Women and Cardiovascular Disease: Risk Assessment
Cardiovascular disease (CVD) is the leading cause of death in women.1,2 However, women are much less likely than men to be assessed for CVD risk based on guidelines and many risk factors that are unique to women may be overlooked.1,3-5 Notably, less than half of all primary care physicians consider CVD a top concern for women after breast health and weight.1
This article discusses CVD, traditional risk factors, risk-enhancing factors, and guideline recommendations for assessing CVD risk in women.
Epidemiology of CVD in women
In 2019, about 1 of every 5 deaths in women were due to CVD.2 The population-adjusted risk mortality from CVD was estimated at 21% for women compared to 15% for men.3 Notably, 90% of women have at least 1 risk factor for atherosclerotic CVD (ASCVD).3
Overall, about 6% of women age 20 and older have coronary heart disease (CHD).6 The prevalence of CHD varies with race/ethnicity, being higher in White, Black, and Hispanic women (about 6% overall) than Asian women (3%).6 In the United States, heart disease is the leading cause of death for Black and White women; equal leading cause of death (with cancer) for American Indian and Alaskan Native women; and second leading cause of death (after cancer) for Hispanic and Asian or Pacific Islander women.6
Despite increased awareness over the past decades, only about half (56%) of women realize that the number 1 cause of death in most women is heart disease.6
Traditional CVD risk factors in women
Women and men share traditional risk factors for CVD, with the 3 most common risk factors being hypertension, high low-density lipoprotein-cholesterol (LDL-C), and smoking.6-8 Approximately half of all people in the United States have at least 1 of these 3 risk factors.6 Insulin resistance is a risk factor for CVD, and other risk factors common to women and men related to insulin resistance include6-9
- Being overweight or obese
- Eating an unhealthy diet
- Physical inactivity
- Excess alcohol consumption
Although traditional risk factors are common to women and men, their effects and symptoms (eg, myocardial infarction, MI) differ between sexes (see Sidebar).1
CVD risk-enhancing factors for women
The 2018 American Heart Association (AHA)/American College of Cardiology (ACC)-Multi-Society Cholesterol guideline and 2019 ACC/AHA Primary Prevention of CVD guideline introduced the concept of “risk-enhancing factors” that are specific to women (see below).7,13 Risk-enhancing factors are associated with an increased risk of ASCVD beyond the traditional risk factors. If present, these factors indicate that increased risk should be mitigated through more intensive lifestyle interventions or statin therapy for primary prevention.7,13-15
Several categories of risk-enhancing factors are shared by women and men,16 although, autoimmune disease predominantly affects women (see below).4
In addition, adverse pregnancy outcomes occur in 10% to 20% of all pregnancies and are associated with a 1.8- to 4.0-fold risk of future CVD.17 The American College of Obstetricians and Gynecologists (ACOG) recommends that women with an adverse pregnancy outcome (see below) and/or cardiovascular risk factors undergo cardiovascular risk screening within 3 months postpartum.17
Examples of CVD-risk enhancing factors specific to women, shared between men and women, and related to pregnancy are given below.
CVD risk-enhancing factors specific to women include
- Polycystic ovarian syndrome (PCOS)14
- Higher prevalence of hypertension, central adiposity, insulin resistance, dyslipidemia, and metabolic syndrome—all of which increase the risk of CVD.
- Higher body-mass indices, waist circumferences, blood pressure, glucose levels, and hyperlipidemia at the time of PCOS diagnosis are associated with greater CVD risk.
- Premature menopause/ovarian failure (menopause or loss of ovarian function prior to 40 or 45 years old [average age for menopause onset is 51 years])14
- Menopause at an age younger than 45 years (compared to ≥45 years): 1.5-fold increased risk of CHD.
- Premature ovarian failure: 1.6-fold increased risk of CVD, 1.7-fold increased risk of CVD mortality.
- Premature menarche (≤10 years of age): 1.3-fold increased risk of CHD.14
- Late menarche (≥17 years of age): 1.2-fold increased risk of CHD.14
- Hormone-based contraceptive methods14
- Can affect the lipid profile and thereby CVD risk (eg, estrogen-based contraceptives typically elevate triglycerides and should be used with caution in women with elevated triglycerides, and contraceptives with androgenic components such as norgestrel may elevate LDL-C and decrease HDL-C levels).
- Breast cancer history and associated treatments14
- Shared risk factors between cancer and CVD include smoking, obesity, and hypertension.
- Radiation to the left breast is associated with an increased risk of CHD.
- Chemotherapeutic agents such as anthracyclines and trastuzumab increase the risk of cardiomyopathy and heart failure (HF).
- Recurrent miscarriages14
- Two miscarriages: 1.7-fold increased risk of CHD.
- Three or more miscarriages: 3.2-fold increased risk of CHD.
CVD risk-enhancing factors shared by women and men include
- Race and genetics (eg, family history of premature ASCVD)16
- Lipid-related (eg, primary hypercholesterolemia)16
- High-risk medical conditions (eg, metabolic syndrome, insulin resistance)16
- Biomarkers (eg, elevated lipoprotein(a) level)16
- Autoimmune/systemic inflammatory diseases4
- Disproportionally affect women (female:male ratio, rheumatoid arthritis 2.5:1; systemic lupus erythematosus 9:1).
- Associated with increased CVD morbidity and mortality—rheumatoid arthritis is associated with an approximately 50% increased risk of cardiovascular events and death.
CVD risk-enhancing factors related to pregnancy include
- Pre-eclampsia: 4-fold increased risk of HF; 2-fold increased risk of CHD14
- Hypertensive disorders of pregnancy (gestational hypertension): 2.2-fold increased risk of CVD; 5.6-fold increased risk of hypertension14
- Gestational diabetes: 8-fold increased risk of developing type 2 diabetes mellitus; 2-fold increased risk of future cardiovascular events14
- Preterm delivery (birth of a baby at <37 weeks gestational age): 1.4-fold increased risk of CVD; overall increased risk of developing chronic hypertension, diabetes, and hypercholesterolemia14
Interestingly, lactation is a CVD risk-reducing factor.14 Breastfeeding is thought to aid in reversing the metabolic changes of insulin resistance, dyslipidemia, and accumulation of fat mass that take place during pregnancy.
Guideline recommendations for assessing CVD risk in women
For both men and women, the 2019 ACC/AHA Guideline on the Primary Prevention of CVD and the 2018 AHA/ACC/Multi-Society Cholesterol Guidelines recommend consideration of risk-enhancing factors for individuals who are at borderline- and intermediate-risk, after estimating their 10-year atherosclerotic cardiovascular disease (ASCVD) risk.7,13 The presence of ≥1 risk-enhancing factor may indicate a higher risk category and favor initiation or intensification of statin therapy.13,16 Risk-enhancing factors should be integrated with other information and patient preferences to inform clinical decision making; guidelines recommend that patients should be informed of their personal ASCVD risk and risk-enhancing factors before discussing therapeutic options.16 Lifetime risk can be assessed for individuals 20 to 59 years of age. Persons with a low 10-year risk but high lifetime risk may be treated with aggressive lifestyle modifications, as recommended by the 2018 AHA/ACC Multi-society cholesterol management guideline and the 2019 ACC/AHA Prevention of CVD guideline.13
Women who have a pregnancy or nonpregnancy CVD risk factor (eg, patients with gestational hypertension) should receive closer monitoring for hypertension after pregnancy.14
Guidelines for assessing CVD risk in men are similar to those for women but also take into account risk-enhancing factors unique to men (eg, erectile dysfunction, low testosterone level).