Risk Assessment for Coronary Heart Disease and Alzheimer's
Risks for Coronary Heart Disease in Women
Frederick R. Jelovsek MD
While women, especially premenopausal women, have significantly less heart disease than men, they are often at a disadvantage when it comes to diagnosing possible heart disease. Doctors don't have a high index of suspicion when a woman presents with chest pain because most of the time it is due to causes other than atherosclerotic coronary heart disease. Women do get angina, however, and they do have heart attacks. It is important to know what the risk factors are for coronary heart disease so that women are more likely to have the recommended diagnostic studies and thus earlier diagnosis.
Marian C. Limacher, MD, Professor of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA, summarized the risk factors for coronary artery disease in The woman with chest pain: Clinical assessment and diagnostic testing, Menopause Management 1997;6:6-11.
Risk factors for coronary heart disease are generally divided into minor, intermediate and major.
Risk factors for coronary heart disease in women*
| Major | Intermediate | Minor |
|---|---|---|
| known coronary artery disease or peripheral vascular disease | hypertension (high blood pressure) | age over 55 years old |
| typical angina pectoris | smoking | obesity, especially central obesity |
| diabetes mellitus | abnormal lipids especially low HDL (high density lipoproteins) ( < 50 mg/dL) and/or elevated triglycerides ( > 400 mg/dL) | |
| postmenopausal status without hormone replacement | - | family history of coronary artery disease |
| - | - | psychosocial factors such as poor social support, high stress with low situational control |
| - | - | hemostatic risk factors such as elevated fibrinogen or plasminogen-activator inhibitor type 1 (blood clotting factors) |
Women at low risk would have two or less minor risk factors and/or one intermediate risk factor but their chest discomfort is not typical for angina. If this is the case, usually there is no further coronary heart disease diagnostic work-up unless no other non-cardiac cause is suspected or unless there is a high level of concern on the part of the physician or woman.
Women at intermediate risk would have no major risk factors except diabetes (alone) or postmenopausal not-on-replacement hormones (alone), but one or more intermediate risk factors (with or without any minor risk factors) and also chest discomfort not typical for angina. They would have some sort of diagnostic testing such as exercise treadmill testing or thallium (imaging) testing or stress echocardiography.
Women at high riskwould be those with typical angina pain, or have more than one major risk factor and/or multiple intermediate and minor risk factors. They usually would undergo cardiac catheterization unless they had stable or infrequent angina and had never had prior stress imaging. In that case they would undergo the stress imaging first and if that were negative, they would not have a cardiac catheterization at that time.
* Modified by Dr Limacher from Douglas and Ginsberg**, NCEP II***, and
Miller Bass et al****.
** Douglas PS, Ginsburg GS. Current Concepts: The evaluation of chest
pain in women.N Engl J Med 1996;334:1311-15.
*** Expert panel on detection, evaluation, and treatment of high blood
cholesterol in adults. Summary of the second report of the National
Cholesterol Education Program (NCEP). (Adult treatment panel II).
JAMA 1993;269:3015-23.
**** Miller Bass K, Newschaffer CJ, Klag MJ, et al. Plasma lipoprotein
levels as predictors of cardiovascular death in women. Arch Intern Med
1993; 153:2209-16.
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Classic features of angina pectoris chest pain
- Location - pain is mid chest and may radiate to the shoulders, left and/or right arms, neck or jaw
- Type - pain is often described as pressure, squeezing or heaviness rather than sharp or burning. It may not even be described as pain but rather as a "feeling"
- Worsening features - physical exertion or emotional distress/stress makes the pain or feeling worse
- Duration - the pain usually lasts less than 5-10 minutes, but can occasionally last longer in unstable syndromes or with infarction
- Relief - pain is relieved by rest, stopping the precipitating activity, or medications such as nitroglycerin
- Associated features - pain may be accompanied by shortness of breath, rapid breathing, and/or nausea. Occasionally these symptoms may be the only complaint.
Three or more of the above classic features would make coronary artery disease "very likely". One or two of these features along with less typical signs would make coronary artery disease "possible". Any one of these features alone would suggest that further diagnostic investigation is necessary.
Central obesity
Two types of obesity are distinguished with respect to their risk for eventual heart disease. In central obesity (android), most of the excess fat is at the stomach or waist level. It produces an "apple" shape. The other type of obesity is lower body (gynoid) mostly in the buttocks and lower legs. It produces a "pear" shape body. It has been empirically found that central obesity is associated with a tendancy toward diabetes, increased male hormone levels (androgens) and lowered levels of the "good" cholesterol, high density lipoproteins. Thus women with central obesity are at higher risk for coronary heart disease than women in whom all the weight is is in their "bottom".
The definition of central obesity is a waist-to-hip ratio of more than 0.85
where waist is defined as the smallest circumference (girth) between the rib cage and
the illiac crests (hip bones) and hip measurement is the largest circumference
between the waist and the thighs. For example a waist of 38 inches and a hip
measurement of 40 inches (38/40=ratio of 0.95) would indicate central obesity.
Gynoid obesity is a waist-to-hip ratio of less than 0.75. A waist measurement
of 38 inches and a hip measurement of 54 inches (38/54=ratio of 0.70) would
be an example of that.
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Risks for Alzheimer's Disease
Frederick R. Jelovsek MD
Alzheimer's disease is much more frequent than many people think. It is
a form of dementia that progresses gradually over 7-10 years. It affects
all functions of the brain including memory, language, judgment, abstract
thinking, behavior, personality and motor abilities. It is estimated that 5% of
people over 65 have Alzheimer's and by age 85 one out of three persons are
affected. The annual incidence(1) is:
| Annual Incidence | Age |
|---|---|
| 0.6% | 65-69 |
| 1.0% | 70-74 |
| 2.0% | 75-79 |
| 3.3% | 80-84 |
| 8.4% | 85+ |
Unfortunately several studies imply that women are more at risk than men. Diabetes, thyroid disease, smoking and previous head trauma which were once thought to be risk factors for Alzheimer's disease are now not thought to increase risk (2). For some reason, having arthritis and/or taking non-steroidal antinflammatory drugs (NSAIDs) such as ibuprofen, decrease the risk of getting Alzheimer's almost in half (1).
The following are the known risk factors for Alzheimer's in addition to being female:
- positive family history of dementia (Alzheimer's or others)
- lower educational status
- lower income
- lower occupational status
- occupational exposure to glues, pesticides and fertilizers
1. The Canadian study of health and aging: Risk factors for Alzheimer's disease in Canada. Neurology 1994; 44(11):2073-80.
2. Katzman R, Aronson M, Fuld P, et al. Development of dementing illness in an 80-year-old volunteer cohort. Ann Neurol 1989; 25(4) 317-24.
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