Faster CAC Progression After Menopause May Warrant Intensified Therapy

Biological changes associated with menopause may accelerate coronary artery calcium (CAC) progression, even in women who are on statins, research suggests.

In the study, postmenopausal women who underwent CAC scans taken one year apart had median score increases that were double that of similarly aged men, report investigators.

“It really is a call for action for people taking care of perimenopausal and postmenopausal women to be a little more diligent about treating heart disease,” senior study author Matthew J. Budoff, MD (Harbor-UCLA Medical Center, Los Angeles, CA), told TCTMD.

The reason for the accelerated progression in older women is not entirely clear, he said.

“We always thought it was a drop in estrogen levels,” said Budoff. “I think that is certainly a significant part of it [but] I don’t think we have a complete answer yet.”

The findings come amid growing interest in research into the impact of women’s aging on overall health. Just last month, President Biden signed an executive order directing the National Institutes of Health to spend $200 million to fund new, interdisciplinary women’s health research, including deep dives into the impact of perimenopause and menopause on heart, brain, and bone health.

The study results will be presented at the upcoming American College of Cardiology (ACC) 2024 Scientific Session by lead author Ella Ishaaya, MD (Harbor-UCLA Medical Center).

Intensification of Therapy May Be Needed

The investigators looked at 579 post-menopausal women without CAD who were taking statins for elevated cholesterol and had undergone a baseline and a follow-up CAC scan at least one year apart. They were compared with age-matched men with similar statin use, blood pressure, and comorbidities.

At baseline, participants were grouped by CAC levels: 1 to 99, 100 to 399, and 400 or higher. In the lowest CAC group, women had a median increase in score of eight points compared with four points in men between the first and second CAC scan (P = 0.003). In the middle CAC group, women had a median increase in score of 31 points versus 16 points in men (P = 0.001). No difference was seen between women and men in those in the highest baseline CAC group.

Budoff said the findings suggest that some women may need proactive intensification of statin therapy or might need to have another agent added to their current regimen to head off future risk of cardiovascular events.

“I think there's [a] good opportunity there for people to be treated more aggressively, if needed,” he commented. For others, “it may be that just diet and exercise are needed.”

An additional take-home message for older women, Budoff added, is that if they have not had a baseline CAC scan in their 50s, it’s prudent to do so.

“It's a very low-dose radiation test. We call it the mammogram of the heart because it’s a good screening test and informative. If the score is zero, which half of all women will [have], then maybe they don't need to be on statins, or at least they can forego statins for a few years. If their score is high, maybe they need more than just a statin,” he added.

The next step in this research will be to look at outcomes and whether changes to therapy based on CAC progression after menopause make a difference, and if so, who benefits the most, Budoff noted.

“We're going to try to expand the research into other cohorts to further validate this concept and then also hopefully look at which of these women go on to have heart attacks or strokes to try to determine what more can be done,” he concluded.