CALGARY, ALTA. — The way Dr. Beth L. Abramson sees it, menopause provides the ideal opportunity to review with patients their risk for heart disease and stroke, and to reinforce heart-healthy behaviors.
“Although it's a bit of a paradigm shift, we need to start talking about heart-healthy behavior in gynecologists' offices,” said Dr. Abramson at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “There is no doubt that risk of heart disease increases with menopause.”
In Canada, one in three women dies from heart disease and stroke, which makes these two conditions the leading causes of death among women, greater than all forms of cancer combined.
“For the first time in 30 years, women have caught up to men when it comes to the number of deaths from cardiovascular disease,” said Dr. Abramson, a cardiologist who directs the cardiac prevention and rehabilitation center at St. Michael's Hospital and is a spokesperson for the Heart and Stroke Foundation of Ontario, both in Toronto.
Moreover, the risk of dying within the first 30 days of a myocardial infarction is 16% higher for women compared with men. The same goes for stroke, which confers an 11% higher risk of death within 30 days for women compared with men. “Women are less likely to be treated by a specialist, are less likely to be transferred to another facility for treatment, and are less likely to undergo cardiac catheterization or revascularization,” she noted.
Despite the well-known risks, awareness of heart disease risk among women is generally poor. According to Dr. Abramson, only one in eight Canadian women understands that heart disease and stroke are her most serious health concerns, whereas only one woman in three knows that the conditions are the leading causes of death.
In an effort to close the current knowledge gap, Dr. Abramson and her associates at St. Michael's are teaching primary care physicians to administer a Framingham risk calculation as a way to assess a woman's risk of developing coronary artery disease. A software program calculates the woman's 10-year risk of a heart attack based on factors including age, blood pressure, smoking status, lipids, fasting blood glucose, and family history. The score “may underestimate some risk, but it's what we are using,” she said. (The assessment is similar to the National Heart, Lung, and Blood Institute's tool for estimating the 10-year risk of having a heart attack, which can be found at http://hp2010.nhlbihin.net/atpiii/calculator.asp
Dr. Abramson also recommends a discussion of risk reduction strategies—including smoking cessation, healthful eating choices, exercise, and weight-loss tips when needed—during each office visit. “It's very hard to make lifestyle changes,” she acknowledged. “I encourage people to make small changes over time. Most heart attacks aren't sudden; they take many years of preparation.”
Most smokers want to quit, she said, yet only about one-third of smokers report receiving smoking-cessation advice from their physician. She often uses this script, which can be delivered in about 20 seconds: “Do you smoke? I know you understand it's bad for you. It's the worst thing for your health. I can help you quit smoking if you want to.”
Finding a way to personalize the effects of smoking cessation is also key. “Tell the women their skin will look better and younger if they quit,” she said. “That's an important motivator.” So is the phrase, “Your children want you to quit so you can be around for your grandchildren.”
Dr. Abramson pointed out that visceral obesity is associated with conditions that lead to heart disease, including increased LDL cholesterol, decreased HDL cholesterol, high triglycerides, diabetes, insulin resistance, increased insulin levels, abnormal blood clotting, glucose intolerance, and poor blood-vessel function. “In menopause, the fat distribution of women changes,” she said. “They are more likely to take on an apple-shaped figure than a pear-shaped one.”
The Heart and Stroke Foundation of Canada has launched “The Heart Truth” campaign aimed at educating women about their risk for coronary heart disease. The campaign includes a dedicated Web site (www.thehearttruth.ca
The campaign advises women to take action and talk with health care professionals about treatment options for risk factors such as high cholesterol, high blood pressure, and smoking.
“You have a role to play,” Dr. Abramson said. “You have an opportunity to take care of women around the time of menopause and try to reduce their risk factors.”
Dr. Abramson disclosed that she receives ongoing research funds from Astra Zeneca Pharmaceuticals LP, Boehringer-Ingelheim Pharmaceuticals Inc., and Merck & Co., and that she has been a speaker for several other pharmaceutical companies.