European Journal of Cardiovascular Medicine

Coronary artery disease (CAD) is one of the leading causes of morbidity and mortality in women, particularly among postmenopausal females [1]. The primary objective of this study is to analyze the clinical profile of CAD in postmenopausal women and to evaluate the major associated risk factors.

The increased cardiovascular risk observed after menopause is largely attributed to hormonal and metabolic alterations [2]. Estrogen is known to exert cardioprotective effects through its influence on lipid metabolism, vascular function, and inflammatory pathways [3]. The loss of estrogen during menopause results in an increased risk of CAD, with postmenopausal women demonstrating CAD incidence rates comparable to men [4].

Clinically, unstable angina is the most frequent presentation in this population. Chest pain remains the most common symptom, followed by dyspnea; thus, these signs should not be disregarded in women after menopause [5].

Major risk factors contributing to CAD in postmenopausal women include hypertension, type 2 diabetes mellitus, dyslipidemia, smoking, and the use of oral contraceptive pills (OCPs) [6]. Dyslipidemia in this group is often marked by low high-density lipoprotein (HDL), elevated triglycerides, and increased low-density lipoprotein (LDL) levels. Estrogen replacement therapy and OCPs may exacerbate these lipid abnormalities [7]. Moreover, type 2 diabetes mellitus is associated with reduced HDL, elevated triglycerides, and platelet dysfunction, all of which further elevate cardiovascular risk [8].

This study was therefore conducted to assess the clinical presentation and risk factor profile of CAD in postmenopausal women, with the aim of improving early detection and preventive care.

This Cross sectional study includes data collected from 99 post menopausal females visiting OPD of Krishna Rajendra Hospital, Mysore during the period of April 2022 to October 2022, without previous history suggestive of heart disease The data was analysed by SPSS software version 2.0 and chi-square tests was applied for qualitative variables.

Inclusion criteria

·         All post menopausal women with age >50 years without any previous history of structural heart diseases visiting to opd with symptoms suggestive of CAD like chest pain, other angina equivalents like dyspnoea, giddiness, and palpitation.

·         Patients’ ECG with Evidence of STEMI, NSTEMI and Pathological Q waves in Chest and Limb leads

·         ECG with loss of R wave in chest leads with significant T inversion in more than 2-3 leads.

·         2D ECHO – RWMA status and features of poor LV functions.

Exclusion criteria

·         All patients with age<50yrs & has not attained menopause.

·         Patients with previous history of Valvular Heart Disease & Cardiomyopathy.

·         Symptomatic patients with Normal Serial ECGs and Normal Echo study.

·         Severe Anaemic patients with Hb < 6 g%,

·         Severe COPD patients.

·         Patients with previous history of abnormal Thyroid function test

Ethical  approval

Ethical approval was obtained from Mysore medical college and research institute Ethics Committee and the ethical protocols of the declaration of Helsinki (1967) including the ethical principles of informed consent, voluntary participation and withdrawal, privacy and confidentiality, were followed.

Data analysis and statistics

Data obtained from the study has been entered in excel sheets and analyzed using SPSS(Statistical package for social sciences) software version 2.0 and has been presented as descriptive statistics in the form of frequency, tables, figures and graphs.

●Descriptive statistics of the explanatory and outcome variables were calculated by mean, Standard deviation for quantitative variables, frequency and proportions for qualitative variables.

●Inferential statistics like-

1) Chi-square test was applied for qualitative variables. Numerical variables were expressed as mean +/- standard deviation.

2) Independent sample t test will be applied to compare the quantitative variables between the groups. The level of significance is set at 5%. A ‘p’ value of <0.05 is considered statistically significant.

The study was conducted among 100 post menopausal women. The study showed almost equal distribution of subjects in the age group of 53-56yrs, 57-60yrs and 65-68yrs with each age group contributes about 26%, and the mean age was 60.3yrs. Among the presenting complaints studied, 35 % subjects presented with chest pain, 45 % presented to OPD with giddiness, 12% presented with dyspnoea and rest 8 % presented with palpitation. Risk factors like HTN, T2DM and Dyslipidemia was also analysed among study subjects and majority of the study subjects were hypertensives contributing about 46 %, 35 % of the study subjects had dyslipidemia and 9 % had T2DM. ECG was done for all patients, and 55% of study subjects had a normal ECG  findings. Among the abnormal ECG findings, 18 % showed features suggestive of LVH in ECG, 19% had T inversions, 1 % showed ST depression, and 3% showed pathological Q waves, 4 % showed poor r wave progression. 2D Echo was also done among all patients, 53% had normal findings, 18% had LVH, 13%  had IHD with EF>50%, 9% had IHD with EF< 50% and 7 % had LV Diastolic dysfunction.

Among the study population, 2D echo findings were correlated with chest pain. Among 35 % of patients presented with chest pain - 12 % had normal finding, 10%  had IHD with            EF >50 %, 5% had IHD with EF <50%, 5 % had an Echo finding suggestive of  Concentric LVH, and  3 % had LV diastolic dysfunction. Therefore showing significant correlation with p value  < 0.05.

Table 1 :  Distribution of Chest Pain Among Patients Based on 2D Echocardiographic Findings

Among the study population, 2D echo findings were correlated with palpitation. Among 8 % of patients presented with palpitation – 2% had normal finding, 1 % had IHD with EF >50 %, 4 % had concentric LVH and 1 % had LV diastolic dysfunction. Hence no significant correlation was found with p value < 0.05.

Among the study population, 2D echo findings were correlated with giddiness. Among 45 % of patients presented with giddiness – 11 % had normal finding, 10 % had IHD with EF >50 %, 12 % had concentric LVH, 6 % had IHD with EF <50% and 6 % had LV diastolic dysfunction. Therefore significant correlation was found with p <0.05.

Among the study population, 2D echo findings were correlated with Dyspnoea. Among 12 % of patients presented with dyspnoea – 1 % had normal finding, 3 % had IHD with EF >50 %, 3 % had concentric LVH, 2 % had IHD with EF <50% and 3 % had LV diastolic dysfunction. Therefore significant correlation was found with p <0.05.

Hence the study concluded that among the post menopausal women presenting to opd with clinical symptoms- chest pain, giddiness and dyspnoea showed a significant correlation with occurrence of coronary artery disease.

Also risk factors like HTN, Diabetes and Dyslipidemia was studied and was correlated with 2D echo findings.

Among   35%   patients with dyslipidemia, 4 % had normal finding, 11 % had IHD with EF >50 %, 7 % had concentric LVH, 7 % had IHD with EF <50% and 6 % had LV diastolic dysfunction. Therefore significant correlation was found  between dyslipidemia and  occurence of coronary artery disease with p <0.05.

Among 46% hypertensives - 6% had normal finding, 12 % had IHD with EF >50 %, 18 % had concentric LVH, 8 % had IHD with EF <50% and 2 % had LV diastolic dysfunction. Therefore significant correlation was found between hypertension and occurrence of coronary artery disease among post menopausal women with p <0.05.

Among 9% with T2DM, 1 % had normal finding, 2 % had concentric LVH, 4 % had IHD with EF <50% and 2 % had LV diastolic dysfunction. Therefore significant correlation was found with p <0.05.

Among the risk factors studied, those with HTN and dyslipidemia showed more significant correlation than diabetes, with occurrence of coronary artery disease.

The present study was conducted in order to determine the clinical profile of coronary artery disease among  post menopausal women. Coronary artery disease is one of leading cause of death among post menopausal women, due to loss of protection by hormones like estrogen and also most of the symptoms are subclinical or minimal, hence left untreated.[9]

The present study is a cross sectional study and  includes data collected from 100 post menopausal females visiting OPD of Krishna Rajendra Hospital, Mysore during the period of April 2022 to October 2022, without previous history suggestive of heart disease.In the present study, among 100 post menopausal women, the mean age of the study population was 60.3years, in comparison with the study conducted by Abdali N, Asif M. et al,were the average age of study population was 64 +/- 1.5 years.[10]

In the present study, 35 % subjects presented with chest pain, 45 % presented to OPD with giddiness, 12% presented with dyspnoea and rest 8 % presented with palpitation. In the study when presenting symptoms were compared with 2 D echo findings and chest pain, dyspnoea and giddiness shows a significant correlation with respect to coronary artery disease, and palpitation does not have a correlation.

In a study conducted by Manoj Kumar Gupta and Satya Narayan Routray et al, among 100 postmenopausal women studied, 70%  presented with chest pain. In a study conducted by Abdali N, Asif M et al,among 135 post menopausal women studied,61.4%  presented with chest pain, followed by dyspnoea and palpitation. Among the patients with chest pain,38.5 % shows a significant correlation with clinical diagnosis in comparison with 2 D Echo findings.

In the present study, risk factors like HTN, T2DM and Dyslipidemia was also analysed among study subjects and majority of the study subjects were hypertensives contributing about 46 %, 35 % of the study subjects had dyslipidemia and 9 % had T2DM. All these risk factors was correlated with 2d echo findings, and among 46% hypertensives,40% shows significant 2d echo findings suggestive of coronary artery disease, among 35% patients with  dyslipidemia ,31% shows significant 2d echo findings suggestive of coronary artery disease  and among 9% patients with diabetes,8 %  showed a significant correlation with occurence of coronary artery disease, and those dyslipidemia and hypertension had more significant correlation with 2d echo findings suggestive of coronary artery disease.

In a study conducted by Abdali N, Asif M et al, among 135 post menopausal women, hypertension, diabetes and dyslipidemia shows significant correlation with occurrence of coronary artery disease among post menopausal women with p value<0.05.[10]

Hence early detection of signs and symptoms of coronary artery disease and early detection of risk factors and management of the same plays an important role in management of future clinical implications among post menopausal women.

The findings from the present study reinforce the growing evidence that postmenopausal women represent a unique and high-risk population for coronary artery disease (CAD). Estrogen is known to have a protective effect on the cardiovascular system through favorable modulation of lipid profiles, vascular tone, and endothelial function. With the onset of menopause, this cardioprotective benefit diminishes, leading to increased susceptibility to atherosclerosis and related cardiovascular conditions [11].

The mean age of 60.3 years in our study population is consistent with the menopausal transition period, which is typically associated with an increased incidence of metabolic syndrome, insulin resistance, and pro-inflammatory states—all of which contribute to the pathogenesis of CAD [12]. Symptomatically, our data highlights that chest pain, giddiness, and dyspnea are the most common presenting features among postmenopausal women with CAD. These symptoms correlate significantly with 2D Echo findings. However, atypical presentations are not uncommon in women, and misinterpretation or under-recognition may lead to underdiagnosis [13]. This is supported by studies indicating that women more frequently present with non-classic symptoms, such as fatigue or dizziness, compared to men [14].

In terms of risk factors, hypertension was the most prevalent comorbidity in our cohort, followed by dyslipidemia and diabetes mellitus. These findings are consistent with global patterns, where hypertension and dyslipidemia are recognized as major contributors to the increasing CAD burden in women post-menopause [15]. Elevated triglycerides, reduced HDL levels, and increased LDL levels—common in postmenopausal women—further exacerbate atherosclerotic processes [16].

LIMITATIONS

Our study comprised a relatively small sample size, and was a single centred study done in short duration span.

Coronary artery disease in the postmenopausal women is a great challenge to deal with unstable angina, which was the most common presentation. The occurrence of CAD was significantly associated with age, HTN, diabetes, dyslipidemia and significant correlation was found. Those presenting to Opd with prior history of HTN, T2DM.and dyslipidemia were more prone to develop coronary artery disease, than those without any risk factors. Hence the study concluded that an early regular medical routine check- ups, awareness about occurrence of each clinical symptom is crucial in a postmenopausal women for early detection and prevention of coronary artery disease.

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