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Presentation and treatement of coronary artery disease in women
 

Presentation and treatement of coronary artery disease in women

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  • Women under 50 years of age are twice as likely to die after an acute MI as men in the same age group (Rosamond et al., 2007). Premenopausal women tend to present atypical symptoms more frequently than postmenopausal women (Heras, 2006). Elderly women, much like older men, can present sudden dyspnea, and present less pain in the arms and less profuse sweating (Heras, 2006). Women are less likely than age-matched men to have obstructive CAD; in particular, triple-vessel or left main CAD is more common in men, even though more women than men die from CAD (Mieres et al., 2005). The high prevalence of nonobstructive CAD and single-vessel disease in women results in an observed decreased diagnostic accuracy and higher false-positive rate for noninvasive testing, and may account for some differences in presentation of the disease in women versus men (Mieres et al., 2005).
  • The average age of first MI is 70.4 years for women (Rosamond et al., 2007). CAD rates in postmenopausal women are 2 to 3 times those of women the same age who are premenopausal (Rosamond et al., 2007) children of adults w/ CAD are more likely to develop it themselves (AHA)
  • Hypertension is associated with a two- to threefold increased risk of coronary events in women (Mikhail, 2005) Women with diabetes have 2.6 times the risk of dying from CAD than women without diabetes, compared to a 1.8-fold risk among men with diabetes.
  • Folic acid – was recommended for high-risk women with elevated homocysteine levels Folic Acid: NORVIT trial -randomized 3749 men and women post acute MI -@ 40mo. Mean total homocysteine level was lowered by 27% among pts. given folic acid and vit B12 -BUT, no significant effect on recurrent MI, strok, or sudden death attributed to CAD -AND, in group given folic acid, B12, and B6, an INC risk was observed ASA: Women’s Health Study 39,876 healthy women > 45 yoa were randomized to receive 100 mg aspirin on alternate days or placebo and were followed for 10 years NO significant effect on the risk of fatal or nonfatal MI or cardiovascular death was seen in the total study population (Ridkerb et al., 2005) BUT, a significant 17% reduction of stroke risk was reported in women receiving aspirin Subgroup analysis – in the 4,097 women >65 yoa, in whom almost 1/3 rd of cardiovascular events were seen, fewer women experienced MIs, strokes, or death from cardiovascular causes (NORVIT trial, which randomized 3749 men and women who had experienced an acute myocardial infarction within seven days prior to trial inception; At a median follow-up of 40 months, the mean total homocysteine level was lowered by 27% among patients given folic acid plus vitamin B12, but there was no significant effect on recurrent myocardial infarction, stroke, or sudden death attributed to CAD (Bønaa et al., 2006). Unexpectedly, in the group given folic acid, vitamin B12, and vitamin B6, an increased risk was observed ) ( While no significant effect on the risk of fatal or nonfatal MI or cardiovascular death was seen in the total study population (Ridkerb et al., 2005), a significant 17% reduction of stroke risk was reported in women receiving aspirin, due to a 24% reduction in the risk of ischemic stroke along with a nonsignificant increase in the risk of hemorrhagic stroke (Wenger, 2006). Subgroup analysis in this study provided evidence that the most consistent cardiovascular benefit was in the 4,097 women aged 65 years or older (10% of the study population), in whom almost one-third of all cardiovascular events were seen (Wenger, 2006). In this subgroup, fewer women experienced MIs, strokes, or death from cardiovascular causes )
  • ( ACC/AHA: Women @ intermediate to high pretest likelihood for CAD = women with typical or atypical chest pain at >50yoa; or women <50yoa with typical angina ) Symptomatic intermediate- and high-risk women are recommended to initially undergo exercise ECG, despite sex-specific limitations on its accuracy due to false-positive ST-segment responses and the influence of submaximal stress on sensitivity (Mieres et al., 2005). According to the American College of Cardiology / American Heart Association (ACC/AHA) practice guidelines for exercise testing, women at intermediate to high pretest likelihood for CAD may be defined as those with typical or atypical chest pain at greater than 50 years of age, and those less than 50 years of age with typical angina (Mieres et al., 2005). It is not recommended that women at a low risk of having CAD undergo cardiac imaging, due to an observed decreased diagnostic accuracy and higher false-positive rate for noninvasive testing in women versus men (Mieres et al., 2005). Exercise ECG testing does have a high negative predictive value in women with a low pretest probability of CAD and a low-risk Duke treadmill score (Mieres et al., 2005). Recent studies have shown that combining parameters such as exercise capacity and heart rate changes with traditional evaluation of ST-segment changes improves the prognostic accuracy of the exercise treadmill test, making it a cost-efficient modality to use in this group of women (Mieres et al., 2005). Imaging is recommended for women with an indeterminate or intermediate-risk exercise ECG test, or an intermediate-risk Duke treadmill score (Mieres et al., 2005). Imaging is also recommended for women at intermediate- or high-risk who have diabetes, an abnormal resting ECG, or questionable exercise capacity (Mieres et al., 2005).
  • The Women’s Health Study supported previous reports that levels of high-sensitivity C-reactive protein provided additional prognostic information beyond the predictive value of all lipid measures (Ridkera, Rifai, Cook, Bradwin, Buring, 2005).

Presentation and treatement of coronary artery disease in women Presentation and treatement of coronary artery disease in women Presentation Transcript

  • Approaches to Prevention and Recognition of Coronary Artery Disease in Women Tara Conzelman Advisor: Dr. Bob Hadley
  • Why talk about this now?
    • CAD is the leading cause of death of women in the US
    Figure 1: CVD and other major causes of death in females, United States 2004. Taken from the AHA Heart disease and stroke statistics - 2007 update.
  • Why talk about this now?
    • In the past decade, incidence of CAD has doubled among women
    • Research has reported underrecognition and underdiagnosis of CAD in women
    • Practioners can improve survival outcomes by adhering to recommendations shown to benefit women
  • Background: Differences in CAD in women vs. men
    • CAD incidence lags by ~ 10 yrs. compared to men; MI and sudden death lag by ~20yrs.
    • Chest pain is the most commonly reported symptom in both sexes, but women more frequently report N/V, indigestion, pain in middle of back and jaw
    • High prevalence of nonobstructive CAD and single-vessel disease in women; affects diagnostic accuracy of non-invasive testing
  • What you need to know
    • What are a woman’s risk factors for developing CAD?
    • What are the current guidelines on CAD prevention for women?
    • What diagnostic tools are useful in risk-stratifying women?
  • What are a woman’s risk factors for developing CAD?
    • Not modifiable:
      • Age
      • Menopause
      • Heredity
  • What are a woman’s risk factors for developing CAD?
    • Modifiable:
      • Smoking
      • High blood cholesterol
      • High blood pressure
      • Physical inactivity
      • Obesity & overweight
      • Diabetes Mellitus
  • What are the current guidelines on CVD prevention for women?
    • New guidelines just published! (March 2007)
    • Changes reflecting recently published studies:
      • Folic acid – now considered a class III intervention (not useful/effective and may be harmful)
      • ASA - should be used in high-risk women unless CI, consider in women ≥65 yoa if no HTN; not recommended in women <65 yoa to prevent MI (class III)
  • What are the current guidelines on CAD prevention for women?
  •  
  •  
  • What diagnostic tools are useful in risk-stratifying women?
    • According to the 2005
    • “ Role of Noninvasive Testing in the Clinical Evaluation of Women With Suspected Coronary Artery Disease: Consensus Statement From the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association ” ….
  • What diagnostic tools are useful in risk-stratifying women?
      • Cardiac imaging NOT recommended for women @ low pretest risk of CAD (due decreased diagnostic accuracy and higher false-positive rate)
      • Symptomatic intermediate- and high-risk women should initially undergo exercise ECG;
      • (parameters such as exercise capacity and HR changes should be included in evaluation for inc. diagnostic accuracy)
  •  
    • Harshida P, Rosengren A, Ekman I. Symptoms in acute coronary syndromes: does sex make a difference. Am Heart J. 2004;148(1):27-33
    • Leibson PR. Women’s Health Initiative (WHI) dietary trial and Norwegian Vitamin Trial (NORVIT). Preventive Cardiology. 9;3:178-182
    • Maxson J. Heart disease and lipids in women. Advance Online Editions for Physician Assistants. 2006 Oct;14(10):33
    • Mieres JH, Shaw LJ, Arai A, Budoff MJ, Flamm SD, Hundley WG, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: consensus statement form the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005;111:682-696.
    • Milan E. Coronary artery disease: The other half of the heaven. QJ Nucl Med Mol Imaging. 2005;49:72-80.
    • Mosca L, Appel LJ, Benjamin EJ, Berra K, Chandra-Strobos N., Fabunmi RP, Grady D, et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women. Circulation. 2004;109:672-693. DOI: 10.1161/01.CIR.0000114834.85476.81
    • Mosca L, Banka C, Benjamin E, Berra K, Bushnell C, Dolor R, Ganiats T, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 Update. Circulation. 2007; 115:0000-0000. DOI: 10.1161/CIRCULATIONAHA.107.181546
    • Ridkera PM, Rifai N, Cook NR, Bradwin G, Buring JE. Non-HDL cholesterol, apolipoproteins A-1 and B100, standard lipid measures, lipid ratios, and CRP as risk factors for cardiovascular disease in women. JAMA. 2005;294(3):326
    • Ridkerb PM, Cook NR, Lee I, Gordon D, Gaziano JM, Manson JE, et al.. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. 2005;352(13):1293
    • Rosamond W, Flegal K, Friday G, Furie K, Go A, Greenlund K, et al. Heart disease and stroke statistics—2007 Update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:000-000. DOI: 10.1161/CIRCULATIONAHA.106.179918
    • Wenger, N. Coronary heart disease in women: highlights of the past 2 years – stepping stones, milestones and obstructing boulders. Nature Clinical Practice Cardiovascular Medicine. 2006 Apr;3(4):194-202.
    • Wexler DJ, Grant RW, Meigs JB, Nathan DM, Cagliero E. Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes. Diabetes Care. 2005;28:514.
    References