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Coronary Heart Disease in Women Elisabeth von der Lohe, MD, FACC, FSCAI Professor of Clinical Medicine (Cardiology) Medical Director, Womens Heart Program.

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Presentation on theme: "Coronary Heart Disease in Women Elisabeth von der Lohe, MD, FACC, FSCAI Professor of Clinical Medicine (Cardiology) Medical Director, Womens Heart Program."— Presentation transcript:

1 Coronary Heart Disease in Women Elisabeth von der Lohe, MD, FACC, FSCAI Professor of Clinical Medicine (Cardiology) Medical Director, Womens Heart Program Associate Director, Cardiac Catheterization Laboratories & Interventional Cardiology Krannert Institute of Cardiology Indiana University School of Medicine Disclosures:none

2 B.R. 37 year old white female with diabetes mellitus for 6 years, no other risk factors; non-smoker 37 year old white female with diabetes mellitus for 6 years, no other risk factors; non-smoker 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 stairs; symptoms were felt to be secondary to an inflammed shoulder and ibuprofen was prescribed 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 stairs; symptoms were felt to be secondary to an inflammed shoulder and ibuprofen was prescribed 7/11/2008 emergency room; left sided shoulder pain got worse. Also increasing shortness of breath while walking or doing any activities. Diagnosis of shoulder arthritis was maintained and patient discharged the same day 7/11/2008 emergency room; left sided shoulder pain got worse. Also increasing shortness of breath while walking or doing any activities. Diagnosis of shoulder arthritis was maintained and patient discharged the same day 7/13/2008; went back to emergency room; excruciating shoulder pain, shortness of breath and sweating. EKG revealed a heart attack. 7/13/2008; went back to emergency room; excruciating shoulder pain, shortness of breath and sweating. EKG revealed a heart attack. Emergency heart catheterization Emergency heart catheterization

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5 Death Rates in Women Coronary Artery Disease Stroke Lung Cancer Breast Cancer Colon Cancer Endometrial Cancer Age (years) Death Rate per 100, At Every Age, More Women Die of Heart Disease Than Breast Cancer National Center for Health Statistics. 1999:

6 Cardiovascular Disease Deaths: Trends for Males and Females United States: Source: CDC/NCHS © AHA, 2004

7 What is Coronary Heart Disease ?

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10 For both men and women For both men and women Smoking Smoking Diabetes Diabetes High Cholesterol (in particular high LDL and/or low HDL) High Cholesterol (in particular high LDL and/or low HDL) High Blood Pressure High Blood Pressure Obesity Obesity Sedentary Lifestyle Sedentary Lifestyle For women only For women only Menopause Menopause Birth Control Pills in Combination with Smoking Birth Control Pills in Combination with Smoking Risk Factors for Coronary Heart Disease

11 Perhaps the most important risk factor for coronary heart disease is the misperception that coronary heart disease is a mens disease Perhaps the most important risk factor for coronary heart disease is the misperception that coronary heart disease is a mens disease

12 Source: Adapted from Krolewski 1991

13 Menopause and the Risk of Coronary Heart Disease (modified data from Menopausal status as a risk for coronary artery disease Arch Intern Med 1995;155:57-61 Age (in years) Annual Occurence of Heart Attack/1000

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

15 Women at High Risk - Established coronary heart disease – Blockage of carotid artery – Circulation problems of the legs – Abdominal aortic aneurysm – Diabetes – Chronic kidney disease Source: Mosca 2004

16 Chest pain or Angina Chest pain or Angina Typical Angina: heaviness, pressure or squeezing sensation behind the breastbone heaviness, pressure or squeezing sensation behind the breastbone with with radiation across the chest, up the neck or down the left arm radiation 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 rest caused or worsened by exercise and eased by rest usually lasts two to five minutes usually lasts two to five minutes Atypical Angina (frequently encountered in women): shortness of breath extreme fatigue lightheadedness or fainting nausea and/or indigestion

17 Diagnosis EKG EKG Stress Test - Exercise or with Medication Stress Test - Exercise or with Medication - with or without Imaging - with or without Imaging (Echo or Nuclear) Echocardiography (ultrasound of heart) Echocardiography (ultrasound of heart) Heart Catheterization Heart Catheterization

18 Womens Early Warning Signs of a 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 Attack At 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;

19 Treatment of a Heart Attack Most important: restoring of blood flow to the blocked artery with either Most important: restoring of blood flow to the blocked artery 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 without stent placement Oxygen Oxygen Medications such as Nitroglycerin, Beta-Blocker, Morphine and Blood Thinners (i.e. Heparin) Medications such as Nitroglycerin, Beta-Blocker, Morphine and Blood Thinners (i.e. Heparin)

20 Prevention of Coronary Heart Disease No Gender Difference !!! No Smoking No Smoking Weight Reduction/Maintenance Weight Reduction/Maintenance Regular Exercise Regular Exercise Control of High Blood Pressure Control of High Blood Pressure Reduction in High Cholesterol Reduction in High Cholesterol

21 Diet Consistently healthy eating Consistently healthy eating –Healthy food selections: Fruits and vegetables Fruits and vegetables Whole grains Whole grains Low-fat or nonfat dairy Low-fat or nonfat dairy Legumes Legumes Low-fat protein Low-fat protein Fish Fish Limit trans fatty acid intake (main dietary sources are baked goods and fried foods) Source: Mosca 2004

22 Weight Maintenance/Reduction Goals BMI between 18.5 and 24.9 BMI between 18.5 and 24.9 Waist circumference < 35 inches Waist circumference < 35 inches Weight loss goals Weight loss goals –10% of body weight over six months or 1-2 pounds weight loss/week –Reduce calories by 500-1,000 per day Source: Mosca 2004, ATP III 2002

23 Weight Reduction No optimal way of weight reduction found (yet) No optimal way of weight reduction found (yet) Weight loss and weight maintenance should be achieved slowly Weight loss and weight maintenance should be achieved slowly Weight cycling increases the risk of heart disease Weight cycling increases the risk of heart disease

24 Recommendations of the AHA for Physical Activity Aerobic exercise of moderate to vigorous activity for min 3-4 days/week, best on all days Aerobic exercise of moderate to vigorous activity for min 3-4 days/week, best on all days Alternative: however count the minutes!! Alternative: however count the minutes!! walking >4 hours/week in form of 10-min intervals

25 Walking Compared with Vigorous Exercise for the Prevention of Heart Disease in Women Manson, JE et al.N Engl J Med 2002;347:

26 Overweight as Compared with Physical Activity in Predicting Death from Heart Disease among Women Body Mass Index < >30 Age-adjusted RR Active (>3.5 h) Age-adjusted RR 1.0 – 3.5 h Age-adjusted RR Inactive (<1 h) Frank B. Hu et al. NEJM 2004;351:

27 High Blood Pressure Optimal blood pressure Optimal blood pressure < 120/80 mm Hg < 120/80 mm Hg Medication are indicated Medication are indicated when blood pressure > 140/90 mm Hg or when blood pressure > 140/90 mm Hg or > 130/80 mm Hg in the setting of diabetes > 130/80 mm Hg in the setting of diabetes Source: Mosca 2004

28 Lipids (cholesterol and triglycerides) Optimal levels of lipids and lipoproteins in women Optimal levels of lipids and lipoproteins in women –LDL < 100 mg/dL –HDL > 50 mg/dL –Triglycerides < 150 mg/d –(total cholesterol not that important) Source: Mosca 2004

29 Interventions that are not useful/effective and may be harmful for the prevention of heart disease Hormone Therapy Hormone Therapy Antioxidant supplements (Vitamin E,C, and beta-carotene) Antioxidant supplements (Vitamin E,C, and beta-carotene) Folic Acid (with or without B6 and B12 supplementation) Folic Acid (with or without B6 and B12 supplementation) Source: Mosca 2007

30 Summary (1) Heart Disease is the leading cause of death in women in the United States Heart Disease is the leading cause of death in 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 risk if they have diabetes mellitus. Genderspecific risks are menopause and intake of birth control pills while smoking women, but women are at particularly high risk if they have diabetes mellitus. Genderspecific risks are menopause and intake of birth control pills while smoking Diagnosis of Heart Disease in women is very difficult since many women have atypical symptoms such as shortness of breath and extreme fatigue Diagnosis of Heart Disease in women is very difficult since many women have atypical symptoms such as shortness of breath and extreme fatigue

31 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)

32 Summary (3) Summary (3) In order to reduce heart disease in women, the importance of heart disease in the female population has to be recognized. In order to reduce heart disease in women, the importance of heart disease in the female population has to be recognized.


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