By Marissa Bergman and Annabelle Santos Volgman, MD
Heart disease long was thought to be solely a men’s health concern, but it’s the No. 1 killer of women as well. In fact, 2013 was the first year since 1984 that fewer women died of heart disease than men. This decline was the result of the tireless work of a small group of women who have dedicated their lives to eradicating the misunderstanding and unequal treatment of women’s heart disease. Since March is Women’s History Month, it’s an apt time to look back on their lifesaving work.
Heart disease first came to medical prominence in 1948 with the start of the long-term, ongoing Framingham Heart Study — which now is in its third generation of subjects residing in the Massachusetts town for which the study is named. It was reported in 1955 that age and sex were clearly risk factors for heart attacks; men suffered from heart attacks as early as their 30s and 40s, while women seemingly were spared, because they had much less incidence and experienced heart attacks about ten years later than men.
By 1979, 30,000 more men were succumbing to heart disease than women, cementing the perception of heart disease as a men’s disease. As a result, medical attention was focused almost exclusively on men and their hearts — the Multiple Risk Factor Intervention Trial started in 1974 only examined one sex.
This inconsistency was particularly evident with the breakthrough development of effective cholesterol lowering drugs, called statins. Men were prescribed statins beginning in the late 1980s, and their mortality from heart disease immediately and rapidly declined. However women were not given statins, but rather hormone replacement therapy, because of the findings of the observational Nurses Health Study, a long-term study of more than 100,000 women nurses that assessed their risk factors for major chronic disease.
The result of this difference in treatment was disastrous. While consistently fewer men were dying of heart disease with the introduction of statins, the mortality rate in women actually began to increase in 1991 with the use of hormone replacement therapy. The disparity in these trends continued until reaching an apex in 2000, at which point there were 70,000 more women than men dying from heart disease.
Heart disease recognized as ‘a genderless killer’
As such, throughout the ’90s, it became more and more apparent that heart disease is a genderless killer. In 1991, Bernadine Healy, MD, a cardiologist and the first woman to lead the National Institutes of Health, launched the $625 million Women’s Health Initiative. It was a comprehensive, long-term health study involving 150,000 women as a means to understand the many different ailments that plague the female sex, such as heart disease, cancers and osteoporosis.
Concurrently, a minority of cardiologists — mainly women themselves — began conducting their own studies on heart disease in women. Nanette Wenger, MD, Noel Bairey Merz, MD, and. Jennifer Mieres, MD, among many others, broke down barriers in their work by simply beginning a dialogue on this issue. Wenger says of the frustration she felt during this integral time, “there was minimal information specific to women, and I believed generalization from data in men was inappropriate.” In 1999, Lori Mosca, MD, led the group that published the first guidelines for the prevention of heart disease in women, approximately fifteen years after the MRFIT study was released for men.
In 2000, the first results of the Women’s Health Initiative were released with one particularly shocking revelation: the popular use of hormone replacement therapy in postmenopausal women actually increased their risk of heart attacks, strokes and breast cancer. Only one year later, there were already 17,000 fewer heart attacks in women as a result of reduced hormone replacement therapy treatment and women with high cholesterol being given statins like men were over a decade prior.
Warning signs of heart attack are different for women
Even with with these upending results, much work was required to change the popular notions and misinformation regarding women and heart disease. Not only was heart disease killing women, but as Nieca Goldberg, MD, outlined in her bestseller, Women Are Not Small Men, the warning signs of heart attack are vastly different between the sexes: women experience nausea, fatigue and restless sleep.
The NIH and American Heart Association quickly launched successful awareness campaigns surrounding these issues, The Heart Truth in 2002 and Go Red for Women in 2004, respectively. The media was also integral in spreading the word, such as the turning point May 2002 issue of O Magazine, in which Oprah Winfrey wrote “The Heart of a Woman,” about her own heart health experiences. Thus, by the end of the decade, the red dress had become a powerful and instantly recognizable symbol of heart disease prevention in women
The medical community thrived on this increased awareness, and specialized health centers were opened to correct gender inequalities regarding heart disease. “The publication and application of guidelines which provide a roadmap for the clinician in preventing and treating heart disease in women,” Mieres posits, was crucial in the dramatic decline of mortality.
Gina Lundberg, MD, was at the forefront of this revolution, and started Atlanta’s first Women’s Heart Center in 1998 and now leads one at Emory University. When discussing her inspiration, Lundberg explains, “I was seeing so many women in my private practice who were being dismissed with symptoms of chest pain; they were being told that women didn’t get heart disease.”
The Barbra Streisand Women’s Heart Center at Cedars Sinai similarly focuses on identifying female-pattern heart disease and lowering lifestyle risk factors. Bairey Merz, MD, the director of this center, cites social justice as the mission and vision of her work.
Outside of the professional medical field, dedicated and passionate women with connections to heart disease also took great strides in raising awareness. Some even started support groups to help cope with the burden of this health risk; WomenHeart, a national coalition of women with heart disease, serves to empower survivors and advocate for their benefit.
Mortality rates declining, but more work to do
Since 2000 there has been a dramatic decline in mortality rates for women from heart disease. This decline is attributed to an increase in awareness, a greater focus on women and cardiovascular disease risk and the increased application of evidence-based treatments for established coronary heart disease.
Yet there are still great strides that must be taken, particularly when looking at the hidden side of heart disease: the doctors treating it. According to the Association of American Medical Colleges in the 2014 Physician Specialty Data Book, only 12 percent of cardiologists are women. When 88 percent of cardiologists are male, it’s inherent that women’s issues and treatments will go less developed than the other gender.
Here’s to all the accomplishments already achieved, and the new ones women look forward to conquering, in the battle against heart disease.
Annabelle Santos Volgman, MD, is the McMullan-Eybel Chair for Excellence in Clinical Cardiology and a professor of medicine in Rush College of Medicine, and medical director of the Rush Heart Center for Women. Marissa Bergman is a former associate editor of Today’s Chicago Woman.