Cardiovascular Disease in Women Module V: Prognosis and Treatment Outcomes

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Cardiovascular Disease in WomenModule V
Prognosis and Treatment Outcomes
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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
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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
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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
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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
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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
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Benefits of ASA in Women with Established CAD


P 0.002 P 0.0001
Source Adapted from Harpaz 1996
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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
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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
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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.
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Simvastatin and Gender Risk for CHD and Mortality
P lt0.05
Source Scandinavian Simvastatin Survival
Study Group 1994
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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
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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
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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
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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
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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
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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
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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
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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
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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