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Cardiovascular (CV) mortality trends have finally begun to decrease among women in the United States similar to the pattern noted in men since the 1980s (Fig. 103–1). The importance of coronary artery disease (CAD) and its prevention in women is gradually receiving increased physician and public attention.1-4 Evidence-based guidelines have been updated after an expert panel review of the literature for the prevention of CAD in women.2 Exploration of sex differences has increased.3 Yet an online survey of primary care physicians, gynecologists, and cardiologists5 found that fewer than 20% of physicians were aware that more women than men die annually of CAD. Intermediate-risk women, defined by Framingham criteria, were more likely to be defined as low risk by the physicians surveyed. Similarly, among more than 1000 American women interviewed by telephone in 2005, only 55% identified heart attack and heart disease as the major cause of mortality for women; this was an improvement from 30% of women surveyed in 19974 (Fig. 103–2). In contrast, 61% of the women reported heart disease as the leading cause of mortality in men. There was substantial ethnic variation among the responses of the women surveyed in 2005 (white, 62%; black, 38%; and Hispanic women, 34%). Interestingly, the most frequent reason women had not discussed heart health with their physicians was that their providers did not bring up this issue (38%).

Figure 103–1.

Graph comparing rates of coronary artery disease and mortality for women and men, 1979 to 2006. From Lloyd-Jones D, Adams RJ, Brown TM, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2010 update: A report from the American Heart Association. Circulation. 2010 Feb 23;121(7):e46–e215..

Figure 103–2.

Trends in American women's perception of the leading cause of death in women. MI, myocardial infarction. Reproduced with permission from Mosca et al.5


Tobacco exposure is the single most important coronary artery risk factor for women and men.1,6,7 In epidemiologic studies, greater tobacco exposure in amount and duration is related to higher CAD events in a dose-related fashion.6-8 Median smoking prevalence in 2007 was 21.3% for men and 18.4% for women.9 Among women, more Native American women smoke (26.8%) than white (20%) or black women (17.3%), with lower rates among Hispanic (11.1%) and Asian women (6.1%).10 Cigarette smoking has been associated with an earlier age of first myocardial infarction (MI) (see also Chap. 51) and menopause.6 Because middle-aged women experience less symptomatic CAD than middle-aged men, the increased risk of MI and sudden death related to tobacco use is greater for women than men.

Over the past several decades, American women's personal use of cigarettes has ...

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