For men and women, the risk factors for cardiovascular disease are largely the same, a large global study involving researchers from the University of Gothenburg shows.
Summary Background There is a paucity of data on the prevalence of risk factors and their associations with incident cardiovascular disease in women compared to men, especially in low- and middle-income countries. Methods In the Prospective Urban Rural Epidemiology (PURE) study, we enrolled participants from the general population in 21 high-, middle-, and low-income countries and followed them for approximately 10 years. We recorded information on participants’ metabolic, behavioral, and psychosocial risk factors. For this analysis, we included participants aged 35 to 70 years at baseline with no history of cardiovascular disease, with at least one follow-up visit. The primary outcome was a composite of major cardiovascular events (deaths from cardiovascular disease, myocardial infarction, stroke, and heart failure). We report the prevalence of each risk factor in women and men, their hazard ratios (HRs), and population attributable fractions (PAFs) associated with major cardiovascular disease. The PURE study is registered with ClinicalTrials.gov, NCT03225586. Results In this analysis, we included 155,724 participants enrolled and followed between January 5, 2005 and September 13, 2021 (90,934 [58·4%] women and 64,790 [41·6%] men), with a median of follow-up of 10.1 years (IQR 8.5-12.0). At baseline, the mean age of women was 49.8 years (SD 9.7) compared to 50.8 years (9.8) for men. As of data cutoff (September 13, 2021), there had been 4,280 major cardiovascular disease events in women (age-standardized incidence rate of 5.0 events [95% CI, 4.9–5.2]). per 1000 person-years) and 4911 in men (8·2 [8·0–8·4] per 1000 person-years). Compared to men, women presented a more favorable cardiovascular risk profile , especially at younger ages. The HRs for metabolic risk factors were similar in women and men, except for non-HDL cholesterol, for which high non-HDL cholesterol was associated with an HR for cardiovascular disease greater than 1·11 (95% CI 1·01 –1·21) in women and 1·28 (1·19–1·39) in men, with a consistent pattern of higher risk among men than among women with other lipid markers. Depression symptoms had an HR of 1·09 (0·98–1·21) in women and 1·42 (1·25–1·60) in men. In contrast, consumption of a diet with a PURE score of 4 or lower (score ranges from 0 to 8) was more strongly associated with major cardiovascular disease in women (1·17 [1·08–1·26]). than in men (1·07 [0·99–1·15]). Total PAFs associated with behavioral and psychosocial risk factors were higher in men (15.7%) than in women (8.4%), predominantly due to the greater contribution of smoking to PAFs in men (i.e., 1, 3% [95% CI 0·5–2·1] in women vs 10·7% [8·8–12·6] in men). Interpretation Lipid markers and depression are more strongly associated with cardiovascular disease risk in men than in women, while diet is more strongly associated with cardiovascular disease risk in women than in men. The similar associations of other risk factors with cardiovascular disease in women and men emphasize the importance of a similar strategy for the prevention of cardiovascular disease in men and women. |
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The study, now published in The Lancet, includes participants from high-, middle- and low-income countries. Cardiovascular disease is more widespread in the latter. The data were taken from the Prospective Urban Rural Epidemiological Study (PURE).
The study included 155,724 people in 21 countries, on five continents. Aged between 35 and 70 years old, participants had no history of cardiovascular disease when they joined the study. All cases of fatal cardiovascular disease, heart attack, stroke and heart failure were recorded during the follow-up period, which averaged ten years.
The risk factors studied were metabolic (such as high blood pressure, obesity and diabetes), behavioral (smoking and diet) and psychosocial (economic status and depression).
No clear gender or income division
Metabolic risk factors were found to be similar in both sexes, except for high values of low-density lipoprotein (LDL, often known as bad cholesterol), where the association with cardiovascular disease was stronger in men. In the opinion of the researchers, however, this finding needs confirmation in further studies.
Depressive symptoms were another risk factor for cardiovascular disease that was found to be more significant among men than women. On the other hand, the relationship between poor diet and cardiovascular disease was closer in women; and smoking, although notably more common among men, was an equally detrimental risk factor for women.
Overall, the researchers found broadly similar cardiovascular disease risk factors for male and female participants, regardless of their country’s income level. This highlights the importance of disease prevention strategies also being the same for both sexes.
Similarities more than differences
Women’s overall lower risk of cardiovascular disease, especially heart attack (myocardial infarction), may be explained by younger women’s greater tolerance to risk factors. Its estrogen makes vessel walls more flexible and affects the liver’s ability to remove LDL.
Among the women in the study (90,934 people), there were 5.0 cases of stroke, myocardial infarction and/or cardiovascular disease per 1,000 people per year. The corresponding number in the male group (64,790 individuals) was 8.2 cases.
Annika Rosengren, professor of medicine at the Sahlgrenska Academy at the University of Gothenburg, is the second author of the study, in charge of the Swedish part of the PURE population study of 4,000 people in Gothenburg and Skaraborg.
“When it comes to cardiovascular disease in men and women, the similarities in terms of risk factors are considerably greater than the differences. But men are more vulnerable to high levels of LDL, cholesterol, and we know from other studies that they develop pathological changes in the coronary arteries at an earlier age than women, and they tend to start developing myocardial infarction much earlier. However, with respect to early stroke, sex differences are less pronounced, as we have also seen in other studies,” says Rosengren.
