Heart Disease Treatment in Women

  • Medical Author:
    Mimi Guarneri, MD, FACC, ABIHM

    Dr. Mimi Guarneri, MD, FACC, ABIHM, is board certified in cardiovascular disease, internal medicine, nuclear medicine, and holistic medicine. Dr. Guarneri is president of the American Board of Integrative Holistic Medicine and serves as Senior Advisor to the Atlantic Health System for the Center for Well Being and Integrative Medicine. Dr. Guarneri is founder and director of Guarneri Integrative Health, Inc. and Taylor Academy for Integrative Medicine Education and Research located at Pacific Pearl La Jolla in La Jolla, CA.

  • Medical Author: Erica Oberg, ND, MPH
    Erica Oberg, ND, MPH

    Dr. Erica Oberg, ND, MPH, received a BA in anthropology from the University of Colorado, her doctorate of naturopathic medicine (ND) from Bastyr University, and a masters of public health (MPH) in health services research from the University of Washington. She completed her residency at the Bastyr Center for Natural Health in ambulatory primary care and fellowship training at the Health Promotion Research Center at the University of Washington.

  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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What is heart disease in women?

Heart disease is the most common cause of death among women. The vast majority of women have at least one risk factor for heart disease.

What is the treatment for heart disease in women?

In 2004, for the first time, female-specific guidelines were developed by the American Heart Association (AHA) in recognition of the gender differences in both the mechanisms and presentation of cardiovascular disease. In 2011, the guidelines were updated and, also for the first time, the AHA discussed the characteristics of "ideal cardiovascular health." Ideal cardiovascular health includes:

Successful treatments for cardiovascular disease address all of these aspects using lifestyle changes as well as medications and surgical interventions (like angioplasty), if necessary.

Diet

The classical heart healthy diet is low fat (<10% saturated fat and <300 mg cholesterol); however, low-fat diets tend to raise triglycerides (TG) and decrease HDL (known risk factors for women). New National Cholesterol Education Panel (NCEP) guidelines recognize that the type of fat matters as much, if not more, than the quantity. It is important to differentiate the good quality fats and eat sufficient quantities while limiting saturated fat, trans fats, and animal fat in general. Heart healthy fats should be consumed to make up 20% to 25% of the diet. Good fats are mono- and poly-unsaturated fats such as olive oil and plant fats (avocado, nuts, seeds, and coconut oil). Unhealthy fats come from animal sources (especially red meat) and processed foods (such as cookies and pastries, especially ones packaged for long shelf life). Several dietary patterns are consistent with this information and are known to protect against and help reverse cardiovascular disease. These include the Dietary Approaches to Stop Hypertension (DASH) diet, the Mediterranean diet, and the Ornish vegetarian diet.

The DASH diet is characterized by being low in saturated fat, cholesterol, and total fat. It is focused on fruits, vegetables, and fat-free or low-fat dairy products. It is rich in whole grains, fish, poultry, beans, seeds, and nuts, and contains fewer sweets, added sugars, sugary beverages, and red meats than the typical American diet. The DASH diet has been studied extensively by researchers, and it consistently helps people lower blood pressure, lose weight, and improve cholesterol levels.

Another well-studied protective pattern is the Mediterranean diet. Adherence to the Mediterranean dietary pattern has been associated with lower all-cause mortality, less cardiovascular disease, as well as lower rates of dementia, diabetes, and cancer. Additionally, following a Mediterranean diet leads to improvement in overall health. A Mediterranean dietary pattern consists of high amounts of fresh fruits and vegetables, healthy fats such as olive oil and low-fat yogurt, plant and marine-based proteins, and moderate wine. Meats and sweets are only rarely consumed. Recently, the large PREDIMED trial compared a low-fat diet to two versions of a Mediterranean diet, enhanced with either olive oil or extra nuts. While all the diets reduced blood pressure, the Mediterranean diets reduced rates of myocardial infarction, stroke, and the number of deaths from cardiovascular causes over a period of about 5 years. The Mediterranean diet also reduced blood sugar and inflammation, as measured by high-sensitivity C-reactive protein (hs-CRP).

The Ornish vegetarian diet has also been well-studied and has been shown to not only treat but also reverse heart disease. The Ornish diet is very low in fat and includes more carbohydrate than the Mediterranean or DASH diet; however, the carbohydrates are from whole grains such as oatmeal, quinoa, and brown rice and legumes such as beans and lentils. The research on the Ornish diet emphasizes that the diet is not the only answer; to reverse heart disease, people must make overall lifestyle changes including being physically active, addressing their emotional heart with group support, and practicing meditation or yoga.

What the DASH, Mediterranean, and Ornish diets have in common is that they are all based on unrefined fresh foods, primarily from plants. Importantly for women with cardiovascular disease, the DASH and Mediterranean dietary patterns are low in refined carbohydrates, which means they will help lower triglycerides and increase HDL -- two major contributors to cardiovascular disease for women.

Quick GuideHeart Disease: Causes of a Heart Attack

Heart Disease: Causes of a Heart Attack

Symptoms of Heart Disease in Women

Signs include hypertension, angina, edema (fluid accumulation in tissues), palpitations, and vague symptoms that are often confused with indigestion or musculoskeletal pain. Overall symptoms get worse with exertion and improve with rest. Women are more likely than men to experience unstable angina (chest pain or sensations that occur irregularly and unpredictably).

Some women experience classic angina symptoms such as chest pain or pressure but more commonly, women experience:

  • chest tightness
  • squeezing
  • burning
  • sense of discomfort

Exercise

Almost all women can benefit from increasing the amount of physical activity they get. It is also important to increase the frequency and intensity of exercise. One tool women can use to plan more physical activity is to use the FITT tool, which helps women create an achievable definition for the Frequency, Intensity, Timing, and Type of activity for them. Once activities are selected, women should strive to accumulate at least 150 minutes per week in moderate-intensity exercise.

For each unit of increased exercise capacity a woman achieves, she experiences at 17% reduction in CVD mortality. To determine if you have an age-appropriate exercise capacity, first calculate your maximum heart rate. To do this, subtract your age from 220 (for example, the calculation for a 65-year-old woman would be: 220-65=155). You should be able to reach 85% of your predicted maximum heart rate (be sure to warm up first) and recover your breath within 1 minute of stopping. To calculate 85% of your maximum heart rate, multiply your maximum heart rate by 0.85 (for example, 155 x 0.85=132).

Weight management

Weight management is especially important because 2 out of 3 women in the United States are overweight or obese. Excess body weight directly increases CVD risk and also leads to a number of conditions that indirectly increase the risk of a heart attack such as diabetes and hypertension. When women adopt healthier lifestyle practices and reduce weight, they immediately reduce the risk of developing more significant heart disease. A recent study showed that women who lost just 10 percent of their body weight and kept it off for 2 years reduced their cholesterol, triglycerides, insulin, glucose, and inflammation markers. Women who had the highest levels of risk at the start of the study benefitted the most from modest weight loss.

Smoking cessation

Quitting smoking both reduces risk for future coronary events and improves health status in the presence of existing cardiovascular disease. Even small amounts of smoking (1 to 14 cigarettes per day) have a significant negative impact. According to research in the Nurses' Health Study, the benefits of quitting are experienced very quickly. Within 2 years of quitting, cardiovascular risk decreases by one-third. Women continue to benefit for each year they abstain; women who haven't smoked for 20 years are at almost equivalent risk as never-smokers. However, quitting smoking is more difficult for women than for men, according to research, because women report using tobacco to self-treat depression, anxiety, weight, and more. In order for women to be successful, they should seek support to address the risk of weight gain and underlying mood issues.

Stress reduction and depression

Stress is a significant and measurable contributor to heart disease. Stress not only raises blood pressure, it impacts our ability to stick with the healthy lifestyle behaviors that are needed to manage and prevent heart disease. There are clear benefits to engaging in stress reducing activities. For example, a recent study suggests that transcendental meditation may help in secondary prevention of coronary heart disease (preventing a secondary heart attack) and may reduce all cardiovascular events by 48% over a 5-year period. Recommendations for meditation, yoga, and similar approaches have even made it into the American Heart Association's recommendations for blood pressure treatment.

For many women, the idea of reducing stress is hard to imagine when the day is already over-full with work, errands, cooking, and taking care of others. While it may seem overwhelming to fit in a separate stress-reducing activity, practices such as mindfulness-based stress reduction (MBSR) are techniques for bring a new perspective and enhanced calmness into day-to-day activities. Studies have demonstrated improvement in stroke recovery with MBSR as well as blood pressure reductions. Mindfulness programs are readily available in many communities.

Screening for and treating depression is also an important part of treating heart disease in women. Women suffer from depression more often than men. Questionnaires like the PHQ-8 can help women and their doctors identify depression quickly. A similar screener is available at Mental Health America. Treatment options such as cognitive behavioral therapy (CBT) and mindfulness training are as effective as antidepressant medication and may have beneficial effects in stress reduction, too.

Quick GuideHeart Disease: Causes of a Heart Attack

Heart Disease: Causes of a Heart Attack

Medications for heart disease in women

Aspirin therapy is a simple and beneficial strategy for both men and women with or at risk for heart disease. Aspirin is especially beneficial for women with angina, hypertension, or previous myocardial infarction. Other medications, available by prescription, have only recently been studied in women. Research now shows show that, in some cases, women respond differently than men to prescription medications and thus doctors may need to personalize prescribing for women. For example, women respond less well to the common anticoagulant, warfarin; they have more adverse bleeding events. Women taking warfarin for atrial fibrillation are at a higher risk for having a stroke compared to men. There are other medications, for example:

  • Beta blockers: These medications appear to be more helpful for women who have had a heart attack.
  • Statins: These medications reduce cholesterol and possibly inflammation and are likely of equal benefit for women and men; however, women have more adverse effects such as myopathy (muscle damage).
  • ACE inhibitors: This is a class of medications that cause blood vessels to relax and may confer less benefit for women. Common side effects such as cough and angioedema are more likely in women. However, they may still be appropriate for many women; women should discuss their options with their doctors.

Historically, it was thought that hormone replacement therapy (HRT) was a therapeutic option to prevent and treat heart disease in women, but the results of several large studies (including the Women's Health Initiative) have proven that HRT with conjugated equine estrogens and progestins increase the risk of CVD for women despite improving lipid levels. Other evidence-based options are available to address the lipid patterns most common in women (high triglycerides and low HDL) such as omega-3 fatty acids from fish oil and niacin.

Angioplasty and stents

Angioplasty involves threading a balloon-tipped catheter into an area of atherosclerosis and inflating it to push the atheroma or fatty deposits against the wall of the artery and reopen the vessel. This is also called a percutaneous intervention (PCI) procedure. Usually, a mesh stent is also put in place, providing a scaffold to hold the blood vessel open. Increasingly, stents include medications that slowly release to keep the blood vessel open. Research shows that PCIs may be better option for women (as compared to coronary artery bypass grafts). However, women have smaller vessels that require more skilled placement of stents. Women are at higher risk of restenosis (a recurrent narrowing of the artery following stent placement), but this may be decreasing with use of drug-eluding stents. Women also have higher rates of complications and bleeding during angioplasty.

Coronary artery bypass grafting (CABG)

Coronary artery bypass grafting is a major surgical procedure in which a blocked vessel is circumvented by sewing in a new vessel next to it, usually taken from the saphenous vein of the leg. This procedure is less commonly done in women (more women get PCIs), and when done, women have more complications. It is thought that this increase in risk is due to the smaller vessels, older age, and increased rates of bleeding issues seen among women. Women undergoing these procedures can reduce their risk of complications with proper surgical preparation and enrolling in cardiac rehabilitation programs afterward.

What is the prognosis for heart disease in women?

Heart disease is the leading cause of death among women. The statistics are that while 1 in 31 American women dies from breast cancer each year, 1 in 3 dies of heart disease. An estimated 90% of women have at least one CVD risk factor. Heart attack symptoms can be different for women and women may not recognize symptoms and call for help in a timely manner. Stroke symptoms can also go unrecognized. Getting treatment immediately -- within 90 minutes for heart attacks or within 4 hours for strokes -- can make the difference between survival, life-long disability, and death.

Women who have already experienced a heart attack (myocardial infarction) or stroke (cerebrovascular event) have a lot that they can do to ensure a successful prognosis. Participation in cardiac and stroke rehabilitation programs is very important. Women should become enrolled in a rehabilitation program before they are released from the hospital so they can start as soon as their doctors allow. It is less common for women to be referred to these programs, so women and their families should advocate for themselves to ensure rapid enrollment. Cardiac rehabilitation programs, such as Dean Ornish's Lifestyle Heart Program, include nutrition advice, supervised exercise training, careful management of medications, psychosocial support, and more. Nearly 2 decades of research has shown that coronary artery disease can not only be managed with comprehensive lifestyle changes, but it can actually be reversed.

Quick GuideHeart Disease: Causes of a Heart Attack

Heart Disease: Causes of a Heart Attack

Can heart disease in women be prevented?

Heart disease is not inevitable for women! Practicing a healthy lifestyle, identifying and treating risk factors and early signs of preclinical disease, and learning to recognize the symptoms of a heart attack or stroke all make a difference and have been proven to prevent heart disease.

Healthy lifestyle changes should be comprehensive. Eating well, such as following a Mediterranean dietary pattern, not only reduces the risk of cardiovascular disease, it reduces risk of other major chronic diseases like cancer. And it is delicious too! A true Mediterranean diet includes unlimited amounts of fruits and vegetables, beans, legumes, and fish. It does not include large amounts of pasta or bread or meat, although these things can be enjoyed occasionally. Most women need intentional exercise beyond their activities of daily living. Women should be able to reach 85% of their age-predicted exercise capacity; women who do have this level of fitness have half the risk of a coronary event compared to women who cannot exercise at 85% of age-predicted capacity. Women need to attend to the stress in their lives, developing healthy stress coping strategies, engaging in stress reduction activities, and evaluating areas of their lives in which they can remove stressful situations.

What research is being done on heart disease in women?

Historically, research has lacked equal representation of women in studies. In 1985, the U.S. Preventive Services Task Force (USPSTF) -- the task force that reviews evidence and makes public health recommendations for health professionals -- launched a campaign to change this. It has made a difference; more women are enrolled in studies and we now know a lot about the differences and similarities in vascular disease among men and women. Additionally, in 2011, the American Heart Association issued a new set of recommendations about CVD among women. This document recommends a new system of risk classification for women that more accurately helps women and their doctors identify and quantify risk, thereby helping more women get appropriate testing, recommendations, and treatment. Using the new criteria, women fall into three categories.

  • High-risk: This risk category is defined by the presence of current disease such as CVD, diabetes, chronic kidney disease, or a 10-year Framingham risk >20%.
  • At-risk: The definition of at-risk includes the presence of one or more risk factors including metabolic syndrome, evidence of subclinical vascular disease (for example, coronary calcification), or poor exercise tolerance on treadmill testing.
  • Optimal risk: This defines women who have successfully minimized their risk factors and is defined as a Framingham Risk score <10% and engagement in healthy lifestyle behaviors.

When these criteria were applied to over 160,000 women aged 50 to 79 enrolled in the Women's Health Initiative, 11% were found to be at high risk, 72% were at risk, and only 4% were at optimal risk (13% were unclassifiable). Among high-risk, at-risk, optimal risk, and unclassified women, the rates of myocardial infarction, death due to cardiovascular causes, or stroke were 19.0%, 5.5%, 2.2%, and 2.6% per 10 years, respectively. This is a big difference. Women who engage in healthy lifestyle behaviors and optimally control risk factors have only a 2% risk of a serious event, compared to high-risk women who have nearly a 20% risk of a serious event. This underscores the importance of prevention and healthy lifestyle for all women.

Medically reviewed by Robert J. Bryg, MD; Board Certified Internal Medicine with subspecialty in Cardiovascular Disease

REFERENCES:

"What Is the DASH Eating Plan?" National Heart, Lung, and Blood Institute. 6 Jun 2014.

Aziz, F. "Coronary Artery Disease in Women: An Unsolved Dilemma." Journal of Clinical Medicine Research 6.2 (2014): 86-90.

Bhardwaj, S., et al. "Muscular effects of statins in the elderly female: a review." Clinical Interventions in Aging 8 (2013): 47-29.

Brook, R. D., et al. "Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the american heart association." Hypertension 61.6 (2013): 1360-1383.

Dow, C. A., et al. "Predictors of improvement in cardiometabolic risk factors with weight loss in women." Journal of the American Heart Association 2.6 (2013): e000152.

Estruch, R., et al. "Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial." Annals of Internal Medicine 145.1 (2006): 1-11.

Estruch, R., et al. "Primary prevention of cardiovascular disease with a Mediterranean diet." New England Journal of Medicine 368.14 (2013): 1279-1290.

Fan, X., et al. "Polymorphisms of ACE2 gene are associated with essential hypertension and antihypertensive effects of captopril in women." Clinical Pharmacology and Therapeutics 82.2 (2007): 187-196.

Flynn, R. M., et al. "The Cardiology Audit and Registration Data Standards (CARDS), European data standards for clinical cardiology practice." European Heart Journal 26.3 (2005): 308-313.

Gottlieb, S. S., et al. "Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction." New England Journal of Medicine 339 (1998): 489-497.

Gulati, M., et al. "The prognostic value of a nomogram for exercise capacity in women." New England Journal of Medicine 353.5 (2005): 468-475.

Hughes, J. W., et al. "Randomized controlled trial of mindfulness-based stress reduction for prehypertension." Psychosomatic Medicine 75.8 (2013): 721-728.

Hulley, S., et al. "Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group." JAMA 280.7 (1998): 605-613.

Johansson, B., et al. "Mindfulness-based stress reduction (MBSR) improves long-term mental fatigue after stroke or traumatic brain injury." Brain Injury 26.13-14 (2012): 1621-1628.

Kohli, P., et al. "Excercise stress testing in women: going back to the basics." Circulation 122.24 (2010): 2570-2580.

Manchanda, S. C. and K. Madan. "Yoga and meditation in cardiovascular disease." Clinical Research in Cardiology 2014.

Marchioli, R., et al. "Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione." Circulation 105.16 (2002): 1897-1903.

Mosca, L., et al. "Effectiveness-based guidelines for the prevention of cardiovascular disease in women -- 2011 update: a guideline from the American Heart Association." Journal of the American College of Cardiology 57.12 (2011): 1404-1423.

Oberg, E. B., et al. "Physical Activity: Our Best Prescription." Integrative Medicine: A Clinician's Journal 6.5 (2007). Ornish, D., et al. "Intensive lifestyle changes for reversal of coronary heart disease." JAMA 280.23 (1998): 2001-2007.

Pancholy, S. B., et al. "Meta-analysis of gender differences in residual stroke risk and major bleeding in patients with nonvalvular atrial fibrillation treated with oral anticoagulants." The American Journal of Cardiology 113.3 (2014): 485-490.

Sandhu, R. K., et al. "Smoking, smoking cessation, and risk of sudden cardiac death in women." Circulation. Arrhythmia and Electrophysiology 5.6 (2012): 1091-1097.

Sofi, F., et al. "Adherence to Mediterranean diet and health status: meta-analysis." BMJ (2008): 337.a1344.

Spielmans, G. I., et al. "Psychotherapy Versus Second-Generation Antidepressants in the Treatment of Depression: A Meta-Analysis." The Journal of Nervous and Mental Disease 199 (2011): 142-149.

Stefanini, G. G., et al. "Safety and efficacy of drug-eluting stents in women: a patient-level pooled analysis of randomised trials." Lancet 382 (2013): 1879-1888.

Last Editorial Review: 9/24/2015

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Reviewed on 9/24/2015
References
Medically reviewed by Robert J. Bryg, MD; Board Certified Internal Medicine with subspecialty in Cardiovascular Disease

REFERENCES:

"What Is the DASH Eating Plan?" National Heart, Lung, and Blood Institute. 6 Jun 2014.

Aziz, F. "Coronary Artery Disease in Women: An Unsolved Dilemma." Journal of Clinical Medicine Research 6.2 (2014): 86-90.

Bhardwaj, S., et al. "Muscular effects of statins in the elderly female: a review." Clinical Interventions in Aging 8 (2013): 47-29.

Brook, R. D., et al. "Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the american heart association." Hypertension 61.6 (2013): 1360-1383.

Dow, C. A., et al. "Predictors of improvement in cardiometabolic risk factors with weight loss in women." Journal of the American Heart Association 2.6 (2013): e000152.

Estruch, R., et al. "Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial." Annals of Internal Medicine 145.1 (2006): 1-11.

Estruch, R., et al. "Primary prevention of cardiovascular disease with a Mediterranean diet." New England Journal of Medicine 368.14 (2013): 1279-1290.

Fan, X., et al. "Polymorphisms of ACE2 gene are associated with essential hypertension and antihypertensive effects of captopril in women." Clinical Pharmacology and Therapeutics 82.2 (2007): 187-196.

Flynn, R. M., et al. "The Cardiology Audit and Registration Data Standards (CARDS), European data standards for clinical cardiology practice." European Heart Journal 26.3 (2005): 308-313.

Gottlieb, S. S., et al. "Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction." New England Journal of Medicine 339 (1998): 489-497.

Gulati, M., et al. "The prognostic value of a nomogram for exercise capacity in women." New England Journal of Medicine 353.5 (2005): 468-475.

Hughes, J. W., et al. "Randomized controlled trial of mindfulness-based stress reduction for prehypertension." Psychosomatic Medicine 75.8 (2013): 721-728.

Hulley, S., et al. "Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group." JAMA 280.7 (1998): 605-613.

Johansson, B., et al. "Mindfulness-based stress reduction (MBSR) improves long-term mental fatigue after stroke or traumatic brain injury." Brain Injury 26.13-14 (2012): 1621-1628.

Kohli, P., et al. "Excercise stress testing in women: going back to the basics." Circulation 122.24 (2010): 2570-2580.

Manchanda, S. C. and K. Madan. "Yoga and meditation in cardiovascular disease." Clinical Research in Cardiology 2014.

Marchioli, R., et al. "Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione." Circulation 105.16 (2002): 1897-1903.

Mosca, L., et al. "Effectiveness-based guidelines for the prevention of cardiovascular disease in women -- 2011 update: a guideline from the American Heart Association." Journal of the American College of Cardiology 57.12 (2011): 1404-1423.

Oberg, E. B., et al. "Physical Activity: Our Best Prescription." Integrative Medicine: A Clinician's Journal 6.5 (2007). Ornish, D., et al. "Intensive lifestyle changes for reversal of coronary heart disease." JAMA 280.23 (1998): 2001-2007.

Pancholy, S. B., et al. "Meta-analysis of gender differences in residual stroke risk and major bleeding in patients with nonvalvular atrial fibrillation treated with oral anticoagulants." The American Journal of Cardiology 113.3 (2014): 485-490.

Sandhu, R. K., et al. "Smoking, smoking cessation, and risk of sudden cardiac death in women." Circulation. Arrhythmia and Electrophysiology 5.6 (2012): 1091-1097.

Sofi, F., et al. "Adherence to Mediterranean diet and health status: meta-analysis." BMJ (2008): 337.a1344.

Spielmans, G. I., et al. "Psychotherapy Versus Second-Generation Antidepressants in the Treatment of Depression: A Meta-Analysis." The Journal of Nervous and Mental Disease 199 (2011): 142-149.

Stefanini, G. G., et al. "Safety and efficacy of drug-eluting stents in women: a patient-level pooled analysis of randomised trials." Lancet 382 (2013): 1879-1888.

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