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Coronary Heart Disease in Women

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Treatment of CHD in older women has been traditionally based on a 'male model' ... Women presenting with angina are older than men ... – PowerPoint PPT presentation

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Title: Coronary Heart Disease in Women


1
Coronary Heart DiseaseinWomen
  • David Putnam, MD
  • Albany Medical College

2
Introduction
  • Cardiovascular disease is the leading cause of
    death in U.S. women
  • Over 250,000 deaths annually
  • Historically CHD has been viewed as a problem of
    middle-aged men

3
Leading Causes of Death in Women
4
Introduction
  • Treatment of CHD in older women has been
    traditionally based on a male model
  • U.S. women do not perceive heart disease as a
    priority health problem

5
Age-Related Issues
  • CHD is more age-dependent in women than in men
  • Women are about 10 years older than men at
    initial manifestation of CHD
  • Women are about 20 years older than men at
    occurrence of first MI

6
Incidence of CHD in Women
7
Incidence of CHD in Women
8
Age-Related Issues
  • Women will spend more than 1/3 of their lives in
    the post-menopausal state
  • Burden of CHD among women will increase

9
Angina in Women
  • Women presenting with angina are older than men
  • Risk for subsequent MI and cardiac death is
    lower
  • Advancing age associated with increasing risk for
    death
  • JAMA 19932692392-7.

10
Long-term Survival of Women with Angina
11
Angina in Women
  • Atypical pain is more common in women than in men
  • Vasospastic and microvascular angina are more
    common in women
  • Syndromes of nonischemic chest pain, such as
    mitral-valve prolapse are more common in women

12
  • In women, especially those under the age of 50,
    coronary artery disease is unusual in the absence
    of diabetes or hypertension. Yet precordial pain
    stimulating angina is a common symptom.
  • Levy and Boas, Mt. Sinai Hosp, NY 1936

13
Angina in Women
  • Unlikely that the natural history of angina in
    women with documented CAD by cath will ever be
    known

14
MI in WomenFramingham Data
  • Initial MI was more often fatal during the first
    year
  • Mortality in the initial weeks following MI was
    greater
  • Prevelance of silent MI was higher

15
MI in WomenMILIS Trial ( 1987 )
  • 555 men, 228 women
  • Greater hospital and post-hospital mortality in
    women
  • More post-infarction angina in women

16
MI in WomenThrombolytic Therapy
  • Equal gender benefit in restoring arterial
    patency and improving outcome
  • Women had an excess of bleeding complications
  • Women more often inelgible for thrombolytic
    therapy

17
CABG in WomenDifferences in Men/Women
  • Women are older
  • Women have more severe and unstable angina
  • Women more likely to have urgent/emergency
    procedures

18
CABG in WomenDifferences in Men/Women
  • Operative mortality higher in women
  • Women have less extensive multivessel disease,
    less left main coronary disease, less prior MI,
    and less abnormal ventricular function
  • Long-term survival rates are similar

19
PTCA in Women
  • In the early years of this procedure (1977-1981)
    women had a lower success rate
  • More recently gender related differences in
    outcome have been eliminated

20
MI in WomenPharmacologic Therapy
  • Beta-blockers reduce fatal/non-fatal reinfarction
  • Aspirin reduces MI/stroke
  • No other drugs have been compared for gender
    efficacy and safety in adequate-sized clinical
    trials

21
Cardiac Risk Factors in Women
  • Both women and men share traditional coronary
    risk factors
  • Potential risk factors unique to women
  • A. Oral contraceptive use
  • B. Hysterectomy
  • C. Menopause
  • D. Post-menopausal hormone replacement

22
CHD in WomenMajor Determinants
  • Typical angina pectoris
  • Postmenopausal status without hormone replacement
  • Diabetes mellitus
  • Peripheral vascular disease

23
CHD in WomenAngina
  • A pattern of non-ischemic pain is associated with
    a very low risk of CHD, although definite angina
    is strongly suggestive of disease

24
Evaluation of Chest Pain in Women
25
CHD in WomenMenopausal Status
  • Premenopausal women have a low risk of CHD
  • Postmenopausal women have a higher risk of CHD
  • Postmenopausal women with hormonal-replacement
    therapy have an intermediate risk of CHD

26
Estrogen TherapyTraditional Teaching
  • Reduces risk for CHD by 35
  • Reduces cardiovascular mortality by 50
  • Improves symptoms of vascular instability
  • Given without progesterin increases the risk of
    endometrial cancer and may increase the risk of
    breast cancer
  • ANN INT MED 19921171016-37.

27
Hormonal Replacement TherapyPossible Mechanisms
of Effect
  • Increased HDL cholesterol
  • Lower LDL cholesterol
  • Decreased lipid uptake into the vascular wall
  • Coronary vasodilation

28
HERS Trial
  • 2763 women ( average age 67 )
  • Estrogen/medroxyprogesterone vs. placebo
  • Average follow-up 4.1 years
  • Primary endpoint CHD death, nonfatal MI
  • JAMA 1998280605-613.

29
HERS Trial
  • No difference in endpoints between groups at end
    of study
  • Increase in cardiovascular events in treatment
    arm after 1 year
  • Decrease in cardiovascular events in treatment
    arm after 4 years
  • Early pro-coagulant effect?
  • JAMA 1998280605-613

30
HERS Trial
  • Does not support initiation of ERT in older
    postmenopausal women with confirmed coronary
    disease
  • For women with CHD already on ERT for 1year, may
    be reasonable to continue therapy
  • What to do with postmenopausal women free of
    vascular disease?
  • JAMA 1998280605-613.

31
Estrogen Therapy
  • The use of estrogen replacement therapy to
    prevent CHD is a difficult health decision for
    postmenopausal women
  • Potential benefits of therapy must be weighed
    against the possible risks

32
CHD in WomenDiabetes
  • More powerful predictor of CHD and its prognosis
    in women than in men
  • Associated with fivefold increase in risk of
    heart disease
  • Asympotmatic hyperglycemia has been shown to
    increase risk in women

33
CHD in WomenPeripheral Vascular Disease
  • Few data are available that specifically assess
    the likelihood of CHD in women with PVD
  • In general the association between the two is
    strong

34
CHD in WomenIntermediate Determinants
  • Hypertension
  • Smoking
  • Lipoprotein abnormalities, especially low HDL
    cholesterol levels

35
CHD in WomenHypertension
  • HTN is a major risk factor for heart disease in
    women
  • Prevalence of HTN reaches 80 in women 75 years
    of age

36
CHD in WomenHypertension
  • Definitive data that antihypertensive treatment
    in women is associated with similar benefical
    cardiovascular effects as compared to men is
    lacking
  • Women have been excluded from several major
    hypertensive treatment trials

37
Treatment of Hypertensionin Women
  • More women then men eventually develop
    hypertension
  • Women suffer less cardiovascular damage
  • Women receive less benefit from therapy
  • Estrogen for postmenapausal replacement therapy
    almost never raises BP
  • ARCH INT MED 1995155563-7.

38
CHD in WomenSmoking
  • Several large studies have clearly established
    that smoking is an important risk factor for CAD
    in women
  • The number of young women beginning to smoke
    exceeds men
  • Decline of smoking in women is substantially less
    than that of men ( 6 vs 21 )

39
CHD in WomenSmoking
  • Average number of cigarettes that women smoke has
    doubled since 1965
  • Smoking has been associated with half of all
    coronary events in women

40
CHD in WomenSmoking
  • Risk of MI conferred by smoking is largely
    dissipated after 2 to 3 years
  • Switching to low nicotine yield cigarettes is not
    an effective substitute for abstinance
  • Reducing consumption to a few cigarettes per day
    is not an acceptable alternative

41
CHD in WomenLipids
  • Abnormal lipid levels increase the risk of CAD in
    women
  • A low level of HDL is a better predictor of the
    risk of CHD in pre-menopausal women than is a
    high LDL

42
Triglycerides and Coronary Risk
  • Casually related to the progress of atherogenesis
  • Significant risk factor for CAD in women, more so
    than in men
  • Predictor of coronary risk in both men and women
    older than 65 years
  • ARCH INT MED 1997157961-968

43
CHD in Women4S Trial
  • Secondary prevention trial
  • Involved 827 women
  • 34 reduction in fatal and non-fatal MI
  • 49 reduction in the need for PTCA and CABG

44
CHD in WomenCARE Trial
  • Secondary prevention trial
  • Involved 576 women
  • 43 reduction in coronary death and MI
  • 50 reduction in stroke

45
CHD in WomenAFCCAPS/TexCAPS Trial
  • Primary prevention trial
  • Included 997 women
  • 57 relative risk reduction for coronary events
    at 5 years

46
Cardiac Risk Factors in Women
  • Risk factors for CHD in women are well documented
  • Compelling data from epidemiological studies and
    randomized clinical trials show that CHD is
    largely preventable

47
CHD in WomenMinor Determinants
  • Age 65 years
  • Obesity, especially central obesity
  • Sedentary lifestyle
  • Family history of coronary heart disease
  • Other risk factors for CHD ( e.g., psychosocial
    or hemostatic )

48
CHD in WomenObesity
  • Nurses Health Study
  • Higher levels of adiposity within normal range
    associated with higher risk
  • 11 to 19 kg weight gain associated with relative
    risk of 1.9
  • JAMA 1995273461-5.

49
CHD in WomenAlcohol Consumption
  • Nurses Health Study
  • Women who consumed light to moderate amounts of
    alcohol had reduced risks for death from CHD
  • 10 to 20 decrease in overall mortality rates
  • NEJM 19953221245-50.

50
CHD in WomenAlcohol Consumption
  • Moderate to heavy alcohol consumption increases
    the risk for breast cancer
  • Women with the highest alcohol consumption had
    increased risk for death from all causes.
  • NEJM 19953221245-50

51
Cardiac Risk Factors in WomenAlarming Trends
  • Smoking rates are declining less for women than
    men
  • Prevalence of obesity is increasing
  • 25 of women report no regular, sustained
    physical exercise
  • 52 of women 45 years old have hypertension
  • 40 of women 55 years old have increased
    cholesterol

52
CHD in WomenMissed Opportunities
  • Initial perception of angina as begign has been
    associated with a number of missed opportunities
  • Lack of emphasis on preventive strategies

53
CHD in WomenMissed Opportunities
  • Lack of inclusion of women in clinical trials
  • Inadequate attention to the need for and
    methodology of risk stratification of women with
    chest pain
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