Women and cardiovascular disease(CVD):What do we need to know? Dr.Udaya Ralapanawa MBBS(SL),MD(Col),MRCP(UK),FRCP(London) Consultant Physician Senior Lecture In Medicine
Myth Cardiovascular disease is mainly a disease of old men
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
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
Magnitude of the Problem • Leading cause of death in US women: CAD • 1990: US Congress directed the National Institutes of Health that women be included in clinical trials and that gender differences be evaluated
Statistics for Women • 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
CVD Mortality Trends (1979-1999) Deaths in Thousands American Heart Association. 2002 Heart and Stroke Statistical Update. 2001
Gender Differences in Heart Attack Symptoms Typical in both sexes • Pain, pressure, squeezing, or stabbing pain in the chest • Pain radiating to neck, shoulder, back, arm, or jaw • Pounding heart, change in rhythm • Difficulty breathing • Heartburn, nausea, vomiting, abdominal pain • Cold sweats or clammy skin • Dizziness Typical in women • Milder symptoms (without chest pain) • Sudden onset of weakness, shortness of breath, fatigue, body aches, or overall feeling of illness (without chest pain) • Unusual feeling or mild discomfort in the back, chest, arm, neck, or jaw (without chest pain)
Prevalence of CVD in the US American Heart Association. 2002 Heart and Stroke Statistical Update. 2001
Although less frequent, CVD occurs in young women More than35,000 women under the age of 65 die annually in the US from CVD
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 Robinson A. Circulation. 2001
Women’s Perceptions of Heart Disease • 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!
Health Threats to Women: Perception vs Reality 1 2 • 1. Gallup survey. 1995 2. American Heart Association. Heart & Stroke Facts. 1996 Statistical Supplement
Death From Breast Cancer or Heart Disease in Women in the US • US Vital Statistics, 1990
Myth Women don’t need to worry about cardiovascular disease before menopause
Relationship between early menopause and accelerated CVD? Traditional Paradigm: Menopause Increasing Risk of CVD Minimal or no CVD Risk Alternative Paradigm: Increasing Risk of CVD Menopause
Coronary heart disease progresses over decades Decades of time The reality: Being premenopausal probably does not protect you from cardiovascular disease and you should be vigilant at all ages … Age, Heredity Smoking, High Blood Pressure, Elevated Cholesterol, Diabetes, Inactivity, Obesity
Estrogen • Critical to reproductive function in men & women • Most produced by ovaries • Some arises from fat, liver, breasts, adrenals • Complex physiologic effects
Is There a Role for HRT? • Secondary prevention • 1998: HERS • 4 years of treatment with conjugated estrogen plus medroxyprogesterone acetate • No reduction in the risk of MI and coronary death in women with established CAD HERS trial. JAMA. 1998.
Is There a Role for HRT? • Secondary prevention • 3/2000: Estrogen Replacement and Atherosclerosis trial (ERA) • 309 postmenopausal women with CAD • Placebo vs conjugated estrogen (.625 mg/day) vs conjugated estrogen (.625 mg/day) with medroxyprogesterone acetate (2.5 mg/day) • Angiographic analysis of the diameter of the coronary arteries at the start of the study and 3 years later • ERA trial results at follow-up angiography • The progression of coronary atherosclerosis was unchanged in the women randomized to either of the estrogen groups ERA trial. J Am Coll Cardiol. 2001
Women’s Health Initiative Estrogen + Progesterone 16,608 Post-menopausal women aged 50-79 with an intact uterus Study stopped after mean follow-up of 5.6 years Placebo • Hormonal replacement associated with: • Increased heart disease (29% ↑) • Increased stroke (41% ↑) • Increased blood clots • Increased breast cancer (26% ↑) • Reduced colon cancer • Reduced hip fracture
RCOG and the hormone replacement therapy (HRT) • RCOG UPDATE (11 June 2013): The British Menopause Society (BMS) and Women’s Health Concern recently published a literature review In summary, their key recommendations are: • The decision whether to use HRT should be made by each woman having been given sufficient information by her healthcare professional, including information about complementary therapies and lifestyle and dietary changes. • HRT dosage, regimen and duration should be individualised, with an annual evaluation of the pros and cons
RCOG and the hormone replacement therapy (HRT) • Arbitrary limits should not be placed on the duration of usage of HRT; if symptoms persist, the benefits of hormone therapy usually outweigh the risks. • HRT prescribed before the age of 60 has a favourable benefit/risk profile.
RCOG and the hormone replacement therapy (HRT) • It is imperative that women with Premature Ovarian Insufficiency (POI) are encouraged to use HRT at least until the average age of the menopause. • If HRT is to be used in women over 60 years of age, lower doses should be started, preferably with a transdermal route of administration.
Coronary Disease Mortality and Diabetes in Women Mortality Rate per 1,000 Sources: Krolewski 1991, National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002.
Diabetes Creates Higher Risks for Women With CAD • 65% of diabetics die from heart disease or stroke • 4.2 million American women have diabetes • Diabetes increases CAD risk 3-fold to 7-fold in women vs 2-fold to 3-fold in men • Diabetes doubles the risk of second heart attack in women but not in men American Heart Association Centers for Disease Control and Prevention Manson JE, et al. Prevention of Myocardial Infarction. 1996
Diabetes: Powerful Risk Factor for CAD in Women • Framingham Heart Study • Women with diabetes mellitus had relative risk of 5.4% for CAD vs women without diabetes • Men with diabetes had relative risk of 2.4% • Nurses’ Health Study • Relative risk of 6.3% for total cardiovascular (CV) mortality • Even if women had diabetes for <4 years, their risk of CAD was significantly elevated Kannel W. Am Heart J. 1987 Manson J, et al. Arch Intern Med. 1991
Clinical Identification of the Metabolic Syndrome • Abdominal obesity • Men >88 cm (>40 in) • Women >80 cm (>35 in) • Triglycerides (TG) >150 mg/dL • HDL cholesterol • Women <50 mg/dL • Men <40 mg/dL • Blood pressure >130/>85 mm Hg • Fasting glucose >100 mg/dL National Heart, Lung, and Blood Institute
Impact of Triglyceride Levels on Relative Risk of CAD Castelli WP. Can J Cardiol. 1988
Smoking • Single most preventable cause of death in US • Smoking by women causes 150% more deaths from heart disease than lung cancer • Women who smoke are 2-6 times more likely to suffer a heart attack
Smoking Nurses’ Health Study: Even a few cigarettes a day correlated with a greater risk of CVD or fatal MI About one-quarter of all women smoke; prevalence greatest among postmenopausal women
Smoking • Younger women who smoke probably cancel out any premenopausal protection • Women who take oral contraceptives and smoke are more likely to have an MI or stroke than those who take the pill but don’t smoke
Stress Puts a woman at greater risk for CVD and poorer outcomes Depression also may increase risk or defer her from seeking medical help Consider screening women with CAD for depression and refer for treatment as needed
Physical Inactivity • Lack of exercise is a proven risk factor for heart disease • A lack of regular physical exercise is a growing epidemic all over the world. “We seem to eat much more than what we burn” • Heart disease is twice as likely to develop in inactive people than in those who are more active
Physical Inactivity • Physical activity helps maintain weight, blood pressure, and diabetes • Women should exercise to increase heart rate for 20-30 minutes a day, 3-5 times per week
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
Coronary Microvascular Disease • Coronary MVD is heart disease that affects the heart's tiny arteries. This disease is also called cardiac syndrome X or nonobstructive CHD. In coronary MVD, the walls of the heart's tiny arteries are damaged or diseased.
Coronary Microvascular Disease • Women are more likely than men to have coronary MVD. Many researchers think that a drop in estrogen levels during menopause combined with other heart disease risk factors causes coronary MVD.
Coronary Microvascular Disease • Although death rates from heart disease have dropped in the last 30 years, they haven't dropped as much in women as in men. This may be the result of coronary MVD.
PET Case Study: Patient FF Stress Rest
Treatment differences • Thrombolysis – equally effective – Cerebral hemorrhage risk is more • Low rates of coronary angiography in women • Under referral for revascularization procedures • CABG - > operative mortality 1.9 % v/s 4.6% • Restenosis after PTCA, or CABG occlusion rates are more for women - ? Smaller lumen sizes