CVD Risk Factors in Women with Diabetes
Cardiovascular disease (CVD) risk factors are different for men and women and diabetes adds another layer of difference. A panel of diabetes experts discussed this topic during a symposium at the American Diabetes Association’s 75th Scientific Sessions, held in Boston this past June.
“We know that cardiovascular disease happens in women just as it does in men. But the presentation is different, and the presence of diabetes increases cardiovascular risks for women more than it does for men,” said Elizabeth L. Barrett-Connor, MD, distinguished head of epidemiology, University of California, San Diego, who is the founder and director of the Rancho Bernardo Heart and Chronic Disease Study that launched in 1972.
She noted the importance of looking at clustering of factors for CVD among men and women, referring to a study she and colleagues conducted that looked at sex-specific clustering of CVD risk factors in patients with and without diabetes. The study found that people with diabetes were more likely to rank in 70th or 90th percentile of clustering for blood pressure, triglycerides, smoking, and obesity. Women had more marked clustering than men, independent of obesity. “This [study] may explain some of the excess risk of heart disease in women living with diabetes versus men living with diabetes,” said Barrett-Connor.
Hypertension is a CVD risk factor that requires attention among women with diabetes. Shawna Nesbit, MD, associate professor of medicine, University of Texas Southwestern Medical Center, shared statistics on hypertension and diabetes. Approximately 73% of adults with diabetes have high blood pressure ≥130/80 mm Hg or use prescription medication for hypertension. Hypertension is 1.5 to 3 times more prevalent in diabetic patients than in age-matched cohorts. Hypertension is associated with a 2- to 4-fold increase in mortality in patients with diabetes. In terms of women and hypertension, she said, “If we look at the prevalence of hypertension as it occurs over a lifetime women have hypertension more commonly as they get older.”
Guidelines such as the Joint National Committee 8 (JNC 8) guidelines for the management of high blood pressure in adults1 outline treatment recommendations for patients with diabetes and hypertension. Guidelines have also recommended the use of ambulatory blood pressure monitoring for suspected white-coat hypertension, resistant hypertension, hypotensive symptoms with medications, episodic hypertension, and autonomic dysfunction.
“It is important to note that guidelines are shifting and changing. A large part of what determines guidelines is how you set the criteria to begin with and so the JNC 8 criteria were set much different than others have set the criteria,” said Nesbitt. “I would really recommend that we look at patients as individuals. We take into consideration what guidelines tell us but they don’t necessarily address an individual patient as they present to you. Guidelines on treatment goals have some differences but there is agreement that special high-risk patients should be treated more aggressively.”
Out of office blood pressure monitoring is also an important tool in evaluating hypertension. “The out of office blood pressure clearly has been shown to be more powerful as a measure of blood pressure risk for cardiovascular events and stroke,” she said noting the importance of clinicians better training their patients to do it more efficiently, to be more accurate, and to provide data back to their clinician.
In conclusion she said, “Women should be approached with a specific eye looking for the things that affect women more commonly. As you address one particular risk factor, you cannot take that in isolation from all of the others. You have to consider [risk factors] that may affect longevity, health, and quality of life overall because it’s not just stroke and heart attack that we are trying to prevent. Those are huge risk factors and causes of death we want to prevent. On the other hand, there may be some other intervening causes that make things a whole lot worse.”
Glycemic control also takes on a special importance in women. Anne L. Peters, MD, professor and director clinical diabetes program, University of Southern California Keck School of Medicine, discussed why improving glycemia reduces CVD risk in both men and women and the importance of treating glycemia in women.
She highlighted a meta-analysis of glycemic control trials and rates of coronary heart disease conducted by Ray et al.2 The study showed that intensive versus standard glycemic control significantly reduces cardiovascular events without an increased risk of death.
“I think it is good to treat diabetes in ways that can help avoid hypoglycemia, particularly severe hypoglycemia,” she added, underscoring the need to use diabetes medications that do not cause hypoglycemia. These include metformin, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter-2 inhibitors, and glucagon-like peptide-1 receptors.
Clinicians need to always consider patient’s health issues when selecting a treatment regimen. For women, these include reproduction, bone health, depression, eating disorders, overweight, and obesity. Clinicians also need to factor in that many women are caregivers and have longer life expectancies with potentially limited resources.
1.James P, Oparil S, Carter B, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults. JAMA. 2014;311(5):507-520.
2.Ray KK, Seshasai SR, Wijesuriya S, et al. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet.2009;373(9677):1765-1772.