The traditional and well-studied risk factors for coronary heart disease in men, namely, hypertension, diabetes mellitus, hypercholesterolemia, cigarette smoking, a family history of premature atherosclerotic vascular disease, and obesity appear to be operative in women as well; however, in the presence of any of these risk factors, the incidence of coronary heart disease is higher in men than in women (3). For example, although the incidence of coronary heart disease is higher among men than among women with systolic hypertension, the relative risk of coronary heart disease (in comparison with a gender-matched population without hypertension) is the same in women and men. Furthermore, women have a higher incidence of hypertensive heart disease and common causes of hypertension, such as renovascular hypertension due to fibro-muscular dysplasia, are more common in women than in men (4,5).
Women with diabetes mellitus have twice the risk of myocardial infarction as nondi-abetic women and the same risk of a myocardial infarction as a nondiabetic male of the same age (3). In addition, the increased risk associated with diabetes appears to be synergistic with gender. In one study, cardiovascular mortality rates were 3-7 X higher in diabetic women than nondiabetic women, as compared to 2-4 X higher in diabetic men than in nondiabetic men (6).
Interestingly, gender differences have been noted in cardiovascular risk attributed to hypercholesterolemia. In fact, decreased high-density lipoprotein (HDL) levels are a stronger predictor of risk in women than in men (7,8), and elevated low-density lipoprotein (LDL) levels, a strong predictor of atherosclerotic heart disease in men, do not constitute as strong a risk factor for coronary artery disease as low HDL levels in women who do not have established clinical coronary disease (9,10). Elevated triglyceride levels also appear to be an independent predictor of coronary disease in older women, and there is evidence to suggest that lipoprotein(a) [Lp(a)] is strongly associated with coronary artery disease in younger women (9,11).
It is noteworthy that cigarette smoking remains the leading cause of preventable coronary heart disease in women and that over 50% of myocardial infarctions occurring among middle-aged women are attributable to tobacco use (12). The magnitude of increased risk, a two- to four-fold increase compared to nonsmokers, is similar in women and men, occurs with even minimal exposure, and is related to the number of cigarettes smoked (13). Moreover, the risk of coronary heart disease begins to decline within months and reaches the level of nonsmokers 3-5 yr after smoking cessation. Although the prevalence of current tobacco use is similar in women and men with acute
coronary syndromes undergoing revascularization procedures, the prevalence of former smoking is higher in men and reflects reports documenting a slower decline in smoking cessation rates in women (Fig. 2) (14). For women over the age of 35 yr who use oral contraceptives, there is a synergistic effect with tobacco use to increase the risk of atherothrombotic coronary artery disease (15). These unfavorable smoking patterns in women, particularly among young women, have widespread clinical implications.
Obesity and sedentary lifestyle contribute to increased risk of coronary artery disease in women (Fig. 2). In fact, one-third of adult women are classified as obese, and up to 60% of women report no regular physical activity. Central, or abdominal, obesity has been identified as a significant coronary disease risk factor for women, and studies suggest women who participate in a regular exercise program have a 50% risk reduction compared to sedentary women (12).
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