Women, Stress, and Heart Disease

Kristina Orth-Gomer, Margaret A. Chesney, Nanette K. Wenger

• Publisher: Psychology Press
• Year: 1998
• Edition: 1
• eBook ISBN:
  9781135691547
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The issue of women's health has long been neglected. This applies to many medical areas, but it has become most evident in the field of cardiology. For a long time, cardiology has been a medical specialty which seemed to be created for men, by men--particularly in research, but also in intensive clinical care units where male patients have been most visible and dominating. Furthermore, the clinical cardiologists--their doctors--have been predominantly male. It is easy to understand that most women think they will die from cancer rather than from heart disease, but this is not true. Heart disease is the leading cause of death for women as it is for men. Female patients are frequently encountered in the cardiology department, but they are older and seem to get less visibility and attention than the male patients. Research on risk factors for heart disease has also been almost entirely focused on men. This is true for psychosocial/behavioral aspects of cardiovascular risk. Aiming to fill this gap, this volume contains contributions from outstanding international and national researchers from different fields such as sociology, psychology, epidemiology, cardiology, clinical medicine, and physiology. These professionals gathered together for an interdisciplinary seminar on women, stress, and heart disease held at the Swedish Society of Medicine. Based on the seminar, this book provides a solid foundation for empirically based scientific conclusions on this important subject.

CHAPTER 1
Coronary Heart Disease in Women: Evolution of Our Knowledge

Nanette K.Wenger
Emory University School of Medicine and Grady Memorial Hospital, Atlanta, Georgia

This chapter addresses the medical components of coronary heart disease (CHD) in women, its presentation and clinical outcomes, and the coronary risk factors important for women. The information should buttress the need to identify the psychosocial components or contributors that relate to CHD because it will become evident that women have less favorable outcomes once CHD becomes clinically manifest than do their male counterparts.

The data presented here derive from information gathered in the United States. Although this information can, in part, be extrapolated to other countries, specific incidence and outcome variables require validation in different populations, particularly where CHD rates are low. Comparable reports to those for the United States have appeared in England and New Zealand. Coronary disease, the medical problem that results in myocardial infarction (MI), is the major cause of mortality among women in the United States, accounting for almost 250,000 deaths annually. However, when one examines the information used in regard to prevention, to clinical features, and to therapy and prognosis of CHD in women, it is based on studies in populations that involved predominantly or exclusively middle-aged men (Wenger, Speroff, & Packard, 1993a). It has yet to be ascertained how much of this middle-aged male model of CHD is applicable to the older women in whom CHD occurs.

Age is an important factor in women regarding CHD (Lerner & Kannel, 1986). Whereas one in eight or nine women in the 45–64-year age group has clinical evidence of CHD, this is present in one in three women older than 65 years of age. What must be addressed, therefore, is the combination of both a female incidence and prevalence of coronary disease and an elderly age incidence and prevalence of coronary disease; often the two may not be separable.

ANGINA PECTORIS

As with much of the epidemiologic information about coronary disease in the United States, the initial components were derived from the Framingham Heart Study; however, whereas Framingham provided enormously valuable information, it also engendered some misinformation that adversely affected the clinical care of women for a number of years. Perhaps one difficulty was the delineation of the benignity of angina pectoris (AP) in women. Angina, which probably should have been titled “chest pain” in the Framingham reports, because it was based solely on the clinical history without objective test documentation, was the major initial manifestation of CHD in women, occurring in 56% of Framingham women as compared with 43% of men. However, one in four men in Framingham who had AP developed MI within the ensuing 5 years, clearly a serious outcome, whereas 86% of women in the Framingham cohort described to have angina never incurred MI (Kannel & Feinleib, 1972; Lerner & Kannel, 1986). The conclusion, although erroneous, was that AP was not a serious problem for women; therefore, little research attention was paid to coronary disease in women and, indeed, little attention was addressed in clinical practice to evaluation of chest pain problems of women, because no serious consequence such as MI was considered to ensue. Of interest is that, even within this Framingham cohort, there was a small overlooked subset, the women aged 60–69 years, who had the same adverse prognosis as did the men; this constitutes further evidence for the important age dependency of CHD in women. It was only with publication of information from the Coronary Artery Surgery Study (CASS) Registry in the 1980s that the challenge was offered to the benignity of AP in women. The CASS Registry was a compilation of information regarding men and women referred for coronary arteriography to participating institutions by their treating physicians because their chest pain was judged of sufficient severity to warrant consideration for coronary artery bypass surgery; coronary arteriography provided objective confirmation as to whether the chest pain reflected myocardial ischemia due to coronary arterial obstruction. In the CASS Registry, 50% of the women had little or no objective documentation of coronary disease at coronary arteriography as contrasted with 17% of the men (Kennedy et al., 1982; The Principal Investigators of CASS, 1981). If this had been the case in Framingham as well, that may explain why 86% of Framingham women never developed MI; their chest pain was not due to coronary atherosclerotic heart disease. One message is that women may have chest pain syndromes that mimic AP, but are due to etiologies other than atherosclerotic obstructive coronary artery disease (CAD). Another message is that for women with chest pain who have CHD, the outlook is more ominous than suggested by the Framingham data.

This misinterpretation of the Framingham findings led to a number of missed opportunities. Inadequate attention was directed to preventive care, that is, coronary risk reduction in women; the research and clinical emphasis focused on preventive care for men. Further, inadequate attention, until very recent years, was devoted to procedures needed to identify whether chest pain syndromes in women were related to CHD and to stratify their risk for proximate coronary events; this diagnostic testing was predominantly studied in and applied to populations of men.

PREVENTION OF CHD IN WOMEN

Why is prevention of CHD important for women? First, in the United States, 40% of all coronary events in women are fatal. Second, 67% of all sudden deaths in women occur in those not previously known to have CHD (Kannel & Abbott, 1987). Certainly this mortality issue is extremely relevant, but morbidity concerns are also of major importance. Of women aged 55–64 years in the United States who have CHD, 36% are disabled by their disease, and this increases to 55% among women older than 75 years of age. High priority must be accorded to education of women about CHD; unless women worldwide consider coronary disease to be part of their illness experience, they are unlikely to heed preventive messages when young or to respond appropriately to chest pain symptoms when older. Coronary disease in the United States, until very recent years, was viewed as a problem of men, to whom informational and educational messages were addressed. Coronary disease was thus considered by women to be a problem for their spouse, their father, their male siblings, and their male children. Today, rather than, to paraphrase a Broadway musical, addressing “why can’t a woman be more like a man?”, we must examine those relevant gender differences that warrant specific attention.

The prevalence of coronary risk factors among United States women is alarming; in the cohort of women aged 20–74 years (National Center for Health Statistics [NCHS], 1991), over one third have hypertension, using as a definition a systolic blood pressure in excess of 140 mm Hg, a diastolic blood pressure in excess of 90 mm Hg, or both, or those using antihypertensive medications. Over one fourth have elevated cholesterol levels, using as a cut point 240 mg/dl. More than one fourth of U.S. women are cigarette smokers, more than one fourth are overweight and more than one fourth have a sedentary lifestyle. In the United States, as in many other nations, coronary risk factors predominate among subsets of the population with less favorable socioeconomic circumstances and with less favorable educational levels, and these two features commonly coexist.

The decreases in both cardiovascular and coronary mortality in recent years in the United States have been less pronounced for women than for men; concomitantly, the decreases in coronary risk factors have been less pronounced for women than for men during the past two to three decades (Eaker et al., 1993). In this period, the emphasis was on risk reduction for men; an important missing link is the exclusion of women and of elderly persons of both genders from research studies that limits reliable estimates both regarding coronary risk attributes and regarding the efficacy of risk interventions in these populations. In another publication (Wenger, 1994), I identified women and elderly persons as the “understudied majority”; the challenge is that coronary risk factors are highly prevalent in the elderly, and we must learn their clinical impact and the effects of their modification.

Gender comparisons of the relative risk of CHD imparted by major risk factors are derived from data amassed in the National Health and Nutritional Evaluation Survey in the United States (Centers for Disease Control, 1992). Hypertension imparts comparable risk by gender, the risk of hypercholesterolemia is somewhat greater for men, diabetes confers substantially greater coronary risk for women, the risk of being overweight is comparable for women and men, and smoking imparts a somewhat greater coronary risk for women than for their male counterparts.

Particular attention is warranted regarding the coronary risk of cigarette smoking for women; in the United States there is currently an equal prevalence of cigarette smoking in women than in men, because there has been greater smoking cessation among men. Unless this trend changes, the United States may be the first nation in the world to have more women than men who smoke cigarettes. From the 1950s to the 1990s, 30% of White women and 36% of Black women in the United States decreased or stopped cigarette smoking; despite these changes, 23% of U.S. women older than 18 years of age currently smoke cigarettes, and the data on younger women, although not reliably tabulated, suggest an even more serious problem. Additionally, women have increased their intensity of smoking (the number of cigarettes smoked daily) and have an earlier onset of smoking behavior. A number of reports document that smoking at least triples the risk of MI, even among premenopausal women. Smoking lowers the age at menopause, on average about 2 years, and this earlier menopause, in addition to the smoking behavior, may be an added feature that imparts coronary risk (Hansen, Andersen, & Von Eyben, 1993; NCHS, 1991). Based on data from the United States Nurses’ Health Study (Willett et al., 1987), the number of cigarettes smoked correlated with the risk of fatal CHD, nonfatal MI, and AP—that is, all of the coronary manifestations. However, smoking imparted the greatest risk for women already at high risk because they were older, had a family history of coronary disease, and were overweight, hypertensive, hyperlipidemic, and diabetic. The converse, that is, the potential benefits of smoking cessation, is that within 2 years of cessation former smokers decreased their cardiovascular mortality risk by almost one fourth. Why the emphasis on smoking cessation for women? Cigarette manufacturers target women with smoking advertisements, both in the United States and likely in others, emphasizing the reason for which many women smoke, namely weight control. Therefore the educational messages from health care professionals, governments, and other concerned health agencies must counteract this advertising targeted at populations at high risk, women and, in particular, young women. Further, smoking cessation programs for women must incorporate dietary and exercise interventions for weight control if they are likely to be successful. In the Nurses’ Health Study (Kawachi et al., 1993), cardiovascular mortality risk declined 24% within 2 years of smoking cessation. Based on data from the CASS Registry (Hermanson, Omenn, Kronmal, Gersh, and Participants in CASS, 1988), the benefit of smoking cessation did not lessen with older age.

In the United States, more than 50% of White women and 79% of Black women older than 45 years of age have hypertension. This percentage increases to 71% among women older than 65 years of age. It is important that, after age 65, more women than men have hypertension, in contrast to the reversed prevalence at a younger age; also, women have more complications of their hypertension at all ages than do men (Anastos et al., 1991; NCHS, 1991). Systolic blood pressure levels in men peak in middle age; systolic blood pressure levels in women continue to rise until beyond age 80, such that isolated systolic hypertension, which imparts comparable risk to combined systolic/diastolic hypertension, is more common in elderly women than in elderly men. Importantly, control of isolated systolic hypertension at an elderly age can decrease the risk of fatal and nonfatal cardiovascular events (SHEP Cooperative Research Group, 1991).

Hypercholesterolemia is more prevalent in men at middle age and in older women, but hypercholesterolemia becomes particularly prominent in women...

Table of contents

• Contents
• Preface
• CHAPTER 1 Coronary Heart Disease in Women: Evolution of Our Knowledge
• PART I CLINICAL FINDINGS AND RISK FACTORS FOR CORONARY HEART DISEASE
• PART II WORK, STRESS, AND SOCIAL CHANGE IN WOMEN
• PART III MULTIPLE ROLES, SOCIAL SUPPORT, AND COPING IN WOMEN
• PART IV PSYCHOPHYSIOLOGY OF CORONARY HEART DISEASE IN WOMEN
• PART V CONCLUSIONS AND RECOMMENDATIONS
• Author Index
• Subject Index