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Cardiovascular disease prevention in women: are we up
to date?
NAOMI RAPEPORT
A pandemic of cardiovascular disease (CVD) is afflicting
women. Heart disease is the leading cause of death in women in
every major developed country and most emerging economies.
1
Although it is often thought of as a disease of affluence, CVD
mortality rates in women over the age of 60 years are more than
double in low- and middle-income countries than in high-income
countries.
2
Much of the burden of this disease can be attenuated by
addressing critical risk factors such as hypertension, type 2
diabetes mellitus (DM), dyslipidaemia, physical inactivity,
tobacco use, overweight and obesity. These risk factors account
for 63% of the deaths due to CVD and DM, and over three-quar-
ters of the deaths from coronary heart disease (CHD).
3
Tobacco
use, overweight and obesity are currently more prevalent in
middle- and high-income countries. However this situation may
change, as it is projected that by 2030, almost 75% of tobacco-
related deaths will occur in low- and middle-income countries.
3
In high-income countries, cardiovascular mortality rates in
women have declined. This is secondary to modifications in risk
behaviour, such as reduced tobacco use and increased physical
activity, better management of hypertension and dyslipidaemia,
and improved treatment of existing cardiovascular conditions.
4
These benefits are not apparent in low- and lower middle-income
countries where only a quarter of women with chronic heart
disease receive treatment.
5
In the USA, a high-income country, these positive trends are
changing. CHD mortality rates in women aged 35 to 54 years are
increasing, attributed to the obesity epidemic.
4
Nearly two out
of every three American women over 20 years of age are over-
weight or obese.
6
This rise in obesity is a major contributor to the
increased prevalence of DM, which has a direct impact on the
overall risk of myocardial infarction (MI) and stroke.
7
In some
ethnic groups, there is a higher prevalence of certain risk factors,
such as hypertension among African-American women and DM
in Hispanics.
6
African-American women have the highest CHD
death rates and the highest overall CVD morbidity and mortality
6
In Africa, data from the Interheart Study showed that women
of African ancestry presented with their first MI at a younger age
than those from western Europe and North America (median age
of 56 vs 68 and 64 years, respectively).
8
In the Heart of Soweto
study, women presented with CVD also in their fifties, and were
slightly younger than the men (53 vs 55 years,
p
=
0.031).
9
In
this cohort, heart failure (HF) was the most common primary
diagnosis. Few had coronary artery disease, but they had a high
prevalence of cardiovascular risk factors, particularly hyperten-
sion and obesity.
While most of the morbidity and mortality from CVD occurs
at older ages, exposure to these risk factors starts earlier in life,
and therefore preventive interventions need to target younger
women. The first women-specific clinical recommendations for
the prevention of CVD were published in 1999, even though
there were little gender-specific research data.
10
Prior to this,
it was advised that women be treated the same as men despite
the exclusion of women from most clinical trials. Since the late
1990s, increasing numbers of women have participated in CVD
studies, resulting in gender-specific analyses. Furthermore,
major randomised, controlled clinical trials in women, such as
the Women’s Health Initiative, have changed the practice of
CVD prevention.
11
In 2004, the Evidence-Based Guidelines for Cardiovascular
Disease Prevention in Women were published.
12
The 2004 guide-
lines confirmed that menopausal therapy [hormone-replacement
therapy (HRT) and selective oestrogen-receptor modulators] was
not a preventive treatment modality. It was given a class III status
(i.e. not useful/effective and may cause harm) for both primary
and secondary prevention of CVD. Oestrogen HRT had previ-
ously been advocated for all postmenopausal women with coro-
nary and other vascular disease. To date this recommendation
