Women and Heart Disease

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Women and Heart Disease

• Cathryn Harbor
• Lexington VA
• May19,2004
• Sponsored by National Organization for Women

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Coronary Artery Disease
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Definitions

• Heart Attack Heart Muscle is damaged because it
  cant get blood and oxygen.
• Angina Heart Muscle is deprived of blood flow
  and oxygen. A charlie horse.

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Women get more disease in small blood vessels of
the heart
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Statistics

• Disease of Arteries is the leading cause of
  death.
• After menopause women develop heart disease at
  the same rate as men.
• After menopause, women are 10 times more likely
  to develop heart disease than to develop breast
  cancer.
• 40 of people who have a heart attack die of it.

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Life Cycle Differences

• Young women develop less disease in the heart
  arteries than young men.
• After menopause, a womans arteries develop
  disease at a similar rate to mens.

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Heart Disease in Women vs Men

• After menopause women are equally susceptible
• Men have more chest pain.
• Women more often have silent heart attacks
• Once diagnosed women do worse

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Red Flag Symptoms

• Chest Pain or Pressure
• Dizziness
• Shortness of Breath
• Neck Pain unassociated with neck movement
• Any Unusual Symptom that occurs with exertion and
  resolves with rest
• Unexplained Sweats
• Nausea

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What to do if you have symptoms

• Take an asprin
• Stop any exertion
• Go to the ER if the symptom persists. If it
  resolves, contact your health care provider.

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Known risk factors

• There are more than 80 known risk factors for
  heart disease
• This means that there is no one cause and no one
  treatment.

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Important Risk Factors

• Smoking
• Being overweight
• Age
• Hypertension
• Diabetes
• Physical Inactivity
• Elevated cholesterols

• Elevated C Reactive Protein
• Elevated Fasting Blood Sugar (90)
• Stress, anxiety, depression
• Elevated homocysteine

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Genetic Contribution

• We know that genetics plays a big role
• .Genes tell your body how to make proteins, that
  is all. To have a genetic problem simply means
  that you inherit the blueprint for less effective
  proteins. It does not mean that you inherit
  heart disease.
• No genetic factors I have found that are not
  modifiable by environment

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The Problem of Choice

• Hard to know what to do.
• Science does not provide clear answers
• Science does not progress rapidly
• What is driving the science?

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Women and Heart Health Choices

• Should I use hormone replacement?
• Should I use medicines to lower my cholesterol?
• Should I change my lifestyle?

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Women and HormonesWhat We Do Know

• Before menopause womens risk of heart disease is
  much lower than mens.
• After menopause, womens risk quickly approaches
  mens.
• In large surveys women who take estrogen after
  menopause have less heart disease (nurses study).

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Evolution of HRT

• Drug companies started producing estrogen from
  pregnant mares urine (Premarin).
• Studies showed that estrogen without progesterone
  causes uterine cancer.
• Drug companies started making combination
  packages of estrogen and progestins.
• Because of Patent issues, the progestins the drug
  companies used were not natural to the body, but
  synthetic.

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Evolution of HRT continued

• Because of the belief, based on good studies,
  that HRT protects against heart disease, women
  were told at menopause that they should start
  premarin to protect their hearts.
• Premarin became the most widely prescribed drug
  in the country

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HERS trial

• 2763 postmenopausal women
• Pre-existing heart disease
• Randomized to placebo or prempro
• 4.1 year study

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HERS Trial Results

• In the first year more women on prempro group had
  more heart attacks than women in the control
  group
• For the 2nd and 3rd years the groups very similar
• By the 4th year more women in the control group
  had heart attacks

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Impression after HERS Trial

• Starting on HRT after heart disease is
  established is dangerous at first
• After a few years on HRT estrogen use seems to
  create no additional risk and possibly to protect
  women

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What Would Explain the Results of HERS?

• We know that estrogen increases womens chance of
  forming clots in our blood vessels
• Women in the trial were known to already have
  diseased arteries.
• Possibly starting a woman on HRT after she has
  developed heart disease was the problem, since a
  clot is a bigger problem in a sickened and
  narrowed artery.

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THE WOMENS HEALTH INITIATIVE (WHI)

• 16,608 post menopausal women without hysterectomy
  not currently on HRT
• Randomized to placebo or prempro
• Planned duration 8 years
• Stopped by safety advisory board after 5.3 years
  increased risk of breast cancer without evidence
  of overall benefit.

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FINDINGS OF WHI

• Breast cancer, heart disease, stroke, lung clots
  and leg clots are all increased by prempro (in
  this population). Prempro may have more negative
  effects than estrogen alone
• Hip fractures and colorectal cancer are reduced
  by prempro (in this population)
• Prempro increased the risk of hysterectomy

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Problems with WHI

• WHI intentionally excluded women with severe
  menopausal symptoms, though these women are most
  likely to use HRT.
• Older women not on HRT were studied. Many of
  them can be presumed to already have heart
  disease.
• The study was too short to show benefits, if any,
  of HRT.

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What we STILL Dont Know

• Is there a heart benefit to giving HRT starting
  right at menopause, before heart disease starts
  to develop?
• Do other types of estrogen and progesterone have
  same risks?
• What if lower doses had been used?
• Do older women on hormones need to come off of
  them?

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Take away

• We still do not have enough information to make
  perfect decisions about putting women on or
  taking them off estrogen
• Right now the pendulum has swung very far to the
  no HRT side.

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Cholesterol

• People who die of heart attacks have changes in
  their heart arteries that are made, in part, of
  cholesterol.

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Where Does Cholesterol Come From?

• We thought cholesterol in diet made cholesterol
  in the body.
• In fact cholesterol is so important that the body
  makes its own.
• Cholesterol is the result of interactions between
  carbohydrates, fats and protein in a diet, level
  of exercise, heredity and hormones.

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Cholesterols Function

• Important in producing hormones
• Forms insulation around nerves to keep signals
  moving
• Needed to maintain cell membrane fluidity
• Has important immune functions (fighting illness)
• Necessary for brain function (thinking)
• Important in neurotransmitter production (mood)

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About Cholesterol

• We usually measure three types of cholesterol
• LDL (bad cholesterol)
• HDL (good cholesterol)
• Triglycerides

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Traditional Approach

• Focused on evidence-based medicine
• Five major studies showed impressive risk
  reduction from using statins (24-39 reduction).
• Drug trials using statins (Lipitor, Pravacol,
  Baycol, and Zocor, etc demonstrated both a
  lowering in LDL cholesterol and a lowering of
  heart attacks.

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Statins some more of the issue

• 61-76 of patients treated with statins STILL
  experience heart attacks.

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Lipids and Women

• LDL (Bad Cholesterol) is a good predictor of
  heart disease in men.
• Simple LDL measurements predict little in women.
• Despite awareness of other modifiable risk
  factors, we tend to focus on one risk factor (LDL
  cholesterol) and one therapy (statin drugs)

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Tangent about problems with LDL

• LDL is clearly bad, at least for men but there
  are differences among the types of LDL
• My LDL is 180 yours is 120. Who has the worst
  problem? We dont know because
• Answer It depends on number of cholesterol
  particles and therefore on the size of the LDL
  particle.

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This Just In

• Women without coronary artery disease do not
  benefit from Statin use.
• For women with known cardiovascular disease,
  treating hyperlipidemia is effective in reducing
  fatal and non fatal heart attacksbut does not
  affect total mortality.

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Another Big Problem

• Coenzyme Q-10 is a very important anti-oxidant.
• Coenzyme Q-10 is produced in the body, in the
  same chemical pathway as cholesterol.
• The enzyme, HMG CoA reductase is essential for
  producing CoQ-10.
• Statin drugs work by disabling this enzyme.

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CoQ-10

• Many of unpleasant effects of statin drugs
  (muscle aches, fatigue) can be reversed by using
  CoQ-10.
• CoQ-10 has now been demonstrated to be important
  in treating Parkinsons disease.
• I believe that everyone on statin drugs should
  take CoQ-10.

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HDL Cholesterol

• HDL (good cholesterol) is very important in
  women
• HDL below 50 makes women 2.7 times more likely to
  die of a heart attack.

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Triglycerides

• Triglycerides between 200 and 400 increase risk
  of heart attack death by 2.4
• Triglycerides above 400 make women 6.9 times more
  likely to die of heart attacks.

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The Metabolic Syndromealso called INSULIN
RESISTANCE

• Abnormal cholesterol profiles High TG, low HDL
  high LDL
• Hypertension
• Type 2 Diabetes
• Coronary artery disease
• Breast, prostate and colon cancer
• Polycystic ovarian disease

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Insulins Role

• High blood sugar is highly toxic to brain tissue.
• When you eat carbohydrates your body turns them
  into sugar, glucose.
• Insulin rises after you eat carbohydrates to
  protect your tissues from excess energy.
• Insulin lets excess energy be quickly cleared
  from the bloodstream to be stored as
  triglycerides and cholesterol.
• In the short term, high insulin levels protect
  your tissues
• In the long run, high insulin levels are
  associated with many health problems, called the
  metabolic syndrome.

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Triglycerides, Insulin and Diabetes

• Learn and control your triglyceride number
• Of all lipid markers, this one is associated with
  the effectiveness of your diet and exercise
  program.
• Triglycerides are where your body stores excess
  carbohydrate calories
• We have long known that Triglycerides are an
  important marker for CAD risk in women.

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A complex problem without an easy solution

• Whats a girl to do?

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How do you protect yourself?

• Lower your risk for heart disease by 70!

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The Lyons Study

• 605 French men and women who had survived heart
  attacks
• Divided into two groups
• American heart Association Diet (low fat)
• Mediterrainian diet
• Olive oil
• Whole grains
• More root and green vegetables
• More fish and poultry, less red meat

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Mediterreanian diet
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Lyon s Study Results

• Study was stopped after only 30 months
• A 70 reduction in deaths from all causes in the
  group with the Mediterainian diet.
• This was in people who had already had heart
  attacks!

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Changes you can make for risk reduction

• Stop or avoid smoking
• Improve your diet (the LYONS Study)
• Maintain a normal weight
• Exercise
• Consider hormone replacement
• Maintain normal blood pressure
• Reduce stress in your life

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• ONE SIZE FITS ALL MEDICINE IS THE BEST FOR THE
  DRUG COMPANIES.
• It is not necessarily the best for your body

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QUESTIONS?
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It begins on the first day of medical school and
lasts through to retirementIt starts slowly and
insidiously, like an addiction, and can end up
influencing the very nature of medical decision
making and practiceAttempts to influence the
judgement of doctors by commercial interests
serving the medical industrial complex are
nothing if not thorough.
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BUT

• In the above studies, not enough women were
  included to determine the effects of lowering LDL
  in women
• Level of LDL cholesterol does not correlate well
  with risk of heart disease

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Problems with the system

• Most medical research is payed for by drug
  companies
• Drug companies need to find drugs that work for
  large groups of people one size fits all model
• Not all people are alike men from women,
  premenopausal from post menopausal women one
  size does not fit all
• Most doctors get their information from drug
  reps, the marketing agents for the drug industry.
• Drug company information is not intended to be
  objective. It is a product of spin artists