The
Lancet,
19
June
2021:
Ana
Olga Mocumbi (May 2021) “Women's cardiovascular health: shifting
towards equity and justice”
Cardiovascular
disease in women is understudied, under-recognised, underdiagnosed,
and undertreated globally, despite being the leading cause of death
in women worldwide, as highlighted by a new Lancet Commission.1
Several misperceptions contribute to this neglect, notably, the
persistent view that cardiovascular disease primarily affects men or
only women in high-income countries and results from poor lifestyle
choices. The Lancet women and cardiovascular disease Commission1
identifies disparities in prevalence and outcomes of cardiovascular
disease in women worldwide, delineates the substantial impact of
socioeconomic deprivation in determining these differences, and
proposes strategies to address these inequities, increase sex-related
research, and support integration of care and strengthening of health
systems.1
From
1990 to 2019 there have been large declines in cardiovascular disease
age-standardised rates of death, disability-adjusted life-years, and
years of life lost.2 There have been declines in
age-standardised prevalence of coronary heart disease and stroke
mortality rates in men and women in most parts of the world, with
greater age-specific reductions in coronary heart disease in men than
in women.3
Between
2010 and 2019, the age-standardised cardiovascular disease death rate
increased or stagnated in many other parts of the world, including
eastern Europe and countries in central, south, and east Asia.2
In a Canadian setting, the 30-day acute myocardial infarction
mortality rates declined similarly for women and men from 2000 to
2009, but women younger than 55 years had an excess mortality risk
compared with men of the same age.4 Under-representation
of young people in clinical studies on cardiovascular disease, as
well as worse risk profile due to comorbidities, might contribute to
these slow improvements. Importantly, because of women's longer life
expectancy, overall deaths from cardiovascular disease are higher in
women than in men, and this excess number of cardiovascular disease
deaths in women is likely to increase with population ageing.
Moreover, the success in declining age-standardised cardiovascular
disease mortality over the past decades has been limited to countries
with a high Socio-demographic Index (SDI); some countries with a low
SDI had the highest cardiovascular disease mortality rate shift from
men to women.2
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Poverty
continues to affect a considerable proportion of the world's
population, determining unique patterns of non-communicable diseases,
including cardiovascular disease in young women.5 In
countries with a low SDI, where premature cardiovascular disease
mortality is largely driven by poverty, poor access to care, and
underuse of interventions of proven efficacy, women face the
coexistence of an increased prevalence of cardiovascular disease, a
rise in metabolic risk factors, and endemic infectious diseases such
as tuberculosis, HIV/AIDS, and schistosomiasis. Furthermore, specific
risk factors and conditions affect women in countries with a low SDI.
Chronic exposure to biomass fuel is common in rural Africa and Asia
and contributes to the burden of acute coronary events and stroke,6
affecting predominantly women; this exposure could partly explain the
high occurrence of and sex differences in isolated right heart
failure in non-smokers in these places.6, 7
Similarly, in poor countries women younger than 40 years are
increasingly affected by neglected or poverty-related conditions,
such as rheumatic heart disease and endomyocardial fibrosis.8,9
Moreover, maternal mortality remains unacceptably high. About 295 000
women died during and after pregnancy and childbirth in 2017.10 94%
of these deaths occurred in low-resource settings, where the maternal
mortality ratio was 462 per 100 000 livebirths versus 11 per
100 000 livebirths in high-income countries.10 Since
cardiovascular disease is the leading non-obstetric cause of maternal
mortality worldwide,11 one should consider the role of
disparity in fertility rates, incidence of peripartum cardiomyopathy,
and pre-existing uncontrolled arterial hypertension8 as potential
determinants of maternal mortality. Indeed, there are a considerable
number of maternal deaths due to cardiovascular disease in low-income
and middle-income countries.12 Unfortunately, even in the
USA, where the maternal mortality ratio was 17·4 maternal deaths per
100 000 livebirths in 2018, the maternal mortality ratio was more
than double among non-Hispanic Black women (37·1 per 100 000
livebirths), with more than half of these deaths and near deaths
being preventable, and cardiovascular disease being the leading
cause.13 Inadequate access to quality and affordable
health care along with long-standing health disparities plays a role
in this disparity; additionally, social determinants of health can
increase the risk of gestational diabetes, peripartum cardiomyopathy,
caesarean deliveries, and future cardiovascular disease in neglected
communities.
To
address the gaps highlighted by this Commission, current knowledge
must be used to achieve health equity so that no one is disadvantaged
from attaining their full health potential because of their social
position or other socially determined circumstance. Reduction of
disparities in clinical outcomes requires the prioritisation of
high-impact solutions in under-resourced areas, involving tailored
strategies for decentralised and integrated care, and support from
global and regional partners to improve the availability of
interventions for cardiovascular disease prevention and management.
Front-line health workers with shared competences for
cardio–obstetric care, digital health, and portable ultrasound
should be used to deliver decentralised care, improve referral
systems, and support surveillance of sex-related outcomes. Digital
health provides opportunities to enhance the quality, efficiency, and
safety of primary health care, as well as help address racial and
ethnic disparities,14 but insufficient digital health
competencies among front-line health workers are among the factors
that hamper the adoption of digital tools and technologies.15
Finally, as emphasised in the Commission, peer-to-peer supporters and
educators in local communities should be used to empower women in
improving their ability to access, understand, appraise, and apply
health information to promote good cardiovascular health.
In
the midst of the COVID-19 pandemic, values of human dignity,
solidarity, altruism, and social justice should guide our communities
to ensure equitable share of wealth and leveraging of efforts towards
the reduction of cardiovascular disease burden in women worldwide.
The Commission's recommendations on additional funding for women's
cardiovascular health programmes, prioritisation of integrated care
programmes, including combined cardiac and obstetric care, and
strengthening of the health systems accords with efforts to bridge
the gap for the world's worst off.5 Such a shift in
women's cardiovascular care would be a major step towards equity,
social justice, and sustainable development.
I
declare no competing interests.
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