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Raising the veil on coronary heart disease in Asian women

Helen Lawless
DPSN BPhil
Coronary Heart Disease Nurse Specialist
E:helen.lawless@hobtpct.nhs.uk

Ginder Dhaliwal
BScCommunity-Nursing
Coronary Heart Disease Nurse Specialist
Heart of Birmingham Teaching Primary Care Trust
E:gurginder.dhaliwal@hobtpct.nhs.uk

Coronary heart disease (CHD) is the single most common cause of premature death in the UK. Mortality rates for men and women born in the Indian subcontinent who live in the UK are consistently higher than the national average. The latest census confirms that the incidence of CHD in Asians originating from the Indian subcontinent remains 38% higher in men and 43% higher in women compared with whites.(1)
The understanding of the causes and processes of CHD is incomplete. Classic risk factors are hypothesised in scientific publications, with the emergence of insulin resistance and obesity considered the determinant cause of the higher rates of CHD in the Asian population.(2,3) Socioeconomic deprivation and racial discrimination have also been emphasised in nonscientific writing.(4,5)
Most people would be surprised to learn that cardiovascular disease is a major cause of death in women. In 2000 in the UK, 120,000 women died of heart and circulatory disease - that is 50,000 more than died of cancer.(6) Not only is the incidence of CHD more prevalent in Asian women, but also the premature death rate is 51% higher.(7)
The NSF for CHD is the blueprint for tackling heart disease in Britain - to reduce inequalities and ensure access to evidence-based care both in the primary and secondary care sector.(8) To achieve these targets attention must be turned to the incidence of CHD in women and specifically those of Asian origin. Historically, CHD studies have been dominated by men, hence evidence-based treatment and care for women has had to be extrapolated from the major research trials.(9) This article will highlight issues relating to the care that women, specifically Asian women, receive concerning CHD.
The authors note that the heterogeneity of Asian populations has been too little acknowledged in the context of CHD research,(3) and the term Asian in this article refers to those people originally from the Indian subcontinent now living in the UK.

Factors contributing to the incidence of CHD
The established risk factors, such as hypertension, cigarette smoking and high cholesterol levels, cannot solely explain the prevalence of CHD in Asians.
As stated earlier, classic risk factors such as insulin resistance and obesity have been hypothesised as determinant causes of the higher rates of CHD in the Asian population.(2,3) As a result, diabetic control, reduction of obesity and an increase in physical activity have been proposed as the best ways to reduce the level of CHD in Asians.(5,8,10)
Low HDL (high-density lipoprotein) has been suggested to be a strong predictor of reinfarction or fatal CHD in women.(11) The NSF for CHD requires GP practices to identify all patients with CHD and offer appropriate treatment. Yet women are less likely than men to have a fasting serum cholesterol recorded and are more likely to have an abnormal reading. Despite this, men are more likely to have a recorded diagnosis of hyperlipidaemia and to have received lipid-lowering treatment.(12)
Diabetes has been found to negate the protective effect of the female sex hormones against CHD and cardiovascular disease.(13,14) The expression of oestrogen-regulated genes affects numerous cell processes relevant to cardiovascular disease: vasodilation, vascular remodelling and cell growth after injury, angiogenesis, endothelial cell proliferation, haemostatic and thrombolytic functions, lipid metabolism and antioxidant effects.(15) Despite the physiological effects of HRT, recent trials have failed to demonstrate any benefit; instead the incidence of CHD increased in those women.(16) The Medicines Control Agency has issued guidelines that women should not be given HRT purely to reduce cardiovascular risk.(17)
There is strong evidence that exercise protects against CHD, influencing cholesterol levels, obesity, diabetes and blood pressure.(18) Physical activity has been recommended as the best way to reduce levels of CHD in Asians,(10) and this is reinforced in Our Healthier Nation and the NSF for CHD.(5,8) There is a lot of work to be done, as health information and promotion activities have all been found to be lacking in the Asian population.(19) This knowledge deficit will hopefully be lessened via the implementation of the NSF for CHD and by utilising the media to communicate the salient points. Women may be reluctant to accept that CHD poses a serious risk to their health. To be successful, health promotion initiatives must be designed to meet the population's needs - working in partnership with patient/community groups and encompassing language and cultural issues. Obesity and diabetes can be influenced by dietary energy intake and physical activity,(20) and in this way risk factors could be minimised.
Despite being at the greatest risk, Asian women demonstrated the least awareness of "healthy lifestyles".(21) To be successful, public health campaigns must demonstrate an understanding of cultural beliefs and behaviours.(22) Information and health promotion activities have all been found to be lacking in the Asian population. (19) The complexity of language (spoken and written) does not make for an easy solution, and the employment of bilingual staff has been proposed as a way forward.(19,23) Raising awareness in women is important for themselves and for future generations to minimise the risk of CHD.
Those people living in poverty are known to have poor access to healthcare.(24) The Acheson Report acknowledged that gender and ethnicity, as well as poverty, affect health outcomes.(25) Stress, lack of social support and racial harassment all influence health and wellbeing. (2,25,26) Women in the working classes are more likely to live in inner-city areas and are at a high risk of suffering from depression, social isolation and poor social support manifesting in poor physical and mental health.(25,26) Asian women were found to experience more stress and social isolation than their white counterparts.(2) The current government is determined to improve the health of the worst off in society,(5) and this is reflected in "Health Improvement Plans". The roots of ill health cannot be dealt with by focusing on health alone. Realising that good health is dependent on various socioeconomic factors, and promoting more integrated communities, will benefit all, but especially the Asian population.
In hospital, women are less likely to receive the benefit of well-established treatments such as thrombolysis, aspirin and b-blockers, which have been shown to reduce mortality from CHD.(11,27) The younger the female patient, the higher the rate of death compared with men. Younger women are more likely than younger men to have complications such as hypotension, heart failure, cardiogenic shock and major bleeding, and are less likely to undergo revascularisation procedures such as angioplasty.(28) Coronary artery narrowing in younger women is less extensive than in men and thus manifests itself as a much more difficult disease to recognise in its early stages. This may account for women having to wait longer for angiography than men.(28) Compounding this disadvantage there is evidence that Asian patients receive suboptimal care - waiting longer for consultations, being underthrombolysed and having difficulty accessing services. (20,29,30)
Yet despite this evidence CHD is generally thought of as a man's disease. Women do not perceive that they are at risk - they are knowledgeable about breast and cervical screening programmes,(31) but are less aware of the signs and symptoms of a heart attack and what action to take.(32) Eleven per cent of Asian women compared with 2% of the general population will develop symptoms of CHD2 - it is imperative that health professionals empower women to know when to seek medical advice.

Conclusion
Asian women could be being shortchanged on two counts: race and gender.
There is, however, limited information available specifically addressing this subject. The management of cardiovascular disease has been influenced by years of studies focusing on the white male experience. The NSF for CHD is the vehicle by which inequalities within healthcare delivery for those people at risk of developing or who have CHD can be addressed. Nurses are at the forefront to make that difference.

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References

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  5. DoH. Our healthier nation. Reducing health inequalities. An action report. London: The Stationery Office; 1998.
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  16. Women's Health Initiative. Women's Health Initiative Update; 2002. Available from URL: http://www.nhlbi.nih.gov/whi/hrt
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  24. DoH. Making a difference. London: The Stationery Office; 1999.
  25. DoH. Independent inquiry into inequalities in health (Acheson report). London: The Stationery Office; 1998.
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Resources
British Heart Foundation
W:www.bhf.org.uk

Primary Care Cardiovascular Society
W:www.pccs.org

British Medical Journal
W:www.bmj.com

Further reading

Balarajan R, et al. Patterns of mortality amongst migrants to England and Wales from the Indian subcontinent. BMJ 1984;289:1185-7
British Heart Foundation. Coronary heart disease statistics. London: BHF; 2002
McKeigue P. Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians. Lancet 1991;337:382-6