Valantine explores new views on women’s cardiac risk

By MITZI BAKER

The first female-specific recommendations for preventive cardiology were published in 1999, but since then a lot more has been uncovered about warding off heart disease in women. Hannah Valantine, MD, professor of cardiovascular medicine, reviewed the latest guidelines in a women’s health journal club meeting held at Fairchild Auditorium Feb. 25.

The gathering, hosted by Linda Giudice, MD, PhD, the Stanley McCormick Memorial Professor, addressed guidelines published last month in the American Heart Association’s journal Circulation. These guidelines point to evidence-based methods for preventing cardiovascular disease in women who have a broad range of risks for the condition.

Valantine focused on coronary heart disease, which accounts for more than half of the deaths due to cardiovascular disease. She emphasized the gender differences that relate to the prevalence and the overall mortality, which is substantially higher in women than in men.

Hannah Valantine (left) finishes speaking to the crowd on emerging views related to the risk of heart disease among women. New guidelines seem to raise more questions on the subject than they answer. Valantine was introduced by obstetrics and gynecology professor Linda Giudice (right). Photo: Mitzi Baker

She summarized what she called “terrible statistics” related to women and heart disease: One in seven women in her 60s will be affected by the disease, as will one in four women in her 70s.

But this is not a problem entirely of old age, she said. More than 20,000 women under age 65 will die each year in the United States from heart attacks. Of these, one-third will be under 55.

More men than women are diagnosed with heart attack; however, Valantine said, people need to realize that since the 1980s, there has been a slow but steady decline in the death rate for men, but not so for women, for whom the rate has slightly increased over the same period.

Why are men and women seemingly following separate paths to heart disease? Valantine outlined a number of possibilities, including differences in risk factors, diagnosis, clinical outcomes following a heart attack, responses to prevention, awareness of the problem and access to care. Some points Valantine made include:

• The definitive diagnosis by noninvasive testing of women is for some reason more challenging than in men. A simple treadmill test without imaging studies is “really questionable ... it’s just a toss of a coin,” she said.

• Although the most common symptom of heart attack in both women and men is chest pain, women are more likely to have atypical symptoms such as neck, abdominal or shoulder pains or generalized fatigue.

• Hormone therapy and antioxidant vitamin supplements are not recommended for cardiovascular disease prevention.

• C-reactive protein, a marker of general nonspecific inflammation, has been shown in many studies to be more predictive of cardiovascular disease than LDL cholesterol levels, but the data for its use as a screening tool are not definitive. The authors of this work suggest there should be more attention to conventional risk factors until there are more studies.

• There is twice as great a risk of death in women following coronary artery bypass graft and coronary artery stenting, despite the initial rates of success being equal. “I think what is true is that acute interventions are very helpful and they work, but we are still questioning why the outcomes differ,” she said.

Although there were nearly 7,000 studies summarized in the Circulation review, she noted there is little known today beyond the awareness that men and women have a different experience when it comes to heart disease.

But the basics of prevention hold true, she said. Smoking is the leading cause for coronary heart disease in women under 50. Obesity and diabetes are epidemic problems that are even greater risk factors in women; the vast majority of people with diabetes will die of a heart attack. Drugs and diet can control the major risk factors of high blood pressure and lipid levels. Exercise improves all factors known to affect heart disease.

“Something that appears over and over again is that the women in these studies are older, have more diabetes, have more hypertension and heart failure at the time of presentation,” said Valantine.

“The risk factors are already there, so regardless of what you can do acutely, we need to focus on prevention efforts.”