Cardiovascular disease is the leading cause of morbidity and mortality in women globally. Cardiac rehabilitation (CR)—a comprehensive program including supervised progressive exercise, education, support, behavior modification, and nutritional guidance over 36 individual sessions—positively impacts morbidity, mortality, function, and quality of life. Overall, less than 30% of those who qualify are referred and participate in CR—referral and completion rates are significantly less in women compared with men despite evidence supporting equal benefit. Barriers contributing to these disparities have been identified, and CR programs can be modified to enhance the participation of women.
Key points
- •
Heart disease is the most common cause of morbidity and mortality in women.
- •
Women have worse outcomes from cardiovascular disease due to disparities in: research; understanding of prevalence and presentation of cardiovascular conditions in women; appropriate therapeutic interventions; poor referral for cardiac rehabilitation.
- •
Despite being under-referred, women completing CR have equivalent benefit to men from participation including improved aerobic fitness, enhanced cardiovascular risk factor profile, reduced risk for secondary cardiovascular events and use of health services, and improved morbidity.
- •
CR programs configured to meet the specific needs of women support the referral, enrollment, participation, and outcomes from the CR intervention.
Introduction
Cardiac rehabilitation (CR) reduces the risk of cardiovascular disease mortality and improves cardiovascular function by limiting the physiologic and psychological stresses associated with cardiovascular disease. CR helps patients optimize their health, function, and quality of life. While significant research has been conducted on the etiology of cardiovascular disease and the benefit of CR, there has been a paucity of research focused on women. To optimize outcomes from CR for women with heart disease (HD), it is essential for the physician practicing CR to understand the unique differences between HD in women and men. Similarly, CR programs have to be tailored to the specific needs of women to achieve the goals of secondary prevention, optimal function, and quality of life.
CR should be prescribed for all individuals diagnosed with qualifying HD or following specified cardiac procedures ( Box 1 ).
Myocardial infarction (MI)
Coronary artery bypass surgery (CABG)
Current stable angina
Heart valve repair or replacement
Coronary angioplasty or coronary stent
Heart or heart-lung transplant
Stable chronic heart failure with reduced ejection fraction (HFrEF) ≤ 35%
Peripheral arterial disease (PAD)
Some private insurances will cover additional diagnoses including arrhythmias, heart failure with preserved ejection fraction (HFpEF), myomectomy, or surgery to the major cardiac vessels.
Heart Disease in Women—Etiology, Incidence, and Diagnosis
HD is the leading cause of morbidity and mortality in women globally. Over 60 million women (44%) have some form of HD in the United States. In 2017, 21.8% of deaths in females in the United States were due to HD and a further 6.2% were due to cerebrovascular disease. HD in women includes coronary artery disease (CAD), valvular heart disease (VHD), arrhythmias, and cardiomyopathies (CMs)/heart failure (HF). Atherosclerotic vascular disease of the brain and PAD should also be considered if CAD has been diagnosed but are beyond the focus of this article.
While the heart in structure and function is the same in both genders, difference in female anatomy, physiology, and the hormonal milieu result in significant differences in risk factors, presentation, course, and outcomes. The general lack of understanding of these differences stems in part from an under-representation of women in clinical research trials and biases underestimating the incidence and impact of HD in women. This has resulted in disparities in diagnosis, referral, and management of HD in women as evidenced by the higher mortality from CAD and other HDs in women than in men. In 2021, 1 in 5 deaths in women was related to HD yet just over half of US women know that HD is the leading cause of death in women.
Coronary Artery Disease in Women
In all women over age 20 years, 5.8% have CAD. Prevalence of CAD increases with age with over 40% having CAD by age 80 years old and 80% of women ages 40 to 60 have one or more risk factors for CAD. CAD and its risk factors demonstrate gender specificity. While there are standard CAD risk factors common in both genders, these risk factors may contribute more significantly to the development of CAD in women than in men.
Hypertension
Globally there are an estimated 600 million women with hypertension (HTN). One-third of all US women between the ages of 30 to 79 years old have HTN. HTN is often underdiagnosed and undertreated in women with control rates under 25%. HTN is often undertreated in women compared with men resulting in a greater risk of developing HF.
Diabetes
In 2021, over 14% (>18 million) of US female adults had diabetes with more—3.9% (5 million)—undiagnosed compared to men with 2.8% (3.7 million) undiagnosed. Women with diabetes demonstrate a 44% greater risk for the development of CAD compared to men with diabetes. Gestational diabetes is also an independent risk factor for CAD.
Dyslipidemia
Over 50 million US women (40.4%) had dyslipidemia in 2018 —a diagnosis often recognized later in women compared with men and often more poorly controlled compared with men.
Overweight/obesity
In 2018, 27.5% of US women were overweight and 41.9% were obese. More women (11.5%) have severe obesity than men (9.2%).
Physical inactivity
In 2020, only 20.4% of women met the physical activity guidelines for aerobic and strength exercise compared with 28.3% of men. The compliance with exercise guidelines in women decreases significantly with age—28.7% of women aged 18 to 34 years old met the guidelines whereas only 10.8% aged 65 years and older met the guidelines.
Metabolic syndrome
Metabolic syndrome is diagnosed when any 3 of the following conditions are present: obesity; hypertriglyceridemia; low high-density lipoprotein; HTN; elevated blood glucose. It has been reported in over 40% of all US women in 2018 and the prevalence continues to increase.
Tobacco use
In 2021, fewer women (10.1%) than men (13.1%) reported regular tobacco use. However, women who smoke tobacco have a 25% increased risk of CAD compared to men who smoke, the risk increasing by a factor of 10 in women who smoke combined with oral contraceptive use.
There are also “nontraditional” risk factors seen more commonly in, or uniquely in, women ( Fig. 1 ).
Unique risk factors for CAD in women are often overlooked and include gender-specific hormonal fluctuations, polycystic ovary syndrome (PCOS), gestational diabetes, pre-eclampsia, preterm delivery, breast cancer therapies, and autoimmune disorders.
Premenopausal women are noted to have lower rates of CAD than men of similar age cohorts and when compared to postmenopausal women, believed to be due to a cardio-protective effect of estrogen. Hormonal irregularities including early menopause, hysterectomy, and PCOS are associated with higher incidence of CAD. Estrogen’s cardio-protective benefits are related to antioxidant and antiplatelet effects which improve vasodilation via endothelial pathways. Estrogen has also been shown to increase nitric oxide, regulate prostaglandin production, and inhibit smooth muscle proliferation all of which reduced CAD risk. Pre-eclampsia results in an increased risk of HF, CAD, and cardiovascular mortality, and this is more significant if the pre-eclampsia occurs before 34 weeks of pregnancy.
While there is overlap in symptoms and signs, HD in women can present differently to men in part, related to differences in pathophysiology. Women are more likely to develop microvascular CAD with endothelial dysfunction and preserved myocardial ejection fraction (EF) resulting in atypical cardiac symptoms, whereas men are more likely to develop macrovascular CAD, have myocardial infarction (MI), and reduced EF resulting in more typically recognized cardiac symptoms. Women are more likely to develop unique coronary syndromes. Spontaneous coronary artery dissection (SCAD) has a 90% female preponderance and is not uncommonly associated with pregnancy. The pathogenesis of SCAD is not well understood but is likely associated with fibromuscular hyperplasia—a condition seen more commonly in women. SCAD has been poorly managed due to a lack of established, evidence-based treatment pathways. Women are at a 5 times greater risk than men having a myocardial infarction with nonobstructive coronary arteries (MINOCA). Women with MINOCA are generally younger, less likely to demonstrate traditional risk factors and more likely to have hypercoagulable states. Of note is that current management strategies for MINOCA are based on research studies conducted on men and older patients.
Presenting symptoms of HD may differ between women than in men. One study indicated 37% of women with an acute coronary syndrome (ACS) report no chest pain compared with 27% of men. A recent meta-analysis reported that compared with men, women with ACS had higher odds of presenting with pain between the shoulder blades (OR, 2.15; 95% CI, 1.95–2.37), nausea or vomiting (OR, 1.64; 95% CI, 1.48–1.82), and shortness of breath (OR, 1.34; 95% CI, 1.21–1.48). Women had lower odds of presenting with chest pain (OR, 0.70; 95% CI, 0.63–0.78) and diaphoresis (OR, 0.84; 95% CI, 0.76–0.94).
Successful and timely diagnosis of CAD and ACS in women requires an understanding of the unique risk factors and presentations discussed earlier, as well as overcoming conscious and subconscious biases. It is vital to consider the risk for HD in women despite atypical symptoms and with recognition that risk factor identification and mitigation, as well as CAD preventive measures are underutilized in women compared with men. This has resulted in a plateau in the rate of decrease in cardiovascular deaths in women and an increase in younger women with one-third of cardiovascular events noted in women younger than 65 years old. A recent review addresses this topic in more detail.
Standard diagnostic testing and management protocols for HD have been described elsewhere and should be adhered to similarly in both genders. Of note, the interpretation of diagnostic tests has been reported to be less reliable in women compared to men. As well, disparities are noted in medication prescriptions for the management of HD and CAD with women less likely to be prescribed aspirin, statins, and angiotensin-converting enzyme inhibitors and more likely to be prescribed diuretics.
Valvular Heart Disease in Women
With the decline in rheumatic valve disease noted in high income countries, the prevalence of age-related degenerative causes of cardiac VHD is rising as the population ages. As women are living longer than men, the proportion of women with VHD is increasing. VHD is most often diagnosed in individuals over 65 years old. Women are more likely to develop mitral valve diseases and less likely to develop aortic valve diseases compared to men. Of note, the majority of patients with aortic stenosis over 80 years old are women due to their greater longevity. Epidemiology, diagnosis, and treatment of VHD in women compared to men are summarized in Fig. 2 . Of note, women are often under-represented in VHD research studies, have smaller hearts than men resulting in inaccurate quantification of VHD, often have greater symptom burden but are referred for surgical intervention later than men. Further multifactorial gender disparities that have resulted in poorer outcomes from the management of VHD in women are reviewed in detail elsewhere. Recent developments resulting in an increased use of transcatheter valve repair and replacement approaches are resulting in decreased gender-based differences in VHD management outcomes.
Arrhythmias in Women
For over 100 years, differences in cardiac electrophysiology between women and men have been appreciated. Fluctuations in gender-specific sex-hormones, differences in autonomic function and differences in body size and cardiac mass contribute, resulting in a variable prevalence of specific arrhythmias between women and men ( Table 1 ).
| Higher | Lower |
|---|---|
| Sick sinus syndrome | Atrioventricular block |
| Inappropriate sinus tachycardia | Carotid sinus syndrome |
| Atrioventricular nodal reentry tachycardia (2x) | Atrial fibrillation (1.5–2x) |
| Supraventricular tachycardia due to right -sided accessory pathways (2.8x) | Supraventricular tachycardia due to left -sided accessory pathways |
| Idiopathic right ventricular tachycardia (1.5x) | Wolff-Parkinson-White syndrome |
| Arrhythmic events in the long-QT syndrome | Reentrant ventricular tachycardia |
| Ventricular fibrillation and sudden death | |
| Brugada syndrome |
A detailed review of incidence, presentation, and management of arrhythmias in women is provided elsewhere. Of note, atrial fibrillation (AF) is the most common arrhythmia globally, and females consistently report greater symptoms and worse quality of life due to AF than males. Outcomes associated with AF, including HF and cognitive decline (but not stroke risk), are more common in women. Risk of an arrhythmogenic (ventricular fibrillation) sudden cardiac death resulting from an acute coronary event is less in women (1.9x increased risk) compared with men (3.3x increased risk).
Cardiomyopathies and Heart Failure in Women
HF affects over 2.6 million women (and 3.4 million men) in the United States. Gender-related differences in the prevalence, response to treatment, and outcomes of management are noted. Peripartum cardiomyopathy (PPCM) is only seen in women, whereas other CMs with significant gender differences include stress-induced (Takotsubo’s) cardiomyopathy, hypertrophic cardiomyopathy (HCM), and CMs related to sarcoidosis and amyloidosis. Despite women having a lower lifetime risk (5.8%) for heart failure with reduced ejection fraction (HFrEF) compared with men (10.6), women are more likely to have a worse quality of life, similar risk for hospitalization and lower mortality when compared with men. Gender differences in the epidemiology and management of HFrEF are summarized in Fig. 3 .
HFpEF is more prevalent in women (2.42%) compared with men (0.88%) most likely related to age-related factors and a greater impact of HTN and obesity in women. Gender differences in cardiac aging and left ventricular remodeling in response to obstructive CAD likely also contributes to the increased prevalence of HFpEF in women. Gender differences in the epidemiology and management of HFpEF are summarized in Fig. 4 .
Related posts:
Rehabilitation Considerations in Women with Traumatic Brain Injury
Rehabilitation Considerations for Women with Spinal Cord Injury
The Role of Rehabilitation for Women with Cancer
Pelvic Pain and Pelvic Floor Disorders in Women
Reproductive and Sexual Health Considerations for Adolescent Females with Disabilities
Osteoporosis Issues Regarding Rehabilitation in Women
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
