Ischemic Heart Disease in Women

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1 Ischemic Heart Disease in Women Lawrence J. Hergott, M.D. Professor of Medicine Director of Outpatient Clinical Services University of Colorado Denver Historical Perspective Regarding IHD In Women Method: literature search Keywords: coronary artery disease/ coronary heart disease/ischemic heart disease in women Timeframe:

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4 Hurst and Logue Textbook of Cardiology 4

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women equally 1993: Congressional Caucus for Women s Health Issues forces NIH to

6 Ischemic Heart Disease in Women Principles Women have been understudied in clinical research over time Diagnostic tests and treatments have been applied to both men and women equally 1993: Congressional Caucus for Women s Health Issues forces NIH to include potential differences in outcomes between the genders in all studies it funds 6

7 Rep. Patricia Schroeder (D-Colorado) Olympia Snow 7

Treatment* Prevention of cardiovascular disease* * Less difference than in other variables -- These

8 Olympia Snowe (R-Maine) Ischemic Heart Disease (IHD) in Women Principles -- In comparison to men, there are differences in: Prevalence Pathophysiology Outcomes Symptoms unclear to what degree Treatment* Prevention of cardiovascular disease* * Less difference than in other variables -- These differences are especially relevant to young and middle-aged women, but continue at lesser levels to age > 65 8

9 Ischemic Heart Disease in Women Principles - Epidemiology -- IHD is the main cause of death in women of all ages: 1 in 2.6 women die of IHD vs. 1 in 4.6 from cancer In 2007 more women s lives were claimed by CVD that than by cancer, chronic lower respiratory disease, Alzheimer disease and accidents combined Ischemic Heart Disease In Women: Principles - Epidemiology American Heart Association 1997 data regarding causes of death in women: Breast cancer: 41,943 Coronary artery disease: 502,938 9

10 Ischemic Heart Disease in Women Principles - Epidemiology -- More women than men die from IHD in the U.S. annually After decades of CHD death rate reduction, rates in U.S. women ages appear to be increasing -- Main factor: greater rates of obesity, DM II -- Each year 55,000 more women than men have a stroke Ischemic Heart Disease in Women Principles - Outcomes -- Mortality in ischemic heart disease, MI, thrombolytic therapy, PCI, CABG higher than in age-matched men -- Though ejection fraction more preserved in women 10

11 IHD In Women Awareness Health workers and women need to be educated re: IHD 78% of women estimated their risk of developing CAD by age 70 at: < 1% Percent of women in AHA survey who said the first thing they would do if they thought they were having an acute MI is call 911: 53% Ischemic Heart Disease in Women Principles Women are undertreated regarding IHD Less often received guideline-directed therapy for IHD When they do outcomes are similar Fewer undergo coronary angiography Fewer receive statins Etc. 11

12 Ischemic Heart Disease in Women Pathophysiology -- Even with documented ischemia, women have less anatomically obstructive disease than men 12

13 Ischemic Heart Disease in Women Principles - Pathophysiology -- Even with documented ischemia, women have less anatomically obstructive disease than men Mechanism: Microvascular Dysfunction Non-epicardial, intra-myocardial vessels Causes: Risk factor clustering Vascular inflammation and remodeling Hormonal alterations Term ischemic heart disease preferred in women vs. coronary artery disease 13

Treadmill Stress Testing Probability of Those With 1.0-1.

Coronary Disease Ischemic Heart Disease in Women

14 Treadmill Stress Testing Probability of Those With mm ST Depression On Exercise Testing Having Important Coronary Disease Ischemic Heart Disease in Women Pathophysiology Greater tendency toward plaque erosion, rupture in women vs. men 14

15 Ischemic Heart Disease in Women Pathophysiology Greater tendency toward plaque erosion, rupture in women vs. men Even in non-obstructed vessels, can cause: Unstable angina Non-STEMI Coronary spasm 15

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18 Risk Factors Traditional Hypertension Tobacco use Dyslipidemia Family history Diabetes Obesity Postmenopausal state Risk Factors Female-specific variants Smoking & Diabetes Negate premenopausal protective effect Dyslipidemia High triglycerides impose greater risk vs. men Inflammatory biomarkers Inflammatory-mediated autoimmune diseases increased Suggests prominent role for inflammation in IHD in women 18

19 Risk Factors Female-specific variants Altered Fibrinolysis Impaired in: CVD, hypertension, obesity, Type 2 DM Can be a cause of coronary thrombosis with even normal coronary arteries Risk Factors Female-specific variants Cardiometabolic Syndrome Associated with estrogen, androgen alterations Polycystic Ovary Syndrome Higher incidence of DM Clustering of risk factors Impaired exercise tolerance Sedentary lifestyle 19

Risk Factors Female-specific variants Pregnancy A state of unique cardiovascular and metabolic stress Preeclampsia doubles risk of IHD, CVA, venous TE events over 5-15 years after pregnancy*

20 Risk Factors Female-specific variants Pregnancy A state of unique cardiovascular and metabolic stress Preeclampsia doubles risk of IHD, CVA, venous TE events over 5-15 years after pregnancy* Metabolic Syndrome of Pregnancy * May unmask endothelial dysfunction, vascular or metabolic disease May be associated with gestational DM, preterm birth, birth of an infant small for gestational age* * Considered an indication for OB referral to PCP or cardiologist for preventive care Practitioners who meet women later in their lives should ask about complications of pregnancy Classification of Cardiovascular Disease Risk for Women Risk for CVA & heart failure exceeds even IHD risk in middle and older age women vs. men 20

21 Presentation of IHD in Women Symptoms Myth? Women with IHD do not present with angina Framingham, CASS, acute coronary occlusion study, etc. show the same or higher rates of angina with CAD Acute Coronary Occlusion During PTCA 21

22 Presentation of IHD in Women Symptoms Myth? Women with IHD do not present with angina Fact: Women develop IHD at a later age than men and thus have more co-morbidities when diagnosed Fact: The elderly & diabetics do have unusual presentations with CAD (nausea, fatigue, dyspnea, etc.) is this the f th th fl ti bi th th IHD In Women Testing Class I indication in asymptomatic patients only for: Taking a family history Performing global risk score Framingham, PROCAM, Reynolds (requires CRP, HbA 1c, not recommended for screening in guidelines), etc. Mainly assess CAD risk, not CVD risk Typically underestimate even coronary risk in women Framingham equations now available for 10- and 30-year CVD risk (IHD, CVA, HF, claudication) 22

23 Risk Estimation Systems Framingham: nhlbl.nih.gov/guidelines/cholesterol/index/htm PROCAM: chd-taskforce.com/calculator SCORE: heartscore.org ASSIGN-SCORE: assign-score.com QRISK1, QRISK2: qrisk.co.uk WHO/ISH: who.int/cardiovascular_diseases/ guidelines Reynolds Risk Score: reynoldsriskscore com IHD In Women Testing Stress testing: Not indicated as screen in asymptomatic patients Standard GXT treadmill preferred Lower specificity for CAD women vs. men Focus on non-st results as well as ST results Functional capacity Heart rate recovery Duke Treadmill Score 23

24 Duke Treadmill Score (Exercise duration in minutes-5x ST deviation*-4x angina index**) Risk Group; (Score) Annual Mortality, % 4-Year Survival, % Low; (>5) 0.25% 99% Intermediate; (-10 to 4) 1.25% 95% High; (<-10) 5% 79% * ST up or down **0= no angina, 1=non-limiting angina, 2=limiting angina IHD In Women Testing Stress echo and stress nuclear studies are as predictive in women as in men Stress echo preferred (depends on institutional experience) No radiation Higher specificity 24

25 IHD In Women Treatment Standard treatments for obstructive lesions effective Guideline indicated therapy for ACS abolishes adverse mortality gap Invasive strategy for ACS with positive biomarkers Greater benefit Conservative strategy for ACS with negative biomarkers Greater risk IHD In Women Treatment Regarding treatment with ischemia and nonobstructive CAD: Calcium antagonists reduce coronary flow reserve, fail to improve symptoms Beta blockers highly effective for chest discomfort relief No controlled studies about the effectiveness of nitrates on outcomes Statins and ACE inhibitors improve endothelial dysfunction Proven benefit of exercise training Novel therapy: imipramine improves symptoms 25

26 IHD In Women Prevention Evolving science suggests that the overwhelming majority of recommendations to prevent CVD are similar for women and men, with few exceptions. Mosca, et al. IHD In Women Prevention Guideline Highlights Aspirin recommendations ( mg/d) High-risk women In presence of CHD unless contraindicated Reasonable in women with DM unless contraindicated If ASA intolerance, substitute clopidogrel 26

27 IHD In Women Prevention Guideline Highlights Aspirin recommendations Other at-risk or healthy women Low dose ( mg/d) useful age > 65 if: BP controlled Benefit for ischemic CVA and MI prevention likely exceeds risk of GI bleeding and hemorrhagic stroke IHD In Women Prevention Guideline Highlights 22, 2011 Mosca L, et al. JACC March Physical activity 150 min/week moderate activity, or 75 min/week vigorous exercise, or Equivalent combination Additional CV benefits by increasing time to 300 min/week, 150 min/week, respectively For weight loss, minutes of moderate activity on most/all days Major muscle group strengthening > 2 days/ week 27

28 References 1. Bengtsson C. Ischaemic heart disease in women. Acta Medica Scandinavica 1973; 549: Steinberg HO, et al. Type II diabetes abrogates sex differences in endothelial function in premenopausal women. Circulation 2000; 101 (17): Hippisley-Cox J, et al. Sex inequalities in ischaemic heart disease in general practice: cross sectional survey. British Medical Journal 2001; 322: Jaraith N. Implications of gender differences in coronary artery disease risk reduction in women. AACN Clinical Issues 2001; 12(1): Vittinghoff e, et al. Risk factors and secondary prevention in women with heart disease: The Heart and Estrogen/progestin Replacement Study. Annals of Internal Medicine 2003; 138: Charney P. Presenting symptoms and and diagnosis of coronary heart disease in women. Journal of Cardiovascular Risk 2002; 9(6) Edwards FH, et al. Impact of gender on coronary bypass operative mortality. Annals of Thoracic Surgery 1998; 66: King KM, et al. Sex differences in outcomes after cardiac catheterization: effect modification by treatment strategy and time. Journal of the American Medical Association 2004; 291: Jacobs AK, et al. Improved outcomes for women undergoing contemporary percutaneous coronary intervention. Journal of the American College of Cardiology 2002; 39: References 10. Vaccarino V, et al. Sex-based differences in early mortality after myocardial infarction. The New England Journal of Medicine 1999; 341: Hochman JS, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. The New England Journal of Medicine 1999; 341: Wexler LF. Studies of acute coronary syndromes in womenlessons for everyone (editorial). The New England Journal of Medicine 1999; 341: Giardina E-G V. Coronary artery disease in women: what all physicians need to know (book review). The New England Journal of Medicine 2000; 342: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Journal of the American College of Cardiology 2004; 43: Tall AR. C-reactive protein reassessed. The New England Journal of Medicine 2004;350: Sullivan AK, Holdright DR, et al. Chest pain in women: clinical, investigative, and prognostic features. British Medical Journal 1994; 308: Reis SE, Olson MB, et al. Mild renal insufficiency is associated with angiographic coronary artery disease in women Circulation 28

29 References 18. Kilaru PK, et al. Utilization of coronary angiography and revascularization after acute myocardial infarction in men and women risk stratified by by the ACC/AHA guidelines. Journal of the American College of Cardiology 2000; 35: Alter DA, et al. Biology or bias: practice patterns and long-term outcomes for men and women with acute myocardial infarction. Journal of the American College of Cardiology 20002; 39: MacIntyre K, et al. Gender and survival: a population-based study of 201,114 men and women following a first myocardial infarction. Journal of the American College of Cardiology 2001; 38: Bourdillon P. Coronary artery disease in women. British Medical Journal 1995; 310: Juhani Airaksinen KE, et al. Gender difference in autonomic and hemodynamic reactions to abrupt coronary occlusion. Journal of the American College of Cardiology 1998; 31: Greenland P, et al ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive Summary. J Am Coll Cardiol 2010;56: References 24. Shaw LJ, et al. Women and ischemic heart disease evolving knowledge. J Am Coll Cardiol 2009;17: Mieres JH, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease. Circulation 2005;111: Pencina MJ, et al. Predicting the 30-year risk of cardiovascular disease The Framingham Heart Study. Circulation 2009;119: Mosca L, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women 2011 update. J Am Coll Cardiol 2011;57:

Management of Stable Ischemic Heart Disease. Vinay Madan MD February 10, 2018

Management of Stable Ischemic Heart Disease Vinay Madan MD February 10, 2018 1 Disclosure No financial disclosure. 2 Overview of SIHD Diagnosis Outline of talk Functional vs. Anatomic assessment Management