Cardiovascular Disease

Transcription

1 증상, 진단및임상양상의차이 충남대학교의학전문대학원의학과박재형 Cardiovascular Center, Chungnam National University Hospital 1 Cardiovascular Disease Cardiovascular Center, Chungnam National University Hospital 2 1

2 CVD Statistics, 2008 Heart Disease and Stroke Statistics, Circulation 2012;135:e2 Cardiovascular Center, Chungnam National University Hospital 3 Cardiovascular Mortality Cardiovascular Disease Mortality U.S. Males and Females, Rosamond W, et al., 2008 Cardiovascular Center, Chungnam National University Hospital 4 2

3 Cardiovascular Mortality Annual # of U.S. Adults Diagnosed with MI and Fatal CHD by Age/Sex: Rosamond W, et al., 2008 Cardiovascular Center, Chungnam National University Hospital 5 Trend of Cardiovascular Death Roger, V.L. et al., 2011 Cardiovascular Center, Chungnam National University Hospital 6 3

4 Causes of Death in Korea 통계청, 2011 Cardiovascular Center, Chungnam National University Hospital 7 Awareness In a study conducted by the AHA in 1997, only 7% of women thought CVD was their greatest health risk In a follow-up survey in 2003, almost half of the women identified CVD as a leading cause of death and 13% thought it was their leading health problem Mosca, Ferris, Fabunmi, & Robertson, 2004 Cardiovascular Center, Chungnam National University Hospital 8 4

5 Awareness Health care provider awareness On-line, cross-sectional study of 500 physicians Lower perceived risk of CVD for women Awareness/implementation of prevention guidelines varied by specialty OB/Gyn substantially less aware 67% of the OB/Gyn s identified themselves as the PCP for their patient s Mosca,.L. et al., 2005 Cardiovascular Center, Chungnam National University Hospital 9 Awareness in Doctors One in 5 primary care physicians are not aware that CHD is the #1 cause of death in US women <50% women have CVD risk factor assessed, fewer treated to goal national treatment guidelines J Women s Health & Gender-Based Med 2001; 17 Cardiovascular Center, Chungnam National University Hospital 10 5

6 Awareness Lack of risk awareness/surveillance 25% of adult women have never had their cholesterol profile tested But, as of % had a Pap smear in the prior 1~3 years 80% of women over age 50 years had a mammogram in the prior 1~2 years 2000 CDC Risk Factor Surveillance System Cardiovascular Center, Chungnam National University Hospital 11 Gender Difference of RF Women Men Hypertension X3 X2 LVH X3 X2 Diabetes X8 X4 Lifetime risk CAD at age 40 1/3 ½ MI Higher HF and Shock Worse survival in 1 st year Cardiovascular Center, Chungnam National University Hospital 12 6

7 Women s Perceptions of Heart Disease 72% of young women (ages 25-40) still consider cancer to be the greatest threat to women s health Some women know about the risks of heart disease but do not hear it from their own doctors and do not personalize it 65% of women recognize that symptoms may be atypical but do not know classic symptoms Most women learn about coronary artery disease (CAD) from magazines and the Web not from their own physicians! Robinson A. Circulation Cardiovascular Center, Chungnam National University Hospital 13 Discrepancy 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Awareness Prevalence Hirsch, AT et al., 2007 Cardiovascular Center, Chungnam National University Hospital 14 7

8 Perception vs Reality Perception 축제목 Reality 1 2, 3 1. Gallup survey American Heart Association. Heart & Stroke Facts Statistical Supplement Cardiovascular Center, Chungnam National University Hospital 15 Heart Attacks in Women 63% of women who die suddenly from CHD had no prior symptoms 42% of women who survive it die within a year vs 24% of men A second MI occurs within 6 years in 35% of women vs 18% of men Thus, early recognition of symptoms and accurate diagnosis of CAD is of great importance AHA Heart and Stroke Statistical Update 2001 Cardiovascular Center, Chungnam National University Hospital 16 8

9 Heart Attacks in Women Clinical dilemmas in women s CAD At presentation of CAD, women are older than men Less specific clinical manifestations of CAD in women Greater difficulty in diagnosis in women More severe consequences on MI when it occurs in women Cardiovascular Center, Chungnam National University Hospital 17 Women in Clinical Trials Women are underrepresented in cardiovascular (CV) trials Evidence-based CV medicine biased toward men Food and Drug Administration/National Institutes of Health mandate: 50% enrollment of women Women need to be empowered to enroll in clinical trials for heart disease Breast-cancer awareness is a good example Cardiovascular Center, Chungnam National University Hospital 18 9

10 Gender Differences in Heart Attack Symptoms Typical in both sexes Pain, pressure, squeezing, or stabbing pain in the chest Pain radiating to neck, shoulder, back, arm, or jaw Pounding heart, change in rhythm Difficulty breathing Heartburn, nausea, vomiting, abdominal pain Cold sweats or clammy skin Dizziness Typical in women Milder symptoms (without chest pain) Sudden onset of weakness, shortness of breath, fatigue, body aches, or overall feeling of illness (without chest pain) Unusual feeling or mild discomfort in the back, chest, arm, neck, or jaw (without chest pain) Cardiovascular Center, Chungnam National University Hospital 19 Less Common Heart Attack Symptoms in Women Milder symptoms without accompanying chest pain Sudden onset of weakness, shortness of breath, fatigue, body aches, overall feeling of illness Burning sensation in the chest, may be mistaken as heartburn An unusual feeling or mild discomfort in the back, chest, arm, neck, or jaw Cardiovascular Center, Chungnam National University Hospital 20 10

11 Gender Difference in Clinical Presentation Women Men Substernal chest pain/ left sided 57% 70% Heavy and tight chest 43% 30% Sweating 30% 23% Jaw/neck pain 15% 16% Dizziness 21% 18% No chest discomfort 30% 29% Am J Cardiol 1999; 84,396 Cardiovascular Center, Chungnam National University Hospital 21 Gender Difference in Clinical Presentation Women Men Mid-back pain 13% 2% Arm/shoulder pain 38% 27% Nausea 30% 16% Dyspepsia 22% 12% Shortness of breath 50% 35% Palpitations 10% 3% Am J Cardiol 1999; 84,396 Cardiovascular Center, Chungnam National University Hospital 22 11

12 Prehospital Delay in MI Review of 42 literatures from Women and older persons were more likely to arrive at the hospital than men and younger persons Factors associated with prehospital delay Sociodemogrpahics Medical history Clinical characteristics Contextual characteristics Nguyen HL, et al. Circ Cardiovasc Qual Outcomes 2010;3:82 Cardiovascular Center, Chungnam National University Hospital 23 Prehospital Delay in MI Nguyen HL, et al. Circ Cardiovasc Qual Outcomes 2010;3:82 Cardiovascular Center, Chungnam National University Hospital 24 12

13 Prehospital Delay in MI Nguyen HL, et al. Circ Cardiovasc Qual Outcomes 2010;3:590 Cardiovascular Center, Chungnam National University Hospital 25 Prehospital Delay in MI Nguyen HL, et al. Circ Cardiovasc Qual Outcomes 2010;3:590 Cardiovascular Center, Chungnam National University Hospital 26 13

14 Diagnosis of Noninvasive Tests in Women ECG Nuclear perfusion study ECHO poor window problem Dipyridamole injection MPI, Stress (Tread mill) Echo Dobutamine infusion Echo Computed tomography MR coronary angiography Cardiovascular Center, Chungnam National University Hospital 27 Publication Bias: Gender Representation and Negative Studies noninvasive testing literature 8% to 27% women Lower diagnostic accuracy in women High false-positive rates Inability to perform maximal stress Cardiovascular Center, Chungnam National University Hospital 28 14

15 Limited Representation of Women in Studies of CAD Testing Women Men Percent of patients ECG Echo MPI Adapted from: Shaw LJ, et al. Coronary Artery Disease in Women: What All Physicians Need to Know Cardiovascular Center, Chungnam National University Hospital 29 Exercise ECG (Treadmill) Despite advances in technology, the exercise ECG remains an important tool in the diagnosis and prognosis of the patient suspected of having CAD The exercise ECG has an overall sensitivity of 68% and a specificity of 77% for the detection of CAD in men The sensitivity and specificity of the exercise ECG in women are about 61% and 70% respectively Kwok Y, et al. Am J Cardiol Cardiovascular Center, Chungnam National University Hospital 30 15

16 Exercise ECG Testing in Women Study, year No of Women Sensitivity(%) Specificity(%) Detry et al., Weiner et al., Barolsky et al., Friedman et al., Guiteras et al., Hung et al., Cardiovascular Center, Chungnam National University Hospital 31 Gender Difference in Exercise ECG Testing sensitivity in women >65 years specificity in women on hormone replacement therapy false-positive results due to autonomic/hormonal influences Digoxin like effect of estrogen Shaw LJ, et al. CAD in Women: What All Physicians Need to Know Cardiovascular Center, Chungnam National University Hospital 32 16

17 Nuclear Imaging in Women Myocardial perfusion imaging (MPI) Large body of evidence in women Gender-specific data available for Tl-201and Tc-99m tracers Tc-99m tracers = agent of choice for women due to decrease attenuation artifacts from breast tissue Gated single-photon emission computed tomography (SPECT) provides post stress ejection fraction and regional wall motion helpful to reduce false positives IV adenosine/dipyridamole stress provides comparable overall accuracy in women and men Cardiovascular Center, Chungnam National University Hospital 33 Nuclear Imaging in Women Myocardial perfusion imaging Gender-specific data available for Tl-201 and Tc- 99m tracers Tc-99m tracers decrease attenuation artifacts from breast tissue Gated SPECT provides post stress ejection fraction and regional wall motion reduce false positive result IV adenosine/dipyridamole stress provides comparable overall accuracy in women and men Cardiovascular Center, Chungnam National University Hospital 34 17

18 Comparative Test Statistics on Diagnostic Accuracy in Women Test Number Sensitivity Specificity Exercise ECG % 70% Echocardiography % 79% Nuclear (Tl-201) % 64% Nuclear(gated tech) % 94% Kwok Y, et al. Am J Cardiol Cardiovascular Center, Chungnam National University Hospital 35 Nuclear Imaging in Women N = 115, P = % 67% Tc-99m reduced breast attenuation in women Tl-201 Tc-99m sestamibi Pharmacologic stress is helpful in older and obese women Hachamovitch R. et al. J Am Coll Cardiol. 1996; Amanullah AM, et al. Am J Cardiol. 1997; Taillefer R, et al. J Am Coll Cardiol Cardiovascular Center, Chungnam National University Hospital 36 18

19 EchoCG in Women More sensitive than ECG testing Increased sensitivity (79~88%) Increased specificity (77~85%) Breast tissue is the major obstacle for good imaging Cardiovascular Center, Chungnam National University Hospital 37 Conclusion Women are more complex than most men There are gender difference in RF, presentation test accuracy and complication of CVD Physicians should pay attention to education, finding and secondary prevention of CVD in women Cardiovascular Center, Chungnam National University Hospital 38 19