The Heart of the Matter: A Quarter Century of Risk for 60% of American Women

With escalating incidences of hypertension, it is projected that almost six out of ten women in the United States will encounter some form of cardiovascular disease (CVD) within the ensuing quarter-century. This projection stems from a recent scientific declaration released in Circulation, the esteemed, peer-reviewed publication of the American Heart Association, an organization dedicated to transforming global health outcomes.

The document, titled “Forecasting the Burden of Cardiovascular Disease and Stroke in the United States Through 2050 in Women: A Scientific Statement From the American Heart Association,” extends the Association’s prior research to estimate the future prevalence of cardiovascular diseases among women and their consequent economic implications, based on the current health landscape.

“Cardiovascular disease claims the lives of one in every three women—this could be your grandmother, mother, or daughter,” stated Karen E. Joynt Maddox, M.D., M.P.H., FAHA, a volunteer chair for the statement’s writing group, as well as a professor of medicine and public health and co-director of the Center for Advancing Health Services, Policy & Economics Research at the Washington University School of Medicine in St. Louis. “Furthermore, over 62 million women in the U.S. are currently living with some form of cardiovascular disease, incurring annual costs of at least $200 billion. Our assessments suggest that if current trends persist, these figures will significantly escalate over the next two to three decades.”

The report’s findings highlight substantial increases in all categories of cardiovascular disease for women, including but not limited to heart disease, heart failure, atrial fibrillation, and stroke. Accompanying these surges are projected increases in numerous primary health factors contributing to cardiovascular disease, such as elevated blood pressure, obesity, and diabetes.

Dr. Joynt Maddox further expressed deep concern regarding the following observations:

• A rising prevalence of certain health risk factors is also being observed among young girls, specifically those between the ages of 2 and 19.
• These escalating rates are disproportionately affecting women and girls who identify as American Indian/Alaska Native, Black, Hispanic, or multiracial individuals.

Cardiovascular disease stands as the leading cause of mortality for women and remains their foremost health risk overall. While many might assume conditions like high blood pressure predominantly affect older women, this is demonstrably not the case. We understand that the precursors to heart disease and stroke develop early in life, impacting even young women and girls. The burden is compounded for those facing adverse social determinants of health, such as poverty, limited literacy, rural residency, and other psychosocial stressors. Identifying the patterns detailed in this report is paramount for instituting meaningful changes capable of reversing this trajectory.”

Stacey E. Rosen, M.D., FAHA, volunteer president of the American Heart Association and executive director of the Katz Institute for Women’s Health and senior vice president of women’s health at Northwell Health, New York City

Statistical Projections

The report forecasts that, assuming present trajectories continue, by the year 2050:

• Approximately 60% of women will experience high blood pressure, a significant jump from the current rate of less than 50%.
• Over 25% of women will be diagnosed with diabetes, compared to roughly 15% at present.
• More than 60% of women will be classified as having obesity, an increase from the current approximate 44%.

The projections for women of color indicate some of the most pronounced upticks; by 2050:

• Hispanic women are expected to see the largest increase in high blood pressure, exceeding 15%.
• Asian women are projected to experience the most substantial rise in obesity, with an increase of nearly 26%.
• Prevalence rates for cardiovascular disease risk factors are generally anticipated to remain highest among Black women. Over 70% of Black women are expected to have high blood pressure, over 71% will have obesity, and nearly 28% will have diabetes.

While older adult women will continue to exhibit some of the highest rates of cardiovascular disease and associated risk factors, these rates are set to escalate considerably among younger women. By 2025:

• Close to one-third of women aged 22-44 will have some form of cardiovascular disease, a rise from the current less than one in four.
• Diabetes rates for women aged 22-44 are projected to more than double, climbing from 6% to nearly 16%.
• More than one-third of women aged 22-44 will have high blood pressure, representing an increase of over 11%.
• More than one in six women aged 22-44 will have obesity, an increment of over 18%.

The report also examines cardiovascular health risk factors among young girls:

• By 2050, nearly 32% of girls aged 2-19 are predicted to have obesity, signifying an increase of over 12%.
• This trend is likely attributed to over 60% of these girls engaging in insufficient physical activity and more than half exhibiting poor dietary habits, rates expected to show only modest improvement in the coming decades.
• Mirroring the trends in adult women, these rates are typically higher among girls of color, particularly Black girls, with an anticipated 40% having obesity by 2050.

“This escalating trend in health risks among girls and young women is particularly alarming, suggesting they will contend with chronic health issues for a significant portion of their lives. Women already face a heightened susceptibility to many of these health conditions due to factors specific to their lifespan,” stated Dr. Rosen. “Significant physiological changes during pregnancy, perimenopause, and menopause underscore the critical importance of close monitoring for increases in health risk factors during these periods.”

A Promising Horizon

Amidst these concerns, there is positive news regarding projected declines in high cholesterol rates across nearly all demographics of women. Furthermore, improvements are anticipated in certain health behaviors influencing CVD, including enhanced dietary habits, increased physical activity, and reduced smoking rates.

“We recognize that people are living longer due to better management of health conditions. As a medical community, we have achieved considerable success in reducing mortality from major cardiovascular events like heart attacks and strokes. However, these data indicate a pressing need to significantly reorient our focus towards health, wellness, and preventive strategies,” commented Dr. Joynt Maddox. “Our imperative is to prevent girls and women from developing cardiovascular risk factors, enabling them to lead long, healthy lives free from cardiovascular disease. This necessitates a highly deliberate focus on optimizing cardiovascular health throughout the entire lifespan.”

The American Heart Association defines optimal health through its Life’s Essential 8™ framework, which encompasses four health behaviors (improved nutrition, increased physical activity, tobacco cessation, and adequate sleep) and four health factors (weight management, cholesterol control, blood sugar management, and blood pressure control).

“These benchmarks for ideal cardiovascular health are substantiated by extensive scientific research, which attests that the majority, up to 80%, of heart disease and stroke are preventable,” explained Dr. Rosen. “I personally view Life’s Essential 8 as a prescription for health. One of its most compelling aspects is the availability of customized guidance for these metrics tailored to different life stages for women, from childhood through menopause and beyond. While this report forecasts a concerning future, it is not too late to initiate the journey toward improved health outcomes.”

An Urgent Appeal for Action

“The most effective, economical, and efficient method for mitigating the prevalence and impact of cardiovascular disease is through prevention. Nevertheless, these projections signal that our current preventive measures are insufficient, particularly for women of color and younger women,” asserted Dr. Joynt Maddox. “Within the report, we have identified several key considerations aimed at enhancing prevention, treatment, and ongoing care throughout the life course for all women.”

Health Behaviors: Proactively addressing health issues before their onset represents one of the most robust strategies for safeguarding heart health.

• Fostering healthy choices within environments where individuals learn, reside, and receive medical care—such as educational institutions, community hubs, pediatric clinics, and gynecology practices.
• Leveraging digital tools, where beneficial, to encourage and reinforce positive lifestyle modifications.

Management of Health Factors: Early and consistent management of chronic conditions like hypertension, diabetes, and obesity can yield substantial benefits, especially for women at elevated risk.

• Healthcare providers and policymakers should prioritize sustained support for managing chronic conditions in women, incorporating early assessments, collaborative team-based care, and the utilization of accessible digital health platforms.
• Research endeavors should specifically investigate the efficacy and safety of novel obesity medications in women to ensure optimal outcomes.

Clinical Cardiovascular Disease: The provision of superior care and high-quality treatment is essential for women experiencing all forms of CVD, including myocardial infarction, heart failure, atrial fibrillation, and cerebrovascular accidents.

• When women present with a heart attack, heart failure, or stroke, the implementation of quality improvement initiatives, such as the American Heart Association’s Get With The Guidelines^® program, is crucial to ensure prompt, effective, and equitable care delivery.
• For chronic conditions like atrial fibrillation and heart failure, care plans must integrate considerations unique to women to facilitate more personalized shared decision-making regarding treatment.
• The preservation of brain health, with a particular focus on dementia, should be regarded as an integral component of blood pressure management, alongside broad CVD prevention and treatment strategies in women.

Care Across Life Stages: Every phase of life presents an opportune moment for early risk identification and the proactive protection of cardiovascular well-being.

• Pediatricians should be cognizant that the onset of early menarche may indicate a heightened risk of future adult cardiovascular issues. A comprehensive menstrual history should be a standard part of routine evaluations across all age groups.
• Integrated, coordinated care across various medical specialties is imperative before, during, and following pregnancy to ensure all patient needs are met comprehensively.
• Ongoing research is vital to explore the impact of lifestyle interventions and hormone replacement therapy around menopause on women’s cardiac health.

Understanding the Influence of Social and Demographic Factors: Societal and environmental influences exert distinct effects on women.

• Programs specifically designed for Black women are urgently needed to address their disproportionately higher rates of cardiovascular disease.
• Healthcare systems must consider the cumulative impact of social challenges—such as access to nutritious food, reliable transportation, or secure housing—on medical risks, and subsequently develop interventions that enhance cardiovascular health within these specific contexts.

Not an Unalterable Fate

Dr. Joynt Maddox also contributed to the American Heart Association’s 2024 presidential advisory, titled “Forecasting the Burden of Cardiovascular Disease and Stroke in the United States Through 2050: Prevalence of Risk Factors and Disease.” This report featured several simulation studies that identified pathways to reverse current unfavorable trends:

• A 10% reduction in risk factors such as hypertension, hyperlipidemia, diabetes, and obesity, coupled with a 20% improvement in the control of blood pressure, blood sugar, and cholesterol levels, could lead to a 17% to 23% decrease in CVD and stroke events, including mortality.
• Halving the prevalence of obesity and doubling the control of risk factors could result in a reduction of CVD events and deaths by 30% to 40%.

“While society has made remarkable strides in medical advancements, the same cannot be said for innovation and progress in cardiovascular health, wellness, and prevention. These projections underscore the critical importance of shifting our focus towards helping all individuals maintain their health,” Dr. Joynt Maddox emphasized. “In this new era characterized by digital health solutions, artificial intelligence, and novel metabolic medication options, healthcare professionals possess an increasing array of tools to achieve this goal, though the systemic infrastructure is not yet fully developed.”

Dr. Rosen observed that at a time when awareness of cardiovascular disease among women has been diminishing, the future scenario depicted in this report should serve as a significant catalyst for change.

“Every woman, irrespective of age, should comprehend her individual risk for heart disease and stroke and be empowered to take proactive steps to mitigate that risk,” she urged. “Understand your personal health metrics, heed your body’s signals, and become an advocate for your own health. Additionally, encourage the girls and women in your life to adopt similar practices. Together, we can effect meaningful change—we can be the agents of that change.”

This scientific statement was meticulously prepared by a volunteer writing group under the auspices of the American Heart Association’s Women’s Health Science Committee. It involved collaboration with the Council on Clinical Cardiology and Stroke Council; Council on Basic Cardiovascular Sciences; Council on Cardiovascular and Stroke Nursing; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and Council on Peripheral Vascular Disease. Scientific statements issued by the American Heart Association aim to foster broader understanding of cardiovascular diseases and stroke-related issues, thereby facilitating informed healthcare decisions. These statements synthesize current knowledge on a given topic and identify areas requiring further investigation. While scientific statements inform the development of clinical guidelines, they do not provide direct treatment recommendations. American Heart Association guidelines represent the Association’s official clinical practice recommendations.