The following are key points to remember from an American Heart Association (AHA) Scientific Statement on cardiovascular disease (CVD) risk factors in women and the impact of race and ethnicity:

1. Although significant progress has been accomplished in reducing cardiovascular disease (CVD) events, disparities continue to exist among women who are socially disenfranchised due to race/ethnicity and unfavorable social determinants. This Scientific Statement uses the contemporary views of race and ethnicity not as biological variables but mainly as social, cultural, environmental, systemic, and demographic constructs that are invaluable in the assessment of access to health care, quality of care, and strategies to improve CV outcomes and to advance CV equity.
2. Limitations to risk prediction include limitations of traditional risk factors and their ability to comprehensively estimate a person’s risk for CVD. Risk assessment tools do not adequately account for sex-specific factors such as pre-eclampsia, gestational diabetes or hypertension, menstrual cycle characteristics, or medical conditions such as polycystic ovarian syndrome or autoimmune disorders.
3. Women are at increased risk for mental health conditions, including depression and anxiety, which can impact a woman’s risk for CVD. Furthermore, environmental and cultural stressors are associated with a higher incidence of depression in women. Psychosocial stressors, including discrimination, poor social support, domestic violence, and caregiving roles, are linked to increasing risk for depression in women.
4. Social determinants, including economic stability, neighborhood safety, education, and social and community context, play a significant role in the risk for CVD and, importantly, vary across racial and ethnic groups. In addition, access to quality health care is linked to unfavorable social determinants.
5. CVD is the leading cause of death for non-Hispanic Black women, of which an estimated 60% over 20 years have some form of CVD. Non-Hispanic Black women have high rates of CVD risk factors. Non-Hispanic Black women have the highest prevalence of hypertension in the world. For non-Hispanic Black women, rates of elevated total cholesterol and low-density lipoprotein cholesterol are lower than for women of other races/ethnicities; however, elevated lipoprotein a [Lp(a)] levels are higher.
6. CVD is the leading cause of death among Hispanic/Latina adults, with nearly 43% of Hispanic/Latina women having some form of CVD. In addition, rates of diabetes, obesity, and metabolic syndrome are elevated in Hispanic/Latina women. However, research has been sparse, consisting mostly of cross-sectional studies focusing on Mexican American individuals or grouping diverse Hispanic/Latino subjects. According to AHA statistics, 40.8% of Hispanic/Latina women have hypertension. Generally, Mexican American women have a significantly lower prevalence of hypertension than all other subgroups, whereas the prevalence is higher in Dominican, Puerto Rican, and Cuban individuals. In addition, dyslipidemia is highly prevalent among Hispanic/Latina women in the United States, and rates of diabetes are approximately 14% in Hispanic/Latina adults, with the highest rates among Mexican American and Puerto Rican women compared to other subgroups.
7. American Indian and Alaska Native people are a heterogeneous population with over 500 federally recognized tribes. CVD is the leading cause of death among American Indian/Alaska Native women, with higher rates among women under the age of 65 years. The prevalence of modifiable risk factors in American Indian/Alaskan Native women is high, with almost 50% of American Indian/Alaska Native adult women having at least two CV risk factors; however, a major limitation is the limited data on CVD events and mortality rates in this population. There are regional differences in the prevalence of hypertension in American Indian/Alaska Native women, with estimates ranging from 25% to 41%. About one in five American Indian/Alaska Native women have been diagnosed with hyperlipidemia. Rates of diabetes are almost 20%; however, the prevalence varies by geographic region, with a range between 19% and 70%.
8. CVD is the leading cause of death for Asian women in the United States; however, there is significant heterogeneity among subgroups for CVD risk factors and outcomes. A report from US national mortality records of the six largest Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese) from 2003 to 2011 revealed significant differences in cause-specific death, with the highest CVD death rates among Asian Indian women. In addition, rates of CV risk factors such as hypertension vary across subgroups; data suggest East/Southeast Asian adults had much higher odds of hypertension than non-Hispanic White adults. Furthermore, Lp(a) is an independent risk factor for CVD and is higher in Asian Indian individuals than non-Hispanic White individuals. Diabetes is highly prevalent among Asian Indian and Filipina women.
9. Factors such as adverse neighborhood characteristics, poverty, and inability to access health care impact risk for CVD and differentially impact women by race/ethnicity. Additionally, environmental factors, including air pollution, are associated with CVD and disproportionally affect women, depending on where they live and work. Evidence also suggests that perceived discrimination and racism contribute to CVD rates. Non-Hispanic Black women living in socially disenfranchised communities are three times more likely to have hypertension, with objective measures of structural racism strongly associated with hypertension and obesity in this population.
10. CVD risk assessment in women is multifaceted and should include sex-specific biologic risk factors and incorporate race, ethnicity, and nonbiologic elements. A greater focus on addressing adverse levels of all CVD risk factors among women of underrepresented races and ethnicities is warranted to reduce future CVD morbidity and mortality.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Lipid Metabolism, Nonstatins, Hypertension

Keywords: African Americans, Alaskan Natives, Asian Continental Ancestry Group, Biological Factors, Cardiovascular Diseases, Cholesterol, LDL, Diabetes Mellitus, Dyslipidemias, Ethnic Groups, Hispanic Americans, Hyperlipidemias, Hypertension, Pregnancy, Primary Prevention, Mental Health, Metabolic Syndrome, Obesity, Poverty, Race Factors, Risk Assessment, Risk Factors, Women

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