Cardiovascular Disease in Women and Vulnerable Populations

Geriatric Population

CVD can occur at any age, but the absolute risk increases incrementally as the population ages and is greatest in the population of patients older than the age of 65 years. This portion of the population is increasing because the baby boomers are entering the older than 65 years population. According to the Population Reference Bureau, in early 2016, the number of Americans aged 65 years and older is projected to more than double from 46 million today to >98 million by 2060, and those in the population who are aged 65 years and older will rise to nearly 24% from 15%. In addition, the older population is becoming more racially and ethnically diverse. Between 2014 and 2060, the share of the older population that is non-Hispanic white is projected to drop by 24%, from 78.3% to 54.6%. This group, which has a higher prevalence of CVD, will further increase the demand on the healthcare system, which underscores the importance of treatment strategies for older adults ( Fig. 72.1, top ).

Clinically, coronary heart disease (CHD) in older adults and/or geriatric patients often presents in an atypical manner. The initial presentation may be dyspnea on exertion, decreased exercise tolerance, fatigue, or heart failure. The patient may also have no symptoms. Because the symptoms are atypical or there are no symptoms, this often delays diagnosis and treatment. This delay, combined with an increase in comorbidities and the underuse of proven beneficial therapies (pharmacological and interventional), contributes to increased rates of morbidity and mortality among older adult patients with post–myocardial infarction (MI). The increased incidence of comorbid conditions contributes to polypharmacy in older adult patients—with the attendant risk of adverse effects—and prevents the addition of medications that would probably lower cardiac risk.

Despite the need for multiple medical therapies, risk factor modification in older adult patients translates into decreased cardiovascular events. Elevated low-density lipoprotein cholesterol (LDL-C) has an important role in the pathogenesis and lifelong risk of CHD, and demonstration that reduction of LDL-C levels decreases risk of cardiovascular events has been found in the older adult/geriatric population. Studies that are more recent have included patients aged older than 65 years and even those aged older than 80 years, and thus recommendations are changing. The decision whether to treat high or high-normal lipids in an older adult individual needs to be individualized and based upon both chronological and physiological age. A patient with a limited life span due to severe comorbid illness is probably not a candidate for drug therapy, whereas an otherwise healthy older adult individual should not be denied drug therapy simply based on age. Preventive therapies (pharmacological and nonpharmacological) in older adult individuals may decrease cardiovascular events even more dramatically than in younger patients, probably because of the increased risk and incidence of CVD in older adult individuals. Age should not exclude patients from treatment for lowering of LDL-C, especially as a therapeutic strategy for secondary prevention, but there is not a large amount of data in patients aged older than 80 years. In primary prevention, the treatment of elevated LDL-C is more controversial. There are benefits of preventive treatment in this population that are substantiated by several smaller trials and by the Heart Protection Study, which included patients up to the age of 80 years. The recommendations from the Adult Treatment Panel III (ATP III) emphasize therapeutic lifestyle changes as an important component of therapy to reduce LDL-C and do not rule out statin therapy.

Hypertension is a common problem in older adults (age older than 60–65 years with a prevalence as high as 60%–80%). In the participants in the National Health and Nutrition Examination Survey, hypertension was observed in 67% of adults aged 60 years or older. Newer guidelines from the Joint National Commission on Blood Pressure suggests target blood pressures based on underlying disease and age. For an older adult with hypertension only, a goal of <150/90 mm Hg is reasonable. Hypertension is a major risk factor for stroke, heart failure, and CHD. Although hypertension was once considered part of normal aging, the benefit of treating older adult patients with elevated systolic and/or diastolic blood pressure is clear. Treatment of isolated systolic hypertension can provide a 30% reduction in the combined fatal and nonfatal stroke rate, a 26% reduction in the rates of fatal and nonfatal cardiovascular events, and a 13% reduction in the total mortality rate.

Women

CVD is the leading cause of death in men and women. In women, CVD and stroke cause one in three deaths in women each year, killing approximately one woman every 80 seconds. In 1984, the number of deaths for women exceeded that for men, but most recent numbers show the incidence is about the same, but more women die from their disease. In 2013, CHD was responsible for the deaths of 289,758 women in the United States, which is approximately one in every four female deaths, with an estimated 44 million women in the United States affected by CVD.

Ethnicity also plays a part in the chance of women developing heart disease. Heart disease is the leading cause of death for African American and white women in the United States, and among Hispanic women, heart disease and cancer cause roughly the same number of deaths each year. In Native American, Alaska Native, Asian, or Pacific Islander women, heart disease is second only to cancer as a cause of death. In the most recent Centers for Disease Control and Prevention data (CDC), approximately 5.8% of all white women, 7.6% of black women, and 5.6% of Mexican American women have CHD (a form of CVD). In this CDC data, it is noted that almost two-thirds (64%) of women who die suddenly from CHD events have no previous symptoms.

Despite increases in awareness over the past decade, only 54% of women recognize that heart disease is their number one killer. Women will still answer “cancer” as the response to the question “what do you think you will die from?” Educating women on their risks, signs, and symptoms of heart disease and available treatments is the number one tool in reducing deaths from heart disease. In addition to receiving information on disease prevalence, women must be taught that CHD and/or CVD symptoms can differ from symptoms that men commonly report. Women often have dyspnea on exertion, heartburn, fatigue, decreased exercise tolerance, or back pain as their presenting symptom, or the anginal equivalent. When questioning women further, they may also describe some subtle typical symptoms with these atypical symptoms. However, the presence of somewhat vague or confusing symptoms often contributes to the delayed or missed diagnoses of CHD ( Fig. 72.1 , bottom).

Most CHD risk factors and strategies for preventing disease applicable to men also apply to women. Risk factors beyond the typical risk factors that frequently occur in women include an isolation postmenopausal state, depression, and lower socioeconomic status. The magnitude of the effects of these typical and atypical risk factors and prevention strategies may be different. For example, diabetes is an even more powerful risk factor for CHD in women ( Fig. 72.2 ). It is associated with a three- to sevenfold increase in the frequency of CHD development, and a diabetic woman is twice as likely to have a recurrent MI compared with a man with equal risk factors.

Smoking is also a stronger risk factor for MI in women than in men. The incidence of MI is increased sixfold in women and threefold in men who smoke at least 1 pack per day (20 cigarettes) compared with individuals who never smoked. In the worldwide INTERHEART study of patients from 52 countries, smoking accounted for 36% of the population-attributable risk of a first MI. In another systematic review and meta-analysis of 75 cohorts that evaluated the risks of smoking on CHD and adjusted for the effects of other known CHD risk factors (>2.4 million persons with >44,000 CHD events), female smokers were 25% more likely than male smokers to develop CHD.

Smoking in women is a concern because smoking rates are declining at a slower rate among women than among men.

Hypertension is more prevalent in men up until the age of 45 years. From age 45 to 54 years, the incidence of hypertension for men and women is similar. After the age of 54 years, a significantly higher percentage of women have high blood pressure. Because this is a modifiable risk factor, education of women about the dangers of hypertension and intensive screening becomes important.

Dyslipidemias, especially elevated triglycerides and low high-density lipoprotein cholesterol (HDL-C), are more commonly seen with CHD in women and are most commonly seen in postmenopausal women. Low HDL-C in postmenopausal women is a potent risk factor for CHD events. Strategies to reduce LDL-C with statins provide at least an equivalent reduction in risk in women compared with men. In some studies, the risk of primary or secondary cardiovascular events was more favorably influenced by statin therapy in women than in men. Menopause, with its associated estrogen loss and effect on the lipid profile, presents a challenge. Hormone replacement therapy (HRT) and estrogen replacement therapy recommendations have evolved over the past 30 to 40 years. Historically, a cardioprotective effect of HRT in women was inferred, based largely on observational data and regardless of the CVD status of the woman. However, no benefit in the rates of nonfatal MI or death from CHD in women with known heart disease receiving combined HRT was found in the largest randomized clinical trial conducted. An increase in CHD events was observed during the first year of HRT use in that trial. A large-scale trial that investigated the primary prevention benefits of combined HRT was stopped early, principally because of the risk of associated invasive breast cancer. However, a significant increase in cardiovascular events was also observed. Taken together, clinical trials do not support the use of combined HRT in primary or secondary prevention of cardiovascular events. The American Heart Association released a statement for healthcare professionals recommending that HRT not be initiated for prevention of heart attack or stroke in women with CVD, which was reemphasized in their 2011 guidelines for treatment of women. Prediction of 10-year mortality by the ATP III guidelines has been advanced by the Reynolds Risk Score. This model includes variables such as diabetes mellitus, family history, and high-sensitivity C-reactive protein, an inflammatory marker. The Reynolds risk predictor can be adjusted for age with predictions for CVD at current age as well as 10, 20, or 30 years into the future, providing a projection of how treatment of certain risk factors might improve risk.

The updated 2011 American Heart Association/American College of Cardiology guidelines for prevention of CVD in women continue to recommend a heart healthy diet (increased fresh fruits and vegetables), increased activity (30 minutes a day to maintain weight and 60–90 minutes to lose weight), eating oily fish in their diet at least twice a week or using fish oil supplements, and the use of aspirin routinely in women aged older than 65 years and earlier in those at high risk.