Women are less likely than men to participate in cardiac rehabilitation (CR) programs despite findings that women achieve similar benefits in exercise capacity, quality of life, and risk factors.1,2 Updated meta-analyses confirm a 20% reduction in total adverse clinical outcomes, including cardiac mortality, for participants in comprehensive or exercise-only CR.3 Comprehensive CR incorporating multifaceted interventions4 to optimize function and reduce clinical outcomes may be the best source of motivation for changing behavior to reduce future risks for women with coronary disease, but cannot be effective if women do not participate. The reasons for lower participation in CR programs by women are multiple, including older age, less family support, fewer resources, lack of third-party coverage for services, limited access, and lack of encouragement and referrals by healthcare providers.5

In this issue, Murphy et al demonstrate that women's assessment of the causes of coronary heart disease (CHD) may be an important factor contributing to a lack of awareness and action about the need to modify behavior to improve cardiac risk factors.6 These Australian investigators enrolled 260 of 428 consecutive women admitted with myocardial infarction or undergoing coronary bypass surgery. A series of open-ended questions about perceptions of the causes of heart problems were asked prior to hospital discharge and at 4 and 12 months. The authors found a conspicuous disconnection between an individual woman's personal risks and her perceived notion of underlying cause for her own CHD and limited knowledge about the reasons for any woman's risk for coronary disease.6

Most publicized reports (including the present) have not directly compared perceptions of risk and causation between women and men. Nonetheless, the importance of patients' causal attribution may be most profound following myocardial infarction. A Swedish study of 98 men younger than 60 years determined that patients' attribution directly predicted change in both objective lifestyle and subjective functioning during rehabilitation, in addition to the level of underlying cardiac risk.7

The relative ignorance of the population regarding coronary artery disease risks is not a new finding, although the contributing risks most cited by women may differ by country of residence. The Australian women interviewed by Murphy et al were most likely to identify family history (43%) and smoking (38%) as causative factors, but only 13% cited high cholesterol and merely 5% identified hypertension even though 69% of women actually were hypertensive.6 Mosca et al recently surveyed a sample of women in the United States of whom only 7% had a prior heart attack or stroke. They reported that overweight and lack of physical activity were cited most frequently (by approximately 40%) as underlying causes of heart disease whereas 36% felt that smoking, 31% high cholesterol, 29% family history, 19% hypertension, and only 7% felt that diabetes contributed to cardiac disease.8 Importantly, only 38% of women reported ever having a discussion about reducing risks for cardiac disease with their healthcare provider.8 Another study of women undergoing coronary angiography found that only 30% recalled being told they were at risk for CHD regardless of the presence of a given risk factor.9 Only the presence of a family history of CHD increased the reported frequency of risk warnings from 27.6% to 37.9% (P = .04).9

A more surprising finding in the Murphy report is the lack of change in reported causal attributions in the months after participation in CR.6 This outcome serves as an indictment of the health education system, including the public health educational endeavor, transmission of information by healthcare providers, and importantly, the CR program itself. While the present study utilized a CR course that included both physical activity (45 minutes) and health education (45-60 minutes) in a group setting, the sessions occurred only once a week for 6 to 8 weeks. Women were considered attendees if they participated in at least one session. We are not told how many sessions were attended or if there was any correlation between participation in more sessions and the likelihood of improving awareness of causative factors for CHD. Recommendations for the CR curriculum generally support more frequent contact and longer duration, although alternatives to on-site, group programs are advocated for those who are unable to participate in structured group settings.5

The fact that the women in this study identified smoking as a cause of CHD highlights the potential effectiveness of public antismoking campaigns undertaken in Australia over recent years.5 In the United States, the higher recognition of high blood cholesterol as a cause of CHD may be due to national efforts to heighten awareness among the public and healthcare providers about the importance of identifying and reducing cholesterol levels. Government- and community- sponsored public programs, therefore, can alter prevailing beliefs about health. In the Mosca survey, approximately three fourths of the 1024 women recalled written, visual, or audio information about heart disease within the past 12 months.8 They cited the media, healthcare providers and the Internet as their most common sources of health information. White women identified magazines as important sources, while black women reported television as their most common source.8 While 93% of women felt that they would be comfortable discussing heart disease with their doctors, only 38% had actually done so.8 The role of the healthcare provider was not directly assessed in the Murphy study, but the failure to see changes in the subjects' beliefs about underlying causes of CHD implicates inadequate knowledge transfer by individual providers.

Murphy and colleagues conclude that individualized education and support are needed to improve patients' understanding of CHD and motivate needed behavior change.6 In addition, consideration of their findings in the broader international context confirming the discontinuity between perceived and actual risk mandates a multipronged effort to improve cardiovascular risk through reduction in modifiable causative factors. Individual practitioners should not be neglected when designing effective educational interventions. National and international agencies must identify and implement long-range campaigns targeting the gaps in health knowledge, awareness, and behavior. Cardiac rehabilitation programs can and should play an important role, but require flexibility in the delivery of a comprehensive and effective message. Women are finally receiving heightened attention in the drive to reduce the burden of CHD, but both men and women will benefit when research defines the underlying behavioral as well as physiologic roots for CHD and guides the design of effective interventions.

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