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The
leading
killer of
women
at all
ages
So how long have we known that
women are just not small men???
Cardiovascular Disease in Women
38.2 million women (34%) are living with
cardiovascular disease and a much larger
population is at risk.
Heart disease and stroke are the no. 1 and no. 3
killers of women over age 25
1 in 30 die of breast cancer, but 1 in 2.5 die of
cardiovascular disease or stroke.
66,000 more women than men die per year of
cardiovascular disease; represents 54% of deaths
in women compared to 46% in men.
NEJM 1999
NIH-NHLBI-sponsored Womens Ischemia
Syndrome Evaluation WISE
About 50% of women sent home with normal
coronaries continue to experience disabling
symptoms
Possibly d/t coronary microvascular or macrovascular
endothelial dysfunction
673/936 enrolled in WISE had persistent chest pain
(PChP)
PChP-w no obstructive disease is not a benign
condition
2x the number of CV events (MIs, strokes,CHF and
CV deaths) than those w/o PChP.
Johnson,D, etal EurHeart Journal 2006
Assessing Ischemic Disease
Stress EKG may be less useful in looking for
ischemia
Guidelines still support for women with normal resting
12 lead EKG
Decreased functional capacity may predict poor
outcomes
WISE showed that women who could not achieve 4.7
METS of work had a risk of death or nonfatal MI 3.7x
higher that others with better functional capacity
Stress ECHO and SPECT are good options in
women
Mortality Rates in Women
At Every Age, More Women Die From Heart Disease Than From Cancer
Lung cancer
2500 Breast cancer
Colon cancer
1600
Endometrial cancer
1200
50% of women (1 in 2) will
800 die from CVD compared
with 4%
400 (1 in 25) who will die from
breast cancer
0
4549 5054 5559 6064 6569 7074 7579 8084 85+
Age (years)
National Center for Health Statistics. 1999:164-167.
Women Experience Menopause..
Changes with Menopause
Lipids
Total-Cholesterol
HDL-Cholesterol
Prevalence Differences
Hypertension
Metabolic Syndrome
4
3.5
Annual Occurence of
3
Heart Attack/1000
2.5
Before menopause
2
After menopause
1.5
1
0.5
0
40 - 45 45 - 49 50 - 54
80
Survival (%)
60
0
0 1 2 3 4 5 6 7 8
Years
Kaplan-Meier estimates
Haffner SM et al. N Engl J Med 1998;339:229234
Framingham Heart Study 30-Year Follow-Up:
CVD Events in Patients With Diabetes
(Ages 35-64)
10
10 9
8 Men Women
11
Risk 6
ratio 30
4 19
38 9 6
20 3*
2
0
Total CHD Cardiac Intermittent Stroke
CVD failure claudication
20
15 LIPID LIPID
CARE
10 HPS CARE
HPS WOSCOPS
5 AFCAPS
AFCAPS WOSCOPS
0
80 90 100 110 120 130 140 150 160 170 180 190 200
LDL-C Achieved (mg/dL)
0 1 2
Note: Risk estimates were derived from the experience of the Framingham Heart Study,
a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. 2001, Professional Postgraduate Services
www.lipidhealth.org
JAMA. 2001;285:2486-2497.
A - Assessment of CHD Risk
Classification of CVD Risk in Women (Mosca et al., Circ 2007)
High Risk:
Established coronary heart disease
Cerebrovascular disease
Peripheral arterial disease
Abdominal aortic aneurysm
End-stage or chronic renal disease
Diabetes mellitus
10-year Framingham global risk >20%
Classification of CVD Risk in Women (Mosca et al., Circ 2007)
At Risk:
Evidence of subclinical vascular disease (e.g., coronary calcium)
Metabolic Syndrome
Poor exercise capacity on treadmill and/or abnormal heart rate recovery
>=1 major risk factor for CVD including:
Cigarette smoking
Poor diet
Physical inactivity
Obesity (esp central obesity)
Family history of premature CVD (<55 male or <65 female relative)
Hypertension
Dyslipidemia
HOT, 1998
PPP, 2001
WHS, 2005
0.2 0.5 1.0 2.0 5.0 0.2 0.5 1.0 2.0 5.0
NIH Web site. Your guide to lowering high blood pressure: issues for women.
Available at: http://www.nhlbi.nih.gov/hbp/issues/issues.htm.
AHA Guidelines for CVD Prevention in
Women: Blood Pressure
Encourage an optimal blood pressure of <120/80
mm Hg through lifestyle approaches (Class I,
Level B)
Pharmacotherapy when BP is
140/90 mm Hg
Get BP even lower when
Target-organ damage
Diabetes
(Class I, Level A)
Cardiovascular Health Study (CHS) (aged 65+): MI or stroke rate 25% over 7 years in
those at highest quintile of combined IMT (OLeary et al. 1999)
Significant Coronary Artery Calcium
(Score >400)
Risk of Total Mortality by Calcium Category in
10,377 Asymptomatic Individuals
Shaw LJ et al., Radiology 2003; 228: 826-33
L Lifestyle Change: First Line of
Defense Against Heart Disease
The AHA expert panel rated the following as Class
I recommendations:
Stop cigarette smoking and avoid secondhand tobacco
smoke
Get at least 30 minutes of physical activity each day
Start a cardiac rehabilitation program if recently
hospitalized for heart disease
Eat a heart-healthy diet
Maintain healthy weight by balancing caloric intake
with caloric expenditure
Mosca et al. Circulation 2004
ATP III: Nutritional Components of the
TLC Diet
Nutrient Recommended Intake
Saturated fat* <7% of total calories
Polyunsaturated fat Up to 10% of total calories
Monounsaturated fat Up to 20% of total calories
Total fat 25%35% of total calories
Carbohydrate (esp. complex carbs) 50%60% of total calories
Fiber 2030 g/d
Protein ~15% of total calories
Cholesterol <200 mg/d
*Trans fatty acids also raise LDL-C and should be kept at a low
intake.
Note: Regarding total calories, balance energy intake and
expenditure
Expert to Detection, Evaluation, and Treatment of
Panel on
maintain
High Blooddesirable body
Cholesterol weight.
in Adults. JAMA. 2001;285:2486-2497. 2001, Professional Postgraduate Services
www.lipidhealth.org
Possible Benefits From Other
Therapies
Therapy Result
3 BMI
measured in
Yes Algorithm
past
2 years?
4 6 BMI
30 OR
Measure weight, 5 BMI 25 OR 7 {[BMI 25 to 29.9
height, and waist waist circumference Yes Assess risk OR waist circumferenceYes
circumference > 88 cm (F) factors >88 cm (F) >102 cm (M)] 8
Calculate BMI > 102 cm (M) AND 2 risk
factors} Clinician and patient
devise goals and
No treatment strategy
No for weight loss and
risk factor control
14 12 Does
Yes Yes
Hx BMI 25? patient want to
lose weight?
9 Progress
Yes
No No being made/goal
15 13 achieved?
Brief reinforcement/ Advise to maintain
educate on weight weight/address No
management other risk factors
Examination 11 10
16
Treatment Periodic weight Maintenance counseling:
Assess reasons for
check Dietary therapy failure to lose
Behavior therapy weight
: Physical activity
Weight Loss Therapy
Whenever possible, weight loss
therapy should employ the
combination of
Low-calorie/low-fat diets
Increased physical activity
Behavior modification
O Other Interventions with Class I
Recommendations
Blood pressure encourage optimal levels
of <120/80 mmHg
Cholesterol levels optimal cholesterol
levels <200 mg/dl, LDL-C< 100 mg/dl,
HDL >50 mg/dl, triglycerides <150 mg/dl
Diabetes recommend control to HgbA1c <
7%
Evidence-based Guidelines for CVD Prevention in
Women Major Risk Factor Interventions
(Mosca et al., Arterioscler Throm Vasc Biol 2004; 24: e29-e50)
I have some bad news for you. While your
cholesterol has remained the same, the research
findings have changed.
When LDL-lowering drug therapy
is employed in high-risk or
moderately high risk patients,
intensity of therapy should be
sufficient to achieve a 3040%
reduction in LDL-C levels.
JNC-7 New Features and Key
Messages
Thiazide-type diuretics should be initial drug
therapy for most, either alone or combined with
other drug classes.
Certain high-risk conditions are compelling
indications for other drug classes.
Most patients will require two or more
antihypertensive drugs to achieve goal BP.
If BP is >20/10 mmHg above goal, initiate
therapy with two agents, one usually should be
a thiazide-type diuretic.
H Highest Priority for Therapy is
for Women at Highest Risk
Those at highest risk, who already have pre-existing
CVD, diabetes, or chronic kidney disease are most
likely to benefit from preventive therapy involving the
following Class I recommendations:
ACE inhibitor therapy (if coughing, subst. ARB)
Aspirin therapy (baby aspirin or maximum dose of 162 mg)
unless contraindicated
Beta-blocker therapy in those with prior MI or current angina
Statin therapy
Niacin or fibrate therapy if low HDL present
Fibrates to lower triglycerides and improve HDL
Warfarin in those with atrial fibrillation unless
contradindicated
H Highest Priority for Therapy is
for Women at Highest Risk
Those at highest risk, who already have pre-existing
CVD, diabetes, or chronic kidney disease are most
likely to benefit from preventive therapy involving the
following Class I recommendations:
ACE inhibitor therapy (if coughing, subst. ARB)
Aspirin therapy (baby aspirin or maximum dose of 162 mg)
unless contraindicated
Beta-blocker therapy in those with prior MI or current angina
Statin therapy
Niacin or fibrate therapy if low HDL present
Fibrates to lower triglycerides and improve HDL
Warfarin in those with atrial fibrillation unless
contradindicated
A Avoid Class III Interventions
(Not proven useful or effective / may be harmful)
Combined estrogen and progestin therapy, and *estrogen
monotherapy since associated with increased risk of CVD
Selective estrogen-receptor modulators (SERMs) also not
recommended
Antioxidant supplements including vigtamin E, C, and beta-
carotene
Folic acid with or without B6 or B12 supplementation
Aspirin for MI prevention in women aged <65 years
Vitamins: Major Vascular Events
Vitamins Placebo Risk Ratio and 95% CI
Vascular Event (n = 10,269) (n = 10,267) Vitamin Better Vitamin Worse
Major coronary 1063 1047
1.00 (0.941.06)
Any of the above 2306 2312 P > 0.9
(22.5%) (22.5%)
0.4 0.6 0.8 1.0 1.2 1.4