Women s Ischemia and cardiac rehabilitation

Transcription

1 Women s Ischemia and cardiac rehabilitation Dr. Pallavi Bellamkonda MD, FACC Financial Disclosures: None 1

2 Objectives Understanding the Unique presentations of Ischemic Disease in Women: Obstructive Coronary disease Non obstructive-microvascular Coronary dysfunction Spontaneous Coronary dissection Cardiac rehabilitation in women and its challenges Percentage breakdown of deaths due to cardiovascular disease (United States: 2007). Prevalence of cardiovascular disease in adults 20 years of age by age and sex (National Health and Nutrition Examination Survey: ). 2

3 Cardiovascular disease and other major causes of death for all males and females (United States: 2007). Cardiovascular disease and other major causes of death for white males and females (United States: 2007). Cardiovascular disease and other major causes of death for black males and females (United States: 2007). 3

4 Cardiovascular disease and other major causes of death for Hispanic or Latino males and females (United States: 2007). Cardiovascular disease and other major causes of death for Asian or Pacific Islander males and females (United States: 2007). Asian or Pacific Islander is a heterogeneous category that includes people at high cardiovascular disease risk (eg, South Asian) and people at low cardiovascular disease risk (eg, Japanese). Cardiovascular disease and other major causes of death for American Indian or Alaska Native males and females (United States: 2007). 4

5 Age-adjusted death rates for coronary heart disease (CHD), stroke, and lung and breast cancer for white and black females (United States: 2007). Mortality & Morbidity Cardiovascular disease (CVD) remains the leading cause of death for women. For almost 3 decades: more women than men have died from CVD with the most recent annual statistics on mortality reporting that CVD accounted for deaths among women in the United States. Mortality & Morbidity Although there have been significant declines in coronary heart disease (CHD) mortality for females, these reductions lag behind those seen in men. In addition, where there has been a decrease in mortality from CHD across all age groups over time in men, in the youngest women (age <55 years there has been a notable increase in mortality from CHD. 5

6 Cardiovascular disease mortality trends for males and females (United States: ). Incidence of angina pectoris* by age and sex (Framingham Heart Study /2003). *Angina pectoris uncomplicated based on physician interview of patient. 6

7 Ischemia and Non obstructive CAD Symptoms suspected to be due to Ischemia: prompting coronary angiogram yet no obstructive CAD(no >=50% diameter stenosis) INOCA the problem 3 to 4 million men & women suffer from signs/symptoms of MI Incur health care costs & disabilities/ repeat testing Women more likely to have Non obstructive CAD Almost 2/3 rds of women had INOCA (in the WISE study) INOCA the problem How about their risk? Intermediate risk: MACE/Death/non fatal MI /stroke & HF hospitalization: >2.5% yearly by 5 yrs At 10 yrs: CVD death or MI: 7 to 12% 7

8 Women more likely to have Non obstructive CAD Women with INOCA: re about 4 times more likely than men, to be readmitted within 180 days for ACS/chest pain How do we treat? reassurance Pathophysiology Coronary Microvascular dysfunction Epicardial Microvascular endothelial Non endothelial dysfunction Limits Myocardial perfusion Reduced coronary flow Sex effects on coronary microvascular dysfunction measured by positron emission tomography and adverse outcomes in symptomatic patients without obstructive coronary artery disease. C. Noel Bairey Merz et al. Circulation. 2017;135:

9 Coronary reactivity testing protocol. C. Noel Bairey Merz et al. Circulation. 2017;135: Ischemia with no obstructive CAD (INOCA). C. Noel Bairey Merz et al. Circulation. 2017;135: Potential therapies for coronary microvascular dysfunction (CMD). C. Noel Bairey Merz et al. Circulation. 2017;135:

10 Hospital discharges for cardiovascular disease (United States: ). Hospital discharges for the 10 leading diagnostic groups (United States: 2007). CHF and Cardiac rehab Patients with chronic heart failure (CHF) and reduced ejection fraction : Exercise training is recommended at a class 1 evidence level 10

11 Hospital discharges for heart failure by sex (United States: ). Spontaneous Coronary Artery Dissection Spontaneous Coronary Artery Dissection (SCAD): an increasingly recognized cause of MI Usually occurs in young and previously healthy women SCAD assoc MI: has higher incidence of depression and anxiety Referral to Cardiac rehab in this population, is in fact- low. Spontaneous Coronary Artery Dissection Role of Cardiac Rehab : CR is safe approach to reintroduce regular exercise : improve Physical and emotional well being Non participants: lack of appropriate facility/no one with whom to exercise/ lack of motivation/cost/ No clear guidelines/ feel at risk 11

12 Cardiac rehabilitation in women and its challenges Cardiac rehab utilization remains low: Particularly in Women: as compared to men Less likely to be referred Less likely to enroll once referred Less likely to complete a full course of CR Cardiac rehab utilization remains Identify gender-related barriers Find solutions to improve the utilization of CR 12

13 Cardiac rehab utilization remains Identify gender-related barriers Barriers to referral, enrolment & completion Patient level factors Provider level factors Social/environmental factors. Solutions to improve the utilization Early access Increased completion rates by 1.4 times Automatic referral no significant difference Patient navigation Education & support by phone & mail by Navigator increased awareness and enrollment by 9 times Solutions to improve the utilization Increase awareness Of both patients & Healthcare providers: improved referral rates by 2 to 32 times One inpatient visit and 2 outpatient calls Increased participation by 2.6 times Home based Uptake was higher/webcast did not show significant difference 13

14 Solutions to improve the utilization Telemedicine In a rural setting: similar results Smart phone/ web based model Improved completion rates by 1/3 rd Gender tailored Intervention Increased attendance by 4-5 sessions Thank you Questions? 14