Cardiovascular disease (CVD) is the leading cause of death in women, and the majority of these deaths are attributable to coronary heart disease (CHD). Nearly one of every two women will die of CVD, and since 1984, the number of CVD deaths in women has exceeded that of men. Although CVD mortality rates have been decreasing for men and women, they have been decreasing less for women, and the absolute number of women dying from CVD is actually increasing because of the aging of the population. African American women have experienced less of a decline in their mortality rate from CVD, and their death rate from CHD is significantly higher than that of white women. Despite these overwhelming statistics, according to a recent American Heart Association (AHA) survey, most women (51%) still believe that cancer is their greatest health threat, whereas only 13% of them correctly perceive heart disease or a heart attack as their greatest health problem.
There is, unfortunately, more bad news. Once a woman develops coronary artery disease, her prognosis is worse than that of a man. The Multicenter Investigation of the Limitation of Infarct Size (MILIS) study documented a higher in-hospital (13% vs. 7%) and 48-month (36% vs. 21%) mortality rate for women compared with men. Black women had an especially high mortality rate at 48 months (48%). At the 6-month follow-up visit, women were also more likely to have angina, congestive heart failure, and reinfarction compared with men. A meta-analysis of fibrinolytic trials4 and a national myocardial infarction registry database5 confirmed higher in-hospital and short-term mortality rates for women after myocardial infarction.
Possible reasons for the poorer prognosis for women include their increased age and more advanced disease at presentation and increased comorbidity. In patients with established CHD, women are more likely to have hypertension and diabetes and to have higher cholesterol levels than men. Other possible explanations may be related to differences in the use or effectiveness of established medical therapies, noninvasive and invasive diagnostic procedures, and interventional or surgical revascularization in women compared with men. For patients presenting with acute or suspected myocardial infarctions and eligible to receive these medical therapies according to American Heart Association guidelines, several studies have shown less utilization of aspirin, -blockers, and thrombolytic therapy for women compared with men.Among women and men with CHD and elevated low-density lipoprotein (LDL) cholesterol levels, lipid-lowering drugs are prescribed less often for women.13 It is reasonable to believe that greater use of these therapies would have improved women’s outcomes because they have been proven effective in women as well as men.
Women are less likely to undergo cardiac catheterization procedures for suspected coronary disease after an abnormal stress test18 or in the setting of a myocardial infarction.19 They are also less likely to be referred for coronary angioplasty and coronary bypass surgery when hospitalized for a myocardial infarction.19 These procedures do impose a higher risk on women, with three times the periprocedural morbidity and mortality rates for angioplasty in women and a higher operative mortality rate for bypass surgery.6 Possible reasons for these increased procedural risks include a woman’s older age, presentation at a later stage of disease, comorbidities, and smaller vessel size. If women survive the procedure, they experience a long-term benefit similar to that of men.
After a myocardial infarction or revascularization procedure, women in cardiac rehabilitation programs have similar improvements in functional capacity, risk factor modification, and psychosocial functioning compared with men.9,20 Unfortunately, this is another area in which women are underrepresented compared with men. In a national survey of participation rates in cardiac rehabilitation after myocardial infarction and coronary bypass surgery, only a minority of patients enrolled in these programs. The rates were particularly low for women, with only 6.9% of women enrolling after myocardial infarction and 20.2% participating after bypass surgery.21
There is, however, reason for hope. The information discussed here highlights the recent literature concerning the problems of diagnosis, treatment, and worse outcomes for women with CHD. This awareness is the first critical step. More attention is now being given to including women in clinical trials of coronary heart disease. Recent articles, consensus statements, and guidelines have been published to enhance clinician awareness and implementation of primary and secondary prevention strategies for women (see sidebar).