While many women, and far too many doctors, apparently still do not know it, cardiovascular disease (CVD) is the number one killer of women; and has been since 1984. Out of the one million individuals that die from heart disease each year in the U.S., more than half are women. Women disproportionately fear dying from breast cancer compared to heart disease, but cardiovascular disease kills nearly ten times as many women each year as breast cancer.  Although it is as important for women as for men to control the risk factors that lead to heart disease, a knowledge gap persists regarding the mechanisms and management of CVD in women.[1] Aggressively managing risk factors can prevent or delay the onset of heart disease, even in women with strong family histories. However, substantial sex differences exist in the prevalence of traditional risk factors as well as in cardiovascular outcomes. Hypertension is more prevalent in men until the age of 59 years, but then contributes to greater morbidity in older women. Low levels of high-density lipoprotein and elevated triglyceride levels pose more of a threat to women, yet high levels of low-density lipoprotein pose equal risk for women and men. The CVD mortality rate is 3 times greater in people with diabetes than in those without diabetes. Among diabetic individuals, CVD mortality is slightly higher in women compared with men.[2] In those who already have heart disease, control of risk factors can delay or even halt the progression of the disease, and strongly improve outcomes.

There is also a growing body of literature documenting important biologic gender differences in CVD that may impact clinical care delivery. There are obvious differences due to the effects of sex hormones. However, differences in symptoms, accuracy of diagnostic tests, response to therapy, prevalence and relative risk of cardiovascular risk factors, as well as social and behavioral issues have all been identified.

An important example is the National Heart, Lung and Blood Institute (NHLBI)-funded multi-center Women’s Ischemic Syndrome Evaluation (WISE) study that demonstrated different patterns of arterial plaque build-up between men and women; more localized in larger arteries for men and more diffusely in smaller arterioles for women.[3] In women with this condition, called coronary microvascular syndrome, pain can be very similar to individuals with blocked arteries but it doesn’t show up on standard tests.  According to the WISE study, about 15% of all coronary artery disease in women is microvascular disease.  Because standard angiograms and treadmill tests often fail to detect ischemic heart disease in women, new methods of evaluation must be implemented.[4]

Cardiopulmonary exercise testing (CPET) is a physiologic assessment technique that augments the risk predictability of standard stress tests.  Measuring changes in O2 pulse and VO2 relative to heart rate enables the potential for detection of ischemia-induced left ventricular (LV) dysfunction in response to increasing work rate.  Both macrovascular and microvascular coronary artery disease elicits similar evidence of cardiac dysfunction during CPET; even when nuclear imaging and cardiac catheterization findings may differ.[5] A recnet study illustrated the potential value of CPET in detecting both macro- and microvascular coronary artery disease (CAD).[6]

Traditional Framingham Risk Scores may grossly underestimate the cardiovascular risk among women.  A study designed to “characterize the prevalence and awareness of traditional CVD risk factors, obesity and coronary artery disease” revealed a strikingly high number of overweight American women whose cardiometabolic risk factors placed them at higher risk for the development of CVD than their initial Framingham score indicated.[7] In this study 59% of the women initially classified as low risk and 50% of intermediate risk were reclassified to higher risk categories when waist circumference was factored into the assessment.

Abdominal or visceral obesity is a well recognized risk factor for heart disease, diabetes and several cancers among men and women.  The abdominal fat lurking behind an expanding waistline is a highly metabolically active organ that releases inflammatory- producing cytokines.  These chemical messengers are involved in immune response, lipid and glucose metabolism, can lead to high blood pressure, insulin resistance, and premature death.  The risk of premature death doubles for women with waist circumference of 35 inches and for men above 40 inches.[8] If you or someone you love are in these categories, it’s time to get serious about shedding those extra pounds and inches.

The bottom line is about prevention, or at least early detection.  The Institute of Medicine estimates that 90% of cardiovascular disease is preventable with lifestyle modifications.  Whether you are a man or a woman over age 40 years, or any age with 2 or more cardiac risk factors and/or abdominal obesity, or just have a concern about your cardiovascular health I recommend an in-depth cardiac evaluation.

At Alternity Healthcare, our cardiovascular screening programs include advanced biomarker analysis, telomere length testing, HeartSmartIMTplus and cardiopulmonary exercise testing (CPET).  This unique combination of cutting edge technologies improves our ability to uncover subclinical and microvascular heart disease.  The early identification of asymptomatic persons with increased cardiovascular risk provides the best opportunity to prevent of future heart attack, stroke and premature death.

[1] Evangelista O, McLaughlin MA. Review of cardiovascular risk factors in women.  Gend Med. 2009;6 Suppl 1:17-36.

[2] Mosca L, Edelman D, et al.  Waist circumference predicts cardiometabolic and global Framingham risk among women screened during National Woman’s Heart Day. J Womens Health (Larchmt). 2006 Jan-Feb;15(1):24-34.

[3]Shaw L, Pepine C, et al.  Insights From the NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE) Study: Part I: Gender Differences in Traditional and Novel Risk Factors, Symptom Evaluation, and Gender-Optimized Diagnostic Strategies.  J. Am. Coll. Cardiol., Feb 2006; 47: S4 – S20

[4] Pries AR, Habazettl H, Ambrosio G, Bugiardini R, et al. A review of methods for assessment of coronary microvascular disease in both clinical and experimental settings. Cardiovasc Res 2008;80:165–174.

[5] Peix A, Garcia EJ, Carrillo R, Garcia-Barreto D, et al. Ischemia in women with angina and normal coronary angiograms. Coron Artery Dis 2007;18:361–366.

[6] Chaudhry S, Arena R, et al. Exercise-Induced Myocardial Ischemia Detected by Cardiopulmonary Exercise Testing .  Am J Cardiol 2009;103:615– 619

[7] Pollin IS, Kral BG, Shattuck T, et al.  High prevalence of cardiometabolic risk factors in women considered low risk by traditional risk assessment. J Womens Health. 2008 Jul-Aug;17(6):947-53.

[8] Gaglione M. M., Can A. S., Schneider H. J.  Obesity and Risk of Death.  N Engl J Med 2009; 360:1042-1044, Mar 5, 2009