CARDIOVASCULAR DISEASE(CVD), which includes dis-eases of the heart, brain bloodsupply, and vascular system, isthe number one cause of death in the United States. About 2,200American adults die of CVD everyday—that’s one out of every threedeaths. Almost 2 million Americanslive with CVD, which can lead tomyocardial infarction (MI), strokes,heart failure, renal disease, and pe-ripheral artery disease.

Despite improvements in treat-ment, CVD remains the leadingcause of mortality in women. (SeeBy the numbers.) Women—andmany healthcare providers—lackknowledge about CVD risk factorsand MI symptoms unique to wo -men, which leads to late recogni-tion and inadequate treatment.

Risk factorsWomen’s CVD risk factors are some-what different from men’s. For ex-ample, women with diabetes andthose who smoke are at higher riskthan men who have diabetes orsmoke. Other risk factors for wo -men include age, inflammatory dis-eases, and pregnancy complications(specifically, pre-eclampsia, preg-nancy-induced hypertension, andgestational diabetes).

Natural estrogen inpremeno paus al women is be-

lieved to be cardioprotective, butreplacement estrogen taken duringmeno pause doesn’t help preventCVD. Researchers are asking why, ifestrogen is cardioprotective, we’reseeing more MIs in young er women.No clear answer exists. How ever,younger women who have MIs aremore likely to be obese or to havehypertension, tachycardia, or type 2diabetes, but that doesn’t completelyanswer the question.

Women of color are at greaterrisk for CVD than white women.Black women in the United Statesare at higher risk for an MI than allother women, and many experiencean MI at a younger age. Becausethey may have no symptoms, theyhave higher rates of sudden cardiacdeath. Typically, Hispanic and Blackwomen have more comorbidities(such as diabetes, hypertension, andobesity) than white women. When

LEARNING OBJECTIVES1. State risk factors for cardiovas-

cular disease (CVD) in women.

2. Compare signs and symptomsof myocardial infarction be-tween men and women.

3. Discuss strategies for prevent-ing CVD in women.

The authors and planners of this CNE activityhave disclosed no relevant financial relation-ships with any commercial companies per-taining to this activity. See the last page of thearticle to learn how to earn CNE credit.

Expiration: 6/1/21

CNE1.47 contact

hours

Women and cardiovascular disease

Understand women’s unique risks and symptoms to ensureearly identification and treatment of CVD.

By Melanie Kalman, PhD, RN, CNS, and Margaret Wells, PhD, RN, APN-BC

22 American Nurse Today Volume 13, Number 6 AmericanNurseToday.com

AmericanNurseToday.com June 2018 American Nurse Today 23

black women present to the emer-gency department (ED), they’re lesslikely than white women to betreated using the American HeartAssociation (AHA) guidelines. Thisis particularly true for younger wo -men of color, who are less likely tobe prescribed angiotensin-convert-ing enzyme (ACE) inhibitors andbeta-blockers after an MI. Further-more, prevention efforts, such ashealthy eating or exercise programs,are less likely to be recommendedto women of color.

MI symptomsMany women aren’t aware that theirMI symptoms may be different fromthose of men. For example, womenmay have prodromal symptoms forup to a year prior to a cardiacevent. (See Prodromal symptoms.)Researchers believe that men devel-op blockages in their main cardiacarteries but that wo men developblockages in the main arteries aswell as smaller cardiac arteries (coro-nary microvascular disease), result-ing in different MI symp toms. Chestpain is still the number one symp-tom of MI in women, but it’s notthe “elephant sitting on your chest”type of pain frequently experienced

by men; instead, women feel it aspressure or discomfort. (See MIsymptoms.) Women’s symptoms arevague and easy to miss, by bothwo men and healthcare providers.

Several factors contribute towomen’s higher MI morbidity andmortality rates. Women (and some

healthcare providers) may believethat CVD is a “man’s disease,” sothey ignore symptoms and delayseeking treatment. In some cases,they delay going to the ED up to 2hours longer than men; women ofcolor delay going to the hospitallonger than white women. Althoughwomen’s awareness of CVD risk hasimproved, a knowledge gap still ex-ists, and it’s even larger for womenof color and those who live in ruralareas.

AHA guidelinesThe 2011 updated AHA guidelinesfor the prevention of heart diseasein women identify three risk levels:ideal cardiovascular health, at risk,and high risk. (See Know the risk.)Women who have ideal cardiovascu-lar health have no presence of CVD,total cholesterol level < 200 mg/dL,blood pressure ≤ 120/80 mmHg,body mass index < 25 kg/m2, andfasting blood glucose < 100 mg/dL.At-risk women have one or moremajor risk factor for CVD—cigarettesmoking, dyslipidemia, family histo-ry of premature CVD, hypertension,obesity, and a sedentary lifestyle.Other women deemed to be atrisk are those with a history of pre-eclampsia, gestational diabetes, preg -nancy-induced hypertension, or sys-temic autoimmune collagen vasculardiseases (such as rheumatoid arthri-tis). Women designated as high riskhave known coronary heart disease,cerebral vascular disease, abdominalaortic aneurysm, peripheral vasculardisease, end-stage or chronic kidneydisease, diabetes, or a 10-year pre-dicted CVD risk ≥ 10%.

The gold standard of treatmentand risk reduction for all women,regardless of their risk category, isadhering to a healthy lifestyle, in-cluding diet, exercise, adequatesleep, stress reduction, and smok-ing cessation.

DietLet your patients know that the ide-al diet consists primarily of whole

Learn about cardiovascular disease (CVD) and women so you can provide the bestcare. And share this information with your female patients so they understandtheir risks.

• More women than men have CVD.

• CVD mortality is greater for women than men.

• The average age for a woman to have her first myocardial infarction (MI) is71.8 years old; for men, it’s 65 years old.

• In the United States, over 6.5 million women die annually from CVD and over53,000 women die from an MI.

• CVD is the leading cause of death for Hispanic and Black women.

• 26% of women die within 1 year of having an MI, compared to 19% of men.

• MIs in younger women (45 to 54 years old) are increasing.

• An estimated 35,000 women younger than 65 years old have an MI each year.

• Hispanic women are likely to develop heart disease 10 years earlier than whitewomen.

Sources: goredforwomen.org/about-heart-disease/facts_about_heart_disease_in_women-sub-category/statistics-at-a-glance; cdc.gov/dhdsp/data_statistics/fact_sheets/fs_women_heart.htm

By the numbers

The gold standard oftreatment and riskreduction for all

women, regardless oftheir risk category, isadhering to a healthy

lifestyle, includingdiet, exercise,

adequate sleep, stressreduction, and

smoking cessation.

24 American Nurse Today Volume 13, Number 6 AmericanNurseToday.com

grains, vegetables, fruits, and pro-tein sources low in saturated fats,such as lean meats and tofu. TheAHA recommends no more than 6%of daily calories (about 13 grams)should come from saturated fatsfound in foods such as red meat,chicken with the skin, cheese, andbutter, and that processed breadsand baked goods made with refinedflour and sugar should be avoided.

The AHA supports the DietaryApproaches to Stop Hypertension(DASH) eating plan for weight lossand hypertension control. Readingfood labels can help people reducesodium, sugar, and saturated fatconsumption because it might re-veal, for example, that somethinglike a “healthy soup” is actuallyhigh in all three. The DASH planrecommends eating no more than2,400 mg of sodium per day. Ingeneral, processed foods such asdeli meats, canned soups, andfrozen meals are very high in so -dium and should be avoided.

ExerciseAccording to the U.S. Department ofHealth and Human Services (DHHS)Physical Activity Guidelines forAmer icans, women should strivefor a mini mum of 150 minutes perweek of moderate-intensity exercise,such as brisk walking. These guide-lines are in DHHS’s review process;an update may be available at theend of 2018. The AHA guidelinesrecommend 150 minutes per weekof moderate exercise or 75 minutesper week of vigorous exercise. Ex-amples of vigorous-intensity exer-cise include running, fast cycling,fast swimming, and heavy shovelingor digging. Two days per week ofmuscle-strengthening activities thatinvolve all major muscle groups of-fer additional cardiovascular benefit.For weight loss, women should par-ticipate in at least 60 to 90 minutesof moderate-intensity physical activi-ty—such as brisk walking, dancing,house cleaning, and gardening—onmost days of the week.

Adequate sleepThe American Academy of SleepMedicine and the Sleep ResearchSociety recommend that healthyadults sleep 7 or more hours pernight. Recommend that your pa-tients go to bed and get up at thesame time every day; remove elec-tronic devices from the bedroom;avoid alcohol, caffeine, and largemeals before bedtime; and get regu-lar exercise.

Stress reductionReducing stress can be challengingfor many women. Suggest that pa-tients try meditation, yoga, listeningto music, and walking. For success,stress-reduction plans should be in-dividualized; for example, walking adog might relieve stress in one per-son but be stress-inducing in another.

Smoking cessationCigarette smoking is contraindicatedfor a heart-healthy lifestyle. If yourpatient smokes, help her develop acessation plan. Start by establishingher readiness to quit. Until she saysshe’s ready to quit, provide educa-tion that outlines the risks associat-ed with smoking. Then, when she’sready, work with her to develop aplan and direct her to supportiveresources, including the “Create myquit plan” tool smokefree.gov/build-your-quit-plan) and “Smokefree Wo -men” (women.smokefree.gov). Thelatter site has tools such as textmessages (including ones specificfor pregnant wo men), mobile apps,and a craving journal.

AHA guidelines and medicationThe AHA guidelines suggest addingmedications when lifestyle interven-tions alone fail to achieve optimalblood pressure, glycosylated hemo-globin (A1C), and low-density lipo -protein (LDL) cholesterol levels. Thepatient’s provider should considerprescribing medications when bloodpressure is ≥ 140/90 mmHg formost women or ≥ 130/80 mmHg forthose with diabetes or chronic kid-ney disease. The guidelines recom-

Women may experience any of these symptoms for up to a year before having amyocardial infarction:

• unusual fatigue

• difficulty sleeping

• shortness of breath, especially in black women

• indigestion

• anxiety

• chest pressure.

Prodromal symptoms

Women usually don’t experiencethe same type of pain as men whenthey have a myocardial infarction(MI). Instead, they’ll present withthese symptoms:

• chest pain, pressure, or discomfort

• fatigue

• shortness of breath

• pain in the neck, jaw, shoulder,arms, or upper back

• nausea or vomiting, sweating, or dizziness (less common symptoms).

MI symptoms

AmericanNurseToday.com June 2018 American Nurse Today 25

mend including a thiazide diureticmedication unless contraindicated.If women are at high risk, treatmentalso should include a beta-blocker,an ACE inhibitor, or an angiotensinII receptor blocker. The guidelinesalso recommend LDL-lowering med -ications such as statins for wo menwith diabetes whose A1C levels are< 7%, at-risk women whose LDL is < 130 mg/dL, high-risk womenwhose LDL is < 100 mg/dL, and insome high-risk wo men whose LDLis < 70 mg/dL.

For most women who’ve had acardiac event, angiotensin II receptorblockers, beta-blockers, and spi ro no -lactone should be prescribed. Avoidaspirin therapy in women youngerthan 65 years old with ideal cardio-vascular health because of bleedingrisk; however, it should be consid-ered in high-risk women and inthose over 65 years old when theirblood pressure is controlled and thebenefit of stroke and MI preventionoutweighs the risk of bleeding. TheAHA guidelines also recommendtreating women who have atrial fib-rillation with aspirin, warfarin, ordabigatran. Postmeno pausal hor-mone therapy and antioxidant andfolic acid supplements are class-threeinterventions that aren’t useful or ef-fective and may even be harmful.

Nursing implicationsMany cardiovascular health dispari-ties exist related to race, ethnicity,and gender, particularly amongBlack and Hispanic women. Cultur-ally sensitive care and educationabout CVD risk factors and MI symp -toms enhance patient adherence toprescribed treatment plans.

When discussing healthy lifestylechanges, assess patients’ changereadiness and what’s important tothem by using motivational inter-viewing techniques. Develop individ-ualized care plans, offering patientsoptions for maintaining their health.For example, logging food intakeand daily exercise may work best forsome patients, while others may pre-

Patient storyJan Kent* is a 62-year-old white woman who presents to her family nurse practi-tioner, Sarah, with flulike symptoms, headache, fatigue, and nausea. Vital signs arepulse 78 beats/minute and blood pressure (BP) 180/110 mmHg. Sarah’s concernedabout Ms. Kent’s symptoms and vital signs and sends her via emergency medicalservices to the emergency department (ED) for evaluation.

In the ED, Ms. Kent’s pulse is 80 beats/minute and her BP is 195/116 mmHg.She complains of a “bad” headache and tingling in both arms, and she is diapho -retic, with nausea and vomiting. Her troponin level is 0.918 ng/mL, and the elec-trocardiogram shows N-STEMI (non-ST-elevation myocardial infarction [MI]).

HistoryMs. Kent has no previous history of cardiovascular disease (CVD) or hypertension.She’s been postmenopausal for 12 years and has sleep apnea, but she doesn’t usea continuous positive pressure airway device. Ms. Kent is overweight; she tries toeat a healthy diet but isn’t always successful. She doesn’t smoke or exercise regu-larly, and she drinks alcohol occasionally. Ms. Kent says she’s had insomnia and un-usual fatigue with no apparent cause for months. She’s not taking any medications.

Both of Ms. Kent’s parents had a history of hypertension and CVD. Her motherdied of an MI at 74 years. Her father had a quadruple bypass after an MI. Both ofMs. Kent’s siblings have hypertension.

TreatmentCardiac catheterization shows that Ms. Kent has a 95% blockage in her left anteri-or descending artery, so a stent is placed. She’s admitted to the cardiac intensivecare unit (ICU), where she recovers and is discharged 2 days later. At discharge, hertotal cholesterol is 212 mg/dL (high-density lipoprotein [HDL] 39 mg/dL, low-den-sity lipoprotein [LDL] 173 mg/dL), and her BP is stabilized to 120/74 mmHg. Ms.Kent’s discharge medications are carvedilol (a beta-blocker), two 3.125-mg tabletstwice a day; losartan potassium (an angiotensin II antagonist), 25 mg every day;aspirin, 81 mg every day; and atorvastatin, 10 mg every day.

AHA guidelinesAccording to the American Heart Association (AHA) guidelines, Ms. Kent is at riskfor heart disease because of her family history, age, weight, and lifestyle. Sheneeds education about preventive measures—lowering cholesterol, increasingphysical activity, and consistently making heart-healthy food choices—to reduceher CVD risk. In addition, she needs education about prodromal and MI symptomsunique to women.

If Ms. Kent experiences similar symptoms in the future, she should call 911 tobe transported to the ED. She also can share her story with others so more peoplebecome aware of MI symptoms in women and what to do if they occur.

*Names are fictitious.

26 American Nurse Today Volume 13, Number 6 AmericanNurseToday.com

fer using smartphone apps to en-courage adherence to treatmentplans and medication regimens. Re-search is needed to determine theeffectiveness of these apps.

For those who are interested insupport groups, provide resourcesand information. Also, direct womento the Go Red for Wo men website(goredforwomen.org) to learn moreabout heart disease, discover ways tolive healthy, and participate in activi-ties to spread the word aboutwomen and heart disease.

Despite education, patients don’talways follow treatment plans. Whenthat happens, explore possible rea-sons, such as lack of access to pri-mary care providers, time constraints,and resistance to lifestyle modifica-

tions. Be nonjudgmental when ex-ploring these reasons, and collabo-rate with the patient to revise thetreatment plan.

Risk reduction begins witheducationEducation is the cornerstone to re-ducing CVD risk and death amongwomen. Remind your female pa-tients of the MI symptoms unique towomen, and explain that they shouldseek immediate medical care if theyexperience any of them.

To ensure early identification andtreatment of women at risk for acardiovascular event, all healthcareprofessionals should adhere to theAHA guidelines for all female pa-tients regardless of race or ethnicity

and provide culturally sensitive care.Empower at-risk women to makewise lifestyle choices, and supportand encourage adherence to pre-scribed treatment plans.

Melanie Kalman is a professor in the college ofnursing at Upstate Medical University in Syracuse,New York. Margaret Wells is a professor and nursingdepartment chair at Le Moyne College in Syracuse,New York.

Selected referencesAmerican Heart Association. Heart andstroke statistics. 2018. heart.org/HEARTORG/General/Heart-and-Stroke-Association-Statistics_UCM_319064_SubHomePage.jsp

Barfield WL, Boyce CA. Sex, ethnicity, andCVD among women of African descent: Anapproach for the new era of genomic re-search. Glob Heart. 2017;12(2):69-71.

Dracup K, Moser DK, Pelter MM, et al. Ruralpatients’ knowledge about heart failure. JCardiovasc Nurs. 2014;29(5):423-8.

Ladwig KH, Fang X, Wolf K, et al. Compari-son of delay times between symptom onsetof an acute ST-elevation myocardial infarc-tion and hospital arrival in men and women<65 years versus ≥ 65 years of age: Findingsfrom the Multicenter Munich Examination ofDelay in Patients Experiencing Acute Myo -cardial Infarction (MEDEA) Study. Am J Car-diol. 2017;120(12):2128-34.

Mayo Clinic. Heart disease in women: Un-derstand symptoms and risk factors. 2018.mayoclinic.org/diseases-conditions/heart-disease/in-depth/heart-disease/art-20046167

Mehta LS, Beckie TM, DeVon HA, et al.Acute myocardial infarction in women: A sci-entific statement from the American HeartAssociation. Circulation. 2016;133(9):916-47.

Mosca L, Hammond G, Mochari-GreenbergerH, et al. Fifteen-year trends in awareness ofheart disease in women: Results of a 2012American Heart Association national survey.Circulation. 2013;127(11):1254-63.

Mosca L, Benjamin EJ, Berra K, et al. Effec-tiveness-based guidelines for the preventionof cardiovascular disease in women—2011update: A guideline from the American HeartAssociation. Circulation. 2011;123(11):1243-62.

Office of Disease Prevention and Health Promotion. Physical activity guidelines forAmericans. 2008. health.gov/paguidelines/guidelines/

Schub T, Pravikoff D. 2016. Acute myocar-dial infarction in women. CINAHL NursingGuide.

Wenger NK. Juggling multiple guidelines: Awoman’s heart in the balance. J WomensHealth. 2016;25(3):213-21.

The American Heart Association Guidelines include three cardiovascular disease(CVD) risk categories for women. Use these guidelines to help you identify at-riskwomen and provide timely care.

Category Criteria

Ideal cardiovascular • No presence of cardiovascular diseasehealth • Total cholesterol level < 200 mg/dL • Blood pressure ≤ 120/80 mmHg • Body mass index < 25 kg/m2

• Fasting blood glucose < 100 mg/dL • Nonsmoker • Regular exercise

At risk for CVD • One or more major risk factors for CVD: • cigarette smoking • dyslipidemia • family history of premature CVD • hypertension • obesity (central) • sedentary lifestyle • poor diet • Advanced subclinical atherosclerosis • Metabolic syndrome • Poor exercise capacity on treadmill test • History of pre-eclampsia, gestational diabetes, or pregnancy-induced hypertension • History of systemic autoimmune collagen vascular disease, such as rheumatoid arthritis

High risk for CVD • Known coronary heart disease, cerebral vascular disease, abdominal aortic aneurysm, peripheral arterial disease, end-stage or chronic kidney disease, or diabetes • 10-year predicted CVD risk > 10%

Source: Mosca et al. 2011

Know the risk

AmericanNurseToday.com June 2018 American Nurse Today 27

Please mark the correct answer online.

1. Which statistics related to women andcardiovascular disease (CVD) are correct?

a. Myocardial infarctions (MIs) in youngerwomen (45 to 54 years old) are decreasing.

b. More than 2.5 million women die annuallyfrom CVD and over 53,000 women die froman MI.

c. 26% of women die within 1 year of havingan MI, compared to 19% of men.

d. The average age for a woman to have herfirst MI is 65 years old; for men, it’s 71 yearsold.

2. Which of the following statements aboutCVD risk factors in men and women is correct?

a. Older women have risk factors similar tomen’s.

b. Men who smoke have a higher risk of CVDthan women who smoke.

c. Women with diabetes have a higher risk ofCVD than men with diabetes.

d. Younger women have risk factors that aresimilar to men’s.

3. Which statement about estrogen and CVDin women is correct?

a. Natural estrogen is believed to becardioprotective in premenopausal women.

b. Natural estrogen does not providecardioprotection for premenopausalwomen.

c. Replacement estrogen taken duringmenopause helps prevent CVD.

d. Replacement estrogen taken after the ageof 60 helps prevent CVD.

4. Which statement about risk of CVD forwomen of color is correct?

a. Hispanic women in the United States are athigher risk for an MI than all other women.

b. Black women are more likely than whitewomen to be treated using American HeartAssociation (AHA) guidelines.

c. Women of color are at less risk for CVD thanwhite women.

d. Women of color are at greater risk for CVDthan white women.

5. Which statement about prodromalsymptoms is correct?

a. Women may experience them for up to ayear before having an MI.

b. Women may experience them for up to 4years before having an MI.

c. They frequently occur in men, but onlyrarely occur in women.

d. They include shortness of breath, especiallyin Hispanic women.

6. Which of the following symptoms of an MI isa woman least likely to have?

a. Fatigueb. Shortness of breathc. Pain in the neck or jaw d. Severe chest pain

7. Your patient smokes one pack of cigarettesa week and has hypertension. Tests show thatshe has metabolic syndrome. What is her CVDrisk category according to AHA guidelines?

a. At low risk for CVDb. At moderate risk for CVDc. At risk for CVDd. At high risk for CVD

8. Which of the following is a criterion for theAHA’s ideal cardiovascular health category?

a. Fasting blood glucose < 160 mg/dLb. Body mass index < 25 kg/m2

c. Total cholesterol level < 250 mg/dLd. Blood pressure ≤ 120/72 mmHg

9. The Dietary Approaches to Stop Hyperten-sion (DASH) plan recommends consuming nomore than how many milligrams of sodium perday?

a. 1,500b. 2,400c. 3,000 d. 3,600

10. The AHA recommends that no more thanhow many grams of daily calories come fromsaturated fats?

a. 13b. 15c. 17 d. 19

11. Your 55-year-old patient wants to ensurethat she is getting enough exercise. Whichadvice would be correct?

a. Complete 150 minutes of moderate exerciseper week.

b. Complete 30 minutes of vigorous exerciseper week.

c. Avoid muscle-strengthening exercises.d. Do muscle-strengthening exercises monthly.

12 Despite making lifestyle changes, yourpatient’s blood pressure is 146/92 mmHg. Shedoes not have any other risk factors. Which ofthe following medications is her primary careprovider most likely to prescribe?

a. Thiazide diureticb. Beta-blocker c. Angiotensin-converting enzyme (ACE)

inhibitord. Angiotensin II receptor blocker

13. Which of the following women is most likelyto be prescribed a low-density lipoprotein (LDL)cholesterol-lowering medication?

a. A woman with diabetes whose A1C is > 8%b. A woman with diabetes whose A1C is < 7%c. A woman at risk whose LDL is < 50 mg/dLd. A woman at risk whose LDL is < 60 mg/dL

14. Appropriate nursing actions to help womenprevent CVD include all the following except:

a. Use motivational interviewing techniques.b. Stress the importance of seeking treatment

promptly. c. Provide resources such as the Go Red for

Women website.d. Recommend always using a smartphone

app to log calories.

POST-TEST • Women and cardiovascular disease Earn contact hour credit online at americannursetoday.com/article-type/continuing-education/

Provider accreditationThe American Nurses Association’s Center for Continuing Edu-cation and Professional Development is accredited as aprovider of continuing nursing education by the AmericanNurses Credentialing Center’s Commission on Accreditation.ANCC Provider Number 0023.

Contact hours: 1.47

ANA’s Center for Continuing Education and Professional Devel-opment is approved by the California Board of Registered Nurs-ing, Provider Number CEP6178 for 1.76 contact hours.

Post-test passing score is 80%. Expiration: 6/1/21

ANA Center for Continuing Education and Professional Devel-opment’s accredited provider status refers only to CNE activitiesand does not imply that there is real or implied endorsement ofany product, service, or company referred to in this activity norof any company subsidizing costs related to the activity. Theauthor and planners of this CNE activity have disclosed no rele-vant financial relationships with any commercial companiespertaining to this CNE. See the banner at the top of this pageto learn how to earn CNE credit.

CNE: 1.47 contact hours

CNE