WOMEN 'S HEALTH AND MENOPAUSE : - National Heart, Lung ...

were women. It can be concluded that extrapolation
of evidence from these trials to older people
and women requires further evaluation.
4.4 Other Prevention Therapies in Women
Similar to the lipid-lowering trials, CHD prevention
through treatment of hypertension is as effective in
women as in men, and ACE inhibitors are as effective
in preventing CHD in women as in men. 167–169
In the recently published Heart Outcomes Prevention
Evaluation (HOPE) study, 2,480 women were
enrolled as a part of larger study to determine the
effect of the ACE inhibitor ramipril (10 mg once
daily orally) versus placebo. 169 The study investigated
the effect of this therapy over a 5-year period on
the risk of the composite endpoint: MI, stroke, or
death from cardiovascular causes. The study participants
were patients at high risk for cardiovascular
events with a mean age of 66 years an without left
ventricular dysfunction or heart failure. Ramipril
decreased the risk of the primary outcome significantly
in women as well as men. There was also a
significant decrease in secondary outcomes, such as
revascularization and hospitalizations for heart failure.
The novelty of this study is that ramipril significantly
reduced the rates of the primary endpoint in
a broad range of high-risk patients who were not
known to have low ejection fraction or heart failure.
In particular, this beneficial effect was shown
in women with diabetes mellitus. The trialists that
estimated the treatment of 1,000 patients with
ramipril for 4 years prevented about 150 events in
approximately 70 patients. Aspirin and beta-blockers
are also effective for secondary prevention in
women. 170,171 Thus, although efforts to prevent CHD
in women are successful using the same approaches
as in men, more data are still required.
5. MYOCARDIAL INFARCTION:
PROGNOSIS
Initial evaluation suggests that gender affects the
course of acute MI in the general population.
However, after adjustment for baseline differences,
the gender disparities in the outcomes become
more uncertain. In a study of 204 consecutive
cases (99 men and 105 women) older than 75
years of age and admitted with the first acute MI,
elderly women experienced a more complicated
hospital course than men. The higher mortality risk
(40 percent versus 23 percent) seemed to be related
more to the impact of cardiovascular risk factors
on left ventricular function than to gender
itself. 172 The Framingham Heart Study confirmed a
greater 1-year mortality in women compared with
men (44 percent versus 27 percent). 173 Early hospital
mortality is also greater in women than in men
(16 percent versus 11 percent). 174,175 The larger
placebo-controlled trials, such as the International
Studies of Infarct Survival-1 and -4 (ISIS–1 and
ISIS–4), both suggested an increased short and
long-term mortality in women. 176,177 More recent
data from the National Registry of Myocardial
Infarction (NRMI) suggest that, after MI, younger
women (but not older women) have higher rates of
death during hospitalization than do men of the
same age. 178 Data from the Swedish National Acute
Myocardial Infarction Register confirms this
observation. 179 Much of the excess mortality seen
in young women in this study was associated with
diabetes mellitus. Some other reasons for these
observations is that women are approximately half
as likely as men to receive known beneficial therapies,
such as beta-blocking agents, aspirin, thrombolysis,
acute cardiac catheterization, percutaneous
transluminal coronary angioplasty (PTCA), or
bypass surgery; however, age probably still plays a
major role in these differences. 171 Sex differences
in the presentation and outcome of patients with
ACS have been reported in the Global Use of
Strategies To Open Occluded Coronary Arteries in
Acute Coronary Syndromes (GUSTO IIb) cohort. 180
In this study, which enrolled 3,662 women, women
had more complications than men during hospitalization,
had a higher mortality rate at 30 days (6
percent versus 4 percent, p < 0.001), but had similar
rates of reinfarction. It is of interest that among
patients with unstable angina, female sex was
161