Sex-Specific ‘Inventory’ Needed to Spot Key CVD Risk Factors in Women

BALTIMORE, MD—From the stressors of pregnancy to unique comorbidities and societal constraints, a number of different factors should inspire a gender-specific approach to combatting cardiovascular disease in women, according to physicians gathered here at a special prevention symposium ahead of the annual Society of Cardiovascular Computed Tomography (SCCT) meeting.

It’s fine to start assessing risk in women using either the standard ASCVD or MESA scoring tools, said Martha Gulati, MD (University of Arizona, Phoenix), who made the case for a tailored approach. “But then, take a sex-specific inventory of the risk factors,” she stressed. Such risk factors include pregnancy and its complications, a history of breast cancer and treatment, menopausal status, use of hormone replacement therapy, and specific, predominantly female conditions that increase CVD risk.

“That's the way we can begin the personalization of the treatment of women,” said Gulati. “I think that we can do fancy genetics—I'm not minimizing their role—but if we don’t even take into account the sex differences that are simple, that really just require us taking a history, any fancy test isn’t going to help us move too far beyond that.”

Ritu Thamman, MD (University of Pittsburgh School of Medicine, PA), who attended the session, echoed some of these points when speaking with TCTMD. Moreover, risk factors play a different role at different stages, she stressed. “Women have very specific times in their lives that we as cardiologists and internists have to be aware of when we're assessing risk.”

Prevalence and Perception

Gulati made a point well-known to cardiologists—but often a surprise for patients—that cardiovascular disease kills more women every year than does breast cancer. “Almost half of US women have some form of cardiovascular disease,” she stated, adding that breast cancer affects 3.5 million women whereas 60 million women have been diagnosed with cardiovascular disease.

The field of women’s health has mainly focused on the breasts and reproductive system, often at the expense of CVD risk, Gulati observed. “When women come in for their preventive health exam, they come out knowing if their mammogram is ok, they know if their pap smear is OK. They rarely come out knowing if they are at risk for cardiovascular disease. That's where I think we really need to change.”

There are also important differences between men and women with regard to the relative weight of traditional risk factors. “Even though the prevalence of smoking is less in women, if a woman smokes the same number of cigarettes, the cardiovascular effects are greater,” Gulati said. “Diabetes is actually more prevalent in women, and if you're a diabetic woman, there's a greater risk of cardiovascular disease than [for] a diabetic man.”

During the CVD prevention symposium, Roger Blumenthal, MD (Johns Hopkins University School of Medicine, Baltimore, MD), pointed out that it’s “really hard” to deem a woman as high risk if you depend only on the commonly used thresholds of CVD risk using traditional tools.

‘Nature’s Free Stress Test’

Pregnancy complications like preeclampsia and gestational diabetes are uniquely female risk factors, but so too are inflammatory conditions like lupus and rheumatoid arthritis that occur more commonly in women and have implications for CVD risk.

Gulati called pregnancy “nature’s free stress test” because any complications that happened can help identify women who might benefit from primary prevention efforts to mitigate their future cardiovascular risk. “When I take a risk assessment of a patient, I do actually ask about pregnancy with a long, detailed list of things I want to know. Sometimes I think my patients think I'm off track and that they've come to the wrong clinic,” she said, highlighting that preeclampsia and gestational diabetes occur in about one-third of pregnancies.

Indeed, it’s during pregnancy that physicians have a golden opportunity to check for risk factors that may prove important down the road. “When we think about [the fact] that over 80% of women bear at least one child, that’s a time that we can be identifying cardiovascular risk,” she said.

The mechanisms linking pregnancy complications with cardiovascular disease down the line aren’t “entirely clear,” according to Gulati. “It may be that there's preexisting conditions that have occurred that are going to be announced during pregnancy. Or there's something about pregnancy and the stress of pregnancy that starts bringing out different things to the heart, things like endothelial dysfunction or maybe unmasking the preexisting risk. Other things like environmental and lifestyle risk factors and inflammation can all potentially [have an impact] along this pathway.”

Women seem often surprised when we tell them that their blood pressure is high when they have spent most of their life being told their blood pressure is actually low. Martha Gulati

She advocated for patient education materials to be displayed and handed out within labor and delivery units so that patients understand why they might be referred to a cardiologist after giving birth.

Also, Gulati stressed the need for more general conversations about blood pressure in women. “It's such a common issue for both men and women, but . . . over a lifetime, there's a difference in how blood pressure changes in women compared to men,” she said. “Women seem often surprised when we tell them that their blood pressure is high when they have spent most of their life being told their blood pressure is actually low. They hear those words: low rather than normal.”

Breast Cancer Survivors, Veterans

Gulati also homed in on the relationship between breast cancer and heart disease. “The BRCA-2 and 1 genes have been associated with breast cancer but they've also been associated with the development of cardiovascular disease,” she said in her talk. “Many of the risk factors that affect a risk of developing breast cancer are also risk factors that are associated with the development of cardiovascular disease, [with] some data suggesting higher LDL may be associated with both diseases.”

But women with breast cancer in particular need to hear a stronger prevention message from their physicians. “Once they've done their treatment for breast cancer, they get focused on regular checkups for that, but I think it’s a perfect time to also talk to them about cardiovascular risk now [that] they're at a heightened risk of developing cardiovascular disease because of some of the treatments, including radiation and chemotherapy,” Gulati said.

It’s hugely important to realize that women vets have unique risk factors that have to do with being in an already highly intense profession with the added issues of misogyny, abuse, and mental/emotional stress. Kavitha Chinnaiyan

Another cohort of women “that we can't forget” are veterans, she emphasized. Citing a recently published study, Gulati said that on top of these women having a higher prevalence of nontraditional risk factors like homelessness, sexual trauma, depression, and posttraumatic stress disorder, “they also have a much higher prevalence of traditional risk factors: 40% of them have hypertension, 44% of them are obese, and about a third of them have hyperlipidemia. So this is a group we really need to be watching for and working on our preventive methods and screening for them.”

Kavitha Chinnaiyan, MD (Beaumont Health System, Royal Oak, MI), agreed. “I think it’s hugely important to realize that women vets have unique risk factors that have to do with being in an already highly intense profession with the added issues of misogyny, abuse, and mental/emotional stress,” she observed to TCTMD. “It must be recognized.”

Making sure that other practitioners beyond cardiology get involved in primary prevention is critical, Gulati said, particularly since much of this work is done by internists and even obstetricians. “A lot of women identify their obstetrician forever as their primary physician. We need to take into account these gender and sex specific risk factors to really give them a full risk assessment,” she advised.