cardiovascular disease in women: common myths

1. Cardiovascular Disease in Women: Common Myths Good morning. First, let me express my very heartfelt thanks to you for attending this event. As you will learn in this, and other presentations today, women are very much affected by cardiovascular disease. But over the years the lions share of research has been directed at middle-aged men, who, probably not coincidentally are doing much better these days. Women are not. Good morning. First, let me express my very heartfelt thanks to you for attending this event. As you will learn in this, and other presentations today, women are very much affected by cardiovascular disease. But over the years the lions share of research has been directed at middle-aged men, who, probably not coincidentally are doing much better these days. Women are not.

2. Disclosures I have no financial interests to disclose � I wish I did! I do not specialize in women�s health issues, but about half of my patients are female. I cannot rule out the influence of my Y-chromosome As an only son and with 4 sisters I am expected to be sensitive to women�s issues � �.but at any given time at least one of my sisters is annoyed with me about something. These days it is customary to disclose to audiences any potential conflicts of interest which may lead to bias in a presentation. With this in mind, I must disclose that: I am not an expert in women�s health issues, but women do constitute a solid half of my clinical practice in cardiology I cannot control, nor predict the influence of my Y-chromosome on my presentation Even though I am an only son and with four sisters � and this should lead to some enlightenment on my part regarding women�s issue � at any given time at least one, if not two of my sisters are mad at me for something I do not have any financial interests that will influence my talk.These days it is customary to disclose to audiences any potential conflicts of interest which may lead to bias in a presentation. With this in mind, I must disclose that: I am not an expert in women�s health issues, but women do constitute a solid half of my clinical practice in cardiology I cannot control, nor predict the influence of my Y-chromosome on my presentation Even though I am an only son and with four sisters � and this should lead to some enlightenment on my part regarding women�s issue � at any given time at least one, if not two of my sisters are mad at me for something I do not have any financial interests that will influence my talk.

3. Are women more complicated than men? Although this slide may get a chuckle in some settings, particularly from the men in the audience, I show it now not to get a laugh, but rather to point out an undeniable reality: women are � whether you consider it a blessing or a curse � provided with a far more complicated physiology surrounding their reproductive capabilities. And this has far-reaching impacts upon their quality of life, health, cancer risk, and cardiovascular health.Although this slide may get a chuckle in some settings, particularly from the men in the audience, I show it now not to get a laugh, but rather to point out an undeniable reality: women are � whether you consider it a blessing or a curse � provided with a far more complicated physiology surrounding their reproductive capabilities. And this has far-reaching impacts upon their quality of life, health, cancer risk, and cardiovascular health.

4. Hormones in Men vs. Women While both men and women show a dramatic increase in their dominant hormone in their teens, testosterone levels tend to remain steady throughout life for men and only gradually fall in late life. Estrogen levels in women, as you well know, rise and fall throughout most of your lives and then become extremely erratic during the period of menopause. And while estrogens may be protective in terms of heart disease, changing levels, along with changes in progesterone levels, leads to wide swings in physiology, health. Again, whether good or bad, this is a complication men do not endure.While both men and women show a dramatic increase in their dominant hormone in their teens, testosterone levels tend to remain steady throughout life for men and only gradually fall in late life. Estrogen levels in women, as you well know, rise and fall throughout most of your lives and then become extremely erratic during the period of menopause. And while estrogens may be protective in terms of heart disease, changing levels, along with changes in progesterone levels, leads to wide swings in physiology, health. Again, whether good or bad, this is a complication men do not endure.

5. Cardiovascular disease is mainly a disease of old men Myth 1 There are many myths I�d like to expose during my short presentation today. The first, and one which I know is beginning to fade, is the concept that cardiovascular disease is primarily a disease of old men.There are many myths I�d like to expose during my short presentation today. The first, and one which I know is beginning to fade, is the concept that cardiovascular disease is primarily a disease of old men.

6. More women are dying of CVD than Men In fact, if you look at the deaths from CVD as a function of time, you can see that women (represented in red on the graph) are dying in significantly great numbers than men these days. The trend in reduction in death has been very steadily falling in men, but not so much for women.In fact, if you look at the deaths from CVD as a function of time, you can see that women (represented in red on the graph) are dying in significantly great numbers than men these days. The trend in reduction in death has been very steadily falling in men, but not so much for women.

7. Cardiovascular disease is the leading cause of death in women Cardiovascular disease, including heart disease and stroke, is the leading cause of death in women and far more frequent than any form of cancer.Cardiovascular disease, including heart disease and stroke, is the leading cause of death in women and far more frequent than any form of cancer.

8. Although less frequent, CVD occurs in young women Is it only old women? Unquestionably the vast majority of CVD deaths in women are in middle-aged and elderly women, it is not a rare event in a young or middle-aged women. Nationwide, more than 35,000 women under the age of 65 die from CVD annually. It is not simply a disease of old men.Is it only old women? Unquestionably the vast majority of CVD deaths in women are in middle-aged and elderly women, it is not a rare event in a young or middle-aged women. Nationwide, more than 35,000 women under the age of 65 die from CVD annually. It is not simply a disease of old men.

9. Women don�t need to worry about cardiovascular disease before menopause Myth 2: Another myth is pre-menopausal women don�t need to worry about heart disease. While it is true that an early menopause increased the risk of CVD, it doesn�t necessarily mean that a women is immune prior to menopause.Another myth is pre-menopausal women don�t need to worry about heart disease. While it is true that an early menopause increased the risk of CVD, it doesn�t necessarily mean that a women is immune prior to menopause.

10. Relationship between early menopause and accelerated CVD? The classic paradigm, shown in the figure above, suggests that menopause is a physiologic phenomenon independent of underlying cardiovascular disease. In this model, the reduction in estrogen at the time of menopause results in loss of a protective hormone and the accelerating development of cardiovascular disease. Increasingly, though, we are learning that the picture is not simple. It turns out that many behaviors and risks that are known to increase CVD (like smoking), will lead to an early menopause. The ovaries are highly vascular organs and it seems likely that the development of CVD likely impact the timing of menopause. So it seems far more likely that cardiovascular risk is a lifelong process occurring in the background and which may influence and lead to an earlier menopause, which, when it happens may feed back and further increase cardiovascular risk.The classic paradigm, shown in the figure above, suggests that menopause is a physiologic phenomenon independent of underlying cardiovascular disease. In this model, the reduction in estrogen at the time of menopause results in loss of a protective hormone and the accelerating development of cardiovascular disease. Increasingly, though, we are learning that the picture is not simple. It turns out that many behaviors and risks that are known to increase CVD (like smoking), will lead to an early menopause. The ovaries are highly vascular organs and it seems likely that the development of CVD likely impact the timing of menopause. So it seems far more likely that cardiovascular risk is a lifelong process occurring in the background and which may influence and lead to an earlier menopause, which, when it happens may feed back and further increase cardiovascular risk.

11. Coronary heart disease progresses over decades This concept is supported by anatomic findings which show that the development of cardiovascular disease, culminating ultimately in the blockage of an artery in the heart or brain, is a process that progresses slowly over decades, clearly spanning into middle age and youth. The point, though, is that it is never too soon to take care of yourself. This concept is supported by anatomic findings which show that the development of cardiovascular disease, culminating ultimately in the blockage of an artery in the heart or brain, is a process that progresses slowly over decades, clearly spanning into middle age and youth. The point, though, is that it is never too soon to take care of yourself.

12. Hormone replacement therapy is dangerous to the heart and should not be taken under any circumstances Myth 3: Another myth which has crept into the human consciousness is that hormone replacement therapy is bad in all circumstances and should never be taken by a women.Another myth which has crept into the human consciousness is that hormone replacement therapy is bad in all circumstances and should never be taken by a women.

13. Estrogen Critical to reproductive function in men & women Most produced by ovaries Some arises from fat, liver, breasts, adrenals Complex physiologic effects Before digging deeper into this concept, it�s worth reminding you that estrogen is critical to reproductive function in both women and men and in women it has important (and complex) physiologic effects throughout the body.Before digging deeper into this concept, it�s worth reminding you that estrogen is critical to reproductive function in both women and men and in women it has important (and complex) physiologic effects throughout the body.

14. Changing Estrogen Levels with Age The issue, as you know, is that at the time of menopause, levels of estrogen become very erratic and eventually fall dramatically, with a similar pattern occurring with the far more widely swinging progesterone.The issue, as you know, is that at the time of menopause, levels of estrogen become very erratic and eventually fall dramatically, with a similar pattern occurring with the far more widely swinging progesterone.

15. The Good The Bad Relief of menopausal symptoms Reduction in osteoporosis (bone thinning) and fractures Cardio-protective effects?? Improvement in lipid profile Breast cancer risk Uterine cancer risk Complex formulation The Good and Bad of Estrogen Replacement The potential rationales for hormonal replacement are many and are shown here. Most important are the potential relief of perimenopausal symptoms such as hot flashes and insomnia. Another is improvement in the bone loss and resulting susceptibility to fractures which occurs after menopause in women. Of particular interest, though, is the potential benefit in terms of cardiovascular disease. The real basis of this thought is many observational studies done a few decades ago that suggested although did not prove that hormone replacement therapy would reduce cardiac risk.The potential rationales for hormonal replacement are many and are shown here. Most important are the potential relief of perimenopausal symptoms such as hot flashes and insomnia. Another is improvement in the bone loss and resulting susceptibility to fractures which occurs after menopause in women. Of particular interest, though, is the potential benefit in terms of cardiovascular disease. The real basis of this thought is many observational studies done a few decades ago that suggested although did not prove that hormone replacement therapy would reduce cardiac risk.

16. Women�s Health Initiative The original Women�s Health Initiative was an NIH sponsored trial designed to document the benefit of estrogen replacement therapy. Because estrogen alone is known to increase the risk of uterine and breast cancer, the study included the administration of progestin to mitigate this effect. More than 16,000 post-menopausal women were randomized to receive either a placebo or combination estrogen and progesterone. What they found, somewhat surprisingly, is that while HRT did improve symptoms and reduce hip fractures due to osteoporosis, it actually did a bunch of bad things, including INCREASING the risk of heart disease, stroke, blood clots and cancer. The conclusion was clearly that HRT should not be used to prevent cardiovascular disease.The original Women�s Health Initiative was an NIH sponsored trial designed to document the benefit of estrogen replacement therapy. Because estrogen alone is known to increase the risk of uterine and breast cancer, the study included the administration of progestin to mitigate this effect. More than 16,000 post-menopausal women were randomized to receive either a placebo or combination estrogen and progesterone. What they found, somewhat surprisingly, is that while HRT did improve symptoms and reduce hip fractures due to osteoporosis, it actually did a bunch of bad things, including INCREASING the risk of heart disease, stroke, blood clots and cancer. The conclusion was clearly that HRT should not be used to prevent cardiovascular disease.

17. WHS: Caveats Overall mortality was identical in the two groups Event rates in both groups was low and absolute rates in the estrogen + progesterone group was low - overall risk of treatment is low Estrogen vs. progesterone influence on outcomes is unknown Several important caveats are worth mentioning.Several important caveats are worth mentioning.

18. Women�s Health Initiative: Estrogen Only Study A parallel study, done at the same time of the main study, was conducted in women who had undergone a hysterectomy and because of removal of the risk of uterine cancer, treatment with estrogen alone was thought to be safe. So in this study, nearly 11,000 women were randomized to either estrogen alone or placebo.A parallel study, done at the same time of the main study, was conducted in women who had undergone a hysterectomy and because of removal of the risk of uterine cancer, treatment with estrogen alone was thought to be safe. So in this study, nearly 11,000 women were randomized to either estrogen alone or placebo.

19. Women�s Health Initiative: Estrogen Only Study Interestingly, if you look at the rates of coronary heart disease events in this study, stratified by age, it becomes clear that in young women, there is actually a dramatic reduction in coronary risk. Similarly, in young women even the risk of stroke was reduced. So clearly the concerns about HRT in women as a whole may not apply to young women. And the suggestion here is not that HRT should be used regularly, or that it should ever be used with the thought of affecting CHD risk, but for the women with early or surgical menopause and particularly such women with significant symptoms, several years of treatment (up to an age in the mid 50�s) is entirely appropriate and supported by the literature.Interestingly, if you look at the rates of coronary heart disease events in this study, stratified by age, it becomes clear that in young women, there is actually a dramatic reduction in coronary risk. Similarly, in young women even the risk of stroke was reduced. So clearly the concerns about HRT in women as a whole may not apply to young women. And the suggestion here is not that HRT should be used regularly, or that it should ever be used with the thought of affecting CHD risk, but for the women with early or surgical menopause and particularly such women with significant symptoms, several years of treatment (up to an age in the mid 50�s) is entirely appropriate and supported by the literature.

20. Oral Estrogen Transdermal Estrogen Large impact on liver metabolism Increase in inflammatory markers Increase in protective HDL cholesterol Bypasses liver No change in Inflammatory markers Reduction in LDL Improvement in �atherogenic index of plasma� Reduction in oxidation index Oral versus Transdermal Estrogen Without getting into the issue in detail, there is some evidence to suggest that the route of administration may have an important impact on the safety of estrogen replacement. When taken orally, estrogen is first metabolized by the liver and it is here that it affects clotting factors and may lead to increase risk of stroke, blood clots and other cardiovascular events. When taken topically, i.e. through a patch, the liver is bypassed and some evidence suggests that liver mediated harmful effects of estrogen may be eliminated.Without getting into the issue in detail, there is some evidence to suggest that the route of administration may have an important impact on the safety of estrogen replacement. When taken orally, estrogen is first metabolized by the liver and it is here that it affects clotting factors and may lead to increase risk of stroke, blood clots and other cardiovascular events. When taken topically, i.e. through a patch, the liver is bypassed and some evidence suggests that liver mediated harmful effects of estrogen may be eliminated.

21. Estrogen Replacement: The reality Estrogen therapy is reasonable for the relief of perimenopausal symptoms if started early and tapered after a few years Estrogen administered transdermally may be less likely to increase risk of blot clots Estrogen should not be given to reduce CVD risk So the bottom line is that estrogen probably is safe when given to young women who are perimenopausal either physiologically or by virtue of surgery, and that a few years of treatment is likely safe and beneficial.So the bottom line is that estrogen probably is safe when given to young women who are perimenopausal either physiologically or by virtue of surgery, and that a few years of treatment is likely safe and beneficial.

22. Vitamin supplementation is key to preventing cardiovascular disease in women. Myth 4: The next myth is the concept that vitamin supplementation is somehow key to preventing cardiovascular disease in women. It would be nice if this were true. Despite the fact that those supporting the very lucrative supplement industry would like you to believe that the �medical establishment� is intentionally steering you away from inexpensive cures for cancer and heart disease, nothing could be further from the truth.The next myth is the concept that vitamin supplementation is somehow key to preventing cardiovascular disease in women. It would be nice if this were true. Despite the fact that those supporting the very lucrative supplement industry would like you to believe that the �medical establishment� is intentionally steering you away from inexpensive cures for cancer and heart disease, nothing could be further from the truth.

23. In fact, the medical and scientific community has applied modern scientific methods to scores of vitamins and supplements � hoping to find evidence for benefit - and with rare exceptions, this has not turned out to be true. One of the most exhaustively studied vitamin � vitamin E � thought to be beneficial by virtue of its antioxidant properties, has been shown in one large trial after another, not to confer benefit through supplementation. Does this mean that vitamin E isn�t helpful? Probably not. It�s more likely that the amount actually needed is quite small and present in sufficient amounts in a healthy diet.In fact, the medical and scientific community has applied modern scientific methods to scores of vitamins and supplements � hoping to find evidence for benefit - and with rare exceptions, this has not turned out to be true. One of the most exhaustively studied vitamin � vitamin E � thought to be beneficial by virtue of its antioxidant properties, has been shown in one large trial after another, not to confer benefit through supplementation. Does this mean that vitamin E isn�t helpful? Probably not. It�s more likely that the amount actually needed is quite small and present in sufficient amounts in a healthy diet.

24. Women�s Health Study � Vitamin E

25. B-Vitamins & Health in Women Intensive treatment with B-vitamins and folic acid have similarly been studied, this time in over 5000 women with either known CAD or multiple risk factors. Again, after about 7 years of follow-up there was no improvement with b-vitamin supplementation.Intensive treatment with B-vitamins and folic acid have similarly been studied, this time in over 5000 women with either known CAD or multiple risk factors. Again, after about 7 years of follow-up there was no improvement with b-vitamin supplementation.

26. The Reality: Vitamin E and B vitamins are probably safe, but there is no convincing evidence that they need be taken regularly Some supplements (ephedra) are downright dangerous Many supplements interact with medications The entire supplement industry is unregulated; the safety and purity is entirely in the hands of the manufacturer.

27. If I�m thin and exercise regularly I should be immune to cardiovascular disease. Myth 5:

28. The Reality: Inactivity and obesity are just two of many CVD risk factors, and probably not the strongest Exercise is great but not necessarily enough!

29. Non-Modifiable Modifiable Age Gender Heredity Tobacco Use Cholesterol Blood pressure Diabetes Physical inactivity Overweight condition Cardiac Risk Factors

30. Eggs are unhealthy and should not be eaten. Myth 6: As the relationship between cholesterol and cardiovascular health became apparent over the last 3-4 decades, many old friends became enemies � including eggs. Are eggs really that bad? In truth, probably not.As the relationship between cholesterol and cardiovascular health became apparent over the last 3-4 decades, many old friends became enemies � including eggs. Are eggs really that bad? In truth, probably not.

31. The Facts Egg yolks do contain cholesterol Studies have shown a clear relationship between serum cholesterol and cardiovascular disease outcomes Studies have not shown a relationship between egg consumption and health outcomes Eggs do contain cholesterol and clearly cholesterol in excess is bad. But there has not been a large study showing that egg consumption per se will cause cardiovascular events.Eggs do contain cholesterol and clearly cholesterol in excess is bad. But there has not been a large study showing that egg consumption per se will cause cardiovascular events.

32. What�s in an Egg? The bad part of an egg, as you know is the yolk, and this contains, on average about 213 mg of cholesterol. The bad part of an egg, as you know is the yolk, and this contains, on average about 213 mg of cholesterol.

33. Most women do not experience chest pain during a heart attack � fatigue and shortness of breath are much more common. Myth 7: Another common myth is the suggestion that women don�t experience chest pain with their heart attacks � and rather that their only symptoms will be vague, non-specific symptoms. It turns out this really isn�t true.Another common myth is the suggestion that women don�t experience chest pain with their heart attacks � and rather that their only symptoms will be vague, non-specific symptoms. It turns out this really isn�t true.

34. The Facts Chest discomfort is the most common symptom of a heart attack in both men and women Women are more likely than men to have additional non-specific symptoms, including: Fatigue Shortness of breath Weakness Study after study has shown that for both men and women, discomfort in the chest (and the emphasis needs to be on the word �discomfort�) is the most common presenting symptom and is present in the overwhelming majority in both genders.Study after study has shown that for both men and women, discomfort in the chest (and the emphasis needs to be on the word �discomfort�) is the most common presenting symptom and is present in the overwhelming majority in both genders.

35. The Facts In this data, for instance, looking at the percentage of men and women experience any of a variety of symptoms at the time of presentation with a heart attack, you can see that about 80-90% of men and women presented with chest pain. It is true, though, that women were more likely to have fatigue, shortness of breath and weakness when compared to men, but actual percentages are fairly close.In this data, for instance, looking at the percentage of men and women experience any of a variety of symptoms at the time of presentation with a heart attack, you can see that about 80-90% of men and women presented with chest pain. It is true, though, that women were more likely to have fatigue, shortness of breath and weakness when compared to men, but actual percentages are fairly close.

36. The Facts

37. The Facts In both men and women, the discomfort of a heart attack tends not to be sharp, but rather a pressure sensation, tightness or heaviness.In both men and women, the discomfort of a heart attack tends not to be sharp, but rather a pressure sensation, tightness or heaviness.

38. The Facts Men and women present relatively similarly with heart attack For both genders the important point is not to ignore symptoms of a potentially life-threatening condition

39. Chocolate is sinfully bad and should be eaten only rarely Myth 8 I finish with what many of us HOPE is a myth � that somehow chocolate is bad for us. While the data is still subject to scrutiny � most of the studies have been very small and the conclusions must be taken with some degree of skepticism, there is some evidence to suggest that DARK CHOCOLATE may actually be beneficial.I finish with what many of us HOPE is a myth � that somehow chocolate is bad for us. While the data is still subject to scrutiny � most of the studies have been very small and the conclusions must be taken with some degree of skepticism, there is some evidence to suggest that DARK CHOCOLATE may actually be beneficial.

40. Beneficial Effects of Dark Chocolate In fact some of the �medicinal� qualities of chocolate, demonstrated in controlled clinical trials, are shown here. The only problem at this point is that the studies are relatively small and tend to be ones studying the clinical effects of dark chocolate in healthy individuals. We do not yet have results of a clinical trial in which individuals are randomized to chocolate or placebo and monitored for the occurrence of disease. In fact some of the �medicinal� qualities of chocolate, demonstrated in controlled clinical trials, are shown here. The only problem at this point is that the studies are relatively small and tend to be ones studying the clinical effects of dark chocolate in healthy individuals. We do not yet have results of a clinical trial in which individuals are randomized to chocolate or placebo and monitored for the occurrence of disease.

41. Recommended Dose If you are contemplating such therapy, this is the recommended prescription:If you are contemplating such therapy, this is the recommended prescription:

42. Exercise is beneficial only if prolonged (No Pain/No Gain) Myth 9 Finally, we�ll end with the myth that exercise is only good if strenuous and prolonged, that is if it doesn�t hurt it probably isn�t doing you any good.Finally, we�ll end with the myth that exercise is only good if strenuous and prolonged, that is if it doesn�t hurt it probably isn�t doing you any good.

43. Exercise: the facts There is a dose-response relationship (more is better) Strenuous exercise is probably better than less strenuous exercise Several studies have shown that repeated intermittent periods of exercise have a cumulative effect similar to prolonged exercise

44. Summary Don�t believe everything you hear Work on traditional risk factors throughout your life Eggs are OK �. in moderation � as is dark chocolate Ovarian hormone therapy is OK in the young women with premature or surgical menopause � taper in early 50�s � some data suggest transdermal best A balanced diet is probably far more helpful than vitamins and supplements Exercise is beneficial � almost any way you do it!

45. Questions?