Cardiovascular Disease in Women: Common Myths

1
Cardiovascular Disease in Women Common Myths
Jon W. Wahrenberger, MD FAHA
February 7, 2009
2
Disclosures

• I have no financial interests to disclose I
  wish I did!
• I do not specialize in womens health issues, but
  about half of my patients are female.
• I cannot rule out the influence of my
  Y-chromosome
• As an only son and with 4 sisters I am expected
  to be sensitive to womens issues
• .but at any given time at least one of my
  sisters is annoyed with me about something.

3
Are women more complicated than men?
4
Hormones in Men vs. Women
5
Myth 1

• Cardiovascular disease is mainly a disease of old
  men

6
More women are dying of CVD than Men
Source American Heart Association
7
Cardiovascular disease is the leading cause of
death in women
Source American Heart Association
8
Although less frequent, CVD occurs in young women
More than35,000 women under the age of 65 die
annually in the US from CVD
9
Myth 2

• Women dont need to worry about cardiovascular
  disease before menopause

10
Relationship between early menopause and
accelerated CVD?
Traditional Paradigm
Menopause
Increasing Risk of CVD
Minimal or no CVD Risk
Alternative Paradigm
Increasing Risk of CVD
Menopause
11
Coronary heart disease progresses over decades
Decades of time
Smoking, High Blood Pressure, Elevated
Cholesterol, Diabetes, Inactivity, Obesity
Age, Heredity
The reality Being premenopausal probably does
not protect you from cardiovascular disease and
you should be vigilant at all ages
12
Myth 3

• Hormone replacement therapy is dangerous to the
  heart and should not be taken under any
  circumstances

13
Estrogen

• Critical to reproductive function in men women
• Most produced by ovaries
• Some arises from fat, liver, breasts, adrenals
• Complex physiologic effects

14
Changing Estrogen Levels with Age
Estrogen
Progesterone
Perimenopausal Symptoms hot flashes, insomnia,
mood changes
Menopausal Physiology osteoporosis, vaginal
mucosal thinning
15
The Good and Bad of Estrogen Replacement

• The Good

• The Bad

• Relief of menopausal symptoms
• Reduction in osteoporosis (bone thinning) and
  fractures
• Cardio-protective effects??
• Improvement in lipid profile

• Breast cancer risk
• Uterine cancer risk
• Complex formulation

16
Womens Health Initiative
Estrogen Progesterone
16,608 Post-menopausal women aged 50-79 with an
intact uterus
Study stopped after mean follow-up of 5.6 years
Placebo

• Hormonal replacement associated with
• Increased heart disease (29 ?)
• Increased stroke (41 ?)
• Increased blood clots
• Increased breast cancer (26 ?)
• Reduced colon cancer
• Reduced hip fracture

Conclusion HRT should not be used to prevent
disease in healthy post-menopausal women
17
WHS Caveats

• Overall mortality was identical in the two groups
• Event rates in both groups was low and absolute
  rates in the estrogen progesterone group was
  low - overall risk of treatment is low
• Estrogen vs. progesterone influence on outcomes
  is unknown

18
Womens Health Initiative Estrogen Only Study
10,739 Post-menopausal women aged 50-79 with
previous hysterectomy
Estrogen Only
Study stopped after mean follow-up of 6.8 years
Placebo

• Estrogen replacement associated with
• 9 reduction in heart disease
• 39 increase stroke
• 33 increase blood clots
• No change in cancer
• 39 reduction hip fracture

19
Womens Health Initiative Estrogen Only Study
Source JAMA 20072971477
Conclusion In younger post-menopausal women
post hysterectomy, estrogen alone may be
beneficial
20
Oral versus Transdermal Estrogen

• Oral Estrogen

• Transdermal Estrogen

• Large impact on liver metabolism
• Increase in inflammatory markers
• Increase in protective HDL cholesterol

• Bypasses liver
• No change in Inflammatory markers
• Reduction in LDL
• Improvement in atherogenic index of plasma
• Reduction in oxidation index

21
Estrogen Replacement The reality

• Estrogen therapy is reasonable for the relief of
  perimenopausal symptoms if started early and
  tapered after a few years
• Estrogen administered transdermally may be less
  likely to increase risk of blot clots
• Estrogen should not be given to reduce CVD risk

22
Myth 4

• Vitamin supplementation is key to preventing
  cardiovascular disease in women.

23
Vitamin E600 IU
636 Deaths
39,876 healthy women age 45
10 years
615 Deaths
Placebo
Source JAMA. 2005294(1)56-65
24
Womens Health Study Vitamin E
In conclusion, the WHS does not support
recommending vitamin E supplementation for CVD or
cancer prevention among healthy women.
25
B-Vitamins Health in Women
Folic AcidVit. B6Vit B12
406 Events
5442 woman with CAD or 3 risk factors
7 years
390 Events
Placebo
Source JAMA. 2008299(17)2027-2036
26
The Reality

• Vitamin E and B vitamins are probably safe, but
  there is no convincing evidence that they need be
  taken regularly
• Some supplements (ephedra) are downright
  dangerous
• Many supplements interact with medications
• The entire supplement industry is unregulated
  the safety and purity is entirely in the hands of
  the manufacturer.

27
Myth 5

• If Im thin and exercise regularly I should be
  immune to cardiovascular disease.

28
The Reality

• Inactivity and obesity are just two of many CVD
  risk factors, and probably not the strongest
• Exercise is great but not necessarily enough!

29
Cardiac Risk Factors

• Non-Modifiable

• Modifiable

• Age
• Gender
• Heredity

• Tobacco Use
• Cholesterol
• Blood pressure
• Diabetes
• Physical inactivity
• Overweight condition

30
Myth 6

• Eggs are unhealthy and should not be eaten.

31
The Facts

• Egg yolks do contain cholesterol
• Studies have shown a clear relationship between
  serum cholesterol and cardiovascular disease
  outcomes
• Studies have not shown a relationship between egg
  consumption and health outcomes

32
Whats in an Egg?
213 mgCholesterol
0 mgCholesterol
OK to eat an egg if consistent with overall daily
cholesterol limits
33
Myth 7

• Most women do not experience chest pain during a
  heart attack fatigue and shortness of breath
  are much more common.

34
The Facts

• Chest discomfort is the most common symptom of a
  heart attack in both men and women
• Women are more likely than men to have additional
  non-specific symptoms, including
• Fatigue
• Shortness of breath
• Weakness

Devon, et al. Amer J Critical Care 200817(1)
14-24
35
The Facts
Devon, et al. Amer J Critical Care 200817(1)
14-24
36
The Facts
Location of Chest Pain
Indicates statistically significant difference
Devon, et al. Amer J Critical Care 200817(1)
14-24
37
The Facts
Quality of Chest Pain
No differences were statistically significant
Devon, et al. Amer J Critical Care 200817(1)
14-24
38
The Facts

• Men and women present relatively similarly with
  heart attack
• For both genders the important point is not to
  ignore symptoms of a potentially life-threatening
  condition

39
Myth 8

• Chocolate is sinfully bad and should be eaten
  only rarely

This could be true, but there is some preliminary
data to suggest dark chocolate may be beneficial!
40
Beneficial Effects of Dark Chocolate

• Raises protective HDL
• Improves insulin sensitivity
• Lowers blood pressure
• Improves endothelial function

Clinically Relevant?
41
Recommended Dose
Rx
Go Red Luncheon Attendee
Dark chocolate, 100 gm Directions 1 bar
dailyDispense 30 day supply
Jon W. Wahrenberger, MD
42
Myth 9

• Exercise is beneficial only if prolonged
• (No Pain/No Gain)

43
Exercise the facts

• There is a dose-response relationship (more is
  better)
• Strenuous exercise is probably better than less
  strenuous exercise
• Several studies have shown that repeated
  intermittent periods of exercise have a
  cumulative effect similar to prolonged exercise

44
Summary

• Dont believe everything you hear
• Work on traditional risk factors throughout your
  life
• Eggs are OK . in moderation as is dark
  chocolate
• Ovarian hormone therapy is OK in the young women
  with premature or surgical menopause taper in
  early 50s some data suggest transdermal best
• A balanced diet is probably far more helpful than
  vitamins and supplements
• Exercise is beneficial almost any way you do it!

45
Questions?