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DEPARTMENTS: Progress in Prevention

Women’s Awareness of Heart Disease and Risk

Two Steps Forward and One Step Back

Coke, Lola A. PhD, ACNS-BC, FAHA, FPCNA, FAAN; Hayman, Laura L. PhD, MSN, FAAN, FAHA, FPCNA

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The Journal of Cardiovascular Nursing: 1/2 2021 - Volume 36 - Issue 1 - p 6-7
doi: 10.1097/JCN.0000000000000772
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Heart disease continues to be the number 1 cause of death among women with nearly 400 000 deaths from heart disease and stroke with continued disparity by ethnic group.1 Awareness campaigns have been developed and implemented by many national cardiovascular organizations, and these campaigns have been shown to improve risk factors and prevalence of disease. For example, the Go Red for Women ( initiatives by the American Heart Association (AHA); The Heart Truth by the National Heart, Lung and Blood Institute (; and Make the Call, Do not Miss a Beat by the US Department of Health and Human Services ( have effectively disseminated information about heart disease in women, stroke symptoms, and reinforcing the need to call 911 when symptoms occur. Since 1997, the AHA has surveyed women to determine their level of awareness of cardiovascular risk and heart disease. The results of the most recent survey designed to determine awareness of women related to coronary heart disease and cardiovascular symptoms were published in Circulation.2 These survey results were compared with the results of the same survey conducted in 2009. This most recent survey added questions about comorbid conditions including hypertension and diabetes and added a question addressing knowledge and use of telehealth methodologies for healthcare practices. Surprisingly and disappointingly, despite all efforts and national awareness campaigns by many organizations for the last decade, comparative results between the 2 survey time points of 2019 versus 2009 showed awareness of cardiovascular disease and symptoms decreased by 21% in these 2 periods (44% vs 65%, respectively). As in the previous survey, women were still more likely to identify breast cancer as the leading cause of death. In the 2019 survey, awareness that heart disease is the leading cause of death decreased to 43.7% from 64.8% in 2009 and identifying cancer as the leading cause of death increased from 26.5% to 40.1% in 2019, with breast cancer specifically increasing from 7.9% to 16.5% in 2019. In a multivariate analysis that accounted for age, educational attainment, household income, and cardiovascular history, non-Hispanic Black, Hispanic, and non-Hispanic Asian women were less likely to identify heart disease as the leading cause of death. Hispanic women had the largest decrease in this knowledge when comparing the 2009 survey data with the 2019 survey data, followed by non-Hispanic Blacks and non-Hispanic Asians. All healthcare providers should be aware of the data results from this recent survey because it reports continued lack of knowledge and continued disparities among women.

The 2019 National AHA Survey of Women's Cardiovascular Disease Awareness had the primary goal of collecting data on women's knowledge of heart disease being the leading cause of death, knowledge about heart attack warning signs, and what actions to take if someone was having a heart attack. The survey was conducted via online submission to 1819 women from an initial sample of 2700 women including oversampling of ethnic groups with age/race quotas to ensure adequate representation of women from diverse racial/ethnic populations. Demographic data included age, ethnicity, educational attainment, household income, and marital status. From this sample, 1553 women (85% response rate) completed the survey. The mean age was 50.6 years. The sample included non-Hispanic Whites (61.7%, n = 660), non-Hispanic Blacks (12.3%, n = 209), non-Hispanic Asians (6.5%, n = 201), and Hispanics (15%, n = 216). Most women (62.3%) were married/cohabitating, with non-Hispanic Black women more frequently single or never married (40.7%). In addition, 36.8% of women reported hypertension and diabetes with hypertension more common in non-Hispanic Black women. Interestingly, having diabetes was not associated with greater awareness. These are important findings for all women who present with multiple comorbid conditions because these further increase the risk of a cardiac event and women may not be recognizing the impact having diabetes has on their cardiovascular risk. Black women may not have the support system to access emergency care when symptoms occur. Developing management plans in this group will need to include chronic disease management plans and innovative ways to connect them with access to emergency care in a timely manner.

Comparative results between the 2009 and 2019 surveys that examined ability of women to correctly identify 13 warning signs and symptoms of a heart attack showed a decline in the overall sample and in all ethnic groups. Overall knowledge decrease was most significant in the 25- to 34-year age range and showed little change in women older than 65 years. Knowledge of chest pain and shortness of breath symptoms was the highest in women older than 65 years and showed a sharp decline in younger women in the 25- to 34-year age group. Clearly, there is a need to develop campaigns targeted at younger women. Often, younger women do not see a provider regularly except for gynecological health. Ensuring that women's health providers are aware of cardiovascular risks, monitoring these risks, and providing education to this group of women is important, and campaigns centered around education for women's health providers should be developed and implemented.

Taking aspirin when cardiac symptoms occur is part of the national guidelines and has been part of national awareness campaigns. Individuals with cardiovascular disease should ingest an aspirin at the onset of symptoms. Compared with the 2009 survey results, fewer women identified this step (14.3% vs 23.4%) in the 2019 survey across all ethnic groups except awareness by non-Hispanic Asians.

Level of education was associated with awareness in both the 2009 and 2019 samples of women with similar results. Women with postgraduate education were more than 10 times more likely to identify heart disease as a leading cause of death compared with women with less than high school education.

These survey results point to the need for renewed and new efforts to educate women of all ages about their cardiovascular risk and health. Existing campaigns need to be reviewed and revised to target ethnic groups. In the past decade, there has been an increase in cardiac events in women in the 35- to 54-year age group, so this age group should be targeted with campaigns that focus on cardiovascular risk. Survey results showed that this age group had more barriers (time, stress, and low self-efficacy) and were less likely to engage in a healthy lifestyle. In addition, results showed that this age group had preexisting hypertension and diabetes. Aggressive education to teach women the connection between these chronic conditions and cardiovascular disease should be a priority, including patient-centered chronic disease management strategies that include individual social determinants of health.

Multilevel interventions at the grassroots community level are key to disseminating information. Models of awareness that include peer-to-peer relationships and community health workers who can provide culturally relevant information should be considered because they would provide support and education.3 In addition to awareness, increases in community screenings and development of support and counseling are needed.

In conclusion, the results of this survey should spark a call to action for all healthcare providers so that awareness statistics can move back in the right direction especially in ethnic populations of women. Too many women, especially those of ethnicity, are losing their lives or becoming chronically ill. Continued efforts and renewed strategies to educate and provide tools for self-care are clearly needed.

Cardiovascular nurses are well prepared and positioned in healthcare and community settings to increase awareness and actions designed to reduce risk for cardiovascular disease and improve the cardiovascular health of all women.


1. Benjamin EJ, Muntner P, Alonso A, et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation. 2019;139:e56–e528. doi:10.1161/CIR.0000000000000659.
2. Cushman M, Shay CM, Howard VJ, et al; American Heart Association. Ten-year differences in women's awareness related to coronary heart disease: results of the 2019 American Heart Association National Survey: a special report from the American Heart Association. Circulation. 2020;142:e000–e000. doi:10.1161/CIR/0000000000000907.
3. Hurtado M, Spinner JR, Yang M, et al. Knowledge and behavioral effects in cardiovascular health: community health worker health disparities initiative, 2007–2010. Prev Chronic Dis. 2014;11:E22. doi:10.5888/pcd11.130250.
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