01 May 2018
CORONARY ARTERY DISEASE IN WOMEN
There is no doubt that beyond the physical differences between men and women, these two groups differ from each other in many ways.
It’s also the case for coronary artery disease in men and women.
2nd cause of death in men
Since 2000, coronary disease is the second cause of death in men, just after cancer.
This change is due to modifications in lifestyle, smoking cessation, a better knowledge of the risks of high cholesterol levels and the benefits of physical activity.
What is the leading cause of mortality in women?
In women, what do you think is the first cause of mortality?
1- breast cancer
2- all forms of cancer
3- coronary artery disease
The answer is coronary artery disease.
This disease is by far the leading cause of mortality, well beyond all types of cancer joined together.
Indeed, one out of 3 woman will die of coronary artery disease, whereas 1 out of 9 women will die of cancer.
Every minute, a woman dies of cardiac disease in the United States.
It is well known that women live longer than men, but coronary artery disease is the 2nd cause of loss of autonomy in the 10 additional years of lifespan that women have compared to men.
A disease occurring later in women
Compared to men, coronary disease among women occurs 10 years later.
This delay in the manifestation of the disease possibly comes from the protective factor of estrogens.
The cholesterol deposits emerge also later than men and the process of atherosclerosis consequently delayed.
Manifestations of coronary artery disease will typically appear around the age of 65 in women, compared to the age of 55 in men.
However, once diagnosed coronary artery disease is often more lethal in women.
This consequence comes from the fact that women are older when the disease occurs and they have several other associated diseases like diabetes, high cholesterol and obesity.
This said, we thus have on one hand the protective factor which “protects” or delays the occurrence of symptoms and clinical events such as unstable angina or heart attack.
On the other end, we have the risk factors, i.e. the factors potentiating the development of the disease. In women, some of these factors are more important.
Two types of risk factors
- Not-modifiable, i.e. it can’t be changed;
· male gender
· Family history
· high blood pressure
· high cholesterol levels
· sedentary lifestyle
Women smoke more than ever and start to smoke earlier.
The present generation adapted again this harmful habit. It should also be noted that women will quit smoking less than men.
Some studies show that smoking can even induce earlier menopause, therefore making the estrogen protective factor disappear prematurely.
Statistically speaking, one to 4 cigarettes per day doubles the risk of heart attack and more than 45 cigarettes per day increase the risk 5 to 6 times!
The incidence of diabetes is undergoing spectacular climb in the world.
This increase is related to bad dietary habits. Indeed, the figures speak by themselves: in 2000, there were 150 million diabetic patients in the world. In 2030, this number will reach 370 million.
In diabetic women, the risk of developing coronary artery disease is increased regardless of the type of treatment used for diabetes.
When presenting with a heart attack, the mortality risk will be more important for a diabetic woman than for a nondiabetic one. A diabetic woman will have an increasing risk of developing heart failure following her heart attack, compared to a nondiabetic
Plaque formation in the coronary arteries is delayed for about 10 years women due to the protective effect of estrogens.
Bad” cholesterol levels are lower, and those of “good” cholesterol are higher before menopause.
However, after menopause, these values are reversed.
“Bad” cholesterol levels become twice more often abnormal than in men. Furthermore, the same level of bad cholesterol is more harmful in women.
HIGH BLOOD PRESSURE
· further increases the risk of coronary disease in women than in men. For equal values of blood pressure, women are more at risk;
· Accelerates the aging process of the artery, which is called arteriosclerosis i.e. the hardening of the arteries;
· Represents 1 cardiovascular death out of 3.
Almost half of women suffering of hypertension are not treated or if treated, they are treated inappropriately!
The influence of menopause is not well known.
It is known however that systolic hypertension, or commonly called the blood pressure of the large number, is more frequent in women than in men older than 50 years.
Moreover, there are twice more hypertensive women after menopause.
Women are less active.
Actually, less than one woman out of 5 does physical activity after the age of 65 and sedentariness increases the risk of cardiovascular disease
There are more obese women than obese men. Obesity is associated with several other anomalies, such as diabetes, high blood pressure and high cholesterol levels. This is not helpful knowing that these 3 factors potentiate the risk of developing coronary artery disease.
On average, there are more and more people who are overweight. The diagnosis of obesity is made more frequently and at an earlier age.
The impact on coronary disease is expected…
IMPACT OF ORAL CONTRACEPTIVES
There is no increased cardiac risk related to the use of oral contraceptives in non-smoking women but for women who smoke, there is no age range that is safe.
In other words, a 35 year old woman, smoker, is at the risk of cardiovascular and pulmonary events.
IMPACT OF MENOPAUSE
When menopause occurs, the risk of coronary artery disease increases by 3 times
We saw the impact of “bad” and “good” cholesterol with aging in women.
Although not proven, there seems to be a certain relationship between blood pressure and menopause. Blood pressure tends to increase more, which accentuates the risk.
In conclusion regarding RICK FACTORS
What leads us to identify the worst risk factors for the occurrence of coronary artery disease in women;
· high blood pressure;
· anomalies of the “good” and “bad” cholesterol;
· oral contraceptive use in women who smoke ;
It necessary to address these factors, since the best treatment is prevention.
Women must be informed and understand the importance of modifying the modifiable risk factors.
Of paramount importance are smoking cessation, increased physical activity and weight loss.
One in the best ways to initiate this therapy is to exercise regularly. It consists in doing 30 minutes of cardiovascular exercise, 4 to 7 days a week.
Walking is a good way of doing exercise every day. This kind of activity is accessible by all and doesn’t cost anything
NEW DIETARY HABITS
Doing regular exercise usually leads us to change dietary habits.
That enables us to achieve or preserve our ideal weight and to reduce our waist circumference.
It is recommended to eat more fruits and vegetables, cereals and fibers and to stay away from trans fat.
IDEAL WEIGHT AND WAIST SIZE
The ideal weight is equivalent to a body mass index (BMI) of less than 25.
Men should aim at a waist size of less than 40 inches and women at a waist size of less than 35 inches.
These values are lower among people of Asian origin.
As doing regular exercise usually leads us to change our dietary habits, it often makes us realize that smoking doesn’t fit anymore in our new lifestyle.
The differences do not stop here
The differences in the coronary artery disease in women compared to men do not stop there.
Medical difficulty attached to the described differences
The presentation or manifestation of coronary artery disease is often different between men and women.
A heart attack is more often the presentation in men whereas angina (chest pain) is often the presentation in women.
In men, the classical presentation of “angina” almost undoubtedly reveals the presence of blockages in the coronary arteries. It is characterized by a pain or discomfort :
· in the chest with exertion or stress ;
· relieved by rest
· reproducible with the same type of effort.
In women, this presentation does not have the same certainty on the presence of blockages in the coronary arteries .
The symptoms of chest pains present often different “patterns” which make the diagnosis less easy to determine in the office.
Nécessité de demander plus d’examens
It is more often necessary to order additional test to determine if these chest discomforts are really angina and originating from the heart.
The results of these various tests are more often nonconclusive in women.
Normally, a woman less than 45-year-old with no or one risk factor, doesn’t have major blockages in the coronary arteries.
The electrocardiogram is often “abnormal” in women. In fact, it is not frankly abnormal but it presents various normal variations.
It is complicated, isn’t it…?
In other words, the electrocardiogram is unique to everyone as a fingerprint.
In women, some electrocardiogram patterns suggest an anomaly of the heart, which are ruled out after further testing is done.
These abnormalities on the electrocardiogram are therefore “normal” for her.
The treadmill test
The diagnostic accuracy of the treadmill test is reduced in women.
When the result is normal, it is normal!
However, there are more often results that are difficult to interpret in women because of the basic anomalies on the electrocardiogram at rest.
It is often difficult for the physician to determine if there are significant blockages in the coronary arteries or not.
Furthermore, the result of the stress test is sometimes clearly abnormal without any blockage present in the coronary arteries. This kind of result is called; false-positives.
Symptoms vague, inconclusive exams…
All these factors, i.e., the various ways of perceiving the symptoms of angina, the baseline anomalies on the electrocardiogram and the difficulties in obtaining a diagnosis on a stress test may result in less investigation of the cause of chest pains and women.
Complementary tests in nuclear medicine, or stress echocardiograms also have a good proportion of false positive results.
We can conclude that these various tests can be useful for the diagnosis, but do not always allow the physician to determine the cause of the chest pain
How to conclude
The ultimate way to solve the problem of all these nonconclusive tests is to proceed with a coronarography or do a less invasive test called a CT scan of the coronary arteries.
The coronarography is called an “invasive” test because it requires an insertion of a catheter inside the human body. It is not done without risk.
The doctor who orders this test will evaluate the pros and cons. It is a decision discussed and made with the patient, with her doctor after having considered various options.
Several factors contribute to the fact that less women are referred for coronarography:
· The age, since coronary artery disease appears more lately;
· A not very convincing presentation of chest discomfort;
· Several women do not consult thinking that their symptoms are due to aging
· Several other diseases present;
· More complications related to coronarography.
In spite of technological and pharmaceutical advances, mortality by coronary artery disease remains higher in women than men.
The unfavourable factors are always the same ones, the women:
· Are older;
· More often have a diagnosis of diabetes;
· More often have a diagnosis of high blood pressure;
· More often have abnormal cholesterol levels.
It was once believed that hormonal replacement by estrogens or hormonal combined therapy, i.e. oestrogen and progesterone was going to prolong the “protective” effect in women.
Clinical studies revealed that it wasn’t true.
Among women with no history of heart disease, estrogen alone caused more stroke. The combined treatment caused more breast cancer.
The results of those large-scale studies put a stop to the use of hormone therapies as a preventive measure for coronary disease. Among women with a history of heart disease HRT did not show a beneficial effect.
It is currently recommended that for women who are less than 60 years old with a recent menopause and without obvious symptomatic coronary artery disease, hormone therapy is possible for in women with very symptomatic menopause.
In fact, we treat women who cannot function because of their menopausal symptoms.
Among women more than 60 years old, the decision to initiate hormone therapy is made by the doctor, while considering the risks and the benefits.
That lowest dose possible for the shortest period of time possible.
Hormone therapy cannot be prescribed for the prevention of coronary artery disease. Factors accelerating the progression of coronary artery disease must be addressed first.