Sex-specific risk factors for cardiovascular disease in women

Author: Natalie Szakun, UBC Island Medical program, MD candidate, Integrative Cardiovascular Physiology Laboratory, Trinity Western University | Editors: Emily Anne Opala (Program Officer), Romina Garcia de leon, and Janielle Richards  (Blog Coordinators) | Expert Reviewer: Jennifer Williams 

Published: January 10th, 2025

The viral Instagram song “We’ve Never Really Studied the Female Body” by Farideh (@ilovefarideh) has struck a chord by humorously highlighting serious conditions like endometriosis and polycystic ovarian syndrome, shedding light on how women’s health concerns are often dismissed or trivialized. This song resonated with women who are frequently told their symptoms are exaggerated or imagined (as Ferideh ironically emphasizes). The song’s impact is evidenced by its 1,275 video responses and over 2.5 million views at the time of writing this blog, reflecting a collective frustration and desire for change. This surge in public engagement underscores a broader movement towards acknowledging and addressing the longstanding neglect of women’s health in medical research. 

Leading Cause of Death

Cardiovascular disease (CVD) has been the leading cause of death worldwide for over 20 years, with one in three women affected by heart disease. However, our understanding of the impact of CVD in women remains inadequate. Many still hold the misconception that CVD primarily affects men. Although more women die of CVD, a  2017 study surveying Canadian physicians found that 38% of primary care physicians and 32% of cardiologists believed more men die from CVD. 

Women continue to receive insufficient, suboptimal care, as evidenced by lower rates of diagnosis, preventative care, attention, and treatment.  For instance, women are less likely to be treated with guideline-recommended drugs (such as aspirin or blood pressure medication) after a cardiac event compared to men. Additionally, over 50% of women’s heart attack symptoms go unrecognized. Perhaps most starkly, women have a 40% higher population-adjusted risk of mortality from CVD compared to men.

Examining Sex-Specific Risk Factors 

It is incredibly frustrating that we know so little about the leading cause of death for a demographic that represents over half of the population. This is one of the driving forces behind the work of Dr. Anita Coté and her team at the Integrative Cardiovascular Physiology Laboratory at Trinity Western University.

Historically, the medical system has attributed the increased CVD death rate in women to a delayed onset of symptoms, as women typically present CVD symptoms about 10 years later than men. This often results in a delayed diagnosis for women whereby the disease is more advanced, resulting in a poorer prognosis. Recently, however, work in the Coté lab has made it clear that this logic is flawed. While delayed symptom presentation contributes to the problem, there are also the unrecognized sex-specific risk factors (SS-RF) that many women silently carry. 

Sex-specific CVD risk factors are specific conditions, attributes or exposures that increase one’s risk of developing CVD in the future. Some examples of SS-RF include, adverse pregnancy outcomes, polycystic ovarian syndrome, endometriosis, breast cancer treatments, and early age of first menstruation (before age 12) are linked to increased CVD rates and associated deaths. Many women are unaware of the relationship between these risk factors and CVD, yet a significant proportion of women are affected. For example, in a study by Dr. Coté, of pre-menopausal Canadian women, 41% had one or more SS-RF. 

Current CVD risk screening tools – when will we think of women?

Current screening tools often overlook significant SS-RFs, which reduces their sensitivity in predicting risk. In Dr. Coté’s research, 82% of premenopausal women were classified as low risk when considering traditional CVD risk factors (e.g. smoking, high blood pressure, diabetes); However, over a third of these women had one or more SS-RF. Given their young age and pre-menopausal status, their risk was expected to be low but when SS-RFs were included, Dr. Coté’s lab discovered that 47% of the women in their study may be at risk for developing CVD.

Incorporating SS-RFs into current risk prediction tools is more complex than simply adding a few checkboxes. Although this is a good place to start, more research in this area is urgently needed to develop effective strategies for reducing this future risk. 

Future Directions

The lack of comprehensive research on women’s health, particularly regarding CVD, is a significant issue that demands immediate attention. Farideh’s song, “We’ve Never Really Studied the Female Body,” poignantly highlights the common experience of countless women who have been misdiagnosed or dismissed.

As awareness grows and more voices join the conversation, hope for change exists. For example, the organisation Wear Red Canada raises awareness about women’s heart health by hosting yearly events on February 13th to increase women’s knowledge, curiosity and action to prevent CVD and improve heart health. The work being done by researchers like Dr. Coté, and organisations such as Wear Red Canada, is paving the way for a future where women’s health is no longer a secondary consideration but a priority.