Women with a low Framingham risk score and a family history of premature coronary heart disease have a high prevalence of subclinical coronary atherosclerosis.

Michos ED, Vasamreddy CR, Becker DM, Yanek LR, Moy TF, Fishman EK, Becker LC, Blumenthal RS.

Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.

BACKGROUND: The Framingham risk estimation (FRE) serves as the basis for identifying which asymptomatic adults should be treated with aspirin and lipid-lowering therapy in primary prevention. However, the FRE generally yields low estimates of 10-year "hard" coronary heart disease (CHD) event risk with few women (<70 years) qualifying for preventive pharmacologic therapy despite relatively high lifetime risk. We postulated that traditional risk factor assessment might fail to identify a sizeable portion of women with a sibling history for premature CHD as having advanced subclinical atherosclerosis.

METHODS: We studied 102 asymptomatic women (mean age 51 ±7 years) who were the sisters of a proband hospitalized with documented premature CHD. Participants underwent risk factor assessment and multidetector computed tomography for coronary artery calcium (CAC) scoring. Based on FRE prediction of 10-year risk for hard CHD events, participants were classified as low risk (<10%) (n = 100), intermediate risk (10%-20%) (n = 2), or high risk (>20%) (n = 0). Significant subclinical atherosclerosis was defined as age-sex adjusted >75th percentile CAC scores.

RESULTS: Ninety-eight percent were at low risk (mean FRE of only 2% ±2%). However, 40% had detectable CAC, 12% had CAC >100, and 6% had CAC > or = 400. Based on CAC score percentiles, 32% had significant subclinical atherosclerosis and 17% ranked above the 90th percentile.

CONCLUSION: Among women classified as low risk by FRE, a third had significant subclinical atherosclerosis. Sisters of probands with premature CHD appear to be a high-risk group and may warrant noninvasive screening for subclinical atherosclerosis to appropriately target individuals for more aggressive primary prevention therapy than what is currently recommended.

EBCT heart scans for coronary calcification are the most accurate means to detect heart disease in women!

It is well established now that women are more likely to die of heart disease than from any other cause. In fact, despite the popular belief that heart disease is a man’s disease, more women than men die of heart disease. What makes detecting heart disease in women more difficult is that women often tend not to have the typical crushing chest pain that men so often present with. The symptoms that women get are far more subtle. Often it may just be breathlessness, or fatigue or distress in the upper abdomen. Adding to the difficulty in making the diagnosis, stress tests seem to be less accurate in detecting coronary artery blockages in women than they are in men. It is not known why stress tests are less accurate in women, but they are. In addition, women when they do present with heart disease, the disease is far more advance and extensive than it is men.            

Women tend to have much higher HDL cholesterol (the good cholesterol) than men do. Doctors often do not treat women who have high total cholesterol and a high HDL. The reasoning has been that the high HDL is protecting the person from heart disease. This is incorrect thinking. Many women with high total cholesterol and very high HDL cholesterol have extensive coronary artery disease. The only way to tell if the high total cholesterol should be treated is to get an EBCT scan for coronary calcium.  If there is no calcium, the high total cholesterol does not need treatment. If there is coronary calcium, then the HDL cholesterol is not protecting you and you need treatment for your cholesterol.

Presently there is a national campaign to focus on heart disease in women. The EBCT scan, in my opinion, should be part of any screening program to detect heart disease in women. Women Heart Centers are being formed at most major medical centers in the country to bring awareness to what many consider a disease epidemic in women. Screening women with resting EKGs, though better that nothing, adds little to detecting heart disease in the asymptomatic women. If you chose to go to a Women’s Heart Center, ask if they have access to an EBCT heart scan, the only reliable means to detect heart disease, especially in women.