While preparing for a talk for the ESC Congress on secondary prevention for women with cardiovascular disease, I came across increasingly ominous data. The majority of women are older when they develop cardiovascular disease (CVD) – on average a decade older than men – and women are relatively protected prior to menopause. However there are worrying trends regarding the incidence and outcomes of myocardial infarction in young women (eg < age 55 or 60).
• The latest WHO data on Europe show that CVD accounts for 49% of all deaths in women
o This is higher than the proportion for men – 41%
o Far higher than the proportion of deaths due to breast cancer (2%) and all cancers (19%)
o Townsend N, et al. EHJ 2015
• Data from the US show that while mortality declined for women < 55 years in 1979 – 1989, there was no improvement 1990 – 1999, and only a slight non-significant decline (-1.0%) in the last decade
o This is compared to a steady 4.5 – 5% decline in mortality for women at older ages in the past decade
o Wilmot KA, et al. Circulation 2015
• Although the proportion of women overall in the ST elevation MI FAST-MI registry in France declined 3% from 1995 to 2010, the proportion of those women who were under the age of 60 increased from 12% in 1995 to 25% in 2010
o There was a significant increase in the proportion of young women not having ‘traditional’ risk factors such as hypertension and diabetes
o Instead an increasing number of women presented with only smoking, obesity or both as their only risk factors
o Puymirat E, et al. JAMA 2012
• Data from British Columbia showed a nearly 2% increase in AMI rate among women aged 20 – 55 years in the last decade
o Izadnegehadar, M et al. J Women’s Health 2014
• Among patients (with known or suspected CAD) undergoing coronary angiography in a single US centre, the highest rate of depressive symptoms (27%) was found in women < age 55
o Depressive symptoms in this group was associated with a significant likelihood of being diagnosed with CAD, having a major cardiac event, and death
o Shah AJ, et al. JAHA 2014
Our knowledge of how to prevent and manage heart disease in young women is inadequate as they have been less studied than older women and men. Dr. Elizabeth Nabel called for research to better understand the worsening risk profile of younger women, and for providers across the health care system to work together to identify women at risk and to intervene to lower cardiovascular disease development.
Izadnegahdar M, Singer J, Lee MK, Gao M, Thompson CR, Kopec J, Humphries KH. Do younger women fare worse? Sex differences in acute myocardial infarction hospitalization and early mortality rates over ten years. J Womens Health (Larchmt). 2014 Jan;23(1):10-7. doi: 10.1089/jwh.2013.4507. Epub 2013 Nov 8.
Nabel EG. Heart Disease Prevention in Young Women: Sounding an Alarm. Circulation. 2015; DOI: 10.1161/CIRCULATIONAHA.115.018352
Puymirat E, Simon T, Steg PG, Schiele F, Gueret P, Blanchard D, Khalife K, Goldstein P, Cattan S, Vaur L, Cambou J-P, Ferrieres J, Danchin N for the USIK USIC 2000 and FAST-MI Investigators. Association of Changes in Clinical Characteristics and Management With Improvement in Survival Among Patients With ST-Elevation Myocardial Infarction. JAMA. 2012; 308(10):998-1006. doi:10.1001/jama.2012.11348
Shah AJ, Ghasemzadeh N, Zaragoza-Macias E, Patel R, Eapen DJ, Neeland IJ, Pimple PM, Zafari M, Quyyumi AA, Vaccarino V. Sex and Age Differences in the Association of Depression With Obstructive Coronary Artery Disease and Adverse Cardiovascular Events. J Am Heart Assoc. 2014;3:e000741 doi: 10.1161/JAHA.113.000741
Townsend N, Nichols M, Scarborough P, Rayner M. Cardiovascular Disease in Europe – Epidemiological Update 2015. European Heart Journal doi:10.1093/eurheartj/ehv428
Wilmot KA, O’Flaherty M, Capewell S, Ford ES, Vaccarino V. Coronary Heart Disease Mortality Declines in the United States From 1979 Through 2011: Evidence for Stagnation in Young Adults, Especially Women. Circulation. 2015; DOI: 10.1161/CIRCULATIONAHA.115.015293