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Women continue to be underrepresented in research for heart disease, and extensive changes are needed in how women's heart health is studied, taught and treated, a new report says.

The report, published Monday as a presidential advisory from the ·¬ÇÑÊÓƵ in its journal , seeks to address problems that range from the way basic science is conducted to how women receive care.

"We are losing ground on key indicators of cardiovascular health among women, including blood pressure control, weight management and diabetes," advisory co-author Dr. Véronique L. Roger said in a news release. Roger is a senior investigator at the National Heart, Lung, and Blood Institute, a division of the National Institutes of Health.

Some heart disease risk factors are specific to women, the advisory said. For example, risks are higher for women who start their menstrual cycle younger than 11 or enter menopause younger than age 40.

Women also face risks related to high blood pressure or diabetes during pregnancy, as well as from oral contraceptive use and hormone replacement therapy. Depression and anxiety are associated with heart disease more frequently and at younger ages in women than in men.

Women also are disproportionately affected by inflammatory and autoimmune disorders such as lupus, rheumatoid arthritis and scleroderma, which are associated with increased risk of heart inflammation, heart and valve disease and heart attacks. And women face heart risks related to treatment for breast, uterine or ovarian cancer.

Despite all that, women continue to be underrepresented in research, leading to gaps in knowledge and understanding of how heart disease affects women.

"Comparing data from women with data from men inherently positions data from men as the gold standard," said Roger. "For example, the belief that women having a heart attack will present more often with atypical symptoms carries an undertone that women present in the 'wrong way.'"

Using data specific to women could improve diagnosis and treatment for heart disease, the advisory said. But nearly 7 out of 10 post-graduate medical trainees reported little to no training regarding gender-based medical concepts. Only 22% of physicians and 42% of cardiologists said they felt prepared to adequately assess heart disease specific to women.

"We must urgently address the pervasive gaps in knowledge and health care delivery to reduce gender-based disparities and achieve equity," said report co-author Dr. Nanette K. Wenger, emeritus professor of medicine in the division of cardiology at Emory University School of Medicine in Atlanta.

The advisory said that declining heart health among U.S. women who are considering pregnancy, and less-than-optimal levels of heart health among pregnant women, was particularly worrisome. Heart problems may lead to pregnancy challenges for the mother and health risks or complications for her and her children.

Solving that will take cooperation from experts in several fields, Wenger said. "We recommend cardiologists, primary care physicians and obstetricians and gynecologists work together to quantify and reduce the risks of cardiovascular disease throughout a woman's life."

According to , heart disease is the leading cause of death for U.S. men and women, and 44% of women age 20 years and older between 2015 and 2018 had some form of cardiovascular disease, including high blood pressure.

But awareness among women, which rose before 2009, is slipping. In 2019, understood that heart disease was women's leading cause of death.

The advisory recommended several actions, such as:

‒ launching new, culturally sensitive heart health awareness campaigns that emphasize the benefits of prevention and education.

‒ conducting more research studies focused on women, especially women from diverse racial and ethnic backgrounds, and at younger ages.

‒ collecting and analyzing data to help deliver more effective health care.

Affordable health insurance coverage and out-of-pocket costs are the two most important factors affecting whether people get health care, the advisory said, noting that under the Patient Protection and Affordable Care Act, signed into law in 2010, women between the ages of 19 and 64 saw the largest coverage gain of any demographic group.

In recent years, Medicaid coverage expansion through the ACA has been shown to increase coverage and health care among low-income women of reproductive age.

"We need to help women develop a 'lifetime approach' to their health, where they are empowered to proactively manage their heart disease risk in every life stage," said Wenger.

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