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Dyslipoproteinemia in women and the elderly
1Lipid Research Clinic, George Washington University Medical Center, DC.
Insights
Women and men share major coronary risk factors, and women benefit from cholesterol lowering. Screening and treatment for high cholesterol are crucial for both genders, especially postmenopausal women and older adults with existing heart disease.
Area of Science:
- Cardiology
- Preventive Medicine
- Endocrinology
Background:
- Coronary atherosclerosis is a leading cause of death in both women and men, with women experiencing it later in life.
- Traditional cardiovascular risk factors are significant in women, but specific lipid profiles (e.g., HDL-c, triglycerides) and diabetes show unique predictive values.
- Hormonal influences, including oral contraceptives (OCs) and hormone replacement therapy (HRT), can impact coronary risk in women.
Purpose of the Study:
- To emphasize that major risk factors for coronary artery disease (CAD) are similar in women and men.
- To advocate for the inclusion of women in cholesterol screening and treatment protocols.
- To review the evidence supporting cholesterol-lowering benefits and hormonal influences on cardiovascular risk in women.
Main Methods:
- Review of existing epidemiological data and clinical evidence regarding cardiovascular risk factors in women and men.
- Analysis of the predictive value of lipid subfractions (LDL-c, HDL-c, triglycerides) and diabetes in different populations.
- Examination of the effects of exogenous gonadal hormones (OCs, HRT) on coronary risk in pre- and postmenopausal women.
Main Results:
- Cholesterol screening is advised for women as they benefit from cholesterol lowering, similar to men.
- Triglycerides are stronger predictors of risk in women, while HDL-c may be more predictive than LDL-c.
- Diabetes significantly increases risk in women, and estrogen may offer protection in postmenopausal women, pending further trials.
Conclusions:
- Excluding women from cholesterol screening and treatment is unwarranted; they benefit from interventions.
- Specific lipid profiles and conditions like diabetes have distinct implications for cardiovascular risk in women.
- Cholesterol-altering therapies are likely effective in postmenopausal women and older individuals with established CAD, regardless of gender or age.
Abstract:
Major risk factors predict coronary risk in both women and men. It is inadvisable and unwarranted to suggest that women be excluded from cholesterol screening. In fact, what evidence is available suggests that women, similar to men, benefit from cholesterol lowering. This is not an insignificant issue. Women, similar to men, die mostly of coronary atherosclerosis, although atherosclerotic death in women occurs 5 to 10 years later than in men. There are some risk factors that are unique in women. LDL-c levels may be less predictive of risk in women than in men; HDL-c levels may be more predictive. Triglycerides are a stronger predictor of risk in women than in men. Finally, diabetes is a major risk factor in women and almost eliminates the differences in risk seen in comparing nondiabetic men and women. Exogenous gonadal hormones, both in the form of OCs and HRT, have the potential to influence coronary risk in women. In premenopausal women, use of OCs is associated with increased risk of coronary disease in women who smoke, particularly in women older than age 35. In postmenopausal women, estrogen use is generally associated with protection against coronary disease. These results may be in part due to favorable effects on circulating lipoproteins but may as well be related to the protective effects of estrogen on the arterial wall. Definitive recommendations about the use of estrogen in postmenopausal women for the primary prevention of coronary disease await the completion of clinical trials of estrogen alone and in combination with progestins. Cholesterol and its lipoprotein subfractions continue to be predictors of both morbidity and mortality in older populations. The value of cholesterol-altering therapy in older individuals is not as well established in clinical trials as in middle-aged men. Nevertheless, there is good reason to believe that the results from both primary and secondary prevention studies in younger individuals can readily be extrapolated to older individuals. In particular, individuals with symptomatic coronary disease but a relatively good prognosis should be offered the same benefits from secondary prevention as younger individuals. Thus, although data are more limited in women and the elderly than in middle-aged men, there is good reason to believe that cholesterol interventions are likely to be effective, particularly in postmenopausal women and in older individuals with established coronary disease. To withhold therapy based simply on gender or chronologic age is a mistake.