Symposium: Cardiovascular disease in women with diabetes. Aspects to consider of cardiovascular disease in women with diabetes

Abstract

The impact of macrovascular complications (coronary heart disease, peripheral vascular disease and stroke) is greater in women.

In the population without diabetes, the risk of coronary heart disease (CAD) is 3-5 times higher in men. But in the presence of diabetes, the "cardioprotective factor" of female sex hormones disappears: type 2 diabetes (T2D) increases the risk of CAD 3-5 times in women vs 1-3 times in men and the risk gap between men and women disappears. Type 1 diabetes (T1D) also has a greater impact on women: it increases the risk of CAD by 44.8 times in women vs 11.8 times in men aged 20 to 29 years. The risk of developing heart failure is higher in women: 9% excess risk in women with T2D and 47% in T2D, compared to men. There are multiple factors involved in these differences.

Biological factors

T2D is associated with an unfavorable distribution of estrogen receptor subtypes, promoting vasoconstriction and inflammation, thus increasing the risk of CVD. On the other hand, androgens, which in men are associated with better beta cell function and prevention of inflammation, in women are associated with oxidative stress, beta cell dysfunction and predisposition to T2D; this mechanism is of particular importance in women with obesity or polycystic ovarian syndrome (PCOS)¹.

The burden of risk factors is higher in women with diabetes: higher levels of obesity and high blood pressure, low HDL cholesterol, and high triglycerides. In a study carried out by our group, female gender was associated with a 69% risk of performing a low level of physical activity². In addition, women go through physiological situations such as pregnancy, in which alterations that confer them high CV risk in the long term may occur, such as: pre-eclampsia or gestational diabetes; and other pathological processes related to sex such as PCOS and premature menopause that are also associated with a high CV risk³.

Management

The risk of cardiovascular complications in women is often underestimated and consequently under-treated: women with diabetes and CAD less consistently prescribed statins, angiotensin-converting enzyme inhibitors, aspirin, and beta-blockers. And they reach the quadruple objective (A1c, blood pressure, LDL cholesterol and absence of smoking) with less frequency: 18.6% vs 23.6%, OR 1.31 (1.26-1.36), p <0.001⁴. Finally, there is incipient evidence that the cardiovascular protection provided by new antidiabetic drugs is greater in women: treatment with GLP1 analogs provides a greater reduction in cardiovascular events in women (HR 0.57 vs 0.82 - interaction p: 0,02)⁵.

We must consider these differences to individualize the approach and treatment: assess the CV risk of women with diabetes or at risk early and adequately; and to carry out intensive management of T2D and CVD, including lifestyle changes and drug therapy.