Atherosclerosis 185 (2006) 227239

Review

Cardiovascular disease in the polycystic ovary syndrome: New insights and perspectives
Andrea J. Cussons a,c , Bronwyn G.A. Stuckey a,b,c , Gerald F. Watts c,
c a Keogh Institute for Medical Research, Nedlands, WA, Australia Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia University of Western Australia, School of Medicine & Pharmacology, Royal Perth Hospital Unit, GPO Box X2213, Perth, WA 6847, Australia b

Received 19 July 2005; received in revised form 29 September 2005; accepted 6 October 2005 Available online 28 November 2005

Abstract The new millennium has brought intense focus of interest on the risk of cardiovascular disease in women. The polycystic ovary syndrome (PCOS) is a common endocrine disorder in women characterised by hyperandrogenism and oligomenorrhoea. Most women with PCOS also exhibit features of the metabolic syndrome, including insulin resistance, obesity and dyslipidaemia. While the association with type 2 diabetes is well established, whether the incidence of cardiovascular disease is increased in women with PCOS remains unclear. Echocardiography, imaging of coronary and carotid arteries, and assessments of both endothelial function and arterial stiffness have recently been employed to address this question. These studies have collectively demonstrated both structural and functional abnormalities of the cardiovascular system in PCOS. These alterations, however, appear to be related to the presence of individual cardiovascular risk factors, particularly insulin resistance, rather than to the presence of PCOS and hyperandrogenaemia per se. However, given the inferential nature of the evidence to date, more rigorous cohort studies of long-term cardiovascular outcomes and clinical trials of risk factor modication are required in women with PCOS. 2005 Elsevier Ireland Ltd. All rights reserved.
Keywords: Polycystic ovary syndrome; Cardiovascular function and structure; Cardiovascular risk; Insulin resistance

Contents
1. 2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cardiovascular risk factors in PCOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Biochemical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.1. Insulin resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.2. Hyperandrogenaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.3. Dyslipidaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.4. Other risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Clinical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Metabolic syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cardiovascular epidemiology of PCOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 228 228 228 228 229 229 229 229 230

3.

Abbreviations: BMI, body mass index; CIMT, carotid intima-medial thickness; DHEAS, dehydroepiandrosterone sulphate; ecNOS, endothelial nitric oxide synthase; FMD, ow mediated dilatation; HDL, high density lipoprotein; IVRT, isovolumetric relaxation time; LBF, leg blood ow; LDL, low density lipoprotein; LV, left ventricular; NIH, National Institutes for Health; NO, nitric oxide; PCO, polycystic ovaries; PCOS, polycystic ovary syndrome; PWV, pulse wave velocity Corresponding author. Tel.: +61 8 9224 0240; fax: +61 8 9224 0246. E-mail address: gfwatts@cyllene.uwa.edu.au (G.F. Watts). 0021-9150/$ see front matter 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.atherosclerosis.2005.10.007

228

A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239

4. 5.

6.

7.

Studies of subclinical cardiovascular disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Functional studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. Ventricular function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2. Arterial stiffness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3. Endothelial function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.1. Conduit arteries: macrovascular endothelial function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.2. Resistance arteries: microvascular endothelial function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Morphological studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1. Carotid wall thickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2. Arterial calcication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions and future perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

230 230 230 230 233 233 234 234 234 235 235 237 237

1. Introduction Polycystic ovary syndrome (PCOS), characterised by chronic anovulation and hyperandrogenism [1,2] is a common diagnosis made in up to 10% of women of reproductive age [3]. Cardiovascular disease and type 2 diabetes are two potential major long-term sequelae of this condition that merit examination. A summary of the most recent diagnostic criteria for the diagnosis of PCOS is shown in Table 1. Application of these criteria to diagnose PCOS also requires excluding other causes of the phenotype, including pituitary and adrenal dysfunction. It should be noted that compared with the Rotterdam Criteria, the National Institutes for Health (NIH) Criteria do not include the detection of polycystic ovaries on ultrasonography. This may have important implications for the sample population and for generalizing the ndings of the cardiovascular studies referred to in this review. Although PCOS is increasingly recognised as being associated with a clustering of cardiovascular risk factors [46], there is no denitive evidence for increased cardiovascular events in PCOS. Nor is there, evidently, data showing that PCOS alone imparts increased risk independent of associated risk factors. The present article aims to review the spectrum of cardiovascular risk factors, the cardiovascular epidemiology and especially the most recent studies of subclinical cardiovascular disease in PCOS, examining cardiovascular structure and function. Whilst not denitive, these latter set
Table 1 Diagnostic criteria for PCOS 1990 NIHa Criteria (2) Anovulation Hyperandrogenism (clinical +/or biochemical) Polycystic ovaries on ultrasound (Exclusion of other aetiologies required for diagnosis of PCOS using either criteria)
a

of studies have in particular further elucidated the causal links between PCOS and cardiovascular disease.

2. Cardiovascular risk factors in PCOS 2.1. Biochemical 2.1.1. Insulin resistance Insulin resistance is thought to play a role in the pathogenesis of PCOS, and is often exacerbated by co-existent obesity [7]. Both lean and obese women with PCOS have increased rates of insulin resistance and type 2 diabetes mellitus compared with body mass index (BMI) matched controls [79]. Both PCOS and obesity have synergistic effects on the incidence and severity of insulin resistance. There is also a strong positive correlation between hyperandrogenaemia and insulin resistance in PCOS [10]. This may chiey reect the stimulatory effect of hyperinsulinaemia on ovarian androgen production [11], although hyperandrogenaemia may also contribute to insulin resistance [12]. This may also underlie the association between hyperandrogenaemia and impaired vascular function in PCOS reported in some studies [1315]. However, although insulin resistance per se has been associated with endothelial dysfunction and increased cardiovascular risk [16,17], there is no consistent evidence that hyperandrogenaemia is a risk factor for cardiovascular disease in women [18], and this is borne out by the studies of subclinical disease in PCOS reviewed later. 2.1.2. Hyperandrogenaemia The gender difference in susceptibility to cardiovascular disease has been attributed to the difference in sex steroids with oestrogen being seen as cardioprotective and androgens as a possible exacerbating cardiovascular risk factor [19]. However, no study in men has shown a positive correlation between circulating androgens and cardiovascular disease [18]. In women without PCOS, the few studies that examine the association between endogenous androgens and the development of cardiovascular disease have not demonstrated that androgen status plays a signicant role [20]. In pre- and post-

2003 Rotterdam Criteria (1) (2 out of 3 required) + + +

+ +

National Institutes for Health.

A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239

229

menopausal women carotid intima-medial thickness (CIMT) has been shown to be inversely correlated with endogenous dehydroepiandrosterone sulphate (DHEAS) and testosterone [21]. Studies of endogenous androgen deprivation in men or testosterone administration to women in gender reassignment have failed to show an effect of either on cardiovascular morbidity or mortality [22]. However, in an experimental model, testosterone administration to female primates was associated with increased atherogenesis, independent of lipid effects [23]. Similar experiments in animal models of PCOS have not been reported to date. It seems that despite the acknowledged consistent gender imbalance in the prevalence of cardiovascular disease, nonhormonal, genetic and environmental risk factors may play a greater role than that of androgens. 2.1.3. Dyslipidaemia Dyslipidaemia may be the most common metabolic abnormality in PCOS, with a prevalence of up to 70% by the National Cholesterol Education Program criteria [4,8]. PCOS is classically associated with an atherogenic lipoprotein prole, characterised by elevated triglyceride-rich lipoproteins, accumulation of small dense low density lipoprotein (LDL) and depressed high density lipoprotein (HDL). All these changes are closely related to insulin resistance, although elevated androgens may contribute to small HDL size by stimulating hepatic lipase activity [24]. The aforementioned qualitative changes in lipoprotein metabolism could account for an increased risk of cardiovascular disease in PCOS independent of changes in total or LDL cholesterol levels, but this notion remains to be demonstrated. 2.1.4. Other risk factors Several studies have demonstrated abnormalities in nontraditional markers of cardiovascular risk related to insulin resistance and obesity in PCOS. The majority, such as those involving C-reactive protein [2527], adiponectin [28,29], plasminogen activator-1 [30], Von Willebrand factor [31], endothelin-1 [32], homocysteine [33] and markers of oxidative stress [34], have shown that their association with PCOS is dependent upon co-existent obesity. 2.2. Clinical Women with PCOS are generally more obese than age matched controls, and have an elevation of both BMI and waist/hip ratio [35]. The expression of obesity in PCOS varies geographically, the obese phenotype being particularly common in the United States of America [3]. Obesity is associated with risk factors for atherosclerosis, such as hypertension, insulin resistance, dyslipidaemia and increased platelet activation [3638]. An android or central pattern of obesity, as evidenced by an elevated waist/hip ratio, is a signicant and independent cardiovascular risk factor. Longitudinal data also show that weight gain, especially accumulation of cen-

tral fat, contributes to the development of impaired glucose tolerance and type 2 diabetes [9]. The association between central obesity and cardiovascular disease in PCOS may be partly related to low plasma adiponectin levels, although this hypothesis has not yet been critically tested [39]. There have also been reports of a higher prevalence of obstructive sleep apnoea in women with PCOS compared with age and weight matched controls [40,41], which is likely to be related to coexisting factors such as central obesity and insulin resistance. Smoking is a major risk factor for cardiovascular disease, but information on its prevalence and signicance in women with PCOS is sparse. Whether the prevalence of hypertension is increased in women with PCOS is unclear. Studies, including those utilising 24-h ambulatory blood pressure monitoring techniques, have reported conicting results [30,4244]. The lack of signicant association with hypertension is surprising given the close link between PCOS and the metabolic syndrome. Pertinent studies have, however, utilised variable denitions of PCOS and employed a wide variety of techniques to assess blood pressure. In summary, there is evidence that multiple biochemical and clinical cardiovascular risk factors are increased in women with PCOS. It is, however, unclear whether this translates to increased rates of cardiovascular events, and specically whether PCOS and hyperandrogenaemia have an effect on cardiovascular risk independent of these coexisting factors. 2.3. Metabolic syndrome The metabolic syndrome is a clustering of factors known to increase the risk of diabetes and cardiovascular disease, and typically includes a combination of insulin resistance, central obesity, dyslipidaemia, hypertension and microalbuminuria [45,46]. The prevalence of the metabolic syndrome is probably increased in subjects with PCOS, and this is likely to represent the interaction of a genetic predisposition to insulin resistance, dyslipidaemia and hypertension with hyperandrogenaemia in the setting of visceral obesity [4749]. This may partly account for the clustering of cardiovascular risk factors within families of women with PCOS [50]. The prevalence of the individual components of the metabolic syndrome is greater than the fully established syndrome in PCOS. As indicated above, hypertension is less common than dyslipidaemia in PCOS. The prevalence of type 2 diabetes, another manifestation of the metabolic syndrome, is increased in PCOS and increases with age, being reported in up to 21% of 3540year-old women with PCOS [5]. South Asian women with PCOS are particularly prone to insulin resistance and diabetes [51]. Focusing on individual and traditional risk factors may be as important as establishing the diagnosis of the metabolic syndrome in young women to predict their future risk of cardiovascular disease [52]. Hence, cardiovascular risk may be underestimated in women with PCOS if the standard

230

A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239

composite diagnosis of the metabolic syndrome, rather than its individual components, is utilised to guide clinical intervention. The validity of employing the National Cholesterol Education Program Adult Treatment Panel III and World Health Organisation criteria to make the diagnosis of the metabolic syndrome in general has recently been strongly challenged [53], and it is likely that similar arguments could also apply to its use in the setting of PCOS. The new International Diabetes Federation denition of the metabolic syndrome may, however, address some but not all of these concerns [54].

In general, epidemiological studies of women with PCOS have been hampered by small sample sizes, relatively short periods of follow-up, use of highly selected clinic populations and potential confounding due to effects of treatments at baseline and changing clinical phenotype over time.

4. Studies of subclinical cardiovascular disease By contrast to the sparse epidemiological data, several studies of markers of subclinical disease have recently elucidated the relationship between PCOS and cardiovascular disease. These studies, which focus on the arterial wall and the myocardium, are summarized in Tables 2 and 3 and are discussed below.

3. Cardiovascular epidemiology of PCOS Although cardiovascular risk factors are more prevalent in women with PCOS, denitive evidence for an increased incidence of cardiovascular disease is lacking. Based on the calculated risk factor prole, Dahlgren et al. predicted a relative risk of myocardial infarction of 7.4 in a small group of women (n = 33) with histopathological evidence of polycystic ovaries (PCO) compared with aged-matched controls [43]. However, a retrospective cohort study from the United Kingdom found that while women (n = 345) with a history of PCOS, diagnosed primarily from ovarian morphology, had more cardiovascular risk factors, including diabetes, hypercholesterolaemia, hypertension and obesity, their mortality and morbidity from coronary heart disease did not differ from age-matched controls (n = 1060) [55]. This surprising nding could be ascribed to ascertainment bias, to use of a non-standard denition of PCOS, or possibly to a cardiovascular protective effect of hyperandrogenaemia. Nevertheless, the odds ratios for developing diabetes and cerebrovascular disease in this study were increased signicantly at 2.3 and 2.8, respectively, even after adjusting for BMI. A 10 year follow-up case-control study (n = 126 versus n = 142) from Pittsburgh showed that the odds ratio of a cardiovascular event in Caucasian women with PCOS, dened principally as hyperandrogenic chronic anovulation, was 5.91 [35]. The PCOS group were, however, more overweight than the reference population. Although a denitive diagnosis of PCOS was not used, the much larger Nurses Health Study reported that of 82,439 women 15% reported usually irregular or very irregular menses between the age of 20 and 35 years. Those with a history of menstrual irregularity or chronic anovulation had increased relative risk of fatal and non-fatal coronary heart disease of 1.25 and 1.67, respectively, after a 14-year followup [56]. That these risks were diminished after adjusting the BMI is consistent with the notion, suggested earlier, that obesity and insulin resistance may chiey mediate the increased coronary risk in women with PCOS. The risk of cardiovascular disease in PCOS may be greater with Southern Asian than Caucasian women owing to the formers heightened predisposition to insulin resistance and diabetes [51], but this remains to be demonstrated.

5. Functional studies 5.1. Ventricular function Left ventricular (LV) diastolic dysfunction is an early manifestation of diabetic cardiomyopathy [57], and has been shown to identify hypertensive patients at increased risk of cardiovascular events [58]. Its aetiology is multifactorial and relates to coronary artery disease, hypertension, autonomic neuropathy, microangiopathy, dyslipidaemia, insulin resistance, endothelial dysfunction and oxidative stress [59]. Specic myocardial mechanisms include altered cardiomyocyte substrate metabolism and bioenergetics, altered collagen metabolism, inammation and brosis [60]. In a case-control, echocardiographic study, women with PCOS were found to have an increased isovolumetric relaxation time (IVRT), an index of early LV diastolic dysfunction, and lower ejection fraction compared with weight matched controls [61] (Tiras et al., Table 2a column 1). A signicant direct relationship between plasma insulin levels and IVRT was demonstrated in the PCOS group. These ndings were consistent with another report showing an independent correlation between hyperinsulinaemia and LV mass [62] (Orio et al., Table 2a column 2). The existing studies support the hypothesis that insulin resistance may contribute to myocardial dysfunction in PCOS. Women with PCOS and diabetes mellitus could exhibit diastolic dysfunction owing to the mechanisms referred to earlier, which may account for the echocardiographic ndings reported to date. No studies have hitherto investigated the effect of PCOS on coronary blood ow or myocardial substrate utilisation. One would, however, predict impaired coronary ow reserve and decreased myocardial glucose utilisation in PCOS related to insulin resistance and type 2 diabetes [63]. 5.2. Arterial stiffness Arterial stiffness of the peripheral circulation is associated with increased systolic blood pressure, pulse pressure

Table 2 Summary of studies of cardiovascular function in PCOS Part a: Author Denition of PCOS Tiras et al. (1999) [61] Clinical and biochemical hyperandrogenism, oligomenorrhoea, and PCO on US 35 PCOS 35 controls Case-control Echocardiography Diastolic dysfunction Orio et al. (2004) [62] 1990 NIH criteria Kelly et al. (2002) [66] Biochemical hyperandrogenism and ovulatory dysfunction Lakhani et al. (2002) [67] PCO on ultrasound, plus hirsutism or menstrual irregularity 20 PCOS 20 PCO 20 controls Case-control Carotid ultrasound Increased arterial stiffness in PCOS and PCO Mather et al. (2000) [14] Oligomenorrhoea plus clinical and biochemical evidence of hyperandrogenism 18 PCOS 19 controls Case-control Flow mediated dilatation of brachial artery Normal endothelial function Orio et al. (2004) [71] 1990 NIH criteria

Study design

Technique employed Outcome in PCOS

30 PCOS 30 controls Case-control Echocardiography Increased LV mass, decreased LV ejection fraction and diastolic lling BMI, insulin resistance No

19 PCOS 12 controls Case-control Pulse wave velocity, myography Abnormal arterial stiffness and endothelial function

30 PCOS 30 controls case-control Flow mediated dilatation of brachial artery Abnormal endothelial function

A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239

Factors associated with outcome in PCOS Independent association with PCOS? Part b: Author Denition of PCOS

Basal and total insulin levels ?

? ?

? Yes

? No

Insulin resistance No

Kravariti et al. (2005) [72] 2003 Rotterdam criteria

Tarkun et al. (2004) [15] 2003 Rotterdam criteria

Diamanti-Kandarakis et al. (2005) [73] 1990 NIH criteria

Paradisi et al. (2001) [13] Menstrual irregularity and clinical and biochemical hyperandrogenism

Bickerton et al. (2005) [81] Menstrual irregularity, biochemical hyperandrogenism, PCO on ultrasound, and gonadotrophin abnormalities 11 PCOS 12 controls Case-control Forearm reactive hyperaemia No difference in endothelial function compared with controls Nil

Carmassi et al. (2005) [82] 1990 NIH criteria

Study design

62 PCOS 17 Control Case-control Flow mediated dilatation of brachial artery Abnormal endothelial function Insulin resistance, testosterone, total cholesterol ?

37 PCOS 25 controls Case-control Flow mediated dilatation of brachial artery Abnormal endothelial function C reactive protein, insulin resistance No

20 PCOS 20 control Case-control and intervention Flow mediated dilatation of brachial artery Abnormal endothelial function; improvement with metformin Fasting insulin; AUC glucose, testosterone ?

12 PCOS 13 controls Case-control Leg blood ow responses Abnormal endothelial function Testosterone, Body mass index No

16 PCOS 6 controls Case-control Intra-arterial insulin infusion Abnormal insulin induced vasodilation in PCOS Insulin resistance

Technique employed Outcome in PCOS

Factors associated with Outcome in PCOS Independent association with PCOS?

No

231

232

Table 3 Summary of studies of cardiovascular structure IN PCOS Author Denition of PCOSa Guzick et al. (1996) [83] Chronic anovulation, and clinical or biochemical hyperandrogenism or LH:FSHb >2 16 PCOS 16 Controls Case-control Carotid IMTd Talbott et al. (2000) [84] Chronic anovulation, and clinical or biochemical hyperandrogenism or LH:FSH >2 125 PCOS 142 Controls Case-control Carotid IMT and plaque count Orio et al. (2004) [71] Vural et al. (2005) [85] 1990 NIHc criteria 2004 Rotterdam criteria Christian et al. (2003) [87] 1990 NIH criteria Talbott et al. (2004) [49] Chronic anovulation, and clinical or biochemical hyperandrogenism or LH:FSH >2 61 PCOS 85 Controls Case-control Electron beam computed tomography of coronary arteries and aorta Increased coronary artery and aortic calcication 1. Coronary artery calcication: Age, BMI, waist circumference, triglycerides, HDLg , insulin, blood pressure 2. Aortic calcication: as for 1. plus testosterone and fasting glucose No A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239

study design

30 PCOS 30 Controls Case-control Carotid IMT

43 PCOS 43 Controls Case-control Carotid IMT

36 PCOS 71 Controls Case-control Electron beam computed tomography of coronary arteries Increased coronary artery calcication BMI, total cholesterol, LDLf , triglycerides

Technique employed

Outcome in PCOS

Increased IMT

Factors associated with outcome in PCOS

BMIe , insulin, total cholesterol, LDL

Premature carotid atherosclerosis in PCOS plus increased IMT in PCOS group >45yo BMI, insulin, age, waist:hip ratio, blood pressure, triglycerides.

Increased IMT

Increased IMT

Free androgen index

BMI Low sex hormone binding globulin

Independent association with PCOS?

a b c d e f g

No

No

No

Yes

No

Polycystic ovary syndrome. Luteinising hormone:follicle stimulating hormone ratio. National Institutes for Health. Intima-medial thickness. Body mass index. Low density lipoprotein. High density lipoprotein.

A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239

233

and ventricular load, as well as with decreased diastolic perfusion of the coronary circulation. Arterial stiffness may be assessed by ultrasonographic estimation of carotid artery distensibility, by measuring pulse wave velocity (PWV), or by analysis of the diastolic component of the radial waveform [64]. In certain patient groups, such as those with renal failure, increased arterial stiffness has been shown to predict cardiovascular events [65]. In a small case-control study, Kelly et al. reported increased pulse wave velocity of the brachial artery, but not of the aorta, in a PCOS group [66] (Kelly et al., Table 2a column 3). Similarly, Lakhani et al. demonstrated increased stiffness of both internal and external carotid arteries in woman with both PCOS and PCO (ultrasonographic polycystic ovaries alone) compared with controls [67] (Lakhani et al., Table 2a column 4). Multivariate analysis suggested independent effects of PCOS and PCO on arterial stiffness. That this study did not show an independent relationship between insulin resistance or other cardiovascular risk factors and arterial stiffness could, however, be due its small sample size. In a study of 80 obese women with PCOS Meyer et al. found a signicant relationship between PWV and blood pressure and between PWV and both insulin and glucose during a glucose tolerance test [68]. The mechanism for increased arterial stiffness reported in some studies of PCOS remains unclear but, as in the metabolic syndrome and insulin resistance, may involve endothelial dysfunction and altered artery wall collagen metabolism. 5.3. Endothelial function Endothelial function of both conduit and resistance arteries is the surrogate cardiovascular endpoint most widely studied in PCOS. Endothelial dysfunction signies not only impaired arterial vasodilatation, but also increased arterial stiffness, hypertension, increased haemostasis and dysbrinolysis and increased vascular oxidative stress. It is causally connected to uncoupling of endothelial nitric oxide synthase (ecNOS) due to stoichiometric imbalance between l-arginine, NADPH and tetrahydrobiopterin, collectively impairing synthesis of nitric oxide (NO). Endothelial dysfunction may also involve increased endothelial cell secretion of the potent vasoconstrictors endothelin-I and/or angiotensin II. Increased vascular oxidative stress due to stimulation of NADPH oxidase and uncoupling of mitochondrial oxidative phosphorylation also contribute to the pathobiology of NO [69]. The foregoing molecular mechanisms collectively account for the endothelial dysfunction reported in subjects with PCOS, as discussed below. 5.3.1. Conduit arteries: macrovascular endothelial function Endothelial dysfunction is an early event in the evolution of atherosclerosis, preceding plaque formation and clinical disease. Measurement of post-ischaemic ow medi-

ated dilatation (FMD) of the brachial artery with highresolution ultrasonography is an established method to assess endothelial function of conduit arteries. FMD is chiey mediated by the abluminal release of the potent vasodilator NO [70]. Mather et al. used FMD of the brachial artery to assess endothelium-dependent vascular function in PCOS [14] (Mather et al., Table 2a, column 5). In spite of signicant differences in plasma lipids, androgen status, body weight and insulin resistance between the cases and controls there was no evidence of impaired endothelial function in the women with PCOS. In particular there was no signicant association between insulin resistance or androgen status and FMD of the brachial artery. By contrast, Orio et al. found impaired FMD of the brachial artery in normal weight PCOS subjects compared with controls [71] (Orio et al., Table 2a, column 6). However, specic evidence of endothelium-dependent shear-stress induced vasodilatory dysfunction (rather than an abnormality at the level of the smooth muscle) could not be inferred from this study, as GTN-mediated dilatation was not assessed. The PCOS subjects had higher plasma androgens, and higher fasting and glucose-stimulated plasma insulin levels. In this study, direct and independent associations were found between impaired FMD and insulin resistance. These ndings are supported by the data from Kravariti et al. using similar techniques [72] (Kravariti et al., Table 2b, column 1). This study did, however, use nitrate-mediated dilatation to demonstrate that the abnormal FMD seen in these subjects was endothelium-dependent. In addition to an association with insulin resistance, this study found total testosterone and total cholesterol to be independent predictors of FMD. These studies therefore suggest that the hyperinsulinaemia of PCOS, and possibly hyperandrogenaemia, can inuence endothelial function of conduit arteries. Tarkun et al. also found signicant differences in both endothelium-dependent and independent vasodilator responses of the brachial artery between PCOS and control subjects using a similar vascular technique [15] (Tarkun et al., Table 2b, column 2). Impaired endothelium-dependent vasodilatation was found to be correlated with insulin resistance and high sensitivity C-reactive protein levels, but not with plasma testosterone levels, challenging the contribution of hyperandrogenaemia to endothelial dysfunction in conduit arteries. These more recent studies contradict the earlier results of Mather et al., despite all studies employing similar diagnostic criteria for PCOS. Mather et al. based their ndings on a smaller sample size and on PCOS cases with plasma HDL levels that did not differ from controls and may have therefore had a lesser degree of insulin resistance than subjects in the other studies. A study from Diamanti-Kandarakis et al. supports the importance of insulin resistance in the endothelial dysfunction seen in PCOS [73] (Diamanti-Kandarakis et al., Table 2b, column 3). This study demonstrates not only that there is

234

A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239

impairment of endothelial dysfunction in PCOS but also that it is reversed by metformin therapy. On balance the weight of evidence from studies of conduit arteries supports the presence of endothelial dysfunction in women with PCOS and a link with insulin resistance. Insulin resistance may contribute to endothelial dysfunction of conduit arteries by diverse mechanisms that affect the biology of NO [74]. Classically, insulin resistance due to impaired phosphatidyl 3-kinase and Akt signalling decreases the activation of ecNOS and release of NO [75]. Elevated cellular free fatty acids, increased redox potential due to accumulated NAPH, and deciency in tetrahydrobiopterin could contribute to ecNOS uncoupling with decreased formation of NO and over production of the pro-oxidant, peroxynitrite [76]. We propose that these molecular mechanisms operate in concert to induce endothelial dysfunction related to the insulin resistance of PCOS. Whether hyperandrogenaemia contributes to uncoupling of ecNOS and increased vascular oxidative stress remains unknown. 5.3.2. Resistance arteries: microvascular endothelial function Invasive studies employing other methodologies, such as intra-arterial infusion of vasoactive agents with thermodilutional or plethysmographic assessment of limb blood ow, have also shown endothelial dysfunction of the microcirculation and resistance vessels in PCOS. By contrast to the brachial artery, vasodilatation of the forearm in response to vasoactive stimuli (e.g. acetylcholine) may also involve a signicant component attributed to the endothelial release of endothelium-derived hyperpolarizing factor [77,78]. Paradisi et al. reported that compared with controls women with PCOS had impaired leg blood ow (LBF) responses to methacholine and to hyperinsulinaemia during a euglycaemic clamp [13] (Paradisi et al., Table 2b, column 4). LBF was measured by an intravenous thermodilution catheter. That LBF response to sodium nitroprusside, an endothelium independent vasodilator, was not assessed meant that the demonstrated defect could not necessarily be localised to the endothelial cell as opposed to smooth muscle. Endothelial dysfunction was positively correlated with the degree of insulin resistance and with plasma free testosterone levels. Using the same techniques, Paradisi et al. also found an improvement of endothelial function after 3 months of treatment with troglitazone, a thiazolidinedione, in PCOS women compared with controls [79]. The improvement in endothelial function was associated with a decrease in insulin resistance, testosterone, and plasminogen activator inhibitor 1 levels. The effects of glitazones on endothelial function may, however, be independent of improvement in insulin resistance and involve a PPAR effect on the expression of ecNOS [80]. Resistance to the vasodilator effects of insulin in PCOS was conrmed by Kelly et al. in an ex vivo study that measured the contractile response of gluteal resistance arteries to noradrenaline before and after incubation with insulin [66] (Kelly et al., Table 2a, column 3). Ex vivo studies,

however, do not strictly represent changes in the whole body model. In contrast, Bickerton et al. found no differences in reactive hyperaemia of the forearm microcirculation, measured by standard occlusion plethysmography, between PCOS women and age/weight matched controls [81] (Bickerton et al., Table 2b, column 5). This arterial response is less reective of endothelial function, being dependent not only on NO, but also on the release of prostaglandins, the opening of potassium channels, changes in pH, and on smooth muscle tone. However, the study groups might also not have had a comparable level of insulin resistance, which would have confounded interpretation of the data. This is made clearer by the study of Carmassi et al. measuring forearm vasodilatation mediated by intra-arterial insulin infusion in PCOS women with and without insulin resistance [82] (Carmassi et al., Table 2b, column 6). This study demonstrated that insulin resistance rather than PCOS confers endothelial dysfunction in this vascular bed. In aggregate, the above studies of arterial dilatory function clearly point to the presence of endothelial dysfunction in different arterial beds in PCOS and to a close association of endothelial dysfunction with insulin resistance and a less consistent one with hyperandrogenaemia. Similar mechanisms probably account for the impact of insulin resistance on the biology of NO in both conduit and resistance arteries in women with PCOS.

6. Morphological studies 6.1. Carotid wall thickness CIMT has been shown in several studies to predict cardiovascular events, with increasing CIMT associated with an elevated age-adjusted cardiovascular risk [64]. Guzick et al. assessed women with PCOS and controls using carotid ultrasonography and found increased CIMT in the PCOS group [83] (Guzick et al., Table 3, column 1). This nding was independent of dyslipidaemia but not obesity or plasma insulin levels. Talbott et al., however, reported that CIMT values were only different in older PCOS subjects compared with controls, and after adjusting for coexisting cardiovascular risk factors PCOS was not a signicant predictor of CIMT [84] (Talbott et al., Table 3, column 2). They also reported a signicantly greater carotid plaque index in the PCOS subjects compared with controls. These observations suggest that in women with PCOS subclinical atherosclerosis may not manifest until the perimenopause. More recently, two studies have demonstrated a significant difference in CIMT between young, normal weight PCOS women compared with controls [71] (Orio et al., Table 3, column 3; Vural et al., Table 3, column 4). Vural et al. found that PCOS, BMI and a reduced sex hormone binding globulin were all independent predictors of CIMT, which again suggests an effect of insulin resistance [85]. In the study by Orio et al., multivariate analyses revealed

A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239

235

a direct correlation between CIMT and the free androgen index, suggesting a contribution of hyperandrogenaemia to progression of atherosclerosis in PCOS. By contrast, in a larger study increased CIMT was inversely correlated in multivariate analysis with plasma DHEAS and androstenedione levels, suggesting an intriguing vasculoprotective effect of hyperandrogenaemia in PCOS [86]. However, in this study a strong independent positive association was also found with lower plasma high density lipoprotein cholesterol, indication an opposing aggravating effect of dyslipidaemia and by implication insulin resistance. A vasculoprotective effect of DHEAS was also suggested by Meyer et al. in a study of 80 obese women with PCOS, where higher DHEAS corresponded to signicantly lower CIMT [68]. Whether elevated DHEAS actually benets atherogenesis in PCOS, however, requires further research in different subtypes of this condition. 6.2. Arterial calcication Coronary artery calcication reects the underlying degree of atherosclerosis and is predictive of clinical events. In the coronary circulation, electron beam computer tomography has been employed to demonstrate increased arterial calcication in PCOS women compared with controls [87] (Christian et al., Table 3, column 5). After adjusting for BMI, dyslipidaemia remained a positive predictor of coronary calcication. Talbott et al. reported an interesting prospective, case-control study showing an increased incidence of coronary and aortic arterial calcication over a 9 year follow-up period in women with PCOS [49] (Talbott et al., Table 3, column 6). The degree of calcication was dependent on features of the metabolic syndrome, including central obesity, elevated blood pressure and dyslipidaemia, and hence insulin resistance. In that study, the degree of aortic calcication was also positively related to plasma testosterone levels, questioning a putative atheroprotective role of hyperandrogenaemia in PCOS. These reports are complemented with angiographic data in women showing an association between coronary artery disease and polycystic ovaries [88]. The foregoing reports of arterial calcication collectively demonstrate that women with PCOS have morphological evidence of coronary atherosclerosis and that insulin resistance in particular, rather than PCOS per se, is the major causal factor. By contrast to the morphological changes reviewed, endothelial dysfunction is more likely to be a feature of the vasculopathy of young women with PCOS.

7. Conclusions and future perspectives While the epidemiology is inconclusive, recent surrogate endpoint studies strongly support an association between PCOS and cardiovascular disease. Discrepancies amongst some studies reviewed to generate this notion may be due

to small sample sizes, bias in case-control designs and use of non-standard denitions of PCOS. The evidence, based solely on association studies to date, indicates that insulin resistance and obesity may be the mediators of early ventricular abnormalities, endothelial dysfunction, arterial stiffness, and both carotid and coronary atherosclerosis. The mechanisms likely relate to the consequences of insulin resistance. These include dyslipoproteinaemia, hypertension, increased oxidative stress, low-grade inammation, altered haemostasis and dysbrinolysis, as well as alterations in myocardial energetics and collagen turnover. Uncoupling of ecNOS activity with decreased production of NO and overgeneration of peroxinitrite is probably a central event in initiating the endothelial dysfunction and atherothrombosis. The role of hyperandrogenaemia in contributing to the cardiovascular abnormalities reviewed remains unclear and controversial. Although androgens may have been proposed as factors in cardiovascular risk in PCOS, the minority of studies reviewed showed an independent association of androgens with impaired cardiovascular structure or function. This further reinforces the view that cardiovascular risk in PCOS resides in insulin resistance rather than hyperandrogenaemia. Moreover, the pro-atherogenic effect of androgens is not supported by observational and clinical studies in women in general. In PCOS, androgens, particularly DHEAS, have been negatively correlated with CIMT. An hypothesis for the pathogenesis of cardiovascular disease in PCOS based on the data reviewed and allowing sequential and interactive effects of genetic factors is depicted in Fig. 1. This gure summarises potential pathways through which the cardiovascular risk factors associated with PCOS may translate in to clinical cardiovascular disease. A nal common path prior to the expression of clinical disease for the risk factors associated with PCOS centres on oxidative stress, inammation and endothelial dysfunction, which then induce physical and morphological changes, such as arterial and ventricular stiffness and atherosclerosis [89]. Prospective clinical endpoint studies, however, are required to verify the hypothetic scheme shown in Fig. 1. In spite of the presence of these cardiovascular risk factors in women with PCOS, there are currently no adequate prospective outcome data documenting the real prevalence of cardiovascular events in women with PCOS. From a clinical perspective, we suggest that physicians should continue to identify cardiovascular risk factors in women with PCOS and treat these accordingly [90]. This accounts for the heightened risk of diabetes and cardiovascular disease with increasing age in these women. Screening for insulin resistance, using a fasting plasma glucose:insulin ratio, and impaired glucose tolerance, using an oral glucose tolerance test, afford earlier opportunities to prevent the development of diabetes. Prevention and reversal of weight gain and obesity through prudent diet and regular exercise, and treatment of dyslipidaemia are crucial. Specic pharmacological treatments that improve insulin resistance and

236

A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239

Fig. 1. Hypothetical scheme for the pathogenesis of cardiovascular disease in PCOS. This gure summarises potential pathways through which the cardiovascular risk factors associated with PCOS may translate into clinical cardiovascular disease. This scheme is hypothetical, however, and while supported by valid a priori studies requires examination and verication in prospective clinical outcome studies.

dysglycaemia, such as metformin [91], thiazolidinediones [92] and acarbose [93], may be warranted in at risk women given that these agents also benet ovulatory function and androgen abnormalities. However, their impact on the development of diabetes and cardiovascular events in women with PCOS remains to be investigated. From an investigational angle, there are multiple avenues for research. First, there is a need for more rigorous prospective studies of cardiovascular outcomes in PCOS, with better denition of baseline variables, including measures of insulin resistance, hyperandrogenaemia and vascular function. Long-term cohort studies are particularly needed in young women with PCOS. These studies should be of large sample size sufcient to investigate the roles of per-

tinent genes, including those regulating, for instance, dyslipidaemia, oxidative stress, the renin-angiotensin-aldosterone system and the biology of NO. Second, based on these studies additional diagnostic criteria for PCOS should be dened to identify subtypes, particularly those at risk of cardiovascular disease, including those with particular adverse metabolic and cardiovascular phenotypes. Third, short-term trials of pertinent interventions, for example lipid regulators, antioxidants, and insulin sensitisers, on surrogate cardiovascular outcomes are warranted to generate new hypotheses for testing in clinical endpoint studies. These should include the impact of the most commonly used therapeutic interventions in PCOS, the oral contraceptive pill and anti-androgen therapy, since their effect on cardiovascular events remains

A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239

237

unknown. Fourth, large-scale clinical outcome trials should be designed based on the initial ndings of epidemiological and vascular studies. In sum, in our view the high incidence of PCOS in women of reproductive age and its implications for cardiovascular health make future research in this area a priority from both public health and clinical perspectives.

Acknowledgement Dr. Andrea Cussons is supported by a postgraduate research scholarship from the National Health and Medical Research Council of Australia.

References
[1] The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus Statement: Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004;81:1925. [2] Zawadski JK, Dunaif A. Diagnostic criteria for polycystic ovary syndrome: towards a rational approach. In: Dunaif A, Givens JR, Haseltine FP, Merriam GR, editors. Polycystic ovary syndrome. Boston: Blackwell; 1992. p. 33784. [3] Knochenhauer ES, Key TJ, Kahsar-Miller M, et al. Prevalence of the polycystic ovary syndrome in unselected black and white women of the southeastern United States: a prospective study. J Clin Endocrinol Metab 1998;83:307882. [4] Talbott E, Clerici A, Berga SL, et al. Adverse lipid and coronary heart disease risk proles in young women with polycystic ovary syndrome: results of a case-control study. J Clin Epidemiol 1998;51:41522. [5] Legro RS, Kunselman AR, Dodson WC, Dunaif A. Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. J Clin Endocrinol Metab 1999;84:1659. [6] Rebuffe-Scrive M, Cullberg G, Lundberg PA, Lindstedt G, Bjorntorp P. Anthropometric variables and metabolism in polycystic ovarian disease. Horm Metab Res 1989;21:3917. [7] Dunaif A, Segal KR, Futterweit W, Dobrjansky A. Profound peripheral insulin resistance, independent of obesity, in polycystic ovary syndrome. Diabetes 1989;38:116574. [8] Legro RS, Kunselman AR, Dunaif A. Prevalence and predictors of dyslipidemia in women with polycystic ovary syndrome. Am J Med 2001;111:60713. [9] Norman RJ, Masters L, Milner CR, Wang JX, Davies MJ. Relative risk of conversion from normoglycaemia to impaired glucose tolerance or non-insulin dependent diabetes mellitus in polycystic ovarian syndrome. Hum Reprod 2001;16:19958. [10] Burghen GA, Givens JR, Kitabchi AE. Correlation of hyperandrogenism with hyperinsulinism in polycystic ovarian disease. J Clin Endocrinol Metab 1980;50:1136. [11] Nestler JE, Jakubowicz DJ, de Vargas AF, et al. Insulin stimulates testosterone biosynthesis by human thecal cells from women with polycystic ovary syndrome by activating its own receptor and using inositolglycan mediators as the signal transduction system. J Clin Endocrinol Metab 2001;83:20015. [12] Rizza RA. Androgen effect on insulin action and glucose metabolism. Mayo Clin Proc 2000;75:s614. [13] Paradisi G, Steinberg HO, Hemping A, et al. Polycystic ovary syndrome is associated with endothelial dysfunction. Circulation 2001;103:14105.

[14] Mather KJ, Verma S, Corenblum B, Anderson TJ. Normal endothelial function despite insulin resistance in healthy women with the polycystic ovary syndrome. J Clin Endocrinol Metab 2000;85:18516. [15] Tarkun I, Arslan BC, Canturk Z, et al. Endothelial dysfunction in young women with polycystic ovary syndrome: relationship with insulin resistance and low-grade chronic inammation. J Clin Endocrinol Metab 2004;89:55926. [16] Petrie JR, Ueda S, Webb DJ, Elliott HL, Connell JM. Endothelial nitric oxide production and insulin sensitivity. A physiological link with implications for pathogenesis of cardiovascular disease. Circulation 1996;93:13313. [17] Baron AD. Insulin resistance and vascular function. J Diabetes Complications 2002;16:92102. [18] Wu FC, von Eckardstein A. Androgens and coronary artery disease. Endocr Rev 2003;24:183217. [19] Liu PY, Death AK, Handelsman DJ. Androgens and cardiovascular disease. Endocr Rev 2003;24:31340. [20] Barrett-Connor E, Goodman-Gruen D. Prospective study of endogenous sex hormones and fatal cardiovascular disease in postmenopausal women. BMJ 1995;311:11936. [21] Bernini GP, Sgro M, Moretti A, et al. Endogenous androgens and carotid intimal-medial thickness in women. J Clin Endocrinol Metab 1999;84:200812. [22] van Kesteren PJ, Asscheman H, Megens JA, Gooren LJ. Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Clin Endocrinol 1997;47:33742. [23] Adams MR, Williams JK, Kaplan JR. Effects of androgens on coronary artery atherosclerosis and atherosclerosis-related impairment of vascular responsiveness. Arterioscler Thromb Vasc Biol 1995;15:56270. [24] Rajkhowa M, Neary RH, Kumpatla P, et al. Altered composition of high density lipoproteins in women with the polycystic ovary syndrome. J Clin Endocrinol Metab 1997;82:3389 94. [25] Kelly CC, Lyall H, Petrie JR, et al. Low grade chronic inammation in women with polycystic ovarian syndrome. J Clin Endocrinol Metab 2001;86:24535. [26] Boulman N, Levy Y, Leiba R, et al. Increased C-reactive protein levels in the polycystic ovary syndrome: a marker of cardiovascular disease. J Clin Endocrinol Metab 2004;89:21605. [27] Mohlig M, Spranger J, Osterhoff M, et al. The polycystic ovary syndrome per se is not associated with increased chronic inammation. Eur J Endocrinol 2004;150:52532. [28] Panidis D, Kourtis A, Farmakiotis D, et al. Serum adiponectin levels in women with polycystic ovary syndrome. Hum Reprod 2003;18:17906. [29] Spranger J, Mohlig M, Wegewitz U, et al. Adiponectin is independently associated with insulin sensitivity in women with polycystic ovary syndrome. Clin Endocrinol 2004;61:73846. [30] Sampson M, Kong C, Patel A, Unwin R, Jacobs HS. Ambulatory blood pressure proles and plasminogen activator inhibitor (PAI1) activity in lean women with and without the polycystic ovary syndrome. Clin Endocrinol 1996;45:6239. [31] Dahlgren E, Janson PO, Johansson S, et al. Hemostatic and metabolic variables in women with polycystic ovary syndrome. Fertil Steril 1994;61:45560. [32] Diamanti-Kandarakis E, Spina G, Kouli C, Migdalis I. Increased endothelin-1 levels in women with polycystic ovary syndrome and the benecial effect of metformin therapy. J Clin Endocrinol Metab 2001;86:466673. [33] Loverro G, Lorusso F, Mei L, et al. The plasma homocysteine levels are increased in polycystic ovary syndrome. Gynecol Obstet Invest 2002;53:15762. [34] Sabuncu T, Vural H, Harma M. Oxidative stress in polycystic ovary syndrome and its contribution to the risk of cardiovascular disease. Clin Biochem 2001;34:40713.

238

A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239 [54] Alberti KG, Zimmet P, Shaw J, IDF Epidemiology Task Force Consensus Group. The metabolic syndromea new worldwide definition. Lancet 2005;366:105962. [55] Wild S, Pierpoint T, McKeigue P, Jacobs H. Cardiovascular disease in women with polycystic ovary syndrome at long-term follow-up: a retrospective cohort study. Clin Endocrinol 2000;52:595600. [56] Solomon CG, Hu FB, Dunaif A, et al. Menstrual cycle irregularity and risk for future cardiovascular disease. J Clin Endocrinol Metab 2002;87:20137. [57] Schannwell CM, Schneppenheim M, Perings S, Plehn G, Strauer BE. Left ventricular diastolic dysfunction as an early manifestation of diabetic cardiomyopathy. Cardiology 2002;98:339. [58] Schillaci G, Pasqualini L, Verdecchia P, et al. Prognostic signicance of left ventricular diastolic dysfunction in essential hypertension. J Am Coll Cardiol 2002;39:200511. [59] Brutsaert DL, Sys SU, Gillebert TC. Diastolic failure: pathophysiology and therapeutic implications. J Am Coll Cardiol 1993;22:31825. [60] Watts GF, Marwick TH. Ventricular dysfunction in early diabetic heart disease: detection, mechanisms and signicance. Clin Sci (Lond) 2003;105:53740. [61] Tiras MB, Yalcin R, Noyan V, et al. Alterations in cardiac ow parameters in patients with polycystic ovarian syndrome. Hum Reprod 1999;14:194952. [62] Orio FJ, Palomba S, Spinelli L, et al. The cardiovascular risk of young women with polycystic ovary syndrome: an observational, analytical, prospective case-control study. J Clin Endocrinol Metab 2004;89:3696701. [63] Iozzo P, Chareonthaitawee P, Dutka D, et al. Independent association of type 2 diabetes and coronary artery disease with myocardial insulin resistance. Diabetes 2002;51:30204. [64] Bots ML, Dijk JM, Oren A, Grobbee DE. Carotid intima-media thickness, arterial stiffness and risk of cardiovascular disease: current evidence. J Hypertens 2002;20:231725. [65] London GM, Marchais SJ, Guerin AP. Arterial stiffness and function in end-stage renal disease. Adv Chronic Kidney Dis 2004;11:2029. [66] Kelly CJ, Speirs A, Gould GW, et al. Altered vascular function in young women with polycystic ovary syndrome. J Clin Endocrinol Metab 2002;87:7426. [67] Lakhani K, Constantinovici N, Purcell WM, Fernando R, Hardiman P. Internal carotid artery haemodynamics in women with polycystic ovaries. Clin Sci (Lond) 2000;98:6615. [68] Meyer C, McGrath BP, Cameron J, Kotsopoulos D, Teede HJ. Vascular dysfunction and metabolic parameters in polycystic ovary syndrome. J Clin Endocrinol Metab 2005;90:46305. [69] Chew GT, Watts GF. Coenzyme Q10 and diabetic endotheliopathy: oxidative stress and the recoupling hypothesis. Qjm 2004;97:53748. [70] Celermajer DS, Sorensen KE, Gooch VM, et al. Non-invasive detection of endothelial dysfunction in children and adults at risk of atherosclerosis. Lancet 1992;340:11115. [71] Orio FJ, Palomba S, Cascella T, et al. Early impairment of endothelial structure and function in young normal-weight women with polycystic ovary syndrome. J Clin Endocrinol Metab 2004;89:458893. [72] Kravariti M, Naka KK, Kalantaridou SN, et al. Predictors of endothelial dysfunction in young women with polycystic ovary syndrome. J Clin Endocrinol Metab 2005;90:508895. [73] Diamanti-Kandarakis E, Alexandraki K, Protogerou A, et al. Metformin administration improves endothelial function in women with polycystic ovary syndrome. Eur J Endocrinol 2005;152:74956. [74] Yki-Jarvinen H. Insulin resistance and endothelial dysfunction. Best Pract Res Clin Endocrinol Metab 2003;17:41130. [75] Steinberg HO, Baron AD. Vascular function, insulin resistance and fatty acids. Diabetologia 2002;45:62334. [76] Katusic ZS. Vascular endothelial dysfunction: does tetrahydrobiopterin play a role? Am J Physiol Heart Circ Physiol 2001;281: H9816.

[35] Talbott E, Guzick D, Clerici A, et al. Coronary heart disease risk factors in women with polycystic ovary syndrome. Arterioscler Thromb Vasc Biol 1995;15:8216. [36] Dalton M, Cameron AJ, Zimmet PZ, et al. Waist circumference, waist-hip ratio and body mass index and their correlation with cardiovascular disease risk factors in Australian adults. J Intern Med 2003;254:55563. [37] Despres JP, Moorjani S, Lupien PJ, et al. Regional distribution of body fat, plasma lipoproteins, and cardiovascular disease. Arteriosclerosis 1990;10:497511. [38] Davi G, Guagnano MT, Ciabattoni G, et al. Platelet activation in obese women: role of inammation and oxidant stress. JAMA 2002;288:200814. [39] Nishizawa H, Shimomura I, Kishida K, et al. Androgens decrease plasma adiponectin, an insulin-sensitizing adipocyte-derived protein. Diabetes 2002;51:273441. [40] Fogel RB, Malhotra A, Pillar G, et al. Increased prevalence of obstructive sleep apnea syndrome in obese women with polycystic ovary syndrome. J Clin Endocrinol Metab 2001;86:117580. [41] Vgontzas AN, Legro RS, Bixler EO, et al. Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: role of insulin resistance. J Clin Endocrinol Metab 2001;86:51720. [42] Conway GS, Agrawal R, Betteridge DJ, Jacobs HS. Risk factors for coronary artery disease in lean and obese women with the polycystic ovary syndrome. Clin Endocrinol 1992;37:11925. [43] Dahlgren E, Janson PO, Johansson S, Lapidus L, Oden A. Polycystic ovary syndrome and risk for myocardial infarction. Evaluated from a risk factor model based on a prospective population study of women. Acta Obstet Gynecol Scand 1992;71:599604. [44] Holte J, Gennarelli G, Berne C, Bergh T, Lithell H. Elevated ambulatory day-time blood pressure in women with polycystic ovary syndrome: a sign of a pre-hypertensive state? Hum Reprod 1996;11:238. [45] Expert Panel on Detection Evaluation and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285:248697. [46] Alberti KG, Zimmet PZ. Denition, diagnosis and classication of diabetes mellitus and its complications. Part 1: diagnosis and classication of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998;15:53953. [47] Glueck CJ, Papanna R, Wang P, Goldenberg N, Sieve-Smith L. Incidence and treatment of metabolic syndrome in newly referred women with conrmed polycystic ovarian syndrome. Metabolism 2003;52:90815. [48] Faloia E, Canibus P, Gatti C, et al. Body composition, fat distribution and metabolic characteristics in lean and obese women with polycystic ovary syndrome. J Endocrinol Invest 2004;27:4249. [49] Talbott EO, Zborowski JV, Rager JR, et al. Evidence for an association between metabolic cardiovascular syndrome and coronary and aortic calcication among women with polycystic ovary syndrome. J Clin Endocrinol Metab 2004;89:545461. [50] Fox R. Prevalence of a positive family history of type 2 diabetes in women with polycystic ovarian disease. Gynecol Endocrinol 1999;13:3903. [51] Wijeyaratne CN, Balen AH, Barth JH, Belchetz PE. Clinical manifestations and insulin resistance (IR) in polycystic ovary syndrome (PCOS) among South Asians and Caucasians: is there a difference? Clin Endocrinol 2002;57:34350. [52] Daviglus ML, Stamler J, Pirzada A, et al. Favorable cardiovascular risk prole in young women and long-term risk of cardiovascular and all-cause mortality. JAMA 2004;292:158892. [53] Kahn R, Buse J, Ferrannini E, Stern M. The metabolic syndrome: time for a critical appraisal: joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2005;28:2289304.

A.J. Cussons et al. / Atherosclerosis 185 (2006) 227239 [77] Mullen MJ, Kharbanda RK, Cross J, et al. Heterogenous nature of ow-mediated dilatation in human conduit arteries in vivo: relevance to endothelial dysfunction in hypercholesterolemia. Circ Res 2001;88:14551. [78] Playford DA, Watts GF. Non-invasive measurement of endothelial function. Clin Exp Pharmacol Physiol 1998;25:6403. [79] Paradisi G, Steinberg HO, Shepard MK, Hook G, Baron AD. Troglitazone therapy improves endothelial function to near normal levels in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2003;88:57680. [80] Calnek DS, Mazzella L, Roser S, Roman J, Hart CM. Peroxisome proliferator-activated receptor gamma ligands increase release of nitric oxide from endothelial cells. Arterioscler Thromb Vasc Biol 2003;23:527. [81] Bickerton AS, Clark N, Meeking D, et al. Cardiovascular risk in women with polycystic ovarian syndrome (PCOS). J Clin Pathol 2005;58:1514. [82] Carmassi F, Negri FD, Fioriti R, et al. Insulin resistance causes impaired vasodilation and hypobrinolysis in young women with polycystic ovary syndrome. Thromb Res 2005;116:20714. [83] Guzick DS, Talbott EO, Sutton-Tyrrell K, et al. Carotid atherosclerosis in women with polycystic ovary syndrome: initial results from a case-control study. Am J Obstet Gynecol 1996;174:12249. [84] Talbott EO, Guzick DS, Sutton-Tyrrell K, et al. Evidence for association between polycystic ovary syndrome and premature carotid atherosclerosis in middle-aged women. Arterioscler Thromb Vasc Biol 2000;20:241421. [85] Vural B, Caliskan E, Turkoz E, Kilic T, Demirci A. Evaluation of metabolic syndrome frequency and premature carotid atherosclero-

239

[86]

[87]

[88]

[89]

[90]

[91]

[92]

[93]

sis in young women with polycystic ovary syndrome. Hum Reprod 2005;20:240913. Vryonidou A, Papatheodorou A, Tavridou A, et al. Association of hyperandrogenemic and metabolic phenotype with carotid intimamedia thickness in young women with polycystic ovary syndrome. J Clin Endocrinol Metab 2005;90:27406. Christian RC, Dumesic DA, Behrenbeck T, et al. Prevalence and predictors of coronary artery calcication in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2003;88:25628. Birdsall MA, Farquhar CM, White HD. Association between polycystic ovaries and extent of coronary artery disease in women having cardiac catheterization. Ann Intern Med 1997;126:325. Beckman JA, Creager MA, Libby P. Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA 2002;287:257081. Mosca L, Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women. J Am Coll Cardiol 2004;43:90021. Lord JM, Flight IH, Norman RJ. Metformin in polycystic ovary syndrome: systematic review and meta-analysis. BMJ 2003;327: 9513. Romualdi D, Guido M, Ciampelli M, et al. Selective effects of pioglitazone on insulin and androgen abnormalities in normo- and hyperinsulinaemic obese patients with polycystic ovary syndrome. Hum Reprod 2003;18:12108. Ciotta L, Calogero AE, Farina M, et al. Clinical, endocrine and metabolic effects of acarbose, an alpha-glucosidase inhibitor, in PCOS patients with increased insulin response and normal glucose tolerance. Hum Reprod 2001;16:206672.