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There is a strong focus on the biological differences between men and women that contribute to differences in cardiovascular disease1, the effects of the medicines used for treatment2, and the prevalence of traditional biological risk factors  (e.g. high blood pressure, obesity, smoking) for cardiovascular disease3. However, there are psychosocial and sociological determinants of cardiovascular health that need to be considered to ensure appropriate and effective health care.

Cardiovascular disease accounts for 14% of Australia’s total burden of disease, but this is borne disproportionately across our population. Cardiovascular disease causes an increasing burden with age, to be the greatest contributor to disease burden in those aged over 70. When adjusted for age and population, cardiovascular disease causes 30.6 disability-adjusted life years (DALYs) per 1000 Australian males (15.1% of total DALY), and 16.8 DALYs/1000 females. The cardiovascular disease burden also varies by geographic location, distance from services (e.g. major cities, outer regional) and socioeconomic status4.

The variations in DALYs that are attributable to cardiovascular disease reflect differences in the prevalence of cardiovascular disease and its health impacts between different population groups. The fact that social factors (e.g. distance from services, socioeconomic status) influence the burden of cardiovascular disease demonstrates that variations in prevalence and severity are not due simply to biology.

Psychosocial factors contribute around one-third of the risk for cardiovascular disease5. There psychological and sociological determinants of cardiovascular health affect men and women differently. The benefit to cardiovascular health of marriage, for example, is different between males and females. An individual’s perception of a ‘positive’ marriage benefits women’s cardiovascular health more than men’s, and a ‘negative’ marriage affects women’s cardiovascular health but not men’s6.

Psychosocial factors may have a greater influence on cardiovascular disease than traditional biological risk factors. ‘Vital exhaustion’, which is characterised by profound fatigue, irritability and demoralisation, was the highest-ranked cardiovascular disease risk factor in men (and second highest in women) in a large Dutch study7.

The pathogenesis of cardiovascular disease can originate very early in life, and the influence of etiological factors accumulates over time. This means that contributors to the development of cardiovascular disease act across the lifespan, and this is true for psychosocialand traditional biological risk factors9.

Just as biological differences between the sexes influence cardiovascular disease risk, so too do gender differences. Gender norms influence the development of stereotypical health behaviours in males and females and result in different exposures to psychosocial risk factors for cardiovascular disease throughout life. For example10:

  • Physical activity is encouraged more in males from very early in life, whereas legitimate fears of harassment or abuse of females discourage physical activity
  • Social support may decline throughout adolescence for males, resulting in high rates of illicit drug use and psychological traits associated with higher rates of cardiovascular disease
  • Cigarette smoking is used to control body weight by almost half of adolescent females, and nearly one-third of adolescent males
  • Early life physical and sexual abuse, which causes abnormal immune, neurological and endocrine function associated with cardiovascular disease, occurs in 1 in 6 Australian females and 1 in 10 males11
  • Work, home and financial stress are generally shared unequally between males and females.

There’s little doubt about the importance of psychosocial factors in the development of cardiovascular disease, but robust evidence to support specific interventions to address these is lacking12.

The German Cardiac Society recommends a person-centred approach that considers a patient’s age, gender, and preferences for diagnosis and treatment options. They provide these useful recommendations for treatment of people with psychosocial risk factors for cardiovascular disease11:

 

Risk factor

Treatment

Low SES

Person-centred communication

In case of cardiac events, cardiac rehabilitation

Social isolation

Person-centred communication

Fostering of social networks (e.g. self-help groups)

In case of cardiac events, cardiac rehabilitation

Work/family stress

Person-centred communication and basic psychosomatic care

Stress management training

In case of cardiac events, cardiac rehabilitation

Depression

Person-centred communication and basic psychosomatic care

Psychotherapy, antidepressants

Collaborative care

Heart groups

In case of cardiac events, cardiac rehabilitation

Anxiety

Person-centred communication and basic psychosomatic care

Psychotherapy, antidepressants

Heart groups

In case of cardiac events, cardiac rehabilitation

Anger/hostility

Person-centred communication and basic psychosomatic care

Stress management training, psychotherapy

In case of cardiac events, cardiac rehabilitation

Type D personality

Person-centred communication and basic psychosomatic care

Stress management training

In case of cardiac events, cardiac rehabilitation

 


[1] Regitz-Zagrosek & Kararigas, 2017. Mechanistic Pathways of Sex Differences in Cardiovascular Disease. Physiological Reviews

[2] Mauvais-Jarvis et al., 2021. Sex- and Gender-Based Pharmacological Response to Drugs. Pharmacological Reviews

[4] Australian Institute of Health and Welfare, 2019. Australian burden of disease study: impact and causes of illness and death in Australia. Available from: https://www.aihw.gov.au/reports/burden-of-disease/burden-disease-study-illness-death-2015/summary

[5] Yusuf et al., 2004. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. The Lancet

[6] Liu & Waite, 2014. Bad Marriage, Broken Heart? Age and Gender Differences in the Link between Marital Quality and Cardiovascular Risks among Older Adults. Journal of Health and Social Behavior

[7] Schnohr et al., 2015. Ranking of psychosocial and traditional risk factors by importance for coronary heart disease: the Copenhagen City Heart Study. European Heart Journal

[8] Lee et al., 2020. Cumulative Social Risk and Cardiovascular Disease Among Adults in South Korea: A Cross-Sectional Analysis of a Nationally Representative Sample. Preventing Chronic Disease

[9] Reinikainen et al., 2015. Lifetime cumulative risk factors predict cardiovascular disease mortality in a 50-year follow-up study in Finland. International Journal of Epidemiology

[10] O’Neil et al., 2018. Gender/Sex as a Social Determinant of Cardiovascular Risk. Circulation

[12] Albus et al., 2019. Significance of psychosocial factors in cardiology: update 2018. Clinical Research in Cardiology

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