women’s health – The Early Career Voice

Anxiety, Food Security, & Beyoncé: Addressing Young Women’s Cardiovascular Health

April 2, 2019April 2, 2019 Elizabeth Knight, PhD, DNP

What can you do to address gender disparities in health and health care? In my last post, I suggested working to identify your own bias by increasing your awareness. I’m walking this path, too. A few years ago, I made a concerted effort to diversity my reading habits after I noticed that a huge percentage of the work I was consuming was produced by white men. I spent a year choosing to read only books by women and people of color instead. I learned that it was not hard to do this, but it required that I pay attention. I read a lot of wonderful work that I might have otherwise overlooked, and I was exposed to much more diverse viewpoints. I continue to seek out broad representation, and I suggest a similar approach to reading scientific literature.

Start by paying attention to 1) study populations, and 2) authorship. Are you reading articles about (and by) underrepresented populations? In cardiovascular health, this includes women, who remain underrepresented in clinical trials (estimates as low as 34% of participants in trials supporting drugs for some CV conditions¹), clinical practice (just 20% of cardiology fellow are women²), and academia (check out the #nomanels hashtag on Twitter).

Clearly, we need more cardiovascular research by and about women. In this post, I want to highlight some exciting research by and about women.

Evidence of the pervasive male bias: we’ve programmed our machines to assume patients are male.

At the recent American Heart Association EPI/Lifestyle conference, a woman-led team from Boston Children’s Hospital presented their work on perceptions of cardiovascular risk among adolescent and young adult (AYA) women. The team recognized that young women didn’t seem particularly informed about or interested in their heart health. Based on this clinical insight, they designed a study to identify barriers to awareness and preventive behaviors among AYA women. I spoke with Courtney Brown, an early-career professional herself and the first author of the abstract³, who explained the team’s findings. First, noted Brown, AYA women have a low baseline knowledge of their cardiovascular risk— lower than expected. They also face competing demands to focusing on their cardiovascular health, such as limited time and financial resources. One key finding was the role of mental health concerns like depression and anxiety: it’s hard to care about something that might happen to you in thirty years when you’re worried about getting through your next few days. Some participants also noted that eating healthy seems too expensive, and sometimes healthy food just isn’t available. These barriers to healthy behaviors are real! Yet behaviors established in young adulthood tend to persist as we age, so AYA women are at a crucial time in their lives for their heart health.

A key point for intervention development, says Brown, is that lifestyle behaviors (including exercise and high-quality nutrition) that are good for mood are also good for heart health. So while cardiovascular health may not be this group’s priority, they will likely benefit from risk-reducing behaviors in multiple ways.

Delivering the message in the setting of competing demands is tricky— and important. When asked what might facilitate their adoption of heart-healthy behaviors, participants in the study indicated that family was their biggest influence, followed by their health care providers and celebrities (favorites were Drake, the Kardashians, and Beyoncé). They also talked about using Facebook, Snapchat, and Instagram to get information and communicate. This is rich data, and it suggests that a “meet them where they’re at” approach is likely to be successful. “We’d love for more people to take up this work— we have more steps to take,” Brown says. “We’d love to create and test materials.” It’s encouraging to see rigorous science targeting the needs of a group that’s often overlooked in cardiovascular research. As the body of evidence grows, perhaps some of the disparities in women’s cardiovascular health will fade.

There are also some great lessons here from a methodological standpoint. This study utilized mixed methods, including online focus groups. Courtney Brown, the researcher from the AYA study, stressed that the qualitative component of the work is highly valuable because it can help researchers develop interventions that will effectively reach the population of interest. “It lets us dig deeper into responses to find out what the unique barriers are and how to reach this population, not just what to tell them”, she says. When so much of existing clinical practice is based on research that excluded women, this approach is very relevant. In a climate where the RCT is king and the p-value determines whether or not a finding is considered significant, qualitative work is often undervalued, but these kinds of studies are crucial in understanding the needs, values, and preferences of patient populations— especially those, such as young women, that have been previously understudied and undertreated.

Have you read (or authored!) any great women’s health studies lately? Try to add some to your reading list!

References:

Scott, P, Unger, E., Jenkins, M. Southworth, M., McDowell, T., Geller, R., Elahi, M. Temple, R., & Woodcock, J. (2018). Participation of women in clinical trials supporting FDA approval of cardiovascular drugs. Journal of the American College of Cardiology, 71(18), 1960-9.
Lau, E. & Wood, M. (2018). How to we attract and retain women in cardiology? Clinical Cardiology, 41(2), 264-268.
Brown, C., Revette, A., de Ferranti, S., Liu, J., Stamoulis, C., & Gooding, H. (2019). Heart Healthy Behaviors in Young Women: What Prevents Teens from Going Red? Abstract presented at American Heart Association Epidemiology, Prevention, Lifestyle & Cardiometabolic Health Scientific Sessions, Houston, TX.

Who is writing what you’re reading? Look at the great mix of people on the AHA early career blogging team!

Addressing Women’s Cardiac Risk in Primary Care: Research & Practice

March 5, 2019March 28, 2019 Elizabeth Knight, PhD, DNP

Last month, I wrote about my roles in research, practice, and education. This month, I’ll delve into how research and practice interface around a critical health issue: coronary heart disease in women.

A study recently published in JAHA suggests that both delay between symptom onset and hospital presentation and post-PCI coronary blood flow are independently associated with excess mortality in women¹.

A key finding for clinical practice is that if delay between symptom onset and hospital presentation is less than two hours, that sex difference in mortality is not significant. One takeaway is that though it’s not the only factor, delay matters— and it’s something we can target now, in primary care (where I work) and in public health.

A key point for research is that PCI doesn’t seem to improve coronary blood flow in women as much as it does in men. What does this mean? Here’s the rub: the whole paradigm of coronary heart disease— from defining acute coronary syndrome to medical management and PCI— is based on the flawed assumption that men and women are essentially the same (as Pande & Jacobs discuss in an accompanying editorial²).

Recall that women have historically been drastically underrepresented in heart disease research, so the foundational assumptions are based on men. Though the evidence is mounting on some of the mechanisms of sex differences— microvascular disease, endothelial dysfunction, MINOCA— this hasn’t yet resulted in meaningful differences in approach to ACS treatment. Before this study’s publication, it had not been clear whether women didn’t do as well post-PCI simply because they were less likely to get in in a timely fashion, or because it didn’t work as well for them. Now we have data suggesting that both are true. Are we using a hammer when we really need a screwdriver? There is an enormous need for research in this area designed with sex differences as a presupposition and with establishing effective treatments as the goal. It will be a long road and we won’t have “the answer” tomorrow.

So as a clinician, knowing that the data isn’t there yet to show us how to improve women’s outcomes in PCI, one of the best tools I have is education and communication with my patients and fellow clinicians around treatment delay. We’ve made great progress educating patients and providers about women’s risks of heart disease (thanks in large part to AHA’s Go Red for Women campaign). Yet women still have longer delays in accessing treatment and worse outcomes in ACS than their male counterpoints.

Since heart disease is the number one killer of U.S. women and men³, preventing and detecting it are high priorities for PCPs like me. Even though short appointments and competing priorities mean finding time for prevention and risk assessment is tricky, we need to do better in our discussions around cardiac risk. We’re doing well at initiating discussions around statin prescriptions and, to a lesser extent, lifestyle measures. We need to work on discussions about symptoms of ACS and response to symptoms.

What are you doing now to improve women’s cardiovascular outcomes? Will you commit to taking one of these steps?

References:

Cenko E, van der Schaar M, Yoon J, Kedev S, Vavlukis M, Vasiljevic Z, Ašanin M, Miličić D, Manfrini O, Badimon L, Bugiardini R. Sex‐specific treatment effects after primary percutaneous intervention: A study on coronary blood flow and delay to hospital presentation. J Am Heart Assoc. 2019; 8:e011190. DOI: DOI: 10.1161/JAHA.118.011190.
Pande, AN & Jacobs, A. Reperfusion and time to presentation in women: Too little too late. J Am Heart Assoc. 2019; 8. DOI: 10.1161/JAHA.118.011835
Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L,Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O’Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics – 2019 update: a report from the American Heart Association [published online ahead of print January 31, 2019]. Circulation. doi: 10.1161/CIR.0000000000000659.
Greenwood B, Carnahan S., & Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. PNAS August 21, 2018 115 (34) 8569-8574; published ahead of print August 6, 2018 DOI: 10.1073/pnas.1800097115

Red Dresses & Red Ribbons: What Every Health Care Provider Needs to Know about Cardiovascular Disease and HIV in Women

February 8, 2019March 28, 2019 Allison Webel, PhD

Lead Image (created by Cynthia Rentrope):

Each February, we celebrate Go Red for Women – a time for healthcare providers to reacquaint ourselves with the shocking fact that on average one woman dies from cardiovascular disease (CVD) every minute – and recommit to doing better. In the United States and the around the globe, women living with HIV are at higher risk for developing cardiovascular disease, yet not all women are affected equally. There are disparities in the quality of cardiovascular care in women, especially younger women, compared to men. Simultaneously, women living with HIV are at increased risk for cardiovascular disease than HIV uninfected women and receive less guideline-based cardiovascular care. In order to provide better preventative, diagnostic, and curative care we have to understand why women living with HIV are at higher risk for cardiovascular disease and stroke and what we can do about it.

Women living with HIV are at higher risk for CVD and stroke

The reasons why women living with HIV are at higher risk for CVD and stroke are not entirely understood. However, scientists have described several likely reasons. HIV is an inflammatory disease and women infected with HIV have higher levels of inflammatory cytokines and markers of immune activation. In turn, this inflammation may increase the risk of CVD by accelerating development of atherosclerotic plaques and making these plaques more ‘vulnerable’ to rupture, causing more heart attacks and strokes. Additionally, we recently reported that inflammation was also associated with reduced cardiorespiratory fitness in adults living with HIV, which may help explain this increased risk. Women living with HIV have elevated rates of depression, obesity, stigma, and homelessness, also associated with increased CVD.

However, there are also unique biological factors that increase the risk for CVD in women living with HIV, particularly with aging. According to Dr. Sara Looby RN, PhD, Assistant Professor of Medicine at Harvard Medical School and Massachusetts General Hospital, hormone changes experienced during menopause such as estrogen loss and reduced ovarian reserve may negatively influence immune activation and the development of subclinical CVD in women living with HIV. Her current study funded by the National Institute of Allergy and Infectious Disease is exploring this and the results are expected in the next 4 years.

Strategies to Reduce the risk of CVD in Women Living with HIV

Yet it is not enough to know there is a risk and even to partially understand why; health care providers- cardiologists, nurses, primary care providers, and HIV and emergency room physicians -chose their profession because they wanted to improve health. And all of us have an important role in helping women living with HIV accomplish this goal. There are several evidence-based strategies we can use to improve cardiovascular health in this population.

Take HIV medications. This strategy is well known among HIV nurses and physicians but those not trained in HIV may not realize the significance of HIV medications to reducing CVD in this population. Having a suppressed HIV viral load, obtained through adherence to effective HIV medicines, is consistently associated with reduced CVD.
Recognize and treat the cluster of traditional cardiovascular risk factors in HIV. Increased traditional cardiovascular risk factors in women living with HIV, including hypertension, dyslipidemia, diabetes, and obesity, need to be effectively addressed using guideline-based care. For a good resource on how to do this, check out the American Heart Association’s Life Simple 7
Assess sex-specific risk factors in women including menopause history. This may not be routine for HIV, cardiovascular or family health providers but it is important for understanding cardiovascular risk. Increasing evidence indicates we should use a woman’s menopause history to improve understanding of her risk of CVD and provide good cardiovascular treatment. Other health conditions unique to women, such as a history of pre-eclampsia, can also influence risk and are recommended as “risk enhancers” in the most recent AHA Cholesterol Practice Guidelines.
Engage women in their cardiovascular health. While this may be the hardest strategy to implement, it is the most important because for so long, women living with HIV have focused on surviving HIV that they do not perceive they are at elevated CVD risk. Dr. Looby acknowledges, “It can be difficult to find time to do this given the competing demands of clinical care, but education is essential to empowering women living with HIV to become active participants in their care. Delivering education in plain language that is easily understood by patients. Asking patients basic questions like, “Do you know what heart disease is?” or “Do you know your cholesterol levels and what they mean?” can provide simple snap shots of important information that can be built upon at subsequent visits, or followed up by providing supplemental educational materials.” Through this patient-focused engagement women living with HIV will be able to take charge and reduce their blood pressure, cholesterol, weight, and smoking resulting in improved cardiovascular health.

Almost every minute a woman dies from heart disease. But they don’t have to. We are privileged to serve in a profession dedicated to improving the health of our fellow humans. But human health is complex and, for women living with HIV, we cannot just treat their HIV or their CVD or their depression or their symptoms of menopause- we have to treat these intertwining conditions together. There are countless barriers to doing this well, and as new models of delivering cardiovascular care in HIV are under investigation, I am confident we will learn how to do this better. In the meantime, we have start today and commit to implementing strategies in our own practice to improve the heart health of women living with HIV.

Healthy Heart for Women

February 8, 2019March 28, 2019 Jacqueline Leachman

Kimble, Richelle. “Heart Attack Signs and Heart Facts.” Women’s Lifestyle Magazine, 8 Apr. 2015, womenslifestyle.com/heart-attack-signs-and-heart-facts/.

As a pre-qualification exam graduate student, I have a full-time class schedule. As a part of my many class requirements, one that I am fulfilling this semester is general physiology. On February 1st in class we were ironically going over the cardiovascular system, which is also National Wear Red Day. Wear Red Day is an awareness campaign where women and men alike are encouraged to wear red in solidarity for women’s heart health. On this day at the University of Kentucky, where I am a graduate student, two professors in the Department of Pharmacology and Nutritional Sciences hosted the 5th Annual Healthy Hearts for Women Symposium. I know what you are thinking, “How does this relate to your physiology class?” Well, I volunteered and attended the event, however, I had to step out for an hour to attend my morning physiology course.

After spending weeks on basic heart anatomy and function, during this class period, we were finally moving on to cardiovascular pathophysiologies. On this day we learned many things but for some reason, the one concept that really resonated with me was the relationship between myocardial ischemia, atherosclerosis and myocardial infarction. Needless, to say it was a very interesting lecture. However, what made it even more interesting was the connection it had with the symposium. Upon returning to the symposium, Dr. Martha Gulati the Division Chief of Cardiology from the University of Arizona College of Medicine, was giving her talk on, “Women and Cardiovascular Disease: Is there really a sex difference?” I arrived late because of my class, but once I got settled into my seat you would never guess what slide she was currently showing — the development of a plaque in atherosclerosis! It was so exciting to me to have just learned this material and to now be in a talk describing the response of women in these disease states. Dr. Gulati brought up some very interesting points during her talk. Such as how the troponin levels during a heart attack in women are not always at levels comparable to men because women’s heart’s are smaller. When you think about it, you sort of say to yourself, “well yeah that makes sense,” however the sex-differences in diseased and even non-diseased states are not always apparent. When doing research, this is also why sex as a biological variable should be considered.

Overall, I would like to end with this quote that I felt summarized the post nicely: “In a generation that promotes equal opportunity for all genders, it’s crucial to not overlook the gender differences that affect health.” (Thompson 2019)¹

For those of you conducting research, how are you incorporating sex into your studies?

References:

Thompson, Elizabeth. “UK Hosts Annual Symposium for Promotion of Women’s Heart Health.” UKNow, University of Kentucky, 30 Jan. 2019, uknow.uky.edu/uk-healthcare/uk-hosts-annual-symposium-promotion-women-s-heart-health.

Women & TAVR: “I Don’t Want Any Procedure”

January 14, 2019March 28, 2019 Mirvat Alasnag, MD

Round 1…

Patient’s son-in-law: “My mother has been turned down for surgery. They tell me her mortality rate at 2 years is high since she had fluids collecting in her lungs. They told me to ask you about catheterization.”

Me: “Yes, she does have a tight aortic valve and did develop heart failure. She is also very high risk for surgery. Percutaneous or catheter-based replacement may be an option. She will need a CT Scan first to determine if she is suitable for that treatment.”

The patient’s son-in-law asked me only one question, but a number of questions rushed through my head.

When is a good time to give the patient a contrast load after her recent admission with pulmonary edema? How safe is contrast given her borderline renal dysfunction and recent pulmonary edema? What is the outcome of trans-catheter aortic valve replacement (TAVR) in women?

I realized that there were no concrete answers. Irrespective of risk of contrast induced nephropathy, she needs the CT Angiogram. Irrespective of the timing, she remains high risk for recurrent pulmonary edema with or without the 50-60 cc of contrast given during the CT scan. Irrespective of her gender, TAVR maybe her only option. So, the CT scan was done with a small amount of contrast & her renal function remained unchanged and she did not develop pulmonary edema. She had borderline parameters with a short distance from the aortic valve annulus to left main, significant calcification into her LVOT, small tortuous and calcified common iliac arteries bilaterally. She was not an “ideal” candidate.

Round 2…

Me: “You are at a higher risk of coronary occlusion. We can place an undeployed stent preemptively in the coronary artery. Your risk of requiring a pacemaker is high and we’ve notified our electrophysiologist. Your risk of rupture is high, so we plan to use a self-expanding valve. We may need to use an alternative access like your armpit artery.”

Patient: “I don’t want any procedure.”

Patient’s son-in-law: “Is there anything else that we can do that is less risky?”

Me: “Palliative balloon valvuloplasty, but the gradient will increase again in 6-12 months.”

Patient: “I don’t want any procedure.”

Patient’s son (in-law): “Can we repeat this valvuloplasty every 6 months if need be?”

Patient: “I don’t want procedure.”

*Awkward silence.*

Me: “She does not want any procedure. It is time you and I listen to her.”

This patient was referred to me by a colleague from another hospital. She had no sons of her own but had her son-in-law to accompany her. She was a small, frail, soft spoken, elderly lady. She was also grateful for the care she received. We immediately had the surgeons evaluate her. While the surgeons were examining her, I did a quick literature review:

Data from Vancouver demonstrated that the mortality rate at 30 days after TAVR was 6.5% in women and 11.2% in men after accounting for other variables.¹ This advantage for the female gender was maintained at 1 year as confirmed by the PARTNER Trial sub-analysis. Whether this was due to worse surgical outcomes in women or an advantage of TAVR in women was further explored by Humphries et al. Although vascular complications were higher in women, the overall survival rate at 2 years was 72.1% for women and 61.7% for men. Real world international registry and the first WIN TAVR registry further confirmed that high risk women had low 30-day and one-year mortality and stroke rates.^2-4

Naturally, I picked up the conversation where the surgeons left off. In retrospect, even as a woman interventional cardiologist, was I dismissive of my patient’s own preference? Do we have a tendency to ignore female patients’ wishes more than men? Do we have a tendency to ignore elderly patients’ wishes more than younger ones? Or do we find it difficult to resolve to hospice care even before exhausting all options? It may be a combination of all of these. I don’t normally dismiss my patients’ wishes, but this time, I was clearly not listening. Maybe I listened to my colleague (a physician) and maybe I just grew attached to this soft spoken grateful woman…and I couldn’t resign myself to writing hospice care for her. Women..men..no matter, we make imperfect choices at times driven by our humanity. May that imperfection continue to drive us to care.

References:

1. Humphries KH, Toggweiler S, Rodés-Cabau J, et al. Sex differences in mortality after transcatheter aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol 2012;60:882–6.

2. Williams M, et al. Sex-related differences in outcomes after transcatheter or surgical aortic valve replacement in patients with severe aortic stenosis: Insights from the PARTNER Trial (Placement of Aortic Transcatheter Valve). J Am Coll Cardiol. 2014 Apr 22;63(15):1522-8.

3. Chieffo A, et al. 1-Year Clinical Outcomes in Women After Transcatheter Aortic Valve Replacement: Results From the First WIN-TAVI Registry. JACC Cardiovasc Interv. 2018 Jan 8;11(1):1-12.

4. Chieffo A, et al. Acute and 30-Day Outcomes in Women After TAVR: Results From the WIN-TAVI (Women’s INternational Transcatheter Aortic Valve Implantation) Real-World Registry. JACC Cardiovasc Interv. 2016 Aug 8;9(15): 1589-600.

Highlights of the 1st Annual Sex and Gender Conference at AHA18

November 10, 2018March 28, 2019 Bailey DeBarmore

Walking into the Palmer House Hotel, the longest continuously operating hotel in the United States, you can’t help but pause in awe at the intricate décor and take in the most photographed ceiling in the world. I make my way to the Honoré Ballroom, named after Bertha Honoré Palmer, the wife of Palmer and an astute businesswoman and well-known Chicago socialite of her time, not knowing what to expect for the 1^st annual Sex and Gender Influence on Cardiovascular Disease (CVD) conference.

Annabelle Volgman, medical director of the Rush Heart Center for Women, kicks off the evening by thanking the speakers and planning members, and encouraging photography and social media sharing. The many photos of the evening include Bertha Honoré’s portrait adjacent to the colorful and modern logo that, I think, will become a recognized image at future AHA Scientific Session meetings.

Dr. Annabelle Volgman welcomes attendees to the 1st Annual Sex and Gender Influences on Cardiovascular Disease at the Palmer Hotel in Chicago, IL (November 11, 2018).

Dr. Nanette Wenger of the Emory Women’s Heart Center starts the conversation with her presentation titled “Why is Mortality from Cardiovascular Disease Rising in Men and Women?” She flashes a graph of CVD mortality on the screen, highlighting the steep decline in the past decades, but the leveling off and reversal in recent years, particularly in women under the age of 55 years. The parallel rise in obesity and diabetes, as well as “non-traditional” CVD risk factors such as depression and perceived stress disproportionally affect women, she explains, and may be responsible for this reversal in CVD death rates. Summarizing the recent paper, “Defining the New Normal in Cardiovascular Risk Factors” by Dr. Donald Lloyd-Jones and Dr. Philip Greenland she points to a combination of health behaviors and ideal levels of total cholesterol, blood pressure, and fasting blood glucose, as key factors in achieving cardiovascular health.

“Behavior change,” she says, “is the ‘Holy Grail’ of heart health” and as “health professionals take back the role [of health educator] and address lifestyle behaviors” we will see favorable trends in biomarker targets we’re so interested in.

Later during the Q+A panel, when asked about the best way to approach behavior change with patients, she advises to first, “Give information – if your patient does not have the information, they can’t make a change. Then, let them start with what they would like to start with. Don’t give them 8-10 [health behaviors] to change – they will tune you out.” Dr. Gina Lundberg, co-director of the Emory Women’s Heart Center, chimes in that the clinician’s “approach to weight loss is similar to smoking cessation. Identify the obstacles in the patient’s way – money, time, desire – and often just identifying those hurdles will lead to improvement.”

Dr. Laxmi Mehta, director of the Women’s Cardiovascular Health Program at the Ohio State University Wexner Medical Center, adds that she includes an emotional appeal – “Where is the patient going and what do they want?” Seeing a child’s wedding or playing with their grandkids, developing rapport with patients and fitting your recommendations to their goals can start the health behavior change process, even in a 5 minute clinician-patient discussion.