Cardiovascular disease is the leading killer of American women, responsible for 1 in 3 deaths annually — more than breast, lung and ovarian cancers combined. The American Heart Association projects that by 2050, nearly 60 percent of women in the United States will have some form of cardiovascular disease, including nearly a third of women between the ages of 20 and 44.
So it’s no exaggeration to say that new guidelines for women’s cardiovascular health, which focuses on hormonal changes and are relevant to care throughout a woman’s life, could prove transformative. The recommendations — issued by the AHA, American College of Obstetricians and Gynecologists, American Academy of Pediatrics and Society for Maternal-Fetal Medicine — may not only be lifesaving but also could help reverse worsening health trends among women.
For years, scientists have known that women’s heart health differs from that of men. How heart attacks develop and present often depends on a patient’s sex, contributing to high rates of missed diagnoses. Conditions unique to women, like polyendocrine metabolic ovarian syndrome, can also substantially increase the risk of diabetes and heart disease.
This is because reproductive hormones, particularly estrogen, play a major role in heart health. The menopause transition marks a key turning point: Before it begins, women have a much lower risk of heart attack than men, but that gap narrows in postmenopausal years.
Pregnancy, too, highlights the connection between reproductive and cardiovascular health. Afshan Hameed, a co-author of the new guidance who is a cardiologist and a maternal-fetal specialist at the University of California at Irvine, describes pregnancy as a “stress test” in which women are essentially on a treadmill for nine months. During pregnancy, the heart must pump as much as 50 percent more blood than usual to support the mother and baby.
This increased workload can unmask heart conditions that have been present since childhood but never caused symptoms. Pregnancy can also trigger new conditions, including preeclampsia, gestational diabetes and peripartum cardiomyopathy, a potentially life-threatening condition in which the heart muscle weakens and can no longer pump blood effectively.
These conditions can cause serious complications. In fact, cardiovascular problems are the No. 1 cause of pregnancy-related deaths in the United States. Those risks are also markers of future heart problems: Women who develop pregnancy-associated complications have a higher risk of heart attack and stroke later in life, even if these conditions resolve after delivery. Yet only about 60 percent of women with pregnancy-related hypertension receive follow-up care for blood pressure within six months of delivery. This is a major missed opportunity to identify higher-risk women and prevent long-term consequences.
The new guidelines call for all women to receive cardiovascular risk assessments as part of routine primary care. This is especially important for pediatricians and OB/GYNs, who may be the only doctors girls and young women see.
These conversations should begin as early as adolescence, because irregular periods can be an early sign of PMOS. Women should also know their family history of heart disease, undergo regular screening for high blood pressure, diabetes and high cholesterol, and discuss other risk factors (such as smoking and physical inactivity) with their primary care providers.
Women who wish to become pregnant should work with their doctors to optimize health before conception. If complications develop during pregnancy, clinicians should ensure prompt follow-ups and document them as part of their medical history going forward. Particular attention should be paid to the menopause transition, during which new cardiovascular risk factors often emerge and decisions about hormone replacement therapy can influence future heart health.
Just as important, cardiologists need to ask women about their reproductive histories. Sadiya Khan, another co-author of the new guidance and a cardiologist at Northwestern University, told me this represents a major shift for patients’ expectations. Many women may question why they should talk about their periods to a cardiologist. The reason is that menstrual patterns, including how regular periods are and at what age they begin and end, reflect hormonal health and are therefore a “vital sign” of cardiovascular risks, Khan said.
Khan and Hameed hope the new guidelines will change medical practice. This process may take time, so they urge women not to wait to act. “Share your story — your menstrual history, your pregnancy, your menopause symptoms,” Khan said. Starting in adolescence, ask about reproductive and cardiac health as part of routine preventive care.
“Heart health doesn’t start in menopause,” Hameed said. Events in a woman’s 20s can influence her health in her 60s and beyond, so early attention to prevention is essential.
Having medical organizations come together to establish this multidisciplinary approach to women’s heart health is a major step forward. This is another area where the scientific evidence is well-established but medical guidelines are only now catching up. The next step is clinician and patient education, along with continued research into the interconnectedness of women’s reproductive health.
Do you have questions about women’s heart health? Please write to me; I will feature your comments in a future edition of The Checkup newsletter.
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