Women and Heart DiseaseWomen and Heart Disease

Kristine Driskill, PA-C MPAS

Cardiology, Via Christi Clinic

Statistics

Cardiovascular disease (CVD) — hypertension, heart disease, stroke, peripheral arterial disease 1 of 2.9 deaths in U.S from CVD 1 death every 39 seconds from CVD 1 of every 6 deaths from coronary artery disease In 2007, three leading causes of death for women

over age 651. Heart disease

2. Cancer

3. Stroke

*Source: 2007 American Heart Association

Women and Heart Women and Heart DiseaseDisease

What we will cover today: Time of onset Symptoms Testing Preventive measures Therapies

Women and Heart DiseaseWomen and Heart Disease

Coronary disease unusual before menopause Protective effect of estrogen

Women develop coronary disease about a decade later than men

Physiologic circumstances of pregnancy and menopause increase cardiac awareness

Symptoms may be less reliable than in men Stress testing much less reliable in women

Implication of later development of Implication of later development of heart diseaseheart disease

Risk of heart attacks directly related to age, independent of gender

With advancing age, patients have more conditions such as:

Kidney disease, lung disease, dementia, etc.

Social structure changes, family support may not be effective

Patients less inclined to opt for aggressive treatment

Symptoms: women vs. menSymptoms: women vs. men

For any given degree of coronary disease, women more likely to experience angina, men more likely to have heart attacks

Women more likely to have normal coronary arteries with definite coronary syndromes

Endothelial dysfunction rather than obstruction

May be subtle differences in symptoms patients experience with a heart attack, but generally atypical symptoms can occur with either gender

Heart diseaseHeart disease

Congenital heart disease Heart valve disorders Rhythm disorders Heart muscle disorders Coronary artery disease

Coronary arteriesCoronary arteries

Coronary artery diseaseCoronary artery disease

Coronary diseaseCoronary disease

For many patients, the process is silent and there are no clinical problems

Heart pain (angina) Pain due to reduced blood supply to heart muscle

Heart attack (myocardial infarction) Cardiac injury due to unstable plaque and artery

occlusion

Heart rhythm abnormality

Patient examplesPatient examples

Patient 1: Heart attack Patient 2: Stable cardiac disease Patient 3: Atypical

Symptoms Risk/likelihood assessment Management

Patient 1: Heart attackPatient 1: Heart attack

75 year old woman who does not see a doctor, mostly due to disinclination; she smokes, takes no medications and does not know her cholesterol numbers. There is a family history of heart disease; she develops chest pain at home

She arrives in the emergency room with typical findings of an acute myocardial infarction (heart attack)

An urgent evaluation is performed, then she undergoes a catheterization and a stent is placed in a coronary artery

Patient 1: Heart attackPatient 1: Heart attack

Process initiated by development of unstable plaque

Promotes platelet aggregation and clotting which occludes the artery

Injury to heart muscle is time dependent, occurring over about 12 hours

The greatest injury occurs in the first several hours

Injury can be interrupted by opening the artery, usually with a coronary intervention

Timing of intervention is very important

Patient 1: Heart attack symptomsPatient 1: Heart attack symptoms

In general, something intense and unusual Location: chest, jaw, arms, upper back, upper

abdomen Duration: usually protracted and ongoing for

hours Associated observations: nausea, shortness

of breath, profuse sweating

Chest pain experienceChest pain experience

Symptoms of heartburn may be either cardiac or gastrointestinal, the conditions frequently co-exist

Pain with taking a breath usually will not be cardiac

Momentary sharp sensations are almost never important

Vague all day long sensations are usually innocent

Chest pain lessonsChest pain lessons

If you have a concern that you may be having a heart attack, call 911 (or your local emergency number) and let the experts sort it out

If you have symptoms that become more intense or frequent, seek attention on an urgent basis

If you have a stable, recurrent symptom, consult your doctor

Patient 2: Stable cardiac diseasePatient 2: Stable cardiac diseasesymptomssymptoms

She experiences chest pain in response to unusual exercise. She is able to do all of her usual activities and travel. Her symptom has not changed in two years

She is generally healthy but has declined cholesterol therapy for high LDL

A stress test demonstrates abnormal findings of “ischemia”

Angina (chest pain) experienceAngina (chest pain) experience

Location: in general, the same as heart attack Duration: usually 2-10 minutes; constant

when present Intensity: often not intense but compelling Provocation: often exertional Aggravating factors: after eating, in the cold

Patient 2: Stable cardiac diseasePatient 2: Stable cardiac disease

She consulted a cardiologist A heart catheterization was performed. The

patient was advised that she has several blockages and that she can have the arteries fixed now or just stay on medications

Hardware for performing the stent is being prepared

What should she do?

Patient 2: Stable cardiac diseasePatient 2: Stable cardiac disease

Medical therapy may be the best solution No survival or heart attack prevention benefit

from aggressive interventions Decision factors are symptom severity and

the extent of jeopardy Our patient might want to think things over or

have a second opinion

Patient 3: Atypical symptomsPatient 3: Atypical symptoms

37-year-old woman with occasional cardiac awareness and palpitations

No smoking, normal cholesterol, active, normal blood pressure

Physical exam is normal A stress test is done at another office, the

patient is advised that the stress test is abnormal and that she should undergo a heart cath just to be sure

Patient 3: Atypical managementPatient 3: Atypical management

Stress testing is often “false positive” in women

In either gender, stress testing is not accurate if there is a low likelihood of disease

Invasive procedures involve risk Patient sought a second opinion Careful review of symptoms and probability of

disease was reviewed, no additional testing advised

Lesson: match the management Lesson: match the management to the conditionto the condition

High acuity conditions require intense, urgent application of diagnostic and therapeutic effort; if heart attack is suspected, urgent attention is indicated

Medical therapy may be the best option for stable patients

Extraordinary cardiac risk in smokers Very important to have a good doctor or advisor Stress testing may be less accurate in women Low acuity conditions and symptoms often simply

require education

Risk scoresRisk scores

Age Smoking Diabetes Blood pressure LDL cholesterol HDL cholesterol CRP (inflammation)

Coronary risk and vascular biologyCoronary risk and vascular biology

Cigarette smoking Physical inactivity Obesity Family history of heart disease Hypertension Elevated LDL Low HDL Metabolic syndrome Inflammatory state

Vascular biologyVascular biology

Smoking increases risk of death/MI 400% For every 20mm increase in BP, risk doubles LDL reduction by 1mg results in 1% risk

reduction HDL change of 1mg results in 2% risk

reduction Activity and diet reduce inflammation, LDL,

diabetes development and increase HDL

Vascular biology Vascular biology —— continued continued

Cholesterol agents promote plaque stability and reduce events

Aspirin reduces potential for vessel clotting Antioxidant vitamins have no benefit Hormone replacement therapy has no cardiac

benefit Omega 3 fatty acids lower triglycerides and

have some platelet effect

Cardiac testing concernsCardiac testing concerns

Stress testing may be much less accurate in women; accuracy depends upon the likelihood of disease

Nuclear and CT studies are associated with large radiation exposure

High expense to yield ratio Risk with invasive procedures

Contrast, vascular injury, embolization

Coronary disease management: Coronary disease management: Changing emphasisChanging emphasis

Symptom preoccupation Extensive testing Inclination to “fix” coronary problems with

intervention and surgery Incentives (3 heart hospitals, 9 cath facilities) Lifelong attention to prevention Aggressive management of lipids and diabetes Incentives for fitness and disease management Educated patients

Key lessonsKey lessons

If you have severe symptoms, do not hesitate to summon emergency help, let the professionals decide whether it is important or not

Remember concepts of plaque stability and vascular biology

Vigilance is not enough, prevention is critical Manage risk factors with the help of your health

care provider A “fix” is often transient; management is forever

Thank you!Thank you!