J. Schwanwede, M.D.
Attending Cardiologist, Saint Barnabas Medical Center

Cardiovascular disease is the leading cause of death and disability for women in the U.S. In 2000, a total of 945,836 deaths in this country were attributed to cardiovascular disease. More than one half of these were women. The common misconception is that coronary heart disease is a "man's disease." A survey by the American Heart Association reported that only 8 percent of women questioned recognized that heart disease and stroke are the leading cause of death and disability among women. Cardiovascular diseases kill more women each year than the next 16 causes combined. One in two women dies of heart disease and stroke, while only one in 25 dies of breast cancer.

Women and Heart Disease

The Major Risk Factors are: Cigarette Smoking Diabetes Mellitus Dyslipidemia (high cholesterol) Hypertension Family History of Premature Coronary Disease (First degree relative less than 55 years of age) Minor Risk Factors Include: Obesity Sedentary Lifestyle Stress Age

A source of confusion is that women usually experience coronary artery disease at an older age than men. Presumably, this is because of the presence of endogenous estrogen in premenopausal women which is protective. This assumption is somewhat supported by observation data that women who have had premature menopause seem to have a higher risk of coronary heart disease (CHD) than premenopausal women of the same age. The mechanism is complex and is partially due to the protective effect of estrogen on lowering total cholesterol and LDL (bad cholesterol).

Women also experience "atypical" anginal symptoms that is, those that are non-exertional and may also have various components to their history. This may include shortness of breath, dizziness, fainting, weakness and arm and shoulder pain. These atypical symptoms may cause a delay in diagnosis. This leads also to the concern that women may be evaluated less intensively and perhaps not treated as aggressively as they should be. Based on data published for the National Registry of Myocardial Infarction (MI) on 350,000 patients hospitalized for MI, women were less likely to receive thrombolytic therapy, aspirin, heparin or beta-blockers. In addition, they underwent cardiac catheterization, interventional therapy or bypass surgery less frequently. As a result there were higher mortality rates among women with heart disease. This may also be attributed to the fact that women present with heart disease at least ten years older than their male cohort and have many more associated medical problems contributing to their poor outcomes.

It makes sense, then, to emphasize primary and secondary prevention and the recognition and treatment of modifiable risk factors for cardiac disease.

Addressing Risk Factors

Nonmodifiable risk factors such as age and family history can be addressed with a recommendation for a heart healthy lifestyle including exercise and healthy diet.

Tobacco use and exposure remains a major area of concern. In a prospective study of 121,000 nurses, the risk of CHD was six times greater among smokers than non-smokers. Also, the risk of sudden death was increased two-to-four fold. It is alarming to note that more than two million women age 18 or older continue to smoke. The risk is even more striking in women with hypertension, diabetes and high cholesterol and/or who use oral contraceptives. Obviously the recommendation is to quit smoking and/or not to start.

Hypertension is more common in American women than American men. Recommendations are to promote factors which lower blood pressure, including weight management, decrease sodium intake, decrease alcohol intake and increase physical activity. The goal is to keep blood pressure lower than 140/90 and optimally around 120/80.

Diabetes Mellitus needs to be aggressively treated with glucose management, careful diet, exercise and careful follow-up with the patient's physicians for strict glucose control.

Some gender differences exist when predicting coronary artery disease based on lipid profiles. Low levels of high-density lipoprotein (HDL) (good cholesterol) predict increased incidents of coronary artery disease in both men and women. Low HDL is affected by such factors as heredity, smoking, obesity, and lack of exercise. Estrogen may elevate HDL.

A number of epidemiologic studies have confirmed the relationship between high cholesterol and cardiovascular disease in both men and women. Low-density lipoprotein (LDL) reduction for patients with coronary disease should be less than 100. In patients without coronary disease the LDL ideally should be less than 130. Recommendations to achieve this are with diet, weight management, smoking cessation and lipid lowering drugs.

Other issues include battling obesity and achieving and maintaining an ideal body weight. In order to achieve this, a healthy diet as well as a physically active lifestyle is necessary. Studies have shown that walking greater than three hours per week can be associated with reducing the risk of coronary artery disease.

The Role of Hormone Replacement Therapy

Hormone replacement therapy (HRT) in perimenopausal women is a topic of great interest. It is not known if estrogen replacement therapy as primary prevention can reduce coronary disease. We await the results of a study called The Women's Health Initiative, slated to be completed in 2006, to give us data on whether giving HRT to perimenopausal women will be beneficial as a primary preventative measure.

Estrogen use in the context of secondary prevention has also been controversial. The HERS study, published in 1998 did not support the use of HRT in postmenopausal women with established coronary artery disease. It is not recommended at this time to give estrogen to postmenopausal women for cardiovascular benefit.

On the horizon, a new class of drugs called selective estrogen receptor modulators is promising. Women may benefit from some of the protective effects traditionally associated with estrogen such as lowering total cholesterol and LDL cholesterol and preventing osteoporosis. Raloxifene is the only selective estrogen receptor modulator clinically available. A study called RUTH ( Raloxifene Use for The Heart) is a clinical trial evaluating the use of the drug in 10,000 postmenopausal women with documented coronary disease or who are at high risk for the disease.

Many of the risk factor modification recommendations apply to all women as both primary and secondary prevention. Our best chance of surviving heart disease is to prevent heart disease.

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