AHA Urges Holistic Cardiovascular Care of Women, With Focus on Race/Ethnicity

With a focus on treating the whole woman, and not simply single facets of her cardiovascular health, a new American Heart Association (AHA) statement emphasizes the need to take into account racial and ethnic differences in cardiovascular risk factors as well as promote preventive therapies for women in the United States. These nuances, its authors say, will help improve women’s care across the board.

“This scientific statement is just a small brushstroke in the whole landscape of women's cardiovascular health and the impact and intersection with race and ethnicity,” writing committee chair Laxmi S. Mehta, MD (The Ohio State University, Columbus), told TCTMD. “There is a lot that has to be done and we hope we have tickled people's interest into the area, not just as clinicians, but as learners that are out there and as [researchers].”

Especially among Black women, Mehta continued, there are a “lot of social determinants of health that impact them, and so we need to be advocating for reforms that can improve their health and acknowledging the nonbiological factors.”

“This statement definitely is a call to action to have the medical community use a much wider lens to look at this differently,” echoed Jennifer H. Mieres, MD (Northwell Health, Lake Success, NY), who served as vice chair of the writing committee. She stressed to TCTMD that the publication of this document during National Minority Health Month was a conscious choice, and reminded clinicians not to simply base decisions on risk calculators because these tools don’t include social determinants of health.

“For the woman in front of you, you need to really find out what matters to her and really understand what her living conditions are like,” said Mieres.

For the woman in front of you, you need to really find out what matters to her and really understand what her living conditions are like. Jennifer H. Mieres

Commenting on the statement for TCTMD, Fatima Rodriguez, MD (Stanford University School of Medicine, CA), commended the authors “for emphasizing that race and ethnicity are sociocultural constructs that impact the way that women experience cardiovascular health and disease across the life course.” Given the heterogeneity—especially for women—within various racial and ethnic categories in terms of CVD risk and outcomes, the “intersectionality of race, ethnicity, and sex can compound health disparities,” Rodriguez said in an email, adding that Black women tend to experience the greatest disparities.

While this statement follows others discussing CVD prevention in women more broadly, it “is important because it directly calls out the importance of the nonbiological factors of race and ethnicity and cardiovascular disease risk,” she continued.

The statement was published online today in Circulation on behalf of the AHA Cardiovascular Disease and Stroke in Women and Underrepresented Populations Committee.

Focus on Nonbiological Risk Factors

In the statement, Mehta, Mieres, and colleagues outline the current available evidence on CVD for several racial ethnic groups, including Black, Hispanic/Latina, American Indian and Alaska Native, and Asian women. They also explore the most common CVD risk factors for women in general, including hypertension, dyslipidemia, diabetes, obesity, and tobacco use.

Digging into nontraditional risk factors, the statement explores what impact a variety of social determinants of health can have on CVD diagnosis and outcomes, with an eye toward how several of these affect different populations differently.

While the writing committee acknowledges “notable progress” has been made for the prevention and treatment of CVD for women across the board in the US, several gaps still need to be addressed. They call for broader representation of women in tools like the American College of Cardiology/AHA Pooled Cohort Equation as well as “specific lifestyle recommendations tailored to cultural norms and behaviors” embedded in CVD prevention guidelines.

Future improvements will likely be found through partnerships with “community-based approaches, faith-based community partnerships, and peer support,” according to the writing committee. “Key considerations in providing culturally competent care are the patient’s preferred language and religion, dietary restrictions, sex identity, cultural norms and practices, health literacy, and cultural differences in communication style.”

In addition, they propose the following eight strategies for improvements in care for women:

1. Coverage of recommended evidence-based therapies without barriers
2. Screening and treatment for cardiovascular risk factors for all by primary care providers
3. Culturally tailored health education, preconception counseling, weight loss, and nutritional counseling
4. Media campaigns that share health messages in a variety of languages
5. Better clinical trial enrollment of underrepresented populations
6. Mandatory sex, race, and ethnicity reporting of participant data in research
7. Better recruitment of underrepresented populations in medicine
8. Better recruitment and retention of women, especially those of underrepresented races and ethnicities, in cardiovascular research

Seeing Patients as Partners

“Cardiovascular disease prevention is so crucial to impact not only mortality, but also quality of life for our patients,” Mieres said, noting that the “biggest gaps” in the realm of CVD prevention research relate to women as well as minority racial and ethnic groups.

Moreover, she highlighted, even with the work that has been done in the last two decades, death rates for women began to increase about 2 years ago, and “we were losing the momentum that we had gained.” Coupled with the fact that an AHA survey showed that between 40-50% of cardiologists feel ill-equipped to truly assess cardiovascular disease in women, the time is ripe for more attention on this issue, Mieres said.

On top of hoping that clinicians and researchers find inspiration to improve their care of women through reading this statement, Mehta said she wants patients, too, to find it useful. “We know patients are becoming better advocates for their own health,” she said. “And so we want to make sure that they are all aware of this document as well.”

To better provide patient-centered care, Mieres said clinicians need to view patients as part of the healthcare team. “When you are coming up with a treatment strategy, you are co-creating a treatment strategy that is going to be sustainable to prevent the catastrophic effects of cardiovascular disease,” she said. This involves understanding a woman’s complete risk, including family history of hypertension and pregnancy related complications, for example.

It’s equally important to be clued into the nonbiological factors like living environment, job status, chronic stress exposure, depression, and literacy level, as these will also “determine how we co-create that treatment plan,” she concluded. “It's really a rethinking of seeing all patients as partners to incorporate what matters to them and their lifestyle changes to really improve adherence to a medical treatment plan, but also to ultimately improve cardiovascular outcomes.”