Breast cancer is not the number one killer of women – yet many women believe it to be their biggest health risk. So what wins this morbid ranking? Heart disease. In fact, 2013 was the first year since 1984 that fewer women died of heart disease than men despite it being viewed as solely a men’s health issue. This decline was the result of the tireless work of a small group of women who have dedicated their lives to eradicating this misunderstanding and unequal treatment of women’s heart disease.

Heart disease first came to medical prominence in 1948 with the start of the long-term, ongoing Framingham Heart Study – now in its third generation of subjects residing in the Massachusetts town. It was reported in 1955 that age and sex were clearly risk factors for heart attacks: men suffered from heart attacks as early as their thirties and forties, while women were seemingly spared because they had much less incidence and experienced them about 10 years later than men. By 1979, 30,000 more men were succumbing to heart disease than women, cementing the perception of heart disease as a men’s disease. As a result, medical attention was focused almost exclusively on men and their hearts. The Multiple Risk Factor Intervention Trial (MRFIT) started in 1974 only examined one sex.

This inconsistency was particularly evident with the breakthrough development of effective cholesterol lowering drugs, statins. Men were prescribed statins beginning in the late 1980s and their mortality from heart disease immediately and rapidly declined. Yet women were not given statins, but rather hormone replacement therapy (HRT) because of the observational Nurses Health Study. The result of this difference in treatment was disastrous. While consistently fewer men were dying of heart disease with the introduction of statins, the mortality rate in women actually began to increase in 1991 with the use of HRT. The disparity in these trends continued until reaching an apex in 2000, at which point there were 70,000 more women than men dying from heart disease.

As such, throughout the 90s, it became more and more apparent that heart disease is a genderless killer. In 1991, Bernadine Healy, MD, FACC, a cardiologist and the first woman to lead the National Institutes of Health (NIH), launched the $625 million Women's Health Initiative. This was a comprehensive, long-term health study involving 150,000 women as a means to understand the many different ailments that plague the female sex, such as heart disease, cancers and osteoporosis.

Concurrently, a minority of cardiologists – mainly women themselves – began conducting their own studies on heart disease in women. Nanette Kass Wenger, MD, MACC; C. Noel Bairey Merz, MD, FACC; and Jennifer Mieres, MD, FACC, among many others, broke down barriers in their work by simply beginning a dialogue on this issue. Dr. Wenger reflects on the frustration she felt during this integral time, stating that “there was minimal information specific to women, and I believed generalization from data in men was inappropriate.” In 1999, Lori J. Mosca, MD, PhD, led the group that published the first guidelines for the prevention of heart disease in women, approximately fifteen years after the MRFIT study was released for men.

In 2000, the first results of the Women’s Health Initiative were released with one particularly shocking revelation: the popular use of HRT in post-menopausal women actually increased the risk of heart attacks, strokes and breast cancer. Only one year later, there were already 17,000 fewer heart attacks in women as a result of reduced HRT and women with high cholesterol being given statins like men were over a decade prior.

Yet with these upending results, much work was required to change the popular notions and misinformation regarding women and heart disease. Not only was heart disease killing women, but as Nieca Goldberg, MD, FACC, outlined in her bestseller, Women Are Not Small Men, the warning signs of heart attack are vastly different between the sexes: nausea, fatigue and restless sleep. The NIH and the American Heart Association quickly launched successful awareness campaigns surrounding these issues, The Heart Truth in 2002 and Go Red for Women in 2004, respectively. With the help of the media, by the end of the decade the ‘red dress’ had become a powerful and instantly recognizable symbol of heart disease prevention in women.

The medical community thrived on this increased awareness, and specialized health centers were opened to correct gender inequalities regarding heart disease. “The publication and application of guidelines, which provide a roadmap for the clinician in preventing and treating heart disease in women,” Dr. Mieres posits, was crucial in the dramatic decline of mortality. Gina Price Lundberg, MD, FACC, was at the forefront of this revolution, starting Atlanta’s first Women’s Heart Center in 1998 and now leading one at Emory University. When discussing her inspiration, Dr. Lundberg explains, “I was seeing so many women in my private practice who were being dismissed with symptoms of chest pain; they were being told that women didn’t get heart disease.”

The Barbra Streisand Women’s Heart Center at Cedars Sinai similarly focuses on identifying female-pattern heart disease and lowering lifestyle risk factors. Dr. Bairey Merz, the director of this center, cites social justice as the mission and vision of her work.

Outside of the professional medical field, dedicated and passionate women with connections to heart disease also took great strides in raising awareness. Some even started support groups to help cope with the burden of this health risk. WomenHeart, a national coalition of women with heart disease, serves to empower survivors and advocate on their behalf.     

Since 2000 there has been a dramatic decline in mortality rates for women from heart disease. This decline is attributed to an increase in awareness, a greater focus on women and cardiovascular disease risk and the increased application of evidence-based treatments for established coronary heart disease. Yet there are still great strides that must be taken, particularly in the other side of heart disease: the doctors. According to the Association of American Medical Colleges in the 2014 Physician Specialty Data Book, only 12 percent of cardiologists are women. When 88 percent of cardiologists are male, it’s inherent that women’s issues and treatments will go less developed than the other gender. Here’s to all the accomplishments already achieved, and the new ones women look forward to conquering, in the battle against heart disease.

This article was authored by Annabelle S. Volgman, MD, FACC.