Dr. Suzanne Steinbaum Director, Women and Heart Disease Lenox Hill - - PowerPoint PPT Presentation

• Dr. Suzanne Steinbaum

Director, Women and Heart Disease Lenox Hill Hospital New York

A CVD (I00-I99; Q20-Q28) B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s Disease

CVD and other major causes of death for all males and FEMALE

DEATHS(United States: 2006). Source: NCHS and NHLBI.

290,069 59,260 269,819 398,563 78,941 36,006 432,709 65,323 51,281 42,658 100,000 200,000 300,000 400,000 500,000 A B C D E A B D F C Deaths Males Females

Age-adjusted death rates for CHD, stroke, lung and breast for white and black females (United States: 2006).

Source: NCHS.

41.1 41.1 22.9 57.0 39.0 31.6 101.5 130.0

50 100 150 200 Coronary Heart Disease Stroke Lung Cancer Breast Cancer Per 100,000 Population White Females Black Females

Menopause and the Risk of Coronary Heart Disease

(modified data from “Menopausal status as a risk for coronary artery disease” Arch Intern Med 1995;155:57-61

0.5 1 1.5 2 2.5 3 3.5 4 40 - 45 45 - 49 50 - 54 Before menopause After menopause

Age (in years)

Annual Occurence of Heart Attack/1000

African-American Women & Heart Disease

African-American women have a higher risk for heart disease than

Caucasians and are less aware of their risk factors, including:

Obesity (53.9% obese and 73.1% overweight and obese)¹ Physical Inactivity (65.4% of African-American women get no leisure time

physical activity)¹

High Blood Pressure¹ Diabetes (15.4% have diabetes)¹ Diet (Sodium Intake)¹

47% of African-American women over the age of 20 have high blood

pressure¹

African-American women bear a disproportionate burden of stroke,

heart failure, and kidney disease, all due to undiagnosed, or poorly controlled high blood pressure.²⁻³

1 Go A S, Mozaffarian, D, Roger, V L, Benjamin E J, et al. Heart Disease and Stroke Statistics 2013 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2013; e39-e90 2 Jha AK, Varosy PD, Kanaya AM, et al. Differences in Medical Care and Disease Outcomes Among Black and White Women With Heart Disease. Circulation. 2003;108:1089-1094. E39-e90 3 Pleis JR, Lucas JW. Summary health statistics for U.S. adults: National Health Interview Survey,

• 2007. Vital Health Stat 10. 2009; No. 240: 1-159.

5 www.womenheart.org

Hispanic-American Women & Heart Disease

Hispanic-American Women also have a slightly higher risk for heart

disease than Caucasians, and are less aware of their risk factors.

Obesity

• Among Mexican-American women, 44.8% are overweight and 78.2% are
• verweight or obese¹

Physical Inactivity High Blood Pressure

• Among Mexican-American women over the age of 20, 28.8% have high blood

pressure.¹

Diabetes (12% have diabetes … Nearly 2x higher than Caucasian women)¹ Diet (Sodium Intake)

Among Mexican-American women, 30.7% have cardiovascular

disease¹

1 Go A S, Mozaffarian, D, Roger, V L, Benjamin E J, et al. Heart Disease and Stroke Statistics 2013 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2013; e60- e111

6 www.womenheart.org

Awareness trends of Heart Disease as leading cause of death in women: FEBRUARY 10, 2010

60% WHITE WOMEN 43% AFRICAN-AMERICAN WOMEN 44% HISPANIC 34% ASIAN 50% women ages 25-34 **** NEED FOR PREVENTION

• Women younger than 55 years old- there was a greater increase in the risk of heart disease

and stroke

*increase is due to an increase in diabetes in this population *there has been a 93% decline of mortality of younger women compared to men due to better recognition and management of coronary artery disease and its risk factors *the disease process is escalating in a younger population.

We need to aggressively empower these women to achieve the lifestyle goals that diminish their risk factors in order to prevent this disease from presenting itself, not only at such a young age, but also in a woman's lifetime.

Epidemic of Heart Disease has reached the younger Population of women: October 2009 Archives of Internal Medicine

1988-1994 1999-2004 MEN 2.5% MEN 2.2% WOMEN 0.7% WOMEN 1%

Low rate of sex-specific reporting in Cardiovascular trials

Major journals- cardiology and internal medicine from July 1st through December 31, 2004 Result reporting for primary outcomes for women NIH funded-51%- 1993 act of inclusion General medical- 37% Cardiology- 23% SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY

AND INTERVENTIONS SCAI 2011- ONLY 25% OF NIH TRIALS TRACK GENDER SPECIFIC OUTCOMES

Differences in Referral for Testing and Treatment : Gusto IIB

10 20 30 40 50 60 % of Pts Referred Stress Testing Cardiac Cath PTCA CABG Women Men P<0.01 for all Tamis et al. Circulation 1997;96:I-536.

• 33%

67% 35% 65% 50%50% 22% 78% 20% 80%

0% 20% 40% 60% 80%

PTCI Peripheral Int. Pacemakers ICDs CRT-D for HF

• 1

2 1 1 2

Sources: 1-AHA: Heart Diseases and Stroke Statistics - 2004 Update 2-Guidant Internal Estimates

Low rate of sex-specific reporting in Cardiovascular trials

Major journals- cardiology and internal medicine from July 1st through December 31, 2004 Result reporting for primary outcomes for women NIH funded-51%- 1993 act of inclusion General medical- 37% Cardiology- 23% SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY

AND INTERVENTIONS SCAI 2011- ONLY 25% OF NIH TRIALS TRACK GENDER SPECIFIC OUTCOMES

15%

Val HeFT

CIBIS-II Clinical Trial; Lancet; Circulation, 2001; 103; 3;375-380; MERIT HF Clinical Trial; Ghali, JK, Circulation, 2002;105; 1585-1591; Val Heft Clinical Trial; Cohn, JN, N Engl J Med, 2001; 345; 1667-1675; COPERNICUS Clinical Trial; Gust, H Bardy; ACC , March 8, 2004. Men Women

Representation of Women in Pharma Heart Failure Trials

32%

COPERNICUS MERIT HF CIBIS II

77% 23% 75% 25% 80% 20% 80% 20%

Physician awareness of CVD prevention guidelines by specialty

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Physician incorporation of CVD prevention guidelines by specialty among respondents who stated they were aware of the guidelines

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The State of our Nation

45% of US has 1 risk factor- high blood pressure, high

cholesterol or diabetes

13% has 2 risk factors 3% have 3 risk factors 15% of adults also had one or more of these conditions

undiagnosed

Study Points to Declining Life Span for Some U.S. Women

Wall Street Journal March 4, 2013 University of Wisconsin study 3,141 women over 10 years In the South and West “unclear reasons”- Most often poor white women Theories- obesity, diabetes Women 81, men 76- women is dropping Started in the late 80’s

AHA 2020 STRATEGIC GOAL

“To improve the cardiovascular health

• f all Americans by 20% while reducing

the deaths from cardiovascular diseases and stroke by 20%”

Must create awareness to multicultural

women and young women

WHAT IS CORONARY ARTERY DISEASE?

ATHEROSCLEROSIS

PLAQUE BUILDUP CHOLESTEROL, FIBROUS TISSUE INFLAMMATORY CELLS BEGINS IN TEENS

Premature atherosclerosis (PDAY)

Abdominal aorta Right coronary artery

McGill HC Jr et al, Circulation 2002

Most Myocardial Infarctions Are Caused by Low-Grade Stenoses

Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al.)

Falk E et al, Circulation, 1995.

Intraluminal thrombus Growth of thrombus Intraplaque thrombus Lipid pool

Blood Flow

Atherosclerotic Plaque Rupture and Thrombus Formation

Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T13–18

Women’s Early Warning Signs of a Heart Attack

Weeks before Heart Attack (95% of women)

Unusual fatigue (70.7%) Sleep disturbance (47.8%) Shortness of breath (42.1%) Indigestion (39.4%) Chest pain (29.7 %)

At time of Heart Attack

Shortness of breath (57.9%) Weakness (54.8%) Fatigue (42.9%) Chest pain (57%)

McSweeney, JC et al. Circulation 2003; 2619-2623

AHA 2/10 survey: 2,300 women interviewed

Only 53% of women said they would call 9-1-1 if they thought they were having heart attack symptoms 56% of women saying chest pain and neck or arm pain 29% shortness of breath 17% chest tightness 15% nausea 7% fatigue

Profiles of Heart Disease in Men vs. Women: AHA

Deaths within one year of 1st MI 25% 38% Sudden deaths with no previous symptoms 50% 64%

Within six years of recognized MI, percent who will:

• have another MI
• have a stroke
• experience SCD*
• be disabled with heart failure

18% 8% 7% 22% 35% 11% 6% 46% Men Women

WISE Demonstrates Challenges in Diagnosis: NHLBI study: 1996 to 2000 Goals:

Improve diagnostic testing for ischemic heart

disease in women

Study pathophysiologic mechanisms and

prognosis in women with myocardial ischemia in the absence of obstructive coronary disease

Evaluate influence of hormones and menopause

• n symptoms and diagnostic testing results

Women with SYMPTOMS and NORMAL CORS

• n CATH

Women’s Ischemia Syndrome Evaluation (WISE)- 954 patients, 4 centers

Noel Bairey Merz, MD (WISE) Diagnosis and Pathophysiology of Ischemic Heart Disease Workshop October 2-4, 2002

Difference in Disease Presentation

Obstructed coronary artery Diffused narrowing in coronary artery

Findings from WISE

936 women with ches pain referred to angiography “typical” angina missed in 65% of cases of CAD Substudy of normal caths- absence of flow limiting

lesions

159- 47% abnormal microvascular flow reserve 163- impaired coronary vasomotor response to

acetylcholine independently linked to adverse CV

• utcomes

Some lesions severe enough to limit coronary perfusion

DETECTION OF CAD IN WOMEN

HISTORY IS VERY VARIABLE DIAGNOSTIC TESTING IS DIFFICULT MORE FALSE POSITIVES- stress ekg Dobutamine echo- not sensitive or specific for single

vessel disease, but diagnostic for multivessel disease

RISK STRATIFICATION OFTEN DIFFICULT,

ESPECIALLY IN YOUNGER WOMEN

THE FRAMINGHAM RISK

After WWII- development of heart disease 1948- stable town Lifestyles were analyzed Until 1961, then the children- Offspring study Our assessment now is based on the results of this

study…

CHOLESTEROL GOALS BASED ON RISK

Cholesterol distribution in CHD and non-CHD populations

In spite of major

advances made in the screening, detection, and management of heart disease, a major need exists for more accurate ways to predict CV risk

Therefore, other factors

must be involved

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Framingham Heart Study — 26-year follow-up

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THE REYNOLD’S RISK SCORE

In women, up to 20% of all coronary events occur in

the absence of risk factors

24,558 healthy US women followed for 10.2 years Women 45 years and older, started September 1992 Incident of MI, stroke, coronary revascularization or

cardiovascular death

Reynolds risk score: ADDED variables

Systolic blood pressure Current smoking Total Cholesterol HDL

__________________________________________

Hemoglobin A1C hsCRP- USE OF THIS- RECLASSIFIED 25% Parental history of myocardial infarction Apoliporproteins A-1 and B-100 Lipoprotein (a)

THE CALCIUM SCORE

A CT SCAN to detect CALCIUM in the arteries.

SPECIFICITY DECREASES WITH INCREASING AGE 85% TO 100% SENSITIVE 41 TO 76% SPECIFIC PRESENTLY ACC/AHA EXPERT CONSENSUS DOES

NOT RECOMMEND IT BECAUSE OF HIGH NUMBR OF FALSE-POSITIVES