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Women and Cardiovascular Disease5th Annual Lourdes Cardiology Services
Symposium: Cardiology for the Primary Care Physician
Hafeza Shaikh, DO, FACC, RPVI
Heart Disease Prevention in the 1960’s
AHA 1964- First Conference for Women and Heart Disease› Title:
Hearts and Husbands› Objective:
Learn how to keep your husbands heart healthy.
Man’s Disease?
Heart disease is the leading cause of death for women in the U.S.
1 in 3 women dies of heart disease, only 1 in 31 of breast cancer
26% of women >45yo who have an initial MI die within one year compared to 19% of men
Women are more likely to describe chest pain that is sharp, burning, and more frequently have pain in the neck, jaw, throat, abdomen, or back
In 2004, <50% of women recognized heart disease as the #1 killer
In 2011, only 53% of women said they would call 911 first if they thought they were having a heart attack
Go Red For Women 2004
Objectives
Recognize the impact of cardiovascular disease in women (CHD and Stroke)
Recognize the presentation of heart disease can be different in women as compared to men
Identify risk factors unique to women for both CHD and Stroke
Recognize treatments that are NOT beneficial for CVD prevention in women
The Jersey Girl Heart disease and stroke account for 31.9% of
female deaths in New Jersey EACH DAY 31 women die from heart disease
and stroke in New Jersey Heart disease alone is the leading cause of
death in NJ, accounting for 9,444 female deaths in 2009
Nearly 53% of women in New Jersey are obese and overweight
In New Jersey, 13.2% of women smoke cigarettes
Guidelines
1999- First female specific guidelines for heart disease prevention
2004- Evidence Based Guidelines for Cardiovascular Disease Prevention in Women
2011-Effectiveness Based Guidelines for Cardiovascular Disease Prevention in Women
2014- Guidelines for the Prevention of Stroke in Women; a statement from the AHA and ASA
2004 Guidelines
Written in the wake of the Women’s Health Initiative and HERS trial
Need for strategies to prevent heart disease in women
2004 Guidelines
Assess and stratify women into high, intermediate, lower, or optimal risk categories
Lifestyle approaches to prevent CVD for all women and a top priority (smoking cessation, regular exercise, weight management, and heart healthy diet)
Other CVD risk-reducing interventions (BP management, lipid management, DM management)
Higher priority for therapy for highest risk patients Avoid Class III interventions (not beneficial, may be
harmful)
Atherosclerosis
Heart disease affects the blood vessels and cardiovascular system.
Atherosclerosis = when plaque builds up in the walls of the arteries
The buildup narrows the arteries, › Makes it harder for blood to flow through› If a blood clot forms, it can stop the blood
flow› This can cause a heart attack or stroke!
Spectrum of Risk
Based on the Framingham Risk Score No such thing as NO risk High Risk (>20%):
Established CHD Cerebrovascular disease Peripheral arterial disease AAA DM CKD
Intermediate Risk (10-20%): Subclinical CHD (coronary Ca) Metabolic syndrome Multiple risk factors (smoking, HTN, HPL,
obesity, poor diet, physical inactivity) Autoimmune collagen vascular disease (SLE,
RA) Family history of early onset CVD History of preeclampsia, gestational DM, or
pregnancy induced HTN)
Lower Risk (<10%): Multiple risk factors, metabolic syndrome, or
1 or no risk factors
Optimal Risk (<10%): Optimal levels of risk factors and heart
healthy lifestyle (ideal lipids, HTN, blood glucose, BMI, non-smoker, physically activity, healthy diet)
Lifestyle Interventions
Recommended for ALL women Smoking cessation Physical activity (30 minutes of moderate-
intensity exercise most days of the week) Cardiac rehab Heart healthy diet Weight maintenance/reduction (BMI 18.5-24.9
kg/m2; waist circumference <35 in.) Psychosocial Factors Omega 3 fatty-acid supplementation in high
risk patients
Typically Atypical !
Women are more likely than men to have heart attack symptoms UNrelated to chest pain
Could present as:› Neck, shoulder, upper back or abdominal
discomfort› Shortness of breath› Nausea or vomiting› Sweating› Lightheadedness or dizziness› Unusual fatigue
McSweeney JC, et al. Circulation 2003;108:2619
Symptoms in women with MI
Study of 515 women with MI› Chest pain absent in 43%› Most common symptom:
Dyspnea in 58% Weakness in 55% Fatigue in 43%
› Prodrome: Fatigue in 71% Sleep disturbance (48%), dyspnea (42%)
Canto JG et al. JAMA 2012;307:813
Symptoms in women with MI
Over 1,000,000 men and women in NRMI registry, 1994-2006 (481,581 women)› 42% of women presented without CP (vs.
31% of men)› Higher in-hospital mortality in women
(14.6%) than in men (10.3%)› Younger women without chest pain were at
the highest risk
Other Interventions
Optimal BP <120/80 Lipid Management DM management
Preventive Drug Interventions
ASA for high or intermediate risk patients, or clopidogrel if intolerant of ASA
Beta Blockers in women with h/o MI ACE-I in high risk women ARB in high risk women intolerant of
ACE Warfarin/ASA for A-Fib stroke
prevention
Class III Interventions
Hormone Therapy (combined estrogen/progestin or unopposed estrogen) should NOT be used for CVD prevention
Antioxidant supplements ASA for lower risk patients
Effectiveness Based Guidelines-2011 Update
Reversing a trend over the last 40 years, CHD death rates in US women 35-54yo appear to be increasing, likely due to the obesity epidemic
Death rates higher in black vs. white women
Leading cause of death in women in every major developed country
Flow diagram for CVD preventive care in women.
Mosca L et al. Circulation. 2011;123:1243-1262
Copyright © American Heart Association, Inc. All rights reserved.
2011 Update
Did not endorse routine use of high-sensitivity CRP for screening purposes
Did discuss unique opportunities to assess a women’s risk, like at time of pregnancy
Preeclampsia may be an early indicator of CVD risk
Class III Interventions
Hormone therapy, including selective estrogen-receptor modulators, should not be used for primary or secondary prevention of CVD
Antioxidant supplements (vitamin E, C, and beta carotene) should not be used for primary or secondary prevention of CVD
Folic Acid with or without B6 and B12 supplementation should not be used for primary or secondary prevention of CVD
Routine use of ASA for prevention of MI in healthy women <65 yo (ASA can be useful in women >65yo if BP controlled and benefit for ischemic stroke prevention and MI prevention is likely to outweigh risk of GIB and hemmorhagic stroke)
Guidelines for the Prevention of Stroke in Women
February 2014 Stroke accounts for a higher proportion of CVD
events than CHD in women (opposite for men) Lifetime risk of stroke higher in women, mostly
because women live longer 53.5% of new or recurrent strokes occur among
women In 2010, 60% of deaths related to stroke were in
women Majority are ischemic strokes vs. hemorrhagic Risk factors unique to women
Stroke In Pregnancy
Preeclampsia/eclampsia and pregnancy-induced HTN
Continue to be at high risk for stroke even after birth
ACOG recommends treatment of severe HTN in pregnancy (systolic BP >160 mmHg or diastolic BP>110 mmHg)
Labetalol is first-line therapy AVOID atenolol, ACE, and ARB
Hypertension
History of preeclampsia, eclampsia, pregnancy induced HTN, gestational DM all are associated with a higher risk of CVD and stroke beyond the childbearing years
In one 2012 study, 18.2 % of women with a history of preeclampsia vs. 1.7 % of women with uncomplicated pregnancies had a CVD event in 10 years
Recommendations
Women with chronic primary or secondary HTN or previous pregnancy related HTN should take a low dose ASA from the 12th week of gestation until delivery
Calcium supplementation (>1g/day) should be considered for women with low dietary intake of calcium to prevent preeclampsia
Severe HTN in pregnancy should be treated Consider treatment of moderate HTN Atenolol, ACE, ARB contraindicated After birth, women with chronic HTN should continue to be
treated and monitored for post-partum preeclampsia Because of increased risk of future HTN and stroke 1-30 years
after delivery in women with a history of preeclampsia, it is reasonable to evaluate and treat for HTN, obesity, smoking, and dyslipidemia
Cerebral Venous Thrombosis
Thrombus formation in >1 of the venous sinuses
0.5%-1% of all strokes >70% of cases in women 2 major risk factors include oral
contraceptive use and pregnancy
Recomendations
Screen and test for prothrombotic conditions Warfarin for 3-6 months in provoked CVT 6-12 months in unprovoked CVT Indefinite anticoagulation for recurrent CVT In CVT with pregnancy, LMWH throughout
pregnancy and >6 weeks post-partum Future pregnancy not contraindicated Women with a history of CVT can be treated
prophylactically with LMWH during future pregnancies
Oral Contraceptive Use
2.75 fold increase in ischemic stroke with any OC use
Progestogen only OCs revealed no significant increased risk
Overall slightly increased risk of hemorrhagic stroke
Increased risk with obesity, HPL, smoking, HTN, migraine headaches and OC use
Recommendations
OCs may be harmful in women with additional risk factors (smoking, prior thromboembolic events)
Among OC users, aggressive therapy of stroke risk factors reasonable
Routine screening for prothrombotic mutations before initiation of OC is NOT useful
Measurement of BP before initiation of OC is recommended
Menopause and Post Menopausal HT
Data seems to suggest increased risk of stroke with earlier onset of menopause (before age 42) although evidence is inconsistent
Studies of HT for primary and secondary prevention of stroke have been negative
HERS, WEST, and WHI HT does not reduce stroke risk and
may increase risk
Recommendations
HT (conjugated equine estrogen with or without medroxyprogesterone) should not be used for primary or secondary prevention of stroke in post-menopausal women
SERMs, such as raloxifene, tamoxifen, or tibolone, should not be used for prevention of stroke
Migraine With Aura
Women are 4 times more likely than men to have migraines
Migraine with aura is associated with double the risk for ischemic stroke
This association is higher in women than men
Risk increases even more with smoking and OC use
Recommendations
Treatment to reduce migraine frequency is reasonable as there is an association between higher migraine frequency and stroke risk
Evidence is lacking that treatment reduced risk of first stroke
Strongly recommend smoking cessation in women with migraine and aura
Obesity, metabolic syndrome, and lifestyle factors
Prevalence of obesity higher in women than in men
Recommendation are same for men and women: regular physical activity, moderate alcohol consumption, abstention from smoking, and healthy diet
Atrial Fibrillation
AF increases with age and women have greater life expectancy
60% of AF patients >75yo are women Risk stratification : CHADS2 and
CHA2DS2-VASc score Female sex is an independent predictor
of stroke in AF
Recommendations
Risk stratify patients Considering the increased prevalence of AF
with age and the higher risk of stroke in elderly women with AF, active screening (age >75) in primary care settings is appropriate
Oral AC in women <65yo with AF alone and no other risk factors is not recommended (CHADS2=0, CHA2DS2-VASc=1). Antiplatelet therapy is a reasonable option
New oral anticoagulants are a useful alternative to warfarin in appropriate patients
Strategies For Prevention of Stroke in Women
Management of carotid disease (symptomatic or asymptomatic) same as for men
ASA therapy in women with DM, high-risk patients, and women >65yo if benefit is likely to outweigh the risk
Conclusions
Many gaps remain in our knowledge regarding sex differences in CVD and prevention
More awareness among women Sex specific risk scores necessary More women need to be represented in
clinical trials of CVD Until then, management remains
essentially the same as for men (ASA)
The Scope of the Problem
Women are referred less often for appropriate testing or treatment
Women with MI are more likely to have complications and increased mortality
Fewer women have been included in studies, so there’s less data
Awareness is lacking!
Mosca L, et al. Fifteen-year trends in awareness of heart disease in women. Circulation 2013; 127.
Awareness is lacking!
~2500 women > 25 y.o. surveyed Between 1997-2012, awareness among
whole study population nearly doubled: 30%56%
Still low in minorities:› Blacks: 36%› Hispanics: 34%
Awareness
Only 1 in 5 American women believe that heart
disease is her greatest health threat.