Cardiovascular Disease in Women
Section snippets
Lack of awareness
Despite the importance of early recognition and treatment of CVD, women commonly underestimate its dangerous potential. In 1997, a survey by the American Heart Association (AHA) found that only 7% of women considered CVD to be their biggest mortality and health risk. Less than one third of women claimed awareness that CVD was the greatest killer of US women, because5 most women surveyed thought that their greatest threat was breast cancer.4 The truth is that although 1 of every 26 US women dies
Prevalence and incidence
CVD affects 42.1 million American women, or 36.6% of the adult female population (Fig. 2). CAD affects 7.2 million American women. The prevalence of CVD increases as women age and affects 36.2% of women aged 45 to 54 years, 52.9% of women aged 55 to 64 years, and more than 68.5% of women aged 65 years and older. Three million women have a history of having had a myocardial infarction, and 3.3 million have had a stroke. Nearly 365,000 American women have heart attacks each year; 83,000 are
Women versus men
There is a significant disparity between women and men in terms of prevalence and treatment with respect to CVD (Fig. 3). CVD is no longer considered to be exclusively a “man's disease,” because since 1983, more women than men have died of CVD every year.10, 11 Over the past few decades, although the number of deaths from CVD has been declining, the decline has been less for women than for men.
The lifetime risk for CVD is 2 in 3 for men and greater than 1 in 2 for women at the age of 40 years.
Presentation of cardiovascular disease in women
Heart disease presents differently in women than in men, which may explain the differences in treatment patterns. The term Yentl syndrome has been coined to describe how a woman with CAD must present like a man to receive the same medical treatment that a man would receive. It was coined after the heroine in Issac Bashevis Singer's short story of a young Jewish girl who disguised herself as a man to study the Talmud at an all-male school in nineteenth century Poland.23 Chest pain is the most
Assessing cardiovascular disease risk
There are several well-recognized risk factors for CVD in women. Although age and hereditary are not modifiable and untreatable, there is considerable interplay among the other risk factors. For example, women who are more sedentary are more likely to gain weight, leading to an increased risk for developing additional comorbidities, including diabetes, hypertension, and hyperlipidemia. Current guidelines recommend a comprehensive assessment of cardiovascular risk factors. This evaluation should
Primary and secondary prevention of cardiovascular disease
The goal of primary prevention is to prevent diseases before they develop. In the case of CVD, primary prevention includes promoting proper dietary habits to lower cholesterol intake, increasing physical activity, and prevention of tobacco use and exposure.32 Primary prevention also includes optimizing the treatment of hypertension, dyslipidemia, and diabetes. The AHA guidelines emphasize the need for women to participate in at least 30 minutes of moderate intense activity 5 days a week.33
Hypertension
High blood pressure is one of the most common and most treatable risk factors for all forms of CVD. There is an age-related increase in the prevalence of hypertension in women and in men. After adolescence, men have a greater prevalence of hypertension than women until 50 to 60 years of age, when the prevalence becomes almost equal.35 This prevalence differs with ethnicity, because African-American women have the highest prevalence, affecting up to 80% of women older than the age of 60 years (
Smoking
Cigarette smoking remains one the key preventable risk factors for CVD in women. It has been estimated that 50% of myocardial infarctions in middle-aged women are attributable to smoking and that women who continue to smoke after a myocardial infarction have a 50% higher risk for recurrent events compared with nonsmokers.37 Women who smoke tend to develop CAD earlier than nonsmokers, up to 19 years earlier according to some studies.38 Smoking may also increase a woman's risk for the development
Physical inactivity
A lack of adequate exercise and a sedentary lifestyle also increase a woman's risk for CVD. This risk is independent of the contribution that being sedentary has on the risk for developing hypertension, high cholesterol, diabetes, and obesity. In the United States, only 28.9% of women get any leisure time physical activity, with minority women disproportionately affected by this problem. Although 39% of white women are sedentary and get no leisure time physical activity, 57% of African-American
Obesity, abdominal obesity, and waist circumference
Obesity is an independent risk factor for CVD in women52 and represents the second most preventable cause of cardiovascular death after smoking. Obesity is especially important, given its epidemic status in the United States. Since 1991, the prevalence of obesity has increased by 75%; more than two thirds of US adults are now overweight, and more than one half are obese. The percentage of people with a BMI of 25 or greater has increased from 55.9% to 65.1%; the percentage of those with a BMI of
Hypercholesterolemia
Dyslipidemia is defined as elevated levels of total cholesterol, low-density lipoprotein cholesterol (LDL-C), or triglycerides, but it can also refer to decreased levels of high-density lipoprotein cholesterol (HDL-C). The association between LDL-C and CVD is well established, and evidence exists that lowering LDL-C can reduce the risk.55 Given the significance of the issue, it is important to explore the various types of cholesterol in addition to treatment options. The current National
Diabetes
Diabetes is a significant risk factor for CVD, and its prevalence is increasing in the United States. An estimated 11.5 million women, or 10.2% of all women aged 20 years or older, have diabetes, but 25% of them are unaware that they have it.79 The risk for CVD is so significant in diabetics that diabetes is considered to be a CVD equivalent. CVD affects diabetics twice as often as those without diabetes.80 Two of three diabetics die from heart disease or stroke. Diabetics are two to four times
Diet
A woman's diet can play a key role in the development of many CVD risks, including dyslipidemia, obesity, and hypertension. The American diet tends to be high in fats and carbohydrates, and the average adult now consumes 300 more calories per day than in 1985, adding to weight gain and the risk for obesity and its related CVD risks. It is important that physicians explore aspects of a women's diet to determine the number of servings each day of meat, grains, dairy products, and various fruits
Antiplatelet therapy
Antiplatelet therapy is essential for the treatment of CVD and usually consists of aspirin as first-line therapy but may also include Plavix or Aggrenox (a fixed-dose combination of aspirin and dipyridamole). Aspirin is quite effective and economic. When discussing aspirin with patients, it is important to distinguish if it is being used for primary or secondary prevention. Until recently, most of the primary prevention studies had been done on men and demonstrated an approximated 32% reduction
Hormone replacement therapy
There has been a lot of excitement in the recent past about the potential for HRT as a means to reduce CVD in women. This excitement stemmed from the observation that the incidence of CVD and many of its risk factors increases precipitously after menopause, at a time when estrogen levels decrease significantly. Moreover, HRT has been shown to increase levels of HDL-C and lower levels of LDL-C.94 Several observational studies in the past seemed to confirm these theories and showed some reduced
Testing women for cardiovascular disease
Testing options for women with suspected CVD are identical to those of men but are not without controversy. These options include exercise stress tests, stress nuclear imaging, stress echocardiography, computed tomographic angiography/electron beam CT, and MRI. Each of these tests has a different sensitivity and specificity for detecting CVD (Table 9). Researchers have shown that some of these tests may have poorer diagnostic accuracy in women than in men. Several studies have shown that women
Cerebrovascular disease
Stroke is the third leading cause of death in the United States and is the leading cause of disability. On average, someone in the United States has a stroke every 45 seconds, with approximately 30% being new strokes and 70% being recurrent strokes. Of those strokes, 88% are ischemic, 9% are intracerebral hemorrhages, and 3% are subarachnoid hemorrhages. Women have more strokes than men and have higher mortality. The lifetime risk for dying from a stroke is 16% in women compared with 8% in men,
Summary
CVD remains the most important health issue facing women and continues to be their number one cause of morbidity and mortality. Women are disproportionately affected by CVD compared with men. It is diagnosed less often and treated less aggressively in the inpatient and outpatient settings; as a result, women have poorer outcomes. It is therefore imperative that physicians take steps to screen women for the risks associated with CVD and actively education them on primary and secondary prevention.
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