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 0 A B C D E A B D F C Males Females A CVD (I00-I99; Q20-Q28) B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer s Disease CVD and other major causes of death for all males and FEMALE DEATHS(United States: 2006). Source: NCHS and NHLBI.

Per 100,000 Population 200 150 100 50 0 101.5 130.0 Coronary Heart Disease 57.0 41.1 41.1 39.0 31.6 22.9 Stroke Lung Cancer Breast Cancer White Females Black Females Age-adjusted death rates for CHD, stroke, lung and breast for white and black females (United States: 2006). Source: NCHS.

Menopause and the Risk of Coronary Heart Disease (modified data from Menopausal status as a risk for coronary artery disease Arch Intern Med 1995;155:57-61 4 3.5 Annual Occurence of Heart Attack/1000 3 2.5 2 1.5 1 0.5 0 40-45 45-49 50-54 Before menopause After menopause Age (in years)

African-American Women & Heart Disease African-American women have a higher risk for heart disease than Caucasians and are less aware of their risk factors, including: Obesity (53.9% obese and 73.1% overweight and obese)¹ Physical Inactivity (65.4% of African-American women get no leisure time physical activity)¹ High Blood Pressure¹ Diabetes (15.4% have diabetes)¹ Diet (Sodium Intake)¹ 47% of African-American women over the age of 20 have high blood pressure¹ African-American women bear a disproportionate burden of stroke, heart failure, and kidney disease, all due to undiagnosed, or poorly controlled high blood pressure.² ³ 1 Go A S, Mozaffarian, D, Roger, V L, Benjamin E J, et al. Heart Disease and Stroke Statistics 2013 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2013; e39-e90 2 Jha AK, Varosy PD, Kanaya AM, et al. Differences in Medical Care and Disease Outcomes Among Black and White Women With Heart Disease. Circulation. 2003;108:1089-1094. E39-e90 3 Pleis JR, Lucas JW. Summary health statistics for U.S. adults: National Health Interview Survey, 2007. Vital Health Stat 10. 2009; No. 240: 1-159. www.womenheart.org 5

Hispanic-American Women & Heart Disease Hispanic-American Women also have a slightly higher risk for heart disease than Caucasians, and are less aware of their risk factors. Obesity Among Mexican-American women, 44.8% are overweight and 78.2% are overweight or obese¹ Physical Inactivity High Blood Pressure Among Mexican-American women over the age of 20, 28.8% have high blood pressure.¹ Diabetes (12% have diabetes Nearly 2x higher than Caucasian women)¹ Diet (Sodium Intake) Among Mexican-American women, 30.7% have cardiovascular disease¹ 1 Go A S, Mozaffarian, D, Roger, V L, Benjamin E J, et al. Heart Disease and Stroke Statistics 2013 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2013; e60- e111 www.womenheart.org 6

Awareness trends of Heart Disease as leading cause of death in women: FEBRUARY 10, 2010 60% WHITE WOMEN 43% AFRICAN-AMERICAN WOMEN 44% HISPANIC 34% ASIAN 50% women ages 25-34 **** NEED FOR PREVENTION

Epidemic of Heart Disease has reached the younger Population of women: October 2009 Archives of Internal Medicine -Women younger than 55 years old-there was a greater increase in the risk of heart disease and stroke 1988-1994 1999-2004 MEN 2.5% MEN 2.2% WOMEN 0.7% WOMEN 1% *increase is due to an increase in diabetes in this population *there has been a 93% decline of mortality of younger women compared to men due to better recognition and management of coronary artery disease and its risk factors *the disease process is escalating in a younger population. We need to aggressively empower these women to achieve the lifestyle goals that diminish their risk factors in order to prevent this disease from presenting itself, not only at such a young age, but also in a woman's lifetime.

Low rate of sex-specific reporting in Cardiovascular trials Major journals- cardiology and internal medicine from July 1 st through December 31, 2004 Result reporting for primary outcomes for women NIH funded-51%- 1993 act of inclusion General medical- 37% Cardiology- 23% SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY AND INTERVENTIONS SCAI 2011- ONLY 25% OF NIH TRIALS TRACK GENDER SPECIFIC OUTCOMES

Differences in Referral for Testing and Treatment: Gusto IIB 60 P<0.01 for all % of Pts Referred 50 40 30 20 10 Women Men 0 Stress Testing Cardiac Cath PTCA CABG Tamis et al. Circulation 1997;96:I-536.

Gender Distribution Estimates for Interventions : 2004 80% 78% 80% 67% 65% 60% 40% 33% 35% 50% 50% Female Male 20% 22% 20% 0% 1 1 1 2 PTCI Peripheral Pacemakers ICDs CRT-D for HF 2 Sources: Int. 1-AHA: Heart Diseases and Stroke Statistics - 2004 Update 2-Guidant Internal Estimates

Low rate of sex-specific reporting in Cardiovascular trials Major journals- cardiology and internal medicine from July 1 st through December 31, 2004 Result reporting for primary outcomes for women NIH funded-51%- 1993 act of inclusion General medical- 37% Cardiology- 23% SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY AND INTERVENTIONS SCAI 2011- ONLY 25% OF NIH TRIALS TRACK GENDER SPECIFIC OUTCOMES

Representation of Women in Pharma Heart Failure Trials CIBIS II 75% 32% 25% MERIT HF 77% 23% Val HeFT 80% 20% COPERNICUS 80% 20% 15% Men Women CIBIS-II Clinical Trial; Lancet; Circulation, 2001; 103; 3;375-380; MERIT HF Clinical Trial; Ghali, JK, Circulation, 2002;105; 1585-1591; Val Heft Clinical Trial; Cohn, JN, N Engl J Med, 2001; 345; 1667-1675; COPERNICUS Clinical Trial; Gust, H Bardy; ACC, March 8, 2004.

Physician awareness of CVD prevention guidelines by specialty p<0.001 p<0.001 p<0.001 p<0.001 100% 90% p<0.001 Aware 80% 70% 60% 50% 40% 30% 20% 10% p<0.001 PCP OBGyn Cardiologist 0% NCEP ATP III JNC 7 clinical guidelines AHA Women's Mosca L et al. Circulation. 2005;111:499.

Physician incorporation of CVD prevention guidelines by specialty among respondents who stated they were aware of the guidelines 100% 90% 80% Incorporated 70% 60% 50% 40% 30% p<0.001 p<0.001 p<0.001 p<0.001 p<0.001 p<0.001 PCP OBGyn Cardiologist 20% 10% 0% NCEP ATP III JNC 7 clinical guidelines AHA Women's Mosca L et al. Circulation. 2005;111:499.

The State of our Nation 45% of US has 1 risk factor- high blood pressure, high cholesterol or diabetes 13% has 2 risk factors 3% have 3 risk factors 15% of adults also had one or more of these conditions undiagnosed

Study Points to Declining Life Span for Some U.S. Women Wall Street Journal March 4, 2013 University of Wisconsin study 3,141 women over 10 years In the South and West unclear reasons - Most often poor white women Theories- obesity, diabetes Women 81, men 76-women is dropping Started in the late 80 s

AHA 2020 STRATEGIC GOAL To improve the cardiovascular health of all Americans by 20% while reducing the deaths from cardiovascular diseases and stroke by 20% Must create awareness to multicultural women and young women

WHAT IS CORONARY ARTERY DISEASE? ATHEROSCLEROSIS PLAQUE BUILDUP CHOLESTEROL, FIBROUS TISSUE INFLAMMATORY CELLS BEGINS IN TEENS

Premature atherosclerosis (PDAY) Abdominal aorta Right coronary artery McGill HC Jr et al, Circulation 2002

Most Myocardial Infarctions Are Caused by Low-Grade Stenoses Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al.) Falk E et al, Circulation, 1995.

Atherosclerotic Plaque Rupture and Thrombus Formation Intraluminal thrombus Growth of thrombus Blood Flow Intraplaque thrombus Lipid pool Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T13 18

Women s Early Warning Signs of a Heart Attack Weeks before Heart Attack (95% of women) Unusual fatigue (70.7%) Sleep disturbance (47.8%) Shortness of breath (42.1%) Indigestion (39.4%) Chest pain (29.7 %) At time of Heart Attack Shortness of breath (57.9%) Weakness (54.8%) Fatigue (42.9%) Chest pain (57%) McSweeney, JC et al. Circulation 2003; 2619-2623

AHA 2/10 survey: 2,300 women interviewed Only 53% of women said they would call 9-1-1 if they thought they were having heart attack symptoms 56% of women saying chest pain and neck or arm pain 29% shortness of breath 17% chest tightness 15% nausea 7% fatigue

Profiles of Heart Disease in Men vs. Women: AHA Men Women Deaths within one year of 1 st MI Sudden deaths with no previous symptoms Within six years of recognized MI, percent who will: have another MI have a stroke experience SCD* be disabled with heart failure 25% 38% 50% 64% 18% 8% 7% 22% 35% 11% 6% 46%

WISE Demonstrates Challenges in Diagnosis: NHLBI study: 1996 to 2000 Women s Ischemia Syndrome Evaluation (WISE)- 954 patients, 4 centers Goals: Improve diagnostic testing for ischemic heart disease in women Study pathophysiologic mechanisms and prognosis in women with myocardial ischemia in the absence of obstructive coronary disease Evaluate influence of hormones and menopause on symptoms and diagnostic testing results Women with SYMPTOMS and NORMAL CORS on CATH Noel Bairey Merz, MD (WISE) Diagnosis and Pathophysiology of Ischemic Heart Disease Workshop October 2-4, 2002

Difference in Disease Presentation Obstructed coronary artery Diffused narrowing in coronary artery

Findings from WISE 936 women with ches pain referred to angiography typical angina missed in 65% of cases of CAD Substudyof normal caths-absence of flow limiting lesions 159-47% abnormal microvascular flow reserve 163- impaired coronary vasomotor response to acetylcholine independently linked to adverse CV outcomes Some lesions severe enough to limit coronary perfusion

DETECTION OF CAD IN WOMEN HISTORY IS VERY VARIABLE DIAGNOSTIC TESTING IS DIFFICULT MORE FALSE POSITIVES- stress ekg Dobutamineecho- not sensitive or specific for single vessel disease, but diagnostic for multivessel disease RISK STRATIFICATION OFTEN DIFFICULT, ESPECIALLY IN YOUNGER WOMEN

THE FRAMINGHAM RISK After WWII- development of heart disease 1948- stable town Lifestyles were analyzed Until 1961, then the children- Offspring study Our assessment now is based on the results of this study

CHOLESTEROL GOALS BASED ON RISK

Cholesterol distribution in CHD and non-chd populations In spite of major advances made in the screening, detection, and management of heart disease, a major need exists for more accurate ways to predict CV risk Framingham Heart Study 26-year follow-up 35% of CHD occurs in people with TC considered optimal (<200mg/dL) No CHD CHD Therefore, other factors must be involved 150 200 250 300 Total cholesterol (mg/dl) Adapted from Castelli W. Atherosclerosis 1996

THE REYNOLD S RISK SCORE In women, up to 20% of all coronary events occur in the absence of risk factors 24,558 healthy US women followed for 10.2 years Women 45 years and older, started September 1992 Incident of MI, stroke, coronary revascularization or cardiovascular death

Reynolds risk score: ADDED variables Systolic blood pressure Current smoking Total Cholesterol HDL Hemoglobin A1C hscrp- USE OF THIS- RECLASSIFIED 25% Parental history of myocardial infarction Apoliporproteins A-1 and B-100 Lipoprotein (a)

THE CALCIUM SCORE A CT SCAN to detect CALCIUM in the arteries. SPECIFICITY DECREASES WITH INCREASING AGE 85% TO 100% SENSITIVE 41 TO 76% SPECIFIC PRESENTLY ACC/AHA EXPERT CONSENSUS DOES NOT RECOMMEND IT BECAUSE OF HIGH NUMBR OF FALSE-POSITIVES