New medical framework redefines women’s heart health starting at puberty

The American Heart Association, American Academy of Pediatrics, American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine released landmark publications that redefine women's heart health, starting at puberty. Amanda Marma Perak, MD, MSCI, a pediatric cardiologist at Ann & Robert H. Lurie Children's Hospital of Chicago was the Vice-Chair of the collaborative writing group.

Three manuscripts published today in the American Heart Association's flagship journal, Circulation, are the first coordinated, multi-society framework to prevent, detect and manage cardiovascular disease among girls and women. The publications outline a path to connect care across the clinical specialties that see women throughout their lives.

Heart health begins long before adulthood. As pediatric clinicians, we have the opportunity to help every girl start strong and to ensure that what we learn about her health follows her as she grows."

Dr. Marma Perak, pediatric cardiologist at Lurie Children's and Associate Professor of Pediatrics and Preventive Medicine, Northwestern University Feinberg School of Medicine

Dr. Marma Perak, a pediatric cardiologist at Lurie Children's and Associate Professor of Pediatrics and Preventive Medicine at Northwestern University Feinberg School of Medicine

The organizations together outline four distinct "Female Life Stages" based on female biology, offering windows of opportunity to prevent heart disease and stroke. The framework allows for earlier recognition of risk, earlier prevention, and better continuity of care beginning in childhood.

Each life stage is anchored in a hormonal transition unique to girls and women, with pregnancy identified as a "modifying life event" for cardiovascular health that can intersect with more than one stage:

• Stage 1 perimenarche - The years around a girl's first menstrual period, as hormone cycles mature. Approximate age range is 8 – 15 years.
• Stage 2 ovarian cycling - Regular ovulatory and hormone cycles are established and when pregnancy may occur. Approximate age range is 15 – 44 years.
• Stage 3 perimenopause - This stage represents the transition to variable cycle length, skipped cycles and hormone changes. Approximate age range is 45-51 years.
• Stage 4 postmenopause – This stage represents the years that begin after menopause or 12 months after the final menstrual period. Approximate age is 51 years and older.
• Pregnancy, in any life stage – the time before, during and after pregnancy is highlighted as a biological "stress test" that can identify cardiovascular risks that may have been previously unrecognized.

"Periods can be a marker of heart health, and we now recognize menstrual cycle patterns as a female-specific vital sign," said Dr. Marma Perak. "Irregular cycles can signal conditions such as polyendocrine metabolic ovarian syndrome, formerly known as polycystic ovary syndrome or PCOS, that carry real cardiovascular risk. Heavy bleeding is the most common cause of iron deficiency in young women, which affects energy, activity, and heart health. The new female life stage framework allows us to start taking female-specific steps to prevent heart disease and stroke as early as puberty. This approach promises to be a significant advance for women's health."

The joint guidance on the management of women's cardiovascular disease across the life course is made up of three papers:

1. Presidential Advisory: A Female-Specific Life Course Approach to the Prevention and Management of Cardiovascular Disease – establishes the female life stage construct and life course framework
2. Scientific Statement: Consensus Guidance for the Female-Specific Prevention and Management of Cardiovascular Disease – provides clinical guidance, including a multi-society guideline crosswalk
3. Science Advisory: Comprehensive Centers of Excellence for Women's Cardiovascular Care – maps the current landscape of women's cardiovascular centers and proposes a national infrastructure

The papers were all prepared by the volunteer writing group on behalf of the American Heart Association, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine.

The societies call for a national infrastructure of Comprehensive Centers of Excellence for Women's Cardiovascular Care, built on four pillars: interdisciplinary clinical care, professional education and training, research and community engagement. Existing tools and therapies offer opportunities to improve cardiovascular health now, while research is needed to continue to address gaps in evidence specific to girls and women by prioritizing inclusion of girls and women in research, expansion of funding of women's health, and translation of evidence into action.