New York, NY (May 10, 2004) -- Women with diabetes are at greater risk for cardiovascular disease (CVD) than men with diabetes and persons without diabetes -- yet prevention and treatment of CVD in women with diabetes is inadequate, according to an article authored by a NewYork-Presbyterian Hospital/Columbia University Medical Center physician-scientist and published today in the Archives of Internal Medicine.

The risk of heart attack is 150 percent greater in women with diabetes than in women without diabetes, but only 50 percent greater in men with diabetes versus men without the disease. Women with diabetes are also more likely to have hypertension than are men with the disease.

Most women with diabetes will develop CVD years earlier than women without diabetes. Between the ages of 65 and 79 years, women with diabetes show a two-fold greater risk of significant functional disability than do women without diabetes, and CVD is a significant contributor to this functional disability.

"Despite these numbers, physicians, researchers, and public health officials are not doing enough to adequately prevent and treat CVD in women with diabetes," says Dr. Elsa-Grace Giardina, director of the Center for Women's Health at NewYork-Presbyterian Hospital/Columbia and professor of clinical medicine at Columbia University College of Physicians & Surgeons.

The article cites one study in which 26 percent of women were misdiagnosed as having some condition other than CVD, compared with 18 percent of men. Specifically, and compared with men, heart attacks in women are more commonly undiagnosed -- leading to delayed medical attention, less aggressive treatment -- and, ultimately -- complications, disability, and premature death.

The authors argue that women -- with or without diabetes -- get inadequate treatment due to the lack of knowledge of how symptoms of CVD can differ between women and men. Women are also more likely to have jaw or neck and shoulder pain, nausea, vomiting, fatigue, or labored breathing, in addition to the more traditional chest pain during a heart attack. Sudden death from heart attack -- especially silent heart attack -- is also more common among women, and women more often delay seeking medical attention. Compounding the problem, even if physicians request testing for CVD, are the sensitivity and specificity of standard diagnostic techniques such as graded exercise tolerance tests and stress imaging studies are poorer for women than for men.

Women with diabetes also manifest high cholesterol differently -- with greater decreases in HDL-C and apolipoprotein A-I levels and LDL size, as well as greater increases in apolipoprotein B levels. Additionally, women with diabetes are more likely than men to have hypertension, and their hypertension is more closely linked to family history.

"To improve diagnosis of CVD in women, health care professionals must explicitly ask their patients about atypical symptoms of CVD and more readily request confirmatory tests when suspicion is high. At the same time, professionals must recognize that interpretation of the tests differs between men and women and that some tests may have a lesser predictive value in women," says Dr. Giardina.

Preventive measures and treatments are also lacking, the authors say. In women with type-2 diabetes, cardio-protective strategies (e.g. aspirin, lipid-lowering drugs, and anti-hypertensive drugs) are underutilized. Further, women with diabetes who have experienced a heart attack are less likely to be treated with reperfusion, beta blockers, angiotensin-converting enzyme inhibitors, and aspirin than are men.

"Researchers need to obtain and report real data in women rather than extrapolating from men to better understand how the presentation, diagnosis, treatment, and prognosis of CVD differs by sex," adds Dr. Giardina. "And promote and assess the quality of medical care, clear therapeutic targets are needed -- such as optimal levels for LDL-C, HDL-C, triglyceride, and body mass index (BMI).

"And, as soon as diabetes is diagnosed, monitoring and treating diabetes-specific elevations in blood glucose level, blood pressure, blood lipid levels, and possibly, hyper-reactivity of platelets are important and potentially lifesaving," says Giardina.

"Together, these measures have the potential to greatly improve outcomes in women with type-2 diabetes," concludes Dr. Giardina.

CVD is the primary cause of death in women in the developed world. In 2001, nearly 500,000 U.S. women died from CVD, compared with 267,000 deaths from cancer.

Along with Dr. Giardina, the article was authored by Dr. Elizabeth Barrett-Conner (University of California School of Medicine), Dr. Anselm K. Gitt (MI Research Institute Ludwigshafen, Germany), Dr. Uwe Gudat (Arataeus sarl, Geneva), Dr. Melmut O. Steinberg (Indiana University School of Medicine), and Dr. Diethelm Tschoepe (Ruhr University Clinic, Germany).

The article is based on a roundtable discussion that was organized and supported by an unrestricted educational grant from the Lilly Centre for Women's Health.

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