Women and Coronary Artery Disease (CAD)

1. Women and Coronary Artery Disease (CAD) Module 1 Introduction

2. Supported by an unrestricted educational grant from Fujisawa Healthcare, Inc.

7. Historical Perceptions in the Medical Profession Misperceptions • Heart disease is a man’s disease • Women’s chest pain symptoms are not due to heart disease Enrollment of women in clinical trials • Research studies (up until recently) included very few women • Our knowledge of heart disease in women has been rather poor Gender bias in diagnosis and treatment • Undertreatment and underdiagnosis of women • Less aggressive care → higher complications and death rates

9. Myths vs Facts

10. Women’s Perceptions of Heart Disease • 72% of young women (ages 25-40) still consider cancer to be the greatest threat to women’s health • Some women know about the risks of heart disease but do not hear it from their own doctors and do not “personalize” it • 65% of women recognize that symptoms may be “atypical” but do not know classic symptoms • Most women learn about coronary artery disease (CAD) from magazines and the Web—not from their own physicians! Robinson A. Circulation. 2001

11. Gender Bias in the Treatment of Women “… The community has viewed women’s health almost with a ‘bikini’ approach, looking essentially at the breast and reproductive system, and almost ignoring the rest of the woman as part of women’s health ….”Nanette Wenger, MD Chief of Cardiology, Grady Hospital Professor of Medicine, Emory University Atlanta, Georgia

12. Magnitude of the Problem • 2.5 million women per year in the US are hospitalized with cardiovascular disease (CVD) • Deaths from CVD = 500,000/yr • Leading cause of death in US women: CAD • >230,000 women die from CAD each year • 1990: US Congress directed the National Institutes of Health that women be included in clinical trials and that gender differences be evaluated

14. Women in Clinical Trials • Women are underrepresented in cardiovascular (CV) trials • Evidence-based CV medicine biased toward men • Food and Drug Administration/National Institutes of Health mandate: 50% enrollment of women • Women need to be empowered to enroll in clinical trials for heart disease • Breast-cancer awareness is a good example

15. Publication Bias: Gender Representation and Negative Studies • 1966-1994 noninvasive testing literature • 8% to 27% women • Lower diagnostic accuracy in women • High false-positive rates • Inability to perform maximal stress

16. CVD Mortality Trends (1979-1999) Deaths in Thousands American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

17. Prevalence of CVD in the US American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

18. Deaths From CVD and Cancer by Age and Sex Anderson RN. National Vital Statistics Reports. 2002

19. Myocardial Infarction (MI) Incidence (1979-1994) Men Women Roger VL, et al. Ann Intern Med. 2002

20. Deaths From CVD (1999) American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

21. 260 240 220 200 180 160 140 Deaths per 100,000 Population 120 100 80 60 40 20 0 1940 1950 1960 1970 1980 1990 Age-Adjusted Death Rates for Major CVD J Am Coll Cardiol. 2000

22. Health Threats to Women: Perception vs Reality 1 2 • 1. Gallup survey. 1995 2. American Heart Association. Heart & Stroke Facts. 1996 Statistical Supplement

23. Death From Breast Cancer or Heart Disease in Women in the US • US Vital Statistics, 1990

24. Does CVD Affect Many People? • 1 in 5 people has some form of CVD • CVD claimed ~1 million lives in 1999 • 40% of all US deaths • 1.1 million heart attacks each year • 7 million doctor visits each year for chest pain • 600,000 strokes each year • CVD accounts for 15% to 33% of all healthcare costs American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

25. Statistics for Women • 503,927 died of CVD in 1998 • 226,467 from heart attack or other cardiac events • 97,303 from stroke • 1 in 5 women has some form of CVD • 38% of women who have a heart attack die within 1 year • 40% of coronary events in women are fatal • Most occur without prior warning

26. Coronary Heart Disease Death Rates by State (1996-1998) American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

27. Diagnosis and Management of CAD in Women • Gender differences in presentation, manifestation, and diagnosis of CAD • Gender differences in mortality • 63% of women who die suddenly from CAD had no prior warning symptoms • 42% of women vs. 24 % of men will die within one year after MI • Thus, early recognition of symptoms and accurate diagnosis of CAD is of great importance

28. Does Gender Matter in CAD? • 2001 Institute of Medicine report: “Exploring the biological contribution to human health: does sex matter?” • Confirmed that significant differences between the sexes affect the prevalence, incidence, and severity of a broad range of diseases and conditions • This is certainly true for CAD