veterans health administration cardiovascular disease in women

VETERANS HEALTH ADMINISTRATION

Cardiovascular Diseasein Women


Objectives


Poll Question• Over the past 20-25 years, more women have been included in

cardiovascular-related clinical trials. We now know more about women and heart disease including how they present, what risk factors are more important, and how they respond to treatment.

• Based on research and general advances in prevention and treatment, death rates from heart disease have come down… but not as fast for women.According to the 2012 Women’s Heart Disease Awareness Study, what percent of women correctly identified cardiovascular disease (CVD) as the leading cause of death for women?

a) 70% b) 56%c) 35% d) 15%


Hear

t Dis

ease

300,000

250,000

200,000

150,000

100,000

50,00

Cancer

Stroke

Pulmonary

Disease

Alzheimer's

Disease

Diabetes

1 in 4 women died from heart diseaseNumber

of Deaths


Poll Answer

Poll Answer

According to the 2012 Women’s Heart Disease Awareness Study, what percent of women correctly identified cardiovascular disease (CVD) as the leading cause of death for women?

a) 70% b) 56%c) 35% d) 15%

Women’s awareness is improving; only 30% of women knew this in 1997, and 56% knew it in 2012. There is still room for improvement. Younger women in the 25-34 age group had the lowest rates of awareness. This is the group that is coming to the VA. Now is our chance to start educating women early.

We are the same,

yet we are different.

• Most recommendations for CVD prevention are similar for men and women with few exceptions

• There may be gender differences in the MAGNITUDE of some risks for women

• Women with CVD are about 10 years older than men at the time of presentation and therefore carry a greater burden of risk at diagnosis

• Women may not identify their initial symptoms as cardiac-related and do not seek medical attention as promptly

• Research now shows women may have more MICROVASCULAR DISEASE

• Women may also be underdiagnosed


Risk factors

Things we have in common


• After age 64, more women than men have hypertension• 18.3 million Americans have diabetes… 10 million are women• Hyperlipidemia is common in women; of those age 20 and older,

41-47% have cholesterol levels over 200• 17.5% of women 18 and older are smokers• Among women age 20 and older, 59% of White, 70% of Black, and

75% of Mexican-American women are overweight or obese• In 2010, only 16.4% of women ages 18 and older met Federal

Physical Activity Guidelines • Although death rates are decreasing, there is a slight increase in

death rates for women 35-54 due to obesity and underdiagnosis

These risk factors can be modified with lifestyle changes or interventions…


Chronic Stress• Has both emotional and physiologic effects on the body• Weakens the immune system • Causes changes to the autonomic nervous system, unregulated BP,

and damage to blood vessels leading to clot formation• May cause stress-induced cardiomyopathy, also called Broken Heart

Syndrome or Takatsubo Syndrome, where people present as if they’re having a heart attack after a traumatic event

• May weaken the heart muscle; happens more in women, especially after menopause

• People with depression and no documented heart disease at baseline, are more likely to develop heart disease later in life

• Depression screening should be part of every CV workup

VETERANS HEALTH ADMINISTRATIONNon-Modifiable Risk Factors

Non-Modifiable Risk Factors for CVD• Increasing age• Positive family hx, especially premature heart disease (CAD in a male

relative <55 or a female relative <65)• Race and ethnicity• Blacks - highest age-adjusted death rates for heart disease• Black women - 1/3 more likely to die from heart disease or stroke than

white women; also higher rates of hypertension• South Asian descent - higher rates of CV morbidity and mortality than

people of European descent; rates not decreasing as quickly• Low SES - less disease awareness, less care seeking due to costs,

different treatment by health care system (fewer meds and testing)• Vulnerable groups, e.g. homeless women veterans (CDC has

WISEWOMEN PROGRAM which offers screening, lifestyle interventions and referrals for women with CVD)


Poll Question

Does a history of preeclampsia during pregnancy correlate with a higher incidence of CVD later in life?

a) Yesb) Noc) Unsure


What’s Different for Women…

Certain risk factors have more prognostic significance for women and should be emphasized in CV workups and treatment options

Monitoring these particular risk factors closely is important


Diabetes & Smoking• DM confers more prognostic significance

than any other risk factor for women• It increases CAD risk 3-7 fold in women vs.

2-3 fold in men• It doubles the risk of a second MI in women,

but not in men

• Smoking is associated with ½ of all coronary events in women

• It is the leading cause of death in younger women with heart disease


Poll Answer

Does a history of preeclampsia during pregnancy correlate with a higher incidence of CVD later in life?

a) Yesb) Noc) Unsure


Pregnancy Issues

• History of preeclampsia:Approximately twice the risk for

developing CVD in the 5-15 years after pregnancy

• History of gestational diabetes:Increases risk of developing CVD

later in life• Pregnancy may unmask unidentified CV issues; it is in a sense a

“failed stress test”• Pregnancy history should be part of any CV risk assessment. If

dealing with a post-partum women, refer for a CV workup.

Framingham Calculator (risk of heart attack in

next 10 years)

AgeGenderTotal cholesterol HDL cholesterol SmokerSystolic blood pressureCurrently taking anti-hypertensive

Reynolds Risk Score (risk of heart attack, stroke, other major heart disease in

next 10 years)AgeGenderTotal cholesterol HDL cholesterol SmokerSystolic blood pressureHigh sensitivity C-reactive protein (hsCRP)Mom/dad heart attack before 60


One-dimensional interventions are

ineffective.

Use multifaceted, interactive

interventions.

Incorporate decision systems

and feedback.

Employ motivational interviewing.

Start with one easily-achievable

small goal.

How to make someone…Thin

Active Nonsmoker

Normotensive Adhere to non-fat, low-

salt dietStress free

Educate patients on goals to prevent or modify risk factors• Take BPs at home to follow over time, looking for persistently high

readings

• Hemoglobin A1c <7%; often requires med + lifestyle mods

• Stop smoking, get weight under control; good goal is BMI <25

• 30 mins of moderate aerobic exercise 5 days/wk or 45 mins of intense aerobic exercise 3 days/wk; strength training twice/wk

• DASH-type diet incorporating low-fat, low-salt, lean protein, fruit and vegetables approach. Vegan diet can lower weight, BP, and cholesterol but hard to adhere

• Lipid levels at target: total cholesterol <200, LDL <130 for healthy person (target changes to <70 for high-risk patients), HDL >50 , triglycerides <150

Goal

s


Antioxidants (vitamins E, C, beta carotene)

Folic acid

Hormone replacement therapy

Not Effective for Primary Prevention of Heart Disease

•Estrogen was initially thought cardioprotective, but HRT did not prevent CVD in women. Largest study was Women’s Health Initiative.

•New trials are assessing what happens if HRT is started earlier after menopause, but not appropriate at this time to recommend HRT for reducing heart disease risk.


Aspirin• Primary prevention measures are aimed at preventing a disease

from happening• Secondary prevention measures treat an already established

disease in an attempt to prevent worsening outcomes

Aspirin:•Used in men to PREVENT heart disease•Not proven to PREVENT heart disease in healthy women under age of 65•Use in both genders who have established heart disease


Clinical Presentations of Angina Atypical Symptoms•Dyspnea

•Excessive fatigue

•Nausea/vomiting

•Diaphoresis

•Presyncope

•Palpitations

Typical Symptoms•Sensation over sternal area

•Sharp, heavy, pressure or squeezing sensation

•Pain radiates to neck, jaw, down arms, or to back

•Pain worsens with exertion or stress

Women, patients with diabetes, and older adults often do not present with classic symptoms


AssessmentTypical Acute Cardiac Symptoms

• Goal: Move patient through the system quickly; ideally, get patient from the door to the cath lab in 90 mins or less

• Know your protocol for what to do when a patient presents with an acute cardiac syndrome

• Quickly assess patient’s overall appearance. Take vitals and a very directed history: when did it start, what have you done, do you have heart disease?

• Notify provider STAT• ECG within 10 mins of presentation

Acute MI: EKG Example 1ST elevations (RED arrows) notify provider STAT & transport

Acute MI: EKG Example 2Yellow shows ST elevations called tombstones. Blue shows ST depressions,

also a sign of ischemia but not quite as severe a crisis as ST elevations.


• Follow your institution’s protocol• Quickly assess patient’s appearance. Take a very

directed history: when did it start, what have you done, do you have heart disease?

• Vital signs stable or unstable?• Duration of symptoms?• What relieves symptoms?• EKG/labs as directed by protocol or provider• Some places have a 23-hr Observation Unit

AssessmentAtypical Acute Cardiac Symptoms

Common atypical presenting symptoms: dyspnea, excessive fatigue, nausea, vomiting, diaphoresis, presyncope, palpitations


Not Sure? Remember, women may present with atypical symptoms

Get advice from other team members Important to establish collegial relationships Err on the side of caution


Take Home Messages


Helpful Resources• Interpreting lipid levels for women: HeartHealthyWomen.org

veterans health administration cardiovascular disease in women

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