Red Alert for Women’s Hearts

Friday, 29 January 2010 00:00

Recommendations to improve the awareness, diagnosis and treatment of Cardio Vascular Diseases in women.

Several European Foundations affiliated to the European Heart Foundation-EHN, together with the European Society of Cardiology-ESC, have recently completed the third section (Work Package 6/WP6) of a three-year program called EuroHeart (1), dedicated to the Heart Health and co-funded by the European Union-EU. Aim of EuroHeart is to address the significant burden of Cardio Vascular Disease–CVD in Europe and to determine specific areas of policies and public health interventions against CVD. The project runs from 1 April 2007 till 31 March 2010. Within the project three main projects have been developed: a) European Heart Health Charter (2), b) Euro Heart Mapping (3), and c) Red Alert for Women’s Hearts (4).

The objective of this last WP6 “Red Alert for Women’s Hearts” is to improve the awareness, diagnosis and treatment of CVD in women. Following the meeting of the Board of WP6 held on 12 January 2010 a list of Recommendations on women and CVD directed to Heart Foundations and Cardiac Societies, Regulators, and Research Funding Entities has been released.

Recommendations for Heart Foundations and Cardiac Societies
•    Initiatives which contribute to awareness raising, education and prevention that   cardiovascular diseases are the major cause of death in women should be encouraged.
•    More opportunities to present on Women and CVD and/or outcome of research on Women and CVD should be created at scientific meetings, conferences, workshops, etc.
•    Initiatives which contribute to improving the knowledge of risk factors, presentation,  treatment and rehabilitation of cardiovascular diseases in women should be encouraged.
•    Scientific guidelines should systematically address gender differences.
•    Heart Foundations and Cardiac Societies should cooperate with European institutions, national health care authorities and regulatory agencies to promote scientific research on gender differences in cardiovascular medicine and a larger representation of women in clinical trials.
•    Increased awareness on gender differences supported by multidisciplinary studies is needed.
•    Time trends show a compelling need for more effective lifestyle management in both genders.
•    A special effort for preventing smoking initiation and favouring smoking cessation in young women is needed. 
•    Further understanding is needed about the reciprocal influences of lifestyle, nutrition, exercise and cardiovascular disease development, mainly after menopause.
•    Health professionals across specialities should be informed about the specific issues related to women who are diabetic.
•    CVD is killer number one among women; the risk of stroke increases drastically after the age of 75. With the increase of life expectancy, which is greater in women than in men, the proportion of older women with heart failure is expected to increase in the future.
•    Decision makers and health-care planners need to be aware of these demographic aspects to ensure that adequate provisions are made.
•    Women who experience hypertensive disorders during pregnancy should receive a strict follow-up in order to identify those who may develop hypertension later in life.
•    Awareness of the magnitude and timing of the risk of type 2 diabetes after gestational diabetes among patients and clinicians needs to be increased. 
•    Women with heart failure and other types of CVD should be encouraged to discuss contraceptives and planned pregnancy with a physician in order to take an informed decision based on assessment of potential risks.
•    Research shows unequal access to treatment for women who suffer from CVD. It shows that excessive drug dosing in women takes place frequently and that women more often than men do not reach the hospital in time in order to start appropriate treatment.
•    Barriers for achieving equal access to treatment in hospitals after a CVD event must be identified and addressed.
•    Steps should be taken to ensure a systematic inclusion of gender-specificity in the training of health-care specialists in general and cardiologists in particular.

Recommendations for Regulators
•    Clinical trials enrolling a significant proportion of women to allow for pre-specified gender analysis should be encouraged, especially in the fields of ischemic heart disease, cholesterol-lowering therapy and heart failure.
•    Clinical trials should systematically allow for an analysis of the results by gender.
•    Enrolment criteria and follow-up duration of clinical trials should allow the inclusion of women at risk of developing cardiac events.
•    External barriers to the enrolment of women in clinical trials need to be addressed, and in particular the transportation difficulties for older women to go to the follow-up visits.
•    Scientific guidelines should systematically address gender differences.
•    Regulatory agencies in the European Union are urged to adopt strict rules on the inclusion of women in clinical trials and a systematic gender analysis.
•    Standardised rules on gender specific biomarkers in drug development should be identified, validated and qualified.

Recommendations for Research Funding Entities
•    Scientific research on gender issues in cardiovascular medicine should be promoted.
•    Increased awareness on gender differences supported by multidisciplinary studies is needed.
•    Additional research is needed in the field of hormone replacement therapy (HRT) for the relief of symptoms in postmenopausal women, in order to assess with precision the added risk of CVD and breast cancer based on:
o    age of the population
o    time of beginning the therapy since menopause
o    type and mode of administration
o    duration of therapy
o    CVD effects of new agents
o    the type and source of hormone preparation
o    ethnic differences on use of HRT
o    phyto-oestrogens
o    impact of new hormonal preparations
•    Promote the development and/or adoption of a risk assessment system which can accurately estimate CVD risk to healthy women over 40 years of age, taking into account such variables like diabetes and features of the metabolic syndrome and consequently to improve the existing risk scores.
•    Undertake research to establish cardiovascular biomarkers in proximity of menopause.
•    Explore the reasons for gender differences in the adverse effects of some hypoglycaemic agents.
•    Encourage research on the risk of developing type 2 diabetes after glycemic alterations during pregnancy.
•    Research is needed on gender specific pathophysiology of overweight and obesity development in all ages of life.
•    Research is needed to better profile gender specific pathophysiology of metabolic syndrome.
•    Research is needed to elucidate the reasons for the adverse prognosis observed in women with stable angina and proven coronary disease, i.e. less non invasive testing and coronary angiography, less revascularization, anti platelet and statin therapies.
•    Encourage research on women with symptoms and signs suggestive of myocardial ischemia but without obstructive coronary artery disease.
•    Encourage research on the long term efficacy and safety of early revascularisation in acute coronary syndromes in women and on antithrombotic therapy in women.
•    Encourage research on the efficacy and safety of therapeutic interventions for heart failure patients with preserved left ventricular function (more common in women).
•    The origin on gender differences in stroke incidence and post stroke disability needs to be examined together with the reasons for the under-treatment of women with thrombolytic therapy despite its greater efficacy when compared to men.
•    Studies of gender specific differences of the established pharmaceutical armamentarium for Cardiovascular Disease should better reflect women with heart diseases.
•    More information and more studies on adverse drug reactions in women is needed.
•    Further understanding is needed about the reciprocal influences of lifestyle, nutrition, exercise and cardiovascular disease development, mainly after menopause.

Read more...."Red Alert" and "Stramba-Badiale M: Women and research on cardiovascular diseases in Europe: a report from the European Heart Health Strategy (EuroHeart) project. Eur Heart J 2010; doi:10.1093/eurheartj/ehq094"

January 2010


(1) EuroHeart: European Heart Health Strategy
To address the significant burden of CVD in Europe and to determine specific areas of intervention to contribute to preventing avoidable deaths and disability, the European Heart Network and the European Society of Cardiology have created a joint project called EuroHeart.  This project, which involves partners in 21 countries in the EU and the EEA, receives co-funding from the European Commission Public Health Programme 2003-2008.  The project, which started in April 2007 and will finish in March 2010, has 5 major objectives: a) Mobilise broad support for cardiovascular health promotion and cardiovascular disease prevention with a view to achieving stronger cross sector cooperation. b) Map and analyze national plans, policies and measures impacting on cardiovascular health promotion and cardiovascular disease prevention c) Investigate issues concerning CVD in women d) Improve prevention practices at primary care level e) Implement and adapt European guidelines on CVD prevention to national situations (http://www.ehnheart.org/content/itemstory.asp?level0=1456&level1=2096&level2=2097)

(2) European Heart Health Charter. Launched on June 12, 2007 at the European Parliament in Brussels in the presence of EU Health Commissioner Markos Kyprianou and Dr. Nata Menabde, Deputy Regional Director of WHO Europe, the Charter is an EU-wide policy document on cardiovascular disease prevention. It is signed by 14 eminent professional and public health organisations and wishes to change the way Europe tackles CVD. Governments, NGOs and health organisations that sign the charter commit to reduce considerably the burden of CVD in Europe (reducing the numbers of smokers, promoting healthy food choices and physical activity, reducing obesity rates and implementing best practices in cardiovascular care). All signatories agree to strive for equity in treatment within their country and across Europe. EU Health Commissioner Markos Kyprianou said: "The European Commission is very pleased to have been able to play a part in bringing the Charter into being. If we are going to beat cardiovascular disease we need to redouble our efforts. We need concerted action by governments together with the health sector, with business and with NGOs and –most importantly - with citizens". (http://www.ehnheart.org/files/EHHC_P_R-114913A.pdf)

(3) Euro Heart Mapping: national plans, policies and measures impacting on cardiovascular health promotion and cardiovascular disease prevention. Second part of the EuroHeart project, is a survey that highlights striking differences across different countries in Europe in terms of national prevention policies (www.euroheart2009.eu).

(4) Red Alert for Women’s Hearts.
Third part of the Euroheart project led by EHN. This campaign aims to reduce cardiovascular disease (CVD) in women by building global attention and commitment to CVD in women. Many heart foundations all over the world have engaged in this campaign. From the countries participating in the EuroHeart project, Italy, Iceland, Finland and Norway have campaigns in parallel with the Go Red for Women campaign. (as far Italia is concerned the campaign is named Red Dress Italia: see www.reddressitalia.it, and www.lorenzinifoundation.org)

(5) “International Position Paper on Women’s Health and Menopause: A comprehensive approach”, published in 2002, which is the result of the close collaboration between the Giovanni Lorenzini Medical Science Foundation (Milan-Houston) and the National Heart and Lung Institute and Office of Research on Women’s Health of the National Institutes of Health (Bethesda, USA). The volume came from the collaboration of a international Committee made of more than 80 experts from over 15 Countries.

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The European Heart Network (EHN) is a Brussels-based alliance of heart foundations and non-governmental organizations throughout Europe. The mission is to play a leading role in the prevention and reduction of cardiovascular disease through advocacy, networking and education. It is possible to find more information about the EHN, its activities as well as copies of all its publications, positions and responses to EU consultations on this website: www.ehnheart.org

The Italian Heart Foundation- Fondazione Italiana per il Cuore – IHF, (www.fondazionecuore.it)
based in Milan, Italy, was established as a not for profit organization in 1990 and registered as a foundation in 2004.
Aims of IHF are: to disseminate scientific information; to develop relationships between specialists, GPs, and the general population; to interact with government bodies to promote the prevention of cardiovascular diseases; to carry out studies and research projects.
The activities of the IHF include among others the organization of scientific meetings, the development of position papers, publications, websites, and other electronic educational material. The IHF also promotes educational campaigns mainly focused on the prevention of CVD and women’s health aimed at the public (Red Dress Italia, www.reddressitalia.it).

The Fondazione Giovanni Lorenzini Medical Science Foundation (www.lorenzinifoundation.org) consists of two not-for-profit scientific organizations, one based in Milan, Italy (established in 1969) and the second in Houston, USA (established in 1984): both are committed to the international  scientific exchange and education in basic and medical research.
The Lorenzini Foundation has the mission to transfer the most recent developments and results in the experimental sciences to clinical and applied research, to be used for the single patient and for the community. The Foundation is collaborating with academia to ensure the constant updating of physicians and basic scientists.
The activities of the Lorenzini Foundation include the organization of International Congresses and Courses, the development of guidelines, position papers, proceedings, highlights, websites, and CD-ROMs. The Lorenzini Foundation also promotes educational campaigns mainly focused on prevention of CVD and women’s health aimed at the public (to mention a few: National Campaign on Cholesterol, National Campaign on Triglycerides, National Campaign on Global Risk and CVD, National Campaign on Women’s Health and Menopause).

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Medical Director - Questions K. Douglas Thrasher, D.O. 2010-04-16 16:06:07 Have you developed an algorithm for advanced lipid testing based on family Hx or other risk factors? Or perhaps you look at specific parameters of the conventional lipid study? And in developing these algorithms do you notice any gender specificities?

Women and atherothrombotic disease W.E. Feeman, Jr, MD 2010-04-12 13:08:39 This worthy commentary deserves additional comment. Atherothrombotic disease (ATD, such as heart attacks and strokes) is the leading killer of women, just as it is of men. The risk factors for ATD in women are the same as those for men: cigarette smoking, dyslipidemia, and hypertension. The difference between men and women lies in the mix of those risk factors. This is important because we cannot protect women (or men) from the ravages of ATD unless we know who is at risk of ATD. The differences in the risk factor mix between men and women undoubtedly accounts for their differences in ATD presentation. In the past, men smoked more cigarettes than women and had their ATD events much sooner than women. In more recent times that has reversed itself and women are having their ATD events earlier, whereas men are having them later. (This is not true for men who continue to smoke or for women who do not smoke.) Hence, the primary objective of any preventive cardiology program must be to encourage smokers as strongly as possible to stop smoking and to try to prevent people from starting in the first place. Hypertension should be straight-foreward. It is easy to detect and easy to treat in most cases. All visits to physicians\' offices should include the determination of blood pressure. Public screenings can be done as well. The matter of dyslipidemia is more confusing. The NCEP in the USA has had tunnel vision in focusing on LDL-cholesterol, giving only second-class citizenship to HDL. This is an error. In the past, women developed their dyslipidemic hypertension at the time before, during, and after the menopause. Nowadays, women are smoking more and developing their dyslipidemic hypertension at an earlier age, and whereas in days gone by women\'s dyslipidemia was primarily an LDL overload, in more recent times their dyslipidemia is often manifested by middling levels of LDL and low levels of HDL-cholesterol. In my opinion, a state of dyslipidemia exists whenever the balance between pro-atherogenic (mainly LDL) and anti-ataherogenic (mainly HDL) lipids favors the accumulation of cholesterol within the intima. This balance is best addressed in terms of a ratio between LDL and HDL, and I advocate the Cholesterol Retention Fraction (CRF, or [LDL-HDL]/LDL), which has been described at this website in the past (2009). I will be presenting a poster at the EAS symposium in Hamburg in June and will be happy to discuss all this with any interested parties.

Answer to Dr. Thrasher's Questions Health Europe Committee 2010-04-16 16:29:12 Dear Dr. Thrasher, the authors are not sure to have understood your questions. Maybe the following papers could give an answer to them: - Circ Cardiovasc Qual Outcomes 2010; 3: 128-134 - JAMA 2007; 297: 611-619 - J Am Coll Cardiol 2010; 55: 1169-77 - J Am Coll Cardiol 2010; 55: 1197-1199

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