Wenger Puts Women at Heart of Research
Heart disease still tops the list of the leading causes of death for men and women in the United States, yet women tend to be affected later in life and often have different symptoms than men. Only half of women who have heart attacks experience chest pain, for example. Women typically report other symptoms such as back pain, heartburn, nausea, extreme fatigue and/or difficulty breathing.
Despite the differing symptoms and risk factors of coronary heart disease among men and women, this life-changing—often life-saving—information wasn’t known for many decades because clinical cardiovascular studies didn’t include women.
One medical pioneer who sought to change that predicament is Dr. Nanette Wenger, who recently spoke at an NHLBI seminar, part of a series to celebrate the institute’s 70th anniversary.
Wenger, professor of cardiology at Emory University School of Medicine, is one of the first American doctors to focus on heart disease in women. Since graduating from Harvard Medical School in 1954, she has devoted much of her career to helping unclog the arteries of the male-dominated field of cardiology.
“We’ve come a long way, baby!” Wenger exclaimed, after showing an American Heart Association ad from the 1960s that urged women to prepare heart-healthy meals for their husbands. In 1964, in Oregon, participants at the first women’s conference on heart disease discussed a woman’s responsibility to care for her husband.
Perhaps those healthier meals made a difference. The mortality rate among men with cardiovascular disease was steadily declining from 1979 to 1998, but the rate remained unchanged for women, said Wenger. Over the last 20 years, though, the statistics started to change, thanks to science-based evidence for preventing, diagnosing and managing heart disease among women.
“Since 2000, there’s been a precipitous decline in cardiovascular mortality in women, a decline much more prominent than in men,” said Wenger. “In 2015, for the first time since 1984, fewer women than men in this country died from cardiovascular disease. We’re delighted to be in second place and hope to remain there.”
Several evidence-based reports and conferences since 2000 have identified knowledge gaps, largely due to recommendations and guidelines for women that were extrapolated from men’s studies. Wenger underscored the need to disaggregate study results and report gender-specific analyses from clinical trials.
One landmark event came in 2001 from the Institute of Medicine report Does Sex Matter? Before this report, and the HERS and WHI hormone trial results, said Wenger, “Women were considered protected from heart disease by their hormones.” Randomized clinical trials soon would find that the supposedly cure-all menopausal hormone replacement therapy did not prevent heart disease or any other chronic illness, for that matter.
Said Wenger, “This was enormously important because it refocused attention on the established cardiovascular preventive therapies for women, no longer the reliance on unreliable menopausal hormone therapy.” Studies then appeared debunking the notion that vitamins, including folic acid and beta carotene, prevent cardiovascular disease. “Women were absolutely enamored with their vitamins. When the results of these studies came out,” recalled Wenger, “my clinicians would tell me how much difficulty they had trying to wean women off these non-helpful therapies and onto beneficial therapies.”
Historically, gender medicine focused on what Wenger calls “bikini research”—the breasts and reproductive system—the parts covered by a bikini. As the areas of women’s research expanded, so too did awareness campaigns such as NHLBI’s Heart Truth and AHA’s “Go Red for Women,” which made the red dress a universal symbol of women’s heart health.
In recent years, guidelines began emerging to screen women based on risk factors such as pregnancy complications. Such conditions as gestational diabetes, preeclampsia and pregnancy-induced hypertension can be early indicators of cardiovascular risk, said Wenger. Identifying such risks can help doctors intervene earlier, if necessary.
Now, more attention is given to comorbidities such as diabetes, stroke and clinical depression. Recent studies have shown, for example, that lifestyle interventions seem to improve cardiovascular mortality more in pre-diabetic women than in pre-diabetic men.
Another area of concern is breast cancer treatment, which, although curative for breast cancer, can put women at risk for long-term cardiac complications. “We need surveillance, prevention and secondary management of cardiotoxicity during breast cancer treatments,” said Wenger.
Despite growing awareness and focus on women’s heart health, women continue to be underrepresented in cardiovascular research as well as undertreated, said Wenger. She argued for more public health campaigns that target racial and ethnic minority women, who have the highest number of cardiovascular-related mortalities.
Wenger said her vision for the next decade is to see women’s cardiovascular health further expanded to incorporate beliefs and behaviors as well as economic, environmental, ethical, political and sociocultural issues.
“Heart disease in women is not solely a medical problem,” said Wenger, “and we have to be much more inclusive in our approach.”
After Wenger’s presentation, she did a sit-down chat/Q&A with NHLBI senior scientist & chief of staff Dr. Nakela Cook.