Download - Heart Disease Prevention and Management in Women...AFSHAN HAMEED, MD, FACOG, FACC Associate Clinical Professor Maternal Fetal Medicine and Cardiology University of California, Irvine

Heart Disease Prevention and Management in

Women

Heart Disease Prevention and Management in

Women

AFSHAN HAMEED, MD, FACOG, FACCAssociate Clinical ProfessorAssociate Clinical Professor

Maternal Fetal Medicine and Cardiology Maternal Fetal Medicine and Cardiology University of California, IrvineUniversity of California, Irvine

Scripps Scripps MercMerc y Hospitaly HospitalJanuary 22January 22,, 20132013

Prevalence of CVDPrevention and Management

of CVD

ACC/AHA guidelines for prevention

of CVD in women 2011 update

Pregnancy related cardiac mortality• CMQCC/PAMR Report 2011

Gender Differences

Key points

Presenter

Presentation Notes

We will review prevalence of CVD. I will share with you the recent guidelines update from ACC/AHA on prevention of CVD in women. Will review the latest on pregnancy related mortality data in California along with the gender differences

Cardiovascular DiseaseCardiovascular DiseaseLeading cause of death

among women

> 500,000 women/yr

6 X breast cancer

Presenter

Presentation Notes

CVD remains the leading cause of death amongst women.

CVD is the Leading Cause of Death in Women

CVD Accounts for More Deaths Than the Next “7” Leading Causes of Death In Women!

CVD is the Leading Cause of Death in CVD is the Leading Cause of Death in Women Women

CVD Accounts for More Deaths Than the Next CVD Accounts for More Deaths Than the Next ““77”” Leading Causes Leading Causes of Death In Women!of Death In Women!

Adapted from Thom T et al. Circulation 2006;113:e85–e151.

Actual Cause of Death of U.S. Women (2003)CVD Cancer COPD Alzheimer’s Diabetes

Dea

ths,

thou

sand

s

500

400

300

200

100

0

600

38,74845,05865,672

267,902

483,842

Presenter

Presentation Notes

Cardiovascular disease (CVD) is by far the leading cause of mortality in U.S. women, responsible for more deaths than the next “7” leading causes of death in women combined (cancer, COPD, Alzheimer’s, diabetes, and accidents).1 2. Mosca L, Ferris A, Fabunmi R, et al. Tracking women's awareness of heart disease: an American Heart Association national study. Circulation. 2004;109:573–579.

Cardiovascular disease in womenCardiovascular disease in women

CVD still causes more deaths in women than cancer, chronic lung disease, Alzheimer's, and trauma combined

5

All Age Groups ………All Age Groups ………Young women

Cardiac risk factors

Metabolic syndrome

Older women

Prevention & treatment

Pregnant

Diagnosed/undiagnosed cardiac disease

Presenter

Presentation Notes

We as OB/GYNs are privileged to interact with women at various stages of their lives. There are opportunities for improvement starting early years of life

Maternal Mortality Rate, California and United States; 1991-2008

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1991-2008. Maternal mortality for California (deaths ≤

42 days postpartum) was calculated using ICD-9 cause of death classification (codes 630-638, 640-648, 650-676) for 1991-1998 and ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) for 1999-2008. United States data and HP2010

Objective were calculated using the same methods. The break in the trend line represents the change from ICD-9 to ICD-10. U.S. data is available through 2007 only. Produced by California Department of Public Health, Maternal, Child and Adolescent Health Division, February,

2011.

Presenter

Presentation Notes

Updated 4.27.11 TALKING POINTS:

THE CALIFORNIA PREGNANCY-ASSOCIATED

MORTALITY REVIEW (CA-PAMR)

Report from 2002-2003 Maternal Death Reviews

THE CALIFORNIA PREGNANCY-ASSOCIATED

MORTALITY REVIEW (CA-PAMR)

Report from 2002-2003 Maternal Death Reviews

This project was supported by federal Title V block grant funds received from the California Department of Public

Health; Center for Family Health; Maternal, Child and Adolescent Health Division

Presenter

Presentation Notes

Updated 4.27.11 ACKNOWLEDGEMENTS The California Pregnancy-Associated Mortality Review (CA-PAMR) requires the work and support of many people who deserve acknowledgement. Dr. Susann Steinberg, former Chief, and Dr. Shabbir Ahmad, Acting Chief of the California Department of Public Health (CDPH); Maternal, Child and Adolescent Health Division provided early leadership to sound the alarm and to act to address the rising rates of maternal deaths. Their requests for action were supported by leadership in the Department of Public Health: Catherine Camacho, Deputy Director of the Center for Family Health; Dr. Kevin Reilly, Chief Deputy Director of Policy and Programs; Dr. Mark Horton, former CDPH Director; and Kim Belshé, former Secretary of the California Health and Human Services Agency. We sadly acknowledge the women who died during or after their pregnancies, the families who love and miss them, and the clinicians who cared for them. Each maternal death in this report represents a woman whose life ended early. This report seeks to honor the memories of these women by improving the experience of expectant mothers everywhere.

Maternal MortalityMaternal MortalityAfrican American Women

4 x likely to die (only 6% of all births)

Leading cause of death is cardiomyopathy

Hispanic Women

Hispanic women have the largest number of pregnancy-related deaths (account for 51% of all births)

Preeclampsia/eclampsia leading clinical cause of death

Preventable DeathsPreventable DeathsChance to alter outcomes

38% of all cases were found to have good or strong chance to alter the outcome• Health care professional factors (97%)• Facility factors (75%)• Patient factors (75%)

CA-PAMR Major Findings CA-PAMR Major Findings • Increased incidence of pregnancy-

related deaths in California for 2002- 2003

• Cardiac disease, especially cardiomyopathy, is the leading cause of pregnancy-related deaths in California

Presenter

Presentation Notes

Updated 4.27.11 Elaborations of bullet points: The emergence of cardiomyopathy as a leading cause of pregnancy-related death should prompt public health efforts to help childbearing women optimize their health before and during pregnancy. This includes appropriate screening, follow-up, and monitoring for underlying conditions, such as heart disease. One example of translation of CA-PAMR data into action is the Obstetric Hemorrhage Toolkit developed by CMQCC (http://www.cmqcc.org/ob_hemorrhage). Using Title V funds provided by CDPH MCAH, the Toolkit and associated Learning Collaborative target improvement in the recognition and response to obstetric hemorrhage in California.

3 million women age 18-44 in the US have cardiac

disease ~ 1-2% of pregnant women

3 million women age 18-44 in the US have cardiac

disease ~ 1-2% of pregnant women

13

Presenter

Presentation Notes

Disease of heart arteries, this process starts very early in life, in teenage years, from the 20’s-30;s there is deposit of fat or plaque in the artery walls. Later in life as this plaque builds it can rupture causing a heart attack.

PDAY study: US Adults 30-34 years of age

14

Presenter

Presentation Notes

Here is more evidence of how early it starts. The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Autopsies, death due to trauma, MVA, homicide, or suicide. This study showed that among US adults 30-34 years of age, 19% of male and 8% of females have an LAD stenosis that is 40% or greater. Most of us would not have guessed that 1 in 5 males and 1 in 10 women the ages of 30-34 has around a 50% diameter lesion in his LAD…Atherosclerosis starts early in life.

Prevalence of Cardiovascular Diseases in Americans Age 20 and Older by Age and Sex

NHANES: 1999-2002

Prevalence of Cardiovascular Diseases in Prevalence of Cardiovascular Diseases in Americans Age 20 and Older by Age and SexAmericans Age 20 and Older by Age and Sex

NHANES: 1999NHANES: 1999--20022002

Source: CDC/NCHS and NHLBI. These data include coronary heart disease, congestive heart failure, stroke and hypertension.

11.222.9

36.2

86.4

52.968.5

77.8

6.217.6

36.6

56.5

75.0

0102030405060708090

100

20-34 35-44 45-54 55-64 65-74 75+

Ages

Perc

ent o

f Pop

ulat

ion

Males Females

Presenter

Presentation Notes

IF you look at the most recent data closely…you see that women now “catch up” with men in terms of the prevalence of CVD by the 4th decade.

PREVENTION AND MANAGEMENT OF CARDIOVASCULAR

DISEASE

PREVENTION AND MANAGEMENT OF CARDIOVASCULAR

DISEASE

Evaluation of CVD RiskEvaluation of CVD RiskHistory

Medical history

Family history

Pregnancy complication history

Symptoms of CVDPhysical exam – BP, BMI, waist sizeLaboratory tests – fasting lipids & glucoseFramingham risk assessment if no CVD or

diabetes

Prevention of CVD in Women - AHA Guidelines 2011 update

Framingham Risk Score in Women

CVD Risk Factors CVD Risk Factors

Family History of premature CHD

male <55, female <65 years

Diabetes

Hypertension

Dyslipidemia

Smoking

Obesity

Physical inactivity


Additional CVD Risk Factors Additional CVD Risk Factors

History of preeclampsia, gestational diabetes, or pregnancy induced hypertension

Metabolic syndrome

Systemic autoimmune collagen vascular diseases – lupus or rheumatoid arthritis


Risk Factors in Women >20 yrsRisk Factors in Women >20 yrs

High Blood PressureHigh Blood Pressure

Abnormal LipidsAbnormal Lipids

OverweightOverweight

High GlucoseHigh Glucose

Physical InactivityPhysical Inactivity

Tobacco UseTobacco Use

3030--45%45%

4040--55%55%

6060--75%75%

55--25%25%

3535--60%60%

~20%~20%

HypertensionDiabetesDyslipidemiaSmokingObesity/InactivityMetabolic syndrome

Prevention of Cardiovascular Disease

Lifestyle InterventionsPrevention of Cardiovascular Disease

Lifestyle InterventionsSmoking cessation Physical activity – at least 150

min/wkWeight - <25 kg/m2

Dietary intake – fruits and vegetables, fish twice a week, limit saturated fatOmega-3 fatty acids


Mediterranean Dietary Pattern

Mediterranean Dietary Pattern

Emphasis on plant foods Legumes Nuts and seedsWhole grains Fresh fruits as dessert Olive oil as the main source of dietary fat Cheese and yogurt as main dairy foodModerate amounts of fish and poultry

2x/week: fish favored over poultry

Small amounts of red meat—few times a month

26

Vegan DietVegan Diet

27

Presenter

Presentation Notes

All the protein comes from plant source…no anmial source of diet

Vegan DietVegan Diet

Emphasizes protein from plant sourcesNo animal source, including dairy/eggsThis diet maybe more effective for those

with severe CAD (after multiple bypass surgeries, multiple stents)

28

Classification of HTN 2003 Joint National Commission VII

Classification of HTN 2003 Joint National Commission VII

BP Classification

SBP DBP Lifestyle Modification

Normal <120 <80 Encourage No meds

Pre-HTN 120-139 80-89 Yes

Stage I HTN 140-159 90-99 Yes Thiazide diuretics

Stage II HTN >160 >100 Yes 2 drug combination

N Engl J Med. 2001;345:1291–1297

Increased CV Risk in Women Starts at 120/80 mmHg

Increased CV Risk in Women Starts at 120/80 mmHg

CV death, MI, Stroke, and HF Among 3,892 WomenCV death, MI, Stroke, and HF Among 3,892 Womenin the Framingham Cohortin the Framingham Cohort

Cu

mu

lati

ve I

nci

den

ce, %

10

8

6

4

2

00 2 4 6 8 10 12 14

Time, years

High Normal130–139/84–89

Normal120–129/80–84

Optimal<120/<80

Adjusted Hazard Ratio=2.5

p<0.001 across categories

Continuous assoc b/t BP and CV risk!

Presenter

Presentation Notes

An analysis of women in the Framingham Heart Study demonstrated that the cardiovascular disease (CVD) risk gradient extends down to the optimal blood pressure (BP) of 120/80 mmHg. In an 10-year follow-up of 3,892 women free from hypertension and CVD at baseline, the incidence of a first cardiovascular (CV) event was 4.4% among those with BP 130-139/84-89 mmHg, compared with 2.8% among those with BP 120–129/80–84 mmHg. This corresponded to a hazard ratio (HR) of 2.5 (adjusted for concomitant CV risk factors), P<0.001 for comparison across categories.1 These findings underscore the continuous association between BP level and CV risk, and demonstrate that even modestly elevated BP can contribute to CV risk. 1.Vasan RS, Larson MG, Leip EP, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med. 2001;345:1291–1297.

Hypertension in WomenHypertension in Women

Who has it (BP >140/90)?

25% > age 18

60% caucasian > age 45

80% African American > age 45

Equal treatment benefit M/F

25% reduction in CHD and CHF

36% reduction in CVA

HTN – Major Independent Risk Factor for MI and Heart Failure HTN – Major Independent Risk Factor for MI and Heart Failure

BP >140/90 mm Hg associated with:

69% of first MI

91% of cases of HF

Increased risk of HF

3 X in females and 2 X in males

Increased risk of LVH in females vs. males

Adapted from Thom T et . al. Circulation. 2006;113:e85–e151

Confers greater CVD risk in women3-7 x vs. 2-3 x risk of CV death in F vs. M

Risk MI: 19% F vs 4% M

2nd MI: 45% F vs 20% M

NEJM 1998 339; 229, JAMA 1998 53; 96

DiabetesDiabetes

Half of all women > 55 yrs have TC > 240Low HDL and high TG are stronger predictors of CV death in women than in men

Treatment benefit is equal M/F (statin Rx)

Half of all women > 55 yrs haveHalf of all women > 55 yrs have TC > 240TC > 240Low HDL and high TG are stronger predictors of CV death in women than in men

Treatment benefit is equal M/F (Treatment benefit is equal M/F (statinstatin Rx)Rx)

Abnormal LipidsAbnormal Lipids

Smoking in WomenSmoking in Women

Doubles the risk of CHDIncreases the risk of sudden cardiac

deathIncreases blood pressure and stroke

riskMore susceptible to lung cancer

33% of U.S. women >18 yrs of age are obese

Women who are > 30 pounds overweight are more likely to develop CHD even if they have NO other risk factors

CVD risk is greater if the weight is around the waist than around the hips (“apple” vs. “pear”)

33% of U.S. women >18 yrs of age are obese

Women who are > 30 pounds overweight are more likely to develop CHD even if they have NO other risk factors

CVD risk is greater if the weight is around the waist than around the hips (“apple” vs. “pear”)

ObesityObesity

Hypertension Increases With Obesity in Women

Hypertension Increases With Obesity Hypertension Increases With Obesity in Womenin Women

Huang Z et al. Ann Intern Med. 1998;128:81–88

Multivariate RR* for Hypertension (140/90) according to Weight CMultivariate RR* for Hypertension (140/90) according to Weight Change hange

*Adjusted for age, BMI at age 18 years, height, family history o*Adjusted for age, BMI at age 18 years, height, family history of myocardial infarction, parity, oral contraceptive f myocardial infarction, parity, oral contraceptive use, menopausal status, postmenopausal hormone use, and smoking.use, menopausal status, postmenopausal hormone use, and smoking.

Nurses Health Study data n=82,473Nurses Health Study data n=82,473

Age <45Age <45Age 45Age 45––5454

Age Age ≥≥5555

LossLoss ≥≥1010

Loss Loss 5.05.0––9.99.9

Loss Loss 2.12.1––4.94.9

Change Change ≤≤2.12.1

Gain Gain 2.12.1––4.94.9

Gain Gain 5.05.0––9.99.9

Gain Gain 1.01.0––19.919.9

Gain Gain 20.020.0––24.924.9

Gain Gain ≥≥2525

Mu

ltiv

aria

te

Mu

ltiv

aria

te

Rel

ativ

e R

isk

Rel

ativ

e R

isk

766

5544

33

22

11

00

Weight Change After 18 Years, kgWeight Change After 18 Years, kg

RR

44%

RR ↑

7x

Presenter

Presentation Notes

In the Nurses' Health Study, a long-term follow-up study of 82,473 female registered nurses who were 30 to 55 years of age at study entry, higher (body mass idex (BMI) was strongly associated with an increasing risk for hypertension. The association between weight change and risk for hypertension was particularly strong among younger women (<45 years), and remained pronounced after adjustment for age, BMI at age 18 years, and other covariates (P for trend<0.001).1 Among these younger women, losing 10 kg or more reduced the relative risk of hypertension by 44%; gaining 25 kg or more increased the relative risk of hypertension by a factor of nearly 7. Among older women (>55 years), the association was attenuated; the relative risks were 0.86 for weight loss of 10 kg or more and 3.72 for gain of at least 25 kg. The strength of the association was intermediate for middle-aged women (45 to 54 years).1 1. Huang Z, Willett WC, Manson JE, et al. Body weight, weight change, and risk for hypertension in women. Ann Intern Med. 1998;128:81–88.

Obesity and Diabetes: Why Does It Matter?

Obesity and Diabetes: Why Does It Matter?

Chan J et al. Diabetes Care 1994;17:961. Colditz G et al. Ann Intern Med 1995;122:481.

Age

-Adj

uste

d R

isk

Body Mass index (kg/m2)

Men

Women

<22 <23 23 24 25 27 29 31 33 35+

1.02.91.0

4.31.0

5.01.5

8.12.2

15.8

4.4

27.6

40.3

54.0

93.2

6.7 11.6

21.3

42.1

0

25

50

75

100DM CV death risk:

3-7 x F vs. 2-3x in M Risk MI: 19%F vs. 4% M 2nd MI: 45% F vs. 20% M

Presenter

Presentation Notes

Relationship between BMI and risk of type 2 diabetes The risk of diabetes increases with increasing BMI values in men and women [1,2]. Moreover, the age-adjusted relative risk for diabetes begins to increase at BMI values that are considered normal for men (24 kg/m2) and women (22 kg/m2) based on mortality risk. The marked increase in the prevalence of obesity is an important contributor to the 25% increase in the prevalence of diabetes in the United States over the last 20 years [3]. Increases in abdominal fat mass, weight gain since young adulthood, and a sedentary lifestyle are additional obesity-related risk factors for diabetes [1,4,5]. Colditz GA, Willett WC, Rotnitzky A, Manson JE. Weight gain as a risk factor for clinical diabetes mellitus in women. Ann Intern Med 1995;122:481-486. Chan JM, Rimm EB, Colditz GA, et al. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 1994;17:961-969. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care 1998;21:518-524. Ohlson LO, Larsson B, Svardsudd K, et al. The influence of body fat distribution on the incidence of diabetes mellitus. Diabetes 1985;34:1055-1058. Helmrich SP, Ragland DR, Leung RW, Paffenbarger Jr RS. Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus. N Engl J Med 1991;325:147-152.

InactivityInactivity

60% of US adults lack a regular physical exercise routine

30% women have no leisure time activity

Risk Reduction for CHD Associated with Exercise in

Women

Risk Reduction for CHD Associated with Exercise in

Women

00.10.20.30.40.50.60.70.80.91

1 2 3 4 5Quintile Group for Activity (MET - hr/wk)

Walking

Any PhysicalExercise

Physically Active Women can reduce CVD risk by nearly 50%

Manson JE, et al. A prospective study of walking as compared with vigorous exercise in the preventionof coronary heart disease in women. N Engl J Med 1999;341:650-658.

Presenter

Presentation Notes

SLIDE INFORMATION SOURCE: Manson JE, et al. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. N Engl J Med 1999;341:650-658. Research has shown that, after controlling for other factors that affect heart disease risk, women who walk the equivalent of three or more hours per week have a risk of coronary events that is 35% lower than women who walk infrequently(1) . (1) Manson JE, et al. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. N Engl J Med 1999;341:650-658.

Metabolic SyndromeMetabolic SyndromeFemale Male

Waist circumference

>35 inches (88 cm) >40 inches (102 cm)

Triglycerides >150 or drug Rx >150 or drug Rx

HDL-cholesterol <50 or drug Rx <40 or drug Rx

Blood pressure >130/85 or drug Rx >130/85 or drug Rx

Fasting plasma glucose

>100 or drug Rx >100 or drug Rx

3 out of 5 = metabolic syndrome National Cholesterol Education Program (NCEP) / Adult Treatment Panel (ATP) III

Guidelines 2005

Metabolic Syndrome …..Metabolic Syndrome …..

Risk increase:

Diabetes 10 X

Cardiovascular disease 2 X

Polycystic ovaries

Obstructive sleep apnea

Fatty liver disease

Gout / increased uric acid

Cognitive decline/dementia

Rx

Weight loss, diet, exercise


Major Risk Factor InterventionsPrevention of Cardiovascular Disease

Major Risk Factor Interventions

Blood pressure: optimal level & life style

<120/80 mm Hg

Weight, exercise, moderate alcohol, sodium restriction, fruits & vegetables, low fat dairy products

Blood pressure: Pharmacotherapy

BP >140/90 or >130/80 with DM or Chronic renal disease

Thiazide diuretics in most

Beta blockers and/or ACE inhibitors/ARBs in CAD



Major Risk Factor InterventionsPrevention of Cardiovascular Disease

Major Risk Factor Interventions

Lipid and lipoprotein levels: optimal levels and lifestyle

LDL-C <100

HDL-C >50

TG <150

Lipids: Pharmacotherapy for LDL-C

> 60 years of age with increased risk and hs-

CRP >2 mg/dl – consider statin therapy

HDL-C therapy if <50 mg/dl


Interventions Class III - Not Effective / May Harm for primary

or secondary prevention of CVD

Interventions Class III - Not Effective / May Harm for primary

or secondary prevention of CVD

Hormone therapy or SERMsAntioxidant supplementation (vitamin

B, C, beta carotene)Folic acidAspirin for healthy women <65 years of

age


Goals ….Goals ….Total Cholesterol

< 200 mg/dL

LDL

< 100 mg/dL

HDL

< 50 mg/dl

Triglycerides

< 150 mg/dl

50

Goals ….Goals ….Blood pressure

< 140/90, normal is 120/80

Waist Circumference

< 30 inches

BMI

< 25 kg/m2

CRP

< 1 mg/L

51

Ideal Cardiovascular HealthIdeal Cardiovascular HealthAbsence of clinical CVDBMI <25 kg/m2Blood pressure <120/80 mm HgTotal Cholesterol <200 mg/dlFasting blood glucose <100 mg/dlNon-smokerPatricipation in physical activityHealthy diet - DASH


Interesting facts …Interesting facts …

Heart attacks are caused by blockages that are less than 70%Cholesterol is not the only reason

to have heart disease, inflammation plays a key role

53

Role of inflammationRole of inflammation

Key for an “event” to occurNeed plaque (built up from high

cholesterol, high blood pressure, smoking, high blood sugar)In order for the plaque to rupture

you need inflammation

54

Presenter

Presentation Notes

What is the role of inflammation, inflammation is a critical factor. Body is connected…what happens in one site of the body effects the other site

Measure of InflammationMeasure of Inflammation

Hs-CRP

Less than 1 mg normal

2-3 mg moderate

>3 high

55

Higher CRP causes higher number of heart attacks

Higher CRP causes higher number of heart attacks

56

Treating inflammation is importantTreating inflammation is important

Large trial of statin therapy

Women with normal cholesterol levels, but CRP levels higher than 1 mg/L, treating with a statin - decreased MI by ~ 50%

57

Presenter

Presentation Notes

There has been controversy on this issue of statins in women over the past few years, mainly because we didn't have a large number of women enrolled in these clinical trials. If you look at the average number of women enrolled in landmark statin trials, it was 20% to 30%, almost across the board. So in JUPITER, (17,800 patient) female patients constituted 38% of patients. Based on JUPITER, we know that if this woman was older, if her LDL cholesterol were lower, and we found that her CRP level was high, then she would definitely be eligible for statin therapy. But I agree with what Francine recommended, first, we always try to do lifestyle changes, since we know lifestyle modification has tremendous benefits, not just smoking cessation, but also having a healthy diet, mainly a lot of fruits and vegetables and fish, and also in terms of weight loss, if she has abdominal obesity or if her BMI is elevated.

How do we treat inflammation

How do we treat inflammation

Statins are not the only answer for treating inflammation

ExerciseDiet

58

Presenter

Presentation Notes

I will come back and discuss those, I quickly want to talk about biological differences in heart disease….

Weight influences CRP levelsWeight influences CRP levels

59

Presenter

Presentation Notes

Weight and level of activity influence inflammation

GENDER DIFFERENCES

How is heart disease different in women?

GENDER DIFFERENCES

How is heart disease different in women?

Biological Differences in Heart Disease


Women get CVD ~10 yrs laterDifferences in risk factors

Women tend to have lower LDL cholesterol

Have lower HDL cholesterol

Higher Triglycerides

Increased relative risk from hypertension, diabetes, triglycerides

61Canto et. al. JAMA 2012



Women can have different symptoms of MI

*Chest pain (58% vs. 70% in males)

Shortness of breath, dizziness, nausea, sweating, shoulder or jaw pain

62*Canto et. al. JAMA 2012

Have we been looking at the wrong risk factors in women? Have we been looking at the

wrong risk factors in women?

Events in pregnancy (preeclampsia, diabetes) are important in determining your risk for heart diseaseWomen have more elevated CRP and

BNP than men when they come in with heart attacksEndothelial dysfunction higher in

women than men63

Have we been looking at wrong measures of atherosclerosis in

women?

Have we been looking at wrong measures of atherosclerosis in

women?Men usually present with significant

major coronary artery stenosesWomen get obstructive disease (70%)

Small vessel disease (microvascular disease) more likely

Women lay down plaque differently

More diffuse disease

64

Small vessel diseaseSmall vessel disease

Women's Ischemia Syndrome Evaluation (WISE) study

Women with significant myocardial ischemia in the absence of obstructive disease

Disease of the small branches.

Women with symptoms, but angiogram doesn’t show blockage

We don't know the prevalence, but it certainly is more prevalent than we thought 10 years ago

65

Presenter

Presentation Notes

This is a very, very important point because there's still some debate as to whether the disease is different. The WISE study shows us that there are differences, and it's really important for us to recognize that in practice. For the women that we see, we might stress-test them, get a positive test, and send them off to catheterization. However, today we actually have some of the tools that if we see some abnormality in a woman like this, we have tools to follow up and do things like flow reserve to understand the extent potentially of small vessel disease or use very focused intravascular ultrasound to really understand the degree of disease in certain areas. So it's important to truly understand the differences. Women often experience chest symptoms differently than men. The Women's Ischemia Syndrome Evaluation (WISE) study is one of the primary studies changing the way women's heart disease is detected and treated. For men, heart disease often manifests as blockage in the large arteries of the heart. One of the major discoveries of the WISE study is that many women with chest pain or other symptoms have microvascular disease, a narrowing of the small arteries and blood vessels of the heart. Blood flow to the heart is restricted by fatty plaque buildup, but the restriction does not show up in traditional diagnostic exams.

MAN

WOMAN

Presenter

Presentation Notes

Its about time we realized that women ARE more complex than most men give them credit for!!!

Shortness of breath 50% vs. 35%Arm/shoulder pain 38% vs. 27%Nausea 30 vs. 16%Dyspepsia 22 vs. 12%Mid-back pain 13 vs. 2%Palpitations 10 vs. 3%

Symptoms of MI in Women vs. Men

Symptoms of MI in Women vs. Men

Am J Cardiol 1999;84,396

Presenter

Presentation Notes

Mid back, arm or shoulder only are more common, as are GI symptoms. SOB is another Sx that is prevalent in women with MI

Women do worse with heart disease

Women do worse with heart disease

Higher chance of death when admitted to the hospital with heart attackHigher risk of not obtaining

proceduresHigher risk of complications with

proceduresYounger women do worse than

younger men68

Cardiac Evaluation During Pregnancy

Cardiac Evaluation During Pregnancy

Limitations of diagnostic tests:

Diagnostic yield

Potential risk to the fetus

Interpretation of test results – account for physiologic changes

B-Type Natriuretic PeptideB-Type Natriuretic Peptide

Neurohormone secreted from cardiac ventricles in response to ventricular volume expansion/pressure overload

Post PartumThird TrimesterSecond TrimesterFirst TrimesterNon-Preg Control

group

140

120

100

80

60

40

20

0

BN

P (p

g/m

l)

Hameed. et. al. Clin Cardiol 2009

Presenter

Presentation Notes

What is BNP? B-type natriuretic peptide is a neurohormone specifically secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload.

TroponinsTroponinsCardiac Troponin I and TcTn I specific to the heartcTn T present in minor amount

in skeletal muscleCardiac troponins rise 2-3 hours

after the onset of AMIPersist for ~ 10 days after AMI

Troponins - PregnancyTroponins - Pregnancy

Minimal increase in pregnancy

Well below the threshold levels

Increased levels seen in PIH

0.155 ng/ml vs. 0.089 ng/ml*

Increased with prolonged tocolytic therapy

0.35 ug/l vs. 0.08 ug/l

*Fleming SM et. al. British J of Obstet and Gynecol 2000;107:1417-1420

Creatine KinaseCreatine KinaseIsoenzymes - dimers or M and B

chains

MM, MB, BB

Starts rising in 4-6 hours and returns to baseline 36-48 hours

Cardiac Markers of Ischemia in Pregnancy

Cardiac Markers of Ischemia in Pregnancy

51 healthy pregnant women in laborTroponin I, myoglobin, creatine kinase

and CK MB were measuredFour measurements

During labor

30 minutes

12 hours and

24 hours after delivery

Bever FN et. al. Am J Obstet Gynecol 2002; 187:1719-1720

Cardiac Markers of Ischemia in PregnancyCardiac Markers of Ischemia in Pregnancy

Myoglobin and CK increase two fold @ 30 minutes after delivery

Peak at 24 hours

Troponin remained undetectable

Bever FN et. al. Am J Obstet Gynecol 2002; 187:1719-1720

Key PointsKey PointsCardiovascular disease is the

leading cause of death among womenRisk factors should be identified

in women of all agesAwareness and education is

needed to modify cardiovascular risk profile

Key PointsKey PointsLeading killer of women

500,000/yr1400 deaths/day; 1 death/minuteOften fatal…if not on 1st MI

…38% in next year2/3 without previously

recognized symptoms

Key PointsKey Points

Cardiac symptoms should be fully evaluatedPregnant & non-pregnant

[email protected]

Download - Heart Disease Prevention and Management in Women...AFSHAN HAMEED, MD, FACOG, FACC Associate Clinical Professor Maternal Fetal Medicine and Cardiology University of California, Irvine

Top Related