Cardiovascular disease (CVD) is the leading cause of death among women and has claimed the lives of more women than men annually since 1984. A woman’s risk of dying from CVD is one in 2.4; her risk of death from breast cancer is around one in 29.¹ Despite the seeming ubiquity of the National Heart, Lung, and Blood Institute’s red dress symbol, surveys continue to demonstrate a low awareness—particularly among minority groups—that CVD is the leading health risk for women.²

One cited barrier to initiating CVD risk-lowering behaviors is confusion in the media. Although media attention to heart disease in women raises awareness, the messaging can be overwhelming. There is clearly an opportunity in the clinical setting to educate women about CVD risk; however, the reason most often given by women for not speaking to their health care professionals about heart health is that the health care professional did not bring it up.² In this issue of American Family Physician, Dr. Hayes discusses the American Heart Association’s (AHA’s) guidelines for assessment and treatment of CVD risk in women, including counseling on lifestyle interventions and management of risk factors.³ We propose that physicians speak to their female patients about the risks of CVD, focusing on two themes: (1) the need for emergency evaluation of any symptoms that suggest acute coronary syndrome (ACS); and (2) the concept of lifetime CVD risk reduction.

Key to the survival of patients with ACS is prompt recognition of symptoms and activation of the emergency response system. The difficulty is that many patients with ACS—men and women alike—do not experience “Hollywood” heart attack symptoms but something far less dramatic. Whereas chest discomfort is the most common symptom of ACS in both sexes, women are more likely than men to report atypical accompanying symptoms, such as dyspnea, nausea, and vomiting,^4–6 that can blur the picture for the patient and possibly the physician. In addition to maintaining clinical vigilance, physicians need to be attentive to the instruction of staff (including receptionists with whom the patient is likely to have initial contact) in the emergent telephone and waiting-room triage of patients with symptoms—variable as they may be—that suggest ACS.

Physicians are ideally positioned to screen and educate female patients of all ages. The annual well-woman visit can serve as a venue to stress the importance of “knowing your numbers.”⁷ Women are unlikely to focus on preventive strategies without being aware of their personal risk status, and surveys indicate that most women fail to personalize the risk of heart disease.² Physicians should encourage every woman to know:

• (1) Her lipid profile—not just low-density lipoprotein (LDL) cholesterol level, but also high-density lipoprotein (HDL) cholesterol and triglyceride levels. Low HDL cholesterol and high triglyceride levels are more potent risk factors for women than for men.

• (2) Her blood pressure. At age 55, a normotensive adult has a 90 percent lifetime risk of developing hypertension⁸—a point worth stressing to middle-age or older women.

In addition, women who are at risk for diabetes should be encouraged to know their fasting glucose level. Diabetes confers a greater CVD risk for women than for men.

Although the Framingham 10-year coronary heart disease (CHD) risk score⁹ is central to evidence-based treatment decisions, it provides weak ammunition for impressing on a patient the importance of making lifestyle changes to improve her heart health. Age is the most powerful risk factor in the Framingham equation, and a woman younger than 55 years with a significant lifetime risk typically has a low risk in the short term. Consider the example of a 40-year-old nonsmoking woman with a total cholesterol level of 240 mg per dL (6.20 mmol per L), an LDL cholesterol level of 180 mg per dL (4.65 mmol per L), an HDL cholesterol of 32 mg per dL (0.85 mmol per L), and a blood pressure of 158/100 mm Hg. Most physicians would view her as a candidate for therapeutic lifestyle change and consider pharmacologic therapies to optimize her lipid profile and blood pressure. Yet, as calculated using the Framingham score, her 10-year risk of myocardial infarction or coronary death is only 1 percent.

Physicians need to impart a message to female patients that will help them view active optimization of their heart health as investing in long-term quality of life, in line with the AHA’s “Go Red for Women” mission to help women live “stronger, longer” lives.¹⁰ There is emerging evidence that midlife CVD risk factors, particularly in combination, not only increase CVD risk but also may predict risk of overall unsuccessful aging (i.e., disease-related disability or poor mental and physical functioning), including dementia.¹¹

We who are entrusted with women’s primary care have the relationships, trust, and knowledge to make an impact on their lifelong health and wellness. Thoughtful, comprehensive guidance on their number one health risk should be the heart of what we do.