Behavioural risk factors and cardiovascular disease: are women at higher risk?

Abstract

Previous work has reported that diabetes, smoking, and hypertension are more strongly associated with cardiovascular disease in women than in men. 1 Millett ERC Peters SAE Woodward M Sex differences in risk factors for myocardial infarction: cohort study of UK Biobank participants. BMJ. 2018; 363k4247 Google Scholar , 2 Manfrini O Yoon J van der Schaar M et al. Sex differences in modifiable risk factors and severity of coronary artery disease. J Am Heart Assoc. 2020; 9e017235 Crossref PubMed Scopus (23) Google Scholar In The Lancet, Marjan Walli-Attaei and colleagues 3 Walli-Attaei M Rosengren A Rangarajan S et al. Metabolic, behavioural, and psychosocial risk factors and cardiovascular disease in women compared with men in 21 high-income, middle-income, and low-income countries: an analysis of the PURE study. Lancet. 2022; 400: 811-821 Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar argue that studies on sex differences in cardiovascular risk factors are mainly from high-income countries and add to the literature by reporting their community-based study conducted in 21 high-income, middle-income, and low-income countries. In their analysis, Walli-Attaei and colleagues included 155 724 adults (90 934 [58·4%] women and 64 790 [41·5%] men) aged 35–70 years without a history of cardiovascular disease from the Prospective Urban Rural Epidemiological (PURE) study, who had a median follow-up of 10·1 years (IQR 8·5–12·0), and assessed the primary composite outcome of major cardiovascular events (cardiovascular disease deaths, myocardial infarction, stroke, and heart failure). As of data cutoff (Sept 13, 2021), 4280 major cardiovascular disease events had occurred in women (age standardised incidence rate of 5·0 events [95% CI 4·9–5·2] per 1000 person-years) and 4911 in men (8·2 [8·0–8·4] per 1000 person-years). The hazard ratios (HRs) for the composite outcome of major cardiovascular disease associated with metabolic risk factors were similar in women and in men, except for high non-HDL cholesterol, for which larger HRs were found in men (1·11 [95% CI 1·01–1·21] in women vs 1·28 [1·19–1·39] in men; pinteraction=0·0037). Larger HRs in men than in women were also observed for symptoms of depression (1·09 [0·98–1·21] in women vs 1·42 [1·25–1·60] in men; pinteraction=0·0002). By contrast, behavioural risk factors, such as consumption of a diet of PURE diet score of 4 or lower 3 Walli-Attaei M Rosengren A Rangarajan S et al. Metabolic, behavioural, and psychosocial risk factors and cardiovascular disease in women compared with men in 21 high-income, middle-income, and low-income countries: an analysis of the PURE study. Lancet. 2022; 400: 811-821 Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar and household air pollution, were more strongly associated with cardiovascular disease in women than in men (diet: HR 1·17 [95% CI 1·08–1·26] in women vs 1·07 [0·99–1·15] in men; pinteraction=0·0065; household air pollution: 1·10 [0·99–1·21] vs 1·06 [0·96–1·16]; pinteraction=0·0055). The difference in associations between women and men for risk factors and myocardial infarction followed a pattern similar to the results for the composite outcome of major cardiovascular disease, with the exception of systolic blood pressure (per 20 mm Hg), hypertension, and household air pollution, for which larger HRs were observed in women than in men. The difference in associations between women and men for risk factors and the composite outcome of major cardiovascular disease were similar among countries at different income levels. These findings raise several important issues. Metabolic, behavioural, and psychosocial risk factors and cardiovascular disease in women compared with men in 21 high-income, middle-income, and low-income countries: an analysis of the PURE studyLipid markers and depression are more strongly associated with the risk of cardiovascular disease in men than in women, whereas diet is more strongly associated with the risk of cardiovascular disease in women than in men. The similar associations of other risk factors with cardiovascular disease in women and men emphasise the importance of a similar strategy for the prevention of cardiovascular disease in men and women. Full-Text PDF