Elsevier

Atherosclerosis

Volume 241, Issue 1, July 2015, Pages 211-218
Atherosclerosis

Sex differences in cardiovascular risk factors and disease prevention

https://doi.org/10.1016/j.atherosclerosis.2015.01.027Get rights and content

Highlights

  • Tailoring risk assessment is important to improve healthcare and cost effectiveness.

  • We review the effects of traditional and female specific risk factors for cardiovascular disease.

  • The effects of most traditional risk factors on cardiovascular outcomes are largely similar between women and men.

  • Prolonged smoking and diabetes are significantly more hazardous for women than for men.

  • Several female-specific risk factors may enable early detection of women with a high lifetime risk of CVD.

Abstract

Cardiovascular disease (CVD) has been seen as a men's disease for decades, however it is more common in women than in men. It is generally assumed in medicine that the effects of the major risk factors (RF) on CVD outcomes are the same in women as in men. Recent evidence has emerged that recognizes new, potentially independent, CVD RF exclusive to women. In particular, common disorders of pregnancy, such as gestational hypertension and diabetes, as well as frequently occurring endocrine disorders in women of reproductive age (e.g. polycystic ovary syndrome (PCOS) and early menopause) are associated with accelerated development of CVD and impaired CVD-free survival.

With the recent availability of prospective studies comprising men and women, the equivalency of major RF prevalence and effects on CVD between men and women can be examined. Furthermore, female-specific RFs might be identified enabling early detection of apparently healthy women with a high lifetime risk of CVD.

Therefore, we examined the available literature regarding the prevalence and effects of the traditional major RFs for CVD in men and women. This included large prospective cohort studies, cross-sectional studies and registries, as randomised trials are lacking. Furthermore, a literature search was performed to examine the impact of female-specific RFs on the traditional RFs and the occurrence of CVD.

We found that the effects of elevated blood pressure, overweight and obesity, and elevated cholesterol on CVD outcomes are largely similar between women and men, however prolonged smoking is significantly more hazardous for women than for men. With respect to female-specific RF only associations (and no absolute risk data) could be found between preeclampsia, gestational diabetes and menopause onset with the occurrence of CVD.

This review shows that CVD is the main cause of death in men and women, however the prevalence is higher in women. Determination of the CV risk profile should take into account that there are differences in impact of major CV RF leading to a worse outcome in women. Lifestyle interventions and awareness in women needs more consideration. Furthermore, there is accumulating evidence that female-specific RF are of influence on the impact of major RF and on the onset of CVD. Attention for female specific RF may enable early detection and intervention in apparently healthy women. Studies are needed on how to implement the added RF's in current risk assessment and management strategies to maximize benefit and cost-effectiveness specific in women.

Introduction

Despite enormous declines in the burden of cardiovascular disease (CVD) in the past decades, mainly due to improvements in primary and secondary prevention, CVD disease remains a main cause of premature death and disability among men and women worldwide. Statistics from the World Health Organization (WHO) show that an estimated 17.3 million people died of CVD in 2008 of which 80% occurred in low- and middle income countries [1]. About 7.3 million deaths were due to coronary heart disease (CHD) and 6.2 million were due to stroke [2]. It is expected that the number of people who die from CVD, mainly from CHD and stroke, will increase to reach 23.3 million by 2030 [1], [3].

Although CVD has been seen as a men's disease for decades, it is actually more common in women. In the European population, 38% of deaths in women before the age of 75 years are due to CVD - in men this figure is 37% - a figure that is partly explained by a higher risk of competing events, i.e. the risk of dying from other causes (Fig. 1) [4]. Most of the burden of CVD can be explained by a set of traditional risk factors that affect both men and women, including elevated blood pressure, smoking, overweight and obesity, diabetes, and elevated cholesterol. Already in 1999 the American Heart Association (AHA) developed the first women-specific clinical recommendations for CVD prevention, which led to increased awareness of women's CVD risk, and to improved risk factor management and treatment of CVD in women [5]. However, despite these women-specific guidelines and accruing evidence for clinically important sex differences in the prevalence of traditional CVD risk factors, and in the effects of these risk factors on CVD outcomes sex-specific risk remains poorly understood and the prevention and management of stroke and cardiovascular risk factors is essentially still the same for men and women.

Recent evidence has emerged that recognizes new, potentially independent, CVD risk factors exclusive to women [6]. In particular, common disorders of pregnancy, such as gestational hypertension and diabetes, as well as frequently occurring endocrine disorders in women of reproductive age (e.g. polycystic ovary syndrome (PCOS) and early menopause) are associated with accelerated development of CVD and impaired CVD-free survival [7], [8]. Other risk factors, although not exclusive to women, have a much higher prevalence in women than men. As an example, migraine occurs 3 times more often in women, and is associated with an increased risk of stroke [9], [10]. The most recent AHA guideline (2011) and AHA/American Stroke Association (ASA) guideline (2014) for the prevention of cardiovascular complications and stroke in women recommends CVD risk assessment in women with certain reproductive manifestations of CVD risk, such as adverse pregnancy outcomes, and suggests that female-specific risk factors may improve current CVD risk assessment strategies [11], [12].

The purpose of this review is to examine the available literature regarding the prevalence and effects of the traditional risk factors on the risk for CVD in men and women. Furthermore, the impact of the female specific risk factors on the occurrence of CVD is examined.

Section snippets

Elevated blood pressure

Elevated blood pressure is a major public-health challenge worldwide; it is estimated to be responsible for an annual 7.5 million deaths, about 12.8% of the total of all deaths and to account for 57 million disability adjusted life years (DALYS), about 3.7% of all DALYS [14]. The prevalence of hypertension is broadly similar in men and women, and is projected to increase with population growth and aging in both sexes. In 2000, nearly a billion adults, 27% of all men and 26% of all women, had

Pregnancy as a risk factor for CV disease

Pregnancy poses a substantial challenge to cardiovascular system of the mother, and pregnancy-associated complications are often the result of the mother's inability to adapt to this vascular and metabolic “stress test” [6]. Consequently, several pregnancy outcomes (e.g. gestational hypertension and diabetes) have the ability to reveal valuable information about the underlying cardiovascular health of the mother. Since about 80–90% of women worldwide have one or more children [69], evaluation

Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women, affecting around 5–10% of women of reproductive age. PCOS is characterized by excessive production of androgens that leads to ovarian dysfunction, and is often accompanied by insulin resistance [87]. As a result, women experience a menstrual disorder and fertility problems. Women with PCOS are predisposed toT2DM, chronic hypertension and dyslipidaemia and several other metabolic disturbances consistent with

Conclusion

Cardiovascular diseases remain the world's leading cause of death and disability in both men and women but affect more women than men. Most of the burden of CVD is by means of the traditional risk factors. While the effects of raised blood pressure, overweight and obesity, and raised cholesterol on cardiovascular outcomes are largely similar between women and men, prolonged smoking and diabetes are significantly more hazardous for women than for men. Further research into the mechanisms

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