Dr. Suzanne Steinbaum Director, Women and Heart Disease ......A CVD (I00-I99; Q20-Q28) B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s

Dr. Suzanne Steinbaum

Director, Women and Heart Disease

Lenox Hill Hospital

New York

A CVD (I00-I99; Q20-Q28)B CancerC Accidents

D Chronic Lower Respiratory DiseasesE Diabetes MellitusF Alzheimer’s Disease

CVD and other major causes of death for all males and FEMALE

DEATHS(United States: 2006). Source: NCHS and NHLBI.

290,069

59,260

269,819

398,563

78,94136,006

432,709

65,32351,281

42,658

0

100,000

200,000

300,000

400,000

500,000

A B C D E A B D F C

Death

s

Males Females

Age-adjusted death rates for CHD, stroke, lung and breast for white and black females (United States: 2006).Source: NCHS.

41.1 41.122.9

57.039.0 31.6

101.5

130.0

0

50

100

150

200

Coronary Heart

Disease

Stroke Lung Cancer Breast Cancer

Pe

r 1

00

,00

0 P

op

ula

tio

n

White Females Black Females

Menopause and

the Risk of Coronary Heart Disease (modified data from “Menopausal status as a risk for coronary artery disease”

Arch Intern Med 1995;155:57-61

0

0.5

1

1.5

2

2.5

3

3.5

4

40 - 45 45 - 49 50 - 54

Before menopause

After menopause

Age (in years)

An

nu

al

Occ

ure

nce

of

Hea

rt A

tta

ck/1

000

African-American Women &

Heart Disease

�African-American women have a higher risk for heart disease than Caucasians and are less aware of their risk factors, including:� Obesity (53.9% obese and 73.1% overweight and obese)¹

� Physical Inactivity (65.4% of African-American women get no leisure time physical activity)¹

� High Blood Pressure¹

� Diabetes (15.4% have diabetes)¹

� Diet (Sodium Intake)¹

�47% of African-American women over the age of 20 have high blood pressure¹

�African-American women bear a disproportionate burden of stroke, heart failure, and kidney disease, all due to undiagnosed, or poorly controlled high blood pressure.²⁻³

1 Go A S, Mozaffarian, D, Roger, V L, Benjamin E J, et al. Heart Disease and Stroke Statistics 2013 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2013; e39-e90

2 Jha AK, Varosy PD, Kanaya AM, et al. Differences in Medical Care and Disease Outcomes Among Black and White Women With Heart Disease. Circulation. 2003;108:1089-1094. E39-e90

3 Pleis JR, Lucas JW. Summary health statistics for U.S. adults: National Health Interview Survey, 2007. Vital Health Stat 10. 2009; No. 240: 1-159.

5www.womenheart.org

Hispanic-American Women &

Heart Disease

� Hispanic-American Women also have a slightly higher risk for heart disease than Caucasians, and are less aware of their risk factors.� Obesity

� Among Mexican-American women, 44.8% are overweight and 78.2% are overweight or obese¹

� Physical Inactivity

� High Blood Pressure

� Among Mexican-American women over the age of 20, 28.8% have high blood pressure.¹

� Diabetes (12% have diabetes … Nearly 2x higher than Caucasian women)¹

� Diet (Sodium Intake)

� Among Mexican-American women, 30.7% have cardiovascular disease¹

1 Go A S, Mozaffarian, D, Roger, V L, Benjamin E J, et al. Heart Disease and

Stroke Statistics 2013 Update: A Report from the American Heart Association

Statistics Committee and Stroke Statistics Subcommittee. Circulation 2013; e60-

e111

6www.womenheart.org

Awareness trends of Heart Disease as

leading cause of death in women:

FEBRUARY 10, 2010

� 60% WHITE WOMEN

� 43% AFRICAN-AMERICAN WOMEN

� 44% HISPANIC

� 34% ASIAN

� 50% women ages 25-34 **** NEED FOR PREVENTION

-Women younger than 55 years old- there was a greater increase in the risk of heart disease and stroke

*increase is due to an increase in diabetes in this population*there has been a 93% decline of mortality of younger women compared to men due to better recognition and management of coronary artery disease and its risk factors*the disease process is escalating in a younger population.

We need to aggressively empower these women to achieve the lifestyle goals that diminish their risk factors in order to prevent this disease from presenting itself, not only at such a young age, but also in a woman's lifetime.

Epidemic of Heart Disease has reached the youngerPopulation of women:October 2009 Archives of Internal Medicine

1988-1994 1999-2004

MEN 2.5% MEN 2.2%

WOMEN 0.7% WOMEN 1%

Low rate of sex-specific reporting in

Cardiovascular trials

� Major journals- cardiology and internal medicine

� from July 1st through December 31, 2004

� Result reporting for primary outcomes for women

� NIH funded-51%- 1993 act of inclusion

� General medical- 37%

� Cardiology- 23%

� SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY AND INTERVENTIONS SCAI 2011- ONLY 25% OF NIH TRIALS TRACK GENDER SPECIFIC OUTCOMES

Differences in Referral for

Testing and Treatment : Gusto IIB

0

10

20

30

40

50

60

% o

f P

ts R

efe

rred

Stress

Testing

Cardiac

Cath

PTCA CABG

Women

Men

P<0.01 for all

Tamis et al. Circulation 1997;96:I-536.

Gender Distribution Estimates for

Interventions : 2004

33%

67%

35%

65%

50%50%

22%

78%

20%

80%

0%

20%

40%

60%

80%

PTCI Peripheral

Int.

Pacemakers ICDs CRT-D for HF

Female

Male

1

2

1 1 2

Sources:

1-AHA: Heart Diseases and Stroke Statistics - 2004 Update

2-Guidant Internal Estimates

Low rate of sex-specific reporting in

Cardiovascular trials

� Major journals- cardiology and internal medicine

� from July 1st through December 31, 2004

� Result reporting for primary outcomes for women

� NIH funded-51%- 1993 act of inclusion

� General medical- 37%

� Cardiology- 23%

� SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY AND INTERVENTIONS SCAI 2011- ONLY 25% OF NIH TRIALS TRACK GENDER SPECIFIC OUTCOMES

15%

Val HeFT

CIBIS-II Clinical Trial; Lancet; Circulation, 2001; 103; 3;375-380;

MERIT HF Clinical Trial; Ghali, JK, Circulation, 2002;105; 1585-1591;

Val Heft Clinical Trial; Cohn, JN, N Engl J Med, 2001; 345; 1667-1675;

COPERNICUS Clinical Trial; Gust, H Bardy; ACC , March 8, 2004.

Men Women

Representation of Women in Pharma Heart Failure Trials

32%

COPERNICUS

MERIT HF

CIBIS II

77% 23%

75% 25%

80% 20%

80% 20%

Physician awareness of CVD prevention guidelines by specialty

NCEP ATP III JNC 7 clinicalguidelines

AHAWomen's

PCP

OBGyn

Cardiologist

0%

70%

60%

50%

40%

30%

20%

10%

80%

90%

100%

Mosca L et al. Circulation. 2005;111:499.

Aware

p<0.001p<0.001 p<0.001 p<0.001

p<0.001

p<0.001

Physician incorporation of CVD prevention guidelines by specialty among respondents who stated they were aware of the guidelines

NCEP ATP III JNC 7 clinicalguidelines

AHAWomen's

PCP

OBGyn

Cardiologist

0%

70%

60%

50%

40%

30%

20%

10%

80%

90%

100%

Mosca L et al. Circulation. 2005;111:499.

Incorporated

p<0.001p<0.001

p<0.001 p<0.001

p<0.001

p<0.001

The State of our Nation� 45% of US has 1 risk factor- high blood pressure, high

cholesterol or diabetes

� 13% has 2 risk factors

� 3% have 3 risk factors

� 15% of adults also had one or more of these conditions undiagnosed

Study Points to Declining Life Span

for Some U.S. Women� Wall Street Journal

� March 4, 2013

� University of Wisconsin study

� 3,141 women over 10 years

� In the South and West

� “unclear reasons”-

� Most often poor white women

� Theories- obesity, diabetes

� Women 81, men 76- women is dropping

� Started in the late 80’s

AHA 2020 STRATEGIC GOAL�“To improve the cardiovascular health

of all Americans by 20% while reducing the deaths from cardiovascular diseases and stroke by 20%”

�Must create awareness to multicultural women and young women

WHAT IS CORONARY ARTERY DISEASE?� ATHEROSCLEROSIS

� PLAQUE BUILDUP

� CHOLESTEROL, FIBROUS TISSUE

� INFLAMMATORY CELLS

� BEGINS IN TEENS

Premature atherosclerosis (PDAY)A

bd

om

ina

l a

ort

a

Rig

ht co

ron

ary

art

ery

McGill HC Jr et al, Circulation 2002

Most Myocardial Infarctions Are Caused

by Low-Grade Stenoses

Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992.(Adapted from Falk et al.)

Falk E et al, Circulation, 1995.

Intraluminal thrombusGrowth of thrombus

Intraplaque thrombus Lipid pool

Blood Flow

Atherosclerotic Plaque Rupture and

Thrombus Formation

Adapted from Weissberg PL. Eur Heart J Supplements

1999:1:T13–18

Women’s Early Warning Signs of a

Heart Attack

� Weeks before Heart Attack (95% of women)� Unusual fatigue (70.7%)� Sleep disturbance (47.8%)� Shortness of breath (42.1%)� Indigestion (39.4%)� Chest pain (29.7 %)

� At time of Heart Attack� Shortness of breath (57.9%)� Weakness (54.8%)� Fatigue (42.9%)� Chest pain (57%)

McSweeney, JC et al. Circulation 2003; 2619-2623

AHA 2/10 survey: 2,300 women

interviewedOnly 53% of women said they would call 9-1-1 if they

thought they were having heart attack symptoms

56% of women saying chest pain and neck or arm pain

29% shortness of breath

17% chest tightness

15% nausea

7% fatigue

Profiles of Heart Disease in

Men vs. Women: AHA

Deaths within one year of

1st MI25% 38%

Sudden deaths with no

previous symptoms50% 64%

Within six years of recognized MI,

percent who will:

• have another MI

• have a stroke

• experience SCD*

• be disabled with heart failure

18%

8%

7%

22%

35%

11%

6%

46%

Men Women

WISE Demonstrates Challenges in Diagnosis:NHLBI study: 1996 to 2000

Goals: � Improve diagnostic testing for ischemic heart

disease in women

� Study pathophysiologic mechanisms and prognosis in women with myocardial ischemia in the absence of obstructive coronary disease

� Evaluate influence of hormones and menopause on symptoms and diagnostic testing results

� Women with SYMPTOMS and NORMAL CORS on CATH

Women’s Ischemia Syndrome Evaluation(WISE)- 954 patients, 4 centers

Noel Bairey Merz, MD (WISE) Diagnosis and Pathophysiology of Ischemic Heart Disease Workshop

October 2-4, 2002

Difference in Disease Presentation

Obstructed coronary artery

Diffused narrowing in coronary artery

Findings from WISE� 936 women with ches pain referred to angiography

� “typical” angina missed in 65% of cases of CAD

� Substudy of normal caths- absence of flow limiting lesions

� 159- 47% abnormal microvascular flow reserve

� 163- impaired coronary vasomotor response to acetylcholine independently linked to adverse CV outcomes

� Some lesions severe enough to limit coronary perfusion

DETECTION OF CAD IN WOMEN

� HISTORY IS VERY VARIABLE

� DIAGNOSTIC TESTING IS DIFFICULT

� MORE FALSE POSITIVES- stress ekg

� Dobutamine echo- not sensitive or specific for single vessel disease, but diagnostic for multivessel disease

� RISK STRATIFICATION OFTEN DIFFICULT, ESPECIALLY IN YOUNGER WOMEN

THE FRAMINGHAM RISK� After WWII- development of heart disease

� 1948- stable town

� Lifestyles were analyzed

� Until 1961, then the children- Offspring study

� Our assessment now is based on the results of this study…

CHOLESTEROL GOALS BASED ON RISK

Cholesterol distribution in CHD

and non-CHD populations

�In spite of major advances made in the screening, detection, and management of heart disease, a major need exists for more accurate ways to predict CV risk

� Therefore, other factors must be involved

35% of CHD occurs in people with TC considered optimal (<200mg/dL)

Adapted from Castelli W. Atherosclerosis 1996

Framingham Heart Study — 26-year follow-up

150 200

No CHD

Total cholesterol (mg/dL)

250 300

CHD

THE REYNOLD’S RISK SCORE

� In women, up to 20% of all coronary events occur in the absence of risk factors

� 24,558 healthy US women followed for 10.2 years

� Women 45 years and older, started September 1992

� Incident of MI, stroke, coronary revascularization or cardiovascular death

Reynolds risk score:

ADDED variables� Systolic blood pressure� Current smoking� Total Cholesterol� HDL__________________________________________� Hemoglobin A1C� hsCRP- USE OF THIS- RECLASSIFIED 25%� Parental history of myocardial infarction� Apoliporproteins A-1 and B-100� Lipoprotein (a)

THE CALCIUM SCOREA CT SCAN to detect CALCIUM in the arteries.

� SPECIFICITY DECREASES WITH INCREASING AGE

� 85% TO 100% SENSITIVE

� 41 TO 76% SPECIFIC

� PRESENTLY ACC/AHA EXPERT CONSENSUS DOES NOT RECOMMEND IT BECAUSE OF HIGH NUMBR OF FALSE-POSITIVES