Fatal myocardial infarction secondary to
atherosclerosis of coronary vessels:
Cardiovascular disease is the leading
cause of death among women regardless of
race or ethnicity. In
the US it accounts for 500,000 deaths a year death of 1:3 women
.This amounts to more deaths from heart
disease than from stroke lung cancer chronic obstructive pulmonary disease
and breast cancer combined.
A forty
year old women has a life time risk of cardiovascular disease of 32% . The global
burden of CVD is rising rapidly
. Hypertension affects more men
than women till 55 years of
age but after 55 years the
percentage of women rises and after the age of 60 years a majority of women have
stage all hypertension or are on antihypertensive treatment . Estrogen deficiency has been linked to rapid in
cardiovascular disease in women who have undergone natural or surgical menopause.
Every year CVD claims the lives of women more than men. More than 450,000 women succumb to
heart disease annually and 250,000 die of coronary artery disease .Cardiovascular disease
risk increases with
menopause which may be due to metabolic and hormonal changes.
Cardiovascular risk for women
with established hypertension
was even greater . Interestingly the increased cardiovascular risk associated with Prehypertension was greater
than that associated with smoking
reinforcing the need for treatement
of pre hypertension group.
Prehypertension was associated with other
modifiable risk factors ie. high total cholesterol and BMI emphasizing the importance of global risk factor
reduction for prevention of both hypertension ans cardiovascular disease
outcomes. including endothelial dysfunction
increased arterial stiffness activation of rennin angiotensin
aldosterone system, increased salt sensitivity oxidative stress obesity and
genetic factors have been implicated in
the pathogenesis of BP increases that occur after natural
menopause or ovariectomy
Hypertension in Postmeno women:-In general the totality of
evidence suggests that menopause
is accompanied by small NP
increases that may be partially accounted for by increasing age and BMI
as well as concomitant
increase in other
cardiovascular risk factors. Rigorous prospective studies employing state of art techniques of BP
measurement and correction for antihypertensive therapy
may elucidate this relationship
further. The pathophysiology of menopause
related rise in BP
has been inferred elegant
mechanistic studies in animals
and human subjects .
Dyslipidaemia and Heart attack;National cholesterol education programme adult treatment panel guidelines proposed an aggressive management of dyslipidemia both for primary prevention of cardiovascular disease and secondary prevention of cardiovascular events .
Women with had multiple risk factors for MI:-Some women may have 1) obesity 2) HTN 3) low
HDL and 4) high TG . The causes of
dyslipidemia may be 5) genetic or 6)
secondary to thyroid disorder diabetes or 7) renal disease . HDL levels predict cardiovascular risk in overall population but sometimes especially
in primary dyslipidemia it may
lead to increase the risk of cardiovascular disorders.
Postmeno
women and prevention of MI by Gynaecologists :--Are we failing in our duties??
In this light it is important that we must classify the individual
patients risk and prevent any
cardiovascular problems This is not only important in women who go to physicians or the
cardiologists for check up but also for
those who come to the menopause clinic
or general OPD for any complaints.
HTN, MI and Sex of the candidate who
suffer from MI at > 50yrs,.:- A greater
proportion of women than
men with MI die of sudden
cardiac death before reaching
hospital 1 and 2/3 of women with MI never completely
recover. There is an 8-10 year
delay in onset of CAD between men and women all over the world.
Despite this delay
in onset mortality from CAD is
increasing more rapidly in women than in men.
Age
& MI:--Aging remains
one of the most important
determinants of post menopausal hypertension and the growing prevalence of obesity often in conjunction
with lack of physical activity is likely to increase the cardiovascular morbidity
in the next decade.
Currently control of BP in post
menopausal women remains sub optimal worldwide. Efforts are needed to screen and
identify patients Prevention and
awareness should start early in life
than in perimenopause.
The
incidence of cardiovascular disease
increases with age in women as well as men. In women there is an additional
risk due to the menopause consequent to the loss of ovarian function .Postmenopausal
Hormone Treatement offered for
definite indications during the window
of opportunity prevents or at least differs many atheromas in coronary vessels.
But at the same time we must remember that genomic mechanism play an important
role on the vascular endothelium on ion channels and on the rennin angiotensin aldosterone
system. -.
The bad news in the era of HRT : :--Case history :-Not uncommonly
we come across cases in our locality
where a postmeno woman who was
acquainted with us / our family was admitted on the night before with severe first time
chest pain and could not be revived and succumbed to coronary thrombosis
(massive heart attack). Most of us must
have listened to such an unfortunate event may come across every year ,may be
our relatives or residing in our housing complex. On analysis it is thought
retrospectively that the above patients must have been a high risk candidate for coronary
heart disease which remained undiagnosed. Many of such women (those woman who died and was known to
us) had a family history of heart attack .She herself was suffering
from obesity and high cholesterol levels
for which she was careless and
never had check up, didn’t control diet was sedentary and above all never
offered HRT soon after menopause(window of opportunity)..
Good news in the era of HRT :--It is equally true to meet women of
identical age who received HRT with
oestrogen for 5 -7 yrs postemono as soon as she achieved menopauses. It is
probable the timely HRT saved her and she is living a good quality life with
Diet control and exercise. She, at the age of 64 yrs is still vesting Gym every
day in contrast to her friend who died suddenly last night without any
premonitory symptom. It is concluded, therefore that hormone therapy instituted in the first seven
to eight years (in the second Group of women ) after menopause in the might have prevented
atherosclerotic process form
setting in .
.
Before menopause the extent of atherosclerosis in
woman is equivalent to that of a man 10-15 years younger to her. However after menopause the
risk of a fatal myocardial infarction
secondary to atherosclerosis of coronary
vessels doubles. These high rates
of disease amongst women have been shown
to result from a decrease in the estrogen
level with a consequent increase
in the atherogenic risk factors.
There is an increase in the total cholesterol level low density lipoprotein level and lipoprotein a decrease
in the high density lipoprotein level
increased thrombotic tendency
and an occasional development
of insulin resistance .
Hormone therapy might benefit the
cardiovascular system by favorably
affecting the lipids and lipoproteins
oral estrogens effectively
reduce LDL cholesterol
and increase HDL cholesterol .
There may also be reductions in
lipoprotein changes in LDL particle
size and clearance and reductions in
LDL oxidation.
Apart from the above estrogens
also favorably affect glucose and insulin metabolism body fat
distribution and may have direct effect on arteries through
various genomic mechanism these include effects on the vascular endothelium
on ion channels and on the rennin
angiotensin aldosterone system.
Women’s health initiative a landmark study for hormone therapy was terminated early because it was perceived that the health risks exceeded the benefits. Experts later reanalyzed the results of WHI and
opined that HT might be beneficial for CHD if started early after menopause they also said that HT given for definite indications during the window
of opportunity after
menopause improved the quality
of life.However larger prospective
trials need to be done to actually know about
the beneficial effects of HT on cardiac profile of menopausal women .
Epidemiology
Hypertension as a
risk factor
Hypertension is a particularly powerful risk factor and
lowering of blood pressure is pivotal . It is an increasingly common condition among the US
population with 65 million
affected individuals in National Health and Nutrition Examination surveys from 1999- 2000 . Overall more than 35 million women had hypertension a 15% higher prevalence than in men. The prevalence of
hypertension increases with age in both the sexes but from
45-54 years of age the escalation was greater in among
women than men the difference in
prevalence reaching statistical
significance at age 75 and beyond in subjects
younger than 35 years of age hypertension was more prevalent
among men than women.
Further
BP control is more difficult to achieve
in older patients particularly older
women. Data from Framingham heart study showed an age related decrease
in BP control rates that
were more pronounced in women
than men.
Recent data from the US National
health and Nutrition Examination Survey
1999-2000 have highlighted a
likely contributory factor to poor BP
control in elderly women as high prevalence of concomitant CVS
risk factors including
central obesity elevated
total cholesterol and
low HDL
cholesterol levels.
Among adults
with hypertension in NHANES
1999-2004 , women were at a high cardiovascular risk compared
to men 53% women
but only 41% men => 3 of the studied risk factor.
A study of 908 women
residents of Prague aged 45-54
years showed that the rise in BP after
menopause appeared to be
due to high BMI rather
than to ovarian failure per se
Recognizing that BP elevation presents
a graded risk for CVS disease
the WHI determined the prevalence
of Prehypertension . Its association
with other CVS risk factors and risk
of incident CVS disease
events in 60,785 post
menopausal women who were
followed prospectively for 7.7
years.
Prehypertension
was identified in 39% of women at
baseline compared to
normotensive women those
with per hypertension had 58% high risk
of cardiovascular deaths . 76%
increased risk of strokes
36% increased risk
of hospitalized heart failure and 66% increased
risk of any cardiovascular
accident .
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