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Women and heart disease: questions remain

Historically women have not been the focus of many studies about heart disease. This is gradually changing, and we’re hopeful many of the questions we have about the similarities and differences between men and women and heart disease will be answered.

We do know, however, based on studying some of the subpopulations of women involved in studies, women do benefit from cholesterol-lowering medications as much, if not more so, than men. The question remains why, as this latest study shows, are they not being treated as aggressively as men. And given the overwhelming evidence cholesterol-lowering medications reduce the incidence of heart attacks and mortality, why were the percentages of people taking the medications so low in this study–men and women.

The study underscores the importance of the questions, but we don’t yet have the answers. In addition to intervention with medications, there is also evidence primary care physicians are not stressing the importance of a low-fat diet and exercise, smoking cessation and blood pressure management with their female patients. These are all well documented lifestyle modifications that can minimize a woman’s risk for heart disease, and physicians need to spend time making sure their patients understand them.

Time and care coordination important for cardiac education
Part of the problem may be lack of time. Many patient visits focus on taking care of immediate health problems and performing physical exams and routine screening tests. Taking time to counsel and educate patients about diet, exercise and risk factors sometimes loses out to the realities of time pressure.

Another factor may be a lack of care coordination. Women often regard their ob-gyns as their primary care physicians, and these specialists may not include cholesterol screening and risk factor analysis as part of their annual visit. Also, women too often regard heart disease as something that affects men more than women, and they may feel a false sense of security that keeps them from being proactive in this regard. The fact is heart disease is the number one killer of both men and women.

Take charge of your health
There are several things women can do to take responsibility for their health. I recommend people have a cholesterol screening when they’re in their 20s with updates every five years. They should know their scores for total cholesterol, high density and low density lipids and triglycerides. Not only should women be screened, they should understand what the numbers mean and what role HDL "good" and LDL "bad" cholesterol play in whether arteries are healthy or diseased.

If a woman’s cholesterol profile places her at risk, she needs to talk with her doctor about lifestyle modifications; specific cholesterol targets should be set and times should be established to measure if these changes are making a difference. If lifestyle modifications don’t sufficiently reduce risk, women need to discuss medication options with their physicians.

Women who are placed on cholesterol-lowering medications need to understand how it is supposed to affect the different components of their cholesterol profile, what side effects they may experience and how the medication may interact with others they may take.

Women who prepare for medical visits with specific questions related to heart disease are more likely to get attention. I give women a checklist of five questions to ask their doctors to help ensure they have the information they need (see box at left).

Those at special risk
Some women with a very strong family history of heart disease and women with diabetes are at high risk for heart disease. It is particularly important they understand that risk and form a relationship with physicians who will work with them to develop an action plan and follow their progress closely.

The good news is that we have several effective medications to reduce cholesterol levels, and pharmaceutical companies have several new ones in their pipelines, which are likely to offer physicians and patients more and better choices.

Dr. Caulin-Glaser is a cardiologist at Yale-New Haven Hospital, an assistant professor of cardiology at the Yale School of Medicine and medical director of the Temple Cardiac Rehabilitation Center.