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This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada., (© 2023 The Authors.)

Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women., (© 2023 The Authors.)

The impact of the presence or absence of sex hormones on women's health is woefully underresearched. Fundamentally, women's bodies are now understood to spend considerable time under widely fluctuating hormonal influences, including puberty, pregnancy, peripartum, and menopause, and a woman's vessels are therefore preset for functional and physiological alterations based on levels of sex hormones. However, our understanding of the influences of sex hormones on the regulation of a multitude of biological and physiological processes has not translated into the development and/or collection or analyses of data on therapeutic treatments and/or outcomes in the context of women's disease management., (© 2023 The Authors.)

Women vs men have major differences in terms of risk-factor profiles, social and environmental factors, clinical presentation, diagnosis, and treatment of cardiovascular disease. Women are more likely than men to experience health issues that are complex and multifactorial, often relating to disparities in access to care, risk-factor prevalence, sex-based biological differences, gender-related factors, and sociocultural factors. Furthermore, awareness of the intersectional nature and relationship of sociocultural determinants of health, including sex and gender factors, that influence access to care and health outcomes for women with cardiovascular disease remains elusive. This review summarizes literature that reports on under-recognized sex- and gender-related risk factors that intersect with psychosocial, economic, and cultural factors in the diagnosis, treatment, and outcomes of women's cardiovascular health., (© 2023 The Authors.)

Background: Cardiovascular diseases (CVD) remain the leading cause of death for women. However, systematic inequalities exist in how women experience clinical cardiovascular (CV) policies, programs, and initiatives., Methods: In collaboration with the Heart and Stroke Foundation of Canada, a question regarding female-specific CV protocols in an emergency department (ED), or an inpatient or ambulatory care area of a healthcare site was sent via e-mail to 450 healthcare sites in Canada. Contacts at these sites were established through the larger initiative-the Heart Failure Resources and Services Inventory-conducted by the foundation., Results: Responses were received from 282 healthcare sites, with 3 sites confirming the use of a component of a female-specific CV protocol in the ED. Three sites noted using sex-specific troponin levels in the diagnosis of acute coronary syndromes; 2 of the sites are participants in the hs- c Tn- O ptimizing the D iagnosis of Acut e M yocardial I nfarction/Injury in Women (CODE MI) trial. One site reported the integration of a female-specific CV protocol component into routine use., Conclusions: We have identified an absence of female-specific CVD protocols in EDs that may be associated with the identified poorer outcomes in women impacted by CVD. Female-specific CV protocols may serve to increase equity and ensure that women with CV concerns have access to the appropriate care in a timely manner, thereby helping to mitigate some of the current adverse effects experienced by women who present to Canadian EDs with CV symptoms., (© 2022 The Authors.)

This Atlas chapter summarizes sex- and some gender-associated, and unique aspects and manifestations of cardiovascular disease (CVD) in women. CVD is the primary cause of premature death in women in Canada and numerous sex-specific differences related to symptoms and pathophysiology exist. A review of the literature was done to identify sex-specific differences in symptoms, pathophysiology, and unique manifestations of CVD in women. Although women with ischemic heart disease might present with chest pain, the description of symptoms, delay between symptom onset and seeking medical attention, and prodromal symptoms are often different in women, compared with men. Nonatherosclerotic causes of angina and myocardial infarction, such as spontaneous coronary artery dissection are predominantly identified in women. Obstructive and nonobstructive coronary artery disease, aortic aneurysmal disease, and peripheral artery disease have worse outcomes in women compared with men. Sex differences exist in valvular heart disease and cardiomyopathies. Heart failure with preserved ejection fraction is more often diagnosed in women, who experience better survival after a heart failure diagnosis. Stroke might occur across the lifespan in women, who are at higher risk of stroke-related disability and age-specific mortality. Sex- and gender-unique differences exist in symptoms and pathophysiology of CVD in women. These differences must be considered when evaluating CVD manifestations, because they affect management and prognosis of cardiovascular conditions in women., (© 2021 The Authors.)

Women have unique sex- and gender-related risk factors for cardiovascular disease (CVD) that can present or evolve over their lifespan. Pregnancy-associated conditions, polycystic ovarian syndrome, and menopause can increase a woman's risk of CVD. Women are at greater risk for autoimmune rheumatic disorders, which play a role in the predisposition and pathogenesis of CVD. The influence of traditional CVD risk factors (eg, smoking, hypertension, diabetes, obesity, physical inactivity, depression, anxiety, and family history) is greater in women than men. Finally, there are sex differences in the response to treatments for CVD risk and comorbid disease processes. In this Atlas chapter we review sex- and gender-unique CVD risk factors that can occur across a woman's lifespan, with the aim to reduce knowledge gaps and guide the development of optimal strategies for awareness and treatment., (© 2021 The Authors.)

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., (© 2020 Canadian Cardiovascular Society. Published by Elsevier Inc.)

Background: There is limited information about the impact of frailty on public payer costs in cardiac surgery. This study aimed to determine quality-adjusted life-years (QALYs) and costs associated with preoperative frailty in patients referred for cardiac surgery., Methods: We retrospectively compared costs of frailty in a cohort of 529 patients aged ≥ 50 years who were referred for nonemergent cardiac surgery in Alberta. Patients were screened preoperatively for frailty, defined as a score of 5 or greater on the Clinical Frailty Scale. The primary outcome measure was public payer costs attributable to frailty, calculated in a difference-in-difference (DID) model., Results: The prevalence of frailty was 10% (n = 51; 95% confidence interval [CI], 7%-12%). Median (interquartile range) costs for frail patients were higher in the first year postsurgery ($200,709 [$146,177-$486,852] vs $147,730 [$100,674-$177,025]; P < 0.001) compared to nonfrail; the difference-in-difference attributable cost of frailty was $57,836 (95% CI, $-28,608-$144,280). At 1 year, frail patients had fewer QALYs realized compared to nonfrail patients (0.71 [0.57-0.77] vs 0.82 [0.75-0.86], P < 0.001), whereas QALYs gained were similar (0.02 [-0.02-0.05] vs 0.02 [0.00-0.04], P  = 0.58, median difference 0.003 [95% CI, -0.01-0.02]) in frail and nonfrail patients., Conclusions: Frailty screening identified a population with greater impairment in quality-of-life and greater healthcare costs. Costs attributable to frailty represent opportunity costs that should be considered in future cardiac surgical services planning in the context of our aging population and the growing prevalence of frailty., (© 2020 Canadian Cardiovascular Society. Published by Elsevier Inc.)