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Last Updated: 28.06.23

Erin Michos: Cardiovascular Disease in Women: Prevention, Risk Factors, Lipids, and more

Attia presents Erin Michos, an expert in preventive cardiology and women’s cardiovascular health. Erin discusses rising major adverse cardiac events, risk factors, interventions, and female-​​specific contributors to cardiovascular disease (CVD). She explores LDL-​​cholesterol, apoB, Lp(a), statins, GLP‑1 agonists, and PCSK9-​​inhibitors. Erin covers pregnancy, oral contraceptives, menopause, and PCOS as CVD risk factors. She shares her approach to hormone replacement therapy and offers advice on lifestyle changes and medications for risk reduction.

Key Takeaways

High level takeaways from the episode.

Cardiovascular disease (CVD) is the leading cause of death in women

  • More women die from CVD than cancer

In younger individuals (<65), cancer is the leading cause of death in women

  • But heart disease mortality is rising in younger women

Lack of awareness about CVD in women is worrisome

  • In 2009, 65% of women knew that heart disease was the leading cause of death
  • In 2019, only 44% of women knew that heart disease was the leading cause of death

Addressing modifiable risk factors can greatly reduce the risk of CVD

  • Smoking cessation, blood pressure treatment, and controlling apolipoprotein B (apoB) levels are key factors

Women with familial hypercholesterolemia (FH) have an earlier onset of atherosclerotic cardiovascular disease (ASCVD) than women without FH.

Cardiovascular disease is not just an old person’s disease

  • Half of men who experience a major adverse cardiac event in their life will do so before the age of 65
  • One-​​third of women who experience a major adverse cardiac event in their life will do so before the age of 65

Young adults with high blood pressure or high cholesterol should be treated early

  • Prevention is better implemented when started earlier

Poor cardiometabolic health increases the risk of adverse pregnancy outcomes like preeclampsia and gestational diabetes.

Overwhelming evidence that LVL is a causal factor in atherosclerosis

  • Data from observational studies, genetic studies, and interventional trials

Acknowledge limitations of ten-​​year risk scores

  • Can overestimate risk in older adults and those with higher socioeconomic status
  • Can underestimate risk in those with social deprivation and unique risk factors

Very low risk individuals: lifestyle changes may be enough.

High risk individuals: use high-​​intensity statin to lower LDL by 50% or more.

Borderline/​​intermediate risk: consider risk-​​enhancing factors (e.g., APO B, Lipoprotein A, early menopause, adverse pregnancy outcomes).

New pharmacological agents for weight loss without cardiovascular harm (e.g., GLP‑1 receptor agonists)

  • Beneficial in reducing risk of major adverse cardiovascular events and stroke in patients with type 2 diabetes

Somaglitide: FDA approved for type 2 diabetes and weight loss

  • Approved for obese individuals (BMI > 30) or overweight (BMI > 27) with obesity-​​related cardiovascular risk factors

Women have unique risk factors for cardiovascular disease

  • Early or late menarche, polycystic ovary syndrome, infertility, spontaneous pregnancy loss, preeclampsia, lack of breastfeeding, early menopause, and chronic inflammatory conditions

It is recommended to measure lipid panel during menses for consistency.

It is important to recognize that women are at lower risk, but not zero risk, for cardiovascular events during their reproductive years.

Polycystic ovary syndrome (PCOS) is the most common endocrine abnormality in women of reproductive age

  • Affects 5–13% of women in the general population

Insulin resistance is a key factor in PCOS

  • 95% of obese women and 75% of lean women with PCOS have insulin resistance

Oral contraceptives can impact lipid levels, depending on the formulation

  • Older formulations with higher estrogen doses can increase triglyceride levels and lower LDL
  • Newer, lower estrogen formulations have more modest effects on lipids

Transdermal contraceptives (e.g., the patch) are less likely to cause significant elevations in triglycerides.

Progesterone-​​based contraceptives (e.g., IUDs) can marginally lower HDL, but usually revert to pre-​​insertion levels within a year

  • Recommended for women with FH or established cardiovascular disease

Lipid levels can rise significantly during pregnancy

  • Triglyceride levels can increase, potentially raising ApoB levels and increasing cardiovascular risk

It is important to optimize women’s cardiometabolic health before and between pregnancies to prevent long-​​term complications.

Lipid panel changes during pregnancy

  • Total cholesterol, triglycerides, LDL cholesterol, lipoprotein, and HDL cholesterol levels increase

Familial Hypercholesterolemia (FH)

  • Affects 1 in 250 people
  • Contraception recommendations: avoid high estrogen compounds, use low-​​dose estrogen oral contraceptives, IUDs, or barrier techniques

Misconception: statins don’t work in women for primary prevention

  • Meta-​​analysis of 18 randomized clinical trials with 40,000 women: Statins benefit women in both primary and secondary prevention

20% of LDL is influenced by diet

  • Reduction in saturated fats
  • Focus on polyunsaturated and monounsaturated fats
  • Increase fiber, fruits, vegetables, and whole grains
  • Avoid processed foods and processed meats

Favorable changes with hormone therapy

  • Lower LDL and increase HDL
  • Dilate blood vessels through nitric oxide effect

Unfavorable changes with hormone therapy

  • Increase CRP (C‑reactive protein)
  • Pro-​​thrombotic effects (increase prothrombin, decrease antithrombin III)
  • Increase triglycerides


We recommend using this distillation as a supplemental resource to the source material.

  • Cardiovascular disease in women: prevention, risk factors, lipids, and more

    Attia The Drive #230

    Attia features Erin Michos, a leader in preventive cardiology, discussing rising major cardiac events, risk factors, and women’s cardiovascular health.

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