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Preventive measures may help reduce CVD risk in younger women
Early intervention for Canadian women younger than 50 years may be beneficial in identifying and managing high risk for CVD, according to a review published in CMAJ.
“Contemporary Canadian data suggest the gap in cardiovascular mortality between men and women may be closing. Yet young women with [STEMI] have 15% to 20% higher rates of death than men of similar age,” wrote Kajenny Srivaratharajah, MD, MSc, of the division of general internal medicine, department of medicine, at McMaster University in Hamilton, Ontario, Canada, and Beth L. Abramson, MD, MSc, associate professor of medicine in the division of cardiology at the University of Toronto. “Whether this is related to systematic differences in care or true biological differences, or a combination, is unclear. ... The postpartum period is an essential window of opportunity for risk stratification and early intervention to prevent long-term CVD.”
Strong predictors of CVD
The researchers reviewed data from several studies, including a 2018 study that identified diabetes as the strongest predictor of ACS in women younger than 45 years (OR = 6.66; 95% CI, 3.47-12.74). Hypertension (OR = 4.3; 95% CI, 3.42-5.38), hypercholesterolemia (OR = 3.45; 95% CI, 2.6-4.29) and smoking (OR = 1.63, 95% CI, 1.34-1.98) were also identifiers.
Srivaratharajah and Abramson analyzed data from the INTERHEART study that determined diabetes, metabolic syndrome and tobacco use were stronger predictors of ischemic heart disease in women younger than 50 years compared with older women.
In a 1996 cohort study, smoking was a stronger MI risk factor in women younger than 45 years compared with men of that age (RR = 7.1 vs. 2.3). Diabetes conferred a higher RR for ACS among women compared with men (RR = 3.5 vs. 2.06).
The researchers identified lower CVD incidence in premenopausal women compared with men of the same age, with estrogen likely being a protective factor due to the hormone’s effects on the CV system.
Trials examining the addition of treatment with estrogen after menopause have not shown a protective benefit for CVD, the researchers wrote.
Higher CVD risk is associated with ovarian dysfunction in younger women, Srivaratharajah and Abramson wrote. Women with premature ovarian failure had 80% higher mortality from ischemic heart disease compared with women going through menopause.
The researchers analyzed studies involving CVD risk in connection with reproductive therapy. Data from a cross-sectional study consisting of women in both the Framingham Heart Study Third Generation and the Omni Cohort 2 Exam 2 showed that self-reported infertility was associated with elevated BMI and waist circumference.
Data analysis from the Women’s Health Initiative observational study did not find infertility tied to CHD.
Pregnancy and CVD risk
Women with maternal placental syndromes in pregnancy had a twofold increase in CVD compared with women who had pregnancies without such complications (mean age of onset, 38 years), the researchers reported.
According to Srivaratharajah and Abramson, the evidence indicates incremental rises in future CVD risk in women with maternal placental syndromes with poor fetal growth (adjusted HR = 3.1) and intrauterine death (aHR = 4.4) compared with gestation hypertension (aHR = 1.8) and preeclampsia (aHR = 2.1).
Data analyzed by researchers identified that during an 8.5-year follow-up, women with gestational diabetes had a 15-fold higher rate of type 2 diabetes (median onset age, 30 years).
There was a higher prevalence of CVD in women with gestational diabetes compared with those without (15.5% vs. 12.4%; aOR = 1.85; 95% CI, 1.21-2.82), with presentation at a younger age (45.5 ± 2.2 years vs. 52.5 ± 11.9 years) independent of development of postpartum diabetes or metabolic syndrome, the researchers wrote.
Srivaratharajah and Abramson wrote that a study involving women in Ontario aged 29 to 49 years with live births between April 1994 and March 1997 found elevated risk for CVD events in women with gestational diabetes (HR = 1.71; 95% CI, 1.08-2.69; median follow-up, 11.5 years). The effect was less clear when adjusted for development of type 2 diabetes, they noted.
A 2018 Canadian retrospective cohort study involving more than 1 million women identified an association between gestational diabetes and elevated ischemic heart disease (HR = 1.23; 95% CI, 1.12-1.36) and MI (HR = 2.14; 95% CI, 1.15-2.47) as much as 25 years after the index pregnancy, Srivaratharajah and Abramson wrote.
The researchers identified both short- and long-term increased CVD risk following maternal placental syndromes. In a large retrospective cohort study, women with any manifestation of maternal placental syndrome had a 19% higher risk for CVD than women without.
Repeated miscarriages were also associated with future CHD (OR = 1.99; 95% CI, 1.13-3.5) but not cerebrovascular disease.
“Long-term assessment and studies examining data on these women at higher risk are needed, and long-term management strategies need to be defined,” Srivaratharajah and Abramson wrote. “Increasing awareness of the interplay between both traditional and nontraditional cardiac risk factors in premenopausal women, greater focus in research on this topic and dissemination of practice guidelines with explicitly screening and target measures, may help reduce the burden of CVD in younger women.” – by Earl Holland Jr.
Disclosures: The authors report no relevant financial disclosures.