Reference: March 2025 | Issue 3 | Vol 11 | Page 9
Menopause potentially linked to adverse cardiovascular health
New research presented at the European Society of Cardiology Congress 2024 in London, UK, shows that women in the menopause transition period show changes in their blood cholesterol profiles which could have an adverse impact on their cardiovascular health.
“We found that menopause is associated with adverse changes in lipoprotein profiles, with the most pronounced changes found to be in increases in ‘bad’ LDL (low density lipoprotein)-particles and subfractions observed for peri-menopausal women,” said study author Dr Stephanie Moreno, University of Texas Southwestern Medical Centre, Dallas, US.
“When looked at together, these changes could help explain the increase of cardiovascular disease (CVD) in post-menopausal women and help determine if earlier interventions are warranted.”
CVD is the biggest killer of women, despite the misconception that CVD is a ‘man’s disease’ – 40 per cent of all deaths in women are from CVD. While women develop CVD approximately 10 years later than men, risk of CVD in women rises after menopause. The mechanisms underlying this acceleration in CVD risk are not well understood, but adverse changes in blood fat (lipid) measures are known to occur during the perimenopause period.
Previous investigations have been largely restricted to traditional lipid measures (LDL cholesterol, high density lipoprotein (HDL) cholesterol, and triglycerides) and have not examined changes in advanced lipids, including lipid subfractions and particle number, which have been shown to be more predictive of CVD in various studies.
In this study, the authors examined the changes over time in lipoprotein particles that occur during the menopause transition. A total of 1,246 participants in the Dallas Heart Study (DHS) with known menopause status underwent measurement of common lipoproteins associated with CVD, including atherogenic LDL-P and small dense-LDL.
Using nuclear magnetic resonance technology, at two time points (DHS1 and DHS2) they compared longitudinal changes in lipoprotein measures between pre-, peri-, post-menopausal women and men using statistical modelling. For their analysis peri-menopause is the group that was pre-menopause at DHS1 and post-menopause at DHS2.
There were also 1,346 men (reference group) included in the study with a mean age of 43 years. There was a total of 1,246 women with a mean age of 42 years for the peri group, 54 years for the post group, and 34 years for the pre group. Of the women, 440 (35 per cent) were pre-menopausal, 298 (24 per cent) were peri-menopausal, and 508 (41 per cent) were post-menopausal.
Over a median follow-up time of seven years, all three female groups had an increase in LDL-P, but the greatest percentage change was found to be between peri and post groups at 8.3 per cent. When compared to men, the post group has the greatest per cent change of HDL-P with a negative change of 4.8 per cent.
Small-dense LDL had a greater per cent change in the peri group when compared to men with a change of 213 per cent; ~15 per cent higher than both pre- and post-menopause groups.
“More research is needed to investigate whether these adverse changes in lipoproteins translate to greater cardiovascular risk,” Dr Moreno concluded.
New ESC hypertension guidelines recommend intensified BP targets
Updated European Society of Cardiology (ESC) guidelines on the management of elevated blood pressure (BP) and hypertension include a new elevated BP category, more ambitious and intensive treatment targets, and, for the first time, recommendations on the use of renal denervation to treat various forms of hypertension. The guidelines have been produced by an international panel of experts that include co-Chairpersons Prof Bill McEvoy, University of Galway, and Prof Rhian Touyz, McGill University, Canada.
Elevated BP and hypertension are by far the most common and important risk factors for heart attack and stroke and as many as 45 per cent of European adults have hypertension.
The new guidelines, officially launched during the ESC Congress 2024, are designed to get more patients to an evidence-based BP treatment target and to increase the eligibility for BP lowering medications to match the best current evidence from clinical trials. The ESC guidelines also provide numerous pragmatic recommendations to avoid patients becoming symptomatic from overtreatment.
The 2024 guidelines maintain the existing definition for ‘hypertension’ as a BP ≥140/90mmHg. However, they introduce a new category of ‘elevated BP’ which is defined as a BP 120-139/70-89mmHg. This new ‘elevated BP’ category is introduced to facilitate consideration of more intensive BP treatment targets among persons at increased risk for CVD.
“This new category of elevated BP recognises that people do not go from normal BP to hypertensive overnight,” said Prof McEvoy. “It is in most cases a steady gradient of change, and different subgroups of patients – for example those at a higher risk of developing CVD (eg, people living with diabetes’) – could benefit from more intensive treatment before their BP reaches the traditional threshold of hypertension.” Moreover, adds Prof Touyz: “The risks associated with increased BP start at systolic BP levels even below 120mmHg.”
In another major change, the 2024 ESC guidelines introduce a new systolic BP treatment target range of 120-129mmHg for most patients receiving BP-lowering medication, with the important proviso that the new target requires that treatment is well tolerated.
The 2024 ESC guidelines also provide pragmatic recommendations on a systolic BP target ‘as low as reasonably achievable’ (known as the ALARA principle) in frail and older persons and in those not tolerating the primary treatment target of 120-129mmHg. The guidelines focus more on ‘frailty’ of individuals rather than chronological age.
This new systolic BP treatment target of 120-129 represents a paradigm shift from prior European guidelines, including the 2018 ESC/ESH Hypertension Guidelines, the 2021 ESC Prevention Guidelines, and the 2023 ESH Hypertension Guidelines.
Specifically, whereas prior guidelines generally recommended patients be treated to a BP <140/90mmHg in the first instance and only thereafter be considered for treatment to <130/80mmHg (a two-step approach), the new 2024 guidelines recommend that most patients be treated to a systolic BP of 120-129mmHg in the first instance (those who cannot tolerate this target can have it relaxed).
“This change is driven by new trial evidence confirming that more intensive BP treatment targets reduce CVD outcomes across a broad spectrum of eligible patients,” says Prof McEvoy.
In part to accommodate this new more intensive systolic BP treatment target range, the 2024 ESC guidelines provide stronger recommendations than prior guidelines for the use of out-of-office BP measurements (including ambulatory BP monitors and validated home BP monitors).
The 2024 guidelines also, for the first time, make recommendations on the use of renal denervation for treatment of hypertension. Due to lack of evidence regarding cardiovascular outcomes benefit, the guidelines do not recommend this medical procedure as firstline treatment, and nor is it recommended for patients with highly impaired renal function, (estimated glomerular filtration rate <40mL/min/1.73m2) or secondary causes of hypertension.
On renal denervation, the guidelines say: “To reduce BP, and if performed at a medium to high volume centre, catheter-based renal denervation may be considered for patients with resistant hypertension who have BP that is uncontrolled despite a three BP-lowering drug combination (including a thiazide or thiazide-like diuretic), and who express a preference to undergo renal denervation after a shared risk-benefit discussion and multidisciplinary assessment.”
Prof Touyz explains: “These evidence-based recommendations provide guidance for clinicians and their patients on the use of this important new technology. However, it must be stressed that this procedure needs to be undertaken in a centre where there is expertise and experience.”
These new ESC guidelines also update dietary advice on sodium and potassium intake and further emphasise the importance of lifestyle modifications for patients in a range of different circumstances and stages of CVD and chronic kidney disease. They also highlight the importance of sex and gender differences in hypertension and integrate this throughout the document, rather than as a separate section, as in most other guidelines.
New ESC AF guidelines launched during Congress
The European Society of Cardiology (ESC) 2024 guidelines for the management of atrial fibrillation (AF), developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS), contain a number of new approaches and treatment-specific recommendations to help manage the surging numbers of patients with AF worldwide.
“AF is one of the most commonly encountered heart conditions, with a broad impact on all health services across primary, secondary and tertiary care,” said Guidelines Chair Prof Isabelle C Van Gelder, University Medical Centre Groningen, Groningen, the Netherlands. “The prevalence of AF is expected to double by 2050 as a consequence of the ageing population, an increasing burden of comorbidities, improved awareness, and new technologies for detection.”
The 2024 guidelines, officially launched during the ESC Congress 2024, stress the importance of optimal care according to the new AF-CARE pathway, which has been designed to ensure that each and every patient with AF can benefit from recent scientific advances: [C] Comorbidity and risk factor management; [A] Avoid stroke and thromboembolism; [R] Reduce symptoms by rate and rhythm control; and [E] Evaluation and dynamic reassessment.
The new guidelines also stress the importance of shared decision-making on treatments and care, including both patients and a multidisciplinary team. Education of patients, family members, and healthcare professionals are emphasised to ensure that all are empowered to make the right treatment choice for each patient. There is also a focus on equal care, stressing the importance of avoiding health inequalities based on gender, ethnicity, disability, and socioeconomic factors.
“The comorbidities sections in these new guidelines highlight that AF cannot be viewed in isolation. Thorough evaluation and management of comorbidities and risk factors are critical to all aspects of care for patients with AF to avoid recurrence and progression of AF, improve success of treatments, and prevent AF-related adverse outcomes,” said Prof Van Gelder. “There should be an increased focus on the range of conditions and lifestyle factors where there is growing evidence of impact on AF and patient care”.
The new guidelines also focus on recent clinical trials and research studies that can change the routine management of patients with AF for the better.
The key new features are: (1) broader application of appropriate anticoagulant therapy, and using the CHA2DS2-VA score (without gender) to assist in decision-making; (2) a ‘safety-first’ approach throughout, for example by delaying cardioversion if AF duration exceeds 24 hours, or considering fully any potential side effects of antiarrhythmic drugs; and (3) integrating rate and rhythm control, with shared decision-making on referral for catheter and surgical ablation.
The authors conclude by making clear that dynamic evaluation and reassessment is needed for patients with AF. They say: “Healthcare teams in primary and secondary care need to periodically reassess therapy and give attention to new modifiable risk factors that could slow or reverse the progression of AF, increase quality of life, and prevent adverse outcomes.”
Study highlights the importance of patient-centred communication in managing elevated cholesterol
Research conducted by Global Heart Hub, the international alliance of heart patient organisations, and presented at the European Society of Cardiology (ESC) Congress 2024 highlighted the need for high cholesterol levels management strategies that prioritise patients’ needs and perspectives.
The Insights from Patients living with Elevated Cholesterol (IPEC) research project reflects insights from individuals with confirmed elevated high low density lipoprotein cholesterol (LDL-C) from Australia, Brazil, and the US on the challenges faced by people living with high cholesterol, to help inform future management of such conditions.
Three key themes emerged from the IPEC results:
- The importance of clear communication about the seriousness of a high cholesterol diagnosis;
- The necessity of supportive, specific treatment plans and target goals;
- The crucial role of healthcare provider presence and availability.
The study also identified structural barriers to effective shared decision-making, including time constraints during appointments, administrative burdens, and access issues. Overcoming these challenges will require policy changes driven by partnerships between patient advocacy organisations and medical societies, according to the Global Heart Hub.
Neil Johnson, Executive Director, Global Heart Hub, said: “The IPEC research emphasises the necessity for comprehensive and direct communication between doctor and patient. When it comes to a diagnosis, the initial interaction with your healthcare provider is particularly important. Our empirical data indicates that this dialogue significantly impacts patients’ cardiovascular health. To put it succinctly, it has the potential to alter the disease journey.”
Prof Kornelia Kotseva, Honorary Professor of Preventive Cardiology at the University of Galway, added: “I’ve seen first-hand how personalised care plans can significantly impact managing high cholesterol. By using clear language and a collaborative approach, we can set realistic goals that fit patients’ lifestyles and preferences. Ultimately, our shared mission is not only to enhance their quality of life, but also, quite simply, to save lives.”
More information about IPEC and the ESC poster: https://globalhearthub.org/IPEC.
Irish Research: Almost 30% of Irish women have never had a heart check
Only half of women say they recognise the symptoms of heart disease and stroke, while 28 per cent have never had a heart health check, new research from the Irish Heart Foundation shows.
The national Ipsos [Global Market Research and Public Opinion Specialist] survey also reveals 70 per cent of the public believe females are more likely to contract breast cancer than both heart disease and stroke – despite statistics showing they are six times more likely to die from both conditions.
The research was commissioned by the Irish Heart Foundation for its ‘Her Heart Matters’ campaign, running throughout September.
It is now well-established that heart disease in women has been under-researched, under-diagnosed, and under-treated.
“The perception is quite different to the reality that one in four women die from heart disease and stroke,” said Dr Angie Brown, Consultant Cardiologist and Medical Director with the Irish Heart Foundation.
“Women are six times more likely to die from heart disease and stroke than they are from breast cancer so a significant gap in awareness of the symptoms has opened up.”
The campaign is being supported by broadcaster Maura Derrane, who noted that one in four women dies from heart disease and stroke, the same as men. “But women often neglect their own heart health. They are caught up taking care of others, their children, and their partners.”
The research, conducted among 1,056 respondents, shows that a third of people in Ireland (33 per cent) believe women are at lower risk of heart disease and stroke than men, 41 per cent believe the risk is the same, and 16 per cent think women are more at risk.
And when women only were asked, just 50 per cent said they recognised the symptoms of heart disease and stroke, 23 per cent did not, and 27 per cent neither agreed nor disagreed.
The 50 per cent figure compares to 64 per cent of women who said they recognise breast cancer symptoms.
The Ipsos poll also showed that 41 per cent of women have spoken to a healthcare professional about their heart health within the last year – but 28 per cent have never done so.
“We are encouraging all women, but especially those in their mid-50s and beyond, to have their heart health checked, particularly if they experience chest or back pain, difficulty breathing, dizziness, or extreme fatigue – please don’t put it on the long finger,” said Dr Brown.
“Society as a whole needs to confront this embedded myth that heart disease is a male disease; it is still not seen as a disease that affects women to the degree that it does.
“Women need to seek help earlier if they have any suspicion something might be wrong, advocate for themselves, recognise the signs, and potentially save their own lives.”
The campaign is supported by the Department of Health and the HSE.
Minister for Health Stephen Donnelly said: “Improving women’s health outcomes and experiences and developing gender-specific health interventions has been a priority for me as Minister. Under the Women’s Health Action Plan 2024-2025 Phase 2: An Evolution in Women’s Health, I have placed a spotlight on and prioritised investment in initiatives targeted at women at midlife and older, with a particular emphasis on improving cardiovascular health.
For information and practical tips, visit: www.irishheart.ie/herheartmatters
