The Gender Divide Women, Men and Heart Disease February 2017

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1 The Gender Divide Women, Men and Heart Disease February 2017 Nandita S. Scott, MD FACC Co-Director MGH Heart Center Corrigan Women s Heart Health Program Massachusetts General Hospital

2 Heart Disease For the last century, heart disease has been the number one cause of death in this country Heart Disease was thought to be a man s problem BUT, more American woman die than American men each year from heart disease

3 Cardiovascular disease (CVD) mortality trends for males and females (United States: ). Dariush Mozaffarian et al. Circulation. 2015;131:e29-e322 Copyright American Heart Association, Inc. All rights reserved.

4 Cardiovascular disease and other major causes of death for all males and females (United States: 2011). Dariush Mozaffarian et al. Circulation. 2015;131:e29-e322 Copyright American Heart Association, Inc. All rights reserved.

5 Cardiovascular disease (CVD) and other major causes of death in females: total, <85 years of age, and 85 years of age. Dariush Mozaffarian et al. Circulation. 2015;131:e29-e322 Copyright American Heart Association, Inc. All rights reserved.

6 Why the Gender Gap? Lack of data Historically women were excluded from research studies to protect them and their children 1985 US Public Health Service Task Force conclusion: we have compromised the health of women. The NIH started to include women of child-bearing age into research trials in 1986.

7 Are Women Aware? Percentage of women who know that heart disease is the leading cause of death in women: 1997: 30 % 2000: 34 % 2003: 46 % 2007: 57% Circulation 2004:109:

8 And in Minorities. Hispanic develop heart disease 10 years earlier 34% of hispanic women aware that heart disease is their greatest risk African American 36% know that this is their greatest risk Of AA women over 20, 48.3% have cardiovascular disease Less likely to have a usual source of medical care and 1/8 say that their MD has discussed heart disease risks 8

9 Why the Gender Gap? Women present on average 1 hour later with AMI Women present later in life and with greater co morbidities Women receive less revascularization procedures Women receive less aggressive medical therapy Differences in coronary artery structure Is mechanism for heart disease different?

10 Cardiac Symptoms in Women Symptoms of heart disease may be less typical in women Chest pain is experienced by most women with CHD, but non-chest pain presentations are more common in women than men

11 Mechanisms of heart attacks Plaque rupture: disruption of fibrous cap over a lipid core with contact of the acute thrombus with the lipid pool Plaque erosion: acute thrombus in direct contact with the plaque without rupture of a lipid pool. Plaque erosion is more common in young people and women Coronary artery dissection

12 Copyright 1996 American Heart Association Farb, A. et al. Circulation 1996;93:

13 55 year old nurse with exertional chest discomfort with accelerating pattern with walking, golfing and now climbing stairs high cholesterol, postmenopausal aspirin 325 mg, atorvastatin 20 mg ex smoker, occasional ETOH

14 Physical exam: BP 106/63, HR 51, otherwise normal Lipids: LDL 93, HDL 44, TG 116, glucose 94 Stress test: 8:45 min, developed chest pain which increased with exercise, nuclear scans were positive for blood flow abnormalities

15 Cardiac cath: normal arteries

16 Heart Disease in Women Are We Approaching This the Right Way? The prevalence of major blockage in women is relatively low before menopause Women with heart disease in general have less major blockages, however have a worse prognosis Nearly 60% of women undergoing coronary angiography have normal arteries Continued symptoms, abnormal stress test and prognosis not necessarily benign

17

18 Camici J Nuclear Med 2009 Slide borrowed from Malissa Wood MD

19 Cardiac Syndrome X Diagnosis of exclusion Three features: angina like chest pain with exertion positive stress tests normal coronary arteries More women than men Treatment not clear Prognosis not necessarily normal

20 Stress Cardiomyopathy First described in 1990 in Japan Novel Heart Syndrome first described in JACC in 2001 Predominantly involves women Triggered by Stress Presents like a heart attack Classic form: Takotsubo or apical ballooning

21

22 Takotsubo/stress cardiomyopathy Wittstein, I. et al. N Engl J Med 2005;352: Wittstein, I. et al. N Engl J Med 2005;352:

23 Clinical Characteristics of 19 Patients with Stress Cardiomyopathy on Admission Wittstein, I. et al. N Engl J Med 2005;352:

24 Serial Echocardiographic Assessment of the Ejection Fraction in 19 Patients with Stress Cardiomyopathy Wittstein, I. et al. N Engl J Med 2005;352:

25 Stress Cardiomyopathy - mechanisms Large artery spasm Small vessel spasm Adrenaline induced injury to heart muscle Unclear why women more susceptible

26 Pregnancy a unique early window Hypertensive disorders of pregnancy Placental abruption and infarction Doubles the risk of cardiovascular disease over lifetime - first described in 1927 Failed Stress Test of Pregnancy

27 Pre-eclampsia and Cardiovascular Outcomes Women with pre-eclampsia were at increased risk of developing HTN: (RR 3.70) CAD: (RR 2.16) CVA: (RR 1.81 VTE(RR 1.79) Absolute risk that a woman with or without a history of pre-eclampsia experiencing one of these events at age 50 to 59 years was estimated to be 17.8 and 8.3 percent, respectively. Bellamy L, et al. BMJ 2007

28 Women with gestational diabetes, preeclampsia or pregnancy induced hypertension puts a woman at risk for CVD Perhaps unmask early or pre-existing endothelial dysfunction Failed Stress test of Pregnancy Circulation 2011

29 Heart Disease in Women The Good News Heart Disease is Preventable!!!

30 Incidence of cardiovascular disease according to the number of ideal health behaviors and health factors. Dariush Mozaffarian et al. Circulation. 2015;131:e29-e322 Copyright American Heart Association, Inc. All rights reserved.

31 Major Cardiac Risk Factors High blood pressure High cholesterol Diabetes Smoking 31

32 Hypertension Both numbers are important 1/3 of US adults have high blood pressure and not do know it the silent killer Only way to know is to have it checked Normal blood pressure is < 120/80 New guidelines: goal blood pressure less than 140/90 Goal less than 150/90 if over 60, unless diabetes or kidney disease

33 Hypertension what can you do? Reduce salt in your diet 1500 mg/day certain groups 2300 mg/day all others Exercise Alcohol in moderation DASH diet

34 Benefits of Lowering Blood Pressure Reduces the chance of: Stroke: % Heart Attack: % Heart Failure: 50 % American Heart Association website:

35 High Cholesterol Cholesterol is made in the liver and also supplied in diet HDL good cholesterol, goal greater than 50 for women LDL bad cholesterol, goal depends on your risk Triglycerides, goal less than 150 The good news is that a 10% decrease in total cholesterol, reduces CHD risk by 30%

36 Smoking Cigarette smokers are 2-4 times more likely to develop heart disease and stroke Good news: After 15 years of abstinence, the risk for coronary heart disease is similar to that of persons who have never smoked Quit smoking programs are available

37 Diabetes Since 1990, the prevalence of diagnosed diabetes has increased by 60% 65% of diabetics die of some form of cardiovascular disease Rates of CAD are 2-3X higher in diabetic men and 3-7X higher in diabetic women

38 Diabetes If you have diabetes, ensure that your blood glucose control is perfect If you do not have diabetes, ensure that you get checked for it by a simple blood test < 99 normal pre diabetes > 126 diabetes

39 Lifestyle Interventions Physical Activity Minimum of 30 minutes of moderate-intensity physical activity (biking, walking, etc) on most and preferably all, days of the week For weight loss, minutes of moderate-intensity physical activity on most if not all days

40 . 10-Year Coronary Event Rates, According to Lifestyle and Genetic Risk in the Prospective Cohorts. 10-Year Coronary Event Rates, According to Lifestyle and Genetic Risk in the Prospective Cohorts. Khera AV et al. N Engl J Med 2016;375:

41 Conclusions More women than men are dying from heart disease in the US each year Perhaps we need to challenge the current thinking Differences exist between a man and woman s heart

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