1

By Dennis Cheek, RN, PhD, FAHA;

Melissa Sherrod, RN;

and Jennifer Tester

Women and heart disease: What’s new?

Nursing2008, JanuaryEarn 2.0 ANCC/AACN contact hoursOnline: http://www.nursing2008.com© 2008 Lippincott, Williams & Wilkins

2

Learning objectives

1. Identify the risk factors for heart disease in women.

2. Describe diagnostic testing for heart disease in women.

3. Identify treatment options for women with heart disease.

3

“Heart disease is the leading killer of men and women in the United States and the second leading cause of death in most developed

nations.”--American Heart Association (2007)

4

Risk factorsNon-modifiable

SexAgeEthnicityGenetics

ModifiableDiabetesHypertensionSmokingDyslipidemiaObesitySedentary lifestyleStress

5

SexAmong women, diagnosis and death rates are steady; among men, they’re declining.

More than 500,000 women die of cardiovascular disease (CVD) each yearGreater than the number of CVD deaths in menAlso greater than the total of the next seven

causes of death in women

6

AgeMen develop CVD at younger ages, but

incidence and prevalence equalize for women after menopause

Postmenopausal status is considered an independent risk factor

Hormone therapy no longer recommended to prevent or manage CVD due to increased rates of thrombotic events, such as myocardial infarction (MI) and stroke, as well as breast cancer

Short-term hormone therapy used to treat menopause symptoms

7

Ethnicity and Genetics

EthnicityRace and ethnicity together affect CVD riskDeath rate for African-American women with

CVD is almost 40% higher than that of white women

GeneticsInherited susceptibility patterns appear in

families

8

DiabetesPoses a greater risk than any other factorNurses’ Health Study: Women with

diabetes had seven times more cardiovascular events than other women and about half of them died of CVD

Women with diabetes and CVD--especially Hispanic and African-American women--die at a much higher rate than men or nondiabetic women

Young women with diabetes lose any premenopausal protection

9

HypertensionPuts women at a much greater risk for CVD,

especially if it develops before menopauseAt least half of women may have

hypertension before menopause, with prevalence greatest in African-American women

Elevated blood pressure is two to three times more common in women who take oral contraceptives, especially older women who are overweight

10

SmokingNurses’ Health Study: Even a few cigarettes a

day correlated with a greater risk of CVD or fatal MI

About one-quarter of all women smoke; prevalence greatest among postmenopausal women

Younger women who smoke probably cancel out any premenopausal protection

Women who take oral contraceptives and smoke are more likely to have an MI or stroke than those who take the pill but don’t smoke

11

Dyslipidemia and ObesityDyslipidemia

Doubles a woman’s risk of CVD compared to women with normal lipid profiles

Low levels of HDL have been shown to be a much stronger predictor of CVD mortality in women than men

ObesityCentral obesity poses a greater risk than increased

body mass index (BMI)Healthy waist circumference

Women: less than 35 inchesMen: less than 40 inches

Desired BMI (men and women): 18.5 to 24.9 kg/m2

12

Sedentary lifestyleCan contribute to obesity, dyslipidemia,

hypertension, and hyperglycemiaExercise can reduce cardiovascular risk by

increasing high-density lipoprotein (HDL) and decreasing BP, blood glucose, and low-density lipoprotein (LDL)

Exercise can cut a woman’s CVD risk by half and may significantly decrease the risk of a second MI in a postmenopausal woman

30 minutes of moderate-intensity physical activity on most days is ideal; 60 minutes for women who need to lose weight or sustain weight loss

13

Stress

Puts a woman at greater risk for CVD and poorer outcomes

Depression also may increase risk or deter her from seeking medical help

Consider screening women with CAD for depression and refer for treatment as needed

14

National Cholesterol Education Program

Provides risk-assessment tool based on the Framingham Heart Study

Estimated 10-year risk of MI and death determined byAgeSexCholesterolBlood pressureSmoking history

Available online: http://hp2010.nhlbihin.net/atpiii/calculator.asp

15

Determining CVD risk: Optimal risk

Framingham global risk <10%

Healthy lifestyle

No risk factors

16

Determining CVD risk: At risk

One or more major risk factors (cigarette smoking, poor diet, physical inactivity, hypertension, dyslipidemia, metabolic syndrome, obesity, family history of premature CVD (<55 in a male relative and <65 in a female relative)

Evidence of subclinical vascular disease

Poor exercise capacity on treadmill test and/or abnormal heart rate recovery after stopping exercise

17

Determining CVD risk: High risk

Established CVDCerebrovascular diseasePeripheral artery diseaseAbdominal aortic aneurysmEnd-stage or chronic renal diseaseDiabetesFramingham global risk >20% (or at high

risk on the basis of another population-adaptive tool to assess goal risk)

18

Signs and symptoms in men

Classic substernal pain characterized by heavy, crushing, or squeezing feeling

Commonly occurs with physical exertion or emotion

If cause is ischemia, rest and sublingual nitroglycerin can relieve the pain

If cause is MI, pain can occur at rest and may only be relieved by intravenous nitroglycerin, morphine, and reperfusion therapy

19

Signs and symptoms in women

More subtle symptoms than in men (shortness of breath, fatigue, changes in sleep patterns)

Discomfort may also be more generalized or subtleHeaviness, squeezing, or pain in left chest,

abdomen, midback, or shoulderArm painPalpitations or pain that’s sharp or fleeting

20

Signs and symptoms in women

Anginal discomfort may occur during rest or sleep or with other symptoms during exertion

Acute MI discomfort more likely to occur in neck, back, arm, shoulder, jaw, or throat, possibly accompanied by other symptomsNausea and vomitingIndigestionUpper abdominal painDyspneaFatigue DiaphoresisDizzinessFainting

An older woman or one with diabetes may not experience any pain

during an MI.

21

ECG findings

“Significantly, electrocardiogram (ECG) findings are different for men and women.

A woman experiencing an MI is far less likely than a man to have concurrent ST-

segment elevation. If she describes atypical pain and has an ECG that doesn’t show any

ST-segment changes, she may be misdiagnosed and not get follow-up

testing.”

22

Diagnostic testingAcute symptoms should be triaged and

treated in the emergency departmentIf patient isn’t having acute symptoms but

may be at risk for CVD, conduct a risk assessment using the Framingham tool

If at risk or high risk:Exercise or pharmacologic stress test

False-positives more common in womenExercise echocardiography (“stress echo”)

More reliable in women, especially when wall motion or valve function in question

23

Cardiac catheterization with coronary angiography

For anyone with a positive or inconclusive stress test or stress echocardiogram

Most reliable diagnostic tool in womenInvasive procedure with risk of bleeding,

infection, and strokeIsn’t indicated unless CVD is strongly

suspected

24

Lifestyle modificationsLow-fat, low-cholesterol diet; avoid saturated

fats (butter, cheese, fatty meats)Limit daily saturated fat intake to <10% of

caloriesLimit cholesterol intake to <300 mgLimit intake of trans fatty acids

Omega-3 fatty acids Protect against CVD Found in oily fish such as tuna and salmon Eat several times a week If pregnant or lactating, avoid fish potentially

high in methylmercury (swordfish, king mackerel)

25

Lifestyle modifications (cont’d)

Eat more fresh fruits, vegetables, whole grains, and other high-fiber foods Recommended daily fiber intake: 20 to 30 grams

Limit salt intake to 2,400 mg/dayLimit alcohol consumption to one drink per day

One drink equals 12-ounce beer, 5-ounce glass of wine, or 1.5-ounce shot of 80-proof liquor

Do at least 30 minutes of moderate aerobic activity daily

Maintain BMI <25 kg/m2 and waist <35 inches (women)

If diabetic or prediabetic, keep blood glucose in normal range and hemoglobin A1C level <7%

Stop smoking and avoid secondhand smokeReduce stress

26

Drugs used to manage CVD

Antiplatelet agents (aspirin, clopidogrel) Prevent thrombotic events

Statins (atorvastatin, pravastatin) Normalize lipid levelsReduce rates of nonfatal MI and strokeDecrease need for percutaneous coronary

intervention (PCI) or coronary artery bypass grafting (CABG)

Beta blockers (metoprolol)Reduce the risk of MI, reinfarction, and sudden

cardiac death

27

Drugs used to manage CVD

(cont’d)

ACE inhibitors (lisinopril)Reduce morbidity and mortality in patients

who've had an MI and those with hypertension, left ventricular dysfunction, or diabetes

Short-acting sublingual or aerosol nitrates Reduce acute angina symptoms

Long-acting nitrates (transdermal nitroglycerin)Prevent angina and improve exercise tolerance

28

Invasive procedures

PCICABG

A woman’s blood vessels may be small and difficult to cannulate or visualize during the above procedures, therefore

her risk of complications is greater. Also, women are more likely than men to experience bleeding at the surgical site or

hemorrhagic stroke, and their in-hospital mortality rate is significantly higher.

29

RehabilitationWomen have higher hospital readmission rates for

unstable angina, reinfarction, heart failure, ventricular tachycardia, and ventricular fibrillation.

Main goals: Reduce risk and restore functional capacity

Follow-up care to focus on signs and symptoms, energy level, blood cholesterol levels, medication use, and ability to cope

Formal rehab after MI, PCI, or CABG includes early ambulation, behavioral modifications, psychosocial support, and vocational and sexual counseling