Check midlife women for cardiovascular disease
By Ivy M. Alexander, MS, C-ANP
Adult Nurse Practitioner, Assistant Professor
Adult and Family Nurse Practitioner Programs
Yale University School of Nursing
New Haven, CT
Cardiovascular disease (CVD) is the No. 1 cause of death among women over 50. In fact, one of every two women will die from heart disease or stroke.1,2 Although those facts are generally well-known by clinicians, they’re not well-known by women. In 1990, less than one-fifth of women responding to a Gallup poll knew CVD was the leading cause of death.2 In 2000, only about 30% of a national sample of women knew that fact.1
CVD encompasses several disease processes such as coronary artery disease, angina, myocardial infarction, and hypertension. Women develop CVD about 10 to 15 years later in life than men, which reflects the sharp rise in incidence after menopause.2 Similarly, the risk for death from CVD increases with age, which nears that of men at age 65.3 Although the cause of that increase is controversial, lower estrogen levels, alterations in the estrogen-to-androgen ratio, and accumulative effects of lifestyle risk factors have been cited.2-4
Check your skill level in recognizing risk factors associated with CVD:
• Know the risk of smoking. Smoking increases the risk of CVD death in a dose-related relationship.3 It accounts for about 50% of MIs in women under 55 and doubles the incidence of CVD.2 The number of U.S. women who smoke has increased in recent years. Coincident with that increase is the expected rise in the percentage of CVD deaths attributable to smoking. Women with hypertension, diabetes, or hyperlipidemia have an exponentially increased risk if they smoke.
Ask women about tobacco use and smoking habits at each visit. Let them know that the CVD risk associated with smoking will return to normal within three to five years after quitting.3
• Check weight gain. Resulting from an imbalance between energy expenditure and caloric intake, an overweight status is defined as excess weight of >10% over ideal (body mass index [BMI] 25 to 29.9). Obesity occurs when weight is more than 20% over ideal (BMI >30).4 BMI is calculated by dividing body weight in kilograms by the meters of height squared. Several "quick-calculate" wheels are commercially available for this purpose. Calculate BMI annually to identify trends over time.
As women age, their energy requirements decrease, but intake frequently remains the same or increases. Body fat also increases and shifts to increase abdominal storage. Abdominal adiposity is associated with hypertension, smoking, and inactivity.3 Both obesity/overweight (by two- to fourfold) and waist-to-hip ratios >0.8 correlate with higher risk of CVD.3,4 Obesity also is associated with type 2 diabetes.4
• Check for a sedentary lifestyle. The risk of CVD is almost double among inactive vs. active women.2 Activity tends to decrease with age, coinciding with the time when CVD risk already is increasing.5 Inactivity also is associated with obesity, hypertension, hyperlipidemia, smoking, and poor conditioning,3,6-7 which confound efforts to adopt an active lifestyle. Highlight the importance of remaining active, which also can aid in reducing osteoporosis risk, by discussing this topic with women at each visit.
• Know that alcohol increases risk. Alcohol consumption that exceeds moderate amounts (one to three drinks per day) increases risk for hypertension and diabetes.3,6 Ask women about alcohol consumption and quantify the amount imbibed to identify this potential risk.
• Question diet choices. Requirements for essential lipids do not decrease with age; however, total calorie requirements do. Diets high in saturated and unsaturated fats can increase cholesterol and body weight. Poor nutritional habits, such as high-calorie diets, high salt intake, and excess fats, can predispose women to develop hypertension, obesity, and type 2 diabetes.3,4,6 Associated diseases for CVD include hyperlipidemia, hypertension, and diabetes.
Most women want to learn about heart disease and preventive care. In a 2000 survey, 90% indicated this interest, yet only about one-third had discussed heart disease with their providers.1 Become knowledgeable about the risk factors that predispose women to CVD, and pass this information to your patients. Screening for risk factors is an important preliminary step for developing treatment plans. Educating women about their risk factors for CVD can improve their awareness and may increase their interest in altering lifestyle behaviors.
(Editor’s note: The December issue will explore approaches for altering or treating CVD risks.)
References
1. Mosca L, Jones WK, King KB, et al. Awareness, perception, and knowledge of heart disease risk and prevention among women in the United States. Arch Fam Med 2000; 9:506-515.
2. Wild RA, Taylor EL, Knehans A. The gynecologist and the prevention of cardiovascular disease. Am J Obstet Gynecol 1995; 172:1-13.
3. Oparil S. Cardiovascular risk reduction in women. J Women’s Health 1996; 5:23-32.
4. Keller C, Fullerton J, Fleury J. Primary and secondary prevention strategies among older women postmenopausal women. J Nurse-Midwifery 1998; 43:262-272.
5. Marcus BH, Forsyth LH. Tailoring interventions to promote physically active lifestyles in women. Women’s Health Issues 1998; 8:104-111.
6. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997; 157:2,413-2,446.
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