Download The Heart Truth - Overview slides

Update on Women and
Cardiovascular
Disease
Amy Rawl Epps, M.D.
Columbia Cardiology
2/5/09
Financial Relationships
 “As it pertains to CME, I have no relevant financial
relationships with any commercial interest to
disclose.”
Why is it so critical to recognize and
diagnose CAD in women?
 Although US men have experienced a decline in CAD
deaths, the number of coronary deaths in women, >240
000 annually, has increased
 CAD is a substantial cause of morbidity and disability for
US women.
 Women, in particular young women (<55 years), have a
worse prognosis from acute MI than their male
counterparts, with a greater recurrence of MI and higher
mortality.
 Up to 40% of initial cardiac events in women are fatal
Circulation 2005
400,000
Heart Disease
366,000
• CHD mortality rate
•10 X that from breast cancer
Number of Deaths*
350,000
300,000
250,000
200,000
150,000
100,000
•50% > all forms of cancer combined
• 38% one-year morality post-MI
• 46% six-year disability rate from CHF
Stroke
103,000
Lung
Cancer
65,000
50,000
0
* Number
COPD
62,000
Breast
Cancer
42,000
Cause of Death
of deaths are rounded to the nearest thousand.
COPD = chronic obstructive pulmonary disease.
National Heart, Lung, and Blood Institute. The Healthy Heart Handbook for Women. 2003.
Mortality Rates for Women
United States 2001
CVD Mortality Trends for
Males and Females: US 1979–2002
Deaths (thousands)
520
480
Males
Females
440
400
NCEP II
NCEP I
0
1979
81
83
85
NCEP = National Cholesterol Education Program.
87
89
91
93
NCEP III
95
Years
American Heart Association. Heart Disease and Stroke Statistics — 2005 Update.
Dallas, Tex: American Heart Association; 2005. ©2005, American Heart Association.
97
99
01
02
Compared with Men:
 38% of women and 25% of men will die within one year of a first
recognized heart attack.
 35% of women and 18% of men heart attack survivors will have another
heart attack within six years.
 46% of women and 22% of men heart attack survivors will be disabled
with heart failure within six years.
 Women are almost twice as likely as men to die after bypass surgery.
 Women are less likely than men to receive beta-blockers, ACE
inhibitors or even aspirin after a heart attack.
 More women than men die of heart disease each year, yet women
receive only:
 33% of angioplasties, stents and bypass surgeries
 28% of inplantable defibrillators and
 36% of open-heart surgeries

Women comprise only 25% of participants in all heart-related research
studies.
Similar risk profile for men and women
Circulation. 2004;109:573-579
Why Women Don’t Women Take
Action Against Heart Disease







Stereotype of only men getting heart disease
More concerned about ‘other’ diseases
Think they’re not old enough to be at risk
More accustomed to the role of caregiver
They don’t put their health as a top priority
Too busy to deal with it…do it later
Already feeling tired & stressed out
Risk
Stratification:
How much risk
am I at?
Risk Stratification:
Major Risk Factors:
Age > 55 years
Smoking
Hypertension (whether or not controlled with medication)
HDL cholesterol < 40mg/dL; LDL (>130-160)
(HDL cholesterol ≥ 60mg/dL is a negative risk factor)
 Family history of premature CVD (Defined as CVD in a female first
degree relative < 65 years old, or a first degree male relative < 55 years
old)
 Obesity/Sedentary Lifestyle




‘CHD equivalent’ (automatically places in “high-risk” category)
 Diabetes
 Established atherosclerotic disease (carotid, peripheral)
 +/- kidney disease
Source: Mosca 2004, ATP III 2002
Key Tests for Heart Disease Risk
Risk Stratification
 Blood pressure
 Blood cholesterol
 Fasting plasma glucose (diabetes test)
 Body mass index (BMI)
Testing
 Electrocardiogram
 Stress test
 Other
Mortality (per 1000 women)
Coronary Disease Mortality
and Diabetes in Women
60
50
40
Diabetic
Women
Nondiabetic
Women
30
20
10
0
0-3
4-7
8 - 11 12 - 15 16 - 19 20 - 23
Duration of Follow-up (yrs)
Relative Risk of Coronary Events for
Smokers Compared to Non-Smokers
6
5.48
5
4
Relative
Risk
3.12
3
2
1
1
0
Never Smoked
1-14 Cigarettes per
day
>
Source: Adapted from Stampfer 2000
15 Cigarettes per
day
Obesity & Heart Disease
<1.0
Body Weight & CHD Mortality Among
Women
7.4
8
7
6
Relative Risk
of CHD
Mortality
5
4
2.6
3
2
1
0
≥
Wt Gain 10-19kg
Wt Gain
20kg
Weight Gain Since Age 18
Source: Adapted from Manson 1995
P for trend < 0.001
Noninvasive diagnostic and
prognostic testing offers the potential
to identify women at increased CAD
risk and establish the basis for
instituting preventive and
therapeutic interventions.
PITFALLS in Diagnosing Heart
Disease in Women
 Some diagnostic tests and procedures may not be as accurate in
women, so physicians may avoid using them.
(For example, the exercise stress test may be less accurate in women and
giving a false positive result.)
 That means the disease process resulting in a heart attack or stroke
may not be detected in women until later, with more serious
consequences.
 More precise noninvasive and less invasive diagnostic tests tend to cost
more. These include nuclear or echocardiographic stress tests and
cardiac CT/MRI.
Evaluating for Ischemic
Heart Disease is Difficult to
do in Women
 Symptoms are more likely to be atypical and
therefore difficult to recognize
 Higher rate of functional disability (due to comorbidities)
 Lower prevalence of obstructive CAD by
coronary angiography as compared to mentherefore diagnostic accuracy of testing is
variable and confusing
Questions to ask yourself
before ordering a test……
 What is the patient's pretest risk of disease?
 How does the sensitivity and specificity of
the alternative tests compare?
 What are the costs and effects on health
outcomes of each test?
 Do special considerations make one test more
suitable than another in a specific patient?
Benefits of the Stress ECG
 Valuable prognostic information can be
learned!!
 Chronotropic and hemodynamic responses to
exercise
 Duke Treadmill Score can predict significant
coronary stenosis
 Women who exercise <5 metabolic
equivalents (METs) are at increased risk of
death
Prognostic value of functional capacity in asymptomatic (n =
8,715) and symptomatic (n = 8,214) women as synthesized
from published reports
Disparity even after Stress
Testing
 Several researchers have found that a positive exercise test
in women is often not followed up with subsequent testing.
This finding has been cited as the reason for lower rates of
catheterization and coronary bypass surgery in women and
for the higher mortality of women after cardiac surgery.
(Annals of Int Med 1990;112:561-7)
 Other researchers have suggested that differences between
the sexes in rates of treatment derive from the
overtreatment of men at low risk of disease or death and an
appropriately conservative level of care for women. (Annals
of Int Med 1992;116: 791-7)
 In men and women with a similar prevalence of abnormal
results on initial stress tests for the diagnosis of coronary
heart disease,additional studies were performed in only
38% of women, as compared with 62.3% of men. Follow-up
revealed a higher incidence of coronary events in the
women, regardless of initial stress-test results (1.6% for
women with normal test results vs. 0.8 % for men; 14.3%
for women with abnormal test results vs. 6.0% for men).
Cardiac CT
Angiography
3-D Volume Rendered Image
Coronary
Angiography
SYMPTOMS OF A
HEART ATTACK
JAMA. 2000;283:3223-3229
Atypical Warning Signs in Women
Early Warning Symptoms in Women
Circulation. 2003;108:2619
Stable Angina
 Women describe their angina using a more emotional
presentation, calling the pain “hot-burning” or “tender” and
rating it as more intense
 More women than men suffer from chronic stable angina
 The female stable angina patient is usually older than the
male stable angina patient and female Syndrome X patients,
and more often has diabetes and high hs-CRP levels
 Compared with men, women with stable angina tend to
receive fewer diagnostic tests, fewer prescriptions for
recommended medications, and fewer interventional
procedures
 Women have a worse prognosis than men in terms of relief
from angina pain after treatment
 Clotting factors, BNP, and hs-CRP have been found to be
predictive of adverse events after treatment for angina
Acute Coronary
Syndrome/Unstable Angina
 UA/NSTEMI is the most common cause of cardiac hospital
admissions
 Women presenting with UA/NSTEMI have worse clinical
profiles, but less extensive CAD compared with men
 Women with ACS are more likely to present with UA than MI
 UA and NSTEMI are differentiated based on the presence of
biomarkers of myocardial injury
 Women with UA/NSTEMI are more likely to present with
atypical symptoms than men
Acute Coronary Syndrome
 The most common cause of UA/NSTEMI is the development
of non-occlusive thrombus on a disrupted atherosclerotic
plaque
 All patients without contraindications should be given
aspirin, nitroglycerin, beta blockers, and heparin
 It is unclear whether female ACS patients managed
medically benefit from the use of GP IIb/IIIa inhibitors
 High-risk patients including women benefit from an early
invasive strategy
 It is unclear whether a routine invasive strategy is beneficial
in women and/or lower-risk patients
 The prognosis of women with UA/NSTEMI is as good as or
better than that of men
Acute Myocardial Infarction
 Female AMI patients are generally 5 to 10 years older and
have more co-morbidities
 Common acute symptoms of AMI in women include
dyspnea, weakness, fatigue, nausea/vomiting, palpitations,
and indigestion
 Women <50 years old are more prone to coronary
thrombosis due to plaque erosion than postmenopausal
women
 Younger female AMI patients have a higher in-hospital
mortality than men of the same age and older female AMI
patients
 Women often have higher short-term mortality rates than
men largely due to their older age and increased comorbidities
 Women are often under prescribed AMI discharge
medications, including aspirin and beta blockers
Lifestyle Interventions
 Smoking cessation
 Physical activity (cardiac rehabilitation)
 Weight reduction/maintenance
 Heart healthy diet
 Omega 3 fatty acids
 Psychosocial factors
Source: Mosca 2004
Women Receive 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
 Fewer referrals to cardiac rehabilitation
Source: Chandra 1998, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 2005
Lifestyle Approaches to Hypertension in
Women
 Maintain ideal body weight
 Weight loss of as little as 10 lbs reduces blood pressure

 DASH eating plan
 Even without weight loss, a diet rich in fruits, vegetables, and low
fat dairy products can reduce blood pressure

 Sodium restriction to 2400 mg/d
 Further restriction to 1500 mg/d may be beneficial, especially in
African American patients

 Increase physical activity
 Limit alcohol to one drink per day

 Alcohol raises blood pressure
 One drink = 12 oz beer, 5 oz wine, or 1.5 oz liquor
Source: JNC VII 2004, Sacks 2001
Guidelines at a Glance
Parameter
Optimal LDL-C
ATP III + Update1
<100 mg/dL
Women2
<100 mg/dL
ADA Position3
<100 mg/dL
Very high risk
(2004 Update)4
<70 mg/dL
Optimal TG
<150 mg/dL
<150 mg/dL
<150 mg/dL
Optimal HDL-C
<40 mg/dL*
>50 mg/dL
>40 mg/dL men
>50 mg/dL women
LDL-C goal for CHD
or equivalents
<100 mg/dL
<100 mg/dL
<100 mg/dL
Non–HDL-C goal
<130 mg/dL
<130 mg/dL
*Defined as high risk.
1. ATP lll. JAMA. 2001;285:2486-2497. 2. Mosca L et al. Circulation. 2004;109:672-693.
3. American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S68-S71. 4. Grundy SM et al. Circulation.
2004;110:227-239.
Framingham CHD Risk:
HDL-C Predicts Risk at All LDL-C Levels*
Patient 1:
LDL-C: 100 mg/dL
HDL-C: 25 mg/dL
Patient 2:
LDL-C: 220 mg/dL
HDL-C: 45 mg/dL
RR for CHD After 4 y
3.0
2.0
1.0
25
0.0
100
160
220
LDL-C (mg/dL)
*Data represent men age 50-70 y from the Framingham Study.
Adapted from Castelli WP. Can J Cardiol. 1988;4(suppl A):5A-10A.
85
45
65 HDL-C (mg/dL)
Jupiter Trial
Trial stopped early
 Looked at significance of elevated hsCRP levels in
15,000 low risk patients without CV disease and low or
normal LDL
 Patients randomized to either Crestor 20mg or placebo
 Showed decreased cardiovascular morbidity and
mortality in Crestor group
Characteristics of the Metabolic Syndrome:
NCEP-ATP III
Abdominal obesity
Glucose intolerance/ Insulin
resistance
Diabetes
Hypertension
CVD
Atherogenic dyslipidemia
Proinflammatory/
Prothrombotic state
National Cholesterol Educational Program (NCEP), Adult Treatment Panel (ATP) III; 2001.
Daily Aspirin
 High risk women
 75-162 mg daily (clopidogrel if intolerant to aspirin)

Unless contraindicated (bleeding, allergy)
 Intermediate risk women
 Consider aspirin therapy (75-162 mg)

if benefit is likely to outweigh risk
 Lower risk women
 Many women, especially those >65 yo, may benefit
from taking low-dose aspirin every other day to
prevent MI or stroke

The use of low dose aspirin should be balanced against
the risk of increased internal bleeding
Hormone Replacement Therapy
Risk vs. Benefit
Risks
Benefits
DVT/PE
Gallbladder Disease
Breast Cancer
Breast/Bleeding Side Effects
CHD
Stroke
Dementia
Pancreatitis
?Ovarian Cancer
Vasomotor Symptoms
Osteoporosis
Vaginal Atrophy
Colon Cancer
Skin Preservation
Depression
Source: ACOG Task Force for Hormone Therapy 2004
Women’s Health Initiative: Estrogen Alone
in Postmenopausal Women
Relative Risk Compared to Placebo
Hip Fracture
0.61
0.77
Breast Cancer
*
CHD
0.91
Total Mortality
1.04
1.08
Colorectal Cancer
1.39
Stroke
0
0.5
Favors Treatment
1
1.5
Favors Placebo
*
2
* P < .05
Menopausal Hormone Therapy and CVD: Summary
of Major Randomized Trials
 Use of estrogen plus progestin associated with a
small but significant risk of CHD and stroke
 Use of estrogen without progestin associated with
a small but significant risk of stroke
 Use of all hormone preparations should be limited
to short term menopausal symptom relief
Source: Hulley 1998, Rossouw 2002, Anderson 2004
Women’s Health Initiative Estrogen and Progestin
Arm: Absolute Excess Risk
 Excess CHD events: 7/10,000 woman-years
 Excess stroke events : 8/10,000 woman-years
 Excess pulmonary emboli: 8/10,000 woman-years
 Excess invasive breast cancer: 8/10,000 woman-years
Women’s Health Initiative Estrogen and
Progestin Arm: Absolute Benefits
 Fewer colorectal cancers: 6/10,000 woman-years
 Fewer hip fractures: 5/10,000 woman-years
Antioxidants, etc.
 Antioxidants, Antibiotics, & Chelation
 Vitamins A, C, E, & homocysteine
 Antibiotics (azithromycin)
 Chelation therapy
 No cardiovascular benefit in randomized trials of
primary and secondary prevention
Depression and CHD: Results from the
Women’s Health Initiative Study
 Depression is an independent predictor of CHD
death among women with no history of CHD
Source: Wassertheil-Smoller 2004
CHD Risk Equivalents
 High Risk > 20% 10-yr risk for CHD events
 Established coronary artery disease
 Carotid artery stenosis
 Peripheral arterial disease
 Abdominal aortic aneurysm
 Diabetes
 Includes many patients with chronic renal disease, especially
ESRD
Source: Mosca 2004
 Intermediate Risk 10-20% 10-yr risk for CHD events
 May include women with metabolic syndrome, especially
women over the age of 60 or with individual factors that
are markedly elevated or severe
 Often includes women with multiple risk factors, a single
markedly elevated risk factor, or a 1st degree relative with
premature CVD
 May include women with subclinical cardiovascular
disease (elevated coronary calcium score)- this is not
included in Framingham risk calculations
Source: Mosca 2004
 Low Risk <10% 10-yr risk for CHD events
 women with one or more risk factors
 women with defined metabolic syndrome, if no
individual factor is severe or markedly elevated
 women with no risk factors, but non-optimal
lifestyle factors, such as lack of regular exercise
or a high fat diet
 Optimal Risk <10% 10-yr risk for CHD events
 Optimal levels of risk factors
 Heart healthy lifestyle
Source: Mosca 2004