For both men and women, cardiovascular disease (CVD) is the leading cause of death worldwide. Although rates have decreased because of advances in diagnosis, prevention, and treatment, still one in three US women will die of heart disease, and more women will die of CVD than men.
The risk for CVD in women increases with age such as it does in men, but the increase starts a little later in women. Most CVD in women occurs during the years after menopause. Cholesterol levels have been found to increase in the early years after menopause. Of note, premature menopause is an established risk factor for CVD.
Risk Factors for CVD
A number of risk factors are associated with CVD. Some risk factors for heart disease, such as family history or race, cannot be changed. Others can be modified.
These are some of the factors that increase a woman’s risk of heart disease
- Age
- Family history, such as a father or brother who had a heart attack before age 55, a mother or sister who had a heart attack before age 65
- Black ethnicity
- High blood pressure
- Abnormal cholesterol levels
- Smoking
- Physical inactivity
- Being overweight or obese
- Waistline more than 35 inches (88 cm)
- Diabetes
- Premature menopause, especially before age 35
- Autoimmune diseases such as lupus or rheumatoid arthritis
- History of preeclampsia, gestational diabetes, or pregnancy-induced hypertension
Smoking
Tobacco use is the single most important preventable risk factor for CVD in women. Women who smoke are two to six times more likely to have a heart attack than are nonsmokers. But there’s good news—when a woman stops smoking, no matter how long or how much she has smoked, her risk of heart disease, along with other health risks, drops quickly.
Blood Pressure
A normal BP reading is when the systolic pressure (upper number) is lower than 120 mm Hg and the diastolic pressure (lower number) is lower than 80 mm Hg. When these levels climb to 130 mm Hg or higher for systolic pressure or 80 mm Hg or higher for diastolic pressure, this is considered high blood pressure (hypertension). Treatment is recommended for women whose BP regularly exceeds these limits. High BP becomes more common as women age—at least 41% of postmenopausal women and more than 75% of US women older than 60 years have hypertension. Regular BP testing is important because high BP rarely causes noticeable symptoms.
High BP can sometimes be managed by
- Controlling weight
- Increasing consumption of dietary fruit, vegetables, whole grains, and low-fat dairy
- Limiting salt and alcohol consumption
- Exercising on a regular basis
Treatment with a variety of medications is recommended if initial lifestyle changes aren’t enough to reduce BP. Regular testing is essential to make sure levels stay under control.
Cholesterol
High levels of cholesterol, especially high levels of low-density lipoprotein cholesterol (LDL-C), in the blood can cause a buildup of plaque on the inner walls of arteries. Plaque slows blood flow or blocks it entirely. If a blood vessel in the heart becomes blocked, a heart attack can occur. If this blockage happens in a blood vessel in the brain, a stroke can occur. Elevated cholesterol levels are a major risk factor for CVD. Most management of cholesterol is focused on lowering LDL-C (the “bad” cholesterol).
Levels of triglycerides, another component of cholesterol, appear to be a better predictor of CVD in women than in men. A low level of high-density lipoprotein cholesterol (HDL-C; the “good” cholesterol) may also serve as a marker of increased CVD risk.
Traditionally, healthcare providers had relied on cholesterol ranges and targets when evaluating CVD risk and recommending treatment. Today, a risk assessment will include factors such as age, race, smoking status, the presence of diabetes, and BP levels, along with various cholesterol measurements, to estimate short- and long-term risk.
Cholesterol levels can be managed with lifestyle changes such as eating a heart-healthy diet, exercising regularly, and keeping weight under control.
For those at increased risk for CVD (see www.cvriskcalculator.com to calculate your 10-year risk for CVD), treatment with statin drugs may be recommended. The American Heart Association recommends that these women talk to their healthcare providers about the risks and benefits of statin therapy if they
- Have a history of known CVD
- Have an LDL-C level greater than 190 mg/dL
- Are age 40 to 75 years and have diabetes
- Are age 40 to 75 years, have an LDL-C level of 70 mg/dL to 189 mg/dL, and have a 10-year risk of CVD that’s between 5% and 20%
- Are age 40 to 75 years, have an LDL-C level of 70 mg/dL to 189 mg/dL, and have a 10-year risk of CVD that’s 20% or greater
Diabetes
People with diabetes are significantly more likely to develop heart disease than are people without diabetes. Preventing diabetes by losing weight and watching your diet is important because these are factors that you can control.
Exercise
Regular physical activity, particularly aerobic exercise, promotes cardiovascular health. Midlife women who exercise regularly have lower weight, BP, and blood glucose levels, as well as healthier cholesterol levels. It’s recommended that women accumulate at least 150 minutes per week of moderate exercise (such as brisk walking) or 75 minutes per week of vigorous exercise. The activity can be spread throughout the week in at least 10-minute sessions. Resistance training is also recommended for 20 minute sessions, two to three times a week.
Weight
Maintaining a healthy body weight is important for optimal cardiovascular health. Women who are overweight can reduce health risks greatly by losing just 10% of their weight. A combined approach of diet and exercise is best. Women who need to lose weight or sustain prior weight loss are recommended to get at least 60 to 90 minutes of moderate physical activity on most or all days of the week.
Nutrition
Choose a diet that includes
- A variety of fruits and vegetables (more than 4.5 cups per day)
- Whole grains and high fiber
- Fish, especially oily fish (at least twice a week)
- Sources of protein that are low in saturated fat and cholesterol, avoiding trans fatty acids
- Limited sodium (less than 1.5 g per day)
- Limited alcohol consumption (no more than 1 drink per day)
Aspirin therapy is commonly recommended for women with existing CVD to reduce risk of a second stroke or heart attack, but the benefits have not been clearly shown to outweigh the risks with the use of a daily low-dose (81 mg) “baby” aspirin as a CVD prevention strategy. This practice is only recommended for women between the ages of 40 and 69 years who have significant risk factors for CVD and a low risk for gastrointestinal bleeding, which is a common adverse event. Don’t begin aspirin therapy without a discussion with your healthcare provider to assess the risks.
Although hormone therapy (HT) is helpful for managing menopause symptoms, it is not recommended for CVD protection at any age. Age and time since menopause are critical factors in the effect of systemic HT on CVD risk. More favorable effects are seen for women aged 50 to 59 years and within 10 years of menopause at treatment initiation. Studies have shown that some types of HT may increase the risk of heart disease, blood clots, and stroke.
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