More than 40 years ago, the American Heart Association (AHA) held its first conference on women and heart disease. The title? “Hearts and Husbands: The First Women’s Conference on Coronary Heart Disease.” Billed as “for women only,” the conference attracted 10,000 female participants to Portland, Ore., where they learned how to keep their husbands healthy. But they were told nothing about ways to recognize symptoms of heart disease in themselves, despite the fact that heart disease has been the number one killer of American women since 1908. No one, not even the women, protested the blatant bias in this gathering because in 1964, physicians and the lay public considered heart disease to be solely a disease of men.

Cardiovascular disease (CVD) kills more than 480,000 women annually, claiming approximately one life a minute.¹ Little is known about cardiovascular physiology and treatment in women because traditionally researchers have not included them in clinical trials.² Instead, results of research with male subjects have been routinely extrapolated to women. Some health professionals and the public still harbor the misconception that women do not get heart disease. However, an emerging body of knowledge indicates that heart disease is not only present, but different in women than men — from presenting symptoms and the age at which they first appear to the response to diagnostic testing and the need for intervention.

Gender-related differences

Women present with angina more often than men and more commonly suffer chest pain for a longer period before they are correctly diagnosed. While men experiencing an acute myocardial infarction (AMI) are more likely to complain of a sudden onset of crushing substernal chest pain and the associated nausea, vomiting, and diaphoresis, women more commonly report vague symptoms such as abdominal pain, jaw pain, shortness of breath, fatigue, and dizziness that occur over a longer period of time, hours to weeks.³ Men are less likely to experience warning signs while women may complain of an unexplained fatigue that’s lasted weeks.^3,4 By the time they present with chest pain, men are more likely to have a full-blown myocardial infarction (MI); and women with atypical signs of coronary heart disease (CHD) who go to the emergency department often are erroneously discharged.^3,4

On average, women exhibit symptoms about seven to 10 years later than men, and when they do receive appropriate attention, they are usually found to be quite ill with more comorbid conditions. Intervention delays increase the risk that thrombolytic therapy won’t be an option. When women have an MI, they are more likely than men to suffer complications and reinfarction, and less likely to survive the initial event.⁵ One researcher, who studied 234 men and women, found a 75% greater mortality rate in the first month after infarction in women, as well as more anginal symptoms and congestive heart failure. According to the American Heart Association, statistics have shown that 38% of women compared to 25% of men will die within one year after a heart attack.^1,6,7 One possible explanation for women’s higher rate of morbidity and mortality may be the difference in primary prevention efforts and the lack of aggressive intervention for early symptoms. Women also experience a greater delay before returning to work, greater psychological distress, and more sexual dysfunction than men following an AMI.⁵

Physiological evidence

Investigations of the cardiovascular functions of women and men have revealed several anatomical and physiological differences that may contribute to contrasting profiles. For example, the right coronary artery has been found to be dominant more frequently in women and the left main coronary artery and left anterior descending artery are smaller.^4,8 Because on average women are smaller than men, their hearts are generally smaller, weigh less, and contain smaller coronary vessels.³ Some researchers believe that the size of the coronary vessels may correlate more with body surface area based on height and weight than with gender, and yet, others found the smaller lumen of women’s coronary vessels was unrelated to body size.^4,9 Women have a higher ejection fraction at rest, yet up to 30% of them do not increase this parameter with exercise, a characteristic that can affect the diagnostic results from exercise testing.⁶ Left ventricular function tends to be better preserved in women than men and more of the lesions found in women involve only one vessel.⁶

The role of estrogen and progesterone in heart disease risk has come under closer scrutiny recently with the findings of the Women’s Health Initiative (WHI). Previously, studies have found that postmenopausal women experience an increase in peripheral resistance, decrease in cardiac index, and left ventricular remodeling, which may contribute to increased risk for cardiac events.^10,11 The cardiovascular protection from estrogen may be related to its roles in carbohydrate metabolism, blood pressure, coagulation, and lipid metabolism. Investigators have found that estrogen improves carbohydrate metabolism by lowering levels of both insulin and plasma glucose.¹² One study suggests that estrogen, when given alone, reduces blood pressure in postmenopausal women; other investigators found that hormone replacement therapy inhibited the exaggerated blood pressure reaction to stress that postmenopausal women who also had family history of CHD experience.^13,14 Evidence suggests that estrogen promotes an increase in HDL cholesterol level, which is beneficial for women while men benefit more from lowering LDL levels.^4,15 Even modest doses of estrogen seem to raise levels of high density lipoprotein (HDL) and reduce levels of low density lipoprotein (LDL), resulting in protection against CVD.¹⁴ Young to middle-aged women have higher HDL and lower cholesterol than men. However, women show increased total cholesterol concentrations with age.¹⁶ Research has also suggested that decreased platelet aggregation and atherogenesis are also protective benefits of estrogen therapy.¹⁶

The postmenopausal benefits of estrogen plus progestin therapy have some limitations. The Heart and Estrogen Replacement Study (HERS) found that preventing subsequent heart attacks or death from CHD was not observed in postmenopausal women with existing CHD who took hormone replacement therapy (HRT), despite the 11% decrease in LDL cholesterol levels, and a 10% increase in HDL cholesterol levels. The Women’s Health Initiative, begun in 1991, sought to demonstrate the cardiovascular benefits of hormone replacement therapy in healthy postmenopausal women. Instead, preliminary findings demonstrated that combination HRT heightened the risk of ischemic stroke and coronary disease, prompting the study to be abruptly halted after the findings were reported in 2003.¹⁷

Discerning real symptoms

Insufficient research data and a lack of attention to their unique needs may leave women doubting the authenticity of their problems. However, research into the treatment experiences and management decisions concerning women is gaining attention.

Women describe their symptoms differently and tend to be more relationship-oriented, which can affect the way they communicate their symptoms. Women seem to have more difficulty correctly identifying their symptoms and seeking care. This may be due in part to the fact that women suffer more atypical symptoms (such as shortness of breath, nausea, and diaphoresis) and report chest pressure not pain. One analysis of several studies concluded that about one-third of women delayed seeking treatment.¹⁸ When women hesitate in going to the hospital, they reduce their chances for successful treatment because early therapy is crucial. For example, thrombolytic therapy should be administered as soon as possible or at least within four hours of the onset of symptoms for maximal effectiveness.¹⁹

When women do seek medical care, they are three times more likely than men to receive a psychological rather than a cardiac diagnosis.²⁰ Even when a cardiac problem is suspected, women are referred for invasive testing less often and receive medical management over surgical treatment more often than men.^4,20 And the lack of research-based guidelines for women interferes with an accurate interpretation of test results, even when women do receive an appropriate referral. One study reported that 30% to 40% of exercise stress testing in women yields false-positive results. Also, ECGs are not generally sensitive to coronary artery spasms, which are more prevalent in women.³ Artifact from breasts can complicate interpretation of nuclear images of the heart in women, and inaccuracies with rest and exercise radionuclide ventriculography may be related to the absence of an increased cardiac ejection fraction in many women.²¹

Finally, little is known about women’s response to commonly prescribed cardiac drugs. Although women suffer more side effects than men from cardiac medications, guidelines for use of some of the most potent drugs are based almost exclusively on men. Differences between race and age, not gender, have usually been the focus in drug trials.²²

Dangerous areas

Several areas need special attention from healthcare providers when assessing CVD risk in women:

Hypertension is the most consistent risk factor for CVD in women over age 35.²³ When hypertension is combined with obesity and oral contraceptive use, a woman’s risk of CVD rises two to four times.²³ Individuals with undiagnosed hypertension are not aware that they are hypertensive despite visiting their physicians an average of three times a year, according to the CDC’s Third National Health and Nutrition Examination Survey (NHANES III).²⁴ The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), has designated a new classification — prehypertension — which includes patients whose blood pressures range from 120 to 139 mmHg systolic and/or 80 to 89 mmHg diastolic.²⁵ A diagnosis of Stage 1 hypertension is made on the basis of a systolic pressure of 140 mm Hg or above and/or a diastolic pressure of 90 mmHg or greater. Stage 2 hypertension is a systolic reading above 160 and/or a diastolic reading above 100 mmHg. Blood pressure should be checked annually from age 40, and elevated readings found during a routine healthcare exam need to be confirmed by a minimum of two subsequent visits.

Obesity may be less predictive of CVD than the distribution of body fat. In older women, the risk for CVD increases as a greater percentage of body fat accumulates in the abdomen. Although this pattern of a higher waist:hip ratio or “apple” shape is more common in men, it can be equally predictive of CVD in women.²³ A waist:hip ratio that exceeds 0.76 is associated with a greater relative risk of death from CVD in women 55 to 69 years of age.²⁶ It is also important to consider ideal weight based on body mass index (BMI). The recommendation is a BMI score of 18.5 to 24.9 for women.

Smoking has a more serious impact on women than men, possibly due to differences in the size of vessel lumens. One study reported a more than fivefold increase in MIs among women who smoked more than 25 cigarettes per day.¹⁷ Cessation has been cited as the most important factor in reducing morbidity and mortality among women with cardiac disease,²⁰ and smoking cessation programs and over-the-counter aids offer women many opportunities to reduce their risk from smoking. Unfortunately, although the rate of smoking has declined significantly over the last 20 years, the rate of women who stopped is less than men; the largest increase in new smokers is teenage girls, and in one study 10% of the women studied continued to smoke after bypass surgery.^4,27

Diabetes mellitus, second only to smoking as a contributor to female mortality from CVD, also has a more serious impact on women than men.²³ The risk of CVD is doubled in persons with diabetes who smoke. Diabetes increases women’s risk for coronary artery disease three to seven times compared to men whose risk increases only two to three times.⁴ Effective glucose control is necessary to prevent the cardiovascular sequelae associated with this disease.

Physical inactivity is associated with a higher incidence of CVD in both men and women.¹⁶ Regular exercise promotes health by reducing stress, improving the lipoprotein profile, reducing blood pressure, enhancing cardiac blood flow, controlling appetite, and stimulating an overall sense of well-being. Unfortunately, estimates are that six of ten women in the U.S. are sedentary; and women traditionally have been less willing to exercise, demonstrating poor attendance and completion rates at cardiac rehabilitation programs, which are often designed for men.^4,28

Stress, a byproduct of living in a fast-paced society, can cause people to become hyperalert and lead to self-destructive behaviors such as overeating, smoking, and abusing alcohol and other drugs. Certain personality types that hold onto stress and react with hostility and aggressiveness are associated with greater CVD risk.

Nurses as educators

Nurses as teachers are strategically positioned to make a difference in the lives of women with CVD. By using current research findings, nurses can intervene to enhance women’s knowledge and awareness of the benefits of a healthy lifestyle. If nurses focus on healthy lifestyle promotion and cardiovascular risk reduction at every encounter, women are less likely to dismiss their importance and may be encouraged to achieve their goals.

Risk factor modification: Educating women begins with an assessment of the family medical history and lifestyle. Encourage women to know their history and to carry the information whenever they visit different healthcare practitioners. A personal knowledge of health history facilitates medical decision-making in areas such as diagnostic testing and therapy.

Nurses need to use strategies that help individuals recognize risk factors and promote healthy lifestyles. However, educating for risk factors can be difficult if women do not see themselves as being at risk. Devices such as a food log may alert women to the amount of fat currently in their diets. Stress the “five-a-day” rule: five servings of fruits or vegetables are basic for good nutrition. Whole grains, low-fat or nonfat dairy products, fish, legumes, and protein sources that are low in saturated fat are important for a healthy immune system. Portion control is also an effective means of controlling calories. Lifestyle change and meal planning are preferable to fad diets.

Prevention of complications: Nurses can play an important role in the lives of women who already have CVD and are at risk for complications. This group may be more amenable to intervention because some of the negative effects are already manifested. Encourage these patients to take responsibility for their health and give them the support they need to focus on themselves and their own needs. Early and prompt intervention when signs of angina are present may alter the course of their disease and prevent progression to MI.

Support for rehabilitation: Nurses need to understand the rehabilitation patterns unique to women. Recovery from a cardiac event progresses differently in women than men. Women frequently display a reduced activity tolerance, which can be related to older age at diagnosis and more comorbid conditions. Although women may tend to take longer to return to their paying jobs, they tend to resume household chores sooner following a cardiac event and experience more guilt if they are unable to regain their former level of activity.³ Nurses can teach women how to adjust to changes in their lives due to illness, such as accepting offers of help and setting realistic goals.

Focus on discharge teaching: As hospital lengths of stay shorten, nurses have less time to quickly assess, plan, and deliver an educational program aimed at specific risk factors. Surveys have shown that female patients most want to know about their medications and next, the risk factors that will enable them to prevent a recurrence of their disease.²⁹ The AHA is an excellent source of teaching materials devoted to women with CVD. Several strategies can help increase effectiveness when teaching women about their disease.

• Obtain materials appropriate to the individual’s level and ability. Consider factors such as interest, literacy, and language. For Hispanic patients, an interpreter or bilingual family member may be most helpful in enhancing communication, as well as Spanish material, which is available from the AHA. Printed material reinforces verbal instructions and teaching.
• Involve the significant other or another important family member in teaching for support and reinforcement. In the case of couples, men may have more difficulty with the caretaker role than women. When the woman is the one in need of care, the man may need help in learning how to care for his partner.
• Use repetition and creativity to promote learning. Give personal examples from your own experience and encourage participation in a support group for women with heart disease. The basis for teaching should be current research findings and recommendations from specialty organizations, such as the AHA and the American Association of Critical-Care Nurses.
• Consult with dieticians to assist women in altering their diet and cooking patterns. Discuss ways to solicit agreement from family members on healthy eating changes. Because many more women are working and traveling on business than ever before, teach them to look for “HeartSmart” menu options in restaurants and to avoid transfats. Role playing using a restaurant menu is a fun and effective modality.
• Encourage exercise by promoting small segments each day or choosing the stairs over the elevator. Even 30 minutes of exercise a day is beneficial. Walking is one of the best means of exercise and can begin with an effort such as parking at a distance and walking to the destination. Exercise can impact all of the risk factors for CHD, especially in women.
• Help smokers to quit. Ask the woman to commit to a stop date. Offer strategies, written techniques, and referrals. If weight gain upon quitting is an issue, offer weight reduction strategies to assist them while quitting. Elicit the help of a buddy or programs such as QuitNet<www.quitnet.com>, a free, internet-based service designed to help tobacco users through the quitting process.

Nurses as role models

As one of the largest groups of healthcare providers, nurses can have a significant influence on their patients not only because of sheer numbers, but also opportunity — many times people turn to them for advice. However, change is most readily accomplished when nurses begin with themselves. Nurses who smoke, overeat, consume many saturated fats, and neglect regular exercise are less credible than those who pay attention to the risk factors for CVD. Nurses need to recognize the importance of complete physical examinations based upon risk, screening, and counseling interventions. Many women feel that going to the gynecologist once a year constitutes adequate screening, but women need to be sure that their gynecologist is providing comprehensive healthcare. Annual physicals for women who are age 40 and older should include a blood pressure check. Yearly ECGs and lipid profiles for those with a strong family history of CVD are also recommended.

Communication is another area where nurses can model beneficial behaviors. Encourage women to communicate clearly to physicians and other health professionals. Presentation plays a role in the way the messages are perceived; when reporting symptoms to providers, women must learn to be clear and persistent. Researchers have found that women who use a clear, business-like approach are the most successful in getting physicians’ attention when experiencing symptoms of CVD.³⁰

Objectivity in deciding what to report, as well as persistence in getting needed attention, also results in better outcomes. Women should be encouraged to be assertive in seeking the best care for their symptoms, before they are gravely ill. They may need support from nurses who can point to their own journeys through the healthcare system in pursuit of providers who really listen and agencies that offer support.

Research and women

Nurses need to take a proactive stance for research that focuses on unique responses to illness at different stages of life. Encourage women to support and participate in studies, as appropriate, and teach them how to evaluate their individual risks when participating. Nurses can both facilitate and use the results of research in the clinical settings that address the specific concerns of women. Many important research questions remain:

• What are the patterns of recovery after cardiac surgery or MI for women, and how are they different from men?
• What roles do personality and mood state play in women with CVD?
• What strategies are effective in promoting healthy lifestyles in areas such as smoking cessation in women? Is health education more effective than environmental change?
• How does maladaptive coping with alcohol dependence affect outcomes after MI, or coronary artery bypass graft surgery in women?
• What gender-sensitive issues need to be addressed regarding the management of the female cardiac client?
• What is the relationship between a woman’s caregiving role and completion of a cardiac rehabilitation program? What strategies are effective in helping women complete the program?

Nurses may well be the connection to better health and improved healthcare for women. Preventing high-risk behaviors in younger women now is one way to ensure the health of an older population in the future.