AHA Scientific Statement Highlights Sex Disparities in CV Risk Among Diabetic Patients

A new scientific statement from the American Heart Association is a call to action to recognize the disparities in how cardiovascular disease affects women who have diabetes compared with their male counterparts. Clinicians need to be aware of how their recommendations and treatment decisions may be contributing to the problem, according to the statement. 

“We felt it was time to get out the state of knowledge, as it was, and to identify a call for research,” Judith G. Regensteiner, PhD, chair of the document’s writing group, told TCTMD.

While studies show that premenopausal, nondiabetic women have fewer cardiovascular events than men of the same age, when diabetes is added to the mix “the effects on women appear to be particularly devastating with regard to cardiovascular disease,” said Regensteiner, of the University of Colorado School of Medicine (Aurora, CO).

The statement cites a range of studies which, taken together, show that compared with diabetic men, diabetic women suffer MIs at an earlier age and are:

• More likely to die after an MI 
• Less likely to have PCI or CABG 
• Less likely to be on pharmacotherapy such as statins, fenofibrates, aspirin, ACE inhibitors, or beta blockers 
• Less likely to have their blood sugar or blood pressure under control  

“Women and men have an equal prevalence of diabetes, so it’s not that women have it more, it’s just that the consequences in women of all ages [is worse],” Regensteiner said.

Risk Factors and Unknowns

The position statement also touches on the differential effect of drugs in men vs women, noting that it is one of several areas where more research is needed. Interestingly, the paper also addresses polycystic ovary syndrome (PCOS) and its impact on cardiovascular disease in women. While women with PCOS have a higher prevalence of cardiovascular risk factors, it remains uncertain if they also have a higher event rate or greater mortality because few rigorous studies have been conducted.

“PCOS emerged as an area that really needs a lot more study,” Regensteiner noted. “It’s fascinating. There are a lot more women who have PCOS than we knew about, and the committee recognizes that studying that condition is important.”

Committee members hope the paper spurs clinicians to think more often about assessing women for cardiovascular risk factors if they also have diabetes, she said, and to focus efforts on lifestyle and behavioral modification that can curb the risk of having an event.

Observational studies suggest that diabetic women “may require greater frequency and intensity of physical activity than their male counterparts to reduce such events,” the committee writes. Current guidelines recommend 150 total minutes of exercise per week, which includes walking. But data from the Nurses’ Health Study found that women who performed moderate to vigorous physical activity for at least 2 compared with less than 1 hour per week had lower cardiovascular event rates of combined coronary heart disease and stroke.

“Telling people who have never exercised to just go exercise without further instruction is not what we are talking about,” Regensteiner noted. Instead, clinicians need to talk about individual-level exercise and work on helping patients to understand that “going from nothing to something produces an effect,” she said.

In addition to inadequate exercise, the statement also notes that abdominal adiposity, insulin resistance, and HbA1_c have been shown to be more predictive of coronary heart disease in diabetic women than in men. Regensteiner said awareness of those risk factors is an important take-away of the paper for clinicians.

Source: 
Regensteiner JG, Golden S, Huebschmann AG, et al. Sex differences in the cardiovascular consequences of diabetes mellitus: a scientific statement from the American Heart Association. Circulation. 2015;Epub ahead of print. 

Disclosures:

• Regensteiner reports research grants from the American Diabetes Association, the National Institutes of Health, and Merck.

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