C. GiannattasioC. Giannattasio

Tenth International Symposium

HEART FAILURE & Co.CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING

ON FEMALE DISEASES

Milano9 - 10 aprile 2010

Prevalence of Cardiovascular Disease inAmericans Age 20 and Older by Age and Sex

NHANES III: 1988-94

Source: © American Heart Association 2004

50 60 70 80 900

0.1

0.2

0.3

0.4

0.5

0.6

0.7

50 60 70 80 900

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Cumulative Incidence of CVD Adjusted for the Competing Risk of Death for Cumulative Incidence of CVD Adjusted for the Competing Risk of Death for Men and Women according to Aggregate Risk Factor (RF) Burden at 50 Years of AgeMen and Women according to Aggregate Risk Factor (RF) Burden at 50 Years of Age

Cumulative Incidence of CVD Adjusted for the Competing Risk of Death for Cumulative Incidence of CVD Adjusted for the Competing Risk of Death for Men and Women according to Aggregate Risk Factor (RF) Burden at 50 Years of AgeMen and Women according to Aggregate Risk Factor (RF) Burden at 50 Years of Age

12640 M12640 M Lloyd-Jones DM et al., Circulation 2006; 113: 791Lloyd-Jones DM et al., Circulation 2006; 113: 791

Ad

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cid

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Attained ageAttained age Attained ageAttained age

MenMen WomenWomen

≥ ≥ 2 major RFs2 major RFs1 major RF1 major RF≥ ≥ 1 Elevated RF1 Elevated RF≥ ≥ 1 Not optimal RF1 Not optimal RFAll optimal RFsAll optimal RFs

69%69%

50%50%

36%36%

46%46%

5%5%

50%50%

39%39%

27%27%

8%8%

Distribuzione dei fattori di rischioin Italia in rapporto al sesso

(dati Istituto Superiore di Sanità, anno 2003)

Rosamond W et al., Circulation 2007; 115: e69Rosamond W et al., Circulation 2007; 115: e69

CVD Mortality Trends for Males and Females CVD Mortality Trends for Males and Females (United States: 1979-2004)(United States: 1979-2004)

CVD Mortality Trends for Males and Females CVD Mortality Trends for Males and Females (United States: 1979-2004)(United States: 1979-2004)

12576 M12576 M

YearsYears

Dea

ths

in t

hou

san

ds

Dea

ths

in t

hou

san

ds

79 85 95 400

450

500

550

MalesMales FemalesFemales

Deaths by Cause, Deaths by Cause, WomenWomen, Latest Available Year, , Latest Available Year, EUEUDeaths by Cause, Deaths by Cause, WomenWomen, Latest Available Year, , Latest Available Year, EUEU

6979 M6979 MEuropean Cardiovascular Disease Statistics, 2000European Cardiovascular Disease Statistics, 2000

CHDCHD15%15%StrokeStroke

14%14%

Other CVDOther CVD17%17%

Stomach cancer 1%Stomach cancer 1%Colo-rectal cancer 3%Colo-rectal cancer 3%

Lung cancer 2%Lung cancer 2%

Other cancerOther cancer12%12%

Respiratory diseaseRespiratory disease8% 8% Injuries and poisoningInjuries and poisoning

4% 4%

Other causesOther causes20%20%

Breast cancer 4%Breast cancer 4%

Acute MI Mortality by Age and Sex

0

5

10

15

20

25

30

<50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89

Age

Death During Hospitalization

(%)

Men

Women

Source: Adapted from Vaccarino N Engl J Med 1999; 341(4): 217-225

Prognosis After MI

38% of women die within first year Compared to 25% of men

35% of women will have second MI within 6 years Compared to 18% of men

Source: Wenger Circulation 2004; 109:558-560

10

L’infarto nella donna giovane

Diagnosis of Coronary Artery Disease in Women

• Chest pain is experienced by most women with CHD, but non-chest pain presentations are more common in women than men

• Other Presenting Symptoms– Upper abdominal pain, fullness, burning sensation– Shortness of breath– Nausea– Neck, back, jaw pain

• Associations– Precipitated by exertion– Precipitated by emotional distress

Source: Charney Cardiovasc Risk 2002, 9:303-307, Goldberg Am Heart J 1998. 136:189-195

Value of the Exercise ECG in Women

6861

7770

0

10

20

30

40

50

60

70

80

Sensitivity Specificity

MenWomen

Source: Kwok Y, Am J Cardiol 1999. 83(5):660-666

Women Receive Less Interventions to Prevent and Treat Heart Disease

• Less cholesterol screening

• Less lipid-lowering therapies

• Less use of heparin, beta-blockers and aspirin during myocardial infarction

• Fewer referrals to cardiac rehabilitation

Source: Chandra 1998, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 2005

Mortality in Recent Cohort Studies of Patients Hospitalized Mortality in Recent Cohort Studies of Patients Hospitalized with Heart Failure according to LVEFwith Heart Failure according to LVEF

Mortality in Recent Cohort Studies of Patients Hospitalized Mortality in Recent Cohort Studies of Patients Hospitalized with Heart Failure according to LVEFwith Heart Failure according to LVEF

11368 M11368 M Hogg et al., JACC 2004; 43: 317Hogg et al., JACC 2004; 43: 317

0 1 2 3 4 5 60

10

20

30

40

50

60

70

80

90Reduced LVEF

Preserved LVEF

% d

eath

% d

eath

Follow-up (years)Follow-up (years)

Processes Underlying Diastolic DysfunctionProcesses Underlying Diastolic DysfunctionProcesses Underlying Diastolic DysfunctionProcesses Underlying Diastolic Dysfunction

9421 M9421 M

HypertensionHypertensionAgingAging

AtherosclerosisAtherosclerosisDiabetesDiabetes

HypertensionHypertensionAgingAging

AtherosclerosisAtherosclerosisDiabetesDiabetes

Diastolic DysfunctionDiastolic DysfunctionDiastolic DysfunctionDiastolic Dysfunction

Heart Failure with Preserved Systolic FunctionHeart Failure with Preserved Systolic FunctionHeart Failure with Preserved Systolic FunctionHeart Failure with Preserved Systolic Function

Blood VesselsBlood VesselsHypertrophyHypertrophy

FibrosisFibrosisAltered elastin & collagenAltered elastin & collagen

calcificationcalcificationEndothelial dysfunctionEndothelial dysfunction

Loss of complianceLoss of compliance

Blood VesselsBlood VesselsHypertrophyHypertrophy

FibrosisFibrosisAltered elastin & collagenAltered elastin & collagen

calcificationcalcificationEndothelial dysfunctionEndothelial dysfunction

Loss of complianceLoss of compliance

MyocardiumMyocardiumHypertrophy (LVH)Hypertrophy (LVH)

FibrosisFibrosisCellular dysfunctionCellular dysfunction

IschemiaIschemiaIncreased stiffnessIncreased stiffness

Impaired relaxationImpaired relaxation

MyocardiumMyocardiumHypertrophy (LVH)Hypertrophy (LVH)

FibrosisFibrosisCellular dysfunctionCellular dysfunction

IschemiaIschemiaIncreased stiffnessIncreased stiffness

Impaired relaxationImpaired relaxation

18

21

120120

120120

150150

MEN MEN Risk of Coronary Heart DiseaseRisk of Coronary Heart Disease

Coronary Risk ChartCoronary Risk ChartWOMEN WOMEN

Risk of Coronary Heart DiseaseRisk of Coronary Heart Disease

Non-smokerNon-smoker

mmol/lmmol/l 44 55 66 77 88

mg/dlmg/dl 200200 250250 300300

150150

mmol/lmmol/l 44 55 66 77 88

mg/dlmg/dl 200200 250250 300300

CholesterolCholesterol

180180

160160

140140

120120

180180

160160

140140

120120

180180

160160

140140

120120

180180

160160

140140

120120

180180

160160

140140

120120

150150

mmol/lmmol/l 44 55 66 77 88

mg/dlmg/dl 200200 250250 300300

150150

mmol/lmmol/l 44 55 66 77 88

mg/dlmg/dl 200200 250250 300300

CholesterolCholesterol

180180

160160

140140

120120

180180

160160

140140

180180

160160

140140

120120

180180

160160

140140

120120

180180

160160

140140

SmokerSmoker

ageage

7070

ageage

6060

ageage

5050

ageage

4040

ageage

3030

120120

120120

150150

Non-smokerNon-smoker

mmol/lmmol/l 44 55 66 77 88

mg/dlmg/dl 200200 250250 300300

150150

mmol/lmmol/l 44 55 66 77 88

mg/dlmg/dl 200200 250250 300300

CholesterolCholesterol

180180

160160

140140

120120

180180

160160

140140

120120

180180

160160

140140

120120

180180

160160

140140

120120

180180

160160

140140

120120

150150

mmol/lmmol/l 44 55 66 77 88

mg/dlmg/dl 200200 250250 300300

150150

mmol/lmmol/l 44 55 66 77 88

mg/dlmg/dl 200200 250250 300300

CholesterolCholesterol

180180

160160

140140

120120

180180

160160

140140

180180

160160

140140

120120

180180

160160

140140

120120

180180

160160

140140

SmokerSmoker

ageage

7070

ageage

6060

ageage

5050

ageage

4040

ageage

3030Very highVery highHighHighModerateModerateMildMildLowLow

over 40%over 40%20% to 40%20% to 40%10% to 20%10% to 20%5% to 10%5% to 10%under 5%under 5%

10 Year Risk Level10 Year Risk Level

5334 M5334 M

SB

P (

mm

Hg)

SB

P (

mm

Hg)

SB

P (

mm

Hg)

SB

P (

mm

Hg)

Staessen JA, 1983 AM J Edipemiol

Focus sulla sindrome metabolica in menopausa

2328 G2328 G

Age-Specific Prevalence of the Metabolic Syndrome Age-Specific Prevalence of the Metabolic Syndrome among 8814 US Adults, NHANES III, 1988-1994among 8814 US Adults, NHANES III, 1988-1994

Age-Specific Prevalence of the Metabolic Syndrome Age-Specific Prevalence of the Metabolic Syndrome among 8814 US Adults, NHANES III, 1988-1994among 8814 US Adults, NHANES III, 1988-1994

Ford S et al., JAMA 2002Ford S et al., JAMA 2002

20-29 30-39 40-49 50-59 60-69 > 700

10

20

30

40

50

Men

Women

Age (years)Age (years)

Pre

vale

nce

(%

)P

reva

len

ce (

%)

Terapia dell’ipertensione nella donna

--I benefici del trattamento antipertensivo sono simili nei due sessi. È tuttavia sconsigliato l’impiego di ACE-inibitori e sartani nelle donne durante il periodo fertile e la gestazione per i potenziali effetti teratogeni

Contraccettivi orali

La terapia con contraccettivi orali a basso contenuto di estrogeni si associa ad un incremento del rischio di ipertensione,ictus e infarto del miocardio……

Terapia ormonale sostitutiva

Le informazioni disponibili suggeriscono che gli unici vantaggi della terapia ormonale sostitutiva sono rappresentati da una minor frequenza di fratture ossee e di neoplasie

del colon, mentre è aumentato il rischio di eventi coronarici e tromboembolici, ictus…

Linee Guida ESH/ESC 2007

….Che farmaco usare?Tutti i farmaci antiipertensivi attraversano la placentaDati comparativi tra i diversi farmaci riguardanti sia l’efficacia sia la sicurezza fetale e materna sono ancorainadeguati

ACE inibitori e ARB controindicati perché teratogeni: stopparli anche nelle donne fertili che stanno programmando una gravidanza!

METILDOPA (simpaticolitico centrale). Aldomet os 250 mg x 2/die, max 3 g/dieSicuro per madre e feto, blando antiipertensivo. Effetti collaterali: stipsi, depressione, sonnolenza, secchezza fauci

LABETALOLO* (alfa 1 bloccante e beta bloccante non selettivo) 100 mg x 2/die, max 2.4 g/dieI beta bloccanti cardioselettivi Beta1 (atenololo) possono ridurre la crescita fetale e placentare.I beta bloccanti non selettivi (propranololo) possono interferire con il rilassamento miometriale (processo beta2 relato)

Calcio antagonisti (Adalat* 30-90 mg/die max 120 mg/die)Sicuri per madre e feto, sebbene non esistano molti studi per Ca antagonisti non diidropiridinici (verapamil, diltiazem), ed amlodipina. Maggiori informazioni per nifedipina

* Consigliati anche durante l’allattamento

Treatment (2)Treatment (2)