Sex-Specific CVD Risk in T2DM: What’s Going On?

Awareness of sex disparities in diagnosis and treatment of cardiovascular disease (CVD) in women has improved over time but women may still receive less effective, less aggressive medical management for CVD risk factors.¹ This inequity is of particular concern among women with type 2 diabetes mellitus (T2DM) who are already at increased risk for CVD. Beyond the need for improved management, several other factors related to sex could be at play, including^1-3:

Cardiovascular/metabolic risk profiles: Worse in women with T2DM-women may have to “travel further” in metabolic decline to become diabetic than men, so they are exposed longer to untreated CVD risk factors

Education/adherence: Women are less likely to use medications as prescribed, and so also less likely to meet treatment goals.

Sex-specific risk factors: Polycystic ovary syndrome, premature menopause, gestational diabetes and hypertension, and a history of preeclampsia

Sex differences in symptoms of acute coronary syndrome: Women often describe symptoms not considered classic (eg, nausea, tiredness, jaw pain), which may be related to female-specific autonomic dysfunction, while men usually describe classic features such as chest pain, left arm pain, diaphoresis.

Atypical or silent myocardical infarction: May occur more frequently in women with T2DM.

Extent of coronary artery disease (CAD): Women with diabetes are similar to men with diabetes, and more often have significant stenosis in all 3 coronary arteries, while women without diabetes more often have nonobstructive CAD.

Management Issues

Experts call for aggressive management of CVD risk factors among women with diabetes or prediabetes, including increased screening for diabetes precursors (ie, impaired fasting glucose, insulin resistance), more intensive follow-up for women at high risk, and earlier diagnosis of CAD and other CVD risk factors.²

In 2011, the American Heart Association (AHA) released guidelines developed specifically for the prevention of heart disease in women.⁴ While not specific to women with diabetes, the guidelines list diabetes as one of the defining criteria for a high-risk state for CVD among women. Metabolic syndrome, a history of preeclampsia, gestational diabetes, or pregnancy-induced hypertension also are listed as criteria for high-risk status. The AHA treatment algorithm’s recommended management for high-risk women (eg, who have diabetes) who have not had a recent cardiovascular event includes:

  • Blood pressure control: beta-blockers

  • LDL-C–lowering therapy: target LDL <100 mg/dL

  • ACE-I/ARB therapy

Among very high-risk women, consider:

  • LDL-C target <70 mg/dL

  • Non–HDL-C target <130 mg/dL

  • HbA1c target <7% when feasible

  • Aspirin/antiplatelet agent

  • Omega-3 fatty acid therapy

Take-home Points

  • Women with diabetes have higher risk for CVD and death from CVD than men

  • This increased risk is likely multifactorial and related to diagnostic issues, medical management, underlying biological attributes 

  • The AHA designates the presence of diabetes as a defining feature of high-risk status for CVD among women and provides treatment recommendations in its 2011 guidelines for the prevention of CVD among women

References:

• Norhammar A, Schenck-Gustafsson K. Type 2 diabetes and cardiovascular disease in women. Diabetologia. 2013;56:1–9. doi:10.1007/s00125-012-2694-y.
• Peters SAE, Huxley RR, Woodward M. Diabetes as risk factor for incident coronary heart disease in women compared with men: a systematic review and meta-analysis of 64 cohorts including 858,507 individuals and 28,203 coronary events. Diabetologia. 2014;16:1-7. doi:10.1007/s00125-014-3260-6.
• Strom Williams JL, Lycnh CP, Winchester R, et al. Gender differences in composite control of cardiovascular risk factors among patients with type 2 diabetes. Diabetes Technol Ther. 2014;1-7. doi:10.1089/dia.2013.0329.
• Lori Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women-2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243-1262 doi:10.1161/CIR.0b013e31820faaf8 .