Urgent action is needed to improve care and prevention, fill knowledge gaps and increase awareness about cardiovascular disease in women, according to a report from the Lancet Commission. The first-ever global report on women and cardiovascular disease was published on 16 May in The Lancet and presented during the Annual Scientific Session of the American College of Cardiology, ACC21.
Authored by 17 leading female experts from 11 countries, the report outlines 10 recommendations to tackle inequities in diagnosis, treatment and prevention to reduce cardiovascular disease in women by 2030 – in line with the United Nations' broader Sustainable Development Goals, to reduce premature deaths from non-communicable diseases.
The recommendations include educating health care providers and patients on early detection to prevent cardiovascular disease in women; scaling up heart health programmes in highly populated and underdeveloped regions; and prioritising sex-specific research on cardiovascular disease in women and intervention strategies.
"Cardiovascular disease in women remains understudied, under-recognised, under-diagnosed, and under-treated globally," said Dr Roxana Mehran, one of the authors, according to material from the American College of Cardiology (ACC).
"Achieving the important target set by the United Nations requires bold, distinct strategies to not only target factors contributing to cardiovascular disease but also to identify sex-specific biological mechanisms in women. Making permanent improvements to the worldwide care of women with cardiovascular disease requires coordinated efforts and partnerships involving policy-makers, clinicians, researchers and the wider community."
The Lancet Commission report is based on data from the 2019 Global Burden of Disease Study, which showed approximately 275 million women around the world with cardiovascular disease in 2019 alone, with global age standardised prevalence estimated at 6,402 cases per 100,000.
The leading cause of death in women worldwide was ischemic heart disease (47% of cardiovascular disease deaths), followed by stroke (36% of cardiovascular disease deaths).
The data also underscored considerable geographical differences in cardiovascular disease, with the highest age-standardised prevalence in Egypt, Iran, Iraq, Libya, Morocco and United Arab Emirates, while the countries with lowest prevalence were Bolivia, Peru, Colombia, Ecuador and Venezuela.
Although globally the prevalence of cardiovascular disease in women has been declining, with an overall decrease of 4.3% since 1990, some of the world's most populous nations have seen an increase in cardiovascular disease, including China (10% increase), Indonesia (7% increase) and India (3% increase).
The highest cardiovascular disease mortality rates were in Central Asia, Eastern Europe, North Africa and the Middle East, Oceania and Central Sub-Saharan Africa, where age-standardised mortality exceeded 300 deaths per 100,000 women.
High-income Asia Pacific, Australasia, Western Europe, Andean Latin America and High-income North America recorded the lowest rates.
The evidence of important regional trends suggests a need for improved data collection at local and regional levels to effectively prevent, recognise and treat cardiovascular disease in women, the authors said, according to the ACC material.
They also note the importance of addressing established risk factors like hypertension, body mass index and high LDL cholesterol, but also said sex-specific risk factors such as premature menopause and pregnancy related-disorders must be more widely recognized and prioritised as part of treatment and prevention efforts worldwide.
They also stress the importance of paying attention to socio-economic and cultural factors, as well as mental health, in prevention and management of cardiovascular disease.
"While some risk factors for cardiovascular disease are similar for women and men, women are more likely to suffer from health disparities due to cultural, political or socio-economic factors," said Dr C Noel Bairey Merz, another author of the report.
"For instance, some social or religious norms – such as restrictions on participation in sport and physical activities – can contribute to cardiovascular disease in women, highlighting an urgent need for culturally appropriate initiatives that are tailored to different regions and populations."
The Commission also highlights the need to increase awareness of cardiovascular disease risk in women among physicians, scientists and health care providers. The authors point out the unmet need for cardiovascular disease prediction models that include sex-specific risk factors, as well as greater inclusion of women in clinical trials.
Tailored interventions for the most vulnerable populations globally, including women from minority or indigenous populations and those whose roles in society are strongly defined by traditional or religious norms, as well as those not typically viewed as being at high risk, such as young women, are also important, the ACC material continues.
In a related editorial, Dr Ana Olga Mocumbi of the Mozambique National Institute of Health, writes: "In the midst of the COVID-19 pandemic, values of human dignity, solidarity, altruism, and social justice should guide our communities to ensure equitable share of wealth and leveraging of efforts towards the reduction of cardiovascular disease burden in women worldwide.
“The Commission's recommendations on additional funding for women's cardiovascular health programmes, prioritisation of integrated care programmes, including combined cardiac and obstetric care, and strengthening of health systems, accords with efforts to bridge the gap for the world's worst off. Such a shift in women's cardiovascular care would be a major step towards equity, social justice and sustainable development."
The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030
Birgit Vogel, Monica Acevedo, Yolande Appelman, C Noel Bairey Merz, Alaide Chieffo, Gemma A Figtree, Mayra Guerrero, Vijay Kunadian, Carolyn SP Lam, Angela HEM Maas, Anastasia S Mihailidou, Agnieszka Olszanecka, Jeanne E Poole, Clara Saldarriaga, Jacqueline Saw, Liesl Zuhlke and Roxana Mehran.
Published in The Lancet on 16 May 2021.
Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum.
Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed and undertreated.
This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030.
This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.
Accurate data on global prevalence and outcomes of cardiovascular disease in women are absent
Recommendation: Direct funding for real-time and accurate data collection on prevalence and outcomes of cardiovascular disease in women globally.
Women with cardiovascular disease remain understudied, under-recognised, underdiagnosed, and undertreated
Recommendation: Develop educational programmes on cardiovascular disease in women for physicians, scientists, allied health-care providers, and communities
Sex-specific mechanisms in the pathophysiology and natural history of cardiovascular disease remain poorly understood
Recommendation: Prioritise sex-specific research focused on identifying the pathophysiology and natural history of cardiovascular disease
Women are under-represented in the majority of cardiovascular clinical trials
Recommendation: Develop strategies to improve enrolment and retention of women in cardiovascular clinical trials
Socio-economic deprivation contributes substantially to the global burden of cardiovascular disease in women
Recommendation: Prioritise funding in global health organisations for cardiovascular disease health programmes in women from socioeconomically deprived regions
Myocardial infarction and cardiovascular disease mortality are increasing in young women
Recommendation: Educate health-care providers and patients regarding early detection and prevention of cardiovascular disease in young women
Hypertension, dyslipidaemia and diabetes are the most crucial risk factors contributing to cardiovascular disease death in women
Recommendation: Establish policy-based initiatives and medical and community-outreach cardiovascular disease risk factor programmes in settings frequented by women
Sex-specific and other under-recognised cardiovascular disease risk factors, such as psychosocial and socioeconomic factors, appear to contribute to the global burden of cardiovascular disease in women
Recommendation: Research is needed to identify the effect of sex-specific, psychosocial, and socioeconomic risk factors on cardiovascular disease in women, and evaluate intervention strategies
Age-adjusted prevalence of cardiovascular disease in women is increasing in some of the most populous countries of the world
Recommendation: Scale up healthy heart programmes in highly populated and progressively industrialised regions
There is no current established global policy to coordinate prevention and treatment of cardiovascular disease in women
Recommendation: embrace public–private partnerships to develop broad-scale programmes to save lives in women with cardiovascular disease
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