The Peter Attia Drive
#230 ‒ Cardiovascular disease in women: prevention, risk factors, lipids, and more | Erin Michos, M.D.
Episode guests
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Quick takeaways
- Early preventive measures are crucial for addressing cardiovascular disease risk in women.
- Lipid profiles fluctuate during key stages like pregnancy and menopause, impacting long-term risk.
- Polycystic ovary syndrome (PCOS) may increase cardiovascular disease risk due to insulin resistance.
- High parity and oral contraceptives can influence triglyceride levels and cardiovascular risk in women.
- Genetic predispositions like familial hypercholesterolemia (FH) require effective management with statins and newer therapies.
- Personalized approaches integrating lifestyle changes and innovative medications are essential for addressing lipid-related cardiovascular concerns.
Deep dives
Cardiovascular Risk in Women with Atherosclerotic Cardiovascular Disease
As females age, the prevalence of atherosclerotic cardiovascular disease (ASCVD) increases, emphasizing the importance of early interventions. Discussions around ASCVD focus on lipids and female biology, highlighting the need to consider lifetime ASCVD risk rather than just a 10-year perspective. The podcast explores how lipid profiles, including triglycerides, LDL, and HDL, fluctuate throughout a woman's life, especially during significant stages like pregnancy and menopause.
Impact of Lipids and Lipoproteins During Menstrual Cycle and Menopause
The fluctuation in lipids and lipoproteins during the menstrual cycle showcases a rise in total cholesterol and LDL during ovulation, and a decline in the luteal phase. This cyclical pattern may influence lipid panel assessments, emphasizing the importance of benchmarking measurements at consistent times during the menstrual cycle. Moreover, the transition to menopause leads to changes in lipid profiles, with postmenopausal women experiencing elevations in LDL cholesterol levels, influencing long-term cardiovascular risk.
Considerations for Polycystic Ovary Syndrome (PCOS) and Cardiovascular Risk
Polycystic ovary syndrome (PCOS) affects 5-13% of women and is linked to higher cardiovascular risk due to insulin resistance and dyslipidemia patterns. Lean PCOS individuals also demonstrate insulin resistance, emphasizing the heterogeneity of the disorder. Studies suggest that PCOS contributes to subclinical atherosclerosis and increased future cardiovascular disease risk, aligning with genetic evidence of causal factors like hyperandrogenism and insulin resistance.
Effects of Parity, Oral Contraceptives, and Pregnancy on Cardiovascular Health
Women with increased parity, especially more than four or five live births, show potential for higher cardiovascular disease risk, possibly due to metabolic changes post-pregnancy. Oral contraceptives, varying in formulations, mildly impact triglyceride levels, with newer formulations posing fewer risks. During pregnancy, total cholesterol, triglycerides, and other lipids rise progressively, influencing lipid panel results and warranting pre-pregnancy lipid evaluations for risk assessment.
Impact of Cholesterol Changes During Pregnancy on Lipid Levels
During pregnancy, there are significant physiological changes in lipid levels, with total cholesterol, triglycerides, and LDL cholesterol increasing to support maternal fat stores and vascularization. These changes, although substantial in percentage increase, are considered non-atherogenic since lipid levels return to pre-pregnancy levels post-delivery.
Familial Hypercholesterolemia Risk and Genetic Testing
Individuals with familial hypercholesterolemia (FH) experience even greater increases in cholesterol levels, particularly LDL, due to a genetic predisposition. Genetic mutations play a crucial role in FH, leading to higher lifetime risks of atherosclerotic cardiovascular disease. Genetic testing helps identify individuals with FH and assess the risk not solely based on LDL levels but also genetic mutations.
Role of Statins and New Therapies in Managing Lipid Levels in Women
For women with FH, the risk of cardiovascular events necessitates effective management of lipid levels. Statins remain a cornerstone of treatment, with newer therapies like PCSK9 inhibitors and Bempedoic acid offering additional options for LDL reduction. Lifestyle modifications, such as a Mediterranean diet and physical activity, complement pharmacotherapy, with stress management also recognized as essential for overall cardiovascular health.
Importance of LP Little a Levels and Gender Disparities
LP Little a levels, a pro-atherogenic marker, display gender disparities with generally higher values in women. Lipid changes post-menopause, including increased LP Little a levels, highlight the impact of hormonal shifts on cardiovascular risk. Despite nutritional interventions, LP Little a elevation and its associated risks underscore the multifaceted approach required to address lipid-related cardiovascular concerns in women.
Wholesome lifestyle choices and genetic predispositions in women
The synergistic interplay between lifestyle practices and genetic predispositions significantly influences lipid profiles in women. A comprehensive approach, encompassing dietary modifications, physical activity, stress management, and personalized genetic testing, is crucial for effectively managing lipid levels and mitigating cardiovascular risks, especially in individuals with familial hypercholesterolemia.
Emphasis on Diverse Therapeutic Avenues for Optimal Lipid Management
Diverse therapeutic avenues, ranging from traditional statins to novel agents like PCSK9 inhibitors and Bempedoic acid, offer tailored options for lipid management in women. The intersection of personalized genetic insights, lifestyle adjustments, and innovative pharmacotherapies enhances the precision and efficacy of lipid-lowering strategies. Addressing LP Little a levels and considering gender-specific lipid dynamics are integral components of a holistic cardiovascular health approach for women.
Future Directions in Women's Cardiovascular Health and Lipid Management
Future avenues in women's cardiovascular health underscore the integration of advanced lipid assessments, tailored therapeutic strategies, and holistic lifestyle interventions to optimize lipid profiles and reduce cardiovascular risk. Enhanced understanding of gender-specific lipid dynamics, including the impact of hormonal transitions like menopause, paves the way for tailored lipid management approaches emphasizing personalization and precision medicine.
Challenges and Opportunities in Lipid Management for Women
Navigating the complexities of lipid management in women demands a multifaceted approach that addresses genetic predispositions, lifestyle behaviors, and gender-specific physiological changes. Integrating innovative pharmacotherapies with lifestyle modifications and stress management fosters a comprehensive strategy to optimize lipid profiles and mitigate cardiovascular risk factors among women.
Future Insights on Lipid-Related Health in Women
As the landscape of lipid management evolves, ongoing research on lipid-related health in women holds promise for unveiling novel therapeutic targets and personalized interventions. Harnessing the interplay between genetic influences, lifestyle choices, and innovative treatment modalities is paramount for advancing cardiovascular health outcomes and enhancing lipid management strategies for women.
Lipoprotein(a) and Cardiovascular Disease Risk
Lipoprotein(a) levels play a significant role in determining the effectiveness of certain therapies like PCSK9 inhibitors, particularly in individuals with elevated levels of lipoprotein(a). New therapies like Pelicarsin and Opusarin target lipoprotein(a) synthesis with promising results of reducing lipoprotein(a) levels by 80 to 90%, a significant improvement over statins and other medications. Trials like the Horizon trial are underway to assess the impact of lowering lipoprotein(a) on reducing major adverse cardiovascular events.
Menopause and Cardiovascular Health
Menopause results in significant hormonal changes, particularly a drastic reduction in estrogen levels, which can lead to unfavorable lipid profiles and increased cardiovascular risk in women. Hormone replacement therapy, while offering benefits like lowering LDL and increasing HDL, has shown adverse effects such as increased CRP levels and prothrombotic risks. Factors like age, duration of therapy, and overall health should be considered when evaluating the risk-benefit profile of hormone therapy for menopausal symptoms and cardiovascular health in women.
View the Show Notes Page for This Episode
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Erin Michos is an internationally-known leader in preventive cardiology and women’s cardiovascular health. In this episode, Erin discusses current trends in cardiovascular disease (CVD) through the lens of female biology and the observation that major adverse cardiac events in both sexes are on the rise. She walks through risk factors including LDL-cholesterol, apoB, and Lp(a) and makes the case for the importance of early preventative measures. She explains various interventions for reducing risk including a discussion of statins, GLP-1 agonists, PCSK9-inhibitors, and drugs that lower Lp(a). She goes in-depth on female-specific factors that contribute to CVD risk such as pregnancy, grand multiparity (having five or more children), oral contraceptives, menopause, and polycystic ovary syndrome (PCOS). Additionally, she explains her approach with patients as it relates to the use of hormone replacement therapy and provides advice for people wanting to lower risk both through lifestyle changes and medications.
We discuss:
- Erin’s background in preventive cardiology and women’s health [2:30];
- Recent trends in cardiovascular disease in women, mortality data, and how it compares to cancer [5:15];
- Why early preventative measures are critical for cardiovascular disease risk [13:15];
- ApoB as a causal agent of CVD, and why high apoB levels are not being aggressively treated in most cases [19:45];
- The rising trend of metabolic syndrome and other factors contributing to the regression in progress of reducing cardiac events [27:00];
- GLP-1 agonists—Promising drugs for treating diabetes and obesity [33:30];
- Female-specific risk factors for ASCVD (pre- and post-menopause) [37:15];
- Polycystic ovary syndrome (PCOS): prevalence, etiology, and impact on metabolic health, lipids and fertility [47:00];
- The effect of grand multiparity (having 5+ children) on cardiovascular disease risk for women [52:30];
- The impact of oral contraceptives on cardiovascular disease risk [55:00];
- The effect of pregnancy on lipids and other metabolic parameters [58:45];
- The undertreatment of women with familial hypercholesterolemia (FH) and how it increases lifetime risk of ASCVD [1:02:00];
- How concerns around statins have contributed to undertreatment, and whether women should stop statins during pregnancy [1:09:45];
- How Erin approaches the prescription of statins to patients [1:16:00];
- PCSK9 inhibitors and other non-statin drugs [1:21:15];
- Advice for the low- and high-risk individual [1:28:30];
- The impact of nutrition, stress, and lifestyle on lipids and CVD risk [1:31:00];
- Lp(a) as a risk enhancer for cardiovascular disease [1:41:15];
- The effect of menopause on cardiovascular disease risk [1:50:30];
- How Erin approaches decisions regarding hormone replacement therapy (HRT) for her patients [1:55:30];
- The urgent need for more data on women’s health [2:03:30];
- Erin’s goal of running a marathon in every state [2:09:45]; and
- More.
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