By George I. Papaioannou, MD, MPH, FACC, FSCAI, Interventional Cardiologist, Hemodynamic Laboratory, Athens Medical Center
Coronary Disease: The first cause of death in women
For many decades it has been thought that women are protected by the coronary heart disease (the creation of stenoses in the arteries of the heart) in relation to men. The main reason was the theory that estrogens had a protective effect in the cardiovascular system of the "weak" sex. Modern epidemiological data prove that coronary heart disease is first cause of death on women, much more than breast cancer. After 1984, the cardiovascular diseases are responsible for the death more women than men.
This fact, along with persistently high rates of smoking in women, a gradual increase in average body weight and the lack of physical exercise, make imperative the need for more effective prevention and more appropriate treatment for all of the factors predisposing to the development of coronary heart disease.
How is the coronary heart disease manifested in women?
It is noteworthy that the women with coronary artery disease manifest it a decade later than men and usually the first manifestation involves angina unlike men in who it myocardial infarction. The symptoms are similar to those of men (chest pain or shortness of breath during fatigue in the event of angina, or intense pre-cardiac pain or feeling of a weight in the chest in case of acute myocardial infarction with or without a reflection on the neck, the back or the hand).
However, it must be emphasized that there is a significant proportion of women manifesting coronary artery disease different from classical symptomatology (feeling weak or gastrointestinal disturbances) and that's why it is imperative for high suspicion levels both on the part of the woman with the symptoms and of the doctor.
To all this we must add the fact that unfortunately and often enough, the first manifestation of coronary artery disease is sudden death. This fist dramatic manifestation of coronary heart disease, with its major socio-economic implications, occurs to relatively young women, with no previous history of symptoms and constitutes 2/3 of all sudden deaths in women, making it even more imperative the need to prevent it.
Risk factors and prevention of coronary artery disease in women (Table 1)
Classic risk factors include hypertension, increased cholesterol, smoking, the presence of diabetes and a family history coronary heart disease. The desired level for "bad" cholesterol (LDL) varies depending on the presence of other risk factors and especially diabetes mellitus, in which case it should be below 100 mg / dl. In most other cases, the upper level of LDL should not exceed 130-160 mg / dl.
Diabetes is probably the strongest risk factor and increases the risk of developing coronary heart disease 5 times compared with women without diabetes. The American Cardiological Society considers the presence of diabetes is equivalent to the presence of coronary heart disease. For this reason it recommends for women with diabetes to carefully adjust sugar as well as properly tackle with all the others risk factors, in particular to quit smoking, fight high cholesterol and regulate the blood pressure levels to 120/80 (systolic / diastolic).
In terms of smoking, it should be noted, that even the minimum quantity (less than 5 cigarettes a day) day) significantly increases the risk for coronary heart disease. Simultaneous administration of hormones formulations after menopause in smoking women multiplies the risk of myocardial infarction.
Finally, daily exercise and the adjustment of body weight they are probably the most important and effective ways of preventing coronary heart disease. In addition, healthy eating in combination with exercise has been shown to greatly reduce the risk factors (hypertension, diabetes mellitus, hypercholesterolemia) as well as the development of coronary heart disease itself.
Estrogens and coronary heart disease
Older epidemiological studies had originally supported the protective cardiovascular action of combined use of hormonal preparations (estrogen and progesterone) in women after menopause.
All previous ones were based on the theoretical knowledge that women are relatively protected against males during their reproduction age. But newer scientifically data proved beyond any doubt that the use of hormonal preparations after menopause to prevent cardiovascular disease does not provide any essential effect and possibly increases the risk for cardiovascular symptoms. Thus, the use of hormonal preparations to prevent coronary heart disease in women after menopause is not indicated.
How is coronary heart disease diagnosed in women?
The simple stress test is, in most cases, the initial test for the detection of coronary heart disease, in case of presence of symptoms. An examination with stress test in women without the symptoms reported is only recommended for a small category with increased total risk (e.g. women with diabetes and additional risk factors). A negative stress test after maximum exercise is especially important since it indicates a very low probability of extensive coronary heart disease. The positive stress test is usually accompanied with further investigation through stress test with radioisotopes or dynamic ultrasound with dobutamine (stress echo) or finally with coronary angiography for the final diagnosis. All imaging methods that do not invade the myocardium can very well be applied to women with excellent results and to guide the treating physician further (no coronary disease indication or treatment with medicines or recommendation for treatment of coronary artery disease).
Lately, computed tomography (CT) coronary angiography has also been developed, a one a bloodless method of detecting coronary heart disease. It is recommended for women with low probability of coronary heart disease presence, mainly for excluding it, but it must be accompanied by protocols of low radiation because of the breast. Such protocols have been implemented with great success both safety- and imaging-wise at Athens Medical Center.
The role of angioplasty and by-pass surgery in women with coronary disease
The interventional treatment for coronary disease in women has advanced a lot in the last ten years. It involves two parts: Dealing with symptoms of chronic angina and the emergency opening of the artery that is responsible for unstable angina or acute myocardial infraction. In both cases the invasive and clinical outcomes are comparable to the results in men. Many clinical studies have proven that, when carried out in well equipped centers from specialized doctors, angioplasty shows better results from treatment with drugs both in cases of unstable angina as well as of acute myocardial infarction.
In case the patient suffers from advanced coronary heart disease, then usually the most appropriate form of treatment is the by-pass surgery. All invasive and surgical techniques are applied with excellent success at the Athens Medical Center both on an emergency and on a fixed basis.
What modern women should be aware of
Coronary heart disease is not exclusively a men's disease. On the contrary, it is the greatest risk and the first cause of death in women today. Prevention of coronary artery disease with restriction and combating of all factors that increase the risk of development is the most essential part in the fight against it among women. Overall, the diagnostic and invasive techniques can offer a lot in the case of clinical manifestations. However, effective prevention remains the angular stone to improving the public health of women.
Table 1: American Society of Cardiology guidelines for the prevention of coronary heart disease in women