Coronary heart disease is the leading cause of death for all women. Significant disparities exist in the prevention, diagnosis, recognition, management, and clinical outcomes of cardiovascular disease in women.

1. Presented byPresented by
Liliana Cohen, MD, FACCLiliana Cohen, MD, FACC
Women and Heart Disease:Women and Heart Disease:
New Concepts in PreventionNew Concepts in Prevention
and Managementand Management

2. What is CardiovascularWhat is Cardiovascular
Disease?Disease?
Cardiovascular disease (or CVD) includesCardiovascular disease (or CVD) includes
heart and blood vessel diseasesheart and blood vessel diseases ——
diseases that affect the circulatory systemdiseases that affect the circulatory system

3. ExamplesExamples
• Coronary heart disease (heart attack)Coronary heart disease (heart attack)
• Cerebrovascular disease (stroke and TIA)Cerebrovascular disease (stroke and TIA)
• High blood pressureHigh blood pressure
• Congestive heart failureCongestive heart failure
• Congenital cardiovascular defectsCongenital cardiovascular defects
• Peripheral vascular diseasePeripheral vascular disease

4. Blockage of the heart arteries by plaque can cause aBlockage of the heart arteries by plaque can cause a
heart attack (myocardial infarction) or a fatal rhythmheart attack (myocardial infarction) or a fatal rhythm
disturbance (cardiac arrest)disturbance (cardiac arrest)

5. Cardiovascular disease is the leadingCardiovascular disease is the leading
cause of death forcause of death for bothboth men andmen and
women in the U.S.women in the U.S.

6. The MythThe Myth
 The myth that heart disease is a “man’s disease”The myth that heart disease is a “man’s disease”
has been debunkedhas been debunked
 The rate of public awareness of CVD as theThe rate of public awareness of CVD as the
leading cause of death among U.S. women hasleading cause of death among U.S. women has
increased from 30% in 1997 to 54% in 2009increased from 30% in 1997 to 54% in 2009
 The death rate from coronary artery disease inThe death rate from coronary artery disease in
females in 2007 had decreased to 1/3 of what itfemales in 2007 had decreased to 1/3 of what it
was in 1980was in 1980

7. Deaths due to CVD* (United States: 1900–2007)Deaths due to CVD* (United States: 1900–2007)
Source: NHLBI from NCHS reports. * -Source: NHLBI from NCHS reports. * - CVD does not includeCVD does not include
congenital.congenital.
©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

8. CVD and other major causes of death for all males andCVD and other major causes of death for all males and
females (United States: 2007).females (United States: 2007).
Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.
©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

9. Prevalence of CVD in adults ≥20 years of age by age andPrevalence of CVD in adults ≥20 years of age by age and
sex (NHANES: 2005–2008).sex (NHANES: 2005–2008).
Source: NCHS and NHLBI. These data include CHD, HF, stroke, and hypertension.
©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

10. PrevalencePrevalence
 Greater than 1 in 3 Americans have one or moreGreater than 1 in 3 Americans have one or more
types of cardiovascular diseasetypes of cardiovascular disease
 Cardiovascular disease still causes approximatelyCardiovascular disease still causes approximately
one death per minute among women in theone death per minute among women in the
United StatesUnited States
Roger et al. 123 (4): e18. (2011)

11. The Need for PreventionThe Need for Prevention inin
WomenWomen
 Over 10,000 US women younger than 45 sustainOver 10,000 US women younger than 45 sustain
a heart attack each yeara heart attack each year
 The priority for coronary prevention isThe priority for coronary prevention is
substantial for women of all agessubstantial for women of all ages
 Mortality associated with acute MI amongMortality associated with acute MI among
women younger than 65 y/o is almost twice thatwomen younger than 65 y/o is almost twice that
of menof men

12. WomenWomen AREARE Different Than MenDifferent Than Men
 Women are more likely to be olderWomen are more likely to be older
 Women are more likely to have high bloodWomen are more likely to have high blood
pressure, diabetes, high cholesterol and heartpressure, diabetes, high cholesterol and heart
failurefailure
 Women are less likely to be smokersWomen are less likely to be smokers

13. Symptoms of Heart Disease…Symptoms of Heart Disease…
 For both genders, chest pressure/pain is theFor both genders, chest pressure/pain is the
most common symptom of heart diseasemost common symptom of heart disease

14. Women May Experience DifferentWomen May Experience Different
Symptoms Than MenSymptoms Than Men
 Women are more likely to experience:Women are more likely to experience:
 Neck and shoulder painNeck and shoulder pain
 Abdominal painAbdominal pain
 NauseaNausea
 FatigueFatigue
 Shortness of breathShortness of breath
 Women are more likely to experience silent heartWomen are more likely to experience silent heart
attacksattacks

15. Risk FactorsRisk Factors
 AgeAge
 Family History of Early Heart DiseaseFamily History of Early Heart Disease
 SmokingSmoking
 High Blood PressureHigh Blood Pressure
 High Blood CholesterolHigh Blood Cholesterol
 DiabetesDiabetes
 Physical InactivityPhysical Inactivity
 Being Overweight or ObeseBeing Overweight or Obese

16.  A fat-like substance in the bloodA fat-like substance in the blood
 Made in the liver and comesMade in the liver and comes
from some foods we eatfrom some foods we eat
 Too much cholesterolToo much cholesterol
can build up in arteries over timecan build up in arteries over time
 Can cause heart attacks and strokesCan cause heart attacks and strokes
What is cholesterol?What is cholesterol?
Normal Artery
Clogged Artery
Cholesterol

17. Types of CholesterolTypes of Cholesterol
 LDL- Low density LipoproteinLDL- Low density Lipoprotein
 ““bad” cholesterolbad” cholesterol
 Contributes to AtherosclerosisContributes to Atherosclerosis
 The lower your LDL, the lower your risk of heartThe lower your LDL, the lower your risk of heart
attack and strokeattack and stroke
 HDL- High density LipoproteinHDL- High density Lipoprotein
 ““good” cholesterolgood” cholesterol
 Helps remove cholesterol from the arteriesHelps remove cholesterol from the arteries

18. The National CholesterolThe National Cholesterol
Education Program RecommendsEducation Program Recommends:
Total Cholesterol = Less than 200 mg/dl
LDL Cholesterol = Less than 100 mg/dl
HDL Cholesterol = Women: Greater than 50
mg/dl
Men: Greater than 40 mg/dl
Triglycerides = Less than 150 mg/dl
To determine how your levels affect your risk of heart disease,
your doctor will also take into account other risk factors.

19. Controlling Cholesterol andControlling Cholesterol and
TriglyceridesTriglycerides
 Healthy EatingHealthy Eating
 Physical ActivityPhysical Activity
 Weight LossWeight Loss
 MedicationMedication

20. Eating HealthyEating Healthy
 Choose more fruits, vegetables, and whole grain breads,Choose more fruits, vegetables, and whole grain breads,
cerealscereals
 Choose baked, skinless chicken and fish, and low-fatChoose baked, skinless chicken and fish, and low-fat
dairy productsdairy products
 Eat less fatEat less fat
 Saturated fatSaturated fat
 Trans fatty acidsTrans fatty acids
 Eat FiberEat Fiber
 Dried beans, peas, oats, fruits and vegetablesDried beans, peas, oats, fruits and vegetables

21. Improving FatsImproving Fats
 Eat fewer solid fatsEat fewer solid fats
 ShorteningShortening
 Stick butter/margarineStick butter/margarine
 Excess fat on meatsExcess fat on meats
 Substitute liquid or soft fats “Heart-HealthySubstitute liquid or soft fats “Heart-Healthy
Fats”Fats”
 Monounsaturated oilsMonounsaturated oils
 Olive oil, canola oilOlive oil, canola oil

22. Improving FatsImproving Fats
 AvoidAvoid TransTrans fatsfats
 TransTrans fatty acids raise LDL and lower HDLfatty acids raise LDL and lower HDL
 Increase risk of heart disease/stroke/Type IIIncrease risk of heart disease/stroke/Type II
DiabetesDiabetes
 Found in fried foods, cookies,Found in fried foods, cookies,
cakes, crackers, snack foodscakes, crackers, snack foods
 Replace trans fats withReplace trans fats with
mono/polyunsaturated fats (fish, seeds)mono/polyunsaturated fats (fish, seeds)

23. Limit Dietary CholesterolLimit Dietary Cholesterol
 Can raise blood cholesterolCan raise blood cholesterol
 Limit foods high in cholesterolLimit foods high in cholesterol
 Liver, organ meats, egg yolks,Liver, organ meats, egg yolks,
full-fat dairy productsfull-fat dairy products
 The American Heart Association recommends:The American Heart Association recommends:
 Less than 300 mg/dayLess than 300 mg/day
 Less than 200 mg/day (with diabetes or heart disease)Less than 200 mg/day (with diabetes or heart disease)

24. TriglyceridesTriglycerides
 Limit sugar and refined carbohydratesLimit sugar and refined carbohydrates
 Limit alcohol consumptionLimit alcohol consumption
 Substitute mono/polyunsaturated fats forSubstitute mono/polyunsaturated fats for
saturated fatssaturated fats
 Exercise/ weight lossExercise/ weight loss

26. Physical ActivityPhysical Activity
 Important even as we get older!Important even as we get older!
HDL CholesterolHDL Cholesterol
LDL CholesterolLDL Cholesterol
Lower triglyceridesLower triglycerides
 30 minutes or more on most days30 minutes or more on most days
 Moderate intensity (150 minutes/week)Moderate intensity (150 minutes/week)
 High intensity (75 minutes/week)High intensity (75 minutes/week)

27. Weight ManagementWeight Management
 Weight loss can…Weight loss can…
 LDLLDL
 TriglyceridesTriglycerides
 HDLHDL
 JustJust 5 to 10 pounds5 to 10 pounds will help showwill help show
improvements!!!improvements!!!

28. High Blood PressureHigh Blood Pressure
 Systolic pressureSystolic pressure —— pressure in arteries when the heartpressure in arteries when the heart
beatsbeats
 Diastolic pressureDiastolic pressure —— pressure when the heart restspressure when the heart rests
between beatsbetween beats
 Goal: below 120/80 mm HgGoal: below 120/80 mm Hg

29. HypertensionHypertension
 65% of all hypertension remains either65% of all hypertension remains either
undetected or inadequately treatedundetected or inadequately treated
 People who are normotensive at 55 havePeople who are normotensive at 55 have
a 90% lifetime risk of developing HTNa 90% lifetime risk of developing HTN
 Prevalence increases with age and womenPrevalence increases with age and women
live longer- hypertension is morelive longer- hypertension is more
common in femalescommon in females
 HTN is more common with OCP andHTN is more common with OCP and
obesityobesity

30. Lifestyle Approaches toLifestyle Approaches to
HypertensionHypertension
Source: JNC 7 2004, Sacks 2001
 Maintain ideal body weightMaintain ideal body weight
 Weight loss of as little as 10 lbs reduces bloodWeight loss of as little as 10 lbs reduces blood
pressurepressure
 Heart healthy dietHeart healthy diet
 Even without weight loss, a diet rich in fruits,Even without weight loss, a diet rich in fruits,
vegetables, and low fat dairy products can help tovegetables, and low fat dairy products can help to
reduce blood pressurereduce blood pressure
 Sodium restriction to 1500 mg/dSodium restriction to 1500 mg/d
 Increase physical activityIncrease physical activity
 Limit alcohol to one drink per dayLimit alcohol to one drink per day
 Alcohol raises blood pressureAlcohol raises blood pressure
 One drink = 12 oz beer, 4 oz wine, or 1 oz liquorOne drink = 12 oz beer, 4 oz wine, or 1 oz liquor

31. What Is Diabetes?What Is Diabetes?
 AA progressive disease in which your body doesn’tprogressive disease in which your body doesn’t
make enough insulin / doesn’t respond properly to itmake enough insulin / doesn’t respond properly to it
 Goal: fasting glucose below 100 mg/dlGoal: fasting glucose below 100 mg/dl

32. Why Is Diabetes Bad?Why Is Diabetes Bad?
 At least 65%At least 65% of people with diabetes die of someof people with diabetes die of some
form of CVDform of CVD
 Diabetes lowers “good” cholesterol, and raises “bad”Diabetes lowers “good” cholesterol, and raises “bad”
cholesterol and triglyceride levelscholesterol and triglyceride levels
 Many people with diabetes also have high bloodMany people with diabetes also have high blood
pressure and are overweightpressure and are overweight

33. Risk Factors: DiabetesRisk Factors: Diabetes
 Diabetes increases the risk of CHD 3-7Diabetes increases the risk of CHD 3-7
times in women versus 2-3 times in mentimes in women versus 2-3 times in men
 Diabetic women who smoke have a 84%Diabetic women who smoke have a 84%
higher risk of developing stroke thanhigher risk of developing stroke than
nonsmokersnonsmokers
 2 of 3 people with diabetes die from2 of 3 people with diabetes die from
CHD or strokeCHD or stroke

34. SmokingSmoking
 Smoking is the single mostSmoking is the single most
preventable cause of death in the USpreventable cause of death in the US
 Cigarette smoking accounts for nearly 440,000Cigarette smoking accounts for nearly 440,000
deaths per year in men and womendeaths per year in men and women
 18.518.5 percent of American women age 18percent of American women age 18
and older smokeand older smoke

35. The #1 Preventable RiskThe #1 Preventable Risk
SmokingSmoking
 50% of heart attacks among women50% of heart attacks among women
are due to smoking. Smokers tend toare due to smoking. Smokers tend to
have their first heart attack 10 yearshave their first heart attack 10 years
earlier than nonsmokersearlier than nonsmokers
 If you smoke, you are 4-6x’s moreIf you smoke, you are 4-6x’s more
likely to suffer a heart attack andlikely to suffer a heart attack and
increase your risk of a strokeincrease your risk of a stroke
 Women who smoke and take OCP’sWomen who smoke and take OCP’s
increase their risk of heart disease 30x’sincrease their risk of heart disease 30x’s

36. Relative Risk of Coronary EventsRelative Risk of Coronary Events
for Smokers Compared tofor Smokers Compared to
Non-SmokersNon-Smokers
3.12
5.48
1
0
1
2
3
4
5
6
Never Smoked 1-14 Cigarettes per
day
15 Cigarettes per
day
Relative
Risk
Source: Adapted from Stampfer 2000

37. Physical InactivityPhysical Inactivity
 Increases heart disease and stroke riskIncreases heart disease and stroke risk
 30 minutes or more of activity on most or all days of30 minutes or more of activity on most or all days of
the week helps reduce risk!the week helps reduce risk!
It:It:
Controls blood cholesterolControls blood cholesterol
Controls diabetes and obesityControls diabetes and obesity
Helps lower high blood pressureHelps lower high blood pressure

38. Body Weight and CHD MortalityBody Weight and CHD Mortality
Among WomenAmong Women
5.8
4.6
3.1
1.4
11
0
1
2
3
4
5
6
19.0-21.9 22.0-24.9 25.0-26.9 27.0-28.9 29.0-31.9 32
BMI
Relative Risk
of CHD
Mortality
Compared to
BMI<19
P for trend < 0.001
Source: Adapted from Manson 1995

39. 1999
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1999, 2009
(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)
2009
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Source: Behavioral Risk Factor Surveillance System, CDC

40. Weight Maintenance/ReductionWeight Maintenance/Reduction
GoalsGoals
 BMI between 18.5 and 24.9BMI between 18.5 and 24.9
 Waist circumference < 35 inches for women, <40Waist circumference < 35 inches for women, <40
inches for meninches for men
 Weight loss goalsWeight loss goals
 10% of body weight over six months or 1-2 pounds10% of body weight over six months or 1-2 pounds
weight loss/weekweight loss/week
 Reduce calories by 500-1,000 per dayReduce calories by 500-1,000 per day
Source: Mosca 2004, ATP III 2002

44. How To Lower Heart DiseaseHow To Lower Heart Disease
RiskRisk
 Begin todayBegin today
 Be physically active—30 minutes of moderate-Be physically active—30 minutes of moderate-
intensity activity on most days of the weekintensity activity on most days of the week
 Follow a healthy eating planFollow a healthy eating plan
 Low in saturated fat,Low in saturated fat, transtrans fat, and cholesterol andfat, and cholesterol and
moderate in total fatmoderate in total fat
 Limit saltLimit salt
 If you drink alcoholic beverages, have noIf you drink alcoholic beverages, have no
more than one a daymore than one a day

45. How To Lower Heart DiseaseHow To Lower Heart Disease
RiskRisk
 Maintain a healthy weightMaintain a healthy weight
 Balance calories taken in with those used up inBalance calories taken in with those used up in
physical activityphysical activity
 Stop smokingStop smoking
 Get checked for high blood pressureGet checked for high blood pressure
 Manage diabetesManage diabetes
 Take medication, if prescribedTake medication, if prescribed

46. How to SurviveHow to Survive
 Call 9-1-1Call 9-1-1
 Emergency medical personnel will beginEmergency medical personnel will begin
treatment at oncetreatment at once
 Don’t drive yourself to the hospitalDon’t drive yourself to the hospital
 Uncertainty is normal—don’t be embarrassed byUncertainty is normal—don’t be embarrassed by
a false alarma false alarm
 Learn the warning signsLearn the warning signs

47. Thank you for listening!!!!Thank you for listening!!!!