Women's Vascular Health PDF

Preface

Women's vascular health is an important topic. It has long been recognized that coronary artery disease is a major health issue. In recent years, there has been a dramatic increase in the number of women suffering from this disease and it is no longer unusual to encounter a woman with coronary artery disease in pregnancy. Despite the large number of women affected, the majority of research is focused on the disease in men. It is also being increasingly recognized that the antecedents to the problems of coronary artery disease in women lies in earlier life and impinges on pregnancy and reproductive health. For example, women who suffer from polycystic ovarian syndrome not only suffer from infertilityrelated problems, but also exhibit metabolic responses that are similar to several of the key risk factors of coronary artery disease. Furthermore, the number of pregnancies a woman has, and a history of preeclampsia, are both associated with an increase in subsequent risk of coronary artery disease. During pregnancy, there are metabolic and haemostatic changes, which are further exaggerated in preeclampsia, that are similar to those seen in established vascular disease. Thus, coronary artery disease in later life may not only be influenced by typical risk factors such as smoking, social deprivation and genetic predisposition, but also by past reproductive experience and problems.

Women's vacular health, of course, encompasses much more than coronary artery disease. Venous disease is also an important problem. It is increasingly recognized that many venous thrombi are associated with congenital or acquired thrombophilic defects. Furthermore, these thrombophilias are not simply associated with venous thrombosis, as there is now increasing evidence linking thrombophilia to pregnancy complications, such as fetal loss, preeclampsia and abruption.

There are also specific problems with vascular disease during pregnancy. Pregnancy is associated with an increase in the risk of venous thromboembolism. Indeed the most common direct cause of maternal death in the UK and other developed countries is pulmonary embolism. Particular vascular complications occur in pregnancy, notably preeclampsia and intrauterine growth restriction. Women with preexisting disease that can impact on the vascular system, also have specific problems in pregnancy. These include women with valvular and congenital heart disease, peripheral or cerebral vascular disease, or underlying connective tissue or renal disease. There are also particular problems with prescribing antithrombotic agents during pregnancy where both the mother and the fetus have the potential to experience side-effects. Furthermore, it is clear that the maternal response to pregnancy may be involved in fetal programming, not simply through established factors such as maternal nutrition and genotype, but also in terms of the maternal response to pregnancy which may be modified by factors such as her body fat distribution, insulin resistance and exercise.

Hormonal therapy in women is also of substantial interest. The use of the combined oral contraceptive pill and hormone replacement therapy (HRT) are associated with increased vascular risk. While the ‘pill' is itself a risk factor for thrombosis, many events may be explained by the interaction of the contraceptive pill with an underlying thrombophilia or acquired risk factors for venous thrombosis. Such interaction impacts on contraceptive choice, particularly in women with a personal or family history of venous thrombosis or hereditary thrombopilia. More recently the association between HRT and vascular disease has been established. This has significant implications for the use of HRT and specific guidance is required for patients with a personal or family history of vascular disease.

Hemorrhagic probems are also important to women's vascular health. These range from menorrhagia to congential disorders of coagulation such as von Willebrand's disease, and extend into pregnancy where hemorrhagic problems may ensue through antepartum hemorrhage and disseminated intravascular coagulation or through preexisting or newly acquired conditions such as idiopathic thrombocytopenic purpura.

Thus, a women's vascular health is relevant throughout her life. Many significant new developments have been made in recent years. All too often, practitioners involved in managing these various problems see only a small aspect of it as it relates directly to their area of expertise. They may not be aware of the wider implications. For example, the obstetrician dealing with the pregnancy-related problems may not appreciate the impact the response to pregnancy may have on the patient's subsequent risk of coronary artery disease and the cardiologist dealing with such a problem may not fully appreciate the antecedents. Thus, we believe there is a need for a book that brings together all aspects of women's vascular health to provide a multidisciplinary resource to give information and advice on the management of these problems with a more holistic view. We believe that this book will go some way to meeting this unmet need, and hope that those who read it not only find it useful, but also enjoy it.