Women and Heart Disease : Separating Fact from Fiction

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1 Women and Heart Disease : Separating Fact from Fiction Maria T. Vivaldi M.D. Director of Education MGH Women s Heart Health Program Corrigan Minehan Heart Center

2 Women and Heart Disease : Separating Fact from Fiction More women die of breast cancer than heart disease. MYTH Heart disease is the number one killer of women. 2

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6 WHY? AHA national survey found that only 53% of women said the first thing they would do if they thought they were having a heart attack was to call 911. This lack of appreciation by many women is a barrier for optimal survival and underscores the need for educational campaigns targeted to women. 6

7 What you can do Seek medical advice for warning signs Act promptly with acute symptoms Seek information related to your own risk level Make appropriate modifications in lifestyle to reduce their risk 7

8 Tell a Friend: Know your Symptoms 8

9 Symptoms of a Heart Attack Symptoms of heart attack require immediate action! Common symptoms may include uncomfortable pressure, fullness, burning or squeezing sensation in the chest shortness of breath nausea, vomiting, dizziness, sweating Symptoms can vary greatly and may be different in women than men You know your body- trust your instincts 9

10 Differences in Heart Attack Symptoms Men Sub-sternal chest pain or pressure Rest pain Pain down left arm and shoulder Weakness Women Pain in chest, upper back, jaw or neck Shortness of breath Flu-like symptoms: nausea or vomiting, cold sweats Fatigue or weakness Feelings of anxiety, loss of appetite, malaise 10

11 #2 Myth or Fact? When it comes to heart disease, what matters is family genes not your jean size. MYTH 11

12 Women and Heart Disease : Separating Fact from Fiction A number of multivariate risk models have been developed for estimating the risk of CV events in apparently healthy, asymptomatic individuals based on assessment of multiple variables. All have advantages and disadvantages, no single risk model will be appropriate for all patients. Framingham, Reynolds, QRISK, SCORE, ACC/AHA. 12

13 Limitations of current vascular disease prediction models 1.- Identify high risk persons, but tend to falsely reassure persons deemed to be at low risk who may have multiple marginal abnormalities. 2.- Identify patients who are more or less likely to develop CVD within a defined period (10 yrs for Framingham), not considering lifetime risk which might be higher and amenable to aggressive risk factor modification. 13

14 Limitations of current vascular disease prediction models 3.-Severity and frequency of first vascular event has decreased over the last 40 yrs. 4.- Some risk models do not include important patient CVD outcomes such as stroke, HF, or development of PAD. 14

15 Women and Heart Disease : Separating Fact from Fiction ACC/AHA pooled cohort hard CVD risk calculator is the first risk model to include data from large populations both Caucasian and African-American patients. Intended to be used if there is no ASCVD AND LDL <190 mg/dl. 15

16 Women and Heart Disease : Separating Fact from Fiction Patients aged 20 years or older without established CVD should undergo periodic CVRA every 3-5 years. Allowing to identify CVD risk factors and offering guidance on the appropriate management of specific RF ( dietary modification for HTN and HL) and overall CVD risk (maintaining healthy diet and regular exercise). 16

17 ACC/AHA pooled cohort hard CVD risk calculator (2013) 1 Age 2 Gender 3 Total cholesterol(mg/dl) 4 HDL cholesterol ( mg/dl) 5 Systolic Blood pressure (mmhg) 6 Blood pressure treatment ( Y or N) 7 Diabetes mellitus ( Y or N) 8 Current Smoking ( Y or N) 17

18 ASCVD RISK ESTIMATOR Optimal risk factors include: TC 170 mg/dl or less HDL 50mg/dl or more SBP 110 mmhg Not taking meds for HTN Not a diabetic Not a smoker 18

19 ACC/AHA pooled cohort hard CVD risk calculator (2013) 1 Age 2 Gender 3 Total cholesterol(mg/dl) 4 HDL cholesterol ( mg/dl) 5 Systolic Blood pressure (mmhg) 6 Blood pressure treatment ( Y or N) 7 Diabetes mellitus ( Y or N) 8 Current Smoking ( Y or N) 19

20 High Cholesterol Cholesterol is made in the liver (75%) and also supplied in diet( 25%) HDL good cholesterol, goal greater than 50 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% 20

21 ACC/AHA pooled cohort hard CVD risk calculator (2013) 1 Age 2 Gender 3 Total cholesterol(mg/dl) 4 HDL cholesterol ( mg/dl) 5 Systolic Blood pressure (mmhg) 6 Blood pressure treatment ( Y or N) 7 Diabetes mellitus ( Y or N) 8 Current Smoking ( Y or N) 21

22 Hypertension Both numbers are important 1/3 of US adults have high blood pressure and do not know it the silent killer Only way to know is to have it checked Normal blood pressure is < 120/80 Hypertension is > 140/90 Prehypertension is /

23 Benefits of Lowering Blood Pressure Reduces the chance of: Stroke: % Heart Attack: % Heart Failure: 50 % American Heart Association website: 23

24 Hypertension what can you do? Reduce salt in your diet Exercise Alcohol in moderation DASH diet available online or google DASH diet 24

25 # 3 Myth or Fact? Couch potatoes are more prone to have heart disease FACT 25 Stamatakis,JACC, Jan

26 # 3 Myth or Fact (cont) Study suggests that two or more hours of screen time each day may place someone at greater risk for a cardiac event. Compared with those spending less than two hours a day on screen-based entertainment, there was a 48% increased risk of all-cause mortality in those spending four or more hours a day and an approximately 125% increase in risk of cardiovascular events in those spending two or more hours a day. Independent of traditional risk factors such as smoking, hypertension, BMI, social class, as well as exercise. 26

27 # 3 Myth or Fact ( Cont) One fourth of the association between screen time and cardiovascular events was explained collectively by C reactive protein (CRP), body mass index, and high-density lipoprotein cholesterol, suggesting that inflammation and deregulation of lipids may be one pathway through which prolonged sitting increases the risk for cardiovascular events. 27

28 Women and Heart Disease : Separating Fact from Fiction 28

29 29 Trends in Obesity Prevalence (%), Adults Aged 18 and older, US,

30 Obesity > 60% of population is overweight and 30% obese BMI should be less than 25 Abdominal girth is an independent risk for CAD There is data in women that the metabolic syndrome is a more potent risk factor than frank obesity for the risk of heart disease 30

31 Metabolic Syndrome Definition Any three of the following: 1) Abdominal obesity (>35 in) 2) Triglycerides > 150 or on treatment 3) HDL < 50 in women or on treatment 4) Blood pressure > 130/85 or tx for hypertension 5) Elevated fasting glucose > 110 or on treatment You can have a simple screening for these factors by physical exam and blood tests 31

32 Women and Heart Disease : Separating Fact from Fiction For each increase in body weight of approx 1 kg (2.2 lbs) the risk of coronary mortality increased by 1 to 1.5% ( HTN). 32

33 Women and Heart Disease : Separating Fact from Fiction OBESITY is associated with: 1.-Diabetes mellitus 2.-Lipid abnormalities 3.-Hypertension 4.-LVH 5.-Endothelial dysfunction 6.-Obstructive sleep apnea 33

35 Women and Heart Disease : Separating Fact from Fiction According to the 2007 YRBS survey of students in grades 9 12, 31.8 % of females and 18 % of males did not engage in 60 minutes of moderate- to-vigorous physical activity even once in the previous seven days (despite recommendations that children do so five or more days per week). 35

36 Women and Heart Disease : Separating Fact from Fiction In 2006, an estimated 145,000,000 U.S. adults (age 20 and older) were overweight or obese (76,900,000 males; 68,1000,000 females.) This represents 66.7 percent of the adult population. 36

37 Women and Heart Disease : Separating Fact from Fiction Physical inactivity is responsible for 12.2 percent of the global burden of heart attack. 37

38 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 American Heart Association website: 38

39 39 Circulation, 2011;123:

40 ACC/AHA pooled cohort hard CVD risk calculator (2013) 1 Age 2 Gender 3 Total cholesterol(mg/dl) 4 HDL cholesterol ( mg/dl) 5 Systolic Blood pressure (mmhg) 6 Blood pressure treatment ( Y or N) 7 Diabetes mellitus ( Y or N) 8 Current Smoking ( Y or N) 40

41 Diabetes mellitus 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 People with diabetes should be treated as aggressively as those with known heart disease. Diabetes markedly reduces the success rate when a woman undergoes bypass surgery or balloon angioplasty procedures. 41

42 American Diabetes Association (ADA) Guidelines Optimal fasting blood sugar <100 mg/dl Criteria for diabetes Fasting glucose 126 mg/dl or higher Random glucose 200 mg/dl or higher Impaired fasting glucose mg/dl 42

43 Women and Heart Disease : Separating Fact from Fiction Diabetes appears to confer greater prognostic information in women than any of the other traditional Cardiac risk factors. 43

44 ACC/AHA pooled cohort hard CVD risk calculator (2013) 1 Age 2 Gender 3 Total cholesterol(mg/dl) 4 HDL cholesterol ( mg/dl) 5 Systolic Blood pressure (mmhg) 6 Blood pressure treatment ( Y or N) 7 Diabetes mellitus ( Y or N) 8 Current Smoking ( Y or N) 44

45 # 4 Myth or Fact? Just a few whiffs of tobacco smoke or dirty air can have a profound negative impact on your heart s health. FACT 45

46 # 4 Myth or Fact ( Cont) Among smokers, the increases in heart disease-related death risk were as follows: Three or less cigarettes a day: 64% increased risk Half pack (about 8-12 cigarettes daily): 79% increased risk Full pack (about cigarettes daily): nearly 100% increased risk Pope III, C.A. Circulation 2010 Jun;121(21):

47 Smoking Cigarette smokers are 2-4 times more likely to develop heart disease and stroke Cigarette smokers are 10 times more likely to develop peripheral vascular disease The Surgeon General states that the annual risk of death from all causes is 80-90% greater in women who smoke than those who don t Quit smoking programs are available at MGH and Quitworks 47

48 Smoking. In 2005, the prevalence for smoking (age 18+) was 47,100,000 (26,200,000 males; 20,900,000 females). This represents 20.8 % of the adult population. (NCHS). From 1965 to 2006, smoking in the United States has declined by 50.4 percent among people age 18 and older. (NCHS). 48

49 SMOKING Smoking has been associated with one half of all coronary events in women (even with minimal use). Incidence of a MI is increased sixfold in women and threefold in men who smoke at least 20 cig/day. 49

50 SMOKING Extrapolation from studies in the 1980 s suggests that Smoking causes 25% of deaths among women and men years of age in the United States. Smokers lose at least one decade of life expectancy, as compared with those who had never smoked. Cessation before the age of 40 years reduces the risk of death associated with continued smoking by about 90%. NEJM, 368;4, Jan 24,

51 Classification of CVD in Women Circulation, 2011;123:

52 Women and Heart Disease : Separating Fact from Fiction Menopausal therapy Antioxidant Supplements ( Vit E, Vit C) Folic Acid Aspirin for women <65 yrs of age Circulation, 2011;123:

53 53 Circulation, 2011;123: Circulation, 2011;123:

54 54

55 Factors involved in Reduction of CAD A recent study of the decrease in U.S. deaths from CHD from1980 to 2000 found that about 47 % of the decrease was attributable to evidence-based medical therapies and 44 % to changes in risk factors. Nevertheless, these improvements have been offset by increases in body mass index and diabetes prevalence. N Engl J Med. 2007;356:

56 Factors involved in Reduction of CAD Improvement in therapy: -Secondary prevention after cardiac event -Initial treatment -Revascularization Cardiac risk factor modification: -Cholesterol(24%) -SBP(20%) -Smoking(12%) -Physical inactivity(5%) -Diet(16%) 56

57 Factors involved in Reduction of CAD Somewhat offset by increased BMI and diabetes mellitus 57

58 # 5 Myth or Fact? Alcohol consumption affects the risk of sudden cardiac death in women. FACT Nurses Health Study ( >80000 women) 295 SCD in 26yrs Lowest risk ½ to 1 glass/d Highest: abstinent and > 4/d 58

59 # 5 Myth or Fact (cont) Conclusion: Light to moderate alcohol intake lowers risk of Sudden cardiac death in women Light to moderate alcohol consumption may reduce the risk of plaque rupture and inflammation and may augment blood concentrations of a long-chain polyunsaturated fatty acid that has antiarrhythmic properties. Heart Rhythm 2010;7:

60 # 6 Myth or Fact? Optimism protects you from heart disease FACT 60

61 # 6 Myth or Fact ( Cont) Women s Health Initiative, a 15-year study that included about 162,000 postmenopausal women. None of the women had heart disease when they entered the study. Surveys: degree of optimism and their general level of hostility and cynicism. Women who scored highest for optimism had a 9% lower risk for developing heart disease and a 14% lower risk of dying from all causes than women who scored lowest for optimism. Women with a high degree of hostility and cynicism were 16% more likely to die than women who scored lowest for hostility and cynicism. 61

62 # 6 Myth or Fact ( Cont) Negative thinkers make poorer lifestyle choices than positive thinkers. They also tend to suffer more from depression. Someone who believes that life is not worth living probably isn t the type of person who goes to the gym three times a week. 62

63 # 6 Myth or Fact (Cont) But can someone who is pessimistic by nature change their tune to improve their health? People can learn these skills, and more and more research is showing that it can not only improve your life but save it Tindle, H.A. Circulation, Aug. 25, 2009;120(8)

64 # 7 Myth or Fact? After a death of a loved one you can die of a broken heart FACT 64

65 65 BROKEN HEART SYNDROME

66 Stress Cardiomyopathy (BROKEN HEART SYNDROME) Described form of heart disease (2% of ACS), predominantly in post menopausal women (80%) Triggered by acute illness, emotional and physical Stress Symptoms similar to a myocardial infarction Pump function unique pattern of dysfunction 66

67 Stress Cardiomyopathy Wittstein et al. NEJM 2005;352: Cause: uncertain Blood vessel spasm Damage to heart cells by catecholamines excess (adrenaline) and microvascular dysfunction Incidence unknown, treatment is supportive Prognosis is excellent once recovered Recurrence is possible 67

68 Women and Heart Disease : Separating Fact from Fiction Chronic Stress has the greatest neg impact on health. Translating into a chronic state of activation with increase wear and tear of biological systems, increasing cardiovascular reactivity, leading to increased incidence of HTN, CVD, DM and obesity. C. M. Arthur / Californian Journal of Health Promotion 2007, Volume 5, Special Issue (Health Disparities & Social Justice),

69 Heart Disease also affects Children If childhood obesity continues to increase, the average lifespan will fall This generation of American children are the first generation in history predicted to live shorter lives than their parents 69

70 Conclusions Heart Disease is the number one health threat to our society Heart Disease is a threat to men, women and children Know how to differentiate myth from fact Know what you can do to reduce your risk for heart disease and stroke! 70

71 71 Know Your Numbers Tell a Friend!

72 72 and men

73 The Good News! Heart Disease is preventable!!! The MGH Institute for Heart, Vascular and Stroke Care Corrigan Minehan Heart Center Women s Heart Health Program THANK YOU!!

The Gender Divide Women, Men and Heart Disease February 2017

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 Heart Disease For