Brattleboro Memorial Hospital

May 3, 2014

Sheila M Conley, BSN RNQuality Improvement Associate –

Clinical Cardiology

Cardiac Disease in Women:

How One Thing Can Lead to Another

• Basics of normal circulation• Understand Cardiac disease in women• Outline the current system in place to

support patients with STEMI in greater Brattleboro area

• Emphasize steps every woman can take to minimize risk

• Understand where to get additional information

Presentation Goals

What do you mean: “How

one thing leads to

another?”

• Plumbing• Coronary Artery Disease

• Electrical• Sudden Cardiac Arrest, Pacemakers,

ICDs• Structural

• Patent Foramen Ovale, Valvular disease• Congenital

• These kids are becoming grown ups!• Any combination there of!

Major Types of Cardiovascular Disease

Normal CirculationRight Heart de-oxygenated blood is returned to the heart from veins. Right ventricles sends this blood to the lungs via pulmonary arteries for the O2 CO2 exchange.

Left heart receives oxygenated blood from pulmonary veins and the left ventricle sends oxygenated blood to the body through the big artery – aorta.First arteries to branch off the aorta are the coronary arteries..

Normal Electrical

Conduction

• Cardiovascular disease is the leading cause of death in women, outnumbering deaths from all other causes combined.

• Each year, >500,000 women experience an MI and >250,000 die of CAD.

• Prevalence of cardiovascular disease in women, including CAD, CHF, stroke, and HTN, exceeds that in men in the population >55 years.

• Mortality rate from cardiovascular disease in men has declined steadily during the past 20 years. In women, unfortunately, this rate has remained relatively unchanged.

• Despite the magnitude of the problem, on average only 25% of subjects in most cardiovascular trials are women.

The Numbers Please

• Evaluation of women with symptoms suggestive of IHD is hampered by the definition of “typical” angina, derived from largely male populations.

• In a study by Dey et al, 92% of the 7,638 women with presumed ACS presented with chest pain. In women, who had atypical symptoms, dyspnea, N/V, and diaphoresis were the most common symptoms.

• Women with typical or atypical CP (nonexertional or prolonged discomfort unrelieved by rest) have calculated obstructive CAD probabilities substantially less than that of men.

• Among those undergoing coronary angiography, as many as 50% of women do not have obstructive CAD.

• This difference may be largely due to noncardiac chest pain, but it may also represent conditions such as vasospasm, microvascular disease, or stress cardiomyopathy, all of which disproportionally affect women.

Symptom Assessment & Prevalence of Ischemia in

Women

• Although most women with ACS present acutely with chest pain, women may have different warning signs than men.

• Only about one-third of women experience angina before presentation.

• Compared with men, women are more likely to complain of shortness of breath, fatigue, and weakness leading up to a diagnosis of an MI.

• Therefore, the symptoms leading up to cardiovascular disease may in fact be significantly more atypical in women than in men, suggesting the need for heightened vigilance in the CV evaluation of women who have non-anginal symptoms.

Atypical warning signs

• One factor contributing to relatively greater IHD risk in women is less intensive use of indicated medical therapy (aspirin, beta-blocker, statin, ACEI, therapeutic lifestyle counseling), despite specific guidelines noting their benefit.

• The Cooperative Cardiovascular Project showed that women received less medical treatment after MI, including 5% that received fewer prescriptions of aspirin at discharge; although they were 5% more likely than men to receive ACE inhibitors, perhaps as the result of Hypertension.

• A more recent registry indicates that this observation has not changed, with women receiving less (indicated) aspirin at discharge (87.5% vs. 90.4%), beta-blockers (80.5% vs. 82.7%), and statins (55.9% vs. 69.4%) compared with men.

Medical Therapy for IHD in Women

http://www.youtube.com/watch?v=_JI487DlgTA

Women aren’t the same as men

• Heart attacks are not created equally!• STEMI• N-STEMI• Demand ischemia

• All “chest pain” aren’t necessarily heart attacks!• Stress induced cardiomyopathy

(Takatsubo)• Pericarditis

What is a “STEMI”?

Options for treating STEMI

• Mechanical• In the cardiac cath

lab, gain arterial access to open the coronary artery within 90/120 minutes of presentation to ED.

• Wrist v Groin• Bare metal v Drug

eluting• Not risk free but

restoring circulation is critical

• Medication• Provide clot busting

drug IV within 30 minutes of presentation to ED.

• Follow by catheterization

• Not risk free

Non-PCI capable hospitalsSTEMI Transfer to PCI capable hospital• Lytic issues• If no lytic, then hurry up!• Helicopter? Ambulance?

NSTEMI ? Transfer• It depends…Communication and process improvements have been key to our success.

The Region• Upper CT Valley, ~60 m

N and 45 m S on I91 and 30-40 m NW or SE on I89.

• 20 Referral Hospitals

• Zone 1 = the local area, APD and VAMC - Primary PCI

• Zone 1 Option = 5 hospitals that have options in treatment

• Zone 2 = everyone else – Thrombolytics

• ~20 Ambulance services• 1 Helicopter based at

DHMC• 1 Helicopter based in

Manchester

Ideal STEMI system schematic

JACC Vol. 61 No. 4, 2013January 29, 2013:e78-140

Brattleboro Memorial Hospital is a “Sending Hospital” in the STEMI system

Cardiac Caths are not performed at BMHFirst line treatment is an intravenous Thrombolytic “Clot-buster” that should be given within 30 minutes of presentation to Emergency Department.

BMH is considered a “Zone 2 Hospital” in the DHMC STEMI Network because we can’t make a “D2B” of less than 2 hours.

Default strategy is Lytic followed by angiography and revascularization.

True STEMI Patients Treated at DHMC May, 2008 - February, 2014 (n=1359)

336

151

125

937976

69

63

55

48

4643

4133

28 20 12 12 115 5 3 22 1 DHMC Cheshire Medical CenterRutland Regional MCSpringfield HospitalBrattleboro Memorial HospitalNVRHNorth Country Hospital Valley Regional HospitalLittleton Regional HospitalNew London HospitalGifford Medical CenterWeeks Memorial HospitalUCVHCottage HospitalMt. Ascutney HospitalVAAlice Peck DaySpeare Memorial HospitalGrace Cottage HospitalAndroscoggin Valley HospitalCVHSWVMCHuggins HospitalLakes Region HospitalMonadnock Hospital

True STEMI Patients Treated at DHMC May, 2008 - February, 2014 (n=1359)

28%

72%

Female Male

Overall mortality rate is 5%

89%

11%

No CHF CHF

BMH STEMI Patients Treated at DHMC May, 2008 - February, 2014 (n=79)

Entire Registry 50 – 50 % lytic treated

16%

84%

Lytic administeredLytic not administered

25%

75%

Female Male

Event Males Females

True STEMIs 59 20In Hospital Death 22 (8%) 5 (25%)

New onset CHF 7 (12%) 4 (20%)Neurologic Event 2 (3%) 1 (5%)Recurrent MI 3 (5%) 1 (5%)

BMH STEMI Patients Treated at DHMC May, 2008 - February, 2014 (n=79)

• 2-3 days in hospital unless there are complications which could cause a longer hospital stay• Labs, additional tests, education

• Referral to Cardiac Rehab• Follow up with primary care• Follow up with cardiology

After the “heart attack” (MI)

• Cardiac Catheterization• Dissection• Unable to open the blockage• Access site problems• Acute Kidney Injury/Radiation injury

• Heart Function post infarct• Rhythm disturbances• “Pump” or Heart failure

Complications?

• This is the situation you hear about with the young athletes, but it can happen to anyone of any age. Typically, it’s a conduction (electrical) defect that can be fixed. It’s important to get it fixed before there is permanent brain damage or cardiac damage.

• If this happens, and an AED (Automatic External Defibrilator) is used quickly and effectively, the person will be OK, but will get an ICD.

• If the person remains unconscious, they will be placed in a medication induced coma and ‘cooled.”

• Therapeutic Hypothermia is the medical term and it can be started by EMS and at Brattleboro Hospital.

• It’s thought that slowing down a person’s metabolism can help recover neurological function.

Sudden Cardiac Arrest

Heart Failure is a scary diagnosis to hear.Tired out Heart

Symptoms include:• Weight gain for more than 2 days in a

row• Increased weight of 2-3 pounds/day

or 5 pounds in a week• Shortness of breath• Fluid retention, belt is tight or

swelling in your feet and legs• Difficulty sleeping/laying flat• Frequent urination at night• Non productive cough

This can be managed with coordinated care!

Get informedUnderstand what steps you can take to reduce your risk of heart disease.It is never too late to start.

Quit Smoking!Get more activeKnow your numbersReduce your stressEat more healthfully

You can’t change your genes or the past, but you can affect your future!

Google “Just a little heart attack” to see the public service announcementShare it with your friends

www.goredforwomen.org/ has a lot of this info in small easy to take in chunks

Questions?Thank you for the opportunity to speak with you today!