Heart Disease in Women:

A Different Perspective

None

DISCLOSURES

Women CHD

♥ Epidemiology

♥ Risk Factors

♥ Management

♥ Clinical Presentation

♥ Stress Testing

♥ Unique Pathophysiology (?)

Women CHD

♥ Epidemiology

♥ Risk Factors

♥ Management

♥ Clinical Presentation

♥ Stress Testing

♥ Unique Pathophysiology (?)

0

5

10

15

20

25

30

35

40

45

35-44 45-54 55-64 65-74 77-84 ≥ 85

PE

RC

EN

T

AGE (yrs)

DEATHS – WOMEN (US 2015)

CANCER

HEART DISEASE

CDC 2015

? ?

? QUESTION?

? ?

Coronary Heart Disease

Rare in premenopausal

nondiabetic women

who do not smoke!

280,000 MIs in women: 2400 (0.9%) <54yo

JAMA 2012;307:873

Women CHD

♥ Epidemiology

♥ Risk Factors

♥ Management

♥ Clinical Presentation

♥ Stress Testing

♥ Unique Pathophysiology (?)

62 yo woman. Risk of CVD (fatal/nonfatal MI, Stroke)

HDL-Cholesterol 50

BP 150/85 (no Rx)

Nonsmoker

Not African-American

10 yr risk for CVD 8.7%

Total Serum Cholesterol 235

2014 ASCVD Risk Calculator

62 yo man. Risk of CVD (fatal/nonfatal MI, Stroke)

HDL-Cholesterol 50

BP 150/85 (no Rx)

Nonsmoker

Not African-American

10 yr risk for CVD 17.4%

Total Serum Cholesterol 235

2014 ASCVD Risk Calculator

Women, Men and CHD

♥ Epidemiology

♥ Risk Factors

♥ Management

♥ Clinical Presentation

♥ Stress Testing

♥ Unique Pathophysiology (?)

CAD in Women and Men♥ Women: Higher risk at onset of CAD Sx

Older

More comorbidities

Greater psychological stress with MI Adverse effect on recovery (Circ131:614, 2015)

Delayed diagnosis

Less intensive therapy in past

Current recommendations same for W & M

Roger et al. Circulation 2011;123:e18-209Source: National Center of Health Statistics

CV Deaths – Men and WomenD

EA

TH

S (

1000s)

Males Females

CV DEATHS – WOMEN and MEN

Women, Men and CHD

♥ Epidemiology

♥ Risk Factors

♥ Management

♥ Clinical Presentation

♥ Stress Testing

♥ Unique Pathophysiology (?)

♥ All Acute Coronary Syndromes

70% of women vs. 72% of men present with

chest pain (n.s.)

♥ MyocardiaI Infarction

6 of 8 studies: No difference in frequency of

chest pain in men and women

>90% of women present with chest pain.

Symptoms in ACS: Gender difference?

The PROMISE StudyCTA coronary angio vs stress nuclear for

detection of CAD in women/men

N = 10,000 : 5,000 women, 5,000 men

Randomized: CTA or Stress Nuc

Chest pain

Primary symptom in Women (73%), Men (72%)

Crushing/pressure/squeezing/tightness

Women 53%, Men 46%

JACCimg 2016;9:337

Women reporting frequent angina were more likely to exhibit ischemia and this may characterize a female-

specific typical angina pattern.

J.Women’s Health 2011

!!!!

``1``

HELL

HERE?

ADP in Low Risk Women

Presenting with CP

N = 212

<50 yo, no DM/smoking,

ED ECG normal, neg. markers

ETT = 138, Stress imaging = 11, no confirmatory test = 63

Negative CPU evaluation in all patients, all directly discharged

5 yr follow-up: No coronary events

Eddin et al, Am Jmed 2014

Aortic Abdominal Aneurysm

Prevalence (65–80 yo) Men: 4-8%

Women: 1.3%

Mortality rate for AAA rupture Men: 93.9%

Women: no data (prevalence/incidence too low)

Women CHD

♥ Epidemiology

♥ Management

♥ Risk Factors

♥ Clinical Presentation

♥ Stress Testing

♥Unique Pathophysiology (?)

Stress Testing in Women with CP

♥ AHA Scientific Statement (2005)

♥ AHA Scientific Statement (2010)

♥ AHA/ACC Stable IHD GL (2012, 2014)

If normal ECG, able to exercise:

Standard Treadmill Test (IA)

If abn ECG/unable to exercise:

Ex/pharm imaging test (1B)

Sensitivity/Specificity of ETTFroelicher, Ex and Heart, 2008

♥Metaanalysis - 41 studiesMen – Sens/Spec: 70%/80%

Women – Sens/Spec: 70%/70%

Comparative Effectiveness of

Exercise ECG with or without SPECT

in Women with Suspected CAD

“Exercise Treadmill was as accurate as Nuclear Stress test in predicting 2 year

outcomes in women with chest pain and

resulted in significant cost savings”

Shaw, Circ 2011;124:1239

n=824, 63 yo, intermed-high risk for CAD

0

10

20

30

40

Duke TM Score and MACE – UC Davis

n=1001 women with CP, FU 6.5 yrs

MA

CE

(%

Pati

en

t)

-1 to 4

Duke Score

-7 to -2-14 to -8 5 to 9 10 to 16

p<0.0001

Chattertion, Amsterdam, Circ 2010

Women CHD

♥ Epidemiology

♥ Management

♥ Risk Factors

♥ Clinical Presentation

♥Stress Testing

♥Unique Pathophysiology (?)

Women with Chest Pain and

Nonobstructed Coronary Arteries (a tale of 2 studies)

Johnson et al. Eur Heart J 2006;27:1408-1415

WISE study

(n=189)

Years

UCD Pilot Study

(n=131)

100

SUMMARYCa: Chief cause of mortality in women <75 yo

Risk factors: Do not differ significantly

Exercise treadmill

1st test for assessment of CP in both sexes

Treatment improved in women

Same recs for both sexes in most instances

Coronary microvascular dysfunction

Women = Men