PERCEPTIONS Vs REALITY:
WOMEN AND HEART DISEASE
Consultant Interventional Cardiologist
What is Heart Disease?
• Heart : The most hard-working muscle of our body –
pumps 4-5 liters of blood every minute during rest
• Supplies nutrients and oxygen rich blood to all body
parts, including itself.
• Coronary arteries
surrounding the heart keep it
nourished with blood
What is Atherosclerosis?
What is Coronary Artery disease?
• Over time, fatty deposits called plaque build up within
the artery walls. The artery becomes narrow. This is
• When this occurs in the coronary arteries, heart does not
get sufficient blood, the condition is called coronary
artery disease, or coronary heart disease
What are the symptoms of Coronary
• No symptoms for long period
• Chest pain for short period on exertion
also known as Angina or minor heart
• Myocardial Infarction or major heart
attack-Severe chest pain, death of heart
muscle, heart failure, irregular heart beats
• Sudden Death
How Big is the Problem ?
No. 1 killer disease worldwide
12 Million deaths annually.
During last 30 years large declines in
developed countries -rising health
awareness and government
Alarming increase in developing
countries especially India
Why Should I (Indian)
be Worried ?
• Indians More susceptible than any other
– 3.4 times more than Americans
– 6 times more than Chinese
– 20 times more than Japanese
– Occurs even at lower cholesterol levels
• Get the disease at much younger age
- 5-10 years earlier than other communities
• Disease follows more severe and malignant course
– 3 times higher rate of second heart attack and two times
higher mortality than whites
Kerala - Statistics
• 110 People die of heart disease daily.
• 38,000 people die of heart attack
every year(ICMR, WHO)
• 50% of total death due to
• (28% in India)
• ↑se to 2/3 by 2020
What do we need to
WOMEN AND HEART
Gender Bias in the Treatment of Women
―… The community has
viewed women‘s health almost
with a ‗bikini’ approach,
looking essentially at the
breast and reproductive
system, and almost ignoring
the rest of the woman as part
of women‘s health ….‖
Heart Disease is the #1 Killer of
• Coronary heart disease is the
single leading cause of death and
a significant cause of morbidity
• In 1997 CHD claimed the lives
of 502,938 women (men had less
• Since 1984, CVD has killed
more women than men each
Death From Breast Cancer or
Heart Disease in Women in the US
US Vital Statistics, 1990
CVD Mortality Trends
American Heart Association. 2002 Heart and Stroke Statistical Update. 2001
• 1 in ―2‖ women will die
of heart disease.
• 1 in ―25‖ women will die
of breast cancer.
Coronary Heart Disease in Women
• Presentation and differences from men
• 2/3 of women who die suddenly have no
previously recognized symptoms.
• Women are more prone to non-cardiac
• 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
Not So Straight Forward
• Because of these atypical symptoms, women
seek medical care later than men and are
more likely to be misdiagnosed.
• 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.
• Because of these comorbid conditions, there
tends to be diagnostic confusion.
Misperceptions and Missed Opportunities
Leading to Access Inequity
• Women were less likely to have an
EKG or be admitted to the telemetry
• Women are under-diagnosed and
can therefore get a false sense of
• Less aspirin, beta-blockers, statins,
anti arrhythmic treatment, cardiac
cath, PTCA, CABG
• Women were less likely to enroll in
cardiac rehabilitation after an MI or
CHD Mortality in Younger Women
< 50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
Figure 1. Rates of death during hospitalization for Myocardial Infarction among w omen and men, according to age. The interaction betw een sex
and age w as significant (P<0.001).
Women under 65 suffer the highest relative sex-specific CHD mortality
Women vs Men
• Mortality from CABG-
particularly among younger
women-is double that among
• More women than men die 1
year after an MI.
• CHD is Largely Preventable
• We need to address risk factors
earlier and more aggressively,
thereby reducing women‘s
What Increases Risk?
• High Cholesterol
• High Blood Pressure
• Physical Inactivity
• Family history of cardiovascular disease.
• If your parents have cardiovascular disease
(especially if they were diagnosed before age
50), you have an increased risk of developing it.
Emerging Risk Factors
• Lipoprotein (a)
• Prothrombotic factors
• Proinflammatory factors
• Impaired fasting glucose
• Subclinical atherosclerosis
– Other clinical forms of atherosclerotic disease
(peripheral arterial disease, abdominal aortic
aneurysm, and symptomatic carotid artery disease)
– Abnormal internal or common carotid CIT, ankle-
arm index <0.9, coronary Ca2+
Gender Differences in CAD Risk
• Increasing recognition that atherosclerosis is
an inflammatory process
• Ridker PM, et al: A prospective case-
controlled study among 28,263
– Among 12 markers of inflammation, C
reactive protein was the strongest
univariate predictor of the risk of CV
Ridker PM, et al. N Engl J Med. 2000
CHOLESTEROL ( A TYPE OF FAT)
• Everybody needs cholesterol, it serves a vital
function in the body.
• It circulates in the blood.
• Too much cholesterol can
deposit in the arteries in the
form of plaque and block
• No symptoms till heart attack
WHERE DOES IT COME FROM ?
• Two sources of
& made in your
• Food sources: All
animal fat and
GOOD VS. BAD CHOLESTEROL
• LDL cholesterol
– known as bad cholesterol. It has
a tendency to increase risk of
– major component of the plaque
that clogs arteries
• HDL cholesterol
– known as the good cholesterol.
Increases with exercise
– helps carry some of the bad
cholesterol out of arteries.
Know your Number!
• Total Cholesterol < 200;
• LDL < 100
• HDL > 40
• Triglycerides < 200
• Get the levels tested routinely and keep them
• The only thing worse than finding out that you
have one of these conditions is…….NOT finding
out that you have it!!
And that’s not your Mobile Number!
Look before your eat
• Eat a variety of fruits and vegetables every
day. (5 servings - they are naturally low in
fat and high in vitamins and minerals and
anti oxidants). Eat colored vegetables and
• Eat a variety of grain products
• Choose nonfat or low-fat products.
• Use less fat meats- chicken, fish and lean
Switch to fat-free milk—toned/skimmed
• Increases blood pressure
• Decreases HDL
• Damages arteries and blood
• Increases heart attacks
• Cigarette smoke contains
more than 4,000 chemicals,
and 200 of these chemicals
Preventable Risk- Smoking
• A. 50% of heart attacks among
women are due to smoking. Smokers
tend to have their first heart attack 10
years earlier than nonsmokers.
• B. If you smoke, you are 4-6x‘s more
likely to suffer a heart attack and
increase your risk of a stroke.
• C. Women who smoke and take
OCP‘s increase their risk of heart
If you think YOU are smoking the cigarette, you are mistaken…
“It’s the other way round”!
• Stop!!!!!(avg. attempt = 8 times)
• Women who have other smokers
in their household have a 2.5 X's
greater likelihood of relapse.
• Smoking cessation was
associated with a 36% reduction
in mortality among patients with
In just 20 mins after quitting , blood pressure
After 24 hrs the chance of heart attack decreases
Within 1 year of quitting, CHD risk decreases,
within 2 years it reaches the level of a non
• 65% of all hypertension remains
either undetected or inadequately
• People who are nor motensive at
55 have a 90% lifetime risk of
• Prevalence increases with age
and women live longer-
hypertension is more common in
• HTN is more common with OCP
CONTROLLING BLOOD PRESSURE
• Adults should have their blood pressure
checked at least once every two years, as
there are no symptoms to tell if you have
high blood pressure
• Optimal levels : 120 /80 mm Hg
• If high
– Modify your lifestyle – Diet, Weight, Exercise,
– Adhere to the prescribed medication without fail,
to decrease chances of getting heart disease – Do
not stop your medicines without consulting your
doctor, even if the blood pressure becomes
On average, ~ 1/2 to 1mm
decrease in blood pressure for
each pound weight loss in
obese hypertensives (up to
Weight reduction can raise
Obesity is the major risk for
• 30-45 mins of walking
5x‘s/week reduces risk of MI
in females 50%.
• Helps control BP, increases
HDL, decreases body fat, DM
risk, possibly prostate, breast
and uterine cancers.
• At any given cholesterol level,
diabetic persons have a 2 or 3 x
higher risk of heart attack or stroke
• A diabetic is more likely to die of a
heart attack than a non-diabetic
• ~80% Diabetics die from heart
• Risk of sudden death from a heart
attack for a diabetic is the same as
that of someone who has already had
a heart attack.
Diabetes Creates Higher Risks for Women
• 65% of diabetics die from heart disease or
• 4.2 million American women have diabetes
– Diabetes increases CAD risk 3-fold to 7-
fold in women vs 2-fold to 3-fold in men
– Diabetes doubles the risk of second heart
attack in women but not in men
• Every year, heart disease kills 50,000 more
American women than men
• Statistics are particularly high among African
American women American Heart Association
Centers for Disease Control and Prevention
Manson JE, et al. Prevention of Myocardial Infarction. 1996
Reported Causes of Death in
People With Diabetes
Controlling Blood Sugar
• Normal blood sugar:
• Fasting < 100; Post meals <140
• Keep HBA1C < 6.5%
• If high
– Modify your lifestyle – Diet, Weight,
– Adhere to the prescribed medication
without fail, to decrease chances of
getting heart disease – Do not stop your
medicines without consulting your
doctor, even if the blood sugar becomes
• People who are overweight (10-30 % more than their
normal body weight)
• Obese have 2 to 6 times the risk of developing heart
• Normal Waist Circumference
<88cm in females
< 92cm in males
• Pears or apples?
A. 1/3 of adult women are obese and its
B. Active women have a 50% risk
reduction in developing heart disease.
Obesity and Coronary Heart Disease Mortality
Nurses‘ Health Study: Women who never smoked
Relative Risk of Coronary Heart Disease mortality
Body Mass Index (kg/m2)
Risk Factor Defining Level
Abdominal Obesity Waist Circumference
Men >40 inches
Women >35 inches
Fasting Glucose >100 mg/dl
In small amounts it acts as a vasodilator-Good!
In large amounts it acts as a vasoconstrictor-BAD!
This is a very fine line!
activity has been shown to
decrease blood pressure.
Moderate to intense
physical activity for 30-45
minutes on most days of
the week is recommended.
Exercise and CVD
Serves several functions in preventing and treating
those at high risk.
Reduces incidence of obesity.
Lowers LDL and total cholesterol
Helps control diabetes and hypertension
Those at high risk should take part in a
specially supervised program.
Exercise, Exercise, Exercise
•Mortality is halved in retired men who
walk more than two miles every day
•Regular exercise can halve the risk of
heart disease, particularly in men who
•Someone who is inactive has as great a
risk of having heart disease as someone
who smokes, has high blood pressure or
has high cholesterol
•Exercise significantly reduces the
chances of diabetes and stroke
•With regular exercise, blood pressure in
those with hypertension is reduced by as
much as 20mms Hg
How is cardiovascular disease
associated with menopause?
• After menopause, a woman‘s risk of
cardiovascular disease increases.
• In women who have undergone early
menopause (before age 50) or surgical
menopause, the risk of cardiovascular
disease is also higher, especially when
combined with other risk factors.
• Estrogen helps a woman‘s body protect her
against cardiovascular disease.
• After menopause, cardiovascular disease
becomes more of a risk for women because
of the reduced level of estrogen.
Therapy and Cardio protection
• First randomized trial
• HERS trial (Heart and
– Secondary CAD
– Randomized trial of
placebo vs estrogen
– Follow-up = 4 years
– N = 2,763 women
with an intact uterus
HERS trial. JAMA. 1998.
• There is a continuum of CVD risk, it is not a
―have or have-not‖ condition.
• CHD is less in women who control their risk
factors. JAMA Oct. 6, 2004
• The average age of our population is
increasing and so CHD will remain a major
public health issue.
Other Heart Diseases In Women
• RHD & Aortorto arteritis more common in
• Congenital heart diseases like ASD more in
• Can cause morbidity & maternal/neonatal
mortality during pregnancy and delivery.
• Needs screening of pregnant women with
“GO RED” Conclusions
Heart disease is a number one killer.
Majority of the causes for heart diseases are
known and can be modified.
Adoption of guidelines for prevention of
cardiovascular diseases can help people to
have a lifelong low level of heart diseases
Chances of Heart disease in women are high
& that is on the increase.
Most of the risk factors have a higher impact
in women than men.
Since younger women have a higher mortality
than men(<40yrs) grave implications in
family & society.
All females should be made aware of this
through educative programmes starting at
school & College levels.
Preventive measures save economy & health.
Girl students be screened for RHD &
Congenital Heart diseases through school
Separate ‗Women & Child care‘ wings for
Concessional rate Cardiac check ups for
Realizing this ‗Cardiac Explosions‘ in women
Govt. schemes on a ‗Go Red‘ Basis!!!.