Article Text

Cross-sectional time trend
Prevalence of myocardial infarction over a 10–15-year period in the USA has decreased in midlife men but increased in women, with a decrease in the excess cardiovascular risk of men compared with women
  1. Colleen M Norris
  1. Correspondence to Colleen M Norris
    Associate Professor, Faculty of Nursing, Adjunct Professor, Cardiology, Cardiovascular Surgery and Public Health Sciences, 4-130F Clinical Sciences Building, University of Alberta, Edmonton, Alberta, T6G 2G3 Canada; colleen.norris{at}

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Although initiatives such as the red dress campaign have substantially increased awareness of the mortality risk for women with coronary heart disease, the belief remains common that women in their midlife years are at an overall lower risk than men of the same age. Although much attention has been directed towards a better appreciation of the influence of sex on cardiovascular risk and management, important gaps in knowledge remain.

Using the cross-sectional, nationally representative National Health and Nutrition Examination Surveys (NHANES), Towfighi and colleagues compared changes between two decade cohorts (1988–1994 and 1999–2004) in myocardial infarction (MI) prevalence and Framingham coronary risk scores (FCRSs) by sex. The study aimed to determine the sex-specific midlife prevalence of MI. The authors also looked at the sex-specific risk of coronary heart disease. They concluded that over the past two decades the gap has narrowed between midlife men and women in the risk of future hard cardiovascular events. Whereas the men's overall risk decreased, the women's overall risk increased. More importantly, MI prevalence increased among midlife women while declining among midlife men. The authors suggested that greater emphasis on vascular risk factor control in midlife women might help lessen the trends identified. (This study included data up to 2004, but the most up-to-date statistics on modifiable risk factors for women with heart disease, which can be found on the American Heart Association and the Heart and Stroke Foundation of Canada websites,1 2 suggest that the trend of increased risk of future cardiovascular events in women continues.)

The cross-sectional design of this study was well suited for assessing sex-specific trends, particularly using the NHANES, a nationally representative sample. Specifically, the NHANES included the data required to calculate the FCRS, including age, sex, total cholesterol level, high-density lipoprotein (HDL) level, systolic blood pressure, history of smoking and presence of diabetes. Of note is that other than age and sex, the risk factors identified for calculating the FCRS are modifiable risk factors.

This study presents the positive finding that middle-aged men included in the NHANES demonstrated improvements in risk factors and MI prevalence between one decade and the next. The marked focus on risk factor reduction in men and the resulting decreases in the prevalence of MI suggest that opportunities exist – and further action is required – to achieve better heart health outcomes for women.

There is evidence to suggest that although the modifiable heart disease risk factors for men – including elevated blood cholesterol levels, hypertension, cigarette smoking, physical inactivity, diabetes mellitus, obesity and certain lipoproteins – also apply to women, they affect women differently.3 Diabetes mellitus, hypertriglyceridaemia and low levels of HDL appear to be stronger risk factors for women.4 Cigarette smoking is the main preventable heart disease risk factor for women; it is a stronger risk factor for MI in middle-aged women than in middle-aged men.2 Furthermore, it has been reported that women who smoke more that 25 cigarettes a day have a greater prevalence of hypertension, and female smokers are more likely than non-smokers to have a body mass index of 25 or more.2 Underestimating the seriousness of symptoms, women are less likely to seek medical attention for angina. This misperception can be reinforced by medical practitioners, who frequently underestimate cardiovascular disease (CVD) risk in women.

More than 16 years ago Eaker and colleagues produced an American Heart Association special report on CVD in women. At the time the authors identified six actions directed at improving the cardiovascular health of women: (1) public education and awareness, (2) education of healthcare providers on the risk associated with CVD in women, (3) studies to clarify the process of behaviour adaption and change in women, (4) studies on the effect of risk modification in women, (5) studies on the prognosis, medical care and rehabilitation of women who survive MI and strokes and (6) knowledge-building among healthcare providers on community resources for referral for smoking cessation, dietary counselling, weight control and physical activity specific to women's heart health. In light of Towfighi and colleagues' results, these recommendations remain paramount if we are to turn the tide in controlling vascular risk factors and prevalence of MI in midlife women.

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  • Competing interests None.

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