His and Hers
Practitioners need to take note of unique characteristics of heartdisease in women
Debra R. Judelson, MD, is on a mission to educate primary care providersabout the differences in heart health between the sexes and the cardiac risksunique to women.
Her advice for primary care providers?
“Screen, screen, screen—especially with women who have diabetesor metabolic syndrome,” says Judelson, a cardiologist with theCardiovascular Medical Group of Southern California in Beverly Hills.“If you don't look, you'll never find it.”
Judelson's additional recommendations echo the American Heart Association's(AHA) 2004 guidelines for preventing cardiovascular disease in women, whichshe helped write. She urges clinicians to discourage cigarette smoking;encourage physical activity and a heart-healthy diet; and, depending on awoman's age and level of risk, initiate aspirin therapy and lipid therapy withniacin, fibrates, and/orstatins.1
Judelson led with some sobering statistics in her January 28 presentationat the annual meeting of the American Medical Women's Association (AMWA) inWashington, D.C. Cardiovascular disease (CVD) is the leading cause of death inwomen, killing nearly 500,000 annually, or 39.3% of women in 2002—moredeaths than result from all cancers, AIDS, and violence combined. More womenthan men die every year from CVD, although women tend to have their heartattacks 10 years later than men.
Too many clinicians are unaware of the unique aspects of heart disease inwomen and have little understanding of what gender differences mean, saysJudelson, who also is creator and chair of the AMWA Education Project onCoronary Heart Disease in Women. Physicians are 40% less likely to classifywomen as high-risk, even when their risk is the same as men's, according toresults of a survey of 500 doctors published in the February 1 issue ofCirculation.2This underestimation of women's heart risk results in their receiving lesspreventive care than men, the authors conclude.
Judelson suggests the AHA and American College ofCardiology–recommended screening of a lipid panel—which, in heropinion, is not being done regularly—should be the first step and isapplicable for all ages.
Another study in the February 1 Circulation finds that among womenat highest risk of a heart attack due to dangerously high cholesterol levels,only one-third are benefiting from drug therapy to lower theircholesterol.3
The guidelines for women with cardiovascular risk suggest LDL cholesterolbe <100 mg/dl, HDL be >50 mg/dl, triglycerides be <150 mg/dl, ornon-HDL be <130 mg/dl.
“We found only 7% of these high-risk women had optimal levels of allcholesterol measurements at the start of the study,” says lead authorLori Mosca, MD, PhD, director of preventive cardiology at NewYork-Presbyterian Hospital, in a written statement. “This improved to12% after 3 years, still far short of where we would like to see thesehigh-risk women.”
Most women over age 40 (younger if there is a family history of early CVD)should be screened for additional risk factors, such as homocysteine, an aminoacid that at elevated levels irritates blood vessels, increases clotting, andmay increase dementia and heart disease. A test for C-reactive protein (CRP),the marker for inflammation, and lipoprotein(a), a more atherogenic lipidfactor, also should be added, she says.
NEED FOR NONINVASIVE TESTS?
Other tests, such as stress echo tests and nuclear perfusion imaging, mayuse imaging to improve predictive accuracy and outcome, Judelson says.Screening for heart disease has become more gender-sensitive in recent years,she notes.
But an AHA scientific statement in the February 8 Circulation sayswomen who are at risk for CVD often are not referred for the right tests, suchas stress single photon emission computed tomography (SPECT) and stressechocardiography, which work as well in women as inmen.4 Recent dataindicate some important differences between men and women for noninvasivetesting of coronary artery disease.
“For example, exercise electrocardiogram (ECG), which has been aroundfor a long time, is not accurate in all women,” says Jennifer H. Mieres,MD, chair of the committee that wrote the statement. “In women who areable to exercise, it is still useful, but its utility depends on the woman'sexercise capability.”
The purpose of the statement is to provide clinicians with an easy guidefor referrals. The committee also concludes that women with diabetes“merit special consideration” and includes them as candidates forcardiac imaging because their risk of cardiovascular death is eight times thatof women who do not have diabetes.
Women with polycystic ovary syndrome or metabolic syndrome also may becandidates for cardiac imaging, the committee concludes.
THE HORMONE-REPLACEMENT QUESTION
Normal premenopausal ovarian function and estrogen offer somecardiovascular protection for women, including improved LDL and HDL lipidprofiles, plaque stabilization, and improved blood-vessel function, insulinsensitivity, and blood pressure, Judelson says.
But the clinical evidence about the CVD risks and benefits ofhormone-replacement therapy (HRT) are anything but black and white and maydepend on a host of contributing factors.
After comparing the designs, conclusions, and limitations of the Heart andEstrogen/Progestin Replacement Study (HERS) and the Women's Health Initiative(WHI) trials, Judelson concludes that HRT should be tailored to the individualpatient.
“Initiation (and continuation) of HRT in the menopausal transition inwomen symptomatic of estrogen deficiency should continue to be individualizedin the context of a woman's age, symptoms, risk factors, history, and personalpreferences,” she says.
Judelson advises women to use the estrogen regimen that makes them feelbest, and adds that she is comfortable swapping regimens to find one thatsuits the patient.
While not the standard of care, consideration of estrogen-sensitiveclotting mutations may be made with an added test to more carefully evaluaterisk in women who are thinking about HRT. Two such mutations, Factor V Leidenand Prothrombin 20210, present in up to 8% of women collectively and can beidentified with a simple blood test.
“Screening for these may enable us to identify women who would be athigher risk of CVD events with oral estrogen,” Judelson says, cautioningthat the results could cause confusion for practitioners who don't know whatthe test means.
Judelson touts the 2004 AHA evidence-based guidelines for CVD prevention inwomen, but also sounds a call for the need for individual assessment.“Data used to establish recommendations might be generated frompopulations that do not reflect the characteristics of the patient beingtreated,” she says. ▪
