More Data Needed

Letters to the Editor Special Aspects of Cholesterol Metabolism in Women by Prof. Dr. med. Ioanna Gouni-Berthold and Prof. Dr. med. Ulrich Laufs in issue 12/2024

The article’s objective was to optimize estimating the risk of cardiovascular diseases in women (1). To this end, changes in the lipid metabolism over the course of life are discussed. The argument is based on a pathophysiologically plausible hypothesis, according to which the cumulative exposure to high LDL cholesterol levels (the “cholesterol years”) is as important for the risk as the postmenopausal rise in cholesterol. To date, this hypothesis of cumulative cholesterol load has been evaluated only in familial hypercholesterolemia and in middle-aged adults. Extrapolations beyond this setting—for example, to postmenopausal women—require explicit validation. In the CARDIA Study, accordingly, a follow-up beyond the 60th year of life is planned (2).

The suggestions for more intensive cholesterol screening in women are not helpful without improved data on the benefit of medication-based primary prevention for women (reduction in cardiovascular events and deaths) (3). The most notably positive effect of a statin in women was observed in the JUPITER Study (4). The participants had no history of cardiac disease, their hsCRP was above 2 mg/L and their LDL cholesterol below 130 mg/dl; they were treated with 20 mg rosuvastatin per day or placebo. The primary combined endpoint from myocardial infarction, stroke, inpatient admission for unstable cardiac angina, arterial revascularization, or cardiovascular death was significantly reduced under rosuvastatin among the 6801 participating women—the overall mortality showed a non-significant trend towards reduction (4). To balance benefits and risks of medication-based cholesterol lowering for primary prevention in the women identified by extended cholesterol screening, further data are required—generated for example by stringent sex-based data collection and evaluation of clinically relevant endpoints in completed or future lipid lowering studies.

DOI: 10.3238/arztebl.m2024.0180

Dr. med. Rainer Burkhardt

Oldenburg

Conflict of interest statement

The author declares that no conflict of interest exists.

References

1. Gouni-Berthold I, Laufs U: Special aspects of cholesterol metabolism in women. Dtsch Arztebl Int 2024; 121: 401–6.

2. Domanski MJ, Tian X, Wu CO, et al.: Time course of LDL cholesterol exposure and cardiovascular disease event risk. J Am Coll Cardiol 2020; 76: 1507–16.

3. Lee SK, Khambhati J, Varghese T, et al.: Comprehensive primary prevention of cardiovascular disease in women. Clin Cardiol 2017; 40: 832–8.

4. Mora S, Glynn RJ, Hsia J, MacFadyen JG, Genest J, Ridker PM: Statins for the primary prevention of cardiovascular events in women with elevated high-sensitivity C-reactive protein or dyslipidemia. Circulation 2010; 121: 1069–77.