Book Review

Cardiovascular Health and Disease in Women

N Engl J Med 1994; 330:515-516February 17, 1994

Article

Cardiovascular Health and Disease in Women
Edited by Pamela S. Douglas. 374 pp., illustrated. Philadelphia, W.B. Saunders, 1993. $65. ISBN: 0-7216-4567-4

Because of the emphasis on coronary artery disease in men, the incidence and severity of this disorder in women has often been minimized or ignored. The introduction to Cardiovascular Health and Disease in Women states that “Recognition of women's health issues has become a battle cry for concerned citizens, for the press, and even for Congress.” The editor answers this call with a review of cardiovascular disease as it affects women. Her goal is to emphasize “current knowledge about the female heart . . . rather than considering it only in comparison to that of the male heart.” In my opinion, she accomplishes her goal.

In this book an impressive group of 23 experts representing a variety of fields such as cardiovascular disease, epidemiology, and women's health enumerate and emphasize the differences in cardiovascular health between men and women. The book is divided into four sections and begins with a discussion of the psychosocial characteristics of women as patients. A review of clinical cardiovascular disease and risk factors for coronary heart disease follows. Pregnancy is then discussed in relation to both preexisting and acquired cardiovascular disease.

In the initial chapter, “The Female Patient,” the authors outline women's special roles, needs, and values as they affect the prevention of cardiovascular disease. Women's attitudes toward health, particularly their focus on reproductive health, are compared with their perception of the threat of cardiovascular disease. Women's high rate of use of health care services is contrasted with their limited access to certain procedures and interventions, which fuels the current debate about bias in clinical decision making. Physicians' attitudes toward women, in particular the assumption that there is a psychosomatic basis for many women's symptoms, are revealed by the chilling statistic that 70 percent of prescriptions for antidepressants and tranquilizers are written for women. Finally, and perhaps most important, the authors discuss barriers that may limit women's adherence to regimens of health promotion and disease prevention.

The section on clinical cardiovascular disease contains chapters on the diagnosis and treatment of coronary heart disease, hypertension, myocardial function, valvular heart disease, stroke, and peripheral vascular disease in women. Wenger reviews differences between men and women in the clinical presentation of coronary artery disease and differences in the value of noninvasive diagnostic testing strategies. She emphasizes how the differing prevalence of coronary heart disease in men and women affects the predictive value of a sign or test. The chapter by Eysmann and Douglas on the management of coronary heart disease is comprehensive; their tables summarizing the current status of treatment are particularly useful. The need for additional research on the management of coronary artery disease in women is readily apparent in this chapter.

A section devoted to cardiovascular risk factors follows. Each chapter begins with an overview of current knowledge, followed by a review of research data as they pertain to women. For example, after a discussion of the epidemiology of smoking and cardiovascular disease in women, Fried and Becker tailor their recommendations for smoking cessation to the specific needs and social concerns of women. The reader cannot help but finish this section with an understanding that women are vulnerable to the same risk factors that affect men -- hypertension, smoking, glucose intolerance, obesity, and a sedentary lifestyle -- all compounded by the additional complexity of hormone replacement after menopause.

The final section of this book deals with cardiovascular disease and pregnancy. The physiologic response to pregnancy is described, followed by chapters on preexisting heart disease and pregnancy. A chapter on heart disease that arises during pregnancy reviews the clinical features, pathophysiology, and treatment of such diseases as toxemia, hypertension during pregnancy, peripartum cardiomyopathy, aortic dissection, and pulmonary hypertension. The reviews are appropriate for both generalists and specialists.

The quality of the individual contributions to Cardiovascular Health and Disease in Women is high. The scope of each chapter is appropriate, with little overlap. Most important, each chapter maintains its focus on women's health and appropriately points out when data are lacking. The references are extensive and comprehensive. The editor and authors have recognized an important need in the area of women's health and have succeeded in providing an up-to-date, comprehensive reference that will arm all involved in women's care with the background and knowledge needed to eliminate bias and improve the prognosis for women with coronary heart disease. Physicians now have no excuse not to join the battle for equality in women's health care, particularly as it relates to cardiovascular disease.

Ellen E.I. Gordon, M.D.
University of Iowa College of Medicine, Iowa City, IA 52242