Yogurt lids. A pink-handled chef's knife. Chocolate truffles embossed with a looped-ribbon logo. As most women know, there is no shortage of goods one can buy to support breast cancer research, and probably just about everyone knows the meaning of the familiar pink-ribbon icon.

But a red dress? That's something new.

Introduced in 2003, the National Heart, Lung, and Blood Institute's Heart Truth campaign and its Red Dress logo is designed to raise awareness that cardiovascular disease is the leading killer of women.

This is no longer a news flash -- but despite public service campaigns aimed at alerting women about the risk factors for heart disease, many women still believe that breast cancer is the biggest threat to their health (although an important health concern, it actually ranks sixth in causes of death for women in the United States).

What's more, gender disparities persist in cardiovascular disease treatment. For instance, women continue to receive less intensive treatments for acute myocardial infarctions, despite the fact that they are more likely than men to die within one year of a first recognized heart attack.

Duke Center for Women's Heart Care

Now, a group of female cardiologists at Duke is making inroads into this knowledge gap among women and the treatment gap among physicians.

Established in 2004, the Duke Center for Women's Heart Care is dedicated to raising awareness about women and heart disease and delivering multidisciplinary care designed specifically to meet women's heart health needs.

"Once the confusion concerning hormone replacement therapy and heart disease was resolved, the differences between men and women became more obvious as far as their risk factors, their awareness of the risk factors, their willingness to accept the risks, and to some extent the treatment of their heart disease," says Pamela Douglas, MD, former chief of cardiovascular medicine at Duke and past president of the American College of Cardiology.

"We want to be sure we take those differences into account so we can offer our patients the very best treatment in a more woman-friendly setting."

Profiling Prevention

The women's heart center is currently a virtual one, with its all-female staff of specialists seeing patients primarily at two satellite clinics in Durham and one in Raleigh (headed by Radha Kachhy, MD).

Even though they are not in one location, however, the cardiologists are consolidated in their efforts to educate women about heart disease and provide personalized information about their risk profiles and ways to reduce the development or progression of the disease.

Indeed, implementing preventive strategies could avert the majority of premature coronary heart disease worldwide. Douglas notes that the landmark 2004 INTERHEART study of patients in 52 countries identified nine factors that account for more than 90 percent of the risk of acute myocardial infarction.

The nine risk factors are:

• Smoking
• Lipids
• Hypertension
• Diabetes
• Obesity
• Diet
• Physical activity
• Alcohol
• Psychosocial

The factors are the same in almost every geographic region, consistent in men and women, easily assessed in clinical practice, and most importantly, modifiable.

But many women continue to be in denial about their personal risk of cardiovascular disease, perhaps because it appears about five to 10 years later in women compared to men.

"Cardiovascular risk evaluation should begin in the 20s," Douglas says. "Lab work should include a lipid profile and a fasting blood glucose, and patients should be encouraged to exercise, follow a healthy diet, lose weight if necessary, quit smoking, and deal more effectively with stress.

"The significance of some risk factors varies between men and women," Douglas continues. "For men bad cholesterol (LDL) is the most important thing, whereas in women, particularly younger women, it's the level of good cholesterol (HDL) that's important. And diabetes carries more of a risk in women."

Metabolic syndrome, a collection of health risks that increase the chance of developing heart disease, stroke, and diabetes, may be the most important marker for early detection of coronary disease in women, says Kristin Newby, MD, one of the physicians in the program.

"Many women who develop heart disease later in life may never have been given a diagnosis of hypertension or hypercholesterolemia, yet they clearly fit into the category of metabolic syndrome," Newby says. "Catching it early and implementing preventive strategies with these women can make a huge difference."

Vive la Difference?

Despite numerous initiatives to remedy the disparities, treatment for heart disease continues to vary according to sex.

From studies of data collected by ACTION, a cardiovascular disease quality-improvement initiative based at the Duke Clinical Research Institute, it's clear that women are less likely than men to receive evidence-based therapies, Newby says. "We need to better understand what is underlying that phenomenon so we can be sure women are receiving treatments that we know work today."

Perhaps one reason women are undertreated for their heart disease is that they often present with different symptoms than men. For instance, the chest pain or pressure of angina predicts heart disease in 80 percent or more of men, but it is only predictive in 50 to 60 percent of women.

Fatigue, nausea, flu-like symptoms, shortness of breath, and pain in the neck, jaw, or shoulder are all warning signs that occur more frequently in women, but may not be recognized.

Compared with men, women are more likely to be misdiagnosed and are more likely to die from their first heart attack than men are (38 percent vs. 25 percent). Of those who survive, 46 percent of women and 22 percent of men will become disabled with heart failure within six years, and 25 percent of women and 18 percent of men will have another heart attack within six years.

And even though more women than men die of heart disease each year, women receive only 33 percent of angioplasties, stents, and bypass surgeries; 28 percent of implantable defibrillators; and 36 percent of open-heart surgeries.

The Lady in Red

Clearly, women can benefit from education about heart disease and a more evidence-based approach to its treatment.

That's why the Duke Center for Women's Heart Care is geared toward raising awareness about women and heart disease and delivering multidisciplinary care to meet each patient's unique heart health needs, says Douglas, the program director. The center provides information about risk factors and women's wellness, and patients also receive a discount at Curves workout facility in Durham.

The Heart Center's director of community education, Leatrice Martin Short, is also developing a Web-based walking club and smoking cessation classes, and the clinic offers periodic risk-factor screening sessions in the community using the Framingham Point Score Estimate of 10-Year Risk for Women (PDF).

The kickoff of the Heart Truth national awareness campaign (with its icon, the Red Dress), coincided with the 2004 release of the American Heart Association's new evidence-based guidelines for cardiovascular disease prevention in women.

"The Red Dress efforts are bringing women's heart health into the limelight," Douglas says. "But many women still aren't getting the message that heart disease is probably what is going to kill you, and you need to prevent or reduce your risk factors instead of treating them later. Through the Duke clinic, we hope to get that message across to as many women as we can.

"So far the response to the clinic has been fabulous. We are providing something more for women. We are partnering with our patients, listening to them instead of telling them what to do. And that level of patient satisfaction is hard to come by."