Cardiovascular Disease in

Women: Common Myths

Jon W. Wahrenberger, MD FAHA

February 7, 2009
 Disclosures

I have no financial interests to disclose I wish I did!

I do not specialize in womens health issues, but about
half of my patients are female.
I cannot rule out the influence of my Y-chromosome
As an only son and with 4 sisters I am expected to be
sensitive to womens issues
.but at any given time at least one of my sisters is
annoyed with me about something.
Are women more complicated than men?
Hormones in Men vs. Women
 Myth 1

CARDIOVASCULAR
DISEASE IS MAINLY A
DISEASE OF OLD MEN
More women are dying of CVD than Men

Source: American Heart Association

Cardiovascular disease is the leading cause of
death in women

Source: American Heart Association

Although less frequent, CVD occurs in young
women

More than35,000
women under the age
of 65 die annually in
the US from CVD
 Myth 2:

WOMEN DONT NEED

TO WORRY ABOUT
CARDIOVASCULAR
DISEASE BEFORE
MENOPAUSE
 Relationship between early menopause and
accelerated CVD?

Traditional Paradigm:
Menopause

Minimal or no CVD Risk Increasing Risk of CVD

Alternative Paradigm:

Increasing Risk of CVD

Menopause
Coronary heart disease progresses over decades

Decades of time

The reality: Being premenopausal probably does not

protect you from cardiovascular disease
Smoking, High and you
Blood Pressure,
Age, Heredity Elevated Cholesterol, Diabetes,
should be vigilant atInactivity,
all agesObesity

 Myth 3:

HORMONE
REPLACEMENT
THERAPY IS
DANGEROUS TO THE
HEART AND SHOULD
NOT BE TAKEN UNDER
ANY CIRCUMSTANCES
 Estrogen
Critical to reproductive
function in men &
women
Most produced by
ovaries
Some arises from fat,
liver, breasts, adrenals
Complex physiologic
effects
 Changing Estrogen Levels with Age

Estrogen Progesterone
Perimenopausal Symptoms: hot flashes, insomnia, mood changes
Menopausal Physiology: osteoporosis, vaginal mucosal thinning
The Good and Bad of Estrogen Replacement

The Good The Bad

Relief of menopausal Breast cancer risk

symptoms Uterine cancer risk
Reduction in
Complex formulation
osteoporosis (bone
thinning) and fractures
Cardio-protective
effects??
Improvement in lipid
profile
 Womens Health Initiative

Estrogen +
16,608 Post- Progesterone
Study stopped
menopausal after mean follow-
women aged 50-79 up of 5.6 years
with an intact
uterus Placebo

Hormonal replacement associated with:

Increased heart disease (29% ) Conclusion: HRT
Increased stroke (41% ) should not be used to
Increased blood clots prevent disease in
Increased breast cancer (26% ) healthy post-
Reduced colon cancer
Reduced hip fracture menopausal women
 WHS: Caveats

Overall mortality was identical in the two groups

Event rates in both groups was low and absolute
rates in the estrogen + progesterone group was low -
overall risk of treatment is low
Estrogen vs. progesterone influence on outcomes is
unknown
Womens Health Initiative: Estrogen Only Study

10,739 Post- Estrogen Only

menopausal Study stopped after
women aged 50-79 mean follow-up of 6.8
with previous years

hysterectomy Placebo

Estrogen replacement associated with:

9% reduction in heart disease
39% increase stroke
33% increase blood clots
No change in cancer
39% reduction hip fracture
Womens Health Initiative: Estrogen Only Study

Age Group Risk of Coronary Risk of Stroke

Heart Disease
50-59 37% reduction 11% reduction
60-69 6% reduction 62% increase
70-69 13% increase 21% increase
Overall 9% reduction 39% increase

Source: JAMA 2007;297:1477

Conclusion: In younger post-menopausal women

post hysterectomy, estrogen alone may be beneficial
 Oral versus Transdermal Estrogen

Oral Estrogen Transdermal Estrogen

Large impact on liver Bypasses liver

metabolism No change in
Increase in Inflammatory markers
inflammatory markers Reduction in LDL
Increase in protective Improvement in
HDL cholesterol atherogenic index of
plasma
Reduction in oxidation
index
 Estrogen Replacement: The reality

Estrogen therapy is reasonable for the relief of

perimenopausal symptoms if started early and
tapered after a few years
Estrogen administered transdermally may be less
likely to increase risk of blot clots
Estrogen should not be given to reduce CVD risk
 Myth 4:

VITAMIN SUPPLEMENTATION
IS KEY TO PREVENTING
CARDIOVASCULAR DISEASE IN
WOMEN.
 Vitamin E 636 Deaths
39,876 600 IU
healthy
women age ~ 10 years
45
Placebo 615 Deaths

Source: JAMA. 2005;294(1):56-65

 B-Vitamins & Health in Women

Folic Acid
Vit. B6 406 Events
5442 woman
Vit B12
with CAD or
3 risk ~ 7 years
factors
Placebo 390 Events

Source: JAMA. 2008;299(17):2027-2036

 The Reality:

Vitamin E and B vitamins are probably safe, but there is

no convincing evidence that they need be taken
regularly
Some supplements (ephedra) are downright dangerous
Many supplements interact with medications
The entire supplement industry is unregulated; the
safety and purity is entirely in the hands of the
manufacturer.
 Myth 5:

IF IM THIN AND
EXERCISE
REGULARLY I
SHOULD BE IMMUNE
TO CARDIOVASCULAR
DISEASE.
 The Reality:

Inactivity and obesity are just two of many CVD risk

factors, and probably not the strongest
Exercise is great but not necessarily enough!
 Cardiac Risk Factors

Non-Modifiable Modifiable

Age Tobacco Use

Gender Cholesterol
Heredity Blood pressure
Diabetes
Physical inactivity
Overweight condition
 Myth 6:

EGGS ARE
UNHEALTHY AND
SHOULD NOT BE
EATEN.
 The Facts

Egg yolks do contain cholesterol

Studies have shown a clear relationship between
serum cholesterol and cardiovascular disease
outcomes
Studies have not shown a relationship between egg
consumption and health outcomes
 Whats in an Egg?

213 mg 0 mg
Cholesterol Cholesterol

One Medium Daily Allowance Daily Allowance

Egg if high risk

213 300 200

OK to eat an egg if consistent with overall daily

cholesterol limits
 Myth 7:

MOST WOMEN DO NOT

EXPERIENCE CHEST PAIN
DURING A HEART ATTACK
FATIGUE AND SHORTNESS
OF BREATH ARE MUCH
MORE COMMON.
 The Facts

Chest discomfort is the most

common symptom of a heart attack
in both men and women
Women are more likely than men
to have additional non-specific
symptoms, including:
Fatigue
Shortness of breath
Weakness

Devon, et al. Amer J Critical Care 2008:17(1): 14-24

 The Facts

Devon, et al. Amer J Critical Care 2008:17(1): 14-24

 The Facts

Location of Chest Pain

Location Women (%) Men (%)
Central Chest 75 81
Left chest 57 56
Left arm 40 42
Neck* 37 22
Right chest 37 34
Upper back 34 26
Jaw* 24 12

*Indicates statistically significant difference

Devon, et al. Amer J Critical Care 2008:17(1): 14-24

 The Facts

Quality of Chest Pain

Location Women (%) Men (%)

Pressure 77 74
Tightness 66 72
Heaviness 58 57
Dull 45 43
Sharp 40 44

No differences were statistically significant

Devon, et al. Amer J Critical Care 2008:17(1): 14-24

 The Facts

Men and women present relatively similarly with

heart attack
For both genders the important point is not to ignore
symptoms of a potentially life-threatening condition
 Myth 8

CHOCOLATE
IS SINFULLY
BAD AND
SHOULD BE
EATEN ONLY
RARELY

This could be true, but there is some preliminary data to suggest dark
chocolate may be beneficial!
 Beneficial Effects of Dark Chocolate

Raises protective HDL

Improves insulin sensitivity Clinically
Lowers blood pressure Relevant?
Improves endothelial function
 Recommended Dose

Rx Go Red Luncheon Attendee

Dark chocolate, 100 gm

Directions: 1 bar daily
Dispense 30 day supply

Jon W. Wahrenberger, MD
Myth 9

EXERCISE IS
BENEFICIAL
ONLY IF
PROLONGED
(NO PAIN/NO
GAIN)
 Exercise: the facts

There is a dose-response relationship (more is

better)
Strenuous exercise is probably better than less
strenuous exercise
Several studies have shown that repeated
intermittent periods of exercise have a cumulative
effect similar to prolonged exercise
 Summary

Dont believe everything you hear

Work on traditional risk factors throughout your life
Eggs are OK . in moderation as is dark chocolate
Ovarian hormone therapy is OK in the young women
with premature or surgical menopause taper in
early 50s some data suggest transdermal best
A balanced diet is probably far more helpful than
vitamins and supplements
Exercise is beneficial almost any way you do it!
Questions?