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Cardiovascular Disease in Women Module V: Prognosis and Treatment Outcomes

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Women 65 yrs have 2 X mortality rate after MI compared to men of same age ... Women are more likely to drop out after beginning cardiac rehabilitation ... – PowerPoint PPT presentation

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Title: Cardiovascular Disease in Women Module V: Prognosis and Treatment Outcomes


1
Cardiovascular Disease in WomenModule V
Prognosis and Treatment Outcomes
2
Women Received Less Interventions to Prevent and
Treat Heart Disease
  • Less cholesterol screening
  • Less lipid-lowering therapies
  • Less use of heparin, beta-blockers and aspirin
    during myocardial infarction
  • Less antiplatelet therapy for secondary
    prevention
  • Fewer referrals to cardiac rehabilitation
  • Fewer implantable cardioverter-defibrillators
    compared to men with the same recognized
    indications

Sources Chandra 1998, Nohria 1998, Scott 2004,
OMeara 2004, Hendrix 2005, Chou 2007, Hernandez
2007, Cho 2008
3
Prognosis After MI
  • 38 of women die within first year
  • Compared to 25 of men
  • 35 of women will have second MI within 6 years
  • Compared to 18 of men

Source Wenger 2004
4
Prognosis
  • Women lt 65 yrs have 2 X mortality rate after MI
    compared to men of same age
  • After MI, women have significantly higher rates
    of
  • Depression
  • Physical disability
  • After CABG, women have significantly higher rates
    of
  • Hospital readmission
  • Reduced mental health and physical functioning

Source Vaccarino 1999, Ades 2002, Lauzon
2003, Vaccarino 2003
5
Undertreatment of MI in Women
  • Compared with men
  • Less emergent thrombolysis
  • Less acute catheterization and angioplasty
  • Less acute surgical revascularization
  • Less use of heparin, beta-blockers, and aspirin

Source Chandra 1998, Nohria 1998
6
Cardiac Rehabilitation for Women
  • Cardiac rehabilitation programs benefit both men
    and women
  • Participation rates for eligible women are
    15-20, compared to 25-31 for eligible men
  • Women are more likely to drop out after beginning
    cardiac rehabilitation
  • Healthcare providers are less likely to encourage
    rehabilitation for female patients

Source Scott 2004
7
Benefits of ASA in Women with Established CAD


P 0.002 P 0.0001
Source Adapted from Harpaz 1996
8
Addition of Clopidogrel to Aspirin and
Fibrinolytic Therapy for MI with ST-Segment
Elevation in Women
P lt 0.05 reduction in odds 38
Source Sabatine 2005
9
Gender Gap in Dyslipidemia Treatment
  • Significantly more men than women have annual
    cholesterol measurements
  • Significantly more men than women receive
    effective lipid-lowering therapy
  • African Americans receive less lipid-lowering
    treatment compared to whites

Source OMeara 2004, Hendrix 2005, Chou
2007, Cho 2008
10
Meta-Analysis of 11 Clinical Trials of Statin
Therapy Including 15,917 Women with Known CHD
CHD Events
Non-Fatal MI
CHD Mortality
Source Grady 2003.
11
Simvastatin and Gender Risk for CHD and Mortality
P lt0.05
Source Scandinavian Simvastatin Survival
Study Group 1994
12
Heart Protection Study Major Findings
  • Randomized, placebo-controlled trial of over
    20,000 patients at risk for CVD
  • Statin treatment reduced the risk of heart
    attacks and strokes by at least one third, as
    well as reducing the need for arterial surgery,
    angioplasty and amputations.
  • Major CV events were reduced in women (5082
    enrolled) as well as men, and in all age groups,
    across all cholesterol levels.

Source HPS Writing Group, Lancet 2002
13
Primary Prevention of CHD Events with Statin
Treatment AFCAPS/TexCAPS
Relative Risk of First Major Coronary Events
P lt 0.001 compared to placebo
Source Downs 1998
14
Implanted Cardioverter Defibrillator (ICD)
Therapy in Women
  • Women appear to have a lower incidence of sudden
    cardiac death then men
  • Women present more frequently with ventricular
    fibrillation than men
  • Women have similar survival rates after ICD
    implantation compared to men
  • In a study of hospitals participating in a heart
    failure quality improvement program, women
    received fewer implantable cardioverter-defibrilla
    tors compared to men with the same recognized
    indications

Source Pires 2002, Hernandez 2007
15
Adjusted Odds for Use of Implantable
Cardioverter-Defibrillator According to
Guidelines by Race and Sex

P lt0.05 compared with white men


Source Adapted from Hernandez 2007
16
Interventional Procedures and Surgery
  • Higher complication and death rates
  • Smaller artery size
  • More co-existing illnesses (older at
    presentation)
  • Higher rates of diabetes
  • More urgent and emergent presentations
  • Higher incidence of congestive heart failure in
    women from diastolic dysfunction

Source Jacobs 2003
17
Coronary Revascularization in Women Compared to
Men
  • Increased use of PTCA compared to stents, because
    of smaller vessel size
  • Decreased rates of glycoprotein IIb/IIIa
    inhibitor use, possibly because of increased
    bleeding complications in women
  • Higher in-hospital mortality for CABG and PCI
  • Higher rates of vascular complications
  • Higher transfusion rates

Source Jacobs 2003
18
Revascularization Outcomes in Women Improvements
in Recent Years
  • NHLBI registry data shows improved clinical
    success rates and lower major complication rates
    for women undergoing PTCA
  • Retrospective data suggest that women have lower
    mortality rates when undergoing off-pump CABG,
    compared to standard CABG

Source Jacobs 1997, Petro 2000
19
Sex Differences for In-Hospital Mortality After
CABG Higher Mortality in Younger Women
P for interaction between sex and age 0.002.

Source Adapted from Vaccarino 2002
20
CABG Outcomes in Women A Vicious Cycle
Perception Higher post-operative
morbidity/mortality in women
Fewer long-term benefits for women
Prompt referral for CABG discouraged in women
Higher operative risk for women
Women referred at later stages of disease, w/
more comorbidities
Source Adapted from Vaccarino 2003
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