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Women's Heart Health: Difference between revisions
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In general cardiovascular events among women appear approximately 7-10 years later in women than in men. The lower incidence of CVD in premenopausal women compared with men of similar age and the menopause associated increase in CVD have long suggested that estrogens underlie a protective effect on the cardiovascular system for women. | In general cardiovascular events among women appear approximately 7-10 years later in women than in men. The lower incidence of CVD in premenopausal women compared with men of similar age and the menopause associated increase in CVD have long suggested that estrogens underlie a protective effect on the cardiovascular system for women. | ||
It is known that estrogens improve the arterial wall response to injury and inhibit the development of atherosclerosis by promoting re-endotheliazation, inhibiting smooth muscle cell proliferation, and matrix deposition following vascular injury. | It is known that estrogens improve the arterial wall response to injury and inhibit the development of atherosclerosis by promoting re-endotheliazation, inhibiting smooth muscle cell proliferation, and matrix deposition following vascular injury.<cite>5</cite> | ||
Estrogens also decrease systemic vascular resistance, improve coronary and peripheral endothelial function and prevent coronary artery spasm in women with and without atherosclerosis. Pre-menopausal women with hormonal imbalances and estrogen deficiencies have a higher risk of developing premature atherosclerosis | Estrogens also decrease systemic vascular resistance, improve coronary and peripheral endothelial function and prevent coronary artery spasm in women with and without atherosclerosis. Pre-menopausal women with hormonal imbalances and estrogen deficiencies have a higher risk of developing premature atherosclerosis.<cite>6</cite> | ||
==Gender Differences in the Pathofysiology of Atherosclerosis== | ==Gender Differences in the Pathofysiology of Atherosclerosis== | ||
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==Risk Factors== | ==Risk Factors== | ||
Risk estimates associated with traditional cardiovascular risk factors are overall similar in women and men across various regions of the World. However, the increased risk associated with hypertension and diabetes and the protective effect of exercise and alcohol appear to be larger in women than in men | Risk estimates associated with traditional cardiovascular risk factors are overall similar in women and men across various regions of the World. However, the increased risk associated with hypertension and diabetes and the protective effect of exercise and alcohol appear to be larger in women than in men.<cite>7</cite> It is also important to make a difference between pre and post menopausal status. Table 1 gives an overview of the global cardiovascular risk factors in women | ||
===Smoking=== | ===Smoking=== | ||
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===Hypertension=== | ===Hypertension=== | ||
Hypertension is a highly prevalent risk factor that becomes more common in women then in men and is particularly prevalent among black women | Hypertension is a highly prevalent risk factor that becomes more common in women then in men and is particularly prevalent among black women.<cite>8</cite> After menopause the renine activity in plasma increases which leads to sodium retention. By the age of 60 almost 50% of all women have clinically manifest hypertension, defined as a systolic blood pressure > 140 mmHg and a diastolic blood pressure of 90 mmHg.<cite>9</cite> Hypertension in women compared to men more often leads to CVA, left ventricular hypertrophy en diastolic dysfunction. The structural changes of the myocardium can become clinical manifest by dyspnea, supraventricular tachycardia such as atrial fibrillation, angina due to endothelial dysfunction. Slightly elevated blood pressure leads in women more then in men to endothelial dysfunction.<cite>10</cite> Hypertension is 2 to 3 times more common in women taking oral contraceptives, especially among obese and older women. Blood pressure lowering strategies have demonstrated to reduce the risk of ischemic heart disease and stroke | ||
===Dyslipidemia=== | ===Dyslipidemia=== | ||
In women there is a stronger fluctuation of lipid levels throughout life. Due to hormonal changes total and LDL cholesterol levels increase with an average of 10-14% after menopause | In women there is a stronger fluctuation of lipid levels throughout life. Due to hormonal changes total and LDL cholesterol levels increase with an average of 10-14% after menopause.<cite>11</cite> Low HDL and high triglycerides seems to be more important risk factors in women than in men. Data from the Nurses Health Study shows that HDL was the lipid parameter that best discriminated the risk of ischemic heart disease.<cite>12</cite> | ||
Hypertriglyceridemia is associated with a 37% increase in CVD risk in women compared to 14% in men | Hypertriglyceridemia is associated with a 37% increase in CVD risk in women compared to 14% in men.<cite>13</cite> The dynamic changes of the lipidprofiles due to age and menopausal status play an important role in the prevention of cardiovascular disease in women. | ||
===Obesity=== | ===Obesity=== | ||
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===Women specific risk factors=== | ===Women specific risk factors=== | ||
Estrogens improve the arterial wall response to injury and inhibit the development of atherosclerosis by promoting re-endotheliazation, inhibiting smooth muscle cell proliferation and matrix deposition following vascular injury. They also have a vasodilative effect. Premenopausal women with hormonal dysfunction and estrogen deficiency have a higher risk for developing premature atherosclerosis | Estrogens improve the arterial wall response to injury and inhibit the development of atherosclerosis by promoting re-endotheliazation, inhibiting smooth muscle cell proliferation and matrix deposition following vascular injury. They also have a vasodilative effect. Premenopausal women with hormonal dysfunction and estrogen deficiency have a higher risk for developing premature atherosclerosis.<cite>14</cite> The polycystic ovarian syndrome, a condition also known as PCOS have a high risk for developing the metabolic syndrome and type 2 diabetes and are therefore an at risk population. Also women with premature ovarian failure (menopause before the age of 40) have a higher risk for developing CVD. | ||
=== “Novel” risk factors=== | === “Novel” risk factors=== | ||
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==Risk Factor Assessment== | ==Risk Factor Assessment== | ||
===Which risk factors should be assessed?=== | ===Which risk factors should be assessed?=== | ||
Global cardiovascular risk should be assessed in | Global cardiovascular risk should be assessed in '''ALL''' women in menopause consulting the physician. | ||
Many women appear healthy with no symptoms of CVD nevertheless, they are potentially at increased risk | Many women appear healthy with no symptoms of CVD nevertheless, they are potentially at increased risk | ||
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Women who are diagnosed with non cardiac chest pain have twofold increased risk to develop a coronary event in the next 5-7 years and have a four times higher risk for re-hospitalization. This implicates that diagnostic testing is limited and that women should be more aggressively treated for their risk factors. | Women who are diagnosed with non cardiac chest pain have twofold increased risk to develop a coronary event in the next 5-7 years and have a four times higher risk for re-hospitalization. This implicates that diagnostic testing is limited and that women should be more aggressively treated for their risk factors. | ||
Chest pain syndromes are more common in women then in men and are less related to the presence of atherosclerosis in the epicardial coronary arteries. | Chest pain syndromes are more common in women then in men and are less related to the presence of atherosclerosis in the epicardial coronary arteries.<cite>15</cite> | ||
There are no gender-specific criteria for the interpretation of ECG’s. Non specific ECG changes at rest, a lower exercise capacity and a smaller vessel size contribute to the lower sensitivity and specificity of non-invasive testing in women. At younger ages, endogenous estrogen level scan induce ECG changes mimicking ischemia. | There are no gender-specific criteria for the interpretation of ECG’s. Non specific ECG changes at rest, a lower exercise capacity and a smaller vessel size contribute to the lower sensitivity and specificity of non-invasive testing in women. At younger ages, endogenous estrogen level scan induce ECG changes mimicking ischemia. | ||
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Symptom management in patients with non-obstructive cardiovascular disease is a challenge. Important to differentiate between vasospastic forms and complaints related to endothelial dysfunction. Table 2 gives an overview of current treatment options. | Symptom management in patients with non-obstructive cardiovascular disease is a challenge. Important to differentiate between vasospastic forms and complaints related to endothelial dysfunction. Table 2 gives an overview of current treatment options. | ||
Lifestyle behaviors can prevent and reduce the risk of getting heart disease and should therefore be primary focus in the GP-practice. Strategies adapt health lifestyle changes are listed below Adapted from Assessment and Management of cardiovascular risk in women ESC/ESH/2007): | Lifestyle behaviors can prevent and reduce the risk of getting heart disease and should therefore be primary focus in the GP-practice. Strategies adapt health lifestyle changes are listed below Adapted from Assessment and Management of cardiovascular risk in women ESC/ESH/2007):<cite>16</cite> | ||
====Smoking: TARGET: permanently stop smoking all forms of tobacco==== | ====Smoking: TARGET: permanently stop smoking all forms of tobacco==== | ||
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==References== | ==References== | ||
<biblio> | <biblio> | ||
#1 | #1 pmid=20019324 | ||
#2 [http://www.bhf.org.uk/publications/view-publication.aspx?ps=1001443 European cardiovascular disease statistics 2008, British Heart Foundation.] | #2 [http://www.bhf.org.uk/publications/view-publication.aspx?ps=1001443 Steven Allender, Peter Scarborough, Viv Peto and Mike Rayner ''European cardiovascular disease statistics 2008'', British Heart Foundation Health Promotiona Research Group.] | ||
#3 | #3 pmid=19788058 | ||
#4 pmid=18036449 | #4 pmid=18036449 | ||
#5 pmid=12575968 | #5 pmid=20160161 | ||
#6 pmid=12575968 | |||
#7 [http://cardiovascres.oxfordjournals.org/content/90/1/9.full Viola Vaccarino, Lina Badimon, Roberto Corti, Cor de Wit, Maria Dorobantu, Alistair Hall, Akos Koller, Mario Marzilli, Axel Pries and Raffaele Bugiardini ''Ischaemic heart disease in women: are there sex differences in pathophysiology and risk factors?'' 2010] | |||
#8 (vacc 18). | |||
#9 (ref 14 AM/p27 | |||
#10 (AMp27 ref15 | |||
#11 ( AMp29/ref16 | |||
#12 (VACC ref 24 | |||
#13 VACC 25) | |||
#14 AM p29/20,21). | |||
#15 Eur.H J/2006;27:2285-93 | |||
#16 Adapted from Assessment and Management of cardiovascular risk in women ESC/ESH/2007 | |||
</biblio> | </biblio> | ||