Why We Need to Screen Women Differently for Heart Disease
A new scientific statement from the American Heart Association says women need to be better screened for heart disease.
Non-biological factors, social determinants of health, and menstrual cycle history should be considered, the statement says.
Doctors applaud the move.
Screening people for heart disease usually involves looking at a few biological risk factors, like blood pressure, smoking status, and cholesterol. But a new American Heart Association (AHA) scientific statement argues that it’s important to consider much more when assessing women for heart disease.
The statement, which was published in the AHA’s journal Circulation, says that, along with more traditional risk factors, non-biological factors, social determinants of health, and elements like a woman’s menstrual cycle history can impact heart disease risk. Heart disease is the leading cause of death for men and women in the U.S.
“Language barriers, discrimination, acculturation, and health care access disproportionately affect women of underrepresented races and ethnicities,” the statement reads. “These factors result in a higher prevalence of cardiovascular disease and significant challenges in the diagnosis and treatment of cardiovascular conditions.”
Because of this, the AHA says that “culturally sensitive, peer-led community and health care professional education is a necessary step in the prevention of cardiovascular disease.”
While you’re probably at least aware on some level on what it means to have high blood pressure or high cholesterol, you may be a little fuzzy or uncertain about terms like non-biological factors and social determinants of health. Here’s what you need to know, plus how these factors can influence heart health.
What are non-biological factors and social determinants of health?
Non-biological factors generally include things like your lifestyle, dietary habits, and socioeconomic status. Social determinants of health are non-medical conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes, according to the Centers for Disease Control and Prevention (CDC).
That can include a lot of different things, like housing, air and water quality, transportation, access to nutritious foods, and opportunities to be physically healthy—and they can all influence a person’s overall health and heart health.
According to the CDC, there are five main social determinants of health:
Healthcare access and quality
Education access and quality
Social and community context
Economic stability
Neighborhood and built environment
What else should doctors be looking for when assessing risk in women?
The AHA statement also says that it’s important for doctors to consider these elements when looking at the cardiovascular disease risk of female patients:
Pregnancy-related conditions, like preeclampsia, preterm delivery, gestational diabetes, gestational high blood pressure, or miscarriage
Menstrual cycle history, like age at first period and at menopause
Types of birth control and/or hormone replacement therapy used
History of chemotherapy or radiation therapy
Polycystic ovarian syndrome (PCOS)
Autoimmune disorders (they’re are associated with faster build-up of plaque in the arteries, higher risk of cardiovascular disease, and worse outcomes after heart attacks and strokes, and are more common in women)
Depression and post-traumatic stress disorder
How do these elements impact heart health?
There are often racial disparities with non-biological factors and social determinants of health, and they can be seen in data about cardiovascular and other aspects of health in the U.S. For example, Black Americans are 30% more likely to die from cardiovascular disease than non-Hispanic whites, according to the US Department of Health and Human Services (HHS). Black adults are also nearly twice as likely as white adults to develop type 2 diabetes and 1.3 times more likely to have obesity than those who are white—and both of these are risk factors for developing cardiovascular disease.
“We recognize that the medical encounter is only 20% of the outcome,” says statement co-author Jennifer H. Mieres, M.D., a professor of cardiology at the Zucker School of Medicine at Hofstra Northwell in Hempstead, N.Y. “All of these other factors, including gestational diabetes and preeclampsia, can predict heart disease five to 10 years later.”
Some of the impact of social determinants of health, comes down to stress. “Science has shown that chronic stress and other factors that affect cardiovascular outcome is important,” Dr. Mieres says.
But specific factors like air pollution also matter, says Sarina van der Zee, M.D., board certified cardiac electrophysiologist and cardiologist at Providence Saint John’s Health Center in Santa Monica, Calif. “We’ve really come to understand that the particulate components of air pollution are extremely important in influencing cardiovascular disease,” she says. “That’s a very, very strong social determinant that we’ve been able to quantify.”
These factors can also influence whether someone seeks care. “Low income, low occupation, low education, and smoking are associated with higher odds of forgoing healthcare and forgoing healthcare for economic reasons predicts adverse health-related consequences,” says Holly S. Andersen, M.D., attending cardiologist and associate professor of clinical medicine at the New York-Presbyterian Hospital, Weill Cornell Medical Center.
“There are a lot of risk factors that you can’t understand just by looking at someone’s blood pressure, blood sugar, and cholesterol,” Dr. van der Zee says. “Research has brought this to light.”
Marc Klapholz, M.D., professor and chair in the Department of Medicine at Rutgers New Jersey Medical School, says the statement reinforces that, among other things, “a person’s environment is important in increasing and decreasing risk.” He continues, “that means access to nutritious foods, having safe neighborhoods for exercise and activities, your exposure to lead—all of those have an impact on cardiovascular health and calling that out is critical.”
Of course, these aren’t the only elements that impact heart health. The AHA notes that the following more traditional risk factors are important to consider, too:
Having type 2 diabetes
Blood pressure
Cholesterol
A family history of cardiovascular disease
Smoking status
Physical activity level
Diet
Weight
Overall, Dr. Andersen says it’s important for people to change the way they think about cardiovascular risk. “The current risk calculator gives a simple assessment of risk, but the medical community has to understand its shortcomings,” she says. “It underestimates the risk of those who experience negative non-biological factors and social determinants of health. Adding a list of these—along with the several female specific risk factors left out of the calculator—alongside would be a great start to making patients and health care professionals more aggressive about prevention.”
What to do if you have risk factors for heart disease
If you’re concerned about your cardiovascular disease risk factors, Dr. Klapholz recommends talking to your doctor and being open about all of your risk factors.
Dr. Mieres stresses that the majority of heart disease is preventable—and that it’s important for women (and everyone) to be on top of their risk factors and see their doctor regularly. “Know your numbers, know all of your traditional risk factors and, when you speak with your doctor, talk about the new risk factors as well,” she says.
“If you had gestational diabetes, it’s important to point that out,” she says. “Talk about your lifestyle—how many jobs you have, whether you’re a night shift person, if you’re getting enough sleep…you have to be active in co-creating a treatment plan that works for you.”
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