Cardiovascular Disease in Women: Common Myths

February 7, 2009

Jon W. Wahrenberger, MD FAHA

Disclosures

I have no financial interests to disclose … I wish I did!

I do not specialize in women’s health issues, but about half of my patients are female.

I cannot rule out the influence of my Y-chromosome

As an only son and with 4 sisters I am expected to be sensitive to women’s issues …

….but at any given time at least one of my sisters is annoyed with me about something.

Are women more complicated than men?

Hormones in Men vs. Women

CARDIOVASCULAR DISEASE IS MAINLY A DISEASE OF OLD MEN

Myth 1

More women are dying of CVD than Men

Source: American Heart Association

Cardiovascular disease is the leading cause of death in women

Source: American Heart Association

Although less frequent, CVD occurs in young women

More than35,000 women under the

age of 65 die annually in the US

from CVD

WOMEN DON’T NEED TO WORRY

ABOUT CARDIOVASCULAR DISEASE BEFORE

MENOPAUSE

Myth 2:

Relationship between early menopause and accelerated CVD?

Increasing Risk of CVD

Minimal or no CVD Risk

Menopause

Traditional Paradigm:

Increasing Risk of CVDMenopaus

e

Alternative Paradigm:

Coronary heart disease progresses over decades

Decades of time

Smoking, High Blood Pressure, Elevated

Cholesterol, Diabetes, Inactivity, Obesity

Age, Heredity

The reality: Being premenopausal probably does not protect you from cardiovascular

disease and you should be vigilant at all ages …

HORMONE REPLACEMENT

THERAPY IS DANGEROUS TO THE HEART AND SHOULD

NOT BE TAKEN UNDER ANY

CIRCUMSTANCES

Myth 3:

Estrogen

Critical to reproductive function in men & women

Most produced by ovaries

Some arises from fat, liver, breasts, adrenals

Complex physiologic effects

Changing Estrogen Levels with Age

Estrogen Progesterone

Perimenopausal Symptoms: hot flashes, insomnia, mood changes

Menopausal Physiology: osteoporosis, vaginal mucosal thinning

The GoodThe Good The BadThe Bad

Relief of menopausal symptoms

Reduction in osteoporosis (bone thinning) and fractures

Cardio-protective effects??

Improvement in lipid profile

Breast cancer riskUterine cancer riskComplex

formulation

The Good and Bad of Estrogen Replacement

Women’s Health Initiative

16,608 Post-menopausal

women aged 50-79 with an

intact uterus

Estrogen +Progesterone

Placebo

Study stopped after mean

follow-up of 5.6 years

Hormonal replacement associated with:•Increased heart disease (29% ↑)•Increased stroke (41% ↑)•Increased blood clots •Increased breast cancer (26% ↑)•Reduced colon cancer•Reduced hip fracture

Conclusion: HRT should not be used to prevent disease

in healthy post-menopausal women

WHS: Caveats

Overall mortality was identical in the two groups

Event rates in both groups was low and absolute rates in the estrogen + progesterone group was low - overall risk of treatment is low

Estrogen vs. progesterone influence on outcomes is unknown

Women’s Health Initiative: Estrogen Only Study

10,739 Post-menopausal

women aged 50-79 with previous

hysterectomy

Estrogen Only

Placebo

Study stopped after mean follow-up of

6.8 years

Estrogen replacement associated with:

•9% reduction in heart disease•39% increase stroke •33% increase blood clots •No change in cancer •39% reduction hip fracture

Women’s Health Initiative: Estrogen Only Study

Conclusion: In younger post-menopausal women post hysterectomy, estrogen alone

may be beneficial

Age Group Risk of Coronary Heart Disease

Risk of Stroke

50-59 37% reduction 11% reduction

60-69 6% reduction 62% increase

70-69 13% increase 21% increase

Overall 9% reduction 39% increaseSource: JAMA 2007;297:1477

Oral EstrogenOral Estrogen Transdermal EstrogenTransdermal Estrogen

Large impact on liver metabolism

Increase in inflammatory markers

Increase in protective HDL cholesterol

Bypasses liverNo change in

Inflammatory markers

Reduction in LDLImprovement in

“atherogenic index of plasma”

Reduction in oxidation index

Oral versus Transdermal Estrogen

Estrogen Replacement: The reality

Estrogen therapy is reasonable for the relief of perimenopausal symptoms if started early and tapered after a few years

Estrogen administered transdermally may be less likely to increase risk of blot clots

Estrogen should not be given to reduce CVD risk

VITAMIN SUPPLEMENTATION IS KEY

TO PREVENTING CARDIOVASCULAR DISEASE

IN WOMEN.

Myth 4:

39,876 healthy

women age ≥ 45

Vitamin E600 IU

Placebo

~ 10 years

636 Deaths

615 Deaths

Source: JAMA. 2005;294(1):56-65

B-Vitamins & Health in Women

5442 woman

with CAD or ≥ 3 risk

factors

Folic AcidVit. B6Vit B12

Placebo

~ 7 years

406 Events

390 Events

Source: JAMA. 2008;299(17):2027-2036

The Reality:

Vitamin E and B vitamins are probably safe, but there is no convincing evidence that they need be taken regularly

Some supplements (ephedra) are downright dangerous

Many supplements interact with medicationsThe entire supplement industry is unregulated; the

safety and purity is entirely in the hands of the manufacturer.

IF I’M THIN AND EXERCISE

REGULARLY I SHOULD BE IMMUNE TO

CARDIOVASCULAR DISEASE.

Myth 5:

The Reality:

Inactivity and obesity are just two of many CVD risk factors, and probably not the strongest

Exercise is great but not necessarily enough!

Non-ModifiableNon-Modifiable ModifiableModifiable

Age GenderHeredity

Tobacco UseCholesterolBlood pressureDiabetesPhysical inactivityOverweight

condition

Cardiac Risk Factors

EGGS ARE UNHEALTHY AND SHOULD

NOT BE EATEN.

Myth 6:

The Facts

Egg yolks do contain cholesterolStudies have shown a clear relationship

between serum cholesterol and cardiovascular disease outcomes

Studies have not shown a relationship between egg consumption and health outcomes

What’s in an Egg?

One Medium Egg

Daily Allowance

Daily Allowance if

high risk

213 300 200

213 mgCholesterol

0 mgCholesterol

OK to eat an egg if consistent with overall daily cholesterol limits

MOST WOMEN DO NOT EXPERIENCE CHEST PAIN DURING A HEART ATTACK

– FATIGUE AND SHORTNESS OF BREATH

ARE MUCH MORE COMMON.

Myth 7:

The Facts

Chest discomfort is the most common symptom of a heart attack in both men and women

Women are more likely than men to have additional non-specific symptoms, including: Fatigue Shortness of breath Weakness

Devon, et al. Amer J Critical Care 2008:17(1): 14-24

The Facts

Devon, et al. Amer J Critical Care 2008:17(1): 14-24

The Facts

Location Women (%) Men (%)

Central Chest 75 81

Left chest 57 56

Left arm 40 42

Neck* 37 22

Right chest 37 34

Upper back 34 26

Jaw* 24 12

Devon, et al. Amer J Critical Care 2008:17(1): 14-24

Location of Chest Pain

*Indicates statistically significant difference

The Facts

Location Women (%) Men (%)

Pressure 77 74

Tightness 66 72

Heaviness 58 57

Dull 45 43

Sharp 40 44

Devon, et al. Amer J Critical Care 2008:17(1): 14-24

Quality of Chest Pain

No differences were statistically significant

The Facts

Men and women present relatively similarly with heart attack

For both genders the important point is not to ignore symptoms of a potentially life-threatening condition

CHOCOLATE IS SINFULLY

BAD AND SHOULD BE EATEN ONLY

RARELY

Myth 8

This could be true, but there is some preliminary data to suggest dark chocolate may be beneficial!

Beneficial Effects of Dark Chocolate

Raises protective HDLImproves insulin sensitivityLowers blood pressureImproves endothelial function

ClinicallyRelevant?

Recommended Dose

Rx

Go Red Luncheon Attendee

Dark chocolate, 100 gmDirections: 1 bar dailyDispense 30 day supply

Jon W. Wahrenberger, MD

EXERCISE IS BENEFICIAL

ONLY IF PROLONGED(NO PAIN/NO

GAIN)

Myth 9

Exercise: the facts

There is a dose-response relationship (more is better)

Strenuous exercise is probably better than less strenuous exercise

Several studies have shown that repeated intermittent periods of exercise have a cumulative effect similar to prolonged exercise

Summary

Don’t believe everything you hearWork on traditional risk factors throughout your lifeEggs are OK …. in moderation … as is dark

chocolateOvarian hormone therapy is OK in the young women

with premature or surgical menopause – taper in early 50’s – some data suggest transdermal best

A balanced diet is probably far more helpful than vitamins and supplements

Exercise is beneficial – almost any way you do it!

Questions?