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Women and Coronary Artery Disease (CAD)

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1 Women and Coronary Artery Disease (CAD)
What do we need to know ? Dr. R.V.S.N.Sarma, M.D., M.Sc., (Canada) Consultant Physician and Chest Specialist Thiruvallur, Chennai

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6 Myths vs Facts Myths Facts Men are more likely to have heart disease
Heart disease is the #1 killer of men and women; 50,000 more women than men die of heart disease every year Cancer is a bigger threat than heart disease Nearly twice as many US women die from heart disease and stroke than from all cancers combined Doctors are aware of women’s risk for heart disease and act accordingly Undertreatment and underdiagnosis of heart disease in women contributes to excess mortality in women

7 Women’s Perceptions of Heart Disease
72% of young women (ages 25-40) still consider cancer to be the greatest threat to women’s health Some women know about the risks of heart disease but do not hear it from their own doctors and do not “personalize” it 65% of women recognize that symptoms may be “atypical” but do not know classic symptoms Most women learn about coronary artery disease (CAD) from magazines and the Web—not from their own physicians! Robinson A. Circulation. 2001

8 Gender Bias in the Treatment of Women
“… The community has viewed women’s health almost with a ‘bikini’ approach, looking essentially at the breast and reproductive system, and almost ignoring the rest of the woman as part of women’s health ….” Nanette Wenger, MD Chief of Cardiology, Grady Hospital Professor of Medicine, Emory University Atlanta, Georgia

9 Magnitude of the Problem
2.5 million women per year in the US are hospitalized with cardiovascular disease (CVD) Deaths from CVD = 500,000/yr Leading cause of death in US women: CAD >230,000 women die from CAD each year 1990: US Congress directed the National Institutes of Health that women be included in clinical trials and that gender differences be evaluated

10 Women in Clinical Trials
Women are underrepresented in cardiovascular (CV) trials Evidence-based CV medicine biased toward men Food and Drug Administration/National Institutes of Health mandate: 50% enrollment of women Women need to be empowered to enroll in clinical trials for heart disease Breast-cancer awareness is a good example

11 Publication Bias: Gender Representation and Negative Studies
noninvasive testing literature 8% to 27% women Lower diagnostic accuracy in women High false-positive rates Inability to perform maximal stress

12 CVD Mortality Trends (1979-1999)
Deaths in Thousands American Heart Association Heart and Stroke Statistical Update. 2001

13 Prevalence of CVD in the US
American Heart Association Heart and Stroke Statistical Update. 2001

14 Deaths From CVD and Cancer by Age and Sex
Anderson RN. National Vital Statistics Reports. 2002

15 Deaths From CVD (1999) American Heart Association Heart and Stroke Statistical Update. 2001

16 Health Threats to Women: Perception vs Reality
1 2 1. Gallup survey American Heart Association. Heart & Stroke Facts Statistical Supplement

17 Death From Breast Cancer or Heart Disease in Women in the US
US Vital Statistics, 1990

18 Statistics for Women 503,927 died of CVD in 1998
226,467 from heart attack or other cardiac events 97,303 from stroke 1 in 5 women has some form of CVD 38% of women who have a heart attack die within 1 year 40% of coronary events in women are fatal Most occur without prior warning

19 Women and Coronary Artery Disease (CAD)
Risk Factors and Gender Differences

20 Warning Signs and Symptoms of CAD

21 Gender Differences in Heart Attack Symptoms
Typical in both sexes Pain, pressure, squeezing, or stabbing pain in the chest Pain radiating to neck, shoulder, back, arm, or jaw Pounding heart, change in rhythm Difficulty breathing Heartburn, nausea, vomiting, abdominal pain Cold sweats or clammy skin Dizziness Typical in women Milder symptoms (without chest pain) Sudden onset of weakness, shortness of breath, fatigue, body aches, or overall feeling of illness (without chest pain) Unusual feeling or mild discomfort in the back, chest, arm, neck, or jaw (without chest pain)

22 Less Common Heart Attack Symptoms in Women
Milder symptoms without accompanying chest pain Sudden onset of weakness, shortness of breath, fatigue, body aches, overall feeling of illness Burning sensation in the chest, may be mistaken as heartburn An “unusual” feeling or mild discomfort in the back, chest, arm, neck, or jaw

23 Major Risk Factors for Heart Disease
Modifiable Nonmodifiable Emerging Risk Factors High blood pressure Family history Homocysteine Abnormal cholesterol levels Age Elevated lipoprotein (a) levels Diabetes Gender Clotting factors Cigarette smoking Markers of inflammation (CRP) Obesity Physical inactivity Grundy SM, et al. Circulation. 1998; Grundy SM. Circulation Braunwald E. N Engl J Med. 1997; Grundy SM, et al. J Am Coll Cardiol. 1999

24 Emerging Risk Factors Lipoprotein (a) Homocysteine
Prothrombotic factors Proinflammatory factors Impaired fasting glucose Subclinical atherosclerosis Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) Abnormal internal or common carotid CIT, ankle-arm index <0.9, coronary Ca2+

25 Diabetes Creates Higher Risks for Women With CAD
65% of diabetics die from heart disease or stroke 4.2 million American women have diabetes Diabetes increases CAD risk 3-fold to 7-fold in women vs 2-fold to 3-fold in men Diabetes doubles the risk of second heart attack in women but not in men Every year, heart disease kills 50,000 more American women than men Statistics are particularly high among African American women American Heart Association Centers for Disease Control and Prevention Manson JE, et al. Prevention of Myocardial Infarction. 1996

26 Lowest Survival Rates for Diabetic Women
CAD mortality rates in diabetics, especially women, have not decreased to the same extent as those in the general population In a large cohort referred for coronary disease, diabetic women had the highest mortality rates Estimate of ischemic burden with stress myocardial perfusion imaging significantly improved risk stratification in diabetic women compared with clinical risk alone Stratification by the number of ischemic vessels demonstrated a significant linear increase in cardiac events with escalating ischemic burden (sex-diabetes interaction, P = .016) Gu K, et al. JAMA. 1999 Giri S, et al. Circulation. 2002

27 Diabetes: Powerful Risk Factor for CAD in Women
Framingham Heart Study Women with diabetes mellitus had relative risk of 5.4% for CAD vs women without diabetes Men with diabetes had relative risk of 2.4% Nurses’ Health Study Relative risk of 6.3% for total cardiovascular (CV) mortality Even if women had diabetes for <4 years, their risk of CAD was significantly elevated Kannel W. Am Heart J. 1987 Manson J, et al. Arch Intern Med. 1991

28 Clinical Identification of the Metabolic Syndrome
Abdominal obesity Men >88 cm (>40 in) Women >80 cm (>35 in) Triglycerides (TG) >150 mg/dL HDL cholesterol Women <50 mg/dL Men <40 mg/dL Blood pressure >130/>85 mm Hg Fasting glucose >100 mg/dL National Heart, Lung, and Blood Institute

29 Impact of Triglyceride Levels on Relative Risk of CAD
Castelli WP. Can J Cardiol. 1988

30 Women and CAD Risk Factors
Higher prevalence of avoidable risk factors1 ↑ blood cholesterol, ↑ TG ↑ physical inactivity ↑ overweight (body mass index, ) Diabetes is a more powerful risk factor for CAD2 3- to 7-fold in women vs 2- to 3-fold in men ↓ HDL cholesterol levels more predictive of CAD2 Women counseled less about nutrition, exercise, and weight control2 1. American Heart Association Heart and Stroke Statistical Update. 1998 2. Mosca L, et al. Circulation. 1999

31 MI or Death Often First Sign of CAD
Levy D, et al. Textbook of Cardiovascular Medicine. 1998

32 Smoking Single most preventable cause of death in US
Smoking by women causes 150% more deaths from heart disease than lung cancer Women who smoke are 2-6 times more likely to suffer a heart attack Use of birth control pills in smokers compounds cardiac risk

33 Overweight American Heart Association Heart and Stroke Statistical Update. 2001

34 Physical Inactivity Lack of exercise is a proven risk factor for heart disease A lack of regular physical exercise is a growing epidemic all over the world. “We seem to eat much more than what we burn” Heart disease is twice as likely to develop in inactive people than in those who are more active Physical activity helps maintain weight, blood pressure, and diabetes Women should exercise to increase heart rate for minutes a day, 3-5 times per week

35 Hormonal Effects on Ischemia and Disease Prevalence
Premenopause Estrogen has digoxin-like effect:  ST  Post-menopause effect on HRT  ST  - vasodilatory effects of HRT Increase exercise duration/decrease chest pain Women with intact uterus take progestin to protect against uterine malignancies Estrogen and medroxyprogesterone attenuate this effect Lloyd GW, et al. Heart. 2000; Webb CM, et al. Lancet. 1998; Morise AP, et al. Am J Cardiol. 1993; Rosano GM, et al. J Am Coll Cardiol. 2000

36 Hormonal Effects on Ischemia and Disease Prevalence
Estrogen modulates chest pain syndromes Premenopausal CAD: angina/ischemia variation by menstrual cycle Early follicular phase estradiol and progesterone levels - low < time to ischemia onset Mid-cycle estrogen levels - highest > time to ischemia onset Lloyd GW, et al. Heart. 2000; Webb CM, et al. Lancet. 1998; Morise AP, et al. Am J Cardiol. 1993; Rosano GM, et al. J Am Coll Cardiol. 2000

37 Postmenopausal Hormone Therapy and Cardioprotection
First randomized trial HERS trial (Heart and Estrogen/Progestin Replacement Study) Secondary CAD prevention trial Randomized trial of placebo vs estrogen and medroxyprogesterone Follow-up = 4 years N = 2,763 women with an intact uterus Outcome measures Primary: nonfatal MI or cardiac death Secondary: unstable angina, coronary revascularization, congestive heart failure HERS trial. JAMA

38 Is There a Role for HRT? Secondary prevention 1998: HERS
4 years of treatment with conjugated estrogen plus medroxyprogesterone acetate No reduction in the risk of MI and coronary death in women with established CAD HERS trial. JAMA

39 Is There a Role for HRT? Secondary prevention
3/2000: Estrogen Replacement and Atherosclerosis trial (ERA) 309 postmenopausal women with CAD Placebo vs conjugated estrogen (.625 mg/day) vs conjugated estrogen (.625 mg/day) with medroxyprogesterone acetate (2.5 mg/day) Angiographic analysis of the diameter of the coronary arteries at the start of the study and 3 years later ERA trial results at follow-up angiography The progression of coronary atherosclerosis was unchanged in the women randomized to either of the estrogen groups ERA trial. J Am Coll Cardiol. 2001

40 Is There A Role for HRT? Primary prevention
Women’s Health Initiative. WHI trial 160,000 women: Initial results: no cardioprotection attributed to HRT in women on HRT American Heart Association: HRT not recommended for primary or secondary cardioprotection

41 Conclusions: Risk Factor Management
CVD begins in childhood and is strongly associated with major risk factors for heart disease Multiple risk factors require more aggressive management Aggressive risk-factor modification (often with multiple medications) is the most effective strategy for reducing the consequences of heart disease Berenson GS, et al. N Engl J Med Neaton JD, et al. Arch Intern Med Kannel WB. in Atherosclerosis and Coronary Artery Disease Grundy SM, et al. Circulation. 1999

42 Gender Differences in CAD Risk Factors
Increasing recognition that atherosclerosis is an inflammatory process Ridker PM, et al: A prospective case-controlled study among 28,263 postmenopausal women Among 12 markers of inflammation, C reactive protein was the strongest univariate predictor of the risk of CV events Ridker PM, et al. N Engl J Med. 2000

43 Women and Coronary Artery Disease (CAD)
Diagnosis and Prognosis

44 Diagnosis and Management of CAD in Women
Gender differences: presentation, manifestation, and diagnosis of CAD Gender differences in mortality 63% of women who die suddenly from CAD had no prior warning symptoms 42% of women vs 24% of men will die within year after MI Thus, early recognition of symptoms and accurate diagnosis of CAD is of great importance

45 Heart Disease in Women: Lessons From the Past Decade
The importance of studying gender-specific aspects of CAD have helped in the following clinical dilemmas: At Presentation of CAD: women are older than men Less specific clinical manifestations of CAD in women Greater difficulty in diagnosis: women > men More severe consequences on MI when it occurs in women

46 Screening for Heart Disease
What Tests Should we use to identify Coronary Heart Disease?

47 Limited Representation of Women in Studies of CAD Testing
Adapted from: Shaw LJ, et al. Coronary Artery Disease in Women: What All Physicians Need to Know. 1999

48 Are There Gender Differences in Noninvasive Diagnostic Tests?
Is There a Difference in Diagnostic Accuracy of Noninvasive Tests?

49 Noninvasive Testing Options
Stress ECG Stress Echo Stress MPI EBCT PET MRI

50 Noninvasive Testing in Symptomatic Women
Stress electrocardiography (ECG) Stress echocardiography (ECHO) Stress nuclear imaging (MPI)

51 Exercise ECG (Treadmill)
Despite advances in technology, the exercise ECG remains an important tool in the diagnosis and prognosis of the patient suspected of having CAD The exercise ECG has an overall sensitivity of 68% and a specificity of 77% for the detection of CAD in men The sensitivity and specificity of the exercise ECG in women are about 61% and 70% respectively Kwok Y, et al. Am J Cardiol

52 ECG Testing in Women Sensitivity and Specificity
No. of Women Study, Year Sensitivity (%) Specificity (%) Detry et al, Weiner et al, Barolsky et al, Friedman et al, Guiteras et al, Hung et al, Adapted from Heller GV, et al. Nuclear Cardiology: State of the Art and Future Directions. 1998

53 Gender Differences in Exercise ECG Testing
 sensitivity in women >65 years  specificity in women on hormone replacement therapy  false-positive results due to autonomic/hormonal influences Digoxin like effect of estrogen Shaw LJ, et al. CAD in Women: What All Physicians Need to Know. 1999

54 Diagnosis of Noninvasive Tests in Women
ECG Nuclear perfusion study ECHO – poor window problem Dipyridamole injection – MPI, Stress (Tread mill) Echo – Dobutamine infusion Echo – Computed tomography MR coronary angiography

55 Nuclear Imaging in Women
Myocardial perfusion imaging (MPI) Large body of evidence in women Gender-specific data available for Tl-201and Tc-99m tracers Tc-99m tracers = agent of choice for women due to decrease attenuation artifacts from breast tissue Gated single-photon emission computed tomography (SPECT) provides post stress ejection fraction and regional wall motion  helpful to reduce false positives IV adenosine/dipyridamole stress provides comparable overall accuracy in women and men

56 Comparative Test Statistics on Diagnostic Accuracy in Women
Kwok Y, et al. Am J Cardiol. 1999

57 Diagnostic Specificity: Stress Thallium Tl-201 vs Tc-99m Sestamibi
Perfusion imaging Regional blood flow Robust evidence in women Gender-specific data for Tl-201 and Tc-99m sestamibi or teboroxime Tc-99m sestamibi is agent of choice for women (reduced breast attenuation) Gated SPECT Post-stress EF and regional wall motion Reduce false-positive tests Pharmacologic stress helpful in older and obese women N = 115, P = .0004 21 false + 10 false + Hachamovitch R. et al. J Am Coll Cardiol. 1996; Amanullah AM, et al. Am J Cardiol. 1997; Taillefer R, et al. J Am Coll Cardiol. 1997

58 Pharmacologic Stress Testing in a Community Setting: Women vs Men
Percent of patients referred for MPI who underwent exercise stress vs pharmacologic stress at Mission Internal Medicine Group, Mission Viejo, CA (4/21/02 to 8/29/02) Data provided by Greg Thomas, MD, Mission Internal Medicine Group

59 ECHO Testing in Women Overall
Convenient/readily available1,2 Avoids ionizing radiation2 Identifies cardiac structure and left ventricular function (LVF) Sensitivity and specificity vs ECG testing1,2 Increased sensitivity (79%-88%) Increased specificity (77%-86%) 1. Williams MJ, et al. Am J Cardiol. 1994 2. Marwick T, et al. J Am Coll Cardiol. 1995

60 PET Imaging for CAD in Women
Positron Emission Tomography

61 PET Case Study: Patient FF
Stress Rest

62 PET Case Study: Patient FF Ischemia of Lateral Wall

63 Electron Beam Computed Tomography (EBCT)
Resting study only Stationary tungsten target permits rapid scanning Detects coronary calcification Abnormality defined as presence of any calcium Courtesy of Howard Lewin, MD, of San Vicente Cardiac Imaging Center

64 Diagnostic Accuracy of EBCT Coronary Calcium Scores by Gender Subsets
Women Men Women Men Devries S, et al. J Am Coll Cardiol Rumberger JA, et al. Circulation Detrano R, et al. Am J Card Imaging

65 Technetium-99m SPECT Imaging Predicts Cardiac Mortality in Women
0.5 1 1.5 2 2.5 3 Years 0.6 0.7 0.8 0.9 1.0 Cardiac survival Women (n = 3402) Men (n = 4500) 98.5% 80-87% Ischemia extent and survival by number of vascular territories Marwick TH, et al. Am J Med. 1999

66 hs-CRP, Lipids, and Risk of Future Coronary Events: Women's Health Study (WHS)
4 3 2 1 9 8 7 6 5 hs-CRP, lipids, and risk of future coronary events: Women's Health Study (WHS) This graph of the additive predictive value of the total cholesterol:HDL cholesterol ratio with the level of CRP also demonstrates that measuring both of these parameters appears to do a better job of predicting vascular risk. Of note, however, even among individuals in the lowest quartile for total cholesterol:HDL cholesterol ratio, a group most of us would presume to be of low vascular risk, the relative risk of future vascular events increases quite dramatically as the level of CRP increases. Reference: Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med 2000;342: Quartile of hs-CRP Quartile of TC: HDL-C Ridker PM et al. N Engl J Med 2000;342:

67 Risk Factors for Future Cardiovascular Events: WHS
Lipoprotein(a) Homocysteine IL-6 TC LDL-C sICAM-1 SAA Apo B TC:HDL-C hs-CRP hs-CRP + TC:HDL-C Risk factors for future cardiovascular events: WHS How well does the CRP test compare with other novel and emerging risk factors for vascular disease? This issue was directly addressed in the Women's Health Study, in this direct comparison of ten putative risk factors for vascular disease. In each case, the point estimate is based on being in the top versus bottom quartile for that particular analyte, and the horizontal bars represent the 95% confidence intervals for that effect. Starting from the top, we see that lipoprotein(a) screening was not a statistically significant predictor of risk, and below that, homocysteine screening, while statistically significant, was only of modest predictive value. This plot also indicates that the predictive value for LDL cholesterol, while highly statistically significant, sits approximately midway in terms of our overall risk prediction models. Interestingly, plasma levels of soluble intercellular adhesion molecule 1 (ICAM-1), a molecular marker associated with the adhesion and transmigration of leukocytes across the endothelial wall, as well as serum amyloid A (SAA), a nonspecific marker of inflammation, were in fact better markers of risk than was the LDL cholesterol or the total cholesterol level. Also of note from a clinical perspective, the best lipid marker was the total cholesterol:HDL cholesterol ratio. This finding is highly consistent with many prior epidemiologic studies and in fact is why many preventive practices prefer to use the ratio rather than any single lipid marker. However, the critical observation in this study was that plasma levels of hs-CRP on their own were actually the single strongest predictor for future vascular events, and those data are shown in the second line from the bottom. On its own, hs-CRP screening was associated with a 4.4-fold increase in risk for future vascular events among these otherwise healthy, middle-aged women. But again, the important issue is to consider combining the inflammatory screening with the lipid screening, and that is shown in the bottom line of data on the slide, suggesting that the combination of CRP level with total cholesterol: HDL cholesterol ratio provides the best overall risk estimate. Reference: Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med 2000;342: 1.0 2.0 4.0 6.0 Relative Risk of Future Cardiovascular Events Ridker PM et al. N Engl J Med 2000;342:

68 Women’s Health Initiative: Trial of Estrogen plus Progestin
16,608 women randomized Conjugated equine estrogens mg/d + medroxyprogesterone acetate 2.5 mg/d vs. placebo Primary outcome: nonfatal MI or CHD death Primary adverse outcome: breast cancer Stopped early (mean follow-up 5.2 years) because health risks exceeded benefits The cardiovascular effects of hormone replacement therapy (HRT) in women with known coronary heart disease (CHD) were shown to be neutral in the Heart and Estrogen/Progestin Study (HERS) and the recent HERS II follow-up. However, there had been no clinical trial evidence concerning the primary CHD preventive effects of estrogen/progestin therapy. The Women’s Health Initiative (WHI) is a large prospective study of postmenopausal women to evaluate the risks and benefits of several strategies that would potentially reduce the risk for CHD, breast cancer, colorectal cancer, and fractures. WHI was intended to confirm/negate a large body of observational data that HRT in postmenopausal women with a uterus decreases risk for first-time CAD-related events. One arm of this study is the use of estrogen and progestin in postmenopausal women with a uterus, and this aspect of the WHI was terminated early because of health risks that outweighed benefits. Writing Group for the WHI Investigators. JAMA 2002;288:

69 Risks and Benefits of Estrogen/Progestin on Clinical Outcomes: Women’s Health Initiative
Hazard Ratio Nominal 95% CI Adjusted 95% CI CHD (MI, coronary death) 1.29 1.02–1.63 0.85–1.97 CABG/PTCA 1.04 0.84–1.28 0.71–1.51 Stroke 1.41 1.07–1.85 0.86–2.31 Venous thromboembolic disease 2.11 1.58–2.82 1.26–3.55 Total CVD 1.22 1.09–1.36 1.00–1.49 Cancer 1.03 0.90–1.17 0.86–1.22 Fractures 0.76 0.69–0.85 0.63–0.92 Death 0.98 0.82–1.18 0.70–1.37 Global index* 1.15 1.03–1.28 0.95–1.39 A total of 16,608 postmenopausal women aged 50–79 years with an intact uterus at baseline were randomized to conjugated equine estrogens mg/d plus medroxyprogesterone acetate 2.5 mg/d in one tablet (n=8506) or placebo (n=8102). The primary outcome was nonfatal myocardial infarction and CHD death, and the primary adverse outcome was invasive breast cancer. A global index summarized the balance of risks and benefits. After a mean of 5.2 years of follow-up, the data and safety monitoring board recommended stopping the trial after the test statistic for invasive breast cancer exceeded the stopping boundary and the global index statistic supported risks exceeding benefits. The estimated hazard ratios for the clinical outcomes suggest adverse effects on CHD, breast cancer, stroke, and pulmonary embolism with HRT. On the other hand, reduced risk for colorectal cancer and hip fractures was noted. The absolute excess risks per 10,000 person-years attributable to estrogen plus progestin included 7 more CHD events, 8 more strokes, 8 more pulmonary embolisms, and 8 more invasive breast cancers.

70 Difference in risk per 10,000 person-years
Absolute Excess Risks and Absolute Risk Reductions per 10,000 Person-Years: Women’s Health Initiative Difference in risk per 10,000 person-years CHD events +7 Strokes +8 Pulmonary embolisms Invasive breast cancer Colorectal cancers –6 Hip fractures –5 Global index +19 The overall health risks exceeded the benefits from using combined estrogen and progestin for a mean 5.2 years in healthy postmenopausal U.S. women. Therefore, this trial does not support the use of combination HRT for the primary prevention of CHD or a variety of other chronic diseases in postmenopausal women with a uterus. Unopposed estrogen in women without a uterus remains under investigation. References Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA 2002;288: Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, Vittinghoff E, for the Heart and Estrogen/progestin Replacement Study (HERS) Research Group. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. JAMA 1998;280: Grady D, Herrington D, Bittner V, Blumenthal R, Davidson M, Hlatky M, Hsia J, Hulley S, Herd A, Khan S, Newby LK, Waters D, Vittinghoff E, Wenger N. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). JAMA 2002;288:49-57. Writing Group for the WHI Investigators. JAMA 2002;288:

71 Treatment differences
Thrombolysis – equally effective – Cerebral hemorrhage risk is more Low rates of coronary angiography in women Under referral for revascularization procedures CABG - > operative mortality 1.9 % v/s 4.6% Restenosis after PTCA, or CABG occlusion rates are more for women - ? Smaller lumen sizes

72 Summary Presentation and symptomatology
Cardiac risk factors – differences Metabolic syndrome, Obesity – IR – DMII Dyslipidemia patterns TMT – lower value Stress Echo, MPI, Sistemibi, Dobuatamine CABG, PTCA risks, long term Above all need for greater clinical suspicion

73 Take-Home Messages The majority of risk factors for CAD can be improved by lifestyle modification. Goals for “optimal” levels continue to decrease with each new guideline version. The gap between “average” and “optimal” will continue to widen unless lifestyle modification is adopted more successfully.

74 Take-Home Messages Diet, exercise (attaining ideal body weight), and smoking cessation are key lifestyle changes. No “quick-fix” Extreme changes are usually not sustainable Medications are not an antidote to an unhealthy lifestyle

75 Take-Home Messages Work with your patient to set realistic goals.
Remember that modest changes in diet, weight, and exercise can have a big impact on cardiac risk. A heart-healthy lifestyle should be encouraged from youth, but even changes later in life lead to important benefits.


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