Clinical:Case Study: Heart Health Part I: Younger Women

Original materials created in September 1999 by Katherine Sherif, M.D.

History

KC is a 41 year old G2P2, administrator who comes for a new patient H+P with two primary concerns: a 20lb weight gain since her last pregnancy, and her cardiovascular risks. She enjoys aerobic exercise one or two times per week, does not drink alcohol, or smoke

PMHx: Hypothyroidism, on levothyroxine, and gestational diabetes three years prior.

FHx: 65 yo mother with dyslipidemia, hypertension (HTN), diabetes mellitus-type 2 (DMtype2), and myocardial infarction at age 53. Father had a fatal stroke at age 51, and 36 yo brother with DM-type 2.

Exam

BP=138/88, HR=76, RR=12, ht=60 inches (1.5m), wt=150lbs (68.2kg), BMI=30.3 (healthy<24.9) Moderate truncal obesity. Normal fundi, no carotid bruits. Heart and lung exam are normal. Abdominal exam normal, no renal bruits. Normal breast, pelvic, and extremity exam, skin w/o acanthosis nigricans.

Data

TSH=3.8 (0.9-5.5), fasting glucose=89 (<126), and lipid profile as follows: triglycerides (TG)=200 (<200), total cholesterol=235 (<200), LDL=190 (<160), HDL=41(>35), and total chol/HDL=6.0. Because of her h/o gestational diabetes, KC is referred for oral glucose tolerance test, which is normal. DISCUSSION: Although cardiovascular (CV) disease is the most common cause of mortality for women in the United States, the evaluation of women for CV disease is neither aggressive nor wide spread. KC was unusual in her concern about heart disease because, according to various surveys, only about 8-14% of women believe they are at risk. ^[1]

Despite her appropriate concerns, KC has been told by various practitioners that she “has nothing to worry about,” either because “she is a woman,” or because she is premenopausal and “protected by estrogen.” In fact, KC has multiple risk factors for developing CV disease, and with the exception of family history, each is modifiable. KC’s modifiable risks are dyslipidemia, history of gestational diabetes, “high normal” blood pressure, hypothyroidism (associated with dyslipidemia), and truncal obesity. For appropriate primary prevention, these risks should be addressed now.

• lipids CV prevention guidelines now recommend routine lipid screening at younger ages for both men and women, but may not recommend lipid profiles that include HDL levels. While an elevated LDL level is widely accepted as a risk factor for CV disease, the data suggest that LDL is generally predictive for men only. A low HDL level is the most predictive cardiovascular risk factor in women, and LDL levels have been shown to be rather weak. ^[2]Even when an HDL level is reported, a value of 41, for example (KC’s value), would not be flagged as “abnormal” because the reference range for “normal” is >35. “Normal” lipid reference ranges are based on epidemiologic data from white males, and not from women. In women, HDL levels <45 are associated with a significant increase in cardiovascular risk, and levels >55-60 with a significant protective effect.

• diabetes mellitus DM is more common in women than in men, and diabetic women have a twofold risk for coronary heart disease over diabetic men. Gestational diabetes has a clear association with subsequent development of DM- type 2, and is often viewed in a continuum of poor glycemic control.

• HTN Whether women have significant reduction in risk of events, or in overall mortality, from pharmacologic treatment of HTN is still debated. KC has “high normal” BP, which deserves attention. ^[3] Practitioners should keep in mind the association between oral contraceptives and elevated BP’s.

• obesity Obesity is not a primary risk for heart disease, but it is accepted as contributing factor due to its effects on BP, lipids, and hyperglycemia. It is measured by body mass index (BMI), calculated by kg/m2. BMI>24.9 is considered overweight, and >29.9, obesity, KC being in the latter category. Truncal distribution of body fat, with a waist to hip ratio of greater than 0.8 in women, is considered an additional risk. Weight loss as little as 10 lbs can have a favorable affect on BP, lipids, and glycemic control. ^[4]

• hypothyroidism Hypothyroidism is also not a primary risk, but is associated with dyslipidemia. Pharmacologic correction of hypothyroidism reduces the effects on lipids.

Plan

KC was encouraged to take an active role in prevention of CV disease, with a focus on lifestyle changes and observation for six months. Dietary adjustment, regular aerobic exercise, and weight loss were stressed as the most important activities to lower blood pressure, increase insulin sensitivity, and positively affect her lipid profile, most importantly, rais ing HDL. She was encouraged to eat as if she was a diabetic already, which means balancing carbohydrate intake with other such dietary components as fats, proteins, and fiber. She was encouraged to avoid saturated fats by exploring vegetable sources for her protein and fats (i.e. soy, beans, whole grains, nuts), and to increase her fresh vegetables and fiber. Regular aerobic exercise for 30-45 minutes 3-4 days of the week was recommended.3

Success in lifestyle modifications requires support in terms of education and empowerment. KC was referred to a nutritionist because of the individual complexity of dietary and exercise patterns. During a six month observation period, the chances for any patient to achieve goals for weight loss, BP control, lipid improvement, and diabetes prevention will be greatly enhanced by ongoing monitoring of progress and reinforcement of goals.

KC expressed guarded enthusiasm with our plan, but with realistic goals, frequent and productive sessions with the nutritionist developing new, personalized dietary and exercise habits, and physician follow-up every two months, she reached all of her goals. KC has continued in her new life style, which has become second nature. She has observed that not only has her “heart health” improved, but her energy level and mental health, as well.

References

1. ↑ Phillips, KA, et al. Putting the risk of breast cancer in perspective. NEJM, 1999;340:141-44
2. ↑ Jacobs, DR, et al. HDL as a predictor of CV disease mortality in men and women. Am J Epidemiol, 1990;131:32-47
3. ↑ JNC-VI on the prevention, detection, evaluation, and treatment of high blood pressure. NIH pub # 98-4080; November, 1999.
4. ↑ NHLBI Obesity Education Initiative. NIH, Bethesda, MD (preprint); June, 1998.

Resources

Wenger, NK, et al. Cardiovascular Health and Disease in Women. Proceedings of the NHLBI Conference, Jan 22-24. LeJacq Communications: Greenwich, CT, 1993

Lemcke, et al. (eds.) Primary Care of Women. Appleton and Lange: Norwalk, CT, 1995

Carlson, et al. (eds.) Primary Care of Women. Mosby: St. Louis, MO, 1995

Legato, MJ, et al. The Female Heart: The Truth about Women and Heart Disease. Simon and Schuster, 1991