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The years leading up to menopause —  or menopause transition — is a time of increasing heart disease risk for women, according to a new Scientific Statement from the American Heart Association (AHA).

Monitoring women’s health and lifestyle while integrating early intervention strategies for good cardiovascular health are important, especially during midlife and menopause to help prevent heart disease, according to the statement, “Menopause Transition and Cardiovascular Disease Risk: Implications for Timing for Early Prevention,” published in AHA’s journal, 

Hormone therapy during the menopause transition period may also help reduce heart disease risks, according to AHA.

“Over the past 20 years, our knowledge of how the menopause transition might contribute to cardiovascular disease has been dramatically evolving. We have accumulated data consistently pointing to the menopause transition as a time of change in cardiovascular health,” Samar R. El Khoudary, Ph.D., M.P.H., chair of the statement writing committee and associate professor of epidemiology at the University of Pittsburgh’s Graduate School of Public Health and the Clinical and Translational Science Institute, said in a 

Physiological changes during menopause, such as increased abdominal fat and visceral fat (body fat around the organs), are associated with a heightened risk of all-cause, cardiovascular disease and cancer mortality — even among those with normal body mass index levels, AHA said.

In addition, cholesterol levels, metabolic syndrome risk and vascular vulnerability appear to increase with menopause beyond the effects of normal aging.

For many women, the menopause transition begins when they are in their late 40s to mid-50s. Before this transition, women produce estrogen, which may also have cardio-protective effects. When women go through the natural menopause transition, their ovaries stop producing as much estrogen, AHA said. The changes can also occur through surgical menopause (a partial or full hysterectomy, which includes removal of one or both ovaries).

Since the increase in heart disease risk during menopause is associated with a decrease in estrogen production, healthcare professionals and scientists have studied if hormone therapy might help reduce cardiovascular risk.

“There is research indicating potential cardiovascular benefits of certain combinations of hormone therapy when initiated in early but not late menopause,” AHA said. “Further research is needed to evaluate the role of other hormone therapies, and how long these interventions impact cardio-metabolic health.”

In addition, some studies show the benefits of hormone therapy — including a decreased risk of type 2 diabetes and protection from bone loss — seem to outweigh the risks for most women in early menopause.

“Current recommendations from leading professional medical societies endorse the use of hormone therapy for women who have recently begun the menopause transition, with appropriate indications,” AHA said.

Healthcare professionals should also consider an aggressive, prevention-based approach for women during the menopause transition to decrease the probability of a future cardiovascular disease occurrence, such as heart attack or stroke, El Khoudary said.

Articles

Women have an increased risk of heart disease in the years leading up to menopause.

Menopause Transition Associated With Higher Cardiovascular Risks

Women face a 20% increased risk of developing heart failure or dying within five years after their first severe heart attack compared with men, according to a new study.

Other studies have looked at gender differences among people who have had heart attacks, but this study zeroed in on whether women and men have different rates heart failure. 

 and his colleagues at the University of Alberta, say their finding that women are more likely to develop heart failure after a heart attack mean  patients, and especially women, should be monitored for signs and symptoms of heart failure after a heart attack. If possible, they say, people should get care that prevents heart failure or keeps mild cases from getting worse.

Ezekowitz and his colleagues had a large database to work with: some 45,000 patients, hospitalized for a first heart attack between 2002 and 2016 in Alberta, Canada. Just over 30% of them were women. One cut of their analysis separated patients into those who had severe, life-threatening  ST-segment elevation myocardial infarction (STEMI) heart attacks and those who had less severe non-STEMI, or NSTEMI, heart attacks 

Women had a higher unadjusted rate of in-hospital mortality than did men in both patients with STEMI (women, 9.4%, vs men, 4.5%) and patients with NSTEMI (women, 4.7%, vs men, 2.9%) heart attacks. But after various statistical adjustments, the gender mortality difference "disappeared" for NSTEMI heart attacks but not for the more severe STEMI ones.  

After discharge, women more commonly developed heart failure after STEMI events (women, 22.5% vs men, 14.9%) as well as after NSTEMI heart attacks (women, 23.2% vs men, 15.7%).

Women were more likely to be an average of 10 years older than men at the time of their heart attack, at an average age of 72 years old versus 61 years old for men. They also had more complicated medical histories, including high blood pressure, diabetes, atrial fibrillation and chronic obstructive pulmonary disease—risk factors that may contribute to heart failure, according to a 

Notably, women were seen less frequently in the hospital by a cardiovascular specialist (72.8% vs 84% for men). In addition, fewer women were prescribed medications such as beta-blockers or cholesterol-lowering drugs.

Women also had slightly lower rates of revascularization procedures to restore blood flow, such as surgical angioplasty, the researchers found.

“Identifying when and how women may be at higher risk for heart failure after a heart attack can help providers develop more effective approaches for prevention,” Ezekowitz, a cardiologist and co-director of the Canadian VIGOUR Centre at the University of Alberta, said in the press release about the study. “Better adherence to reducing cholesterol, controlling high blood pressure, getting more exercise, eating a healthy diet and stopping smoking, combined with recognition of these problems earlier in life would save thousands of lives of women—and men.”

In addition to the elevated risk for heart failure among women, researchers found that 65.7% of men had NSTEMI heart attacks, while 34.3% of women experienced them.

More men (73.5%) also experienced the more severe STEMI heart attacks, while only 26.5% of women had them.

The next step is to further examine if all patients — particularly women — are receiving the best care and where interventions can address oversights, the study’s co-author, 

, Ph.D., co-director of the Canadian VIGOUR Centre, said in the press release.

“There are gaps across diagnosis, access, quality of care and follow-up for all patients, so we need to be vigilant, pay attention to our own biases and to those most vulnerable to ensure that we have done everything possible in providing the best treatment,” Kaul said.

Women are disproportionately affected by heart failure after heart attacks, according to a Canadian study. 

Women Have Higher Rate of Heart Failure, Mortality After Heart Attacks Than Men

Building relationships with state Medicaid agencies and local health plans is essential for sharing the value of evidence-based health promotion and disease prevention programs and obtaining reimbursement for those efforts, according to a new report from the National Council on Aging.

The council, with support from the Administration for Community Living, contracted with Health Management Associates to develop the 

, titled “Reimbursement for Evidence-Based Health Promotion Programs in the Community.”

The report is based on a extensive literature review and interviews with many stakeholders.

from state Medicaid and state and city aging agencies officials. The goal, it says, was to identify “promising practices establishing reimbursable, evidence-based health promotion programs and approaches that may be replicated in other states in Medicaid, Medicare Advantage and other emerging markets to support program sustainability beyond grant funding.”

One of the report’s principal findings is the importance of “ongoing, regular communication” with state agencies about evidence-based programs and the improved health outcomes they can achieve.

The report also recommending building relationships through statewide networks of community-based organizations that have experience with Medicaid and Medicare Advantage health plan contracting. “These entities provide business function support including marketing, negotiating contracts, executing required paperwork, delivery system development and management, and complying with health care privacy laws,” the report says. Some of the networks named in the report include the Partners in Care Foundation in San Fernando, California; The Healthy Living Center of Excellence in Lawrence, Massachusetts; and The CommunityCare Linkprogram in New York

Community-based organizations should position themselves as community partners that can identify the most suitable evidence-based programs, based on community needs, the report says. “It is important for CBOs (community-based organizations) to demonstrate their essential knowledge of local geographies, communities, and residents to health plan and system partners."

Community-based organizations that entered into contractual relationships with health plans often benefited from using grant funding to build out the organization’s capacity and infrastructure, the report notes.

The New York City Department of Health obtained grant funding from the state of New York to develop a model contract for health plans and community-based organizations. The model is designed to support contracting with Medicaid, Medicare Advantage and commercial health plans.

Community-based organizations will also benefit from establishing reimbursement relationships with multiple payers to diversify business and funding streams

CBOs with a single payer source may experience disruption in referrals and business due to discontinuance of health plan and/or program coverage of services,” the report says.

Community-based organizations should position themselves as groups with a deep, working knowledge of an area's geography, communities and residents.

What Does It Take To Be a Successful, Reimbursable Health Promotion Program?

 The impact of psoriatic arthritis (PsA) differs widely between genders, several studies show.

In the most recent research, published online in 

 last month, found that disease activity, physical disability, functional limitation, depression and anxiety scores were higher among women with PsA than amone men with the disease. The researchers reported that quality of life and Psoriasis Area and Severity Index (PASI) scores were higher in male patients.

The study of more than 1,000 patients with PsA at 25 centers in Turkey zeroed in on patients with “axial” PsA, a recognized categorization of PsA that means the disease affects the spine, hips and shoulders in contrast to the “peripheral” PsA, which affects the arms and legs).

Pain score, fatigue, quality of life, anxiety, depression, and other scores were significantly worse in females than males with axial PsA. However, quality of life was better and PASI scores were worse in men than in women, the research team led by Kemal Nas of Sakarya University.

“This study has shown that the burden of disease in axial PsA has significant difference between genders. Therefore, we suggest that new strategies should be developed for more effective treatment of axial PsA in female patients,” wrote Nas and his colleagues.

Nas was the lead author of a previous study exploring gender differences among people with PsA that was also published in 

. That 2017 study found that women with PsA had higher symptom duration and body-mass indexes than men with the disease.

“Men with PsA are more likely to have higher PASI scores and longer duration to develop arthritis after the onset of psoriasis, while women are more likely to have higher disease activity and report more fatigue and physical activity limitations,” says the abstract.

Not all of Nas’ findings have pointed to differences between the sexes. In the 2017 study, for example, Nas and his colleagues found that that quality of life, extra-articular features (including uveitis and iritis), family history of PsA and the rates of spondyloarthritis and ankylosing spondylitis were very similar among both men and women.

Research documents that the disease affects men and women differently.

Christine Blank

Articles

Menopause Transition Associated With Higher Cardiovascular Risks

Women Have Higher Rate of Heart Failure, Mortality After Heart Attacks Than Men

What Does It Take To Be a Successful, Reimbursable Health Promotion Program?

The Difference Gender Makes in Psoriatic Arthritis