AHA Document Builds the Case for How to Improve Outcomes for Women With Acute MI

The good news, according to a new American Heart Association (AHA) scientific statement, is that women have a substantially lower risk of dying from an acute MI now than they did 20 years ago. The bad news is that women still lag behind men when it comes to cardiovascular mortality and, as a whole, their heart disease remains “understudied, underdiagnosed, and undertreated,” the document says.

Many of the patterns were already well-known, writing chair Laxmi Mehta, MD, of Ohio State University (Columbus, OH), told TCTMD, but the specific details were lacking. As investigators focused in recent years on documenting sex disparities in acute MI, more data have become available, making it possible to distill all of the evidence into a comprehensive resource. Beyond encouraging research and policy changes, it is also “a go-to document for people looking for just a good synthesis of current medical knowledge of heart attacks in women,” she said.

Commenting on the AHA statement in an interview with TCTMD, Roxana Mehran, MD, of Mount Sinai Hospital (New York, NY), described the effort as a “fantastic step forward for us to start recognizing that, while we’ve made huge impacts in reducing deaths from heart attacks, we continue to have a dilemma in our female patient population.”

The issue is taking on even greater importance, she continued, now that research is showing today’s young women are more likely than those of previous generations to smoke and to not exercise. “There could be even a higher epidemic down the line if we don’t focus on these important gender differences and [understand] how to best treat and prevent acute MI in our female patient population,” Mehran explained.

Due to campaigns such as the AHA’s Go Red For Women, “there has been huge attention in this area but we’re still not seeing the effect of it in reducing the number of heart attacks in women and improving their outcomes,” she said. “We have to take the next step, and what that is has yet to be determined.”

The scientific statement, published online today in Circulation, is a “great first step” to invigorate more focus on the issue, Mehran noted. Importantly, any progress made stands to benefit society as a whole, not just women, she stressed. “If you actually go after the unrecognized people, the people already recognized will still be benefiting. But if we just continue our quest in the already well-recognized population, we’re never going to make a dent on the other side.”

Continued Need for More Awareness

Cardiovascular disease “is an equal-opportunity killer,” Mehta and colleagues write, “and since 1984 the mortality burden has been higher in women than men, but a significant decline has occurred since 2000. This dramatic decline may be the result of the application of evidence-based therapies and education to improve the public and medical communities’ awareness of heart disease in women.

According to numbers cited in the AHA statement, death rates due to coronary heart disease in women fell by 2.6%/year in the 1980s, by 2.4%/year in the 1990s, and 4.4%/year after 1999.

While the shifts are encouraging, the multifactorial nature of why women continue to have an “excess in mortality” makes it challenging to address, the AHA paper explains. Beyond the more obvious factors such as outright undertreatment, there are sex differences in pathophysiology and presentation.

Even women who are promptly and effectively treated for an acute MI are then less likely to adhere to secondary prevention or complete cardiac rehab, Mehta said. “Some of it is just fear of medications … but also some societal barriers make it hard,” she noted. For example, women might prioritize spending time with their children over pursuing cardiac rehab, thinking they can just make time for exercise at home.

As an interventional cardiologist, Mehran says she sees evidence that “women are presenting at least an hour later than men. For whatever reason—whether its denial, their symptoms are different than men, … or even less recognition on the part of the woman who’s having the symptoms and experiencing the heart attack—they are coming later.”

Thus, raising awareness is still the key ingredient, one that may be best addressed through social media and technology, she suggested, citing Google’s One Brave Idea project for its potential. Women are avid participants in these media, and “they are the ones who actually get the healthcare for the family. It’s an incredible opportunity for us to dive into this particular opportune moment and grab their attention and make an impact,” Mehran noted.

Mehta agreed that women simply not realizing they are having a heart attack remains a big problem. “I still think there is a dearth of women understanding that they are at risk of heart disease,” she said. Many people—men and women—still erroneously think that breast cancer is the major killer. And given that many women have atypical symptoms, it can be challenging for not only them and their families but also sometimes their healthcare providers to recognize an acute MI.

The AHA statement offers numerous suggestions as means to improve outcomes of women with acute MI:

• Increasing awareness among women, healthcare providers, the public, and policymakers of MI risk and sex-specific symptoms and clinical presentation
• Examining interactions between genes and the environment to help predict early onset heart disease in women
• Evaluating how psychosocial risk factors (eg, depression, perceived stress, marital conflict, anxiety, poor social support) influence the development and progression of cardiovascular disease
• Improving methods to diagnose and treat coronary artery spasm, spontaneous coronary artery dissection, and microvascular CAD in women
• Offering sexual counseling to all women and their partners before hospital discharge after ACS
• Increasing pharmacological treatment rates for secondary prevention, with particular emphasis on adherence—by both clinicians and patients—to guidelines
• Implementing effective psychological treatments to reduce barriers and to increase adherence to guideline-based recommendation and improve quality of life
• Developing and evaluating novel, adaptive, tailored secondary prevention strategies for women after acute MI as an alternative to center-based cardiac rehab programs using mobile technology, peer support, health coaches, community health workers, and telehealth
• Developing and testing effective primary and secondary prevention behavioral interventions that are culturally appropriate for women across the life span and in a variety of clinical and community settings
• Creating strategies to increase the inclusion of women of all ages in cardiovascular clinical research (eg, raise mandatory inclusion rates and require sex- stratified data reporting)

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Source: 
Mehta LS, Beckie TM, DeVon HA, et al. Acute myocardial infarction in women: a scientific statement from the American Heart Association. Circulation. 2016;Epub ahead of print.

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