Coronary Heart Coronary Heart DiseaseDisease

in Women in Women

Elisabeth von der LoheElisabeth von der Lohe, MD, FACC, , MD, FACC, FSCAIFSCAI

Professor of Clinical Medicine (Cardiology)Professor of Clinical Medicine (Cardiology)

Medical Director, Women’s Heart ProgramMedical Director, Women’s Heart Program

Associate Director, Cardiac Catheterization Associate Director, Cardiac Catheterization Laboratories & Interventional CardiologyLaboratories & Interventional Cardiology

Krannert Institute of CardiologyKrannert Institute of Cardiology

Indiana University School of MedicineIndiana University School of Medicine

Disclosures:noneDisclosures:none

B.RB.R..• 37 year old white female with diabetes mellitus for 6 years, no other 37 year old white female with diabetes mellitus for 6 years, no other

risk factors; non-smokerrisk factors; non-smoker

• 7/7/2008 presentation to her family doctor with left sided shoulder 7/7/2008 presentation to her family doctor with left sided shoulder pain for the past 2-3 weeks; pain got worse with walking or climbing pain for the past 2-3 weeks; pain got worse with walking or climbing stairs; symptoms were felt to be secondary to an inflammed stairs; symptoms were felt to be secondary to an inflammed shoulder and ibuprofen was prescribedshoulder and ibuprofen was prescribed

• 7/11/2008 emergency room; left sided shoulder pain got worse. Also 7/11/2008 emergency room; left sided shoulder pain got worse. Also increasing shortness of breath while walking or doing any activities. increasing shortness of breath while walking or doing any activities. Diagnosis of shoulder arthritis was maintained and patient Diagnosis of shoulder arthritis was maintained and patient discharged the same daydischarged the same day

• 7/13/2008; went back to emergency room; excruciating shoulder 7/13/2008; went back to emergency room; excruciating shoulder pain, shortness of breath and sweating. EKG revealed a heart attack.pain, shortness of breath and sweating. EKG revealed a heart attack.

• Emergency heart catheterizationEmergency heart catheterization

Death Rates in WomenDeath Rates in Women

Coronary Artery Disease

Stroke

Lung Cancer

Breast Cancer

Colon Cancer

Endometrial Cancer

Age (years)

Dea

th R

ate

per

100

,000

6500

4500

2500

1600

1200

800

400

045-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

At Every Age, More Women Die of Heart Disease Than Breast CancerAt Every Age, More Women Die of Heart Disease Than Breast Cancer

National Center for Health Statistics. 1999:164-167.

Cardiovascular Disease Deaths: Trends Cardiovascular Disease Deaths: Trends for Males and Females for Males and Females United States: 1979- United States: 1979-

20012001 Source: CDC/NCHS © AHA, 2004

What is Coronary Heart What is Coronary Heart Disease ?Disease ?

For both men and womenFor both men and women• SmokingSmoking• DiabetesDiabetes• High Cholesterol (in particular high LDL and/or low High Cholesterol (in particular high LDL and/or low

HDL)HDL)• High Blood PressureHigh Blood Pressure• ObesityObesity• Sedentary LifestyleSedentary Lifestyle For women onlyFor women only• MenopauseMenopause• Birth Control Pills in Combination with SmokingBirth Control Pills in Combination with Smoking

Risk Factors for Coronary Heart Risk Factors for Coronary Heart DiseaseDisease

Perhaps the most important Perhaps the most important risk factor for coronary heart risk factor for coronary heart disease is the misperception disease is the misperception that coronary heart disease is that coronary heart disease is a men’s diseasea men’s disease

C o r o n a r y D i s e a s e M o r t a l i t y a n d D ia b e t e s i n W o m e n

0

10

20

30

40

50

60

0 - 3 4 - 7 8 - 11 12 -15

16 -19

20 -23

Duration of follow-up (yrs)

Morta

lity

Rate

(per

100

0 wo

men

) Diabetic Women

NondiabeticWomen

Source: Adapted from Krolewski 1991

Menopause and Menopause and the Risk of Coronary Heart Disease the Risk of Coronary Heart Disease (modified data from “Menopausal status as a risk for coronary artery (modified data from “Menopausal status as a risk for coronary artery disease”disease”Arch Intern Med 1995;155:57-61Arch Intern Med 1995;155:57-61

0

0.5

1

1.5

2

2.5

3

3.5

4

40 - 45 45 - 49 50 - 54

Before menopauseAfter menopause

Age (in years)

An

nu

al O

ccu

ren

ce o

f H

eart

Att

ack

/100

0

Relation between Smoking, Use of Birth Relation between Smoking, Use of Birth Control Pills and the Risk of a Heart Control Pills and the Risk of a Heart AttackAttack (modified data from Rosenberg L et al.Myocardial infarction and (modified data from Rosenberg L et al.Myocardial infarction and cigarette smoking in women younger than 50 years of age. JAMA cigarette smoking in women younger than 50 years of age. JAMA 1985;253:2965-2969)1985;253:2965-2969)

05

1015202530

current former never

Never smoked

25+ cigarettes

Never smoked1-24 cigarettes25+ cigarettes

Use of Birth Control Pills

R

elat

ive

risk

of

a H

eart

Att

ack

Women at High Risk Women at High Risk

- - Established coronary heart diseaseEstablished coronary heart disease– Blockage of carotid arteryBlockage of carotid artery– Circulation problems of the legsCirculation problems of the legs– Abdominal aortic aneurysmAbdominal aortic aneurysm– DiabetesDiabetes– Chronic kidney disease Chronic kidney disease

Source: Mosca 2004

Chest pain or AnginaChest pain or Angina

Typical Angina:Typical Angina: heaviness, pressure or squeezing sensation behind the breastboneheaviness, pressure or squeezing sensation behind the breastbone with with

radiation across the chest, up the neck or down the left armradiation across the chest, up the neck or down the left arm or “strangling” or “suffocating” sensation. or “strangling” or “suffocating” sensation.

caused or worsened by exercise and eased by restcaused or worsened by exercise and eased by rest usually lasts two to five minutesusually lasts two to five minutes

Atypical AnginaAtypical Angina (frequently encountered in (frequently encountered in women):women):shortness of breathshortness of breathextreme fatigueextreme fatiguelightheadedness or faintinglightheadedness or faintingnausea and/or indigestionnausea and/or indigestion

DiagnosisDiagnosis

• EKGEKG• Stress Test - Exercise or with MedicationStress Test - Exercise or with Medication

- with or without Imaging - with or without Imaging (Echo or Nuclear)(Echo or Nuclear)

• Echocardiography (ultrasound of heart)Echocardiography (ultrasound of heart)• Heart CatheterizationHeart Catheterization

Women’s Early Warning Signs of a Women’s Early Warning Signs of a Heart Attack Heart Attack

• Weeks before Heart Attack (95% of women)Weeks before Heart Attack (95% of women) Unusual fatigue (70.7%)Unusual fatigue (70.7%) Sleep disturbance (47.8%)Sleep disturbance (47.8%) Shortness of breath (42.1%)Shortness of breath (42.1%) Indigestion (39.4%)Indigestion (39.4%) Chest pain (29.7 %)Chest pain (29.7 %)

• At time of Heart AttackAt time of Heart Attack Shortness of breath (57.9%)Shortness of breath (57.9%) Weakness (54.8%)Weakness (54.8%) Fatigue (42.9%)Fatigue (42.9%) Chest pain (57%)Chest pain (57%)

McSweeney, JC et al. Circulation 2003; 2619-2623

Treatment of a Heart AttackTreatment of a Heart Attack

• Most important: restoring of blood flow to the blocked Most important: restoring of blood flow to the blocked artery with eitherartery with either

- Administration of a Clot buster (i.e tPA or TNK) or- Administration of a Clot buster (i.e tPA or TNK) or – Mechanically (Balloon angioplasty or so called Primary Angioplasty) with or Mechanically (Balloon angioplasty or so called Primary Angioplasty) with or

without stent placementwithout stent placement

• OxygenOxygen• Medications such as Nitroglycerin, Beta-Blocker, Medications such as Nitroglycerin, Beta-Blocker,

Morphine and Blood Thinners (i.e. Heparin)Morphine and Blood Thinners (i.e. Heparin)

Prevention of Coronary Prevention of Coronary Heart DiseaseHeart Disease

No Gender Difference !!!No Gender Difference !!!

• No SmokingNo Smoking

• Weight Reduction/MaintenanceWeight Reduction/Maintenance

• Regular ExerciseRegular Exercise

• Control of High Blood PressureControl of High Blood Pressure

• Reduction in High CholesterolReduction in High Cholesterol

DietDiet• Consistently healthy eatingConsistently healthy eating

– Healthy food selections:Healthy food selections:•Fruits and vegetablesFruits and vegetables•Whole grainsWhole grains•Low-fat or nonfat dairyLow-fat or nonfat dairy •LegumesLegumes•Low-fat proteinLow-fat protein•FishFish

Limit trans fatty acid intake (main dietaryLimit trans fatty acid intake (main dietarysources are baked goods and fried foods)sources are baked goods and fried foods)

Source: Mosca 2004

Weight Weight Maintenance/Reduction Maintenance/Reduction GoalsGoals

• BMI between 18.5 and 24.9BMI between 18.5 and 24.9• Waist circumference < 35 inchesWaist circumference < 35 inches• Weight loss goalsWeight loss goals

– 10% of body weight over six months or 1-2 10% of body weight over six months or 1-2 pounds weight loss/weekpounds weight loss/week

– Reduce calories by 500-1,000 per dayReduce calories by 500-1,000 per day

Source: Mosca 2004, ATP III 2002

Weight ReductionWeight Reduction

• No optimal way of weight reduction No optimal way of weight reduction found (yet)found (yet)

• Weight loss and weight maintenance Weight loss and weight maintenance should be achieved slowlyshould be achieved slowly

• Weight cycling increases the risk of Weight cycling increases the risk of heart diseaseheart disease

Recommendations of the Recommendations of the AHA for Physical ActivityAHA for Physical Activity

• Aerobic exercise of moderate to Aerobic exercise of moderate to vigorous activity for 30-60 min 3-4 vigorous activity for 30-60 min 3-4 days/week, best on all days days/week, best on all days

• Alternative: however count the Alternative: however count the minutes!!minutes!!

walking >4 hours/week in form of walking >4 hours/week in form of

10-min intervals10-min intervals

Walking Compared with Vigorous Exercise for Walking Compared with Vigorous Exercise for the Prevention of Heart Disease in Womenthe Prevention of Heart Disease in Women

Manson, JE et al.N Engl J Med 2002;347:716-25.

Overweight as Compared with Overweight as Compared with Physical Activity in Predicting Death Physical Activity in Predicting Death from Heart Disease among Womenfrom Heart Disease among Women

Body MassBody Mass

IndexIndex< 25< 25 25-3025-30 >30>30

Age-adjustedAge-adjusted RRRRActive (>3.5 h)Active (>3.5 h)

1.001.00 1.581.58 2.872.87

Age-adjustedAge-adjusted RRRR1.0 – 3.5 h1.0 – 3.5 h

1.511.51 2.062.06 4.264.26

Age-adjustedAge-adjusted RRRRInactive (<1 h)Inactive (<1 h)

1.891.89 2.522.52 4.734.73

Frank B. Hu et al. NEJM 2004;351:2694-703

High Blood PressureHigh Blood Pressure

• Optimal blood pressure Optimal blood pressure

< 120/80 mm Hg < 120/80 mm Hg

• Medication are indicatedMedication are indicated

when blood pressurewhen blood pressure>> 140/90 mm Hg or 140/90 mm Hg or

>> 130/80 mm Hg in the setting of 130/80 mm Hg in the setting of diabetes diabetes

Source: Mosca 2004

Lipids Lipids (cholesterol and triglycerides)(cholesterol and triglycerides)

• Optimal levels of lipids and Optimal levels of lipids and lipoproteins in womenlipoproteins in women

– LDL < 100 mg/dLLDL < 100 mg/dL– HDL > 50 mg/dLHDL > 50 mg/dL– Triglycerides < 150 mg/dTriglycerides < 150 mg/d– (total cholesterol not that important)(total cholesterol not that important)

Source: Mosca 2004

Interventions that are not Interventions that are not useful/effective and may be useful/effective and may be harmful for the prevention harmful for the prevention of heart diseaseof heart disease

• Hormone TherapyHormone Therapy

•Antioxidant supplements Antioxidant supplements (Vitamin E,C, and beta-(Vitamin E,C, and beta-carotene)carotene)

•Folic AcidFolic Acid (with or without B6 (with or without B6 and B12 supplementation)and B12 supplementation)

Source: Mosca 2007

Summary (1)Summary (1)

Heart Disease is the leading cause of death Heart Disease is the leading cause of death in women in the United Statesin women in the United States

Most risk factors are the same for men and Most risk factors are the same for men and women, but women are at particularly high women, but women are at particularly high

risk if they have diabetes mellitus. risk if they have diabetes mellitus. Genderspecific risks are menopause and Genderspecific risks are menopause and intake of birth control pills while smokingintake of birth control pills while smoking

Diagnosis of Heart Disease in women is very Diagnosis of Heart Disease in women is very

difficult since many women have atypical difficult since many women have atypical symptoms such as shortness of breath and symptoms such as shortness of breath and extreme fatigueextreme fatigue

Prevention of heart disease is crucial

Almost 50 % of heart disease problems can be avoided by lifestyle changes

Ineffective interventions such as antioxidants and hormone replacement therapy should be avoided

Summary (2)Summary (2)

Summary (3)Summary (3)

In order to reduce heart disease in In order to reduce heart disease in women, the importance of heart women, the importance of heart disease in the female population has to disease in the female population has to be recognized.be recognized.