Coronary heart disease risk factors in women

Despite the obvious predominance of coronary heart disease in middle-aged men, cardiovascular disease including coronary heart disease and cerebrovascular accidents is currently the major cause of death in women (54% cardiovascular mortality, 46% coronary mortality; 28% of all deaths). Before menopause, coronary heart disease is infrequent which suggests that female hormones and metabolism offer protection. Without hormone replacement therapy after menopause women may develop coronary atherosclerosis. Ageing is among the non-modifiable risk factors for coronary heart disease in women, while genetic predisposition and environmental factors remain controversial. The modifiable risk factors are mostly common to both sexes and include heavy cigarette smoking (especially in women under oral contraception) dyslipidaemia, high blood pressure, and diabetes; some factors are peculiar to women. The delayed onset of coronary heart disease in women, roughly 10 years later than in men, and greater feminine longevity (81 years vs 74 in men on average) points to the potential benefit of post-menopause hormone replacement therapy together with reduction of other modifiable risk factors. After menopause, the protective HDL cholesterol decreases whereas high LDL cholesterol, high triglycerides and high blood pressure are major risk factors for coronary heart disease as well as for cerebrovascular accident. The role of hormone replacement therapy in the prevention of cardiovascular disease in women is still controversial despite the results of meta-analyses which suggest a 25% to 44% reduction in coronary heart disease following oestrogen therapy alone or in combination with progestogen, depending on the hormonal regime. In conclusion, menopause, now considered as the marker for the end of natural protection against coronary heart disease, should be followed by early and prolonged combined hormone replacement therapy in order to reduce the low compliance with long-term hormone replacement therapy.