Cardiovascular risk factors: gender differences

According to the World Health Organization, cardiovascular disease (CVD) remains the leading cause of death worldwide.
They are responsible for more deaths among women than breast cancer, lung cancer and chronic lung disease combined.
In France, ACF likes to highlight the 33 daily deaths from breast cancer, compared with the 200 daily deaths from CVD.
Most cardiovascular deaths in women are due to stroke, ahead of myocardial infarction and heart failure.
Stroke mortality rates in young women, aged 35 to 54, are increasing, compared with the decrease observed in men.
Many women, who do not care enough about their health, as well as ill-informed doctors, do not consider CVD to be an important cause of morbidity and mortality in women, contributing to delays in diagnosis and management.
Yet the need to reduce the global burden of CVD in women by 2030 has been highlighted, emphasizing the significant gaps in prevention, treatment, research and access to care for women.
Traditional risk factors (RFs) contribute to women's risk of developing CVD. However, taking these very important elements into account does not allow for a relevant estimation of short- and long-term risks, nor of lifetime risk for women. In general, women are at medium to high risk of CVD, given that almost one in two women will develop CVD during her lifetime, reinforcing the need for a gender-specific risk assessment.

This is the subject of a very interesting article published in the journal of the European Society of Cardiology (ESC), which distinguishes between the classic factors and those specific to women that increase the risk of CVD.




Classical risk factors:

They are common to both sexes, but there are notable differences, all to the disadvantage of women:

- Arterial hypertension:
increases the risk of stroke more than in men
is favoured by the use of contraceptives containing estrogens
systolic (maximum) pressure is higher for the same age.

cholesterol levels are higher than in men
women tolerate statin treatment less well
Lipoprotein (a) rises at menopause.

is responsible for a higher level of risk in both type 1 and type 2.

more frequent in women
abdominal fat distribution is more deleterious
- Migraine:
is a typically female pathology
is associated with vascular motricity and coagulation disorders.
- Inflammation:
is more frequent in women
who more often have autoimmune pathologies that increase RCV.

Risk factors specific to women:

They are specific to women and also contribute to the RCV and therefore CVD
- Menopause
This is what we think of first
It is associated with an increase in all FDRs
Early menopause increases the risk of heart attack by 70%:
before age 40
- Polycystic ovary syndrome
increases stroke risk by 41%; no impact on infarctions
- Endometriosis and even fibroids
increase CVD risk by 23% and 32% respectively through hypertension and dyslipidemia-hypertension.
- Finally, infertility is associated with a 13% increase in risk for coronary arteries, risk moreover higher during the menstrual cycle with 90% of infarctions occurring during this period.





Pregnancy:

Represents a real "stress test" for the body and has its specific cardiometabolic complications:
- Changes in blood pressure.
With a 2-8% risk of CVD in the case of abnormalities, essentially if there is preeclampsia
- Changes in blood glucose.
This is the classic gestational diabetes
Which may persist after pregnancy, like hypertension, hence the need for increased monitoring that is little or poorly assured.
Less well known are inflammation and lipid abnormalities.
- Older pregnancy ages (over 35), prematurity and low birth weight are also associated with coronary risk.

Lifestyle:

We have observed (and this is not a criticism) in recent decades a "rapprochement" of women's lifestyles tending towards those of men, which is to their disadvantage.
- Smoking
Long non-existent among women
Its frequency is declining, but it has a greater vascular impact, especially if combined with the use of contraceptives containing estrogen
- Physical activity
represents a positive example with greater benefits in women
- Diet
Here again, benefits are greater including on all-cause mortality, but the dietary pattern tends to standardize with men
- Sleep
Inadequate" sleep: of poor quality and/or lasting less than 6 hours is more frequent than in men
Insomnia and sleep apnea with their consequences on blood pressure are more frequent
Poor-quality sleep is associated with an increase in inflammation parameters, unlike in men.

Changes at different ages of life:

There are 4 main periods in a woman's life (which can be reduced to 3 basic stages: contraception, pregnancy, menopause).



- Adolescence
Early or late onset of menstruation
Onset of endometriosis
Increased weight / sedentary lifestyle
Poor diet with explosion of obesity
- "Reproductive" period
Increase in obesity
Unsuitable contraception
Pregnancy with blood pressure, glycemia and lipid disorders
Migraine, particularly accompanied by
Age over 35
- Middle age or maturity
Continued weight gain, particularly after pregnancy
Accumulation of classic FDRs
Peri-menopausal symptoms
Lack of prevention strategies
- Post-menopause
Disappearance of the protective effect of natural estrogens
Increased weight
Onset of arterial hypertension (50% of women)
Changes in lipids, including lipoprotein (a)
Tendency to hyperglycemia, even diabetes
Decline in physical capacity
Insomnia and depression
Impaired quality of life
Poor control of FDR (if only because undetected)

Proposed explanations:

Since these differences exist, why aren't they taken into account?
The authors point to several reasons for this state of affairs:
Insufficient knowledge on this subject, anatomical and biological differences between men and women, differences in apparently similar pathologies, selection bias in studies where women are under-represented, the flagrant and constant inadequacy of treatments and finally the inadequacy of screening and prevention of CVD particularly in women.

In conclusion:

On reading the foregoing, "it's better not to be a woman", as the elements evoked are not very reassuring.
CVD remains the leading cause of death in women, yet it remains largely underestimated - both by healthcare professionals and by women themselves, who are more concerned about others than their own health - as a major threat to women's health.
This lack of awareness often contributes to late diagnosis and inappropriate treatment. Although progress has been made in improving the diagnosis and treatment of CVD in women, significant gaps remain.
New insights suggest that strategies could be implemented in public health with a more proactive approach, taking into account a woman's entire health pathway throughout her life and emphasizing early risk assessment. Critical phases such as the onset of risk factors in early adulthood, pregnancy and menopause should be key points in a more comprehensive care model; the recently proposed cardiovascular check-up at menopause is a very good example.
This article highlights the established, gender-specific risk factors that influence cardiovascular health in women.

Ultimately, in addition to greater information through all possible communication channels - and Agir pour le Coeur des Femmes is making a major contribution to this - we need to move our healthcare system towards a life-course that incorporates prevention, early detection and personalized treatment tailored to women's specific cardiovascular risks.
We know what we should be doing. It's just a question of getting started...


Reference

Appleman Y. et al. Cardiovascular disease in women: traditional and sex-specific risk factors. Eur Heart Journal 2025: https://doi.org/10.1093/eurheartj/ehaf1001