Heart Disease in Women-Where do we stand?
Does estrogen prevent heart attacks in postmenopausal women?
Cardiovascular Disease (CVD) is the number one killer of women in the United States. In my practice as a cardiovascular surgeon and cholesterol expert, I had a large number of female patients who did not know the extent of heart disease in women. Many women are often told by their primary care physician that if they take estrogen replacement therapy then they are protected from heart disease. Nothing could not be further from the truth. It is frightening that so many physicians still believe this falsehood.
Real progress in both our understanding of CVD and making therapeutic decisions in women began in the mid 1990s as randomized clinical trial data started to emerge. Many of our previous beliefs and paradigms based on men’s data or observational trials of women have had to undergo a radical rethinking.
Prior to 1998, estrogen replacement was a standard part of cardiovascular prevention regimens in postmenopausal women. It was thought that estrogen helped prevent atherosclerotic plaque breakage in the arteries which is a major cause of heart attack and stroke. However, guidelines from the American Heart Association and American College of Cardiology have refocused efforts on how to accurately assess risk and to prevent and treat atherosclerosis with evidence based therapies. All of the organizations have removed estrogen from the list of therapeutic modalities which should be used for cardioprotection. There is now data available from multiple large and small randomized controlled trials looking at cardiovascular outcomes and plaque prevention and stabilization, and estrogen has been successful in only one carotid artery plaque study. These trials included both primary and secondary prevention settings. Data from the giant Women’s Health Initiative, looking at over 27,000 postmenopausal women has failed to detect any cardioprotection from estrogen. In contrast, other therapies such as statins used to lower cholesterol have demonstrated an ability to improve cardiovascular outcomes in women.
It is now recognized that atherothrombosis (plaque breakage and clot formation in an artery) is a chronic inflammatory disease of the arteries that begins very early in life and causes clinical events in adulthood. It is rupture of nonocclusive plaques (blockages that DO NOT cause critical narrowing), which generates an arterial thrombus (clot) that causes most of the morbidity and mortality of cardiovascular disease. Therapies that stabilize the plaque have been successful in improving outcomes.
New insights into lipid biology have identified lipoproteins (the cars which drive the cholesterol and triglycerides) into the arterial wall as the major players in plaque formation and inflammation. The concentrations and sizes of VLDL, IDL, LDL and HDL are culprits in initiating and worsening arterial plaque. An analysis of the lipoproteins can be done by performing Advanced Lipoprotein Testing. Removing atherogenic lipoproteins or modifying them into non-atherogenic particles has emerged as a very effective strategy.
The timing of estrogen therapy with respect to earlier versus later in menopause is emerging as critical to vascular response. If we are to begin to make real progress in the battle against CVD in women, we must identify risk using new diagnostic tools, much earlier in life and become extremely aggressive in our therapies including lifestyle and pharmacologic strategies. We also need to fine tune those patients in which estrogen will or will not show benefit. It is my personal opinion that all women with any cardiovascular risk factors should undergo advanced lipoprotein testing. For more information, you can go to PaladinMDs because “it’s like having a doctor in the family.”
I am so glad that you are sharing these articles with everyone. All so very very important, Thank you!