Perceptions Versus Reality: Women and Heart Disease


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  • women presenting with mi have greater complications from tpa then men women derive greater benefit from ptca than men vs tpa
  • Cardiovascular (CV) risk factors (JNC 7) JNC 7 recognizes the following as CV risk factors1: Hypertension Dyslipidemia Cigarette smoking Obesity (BMI ≥30 kg/m2) Physical inactivity Diabetes mellitus Microalbuminuria (or estimated GFR* <60 mL/min) Age (>55 years for men, >65 years for women) Family history of premature CVD (men <55 years or women <65 years) Hypertension and dyslipidemia are 2 of the most common modifiable CV risk factors.2 *Glomerular filtration rate. References: 1. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003;289:2560-2572. 2. American Heart Association. Heart Disease and Stroke Statistics — 2003 Update. Dallas, Tex: American Heart Association; 2002. emerging risk factors include metabolic syndrome, tg's, Lp(a), Lp-PLA2, homocyteine, hsCRP ABI, ebt emerging risk factors should not be given undue weight relative to major risk factors
  • Increasing Prevalence of Obesity in US Adults Researchers used from the 2001 Behavioral Risk Factor Surveillance System (BRFSS) to determine the rate of obesity (BMI  30 kg/m 2 ) in US adults aged 18 years or older. Prevalence of obesity among US adults increased 74% between 1991 and 2001, from 12% of the population to 20.9%. Mississippi had the highest obesity prevalence at 25.9%, and Colorado, at 14.4%, had the lowest. In 1991, 8 states reported obesity prevalences of  10%, 35 reported 10%-14%, and 4 reported  15% (3 states had no report). In 2001, no states had  10% obesity prevalence, only Colorado had  15%, 20 states had 15%-19%, 28 states had 20%-24%, and one state, Mississippi, had 25% or greater. BRFSS data was obtained by the Centers for Disease Control and Prevention and state health departments with random calls to 195,005 adults in all 50 states and the District of Columbia. Participants were asked a number of health-related questions, including their weight and height. Researchers caution that the percentages are conservative estimates compared to other studies due to the self-reported nature of the BRFSS data, with a tendency for people to underestimate their weight and overestimate their height. Mokdad AH et al. JAMA . 2003;289:76-79.
  • This data supports the premise that the greater the BMI, the higher the risk of CHD mortality. This study examined nurses who never smoked. As the BMI increased beyond 26.9, the relative risk increased sharply.
  • Reported Causes of Death in People With Diabetes Data from death certificates reveal that CVD accounts for >50% of deaths in people with type 1 and type 2 diabetes. Diabetes (acute diabetes-related complications, such as ketoacidosis and hyperosmolar coma) is the next most common cause overall, accounting for 13% of deaths. Cancer, stroke, infections, and all other causes account for the remaining 34%. For older individuals with type 2 diabetes, the relative contribution of CVD increases and the contribution of diabetes per se (acute complications) decreases. Renal disease does not appear as a separate category, because dialysis and transplantation have made renal failure an uncommon immediate cause of death. However, mortality from CVD is high in patients who are on long-term dialysis.   Geiss LS et al. In: Diabetes in America . 2nd ed. 1995; chap 11.
  • Optimal level of hdl-c>50 Intiate niacin or fibrate therapy for low hdl or elevated nonhdl in high risk women is a class 1 recommendation
  • metabolic syndrome and diabetes are risk factors for stroke interventions that target prevention or treatment of metabolic syndrome may lead to important reductions in the risk of CVD Reduce sat fats to <10% and cholesterol <300, limit sodium to <2.4g/day,reduce trans FA Metabolic syndrome is a precursor for heart disease and type 2 dm and affects up to ¼ of americans older than 20 Expected to increase as we get older and heavier
  • asa risk of bleed ing from pud and hemorrhagic bleed from elevated bp
  • HPS says women at high risk should be on a statin regardless of LDL Arb’s for high risk women with clinical evidence of chf or decrease in lvef or intolerant to acei’s HDL level should be greater than 50 for high risk women and use niacin or fibrate only after ldl at goal with statin
  • The age adjusted cv death rate per 10,000 was lowest for low risk women and increased with the number of risk factors Risk factors: bp, choles, bmi, dm smoking 0.19, 1.5, 1.71, 5.0, 9.1 rr of cv dz mortality So you see, it does matter how many risk factors and pts shouldn’t give up because they have one risk factor because the more you have the worse off you are
  • Perceptions Versus Reality: Women and Heart Disease

    1. 1. Perceptions Versus Reality: Women and Heart Disease Ginger Hook, MSN, RN
    2. 2. Overview <ul><li>Heart Disease </li></ul><ul><ul><li>Discuss Statistics of heart disease </li></ul></ul><ul><ul><li>Identify risk factors for women and heart disease </li></ul></ul><ul><ul><li>Discuss evidence-based guidelines for Cardiovascular Disease Prevention in Women </li></ul></ul><ul><li>Metbolic Syndrome </li></ul><ul><ul><li>Define MetS </li></ul></ul><ul><ul><li>Discuss statistics of MetS </li></ul></ul><ul><ul><li>Discuss the findings of the ARIC Study </li></ul></ul><ul><ul><li>Discuss study from Arch Intern Med, 2004 </li></ul></ul><ul><ul><li>Discuss NHANES II 1976-80, Follow up study </li></ul></ul><ul><ul><li>Identify Scientific Evidence related to Definition </li></ul></ul>
    3. 3. Statistics
    4. 4. Statistics <ul><li>Heart Disease and Stroke </li></ul><ul><ul><li>First and third leading causes of death in US </li></ul></ul><ul><ul><li>Accounts for more than 40% of all deaths </li></ul></ul><ul><li>About 95,000 Americans die of heart disease or stroke each year </li></ul><ul><ul><li>Amounts to one death every 33 seconds </li></ul></ul><ul><li>Heart Disease is the leading cause of disability among working adults </li></ul>
    5. 5. Age-Adjusted Mortality 2005 Epidemiological Report – Northwest Indiana
    6. 6. Economics <ul><li>2001 </li></ul><ul><li>Nationwide cost for all cardiovascular disease was $300 billion </li></ul><ul><li>Heart disease the cost was $105 billion </li></ul><ul><li>Stroke, $28 billion </li></ul><ul><li>Lost productivity due to stroke and heart disease cost mor than $129 billion </li></ul>2005 Epidemiological Report – Northwest Indiana
    7. 7. Age-Adjusted Mortality 2005 Epidemiological Report – Northwest Indiana
    8. 8. 2005 Epidemiological Report – Northwest Indiana Sources: Indiana State Department Lake LaPorte Porter IN US HP 2010 Diseases of the Heart 264.1 271.7 224.6 246.1 240.8 213.7* Malignant Neoplasms 223.6 198.6 195.3 208.3 193.5 159.9 Chronic Lower Resp Diseases 44.6 52.4 36.6 51.1 43.5 Cerebrovascular Disease 52.7 48.6 45.3 59.4 56.2 48.0 Influenza/Pneumonia 13.2 10.8 10.5 21.6 22.6 Diabetes Mellitus 34.2 20.1 25.7 27.3 25.4 15.1* Motor Vehicle Accidents 14.6 19.6 16.9 15.0 15.7 9.2 Intentional Self-Harm 10.6 9.2 12.1 11.9 10.9 5.0 Assault 19.0 8.3 2.4 6.1 6.1 3.0
    9. 9. Age-Adjusted Mortality
    10. 10. Women and Heart Disease
    11. 11. Heart Disease is the #1 Killer of Women <ul><li>Coronary heart disease is the single leading cause of death and a significant cause of morbidity among American women. </li></ul><ul><li>In 1997 CHD claimed the lives of 502,938 women (men had less deaths) </li></ul><ul><li>Since 1984, CVD has killed more American women than men each year. </li></ul>
    12. 12. “ Breast Cancer is the REAL issue!” <ul><li>Who cares about heart disease doc…I am more concerned about: </li></ul><ul><li>BREAST CANCER and lung cancer!” </li></ul><ul><li>In a recent survey, 75% of women identified cancer as their leading cause of death… </li></ul>
    13. 13. Recent Screening
    14. 14. In perspective: <ul><li>1 in 2 women will die of heart disease. </li></ul><ul><li>1 in 25 women will die of breast cancer. </li></ul>
    15. 15. Coronary Heart Disease in Women <ul><li>Presentation and differences from men </li></ul><ul><li>2/3 of women who die suddenly have no previously recognized symptoms. </li></ul><ul><li>Women are more prone to non-cardiac chest pain….. </li></ul><ul><li>In fact they may experience little or no squeezing chest pain in the center of the chest, lightheadedness, fainting, or shortness of breath with an MI (as seen on “ER”). </li></ul>
    16. 16. Nationally: The Problem – AWARENESS <ul><li>Perception </li></ul><ul><li>67% knowledgeable that chest pain can be heart disease </li></ul><ul><li><10% knowledgeable that SOB, nausea, indigestion can be heart disease </li></ul><ul><li>Reality </li></ul><ul><li>chest pain is the presenting symptom in <50% of women </li></ul><ul><li>Almost half of MIs in women present with SOB, nausea, indigestion, fatigue and shoulder pain </li></ul>
    17. 17. Causes of Confusion: <ul><li>Women may experience more dizziness, nausea, indigestion, and fatigue than men. </li></ul><ul><li>Women are more likely to have neck, arms, back and shoulder pain. </li></ul>
    18. 18. Evidence based information about symptoms suggests a gender focus Women have More atypical Symptoms of MI Source: Milner Am J Cardiol 1999;84:396
    19. 19. Not so straightforward <ul><li>Because of these atypical symptoms , women seek medical care later than men and are more likely to be misdiagnosed. </li></ul><ul><li>Women presenting with MI and CAD are more likely to be older, have a history of DM, HTN, Hyperlipids, CHF, and unstable angina than male counterparts. (J Am Coll Cardiol 1997;29) </li></ul><ul><li>Because of these comorbid conditions , there tends to be diagnostic confusion. </li></ul>
    20. 20. Misperceptions and Missed Opportunities Leading to Access Inequity <ul><li>Women were less likely to have an EKG or be admitted to the telemetry floors. </li></ul><ul><li>Women are under-diagnosed and can therefore get a false sense of security. </li></ul><ul><li>Less aspirin, beta-blockers, statins, antiarrhythmic treatment, cardiac cath, PTCA, CABG </li></ul><ul><li>Women were less likely to enroll in cardiac rehabilitation after an MI or bypass surgery. </li></ul>
    21. 21. CHD Mortality in Younger Women Women under 65 suffer the highest relative sex-specific CHD mortality
    22. 22. The Need for Prevention in Women <ul><li>9,000 US women younger than 45 sustain a heart attack each year. </li></ul><ul><li>“ Thus the priority for coronary prevention is substantial for women of all ages.” </li></ul><ul><li>Mortality associated with acute MI among women younger than 65 y/o is almost twice as high among men . </li></ul>
    23. 23. Women vs. Men: <ul><li>Mortality from CABG-particularly among younger women-is double that among men. </li></ul><ul><li>More women than men die 1 year after an MI. </li></ul><ul><li>CHD is Largely Preventable </li></ul><ul><li>We need to address risk factors earlier and more aggressively, thereby reducing women’s cardiovascular risk. </li></ul>
    24. 24. Women and Heart Disease Risk Factors
    25. 26. Non-modifiable Risk Factors <ul><li>Age > 55 </li></ul><ul><ul><li>CAD rates are 2-3x’s higher in postmenopausal women </li></ul></ul><ul><li>Family history </li></ul><ul><ul><li>CHD in primary 1 st degree relative male<55 or female<65 </li></ul></ul>
    26. 27. The #1 Preventable Risk - Smoking <ul><li>A. 50% of heart attacks among women are due to smoking. Smokers tend to have their first heart attack 10 years earlier than nonsmokers. </li></ul><ul><li>B. If you smoke, you are 4-6x’s more likely to suffer a heart attack and increase your risk of a stroke. </li></ul><ul><li>C. Women who smoke and take OCP’s increase their risk of heart disease 30x’s. </li></ul>
    27. 28. 2. Obesity <ul><li>A. 1/3 of adult women are obese and its increasing </li></ul><ul><li>B. Active women have a 50% risk reduction in developing heart disease. </li></ul>
    28. 29. Increasing Prevalence of Obesity in US Adults
    29. 30. Obesity and Coronary Heart Disease Mortality Nurses’ Health Study: Women who never smoked Relative Risk of Coronary Heart Disease mortality Body Mass Index (kg/m 2 ) P<0.001 for trend Manson JR, et al. N Engl J Med. 1995;333:677-685.
    30. 31. Hypertension <ul><li>65% of all hypertension remains either undetected or inadequately treated. </li></ul><ul><li>People who are normotensive at 55 have a 90% lifetime risk of developing HTN. </li></ul><ul><li>Prevalence increases with age and women live longer- hypertension is more common in females. </li></ul><ul><li>HTN is more common with OCP and obesity. </li></ul>
    31. 32. Risk Factors: Diabetes <ul><li>Diabetes increases the risk of CHD 3-7 X’s in women versus 2-3 X’s in men. </li></ul><ul><li>Diabetic women who smoke have a 84% higher risk of developing stroke than nonsmokers. </li></ul><ul><li>2 of 3 people with diabetes die from CHD or stroke. </li></ul>
    32. 33. Reported Causes of Death in People With Diabetes C
    33. 34. Cholesterol <ul><li>More than 55 million women (45million men) have TC>200. </li></ul><ul><li>Check cholesterol at least once q 5yr’s starting at age 20. </li></ul><ul><li>36 Million people in the US should be taking a statin according to guidelines, but only 11 million are. </li></ul>
    34. 35. Treatments Based on Risk Factors
    35. 36. SMOKING: <ul><li>Stop!!!!! (avg. attempt = 8 times) </li></ul><ul><li>Women who have other smokers in their household have a 2.5 X's greater likelihood of relapse. Circulation 2002:106 </li></ul><ul><li>Smoking cessation was associated with a 36% reduction in mortality among patients with CHD. JAMA 2003:290 </li></ul>
    36. 37. Women and HTN—JNC VII <ul><li>The relationship bet. BP and CV events is continuous, consistent and independent of other risk factors. </li></ul><ul><li>The higher the BP the greater the chance of MI, CHF, stroke, and kidney disease. </li></ul><ul><li>Can try to achieve good BP through lifestyle changes. </li></ul>
    37. 38. Lifestyle Modification for HTN Modification Recommendation Expected systolic reduction Weight reduction Goal of BMI 18-25 Waist <35inches 5-20 mm Hg per 10kg wt loss DASH Fruits, veges, low-fat dairy products, less fat 8-14 mm Hg Sodium restriction <2.4 g every day 2-8 mm Hg Physical activity 30 mins of aerobic 4x’s a week 4-9 mm Hg Reduced EtOH (1/2 for women) 2-12 oz beer, 1 10oz wine, 3 oz 80proof whiskey in men 2-4 mm Hg
    38. 39. Exercise <ul><li>30-45 mins of walking 5x’s/week reduces risk of MI in females 50%. </li></ul><ul><li>Helps control BP, increases HDL, decreases body fat, DM risk, possibly prostate, breast and uterine cancers. </li></ul>
    39. 40. Glycemic control In Diabetes <ul><li>Treatment of hyperglycemia has been shown to reduce or delay complications of diabetes such as retinopathy, neuropathy, and nephropathy </li></ul><ul><li>keep HBA1C < 6.5% </li></ul><ul><li>FPG <100 </li></ul><ul><li>2 hour 75g GTT-Impaired glucose tolerance- 140-199. </li></ul>
    40. 41. Cholesterol <ul><li>Women at high risk should be considered for statin therapy regardless of cholesterol-LDL levels. </li></ul><ul><li>Statin drugs have already surpassed all other classes of medicines in reducing the incidence of the major adverse outcomes of death, MI, and stroke. NEJM 350:15 April 8, 2004 </li></ul>
    41. 42. Coronary Heart Disease Whom Do You Treat? How Aggressive should you be?
    42. 43. Evidenced-Based Guidelines for Cardiovascular Disease Prevention in Women The AHA Guidelines February 2004
    43. 44. Framingham Heart Study <ul><li>An individualized approach based on cardiovascular risk- </li></ul><ul><li>First- Assess and stratify women into high, intermediate, lower/optimal risk categories. </li></ul><ul><li>The aggressiveness of treatment should be linked with your risk of having a heart attack or event in the next 10 years - based on the Framingham Heart Study. </li></ul>
    44. 45. Framingham Point Score <ul><li>You get points for: </li></ul><ul><li>Age </li></ul><ul><li>Total Cholesterol </li></ul><ul><li>HDL Cholesterol </li></ul><ul><li>Smoking </li></ul><ul><li>Systolic Blood Pressure </li></ul><ul><li>Add these numbers --you get a 10 yr CHD risk % (category): </li></ul>
    45. 46. Risk Stratification - Lower Risk <ul><li>A. Low Risk : 10% or less risk of having a heart attack or dying of heart disease in the next 10 years. </li></ul><ul><li>May include women with multiple risk factors , Metabolic Syndrome, or 1 or no risk factors. </li></ul>
    46. 47. Metabolic Syndrome RISK FACTOR DEFINING LEVEL Abdominal Obesity Waist Circumference Men >40 inches Women >35 inches TG’s > 150 HDL Men <40 Women <50 BP > 130/85 Fasting Glucose > 100 mg/dl
    47. 48. Mortality Associated With Metabolic Syndrome Lakka H - M et al. JAMA . 2002;288:2709 - 2716. 18 9 6 8 3 2 0 2 4 6 8 10 12 14 16 18 20 All-cause mortality* CVD mortality* CHD mortality* Metabolic syndrome No metabolic syndrome Mortality (% of patients)  2003 PPS ® *Adjusted for known CHD risk factors. POWERSEARCH PLUG-IN™ 2.0 Copyright © 2001-02 Accent Graphics, Inc. Slide Source: &quot;R:NDEI-22004 GrantT108ARST095 ARS Case 2 FINAL-Baton Rouge 12-09-03.ppt&quot; <OPEN> Last Modified: December 9, 2003 2:17:25 PM Slide Number: 19
    48. 49. Intermediate Risk <ul><li>Those with a 10-20% chance of a heart attack in the next 10 yrs. </li></ul><ul><li>Pts with the metabolic syndrome, multiple risk factors, marked elevations of a single risk factor, first degree relative with CHD (male<55, female<65) </li></ul>
    49. 50. High Risk: >20% <ul><li>You are automatically considered high risk if you have: </li></ul><ul><li>PAD </li></ul><ul><li>CRF </li></ul><ul><li>AAA </li></ul><ul><li>DM </li></ul><ul><li>history of stroke </li></ul>
    50. 51. Practice Prevention <ul><li>Low Risk Women <10%: </li></ul><ul><li>Class I recommendations: Intervention is useful and effective: </li></ul><ul><li>Lifestyle Interventions” Smoking Cessation Physical Activity Heart Healthy Diet- DASH Diet Weight Reduction Treat Individual CVD risk factors </li></ul>
    51. 52. Practice Prevention <ul><li>Intermediate Risk Women (10-20%): Smoking Cessation Physical Activity Heart Healthy Diet- DASH Diet Weight Reduction Control BP and Lipids </li></ul><ul><li>Class Ila- most scientific evidence favors this type of therapy: ASA Rx- as long as BP is controlled (hemorrhagic stroke) and minimal risk of GI bleed </li></ul>
    52. 53. Practice Prevention <ul><li>High Risk Women (>20%): Class I Smoking Cessation Physical Activity/cardiac rehab Heart Healthy Diet- DASH Diet Weight Reduction Control BP and Lipids- statin ASA therapy  blocker therapy -esp in all s/p MI ACE-I or ARBS Glycemic control in DM </li></ul>
    53. 54. Heart Disease <ul><li>There is a continuum of CVD risk, it is not a “have or have-not” condition. </li></ul><ul><li>CHD is less in women who control their risk factors. JAMA Oct. 6, 2004 </li></ul><ul><li>The average age of our population is increasing and so CHD will remain a major public health issue. </li></ul>
    54. 55. Women and Heart Disease – Treatment - Summary <ul><li>Aggressive medical therapy appears particularly effective in women. </li></ul><ul><li>Women face more adverse outcomes with revascularization, due to procedural complications, suboptimal gender-based risk Stratification and possibly microvascular disease. </li></ul><ul><li>Long term revascularization risk reduction and outcomes for women are similarly beneficial to men. </li></ul>
    55. 56. EDUCATE!!! <ul><li>Women’s main source of information on heart disease: Magazines 45% TV 34% Newspaper 27% MD’s 24% </li></ul><ul><li>Only 38% of pts in a recent survey said they discussed CHD prevention with their MD’s. </li></ul>