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Antonio de Padua Mansur
R elationship betw een risk factors and
coronary heart disease in prem enopausal and
postm enopausal w om en
Grllpo de Coromiria do Institllto do CorO:fiio do Hospital
das Clfnicas -
FMUSP
C o ro n ary h eart d isease is th e m ain cau se o f d eath am o n g w o m en in d ev elo p ed reg io n s in B razil w ith a en o rm o u s p u b -lic h ealth co sts. T h e in cid en ce o f co ro n ary h eart d isease in -creases after th e m en o p au se, resu lted fro m a m ark ed o v arian d eficien cy in p ro d u cin g en d o g en o u s estro g en . It is also w el1 estab ilish ed th e lo w rate o f co ro n ary artery d isease in p re-m en o p au sal an d in p o stre-m en o p au sal w o m en receiv in g h o rm o n e rep lacem en t th erap y . O n th e o th er h an d , th e p ro g n o sis after m y o card ial in farctio n , co ro n ary an g io p lasty , an d co ro n ary b y p ass su rg ery is w o rse in w o m en th an am o n g m en . It is n o t w el1 k n o w n th e cau se o f th is ex cess m o rtality . T h is fact m ay b e related to th e sex d ifferen ces in access to h ig h -q u ality m ed ical th erap y an d strateg ies to w o m en . T h u s, b est ap -p ro ach es are n eed ed , esp ecially in p o stm en o p au sal w o m en w h o h av e an in creased risk fo r card io v ascu lar d iseases.
T h e p rim ary p rev en tio n o f co ro n ary h eart d isease in w o m en en v o lv es ch an g es o f th ese m o st im p o rtan t m o d ifiab le risk facto rs: sm o k in g , h y p erch o lestero m ia, d iab etes m elito an d h y p erten sio n . S m o k in g an d d iab etes m elito are th e m o st im -p o rtan t risk facto rs in -p rem en o -p au sal w o m en . P rev io u s stu d -ies h av e sh o w n g reater p rev alen ce o f card io v ascu lar d iseases am o n g w h o sm o k e, a straig h t relatio n w ith th e n u m b er o f cig arrete p er d ay an d th e asso ciatio n w ith o th er risk facto rs. S m o k in g in creased am o n g y o u n g an d d isad v an tag ed w o m en , an d w as asso ciated w ith an early n atu ral m en o p au se. H ig h p rev alen ce o f card io v ascu lar d iseases w as also o b serv ed in y o u n g w o m en u sin g co n tracep tiv es d ru g s, sp eccialy in sm o k -in g w o m en . T h e co n tracep tiv es an d cig arrete sm o k in g , . sy n erg isty cal1 y , are asso ciated w ith ad v erse effects in lip id p ro file, co ag u latio n sy stem , an d p latelet ag g reg atio n . A l-th o u g h , co n sisten t ev id en ces w eren o t su p p o rted w ith co n tra-cep tiv es w ith lo w d o eses o f stro g en . In fact, stro g en in n o sm o k in g w o m en p ro m o tes a n atu ral p ro tectio n ag ain st car-d io v ascu lar d iseases. T h e th ro m b u s fo rm atio m an d ath e-ro m ato u s p laq u e d ev elo p m en t are fav o rated b y sm o k in g in -d u ce-d ex ten siv e en d o th elial d am ag e th at en h an ce p latelet ac-tiv atio n w ith release o f g ro u th facto rs, raises seru m lev el o f fib rin o g en , an d d ecreases h ig h -d en sity lip o p ro tein . T h o u g h , th e p ath o p h y sio lo g y o f co ro n ary h eart d isease in p rem en o -p au sal sm o k in g w o m en th o se w h o u se co n tracep tiv es p ro
-b a-b ly acco u n ts m o re fo r a th ro m b o g en ic th an a ath eo g en ic p ro cess. F u rth erm o re, sm o k in g h as a an ti-estro g en ic effect, in creasin g th e h y d ro x ilatio n o f carb o n -2 fro m estrad io l, an d red u cin g th e carb o n -1 6 h y d ro x ilatio n . T h e fo rm er p ath w ay g en erates m etab o lites w ith less p o ten t estro g en effects.
T h e risk o f card io v ascu lar d iseases is also in creased in y o u n g d iab etic w o m en w ith a d irect relatio n sh ip b etw een ch ro n ic h y p o g licem ia d etected b y su stain ed h ig h p lasm a lev -els o f g ly co silated h em o g lo b in . In o u r ex p erien ce, th e p rev a-len ce o f d iab etes m elito in su lin -d ep en d en t w as g reater in p rm en o p au sal w o rm en . B ecau se d iab etes d arm ag es th e en d o th e-liu m , th e n atu ral p ro tectio n o f in tact en d o th eliu m is co m -p ro m issed , b y red u ced au to crin e v aso d ilato rs p ro d u ctio n , o r ev en th o se related to th e im p aired effect o f estro g en o n in -ju red v ascu lar tissu e. It w as also o b serv ed th e freq u en t asso -ciatio n o f o th ers risk facto rs am o n g d iab etic w o m en . A lth o u g h , a m in o rity o f p rem en o p au sal w o m en are afflicted w ith p re-m atu re ath ero sclero sis, sm o k in g cessatio n an d b etter co n tro l o f h ip erten sio n an d p lasm a g ly cem ia lev els m ay h av e an im -p o rtan t im -p act o n th e in cid en ce o f card io v ascu lar d iseases in y o u n g fem ales.
T h e p rev alen ce o f sm o k in fg an d d iab etes m elito are lo w er in p o stm en o p au sal th an in p rem en o p au sal w o m en . H o w ev er, th ere are an ab ru p t in crease in th e in cid en ce if co ro -n ary h eart d isease in p o stm en o p au sal w o m en , p ro b ab ly b y lo sin g th e ath ero p ro tectio n co n fered b y th e estro g en s, asso ci-ated b y th e in creased p rev alen ce o f h ip erten sio n an d d y slip item ia. E p id em io lo g ic ev id en ce in d icates alm o st 5 0 % in th e in cid en ce o f card io v ascu lar d isease in p o stm en o p au sal w o m en receiv in g estro g en th erap y . T h e h o rm o n al rep lacem en t seem s to im p ro v e th e ch o lestero l p ro file, th e lo w d en sity li-p o li-p ro tein an ti-o x id atio n , th e en d o th eliu m -d eriv ed v aso activ e su b stan ces, an d th e p erfo rm an ce o n ex ercise-in d u ced m io card ial isch em ia. T h erefo re, b esid es risk facto rs co n tro l b y ch an g in g so m e lifestiles, as th e d iet, sm o k in g , an d p h y si-cal in activ ity , an d treatin g th e d iseases asso ciated w ith co ro -n ary h eart d isease, it is w ise to i-n tro d u ce estro g en rep lace-m en t th erap y in p o stlace-m en o p au sal w o m en , in o rd er to en h an ce b o th th e q u ality an d th e life ex p ectan cy .
