Volume 4 Supplement 1
© Grace et al; licensee BioMed Central Ltd 2004
Published: 25 August 2004
Cardiovascular disease (CVD) is the leading cause of death in Canadian women and men. In general, women present with a wider range of symptoms, are more likely to delay seeking medial care and are less likely to be investigated and treated with evidence-based medications, angioplasty or coronary artery bypass graft than men.
In 1998, 78,964 Canadians died from CVD, almost half (39,197) were women. Acute myocardial infarction, which increases significantly after menopause, was the leading cause of death among women.
Cardiovascular disease accounted for 21% of all hospital admissions for Canadian women over age 50 in 1999. Admissions to hospital for ischemic heart disease were more frequent for men, but the mean length of hospital stay was longer for women.
Mean blood pressure increases with age in both men and women. After age 65, however, high blood pressure is more common among Canadian women. More than one-third of postmenopausal Canadian women have hypertension.
Diabetes increases the mortality and morbidity associated with CVD in women more than it does in men. Depression also contributes to the incidence and recovery from CVD, particularly for women who experience twice the rate of depression as men.
Data Gaps and Recommendations
CVD needs to be recognized as a woman's health issue given Canadian mortality projections (particularly heart failure). Health professionals should be trained to screen, track, and address CVD risk factors among women, including hypertension, elevated lipid levels, smoking, physical inactivity, depression, diabetes and low socio-economic status.
Cardiovascular disease (CVD) is a leading cause of death in Canadian women and men. In general, the onset of CVD is approximately 10 years later in women than in men; women present with a wider range of symptoms; and women are less likely to seek medical care and are less likely than men to be investigated and treated for CVD with specific medications, angioplasty or coronary artery bypass graft [3–7]. Sex differences have also been described in CVD risk factors, including cigarette smoking, depression, low income, elevated serum lipids, hypertension, obesity and lack of physical activity[8, 9]. Vulnerable subpopulations include Aboriginal women[10, 11], South Asian women and women with diabetes mellitus.
The results of searches of MEDLINE, PsycINFO and Social Science Abstracts published in English from 1990 to 2002 were used to select the articles included in the literature review. Prevalence data were available through self-report in the National Population Health Survey (NPHS) 1998–1999 cycle and the 2000 Canadian Community Health Survey (CCHS). Vital statistics databases were analyzed to determine mortality by sex and province. Population rates of hospital admission for CVD by sex and province were obtained with the use of databases from the Canadian Institute for Health Information (CIHI). Data from the NPHS and the CCHS were analyzed to determine the associations of risk factors such as cigarette smoking, leisure-time activity and overweight with self-reported heart disease, as well as to examine vulnerable subgroups according to income, education, ethnicity/culture, social support, marital status and family structure, by sex and province. The results of the Canadian Heart Health Survey were examined to ascertain the prevalence of high serum cholesterol levels and hypertension, and people's knowledge of the major causes of CVD. International comparisons were obtained from Organization for Economic Co-operation and Development (OECD) data.
Prevalence and Incidence
The Canadian prevalence of CVD is available only through self-reported data from the NPHS or CCHS. When asked if they had CVD, 3.9% of men and 3.5% of women responded affirmatively, the highest proportion being reported by males in the Atlantic provinces. Although the mortality rate for CVD, particularly ischemic heart disease (IHD), is declining, it is unclear whether the incidence is decreasing as well or the decline in mortality simply reflects increased survival.
In 1998, there were 78,964 deaths attributable to CVD in Canada, with generally equivalent numbers in men (39,767) and women (39,197). Acute myocardial infarction (AMI), incidence of which in women increases significantly after menopause and continues to increase with advanced age, was the overall leading cause of death among women.
With regard to trends over time, mortality rates declined by half from 1969 to 1997. There is still uncertainty with regard to the causes of this decline, but it is suspected that the reduced incidence is partially explained by declines in risk factors as well as a reduction in case-fatality due to treatment advances. Over the lifespan, Canadian CVD/CBVD mortality rates increase substantially with age, and male rates are considerably higher than female rates for AMI and IHD. Rates of CBVD are similar among men and women until age 55, after which men have increased mortality until age 85, when mortality rates among women become higher.
CVD is the leading cause of death worldwide, but rates vary considerably between countries. In countries with established market economies, CVD and CBVD still contribute to approximately half of all deaths in spite of declines in mortality rates over the past 30 years. Overall, CVD mortality rates are about twice as high among men as women, but in many countries the actual number of deaths from CVD among women is similar to that among men because of their longer life expectancy.
Diabetes mellitus (DM) increases rates of mortality and morbidity from CVD more in women than in men and eliminates the advantage for women in all atherosclerotic disease outcomes except stroke [26–29]. Diabetic women are significantly more likely than diabetic men or non-diabetic women to have coronary events. DM is often associated with obesity, a sedentary lifestyle and lower socio-economic status (SES).
Depression also contributes to the incidence of and poorer recovery from CVD [31–36], particularly for women, who experience twice the rate of depression as men. Beaudet showed that Canadians aged 55 to 74 who had had a depressive episode in the previous 12 months were nearly three times as likely to have CVD within the following four years as people who had not experienced any depressive episode (odds ratio [OR] = 2.7, 95% confidence intervals [CI] 1.01–7.04). Frasure-Smith et al. analyzed the impact of gender and depression after AMI in a Canadian sample and found that 8.3% of the depressed women died of cardiac causes in contrast to 2.7% of the non-depressed. Depression during hospitalization was found to have a significant impact on long-term mortality, with the increased risk being largely independent of CVD severity. Patients of both sexes who experienced depression tended to report more advanced cardiac disease.
According to self-reported data, Canadian women and men with CVD tend to have annual income levels in the range of $5,000 to $30,000. Moreover, most Canadians with self-reported CVD have less than secondary education, and those with less education are more likely to show early stage atherosclerosis for any given age group. Socio-economic determinants act in part through an increased prevalence of risk factors, but they also have an independent effect that may be mediated through social isolation, coping styles, health behaviour, job strain or stress, and anger or hostility[41, 42].
Approximately 1 in 5 Canadians is a first-generation immigrant. In addition to genetic factors, immigrants tend to bring with them cultural habits (e.g. food choices, smoking behaviour) that influence their risk of developing CVD/CBVD. The largest non-European migrant groups are from China and South Asia, and these groups show lower all-cause mortality rates among both men and women. However, South Asian immigrant women have the highest rate of IHD among Canadian women[19, 44]. Studies from the United States show increased rates of IHD among Black women [45–47]. Canadian data indicate that 7.3% of Black women versus 2.8% of Black men have self-reported CVD, as compared with 3.5% and 3.9% for the entire population respectively.
Social Support/Family Structure
Social support plays an important role in an individual's ability to maintain a healthy lifestyle and recover from illness and surgery [48–51]. This may be a greater problem for women, many of whom are widowed or isolated. For instance, 6.8% of Canadian men with self-reported CVD versus 3.9% of women are married, and 15.6% of men with self-reported CVD versus 16.5% of women are widowed. Moreover, women with self-reported CVD are more often living on their own (9.7%), whereas men are most frequently living with a partner (11.5%). These differences in risk factors likely arise from the age-distribution shift in women's CVD.
Associations between Risk Factors and Self-Reported Heart Disease by Sex
Physical activity reduces CVD rates of morbidity and mortality among women. The Canadian Heart Health Survey reported that 36% of Canadian women aged 18 to 74 were classified as physically inactive based on their self-report of leisure-time physical activities. In the 1998–1999 NPHS, 53% of Canadian adults were classified as physically inactive, and this was more prevalent among Canadian women (56.9%) than men (48.6%), in populations with lower SES, and with increasing age (please also refer to the "Personal Health Practices" chapter in this report).
Cigarette smoking is the main preventable CVD risk factor for women and men. It is a stronger risk factor for AMI in middle-aged women than in men, and in women who use oral contraceptives. In 1998–1999, more men than women were daily smokers in all age groups except the under 24 group (21% of women versus 20% of men). For instance, daily smoking between the ages of 25 and 39 was reported by 30% of men and 28% of women, between the ages of 40 and 54 by 28% of men and 24% of women, and for those aged 55 and over by 18% of men and 13% of women. Smoking rates tend to be higher in Quebec and the Atlantic provinces than in other Canadian provinces (please also refer to the "Sex And Gender Differences in Smoking and Self Reported Indicators of Health in Canadian Women" chapter of this report).
Obesity is highly prevalent among Canadians, and notable increases across North America have been the trend. The Canadian Heart Health Survey reported that 41% of Canadian women aged 18 to 74 years were overweight (defined as a BMI of > 25 kg/m2), and 27% were obese (defined as a BMI > 27 kg/m2). The prevalence of obesity was shown to increase steadily with age and to be higher among men than women (please also refer to the "Physical Activity and Obesity in Canadian Women" chapter of this report).
Interventions Aimed at Women
Mortality from CVD and CBVD among Canadian women has generally declined over the past three to four decades. However, given that reduced mortality has been seen to a greater degree among men and those of northwestern European ancestry, we must do more. Unfortunately, there are currently no representative Canadian data concerning the efficacy of primary or secondary CVD prevention programs.
North American data generally show significant sex differences in referral to and participation in secondary prevention programs such as cardiac rehabilitation (CR) [55–60]. In general, 20% fewer women are enrolled in CR than men,[61, 62] a proportion significantly lower than expected on the basis of morbidity. Despite women's lower participation[64, 65], women of all ages benefit from CR [66–69], with improvements in functional capacity, coronary risk and psychosocial well-being that are comparable with or exceed those of men.
A gap exists in Canadian CVD surveillance data with regard to diagnosis and detection programs. Data from the Canadian Heart Health Survey (1986–1992) show that risk factors for CVD are under-diagnosed and under-detected. For instance, only 42% of Canadians with hypertension were aware that they had hypertension. Of those aged 18 to 74, 26% of men and 18% of women were hypertensive. Among men, 47% were unaware of their hypertensive state, for 21% the condition was not treated and was uncontrolled, for 19% it was treated but not controlled, and for 13% it was treated and under control. Among women, 35% were unaware of their hypertensive status, for 15% it was not treated and was uncontrolled, for 29% it was treated but not controlled, and for 20% it was treated and under control.
Canadian female AMI patients in every age group are less likely to undergo either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) revascularization[1, 71]. This may be partially explained by women's higher age at CVD onset, given that the best candidates for revascularization are younger individuals without comorbid conditions.
To improve our understanding and management of CVD among women, we must examine surveillance capabilities, research methodologies, and heart health policies and services (see also the gaps identified in the bulleted points below). With regard to the surveillance of the diagnosis and detection of CVD, we urgently need incidence estimators at the population level (such as the MONICA/ICONS project in Nova Scotia). We lack data on recent physical measures (i.e. hypertension, lipid profiles), for which self-reporting is notoriously poor. We need recent data on who is undergoing treatment for hypertension, hyperlipidemia and depression, and the effectiveness of these treatments. We are unable to capture the number of women or men undergoing stress tests, angiography, echocardiography or 24-hour blood pressure monitoring.
Information on risk factor incidence and prevalence across the lifespan is also lacking. Methodologically speaking, person-oriented data for women (and men) would enable us to follow Canadians longitudinally through the health care system and across the lifespan.
Surveillance data regarding health services evaluation are lacking. We are unable to determine the prevalence of medication prescription, compliance with treatment, or prevention of CVD and CBVD. Physician service utilization data for CVD/CBVD (as compared with those without CVD/CBVD), patient access to physician offices for prevention of CVD/CBVD (i.e. determined through physician billing data at the provincial level), and hospitalization data for patients with CVD/CBVD versus those without it are deficient. In short, the following gaps are notable:
• incidence indicators at the population level;
• recent data on physical measures, such as hypertension and lipid profile;
• information on people undergoing treatment for hypertension and hyperlipidemia, and the control rate;
• person-oriented data to follow people through the health care system;
• prevalence of prevention and detection programs, including community heart health and smoking cessation programs;
• national drug data for the treatment and prevention of CVD/CBVD;
• the changing prevalence of congestive heart failure; and
• the number of women and men undergoing stress tests, angiograms, echocardiography and holteronitoring.
With regard to healthy public policy, CVD needs to be recognized as a women's health issue, given the Canadian mortality projections, the aging population, and rampant inequities in health care access and provision. Health professionals should be trained to screen and address CVD risk factors in women, such as hypertension, elevated lipid levels, smoking, physical inactivity, depression, diabetes mellitus and low SES. We need to continue developing and evaluating educational resources for women across the lifespan regarding their risk for CVD and symptom presentation. Efforts to encourage healthy eating habits and physical activity through a multiplicity of approaches should be pursued. This may include working with local governments, workplaces, health care providers and the media to promote the importance of physical activity while recognizing the unique circumstances of women and girls (e.g. by providing a safe environment). Finally, attention must be paid to barriers to physical activity among women of diverse ethnocultural backgrounds and social classes.
The views expressed in this report do not necessarily represent the views of the Canadian Population Health Initiative, the Canadian Institute for Health Information or Health Canada.
- Canadian Institute for Health Information: Hospital Mortality Database. Ottawa: CIHI. 2002Google Scholar
- Milner KA, Funk M, Richards S, Wilmes RM, Vaccarino V, Krumholz HM: Gender differences in symptom presentation associated with coronary heart disease. Am J Cardiol. 1999, 84: 396-399. 10.1016/S0002-9149(99)00322-7.View ArticlePubMedGoogle Scholar
- Heart and Stroke Foundation of Canada: Women, heart disease and stroke in Canada. Ottawa. 1997Google Scholar
- Kudenchuk P, Maynard C, Martin J, Wirkus M, Weaver WD: Comparison of presentation, treatment, and outcome of acute myocardial infarction in males versus females. Am J Cardiol. 1996, 78: 9-14. 10.1016/S0002-9149(96)00218-4.View ArticlePubMedGoogle Scholar
- Majeed FA, Cook DG: Age and sex differences in the management of ischaemic heart disease. Public Health. 1996, 110: 7-12. 10.1016/S0033-3506(96)80027-8.View ArticlePubMedGoogle Scholar
- Schwartz LM, Fisher ES, Tostson ANA, Woloshin S, Chang C, Virnig BA, et al: Treatment and health outcomes of women and men in a cohort with coronary artery disease. Arch Intern Med. 1997, 157: 1545-1551. 10.1001/archinte.157.14.1545.View ArticlePubMedGoogle Scholar
- Vaccarino V, Krumholz HM, Yarzebski J, Gore JM, Goldberg RJ: Sex differences in two-year mortality after hospital discharge for myocardial infarction. Ann Intern Med. 2001, 134 (3): 173-181.View ArticlePubMedGoogle Scholar
- Abbey S, Stewart DE: Gender and psychosomatic aspects of ischemic heart disease. J Psychosom Res. 2000, 48 (5): 417-423. 10.1016/S0022-3999(99)00112-9.View ArticlePubMedGoogle Scholar
- Lonn E: Epidemiology of ischemic heart disease in women: women and ischemic heart disease. Canadian Cardiovascular Society, Consensus Conference. 2000Google Scholar
- Shah BR, Hux JE, Zinman B: Increasing rates of ischemic heart disease in the native population. Arch Intern Med. 2001, 160 (12): 1862-1866. 10.1001/archinte.160.12.1862.View ArticleGoogle Scholar
- Anand S, Tookenay V: Cardiovascular diseases and aboriginal peoples. Can J Cardiol. 1999, 15 (Suppl G): 44G-46G.PubMedGoogle Scholar
- Shin AY, Anand SS, Wall C, Tu JV, Yusuf S, Naylor DC: Ethnoracial origins and heart disease. In: Cardiovascular health and services in Ontario. Edited by: Naylor DC, Slaughter PM. 1999, Toronto: Institute for Clinical Evaluative Sciences and Heart and Stroke Foundation of Ontario, 267-282.Google Scholar
- Shin AY, Jaglal S, Slaughter PM, Iron K: Women and heart disease. In: Cardiovascular health and services in Ontario. Edited by: Naylor DC, Slaughter PM. 1999, Toronto: Institute for Clinical Evaluative Sciences and Heart and Stroke Foundation of Ontario, 336-354.Google Scholar
- Statistics Canada: National Population Health Survey:. 1998, –99. Ottawa: Health Statistics Division, Statistics Canada.Google Scholar
- Canadian Community Health Survey: [http://www.statcan.ca/english/concepts/health/]
- Statistics Canada: Vital statistics. 1999Google Scholar
- MacLean DR, Petrasovits A, Nargundkar M, et al: Canadian Heart Health Surveys: a profile of cardiovascular risk. Survey methods and data analysis. Canadian Heart Health Surveys Research Group. Can Med Assoc J. 1992, 146 (11): 1969-1974.Google Scholar
- Organization for Economic Co-operation and Development. International mortality data. OECD. 2001
- Heart and Stroke Foundation of Canada: The changing face of heart disease and stroke in Canada. Ottawa. 2000, 1-107.Google Scholar
- Advisory Board of the First International Conference on Women, Heart Diseases and Stroke. The 2000 Victoria declaration on women, heart diseases, and stroke. CVD Prev. 2000, 3: 174-327.
- Heart and Stroke Foundation of Canada: Heart disease and stroke in Canada. Ottawa. 1995Google Scholar
- Kirkland SA, MacLean DR, Langille DB, Joffres MR, MacPherson KM, Andreou P: Knowledge and awareness of risk factors for cardiovascular disease among Canadians 55 to 74 years of age: results from the Canadian Heart Health Surveys, 1986–1992. Can Med Assoc J. 1999, 161 (Suppl 8): S10-S16.Google Scholar
- Langille DB, Joffres MR, MacPherson KM, et al: Prevalence of risk factors for cardiovascular disease. Can Med Assoc J. 1999, 161: S3-S9.Google Scholar
- Connelly PW, MacLean DR, Horlick L, O'Connor B, Petrasovits A, Little JA: Plasma lipids and lipoproteins and the prevalence of risk for coronary heart disease in Canadian adults. Can Med Assoc J. 1992, 146 (11): 1977-1987.Google Scholar
- Health Canada: Canadians and heart health: reducing the risk. Ottawa. 1995Google Scholar
- Wilson PWF: Diabetes mellitus and coronary heart disease. Am J Kidney Dis. 1999, 32 (Suppl 3): S89-S100.Google Scholar
- Sowers JR: Diabetes mellitus and cardiovascular disease in women. Arch Intern Med. 1998, 158: 617-621. 10.1001/archinte.158.6.617.View ArticlePubMedGoogle Scholar
- Pan WH, Cedres LB, Liu K: Relationship of clinical diabetes and asymptomatic hyperglycemia to risk of coronary heart disease mortality in men and women. Am J Epidemiol. 1986, 123 (3): 504-516.PubMedGoogle Scholar
- Gaba MK, Gaba S, Clark LT: Cardiovascular disease in patients with diabetes: clinical considerations. J Assoc Academic Minority Physicians. 1999, 10 (1): 15-22.Google Scholar
- Beckles GL, Thompson-Reid PE: Socioeconomic status of women with diabetes – United States 2000. MMWR. 2002, 51 (7): 147-148.Google Scholar
- Ferketich AK, Schwartzbaum JA, Frid DJ, Moeschberger ML: Depression as an antecedent to heart disease among women and men in the NHANES I study. Arch Intern Med. 2000, 160 (9): 1261-1268. 10.1001/archinte.160.9.1261.View ArticlePubMedGoogle Scholar
- Lane D, Carroll D, Ring C, Beevers DG, Lip GYH: Effects of depression and anxiety on mortality and quality-of-life four months after myocardial infarction. J Psychosom Res. 2000, 49: 229-238. 10.1016/S0022-3999(00)00170-7.View ArticlePubMedGoogle Scholar
- Stansfeld SA, Fuhrer R, Shipley MJ, Marmot M: Psychological distress as a risk factor for coronary heart disease in the Whitehall II study. Int J Epidemiol. 2002, 31: 248-255. 10.1093/ije/31.1.248.View ArticlePubMedGoogle Scholar
- Schwartzman JB, Glaus KD: Depression and coronary heart disease in women: implications for clinical practice and research. Professional Psychology: Research and Practice. 2000, 31 (1): 48-57. 10.1037//0735-7028.31.1.48.View ArticleGoogle Scholar
- Ziegelstein R, Fauerbach J, Stevens S, Romanelli J, Ritcher D, Bush D: Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. Arch Intern Med. 2000, 160 (12): 1818-1823. 10.1001/archinte.160.12.1818.View ArticlePubMedGoogle Scholar
- Wassertheil-Smoller S, Applegate WB, Berge K, Chang CJ, Davis BR, Grimm R, et al: Change in depression as a precursor of cardiovascular events. Arch Intern Med. 1996, 156: 553-561. 10.1001/archinte.156.5.553.View ArticlePubMedGoogle Scholar
- Nolen-Hoeksema S, Larson J, Grayson C: Explaining the gender difference in depressive symptoms. J Pers Soc Psychol. 1999, 77 (5): 1061-1072. 10.1037//0022-35126.96.36.1991.View ArticlePubMedGoogle Scholar
- Beaudet M: Depression and incident heart disease. Toronto: Annual Epidemiology Conference. 2001Google Scholar
- Frasure-Smith N, Lesperance F, Juneau M, Talajic M, Bourassa MG: Gender, depression, and one-year prognosis after myocardial infarction. Psychosom Med. 1999, 61 (1): 26-37.View ArticlePubMedGoogle Scholar
- Gallo LC, Matthews KA, Kuller LH, Sutton-Tyrrell K, Edmundowicz D: Educational attainment and coronary aortic calcification in post-menopausal women. Psychosom Med. 2001, 63 (6): 925-935.View ArticlePubMedGoogle Scholar
- Escobedo LG, Giles WH, Anda RF: Socioeconomic status, race, and death from coronary heart disease. Am J Prev Med. 1997, 13: 123-130.PubMedGoogle Scholar
- Kaplan G, Keil J: Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation. 1993, 88 (4 pt 1): 1973-1998.View ArticlePubMedGoogle Scholar
- Rubia M, Marcos I, Muenning AP: Increased risk of heart disease and stroke among foreign-born females residing in the United States. Am J Prev Med. 2002, 22 (1): 30-35. 10.1016/S0749-3797(01)00400-7.View ArticlePubMedGoogle Scholar
- Bhopal R: Epidemic of cardiovascular disease in South Asians. BMJ. 2002, 324: 625-626. 10.1136/bmj.324.7338.625.PubMed CentralView ArticlePubMedGoogle Scholar
- Rosenberg L, Palmer JR, Rao RS, Adams-Campbell LL: Risk factors for coronary heart disease in African-American women. Am J Epidemiol. 1999, 150 (9): 904-909.View ArticlePubMedGoogle Scholar
- Sundquist J, Winkleby MA, Pudaric S: Cardiovascular disease risk factors among older Black, Mexican-American, and White women and men: an analysis of NHANES III, 1988–1994. Third national health and nutrition examination. J Am Geriatr Soc. 2001, 49 (2): 109-116. 10.1046/j.1532-5415.2001.49030.x.View ArticlePubMedGoogle Scholar
- Tofler GH, Stone PH, Muller JE: Effects of gender and race on prognosis after myocardial infarction: adverse prognosis for women, particularly Black women. J Am Coll Cardiol. 1987, 9 (3): 473-482.View ArticlePubMedGoogle Scholar
- Cohen S, Kaplan JR, Manuck SB: Social support and coronary heart disease: underlying psychological and biological mechanisms. In: Social support and cardiovascular disease. Plenum series in behavioral psychophysiology and medicine. Edited by: Shumaker SA, Czajkowski SM. 1994, New York: Plenum Press, 195-221.View ArticleGoogle Scholar
- Ell K, Dunkel-Schetter C: Social support and adjustment to myocardial infarction, angioplasty, and coronary artery bypass surgery. In: Social support and cardiovascular disease. Plenum series in behavioral psychophysiology and medicine. Edited by: Shumaker SA, Czajkowski SM. 1994, New York: Plenum Press, 301-332.View ArticleGoogle Scholar
- Holahan CJ, Moos RH, Holahan CK, Brennan PL: Social support, coping, and depressive symptoms in a late-middle-aged sample of patients reporting cardiac illness. Health Psychol. 1995, 4 (2): 152-163. 10.1037/0278-6188.8.131.52.View ArticleGoogle Scholar
- Orth-Gomer K: International epidemiological evidence for a relationship between social support and cardiovascular disease. In: Social support and cardiovascular disease. Plenum series in behavioral psychophysiology and medicine. Edited by: Shumaker SA, Czajkowski SM. 1994, New York: Plenum Press, 97-117.View ArticleGoogle Scholar
- Brummett BH, Barefoot JC, Siegler IC, Clapp-Channing NE, Lytle BL, Bosworth HB, et al: Characteristics of socially isolated patients with coronary artery disease who are at elevated risk for mortality. Psychosom Med. 2001, 63: 267-274.View ArticlePubMedGoogle Scholar
- Stephens T: International trend in the prevalence of physical activity and other health determinants. Orlando: Federation international de médecin du sport, World Congress of Sports Medicine. 1998Google Scholar
- Statistics Canada: National Population Health Survey overview, 1996–97. Ottawa: Minister of Industry, Cat. No. 82-567-XPB. 1998Google Scholar
- Barber K, Stommel M, Kroll J, Holmes-Rovner M, McIntosh B: Cardiac rehabilitation for community-based patients with myocardial infarction: factors predicting discharge recommendation and participation. J Clin Epidemiol. 2001, 54 (10): 1025-1030. 10.1016/S0895-4356(01)00375-4.View ArticlePubMedGoogle Scholar
- Burns KJ, Camaione DN, Froman RD, Clark BA: Predictors of referral to cardiac rehabilitation and cardiac exercise self-efficacy. Clin Nurs Res. 1998, 7 (2): 147-163. 10.1177/105477389800700205.View ArticlePubMedGoogle Scholar
- Cannistra LB, Balady GJ, O'Malley CJ, Weiner DA, Ryan TJ: Comparison of the clinical profile and outcome of women and men in cardiac rehabilitation. Am J Cardiol. 1992, 69: 1274-1279. 10.1016/0002-9149(92)91220-X.View ArticlePubMedGoogle Scholar
- Carhart R, Ades P: Gender differences in cardiac rehabilitation. Cardiol Clin. 1998, 16 (1): 37-43. 10.1016/S0733-8651(05)70382-9.View ArticlePubMedGoogle Scholar
- Caulin-Glaser T, Blum M, Schmeizl R, Prigerson HG, Zaret B, Mazure CM: Gender differences in referral to cardiac rehabilitation programs after revascularization. J Cardiopulm Rehabil. 2001, 21: 24-30. 10.1097/00008483-200101000-00006.View ArticlePubMedGoogle Scholar
- Cristian A, Mandy K, Root B: Comparison between men and women admitted to an inpatient rehabilitation unit after cardiac surgery. Arch Phys Med Rehabil. 1999, 80: 183-185. 10.1016/S0003-9993(99)90118-1.View ArticlePubMedGoogle Scholar
- Grace SL, Abbey S, Shnek Z, Irvine J, Franche RI, Stewart D: Cardiac rehabilitation II: referral and participation. Gen Hosp Psychiatry. 2002, 24 (3): 127-134. 10.1016/S0163-8343(02)00178-0.View ArticlePubMedGoogle Scholar
- Ades P, Waldmann M, Polk D, Coflesky J: Referral patterns and exercise response in the rehabilitation of female coronary patients aged > 62 years. Am J Cardiol. 1992, 69: 1422-1425. 10.1016/0002-9149(92)90894-5.View ArticlePubMedGoogle Scholar
- Thomas R, Miller N, Lamendola C, Berra K, Hedback B, Durstine J, et al: National survey of gender differences in cardiac rehabilitation programs. J Cardiopulm Rehabil. 1996, 16: 402-412. 10.1097/00008483-199611000-00010.View ArticlePubMedGoogle Scholar
- Hawthorne MH: Women recovering from coronary artery bypass surgery. Scholarly Inquiry for Nursing Practice: An International Journal. 1993, 7 (4): 223-52.Google Scholar
- Schuster P, Waldron J: Gender differences in cardiac rehabilitation patients. Rehabil Nurs. 1991, 16 (5): 248-253.View ArticlePubMedGoogle Scholar
- O'Callaghan W, Teo K, O'Riordan J, Webb H, Dolphin T, Horgan JH: Comparative response of male and female patients with coronary artery disease to exercise rehabilitation. Eur Heart J. 1984, 5: 649-651.PubMedGoogle Scholar
- Oldridge N, LaSalle D, Jones N: Exercise rehabilitation of female patients with coronary heart disease. Am Heart J. 1980, 100: 755-757. 10.1016/0002-8703(80)90244-6.View ArticlePubMedGoogle Scholar
- O'Farrell P, Murray J, Huston P, LeGrand C, Adamo K: Sex differences in cardiac rehabilitation. Can J Cardiol. 2000, 16 (3): 319-325.PubMedGoogle Scholar
- Lavie C, Milani R, Cassidy M, Gilliland Y: Effects of cardiac rehabilitation and exercise training programs in women with depression. Am J Cardiol. 1999, 83: 1480-1483. 10.1016/S0002-9149(99)00127-7.View ArticlePubMedGoogle Scholar
- Joffres MR, Ghadirian P, Fodor JG, Petrasovits A, Chockalingam A, Hamet P: Awareness, treatment, and control of hypertension in Canada. Am J Hypertens. 1997, 10 (10): 1097-1102. 10.1016/S0895-7061(97)00224-0.View ArticlePubMedGoogle Scholar
- Johansen H, Nair C, Wolfson M: Revascularization and heart attack outcomes. Health Rep. 2002, 13 (2): 35-46.PubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.