Heart Disease in Women 10 Things Every Woman Should Know About Heart Disease Susan P. D’Anna ARNP Clinical Instructor in Medicine Section of Cardiology - DHMC

#1Cardiovascular Disease Is the Number 1 Cause of Death in American Women Myth: ♥ Heart disease is a man’s disease Fact: Each year heart disease kills more women than men 38% of women die within one year of suffering a heart attack (compared to 25% of men) CDC National Vital Statistics Report, Vol.49, No., Adapted from the American Heart Association website, 2002

Heart Disease Affects Women in Every Age Group AHA 2003 Heart and Stroke Statistical Update; 2002:8. U.S.: Estimated Prevalence of CVD by Age and Gender

Source: Tracking Women’s Awareness of Heart Disease – AHA National Study; Circulation 2004;109: Women Do Not Perceive Heart Disease as Their Major Health Threat But, awareness is improving 46% 34% 30% 13% 8% 7% 35% 40% 50% 51% 62% 61% Cancer (net) Heart Disease Awareness of Leading Cause of Death for Women Female Perception of Their Greatest Health Risk Women still fear cancer most Cancer (net) Heart Disease

Source: National Vital Statistics Report, Vol. 50, No. 15, September 16, 2002 Cardiovascular Disease 41% Cancer 22%

Age: As women grow older, the chance of developing heart disease increases (especially after the onset of menopause) – The risk of CAD increases 2 to 3 times after menopause Race: African-American women have a higher risk of death from heart disease than white women women.americanheart.org #2 Risk Factors Help Predict Who Is at Risk to Develop Coronary Artery Disease

Cholesterol: Low blood levels of “good” cholesterol (HDL) and high triglycerides are stronger predictors of heart disease death in women than in men

Blood Pressure: More than half of all women over 55 have high blood pressure, which increases their risk of heart disease, stroke and other serious conditions Diabetes: Increases the risk of heart disease 3-7 fold A more powerful risk for heart disease in women than in men Jneid and Thacker, Cleveland Clinic J of Med. 2001: women.americanheart.org

Why Women Don’t Take Action Against Heart Disease  They don’t put their health as a top priority  They think they’re not old enough to be at risk  They feel too busy to make changes in their lives  They’re already feeling stressed  They don’t have the familial and social support

#3Women’s Experience of Heart Disease Is Different Than Men’s Women are more likely to die within one year after a heart attack Women are less likely to survive coronary artery bypass surgery Women are more likely to experience complications after angioplasty Women are more likely to have life threatening arrhythmias (irregular heart beats) These differences may be partially due to hormones, a woman’s smaller heart size and advanced age at diagnosis Wenger, N.K., J. Am. Med. Women’s Assoc. 1994:49:181 Wenger, N.K., Int. J. Fertile Women’s Med. 1998; 43:84

Traditional Heart Attack Warning Signs  Pressure, burning, squeezing in the center of the chest  Discomfort in one or both arms, shoulders, neck, jaw, stomach, or back  Shortness of breath  Fatigue, cold sweat, nausea, weakness Adapted from the Harvard Medical School website –

Symptoms of Coronary Heart Disease Can Differ in Women  Pain in upper back, jaw or neck  Shortness of breath  Flu-like symptoms: nausea or vomiting, cold sweats  Fatigue or weakness  Feelings of anxiety, loss of appetite, discomfort Adapted from the Harvard Medical School website – Women’s signs are non-specific and more easily overlooked.

Severity of Heart Disease: Men and Women Deaths within one year of 1 st MI 25%38% Sudden deaths with no previous symptoms 50%63% Within six years of recognized MI, percent who will:  have another MI  have a stroke  experience SCD  be disabled with heart failure 18% 8% 7% 22% 35% 11% 6% 46% Men Women AHA 2003 Heart and Stroke Statistical update; 2002:12, 14, 17

61 million Americans with CVD Yet, more men are being treated than women 1. The AHA 2001 Heart and Stroke Statistical Update 3. PTCI: J Am Coll Card 2002 Apr 3; 39(7): CABG: Ann Thorac Surg 2001 Feb; 71(2): Estimated from internal Guidant records % are men 1 52% are women 1

Heart Disease Gender Bias or Sex Difference?  Data used for the care of women derived from studies conducted in middle-aged men  Initial efforts for prevention focused more on men than women  Women and doctors often attribute chest pain in women to noncardiac causes Exploring the Biological Contributions to Human Health-Does Sex Matter: Institute of Medicine 2001

Heart Disease Gender Bias or Sex Difference?  Women tend to have heart attacks later in life than men  Women present more often than men with atypical symptoms  Some diagnostic tests and procedures may not be as accurate in women  Heart disease may be different in women and men Exploring the Biological Contributions to Human Health-Does Sex Matter: Institute of Medicine 2001

#4Heart Attacks Are Caused by Coronary Artery Disease (CAD)

Obstructed coronary artery Diffuse narrowing in coronary artery

#5 Know Which Tests are More Effective in Women Test Other Names Description Fasting Lipid ProfileMeasures total, “good” (HDL) and “bad” (LDL), levels of cholesterol ElectrocardiogramECG or EKGMeasures electrical impulses of heart Stress TestTests function of heart during strenuous physical exercise EchocardiogramEchoUses ultrasound waves to evaluate heart structure and function Nuclear ImagingThallium, Sestamibi, MUGA scan Uses radioactive isotope injected into blood stream to evaluate heart function Cardiac Catheterization Angiogram “cath” Used to diagnose coronary artery disease(CAD). An invasive procedure in which tubes are inserted through blood vessels, dye is injected and x-rays of the heart are taken Shaw et al. Card. In Review, 2000: 65-74

#6Estrogen and Menopause May Be Related to Heart Disease Estrogen increases production of “good” cholesterol (HDL) As estrogen decreases, women experience lower levels of “good” cholesterol (HDL) and the flexibility in arteries decreases. Women will live one third of their lives after menopause Hormone Replacement Therapy (HRT) should not be used for the purpose of reducing the risk of cardiovascular disease in women Jneid and Thacker, Cleveland Clinic J of Med. 2001:

Source: JAMA 2002; 288: National Institutes of Health * mdash study shows a trend toward increase in risk WHI Had Unexpected Results Increased Risk  Heart attack 29%  Breast cancer 26%  Blood clots2X  Strokes 41%  Dementia  Ovarian Cancer  Strokes  Probable dementia or memory loss* Decreased Risk  Hip fractures34%  Colorectal cancer 37%  Cancer of uterine lining  Hip fractures No Effect  Quality of life  Number of deaths  Breast cancer  Heart disease Estrogen plus progestin - July 2002 Estrogen alone – March 2004

CONCLUSIONS of WHI After a 5.2 year follow up:  Health risks exceeded benefits of combined estrogen plus progestin  All-cause mortality was not affected  This regimen should not be initiated or continued for primary prevention of CHD. JAMA 2002; 288:

#7 More Research on Women and Heart Disease Is Needed Historically, women have been under-represented in clinical trials related to heart disease There is little knowledge regarding the effects of commonly used cardiovascular drugs in women Practice patterns are based on research in middle- aged men that may not apply to older women There is limited information regarding therapies used to treat heart disease in the very elderly Evelyn et al. “ Women's Participation in Clinical Trials and Gender-Related Labeling” FDA special report

Enrollment of Women in CVD Trials  1993 – NIH mandated inclusion of women in federally funded clinical research  Enrollment increasing for women, but with single- sex trials excluded, enrollment rate was 38%, unchanged over time  No change in gender composition of cohorts in majority of studies  Federal efforts have been only moderately successful, mainly due to small number of large single-sex trials  Even when women are included in trials, rarely are the results broken-out NEJM 2000;

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;372.

#8There Are a Variety of Options Available to Treat Heart Disease Medications – including Aspirin Balloon angioplasty and stenting Heart bypass surgery Pacemakers for slow heart rhythms and defibrillators for rapid heart rhythms

#9Women Can Take Action to Lower the Risk of Heart Disease 1.Know your risk factors 2.Stop smoking 3.Maintain a healthy body weight 4.Eat a nutritious balanced diet low in saturated fats 5.Monitor and manage blood pressure and diabetes 6.Exercise regularly 7.Limit alcohol intake 8.Learn stress management skills 9.Maintain social relationships 10.Know the warning signs for heart attack and stroke

#10 Women Can Save Lives If you or someone you know has risk factors for heart disease, adopt a heart healthy lifestyle and discuss a plan of care with your physician If you experience symptoms of heart attack or stroke, call 911 immediately LEARN CPR

Why Focus on Women’s Cardiovascular Health?  Cardiovascular disease is the largest killer of American women and CVD mortality in women is rising at a disproportionate rate compared to men  The majority of American women are unknowledgeable about their personal risk for CV disease  Changing a woman’s CV risk from higher risk to lower risk with present medical knowledge and tools reduces her chance of coronary events  Women are often decision makers for the family Adapted from American Heart Association and the Nurse’s Health Study

The following organizations can provide information on heart disease: * American Heart Association AHA's mission is to reduce disability and death from cardiovascular diseases and cardiovascular diseases and stroke. Several consumer publications are available through AHA, including the AHA Guide to Heart Attack Treatment, Recovery and Prevention. * Health and Human Services Office of Women's Health WOMAN (96626) OWH investigates a broad spectrum of women's health activities across governmental offices and agencies. It also sponsors the National Information Center, which links the general public to a wide variety of health-care resources and publications, including those related to heart disease. * National Heart, Lung, and Blood Institute The NHLBI publishes the Healthy Heart Handbook for Women ( which features the latest information on preventing cardiovascular diseases. The publication also helps women develop a personal action plan for reducing the major risk factors. In addition, The Heart Truth website contains helpful information. * American Medical Women's Association Mayo Clinic Health Oasis

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