Women with endometriosis at greater associated risk of heart attack and stroke

According to research presented at ESC Congress 2024,1 women with endometriosis have a 20% greater risk of significant cardiac outcomes compared with women without endometriosis.

“For decades, cardiovascular disease (CVD) has been thought of as a man’s disease and risk factors have been considered from the male perspective, for example, including erectile dysfunction in guidelines on CVD risk assessment.2 Yet, 1 in 3 women die from CVD and 1 in 10 women suffer from endometriosis.3 Our results suggest that it may be time to routinely consider the risk of CVD in women with endometriosis,” said lead study author, Dr. Eva Havers-Borgersen from Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark.

The study used Danish nationwide registries of all women with a diagnosis of endometriosis between 1977 and 2021. They were matched with women from the background population without endometriosis in a 1:4 ratio based on year of birth. The primary outcome was a composite of acute myocardial infarction and ischaemic stroke. The secondary outcomes were the individual components of the primary outcome, as well as arrhythmias, heart failure and mortality.

There were 60,508 women with endometriosis and 242,032 matched controls included in the analysis (median age, 37.3 years) who were followed for a median of 16 years and a maximum of 45 years.

Women with endometriosis had around a 20% increased risk of the composite endpoint of acute myocardial infarction and ischaemic stroke compared with those without endometriosis (unadjusted hazard ratio [HR] 1.18; 95% confidence interval [CI] 1.14−1.23; adjusted HR 1.15; 95% CI 1.11−1.20). The 40-year cumulative incidence of the composite of acute myocardial infarction and ischaemic stroke was 17.5% (95% CI 16.6−18.2%) and 15.3% (95% CI 15.0−15.7%) in women with and without endometriosis, respectively (p<0.0001).

When this was broken down to the individual components, women with endometriosis had around a 20% increased risk of ischaemic stroke (adjusted HR 1.18; 95% CI 1.12−1.23) and around 35% increased risk of acute myocardial infarction (adjusted HR 1.35; 95% CI 1.31−1.40) compared with those without endometriosis. Moreover, women with endometriosis also had increased risk of arrhythmias (adjusted HR 1.21; 95% CI 1.17−1.25) and heart failure (adjusted HR 1.11; 95% CI 1.05−1.18) compared with those without endometriosis.

Growing evidence suggests there is a close relationship between endometriosis and the cardiovascular system and that they may share common disease pathways.3 Dr. Havers-Borgersen concluded: “Although the absolute differences were small, the relative differences were 20%, and with the high prevalence of endometriosis, these results provide more evidence that female-specific risk factors and CVD in women need greater attention. We suggest that women with endometriosis undergo CVD risk assessment, and it is now time for female-specific risk factors – such as endometriosis, but also gestational diabetes and pre-eclampsia – to be considered in cardiovascular risk prediction models. Further research is needed to confirm our findings and integrate these factors into effective risk prediction models.”

Funding: None.

Disclosures: None.

References and notes

1The abstract “Endometriosis, a prevalent disease, is associated with significant cardiac disease” will be presented at the session ‘Cardiovascular disease in women (5)’, which takes place on 2 September 2024, Station 6 in the Research Gateway.

2Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42:3227–3337.

3Marchandot B, Curtiaud A, Matsushita K, et al. Endometriosis and cardiovascular disease. Eur Heart J Open. 2022;2:oeac001.

CVD is the leading cause of death in women, both in Europe and worldwide.  Yet, compared with men, women with CVD are typically underdiagnosed and undertreated. The ESC supports measures to reduce the gap in the prevention, diagnosis and treatment between women and men as integral to reducing the overall burden of CVD.