Carotid intima-media thickness in pre-and postmenopausal women with suspected coronary artery disease

Carotid intima-media thickness (CIMT) is an early marker of coronary artery disease (CAD). This study aimed to evaluate CIMT value for CAD prediction in pre-and postmenopausal women referred for coronary angiography with angina-like symptoms and a positive result of the treadmill test. The study comprised 321 women referred for coronary angiography with symptoms suggesting CAD. Carotid intima-media thickness was measured in common, bifurcation, and internal carotid artery, and expressed as the mean maximum value. Coronary angiography showed coronary stenosis >/=50% in 211 (65.7%) women, including 27 with regular menses (47.3 +/- 3.4 years) and 184 postmenopausal (65.8 +/- 7.2 years). Normal coronary arteries were found in 110 women: 17 (47.3 +/- 4.9 years) with regular menses and 93 postmenopausal (64.3 +/- 6.5 years). The highest CIMT values were found in postmenopausal CAD women (1.360 +/- 0.32 mm), as compared to premenopausal with CAD (1.178 +/- 0.36 mm, P = 0.005), pre-(0.860 +/- 0.23 mm, P < 0.001) and postmenopausal (1.022 +/- 0.30 mm, P < 0.001) women without CAD. Carotid intima-media thickness (P < 0.001), hyperlipidemia (P = 0.018), and myocardial infarction (P < 0.001), but not menopause itself or the number of years since menses cessation, were found to be independent CAD predictors. By receiver operating characteristic calculation, the mean maximum CIMT cut-off values discriminating CAD were lower in premenopausal (>/=0.933 mm) than in postmenopausal women (>/=1.075 mm; P < 0.05) resulting in similar sensitivity (85.2% and 82.6%) and specificity (70.6% and 69.9%). Carotid intima-media thickness is a strong CAD predictor in both pre-and postmenopausal women, in contrast to the menopausal status.     

Serum squalene in postmenopausal women without and with coronary artery disease.

Squalene, found in earlier studies in human atherosclerotic plaques, was measured in the serum of postmenopausal women with coronary artery disease (CAD) (n = 25) and randomly chosen age-matched healthy controls (n = 30). The squalene concentrations of the whole population ranged from 37.5 to 115.5 microg/dl, and were higher in serum of the CAD than healthy women (91.4+/-2.6 versus 65.2+/-2.6 microg/dl, P = 0.000), a finding observed also in relation to cholesterol (43.8+/-1.8 versus 32.9+/-1.1 10(2)x mmol/mol of cholesterol, P = 0.000). The squalene concentration was also increased in chylomicrons, VLDL and d>1.006 g/ml lipoproteins, and the proportions to cholesterol in VLDL and d>1.006 g/ml lipoproteins. The respective squalene and cholesterol concentrations were related to each other in serum, VLDL and d>1.006 g/ml lipoproteins (r = 0.52, 0.85 and 0.55, respectively), whereas the correlation with triglycerides was seen only in VLDL (r = 0.84) over the whole population. Besides enhanced intestinal secretion, it remains to be shown whether higher serum squalene in postmenopausal coronary women is due to increased cholesterol synthesis or a defect in squalene conversion to lanosterol.     

Plasma total homocysteine levels in postmenopausal women with unstable coronary artery disease

An elevated plasma total homocysteine (tHcy) level is considered a risk factor for coronary artery disease (CAD), but the relationship between plasma tHcy and well-defined CAD in women is still unclear. Plasma tHcy concentrations and the covariates serum folate, vitamin B12, and creatinine were analysed in 157 angiographically examined postmenopausal women with unstable CAD and in 101 healthy controls. At coronary angiography, 16% had normal vessels and 84% had coronary atherosclerosis. Mean plasma tHcy concentration (micromol/l, 95% confidence interval) did not differ in patients compared to controls (13.1 (12.3-13.8) vs. 12.5 (11.6-13.5)) or in patients with or without coronary atherosclerosis (13.3 (12.4-14.1) vs. 12.0 (10.8-13.2)). A trend to an increasing plasma tHcy with increasing degree of coronary atherosclerosis was attenuated after adjustment for age and the previous mentioned covariates. Odds ratio for the risk of coronary artery disease and coronary atherosclerosis in hyperhomocysteinemic patients (> or =90th percentile in controls) was approximately 3. However, the confidence interval included unity in half of the groups and the significance was therefore difficult to judge. Receiver operating characteristics showed age to be the only variable with a significant discriminatory ability regarding the presence of coronary atherosclerosis (area 0.77). Mild hyperhomocysteinemia seems not to be related to the risk of unstable CAD in postmenopausal women. The trend towards higher plasma tHcy with increasing degree of coronary atherosclerosis may be a marker of the disease. In future studies adjustment for age and the other three covariates should be considered.     

Coronary artery disease

In the six patients described here the shoulder-hand syndrome proved to be a painful, disabling condition leading in some instances to long standing, and in one case possibly permanent, trophic changes of the hand. Its appearance requires thorough study of the patient and evaluation of the cardiac status. For the present it must be regarded in cases like ours as a non-traumatic, non-cardiac, idiopathic disorder acting through a disturbed neurovascular mechanism. If the differentiation of this clinical picture serves only to avoid unsuitable therapy and to provide a better insight into the prognosis, its recognition as a special entity is justified.     

Coronary artery disease

SUMMARY: Prevention is equivalent to causal treatment of cardiovascular disease. Nowadays, guidelines are elaborated on the basis of large-scale long-term intervention studies and structured meta-analyses. This review attempts a synopsis of guidelines of the American and German Heart Associations. For secondary prevention, smoking cessation, blood pressure treatment, dietary lipid management, aerobic activity, correct body weight, Mediterranean diet, treatment of diabetes to a HbA1c of 7%, ingestion of marine w-3 fatty acids (1 g / day), platelet inhibitors, lipid-lowering agents (statins), beta-blockers and ACE-inhibitors are established. In primary prevention pharmaceutical agents are not incorporated, but all non-pharmacological approaches are being recommended. The guidelines mentioned are based on unequivocal evidence, risk-benefit and cost-benefit ratios are good, nevertheless implementation remains a serious problem. Primary and secondary prevention are already giving way to risk-adapted prevention, based on an individual assessment of a person's cardiovascular risk.     

Coronary artery bypass surgery in women

Coronary bypass surgery is performed more frequently in men than in women. A selection bias in favor of men may exist in currently utilized evaluation precesses for patients with both chest pain syndromes and documented coronary artery disease. Surgery should be considered in women with significant left main coronary artery stenosis, "left main equivalent" coronary disease, severe three-vessel coronary disease with/without left ventricular dysfunction, two-vessel coronary disease (including a proximal left anterior descending artery stenosis), and unstable angina pectoris with decreased left ventricular function. Women and men undergoing coronary bypass surgery seem to benefit from internal mammary artery grafts used alone or in combination with saphenous vein grafts. Surgical mortality, incomplete revascularization, early and late graft occlusion, and recurrent angina are more prevalent in women who undergo surgery. However, long-term mortality following surgery is similar in men and women.     

The association of lower testosterone level with coronary artery disease in postmenopausal women

OBJECTIVE: Testosterone (T) is assumed to be a risk factor for coronary artery disease (CAD). However, recent studies have demonstrated a beneficial effect of T on myocardial ischaemia in men with CAD. To assess the potential role of T in CAD in postmenopausal women we investigated the association between T level and CAD and relationship between T and other CAD metabolic risk factors. RESULTS: Within the 12-month study period, 108 consecutive, postmenopausal women (age 62+/-7 years) referred for diagnostic coronary angiography were prospectively included in the study. In all patients serum level of T, sex hormone-binding globulin (SHBG), total cholesterol (T-chol), LDL-chol, HDL-chol, triglycerides (TG), apolipoproteins A(1) and B (apo A(1), apo B), lipoprotein a [Lp(a)], and C reactive protein were measured. Testosterone free index (TFI) was calculated as Tx100/SHBG. CAD was documented in 51 (47%) patients (CAD+). Women with CAD had decreased T level and lower TFI (T: 0.99+/-0.4 vs. 1.41+/-0.7 nmol/l, P=0.005; TFI: 3.2+/-1.4 vs. 4.2+/-2.2, P=0.04, CAD+ vs. CAD-, respectively). No difference in SHBG was found between the two groups. In 16 women (six CAD+, 10 CAD-) who were on hormonal replacement therapy (HRT+) we observed significantly elevated T level and TFI (T: 1.62+/-0.5 vs. 1.15+/-0.7 nmol/l; TFI: 5.0+/-2.2 vs. 3.5+/-1.8, HRT+ vs. HRT-, respectively, P<0.05). When these women were excluded from the analysis, T level remained decreased in CAD+ group (0.96+/-0.4 vs. 1.22+/-0.5 nmol/l, CAD+ vs. CAD- respectively, P<0.02). CAD+ group had an unfavourable profile of metabolic CAD risk factors as evidenced by elevated T-chol, LDL-chol, Lp(a), apoB, and decreased apoA(1) (P<0.05 vs. CAD- in all comparisons). Neither T nor TFI correlated with CAD metabolic risk factors (r<0.2, P>0.1 for all correlations), apart from an inverse correlation between T and Lp(a) (r=-0.24, P=0.04). CONCLUSION: In postmenopausal women decreased T level is associated with CAD independently of the other CAD metabolic risk factors. Hormonal replacement therapy tends to increase T level which may further support the beneficial role of HRT in postmenopausal women.     

Estrogen replacement and coronary artery disease. Effect on survival in postmenopausal women

The relationship among postmenopausal estrogen use, coronary stenosis, and survival was examined retrospectively in 2268 women undergoing coronary angiography. The patients were selected for study if their age was 55 years or older at the time of angiography or if they had previously undergone bilateral oophorectomy. Postmenopausal estrogen use in 1178 patients with coronary artery disease (greater than 70% stenosis) and 644 patients with mild to moderate coronary artery disease (5% to 69% stenosis) was compared with 446 control subjects (0% stenosis) using life-table analysis. Over 10 years of follow-up, there was no significant difference in survival among patients initially free of coronary lesions on arteriography who had either never used (377) or ever used (69) estrogens. Among patients with mild to moderate coronary stenosis, 10-year survival of those who had never used estrogens was 85.0% and it was 95.6% among 99 "ever users." Survival was 60.0% among those with more than 70% coronary stenosis who had never used estrogen and it was 97.0% among 70 ever users. The "never users" group were older (65 vs 59 years), had a lower proportion of cigarette smokers (40% vs 57.1%), a higher proportion of subjects with diabetes (21.7% vs 12.9%) and hyperlipidemia (58% vs 44%), and approximately equal numbers of hypertensives (56.0% vs 54.3%). Cox's proportional hazards model was used to estimate survival as a function of multiple covariables. Estrogen use was found to have a significant, independent effect on survival in women. We conclude that estrogen replacement after menopause prolongs survival when coronary artery disease is present, but it has less effect in the absence of coronary artery disease.     

Chronic kidney disease in postmenopausal women

Menopause is derived from the Greek words men (month) and pauses (cessation) and means permanent cessation of menstruation after the loss of ovarian activity. Chronic kidney disease (CKD) has recently been associated with cardiovascular events in several studies. CKD patients have a heavy burden of traditional cardiovascular risk factors in addition to a range of nontraditional risk factors such as inflammation and abnormal metabolism of calcium and phosphate. In this review, the association of CKD and cardiovascular disease (CVD), as well as of osteoporosis in postmenopausal women is discussed. CKD mineral and bone disorder, characterized by disturbances of calcium/phosphate/parathyroid hormone, bone abnormalities and vascular and soft tissue calcification, is highly prevalent in CKD and is a strong, independent predictor of bone fracture, CVD and death. Estrogen has been shown to: (a) decrease the expression of angiotensin type 1 receptors in vasculature and kidneys; (b) reduce the expression and activity of angiotensin-converting enzyme, and (c) cause the release of angiotensinogen substrate from the liver. However, the degree of activation or suppression of the renin-angiotensin-aldosterone system by estrogen has not been clearly established. Clinical data on the effects of estrogen therapy on bone mineral densities are extremely limited in the ESRD population. CVD is the most common cause of death in postmenopausal women with CKD and many contributing factors have been explored. Future research for prevention of CVD in postmenopausal women with CKD would focus on the biology of vascular calcification as well as bone loss.     

Coronary artery disease: Clinical presentation,diagnosis and prognosis in women

Recent advances in the field of cardiovascular medicine have not led to significant declines in case-fatality rates for women as in men. There are gender-specific differences in symptoms profile, diagnosis and treatment of coronary disease in women. For women presenting for coronary heart disease (CHD) evaluation, traditional disease management approaches that focus on detection of a ‘critical stenosis’ often fail to identify those women critically at-risk. Symptoms do not help physicians in differential diagnosis of chest pain in women; indeed the most common presentation of obstructive CHD in women is atypical symptoms. In 50% of the cases, non-obstructive CHD at coronary angiography, due to ‘noncardiac chest pain’ or coronary microvascular dysfunction is frequently reported. For these reasons, the evidence reviewed suggests that prognostic risk assessment may work relatively better than diagnostic obstructive coronary disease assessment for women.     

Coronary artery disease in young women and men with long-standing insulin-dependent diabetes

The prevalence and predictors of coronary artery disease were examined in people aged 40 years and younger with insulin-dependent diabetes mellitus. Analysis was performed on those who presented between 1999 and 2003 for kidney and/or pancreas transplant at the University of Minnesota, as all patients who have diabetes mellitus are required to have perioperative cardiology evaluation. The mean age was 33.5 +/- 4.4 years for 88 subjects, all had insulin-dependent diabetes mellitus, and 33% were dialysis dependent. Severe coronary artery disease was found in 18.2% of women and in 24.2% of men. Three-vessel coronary artery disease trended less in women (9.1%) compared with men (12.1%). Multivariate predictors for severe and 3-vessel coronary artery disease included prior coronary artery disease, hypertension duration, and ST-T wave changes on electrocardiogram. Coronary artery disease is twice as high as expected in young woman. Studies on early management for atherosclerosis are warranted in this high-risk population.     

Coronary artery disease in Asians

From available studies, there appears to be a racial preponderance of coronary artery disease (CAD) among Indians when compared to other ethnic groups. We found that this racial difference exists even in a young Asian population with premature atherosclerosis. In this small series, these racial differences could not be explained by the commonly known risk factors for coronary artery disease – smoking, hypertension, diabetes and hypercholesterolaemia, findings similar to those found in older patients elsewhere. Only fasting triglyceride levels were significantly higher among young Indians compared to non Indians ( p <0.02) although the importance of this finding as a risk factor for CAD remains controversial. The majority of these young patients were treated medically and their one year survival was good.     

Coronary artery calcification in black women and white women

Background Coronary calcification is a potent independent predictor of coronary risk. Sex-specific risk categories based on calcium scores have been established, but ethnic differences in coronary calcification have been little studied. This prospective cohort study compares coronary calcification, assessed by computed tomography, in postmenopausal black women and white women. Methods and Results Computed tomographic scans were performed on 128 black women and 733 white women without known coronary artery disease (mean age 63 ± 8 years). Although coronary risk factors were more prevalent among black women (P < .0001), total calcium scores were similar to those in white women. By use of the Framingham algorithm, higher calcium scores were associated with higher 10-year risk of myocardial infarction or coronary death. In multiple regression analysis, age was independently associated with higher calcium scores in both ethnic groups (P = .002 for black women, P < .0001 for white women). Diabetes mellitus and not exercising at least 3 times per week were independently associated with higher calcium scores in white women but not black women. Educational level, body mass index, current hormone replacement therapy, hysterectomy, dietary fat consumption, family history of premature coronary disease, hypertension, self-reported high cholesterol, and current smoking were not independently associated with coronary calcium score in black women, white women, or the combined cohort; neither was ethnicity an independent predictor of coronary calcification. Conclusions Despite higher dietary fat consumption, higher body mass index, and greater prevalence of hypertension, diabetes, and smoking, black women had coronary calcium scores similar to those of white women. Ethnicity was not an independent predictor of coronary calcification. (Am Heart J 2003;145:724-9.)