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Women and Heart Disease

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Title: Women and Heart Disease


1
Women and Heart Disease
  • Cathryn Harbor
  • Lexington VA
  • May19,2004
  • Sponsored by National Organization for Women

2
Coronary Artery Disease
3
Definitions
  • Heart Attack Heart Muscle is damaged because it
    cant get blood and oxygen.
  • Angina Heart Muscle is deprived of blood flow
    and oxygen. A charlie horse.

4
Women get more disease in small blood vessels of
the heart
5
Statistics
  • Disease of Arteries is the leading cause of
    death.
  • After menopause women develop heart disease at
    the same rate as men.
  • After menopause, women are 10 times more likely
    to develop heart disease than to develop breast
    cancer.
  • 40 of people who have a heart attack die of it.

6
Life Cycle Differences
  • Young women develop less disease in the heart
    arteries than young men.
  • After menopause, a womans arteries develop
    disease at a similar rate to mens.

7
Heart Disease in Women vs Men
  • After menopause women are equally susceptible
  • Men have more chest pain.
  • Women more often have silent heart attacks
  • Once diagnosed women do worse

8
Red Flag Symptoms
  • Chest Pain or Pressure
  • Dizziness
  • Shortness of Breath
  • Neck Pain unassociated with neck movement
  • Any Unusual Symptom that occurs with exertion and
    resolves with rest
  • Unexplained Sweats
  • Nausea

9
What to do if you have symptoms
  • Take an asprin
  • Stop any exertion
  • Go to the ER if the symptom persists. If it
    resolves, contact your health care provider.

10
Known risk factors
  • There are more than 80 known risk factors for
    heart disease
  • This means that there is no one cause and no one
    treatment.

11
Important Risk Factors
  • Smoking
  • Being overweight
  • Age
  • Hypertension
  • Diabetes
  • Physical Inactivity
  • Elevated cholesterols
  • Elevated C Reactive Protein
  • Elevated Fasting Blood Sugar (90)
  • Stress, anxiety, depression
  • Elevated homocysteine

12
Genetic Contribution
  • We know that genetics plays a big role
  • .Genes tell your body how to make proteins, that
    is all. To have a genetic problem simply means
    that you inherit the blueprint for less effective
    proteins. It does not mean that you inherit
    heart disease.
  • No genetic factors I have found that are not
    modifiable by environment

13
The Problem of Choice
  • Hard to know what to do.
  • Science does not provide clear answers
  • Science does not progress rapidly
  • What is driving the science?

14
Women and Heart Health Choices
  • Should I use hormone replacement?
  • Should I use medicines to lower my cholesterol?
  • Should I change my lifestyle?

15
Women and HormonesWhat We Do Know
  • Before menopause womens risk of heart disease is
    much lower than mens.
  • After menopause, womens risk quickly approaches
    mens.
  • In large surveys women who take estrogen after
    menopause have less heart disease (nurses study).

16
Evolution of HRT
  • Drug companies started producing estrogen from
    pregnant mares urine (Premarin).
  • Studies showed that estrogen without progesterone
    causes uterine cancer.
  • Drug companies started making combination
    packages of estrogen and progestins.
  • Because of Patent issues, the progestins the drug
    companies used were not natural to the body, but
    synthetic.

17
Evolution of HRT continued
  • Because of the belief, based on good studies,
    that HRT protects against heart disease, women
    were told at menopause that they should start
    premarin to protect their hearts.
  • Premarin became the most widely prescribed drug
    in the country

18
HERS trial
  • 2763 postmenopausal women
  • Pre-existing heart disease
  • Randomized to placebo or prempro
  • 4.1 year study

19
HERS Trial Results
  • In the first year more women on prempro group had
    more heart attacks than women in the control
    group
  • For the 2nd and 3rd years the groups very similar
  • By the 4th year more women in the control group
    had heart attacks

20
Impression after HERS Trial
  • Starting on HRT after heart disease is
    established is dangerous at first
  • After a few years on HRT estrogen use seems to
    create no additional risk and possibly to protect
    women

21
What Would Explain the Results of HERS?
  • We know that estrogen increases womens chance of
    forming clots in our blood vessels
  • Women in the trial were known to already have
    diseased arteries.
  • Possibly starting a woman on HRT after she has
    developed heart disease was the problem, since a
    clot is a bigger problem in a sickened and
    narrowed artery.

22
THE WOMENS HEALTH INITIATIVE (WHI)
  • 16,608 post menopausal women without hysterectomy
    not currently on HRT
  • Randomized to placebo or prempro
  • Planned duration 8 years
  • Stopped by safety advisory board after 5.3 years
    increased risk of breast cancer without evidence
    of overall benefit.

23
FINDINGS OF WHI
  • Breast cancer, heart disease, stroke, lung clots
    and leg clots are all increased by prempro (in
    this population). Prempro may have more negative
    effects than estrogen alone
  • Hip fractures and colorectal cancer are reduced
    by prempro (in this population)
  • Prempro increased the risk of hysterectomy

24
Problems with WHI
  • WHI intentionally excluded women with severe
    menopausal symptoms, though these women are most
    likely to use HRT.
  • Older women not on HRT were studied. Many of
    them can be presumed to already have heart
    disease.
  • The study was too short to show benefits, if any,
    of HRT.

25
What we STILL Dont Know
  • Is there a heart benefit to giving HRT starting
    right at menopause, before heart disease starts
    to develop?
  • Do other types of estrogen and progesterone have
    same risks?
  • What if lower doses had been used?
  • Do older women on hormones need to come off of
    them?

26
Take away
  • We still do not have enough information to make
    perfect decisions about putting women on or
    taking them off estrogen
  • Right now the pendulum has swung very far to the
    no HRT side.

27
Cholesterol
  • People who die of heart attacks have changes in
    their heart arteries that are made, in part, of
    cholesterol.

28
Where Does Cholesterol Come From?
  • We thought cholesterol in diet made cholesterol
    in the body.
  • In fact cholesterol is so important that the body
    makes its own.
  • Cholesterol is the result of interactions between
    carbohydrates, fats and protein in a diet, level
    of exercise, heredity and hormones.

29
Cholesterols Function
  • Important in producing hormones
  • Forms insulation around nerves to keep signals
    moving
  • Needed to maintain cell membrane fluidity
  • Has important immune functions (fighting illness)
  • Necessary for brain function (thinking)
  • Important in neurotransmitter production (mood)

30
About Cholesterol
  • We usually measure three types of cholesterol
  • LDL (bad cholesterol)
  • HDL (good cholesterol)
  • Triglycerides

31
Traditional Approach
  • Focused on evidence-based medicine
  • Five major studies showed impressive risk
    reduction from using statins (24-39 reduction).
  • Drug trials using statins (Lipitor, Pravacol,
    Baycol, and Zocor, etc demonstrated both a
    lowering in LDL cholesterol and a lowering of
    heart attacks.

32
Statins some more of the issue
  • 61-76 of patients treated with statins STILL
    experience heart attacks.

33
Lipids and Women
  • LDL (Bad Cholesterol) is a good predictor of
    heart disease in men.
  • Simple LDL measurements predict little in women.
  • Despite awareness of other modifiable risk
    factors, we tend to focus on one risk factor (LDL
    cholesterol) and one therapy (statin drugs)

34
Tangent about problems with LDL
  • LDL is clearly bad, at least for men but there
    are differences among the types of LDL
  • My LDL is 180 yours is 120. Who has the worst
    problem? We dont know because
  • Answer It depends on number of cholesterol
    particles and therefore on the size of the LDL
    particle.

35
This Just In
  • Women without coronary artery disease do not
    benefit from Statin use.
  • For women with known cardiovascular disease,
    treating hyperlipidemia is effective in reducing
    fatal and non fatal heart attacksbut does not
    affect total mortality.

36
Another Big Problem
  • Coenzyme Q-10 is a very important anti-oxidant.
  • Coenzyme Q-10 is produced in the body, in the
    same chemical pathway as cholesterol.
  • The enzyme, HMG CoA reductase is essential for
    producing CoQ-10.
  • Statin drugs work by disabling this enzyme.

37
CoQ-10
  • Many of unpleasant effects of statin drugs
    (muscle aches, fatigue) can be reversed by using
    CoQ-10.
  • CoQ-10 has now been demonstrated to be important
    in treating Parkinsons disease.
  • I believe that everyone on statin drugs should
    take CoQ-10.

38
HDL Cholesterol
  • HDL (good cholesterol) is very important in
    women
  • HDL below 50 makes women 2.7 times more likely to
    die of a heart attack.

39
Triglycerides
  • Triglycerides between 200 and 400 increase risk
    of heart attack death by 2.4
  • Triglycerides above 400 make women 6.9 times more
    likely to die of heart attacks.

40
The Metabolic Syndromealso called INSULIN
RESISTANCE
  • Abnormal cholesterol profiles High TG, low HDL
    high LDL
  • Hypertension
  • Type 2 Diabetes
  • Coronary artery disease
  • Breast, prostate and colon cancer
  • Polycystic ovarian disease

41
Insulins Role
  • High blood sugar is highly toxic to brain tissue.
  • When you eat carbohydrates your body turns them
    into sugar, glucose.
  • Insulin rises after you eat carbohydrates to
    protect your tissues from excess energy.
  • Insulin lets excess energy be quickly cleared
    from the bloodstream to be stored as
    triglycerides and cholesterol.
  • In the short term, high insulin levels protect
    your tissues
  • In the long run, high insulin levels are
    associated with many health problems, called the
    metabolic syndrome.

42
Triglycerides, Insulin and Diabetes
  • Learn and control your triglyceride number
  • Of all lipid markers, this one is associated with
    the effectiveness of your diet and exercise
    program.
  • Triglycerides are where your body stores excess
    carbohydrate calories
  • We have long known that Triglycerides are an
    important marker for CAD risk in women.

43
A complex problem without an easy solution
  • Whats a girl to do?

44
How do you protect yourself?
  • Lower your risk for heart disease by 70!

45
The Lyons Study
  • 605 French men and women who had survived heart
    attacks
  • Divided into two groups
  • American heart Association Diet (low fat)
  • Mediterrainian diet
  • Olive oil
  • Whole grains
  • More root and green vegetables
  • More fish and poultry, less red meat

46
Mediterreanian diet
47
Lyon s Study Results
  • Study was stopped after only 30 months
  • A 70 reduction in deaths from all causes in the
    group with the Mediterainian diet.
  • This was in people who had already had heart
    attacks!

48
Changes you can make for risk reduction
  • Stop or avoid smoking
  • Improve your diet (the LYONS Study)
  • Maintain a normal weight
  • Exercise
  • Consider hormone replacement
  • Maintain normal blood pressure
  • Reduce stress in your life

49
  • ONE SIZE FITS ALL MEDICINE IS THE BEST FOR THE
    DRUG COMPANIES.
  • It is not necessarily the best for your body

50
QUESTIONS?
51
It begins on the first day of medical school and
lasts through to retirementIt starts slowly and
insidiously, like an addiction, and can end up
influencing the very nature of medical decision
making and practiceAttempts to influence the
judgement of doctors by commercial interests
serving the medical industrial complex are
nothing if not thorough.
52
BUT
  • In the above studies, not enough women were
    included to determine the effects of lowering LDL
    in women
  • Level of LDL cholesterol does not correlate well
    with risk of heart disease

53
Problems with the system
  • Most medical research is payed for by drug
    companies
  • Drug companies need to find drugs that work for
    large groups of people one size fits all model
  • Not all people are alike men from women,
    premenopausal from post menopausal women one
    size does not fit all
  • Most doctors get their information from drug
    reps, the marketing agents for the drug industry.
  • Drug company information is not intended to be
    objective. It is a product of spin artists
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