Approaches to Prevention and Recognition of

Coronary Artery Disease in Women

Tara Conzelman

Advisor: Dr. Bob Hadley

Why talk about this now? CAD is the leading cause of death of

women in the US

Figure 1: CVD and other major causes of death in females, United States 2004. Taken from the AHA Heart disease and stroke statistics - 2007 update.

Why talk about this now?

In the past decade, incidence of CAD has doubled among women

Research has reported underrecognition and underdiagnosis of CAD in women

Practioners can improve survival outcomes by adhering to recommendations shown to benefit women

Background: Differences in CAD in women vs. men

CAD incidence lags by ~ 10 yrs. compared to men; MI and sudden death lag by ~20yrs.

Chest pain is the most commonly reported symptom in both sexes, but women more frequently report N/V, indigestion, pain in middle of back and jaw

High prevalence of nonobstructive CAD and single-vessel disease in women; affects diagnostic accuracy of non-invasive testing

What you need to know

What are a woman’s risk factors for developing CAD?

What are the current guidelines on CAD prevention for women?

What diagnostic tools are useful in risk-stratifying women?

What are a woman’s risk factors for developing CAD?

Not modifiable: Age

Menopause

Heredity

What are a woman’s risk factors for developing CAD?

Modifiable: Smoking High blood cholesterol High blood pressure Physical inactivity Obesity & overweight Diabetes Mellitus

What are the current guidelines on CVD prevention for women?

New guidelines just published! (March 2007)

Changes reflecting recently published studies: Folic acid – now considered a class III

intervention (not useful/effective and may be harmful)

ASA - should be used in high-risk women unless CI, consider in women ≥65 yoa if no HTN; not recommended in women <65 yoa to prevent MI (class III)

What are the current guidelines on CAD prevention for women?

What diagnostic tools are useful in risk-stratifying women?

According to the 2005 “Role of Noninvasive Testing in

the Clinical Evaluation of Women With Suspected Coronary Artery Disease: Consensus Statement From the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association” ….

What diagnostic tools are useful in risk-stratifying women?

Cardiac imaging NOT recommended for women @ low pretest risk of CAD (due decreased diagnostic accuracy and higher false-positive rate)

Symptomatic intermediate- and high-risk women should initially undergo exercise ECG; (parameters such as exercise capacity and HR changes should be included in evaluation for inc. diagnostic accuracy)

Harshida P, Rosengren A, Ekman I. Symptoms in acute coronary syndromes: does sex make a difference. Am Heart J. 2004;148(1):27-33

Leibson PR. Women’s Health Initiative (WHI) dietary trial and Norwegian Vitamin Trial (NORVIT). Preventive Cardiology. 9;3:178-182

Maxson J. Heart disease and lipids in women. Advance Online Editions for Physician Assistants. 2006 Oct;14(10):33

Mieres JH, Shaw LJ, Arai A, Budoff MJ, Flamm SD, Hundley WG, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: consensus statement form the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005;111:682-696.

Milan E. Coronary artery disease: The other half of the heaven. QJ Nucl Med Mol Imaging. 2005;49:72-80. Mosca L, Appel LJ, Benjamin EJ, Berra K, Chandra-Strobos N., Fabunmi RP, Grady D, et al. Evidence-Based

Guidelines for Cardiovascular Disease Prevention in Women. Circulation. 2004;109:672-693. DOI: 10.1161/01.CIR.0000114834.85476.81

Mosca L, Banka C, Benjamin E, Berra K, Bushnell C, Dolor R, Ganiats T, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 Update. Circulation. 2007; 115:0000-0000. DOI: 10.1161/CIRCULATIONAHA.107.181546

Ridkera PM, Rifai N, Cook NR, Bradwin G, Buring JE. Non-HDL cholesterol, apolipoproteins A-1 and B100, standard lipid measures, lipid ratios, and CRP as risk factors for cardiovascular disease in women. JAMA. 2005;294(3):326

Ridkerb PM, Cook NR, Lee I, Gordon D, Gaziano JM, Manson JE, et al.. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. 2005;352(13):1293

Rosamond W, Flegal K, Friday G, Furie K, Go A, Greenlund K, et al. Heart disease and stroke statistics—2007 Update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:000-000. DOI: 10.1161/CIRCULATIONAHA.106.179918

Wenger, N. Coronary heart disease in women: highlights of the past 2 years – stepping stones, milestones and obstructing boulders. Nature Clinical Practice Cardiovascular Medicine. 2006 Apr;3(4):194-202.

Wexler DJ, Grant RW, Meigs JB, Nathan DM, Cagliero E. Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes. Diabetes Care. 2005;28:514.

References