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Calculate 'Sum of the Parts' to Pinpoint CV Risk in Women

(from the January 2018 ACP Internist)

Women face a steep increase in cardiovascular risk after menopause, requiring internists to incorporate composite indicators into the annual exam at midlife.

By Jennifer Kearney-Strouse

Clinicians should take a long-term view when managing cardiovascular risk in women at midlife, according to Beth L. Abramson, MD, MSc.

“When you're seeing your perimenopausal and postmenopausal women in your office, your goal is to make [them] feel well and live a long, vibrant life,” she told attendees at the North American Menopause Society's 2017 meeting in Philadelphia in October. “We're in it for the long run, and there's a lot of data on prevention. … We're here for long-term health and vibrancy of our female patients.”

Women face a steep increase in cardiovascular risk after menopause so clinicians must address such issues as weight and smoking.

Women face a steep increase in cardiovascular risk after menopause, said Dr. Abramson, who is associate professor of medicine at the University of Toronto and director of the Cardiac Prevention Center and Women's Cardiovascular Health in the division of cardiology at St. Michael's Hospital. “And our job as health care providers and menopause experts is to address that risk, as women go through midlife and beyond to reduce the death statistics,” she said.

Dr. Abramson noted that while data from the American Heart Association indicate a decrease in cardiovascular mortality rates over the past 30 to 40 years in older women, mortality rates in younger women have not decreased.

“We need to be aware of this, because there may be an explosion of cardiovascular issues at midlife and beyond that we will start seeing in the next decade or so,” she said. “This is actually very concerning.”

Beyond traditional risk factors

Traditional risk factors for cardiovascular disease are age, sex, high blood pressure, smoking, family history, and abnormal lipid levels, Dr. Abramson said. However, she stressed that composite indicators such as the Framingham Risk Score should also be incorporated into the annual exam for women at midlife, and that clinicians should take care to avoid underestimating risk in women.

“My risk at face value, as a younger, non-gray-haired woman—as we are taught in medical school, and in our training—is that it's lower than the older gray-haired man. And while that's probably true, there are other aspects of the risk that we need to consider,” she said. “The sum of the parts is greater than the individual.”

Dr. Abramson gave the example of a postmenopausal 56-year-old woman who smokes, has slightly elevated blood pressure, and has a brother who had a heart attack at age 54. Her 10-year risk according to the Framingham Risk Score would be “high for cardiovascular events over the next 10 years,” she said.

In discussions of risk factors, smoking should be at or near the top of the list, Dr. Abramson stressed. “I would say we're shuffling deck chairs on the Titanic if we're talking about differences in millimole or milligrams per deciliter of lipids that we're lowering, if a woman is still smoking,” she said.

Visceral fat is another important risk factor, she noted, with changes in fat distribution making the “apple shape” more likely as a woman ages. “The problem with that apple shape is that it's the dangerous inner fat, the visceral adiposity, that's associated biologically with adverse events,” she said.

Read the full article in ACP Internist.

ACP Internist provides news and information for internists about the practice of medicine and reports on the policies, products, and activities of ACP.

Back to the March 2018 issue of ACP IMpact