Major risk factors predict coronary risk in both women and men. It is inadvisable and unwarranted to suggest that women be excluded from
cholesterol screening. In fact, what evidence is available suggests that women, similar to men, benefit from
cholesterol lowering. This is not an insignificant issue. Women, similar to men, die mostly of
coronary atherosclerosis, although atherosclerotic death in women occurs 5 to 10 years later than in men. There are some risk factors that are unique in women.
LDL-c levels may be less predictive of risk in women than in men; HDL-c levels may be more predictive.
Triglycerides are a stronger predictor of risk in women than in men. Finally, diabetes is a major risk factor in women and almost eliminates the differences in risk seen in comparing nondiabetic men and women. Exogenous
gonadal hormones, both in the form of OCs and HRT, have the potential to influence coronary risk in women. In premenopausal women, use of OCs is associated with increased risk of
coronary disease in women who
smoke, particularly in women older than age 35. In postmenopausal women,
estrogen use is generally associated with protection against
coronary disease. These results may be in part due to favorable effects on
circulating lipoproteins but may as well be related to the protective effects of
estrogen on the arterial wall. Definitive recommendations about the use of
estrogen in postmenopausal women for the primary prevention of
coronary disease await the completion of clinical trials of
estrogen alone and in combination with
progestins.
Cholesterol and its
lipoprotein subfractions continue to be predictors of both morbidity and mortality in older populations. The value of
cholesterol-altering
therapy in older individuals is not as well established in clinical trials as in middle-aged men. Nevertheless, there is good reason to believe that the results from both primary and
secondary prevention studies in younger individuals can readily be extrapolated to older individuals. In particular, individuals with symptomatic
coronary disease but a relatively good prognosis should be offered the same benefits from
secondary prevention as younger individuals. Thus, although data are more limited in women and the elderly than in middle-aged men, there is good reason to believe that
cholesterol interventions are likely to be effective, particularly in postmenopausal women and in older individuals with established
coronary disease. To withhold
therapy based simply on gender or chronologic age is a mistake.