Treating Cardiovascular Disease in Women

Treating Cardiovascular Disease in Women

The Heart of Go Red,
Women Fighting Back
AHA Go Red For Women
2009 Update-Treating Cardiovascular Disease
In Women
Rick Birkhead MD FACC
Chief of Cardiology
Medical Director
Heart & Vascular Center
Lowell General Hospital
Merrimack Valley Cardiology
[National Wear Red Day 2 6 09]
1
GENDER BIAS IN THE TREATMENT
OF WOMEN
“…The community has viewed women’s
health almost with a ‘bikini’ approach, looking
essentially at the breast and reproductive
system, and almost ignoring the rest of the
woman as part of women’s health.”
Nanette Wenger, MD
Chief of Cardiology, Grady Memorial Hospital and Professor of
Medicine, Emory University School of Medicine, Atlanta
CASE PRESENTATION
• 47 year old Nurse “C.S.” …
• Exercises, eats well
• Vague intermittent mid chest pressure over the last
week, not with exertion, associated with anxiety
• Asked her husband what to do…
• RF: gestational DM, LDL<100, nonsmoker
• Exam normal HR 90 BP 132/76
• TROPONIN 0.09
• Admitted to stepdown with ongoing chest pain
2
3
Before Balloon
After
The Heart of Go Red, A Community of Stories
At the age of 34 I had a massive
heart attack which left me with
extensive left ventricle damage.
– Angel
My mother was only 47 years
old when she died from
sudden cardiac arrest.
At 44 years old I am now a
statistic. I had a 100% blockage
in one of my arteries. Now my
life is forever changed.
– Kristen
- Cheryl
4
My discussion today will include…
1.
2.
3.
4.
5.
Epidemiology of Heart Disease in Women
Pathophysiologic and Clinical differences
Women’s attitudes of heart disease
Gender differences in Risk Factors
Gender differences in Assessment and
Management
6. Evidence-Based Guidelines via a case
presentation
7. GO RED FOR WOMEN and future innovations
What’s the Big Deal?
•
Heart attack, stroke and other cardiovascular diseases claim the lives of over
460,000 women each year.
•
While 1 in 30 American women die from breast cancer, almost 1 in 3 will die from
cardiovascular disease.
•
The heart disease mortality for men in the last 25 years has declined 17%
compared to only 2.5% for women
•
One woman dies each minute of heart disease
•
Young women have worse survival after MI than men
•
64% of women who die suddenly of coronary heart disease have no previous
symptoms of this disease.
•
43 Million American women are living with cardiovascular disease.
5
CV Disease Mortality Trends
for Males and Females
United States: 1979-2001
Source: © American Heart Association 2004
Acute MI Mortality by Age and Sex
30
25
Men
20
Death During
Hospitalization
(%)
Women
15
10
5
0
<50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
Age
Source: Adapted from Vaccarino 1999
6
Women’s CAD is somewhat a
different disease…
• Normal or minimal CAD at cath commonly
appreciated in Women with CP, and this population
had 2X more CV events!
• VASCULOPATHY: smaller vessels, more diffuse, micro
rather than macrovascular, functionally if not
structurally impaired endothelium, erosion of plaque
not rupture, and coronary dissection
• NOVEL RISK FACTORS: Premenopausal estrogen
deficiency, inflammatory disease, vascular
conditions, protracted dysmetabolic state,
depression
7
8
9
10
11
www.marketstrategies.com
2005 Phone
Survey
LGH Women’s Outreach Initiative
February 25, 2005
Methodology:
•500 women 40-75 years old were randomly
selected from the Lowell market to
participate in this research.
• Zip codes from two service areas specified
by the study group were sampled using
random digit dialing.
•Definite sampling issues here…
12
SURVEY RESULTS:
NOT AT RISK
12%
ALREADY HAD
AN MI
4%
MULTIPLE
RISK FACTORS
BUT NO
PERCEIVED
RISK
29%
AT RISK AND
PERCEIVED
RISK
29%
SINGLE RISK
FACTOR BUT
NO PERCEIVED
RISK
26%
n=500 (total population)
The majority of women in Lowell do know
the basic heart attack warning signs.
Warning Signs of a Heart Attack (Total Mentions)
97%
97%
95%
95%
74%
70%
68%
34%
7%
Chest pain
Tightness in
the chest
Shortness of
breath
Pain in the
arm
Fatigue or
tiredness
Nausea
Dizziness
Headache
Itching
Q18B, n=500 (total population)
13
CARDIOVASCULAR IMAGING IN WOMEN:
• ECG STRESS TEST often inaccurate (?Estrogen
effectsÆFALSE +). Supported by guidelines if the
baseline ECG is normal, otherwise do imaging
• NUCLEAR studies (breast artifact)
• STRESS ECHO ***not a bad choice!
• CTA CORONARIES (malignancy potential)
• CORONARY ANGIOGRAPHY (may miss extraluminal
disease, microvascular disease, endothelial
dysfunction)
• WISE TRIAL 20-40% nonobstructive at cath still have
demonstrable ischemia and a worse prognosis
RISK FACTORS HAVE DIFFERENT
IMPLICATIONS
• Diabetes Effects more women after age 60,
and is more predictive of death in women
• Hypertension More women than men after
age 45, and 73% over age 65
• Dyslipidemia With menopause less HDL and
more LDL. Low HDL is especially predictive
• Smoking 6-9 X risk of MI. More second hand
smoke in women.
• Postmenopausal, Estrogen deficiency,
Inactivity, Obesity
14
Percent of Population
Prevalence of high blood pressure in Adults by age and sex
(NHANES: 20052005-2006). Source: NCHS and NHLBI.
90
80
70
60
50
40
30
20
10
0
64.7
69.6
76.4
64.1
53.7 55.8
36.2 35.9
23.2
13.4
16.5
6.2
20-34
35-44
45-54
Men
55-64
65-74
75+
Women
30
15
Body Weight and CHD Mortality
Among Women
7.4
8
7
6
Relative Risk
of CHD
Mortality
5
4
3
2.6
2
1
P for trend < 0.001
0
Wt Gain 10-19kg
Wt Gain ≥ 20kg
Weight Gain Since Age 18
Source: Adapted from Manson 1995
16
NHANES III: Age-Adjusted Prevalence of
≥3 Risk Factors for the Metabolic Syndrome*
40
35.6
Prevalence( %)
35
28.3
30
25
Men
Women
25.7
24.8
22.8
20
16.4
15
10
5
0
White
African American
Mexican American
*Criteria based on ATP III; diabetics were included in diagnosis;
overall unadjusted prevalence 21.8%. Ford ES et al. JAMA.
2002;287:356-359.
WOMEN ARE TREATED DIFFERENTLY…
>More likely to be misdiagnosed
>More likely to experience EMS Delays (52% higher odds)
>Undertreated medically (14% les likely ASA, 10% BBlocker, 13% 90
min D2B)
>More likely overdosed with 2B3A thus excessive bleeding
>Less likely to have revascularization(33 vs. 67%)
>Less likely to have an ICD (28 vs. 72%)
>Less likely to participate in Cardiac Rehab (39% men, 27%
women)
>STEMI Mortality rate higher (10.2 vs. 5.5%) [mostly related to
being older and having more comorbidities]
>more frequent vascular complications of PCI and mortality at
CABG but still very worthwhile: “CABG should not be denied to
women who have the appropriate indications”
17
Women only 27% of MI research
18
2007 Science
• 2007 Updated Guidelines
– Available at www.goredforwomen.org
– Pocket version at the AHA table
– Downloadable PDA Version online too!
• Are you implementing the guidelines in your
practice?
– Case Study – A Women At Risk
19
20
21
22
23
Continuum of Patients at Risk for a
CHD Event
Secondary
Prevention
Post MI/Angina
Other Atherosclerotic
Manifestations
Subclinical
Atherosclerosis
Primary
Prevention
Multiple Risk
Factors
Low Risk
Courtesy of CD Furberg.
HI RISK
AT RISK
(≥1 major risk
factors for
CVD)
OPTIMAL
RISK
Established coronary heart disease
Cerebrovascular disease
Peripheral arterial disease
Abdominal aortic aneurysm
End-stage or chronic renal disease
Diabetes mellitus
10-year Framingham global risk >20%*
Cigarette smoking
Poor diet
Physical inactivity
Obesity, especially central adiposity
Family history of premature CVD**
Hypertension
Dyslipidemia
Evidence of subclinical vascular disease (eg, coronary calcification)
Metabolic syndrome
Poor exercise capacity on treadmill test and/or abnormal heart rate
recovery after stopping exercise
Framingham global risk <10% and a healthy lifestyle
Adapted from: Mosca et al. Circulation
2007: Feb 19; [Epub]
24
25
26
27
What Have We Learned?
Heart disease can strike women at any age
Factors leading to heart
disease originate in young
women and develop over time
Lifestyle changes can prevent or at least
postpone heart disease
The Future and Women Heart Issues
• AHA GOAL by 2010 of 25% reduction in CHD
and Stroke risk
• VIRGO STUDY - Variation in Recovery: Role of
Gender on Outcomes of Young AMI Patients,
Yale and NHLBI 2000 women 1000 men from a
variety of perspectives
• WISE WOMAN – Heart Disease Screening and
Risk Reduction Counseling for Indigent Women,
a legislative mandate
• HEART FOR WOMEN ACT
28
Heart for Women Act
• Women: Better Treatment for Heart Disease
Take action: Support the HEART for Women Act, bipartisan
legislation pending in Congress (passed unanimously in the house
2008) to help eliminate the heart disease diagnosis, treatment,
and prevention disparities that women currently face 1 GENDER
SPECIFIC DATA COLLECTION, 2 RISK FACTOR SCREENING, 3 RAISE
AWARENESS
• Research and Prevention Save Lives
Take action: Speak out for increased funding of medical
research and prevention.
• Combating Childhood Obesity
Take action: Advocate for regular, quality physical education
and a healthy school environment for all children.
• Deadly Killer: Tobacco
Take action: Support smoke-free communities and other
tobacco prevention policies for your family and friends.
Heart for Women Act
29
• Nobody can go back and start a new
beginning, but anyone can start today and
make a new ending.
— Maria Robinson
Circulation. 2009;119:362-364
QUESTIONS, COMMENTS, CRITICISMS?
THANK YOU!
30