Hormonal, Metabolic, and Cellular Influences on Cardiovascular Disease in Women
Trudy M. Forte, PhD. 365 pp. Armonk, NY: Futura Publishing Co Inc; 1997. $85.00. ISBN 0-87993-668-1.
A recent survey commissioned by the American Heart Association found that only 7% of all women identify heart disease as their greatest health threat, despite the fact that it is actually the leading cause of death in women. With increasing awareness in the medical as well as the lay community of the major role cardiovascular disease plays in morbidity and mortality of women, there has been mounting attention to gender differences in cardiovascular disease. It is striking that heart disease does not begin to appear in noticeable numbers in women until after menopause, a fact that stimulates discussion and investigation of the role of estrogen in warding off the ravages of atherosclerosis. This book is a comprehensive and scholarly discussion of the current state of knowledge of possible mechanisms for interaction between estrogen and cardiovascular disease in women.
Although it has been known for some time that estrogen regulates lipoprotein binding and clearance by the liver with a favorable effect on the lipid profile, it has also been clear that the hypocholesterolemic effect of estrogen accounts for less than half of its associated cardiac risk reduction. Other possible mechanisms are explored in fascinating detail in this monograph, such as the antioxidant properties of estrogen, the effect of estrogen on the composition of connective tissue molecules, the effect of estrogen on inhibiting monocyte differentiation into macrophages, and the role of estrogen in regulating vascular cell proliferation at both the level of smooth muscle proliferation and collagen and elastin synthesis. The book begins with a discussion of the pathophysiology of atherosclerosis, proceeds with data from nonhuman primates, genetic mechanisms and estrogen receptors, vascular smooth muscle, the interaction of sex hormones in endothelial function, vascular calcification, and the effect of estrogen on lipoprotein metabolism as well as epidemiological data and a cursory discussion of hormone replacement therapy.
Although the word estrogen is not specifically contained in the title of the book, it (or the word hormone) is included in the title of 18 of the 21 chapters, and the monograph serves as an excellent resource on cellular and molecular mechanisms of estrogen on the cardiovascular system.
This monograph stems from an AHA conference chaired by Dr Forte in October 1995, entitled “Hormonal, Metabolic, and Cellular Influences on Cardiovascular Disease in Women.”
The introductory chapter by Michael Rosenfeld is an excellent summary of the cellular events of atherosclerosis that stands well on its own as well as providing a thorough background for gaining an understanding of the possible effects of estrogen at each step of the atherogenic cascade.
Linda Demer’s chapter (chapter 9) presents a fascinating theory about the paradox of vascular calcification and osteoporosis and the reason for this dual occurrence as we age as well as the latest information on mechanisms of vascular calcification. In chapter 11, David Herrington provides an excellent review of the currently available data on the effects of estrogen on anatomic and functional sequelae of coronary atherosclerosis: abnormal wall thickening and lumenal encroachment, abnormal endothelial-dependent vasodilator capacity, and abnormal thrombogenic potential as well as an overview of ongoing angiographic trials of estrogen replacement.
There is a comprehensive summary of the literature on hypertriglyceridemia as an independent cardiac risk factor with attention to gender differences, suggesting that the relative risk is greater for women than for men. Chapter 17 presents epidemiological data from the Healthy Women’s Study on changes in risk factors 5 years after menopause.
The book’s greatest strengths are an exhaustive review of the pathophysiology of atherosclerosis and the interaction of estrogen in this pathway, including the mechanisms of regulation of gene expression by estrogen receptors, effects on endothelium-derived factors in coronary arteries and vascular smooth muscle, and a discussion of the antioxidant effect of estrogen as well as vascular calcification data. Any reader who seeks to understand the molecular biology of estrogen and the role that sex hormones play in the atherosclerotic cascade will be well served by this volume. The numerous diagrams, tables, and summaries at the end of most chapters are particularly useful. There is some duplication among chapters. It would be helpful to include a condensed abstract for each chapter along with the chapter titles in the table of contents.
The clinician seeking practical advice on how to diagnose and treat heart disease in women would not be best served by this book. Although the final chapter gives a brief summary of the current status of hormone replacement therapy, it is by no means an exhaustive discussion of the current literature, pros and cons of hormone replacement therapy, or practical advice on dosing or cyclic versus continuous regimens. This chapter does mention phytoestrogens, the latest estrogen to receive much attention, highlighting the complexity of clinical decision making in this important area. However, I highly recommend this monograph to any researcher or clinician wanting a better understanding of hormonal, metabolic, and cellular influences on cardiovascular disease in women.
- Copyright © 1998 by American Heart Association