Cardiovascular disease, or CVD, still ranks No. 1 in causes of death for women, according to the American Heart Association. While cardiologists have known that heart disease affects women differently than it does men, little has been published about risk factors, specific to women, that contribute to heart disease being the cause of death for one in three women in the United States.
“We’ve had no real updates to guidelines for the prevention of cardiovascular disease in women since 2011,” said Paula Montana De La Cadena, M.D., a cardiologist at Miami Cardiac & Vascular Institute. “In May 2020, the American College of Cardiology and the American Heart Association released the latest guidance, which outlines risk factors related specifically to women and treatments that have been shown to benefit women.”
Cardiovascular Disease Risk Factors Unique to Women
Highlighted in the 2020 guidelines are risk factors related to women’s reproductive health and pregnancy. For example, research has shown that adverse pregnancy outcomes, or APOs, increase a woman’s likelihood of developing cardiovascular disease by up to four times. In women with the following conditions, the American College of Cardiology recommends early screening and close monitoring to ensure early and effective treatment.
Dr. Montana says these pregnancy-associated conditions include gestational hypertension – or high blood pressure, gestational diabetes, pregnancy loss or pre-term labor, and intrauterine growth restriction (IUGR). The published guidelines also name placental abruption, pre-eclampsia, eclampsia and HELLP syndrome as pregnancy-related conditions that increase a woman’s risk of future CVD. The American College of Obstetrics and Gynecology recommends that women with these conditions during pregnancy get a cardiovascular risk screening within three months after their pregnancy.
“There’s no specific timeline for when cardiovascular disease shows up following these conditions, but we know from research and experience that women with these complications during pregnancy have an associated increased risk of hypertension, ischemic heart disease, stroke and overall mortality,” Dr. Montana explained.
Polycystic Ovarian Syndrome (PCOS)
The 2020 guidelines also highlight that women with polycystic ovarian syndrome, or PCOS, also have an increased risk for developing cardiovascular disease. PCOS, an endocrine disorder characterized by irregular or dysfunctional ovulation, infertility and excess male hormones, is also associated with abdominal obesity, diabetes, high blood pressure and high cholesterol, according to the guidelines. These characteristics have been shown to be markers of metabolic syndrome and to contribute to endothelial dysfunction (when blood vessels constrict without signs of obstruction) and other abnormalities, including atherosclerosis or the buildup of plaque in the arteries.
Past studies have indicated that premature menopause – that occurring before 40 and up to 49 years of age – is associated with an increased risk of the development of cardiovascular disease. The 2020 guidelines still do not clearly address whether CVD occurs because of the early withdrawal of estrogen’s protective properties or whether women with an increased risk for cardiovascular disease go through menopause at an earlier age than most women.
Cardiovascular Disease ‘Risk Enhancers’ in Women
Dr. Montana stresses that certain conditions, such as high blood pressure and diabetes, which are not unique to women, can enhance the risk of CVD or cardiovascular events in women.
The 2020 guidelines point out that women with high blood pressure prior to menopause likely have a secondary cause for their hypertension, including the use of hormonal contraceptives, which can result in increased blood pressure, according to the guidelines. Dr. Montana adds these contraceptives have also been shown to increase the risk for blood clot formation.
The guidelines also note that hypertension becomes more prevalent in post-menopausal women. Moreover, incremental increases in blood pressure starting at age 20 climb steeper among women than men, resulting in longer-term effects of high blood pressure on the cardiovascular system.
Type 2 diabetes
Similarly, type 2 diabetes strikes girls in their youth, whereas men tend to develop type 2 diabetes more often in their midlife. The updated guidelines signal that this difference between women and men may be related to the higher insulin resistance that girls experience in childhood to puberty. This longer duration of diabetes over a lifetime for women can, as a registry out of Sweden found, significantly increases the chance of dying from a cardiovascular-related condition or event.
“Diabetes has been shown to increase the risk of a future cardiovascular event like a heart attack or stroke in both men and women, but the mortality rate from these events is higher for women,” Dr. Montana said. The new guidelines highlight that diabetes’ affect on women also includes higher incidence of heart failure and death from heart failure than in men.
Treating Women With CVD Risk Factors Differently
The 2020 guidelines capture the common approaches used to manage these conditions and reduce the risk of developing CVD or having a cardiovascular event. While many of the most effective treatments available have been used by both men and women, cardiologists recognize the need for different approaches between the two groups.
Treating high blood pressure
The current definition of a normal blood pressure is less than 120/80 mm Hg, according to the American Heart Association. To bring high blood pressure down to the normal range, the new guidelines recommend restricting salt intake to between 1,000 and 1,500 mg a day, as this decrease has been shown to reduce blood pressure in women. The guidelines report that there’s no significant difference between how men and women respond to antihypertensive medications, but women tend to experience more side effects. Furthermore, the use of blood pressure medications by premenopausal women can lead to birth defects, so close monitoring is required.
Treating diabetes in women
Dr. Montana says that women’s response to diabetes treatment is different than that of men.
“Cardiologists should consider treating diabetes in women more aggressively than they do men, because women’s risks are greater for significant adverse cardiovascular events like heart attack and stroke,” she said. That treatment involves keeping blood sugar and cholesterol within normal ranges to prevent damage to the heart and blood vessels.
Lowering cholesterol with statins
Since high levels of bad, or LDL, cholesterol in the blood has been linked to atherosclerosis and the buildup of plaque in the arteries, which can lead to heart attacks, stroke and peripheral artery disease, controlling these levels is key to preventing these events or conditions in the first place.
Studies have shown the benefits of using statin therapy to lower cholesterol in men and to offer primary prevention against atherosclerosis, but women have been historically underrepresented in many of the larger studies. That has, in part, led to women being reluctant to take statins to lower or maintain their cholesterol. Furthermore, Dr. Montana points out that statin therapy should be stopped a few months prior to becoming pregnant and cannot be used during pregnancy. Fortunately, updated guidelines are showing that overall, statin therapy is well tolerated by most women and is effective in preventing repeat cardiovascular events.
“These new guidelines have validated much of what we knew, but they also have addressed some of the confusion we’ve faced when studies or data have conflicted,” Dr. Montana said. “Regular review of risk factors and treatments related to women helps us best care for our female patients and helps us know how to prevent cardiovascular disease in the first place.”