Dyslipidemia, gender, and the role of high-density lipoprotein cholesterol: implications for therapy

  • Marianne J Legato
    Address for reprints: Marianne J. Legato, MD, Partnership for Women’s Health, 14 East 60th Street, PH Floor, New York, New York 10022
    Columbia University College of Physicians and Surgeons, New York, New York, USA
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      Cardiovascular disease, which kills more US women than all cancers combined, may pose an even greater risk for women than for men. For example, the risk factors, testing modalities, presenting symptoms and the therapeutic choices made for women with coronary artery disease are significantly different from those for men. Low levels of high-density lipoprotein cholesterol (HDL-C), <35 mg/dL in men and <45 mg/dL in women, is associated with a greater risk of coronary artery disease and more progression of angiographically demonstrated disease in women, while increasing HDL-C has a more cardioprotective effect in the female than in the male population. The total cholesterol-to-HDL-C ratio is also more predictive of coronary artery disease in women than in men. Because average HDL-C levels in women are approximately 10 mg/dL higher than in men, target HDL-C should be higher (>45 mg/dL) in women. This is not yet reflected in clinical guidelines. Diabetes is particularly hazardous in women, and low HDL-C levels constitute a disproportionate risk for coronary artery disease in diabetic women compared with diabetic men. Regrettably, although lipid-lowering drugs have been shown to be effective in women, they are more rarely prescribed for women than for men.
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      1. AHA Heart and Stroke Guide: Women, Heart Disease, and Stroke Statistics.

        • Kannel W.B
        Contributions of the Framingham Study to the conquest of coronary artery disease.
        Am J Cardiol. 1988; 62: 1109-1112
      2. Abbott RD, Wilson PWF, Kannel WB, Castelli WP. High density lipoprotein cholesterol, total cholesterol screening, and myocardial infarction: the Framingham Study. Arteriosclerosis 1988;8:207–211.

        • Pearson T.A
        • Bulkley B.H
        • Achuff S.C
        • Kwiterovich P.O
        • Gordis L
        The association of low levels of HDL cholesterol and arteriographically defined coronary artery disease.
        Am J Epidemiol. 1979; 109: 285-295
        • Gordon D.J
        • Probstfield J.L
        • Garrison R.J
        • Neaton J.D
        • Castelli W.P
        • Knoke J.D
        • Jacobs Jr, D.R
        • Bangdiwala S
        • Tyroler H.A
        High-density lipoprotein cholesterol and cardiovascular disease.
        Circulation. 1989; 79: 8-15
        • Miller M
        • Mead L.A
        • Kwiterovich Jr, P.O
        • Pearson T.A
        Dyslipidemias with desirable plasma total cholesterol levels and angiographically demonstrated coronary artery disease.
        Am J Cardiol. 1990; 65: 1-5
      3. Barnard RJ. Effects of life-style modification on serum lipids. Arch Intern Med 1991l;151:1389–1394.

        • Lewis S.J
        • Sacks F.M
        • Mitchell J.S
        • East C
        • Glasser S
        • Kell S
        • Letterer R
        • Limacher M
        • Moye L.A
        • Rouleau J.L
        • Pfeffer M.A
        • Braunwald E
        Effect of pravastatin on cardiovascular events in women after myocardial infarction.
        J Am Coll Cardiol. 1998; 32: 140-146
        • Miettinen T.A
        • Pyorala K
        • Olsson A.G
        • Musliner T.A
        • Cook T.J
        • Faergemoan O
        • Berg K
        • Pedersen T
        • Kjekshus J
        Cholesterol-lowering therapy in women and elderly patients with myocardial infarction or angina pectoris.
        Circulation. 1997; 96: 4211-4218
        • Knopp R.H
        • Ginsberg J
        • Albers J.J
        • Hoff C
        • Ogilvie J.T
        • Warmick G.R
        • Burrows E
        • Retzlaff B
        • Poole M
        Contrasting effects of unmodified and time-release forms of niacin on lipoproteins in hyperlipidemic subjects.
        Metabolism. 1985; 34: 642-650
      4. Niaspan patient information Package Insert. Kos Pharmaceuticals, 1998.

        • Sueta C
        • Chowdhury M
        • Boccuzzi S.J
        • Smith Jr, S.C
        • Alexander C.M
        • Londhe A
        • Lulla A
        • Simpson Jr, R.J
        Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease.
        Am J Cardiol. 1999; 83: 1303-1307
      5. Miller M, Byington R, Hunninghake D, Pitt B, Furberg CD, for the Prospective Randomized Evaluation of the Vascular Effects of Norvasc Trial (PREVENT) Investigators. Sex bias and underutilization of lipid-lowering therapy in patients with coronary artery disease at academic medical centers in the United States and Canada. Arch Intern Med 2000;160:343–347.

      6. The Writing Group for the PEPI Trial. Effects of estrogen or estrogen/progestin regimens on heart disease risk factors in postmenopausal women. Jama 1995;273:199–208.

      7. Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, Vittinghoff E, for the Heart and Estrogen/progestin Replacement Study (HERS) Research Group. Randomized trial of estrogen plus progestin for secondary prevention of coronary artery disease in postmenopausal women. Jama 1998;280:605–613.

      8. Sbarouni E, Kyriakides ZS, Kremastinos DTh. The effect of hormone replacement therapy alone and in combination with simvastatin on plasma lipids of cholesterolemic postmenopausal women with coronary artery disease. J Am Coll Cardiol 1998;32:1244–1250.

        • Walsh B.W
        • Kuller L.H
        • Wild R.A
        • Paul S
        • Farmer M
        • Lawrence J.B
        • Shah A.S
        • Anderson P.W
        Effects of raloxifene on serum lipids and coagulation factors in healthy postmenopausal women (see comments).
        Jama. 1998; 279: 1445-1451