s heart disease preventative guidelines.(4) Of the physicians who were aware of the guidelines only about 40% of the PCPs and cardiologists, and only 20% of the OB-GYNs stated they actually utilized the guidelines in the care of their female patients.(4) Another alarming finding from this study was that only 8% of PCPs, 13% of OB-GYNs, and 17% of cardiologists knew that heart disease kills more women than men every year.(4) In order to effectively modify heart disease risk factors and decrease heart disease mortality in women healthcare providers require additional education. Information like this is exactly what prompted us to write this article.

In March 2007 updated women’s heart disease prevention guidelines were released by the American Heart Association which focus on lowering the lifetime risk of heart disease in women and more aggressive strategies for higher risk women.(5) (See Table Prevention Guidelines in Women)

Evaluating Risk Factors in Women

The majority of the risk factors that can lead to the development of heart disease are similar for both men and women. (See Risk Factor table) One unique risk factor women experience is menopause. Prior to menopause estrogen protects most women from developing heart disease.(6) After menopause (and the loss of estrogen) a clustering of heart disease risk factors occurs (including dyslipidemia, hypertension, and weight gain) which dramatically increases a woman’s risk for heart attacks and strokes. We need to empower women to identify their individual risk factors and make the necessary lifestyle changes.

As nurses we are on the forefront; we are vital patient advocates and patient educators. We all need to work towards a common goal of educating women about heart disease risk factors. As cardiac nurse practitioners at the Women’s Heart Center (WHC) at St. Joseph’s, we attempt to achieve this goal by providing community outreach programs discussing women and heart disease. After attending one of these programs or through other referral sources, women are encouraged to register for a 45-60 minute comprehensive cardiovascular screening at the WHC. This screening includes: a complete personal and family history review, a physical examination including body fat analysis, BMI measurement, waist/hip/waist to height/waist to hip measurements, ankle-brachial index, and point of care testing which evaluates the fasting lipid profile and glucose levels. Screening for the metabolic syndrome (MS), a clustering of risk factors, which increases a women’s risk for diabetes and heart disease, is also included. (See table-Components of the Metabolic Syndrome) Following the physical examination, an individualized plan to reduce cardiovascular risk factors is developed. Further cardiovascular testing or referral to a cardiologist may also be recommended.

Preventing Heart Attacks

Valerie Smith* is a 48 year old working mother with three teenagers living at home. She is peri-menopausal, a former smoker and has a family history of breast cancer and heart disease. Over the past two months Ms. Smith had been experiencing increasing fatigue and exertional shortness of breath which she attributed to being overweight. Like many women in this country Ms. Smith thought that breast cancer was her biggest health threat until she attended one of our educational outreach programs offered at her church discussing women and heart disease. Upon hearing that heart disease is the number one cause of death for women in the United States and because she had a history of hypertension. Ms. Smith decided to undergo a comprehensive cardiovascular screening at the Women’s Heart Center to help her identify her risk for a heart attack. Her screening results revealed dyslipidemia, uncontrolled hypertension, the presence of the metabolic syndrome and a high Framingham risk score. (The Framingham Risk Score is a tool that estimates ten year risk of developing a heart attack by evaluating age, total cholesterol, HDL (good cholesterol), smoking status, and blood pressure.)

In addition to receiving counseling about her about diet, exercise and pharmacotherapy to control her cardiovascular risk factors, Ms. Smith was also scheduled for a nuclear stress test and echocardiogram to further evaluate her risk for cardiac disease. Both of these tests revealed abnormalities requiring further follow-up, and Ms. Smith was referred to a cardiologist. She underwent a diagnostic cardiac catheterization which revealed an 80 % stenosis in her left anterior descending coronary artery, which was subsequently treated with an intracoronary stent. By undergoing this evaluation of her risk factors Ms. Smith prevented a potential heart attack.

The World Health Organization reports that eighty percent of heart attacks are preventable by controlling and optimizing risk factors. It is imperative that women of all ages evaluate their risk factors (especially prior to menopause) in order to decrease their risk of developing heart disease.

There are a lot of excellent resources available (see Women and Heart Disease Online Resource table) to assist both women and healthcare professionals to increase their awareness/knowledge of heart disease. Knowledge is Power. By working together as a profession nurses can make a dramatic impact on decreasing the incidence of heart disease among women.

Heart Disease Prevention Guidelines for Women: (5)

1) Smoking cessation, avoid second hand smoke

2) Thirty minutes of moderate-intensity activity all or most days of the week, 60 to 90 minutes of daily activity in women trying to lose weight/sustain weight loss

3) Diet rich in fruits/vegetables, whole-grain, high-fiber foods, fish twice a week, limit alcohol intake to no more than one drink a day, and limit sodium intake to less then 2.3 grams/day (1 teaspoon salt/day)

4) Maintain BMI less than 25 kg/m2, waist circumference less than 35 inches

Optimal Values for Women: (5)

Total Cholesterol less than 200 mg/dl

HDL (good) Cholesterol over 50 mg/dl

LDL (bad) Cholesterol less than 100 mg/dl (less than 70 mg/dl if high risk)

Triglycerides less than 150 mg/dl

Fasting Blood Sugar less than 100 mg/dl

Hemoglobin A1C less than 7%

Blood pressure Optimal less than 120/80mmHg

Normal 120/80-129/84mmHg

RISK FACTORS FOR HEART DISEASE:

Non-modifiable risk factors:

1) Increased age (menopause)

2) Family history of heart disease

Modifiable risk factors:

1) Dyslipidemia

2) Hypertension

3) Physical inactivity

4) Overweight/Obesity

5) Smoking

6) Emotional stress

7) Diabetes/Metabolic syndrome

COMPONENTS OF THE METABOLIC SYNDROME: (7)

1) Waist circumference >35 inches-women, >40 inches-men

2) Blood Pressure > 130/85 mmHg

3) HDL < 50 mg/dl-women, < 40 mg/dl-men

4) Triglycerides > 150 mg/dl

5) Fasting glucose > 100 mg/dl

The diagnosis of the MS is made when 3 or more components are present.

WOMEN AND HEART DISEASE FREE ONLINE RESOURCES:

American Heart Associations Go Red Campaign (http://www.goredforwomen.org/)

Choose to Move (http://www.choosetomove.org/)

Cholesterol Low Down (http://www.cholesterollowdown.org/)

NHLBI Heart Truth Campaign (http://www.nhlbi.nih.gov/health/hearttruth/index.htm)

Women Heart (http://www.womenheart.org/)

Heart Healthy Women (http://www.hearthealthywomen.org/)

Preventive Cardiovascular Nurses Association (http://www.pcna.net/)

Women’s Heart Foundation (http://www.womensheartfoundation.org/)

WOMEN’S HEART CENTER AT ST. JOSEPH’S:

Women can register for an appointment at the Women’s Heart Center at St. Joseph’s for comprehensive focused cardiovascular risk screenings. This program is managed by cardiac nurse practitioners in three different locations (St. Joseph’s Medical Center in Paterson New Jersey, St. Joseph’s Wayne Hospital in Wayne New Jersey, and St. Joseph’s Ambulatory Imaging Center in Clifton New Jersey). 973-754-2600 or

http://stjosephswomensheart.org/

References:

1) American Heart Association. Heart Disease and Stroke Statistics—2006 Update. Dallas, Tex: American Heart Association; 2006.

2) Mosca, L, Mochari, H., Christian, A., et.al. National study of women's awareness, preventive action, and barriers to cardiovascular health. Circulation. 2006, 113: 525-534.

3) Mosca, L., Appel, A., Benjamin, E., et.al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women. Circulation. 2004, 109: 672-693.

4) Mosca, L., Linfante, A., Benjamin, E., et.al. National Study of Physician Awareness and Adherence to Cardiovascular Disease Prevention Guidelines. Circulation. 2005, 111: 499-510.

5) Mosca, L., Banka, C., Benjamin, E., et.al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. Circulation. 2007,115.

6) Mosca, L., Manson, J., Sutherland, S., et.al. Cardiovascular Disease in Women a Statement for Healthcare Professionals from the American Heart Association. Circulation. 1997, 96: 2468-2482.

7) Grundy, S., Cleeman, J., Daniels, S., et.al. Diagnosis and Management of the Metabolic Syndrome An American Heart Association National Heart, Lung, Blood Institute Scientific Statement: Executive Summary. Circulation. 2005, 112: e285-e290.

*name has been changed