(Heart Disease, Strokes, Peripheral Vascular Disease in Women)
by: Samuel (Jody) Stagg, III M.D., F.A.C.C., F.A.C.P.
In Part 1 on this topic I discussed the scope of the problem. Heart disease is the number 1 killer of women, and we need to increase the awareness of this in women, especially minorities. Women have different risk factors for heart disease and different clinical symptoms of heart disease and heart attacks. They also develop the disease later in life but also in greater numbers than men. Now we will move our discussion to:
1) Specific predictors of heart disease in women
2) Hormone replacement therapy
3) Ethnic and racial disparities in heart disease in women
4) Healthcare providers’ lack of awareness of the severity of the problem in women
5) Appropriate diagnostic and treatment modalities for heart disease in women
What factors are more predictive of coronary artery disease in women?
1) Diabetes – Women with diabetes have 3 to 7 times higher death rates from cardiovascular disease than women without diabetes, whereas men only have 2 to 3 times higher risk from diabetes than in men without diabetes.1
2) Obesity – There is a higher prevalence of obesity in women than in men, and this is a significant risk factor for developing cardiovascular disease.1
3) High risk lipid profile is somewhat different in women than in men. HDL cholesterol is a strong and independent risk factor for coronary artery disease and death risk from coronary disease.
4) Elevated triglycerides, especially above a level of 400, is an independent risk factor in women.
5) Lowering LDL cholesterol reduces the risk of cardiovascular morbidity and mortality equally in men and women with statin therapy.2, 3
6) HDL goal level in men is greater than 40; however, in women the goal is greater than 50.
7) CRP (C-reactive protein) – This is a marker of systemic inflammation and is an independent risk factor for coronary artery disease and more predictive in women than in men. Women with the highest levels of CRP have four times the risk of cardiac events than women with the lowest levels.4
8) Smoking – Smoking is associated with half of all coronary artery disease events, and even minimal tobacco use is a significant risk factor.5 Women smokers have six times the risk of non-smokers of developing a myocardial infarction and is a more predictive risk factor than in men.6
9) Menopause – Women develop coronary artery disease on average ten years later than men secondary to the protective effects of endogenous estrogens in premenopausal women.7
Hormone Replacement Therapy
There is no current evidence for any cardiovascular protective effect of hormone replacement therapy. The HERS trial demonstrated this.8
The Women’s Health Initiative trial showed a significant increased risk of thrombotic events in women given hormone replacement therapy.9 So hormone replacement therapy has no indication for coronary artery disease prevention and is fraught with increased clotting side effects.
Ethnic and Racial Disparities
There are significant ethnic and racial disparities in the development of risk factors for cardiovascular disease and death rates from cardiovascular disease. Minority women develop diabetes and heart disease at an earlier age, and their outcomes are generally worse with an increased death rate compared to non-minority populations. This is likely attributable to significantly less awareness of the risk and an increase in disease prevalence, as well as less access to medical diagnosis and care.7, 10
Different Levels of Diagnosis and Treatment of Coronary Artery Disease in Women versus Men
Healthcare professionals are much better at this than they used to be, but the facts are that women still are less likely to get timely and aggressive diagnosis and treatment of coronary artery disease and heart attacks than men.7
The facts are that women should be evaluated and treated for heart disease just as vigorously and aggressively as men.
Early diagnosis and aggressive treatment is critical in lowering the death rate from heart disease in women. Patients and healthcare providers need to be more aware of the particular symptoms that develop in women, the risk factors that are more predictive of developing CAD (coronary artery disease) in women, and making early diagnoses of this potentially life-threatening disease.
Diagnostic studies that should be considered to evaluate the potential for coronary artery disease and ischemic heart disease include:
1) Exercise tolerance test
2) Nuclear stress test
3) Stress echocardiography
4) Cardiopulmonary exercise testing
5) Cardiac calcium scores
6) Coronary CTA (CT angiography)
7) Cardiac catheterization and angiography
Once the diagnosis of cardiovascular disease is made in women, then early and aggressive therapy should be utilized. Treatment modalities should include:
1) Diet and exercise and other lifestyle modifications
2) Medical management including blood pressure control, diabetes diagnosis and treatment, consideration for cholesterol-lowering therapy, especially statin medications, and consideration of anti-platelet agents such as aspirin and others available.
Women who do present with heart attacks and ischemic heart disease should be diagnosed quickly and offered the same aggressive interventional therapy—including angiography, angioplasty, stenting, and heart surgery—that have been routinely offered to men.
1. Heart disease is the number 1 killer of women and at best only 50 percent of women are aware of this.
2. Cardiovascular disease develops later in women than men, corresponding to menopause.
3. More women die each year of heart disease and heart failure than men. So it’s not a disease just of men, and we all need to be aware of that.
4. Women can have different risk factors and symptoms that they present with than men, and they often seek medical treatment later in the course of the event and therefore have worse outcomes.
5. Hormone replacement therapy is not beneficial for the treatment and prevention of coronary artery disease and has significant potential side
6. Statin therapy is very beneficial in women for the prevention and treatment of coronary artery disease.
- Skerrett, PJ, et al. Cardiovascular Health and Disease in Women, 2nd Edition, Philadelphia, WB Saunders, 2002:39-70.
- Bass, KM, et al., Archives of Internal Medicine, 1993:2209-2216.
- Larosa, JC, et al. JAMA 1999; 282:2340-2346.
- Ridker, DM, et al., NEJM:2000.
- Willett, WC, et al., NEJM, 1987:317:1303.
- Njolstad, I, et al., Circulation, 1996:93(3):450.
- Cheng, C, et al. Chest 2004; 126:47-53.
- Hulley, S, et al., JAMA:280:605-613.
- Manson, JE, et al., NEJM:2003:349;523-534.
- Mosca, L, et al., Circulation 2004, 109:573-579.