1.Review studies in women and apply to a real pt. 2. Calculate risk of Cardiac Events using the Reynolds Risk Score

Transcription

1 Dr Margaret Blackwell FRCPC Cardiology Assistant Clinical professor of Medicine U.B.C. APRIL

2 1.Review studies in women and apply to a real pt 2. Calculate risk of Cardiac Events using the Reynolds Risk Score

3 Deaths age greater than 65 : CHD = 56% CANCER = less than 20%

4 higher in women in part due to increase in Co- morbidities and increased age at presentation CVS mortality has declined in women over the yrs Nurses Health Study = 31% decrease of CHD in due reduction in risk factors # smokers down by 40% = 13% decrease in CHD # on HRT increased by 175% = no change # over wt increased by 38% = 8% increase in CHD # improved diet = 16% decrease in CHD

5 85,000 WOMEN x 14 yrs RESULTS: 85% reduced CVS risk if : Desirable body wt Healthy diet Regular exercise No smoking NEJM 2000 Hu et al

6 Prevalence of hypertension in women in the United States Prevalence of hypertension in women according to age and race/ethnicity in the United States from the NHANES-III survey. Hypertension occurs earlier and more frequently in African-American women. Data from Burt, VL, Whelton, P, Roccella, EJ, et al, Hypertension 1995; 25:305. Prevalence of hypertension in women according to age and race/ethnicity in the United States Hypertension occurs earlier and more frequently in African- American women. Data from Burt, VL, Whelton, P, Roccella, EJ, et al, Hypertension 1995; 25:305.

7 37,000 WOMEN > 45 yrs X 10 yrs Healthy women living a healthy lifestyle had reduced risk of CVA by 55% but Only 3 5 % of these health professionals were in the lowest risk categories

8 2008 UpToDate Print Kaplan-Meier estimates of cumulative hazard rates of CHD In the Women's Health Initiative, combined estrogen-progestin therapy was associated with a significant increase in coronary events. CHD included nonfatal myocardial infarction and death due to CHD. The overall hazard ratio for CHD was 1.24 (nominal 95 percent confidence interval, 1.00 to 1.54). Data from Manson, JE, Hsia, J, Johnson, KC, et al. Estrogen plus progestin and the risk of coronary heart disease. N Engl J Med 2003; 349:523. Estrogen therapy not beneficial for secondary prevention of coronary heart disease Data from the HERS-II trial on the incidence of coronary heart disease events (death or nonfatal myocardial infarction) in 2763 postmenopausal women with a prior history of myocardial infarction or interventional procedure who were treated with combined hormone replacement therapy of placebo. There was no difference between the two groups. The curves are truncated at year seven when less than half of the cohort remained in follow-up. Data from Grady, D, Herrington, D, Bittner, V, et al, JAMA 2002; 288:49. ONLINE 16.2

9 RISK FACTORS IN WOMEN: Personal Hx CHD Age > 55 Dyslipidemia = Increased LDL or Decreased HDL FH = Father < 55 Mother < 65 DM Smoking HT PAD

10 High TG, Obesity, Sedentary = greater frequency in ethnic minorities Rate of Fatal MI or Death No risks = 1.3% 5 or more risks =8.7%

11 Low HDL more important than high LDL High LPa in premenopausal or women less than 66 yrs increases risk of angina or MI ODDS RATIO = 5.1 angina = 2.4 MI

12 Increased Ratio APO B/HDL = HR 3.56 Increased Ratio LDL/HDL = HR 3.18 Increased ratio APOB /APOA = HR 3.01 Optimum Values: TC/HDL < 3.2 APOB/HDL < 1.4 LDL/HDL < 1.8 APOB100/APOA1 <.54

13 Every woman > 20 yrs needs a fasting lipid profile. If it is normal and they have premature CHD they need Lpa and APOB and APOA1

14 Diabetes increases coronary mortality with & without a prior MI In a seven year follow up of 1059 subjects with type 2 diabetes and 1378 nondiabetics, diabetics with or without a prior myocardial infarction (MI) had a greater mortality from coronary disease compared to nondiabetics (42 versus 16 percent for those with a prior MI and 15 versus 2 percent for those without a prior MI. The rate of coronary death and fatal and nonfatal MI in diabetics without a prior MI was the same as in nondiabetics with a prior MI, providing part of the rationale for considering type 2 diabetes a coronary equivalent. Data from Haffner, SM, Lehto, S, Ronnemaa, T, et al, N Engl J Med 1998; 339:229.

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16 Women with the highest intake of folate & alcohol have the lowest risk for coronary heart disease The relative risk of coronary heart disease (nonfatal myocardial infarction and fatal coronary heart disease) by quintiles of folate intake across levels of alcohol consumption among 80,082 women in the Nurses' Health Study. Women in the lowest quintile of folate who did not drink alcohol were the reference category (relative risk 1.0). The benefits from increasing amounts of folate intake are seen primarily in women who consume alcohol and the benefit increases as alcohol consumption increases. Data from Rimm, EB, Willeh, WC, Hu, FB, et al, JAMA 1998;279:359.

17 1 gm =.035 ounces 14.9 gm = 5 ounces

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19 2008 UpToDate Print C-reactive protein predicts cardiovascular events in healthy postmenopausal women Among 28,263 postmenopausal women enrolled in the Women's Health study, C-reactive protein (CRP) was a significant predictor of cardiovascular events; the relative risk of events for women in the highest as compared with the lowest quartile for this marker was 4.4. Prediction models that incorporated CRP in addition to lipids were significantly better at predicting risk than models based on lipid levels alone (P < 0.001). Data from Ridker, PM, Hennekens, CH, Buring, JE, Rifai, N. N Engl J Med 2000; 342:836. ONLINE 16.2

20 Diagnostic yield of calcium screening in symptomatic men and women In a study of 1764 symptomatic patients with suspected coronary heart disease who underwent electron beam computed tomography (EBCT) and coronary angiography, the calcium score on EBCT correlates with the presence or absence of a significant stenosis on angiography. The higher scores (A for men and C for women) define the calcium score thresholds (CSTs) for the 90 percent of patients with significant stenoses, The lower scores (B for men and D for women) define the CSTs for the 95 percent of patients without significant stenoses. For example, a man at the age of 50 years is probably free of coronary stenosis if his score is <56; at score values >217, he has a high risk of stenosis. Data from Haberl, R, Becker, A, Leber, A, et al, J Am Coll Cardiol 2001; 37:451.

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23 37% OF WOMEN WITH ACS DID NOT HAVE CP vs 27% OF MEN ( this was especially true in younger women <65) STUDIES HAVE DIFFERENT CRITERIA FOR REPORTING SYMPTOMS ie NO STANDARDIZED DEFINITIONS OF CP WOMEN WAIT LONGER THAN MEN BEFORE SEEKING TREATMENT

24 Women with ACS have higher mortality Cadillac Trial : Circ 2005 Women had lower BSA, greater # of co-morbidities (DM/ HT / high Lipids), greater delays to treatment but better baseline and final TIMI grade 3 flow Increased MACE and death in women

25 Smoking is assoc with 50% of ACS in Women (even if low # of cigs / day) RR = 2.4 for 1.4 cigs/day NEJM 1987

26 25% 20% 15% 10% 5% 0% Fraser Health British Columbia Female 13.9% * 15.5% Male 17.3% * 20.1% *CV's are greater than 16.6%, use with caution. Proportions represent respondents who are daily or occasional smokers.

27 Prevalence = 70-80% in women > 70 yrs Premenopausal HT = 10X RR CHD death

28 BMI > 32 kg/m2 RR death from CHD=4.1 RR death all cause=2.2 ( the risk was independent of presence of DM) Waist:Hip ratio >.9 was more predictive than BMI RR for CHD BMI ( ) =1.19 ( ) =1.46 ( ) =2.06 (> 29 ) =3.56 Indep of physical activity Wt cycling increased++ risk of CHD death

29 60% 40% 20% 0% Female Male Female Male Fraser Health British Columbia Obese 10.8% 9.3% 10.7% 12.3% Overweight 19.4% 38.7% 21.6% 37.9% *Note: All CV's are less than 16.6%. Data include respondents ages 18 years and older.

30 HPS all-cause mortality.mht

31 RECENT MI WOMEN HAD A GREATER DECREASE IN CORONARY EVENTS THAN MEN CARE TRIAL 1998 Sacks et al

32 More likely to be treated with Ntg and sedatives Less likely to get ASA and Lipid lowering drugs B Blocker and ACEI the same as men Less likely to have H Cath or CABG Greater mortalty Less likely to attend Cardiac Rehab

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35 Framingham Olmsted County 1998 Reynolds Boston 2007 Score (European) ESC 2007 QRISK + QRISK 2 ( England + Wales) BMJ 2007

36 Age <60 Hs CRP<2 TC/ HDL <3.4 HbA1C in DM<6 Nonsmoker Fam Hx < 60 yrs D.W.Reynolds Brigham and Womens Hospital Boston 2007

37 24,500 healthy women > 45 yrs X 10 yrs % of Framingham pts at intermediate risk were re-classified into higher or lower categories using the RRS

38 Deb Hynes from NFLD / checkup 60yrs Smokes 1 pk/day Drinks 1 pt/d Works in Fred s BMI = 31 Hobby = plays an ugly stick with a band Favorite food = cod tongues, chips with gravy, poutine and dressing

39 BP=160/100 Random BS = 13mmol = (234 mg/dl) HDL =.8 mmol/l = ( 31 mg/dl) TC = 4 mmol/l = ( 156 mg/dl) Calculate her 10 yr risk of coronary events

40 = 21% greater than a 60 yr old woman without any risk factors

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