Coronary Heart Disease Events In Women Research Articles

Sex differences in risk factors for coronary heart disease events: a prospective cohort study in Iran

We investigated sex-specific associations and their differences between major cardiovascular risk factors and the risk of incident coronary heart disease (CHD) and hard CHD (defined as nonfatal myocardial infarction and CHD death). A total of 7518 (3377 men) participants from the Tehran Lipid and Glucose Study were included. Cox models were used to estimate the hazard ratios (HRs) and women-to-men ratios of HRs for CHD events associated with each risk factor. During 20 years of follow-up (1999–2018), 1068 (631 men) and 345 (238 men) new cases of CHD and hard CHD, respectively, were documented. In total population, the incidence rates per 1000 person-years were 9.5 (9.0–10.1) and 2.9 (2.6–3.2) for CHD and hard CHD, respectively. Hypertension, diabetes, pre-diabetes, and a high waist-to-hip ratio (WHR) were associated with a greater HR of hard CHD in women than men; the women-to-men HRs were 2.85 [1.36–5.98], 1.92 [1.11–3.31], 2.04 [1.09–3.80] and 1.42 [1.10–1.82], respectively. Diabetes was associated with a higher HR of CHD in women than men (ratio of HRs 1.49 (1.10–2.01). In conclusion, we found that hypertension, diabetes, pre-diabetes, and high WHR conferred a greater excess risk of CHD events in women than in men, suggesting that Iranian women may require greater attention for the prevention of CHD events.

Sex differences in the rates of incident and recurrent coronary heart disease and all-cause mortality

Abstract Background Women have lower age-specific rates of incident coronary heart disease (CHD) than men. However, it remains unclear whether women maintain the same advantage once they have had a cardiac event. Purpose To assess whether sex differences in the rates of cardiac events and all-cause mortality among individuals without a history of CHD persist following a myocardial infarction (MI). Methods We identified 171,897 women and 167,993 men <65 years of age with commercial health insurance and ≥66 years of age with government health insurance through Medicare who had a MI hospitalization between 2015 and 2016 in the US. These beneficiaries were matched to 687,588 women and 671,972 men without a history of CHD based on age and calendar year. Beneficiaries were followed until December 2017 for the occurrence of MI, CHD, heart failure, and all-cause mortality (Medicare only). Results The age-standardized rates of MI per 1,000 person-years were 4.5 in women and 5.7 in men without a history of CHD (multivariable-adjusted hazard ratio [HR] [95% confidence interval] of female sex: 0.64 [0.62; 0.67]) and 60.2 in women and 59.8 in men with a history of MI (HR: 0.94 [0.92, 0.96]) (Figure 1). Rates of CHD events in women vs. men were 6.3 vs. 10.7 among those without CHD (HR: 0.53 [0.51, 0.54]) and 84.5 vs. 99.3 among those with MI (HR: 0.87 [0.85, 0.89]). Heart failure hospitalization rates in women vs. men were 9.3 vs. 6.6 for those without CHD (HR: 0.93 [0.90, 0.96]) and 114.9 vs. 97.9 among those with MI (HR: 1.02 [1.00, 1.04]). All-cause mortality rates in women vs. men were 63.7 vs. 59.0 among those without CHD (HR: 0.72 [0.71; 0.73]) and 311.6 vs. 284.5 among those with a MI (HR: 0.90 [0.89, 0.92]). Conclusion The women advantage against MI, CHD, heart failure and all-cause mortality is considerably attenuated following a MI, suggesting that a prior MI puts women at almost the same high-risk of subsequent events as men. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): This work was funded by an industry/academic collaboration between Amgen Inc. and University of Alabama at Birmingham.

The addition of depression to the Framingham Risk Equation model for predicting coronary heart disease risk in women

BackgroundDepression is widely considered to be an independent and robust predictor of Coronary Heart Disease (CHD), however is seldom considered in the context of formal risk assessment. We assessed whether the addition of depression to the Framingham Risk Equation (FRE) improved accuracy for predicting 10-year CHD in a sample of women. DesignA prospective, longitudinal design comprising an age-stratified, population-based sample of Australian women collected between 1993 and 2011 (n=862). MethodsClinical depressive disorder was assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID-I/NP), using retrospective age-of-onset data. A composite measure of CHD included non-fatal myocardial infarction, unstable angina coronary intervention or cardiac death. Cox proportional-hazards regression models were conducted and overall accuracy assessed using area under receiver operating characteristic (ROC) curve analysis. ResultsROC curve analyses revealed that the addition of baseline depression status to the FRE model improved its overall accuracy (AUC:0.77, Specificity:0.70, Sensitivity:0.75) when compared to the original FRE model (AUC:0.75, Specificity:0.73, Sensitivity:0.67). However, when calibrated against the original model, the predicted number of events generated by the augmented version marginally over-estimated the true number observed. ConclusionsThe addition of a depression variable to the FRE equation improves the overall accuracy of the model for predicting 10-year CHD events in women, however may over-estimate the number of events that actually occur. This model now requires validation in larger samples as it could form a new CHD risk equation for women.

Preventable Coronary Heart Disease Events from Control of Cardiovascular Risk Factors in US Adults With Diabetes (Projections from Utilizing the UKPDS Risk Engine)

Type 2 diabetes mellitus (T2DM) carries significant risks for coronary heart disease (CHD). We examined the potential US population impact of single and composite risk factor control. Among US adults with diagnosed T2DM aged≥30 years in the National Health and Nutrition Examination Survey 2007 to 2012, we assessed CHD events preventable using the United Kingdom Prospective Diabetes Study CHD risk engine. We examined in all those not at goal the impact of statistical control of smoking, glycated hemoglobin, systolic blood pressure, and total and high-density lipoprotein cholesterol, according to the predefined criteria setting risk factors at different levels of control representing (1) "All to Goal," (2) at "Nominal Control," or (3) at "Aggressive Control." Preventable CHD events represented the difference between the number of events estimated from the control of these risk factors versus current levels of the risk factors. Of 606 men (representing 6.2 million) and 603 women (6.3 million) with DM and no previous CHD, 1.3 million men and 0.7 million women would develop a CHD event within 10 years if left uncontrolled. Controlling all risk factors to goal was projected to prevent 35% and 45% of CHD events in men and women, respectively. Nominal risk factor control was projected to prevent 36% and 38% and aggressive control 51% and 61% of CHD events, respectively. In conclusion, a significant proportion of CHD events in adults with T2DM could be prevented from composite control of risk factors often not at goal.

WOMEN WITH CORONARY HEART DISEASE ARE LESS AGGRESSIVELY TREATED WITH LIPID LOWERING MEDICATIONS THAN MEN

Coronary heart disease (CHD) is the leading cause of death in women in the United States, and lipid-lowering therapy can reduce CHD events in women. Previous studies have shown that women are less likely to achieve optimal low-density lipoprotein (LDL) levels compared to men. We hypothesized that

Meta-analysis: Retinal Vessel Caliber and Risk for Coronary Heart Disease

Retinal vessel caliber may be a novel marker of coronary heart disease (CHD) risk. However, the sex-specific effect, magnitude of association, and effect independent of traditional CHD disease risk factors remain unclear. To determine the association between retinal vessel caliber and risk for CHD. Relevant studies in any language identified through MEDLINE (1950 to June 2009) and EMBASE (1950 to June 2009) databases. Studies were included if they examined a general population, measured retinal vessel caliber from retinal photographs, and documented CHD risk factors and incident CHD events. 6 population-based prospective cohort studies provided data for individual participant meta-analysis. Proportional hazards models, adjusted for traditional CHD risk factors, were constructed for retinal vessel caliber and incident CHD in women and men. Among 22,159 participants who were free of CHD and followed for 5 to 14 years, 2219 (10.0%) incident CHD events occurred. Retinal vessel caliber changes (wider venules and narrower arterioles) were each associated with an increased risk for CHD in women (pooled multivariable-adjusted hazard ratios, 1.16 [95% CI, 1.06 to 1.26] per 20-microm increase in venular caliber and 1.17 [CI, 1.07 to 1.28] per 20-microm decrease in arteriolar caliber) but not in men (1.02 [CI, 0.94 to 1.10] per 20-microm increase in venular caliber and 1.02 [CI, 0.95 to 1.10] per 20-microm decrease in arteriolar caliber). Women without hypertension or diabetes had higher hazard ratios. Error in the measurement of retinal vessel caliber and Framingham variables was not taken into account. Retinal vessel caliber changes were independently associated with an increased risk for CHD events in women.

Comparison of Prognostic Usefulness of Coronary Artery Calcium in Men Versus Women (Results from a Meta- and Pooled Analysis Estimating All-Cause Mortality and Coronary Heart Disease Death or Myocardial Infarction)

Women with coronary heart disease (CHD) have higher mortality compared with men. Atherosclerotic imaging risk markers are associated with higher mortality and relative risk of CHD events in women compared with men. However, data on the predictive accuracy of coronary artery calcium (CAC) in women are scarce. We performed a systematic review of the published literature from 2003 to 2006 on the prognostic value of CAC in women and men. Two investigators reviewed Medline for prospective registries on annual rates of CHD death or myocardial infarction (MI) by CAC results. Three studies in 6,481 women and 13,697 men reported results by gender. We also analyzed 2 observational registries for annual all-cause death rates by CAC scores in women (n = 17,779) and men (n = 17,850). Summary relative risk ratios and 95% confidence intervals were calculated using a random effects model. For all-cause mortality, rates were 0.1% to 1.6% per year for women and 0.1% to 2.6% for men with CAC scores from 0 to 10 to > or =1,000, respectively (p <0.0001). For CHD death or MI, annual rates were 0.2% to 1.3% in women and 0.3% to 2.4% for men with low- to high-risk CAC scores. For women with a CAC score of 0, annual CHD death or MI rates were 0.16%, similar to that of men (p = 0.55). Summary relative risk ratios increased 4.9-fold (p = 0.006), 5.5-fold (p = 0.002), and 8.7-fold (p <0.0001) for mild-, moderate-, and high-risk CAC scores, respectively. A comparative analysis of gender differences showed no significant differences between women and men for mild- to high-risk CAC scores (p = 0.66), suggesting an equivalent ability to risk stratify by gender. In conclusion, this meta- and pooled analysis revealed that CAC screening is equally accurate in stratifying risk in women and men.

Occupational, commuting and leisure-time physical activity in relation to coronary heart disease among middle-aged Finnish men and women

Objective To examine the association of different levels of occupational, commuting, and leisure-time physical activity with the risk of coronary heart disease (CHD) events. Methods and results The study comprised 47,840 Finnish participants aged 25–64 years without history of CHD and stroke at baseline. During a mean follow-up of 18.9 years, 4660 new CHD events were documented. The multivariable-adjusted (age, body mass index, systolic blood pressure, total cholesterol, education, alcohol consumption, smoking, history of diabetes, and other two types of physical activity) hazard ratios (HRs) of CHD events associated with low, moderate, and high occupational activity were 1.00, 0.87, and 0.90 ( P trend = 0.019) for men, and 1.00, 0.75, and 0.80 ( P trend < 0.001) for women, respectively. The multivariable-adjusted HRs of CHD events associated with low, moderate, and high leisure-time physical activity were 1.00, 0.95, and 0.84 ( P trend = 0.026) for men, and 1.00, 0.85, and 0.77 ( P trend = 0.003) for women, respectively. Active commuting had a significant inverse association with the risk of CHD events in women but not in men. Conclusion Moderate or high levels of occupational or leisure-time physical activity are associated with a reduced risk of CHD. Daily walking or cycling to and from work is associated with a decreased risk of CHD among women.

Drug treatment of hyperlipidemia in women.

Several clinical trials have evaluated the effects of lipid-lowering medications on coronary heart disease (CHD). Many of the trials have not included enough women to allow sex-specific analyses or have not reported results in women separately. To assess and synthesize the evidence regarding drug treatment of hyperlipidemia for the prevention of CHD events in women and to conduct a meta-analysis of the effect of drug treatment on mortality. We searched MEDLINE, the Cochrane Database, and the Database of Abstracts of Reviews of Effectiveness for articles published from 1966 through December 2003. We reviewed reference lists of articles and consulted content experts. Studies of outpatients that had a treatment duration of at least 1 year, assessed the impact of lipid lowering on clinical outcomes, and reported results by sex were included. Outcomes evaluated were total mortality, CHD mortality, nonfatal myocardial infarction, revascularization, and total CHD events. Summary estimates of the relative risks (RRs) with therapy were calculated using a random-effects model for patients with and without a previous history of cardiovascular disease. Thirteen studies were included. Six trials included a total of 11 435 women without cardiovascular disease and assessed the effects of lipid-lowering medications. Lipid lowering did not reduce total mortality (RR, 0.95; 95% confidence interval [CI], 0.62-1.46), CHD mortality (RR, 1.07; 95% CI, 0.47-2.40), nonfatal myocardial infarction (RR, 0.61; 95% CI, 0.22-1.68), revascularization (RR, 0.87; 95% CI, 0.33-2.31), or CHD events (RR, 0.87; 95% CI, 0.69-1.09). However, some analyses were limited by too few CHD events in the available trials. Eight trials included 8272 women with cardiovascular disease and assessed the effects of lipid-lowering medications. Lipid lowering did not reduce total mortality in women with cardiovascular disease (RR, 1.00; 95% CI, 0.77-1.29). However, lipid lowering reduced CHD mortality (RR, 0.74; 95% CI, 0.55-1.00), nonfatal myocardial infarction (RR, 0.71; 95% CI, 0.58-0.87), revascularization (RR, 0.70; 95% CI, 0.55-0.89), and total CHD events (RR, 0.80; CI, 0.71-0.91). For women without cardiovascular disease, lipid lowering does not affect total or CHD mortality. Lipid lowering may reduce CHD events, but current evidence is insufficient to determine this conclusively. For women with known cardiovascular disease, treatment of hyperlipidemia is effective in reducing CHD events, CHD mortality, nonfatal myocardial infarction, and revascularization, but it does not affect total mortality.

Prevention and Rehabilitation: Preventing heart disease by controlling hypertension: Impact of hypertensive subtype, stage, age, and sex

BackgroundHypertension is related to significant morbidity and mortality rates from coronary heart disease (CHD). This report examines the relative and absolute impact on risk for CHD by controlling hypertension to high normal and optimal levels. MethodsAmong all subjects with untreated or inadequately treated hypertension in the National Health and Nutrition Examination Survey (NHANES) III who were 30 to 74 years of age and without prior CHD, the 10-year risk of CHD was calculated. With the use of sampling weights, the number of CHD events by age group, hypertension subtype (isolated diastolic hypertension [IDH], systolic-diastolic hypertension [SDH], and isolated systolic hypertension [ISH]), and stage of hypertension was estimated. Risk was recalculated and the number of events reestimated, assuming a reduction in blood pressure (BP) to high normal and optimal levels. The number and proportion (population-attributable risk, or PAR%) of events that could be prevented were determined from the differences in events and risk between uncontrolled and controlled BP levels. Derived from this was the number of persons needing treatment per CHD event prevented. ResultsControl of hypertension to high normal levels could prevent approximately one fifth (PAR = 19%) of CHD events in men and one third (PAR = 31%) of CHD events in women, whereas control to optimal levels may prevent 37% and 56% of CHD events, respectively (P < .01 for differences between men and women). Of CHD events that could be prevented, the greatest proportion occurred from controlling BP among older persons, men, and those with stage 1 hypertension (vs stages 2 and 3) or with ISH (vs IDH or SDH). The number of persons with hypertension needing treatment to prevent one CHD event ranged from 20.5 in men to 38.6 in women when controlled to high normal BP and 10.7 in men and 21.3 in women when controlled to optimal BP. ConclusionsThe greatest impact from control of hypertension occurs in older persons, men, and those with ISH, whereas the greatest PAR% occurred in women. Optimal control of BP could prevent more than one third of CHD events in men and more than half of events in women. Greater efforts to control hypertension in these populations may have a substantial impact in preventing CHD events.

Dietary fat predicts coronary heart disease events in subjects with type 2 diabetes.

To investigate whether quantity or quality of dietary fat predicts coronary heart disease (CHD) events in middle-aged type 2 diabetic subjects. The dietary habits of 366 type 2 diabetic men and 295 women, aged 45-64 years and free from CHD, were assessed with a 53-item food frequency questionnaire. They were followed up for 7 years. Men in the highest tertile of the polyunsaturated/saturated fat (P/S) ratio (>0.28) had a significantly lower risk for CHD death than men in the two lowest tertiles (5.0 vs. 14.2%, P = 0.009). The risk for all CHD events was 14.2 vs. 23.2%, respectively (P = 0.044). P/S ratio did not predict CHD events in women. In Cox multiple regression analyses taking into account other cardiovascular risk factors, the highest P/S ratio tertile was associated with the lowest rate of CHD death in men (P = 0.048). Low P/S ratio in men predicted future CHD events in type 2 diabetic subjects independently of conventional CHD risk factors.

Migraine and coronary heart disease in women and men.

We evaluated migraine as an independent risk factor for subsequent coronary heart disease (CHD) events among women in the Women's Health Study (WHS) and men in the Physicians' Health Study (PHS). Although several studies have suggested that migraine is associated with increased risk of stroke, there are few and conflicting data on whether migraine predicts risk of future CHD events. The WHS is an ongoing randomized, double-blind, placebo-controlled trial of low-dose aspirin and vitamin E in the primary prevention of cardiovascular disease and cancer in 39876 women health professionals aged > or =45 years in 1993, and the PHS is a completed randomized, double-blind, placebo-controlled trial of aspirin and beta-carotene in the primary prevention of cardiovascular disease and cancer in 22071 men physicians aged 40 to 84 years in 1982. Primary endpoints were defined as major CHD (nonfatal myocardial infarction [MI] or fatal CHD) and total CHD (major CHD plus angina and coronary revascularization). After adjusting for other CHD risk factors, female health professionals and male physicians reporting migraine were not at increased risk for subsequent major CHD (women: relative risk [RR], 0.83; 95% confidence interval [CI], 0.53 to 1.29; men: RR, 1.02; 95% Cl, 0.79 to 1.31) or total CHD (women: RR, 1.01; 95% Cl, 0.76 to 1.34; men: RR, 0.98; 95% Cl, 0.82 to 1.18). When considered separately, there was also no increase in risk of MI or angina. These prospective data suggest that migraine is not associated with increased risk of subsequent CHD events in women or men.

Serum Uric Acid and Risk of Coronary Heart Disease: Atherosclerosis Risk in Communities (ARIC) Study

PURPOSE: Approximately half of previous studies on serum uric acid have reported it to be an independent risk factor for coronary heart disease (CHD). We tested this hypothesis in the Atherosclerosis Risk in Communities (ARIC) Study. METHODS: A total of 13,504 healthy middle-aged men and women were followed prospectively for up to eight years. We identified 128 fatal and nonfatal CHD events in women and 264 in men. RESULTS: The age-, race-, and ARIC field center-adjusted relative risk of CHD for sex-specific quartiles of serum uric acid were 1.0, 1.39, 1.08, and 2.35 in women ( p for trend = 0.009) and 1.0, 1.03, 0.89, and 1.21 in men ( p for trend = 0.44), respectively. However, serum uric acid was correlated positively with many risk factors, and after multivariable adjustment, there was little evidence of an association of uric acid with CHD in either sex. CONCLUSIONS: Our results are not consistent with serum uric acid being an independent risk factor for CHD.

Heart and Estrogen/progestin Replacement Study (HERS): Design, Methods, and Baseline Characteristics

The Heart and Estrogen/progestin Replacement Study (HERS) is a randomized, double-blind, placebo-controlled trial designed to test the efficacy and safety of estrogen plus progestin therapy for prevention of recurrent coronary heart disease (CHD) events in women. The participants are postmenopausal women with a uterus and with CHD as evidenced by prior myocardial infarction, coronary artery bypass graft surgery, percutaneous transluminal coronary angioplasty, or other mechanical revascularization or at least 50% occlusion of a major coronary artery. Between February 1993 and September 1994, 20 HERS centers recruited and randomized 2763 women. Participants ranged in age from 44 to 79 years, with a mean age of 66.7 (SD 6.7) years. Most participants were white (89%), married (57%), and had completed high school or some college (80%). As expected, the prevalence of coronary risk factors was high: 62% were past or current smokers, 59% had hypertension, 90% had serum LDL-cholesterol of 100mg/dL or higher, and 23% had diabetes. Each woman was randomly assigned to receive one tablet containing 0.625 mg conjugated estrogens plus 2.5 mg medroxyprogesterone acetate daily or an identical placebo. Participants will be evaluated every 4 months for an average of 4.2 years for the occurrence of CHD events (CHD death and nonfatal myocardial infarction). We will also assess other major CHD endpoints, including revascularization and hospitalization for unstable angina. The primary analysis will compare the rate of CHD events in women assigned to active treatment with the rate in those assigned to placebo. The trial was designed to have power greater than 90% to detect a 35% reduction in the incidence of CHD events, assuming a 50% lag in effect for 2 years and a 5% annual event rate in the placebo group. The design, analysis, and conduct of the study are controlled by the Steering Committee of Principal Investigators and coordinated at the University of California, San Francisco. HERS is the largest trial of any intervention to reduce the risk of recurrent CHD events in women with heart disease and is the first controlled trial to seek evidence of the efficacy and safety of postmenopausal hormone therapy to prevent recurrent CHD events.

Sudden coronary death in women

Objectives The objective of this study was to examine prospectively the incidence, predisposing cardiovascular conditions, and risk factors for sudden death in women compared with men.Methods and Results The study design was a prospective general population examination of a cohort of 2873 women for development of sudden coronary death in relation to antecedent overt coronary heart disease (CHD), cardiac failure, and risk factors for coronary heart disease. Participants were women aged 30 to 62 years participating in the Framingham Study, receiving routine biennial examinations for risk factors and cardiovascular conditions. Among women monitored over a period of 38 years, there were 750 initial coronary events, of which 94 (12%) were sudden cardiac deaths. Of the 292 CHD fatalities in women, 32% were sudden cardiac deaths and 37% of the women had a history of prior CHD. Sudden death incidence in women lagged behind that in men by >10 years. However, above age 75 years, 17% of all CHD events in women were sudden deaths. Sudden death risk in women with CHD was half as high as in men if they had CHD. In both sexes, a myocardial infarction conferred twice the risk of angina. Cardiac failure escalated sudden death risk of women 5-fold but was only one fourth that of men with failure or CHD. Ventricular ectopy increased sudden death risk only in women without prior overt CHD. Except for diabetes, CHD risk factors imposed a lower sudden death risk in women than men. However, even in women, sudden death risk increased over a 17-fold range in relation to their burden of CHD risk factors.Conclusions Sudden death is a prominent feature of CHD in women as well as men, particularly in advanced age. A higher fraction of sudden deaths in women than men is unexpected occurring in the absence of prior overt CHD. It is subject to the same risk factors and as predictable in women as in men. However, at any level of multivariate risk, women are less vulnerable to sudden death than men. (Am Heart J 1998;136:205-12.)