1. 1 Women and Coronary Artery Disease (CAD) Module 1 Introduction

2. 2 Supported by an unrestricted educational grant from Fujisawa Healthcare, Inc.

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7. 7 Historical Perceptions in the Medical Profession Misperceptions Heart disease is a man’s diseaseHeart disease is a man’s disease Women’s chest pain symptoms are not due to heart diseaseWomen’s chest pain symptoms are not due to heart disease Enrollment of women in clinical trials Research studies (up until recently) included very few womenResearch studies (up until recently) included very few women Our knowledge of heart disease in women has been rather poorOur knowledge of heart disease in women has been rather poor Gender bias in diagnosis and treatment Undertreatment and underdiagnosis of womenUndertreatment and underdiagnosis of women Less aggressive care → higher complications and death ratesLess aggressive care → higher complications and death rates

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9. 9 Myths vs Facts MythsFacts Men are more likely to have heart disease Heart disease is the #1 killer of men and women; 50,000 more women than men die of heart disease every year Cancer is a bigger threat than heart disease Nearly twice as many US women die from heart disease and stroke than from all cancers combined Doctors are aware of women’s risk for heart disease and act accordingly Undertreatment and underdiagnosis of heart disease in women contributes to excess mortality in women

10. 10 Women’s Perceptions of Heart Disease 72% of young women (ages 25-40) still consider cancer to be the greatest threat to women’s health72% of young women (ages 25-40) still consider cancer to be the greatest threat to women’s health Some women know about the risks of heart disease but do not hear it from their own doctors and do not “personalize” itSome women know about the risks of heart disease but do not hear it from their own doctors and do not “personalize” it 65% of women recognize that symptoms may be “atypical” but do not know classic symptoms65% of women recognize that symptoms may be “atypical” but do not know classic symptoms Most women learn about coronary artery disease (CAD) from magazines and the Web—not from their own physicians!Most women learn about coronary artery disease (CAD) from magazines and the Web—not from their own physicians! Robinson A. Circulation. 2001

11. 11 Gender Bias in the Treatment of Women “… The community has viewed women’s health almost with a ‘bikini’ approach, looking essentially at the breast and reproductive system, and almost ignoring the rest of the woman as part of women’s health ….” Nanette Wenger, MD Chief of Cardiology, Grady Hospital Professor of Medicine, Emory University Atlanta, Georgia

12. 12 Magnitude of the Problem 2.5 million women per year in the US are hospitalized with cardiovascular disease (CVD)2.5 million women per year in the US are hospitalized with cardiovascular disease (CVD) Deaths from CVD = 500,000/yrDeaths from CVD = 500,000/yr Leading cause of death in US women: CADLeading cause of death in US women: CAD >230,000 women die from CAD each year>230,000 women die from CAD each year 1990: US Congress directed the National Institutes of Health that women be included in clinical trials and that gender differences be evaluated1990: US Congress directed the National Institutes of Health that women be included in clinical trials and that gender differences be evaluated

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14. 14 Women in Clinical Trials Women are underrepresented in cardiovascular (CV) trialsWomen are underrepresented in cardiovascular (CV) trials –Evidence-based CV medicine biased toward men Food and Drug Administration/National Institutes of Health mandate: 50% enrollment of womenFood and Drug Administration/National Institutes of Health mandate: 50% enrollment of women Women need to be empowered to enroll in clinical trials for heart diseaseWomen need to be empowered to enroll in clinical trials for heart disease –Breast-cancer awareness is a good example

15. 15 Publication Bias: Gender Representation and Negative Studies 1966-1994 noninvasive testing literature1966-1994 noninvasive testing literature –8% to 27% women Lower diagnostic accuracy in womenLower diagnostic accuracy in women –High false-positive rates –Inability to perform maximal stress

16. 16 CVD Mortality Trends (1979-1999) American Heart Association. 2002 Heart and Stroke Statistical Update. 2001 Deaths in Thousands

17. 17 Prevalence of CVD in the US American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

18. 18 Deaths From CVD and Cancer by Age and Sex Anderson RN. National Vital Statistics Reports. 2002

19. 19 Myocardial Infarction (MI) Incidence (1979-1994) Roger VL, et al. Ann Intern Med. 2002 Men Women

20. 20 Deaths From CVD (1999) American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

21. 21 Age-Adjusted Death Rates for Major CVD J Am Coll Cardiol. 2000 260 240 220 200 180 160 140 120 100 80 60 40 20 0 Deaths per 100,000 Population 194019501960197019801990

22. 22 Health Threats to Women: Perception vs Reality 1. Gallup survey. 1995 2. American Heart Association. Heart & Stroke Facts. 1996 Statistical Supplement 1 2

23. 23 Death From Breast Cancer or Heart Disease in Women in the US US Vital Statistics, 1990

24. 24 Does CVD Affect Many People? 1 in 5 people has some form of CVD1 in 5 people has some form of CVD CVD claimed ~1 million lives in 1999CVD claimed ~1 million lives in 1999 –40% of all US deaths 1.1 million heart attacks each year1.1 million heart attacks each year 7 million doctor visits each year for chest pain7 million doctor visits each year for chest pain 600,000 strokes each year600,000 strokes each year CVD accounts for 15% to 33% of all healthcare costsCVD accounts for 15% to 33% of all healthcare costs American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

25. 25 Statistics for Women 503,927 died of CVD in 1998503,927 died of CVD in 1998 –226,467 from heart attack or other cardiac events –97,303 from stroke 1 in 5 women has some form of CVD1 in 5 women has some form of CVD 38% of women who have a heart attack die within 1 year38% of women who have a heart attack die within 1 year 40% of coronary events in women are fatal40% of coronary events in women are fatal –Most occur without prior warning

26. 26 Coronary Heart Disease Death Rates by State (1996-1998) American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

27. 27 Diagnosis and Management of CAD in Women Gender differences in presentation, manifestation, and diagnosis of CADGender differences in presentation, manifestation, and diagnosis of CAD Gender differences in mortalityGender differences in mortality –63% of women who die suddenly from CAD had no prior warning symptoms –42% of women vs. 24 % of men will die within one year after MI Thus, early recognition of symptoms and accurate diagnosis of CAD is of great importanceThus, early recognition of symptoms and accurate diagnosis of CAD is of great importance

28. 28 Does Gender Matter in CAD? 2001 Institute of Medicine report: “Exploring the biological contribution to human health: does sex matter?”2001 Institute of Medicine report: “Exploring the biological contribution to human health: does sex matter?” –Confirmed that significant differences between the sexes affect the prevalence, incidence, and severity of a broad range of diseases and conditions –This is certainly true for CAD