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The statement suggests the importance of including non-biological factors and social determinants of health in CVD risk assessment for women of diverse races and ethnicities.
A new scientific statement from the American Heart Association (AHA) suggests the importance of including non-biological factors and social determinants of health in cardiovascular disease (CVD) risk assessment for women, particularly those of diverse backgrounds.1
The scientific statement writing committee indicates current CVD risk assessment is inadequate for women of diverse races and ethnicities other than white, due to various factors including language barriers, discrimination, and lack of access to health care.
“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 CVD,” said Jennifer H. Mieres, MD, vice chair of the scientific statement writing committee and a professor cardiology at the Zucker School of Medicine, Hofstra Northwell.2
In 2022, an AHA presidential advisory noted the importance of recognizing the impact of race and ethnicity on cardiovascular risk factors in women in order to incorporate specific risks into prevention plans and ultimately reduce the burden of CVD among those from diverse backgrounds. The new AHA scientific statement serves as a response to the advisory and provides a review of current evidence on racial and ethnic differences in cardiovascular risk factors for women in the US.
Traditional Risk Factors
Formulas used to analyze CVD risk traditionally include type 2 diabetes (T2D), blood pressure, cholesterol, family history, smoking status, physical activity level, diet, and weight. However, these formulas may not account for sex-specific biological influences on cardiovascular risk of medications and conditions more common among women than men.
The updated statement marked female-specific risk factors to include in assessing cardiovascular risk in women. Pregnancy-related conditions, such as preeclampsia, preterm delivery, gestational diabetes, gestational high blood pressure, or miscarriage, were recommended to be included in the assessment. Additionally, the statement pointed to menstrual cycle history, types of birth control and/or hormone replacement therapy used, and history of chemotherapy or radiation therapy as factors to be considered in the assessment.
The writing committee suggested accounting for various systemic disorders, including polycystic ovarian syndrome (PCOS), which affects up to 10% of women of reproductive age and is associated with a higher risk for CVD. Autoimmune disorders, such as rheumatoid arthritis or lupus, are associated with faster plaque-build in the arteries, higher risk of CVD, and worse outcomes after heart attack or stroke. Depression and posttraumatic stress disorder are more common among women and are associated with higher CVD risk.
Social Determinants of Health
Social determinants of health are a significant factor in the development of CVD among women and have disproportionate effects on those from diverse racial and ethnic backgrounds. The statement recommended assessment be expanded to reflect determinants as risk factors, including economic stability, neighborhood safety, working conditions, environmental hazards, educational level, and access to quality health care. It additionally reflected the impact of social factors on behavioral risk factors, such as smoking status, physical activity, diet, and proper medication use.
Race and Ethnicity
CVD is the leading cause of death for all women, but the statement highlighted significant racial and ethnic differences in cardiovascular risk profiles.
Non-Hispanic Black women have the highest prevalence of high blood pressure globally (≥50%) and are more likely to develop T2D, have obesity, and die of smoking-related diseases. This group is disproportionately affected by traditional risk factors and experiences an earlier onset of CVD, with social determinants of health indicated as a key driver for the disparity.
Hispanic/Latina women have a higher rate of obesity than Hispanic men. However, despite higher rates of T2D, obesity, and metabolic syndrome, data has shown CVD death rates are 15-20% lower in Hispanic Latina women than among non-Hispanic white women. The statement notes that this “paradox” may be due to grouping diverse Hispanic subcultures together in research data and does not account for different levels of risk among subgroups or the possibility of healthy immigrant bias.
American Indian and Alaska Native women are a heterogenous population that consists of 574 federally recognized tribes and non-recognized tribes across the United States. There is substantial variation in CVD-related death rates by geographic region and T2D is the primary risk factor for heart disease. However, understanding the cardiovascular health of this group is challenging due to small sample sizes in national data sets, racial and/or ethnic misclassification, or underreporting.
The statement indicates that Asian-American women have varied rates of CVD risk within groups. Asian Americans are less likely to be overweight or have obesity compared to other racial groups, but at the same body mass index (BMI), have higher rates of high blood pressure, CVD, and T2D. The statement suggests that higher body fat levels may explain the differences, as research has shown that Asian people have a higher percentage of body fat than non-Hispanic white people of the same age, sex, and BMI.
According to the writing committee, future CVD prevention guidelines may be strengthened by tailoring culturally specific lifestyle recommendations to cultural expectations that influence behaviors and attitudes about diet, physical activity, and healthy weight.
Community-based approaches, faith-based community partnerships, and peer support additionally may help improve primary CVD prevention among women from underrepresented groups.
“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.2 “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.”