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JOURNAL OF WOMEN’S HEALTHVolume 15, Number 1, 2006© Mary Ann Liebert, Inc.

Women and Heart Disease: Progress, Persistent Gaps, and Future Promise

C. NOEL BAIREY MERZ, M.D.

FEBRUARY IS HEART HEALTH MONTH and numer-ous organizations are holding special events,

publishing special editions, and focusing atten-tion on women and heart disease. More womenthan men now die of coronary heart disease(CHD) annually in the United States, there aremore CHD deaths annually in women of all agesthan breast cancer deaths and the largest adversegender gaps with regard to CHD mortality occurin relatively young women (�65 years) comparedwith similarly aged men. These data tell us thatwe can and must do better.

A personal anecdote brought these statisticshome to me several years ago. Over the winterholidays, a 49-year-old friend and mother of aclassmate of one of my teenaged children had bi-lateral aggressive breast cancer detected by rou-tine mammography. We supported and encour-aged her through her biopsies, chemotherapy,and reconstructive breast surgery. She is alive to-day, doing well, and we all anticipate having herwith us and with her family in the years to come.Later that winter, a 48-year-old neighbor andmother of another teen in this class, who was anonsmoker, lean, and fit from her daily runningperformed to manage a family history of highcholesterol, developed nausea and vomiting overa weekend. On Monday morning, when her hus-band suggested that she see a physician becauseshe was not improved, she declined and wasfound dead on the sofa when the family returnedhome at the end of the day. Autopsy demon-strated sudden cardiac death from an acute my-ocardial infarction. Needless to say, we did notget to support or help care for her. Indeed, noneof her friends knew she was ill until it was toolate, including myself, a physician.

These alarming facts and this tragic story painta very clear picture about the need for additionalwork in two critically important areas of womenand heart disease: (1) improved application of theexisting knowledge and guidelines to identifyand treat women at risk and (2) continued andexpanded current research efforts into gender dif-ferences in heart disease. Both these areas shouldbe aimed at uncovering truths that can be trans-lated into improved clinical care for women.

The following four papers in this issue of theJournal of Women’s Health address these two areasof need. Mosca et al. demonstrate the high preva-lence of cardiac risk factors among women in thecommunity and how a new but simple marker,elevated waist circumference, can identify wo-men with clustering of risk factors. Duvernoy etal. demonstrate observationally a link betweenself-reported physical activity and myocardialblood flow reserve measured by positron emis-sion tomography (PET). The value of physical ac-tivity with regard to reduction of CHD is criti-cally important, with effects seen in largeoutcome studies with as little as 5 minutes ofwalking daily in women up to maximal benefitassociated with 30 minutes of walking daily. Re-cent findings from the Women’s Ischemia Syn-drome Evaluation (WISE) study demonstrate thecritical role of coronary flow reserve and en-dothelial function in women in all stages of coro-nary artery disease (CAD).

The other two papers, by Crandall et al. andGrodstein et al., address the area of gender dif-ferences with regard to CHD, specifically the roleof endogenous and exogenous reproductive hor-mones. Women and men differ most with regardto reproductive hormone levels, which impact

Division of Cardiology, Department of Medicine, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center,Women’s Guild Endowed Chair, Los Angeles, California.

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every cell and tissue in the body. Crandall et al.demonstrate from the Postmenopausal Estro-gen/Progestin Intervention (PEPI) study that en-dogenous testosterone and sex hormone binding-globulin (SHBG) levels are associated withvascular inflammation, measured by high-sensi-tivity C-reactive protein (hsCRP) in postmeno-pausal women, providing a mechanistic under-standing of the complex interplay amongreproductive hormones, risk factors, and CHDoutcomes. Grodstein et al. evaluate the timing ofthe onset of exogenous reproductive hormonetherapy (HT) in the menopause. Their resultsdemonstrate that few (16%) women initiate HT at10 years or longer after menopause, demonstrat-ing a critically important deficit in our existingHT clinical trial database, which almost exclu-sively enrolled these older women naïve to HT atearlier ages. This and their further result sug-gesting a diminution of the beneficial association

between HT and CHD in these older women withlate initiation of HT provide support for two newHT trials, the Kronos Early Estrogen PreventionStudy (KEEPS) and the Early versus Late Inter-vention Trial with Estradiol (ELITE), both de-signed to test whether midlife use of HT is ben-eficial for CHD.

We have much work ahead of us, but the abun-dance of interest and data, along with a passion-ate pursuit of truth, should prove fruitful towardour aim of improved heart health for all women.

Address reprint requests to:C. Noel Bairey Merz, M.D.

Cedars-Sinai Medical CenterWomen’s Guild Endowed Chair

444 S. San Vicente Boulevard, Suite 600Los Angeles, CA 90048

E-mail: merz@cshs.org

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