By Kimberly P. Champney, M.D., MSCR
From ATLANTA Medicine, 2012, Women’s Health, Vol. 83, No. 1
National public awareness campaigns for heart disease in women from the American Heart Association and other organizations have seen initial success. Between 1997 and 2006, the number of women recognizing that the leading cause of death among women is heart disease increased from 30 percent to 55 percent (1). Along with this increased knowledge, women have seen a decline in deaths secondary to cardiovascular disease. However, areas of concern still remain. For example, women know that cholesterol is an important risk factor for cardiovascular disease, but few women know their own personal cholesterol levels and other risk factors (1).
“Fifty is the new forty” is a common phrase heard today, especially as many famous women such as Oprah Winfrey, Christie Brinkley, Madonna and Sharon Stone approach or have turned 50. However, in terms of vascular age, 50 may really be the new 60 for women. For example, a 51-year-old teacher with a family history of heart disease reports good health. She feels well, is currently enrolled in Weight Watchers at work that meets twice a week. Her blood pressure is 140/82, total cholesterol 220mg/dL, HDL 34 mg/dL, LDL 145 mg/dL, and triglycerides are 198 mg/dL. She would like to know if she needs to take a statin, as prescribed by her primary care physician. She is 5’1”, weighs 147 lbs, body mass index (BMI) 27 and has a waist circumference of 37 inches. This 51-year-old lady is clearly not the “new forty” and in fact has a coronary artery calcium score of 25 estimated vascular age of 63. Vascular age can be calculated using data from the Multi-Ethnic Study of Atherosclerosis(MESA) knowing age, gender, cholesterol values, blood pressure and use of tobacco (3).
While this particular patient is not the “new forty,” epidemiologic data suggest that she is a more representative 50-year-old female today. Two out of every three women in the U.S. are overweight or obese, one out of three women will have high blood pressure, almost one in two will have elevated cholesterol, and less than one third of women report regular physical activity. By the age of 50, 40 percent of women will have one cardiovascular risk factor and 17 percent of women will have two or more traditional risk factors (2).
Heart Disease in Young Women
Despite the overall improvement in heart disease awareness and mortality among women, there is a slight increase in heart disease death rates seen in young women, ages 35-54 years. This trend “may represent the leading edge of a brewing storm (3).” We also know that it is younger, not older women, who have higher risk of death after myocardial infarction relative to men (4). This increase in cardiovascular mortality among young women is likely linked to obesity and the cardiovascular risk factors associated with obesity. Particular attention to cardiovascular risk should be given to women in this younger age group.
Cardiovascular Disease Among Minority Women
Racial disparities in healthcare are evident among many diseases, and this is of particular importance in Atlanta given the diverse population. Black women, particularly in southern states, have the highest incidence of uncontrolled hypertension, obesity, sedentary lifestyle and dyslipidemia. This combination of uncontrolled risk factors leads to increased mortality among minority women, particularly black women. Among young women, ages 45-64, with a first myocardial infarction, 18 percent of non-Hispanic white women will die within five years. More alarming is that among that same younger age group, 28 percent of black women will die within five years after a first myocardial infarction. This racial disparity among women is not as great among older women. This is a cause for concern because it is the younger age minority women at greatest mortality risk (2).
Identifying Cardiovascular Risk in Women
All women should have their cardiovascular risk classified by their provider as high risk, at risk, or ideal cardiovascular health. Along with appropriate risk stratification, providers must make it a priority to educate each woman regarding their personal cardiovascular risk factors and overall risk for future cardiovascular disease.
Pregnancy: A Unique Opportunity to Estimate a Woman’s Future Risk
The short-term risk to both mother and baby of preeclampsia and gestational diabetes is well understood. However, we are now learning that these pregnancy complications have long-term risk as well. Pregnancy is an early metabolic and cardiovascular “stress test” for many women. Women with a history of preeclampsia have a twofold increased risk of ischemic heart disease, stroke or thromboembolic event in the five to 15 years following pregnancy (6). Pregnancy can unmask endothelial and metabolic dysfunction early in life, and obstetricians should not miss this opportunity to intervene early on these at-risk women. Postpartum, women with preeclampsia and gestational diabetes should be referred to a primary care provider or cardiologist for risk factor modification (5).
Early Intervention on Future Cardiovascular Risk
While cardiovascular disease typically does not manifest until the fifth or sixth decade in life, it is well known that atherosclerotic process begins in the second and third decades. Despite this knowledge of the atherosclerotic process, risk factor modification is typically not emphasized early enough. Clinical trials have shown a 30 percent reduction in cardiovascular events when statins are started in patients age 50 to 60. Initiating statin therapy at age 30 may prevent 60 percent of cardiovascular events when initiated early in the disease process and outcomes measured over a lifetime rather than the standard five years in most clinical trials. Primordial prevention (prevention of risk factors) and early risk factor modification need to be a primary focus for medical providers.
In summary, significant improvements in the awareness and treatment or heart disease in women have been made. However, heart disease remains the leading cause of death for women. The increasing rates of obesity and heart disease in young women raise concern about the future of women’s health. Health care providers need to identify and intervene on women with cardiovascular risk factors early, making special note of high-risk subgroups like black women. Pregnancy complications such as preeclampsia and gestational diabetes should be viewed as a “failed metabolic stress test” and serve as an early warning sign of potential risk both to patients and their obstetric provider.
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2. American Heart Association. Heart Disease and Stroke Statistics – 2012 Update. Circulation. 2012:125:e2-220.
3. McClelland RL, Chung H, Detrano R, et. al., Distribution of coronary artery calcium by race, gender, and age: results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2006;113:30-7.
4. Ford ES, Capewell S. Coronary heart disease mortality among young adults in the US from 1980 through 2002. J Am Coll Cardiol. 2007;50:2128-32.
5. Vaccarino V, Parsons L, Every NR, Barron HV, Krumholtz HM. Sex-Based Differences in Early Mortality after Myocardial Infarction. N Engl J Med. 1999;341:217-225.
6. Mosca L, Benjamin EJ, Berra K, et. al., Executive Writing Committee. Effectiveness-based guidelines for the prevention of cardiovascular disease in women-2011 update. J Am Coll Cardiol. 2011;57:1404-23.
7. Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ. 2001;335:974.
8. Steinberg D. Earlier Intervention in the Management of Hypercholesterolemia: What Are We Waiting For? J Am Coll Cardiol. 2010;56:627-29.
Kimberly P. Champney, M.D., MSCR is a cardiologist at Northside Hospital. She received her medical degree from the Medical College of Georgia and her Masters of Science in Clinical Research from Emory University. She has been at Northside Hospital since August 2007. Her interests are in preventive cardiology, women and heart disease, pulmonary hypertension, and cardiac imaging. Dr. Champney is a member of the American Heart Association and a Fellow of the American College of Cardiology.