Jennifer Tremmel - Sex Differences In Cardiovascular Disease

Sex Differences in Cardiovascular Disease

Jennifer A. Tremmel, MD, SM

What heart disease looks like

Historical Perspective

! Surge of interest in the 1940s and 1950s with a focus on middle-aged men

! Studies enrolled primarily men

Lee et al. JAMA. 2001;286:708-713

Women in Cardiology Trials

Trial % Women

BARI 26%

CAVEAT 18%

COMET 20%

VANQUISH 3%

BENESTENT 19%

4S 18%

CABRI 22%

HOPE 25%

TNT 19%

PAMI 25%

SIRIUS 28%

TAXUS 18%

COURAGE 15%

Enrollment of Women in NHLBI RCTs

Kim et al. J Am Coll

Cardiol

2008;52:672-675

Mean percent of women enrolled in all trials (27%) vs. mean percent of all patients with CVD who were women (53%)

Mortality Trends

Rosamond et al. Circulation 2007;115;e69-e171, Source: NCHS and NHLBI

Cardiovascular Disease Mortality Trends for Women and Men

United States: 1979-2004

380

400

420

440

460

480

500

520

79 80 85 90 95 00 04

Years

Dea

ths

in T

hous

ands

Males Females

0380

400

420

440

460

480

500

520

79 80 85 90 95 00 04

Years

Dea

ths

in T

hous

ands

Males Females

0

www.nhlbi.nih.gov/health/hearttruth

www.goredforwomen.org

AHA survey of women’s knowledge

ALL WOMEN 1997 2000 2003 2005

Identify heart disease as leading cause of death

30%

34%

46% 55%

Perceive heart disease as their greatest health threat

7%

8%

13%

21%

Perceive cancer as their greatest health threat

61%

62%

51%

(38%)

Report heart health discussions initiated by their doctor

30%

38%

38%

46%

!! Minority women face the highest risk of dying from CVD, however they have a poor awareness that heart disease is the leading killer of women

-European-American: 68%-African-American: 31%-Hispanic-American: 29%

Mosca

et al. J Women’s Health 2007;16:68-81

Cardiovascular Disease

! Leading cause of death among women in US

–

1 in 4 deaths attributable to CAD

–

1 in 2 deaths for all forms of CVD

! Heart disease:

!

Second-leading cause of death for women 45 to 64 years

!

Third-leading cause of death for women age 25 to 44 years

! Kills more than 500,000 women per year

! Kills 6 times as many women as breast cancer

! Kills almost twice as many women as all forms of cancer combined

Sex Differences

! Women differ from men in terms of:

!

Risk factor profiles

!

Presentation

!

Testing

!

Treatment

!

Outcomes

!

Pathophysiology (?)

! Age: women, " 55 yrs; men, " 45 yrs

! High LDL-cholesterol: " 160 mg/dl

! Low HDL-cholesterol: < 40 mg/dl*

–

*

< 50 mg/dl may be more appropriate cut-point for women

–

Optimal, "

60 mg/dl (considered a “Negative Risk Factor”)

! Diabetes (fasting glucose " 126 mg/dl) = CHD equivalent

! High Blood Pressure: " 140/90 mm Hg

! Obesity

! Sedentary Lifestyle

! Cigarette Smoking

! Family History of premature CHD:

!

1st degree male relative (father, brother) < 55 yrs

!

1st degree female relative (mother, sister) < 65 yrs

Heart Disease Risk Factors

Diabetes

!! Having diabetes confers a greater relative risk of CVD events inHaving diabetes confers a greater relative risk of CVD events inwomen compared with menwomen compared with men

Barrett-Connor et al. Arch Int Med. 2004;164:934-942

Diabetes Trends from 1971 to 2000

! Mean BMI increased (for all)

! Average age of diagnosis decreased for women (mean age 51.6 to 48.7, p<0.05 )

! Men with diabetes experienced a 43% relative reduction in age-adjusted all-cause mortality, but women had no change

! The difference in all-cause mortality between women with and without diabetes more than doubled

Gregg, E. W. et. al. Ann Intern Med 2007;147:149-155, NHANES data

Age-adjusted cardiovascular disease mortality rates among men and women age 35 to 74 years

16.8

8.1

5.8

7.1

*Annual deaths per 1000 persons

Impaired Fasting Glucose

! Women with IFG have a significantly increased 4-year odds of developing CHD or CVD compared to men

Levitsky

et al. J Am Coll

Cardiol

2008;51:264-70

CHD CVD

Women Men Women Men

2003 Definition*(FPG 100-125) 1.7 (p=0.048) 0.9 (p=0.55) 1.4 (p=0.16) 1.1 (p=0.56)

1997 Definition†(FPG 110-125) 2.2 (p=0.02) 0.9 (p=0.67) 2.1 (p=0.01) 1.0 (p=0.98)

Diabetic*(FPG !126 or on med) 2.5 (p=0.01) 2.6 (p<0.001) 2.3 (p=0.007) 2.8 (p<0.001)

CHD = MI, stable and unstable angina, a CHD deathCVD = any CHD event, CVA, TIA, claudication, CHF, or CVD death

* Referent group is FPG <100mg/dl†

Referent group is FPG <110mg/dl

Prehypertension (120-139/80-89)

! Prehypertension is independently associated with an increased risk of MI, CVA, HF, and CV death in post-menopausal women

Hsia et al. Circulation 2007;115:855-860

Cumulative hazard of cardiovascular events by JNC7 blood pressure category

Prehtn: HR 1.66 (1.44 to 1.92)Htn: HR 2.89 (2.52 to 3.32)*Adj

by BMI, DM, hyperchol, tob

use

WHI data, n=60K39% had prehtn

at baseline

Lipids

! Low HDL and high triglycerides:

!

Independent predictors of CVD mortality in women

!

More powerful determinants of CAD risk in women than total cholesterol and LDL levels.

Bass et al. Arch Int Med. 1993;153:2209-2216

Obesity and Physical Activity

! More adult women than men in the United States are obese and sedentary

! Obesity and physical inactivity independently contribute to the development of CHD in women

Li et al. Circulation. 2006;113:499-506

?Other risk factors

! Maternal Placental Syndrome (gestational hypertension, pre-eclampsia, placental abruption, placental infarction)

!

Doubled risk of premature CVD, +/-

simply reflection of pre-

pregnancy risks

Ray et al. Lancet 2005;3666:1797-1803 (CHAMPS)

Others:• Gestational Diabetes• Peripartum

Vasc

Dissection• Low birth-weight children• PCOS• Hypothalamic hypoestrogenemia

• Weight gain during pregnancy

Class III Recommendations

! Menopausal Hormone Therapy

! Antioxidants (Vitamin E, C, beta-carotene)

! Folic Acid

! Aspirin in women < 65 years for primary prevention of MI

Not recommended for primary or secondary prevention}

Mosca

et al. Circulation 2007;115:1481-1501

Menopausal Hormone Therapy

! Secondary analysis of WHI E+P trial (2003)1

!

Non-significant reduction of CHD risk in women less than 10 years since menopause

! Secondary analysis of WHI CEE trial (2006)2

!

Non-significant reduction of CHD risk in women age 50-59

!

Significant reduction in revascularizations in women age 50-59

! Small numbers in subgroups may have obscured a real effect

! Both trials showed an increased risk of stroke not modified by age or years since menopause

1.

Manson et al. N Engl J Med 2003;349:523-5342.

Hsia et al. Arch Intern Med 2006

Are Hormone Effects on Clinical CVD Different if Started Closer to Menopause?

HT and CVD

! Combined WHI trials of CEE and CEE+MPA

! 27,347 postmenopausal women

! Main outcomes:!

CHD (nonfatal MI, silent MI, or CHD death)

!

Stroke

! Other outcomes:!

Mortality (all-cause)

!

Global Index (first occurrence of CHD, CVA, PE, breast CA, colorectal CA, endometrial CA, hip fracture, or death from other causes)

Rossouw

et al. JAMA 2007;297:1465-1477

Events by Age Group at Baseline in Combined Trials

5050--59 years59 years

N= 8,832

6060--69 years69 years

N= 12,362

7070--79 years79 years

N= 6,153

P for Trend

No. of Cases

HR

(95% CI)

No. of Cases

HR

(95% CI)

No. of Cases

HR

(95% CI)

CHD 120 0.93

(0.65-1.33)

352 0.98

(0.79-1.21)

294 1.26

(1.00-1.59)

0.16

Stroke81 1.13

(0.73-1.76)

258 1.50

(1.17-1.92)

237 1.21

(0.93-1.58)

0.97

Death 164 0.70

(0.51-0.96)

465 1.05

(0.87-1.26)

445 1.14

(0.94-1.37)

0.06

Global Index

556 0.96

(0.81-1.14)

1378 1.08

(0.97-1.20)

1134 1.14

(1.02-1.29)

0.09

Rossouw

et al. JAMA 2007;297:1465-1477

Events by Years Since Menopause in Combined Trials

<10 years<10 years

N= 7,137

1010--19 years19 years

N= 8,977

>>20 years20 years

N= 8,293

P for Trend

No. of Cases

HR

(95% CI)

No. of Cases

HR

(95% CI)

No. of Cases

HR

(95% CI)

CHD 90 0.76

(0.50-1.16)

216 1.10

(0.84-1.45)

352 1.28

(1.03-1.58)

0.02

Stroke64 1.77

(1.05-2.98)

179 1.23

(0.92-1.66)

255 1.26

(0.98-1.62)

0.36

Death 120 0.76

(0.53-1.09)

291 0.98

(0.78-1.24)

507 1.14

(0.96-1.36)

0.51

Global Index

425 1.05

(0.86-1.27)

922 1.12

(0.98-1.27)

1307 1.09

(0.98-1.22)

0.82

Rossouw

et al. JAMA 2007;297:1465-1477

Age and Years Since Menopause

! Short-term use of HT has no apparent benefit or harm in CHD risk in younger women close to menopause

! Increased risk of stroke (and breast CA) in women closer to menopause

!

Screen for and treat risk factors for CVA before starting HT

! Increased risk of CHD for older women "20 years from menopause, particularly those with vasomotor symptoms

!

Vasomotor sxs

in older women may be a marker of increased CHD risk

Conclusions on HT

! HT should not be initiated (or continued) for the express purpose of preventing cardiovascular disease in either younger or older postmenopausal women

! The current recommendations are that hormone therapy be limited to the treatment of moderate-to-severe menopausal symptoms, with the lowest effective dose used for the shortest duration necessary

Symptoms

! Chest pain is most common symptom in men and women

! Men tend to report chest pain more often

! In women, it’s not always the first or most significant symptom

! Women may experience more transient pain and may have more subtle differences in their description

!

heaviness

!

pressure

!

tightness

!

squeezing

!

sharp

!

stabbing

Symptoms

! SOB

! Nausea/Vomiting

! Transient non-specific chest discomfort

! Arm/shoulder pain, usually left-sided, but more often right sided than men

! Abdominal pain

! Indigestion

! Back pain or pain radiating to the back

! Neck pain

! Jaw pain

! Headache

! Fatigue

! Dizziness

! Loss of appetite

! Palpitations

! Cough

! Women report a greater number of less common symptoms

! Men report more chest pain, diaphoresis, belching, and hiccups

! Although equally likely to have exertional symptoms, more likely to report pain at rest, during sleep, or with mental stress

! Symptoms may be worse during menstrual period

Prodromal Symptoms

! 95% of women report prodromal symptoms

! Average 5 symptoms

! Most common are fatigue (71%), sleep disturbance (49%), SOB (42%), indigestion (40%), and anxiety (36%)

! Only 30% report chest discomfort

! General occur for at least a month prior to event

Non-invasive Testing

! Exercise treadmill testing

!

Lower specificity in women compared with men (higher false positive rate), but slightly higher sensitivity

! Stress echocardiography and nuclear perfusion scan

!

Sensitivity is similar to ETT (~80%), specificity better(~80%)

! CAC with EBCT or MDCT

!

Sensitive, but not specific for significant CAD

!

Radiation. Angio

based on CAC alone not currently recommended

! Cardiac MRI

!

Still not sufficient for coronaries, but may become more useful as a non-invasive study of the coronary microcirculation

Coronary Artery Disease

! Trends apparent across stable angina, unstable angina, NSTEMI, and STEMI

•

older at presentation (~5-10 years)

•

more comorbidities (hypertension, high cholesterol, diabetes)

•

more likely to have depression before and after their diagnosis

•

more likely to be in heart failure

•

more likely to have a history of angina (and more severe)

•

less likely to present with STEMI

•

more likely to have NO obstructive disease

Daly et al. Circulation 2006;113:490-498GUSTO IIb

trial. Hochman

et al. NEJM 1999;341:226-32Gan

et al. NEJM 2000;343:8-15Fang et al. Am J Cardiol 2006;97:1722-1726Anand

et al. JACC. 2005;46:1845-51 (post-hoc analysis of the CURE trial)

Coronary Artery Disease

! Trends apparent across stable angina, unstable angina, NSTEMI, and STEMI

•

later to present, slower to receive treatment

•

less likely to receive guideline-based medical therapy including aspirin and statins

•

less likely to have an angiogram or undergo revascularization

•

significantly higher rates of moderate or severe bleeding

•

more likely to have continued/recurrent angina after treatment

•

less likely to be referred for cardiac rehab

•

more death and MI at short-

and long-term follow-up

Daly et al. Circulation 2006;113:490-498GUSTO IIb

trial. Hochman

et al. NEJM 1999;341:226-32Gan

et al. NEJM 2000;343:8-15Fang et al. Am J Cardiol 2006;97:1722-1726Anand

et al. JACC. 2005;46:1845-51 (post-hoc analysis of the CURE trial)

Stages of CAD

Acute Coronary Syndromes (ACS)

Asymptomatic ! Stable angina ! USA ! NSTEMI ! STEMI

USA=unstable angina

NSTEMI=non-ST elevation myocardial infarction

STEMI=ST elevation myocardial infarction (big heart attack

STEMI

PCI (Percutaneous Coronary Intervention)

Angina

! 74 population samples of 13,331 angina cases in 199,494 women and 11,511 cases in 201,821 men from 31 countries, 5 countries being English speaking

! Angina is more prevalent among women than men (pooled random-effects sex ratio of 1.20 (95% CI 1.14 to 1.28, P<0.0001)).

! Ratio was 1.40 (95% CI 1.28 to 1.52) among Americans (non-whites>whites)

Hemingway et al. Circulation 2008;117:1526-1536

Stable Angina

Daly et al. Circulation 2006;113:490-498

Stable Angina: after visit to cardiologist

! Of patients having an angiogram, 63% of women and 87% of men hadsignificant CAD (p<0.001)

! Women had more single vessel disease (46% vs. 30%)

! Men had more double/triple vessel disease (32%/38% vs. 22%/32%)

! Among patients with proven CAD, women were less likely to be revascularized (adjusted OR 0.70, 95% CI 0.52 to 0.94, p=0.019) or to receive statins and antianginal drugs

Stable Angina: one year follow-up

! Women with confirmed CAD were

!

more likely to have continued angina (57% vs. 47%, p=0.007)

!

Suffered more death and MI

Cumulative probability of death or MI

USA & NSTEMI: Early Invasive vs. Conservative

! Three major randomized, controlled trials with sex data

!

FRISC II

!

RITA-3

!

TACTICS-TIMI 18

Lagerqvist

et al. J Am Coll

Cardiol

2001;38:41-8

USA & NSTEMI: Early Invasive vs. Conservative

! Higher risk women benefit similarly to men from an early invasive strategy, whereas lower risk women may have excess events

MACE events at 180 days in higher risk

patients

Glaser et al. JAMA 2002;288:3124-3129 (TACTICS-TIMI 18)

STEMI

Variable Men n=740

Women n=308

p- value

Age (mean) 57.21 64.45 <0.01Diabetes 18.78 25.65 0.01History of Congestive Heart Failure 3.78 9.09 <0.01Hypertension 53.78 68.83 <0.01Cardiogenic Shock 8.11 18.83 <0.01OutcomesMortality 3.11 7.47 <0.01Re-infarction 0.95 1.62 0.35Median Time to TreatmentSymptom Onset to Door (min) 84.0 97.0 0.02Door to Balloon (min) 105.0 118.2 <0.01PCI within 90 min 35% 26% 0.006

Moscucci

et al. AHA abstract 2004

STEMI

! Later presentation, slower treatment

! Less thrombolysis, aspirin, and cath

! Less likely to be admitted to a hospital capable of revascularization (45% vs. 52%, p<0.001)

! Less likely to undergo revascularization when admitted to a capable hospital (54% vs. 60%, p<0.001)

! Higher adjusted short-term mortality

Characteristic Women (n = 68,108) Men (n = 70,848) p Value

Time to EKG – min 37.2 ± 50.0 33.5 ± 48.9 <0.001

Chest pain >6 hr before arrival 30.8% 27.6% <0.001

Gan

et al. NEJM 2000;343:8-15Fang et al. Am J Cardiol 2006;97:1722-1726

When Guidelines are Followed

Novack

et al. Am J Med 2008;121:597-603

Symptoms and D2B-Case

! 62 yo Tongan woman arrives in ER at 0129

! PMHx: DM, htn, dyslipidemia, obesity, CRI

! Complains of 1-2 hours of constant, nonradiatingchest/epigastric pain, weakness, diaphoresis, headache, SOB, N/V, palpitations, and light-headed. No cough, fevers, or chills. BP 220/110.

EKG

Sequence of Events

! ASA at 0205, serial SLNTG

! STEMI call at 0211

! Interventional Fellow consenting at 0230

! Heparin bolus at 0239, Aggrastat at 0253

! Patient arrives cath lab at 0305

! Sheath in at 0313, left coronary images 0324

! Balloon inflated at 0336

! D2B = 127 minutes

Angiogram

Peak TnI

0.9, peak CKMB 5.6, peak total CK 256

Predictors of D2B Delay

Angeja

et al. Am J Cardiol

2002;89:1156-1161, NRMI data

40K patients who underwent primary angioplasty for MI

Delay with EMS

! Women are 50% more likely to be delayed in the EMS setting

Concannon

et al. Circ Cardiovasc Qual Outcomes. 2009;2:9-15

Relative impact of delayed D2B time in women

! Delays in D2B time have a greater impact on late mortality in women compared with men

Brodie

et al. JACC 2006;47:289-295

STEMI: Younger Women

! Younger women present later, have more diabetes, and are sicker (higher Killip class, lower SBP)

! They have more complications such as hypotension, heart failure, cardiogenic shock, and major bleeding, and are less likely to undergo angiography and revascularization

OR for Death during Hospitalization for MI in Women vs. Men

Vaccarino

et al. NEJM 1999;341:217-25

STEMI: Long-term Survival

Alter et al. J Am Coll

Cardiol

2002;39:1909-16

Depression after an MI

! Following an MI, the prevalence of major depression is higher inwomen than men, with younger women have the highest prevalence of depression (40%)

Prevalence of Depression by Age and Sex

0

5

10

15

20

25

30

35

40

45

50

!60 >60Age

Patie

nts

with

Dep

ress

ion,

%

menwomen

Mallik, S. et al. Arch Intern Med 2006;166:876-883

PCI: NHLBI Dynamic Registry

! Shows improving outcomes (in-hospital mortality)

!

1985-1986: Adjusted OR 4.53, 95% CI 1.39-14.7

!

1997-1998: Adjusted OR 1.60, 95% CI 0.76-3.35

! Most recent analysis includes BMS and DES (2001-2004)

!

Attempted lesions in women had a smaller reference vessel diameter than those in men in both BMS and DES

!

Men had more vein graft PCIs

!

Otherwise, similar angiographic characteristics

Abbott et al. Am J Cardiol 2007;99:626-631

PCI: NHLBI Dynamic Registry

! No sex difference in death or MI in-hospital or at one year

! No sex difference in IIb/IIIa or antiplatelet therapy

! No sex difference in stent thrombosis rates

! Women have more vascular access site complications (p<0.001)

One-year event rates for repeat PCI

PCI Complications

! Bleeding complications more common in women (RPH, bleed requiring transfusion, hematoma requiring repair or prolonged hospital stay)

! Coronary vascular injury seen in younger women (intimal tear, dissection, acute occlusion, or side branch closure)

Argulian

et al. Am J Cardiol

2006;98:48-53

RPH — Independent Predictors

! Smaller body surface area (BSA <1.73m2)

! High puncture

! Being a woman (73% were ")

! Use of a IIb/IIIa inhibitor*

Farouque

et al. JACC 2005;45:363-8 *Significant in Whitlow et al, CCI 2006n=28,378

IIb/IIIa Inhibitors

! Women benefit from IIb/IIIa inhibitor use similar to men

! But women have higher rates of bleeding

Cho et al. J Am Coll

Cardiol

2000;36:381-6 (Pooled analysis of EPIC, EPILOG, and EPISTENT)

p < 0.001 for both "

and # p = 0.004 for major bleeding eventp < 0.001 for minor bleeding events

IIb/IIIa Inhibitors

! Women have more bleeding whether or not IIb/IIIainhibitors are used, however, 25% of the bleeding risk in women is attributable to excess dosing

Alexander et al. Circulation 2006;114:1380-1387

Radial vs. Femoral Access

! 3261 consecutive interventional and/or diagnostic procedures

! Major bleeding (A)

!

RPH or death

!

Required surgical intervention

!

Required blood transfusions

!

Hg <4g/dl

!

Hematoma >50% of the limb, associated with pt. discomfort and prolonged hospital stay

! Minor bleeding (B)

!

All other puncture-related hemorrhages

Pristipino

et al. Am J Cardiol

2007;99:1216-1221 *p=0.0008 vs. radial; **p=0.00001 vs. radial

Women=blackMen=gray

Effect Most Pronounced in Women

! The protective effects of transradial interventions are most pronounced in women

Rao

et al. J Am Coll

Cardiol

Intv

2008;1:379-86

CABG: In-hospital Mortality

! Women have higher in-hospital mortality than men, as well as higher rates of postoperative MI, neurologic complications, and renal failure. This is particularly true for younger women

Vaccarino

et al. Circulation 2002;105:1176-1181

CABG: Outcomes

! After CABG, women are more likely to be readmitted than men, typically for unstable angina and CHF rather than MI

! Overall, women have similar or better long-term survival than men, but are more likely to have recurrent angina and lower QOL

Humphries et al. J Am Coll Cardiol 2007;49:1552-8Guru et al. Circulation 2006;113:507-16

! The 30 day mortality after CABG decreased significantly from 1991-2004, particularly in women

! Increased use of arterial grafts

Pathophysiology: Non-obstructive CAD

Up to 20% of symptomatic patients presenting for coronary angiography will have no significant coronary artery disease on angiography

While ~60% are women, nearly 40% are men

Pathophysiology

! Women presenting with symptoms suggestive of angina are significantly less likely than men to have angiographic evidence of obstructive CAD

!

Women tend to get more diffuse atherosclerosis

!

Women frequently have evidence of microvascular disease

!

Women frequently have evidence of endothelial dysfunction

!WISE Study (Women’s Ischemic Syndrome Evaluation)

!Sponsored by AHA/NHLBI

!Four-center project, ~1000 women (mean age 59±12 years) enrolled. Women were presenting with suspected ischemia and were referred for elective coronary angiography.

NOT A BENIGN PATHOLOGYAssociated with long-term CV events and death

Sex Differences Research

Is there truly a sex difference in

coronary pathophysiology?

Plaque Distribution

! A long, diffuse lesion that is moderately narrowed can cause a similar reduction in distal flow as a short, focal lesion that is severely narrowed

Case

! 60 yo woman

! Hypertension

! Recent presentation to ER with CP, ruled out

! Stress echo: mid-distal anterior and apical ischemia

! Movie Removed

IVUS

! MLA 2.7mm2

! 24-26mm long! Movie Removed

Post-stent

! 2.5 x 28mm Cypher stent

! Post-dilated with a 2.75mm balloon.

! Movie Removed

The Coronary Microcirculation

The resistance vessels are all lined by a single layer of endothelial cells

Microcirculatory Dysfunction

! FFR 0.86

! CFR 1.6

! IMR 35

! Adenosine (endothelium-independent vasodilator) induces hyperemia

! CFR: (normal " 2.5)

hyperemic coronary flow

resting coronary flow

! IMR: (normal < 20)

distal coronary pressure

hyperemic coronary flow

Microcirculatory Dysfunction

IMR: 63 x 0.52 = 32.8

Endothelial Dysfunction

All major cardiac risk factors have been found to associated with endothelial dysfunction in a cumulative fashion.

Endothelial dysfunction is at least partially reversible through risk factor modification.

Case

! 48 yo woman

! No significant risk factors except a 15-pack yr hx of tobacco use 18 years ago

! Low stamina and excessive tachycardia with exercise for the past year

! VO2 stress echo ! anterior ischemia

! Cath lab

!

Normal appearing coronary arteries on angiography

!

Only minimal plaque on IVUS

!

Mild microvascular disease (IMR 23)

!

Tested endothelial function

Endothelial Dysfunction

!Movie Removed

Example Patient

! Started Imdur 30 mg daily

! Decreased max. exertional heart rate from 180s to 160s

! Increased running distance from 0.5 to 2 miles

! Decreased running time from 14 min/ml to 11-12 min/ml

! More energy after work-outs

Sex Differences in Atheroma Burden and Vascular Function Abnormalities

Han et al. Eur

Heart J 2008;29:1359-1369

Summary

! Focus on exercise, weight reduction, avoidance of insulin resistance/diabetes, hypertension, and ! triglycerides and " HDL

! Hormone Therapy: Smallest dose, shortest duration

! Aspirin for 1° prevention of MI or CV death if " 65

! Be attuned to “atypical” symptoms

! Women tend to be older, present later and sicker, have less extensive CAD, have more complications (particularly bleeding), and more recurrent/refractory symptoms

! Post-PCI/Post-MI/Post-CABG!

Standard medical care (ASA, b-blocker, statin, ACE inhibitor, Plavix)!

Continued aggressive risk factor modification!

Rehab (!)!

Depression/Stress

Summary

! Throughout care, treat a woman like a woman (except when we know there’s a benefit to treating her like a man)

!

New paradigm

!

Key to ultimately changing outcomes

www.womensheart.stanfordhospital.com

(and Monterey)

Thank You