Menopause presents critical time for CVD risk reduction
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Menopause can be a good time to start addressing CVD risk reduction even though it should be discussed way before then, according to a presentation at the virtual Heart in Diabetes Conference.
There are different types of myocardial ischemia in women, which includes plaque rupture, plaque erosion, spontaneous coronary artery dissection, microvascular dysfunction, coronary vasospasm, nonobstructive CAD and nonobstructive myocardial ischemia, Gina P. Lundberg, MD, FACC, FAHA, clinical director of the Emory Women’s Heart Center and associate professor of medicine at Emory University School of Medicine, said during her presentation. In addition, atherosclerotic CVD in women leads to a higher prevalence of angina despite a lower burden of obstructive CAD, she said.
“Unfortunately, this is not benign,” Lundberg said. “Women have a poorer prognosis even with less obstructive coronary artery disease, and the clinical presentation, as we’ve heard for decades now, can be more atypical in women. Because it’s really not that uncommon, we should probably quit using the word ‘atypical,’ and men can present this way as well.”
Microvascular or endothelial dysfunction occurs when coronary flow reserve is limited without a fixed obstructive lesion, and this is associated with increased risk for cardiac death, stroke and HF, Lundberg said.
Plaque rupture, associated with hyperlipidemia and vulnerable plaque, is the most common cause of acute MI in women older than 50 years, but plaque erosion is more often responsible for infarction in younger women, especially those who smoke, according to the presentation.
“It may be that estrogen plays a protective role in the plaque rupture,” Lundberg said. “This is why plaque rupture is more common in older women, but it does not protect against plaque erosion.”
Takotsubo cardiomyopathy is another common form of myocardial ischemia in women, especially postmenopausal women. It is often observed after a strong emotional trigger or intense exercise, according to the presentation.
MI with nonobstructive coronary arteries (MINOCA) is found in 6% of all MIs, with a median age of 58 years, according to the presentation. In addition, 50% of these events, which may be due to endothelial dysfunction, vasospasm and thrombotic disorders, occur in women.
“It does have a guarded prognosis long term, but it is better compared to an obstructive coronary artery disease and acute coronary syndrome,” Lundberg said.
Not only do women present differently than men, but they also often have unfavorable outcomes vs. men. These are due to sex-based disparities including less diagnostic testing or angiography, reperfusion delays and fewer revascularizations. Women also receive less pharmacotherapy and fewer referrals for and completion of cardiac rehabilitation.
“A lot of times, physicians feel that women aren’t interested,” Lundberg said. “Women get there and there are fewer women in the classes, so they don’t feel comfortable and they have a higher dropout rate.”
Women also have higher morbidity after MI; a higher in-hospital mortality with STEMI, angina and ACS, and higher mortality in women 55 years and younger, according to the presentation.
In a study published in Circulation in 2019, researchers found that young women were less likely to receive evidence-based medications for acute MI compared with men, including aspirin (86% vs. 89%), non-aspirin antiplatelet agents (51% vs. 62%), lipid-lowering agents (63% vs. 72%), beta-blockers (81% vs. 84%) and ACE inhibitors or angiotensin II receptor antagonists (59% vs. 64%).
There are also differences among women and men regarding statin prescriptions and attitudes towards this therapy, according to the presentation.
“You all know how difficult it can be to convince a patient that statins are safe, effective and save lives, but we found that there’s a difference when it comes to women,” Lundberg said.
In a study published in Circulation: Cardiovascular Quality and Outcomes in 2019, researchers found that compared with men, women were prescribed statins less often (67% vs. 78.4%), received less intense statin therapy (36.7% vs. 45.2%) and were offered the therapy less often (18.6% vs. 13.5%). In addition, women more often declined statin therapy (3.6% vs. 2%) and were more likely to discontinue statins (10.9% vs. 6.1%).
“There is an attitude about statins that we need to spend more time educating our women so that they will be on the right therapy,” Lundberg said. “As providers, we need to make sure that we’re prescribing the right therapy.”
Several traditional risk factors for ASCVD are not specific to women such as diabetes, smoking, obesity and overweight, physical inactivity, hypertension and dyslipidemia. But there are some nontraditional risk factors for women, especially those related to pregnancy including preterm delivery, hypertensive disorders of pregnancy and gestational diabetes. Other novel risk factors for women include treatment for breast cancer, autoimmune disease and depression.
“We’re starting to look at pregnancy as the first stress test in a woman for her cardiovascular risk, and this should be taken into account even in a postmenopausal woman,” Lundberg said. “Sometimes when I’m asking my 60-year-old woman about their pregnancy events, they’re wondering if I’m crazy, but I explain to them that how you did with your pregnancies will tell us a little bit about your future risk of cardiovascular disease.”
Hypertensive disorders of pregnancy can increase a woman’s risk for chronic hypertension by 370%, stroke by 81%, atrial arrhythmias by 50%, CHD by 250%, all-cause death by 50% and CV death by 221%, according to a study published in Current Treatment Options in Cardiovascular Medicine in 2018.
“Hypertensive disorders of pregnancy are very important to ask about for later life risk assessment,” Lundberg said.
Women’s lipid levels become unfavorable after menopause, as there are increases in total cholesterol, LDL and triglycerides and a decrease in HDL, according to the presentation. All women including those after menopause require several approaches for CHD prevention including hypertension control, diabetes control and lipid control, in addition to smoking cessation, weight control and positive lifestyle changes, according to the presentation. The American College of Cardiology/American Heart Association Pooled Cohort Risk Equation can be used to assess risk in women, Lundberg said.
Although menopause hormone therapy is not meant to be used for the management of chronic disease, it can be used to manage menopausal symptoms, according to the presentation. Before initiation, women should undergo risk evaluation that is personalized for that particular patient, which will help determine which hormone therapy is best. It is important to note that menopausal hormone therapy is not recommended for CVD protection in women.
“The North American Menopause Society, the ACC and the AHA are still not recommending it for prevention of heart disease, but when it’s initiated in a younger woman, we might get a beneficial vasomotor response,” Lundberg said. “Basically, if your patient is low risk, near the time of menopause, normal weight, normal blood pressure and an active, healthy female with a low ASCVD risk score, she would qualify for hormone therapy for vasomotor symptoms.”
References:
- Arora S, et al. Circulation. 2019;doi:10.1161/CIRCULATIONAHA.118.037137.
- Coutinho T, et al. Curr Treat Options Cardiovasc Med. 2018;doi:10.1007/s11936-018-0653-8.
- Nanna MG, et al. Circ Cardiovasc Qual Outcomes. 2019;doi:10.1161/CIRCOUTCOMES.118.005562.
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Lundberg GP. Women and CVD. Presented at: Heart in Diabetes CME Conference; August 21-24, 2020 (virtual).
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