Heart disease is different for women and men

Most women believe that their greatest health risk comes from breast cancer but in fact, the number one killer in women is cardiovascular disease: women are three times more likely to die from cardiovascular disease than breast cancer. More women die from heart disease than men: heart and circulatory disease kills more than 82,000 women in the UK each year compared with 79,000 men. Compared to men, women also tend to be under-diagnosed, under-treated and less likely to participate in cardiac rehab than men.

For women, there does seem to be a link between menopause and cardiovascular disease. Before the menopause women have a  lower heart attack risk than men, and the risk only becomes equivalent to men’s risk years after the menopause. Oestrogen promotes better cholesterol profiles as well as having other cardioprotective metabolic effects.

This is why following the Women’s Health Initiative which showed adverse outcomes of hormone replacement therapy (now thought to be due to high doses of HRT given to an elderly population with more comorbidities than the average menopausal woman),  a 2012 Danish study and a 2013 study from Yale have gone the other way to ask how many women have died prematurely from heart disease by NOT taking hormone replacement therapy! [1]

The symptoms of heart attacks in women are different and so it seems might be the pathology: men more often suffer from plaque build-up in the large arteries around the heart, whilst in women the arteries are more frequently clear of plaque,  and one problem might be that the vessels go into spasm, creating the lack of blood flow and oxygen to the heart. In women, heart disease symptoms can be quite vague and nonspecific. Traditional symptoms are chest pain or pressure, shortness of breath, sweating, nausea and pain in the arm or neck. Women may experience these traditional symptoms but may also present with atypical symptoms such as a feeling of dread, flu-like symptoms, fatigue, anxiety or pain in the back.

Are statins as beneficial for women as for men?

There are no clinical trials of statin use in women alone  – we desperately need this – but sex-specific outcomes have been analysed as sub-groups in existing trials. For men, trials show that cholesterol-lowering drugs reduce the risk of cardiovascular disease events both in primary prevention (i.e. they benefit men who don’t yet have established cardiovascular disease) and secondary prevention (i.e. they benefit men who do have established cardiovascular disease). For women, cholesterol-lowering drugs reduce the risk of cardiovascular disease events in secondary prevention (i.e. in women with established cardiovascular disease) but we don’t yet have the evidence that statins work in primary prevention for women (i.e. reducing the risk of cardiovascular disease events in women without cardiovascular disease). This has been discussed in BMJ features such as: Should women be offered cholesterol-lowering drugs to prevent cardiovascular disease? which gives “Yes” and “No” sides of the argument.

Currently, women have prescribed statins for primary prevention but women may be more likely than men to suffer side effects of statins. For example, statin medication use in postmenopausal women is associated with a significantly increased risk of type 2 diabetes[2].

So where to go from here?

1) Diet:

When it comes to diet, the good news is that there IS consensus about what to eat for your heart, and here it is:

Eating cholesterol-containing foods such as eggs doesn’t negatively impact cholesterol [3]; lean meat or game aren’t banned and seafood is positively beneficial; fats in the form of olive oil or nuts are promoted.  Buttermilk and greek yoghurt fall into the ‘eat in moderation’ category. Fibre such as vegetables and beans and fruits should still be high on the list of most of what you’re eating.

A meta-analysis of 21 large observational studies looking at saturated fat consumption found no association between saturated fat in the diet and subsequent heart disease or stroke.[4] But that doesn’t mean you can eat lots of bacon, sausages, pork pies and desserts – processed foods, and trans-fats have to be avoided, and moderation of fat intake would still seem sensible.  The point is not that huge amounts of fat is fine, the point is that our historical attempts to replace fats in the diets with what have turned out to be more inflammatory refined carbs (pasta, bread sugar) was not a good idea – in fact  is likely responsible for our current obesity and diabetes epidemic. Low carb diets which tend to be higher in saturated fats have been associated with weight loss, improved insulin sensitivity, weight loss, lower blood pressure and lower fasting glucose.[5] This statement is not meant to demonise carbs, but it does recognise that, just as there are different types of saturated fats, there are different types of carbs – and heavily refined carbs should be avoided as they contribute to inflammation.

2) Engage with a healthcare provider. Too many women don’t know their cholesterol, fasting glucose, inflammatory markers or blood pressure! Understand your risk factors and modify them through diet, exercise and, if necessary, treatment of other conditions such as hypertension, diabetes, hyperlipidaemia and hypothyroidism.

 

[1] The Mortality Toll of Estrogen Avoidance: An Analysis of Excess Deaths Among Hysterectomized Women Aged 50 to 59 Years

[2] Statin Use and Risk of Diabetes Mellitus in Postmenopausal Women in the Women’s Health Initiative

[3] Dietary cholesterol and coronary artery disease: a systematic review

[4] Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease

[5] Systematic review of clinical trials of the effect of low carbohydrate diets on cardiovascular risk factors

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