Many steps needed to improve CV health in women
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There are many ways in which women’s CV risk differs from that of men, and addressing it requires solutions tailored to women, according to a presentation at the virtual American Society for Preventive Cardiology Congress on CVD Prevention.
Cardiology Today Editorial Board Member Nanette K. Wenger, MD, MACC, MACP, FAHA, FASPC, emeritus professor of medicine (cardiology) at Emory University School of Medicine, consultant at Emory Heart and Vascular Center and founding consultant at Emory Women’s Heart Center, presented the lecture in honor of being given the American Society for Preventive Cardiology’s Honorary Fellowship Award.
It is crucial to remember that women have nontraditional CV risk factors unique to or more predominant in them, and that traditional CV risk factors may present different degrees of risk for women than they do for men, Wenger said.
“Very importantly, gender-specific risk assessment and management has the potential to improve cardiovascular outcomes in women,” she said.
Of note, she said, the decline in CV mortality in the U.S. from 1970 to 2000 occurred predominantly in men, “then, about in 2000, as we began to address gender-specific issues, [there was] a very sharp decline in cardiovascular mortality for women, more abrupt than that for men.”
She noted that 2014 was the first year in which fewer women than men died from CVD in the U.S. “We are delighted to be in second place, and we hope to remain there,” she said.
One in four U.S. women die of CVD, and the CVD mortality rate is twice that of cancer in U.S. women, she said, noting that two of three U.S. women have at least one major coronary risk factor, the odds of which increase with age.
Unfortunately, she said, U.S. women aged 35 to 54 years have had an increase of approximately 1% annually in CVD mortality in recent years, likely driven by obesity and sedentary lifestyles. Of concern, Black and Hispanic women have more CVD risk factors than white women, she noted.
Factors unique to women
Pregnancy complications are the most prominent CVD risk factors unique to women, Wenger said.
“If you take away but one message from this presentation, it’s that a detailed pregnancy history is an integral component of risk assessment for women,” she said. “Pregnancy complications ... are indicators of increased cardiovascular risk. It is likely that the cardiovascular and metabolic stresses of pregnancy give us the potential for the future prediction of early cardiovascular risk, because likely there are shared risk factors for preeclampsia and for cardiovascular disease. We’ve been taught traditionally that preeclampsia subsides with the delivery of the placenta. But the vascular complications do not. There is measurable endothelial dysfunction, and it is associated with an increase in coronary artery calcium.”
Also unique to women are risks from oral contraceptives. These are not present in healthy women with no risk factors, but women who take oral contraceptives and smoke or have hypertension are at elevated CVD risk, Wenger said.
“In women who use oral contraceptives, the prescriber should assess for the conventional coronary risk factors and control them as appropriate,” she said.
Another consideration unique to women is hormonal fertility therapy, Wenger said.
“What was found was that ... women who had successful fertility therapy were at decreased risk of all-cause mortality, nonfatal ischemia, stroke, transient ischemic attack, thromboembolism and heart failure in all age and income groups,” she said. “This is likely a reflection of a healthy cohort selection bias, because when there is unsuccessful fertility therapy, these women have an increase in cardiovascular risk. We’re not sure whether this depends on the patient characteristics, because that has not been well-explored, or whether it reflects multiple cycles of hormonal therapies or whether it is a combination of both of these.”
Menopausal hormone therapy was thought to be cardioprotective, but clinical trial data disproved that, Wenger said, so it is no longer recommended for primary or secondary CVD prevention.
Factors different in women
Systemic autoimmune diseases are more prevalent in women than men and also contribute to CVD risk, so patients with these conditions need CV screening, according to the presentation.
Although hypertension is common in both sexes, women are less likely to have it than men before age 45 years but are more likely to have it after age 65 years, and older women are less likely to have their high BP under control than older men, Wenger said.
Smoking is more common in younger women than in younger men, and “the issue at hand is there is a 25% greater cardiovascular risk in women smokers than in men smokers, and smoking triples the risk for myocardial infarction for women, while smoking is also associated with greater risk for STEMI in women than men, with the greatest increased risk being in the younger women. Smoking cessation is the most cost-effective cardiovascular risk modification in the U.S., and one we should all address.”
Diabetes confers almost double the risk for CVD in women compared with men, and among those admitted for a first MI, more women than men are diabetic, Wenger said.
“Diabetic women tend to have clustering of their risk factors, but sadly, diabetic women have less treatment and control of their cardiovascular risk factors than do men, despite the fact that lifestyle interventions may improve cardiovascular mortality more in prediabetic women than in prediabetic men,” she said. “The bottom line is that women who are diabetic lose their gender advantage of lesser cardiovascular events, and their incidence of cardiovascular events is the same as in comparably aged men.”
The 2018 American College of Cardiology/American Heart Association Guideline on the Management of Blood Cholesterol added premature menopause and pregnancy-associated disorders to the list of factors to consider in decisions on lifestyle interventions and statin therapy, Wenger said.
Obesity is prevalent in both sexes but “increases coronary risk more for women than for men,” Wenger said.
The INTERHEART study showed that physical activity was more cardioprotective for women than for men and “physical inactivity is the most prominent risk factor for women,” she said. She also noted the Nurses’ Health Study found that physical activity decreased diabetes incidence in women and decreased CV event risk in women with diabetes.
Depression “is an important issue to address, because the psychosocial issues, particularly depression, disadvantage women,” Wenger said, noting they had a stronger link to CVD mortality in women than in men in INTERHEART.
Raising awareness
There is more work to do on the awareness front, Wenger said, noting 54% of women now recognize that heart disease is the leading cause of death in women. Campaigns such as Go Red for Women increased the awareness, which 15 years ago was approximately 30%, “but there has been a recent plateau, and the lack of awareness, sadly, is greatest in the highest-risk populations: the women of racial and ethnic minorities,” she said.
Many health care providers are also unaware that heart disease is the leading cause of death in women, “which translates into suboptimal application of preventive interventions, into less appropriate diagnostic testing and less adherence to evidence-based guidelines, and not surprisingly, into poorer outcomes for women,” she said.
“The first step to personalized medicine is incorporating information about sex and gender differences,” Wenger said.
To improve CV risk, providers must better educate the population, especially women, about CV risk factors, and convey the message that “basic lifestyle modifications can lessen the occurrence of hypertension, dyslipidemia, obesity, diabetes and cardiovascular risk,” she said. “Most prominent among these are smoking cessation, a heart-healthy diet with less sodium and saturated fats and more fruits and vegetables and an increase in daily exercise as part of routine lifestyle.”
To be most effective, these messages must be specifically targeted to women, particularly those in low- and middle-income countries, Wenger concluded. “The organizations devoted to women’s heart health must engage women on a local, community level with culturally appropriate messages. This is the only way we will lessen the risk of cardiovascular disease, myocardial infarction and sudden death for women.”
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Wenger NK. Transforming CVD Prevention for Women: Time for the Pygmalion Construct to End. Presented at: American Society for Preventive Cardiology Congress on CVD Prevention; July 25-26, 2020 (virtual meeting).
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