Cardiovascular disease prevention in women: A discussion with Erin Donnelly Michos, MD – Contemporary OB/GYN

Report on Cardiovascular Disease Prevention in Women: Aligning with Sustainable Development Goals

Introduction: A Global Health Imperative

This report analyzes key strategies for the primary prevention of cardiovascular disease (CVD) in women, framing the issue within the context of the United Nations Sustainable Development Goals (SDGs). Addressing CVD, the leading cause of mortality in women, is fundamental to achieving SDG 3 (Good Health and Well-being), particularly Target 3.4, which aims to reduce premature mortality from non-communicable diseases. Furthermore, the persistent undertreatment and underestimation of risk in women highlight critical gaps in health equity, directly relating to SDG 5 (Gender Equality) and SDG 10 (Reduced Inequalities).

Current State of Cardiovascular Risk Assessment and Management

An analysis of current practices reveals significant disparities in the prevention and treatment of CVD in women, undermining progress toward global health targets.

• Inadequate Risk Calculation: Standard risk calculators often fail to incorporate female-specific risk enhancers, such as premature menopause and adverse pregnancy outcomes. This systemic oversight leads to an underestimation of true cardiovascular risk, contributing to undertreatment and violating principles of gender-equitable healthcare (SDG 5).
• Preventability of CVD: An estimated 90% of CVD is attributable to modifiable risk factors, underscoring the critical importance of proactive and early prevention strategies to meet SDG 3.
• Undertreatment in Midlife: Midlife women are frequently undertreated for major risk factors, including hypertension, dyslipidemia, and diabetes, despite evidence of equal or greater benefit from therapies compared to men. This inequality in care access and delivery is a direct challenge to SDG 10.

Key Areas for Intervention to Advance SDG 3 and SDG 5

Targeted interventions in the management of hypertension, lipids, and diabetes are essential to close the gender gap in cardiovascular outcomes.

1. Hypertension Management

1. High Prevalence and Poor Control: Over 50% of midlife women have hypertension, yet less than 25% achieve adequate blood pressure control.
2. Sex-Specific Risk Thresholds: Evidence suggests that cardiovascular risk in women begins at lower blood pressure thresholds than in men, indicating a need for gender-sensitive guidelines to achieve SDG 3.
3. Therapeutic Imperative: All women with stage 2 hypertension (≥140/90 mm Hg) and high-risk women with stage 1 hypertension require pharmacologic therapy in addition to lifestyle modifications.

2. Lipid Management

• Causal Role of Cholesterol: Elevated LDL cholesterol is a direct cause of atherosclerotic CVD. For every 40 mg/dL reduction in LDL, major cardiovascular events can be reduced by approximately 22%.
• Menopausal Transition: During menopause, women experience a rise in cholesterol and lipoprotein(a) levels, making this a critical period for intervention.
• Therapeutic Options: While statins are first-line therapy, nonstatin agents and combination therapies offer effective alternatives, particularly for women who experience side effects. Ensuring access to a full range of therapies supports health equity (SDG 10).
• High-Risk Populations: Women with conditions like familial hypercholesterolemia lose any “female advantage” and face a significantly elevated risk of early myocardial infarction, requiring aggressive and lifelong management.

3. Diabetes Management

• Disproportionate Risk: Diabetes confers a greater relative risk for myocardial infarction in women (a four-fold increase) compared to men (a two-fold increase), highlighting a significant gender-based vulnerability.
• Benefit from Modern Therapies: Women derive significant, and potentially greater, cardiovascular benefits from SGLT2 inhibitors and GLP-1 receptor agonists.
• Integrated Care Approach: All adults over 40 with diabetes should be on a statin, and glucose-lowering agents with proven cardiovascular benefits should be prioritized to holistically address NCD risk factors as outlined in SDG 3.

Conclusion: A Paradigm Shift Toward Lifelong Prevention and Health Equity

A fundamental paradigm shift is required to align clinical practice with the Sustainable Development Goals. This involves moving from late-stage intervention to a model of primordial and primary prevention that begins early in life. Achieving better cardiovascular outcomes for women is not merely a clinical goal but a prerequisite for advancing global health, promoting gender equality, and reducing systemic inequalities. Clinicians must treat women according to guideline recommendations, actively countering the historical biases that have led to their undertreatment and ensuring that every woman has the opportunity to live a healthy life.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

1. SDG 3: Good Health and Well-being

   • The article’s primary focus is on preventing and managing non-communicable diseases (NCDs), specifically cardiovascular disease (CVD), hypertension, and diabetes in women. This directly aligns with SDG 3, which aims to ensure healthy lives and promote well-being for all at all ages. The text emphasizes that “Cardiovascular disease is still the leading cause of death in women” and that “90% of cardiovascular disease as being due to modifiable, preventable factors,” highlighting the critical need for better health interventions.

2. SDG 5: Gender Equality

   • The article consistently points out the disparities in cardiovascular care between men and women. It states that “midlife women are frequently undertreated for hypertension, dyslipidemia, and diabetes” and that they are “often presumed lower risk because of sex.” This addresses SDG 5 by highlighting a significant gender-based inequality in access to and quality of healthcare, and it calls for treating patients “according to guideline recommendations, without regard to sex.”

2. What specific targets under those SDGs can be identified based on the article’s content?

1. Targets under SDG 3: Good Health and Well-being

   • Target 3.4: By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.
     • The article directly supports this target by focusing on the prevention and treatment of CVD, the leading NCD-related cause of death in women. It advocates for “primordial prevention—optimizing cardiovascular health before midlife” and discusses various treatments like statins, nonstatin therapies, and diabetes medications (SGLT2 inhibitors, GLP-1 receptor agonists) to reduce major cardiovascular events.

2. Targets under SDG 5: Gender Equality

   • Target 5.1: End all forms of discrimination against all women and girls everywhere.
     • The article identifies a form of systemic bias or discrimination in healthcare where women’s cardiovascular risk is underestimated and undertreated. The statement, “Clinicians should not assume women are lower risk—they should be treated according to guideline recommendations, without regard to sex,” is a direct call to end this discriminatory practice in clinical settings.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. Indicators for SDG 3 Targets

   • Official Indicator 3.4.1: Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease.
     • The article’s central theme is reducing mortality from CVD, stating it is the “leading cause of death in women.” Progress would be measured by a reduction in this mortality rate.
   • Implied Indicators:
     • Prevalence and control of hypertension: The article provides a baseline, stating “over half of [midlife women] have hypertension” and “less than 25% have their blood pressure under control.” An increase in the control rate would indicate progress.
     • Prevalence of diabetes and associated risk: The article notes that diabetes confers a “4-fold increased risk of myocardial infarction” in women. Tracking the incidence of diabetes and related cardiovascular events in women would be a key indicator.
     • Rate of treatment with evidence-based therapies: The article discusses the need for women to be treated with statins, nonstatin therapies, and specific diabetes medications. Measuring the prescription and adherence rates for these therapies in eligible women would serve as a progress indicator.

2. Indicators for SDG 5 Targets

   • Implied Indicators:
     • Disparity in treatment rates between men and women: The article’s assertion that women “remain undertreated” for hypertension, dyslipidemia, and diabetes implies that a key indicator would be the gap in treatment rates between genders for the same conditions. Closing this gap would signify progress towards Target 5.1.
     • Inclusion of women in clinical trials: The question posed in the article, “why is it important that trials include sufficient numbers of women?” suggests that the proportion of women in cardiovascular clinical trials is an important indicator of gender equality in health research.

4. Table of SDGs, Targets, and Indicators

Source: contemporaryobgyn.net