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

A journal where Dr. Mikos's study on death rates in younger U.S. women was published, highlighting rising heart disease mortality.

A paper that criticized the over-reliance on 10-year risk assessment for cardiovascular disease, especially in younger individuals.

Guidelines co-authored by Dr. Mikos that acknowledge the limitations of 10-year risk scores and allow for consideration of risk-enhancing factors and coronary artery calcium scores.

A journal that publishes cardiovascular guidelines, including those promoting a Mediterranean-style diet for heart health.

A statement co-authored by Dr. Mikos that emphasizes the influence of both positive and negative psychological factors (like stress, anxiety, depression) on cardiovascular health through direct and indirect mechanisms.

A registry in the U.S. showing that more than two-thirds of high-risk ASCVD patients remain above the LDL goal of 70 mg/dL and undertreated.

A leading medical journal where major cardiovascular trials are published.

A study cited for data indicating that 90% of coronary heart disease risk is attributable to preventable risk factors.

A study showing that Lp(a) levels above 50 mg/dL are associated with increased cardiovascular risk even when LDL is below 70 mg/dL.

A cardiovascular outcome trial for Alirocumab (a PCSK9 inhibitor) in patients with recent acute coronary syndrome, showing a 15% reduction in major adverse cardiovascular events.

Trials for Inclisiran, demonstrating its LDL-lowering effects (around 50%), with women showing similar reduction.

The ongoing cardiovascular outcome trial for Inclisiran, anticipated to show reduction in major adverse cardiovascular events due to LDL lowering.

A study cited as foundational evidence for the benefits of monounsaturated fatty acids (MUFAs) in heart health.

A study cited as foundational evidence for the benefits of monounsaturated fatty acids (MUFAs) in heart health.

A study that showed women with higher androgens had more coronary artery calcium progression, worse endothelial reactivity, and increased concentric remodeling.

The major cardiovascular outcome trial for Bempedoic Acid, which enrolled nearly 50% women (likely due to higher statin intolerance) and is anticipated to show significant benefits.

A leading medical journal where major cardiovascular trials are published.

A cohort study showing women were less likely to have been treated and accurately perceived to be at lower risk for myocardial infarction prior to an event.

Clinical trials for Semaglutide (agonists) that showed approximately 30 pounds of weight loss.

A registry indicating that women are less likely to be offered statin therapy by physicians compared to men.

A landmark study that demonstrated increased cardiovascular risk with hormone therapy, especially in older women far from menopause, leading to changes in guidelines.

A registry in Europe that, similar to the GOLD registry, indicated undertreatment and failure to reach LDL goals in high-risk ASCVD patients.

The ongoing outcome trial for Tirzepatide in diabetes.

A trial that demonstrated a significant nocebo effect, with up to 90% of reported statin-associated muscle symptoms occurring with placebo as well.

A cardiovascular outcome trial for Evolocumab (a PCSK9 inhibitor) in patients with stable ASCVD, showing a 15% reduction in major adverse cardiovascular events.

A long-acting reversible contraception method (Tier 1) considered safe and effective for high-risk women, including those with FH or established cardiovascular disease.

A progesterone-releasing IUD system that can marginally lower HDL, but these levels typically revert to pre-insertion levels by one year.

A treatment option for patients with very high Lp(a) and progressive cardiovascular disease.

A PCSK9 inhibitor (monoclonal antibody) that lowers LDL by 50-60% and Lp(a) by 25%, with positive cardiovascular outcome data from the FOURIER trial.

A high-intensity statin, often preferred due to potentially fewer muscle-associated symptoms and lower-appearing doses (5, 10, 20 mg), but requires dose adjustment in chronic kidney disease.

A new dual agonist (GIP and GLP-1 receptor agonist) approved for diabetes with dramatic weight loss effects (up to 50 pounds), but cardiovascular outcome trials for diabetes are ongoing, and not yet FDA approved for weight management.

Used to treat symptoms of PCOS by reducing hyperandrogenism, but older, higher-estrogen formulations can increase triglyceride levels, while lower-estrogen and transdermal forms have more modest lipid impacts. Generally safe for high-risk women with IUDs.

A GLP-1 receptor agonist available in injectable (oral formulation outcome data ongoing) form, approved for type 2 diabetes with cardiovascular outcome data, and a separate weight loss indication for obesity/overweight with risk factors.

A class of drugs mentioned in passing, with Peter Attia asking about their mechanism of cardiac event reduction beyond weight loss, similar to GLP-1 agonists.

A statin mentioned among those Peter Attia considers. Not a first choice for Dr. Mikos in general, but relevant for conversations about statin class.

Lipid-lowering medications that generally benefit women in both primary and secondary prevention, without sex interaction, but women are often less likely to be offered, more likely to decline/discontinue, and more likely to report muscle symptoms.

A small interfering RNA (siRNA) that inhibits PCSK9 synthesis, lowering LDL by about 50%, with a convenient every-six-month dosing, but outcome data is still pending.

The first statin approved in 1987, marking a turning point in cardiovascular disease prevention efforts.

A high-intensity statin used for potent LDL lowering. It is one of the preferred first-line agents in high-risk patients.

A PCSK9 inhibitor (monoclonal antibody) that lowers LDL by 50-60% and Lp(a) by 25%, with positive cardiovascular outcome data from the ODYSSEY trial. Often chosen based on insurance approval and ease of use (SureClick device).

Estrogen therapy that lowers LDL and increases HDL in women but also has unfavorable properties like increasing CRP levels, being pro-thrombotic, and increasing triglycerides. Not recommended solely for CVD prevention.

An autosomal dominant genetic disorder affecting 1 in 250 individuals, associated with a 20-fold increased risk of cardiovascular disease and earlier onset of ASCVD, with women equally affected as men and often undertreated.

A tool used to refine cardiovascular risk assessment, especially in individuals with borderline or intermediate risk, but less reliable in those under 40 due to time required for plaque calcification.

A diagnostic imaging technique that can detect calcification and soft plaque in arteries with finer detail than a CAC score, potentially revealing more disease in zero CAC scores.

The most common endocrine abnormality in women of reproductive age (5-13% prevalence), characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovary morphology, strongly linked to cardiovascular risk through insulin resistance.

Host of The Drive podcast, focused on longevity science and health.

Cardiologist whose work emphasizes that time exposure to ApoB is a major driver of atherosclerosis, advocating for earlier intervention.

Guest on the podcast, an internationally known leader in preventative cardiology, women's cardiovascular health, and cardio-obstetrics at Johns Hopkins School of Medicine.

A class of injectable lipid-lowering drugs (monoclonal antibodies) that significantly lower LDL (50-60%) and Lp(a) (25%), with proven cardiovascular outcome benefits in high-risk patients.

An oral drug that blocks cholesterol synthesis (Upstream of HMG CoA reductase), lowering LDL by ~18% (monotherapy) or ~36% (with ezetimibe). It does not cause muscle symptoms or increase glucose, making it a good option for statin-intolerant patients.

A drug that lowers Lp(a) but has not shown clinical cardiovascular benefit in outcome studies, hence not recommended for Lp(a) lowering.

A non-statin lipid-lowering therapy that can lower LDL cholesterol by about 16 mg/dL, used as an adjunct or in statin-intolerant patients.

A class of pharmacological agents beneficial for weight loss and cardiovascular health, independent of A1C lowering effects, and potentially anti-inflammatory and anti-atherosclerotic.

University where Dr. Mikos completed her undergraduate studies as a molecular biology major.

Public health institution where Dr. Mikos holds a joint appointment in the Department of Epidemiology.

A source of systematic reviews and meta-analyses, cited as showing ambiguity in data regarding the specific impact of various fatty acids on cardiovascular disease in the context of energy balance.

Academic medical institution where Dr. Mikos is an Associate Professor of Medicine in the Division of Cardiology.

Organization that published a survey in 2021 showing declining awareness among women about heart disease being their leading cause of death.

A leading medical journal where major cardiovascular trials are published, also referred to as the Journal of the American Medical Association.

A tool used to demonstrate how age is a dominant factor in 10-year cardiovascular risk assessment, showing it often underestimates risk in the young and overestimates in the old.