21-May-15

1

When it comes to ischaemic

heart disease:

women are from venus and

men are from mars

Understanding the gender discrepancies

Assoc. Prof. Margaret Arstall

Director of Cardiology, NALHN

University of Adelaide

What are the facts?

Population statistics

Australian Institute of Health &

Welfare / Heart Foundation report

2010

> Cardiovascular diseases (CVD) are

confirmed as the number one killer of

Australian women

• accounting for 37% of all female deaths and 29%

of premature deaths in women.

> About 2 million Australian women living with

CVD in 2004-05,

• 226,000 women having coronary heart disease,

• 168,000 who have had a stroke and

• 176,000 who have heart failure.

Atherosclerosis risk factors in

women

15% smoke

54% obese

48% high cholesterol

27% hypertension

2-7% diabetes

93% poor diet 76% sedentary

AIHW 2010

90% have 1 risk factor

50% have 2 risk factors

Pregnancy is the stress test

Complications of pregnancy are a marker of future CV risk

the problem doesn’t “go away” after delivery

Complication of pregnancy Relative risk of later cardiovascular event

Low birth weight baby 1.2 – 2.5

Preterm delivery 1.3 – 3.0

Gestational diabetes 1.6 – 1.7

Hypertension 1.7 – 3.6

Complications occur in 20 – 30% of pregnancies

• Multiple complications multiplies the risk

• Up to nine times increased risk!

Rich-Edwards et al. Epidemiol Rev 2014

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Is the pregnancy complication declare an underlying CV risk

Does the pregnancy complicationcreate the CV risk?

complication in pregnancy

encourage lifestyle changes

treat conventional CV risk factors as they reappear follow-up the

women

will this prevent premature CV event?

How should this be managed?

Chest Pain in Women 20 years ago

Retrospective cohort study of 3975 middle-aged patients referred for outpatient exercise testing. The women were:

> More likely to have “atypical” pain

> Less likely to be referred on

• Further testing (angiography)

• Revascularisation

> Higher 2 year incidence of cardiac death or myocardial infarction

Shaw LJ. Ann Int Med 1994;120:559

Managing women with angina in

general practice

The CADENCE study (2006 - 2007)

Rachel Dreyer et al. Eur Heart J 2011

Stable angina in Australian

general practice

> CADENCE STUDY

> Prospective, cross-sectional study

> Australian primary care practices.

> Examined symptomatic chronic stable angina

status

> Impact on health-related quality of life in men

and women with chronic stable angina

Rachel Dreyer et al. Eur Heart J 2011

The patient group

> Data collection time: October 2006 to

March 2007

> 207 participating GPs

> 2005 consecutive chronic stable angina

patients who attended their clinics,

irrespective of the purpose of the

consultation.

• 1284 males and 721 females recruited

• female patients considerably older than the

males

69±12 vs 73±11years, p < 0.0001).

> All analysis was age adjusted

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CV risk factors

RISK FACTOR MEN (n=1284)

WOMEN (n=721)

AGED ADJUSTED p

value

Diabetes 31% 29% ns

Diabetes within HbA1C target

54% 53% ns

Hypertension 69% 78% <0.0011

Hypertension within BP targets

60% 59% ns

Lipid targets achieved 22% 16% 0.0003

Ex-smoker 59% 29% <0.0001

Current smoker 11% 8% 0.0063

Obesity 84% 87% 0.0198

Angina characteristics

MEN WOMEN AGE ADJUSTED p value

Angina duration (yrs) 8.3±8.0 7.9±7.6 0.0028

Pain provoked by exertion 68% 62% 0.0028

Pain provoked by emotion 21% 27% 0.0018

ACS in the past 75% 62% <0.0001

AMI in the past 53% 38% <0.0001

Persistent angina 81% 78% ns

Canadian clinical class • I • II • III • IV

65% 26% 8% 1%

54% 33% 10% 3%

<0.0001 <0.0066

ns ns

Angina Investigation

TEST MEN WOMEN AGED ADJUSTED p value

Exercise test done 65% 57% 0.0176

• CAD detected 85% 81% 0.0096

Coronary angiogram done 83% 67% <0.0001

• CAD detected 98% 93% 0.0003

Angina treatment

> Women were less likely to be

reviewed by a cardiologist

> Treatment options for women

• Receive less cardioprotective

medications

• Less likely to undergo coronary

revascularisation procedures

• More likely to be prescribed long

acting nitrate therapy and calcium

channel blockers

Quality of life

> Women had a higher angina

frequency

> Women were more physically

limited by their angina

> Women had a poorer quality of

life.

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Coronary artery disease is

complex in women

Smaller calibre arteries

More diffuse disease

Less suitable for PCI or

CABG

Less obstructive CAD found

More microvascular dysfunction

More vasospasm

alters the clinical syndrome

alters the prognosis

challenges our treatment options

Women’s response is different to men

Challenges our diagnostic paradigms

Acute coronary syndrome in

women

A local experience

AMI with ST elevation on ECG

management

• Immediate

transfer to the

CVIS for PCI.

• “code blue

STEMI” paging

system.

• Readiness in 30

minutes.

STEMI database

> A comprehensive database is kept

for all ST elevation acute coronary

syndrome patients treated with

immediate PCI at LMH & TQEH

> In 2005-10 there were 735 STEMI

patients undergoing primary PCI

• 173 women (24%) vs 562 men

Rachel Dreyer , Bernadette Hoffmann et al, QCOR 2011

STEMI Features Men (n = 562) Women (n =173)

Door-to-Code Time 16 (7; 39) min 21 (7; 50) min

Code-to-Balloon Time 56 (45; 67) min 62 (49; 74) min

Door-to-Balloon Time 72 (55; 102) min 91 (68; 138) min

Door-to-Balloon time

≥ 90 minutes

162 (33%) 78 (54%)

Peak ST Elevation on ECG 3.11±2.5mm 2.79±1.88mm

Peak Creatine Kinase 2057±2739 IU 1712±2021 IU

30-Day All-cause

Mortality/Re-infarction

36 (6%) 27 (16%)*

Gender discrepancies analysis

> Women were significantly older

than men

• 6 years ±14 vs. 60±12years,

P<0.001

> Female gender was the

strongest predictor of 30-day

death and re-infarction

• 3 times more likely than men

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Why the delays?

Atypical symptoms & differing pathology

Delay seeking

help

It takes longer to do an ECG

staff take longer to

realise the diagnosis

more often have

technique challenges

more likely to have a

complicated clinical journey

Why the discrepancy in 30 day

mortality & re-infarction rate?

Delay in coming to

ED

Delay in treatment

Similar infarct size

Similar site of infarction

Haemo-dynamic

response is worse

Heart failure

more likely

The world view over time:

a meta-analysis of 5-10 year mortality

after AMI “Sex differences in long-term mortality after acute myocardial infarction are largely explained by differences in age, comorbidities, and treatment use between women and men.”

Bucholz EM et al. Circulation 2014. 130(9): 757–767

“Although risk ratios varied considerably over time, there appeared to be a slight downward trend, suggesting these sex differences have attenuated slightly over time.”

How do we speed up the diagnosis of

ACS?

How do we improve stent technology?

How do we better manage

vasoactive angina?

How do we better

manage CV risk?

How do we better manage angina in older

women?

How do we improve quality

of life in women with

angina?

Challenges