Mega Doctor News
By American Heart Association
A new approach to women’s heart health may offer them a lifetime of opportunities.
A trio of scientific papers, published in the journal Circulation, spells out how fluctuating hormones, mental health and well-being, the heart and the brain are linked and how those connections need to be a routine part of care from a young age.
“Women experience their healthcare across clinical specialties, but it often is fragmented or disconnected. Specifically, these reports connect the dots for clinicians, for patients, and across health domains so that care is holistic and begins in adolescence,” said Dr. Sadiya Khan, chair of the writing group. Khan is the Magerstadt Professor of Cardiovascular Epidemiology at Northwestern University’s Feinberg School of Medicine in Chicago.
“Heart disease and other forms of cardiovascular disease don’t suddenly become relevant when we become older women,” said Dr. Stacey E. Rosen, immediate past volunteer president of the American Heart Association, who helped write the reports. They view a woman’s life in distinct stages – each of which offers chances for early detection, risk factor identification and treatment, she said.
The publications are a joint effort among the Heart Association, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. They represent “a paradigm shift in how we look at women’s cardiovascular and brain health,” Rosen said.
For pediatricians, primary care clinicians, endocrinologists, obstetricians, gynecologists and cardiologists, the documents offer a unified approach to cardiovascular concerns specifically for women, said Dr. Esther S.H. Kim, director of the Center for Women’s Cardiovascular Health at Atrium Health in Charlotte, North Carolina. She also helped write the publications.
Each stage of a woman’s life offers “windows of opportunity” to prevent heart disease, she said.
“We can go all the way back to adolescence and even childhood and figure out, ‘This person is at risk; we need to keep a closer eye on them,’” said Kim, who is also a professor and chair of cardiovascular medicine at the Wake Forest University School of Medicine in Charlotte.
For women themselves, it comes down to a simple point, said Dr. Natalie A. Cameron, an internal medicine specialist who is an assistant professor at Northwestern. She led the writing team for one of the documents and contributed to the other two.
“We don’t want heart attacks and strokes to happen,” she said. By being proactive, women have opportunities to lower their risks.
Read more: Leading health groups redefine heart health for girls and women
Here are some of the key points from the new publications that women may want to discuss with their healthcare team to ensure their hearts are as healthy as possible.
How does heart disease differ in men and women?
The reports emphasize how hormonal health affects cardiovascular health across a woman’s life.
For years, scientists ignored the importance of hormones in women’s heart health, Rosen said, because the monthly fluctuations made research more complicated. But estrogen, estradiol and progesterone “impact cells in blood vessels, in the brain, in heart muscle,” Rosen said. They affect cholesterol levels, the stickiness of blood cells, inflammation, blood pressure and the body’s stress response.
“If you appreciate the understanding that these hormones are not just affecting the uterus, ovaries and fallopian tubes but affecting in a rhythmic way every part of the cardiovascular system and brain, you can appreciate why these fluctuations or issues related to these hormones in women have an enormous impact” on heart and brain health, she said.
And while the most common cardiovascular issue in women is the same as in men – plaque buildup that narrows arteries – Kim said that women are more likely to have other serious problems.
The classic image of heart disease, Kim said, is a “Homer Simpson-type of person – a middle-aged or older man with very obvious cardiovascular risk factors. But you know, Marge Simpson can also have heart disease.”
“And the heart disease that Marge could have may look different than Homer’s; things like microvascular coronary disease, which affects small blood vessels in the heart; or heart failure with preserved ejection fraction, in which the heart contracts normally but fails to relax properly between beats; or spontaneous coronary artery dissection, where a heart artery suddenly tears,” Kim said.
Doctors need to think about such conditions in women, Kim said, because they require specific diagnostic tests, “and if you don’t think of the disease processes, you won’t order the right tests, and these diseases will be missed.”
And women should not be afraid to speak up, Kim said.
“Know the symptoms of cardiovascular disease, and if you’re having them, talk about them,” Kim said. “And if your doctor is ignoring you, you should be persistent.”
Why the teen years matter in women’s heart health
“Heart health for women doesn’t start at menopause,” said Dr. Amanda M. Perak, an associate professor of pediatrics and preventive medicine at Northwestern. “Puberty is a big turning point.”
For example, details about menstrual cycles, or periods, offer a look at future heart health, said Perak, who is also a pediatric cardiologist at Ann & Robert H. Lurie Children’s Hospital of Chicago who worked on all three publications. She said:
- A first period before age 10 is linked to a higher risk of heart disease later in life. “That’s not automatically a reason for alarm or medication,” Perak said. “It’s a reason to pay a little closer attention to healthy habits and routine checkups.”
- Irregular periods, especially along with stubborn, deep acne or unusually extra facial or body hair growth, can be a sign of polyendocrine metabolic ovarian syndrome (previously known as polycystic ovary syndrome, or PCOS), which has been linked to problems regulating blood sugar, diabetes and heart disease later on. “Some irregularity is expected in the first one to three years after a girl’s first period,” Perak said, “so what matters is a pattern that persists.”
- By knowing their period history, older teens can be ready to talk with their adult doctor or healthcare professional after they leave a pediatrician’s care.
“The goal isn’t to worry teens about the chance of a heart attack, which are decades away for nearly all of them,” Perak said. “It’s that the teen years are when patterns get set, and it’s much easier to keep good heart health than to get it back.”
Early adulthood: What women may want to discuss with their doctors
“Women should just be aware that they can be at risk for cardiovascular disease,” Kim said. She has worked with older women who were referred to her for testing that measures plaque buildup in the heart’s arteries and were “shocked out of their minds” to see abnormal scores.
If those women had been aware of cholesterol problems, family history issues or the need for healthy habits at an earlier age, their abnormal scores might have been prevented, she said.
“At every phase of life, women can ask their clinicians, ‘How can I optimize my heart health?’” Cameron said. And at every phase, the basics known as Life’s Essential 8 will be part of the answer.
That means maintaining healthy weight, blood pressure, blood sugar and cholesterol levels; eating a healthy diet; getting enough physical activity and quality sleep; and avoiding tobacco.
Other important questions Cameron suggested include:
- What is a normal period? Abnormalities at this age can signal higher cardiovascular risk.
- How do contraceptive options affect heart health? Some are better for women with heart disease or cardiovascular disease risk factors.
- If a woman is planning pregnancy, does she need any specific tests related to her history or medication adjustments?
The reports emphasize the importance of having good cardiovascular health before pregnancy. But 9 out of 10 women ages 20 to 44 have less-than-ideal heart health when they become pregnant.
After pregnancy: Why heart health still matters postpartum
Pregnancy is often seen as a stress test for the heart. High blood pressure in pregnancy, gestational diabetes, or having a preterm birth, are linked to higher risk of heart disease later in life, Cameron said.
The first year after a pregnancy is also “a very critical time” for controlling and monitoring those risks, she said. But many women face challenges that prevent them from getting follow-up care.
The links between a woman’s mental health and their heart
For women, mental health and well-being, hormonal health and heart health are connected in many ways at every life stage.
- Mood changes, which may include symptoms of anxiety and depression, can be related to hormonal fluctuations.
Anxiety or depression may influence lifestyle choices. “You may exercise less or eat less healthy foods if you’re feeling very depressed,” Cameron said.
- Starting around age 12, eating disorders, which can affect future cardiovascular health, become more common in girls, Perak said.
- By age 17, girls are twice as likely as boys to be diagnosed with depression. Teens with depression are more likely to develop obesity later, Perak said, and teens with obesity are more likely to develop depression.
- Women with established cardiovascular disease are more likely to have depression and anxiety, Rosen said, while depression and anxiety can harm their cardiovascular health.
The new series of papers call for making mental health and well-being screening a routine part of a woman’s care.
What happens to heart health before and after menopause?
Hormones fluctuate in the years before menopause, Cameron said. “In general, as those changes are happening, women may experience increases in their low-density lipoprotein (“bad cholesterol”) levels, weight gain and potentially rising blood pressure.”
It’s also a time when years of unhealthy lifestyle choices may start to catch up, and overt heart disease may emerge.
Does that mean it’s time to throw in the towel and surrender to something inevitable?
“The answer is an absolute, positive, emphatic no,” Rosen said. It’s never too late to make healthy changes.
But the years around menopause are a good time for a woman and her healthcare team to discuss questions such as:
- Am I at risk for heart disease?
- What tests should I have?
“It’s really important to know your numbers and monitor those numbers with a clinician at your annual visits, or more often” if you’re actively managing blood pressure or cholesterol levels, Cameron said.
What should women know about menopause and heart health?
Menopause marks the end of a woman’s periods. But if she lives an average life span, 40% of her life is still ahead of her.
Key things a woman may want to discuss with her healthcare team, Rosen said, include:
- How do I predict my risk? A doctor may use a risk calculator, such as the American Heart Association’s PREVENT equations, to guide care.
- What can I do to address those essential risk factors?
Sleep, for example, is often a concern during menopause, Rosen said. Anyone having problems may want to ask, “Is this something to be concerned about and how should I be evaluated? What are treatment options?”
- What else can I do to make sure the next 40 years are as healthy as possible?
It’s never too late to do something, Rosen emphasized, noting that her mother, 87, was just put on cholesterol-lowering medications – a decision she heartily endorsed.
“It’s always about opportunities,” she said.
How coordinated care can support women’s heart health
Women’s healthcare is fragmented, Cameron said. Over the course of her life, she may see a pediatrician, primary care doctor, obstetrician/gynecologist, cardiologist and psychologist. Communication is not a given, and health records do not always transfer.
The new publications spell out the need for unified care, but women can find ways to own and organize their own health journey as well, Rosen said.“
I joke with new patients, ‘You would never go to your accountant before tax season without your paperwork,’” expecting them to know your salary and what taxes you’ve paid in the past. So whether it’s in a notepad or a digital folder, Rosen encourages tracking that medical history as a way of taking an active role in care.
Cameron suggested asking anyone who sees multiple doctors if their clinicians can see each other’s medical notes and whether they’ve talked. Some of her patients have provided phone numbers to help her connect with clinicians outside of her healthcare system.
Some women are better taking such steps on behalf of others, Rosen said. A woman caring for a sick parent or child can be “a lioness” about preventive care. “Remind yourself that you’re worthy of doing that work for yourself.”
Cardiovascular disease, which includes heart disease and stroke, is the leading cause of death in women, claiming more than 400,000 lives in the U.S. each year. That’s more than breast cancer, lung cancer and chronic lung disease combined. Yet only about 4 in 10 women recognize it as their greatest health threat.The American Heart Association, through its Go Red for Women initiative, aims to empower women to take charge of their heart health. Resources are available to help protect and strengthen your heart at every stage of life
Information source: American Heart Association
