Women and Heart Disease: The Primary Care Perspective

1
Women and Heart Disease The Primary Care
Perspective

• Len Fromer, MD
• Assistant Clinical Professor
• Department of Family Medicine
• UCLA School of Medicine
• Los Angeles, California

Disclosures Keynote Speaker Astellas Pharma
US, Inc.
2
Leading Cause of Death in Women
National Heart, Lung, and Blood Institute. The
Healthy Heart Handbook for Women. 2005.
3
Undertreatment in Women, Despite Increased
Prevalence

• Less cholesterol screening
• Less use of lipid-lowering therapies
• Less use of heparin, beta-blockers, and aspirin
  during myocardial infarction
• Fewer referrals to cardiac rehabilitation

Chandra NC, et al. Arch Intern Med.
1998158981-988. Nohria A, et al. Cardiol Clin.
19981645-57. Scott LB, Allen JK. J Cardiopulm
Rehab. 200424387-391. OMeara JG, et al. Arch
Intern Med. 20041641313-1318. Hendrix KH, et
al. Ethn Dis. 20051511-16.
4
Undertreatment in Women Role of the PCP and
OBGyn

• Increased prevention
• Screening in the primary care setting
• Includes OBGyns acting as PCPs
• Increased treatment
• Increased referral to cardiologists

5
When to Refer to a Cardiologist

• Assess risk level based on age, sex, total and
  LDL cholesterol, smoking, and systolic blood
  pressure
• Low
• Intermediate
• High
• Consider referral with intermediate- and
  high-risk patients
• Assess the ability of the current primary care
  practice to meet the patients needs
• Physician comfort level
• Tyranny of the urgent
• Staff training and facilities
• Consider consultation as an alternative to
  referral
• Develop a standing relationship with a cardiology
  practice

6
US 2004 Visits to PCPs by Gender
Percent
Of female visits to PCPs, 90.1 were for
preventative care. In men the percentage for
preventative care was 81.2.
Hing E, et al. Available at http//www.cdc.gov/nch
s/data/ad/ad374.pdf. Accessed 9/26/06.
7
Encouraging Participatory
Patient-Physician Decision Making

• Understand the patients and family members
  experience and expectations
• Build partnership
• Provide evidence
• Include a balanced discussion of uncertainties
• Present recommendations
• Check for understanding and agreement

Epstein RM, et al. JAMA. 20042912359-2366.
8
Women and Health Care Decision-Making

• Women often play a central role in family health
  care decisions
• According to a recent health insurance industry
  survey
• 79 of mothers are responsible for choosing
  childrens doctors
• 84 are responsible for taking children to
  doctors appointments
• 78 are responsible for ensuring children receive
  recommended care

Kaiser Family Foundation. Women and Health Care
A National Profile, July 2005.
9
Preventing CHD in Postmenopausal Women

• OBGyns provide primary health care for many
  postmenopausal women
• OBGyns should take a greater role in CHD risk
  management
• CHD risk factors in women are well established
• Risk-factor management must be incorporated into
  routine primary care practice

Welty FK. Menopause. 200411484-494.
10
Promoting Early Diagnosis The Importance of
Screening
Framingham NCEP ATP III10-year Absolute Risk of
CAD
The Framingham-based risk calculator measures
risk of angina, myocardial infarction, or
coronary death within 10 years using a system
that includes LDL cholesterol, age, sex, total
cholesterol, smoking, and systolic blood pressure.
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA. 20012852486-2497.
11
Physician CVD Prevention Guideline Awareness

• Online study of 500 physicians
• 300 primary care
• 100 obstetricians/gynecologists
• 100 cardiologists
• Questionnaire assessed awareness and adoption of
  CVD prevention guidelines by specialty
• 3 national CVD prevention guidelines used
• NCEP ATP III
• JNC 7
• AHA Evidence-Based
• Physician accuracy at assigning CVD risk level
  assessed

Mosca L, et al. Circulation. 2005111499-510.
12
Physician Awareness of CVD Prevention by
Specialty

Plt.001
Plt.001
Plt.001
Plt.001
Plt.001
Plt.001
Mosca L, et al. Circulation. 2005111499-510.
13
Physician Incorporation of CVD Prevention
Guidelines Among Aware Respondents
Plt.001
Plt.001
Plt.001
Plt.001
Plt.01
Plt.01
Mosca L, et al. Circulation. 2005111499-510.
14
Physicians Recommendations on Lifestyle,
Supplement, and Aspirin by Specialty and Patient
Risk Level
Intermediate Risk
High Risk
Low Risk




Plt.05, PCPs vs OBGyns and cardiologists. Plt.05,
OBGyns vs PCPs and cardiologists. Plt.05, OBGyns
vs cardiologists.
Mosca L, et al. Circulation. 2005111499-510.
15
Identification of Optimal Levels of
Lipid/Glycemic Control by Patient Gender and
Physician Specialty
Male Patients
Female Patients







Values are mg/dL
Plt.05, cardiologists vs PCPs. Plt.05,
cardiologists vs PCPs and OBGyns. Plt.05, PCPs vs
cardiologists. Plt.05, PCPs and cardiologists vs
OBGyns. Plt.05, cardiologists vs OBGyns.
Mosca L, et al. Circulation. 2005111499-510.
16
Correct Categorization of Risk by Specialty
Male Patients
Female Patients
There was a significant influence of gender on
assignment of risk category by PCPs (OR, 0.62
95 CI, 0.49 to 0.78) there was a similar but
nonsignificant trend for OBGyns and cardiologists.
Mosca L, et al. Circulation. 2005111499-510.
17
Physician CVD Prevention Guideline Awareness

• OBGyns in this study provide primary care to 67
  of their patients
• An opportunity exists for OBGyn education
  andidentification of CVD in women
• Cardiologists may be more effective at
  identifying optimal levels of lipid/glycemic
  control vs PCPs or OBGyns
• Collaboration between physician specialties could
  improve CVD prevention and treatment

Mosca L, et al. Circulation. 2005111499-510.
18
Parallel Care vs Serial Care Model

• Parallel care model (preferred)
• After a referral for cardiac disease, the PCP
  continues to care for the entire patient, even
  the cardiac problem
• The cardiologist provides crucial input in
  parallel with the PCPs overall care
• Serial care model
• The patient is cared for by the cardiologist
  while the cardiac problem is addressed
• The patient is then sent back to the PCP

19
Heart Disease in Primary Care

• PCPs may not always be comfortable following
  AHA/ACC guidelines
• Practice guidelines do not assure changes in
  physician behavior, such as data sharing (for
  example, test reports)
• Could benefit from communication and
  collaboration with cardiologists

Cabana M, Kim C. Womens Health Issues.
200313142-149.
20
Barriers and Interventions
Cabana M, Kim C. Womens Health Issues.
200313142-149.
21
Barriers and Interventions
Cabana M, Kim C. Womens Health Issues.
200313142-149.
22
Heart Failure in Primary Care

• Heart failure is prevalent in women and generally
  treated in primary care. A recent UK survey
  (conducted in 15 countries) assessed how PCPs
  believe heart failure should be managed
• 1363 physicians provided data for 11,062 patients

Cleland J, et al. Lancet. 20023601631-1639.
23
Primary Care Perceptions of Drug Effectiveness
and Treatment Aims
Physicians were aware of ACE inhibitor benefits,
less aware of beta-blockers. Slowing disease
progression was the main therapeutic aim.
Cleland J, et al. Lancet. 20023601631-1639.
24
Percentage of Patients Receiving an ACE Inhibitor
at or Above Target Dose
Doses were about 50 of the target doses
suggested in European guidelines.
Cleland J, et al. Lancet. 20023601631-1639.
25
Heart Failure in Primary Care

• Physicians well informed about ACE inhibitor
  benefits, lesser awareness of beta-blockers
• Up to 90 of patients diagnosed with heart
  failure receive correct investigations
• Possibly due to high hospital admission rate in
  this study
• Actual treatment suboptimal
• 60 of patients received ACE inhibitor
• Only 20 received ACE with beta-blocker
• Heart failure knowledge and resources adequate,
  actual care lagging
• Better care coordination needed, such as
  consultation with cardiologists

Cleland J, et al. Lancet. 20023601631-1639.
26
Specialist Intervention Influence on PCP Care of
MI and Heart Failure

• 509 patients with MI, 323 patients with heart
  failure
• Two PCP groups assessed with or without
  guideline compliance
• PCP records reviewed over 6 months to assess
  guideline compliance
• Seven measures of MI care
• Eight measures of heart failure care
• Subgroup of PCPs who followed practice guidelines
  assessed with or without cardiologist
  collaboration

Guadagnoli E, et al. Am J Med. 2004117371-379.
27
Cardiologist Influence on PCP Care of MI

100
90


80
70
60
Cases Meeting Performance Criteria
50
40
30
20
10
0
ACE
Aspirin
Left VEF
Composite
Depression
Beta-blocker
Cholesterol test
Smoking cessation
PCPs Only
PCPs/Cardiologists
Plt.0001. VEF ventricular ejection fraction
Guadagnoli E, et al. Am J Med. 2004117371-379.
28
Cardiologist Influence on PCP Care of Heart
Failure





Cases Meeting Performance Criteria
Plt.0001. P.01. P.0004. VEF ventricular
ejection fraction.
Guadagnoli E, et al. Am J Med. 2004117371-379.
29
Cardiologist Influence on
PCP Care of Heart Failure

• Treatment better for patients seen by both PCPs
  and cardiologists
• Approximately half of patients with MI and 40
  of those with heart failure saw a cardiologist
  after hospital discharge
• Care for patients with MI or heart failure is
  improved when a cardiologist is involved

Guadagnoli E, et al. Am J Med. 2004117371-379.
30
Heart Failure in Primary Care

• Heart failure (HF) disease management program
  (DMP), 4 patients w/advanced HF and low ejection
  fractions almost fully recovered at 4-45 months
• With later PCP treatment, symptom relapse and
  left ventricular function deterioration occurred
  in all
• Readmission to the HF DMP reinstated improvement

Saucier N, et al. Am J Cardiol. 20069253-255.
31
Heart Failure in Primary Care

• 113 patients with confirmed left ventricular
  systolic dysfunction randomized to specialist or
  primary care
• ACE inhibitors (85 vs 64) and beta-blockers
  (50 vs 2) higher in specialist care patients

Rao A, Walsh J. Int J Cardiol. 2006 Jun 28 Epub
ahead of print.
32
Roads to Collaboration

• Prevention, screening, and care is improved by
  PCP/specialist collaboration
• Local opinion leader advocacy can help change
  physician practice and encourage collaboration1

1. Mittman BS, et al. QRB Qual Rev Bull.
199218413-422.
33
Roads to Collaboration

• CME or educational programs (such as this one)
  combining the efforts of cardiologists and PCPs
  can help, particularly if a mixed cardio/PCP
  audience attends
• Review articles emphasizing collaboration with
  cardiologists published in PCP journals may
  encourage collaboration
• Awareness of heart disease in women needs to be
  improved in all physician specialties