The Canadian Women’s Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women—Chapter 2: Scope of the Problem

Open AccessPublished:October 15, 2020DOI:https://doi.org/10.1016/j.cjco.2020.10.009

      Abstract

      Background

      This Atlas chapter summarizes the epidemiology of cardiovascular disease (CVD) in women in Canada, discusses sex and gender disparities, and examines the intersectionality between sex and other factors that play a prominent role in CVD outcomes in women, including gender, indigenous identity, ethnic variation, disability, and socioeconomic status.

      Methods

      CVD is the leading cause of premature death in Canadian women. Coronary artery disease, including myocardial infarction, and followed by stroke, accounts for the majority of CVD-related deaths in Canadian women. The majority of emergency department visits and hospitalizations by women are due to coronary artery disease, heart failure, and stroke. The effect of traditional cardiovascular risk factors and their association with increasing cardiovascular morbidity is unique in this group.

      Results

      Indigenous women in Canada experience increased CVD, linked to colonization and subsequent social, economic, and political challenges. Women from particular racial and ethnic backgrounds (ie, South Asian, Afro-Caribbean, Hispanic, and Chinese North American women) have greater CVD risk factors, and CVD risk in East Asian women increases with duration of stay in Canada.

      Conclusions

      Canadians living in northern, rural, remote, and on-reserve residences experience greater CVD morbidity, mortality, and risk factors. An increase in CVD risk among Canadian women has been linked with a background of lower socioeconomic status, and women with disabilities have an increased risk of adverse cardiac events.

      Résumé

      Contexte

      Ce chapitre de l'Atlas condense l'épidémiologie des maladies cardiovasculaires (MCV) chez les femmes au Canada, aborde les disparités entre les sexes et les genres, et examine l'interrelation entre le sexe et d'autres facteurs qui jouent un rôle important dans l'émergence des MCV chez les femmes, notamment le genre, l'identité autochtone, les variations ethniques, le handicap et le statut socio-économique.

      Méthodes

      Les MCV sont la principale cause de décès prématuré chez les femmes canadiennes. Les maladies coronariennes, y compris l'infarctus du myocarde, suivies des accidents vasculaires cérébraux, sont à l'origine de la majorité des décès liés aux MCV chez les femmes canadiennes. La majorité des visites aux urgences et des hospitalisations des femmes sont dues à des maladies coronariennes, des insuffisances cardiaques et des accidents vasculaires cérébraux. L'effet des facteurs de risque cardiovasculaire traditionnels et leur association avec l'augmentation de la morbidité cardiovasculaire est unique dans ce groupe.

      Résultats

      Les femmes autochtones du Canada connaissent un accroissement des maladies cardiovasculaires, liée à la colonisation et aux défis sociaux, économiques et politiques qui en découlent. Les femmes d'origines raciales et ethniques spécifiques (par exemple les femmes sud-asiatiques, afro-caribéennes, hispaniques et chinoises d'Amérique du Nord) présentent des facteurs de risque de MCV plus importants, et le risque de MCV chez les femmes d'Asie de l'Est augmente avec la durée de leur séjour au Canada.

      Conclusions

      Les canadiens qui vivent dans les régions nordiques, rurales, éloignées et dans les réserves présentent une morbidité, une mortalité et des facteurs de risque de MCV plus élevés. L'augmentation du risque de MCV chez les femmes canadiennes a été associée à un statut socio-économique plus bas, et les femmes handicapées ont un risque accru de survenue d'événements cardiaques indésirables.
      Cardiovascular disease (CVD) is the leading cause of premature death in women in Canada.
      Heart and Stroke Foundation. Ms.Understood. 2018 Heart Report.
      Beyond sex-unique CVD risk factors in women, several traditional risk factors have a greater morbidity and mortality impact in women compared to men. Rates of CVD vary substantially among provinces and within regions of Canada. This Atlas chapter aims to do the following: summarize the epidemiology of cardiovascular disease in women in Canada; discuss sex and gender disparities; and examine the intersectionality between sex and other disparities that play a prominent role in CVD outcomes in women, including indigenous identity, ethnic variation, disability, and socioeconomic status (SES). Figure 1 summarizes the key concepts presented in this chapter.
      Figure thumbnail gr1
      Figure 1Summary of current state of cardiovascular disease mortality, healthcare utilization, risk factors, and other important health determinants for women in Canada.

      Demographics

       Cardiovascular wellness indicators/traditional risk factors

      Most Canadian women have at least one risk factor for CVD.
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      Although the burden of CVD has been improving over time, outcomes for women, particularly those aged < 55 years, have stagnated.
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      Recent trends in hospitalizations for cardiovascular disease, stroke, and vascular cognitive impairment in Canada.
      Women are more likely than men to die in the year following an acute myocardial infarction (MI) and to experience death, heart failure, or stroke within 5 years after acute MI.
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      Acute myocardial infarction in women: a scientific statement from the American Heart Association.
      Women who experience a stroke are at higher risk of mortality, have poorer outcomes, and are less likely to return home, while also being less likely to participate in rehabilitation than men.
      Heart and Stroke Foundation
      Lives disrupted: The impact of stroke on women. 2018 Stroke Report.
      Women who do complete rehabilitation, however, experience greater reduction in mortality and greater relative benefit compared to men.
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      Factors describing community ambulation after stroke: a mixed-methods study.
      A recent publication from the Prospective Urban Rural Epidemiological (PURE) study examining differences in risk factors, treatments, CVD incidence, and mortality between women and men from 27 high-, middle-, and low-income countries, found that the CVD risk factor burden was lower in women, compared to men, across all economic levels and geographic regions.
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      Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.
      However, several previous studies have found that traditional CVD risk factors, including type 2 diabetes mellitus, hypertension, smoking, and dyslipidemia, pose a greater risk for complications in women.
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      Sex differences in cardiovascular disease—impact on care and outcomes.
      We are also beginning to understand that each of the CVD risk factors may be further exacerbated by gender factors. Diabetes in women is associated with significantly increased cardiovascular risk, MI, and stroke mortality, with a loss of the protective effect of sex hormones in younger premenopausal women lose the protective effect of sex hormone.
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      Risk factors for myocardial infarction in women and men: insights from the INTERHEART study.
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      Impact of sex on cardiovascular outcome in patients at high cardiovascular risk: analysis of the Telmisartan Randomized Assessment Study in ACE-Intolerant Subjects with Cardiovascular Disease (TRANSCEND) and the ongoing Telmisartan Alone and in Combination with Ramipril Global End Point Trial (ONTARGET).
      • Kautzky-Willer A.
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      • Pacini G.
      Sex and gender differences in risk, pathophysiology and complications of type 2 diabetes mellitus.
      Obesity and psychosocial stress appear to have greater effect in the development of diabetes in women compared to men,
      • Kautzky-Willer A.
      • Harreiter J.
      • Pacini G.
      Sex and gender differences in risk, pathophysiology and complications of type 2 diabetes mellitus.
      and women diagnosed with metabolic syndrome are at an intermediate risk of CVD mortality.
      • Garcia M.
      • Mulvagh S.L.
      • Merz C.N.B.
      • Buring J.E.
      • Manson J.E.
      Cardiovascular disease in women: clinical perspectives.
      ,
      • Shaw L.J.
      • Bairey Merz C.N.
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      • et al.
      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.
      The prevalence of obesity continues to rise in women in Canada and worldwide. The metabolic effects of obesity and physical inactivity are associated with increased CVD risk, with the latter being particularly prevalent in women aged > 70 years.
      • Garcia M.
      • Mulvagh S.L.
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      • Buring J.E.
      • Manson J.E.
      Cardiovascular disease in women: clinical perspectives.
      ,
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      • Wall R.W.
      • et al.
      Evidence brief—trends and projections of obesity among Canadians.
      ,
      • Bryan S.
      • Walsh P.
      Physical activity and obesity in Canadian women.
      The prevalence and incidence of hypertension in Canada is higher in women over the age of 60 years, compared to men.
      • Robitaille C.
      • Dai S.
      • Waters C.
      • et al.
      Diagnosed hypertension in Canada: incidence, prevalence and associated mortality.
      Hypertension in older Canadian women and those with diabetes is not well controlled, and women treated with antihypertensive medications report higher systolic blood pressures than do men.
      • Wenger N.K.
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      • Bairey Merz C.N.
      • et al.
      Women, Hypertension, and the Systolic Blood Pressure Intervention Trial.
      Smoking is less prevalent in women than in men; however, the progressive decline of tobacco use over time has occurred less markedly in women.
      • Reid J.L.
      • Hammond D.
      • Tariq U.
      • et al.
      Tobacco use, the single most important modifiable risk factor for developing MI, has a 7-fold increased risk for CVD in women aged < 55 years.
      • Mehta L.S.
      • Beckie T.M.
      • DeVon H.A.
      • et al.
      Acute myocardial infarction in women: a scientific statement from the American Heart Association.
      Current smoking and diabetes mellitus, in particular, increase the risk of obstructive coronary artery disease (CAD) in women to a greater extent than they do in men; obstructive CAD, specifically, yields a higher 30-day mortality risk for women.
      • Manfrini O.
      • Yoon J.
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      • et al.
      Sex differences in modifiable risk factors and severity of coronary artery disease.
      Elevated levels of triglycerides and low levels of high-density lipoprotein (HDL) cholesterol are strong predictors of CVD death in women, with HDL level being a greater predictor of CVD mortality in women, compared to men, particularly in those aged > 65 years.
      • Phan B.A.P.
      • Toth P.P.
      Dyslipidemia in women: etiology and management.
      Elevated low-density lipoprotein (LDL) cholesterol is a strong predictor of CVD risk in women aged < 65 years, but less predictive in women aged > 65 years.
      • Welty F.K.
      Cardiovascular disease and dyslipidemia in women.
      LDL particle size is important; young women with high levels of small atherogenic LDL particles appear to have a significantly greater risk for early MI.
      • Phan B.A.P.
      • Toth P.P.
      Dyslipidemia in women: etiology and management.
      The incidence of depression is twice as high in women as it is in men.
      • Albert P.R.
      Why is depression more prevalent in women?.
      ,

      Finks SW. Cardiovascular disease in women. Cardiovasc Dis Women 21.

      Depression increases a woman's risk for a cardiac event by between 50% and 70%,
      • Hare D.L.
      • Toukhsati S.R.
      • Johansson P.
      • Jaarsma T.
      Depression and cardiovascular disease: a clinical review.
      ,
      • Vaccarino V.
      • Badimon L.
      • Corti R.
      • et al.
      Ischaemic heart disease in women: Are there sex differences in pathophysiology and risk factors?.
      and it is directly associated with fatal cardiac events in postmenopausal women.
      • Whang W.
      • Kubzansky L.D.
      • Kawachi I.
      • et al.
      Depression and risk of sudden cardiac death and coronary heart disease in women: results from the Nurses' Health Study.
      Women are almost twice as likely as men to experience depression after a cardiac diagnosis, and the risk of cardiac morbidity and both cardiac and all-cause mortality are increased by 2-3–fold for those with post-MI depression.
      • Meijer A.
      • Conradi H.J.
      • Bos E.H.
      • et al.
      Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis of 25 years of research.
      • Möller-Leimkühler A.M.
      Higher comorbidity of depression and cardiovascular disease in women: a biopsychosocial perspective.
      • Shanmugasegaram S.
      • Russell K.L.
      • Kovacs A.H.
      • Stewart D.E.
      • Grace S.L.
      Gender and sex differences in prevalence of major depression in coronary artery disease patients: a meta-analysis.
      Women are also twice as likely as men to be diagnosed with an anxiety-related psychiatric disorder, and the prevalence of anxiety is higher among women with congenital heart disease, compared to men.
      • Kessler R.C.
      • Berglund P.
      • Demler O.
      • et al.
      Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication.
      ,
      • Olsen S.J.
      • Schirmer H.
      • Wilsgaard T.
      • Bønaa K.H.
      • Hanssen T.A.
      Cardiac rehabilitation and symptoms of anxiety and depression after percutaneous coronary intervention.
      Anxiety increases the risk of congenital heart disease by > 25% and of cardiac death by nearly 50%.
      • Cohen B.E.
      • Edmondson D.
      • Kronish I.M.
      State of the art review: depression, stress, anxiety, and cardiovascular disease.
      In summary, most Canadian women have at least one risk factor for CVD. Women experience poorer outcomes compared to men following a cardiovascular event. Traditional CVD risk factors, including smoking, hypertension, diabetes, obesity, physical inactivity, depression, and anxiety, have a greater impact on women as compared to men.

      CVD Mortality, Emergency Department (ED) Visits, and Hospitalizations for Women

       Mortality

      The most recent (2018) absolute and age-standardized mortality rates for heart diseases and stroke in Canada for females and the total population are presented in Table 1. Mortality rates vary considerably among provinces and within regions of Canada. Similar to the total population, the absolute mortality rate due to heart disease among females was highest in Prince Edward Island, followed by Alberta, Saskatchewan, and Newfoundland and Labrador. The northern territories of Nunavut and the Northwest Territories reported the lowest absolute mortality rates.
      Statistics Canada
      Deaths and mortality rate (age standardization using 2011 population), by selected grouped causes.
      Age-standardized mortality rates for heart diseases among females in 2018 were highest in the least-populated provinces and territories of Nunavut, Northwest Territories, Newfoundland, and Prince Edward Island, and they were lowest in the larger provinces of British Columbia, Ontario, and Quebec. Similar trends for mortality due to stroke were observed, with lowest absolute and highest age-standardized mortality rates among smaller territories and provinces.
      Table 12018 absolute and age-standardized mortality rates for heart disease and stroke for females, and total population, by province/territory
      Province/territoryHeart diseaseStroke
      Women/girlsTotal populationfemalesTotal population
      Mortality (%)Age-standardized mortality rate (per 100,000)Mortality (%)Age-standardized mortality rate (per 100,000)Mortality (%)Age-standardized mortality rate (per 100,000)Mortality (%)Age-standardized mortality rate (per 100,000)
      Prince Edward Island20.6114.821.5153.37.039.55.339.5
      Alberta19.8108.420.8145.05.228.04.329.8
      Saskatchewan19.1109.221.0153.94.727.24.130.0
      Newfoundland/ Labrador18.9135.020.3167.85.942.75.144.2
      New Brunswick17.8108.818.6140.65.433.84.634.8
      British Columbia17.686.218.3114.67.035.25.937.2
      Ontario17.489.418.5118.35.428.24.629.7
      Quebec17.291.218.4117.45.127.24.428.1
      Manitoba16.7100.617.6132.75.633.64.835.5
      Nova Scotia15.699.118.3142.76.742.45.543.5
      Northwest Territories11.2121.316.3171.03.742.62.934.6
      Nunavut9.9214.79.7216.13.750.43.146.5
      Yukon
      Canada17.693.418.7123.65.629.84.831.4
      Data from Statistics Canada.
      Table 2 summarizes cardiovascular-related deaths by cause for women in Canada in 2016-2017. Across the various CVD mortalities examined, the majority of diagnosed individuals resided in Ontario, followed by Quebec and British Columbia. CAD was the most common cause of CVD mortality in all provinces and territories, followed by stroke.
      Table 2Total CVD-related mortality in Canadian women, by province/territory and CVD condition, 2016-2017
      CAD (incl. MI)StrokeHeart failureVascular disease (incl. PAD)Atrial fibrillationValvular heart diseaseArrhythmiaCongenital heart diseaseTotal
      Province/territory
      Ontario13,205 (40)3955 (36)1475 (29)1230 (40)1070 (37)985 (35)260 (20)130 (42)22,310 (38)
      Quebec6660 (20)2515 (23)1665 (32)590 (19)490 (17)765 (27)740 (56)45 (15)13,470 (23)
      British Columbia4245 (13)1805 (16)670 (13)455 (15)580 (20)485 (17)135 (10)45 (15)8420 (14)
      Alberta3,590 (11)935 (8)425 (8)325 (10)260 (9)190 (7)50 (4)40 (13)5815 (10)
      Manitoba1245 (4)500 (5)200 (4)115 (4)130 (4)95 (3)30 (2)35 (11)2350 (4)
      Saskatchewan1120 (3)380 (3)265 (5)110 (4)120 (4)65 (2)35 (3)5 (2)2100 (4)
      Nova Scotia1105 (3)430 (4)130 (3)105 (3)115 (4)80 (3)20 (2)1985 (3)
      Newfoundland/Labrador675 (2)220 (2)90 (2)60 (2)55 (2)50 (2)10 (1)10 (3)1480 (2)
      New Brunswick790 (2)280 (3)180 (4)80 (3)70 (2)50 (2)30 (2)1170 (2)
      Prince Edward Island175 (1)50 (0.5)20 (0.4)30 (1)10 (0.3)15 (1)300 (1)
      Northwest Territories30 (0.1)10 (0.1)5 (0.2)45 (0.1)
      Yukon Territory10 (0.1)5 (0.1)5 (0.2)20 (0.03)
      Nunavut10 (0.03)10 (0.02)
      Canada32,85011,0905125310529002785131031059,475
      Values are n (%). A value < 5 is indicated by a — and does not necessarily mean that there were zero deaths. Data from Statistics Canada, Canadian Vital Statistics Deaths Database.
      CAD, coronary artery disease; CVD, cardiovascular disease; incl, include; MI, myocardial infarction; PAD, peripheral artery disease.
      In summary, CAD, including MI, is accountable for the majority of CVD-related deaths among Canadian women. Age-standardized mortality among women is highest in Canada’s less-populous territories and provinces.

       ED visits

      Data were analyzed from the Canadian Institute for Health Information National Ambulatory Care Reporting System, which included 8 provinces and territories and represented 64% of Canadian ED visits. Overall, an estimated 175,000 cardiovascular disease–related ED visits by women took place in 2016-2017. Table 3 summarizes the causes for CVD-related ED visits; the majority were for CAD, stroke, and heart failure, followed closely by atrial fibrillation. The majority of women with heart failure, CAD, and stroke were admitted to inpatient care, while women with atrial fibrillation, arrhythmia, vascular disease, heart valve disease, and congenital heart disease were more likely to be discharged without hospital admission. For most CVD-related ED visits, the majority of women were aged ≥ 52 years, with the exception of those with congenital heart disease, with 77% aged < 52 years.
      Table 3CVD-related ED visits for Canadian women, by condition, 2016-2017
      Visit-related variablesCAD (incl. MI)StrokeHeart failureAtrial fibrillationArrhythmiaVascular disease (incl. PAD)Heart valve diseaseCongenital heart diseaseTotal
      ED visits, n31,91025,67221,96919,11011,02540581729260115,733
      Age ≥ 52 years918997956773932389
      Discharged home354234697264767249
      Admitted to inpatient care625766312734242550
      Values are %, unless otherwise indicated. Includes data from 8 provinces and territories (Yukon Territory, British Columbia, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia, and Prince Edward Island) representing 64% of Canadian ED visits. Data from Canadian Institute for Health Information, National Ambulatory Care Reporting System.
      CAD, coronary artery disease; CVD, cardiovascular disease; ED, emergency department; incl, including; MI, myocardial infarction; PAD, peripheral artery disease.
      In summary, the most common CVD-related visits to EDs by women are due to CAD (including MI), stroke, and heart failure.

       Inpatient hospitalizations

      Cardiovascular disease is the leading cause of hospitalization among Canadian women, aside from giving birth. Table 4 presents the frequency of hospitalizations for specific cardiovascular conditions for women in Canada in 2016-2017. CAD (including MI), heart failure, and stroke caused the highest number of hospitalizations. Up to 60% of those hospitalized due to stroke and CAD, and over 40% of those hospitalized due to heart failure and heart valve disease, had comorbid hypertension. Between 30% and 40% of women hospitalized for CAD or heart failure had comorbid diabetes mellitus. Over 80% of CVD-related hospitalizations were in women aged ≥ 52 years, with the exception of congenital heart disease (16%). Greater than 65% of women (except for those who suffered a stroke, 51%) returned home after their hospitalizations, whereas others were transferred to long-term care or to another care facility, including palliative care.
      Table 4CVD-related hospitalizations for Canadian women, by condition, 2016-2017
      CAD (incl. MI)Heart failureStrokeAtrial fibrillationArrhythmiaVascular disease (incl. PAD)Heart valve diseaseCongenital heart diseaseTotal
      Hospitalizations, n41,10230,71225,4769998971168076,1262363132,295
      Comorbid hypertension,58446028353746749
      Comorbid diabetes,33392720192126230
      Age ≥ 52 years,939893968292941692
      Discharged home (excl. Quebec)667351888074668568
      Values are %, unless otherwise indicated. Data from Canadian Institute for Health Information, Discharge Abstract Database; Quebec Integrated Chronic Disease Surveillance system.
      CAD, coronary artery disease; CVD, cardiovascular disease; excl, excluding; incl, including; MI, myocardial infarction; PAD, peripheral artery disease.
      A recently published Canadian age- and sex-specific analysis of hospitalizations across all provinces except Quebec demonstrated that the burden of several major cardiovascular diseases appears to be shifting to earlier in life.
      • Botly L.C.P.
      • Lindsay M.P.
      • Mulvagh S.L.
      • et al.
      Recent trends in hospitalizations for cardiovascular disease, stroke, and vascular cognitive impairment in Canada.
      Between 2007 and 2016, women aged 20-39 years were the only cohort that did not see a significant decrease in hospitalization for CAD and vascular disease. Furthermore, younger women experienced a relative increase of 25% in stroke hospitalizations, compared to a nonsignificant relative decrease in stroke hospitalizations among men of the same age group. Despite an overall age- and sex-standardized decrease of 2.4% in heart failure hospitalizations over the decade, women aged 20-39 years experienced a 25% increase in heart failure hospitalizations (of note, an even greater increase of 56% in heart failure hospitalizations was found for men in this age bracket). These findings may be due to an increase in risk-factor burdens (eg, obesity, metabolic syndrome, type 2 diabetes mellitus) in younger women, as well as increased recognition and diagnosis of different forms of CAD in younger women (eg, spontaneous coronary artery dissection).
      In summary, CVD is the leading cause of hospitalization for Canadian women. Hospitalizations for certain cardiovascular conditions are increasing among younger Canadian women (aged 20-39 years); this increase is not demonstrated in men of the same group or women in older cohorts.

       Disparities beyond sex

       Indigenous

      Indigenous peoples of Canada include First Nations, Métis and Inuit, as recognized within the Canadian Constitution Act.
      • Reading J.
      Confronting the growing crisis of cardiovascular disease and heart health among Aboriginal peoples in Canada.
      Indigenous knowledge, voice, perspectives, and worldviews, which for centuries helped indigenous peoples thrive, have been fragmented or silenced, due to colonialism and racism, leading to disproportionately negative impacts on social determinants of health, and increased rates of chronic disease, including cardiovascular and infectious diseases.
      • Barclay R.
      • Ripat J.
      • Mayo N.
      Factors describing community ambulation after stroke: a mixed-methods study.
      ,
      • Reading J.
      Confronting the growing crisis of cardiovascular disease and heart health among Aboriginal peoples in Canada.
      ,
      National Collaborating Centre for Aboriginal Health
      The state of knowledge of Aboriginal health: a review of Aboriginal public health in Canada.
      Social inequalities, resulting from socioeconomic and connectivity challenges, globalization, migration, loss of language and culture, and disconnection from the land, have greatly contributed to the health disparities experienced by indigenous adults.
      • King M.
      • Smith A.
      • Gracey M.
      Indigenous health part 2: the underlying causes of the health gap.
      From 2011 to 2014, elevated rates of CVD were reported in Canada among First Nations (16.7%), Métis (17.1%), and Inuit (17.9%) women, compared to non-indigenous women (14.4%),

      Statistics Canada. Table 13-10-0099-01. Health indicator profile, by Aboriginal identity and sex, age-standardized rate, four year estimates. Available at: https://doi.org/10.25318/1310009901-eng. Accessed July 18, 2020.

      with many studies identifying 2-3–fold greater experiences of heart disease and stroke among indigenous populations.
      • Reading J.
      Confronting the growing crisis of cardiovascular disease and heart health among Aboriginal peoples in Canada.
      ,
      • Prince S.A.
      • McDonnell L.A.
      • Turek M.A.
      • et al.
      The state of affairs for cardiovascular health research in indigenous women in Canada: a scoping review.
      Available research indicates that experiences of CVD among indigenous women are increasing, unlike the declining or plateauing experiences among non-indigenous women.
      • Reading J.
      Confronting the growing crisis of cardiovascular disease and heart health among Aboriginal peoples in Canada.
      ,
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      Ethnic differences in vascular function and factors contributing to blood pressure.
      Risk profiles for CVD are unique among indigenous peoples, with lower rates of hypertension,
      National Collaborating Centre for Aboriginal Health
      The state of knowledge of Aboriginal health: a review of Aboriginal public health in Canada.
      and identified relationships between cultural connectedness and hypertension.
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      Ethnic differences in vascular function and factors contributing to blood pressure.
      However, indigenous women experience greater rates of elevated cholesterol levels, dyslipidemia, blood glucose, diabetes mellitus, and obesity compared to non-indigenous women.
      • Prince S.A.
      • McDonnell L.A.
      • Turek M.A.
      • et al.
      The state of affairs for cardiovascular health research in indigenous women in Canada: a scoping review.
      ,
      • Foulds H.J.A.
      • Bredin S.S.D.
      • Warburton D.E.R.
      Ethnic differences in vascular function and factors contributing to blood pressure.
      Indigenous women also experience social, economic, and political inequality, which contributes to their elevated health risks.
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among indigenous women in Canada.
      Colonial impacts of residential schools, interpersonal and lateral violence, discrimination, racism, and loss of culture influence the physical health of indigenous peoples and carry across generations, contributing to intergenerational trauma.
      National Inquiry into Missing and Murdered Indigenous Women and Girls. Reclaiming power and place: the final report of the national inquiry into missing and murdered indigenous women and girls.
      Access to health care systems and structures for indigenous peoples in Canada is hampered by limited accountability, fragmented delivery and jurisdictional ambiguity, and insufficient medical coverage through the federal Non-Insured Health Benefit plan, and it is further challenged through displacement of indigenous peoples and a lack of access to medical professionals, particularly physicians and specialists.
      • Reading J.
      Confronting the growing crisis of cardiovascular disease and heart health among Aboriginal peoples in Canada.
      ,
      National Inquiry into Missing and Murdered Indigenous Women and Girls. Reclaiming power and place: the final report of the national inquiry into missing and murdered indigenous women and girls.
      Residence location, including large proportions living in rural, remote, and northern communities (48.2%), combined with lower income levels, create economic barriers to accessing health care for many indigenous peoples, and women in particular.
      • Reading J.
      Confronting the growing crisis of cardiovascular disease and heart health among Aboriginal peoples in Canada.
      ,
      Statistics Canada
      Aboriginal peoples in Canada: key results from the 2016 Census.
      ,
      Statistics Canada
      Aboriginal statistics at a glance: 2nd Ed.
      In summary, indigenous women in Canada experience elevated rates of CVD and CVD risk factors. Social, economic, colonial, and political challenges contribute to this elevated experience of CVD for indigenous women.

       Ethnic variations

      Canada is a highly ethnically diverse country. The rates of CVD and CVD risk factors among ethnic minority groups, including South Asian, Afro-Caribbean, Hispanic, and Chinese North Americans, are higher when compared to their Caucasian counterparts.
      • Gasevic D.
      • Ross E.S.
      • Lear S.A.
      Ethnic differences in cardiovascular disease risk factors: a systematic review of North American evidence.
      ,
      • Rana A.
      • de Souza R.J.
      • Kandasamy S.
      • Lear S.A.
      • Anand S.S.
      Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis.
      Moreover, poorer outcomes have been reported for women in these ethnic groups.
      • Gasevic D.
      • Ross E.S.
      • Lear S.A.
      Ethnic differences in cardiovascular disease risk factors: a systematic review of North American evidence.
      Although these ethnic groups share similar CVD risk factors, there is marked variability in the prevalence of risk factors related to ethnicity.
      Heart and Stroke Foundation. Ms.Understood. 2018 Heart Report.
      ,
      • Chiu M.
      • Austin P.C.
      • Manuel D.G.
      • Tu J.V.
      Comparison of cardiovascular risk profiles among ethnic groups using population health surveys between 1996 and 2007.
      SES has been reported to contribute to the disparities of CVD burden that ethnic women face.
      Heart and Stroke Foundation. Ms.Understood. 2018 Heart Report.
      ,
      • Anand S.S.
      • Razak F.
      • Davis A.D.
      • et al.
      Social disadvantage and cardiovascular disease: development of an index and analysis of age, sex, and ethnicity effects.
      South Asians are the largest visible minority in Canada and have the highest rates of atherosclerotic CVD, hypertension, and stroke compared to other non-indigenous ethnic groups, for both men and women.
      Heart and Stroke Foundation. Ms.Understood. 2018 Heart Report.
      ,
      • Rana A.
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      • Kandasamy S.
      • Lear S.A.
      • Anand S.S.
      Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis.
      ,
      • Chiu M.
      • Austin P.C.
      • Manuel D.G.
      • Tu J.V.
      Comparison of cardiovascular risk profiles among ethnic groups using population health surveys between 1996 and 2007.
      ,
      • Fernando E.
      • Razak F.
      • Lear S.A.
      • Anand S.S.
      Cardiovascular disease in South Asian migrants.
      The South Asian (SA) portion of the INTERHEART Study concluded that 9 modifiable risk factors— dyslipidemia, smoking, hypertension, diabetes, abdominal obesity, psychosocial stress, reduced consumption of fruits and vegetables, moderate consumption of alcohol, and physical inactivity—accounted for 94% of the population attributable risk of MI in SA women.
      • Yusuf S.
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      • et al.
      Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
      Moreover, the risk for MI was greater at a younger age in South Asians.
      SA women demonstrate metabolic abnormalities at lower body mass index and waist circumference than other groups, and SA women have higher waist–hip ratios compared to Caucasian Canadian women. These factors may contribute to the disproportionately higher prevalence of insulin resistance, metabolic syndrome, and diabetes among the SA population compared to Caucasian and Chinese groups.
      • Rana A.
      • de Souza R.J.
      • Kandasamy S.
      • Lear S.A.
      • Anand S.S.
      Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis.
      ,
      • Fernando E.
      • Razak F.
      • Lear S.A.
      • Anand S.S.
      Cardiovascular disease in South Asian migrants.
      ,
      • Enas E.A.
      • Mohan V.
      • Deepa M.
      • et al.
      The metabolic syndrome and dyslipidemia among Asian Indians: a population with high rates of diabetes and premature coronary artery disease.
      • Flowers E.
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      • Mathur A.
      • et al.
      Prevalence of metabolic syndrome in South Asians residing in the United States.
      • Flowers E.
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      • Mathur A.
      • Reaven G.M.
      Adiposity and cardiovascular risk clustering in South Asians.
      • Kanaya A.M.
      • Kandula N.
      • Herrington D.
      • et al.
      Mediators of atherosclerosis in South Asians living in America (MASALA) study: objectives, methods, and cohort description.
      • Leenen F.H.
      • Dumais J.
      • McInnis N.H.
      • et al.
      Results of the Ontario survey on the prevalence and control of hypertension.
      • Misra A.
      • Luthra K.
      • Vikram N.K.
      Dyslipidemia in Asian Indians: determinants and significance.
      • Misra A.
      • Vikram N.K.
      Insulin resistance syndrome (metabolic syndrome) and obesity in Asian Indians: evidence and implications.
      Given that lower body mass index and waist circumference cut-offs are better predictors of metabolic syndrome,
      • Misra A.
      • Wasir J.S.
      • Pandey R.M.
      An evaluation of candidate definitions of the metabolic syndrome in adult Asian Indians.
      ,
      • Razak F.
      • Anand S.S.
      • Shannon H.
      • et al.
      Defining obesity cut points in a multiethnic population.
      sex- and ethnic group–specific cut-offs have been recommended in cardiovascular risk assessment.
      • Zimmet P.
      • Alberti K.G.M.M.
      • Serrano Ríos M.
      A new International Diabetes Federation worldwide definition of the metabolic syndrome: the rationale and the results.
      Evidence indicates that SA Canadian women have lower HDL and adiponectin levels and elevated ApoB/ApoA1 ratios and lipoprotein(a) levels compared to their Caucasian counterparts.
      • Rana A.
      • de Souza R.J.
      • Kandasamy S.
      • Lear S.A.
      • Anand S.S.
      Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis.
      ,
      • Bilen O.
      • Kamal A.
      • Virani S.S.
      Lipoprotein abnormalities in South Asians and its association with cardiovascular disease: current state and future directions.
      • Frank A.T.
      • Zhao B.
      • Jose P.O.
      • et al.
      Racial/ethnic differences in dyslipidemia patterns.
      • Martin M.
      • Palaniappan L.P.
      • Kwan A.C.
      • Reaven G.M.
      • Reaven P.D.
      Ethnic differences in the relationship between adiponectin and insulin sensitivity in South Asian and Caucasian women.
      Increased high-sensitivity C-reactive protein level is associated with increased cardiovascular risk; however, its utility as a biomarker is confounded by varying levels among women, depending on ethnicity.
      • Albert M.A.
      • Glynn R.J.
      • Buring J.
      • Ridker P.M.
      C-reactive protein levels among women of various ethnic groups living in the United States (from the Women's Health Study).
      ,
      • Shah T.
      • Newcombe P.
      • Smeeth L.
      • et al.
      Ancestry as a determinant of mean population C-reactive protein values: implications for cardiovascular risk prediction.
      Canadian women of Afro-Caribbean ethnicity have greater prevalence rates of stroke and hypertension among ethnic groups there and have been found to have higher rates of physical inactivity and obesity compared to the overall population
      • Fernando E.
      • Razak F.
      • Lear S.A.
      • Anand S.S.
      Cardiovascular disease in South Asian migrants.
      ,
      • Choi D.
      • Nemi E.
      • Fernando C.
      • Gupta M.
      • Moe G.W.
      Differences in the clinical characteristics of ethnic minority groups with heart failure managed in specialized heart failure clinics.
      ,
      • Tu J.V.
      • Chu A.
      • Rezai M.R.
      • et al.
      The incidence of major cardiovascular events in immigrants to Ontario, Canada: The CANHEART Immigrant Study.
      ; Chinese and SA women are also less likely to participate in daily physical activity.
      • Chiu M.
      • Austin P.C.
      • Manuel D.G.
      • Tu J.V.
      Comparison of cardiovascular risk profiles among ethnic groups using population health surveys between 1996 and 2007.
      Among all Canadian ethnic groups, East Asian Canadian women of predominantly Chinese descent have the lowest incidence of CVD. However, greater duration of stay in Canada is linked with increased CVD risk among these women.
      • Chiu M.
      • Austin P.C.
      • Manuel D.G.
      • Tu J.V.
      Comparison of cardiovascular risk profiles among ethnic groups using population health surveys between 1996 and 2007.
      ,
      • Tu J.V.
      • Chu A.
      • Rezai M.R.
      • et al.
      The incidence of major cardiovascular events in immigrants to Ontario, Canada: The CANHEART Immigrant Study.
      In specialized heart failure clinics in Ontario, more Chinese women had heart failure compared to non-Chinese and non-SA patients.
      • Choi D.
      • Nemi E.
      • Fernando C.
      • Gupta M.
      • Moe G.W.
      Differences in the clinical characteristics of ethnic minority groups with heart failure managed in specialized heart failure clinics.
      Cardiovascular risk for women can be determined using the QRISK3 algorithm, which incorporates ethnicity and improves prediction when compared to the Framingham risk engine.
      • Hippisley-Cox J.
      • Coupland C.
      • Brindle P.
      Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study.
      Presently, there are no Canadian CVD guidelines or scientific statements specific to ethnicity. The American Heart Association has published a comprehensive scientific statement, including recommendations, pertaining to atherosclerotic CVD in American South Asians, and although the contemporary American risk scoring system includes sex, it does not include ethnicity.
      • Goff D.C.
      • Lloyd-Jones D.M.
      • Bennett G.
      • et al.
      2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk.
      ,
      • Volgman A.S.
      • Palaniappan L.S.
      • Aggarwal N.T.
      • et al.
      Atherosclerotic cardiovascular disease in South Asians in the United States: epidemiology, risk factors, and treatments: a scientific statement from the American Heart Association.
      When implemented, guideline adherence has demonstrated success with specific programs directed toward recognition of ethnicity differences in the treatment of CVD.
      • Cohen M.G.
      • Fonarow G.C.
      • Peterson E.D.
      • et al.
      Racial and ethnic differences in the treatment of acute myocardial infarction: findings from the Get With the Guidelines-Coronary Artery Disease program.
      In summary, there exists an excess burden of CVD and associated risk factors, particularly diabetes, obesity, and hypertension, in the ethnically diverse Canadian population, inclusive of women. Ethnically tailored prevention strategies are required to reduce these disparities, and more robust inclusive clinical research in these groups is warranted.

       Disabilities

      The focus on disability puts emphasis on current health policy and addresses a persistent knowledge gap related to lack of inclusion of women with disabilities in clinical research.
      City for All Women Initiative. People living with disabilities: equity and inclusion lens snapshot.
      • Gulley S.P.
      • Rasch E.K.
      • Bethell C.D.
      • et al.
      At the intersection of chronic disease, disability and health services research: a scoping literature review.
      • Savage A.
      • McConnell D.
      The marital status of disabled women in Canada: a population-based analysis.
      Despite the growing health and major medical advances in Canada, a substantial number of women are living with disabilities. Disability is an umbrella term for impairments, activity limitations, and participation restrictions in both social and physical activities.

      Berghs M, Atkin K, Graham H, Hatton C, Thomas C. Implications for public health research of models and theories of disability: a scoping study and evidence synthesis. Southampton (UK): NIHR Journals Library; 2016. PMID: 27512753.

      ,
      The Lancet. World report on disability.
      Approximately 23% of Canadian women aged 18 to 59 years report activity limitations associated with a long-term condition or health problem.
      • Savage A.
      • McConnell D.
      The marital status of disabled women in Canada: a population-based analysis.
      The average age of disability onset is in the early 40s, and the prevalence of disability increases with age.
      Ontario Human Rights Commission
      Call it out: racism, racial discrimination and human rights.
      Women with disabilities report lower levels of educational attainment, workforce participation, and annual personal income. They are more likely to be single (odds ratio 1.37) or separated/divorced/widowed odds ratio 1.47) compared to the general population, with higher rates of obesity, physical inactivity, diabetes, and smoking.
      • Krahn G.L.
      • Walker D.K.
      • Correa-De-Araujo R.
      Persons with disabilities as an unrecognized health disparity population.
      Compared to women without disabilities, women with disabilities are less knowledgeable about CVD risk factors and experience significant deficiencies in CVD preventive screening (eg, family history/smoking queries).
      • Capriotti T.
      Inadequate cardiovascular disease prevention in women with physical disabilities.
      Women live longer than men and are thus at higher risk of morbidity and disability over their lifespan. For example, women have 4 times the risk of men of developing osteoporosis. Additionally, the prevalence of systemic autoimmune rheumatic diseases is greater in women aged > 45 years compared to men, with prevalence rates approaching or exceeding 1 in 100 for women with primary Sjögren syndrome.
      • Broten L.
      • Avina-Zubieta J.A.
      • Lacaille D.
      • et al.
      Systemic autoimmune rheumatic disease prevalence in Canada: updated analyses across 7 provinces.
      Women with autoimmune rheumatic diseases have greater cardiovascular morbidity and mortality, most likely related to inflammation and accelerated atherogenesis, and to the difficulty of distinguishing between cardiac and disability symptom presentations (eg, shoulder discomfort, shortness of breath). A significant factor influencing the time between symptom onset and access of medical care is recognition that symptoms are cardiac in origin. In Canada, women are 3 times more likely to be diagnosed with multiple sclerosis than men.
      • Gilmour H.
      • Ramage-Morin P.L.
      • Wong S.L.
      Multiple sclerosis: prevalence and impact.
      Multiple sclerosis increases the risk of venous thromboembolism and peripheral vascular disease for both women and men, with a 2.5 times higher risk of myocardial infarction in women only.
      • Persson R.
      • Lee S.
      • Yood M.U.
      • et al.
      Incident cardiovascular disease in patients diagnosed with multiple sclerosis: a multi-database study.
      A subgroup analysis by sex (n = 2 studies) included in a recent systematic review suggests that there is an increased risk of stroke in women who have multiple sclerosis (odds ratio 2.13; 95% confidence interval [CI], 1.84-2.46; P < 0.001).
      • Hong Y.
      • Tang H.R.
      • Ma M.
      • et al.
      Multiple sclerosis and stroke: a systematic review and meta-analysis.
      Cardiovascular morbidity results are similar to those reported in a recent Canadian population-based study, although CVD mortality was reported to be higher in men (n = 515) compared to women (n = 901) with multiple sclerosis.
      • Kingwell E.
      • Zhu F.
      • Evans C.
      • et al.
      Causes that contribute to the excess mortality risk in multiple sclerosis: a population-based study.
      Adults with disabilities are 4 times more likely to report their health to be fair or poor compared to people with no disabilities (40% vs 10%),
      • Krahn G.L.
      • Walker D.K.
      • Correa-De-Araujo R.
      Persons with disabilities as an unrecognized health disparity population.
      and women with disabilities are particularly vulnerable due to having fewer resources and protective factors.
      • Savage A.
      • McConnell D.
      The marital status of disabled women in Canada: a population-based analysis.
      Adjusted for age, women with physical disabilities have 6.6 (95% CI, 5.2-8.4) times higher odds of having CAD, 5.9 (95% CI, 4.3-8.1) times higher odds of having cardiac symptoms,
      • Iezzoni L.I.
      • Yu J.
      • Wint A.J.
      • Smeltzer S.C.
      • Ecker J.L.
      General health, health conditions, and current pregnancy among U.S. women with and without chronic physical disabilities.
      and are less likely to receive preventive or urgent care compared to women without disabilities.
      City for All Women Initiative. People living with disabilities: equity and inclusion lens snapshot.
      ,

      Berghs M, Atkin K, Graham H, Hatton C, Thomas C. Implications for public health research of models and theories of disability: a scoping study and evidence synthesis. Southampton (UK): NIHR Journals Library; 2016. PMID: 27512753.

      ,
      • Krahn G.L.
      • Walker D.K.
      • Correa-De-Araujo R.
      Persons with disabilities as an unrecognized health disparity population.
      Although annual electrocardiograms and cardiac screening for low-risk women without symptoms are not recommended by Choosing Wisely Canada, it is important to recognize that cardiovascular risk and symptoms may be different and more difficult to interpret in women who have disabilities. To reduce risk, the Canadian Society for Exercise Physiology provides recommendations for adults with disabilities (eg, spinal cord injury), including those disabilities that are more prevalent in women (eg, multiple sclerosis).
      Canadian Society for Exercise Physiology
      Canadian 24-hour movement guidelines: an integration of physical activity, sedentary behaviour, and sleep.
      Activities for women with multiple sclerosis are performed at a lower intensity and duration and include both aerobic activity and strength training at least twice weekly.
      In summary, the cumulative effects of disability contribute to an increased disease burden and even higher risk for adverse cardiac events among women with disabilities. Limited data exist about the cardiac health care experiences of women with disabilities, and these women are at risk of not receiving the same level of available evidence-based patient-centred care.

       Geographic living environment

      Experiences of CVD differ across provinces and regions, as described above, but they also vary with geographic living environment. Variations exist in Canada, including from northern to southern locations, between urban and rural residence areas, and between on- and off-reserve residences. The national average for CVD mortality (123.7 per 100,000 residents) is higher for women living in more rural or remote locations compared to women living in major urban centres.
      • Tu J.V.
      • Chu A.
      • Maclagan L.
      • et al.
      Regional variations in ambulatory care and incidence of cardiovascular events.
      The health regions with the lowest CVD mortality among women in Canada in 2013 were the largest metropolitan areas of Toronto, Vancouver, and Montreal (104.2 per 100,000 residents), followed by the suburbs of these major centres (115.2 per 100,000 residents) and other large centres in Canada (Calgary, Edmonton, Ottawa, Waterloo, Durham, Halton, Simcoe Muskoka, Wellington-Dufferin-Guelph; 122.3 per 100,000 residents). The health regions with the highest rates of CVD death among Canadian women were the northern, rural, and remote locations within each province, and Canada as a whole (138.6-147.6 per 100,000 residents). Experiences of CVD are striking when comparing on- and off-reserve locations. From 2003-2007, the age-standardized CVD mortality rates among on-reserve populations were 86.3 per 100,000 residents, compared to 62.9 per 100,000 for off-reserve residents.
      Health Canada
      A statistical profile on the health of First Nations in Canada: vital statistics for Atlantic and Western Canada, 2003-2007.
      Knowledge of CVD and CVD risk factors is greater among women living in urban centres.
      Health Canada
      A statistical profile on the health of First Nations in Canada: vital statistics for Atlantic and Western Canada, 2003-2007.
      Rates of CVD events are inversely related to availability of and visits to family physicians, and frequency of periodic health examinations, with health system factors accounting for 15.5% of regional variation in incidence of CVD events.
      • Tu J.V.
      • Chu A.
      • Maclagan L.
      • et al.
      Regional variations in ambulatory care and incidence of cardiovascular events.
      Canadian residents living in remote and sparsely populated areas experience fewer family physician visits, less lipid screening, poorer blood pressure control, and less use of statins compared to urban, metropolis residents.
      • Tu J.V.
      • Chu A.
      • Maclagan L.
      • et al.
      Regional variations in ambulatory care and incidence of cardiovascular events.
      In summary, geographic disparities in CVD mortality and CVD risk factors within Canada are considerable. Canadians living in metropolitan areas experience the lowest burden of CVD, with rural and remote, northern, and on-reserve individuals experiencing the greatest burdens.

       Income

      Across North America, women of lower-income SES are at greater risk of health-related issues compared to women of higher SES.
      • Moran B.
      • Walsh T.
      Cardiovascular disease in women: how nurses can promote awareness and prevention.
      Canadian women who are socially or economically disadvantaged experience challenges in accessing health services, resources, and treatments. Paired with the challenges of engaging in risk-reducing behaviours, women with a low SES in Canada are more susceptible to CVD than those with a high SES.
      • Kandasamy S.
      • Anand S.S.
      Cardiovascular disease among women from vulnerable populations: a review.
      Even in the context of the Canadian universal health care system, associations between SES and outcomes in acute coronary syndrome have been identified. Compared to both other income groups and men, low-income women had less access to cardiac catheterization and had higher 30-day mortality.
      • Fabreau G.E.
      • Leung A.A.
      • Southern D.A.
      • et al.
      Sex, socioeconomic status, access to cardiac catheterization, and outcomes for acute coronary syndromes in the context of universal healthcare coverage.
      Given the rapidly increasing inequality gap, and the inverse gradient for SES groups, CVD rates in the Canadian population are predicted to increase significantly in the future.
      • Kandasamy S.
      • Anand S.S.
      Cardiovascular disease among women from vulnerable populations: a review.
      Critical scholars have noted that minority women such as those from lower SES backgrounds report a general lack of awareness and misaligned beliefs/perceptions about their personalized risk for CVD.
      • Flink L.E.
      • Sciacca R.R.
      • Bier M.L.
      • Rodriguez J.
      • Giardina E.G.
      Women at risk for cardiovascular disease lack knowledge of heart attack symptoms.
      ,
      • Mosca L.
      • Hammond G.
      • Mochari-Greenberger H.
      • et al.
      Fifteen-year trends in awareness of heart disease in women: results of a 2012 American Heart Association national survey.
      Gonsalves et al. report that women of low SES were excluded from the construction of social media public health messaging on CVD risk by a national campaign on women’s heart health in Canada.
      • Gonsalves C.A.
      • McGannon K.R.
      • Pegoraro A.
      A critical discourse analysis of gendered cardiovascular disease meanings of the #MoreMoments campaign on Twitter.
      ,
      • Gonsalves C.A.
      • McGannon K.R.
      • Schinke R.J.
      Social media for health promotion: what messages are women receiving about cardiovascular disease risk by the Canadian Heart and Stroke Foundation?.

      Gender

      Gender is a complex social construct defined by 4 domains: gender identity, gender roles, gender relations, and institutionalized gender.
      Canadian Institutes of Health Research
      What is gender? What is sex?.
      Many traditional psychosocial determinants of health are gendered and may therefore impact health outcomes differently for women, men, and gender-diverse individuals through various pathways.
      Canadian Institutes of Health Research
      What is gender? What is sex?.
      The GENESIS-PRAXY (Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary Syndrome) study
      • Pelletier R.
      • Khan N.A.
      • Cox J.
      • et al.
      Sex versus gender-related characteristics:which predicts outcome after acute coronary syndrome in the young?.
      created a “gender index” to assess the role of variables that are traditionally ascribed to each sex in society. Pelletier et al.
      • Pelletier R.
      • Khan N.A.
      • Cox J.
      • et al.
      Sex versus gender-related characteristics:which predicts outcome after acute coronary syndrome in the young?.
      demonstrated that personality traits and social roles traditionally ascribed to women were associated with adverse cardiovascular outcomes in young patients with acute coronary syndromes. More importantly, regardless of biological sex, patients with high gender scores (reporting traits and roles traditionally ascribed to women) were 4 times as likely to be readmitted to the hospital within the first year post–acute myocardial infarction. Using the GENESIS-PRAXY gender index in a cohort of patients (aged 21-92 years) undergoing cardiac catheterization, results demonstrated that health status outcomes were associated with a patient's gender-related characteristics. Patients with CAD and higher gender index scores reported significantly worse health-related quality of life at 1 year (compared to those with low gender index scores) regardless of biological sex.
      • Norris C.M.
      • Johnson N.L.
      • Hardwicke-Brown E.
      • et al.
      The contribution of gender to apparent sex differences in health status among patients with coronary artery disease.
      In summary, gender intersects with race, ethnicity, indigenous status, sexuality, geography, age, disability/ability, migration status, socioeconomic status, and religion,
      • O'Neill J.
      • Tabish H.
      • Welch V.
      • et al.
      Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health.
      • Dunn J.R.
      • Walker J.D.
      • Graham J.
      • Weiss C.B.
      Gender differences in the relationship between housing, socioeconomic status, and self-reported health status.
      • Williams D.R.
      • Priest N.
      • Anderson N.B.
      Understanding associations among race, socioeconomic status, and health: patterns and prospects.
      emphasizing the importance of considering gender-related characteristics to further our understanding of CVD in women, as well as the need for an intersectional approach to future clinical research studies.

      Conclusions

      Canadian women are at risk for CVD, the leading cause of their premature mortality and their healthcare utilization. Risk factors including smoking, hypertension, diabetes, obesity, physical inactivity, depression, and anxiety are particularly more harmful in women than in men. Cardiovascular mortality rates in women are highest in the northern, rural, and remote locations in Canada.
      Indigenous women and women of SA origin are at notably greater risk of CVD and experience poorer cardiovascular outcomes, as do marginalized populations such as those with disabilities and lower SES.

      Acknowledgements

      The authors gratefully acknowledge Lisa Comber for her coordination of this effort. A special thanks goes to Alexa Desjarlais from the Libin Cardiovascular Institute CV & Me program, and to Manu Sandhu and Angela Poitras from the University of Ottawa Heart Institute for their graphic design of the chapter illustration. Thanks also go to the Heart & Stroke Foundation for acquiring some of the data used in this Atlas chapter. This chapter has been submitted on behalf of the Canadian Women’s Heart Health Alliance (CWHHA), a pan-Canadian network of ∼60 clinicians, scientists, allied health professionals, program administrators, and patient partners, whose aim is to develop and disseminate evidence-informed strategies to transform clinical practice and enhance collaborative action on women’s cardiovascular health in Canada. The CWHHA is powered by the Canadian Women’s Heart Health Centre at the University of Ottawa Heart Institute.

      Funding Sources

      Support for this work was provided by the University of Ottawa Heart Institute Foundation .

      Disclosures

      S.L.M. is a member of the Novo Nordisk steering committee and is a consultant of Lantheus Medical Imaging. The other authors have no conflicts of interest to disclose.

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