Cardiovascular risk burden for women on the rise, while men see improvement


Middle-aged (35 to 54 years) women are gaining ground on their male counterparts in their prevalence of myocardial infarction (MI) and their cardiovascular risk factor scores, according to an examination of the National Health and Nutrition Examination Survey (NHANES) over time.

Key Points

Middle-aged (35 to 54 years) women are gaining ground on their male counterparts in their prevalence of myocardial infarction (MI) and their cardiovascular risk factor scores, according to an examination of the National Health and Nutrition Examination Survey (NHANES) over time.1

The data point to a cardiovascular risk burden is worsening among women in relation to men, whose risk factor burden is improving slightly, said the study's principal investigator, Amytis Towfighi, MD.


The prevalence of MI decreased among men, from 2.5% during the first phase of NHANES to 2.2% during the second phase, while it increased from 0.7% to 1.0% among women.

Among those without a history of MI, the mean FCRS declined in men between the first and second surveys but remained stable in women. Assessment of individuals with an FCRS of 20% or greater revealed stability in the prevalence among men 35 to 44 years old and a decline among men 45 to 54 years old. None of the women 35 to 44 years old had an FCRS of 20% or greater during either period. The prevalence of an FCRS of 20% or greater remained stable in women 45 to 54 years old. Therefore, the ratio of men to women with an FCRS of 20% or greater declined from 32 to 18.

"In the past, we thought that this age group of women was protected against heart disease. Although their rates are still lower than men's, they are going up, so they're not absolutely protected," said Dr Towfighi, clinical assistant professor, department of neurology, University of Southern California, Los Angeles, and director, acute neurology unit, and chair, neurology department, Rancho Los Amigos National Rehabilitation Center.

"It's hard to know what's driving the increase [in the rate of MI] but we looked at components of the FCRS and others and noted that in women there haven't been as many improvements as in men," Dr Towfighi said.

Only levels of high-density lipoprotein (HDL) cholesterol improved in women. Total cholesterol levels, systolic blood pressure (SBP), and the prevalence of smoking remained stable, whereas the presence of diabetes mellitus and obesity got worse, she said. In contrast, men showed improvements in HDL cholesterol, SBP, and history of smoking. As in women, the men showed higher rates of diabetes and obesity from the first survey to the second.

"We've known that women's risk factors were not as well-controlled as men's," said Dr Towfighi. "The take home is that we have to be more aggressive in identifying and treating cardiovascular risk factors in women."

According to David Calabrese, RPh, MHP, chief clinical officer, MedMetrics Health Partners, Worcester, Mass., and clinical editor of Formulary, the finding may represent an important opportunity for the pharmacy community to refocus medication therapy management and retrospective drug utilization review efforts toward women at high risk of cardiovascular events who may not be receiving adequate pharmacologic intervention."


One reason that lipid levels are staying stable despite the increased prevalence in obesity is that medication use, particularly statins, is increasing, Dr Towfighi believes. "However, markers of diabetes went up in this study, suggesting that the metabolic syndrome is probably taking effect here but is being masked by medications," she said.

The FCRS is an important determination of risk because of its many different components, said Michael White, PharmD, professor of pharmacy at the University of Connecticut, Storrs, who agrees that obesity and "all of the negative health consequences that go along with it" may be the most important component of the FCRS.

The impact of the obesity epidemic on pharmacy and therapeutics is that "the number of patients who are going to be eligible for diabetes management, hypertension management, and hypercholesterolemia management is going to continue to increase over the course of time," said Dr White.

He continued, "the processes that the healthcare system has in place to detect aspects of metabolic syndrome-high blood pressure, high glucose levels, and high lipids-are already there, but there are going to be more patients detected within that spectrum. The number of people [men or women] who qualify for pharmacologic therapy is going to continue to increase."

According to Robert A. Quercia, MS, RPh, improving risk factor profiles in high-risk middle-aged women is in part a matter of education and counseling on the part of pharmacists, who need to reinforce the lifestyle message that patients should receive from physicians, and emphasize medication adherence to control risk factors.

"One of the problems with some patients is that they will admittedly say they eat fatty foods but feel safe since they are taking their statins to keep their cholesterol down," said Mr Quercia, clinical manager, department of pharmacy services, Hartford Hospital, Hartford, Conn., and adjunct associate professor, University of Connecticut, Storrs.


Pharmacy's challenge in identifying middle-aged women at high risk of cardiovascular events is that medical review processes or diagnoses are not available from pharmacy claims data, said Mr Calabrese. "Nonetheless there still may be opportunities working directly from pharmacy claims activity to try to evaluate when women are being treated for specific cardiovascular conditions based on the drugs that are in their profile," he said. "Are they being treated appropriately? Are they adherent to therapy? Is there a proper mix and dosing of drugs being utilized? And are drugs being utilized in accordance with current guidelines?"

The answers to these questions are within easier reach in managed care plans that have access to integrated medical and pharmacy claims activity, "where you can more accurately drill down to women with specific diagnoses at higher cardiovascular risk to ensure that those women are receiving therapy, are receiving the most appropriate therapy, and are adhering to such therapy," Mr Calabrese said.

"If you can identify those women based on their medications who are high risk, you can counsel and follow those patients more carefully," said Mr Quercia. "My feeling is to identify these high-risk women before they have an MI. This can be accomplished in the ambulatory care setting, such as clinics, whether tied to a hospital or not, and community pharmacies where patient counseling is performed."

Although many managed care organizations (MCOs) already have cardiovascular risk screening programs and drug utilization activities that are focused on cardiovascular disease, they are not necessarily gender-specific. "That may be an area that we need to consider looking at on a more routine basis," said Mr Calabrese, who is also clinical assistant professor, School of Pharmacy, Northeastern University Bouvé College of Health Sciences, Boston.

"In general, we're probably not doing a good enough job in terms of monitoring the use of these cardiovascular medications the way that we should be to ensure that patients are receiving optimal benefit, whether they're male or female," he said. "The more recent data [from Towfighi et al] is probably another reason why we do need to be refocusing more energy in those areas; ensuring optimized quality of patient care and outcomes by more closely monitoring these patient populations."

When it comes to the health of middle-aged women, both Dr Towfighi and Mr Calabrese agree that health systems may overlook cardiovascular risk factors in favor of risk factors for other diseases that strike women disproportionately.

"The employment of health, wellness and disease management efforts within the MCO setting is often slanted more toward women's health initiatives than men's, however, cardiovascular disease rarely rises to the top as an area of focus in the development of these types of initiatives," said Mr Calabrese. "More frequently, such programming is focused around areas such as osteoporosis, menopause, chlamydia screening, and breast cancer screening. As a result of some of this more recent information about a narrowing in the prevalence of MI between men and women, MCOs may need to be thinking about cardiovascular disease as well as developing women's health initiatives; and devoting enhanced resources toward the care of the female population."


Meanwhile, a second study shows that the gap in hospital mortality following acute MI between younger men and younger women is shrinking.2 Temporal changes in risk profiles appear to explain much of this narrowing of the mortality difference, found Viola Vaccarino, MD, PhD, professor of medicine, division of cardiology, Emory School of Medicine, Atlanta.

She and colleagues examined case-fatality rates of MI over 4 periods (1994-1997, 1998-1999, 2000-2003, and 2004-2006) using the National Registry of Myocardial Infarction, a prospectively collected nationwide database of patients admitted with acute MI at approximately 1,600 hospitals.

Hospital mortality rates declined over time in both genders in all age groups. The decline was largest in the women younger than 55 years (a decline of 52.9%) and smallest in the men younger than 55 years (a decline of 33.3%). The absolute decrease in hospital mortality was 3 times greater in the women in the youngest age group relative to their male counterparts (absolute reductions of 2.7% and 0.9%, respectively).

Women were less likely than men to undergo coronary catheterization and revascularization procedures at all time points in the study, so in-hospital treatment could not account for the narrowing in mortality between younger women and younger men, said Dr Vaccarino, professor of medicine, division of cardiology, Emory School of Medicine, Atlanta.

"It looked mostly like it was the risk profile upon presentation that explained this narrowing of the gap in mortality," she said. It was not that the risk factors examined had improved in women; in fact, the overall risk factor profile worsened over time in both men and women. Rather, sex differences in the prevalence of diabetes and hypertension, and the Killip class on admission, were less pronounced in the later years. (Although apparently contradictory to Dr Towfighi's findings regarding the changes in risk profiles between the 2 sexes, Dr Towfighi notes the different risk factors assessed in each study.)

Dr Vaccarino cautioned that although the gap in hospital mortality between the 2 sexes is narrowing in patients younger than 55 years, "there is still a difference between women and men and it's still significant, so more needs to be done to address this gap," she said.

"We need to make sure that people at high risk are recognized early enough so that intervention can be started," she said. "We need to focus on many behavioral risk factors that are among the strongest risk factors for heart disease-a healthy diet, physical activity, medication adherence, and avoiding smoking."

Mr Kuznar is a clinical writer based in Cleveland and a frequent contributor to Formulary.

Disclosure Information: The author reports no financial disclosures as related to products discussed in this article.


1. Towfighi A, Zheng L, Ovbiagele B. Sex-specific trends in midlife coronary heart disease risk and prevalence. Arch Intern Med. 2009;169:1762-1766.

2. Vaccarino V, Parsons L, Peterson ED, Rogers WJ, Kiefe CI, Canto J. Sex differences in mortality after myocardial infarction: changes from 1994 to 2006. Arch Intern Med. 2009;169:1767-1774.

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