Home Forums Other Specialities Cardiothoracic Medicine & Surgery CARDIO VASCULAR DISEASE IN WOMEN.

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    Lack of awareness adds to risk of CVD in women

    Women present later than men with CHD and are not always considered to be at risk.

    Cardiovascular disease (CVD) remains the leading cause of death in men and women worldwide, exceeding the number of deaths from all cancers combined.

    CVD, including stroke, is responsible for 36 per cent of deaths in women, compared to 4 per cent of deaths caused by breast cancer.

    In Europe, CVD kills a higher percentage of women
    (55 per cent) compared to men (43 per cent)

    Yet many women are still unaware that CVD is their main killer. There also appears to be a disturbing lack of general understanding and awareness of CVD in women among medical practitioners.

    When a woman presents with CHD, she is usually 10 years older than her male counterpart. At the time of her first MI, she tends to be 20 years older.

    This is largely due to the protective effects of oestrogen until after the menopause. Many women, therefore, believe that reducing risk factors can be postponed. They also tend to have more comorbid factors such as diabetes mellitus, hypertension, hypercholesterolaemia and heart failure.

    Although risk factors are common to both genders, women with diabetes have 2.6 times the risk of dying from CHD than women not affected by diabetes; this compares to a 1.8-fold risk in men with diabetes.
    Also, low levels of HDL appear to be a better predictor of coronary risk in women than high levels of LDL.

    Gender differences
    Clear gender differences exist in CHD, posing a challenge to the managing physician.

    Women tend to present with more atypical symptoms, such as breathlessness, burning in the chest, back pain, abdominal discomfort, nausea or fatigue, making diagnosis more difficult. Cardiac investigations, such as ECG and exercise-tolerance tests, are also less specific and less sensitive in women.

    Women are less likely to seek medical help and so tend to present later to hospital, compared to men. They are also less likely to undergo appropriate investigations, such as coronary angiography.

    This, together with late presentation, may result in delays in receiving effective treatment.
    Women presenting to their GP with atypical symptoms and who have risk factors for CHD should be referred for a specialist opinion, to undergo cardiac investigations.

    If ECG and exercise tests are unhelpful in making the diagnosis, the next step would be a myocardial perfusion scan or a stress echocardiogram. Such functional tests tend to be more sensitive and specific in women than in men.

    Coronary revascularisation is also associated with a higher mortality in women.
    This is partly due to the fact that women’s coronary vessels are generally smaller than men’s. Although the mortality for women undergoing percutaneous and surgical revascularisation appears to be improving, it still remains higher than that for men.

    Gender alone is not responsible for the worse outcome seen in women. Most studies have shown that, after adjustment for the increase in overall risk seen in women, in-hospital mortality is similar in men and women undergoing coronary revascularisation.

    With increasing use of drug-eluting stents, adjunctive medical therapy, such as glycoprotein IIb/IIIa inhibitors, and improved procedural techniques, such as off-pump and minimally invasive coronary surgery, outcome in women undergoing coronary revascularisation continues to improve.

    Lack of trial data
    The majority of studies and clinical trials in cardiology include no more than 30 per cent of women in their study population.
    Women, therefore, continue to be under-represented. As a result, women are being treated on the basis of evidence extrapolated from studies mainly based on men.

    Better education and awareness are needed to highlight gender differences in CVD.

    G Mohan.

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