In 2004, the American Heart Association launched its “Go Red for Women” campaign. This campaign was an effort to educate women of all ages regarding cardiovascular (CV) disease. CV disease is a major health threat not just for men but also for women. In 2003, 483,842 women died as a result of CV disease; this number is increasing annually. More than half of these deaths were the result of an acute myocardial infarction. Unfortunately, many women with CV disease sought treatment so late that significant CV damage already occurred; more unfortunate was the fact that many of these women never even reached the hospital. For women who do seek medical attention, emergency department personnel are often the first providers of care. Therefore, it is imperative that emergency department providers recognize and treat acute cardiac events promptly and efficiently to promote positive patient outcomes to reduce morbidity and mortality in women with CV disease.
CORONARY ARTERY DISEASE is the leading cause of death and disability in the United States for both men and women (Merz et al., 2006). In the past decade, the number of cardiovascular (CV)-related deaths in men has declined; however, the number of CV-related deaths in women has continued to climb (Grant, Jacobs, & Clancey, 2004; Lefler & Bondy, 2004; Mieres et al., 2005; Wenger, 2004). This disturbing fact is a clear indication that advanced practice nurses (APNs) and the public alike need to have a greater understanding of how to improve the CV health of women. Of the more than 500,000 women who die each year from CV disease, many of these women never arrived at a hospital. For those women with CV disease who do make it to the emergency department (ED), it is imperative that APNs, as part of the healthcare team, promptly recognize and manage these critically ill patients. This article is intended to further educate APNs regarding the gender differences with regard to CV health in an effort to reduce CV-related morbidity and mortality in the female population.
Wenger (2004) eloquently describes the historical view on women's health as the bikini approach, stating that the main focus has been on breast and reproductive health. Although breast cancer is often portrayed by the media as the leading cause of morbidity and mortality for women, the fact is that the risk of a woman dying from heart disease is 5.5 times greater than dying from breast cancer (Canto et al., 2007; Stramba-Badiale et al., 2006). Wenger (2004) also states that heart disease has long been perceived as a male problem, dating as far back as 2600 BC. In more recent years, the medical community has studied CV disease primarily in men, rarely if ever including women in their clinical trials (Huxley, 2007; Stramba-Badiale & Priori, 2005). The Framingham Heart Study (2008) is a noteworthy exception in that it was the first major heart study to include women from the onset; this ongoing study began 60 years ago. In 1948, 5,209 men and women, aged 30–62, were recruited from the town of Framingham, MA. In a longitudinal study, researchers identified common factors that contribute to CV disease. In 1971, adult children of these participants were recruited, and in 2002, their grandchildren were recruited. The growing awareness that CV disease is a major health threat for women has prompted the inclusion of more women in trials; however, women remain underrepresented by 50% (Rosenfeld, 2006).
The majority of women surveyed have indicated that they feel that heart disease is a problem more frequently encountered by men than women (Canto et al., 2007; Lefler & Bondy, 2004). A study conducted in 2005 among 500 randomly selected physicians revealed that, of those surveyed, only 8% of primary care physicians, 13% of obstetrician/gynecologists, and 17% of cardiologists were cognizant of the fact that more women than men die each year from heart disease, indicating that even healthcare professionals tend to underscore the possibility of an adverse CV event in women (Mosca et al., 2005; Rautaharju, Kooperberg, Larson, & Lacroix, 2006). This misconception has led to a myriad of misgoverned cases of acute coronary syndrome, and it has affected many areas of patient care.
Risk factors that contribute to CV disease in women can be modifiable or nonmodifiable, as shown in Table 1. The American Heart Association (AHA, 2008) defines nonmodifiable risk factors as those risk factors that a person is unable to change. Modifiable risk factors are those that can be improved upon by instituting changes in lifestyle and behavior.
| | Table 1. Risk factors for cardiovascular disease |
Coronary heart disease most often occurs in women who are postmenopausal and are on average about 10 years older than men when they develop CV-related illness but 20 years older when encountering their first myocardial infarction (Stramba-Badiale et al., 2006). Postmenopausal status, whether by natural causes or by surgery, is considered an independent risk factor for CV disease. Menopause is associated with an increase in the level of low-density lipoprotein cholesterol (LDL-C), or the bad cholesterol, and a decrease in the level of high-density lipoprotein cholesterol (HDL-C), or the good cholesterol. The benefit versus risk of hormone replacement therapy should be assessed on a case-by-case basis (Mosca, 2004).
There is strong evidence that supports heredity as a risk factor for heart disease. Studies have demonstrated that a person whose mother, father, or sibling has heart disease is more likely to develop heart disease himself or herself (Arnett et al., 2007). Many forms of genetic heart disease have been identified, one of the most well known being atherosclerotic CV disease. Atherosclerotic CV disease manifests itself as coronary heart disease, stroke, or peripheral arterial disease.
The AHA (2008) recognizes race as playing a role in the incidence of CV disease, with African Americans and Mexican Americans more likely than Caucasians to develop CV disease. Research is under way to identify and characterize the genes that contribute to CV disease to improve the quality of care that the healthcare team can provide. It is important for APNs to counsel patients with a genetic predisposition to heart disease to decrease their risk by addressing modifiable risk factors such as quitting smoking, maintaining an appropriate weight, and engaging in regular exercise.
Cigarette smoking is the leading preventable cause of death in the United States (Shaw et al., 2006). Cigarette smoking increases inflammation and thrombosis and affects oxidation of LDP. Women who smoke even one to four cigarettes per day have twice the risk of heart disease as women who do not smoke at all. In women who smoke and use oral contraceptives, the risk of CV disease is even greater (Stramba-Badiale et al., 2006). Smoking cessation is directly related to an instant decline in the risk of heart disease, with the risk returning to that of a nonsmoker within 3–5 years. Counsel all women not to smoke and avoid secondhand smoke as much as possible.
A greater number of women than men develop hypertension as they age, especially women older than 45 years (Stramba-Badiale et al., 2006). Blood pressure should be maintained below 120/80 mmHg to reduce the risk of coronary heart disease (Mosca et al., 2004). The clinician should counsel all patients who present with less than optimal blood pressure to first continue to monitor blood pressure and modify lifestyle habits. If blood pressure remains above 140/90 mmHg, or if diabetic, 130/80 mmHg, pharmaceutical intervention may be required.
Women who are obese, as defined by a body mass index (BMI) of 30 or higher, are predisposed to other CV risk factors such as hypertension, dyslipidemia, and diabetes mellitus (Kip et al., 2004). In fact, obesity is an independent risk factor in the development of CV disease in women, and studies suggest that excess abdominal fat may further increase the risk (Li et al., 2006). Weight maintenance is crucial for women because weight loss has been proven to be very difficult. Women have a 35%–60% lower risk of developing heart disease if they maintain ideal weight. The recommendation is that BMI be maintained between 18.5 and 24.9 and a waist circumference less than 35 in. (Mosca et al., 2004).
Women with diabetes have a significantly greater risk for heart disease than do men with diabetes, with heart disease being the most common complication of diabetes in women (Rosenfeld, 2006). Premenopausal women who are diabetic are at higher risk for heart disease due to the impairment of estrogen binding. Recommendations are for tight glycemic control to achieve a hemoglobin A1c level of less than 7% as well as the modification of other risk factors such as smoking, hypertension, and weight control (Mosca et al., 2004). The American Diabetes Association (2008) states that although a hemoglobin A1c level of 7% has been proven to reduce microvascular disease and possibly macrovascular disease, epidemiologic studies suggest a small benefit in lowering the hemoglobin A1c level to 6.5% or less. This goal, however, is not feasible in those patients with a history of severe hypoglycemia, those with comorbid conditions, and children, nor is it necessary in those patients with minor or stable microvascular compromise.
A low level of HDL-C is associated with an increased risk of heart disease in women. Furthermore, evidence strongly supports the relationship between elevated triglyceride levels and the risk of a CV event (Sarwar et al., 2007). Current recommendations are to maintain HDL-C levels above 50 mg·dl-1 and triglycerides below 150 mg·dl-1 through lifestyle modification (Blaha et al., 2008). When history reveals the use of statin, niacin, or fibrate therapy, this should alert APNs that this patient has been diagnosed with dyslipidemia.
Studies suggest that a high consumption of alcohol is harmful to CV health, possibly causing cardiomyopathy, arrhythmias, and hypertension (Kloner & Rezkalla, 2007). Excess alcohol use can raise the level of triglycerides in the blood, and the excess calories consumed could contribute to obesity. Conversely, mild to moderate alcohol consumption has been associated with a reduced incidence of CV events. Whether or not alcohol has a direct cardioprotective effect is controversial. The benefits of mild to moderate alcohol intake are thought to include an increase in HDL-C, reduction in plasma viscosity, a decrease in platelet aggregation, improved endothelial function, and promotion of antioxidant effects.
Heavy alcohol consumption is defined as more than 2 drinks daily for men and more than 1 drink daily for women; 6 g of alcohol daily, or about 1/2 a drink, has been demonstrated as most beneficial. A drink is typically described as 12 oz of beer, 5 oz of wine, or a “shot” (1.5 oz) of 80-proof distilled spirits, such as gin, vodka, or rum (Kloner & Rezkalla, 2007).
The current recommendation of the AHA (2008) is that if alcohol is consumed, do so in moderation. For those who do not drink, do not start. Alcohol is a depressant drug and increases health hazards such as alcoholism, suicide, and accidents. Pregnant women should not consume alcohol at all owing to the increased risk of birth defects. Finally, alcohol and aspirin do not mix. Concurrent use of alcohol and aspirin may increase the bleeding risk. If prescribed aspirin, patients should stop consuming alcohol and continue aspirin therapy.
Lack of regular physical activity has been identified as an independent risk factor for CV disease (Li et al., 2006). Regular physical activity can help reduce or eliminate other risk factors such as hypertension, diabetes, obesity, smoking, and dyslipidemia (AHA, 2008). Men and women who are inactive are almost twice as likely to develop heart disease as those who engage in regular physical activity. The recommendation of the AHA is for those who are able to engage in at least 30 min of physical activity on most or all days of the week.
Stress can be viewed as both a modifiable and nonmodifiable risk factor. In the average person, acute mental stress can affect heart rate, cardiac output, stroke volume, and cardiac microcirculation. Chronic mental stress can result in CV ischemia, arrhythmias, and pump failure. Hans Selye, considered a pioneer in modern stress research, defines stress as “essentially the rate of all wear and tear caused by life,” which suggests that not all stress is avoidable (Kumar & Goel, 2008). Kumar and Goel, however, recognize stress as a modifiable risk factor for CV disease that can be managed by a healthy lifestyle, anger management, meditation, yoga, prayer, and treatment of mental illness.
Healthcare professionals are aware of many differences that exist between males and females, from the gross anatomy that can be viewed with the naked eye to differences in hormone production. What is not always apparent, however, are the physiological differences that maintain the CV health of men and women. APNs should consider the special physiology of women when evaluating and treating female patients.
Huxley (2007) elaborates on some of the physiological differences in men and women relative to cardiac function, stating that the healthy bodies of men and women are in homeostasis, with the CV system of each gender harboring the same gross anatomy. These differences affect the presentation, treatment, and prevention of CV disease. Take the case of cardiac index, for instance, calculated by using the formula shown in Table 2. In studies of normal healthy adults, the heart of a woman is smaller than that of a man, resulting in a smaller stroke volume, and therefore and a lower cardiac output. The heart rate is on average greater in the woman. Therefore, after making allowances for the smaller body surface area of the female body, there would be no difference in the cardiac index. There are also differences in the electrocardiogram (ECG), noted to be evident after puberty, with women being associated with a longer corrected QT (QTc) interval for heart rate (Huxley, 2007; Stramba-Badiale & Priori, 2005). The physiology lesson, presented by Huxley (2007), becomes much more complex as gender differences in the regulation of blood pressure and volume balance are discussed. There is a difference in the design of cardiac repolarization between the sexes, which may attribute to differences in the response to various cardiac drugs and incidence of cardiac arrhythmias. In addition, ventricular depolarization-related ECG abnormalities, such as those associated with myocardial infarction, are recognized by APNs as predictors of further CV events and mortality; research has revealed that in women, particularly those who are postmenopausal, ventricular repolarization abnormalities are also important indicators of future CV events and mortality (Rautaharju et al., 2006).
| | Table 2. Formula for cardiac index |
With respect to drug metabolism and elimination, again there are significant gender differences. Women have a lower glomerular filtration rate than men, affecting drug elimination (Stramba-Badiale & Priori, 2005). Most CV drugs are metabolized by cytochrome P450 enzymes; gender differences in the activity of these enzymes have been demonstrated. Anderson (2005) reports a significantly increased risk of women over men in the incidence of adverse drug events. Quinidine may change the slope of the QTc interval in women, with the greatest increase occurring during the first half of the menstrual cycle. Women are at increased risk for drug-induced long QT syndrome and two thirds of all drug-induced torsades de pointes occur in women. APNs should recognize that certain drugs (e.g., amiodarone, bepridil, disopyramide, ibutilide, quinidine, sotalol, erythromycin, pentamidine, terfenadine, chlorpromazine, pimozide) have a greater likelihood of inducing torsades de pointes or prolonging the QT interval in women versus men and should be considered in treating patients with these arrhythmias (Anderson, 2005).
APNs should also consider the use of low-dose aspirin in women. Ridker et al. (2005) report that the use of low-dose aspirin among women has failed to demonstrate a correlation in primary prevention of heart disease but did reduce the incidence of stroke. The benefits of aspirin use must be weighed against the risks of bleeding on an individual basis. For men with an intermediate risk of bleeding, the AHA gives a Class I recommendation for the use of 75–162 mg of aspirin daily; however, for women with the same risk, a Class IIa recommendation for the use of same dose among women 65 years and older and a Class IIb recommendation among women younger than 65 years (Blaha et al., 2008). A woman with no history of heart disease who presents to the emergency department and who reports taking an aspirin daily should be questioned as to the reason for taking the aspirin, and if it was recommended by her primary care provider, the benefit versus risk must be considered. Many women take aspirin daily in an effort to be “heart healthy,” but they may actually be increasing their risk of stomach ulcers or gastrointestinal bleeding. The regular use of aspirin is also contraindicated in those with liver or kidney disease, those with an aspirin allergy, or those with gastrointestinal diseases (Mosca et al., 2004).
Women are typically about 20 years older than men when they first present with acute myocardial infarction (AMI). However, it is important to note that young women also experience myocardial infarctions. Women younger than 50 years who experience AMI have a higher rate of complications and a higher rate of in-hospital mortality, possibly due to delay in diagnosis. There also tends to be a higher rate of complications among women older than 65 years, possibly due to comorbid factors (e.g., diabetes).
Thuresson et al. (2005) have identified the trends in women with AMI: (1) women are more likely to experience atypical symptoms, which (2) delays treatment time.
Shaw et al. (2006) report “substantial differences” in symptom presentation between men and women during the assessment of myocardial ischemia and obstructive coronary artery disease. As discussed previously, men have been the subject of most cardiac studies; therefore, “typical” chest pain is based primarily on the male model. A description of “typical” and “atypical” chest pain as defined by Canto et al. (2007) can be found in Table 3.
| | Table 3. Typical versus atypical symptom presentation of cardiovascular events in women |
The pain sensed during myocardial ischemic attack is by way of the vagus nerve because the heart in itself has no c-fibers for pain detection (Peterson & Alexander, 1998). The vagus nerve, when stimulated, carries a visceral discomfort through the parasympathetic pathway, and for this reason, the experienced discomfort is oftentimes difficult to localize or describe. Most patients of both sexes do experience chest pain with AMI; however, women are more likely than men to have no chest pain at all (Culic, Eterovic, Miric, & Silic, 2002; DeVon, Ryan, Ochs, & Shapiro, 2008; Horne, James, Petrie, Weinman, & Vincent, 2000; Merz et al., 2006). Women are more likely than men to experience pain in the middle or upper back, nausea, vomiting, indigestion, loss of appetite, shortness of breath, cough, generalized weakness or fatigue, paroxysmal nocturnal dyspnea, palpitations, and diaphoresis; some symptoms, considered prodromal symptoms such as difficulty sleeping, unusual fatigue, and anxiety, may be experienced several days to weeks prior to a cardiac event (Canto et al., 2007; McSweeney et al., 2003). These differences in presentation are important because when it comes to matters of the heart, time is muscle. Atypical presentation may delay treatment time as a result of several factors, and this may lead to a poorer patient outcome (Canto et al., 2007; Dorsch et al., 2001; Lefler & Bondy, 2004; McSweeney et al., 2003; Pope et al., 2000; Shaw et al., 2006).
Riegal et al. (2007) have identified three phases of delay in treatment time: (1) time from symptom onset to the patient's decision to seek medical treatment; (2) transportation time; and (3) in-hospital delays.
Patient decision time has been identified as the primary reason for delay in treatment (Thuresson et al., 2005). Women delay seeking treatment, or fail to seek treatment, more often than men owing to failure to recognize symptoms, dismissing their symptoms, and preferring to self-medicate (Higginson, 2008). Delays in decision time to seek treatment have also been associated with a lower education level, age greater than 65 years, minorities, and the presence of other chronic illnesses causing confusion with cardiac symptoms, such as chronic obstructive pulmonary disease (Lefler & Bondy, 2004).
Early recognition of coronary symptoms is key because rapid entry into the healthcare system is associated with reduced mortality because late presentation in women experiencing an AMI can lead to delays in reperfusion therapy, such as thrombolysis and angioplasty (Rosenfeld, 2006). Many research studies have shown that the decision to seek medical treatment after onset of symptoms is often 4 hr or more. In the past, physicians have been more hesitant in the use of antithrombolytics and percutaneous transluminal coronary angioplasty in women versus men owing to increased risk of complications (Mikhail, 2006). Again, most women who present with symptoms of a myocardial infarction are typically older than their male counterparts and may have more comorbid factors, such as diabetes, hypertension, and high cholesterol level. The coronary vessels of a female tend to be smaller than that of the male, thus making percutaneous revascularization more difficult. In using antithrombolytics, women are often overdosed, leading to bleeding complications (Harrington, 2007). Advances have been made in these techniques, such as the use of weight-adjusted heparin and smaller sheath sizes; it is suggested that women should be considered for these interventions in a more rapid fashion and more often. The Myocardial Infarction Triage and Intervention trial demonstrated that reperfusion therapy, when instituted within 70 min of symptom onset, is associated with a sevenfold decrease in patient mortality; therefore, it is essential for patients to recognize their symptoms as cardiac related as well as to seek treatment immediately.
Transportation time, whether it is by private vehicle or it is by emergency medical services, is usually relatively short (Riegal et al., 2007). Further delay in treatment time is due to in-hospital delays. Research suggests that clinical presentation is important because it affects diagnostic testing and treatment decisions (Brieger et al., 2004). Emergency department staff must first suspect cardiac involvement before appropriate testing and treatment can begin. Of particular importance is the assessment of the triage nurse and the emergency department physician or APN. Staff should keep in mind that myocardial infarctions do not always present in the classic, or typical, fashion as previously described, especially in women. In the study conducted by Thuresson et al. (2005), only 20% of patients presenting with an ST elevation reported the typical symptoms associated with a severe myocardial infarction. It is suggested that an acute cardiac event be considered in any patient who presents with any sort of pain between the naval and the jaw (Anonymous, 2007). If there is any doubt, obtain an ECG, which is regarded as the single most diagnostic test in AMI (Peterson & Alexander, 1998). Patients with ST elevation or depression should be regarded as having myocardial ischemia, and these patients should be admitted and treated with no further delay. Biochemical markers also aid in the diagnosis of AMI. A diagnosis of AMI can be ruled out with 99.7% accuracy through the use of serial troponin I measurements, at least two performed at least 4 hr apart (Peterson & Alexander, 1998). Finally, risk factors should be considered when presented with a patient who may have AMI in progress.
Cardiovascular disease is the primary cause of death among women in the United States. APNs have increasingly become a critical resource to women with CV disease. APNs must use every opportunity to educate these women in all aspects of CV disease prevention, recognition, and treatment. Whereas prevention of heart disease is ideal, recognizing and appropriately treating heart disease is imperative. In order for this to be accomplished, women and healthcare workers alike need to have a greater understanding of how women may differ from men when it comes to “heart health.” Programs such as the AHA's “Go Red for Women” campaign were launched in recent years in an effort to bring more attention to this healthcare burden (Grant et al., 2004). This article was written with the intention of bringing a new piece of knowledge to the reader that may positively affect clinical practice but more importantly, work for more positive patient outcomes.
American Diabetes Association. (2008). Position statement. Standards of Medical Care in Diabetes—2008. Diabetes Care, 31, S12–S54. [Context Link]
American Heart Association. (2008). Statements and practice guidelines. Retrieved August 11, 2008, from http://www.americanheart.org [Context Link]
Anderson, G. (2005). Sex and racial differences in pharmacological response: Where is the evidence? Pharmacogenetics, pharmacokinetics, and pharmacodynamics. Journal of Women's Health, 14, 19–29. [Context Link]
Arnett, D., Baird, A., Barkley, R., Basson, C., Boerwinkle, E., Ganesh, S., et al. (2007). Relevance of genetics and genomic for prevention and treatment of cardiovascular disease: A scientific statement from the American Heart Association Council on Epidemiology and Prevention, the Stroke Council, and the Functional Genomic and Translational Biology Interdisciplinary Working Group. Circulation, 115, 2878–2901. [Context Link]
Anonymous. (2007). 10% of heart attacks go untreated: Don't let this happen in your ED. ED Nursing, 11, 1–3. [Context Link]
Blaha, M., Bansal, S., Rouf, R., Golden, S., Blumenthal, R., & Defilippis, A. (2008). A practical “ABCDE” approach to the metabolic syndrome. Mayo Clinic Proceedings, 83(8), 932–943. [Context Link]
Brieger, D., Eagle, K., Goodman, S., Steg, P., Budaj, A., White, K., et al. (2004). Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: Insights from the Global Registry of Acute Coronary Intervention. Chest, 126, 461–469. [Context Link]
Canto, J., Goldberg, R., Hand, M., Bonow, R., Sopko, G., Pepine, C., et al. (2007). Symptom presentation of women with acute coronary syndromes: Myth vs. reality. Archives of Internal Medicine, 167, 2405–2413. [Context Link]
Culic, V., Eterovic, D., Miric, D., & Silic, N. (2002). Symptom presentation of acute myocardial infarction: Influence of sex, age, and risk factors. American Heart Journal, 144, 1012–1017. [Context Link]
DeVon, H., Ryan, C., Ochs, A., & Shapiro, M. (2008). Symptoms across the continuum of acute coronary syndromes: Differences between women and men. American Journal of Critical Care, 17, 14–24. [Context Link]
Dorsch, M., Lawrance, R., Sapsford, R., Durham, N., Oldham, J., Greenwood, D., et al. (2001). Poor prognosis of patients presenting with symptomatic myocardial infarction but without chest pain. Heart, 86, 494–498. [Context Link]
Framingham Heart Study. (2008). The Framingham Heart Study: The town that changed America's heart. Retrieved February 19, 2008, from http://www.framingham.com/heart/backgrnd.htm [Context Link]
Grant, A., Jacobs, A., & Clancy, C. (2004). Cardiovascular disease in women: Are there solutions? Circulation, 109, 561. [Context Link]
Harrington, R. (2007). Women, acute ischemic heart disease, and antithrombotic therapy: challenges and opportunities. Circulation, 115, 2796–2798. [Context Link]
Higginson, R. (2008). Women's help-seeking behaviour at the onset of myocardial infarction. British Journal of Nursing, 17, 10–14. [Context Link]
Horne, R., James, D., Petrie, K., Weinman, J., & Vincent, R. (2000). Patients' interpretation of symptoms as a cause of delay in reaching hospital during acute myocardial infarction. Heart, 83, 388–393. [Context Link]
Huxley, V. (2007). Sex and the cardiovascular system: The intriguing tale of how women and men regulate cardiovascular function differently. Advances in Physiology Education, 31, 17–22. [Context Link]
Kip, K., Marroquin, O., Kelley, D., Johnson, D., Kelsey, S., Shaw, L., et al. (2004). Clinical importance of obesity versus the metabolic syndrome in cardiovascular risk in women. A report from the Women's Ischemia Syndrome Evaluation (WISE) study. Circulation, 109, 706–713. [Context Link]
Kloner, R., & Rezkalla, S. (2007). To drink or not to drink? That is the question. Circulation, 116, 1306–1317. [Context Link]
Kumar, R., & Goel, N. (2008). Current status of cardiovascular risk due to stress. Internet Journal of Health, 7. Retrieved October 10, 2008, from http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijh/vol7n1/stress.xml [Context Link]
Lefler, L., & Bondy, K. (2004). Women's delay in seeking treatment with myocardial infarction: A meta-synthesis. Journal of Cardiovascular Nursing, 19, 251–268. [Context Link]
Li, T., Rana, J., Manson, J., Willett, W., Stampfer, M., Colditz, G., et al. (2006). Obesity as compared with physical activity in predicting risk of coronary heart disease in women. Circulation, 113, 499–506. [Context Link]
McSweeney, J., Cody, M., O'Sullivan, P., Elberson, K., Moser, D., & Garvin, B. (2003). Women's early warning symptoms of acute myocardial infarction. Circulation, 108, 2619–2623. [Context Link]
Merz, C., Shaw, L., Reis, S., Bittner, V., Kelsey, S., Olson, M., et al. (2006). Insights from the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study: Part II: Gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. Journal of the American College of Cardiology, 47, 21–29. [Context Link]
Mieres, J., Shaw, L., Arai, A., Budoff, M., Flamm, S., Hundley, G., et al. (2005). Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: Consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation, 111, 682–696. [Context Link]
Mikhail, G. (2006). Coronary revascularization in women. Heart, 92, 19–23. [Context Link]
Mosca, L. (2004). Heart disease prevention in women. Circulation, 109, e158–e160. [Context Link]
Mosca, L., Appel, L., Benjamin, E., Berra, K., Chandra-Strobos, N., Fabunmi, R., et al. (2004). Evidence-based guidelines for cardiovascular disease prevention in women. Circulation, 109, 672–693. [Context Link]
Mosca, L., Linfante, A., Benjamin, E., Berra, K., Hayes, S., Walsh, B., et al. (2005). National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation, 111, 499–510. [Context Link]
Peterson, E., & Alexander, K. (1998). Learning to suspect the unexpected: Evaluating women with cardiac syndromes. American Heart Journal, 136, 186–188. [Context Link]
Pope, J., Aufderheide, T., Ruthazer, R., Woolard, R., Feldman, J., Beshansky, J., et al. (2000). Missed diagnosis of acute cardiac ischemia in the emergency department. The New England Journal of Medicine, 342, 1163–1170. [Context Link]
Rautaharju, P., Kooperberg, C., Larson, J., & Lacroix, A. (2006). Electrocardiographic abnormalities that predict coronary heart disease events and mortality in postmenopausal women: The women's health initiative. Circulation, 113, 473–480. [Context Link]
Ridker, P., Cook, N., Lee, I., Gordon, D., Gaziano, J., Manson, J., et al. (2005). A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. The New England Journal of Medicine, 352, 1293–1304. [Context Link]
Riegal, B., McKinley, S., Moser, D., Meischke, H., Doering, L., & Dracup, K. (2007). Psychometric evaluation of the acute coronary syndrome (ACS) response index. Research in Nursing & Health, 30, 584–594. [Context Link]
Rosenfeld, A. (2006). State of the heart: Building science to improve women's cardiovascular health. American Journal of Critical Care, 15, 556–565. [Context Link]
Sarwar, N., Danesh, J., Eiriksdottir, G., Sigurdsson, G., Wareham, N., Bingham, S., et al. (2007). Triglycerides and the risk of coronary heart disease; 10158 incident cases among 262525 participants in 29 western prospective studies. Circulation, 115, 450–458. [Context Link]
Shaw, L., Merz, N., Pepine, C., Reis, S., Bittner, V., Kelsey, S., et al. (2006). Insights from the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study: Part I: Gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies. Journal of American College of Cardiology, 47, 4S–20S. [Context Link]
Stramba-Badiale, M., Fox, K., Priori, S., Collins, P., Daly, C., Graham, I., et al. (2006). Cardiovascular diseases in women: A statement from the policy conference of the European Society of Cardiology. European Heart Journal, 27, 994–1005. [Context Link]
Stramba-Badiale, M., & Priori, S. (2005). Gender-specific prescription for cardiovascular disease? European Heart Journal, 26, 1571–1572. [Context Link]
Thuresson, M., Jarlov, M., Lindahl, B., Svensson, L., Zedigh, C., & Herlitz, J. (2005). Symptoms and type of symptom onset in acute coronary syndrome in relation to ST elevation, sex, age, and a history of diabetes. American Heart Journal, 150, 234–242. [Context Link]
Wenger, N., (2004). You've come a long way, baby. Cardiovascular health and disease in women: Problems and prospects. Circulation, 109, 558–560. [Context Link]
Key words: cardiovascular disease; cardiovascular health; heart disease; heart disease prevention
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| Advanced Emergency Nursing Journal January/March 2009 Volume 31 Number 1 Pages 63 - 72 |
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