Improving global cardiovascular health begins by closing the gap in sex disparities

Cardiovascular disease (CVD) is the leading cause of death in both women and men in most if not all countries of the developed world. Although CVD mortality rates have decreased steadily over the past 30 years, more women have died from heart disease than men during that period. Research investigations have shown on numerous occasions that the importance of CVD risk factors could be different in women and men, that they have different symptoms when presenting with a myocardial infarction (MI) and that the pathophysiology of the disease could be substantially different in women than in men.

A recent scientific statement issued by the American Heart Association (AHA) aimed at synthesizing thoroughly (for the first time) the science of cardiovascular prevention conducted in women, to identify the gaps in knowledge of CVD in women and to identify priorities for future research to improve outcomes in these women. The scientists argued that although CVD risk factors are usually the same for women and men (smoking, diabetes, hypertension, cholesterol, obesity, poor diet, physical inactivity, low socioeconomic status, etc.) some risk factors such as tobacco abuse, type 2 diabetes and hypertension could be more strongly associated with the risk of CVD in women compared to men. Many physiological factors such as emotional stress and depression could also put more women at risk for CVD. Taken together, these risk factors could explain up to 96% of CVD cases in women. It has also become evident that there could be several sex differences in clinical presentation among patients with MI such as the fact that while men usually present with typical chest pain or chest discomfort, women experiencing MI may also present with atypical chest pain, dyspnea, fatigue, weakness, and indigestion. Studies have also shown that women present later to MI treatment compared to men. Following MI, cardiac rehabilitation is an essential component of CVD prevention in women. Although undergoing cardiac rehabilitation has been shown to reduce morbidity and mortality in women, cardiac rehabilitation is underused and underprescribed in women as it has failed to reach more than 80% of eligible women in the past 3 decades.

One of the suggestions of the AHA scientists was to include more women in randomized clinical trials in preventive cardiology. CVD is an equal opportunity killer and although women represent 40-50% of participants in longitudinal studies or registries, they represent at best 20% of the population included in randomized clinical trials, which is far from enough to provide evidence-based strategies for the prevention of CVD in women. The statement concluded that women are undertreated with guidelines-based recommendations, which leads to increased rates of reinfarction, readmission and death following MI. As this field is steadily moving towards favouring a more personalized approach of medicine, there is no doubt that one of the first steps should be to pay attention to sex-specific characteristics and sex disparities, and closing this research gap should be a priority for the improvement of cardiovascular health in the population.