Cardiovascular disease in postmenopausal women: myths and reality

Uterine arcuate artery calcification as a potential marker of cardiovascular risk-a preliminary study

OBJECTIVE

Atherosclerotic cardiovascular disease is the most common cause of death in postmenopausal women. As this is a progressive disease, it is important to identify markers at an early stage during the subclinical period. Arterial calcifications are an indicator of overall atherosclerotic disease and therefore may be used as a marker for the estimation of future atherosclerotic cardiovascular events. The aims of this study are to investigate the relationship between uterine myometrial calcification (UMC) and carotid artery intima-media thickness (CIMT) and to evaluate whether UMC can be a predictive marker for the estimation of future atherosclerotic cardiovascular risk in asymptomatic postmenopausal women.

METHODS

In this cross-sectional study, we assessed 81 postmenopausal women without gynecological complaints for cardiovascular risk factors, UMC, and CIMT. Participants were divided into two risk groups according to their cardiovascular risk factors. The level of UMC was determined using a new scoring system, which was based on transvaginal ultrasonography. Demographic, clinical, and laboratory parameters, UMC scores, and measurements of CIMT were evaluated.

RESULTS

A moderately positive correlation was detected between CIMT and UMC scores (r = 0.62). There was a significant relationship between UMC scores and atherosclerotic cardiovascular risk; the risk of atherosclerosis was 15.4 times higher (OR: 15.4, 95% CI: 5.1-46.8; P = 0.001) in participants with a high UMC score (≥2). According to the multivariable logistic regression model adjusted by age and duration of menopause, the risk of cardiovascular atherosclerosis increased 27.8 fold for those with CIMT of 0.075 or greater (OR: 27.8, 95% CI: 5.3-147.1; P = 0.001) and 9.2 fold for those with a UMC score of 2 or greater (OR: 9.2, CI: 1.22-69.3; P = 0.032).

CONCLUSIONS

The presence of UMC has been identified as an independent predictive factor for atherosclerotic risk. Accordingly, considering UMC as an atherosclerotic cardiovascular risk factor may provide an opportunity to identify cardiovascular disease in asymptomatic postmenopausal women. When UMC is detected, women should be assessed for cardiovascular risk.

Endothelin-1 axes in the framework of predictive, preventive and personalised (3P) medicine

Endothelin-1 (ET-1) is involved in the regulation of a myriad of processes highly relevant for physical and mental well-being; female and male health; in the modulation of senses, pain, stress reactions and drug sensitivity as well as healing processes, amongst others. Shifted ET-1 homeostasis may influence and predict the development and progression of suboptimal health conditions, metabolic impairments with cascading complications, ageing and related pathologies, cardiovascular diseases, neurodegenerative pathologies, aggressive malignancies, modulating, therefore, individual outcomes of both non-communicable and infectious diseases such as COVID-19. This article provides an in-depth analysis of the involvement of ET-1 and related regulatory pathways in physiological and pathophysiological processes and estimates its capacity as a predictor of ageing and related pathologies,a sensor of lifestyle quality and progression of suboptimal health conditions to diseases for their targeted preventionand as a potent target for cost-effective treatments tailored to the person.

Exploratory study into awareness of heart disease and health care seeking behavior among Emirati women (UAE) - Cross sectional descriptive study

Background

Cardiovascular disease was the leading cause of death among women in the United Arab Emirates (UAE) in 2010. Heart attacks usually happen in older women thus symptoms of heart disease may be masked by symptoms of chronic diseases, which could explain the delay in seeking health care and higher mortality following an ischaemic episode among women. This study seeks to a) highlight the awareness of heart diseases among Emirati women and b) to understand Emirati women’s health care seeking behaviour in UAE.

Method

A cross sectional, descriptive study was conducted using a survey instrument adapted from the American Heart Association National survey. A convenience sample of 676 Emirati women between the ages of 18–55 years completed the questionnaire.

Results

The study showed low levels of awareness of heart disease and associated risk factors in Emirati women; only 19.4% participants were found to be aware of heart diseases. Awareness levels were highest in Dubai (OR 2.18, p < 0.05) among all the other emirates and in the 18–45 years age group (OR 2.74, p < 0.05). Despite low awareness levels, women paradoxically perceived themselves to be self-efficacious in seeking health care. Interestingly, just 49.1% Emirati women believed that good quality and affordable health care was available in the UAE. Only 28.8% of the participants believed there were sufficient female doctors to respond to health needs of women in UAE. Furthermore, only 36.7% Emirati women chose to be treated in the UAE over treatment in other countries.

Conclusion

Emirati women clearly lack the knowledge on severity and vulnerability to heart disease in the region that is essential to improve cardiovascular related health outcomes. This study has identified the need for wider outreach that focuses on gender and age specific awareness on heart disease risks and symptoms. The study has also highlighted potential modifiable barriers in seeking health care that should be overcome to reduce morbidity and mortality due to heart disease among national women of UAE.

Women and heart disease

In the United States heart disease causes more than one-third of all deaths and most of these occur in women, not men, although women and health care professionals alike continue to view death from heart disease as a threat primarily to middle-aged men. The disparity between genders in the incidence of cardiovascular disease (CVD) may be the result of significant differences in both cardiovascular risk factors and presentation between men and women. This article reviews recent data regarding unique sex-specific characteristics of both risk for, and presentation of, CVD in women.

Endothelin in the female vasculature: a role in aging?

Cardiovascular diseases are the leading cause of morbidity and mortality in the world. Aging is associated with an increased incidence of cardiovascular disease. Premenopausal women are relatively protected from vascular alterations compared with age-matched men, likely due to higher levels of the female sex hormones. However, these vasoprotective effects in women are attenuated after menopause. Thus, the vascular system in aging women is affected by both the aging process as well as loss of hormonal protection, positioning women of this age group at a high risk for cardiovascular diseases such as hypertension, myocardial infarction, and stroke. The endothelin system in general and endothelin-1 (ET-1) in particular plays an important role in the pathogenesis of vascular dysfunction associated with aging. Evidence suggests that the female sex steroids can interfere with the vascular expression and actions of ET-1 via several mechanisms, which may further contribute to pathological processes in the vasculature of aging women. In this review, we have summarized hormone-dependent vascular pathways whereby ET-1 may mediate the deleterious effects of aging in postmenopausal females.

Improvements in time to reperfusion: do women have an advantage?

Several studies demonstrate that women have greater delays in primary percutaneous coronary intervention (PCI). To improve care for women, the Women's Heart Advantage at Yale-New Haven Hospital (YNHH) developed patient- and physician-level interventions to improve knowledge about chest pain syndromes to promote early presentation, diagnosis, and timely management of ST-elevation myocardial infarction (STEMI) in women presenting to the emergency department. Specifically, we analyzed chart-abstracted data from all patients undergoing PCI for STEMI at YNHH from January 2004 to July 2007 and assessed quality of care for STEMI and trends in time to reperfusion. Women's Heart Advantage and YNHH orchestrated several clinical initiatives and instituted hospital-wide systems to improve STEMI care over this period. Both men and women had declines in time to reperfusion (91-73 minutes for men and 120-74 minutes for women). Notably, improvements in time to reperfusion were more substantial in women; the greatest improvement was reduction in door-to-table time (50% decrease in women vs. 19% decrease in men [P < 0.05]). In this single-site study of men and women undergoing primary PCI at a large, urban teaching hospital, where ongoing interventions to increase both patient and physician awareness regarding heart disease in women were initiated, time to reperfusion for women improved to a greater degree than in men. These results are encouraging, showing that significant improvements can be made over a relatively short time frame. It is hoped these reductions in time to reperfusion are associated with improved outcomes; however, further studies are needed to verify this potential benefit.

Menopause, the metabolic syndrome, and mind-body therapies

Cardiovascular disease risk rises sharply with menopause, likely due to the coincident increase in insulin resistance and related atherogenic changes that together comprise the metabolic or insulin resistance syndrome, a cluster of metabolic and hemodynamic abnormalities strongly implicated in the pathogenesis and progression of cardiovascular disease. A growing body of research suggests that traditional mind-body practices such as yoga, tai chi, and qigong may offer safe and cost-effective strategies for reducing insulin resistance syndrome-related risk factors for cardiovascular disease in older populations, including postmenopausal women. Current evidence suggests that these practices may reduce insulin resistance and related physiological risk factors for cardiovascular disease; improve mood, well-being, and sleep; decrease sympathetic activation; and enhance cardiovagal function. However, additional rigorous studies are needed to confirm existing findings and to examine long-term effects on cardiovascular health.

Why do women underestimate the risk of cardiac disease? A literature review

BACKGROUND

Despite the quantity of information available to women about risk factors for cardiovascular disease (CVD), many women do not perceive this risk.

AIM

This paper seeks to identify factors in the published literature that influence women's risk perception of heart disease, and how these perceptions influence health outcomes.

METHOD

A literature search from 1985 to 2006 using the CINAHL, Medline, Embase and PsycINFO electronic databases was undertaken. The keywords used were 'perceived risk', 'cardiac risk factors', 'cardiovascular disease', 'risk misconception', and 'heart disease', combined with 'women' and/or 'gender'. Additional data was obtained by manual searches of bibliographies of articles identified in the electronic searches, and Internet searches.

FINDINGS

Until the late 1980s, CVD was perceived as a disease which primarily affected men, as few large clinical trials recruited women. This resulted in a lack of data documenting the relationship between known risk factors and gender. Until recently, health professionals have not focused on disseminating gender-specific information about CVD risks to women, causing women to underestimate their risk of developing CVD even when risk factors are clearly evident. Furthermore, women are less likely than men to recognise the signs and symptoms of CVD, delay in seeking treatment, and fail to adopt healthy lifestyles, all of which increase the incidence of mortality and morbidity in a disease that is largely preventable.

CONCLUSION

This review highlights the need for health professionals to 'bridge the gap' between perceived and actual risk of CVD in women, and to develop educational programs that specifically target women.

Evidence against a role for ovarian hormones in the regulation of blood flow

OBJECTIVE

To determine the effect of ovarian hormone deficiency on peripheral vascular function.

DESIGN

Randomized, single-blind, placebo-controlled.

SETTING

General clinical research center.

PATIENT(S)

Twelve healthy, lean, premenopausal women with regular menstrual cycles.

INTERVENTION(S)

Measurements were made during the early to midfollicular and midluteal phases of the menstrual cycle. Patients were then randomized to an 8-week course of gonadotropin-releasing hormone agonist (GnRHa) (n = 6) or placebo (n = 6) and retested. On each occasion, blood flow was assessed in the basal postabsorptive state and under euglycemic-hyperinsulinemic-hyperaminoacidemic conditions.

MAIN OUTCOME MEASURE(S)

Calf blood flow by venous occlusion plethysmography.

RESULT(S)

No differences in calf blood flow under postabsorptive (1.65 +/- 0.09 vs. 1.73 +/- 0.16 mL/100 g tissue per minute) or insulin-stimulated conditions (2.24 +/- 0.20 vs. 2.30 +/- 0.18 mL/100 g tissue per minute) were found between the follicular and luteal phases of the menstrual cycle, respectively; therefore, pretreatment data were averaged. Ovarian hormone suppression did not alter postabsorptive calf blood flow (GnRHa: 1.68 +/- 0.13 to 1.69 +/- 0.15; placebo: 1.69 +/- 0.21 to 1.64 +/- 0.14 mL/100 g tissue per minute) or the blood flow response to insulin infusion (GnRHa: 2.40 +/- 0.21 to 2.37 +/- 0.29; placebo: 2.10 +/- 0.28 to 2.19 +/- 0.35 mL/100 g tissue per minute).

CONCLUSION(S)

Variation in ovarian hormones associated with the menstrual cycle or short-term ovarian hormone deficiency induced by GnRHa do not affect calf blood flow under postabsorptive conditions or the response to hyperinsulinemia.

Lowering cortisol and CVD risk in postmenopausal women: a pilot study using the Transcendental Meditation program

Unlike younger women, the risk of cardiovascular disease in older women matches or exceeds that of men. Excessive cortisol may play a role in this increased risk. Here we explore the possibility that the Transcendental Meditation (TM) program may reduce the cortisol response to a metabolic stressor as a way of reducing disease risk in older women. Data from 16 women who were long-term practitioners of transcendental meditation (mean = 23 y) were compared with data from 14 control women matched for age (mean = 75 y, range = 65-92 y). Data on demographics, disease symptoms, and psychological variables were collected, and cortisol response to a metabolic stressor (75 g of glucose, orally) was examined in saliva and urine. Pre-glucose levels of salivary cortisol were identical for the two groups. Post-glucose cortisol rose faster in the controls and was significantly higher than that in the TM women (P < 1 3 10(-4)). Urinary excretion of cortisol during this period was 3 times higher in controls than in the TM women (2.4 +/- 0.17 and 0.83 +/- 0.10 microg/h, respectively; P = 2 x 10(-4)). In addition, the number of months practicing transcendental meditation was inversely correlated with CVD risk factors. Lower cortisol response to metabolic challenge may reflect improved endocrine regulation relevant to the disease-preventing effects of transcendental meditation in older women.

Comprehensive evaluation of the older woman

Nearly 50% of American women will be older than 45 years by the year 2015. Because the life expectancy of women is anticipated to extend to an average age of 81 years by 2050, the aging woman will become the predominant patient seeking health care. These statistics reveal the importance for health care providers to become familiar with the health care needs of this segment of the population. Over their life span, women are more likely to experience disease and disability and subsequently require intervention and treatment. This review is an evaluation of the older woman in the primary care setting. In the first section, which is an overall assessment of the older woman, we introduce common geriatric syndromes that should be recognized by health care professionals. We include an approach to the older woman and specific clinical tools that may be useful for comprehensive evaluation in the outpatient setting. In the second section, we discuss sex-specific illnesses as they relate to the older woman. In the third section, we provide insights on end-of-life issues, cultural competence, and socioeconomic concerns. In the last section, we summarize the key components in the evaluation and management of the older woman. The goal of this article is to provide the health care provider with a clear understanding of factors that must be considered to provide optimal care to these patients.