In support of International Women’s Day 2024, THE National Institute for Prevention and Cardiovascular Health (NIPC) hosted a NIPC Series webinar Women and CVD Matters! on Tuesday 5th March.
A panel of experts came together to share their insights on key challenges specific to women’s heart health. Women face many unique health challenges throughout their lives and this webinar explored cardiovascular disease (CVD) risk factors and menopause, lipid management, important messages for CVD prevention and control, and the lived experience of SCAD.
Topics included:
- Spotlight on Sex-Specific Risk Factors
- Peri-Menopause, Menopause, HRT and CVD – Your Top Questions Answered
- Is Lipid Management Important in Women and if So When, in Whom and How Best?
- What are the most Important Messages for Women in CVD Prevention and Control?
- Spontaneous Coronary Artery Dissection – What Every Practitioner Should Know?
Below and over the next few pages, we give an overview of some of the keynote talks and interviews which were carried out with Dr Jenni jones, Director of Training and Education for the NIPC.
Dr Jenni Jones speaking Dr Nicola Cochrane, GP & Menopause Specialist, Carrig Clinic and National Maternity Hospital
Should HRT be advocated and if so, when? Is it something we should be actively promoting?
The logic would be the HRT is advocated for women who are experiencing distressing symptoms of menopause. That can be before menopause. Women in perimenopause have often developed so many symptoms that their quality of life is very much obliterated and at that point it is logical to start HRT even though they’re still having periods. Their periods may be irregular, but they would gain a lot of benefit from starting it when they discover they have symptoms. Most women will ask their doctor.
From the point of view of whether it is suitable for everyone, there are only a very small number of women where we would have some considerable caution about giving it. It is very much the women where they’ve perhaps already had a diagnosis of a hormone receptor cancer, where their oncologist would be concerned that using extra estrogen might reignite that cancer process.
For heart disease, there has been studies and evidence and the information we have now is incredibly encouraging and reassuring.
When or if you have a female in the CCU, with acute coronary syndrome and has been on HRT, should they continue with HRT?
Absolutely, to be honest, a woman experiencing a devastating health event such as a heart attack who’s in a coronary care unit, which is a terrifying place to be – the last thing you want to do is take her estrogen away from her and be suddenly thrown into menopause symptoms.
In the middle of that is creating emotional and physical stress on your body. Its achieving absolutely no benefit as far as health protection and you could argue that its nearly exposing you to increased risk of further cardiac events. So the logic would be that is they’re on it, let them stay on it. We often meet women who present when they develop really troublesome menopause symptoms, and they already got a diagnosis of heart disease. They have had a previous heart attack; they’ve got coronary artery disease and they’re on treatment from a specialist and they are concerned about where its safe for them to take HRT. After many studies, over many years, it is entirely safe for women who have already got heart disease to take HRT. The benefit and the logic would be to start your HRT when your menopause starts or within 10 years of when your menopause starts. So if its actually much later, if you were then into your sixties and you hadn’t started it before, we would have concerns. You wouldn’t say it is impossible, but you would have concerns that is might then offer some risks.
Is there a best form of HRT?
When we think about heart disease, in parallel with that, the concern would be around risk of blood clots. When we prescribe PHRT, currently we will tend to ask women to use a transdermal product that’s with a patch, gel or spray gel because we have overwhelming evidence now to probe that those are very, very safe and there is no increased risk of blood clot with those products. But a tablet of estrogen can slightly increase your risk of blood clots and particularly in any women with a heart condition or blood pressure, they would be at a little bit more risk from blood clots. We would prefer to have them on a transdermal product.
There has been some negative publicity around estrogen, could you talk us through your views on that?
The big study that people would have been first aware of it, was when the American studies from the Women’s Health Institute were published in 2001. This raised overwhelming concern about risk of stroke, heart attack with HRT. But that study was doing using tablet-based HRT and they were offering the medication to women in their sixties. They were working at the beginning with the idea that it was already well recognised that HRT was beneficial to women at normal menopause age. So maybe, it could also be beneficial to older women and the obvious result was no. It can actually be quite dangerous to suddenly introduce a very high done of estrogen to someone in their sixties who’s never used HRT. But we didn’t see what might have happened in that age group if they used a lower dose patch. That study was subsequently done with some of the early estrogen studies done in the UK and in France and Denmark. So we have good data on that now, and it clarified the difference between tablets and patches or gels.
People with familial hypercholesterolemia – perhaps HRT is considered carefully in this group. Any comments on that?
That brings us into a discussion on the imminent new guidelines from NICE on menopause care, particularly om cardiovascular. They published their draft evidence already and they’re not going to look at new evidence. They have already offered their conclusions on the evidence that they have and said in all cardiovascular disease, that includes families with hypercholesterolemia, that is no recognized from the evidence to date, that it is safe for them to use. But the proviso would probably be that under specialist input from a menopause specialist or GP who has expertise in menopause, know how to prescribe safely, particularly to give them a transdermal estrogen rather than a tablet. Its very good news to see that NICE have concluded that they’re satisfied that transdermal HRT is safe for heart disease and I think it is going to be welcomed by most of those groups who are experiencing conditions like familial hypercholesterolemia, premature heart disease.
Are there any new messages from NICE that we haven’t touched on yet?
So some of their guidance extended as well to stroke and they came out with the really clear message that timing is really important, that using transdermal estrogen under the age of 60 or within 10 years of menopause was safe. But that you could see an increased risk of stroke in people who were given HRT over 60, and a really important group to consider carefully when prescribing were women with black ethnicity. We know that quite a lot of women with black ethnicity have hypertensive heart disease and have preexisting heart disease by their genetic dispositions. So they are more vulnerable to complications and certainly you would prefer to give them a transdermal estrogen and not a tablet.
What about Progesterone? How does that fit?
They’re only relatively recently starting to look at what role progesterone plays in, risk and safety with HRT, are preferred at the moment from the knowledge we have based on research is to use a micronized progesterone, and that is sometimes referred to in women, might be familiar with the term a body similar because it’s the most closely, connected to natural progesterone. The reason that we usually prescribe that as a first line, and that would be EU progestin or Avastin, which is droge, is because it has a very good record of breast safety and it has a lower side effect profile than some of the other progesterones that sometimes give people almost a feeling of premenstrual, irritability, puffiness, bloating. They just really don’t feel good on some of them. Whereas we don’t tend to run into that quite so much with micronized. And there’s one honourable exception, which we don’t yet have licensed in Ireland, but it is available in the uk. Sperone is a tablet based, progesterone, it’s a fourth generation progesterone. It’s based on the diuretic tablet, which what used to be used for high blood pressure spironolactone. So it’s very low on progesterone side effects because it actually clears fluid out of your system. So rather than feeling puffy, you feel the opposite. It’s very skin friendly for people that are prone to acne. But what the research has also found is that it’s very helpful for cholesterol. So it actually lowers cholesterol and that’s been welcomed by menopause doctors so that it’s now included in British menopause guidance to doctors prescribing because they have sperone only in the UK now it’s called Lindy, which is a slightly funny name, but we’ll see it in Ireland over the next six to 12 months hopefully. And they’re offering it as an adequate progesterone to balance any estrogen, and they said that we’re, it’s not currently licensed for that usage. There’s ample evidence to support the safety of it for that method. So that’s a very helpful endorsement, and it will be something that will be very welcome as another option.
Is HRT enough to treat your lipids? Is there a belief that is I take HRT, my lipids will be magically improved?
There’s quite divided opinion on that. So we would have very, very optimistic ideas that it stops the clock in that estrogen is very protective to, arteries and the lining of arteries, and it minimizes buildup of cholesterol deposits. We know that from a lot of research. Starting your HRT at menopause, if you were at normal population risk, you could be optimistic that it, it’s likely to be somewhat helpful at preserving the integrity of your arteries.
But if you’re in a family where other people in the family have suffered heart disease at a much younger age, maybe in their thirties or in their forties, then we know that it’s not enough in itself and that you very definitely may need to use cholesterol medication or other medication under specialist guidance so that the HRT would be a reasonable parallel, to manage your menopause symptoms, but your heart health might need a little bit more.
Dr Jenni Jones talks to Dr Catherine McGorrian, Consultant Cardiologist, The Mater Misericordiae University Hospital
Managing Lipids – is it going to be different to men or the same as men? Can younger women need lipid lowering? Catherine what are your views in terms of managing lips in women?
We know when it comes to risk factors, so first of all, of course we know cholesterol and LDL cholesterol as a significant risk factor for coronary artery disease, but also cerebral vascular disease, peripheral arterial disease, and atherosclerotic disease in general. When it comes to women’s risks, we know that women, have a lower risk profile up to menopause, and then once they reach menopause at the cholesterol, can actually increase at that point. I know we spoke about this, there’s some very nice work coming out of Galway, where we see that the average men, average cholesterol for women actually goes a little bit higher than that of the men, around that time of menopause and there on in. But there are situations where lipid profile, can lead treatment at younger ages even before menopause. Nicola already mentioned, for instance, you know, if a person had a particular family history of coronary artery disease, and I can see somebody in the chat has alluded to familial hypercholesterolemia. There are some situations, where a person can, it doesn’t matter which sex they are, can have, a very elevated cholesterol during the life course. And exactly as Nicola says, we know that LDL cholesterol is what we call atherogenic, so it predisposes to atherosclerotic plaque. I suppose it can be, we can be more at risk in one of two ways with regards to our cholesterol burden. Either that our absolute cholesterol burden itself is higher, or that we’re ex we’re exposed to it over a longer period during the life course. So people with familial hypercholesterolemia, which is a genetic condition, they will have a higher cholesterol for a longer period of life and it doesn’t matter if you’re a man or a woman. So knowing your family history is really helpful there. And then knowing the other cardiac risk factors as well and how they build into your cholesterol risk.
Am I right in understanding that sort of perimenopause menopause, the time when we have these significant hormonal changes, the time where we accumulate a bit more visceral adipose tissue, you are saying that at that point almost our lipids can overtake men in a sense? Is that what I am understanding correctly?
That’s what the data showed actually, and it came out of quite a comprehensive study out of, university Hospital Galway. Whether our cholesterol as women is higher itself or whether that perhaps we are getting it treated less, that wasn’t explored. And I did wonder myself if perhaps, as women, we’re maybe geared to think of, cholesterol as something that, you know, is for the men. But it definitely isn’t. So whether we’re, you know, perhaps not accessing the right care and treatment around it, it’s very well established. You know, women suffer atherosclerotic cardiovascular events about 10 years later than men do in the life course. But we live longer, it’s really important to be aware of our risk factors, and have them treated.
In terms of lipid treatments, therapies, are there any exciting in the future? Any exciting additions to the basket of options in Ireland?
The standard treatment, of course, is starting off with our diet, which is our Mediterranean diet. The big piece is to try and avoid, the trans fats, the saturated fats, the processed meats, and a Mediterranean diet. But it does give us a nice kind of framework and that idea of the more modern food pyramid. Then we have our statins, which are H mg quinzy, a reductase inhibitors, and they’re fantastically efficacious. They reduce all cause mortality, reduce stroke, heart attack. They’re really our go-to, and of course they can be limited in some people, relating to myopathy, abnormal liver function tests, etc. A fibrates in particular for hypertriglyceridemia. So that’s your biso fate or your fenofibrate is the other one. Up and coming is bemed doic acid, it’s a pro-drug. It comes in the pathway before the statins. As a pro-drug, essentially, it doesn’t have the panoply of side effects in terms of myopathy. It’s broken down in the liver, so it’s very promising. Then the other one is the one I always have to try and say carefully in Razan, a little bit like the PCSK nines, which I neglected to mention. But it’s a small interfering RNA substance. It essentially affects the PCSK nine protein, which is a protein that recycles our LDL receptors. So why is that important? You’ll know, of course, that we eat cholesterol, we make cholesterol, and it circulates in our bloodstream, particularly the LDL is the one that we always look at, in terms of atherogenic. But there are other ones. There’s the VLDL and the IDL as well. But essentially, we circulate our LDL cholesterol, it’s atherogenic, and then our LDL receptors suck it out of circulation and send it back to be repackaged. But if we’ve got a problem with our LDL receptors, we leave our cholesterol circling for longer. And that’s specific, for instance, to familial hypercholesterolemia. We’ve heard already people with heterozygous homozygous, familial, familial hypercholesterolemia will have a problem with their LDL receptors, so their cholesterol will circulate for long. In Rizza and the PCSK nines as well, they stop us recycling our LDL receptors so we have more of them for longer, so we can suck the cholesterol out for longer. So these allow us to reduce our LDL cholesterol burden and its very clear than then reduce cardiovascular risk.
My understanding is that both of those, agents are used in the UK but they are licensed and its really looking at the reimbursement side in Ireland, but it’s looking hopeful that we’re going to have more options in treating people who are perhaps statin intolerant or with conditions like FH, which leads me to that media side, the newspapers saying that statins causing of all sorts of side effects. How common is statin intolerance?
For instance, maybe we’ve used our risk factor calculator, we’ve used our score two or our Q risk and we’re recommending a statin for somebody, male or female. The first thing people will say to you is, do I have, will I be on this for a life? That’s a difficult conversation because you’re introducing the idea of a daily medication. Once there’s an indication for it, I always try to explain to people the indication doesn’t go away. So, if it’s indicated for you now, it’ll still be indicated for you in 5, 10, 15 years’ time. In terms of the side effect profile, I, my own feel is that I’m seeing fewer and fewer side effects. I think people are less, are more trustful of statins.
I mean, realistically, what are the side effects about one person in 10 might get a myopathy. Although the research does show that many of these myopathies are actually not themselves related to the statin that they may be, there’s an element of subjectivity or an element that there’s something else causing it. Abnormal liver function tests, which are usually tolerated and usually don’t require, uh, withdrawal of the statin. I mean, the options are to change to a different type of statin, or to change the dose. I do find that sometimes with the high potency statins, people will tell me that they get very lucid dreams with them. I don’t know if anybody else hears that. I hear that a fair bit and I tell them to take them in the morning then, to save themselves from the lucid dreams. But typically, they’re well tolerated, and they are such an efficacious medication in terms of all the information we have. They’re kind of the building block, aren’t they? And then we layer on top the ezetimibe if we need that or move to the PCSK nine if that’s indicated. But there’s very few people in Ireland at the moment getting PCSK nine inhibitor agents. Perhaps for these newer agents, we’ll see, see more of these usages down the line.
What are your views in terms of calculating risk?
When we talk about personalised medication, personalized advice, is really at the heart of it because those risk scores. Ireland’s own Professor Graham was one of the original, creators of those risk scores. They’re mathematical modelling, based on large pieces of the population. When you build those kind of risk scores, it’s very interesting. We all have predetermined ideas of what we think should go into risk scores. But mathematically, when you put those things in, they don’t always have an improvement around how effective they are at calculating risk. So, I think it comes down to the individual. You take what you get from the risk score, but then you must modify it further based on what your own personal risk elements are. And these might be your gestational diabetes, or gestational hypertension. Or indeed, if you’ve had a history of breast cancer, radiation therapy, to the chest wall or family history, of course it doesn’t feature in the score. There’s a lot of gaps. And that’s where your personalised information must be layered on top of that risk score.