Misconceptions about the prevalence of heart disease in women has plagued physicians and their patients. A survey by the American Heart Association showed that more than two thirds of women aged 25 to 44 did not realize that heart disease was the major cause of death in women in the US. In the past, women were thought to be at significantly lower risk for heart disease than men. Due to this belief, women were screened less aggressively for risk factors, had less diagnostic testing, and less treatment. Now that we have all but abandoned the notion that hormone replacement therapy reduces the risk of heart disease, at least for the time being, it is time to improve our risk assessment, screening, diagnosis and treatment of heart disease in the postmenopausal woman.

Up until this point, the less aggressive assessment and management of women may have been related to greater frequency of noncoronary chest pain in younger women, the tendency to be 10 years older than men at the initial clinical symptoms and signs of coronary disease, women being 20 years older than men at the time of myocardial infarction, and the 30 year practice of prescribing HRT as an assumed prevention strategy, thinking that not much more was needed.

Lifestyle factors and risk factors are similar in women and men. Dyslipidemia, hypertension and diabetes tend to develop in women at an older age than in men and it is recommended that screening for these conditions begin at about age 45 in women, 10 years later than for men. Lifestyle factors should be assessed at a much earlier age. Screening for smoking, alcohol intake, exercise and nutritional habits, stress, body mass index (BMI) and weight loss/weight gain patterns should be done at a much earlier age as part of regular annual exams.

Overweight women and those with the “apple” fat distribution are at greater risk for developing coronary artery disease than are slim women and those with the pear fat pattern. This abdominal obesity also increases the risk of high blood pressure and diabetes and may lower the HDL-cholesterol level and raise the triglyceride level. A waist-to-hip ratio for middle-aged women <0.8 is considered desirable. A BMI < 25 is associated with a lower risk of cardiovascular disease and a BMI >29 has been associated with triple the risk of coronary heart disease compared with women who were lean and with a BMI of 21. (1) Women with a BMI of 25-28.9 and only moderately overweight had almost double the risk.

Another critical risk factor is family history. Women whose father had a heart attack or stroke before age 50, or a mother before age 65 are at increased risk of premature heart disease.

Diabetes predicts a higher risk of heart disease in women than in men and elevates the risk three to seven times above that of women who do not have diabetes. (2) Women with diabetes also have more adverse lipid profiles, greater obesity and higher blood pressures than diabetic men.

There may be gender differences in risk related to dyslipidemia, although this is not yet clear. Elevated triglycerides may be an independent risk factor for women, but not for men. The combination of high triglycerides and low HDL appears to present substantial risk in women. For older women, the predictive value of total cholesterol and LDL is diminished, yet on the other hand, HDL levels are more predictive in older women than they are in men. (3) For women with no coronary artery disease and fewer than two risk factors, the LDL goal is < 160mg/dL. If no coronary disease and two or more risk factors, then the goal is < 130mg/dL. For women with coronary artery disease, then LDL levels should be < 100 mg/dL.

Several other risk factors should be considered, although are not yet part of the standard risk-factor panel for women or men. Some of these may in fact be more predictive for women than men although it is not yet known whether lowering the levels of these factors will significantly benefit women.

C-reactive protein: C-reactive protein (CRP) is produced in the liver and is a marker of systemic inflammation. It appears to be a risk factor for atherosclerosis and for infarction. In the Women’s Health Study, CRP was the strongest predictor of risk of cardiovascular events. (4) In the Postmenopausal Estrogen/Progestin Interventions (PEPI) trial, all hormonal regimens studied caused a large and sustained increase in CRP, and was hypothesized to be related to the risk of clots and strokes within the first year of initiating HRT in women with pre-existing heart disease. (5)

Homocysteine: Homocysteine is another marker of inflammation and has been shown to be an independent predictor of new coronary events in older men and women. (6) The relative risk of coronary events in women in the Women’s Health Study was 2.0 in those with the lowest levels of homocysteine. (4) It still needs to be determined whether or not reducing homocysteine with folic acid will actually reduce the risk of coronary heart disease (CHD), although most practitioners would consider this to be a simple, safe strategy.