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Cardiovascular Disease in Women Module II: Risk Factors

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Title: Cardiovascular Disease in Women Module II: Risk Factors


1
Cardiovascular Disease in WomenModule II Risk
Factors
2
Module II Risk Factors
  • Traditional Risk Factors
  • Evolving Risk Factors

3
Cardiovascular Risk Factors in Women
  • Unmodifiable
  • Age
  • Family History
  • Modifiable
  • Diabetes
  • Dysplipidemia
  • Hypertension
  • Obesity
  • Poor Diet
  • Sedentary Lifestyle
  • Cigarette Smoking

Source ATP III 2002, Mosca 2007
4
Cardiovascular Risk Factors
  • Sedentary Lifestyle

5
Modifiable Risk Factors Sedentary Lifestyle
  • 40 of women report no leisure time physical
    activity
  • Exercise is less prevalent among white women
    compared to white men
  • African American and Hispanic women have the
    lowest prevalence of leisure time physical
    activity

Source U.S. Surgeon General 1996, Rosamond 2008
6
Estimated Percentage of Americans Age 18 and
Older Who Report Regular Physical Activity 2005
By Race and Sex
Source Rosamond 2008
7
Risk Reduction for CHD Associated with Exercise
in Women
Source Adapted from Manson 1999
8
Cardiovascular Risk Factors
  • Cigarette Smoking

9
Relative Risk of Coronary Events for Smokers
Compared to Non-Smokers
Source Adapted from Stampfer 2000
10
Smoking
  • The same treatments benefit both women and men
  • Women face different barriers to quitting
  • Concomitant depression
  • Concerns about weight gain

Source Fiore 2000
11
Five As
  • Ask about tobacco use at every visit
  • Advise in a clear and personalized message
  • Assess willingness to quit
  • Assist to quit
  • Offer counseling/support (eg, support groups,
    phone lines)
  • Offer pharmacotherapy unless contraindicated
  • Arrange follow-up
  • For more information http//www.surgeongeneral.go
    v/tobacco/

Source Fiore 2000
12
Cardiovascular Risk Factors
  • Obesity

13
Obesity Trends Among U.S. AdultsBehavioral Risk
Factor Surveillance System BRFSS, 1990-2006
1998
1990
(BMI 30, or 30 lbs overweight for
5 4 woman)
2006
No Data lt10 1014
1519 2024 2529
30
Source CDC
14
Body Mass Index Definition
  • BMI weight in kilograms divided by the square
    of the height in meters (kg/m2)
  • BMI chart showing BMI based on weight in pounds
    and height in inches available at
    http//www.nhlbi.nih.gov/guidelines/obesity/ob_hom
    e.htm

Source NHLBI
15
Body Weight and CHD Mortality Among Women
P for trend lt 0.001
Source Adapted from Manson 1995
16
Body Weight and CHD Mortality Among Women
P for trend lt 0.001

Source Adapted from Manson 1995
17
Adult Treatment Panel III Guidelines
  • Sample menus for different ethnic cultural
    preferences
  • Assessment tools
  • Counseling tools
  • Adherence tips
  • Patient handouts

Source ATP III 2002
18
Cardiovascular Risk Factors
  • Diabetes

19
Diabetes
  • Diabetes affects 8.8 of all U.S. women age 20
    years or older
  • Compared to whites
  • African Americans, Latinas, American Indians,
    Asian Americans, and Pacific Islanders have a
    1.5-2.2 times greater prevalence of diabetes

Source CDC, NIDDK 2005
20
Diabetes
  • 65 of diabetics die of cardiovascular disease
  • Diabetics have death rates from heart disease
    that are 2 to 4 times higher than non-diabetics

Source CDC 2003
21
Coronary Disease Mortality and Diabetes in Women
Source Adapted from Krolewski 1991
22
Race/Ethnicity and Diabetes
  • At high risk
  • Latinas
  • American Indians
  • African Americans
  • Asian Americans
  • Pacific Islanders

Source American Diabetes Association 2001
23
Definition of Metabolic Syndrome in Women
  • Abdominal obesity - waist circumference gt 35 in.
  • High triglycerides 150mg/dL
  • Low HDL cholesterol lt 50mg/dL
  • Elevated BP 130/85mm Hg
  • Fasting glucose 100mg/dL

Source AHA/NHLBI 2005
24
Cardiovascular Risk Factors
  • Hypertension

25
Treatable Risk Factors Hypertension
  • 32 of women in the United States have
    hypertension
  • Hypertension is more prevalent among older women
    than older men
  • Death from CHD progresses increasingly and
    linearly as blood pressure increases
  • For every 20 mmHg systolic or 10 mmHg diagnostic
    increase in blood pressure, risk of death from
    CHD doubles

Source American Heart Association 2004, JNC 7
2004, Rosamond 2008
26
Lifestyle Approaches to Hypertension in Women
  • Maintain ideal body weight
  • Weight loss of as little as 10 lbs reduces blood
    pressure
  • DASH eating plan
  • Even without weight loss, a diet rich in fruits,
    vegetables, and low fat dairy products can reduce
    blood pressure
  • Sodium restriction to 2300 mg/d
  • Further restriction to 1500 mg/d may be
    beneficial, especially in African American
    patients
  • Increase physical activity
  • Limit alcohol to one drink per day
  • Alcohol raises blood pressure
  • One drink 12 oz beer, 5 oz wine, or 1.5 oz
    liquor

Source JNC VII 2004, Sacks 2001, Mosca 2007
27
JNC 7 Report
  • Classification of blood pressure
  • Treatment algorithms
  • Lifestyle strategies
  • Antihypertensive drug choices
  • Special indications and situations
  • Resistant hypertension

Source NIH 2004
28
Trends in Age-adjusted Prevalence of Hypertension
in United States
Source MMWR 2005
29
Hypertension Prevalence Among White and Black
Women in the United States Trends

Source Adapted from Hertz 2005
30
Prevalence of High Blood Pressure by Age and
Race
Source Data from National Vital Statistics
System, Health, United States, 1996-97
31
African Americans and Hypertension
  • Compared to whites
  • African Americans develop hypertension earlier in
    life
  • African Americans have much higher average blood
    pressures
  • African Americans have a 1.5 times greater risk
    of heart disease death

Source American Heart Association 2008
32
Age-Adjusted 16-Year Incidence of End Stage Renal
Disease by Diastolic Blood Pressure and Race
(MRFIT data)
P e r c e n t
Diastolic Blood Pressure
Source Klag 1997
33
DASH Eating Plan
  • 78 servings of grains, grain products daily
  • 45 servings of vegetables daily
  • 45 servings of fruits daily
  • 23 servings of low-fat or nonfat dairy foods
    daily
  • 2 servings of meats, poultry, fish daily
  • 45 servings of nuts, seeds, legumes weekly
  • Limited intake of fats, sweets

Source NHLBI 1998
34
DASH Diet with Low Sodium Intake in Hypertensive
Individuals Compared to Control Diet with Average
U.S. Sodium Intake
African American Non-African American


Plt.001 from baseline
Source Sacks 2001
35
Cardiovascular Risk Factors
  • Dyslipidemia

36
Approximate and Cumulative LDL Cholesterol
Reduction Achievable By Dietary Modification
Dietary Component Dietary Change Approximate
LDL
Reduction Major Saturated fat lt7 of
calories 8-10 Dietary cholesterol lt200
mg/day 3-5 Weight reduction Lose 10
lbs 5-8 Other LDL-lowering options Viscous
fiber 5-10 g/day 3-5 Plant/sterol 2g/day 6
-15 stanol esters Cumulative
estimate 20-30
Source Adapted from ATP III 2002
37
ATP III Full Report
  • How to choose a statin
  • Dosing regimens
  • How to monitor when combining drugs
  • Side effect management
  • Reprintable nutritional hand-outs
  • Menu samples for different cultures
  • Adherence strategies/barrier reduction

Source ATP III 2002
38
Treatable Risk Factors The Epidemiology of
Cholesterol Levels and Subfractions
  • Low HDL more important in women than men
  • For every 1 mg/dL increase in HDL 3 decrease in
    CHD risk for women and 2 decrease in CHD risk
    for men
  • Total cholesterol/HDL ratio very predictive of
    CHD risk in women
  • Triglyceride elevation associated with greater
    atherogenic significance in women than in men

Source Maron 2000
39
Treatable Risk Factors Cholesterol Level and
Subfractions
  • LDLgt160 mg/dL associated with 3.3-fold elevation
    in risk for women less than 65 years old
  • LDL pattern of small, dense particles (more
    atherogenic) present in 25 of population, but
    less frequently seen in women
  • Menopausal transition associated with increasing
    proportion of this subfraction

Source Keil 2000, Carr 2000, Hokanson 1996
40
Relative Risk of Various Factors for CHD for
Women and Men
2.4
2.5
1.9
2
1.8
Relative Risk
1.6
1.5
1.5
1.4
1.4
1.5
1.3
Men
1.1
Women
1
0.5
0
HTN
CHOL
DM
Obesity
Smoking
Source MMWR 1992
41
Cardiovascular Risk Factors
  • Poor Diet

42
Low Risk Diet is Associated with Lower Risk of
Myocardial Infarction in Women
Relative Risk of MI
Adjusted for other cardiovascular
risk factors
Plt .05 for quintiles 3-5 compared to 1-2
Diet Score by Quintile (1 least vegetables,
fruit, whole grains, fish, legumes)
Source Akesson 2007
43
Emerging Risk Factors for CHD
  • Pro-inflammatory markers
  • C-reactive protein (hs-CRP)
  • Fibrinogen
  • Hyperhomocysteinemia
  • Homocysteine lowering to prevent CHD events has
    been shown to be ineffective or possibly harmful
    in randomized clinical trials

Source ATP III 2002 Mosca 2007
44
Relative Risk of Cardiovascular Events According
to Baseline Levels of hs-CRP in Healthy
Postmenopausal Women
P for trend lt 0.001
Source Ridker 2000
45
Fibrinogen Levels and CHD Risk in Women
P for trend lt0.0001
gt3.6
gt2.8, ? 3.1
gt3.1, ? 3.6
? 2.8
Adjusted for age, smoking, BMI, systolic blood
pressure, total cholesterol, HDL, triglycerides,
and educational level
Source Eriksson 1999
46
Relative Risk of Cardiovascular Events According
to Baseline Levels of Homocysteine in Healthy
Postmenopausal Women
P for trend 0.02 (not significant)
µ
µ
µ
µ
Source Ridker 2000
47
The NORVIT Trial Homocysteine Lowering Did Not
Reduce Cardiovascular Events in Women with Prior
MI
Relative Risk of CVD Event
Compared to B12 alone
Compared to placebo


Source Bonaa 2006
48
Psychosocial Stressors in Women with CHD The
Stockholm Female Coronary Risk Study
  • Among women who were married or cohabitating with
    a male partner, marital stress was associated
    with nearly 3-fold increased risk of recurrent
    CHD events
  • Living alone and work stress did not
    significantly increase recurrent CHD events

Source Orth-Gomer 2000
49
Depression and CHD Results from the Womens
Health Initiative Study
  • Depression is an independent predictor of CHD
    death among women with no history of CHD

Source Wassertheil-Smoller 2004
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