WomenWomenCardiovascular Cardiovascular Risk FactorsRisk Factors

By By Mohhammedamin Mohhammedamin

AdelAdel20162016

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Objective Objective To provide an updated assessment

of cardiovascular modifiable risk factors in women, with a focus on cardiometabolic risk (excluding age and genetics)

What is cardiometabolic risk?What is cardiometabolic risk?

Cardiometabolic risk represents the overall risk of developing cardiovascular disease (including MI and stroke), and/or type 2 diabetes

due to a cluster of modifiable risk factors/markers

These includes as :◦ Smoking, high LDL, HTN, elevated BG and ◦ Abdominal obesity ( intra-abdominal adiposity),

insulin resistance, low HDL, high triglycerides and inflammatory markers

Risk factorsRisk factors Behavior

• Unhealthy diet• Physical

inactivity/sedentary

• Obesity• Too much alcohol• Tobacco use• Stress

Conditions Diabetes Hypertension Dyslipidemia

Non-modifiable

Sex Age Ethnicity/race Genetics

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Traditional Risk FactorsTraditional Risk FactorsTobacco ExposureHypertensionDiabetes Mellitus

70%Lipid DisordersFamily History

……cont.cont.over the years it has become clear that

these factors alone cannot explain all cardiovascular disease.

New predictors of cardiovascular risk; sex differences exist in the prevalence of traditional risk factors as well as in cardiovascular outcomes

IntroductionIntroductionAmong women, diagnosis and death

rates are steady; among men, they’re declining.

More than 500,000 women die of cardiovascular disease (CVD) each year◦ Greater than the number of CVD deaths in men◦ Also greater than the total of the next seven

causes of death in womenWhy?

• Atypical Sn/Sx of CVD unrecognized under Dx and under Rx

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Ethnicity Ethnicity Ethnicity

◦Race and ethnicity together affect CVD risk◦Death rate for African-American women

with CVD is almost 40% higher than that of white women

◦CDC 2003: CVD risk factors and mortality are both higher in black • obesity was 47.3% in black women and 52%

hypertensive• hypercholesterolemia high among white

women 52.4%

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SmokingSmoking Women who smoke are two to six times more likely to

suffer a heart attack than nonsmoking women, and the risk increases with the number of cigarettes smoked each day

Case control study women <45 years: Even a few cigarettes a day correlated with a greater risk of CVD or fatal MI (OR= 2.47 1-5cig) and OR=74.6 >50 cig compared to non smokers

Younger women who smoke probably cancel out any premenopausal protection. About one-quarter of all women smoke; prevalence greatest among postmenopausal women

smoking appears to be a stronger risk factor for myocardial infarction in middle-aged women than in men

Women who take oral contraceptives and smoke are more likely to have an MI or stroke than those who take the pill but don’t smoke

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Diet/AlcoholDiet/AlcoholChange in diet quality and quantity

of fat improve lipid profile, decrease BP ( Na and K )

Moderate alcohol consumption (1-2 drinks/d) may decrease cardiovascular disease risk in postmenopausal women by improving lipid profiles. ?????◦plasma HDL cholesterol improves only

after 30 g alcohol/d.11

Sedentary lifestyleSedentary lifestyleCan contribute to obesity, dyslipidemia,

hypertension, and hyperglycemiaExercise can reduce cardiovascular risk by

increasing HDL and decreasing BP, BG, and LDLExercise can cut a woman’s CVD risk by half and

may significantly decrease the risk of a second MI in a postmenopausal woman

30 minutes of moderate-intensity physical activity on most days is ideal; 60 minutes for women who need to lose weight or sustain weight loss

Follow up study Sweden : 41% decrement in risk of CHD

Gulati et al study: physical fitness as measured by exercise capacity is strong independent predictor of all cause of death after adjusting for traditional RF (asymptomatic women) 12

ObesityObesity◦ Fat, especially intra-abdominal fat, has significant impact on our

metabolism. ◦ Abdominal obesity seems more closely associated with increased risk of

DM and CVD◦ Women’s lifestyle and health study: found that increase in waist

circumference and waist to hip ratio were associated with increased risk of CHD in women

Central obesity poses a greater risk of CHD than increased body mass index (BMI

◦ Healthy waist circumference Women: less than 35 inches Men: less than 40 inches

◦ Desired BMI (men and women): ◦18.5 to 24.9 kg/m2

◦ Waist to hip ratio: • men < 0.85 risk begin above 0.95 • women <0.75 risk begins to above 0.85.

Waist hip ratio of 0.76 or higher or waist circumference of 76.2 cm had a markedly increased cardiovascular risk even after 13

Abdominal obesityAbdominal obesity

Gelfand EV et al, 2006; Vasudevan AR et al, 2005* working definition

Women vs menVAT SAT

Sex hormone

HypertensionHypertensionPuts women at a much greater risk for CVD,

especially if it develops before menopauseElevated blood pressure is two to three times

more common in women who take oral contraceptives, especially who are overweight

NHNE survey 2007: HTN is higher in male until age 59 when it become more prevalent in women especially in those who are obese

C sectional study1989: High BPs in postmenopausal than premenopausal

C.sectional study 2008 : Association b/n gender and HTN control women were less likely than men to meet BP control target 54% (P<0.02) 15

Dyslipidemia Dyslipidemia Directly contribute to dev’t and progression of

CVD

TC and LDL are lower in premenopausal and after menopausal, than in age matched men +

HDL is significantly high both at premenopausal and after menopausal

Low levels of HDL have been shown to be a much stronger predictor of CVD mortality in women than men

Doubles a woman’s risk of CVD compared to women with normal lipid profiles

Meta-analysis 17 studies: Hypertriglyceridemia pose more risk in women 37% than men 14% 16

… …CONTCONTLDL and TG levels have been found to have

a greater impact on CHD risk in women compared to men.

Total cholesterol and LDL levels in women rise or even exceed the levels in men following the menopause

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DiabetesDiabetes

Poses a greater risk than any other factorFramingham heart study: Women with

diabetes had 3 times more cardiovascular events than other women and 2.2 times dying from CVD

Among diabetic individual, CVD mortality is higher in women than men

Young women with diabetes lose any premenopausal protection

Compared to diabetic men, who have a 2-3 fold increased risk of CHD, diabetic women are reported to have a 3-7 fold increased risk

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hs-C-reactive proteinhs-C-reactive proteinSynthesized in liver, induced primarily by

interleukin-6 (IL-6) response to factors released by macrophages and fat cells (adipocytes)—>(infection and inflammation)

prospective Physicians' Health Study: elevated basal levels of CRP increased risk of DM, HTN and CVD

High plasma concentration associated with 2 times risk of stroke and 3 times risk of MI◦ hs-CRP level under 1.0 mg/L◦ average: between 1.0 and 3.0 mg/L◦ high: above 3.0 mg/L

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Postmenopausal statusPostmenopausal status

Postmenopausal status is considered an independent risk factor

Hormone therapy no longer recommended to prevent or manage CVD due to increased rates of thrombotic events, such as MI and stroke, as well as breast cancer

Men develop CVD at younger ages, but incidence and prevalence equalize for women after menopause

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DepressionDepressionComorbidity of depression and CAD puts a

woman at greater risk for CVD and poorer outcomes

It accelerate CAD with DM in womenAssociated with less compliance with their

medication and recommendation by physicianDepression also may increase risk or deter her

from seeking medical helpCRP is found to be increase in with depressionCardiac arrhythemia due to antidepressants

toxicity

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Framingham Risk scoreFramingham Risk scoreProvides risk-assessment tool based on the

Framingham Heart StudyEstimate 10-year risk of MI and death

determined by◦ Age◦ Sex◦ Cholesterol◦ Blood pressure◦ Smoking history

Available online: http://hp2010.nhlbihin.net/atpiii/calculator.asp

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Determining CVD risk: Determining CVD risk:

Three categories1. Optimal risk/Low

Framingham global risk <10% risk in 10 years

Healthy lifestyle

No risk factors

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Determining CVD risk: Determining CVD risk:

2. At risk/intermediate(10%-20% risk)One or more major risk factors (cigarette

smoking, poor diet, physical inactivity, hypertension, dyslipidemia, metabolic syndrome, obesity, family history of premature CVD (<55 in a male relative and <65 in a female relative)

Evidence of subclinical vascular diseasecalcification

Poor exercise capacity on tread mill test and/or abnormal heart rate recovery after stopping exercise 24

Determining CVD risk: Determining CVD risk:

3. High risk (>20% risk)Established CVDCerebrovascular diseasePeripheral artery diseaseAbdominal aortic aneurysmEnd-stage or chronic renal diseaseDiabetesFramingham global risk >20% (or at high

risk on the basis of another population-adaptive tool to assess goal risk)

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InterventionsInterventions

◦Stop smoking◦Increase physical exercise◦Healthy eating◦ weight reduction◦ screen for depression◦Regular checkup

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summarysummaryIncrease in knowledge of gender

specific risk factors for CVD has led towards educating women

Awareness of risk factors is a central issue for CVD prevention

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Thank you