Women and Ischemic Heart Disease Lessons Learned

Transcription

1 Women and Ischemic Heart Disease Lessons Learned Bina Ahmed MD Interventional Cardiology Dartmouth-Hitchcock Medical Center Assistant Professor of Medicine Geisel School of Medicine Lebanon, NH

2

3 Lesson 1: Same but Different

4 Symptoms Complications Co-morbidities Treatment

5 Lesson 2 : Case Presentation Mid LAD with a diffuse % narrowing. There is an abrupt change in caliber of the vessel. No response to IC Nitroglycerin HPI: 39 y-old female Sudden onset of throat numbness and chest pain No relevant PMH, FH or SH 20 months post-partum

6 Lesson 2: Alternative MI : MI in the absence of obstructive CAD due to atherosclerosis

7 Alternative Myocardial Infarction: Not an Alternative Fact! Arnett, E. N., & Roberts, W. C. (1976). Acute myocardial infarction and angiographically normal coronary arteries. An unproven combination. Circulation 1976 Reynolds et al. Mechanisms of myocardial infarction without obstructive coronary artery disease. Trends in Cardiovascular Medicine December; 2014 Agewall et al. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. European Heart Journal; 2016

8 Lesson 2: Alternative Myocardial Infarction True facts: Also known as MINOCA SCAD Type 2 AMI Plaque Disruption Alternative MI Myocarditis Coronary Vasospasm Stress induced CM (Myocardial Infarction with Non Obstructive Coronary Arteries) Symptoms + biomarkers +absence of obstructive CAD due to atherosclerosis On the rise (sensitive troponin assays + coronary angiography) Women presenting with ACS are 2X more likely to have Alt MI Highlights differences in pathophysiology of Ischemic heart disease among women Causes include

9 Lesson 2: Case Presentation HPI: 39 y-old female Sudden onset of throat numbness and chest pain No relevant PMH, FH or SH 20 months post-partum

10 Spontaneous Coronary Artery Dissection Prevalence and Epidemiology > 90% women Estimated 2-4% of all ACS; Women < 60 years of age: 20-35% of ACS presentations Most common cause of AMI in pregnancy Almost always related to emotional or physical trigger Pathophysiology Classification Type 1: multiple lumens Type 2: abrupt change in vessel caliber Type 3: mimics atherosclerosis Saw, J. et al. J Am Coll Cardiol. 2017;70(9):

11 Spontaneous Coronary Artery Dissection Management Coronary angiography Intra-vascular imaging OCT and IVUS: Risky Medical management >> mechanical revascularization PCI associated with low success rates and increased need for emergent CABG Saw et al. SCAD-Clinical Outcomes and Risk of Recurrence. JACC 2017

12 Spontaneous Coronary Artery Dissection F/U Screening of FMD: 60% have FMD (15% with ICA) Medical management Beta Blockers ASA Avoid anticoagulants (GPI, Thrombolytics) Outcomes Recurrent MACE: 20% Death (3 years): <2% Recurrent SCAD: 10% Risk reduced by beta blockers and increased by history of HTN Saw et al. SCAD-Clinical Outcomes and Risk of Recurrence. JACC 2017

13 Case Presentation Hospital Course: Admitted for 72 hours One episode of NSVT (asymptomatic) Trop T peaked 1.71 Echo: LVEF 48%; Extensive LAD territory wall motion abnormalities Discharge meds/instructions: ASA 81 mg Plavix 75 mg Lisinopril 2.5 mg Metoprolol succinate 50 mg Cardiac rehab

14 Case Presentation F/U: Represented 72 hours later with Sudden onset of chest pain Less intense; No associated symptoms Persistent symptoms 126/73; 66; 99% RA

15 Intimal Tear Repeat Coronary Angiography with Intravascular US performed Continued on medical therapy D/C on Day 2 Occasional episodes of chest pain/sob

16 Lesson 3: Have to Rethink (Hormone) Therapy

17 Lesson 3: Have to Rethink (Hormone) Therapy

18 Lesson 3: Timing Hypothesis

19 Lesson 3: Have to Rethink (Hormone) Therapy (again)) True facts: Consider HT for young women (< age 59 or within 10 years of menopause) who are bothered by moderate to severe menopausal symptoms. Both estrogen therapy and estrogen with progestogen therapy increase the risk of DVT/PE, similar to birth control pills, patches, and rings. Although the risks of blood clots and stroke increase with either type of hormone therapy, the risk is rare in women ages An increased risk in breast cancer is seen with 5 or more years of continuous estrogen with progestogen therapy, possibly earlier. The risk decreases after hormone therapy is stopped. Manson, JE. NEJM 2016

20 There is an app for it..menopro

21 Lesson 4: (IN BLEEDING)

22 Lesson 4: Women, Bleeding and Coronary Intervention P < for temporal trends In both men and women Ahmed et al. Circ Intervention

23 Lesson 4: Women, Bleeding and Coronary Intervention

24 Lesson 4: Women, Bleeding and Coronary Intervention- Gender Specific Differences And Risk Factors.

25 Lesson 4: Women, Bleeding and Coronary Intervention

26 Summary/Conclusions

27 40% decline in CVD mortality among Women from Many aspects of Ischemic heart disease are different in women (sex specific risk factors, symptoms, pathophysiology, outcomes) Alternative MI (MI without obstructive CAD due to atherosclerosis) is a common cause of AMI among women SCAD (women +ACS + emotional/physical trigger + FMD) is underdiagnosed. Consider HRT for young women early in menopause for symptoms relief Women undergoing cardiac catheterization are at increased risk for bleeding and vascular complications This risk is mitigated by tailoring our approach (radial access, avoidance of GPI, smaller sheaths) in women

28 Thank You