Coronary Artery Disease Prevention: What’s Different for Women?

Coronary Artery Disease Prevention: What’s Different for Women?

Joan Bedinghaus

Cardiovascular disease is the leading cause of death in women, as well as an important cause of disability, although many women and their physicians underestimate the risk. Exercise, hypertension treatment, smoking cessation and aspirin therapy are effective measures for the primary prevention of coronary artery disease in women. The roles of lipid-lowering agents and hormone replacement therapy in primary prevention are not well established. In secondary prevention, hormone replacement therapy has not been effective in lowering the risk of recurrent myocardial infarction, but several lipid-lowering agents have been shown to reduce this risk and to lower mortality rates in women with known coronary artery disease. Other secondary prevention measures, including aspirin, beta blockers, angiotensin-converting enzyme inhibitors, revascularization and rehabilitation, have proven benefits in women but are underused, especially in minority women. Family physicians should emphasize the use of proven treatments, with particular attention given to underserved populations. (Am Fam Physician 2001;63:1393-400,1405-6.)

Coronary artery disease has been widely considered a “man’s disease” and not a major concern for women. Yet cardiovascular disease is the leading cause of death in adult women in the United States. A 1995 Gallup poll found that one in three primary care physicians in this country, as well as four out of five women, was unaware of this fact.(1(p3))

Women’s age-adjusted mortality rates from heart disease are four to six times higher than their mortality rates from breast cancer. Yet, because public campaigns have emphasized breast cancer risks in the effort to promote screening mammography, many women are more afraid of breast cancer than of coronary artery disease.

Over the past two decades, public education efforts related to cardiovascular disease prevention have been aimed primarily at male populations. As a result, the prevalence of coronary risk factors and the number of cardiovascular deaths have decreased in men–but not in women.(1(pp4,6))

Lipid-lowering medications and hormone replacement therapy have raised great hopes for primary prevention of coronary artery disease (i.e., prevention of a first myocardial infarction or the onset of symptomatic coronary artery disease). However, in caring for women, physicians await evidence from randomized, controlled trials to support the effectiveness of these measures, while sorting among conflicting sets of recommendations. In secondary prevention, which includes measures to prevent reinfarction and cardiovascular death, there is good evidence for the effectiveness of many therapies. However, studies indicate that women may not be prescribed beneficial therapies as frequently as men.

This article reviews the characteristics of coronary artery disease, the prevalence and significance of coronary risk factors, and the evidence for the effectiveness of preventive strategies in women. Approaches to targeting preventive efforts to women’s special needs are also addressed.

Characteristics of Coronary Disease in Women

When women present with myocardial infarction, they are more likely than men to be misdiagnosed, and they are also more likely to die of their first infarction(2) (Table 1).(1-9) Chest pain in perimenopausal women is often difficult to diagnose because it may present atypically. Shoulder or neck pain, nausea, fatigue or dyspnea are more likely to signal myocardial infarction in women than in men.(1) Classic substernal pressure symptoms are comparatively less predictive of myocardial infarction in women.(2-4)

Because studies have shown that women with coronary artery disease present with a mix of typical and atypical symptoms, it is important that physicians consider risk factors when evaluating chest pain syndromes in women.(4) An approach that uses risk-factor scoring to guide an appropriate assessment of chest pain in women without known coronary artery disease is presented in Figure 1.(4)

Chest Pain in Women Without Known Coronary Artery Disease

Assign appropriate points for each of the patient’s risk factors.

Add the points to obtain the total score, which guides the diagnostic

strategy.

Risk determinants

Major risk factors (3 points each)

Typical anginal pain ____

Postmenopausal status without hormone replacement therapy ____

Diabetes ____

Peripheral vascular disease ____

Intermediate risk factors (2 points each)

Hypertension ____

Smoking ____

Total cholesterol level [greater than] ____

265 mg per dL (6.85 mmol per L)

Minor risk factors (1 point each)

Patient age [greater than] 65 years ____

Obesity ____

Sedentary lifestyle ____

Family history of coronary artery disease ____

Stress ____

Total score: ____

Diagnostic strategy

[less than Low likelihood of coronary artery disease

or equal]2 ([less than] 20%): no tests indicated

points

3 or 4 Moderate likelihood of coronary artery disease (20% to 80%):

points exercise tolerance test or imaging study

[greater than Strong likelihood of coronary artery disease

or equal]5 ([greater than] 80%): exercise tolerance test, with

points cardiac catheterization performed if test is

inconclusive or positive

FIGURE 1. Approach to the assessment of chest pain in women not known to

have coronary artery disease.

Information from Douglas PS, Ginsburg GS. The evaluation of chest pain in

women. N Engl J Med 1996;334:1311-5.

Coronary risk factors are more prevalent in women who are older, poor, African American, Hispanic or Native American. Primary and secondary prevention in these underserved populations requires particular attention to the context of these women’s lives. There is evidence that several preventive measures can reduce the risk of coronary disease (Table 2).(10-17)

PHYSICAL INACTIVITY, OBESITY AND DIABETES

Sedentary lifestyle is the most common risk factor for coronary artery disease in women. Data from the National Center for Health Statistics indicate that 39 percent of white women and 57 percent of women of color do not get enough physical exercise.(18) Rates of physical inactivity are highest among poor women.

Physical inactivity contributes to obesity and is an independent risk factor for myocardial infarction.(13) Conversely, modest exercise has been strongly associated with risk reduction in observational studies. Investigators in the Nurses’ Health Study(19) found that 30 to 45 minutes of walking three times weekly reduces the risk of myocardial infarction by 50 percent in women (even older women). Exercise has also been found to reduce the risk of type 2 diabetes (formerly known as non-insulin-dependent diabetes, and also a risk factor for coronary artery disease), even in women with obesity and a family history of diabetes.(20)

Obesity is an independent risk factor for all-cause mortality. It is highly associated with diabetes, hyperlipidemia and hypertension.(21) According to the National Center for Health Statistics,(18) 33 percent of African American women and 17 percent of white women are obese (i.e., body mass index [BMI] greater than 30). The risk of cardiovascular disease becomes higher with increasing weight, even at lower BMIs. Central obesity (a waist-to-hip ratio greater than 0.8) is associated with a disproportionate increase in coronary risk. The most effective treatment for obesity in women has not been determined, and exercise appears to be less effective in promoting weight loss in women than in men.(22)

Obesity is also a major risk factor for the development of type 2 diabetes, which is the most important risk factor for coronary disease in women. Coronary artery disease generally presents at an older age in women than in men, but diabetes wipes out this gender-protective effect. Furthermore, coronary disease is more likely to be fatal in women with diabetes.(5) Native Americans and African Americans have higher rates of diabetes and its cardiovascular sequelae.

Although there is a dose-response relationship between the level of hyperglycemia and the incidence of coronary artery disease, studies have not clearly shown that tight control of type 2 diabetes reduces the risk of cardiovascular disease. However, secondary prevention trials have found that aggressive control of hypertension and hyperlipidemia does reduce the risk of reinfarction in women with diabetes.(17)

In some patients, central obesity, hypertension, impaired glucose metabolism and hyperlipidemia are clustered in the insulin resistance syndrome, which, in women, also overlaps with the polycystic ovary syndrome.(1(p78)) Both syndromes are associated with increased cardiovascular risk. Drugs that alter insulin resistance, such as metformin (Glucophage) and rosiglitazone (Avandia), may be useful for primary prevention in patients with this pattern of metabolic dysfunction, but their long-term effect on cardiovascular morbidity and mortality is yet to be determined.

Given that inactivity and obesity are major contributors to cardiovascular disease, increased physical activity is clearly important in the primary and secondary prevention of heart disease. Exercise rehabilitation after myocardial infarction increases functional capacity. However, women are less likely than men to be referred for this therapy.(1(p213)) Even when referred, they are less likely to remain enrolled.

Barriers to physical activity in women include lack of leisure time because of household and care-taking responsibilities, comorbid conditions such as arthritis, and lack of appropriate programs and access to facilities. Lack of access is especially severe among low-income women, who have the highest rates of obesity and cardiovascular morbidity and mortality. Even a walking program can be difficult and dangerous in a neighborhood where the streets are not safe.

It is important that physicians encourage the development of accessible, appropriate exercise options for women. For instance, walking clubs provide safety and social support for exercise, and water exercise programs are helpful for patients with arthritis. Cardiac rehabilitation programs should track successful participation of women as a measure of their effectiveness. Taking the longer view, a holistic approach to cardiovascular disease prevention among women includes the promotion of sports and other types of physical activity for girls and young women, perhaps increasing the likelihood of lifelong physical activity.

HYPERTENSION

Fortunately, major trials of hypertension treatment, such as the Hypertension Detection and Follow-up Program (HDFP)10 and the Systolic Hypertension in the Elderly (SHEP)(11) trial, included adequate numbers of African American and white women, and demonstrated the benefits of treatment. Hypertension treatment reduced the incidence of coronary artery disease by 15 percent in HDFP and by 33 percent in SHEP.

Because major long-term trials have demonstrated the efficacy of beta blockers and thiazide diuretics in reducing coronary artery disease and stroke, these agents should be considered as initial therapy in all patients who have not lowered their blood pressure with diet and exercise. Thiazide diuretics have a favorable effect on calcium excretion and, thus, may be especially appropriate for use in women who are at risk for osteoporosis. hyperlipidemia

In women, low-density lipoprotein (LDL) cholesterol and total cholesterol levels increase after the age of 55 years and peak between 55 and 65 years of age, about a decade later than in men. A meta-analysis of pooled observational data demonstrated an increased risk of coronary artery disease in women younger than 65 years who had hyperlipidemia,(7) with a much weaker association in women (and men) older than 65 years.

High triglyceride levels seem to increase the risk of coronary artery disease in women, but this association has been difficult to separate from the effects of obesity and diabetes. Although high lipoprotein(a) levels are associated with an increased risk of cardiovascular disease in men, limited studies in women have found an increased risk only in young women who did not have other coronary risk factors.

Compared with men, women have slightly higher high-density lipoprotein (HDL) cholesterol levels, and these levels tend to remain steady throughout life. Several studies have demonstrated the protective effects of high HDL cholesterol levels, even in patients with high total cholesterol levels. An HDL cholesterol level higher than 60 mg per dL (1.55 mmol per L) is considered a “negative risk factor” (i.e., it offsets one of the other coronary risk factors).

Almost all major trials on primary prevention of coronary artery disease using cholesterol-lowering medications have not included women. The exception is the Air Force/Texas Coronary Atherosclerosis Prevention Study.(23) Although this trial showed a reduction in cardiac events when men and women were analyzed together, careful examination of the data presented on the female patients does not unequivocally demonstrate a benefit in women. The role of lipid-lowering medications in primary prevention is still controversial. However, in secondary prevention in women with known coronary disease, evidence from clinical trials(17) that included women is adequate to support their use.

The cholesterol screening and treatment recommendations summarized in Table 3(6,24,25) reflect differences in the thresholds for evidence of benefit as determined by various expert panels. The National Cholesterol Education Program (NCEP)(6) goes farthest in extrapolating to women the evidence of benefit for cholesterol-lowering medications in men. In contrast, the American College of Physicians (ACP)(25) acknowledges the lack of evidence that treatment of hyperlipidemia in asymptomatic women is effective. The NCEP, ACP and U.S. Preventive Services Task Force(24) all recommend risk factor assessment, prudent diet and exercise.

The natural history of serum lipid levels and the risk of coronary artery disease reflect the influence of female hormones and their decline after menopause. Theoretically, estrogen acts to reduce cardiac risk by, among other mechanisms, dilating coronary arteries, decreasing platelet aggregation and fibrinogen levels, serving as an antioxidant, raising HDL cholesterol levels and lowering LDL cholesterol levels.

HORMONE REPLACEMENT THERAPY

Investigators in observational studies such as the Nurses’ Health Study(26) found decreases in coronary artery disease outcomes among women receiving hormone replacement therapy. However, observational studies suffer from “healthy user” bias: women who are receiving hormone replacement therapy are more likely to be of higher socioeconomic status, to be healthier, to seek medical care and to exercise. These studies were not designed to detect the possible adverse effects of hormone therapy. In the Prospective Estrogen-Progesterone Interventions (PEPI) trial,(27) estrogen replacement improved lipid profiles. However, the PEPI trial was not designed to evaluate the effects of this treatment on the incidence and mortality of coronary artery disease.

The Women’s Health Initiative,(28) a randomized, controlled trial of hormone replacement therapy for the prevention of coronary artery disease, is expected to yield definitive information about the value of estrogen replacement as primary prevention. The results of this trial are expected in 2006.

The Heart and Estrogen/Progestin Replacement Study (HERS)(29) was a randomized, controlled trial of combined continuous hormone replacement therapy as secondary prevention in women with known coronary artery disease. In the HERS hormone replacement group, the rate of coronary events increased in the first two years and decreased in the third and fourth year, with no net benefit over the study period.

The possible increased risk of breast cancer in women who receive hormone replacement therapy remains a concern.(30) Estrogen replacement has proven benefits for reducing perimenopausal symptoms and preventing osteoporosis. At present, however, there is insufficient evidence to recommend hormone replacement therapy for the prevention of coronary artery disease.

SMOKING

Smoking is a major risk factor for the development of cardiovascular disease in women. More than 60 percent of myocardial infarctions in women younger than 50 years are attributable to smoking, as are 21 percent of all deaths from coronary artery disease. All women benefit from quitting smoking. Investigators in the Nurses’ Health Study(14) found that the risk of coronary artery disease decreases by one third two years after smoking cessation.

In the United States, fewer women than men currently smoke, and the prevalence of smoking among women has declined over the past three decades. However, tobacco use has decreased more dramatically in men than in women. Compared with male smokers, women more often smoke to relieve stress, anger, boredom or depression. Women are more likely than men to cite smoking as a strategy for weight loss, and they more often give weight gain as a major reason for relapsing after quitting.(31)

Compared with men, women find it harder to quit smoking initially, with and without treatment, and are also more likely to relapse. Some evidence shows that nicotine replacement appears to be more effective in men.(32) In women seeking to quit smoking, combination therapy with bupropion (Zyban) and the nicotine patch appears to produce the best long-term results.(33)

Because of gender-based differences in reasons for smoking, reasons for quitting and responses to pharmacologic agents, research on gender-specific smoking cessation strategies is needed. For example, it might be helpful for women to quit smoking early in their menstrual cycle (when withdrawal symptoms are not overlapping with premenstrual symptoms), to use bupropion to minimize weight gain and to address psychosocial stressors. Consideration of factors unique to women may help physicians be more successful in treating women smokers.

ASPIRIN AND CARDIOACTIVE DRUGS

Investigators in the Nurses’ Health Study34 observed a decreased risk of first myocardial infarction and death in women who took one to six aspirins per week. In the Hypertension Optimal Treatment (HOT) study,(12) men (53 percent) and women (47 percent) were randomized to receive 75 mg of aspirin per day or placebo, in addition to hypertension treatment. The HOT study showed an association between aspirin use and reductions in major cardiovascular events and myocardial infarctions.

The use of aspirin therapy for primary prevention of cardiovascular disease appears to be justified in women with hypertension. However, further studies are needed to determine the optimal aspirin dose and whether other groups of women are likely to benefit from this treatment. Aspirin therapy is clearly beneficial in women with chronic stable angina, unstable angina and evolving myocardial infarction, and for the prevention of recurrent infarction.

Women, especially if older, African American or Hispanic, are less likely than white men to receive aspirin, beta blockers, angiotensin-converting enzyme inhibitors and lipid-lowering drugs after myocardial infarction, despite evidence of benefit.(9,35) These patients are also less likely to be referred for revascularization procedures(8,36) and cardiac rehabilitation. Family physicians have an important role in ensuring that their patients have access to these therapies.

The authors thank Chris McLaughlin for her help in clarifying and editing the manuscript.

REFERENCES

(1.) Charney P, ed. Coronary artery disease in women: what all physicians need to know. Philadelphia: American College of Physicians, 1999.

(2.) Kudenchuk PJ, Maynard C, Martin JS, Wirkus M, Weaver WD. Comparison of presentation, treatment, and outcome of acute myocardial infarction in men versus women (the Myocardial Infarction Triage and Intervention Registry). Am J Cardiol 1996;78:9-14.

(3.) Sullivan AK, Holdright DR, Wright CA, Sparrow JL, Cunningham D, Fox KM. Chest pain in women: clinical, investigative, and prognostic features. BMJ 1994;308:883-6.

(4.) Douglas PS, Ginsburg GS. The evaluation of chest pain in women. N Engl J Med 1996;334:1311-5.

(5.) Barrett-Connor EL, Cohn BA, Wingard DL, Edelstein SL. Why is diabetes mellitus a stronger risk factor for fatal ischemic heart disease in women than in men? The Rancho Bernardo Study. JAMA 1991;265:627-31 [Published erratum appears in JAMA 1991;265:3249].

(6.) National Cholesterol Education Program. The second report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II): National Cholesterol Education Program, executive summary. Bethesda, Md.: National Institutes of Health, National Heart, Lung, and Blood Institute, 1993.

(7.) Manolio TA, Pearson TA, Wenger NK, Barrett-Connor E, Payne GH, Harlan WR. Cholesterol and heart disease in older persons and women. Review of an NHLBI workshop. Ann Epidemiol 1992;2:161-76.

(8.) Bearden D, Allman R, McDonald R, Miller S, Pressel S, Petrovitch H. Age, race, and gender variation in the utilization of coronary artery bypass surgery and angioplasty in SHEP. SHEP Cooperative Research Group. Systolic Hypertension in the Elderly Program. J Am Geriatr Soc 1994;42:1143-9.

(9.) Herholz H, Goff DC, Ramsey DJ, Chan FA, Ortiz C, Labarthe DR, et al. Women and Mexican Americans receive fewer cardiovascular drugs following myocardial infarction than men and non-Hispanic whites: the Corpus Christi Heart Project, 1988-1990. J Clin Epidemiol 1996;49:279-87.

(10.) Maxwell MH, Ford CE. Cardiovascular morbidity and mortality in HDFP patients 50-69 years old at entry. J Cardiovasc Pharmacol 1985;7(suppl 2):S5-9.

(11.) Curb JD, Pressel SL, Cutler JA, Savage PJ, Applegate WB, Black H, et al. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA 1996;276:1886-92 [Published erratum appears in JAMA 1997;277:1356].

(12.) Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998;351:1755-62.

(13.) Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000;343:16-22.

(14.) Kawachi I, Colditz MB, Stampfer MJ, Willett WC, Manson JE, Rosner B, et al. Smoking cessation and time course of decreased risks of coronary heart disease in middle-aged women. Arch Intern Med 1994;154:169-75.

(15.) Shepherd J, Cobbe SM, Ford I, Isles CG, Lorimer AR, MacFarlane PW, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med 1995;333:1301-7.

(16.) Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000;342:145-53 [Published errata appear in N Engl J Med 2000; 342:748 and 2000;342:1376].

(17.) Pedersen TR. Coronary artery disease: the Scandinavian Simvastatin Survival Study experience. Am J Cardiol 1998;82:53T-56T.

(18.) National Center for Health Statistics. Retrieved December 2000, from: http://www.cdc.gov/nchs/ products/pubs/pubd/hestats/3and4/sedentary.htm.

(19.) Colditz GA, Coakley E. Weight, weight gain, activity, and major illnesses: the Nurses’ Health Study. Int J Sports Med 1997;18(suppl 3):S162-70.

(20.) Manson JE, Rimm EB, Stampfer MJ, Colditz GA, Willett WC, Krolewski AS, et al. Physical activity and incidence of non-insulin-dependent diabetes in women. Lancet 1991;338:774-8.

(21.) Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Arch Intern Med 1998;158:1855-67.

(22.) Gleim GW. Exercise is not an effective weight loss modality in women. J Am Coll Nutr 1993;12:363-7.

(23.) Downs JR, Clearfield M, Weis S, Whitney E, Shapiro DR, Beere PA, et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study. JAMA 1998;279:1615-22.

(24.) U.S. Preventive Services Task Force. Screening for high blood cholesterol and other lipid abnormalities In: Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.

(25.) Guidelines for using serum cholesterol, high-density lipoprotein cholesterol, and triglyceride levels as screening tests for preventing coronary heart disease in adults. American College of Physicians. Part 1. Ann Intern Med 1996;124:515-7.

(26.) Stampfer MJ, Colditz GA, Willett WC, Manson JE, Rosner B, Speizer FE, et al. Postmenopausal estrogen therapy and cardiovascular disease. Ten-year follow-up from the Nurses’ Health Study. N Engl J Med 1991;325:756-62.

(27.) Effects of estrogen or estrogen/progestin regimens on heart disease risk factors in postmenopausal women. The Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial. The Writing Group for the PEPI Trial. JAMA 1995;273:199-208 [Published erratum appears in JAMA 1995;274:1676].

(28.) Finnegan LP. The NIH Women’s Health Initiative: its evolution and expected contributions to women’s health. Am J Prev Med 1996;12:292-3.

(29.) Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. JAMA 1998;280:605-13.

(30.) Schairer C, Lubin J, Troisi R, Sturgeon S, Brinton L, Hoover R. Menopausal estrogen and estrogen-progestin replacement therapy and breast cancer risk. JAMA 2000;283:485-91.

(31.) Sorensen G, Pechacek TF. Attitudes toward smoking cessation among men and women. J Behav Med 1987;10:129-37.

(32.) Killen JD, Fortmann SP, Newman B, Varady A. Evaluation of a treatment approach combining nicotine gum with self-guided behavioral treatments for smoking relapse prevention. J Consult Clin Psychol 1990;58:85-92.

(33.) Jorenby DE, Leischow SJ, Nides MA, Rennard SI, Johnston JA, Hughes AR, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999; 340:685-91.

(34.) Manson JE, Stampfer MJ, Colditz GA, Willet WC, Rosner B, Speizer FE, et al. A prospective study of aspirin use and primary prevention of cardiovascular disease in women. JAMA 1991;266:521-7.

(35.) Krumholz HM, Radford MJ, Ellerbeck EF, Hennen J, Meehan TP, Petrillo M, et al. Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcomes. Ann Intern Med 1996;124:292-8.

(36.) Gan S, Beaver S, Houck PM, MacLehose RF, Lawson HW, Chan L. Treatment of acute myocardial infarction and 30-day mortality among women and men. N Engl J Med 2000;343:8-15.

Members of various medical faculties develop articles for “Practical Therapeutics.” This article is one in a series coordinated by the Department of Family and Community Medicine at the Medical College of Wisconsin, Milwaukee. Guest editors of the series are Linda N. Meurer, M.D., M.P.H., and Douglas Bower, M.D.

JOAN BEDINGHAUS, M.D., is assistant professor in the Department of Family and Community Medicine at the Medical College of Wisconsin, Milwaukee. Dr. Bedinghaus graduated from Harvard Medical School, Boston, and completed a family practice residency at MetroHealth Medical Center, Cleveland.

LOREN LESHAN, M.D., is associate professor in the Department of Family and Community Medicine at the Medical College of Wisconsin and director of the family practice residency program at St. Mary’s Hospital, Milwaukee. Dr. Leshan received her medical degree from Tufts University School of Medicine, Boston, and completed a family practice residency at MetroHealth Medical Center, Cleveland.

SABINA DIEHR, M.D., is assistant professor in the Department of Family and Community Medicine at the Medical College of Wisconsin and medical director of the Family Medicine Clinic at Curative Rehabilitation Services, Milwaukee. Dr. Diehr graduated from Temple University School of Medicine, Philadelphia, and completed a family practice residency at Sacred Heart Hospital, Allentown, Pa.

Address correspondence to Joan Bedinghaus, M.D., Department of Family and Community Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226 (e-mail: jbmd@mcw.edu). Reprints are not available from the authors.

TABLE 1

Coronary Artery Disease: What’s Different for Women?

Presentation

Women present at a later age.(1(p3)-3)

In women, typical angina is less predictive of coronary artery disease

(pretest probability is 50 to 60 percent in women versus 80 to 99

percent in men).(3,4)

Women may present with shoulder or jaw pain, dyspnea or nausea.(1(p316),4)

Risk factors

Diabetes has a stronger influence in women.(3,5)

High HDL cholesterol levels, which lower the risk of coronary artery

disease, are more common in women.(6)

The roles of total cholesterol, LDL cholesterol and lipoprotein(a)

in women are unclear.(7)

The risk of coronary artery disease increases after menopause.

Prognosis

Women are more likely to die of a first myocardial infarction.(2)

Women experience more long-term disability.(1(p25))

Women have more comorbidity (because they are usually older on

presentation).

Primary prevention

There is insufficient evidence for the benefits of cholesterol-lowering

drugs in women.

There is insufficient evidence for the benefit of estrogen replacement

therapy.

Secondary prevention

Women are less likely to undergo angioplasty or bypass surgery.(8)

Fewer women receive cardiac rehabilitation.(1(p213))

Fewer women receive therapy with aspirin, beta blockers or

angiotensin-converting enzyme inhibitors.(9)

HDL = high-density lipoprotein; LDL = low-density lipoprotein.

Information from references 1 through 9.

TABLE 2

Measures for Primary and Secondary Prevention of Coronary Artery Disease

Primary prevention

Proven benefit in controlled trials(10,11)

Hypertension control

Beta blockers

Thiazide diuretics

Aspirin(12)

Benefit in observational studies

Exercise(13)

Smoking cessation(14)

Proven benefit in men but controversial

in women

Drug therapy to lower cholesterol levels(15)

Insufficient evidence of benefit

Estrogen replacement therapy

Secondary prevention

Proven benefit in controlled trials

Hypertension control

Beta blockers

Aspirin

Angiotensin-converting enzyme inhibitors(16)

Aggressive cholesterol-lowering therapy(17)

Angioplasty

Coronary artery bypass surgery

Benefit in observational studies

Smoking cessation

Exercise rehabilitation[*][*]–Functional improvement; no studies on mortality reduction.

Information from references 10 through 17.

TABLE 3

Recommendations on Cholesterol Screening and Treatment for Women:

Primary Prevention of Coronary Artery Disease[*]

Screening

Group Normal risk

USPS Task Total cholesterol level in women

Force(24) 45 to 65 years of age

ACP(25) Total cholesterol level “appropriate

but not mandatory” in women

45 to 65 years of age

Unknown value in women 65 to

75 years of age

Not recommended in women

older than 75 years

NCEP(6) Total and HDL cholesterol levels

in all persons 20 years and older

Screening

Group High risk[]

USPS Task Total cholesterol level

Force(24) obtained earlier in

women at high risk

ACP(25) Total cholesterol level

obtained earlier in

women at high risk

Not recommended in

women older than

75 years

NCEP(6) Consider obtaining total

and HDL cholesterol

levels in children

and adolescents.

Treatment Treatment

Group Normal risk High risk[]

USPS Task Low-fat diet Consider drug therapy.

Force(24) Exercise

ACP(25) Drug therapy not No recommendation

necessary in

premenopausal

women

NCEP(6) Drug therapy if LDL Drug therapy if LDL cholesterol

cholesterol level level is higher than 160 mg per

is higher than dL (4.15 mmol per L). The goal

190 mg per dL is an LDL cholesterol level below

(4.90 mmol per L) 130 mg per dL (3.35 mmol per L).

USPS = U.S. Preventive Services; ACP = American College of Physicians;

NCEP = National Cholesterol Education Program; HDL = high-density

lipoprotein; LDL = low-density lipoprotein.

[*]–These recommendations apply to women with no history of

myocardial infarction, angina pectoris or known coronary artery disease

(primary prevention). Women with a previous myocardial infarction or

known coronary artery disease should be treated aggressively to achieve

an LDL cholesterol level below 100 mg per dL (2.60 mmol per L) to

lower their risk of a second cardiac event (secondary prevention).

[]–Women should be considered at high risk if they have diabetes or other

macrovascular disease, a family history of premature coronary artery

disease or two of the following: a family history of coronary artery

disease, smoking, hypertension, older than 55 years, severe

hyperlipidemia or an HDL cholesterol level below 35 mg per dL

(0.90 mmol per L).

Information from references 6, 24 and 25.

COPYRIGHT 2001 American Academy of Family Physicians

COPYRIGHT 2001 Gale Group