Women and Heart Disease Mini-Med School Teresa Daniele, M.D., FACC - - PDF document

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Women and Heart Disease Mini-Med School Teresa Daniele, M.D., FACC - - PDF document

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9/24/2019 Women and Heart Disease Mini-Med School Teresa Daniele, M.D., FACC Chief of Cardiology, UCSF-Fresno Associate Professor of Clinical Medicine UCSF Program Director, Adult Cardiovascular Fellowship Director, Center for Womens

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Teresa Daniele, M.D., FACC

Chief of Cardiology, UCSF-Fresno Associate Professor of Clinical Medicine UCSF Program Director, Adult Cardiovascular Fellowship Director, Center for Women’s Cardiovascular Health

Women and Heart Disease Mini-Med School

Questions to answer today

  • Why should women worry about heart disease?
  • What is heart disease?
  • How is heart disease different in women than

men?

  • What are the risk factors for heart disease?
  • How can women prevent heart disease?
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Questions to answer today

  • Why should women worry about heart disease?
  • What is heart disease?
  • How is heart disease different in women than

men?

  • What are the risk factors for heart disease?
  • How can women prevent heart disease?

Heart Disease leading cause of death in women in US

100,000 200,000 300,000 400,000 500,000 A B C D E Number of Deaths A Total CVD B Cancer C Chronic Lower Respiratory Diseases D Diabetes Mellitus E Alzheimer’s Disease CDC/NCHS.

Heart Disease and Stroke Statistics - 2004 Update American Heart Association (AHA)

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Reynen DJ, Kamigaki AS, Pheatt N, Chaput LA. Th e Burden of Cardiovascular Disease in California: A Report of the California Heart Disease and Stroke Prevention Program. Sacramento, CA: California Department of Public Health, 2007.

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How long have we known this for?

1970’s 1980’s 1990’s 2000’s

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Cardiovascular Disease Mortality: U.S. Males and Females 1980-2004

400,000 450,000 500,000 550,000 1980 1985 1990 1995 2000 2004 Men Women

Source: Adapted from Rosamond 2008

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Prevalence of Disease by Age

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Knowledge = Power

Heart disease can be prevented

Questions to answer today

  • Why should women worry about heart disease?
  • What is heart disease?
  • How is heart disease different in women than

men?

  • What are the risk factors for heart disease?
  • How can women prevent heart disease?
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Types of Heart Disease

  • Coronary atherosclerosis (plaques)
  • Congestive Heart Failure
  • Abnormal Heart Rhythms
  • Cardiac Valve Disease
  • Congenital Heart Defect

Normal Coronary Artery Normal Coronary Artery

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The Vulnerable Plaque

Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.

Large Lipid Core Thin, Vulnerable, Fibrous Cap

Characteristics of Unstable and Stable Plaque

Thin fibrous cap Inflammatory cells Few SMCs Eroded endothelium Activated macrophages Thick fibrous cap Lack of inflammatory cells Foam cells Intact endothelium More SMCs

Adapted with permission from Libby P. Circulation. 1995;91:2844-2850. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Unstable Stable

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Ruptured Plaque with Occlusive Thrombus Formation

Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.

Thrombus Formation

Questions to answer today

  • Why should women worry about heart disease?
  • What is heart disease?
  • How is heart disease different in women than

men?

  • What are the risk factors for heart disease?
  • How can women prevent heart disease?
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Women have more diffuse narrowing of their coronary arteries than men Women have more diffuse narrowing of their coronary arteries than men

Men Men Women Women

Gender Differences

Men:

Luminal obstruction

Women:

Abnormal coronary reactivity Microvascular dysfunction Plaque erosion/distal microembolization

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Progression of Plaque Disease Without Luminal Narrowing Progression of Plaque Disease Without Luminal Narrowing

A A B B C C A A B B C C

V3016 V3016

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Macro vs. Microvascular Circulation

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Women’s Early Warning Signs of a Heart Attack

  • Weeks before Heart Attack (95% of women)
  • Unusual fatigue (70.7%)
  • Sleep disturbance (47.8%)
  • Shortness of breath (42.1%)
  • Indigestion (39.4%)
  • Chest pain (29.7 %)
  • At time of Heart Attack
  • Shortness of breath (57.9%)
  • Weakness (54.8%)
  • Fatigue (42.9%)
  • Chest pain (57%)

McSweeney, JC et al. Circulation 2003; 2619-2623

Questions to answer today

  • Why should women worry about heart disease?
  • What is heart disease?
  • How is heart disease different in women than

men?

  • What are the risk factors for heart disease?
  • How can women prevent heart disease?
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Risk factors for Heart disease

  • Age
  • Family History
  • Menopause
  • Smoking
  • Hypertension
  • High cholesterol
  • Diabetes
  • Obesity
  • Physical inactivity
  • Inflammatory Disease

Impact of Hypertension

  • The risk of heart disease doubles with each

increment of 20/10 mm Hg above normal

  • A 5-10 mm Hg improvement in systolic blood

pressure can decrease heart disease risk by 20%

  • 66% of people with hypertension do not have

adequate blood pressure control

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Hypertension is the most common risk factor for heart disease

Source: CDC/NCHS and NHLBI. 11.1 21.3 34.1 5.8 55.5 74.0 46.6 60.9 69.2 18.1 34.0 83.4

20 40 60 80 100 20-34 35-44 45-54 55-64 65-74 75+

Ages

Percent of Population

Men Women

Smoking is the #1 preventable risk factor for heart disease

  • 2-6 times more likely to have a heart attack
  • 150% more deaths from cardiac cause than from lung CA
  • Oral contraceptive users who smoke have significantly

higher cardiac risk

  • 50% reduction in CAD after first year of smoking cessation

and in 10-15 yrs, risk of heart disease decreases to the same level of a non-smoker.

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Relative Risk of Coronary Events for Smokers Compared to Non- Smokers

3.12 5.48 1 1 2 3 4 5 6

Never Smoked 1-14 Cigarettes per day 15 Cigarettes per day Relative Risk Source: Adapted from Stampfer 2000

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Framingham Heart Study

CHD likelihood ratio 5.0 4.0 3.0 2.0 1.0 0.0

Total-C LDL-C Trig.

Men Women

Total-C LDL-C Trig

Elevated cholesterol levels are a risk factor for heart disease in men and women Elevated Triglyceride levels are associated with greater cardiac risk in women

Framingham Heart Study

0.55 1 1.4 1.45 1.8 1.85 2.2 2.15 0.65 0.8 0.75 1 1.2 1.3 1.25 1.25

0.5 1 1.5 2 2.5 50 100 150 200 250 300 350 400 Relative Risk (x-fold) Women Men

Castelli WP. Can J Cardiol. 1988

Triglyceride levels Triglyceride levels

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Diabetes is a potent risk factor for heart disease

  • Diabetes is considered a “coronary heart disease

equivalent”

  • Women now make up more than 50% of the diabetic

population

  • Women with diabetes are at 3-7 times greater risk of

heart disease than non-diabetic women

  • Young women who are diabetic lose “gender

protection”

Source: National Diabetes Fact Sheet, Atlanta, GA, Department of Health and Human Services, Centers for Disease Control and Prevention, 1997.

2000

Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person) 2010 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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Women are more likely to be obese than men

56.3 52

18.7 25.6

10 20 30 40 50 60

Men Women

Overweight defined as >25 BMI; obese defined as >30 BMI.

Number of persons (in millions)

Overweight Obese

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

American Heart Association. 2002 Heart and Stroke Statistical Update American Heart Association. 2002 Heart and Stroke Statistical Update

Impact of Weight on Cardiac risk

Obesity increases the risk for cardiac disease, hypertension, and diabetes. Being overweight mildly increases the risk of cardiovascular disease, even in young women. Being obese increases the risk fourfold. Central adiposity, defined as a waist size greater than 35 inches in women, is a significant predictor of CHD.

(Source: NHLBI)

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Body Mass Index Evaluation

  • Body Mass Index formulas

Metric formula: (weight in kilograms) (height in meters) x (height in meters) English formula: (weight in pounds) (height in inches) x (height in inches) X 703

  • Classification by BMI

Overweight >25 but <30 Obese >30 but <40 Extreme Obesity >40

Body Weight and CHD Mortality Among Women

5.8 4.6 3.1 1.4 1 1 1 2 3 4 5 6

19.0-21.9 22.0-24.9 25.0-26.9 27.0-28.9 29.0-31.9 32

BMI Relative Risk

  • f CHD

Mortality Compared to BMI<19

P for trend < 0.001

Source: Adapted from Manson 1995

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Questions to answer today

  • Why should women worry about heart disease?
  • What is heart disease?
  • How is heart disease different in women than

men?

  • What are the risk factors for heart disease?
  • How can women prevent heart disease?
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Make time for yourself! Make time for yourself!

The goal targets for cardiac risk factors

Risk Factor Minimal Goal Optimal Goal Hypertension (mm Hg) Systolic <140 Diastolic <90 Systolic <120 Diastolic <80 High cholesterol (mg/dL) LDL-C: 100-129 Total Chol: 160-199 HDL-C : 55 Primary: LDL-C < 100 Secondary: HDL-C >35 TG< 200 Diabetes Near-normal fasting glucose (HbA1c <7%) Same Cigarette smoking Complete cessation Same

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Vigorous activity, 30 minutes at least, 3-4 days a week

  • Stairclimbing
  • Jogging or brisk walking
  • Rowing
  • Jumping rope
  • Bicycling
  • Tennis
  • Swimming

Moderate activity, 30 or more minutes 5 days per week

  • Walking
  • Gardening, mowing, raking leaves
  • Dancing
  • Pushing a stroller
  • Housework
  • Golf

What kind of physical activity is best? What kind of physical activity is best? Increase your level of Physical Activity Epidemiologic studies suggest active women experience a 50% reduction in cardio- vascular risk.

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  • Eat 5 or more fruits and vegetables daily
  • Eat 6 or more servings of grain products,

especially whole grains, daily

  • Limit foods high in saturated fat, trans fat

and/or cholesterol

  • Choose low-fat dairy products
  • Choose fats with < 2g. of saturated fat per

serving

  • Consume less than 1 tsp. of table salt per

day; limit foods high in sugar

  • Limit alcohol to one drink/per day
  • Eat at least two servings of fish a week
  • Optimal total caloric intake per day

moderately active: current weight X 15 inactive: current weight X 13

Follow a Heart Healthy Diet Having a “little” of a few risk factors can be a serious problem

Metabolic Syndrome

Women are diagnosed with metabolic syndrome if they have three or more of the following conditions:

  • Waist measurement > 35 inches
  • Triglyceride level > 150 mg/dL
  • Fasting glucose > 110 mg/dL
  • HDL < 50 mg/dL
  • Blood pressure > 130/85 mmHg
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Assess your risk for Heart Disease Speak with your physician to find out if you have risk factors for cardiac disease If you have modifiable risk factors, know the target goals and try to achieve them

Case Study

  • 46 year old female presents with c/o SOB

and dry throat while exercising.

  • Recently HTN on Lisinopril 2.5mg qd
  • BMI 27 Gained 15lbs. last few years and

started exercise program

  • Father CABG at age 60.
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Bruce Protocol 5min 30sec SOB, Fatigue, Dry throat Recovery Sympoms persisted until 6min after resting

Exercise Echocardiogram

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Case Study

  • 54 year old female presents with c/o

jaw/teeth pain with exertion or emotional distress

  • Post-menopausal, father had CABG in 50’s,

brother PCI age 45

  • BMI 25, normotensive
  • Cholesterol 198, LDL 111, HDL 52

Exercise Cardiolite Stress Test

Bruce Protocol 6 min SOB and pain in teeth Perfusion Study

  • normal, no TID
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Normal Cardiac Catheterization

Case Study

  • 42 year old female with a family history of premature
  • CAD. Normotensive, LDL 72, BMI 26, non-smoker
  • Chest, left arm and neck pressure with emotional

distress for the last year.

  • Underwent a stress test in the last year that was

normal.

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Case Study

  • Given SL Nitroglycerin x 2 without relief
  • Underwent emergent cardiac catheterization with

normal coronary arteries.

  • Stress or microvascular angina??
  • Psychotherapy?
  • Antidepressants?
  • Reassurance that is not her

heart due to a normal cath?

Case Study

  • Classic Microvascular Angina
  • Treatment with Aspirin, BB and Statin with resolution
  • f all symptoms.
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.

Conclusions

Thank You