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Improving Cardiovascular Health in Women: An Opportunity for Nursing

Hughes, Suzanne MSN, RN; Hayman, Laura L. PhD, RN, FAAN

The Journal of Cardiovascular Nursing: March-April 2004 - Volume 19 - Issue 2 - p 145–147
DEPARTMENTS: Progress in Prevention
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Suzanne Hughes, MSN, RN, Heart and Vascular Center, Akron General Medical Center, Akron, Ohio.

Laura L. Hayman, PhD, RN, FAAN, Professor, Division of Nursing, The Steinhardt School of Education, New York University, New York, NY.

Laura L. Hayman, PhD, RN, FAAN, Center for Hypertension & Cardiovascular Medicine, Lenox Hill Heart & Vascular Institute, New York, NY.

Corresponding author: Suzanne Hughes, MSN, RN, Women's Heart Advantage, Health & Wellness Center, Suite 205, 4125 Medina Rd, Akron, OH 44333.

Cardiovascular disease (CVD) accounts for 43% of the annual mortality in American women, well ahead of the 22% caused by all forms of cancer. Mortality rates from CVD in males have decreased over the past 20 years, but the statistics do not follow the same downward trajectory for women. In fact, CVD deaths in women now comprise more than 52% of the annual deaths from CVD.1

Surveys indicate that most women believe that breast cancer is their greatest health threat.2 In reality, a woman is more than 8 times as likely to die from heart disease as from breast cancer. Although early detection greatly improves outcomes, sadly, breast cancer is thus far not preventable. This is in stark contrast to the plethora of evidence-based strategies for cardiovascular risk reduction.

The first step toward reduction of CVD in women is to raise awareness about the magnitude of the problem. Awareness-raising campaigns have been at the forefront of the agendas for both the National Institutes of Health (NIH) and the American Heart Association (AHA). These efforts are directed toward putting to rest the myth that heart disease is something that happens to a woman's husband or brother. It is only when women perceive that CVD is a relevant health issue for them that they will seek screening opportunities to identify and quantify their personal CVD risk, adopt lifestyle changes to reduce risk, partner with their healthcare providers in initiating and persevering with evidence-based pharmacologic therapies, and respond promptly to symptoms.

The Heart Truth Campaign was launched by the National Heart Lung and Blood Institute of NIH in 2002.3 With the involvement of the fashion industry, the red dress became a symbol of women and heart disease, in much the same way that the pink ribbon is a symbol of breast cancer. The national campaign has drawn attention to this initiative using the red dress as a symbol of empowerment, urging women to find their voice and to initiate a dialogue with their primary care providers regarding cardiovascular health. The AHA has several consumer tools directed to women. Simple Solutions4 and Choose to Move5 are designed to support women in making small changes to improve their heart health and to encourage increased physical activity respectively. In February, the AHA's “Go Red for Women” further reinforced the symbol of the red dress.

In addition to raising awareness regarding the prevalence of CVD in women, public education efforts have been directed toward 2 other important issues: (1) differences in women's symptoms of CVD, and (2) the apparent gender disparity in outcomes for women who sustain a cardiovascular event. There is a growing appreciation that women's symptoms of CVD appear to differ from those in men. A study by Milner and colleagues6 indicates that women are significantly more likely than men to report 6 of 7 non-chest pain symptoms upon presentation of acute myocardial infarction. Women are more likely to experience dyspnea, nausea and vomiting, indigestion, fatigue, sweating, and arm and shoulder pain; the only non-chest pain symptom more common in males was dizziness and fainting. In addition to these gender differences in acute presentation, McSweeney and colleagues recently reported on the prodromal symptoms of 515 women with acute myocardial infarction.7 The study by these 5 nurse researchers revealed that 70% of women felt unusual fatigue in the month period preceding the acute event. Sleep disturbances and shortness of breath were also commonly reported. Less than 30% reported having chest discomfort (considered a classic symptom in men) preceding acute symptoms. If these findings are confirmed by additional studies, perhaps in the future, “unusual fatigue” will be deemed a typical prodromal symptom for acute coronary syndrome in women. Identification of women with these early warning signs may lead to the development of urgent preventive treatments.

The mortality rate for women in the first year after myocardial infarction is 38% compared to 24% in men.1 Only a portion of this disparity is explained by age and associated comorbidities. It has been shown that women are less likely to receive evidence-based secondary prevention treatments,8 including referrals to cardiac rehabilitation.9

In addition to the compelling data citing the number of women who die from CVDs, there are 8 million women currently living with heart disease, which includes 25% of women older than 65.1 Quality of life is a key component of the message. The life expectancy of an American woman has risen from 48.3 to 79.4 years in the last century. In the year 1990, a 50-year-old woman had a 22.3% chance of living to age 90, up from 3.4% in 1900!10 The reflection of the late Mickey Mantle, “If I had known I was going to live this long, I would have taken better care of myself!” has particular relevance to women today, who are now likely to live into their 80s or even 90s. What is done to invest in health during the 40s, 50s, and 60s will have marked impact on the quality of those later years. Recent work by Newman and colleagues demonstrated that absence of cardiovascular risk factors (diabetes and hypertension) at ages 65 to 69 predicts “successful aging.” In this multisite observational study, participants who did not smoke, whose lipids and blood pressure were under control, and who were not obese were less likely to have significant physical and cognitive decline 8 years later.11

Supplementing the government and nonprofit- based campaigns, hospitals and healthcare systems have wisely directed resources to public outreach in educating women about CVD risk and in assuring that there is no disparity in the quality of care received by female patients upon entering the healthcare system. Raising the awareness of cardiovascular disease risk in women is likely to have benefits extending beyond her own health to that of her family. Targeting the dissemination of heart healthy information has indirect benefit for all. A recent survey indicates that two thirds of women are the sole decision-makers for the health of their families.12 Women are responsible for 60% of the healthcare decisions within a family, and arrange for 80% of provider appointments.

Parallel to this groundswell of well-deserved attention to women's heart health has been a change in the recommendation regarding postmenopausal hormone therapy (HT) as a strategy for cardiovascular risk reduction. Based on the results of the Heart and Estrogen/Progestin Replacement Study13 and (the early termination of) the Women's Health Initiative,14 HT is no longer recommended as a tool in the prevention of CVD. This has prompted an important shift in focus for preventive cardiology in women. Appropriate emphasis is now being placed on the proven strategies for cardiovascular risk reduction; namely, optimization of the lipid profile, achievement of ideal blood pressure, prevention of type 2 diabetes, regular physical activity, and avoidance of tobacco products.

These public health and hospital-based initiatives provide the cardiovascular nursing community an opportunity to participate in some of the things we do best: health promotion and risk reduction. There are many venues for cardiovascular nurses to contribute both strength and passion to this mission.

  • Nursing research and nursing involvement to increase recruitment of women in medical research: More research is needed to study gender-based differences in risk factors, symptoms, diagnostic testing, and treatment.15 This is critical for cardiovascular health of all people. Recently the FDA Cardiovascular and Renal Drugs advisory committee voted against a petition to expand the labeling of low-dose aspirin for primary prevention; among the concerns cited at the hearing was the paucity of women in trials evaluating aspirin in cardiovascular risk reduction.16
  • Professional education: Surveys indicate that the perception that heart disease is a man's problem has extended to healthcare professionals as well as the lay public.17 Professional educational initiatives to increase the knowledge and awareness in the nursing community is an important vehicle to change knowledge and attitudes.
  • Community-based and public health initiatives to educate women in the community and the workplace about cardiovascular health: Reaching minority women is particularly critical. Minority women, who are more likely to have diabetes and hypertension than do white women, have a significantly increased risk of CVD.1 The guidelines for diabetes18 and hypertension19 have seen recent changes, and this information needs to be reinforced to the public with cultural sensitivity.
  • Collaboration with our colleagues in other specialties: The initiative to raise awareness of cardiovascular disease risk and to advocate for increased quality of cardiovascular care in women is one that allows and encourages the collaboration of cardiovascular nurses with our colleagues in the primary care and women's health specialties. Many women in the target population are those whose point of contact with the healthcare system is a clinician in the obstetrics/gynecology field, often a nursing professional.
  • Quality improvement initiatives, particularly those designed to correct gender disparities: These include all of the areas where cardiovascular nurses practice, such as emergency rooms, diagnostic areas, cardiac cath and interventional labs, and cardiac rehabilitation programs.

In addition, the demographics of the nursing profession are ideally suited to addressing women's cardiovascular health. A profession whose membership is 95% female and whose mean age is 44.3 years20 can well identify with the population targeted by this campaign. We have a significant personal as well as professional stake in this initiative. The population targeted by these campaigns include our coworkers and neighbors. They are our colleagues, our sisters, and our friends. “They” are us.

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