#33224: Women and Coronary Heart Disease

Age

As men and women age, they become progressively more likely to develop CHD. Men's heart problems tend to peak earlier than women's; however, the incidence in women tends to catch up to that in men around 65 years of age. Until that time, estrogen produced during the premenopausal years provides some protection. As a result, CHD usually manifests itself 10 years later in women compared to men. Women are also more likely to have other age-related health problems, such as diabetes, hypertension, or arthritis [36,37].

Family History

Family history is a significant traditional CHD risk factor. Premature family history of CHD (before 55 years of age in fathers and before 65 years of age in mothers) is a risk-enhancing factor for both men and women. [28,38,39,340].

Ethnic Background

Like family history and age, ethnic background is a factor that cannot be modified. For example, non-Hispanic Black women are at higher risk of developing and dying from CHD compared with non-Hispanic White and Hispanic women [40,41]. Women of south Asian descent are also at increased risk, which has been attributed to a higher incidence of uncontrolled hypertension, obesity, and sedentary lifestyle in this population [340]. Differences in access to and utilization of healthcare services, as well as the need for risk reduction interventions targeted at specific socioeconomic status, may also be contributing factors [40,42,43].

Again, alterable cardiovascular risk factors require the most attention when counseling female patients. These factors include smoking, hypertension, hyperlipidemia, diabetes, obesity, metabolic syndrome, sedentary lifestyle, obstructive sleep apnea, and psychosocial wellness.

Smoking

Although there has been a consistent decline in cigarette smoking in the United States over the past several decades, an estimated 14.1% of men and 11.0% of women continue to smoke [45,344]. Cigarette smoking remains the most dominant independent cardiovascular risk factor for women, especially for those younger than 55 years of age, increasing their risk sevenfold [338,344].

As a risk factor, smoking accounts for more than one-half of all cardiac events [47]. Results of the Nurses' Health Study (NHS) and NHS II have indicated that the mortality rate of women who smoke is higher than that of former smokers (i.e., those who have quit smoking) and is twice that of women who have never smoked. The NHS results have also indicated that women who smoke are more likely to have comorbid conditions than women who do not smoke [48]. Smoking also increases the risk of sudden death in both men and women [49].

According to the Centers for Disease Control and Prevention (CDC), cigarette smoking causes an estimated 201,773 deaths among women each year and increases a woman's risk of dying threefold [50]. The risk increases with the number of cigarettes smoked per day and the duration smoking history [51]. Women who smoke more than 24 cigarettes per day have a 10-fold increase in MI risk compared with nonsmokers. However, the risk of a first MI decreases soon after a person stops smoking. The risk of having a nonfatal MI declines within three to four years to the same level as that of women who have never smoked [19,26,36].

Smoking produces harmful physiologic effects by decreasing high-density lipoprotein (HDL) levels and increasing platelet aggregation and fibrinogen levels [42]. Smoking is also associated with early menopause and may exert an antiestrogenic effect [44]. The widespread use of cigarettes, and the significance of smoking as a risk factor, led the Surgeon General to state that it is the leading preventable cause of disease and deaths in the United States [46]. Women are less likely to quit smoking than are men due to a desire for slimness. And, when women do quit smoking, they tend to experience greater weight gain than do men [20,36].

Cigarette smoking also works synergistically with other cardiovascular risk factors in influencing the development of CHD. For instance, women who smoke and also use oral contraceptives increase their risk for CHD compared to those women who neither smoke nor use the pill [52,53]. Coronary-related mortality rates are also higher in women smokers who have high cholesterol levels [54].

Hypertension

Like smoking, hypertension is a powerful independent risk factor for the development of CHD in men and women. Compared with men, hypertension is twice as prevalent in women with CHD. Additionally, women with hypertension have three to four times the risk of developing CHD than women with normal blood pressure [56]. Among non-Hispanic Black women, hypertension tends to occur at an earlier age, be more severe and treated less adequately, and result in more significant morbidity and mortality rates. More than 57.6% of non-Hispanic Black women in the United States have hypertension, compared with 40.5% of White women [1]. In addition to Black women, pregnant women and postmenopausal women older than 65 years of age are also at high risk for developing hypertension [57].

Hypertension damages the lining of blood vessels and promotes the deposition of plaque, thereby predisposing people to CHD. Hypertensive women are also more likely to have other significant cardiovascular risk factors, including diabetes, obesity, or high cholesterol levels. If accompanied by obesity and oral contraceptive use, a woman's risk of CHD increases two- to fourfold.

Hypertension is one of the most modifiable cardiovascular risk factors [55]. Patients with prehypertension (defined as blood pressure 120–139/80–89 mm Hg) may be at risk for progression to hypertension and in need of lifestyle modifications [55]. Hypertension has been defined as a blood pressure of 140/90 mm Hg or greater. Even among individuals with no evidence of hypertension by 55 to 65 years of age, an estimated 90% will eventually develop hypertension [59]. CHD risk increases approximately twofold in men and threefold in women with hypertension [60]. Even modest increases in blood pressure have been shown to be dangerous. As little as a 10 mm Hg rise in systolic blood pressure may increase a woman's risk for CHD and stroke by 20% to 30% [26,36,61]. Tight control (<130 mm Hg systolic) has been associated with a 42% lower incidence of stroke [344].

The measurement of the ankle-brachial index (ABI) may play a role in assessing a person's level of CHD risk for CHD. Normally, blood pressure values are equal to or higher in the ankles compared to those in the arm. While a lower blood pressure in the ankle has been recognized as a sign of peripheral vascular disease, the ABI is a marker for overall CHD risk. A low ABI (i.e., less than 0.9) has been associated with an increased risk of CHD and stroke [61,63,64]. However, a systematic review conducted by the U.S. Preventive Services Task Force found insufficient evidence to support ABI as a useful screen to identify asymptomatic patients at risk of cardiovascular events [61].

Hyperlipidemia

Hyperlipidemia is a strong traditional cardiovascular risk factor [355]. From 2015 to 2018, hyperlipidemia was present in 38.1% of U.S. adults [344]. In 2015–2018, 40.4% of women 20 years of age and older had total blood cholesterol levels of 200 mg/dL or greater [1]. Of these, 14.8% of non-Hispanic White, 10.3% of non-Hispanic Black, and 9.0% of Mexican Americans have total blood cholesterol levels of 240 mg/dL or greater [66].

CHD risk is low if total cholesterol levels are less than 200 mg/dL. Cholesterol levels are considered borderline-high risk between 200 and 239 mg/dL and high risk when total cholesterol climbs to greater than 240 mg/dL. These high levels are also the point at which a woman's risk of CHD doubles [65]. In general, younger women tend to have more favorable lipid profiles (e.g., high HDL, lower low-density lipoprotein [LDL]/very low-density lipoprotein [VLDL] and triglycerides).

While total cholesterol plays an important role in global risk assessment, individual components have a more integral role in the development and progression from fatty streak to atherosclerotic plaque formation [343,355]. Elevated total cholesterol (sum of HDL, LDL, and VLDL) and LDL predict cardiac death in both middle-aged and older women. LDL transports cholesterol to organs and blood vessels. Thus, LDL is associated with the development of atherosclerotic plaque and has been referred to as "bad cholesterol." CHD risk increases when LDL reaches 160–189 mg/dL [340]. VLDL consists of small particles with very high triglyceride and cholesterol content.

Triglyceride levels are considered normal if they are less than 150 mg/dL when cholesterol levels are also normal. Borderline-high blood triglyceride levels fall in the 150–199 mg/dL range. Levels increase following a meal and are also affected by time of day, diet, hormones, medications, recent exercise, and alcohol intake. Very few individuals have levels greater than 500 mg/dL which is considered very high [67,68,338]. These extremely high levels are rarely caused by diet alone and usually involve other cardiovascular risk factors [67].

In contrast, HDL is responsible for transporting cholesterol away from blood vessels and back to the liver. Because HDL helps remove cholesterol from the blood, it has been coined the "good cholesterol." Low HDL is another powerful CHD risk factor in women [338].

Diabetes

Of the estimated 26.8 million persons in the United States with diagnosed diabetes, about 12.8 million are female, a number that has more than tripled since 1980 [70]. From 2015 to 2018, another 9.8 million adults were estimated to have undiagnosed diabetes and 113.6 million adults with undiagnosed prediabetes [344]. In 2017, diabetes was the cause of death of 37,262 women, which represented 44.5% of the total number of deaths from diabetes [71].

Next to smoking, diabetes has the most significant negative effect on cardiovascular-related mortality in women [44]. Women with diabetes have twice the risk of developing CHD compared with nondiabetic women and experience more serious outcomes. For instance, women with diabetes are 25% more likely to experience stroke and are twice as likely to die after an MI compared with men with diabetes [72,349]. Diabetes also doubles the risk of a second heart attack in women but not in men [56].

High glucose levels irritate the endothelial layer of blood vessels, leading to the development of atherosclerosis. Moreover, diabetes leads to abnormalities in the lipid profile, increasing total cholesterol, LDL, and triglyceride levels and decreasing HDL. In addition, the protective effects of estrogen may be negated in women with diabetes. As a result, diabetic women may be placed in the same cardiovascular risk level as men of the same age who do not have diabetes [56,72]. For these reasons, diabetes appears to be a more significant risk factor for CHD in women [19,36,44,73]. Although secondary cardiovascular prevention has become more equitable between the sexes, women with diabetes still experience greater coronary hazard than their male counterparts. Sex differences may explain these outcomes in that men develop diabetes at a lower BMI than women. In women with prediabetes, impaired glucose tolerance elevates cardiovascular risk. This finding points to the need for greater screening for prediabetes and clinical follow-up [349].

Obesity

Obesity is another traditional risk factor. In 2016, 39.8% of U.S. adults were obese, an incidence that has greatly increased in the last 20 years [74,75]. As of 2018, every state had a prevalence of obesity greater than 20%. Twenty-two states reported an obesity prevalence of 30% to 35%, and nine states reported rates greater than 35% prevalence [75].

One-third of U.S. women are obese, and 7% are extremely obese [338]. From 2017 to 2018, the prevalence of obesity among women increased from 33.4% to 41.9% and severe obesity from 6.2% to 11.5% [344]. Women 20 to 34 years of age have the fastest increase in being overweight or obese. Minority women as well as low socioeconomic status individuals are disproportionately affected across all age groups, with 50% at risk of being obese. Approximately 54.8% of non-Hispanic Black women and 50.6% of Hispanic women in the United States are overweight or obese [76].

If a woman is 30% overweight, she is at increased risk for developing an MI, heart failure, stroke, and even death. Mild-to-moderate obesity (i.e., 5% to 15% overweight) may also be detrimental. Women who are overweight have a two to three times greater risk of an MI compared to lean women [77]. Fluctuations in weight may also impact a women's overall risk for metabolic syndrome and CHD [78]. Like the other cardiovascular risk factors, CHD risk increases with certain risk factor combinations, such as obesity and smoking [20,36,42,48,79]. Obesity unfavorably influences other metabolic processes, including elevation of blood pressure, triglyceride, and uric acid levels; reduction of HDL cholesterol; and alteration of glucose tolerance and insulin sensitivity [20].

Metabolic Syndrome

A clustering of symptoms has been recognized as playing an important role in the development of CHD. This symptom cluster, referred to as metabolic syndrome, is defined as central obesity (i.e., waist circumference ≥80 cm in women and ≥90–94 cm in men), plus any two or more of the following factors [80]:

The age-adjusted prevalence of the metabolic syndrome for adult women in the United States is 35.5% among non-Hispanic Black women, 38.6% among Hispanic women, and 37.4% among non-Hispanic White women [81]. All individuals diagnosed with metabolic syndrome are at greater risk for the development of type 2 diabetes and CHD [82]. However, younger women with metabolic syndrome have a five-fold increase in CHD risk [338].

Physical Inactivity

Inactivity or the lack of consistent aerobic exercise is another traditional cardiovascular risk factor. Among women 18 years of age and older, only 20.8% met the 2018 Federal Physical Activity Guidelines for both aerobic and strengthening physical activity [1]. Research studies have shown that women report lower levels of physical activity compared to men, which may place women in a higher CHD risk category [83]. However, these results should be interpreted cautiously because the measurement tools used may not have been accurate in measuring activities specific to women [36].

Obstructive Sleep Apnea

Growing evidence from large population and clinical cohort studies suggests untreated obstructive sleep apnea is associated with an increased incidence of serious cardiovascular events such as stroke, especially in women younger than 65 years of age. Approximately 50% the general population have apnea with an apnea-hypopnea index (AHI) score of at least 5 events perhour. One study found a nearly three-fold increased risk of first time stroke or cardiovascular events in individuals with obstructive sleep apnea relative to controls [352]. Adequate CPAP treatment (over four hours per day) reduces cardiovascular risk, with greater adherence (over seven hours per day) reducing the incidence of cardiovascular outcomes.

Psychosocial Factors

Psychosocial CHD risk factors include stress/anxiety, anger/hostility, cynicism, depression, and social isolation While single psychosocial risk factors are generally unrelated to level of CHD or its progression, depression is predictive of CHD [358]. Two times more prevalent in women than men, depression increases women's CHD risk by at least 50%. As a powerful risk factor, depression has been associated with early-onset MI, especially in younger and middle-aged women [338,358]. Additionally, social isolation increases with age. New evidence demonstrates such isolation is a risk factor for heart failure independent of traditional cardiovascular risk factors. Social isolation may influence heart failure risk by inducing a negative psychological state that reduces protective hormones, leading to adverse effects on the heart, blood pressure, and blood vessel wall repair, as well as immune function. As socially isolated individuals lack social support, they may also experience more stress and depression, influencing their engagement in health-promotion activities [357].

Oral Contraceptive Use

Women who use combination hormonal contraceptives have an increased risk of MI. Women who take hormonal contraceptives and smokes experience a risk 20 greater than that of a woman who neither smokes nor uses oral contraceptives. However, the risk of CHD diminishes after the contraceptives are stopped [19].

Research has indicated that third-generation contraceptives are the first to have been associated with no excess risk of MI [101]. However, other studies have found that women taking third-generation oral contraceptives have an estimated two-fold increased risk of venous thrombosis compared with those taking second-generation oral contraceptives [102,103,104]. Additionally, the risk appears to depend upon the class of estrogen, the dose, and the duration of use [105]. A retrospective cohort study used Medicaid data from 2000 to 2013 to assess the relationship between types of oral contraceptives and incidence of CHD in women in South Carolina [106]. Compared with combined oral contraceptives, progestin-only oral contraceptives were associated with decreased CHD and stroke incidence. However, a positive association was found between progestin-only contraceptive plus combined oral contraceptive and incidence of both CHD and stroke. The debate over which contraceptives have the least possibility of harmful side effects continues; more research is needed for a definitive answer.

Menopause

At the time of menopause, serum estrogen levels decrease. The absence of estrogen increases a postmenopausal woman's vulnerability to CHD due to the effects on lipoprotein metabolism. These changes include a decrease in HDL levels and an increase in LDL levels. In addition, blood vessels become less flexible due to the reduction in circulating estrogen after menopause [107]. Premature menopause enhances this risk for women [340].

Research has demonstrated that elevated iron levels increase men's risk of CHD. However, additional studies are needed to determine if the iron retention that occurs in nonmenstruating women is a significant cardiovascular risk factor [108,109].

Rotating Shift Work

Evidence suggests longer durations of rotating shift work can impact cardiovascular health. In one study, female nurses working rotating night shifts had a small but absolute increased risk of CHD [354]. CHD risk waned after the cessation of shift work, with risk decreasing over time. More research is needed to examine the risk associated with specific work hours and individual characteristics, such as sleep duration and quality, hypertension, hyperlipidemia, diabetes, and social support.

In 2016, women comprised 51.7% of the total U.S. work force and are projected to account for 51.9% of the total labor force by 2024 [92]. It was once believed that with more women entering the work force, they would begin to have the same cardiac disease profile as men. While studies have established job strain (a particular form of job stress) to be predictive of CHD in men, studies in women have been few and have produced inconsistent results [93].

For example, one study of 35,038 women, which was conducted within the NHS, found no relationship between job demands, job control, or social support and CHD [93]. The study examined four types of work experience based on the level of job demands (i.e., low or high) and the level of job control (i.e., low or high). Examples of job demands examined included excessive work, conflicting demands, insufficient time to work, fast work pace, and working hard. Examples of job control examined included skill discretion (e.g., learning new things, task variety) and decision authority (e.g., freedom to make decisions, having a voice in the workplace). The level of support received from coworkers and managers was also included in the assessment. The Framingham Offspring Study found that women with active job strain (i.e., high job demand, high job control) had a 2.8-fold increased risk of CHD when compared to women with high job strain (i.e., high job demand, low job control) [94]. Other studies have indicated that women in male-dominated jobs, women who perform caregiving outside work, and women experiencing marital stress may be at increased risk for CHD [93,95,96,97,98,99]. One review of evidence from more than 600,000 women and men in 27 cohort studies in Europe, the United States, and Japan found that work stressors (e.g., job strain, long working hours) were associated with a moderately elevated risk of CHD and stroke but that the risk was similar for men and women [100]. Most researchers agree that additional research is needed that specifically includes women.

Homocysteine, an amino acid by-product of foods rich in protein, occurs naturally in blood and tissues. The prevalence of elevated homocysteine, or hyperhomocysteinemia, increases with age in both sexes and has been linked to atherosclerosis, premature CHD, stroke, and blood clots, even among those with normal cholesterol levels. Research has demonstrated that elevated homocysteine (>12 mmol/L) is relatively common, with hereditary and high dietary consumption of animal protein playing a role [111]. Homocystinuria (>15 mmol/L) elevates the risk for atherosclerosis by increasing oxidative stress and secretion of pro-inflammatory factors that damage the interior lining of arteries. A direct relationship between homocysteine and severity of artery blockages has been established. Researchers have additionally found a 20% increase in risk of coronary events among men and women for every 5 mmol/L increase in homocysteine level [90,112,343]. Thus, homocysteine may become as important as other risk factors for CHD in the future.

Lipoproteins are molecules that transport fats throughout the body. While LDL has been well documented to be deleterious to the heart, lipoprotein(a) may also wreak havoc. Lipoprotein(a) accelerates the transformation of LDL into plaque and slows the dissolution of blood clots. Any lipoprotein(a) level greater than 30 mg/dL is considered elevated for adults [116]. CHD risk increases with lipoprotein(a) levels greater than 50 mg/dL [340].

C-reactive protein (CRP) is a specialized protein released when an injury must be repaired or a microbe warded off. CRP is circulated in the body at low concentrations in healthy people. Levels are increased, however, when infection and injury stimulate the body's repair mechanisms. Measuring serum levels of CRP has been shown to be a good predictor of outcome in cardiac patients (Table 3). If a patient with angina has large amounts of the protein in the blood, the likelihood of MI increases. Risk of subsequent infarctions increases in patients who have suffered a MI when CRP levels remain elevated [120].

C-reactive protein may also signal whether a healthy person is at risk. Although a direct correlation between elevated CRP levels and new coronary events has not been established, prospective studies of men, women, and older adults have found that those in the upper third of CRP levels have twice the risk of MI as those with CRP levels in the lower third [120]. Another study found that C-reactive levels are a stronger predictor of cardiovascular events than LDL cholesterol levels [121]. In one study of healthy women, those with metabolic syndrome and a baseline high-sensitivity C-reactive protein (hs-CRP) of 3.0 mg/L had almost twice the risk of future cardiovascular events than those with the syndrome and hs-CRP <3.0 mg/L [122].

The Reynolds risk score (a risk assessment tool) incorporates hs-CRP and has been shown to improve risk prediction in women [121,122,123,124]. Studies have suggested that measuring CRP may increase the predictive value of other cardiovascular risk factors in women. In a study of 122 women, those who experienced a fatal or nonfatal MI, stroke, or underwent a coronary revascularization procedure had significantly higher baseline levels than the control group of four markers of inflammation: hs-CRP, serum amyloid A, soluble intercellular adhesion molecule-1 [sICAM-1], interleukin-6), total and LDL cholesterol, homocysteine, and total cholesterol to HDL cholesterol ratio [124]. Researchers concluded atherosclerosis must be recognized as an inflammatory disease. While high cholesterol levels foster the development of atherosclerosis, plaque instability and adverse cardiovascular outcomes result from inflammation. As a result, monitoring CRP levels may assist in identifying women who might benefit from statin therapy to reduce inflammation beyond the anti-inflammatory effects provided by aspirin [124; 125]. The ability of statins to lower CRP levels has also been shown to be significantly associated with its LDL-lowering ability [126].

Given the increasing evidence supporting the role for inflammation in atherosclerotic process, the role of the leukocyte count in predicting CHD has been receiving increased research attention. White blood cell (WBC) count is an independent predictor of cardiovascular events and all-cause mortality in postmenopausal women [131]. Specifically, a WBC count of greater than 6.7x109 cells/L may identify high-risk women who may not be currently identified by traditional cardiovascular risk factors. A high leukocyte count also appears to be a risk factor independent of the atherosclerotic disease status [132].

Periodontal disease may also increase the risk of CHD in adults by exacerbating several cardiovascular risk factors [136]. A significant association has been found between poor periodontal status and increased levels of CRP and fibrinogen.

Periodontal status has been weakly associated with an increased total cholesterol level, but not an increased HDL level. Explanations for this association include the repeated systematic exposure of individuals with periodontal disease to bacteria, endotoxin, lipopolysaccharide, and other bacterial products that influence lipid metabolism and homeostasis. Total cholesterol, CRP, and fibrinogen may be possible intermediary factors linking periodontal disease to elevated CHD risk [137]. While plasma fibrinogen levels have been associated with the risk of CHD and stroke, a direct causal relationship has not yet been established [118,119].

While subclinical hypothyroidism has also been associated with increased risk of aortic atherosclerosis and MI in postmenopausal women, this association has not been confirmed [133]. Subclinical hypothyroidism has been defined as an elevated thyroid-stimulating hormone level greater than 4.0 mU/L and a normal serum free thyroxine level (11–25 mmol/L) [134]. It occurs in 5% to 20% of women older than 60 years of age [111]. Subclinical hypothyroidism in patients younger than 60 years of age is associated with an increased risk of CHD, heart failure, and cerebrovascular disease. The risk increases with increasing levels of thyroid-stimulating hormone and is highest in patients with levels 10.0 mU/L and greater [135].

Approximately 12.2% of women in the United States are cigarette smokers [285]. Smoking cessation is considered vital to decreasing several negative public health effects, including CHD. For teenage female smokers, emphasizing social undesirability, rather than long-term health implications, may be more successful in reducing tobacco use. For older patients, the 60% reduction in MI risk that has been associated with smoking cessation may be more persuasive as a reason to quit [286].

The use of nicotine gum or patches, varenicline, bupropion, counseling, and/or smoking cessation programs (alone or in combination) may be very helpful for smoking cessation, especially for those who smoke more than 25 cigarettes per day. While the overall cost-effectiveness of smoking cessation counseling may not seem impressive, its success is considerable when compared with the ability to influence other cardiovascular risk factors [287].

The fear of weight gain may be a major obstacle or concern for women contemplating quitting smoking. Diet and exercise strategies should be incorporated into the overall cessation plan because women have been reported to gain more weight after quitting than men [46]. One study found that cognitive-behavioral therapy reduced weight concerns and was more effective than weight control counseling in ensuring smoking cessation after one year [288].

Dietary factors play a significant role in the prevention of CHD. Major dietary goals include achieving and maintaining healthy weight for height and body size and decreasing intake of sodium, cholesterol, and fat [2,280]. Maintaining a healthy weight is essential due to the negative health consequences associated with obesity and weight fluctuation [289]. National guidelines define a BMI of 25 or greater as overweight and a BMI of 30 or greater as obese [290]. One drawback to the use of BMI is that it does not distinguish between individuals with high percentages of body fat versus those who are muscular. A measurement of waist circumference and/or WHR may be useful in identifying abdominal adiposity and determining the distribution of weight and total body fat [290]. One study demonstrated women with a waist circumference of 76.2 cm or greater and/or a WHR of 0.76 or greater had a more than twofold increase in risk of CHD [291]. Significant health improvements may be achieved by a 5% to 10% reduction in body weight [292].

In terms of diet composition, the intake of saturated fatty acids significantly increases risk of CHD in both men and women [350]. In a large prospective cohort of more than 100,000 postmenopausal women, plant protein intake was inversely associated with all-cause, cardiovascular, and dementia-related mortality [339]. Unprocessed red meat, eggs, and dairy products were associated with a higher risk of CHD mortality. Thus heart-smart eating includes choosing from a wide variety of foods and concentrating more on whole foods, such as fruits, vegetables, and nuts/legumes, than on processed or refined foods.

In 2005, the traditional Food Pyramid was replaced as the national dietary guideline with the U.S. Department of Agriculture's ChooseMyPlate (later renamed MyPlate). This model individualizes dietary recommendations based on age, sex, and activity level [293]. These guidelines continue to emphasize the importance of whole grains, fruits, and vegetables, and in addition, provide an upper limit of calories that may be derived from extra fats and sugars. The ACCF/AHA also recommend adoption of dietary approaches to stop hypertension (DASH) to improve heart health [85]. The DASH diet plan was developed by the U.S. National Institutes of Health to help lower blood pressure without medication. The DASH diet emphasizes vegetables, fruits, and low-fat dairy foods and moderate amounts of whole grains, fish, poultry, and nuts. It also recommends limiting sodium intake [294].

Teaching how to read nutrition labels is vital. Such health literacy can impact a woman's ability to choose low-fat, low-sodium, and low-calorie food items that support heart health [293]. For instance, folate, an essential B vitamin found in fruits, vegetables, beans, and fortified grain products, has been shown to improve endothelial function and decrease homocysteine levels, and thus, may significantly lower CHD risk [322].

A moderate alcohol intake is associated with beneficial changes in serum lipids and lipoproteins. One glass of red wine per day has been shown to increase HDL levels and may reduce the risk of MI. However, regular exercise has the same benefit, and the AHA does not recommend consuming alcohol to derive any potential gains. Thus, women who do not drink should not be encouraged to start [295]. Other health risks, such as obesity, hypertension, and cancer, may be associated with alcohol use [295]. A University of Wisconsin study found that drinking red grape juice may also render beneficial heart effects without the other risks associated with alcohol. Red grape juice may delay the oxidation of LDL among people with CHD [295,296].

Laboratory Tests

Cholesterol screening is an essential component of primary prevention. Women with high cholesterol have been found to be 23% less likely than men to have their cholesterol medically managed [69]. Thus, if total cholesterol level is elevated, a lipid profile should be done to examine lipoproteins, specifically HDL and LDL. Recommended lipoprotein levels for women include HDL levels greater than 50 mg/dL and LDL levels less than 100 mg/dL [62,68]. Additionally, lipoprotein(a) tests are available but generally are reserved for young patients who suffer an MI without an apparent cardiovascular risk profile, those with family histories of very high cholesterol, or those who are not responding to cholesterol-lowering treatment [116].

Homocysteine assays are available; however, screening of asymptomatic women with no history of CHD is not recommended [113]. Plasma homocysteine levels are inversely related to vitamin intake, especially vitamins B6, B12, and folate. As a result, high levels of homocysteine may usually be remedied by increasing folic acid intake through diet or supplements (400 mcg/day) [114]. Dietary sources of folate include orange juice, green leafy vegetables, and fortified cold breakfast cereals [114,115].

A CRP test (i.e., the hs-CRP assay) is widely available and may be completed at the same time as cholesterol screening. There is a general consensus that the hs-CRP assay should be reserved for individuals with a 10% to 20% (i.e., intermediate) 10-year risk of CHD after screening for traditional risk factors (e.g., family history, age, hypertension) has been performed [113,127]. Increased CRP may predict future cardiovascular events in both women and men with CHD; therefore, using both cholesterol and CRP to determine heart attack risk is more accurate than either test alone. When both values are elevated, there is a significantly increased risk for CHD [121,124]. It is important to recognize that CRP is only a good predictor of cardiac risk if the test is done when there is no current infection (e.g., sinus infection) or other chronic underlying inflammatory process (e.g., rheumatoid arthritis, lupus, Crohn disease). Additionally, there is a general consensus that CRP levels are most effectively used to determine risk classification and to reclassify risk of coronary events in some individuals [128]. Reducing CRP levels has not been shown to reduce coronary events [127,129,130].

Reports on physical activity and CHD in women have been conflicting. While some studies have found no reduction in CHD risk, many other studies have demonstrated lower all-cause mortality in women and men with higher levels of fitness. A study published in 2001 reported that even light-to-moderate amounts of exercise (i.e., at least one hour of walking a week) were associated with a lowered risk of CHD in women [297]. This correlation extended to women with heightened risk for CHD, including those who were overweight, had high cholesterol, or smoked.

According to the American Heart Association, women should be advised to accumulate at least 150 minutes per week of moderate exercise, 75 minutes per week of vigorous exercise, or an equivalent combination of moderateand vigorous-intensity aerobic physical activity. Aerobic activity should be performed in episodes of at least 10 minutes, preferably spread throughout the week.

(https://ahajournals.org/doi/10.1161/cir.0b013e31820faaf8 Last Accessed: December 12, 2022)

Level of Evidence: IB (Intervention is deemed useful and effective based on limited evidence from single randomized trial or other nonrandomized studies.)

Exercise may favorably modify other cardiovascular risk factors by increasing HDL, decreasing total cholesterol levels, augmenting fibrinolytic activity decreasing the risk of thromboembolism, and improving insulin resistance, especially in obese women. Additional benefits associated with exercise include weight and blood pressure control, as well as promoting a general sense of well-being [298].

Female patients should be instructed on the importance of aerobic exercise for cardiovascular fitness. Aerobic exercise lowers blood pressure and resting heart rate, as well as counteracts the detrimental effects of other cardiovascular risk factors, such as obesity and stress [36,83,85]. Like men, women should engage in aerobic exercise for at least 30 minutes, five times per week [84,85]. Women who have previously been sedentary should begin with short intervals of activity (e.g., 5 to 10 minutes) and gradually increase the intervals. Moderate- to vigorous-intensity exercise for 30 minutes on most days of the week is ideal [299]. Cardiovascular fitness is reached when the patient's heart rate decreases 30 beats per minute within the first minute after stopping maximum exercise [73]. However, women with chronic health problems as well as those 50 years of age and older who are just beginning a physical activity program should first consult with a physician [83].

New evidence points to the impact of psychosocial well-being on heart health. Findings from the Study of Women's Health Across the Nation (SWAN) study of 312 women found well-being was associated with less progression of CHD even after adjustment for health behaviors, depression, and other potential confounding factors. Well-being was measured through a composite score of optimism, life engagement, life satisfaction, rewards from multiple roles, positive affect, and vitality [358]. These results demonstrate the importance of the mind-heart-body connection in CHD prevention across the lifespan.

Psychosocial well-being in women can be encouraged in multiple ways. First, women can be encouraged to assess the stressors in their lives and incorporate methods to lessen them, thereby promoting well-being and a healthy outlook on life. Stress management techniques that are effective vary from person to person but may include exercise, hobbies, daily periods of solitude, looking for ways to better organize and simplify their lives, and spending time with friends and loved ones. Building and maintaining supportive social networks are critical as well.

As discussed, contraceptives containing both estrogen and progestin have been associated with an increased risk of CHD. The risk is highest in women who are older than 35 years of age, smoke, and have other cardiovascular risk factors. While estrogen has been linked to some favorable effects on lipids and serum lipoproteins—namely increased HDL and decreased LDL—it also is associated with increased triglyceride levels. Progestins are believed to produce unfavorable effects by decreasing HDL and increasing LDL levels. In addition to changes in lipid metabolism, hormonal contraceptives have an effect on blood pressure for some patients [300].

As a result of these lipid changes, birth control counseling is a mainstay of primary prevention in high-risk women. These women should be advised to explore safer birth control methods, such as the diaphragm, contraceptive sponge, or condoms. While the birth control pill poses increased risk, the oral contraceptives available today are safer and contain less estrogen than those seen during the 1960s [301].

The American Heart Association asserts that pharmacotherapy is indicated when blood pressure is ≥140/90 mm Hg (≥130/80 mm Hg in the setting of chronic kidney disease and diabetes). Initial treatment of high-risk women with acute coronary syndrome or myocardial infarction should be with beta blockers and/or angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), with addition of other drugs such as thiazides as needed to achieve goal blood pressure. However, ACE inhibitors are contraindicated in pregnancy and ought to be used with caution in women who may become pregnant.

(https://ahajournals.org/doi/10.1161/cir.0b013e31820faaf8 Last Accessed: December 12, 2022)

Level of Evidence: IA (Intervention is deemed useful and effective based on Sufficient evidence from multiple randomized trials.)

Appropriate management of systolic and diastolic hypertension is critical to reduce adverse cardiac effects. Lifestyle changes that may assist in achieving healthy blood pressure include weight control, physical activity, as well as moderation of alcohol intake and sodium restriction. If blood pressure readings remain ≥140/90 mm Hg (≥130/80 mm Hg in the setting of chronic kidney disease and diabetes) after three months of lifestyle modification, or if initial readings are greater than 160 mm Hg systolic or 100 mm Hg diastolic, pharmacologic intervention should be initiated and individualized for each woman [59,62,281].

Primary prevention is aimed at lowering elevated serum cholesterol and triglyceride levels. Controlling diet, weight management, smoking avoidance, and exercise are positive lifestyle choices that should be promoted in all women, and especially those with elevated lipid profiles. Lifestyle interventions that may help lower high cholesterol and triglyceride levels include [281]:

Despite positive lifestyle changes, some women may require a lipid-lowering agent (Table 4) [281].

The effects of glycemic control in reducing cardiovascular risk in patients with diabetes are unclear. A diet with less than 30% of calories from fat, less than 7% of calories from saturated fat, 0% from trans-fatty acids, and cholesterol intake less than 150 mg/day should be encouraged [281]. When indicated, the use of insulin and hypoglycemic agents may be used to control blood glucose levels based on the type of diabetes and patient response. Regular physical activity should also be encouraged in women with diabetes [281]. In addition, for metabolic syndrome, lifestyle changes such as weight loss, exercise, and smoking cessation are the main treatment strategies [302].

Antioxidants such as vitamin C, vitamin E, and beta-carotene have been found to be effective in inhibiting either the oxidation of LDL cholesterol or its uptake into the endothelium of coronary arteries. Although more research is needed, some preliminary studies have demonstrated a significant inverse relationship between the use of antioxidant vitamins and a reduction in CHD [20,79]. On the other hand, the Alpha-Tocopherol Beta Carotene Cancer Prevention Study Group reported no significant reduction in the incidence of CHD in middle-aged male smokers who took beta-carotene and/or vitamin E daily supplements. Rather, in this study there was a concern for an increased risk of hemorrhagic stroke among those subjects who took vitamin E supplements. Therefore, the findings of these and other studies are inconclusive regarding the benefits of antioxidant vitamins in reducing CHD risk and also point out some of the potential associated health risks [311,312,313]. In 2004, after reviewing all available studies regarding antioxidant supplementation and CHD, the AHA concluded the evidence indicated antioxidant supplements had little to no definitive effect on preventing or treating CHD. Due to this analysis, the AHA does not recommend the use of antioxidant vitamins as part of prevention or treatment of CHD [314]. Rather, AHA continues to stress the importance of diet but does not rule out the possible beneficial role of antioxidants derived from food sources for patients with CHD [281,314].

Calcium supplementation, especially with vitamin D, has been a recommended public health intervention for older postmenopausal women to reduce fracture risk. Meta-analyses suggest calcium with or without vitamin D increases MI risk. With concerns over the quality of these meta-analyses, a more recent meta-analysis of randomized controlled trials found calcium supplementation with or without vitamin D did not increase CHD or all-cause mortality risk in older women [351].

As with men, low-dose aspirin therapy may play a role in the primary prevention of CHD in women. Aspirin works as a thromboxane inhibitor keep blood platelets from sticking together and forming clots [281]. The NHS demonstrated a 32% reduction in risk of first MI in women who took low-dose aspirin (i.e., one to six aspirin per week) [303]. While low-dose aspirin may be associated with a somewhat lower cardiovascular and total mortality rate in women, its cardioprotective role is not without limitations. The benefit of such therapy should be weighed against the risk of hemorrhagic stroke and gastrointestinal bleeding [304]. In 2022, the U.S. Preventive Services Task Force issued updated guidance regarding the use of aspirin for cardioprotection [304]. They recommend against initiating low-dose aspirin use for the primary prevention of cardiovascular disease in adults 60 years or older. The decision to initiate low-dose aspirin use for the primary prevention of cardiovascular disease in adults 40 to 59 years of age who have a 10% or greater 10-year risk should be an individual one. Evidence indicates that the net benefit of aspirin use in this group is small. Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit [304].

Like aspirin, clopidogrel inhibits platelet aggregation but through the adenosine diphosphate pathway. It is recommended as a preventive intervention in high-risk women who are intolerant of aspirin therapy [281].

Additional research has evaluated clopidogrel versus aspirin. The Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) study was one of the largest studies conducted on a medication in development. This three-year, international study enrolled 19,185 patients who had previously suffered an ischemic stroke, MI, or symptomatic peripheral arterial disease. Patients received either 75 mg of clopidogrel or 325 mg of aspirin daily. Clopidogrel was shown to be more effective than aspirin in reducing the number of MIs, strokes, and vascular deaths in at-risk patients. Researchers found aspirin prevented about 25% of these events, whereas clopidogrel prevented about 33% of them [306]. All of the patients in CAPRIE had been diagnosed with atherosclerosis. Atherosclerotic plaques can cause cracks or fissures in the vessel wall. Blood platelets aggregate around these fissures and cause the formation of thrombi that can completely block or occlude arteries. This process, atherothrombosis, is the common link that results in ischemic strokes, MIs, and vascular death. Importantly, CAPRIE showed that patients treated with clopidogrel were significantly less likely to suffer from severe gastrointestinal bleeding than those treated with aspirin. This finding is particularly striking because the entire study population had been rigorously selected to exclude those patients with a history of ulcers or gastrointestinal bleeding. The study showed no other relevant differences in clinical or biologic effects between the groups. In CAPRIE, the most common clinically important side effects were pruritus, purpura, diarrhea, and rash. Infrequent events included intracranial hemorrhage (0.4%) and severe neutropenia (0.04%). Suspected cases of thrombotic thrombocytopenic purpura have been reported at a rate of about four cases per million patients exposed [306].

The U.S. Preventive Services Task Force recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons.

(https://jamanetwork.com/journals/jama/fullarticle/2797867 Last Accessed: December 12, 2022)

Strength of Recommendation: D (USPSTF recommends against routinely providing the service based on at least fair evidence that it is ineffective or that harms outweigh benefits.)

Estrogen was once thought to have a relative protective value against CHD in premenopausal women. In the past, hormone replacement therapy was shown to decrease this risk by as much as 50% [17,44,73]. It was believed to confer protection not only by decreasing triglyceride and LDL levels, but also by increasing HDL levels. While further evidence suggests estrogen provides protection by improving lipid and carbohydrate metabolism, lowering blood pressure, and producing beneficial coagulation patterns, newer studies indicate that hormone replacement therapy does not provide protection against CHD in women as once believed [17,315,316,317,318]. The AHA, the U.S. Preventive Services Task Force, and the Institute for Clinical Systems Improvement agree that hormone replacement therapy should neither be initiated nor continued to prevent CHD [235,319,320,321].

The resting ECG is the first-line screening test used in men. It is also an important test in women due to the increased proportion of unrecognized or "silent" infarctions. The presence or absence of abnormal Q waves on the resting ECG may be affected by the use of HRT in women older than 50 years of age. Study results have shown that HRT, specifically estrogen therapy, lengthens the QT interval in postmenopausal women [148,149].

Exercise ECG (also referred to as the stress test or exercise treadmill test) may not be as accurate in the diagnosis of CHD in women as in men [347]. However, the ACCF and the AHA recommend the routine use of the exercise ECG (when combined with traditional analysis of ST-segment and heart rate changes) for evaluating suspected CHD in women who have a normal resting ECG and good exercise tolerance [150]. Women with nonobstructive disease and stress test abnormalities are no longer defined as having a false-positive test. Instead, their test is classified as abnormal, and they are noted as being at an elevated risk of obstructive CHD [150]. A test result that is clearly negative has been found to be equally reliable in both women and men [141]. Better diagnostic results are seen in women with multivessel involvement versus single vessel or no disease. With multivessel disease, an overall accuracy of 84% has been reported [150].

Even in women with CHD, the accuracy of using exercise ECG for diagnosis alone is not recommended. When test results are clearly positive or not clearly positive or negative, additional risk stratification with cardiac imaging is recommended [150]. The ACCF/AHA have recommended cardiac imaging for symptomatic women with established CHD, women who have an indeterminate or intermediate-risk exercise ECG test, and women with an intermediate-risk Duke treadmill score. Cardiac imaging has also been recommended for women with diabetes, metabolic syndrome, and polycystic ovary syndrome because of their increased risk of cardiovascular death [122,150].

A second difficulty associated with the exercise ECG is women must be able to raise their heart rate up to 85% of maximum capacity by exercising for about 15 minutes. Women have a lower maximal aerobic capacity, which limits their ability to exercise to adequate intensity levels. As a result, the test is too strenuous for many women who are older, sedentary, or have other medical conditions limiting their ability to exercise (e.g., arthritis) [150].

The exercise echocardiogram is a two-dimensional exam used to assess synergy of myocardial contraction. This test is more specific and reliable than the exercise ECG and a strong, independent prognostic indicator [156,157,158]. The exercise echocardiogram is a useful diagnostic test in women because of its sensitivity to single-vessel disease (greater than 50% stenosis), which occurs more frequently in women than men (18% versus 9%) [159]. When properly performed (i.e., not stopped too quickly), the exercise echocardiogram has been found to have high sensitivity and specificity (86%) for the detection of CHD in women [25].

Due to the difficulty of diagnosing changes with exercise, drugs such as dipyridamole, adenosine, or regadenoson may be used to stress the heart [159]. Dipyridamole is a potent coronary artery vasodilator. Side effects from its use include dizziness, gastrointestinal upset, nausea and vomiting, headache, and rash. Adenosine has a more rapid onset but wears off more quickly. Adverse reactions include transient new arrhythmias and heart block [160]. Regadenoson increases coronary blood flow and mimics the increase in coronary blood flow caused by exercise. Adverse reactions include tachycardia, flushing, chest discomfort, and headache [160]. In 2013, the FDA issued a warning of a rare but serious risk of MI and death associated with both adenosine and regadenoson [161]. The FDA has approved changes to the drug labels to reflect these events and updated its recommendations for their use [162]. These agents should be avoided in patients with evidence of unstable angina or cardiovascular instability.

The American Society of Nuclear Cardiology has stated that dobutamine infusion may be an effective alternative agent for stress echocardiography [163]. Dobutamine stimulates beta-adrenergic receptors, resulting in increased contractility and heart rate. It may cause premature ventricular contractions, chest pain, and hypotension. Adverse reactions include nausea, dyspnea, and fever. It is important to note that dobutamine infusion for stress echocardiography is an off-label use [160].

The nuclear medicine myocardial perfusion scan is another noninvasive test that may be used in women. At peak exercise, a small amount of radioactive tracer is injected and a series of images of myocardial blood flow are then evaluated. Normal myocardial blood flow is indicated by a homogeneous distribution of thallium throughout the myocardium, while myocardial ischemia and/or infarction is suggested by either a transient or persistent defect in tracer uptake. Compared with exercise ECG, nuclear medicine perfusion tests have better accuracy with fewer false-positive results in women, especially in patients with multivessel disease [141,151,152,153].

Stress myocardial perfusion imaging (MPI) is recommended to diagnose CHD in women with intermediate-to-high risk who have resting ECG abnormalities. Stress MPI may be performed with single photon emission computed tomography (SPECT) or positron emission tomography (PET) imaging. Widely available, SPECT has robust evidence of utility in women; however, false-positive results from breast attenuation and obesity-related artifacts are its main limitation [347].

PET is another tool in the assessment of functional ischemia replacing the need for invasive angiography. PET imaging is well suited in the diagnosis of women, with its built-in attenuation correction and lowered radiation exposure compared with SPECT. In addition to assessing relative perfusion, PET assesses absolute quantitative coronary flow and flow reserve from the coronary macro- to microvasulature. Thus, this test can aid the diagnosis of microvascular dysfunction (nonobstructive CHD), which is defined as a functionally reduced coronary flow reserve in the absence of flow-limiting CHD. More prevalent among women and those at high cardiovascular risk, microvascular dysfunction is associated with adverse outcomes [347].

Cardiac magnetic resonance imaging (CMR) has grown considerably in the last decade and is a recommended test in the evaluation of suspected ischemia in symptomatic women at intermediate-to-high CHD risk [347,348]. CMR is a comprehensive imaging modality that can provide detailed evaluation including myocardial structure, function, viability, ischemia and valvular heart disease and, thus, is useful in detecting coronary microvascular dysfunction. It avoids the risks of ionizing radiation exposure with high resolution and diagnostic accuracy [347].

Electron beam computerized tomography (EBCT), also called an ultrafast CT scan, is a rapid form of non-contrast imaging technology that results in a clear image of the heart and surface of the coronary arteries. EBCT has been studied as a tool to identify individuals at risk for CHD by measuring calcium deposits in the coronary arteries which correlate to the amount of atherosclerosis. Experts have indicated, however, that the amount of coronary calcification does not necessarily indicate that an individual will suffer an MI, and the absence of calcification does not rule out CHD. Still, calcium scoring has been shown to improve risk prediction in women and assist therapeutic guidance, especially for intermediate-risk women [164,347]. The Multi-Ethnic Study of Atherosclerosis (MESA) trial included 3,601 women, 90% of whom were classified as low risk [165]. The prevalence of any coronary calcium was associated with a six-fold increased risk of CHD, adjusted for age, ethnicity, body mass index, LDL, hypertension, smoking, estrogen, and statin therapy. The results showed that the presence of coronary calcium redefined the women who had been improperly labeled as low-risk, based on Framingham criteria.

Rapid development has also occurred in coronary computed tomographic angiography (CCTA) in recent years. CCTA can assess many causes of CHD in one test. It has high sensitivity as well as diagnostic and prognostic accuracy for detecting and excluding CHD and coronary anomalies in both men and women [347,348].

Coronary angiogram is the definitive diagnostic test to detect CHD despite major drawbacks, such as its invasive nature, cost, and potential complications [11]. While the number of catheterizations performed on women has increased, men are more likely to be referred for catheterization than women, possibly because women may be at greater risk of adverse events after angiogram, including death [167,168,169,170]. One study found that men were 40% more likely to undergo angiography than women, despite angiography data indicating women have more functional impairment and unstable symptoms than men [171,172].

A number of factors may affect the decision to perform invasive testing. Patient factors may include symptom severity, response to treatment, lifestyle modification, comorbidities, age, social circumstances, and personal preferences. A Canadian study found that, after detection of acute coronary syndrome, neighborhood socioeconomic status negatively affected the receipt of cardiac catheterization and mortality for women but not men. Every incremental decrease in income quintile for women was associated with 6% lower odds of receiving cardiac catheterization within 30 days and 14% higher odds of 30-day mortality [173]. Women may also be more likely to defer invasive testing until a cardiac crisis occurs because they tend to underestimate the impact of CHD on their lives [174,175,176]. Provider factors may include interpretation of symptoms and their severity and noninvasive test results, as well as perceptions of the probability of CHD and the risk/benefit of potential revascularization strategies. Thus, bias can influence provider perceptions and interpretations. Social factors center on the availability of noninvasive testing and cardiac catheterization facilities [177].

Compared with men, when angiography is performed in women the test usually reveals less extensive disease [172]. Single-vessel disease occurs in 50% of women, with the left anterior descending artery the most common site of lesions (i.e., in 43% to 54% of cases). In the remaining 50% of women, 25% have two-vessel disease and 25% have three-vessel disease. In addition, left main disease is less common in female cardiac patients compared to men [11,19,35]. Despite these findings, women continue to experience persistent symptoms, poor functional status, and recurrent hospitalizations and repeat angiograms [347].

The sexes differ in still other ways when it comes to cardiac symptomatology. Men often experience textbook cases of angina and other CHD symptoms, perhaps because the texts were written to describe men's symptoms. However, the classic picture of CHD in women is just not known. For example, the hallmark symptoms of an MI (i.e., chest discomfort, pain that spreads, cold sweats, nausea) are experienced more frequently by men than women. Additionally, while chest pain is the most common symptom reported among both women and men, women more frequently report "vague" chest discomfort that comes and goes with no particular precursor [139,187,188].

Women may complain of classic substernal pain or have variations in their chest pain syndromes for reasons that are not completely understood. Women frequently report pain centered in the chest, pain in one or both arms, pain in the neck and/or jaw, or pain centered in the back and/or shoulders. Women also frequently report nausea, back pain, dizziness, generalized fatigue, shortness of breath, and palpitations [139,145,187,189,190]. Recognition of these sex differences in symptom reporting may result in more prompt and accurate diagnosis and treatment, as well as preventable deaths.

Clopidogrel is an antiplatelet agent approved since 1997 for use in the reduction of atherosclerotic events in patients with recent MI [305]. The Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events (CURE) trial enrolled 12,562 patients with unstable angina or non-Q-wave MI. The study found that the addition of clopidogrel to aspirin for patients with acute coronary syndrome reduced the risk of death, reinfarction, or stroke by 20% in people who had survived a mild heart attack. These patients were at serious risk of further complications in the days and months following their attack. The drug showed equal benefits for those with unstable angina. The effects were evident within two hours and were sustained [305]. A major side effect was serious bleeding, such as stomach ulcers, which occurred in about 1% of patients (a similar rate to the effects of aspirin) [305].

Studies have revealed responsiveness to clopidogrel is not uniform, and a low response is linked to a higher incidence of thrombotic events. As a result, newer P2Y12 receptor antagonists (e.g., prasugrel, ticagrelor) and a combination of clopidogrel with newer oral anticoagulants (e.g., dabigatran, apixaban, rivaroxaban) are being studied for their use in patients with stable and unstable CHD [307,308,309,310].

Thrombolytic therapy is frequently given to patients within the first six hours of presenting with possible cardiac symptoms. It has proved beneficial in restoring vessel patency and improving clinical outcomes in both men and women (i.e., 25% to 30% reduction in short-term mortality) [209,216]. However, women are less likely to receive thrombolysis to restore vessel patency in the management of acute MI for several reasons, including advanced age, delayed arrival at the hospital, and medical contraindications [216]. Even in those eligible, women are less likely to receive thrombolytic therapy [217]. The Gruppo Italiano per lo Studio della Streptochinasi nell'infarto Miocardico (GISSI-1) first validated streptokinase as an effective therapy and reported a significant reduction in the 21-day mortality in women who received IV streptokinase within six hours post-MI. Despite these promising outcomes, treated women's mortality rates remain higher than men's [217,218,338]. The AHA recommends thrombolytic therapy be used at non-PCI centers when a significant delay to performing a primary PCI within 120 minutes of first medical contact is anticipated [338].

Women who are treated with thrombolytic therapy tend to experience more complications, such as major bleeding and stroke. Increased bleeding, especially severe intracranial bleeding, has been reported in some women, particularly with advanced age [216,338]. These adverse reactions may be due to the administration of fixed dosages as women may require lower doses to be consistent with their smaller body mass. Indeed, differences may exist between the sexes in how drugs are absorbed, distributed, metabolized and excreted. Historically excluded from clinical trials related to cardiac medications, women continue to be under-represented in drug studies. Inclusion of women in these trials is imperative in order to understand differences that may exist so clinical care can be individualized accordingly to enhance best possible cardiovascular outcomes for women. [217; 342; 346; 353].

PCI is the treatment of choice for patients with single-vessel disease [207]. It offers patients a lower 30-day mortality rate compared with thrombolytic therapy [338]. An estimated 35% of PCIs in the United States are performed in women [208]. At the time this procedure was first performed, women tended to be on average nine years older than men, with more cardiovascular risk factors and severe unstable angina [208]. However, angiographically documented CHD has not been found to be more extensive in women compared to men [209]. On a per-lesion basis, angiographic success rates have been found to be similar between men (88%) and women (89%), as were clinical success rates [209,210]. Determinants of PCI success include lesion-specific angiographic features, such as the severity of stenosis, coronary calcification, and intralesional thrombosis-factors that are not influenced by either age or sex [211]. In treating left anterior descending disease, CABG surgery is an attractive option due to the high rate of post-PCI restenosis [208].

Women undergoing PCI with stenting have a greater incidence of initial post-procedure complications. These short-term complications include bradycardia, hypotension, MI, bleeding, and vascular complications [210,347]. Radial versus femoral access sites has significantly decreased these complications in women [347]. A higher rate of unsuccessful PCIs, or inability to cannulate the vessel and pass the lesion with the balloon catheter, has also been reported in female patients. [210]. These women are more likely to have elective CABG surgery after PCI than men. Advances in new techniques and equipment, such as angioplasty catheters, as well as the clinical expertise of the physician performing the procedure, are helping to bring these rates into comparable levels between men and women [210,212,213].

Historically, women had a significantly higher in-hospital mortality rate compared with men [212,214]. However, according to the results of one meta-analysis, reported increases in both all-cause and in-hospital mortality in women is confounded by baseline cardiovascular risk factors and differences in the clinical profile of male and female patients, suggesting that intensive risk modification efforts in women may help reduce the sex disparities [215]. Long-term follow-up at 20 months post-procedure shows women tend to have decreased mortality after stenting compared with men [347].

Additionally, survival rates post-PCI are similar for men and women with regard to long-term outcomes [215]. While women have slightly fewer coronary events and a lower incidence of restenosis and need for additional revascularization (i.e., repeat PCI or CABG), symptomatic improvement is similar for men and women [210].

The Coronary Artery Surgery Study (CASS) investigated 2,800 women and 5,300 men who were experiencing severe enough chest pain to warrant a coronary angiogram. This study revealed a number of differences in the preoperative status of men and women. As discussed earlier, women were found to be at increased surgical risk because they tend to be older, have more unstable angina, frequent cardiac enlargement on chest x-ray, severe mitral regurgitation, and more symptoms and comorbidities, such as hypertension, diabetes, and heart failure. Factors that place women at lower risk include they tend to have fewer diseased arteries and less myocardial damage. In other words, women generally have better EFs and ventricular wall motion, as well as less left main stenosis and three-vessel disease [11,19,26,27,35]. It has been suggested these differences in preoperative status may be less related to sex than to delays in the initial diagnosis and treatment of symptomatic CHD in women. This delay translates into an older age and more frequent comorbidity in women at surgical presentation [219,220].

CABG surgery continues to be the criterion standard in the treatment of multi-vessel CHD in both men and women. However, women tend to be referred for surgery much later in relation to men. In one study, fewer women with symptoms were referred for angiogram, and men underwent CABG four times as often as women. Women were referred more for symptoms of unstable angina, heart failure, and post-MI angina, while men were referred on the basis of a positive exercise ECG [19,26]. As a result, women are more likely to have surgery on an emergency basis, with potentially fewer techniques available to the surgeon, rather than on an elective basis, as is common in men. For example, the use of left internal mammary artery (LIMA) grafts is accepted as the criterion standard for surgical revascularization. Many studies have demonstrated better long-term patency rates and survival in patients undergoing CABG with LIMA [223,224]. The benefit of LIMA grafts has been observed consistently regardless of age, sex, stenosis severity, or LV function. Although a number of risk factors have been identified to result in LIMA graft failure, they are less common than for other grafts [224]. Nevertheless, the risk-to-benefit question is of increasing importance as the proportion of high-risk subgroups continues to rise [223,225].

In terms of operative success, the perioperative mortality rate has been documented to be higher in women than in men despite less preoperative coronary plaque burden [347]. These outcomes are particularly true for women younger than 60 years of age; however, advanced age is still considered a significant risk factor for women [226]. The higher mortality in women may be attributed to pre-operative clinical status, other cardiovascular risk factors, and smaller body size and coronary artery diameter, which make anastomosing grafts more difficult. As surgical techniques become more refined, the latter issue may be less of a problem. For both men and women, operative mortality decreases as height and vessel diameter increases. Therefore, vessel diameter, and perhaps not sex, is most indicative of operative success [19,26,35,36].

Improved surgical techniques, such as off-pump coronary artery bypass, appear to be safe, effective surgical alternatives for high-risk patients, including women [228]. However, evidence is conflicting on the long-term outcomes [228]. A Canadian study reported the five-year survival rates to be similar between on- and off-pump CABG, while a study funded by the Department of Veterans Affairs found that off-pump CABG led to lower rates of five-year and event-free survival compared with on-pump CABG [229,230]. Factors that may contribute to long-term survival include the completeness of revascularization and surgeon experience [231,232].

Postoperative outcomes of women after CABG surgery have also been studied. The findings indicate that women experience increased hospital stays, higher complication rates, and greater postoperative morbidity, leading to more hospital readmissions compared with men [26,227,228]. Women report less relief of angina, more symptoms, and poorer overall health than men [35,225].

An interesting study compared the symptoms experienced by men and women during the first four weeks of recovery post-CABG surgery. Women reported numbness and discomfort in their breasts, while men reported more fatigue, incisional pain, and negative emotions. Both men and women felt their recovery emotions were related to their social roles and circumstances [225]. For instance, women were concerned and anxious about who would care for them during their home recovery, as they tended to be older and live alone. In contrast, men were more concerned first with their immediate physical recovery symptoms and secondly with return to work issues [233]. Researchers have noted that women tend to find strength for the postoperative recovery phase from their own spirituality and relationships with others, especially their families, friends, and social networks [234]. One study found that women's primary concerns shifted over the course of one year after CABG surgery [235]. In the first postoperative month, women were most concerned with issues related to future plans, such as progress in recovery and resuming their lifestyle. By one year after surgery, women were most concerned about diet, and more than half of the women were exercising more.

Additional studies offer more encouraging news for women. A study conducted by several leading New England hospitals compared patients and outcomes from 1987–1989 with those from 1993–1997. Researchers found that although women having CABG in the latter date range were older and sicker than those in the earlier range, the mortality rate had decreased [221]. Another study of 2,200 patients who underwent CABG at Cleveland Clinic between 1993 and 2003 found no sex difference for in-hospital mortality but did find that women have a longer length of stay after surgery, as well as higher postoperative complications rates, factors that may affect a woman's postdischarge recovery.

The Surgical Treatment for Ischemic Heart Failure (STICH) trial randomized 148 women and 1,064 men with heart failure to either CABG plus medical therapy or medical therapy alone [222]. Ten-year outcomes with each treatment were compared according to sex. At baseline, women were older with higher BMI, more cardiovascular risk factors (e.g., diabetes, hypertension, hyperlipidemia), and lower rates of prior CABG than the men. Women also had higher NYHA class and lower six-minute walk capacity. However, over 10 years of follow-up, all-cause mortality and cardiovascular mortality were significantly lower in women compared with men. Additionally, there was no significant association between sex and treatment groups in all-cause mortality, cardiovascular mortality, or the composite of all-cause mortality or hospitalization [222].

While women have a lower aerobic capacity at baseline and after exercise training, the magnitude of their improvement is similar to or greater than that of men after a 12-week program. In other words, cardiac rehabilitation may actually have greater benefit for women because they begin with a lower functional capacity. Women develop increased physical work capacity and lower their myocardial oxygen demand through exercise training and achieve the same training effects as men [245,251]. In addition to exercise, cardiac rehabilitation favorably alters other cardiovascular risk factors [252,253]. In one study, both men and women showed a trend in decreasing mean weight and quitting smoking. Yet, no changes in their lipid profiles were found before or after the program [245].

Women have a tendency to begin household activities early in the postdischarge period, often immediately upon discharge, then increase progression of their activities by the third or fourth week. In studying psychosocial responses, women tend to experience guilt feelings if they are not able to assume their usual household activities after their cardiac illness and often resist help from their family members because they do not perceive chores as a strenuous activity [225]. In contrast, men tend to rest for a period prior to progressing activity levels and begin to walk at approximately three to four weeks after discharge from the hospital [26]. As a result, women tend to be active at higher metabolic equivalent levels compared to men, most likely due to the earlier resumption of household activities. This is an area of major concern in the treatment of female patients due to their higher mortality rate post-MI. Women also experience more depression in association with their cardiac illness compared to men, which may be associated with activity limitations due to recurring symptoms and poorer health [19,237].

According to research presented at the Acute Cardiac Care Congress 2013, a delay in treating patients with MI postpones their return to work and increases early retirement [254]. Researchers conducted a population-based cohort study that included 4,061 patients younger than 67 years of age admitted with STEMI who were treated with PCI during a 13-year period (1999–2011). Only patients who were employed either full-time or part-time before their admission were included in the study. After four years of follow-up, 91% of the study population had returned to work. After eight years of follow-up, 29% had retired. After adjusting for confounding factors, the researchers found that a delay in treatment of more than 120 minutes was associated with a postponed return to work. Researchers also discovered that after eight years, a long delay in treatment of MI resulted in a 21% increase in retirement rate. Researchers found no differences between men and women in the effect of treatment delay but did find that men returned to work later than women [254].

Another component of cardiac rehabilitation involves psychosocial support. This support may be provided either individually or in group settings [237]. Support groups may be offered as an intervention to meet the unique needs and concerns of women with CHD. Because women tend to be more process- and relationship-oriented, they may have a need to talk about their experience with other women, family, friends, and healthcare providers after the cardiac event. Asking female cardiac patients what they believe caused their cardiac illness and what fears they have, as well as what the experience means to them or what they have learned as a result of their heart condition, may be helpful [19,192].

Cardiac support groups may also be designed to include family members in addition to the female cardiac patient. Many different kinds of groups may be offered to provide support during the acute and convalescent phases. For instance, a support group could be offered to the families of women who have undergone CABG surgery. Family members could be asked how they perceive their relative is responding to the cardiac event and how the event is affecting their lives [192]. Other groups may be offered for only the patient, for example after recovering from an MI, or the group may be structured to also include the patient's spouse or significant other. Regardless of the approach used, the group sessions should be scheduled at times that are convenient for women and their families.

Several experts have described the common themes discussed in either patient, spouse, or couple support group settings. The common themes often discussed in patient-only groups include [255]:

While these themes have been reported in numerous group settings with cardiac patients and families, more research is needed to determine whether the themes are equally common when the patient is a female [255]. Perhaps some of these themes are more prevalent or are only reported in cases of men with CHD. In addition, some themes would undoubtedly only be present when a woman in the family has CHD.

In contrast, couple groups were concerned with issues such as expressing anger, imparting information, instilling hope, redefining wellness, identifying with others, and an altruistic concern for others. Themes in spouse groups have centered on the following areas [255]:

As with patient-only group themes, further investigation is needed to determine if the themes of couple and spouse groups are similar when the cardiac patient is a woman. These relationships will most likely be affected in unique ways when a woman in the family is struck with CHD.

Regardless of whether a medical or surgical approach is taken in the treatment of women with CHD, patients should be encouraged to enroll in an outpatient cardiac rehabilitation program. These programs have shown that women can favorably impact their cardiovascular risk profile and obtain physiologic benefits of aerobic exercise. Furthermore, addressing psychosocial aspects of care through support groups or individual therapy may be helpful.

The main implication for assessment in women is recognition that chest pain may not be their presenting symptom. Women have more complaints of vague chest pain that warrant further workup. It is important to anticipate nonspecific signs and symptoms, such as back pain and loss of appetite. It is important to be aware of the possibility of occult CHD in women older than 65 years of age. Unrecognized CHD may complicate the recovery course of women who are hospitalized for noncardiac problems, as women have more episodes of silent ischemia and infarction. Nurses have a critical role in the thorough assessment of patients and in providing education on reduction of cardiovascular risk factors and recognition of signs and symptoms of CHD [256].

Historically, it has been believed that women will respond to the same cardiovascular interventions as men. However, the clinical outcomes may be quite different. Therefore, it is important not to assume that what has been learned about men through practice or research may be equally applied to women [257,258]. The unique physiologic aspects of women's cardiovascular systems should be considered when implementing medical therapy [257,258].

Nurses have a special role to play as patient advocates when caring for women with cardiac problems. Nurses should encourage symptomatic women to interact with their physician to obtain a correct diagnosis and suggest appropriate cardiac diagnostic tests, such as exercise echocardiograms. If female patients are not responding to medical or nursing interventions, nurses should question if these are the right therapies. By detecting subtle changes in a woman's response to treatment, nurses can provide input and suggestions for the plan of care. For instance, if anginal episodes post-MI are not resolving, changing to a cardioselective beta blocker and adding nitrates to the medication regime may be suggested. In addition, nurses can request researchers to gather data on women or replicate studies with women. With increased understanding of female responses to CHD, nurses will be able to identify and test more appropriate interventions. If women and men respond differently to cardiac events, nursing care standards should then be modified and integrated into clinical practice accordingly [257,258].

Several sequelae may occur in women with CHD during the acute hospitalization phase, including decreased cardiac output, alteration in comfort level or pain, knowledge deficit, activity intolerance, body image disturbance, and sexual dysfunction [258,338]. Each of these will be further explored, with special consideration given to implications for treatment in female patients.

Decreased Cardiac Output

Decreased cardiac output is one of the most significant sequelae in women with CHD. This diagnosis exists whether the woman is experiencing angina or MI or is recovering from CABG surgery, although the nursing implications may vary with each clinical scenario.

It is important to recognize female cardiac patients experiencing angina have a more favorable prognosis than men. However, prevention of an acute MI is paramount in this group, because when a woman does have an MI, she has an unfavorable prognosis. A comprehensive cardiovascular risk assessment should be performed, focusing on both traditional and sex- and gender-specific risk factors (e.g., myocardial dysfunction, blood loss, increase in intrapericardial pressure, changes in cardiac rhythm and/or electrical conduction) [259]. When these risk factors have been identified, female patients may be educated and counseled about strategies to reduce their cardiovascular risks through various lifestyle modifications [145,259].

During the post-MI phase, female patients have significant morbidity and mortality. Assess for the presence of other diseases that may impact the patient's recovery, such as diabetes or hypertension, as well as early manifestations of heart failure [145]. Several pharmacologic considerations in relation to cardiac output status apply in these patients. Cardiac medications, such as antidysrhythmics, may be less indicated in women because complex ventricular ectopy or ventricular dysrhythmias are not associated with as severe adverse prognoses as in men. It is also important to recognize that thiazide diuretics used in conjunction with antihypertensives to treat hypertension may have hyperlipidemic effects. Estrogen protects women against hyperlipidemia, so cholesterol levels should be closely monitored, especially in menopausal women [19].

Beta-blockers have been extensively evaluated in placebo-controlled clinical trials including many types of patients, including women and older adults [260]. Three beta-blockers (i.e., carvedilol, bisoprolol, and sustained-release metoprolol [succinate]) have been found to be beneficial in women with heart failure when added to an ACEI [261; 262; 263]. Carvedilol is a nonselective agent that improved survival in the 256 women who participated in the U.S. Carvedilol Heart Failure Study; it also reduced the combined end point of death or hospital stay in the 469 women who participated in the Carvedilol Prospective Randomized Cumulative Survival Study (COPERNICUS) trial. Bisoprolol and metoprolol succinate are beta-selective agents. Bisoprolol improved survival in the 515 women who participated in the European CIBIS II (Cardiac Insufficiency Bisoprolol Study); its use in heart failure is unlabeled. Metoprolol succinate had no survival benefit in the 898 women who participated in the Metoprolol Extended-Release Randomized Intervention Trial in Heart Failure but did reduce heart failure hospital stay by 42% [261]. Because reinfarction rates tend to be higher in women, beta blockers are an important part of treatment [11]. However, women tend to experience more medication side effects and suffer from more peripheral vascular disease, such as Raynaud's phenomenon, than men. Cardioselective beta blockers, such as atenolol or metoprolol, are a better choice for therapy in women, as nonselective agents have adverse effects on the peripheral circulation, magnifying vasospasm and vasoconstriction [260]. Additionally, beta blockers may not be the optimal first-line medication choice in diabetic women and should be used cautiously due to their hyperglycemic effects [160].

After PCI or CABG surgery, female cardiac patients are also at increased risk for mortality, primarily those who are older and have more comorbid disease [264]. At the time of these procedures, assess the patient's status to determine the presence of other factors or comorbidities that may impact recovery. Anticipating potential complications during the acute phase may help reduce morbidity and mortality [264]. Management during the acute phase should be directed toward early detection and prevention of possible complications and prompt intervention when adverse events occur [264]. Unless contraindicated, angiotensin receptor blockers (ARBs) are recommended for women with heart failure with current or prior symptoms who are intolerant of ACEIs to reduce morbidity and mortality [262,263].

Pain

Pain is another nursing diagnosis that applies to women with CHD. Nitrates and calcium channel blockers are the drugs of choice for the management of angina in women [265,266,267]. These medications dilate coronary arteries and are used to treat coronary artery spasms. Sublingual nitroglycerin can be used for acute relief of angina and prophylactically before activities that may precipitate angina. Long-acting, heart rate-slowing calcium channel blockers can be used to control anginal symptoms in patients with a contraindication to beta-blockers [266]. Because few women have been included in clinical trials of cardiac medications, sex-specific differences in the efficacy of these medications are not known. Therefore, women may not require the same drug dosage as men. Fluctuations in vasomotor tone may be significant because women have smaller coronary arteries. Consequently, women may require lower doses of medications such as nitrates and calcium channel blockers. However, because angina tends to be more severe in women than in men, anti-anginal treatment may need to be more intensive [11,35].

Special considerations exist in relation to assessing chest pain in premenopausal women who may have cyclic hormonal variation to their cardiac symptoms. For instance, angina tends to occur during the second half of the menstrual cycle, when estrogen levels are low. Therefore, current menstrual cycle information is an essential part of assessment [268,269,270].

Knowledge Deficit

Patient education for women with CHD should incorporate several components, including the disease process, diagnostic tests, medications, the recovery process, and risk-factor modification. In relation to the disease process, female patients should be taught symptom recognition and early treatment of complications. The positive long-term outcomes of women with angina and post-PCI and CABG surgery should be stressed when counseling patients regarding the recovery process. Medication teaching should include a description of the action and effects of the cardiac medication, along with the dosage, frequency, and possible side effects. The nurse may also act as a patient advocate with regard to diagnostic testing. Attempt to ensure that the appropriate diagnostic tests and treatment procedures are provided to the patient. Finally, risk factor modification enhances the patient's progress and quality of life [271].

Other considerations related to patient teaching focus on providing women-centered education. Much of the teaching and audio-visual materials available to women with CHD were developed primarily with men in mind. Therefore, patient teaching materials should be modified so that patients can see other women and learn about their own unique needs [271]. The National Institutes of Health (NIH) offers booklets that cover heart healthy topics such as prevention, awareness, diet, exercise, and smoking cessation [271,272]. Additionally, a woman's level of health literacy can affect the course of CHD, including readmissions and early death. According to a research summary compiled by the CDC, patients with limited health literacy face difficulties performing self-care activities (e.g., monitoring weight, salt, fluid intake) [273]. The findings support training healthcare staff to deliver tailored education that matches a patient's health literacy skills. Family members should also be included in cardiac teaching, with emphasis on how they can support the female family member with CHD. For instance, family members can be taught to encourage the patient to follow activity recommendations after discharge from the hospital. Family involvement to recognize signs and symptoms of complications postdischarge has become more important than ever with the trend towards shortened hospital stays. Other strategies to detect early complications after discharge include follow-up telephone programs and the use of home health nursing when appropriate [249,272].

Activity Intolerance

Due to complications, women may be slow to mobilize in the acute care setting. Comorbidities such as arthritis and diabetes may also affect activity levels. As a result, activity progression should be modified as needed. However, cardiac rehabilitation should begin as soon as possible during the inpatient phase as well as in the outpatient phase. Ensuring that female patients are connected with cardiac rehabilitation programs in their community may facilitate this intervention [274].

Body Image Disturbance

A qualitative study with female CABG patients has examined experiences related to body image. The most frequently occurring themes were concern over lack of privacy in the hospital setting, difficulty adjusting to short-term memory loss, extreme breast discomfort, and visibility of chest and leg scars [35]. Therefore, female cardiac patients may need assistance in exploring concerns and attitudes related to the impact of their cardiac illness on their body image.

Sexual Dysfunction

Researchers interviewed 17 women with monogamous sexual partners in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) registry to understand the recovery of sexual function and improve sexual outcomes in women post-MI [208]. Although the women universally expressed a desire to receive direct advice from their physician (particularly their cardiologist) about when they could safely resume sexual activity and how much exertion would be safe for their heart, the study findings indicated that the few women who had discussed sexual activity with their physician found the counseling to be vague or confusing. Lack of counseling by a physician has been found to be one of the predictors of loss of sexual activity following MI, despite recommendations for such counseling by the ACCF/AHA and the European Society of Cardiology [208]. Guidelines for safe return to sexual activities are available to guide individualized and culturally appropriate sexual counseling with female patients [338].

Several nursing diagnoses are relevant to the female cardiac patient during both the preventive and acute care stages. This section will summarize these nursing diagnoses along with appropriate nursing interventions and measurable expected outcomes for both the patient and the family [254].

Caring for women with CHD requires knowledge of several nursing considerations, which may be broken down into the primary prevention, acute, and secondary prevention phases. Common nursing diagnoses and interventions focus on maintaining an adequate cardiac output, controlling pain, progressing activity and exercise, teaching the patient and family about the disease process and treatment, as well as attending to psychosocial concerns, such as body image alterations and sexual difficulties. Of course, women who suffer an acute cardiac event will benefit from secondary prevention strategies during the recovery phase to reduce continued risk and improve quality-of-life outcomes.

Patient S

Counseling recommendations for Patient S would primarily focus on cardiac nutrition aspects and developing an exercise program for cardiovascular fitness. Because she is more than 30% overweight, she is at a tremendously increased risk of CHD due to the added stress on her heart and the changes that occur in lipid metabolism when fat is distributed in the abdominal versus gluteal region. Therefore, patient teaching should emphasize good nutrition and reading nutrition labels to manage caloric intake, as well as limiting intake of fat and cholesterol. In addition to changes in diet, Patient S should be counseled on incorporating some form of aerobic exercise, such as walking, three to five times a week to achieve cardiovascular fitness. The exercise will also have the added benefit of helping her modify her weight level.

Patient J

Two major concerns become evident in assessing Patient J's health status—her smoking history and her hyperlipidemia. Recommendations would focus on encouraging and motivating the patient to quit smoking, through the use of the nicotine patch or gum with the additional support of bupropion and/or a smoking cessation program to increase her chances of successfully quitting. These programs are essential because they teach the patient behavioral and psychologic techniques to utilize at various stages of the quitting process and help the person identify specific problem situations and how these can be realistically managed. Patient J's lipid profile should be closely monitored to determine the effectiveness of gemfibrozil in lowering her LDL levels. In addition, patient teaching should focus on the deleterious effects of smoking on lipid profiles, specifically HDL levels. Smoking tends to decrease levels of HDL, which could be used as another health information tidbit to motivate Patient J to quit smoking.

Patient V

Recommendations for cardiac health for Patient V would primarily focus on the alterable factors rather than her significant family history, which cannot be changed. As a result, patient teaching and counseling would be geared toward getting her weight into a more desirable range by paying attention to nutrition and getting some form of regular aerobic exercise. Patient V would also benefit from more health teaching regarding alcohol consumption. While a moderate intake of alcohol may be associated with positive antioxidant effects that can impart some protection against the development of CHD, the key is moderation. One drink per day is the recommendation for alcohol consumption in women.

Patient D

In assessing Patient D's health history, her diabetes and smoking habit are big concerns. In terms of her diabetes, she is in need of strict control to prevent further progression and significant complications associated with the disease, such as CHD. Another major factor that would help prevent a major cardiac event is for her to quit smoking. Remember that many cardiovascular risk factors are synergistic. In other words, risk factors work together in increasing an individual's risk of developing CHD. Cigarette smoking and diabetes are both powerful independent risk factors for CHD, and together, they significantly elevate the chances of developing the disease.

Patient F

Patient counseling recommendations for Patient F are twofold: continued control of her hypertension and stress management. Patient F and all of the women should be applauded regarding the positive habits they have incorporated into their lifestyle. In this patient's case, these positive aspects include attention to nutrition, aerobic exercise, and staying away from smoking or alcohol use. She does, however, need assistance with stress management. While her regular exercise program is most likely one avenue for her to deal with this stress, it obviously is not singly effective. In other words, additional stress management strategies could be added to her repertoire.

The following cardiovascular risk factors are negative:

Patient outcomes may be measured both during the hospitalization and postdischarge phases. During the hospitalization phase, examples of clinical outcomes to be assessed for a population of female cardiac patients include complication rates (e.g., perioperative MIs, dysrhythmias, pseudoaneurysms); length of stay (both intensive care unit and hospital length of stay); and readmissions (both intensive care units and hospital readmissions), along with the clinical reasons.

After the hospitalization phase, patient outcomes may be assessed again. Examples of outcomes to be measured in the early discharge phase include pain, appetite, wound healing (incisions in surgical patients), rest/sleep patterns, psychologic comfort, and exercise patterns. Teaching and learning outcomes are also important to assess, including whether the female cardiac patient understood her discharge instructions related to activity and exercise, cardiac medications, diet, and when to return to work. Quality of life becomes an important consideration for this population. Research suggests that women experience more days of restricted activity due to continuing cardiac symptomatology, such as recurring chest pain and dyspnea. Ability to return to work and previous hobbies and pastimes would be an important area to assess in this regard.

Patient A's cardiac event is atypical for women in terms of initial presentation of the disease process. MI and sudden cardiac death are more commonly a first manifestation of CHD in men, while angina is the most common presenting scenario for women. Women tend to lag behind men in both the occurrence and incidence of CHD, as well as sudden cardiac death events. In terms of Patient A's history, it is possible that she initially suffered an MI, which was not recognized, and went on to develop heart failure as a post-MI complication. This then explains her increased risk for earlier reinfarction and higher mortality.

The following cardiovascular risk factors are negative:

Many factors have been studied regarding women's participation in formal outpatient cardiac rehabilitation programs. Some of the most common reasons women give for decreased attendance include family commitments, financial concerns, and medical problems, such as increasing angina and/or other cardiac symptoms.