I have always had an interest in women's cardiovascular health. Cardiovascular disease is the number one killer in women, with one in three women dying from heart disease compared to one in 13 from breast cancer based on the 2015 American Heart Association heart disease and stroke data. Moreover, women are less likely to recieve prompt diagnosis or be referred for an invasive procedure and tend to have higher complications after coronary events. Equally important is that I am currently practicing cardiology in the Southeast of the U.S., which has the highest prevalence of cardiovascular disease among men and women.

As the only female cardiologist at my veterans' (VA) hospital in Columbia, South Carolina, my situation is very unique compared to other cardiologists practicing in non-veteran settings. The overall perception nationwide is that the VA hospital system is male-dominated. My current VA hospital and surrounding clinics see about one million veterans annually. Female veterans make up roughly 5 percent of that number and a large majority still seek care outside of the VA. Nationwide, women make up 15 percent of active military and 20 percent of new military recruits. Female veterans are one of the fastest growing users of the VA health care system and as gender equality continues to improve, that number is predicted to grow even more.

The female veteran population tends to have a distinct set of health related challenges, which are not common in their non-veteran counterparts. A majority of those I see in the clinic have been victims of military-related sexual trauma and usually do not feel comfortable interacting with male providers. In addition, post traumatic stress disorder (PTSD), depression/anxiety and substance abuse are high in this population compared to their non-veteran counterparts. Consequently, this high level of exposure to stress can contribute to accelerated athersclerosis and premature cardiovascular events. Vimalananda, et al., (NEJM 2014) demonstrated that women veterans are more likely to develop cardiovascular risk factors at a younger age, which can lead to early occurence of cardiovascular events compared to their non-veteran counterparts.

Part of my advocacy efforts since I started at the VA hospital have been working to improve our female veterans' access to care. For the most part, I see all of the female veterans referred to the clinic. I am also part of the female veterans' committee in our hospital, looking for ways to make the VA hospital more "female friendly." For instance, our committee worked extensively to make sure that there is a breastfeeding room in the hospital for our new veteran mothers, and we are currently in the middle of pushing for sanitary hygiene products in every female bathroom in the hospital. Each year in February, we hold hospital-wide education events, targeted at female veterans, to emphasize the importance of good cardiovascular health. We also host a "ladies' night" once a year, which is more of an informal gathering for our female veterans and their health care practitioners outside of work hours.

Despite all these outreach efforts, I and other female veteran health care providers still face significant challenges and obstacles; women veterans tend to have the highest rate of no-shows/cancelled appointments, largely due to transpotartion issues, having to care for young children and other family obligations. To combat this, our clinic has instituted call reminders to veterans the day before their appointment and an outreach clinic to reach veterans without access to transportation.

We still have along way to go with women's cardiovascular health both in the VA and non-VA hospital settings, but the future is bright. Futhermore, as we continue to educate and enlighten women about cardiovascular disease, I believe the outcomes will certainly change too.

This article was authored by Ifeoma Onuorah-Ezenekwe, MD, FACC.