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Risk Management

Cardiovascular Disease in Women

Both women and their doctors can miss or ignore the early warning signs of cardiovascular disease. Although many people think heart disease is a man's disease, it is the number one killer of women in the U.S.


Heart disease is rated as the number one killer for women in the U.S.--one in three die from it.1 Yet only 54 percent of women are aware of this statistic.2 In addition, Hispanic women are more likely to develop heart disease 10 years earlier than their Caucasian counterparts.1

The following scenario is a common patient presentation related to female cardiovascular disease symptomatology.

Shelia, age 64, had been seeing a chiropractor intermittently for the past 20 years for musculoskeletal complaints. Recently, after taking a hiatus from seeing her practitioner, she began to notice a small amount of lower extremity edema, fatigue and some shortness of breath.

Sheila walked an average of two miles per day, five days a week and had a relatively healthy diet. She attributed her symptoms to a new job where she sits frequently, as well as an increase of salt in her diet.

Her history includes hypothyroidism, for which she takes daily medication, and a family history significant for heart disease. When she presented to her chiropractor, she mentioned she had thoracic spine pain, which has been tight for the past two weeks. She showed her doctor lower extremity edema and mentioned the fatigue and shortness of breath she’s been experiencing.

As chiropractic practitioners, it is important to identify if this presentation is an emergent, urgent or routine. Additionally, consideration should be given relative to the course of care and referral or comanagement. Thinking beyond this scenario, patient education regarding cardiovascular disease and preventative measures is essential.

Symptoms Are Easy to Overlook

Women tend to report much more subtle symptoms than men, such as fatigue, shortness of breath, indigestion, back pain and sometimes jaw pain. In contrast, men tend to exhibit the more classic symptoms of left-sided chest pain or pressure in the arm or jaw radiation.

Since the signs and symptoms are so subtle, women tend to attribute them to other factors. It has been identified that two-thirds of females who experienced sudden death due to heart disease did not report previous symptomatology.3,4

There are many risk factors women cannot control such as age, gender, heredity, race and a previous history of a heart attack or stroke. However, many traditional risk factors such as hypertension, hypercholesterolemia, obesity, diabetes, poor physical activity and smoking can be evaluated and managed readily.

Hypertension, in particular, tends to have a greater effect on women over the age of 65 relative to their male counterparts.5,6 Encouraging patients to have a routine labs and physical exam procedures that identify serum cholesterol, fasting blood sugar, BMI and blood pressure assist in prevention and recognition.

While traditional risk factors are more commonly discussed, nontraditional risk factors can have long-term effects on cardiac health. These include pregnancy-related disorders (preterm delivery, hypertensive pregnancy disorders, gestational diabetes and persistence of postpartum weight gain), autoimmune diseases (rheumatoid arthritis and systemic lupus erythematosus), radiation and chemotherapy for breast cancer and depression.7

How Does Estrogen Play a Role?

Estrogen tends to be a cardioprotective agent because it keeps the inner wall of arteries flexible, assists with vasodilation and combats inflammatory responses in atherosclerosis.

It is also noted that as estrogen decreases, the level of LDL cholesterol tends to rise and HDL cholesterol tends to fall. Correspondingly, when estrogen declines, which is common in post-menopausal patients, women may at risk for heart disease. The average female in the United States experiences menopause around the age of 51.8,9

One consideration is the utilization of Menopausal Hormone Therapy (MHT) that is used by many women to relieve the symptomatology associated with the physiological change of menopause. However, MHT is not indicated to prevent cardiovascular disease.

It has been widely noted that if a female experiences early menopause, either naturally or as a result of a bilateral oophorectomy before age 45, she has a greater likelihood of mortality from cardiovascular disease. This likelihood increases if the individual was not treated with estrogen replacement.8,9

How Can We Help Our Patients?

We must educate our patients not only about the signs and symptoms of heart disease, but also about prevention and lifestyle interventions. It is important to stress to our female population the need to be conscious of good cardiovascular health at an early age.

According to the Evidence Based Guidelines for Cardiovascular Disease Prevention in Women 2007, women should:10

  • Avoid tobacco smoke exposure and utilization
  • Partake in a minimum of 30 minutes of physical activity every day
  • Eat a diet rich in fiber, fruits and vegetables and fish oil
  • Maintain or reduce their weight to attain a BMI between 18.5 and 24.9 kg/m2
  • Take in omega-3 fatty acids
  • Monitor their blood pressure, cholesterol (including HDLs and LDLs) and blood sugar levels

An excellent resource to educate young women on heart health is the American Heart Association’s Life’s Simple 7 for Kids campaign,11 a seven-step approach for children to stay heart healthy and make good choices.

Additionally, as providers we must fine tune our history questions and intake forms to inquire about related risk factors, both traditional and nontraditional with an emphasis on pregnancy and the female physiological journey and its role in cardiovascular health. It is imperative that we help women understand both preventative strategies and early warning signs and symptoms of heart disease.

1 American Heart Association: Go Red for Women, www.heart.org, www.goredforwomen.org

2 Mosca L, Mochari-Greenberger H, Dolor RJ, Newby LK, Robb KJ. Twelve-year follow-up of American women’s awareness of cardiovascular disease risk and barriers to heart health. Circulation: Cardiovascular Quality Outcomes. 3:120-7.(2010)

3 Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB. Heart Disease and Stroke Statistics-2012 Update: A Report from the American Heart Association. Circulation. 125(1)2-220. (2012)

4 Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferrant SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jimenez MC, Jordan LC, Judd SE et al. Heart Disease and Stroke Statistics-2017 Update: A Report from the American Heart Association. Circulation. (2017)

5 Everett B, Zajacova A. Gender Differences in Hypertension and Hypertension Awareness Among Young Adults. Biodemography Soc Biol. 61(1): 1-17. (2015)

6 Gudmundsdottir H, Hoieggen A, Stenehjem A, Waldum B, Os I. Hypertension in Women: Latest Findings and Clinical Implications. Ther Adv Chronic Dis 3 (3): 137-146. (2012)

7 Garcia M, Mulvagh C, Bairey Merz N, Buring J and Manson J. Cardiovascular Disease in Women: Clinical Perspectives. Circ Res. 118:1273-1293 (2016)

8 Baker L, Meldrum KK, Wang M, Sankula R, Vanam R, Raiesdana A, Tsai B, Hile K, Brown JW, Meldrum DR. The Role of Estrogen in Cardiovascular Disease.

9 Gold, Ellen B. The Timing of the Age at Which Natural Menopause Occurs. Obstetrics and Gynecology Clinics of North America 38.3 (2011): 425–440. PMC. Web. 3 Oct. 2017.

10 Mosca L, Banka C, Benjamin E, Berra K, Bushnell C, Dolor R, Ganiats T, Gomes A, Gornik H, Gracia C, Gulati M, Haan C. Judelson D, Keenan N, Kelepouris E. et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. Circulation. 2007;115:1481-1501, originally published March 19, 2007

11 American Heart Association: Life’s Simple 7 for Kids, https://www.heart.org/HEARTORG/HealthyLiving/HealthyKids/LifesSimple7forKids/Lifes-Simple-7-for-Kids_UCM_466610_SubHomePage.js


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