Non-biological factors and social determinants of health are important to include in CVD risk assessment for women, particularly for women of diverse races and ethnicities other than white, according to a new American Heart Association scientific statement published today in Circulation, the Association's flagship, peer-reviewed journal.
"Risk assessment is the first step in preventing heart disease, yet there are many limitations to traditional risk factors and their ability to comprehensively estimate a woman's risk for cardiovascular disease," said Jennifer H. Mieres, M.D., FAHA, vice chair of the scientific statement writing committee and a professor of cardiology at the Zucker School of Medicine at Hofstra Northwell in Hempstead, N.Y. Of note, large patient data registries used to develop cardiovascular risk assessment formulas or algorithms lack racial and ethnic diversity, so they may not accurately reflect risk for women of underrepresented groups.
A 2022 American Heart Association presidential advisory deemed it critical to understand the impact of race and ethnicity on cardiovascular risk factors in women in order to incorporate those specific risks into prevention plans and reduce the high burden of CVD among women from diverse backgrounds. This new scientific statement responds to the presidential advisory as a review of the current evidence on racial and ethnic differences in cardiovascular risk factors for women in the U.S.
What traditional risk formulas miss about women in general
Traditional formulas to determine cardiovascular disease risk include Type 2 diabetes, blood pressure, cholesterol, family history, smoking status, physical activity level, diet and weight. These formulas do not account for sex-specific biological influences on cardiovascular risk or medications and conditions that are more common among women than men.
Female-specific factors that should be included in assessing cardiovascular risk are:
"The delivery of equitable cardiovascular health care for women depends on improving the knowledge and awareness of all members of the health care team about the full spectrum of cardiovascular risk factors for women, including female-specific and female-predominant risk factors," said Mieres, who is also the chief diversity and inclusion officer at Northwell Health.
Importance of social determinants of health in risk assessment
Social determinants of health play a significant role in the development of CVD among women, with disproportionate effects on women from diverse racial and ethnic backgrounds. These determinants include economic stability, neighborhood safety, working conditions, environmental hazards (such as exposure to air pollution), education level and access to quality health care. The impact of social factors is recognized in how they affect behavioral risk factors, such as smoking status, physical activity, diet and proper medication use.
"It is critical that risk assessment be expanded to include social determinants of health as risk factors if we are to improve health outcomes in all women," said Laxmi S. Mehta, M.D., FAHA, chair of the writing group and director of preventative cardiology and women's cardiovascular health at The Ohio State University Wexner Medical Center in Columbus, Ohio. "It is also important for the health care team to consider social determinants of health when working with women on shared decisions about cardiovascular disease prevention and treatment."
Differences in women's cardiovascular disease risk by race and ethnicity
Although cardiovascular disease is the leading cause of death for all women, the statement highlights significant racial and ethnic differences in cardiovascular risk profiles:
"When customizing CVD prevention and treatment strategies to improve cardiovascular health for women, a one-size-fits-all approach is unlikely to be successful," Mieres said. "We must be cognizant of the complex interplay of sex, race and ethnicity, as well as social determinants of health, and how they impact the risk of cardiovascular disease and adverse outcomes in order to avert future CVD morbidity and mortality."
Future cardiovascular disease prevention guidelines may be strengthened by urging culturally specific lifestyle recommendations tailored to the cultural norms and expectations that influence behaviors, beliefs and attitudes about diet, physical activity and healthy weight, according to the statement. The writing committee calls for community-based approaches, faith-based community partnerships and peer support in encouraging a healthy lifestyle to improve the primary prevention of cardiovascular disease among women from underrepresented groups. The statement also urges more research to address gaps in our knowledge about risk factors among women, including gathering data specific to subgroups of each race and ethnicity.
This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association's Cardiovascular Disease and Stroke in Women and Underrepresented Populations Committee of the Council on Clinical Cardiology; the Council on Cardiovascular and Stroke Nursing; the Council on Hypertension; the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; the Council on Lifestyle and Cardiometabolic Health; the Council on Peripheral Vascular Disease; and the Stroke Council. American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association's official clinical practice recommendations.
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