Nearly a third of women aged 20 to 44 will have been diagnosed with a cardiovascular disease by 2050, according to a recent study, with the researchers warning that few advances have actually been made in preventing the disease.
Scientific American reports that heart disease is the top cause of death for women in the United States, killing more of them than all forms of cancer combined. But the unique signs and symptoms of the condition in women are more likely go undetected and untreated than those in men.
This most recent analysis found that based on national data between 2010 to 2020, by 2050, the prevalence of serious CVD and stroke in women in America will rise from 10.7% to 14.4%, affecting more than 22m people. And that’s not counting high blood pressure.
The study was published in Circulation.
“The projection is really a wake-up call,” said Karen Joynt Maddox, lead author of the study and a cardiologist at Washington University. She is also vice-chair of the Council on Quality of Care and Outcomes Research at the American Heart Association, which publishes these forecasts every year.
“Despite all of our amazing advances in treating CVD, we have not made many advances in preventing the disease. And in fact, the projections would suggest that we’re doing worse and worse in preventing the cardiovascular risk factors,” she added.
The estimates represent a setback in the fight against CVD, said Noel Merz, a cardiologist at Cedars-Sinai Medical Centre in Los Angeles, who was not involved in the study.
“We had this idea that maybe by the end of this century, cardiovascular disease would be a rare condition,” he said. “Up until 2010, we had got CVD down to one in four women, and now we’re back to one in three. It’s a sad reality.”
Hypertension – a form of high blood pressure that is an early risk factor of heart disease – could spike, according to the projections. Nearly 60% of women will have high blood pressure by 2050, up from 50% in 2020. And the rates of numerous cardiovascular conditions, like coronary disease, heart failure, stroke and atrial fibrillation, could all rise slightly, according to the study.
By 2050, the prevalence of diabetes could increase by 10%, while obesity may increase by about 17%. Similar trends were observed in girls aged two to 19, with obesity predicted to increase from 19.6% to 32% by 2050.
“CVD is a life course disease. We can see risk factors start in childhood,” Maddox said. “I worry a lot about the increases that we’re projecting in young people, about setting people up for having heart problems when they’re in their 30s and 40s and 50s instead of their 60s and 70s and 80s.”
Older women have a higher prevalence of disease, but cardiovascular risk factors are high and rising in younger groups. Those two trends could feed each other in a vicious cycle, Maddox added.
As women age, they might experience greater rates of cardiovascular disease associated with a prior heart or metabolic issue. People with a past history of stroke and heart attacks are more likely to die from heart failure years later.
Similar trends could be seen in men, she noted. “It’s not that women are uniquely experiencing the increase in obesity or high blood pressure, but there are additional layers on top of that.”
Part of the reason why women may be at particular risk could relate to the significant hormonal changes they experience throughout life, and during menstruation, pregnancy and menopause, Maddox said.
Determining how these life events affect heart health will require more research, but these are “issues that we can definitely build upon”, said Merz.
Socio-economic and demographic factors also affect outcomes. For example, black women have the highest incidence of high blood pressure, obesity and diabetes, which are all CVD risk factors, and this is expected to still be the case in 2050. They could also see the greatest jumps in heart failure and stroke.
“The double whammy is these intersectionalities – you’re black or brown, and live in a rural or under-served area, and you have absolutely no access to healthcare or insurance,” Merz said.
These racial health disparities are well documented, but the new forecast underscores the need for better prevention measures and healthcare policies. New glucagonlike peptide 1 (GLP-1) drugs, for example, could help mitigate rates of cardiovascular disease and obesity.
How much GLP-1 drugs will do this “is an enormous unanswered question”, Maddox said, adding that the data on which the projections are based do not fully overlap with the rise in GLP-1 drugs. “But I’m optimistic that it’s going to be part of helping us bend the curve.”
Less plaque but higher risk
Meanwhile, a study by another team of scientists elsewhere in the US has suggested that despite having less plaque overall, the rates at which females experience cardiovascular events is similar to that of males.
But in women, their study found, cardiovascular risk increased earlier and more steeply at lower plaque levels than in men, suggesting that uniform plaque thresholds may under-estimate this risk.
The findings by the team from Mass General Brigham could indicate that sex-specific interpretation might improve risk assessment.
MedicalNewsToday reports that coronary artery disease (CAD) is the most common type of heart disease, affecting roughly one in 20 adults aged 20 and older.
Previous research has highlighted sex-specific differences for CAD, with women having a significantly greater risk of experiencing complications – notably, plaque characteristics differ between men and women.
Females often have a smaller coronary artery diameter, meaning they can present with a higher total plaque burden – or the total amount of fatty deposits within an artery, typically expressed as the percentage of the vessel area occupied by plaque.
This latest study published in Circulation: Cardiovascular Imaging, suggests that females may face a heightened risk of major cardiac events at lower levels of coronary plaque than men.
The findings indicate that using the same plaque thresholds for both sexes could under-estimate cardiovascular risk in females.
PROMISE trial: Less plaque does not mean low risk
Although previous research has shown sex-specific plaque characteristics and that females tend to have smaller overall plaque volumes, it is still unclear how these differences translate into the risk of major adverse cardiovascular events (MACE), like heart attack, hospitalisation for chest pain, or death.
To explore this question, the Mass General Brigham researchers analysed data from nearly 4 300 stable outpatients with chest pain and no known history of CAD.
They drew on data from the Prospective Multicentre Imaging Study for Evaluation of Chest Pain (PROMISE) trial, which included participants across 193 sites in North America.
Using coronary computed tomography angiography (CCTA), they assessed total plaque volume, total plaque burden, and plaque subtype, including stable and high-risk plaques.
They found that while women had a lower median total plaque volume than men, their vessel size-adjusted total plaque burden was similar.
After a median follow-up of 26 months, females and males experienced comparable rates of MACE.
Lead author Jan Brendel, MD, of the Cardiovascular Imaging Research Centre (CIRC) in the Mass General Brigham Department of Radiology, was surprised at the similar MACE rates despite differences in total plaque volume:
“That was notable. Because women have smaller coronary arteries, a smaller absolute plaque volume may reflect a comparable relative disease burden, helping explain why event rates were similar despite differences in total plaque volume.”
Kevin Shah, MD, cardiologist and programme director of heart failure outreach at MemorialCare Heart & Vascular Institute at Long Beach Medical Centre, who was not involved in the study, said: “This study reinforces that plaque biology and distribution matter – not just total quantity. Less plaque does not necessarily mean low risk in women.”
CVD risk emerges earlier in females
A key finding was that female cardiovascular risk appeared at a lower level of plaque burden. In particular, the risk of MACE increased at a total plaque burden of about 20% in females, compared with around 28% in males.
“From a clinical perspective, this suggests that modest plaque burden warrants careful attention rather than being assumed benign, particularly in women,” Brendel added.
Additionally, the pattern of risk progression also differed. In females, MACE risk rose more steeply at lower plaque levels. In contrast, males displayed a more gradual increase in risk, typically requiring a higher plaque burden before risk accelerated.
Importantly, these sex-based differences persisted even after researchers adjusted for traditional cardiovascular risk factors and imaging findings, such as the presence of high risk plaques.
Brendel notes that these findings could help to avoid under-estimating cardiovascular risk in females.
“First, avoid assuming that low plaque volume equals low risk. Second, consider plaque burden – which accounts for vessel size – rather than volume alone. And third, integrate imaging findings with clinical risk factors to ensure women receive appropriate preventive evaluation and follow-up.”
The study findings indicate that current approaches to interpreting coronary plaque measurements may need refinement.
If clinicians rely on uniform thresholds for plaque burden, females could be classified as lower risk, despite having a meaningful likelihood of adverse events.
Therefore, incorporating sex and potentially age into plaque interpretation could potentially improve risk prediction and help guide earlier preventive strategies.
“Currently, there are no widely established plaque burden thresholds in routine clinical practice,” Brendel highlighted.
“Our data do not justify immediate sex-specific cut-offs. Rather, they support the need for future research to develop such age- and sex-specific thresholds or reference ranges, similar to percentile-based approaches used for coronary calcium scoring.”
The researchers suggest that tailoring cardiovascular risk assessment could help to reduce missed opportunities for prevention. This may be particularly true for females, who have historically been under-recognised and under-treated in cardiovascular care.
Shah shared similar sentiments on potential changes to risk thresholds: “The data suggest that risk thresholds may not be one-size-fits-all. Women may reach clinically meaningful risk at lower plaque burdens than men.
“Future guidelines may benefit from incorporating sex-specific interpretations, but additional validation of these findings would be important before formal changes are made.
See more from MedicalBrief archives:
Causes of heart attack in younger women more varied – Mayo Clinic study
Scientists find 16 genes that increase women’s heart attack risk
Women’s reproductive history linked to CVD risk – UK-Yale study
Experts urge action to reduce global burden of cardiovascular disease in women
Women dying from heart attacks because of failure to recognise symptoms