Objectives. Who faces a higher mortality from cardiovascular related illness? Epidemiology of CVD. Cardiovascular Disease Management in Women

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1 Cardiovascular Disease Management in Objectives. Epidemiology 2. Risk Stratification 3. Depression Screening in 4. Aspirin Use in 5. Summary Lisa Ward, MD, MSPH, MS Associate Clinical Professor Santa Rosa Family Medicine Residency Program April 2 th, 200 Epidemiology of CVD CVDs are the most common cause of mortality in men & women world wide () Cost annually for CVD for medical care and lost productivity in 2006: $503 Billion (2) Who faces a higher mortality from cardiovascular related illness?. Men About the same in both genders 7% 66% 27% 2 3

2 Gender Differences in CVD Mortality in Men and More women than men die of CVD annually (3) 38% of women die within a year after a first MI, 25% of men (4) Median age of first MI in men 66 years, 70 years in women (4) CVD Cancer Accidents Lung Disease Diabetes CVD Cancer Lung Disease Alzheimer s Accidents Heart Disease and Stroke Statistics, 200-AHA Acute MI Mortality by Age & Sex Cardiovascular Disease Mortality: US Males and Females Men 550, , ,000 Men Men 400, Vaccarino V. et al. N Engl J Med 999; 34(4): Rosamond W, et al. Heart disease and stroke statistics 2008 Update. Circulation 2008; 7:e25-e46. 2

3 Health Disparities In Primary and Secondary CVD Treatment Less cholesterol screening Less lipid-lowering therapies Less use of heparin, beta-blockers and aspirin during myocardial infarction Less anti-platelet therapy for secondary prevention Fewer referrals to cardiac rehabilitation Fewer pacemakers compared to men, despite same indications Outline Epidemiology Risk Stratification Depression Screening Aspirin Use in Major Risk Predictors of CVD in Relative Risk of Coronary Events in Smokers Versus Non-Smokers Smoking Obesity DM HTN HDL reduction LDL elevation Female > Male Female > Male Female > Male Female > Male Female > Male Male > Female Relative Risk Never Smoked -4 Cigarettes per day 5 Cigarettes per day NHANES Study, Archives of Internal Medicine 49: , 989 Stampfer, MJ, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000; 343:6-22 3

4 Body Weight and CHD Mortality Among Relative Risk of CHD Mortality Compared to BMI< BMI Manson JE, et al. N Engl J Med 995; 333: Coronary Disease Morality In Diabetic Duration of Follow-up (yrs) Diabetic Nondiabetic Krolewski AS, et al. Evolving natural history of coronary artery disease in diabetes mellitus. Am J Med 99.; 90: 56S-6S. Depression Screening AHA Guidelines for Cardiovascular Disease Prevention and Treatment in -200 Aspirin Use Cardiovascular Disease Prevention in : Current AHA Guidelines Assess and stratify women into high risk, at risk, and optimal risk categories Lifestyle approaches recommended for all women Other treatments of CVD risks: treatment of HTN, DM, lipid abnormalities Highest priority is for interventions in high risk patients Avoid therapies that have been shown to lack benefit 4

5 Risk Stratification High Risk High Risk At Risk Ideal Risk >20% 0-year risk 0-20% 0-year risk <0% 0-year risk. Established history of CVD 2. Peripheral Vascular Disease 3. Abdominal Aortic Aneurysm 4. Chronic Kidney Disease 5. Diabetes At Risk > major risk factors for CVD, including: Cigarette smoking Hypertension Dyslipidemia Family history of premature CVD in st degree relative < 55 years in males < 65 years in females Obesity, especially central obesity Physical inactivity Poor diet Metabolic Syndrome Framingham Risk Stratification 5

6 Case: 65 yo woman with TC=67, HDL=43, & blood pressure 49/90 treated with HCTZ. Case: 70 yo woman with TC=67, HDL=43, blood pressure 49/90 treated with HCTZ & a smoker. Framingham Risk Calculator Sex: Female Age: 65 Total Chol: 67 mg/dl HDL Chol: 43 mg/dl SBP: 49 mmhg Diabetes: No Smoker: No TOTAL SCORE= 9% Framingham Risk Calculator Sex: Female Age: 65 Total Chol: 67 mg/dl HDL Chol: 43 mg/dl SBP: 49 mmhg Diabetes: No Smoker: Yes TOTAL SCORE= 2% Risk Stratification Cardiovascular Disease Prevention in : Current AHA Guidelines High Risk At Risk Ideal Risk >20% 0-year risk 0-20% 0-year risk <0% 0-year risk Assess and stratify women into high risk, at risk, and optimal risk categories Lifestyle approaches recommended for all women Other treatments of CVD risks: treatment of HTN, DM, lipid abnormalities Highest priority is for interventions in high risk patients Avoid therapies that have been shown to lack benefit 6

7 Implement Healthy Lifestyle Recommendations in All. Smoking Cessation 2. Heart Healthy Diet 3. Physical Activity 4. Weight Management 5. Omega-3-Fatty Acids 6. Depression Screening 7. Cardiac Rehabilitation Cardiovascular Disease Prevention in : Current AHA Guidelines Assess and stratify women into high risk, at risk, and optimal risk categories Lifestyle approaches recommended for all women Other treatments of CVD risks: treatment of HTN, DM, lipid abnormalities Highest priority is for interventions in high risk patients Avoid therapies that have been shown to lack benefit ATP III-Cholesterol Goals by Risk Category JNC-7 Blood Pressure Goals Average CVD Risk: Goal Blood Pressure <40/90 mmhg DM or CKD (Elevated Risk): Goal Blood Pressure <30/80 mmhg 7

8 Cardiovascular Disease Prevention in : Current AHA Guidelines Assess and stratify women into high risk, at risk, and optimal risk categories Lifestyle approaches recommended for all women Other treatments of CVD risks: treatment of HTN, DM, lipid abnormalities Highest priority is for interventions in high risk patients Avoid therapies that have been shown to lack benefit Avoid Unproven Therapies in All. Antioxidants e.g. Vitamin C & E 2. Folic Acid -With or without Vit B6 or B2 3. Hormone Replacement 4. SERMs Outline Epidemiology Risk Stratification Depression Screening in Aspirin Use in Depression Screening WHI-Observational Study Sample Size 93,000 women Post menopausal women age years Follow-up > 4 years Identified 5.8% of the study population with depression Prospective 8

9 Survival Curves for CVD Outcomes Depression is a key, independent risk factor for CVD Effect of depression on CAD outcomes significant and prolonged Must be a factor in risk stratification in women Wasserheil-Smoller S, et al. Arch Intern Med 2004;64: Outline Epidemiology Risk Stratification Depression Screening in Aspirin Use in Aspirin as Primary Prevention Randomized clinical trial of aspirin use in women without CAD Sample Size 40,000 women were > 45 years with no CAD, stroke or other chronic illnesses ASA dose 00 mg every other day Follow-up 0 years 9

10 Cumulative Incidence of Major Cardiac Event Cumulative Incidence Rates for MI and Hemorrhagic Stroke Ridker, P, et al. N Engl J Med 352;3, March 3, 2005 Ridker, P, et al. N Engl J Med 352;3, March 3, 2005 Incidence and Relative Risk of Other Side Effects Sub-Group Analysis by Age > 65 years (0% of study) particularly benefited from ASA CVD events RR 0.74 [ ] Ischemic Stroke RR 0.70 [ ] MI events RR 0.66 [ ] 0

11 Summary All risk is not the same-stratify! Use depression as a part of CVD risk assessment in women Avoid use of ASA as primary prevention in women < 65 years of age Refer to key guidelines ATP III -JNC-7 about to be 8. NCEP -AHA References.. World Heart Federation Web site. Available at: Accessed March 5, Heart Disease and Stroke Statistics, 200-AHA. 3. Thom T, et al. AHA Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics 2006 Update. 4 Vaccarino V. et al. Sex-based differences in early mortality after myocardial infarction. National registry of myocardial infarction participants. N Engl J Med 999; 34(4): Rosamond W, et al. Heart disease and stroke statistics 2008 Update. Circulation 2008; 7: e25-e Mosca L, et al. Evidence-based Guidelines for Cardiovascular Disease Prevention in -Updates Circulation 2007; 5: Wasserheil-Smoller S, et al. Depression and Cardiovascular Sequelae in Postmenopausal. Arch Intern Med 2004;64: Wolff T, et al. Aspirin for the Primary Prevention of Cardiovascular Events: An Update of the Evidence for the USPSTF. Annals of Internal Medicine 2009;50(6). 9. Ridker PM, et al. A RCT of low-dose aspirin in the primary prevention of CVD in women. NEJM. 2005;352: