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Heart disease in women: an update

Session presentations

This session included topics related to differences in pathophysiology and risk factors in women, versus men, acute coronary syndromes in women, managing hypertension, and best preventive strategies in women. 

Professor Raffaele Bugiardini reported that women have a higher prevalence of angina and a lower prevalence of obstructive CAD (as observed in the CASS and WISE studies), but tend to be older, have a greater risk factor burden, and a more adverse prognosis.  These findings suggest an alternative sex specific pathophysiology for ischemic heart disease in women, which is less flow-limiting stenoses, more outward remodelling, plaque erosion as a precipitating event, and more microvascular disease responsible for a woman’s atypical and more frequent symptoms. 

Professor Eva Swahn addressed that fewer women have been included in clinical trials.  When discussing causes of STEMI, she noted that platelet reactivity is greater in women compared to men.  Renal insufficiency is common in women, which is a marker for in-hospital mortality.  Women have gender-specific risk factors: pregnancy complications (pre-eclampsia), risk of thromboembolism from oral contraceptives, fetal growth restriction, and the menopausal transition.  Women are less likely to undergo coronary angiography and CABG.  Although women have a greater risk factor burden than men, they tend to have equal outcomes as men with invasive strategies.

Professor Renata Cifkova stated that hypertension contributes to CVD deaths in women, and the prevalence of hypertension increases with age.  Women tend to have better treatment and control rates.  In women post menopause, there is a steeper rise in SBP than in older men, most likely related to a change in estrogen/progesterone ratio, an increase in BMI and an increase in insulin resistance.  Ultimately, renal vasoconstriction occurs, although greater sympathetic activity has also been observed.  HRT remains a Class III intervention in the Guidelines for CVD Prevention in women because of an increase risk of DVT and stroke and the lack of effectiveness in preventing CHD.  However, blood pressure does not change in most women using HRT.  Hypertension in pregnancy increases CVD risk.  Hypertension may be an adverse effect of oral contraceptives, most often it is mild and blood pressure normalizes upon oral contraceptive withdrawal.  Response to antihypertensive agents and the beneficial effects of blood pressure lowering appear to be similar in women and men, however ACE inhibitors and ARBs should be avoided in pregnant women and those with a child-bearing potential.

Kathy Berra reported that the awareness of heart disease as the leading cause of death in women is the single largest predictor of a woman taking personal action to lower her risk of heart disease and encouraging her family to do the same.  In the awareness survey, women were more likely to have an annual check-up, increase physical activity, and avoid unhealthy foods.  More than half of women reported that someone else’s health is most important to them, especially their children’s health.  Childhood obesity is associated with certain maternal characteristics, e.g., eating habits and knowledge of nutrition, perception’s of children’s body sizes, depression, concern abut personal overweight, and dieting behaviors.  Children have a greater risk of being overweight if they are allowed to watch more TV and if one or both parents are overweight.  It is important for women to increase their personal awareness of CVD/stroke risk factors; reduce their risk factors through heart-healthy diet, weight loss, physical activity, and smoking cessation; encourage their family’s understanding of and participation in risk reduction efforts; and advocate for healthier schools through better nutrition and greater physical activity. The “magic bullet” for women is exercise to increase functional capacity, which has been shown to reduce mortality.




Heart disease in women: an update

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.