1. Massachusetts Women’s Legislative Caucus Women and Heart Disease Paula A. Johnson, MD, MPH Brigham and Women’s Hospital

2. Who We Are Mary Horrigan Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital  Women’s Health Policy and Advocacy Program  Center for Cardiovascular Disease in Women

3. Why heart disease? Heart disease is the leading killer of women in Massachusetts and the United States Women experience heart disease differently from men, but these differences are not well understood By taking measures to prevent heart disease, women can protect themselves from a whole host of chronic illnesses

4. Women & heart disease - 1936 “Mistaken diagnoses of coronary artery disease in women are common because of the erroneous interpretation of symptoms, such as precordial pain with or without radiation to the left arm, a sense of choking, and fear of death. Such symptoms are common in the absence of organic heart disease.” - Levy and Boas. JAMA 1936

5. Women & heart disease - 2004 Half of all U.S. women will die of heart disease or stroke Heart disease claims the lives of more women than the next seven causes of death combined Significant racial and ethnic disparities exist among women Only 13% of US women believe that heart disease and stroke are their greatest health threats

6. Source: Massachusetts Department of Public Health

7. Differences between women & men More women than men die each year from heart attacks – and the gap is growing Women tend to get heart disease later in life Women are, on average, ten years older than men at the time of their first heart attack Women are much more likely to die from their first heart attack than men Women can experience different symptoms of heart attack than men

8. Why are there differences? Do women delay going to the hospital because they don’t recognize their symptoms? Are health care providers not recognizing women’s symptoms or treating the symptoms less aggressively? Do medications or treatments for heart attacks have different affects on women? We still have more questions than answers

9. Prevention: The Key to Heart Health Approximately 80% of cardiovascular disease can be prevented by modifying preventable risk factors including… cigarette smoking being overweight or obese lack of physical activity diabetes high blood pressure high cholesterol

10. Smoking Tobacco is responsible for 17% of all female deaths in the U.S. Smoking is the most preventable risk factor for heart attack Women who smoke one to four cigarettes per day are at almost twice as likely to develop heart disease than nonsmokers A woman who smokes is at risk for heart attack 19 years earlier than one who does not smoke Women of all ages who quit smoking greatly reduce their risk of dying prematurely

11. Women, girls & tobacco Tobacco companies market to women and girls by –creating brands and types of cigarettes specifically for women and girls –suggesting that smoking will make women & girls feel attractive, slim & less stressed –advancing the myth that low-tar, low- nicotine brands are less harmful Smoking accounts for an estimated $4.4 billion annually in health care costs and lost productivity in Massachusetts

12. Overweight & Obesity Obesity is a widespread, disabling, and costly risk factor for heart disease. The number of excessively heavy adults in MA increased 30% from 1990 to 2000 In MA, black and Hispanic women experience the highest rates of overweight and obesity Women with low education and incomes have higher rates of overweight and obesity The percentage of overweight children has doubled over the past 20 years. Overweight children are 10 times more likely to be overweight as adults

13. Source: CDC, National Center for Health Statistics, Health, United States, 2002

15. Estimated Percent of Americans  18 Years Who Report No Leisure-time Activity 1991: National Health Interview Survey 2000: Heart & Stroke Facts AHA Physical Activity

16. Diabetes Davidson MB. Diabetes Mellitus: Diagnosis and Treatment. 4th ed. Philadelphia: WB Saunders; 1998. Adjusted Risk of Heart Attack among Diabetic vs. Non-Diabetic Adults

17. High Blood Pressure High blood pressure, also known as hypertension, greatly increases the chances of developing cardiovascular diseases, and it is the most important risk factor for stroke. Even slightly high levels double your risk. More than half of American women will develop high blood pressure at some point in their lives.

18. Age Adjusted Prevalence of High Blood Pressure among US Females Age 20 Years and Older, 1998-94 High Blood Pressure

19. Cholesterol Low blood levels of "good“ cholesterol (high density lipoprotein or HDL) appears to be a stronger predictor of heart disease death in women than in men in the over 65 age group High blood levels of triglycerides (another type of fat) may be a particularly important risk factor in women and the elderly

20. Stress & Depression Stress may be associated with an increased risk of heart disease in women for a number of reasons –Occupational factors: lower-level jobs with greater job strain, low pay, and unequal –Economic factors: More women live in poverty than men and may have fewer environmental resources for support Depression - the most common psychological disorder among women – has also been found to increase the risk of heart disease

21. Symptoms Early recognition of warning symptoms is critical to reducing death from heart disease, since interventions are most effective within six hours after a heart attack. Almost half of women having a heart attack do not experience “typical” heart disease symptoms Symptoms among women include indigestion, unexplained weakness and fatigue, sleeplessness, or shortness of breath Women experiencing symptoms of a heart attack are more likely to delay going to the hospital than men

22. Treatment Women are less likely than men to be: Referred for some heart disease treatment procedures Prescribed “clot-busting” therapies, aspirin and other medications after a heart attack Referred for cardiac rehabilitation

23. Racial and Ethnic Disparities Black women: Tend to develop heart disease at an earlier age and are more likely to die from heart disease than white women Are less likely to receive appropriate preventive therapy and adequate risk factor control than white women Are less likely to receive life-saving therapies after a heart attack than white women

24. The cost of cardiovascular disease (CVD) CVD costs the U.S. $368 billion in direct and indirect costs in 2003 CVD accounts for over half of all hospital charges in MA The estimated incremental lifetime medical cost of treating a woman with CVD is almost 3½ times greater than treating a woman without CVD

25. What can you do? - personally - Reduce your risk for heart disease by keeping physically active, eating heart healthy foods, quitting smoking, and caring for your overall health Make sure your doctor is evaluating your risk for heart disease with the newest female specific criteria developed by the American Heart Association

26. What can you do? - in your community - Work to increase awareness that heart disease is the leading killer of women and that there are lifestyle changes women can make to reduce their risk Create environments that contribute to our health – safe streets and parks to walk in and reduced exposed to secondhand smoke

27. What can you do? - to reduce smoking - Work to restore funding for smoking prevention and cessation initiatives in Massachusetts Advocate for health insurance coverage of smoking cessation aides Combat marketing of smoking products to women and girls Reduce access of minors to tobacco products

28. What can you do? - to reduce overweight and obesity - Work to improve access to healthy food sources for low-income families Increase the development and dissemination of culturally appropriate menus and meals Promote healthy eating and physical activity in schools and workplaces

29. Invest in research to learn more about the differences between men and women in relation to heart disease Insure access to screening, diagnosis, treatment and rehabilitation of heart disease for uninsured MA residents Promote adoption of the American Heart Association’s guidelines for the prevention of heart disease among women What can you do? - to improve heart care for women -

30. Discussion What is currently being done? –Public Information Campaigns –Promotion of Clinical Prevention Guidelines –Community Initiatives –National and State Policy –Other What else should be done?

31. Contact Information Paula A. Johnson, MD, MPH Chief, Division of Women’s Health Executive Director, Connors Center for Women’s Health & Gender Biology Ph: (617) 732-8985, Fx: (617) 264-5191, Email: pajohnson@partners.org Rachel A. Wilson, MPH Director, Women’s Health Policy and Advocacy Ph: (617) 525-7516, Fx: (617) 525-7746, Email: rwilson1@partners.org Rachael Fulp, MPH Administrative Director, Center for Cardiovascular Disease in Women Ph: (617) 732-7076; Fx: (617) 524-7746, Email:rfulp@partners.org Brigham and Women’s Hospital 75 Francis Street, Boston, MA 02115