Cardiovascular Health in Women: Beyond the Basics

September 12, 2024|Stephanie Rollins

Nurses have a powerful influence on our daily care of patients, even if just for a few moments.
This article reviews women’s cardiovascular health and cardiology care specific to women to support nursing awareness of specific symptoms, risk factors, and disparities many women experience. We make a vital impact by increasing our sensitivity and understanding of each individual’s needs.

Women’s cardiovascular health has improved over the last two decades. Despite this,
cardiovascular disease (CVD) and coronary artery disease (CAD) remain the #1 cause of death
in women. CVD and CAD cause more deaths and diseases than any other conditions in the US
and worldwide in both women and men. Women-specific factors that contribute to delays in the
treatment of CVD in women include underrepresentation, pain descriptors, racial and ethnic
disparities, and estrogen effects.1-5

Underrepresentation of Women in Cardiovascular Studies

Recent inquiries into past research reveal frequent underrepresentation of women, leading to
misperceptions about typical versus atypical cardiac symptoms, with women participants as low
as one-third.1-5 The information discrepancy between sexes points to potential incorrect
treatment for women.

Atypical Versus Typical Chest Pain for Women

As a review, typical chest pain traditionally includes pain behind or near the sternum that is
squeezing, heavy, stabbing, or tight, that increases with exertion and resolves with rest or
Nitroglycerin. The pain or sensations may radiate to the left arm, shoulder, jaw, or back.
Atypical chest pain may include feeling sharp, brief, tender to touch, occurring in a small area
(localized), worse with inhalation or position change, or may feel like heartburn or other stomach
symptoms.3

Earlier research also showed what is common knowledge to many, that women primarily feel
atypical chest symptoms more often than men. However, data collected over the last decade
revealed women presented to emergency services with typical chest symptoms as frequently as
men but also described a higher incidence of additional symptoms, contributing to atypical
labeling.1-5

Discrepancy Using “Pain” Descriptors

In addition, investigations show a misunderstanding of chest pain assessment terms at times.
Commonly, individuals describe chest symptoms as, “It’s not pain; it’s pressure or tightness,” or
state the sensation is vague. Healthcare professionals and the general public benefit from
learning additional descriptive words for chest symptoms. It is essential when assessing
symptoms to ask beyond the word “pain.” Women also describe chest pain more often as
discomfort, making the term an additional factor contributing to delays in and less aggressive
treatments during ACS in women.1-5

Interestingly, women present with NSTEMI (Non-ST-elevation Myocardial Infarction) and
nonobstructive CAD more often than men. Despite a lower percentage of blockages, women
with ACS and those after coronary revascularization have more prolonged hospitalizations,
higher in-hospital mortality, more bleeding complications, and a 30% higher readmission rate
within 30 days after the initial hospital stay. Some researchers question whether this is partly
due to the delayed treatment mentioned above.1-5

Estrogen

Post-menopause significantly impacts the cardiovascular health of those with ovaries. How
does estrogen affect the heart? Estrogen releases nitric acid, which causes cardioprotective
effects, including vasodilation and decreased smooth muscle proliferation. On average, women
experience CHD events later in life than men, likely due to the decrease in estrogen’s protective
effect on the blood vessels’ endothelium, causing postmenopausal incidents to increase
significantly. After menopause, low estrogen levels correlate with increased hyperlipidemia and
endothelial abnormalities. The Women’s Health Organization (WHO) studied estrogen therapy
in those menopausal and discouraged HRT (hormone replacement therapy) use for both
primary and secondary prevention of CAD. WHO also found HRT may increase ACS incidence
during postmenopause and does not reverse already established plaque. HRT in
cardiovascular disease prevention still needs further research but may be beneficial in other
areas of health, in collaboration with each person and their healthcare provider.6

Ethnic and Race Disparity

Racism affects women in every area of life. Racial and ethnic disparities impact women’s health
to staggering degrees, specifically with CVD. Sarah West of diversitynursing.com defines health
disparity as “any barriers that limit a person’s access to quality medical care.”9 Black women
have a higher incidence of heart attacks than any other ethnicity or race in women globally.
Compared to non-Hispanic white women, black women also have higher rates of sudden
cardiac death as a first presentation of Acute Myocardial Infarction (AMI) and have
one-third of the survival rate after cardiac arrest occurring outside the hospital setting. Black
and Hispanic women have a more significant number of comorbidities than non-Hispanic white
women, contributing to the higher incidence of AMI in these populations. Additionally, more than
50% of black women have three or more comorbidities at the time of an AMI.7
Indigenous Americans have twice the incidence of CVD than the rest of the U.S. population.
78% of cardiovascular events in this population occurred in those with Diabetes.7
As nurses, we must continually educate ourselves and act against inequality. See further
resources below for support.

Risk Factors and Socioeconomic Disparity

Globally, 80% of cardiovascular disease occurs in low and middle-income populations, with risk
factor occurrence broadly consistent across all races, ethnicities, and genders. The
INTERHEART study discovered nine risk factors accounted for 90% of the risk factors for CVD
globally: smoking, abnormal lipid levels, high blood pressure, Diabetes, abdominal obesity,
alcohol use, low consumption of fruits and vegetables, and lack of physical exercise.
Proportionately, reducing these risk factors most effectively decreases the rate of CVD.8
Of these risk factors, smoking is the leading cause of AMI in women overall and a leading cause of
AMI in women under age 55. After 1-2 years of smoking cessation, however, cardiovascular
risk dramatically reduces, and after 10-15 years, the risk further reduces to that of a non-smoker.7,8

Related risk factors specific to pregnant individuals include gestational diabetes and
pre-eclampsia, with the need for improved blood sugar and blood pressure control.8

What We Can Do

Nurses have dynamic opportunities to create change in the great variety of roles we work in,
even the nurse author of this article! We impact countless lives daily, from acute care, remote
work, clinic work, public health, school nursing, and so much more. We can each use our
unique positions to create change by growing in our awareness, ensuring greater diversity and
representation where we are, having a voice and listening to the voices around us, growing in
cultural competence, and creating change in policies that include the diversity of all people (10).
Nursing unions are growing in number across the United States and are creating change for
health equality. Joining and supporting National Nurses United is a powerful way to achieve change locally and nationally.

This article touches on just a few health challenges women face, especially women of color.
Consider what further action you can take to educate yourself and advocate for equality in
healthcare. Additional resources are listed below.

References

  1. Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson MN, Lindley KJ, Vaccarino V, Wang TY, Watson KE, Wenger NK; American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation. 2016 Mar 1;133(9):916-47. doi:10.1161/CIR.0000000000000351. Epub 2016 Jan 25. PMID: 26811316.
  2. Khan IA, Karim HMR, Panda CK, Ahmed G, Nayak S. Atypical Presentations of Myocardial Infarction: A Systematic Review of Case Reports. Cureus. 2023 Feb 26;15(2):e35492. doi: 10.7759/cureus.35492. PMID: 36999116; PMCID: PMC10048062.
  3. Ferry AV, Anand A, Strachan FE, Mooney L, Stewart SD, Marshall L, Chapman AR, Lee KK, Jones S, Orme K, Shah ASV, Mills NL. Presenting Symptoms in Men and Women Diagnosed With Myocardial Infarction Using Sex-Specific Criteria. J Am Heart Assoc. 2019 Sep 3;8(17):e012307. doi: 10.1161/JAHA.119.012307. Epub 2019 Aug 20. PMID:31431112; PMCID: PMC6755854.
  4. Canto JG, Canto EA, Goldberg RJ. Time to standardize and broaden the criteria of acute coronary syndrome symptom presentations in women. Can J Cardiol. 2014 Jul;30(7):721-8. doi: 10.1016/j.cjca.2013.10.015. Epub 2013 Oct 25. PMID: 24530216.
  5. Olic JJ, Baessler A, Fischer M. Brustschmerz und kardiovaskuläre Erkrankungen bei Frauen : Diagnostik und Therapie [Chest pain and cardiovascular diseases in women: Diagnostics and treatment]. Herz. 2023 Dec;48(6):487-498. German. doi:10.1007/s00059-023-05215-0. Epub 2023 Nov 6. PMID: 37930367.
  6. Humphrey, L. L., Chan, B. K. S., & Sox, H. C. (2002). Postmenopausal hormone replacement therapy and the primary prevention of cardiovascular disease. Annals of internal medicine, 137(4), 273-284.
  7. Laxmi S. Mehta, Theresa M. Beckie, Holli A. DeVon, Cindy L. Grines, Harlan M. Krumholz, Michelle N. Johnson, Kathryn J. Lindley, Viola Vaccarino, Tracy Y. Wang, Karol E. Watson and Nanette K. Wenger. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation. 2016.
  8. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, McQueen M, Budaj A, Pais P, Varigos J, Lisheng L; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004 Sep 11-17;364(9438):937-52. doi: 10.1016/S0140-6736(04)17018-9. PMID: 15364185.
  9. Sarah West APRN, FNP-BC. How Nurses Can Influence Health Equity. Accessed 5/3/2023
  10. From Diversity Nursing. Why Representation In Nursing Is Important. Accessed 12/1/23.

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