1. Coronary Heart Disease in Women Dr.AHMAD ALAYED د.أحمد العايد إستشاري أمراض القلب و القثطرة القلبية مركز الباسل لأمراض و جراحة القلب بدمشق

2. Death Rates in Women Coronary Artery Disease Stroke Lung Cancer Breast Cancer Colon Cancer Endometrial Cancer Age (years) Death Rate per 100,000 6500 4500 2500 1600 1200 800 400 0 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ At Every Age, More Women Die of Heart Disease Than Breast Cancer

3. Cardiovascular Disease Deaths: Trends for Males and Females United States: 1979-2001 Source: CDC/NCHS © AHA, 2004

4. What is Coronary Heart Disease ?

5. 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

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

8. Menopause and the Risk of Coronary Heart Disease Age (in years) Annual Occurence of Heart Attack/1000

9. Relation between Smoking, Use of Birth Control Pills and the Risk of a Heart Attack Use of Birth Control Pills Relative risk of a Heart Attack

10. Women at High Risk - Established coronary heart disease – Blockage of carotid artery – Circulation problems of the legs – Abdominal aortic aneurysm – Diabetes – Chronic kidney disease

11. 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

12. 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

13. Women’s 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%)  Sleep disturbance (47.8%)  Shortness of breath (42.1%)  Indigestion (39.4%)  Chest pain (29.7 %) At time of Heart Attack At time of Heart Attack  Shortness of breath (57.9%)  Weakness (54.8%)  Fatigue (42.9%)  Chest pain (57%)

14. 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)

15. 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

16. 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)

17. 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

18. 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

19. 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 Aerobic exercise of moderate to vigorous activity for 30-60 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

20. Walking Compared with Vigorous Exercise for the Prevention of Heart Disease in Women

21. Overweight as Compared with Physical Activity in Predicting Death from Heart Disease among Women Body Mass Index < 25 25-30>30 Age-adjusted RR Active (>3.5 h) 1.001.582.87 Age-adjusted RR 1.0 – 3.5 h 1.512.064.26 Age-adjusted RR Inactive (<1 h) 1.892.524.73 Frank B. Hu et al. NEJM 2004;351:2694-703

22. 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

23. 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)

24. 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)

25. 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 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

26.  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)

27. 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.