Sex differences in cardiovascular risk factors and disease prevention
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
References (102)
- et al.
Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study
Lancet
(2005 Nov 19) - et al.
Global burden of hypertension: analysis of worldwide data
Lancet
(2005 Jan 15) - et al.
National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participants
Lancet
(2011 Feb 12) - et al.
Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study
Lancet
(2010 Jul 10) - et al.
Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study
Lancet
(2004 Sep 11) - et al.
Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys
Lancet
(2012 Aug 18) - et al.
Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies
Lancet
(2011 Oct 8) - et al.
Smoking characteristics and inhalation biochemistry in the Scottish population
J. Clin. Epidemiol.
(1991) - et al.
National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants
Lancet
(2011 Jul 2) - et al.
Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the American heart association
J. Am. Coll. Cardiol.
(2011 Mar 22)
Diabetes as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 64 cohorts, including 775,385 individuals and 12,539 strokes
Lancet
Women show worse control of type 2 diabetes and cardiovascular disease risk factors than men: results from the MIND IT study group of the Italian society of diabetology
Nutr. Metab. Cardiovasc Dis.
Oxidized lipids in insulin-dependent diabetes mellitus: a sex-diabetes interaction?
Metabolism
Selected major risk factors and global and regional burden of disease
Lancet
National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants
Lancet
National, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3.0 million participants
Lancet
Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy
Best. Pract. Res. Clin. Obstet. Gynaecol.
Ten-year, thirty-year, and lifetime cardiovascular disease risk estimates following a pregnancy complicated by preeclampsia
J. Obstet. Gynaecol. Can.
Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis
Lancet
First trimester bleeding and maternal cardiovascular morbidity
Eur. J. Obstet. Gynecol. Reprod. Biol.
Parity and cardiovascular disease risk among older women: how do pregnancy complications mediate the association?
Ann. Epidemiol.
Primary ovarian insufficiency
Lancet
Early or recurrent preterm birth and maternal cardiovascular disease risk
Ann. Epidemiol.
Global Status Report on Noncommunicable Diseases 2010
Global Atlas on Cardiovascular Disease Prevention and Control
Projections of global mortality and burden of disease from 2002 to 2030
PLoS Med.
European Cardiovascular Disease Statistics
Guide to preventive cardiology for women. AHA/ACC scientific statement consensus panel statement
Circulation
Pregnancy complications and maternal cardiovascular risk: opportunities for intervention and screening?
BMJ
Polycystic ovary syndrome and early-onset preeclampsia: reproductive manifestations of increased cardiovascular risk
Menopause
Migraine as a risk factor for subclinical brain lesions
JAMA
Hypertension and migraine comorbidity: prevalence and risk of cerebrovascular events: evidence from a large, multicenter, cross-sectional survey in Italy (MIRACLES study)
J. Hypertens.
Evidence-based guidelines for cardiovascular disease prevention in women. American heart association scientific statement
Arterioscler. Thromb. Vasc. Biol.
Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the american heart association/American stroke association
Stroke
European Cardiovascular Disease Statistics
Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks
Worldwide prevalence of hypertension: a systematic review
J. Hypertens.
US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008
JAMA
Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies
Lancet
Blood pressure and cardiovascular disease in the Asia Pacific region
J. Hypertens.
Comparison of the sex-specific associations between systolic blood pressure and the risk of cardiovascular disease: a systematic review and meta-analysis of 124 cohort studies, including 1.2 million individuals
Stroke
Differences in prevalence, awareness, treatment and control of hypertension between developing and developed countries
J. Hypertens.
The Tobacco Atlas
Gender empowerment and female-to-male smoking prevalence ratios
Bull. World Health Organ
A Descriptive Model of the Cigarette Epidemic in Developed Countries
Smoking and risk of myocardial infarction in women and men: longitudinal population study
BMJ
Smoking, quitting, and the risk of cardiovascular disease among women and men in the Asia-Pacific region
Int. J. Epidemiol.
Smoking as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 81 cohorts, including 3,980,359 individuals and 42,401 strokes
Stroke
Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies
BMJ
Sex disparities in control and treatment of modifiable cardiovascular disease risk factors among patients with diabetes: translating research into action for diabetes (TRIAD) study
Diabetes Care
Cited by (378)
Menopause and accelerated aortic stiffness
2024, MaturitasLDL-cholesterol target levels achievement in high-risk patients: An (un)expected gender bias
2024, Nutrition, Metabolism and Cardiovascular DiseasesA comparison of alcohol and commercial tobacco use in populous American Indian/Alaska Native states
2023, Drug and Alcohol DependenceImplementation of risk enhancers in ASCVD risk estimation and hypolipidemic treatment eligibility: A sex-specific analysis
2023, Hellenic Journal of Cardiology