The Women's Heart Bus: an innovation in preventive medicine

In France, cardiovascular disease remains the 1st cause of death for women (26%, ahead of cancer 25%), with 76,000 deaths per year (1). And yet, in 8 out of 10 cases, a cardiovascular accident can be avoided by identifying risk situations and taking appropriate care. It's a disease of the environment, and it's women in vulnerable situations (according to the simplified Epices score) who are most affected (2). The prolonged confinement of the last two years has also pushed them further away from gynecological surveillance.
In 2020, Thierry Drilhon and I co-founded Agir pour le Coeur des Femmes / Women's cardiovascular healthcare foundation (www.agirpourlecoeurdesfemmes.com) to make cardiovascular disease in women a public health priority. Its aim is to save the lives of 10,000 women over the next 5 years, through its national screening campaign "Le Bus du Coeur des Femmes". Vascular practitioners across France have been quick to get involved in this preventive medicine adventure. Agir pour le Coeur des Femmes is developing in close partnership with the Société Française de Médecine Vasculaire (SFMV), the Club des Jeunes Médecins Vasculaires and the Collège des Enseignants de Médecine Vasculaire. The SFMV relays the stages of the Women's Heart Bus on its website, and organizes webinars and communications to train vascular physicians in the specificities of women's cardiovascular disease, giving them an opportunity to become more concretely involved in prevention. Virtual meetings prior to each "Bus du Coeur" stage remind participants of the objectives and methods of the "Bus du Coeur des Femmes" screening program.



The Women's Heart Bus: what's the 1-year review?
The Women's Heart Bus made stops in 5 cities between September and November 2021: Lille, Marseille, Avignon, La Rochelle, Saint-Etienne. It offers free cardiovascular, metabolic and gynecological screening to women in vulnerable situations after obtaining their informed consent. In some towns, aortic aneurysm screening by echo-Doppler has been set up by vascular physicians in a dedicated area.
Pre-registration with the services of the host city enables access to the screening program, which lasts an average of one hour and fifteen minutes. Follow-up is then organized with the help of the Caisse Primaire d'Assurance Maladie and local health professionals. The aim is to put these at-risk women back on an optimized care pathway. Appointments for specialized consultations are pre-booked for them, and they receive a summary letter for their GP. Women are introduced to self-monitoring of blood pressure, so that they can get involved in their own care, with a free blood pressure monitoring device, an explanation of the procedure and self-monitoring records to fill in.
A Health and Well-being Village, freely accessible to all, provides a further introduction to prevention, with numerous advice stands (nutrition, family planning, life-saving gestures, women's words, respirology & stress management...).
The Women's Heart Bus is financed by private foundations and companies, individual donations and voluntary contributions in kind (city services, partner associations, volunteer health professionals).
This initiative is supported by learned societies, medical colleges (vascular medicine, gynecology, obstetrics, cardiology) and the Caisse Nationale d'Assurance Maladie (French National Health Insurance Fund) https://www.agirpourlecoeurdesfemmes.com/partenaires.php
Towns, local authorities, hospitals and private healthcare establishments are strong and committed players in the development of this regional action.
The media is another key to the success of this step, by communicating about the action. The women themselves are real hummingbird relays, encouraging those around them to go for screening.
After this first year, the anonymized data were analyzed by a team of researchers from the Lille University Hospital's Research and Innovation Department. Each city has the option of analyzing its own data. A thesis in vascular medicine will be set up with Pr Gabrielle Sarlon in Marseille, covering 3 years of consecutive screening. An initial global analysis of the five cities has enabled us to assess the characteristics of 1,065 women aged between 15 and 90 (average age 52).
The results are edifying, with some shocking figures: 90% of the participants combined at least 2 cardiovascular and metabolic risk factors; 73% were abdominally obese (abdominal circumference > or = 88 cm); 67% reported being stressed and 26% had a depressive syndrome, which are major risk factors for cardiovascular events; 43% had blood pressure > or = 140/90 mm Hg, and more than one in three did not know they were hypertensive before screening; 43% have at least 2 gyneco-obstetrical risk factors and at least 2 cardiovascular and metabolic risk factors; among young women taking contraception with synthetic estrogen, 76% have at least one contraindication to their prescription: age > 35 years, BMI > 30 kg/m², active smoking. (3-6)
These results are well above national averages. Socio-economic vulnerability accelerates the onset of the disease! (2). The women screened in the Bus are at high risk of cardiovascular, metabolic and gynecological disease, confirming the data from the ESTEBAN study (7). Another edifying finding is that these women are also insufficiently followed-up! 11% no longer have an attending physician; 70% of women with at least 2 cardiovascular risk factors have never seen a cardiologist or vascular physician; 31% of women have not had a gynaecological consultation for over 3 years; 22% of women are not up to date with their mammography follow-up. The COVID pandemic has certainly played a role in accelerating this cardiovascular risk by delaying screening.
There are also results that should encourage us in this preventive medicine. The satisfaction survey notes that 99% of women screened understood the prevention messages, became aware of the importance of their health, and will encourage the women in their circle to get screened.

The Women's Heart Bus aims to be a long-term project, helping to set up local care pathways.
In concrete terms, saving a life means screening for at least one cardiovascular or gynecological risk factor, and thus preventing women from suffering a sometimes fatal and often avoidable accident. The Women's Heart Bus saved the lives of over 900 women in 2021. But to come to a town for three days a year for a one-off screening would be reductive! That's why screening is carried out by local healthcare professionals, with two to three months' preparatory work to forge links with local players and build a truly effective prevention network. At the end of the screening, these women are put back on a healthcare pathway with scheduled appointments with local private or hospital healthcare professionals (8).
An evaluation of the follow-up of these women is scheduled for 2022, following the more operational formalization of follow-up appointments. A learning curve has been built up based on the 13 milestone cities in 2021 and 2022 (March to June), enabling us to refine the screening pathway to make it smoother and more efficient, with more women screened at each stage. Finally, ultrasound screening for aortic aneurysms, initiated by Dr. Jean-Pierre Laroche in Avignon, was able to go ahead in 2022 thanks to the strong involvement of vascular physicians in Cannes, Pessac, Toulouse, Mulhouse and Six-Fours les Plages. The constraint is the availability of an ultrasound machine loaned by an industrial or hospital establishment, which was not the case in Calais, Maubeuge and La Rochelle. In September 2022, we hope to be able to screen for atrial fibrillation using a resting electrocardiogram. The Caisse Primaire d'Assurance Maladie, which is contacted in each town, helps to bring certain women's entitlements up to date, and to find them an attending physician if necessary. Women can also take advantage of health support services offered by the Caisse Nationale d'Assurance Maladie's health examination centers.
The Women's Heart Bus has helped to raise awareness among these women of the importance of good health and regular check-ups, with concrete tools such as integration into a care program, the provision of an automatic blood-pressure monitor, and education to encourage self-monitoring.
On the strength of this 1st edition, our ambition is to accelerate our action from 2022 by covering 15 towns, and to extend this operation until 2025. Since March 2022, almost 2,000 new women have been screened and offered complementary care. The success of our action relies on the strong involvement of towns and cities, the expertise of healthcare professionals and the region's medico-associative ecosystem trained in the specificities of women's cardiovascular risk.

What you need to know...
This collective action of "Going towards women", restores meaning, connection, positive listening and benevolence after this complicated period of COVID. This unprecedented pandemic has made us aware of the importance of our health capital. Prevention must become a public health priority in France, a major national cause, with our discipline, vascular medicine, already heavily involved in cross-disciplinary care.


The recent change in the title of our Ministry to "Ministry of Health and Prevention" is, we hope, a strong signal of our supervisory bodies' commitment to preventive medicine.
The Women's Heart Bus is a large-scale national prevention initiative, the result of an innovative collective effort combining goodwill, expertise and know-how. This initiative gives new meaning to the mission of healthcare professionals, who have often been in distress in recent years, after going through the COVID period and the restructuring of hospital life. For their part, these vulnerable women appreciate feeling at the center of attention and listened to. When their difficulties are taken into account, smiles light up their faces and sparks shine in their eyes. It's a time for valuing those who are often invisible in society. The feeling of equal opportunity in the face of health has enabled a number of them to regain a better self-esteem. Many thanks to the vascular doctors who have been so involved in these first 13 towns, and to those who will be joining the adventure from September 13.
You're all welcome to join us on the Women's Heart Bus adventure, by accompanying us on one of the forthcoming regional stops, which can be consulted at https://www.agirpourlecoeurdesfemmes.com/les-bus-du-coeur.php.

Bibliography
1- Surveillance de la mortalité par cause médicale en France: les dernières évolutions. beh.santepubliquefrance.fr/beh/2019/29-30.
2- Public report. Health and access to healthcare: an emergency for women in precarious situations
La santé et l'accès aux soins : une urgence pour les femmes précaires. Report by the High Council for Equality between Women and Men. July 2017. https://www.egalite-femmes-hommes.gouv.fr.
3- Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Euro Heart J. 2016 ;37, 2315-81.
4- Maas A H E M, Rosano G, Cifkova R et al. Cardiovascular health after menopause transition , pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists. Eur Heart J 2021 Mar 7;42(10):967-984.
5- HTA-hormones and women. Expert consensus. December 2018. Downloadable from www.sfhta.eu
6- Smolderen KG, Strait KM, Dreyer RP, D'Onofrio G, Zhou S, Lichtman JH, Geda M, Bueno H, Beltrame J, Safdar B, Krumholz HM, Spertus JA. Depressive symptoms in younger women and men with acute myocardial infarction: insights from the VIRGO study. J Am Heart Assoc. 2015;4.e001424. doi:10.1161/JAHA.114.001424
7- Santé publique France. Health study on the environment, biomonitoring, physical activity and nutrition (Esteban) 2014-2016. Bulletin Epidémiologique Hebdomadaire, April 24, 2018 n°10.
8- Brown HL, Warner JJ, Gianos E, Gulati M, Hill AJ, Hollier LM, Rosen SE, Rosser ML, Wenger NK; American Heart Association and the American College of Obstetricians and Gynecologists. Promoting Risk Identification and Reduction of Cardiovascular Disease in Women Through Collaboration With Obstetricians and Gynecologists: A Presidential Advisory From the American Heart Association and the American College of Obstetricians and Gynecologists. Circulation. 2018 Jun 12;137(24):e843-e852.

Calendar of confirmed stopover cities as of back-to-school date
Le Havre: September 13-14, 2022
Lille: September 21-23, 2022
Paris: September 27-29, 2022
Marseille: October 18-20, 2022
La Baule: November 16-18, 2022

Contact Women's Heart Bus: vincent.morel@agirpourlecoeurdesfemmes.com