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Dr. Suzanne Steinbaum
Director, Women and Heart Disease
Lenox Hill Hospital
New York
A CVD (I00-I99; Q20-Q28)B CancerC Accidents
D Chronic Lower Respiratory DiseasesE Diabetes MellitusF Alzheimer’s Disease
CVD and other major causes of death for all males and FEMALE
DEATHS(United States: 2006). Source: NCHS and NHLBI.
290,069
59,260
269,819
398,563
78,94136,006
432,709
65,32351,281
42,658
0
100,000
200,000
300,000
400,000
500,000
A B C D E A B D F C
Death
s
Males Females
Age-adjusted death rates for CHD, stroke, lung and breast for white and black females (United States: 2006).Source: NCHS.
41.1 41.122.9
57.039.0 31.6
101.5
130.0
0
50
100
150
200
Coronary Heart
Disease
Stroke Lung Cancer Breast Cancer
Pe
r 1
00
,00
0 P
op
ula
tio
n
White Females Black Females
Menopause and
the Risk of Coronary Heart Disease (modified data from “Menopausal status as a risk for coronary artery disease”
Arch Intern Med 1995;155:57-61
0
0.5
1
1.5
2
2.5
3
3.5
4
40 - 45 45 - 49 50 - 54
Before menopause
After menopause
Age (in years)
An
nu
al
Occ
ure
nce
of
Hea
rt A
tta
ck/1
000
African-American Women &
Heart Disease
�African-American women have a higher risk for heart disease than Caucasians and are less aware of their risk factors, including:� Obesity (53.9% obese and 73.1% overweight and obese)¹
� Physical Inactivity (65.4% of African-American women get no leisure time physical activity)¹
� High Blood Pressure¹
� Diabetes (15.4% have diabetes)¹
� Diet (Sodium Intake)¹
�47% of African-American women over the age of 20 have high blood pressure¹
�African-American women bear a disproportionate burden of stroke, heart failure, and kidney disease, all due to undiagnosed, or poorly controlled high blood pressure.²⁻³
1 Go A S, Mozaffarian, D, Roger, V L, Benjamin E J, et al. Heart Disease and Stroke Statistics 2013 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2013; e39-e90
2 Jha AK, Varosy PD, Kanaya AM, et al. Differences in Medical Care and Disease Outcomes Among Black and White Women With Heart Disease. Circulation. 2003;108:1089-1094. E39-e90
3 Pleis JR, Lucas JW. Summary health statistics for U.S. adults: National Health Interview Survey, 2007. Vital Health Stat 10. 2009; No. 240: 1-159.
5www.womenheart.org
Hispanic-American Women &
Heart Disease
� Hispanic-American Women also have a slightly higher risk for heart disease than Caucasians, and are less aware of their risk factors.� Obesity
� Among Mexican-American women, 44.8% are overweight and 78.2% are overweight or obese¹
� Physical Inactivity
� High Blood Pressure
� Among Mexican-American women over the age of 20, 28.8% have high blood pressure.¹
� Diabetes (12% have diabetes … Nearly 2x higher than Caucasian women)¹
� Diet (Sodium Intake)
� Among Mexican-American women, 30.7% have cardiovascular disease¹
1 Go A S, Mozaffarian, D, Roger, V L, Benjamin E J, et al. Heart Disease and
Stroke Statistics 2013 Update: A Report from the American Heart Association
Statistics Committee and Stroke Statistics Subcommittee. Circulation 2013; e60-
e111
6www.womenheart.org
Awareness trends of Heart Disease as
leading cause of death in women:
FEBRUARY 10, 2010
� 60% WHITE WOMEN
� 43% AFRICAN-AMERICAN WOMEN
� 44% HISPANIC
� 34% ASIAN
� 50% women ages 25-34 **** NEED FOR PREVENTION
-Women younger than 55 years old- there was a greater increase in the risk of heart disease and stroke
*increase is due to an increase in diabetes in this population*there has been a 93% decline of mortality of younger women compared to men due to better recognition and management of coronary artery disease and its risk factors*the disease process is escalating in a younger population.
We need to aggressively empower these women to achieve the lifestyle goals that diminish their risk factors in order to prevent this disease from presenting itself, not only at such a young age, but also in a woman's lifetime.
Epidemic of Heart Disease has reached the youngerPopulation of women:October 2009 Archives of Internal Medicine
1988-1994 1999-2004
MEN 2.5% MEN 2.2%
WOMEN 0.7% WOMEN 1%
Low rate of sex-specific reporting in
Cardiovascular trials
� Major journals- cardiology and internal medicine
� from July 1st through December 31, 2004
� Result reporting for primary outcomes for women
� NIH funded-51%- 1993 act of inclusion
� General medical- 37%
� Cardiology- 23%
� SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY AND INTERVENTIONS SCAI 2011- ONLY 25% OF NIH TRIALS TRACK GENDER SPECIFIC OUTCOMES
Differences in Referral for
Testing and Treatment : Gusto IIB
0
10
20
30
40
50
60
% o
f P
ts R
efe
rred
Stress
Testing
Cardiac
Cath
PTCA CABG
Women
Men
P<0.01 for all
Tamis et al. Circulation 1997;96:I-536.
Gender Distribution Estimates for
Interventions : 2004
33%
67%
35%
65%
50%50%
22%
78%
20%
80%
0%
20%
40%
60%
80%
PTCI Peripheral
Int.
Pacemakers ICDs CRT-D for HF
Female
Male
1
2
1 1 2
Sources:
1-AHA: Heart Diseases and Stroke Statistics - 2004 Update
2-Guidant Internal Estimates
Low rate of sex-specific reporting in
Cardiovascular trials
� Major journals- cardiology and internal medicine
� from July 1st through December 31, 2004
� Result reporting for primary outcomes for women
� NIH funded-51%- 1993 act of inclusion
� General medical- 37%
� Cardiology- 23%
� SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY AND INTERVENTIONS SCAI 2011- ONLY 25% OF NIH TRIALS TRACK GENDER SPECIFIC OUTCOMES
15%
Val HeFT
CIBIS-II Clinical Trial; Lancet; Circulation, 2001; 103; 3;375-380;
MERIT HF Clinical Trial; Ghali, JK, Circulation, 2002;105; 1585-1591;
Val Heft Clinical Trial; Cohn, JN, N Engl J Med, 2001; 345; 1667-1675;
COPERNICUS Clinical Trial; Gust, H Bardy; ACC , March 8, 2004.
Men Women
Representation of Women in Pharma Heart Failure Trials
32%
COPERNICUS
MERIT HF
CIBIS II
77% 23%
75% 25%
80% 20%
80% 20%
Physician awareness of CVD prevention guidelines by specialty
NCEP ATP III JNC 7 clinicalguidelines
AHAWomen's
PCP
OBGyn
Cardiologist
0%
70%
60%
50%
40%
30%
20%
10%
80%
90%
100%
Mosca L et al. Circulation. 2005;111:499.
Aware
p<0.001p<0.001 p<0.001 p<0.001
p<0.001
p<0.001
Physician incorporation of CVD prevention guidelines by specialty among respondents who stated they were aware of the guidelines
NCEP ATP III JNC 7 clinicalguidelines
AHAWomen's
PCP
OBGyn
Cardiologist
0%
70%
60%
50%
40%
30%
20%
10%
80%
90%
100%
Mosca L et al. Circulation. 2005;111:499.
Incorporated
p<0.001p<0.001
p<0.001 p<0.001
p<0.001
p<0.001
The State of our Nation� 45% of US has 1 risk factor- high blood pressure, high
cholesterol or diabetes
� 13% has 2 risk factors
� 3% have 3 risk factors
� 15% of adults also had one or more of these conditions undiagnosed
Study Points to Declining Life Span
for Some U.S. Women� Wall Street Journal
� March 4, 2013
� University of Wisconsin study
� 3,141 women over 10 years
� In the South and West
� “unclear reasons”-
� Most often poor white women
� Theories- obesity, diabetes
� Women 81, men 76- women is dropping
� Started in the late 80’s
AHA 2020 STRATEGIC GOAL�“To improve the cardiovascular health
of all Americans by 20% while reducing the deaths from cardiovascular diseases and stroke by 20%”
�Must create awareness to multicultural women and young women
WHAT IS CORONARY ARTERY DISEASE?� ATHEROSCLEROSIS
� PLAQUE BUILDUP
� CHOLESTEROL, FIBROUS TISSUE
� INFLAMMATORY CELLS
� BEGINS IN TEENS
Premature atherosclerosis (PDAY)A
bd
om
ina
l a
ort
a
Rig
ht co
ron
ary
art
ery
McGill HC Jr et al, Circulation 2002
Most Myocardial Infarctions Are Caused
by Low-Grade Stenoses
Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992.(Adapted from Falk et al.)
Falk E et al, Circulation, 1995.
Intraluminal thrombusGrowth of thrombus
Intraplaque thrombus Lipid pool
Blood Flow
Atherosclerotic Plaque Rupture and
Thrombus Formation
Adapted from Weissberg PL. Eur Heart J Supplements
1999:1:T13–18
Women’s Early Warning Signs of a
Heart Attack
� Weeks before Heart Attack (95% of women)� Unusual fatigue (70.7%)� Sleep disturbance (47.8%)� Shortness of breath (42.1%)� Indigestion (39.4%)� Chest pain (29.7 %)
� At time of Heart Attack� Shortness of breath (57.9%)� Weakness (54.8%)� Fatigue (42.9%)� Chest pain (57%)
McSweeney, JC et al. Circulation 2003; 2619-2623
AHA 2/10 survey: 2,300 women
interviewedOnly 53% of women said they would call 9-1-1 if they
thought they were having heart attack symptoms
56% of women saying chest pain and neck or arm pain
29% shortness of breath
17% chest tightness
15% nausea
7% fatigue
Profiles of Heart Disease in
Men vs. Women: AHA
Deaths within one year of
1st MI25% 38%
Sudden deaths with no
previous symptoms50% 64%
Within six years of recognized MI,
percent who will:
• have another MI
• have a stroke
• experience SCD*
• be disabled with heart failure
18%
8%
7%
22%
35%
11%
6%
46%
Men Women
WISE Demonstrates Challenges in Diagnosis:NHLBI study: 1996 to 2000
Goals: � Improve diagnostic testing for ischemic heart
disease in women
� Study pathophysiologic mechanisms and prognosis in women with myocardial ischemia in the absence of obstructive coronary disease
� Evaluate influence of hormones and menopause on symptoms and diagnostic testing results
� Women with SYMPTOMS and NORMAL CORS on CATH
Women’s Ischemia Syndrome Evaluation(WISE)- 954 patients, 4 centers
Noel Bairey Merz, MD (WISE) Diagnosis and Pathophysiology of Ischemic Heart Disease Workshop
October 2-4, 2002
Difference in Disease Presentation
Obstructed coronary artery
Diffused narrowing in coronary artery
Findings from WISE� 936 women with ches pain referred to angiography
� “typical” angina missed in 65% of cases of CAD
� Substudy of normal caths- absence of flow limiting lesions
� 159- 47% abnormal microvascular flow reserve
� 163- impaired coronary vasomotor response to acetylcholine independently linked to adverse CV outcomes
� Some lesions severe enough to limit coronary perfusion
DETECTION OF CAD IN WOMEN
� HISTORY IS VERY VARIABLE
� DIAGNOSTIC TESTING IS DIFFICULT
� MORE FALSE POSITIVES- stress ekg
� Dobutamine echo- not sensitive or specific for single vessel disease, but diagnostic for multivessel disease
� RISK STRATIFICATION OFTEN DIFFICULT, ESPECIALLY IN YOUNGER WOMEN
THE FRAMINGHAM RISK� After WWII- development of heart disease
� 1948- stable town
� Lifestyles were analyzed
� Until 1961, then the children- Offspring study
� Our assessment now is based on the results of this study…
CHOLESTEROL GOALS BASED ON RISK
Cholesterol distribution in CHD
and non-CHD populations
�In spite of major advances made in the screening, detection, and management of heart disease, a major need exists for more accurate ways to predict CV risk
� Therefore, other factors must be involved
35% of CHD occurs in people with TC considered optimal (<200mg/dL)
Adapted from Castelli W. Atherosclerosis 1996
Framingham Heart Study — 26-year follow-up
150 200
No CHD
Total cholesterol (mg/dL)
250 300
CHD
THE REYNOLD’S RISK SCORE
� In women, up to 20% of all coronary events occur in the absence of risk factors
� 24,558 healthy US women followed for 10.2 years
� Women 45 years and older, started September 1992
� Incident of MI, stroke, coronary revascularization or cardiovascular death
Reynolds risk score:
ADDED variables� Systolic blood pressure� Current smoking� Total Cholesterol� HDL__________________________________________� Hemoglobin A1C� hsCRP- USE OF THIS- RECLASSIFIED 25%� Parental history of myocardial infarction� Apoliporproteins A-1 and B-100� Lipoprotein (a)
THE CALCIUM SCOREA CT SCAN to detect CALCIUM in the arteries.
� SPECIFICITY DECREASES WITH INCREASING AGE
� 85% TO 100% SENSITIVE
� 41 TO 76% SPECIFIC
� PRESENTLY ACC/AHA EXPERT CONSENSUS DOES NOT RECOMMEND IT BECAUSE OF HIGH NUMBR OF FALSE-POSITIVES