For Women with CVD, Lipid-Centric Strategies Often Fail

The cholesterol-centric approach to assessing and treating heart disease results in a “treatment gap,” especially among women, said Mark Houston, MD, at the recent Lifestyle Medicine Summit in Chicago.

Over 50% of patients who have heart attacks did not have any conventional risk factors prior to the index event; for 46% of women, the first symptom of CHD is a heart attack itself, said Dr. Houston, associate clinical professor of medicine at Vanderbilt University School of Medicine in Nashville.

He believes the clinical community needs to take an entirely different tack when assessing and treating cardiovascular risk in women, for whom CVD represents the number one cause of death.

“If we treat CHD according to the traditional (cholesterol) model, we only reduce CHD by 50%, but we can reduce cardiovascular disease by 80% using exercise, optimal nutrition, fruits and vegetables, not smoking, low body weight, and a little red wine,” he said.

A New Roadmap

Dr. Houston contends that lipid profiles–the primary “roadmap” guiding conventional risk reduction strategies—are actually of limited value by themselves. Another common measure, the treadmill test, is only barely useful. Though it has a 68% predictive value in women over the age of 65, its effectiveness is only 36% in women under 50, and has an overall predictive value of only 51%.

He stressed that women often have “atypical” symptoms of CVD, and more women than men die from it.

Clinicians, he says, should use a new tool to define a woman’s risk for coronary heart disease: the seven-characteristic scoring system developed by Monica Lo and colleagues at the University of Texas Southwestern Medical Center and published earlier this year in the American Journal of Cardiology.

The scoring system incorporates the following seven independent factors predictive of CAD in women with abnormal stress test findings:

· Age ≥55 years (odds ratio 2.3)

· Body mass index <30 kg/m2 (odds ratio 1.9)

· Smoking (odds ratio 2.6)

· Low HDL (odds ratio 2.9)

· Family history of premature CAD (odds ratio 2.4)

· Lateral abnormality on stress imaging (odds ratio 2.8)

· Exercise capacity <5 metabolic equivalents (odds ratio 2.4).

To use the system, simply assign one point for each variable. A score under 2 indicates little risk of CAD; over 2 signals trouble, according to data from the study conducted by Dr. Lo and her colleagues (Lo MY, et al. Am J Cardiol. 2013; 111(6): 781-785).

“If the score is less than 2, the test has a negative predictive value of 80%,” Dr. Houston explained.

Different Mechanisms

Clinicians need to recognize there are significant gender differences in the mechanisms underlying CHD symptoms. In women, symptoms often have more to do with microvascular angina and stress cardiomyopathy, noted Houston. The most common symptom of a heart attack in women is sweating, and while 60% experience pain, pressure, or chest discomfort, 40% of women having a heart attack have no pain, Houston said.

He added that primary treatment with statins is less effective in women than in men, he added.

“The problem is that we beat the heart up with drugs, but do not give it the nutrition it needs. We need to give the myocyte mitochondria the nutrition it needs, by advising the patient to take taurine, aged garlic, Omega 3, and supplements like 5 grams of curcumin per day, and beet root extract for endothelium dysfunction.”

Dr. Houston pointed to research showing that diuretics decrease important nutrients such as magnesium, phosphorous, sodium, chloride, and iodide, while beat blockers and statins decrease coenzyme Q10. ACE inhibitors and angiotensin receptor blockers (ARBs) decrease the body’s zinc.

His recommendations to women at risk go a bit further than the standard advice to adopt a Mediterranean diet high in fruit and vegetables, smoking cessation, and to supplement with vitamins E, A, D, C, and B (not in alphabetic order). He stresses that women—as well as men—need to lose their visceral fat.

He also recommends the use of grape seed extract, ginger, nettles, rosemary, magnesium, fiber, selenium, aspirin, and/or dark chocolate to modulate the inflammation that often underlies a woman’s risk for heart attack.

For many patients, a 12-hour overnight fast between 4 and 7 days per week can be very helpful, as is daily exercise regimen of 40 minute resistance training, with 20 minutes of aerobics.



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