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
My conflicts are inner conflicts and I do not choose to reveal them
Neitzsche GOD CREATED WOMAN BOREDOM CEASED!
Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
Deaths - Women (US - 2006) (CDC) (yr.)
QUESTION
Coronary Heart Disease Rare in premenopausal p nondiabetic women who do not smoke
Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
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
CV Deaths Men and Women 000s) EATHS (10 DE Males Females Roger et al. Circulation 2011;123:e18-209 Source: National Center of Health Statistics
Am I Wearing Red for Women? YES! But I m also wearing BLACK for Men!
Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
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.
Risk Factor Prediction of CHD 50 yo Man and 50 yo Woman Framingham Risk Score Cholesterol 250 BP 140/80 Nonsmoker HDL 40 10 yr risk of Coronary Heart Disease
A Big Difference! 50 yo Man compared to 50 yo Woman Framingham Risk Score for CHD Cholesterol 250 BP 140/80 Nonsmoker HDL 40 10 year risk of Coronary Heart Disease: Man 16% Woman 2%!!!
Little Difference! 70 yo Man compared to 70 yo Woman Cholesterol 250 BP 140/80 Nonsmoker HDL 40 10 year risk of Coronary Heart Disease: Man 20% Woman 17%
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
Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
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
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
Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
Vasculopathic Differences CAD in Women Diffuse disease (plaque erosion > rupture) Smaller vessel size Coronary microemboli Endothelial dysfunction Vasculitis JACC 2006;47:30S-5S
Gender Effects on Coronary Microvascular Dysfunction in Patients with Suspected Coronary Artery Disease Murthy, JACC 2012;59:E1373 307 women, 97 men Frequency/magnitude of coronary microvascular dysfunction are similar in both genders Copyright 2012 American College of Cardiology Foundation. Restrictions may apply.
WISE Study - 2006 PChP, no CAD Johnson, et al. Euro Heart J 2006;27:1408-1415
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;27:1408-1415
Women, Men and CHD Epidemiology Management Risk Factors Clinical Presentation Unique Pathophysiology (?) Stress Testing
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
Duke Treadmill Score Surviv val at 5-Y ears 100 90 80 70 60 50 40 30 20 10 0 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 -45-40 -35-30 -25-20 -15-10 -5 0 5 10 15 20 Duke Treadmill Score Alexander, et al. JACC 1998;32:1657
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!!!
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
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
Results of ETT Positive (1.0 mm ST depression) - 16% Negative - 78% Nondiagnostic 6% (Peak HR <85% predicted)
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%
Conclusions: ETT in Women Rate of positive ETT not excessive 16% Mortality Functional capacity No correlation with ST depression
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