CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 3, May/June 2011
AFRICA
163
ance. ‘Although there are no data from
randomised clinical trials, weight loss,
diet and exercise are key. Bariatric
surgery is defined as the best therapy for
the morbidly obese.
Patients should be treated with statins
and either an ACE inhibitor or ARB for
accompanying hypertension. In a recent
post-
ad hoc
study of the GREACE study
of atorvastatin to lower LDL, patients
with modestly abnormal liver enzyme
levels showed reductions of some 50%,
and there were significantly fewer cardio-
vascular events in statin-treated patients.
7
‘The figures are highly significant and
stress the fact that these patients should
not be denied statin therapy. A small
study has provided some evidence that
ezetimibe is useful in NASH patients’, Dr
Abelson noted.
‘There is more to women than
just levels’
‘Despite the 2007 publication of a new
algorithm for women at risk of cardiovas-
cular disease, which stratified women into
high risk (10-year predicted risk for coro-
nary heart disease
>
20%), and “at risk”
being the presence of one or more cardio-
vascular disease risk factors, cardiovascu-
lar mortality in women is not decreasing’,
Dr Naomi Rapeport, physician at Milpark
Hospital, Johannesburg noted.
‘We also know now that hormone
replacement therapy should not be used
for primary or secondary intervention in
women with coronary artery disease. Yet
many women are not being treated with
statins, for example, because the tradi-
tional Framingham cardiovascular score
underestimates women’s vascular risk.’
‘Myocardial infarction (MI) is occur-
ring in younger women, and post-MI
in-hospital mortality is higher in women
than in men. In the African cohort of
myocardial infarction patients in the
INTERHEART study, the mean age of
women having their first MI was 56 years
of age.’
The American Heart Association has
recently (February 2011)
8
released new
effectiveness-based guidelines for the
prevention of cardiovascular disease in
women, which has lowered the threshold
for ‘high risk’ to equal to or more than a
10% risk of dying from any cardiovascu-
lar event in the next 10 years.
The ‘at-risk’ classification for women
is as before, except that the presence of
systemic lupus erythrematosus and rheu-
matoid arthritis are added as significantly
increasing the relative risk of cardiovascu-
lar disease and rank as cardiovascular risk
factors. Also, a history of pre-eclampsia,
gestational diabetes or pregnancy-induced
hypertension also ranks as a cardiovascu-
lar risk in the ‘at risk’ population.
‘These new guidelines mean that more
women will qualify for therapy, including
statins, as we apply these new standards
to our population’, Dr Rapeport stressed.
‘With regard to lipid therapy in the
high-risk women, it would be reasonable
to target 2.6 mmol/l, although in patients
who have had a recent acute coronary
syndrome event, a target of 1.8 mmol/l
would be justified. This may well imply
the use of statin combination therapy’, Dr
Rapeport noted.
‘In the at-risk population, women
should be treated with statins to a target
LDL cholesterol level of 3.4 mmol/l. It
is important to note that in modern statin
trials, such as JUPITER, women benefit-
ed as much as men.’
The difference between previous guide-
lines and the new AHA guidelines is that
cost effectiveness with regard to gender
is also considered. Antihypertensive ther-
apy, aspirin in women over 65 years of
age with moderate to severe cardiovas-
cular disease risk, and smoking cessation
treatments appear to be cost effective for
women. Other therapies such as weight
management and gastric bypass surgery
require further gender-focused cost stud-
ies.
J Aalbers, Special Assignments Editor
1.
Rowland NE, Vaughan CH, Mathes CM,
Mitra A. Feeding behaviour, obesity and
neuroeconomics.
Physiol Behav
2008;
93
(1–2): 97–109. E-pub 2008 Jul 1.
2.
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The burden of diabetes mellitus among US
youth.
Pediatrics
2000;
118
(4): 1510–1518.
3.
Couper JJ, Beresford S, Hirte C, Baghurts
PA, Pollard A, Tait BD,
et al
. Weight gain in
early life predicts risk of Islet autoimmun-
ity in children with a first-degree relative
with type 1 diabetes.
Diabetes Care
2009;
32
(1): 94–99.
4.
Wilkin TJ. Diabetes: 1 and 2, or one and
the same? Progress with the accelatator
hypothesis.
Pediatric Diabetes
2008;
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(3
part 2): 23–32.
5.
Williams CD,
et al
. Prevalence of non-alco-
holic fatty liver disease and non-alcoholic
steatohepatitis (NASH) among a largely
middle-aged population utilising ultra-
sound and liver biopsy: a prospective study.
Gastroenterology
2011;
140
(1): 25–28.
6.
Tagher G,
et al
. Relations between carotid
artery wall thickness and liver histology in
subjects with NAFLD.
Diabetes Care
2006;
29
(6): 1325–1330.
7.
Athyros VG, Tziomalos K, Gossios TD,
Griva T, Anagnostis P, Kargiotis K,
et al
;
GREACE Study Collaborative Group.
Safety and efficacy of long-term statin treat-
ment for cardiovascular events in patients
with coronary heart disease and abnor-
mal liver tests in the GREek Atorvastatin
and Coronary heart disease Evaluation
(GREACE) study: a post-hoc analysis.
Lancet
2010;
376
(9756): 1916-1922. Epub
2010 Nov 23.
8.
AHA Effectiveness-Based Guidelines for
the Prevention of Cardiovascular Disease
in women 2011 update.
Circulation
2011;
123
:1234–1262.
‘Fatty liver is your liver telling you
your heart is not happy!’
Take-home message
•
There is a strong association
between NAFLD and cardiovascu-
lar disease.
•
Careful monitoring and aggressive
management of risk factors is key.
•
It is not known whether ameliorat-
ing NAFLD will ultimately prevent
or slow progression of cardiovas-
cular disease (likely to be shown in
the next three to five years).
•
Do not avoid statins in patients with
moderately elevated ALT/AST as
they are likely to benefit most.
‘Some studies have shown that
NAFLD is an independent risk factor
for ischaemic heart disease, others
have not; so the jury is still out’
– Dr Abelson
