Sex differences in cardiovascular disease: What are we learning?

Transcription

1 Sex differences in cardiovascular disease: What are we learning? February 2018 Amy Sarma, MD MHS Cardiology and Advanced Echocardiography Fellow Massachusetts General Hospital

2 2 No disclosures

3 3 The scope of the problem

4 More women than men die from cardiovascular disease 4

5 What do women think?

6 Many women do not experience heart attacks like men do 6

7 A patient story 38 year old woman with three children She survived leukemia after a bone marrow transplant She has a seizure disorder that gets worse when she is stressed She has not been able to work because of her illnesses and relies on her family to help her make ends meet She woke up New Years day feeling nauseated, lightheaded, and had some vague chest discomfort. She had plans to go the movies with her boyfriend that day so she went. She gets much worse at the movies and collapses 911 is called

8 In the emergency room She is emergently placed on a breathing machine and cannot say what she has been experiencing all day. She never told her boyfriend about her symptoms, so he cannot speak for her. Her oncologist is the first call from the ED team. Then, everyone sees her EKG.

9 Severe coronary disease Before After 9

10 It is hard for women and doctors alike to recognize heart disease in women Women are more likely than men to present with atypical symptoms Indigestion Shortness of breath Fatigue Jaw pain They themselves don t think of heart disease Without the typical heart attack story doctors take longer to figure out that a woman is having a heart attack

11 Women are often more medically complex when they present with a heart attack Women s heart attacks are often more complicated Women present with a higher burden of comorbidities than men when they present with heart attacks Older age Diabetes Heart failure High blood pressure Kidney disease Peripheral vascular disease Depression 11

12 Risk factors for cardiovascular disease differ between men and women 12

13 13 Sex differences in risk factors for heart disease

14 14 New hypertension guidelines

15 15 What is hypertension?

16 30 mins of moderate-intensity physical activity on most (preferably all) days of the week For weight loss, minutes of moderate-intensity activity on most (preferably all) days of the week 16

17 When do you treat? Treatment reduces the chance of: Stroke: % Heart Attack: % Heart Failure: 50 % 17

18 Treating cholesterol- new guidelines No sex-differences in treatment recommendations Premenopausal women on statins need effective contraception 18

19 19 More women are obese than men

20 Lifestyle can overcome genetics! Khera AV et al. N Engl J Med 2016;375:

21 21 Real-world barriers that women face

22 Pregnancy is both a time of risk and can provide insight into future risk 22

23 Cardiovascular disease is the leading cause of death in pregnancy

24 Cardiovascular maternal mortality is rising in the United States Creanga et al. Obstet Gynecol 2015

25 Pregnancy is a cardiovascular stress test

26 Labor is a particularly important period Hunter S, Br Heart Journal 1992

27 Women with heart disease need multidisciplinary care during pregnancy Siu S. Circulation 2001

28 Pregnancy is a window into the future Women with a history of: gestational hypertension Pre-eclampsia preterm delivery gestational diabetes small for gestational age infant are at higher risk of later-life cardiovascular disease Pre-eclampsia: we still do not know the mechanism of increased risk An opportunity for early intervention?

29 Women experience more atypical mechanisms of heart attacks

30 Microvascular disease Courtesy of Nandita Scott

31 Microvascular disease Camici J Nuclear Med 2009 Hard to diagnose Hard to treat Courtesy of Malissa Wood

32 Spontaneous coronary artery dissection Hard to diagnose Treatment is very different from a traditional heart attack

33 Stress Cardiomyopathy Also called Takotsubo Cardiomyopathy or Broken Heart Syndrome More common in women Presents similarly to a heart attack NEJM

34 Conclusions Heart disease differs between men and women Differences in: Complexity Presentation Risk factors Mechanism of disease Experience of pregnancy We are still learning about how to optimally detect and treat heart disease in women 34