Cardiovascular Disease in Women

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Cardiovascular Disease in Women
Amy Epps, MD Jean Nappi, PharmD, BCPS Christine
Mancine, RN, CNL
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Cardiovascular Disease in Women Why the Hype?

• Amy Epps, MD

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Cardiovascular Disease Mortality Trends for
Males and Females
United States 1979-2003
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Mortality In Women

• Heart disease is the 1 cause of death of
  American women and kills 32 of them.
• 43 of deaths in American women, or nearly
  500,000, are caused by cardiovascular disease
  (heart disease and stroke) each year.
• 267,000 women die each year from heart attacks,
  which kill six times as many women as breast
  cancer.
• 31,837 women die each year of congestive heart
  failure, or 62.6 of all heart failure deaths.

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Is women's health risk due to gender difference
or gender bias?

• In the past, many of the major cardiovascular
  research studies were conducted on men. 
• Both women and men may present classic chest
  pain that grips the chest and spreads to the
  shoulders, neck or arms.  Women may have a
  greater tendency to have atypical chest pain or
  to complain of abdominal pain, difficulty
  breathing (dyspnea), nausea and unexplained
  fatigue.
• Women may avoid or delay seeking medical care,
  perhaps out of denial or not being aware of both
  typical and atypical heart attack symptoms.

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• Some diagnostic tests and procedures may not be
  as accurate in women, so physicians may avoid
  using them. 
• The exercise stress test may be less accurate in
  women.  For example, in young women with a low
  likelihood of coronary heart disease, an exercise
  stress test may give a false positive result.  In
  contrast, single-vessel heart disease, which is
  more common in women than in men, may not be
  picked up on a routine exercise stress test.
• More precise noninvasive and less invasive
  diagnostic tests tend to cost more. These include
  thallium, sestamibi or echocardiographic stress
  tests.

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Prevalence in Women

• 8 million American women are currently living
  with heart disease - 10 of women ages 45 - 64
  and 25 age 65 and over.
• 6 million of women today have a history of heart
  attack and/or angina or both.
• 13 of women age 45 and over have had a heart
  attack.
• 435,000 American women have heart attacks each
  year 83,000 are under age 65 and 9,000 are under
  age 45. Their average age is 70.4.
• 4 million women suffer from angina, and 47,000 of
  them were hospitalized in 1999

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Compared with Men

• 38 of women and 25 of men will die within one
  year of a first recognized heart attack.
• 35 of women and 18 of men heart attack
  survivors will have another heart attack within
  six years.
• 46 of women and 22 of men heart attack
  survivors will be disabled with heart failure
  within six years.
• Women are almost twice as likely as men to die
  after bypass surgery.
• More women than men die of heart disease each
  year, yet women receive only
• 33 of angioplasties, stents and bypass surgeries
  
• 28 of inplantable defibrillators and
• 36 of open-heart surgeries

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At Risk Women

• The age-adjusted rate of heart disease for
  African American women is 72 higher than for
  white women, while African American women ages
  55-64 are twice as likely as white women to have
  a heart attack and 35 more likely to suffer from
  coronary artery disease.
• Women who smoke risk having a heart attack 19
  years earlier than non-smoking women.
• Women with diabetes are two to three times more
  likely to have heart attacks.

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Warning Signs

• Chest discomfort. Most heart attacks involve
  discomfort in the center of the chest that lasts
  more than a few minutes, or that goes away and
  comes back. It can feel like uncomfortable
  pressure, squeezing, fullness or pain.   
• Discomfort in other areas of the upper
  body. Symptoms can include pain or discomfort in
  one or both arms, the back, neck, jaw or
  stomach.   
• Shortness of breath. May occur with or without
  chest discomfort.  
• Other signs These may include breaking out in a
  cold sweat, nausea or lightheadedness       

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• As with men, women's most common heart attack
  symptom is chest pain or discomfort. But women
  are somewhat more likely than men to experience
  some of the other common symptoms, particularly
  shortness of breath, nausea/vomiting, and back or
  jaw pain.

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Acute Myocardial Infarction in Women

• Female AMI patients are generally 5 to 10 years
  older and have more comorbidities than male AMI
  patients
• During AMI, women are less likely to experience
  chest pain than men, and may delay getting to the
  hospital for treatment
• Women thrombosis due to plaque erosion than
  postmenopausal women
• Younger female AMI patients have a higher
  in-hospital mortality than men of the same age
  and older female AMI patients
• Women often have higher short-term mortality
  rates than men largely due to their older age and
  increased comorbidities (diabetes, heart failure,
  depression)
• After age adjustment, women generally experience
  similar long-term mortality rates as men
• Women are often underprescribed AMI discharge
  medications, including aspirin and beta blockers

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Unstable Angina/NSTEMI in Women

• UA/NSTEMI is the most common cause of cardiac
  hospital admissions
• Women presenting with UA/NSTEMI have worse
  clinical profiles, but less extensive CAD
  compared with men
• Women with ACS are more likely to present with UA
  than MI
• Women with UA/NSTEMI are more likely to present
  with atypical symptoms than men
• It is unclear whether female UA/NSTEMI patients
  managed medically benefit from the use of GP
  IIb/IIIa inhibitors
• High-risk patients including women benefit from
  an early invasive strategy
• It is unclear whether a routine invasive strategy
  is beneficial in women and/or lower-risk patients
  
• The prognosis of women with UA/NSTEMI is as good
  as or better than that of men

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Stable Angina in Women

• More women than men report angina pain in the
  shoulder and middle back, as well as the throat,
  neck, and jaw
• Women describe their angina using a more
  emotional presentation than men, calling the pain
  hot-burning or tender and rating it as more
  intense than men
• More women than men suffer from chronic stable
  angina
• The female stable angina patient is usually older
  than the male stable angina patient and more
  often has diabetes
• Compared with men, women with stable angina tend
  to receive fewer diagnostic tests, fewer
  prescriptions for recommended medications, and
  fewer interventional procedures
• Women have a worse prognosis than men in terms of
  relief from angina pain after treatment

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• Statistics complied fromNational Center on
  Health Statistics National Heart, Lung and Blood
  Institute and American Heart Association's 2002
  Heart and Stroke Statistical Update

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Therapeutic Issues Related to Cardiovascular
Disease in Women
Jean Nappi, PharmD, FCCP, BCPS
Professor, Department of Pharmacy and Clinical
Sciences South Carolina College of Pharmacy, MUSC
campus Clinical Pharmacy Specialist, Cardiology
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www.goredforwomen.org
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www.goredforwomen.org
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Determine 10-year Risk for CHD Event
Category of Risk Significance Higher
Risk 20 chance of a CHD event within 10
years Intermediate Risk 10-20 chance of CHD
event within 10 years Lower risk chance of CHD event within 10 years
Circulation 2004109672-93
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Determine 10-year Risk for CHD Event

• Higher Risk (20)
• Established CHD
• Any atherosclerotic disease
• Diabetes
• Chronic kidney disease
• Framingham risk
• score 20

Circulation 2004109672-93
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Determine 10-year Risk for CHD Event

• Higher Risk (20)
• Established CHD
• Any atherosclerotic disease
• Diabetes
• Chronic kidney disease
• Framingham risk
• score 20

• Intermediate Risk
• (10-20)
• First-degree relative(s) with early-onset
  atherosclerotic disease
• Marked elevation of a single risk factor
• Framingham risk score 10-20

Circulation 2004109672-93
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Determine 10-year Risk for CHD Event

• Intermediate Risk (10-20)
• First-degree relative(s) with early-onset
  atherosclerotic disease
• Marked elevation of a single risk factor
• Framingham risk score 10-20
• Lower risk (
• Framingham risk score

• Higher Risk (20)
• Established CHD
• Any atherosclerotic disease
• Diabetes
• Chronic kidney disease
• Framingham risk
• score 20

Circulation 2004109672-93
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How to Calculate a Framingham Risk Score

• Data needed
• Age
• HDL cholesterol
• Total cholesterol
• Systolic blood pressure
• treated or not with anti-HTN medications
• Smoking status
• Go to
• Circulation 2004109672-93
• www.goredforwomen.org

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Optimal Risk Category

• Optimal Risk
• Framingham risk score
• Optimal levels of risk factors
• Blood pressure
• Blood glucose-HbA1c
• LDL 50 mg/dL, TG
• BMI 18.5 25 kg/m2
• Heart-healthy lifestyle
• No smoking
• Physical activity
• Heart-healthy diet

Circulation 2004109672-93
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Implement AppropriateCVD Prevention Strategy

• Lower Risk (
• Treat specific risk factors per guidelines if
  present (HTN, Lipids)
• 1. Smoking cessation/environmental smoke
  avoidance
• 2. Physical activity
• 30 minutes of moderate-intensity activity (brisk
  walking) most days/week
• 3. Heart-healthy diet
• 4. Weight maintenance/reduction to BMI

Circulation 2004109672-93
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Heart Healthy Dietwebsitecirc.ahajournals.org/cg
i/content/full/106/25/3253

• Fruits
• Vegetables
• Grains (preferably whole grain)
• Lowfat/nonfat dairy products
• Fish
• Proteins low in saturated fat
• Poultry
• Lean meats
• Legumes (beans, peas, lentils, peanuts, soy
  products)
• Saturated fat
• No trans fatty acids
• Cholesterol

Circulation 2004109672-93
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Implement AppropriateCVD Prevention Strategy

• Intermediate Risk (10-20)
• Smoking cessation, physical activity, heart
  healthy diet, weight maintenance/reduction
• Blood pressure management (optimum
• Minimum goal
• DM or chronic kidney disease minimum goal 130/80
• In general, a thiazide should be used
• Dietary sodium intake
• Lipid management
• Initiate if LDL ? 130 mg/dL despite Step 1
  (statin preferred)
• Aspirin 75-162 mg/day (conditionally)

Circulation 2004109672-93
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Implement AppropriateCVD Prevention Strategy

• Higher risk ( 20)
• Smoking cessation, physical activity, heart
  healthy diet, weight maintenance/reduction,
  cardiac rehabilitation classes (if known CHD)
• If present, treat DM to HbA1c
• Blood pressure management
• Lipid management
• Saturated fat
• Cholesterol
• Initiate statin regardless of LDL level
• Aspirin 75-162 mg/day
• ACE inhibitor therapy
• ?-blocker therapy if history of MI or angina

Circulation 2004109672-93
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Discourage Inappropriate Therapies

• Should not be used for the prevention of CVD
• Vitamin E
• Vitamin C
• ? carotene
• Hormone therapy in postmenopausal women

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The Facts about Postmenopausal Hormone Therapy

• Estrogen Progestin
• (for women with a uterus)
• treat menopausal symptoms
• prevent bone loss (delay osteoporosis)
• improve cholesterol levels

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The Facts about Postmenopausal Hormone Therapy

• Compared to those taking no hormones, for every
  10,000 women taking Estrogen Progestin there is
  on an annual basis
• 8 additional cases of breast cancer
• 7 more cases of heart disease
• 8 more strokes
• 8 more pulmonary emboli

N Engl J Med 2003349523-34
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The Facts about Postmenopausal Hormone Therapy

• Compared to those taking no hormones, for every
  10,000 women taking Estrogen Progestin there is
  on an annual basis
• 8 additional cases of breast cancer
• 7 more cases of heart disease
• 8 more strokes
• 8 more pulmonary emboli
• 5 fewer hip fractures
• 6 fewer cases of colorectal cancer

N Engl J Med 2003349523-34
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The Facts about Postmenopausal Hormone Therapy

• Compared to those taking no hormones, for every
  10,000 women taking Estrogen Progestin there is
  on an annual basis
• 8 additional cases of breast cancer
• 7 more cases of heart disease
• 8 more strokes
• 8 more pulmonary emboli
• 5 fewer hip fractures
• 6 fewer cases of colorectal cancer
• 23 more cases of dementia (in women 65)

N Engl J Med 2003349523-34 JAMA 20032892651-62
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The Facts about Postmenopausal Hormone Therapy

• Estrogen alone
• (women with hysterectomy)
• No increase in breast cancer
• No increase in heart disease
• Small increase in venous thromboembolism
• Small increase in dementia
• Similar increase in stroke to Estrogen Progestin

Arch Intern Med 2006166772-780 Circulation
20061132425-2434 JAMA 20042912947-2958
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Unanswered Questions

• Are the dangers the same for younger
  post-menopausal women?
• Average age was in the mid-sixties.
• Suggestion from post-hoc analyses that not
  detrimental in younger subgroups

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Hormone Therapy Recommendations

• Do not use to prevent CV disease
• Do not use in women with CV disease
• Useful for menopausal symptom relief
• Balance risks for the individual woman
• Use lowest effective dose
• Reassess necessity/usefulness periodically

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Useful Resources

• Smoking cessation
• surgeongeneral.gov/tobacco/treating_
  tobacco_use.pdf
• Weight management
• nhlbi.nih.gov/guidelines/obesity/ob_home.htm
• NCEP III Guidelines (Lipids)
• circ.ahajournals.org/cgi/reprint/106/25/3143.pdf
• JNC VII (Blood pressure)
• hyper.ahajournals.org/cgi/content/full/42/6/1206
• ADA Clinical Practice Recommendations 2006
• care.diabetesjournals.org/content/vol29/suppl_1/

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Patient Education Aspects of Women with Heart
Disease

• Christine Mancine, RN, CNL
• Patient / Family Educator, 9PCU
• Phone [phone]
• Pager 1-2777

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The sad, but true

• Heart disease is the number ONE cause of death
  for women in this country.
• When surveyed, 50 of women reported cancer as
  our countrys number one cause of death, with
  only 13 of them reporting coronary artery
  disease as the first cause.
• 1 of every 4 women, over the age of 65, has some
  form of heart disease.
• 8 times as many women die of heart disease each
  year than of breast cancer.

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And sadder yet, after menopause

• The rate of coronary artery disease, in women,
  increases 2 to 3 times.
• Women quickly begin to die at a rate equal to
  that of men.
• Estrogen replacement therapy, which was once
  thought to be cardio-protective may actually
  increase the risk of heart disease.
• Source Coronary Artery Prevention
• Whats Different for Women
• American Family Physician, April 2001

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Education can save lives

• Provide knowledge to enable patients to make
  informed decisions
• Decrease mortality by providing skills for
  primary prevention of heart disease
• Increase patient family understanding, while
  decreasing anxiety
• Correct misconceptions regarding healthcare

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They are going to blow up my heart with a
balloon.We need to listen to what our
patients say, so we may correct their
misconceptions, and help patients understand
their risk.
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Teach patients to know their risk

• Age risk of developing CAD in women greatly
  increases after menopause
• Family history of heart disease
• Hypertension
• High cholesterol diet, or high total cholesterol
  level with high LDL and low HDL levels
• Diabetes
• Lack of exercise
• Obesity
• Stress
• Ingesting tobacco products

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Risk Assessment for Women Without Known Coronary
Artery Disease

• Major Risk Factors (3 points each)
• Typical anginal pain _____
• Postmenopausal with hormone replacement
  therapy _____
• Diabetes _____
• Peripheral vascular disease _____
• Intermediate risk factors (2 points each)
• Hypertension _____
• Smoking _____
• High total cholesterol level _____
• Minor risk factors (1 point each)
• Patient age 65 _____
• Obesity _____
• Sedentary lifestyle _____
• Family history of coronary artery
  disease _____
• Stress _____

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Teach your Patients to Know the
SymptomsAtypical May Actually Be Typical

• Unusual fatigue or sleep disturbances which can
  occur up to one month prior to MI
• Feeling breathless, often without chest pain of
  any kind
• Flu like symptoms, especially nausea,
  clamminess or cold sweats
• Unexplained weakness or dizziness
• Pain in upper back, shoulders, neck or jaw
• Anxiety

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Women are more likely to disregard vague
symptoms.

• Educate your patients to call 911 or EMS in their
  area
• NEVER drive themselves to the hospital
• Prevention is the Key to decreasing CAD

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Healthy eating tips

• Encourage patients to maintain a low sodium, low
  cholesterol diet
• Encourage patients to have realistic goals in
  regards to their diet
• Remind patients that portion size and how their
  food is prepared is as important as what is eaten
• Recommend patients to strive to
• Keep total cholesterol level less than
  200mg/dL
• Keep HDL (High Density Lipoprotein) the
  good cholesterol at 40mg or higher
• Keep LDL (Low Density Lipoprotein) the bad
  cholesterol less than 100mg
• Keep Triglycerides less than 150mg

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Patient Quote of the Week

• I always take the skin off of my fried
  chicken, before I eat it.
• Once again, correct misconceptions
  patients have with respect to
• lifestyle changes.

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Calorie consumption

• How many calories are needed?
• Level of exercise Calories needed
• Less active (2 - 3 times per week) 13
• Moderately active (4 - 5 times per week) 15
• Very active (6 - 7 times per week) 18
• Healthy Body Weight____ x level of activity
  ____ calories needed
• Source MUSC Nutritional Guide 2006

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Fitness Highlights

• Exercise lowers blood pressure, raises HDL
  levels, and can help maintain a healthy weight
• Patients need to have aerobic exercise at least
  3 times per week for 20 - 30 minutes per workout
• Encourage your patients to start small, and
  work up gradually. Also to pick activities which
  they enjoy. If they hate to walk outside, they
  wont stick to it. Make it fun!

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Stress

• Excess stress can raise blood pressure, and for
  some people, make them overeat
• Teach your patients to be aware of their own
  triggers.
• Find positive activities which they enjoy and
  help reduce stress.
• Set limits and realistic goals
• Never be afraid to say no, or to ask for help

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Stress
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Tobacco Facts

• Smoking one pack of cigarettes per day triples
  the risk for dying from heart disease
• Two or more packs per day will reduce one minute
  off a persons life for every one minute he or
  she smokes
• Quitting, reverts the person's risk back to that
  of a non-smoker in 10 years

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Prevention
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Tips to help your patients quit

• Explain the risks of smoking and the benefits of
  no longer using tobacco products
• Encourage patients to make a plan, set a date,
  locate support, remove all tobacco and ashtrays
  from the house, and to implement the plan
• Provide support and encouragement to the patient
  to stick with it. Help patients to brain storm
  about other activities they can with their free
  time instead of smoking
• Teach patients to reward themselves in positive
  ways
• Teach patients, if they slip, it is okay, and to
  keep trying

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Resources

• Health Information Topics on Intranet
• Micromedex
• Patient/Family Education site
• Get Well Network
• Online Resources
• www.medlineplus.com
• www.heartcenteronline.com
• www.quitsmoking.com
• www.americanheart.org
• MUSC Print Shop
• Stop Smoking Guide OTC 801278