Yes, it does, but should it?

Transcription

1 Does Gender Make a Difference When Managing CVD in General Practice? Does Gender Make a difference in the Treatment of CHD? Dr Jennifer Johns MBBS, FRACP, FCSANZ Cardiologist Austin Health Cardiologist Epworth Hospital President National Heart Foundation Yes, it does, but should it? Outline Epidemiology Risk factors and gender differences Presentation of CHD Investigation of suspected CHD Treatment of CHD and gender disparity Summary Why a focus on women? Leading cause of death for Australian women especially older age group Heart disease kills 30 women per day Significant cause of disability in older years Modifiable risk factors account for two thirds of CVD deaths and disease burden Low awareness Only 22% Australian women were aware that heart disease is the leading cause of death in females 42% thought breast cancer was the leading cause of death 1

2 Women are unaware of the problem! % Perceived Causes of Death 55 0 Cancer Breast Cancer 22 Heart Disease 2 Heart Attack % Actual Leading Causes of Death CVD Cancer COPD PI* Diabetes *PI = pneumonia/influenza CHD risk factors Non-modifiable risk factors include increasing age a family history of premature death from heart disease (<60 years) gender Modifiable risk factors include High blood cholesterol Diabetes Hypertension Physical inactivity Overweight/obesity SHEEP: Risk Factors for Nonfatal MI in Men and Women Risk Factor Diabetes High TC ( 6.5 mmol/l) High TG ( 6.3 mmol/l) HTN ( 170/95 mm Hg) Overweight (BMI 30 kg/m²) WHR ( 0.85) Physical inactivity Job strain Women Men Odds Ratio SHEEP=Stockholm Heart Epidemiology Program. Reuterwall C et al. J Intern Med. 1999;246: Approx. 15% of women smoke (higher in young women) 1-4 cigarettes/day doubles the CHD fatality in women and > 25/day increases risk X 5 after MI doubles risk of recurrent MI or death Quitting smoking reduces cardiovascular risk significantly within 1 year, back to baseline after 5 years Diabetes Epidemic of type 2 diabetes the diabesity epidemic 7% of women have type 2 diabetes and many more are undiagnosed Risk of death from heart disease is 2-4 times higher in people with diabetes In women with type 1 diabetes, there is complete loss of the 10- year protective effect conferred by female sex % of PCI Patients with Diabetes Mellitus Cardiovascular Research Foundation Database 50% Women N=1761 Men N=4323 % 37% 37% 31% 30% 28% 27% 24% 21% 19% 20% 14% 10% 0% < Age (years) 2

3 Hypercholesterolaemia Hypercholesterolaemia Elevated lipid levels are associated with increased risk of CVD 80% genetic 20% diet If treating, treat to target! TC < 4mmol/L LDLC < 2mmol/L Almost 50% of Australian women have elevated lipids Very important to assess overall risk before treating isolated high cholesterol Hypertension Major risk factor for CHD, stroke, heart failure and PVD 27% of women have HT, increasing to 75% in mid-70s Generally under recognised and undertreated Hypertension Category Systolic Diastolic Optimal <130 <80 Pre High <139 <90 HTN 1 90 Reduce weight Exercise Reduce salt intake Reduce alcohol intake Medications Physical Inactivity Women more sedentary than men across all age groups 75% of women do not exercise regularly Exercise reduces CHD mortality just 30 minutes of moderate physical activity 5 times per week significantly reduces mortality Obesity Obesity contributes to heart disease by increasing blood pressure, blood sugar, and high cholesterol. ~45% of people are overweight and 23% are obese. ~Weight gain around the waist is the best Measurement of risk 3

4 Absolute Risk Assessment of an individual s absolute risk of cardiovascular disease is more important than treating isolated risk factors Use the Australian cardiovascular risk charts or web calculator Gender differences in Presentation of CAD Women are more likely to have atypical features of myocardial ischaemia breathlessness, nausea, fatigue, pain in back Women more likely to delay in seeking help when having ischaemic symptoms Diagnostic and treatment delay partly account for worse outcomes in women Investigation of Suspected CHD Functional testing Stress ECG, lower sensitivity and specificity than men Stress echo, 80-90% sensitivity, 86% specificity. Dobutamine used in patients unable to exercise Myocardial perfusion imaging, similar sensitivity and specificity to stress echo. Dipyridamole used in patients unable to exercise Investigation of Suspected CHD CT coronary angiography Excellent sensitivity (98%), very good specificity (88%). Reliable in ruling out significant CAD (negative PV 98%) Used in symptomatic patients with low to intermediate probability of CAD Patients need to be in SR, heart rate < 65/min, tolerate beta-blockers, able to breath hold for 10 seconds Coronary angiography The gold standard Increasingly used for therapeutic procedures (ACS) Treatment of CHD Women derive similar clinical benefit to men, from treatment of CHD Women receive less medical therapy aspirin, beta-blockers, statins, ACE inhibitors?why Women receive less intervention with CABG and PCI, even when adjusted for age and co-morbidity 4

5 Gender and Hospitalisation in Australia More women see specialists than men in the 75+ age group, however they appear to be treated medically and not be admitted to hospital Males are more likely to be hospitalized for CVD, stroke and heart failure, and are twice as likely to be hospitalised for CHD than females Females hospitalised are more likely than males to die in hospital CVD (4.7% vs 3.9%) Acute myocardial infarction (3.9% vs 2.4%) Stroke (12.3% vs 9.2%) Heart failure (9.2% vs 8.6%) Key Points CVD remains the biggest killer of women in Australia Most women have 2 or more modifiable risk factors It is important to raise doctor and patient awareness of CVD Women derive a benefit from treatment of CHD similar to men, but remain undertreated Women with CHD have a worse prognosis than men Final Comment Women with CHD are treated differently from men, but they should be treated more like men! 5