Cardiovascular Disease in WomenModule V: Prognosis and

Treatment Outcomes

Women Received 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 Less antiplatelet therapy

for secondary prevention Fewer referrals to cardiac rehabilitation Fewer implantable cardioverter-defibrillators compared

to men with the same recognized indications

Sources: Chandra 1998, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 2005, Chou 2007, Hernandez 2007, Cho 2008

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 2004

Prognosis

Women < 65 yrs have 2 X mortality rate after MI compared to men of same age

After MI, women have significantly higher rates of: Depression Physical disability

After CABG, women have significantly higher rates of: Hospital readmission Reduced mental health and physical functioning

Source: Vaccarino 1999, Ades 2002, Lauzon 2003, Vaccarino 2003

Undertreatment of MI in Women

Compared with men: Less emergent thrombolysis Less acute catheterization and angioplasty Less acute surgical revascularization Less use of heparin, beta-blockers, and aspirin

Source: Chandra 1998, Nohria 1998

Cardiac Rehabilitation for Women

Cardiac rehabilitation programs benefit both men and women

Participation rates for eligible women are 15-20%, compared to 25-31% for eligible men

Women are more likely to drop out after beginning cardiac rehabilitation

Healthcare providers are less likely to encourage rehabilitation for female patients

Source: Scott 2004

Benefits of ASA in Women with Established CAD

2.7

5.15.1

9.1

0123456789

10

Aspirin No Aspirin

Mortality at 3 Years

Follow-Up (%)

CVDMortality

All CauseMortality

* P = 0.002 **P = 0.0001

*

**

Source: Adapted from Harpaz 1996

Addition of Clopidogrel to Aspirin and Fibrinolytic Therapy for MI with ST-Segment Elevation in Women

16.9

24.7

0

5

10

15

20

25

30

Clopidogrel Placebo

% with Antiographic Reocclusion,

Death, or Recurrent MI

Before Angiography

P < 0.05; reduction in odds = 38%

Source: Sabatine 2005

Gender Gap in Dyslipidemia Treatment

Significantly more men than women have annual cholesterol measurements

Significantly more men than women receive effective lipid-lowering therapy

African Americans receive less lipid-lowering treatment compared to whites

Source: O’Meara 2004, Hendrix 2005, Chou 2007, Cho 2008

Meta-Analysis of 11 Clinical Trials of Statin Therapy Including 15,917 Women with Known CHD

-21

-36

-26

-40

-35

-30

-25

-20

-15

-10

-5

0

% Reduction

CHD Events Non-Fatal MI CHD Mortality

Source: Grady 2003.

Simvastatin and Gender Risk for CHD and Mortality

0.65*

1.12

0.66* 0.66*

0

0.2

0.4

0.6

0.8

1

1.2

Total Death Major CoronaryEvent

Rela

tive R

isk

(Co

x r

eg

ressio

n a

naly

sis

)

WomenMen

*P <0.05

Source: Scandinavian Simvastatin Survival Study Group 1994

Heart Protection Study: Major Findings

Randomized, placebo-controlled trial of over 20,000 patients at risk for CVD

Statin treatment reduced the risk of heart attacks and strokes by at least one third, as well as reducing the need for arterial surgery, angioplasty and amputations.

Major CV events were reduced in women (5082 enrolled) as well as men, and in all age groups, across all cholesterol levels.

Source: HPS Writing Group, Lancet 2002

Primary Prevention of CHD Events with Statin Treatment: AFCAPS/TexCAPS

-46

-37

-50-45-40-35-30-25-20-15-10

-50

% MenWomen

Relative Risk of First Major Coronary Events

P < 0.001 compared to placebo

Source: Downs 1998

Implanted Cardioverter Defibrillator (ICD) Therapy in Women Women appear to have a lower incidence

of sudden cardiac death then men Women present more frequently with

ventricular fibrillation than men Women have similar survival rates after

ICD implantation compared to men In a study of hospitals participating in a heart failure

quality improvement program, women received fewer implantable cardioverter-defibrillators compared to men with the same recognized indications

Source: Pires 2002, Hernandez 2007

Adjusted Odds for Use of Implantable Cardioverter-Defibrillator According to Guidelines by Race and Sex

00.10.20.30.40.50.60.70.80.9

1

White Men Black Men WhiteWomen

BlackWomen

Rela

tive R

isk *P <0.05

compared with white men

Source: Adapted from Hernandez 2007

** *

Interventional Procedures and Surgery

Higher complication and death rates Smaller artery size More co-existing illnesses (older at presentation) Higher rates of diabetes More urgent and emergent presentations Higher incidence of congestive heart failure in

women from diastolic dysfunction

Source: Jacobs 2003

Coronary Revascularization in Women Compared to Men Increased use of PTCA compared to stents,

because of smaller vessel size

Decreased rates of glycoprotein IIb/IIIa inhibitor use, possibly because of increased bleeding complications in women

Higher in-hospital mortality for CABG and PCI Higher rates of vascular complications Higher transfusion rates

Source: Jacobs 2003

Revascularization Outcomes in Women: Improvements in Recent Years NHLBI registry data shows improved clinical success rates

and lower major complication rates for women undergoing PTCA

Retrospective data suggest that women have lower mortality rates when undergoing off-pump CABG, compared to standard CABG

Source: Jacobs 1997, Petro 2000

Sex Differences for In-Hospital Mortality After CABG: Higher Mortality in Younger Women

2.23

1.86

1.161.47

1.02

0

0.5

1

1.5

2

2.5

< 50 50-59

60-69

70-79

80

Age Group

AdjustedOddsRatio forIn-HospitalMortality

P for interaction between sex and age = 0.002.

≥

Source: Adapted from Vaccarino 2002

CABG Outcomes in Women: A Vicious Cycle

Perception: Higher post-operative morbidity/mortality in women

Prompt referral for CABG discouraged in women

Women referred at later stages of disease, w/ more comorbidities

Higher operative risk for women

Fewer long-term benefits for women

Source: Adapted from Vaccarino 2003