E ThomasEapen MD FAAFP Assistant Professor of Family Medicine University of Kentucky October 2017 Objectives Statistics of heart disease in women Gender variations of the disease in women ID: 804539
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Slide1
Heart Disease in Women
Neena E. Thomas-Eapen, MD, FAAFPAssistant Professor of Family MedicineUniversity of Kentucky October 2017
Slide2ObjectivesStatistics of heart disease in women
Gender variations of the disease in womenManagement and prognostic variationsPrevention strategies
Slide3Number one killer of women?!Answer from patients
Breast Cancer!StatisticsHeart Disease!Christian et al J. Women Health 2007American heart association statistics 2011
Slide4It is important for Kentucky
Slide5Coronary vascular disease(CVD)Coronary Heart Disease( CHD) and Hypertension data are from
Several gender specific studies:Nurses’s health Study(NHS)Women’s health Study(WHS)Women’s health Initiative(WHI)Good News: CVD is preventable!
Slide6AHA 2016 statistical update
Circulation.2016; 133: e38-e360 http://circ.ahajournals.org/content/133/4/e38.figures-only
Slide7Cardiovascular disease and other major causes of death for all males and females (United States: 2013).
Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360
Copyright © American Heart Association, Inc. All rights reserved.
Slide8Prevalence of cardiovascular disease in adults ≥20 years of age by age and sex (National Health and Nutrition Examination Survey: 2009–2012).
Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360
Copyright © American Heart Association, Inc. All rights reserved.
Slide9Incidence of heart attack or fatal coronary heart disease by age, sex, and race (Atherosclerosis Risk in Communities Surveillance: 2005–2011).
Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360
Copyright © American Heart Association, Inc. All rights reserved.
Slide10Prevalence of cardiovascular disease in adults ≥20 years of age by age and sex (National Health and Nutrition Examination Survey: 2009–2012).
Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360
Copyright © American Heart Association, Inc. All rights reserved.
Slide11Cardiovascular disease (CVD) and other major causes of death in females: total, <85 years of age, and ≥85 years of age.
Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360
Copyright © American Heart Association, Inc. All rights reserved.
Slide12Prevalence of heart failure by sex and age (National Health and Nutrition Examination Survey: 2009–2012).
Dariush Mozaffarian et al. Circulation. 2016;133:e38-e360
Copyright © American Heart Association, Inc. All rights reserved.
Slide13Risk Calculator
ACC/AHA ASCVD Risk Calculatorwww.cvriskcalculator.com/
Calculate your 10-year risk of heart disease or stroke using the ASCVD algorithm published in 2013 ACC/AHA
Slide14ASVD
risk estimator
plus
New- August 2017
From
American College of Cardiology
http
://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
Additional information and risk factors included
LDL
Aspirin therapy
Statin therapy
Slide15Classification of CVD Risk in Women
Mosca et al , Circulation 2007;115:1481-1501Optimal risk:Score<10%& healthy lifestyle with no risk factorsHigh risk:Established CHD, CVD, PAVD,AAA, End stage Ch. RF, DM, 10
yr. FGR>20%
At risk:
1 or >1 risk for CVD-
Smoking
Poor diet
Physical inactivity
Obesity, central adiposity
F. His. of premature CVD
(Male<55, Female<65)
Hypertension
Dyslipidemia
Subcli.vas. disease-
Coro.calcification
Metabolic syndrome
Poor exercise capacity
Abnormal heart recovery after stopping exercise
Slide16CVD risk factors unique to women
Post - menopausal statusPrior hysterectomyOral contraceptive usePregnancy and complications from pregnancyOver view of cardiovascular risk factors in women, page 9- UpTodate.com- searched 10/18/17
Slide17Gender specific issues of CVD in womenDifferent presentation of symptomsVague symptomsDifferent pathophysiology in women
Difficult diagnostic testing: Hormone related ECG changes Breast attenuation changesTreatment does not yield same results in womenChristian et al, 2007Women’s Ischemia Syndrome evaluation studyAmerican Heart Association Statement 2008
Slide18Heart failure in women
Heer T et al.Am J Cardiol 2002; Collins L, Douglas PS- Acute myocardial infarction, 1996
Slide19CHD Symptoms in women
60% who had sudden death did not have classic warning symptomsInitially present with angina rather than acute MI30% women with ACS do not present with chest pain Vs 20% menWomen have other symptoms- Upper back pain, neck pain, SOB, palpitation, indigestion, fatigue
Prodromal symptoms of fatigue and SOB a month before
Despite these differences, majority present with chest pain.
AHA heart disease and stroke statistics update 2008
Hemingway et al 2008,Canto2007, Milner et al 1999,
Patel et al 2004,
McSweeney
et al 2003
Slide20Patho-physiology of atherosclerosis in women
WISE study – in cases with chest pain and documented Myo. Ischemia Lower incidence of obstructive CADWith persistent symptoms these women had increased risk of MI or sudden death in spite of no obstructive CADVasculopathy is suggested as the source of ischemiaRather than traditional plaque, women have intramural atherosclerosis
Fatal MI – women tend to have plaque erosion than rupture
Women with Coronary calcification has more mortality rate than men with same scores
Merz
et al 2006
Raggi
et al 2004
Slide21Non invasive diagnostic testing
Symptoms less reliable – Less threshold for testing, Lower utilization of stress testing in womenAccuracy
of exercise electrocardiography is
low
Lowest
pretest probability
,
Effect
of estrogen, anatomy(MVP)
Duration
of exercise and achieving highest
METs- strongest
prognostic
predictors
Inability to achieve five METS – poor prognosis
Mieres
et al 2005
Slide22Non invasive diagnostic testing
Non diabetic, normal ECG, able to exercise :Exercise treadmill test Diabetes
, abnormal rest ECG, poor exercise capacity :
Stress
test with cardiac imaging or stress
echocardiogram
Mieres
et al 2005
Slide23Outcome differences Women <65yrs with acute MI – 50-100% mortality rate than age matched men.
> 65 yrs – no major differenceWomen presenting with unstable angina – better outcomes than menWomen with non ST segment elevation MI – same as menAfter CABG – women fair worse than menFor acute ST segment elevation MI, PCI is superior to throbolytics in both men and womenAlter et al 2002,
Vaccarino et al 1999, Hochman
1999,
Weneger
et al 2008b
Slide24Heart disease facts for patients
Resources for the patients:womens health.gov A project of U.S Department of human health office of women’s healthhttps://www.womenshealth.gov/heart-disease-and-stroke/heart-disease/heart-disease-and-women
Slide25Aspirin use
United states preventive task force
Slide26Aspirin use
USPTF- Primary prevention Women- age 50–59 - reduces risk of cardiovascular disease when a net benefit is present> 10 % risk for CVD risk over 10 years without increased bleeding risk and > 10 year life expectancy
Optimal dose- unknown
T
rials- used
75-100
mg per day
or 100-325
mg
/ alternate days
75 mg - as effective as higher doses.
https
://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer
Slide27Class III Interventions (Not Useful/Effective and MayBe Harmful) for the Prevention of CVD in WomenCirculation 2011, 123:1243-1262American heart associationMenopausal therapy
No hormone therapy and selective estrogen-receptor modulators (SERMs)
for the primary or secondary prevention of CVD (
Class III, L. of
Evi
. A).
Antioxidant Supplements
No antioxidant vitamin supplements (
eg
, vitamin E, C, and beta carotene) for the primary or secondary prevention of CVD (
Class III, L. of
Evi
. A).
Folic Acid
No folic Acid, with or without B6 and B12 supplementation for primary or secondary prevention of CVD (
Class III,
L.of
Evi. A).
Aspirin for MI in women <65 years of ageRoutine use of aspirin in healthy women <65 years of age is not recommended to prevent MI (Class III, L. of Evi.e B).
Slide28Treat hypertensionAbove age 60, elevated SBP – higher relative risk of CVD
Decrease in BP decreases CVD morbidity and mortalityWomen on oral contraceptives tend to have higher BPsMultimodality treatmentFranklin et al 2001Lewington et al 2002SPRINT Trial 2015
Slide29SPRINT Trial
Slide30Treatment of hyperlipidemia
IdealoptionsLDL-C- < 100mg/dLHDL-C - >50mg/dLTriglycerides < 150mg/dLWenger et al 2008aLife styleStatins, Ezetimibe, Fibrates, Bile acid sequestrants,others including Repatha( Evolocumab)Phytosterols from plantsFish oil/ Omega 3 supplements, LovazaRed yeast rice – contains monacolin K/lovastatin, sterols, isoflavones,monosaturated fatty acids
Slide31Nutrition and DietTypes
ResultUltra-low-fat diets : may worsen omega-3 fatty acid deficiency & fail to lower glycemic loadUltra-low-carbohydrate diets : may be high in animal foods and unhealthy fats and low in protective phytonutrients and micronutrientsCalorie-restricted diets: may include processed foods and worsen deficiencies of essential fatty acids. All of these diets can reduce risk of cardiovascular diseaseNo significant advantage to any one of them JAMA : the journal of the American Medical Association 293(1):43-53 Jan, 2005
All may fail to promote optimum long-term health by complicating existing issues,
failing to address all dietary
problems and being overly
restrictive, making long-term
adherence difficult
Slide32Slide33DIET
Slide34Diet- Bottom line
Plant based diets- fruits, vegetables, whole grains, legumes, and nuts in moderationHealthy Mediterranean style diet- above foods plus lean meat, fish, low-fat and nonfat dairy products, and liquid vegetable oils
Slide35Nutrition
Mediterranean diets have a protective effect on CVD5-8 servings of vegetables & fruits/dayBeans and lentilsWhole grainsOily fish 2-4 times/ weekOlive oilAvoid trans fats
Limit saturated fats and animal proteins
Sodium restriction
Have foods high in omega 3 fatty acids like tree nuts
Circulation.
1999 Feb 16;99(6):779-85.
Final report of the Lyon Diet Heart Study
Slide36Fats
Patients should choose fats that reduce or minimize the harmful lipids LDL and Lp(a) and, ideally, increase levels of helpful HDL Mensink et al Amer. J. of clinical nutrition 77(5):1146-55 May, 2003 Mozaffarian et al New Eng. J. of medicine 354(15):1601-13 Apr, 2006 Good Monounsaturated Fat: Olives, olive and canola oils, most nuts, avocados lowers LDL raises HDL
Good Polyunsaturated Fat:
Fish high in omega-3, Grape seed oil, walnut oil
safflower , sunflower oil
lowers LDL raises HDL
Bad
Saturated Fat:
Red meat, dairy products, butter, ?coconut
raises LDL raises HDL
Very Bad
Trans Fat:
Margarine; vegetable shortening, partially hydrogenated oil
raises LDL lowers HDL raises TG
Slide37Trends in American Heart Association (AHA) defined healthy diet score components for children (5–19 years old) by survey year: National Health and Nutrition Examination Survey 2003 to 2004, 2005 to 2006, 2007 to 2008, 2009 to 2010, and 2011 to 2012.
Dariush
Mozaffarian
et al. Circulation. 2016;133:e38-e360
Copyright © American Heart Association, Inc. All rights reserved.
Slide38ExerciseBoth men and women gets benefits from exerciseWomen with highest quantity of exercise benefits the most
30 minutes of moderate intensity work out like brisk walking most days of the weekManson et al 1999, 2002Pate et al 1995
Slide39Emotions and heartStressDepressionAngerHostility
AnxietyAll associated with increased CVD riskHence screen for these factors and address it with appropriate techniques, suggestions and stress management strategiesRozanski et al 2005
Slide40Acute emotional stressBroken Heart!Tako-tsubo
cardiomyopathyTransient Apical ballooning Syndrome
Slide41Tako-tsubo cardiomyopathy
Broken Heart Syndrome or Tako-Tsubo cardiomyopathy Nikhil Batra1 , Neena E Thomas-Eapen2 , Robert L Percell3 http://gulfmedicaljournal.com/download/Broken_Heart_Syndrome_or_Tako_Tsubo_cardiomyopathy.pdf
Slide42Summary Prevention
Healthy habits – No smockingAlcohol if used only moderateHealthy nutritionOptimum weightModerate physical activity most daysHealthy approach to emotions
Slide43Summary
Treat hypertension to goal for age and co- morbiditiesTreat diabetes mellitus to have optimum goal of A1C without hypoglycemiaTreat with statin for increased ASVD risk calculated by a risk calculator Keep in mind special situations of women in etiology, symptoms, evaluation and treatment
Slide44Slide45Women and Heart DiseaseThank you
Questions