Is Cardiovascular Disease in Young Women Overlooked?

“Heart disease in women is often under-recognized and undertreated … young women have unique risk factors that should be carefully assessed at each clinical encounter.”

Cardiovascular disease (CVD) remains the number one killer of women in the USA [1]. Although mortality rates for heart disease in men are declining, CVD death rates for women continue to rise precipitously. However, many overlook that CVD and its important risk factors – namely obesity, diabetes, hypertension and dyslipidemia – develop at a young age and are highly prevalent in young women. Importantly, young women are often unaware of their cardiovascular risk profile. For policy-makers and clinicians, it is precisely young women who should be targeted through primary prevention efforts to reduce the subsequent development of CVD morbidity and mortality.

With the increasing rates of obesity and associated risk factors, it is no surprise that women are now facing heart disease at younger and younger ages. Even more worrisome; many women remain unaware of their risk. A recent study by Mosca and colleagues exploring cardiovascular awareness in a large national sample showed that young women aged 25–34 years had the lowest awareness of CVD risk factors [2]. These young women cited time constraints as well as lower perception of risk as barriers to prevention. Many community-dwelling women are unaware of their metabolic risk profiles [3], and young women are less likely to speak to their doctors about heart disease [4].

Data show that young women admitted to the hospital suffering from myocardial infarction experience higher in-hospital mortality as compared with men [5–9]. Women may experience more atypical symptoms, such as indigestion, sleep disturbances and neck pain, which may lead to a delayed diagnosis. Alternatively, it is possible that coronary disease that occurs in younger women is more aggressive and may be driven by associated comorbidities. Gender differences in the misuse and underuse of life-saving treatment strategies and evidence-based therapies have also been widely reported. Over half of the women who die from ischemic heart disease, many of them young, report no ‘traditional’ risk factors or symptoms for heart disease. This, again, emphasizes the need for primary prevention of cardiac risk factors in young women who remain at high risk for stroke and myocardial infarction, as well as pregnancy-related cardiovascular complications [10,11].

Although age is the strongest risk factor for CVD, studies have shown that atherosclerosis begins early in life. For example, the PDAY study, has demonstrated that atherosclerosis begins as early as in childhood and progresses into adolescence and young adulthood, largely due to underlying risk factors [12]. As heart disease is an insidious process that takes decades to develop, young women represent the ideal group to target preventive efforts.

The growing burden of CVD among young women is not distributed equally, with the highest mortality rates borne by African–American and Hispanic women [1,13]. Alarmingly, these disparities persist even controlling for socioeconomic and clinical factors. Hispanic women have the youngest average age of those with undiagnosed Type 2 diabetes mellitus and the worst glycemic control of any racial or ethnic group [14]. In a recent study, we found a high prevalence of metabolic syndrome in community-dwelling, young Hispanic women, many of whom reported no baseline CVD risk factors [15]. Particular attention must be paid to the complex nature of these persistent health disparities. Young Hispanic and African–American women represent patient subgroups that should be specifically targeted in health education campaigns. Special efforts are also warranted to ensure that education materials are culturally and linguistically representative of the increasingly diverse US demographic landscape.

Traditional risk estimation calculators, such as the Framingham Risk Score, underestimate CVD in young women who may have nontraditional risk factors. Novel risk classification schemes such as the Reynolds Risk Score have been used to predict the 10-year coronary heart disease risk for women using the Women's Health Initiative cohort [16]. Importantly, primary prevention relies on screening for heart disease before it develops. Although young women may have a reportedly low 10-year CVD risk by traditional calculations, their lifetime risk remains high.

Equally important is for physicians to recognize and aggressively treat modifiable risk factors for coronary heart disease. These include hypertension, dyslipidemia, smoking and diabetes (as well as metabolic syndrome). Diabetes is perhaps the most important risk factor for coronary artery disease in women, irrespective of age. Once a diagnosis of diabetes is established, persistent gender disparities exist in the management of other CVD risk factors, such as hypertension and dyslipidemia [17]. Similarly, smoking rates remain high in young women who often cite weight maintenance as a reason for smoking. For women, differences in fat distribution confer different CVD risks. Women with coronary artery disease have higher waist-to-hip ratios; this type of ‘central adiposity’ is associated with higher low-density lipoprotein cholesterol and lower high-density lipoprotein cholesterol and often clusters with metabolic syndrome.

“…many overlook that cardiovascular disease and its important risk factors … develop at a young age and are highly prevalent in young women.”

Primary prevention guidelines from the American Heart Association recommend that beginning at the age of 20 years, all adults should undergo routine screening for cardiovascular risk factors including smoking status, diet, physical activity and alcohol intake [18]. Blood pressure, BMI and waist circumference should be measured at each visit, occurring at least every 2 years. Additionally, young women have unique risk factors including gestational hypertension and diabetes, which further increase their risk for the development of CVD. Autoimmune conditions that are particularly prevalent in young women, such as systemic lupus erythematosus and rheumatoid arthritis, confer increased cardiovascular risk, independent of other risk factors. Pregnancy also poses a unique risk for coronary artery disease, coronary artery dissection, pre-eclampsia and peripartum cardiomyopathy. Women who suffer from gestational diabetes, for example, should undergo aggressive screening for hyperglycemia because they have a ninefold increase in the development of Type 2 diabetes mellitus [19].

“Traditional risk estimation calculators … underestimate cardiovascular disease in young women who may have nontraditional risk factors.”

Importantly, CVD is largely preventable through behavioral and lifestyle modifications. The AHA has defined a goal of ‘ideal cardiovascular health’ that seeks to reduce cardiovascular and stroke mortality by 20% by 2020 [1]. These health behaviors include not smoking, BMI of <25 kg/m², moderate exercise, a healthy diet and maintenance of normal values of cholesterol, fasting glucose and blood pressure, also known as ‘Life's Simple 7’. A recent study by Yang and colleagues demonstrated that meeting all seven criteria established by the American Heart Association of optimal CVD health may prevent 59% of all deaths, 64% of those from CVD and 63% of those from ischemic heart disease over an approximate 20-year period [20]. All healthcare providers should strive for their patients, even young women who are often perceived to have a lower CVD risk, to maintain ‘ideal cardiovascular health’.

In conclusion, the epidemic of CVD will continue to rise, in parallel with the growing burden of cardiometabolic risk factors such as obesity and diabetes. Heart disease in women is often under-recognized and undertreated. In addition to traditional risk factors, young women have unique risk factors that should be carefully assessed at each clinical encounter. As prevention is the most effective strategy to combat this epidemic, policy efforts should be targeted toward increasing awareness of heart disease and risk factors for young women. Once risk factors are established, aggressive treatment should be undertaken to prevent associated CVD morbidity and mortality.