Heart Disease in Women

1
Heart Disease in Women

• Lubna Piracha, D.O.
• West Suburban Cardiologists
• Advocate Christ Medical Center

2
Some Facts

• Cardiovascular disease remains the leading killer
  of women of all races in America today.
• It is estimated that 1 in 2 women will eventually
  die of heart disease or stroke, compared with 1
  in 25 who will eventually die of Cancer.

3
Some More Facts

• Coronary artery disease has claimed 50 of all
  cardiovascular deaths in women over the past 3-5
  years.
• Coronary artery disease is 34 higher in the
  African American women, and death rates here have
  decreased the least.

4
Cardiovascular Disease Mortality Trends for Males
and Females
5
Why the new epidemic???

• Increased awareness that we can have the same
  problems as men.
• Increased number of women in the work force.
• Increased rate of smoking.
• Increased awareness that women can develop heart
  disease.
• Loss of estrogen protection as we get older.

6
What is a Coronary Artery?

• The heart is a muscle that pumps blood so that
  the body can receive oxygen and nutrients.
• The coronary artery is a vessel that deliverys
  blood to the heart so that it can also receive
  oxygen and nutrients.

7
What is a MI (Heart Attack)?

• It is when the coronary artery can no longer
  deliver oxgenated blood to the heart.
• Coronary artery disease implies build-up of
  cholesterol leading to damage of the lining of
  the artery, and this can lead to blood clot
  formation in the artery, occluding it and not
  allowing oxgenated blood through to the heart.

8
Risk Factors Those we have control over

• Hypercholesterolemia
• Smoking
• Hypertension
• Diabetes
• Obesity
• Sedentary Lifestyle

9
Risk Factors Those we have no control over.

• Age
• Gender
• Genetics
• Postmenopausal state???

10
So What Is Your Risk For Having A Cardiac Event

• Framingham Risk Assessment System for Calculating
  your 10-Year Risk Look at handout.
• This assessment is for asymptomatic patients
  without evidence of coronary heart disease.

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Example

• RISKS
• Age 42
• Total Chol 222
• Smoking Yes
• HDL 50
• Systolic BP 130
• Treated
• TOTAL POINTS

• POINTS
• 0
• 6
• 7
• 0
• 4
• 17

5 RISK OF HAVING A CARDIAC EVENT IN THE NEXT 10
YEARS.
12
Another Example

• RISKS
• Age 60
• Total Chol 240
• Smoking No
• HDL 35
• Systolic BP 160
• Untreated
• Total Points

• POINTS
• 10
• 3
• 0
• 2
• 4
• 19

8 RISK OF HAVING A CARDIAC EVENT IN THE NEXT 10
YEARS.
13
RISK FACTORS

• What do we hear about all the time?
• Hypercholesterolemia

14
Hypercholesterolemia

• Increased Total Cholesterol
• Increased LDL
• Decreased HDL
• Increased TG

• Apoprotein E
• Increased Lp(a)
• Increased Homocysteine levels

The above has been shown to be risk factors for
promoting atherosclerosis.
15
What Is Cholesterol?????

• We want your LDL to be LOW, LOW, LOW..
• We want your HDL to be HIGH, HIGH, HIGH...

16
Lipoprotein Classes and Inflammation
Chylomicrons,VLDL, and their catabolic remnants
HDL
LDL
30 nm
2022 nm
915 nm
Potentially anti- inflammatory
Potentially proinflammatory
Doi H et al. Circulation 2000102670-676 Colome
C et al. Atherosclerosis 2000149295-302
Cockerill GW et al. Arterioscler Thromb Vasc Biol
1995151987-1994.
17
Role of LDL in Inflammation
LDL Readily Enter the Artery Wall Where They May
be Modified
Vessel Lumen
Endothelium
LDL
Oxidation of Lipidsand ApoB
Hydrolysis of Phosphatidylcholineto
Lysophosphatidylcholine
Aggregation
Other Chemical Modifications
Modified LDL
Intima
Modified LDL are Proinflammatory
Steinberg D et al. N Engl J Med 1989320915-924.
18
HDL Prevent Formation of Foam Cells
Monocyte
Vessel Lumen
LDL
Endothelium
AdhesionMolecules
MCP-1
LDL
Cytokines
Modified LDL
Foam Cell
Macrophage
Intima
HDL Promote Cholesterol Efflux
Miyazaki A et al. Biochim Biophys Acta
1992112673-80.
19
Framingham Offspring Study

• Cholesterol and Probability of
  Survival

20
CARE Trial
21
Hypercholesterolemia Secondary Prevention
reduction in coronary events
4S Study
22
Apoprotein E

• New cholesterol marker that is considered a risk
  factor for developing coronary heart disease.

Lp(a)

• Another cholesterol marker that is considered
  a risk factor for developing coronary
  artery disease.

23
Is there clinical evidence that inflammatory
markers predict future coronary events and
provide additional predictive information beyond
traditional risk factors?
24
hs-CRP and Risk of Future Cardiovascular Events
in Apparently Healthy Women
P Trend Any Event
MI or Stroke
Relative Risk
120.150.37
30.370.73
40.73
Quartile of hs-CRP (range, mg/dL)
Ridker PM et al. Circulation 199898731-733.
25
Risk Factors for Future Cardiovascular Events WHS
Lipoprotein(a) Homocysteine IL-6 TC LDL-C sIC
AM-1 SAA Apo B TCHDL-C hs-CRP hs-CRP
TCHDL-C
0
1.0
2.0
4.0
6.0
Relative Risk of Future Cardiovascular Events
Ridker PM et al. N Engl J Med 2000342836-843.
26
Summary

• Lifestyle modification and some pharmacotherapies
  (full-dose ASA, statins) lower hs-CRP
• Lipid-modifying therapies with oral estrogens and
  fibrates are not associated with reduction in
  hs-CRP
• Individuals with high levels of hs-CRP are at
  increased risk for CHD events and benefit from
  ASA and statins

27
What Does Hypertension Cause?????

• Coronary Artery Disease (MI)
• Strokes (Fatal and Non-Fatal)
• Congestive Heart Failure
• Kidney Failure
• Loss of Vision
• And More!!!!!!!!!!

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HYPERTENSION
P R E V A L E N C E
()
Prevalence of high blood pressure in US white men
and women
29
Hypertension Therapy Meta-Analysis

• Men who received therapy had reductions in
• Total Mortality
• CV Death
• Fatal Stroke
• All Stroke
• Major CV Events

• Women who received therapy had reductions in
• Fatal Strokes
• Major CV Events
• No increased risk for the other endpoints

Individual Data Analysis of Antihypertensive
Intervention Trials Database
30
Lifestyle Modifications
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Lifestyle Modifications Continued
32
Risk Factors Reduction
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Risk Factor Reduction

• Lipids Continued Secondary Goals
• HDL 45 mg/dl
• TG
• Diabetes
• Maintain Blood Glucose LDL
• Preprandial 80-120 mg/dl TG
• Bedtime 100-140 mg/dl
• Hb A1c Maintain B/P Control