Tamara H Horwich , M , MD, M , MS Co Co-Director, U , UCLA W - - PowerPoint PPT Presentation

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Tamara H Horwich , M , MD, M , MS Co Co-Director, U , UCLA W - - PowerPoint PPT Presentation

Tamara H Horwich , M , MD, M , MS Co Co-Director, U , UCLA W Women's C Cardiovascular C Center, A , Ahmanson-UCLA C Cardiomyopathy Center; A ; Associate C Clinical P Professor o of C Cardiovascular M Medicine, U , UCLA; M ;


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Tamara H Horwich, M

, MD, M , MS

Co Co-Director, U , UCLA W Women's C Cardiovascular C Center, A , Ahmanson-UCLA C Cardiomyopathy Center; A ; Associate C Clinical P Professor o

  • f C

Cardiovascular M Medicine, U , UCLA; M ; Medical Director, U , UCLA C Cardiac R Rehabilitation P Program

Tamara Horwich, MD, MS is an attending cardiologist and Health Sciences Associate Clinical Professor of Medicine/Cardiology at the David Geffen School of Medicine at UCLA. She is Medical Director of UCLA's Cardiac Rehabilitation Program, including the Dr. Dean Ornish Comprehensive Lifestyle Program for Reversing Heart Disease, Co-Director of the UCLA Women's Cardiovascular Health Center, and an active member of the Ahmanson-UCLA Cardiomyopathy Center. Dr. Horwich's clinical interests include treating and preventing heart disease in women, cardiac rehabilitation, treating patients with heart failure, and performing and interpreting

  • echocardiograms. Dr. Horwich's main research interests include studying obesity, body composition and

cardiovascular disease, as well as risk factors and novel therapies for patients with heart disease, with a focus

  • n women. She has been a grant recipient from the National Institutes of Health, the Heart Failure Society of

America, as well as the Iris Cantor Women's Center at UCLA. Dr. Horwich is a Fellow of the American College

  • f Cardiology and American Heart Association and has helped draft national guidelines on management of heart

failure.

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Women’s Heart Health: What We Know

Tamara Horwich, MD, MS Associate Clinical Professor of Medicine / Cardiology May 21, 2020

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Canadian Physician Sir William Osler (1849-1919)

A typical heart attack patient is a “keen and ambitious man, the indicator of whose engine is always ‘full speed ahead’” . . . a “well ‘set’ man from 45-55 years of age, with a military bearing, iron-gray hair, and a florid complexion.”

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Frank Netter’s Atlas of Human Anatomy

Frank Netter

1906 - 1991

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  • Dr. Bernadine Healy (1944-2011)

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Salim S. Virani. Circulation. Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association, Volume: 141, Issue: 9, Pages: e139-e596,

Deaths in Thousands

550 530 510 490 470 450 430 410 390 370 350

1980 1985 1990 1995 2000 2005 2010 2015 2020

men women

1st statin released WHI HRT Stopped Awareness campaigns

  • n women

and heart disease

Heart Disease - Leading Cause of Death

Everyone losing ground

Salim S. Virani. Circulation. Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association, Volume: 141, Issue: 9, Pages: e139-e596,

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Women and Heart Disease: What We Know

  • 1. Coronary Artery Disease in Women
  • 2. Heart Failure in Women
  • 3. Unique Risk Factors in Women and Cardiovascular

Syndromes Pertinent to Women

  • 4. What We Are Doing

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Co Coronary y Ar Artery y Disease (C (CAD) in ) in Wo Women

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Change in Coronary Artery Disease Incidence 1996-2005 in the UK

  • 5
  • 4
  • 3
  • 2
  • 1

1 2 3 4 5 6

Men Women

35-45 45-54 55-64 65-74 75-84 85+

Davies A et al, Eur Heart J 2007

%

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Young Women (ages 18 – 55 years) and Acute Myocardial Infarctions (Heart Attacks)

  • Heart attacks are decreasing in the overall population but increasing

in young women (<55 years)

  • Women have LONGER hospital stays and HIGHER in-hospital mortality
  • Women compared to men are LESS LIKELY to receive reperfusion

therapy

  • Women compared to men are MORE LIKELY to have delays in

treatment including

  • Door to balloon time
  • Door to needle time
  • Shaw. JACC 2014; D’Onofrio G, et al. Circulation. 2015; Davies A et al, Eur Heart J 2007; Acute MI in Women.

Circulation 2016

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Chest pain

  • r

discomfort Unusual upper body discomfort Shortness of breath Diaphoresis Unusual or unexplained fatigue Light-headedness or sudden dizziness Nausea

The Heart Truth Campaign, NHLBI

Women have “atypical” symptoms

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Symptom Recognition and Healthcare Experiences

  • f Young Women with Acute Myocardial Infarction

(Age ≤ 55)

Lichtman et al. Circ Cardiovasc Out 2016

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Symptom Recognition and Healthcare Experiences

  • f Young Women with Acute Myocardial Infarction

(Age ≤ 55)

Lichtman et al. Circ Cardiovasc Out 2016 “I felt so stupid laying in the ER...the nurse comes in and goes, ‘all your lab work, everything looks great’...and I burst into tears like I'm so embarrassed...The nurse comes in about 20 minutes later and goes, ‘we need to move you to ICU...you've had a heart attack.’ But it was a sense of relief...I was tryin’ to justify it. I was mortified...I felt like, oh my gosh, what are these people in the ER thinking of me? That here I am, a CRNA [Certified Registered Nurse Anesthetist], and I'm so stupid, you know, like a hypochondriac...

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Symptom Recognition and Healthcare Experiences

  • f Young Women with Acute Myocardial Infarction

(Age ≤ 55)

Lichtman et al. Circ Cardiovasc Out 2016 “I remember callin’ a doctor and tellin’ him I was having these chest pains and all that stuff, and they just scheduled a regular appointment for me...I would not know that I'm havin’ a heart attack...I would consider that your [the doctor's] responsibility...they should of pushed me in faster...

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MEN WOMEN

CAD may develop differently in women

Diffuse atherosclerosis Focal Stenosis

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Women are More Likely to have MI MINOCA (Myocardial Infarction in the Absence of Coronary Artery Disease)

ACUTE CORONARY SYNDROME WOMEN MEN

p

GUSTO (overall) 19.4% 8.4%

<0.001

GUSTO (unstable angina) 30.5% 13.9%

<0.001

GUSTO (NSTEMI) 9.1% 4.2%

<0.001

GUSTO (STEMI) 10.2% 6.8% TIMI 18 (USA or NSTEMI) 17% 9.0%

<0.001

TIMI IIIa (USA or NSTEMI) 26.5% 8.3%

<0.001

Cannon CP et. al. N Engl J Med. 2001 Jun 21;344(25):1879-87 Cannon EP et. al. Circulation. 1993;87:38-52 Buargini and Bairey-Merz. JAMA. January 26, 2005, Vol 293, No. 4 Cannon CP et. al. N Engl J Med. 2001 Jun 21;344(25):1879-87 Cannon EP et. al. Circulation. 1993;87:38-52 Buargini and Bairey-Merz. JAMA. January 26, 2005, Vol 293, No. 4 17

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What’s really there

Image from Prof. P Camici

What we see on an angiogram

Coronary Angiogram: the Gold Standard

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Bertil Lindahl et al. Circulation. 2017;135:1481-1489

Not treated Treated

STATINS ACEi / ARB ß Blocker Dual Antiplatelet

Cumulative Hazard

Treatment of MINOCA

Statins, ACE/ARBs and ßblockers improve outcomes in MINOCA. Dual antiplatelet therapy does not

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Wo Women and Hear Heart t Failur ailure

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Majority is HFrEF (low LVEF) Therapies! Beta-blockers ACEI/ARBs AAs CRT / ICD Ivabradine Neprilysin inhibitors SGLT2 inhibitors Majority is HFpEF (“Diastolic HF”) Therapies ??

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HFpEF: Heart Failure with Preserved Ejection Fraction

Typical Patient Female Older High BMI Hypertension Atrial Fibrillation NO epicardial CAD

Owan TE et al. N Engl J Med 2006;355:251-259.

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Peripartum cardiomyopathy

  • Peripartum cardiomyopathy is marked by loss of cardiac

contractile function in women late in pregnancy or soon after

  • delivery. PPCM affects approximately 1:1000 births worldwide

Reimold S & Rutherford NEJM 2001; Silwa et. al. Lancet 2006; Silwa et al. EJHF 2010; Hilfiker-Kleiner and Silwa Nature Cardiol 2014; Hilfiker-Kleiner et al. EHJ 2015 24

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South Africa Nigeria Niger India China Pakistan USA California USA Tennessee Kentucky Chicago Georgia HAITI

Blauwet et. al. Heart 97:23 2011

Incidence of PPCM

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Women have Unique Risk Factors for Coronary Artery Disease

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Wilson et al. In: Ruderman et al, eds. Hyperglycemia, Diabetes, and Vascular Disease. 1992:21-29.

CVD Events in Patients With Diabetes: Framingham 30-Year Follow-Up

Relative Risk Ratio‡ Women Total CVD * * CHD * * Heart Failure * * Intermittent Claudication * * Stroke

2 4 6 8 10 12 Men

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Women with DM have ~40% greater risk of developing Cardiovascular Disease compared to Men with DM

Meta-analysis of 64 Cohorts. Peters Diabetologia 2014

  • Hazard ratio 2.68

in women vs 1.85 in men

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Recent Research from the UCLA Women’s Cardiovascular Center

  • Men: 4% increased probability of coronary artery calcium per 10 kg increase in fat mass
  • Women: No increased risk of coronary artery calcification with increasing levels of body

fat mass

Women, Obesity, and Coronary Artery Disease

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1 2 3 4 5 6 7

<40 40-44 45-49 50-54

Premenopausal Postmenopausal

Incidence of Cardiovascular Disease: Relation to age and Menopausal Status

Incidence (per 1,000 women)

Age (years)

Kannel W, et al. Ann Intern Med. 1976;85:447-52.

The Menopause Bump

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Pre and Post Menopause Changes

  • Cross-sectional

study of 3,636 women

  • (40–59 years old)

Variable PRE POST

p

AGE 49.7 55.2

0.001

Activity (METS) 5502 2458

NS

BMI 26.9 28.1

0.001

% BF 34.1 36.2

0.001

HTN (%) 55.2% 60.4%

0.01

LDL-c 121.6 132.2

0.001

HDL-c 63.7 62.5

NS

TG 100.8 113.0

0.001

Glucose 92.0 95.8

0.001

PLOS ONE 11(4): e0154511. https://doi.org/10.1371/journal.pone.0154511 31

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Adverse Pregnancy Outcomes Which are Associated 1.8 – 4.0x Greater Risk of Future CVD

JACC 2020 State of the Art Review

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Pregnancy – a Stress Test for the Heart

Bellamy et. al BMJ 2007;335:974. Bellamy et. al. 2009;373:1773-1779 Kessous et. al. Am J Obstet Gynecol. 2013;209:368.e1-8

1 2 3 4 5 6 7 8 9

HTN IHD stroke VTE

Pre-eclampsia

1 2 3 4 5 6 7 8 9 T2DM Stroke MI

GDM

1 2 3 4 5 6 7 8 9 IHD CHD death

Preterm birth

1 2 3 4 5 6 7 8 9 MI

stillbirth

1 2 3 4 5 6 7 8 9 MI

recurrent miscarriages

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“BROKEN HEART” Syndrome

Sharkey et al. Circulation 2005. Chou and Shaw. Can J Cardiol 2014.

  • Acute heart attack and heart

failure presentation with normal coronary arteries

  • Preceding emotional

stressor, “lifetime crisis”

  • 90% post-menopausal

females

Women, Stress, And Heart Disease: Tako-Tsubo Cardiomyopathy

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  • First described in 1931
  • A non-atherosclerotic form of acute coronary

syndrome

  • Underdiagnosed and often not considered in younger

women presenting with chest pain

Spontaneous Coronary Artery Disease (SCAD)

Previously considered rare, SCAD now recognized to cause 2–4% of all ACS, 24–36%

  • f MIs in women <50y, and the most common cause of pregnancy-associated MI

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What are We Going to Do?

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Recent Research from UCLA Women’s CVD Center: Urinary Stress Hormones in Women vs Men

50 100 150 200 250

Epinephrine Norepinephrine Dopamine

women men

No difference <0.0001 <0.0001

Zipursky, …Horwich, et. al. Am J Cardiol. 2017 Jun 15;119(12):1963-1971.

ng/dl

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Arterial Stiffness

Baseline Characteristics of Men and Women in MESA

Women Men p-value N (%) 3097 (52.0%) 2862 (48.0%)

  • Age

62.1 (10.26) 62.2 (10.21) 0.7832 Augmentation Index (AIx) 15.5 (2.30) 14.3 (1.88) <0.00001 Pulse Pressure Amplification (PPA) 11.0 (0.48) 11.5 (0.50) <0.00001 Reflection Magnitude (RM) 8.41 (0.83) 8.38 (1.07) <0.00001

Chester, Watson, Horwich, et al. J Am Coll Cardiol. 2016; 67:1314.

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Healthy Lifestyle in Women = Heart Disease Prevention!

Optimal Lifestyle Factor Reduced Risk of Coronary Heart Disease* Not Smoking ↓ 71% Exercise ≥ 2.5 hours / week ↓ 28% Healthy Eating Index (top 40%) ↓ 31% Alcohol ≤ 1 drink / day ↓ 33% Normal Body Weight (BMI) ↓ 32% TV watching < 7 hours / week

  • *After adjustment for all other potential risk factors

Study of >88,000 women followed for 20 years

  • Women who engaged in all 6

healthy lifestyles had a 92% lower risk of getting coronary heart disease

Chomistek et al. JACC 2015

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How Much Exercise? Moderate Physical Activity Reduces Cardiovascular Risk in Women

Study of 1.3 million women in the UK. Armstrong et al. Circulation Cariovascular Outcomes 2015 40

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Ornish Intensive Cardiac Rehab: Four key elements working in concert …

Exercise

1 hour of group exercise

Stress Management

1 hour of stress management techniques

Community

1 hour of group support

Nutrition

group meal

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ECHOS: Research Effort Aimed at Decreasing Stress and Increasing Wellness in UCLA undergraduates. PI Kimberly Uehisa, UCLA undergrad

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Meta-analysis of Primary Prevention Statin Trials in Women

.75 1 AFCAPS/ TexCAPS

1998

MEGA

2006

JUPITER

2008

0.63 (0.49-0.82) p < 0.001

Combined

Favors Statin Favors Placebo

(0.34-1.31) (0.49-1.10) (0.37-0.80)

RR

95% CI

0.67 0.73 0.54

Mora S et al Circulation 2010; 1069 43

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Santeema et. Al., Lancet 2019;394:1254-63

What are the optimal doses for medications in women with Heart Failure?

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Summary

  • More women die of CVD every year than all cancers combined
  • Ischemic heart disease may present differently in men compared to

women and can be more difficult to diagnose

  • Young women presenting with MI have higher in-hospital mortality
  • Women tend to have HFpEF while men tend to have HFrEF
  • There are unique risk factors for heart disease in women compared to

men, including gestational diabetes and menopause. Risk factors with more impact in women compared to men include stress, anxiety, depression, diabetes

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Chilian WM. J Nucl Cardiol. 2001;8:599.

Thank you

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