Download The Heart Truth Educational Slide Module: Prognosis and treatment

Cardiovascular Disease in Women
Module V: Prognosis and
Treatment Outcomes
Women Received Less Interventions
to Prevent and Treat Heart Disease
 Less cholesterol screening
 Less lipid-lowering therapies
 Less use of heparin, beta-blockers and
aspirin during myocardial infarction
 Less antiplatelet therapy
for secondary prevention
 Fewer referrals to cardiac rehabilitation
 Fewer implantable cardioverter-defibrillators compared
to men with the same recognized indications
Sources: Chandra 1998, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 2005, Chou 2007, Hernandez 2007, Cho 2008
Prognosis After MI
 38% of women die within first year
 Compared to 25% of men
 35% of women will have second MI
within 6 years
 Compared to 18% of men
Source: Wenger 2004
Prognosis
 Women < 65 yrs have 2 X mortality rate after MI
compared to men of same age
 After MI, women have significantly higher rates of:
 Depression
 Physical disability
 After CABG, women have significantly higher rates of:
 Hospital readmission
 Reduced mental health and physical functioning
Source: Vaccarino 1999, Ades 2002, Lauzon 2003, Vaccarino 2003
Undertreatment of MI in Women
 Compared with men:




Less emergent thrombolysis
Less acute catheterization and angioplasty
Less acute surgical revascularization
Less use of heparin, beta-blockers, and aspirin
Source: Chandra 1998, Nohria 1998
Cardiac Rehabilitation for Women
 Cardiac rehabilitation programs benefit both men
and women
 Participation rates for eligible women are 15-20%,
compared to 25-31% for eligible men
 Women are more likely to drop out after
beginning cardiac rehabilitation
 Healthcare providers are less likely to encourage
rehabilitation for female patients
Source: Scott 2004
Benefits of ASA in Women with
Established CAD
10
9
8
7
6
Mortality
at 3 Years
5
Follow-Up (%) 4
3
2
1
0
9.1
5.1**
All Cause
Mortality
2.7 *
* P = 0.002 **P
= 0.0001
Aspirin
Source: Adapted from Harpaz 1996
5.1
CVD
Mortality
No Aspirin
Addition of Clopidogrel to Aspirin
and Fibrinolytic Therapy for MI with
ST-Segment Elevation in Women
30
24.7
25
% with
Antiographic
Reocclusion,
Death, or
Recurrent MI
Before
Angiography
20
16.9
15
10
5
P < 0.05; reduction
in odds = 38%
0
Clopidogrel
Source: Sabatine 2005
Placebo
Gender Gap in Dyslipidemia Treatment
 Significantly more men than women have annual
cholesterol measurements
 Significantly more men than women receive effective
lipid-lowering therapy
 African Americans receive less lipid-lowering treatment
compared to whites
Source: O’Meara 2004, Hendrix 2005, Chou 2007, Cho 2008
Meta-Analysis of 11 Clinical Trials
of Statin Therapy Including 15,917
Women with Known CHD
0
CHD Events
Non-Fatal MI
CHD Mortality
-5
-10
-15
%
-20
Reduction
-25
-21
-26
-30
-35
-40
Source: Grady 2003.
-36
Relative Risk
(Cox regression analysis)
Simvastatin and Gender Risk
for CHD and Mortality
1.2
1.12
1
0.8
0.6
0.66*
0.65* 0.66*
0.4
Women
Men
0.2
*P <0.05
0
Total Death
Source: Scandinavian Simvastatin Survival Study Group 1994
Major Coronary
Event
Heart Protection Study: Major Findings
 Randomized, placebo-controlled trial of over 20,000
patients at risk for CVD
 Statin treatment reduced the risk of heart attacks and
strokes by at least one third, as well as reducing the
need for arterial surgery, angioplasty and amputations.
 Major CV events were reduced in women (5082 enrolled)
as well as men, and in all age groups, across all
cholesterol levels.
Source: HPS Writing Group, Lancet 2002
Primary Prevention of CHD Events with
Statin Treatment: AFCAPS/TexCAPS
0
-5
-10
-15
-20
% -25
-30
-35
-40
-45
-50
Relative Risk of First Major Coronary Events
Source: Downs 1998
Men
Women
-37
-46
P < 0.001
compared to
placebo
Implanted Cardioverter Defibrillator
(ICD) Therapy in Women
 Women appear to have a lower incidence
of sudden cardiac death then men
 Women present more frequently with
ventricular fibrillation than men
 Women have similar survival rates after
ICD implantation compared to men
 In a study of hospitals participating in a heart failure
quality improvement program, women received fewer
implantable cardioverter-defibrillators compared to
men with the same recognized indications
Source: Pires 2002, Hernandez 2007
*P <0.05
compared
with white
men
Relative Risk
Adjusted Odds for Use of Implantable
Cardioverter-Defibrillator According
to Guidelines by Race and Sex
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
*
White Men
Source: Adapted from Hernandez 2007
Black Men
*
*
White
Women
Black
Women
Interventional Procedures and Surgery
 Higher complication and death rates





Smaller artery size
More co-existing illnesses (older at presentation)
Higher rates of diabetes
More urgent and emergent presentations
Higher incidence of congestive heart failure in
women from diastolic dysfunction
Source: Jacobs 2003
Coronary Revascularization
in Women Compared to Men
 Increased use of PTCA compared to stents,
because of smaller vessel size
 Decreased rates of glycoprotein IIb/IIIa inhibitor
use, possibly because of increased bleeding
complications in women
 Higher in-hospital mortality for CABG and PCI
 Higher rates of vascular complications
 Higher transfusion rates
Source: Jacobs 2003
Revascularization Outcomes in Women:
Improvements in Recent Years
 NHLBI registry data shows improved clinical success
rates and lower major complication rates for women
undergoing PTCA
 Retrospective data suggest that women have lower
mortality rates when undergoing off-pump CABG,
compared to standard CABG
Source: Jacobs 1997, Petro 2000
Sex Differences for In-Hospital
Mortality After CABG: Higher
Mortality in Younger Women
2.5
2.23
1.86
2
1.47
1.5
1.16
1.02
1
0.5
Adjusted
Odds
Ratio for
InHospital
Mortality
P for interaction between
sex and age = 0.002.
0
< 50
5059
6069
Age Group
Source: Adapted from Vaccarino 2002
7079
≥ 80
CABG Outcomes in Women:
A Vicious Cycle
Perception: Higher post-operative
morbidity/mortality in women
Fewer long-term
benefits for women
Prompt referral for CABG
discouraged in women
Higher operative
risk for women
Women referred at later stages
of disease, w/ more comorbidities
Source: Adapted from Vaccarino 2003