adolescence, the reproductive years, and maturity, is important. It has been shown that risk factors experienced during pregnancy, such as hypertension of pregnancy, gestational diabetes, and preeclampsia, place women at risk for the development of cardiovascular disease as they age.

Prevalence/Burden

More women die annually from heart disease than men, but overall, men have a higher burden of CVD (Roger et al., 2011). Likely because of the obesity epidemic in the United States, rates of mortality from CHD (CVD affecting the coronary arteries) in women aged 35 to 54 years have increased in recent years.

CVD rates for American black females are significantly higher than those for their white counterparts (286.1/100,000 population and 205.7/100,000 population, respectively) (Mosca et al., 2011; Roger et al., 2011). The black female population also has a lower rate of awareness of heart disease than white women (Ferris et al., 2005; Kleindorfer et al., 2009; Mosca et al., 2010; Roger et al., 2011). More women die each year of stroke and stroke constitutes a higher proportion of CVD events in women, compared with a higher proportion of coronary heart disease in men. The majority of the research from which preventive care recommendations are derived is based on CHD and not stroke (Mosca et al., 2011).

Evidence shows differences in the pathology of CHD by sex, with women having a higher prevalence of disease of the small coronary vessels than men (Bairey Merz et al., 2006; Jacobs, 2006). Symptoms of CHD are more likely to be atypical, including dyspnea and epigastric discomfort (Canto et al., 2007). Lastly, premenopausal women who suffer sudden death are more likely to have pathologic findings of plaque erosion than plaque rupture, which is more common in men and postmenopausal women (Burke et al., 1998; Oparil, 1998). Older women who suffer a myocardial infarction are more likely than men to have plaque rupture with thrombus (Kruk et al., 2007). The relevance of these findings is unclear but points to biological differences in CHD in women, the full extent of which remains unknown.

Risk Factors for CVD

Most modifiable risk factors for the primary prevention of CVD, such as hypertension, hyperlipidemia, diabetes mellitus, smoking, obesity, metabolic syndrome, and physical inactivity, are similar in women and men; but the prevalence and impact of certain risk factors may differ by sex. Risk factors in which there are sex differences in prevalence and impact or in



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