Thirty years ago, the average cholesterol level for a middle-aged man was 235 mg/dL and the average cholesterol at the time of first myocardial infarction was 235. Therefore, it was not advisable to be “average.” Consensus has been that women debuted with coronary heart disease about 10 years later, on average, than men did. This has been attributed to hormonal and other factors. However, risk factors such as diabetes, cigarette smoking and hypertension can lead to coronary artery disease at a younger than expected age in women.
It has long been said that the greatest risk factor for coronary artery disease (CAD) is having a family history. This is usually directly related to issue of an unfavorable lipid profile such as high cholesterol. Either an elevated LDL-cholesterol or low HDL-cholesterol can predisposed to coronary blockage. Environmental or learned exposures can also increase coronary risk, such as overeating and sedentary lifestyle.
Over the past 30 years, statin drugs were the mainstay of therapy to lower cholesterol and reduce CAD risk. However, over time, it became clear that up to 40-45 percent of people could either not take these drugs due to side effects or that they did not achieve lipid goals on maximally tolerated doses of the medication. It would be unthinkable that a patient with cancer would go untreated for their condition. Yet, many patients were running around after multiple stents and bypass surgery, not taking the very medicine that has been shown to prolong lives: statins. This paved the way for novel therapy.
Since hypertension and CAD are often silent conditions, the challenge is finding them early enough to make a significant preventative impact. For women, the onset of symptomatic CAD may not be the classic exertional chest pain or heaviness but may have vague presentations such unusual fatigue, shortness of air or dizziness.
Two developments in the past 10-12 years have been intensely studied and validated: the utility of the coronary calcium score and the value of cardiac computed tomography or coronary CTA. The presence of calcium in the coronary arteries is abnormal and a marker for atherosclerotic disease. The higher the calcium score, the greater likelihood of symptoms of CAD over time.
For the individual with some type of chest discomfort, coronary CTA may be useful; especially, if presenting to the emergency department with normal appearing EKG and enzymes. Coronary CTA has an extremely high negative predictive value meaning a normal study indicates less than a 1 percent chance of CAD. The study does require intravenous injection of iodinated contrast and exposure radiation.
The new paradigm is a structural approach to CAD rather than a functional one. That is, imaging that arteries in symptomatic individuals rather than making inferences from a stress test that could be false positive or negative.
Optimization of women’s health also requires vigilance for abnormal rhythms of the heart. One of the most common causes for stroke in an aging woman with longstanding hypertension is atrial fibrillation. Diagnosis and appropriate management of this common condition is critical to survival and survival without major disability.
Other organ systems are also in play. If a woman has smoked less than 30 years and still smokes or quits less than 15 years ago, she should have annual CT scans of the chest to look for suspicious pulmonary nodules that could represent early lung cancer. Vitamin D levels and DEXA scans are important to assess for bone disease to avoid stooped posture and fractures. Fecal immunochemical testing and screening colonoscopy are important to exclude colon polyps and risk of cancer. Women with BMI’s greater than 30-35 should be assessed for possible fatty liver with inflammation, which could lead to cirrhosis and liver transplant. Carrying extra weight also increases risks of obstructive sleep apnea, GERD, uterine and some other cancers, joint deterioration, heart stiffness and various skin conditions. If a woman is more than 100 pounds overweight, formal weight reduction efforts and bariatric surgery need to be considered.