ORIGINAL ARTICLE

Non-conventional Determinants of Cardiovascular Health in Latin American Women

Determinantes no convencionales de la salud cardiovascular de la mujer en Latinoamérica

Alejandra Avalos Oddi¹, Verónica Lía Crosa^{1, MTSAC}, Silvina Verdugo¹, María Romera¹, Ivana Patiño¹, Yanina Castillo Costa^{2, MTSAC}, Heraldo D’imperio^{2, MTSAC}, Bibiana Rubilar^{1, MTSAC}

¹ Área Corazón y Mujer ¨Dra. Liliana Grinfeld” de la Sociedad Argentina De Cardiología, Buenos Aires, Argentina.

² Área de Investigación de la Sociedad Argentina De Cardiología, Buenos Aires, Argentina.

Address for reprints: Alejandra Ávalos Oddi. E-mail: investigación@sac.org.ar

Rev Argent Cardiol 2023;91:252-266. http://dx.doi.org/10.7775/rac.v91.i4.20647

ABSTRACT

Background: Besides traditional risk factors (RF), non-conventional determinants (NCD) of cardiovascular (CV) health are additional risk factors in women. Therefore, they should be explored to establish their prevalence and association with the female gender.

Objective: The aim of this study is to know the prevalence of socioeconomic (SE) and psychosocial (PS) factors as NCD in CV health in Latin American (LATAM) women.

Methods: We conducted an observational, cross-sectional study using an anonymous survey distributed among LATAM women between May and June 2022. The information gathered included SE and PS NCD, traditional RF and cardiovascular disease (CVD). Results: A total of 4915 women participated; mean age was 49 ± 13 years. Most respondents (49.6%) lived in Argentina, 55.8% in large cities; 94.4% reported adequate access to healthcare services and 89% had access to some level of education. Although 79.9% had a paid job, more than half reported their salary was not commensurate (59.5%) and 26.7% reported exposure to violence at the workplace. The most prevalent PS factors were low to moderate level of satisfaction (68.3%), anxiety or irritability (51.9%), apathy, negative thoughts, or unhappiness (41.7%). Age > 45 years was significantly associated with overweight, obesity, unemployment, and violence at the workplace.

On multivariate analysis, sleep disorders (OR 1.7; p = 0.001), living in a city with low population density (OR 0.5; p < 0.001), violence at the workplace (OR 1.8; p = 0.001), anxiety (OR 1.5; p = 0.001) and a history of pregnancy complications (OR 1.6; p = 0.022) were independently associated with CVD.

Conclusion: The prevalence of PS and SE factors affecting the CV health of LATAM women was significant. Variables such as violence at the workplace, anxiety, or irritability, living in cities with low population density, sleep disorders and pregnancy complications were independently associated with CVD. This survey shows the impact of SE and PS factors as NCD on the cardiometabolic burden and CV health of women in LATAM, mainly in those > 45 years.

Key words: Cardiovascular - Diseases - Women - Latin America - Risk Factors - Psychosocial Factors - Socioeconomic Factors

RESUMEN

Introducción: Más allá de los factores de riesgo (FR) tradicionales, hay determinantes no convencionales (DnoC) de la salud cardiovascular (CV) que operan en las mujeres como factores de riesgo adicional. Es por ello necesario explorarlos y establecer su prevalencia y vínculo con el género femenino.

Objetivo: conocer la prevalencia de los DnoC socioeconómicos (SE) y psicosociales (PS) y su impacto en la salud CV de la mujer en Latinoamérica (LATAM).

Material y métodos: estudio observacional, de corte transversal realizado a través de una encuesta anónima en mujeres de LATAM entre mayo y junio de 2022. Se recabaron datos sobre DnoC (SE y PS), FR convencionales y enfermedad cardiovascular (ECV).

Resultados: participaron 4915 mujeres con edad media de 49 ±13 años. El 49,6 % residía en Argentina, el 55,8 % en grandes ciudades, el 94,4 % declaró acceso adecuado a la salud y el 89 % tuvo acceso a algún nivel de educación. Si bien el 79,9 % expresó tener trabajo remunerado, más de la mitad refirió percibir un salario no acorde (59,5 %) y una exposición a la violencia en el ámbito laboral (26,7 %). Los determinantes PS más prevalentes fueron el bajo a moderado nivel de satisfacción (68,3 %), la ansiedad o irritabilidad (51,9 %), el desinterés, los pensamientos negativos o la infelicidad (41,7 %). El grupo de edad mayor de 45 años se asoció significativamente a más sobrepeso, obesidad, desempleo y violencia laboral.

En el análisis multivariado se encontró asociación independiente con ECV para el trastorno del sueño (OR 1,7; p = 0,001), residir en una ciudad de baja densidad poblacional (OR 0,5; p < 0,001), la violencia laboral (OR 1,8; p = 0,001), la ansiedad (OR 1,5; p = 0,001) y al haber padecido complicaciones del embarazo (OR 1,6; p = 0,022).

Conclusión: se demostró una importante prevalencia de factores PS y SE que impactan en la salud CV de las mujeres en LATAM. Variables como la violencia laboral, la ansiedad o la irritabilidad, residir en ciudades de baja densidad poblacional, así como los trastornos del sueño y complicaciones del embarazo se asociaron de forma independiente con la ECV. Esta encuesta muestra el impacto de los DnoC SE y PS en la carga cardiometabólica (CCM) y la salud CV de las mujeres en LATAM, principalmente en aquellas mayores de 45 años.

Palabras clave: Enfermedades Cardiovasculares Mujeres Latinoamérica Factores de Riesgo Factores Psicosociales Factores Socioeconómicos

Received: 05/15/2023

Accepted: 07/18/2023

INTRODUCTION

The idea that the differences between men and women are exclusively due to biological differences is a reductionist concept, since there are emotional and sociocultural differences between both genders. In the emotional and psychological sphere, women are not only affected by hormonal fluctuations throughout their lives, but also by the complexity of their neurocognitive functions, shaped by the culture of different societies throughout history. ⁽¹⁾

Belonging to certain sociodemographic groups may have additional adverse health effects; many of these groups are underrepresented in randomized or observational studies. The factors contributing to this reality include problems with access to healthcare, low per capita income, educational level, assignment of multiple tasks and roles, and gender-based violence. Underrepresentation of women in clinical trials contributes to the lack of evidence of the impact of cardiovascular disease (CVD) on them. This could partly explain why CVD continues to disproportionately affect women, both in those conditions they share with men and in disorders that are more prevalent in women, as stroke, heart failure (HF) with preserved left ventricular ejection fraction, and myocardial infarction (MI) and nonobstructive coronary arteries. ⁽²⁾

The Pan American Health Organization (PAHO) states that 80% of worldwide cardiovascular deaths occur especially in lowand middle-income countries and indicates that the incidence is the same in men and women. ⁽³⁾

Poverty and the resulting impact on the psychosocial sphere have a greater impact on women, who are more likely to suffer a heart attack than their male counterparts. ^(4-8) The most marginalized and poorest populations are at greater risk for CVD, and among these populations, women are the most prone to suffer such episodes. ⁽⁴⁾

In Latin America, unfavorable socioeconomic conditions have a major impact on female gender, affecting quality of life and access to decent housing, healthy diet or scheduled physical exercise, together with poor access to education since childhood, with unsatisfied basic needs. ⁽⁹⁾

Nowadays we count with evidence about the impact of stressful triggers, as acute-chronic stress, anger-hostility complex, depression, vital exhaustion, anxiety, and gender-based violence at home and at the workplace. Low sociocultural, economic, and demographic level, and even harmful environmental exposures, are associated with higher risk of developing physical and mental diseases. ^(4,10-19) Other pollutants, as tropospheric ozone, nitrogen dioxide and volatile organic compounds, play a role in the development of diseases. More than 90 percent of the world's population lives in areas where pollution levels exceed World Health Organization guidelines. The effects of air pollution are associated with large urban centers, manufacturing centers and areas with heavy traffic. In addition, we must add "indoor" air pollution that mainly affects the population of low to middleincome countries who still cook and heat their homes with firewood or coal. ^(10,11) All these factors have different effects according to gender, as in coronary syndromes, ischemia without obstructive coronary arteries (MINOCA/INOCA), takotsubo syndrome, and X syndrome. The latter are not associated with traditional risk factors, and adverse psychological and sociodemographic profiles seem to play a determining role. We now know that these conditions have a less benign course than was previously thought. ^(20,21)

In this context, it is necessary to implement a gender mainstreaming approach in trials, research, and medical practice. The lack of attention in this regard constitutes a gender bias or gap that has had a negative impact on the diagnosis and prognosis of a disease considered not prevalent in women, when in fact it has been disregarded or ignored. ⁽²²⁾

OBJECTIVE

The aim of this study is to know the prevalence of SE and PS factors as NCD in CV health in a population of Latin American (LATAM) women.

METHODS

We conducted an observational, cross-sectional study using an anonymous survey with closed questions developed in REDCap. The participation was voluntary. The survey was distributed among women >18 years between May and June 2022 through social networks (WhatsApp, e-mail, Facebook, and others) of members and district leaders of the Heart and Women Area of the Argentine Society of Cardiology (SAC) in different geographic regions of Argentina. The participation of the Council of Cardiovascular Disease in Women of the South American and Interamerican Society of Cardiology (SSC-SIAC) made it possible to distribute the survey in different LATAM countries. The survey is published in the Appendix. The questions dealt with personal and occupational psychosocial sphere, gender-based violence ⁽²³⁾, and conventional risk factors and CVD.

Statistical analysis

The population was divided into two groups: the first group was made up of women aged 45 years and the second group of those respondents > 45 years, to explore differences in the main variables in two different generations. Mean age of onset menopausal transition (WHO), when estrogen levels decline and cardiometabolic changes begin to occur, was used to define the cut-off point (Figure 1). The association between non-conventional and traditional factors was also explored.

Fig. 1. Proportion of participant from the different Latin American countries

Qualitative variables are presented as frequencies and percentages. Quantitative variables are expressed as mean ± standard deviation (SD), or median and interquartile range (IQR 25-75), according to their distribution.

Discrete variables were analyzed using the chi square test or Fisher's exact test, as applicable. For continuous variables, the t test or the Mann-Wihtney test were used, as applicable, and in case of 3 groups or greater, ANOVA or the Kruskall-Wallis test were used, as applicable. A p value < 0.05 was considered statistically significant.

All the calculations were performed with the software package R.

Ethical considerations

The survey was approved by the Committee on Ethics of the Argentine Society of Cardiology. An informed consent was not required due to the design of the study.

RESULTS

A total of 4915 women responded the survey. Mean age was 49 ±13 years.

Fourteen women (0.3%) identified themselves as belonging to the LGTBIQ+ (acronym for lesbian, gay, bisexual, transgender, intersex and queer; the plus sign represents people with diverse sexual orientation and gender identity) community.

Most respondents (49.6%) lived in Argentina, followed by Uruguay (15.5%), Chile (4.3%) and Peru (3.8%), among other countries (Figure 1).

Of those surveyed, 55.8% lived in large cities and 10.5% in towns. Quick and easy healthcare access was reported by 94.4% of respondents, and mostly in the private sector (83.6%). Lower population density (< 500 000 inhabitants) was associated with higher body mass index (BMI, 26 vs. 25 kg/m², p = 0.002) and CVD (9% vs. 5%; p = 0.046).

Most survey respondents have access to basic services, such as public water system (90.2%), electrical grid (97.9%) and sewage system (82.5%); only 57% had access to pipe gas.

In terms of marital status, most respondents were married or had a partner (65.3%) or were cohabiting with a partner or children (66.9%). Hypertension (HTN) and tobacco use were more common in those without a partner (24% vs. 20%, p = 0.002, and 13% vs. 9%, p < 0.001, respectively).

Eighty-nine percent received some level of education and 4.1% did not complete compulsory education. ⁽²⁴⁾ Educational level less than secondary school graduation was significantly associated with HTN (30% vs. 2%), diabetes (DM, 9% vs. 5%) and CVD (10% vs. 5%), in all cases with p < 0.001.

A total of 79.9% had a paid job, half of them were professionals (51.2%) and most of them were employees (68.7%). Forty-five percent reported working more than 44 hours per week, mainly those < 45 years (51% vs 40%, p < 0.001); 38.7% considered the workload was excessive and 85.7% reported their physical and emotional health was compromised. The variable "salary not commensurate with workload" (59.5%) was associated with HTN, higher BMI and CVD, in all cases with statistical significance. Labor inequity in terms of hierarchical positions or remuneration was reported by 33.8%.

Unemployment was associated with HTN, DM, smoking habits and CVD (p < 0.001).

Gender-based violence (physical, psychological, sexual, and institutional violence based on sexual orientation or gender identity, UN) occurred at the workplace (26.7%) and at home (22.4%). Violence at the workplace was associated with CVD (8% vs. 5%, p < 0.001), while violence at home was associated with dyslipidemia (DLP, 40.5% vs. 37%, p = 0.047], higher BMI (26.4 vs. 25.7 kg/m², p < 0.001) and smoking habits (15% vs. 9%, p < 0.001, respectively).

A total of 25.4% of the respondents had experienced sexual violence or sexual abuse during their lifetime, associated with higher BMI (26.3 vs. 25.7 kg/ m², p < 0.001) and smoking habits (13% vs. 9%, p < 0.001, respectively).

Only 31.7% reported high level of satisfaction in their personal life. Low to moderate level of satisfaction (68.3%) was significantly associated with higher cardiometabolic burden, and higher rates of DBT, DLP, higher BMI, smoking habits, and CVD. Social discrimination was reported by 19.8%, mainly due to physical appearance; this variable was associated with higher BMI (p < 0.001), smoking habits (12% vs. 10%, p = 0.043) and CVD (15% vs. 9%, p < 0.001).

Mood disorders (apathy, negative thoughts, or unhappiness) in the last two weeks (41.7%), were associated with higher rates of DLP (40% vs. 36%) and smoking habits (13% vs. 9%), while irritability or anxiety (51.9%) were associated with higher rates of smoking habits, higher BMI, and CVD (7% vs. 5%, p < 0.001). Sleep disorders (57%) were associated with DLP (40% vs. 34%) and CVD (7% vs. 4.5%, p < 0.001).

Regarding conventional RF, 21.6% had hypertension and were taking antihypertensive drugs, 5.2% were diabetics, 10.4% were current smokers and 30% were former smokers. Tobacco exposure was higher in transgender respondents (p = 0.026).

More than half of the respondents (54.1%) reported cholesterol levels > 200 mg/dL, and 48% reported a waist circumference > or equal to 88 cm.

Forty-six percent had a BMI below 25 kg/m², 34% had overweight (between 25 and 30 kg/m²), mainly those > 45 years (36% vs. 31%, p < 0.001) and 20% had obesity (BMI > 30 kg/m²), which was also more common in those > 45 years (22% vs. 17%, p < 0.001). Less than half (46.4%) of the women surveyed perform at least 150 minutes of physical exercise per week; 63.9% mentioned having little or no time for personal leisure activities. A total of 58.8% did not follow a balanced and healthy diet; 9.5% drank more than 100 g of alcohol per week and 5.3% took drugs; both variables were associated with a higher prevalence of smoking habits.

Annual heart health check was reported by 43.4% and 77.5 % underwent an annual gynecological exam. Cardiovascular disease was reported by 6.6%: arrhythmias (50.3%), coronary artery disease (21.8%),

heart failure (21.5%), cerebrovascular disease (9.7%), aortic and peripheral artery disease (6.7%) and renal artery disease (0.7%). Regarding coronary artery disease, 46.8% reported a history of angina, 35.5% myocardial infarction, 30.6% percutaneous coronary intervention with or without stenting, and 19.4% myocardial revascularization surgery.

Half of the respondents (50.3%) were taking some type of medication on a regular basis. The most commonly used drugs were antihypertensive agents (34.6%), lipid-lowering agents (21.7%) and anxiolytics/antidepressants (25.2%).

When asked about the obstetric history, 72.8% responded having at least one pregnancy and 15.6% of them reported one or more of the following complications: hypertension (44.9%), premature delivery (58.6%), miscarriage (2.9%), voluntary termination (1.1%) and gestational diabetes (16.9%). An adverse obstetric history was associated with HTN (32 % vs. 23 %, p < 0.001), DM (10 % vs. 5 %, p < 0.001), higher BMI (27 vs. 26 kg/m², p < 0.001) and current CVD (9 % vs. 5 %, p = 0.022).

Cancer was considered the leading cause of death in women by 44.4% of respondents, followed by CVD (38.1%) and feminicide (14.4%).

On multivariate analysis, sleep disorders (OR 1.7, p = 0.001), living in a city with low population density (OR 0.5, p < 0.001), violence at the workplace (OR 1.8, p = 0.001), anxiety (OR 1.5, p = 0.001) and a history of pregnancy complications (OR 1.6, p = 0.022) were independently associated with CVD.

Age > 45 years was significantly associated with overweight, obesity, unemployment, and violence at the workplace, while sexual violence, higher workload with commensurate salary and higher educational level were related with age < or equal to 45 years (Figure 2).

Fig. 2. Significant factors by age

DISCUSSION

This survey shows the impact of self-referred PS and SE determinants on the cardiometabolic burden (CMB) and CV health of women in LATAM, mainly in those > 45 years.

In Latin America, the proportion of overweight and obese adults has significantly increased in recent decades, ⁽²⁵⁾ and this epidemic has spread to lowand middle-income countries. Malnutrition in all its forms, whether overweight, obesity or undernutrition, is associated with poverty. ⁽²⁶⁾ In Argentina, the prevalence of overweight and obesity over the years has shown a clear upward trend, particularly in the most socially vulnerable groups. ⁽²⁷⁾

A multinational South American cohort examined variations in the incidence and mortality rates of CVD and analyzed the contribution of modifiable risk factors to the development of CVD and to all-cause death. Deaths were higher in rural areas compared to urban areas, and low educational level ranked as the third risk factor. ⁽²⁸⁾ In addition, exposure to an excessive workload associated with dissatisfaction with the salary earned in relation to workload, together with inequity, constitute chronic stress factors that affect mental and physical health (85.7%), a situation that was exacerbated during the COVID-19 pandemic (the prevalence of depression and anxiety in Argentina reached 36.4%). ^(29,30) Mood disorders as apathy, negative thoughts or unhappiness in the last two weeks, and irritability or anxiety were significantly associated with higher CMB and CVD.

In 2021, the American Heart Association (AHA) published a scientific statement associating certain positive psychological factors (e.g., optimism, sense of purpose, happiness) and negative psychological factors (e.g., stress, depression, anxiety) to CV health and CV risk, respectively. ⁽³¹⁾ Emotional distress is considered a risk factor associated with increased CMB and CVD with increased platelet reactivity, risk of coronary heart disease, and incidence of depression, anxiety, and suicide. ^(32-34)

Gender-based violence is an emerging risk factor that begins early, affects adolescents and young women, and is more prevalent in low-income countries over lifetime. ⁽³⁵⁾ In the population surveyed, gender-based violence occurred both at the workplace (26.7%) and at home (22.4%) representing a global public health problem and a violation of human rights.

⁽³⁶⁾ Even cardiometabolic disorders developed after a childhood marked by abuse can lead to unhealthy lifestyle habits (sedentary lifestyle, unhealthy diet, sleep disorders, use of toxic substances and smoking) and psychological disorders (post-traumatic stress) with an impact on the immune, metabolic, neuroendocrine, and autonomic nervous systems. ⁽³⁷⁾

Sleep disorders were associated with CVD in the surveyed population. During 2022, the AHA published "Life's Essential 8" (LE8). ⁽³⁸⁾ This update document included "quality of sleep" as an essential factor. The evidence demonstrates that fragmented sleep and inappropriate sleep duration (short duration, < 6 h, or long duration, > 9 h) is associated with increased morbidity and mortality, primarily from cardiovascular disorders and increased risk of type 2 diabetes.

⁽³⁹⁾ Furthermore, short and fragmented sleep patterns are independently associated with higher atherosclerotic plaque burden in middle-aged individuals in multiple territories. ⁽⁴⁰⁾

CONCLUSION

We demonstrated a significant prevalence of PS and SE factors affecting the CV health of women in LATAM, where variables such as violence at the workplace, anxiety, or irritability, living in cities with low population density, sleep disorders and pregnancy complications were independently associated with CVD. This is the most extensive survey to date showing the impact of SE and PS factors as NCDs on the CMB and CV health of women in LATAM, mainly in those > 45 years.

In this context, it is necessary to implement a gender mainstreaming approach in trials, research, and medical practice. The lack of attention in this regard constitutes a gender bias or gap that has had a negative impact on the diagnosis and prognosis of CVD in women.

Changes in policies, education and training, innovations in health care delivery, and diversification of cardiology are essential to overcome disparities that affect cardiovascular health in LATAM women. It is necessary to think of women as part of a whole rather than a simple part of a whole.

Study limitations

As this study is based on a non-probabilistic sample, it is difficult to accurately establish the prevalence of RFs in the target population. There is also a disproportion among respondents, with high participation of Argentine women and low representation of the rest of LATAM countries. The information gathered was self-reported by the participants, without corroborating the answers.

Conflicts of interest

None declared.

(See authors’ conflict of interests forms on the web).

Financing

None.

https://creativecommons.org/licenses/by-nc-sa/4.0/

©Revista Argentina de Cardiología

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APPENDIX

1) Analysis of variables

BMI: body mass index; HTN: hypertension; SD: standard deviation

2) Questionnaire of non-conventional determinants in Latin American women