CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 3, May/June 2014
AFRICA
139
High Lp(a) values together with abnormal blood lipid levels
are risk factors for cardiovascular disease in women, even in
those under 60 years.
16
New research on women offers strong
evidence that heart attack risk increased as Lp(a) levels rose.
28
Lipoprotein-associated phospholipase A2 (Lp-PLA2)
Recent data confirm the involvement of Lp-PLA2 in the
development of atherosclerosis by modifying the affinity of
LDL particles for extracellular matrix proteins.
30-32
Moreover,
Lp-PLA2 favours lipid accumulation in arterial walls, lipid
peroxidation, and hydrolysis of lysophospholipids and free fatty
acids.
33,34
Lp-PLA2 may be identified as an independent risk
factor for rupture of atheroma plaque and thrombo-embolic
events.
12
The latest European guidelines on cardiovascular disease
prevention in clinical practice recommend the determination
of Lp-PLA2 values as part of a refined risk assessment in
patients at high risk of a recurrent acute atherothrombotic
event (class IIB, level B).
11
The 2010 ACCF/AHA Guideline
for the Assessment of Cardiovascular Risk in Asymptomatic
Adults reported that calculation of Lp-PLA2 levels may be
reasonable for cardiovascular risk assessment in intermediate-
risk asymptomatic adults (class IIb level B).
35
The recent Nurses’ Health study showed that levels of
Lp-PLA2 were significantly associated with the incidence of
ischaemic heart disease in women.
36
According to some research
results, women have higher levels of secretory phospholipase A2
(sPLA2) than men. It was reported that elevated sPLA2 levels
were correlated with high CRP levels.
27,37
Homocysteine
In general, women present with lower homocysteine values than
men, but elevation occurs during the menopausal years.
16,38
Also,
a number of studies suggested a relationship between serum
homocysteine levels and the presence of coronary artery disease
in women, but not in men.
14
Therefore, it represents a stronger
atherogenic factor in women than in men.
16
Other studies however
did not identify homocysteine as a significant factor in predicting
statistical risk of coronary heart disease after adjustment for
traditional risk factors, even though they found a positive
correlation between this biomarker and ischaemic heart disease.
38
Nevertheless, the latest European guideline on cardiovascular
disease prevention in clinical practice states that homocysteine
may be measured as part of a refined risk assessment in patients
with an unusual or moderate CVD risk profile (class IIB, level
B).
11
The measurement of serum homocysteine levels is not
part of the routine screening process for cardiovascular risk
assessment.
11
Other markers
Natriuretic peptides
The Framingham Offspring study showed that 10 elevated
biomarkers, and high B-type natriuretic peptides (BNP)
indicated cardiovascular risk.
39
On the other hand, the Swedish
Malmö diet and cancer cohort showed that only BNP and
mid-region pro-adenomedulin levels were associated with a
doubled cardiovascular risk.
40
The 2012 ESC guidelines for the management of heart failure
revealed that BNP, N-terminal pro B-type natriuretic peptide
(NT-proBNP) and mid-regional pro-atrial natriuretic peptide
(MR-proANP) levels showed usefulness in detecting heart
failure patients, a differential diagnosis of dyspneoa and risk
stratification.
41
The KORA study included 1 005 women and men aged
between 25 and 75 years. The goal of this study was to determine
the variation in the NT-proBNP and BNP levels in a 10-year
period. They reported a strong correlation between gender, age
and plasma levels of natriuretic peptides. Both NT-proBNP
and BNP serum concentrations recorded an elevation during
the follow-up period, especially in women.
42
However, it has
been shown that a BNP value that exceeds 500 pg/ml represents
a stronger predictor of death in women than men with heart
failure.
43
Growth differentiation factor-15 (GDF-15) is a novel
biomarker under investigation, which is synthesised in ischaemic
myocytes. There is evidence that it strongly indicates an increased
risk of cardiovascular death.
44
Conclusion
Despite the use of these novel cardiovascular risk factors, the
presence of hypertension, diabetes, physical inactivity and
inflammatory markers remain the most potent cardiovascular
risk factors in women, regardless of age. Novel cardiovascular
risk factors may play a decisive role in the early diagnosis of
ischaemic heart disease, especially in women with suspected
myocardial ischaemia, but without electrocardiographic,
echocardiographic or angiographic findings. However, their
routine measurement is difficult to implement. The guidelines
regarding coronary artery disease in women could suggest the
determination/evaluation of these novel cardiovascular risk
factors when a differential diagnosis should be considered.
References
1.
Newby LK, Douglas PS. Cardiovascular disease in women. In: Bonow
RO, Mann DL, Zipes DP, Libby P.
Braunwald’s Heart Disease: A
Textbook of Cardiovascular Medicine.
9th edn. Ed Saunders, 2011:
1757–1769.
2.
Mosca L, Benjamin EJ, Berra K,
et al
. Effectiveness-based guidelines
for the prevention of cardiovascular disease in women – 2011 update:
a guideline from the American Heart Association.
Circulation
2011;
123
: 1243–1262.
3.
Alfonso F, Bermejo J, Segovia J. Cardiovascular disease in women.
Why now?
Rev Esp Cardiol
2006;
59
: 259–263.
4.
Stramba-Badiale M, Fox KM, Priori SG,
et al
. Cardiovascular diseases
in women: a statement from the policy conference of the European
Society of Cardiology.
Eur Heart J
2006;
27
: 994–1005.
5.
Wenger NK, Shaw LJ, Vaccarino V. Coronary heart disease in women:
update 2008.
Clin Pharmacol Ther
2008;
83
: 37–51.
6.
Pilote L, Dasgupta K, Guru V,
et al
. A comprehensive view of sex-
specific issues related to cardiovascular disease.
Can Med Assoc J
2007;
176
: S1–S41.
7.
Andreotti F, Marchese N. Women and coronary heart disease.
Heart
2008;
94
: 108–116.
8.
Anand S, Islam S, Rosengren A,
et al
. Risk factors for myocardial
infarction in women and men: insights from the INTERHEART study.
