1. Barbara Furry RNC, MS, CCRN ACS: Still the Silent Killer of Women

3. 3 “Heart disease is the leading killer of women in the United States and the second leading cause of death in most developed nations.” --American Heart Association (2007)

4. Why Do Women Have a More Adverse CHD Prognosis? Is it due to age? Is it due to comorbidity? Is it due to gender gap in medical therapy? Is it due to more advanced angiographic CAD? The answers are at the end!

5. Prognosis After MI  38% of women die within first year –Compared to 25% of men  35% of women will have second MI within 6 years –Compared to 18% of men Source: Wenger 2004

6. 6 Risk Factors Non-modifiable –Gender? –Age –Ethnicity –Genetics Modifiable Diabetes Hypertension Smoking Dyslipidemia Obesity Sedentary lifestyle Stress

7. 7 Diabetes and Smoking Diabetes poses a greater risk than any other factor Nurses’ Health Study: Women with diabetes had seven times more cardiovascular events than other women and about half of them died of CVD Women with diabetes and CVD--especially Hispanic and African-American women--die at a much higher rate than men or nondiabetic women Young women with diabetes lose any premenopausal protection Nurses’ Health Study: Even a few cigarettes a day correlated with a greater risk of CVD or fatal MI Younger women who smoke probably cancel out any premenopausal protection

9. 9 Dyslipidemia and Obesity Dyslipidemia –Doubles a woman’s risk of CVD compared to women with normal lipid profiles –Low levels of HDL have been shown to be a much stronger predictor of CVD mortality in women than men Obesity –Central obesity poses a greater risk than increased body mass index (BMI) –Healthy waist circumference Women: less than 35 inches Men: less than 40 inches –Desired BMI (men and women): 18.5 to 24.9 kg/m 2

10. 10 Stress Puts a woman at greater risk for CVD and poorer outcomes Depression also may increase risk or deter her from seeking medical help Consider screening women with CAD for depression and refer for treatment as needed

11. 11 Signs and Symptoms in Women Number one symptom is SOB! Other symptoms include: fatigue, GI symptoms, changes in sleep patterns May also have: –Heaviness, squeezing, or pain in left chest, abdomen, midback, or shoulder –Arm pain –Palpitations or pain that’s sharp or fleeting An older woman or one with diabetes may not experience any pain during an MI.

12. 12 EKG Findings “ Significantly, electrocardiogram findings are different for men and women. A woman experiencing an MI is far less likely than a man to have concurrent ST- segment elevation. If she describes atypical pain and has an EKG that doesn’t show any ST-segment changes, she may be misdiagnosed and not get follow-up testing.”

13. 13 Diagnostic Testing If at risk or high risk: –Exercise echocardiography (“stress echo”) More reliable in women, especially when wall motion or valve function in question –Invasive Procedures: PCI/CABG –Exercise or pharmacologic stress test False-positives more common in women A woman’s blood vessels may be small and difficult to cannulate or visualize during the above procedures, therefore her risk of complications is greater. Also, women are more likely than men to experience bleeding at the surgical site or hemorrhagic stroke, and their in-hospital mortality rate is significantly higher.

14. Women Receive Less Interventions to Prevent and Treat Heart Disease Less cholesterol screening Less lipid-lowering therapies Less use of heparin, beta- blockers and aspirin during myocardial infarction Fewer referrals to cardiac rehabilitation Source: Chandra 1998, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 2005

15. And the Answer is……. Differences in physiological vascular function. The coronary endothelial and microvascular reactivity are the believed key players. WISE Study

16. Websites on Sex-Based Differences in Health and Disease Society for Women’s Health Research: –Overview of sex-based differences –Links to additional sources of information –http://www.womenshealthresearch.org/hs/links.htm http://www.womenshealthresearch.org/hs/healthfacts.htmhttp://www.womenshealthresearch.org/hs/links.htm http://www.womenshealthresearch.org/hs/healthfacts.htm Centre for Research in Women’s Health –http://www.crwh.org/http://www.crwh.org/ National Center for Gender Physiology at the University of Missouri –http://www.genderphysiology.orghttp://www.genderphysiology.org Partnership for Gender-Specific Medicine –http://cpmcnet.columbia.edu/dept/partnership/