Heart Disease and Women Part 3: Emerging Risk Factors

Risky Character Showing Dangerous Hazard Or Risk

The emphasis on traditional risk factors alone has been criticized for underestimating heart disease in women, especially those who are not yet manifesting symptoms. Several additional factors have been identified that may improve detection of heart disease in women. Are any of these on your clinical judgement radar when evaluating women and possible heart disease?

Periodontal disease has been linked to increased risk of heart disease for several years now. Specifically, the repeated systemic exposure of the gums to bacteria and bacterial byproducts increase levels of C-reactive protein (CRP) and fibrinogen; both of which are associated with increased likelihood of heart disease. Women with metabolic syndrome and elevated CRP levels had twice the risk of an acute cardiac event as those with metabolic syndrome but low CRP levels. It has been suggested that measuring CRP levels in women with at least intermediate risk of heart disease or metabolic syndrome may identify additional individuals who would benefit from treatment with statins.

Autoimmune disease, such as rheumatoid arthritis and systemic lupus erythematous (SLE), is associated with significantly increased risk of heart disease. Women ages 35-44 years with SLE were found to be 50 times more likely to have an acute myocardial infarction compared to women of the same age without SLE. Systemic autoimmune collagen-vascular disease was listed as a risk factor for heart disease in the Effectiveness-Based Guidelines for Prevention of Cardiovascular Disease in Women, published by the American Heart Association in 2011.

Complications of pregnancy, specifically pre-eclampsia and gestational diabetes, are associated with greater risk of subsequent heart disease. Women with pre-eclampsia, or pregnancy associated hypertension have double the risk of developing cardiovascular disease in the first five to ten years after delivery. They also are significantly greater risk of developing hypertension which is recognized as a traditional risk factor already. Women who experience gestational diabetes are at 1 ½ times greater risk of heart disease compared to those who did not. Women with gestational diabetes have double the risk of developing diabetes mellitus, which is another traditional risk factor for heart disease. Gestational diabetes was also listed as a risk factor for women in the American Heart Association’s 2011 update.

Menstrual irregularities increase the risk of ischemic heart disease in women by 50%. One of these is polycystic ovarian syndrome, a hormone imbalance that prevents normal development and release of eggs. As a result, women experience irregular menstruation (irregular, light or heavy flow) and have difficulty getting pregnant. Polycystic ovarian syndrome is associated with high levels of insulin, which contribute to development of metabolic syndrome and insulin resistance. Another is a type of amenorrhea caused by psychological stress or metabolic insult (caloric reduction or excessive exercise) which results in a hormone imbalance that contributes to risk of heart disease.

Breast cancer treatment is associated with various degrees of injury to the cardiovascular system. Radiation therapy, in particular has an established association with risk of heart disease. With other treatments it is not yet clear if the treatment itself or resulting lifestyle changes increase women’s’ risk of heart disease. Since the rate of breast cancer survival increases more women need providers who are attentive to their cardiovascular risk and prevention.

Sleep apnea is another disease more commonly associated with the male gender and yet there is increasing evidence that women with this disorder present differently and are often misdiagnosed with depression, anxiety, insomnia and fatigue instead. Women with sleep apnea have increased risk of hypertension, coronary artery disease, stroke and atrial fibrillation and have 3 1/2 times greater risk of dying from cardiovascular disease. Treatment with continuous positive pressure reduces the risk to that of women who do not have sleep apnea.

The following table summarizes the traditional as well as the newer risk factors for heart disease in women that we have reviewed the last two weeks.

Risk Factors for Heart Disease in Women
Traditional Risk Factors Emerging Risk Factors
Obesity Periodontal disease
Dyslipidemia Autoimmune disease
Diabetes Complications of pregnancy
Metabolic syndrome Menstrual irregularities
Physical inactivity Breast cancer treatment
Hypertension Sleep apnea
Tobacco use
Psychosocial (depression, loneliness, hostility)
Hormones (postmenopausal and contraceptives)

It can be challenging to convince women to make the lifestyle changes that are necessary to control or limit the risk factors listed above. This is especially so in the absence of symptoms of heart disease and the fact that the benefits of doing so are not immediately apparent. One way that is recommended to assist women to make the necessary lifestyle changes is for health care providers to engage women at a young age and on a regular basis in discussion about their own personal risk of heart disease.

Correctional nurses have the opportunity to make a real difference in the cardiac health of their female patients when completing the initial and periodic health appraisals during incarceration, during every contact with patients who have chronic disease, while caring for women during pregnancy and in any health education programs provided to the population at large. Further correctional nurses are often asked to spear head employee wellness programs which can bring this same information to female employees.

Next week’s post will provide some case examples to practice assessing cardiac risk. In the meantime, what are your thoughts about working with women while they are incarcerated to increase their recognition of cardiac risk and how to prevent heart disease? Please share your thoughts by replying in the comments section of this post.

The following are some excellent online resources about heart disease and women:

To read more about nursing care of women patients in correctional settings with cardiovascular disease and other chronic diseases see Chapters 6 and 9 of the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

References:

McSweeney, J.C., et al. (2016) Preventing and experiencing ischemic heart disease as a woman: State of the Science. A scientific statement from the American Heart Association. Circulation:133.

Halm, M. A (2014) Women and Heart Disease. NetCE Course # 33221. Accessed March 2016 at http://www.netce.com/courseoverview.php?courseid=1001

Photo credit: © Stuart Miles – Fotolia.com

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