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Cardiovascular Disease in Women

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Breast cancer. Age specific death rates from CHD, women, 1968-2003., UK, ... Many women lack the basic awareness that CVD is their leading cause of death ... – PowerPoint PPT presentation

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Title: Cardiovascular Disease in Women


1
Cardiovascular Disease in Women
  • Dr Ghada Mikhail
  • Consultant Cardiologist
  • St Marys Hospital Trust

2
Death By Cause - Women 2004 UK
  • CVD is responsible for
  • 36 of deaths in women
  • (37 in men)
  • Higher than deaths from
  • all cancers combined
  • Breast CA is responsible
  • for 4 deaths in women
  • Deaths from CVS is almost 9 times higher
  • than deaths from breast cancer.

BHF 2006 heartstats.org
3
Death By Cause - Women 2004 Europe
CVD is responsible for 55 of deaths in
women (43 in men) 18 x mortality compared
to Breast cancer
4
Age specific death rates from CHD, women,
1968-2003., UK, plotted as a percentage of the
rate in 1968
In women 50 (50 in men) fall in death rates in
those aged 55-64yrs 32 (35 in
men) fall in death rates in those aged 35-44 yrs
BHF 2005 heartstats.org
5
Age standardised coronary event rates, women aged
34-65 MONICA-WHO (MONitoring trends and
determinants In CArdiovascular disease)
BHF 2005 heartstats.org
6
  • Many women lack the basic awareness that CVD is
    their leading cause of death
  • Health care professionals- Mx remains a challenge
  • Research- women are underrepresented in clinical
    studies

7
CVD in Women under-diagnosed, under-treated and
under-researched
  • Gender Differences
  • Presentation
  • Investigation
  • Treatment
  • Prognosis

8
  • Risk Factors
  • Age
  • Smoking
  • Diabetes Mellitus
  • Hypertension (LVH)
  • Hyperlipidaemia (especially HDL,TG in women)
  • Family History of CHD
  • Homocysteine
  • CRP
  • Menopause
  • Sedentary Lifestyle
  • Biggest Risk factor is the misconception that
    CHD is a Mans Disease
  • AHA and ACC guidelines for gender specific risk
    assessment
  • - guidelines for
    primary and secondary prevention
  • ESC
  • BCS- guidelines in progress

9
Euro Heart Survey of Angina n3779
North n 521
Mediterranean n966 Central
n1341 West n951
Caroline Daly ESC 2005
10
Caroline Daly ESC 2005
11
Caroline Daly ESC 2005
12
Caroline Daly ESC 2005
13
Effect of gender on risk of death/MI
Multivariate HR adjusted for age, DM, LV function
and severity of CAD
Caroline Daly 2005
14
  • Coronary Revascularisation PCI/CABG
  • At the time of presentation with CAD, women are
    older and have more
  • co-morbid factors
  • Increased co-morbid factors
  • Older
  • Smaller in size
  • Hypertension
  • Diabetes mellitus
  • Hypercholesterolaemia
  • Peripheral vascular disease
  • Congestive cardiac failure (diastolic
    dysfunction)

15
  • Coronary Revascularisation- PCI/CABG
  • Smaller vessel size
  • Coronary lesion distribution and morphology is
    similar
  • Women tend to have more ostial vessel disease
  • Women receive less IMA conduits than men
  • Stent usage is less
  • Use of GPIIb/IIIa is less in women
  • Higher incidence of urgent procedures

16
  • Coronary Revascularisation- PCI/CABG
  • Higher mortality rate
  • In-hospital mortality x 2 times higher for CABG
  • Increased mortality in younger women (? Ovarian
    dysfunction,
  • ? Abnormalities of oestrogen receptors )
  • Higher vascular (stroke, groin) complications
  • Higher bleeding and renal complications in women
  • At 5 years after CABG and PCI- survival similar
    for men women

17
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18
TAXUS IV Gender Analysis
  • TAXUS IV n 1,314
  • 662 patients (187 28.2 women) randomised to
    TAXUS
  • 652 patients (180 27.2 women) randomised to
    BMS
  • Primary endpoint
  • Rate of ischemia-driven target vessel
    revascularisation at 9 months
  • Key Secondary Endpoints
  • MACE
  • Angiographic (QCA) endpoints pre-specified in 732
    patients
    Lanskey et al JACC 2005



19
TAXUS IV- Female Group MACE at 1 Year
Control (N180)
TAXUS (N187)
Patients ()
Cardiac death
MI
TLR
TVR
MACE
Lanskey et al JACC 2005

MC
Morice Euro PCR 2005
No stent thrombosis in either group at 1 year
20
TAXUS IV- Female Group Angiographic Results at 9
months
Control (N72)
TAXUS (N81)
MLD
Late Loss
Late Loss
MLD
mm
mm
In-stent
AnalysisSegment
AnalysisSegment
In-stent
Significant improvement in outcomes for MLD and
Late Loss in TAXUS compare to Control
Lanskey et al JACC 2005
21
TAXUS IV- Female Group Angiographic Results at 9
months
Control (N72)
TAXUS (N81)
Diameter Stenosis
Diameter Stenosis
Restenosis


In-stent
AnalysisSegment
In-stent
AnalysisSegment
Restenosis was significantly reduced with the
TAXUS stent
Lanskey et al JACC 2005
22
TAXUS IV Gender Analysis
  • Women older, hypertension, diabetes, renal
    impairement, unstable angina, heart failure
  • Women- higher unadjusted 1 year rates of TLR
    (7.6 vs 3.2, p0.03)
  • Female gender - not an independent predictor of
    TLR or TVR

23
M Leon ACC 2005
24
Experience in Milan
Baseline Patient Characteristics (I)
25
Experience in Milan
Baseline Patient Characteristics (II)
26
Experience in Milan
In-Hospital and 30-days Outcomes
excluding peri-procedural MI
27
Clinical Outcomes at 1 year
Median clinical follow-up 13.9 months (IQR
11.5-17.5)
28
AMI
  • Women
  • Older (approx 20 yrs)
  • Higher incidence of risk factors
  • Increased incidence in young women (lt45 yrs)
  • Present more often with angina rather than AMI
  • Present more often with NSTEMI than with STEMI
  • Higher proportion of silent AMI (? older,
    diabetes, less awareness)
  • Present later to hospital with AMI (? atypical
    symptoms, less awareness, mans disease)

29
AMI
  • Women have higher rate of complications
  • - cardiogenic shock
  • - congestive cardiac failure
  • - reinfarction
  • - peripheral bleeding
  • - stroke
  • Higher risk of cerebral bleeding with
    thrombolysis
  • Higher early mortality than men
  • Gender is an independent risk factor for
    mortality in AMI
  • Mortality rate in younger women (lt45 years) is
    over twice that in men
  • Late presentation to hospital
  • Less aggressively treated

30
CABG
  • Complications
  • Stroke
  • Post operative haemorrhage
  • Prolonged mechanical ventilation
  • Post-operative renal failure
  • Cardiac failure

31
  • Coronary Revascularisation- PCI/CABG
  • Earlier detection of CAD by non-invasive imaging
  • Wider use of stents
  • Role of drug eluting stents
  • Increasing use of GIIb/IIIa inhibitors
  • Off-pump bypass surgery
  • Minimal access procedures
  • Research Studies / Trials

32
  • Women are evaluated less intensively and are
    undertreated
  • Women under-represented in research studies
  • Better awareness
  • Appropriate access to diagnosis treatment
  • Earlier more aggressive control of risk factors

33
  • AWARENESS

HEALTH CARE PROFESSIONALS GENERAL PUBLIC
  • Education /Scientific Meetings
  • Research
  • Education / Scientific Meetings
  • Research

34
  • Scientific Initiatives Awareness Campaigns
  • Go Red Campaign AHA
  • Heart Truth Campaign-
  • NHLBI

35
European Society of Cardiology 2005
36
UK Scientific Public Awareness Campaign
37
CVD in Women- Healthcare Professionals
  • Primary Care- GPs
  • General Physicians
  • Cardiologists
  • Nursing staff- chest pain nurses
  • Dept of Health
  • BCS / BCIS
  • Cardiac Networks
  • CHD Leads
  • Nursing Leads

38
CVD in Women- Healthcare Professionals
  • Symposium on CVD in Women- Friday 7th July
  • Recommendations
  • Consensus Statement
  • Working Group of BCS
  • Research

39
CVD in Women- General Public
  • Symbol
  • Website- heratheart.org.uk

40
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41
CVD in Women- General Public
  • Posters
  • Patient Leaflets

Endorsed by BCS
42
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