1. Women and Cardiovascular Disease
Anthony Camuglia MBBS(HonsI), FRACP
Interventional and General Cardiologist
Mater Hospitals, Brisbane, Australia
Princess Alexandra Hospital, Brisbane, Australia
Senior Lecturer, University of Queensland, Australia
Cardiologist, HeartCare Partners, Brisbane, Australia

2. Disclosures
Medical advisory board member for Boston Scientific (including receiving consulting fees)

3. Background Most common cause of death in Women
Just as for men, mortality rates for cardiovascular disease in women continue to fall
Mortality after acute ST elevation MI higher in women than men

4. Background
Women (and doctors) seem less aware of cardiovascular risk compared with other conditions like breast cancer
Women develop heart disease around 8 – 10 years later than men
Smoking rates in young women of great concern

5. Modifiable Risk Factors
Hypertension
Diabetes and the metabolic syndrome
Lifestyle factors
Especially smoking
Dyslipidaemia

6. Clinical Presentation
Conventional wisdom that women more likely to present with ‘atypical’ symptoms
Data is somewhat conflicting but is evidence to support this
Most women still present with chest pain
Need to be aware of non-chest pain symptoms as cause for presentation: chest tightness, shoulder, arm and jaw pain, dyspnoea, ‘heart burn’ or ‘indigestion’
Women often older with more comorbidities at presentation

7. Two of three: urgent specialist referral.
Initial assessment
Clinical features
ECG
Cardiac biomarkers
Two of three: urgent specialist referral.

8. Non-Invasive Assessment
Exercise stress test: Non-specific with high false positive rate
Exercise Stress Echo: More specific and sensitive, no ionising radiation (Dobutamine Stress Echo if unable to exercise)
Myocardial perfusion study: Cannot exclude balanced ischaemia (LMCA or multivessel disease), no information on valvular status, radiation.

9. Non-Invasive Assessment
CT coronary angiography:
Currently need a specialist referral for patient to receive rebate
Ionising radiation
Very sensitive but variable specificity and positive predictive value for significant CAD (highly centre/operator/experience dependent)
CT calcium score: Risk stratification tool only, should not be used to assess for CAD in symptomatic patients.

10. Acute Coronary Syndromes
Symptoms with either biomarker elevation or documented ECG changes
Women are older at time of presentation with more comorbidities as a result
Less likely to be treated with an invasive management strategy but likely to benefit if so treated
Less likely to treated with CABG

11. Acute Coronary Syndrome
Women have been shown to be less likely to received appropriate secondary preventative therapies (including statins and ACE inhibitors)
Where they are used women benefit from the treatment

12. Heart Failure
Again, women present at an older age than men (in general)
More frequently present with HFPEF which has no clear therapy to improve overall mortality (compare this with HF with impaired systolic function).

13. Hormone Replacement Therapy
No role to use HRT as primary or secondary preventative strategy for cardiovascular disease
Women < 60 years old without cardiovascular risk factors probably have no significant change in cardiovascular risk with HRT
Caution with use of HRT in women > 60 years of age and careful risk assessment and modification

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