American College of Physicians: Internal Medicine — Doctors for Adults ®

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Prevention key to reducing coronary disease in women

From the June 1996 ACP Observer, copyright 1996 by the American College of Physicians.

By Deborah Gesensway

Traditionally, coronary heart disease was considered a disease of men, but it is now the leading cause of mortality among women in the United States. The difference is the age at which it strikes, said Nanette Kass Wenger, FACP, professor of medicine and cardiology at Emory University School of Medicine, speaking at a Meet-the-Professor course titled "Coronary Heart Disease in Women: The Importance of Prevention."

Studies have shown, she said, that women do not recover as well as men from heart attacks or revascularization procedures related to coronary heart disease—and are more likely to report that they are disabled by symptoms of the disease. More than half of women over age 75 with coronary disease are disabled by their symptoms, Dr. Wenger said. Among women younger than 65, only one of eight or nine will have coronary heart disease; among women older than 65, the rate is one in three.

"As the total population of our country ages, the implications are obvious," she said. "Unless we highlight major preventive interventions at a younger age, we will have an epidemic of coronary disease among elderly women."

It remains a question, however, whether women do not have as favorable an experience with coronary events as men because of gender or age. "Issues of age and gender intersect because women who come to [the point of] myocardial infarction and revascularization, in general, are older than men. In addition, [women] have more co-morbidities. They have more diabetes, they have more hypertension. For the surgical procedures, they often have greater urgency or emergency procedures. All of these may be contributory variables," Dr. Wenger said.

Studies show that although women and men share the same risk factors for coronary disease, some factors—such as smoking, obesity and diabetes—pose a greater danger for women than men. Other risk factors include hypertension, dyslipidemia and a sedentary lifestyle. The role of estrogen in reducing coronary risk in postmenopausal women is under study.

Dr. Wenger recommended that internists focus on these preventive measures when treating women patients at risk for coronary disease:

  • Smoking cessation. Because smoking increases women's risk of a coronary event by three to seven times—even for premenopausal women—convincing women to quit smoking should be physicians' primary goal, Dr. Wenger said. The problem is that men have been much more successful than women at quitting.

Former smokers (after two years), meanwhile, tend to have the same rates of myocardial infarction and fatal coronary heart disease as women who never smoked, she said. And elderly men and women can still reduce their coronary risk if they quit smoking, she added.

Smoking lowers the age of menopause by two years on average, Dr. Wenger said. This may further contribute to the coronary risk.

  • Hypertension control. Dr. Wenger said physicians should emphasize the need for patients to lower and control blood pressure, but they also need to keep in mind that many of the blood pressure-lowering drugs can cause orthostatic hypotension. "You really don't want to substitute a fall and a fractured hip for some slight difference in blood pressure control," she said. She suggests doctors measure their patients' blood pressure in both the seated and standing positions after therapy. The beta-blocker-type drugs seem to cause less orthostasis, she said.

Because women's blood pressure often rises at about the age of menopause, Dr. Wenger recommended that physicians carefully measure the blood pressure of their middle-aged women patients and get increased blood pressure well under control.

  • Cholesterol reduction. Dr. Wenger contested the suggestion that hyperlipidemia can be ignored in the elderly. Elderly women are at highest risk for a coronary event, and benefit may be prominent, she said. "The more risk factors, the stronger the family history, the more aggressive I am about cholesterol lowering," she added.
  • Diabetes. Dr. Wenger suggested physicians pay particular attention to all other risk factors in diabetic women. Diabetes essentially negates gender benefit where it comes to coronary risk, she said.
  • Hormone replacement therapy. Estrogen studies done to date, which associate oral estrogen therapy with as much as a 50% decrease in the risk of coronary events, have been observational and typically have involved women who are white, generally healthy and young, and of higher educational and socioeconomic levels. That accounts for the difficulty physicians have in recommending the therapy, Dr. Wenger said. Moreover, she said, women who continue to take estrogen after menopause are demonstrating compliance with a medical regimen—in itself a marker for other healthy behaviors.

Estrogen decreases LDL cholesterol levels and increases HDL levels; on the other hand, it increases triglyceride concentration. And there are potential adverse effects on breast cancer rates. Ongoing studies should clarify recommendations.

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