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Sunday, November 16, 2014

To Care For a Woman's Heart

Heart disease kills women and men in roughly equal numbers.   And nearly equal numbers of women and men suffer from high cholesterol, which is a leading cause of heart disease.   But our health system cares for the hearts of men and neglects the hearts of women.

Medical guidelines decree that men over 35 years of age should have cholesterol screening as part of the standard health maintenance.   Cholesterol screening for men is paid by insurance, as required by the Affordable Care Act.  However, cholesterol screening for women is not covered by insurance, unless the woman has known risk factors and brings those factors to the attention of the doctor.  If a healthy woman is interested in cholesterol screening, she must pay for the test herself.

About two-thirds of the women who die suddenly from heart disease have no previous symptoms and are unaware of their risk.  High cholesterol is easy and inexpensive to control, if the condition is recognized.  Screening for high cholesterol should be one of the most basic components of a health maintenance program for women, to prevent illness and death from heart disease. 

A publication from the CDC clearly states that heart disease should no longer be regarded as a “man’s disease”.   But guidelines from medical authorities, our laws, and our health insurance are not in accordance with that view.
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It is interesting to compare fact sheets published by the Centers for Disease Control (CDC) for Men’s Heart Health and Women’s Heart Health.   The publications can be found here:

The publications are generally parallel, as seen in the following quotes.

Women
·         Heart disease is the leading cause of death for women in the United States, killing 292,188 women in 2009—that’s 1 in every 4 female deaths.
·         Heart disease is the leading cause of death for African American and white women in the United States.
·         About 5.8% of all white women, 7.6% of black women, and 5.6% of Mexican American women have coronary heart disease.
·         Almost two-thirds (64%) of women who die suddenly of coronary heart disease have no previous symptoms. Even if you have no symptoms, you may still be at risk for heart disease.
·         High blood pressure, high LDL cholesterol, and smoking are key risk factors for heart disease. About half of Americans (49%) have at least one of these three risk factors.

Men
·         Heart disease is the leading cause of death for men in the United States, killing 307,225 men in 2009—that’s 1 in every 4 male deaths.
·         Heart disease is the leading cause of death for men of most racial/ethnic groups in the United States, including African Americans, American Indians or Alaska Natives, Hispanics, and whites.
·         About 8.5% of all white men, 7.9% of black men, and 6.3% of Mexican American men have coronary heart disease.
·         Half of the men who die suddenly of coronary heart disease have no previous symptoms. Even if you have no symptoms, you may still be at risk for heart disease.
·         High blood pressure, high LDL cholesterol, and smoking are key risk factors for heart disease. About half of Americans (49%) have at least one of these three risk factors.

The Women’s Heart Health Fact Sheet includes two sections not contained in the Men’s Fact Sheet.  One section addresses symptoms of heart disease, and the other section addresses health screening, including cholesterol screening.  Women are advised to discuss cholesterol testing with their doctor, and proceed with screening if the woman has any of several risk factors for heart disease.

However, the CDC Men’s Fact Sheet publication is silent about cholesterol screening.  The reason for the omission is simple: men’s cholesterol screening is the default recommendation under guidelines of the Affordable Care Act, and according to guidelines issued by the American College of Cardiology/American Heart Association (CDC/AHA).  No discussion is needed for the man.  The doctor will perform a cholesterol screening for every man over 35, as part of his annual wellness physical exam.  The doctor may not perform the screening for women, unless she has a risk factor and brings it to the attention of the doctor, or she specifically requests the test. 

Guidelines for preventive treatment of heart disease are established by the CDC and the ACC/AHA.  These guidelines are transformed into policies, in both meanings of the word.  The discriminatory guidelines are enshrined as policy in the fine print of the Affordable Care Act (ObamaCare), and as the terms of insurance policies governed by the legislation.  Thus, a man’s annual cholesterol test will be paid for by his insurance.  If a woman asks for a cholesterol test and doesn’t present any of the risk factors, she must pay for the test herself.

Prevalence of high LDL-c Cholesterol in Men and Women
Based on data from 2005 – 2008, an estimated 71 million adult Americans have levels of LDL-c (bad) cholesterol above recommended guideline.  About half of those receive treatment, with about two-thirds of treated patients achieving success in lowering LDL-c cholesterol below the recommended threshold. 

There is a small, but immaterial difference between men and women in the prevalence of high LDL-c cholesterol.  About 36 percent of adult men (> age 20) have high levels of bad cholesterol, while about 31 percent of adult women have high levels of bad cholesterol, based on data from 2005 - 2008.  Using these ratios and current population figures, about 39 million American men are in need of cholesterol screening and treatment, while about 36 million American women are in need of cholesterol screening and treatment.

Effectiveness of Cholesterol Screening and Control
Treatment of high LDL-c cholesterol is improving in effectiveness.   In comparing data from 1999-2002 to data from 2005-2008, the percentage of patients receiving treatment for high LDL-c cholesterol increased from 30% of affected patients to about 50% of affected patients.  Also, the percentage of patients successfully controlling high cholesterol more than doubled, from 15% to 33% of all patients.  Recognition of patients with high cholesterol is clearly essential to prescribing treatment and successfully controlling the condition.

Cholesterol screening is simple.   Treatment of high cholesterol is effective and low-cost.  Millions of women are at nearly equal risk with men regarding heart disease, and there is no reason why there should be a difference in standard guidelines for cholesterol screening and insurance coverage of the procedure.

Differences between Women’s and Men’s Heart Health
There are differences in women’s and men’s heart health.  In the interest of objectivity, I’ll look at those differences in this section.

First, as noted above, more men than women suffer from high LDL-c (bad) cholesterol.   The percentage of men with high bad cholesterol is about 36%, while the percentage of woman with bad cholesterol is about 31%.  Still that leaves 36 million women with a treatable condition that places them at risk of sudden death. 

Second, men tend to die of heart disease at a younger age than women.  Let’s look at two maps presented on the fact sheets prepared by the CDC.  These show the age-corrected death rates from heart disease for men and women.
Superficially, the maps appear almost identical.  But the scaling on the maps is different.   All of the women’s categories except the highest level would be displayed as the lightest color on the men’s map.  If the maps were displayed with the same color scale, the woman’s map would be much lighter than the men’s map.   On an age-corrected basis, the women’s death rate from heart disease is visibly lower than the men’s rate.  I would need addition information about the age-corrected death rate to quantify the difference.

Third, men’s heart attacks tend to be more sudden and incapacitating than women’s heart attacks, according to various literature.  A man’s stereotypical heart attack is traumatic and catastrophic, while a woman’s heart attack is a subtle and silent killer.  Thus, men’s heart disease attracts the attention of the public and medical community, while women’s heart disease is ignored.
While acknowledging these differences exist, it seems to me that they do not justify systematically neglecting women’s cholesterol and heart health.   It should be noted that the death rates from heart disease for women between the ages of 29 and 45 have been rising since the year 2000.

Conclusion
Cholesterol testing addresses the number one killer of American women, and should be a standard preventative health treatment for women.  Testing for cholesterol will also help communicate the risk of heart disease to women, and prompt discussion with patients about other risk factors, such as blood pressure and life style, that may also lead to heart disease or other illnesses. 
Strangely, the CDC Fact Sheet on Women and Heart Disease includes this acknowledgement:
“Although heart disease is sometimes thought of as a ‘man's disease’, around the same number of women and men die each year of heart disease in the United States.  Despite increases in awareness over the past decade, only 54% of women recognize that heart disease is their number 1 killer.”

However, the entire medical establishment, as represented by CDC fact sheets, the guidelines of the ACC/AHA, and the provisions of the Affordable Care Act, continues to regard heart disease as a ‘man’s disease’.   Men receive automatic cholesterol screening, paid for by insurance, to reduce their risk of illness and death.  Women must specifically inquire about screening, and in most cases pay for the screening themselves, while they face nearly equal odds of preventable illness and death. 

That’s just not right.

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Related information
Actress and singer Barbara Streisand has become an activist for women’s heart health.  Streisand’s philanthropy supports the Barbara Streisand Women’s Heart Center, at the Cedars-Sinai Medical Center in Los Angeles.  Streisand also founded the Women’s Heart Alliance.  The Women’s Heart Alliance recently launched a campaign for women’s heart health called “Fight the Ladykiller”.  Links are included in references listed below.
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References
Women and Heart Disease Fact Sheet; Centers for Disease Control.

Men and Heart Disease Fact Sheet; Centers for Disease Control.

Vital Signs: Prevalence, Treatment, and Control of High Levels of Low-Density Lipoprotein Cholesterol --- United States, 1999--2002 and 2005—2008, Morbidity and Mortality Weekly Report (MMWR), Centers for Disease Control and Prevention, February 4, 2011 / 60(04);109-114.

Million Hearts Program, Centers for Disease Control.
Strategies that address leading Cardio-Vascular Disease (CVD) risk factors, such as hypertension, high cholesterol levels and smoking, that can greatly reduce the burden of CVD.

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Preventative Health Care Services for Women, Healthcare.gov.
Health care services under the ACA; there is no immediate mention of different cholesterol screening for men and women, on these websites, until you drill down to the following page on HealthFinder.gov.

Get your cholesterol checked, HealthFinder.gov
Different standards for women’s and men’s  cholesterol screening.

Population by Age and Sex, 2012, US Census Bureau

Barbara Streisand and Women’s Heart Health


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