Identifying and managing younger women at high risk of cardiovascular disease

Abstract

C ardiovascular disease (CVD), which is largely preventable, is a leading cause of morbidity and mortality among Canadian women. For this article, we use CVD to refer to ischemic heart disease and stroke. Data for peripheral arterial disease in women are limited and are addressed elsewhere. 1 Until now, risk reduction has focused largely on postmenopausal woman with traditional risk factors: diabetes, smoking, hypertension and hyperlipidemia. Consequently, CVD mortality has declined, largely driven by those aged 50 years and older. 2 A recent study of 20-year temporal trends in admissions to hospital and deaths caused by atherosclerotic cardiovascular disease in Ontario reported that mortality rates for circulatory diseases in women declined 52.8% between 1994 and 2012. 3 However, annual rates of decline were least evident in individuals younger than 50 years of age, suggesting that CVD among younger adults remains a cause for concern. 3 The lowest rate of decline in CVD-related mortality and, in some cases, an increase in CVD-related admissions to hospital and mortality have been observed in younger women. 3,4 Contemporary Canadian data suggest the gap in cardiovascular mortality between men and women may be closing. 5 Yet young women with ST-segment elevation myocardial infarction (MI) have 15%-20% higher rates of death than men of similar age. 6 Whether this is related to systematic differences in care or true biological differences, or a combination, is unclear. What is clear is that addressing cardiovascular health in women younger than 50 years of age requires thinking beyond traditional risk factors in primordial prevention. We present a brief overview of sex differences in traditional cardiovascular risk factors and a focused review of key nontraditional risk factors in younger women (i.e., ovarian dysfunction, infertility, reproductive therapies and pregnancy complications). Our approach to gathering evidence is outlined in Box 1.

Cardiovascular disease risk among hypertensive patients and associated determinants in Addis Ababa, Ethiopia: an institutional-based cross-sectional study

“…CVDs are a group of disorders of the heart and blood vessels 7. They are generally classified as atherosclerotic CVDs (related to atherosclerosis of arteries that supply organs (coronary heart disease, cerebrovascular disease and peripheral arterial diseases)8 and non-atherosclerotic CVDs that include rheumatic heart disease, congenital heart disease, cardiomyopathies and others 9…”

“…Most CVDs are preceded by many years of cardiovascular risk factors. Early detection and treatment of modifiable risk factors can lower an individual’s risk of developing CVD 2 9. Modifiable risk factors are those conditions for which interventions exist to reduce their levels and decrease the occurrence of CVDs.…”

Randomised controlled trial of breast cancer and multiple disease prevention weight loss programmes vs written advice amongst women attending a breast cancer family history clinic

“…Low CVD risk factors (i.e., lipid and blood pressure) may lead to underestimation of subsequent lifetime risk amongst the relatively young women in the FHRPC. It is not known whether better lifetime CVD risk assessment tools could increase engagement amongst young women [ 59 ].…”

Risk of type 2 diabetes mellitus in women with prior hypertensive disorders of pregnancy: a systematic review and meta-analysis

“…Additionally, we included more studies that had a length of follow-up greater than 10 years and found that among women who participated in such studies, the risk of diabetes was greatest at age 35-40 years. Further, several studies have found a relationship between HDP and future CVD [22,23,27,[48][49][50][51]. A large population-based retrospective cohort All included studies in the meta-analysis have controlled for baseline diabetes mellitus aHR = pooled adjusted hazard ratios, reference groups = no history of HDP a Studies that controlled for GDM either by exclusion or regression b Studies that followed women from the time of delivery (mean age: 28.2 years, range: 25-33 years) GH, gestational hypertension; HTN, hypertension; PEC, pre-eclampsia study found that maternal placental syndromes, including HDP and placental abruption, were associated with a twofold increase in CVD compared with those without maternal placental syndrome, with the mean age of onset of 38 years [52].…”