Cardiovascular disease is the leading cause of morbidity and mortality in women, contributes markedly to healthcare expenditures, and is projected to increase substantially by 2050 if current trends continue. There is growing recognition of the complex role of sex as a biologic variable and its influence on cardiovascular health and disease. However, cardiovascular risk remains underrecognized and underaddressed in girls and women, particularly as it relates to female-specific exposure to sex hormones (both endogenous and exogenous), which are systemic modulators of cardiovascular biology. Moreover, girls and women uniquely experience fragmented care spanning specialties, including pediatrics, adolescent medicine, primary care, obstetrics and gynecology, maternal-fetal medicine, cardiology, endocrinology, hematology, and neurology. Consequently, there is a need for a unified life course approach that addresses the female-specific interconnectedness of hormonal, psychosocial, and cardiovascular health. To address these gaps, the American Heart Association, in collaboration with the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine, established a Female Life Stage framework to optimize the prevention and management of cardiovascular disease in girls and women. Physiologic changes in sex hormones define clinically distinct life stages (ie, perimenarche, ovarian cycling, perimenopause, postmenopause), which directly inform female-specific considerations for screening, prevention, and management of cardiovascular disease. This presidential advisory details the framework and its scientific rationale, highlights opportunities for implementation across settings, and identifies priorities for research, clinician education, patient advocacy, and policy. This framework offers a transformative opportunity to equitably improve cardiovascular health for all girls and women.
There is growing recognition that the optimal prevention and management of cardiovascular disease in girls and women requires attention to sex-specific considerations relevant to the interconnected domains of hormonal, psychosocial, and cardiovascular health across the life course. Dysregulation in these health domains tends to co-occur and is associated with increased risk of cardiovascular disease. However, healthcare for girls and women is uniquely fragmented across clinical specialties, including pediatrics, adolescent medicine, primary care, obstetrics, maternal-fetal medicine, gynecology, cardiology, endocrinology, hematology, and neurology. Furthermore, inconsistent alignment across society guidelines contributes to missed opportunities to optimize cardiovascular health. Therefore, the American Heart Association, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine convened a multisociety science advisory group and developed the Female Life Stage construct. This construct defines 4 distinct and clinically meaningful stages-perimenarche (S1), ovarian cycling (S2), perimenopause (S3), and postmenopause (S4)-to enable female-specific screening, prevention, and treatment considerations. In addition, this construct incorporates pregnancy as a unique modifying life event when cardiovascular risk may emerge or be unmasked (eg, adverse pregnancy outcomes). This scientific statement crosswalks major society guidelines, synthesizes the evidence, and provides consensus-based clinical guidance for each Female Life Stage and interconnected health domain (ie, hormonal, psychosocial, and cardiovascular health). We conclude with a call to action to improve clinical workflows, enhance clinician education, and address scientific and implementation gaps to improve cardiovascular health in girls and women.