How to Prevent Cardiovascular Disease: New Recommendations Specifically for Women

Classic cardiovascular risk factors have different consequences or frequencies in women and they have some risk factors that only apply to them. Cardiovascular disease may show up differently for them. Finally, they don’t react to treatment in the same way. Risks During Pregnancy In 10% to 20% of cases, vascular complications like high blood pressure are observed during the second trimester of pregnancy due to a defect in the placenta’s initial development. These complications are linked to a higher risk of cardiovascular disease in the short, medium and long term if there isn’t appropriate follow-up. This increases the risk by 1.8 to 4 times in comparison with women who have pregnancies without complications. Hypertension in pregnancy is associated with an increased risk of developing chronic hypertension, as well as a cardiovascular event later in the woman’s life, if she doesn’t receive suitable treatment. Other pregnancy complications that increase the risk of diabetes, severe high blood pressure or a cardiovascular event include type 2 diabetes during pregnancy, premature birth before the 37th week, delayed in-utero growth and stillbirth. Early Menopause
Early menopause that begins before age 40 increases the risk of cardiovascular disease due to estrogen deficiencies that contribute to weight gain, high blood pressure and arteriosclerosis. Polycystic Ovary Syndrome
Polycystic ovary syndrome is an endocrine disease among young women characterized by issues with ovulation, hyperandrogenism (high levels of male hormones), infertility and insulin resistance. This syndrome is associate with increased cardiovascular and metabolic risks (with more obesity). Autoimmune Diseases
Women are more at risk for autoimmune and inflammatory diseases that contribute to an increased risk of cardiovascular disease. This is the case for systemic lupus erythematosus and rheumatoid arthritis, conditions that are associated with faster development of atherosclerosis and coronary microvascular dysfunction (small coronary arterioles inside the cardiac muscle).
High Blood Pressure
Risk factors for high blood pressure among women include obesity, a sedentary lifestyle, excessive salt intake, diabetes, and consumption of more than one glass of alcohol per day. People who are obese are more likely to develop high blood pressure. Certain aspects are specific to women. Among the diseases that can cause high blood pressure, 90% of cases of fibromuscular dysplasia of the renal artery are observed in women. In this condition, the blood vessels twist until they look like a string of beads. Estrogen-progestin contraceptives can cause an increase in blood pressure by affecting the endocrine systems that regulate blood pressure. Data shows that women can present higher increases in blood pressure than men, and that these increases last longer. These issues are observed in young women beginning at age 30. This means cardiovascular diseases can appear early in women, rather than much later than men, as people often think. Studies suggest that menopausal women have a higher risk of elevated blood pressure at night. This observation may explain the higher incidence of cardiovascular events attributable to high nocturnal blood pressure compared to what is observed in men. When treating women of childbearing age, it’s important to consider that certain blood pressure medications may lead to an elevated risk of fetal malformation during pregnancy, especially angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. Finally, studies suggest that although there don’t appear to be any differences in the effectiveness of blood pressure medications between men and women, the latter may experience more side effects with certain classes of medication. Type 2 Diabetes
The incidence of type 2 diabetes differs over a lifetime depending on one’s gender. For young people, type 2 diabetes is more common among women, while in contrast it’s more common in middle age men. Among older adults, the incidence is the same among men and women. This higher incidence of type 2 diabetes among young women is highly significant given that cardiovascular mortality significantly increases when diabetes appears before age 40. In addition, studies suggest that women with type 2 diabetes have a higher cardiovascular risk than men with the same diagnosis. Differences in the effects of treatment have been shown between men and women. Finally, several studies show that type 2 diabetes is under-diagnosed and insufficiently treated in women compared to men. Their diabetes, blood pressure and blood sugar levels aren’t as well controlled. Cholesterol Control
Women are less likely than men to be prescribed statins for high cholesterol. They’re more likely to refuse to start taking a medication. And when they start a medication, they’re less likely to continue it. Studies on large populations of women confirm the benefit of statins for women. However, a few studies suggest that women are more at risk for muscle-related side effects. In addition, special attention must be paid to their health history and any concomitant medications that may increase unwanted muscle-related effects. A woman who wants to get pregnant should stop taking statins one to two months before trying to conceive. If she gets pregnant and hasn’t taken this precaution, statins should be stopped as soon as possible and replaced, if necessary, with another medication that can be used during pregnancy, such as bile acid sequestrants. No difference in efficacy has been shown between men and women for non-statin therapies used to reduce bad cholesterol (LDL cholesterol using ezetimibe and some new biotherapeutics with specific indications such as PCSK9 inhibitors. PCSK9 is an enzyme involved in lipid metabolism in the liver). Still, the number of women participating in the trial was lower than the number of men in certain studies. Treatment with Aspirin
Aspirin has proven benefits for secondary prevention of arteriosclerosis. When it comes to primary prevention of the first cardiovascular disease, the benefit of aspirin is debated and controversial. From what we currently know, it appears that in the majority of cases, aspirin doesn’t provide any benefits to women who don’t have diagnosed cardiovascular disease. Preventing Stroke in Atrial Fibrillation
Atrial fibrillation is an irregular contraction of the heart’s atria that can lead to blood clots and other problems. Studies have shown that women with this condition have a higher risk of stroke than men for reasons that have not yet been identified. With equivalent risk factors and the same blood thinner medication, which may be recommended in this context, women have a 20% to 30% higher risk of stroke than men. Compared to men, in women with atrial fibrillation, a stroke is more severe and often leads to long-lasting disability. Treating Menopause with Hormones
Hormone replacement therapy during menopause doesn’t prevent cardiovascular disease in women and is contraindicated in women who’ve already had an arterial or venous cardiovascular event. An increased risk of a venous thromboembolic event (phlebitis or pulmonary embolism) has been observed with all oral forms of hormone therapy, but not with transdermally administered estrogen. That’s why any therapy for young women with significant body temperature fluctuations must take into account individual and family risk factors for venous as well as arterial thromboembolic events. Managing Depression and Psychosocial Factors in Women
Numerous studies have established a link between acute and chronic emotional stress and psychosocial factors like depression with increased cardiovascular disease risk. Psychosocial stress tends to be a higher risk factor for cardiovascular and metabolic diseases for women than men because of their higher exposure to these factors as well as the fact that women are likely more vulnerable to these factors. Depression, childhood trauma, socioeconomic challenges and posttraumatic stress disorder (PTSD) are more frequent in women than men. In addition, the harmful combination of these psychosocial factors with the risk of cardiovascular and metabolic diseases has a more negative impact on women than men, especially for younger women and those exposed to these factors at an early age. Depression affects around 7% of the population and occurs twice as often among women in comparison with men. It is a known risk factor for heart attack and death from cardiovascular disease. Women are more often survivors of severe trauma during childhood, such as physical abuse, sexual assault and neglect. These situations are gaining recognition as risk factors for cardiovascular disease, along with PTSD. Overall, women are more sensitive to the harmful effects of certain cardiovascular risk factors like hypertension, diabetes, smoking and psychosocial stress. Some are also exposed to specific risk factors at different hormone stages (contraception with synthetic estrogen, high-risk pregnancy, menopause, etc.). It’s essential to address these unique cardiovascular risk factors for optimal screening, treatment and follow-up care to effectively protect every woman’s cardiovascular health no matter their age. Cho L. et al. Summary of Updated Recommendations for Primary Prevention of Cardiovascular Disease in Women. JACC State-of-the-Art Review. ACC 2020;75(20): 2602-18 https://doi.org/10.1016/j.jacc.2020.03.060