Coronary Artery Disease in Women

Transcription

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2 Coronary Artery Disease in Women by Wael Almahmeed MD, FCCP, FRCPC, FRCPE, FACP, FACC, FESC Clinical Associate Professor of Medicine, UAE University Consultant Cardiologist at Cleveland Clinic, Abu Dhabi 2

3 Objectives 1. Case Presentation 2. Coronary Artery Disease in women in the West. 3. Coronary Artery Disease in women in the Gulf States. 4. Summary 3

4 Case Presentation 59 year old woman presented to my clinic with chest pain on exertion Gets the pain after 50 meters Resolves with rest Known: Diabetes Meds: ASA Obesity Lipitor 20 Dyslipidemia Janumet Glargine Empagliflozin 4

5 Case Presentation (cont.) O/E : BP 120/60 P 80 Rg CVS was normal, RS was normal ECG showed non specific ST changes Tot Cholesterol 3.65 TG 1.09 LDL 1.79 HDL 1.36 Echo: Normal CV size and systolic function. 5

6 Case Presentation (cont.) Mobi scan: Large defect which is reversible in the anterior and inferior walls. Angiography: Proximal tight stenosis of the LAD, Mid RCA stenosis CABG: LIMA to LAD SVG to RCA The procedure was uncomplicated and she was discharged to home. 6

7 Age-adjusted prevalence of obesity in adults 20 to 74 years of age by sex and survey year (National Health Examination Survey: ; National Health and Nutrition Examination Survey: , , , , , and ). Mozaffarian D et al. Circulation. 2015;131:e29-e322 Copyright American Heart Association, Inc. All rights reserved.

8 Prevalence of cardiovascular disease in adults 20 years of age by age and sex (National Health and Nutrition Examination Survey: ). Mozaffarian D et al. Circulation. 2015;131:e29-e322 Copyright American Heart Association, Inc. All rights reserved.

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

10 Cardiovascular disease (CVD) mortality trends for males and females (United States: ). Mozaffarian D et al. Circulation. 2017;131:e29-e322 Copyright American Heart Association, Inc. All rights reserved.

11 Prevalence of CAD in Women Coronary Artery Disease is the leading cause of death in Women. CAD mortality is higher in Women than Men. Impact of obesity is greater in Women than in Men. Incidence of CAD lags 10 years behind Men. Consequences of CAD are worse in Women than in Men. Sharma K, et al; Global Heart; Vol. 8 No. 2,

12 Pathophysiology of CAD is different in Women. Women have smaller Coronary Arteries. Less obstructive CAD. Disorders of the microvasculature and Endothelial dysfunction have been implicated in Women. Women have a greater frequency of plaque erosion and distal embolization. Sharma K, et al; Global Heart; Vol. 8 No. 2,

13 Risk Assessment Sharma K, et al; Global Heart; Vol. 8 No. 2,

14 Risk Assessment Sharma K, et al; Global Heart; Vol. 8 No. 2,

15 Risk Assessment Sharma K, et al; Global Heart; Vol. 8 No. 2,

16 Diagnosis of Myocardial Ischemia in Women A negative exercise test is a good negative predictor of CAD in Women. Sharma K, et al; Global Heart; Vol. 8 No. 2,

17 Management of Obstructive CAD in Women Why is mortality due ACS in Women higher than in Women? 1. Women are treated less aggressively than men. 2. Receive less EB medicine. Sharma K, et al; Global Heart; Vol. 8 No. 2,

18 With regards to surgery: CABG Female sex is an independent risk factor for morbidity and mortality. Sharma K, et al; Global Heart; Vol. 8 No. 2,

19 Management of Non-Obstructive CAD Women with myocardial ischemia and non-obstructive CAD, the prognosis was felt to be benign in the past. More recent data has shown that the prognosis is not benign and the risk of CV events is higher than for asymptomatic women. Sharma K, et al; Global Heart; Vol. 8 No. 2,

20 In the WISE Study:- Symptomatic women with non-obstructive CAD had an event rate of 16% vs 7.9% in Symptomatic women with no CAD and event rate was 2.4% in asymptomatic controls. Sharma K, et al; Global Heart; Vol. 8 No. 2,

21 Treatment of Non-Obstructive CAD 1. Improve Endothelial function with Statins and ACE Inhibitors. 2. Symptoms with Beta Blockers and Imipranine and L arginine. 3. Ranolazine is promising. Sharma K, et al; Global Heart; Vol. 8 No. 2,

22 Undertreatment of CAD Women are still less likely to receive preventive recommendations, such as lipid lowering, ASA, life style modification. Hypertensive women are less likely to have their BP at goal. Dyslipidemic women are less likely to reach their LDL goals, (particularly diabetic women). Women receive less cardiac rehabilitation. Sharma K, et al; Global Heart; Vol. 8 No. 2,

23 Coronary Artery Disease in Women of the Middle East is not new. It has recently been identified in Egyptian Mummies. Allam et al (JAMA 2009;302(19) )

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25 Gulf RACE I 6 months prospective multi center Registry of ACS in 6 Gulf States. 8,169 consecutive patients were recruited from 64 hospitals with diagnosis of ACS, including unstable angina, STEMI and NSTEMI. Am J Cardiol 2009;104:

26 The Distribution of Men and Women in relation to Citizenship 6 Middle-eastern Countries Women Men 48% Citizens Expatriates Expatriates 82% p<0.001

27 Clinical Characteristics Variable Men Women (n=6,183) (n=1,983) Age (years) 53 (16) 62 (17) p Value Previous angina pectoris 2,295 (37%) 1,017 (51%) Previous MI 1,531 (25%) 463 (23%) Previous CABG 329 (5%) 132 (7%) Diabetes Mellitus 2,226 (36%) 1,085 (55%) Hypertension 2,665 (43%) 1,390 (70%) 0.001

28 Clinical Characteristics (cont.) Variable Men (n=6,183) Women (n=1,983) p Value Dyslipidemia 1,736 (28%) 872 (44%) Current smokers 2,886 (47%) 101 (5%) Renal impairment 807 (14%) 277 (15%) 0.22 COPD 281 (5%) 154 (8%) Stroke 225 (4%) 153 (8%) PVD 127 (2%) 68 (3%) 0.001

29 Age 6 Middle-eastern Countries

30 Clinical Characteristics (cont.) Variable Men Women (n=6,183) (n=1,983) BMI (kg/m 2 ) 26.3 (5.4) 28.3 (8.4) p Value Heart Rate (beats/min) 80 (26) 88 (24) Systolic BP (mm Hg) 136 (38) 140 (40) Killip class > I 1,206 (20%) 568 (29%) Ischemic Chest Pain 5,084 (82%) 1,400 (71%) Atypical Chest pain 379 (6%) 158 (8%) Dyspnea 499 (8%) 300 (15%) 0.001

31 Clinical Characteristics (cont.) Variable Men (n=6,183) Women (n=1,983) p Value GRACE risk score llow 1,073 (46%) 84 (25%) lmedium 702 (30%) 102 (29%) lhigh 585 (25%) 161 (46%)

32 WOMEN Ü 9 years older than men Ü more diabetes Ü more HTN Ü more obesity Ü more dyslipidemia Ü less smoking Ü more co-morbidities

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34 Variability Variable Men Women p Value STEMI at discharge 2, Presentation > 12 hrs 731 (28%) 173 (42%) Door-to-needle time 35 (40) 40 (50) Eligible for reperfusion 1,929 (73%) 244 (59%) Shortfall 153 (8%) 37 (15%) 0.001

35 Statins 2,238 (81%) 354 (80%) 0.35 Variability (cont.) Variable Men Women p Value Thrombolysis 1,613 (84%)* 195 (80%)* Primary PCI 163 (8%) 12 (5%) Asprin 2,617 (96%) 408 (98%) Beta Blockers 1,682 (63%) 234 (56%) ACE inhibitors/arbs 1,824 (69%) 272 (65%) Clopidogrel 1,588 (60%) 229 (55%) Heparin 2,438 (92%) 383 (92%) Glycoprotein inhibitors 239 (9%) 9 (2%) 0.003

36 100 P=NS 96% 98% P=NS 6 Middle-eastern Countries 90 84%* 80%* P= % P= % 60% 55% Men Women P=07 8% 5% Lytics Pri PCI Aspirin b-blockers Clopidogrel * Of patients eligible for thrombolysis.

37 Variability (cont.) Variable Men Women p Value Death 137 (5%) 62 (14%) Heart failure 420 (15%) 128 (29%) Cardiogenic shock 204 (7%) 91 (21%) Reinfarction 77 (3%) 21 (5%) 0.02 Recurrent ischemia 241 (9%) 69 (16%) Stroke 23 (1%) 13 (3%) Major bleeding 28 (1%) 7 (2%) 0.38 Hospital stay 5 (3) 6 (4)

38 Hospital Outcome 6 Middle-eastern Countries 30 P< % 25 P< P< % 15 14% 15% Men P=0.02 Women 10 7% P= % 3% 5% 3% 1% 0 Death CHF Shock Re-MI Stroke

39 6 Middle-eastern Countries Mortality Rate Stratified According to type of ACS and Gender 14 14% P= % P= % Men Women 4 2 2% P=0.68 1% 1.2% 0 STEMI NSTEMI U.Angina

40 WOMEN Ü presented more often after 12 hrs Ü STEMI missed in women compared to men (6% vs 3%) Ü HR high Ü BP high Ü presented with more dyspnea and atypical chest pain. Ü heart failure was more prevalent in women

41 Women Less likely to receive thrombolysis, primary PCI and have a prolonged door- -to-needle time.

42 WOMEN: Ü Received less EB medicines verses the men. Ü Had high GRACE scores Ü Higher morbidity Ü High in Hospital mortality Ü Higher :- heart failure cardiogenic shock recurrent ischemia stroke

43 Multivariate Analysis Predictor OR 95% CI p Value Female gender PCI Asprin Clopidogrel Glycoprotein IIb/IIIb Beta blockers ACE Inhibitors Thrombolysis

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45 After adjustment for Age, HR, DM, HTM, GRACE Risk Score: Female gender comes associated with increased in hospital mortality. Under use of EB therapies was also associated with increased mortality.

46 This is the 1 st study from the Middle East to show that Women with ACS had a high mortality rate compared to men, after adjustment of all co-founders.

47 It confirms previous studies that women have different risk profiles :- Ü Present late Ü Atypical symptoms Ü Longer door-to-needle times Ü Less perfusion therapies

48 Recognition of gender differences will lead to a number of quality improvement projects to improve the process of care. Physician and public awareness programs are important to improve the management of women with ACS.

49 Gender Differences in Gulf RACE2 Females comprised 21.3% of the ACS population. Baseline characteristics: Females were; Older Higher BMI More NSTEMI, UA more HTN Diabetes Dyslipidemia More atypical chest pain Shehab A, et al; Plos One, 2013; Vol 8. 49

50 Gender Differences in Gulf RACE2 Medical treatment: Males received more: Females received more: Beta Blockers Clopidogrel CCB ARBs Insulin and OHA Men had more PCI vs Women: 15.6% vs 10.5% Men had more reperfusion 20.2% vs 6.9 therapy Shehab A, et al; Plos One, 2013; Vol 8. 50

51 Gender Differences in Gulf RACE2 At discharge: Men got more: ASA Plavix Beta Blockers ACE Statins Shehab A, et al; Plos One, 2013; Vol 8. 51

52 Figure 1. Proportion of patients dying in-hospital and within one year from hospital discharge (n = 6132). Shehab A, Al-Dabbagh B, AlHabib KF, Alsheikh-Ali AA, et al. (2013) Gender Disparities in the Presentation, Management and Outcomes of Acute Coronary Syndrome Patients: Data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2). PLoS ONE 8(2): e doi: /journal.pone

53 Clinical Outcomes & Mortality Recurrent ischemia CHF Ventilation Shock In Hospital Death Death at 1 month Death at 1 year Were all higher in Women. Shehab A, et al; Plos One, 2013; Vol 8. 53

54 Figure 2. Association of gender (female) and mortality derived from multivariate-adjusted analyses (n = 7930). Shehab A, Al-Dabbagh B, AlHabib KF, Alsheikh-Ali AA, et al. (2013) Gender Disparities in the Presentation, Management and Outcomes of Acute Coronary Syndrome Patients: Data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2). PLoS ONE 8(2): e doi: /journal.pone

55 Clinical Outcomes & Mortality When adjusting for: Age BMI presenting Symptoms Country Killip class medical history Diagnosis Tobacco invasive procedures Medications There is no difference in the 1 year mortality between genders Shehab A, et al; Plos One, 2013; Vol 8. 55

56 Table 3. In-hospital outcomes and 1-month and 1-year post discharge mortality of the study cohort by gender (n = 7930). Shehab A, Al-Dabbagh B, AlHabib KF, Alsheikh-Ali AA, et al. (2013) Gender Disparities in the Presentation, Management and Outcomes of Acute Coronary Syndrome Patients: Data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2). PLoS ONE 8(2): e doi: /journal.pone

57 Gulf RACE II Women presented with more NSTEMI/UA 70.2% vs 50.2% While Men presented with STEMI 49.8% vs 29.8% Women had more HTN DM Dyslipidemia Shehab A, et al; Plos One, 2013; Vol 8. 57

58 Gulf RACE II Women are treated more conservatively. This may have been due to the following: 1. More co-morbidities 2. Atypical presentation 3. Patient preference 4. Physicians preference or Fear Shehab A, et al; Plos One, 2013; Vol 8. 58

59 Gulf RACE II In this Study, in contrast to Gulf RACE I, the Multivariate Regression Models indicated that most of the differences in mortality can be explained by the confounding baseline variables and the differences in management. Greater awareness of CAD in Women may eliminate the gender gap. Shehab A, et al; Plos One, 2013; Vol 8. 59

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61 Is there a gender disparity in achieving Lipid targets in patients in the Arabian Gulf? CEPHUES Study :- Multi Center Study of Lipid lowering in the Arabian Gulf patients were enrolled A fasting blood sample were taken from each patient for lipids. 40% (1763) of the patients were females. Zakwani et al; Current Vascular Pharmacology, 2017; 15.

62 Table 1 Demographic and clinical characteristics of the CEPHEUS cohort stratified by gender Characteristic, n (%) unless specified otherwise All (n = 4,384) Female (n = 1,763) Male (n = 2,621) P Gulf citizen 3,298 (75%) 1,558 (88%) 1,740 (66%) <0.001 Age, mean±sd, years 57±11 57±10 56± Weight, mean±sd, kg 82±17 79±17 84±17 <0.001 Waist circumference, mean±sd, cm 104±14 104±14 104± BMI, mean±sd, kg/m 2 31±7 34±8 30±6 <0.001 Current smoker 561 (13%) 35 (2.0%) 526 (20%) <0.001 CHD 1,611 (37%) 366 (21%) 1,245 (48%) <0.001 PAD 149 (3.4%) 54 (3.1%) 95 (3.6%) CVD 191 (4.4%) 66 (3.7%) 125 (4.8%) Diabetes mellitus 3,336 (76%) 1,486 (84%) 1,850 (71%) <0.001 MetS 1,786 (41%) 869 (49%) 917 (35%) <0.001 ASCVD risk factors (2.5%) 67 (3.8%) 43 (1.6%) (15%) 365 (21%) 294 (11%) 2 1,568 (36%) 673 (38%) 895 (34%) < ,568 (36%) 561 (32%) 1,007 (38%) (9.8%) 93 (5.3%) 335 (13%) 5 51 (1.2%) 4 (0.2%) 47 (1.8%) ASCVD risk status High risk 959 (22%) 511 (29%) 448 (17%) <0.001 Very high risk 3,425 (78%) 1,252 (71%) 2,173 (83%) <0.001 Zakwani et al; Current Vascular Pharmacology, 2017; 15.

63 Characteristic, n (%) unless specified otherwise All (n = 4,384) Female (n = 1,763) Male (n = 2,621) P Dyslipidaemic therapy Statin monotherapy 4,122 (94%) 1,693 (96%) 2,429 (93%) <0.001 Simvastatin 1,785 (43%) 862 (51%) 923 (38%) <0.001 Atorvastatin 1,779 (43%) 668 (39%) 1,111 (46%) <0.001 Rosuvastatin 486 (12%) 142 (8.4%) 344 (14%) <0.001 Statin combination 220 (5.0%) 61 (3.5%) 159 (6.1%) <0.001 Others 42 (1.0%) 9 (0.5%) 33 (1.3%) Lipid levels on treatment, mean±sd, mmol/l, unless specified otherwise TC 4.30± ± ±1.09 <0.001 LDL-C 2.53± ± ±0.93 <0.001 HDL-C 1.15± ± ±0.27 <0.001 Apo B, g/l 0.91± ± ±0.27 <0.001 Non-HDL-C 3.15± ± ±1.07 <0.001 TG 1.74± ± ± Zakwani et al; Current Vascular Pharmacology, 2017; 15.

64 Characteristic, n (%) unless specified otherwise All (n = 4,384) Female (n = 1,763) Male (n = 2,621) P Lipid goal attainments, n (%) HDL-C goal 2,058 (47%) 745 (42%) 1,308 (50%) <0.001 LDL-C goal 1,340 (31%) 493 (28%) 847 (32%) Apo B goal 1,775 (41%) 674 (38%) 1,101 (42%) Non-HDL-C goal 1,809 (41%) 713 (40%) 1,096 (42%) SD standard deviation, BMI body mass index, CHD coronary heart disease, PAD peripheral arterial disease, CVD cardiovascular disease, MetS metabolic syndrome, ASCVD atherosclerotic cardiovascular disease, HDL-C high-density lipoprotein cholesterol, LDL-C low-density lipoprotein cholesterol, Apo B apolipoprotein B, TG triglyceride. Criteria for ASCVD risk status was adapted from the National Lipid Association. High risk group included patients with 3 major ASCVD risk factors, diabetes mellitus (type 1 or 2) with 0/1 major ASCVD risk factors, LDL-C 190 mg/dl (5.02 mmol/l) (severe hypercholesterolemia). Very high risk group included ASCVD (CHD, PAD, CVD), diabetes mellitus with 2 other major ASCVD risk factors. Despite the lack of a recommended HDL-C goal by guidelines, satisfactory HDL-C was defined as <40 mg/dl (1.04 mmol/l) for males or <50 mg/dl (1.3 mmol/l) for females. Therapeutic lipoprotein targets for the high risk patients were LDL-C <2.6 mmol/l, apo B <0.90 g/l and non-hdl-c <3.3 mmol/l. For the highest risk group therapeutic lipoprotein targets were LDL-C <1.8 mmol/l, apo B <0.80 g/l and non-hdl-c <2.6 mmol/l. Age was missing in 8 patients, weight in 4 patients, waist in 123 patients, BMI in 15 patients, MetS in 26 patients and Apo B in 14 patients. Zakwani et al; Current Vascular Pharmacology, 2017; 15.

65 Women were less likely to attain HDL C Goals LDL C Goals Apo B Goals There was no difference in Non-HDL Goal. Women with very high ASCVD were less likely to be treated with potent Statins. Zakwani et al; Current Vascular Pharmacology, 2017; 15.

66 Fig 1 Overall lipid target achievements (LDL-C, non HDL-C and Apo B) in high and very high atherosclerotic cardiovascular disease (ASCVD) risk cohort stratified by gender (N = 4,384) LDL-C low-density lipoprotein cholesterol, Apo B apolipoprotein B. Therapeutic lipoprotein targets for the very high ASCVD risk group were LDL-C <70 mg/dl (<1.8 mmol/l), Apo B <80 mg/dl (<0.80 g/l) and non-hdl-c <100 mg/dl (<2.6 mmol/l). Whereas for the high ASCVD risk cohort, lipid target attainments were LDL-C <100 mg/dl (2.6 mmol/l), Apo B <90 mg/dl (0.90 g/l) and non HDL-C <130 mg/dl (3.3 mmol/l). Lipid goal attainments for LDL-C, non HDL-C and Apo B between very high ASCVD risk women and men were all significant (P 0.001).

67 Fig 2. Overall lipid target achievements (LDL-C, non HDL-C and Apo B) in those with triglycerides (>200 mg/dl/ 2.26 mmol/l) and high and very high atherosclerotic cardiovascular disease (ASCVD) risk cohort stratified by gender (N = 844) LDL-C low-density lipoprotein cholesterol, Apo B apolipoprotein B. Therapeutic lipoprotein targets for the very high ASCVD risk group were LDL-C <70 mg/dl (<1.8 mmol/l), Apo B <80 mg/dl (<0.80 g/l) and non-hdl-c <100 mg/dl (<2.6 mmol/l). Whereas for the high ASCVD risk cohort, lipid target attainments were LDL-C <100 mg/dl (2.6 mmol/l), Apo B <90 mg/dl (0.90 g/l) and non HDL-C <130 mg/dl (3.3 mmol/l). Lipid goal attainments for LDL-C (p < 0.001), non HDL-C (P = 0.055) and Apo B (P = 0.028) between very high ASCVD risk women and men were all significant or marginal significant. Zakwani et al; Current Vascular Pharmacology, 2017; 15.

68 Table 2 Gender disparity in the LDL-C goal attainment in observational studies Study name (country) Year LAP (USA) 2000 LAP-2 (USA and Europe) 2009 EUROASPIRE III (Europe) 2010 N LDL-C goal Women Age (years) LDL-C goal achievement (percentage) Women Men P 4,888 NCEP guidelines 49.6% 60 39% 37% 0.145* 9,955 NCEP guidelines 45.3% Women: 63 Men: 61 8,966 <100 mg/dl in CHD secondary prevention 25.3% Women: 66 Men: % 73.7% % 53.7% <0.001 Japan society of Ningen Dock database (Japan) ,991 JAS guideline in primary prevention; <100 mg/dl in CHD secondary prevention; 39.2% 17.8% Women: 61 Men: % 28.3% 73.6% 48.0% <0.001 <0.001 TLRS (China 2013 Chen CY et al (China) 2013 Li X et al (China) ,584 <100 mg/dl in CHD secondary prevention 25.0% Women: 69 Men: 65 1,808 Chinese guideline** 37.3% Women: 62 Men: 64 4,778 <100 mg/dl in CHD secondary prevention; 36.0% Women: 66 Men: % 52.9% % 53.8% % 45.5% <0.001 <70 mg/dl in CHD secondary prevention 9.0% 11.9% <0.001 CEPHEUS the current study (Arabian Gulf) ,384 <100 mg/dl <70 mg/dl 53.3% 36.6% Women: 57 Men: % 26.7% 43.6% 31.2% LDL-C low-density lipoprotein cholesterol, NCEP National Cholesterol Education Program, CHD coronary heart disease, JAS Japan Atherosclerosis Society. *Even though not significant overall, the differences were more apparent in very high ASCVD risk status (P = 0.006). **Chinese Guidelines on the Prevention and Treatment of Dyslipidemia in Adults. Zakwani et al; Current Vascular Pharmacology, 2017; 15.

69 The reasons for this gender disparity are not known. May be because there is more obesity, DM, MS and dyslipidemia in women. One of the warnings to reduce CV Risk in women is to use high dose more potent Statins in order to attain Lipid targets. Zakwani et al; Current Vascular Pharmacology, 2017; 15.

70 Summary of Statin Initiation Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults (See Figures 3, 4, and 5 for More Detailed Management Information). Stone N J et al. Circulation. 2014;129:S1-S45 Copyright American Heart Association, Inc. All rights reserved.

71 Summary of Statin Initiation Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults (See Figures 3, 4, and 5 for More Detailed Management Information). Stone N J et al. Circulation. 2014;129:S1-S45 Copyright American Heart Association, Inc. All rights reserved.

72 Menopausal Hormone Therapy, SERMs and CVD: Summary of Major Randomized Trials Use of estrogen plus progestin associated with a small but significant risk of CHD and stroke Use of estrogen without progestin associated with a small but significant risk of stroke Use of all hormone preparations should be limited to short term menopausal symptom relief Use of a selective estrogen receptor modulator (raloxifene) does not affect risk of CHD or stroke, but is associated with an increased risk of fatal stroke Source: Hulley 1998, Rossouw 2002, Anderson 2004, Barrett-Connor 2006

73 Interventions that are not useful/effective and may be harmful for the prevention of heart disease Hormone therapy and selective estrogen-receptor modulators (SERMs) should not be used for the primary or secondary prevention of CVD Source: Mosca 2007

74 Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians Ref: Tsugawa, et al; JAMA Internal Medicine

75 Analyzed 20% sample of medicare beneficiaries 65 years or older. They looked at association between physician sex and 30 day mortality and readmission rates. 75

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77 Elderly hospitalized patients treated by female internists have a lower mortality and readmissions compared with these cared for by male internists. 77

78 HEART DISEASE IN WOMEN 1. Less obstructive CAD. Summary 2. More chest pain without obstructive CAD. 3. Symptoms do not correlate with severity of stenoses. 4. Young and middle aged women show high rates of adverse outcomes after MI. Vaccarino, Circ Cardiovasc Quality Outcomes, 2010

79 Ü Women do worse than men when they have an STEMI. Ü Sex differences are found in younger women with MI. Ü These women have a higher rate of risk factors and co-morbidities compared to men.

80 Ü Sex differences in EB medications are significant. Ü There are larger differences in reperfusion therapy. Ü Also differences in catheterization and revascularization.

81 1. Introduction Summary 2. Case Presentation 3. Coronary Artery Disease in women in the West. 4. Coronary Artery Disease in women in the Gulf States. 81