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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.

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Presentation on theme: "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."— Presentation transcript:

1 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 6 Myths vs Facts MythsFacts 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 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 health72% 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” itSome 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 symptoms65% 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!Most women learn about coronary artery disease (CAD) from magazines and the Web—not from their own physicians! Robinson A. Circulation. 2001

8 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 9 Magnitude of the Problem 2.5 million women per year in the US are hospitalized with cardiovascular disease (CVD)2.5 million women per year in the US are hospitalized with cardiovascular disease (CVD) Deaths from CVD = 500,000/yrDeaths from CVD = 500,000/yr Leading cause of death in US women: CADLeading cause of death in US women: CAD >230,000 women die from CAD each year>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 evaluated1990: US Congress directed the National Institutes of Health that women be included in clinical trials and that gender differences be evaluated

10 10 Women in Clinical Trials Women are underrepresented in cardiovascular (CV) trialsWomen 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 womenFood and Drug Administration/National Institutes of Health mandate: 50% enrollment of women Women need to be empowered to enroll in clinical trials for heart diseaseWomen need to be empowered to enroll in clinical trials for heart disease –Breast-cancer awareness is a good example

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

12 12 CVD Mortality Trends ( ) American Heart Association Heart and Stroke Statistical Update Deaths in Thousands

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

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

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

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

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

18 18 Statistics for Women 503,927 died of CVD in ,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 CVD1 in 5 women has some form of CVD 38% of women who have a heart attack die within 1 year38% of women who have a heart attack die within 1 year 40% of coronary events in women are fatal40% of coronary events in women are fatal –Most occur without prior warning

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

20 20 Warning Signs and Symptoms of CAD

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

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

23 23 Major Risk Factors for Heart Disease ModifiableNonmodifiable Emerging Risk Factors High blood pressureFamily historyHomocysteine Abnormal cholesterol levelsAgeElevated lipoprotein (a) levels DiabetesGenderClotting factors Cigarette smokingMarkers 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 24 Emerging Risk Factors Lipoprotein (a)Lipoprotein (a) HomocysteineHomocysteine Prothrombotic factorsProthrombotic factors Proinflammatory factorsProinflammatory factors Impaired fasting glucoseImpaired fasting glucose Subclinical atherosclerosisSubclinical 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 Ca 2+

25 25 Diabetes Creates Higher Risks for Women With CAD 65% of diabetics die from heart disease or stroke65% of diabetics die from heart disease or stroke 4.2 million American women have diabetes4.2 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 menEvery year, heart disease kills 50,000 more American women than men Statistics are particularly high among African American womenStatistics 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 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 populationCAD 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 ratesIn 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 Giri S, et al. Circulation. 2002

27 27 Diabetes: Powerful Risk Factor for CAD in Women Framingham Heart StudyFramingham 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 StudyNurses’ 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 Manson J, et al. Arch Intern Med. 1991

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

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

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

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

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

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

34 34 Physical Inactivity Lack of exercise is a proven risk factor for heart diseaseLack 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 activeHeart 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 diabetesPhysical activity helps maintain weight, blood pressure, and diabetes Women should exercise to increase heart rate for minutes a day, 3-5 times per weekWomen should exercise to increase heart rate for minutes a day, 3-5 times per week

35 35 Hormonal Effects on Ischemia and Disease Prevalence PremenopausePremenopause –Estrogen has digoxin-like effect:  ST  Post-menopause effect on HRTPost-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 malignanciesWomen 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 36 Hormonal Effects on Ischemia and Disease Prevalence Estrogen modulates chest pain syndromesEstrogen modulates chest pain syndromes Premenopausal CAD: angina/ischemia variation by menstrual cyclePremenopausal 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 37 Postmenopausal Hormone Therapy and Cardioprotection First randomized trialFirst randomized trial HERS trial (Heart and Estrogen/Progestin Replacement Study)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 deathPrimary: nonfatal MI or cardiac death Secondary: unstable angina, coronary revascularization, congestive heart failureSecondary: unstable angina, coronary revascularization, congestive heart failure HERS trial. JAMA

38 38 Is There a Role for HRT? Secondary preventionSecondary prevention –1998: HERS 4 years of treatment with conjugated estrogen plus medroxyprogesterone acetate4 years of treatment with conjugated estrogen plus medroxyprogesterone acetate No reduction in the risk of MI and coronary death in women with established CADNo reduction in the risk of MI and coronary death in women with established CAD HERS trial. JAMA

39 39 Secondary preventionSecondary prevention –3/2000: Estrogen Replacement and Atherosclerosis trial (ERA) 309 postmenopausal women with CAD309 postmenopausal women with CAD Placebo vs conjugated estrogen (.625 mg/day) vs conjugated estrogen (.625 mg/day) with medroxyprogesterone acetate (2.5 mg/day)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 laterAngiographic analysis of the diameter of the coronary arteries at the start of the study and 3 years later ERA trial results at follow-up angiographyERA trial results at follow-up angiography –The progression of coronary atherosclerosis was unchanged in the women randomized to either of the estrogen groups Is There a Role for HRT? ERA trial. J Am Coll Cardiol. 2001

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

41 41 Conclusions: Risk Factor Management CVD begins in childhood and is strongly associated with major risk factors for heart diseaseCVD begins in childhood and is strongly associated with major risk factors for heart disease Multiple risk factors require more aggressive managementMultiple 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 diseaseAggressive 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 42 Gender Differences in CAD Risk Factors Increasing recognition that atherosclerosis is an inflammatory processIncreasing recognition that atherosclerosis is an inflammatory process Ridker PM, et al: A prospective case- controlled study among 28,263 postmenopausal womenRidker 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 43 Women and Coronary Artery Disease (CAD) Diagnosis and Prognosis

44 44 Diagnosis and Management of CAD in Women Gender differences: presentation, manifestation, and diagnosis of CADGender differences: presentation, manifestation, and diagnosis of CAD Gender differences in mortalityGender 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 1 year after MI Thus, early recognition of symptoms and accurate diagnosis of CAD is of great importanceThus, early recognition of symptoms and accurate diagnosis of CAD is of great importance

45 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: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 46 Screening for Heart Disease What Tests Should we use to identify Coronary Heart Disease?

47 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 48 Are There Gender Differences in Noninvasive Diagnostic Tests? Is There a Difference in Diagnostic Accuracy of Noninvasive Tests?

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

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

51 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 CADDespite 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 menThe 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% respectivelyThe sensitivity and specificity of the exercise ECG in women are about 61% and 70% respectively Kwok Y, et al. Am J Cardiol

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

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

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

55 55 Nuclear Imaging in Women Myocardial perfusion imaging (MPI)Myocardial perfusion imaging (MPI) Large body of evidence in womenLarge 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 56 Comparative Test Statistics on Diagnostic Accuracy in Women Kwok Y, et al. Am J Cardiol. 1999

57 57 Diagnostic Specificity: Stress Thallium Tl-201 vs Tc-99m Sestamibi Perfusion imagingPerfusion imaging –Regional blood flow Robust evidence in womenRobust 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 SPECTGated SPECT –Post-stress EF and regional wall motion –Reduce false-positive tests Pharmacologic stress helpful in older and obese womenPharmacologic stress helpful in older and obese women 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 N = 115, P = false + 10 false +

58 58 Pharmacologic Stress Testing in a Community Setting: Women vs Men Data provided by Greg Thomas, MD, Mission Internal Medicine Group 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)

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

60 60 PET Imaging for CAD in Women Positron Emission Tomography

61 61 PET Case Study: Patient FF Stress Rest

62 62 PET Case Study: Patient FF Ischemia of Lateral Wall

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

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

65 65 Technetium-99m SPECT Imaging Predicts Cardiac Mortality in Women Years Cardiac survival Women (n = 3402) Years Men (n = 4500) % 80-87% Ischemia extent and survival by number of vascular territories Marwick TH, et al. Am J Med. 1999

66 Quartile of TC: HDL-C Quartile of hs-CRP hs-CRP, Lipids, and Risk of Future Coronary Events: Women's Health Study (WHS) Ridker PM et al. N Engl J Med 2000;342:

67 Risk Factors for Future Cardiovascular Events: WHS Relative Risk of Future Cardiovascular Events 0 Ridker PM et al. N Engl J Med 2000;342: Lipoprotein(a) Homocysteine IL-6 TC LDL-C sICAM-1 SAA Apo B TC:HDL-C hs-CRP hs-CRP + TC:HDL-C

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 Writing Group for the WHI Investigators. JAMA 2002;288:

69 Risks and Benefits of Estrogen/Progestin on Clinical Outcomes: Women’s Health Initiative Outcome Hazard Ratio Nominal 95% CI Adjusted 95% CI CHD (MI, coronary death) – –1.97 CABG/PTCA – –1.51 Stroke – –2.31 Venous thromboembolic disease – –3.55 Total CVD – –1.49 Cancer – –1.22 Fractures – –0.92 Death – –1.37 Global index* – – 1.39

70 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+8 Invasive breast cancer+8 Colorectal cancers–6 Hip fractures–5–5 Global index+19 Writing Group for the WHI Investigators. JAMA 2002;288:

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

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

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

74 74 Take-Home Messages Diet, exercise (attaining ideal body weight), and smoking cessation are key lifestyle changes.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 75 Take-Home Messages Work with your patient to set realistic goals.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.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.A heart-healthy lifestyle should be encouraged from youth, but even changes later in life lead to important benefits.


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