“Monzino Women”: in Milan, a center dedicated to cardiovascular prevention in women
Cardiovascular diseases are the leading cause of death in women and their recognition and early diagnosis are instruments for effective prevention. In Italy, cardiovascular diseases cause the death of over 123,000 women each year.
Until now, the relevance of cardiovascular diseases in women was scarcely considered and women were under-represented in clinical trials relating to heart disease. Moreover, although the manifestations of the disease are similar in both sexes, a clear understanding of the pathophysiological mechanisms of cardiovascular diseases in women is still lacking. Although heart diseases are more often fatal in women than in men, the treatment of these pathologies in women has been so far based on the results of medical and pharmacological research carried out on male subjects. It follows that some elements are still unclear:
1. differences in cardiovascular disease biomarkers between men and women;
2. impact of pregnancy and pathologies of pregnancy on the development at a later stage of cardiovascular pathologies in the newborn child and mother;
3. socio-economic determinants of health and their effect on the cardiovascular outcome in both sexes;
4. correlation between non-conventional cardiovascular disease risk factors and heart disease (e.g., autoimmune systemic diseases, endocrinopathies);
5. effect of psychosocial factors such as anxiety and stress in everyday life on the development of cardiac symptoms in women.
Increasing aging of the female population calls for a broader reflection on the importance that should be attached to the knowledge, awareness and prevention of cardiovascular disease, even in terms of socio-economic impact. Women have cardiovascular peculiarities that are not only sex-specific, but also an age-dependent. The incidence of cardiovascular diseases is lower compared to men during fertile age, catches up with men in menopause, ultimately surpassing them after 75 years of age. All this stems from endocrine and metabolic changes that occur with the loss of estrogen protection. Young women are less likely to become ill but have increased mortality and complications in case of the onset of ischemic disease.
Inadequate awareness of the incidence of cardiovascular diseases in women is their worst enemy. It is therefore essential that women gain awareness of their individual cardiovascular risk that may be even higher than that of men. The female sex is also more exposed to stress and depression which represent many favoring conditions. In women, the new emerging cardiovascular risk factors (pathologies of pregnancy, eclampsia, recurrent miscarriage, polycystic ovary syndrome, endometriosis, pre-term pregnancies as well as vitamin D deficiency and autoimmune diseases) should be taken into consideration as potential predisposing factors for the future development of cardiovascular diseases. Therefore, correct information and prevention need a better relationship between research, guidelines and dissemination.
Despite these premises, women are still indicated as “special” populations in many guidelines relating to the prevention and treatment of cardiovascular diseases, although they constitute the majority of the general population. Women are different, in cardiovascular disease, also when it comes to therapy which is often started late because they themselves (and often times their attending doctors) underestimate the early signs of disease.
In early 2017, at Centro Cardiologico Monzino in Milan, “Monzino Women” was launched, with the aim of providing quality care through targeted attention to prevention, treatment and management of cardiovascular health issues in women in synergy with male and female specialists in endocrinology, diabetology, gynecology, lipidology, nutrition and psychology. The clinical activity is targeted at women between 35 and 60 years through a preliminary outpatient clinical evaluation, targeted instrumental diagnosis and second-level counseling, to achieve a prospective evaluation of a patient, considering her age, prior history, lifestyles and risk factors to which she is most exposed. Women also receive a questionnaire on their state of health that includes the assessment of anxiety and depression personality traits as aspects of a broader psychosocial framework targeted at analyzing physical and cognitive symptoms associated with depression. General and sex-specific cardiovascular risk factors are analyzed together with the results of genetic, metabolic, inflammatory, and first-level diagnostic tests, combined with a patient’s psychological evaluation.
Therefore, “Monzino Women” brings together super-specialized skills and innovative technologies already present in the hospital, and integrates them with multi-disciplinary collaborations. In addition to male and female specialists in clinical cardiology, hypertension, arrhythmology, and hemodynamics, where necessary, male and female specialists in gynecology, diabetology, endocrinology, lipidology, nutrition, and psychology interact.
Preliminary data of the first two hundred women examined at “Monzino Women”, all without symptoms or previous cardiovascular events, confirm a framework that deserves our full attention: 30% had serious risk factors, mainly hypertension and hypercholesterolemia, and there was a significant presence of anxiety, depression and stress. So, we decided to investigate further the psychosocial risk factors also through an ad-hoc study.
“Monzino Women” also helps to develop and increase awareness among women of their own risk through seminars, lectures, and debates for women and family doctors to make them more cognizant of early prevention. The education and awareness-raising process should also serve to provide the tools for better estimating individual risk.
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3. Shaw LJ, Pepine CJ, Xie J, et al. Quality and equitable health care gaps for women: attributions to sex differences in cardiovascular medicine. J Am Coll Cardiol 2017; 70: 373-88. doi: 10.1016/j.jacc.2017.05.051.
4. Lee G, Tubby J. Preeclampsia and the risk of cardiovascular disease later in life. A review of the evidence. Midwifery 2015; 31: 1127-34. doi: 10.1016/j.midw.2015.09.005. Epub 2015 Sep 28.
MD, FESC, FACC
Department of Cardiovascular Sciences
Centro Cardiologico Monzino, IRCCS
Via Parea 4 - 20138 Milan (Italy)