Cardiovascular disease (CVD) risk assessment and risk reduction strategies in postmenopausal women were recently addressed at the 2017 Annual North American Menopause Society (NAMS) meeting.
The overall female population is ageing. Women in Canada can expect to live on average nearly 83 years, approximately 5 years longer than men. Women spend at least one third of their lives postmenopause, and it is these women for whom cardiovascular disease (CVD) is a leading health threat.
Traditional risk factors for CVD include age, sex, dyslipidaemia, diabetes, smoking, and a family history of premature CVD.
Menopause is an important milestone and may be one of the first times a woman seeks medical advice around issues of long-term CVD prevention. Many of the risk factors for the conditions prevalent among older women are modifiable through changes in lifestyle. Others will need medication. The INTERHEART study examined modifiable risk factors and determined the main risks for CVD are modifiable and for women 94% of CVD risk can be attributed to modifiable factors.
Factors identified in this study as contributing substantially to increased CVD risk include diabetes mellitus, hypertension, abdominal obesity, current smoking, and psychosocial stress. Each of these risks can be reduced through appropriate choices, interventions, or both.
Despite overall health care improvements, risk of heart disease in women continues to be underestimated. CVD remains the leading cause of death and an important contributor to illness and disability among women. Half of all postmenopausal women will have CVD, and a third will die from it. Health behaviour interventions remain a cornerstone of chronic disease prevention in women, including CVD prevention, and should be highlighted during healthcare visits.
Observational studies show a relationship between serum cholesterol levels and CVD, and dietary measures to lower these levels are an important part of disease prevention. A diet low in sodium and simple sugars, with substitution of unsaturated fats for saturated and trans fats, as well as increased consumption of fruits, vegetables, and fibres is recommended. Evidence from the Nurses’ Health Study suggests that replacing dietary saturated fat and trans fatty acids with nonhydrogenated, monounsaturated, and polyunsaturated fats may be more effective in reducing the CVD risk than reducing overall fat intake in women. Recent AHA statements support the importance of addressing dietary fat in prevention of CVD.
Blood pressure generally increases after menopause. Menopause-related hormonal changes can lead to weight gain and make blood pressure more reactive to salt in diet, which, in turn, can lead to higher blood pressure. Blood pressure should be assessed in women at all appropriate visits in order to screen for hypertension (HTN), assess CVD risk, and monitor antihypertensive treatment if applicable. Reversible risks for developing HTN include obesity, poor dietary habits, high sodium
intake, sedentary lifestyle, and high alcohol consumption. Close attention to these factors should occur when assessing menopausal and postmenopausal women.
A composite CV risk assessment in the postmenopausal woman should be part of the health exam. CCS Dyslipidaemia Guidelines state that women ≥50 years of age or postmenopausal, and those with additional risk factors such as current cigarette smoking, diabetes, and arterial hypertension, have a full lipid profile screening done every 1-3 years. A CV risk assessment using the ‘10-year risk’ provided by the Framingham model (the Framingham Risk Score, FRS) should be completed every 3-5 years for women age 50-75. If there is a positive family history of premature CVD (ie, first degree relative <55 years for men; <65 years for women) the age parameters should be modified. A risk assessment may also be completed whenever a patient’s expected risk status changes. The Reynolds Risk Score, an alternative tool, takes into account both hsCRP (high-sensitivity C-reactive protein) and family.