Download Recognizing Women at Risk for Developing Coronary

Recognizing Women at Risk for
Developing Coronary
Heart Disease
Jean McSweeney, PhD, RN, FAHA, FAAN
Interim Dean, Associate Dean for Research
College of Nursing
University of Arkansas for Medical Sciences
Key Facts
Cardiovascular Diseases (CVDs)
In 2008, 17.5 million people died
from CVDs, (31% of global deaths)
7.4 million deaths due to CHD
By 2030, almost 23.3 million will
die from CVDs
– Economic impact in billions
WHO; CVD Fact sheet, (2013); AHA Heart Disease Statistics - Update. (2015).
CVD Mortality Trends for Males & Females
(United States: 1979–2011).
Source:
NCHS, NHLBI.
Dariush Mozaffarian et al., Circulation. 2015;131:e29-e322.
Prevalence of CVD in Adults ≥ 20 Years
of Age (NHANES : 2009–2012).
100
90
84.7 85.9
80
69.1
70
67.9
60
50
Men
Women
40.5
35.5
40
30
20
10
11.9
10
0
20-39
40-59
60-79
Dariush Mozaffarian et al., Circulation. 2015;131:e29-e322.
80+
Incidence of MI or Fatal CHD by
Age, Sex, & Race
(Atherosclerosis Risk in Communities Surveillance: 2005–2011).
Source:NHLBI, Dariush Mozaffarian et al., Circulation. 2015;131:e29-e322
Leading Causes of Death: Females
(2010)
NCHS and NHLBI. (2013)
Contributing Factor to Disparities in
Mortality Rates for CVD
Women are generally about 7 years older than
men when they present with MI
Entered menopause and lost the benefit of
estrogen
Women tend to have more co-morbid
conditions at time of diagnosis
– diabetes
– systolic hypertension
– obesity
Lack of symptom recognition of CHD and MI
in women contributes to disparities
Lloyd-Jones et al., (2009).
Women’s Awareness of Heart Disease
as # 1 Cause of Death
Lori Mosca et al. Circulation. 2013;CIR.0b013e318287cf2f
Impact of CHD in Women as
Compared to Men
After MI 26% women > 45 as compared
to 19% men die within 1 year
If women under age 50 at time of MI,
twice as likely to be fatal as in men of
comparable age
After MI, 46% women as compared to
22% are disabled within 6 years
AHA, Women’s Health (2011), (2014).
Impact of CHD in Women as
Compared to Men (Cont.)
More CHD symptoms
More physical limitations after event;
especially young and mid-life
Have less obstructive CHD when referred
for revascularization
More microvascular disease
Lower levels of biomarkers of cardiac
necrosis
Go, A. S., Mozaffarian, D., Roger, V. r. L., Benjamin, E. J., Berry, J. D., Borden, W. B. et al. (2013). Heart
Disease and Stroke Statistics 2013 Update: A Report From the American Heart Association. Circulation,
127(1), e6-e245.
Vaccarino, V. (2010). Ischemic heart disease in women: Many questions, few facts. Circ Cardiovasc Qual
Outcomes, 3(2), 111-5.
Sex Differences in
Cardiovascular System
After the reproductive system, the CV
system has the most sex- based
differences
Women have smaller coronary arteries,
more breast tissue, impacts diagnostic
test results
Differences between sexes in hematocrit
and estrogen levels, frequency of mitral
valve prolapse, left ventricular
hypertrophy, and myocardial blood flow
Sweitzer & Douglas, (2005); Hravnak et al., (2007); McSweeney & Lefler, (2007);
Institute of Medicine. (2002). Unequal treatment: Confronting racial and ethnic disparities in
health care Institute of Medicine.
Delay in Seeking Treatment for MI
Profile of delayers
–
–
–
–
–
–
Older age
Female
African American race
Low socioeconomic status
Low awareness of symptoms
History of comorbidities
Moser et al., (2006). Reducing delay in seeking treatment by patients with Acute Coronary
Syndrome & Stroke. Circulation, 114:168-182.
Consequences of Delay in
Seeking MI Treatment
Treatment is time dependent
7-fold decrease in mortality if treated
within 70 minutes of symptom onset
– 250,000 die annually before reaching the
hospital
Average delay 2 - 4 hours
– Minority populations delay longer
Mosca, et al., (2010). Twelve-year follow-up of American women's awareness of
cardiovascular disease risk and barriers to heart health. Circ Cardiovascular Quality
Outcomes, 3(2), 118-9.
Lack of Symptom Identification
If CP is not chief symptom, more likely to be
misdiagnosed
Twice as likely to die after misdiagnosis compared to
those diagnosed with MI
Women < 55 years old or minorities with shortness of
breath as chief complaint are most misdiagnosed
Little is known about women’s symptoms or possible
racial differences in symptoms
Need to address factors that shape women’s
symptom presentation
AHRQ, (2005); Dracup, (2007).
Why Do Women’s Risks
Remain High?
Fail to discuss risk factor
modification with every health care
encounter
–
–
Clinic
Hospital
Inadequate education R/T gender
racial differences
–
–
All heath care providers
Public
Roger et al., - Update. (2012).
Modifiable Risk Factors for CHD in
Women in the U.S.
35
30.8
30
29.9
27.8 28
27.2
23.7
25
26.2 27.1
25.6
26.3
23.4
24
20.7
21.2
20
17.2
15
10
5
0
U.S. 2006-08
High Blood Pressure
Obese
Inactive
Fruits & Veggies
Smoking
U.S. 2009-11
U.S. 2013
Kaiser Family State Health (2006-08) and BRFSS Prevalence and Trends Data (2009-2013).
Prevalence* of Self-Reported Obesity Among
U.S. Adults by State & Territory, (BRFSS, 2013)
*Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates
should not be compared to prevalence estimates before 2011.
2011
2012
2013
Source: Behavioral Risk Factor Surveillance System, CDC.
Heart Disease Risk Factor “Multiplier
Effect” in Midlife Women
Association of Sleep Duration with
CHD Mortality: Risk Factor?
Substantial gender differences with women
more susceptible to adverse cardiac effects
of short sleep
– Women with <5 hr sleep 2.3 X more likely
to have fatal event than those >7 hr
– No elevated risk in men
– Reduced sleep in women associated with
incident hypertension but not in men
Patel S, et al., (2009). Association of Sleep Duration with Mortality from Cardiovascular Disease and Other
Causes for Japanese Men and Women. Sleep; 32:295-301.
Cappuccio FP, et al., (2007). Gender-Specific Associations of Short Sleep Duration With Prevalent and
Incident Hypertension. The Whitehall II Study. Hypertension; 50:694-701.
Exposure to Particulate Matter –
Risk Factor?
CVD risks associated with exposure to
particulate matter in air pollution
– Automobile exhaust
Living close to heavily trafficked freeways
has been linked to increases in coronary
artery calcification, a potent risk factor for
MI
Particulates set in place a series of
responses triggering a systemic
inflammatory response and is dose
dependent
Brook et al., (2010); American Heart Association. (2007).
Oral Contraceptive Hormones
Assess women > 35 CHD for CHD
risks prior to presenting oral
contraceptives
Especially important if current
smokers, with known or uncontrolled
HTN or a history of migraine
headaches
Contraceptives HDL, LDL, BP,
worsen glucose tolerance
Shufelt & Bairey Merz, (2009).
Hormone Replacement Therapy (HRT)
Controversy continues about the impact
of HRT on the development of CHD
One study examined the influence of the
timing of HRT on the development of
CVD. They concluded that the timing of
initiating HRT is an important variable:
– Women who initiated HRT closer to onset of
menopause had an risk of developing CHD
than did those more distant
Rossouw et al., (2007).
To Make Diagnosis of CHD
in Women
Identify risk factors
Assess for prodromal
symptoms (PS)
Implement primary &
secondary prevention
measures
Following Content Based on the
Following Publication
McSweeney, J., O’Sullivan, P., Cleves,
M., Lefler, L., Cody, M., Moser, D.,
Dunn, K., Kovacks, M., Crane, P.,
Ramer, L., Messmer, P., Garvin, B., &
Zaho, W. (2010). Racial differences in
women’s prodromal and acute
myocardial infarction symptoms.
American Journal of Critical Care,
19,(1), 63-73.
Research Supported by the
National Institutes of Health
MI Symptoms in Women: Disparities
in Women of Color
PI: Jean C. McSweeney, NIH: NINR,1 R01 NR05265
Purpose & Recruitment
Describe and compare ethnic
differences in prodromal and acute
myocardial infarction (AMI) symptoms
Recruited from 15 sites nation-wide
Rural and urban, large and small
medical centers in AR, CA, FL, NC, LA,
OH, SC, TX
Methods
Descriptive Retrospective Survey,
(4-6 months post-MI)
Blessed Cognitive Screen
McSweeney Acute and Prodromal
Myocardial Infarction Symptom
Survey (MAPMISS©)
– 33 Prodromal and 37 Acute
symptoms, RF & comorbidities
McSweeney, O'Sullivan, Cody, & Crane. (2003).
Data Base
1270 women
– 43% black, 42% white and 15%
Hispanic
All women were >21 years of age
and 4-6 months post-MI
hospitalization
White women oldest, most educated
and had highest income
Prodromal Symptoms
N= 1270
95% (n=1239) reported at least 1
Unusual fatigue most frequent
(73%, n=930)
Significant (p<.01) ethnic differences
in frequency of reporting 17 of 33
prodromal symptoms
Prodromal Symptoms
and Mean Scores (p<.001)
Black
n=545
Hispanic
n=186
White
n=539
Mean #
prodromal
symptoms
(SD)
7.50*
7.02*
5.86†
+ 4.83
+ 5.30
+ 4.31
Prodromal
score (SD)
76.7*
69.1
60.1†
+ 59.7
+ 57.5
+ 52.7
Superscripts that differ indicate significant post hoc differences at P<.003
10 Most Frequent Prodromal Symptoms
80
70
60
50
* *†
40
30
*
20
†
10
0
Fatigue
Sleep
Black
Anxiety
Hispanic
SOB
Indig.
White
Superscripts that differ indicate significant post hoc differences at P<.003
10 Most Frequent Prodromal Symptoms
(cont.)
45
40
35
*
*
*
30
25
†
20
†
*
*
†
† †
†
15
10
5
0
Hrt Race
Vision
Black
Chest P/D
Hispanic
Thinking
Appetite
White
Superscripts that differ indicate significant post hoc differences at P<.003
% of Women Reporting a Symptom in
the Prodromal Phase Reporting the Same
Symptom in the Acute Phase
Cluster Analysis of Women’s
Prodromal and Acute Myocardial
Infarction Symptoms
McSweeney, J., Cleves, M., Zhao, W.,
Lefler, L., & Yang, S. (2010). Cluster
analysis of women’s prodromal and
acute myocardial Infarction symptoms
by race and other characteristics.
Journal of Cardiovascular Nursing,
25(4), 311 - 322.
Step 1
Three clusters were identified the
prodromal symptoms
– Each contained women with increasing
frequency and severity of symptoms
Prodromal Symptom Clusters
Cluster
High probability
(70-100%)
1 (N=552)
Medium probability
(40-70%)
Very tired, unusual fatigue
2 (N=435)
Very tired, unusual fatigue
Sleep disturbance
Anxious
Heart racing
Shortness of breath
Frequent indigestion
Change in thinking/remembering
3 (N=283)
Very tired, unusual fatigue
Sleep disturbance
Anxious
Shortness of breath
Arms weak/heavy
Hand/arms tingling
Any chest pain/discomfort
Cough
Heart racing
Difficulty breathing during night
Loss of appetite
Frequent indigestion
Arms ache
Numbness or burning in
hands/fingers
Vision problems
Change in thinking/remembering
Step 2: Examine the Association
Between Women’s Characteristics
& Clusters
Six of ten characteristics were
strongly associated with the
clusters:
– Age, race, BMI, personal history of heart disease,
diabetes and smoking status
Characteristics of Women within
Clusters: Prodromal Symptoms
Prodromal Summary
Chest pain/discomfort was not
identified as a primary prodromal
symptom
African-American women <50
years were more likely to
complain of frequent and intense
symptoms compared to other
women
Clinical Application: Prevention
Earlier and more aggressive measures
needed to identify, control, and eliminate
risk factors
Further gender-specific research to develop
evidence-based practice
Need to change our focus from treatment to
prevention and early treatment to delay
progression
Evidence based tailored, gender-specific
education for women and HC professionals
Lifestyle Interventions
Cigarette smoking
–
Providers must advise not to smoke and to avoid
environmental tobacco smoke
Physical activity
–
–
Accumulate at least 150 min/wk of moderate exercise, 75
min/wk of vigorous exercise, or equivalent performed
in 10 minute bouts/ week
Muscle-strengthening activities
Cardiac rehabilitation
–
Recommended to women with ACS, after
revascularization, or angina
Mosca et al., Guidelines for the Prevention of CVD in Women - Update (2011).
Lifestyle Interventions (cont.)
Physical activity
‒ Accumulate at least 150 min/wk of
moderate exercise, 75 min/wk of
vigorous exercise, or equivalent
performed in 10 minute bouts/ week
‒ Muscle-strengthening activities
‒ Cardiac rehabilitation
Many insurers will pay costs, (ex)
silver sneakers
‒ Unsafe neighborhoods detriment
Mosca et al., Guidelines for the Prevention of CVD in Women – Update (2011).
Specific Dietary Intake
Recommendations for Women
Nutrient
Serving
Fruits & Vegetables
>4.5 cups/d
Fish
2/wk
Fiber
30 g/d (1.1 g/10 g carbohydrate)
Whole grains
3/d
Sugar
<5/wk (<450 kcal/wk from sugarsweetened beverages
Nuts, legumes, and seeds
>4/wk
Saturated fat
<7% total energy intake
Cholesterol
<150 mg/d
Alcohol
<1/d
Sodium
<1500 mg/d
Mosca et al., Guidelines for the Prevention of CVD in Women – Update (2011).
Summary: Projected Results of
Prevention
78% of all adults alive in U.S. today
(20-80 years old) are candidates for
modification of at least 1 CHD risk
factor
If implemented, estimate MI’s could be
reduced by 63%
– Smoking cessation most cost saving
intervention
Could save over 36 million worldwide
Kahn, R., Robertson, M., Smith, R., & Eddy, D. (2008). The impact of reducing the
burden of cardiovascular disease, Circulation.
Questions