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EPIDEMIOLOGY

Cardiovascular disease (CVD) is the no. 1 cause of death among American women. In relative terms, more women die of CVD than men. CVD occurs one decade later in women and accelerates after menopause. 250,000 women die each year from heart attack or myocardial infarction (MI). 90,000 die each year from stroke or cerebrovascular accident (CVA). By contrast, 56,000 and 46,000 respectively die from lung and breast CA. Death from breast CA is more common in pre-menopausal women.

RISK FACTORS

The prevalence of risk factors is greatest after age 55 when menopause has occurred. 50% of women over 55 are overweight and have high cholesterol or BP.

Lipids; Cholesterol & Triglycerides: As in men, the "good cholesterol" (HDL) is protective; the "bad" (LDL) increases risk. Total cholesterol above 260 mg/dl increases risk 3-fold compared to less than 200. Triglyceride is a better predictor of CVD in women compared to men.

Cigarettes: By year 2000, the percentage of women smokers (23%) will exceed men (20%). Women who smoke are at 4 times risk of MI compared to non-smoking women. Cessation of smoking markedly attenuates the risk within 1-2 years. CVA risk is 2 fold for moderate and 4 fold for heavy women smokers.

Diabetes: While pre-menopausal women are generally protected from CVD, the onset of diabetes reverses the protection. Women with diabetes often have other risk factors.

Hypertension: Each 10 mm Hg rise in BP increases CVD event rate by 20%. More women (90,000) than men (60,000) die of stroke each year.

Obesity: Marked obesity is an independent risk factor in women. Each 6 inch increase in waist size confers an additional 60% increase in all-cause mortality.

Menopause: Menopause before age 35 without hormonal replacement therapy (HRT) triples the CVD event rate. The absence of HRT increases CVD mortality rate after menopause. However, the risk is greatest in women already predisposed to CVD; i.e. those with angiographic evidence of coronary artery disease (CAD).

DIAGNOSING CAD IN WOMEN

MI: Severe CAD can be relatively symptom-free in both sexes. One-half of acute MI can occur either without symptoms or the symptoms are not recognized as MI. Before an MI, women are twice as likely to present with chest pain or angina pectoris. However, despite having less angina, more men are likely to suffer MI. When MI occurs in women, the symptom is less likely chest pain and more likely shortness of breath, abdominal pain, nausea, and severe fatigue. As a result of the MI, women are more likely than men to die or have subsequent MI.

Tests: The false positive rate for EKG Stress Tests is 54% higher in women compared to men. Radionuclide imaging in women is less accurate because of breast attenuation. Women are generally perceived to have less CAD than men. As a result, women are less likely to receive invasive diagnostic procedures.

TREATMENT

In predisposed women, CAD occurs later and is more rapidly progressive than compared to men.

Coronary Artery Bypass Surgery (CABG): Women referred for CABG are older compared to men and are more likely to present with unstable symptoms, congestive heart failure (CHF), and diabetes with small, diffusely diseased vessels. CABG is more likely to be performed urgently or emergently. Operative mortality is, thus, somewhat higher in women compared to men.

Percutaneous Transluminal Coronary Angioplasty (PTCA): With comparable anatomy, the result of PTCA is equally good in women and men. However, due to older age at presentation and a poorer CVD risk profile, women, overall, have a higher complication rate. The key is the anatomy of the coronary arteries.

Hormonal Replacement Therapy (HRT): HRT markedly reduces the risk of developing CAD; i.e. primary prevention. The primary factor is estrogen. The addition of progesterone eliminates uterine bleeding and reduces endometrial hyperplasia; i.e. enlargement of uterine tissue. The role of HRT in women with manifested CAD is less well established; i.e. secondary prevention.

Lipid Lowering Medications: With regard to secondary prevention, HMG -CoA reductase inhibitors (the "statin" drugs) have been shown to reduce cardiovascular mortality in both women and men. The role of such drugs in primary prevention for women has not been established, although data in men would suggest a positive effect.

Aspirin: The role of aspirin in secondary prevention is well established. Limited consumption of aspirin may be useful in primary prevention; trials are on going.

Anti-oxidants: Everyone should be on anti-oxidants!

Robert C. Wesley, Jr., MD
New Life Cardiology
September 14, 1999

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