Managing young women at high risk of heart disease

Deaths from heart disease have decreased in recent decades, but these decreases have not occurred in women younger than 50. A new review in CMAJ (Canadian Medical Association Journal) provides guidance for physicians to identify and manage premenopausal women at high risk of heart disease.

"Addressing cardiovascular health in women younger than 50 years of age requires thinking 'outside the box' of traditional risk factors in primary prevention," says cardiologist Dr. Beth Abramson, St. Michael's Hospital, and the University of Toronto, Toronto, Ontario, with coauthors.

The review is based on the latest, high-quality evidence published from 2008 to 2018.

Some highlights:

• Diabetes, metabolic syndrome and smoking are stronger risk factors in younger women.
• Younger women with ovarian dysfunction may be at higher risk of cardiovascular disease.
• Early menopause because of surgical or chemical interventions may be a risk factor.
• Pregnancy complications, such as gestational hypertension and preeclampsia, are linked to higher risk of cardiovascular disease.
• There are limited and conflicting data on whether infertility treatments are a risk factor; further research is needed.

"A challenge in risk assessment is addressing the subpopulation at elevated risk within a lower-risk group," write the authors. "Current risk assessment tools are largely based on age and traditional risk factors and tend to underestimate risk in certain groups of younger women who are at higher risk."

The authors suggest that premenopausal women with these risk factors should be screened early for cardiovascular disease with close follow up and advice on lifestyle modifications where appropriate. Physicians should place more emphasis on sex-specific risk factors in younger women such as preeclampsia and other pregnancy complications, infertility and reproductive technologies.

Identifying higher risk premenopausal women, who have traditionally been considered low risk for future events, is an important step in improving the cardiovascular health of young women. Starting the conversation with these women at risk is the first step in prevention.