Women and Heart Disease


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  • I worry she won’t make it through this many slides unless she talks and moves fast. Seems like some slides could be eliminated or have fewer words, but maybe she’ll go through them quickly. Also make slides so they are more bullets rather than lots of text – she will lose people. Consider making the bullets one word or small phrase on all slides. This presentation comes off as pretty technical. We probably need to know if she can present the topic in everyday terminology – I think people could get lost just reading the slides.
  • Too many slides for each patient example … cut down to most important info.
  • This is a slide women will really care about … they want to know what causes, when, why, etc.
  • This is a slide women will really care about … they want to know what causes, when, why, etc.
  • Begins to become repetitive
  • Women and Heart Disease

    1. 1. Women and Heart Disease Kristine Driskill, PA-C MPAS Cardiology, Via Christi Clinic
    2. 2. Statistics <ul><li>Cardiovascular disease (CVD) — hypertension, heart disease, stroke, peripheral arterial disease </li></ul><ul><ul><li>1 of 2.9 deaths in U.S from CVD </li></ul></ul><ul><ul><li>1 death every 39 seconds from CVD </li></ul></ul><ul><ul><li>1 of every 6 deaths from coronary artery disease </li></ul></ul><ul><ul><li>In 2007, three leading causes of death for women over age 65 </li></ul></ul><ul><ul><ul><li>Heart disease </li></ul></ul></ul><ul><ul><ul><li>Cancer </li></ul></ul></ul><ul><ul><ul><li>Stroke </li></ul></ul></ul><ul><ul><ul><li>*Source: 2007 American Heart Association </li></ul></ul></ul>
    3. 3. Women and Heart Disease <ul><li>What we will cover today: </li></ul><ul><ul><li>Time of onset </li></ul></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><li>Testing </li></ul></ul><ul><ul><li>Preventive measures </li></ul></ul><ul><ul><li>Therapies </li></ul></ul>
    4. 4. Women and Heart Disease <ul><ul><li>Coronary disease unusual before menopause </li></ul></ul><ul><ul><ul><li>Protective effect of estrogen </li></ul></ul></ul><ul><ul><li>Women develop coronary disease about a decade later than men </li></ul></ul><ul><ul><li>Physiologic circumstances of pregnancy and menopause increase cardiac awareness </li></ul></ul><ul><ul><li>Symptoms may be less reliable than in men </li></ul></ul><ul><ul><li>Stress testing much less reliable in women </li></ul></ul>
    5. 5. Implication of later development of heart disease <ul><ul><li>Risk of heart attacks directly related to age, independent of gender </li></ul></ul><ul><ul><li>With advancing age, patients have more conditions such as: </li></ul></ul><ul><ul><ul><li>Kidney disease, lung disease, dementia, etc. </li></ul></ul></ul><ul><ul><li>Social structure changes, family support may not be effective </li></ul></ul><ul><ul><li>Patients less inclined to opt for aggressive treatment </li></ul></ul>
    6. 6. Symptoms: women vs. men <ul><ul><li>For any given degree of coronary disease, women more likely to experience angina, men more likely to have heart attacks </li></ul></ul><ul><ul><li>Women more likely to have normal coronary arteries with definite coronary syndromes </li></ul></ul><ul><ul><ul><li>Endothelial dysfunction rather than obstruction </li></ul></ul></ul><ul><ul><li>May be subtle differences in symptoms patients experience with a heart attack, but generally atypical symptoms can occur with either gender </li></ul></ul>
    7. 7. Heart disease <ul><ul><li>Congenital heart disease </li></ul></ul><ul><ul><li>Heart valve disorders </li></ul></ul><ul><ul><li>Rhythm disorders </li></ul></ul><ul><ul><li>Heart muscle disorders </li></ul></ul><ul><ul><li>Coronary artery disease </li></ul></ul>
    8. 8. Coronary arteries
    9. 9. Coronary artery disease
    10. 10. Coronary disease <ul><ul><li>For many patients, the process is silent and there are no clinical problems </li></ul></ul><ul><ul><li>Heart pain (angina) </li></ul></ul><ul><ul><ul><li>Pain due to reduced blood supply to heart muscle </li></ul></ul></ul><ul><ul><li>Heart attack (myocardial infarction) </li></ul></ul><ul><ul><ul><li>Cardiac injury due to unstable plaque and artery occlusion </li></ul></ul></ul><ul><ul><li>Heart rhythm abnormality </li></ul></ul>
    11. 11. Patient examples <ul><ul><li>Patient 1: Heart attack </li></ul></ul><ul><ul><li>Patient 2: Stable cardiac disease </li></ul></ul><ul><ul><li>Patient 3: Atypical </li></ul></ul><ul><ul><ul><li>Symptoms </li></ul></ul></ul><ul><ul><ul><li>Risk/likelihood assessment </li></ul></ul></ul><ul><ul><ul><li>Management </li></ul></ul></ul>
    12. 12. Patient 1: Heart attack <ul><ul><li>75 year old woman who does not see a doctor, mostly due to disinclination; she smokes, takes no medications and does not know her cholesterol numbers. There is a family history of heart disease; she develops chest pain at home </li></ul></ul><ul><ul><li>She arrives in the emergency room with typical findings of an acute myocardial infarction (heart attack) </li></ul></ul><ul><ul><li>An urgent evaluation is performed, then she undergoes a catheterization and a stent is placed in a coronary artery </li></ul></ul>
    13. 13. Patient 1: Heart attack <ul><ul><li>Process initiated by development of unstable plaque </li></ul></ul><ul><ul><ul><li>Promotes platelet aggregation and clotting which occludes the artery </li></ul></ul></ul><ul><ul><li>Injury to heart muscle is time dependent, occurring over about 12 hours </li></ul></ul><ul><ul><ul><li>The greatest injury occurs in the first several hours </li></ul></ul></ul><ul><ul><li>Injury can be interrupted by opening the artery, usually with a coronary intervention </li></ul></ul><ul><ul><ul><li>Timing of intervention is very important </li></ul></ul></ul>
    14. 14. Patient 1: Heart attack symptoms <ul><ul><li>In general, something intense and unusual </li></ul></ul><ul><ul><li>Location: chest, jaw, arms, upper back, upper abdomen </li></ul></ul><ul><ul><li>Duration: usually protracted and ongoing for hours </li></ul></ul><ul><ul><li>Associated observations: nausea, shortness of breath, profuse sweating </li></ul></ul>
    15. 15. Chest pain experience <ul><ul><li>Symptoms of heartburn may be either cardiac or gastrointestinal, the conditions frequently co-exist </li></ul></ul><ul><ul><li>Pain with taking a breath usually will not be cardiac </li></ul></ul><ul><ul><li>Momentary sharp sensations are almost never important </li></ul></ul><ul><ul><li>Vague all day long sensations are usually innocent </li></ul></ul>
    16. 16. Chest pain lessons <ul><ul><li>If you have a concern that you may be having a heart attack, call 911 (or your local emergency number) and let the experts sort it out </li></ul></ul><ul><ul><li>If you have symptoms that become more intense or frequent, seek attention on an urgent basis </li></ul></ul><ul><ul><li>If you have a stable, recurrent symptom, consult your doctor </li></ul></ul>
    17. 17. Patient 2: Stable cardiac disease symptoms <ul><ul><li>She experiences chest pain in response to unusual exercise. She is able to do all of her usual activities and travel. Her symptom has not changed in two years </li></ul></ul><ul><ul><li>She is generally healthy but has declined cholesterol therapy for high LDL </li></ul></ul><ul><ul><li>A stress test demonstrates abnormal findings of “ischemia” </li></ul></ul>
    18. 18. Angina (chest pain) experience <ul><ul><li>Location: in general, the same as heart attack </li></ul></ul><ul><ul><li>Duration: usually 2-10 minutes; constant when present </li></ul></ul><ul><ul><li>Intensity: often not intense but compelling </li></ul></ul><ul><ul><li>Provocation: often exertional </li></ul></ul><ul><ul><li>Aggravating factors: after eating, in the cold </li></ul></ul>
    19. 19. Patient 2: Stable cardiac disease <ul><ul><li>She consulted a cardiologist </li></ul></ul><ul><ul><li>A heart catheterization was performed. The patient was advised that she has several blockages and that she can have the arteries fixed now or just stay on medications </li></ul></ul><ul><ul><li>Hardware for performing the stent is being prepared </li></ul></ul><ul><ul><li>What should she do? </li></ul></ul>
    20. 20. Patient 2: Stable cardiac disease <ul><ul><li>Medical therapy may be the best solution </li></ul></ul><ul><ul><li>No survival or heart attack prevention benefit from aggressive interventions </li></ul></ul><ul><ul><li>Decision factors are symptom severity and the extent of jeopardy </li></ul></ul><ul><ul><li>Our patient might want to think things over or have a second opinion </li></ul></ul>
    21. 21. Patient 3: Atypical symptoms <ul><ul><li>37-year-old woman with occasional cardiac awareness and palpitations </li></ul></ul><ul><ul><li>No smoking, normal cholesterol, active, normal blood pressure </li></ul></ul><ul><ul><li>Physical exam is normal </li></ul></ul><ul><ul><li>A stress test is done at another office, the patient is advised that the stress test is abnormal and that she should undergo a heart cath just to be sure </li></ul></ul>
    22. 22. Patient 3: Atypical management <ul><ul><li>Stress testing is often “false positive” in women </li></ul></ul><ul><ul><li>In either gender, stress testing is not accurate if there is a low likelihood of disease </li></ul></ul><ul><ul><li>Invasive procedures involve risk </li></ul></ul><ul><ul><li>Patient sought a second opinion </li></ul></ul><ul><ul><li>Careful review of symptoms and probability of disease was reviewed, no additional testing advised </li></ul></ul>
    23. 23. Lesson: match the management to the condition <ul><ul><li>High acuity conditions require intense, urgent application of diagnostic and therapeutic effort; if heart attack is suspected, urgent attention is indicated </li></ul></ul><ul><ul><li>Medical therapy may be the best option for stable patients </li></ul></ul><ul><ul><li>Extraordinary cardiac risk in smokers </li></ul></ul><ul><ul><li>Very important to have a good doctor or advisor </li></ul></ul><ul><ul><li>Stress testing may be less accurate in women </li></ul></ul><ul><ul><li>Low acuity conditions and symptoms often simply require education </li></ul></ul>
    24. 24. Risk scores <ul><ul><li>Age </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><ul><li>LDL cholesterol </li></ul></ul><ul><ul><li>HDL cholesterol </li></ul></ul><ul><ul><li>CRP (inflammation) </li></ul></ul>
    25. 25. Coronary risk and vascular biology <ul><ul><li>Cigarette smoking </li></ul></ul><ul><ul><li>Physical inactivity </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Family history of heart disease </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Elevated LDL </li></ul></ul><ul><ul><li>Low HDL </li></ul></ul><ul><ul><li>Metabolic syndrome </li></ul></ul><ul><ul><li>Inflammatory state </li></ul></ul>
    26. 26. Vascular biology <ul><ul><li>Smoking increases risk of death/MI 400% </li></ul></ul><ul><ul><li>For every 20mm increase in BP, risk doubles </li></ul></ul><ul><ul><li>LDL reduction by 1mg results in 1% risk reduction </li></ul></ul><ul><ul><li>HDL change of 1mg results in 2% risk reduction </li></ul></ul><ul><ul><li>Activity and diet reduce inflammation, LDL, diabetes development and increase HDL </li></ul></ul>
    27. 27. Vascular biology — continued <ul><ul><li>Cholesterol agents promote plaque stability and reduce events </li></ul></ul><ul><ul><li>Aspirin reduces potential for vessel clotting </li></ul></ul><ul><ul><li>Antioxidant vitamins have no benefit </li></ul></ul><ul><ul><li>Hormone replacement therapy has no cardiac benefit </li></ul></ul><ul><ul><li>Omega 3 fatty acids lower triglycerides and have some platelet effect </li></ul></ul>
    28. 28. Cardiac testing concerns <ul><ul><li>Stress testing may be much less accurate in women; accuracy depends upon the likelihood of disease </li></ul></ul><ul><ul><li>Nuclear and CT studies are associated with large radiation exposure </li></ul></ul><ul><ul><li>High expense to yield ratio </li></ul></ul><ul><ul><li>Risk with invasive procedures </li></ul></ul><ul><ul><ul><li>Contrast, vascular injury, embolization </li></ul></ul></ul>
    29. 29. Coronary disease management: Changing emphasis <ul><ul><li>Symptom preoccupation </li></ul></ul><ul><ul><li>Extensive testing </li></ul></ul><ul><ul><li>Inclination to “fix” coronary problems with intervention and surgery </li></ul></ul><ul><ul><li>Incentives (3 heart hospitals, 9 cath facilities) </li></ul></ul><ul><ul><li>Lifelong attention to prevention </li></ul></ul><ul><ul><li>Aggressive management of lipids and diabetes </li></ul></ul><ul><ul><li>Incentives for fitness and disease management </li></ul></ul><ul><ul><li>Educated patients </li></ul></ul>
    30. 30. Key lessons <ul><ul><li>If you have severe symptoms, do not hesitate to summon emergency help, let the professionals decide whether it is important or not </li></ul></ul><ul><ul><li>Remember concepts of plaque stability and vascular biology </li></ul></ul><ul><ul><li>Vigilance is not enough, prevention is critical </li></ul></ul><ul><ul><li>Manage risk factors with the help of your health care provider </li></ul></ul><ul><ul><li>A “fix” is often transient; management is forever </li></ul></ul>
    31. 31. Thank you!