Caring for a Woman s Heart: Setting the Stage for Family Health

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Copyright 2011 by the Preventive Cardiovascular Nurses Association Caring for a Woman s Heart: Setting the Stage for Family Health Guest Speaker Kathy Berra, MSN, ANP, FAANP, FPCNA, FAAN Stanford

Heart Network What are the childbearing years?? In 1970, average woman had her first child at 21. In 2000, this rose to between 25 and 29 (developed countries).

1 Copyright 2011 by the Preventive Cardiovascular Nurses Association Caring for a Woman s Heart: Setting the Stage for Family Health Guest Speaker Kathy Berra, MSN, ANP, FAANP, FPCNA, FAAN Stanford Prevention Research Center Stanford, CA Childbearing Women and Their Families Setting the Stage for Heart Health Kathy Berra, MSN, NP, FAHA, FPCNA, FAAN Stanford Prevention Research Center Stanford Heart Network What are the childbearing years?? In 1970, average woman had her first child at 21. In 2000, this rose to between 25 and 29 (developed countries). In the US and Britain, between 1997 and 1999, ~700 births were reported among mothers over age 50, ~200 being over 55 (through in-vitro fertilization). The oldest known birth mother is an Indian woman who delivered twins at the age of 70 in million (2000 US Census) households grandparents (mostly grandmothers) raising grandchildren - 57% still in workforce - 17% live in poverty. Jacobsson, B., Ladfors, L., and I. Milsom. Advanced Maternal Age and Adverse Perinatal Outcome. OB&Gyn : Salihu,Hm et al., Obstetrics & Gynecology, (2007) 102 (5), Hall, Sarah. (May 8, 2006). Surge in number of children in UK born to mothers over 50." The Guardian..

2 Pender, Murdaugh et al Health Promotion in Nursing Practice 2006 Childbearing Women and Their Families Setting the Stage for Heart Health The role of the mother in family heart health Can we influence the heart health of high risk families? Is it all about awareness and action on the part of the mother? Do we understand motivators and barriers for women to pursue improved heart health? How is the AHA helping women and families? What s a mother to do? What is the Role of the Mother and Family Heart Health?? When asked whose health is most important to them, 56% of women - someone else s health (children, 30%; spouse/partner, 17%; parents, 7%; other, 2%) What would help them improve family health? 91% - access to better fruits, vegetables, and healthy foods 80% - greater access to indoor/outdoor recreation facilities 79% - require restaurants to post nutrition information 75% - require smoking bans 74% - stricter regulations on pollution 73% - ban trans fats in restaurants 62% - increase public safety in public recreation areas Mosca et al, Women s awareness of CVD Risk and Barriers to Health Circ. 2006, Mosca et al Circulation Cardiovasc Qual Outcomes. 2010;3:

3 Do Mothers influence family eating habits? Childhood Obesity is associated with certain maternal characteristics: 1. Eating habits and knowledge of nutrition 2. Perceptions of their children s body sizes 3. Depression 4. Concern about personal overweight (more likely to restrict specific foods and less likely to pressure children to eat) 5. Dieting behaviors (overemphasis on weight control and may lead to obesity or eating disorders) Matheson DA et al J Am Diet Assoc. 2006;106: Can Mothers influence Life Style behaviors? 1 hour of TV per day plus 1 or 2 overweight parents = 15% and 32% greater risk of being overweight than with normalweight parents. Children of parents with MET and CVD risk factors are at High Risk of MET d/t shared genetic and environmental factors. Children with parents + early ASHD - more obese, worse lipids, HTN, glucose, reduced endothelial function and evidence of C-IMT. Steinberger J, METS in children and adolescents.. Circulation 2009;119; Bao et al, Bougalousa Heart Study JAMA 1997 Children s food consumption during television viewing 1. Ethnically diverse third-grade children (n=90) 2. Predominantly Latino fifth-grade children (n=129) Three nonconsecutive 24-h dietary recalls TV watching time Physical measures for BMI Matheson DM et al Am J Clin Nutr 2004;79:

4 Children s food consumption during television viewing ~18% and 26% (weekdays and weekend days) of total daily energy is consumed during television viewing In the third-graders, fat content of foods consumed during television viewing was associated with BMI A significant proportion of children s daily energy intake is consumed during television viewing, and the consumption of high-fat foods on weekends may be associated with BMI in younger children Interventions to change the types of foods consumed during television viewing, reduce food consumption during television viewing, or even reduce television viewing may markedly change children s dietary intake patterns Mattheson DM et al Am J Clin Nutr 2004;79: Do Mexican-American Mothers Food-Related Parenting Practices InfluenceTheir Children s Weight and Dietary Intake? 40% of Hispanic American children C/T 26% of Non-Hispanic White and 36% of Non-Hispanic Black Children are overweight or at risk th grade Hispanic children and their mothers were evaluated by food records, food attitudes, and biometric measures: Mothers pressure to eat was inversely correlated with children s weight. Mothers of thinner children pressured them to eat more and did not pressure heavier children In food-secure families the mothers attitudes about providing healthy foods resulted in greater intake of fruits but not vegetables In food-insecure families, the mothers attitudes about providing healthy foods resulted in more quantity of foods not necessarily more healthy foods Matheson DA et al J Am Diet Assoc. 2006;106: A Novel Family Based Intervention Trial to Improve Heart Health: FIT Heart: Results of a Randomized Controlled Trial RCT of 504 healthy adult family members of patients hospitalized for CVD to evaluate the effects of a special intervention (SI) versus usual care (UC) that included: Personalized risk factor screening Therapeutic lifestyle counseling Progress reports to physicians Primary outcome - mean % change in LDL C Secondary outcomes - change in other risk factors Mosca et all Circulation: Cardiovascular and Quality Outcomes 2008

A Novel Family Based Intervention Trial to Improve Heart Health: FIT Heart: Results of a Randomized Controlled Trial Non significant difference in LDL-C (2% vs 1%) mean reduction was similar in both

5 A Novel Family Based Intervention Trial to Improve Heart Health: FIT Heart: Results of a Randomized Controlled Trial Non significant difference in LDL-C (2% vs 1%) mean reduction was similar in both groups ~ 4.4 mg/dl Diet significantly improved in SI vs UC HDL declined significantly in UC but not in SI At 1 year SI was more likely to exercise > 3 days per week than UC P = 0.04 Screening identifies persons at high CVD risk who were unaware of this risk (50% unaware of LDL-C levels). Lifestyle change was achieved in SI. Efforts need to focus on effective interventions in this high risk population. National Study of Women s Awareness, Preventive Action, and Barriers to Preventive Cardiovascular Health 1008 women (random digit dialing) over 25 Standardized questionnaire: History of CVD risk factors: Awareness of leading cause of death for women Knowledge of personal risk factors Actions taken to reduce personal CVD risk Barriers to heart health Did knowledge influence family health and CVD risk reducing actions Mosca et al Circulation 2006,

National Study of Women s Awareness, Preventive Action, and Barriers to Preventive Cardiovascular Health Top 10 Motivators for CVD Preventive

health information about heart disease Their health care provider told them to A relative developed heart disease A relative encouraged them

6 National Study of Women s Awareness, Preventive Action, and Barriers to Preventive Cardiovascular Health Top 10 Motivators for CVD Preventive Measures Improve their health (95%) Feel better (92%) Live longer (90%) Avoid taking medication (69%) Did it for their family (67%) Saw/read health information about heart disease Their health care provider told them to A relative developed heart disease A relative encouraged them to They developed symptoms related to heart disease Mosca et al, Women s awareness of CVD Risk and Barriers to Health Circ. 2006,

7 Top 10 Barriers for CVD Preventive Measures Too much confusion in the media (49%) God or a higher power determines health status (44%) Had family obligations and people to take care of (36%) Did not perceive herself at risk Did not what to change lifestyle Did not have money or insurance coverage Her healthcare provider did not say it was important Not confident she could change Family told her she did not need to change She was fearful, too stressed, it was too complicated, did not know what to do, was confused, depressed, too ill Mosca et al, Circ. 2006, Additional barriers to heart health Low income and low SES is know to predict mortality from chronic disease such as CHD and Diabetes Lack of formal education is associated with lack of access to health care Social support from family and friends together significantly predict physical activity behavior Family and social support independently predict physical activity behavior Okun et al AJHB. 2003:27(5), :Keriger et al Amer J of Epi, ,(5), :Mosca et al Circulation 2006, :Steinberger J, Circulation Circulation 2009;119; Additional barriers to heart health Mothers who are caregivers report: Increased stress More exhaustion Less time for one s self Trouble sleeping Not enough time to spend with other Friends/family members Mosca et al Circulation Cardiovasc Qual Outcomes. 2010;3:

Circula Jones et al Circulation January 2009 Go Red for Women Heart Checkup Fall of 2007 1.

8 Circula Jones et al Circulation January 2009 Go Red for Women Heart Checkup Fall of million have taken the online CDV risk assessment 93% have seen their MD 90% have had BP checked 75% cholesterol checked 96% have taken some action % taken some risk reduction action 53% cholesterol checked 65% eat more healthy food 100,000 have joined Choose to Move and have completed a12 week online motivational/behavioral program for Physical Activity Jones et al Circulation January 2009 Alliance for a healthier generation 1. Stop the increasing prevalence of childhood obesity by 2010 and reduce obesity by 2015 (Clinton Foundation, Schwarzenegger, AHA) 2. Initiatives Beverage and snack food industry - decrease sugared drinks and lower saturated fat in snacks and meals (voluntary) 65% decrease in full calorie carbonated soft drink sales (58% fewer beverage calories being sold to schools c/t 2004) 79% of Alliance schools in compliance Let s Just Play go Healthy Challenge (Nickelodeon -1million children have signed pledges) Developing reimbursement for obesity and nutrition counseling Jones et al Circulation January 2009

Encourage family understanding of CVD risk factors and participation in CV risk reduction efforts Request health care providers to support their CVD risk reduction efforts and measures of outcomes

choices Awareness of heart disease as the leading cause of death for women was a significant predictor of taking personal action to lower risk of heart disease, and the majority of women also

9 What is a mother to do? Increase personal awareness of CVD and Stroke risk Reduce personal risk factors through diet, weight loss, physical activity, smoking cessation, stress management, plus medications as indicated Encourage family understanding of CVD risk factors and participation in CV risk reduction efforts Request health care providers to support their CVD risk reduction efforts and measures of outcomes Advocate for healthier schools and communities through nutrition and physical activity Advocate for societal support of disadvantaged families PA, smoking cessation, healthy affordable food choices Awareness of heart disease as the leading cause of death for women was a significant predictor of taking personal action to lower risk of heart disease, and the majority of women also encouraged action for someone in their family Mosca et al Circulation 2006, Caring for a Woman s Heart: Setting the Stage for Family Health The New 2011 Women's Prevention Guidelines: What Every Clinician Should Know Guest Speaker JoAnne M. Foody, MD, FACC, FAHA Brigham & Women's Hospital Boston, MA Copyright 2011 by the Preventive Cardiovascular Nurses Association

10 Objectives To present strategies to assess and stratify women into high risk, at risk, and optimal risk categories for cardiovascular disease To summarize lifestyle approaches to the prevention of cardiovascular disease in women To review evidence-based approaches to cardiovascular disease prevention for patients with hypertension, lipid abnormalities, and diabetes To review an evidence-based approach to pharmacological risk intervention for women at risk for cardiovascular events Women Received Less Interventions to Prevent and Treat Heart Disease Less cholesterol screening Less lipid-lowering therapies Less use of heparin, beta-blockers and aspirin during myocardial infarction Less antiplatelet therapy or secondary prevention Fewer referrals to cardiac rehabilitation Fewer implantable cardioverter-fibrillators compared to men with the same recognized indications Evidence-based Guidelines for Cardiovascular Disease Prevention in Women: 2011 Update Mosca et al. Circulation; February 15, 2011 Electronic release

11 Cardiovascular Disease Prevention in Women: Current Guidelines IS1 A five-step approach Assess and stratify women into high risk, at risk, and optimal risk categories Lifestyle approaches recommended for all women Other cardiovascular disease interventions: treatment of HTN, DM, lipid abnormalities Highest priority is for interventions in high risk patients Avoid initiating therapies that have been shown to lack benefit, or where risks outweigh benefits Source: Adapted from Mosca 2004 Risk Stratification: High Risk (> 1 high risk state) Documented atherosclerotic disease Established coronary heart disease Cerebrovascular disease Peripheral arterial disease Abdominal aortic aneurysm Diabetes mellitus Includes many patients with End Stage chronic kidney disease, 10 year predicted CVD risk > 10% IS2 Risk Stratification: At Risk (> 1 risk factor) Cigarette smoking SBP > 120 mmhg or DP > 90 mmhg or treated HTN TC 200 mg/dlor HDL < 50 mg/dl or treated for dyslipidemia Obesity, particularly central obesity Poor diet Physical inactivity Family history of premature CVD in 1 st degree relatives (< 55 year old male relative or < 65 year old woman) Metabolic syndrome Evidence of subclinical atherosclerosis (eg coronary calcification, carotid plaque or thickened IMT) poor exercise capacity on treadmill test or abnormal heart rate recovery after stopping exercise Systemic autoimmune collagen-vascular disease (e.g., lupus or rheumatoid arthritis) Source: Mosca Circulation Feb 15, 2011

12 Risk Stratification: Ideal Cardiovascular Risk Factors (All of these) Non-HDL-C <130 mg/dl (untreated) BP <120/<80 mm Hg (untreated) Fasting blood glucose <100 mg/dl (untreated) Body mass index <25 kg/m 2 Abstinence from smoking (never or quit >12 months) Physical activity at goal DASH-like diet IS3 Source: Mosca, Circulation Feb 15, 2011 Lifestyle Interventions Smoking cessation Physical activity Heart healthy diet Weight reduction/maintenance Relative Risk of Coronary Events for Smokers Compared to Non-Smokers Relative Risk Never Smoked 1-14 Cigarettes per day 15 Cigarettes per day Source: Adapted from Stampfer 2000

13 Smoking All women should be consistently encouraged to stop smoking and avoid environmental tobacco The same treatments benefit both women and men Women face different barriers to quitting Concomitant depression Concerns about weight gain Provide counseling, nicotine replacement, and other pharmacotherapy as indicated in conjunction with a behavioral program or other formal smoking cessation program at each encounter Risk Reduction for CHD Associated with Exercise in Women Quintile Group for Activity (MET - hr/wk) Source: Manson 1999 Walking Any Physical Exercise Physical Activity Consistently encourage women to accumulate a minimum of 30 minutes of moderate intensity physical activity on most, or preferably all, days of the week Women who need to lose weight or sustain weight loss should accumulate a minimum of minutes of moderate-intensity physical activity on most, and preferably all, days of the week Source: Mosca 2007

14 Body Weight and CHD Mortality Among Women Relative Risk of CHD Mortality Compared to BMI< BMI Weight Maintenance/Reduction Goals Women should maintain or lose weight through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain or achieve an appropriate body weight, waist size or other target metric of obesity Low Risk Diet is Associated with Lower Risk of Myocardial Infarction in Women Relative Risk of MI* P<.05 for quintiles 3-5 compared to *Adjusted for other cardiovascular risk factors Diet Score by Quintile (1= least vegetables, fruit, whole grains, fish, legumes) Source: Akesson 2007

15 Diet Women should be advised to consume a diet rich in fruits and vegetables; choose whole-grain, high-fiber foods; consume fish, especially oily fish at least twice a week; limit intake of saturated fat, cholesterol, alcohol, sodium and sugar Note: Pregnant women ought to be counseled to avoid eating fish with the potential for the highest level of mercury contamination (e.g. shark, swordfish, king mackerel, or tilefish). Diet Omega 3 fatty-acids Consumption of omega-3 fatty acids in the form of fish or in capsule form (e.g. EPA 1800 mg/day) may be considered in women with hypercholesterolemia and/or hypertriglyceridemia for primary and secondary prevention Source: Mosca 2007 Major Risk Factor Interventions Blood Pressure Lipids Diabetes

16 Lifestyle Approaches to Hypertension in Women Maintain ideal body weight Weight loss of as little as 10 lbs reduces blood pressure DASH eating plan Even without weight loss, a diet rich in fruits, vegetables, and low fat dairy products can reduce blood pressure Sodium restriction to 2300 mg/d Further restriction to 1500 mg/d may be beneficial, especially in African American patients Increase physical activity Limit alcohol to one drink per day Alcohol raises blood pressure One drink = 12 oz beer, 5 oz wine, or 1.5 oz liquor Source: JNC VII 2004, Sacks 2001, Mosca 2007 Lipids Optimal levels of lipids and lipoproteins in women are as follows (these should be encouraged in all women with lifestyle approaches): LDL < 100mg/dL HDL > 50m/dL Triglycerides < 150mg/d Non-HDL (total cholesterol minus HDL) < 130mg/d Lipids High Risk Women LDL-C lowering drug therapy is recommended simultaneously with lifestyle therapy in women with CHD to achieve an LDL-C <100 mg/dl, and is also indicated in women with other atherosclerotic CVD or diabetes mellitus or 10-year absolute risk >20%. A reduction to <70 mg/dl is reasonable in very-high-risk women (e.g., those with recent ACS or multiple poorly controlled CV risk factors) with CHD and may require an LDLlowering drug combination.

17 Lipids LDL-C lowering with lifestyle therapy is useful if LDL-C level is >=130 mg/dl and there are multiple risk factors and 10-year absolute risk 10% to 20% LDL-C lowering is useful with lifestyle therapy if LDL-C level is >=160 mg/dl and multiple risk factors even if 10-year absolute risk is <10% LDL-C lowering with lifestyle therapy is useful if LDL >=190 mg/dl regardless of the presence or absence of other risk factors or CVD At-Risk Women: No Other Risk Factors, 10-Year CHD Risk < 10% Initiate drug therapy if LDL > 190 mg/dl after lifestyle therapy Drug therapy optional for LDL mg/dl after lifestyle therapy Source: Grundy 2004, Mosca 2007 Diabetes Recommendation: Lifestyle and pharmacotherapy should be used as indicated in women with diabetes to achieve a HbA1C < 7%, if this can be accomplished without significant hypoglycemia

Preventive Drug Interventions Aspirin High risk women 75-325 mg/day, or clopidogrel if patient intolerant to aspirin, should be used in high-risk women unless contraindicated Aspirin- Other at-risk

18 Preventive Drug Interventions Aspirin High risk women mg/day, or clopidogrel if patient intolerant to aspirin, should be used in high-risk women unless contraindicated Aspirin- Other at-risk or healthy women Consider aspirin therapy (81 mg/day or 100 mg every other day) if blood pressure is controlled and benefit is likely to outweigh risk of GI side effects and hemorrhagic stroke Benefits include ischemic stroke and MI prevention in women aged > 65 years, and ischemic stroke prevention in women < 65 years Prevention of Cardiovascular Disease in Women Stratify women into high, at risk, and Ideal risk cardiovascular risk factor categories Encourage lifestyle approaches for all groups Treat hypertension, lipid abnormalities, and diabetes Implement pharmacologic interventions for women at high and intermediate risk, pharmacologic interventions should be individualized based on risk classification for all women Avoid initiating therapies without benefit, or where risks outweigh benefits Source: Mosca 2007 Released !! Available at PCNA.net/women

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PREVENTION OF CARDIOVASCULAR DISEASE IN WOMEN

PREVENTION OF CARDIOVASCULAR DISEASE IN WOMEN 1980 to 2000: Death rate fell from: 542.9 to 266.8 per 100K men 263.3 to 134.4 per 100K women 341,745 fewer deaths from CHD in 2000 Ford ES, NEJM, 2007 47% from CHD treatments, 44% from risk factor modification