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Heart Disease
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Heart Disease

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  • 1. Don’t Go Breaking My Heart: Understanding Heart Disease in Women
  • 2. “Tell a Friend” Campaign • Raise Awareness – heart disease is the leading cause of death in women. y p – of the symptoms of heart disease, and how they may differ in women. – of the importance of “knowing your numbers numbers” • cholesterol • blood pressure • body mass index • blood sugar. • Encourage women to talk to their primary h lth i healthcare providers about id b t heart health.
  • 3. Overview • Scope of the Problem • Gender disparities in care? • Challenges in public awareness g p • Challenges in awareness among clinicians • Gender differences in presentation? • Reducing CVD risk in women • Role of postmenopausal HT?
  • 4. Heart Disease: The Leading Cause of Death for American Women
  • 5. Cardiovascular Disease Mortality Trends United States: 1979-2001 1979- Source: CDC/NCHS.
  • 6. Death Rates from Heart Disease per 100,000 Women, 2002 (CDC)
  • 7. Are Women Aware ? Percentage of women who know that heart disease i the l di cause of d h i women: di is h leading f death in Circulation 2004 109 573 579 Ci l i 2004:109:573-579 50 45 40 35 30 46% 25 34% 20 30% 15 10 5 0 1997 2000 2003
  • 8. Fact or Fiction? Recent studies show that women perceive heart disease to the biggest threat to their health?
  • 9. Greatest Health Problem Mosca, Circulation 2004 40 35 30 25 % 20 1997 15 2000 10 2003 5 0 Breast Cancer Heart Cancer General Disease
  • 10. Flawed Concept of Women’s Health? “… The community has viewed women’s health almost with a ‘bikini’ approach bikini approach, looking essentially at the breast and reproductive system, and almost ignoring the rest of the woman as part of women’s f h f ’ health.” Nanette Wenger, MD Chief of Cardiology, Grady Hospital Professor of Medicine, Emory University Atlanta, G Atl t Georgia i
  • 11. Perception of Heart Disease Risk Factors Mosca, Circulation 2004 45 40 Smoking 35 High Cholesterol 30 Family History 25 HTN % Diabetes 20 15 High Tg 10 Overweight Lack of exercise 5 0
  • 12. Why The Gender Gap? • Women present to emergency rooms or chest pain centers 1- 2 hours later than men. men p • The multiple roles a woman takes on may delay care because of her responsibilities to others? • Women delay care because they perceive that heart disease is something that happens to one s one’s father, brother, or spouse?
  • 13. Why The Gender Gap?
  • 14. Why The Gender Gap?
  • 15. Why The Gender Gap? y p “Vintage” AHA teaching materials! g g
  • 16. Gap May Extend to Healthcare Professionals • 2003 survey indicates only 38% of women have discussed heart health with their healthcare provider. provider • One year death rate for men following a heart attack is 25%, for women 38% 25% 38%* – only part of this gap can be explained by age • Recommended treatments for heart disease are less likely to be used in women. – Aspirin – Referrals to cardiac rehab programs – Revascularization Cholesterol-lowering – Cholesterol lowering medicines *Heart Disease & Stroke Statistics 2004 Update (American Heart Association)
  • 17. Fact or Fiction? The survival rate for women after a heart attack is the same as for men?
  • 18. Mortality for Women and Men Post-AMI* j y and After Adjustment by Risk Score † 50 40 Women 30 Men (%) 20 10 0 12 24 36 48 Post-AMI 50 40 (%) 30 20 10 0 p *p<0.001; †p<0.002. ; p 12 24 36 48 After adjustment by risk score
  • 19. CHD Mortality in Younger Women W ff h highest l i Women under 65 suffer the hi h relative d sex-specific CHD mortality
  • 20. What can you do….. y • Seek medical advice for g g warning signs • Act promptly with acute symptoms • Seek information related to your own risk level • Make appropriate modifications in lifestyle to reduce their risk
  • 21. SYMPTOMS OF HEART DISEASE IN WOMEN
  • 22. Symptoms Of A Heart Attack • Require immediate action! – uncomfortable pressure, fullness, b i or f ll burning squeezing sensation in the chest – shortness of breath – nausea, vomiting, dizziness, sweating • Symptoms can vary greatly and may be different in women than th men • You know your body- y trust your instincts
  • 23. Differences in Heart Attack Symptoms Men Women • Sub-sternal chest pain or pressure , pp • Pain in chest, upper back, , jaw or neck • Pain at rest • Shortness of breath • Pain down left arm and shoulder Flu-like • Fl lik symptoms: nausea or vomiting, cold • Weakness sweats • Fatigue or weakness • Feelings of anxiety, loss of appetite, malaise pp ,
  • 24. Gender Differences in ED Presentation for CAD Without Chest Pain 48 50 41 Women (n = 90) 40 35 33 32 Men (n = 127) 30 30 26 22 22 19 19 20 14 11 P Percent of patients 8 10 0 a g n g g in ne itin io tin ue in a e st in ig at rp y sp om g fa at e e D /v di / F ld a In ss Sw ou se i ne h au /s N izz rm D A
  • 25. Women’s Early Warning Symptoms of Heart Attack 3, • Published online before print Nov 3 2003 • 515 women with AMI from 5 sites Prodromal symptoms 1 month b f • P d l h before AMI – unusual fatigue (70.7%) – sleep disturbance (47.8%) – shortness of breath (42.1%) – chest discomfort (29.7%)
  • 26. KNOW YOUR RISK FACTORS FOR HEART DISEASE
  • 27. Risk Factors for Heart Disease Non-modifiable Modifiable • Age • Physical Inactivity • Family • Psychosocial Factors history y High Blood Pressure • Hi h Bl d P • Gender • Obesity • Diabetes • High Cholesterol and Triglycerides, Low HDL • Cigarette Smoking • High fat diet
  • 28. Fact or Fiction? There is nothing that can be done to reduce the risk of heart disease in individuals with strong family history of CHD.
  • 29. “Genetics loads the gun, but environment pulls the trigger…” trigger Judith Stern Professor of Nutrition and Internal Medicine University of California at Davis
  • 30. Determining Your Risk for HD • The Framingham Heart Study established major predisposing risk factors for HD-age, DB, HTN, Smoking, Dyslipidemia p p p y prevention • Important step in primary p • Estimates 10 yr probability for CHD
  • 31. Framingham Risk Score: Women Step 1: Age Points Step 4: SBP Points Step 5: Smoking Status Points Years Points SBP If If Age Age Age Age Age (mmHg) treated untreated 20-39 40-49 50-59 60-69 70-79 20-34 -7 <120 0 0 Nonsmoker 0 0 0 0 0 35-39 -3 120-129 1 3 Smoker 9 7 4 2 1 40-44 0 45-49 3 130-139 130 139 2 4 140-159 3 5 Step 6: Sum of Points 50-54 6 >160 4 6 Age 55-59 8 Total Cholesterol 60-64 10 HDL-C 65-69 12 Systolic Bl d P S t li Blood Pressure 70-74 14 Smoking Status 75-79 16 Point Total Step 2: Total Cholesterol Points Step 7: 10-year CHD Risk TC Age Age Age Age Age (mg/dl) 20-39 40-49 50-59 60-69 70-79 <160 0 0 0 0 0 Point 10-year Point 10-year Point 10-year Total Risk Total Risk Total Risk 160-199 4 3 2 1 1 <9 <1% 15 3% 22 17% 200-239 8 6 4 2 1 9 1% 16 4% 23 22% 240-279 240 279 11 8 5 3 2 10 1% 17 5% 24 27% >280 13 10 7 4 2 11 1% 18 6% >25 >30% 12 1% 19 8% Step 3: HDL-C Points 13 2% 20 11% HDL-C (mg/dl) Points 14 2% 21 14% >60 -1 50-59 0 40-49 1 <40 2
  • 32. Guide to Preventive Cardiology in Women • Women have a low, intermediate, or high risk for heart attack depending on their “risk factors risk factors” p g , gg • Depending on level of risk, more aggressive cardiovascular risk reduction strategies are recommended including lifestyle and medications
  • 33. WHAT CAN YOU DO TO REDUCE YOUR RISK OF HEART DISEASE?
  • 34. Modifiable Risk Factors • Cigarette Smoking • Diabetes p • Abnormal lipid levels • High Blood Pressure Obesity • Ob i • Psychosocial factors • High fat diet • Physical Inactivity
  • 35. Impact of Multiple Risk Factors in Women • N EnglJ Med. Stampfer, MJ. 2000:343:16-22 N Engl J Med. Stampfer, MJ. 2000:343:16-22
  • 36. TOBACCO #1 PREVENTABLE RISK • Female smokers have 2-6 times the risk of sudden cardiac death than non smokers. The risk is higher for heavy smokers. smokers • Second-hand smoke increases cardiac risk. • The health benefits of quitting smoking begin y immediately.
  • 37. Fact or Fiction? The fastest growing group of new smokers are adolescent males
  • 38. Smoking Cessation Five Keys for Quitting: 1. Get 1 G t ready. d 2. Get support. 3. 3 Learn new skills and behaviors behaviors. 4. Get medication and use it correctly. 5. 5 Be prepared for relapse or difficult situations situations. www.smokefree.gov National Quitline: 1-800-QUITNOW
  • 39. Diabetes Prevalence per 100 Adults: 1996
  • 40. Diabetes Prevalence per 100 Adults: 2004
  • 41. Women and Diabetes • Type 2 diabetes has increased 50% in the last 10 years. • 2 of 3 persons with diabetes die of cardiovascular disease. • Diabetes increases a woman’s risk of heart disease 3-7X (2-3X in men). • People with diabetes should be treated as aggressively as those with known heart disease. disease • Diabetes markedly reduces the success g yp rate when a woman undergoes bypass surgery or balloon angioplasty procedures.
  • 42. Fact or Fiction? An optimal fasting blood glucose level is between 100-125
  • 43. American Diabetes Association (ADA) Guidelines p g g g/ • Optimal fasting blood sugar 100 mg/dL • Criteria for diabetes gg g g – Fasting glucose 126 mg/dL or higher – Random glucose 200 mg/dL or higher • Impaired fasting glucose 100 - 125 mg/dL
  • 44. Lifestyle and Diabetes • Research shows that diabetes can be p prevented by improving diet and physical y p g p y activity levels. l i k for diabetes who f ll a di • People at risk f di b h follow diet and exercise plan (with only a modest weight loss) can decrease their risk of developing diabetes by almost 50%.
  • 45. The Lipid Profile: Know Your Numbers! Total <200 mg/dL Cholesterol LDL <100mg/dL g Low-Density Lipoprotein Triglycerides Ti l id <150 mg/dL /dL HDL >40 mg/dL for men /dL f High-Density Lipoprotein >50 mg/dL for women
  • 46. Fact or Fiction? The number 1 dietary contributor to elevated LDL cholesterol is eating foods high in g g saturated fats.
  • 47. Therapeutic Lifestyle Changes Diet – Minimize dietary intake of saturated fats and trans fatty acids f id – Add plant stanol/sterols and soluble fiber to the diet Weight g – Maintain a desirable body weight and prevent weight gain Exercise – Engage in physical activity to include enough moderate exercise to expend at least 200 kilocalories/day • Depending on level of risk, medication may be initiated along with diet. diet
  • 48. PCNA’s What’s Missing in CholesterALL Campaign “What’s Missing in CholesterALL?” invites women to become detectives in investigating all the potential clues to a healthy cholesterol profile. PCNA’s brochure, website and toll-free number makes it fun and interesting for women to search out the culprits of heart disease. To receive a free brochure: Call: 877-HDL-GOAL (877-435-4625) Visit: htt // Vi it http://www.pcna.net t http://www.raiseyourcholesterol.com
  • 49. Recognizing High Blood Pressure • More men than women have hypertension until age 55. yp g • High blood pressure is more common in older women than older men. p • A person who has a normal blood pressure at age 55 has a 90% lifetime chance of developing hypertension. hypertension
  • 50. Blood Pressure: Know you numbers! Category Systolic BP Diastolic BP (mmHg) ( H ) (mmHg) ( H ) Normal < 120 < 80 Prehypertension 120-139 80-89 Stage 1 140-159 90-99 Hypertension Stage 2 > 160 >100 yp Hypertension National Heart Lung and Blood Institute – Joint National Committee -7
  • 51. Fact or Fiction? One in five adult Americans has high blood p pressure.
  • 52. Benefits of Lowering Blood Pressure • Reduces the chance of: Heart Attack: 20-25 % Stroke: 35 40 % 35-40 Heart Failure: 50 % American Heart Association website: www.americanheart.org
  • 53. Lifestyle Change: What Difference Does it Make ? • Weight loss – (decreases SBP 1.6 mm Hg for each kg lost) • Dietary Approaches to Stop Hypertension: DASH diet: 8 14 – (decreases SBP 8-14 mmHg) • Reducing salt in the diet – (decreases SBP 2-8 mmHg) • 30-45 minutes daily aerobic exercise ( g) – (decreases SBP 4-9 mmHg) • Limit alcohol – (decreases SBP 2-4 mm Hg) • Avoidance of tobacco products
  • 54. Obesity • Growing epidemic in U.S. • Increases risk of : • high blood pressure p • lipid abnormalities • diabetes • Current focus is on taking small steps: • small changes in dietary patterns • increasing “incidental” exercise
  • 55. CHEESEBURGER 20 Years Ago Today 333 calories How many calories are in today’s cheeseburger?
  • 56. CHEESEBURGER 20 Years Ago Today 333 calories 590 calories Calorie Difference: 257 calories
  • 57. BMI: Know your numbers! Classification of Overweight and Obesity by BMI Obesity Class BMI kg/m 2 Underweight <18.5 <18 5 Normal 18.5–24.9 Overweight 25–29.9 Obesity I 30.0–34.9 II 35.0–39.9 Extreme Obesity E Ob i III t 40.0
  • 58. Waist Circumference High Risk Men > 40 inches Women > 35 inches
  • 59. Health Benefits of Weight Loss g • Decreased cardiovascular risk • Decreased glucose and insulin levels • Decreased blood pressure • Decreased LDL and triglycerides, increased HDL • y p p Decreased severity of sleep apnea • Reduced symptoms of degenerative joint disease • Improved gynecological conditions
  • 60. National Strategy to Address y p Obesity Epidemic • U.S. Department of Health and Human Services Initiative • Small Steps: www.smallstep.gov • Examples: • choose fat free over whole milk • park further from the store and walk • share an entrée • walk to a co-worker’s desk instead of e-mailing
  • 61. The Metabolic Syndrome • Certain “risk factors” for heart disease tend to cluster together and markedly increase your risk: – overweight, especially when carried around the waist – high blood pressure – cholesterol abnormalities (low HDL and high triglycerides) – elevated blood glucose • People with these risk factors need to be treated very aggressively for heart disease prevention: lifestyle changes are key! k !
  • 62. Psychosocial Factors Stress Depression
  • 63. Postmenopausal Hormone Therapy • Postmenopausal HT is no longer recommended as a strategy to prevent heart disease. • Short term hormone therapy, ma therap may still be used sed to treat symptoms of p menopause - this is a decision between a woman and her healthcare provider.
  • 64. Heart Healthy Diet • Eat a variety of fruits, vegetables, vegetables grains • Limit foods high in saturated fat, trans fatty fat acid and cholesterol • Substitute with unsaturated fat from vegetables, fish, legumes, g , , g , and nuts • Limit salt intake
  • 65. Physical Activity •What is the most common excuse for not exercising? Not N enough time h i • What exercise has the lowest dropout rate of any physical activity? Walking
  • 66. FITT: The Exercise Prescription Frequency: 3-5 times per week Intensity y Moderate intensity Time 30-45 minutes Type Low-impact activities
  • 67. Summary • Know the symptoms of heart disease. • Know your risk factors for heart disease. Visit h lth id • Vi it your healthcare provider: – Discuss your risk factors q – Ask questions about y your heart tests • Maintain a healthy lifestyle. • Heart disease is largely preventable.
  • 68. The Red Dress Campaign
  • 69. ... a coworker, a neighbor, a sister About Women and Heart Disease
  • 70. Preventive Cardiovascular Nurses Association Healthcare Professionals: Interested i j i i PCNA? I d in joining - Membership includes a 1 year subscription of the Journal of Cardiovascular Nursing and so much more! Visit http://www.pcna.net or call (608) 250-2440 for more i f information. i
  • 71. Preventive Cardiovascular Nurses Association Click below to view: Printable Resources And Framingham Risk Scale
  • 72. Resources AUGUST 2005 HEART TALK: Nourishing Healthy Hearts Presented by Preventive Cardiovascular Nurses’ Association and Promise Spread
  • 73. Resources Websites for Patient Education Copyright 2005, developed by Jo Ann Carson. Used with permission Therapeutic Lifestyle Changes - http://www.nhlbi.nih.gov/cgi- bin/chd/step2intro.cgi Live Healthier, Live Longer - http://www.nhlbi.nih.gov/chd Health Heart Handbook for Women - http://www.nhlbi.nih.gov/health/public/heart/other/hhw/hdbk_wmn.pdf NHLBI general prevention of heart disease and care for patients - http://www.nhlbi.nih.gov/chd/index.htm Live Healthier, Live Longer Portion Distortion - http://hin.nhlbi.nih.gov/portion/ Be Heart Smart (eat foods lower in saturated fat and cholesterol---part of a series for African-Americans) - http://www.nhlbi.nih.gov/health/public/heart/other/chdblack/smart.pdf Heart Healthy Recipes from NHLBI Keep the Beat - http://www.nhlbi.nih.gov/health/public/heart/other/ktb_recipebk/ktb_recipeb k.pdf “Stay Young at Heart, The Heart Healthy Cooking Way” http://www.nhlbi.nih.gov/health/public/heart/other/syah/index.htm “Heart Healthy Home Cooking, African-American Style:” - http://www.nhlbi.nih.gov/health/public/heart/other/chdblack/cooking.pdf “Latino Heart Healthy Recipes,” - http://www.nhlbi.nih.gov/health/public/heart/other/sp_recip.pdf American Heart Association, http://www.americanheart.org and http://www.deliciousdecisions.org National Restaurant Association - http://www.restaurant.org/dineout/nutrition.cfm Guidance on How to Understand and Use the Nutrition Facts Panel on Food Labels, US Food and Drug Administration http://www.cfsan.fda.gov/~dms/foodlab.html HEART TALK: Nourishing Healthy Hearts Resources 1
  • 74. “Healthy Eating and Physical Activity across Your Lifespan,” provides a four-part series, including “Better Health for You” (for adults) and “Young at Heart” (older adults) from the Weight Control Information Network - http://www.niddk.nih.gov/health/nutrit/nutrit.htm Aim for a Healthy Weight - http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/ DASH - http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf DASH Recipes - http://hin.nhlbi.nih.gov/nhbpep_kit/recipes.htm Reduce Salt and Sodium in Your Diet - http://www.nhlbi.nih.gov/hbp/prevent/sodium/sodium.htm Maintaining a Healthy Weight - http://www.nhlbi.nih.gov/hbp/prevent/h_weight/h_weight.htm HEART TALK: Nourishing Healthy Hearts Resources 2
  • 75. Registered Dietitian as a Resource As described in Section III, evidence supports the benefits of referral to the registered dietitian for lowering serum lipids. The Institute of Medicine describes the registered dietitian as the nutrition professional uniquely prepared with academic preparation, clinical training, national examination and continuing education. Description of MNT provided by the RD In general, patients with risk factors for heart disease can benefit from one or more sessions with the dietitian to address improving lifestyle. but referral to the registered dietitian (RD) is more important for some patients. Examples of such patients include: x Patients with diabetes who need counseling or have never been to the RD x Patients with genetically elevated triglycerides above 500 mg/dL x Patients with hypertriglyceridemia who need to increase fat and lower carbohydrate. x Patients who wish to defer use of indicated lipid-lowering medications. x Patients who have difficulty adopting TLC parameters due to dining out, travel, economic or other restraints. x Patients with lots of alternative medicine/dietary supplement questions Tips for Reimbursement for Medical Nutrition Therapy ƒ The provider should provide written referral to a registered dietitian ƒ Some registered dietitians are listed by geographic area and area of expertise at www.eatright.org ƒ The provider’s order for referral to the dietitian should request Medical Nutrition Therapy ƒ Accurate diagnoses should be included o As of 2005, Medicare specifically covers MNT for diabetes and pre- dialysis renal disease o Metabolic syndrome has now been assigned an International Classification of Disease code (ICD9). Insurance coverage for MNT varies, but is enhanced when the above listed steps are included. HEART TALK: Nourishing Healthy Hearts Resources 3
  • 76. Framingham Risk Score: Women Step 1: Age Points Step 4: SBP Points Step 5: Smoking Status Points Years Points SBP If If Age Age Age Age Age (mmHg) treated untreated 20-39 40-49 50-59 60-69 70-79 20-34 -7 <120 0 0 Nonsmoker 0 0 0 0 0 35-39 -3 120-129 1 3 Smoker 9 7 4 2 1 40-44 0 45-49 3 130-139 130 139 2 4 140-159 3 5 Step 6: Sum of Points 50-54 6 >160 4 6 Age 55-59 8 Total Cholesterol 60-64 10 HDL-C 65-69 12 Systolic Blood Pressure S t li Bl d P 70-74 14 Smoking Status 75-79 16 Point Total Step 2: Total Cholesterol Points Step 7: 10-year CHD Risk TC Age Age Age Age Age (mg/dl) 20-39 40-49 50-59 60-69 70-79 Point 10-year Point 10-year Point 10-year Total Risk Total Risk Total Risk <160 0 0 0 0 0 <9 <1% 15 3% 22 17% 160-199 4 3 2 1 1 9 1% 16 4% 23 22% 200-239 8 6 4 2 1 10 1% 17 5% 24 27% 240-279 240 279 11 8 5 3 2 11 1% 18 6% >25 >30% >280 13 10 7 4 2 12 1% 19 8% 13 2% 20 11% Step 3: HDL-C Points 14 2% 21 14% HDL-C (mg/dl) Points >60 -1 50-59 0 40-49 1 <40 2
  • 77. Framingham Risk Score: Men Step 1: Age Points Step 4: SBP Points Step 5: Smoking Status Points Years Points SBP If If Age Age Age Age Age (mmHg) treated untreated 20-39 40-49 50-59 60-69 70-79 20-34 -9 <120 0 0 Nonsmoker 0 0 0 0 0 35-39 -4 120-129 0 1 Smoker 8 5 3 1 1 40-44 0 45-49 3 130-139 130 139 1 2 140-159 1 2 Step 6: Sum of Points 50-54 6 >160 2 3 Age 55-59 8 Total Cholesterol 60-64 10 HDL-C 65-69 11 Systolic Blood Pressure S t li Bl d P 70-74 12 Smoking Status 75-79 13 Point Total Step 2: Total Cholesterol Points Step 7: 10-year CHD Risk TC Age Age Age Age Age (mg/dl) 20-39 40-49 50-59 60-69 70-79 Point 10-year Point 10-year Point 10-year Total Risk Total Risk Total Risk <160 0 0 0 0 0 <0 <1% 6 2% 13 12% 160-199 4 3 2 1 0 0 1% 7 3% 14 16% 200-239 7 5 3 1 0 1 1% 8 4% 15 20% 240-279 240 279 9 6 4 2 1 2 1% 9 5% 16 25% >280 11 8 5 3 1 3 1% 10 6% >17 >30% 4 1% 11 8% Step 3: HDL-C Points 5 2% 12 10% HDL-C (mg/dl) Points >60 -1 50-59 0 40-49 1 <40 2

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