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Cardiovascular Risk Assessment in Women Elizabeth Scruth RN MN MPH CCNS CCRN PhD (c) September 2011.

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Presentation on theme: "Cardiovascular Risk Assessment in Women Elizabeth Scruth RN MN MPH CCNS CCRN PhD (c) September 2011."— Presentation transcript:

1 Cardiovascular Risk Assessment in Women Elizabeth Scruth RN MN MPH CCNS CCRN PhD (c) September 2011

2 Program of Research Undertaken as part of PhD research St Vincent's Cardiovascular Nursing Research Center- Melbourne Australia Combined medical and nursing research center- 60 researchers Professor of Nursing and Professor of Medicine- Interventional Cardiologist – directors of the center

3 Acknowledgement of Supervisors Professor Worrall-Carter- Nursing Director of SVCNR Professor Michelle Campbell- Dean of Nursing School at ACU Dr Karen Page- A/Professor-ACU Professor Robert Whit bourn- MD- Medical Director of SVCNR/Director of Cardiac Catheter Labs/CCU at St Vincent's Public Hospital in Melbourne Eugene Cheng MD- Kaiser Permanente

4 Grants for Research PhD : Australian Government –fully funded Statistical Analysis: DOR KP- through community funds Quality Outcomes in CV and Stroke Research conference 2011 in DC- expenses paid by Australian Government

5 5 Cardiovascular Risk in Women Phases of Research

6 Overview of Presentation The global burden of CVD Assessing cardiovascular risk Limitations of current cardiovascular risk prediction tools- secondary Comparison of cardiovascular risk tools Utilization of evidence based guidelines (part of post doctoral studies)

7 Background Cardiovascular disease (CVD); number one cause of mortality for both genders In the USA 1 in 3 people have CVD; one death every minute CVD accounts for 18% of the total burden of disability adjusted life years Cost in 2010 ( estimate) 510 billion Risk factors different in men and women 2 in 3 males and 1 in 2 females at age 40 have CVD so prevention is important Centres for Disease Control (CDC) (2011): Heart Disease and Stroke Statistics: 2010 AHA Update

8 Women CDC 2010

9 MEN CDC 2010

10 10 Risk Factors for CVD - Men Personal history of CVD Hypertension Age over 55 Inactivity Peripheral vascular disease DyslipidemiaFamily history of CVD SmokingDiabetes Mellitus American Heart Association (2008), (2010): Johannes & Bairey Merz (2011) Cardiology in Review 19;76-80

11 11 Risk Factors for CVD -Women Personal history of CVD Hypertension Age over 55 Inactivity Peripheral vascular disease DyslipidemiaFamily history of CVD SmokingDiabetes Mellitus 90% of all cardiac events occur with only one elevated risk factor American Heart Association (2008): Mosca et al (2007)

12 12 Risk Factors for CVD -Women Hypertension Mortality for HTN higher in women; differences of 20 mm Hg systolic and 10 mm Hg diastolic pressure in women are associated with a 2 fold increase in mortality. Systolic more than diastolic predicts mortality Both of these risk factors are more prevalent in women than men upon presentation with their first myocardial infarction Diabetes Mellitus 90% of all cardiac events occur with only one elevated risk factor American Heart Association (2008), (2010): Johannes & Bairey Merz (2011) Cardiology in Review 19;76-80.

13 CV Risk Factors in Women and Men ( Phase 1) Sample: M=109, W=77 Smoking Men Women Hypertension56 54 Diabetes26 22 Previous MI3 5 Hyperlipidemia69 52

14 Cardiovascular Risk 14 Go Red for Women Campaign Originated in the USA Cardiovascular risk assessment: The basis for prevention (American Heart Association Guidelines updated in 2011 for preventing CVD in women )

15 What the literature reveals Accurate risk assessment of CVD is vital for the prevention of CVD and tailoring therapeutic strategies for ACS Many aspects of risk assessment are poorly understood by healthcare providers Primary (initial) and secondary (at time of ACS) cardiac risk assessment tools need further study as new diagnostic and technology emerges

16 Current primary cardiac risk assessment tools studied mainly in white men and women- ethnic groups? Secondary cardiac risk assessment tools- need to be utilized more 38.2 million women with CVD in the USA Evidence based guidelines for the prevention and treatment of CVD are not utilized fully despite proven benefits American Heart Association (2008), (2010): Johannes & Bairey Merz (2011) Cardiology in Review 19;76-80

17 Primary CVD Risk Assessment Assessing the risk of CVD requires the synthesis of multiple risk factors into a multivariate profile Framingham risk score (10 year risk ) Age, HT, smoking, hyperlipidemia Reynolds risk score (10 year risk) 35 risk factors including traditional and novel risk factors SCORE risk system (10 year risk) Age, gender, SBP, total cholesterol, HDL cholesterol and smoking ( estimates 10 year risk of any first atherosclerotic event- not just coronary heart disease related deaths)

18 Limitations Framingham study failed to explain 50% of cardiovascular events Framingham risk factors: women have a cardiac event in the absence of these Reynolds: Only predicts 10 year risk of cardiac events and studies to date mainly conducted on white women

19 SCORE risk system unique: separate risk scores for high risk and low risk regions of Europe validated only on European populations

20 Secondary Risk Estimation Early risk stratification at the time of an ACS plays a pivotal role Different scores are available based on initial presentation and history Scores assist in determining short and long term outcomes after an ACS

21 Risk Tools Studied TIMI CADILLAC GRACE

22 TIMI Risk Tool Morrow, D. A., Antman, K. M., Charlesworth, A. et al 2000 Risk factorsPoints (0-14) Age > DM/HT or angina1 Systolic blood pressure <1003 HR >1002 Killip class II-IV2 Weight<67kg1 Anterior MI or LBBB1 Time to treatment >4 hours1 High Risk > 8 points/Moderate Risk 6 – 7 points/Low Risk 0-5 points

23 CADILLAC risk score for 30-day and one-year mortality after primary percutaneous coronary intervention for ST elevation myocardial infarction Risk FactorPoints (0-18) LVEF <40 percent4 Killip class 2/33 Renal insufficiency (estimated creatinine clearance <60 mL/min)3 TIMI flow grade after PCI of 0 to 22 Age >65 years2 Anemia ( hematocrit <39 percent in men and <36 percent in women)2 Triple vessel disease2 Risk Score30-day mortalityOne-year mortality Low risk score 0 to 2)0.1 to 0.2 percent0.8 to 0.9 percent Intermediate risk (score 3 to 5)1.3 to 1.9 percent4.0 to 4.5 percent High risk (score >6)6.6 to 8.1 percent12.4 to 13.2 percent Halkin, A., Sing, M., Nikolsky, E., Grines, C. L., Tcheng, J. E., Garcia, E. el al 2005

24 GRACE Risk Tool Steg, Goldberg, Gore et al. 2002, GRACE website Risk factorsPoints (0-372) Age0 to 100 Killip class0-59 Systolic blood pressure0-58 Presence of ST segment deviation28 Cardiac arrest during presentation39 Serum creatinine concentration1-28 Presence of elevated serum cardiac biomarkers14 Heart rate0-46

25 GRACE Risk Categories (Tertiles) GRACE risk score Probability of Death In-hospital (%) Low49-125<2 Intermediate High >5 Risk Categories (Tertiles) GRACE risk score Probability of Death In-hospital (%) Low27-99<4.4 Intermediate High ACS-STEMI- In Hospital ACS-STEMI Post Discharge- 6 month Mortality

26 26 Comparing the Risk Tools Aim: Compare and contrast the secondary cardiovascular risk assessment tools TIMI, GRACE and CADILLAC used at the time of ACS in women to determine predictability in women and Men Research method: Retrospective descriptive design: TIMI, GRACE and CADILLAC scores will be calculated on admission and cases followed for 12 months. Men and women admitted with ACS (STEMI) from in KP NCAL Sample size: 200 ( Men and Women) Expected outcome: One of the three scores will be more predictive- C statistic

27 Preliminary Analysis of Research – Unpublished data N=186 W=77, M=109 Type of MI on presentation: Anterior MI= M(49) F(28) Inferior MI = M(60) F(47) Lateral MI = M(0) F(2) Anterior MI =41.40%, Inferior MI=57.53%, Lateral MI=1.08%

28 Coronary Artery Disease- Women CAD Frequency Percent Cumulative Frequency Cumulative Percent Multiple Vessel Disease Single Vessel Disease

29 EVENTSCADILLAC C Statistic GRACE C Statistic TIMI C Statistic MCE NMCE MCE ( 1 year) NMCE ( 1 year) Death in hospital Death at 1 year Analysis of Secondary CV Risk Tools

30 Ideal Cardiovascular Health for men and women Total cholesterol: less than 200 mg/dL HDL cholesterol- 60mg/dL and above BP- Systolic 120 or below, diastolic 80 or below BMI - Normal 18.5 to 25.0 Exercise- 150 minutes per week Heart healthy diet

31 Publications Publications related to PhD studies: Currently under review Worrall-Carter, L., Ski, C., Scruth, E., Campbell, M., Page, K. Assessing Cardiovascular Risk In Women. Journal of Health and Sciences ( Accepted for Publication August 2011) Manuscripts ready for submission: Scruth, E., Worrall-Carter, L., Page, K., Cheng, E., Campbell, M. Risk determination after PCI for ACS: review of the commonly used risk prediction tools for the Clinical Nurse Specialist. Currently being reviewed by Clinical Nurse Specialist Journal Scruth, E., Worrall-Carter, L., Rolley, J., Page, K.. Psychometric properties of secondary risk prediction tools used after PCI for STEMI. Being submitted to European Journal of CV Nurisng Manuscripts currently being developed for submission: 1. Assessing a profile of cardiovascular Risk in men and women with STEMI 2. Secondary cardiovascular risk tools: A comparison of the tools in men and women post PCI for STEMI 3. A follow up of patients one year after PCI for STEMI: Do secondary cardiovascular risk tools accurately predict events?

32 Cardiac Publications not related to PhD studies Scruth. E., Haynes. A.. Cardiovascular Disease: Chapter in Thelan’s Critical Care Nursing: Diagnosis and Management (October 2009) Scruth. E. Cardiogenic Shock: Chapter in Manual of Critical Care Nursing- Nursing Interventions and Collaborative Management. (2011) Baird;Bethel Scruth, E. Haynes, A. Review of Cardiovascular Disease: Chapter in Priorities in Critical Care ( Due out late 2011). Scruth, E. Cheng. E. (2006). Measuring Cardiac Output. Contemporary Critical Care

33 Critical Care Publications not related to PhD studies Cheng, E. Jaramillo. K., Scruth, E., Cheng, E. (2009). Prolonged Paralysis and apnoea after receiving neuromuscular blocking agent: what nurses need to know. Accepted for publication March American Journal of Critical Care Nursing Scruth, E., Read. J., Cheng. E. (2007). Collaboration between the ICU Manager, Clinical Nurse Specialist and the Medical Director. Journal of Critical Care Nursing Read, J., Scruth E. (2006). Collaboration in the ICU: Use of Advisory Councils. Journal of Critical Care Nursing Cheng, E. Scruth E., Guitterrez, V., Chassy, Patel. D. (2006). Introducing the use of end tidal CO2 to determine feeding tube placement in a community hospital. Journal of Critical Care Medicine


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