Four Major Medical Groups Release First Unified Women’s Heart Health Framework

DALLAS — Four leading U.S. medical organizations have joined together for the first time to reshape how heart health is defined for girls and women. The American Heart Association, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine have issued a three-part publication that organizes cardiovascular care around distinct female life stages, from the first menstrual period through menopause and beyond. Published in the American Heart Association’s journal Circulation, the guidance is the first multi-society framework aimed at preventing, finding and treating cardiovascular disease in girls and women by linking care across the specialties that see them over a lifetime.

At the center of the publication is the Female Life Stage framework, which divides a woman’s life into four biologically defined phases marked by hormonal transitions unique to females. The first stage, perimenarche, covers the years around the first menstrual period, roughly ages 8 to 15. The second stage, ovarian cycling, extends from about ages 15 to 44, when regular ovulation and hormone cycles are established and pregnancy commonly occurs. The third stage, perimenopause, spans approximately ages 45 to 51 and involves changing cycle length, skipped cycles and shifting hormones. The fourth stage, postmenopause, begins after menopause, defined as 12 months after the final menstrual period, and generally starts around age 51 and older. Pregnancy, which can occur at any stage or more than once across stages, is identified as a biological stress test that may reveal hidden cardiovascular risk.

The need for this effort is urgent. The American Heart Association says cardiovascular disease, including heart disease and stroke, remains the leading cause of death among women, taking more than 400,000 lives in the United States each year — more than breast cancer, lung cancer and chronic lung disease combined. Even so, only about 41 percent of women recognize it as their greatest health threat. Progress in reducing cardiovascular deaths among women has stalled over the past two decades, while maternal mortality has risen. Cardiovascular conditions are now the leading cause of medical-related death during pregnancy and account for more than one-third of maternal deaths in the country.

A scientific statement from the American Heart Association that projected women’s health risks also offers a troubling outlook: if current trends continue through the middle of the century, the share of U.S. women ages 20 and older living with high blood pressure is expected to rise from about 49 percent to 59 percent. The writing group says these projections make clear that cardiovascular health must be addressed throughout a woman’s life, rather than waiting until disease appears later in adulthood.

“Women experience their healthcare across clinical specialties, but it often is fragmented or disconnected,” said Sadiya S. Khan, M.D., M.Sc., FAHA, chair of the collaborative writing group and Magerstadt Professor of Cardiovascular Epidemiology at Northwestern University Feinberg School of Medicine in Chicago. “Specifically, these reports connect the dots for clinicians, for patients and across health domains so that care is holistic and begins in adolescence, recognizing that women’s heart health is uniquely shaped by biological transitions not experienced by men — periods, pregnancy, perimenopause and menopause.”

The framework takes a broad view, bringing cardiovascular, hormonal and emotional health together within each stage of life. Khan said this approach shows that heart health cannot be understood by looking only at the heart. The publication also highlights several important links: menstrual cycle patterns are now viewed as a female-specific vital sign, and heavy or irregular bleeding may signal cardiovascular risk, including polyendocrine metabolic ovarian syndrome, or PMOS, formerly known as polycystic ovary syndrome, or PCOS. Perimenopause is described as a key cardiovascular turning point because changes in cholesterol and metabolic health may be early indicators of risk, and identifying those changes early may lower the chance of later cardiovascular disease.

The postmenopausal years are given special emphasis in the new guidance. This period can represent up to 40 percent of a woman’s lifetime, and most heart attacks, strokes and heart-failure events occur then. The publications note that more than 80 percent of these events could be prevented with early action. The guidance also explicitly addresses psychosocial health, noting that women are more likely to face anxiety, depression and eating disorders, all of which can undermine heart health. By combining these elements, the framework is intended to help clinicians see a more complete picture of risk rather than isolated findings from separate appointments.

Pregnancy history, the writing group says, is heart history. Changes during pregnancy can expose underlying cardiovascular risk, and complications such as high blood pressure, preeclampsia, gestational diabetes, preterm birth, small-for-gestational-age infants and stillbirth are recognized as female-specific risk enhancers. The latest American Heart Association/American College of Cardiology cholesterol guideline now includes pregnancy-related factors in cardiovascular risk assessment for women. Even so, postpartum care remains a major missed opportunity: only about 60 percent of U.S. women with high blood pressure-related pregnancy complications receive follow-up for high blood pressure within six months after delivery, a prevention gap the societies want closed quickly.

“Pregnancy and the postpartum period are important windows into cardiovascular health throughout the life course,” said William A. Grobman, M.D., MBA, vice-chair of the writing group and professor of obstetrics and gynecology at The Warren Alpert Medical School of Brown University in Providence, Rhode Island. “An adverse pregnancy outcome can unmask increased cardiovascular risk and that information should guide care well beyond pregnancy. This multi-society guidance gives clinicians who provide obstetric, gynecologic, and cardiovascular care a shared framework for recognizing and acting on that risk.” Grobman is also a former president of the Society for Maternal-Fetal Medicine. Pediatric care is also central to the initiative. “Heart health begins long before adulthood,” said Amanda Marma Perak, M.D., M.Sc., FAHA, vice-chair of the collaborative writing group and a pediatric cardiologist at Lurie Children’s Hospital in Chicago. “As pediatric clinicians, we have the opportunity to help every girl start strong and to ensure that what we learn about her health follows her as she grows.”

In addition to clinical recommendations, the societies are calling for a national network of Comprehensive Centers of Excellence for Women’s Cardiovascular Care built on four pillars: interdisciplinary clinical care, professional education and training, research and community engagement. The accompanying science advisory outlines the current landscape of women’s cardiovascular centers and presents this network as a way to deliver more coordinated care. The publications also stress that existing tools and treatments can already improve women’s cardiovascular health, while further research is needed to close evidence gaps by including more women in studies, expanding funding for women’s health and turning evidence into practice. “Over the last several decades, research has led to substantive advances in the understanding of female-specific risk of cardiovascular disease,” Khan said. “Today, cardiovascular risk can be identified earlier in women with 10- and 30-year sex-specific risk estimation using the American Heart Association PREVENT equations. The goal is to assess health comprehensively and longitudinally across life stages, identify earlier opportunities for prevention, and close implementation gaps for women.”

The joint guidance includes three papers in Circulation: a Presidential Advisory establishing the female life stage construct and life course framework, a Scientific Statement offering consensus clinical guidance along with a multi-society guideline crosswalk, and a Science Advisory mapping women’s cardiovascular centers and proposing the national infrastructure. The papers were produced by a volunteer writing group on behalf of the four societies. “Women make up more than half the population, and their heart health must be a part of everyday care across medicine,” said Mariell Jessup, M.D., FAHA, chief science and medical officer of the American Heart Association. “These publications give clinicians and health systems a shared foundation for recognizing risk throughout a woman’s life.” Khan added, “All girls and women deserve more healthy years to live their fullest lives. Advancing women’s health is a responsibility we all share. This investment improves not only women’s health, but also the health of their families and their communities.”