Heart disease is the leading cause of death in women – here’s how we can address it

It’s a common misconception that cardiovascular diseases only affect men or women in high-income countries, or that they result from poor lifestyle choices.

However, the glaring reality is that they account for 35% of deaths among women globally.

And worse, cardiovascular diseases (CVD) in women remain “understudied, underrecognised, underdiagnosed and undertreated,” with women underrepresented in clinical trials, according to a new report by The Lancet Commission on women and cardiovascular disease. This is despite decades of grassroots campaigns which have raised awareness about the impact of CVD on women.

The all-female-led Lancet Commission aims to reduce the global burden of cardiovascular conditions – including heart disease and stroke – by 2030, as well as align with the United Nations Sustainable Development Goals (SDGs) aims to reduce premature deaths from non-communicable diseases, including CVD, by one-third by 2030.

The Commission outlines inequalities in prevalence and outcomes of CVD in women globally, delineates the considerable impact of socioeconomic deprivation in influencing these differences, and recommends strategies to resolve them, increase sex-related research, and support integration of care and strengthening of health systems.

The Commission’s report – the first of its kind – is based on data from the 2019 Global Burden of Disease study. The study finds there are approximately 275 million women around the world with CVD, with global age-standardised prevalence estimated at 6,402 cases per 100,000. Ischemic heart disease (47% of CVD deaths) followed by stroke (36% of CVD deaths) are the leading causes of death in women in worldwide.

Globally, the prevalence of CVD in women is declining, with an overall decrease of 4.3% since 1990. However, some of the world’s most populous nations, all of which are in Asia, have seen an increase in CVD, including China (10% increase), Indonesia (7%) and India (3%). These increases clearly indicate a need for approaches to expand prevention, diagnosis and treatment of CVD in women who live in densely populated and industrialised regions.

The data also highlighted significant geographical variances in cardiovascular disease, with the highest age-standardized prevalence in Egypt, Iran, Iraq, Libya, Morocco and the United Arab Emirates, while the countries with lowest prevalence were Bolivia, Peru, Colombia, Ecuador and Venezuela. The high-income Asia Pacific, Australasia, Western Europe, Andean Latin America and high-income North America recorded the lowest rates, with fewer than 130 deaths per 100,000 women. However, the highest CVD mortality rates have been recorded in Central Asia, Eastern Europe, North Africa, and the Middle East, Oceania and Central Sub-Saharan Africa, where age-standardised mortality exceeds 300 deaths per 100,000 women. The regional trends are significant and necessitate a need for improved data collection at local and regional levels to effectively prevent, recognise and treat CVD in women.

High blood pressure is the single-largest risk factor for CVD in women, followed by high body mass index and high LDL cholesterol. While these need a focus, there are sex-specific risk factors – such as premature menopause and pregnancy-related disorders – that should be more widely recognised and prioritised as part of treatment and prevention efforts, too. Several under-recognised CVD risk factors also require attention, such as unemployment – linked to anxiety and depression – and disparities based on socioeconomic and cultural status, race and poverty. A greater focus on mental health in clinical practice is also amongst the recommendations, alongside increasing awareness of risk in women among physicians, scientists and healthcare providers.

The commissioners say interventions need to be tailored for the most vulnerable populations, including women from minority or indigenous populations and those whose roles in society are strongly demarcated by traditional or religious norms.

They outline 10 ambitious recommendations to tackle inequities in targeting diagnosis, treatment and prevention to reduce CVD in women. At this juncture, it is also important to reach groups which are not characteristically regarded as being at high risk, such as young women – a group in which heart attacks and smoking rates are increasing.

To address sex-related differences in optimal treatment and improved outcomes in patients of both sexes, it is necessary to increase participation of women in clinical trials. The authors recommend a number of strategies, including addressing barriers to participation – such as family care issues – adopting more inclusive enrolment criteria, and educating recruitment staff on the importance of involving women. Other recommended interventions include educating healthcare providers and patients on early detection, scaling up heart health programs in highly populated and underdeveloped regions and prioritising sex-specific research on heart disease in women and intervention strategies for women.

The commissioners acknowledge some limitations of the report. Since the report aimed to capture sex-related differences – and not a systematic review – a bias towards highlighting evidence for sex-related disparities over neutral findings cannot be excluded.

Dr. Roxana Mehran, who led the report, states, “It is our hope that this roadmap will be the north star for the future of women’s heart health.”