Acute Myocardial Infarction in Women

PresenterDR PRAVEEN GUPTA

Moderator DR AJIT ANANTHAKRISHNA

PILLAI

Date -17/02/2016

Department of Cardiology,JIPMER

Pondicherry, India

Cardiovascular disease (CVD)

Leading cause of mortality,

Understudied

Underdiagnosed

Undertreated

Annual CVD mortality remained greater

Women living with & dying of CVD are larger than men

Cardiovascular disease (CVD)

Different plaque characteristics

Greater role of microvascular disease

Less severe obstructive disease of epicardial coronary

arteries

Prevalence of AMI

6.6 million US women

< 1 year of a first AMI, 26% of women and 19% of men will

die

< 5 years of a first AMI, more women than men will die (47%

of women and 36% of men), have heart failure (HF), or suffer

from a stroke

Prevalence of AMI

Characterstics of CAD in Women

Higher prevalence Diabetes mellitus (DM) HF Hypertension Depression Renal dysfunction NSTEMI and nonobstructive CAD

Characterstics of CAD in Women

Spontaneous coronary artery dissection (SCAD)

Coronary artery spasm (CAS) Longer hospitalizations Higher in-hospital mortality Bleeding complications

Pathophysiology of AMI

Coronary Artery Spasm

OCT showing Coronary plaque

Representative Case of OCT-Defined Erosion(A) Coronary angiography shows nonsignificant stenosis in mid-left anterior descending coronary artery.(B) Intracoronary ergonovine injection resulted in complete occlusion. (C) This normalized with 200 μg of intracoronary nitroglycerin administration. (E, F) Optical coherence tomography (OCT) revealed a red thrombus with high backscattering protrusion mass with signal-free shadowing. (D to F) An intact fibrous cap and an irregular luminal surface are visible. Asterisk indicates the total occlusion site by ergonovine provocation test and arrows indicate the sites of OCT findings after nitroglycerine injection.

J Am Coll Cardiol Img. 2015;8(9):1059-1067. doi:10.1016/j.jcmg.2015.03.010

Plaque Rupture and Erosion

Spontaneous Coronary Artery Dissection

Rare cause of AMI Suspect in young

woman Prevalence 0.2% to

4%

Associated with Peripartum and Postpartum status Oral contraceptive use Exercise Connective tissue

disorders vasculitides

A, Distal normal left anterior descending (LAD) artery. The intact normal arterial wall was shown well by both modalities (arrow on optical coherence tomography [OCT] image. B, Distal dissection. Intravascular ultrasound (IVUS) images showing intramural hematoma and luminal compression, but it was unable to demonstrate the intimal flap. OCT showed clearly the distal exit point of the dissection with the intimal flap and communication between the intramural hematoma and true lumen (arrow). C, Mid-LAD dissection. A large crescent-shaped eccentric hematoma (*). IVUS showed well the inner lumen (thick arrow) and external vessel reference (thin arrow); OCT showed the hematoma compression and demonstrated the integrity of an otherwise disease-free intima but did not reveal the vessel reference diameter as clearly as IVUS. D, Normal proximal LAD. OCT measurement of reference lumen

area and diameter for stent sizing are shown. Circ Cardiovasc Interv. 2011 Apr 1;4(2):e5-7. doi: 10.1161/CIRCINTERVENTIONS.110.959593

Clinical Presentation

Atypical chest pain

Angina equivalent-dyspnea, weakness, fatigue, and indigestion

Lead to misdiagnosis, delayed revascularization, & higher

AMI mortality rates

Atypical Symptoms

Chest pain: sharp, pleuritic, burning, aching, soreness,

Unusual fatigue

Unusual shortness of breath

Upper back/chest pain

Neck, jaw, arm, shoulder, back, epigastric pain

Flu-like symptoms

Atypical Symptoms

Dizziness

Generalized scared/anxiety feeling

Generalized weakness

Indigestion

Palpitations

Delay in seeking treatment for AMI

Due to lack of awareness of risk Passivity Inaccurate symptom attributionBarriers to selfcareOlder ageLower education and socioeconomic levels A history of angina

Delay in seeking treatment for AMI

DM

Hypertension

HF

Dyslipidemia

Living alone

Interpreting symptoms as

nonurgent

Temporary, consulting with

a physician or family

member

Fear

Embarrassment

VIRGO study

Women fail to assess their risk of heart disease

Women -limited access to preventive cardiac care before AMI

J Am Heart Assoc. 2014;3:e001252 doi:10.1161/JAHA.114.001252

Treatment of AMI

Less frequently referred for appropriate treatment More Mechanical complications & HF Ventricular arrhythmias occur at similar rates. More favorable outcome with PCI compared with

thrombolytic therapy

STEMI Revascularization Thrombolytic Therapy

Higher morbidity and mortality

GUSTO trial –More complications such as shock, HF,

reinfarction, recurrent ischemia, bleeding, and stroke

(ASSENT-2) trial- Increased risk of reinfarction Multiple relative contraindications age, hypertension, and

small body size Beneficial and reduce mortality and morbidity

Primary PCI

Benefit the most GUSTO II-B angioplasty-56

deaths in women/42 deaths in men/ 1000

Vascular complications & the need for blood transfusions occur more in women

Female sex-Independent predictor of bleeding

DES- reduced death or MI and reduced target vessel revascularization

CABG Surgery

Older and sicker

Increased risk of in-

hospital mortality

Less likely to receive IMA

graft

More renal failure,

neurological complications,

and postoperative MI

NSTEMI Revascularization

More complications bleeding HF, shock renal failure Reinfarction stroke readmission benefit from invasive managment

Medical Therapies Same as in men

Consideration of weight & renal

dosing

HRT should not be given

Antioxidant vitamin supplements

should not be used

Aspirin & Clopidogrel reduced

the risk of a major coronary

event

Medical Therapies

Prasugrel

Ticagrelor

Glycoprotein IIb/IIIa

inhibitor

Low-molecularweight

heparins Bivalirudin Fondaparinux

Medical Therapies

Nonselective β-blockers should be avoided in patients whose AMI is due to

coronary arterial vasospasm

ACE inhibitor improved survival in women

ACE inhibitors and ARBs are pregnancy category C for the first trimester

& category D during the second and third trimesters

Benefit from lipid-lowering therapy

Statins are pregnancy category X, avoid during pregnancy

Aldosterone antagonist in the absence of contraindications

Nonpharmacological TreatmentCardiac Rehabilitation Referral and

Participation

Class I recommendation

SAFE-PCIStudy of Access Site for Enhancement of PCI

for Women Trial of specific PCI access strategies

that was exclusive to women

Reductions in bleeding or vascular

complications with the radial access

J Am Coll Cardiol Intv. 2014;7(8):857-

867. doi:10.1016/j.jcin.2014.04.007

Take Home Message

CVD is an equal-opportunity killer, Sex differences occur in the pathophysiology &

clinical presentation of MI & affect treatment delays.

Recommended perfusion therapies for AMI in women are similar to those in men,

Bleeding risks & other complications remain greater