Women and Heart Disease. Susan Thompson Hingle, M.D

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1 Women and Heart Disease Susan Thompson Hingle, M.D

2 Causes of Death in Women Heart Disease Cerebrovascular Disease Lung Cancer COPD Pneumonia/Flu Breast Cancer Accidents Diabetes Ovarian Cancer 370/1000 deaths 100/1000 deaths 60/1000 deaths 50/1000 deaths 49/1000 deaths 47/1000 deaths 40/1000 deaths 40/1000 deaths 7/1000 deaths

3 Causes of Death

4 Comparisons If all major forms of cardiovascular disease were eliminated, life expectancy would rise by 7 years If all forms of cancer were eliminated, life expectancy would rise by 3 years Lifetime risk of dying of CVD is 47% Lifetime risk of dying of cancer is 22%

5 Coronary Heart Disease Number 1 cause of death in American women(and men) Almost 1 out of 2 deaths in women (and men) are due to CHD 1 out of 28 deaths in women are due to breast cancer 1 in10 women age have CHD 1 in 4 women age > 65 have CHD Every 29 seconds someone has a coronary event, every 1 minute someone dies from one

6 Trends in Cardiovascular Disease

7 Risk Factors for CHD Age Diabetes Mellitus (7 fold increased risk) Hypertension (10 fold increased risk) Smoking (6 fold increase risk of CHD, even w/ just 3cigs/day) High Cholesterol Family History ( 3 fold increased risk)

8 Other Risk Factors Elevated triglycerides Elevated lipoprotein a Elevated homocysteine Insulin resistance Obesity (increased risk by 3 fold) Central hormone loss Coagulation abnormalities

9 Other Risk Factors Stress Type A behavior Depression Poor social support Poverty Single motherhood

10 Risk Factors Continued Unmodifiable Age Family history Ethnicity Modifiable Increased LDL, TG s, Lp(a), homocysteine Decreased HDL Tobacco Use Uncontrolled DM Uncontrolled HTN Loss of estrogen Inactivity Central Obesity

11 Pathophysiology of CHD LDL increases size and instability of lipid cores/plaques HDL causes LDL to detach from lipid core and reduce it s size Lp(a) increases entry of LDL into blood vessel wall

12 Pathophysiology Continued Fibrous cap formation Calcifications Ulcerations of blood vessel wall Endothelial damage/dysfunction Coronary vasospasm

13 Gender Differences in MI Women are older Chest pain is not a good predictor of CHD in women Women present later in course of MI Women have more complications and higher mortality post-mi Women receive interventions (cardiac cath, thromolytics, CABG, cardiac rehab) less often

14 Diagnosis of CHD Treadmill tests have a false positive rate of 22% in women (7% in men) and a false negative rate of 13% in women (13% in men); therefore they are misleading 35% of the time Nuclear stress tests with imaging offer a high sensitivity (84-90%) and a relatively high specificity (75-87%) in women

15 Prevention of CHD Smoking cessation? Hormone replacement therapy Treat DM (goal HgA1C is < 7%) Treat HTN (goal is < 130/85) Treat hyperlipidemia

16 Treatment of High Cholesterol Initiation Goal of Goal of Level Therapy Therapy LDL LDL Total Without CHD < 2 risks >160 <160 <240 >2 risks >130 <130 <200 With CHD >100 <100 <160

17 Clinical Trials Involving Women and CHD WHI (Women s Health Initiative) Started in 1992 Long term (15 year) double blind clinical trial (64,500 women) and observation study (100,000 women) Objective is to evaluate strategies for preventing CHD, breast cancer, colon cancer, and osteoporosis Subjects are > 160,000 multi-ethnic women aged 50-79yo; > 27,000 women on HRT for 6-11 years

18 Clinical Trials Continued 4S Trial (Scandinavian Simvastatin Survival Study) looked at 4444 patients with CHD and hyperlipidemia (827 were women) overall 42% reduction in risk of death from CHD, similar results in men and in women

19 Clinical Trials Continued CARE (Cholesterol and Recurrent Events Trial) double-blind placebo controlled trial lasting 5 years, looked at effect of Pravastatin on coronary events in people with known CHD 3583 men and 576 women 43% decrease in coronary death & nonfatal MI 56% decrease in stroke 48% decrease in PTCA 40% decrease in CABG

20 Clinical Trials Continued LIPID (Long Term Intervention with Pravastatin in Ischemic Disease Study Group) 6 year double-blind placebo control trial 9014 patients, 1516 were women 29 % decrease in MI 24% decrease in death from CHD 19% decrease in stroke results similar between men and women

21 Clinical Trials Continued PEPI (Postmenopausal Estrogen and Progesterone Interventions) Started in year randomized double blind placebo-controlled clinical trial Objective was to determine HRT effects on CHD risks and on cholesterol Results showed an increase in HDL and in TG s Subjects were 875 postmenopausal women

22 Clinical Trials Continued HERS (Heart and Estrogen Replacement Study) Started in 1998 Large, randomized, double-blinded, placebocontrolled secondary prevention trial Objective is to determine whether HRT alters risk for CHD Results showed a decrease in LDL, an increase HDL, an increase in TG s, no change in cardiac events Subjects were 2763 postmenopausal women with known CHD

23 Clinical Trials Continued ERA(Estrogen Replacement and Atherosclerosis) Started in 1999 Randomized placebo-controlled, double-blind trial using angiography to demonstrate CHD Objective is to determine effects of ERT vs placebo on progression of atherosclerosis Results have shown no difference between those on ERT and those on placebo Subjects are 309 postmenopausal women

24 Clinical Trials Continued Study on Raloxifene Started in 1997 Objective to determine the effect of raloxifene on serum lipoprotein levels Results showed lower LDL Subjects were 601 postmenopausal women aged 45-60yo

25 Clinical Trials Continued RUTH (Raloxifene Use for the Heart) Started in 1998 Large prospective randomized clinical trial Objective is to determine if raloxifene reduces risk for MI and other CHD related deaths in postmenopausal women at risk for CHD Subjects are 10,000 postmenopausal women aged >55yo with known or at high risk for CHD

26 Summary Consider HRT Start aspirin therapy Aggressively pursue modifiable risks tobacco abuse treatment of hyperlipidemia treatment of DM treatment of HTN obesity

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