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	James L. Holly, M.D.

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Your Life Your Health - Women and Heart Disease: Primary Prevention

James L. Holly,M.D.

March 01, 2005

Cardiology Review, Vol 22 No 3

Introduction

500,000 women die annually from CHD.
This exceeds the number of deaths in men from CAD.
This exceeds the number of deaths in women from all cancers combined.
4 out of 5 women are unaware that heart disease is their greatest health threat.

Hypertension

Prevalence in women increases with age.
By age 60, systolic blood pressures are greater in women than in men.
Over 75 years of age, 80% of women are hypertensive.
Association between hypertension and CAD in women is clear.
Women with hypertension have four times the relative risk of myocardial infarction
Women with hypertension have seven times the risk of fatal coronary events.
Decreasing blood pressure has proven effective in lowering CVD risk.
Modest reductions due to the following can have a significant effect on risk reduction.
1. increasing physical activity
2. reducing weight
3. decreasing alcohol intake
4. Decreasing sodium intake.
Women generally have inadequate blood pressure control.
71% of women over 70 have inadequate blood pressure control in one study.

Diabetes

Major risk factor for CHD.
Increased risk for CHF is greater for women than for diabetic men.
Diabetic women are more likely to die after an MI than men.
Women with diabetes have higher rates of other CHD risk factors
1. Hypertension
2. High cholesterol
3. Obesity
4. Sedentary life style
However, even eliminating these factors, women still have an increased risk of cardiovascular disease mortality compared with diabetic men.
Increasing evidence of a continuous linear relationship between blood glucose levels and macrovascular disease such as CAD.
January, 2004, ADA set goals of 7% HgbA1c and 130/80 blood pressure for diabetics. Given the excess mortality among diabetic women compared with diabetic men, these guidelines may be inadequate.

Cholesterol

Framingham study and others have clearly established the association between hyperlipidemia and CHD risk.
There is a difference in the risk between men and women.
Cholesterol levels change differently for men and women:
1. Under the age of 20, cholesterol levels are comparable between men and women.
2. From 20-55, men have on average higher total cholesterol values.
3. After age 55, cholesterol values in women rise, with an increase in both total and LDL cholesterol.
4. HDL levels decrease slightly after menopause but throughout their lifetime, women have on average higher HDL than men.
LDL seems to a less potent risk factor for CHD in women compared with men.
1. Especially true for women over 65
2. For women age 65 and older an LDL value 160 mg/dl or higher increased risk by 1.13 for a CHD event compared with women with an LDL less than 140 mg/dl.
3. For women younger than 65, LDL of 160 mg/dl or greater had a risk 3.27 compared with LDL values less than 140.
HDL and CHD risk
1. Women older than 71 with HDL above 60 mg/dl had half the risk of CHD compared with women with HDL cholesterol lower than 35 mg/dl.
2. For women over 65, HDL is the only significant lipid predictor for CHD.
Triglyceride levels may be an important risk factor for CHD in women.
Secondary prevention studies have shown risk reduction with cholesterol treatment for men and women.
For women with above average risk for heart disease, aggressive management of high cholesterol levels I necessary for CHD risk reduction

Smoking

Cigarette smoking has been linked to CHD in women since 1976
Women who smoke more than 34 cigarettes ad day have a sevenfold increased risk of coronary events.
Smoking has been linked to an increased risk of fatal and nonfatal MI.
Men have higher quit rates than women smokers.
1. Women are less likely to associate smoking with negative health risks.
2. Although lung cancer surpasses breast cancer as the number one cancer killer of women, women sill fear breast cancer as their greatest health risk and are less likely to fear heart disease.
3. Women have a harder time quitting.
4. Women use smoking as a coping mechanism.
5. Nicotine results in a state of euphoria and an increased state of alertness that may enhance psychological addition.

Obesity

Obesity is associated with CHD risk factors of:
1. Diabetes
2. Hypertension
3. High cholesterol
Women with a BMI of 32 or greater had a relative risk of 4.1 versus those with a BMI less than 19.
Weight reduction alone may not improve CHD risk but does improve:
1. Glucose control
2. Blood pressure
3. Lipid profiles

Exercise

Beneficial results of exercise on CHD risk have been proved.
Walking briskly or exercising vigorous for at least 2.5 hours per week conferred a 30% risk reduction in cardiovascular events.
Prolonged sitting was associated with a significantly increase in cardiovascular risk.

Aspirin

Aspirin irreversibly inhibits platelet aggregation.
Role of aspirin in women is less clear.
Decreased risk of CHD in women on aspirin is not significant.
The benefits of aspirin increases with increasing cardiovascular risk.
Use of aspirin for the primary prophylaxis of CHD should be initiated:
1. For patients with a Framingham 10-year risk score of 15% or greater who do not have contraindications to its use.
2. For patients with a Framingham 10 year risk score of 6% or less, they should not receive aspirin.
3. For patients with a Framingham risk score 7%-14% should be considered on an individual basis.

Conclusion

CHD mortality rates have been declining for the past few decades, this decline ahs been greater for men than for women.
Given that CHD increases with age and that women over 75 make up the fastest growing portion of the population, strategies to prevent CD are paramount to the health of women.
Modifiable risk factors for heart disease include:
1. Control of hypertension
2. Control or prevention of diabetes
3. Cessation of smoking
4. Prevention f weight gain
5. Increase of physical activity
For women at above-average risk for heart disease aggressive management of cholesterol and the use of low-dose aspirin are likely to be beneficial for CHD risk reduction.

Other Articles in the Cardiovascular Disease in Women Series

	Women and Heart Disease: Congestive Heart Failure Women and Heart Disease: Testing Guidelines Women and Heart Disease: Hormone Usage Women and Heart Disease: Hormone Replacement Therapy Women and Heart Disease: It can be prevented!

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