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Ischemic Heart Disease: Minority and Gender Issues

Ischemic Heart Disease: Minority and Gender Issues. Charles K. Francis, M.D., FACP President American College of Physicians. Cardiovascular Disease Mortality Trends for Males and Females United States: 1979-2002. Source: CDC/NCHS.

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Ischemic Heart Disease: Minority and Gender Issues

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  1. Ischemic Heart Disease:Minority and Gender Issues Charles K. Francis, M.D., FACP President American College of Physicians

  2. Cardiovascular Disease Mortality Trends for Males and Females United States: 1979-2002 Source: CDC/NCHS.

  3. Age-Adjusted Death Rates for Coronary Heart Disease, Stroke, and Lung and Breast Cancer for White and Black Females United States: 2002 Source: CDC/NCHS.

  4. Deaths From Diseases of the Heart* United States: 1900–2002 Total CVD data are not available for much of the period covered by this chart. Source: CDC/NCHS.

  5. Hospital Discharges* for Cardiovascular Diseases as First Listed Diagnosis United States: 1970-2002 Note: Hospital discharges include people both living and dead. Source: CDC/NCHS.

  6. Percentage Breakdown of Deaths From Cardiovascular Diseases United States:2002 Preliminary Source: CDC/NCHS.

  7. Prevalence of Cardiovascular Diseases in Americans Age 20 and Older by Age and Sex NHANES: 1999-2002 Source: CDC/NCHS and NHLBI. These data include coronary heart disease, congestive heart failure, stroke and hypertension.

  8. Leading Causes of Death for All Males and Females United States: 2002 Deaths in Thousands A Total CVD (Preliminary) B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s Disease Source: CDC/NCHS

  9. Leading Causes of Death for White Males and Females United States: 2002 Percent of Total Deaths A Total CVD (Preliminary) B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s Disease G Influenza and Pneumonia Source: CDC/NCHS

  10. Leading Causes of Death for Black or African-American Males and Females United States: 2002 Percent of Total Deaths A Total CVD (Preliminary) B Cancer C Accidents D Assault (Homicide) E HIV(AIDS) F Diabetes Mellitus G Nephritis, Nephrotic Syndrome and Nephrosis Source: CDC/NCHS

  11. Leading Causes of Death for Hispanic or Latino Males and Females United States: 2002 Percent of Total Deaths A Diseases of the Heart, and Stroke B Cancer C Accidents D Diabetes Mellitus E Assault (Homicide) F Chronic Lower Respiratory Disease Source: CDC/NCHS

  12. Leading Causes of Death for Asian or Pacific Islander Males and Females United States: 2002 Percent of Total Deaths A Diseases of the Heart, and Stroke B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Influenza and Pneumonia Source: CDC/NCHS

  13. Leading Causes of Death for American Indian or Alaska Native Males and Females United States: 2002 Percent of Total Deaths A Diseases of the Heart, and Stroke B Cancer C Accidents D Diabetes Mellitus E Chronic Liver Disease and Cirrhosis F Chronic Lower Respiratory Diseases Source: CDC/NCHS

  14. Coronary Heart Disease in the U.S. • CHD largest killer of U.S. men and women • From 1992-2002 death rate from CHD declined 26.5% but # of deaths fell only 9.9% • 83% of people who die are age 65 or older • 2002 overall CHD death rate 170.8/100,000. • 2002 death rates/100,000: WM 220.5; BM 250.6; WF 131.2; BF 169.7; 1999 Hisp. 138.4; American Indian/Alaskan Native 123.9 Asian Pacific Islanders 115.7 Heart and Stroke Facts, American Heart Association 2002

  15. Coronary Heart Disease in the U.S. Prevalence of CHD: Race, ethnicity and gender Adults >age 20 CHD MI White males 6.9% 5.2% White females 5.4% 2.0% Black males 7.1% 4.3% Black females 9.0% 3.3% Mex.Am.Males 7.2% 4.1% Mex.Am.Females 6.8% 1.9% Heart and Stroke Facts. American Heart Association 2000

  16. Tracking Women’s Awareness of Heart Disease (Circ 2004:109:573-579) Prior research has shown a lack of awareness of the risk of CHD among women. Telephone survey of 1024 women >25 yrs; 68% Wht; 12% Blk;12% Hisp; 8% other. CVD leading killer: 30% in 1997; 34% in 2000 and 46% in 2003. Fewer women reported that cancer was leading killer Black, Hispanic and younger women (<45 yrs) were less aware of heart disease as main killer 38% reported that doctors had discussed CVD

  17. Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study A B C D Blood Pressure (mm Hg) 120/80 140/90 140/90 140/90 Total Cholesterol (mg/dL) 200 240 240 240 HDL Cholesterol (mg/dL) 50 50 40 40 Diabetes No No Yes Yes Cigarettes No No No Yes mm Hg = millimeters of mercury mg/dL = milligrams per deciliter of blood l Source: Wilson PWF, et al. Circulation 1998;97:1837-1847.

  18. Annual Number of Americans Having Diagnosed Heart Attack by Age and Sex ARIC: 1987-2000 Source: Extrapolated from rates in the NHLBI’s ARIC surveillance study, 1987-2000. These data don’t include silent MIs.

  19. Annual Rate of First Heart Attacks by Age, Sex and Race ARIC: 1987-2000 Source: NHLBI’s ARIC surveillance study, 1987-2000.

  20. Prevalence of Coronary Heart Diseases by Age and Sex NHANES :1999-2002 Source: CDC/NCHS and NHLBI.

  21. Hospital Discharges for Coronary Heart Disease by Sex United States: 1970-2002 Note: Hospital discharges include people both living and dead. Source: CDC/NCHS.

  22. Prevalence of High Blood Pressure in Americans by Age and Sex NHANES: 1999-2002 Source: CDC/NCHS and NHLBI.

  23. Extent of Awareness, Treatment and Control of High Blood Pressure by Age NHANES : 1999-2000 Source: JAMA 2003;290:199-206.

  24. Age-Adjusted Prevalence Trends for High Blood Pressure in Americans Age 20 -74 by Race/Ethnicity, Sex and Survey NHANES: 1976-80, 1988-94 and 1999-2002 Source: CDC/NCHS. Data based on a single measure of BP.

  25. Extent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity NHANES: 1999-2000 Source: JAMA 2003;290:199-206.

  26. Prevalence of Congestive Heart Failure by Age and Sex NHANES: 1999-2002 Source: CDC/NCHS and NHLBI.

  27. Hospital Discharges for Congestive Heart Failure by Sex United States: 1970-2002 Note: Hospital discharges include people living and dead. Source: CDC/NCHS.

  28. Prevalence of High School Students in Grades 9-12 Reporting Current Cigarette Smoking by Race/Ethnicity and Sex YRBS:2003 Source: MMWR, Vol. 53, (23), June 18, 2004, CDC/NCHS.

  29. Prevalence of Current Smoking for Americans Age 18 and Older by Race/Ethnicity and Sex NHIS:2002 Source: MMWR, Vol. 53, (20);427-31, May 28, 2004, CDC/NCHS.

  30. Trends in Mean Total Blood Cholesterol Among Adolescents Ages 12-17 by Sex, Race and Survey NHES III: 1966-70; NHANES I & III: 1971-74, 1988-94 Source: CDC/NCHS. Prev Med 1998;27:879-90.

  31. Prevalence of Students in Grades 9-12 Who Participated in Sufficient Vigorous or Moderate Physical Activity During the Past 7 Days by Race/Ethnicity and Sex YRBS: 2003 Note: “Vigorous activity” is defined as activity causing sweating and hard breathing for at least 20 minutes on 3 or more of the 7 days. “Moderate activity” is defined as activities such as walking or bicycling lasting for at least 30 minutes on 5 or more of the 7 days. Source: MMWR, Vol. 53, No. SS-2, May 21, 2004, CDC/NCHS.

  32. Prevalence of Moderate or Vigorous Physical Activity in Americans Age 20 and Older by Sex, Race/Ethnicity and BMI NHANES III: 1988-94 Note: BMI indicates body mass index: weight in kilograms divided by height in meters squared (kg/m2). Source: CDC/NCHS.

  33. Prevalence of Overweight among Students in Grades 9-12 by Sex and Race/Ethnicity YRBS: 2003 Source: BMI 95th percentile or higher. MMWR, Vol. 53,No. SS-2, May 21,2004, CDC/NCHS.

  34. Age-Adjusted Prevalence of Obesity in Americans Ages 20-74 by Sex and Survey NHES, 1960-62; NHANES, 1971-74, 1976-80, 1988-94 and 1999-2002 Note: Obesity is defined as a BMI of 30.0 or higher. Source: CDC/NCHS.

  35. Age-Adjusted Prevalence of Physician-Diagnosed Diabetes in Americans Age 20 and Older by Sex and Race/Ethnicity NHANES: 1999-2002 Source: CDC/NCHS and NHLBI.

  36. Prevalence of Non-Insulin-Dependent (Type 2) Diabetes in Women* Ages 25-64 by Race/Ethnicity and Education NHANES III: 1988-94 * Findings for men are similar but of lower magnitude. See Pathways by which SES and ethnicity influence CVD risk factors. Annals NY Academy of Science. 1999;896:191-209 Source: JAMA. 1998;280:356-62.

  37. Trends in Heart Transplants UNOS: 1968-2003 Source: United Network for OrganSharing (UNOS), scientific registry data.

  38. Trends in Cardiovascular Operations and Procedures United States: 1979-2002 Source: CDC/NCHS.

  39. Total Mortality Rates in U.S. Adults, Age 30-75, with Metabolic Syndrome (MetS), With and Without Diabetes Mellitus and Pre-Existing CVD NHANES II: 1976-80 Follow-up Study** ** Average of 13 years of follow-up. Source: Circulation 2004;110:1245-50.

  40. Estimated Direct and Indirect Costs of Cardiovascular Diseases and Stroke United States: 2005 Source: Heart Disease and Stroke Statistics – 2005 Update.

  41. Angina Pectoris in the U.S. • About 400,000 new cases occur each year • 27% of men and 14% of women will develop angina within 6 years of a heart attack • Prevalence of angina age 40-70 higher in women. • Increased prevalence for Mex-Am men and women and for African American women (NS) • Annual rates (per 1000 population) of new and recurrent angina : Ages 65-74: NBM 44.3; NBW 18.8; BM 26.1; BW 29.4: Ages 75-84: NBM 56.4; NBW 30.8; BM 52.2; BW 37.7; Ages 85 < : NBM 42.6; NBW 19.8; BM 43.5; BW 15.2 • Black women at greatest risk • Heart and Stroke Facts. American Heart Association 2005

  42. Angina-like Chest Pain With “Normal” Coronary Arteriography • Clinical Features: • 10-20% of pts cath’d for angina pectoris • More common in women, premenopausal • Usually have atypical chest pain • Physical findings are usually normal • May have positive exercise test in 20% • May have abnormal coronary reserve • Long term survival is excellent • Nitrates or beta blockers are rarely effective

  43. Angina-like Chest Pain With “Normal” Coronary Arteriography • Often referred to a “Syndrome X” (should be distinguished from the endocrine syndrome • May be due to a number of conditions: 1. Abnormal pain perception of sensitivity 2. Microvascular dysfunction a. Abnormal coronary reserve b. Increased sympathetic or RAAS function c. Endothelial dysfunction d. Hypertension/left ventricular hypertrophy

  44. Angina-like Chest Pain With “Normal” Coronary Arteriography • Clinical Features: • 10-20% of pts cath’d for angina pectoris • More common in women, premenopausal • Usually have atypical chest pain • Physical findings are usually normal • May have positive exercise test in 20% • May have abnormal coronary reserve • Long term survival is excellent • Nitrates or beta blockers are rarely effective

  45. Angina-like Chest Pain With “Normal” Coronary Arteriography • Often referred to a “Syndrome X” (should be distinguished from the endocrine syndrome • May be due to a number of conditions: 1. Abnormal pain perception of sensitivity 2. Microvascular dysfunction a. Abnormal coronary reserve b. Increased sympathetic or RAAS function c. Endothelial dysfunction d. Hypertension/left ventricular hypertrophy

  46. Antihypertensive/anti-ischemic Pharmacologic Therapy • Specific antihypertensive agents -- Beta Blockers -- Nitrates -- Calcium Antagonists -- ACE inhibitors (AII blockers?) -- Drug combinations

  47. Management of the hypertensive patient with ischemic heart disease • Initial Evaluation: -- extent of target organ damage (cardiac disease, cerebrovascular disease, peripheral vascular disease, renal disease, retinopathy) -- overall cardiovascular risk (age, sex, race, menopausal status, cholesterol status, glucose tolerance, cigarette smoking, alcohol intake) -- extent and severity of coronary disease

  48. Management of the hypertensive patient with ischemic heart disease • It is more complex than simply lowering BP -- Reduce absolute cardiovascular disease risk -- Control symptoms of myocardial ischemia -- Retard cardiac and vascular disease progress -- Correct aggravating conditions (e.g. thyro-toxicosis, anemia, psychological stress) -- Improve quality of life (exercise, diet, Viagra)

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