Heart Disease in Women: Diagnostic Approaches and Management
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1 Heart Disease in Women: Diagnostic Approaches and Management Ezra A. Amsterdam MD Professor, Internal Medicine Associate Chief (Academic Affairs) Chair, Writing Group of ACC/AHA UA/NSTEMI Guidelines Cardiovascular Medicine 11/10/12
2 My conflicts are inner conflicts and I do not choose to reveal them
3 Neitzsche GOD CREATED WOMAN BOREDOM CEASED!
4 Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
5 Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
6 Deaths - Women (US ) (CDC) (yr.)
7 QUESTION
8 Coronary Heart Disease Rare in premenopausal p nondiabetic women who do not smoke
9 Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
10 Men and Women with CAD Women are higher risk when they present with clinical CAD: Older More DM and metabolic syndrome Higher rates of other risk factors Delayed diagnosis Delayed therapy Less intensive therapy Less favorable response to revascularization procedures Smaller arteries
11 CV Deaths Men and Women 000s) EATHS (10 DE Males Females Roger et al. Circulation 2011;123:e Source: National Center of Health Statistics
12 Am I Wearing Red for Women? YES! But I m also wearing BLACK for Men!
13 Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
14
15 Effectiveness-based guidelines for prevention of CVD in women: 2011 update (Mosca et al, Circulation 2011) Evolving science suggests that the overwhelming majority of recommendations to prevent CVD are similar for women and men, with few exceptions.
16 Risk Factor Prediction of CHD 50 yo Man and 50 yo Woman Framingham Risk Score Cholesterol 250 BP 140/80 Nonsmoker HDL yr risk of Coronary Heart Disease
17 A Big Difference! 50 yo Man compared to 50 yo Woman Framingham Risk Score for CHD Cholesterol 250 BP 140/80 Nonsmoker HDL year risk of Coronary Heart Disease: Man 16% Woman 2%!!!
18 Little Difference! 70 yo Man compared to 70 yo Woman Cholesterol 250 BP 140/80 Nonsmoker HDL year risk of Coronary Heart Disease: Man 20% Woman 17%
19 Reynolds Risk Score (Adds FH, hs-crp to FRS) Women s Health Study, n=24,558, 10.5 yr Reclassification of FRS status 5.4%: Intermediate risk - FRS Reclassified to High Risk 13.4% Intermediate risk - FRS Reclassified to Very Low risk Ridker, et al. JAMA 2007;297:611
20 Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
21 Symptoms in ACS: Gender difference? back pain, dyspnea, indigestion, n/v, palpitations, anorexia, dizziness, abdominal pain, neck pain, syncope all more common in women than men with ACS BUT... Patel, et al. Am Heart J 2004;148:27-33
22 Symptoms in ACS: Gender difference? All Acute Coronary Syndromes 70% of women vs. 72% of men present with chest pain (n.s.) MyocardiaI Infarction 6 of 8 studies: No difference in frequency of chest pain in men and women >90% of women present with chest pain Patel, et al. Am Heart J 2004;148:27-33
23 Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
24 Vasculopathic Differences CAD in Women Diffuse disease (plaque erosion > rupture) Smaller vessel size Coronary microemboli Endothelial dysfunction Vasculitis JACC 2006;47:30S-5S
25 Gender Effects on Coronary Microvascular Dysfunction in Patients with Suspected Coronary Artery Disease Murthy, JACC 2012;59:E women, 97 men Frequency/magnitude of coronary microvascular dysfunction are similar in both genders Copyright 2012 American College of Cardiology Foundation. Restrictions may apply.
26 WISE Study PChP, no CAD Johnson, et al. Euro Heart J 2006;27:
27 Chest Pain in Women with No Obstructive CAD (a tale of 2 studies) 100 UCD Study Prelim data (n=220) WISE study (n=189) Years Johnson, et al. Euro Heart J 2006;27:
28 Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
29 Stress Testing in Women AHA Scientific Statement Evidence is insufficient to replace the exercise treadmill test as the initial screening test for coronary artery disease in women with normal resting ECG and adequate exercise capacity Mieres, et al. Circulation 2005;111:682
30 Duke Treadmill Score Surviv val at 5-Y ears Estimating 5-Year Survival By Duke Treadmill Score (Ex Time - (5 x ST Dev) - (4 x CP[1=non-limiting, 2=limiting]) Women (n=976) Men Int Low (n=2,249) High Consider Cath Refer to Imaging Watchful Waiting Duke Treadmill Score Alexander, et al. JACC 1998;32:1657
31 Low Risk Women Presenting to the ED with CP (UCDavis) N = 215, 50 yo, no DM or smoking Clnically stable, 1st ECG/Ti neg Discharged from CPU (2-6 hr) 30% with no confirmatory test ~1/4 return to ED or clinic with c/o CP Cardiac events at >5.0 yr follow-up:0!!! - 0!!!
32 Treadmill Exercise Test in Women Limited specificity (?) false positive rate Positive or negative ETT based solely on ECG Obsolete method of interpretation Functional capacity most important prognostic factor
33 Treadmill Exercise Test in Women Hypothesis - ETT provides accurate prognosis in women with normal resting ECGs no prior cardiac disease adequate exercise capacity N 1971 women referred for ETT to evaluate chest pain Age 53 yo (21-86) 2 Cardiac RFs - 42% of patients
34 Results of ETT Positive (1.0 mm ST depression) - 16% Negative - 78% Nondiagnostic 6% (Peak HR <85% predicted)
35 Mortality (8.5 yr FU) No relation to ischemic ETT Positive test t 35% 3.5% Negative - 3.2% NonDx 12.0% <5 Mets -13.0%
36 Conclusions: ETT in Women Rate of positive ETT not excessive 16% Mortality Functional capacity No correlation with ST depression
37 Summary: Current Concepts of Heart Disease in Women CVD leading cause of death in women Rare in premenopausal non-dm women Risk factors same as in men Sx atypical in minority Older women and men First test in women with chest pain Treadmill exercise (if ECG normal and can exercise) Management of CVD in women Improving but not optimal
Dr. Suzanne Steinbaum Director, Women and Heart Disease Lenox Hill Hospital New York
Dr. Suzanne Steinbaum Director, Women and Heart Disease Lenox Hill Hospital New York 500,000 400,000 398,563 432,709 Deaths 300,000 200,000 290,069 269,819 100,000 78,941 59,260 36,006 65,323 51,281 42,658
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Getting the Most Out of Stress Echo Vera H. Rigolin, MD, FASE, FACC, FAHA Professor of Medicine Northwestern University Feinberg School of Medicine Medical Director, Echocardiography Laboratory Northwestern
Stable Angina: Indication for revascularization and best medical therapy
Stable Angina: Indication for revascularization and best medical therapy Cardiology Basics and Updated Guideline 2018 Chang-Hwan Yoon, MD/PhD Cardiovascular Center, Department of Internal Medicine Bundang
Heart Rate Recovery in association with exercise stress testing
Heart Rate Recovery in association with exercise stress testing Daniel E. Forman, M.D. Director, Exercise Laboratory Brigham and Women s Hospital April 21, 2006 Stress Testing Historical Rationale for
Management of Lipid Disorders and Hypertension: Implications of the New Guidelines
Management of Lipid Disorders and Hypertension Management of Lipid Disorders and Hypertension: Implications of the New Guidelines Robert B. Baron MD MS Professor and Associate Dean UCSF School of Medicine
CASES IN ADVANCED IMAGING
CASES IN ADVANCED IMAGING DAVID A. ORSINELLI, MD PROFESSOR, CLINICAL INTERNAL MEDICINE THE OHIO STATE UNIVERSITY DIVISION OF CARDIOVASCULAR MEDICINE OHIO ACC ANNUAL CONFERENCE OCTOBER 2010 WHICH IMAGING