Site Home   Gender and Cardiovascular Disease       Introduction to Gender and Health   The Gender Lens Tool


One of the most powerful predictors of participation in cardiac rehabilitation programs is the patient’s perception of the strength of the treating physician’s recommendation[3].

Heart disease affects many aspects of women’s lives. A significant percentage of women continue to have adverse consequences long after the diagnosis is made. Furthermore, proven beneficial lifestyle changes may not be implemented, most likely because of dissatisfaction with care, lack of educational and rehabilitative resources, symptoms of depression and anxiety, and suboptimal social support. There are several reasons that may help explain why women with heart disease have poorer medical outcomes than men do[1]:

Attitudes and awareness of heart disease risk and symptoms

Studies have demonstrated that even when risk factors are present and self reported:

  • patients do not necessarily present earlier for treatment or have better knowledge of cardiac disease symptoms[2]

  • lower socioeconomic status and lower educational status are risk factors for poor knowledge of heart disease

...leading to the conclusion that there are opportunities to educate patients who have these risk factors[2].

Lifestyle and behavior changes after diagnosis

Little is known about why women find it difficult to make lifestyle changes. One survey of risk factors and health behaviour counselling by providers established that there were low levels of counselling for physical activity, diet, and weight reduction for all patients and that a smaller percentage of women than men received this type of counselling[3]. Furthermore, women who obtained counselling about their risks and about the benefits of lifestyle changes do not necessarily implement new behaviours.

Interaction with the health care system

Although overall satisfaction with their own physicians was high, the surveyed women were frequently dissatisfied with another aspect of their health care experience. Physician attitudes and interactions were the sources of most of the disappointments. Women frequently felt that they were not taken seriously enough, which resulted in delayed or missed diagnoses. They also perceived that in the health care system they were unable to receive the type of information that they needed[3].

Cardiac rehabilitation

One of the most powerful predictors of participation in cardiac rehabilitation programs is the patient’s perception of the strength of the treating physician’s recommendation. Among patients with heart disease, older women are less likely than older men to participate but are also less likely to be given a strong recommendation by their physicians as they do with men[3]. Consequently, older women may be doubly disadvantaged; they have the lowest baseline functional status for fitness and psychosocial status, and thus would benefit the most from rehabilitation programs, but they are less likely to be strongly urged to participate.

Despite the older age and higher prevalence of risk factors and co-morbid disease in women, the mortality rate after primary angioplasty for AMI appears to be equal when compared to men[4].

Although the frequency of cognitive dysfunction after cardiac operation is comparable for women and men, women seem more likely to suffer injury to brain areas subserving visuospatial processing[5].

The prognosis after myocardial infarction is worse in women because of a more difficult diagnosis (atypical symptoms, unclear ECG abnormalities) and because of social and economic factors. This difference is not entirely explained by the more advanced age of women, thrombolytic therapy, concomitant diseases, and by the severity of coronary injuries. It could probably be explained by an elevated risk factor rate among females, recurrent ischemia and under-utilization of therapies, which have the same efficacy in both sexes. A statement from the American Heart Association in 2001[6] recommends the control of risk factors to all women, and specific therapy with antiplatelet agents or anticoagulants (when indicated), beta-blockers, and ACE-inhibitors to those with existing CHD, according to their clinical conditions[7].

Savage et al[8] demonstrated that women experience a greater improvement in HDL-C with cardiac rehabilitation than men despite similar changes in fitness and body composition. Women, regardless of baseline HDL-C, demonstrated improvements in HDL-C, whereas only men with low HDL-C experienced an increase in HDL-C. These results describe a differing impact of cardiac rehabilitation on changes in HDL-C based on sex.


1. Marcuccio E., Loving N., Bennett S. K. and Hayes S. N., A survey of attitudes and experiences of women with heart disease, Women's Health Issues 13 (2003) 23--31

2. Goff DC Jr, Sellers DE, McGovern PG, et al., Knowledge of heart attack symptoms in a population survey in the United States: The REACT Trial. Rapid Early Action for Coronary Treatment. Arch Intern Med 1998;158:2329--2338.

3. Missed opportunities in preventive counseling for cardiovascular disease: United States, 1995. MMWR Morb Mortal Wkly Rep 1998;47:91--95.

4. Berger J., S. and Brown D., L., Impact of Gender on Mortality Following Primary Angioplasty for Acute Myocardial Infarction, Progress in Cardiovascular Diseases, Vol. 46, No. 4, (January/February) 2004: pp 297-304

5. Hogue C. W., Lillie R., Hershey T., Birge S., Nassief A., Thomas B, Freedland K. E., Gender Influence on Cognitive Function AfterCardiac Operation, Annual Thoracic Surgery, 2003;76:1119--25

6. Mosca L, Collins P, Herrington DM, et al. Hormone replacement therapy and cardiovascular disease: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104: 499-503.

7. Penco M., Fratini S., Romano S., Novo S., Gender differences in the outcome of noninvasive cardiovascular treatment, Italian Heart Journal: Official Journal of the Italian Federation of Cardiology. 4(8):514-7, 2003

8. Savage PD, Brochu M, Ades PA., Gender Alters the High-density Lipoprotein Cholesterol Response to Cardiac Rehabilitation, Journal of Cardiopulmonary Rehabilitation. 24(4):248-254, July/August 2004

All references for this section