Cardiovascular disease in women with Diabetes
Summary points
- There is evidence of increased risk for CVD in patients with type 2 diabetes compared with the general population and that this increased relative risk for CVD due to diabetes is greater in women than men.
- The decline in all-cause mortality have occurred among men with diabetes, but not in women. To contrary, Inpatients with type 2 diabetes some reported greater mortality due to CVD in women compared with men
- Women with type 2 diabetes have a more adverse cardiovascular risk factor profile than men, despite similar glycemic control.
- Loss of the female sex as a protective factor against the development of CVD in type 2 diabetes may, in part, be explained through the decline in estrogen levels and therefore loss of the estrogen-induced insulin secretion.
- Women with type 2 diabetes have higher systolic as well as diastolic blood pressure. Furthermore, women have a greater chance of failing therapeutic goals for treatment of their blood pressure.
- Visceral adiposity in obese women increases the risk for CVD to a much greater extent than in men . This observation may be surprising given that adipose tissue is a known source of estrogens which, in turn, have known cardioprotective effects
- The risk of acute myocardial infarction (MI) is 150% greater in diabetic than non-diabetic women, but only 50% greater in diabetic than non-diabetic men according to studies.
- Intermediate(pre-diabetic) levels of hyperglycemia are even more dangerous for women than for men. The presence of diabetes nearly tripled the risk of incident CHD in women, whereas it little more than doubled the risk in men.
- Women with diabetes mellitus have a 27% greater increased risk of stroke compared to males.
- Pre-menopausal women usually have a lower risk of CVD than men and post-menopausal women. However, this “female advantage” disappears once a woman becomes diabetic possibly due to loss of estrogen induced insulin secretion.
- Diabetic women have greater established and novel risk factors than diabetic men, such as markers of coagulation, fibrinolysis, lipids and blood pressure, which are potentially mediated by differences in central adiposity and insulin resistance in women.
- Females with diabetes have higher prevalent abdominal obesity, increasing the incidence of hypertension, a worse lipid profile (low levels of HDL cholesterol, small amount of LDL cholesterol, and high levels of triglycerides), a more marked endothelial dysfunction, and also an increased prevalence of hypoglycemic events compared to male diabetic patients. Women have some unique risk profiles such as hypoestrogenemia and protracted dysmetabolic state which may promote an inflammatory milieu.
- Poor glycemic control increases arterial stiffness and intima-media thickness, suggesting that diabetes exerts some of its detrimental effects directly by damage to the vascular wall and its function. In particular, the increased risk associated with poor glycemic control was 8.5-fold among women.
- Nitric oxide-dependent vascular tone and endothelial-dependent vasodilation are enhanced in non-diabetic pre-menopausal women compared with men. Obese women with DM have impaired endothelium-dependent vasodilation beyond that observed with obesity alone. Diabetes and pre-diabetes poses a greater threat of endothelial dysfunction in women than men
- Women with pre-diabetes had significantly higher biomarker levels of endothelial dysfunction (E-selectin and soluble intracellular adhesion molecule) and fibrinolysis (plasminogen activator inhibitor, VWF, and t-PA) than their counterparts without pre-diabetes, while men with and without pre-diabetes had similar biomarker levels. These biomarkers have been shown to predict CHD
- Insulin resistance was significantly more related to left ventricular mass in women than in men. It is attributable to a trophic stimulating effect of insulin resistance that leads to increases in wall thickness and ventricular dimensions. Diabetic women are more often obese than diabetic men, and therefore may be more prone to the development of concentric hypertrophy. Left ventricular hypertrophy is independently associated with congestive heart failure and cardiovascular mortality.
- Diabetic cardiomyopathy that is associated with heart failure particularly in diabetic women, independent of coronary disease. In patients with cardiac heart failure(diabetes-associated ), mortality were more pronounced in women than in men
- Atypical chest pain is more common in women and individuals with diabetes, and sudden death from myocardial infarction, especially silent MI, is more common in women. Jaw or neck and shoulder pain, nausea, vomiting, fatigue, or dyspnea, in addition to the more traditional substernal chest pain, are symptoms common in women.
- Prominent symptoms :Women: coronary calcification, coronary artery disease, myocardial infarction (worse than in men), CHD (better prognosis than in men), diastolic abnormality (usually more severe in women), autonomic neuropathy, congestive heart failure (fivefold the frequency in non-diabetic women).
- Women with diabetes are less frequently on target for cardiovascular risk factors. Men with diabetes or established CVD are more likely to receive aspirin, statins, or antihypertensive drugs than are women. Therefore, more aggressive treatment of risk factors for CHD in men with diabetes may explain a large component of the excess risk associated with diabetes in women
