Highlights from ‘7 Questions About Cardiovascular Disease in Women: 2022 Edition’

By Rina Mauricio, M.D.

Assistant Professor of Internal Medicine

The field of women’s cardiovascular health is vast and rapidly evolving. Recognizing this trend, #AHA22 included a session tailored to what is new in the field of women’s cardiovascular disease, which I had the pleasure of moderating.

Sex-specific risk factors for future CVD have now been recognized. Indeed, the importance of menopause as a sex-specific risk factor was highlighted. Research has shown that acceleration of CVD begins during the perimenopausal period, earlier than the onset of menopause. Further, premature menopause (< 40 years old) is an independent risk factor for CVD. Thus, taking a thorough menopause history should be a routine part of care, and prevention efforts should begin before a woman has entered menopause. Menopause results in altered lipid profiles, vascular health, and body fat composition in women, and these differences unique to women affect future cardiovascular risk.

There are likewise sex-specific differences in the presentation of and therapeutic approach to acute coronary syndromes (ACS). Plaque morphology differs between men and women. Results from SCOT-HEART demonstrated that women with stable chest pain have less atherosclerotic plaque than men. Furthermore, quantitative low attenuation plaque is a predictor of subsequent myocardial infarction in women.

There also is a concerning trend of rising maternal mortality in the United States, of which 20% is accounted for by pregnancy-associated myocardial infarction (PAMI). A multidisciplinary cardio-obstetrics team is critical in the management of these patients. PAMI can be due to atherosclerotic cardiovascular disease (one-third of patients), spontaneous coronary artery dissection (SCAD), or MI with nonobstructive coronary arteries (MINOCA). Pregnant patients presenting with an ST-elevation myocardial infarction (STEMI) should be offered the same invasive management as is done for their non-pregnant counterparts. In patients presenting with a non-ST-elevation myocardial infarction (NSTEMI), the decision whether to pursue invasive management is made after risk stratification based on cardiac biomarkers and the patient’s clinical/hemodynamic status, as well as following multidisciplinary discussion.

Heart failure also differs in men and women. Specifically, women are more likely to have heart failure with preserved ejection fraction (HFpEF). There also are sex-specific differences in cardiometabolic traits and exercise capacity in HFpEF patients; women have a lower systolic and diastolic reserve and peripheral oxygen extraction.

Breast cancer patients who receive radiation therapy are at risk for radiation-associated cardiac disease, in particular coronary artery disease. While advances in the delivery of radiation therapy decrease off-target effects on the myocardium, cardiovascular events may be underreported in radiation therapy trials. This is unfortunate given that radiation therapy is associated with adverse cardiovascular outcomes.

The session ended with a call-to-action to increase representation of women in clinical trials – both as enrollees and in clinical trial leadership. The participation to prevalence ratio (PPR) for women, used to describe the ratio of women enrolled in a trial relative to the proportion of women with that given disease in the population, is below what is considered acceptable in many trials. Recommendations to increase participation of women in cardiovascular clinical trials include increasing clinical trial awareness, reducing logistical barriers, and increasing the involvement of female trial investigators.

Email: rina.mauricio@utsouthwestern.edu