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

B.R. 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 7/11/2008 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. Emergency heart catheterization Mention that IDDM and CAD positively correlated

At Every Age, More Women Die of Heart Disease Than Breast Cancer Death Rates in Women At Every Age, More Women Die of Heart Disease Than Breast Cancer 6500 4500 2500 1600 1200 800 400 Coronary Artery Disease Stroke Lung Cancer Breast Cancer Colon Cancer Endometrial Cancer Death Rate per 100,000 The significance of cardiovascular disease (CVD) as a health concern is illustrated by examining mortality rates per 100,000 women aged 45 years and older. The number of women who die each year from CVD is higher than the number who die from stroke, or from lung, breast, colon, or endometrial cancer in any age group. 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Age (years) National Center for Health Statistics. 1999:164-167.

Cardiovascular Disease Deaths: Trends for Males and Females United States: 1979-2001 Source: CDC/NCHS © AHA, 2004 GRAPHIC SOURCE: Heart Disease and Stroke Statistics-2004 Update, American Heart Association. This slide from the American Heart Association show mortality trends by gender. While mortality in males has been steadily declining over the past 15-20 years, cardiovascular mortality for women has remained flat or increased slightly(1). (1) Heart Disease and Stroke Statistics-2004 Update, American Heart Association.

What is Coronary Heart Disease ?

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

Perhaps the most important risk factor for coronary heart disease is the misperception that coronary heart disease is a men’s disease

SLIDE INFORMATION SOURCE: Krolewski AS, et al SLIDE INFORMATION SOURCE: Krolewski AS, et al. Evolving natural history of coronary artery disease in diabetes mellitus. Am J Med 1991. 90(2A): 56S-61S. This graph represents results from a study of 116,000 subjects, aged 30-55, who were followed for 8 years (1). The risk of nonfatal and fatal CHD was >6 fold that of women without diabetes (1). Risks for all forms of CVD are elevated in type 1 and type 2 diabetics(2). Diabetics with CHD are more likely to die than non-diabetics with CHD(2). (1) Krolewski AS, et al. Evolving natural history of coronary artery disease in diabetes mellitus. Am J Med 1991. 90(2A): 56S-61S. (2) Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), NIH, NHLBI, 2002. Source: Adapted from Krolewski 1991

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 Annual Occurence of Heart Attack/1000 Age (in years)

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;253:2965-2969) Relative risk of a Heart Attack Use of Birth Control Pills

Women at High Risk - Established coronary heart disease Blockage of carotid artery Circulation problems of the legs Abdominal aortic aneurysm Diabetes Chronic kidney disease SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693. High risk patients have a greater than 20% 10-year risk of CHD events based on Framingham data. Among patients with chronic renal disease, those with end stage renal disease are at particular risk (1) (1) Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693. Source: Mosca 2004

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

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

Women’s Early Warning Signs of a Heart Attack Weeks before Heart Attack (95% of women) Unusual fatigue (70.7%) Sleep disturbance (47.8%) Shortness of breath (42.1%) Indigestion (39.4%) Chest pain (29.7 %) At time of Heart Attack Shortness of breath (57.9%) Weakness (54.8%) Fatigue (42.9%) Chest pain (57%) McSweeney, JC et al. Circulation 2003; 2619-2623

Treatment of a Heart Attack Most important: restoring of blood flow to the blocked artery with either - 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 Medications such as Nitroglycerin, Beta-Blocker, Morphine and Blood Thinners (i.e. Heparin)

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

Diet Consistently healthy eating Healthy food selections: Fruits and vegetables Whole grains Low-fat or nonfat dairy Legumes Low-fat protein Fish Limit trans fatty acid intake (main dietary sources are baked goods and fried foods) SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693. Trans fatty acids are found in hydrogenated vegetable oils and some animal fats(1). Major sources are baked foods like crackers, cookies, doughnuts, breads, and food fried in hydrogenated vegetable oil, like french fires and fried chicken(1). Based on data from randomized trials, trans fatty acids raise LDL cholesterol(1). (1) Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III), NIH, NHLBI, 2002. Source: Mosca 2004

Weight Maintenance/Reduction Goals BMI between 18.5 and 24.9 Waist circumference < 35 inches 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 SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693.;Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III), NIH, NHLBI, 2002 Source: Mosca 2004, ATP III 2002

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

Recommendations of the AHA for Physical Activity Aerobic exercise of moderate to vigorous activity for 30-60 min 3-4 days/week, best on all days Alternative: however count the minutes!! walking >4 hours/week in form of 10-min intervals

Walking Compared with Vigorous Exercise for the Prevention of Heart Disease in Women Manson, JE et al.N Engl J Med 2002;347:716-25.

Overweight as Compared with Physical Activity in Predicting Death from Heart Disease among Women Frank B. Hu et al. NEJM 2004;351:2694-703 Body Mass Index < 25 25-30 >30 Age-adjusted RR Active (>3.5 h) 1.00 1.58 2.87 1.0 – 3.5 h 1.51 2.06 4.26 Inactive (<1 h) 1.89 2.52 4.73

High Blood Pressure Optimal blood pressure < 120/80 mm Hg Medication are indicated when blood pressure > 140/90 mm Hg or > 130/80 mm Hg in the setting of diabetes SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693. These guidelines were adopted from the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure, (JNC 7), published in 2004. Systolic BP is often more difficult to control, but is more of a CVD risk factor in those over age 50 (1). Both systolic and diastolic BP need to be treated to goal levels (1). (1)Third Report of the National Cholesterol Education Program (NCEP) Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III), NIH, NHLBI, 2002. Source: Mosca 2004

Lipids (cholesterol and triglycerides) 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) SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693. Source: Mosca 2004

Interventions that are not useful/effective and may be harmful for the prevention of heart disease Hormone Therapy Antioxidant supplements (Vitamin E,C, and beta-carotene) Folic Acid (with or without B6 and B12 supplementation) SLIDE INFORMATION SOURCE: Mosca L, et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2004; 109:672-693. Both the American College of Obstetricians and Gynecologists (ACOG) and the United States Food and Drug Administration (FDA) have concluded that hormone therapy should not be initiated or continued to prevent CVD in post-menopausal women(1,2). (1) American College of Obstetricians and Gynecologists Task Force for Hormone Therapy. Executive summary. Obstet Gynecol 2004;104 (4Suppl):IS-4S. (2) FDA approves new labels for estrogen and estrogen plus progestin therapies for postmenopausal women following review of Women’s Health Initiative data. Rockville, Md:Food and Drug Administration, January 8,2003. Source: Mosca 2007

Summary (1) Heart Disease is the leading cause of death in women in the United States 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 Diagnosis of Heart Disease in women is very difficult since many women have atypical symptoms such as shortness of breath and extreme fatigue

Summary (2) 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 (3) In order to reduce heart disease in women, the importance of heart disease in the female population has to be recognized.