Go Red for Women: Nearly 20 Years of Much Progress, Some Setbacks
The AHA’s initiative has raised awareness and funded research, but even its strongest supporters see room to grow.
That signature red dress, the pins, red shirts, mugs, and other merch: these are some of the easily recognized trappings of Go Red for Women. Nearly 20 years since its debut, what has this high-profile campaign achieved and what more remains to be done?
The initiative, launched by the American Heart Association (AHA) in 2004, seeks to raise awareness that women, not just men, are vulnerable to heart disease.
Financially, it ticks the boxes for success. Go Red for Women as a whole brings in a sizeable amount of money—in 2022, activities related to National Wear Red Day, Heart Month, and maternal health raised more than $16 million, the AHA told TCTMD.
A considerable amount of that cash is then funneled towards key areas of need, most notably research. For example, between 2016 and 2021, the AHA invested $20 million in the Go Red for Women Strategically Focused Research Network (SFRN), which also received $52 million from the National Institutes of Health; since then, AHA has continued to provide millions earmarked for the program.
It’s more than just fundraising and spreading the word through health statistics and the call to wear red on that first Friday to kick off Heart Month—another key goal, the AHA says, is “to serve as a catalyst for change to improve the lives of women globally.”
Numerous cardiologists told TCTMD that Go Red for Women has in fact made a difference in how women see themselves and how physicians perceive their own patients, not only through awareness campaigns but also by supporting science that gets to the root of sex-related differences in CVD.
Nanette Wenger, MD (Emory University, Atlanta, GA), said that in considering Go Red’s impact, it’s important to look at what came before.
“Until the last 10, 15 years or so, heart disease, particularly coronary disease, was considered a problem for men. And women were essentially ignored in the whole heart disease spectrum. I think this was a major problem,” said Wenger, whose lengthy experience dates back to 1954, when she was one of Harvard Medical School’s first female graduates. “And when we talked about women's health in general, until the 1990s really, it was what I had termed bikini medicine, meaning it just addressed the areas that were covered by the bikini bathing suit: the breasts, and the reproductive system. Nobody paid any attention to anything else about the women, including their heart.”
The survivability from heart disease has improved over time, and I think women as well as men lots of times don’t really consider heart disease as something they should be afraid of. But in fact, it’s still the number one killer. Michelle Albert
Go Red for Women “changed the landscape” by getting the message out on a wider scale that CVD risks aren’t restricted to men, Wenger pointed out. "Nobody had ever told that to women.” The campaign helped female patients become aware that prevention and lifestyle—to have a healthy weight, not smoke, and take steps to control hypertension, hyperlipidemia, and diabetes, for example—also applied to them.
Many women for the first time sought out care “because they realized they didn't know their numbers” for things like cholesterol and blood pressure, she continued. And clinicians, for their part, “began to realize that women had heart disease. They took more seriously their complaints of chest pain. They tried to control their risk factors.”
Scope of the Problem
The AHA’s 2019 survey of US women alarmingly showed that, compared with earlier years, fewer were aware heart disease is the leading cause of death among women. The trend was especially pronounced among Hispanic and Black individuals, and younger respondents ages 25 to 34. The results are “very discouraging, . . . because initially they saw a gain in awareness, but now they're seeing a fallback,” Harmony Reynolds, MD (NYU Langone Health, New York, NY), one of the paper’s co-authors, commented to TCTMD.
Robert A. Harrington, MD (Stanford University, CA), who served as president of the AHA from 2019 to 2020, was in that leadership role when the survey was published.
“Not surprisingly, the demographic that we had focused on—women who were felt to be in the age groups that were most at risk for cardiovascular disease—[had] good awareness of cardiovascular disease as an important health condition,” he told TCTMD. “What was concerning is the young women and the lack of awareness, [which] really pointed out to us at that time a big opportunity to address that age group to really let people know about [CVD], because these aren't things from a health perspective you address overnight.”
Harrington said the younger demographic is worthy of a closer look. “As we learn more, for example, about pregnancy and heart disease, as we learn more about the cumulative effects of lifestyle changes over time, I think there's been a natural focus of the AHA to look earlier and earlier to engage people in what would be the lifelong conversation about your heart health,” he commented.
Overall, Go Red for Women’s awareness campaign has “worked pretty well,” said Harrington. It’s more a matter of “targeting certain demographics, making sure that we're bringing everybody along in a way that really reflects the disease itself.”
Renée Bullock-Palmer, MD (Deborah Heart and Lung Center, Browns Mills, NJ, and Thomas Jefferson University, Philadelphia, PA), who chairs the AHA’s Women in Cardiology Committee, described the on-the-ground energy that happens each February, a busy month in terms of outreach activities like health fairs where women can get screened for hyperlipidemia, hypertension, and other risk factors.
Thanks to Go Red, more than “2 million women have used the opportunity to find out their own risk. And not only their own risk, but risk of their loved ones, their sisters, their parents, cousins, and such,” she noted.
That so many “women have learned their personal risk of developing heart disease” stands out as a major accomplishment of Go Red for Women, members of the Women in Cardiology Committee said in a joint statement to TCTMD. Another highlight is the Woman of Impact and Teen of Impact awards, which launched in 2021, they said. “Nearly 450 nominees have made a significant impact by raising [more than] $2.1 million in the first year.”
The breadth of Go Red’s reach can be captured by numbers released by the AHA. In addition to the millions who’ve checked their heart stats, more than 900,000 women have “joined” the campaign and receive updates on what they can do to improve their health. Annually, more than 150 Go Red luncheons and other events are held.
We need to emphasize the very true fact that heart disease is largely preventable. If we give people more of a sense of action, maybe that'll be effective, [but] I don’t know. Harmony Reynolds
Volunteers are integral to the work. In 2008, nine women were the first to take part in the “Real Women” project, sharing their experiences with heart disease and stroke—that number has since reached more than 130. In 2017, the Go Red National Leadership Council began as a way to engage female executives. And then there’s the Circle of Red, whose members are advocates within their communities. Around 300,000 volunteers receive monthly emails, and Go Red for Women’s social media channels had an audience of more than 5.3 million in 2022 alone.
Additional projects include Research Goes Red, with more than 19,000 participants, as well as awareness campaigns tied to women in STEM careers, maternal health, and, of course, National Wear Red Day. Last year, 254 television anchors wore red during their broadcasts to mark the occasion. There’s also an international footprint: Go Red has a presence in over 50 countries worldwide.
Its work intertwines with Heart Month. This year, for instance, the AHA is promoting the “Be the Beat” challenge to learn CPR, with the knowledge that currently women are less likely than men to receive bystander CPR in public locations and, perhaps as a consequence, have worse survival. The goal of this program is for at least one member of every household to know how to use the technique in an emergency.
Steps Forward and Back
Despite all of these efforts, the dispiriting survey from 2019 should inspire a doubling down to get the word out on women and cardiovascular disease, all agreed.
Reynolds, whose hospital was one of five centers working with the Go Red for Women SFRN, said the AHA “has been very attentive to this. . . . They want to raise awareness, and they want to know why it's not working and how it can be fixed.
“So they're talking a lot about community engagement and just changing the way we deliver the message. Everything from where the message goes—a lot of stuff has to be done through social media now, that's where people are—to what the message is,” said Reynolds. “If we're talking about the leading killer, I think [this lack of knowledge] is kind of frightening. We need to emphasize the very true fact that heart disease is largely preventable. If we give people more of a sense of action, maybe that'll be effective, [but] I don’t know.”
Wenger also noted shifts in perception. “What we've seen is that over the last several years, because that campaign has not been as intensive as it was early on, we've almost lost a decade,” she said. “When we query women now, a majority of them don't realize the symptoms of a heart attack [and] don't realize that they're vulnerable.” She noted that “the lack of recognition is greatest among the most vulnerable populations, . . . the young women and the women of racial and ethnic minorities.”
Some of the backsliding is due to the obesity epidemic and tendency toward a sedentary lifestyle. The effects of these are being felt earlier and earlier, said Wenger. “We used to pay attention [and] screen beginning at age 40. Well, I'm seeing women in the hospital with heart attack in their 30s.” Moreover, it’s becoming ever more clear that pregnancy-related complications, such as preeclampsia, can cause long-term harm.
We used to pay attention [and] screen beginning at age 40. Well, I'm seeing women in the hospital with heart attack in their 30s. Nanette Wenger
Bullock-Palmer agreed that “there's been a mounting of risk factors to the point where even younger women are now presenting with heart disease, because everything all adds up over the number of years.” Clinicians may not be attuned to this, such that a 40-year-old female patient who presents to the emergency room with chest pain doesn’t raise red flags of an MI.
“We also have to dig deep and reach into underserved populations: African Americans, Hispanics, and Native Americans as well,” she said, and making connections will require a multifactorial approach. On one level, it’s about outreach and “getting these people involved” in clinical trials, Bullock-Palmer noted. “The second thing is having them trust the healthcare system, because historically they've had bad experiences that sometimes they remember.” There can be reluctance, she said, to enter research studies when people have the question on their minds: “Is it going to harm me?”
Wenger noted, too, that the COVID-19 pandemic served as a valuable reminder of the underlying racial/ethnic inequities in healthcare, though it also pressed the pause button on many public health campaigns unrelated to stopping SARS-CoV-2.
Now, as the world returns to normal, Wenger and her colleagues recently published a “call to action” for greater attention to cardiovascular disease in women. “What we need to do is to meet the women where they are,” she said, referencing the success of the famed barbershop-based hypertension study. “We need to get into the hair salons. We need to get into the nail places. . . . We have to go to the churches for their health ministries, etc.”
The need for awareness of CVD is not just about patients, it’s also about clinicians, Reynolds stressed. “I still hear horror stories of women who were told by a paramedic that their heart attack was really just something that was a panic attack, and ER doctors who sent people home when it really seems there might have been a gender-biased interaction,” she explained. “But there’s less of it now. I see much more of people getting treated equally and being taken seriously no matter what they look like.”
Research Forges Ahead
Work is still needed to better understand the features of cardiovascular disease and stroke in women, urged Wenger, who’s the namesake for an award from Research Goes Red highlighting the best paper on the topic published each year in an AHA journal.
“Women are not just small men, and they really have a unique pattern of disease,” she noted. For example, “the classic model of disease—and what was considered the gold standard—is the one we saw in men, with obstructive disease of the epicardial coronary. But now we realize that women have that, but also they have microvascular disease, they have heart attacks without obstruction of the arteries.” Traditional risk factors, such as diabetes, can exert greater impact on women versus men, and new links are being recognized with conditions like autoimmune disease, she added.
Indeed, some of the biggest influence of Go Red for Women lies in its support of research studies on sex-related aspects of heart health, not only in terms of funding but also in advocating that governmental research includes sufficient proportions of women, said Wenger.
We all have, or will have, a woman in our lives who is affected, potentially, with cardiovascular disease. . . . And I think it's one of the reasons that the campaign has been so enduring. Robert A. Harrington
Bullock-Palmer also made a case for greater inclusion of female participants, noting the “stark” imbalance—although the real-world population is divided 50/50, cohorts in cardiology studies skew strongly male.
“The fear with that is that [in clinical practice] we're actually extrapolating that evidence that has been predominantly male focused from those studies and applying [it] to women,” she continued. “So sometimes it’s not surprising that we’re doing treatment X for the general population and then 10 years down the line we're realizing women have been harmed . . . , of course, because the studies that have studied that particular treatment did not involve more women.”
An area particularly in need of better understanding is the cardiovascular health of women during and shortly after pregnancy, an issue that in recent years has begun being addressed by cardio-obstetrics. “It's a very big problem, because we as a developed country have the highest rates of morbidity and mortality for pregnant women compared to all the developed countries,” said Bullock-Palmer. African-American women, no matter their socioeconomic status, bear a disproportionate brunt of that risk, she added.
AHA President Michelle A. Albert, MD, MPH (University of California, San Francisco), said the area of pregnancy and CVD is “something the organization has really been leaning into,” because it’s such a key moment in many women’s lives. “We know that the first window into cardiovascular disease for a woman who chooses to become pregnant is actually during pregnancy,” she noted, citing AHA-led guidelines for clinicians and maternal health campaigns for outreach. “This is particularly important for Black women and Native American women, who have three times the maternal morbidity [compared with] other women,” most of it cardiovascular.
She called out Research Goes Red as being an innovative way to better understand, beyond statistics, the barriers to better heath. The strategy “is to meet people where they are and collect information from women themselves, to understand what are the most pressing issues for women that actually impede a healthy lifestyle [and] then work with women to address their cardiovascular health based on what their needs are,” Albert explained.
Then there’s the Go Red for Women SFRN, which involves three aspects: “It's a clinical project, a basic or translational project, and a population health project,” said Reynolds. For her, the research has focused on MI with nonobstructive disease in women and has continued on to a comparison of this phenomenon between female and male patients. Other studies have explored sex-based differences in the roles of thrombosis and stress in MI.
“We’ve made some great observations. I'm excited about the work that we're doing. Some of it is published, some of it is yet to be published,” she said. Another component of the SFRN worth noting is a 2-year fellowship program funded by the AHA to train next-generation investigators, she continued.
And finally, the program also emphasizes teamwork across the various SFRN sites. “So I now have all these people that I collaborate with from four different universities, a lot of whom I really didn't know before. We’ve traded research techniques,” Reynolds said, giving the example of learning from colleagues who study heart disease in pregnancy and being able to apply their reproductive medical history questionnaire in their own work.
A Look in the Mirror
Reynolds said now’s the time to build on the growing awareness among healthcare providers that female patients merit attention. “We can take the next step in making sure that everybody really understands what the differences are, but also what to do about them. [For example], how women might need additional diagnostic testing—I'd love to see that become routine,” she said. “I think that's a place where AHA can move forward, making sure that everybody feels comfortable, not just with the idea that women are different, but women are different and this is what we do about it.”
Beyond research and practice, Go Red for Women’s message has implications for the healthcare workforce, said Harrington.
“We all know that cardiology's not done a great job of recruiting women to our specialty,” he said. “Recent data would suggest that it's getting better, but we're still a long way from having a specialty that's equally represented by both men and women as cardiologists. That to me is an area where a lot of focus needs to come, because we do know that, for example, if you have women cardiologists participating as investigators in clinical research projects, you are more likely to have a higher number of women enrolled in that project.”
Professional societies like the American College of Cardiology and academic medical centers involved in training fellows, said Harrington, must be “constantly attentive” to ways they can foster a more-diverse, representative workforce.
And already there’s progress. He cited the 2021 chest pain guidelines, led by writing chair Martha Gulati, MD (Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA), as a positive example for its discussion of CVD in women—the document discouraged the use of “atypical,” a term that has downplayed female patients’ symptoms, as a “misleading descriptor of chest pain.” This, said Harrington, has “implications for how we think about the different presentation of ischemic heart disease in men and women, and it tries to get us as clinicians to think very consciously about those issues, . . . [which] is critically important if we're going to improve outcomes,” not just for women but for men, who also can come in with symptoms that in the past would have been dismissed.
Reynolds said that things do appear to be getting better. For one thing, “I feel that women are more empowered to talk about heart disease,” she noted.
Acknowledging that as a specialist with an 80% female practice, she may have a unique vantage point, she added: “They find their way to me and they are talking about how they think they have a syndrome, a women's type syndrome, and they think they need more testing in order to figure it out. . . . There just wasn't as much of that 5, 10 years ago. I think that the message is penetrating and it takes time, but I think people are getting it that women's heart disease may or may not be different, that heart disease really is important for women, . . . and that they need to [put more effort into] prevention.”
For Harrington, the connection to Go Red continues, he said: “I wear the red dress button on my white coat [or] my suit coat most days.”
Harrington said he believes that many people also feel that connection. “We all have, or will have, a woman in our lives who is affected, potentially, with cardiovascular disease. . . . And I think it's one of the reasons that the campaign has been so enduring. It does hit people personally and they make donations from a personal perspective—that I think is something we shouldn't forget. It's not just stats, right? Everybody has their personal story,” he stressed.
Albert said the major contribution of Go Red for Women has been spreading the word that heart disease is the leading cause of death, though as “with any initiative, there’s always going to be room to grow.”
“Because of the science that the AHA does and funds, the survivability from heart disease has improved over time, and I think women as well as men lots of times don’t really consider heart disease as something they should be afraid of. But in fact, it’s still the number one killer and [with delayed treatment] the likelihood of death or disability is pretty high,” she commented.