Erin Donnelly Michos, MD, discusses optimizing cardiovascular disease prevention in women through earlier risk assessment and tailored management.
Cardiovascular disease remains the leading cause of death in women, and most cases are preventable through early and aggressive risk management.
Midlife women are frequently undertreated for hypertension, dyslipidemia, and diabetes despite equal benefit from evidence-based therapies.
Earlier, sex-specific prevention strategies—including nonstatin and diabetes therapies—are essential to improving cardiovascular outcomes.
Erin Donnelly Michos, MD, professor of Medicine, Division of Cardiology, Johns Hopkins School of Medicine, and director of Women’s Cardiovascular Health and associate director of Preventive Cardiology at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease in Baltimore, Maryland, presented on “Primary Prevention of Cardiovascular Disease in Women: Blood Pressure, Lipids, and Diabetes” at the 2025 Menopause Society Annual Meeting. She spoke with Contemporary OB/GYN about improving cardiovascular disease (CVD) prevention in women through earlier intervention, better hypertension and lipid management, and appropriate use of nonstatin and diabetes therapies.
Michos: Cardiovascular disease is still the leading cause of death in women, and we think about 90% of cardiovascular disease as being due to modifiable, preventable factors. The best intervention is prevention.
It is important to take a risk assessment. We have tools such as the new American Heart Association PREVENT score to estimate both short-term risk over the next 10 years and longer-term risk over 30 years. But these are just a starting framework. There are still limitations, as several factors are not included in these calculators—such as premature menopause, a history of adverse pregnancy outcomes, elevated inflammation markers like high-sensitivity C-reactive protein or lipoprotein(a), or a family history of premature coronary disease. It’s really important that we consider a holistic approach and these risk enhancers, because many women are at higher risk than the calculators estimate, leading to undertreatment.
Michos: The majority of women—over half of those in midlife—have hypertension. Unfortunately, less than 25% have their blood pressure under control. Blood pressure is a risk factor for both men and women, but cardiovascular risk begins at lower thresholds for women. Even though we don’t yet have sex-specific cut points for blood pressure, maybe we should, because women are at risk even at lower levels.
The 2025 American Heart Association hypertension guidelines emphasize that normal blood pressure is less than 120/80 mm Hg. Stage 1 hypertension is defined as 130-139/80-89 mm Hg, and stage 2 is 140/90 mm Hg or higher. All patients with stage 2 hypertension should receive pharmacologic therapy. Those with stage 1 hypertension and a 10-year PREVENT score of more than 7.5%, diabetes, or chronic kidney disease should also be treated. Lifestyle modification is foundational, but many women will still require pharmacologic therapy—and women benefit just as much as men when treated, though they often remain undertreated.
Michos: There is overwhelming evidence that LDL cholesterol and apolipoprotein B are causally related to atherosclerotic cardiovascular disease. Lipids matter just as much—if not more—in women than in men. For every 40 mg/dL reduction in LDL, you can reduce major cardiovascular events by about 22%. Statins are first-line therapy, but women benefit equally from all LDL-lowering therapies, including nonstatin oral and injectable agents.
Women with familial hypercholesterolemia are at particularly high risk—about 30% of untreated women will experience myocardial infarction before age 60. We must minimize time off therapy because the total years of exposure to elevated lipoprotein levels matters. During menopause transition, cholesterol and lipoprotein(a) levels rise, worsening cardiometabolic patterns. Lipid management is critical during this stage.
Michos: Statins remain our first-line therapy, but they’re not the only game in town. What really matters is the degree of LDL and apolipoprotein B lowering—proportional reductions translate into proportional decreases in cardiovascular risk, regardless of therapy type. This gives us more options, particularly because women are more likely to report statin-associated symptoms and discontinue therapy.
Combination therapy can be beneficial. The RACING trial, for example, compared moderate-intensity rosuvastatin 10 mg plus ezetimibe 10 mg vs high-intensity rosuvastatin 20 mg. The combination achieved better LDL control, similar reductions in cardiovascular events, and fewer discontinuations due to side effects. It’s really about providing patients with options to achieve their LDL goals and reduce cardiovascular risk.
Michos: Diabetes is slightly more prevalent in men, but when women have diabetes, it confers a greater relative risk—about a 4-fold increased risk of myocardial infarction compared with a 2-fold risk in men. Women tend to have higher BMI and more metabolic risk factors at diagnosis.
Women benefit just as much from preventive therapies, including SGLT2 inhibitors and GLP-1 receptor agonists, both of which reduce major cardiovascular events. Real-world data suggest women may even experience greater benefit from GLP-1 receptor agonists. All adults over 40 with diabetes should be on a statin, and for those with additional cardiovascular risk, we should prioritize glucose-lowering agents that confer cardiovascular protection.
Michos: We need to start prevention earlier. Too often, we intervene too late—after atherosclerosis has already developed. We gain more life years if we start with moderate lipid reduction earlier in life than if we begin high-intensity therapy later. The key is primordial prevention—optimizing cardiovascular health before midlife. Women who enter menopause with better cardiometabolic health have better long-term outcomes and longevity.
Michos: Women remain at risk for cardiovascular disease—it’s still their number one health threat. Lipids, blood pressure, and diabetes are additive risk factors. Women benefit from treatment, yet remain undertreated. They’re often presumed lower risk because of sex, but women with familial hypercholesterolemia or diabetes lose that “female advantage” and experience early-onset CVD like men. Clinicians should not assume women are lower risk—they should be treated according to guideline recommendations, without regard to sex.
Reference:
Donnelly Michos E. Primary Prevention of Cardiovascular Disease in Women: Blood Pressure, Lipids, and Diabetes. Presentation. Presented at: The Menopause Society’s 2025 Annual Meeting. October 21–25, 2025. Orlando, Florida.
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