During the early part of this century coronary heart disease (CHD) was thought to be a normal process that could be expected to develop with age. Significantly, CHD was considered primarily a killer of men. With America literally under construction, the prevailing androcentric perspective caused men's work to be viewed as indispensable to the growth of the economy.
Women, especially older women who were more likely to develop CHD, were not seen as decisive players in the construction of American society. Despite their participation in the work force during wartime, women were viewed predominantly in terms of their social roles as childbearers and homemakers (King & Paul, 1996). Moreover, most women simply did not live long enough to experience heart disease. Life expectancy for women has increased dramatically. Women born in 1900 could anticipate living only 53 years. By 1990, life expectancy for women reaching age 65 increased to 83.7 years (United States Department of Health and Human Services, Public Health Service, 1990).
Currently, CHD is recognized as the most frequent cause of death among women older than 50 (American Heart Association, 1997). The incidence of CHD in women older than age 75 exceeds that of men. Compared with its impact on men, CHD among women is characterized by a poorer prognosis, greater disability, and a higher rate of morbidity and early death after myocardial infarction (MI) (Oparil, 1998).
Reasons for the high incidence of CHD and its poorer prognosis among older women include the effects of aging as well as associated comorbidities such as hypertension, diabetes, and arthritis (Rankin, 1996). Coronary heart disease in women exacts serious costs, not only in economic terms, but in quality of life for those individuals and families it affects (Farmer & Gotto, 1997). Clearly, these costs will escalate as women live longer.
The purpose of this article is to present an overview of existing knowledge about CHD in women and to discuss cardiac risk factors specific to the older woman. The article concludes with current recommendations for cardiac risk factor modification.
THE FEMALE CARDIAC PROFILE
Overall CHD mortality rates have generally fallen since 1980, though the rate of decline has been slower for women. The discrepancy in death rates between women and men can be attributed to a variety of factors, including inadequate access to surgical and medical care among women as well as biologic changes accompanying aging and menopause (Gillum, 1994). Thirtysix percent of women age 55 to 64 are disabled as a result of CHD. Among women older than age 75, the CHD disability rate increases to 55%. There have been too few studies to draw firm conclusions about gender differences in relation to CHD; however, as data are beginning to accumulate from studies of CHD in women, the tendency to view cardiac disease exactly as it is seen in men is beginning to fade.
Women's hearts are smaller and their coronary vessels have a narrower diameter than their male counterparts. These anatomical characteristics appear to adversely affect revascularization outcomes in women. Although long-term survival rates after coronary artery bypass surgery and percutaneous transluminal coronary angioplasty are similar for men and women (Eysmann & Douglas, 1993), early perioperative and procedural mortality rates for women exceed those of men. There is evidence that women's smaller coronary artery diameters may contribute to greater early postoperative mortality (O'Connor, Morton, Birkmeyer, Olmstead, & O'Connor, 1996). Other factors that seem to contribute to early mortality among women during and after revascularization efforts include their older age, their greater number of comorbidities, and the proportionately larger number of women having emergency procedures compared with men (Magovern et al., 1996).
Regardless of age, women more commonly first present with angina than with acute myocardial infarction (MI), and angina in women is less likely to lead to a subsequent MI (Douglas, 1997). Chest pain, however, remains a major determinant of CHD in women. Its evaluation is problematic because women are more likely to experience chest discomfort as a result of coronary vasospasm, microvascular angina, and nonischemic disorders such as mitral valve prolapse. Although exertional angina is as common among women as among men, women often experience rest angina and chest discomfort during sleep or times of mental stress.
Atypical chest discomfort in women can signal myocardial ischemia and is characterized by neck, shoulder, and arm pain as well as fatigue, vomiting, and dyspnea. Symptoms such as these, as well as chest pain during rest, are probable indicators of CHD in women. Similar symptoms in men are less often caused by CHD (Douglas & Ginsburg, 1996).
Standard exercise treadmill testing is distinguished by higher falsepositive results in most women at any age. At rest, women's cardiac ejection fraction tends to be higher than men's. During exercise, however, many normal women fail to increase their ejection fraction, a characteristic that frequently complicates the interpretation of exercise tests (Klapholz & Buttrick, 1993). The addition of imaging procedures (e.g., thallium scans) to exercise stress testing has improved its accuracy in women (Douglas, 1997). Level of fitness, a factor that could contribute to the differences noted in response to exercise, was not addressed in the studies reported by Klapholz and Buttrick (1993). It is noteworthy that a lower level of fitness has been linked in an increased risk for all-cause mortality among women.
FEMALE CARDIAC RISK FACTOR PROFILE
Regardless of age, 40% of all acute cardiac events (e.g., MI, dysrhythmias, and cardiac arrest) that occur among women are fatal. Considering only MI, 68% of women, compared with 49% of men, have a fatal event without prior symptoms of heart disease. When a woman does present with symptoms of MI she is more likely to suffer complications and to reinfarct. As already indicated, she also has less chance of survival. Women who do survive MI experience high morbidity rates as a result of recurrent angina, heart failure, and psychological distress (Wenger, Speroff, & Packard, 1993).
The Estrogen Effect
Endogenous estrogen appears to protect against CHD in premenopausal women, primarily through its beneficial effect on serum lipid levels. The hormone is associated with elevated levels of serum high-density lipoprotein cholesterol (HDLC), decreased levels of serum low-density lipoprotein cholesterol (LDLC), and increased serum triglycerides. In addition, estrogen contributes to a decreased thrombotic potential, lower insulin and glucose levels, and produces a mild antihypertensive effect (The Postmenopausal Estrogen/Progestin Interventions Trial [PEPI], 1995). Estrogen may also influence the regulation of vascular smooth muscle cell proliferation - an important mechanism in the pathology of atherosclerosis (Douglas, 1997).
The natural cessation of menstruation does not cause an abrupt increase in risk for CHD among women. Estrogen release decreases gradually over approximately a 10year period (Rich-Edwards, Manson, Hennekens, & Buring, 1995). Studies have confirmed that estrogen deprivation during and after menopause causes women to lose their cardioprotective edge unless hormone levels are maintained through estrogen replacement therapy (ERT) (PEPI, 1995). The United States Preventive Services Task Force (1996) reported that an estimated 37% to 44% reduction in CHD risk among postmenopausal woman might be achieved though the use of ERT.
Probably as a result of the gradual loss of estrogen protection, CHD among women is highly age dependent, showing a 40-fold increase in morbidity at ages 75 to 84 compared with ages 35 to 44. On average, women are approximately 10 years older than men when CHD first strikes (Douglas, 1997). After age 75, substantially more women than men die from CHD.
CARDIAC RISK FACTORS FOR WOMEN
Coronary heart disease is associated with multiple modifiable and fixed risk factors. Risk hazards increase when multiple risk factors exist. Hyperlipidemia, smoking, diabetes, and hypertension are wellestablished major risk factors for both sexes. Other traditional cardiac risk factors include advancing age, male gender, family history of premature CHD, physical inactivity, obesity, and psychological stress (Farmer & Gotto, 1997). Women age 55 or older are particularly vulnerable to the development of CHD if they use tobacco, have diabetes, fail to exercise regularly, or consume a diet high in animal fats (Table 1). The reduction of major, modifiable risks (e.g., elevated serum lipids, smoking, and hypertension) retards progression of CHD after a cardiac event such as acute MI or a revascularization procedure (Campeau et al., 1997). The following sections review individual cardiac risks and their specific significance for women.
Despite the danger of cigarette smoking being as great in women as in men, the rate of decrease in smoking among women currently lags behind that of men by 15% (Wenger, 1997). Cigarette smoking is the single most important independent, modifiable risk factor for CHD among women. Risk increases as consumption of cigarettes increases, although no level of consumption is benign. The tendency for women to begin smoking cigarettes during their teenage years continues to increase (Hanson, 1994). Wenger (1997) noted that smoking cessation is as beneficial among the elderly as among younger people, a fact which emphasizes the importance of recommending smoking cessation for elderly women. It is important to emphasize that no level of smoking has been determined to be safe; neither is there any protection in smoking low-yield cigarettes. Smoking as little as one to four cigarettes a days is associated with a twofold increase in the risk of CHD. Regardless of age, deaths from MI and CHD are reduced by half for those who have not smoked for 1 year. After 5 years of cessation, the CHD risk from smoking is reduced to that of non-smokers (United States Preventive Services Task Force, 1996).
Diabetes mellitus increases the chance of developing CHD because it accelerates atherogenesis. Lipoprotein abnormalities are more severe, and triglyceride levels are more predictive of cardiovascular risk among diabetic women than among women without diabetes. Women with maturity onset diabetes demonstrate a rate of CHD mortality three to seven times higher (Rich-Edwards et al., 1995). Findings from the Rancho Bernardo Study (Barrett-Connor, Cohn, Wingard, & Edelstein, 1991) showed that after adjusting for all other risk factors, diabetes is an independent risk factor for CHD among both men and women, with a significantly greater relative hazard for women. The relative hazard of ischemic heart disease death in diabetics compared with nondiabetics was 3.3 for women and 1.9 for men (p = .08). Diabetes is second only to smoking in its significance as a risk factor for CHD among women.
The association between elevated levels of total and low-density lipoprotein cholesterol and CHD is lower for women than for men (Douglas, 1997). With respect to blood lipids, what seems to be particularly important for women is the serum level of HDLC and its ratio to total cholesterol (TC). Gordon et al. (1989) completed a meta-analysis of four major studies in an effort to determine the relationship between HDLC levels and the incidence of CHD. The researchers found support for an independent, inverse association of HDLC levels and CHD events in which CHD risk decreased by 2% to 3% for every 1 mg/dL increment in HDLC levels for both men and women. In two studies (i.e., Framingham Heart Study, Lipid Research Clinics Prevalence Mortality Follow-up Study), mortality rates were at least four times higher in women with low HDLC levels compared to those with high HDLC levels. When mortality rates of men and women in these two studies were compared, women's survival advantage was confined to the mid- to high-serum levels of HDLC (s*40 to 50 mg/dL). Hong, Romm, Reagan, Green, and Rackley (1991) also found the higher the TC/HDLC ratio, the more likely it is for CHD to develop. In this study, women with CHD had a mean TC/HDLC ratio of 5.5 ± .3. Those without CHD had a mean ratio of 4.2 ±0.2 (N= 1 80, />< .0001).
Most of the fat consumed in the American diet is absorbed in the intestine and released into lymphatic circulation as chylomicron, a form of metabolized lipid consisting primarily of triglyceride. Triglycerides are also manufactured by the liver from free fatty acids and glucose. Triglycerides appear to be markers for an especially atherogenic form of small, dense LDLC that becomes more prevalent with age (LaRosa, 1997). Additionally, elevated triglycerides are associated with lower levels of HDLC. Multivariate analysis in several American and European studies has lead researchers to conclude that elevated triglycerides are a significant risk factor for CHD, especially among women and elderly individuals. Triglyceride levels appear to be a better predictor of CHD risk in postmenopausal women than in men of the same age. Postmenopausal women who gain weight are inclined to have higher triglyceride levels (Table 2).
The presence of diabetes mellitus is also associated with higher triglyceride levels in the older woman. Though diet as well as drug therapy should be considered when hypertfiglyceremia is identified (National Cholesterol Education Program, 1994), clinical trials are needed to confirm the therapeutic effectiveness of interventions to lower serum triglycerides.
Finally, trans-fatty acids found in stick margarines, many fast foods, and commercial baked goods as partially hydrogenated vegetable oils have been shown to equal the atherogenesis of saturated fats. Willett et al. (1993) found a 50% increased risk of CHD associated with consumption of trans-fatty acids by women.
Approximately 51% of White women and 79% of Black women older than age 45 are hypertensive (i.e., blood pressure higher than 140/90). There is a significant increase in the prevalence of hypertension among women as they grow older, so much so that nearly 80% of women older than age 75 are hypertensive (Douglas, 1997). Of special concern for older women is the problem of isolated systolic hypertension associated with an increased risk of death from stroke and CHD. Approximately 30% of women older than age 65 experience isolated systolic hypertension.
Hypertension alters the structure and function of the circulatory system and results in abnormal blood flow patterns. Alone, it is insufficient to induce CHD, but together with other risk factors, notably hyperlipidemia, hypertension greatly accelerates the progress of atherosclerosis by directly damaging the endothelial lining of arteries and fostering the deposition of atheromatous material (Hanson, 1994). While treatment of hypertension has most significantly reduced cerebrovascular morbidity and mortality, reductions in the incidence of CHD have also been identified (United States Preventive Services Task Force, 1996).
Obesity, especially that characterized by truncal or central body fat distribution, is an independent risk factor for CHD among women and has recently been classified by the American Heart Association as a major, modifiable risk factor for CHD (Eckel & Krauss, 1998). Issues surrounding obesity in women include decreased physical activity, impaired glucose tolerance, and elevated blood pressure. Among older women obesity is closely linked to non-insulin dependent diabetes, elevated blood lipids, and hypertension. When smoking is added to these factors, a woman's risk for CHD increases dramatically. Examination of the Framingham study showed that among women whose body weight was 35% above the mean, the mortality rate from CHD was 1.4 times higher. Among women in the Nurse's Health Study, even those who were mildly to moderately overweight, had nearly twice the risk of CHD than women whose weight was normal (Manson et al., 1990). Weight loss, often as little as 10 pounds, results in a lowering of blood pressure levels.
CURRENT RECOMMENDATIONS FOR SERUM LIPID LEVELS IN WOMEN
The distribution of body fat is of particular importance with regard to women's risk for CHD. Comparing waist and hip circumferences (waistto-hip ratio) it has been shown that among middle-aged and older women higher ratios (those approaching 2 or greater) are associated with a higher incidence of CHD (Larsson et al., 1992). The higher waist-to-hip ratio, often referred to as truncal obesity, is similar to the masculine distribution of fat. There is a tendency toward truncal obesity among aging women.
It is well established that a sedentary lifestyle is associated with increased risk of CHD; however, most research in this area has involved men. Estimates derived from studies on men suggest women who exercise regularly have a 50% lower risk of CHD (RichEdwards et al., 1995). The beneficial effects of physical activity are associated with improvements in serum lipid levels, weight loss, and lower blood pressure (United States Preventive Services Task Force, 1996). The lipid response to exercise is related to the intensity and duration of activity. In women, however, the HDLC increases and, to some extent, the weight loss benefits of exercise appear to be somewhat less than in men (Douglas, 1997). Finally, there is some indication that physically active women have lower fibrin plasma levels, which have been associated with increased risk for CHD, though the precise mechanism for this has not been adequately studied (DeSouza, Stevenson, Davy, Jones, & Seals, 1997).
Of particular significance to women in general and to older women in particular is the fact that, on average, fewer women than men participate in cardiac rehabilitation programs after undergoing an acute cardiac event. A recent study found that women exercised far below the American Heart Association recommended guidelines (Moore, Ruland, Pashkow, & Blackburn, 1998). Women tended to engage far less frequently in active leisure time pursuits compared to men.
The relationship between psychosocial stress and the development of CHD in women is unclear. Factors such as limited education, multiple roles, work overload, and limited control over life choices seem to lead to depression, anxiety, and anger all of which may predispose to CHD (Hanson, 1994). Older women with heart failure report most stress when experiencing symptoms and performing household activities. There is evidence that excess risks are related to a person's experience within occupational and interpersonal roles rather than the type and number of roles.
The Type A behavior pattern is an action-emotion complex characterized by aggressive involvement in a chronic, incessant struggle to achieve more and more in less and less time. Hostility and the expression of anger are the toxic core of Type A behavior. Women do not appear to score as high on hostility measures as men; however, the instruments designed to measure hostility have been developed for men and may not accurately identify anger among women (Haynes & Czajkowski, 1993). The need for further study is evident.
CARDIAC RISK FACTOR MODIFICATION IN WOMEN
The downward trend in CHD mortality since the 1960s is not only associated with improved therapies, but with national risk modification efforts directed toward hyperlipidemia, smoking, and hypertension (Farmer & Gotto, 1997). Cardiac risk factor modification includes both pharmacologic and nonpharmacologic efforts designed to improve serum lipid levels; combat smoking; increase physical activity; and control hypertension, obesity, and diabetes. Nonpharmacologic efforts toward risk factor modification center on lifestyle changes involving diet, exercise, smoking cessation strategies, and stress management. Nonpharmacologic interventions have a cascading effect leading to improvements in other cardiac risks (e.g., hypertension and diabetes). Heart healthy lifestyle changes, if instituted and sustained, are effective strategies for both primary and secondary prevention of CHD among women (Campeau et al., 1997).
Recent nutritional approaches to the prevention of CHD in women include advice to consume at least 25% of calories in fat because extremely low fat diets lower HDLC levels and elevate triglyceride levels (Olson & Labat, 1995). Saturated fats and trans-fatty acids (partially hydrogenated fats) should be limited, and monounsaturated fats emphasized. Moderate consumption of alcohol (i.e., one drink a day for women) appears to contribute to an increase in HDLC levels. Because the current National Cholesterol Education Program Guidelines do not include treatment recommendations about triglyceride and HDLC, Douglas (1997) suggested the needs of women, particularly older women have not been met.
Studies to date indicate that diet, weight loss, and exercise may be somewhat less effective in lowering LDLC and elevating HDLC in women than in men. Nevertheless, recommendations for lipid-lowering diets are currently the same for women as for men. Pharmaceutical therapy, in contrast, is equally effective in both women and men. Table 3 contains current recommendations for serum lipid levels for women.
Weight reduction of 5% to 10% of body weight decreases blood pressure and improves serum cholesterol levels as well as glucose tolerance. In view of the strong link between elevated triglycerides and low levels of HDLC among diabetic women, maintenance of normal body weight is emerging as an increasingly important preventive strategy. For the older woman, obesity and hypertension are an especially lethal combination. Thus, weight management through increased consumption of fruits and vegetables (at least five servings per day) and increased physical activity on a regular basis are important adjuncts to the usual advice to follow a low-fat diet (Eckel & Krauss, 1998). Failure rates for women who engage in weight loss regimens range from 60% to 90%. The need for further study in this area is evident.
Smoking cessation is imperative regardless of how long or how little a woman has smoked. The synergistic relationship among smoking, elevated serum lipids, hypertension, and diabetes is widely documented.
Multiple studies have shown that the use of ERT is effective in the primary prevention of CHD in postmenopausal women (Douglas, 1997). Although the use of unopposed estrogen is associated with a five- to eightfold increase in the incidence of endometrial cancer, the addition of progestin to the regimen mitigates this danger. Some researchers have suggested that the addition of progestin would decrease the cardioprotective effects of estrogen because of its androgenic effect on circulating lipids. Recent studies (Grady, Gebretsadik, Kerlikowske, Ernster, & Petitti, 1995) indicate that this concern is unwarranted, especially when lower doses and more inert forms of progestin are administered.
With long-term use of estrogen, the risk of breast cancer appears to increase (Colditz et al., 1995). Additional negative effects of ERT include increased triglyceride levels, increased frequency of migraine, and gallbladder disease. Current guidelines from the American College of Physicians support the use of ERT in asymptomatic, postmenopausal women with a high risk for CHD, and for secondary prevention in women with diagnosed CHD who are not at risk for breast cancer. Today most researchers agree the risk of heart disease can be reduced by more than 30% in postmenopausal women who undergo ERT. Until results from current trials are reported, a careful evaluation of the risks and benefits of ERT for individual women is crucial.
Finally, with current emphasis on health promotion and cost containment, the value of effective primary and secondary psychosocial preventive strategies is clear. In a review of CHD risks among women, Hanson (1994) noted the existence of gender differences in cardiac reactivity to various stresses. Although additional study is urgently needed, stress management is emerging as an effective approach in assisting female clients to deal with CHD risks. Techniques such as controlled breathing, desensitization, and the use of imagery have been found to be effective methods of establishing control and minimizing anxiety (Ulmer, 1996).
IMPLICATIONS FOR GERONTOLOGICAL NURSING
Any expected improvement in the health of the aging woman rests on effective primary and secondary prevention of CHD. It is important for health care providers and clients to recognize that preventive behaviors are appropriate for any age. Unique aspects of the female cardiac profile and cardiac risk factors significant for the older woman have been described in this article. Nursing literature is currently replete with recommendations to implement educational efforts to improve women's lifestyles and reduce cardiac risks. Achieving such outcomes for older female clients requires that the health care provider understand how the older woman views being healthy.
Even though many older women frequently suffer from several chronic illnesses, including CHD, they often tend to view themselves as healthy. The same applies when older women experience functional disabilities as a result of chronic illness (Perry & Woods, 1995). This suggests a developmental component to the aging woman's images of health. It is possible that older women draw on a variety of positive images in defining themselves, and these personal views of health may be quite different from those of physicians and other health care providers. In a qualitative/descriptive study of older women's beliefs about preventive behaviors for heart disease, Conn, Libbus, Thompson, and Kelly (1994) found that family was a more salient referent group than the larger social network of neighbors and friends. This distinction was even more pronounced with respect to health care providers. The investigators suggested that interventions intended to heighten social support for health promotion be targeted to the families of older women.
Nurses caring for aging women in a variety of settings need to adapt health assessments and recommendations to reflect a rapidly changing body of knowledge regarding women's cardiac health. The older woman, in particular, has often been excluded from clinical studies of CHD, and there remains much to be learned about her unique experiences and responses to chronic cardiac disorders. Thus the current focus must first be the very real problem of CHD in the older female client, without disregarding her individual perspective or the social context of her day-to-day life.
The implementation of primary and secondary prevention of CHD among older women should contain an emphasis on:
* The dangers of low HDLC and elevated triglyceride levels.
* The management impact of the diabetes-hypertension-hyperlipidemia triad.
* Carefully individualized decisions about the efficacy of estrogen replacement therapy.
* Assistance to older women with regard to the significance of atypical chest discomfort.
* The necessity of smoking cessation.
* Strategies to increase and maintain an exercise regimen that will avoid pain and injury while fostering adherence.
For too long CHD has been considered a man's disease. The public continues to identify breast cancer rather than heart disease as the major health problem for women. As clients are taught about the prevalence of CHD among older women, the tendency to apply health recommendations derived from studies of male subjects to women must be avoided. Although there are similarities in cardiac risk factors, determinants, and treatments for men and women, heart health for the older woman has gender- and age-specific characteristics that cannot be ignored. Epidemiological studies and clinical trials have provided conclusive evidence that CHD is largely preventable. Nurses have a responsibility to direct preventive efforts to aging women to improve prognosis, functional capacity, and quality of life for this growing segment of the population.
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FEMALE CARDIAC RISK FACTOR PROFILE
CURRENT RECOMMENDATIONS FOR SERUM LIPID LEVELS IN WOMEN