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Women and Coronary Artery Disease (CAD). Module 1 Introduction. Supported by an unrestricted educational grant from Fujisawa Healthcare, Inc. Historical Perceptions in the Medical Profession. Misperceptions Heart disease is a man’s disease

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historical perceptions in the medical profession
Historical Perceptions in the Medical Profession


  • Heart disease is a man’s disease
  • Women’s chest pain symptoms are not due to heart disease

Enrollment of women in clinical trials

  • Research studies (up until recently) included very few women
  • Our knowledge of heart disease in women has been rather poor

Gender bias in diagnosis and treatment

  • Undertreatment and underdiagnosis of women
  • Less aggressive care → higher complications and death rates
women s perceptions of heart disease
Women’s Perceptions of Heart Disease
  • 72% of young women (ages 25-40) still consider cancer to be the greatest threat to women’s health
  • Some women know about the risks of heart disease but do not hear it from their own doctors and do not “personalize” it
  • 65% of women recognize that symptoms may be “atypical” but do not know classic symptoms
  • Most women learn about coronary artery disease (CAD) from magazines and the Web—not from their own physicians!

Robinson A. Circulation. 2001

gender bias in the treatment of women
Gender Bias in the Treatment of Women

“… The community has viewed women’s health almost with a ‘bikini’ approach, looking essentially at the breast and reproductive system, and almost ignoring the rest of the woman as part of women’s health ….”Nanette Wenger, MD Chief of Cardiology, Grady Hospital Professor of Medicine, Emory University Atlanta, Georgia

magnitude of the problem
Magnitude of the Problem
  • 2.5 million women per year in the US are hospitalized with cardiovascular disease (CVD)
  • Deaths from CVD = 500,000/yr
  • Leading cause of death in US women: CAD
  • >230,000 women die from CAD each year
  • 1990: US Congress directed the National Institutes of Health that women be included in clinical trials and that gender differences be evaluated
women in clinical trials
Women in Clinical Trials
  • Women are underrepresented in cardiovascular (CV) trials
    • Evidence-based CV medicine biased toward men
  • Food and Drug Administration/National Institutes of Health mandate: 50% enrollment of women
  • Women need to be empowered to enroll in clinical trials for heart disease
    • Breast-cancer awareness is a good example
publication bias gender representation and negative studies
Publication Bias: Gender Representation and Negative Studies
  • 1966-1994 noninvasive testing literature
    • 8% to 27% women
  • Lower diagnostic accuracy in women
    • High false-positive rates
    • Inability to perform maximal stress
cvd mortality trends 1979 1999
CVD Mortality Trends (1979-1999)

Deaths in Thousands

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

prevalence of cvd in the us
Prevalence of CVD in the US

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

deaths from cvd and cancer by age and sex
Deaths From CVD and Cancer by Age and Sex

Anderson RN. National Vital Statistics Reports. 2002

myocardial infarction mi incidence 1979 1994
Myocardial Infarction (MI) Incidence (1979-1994)



Roger VL, et al. Ann Intern Med. 2002

deaths from cvd 1999
Deaths From CVD (1999)

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

age adjusted death rates for major cvd








Deaths per 100,000 Population














Age-Adjusted Death Rates for Major CVD

J Am Coll Cardiol. 2000

health threats to women perception vs reality
Health Threats to Women: Perception vs Reality



  • 1. Gallup survey. 1995 2. American Heart Association. Heart & Stroke Facts. 1996 Statistical Supplement
does cvd affect many people
Does CVD Affect Many People?
  • 1 in 5 people has some form of CVD
  • CVD claimed ~1 million lives in 1999
    • 40% of all US deaths
  • 1.1 million heart attacks each year
  • 7 million doctor visits each year for chest pain
  • 600,000 strokes each year
  • CVD accounts for 15% to 33% of all healthcare costs

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

statistics for women
Statistics for Women
  • 503,927 died of CVD in 1998
    • 226,467 from heart attack or other cardiac events
    • 97,303 from stroke
  • 1 in 5 women has some form of CVD
  • 38% of women who have a heart attack die within 1 year
  • 40% of coronary events in women are fatal
    • Most occur without prior warning
coronary heart disease death rates by state 1996 1998
Coronary Heart Disease Death Rates by State (1996-1998)

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

diagnosis and management of cad in women
Diagnosis and Management of CAD in Women
  • Gender differences in presentation, manifestation, and diagnosis of CAD
  • Gender differences in mortality
    • 63% of women who die suddenly from CAD had no prior warning symptoms
    • 42% of women vs. 24 % of men will die within one year after MI
  • Thus, early recognition of symptoms and accurate diagnosis of CAD is of great importance
does gender matter in cad
Does Gender Matter in CAD?
  • 2001 Institute of Medicine report: “Exploring the biological contribution to human health: does sex matter?”
    • Confirmed that significant differences between the sexes affect the prevalence, incidence, and severity of a broad range of diseases and conditions
    • This is certainly true for CAD