The Little Red Dress: Understanding Gender Differences Concerning Cardiovascular Disease in Women

1. The Little Red Dress: Understanding Gender DifferencesConcerning Cardiovascular Disease in Women By Jama C. Barker Eileen Van Dyke Advisor April 6, 2006

2. Objectives • Understand the differences in perception of severity of symptoms of CVD • Review the historical lack of inclusion of women in cardiac research • Understand gender differences in • Presentation • Diagnosis • Treatment

3. What is Cardiovascular Disease • Intricate topic encompassing all vessel diseases of the heart including: • arrhythmias, angina, valvular disease, cardiomyopathy, heart failure, stroke and coronary artery disease.

4. Cardiovascular Disease • Claims more than 500,000 women each year. • Cardiovascular disease is the number one killer of women. (American Heart Association, 2005)

5. Cardiovascular Disease • When women enter menopause, their risk of CVD increases two times that of premenopausal women. • Decreased estrogen levels also increases LDL levels and decreases HDL levels, therefore, further increasing a woman’s risk for cardiovascular disease.

6. Perception of Cardiovascular Disease • It was once believed that women were immune to cardiovascular disease. • This has been proven wrong but now… • After sustaining a MI women perceive the severity of their symptoms to be less severe than men do following a MI.

7. Perception of Cardiovascular Disease • A retrospective study of men and women using a functional scale found that both sexes reported the same problems with physical, mental and general health status post myocardial infarction, but women did not recognize the severity of their disease. • Women rated their severity to be less than men.

8. Historical Background • Prior to 1990, in general, women were excluded from research studies. • The male model was established in the medical world as the “normal” physiological state.

9. Historical Background • Women were excluded from cardiovascular research studies due to the belief that coronary artery disease did not affect women (Caves,1998).

10. Men Prolonged Chest Pain Radiates down left arm Shortness of breath Women Nausea/Vomiting Abdominal Pain Jaw Pain Back Pain Dizziness Clinical Presentation

11. Clinical Presentation of MI in Women • Women also experience prodromal symptoms such as: • Fatigue • Discomfort around the shoulder blades • Chest sensations

12. Diagnosis • Exercise electrocardiogram (EKG) is the gold standard for diagnosis of cardiovascular disease in men. • Women tend to have higher ejection fractions at rest and approximately thirty percent of women, when exercising, do not increase their ejection fraction.

13. Diagnosis • To exclude cardiovascular disease in women, they must have a normal resting EKG and no risk factors for cardiovascular disease.

14. Diagnosis • A woman who has an abnormal resting EKG or has risk factors such as a family history of cardiovascular disease, hypertension, diabetes mellitus, postmenopausal status, smokes, older than 65 years old etc., must undergo a cardiac imaging study rather than an exercise EKG (Wenger, 2005, Medscape, 2005). • Exercise or dobutamine echocardiography will increase the diagnosis specificity.

15. Diagnosis • Women have higher mortality rates due to arrhythmias than men. • Women have fatal arrhythmias as the first indicator of cardiovascular disease more often than men.

16. Diagnosis • Women have longer rate-corrected QT intervals than men. • It has been determined that males who have long QT intervals have a strong correlation with fatality post myocardial infarction, so there is an indication that since women have longer QT intervals, they may be at an increased risk for sudden cardiac failure. (Malloy, 1999)

17. Treatment • While the primary benefit of digoxin is to decrease hospitalizations, women have benefited less than men. • Women who had stable heart failure and were taking digoxin had higher death rates than men.

18. Treatment • Women had no decrease in cardiovascular events when taking an ACE inhibitor, whereas men had a 17% reduction in cardiovascular events when taking an ACE inhibitor.

19. Treatment • Women also experience more side effects due to an ACE inhibitor. • Women have more side effects from anti-hypertensive drugs than men, including hyponatremia and hypokalemia.

20. Treatment • Thrombolytics such as tissue plasminogen activator, have been proven beneficial in both men and women but there is an increased risk of intracerebral hemorrhage in women, possibly because of inappropriate dosing due to smaller body size in women.

21. Treatment • Streptokinase and t-plasminogen activator was found to have a three-time higher 30-day mortality rate for women than men. • Women probably receive thrombolytic therapy later than men due prolongation of diagnosis.

22. Treatment • It has been found that women have smaller hearts than men and, therefore, smaller coronary arteries, which contributes to the more extensive complications that women have when they undergo invasive procedures such as angiography and CABG. (McCormick and Bunting, 2002, Caves 1998)

23. Treatment • A retrospective study of 345,000 outcomes concering coronary bypass surgery, since 1994 showed that women had a “significantly higher operative mortality rate than equally matched men”. (Malloy, 1999)

24. Treatment • Lipid lowering drugs have shown to be more of a benefit in women than men. (Malloy, 1999) • The effects of pravastatin in women resulted in a 43% reduction in risk of sudden cardiac death and nonfatal myocardial infarction and a 55% reduction in stroke compared to placebo.

25. Treatments on the Horizon • Selective estrogen receptor modulators (SERMS) • Tamoxifen and Raloxifene have shown the capability of reducing LDL levels of cholesterol in postmenopausal women without affecting high density lipoproteins or triglycerides.

26. Conclusion • When women go to their medical providers seeking attention for their symptoms, they are often not treated as a medical emergency. • Clinicians need to be able to recognize cardiovascular disease in women just as rapidly as they do in men.

27. Conclusion • Since coronary artery disease occurs in women approximately 10 years later than men due to the protective benefits that estrogen provides prior to menopause, women have more time to incorporate prevention into their lifestyles.

28. Conclusion • Women need to be aware of risk factors for cardiovascular disease in order to protect themselves, especially when they have a positive family history. Such risk factors as sedentary lifestyle, smoking, obesity, diabetes, hyperlipidemia and hypertension can be changed over time with education.

29. Conclusion • Cardiovascular disease is an “equal opportunity” killer, meaning there is no immunity from the disease based on sex.

30. References • American Heart Association. “Women and Coronary Heart Disease”. http://www.americanheart.org/presenter.jhtml?identifier=2859. Accessed on 06 November 2005. • Blake, Mary B. et al. “Inclusion of Women in Cardiac Research: Current Trends and Need for Reassessment”. Gender Medicine. 2005. Vol. 2. No. 2. • Caves, Whynne. “Women and Heart Disease: Same Disease, Different Issues”. Canadian Journal of Cardiovascual Nursing. 1998. 9(2):29-33. • Clearfield, Michael. “The Role of Statin Therapy and Hormone Replacement Therapy”. Medscape. http://www.medscape.com/viewarticle/484038_1. 2004. Accessed on 11 November 2005. • Endoy, Mara P. “CVD in Women: Risk Factors and Clinical Presentation”. The American Journal for Nurse Practitioners. Vol. 8. Issue 2. 2004. • Grimes, William. “Myocardial Infarction”. University of Kentucky. 12 October 2005. • Hirao-Try, Yumiko. “Hypertension and Women: Gender Specific Differences”. Clinical Excellence for Nurse Practitioners. 2003. Vol. 7. No. 1-2.

31. References • Kip, Kevin E. et al. “Global inflammation predicts cardiovascular risk in women: A report from the Women’s Ischemia Syndrome Evaluation (WISE) study”. American Heart Journal. 2005. Vol. 150. No. 5. • Malloy, Kevin J. and Anthony Bahinski. “Cardiovascular Disease and Arrhythmias: Unique Risks in Women”. 1999. J Gend Specif Med. Jan-Feb. 2(1): 37-44. • McCormick, Kim M. and Sheila M. Bunting. “Application of Feminist Theory in Nursing Research” The Case of Women and Cardiovascular Disease”. Health-Care-for-Women-International. Vol. 23. Issue 8. Page 820-34. December 2002. • Medscape. “Cardiovascular Disease May Be Overlooked in Women”. http://www.medscape.com/viewarticle/416554_2. 2005. Accessed on 06 September 2005. • Medscape. “Risk Factors for CVD in Women”. http://www.medscape.com/viewarticle/416554_3. Accessed on 06 September 2005. • Mosca, Lori. “Cardiovascular Disease New Recommendations for Minimizing the Threat”. The Female Patient”. March 2002. • Nau, David P. et al. “Gender and perceived severity of cardiac disease: Evidence that women are “tougher””. The American Journal of Medicine. 2005. Volume 118. Number 11.

32. References • Steffen, Kristen A. et al. “Changing Protocols in the Care of Women”. Emergency Medicine. March 2004. • Wenger, Nanette K. “Noninvasive Testing to Evaluate Coronary Heart Disease in Women”. Women’s Health in Primary Care. 2005. Vol.8. No. 5. • Zaman, Amin M. and Suzanne Oparil. “Identifying Hypertension in Postmenopausal Women Understanding the effects of Age and Sex”. Women’s Health in Primary Care. Volume 5 Number 9. September 2002. P 571-578. • Zuzelo, Patti Rager. “Gender and Acute Myocardial Infarction Symptoms”. Medsurg Nursing. 2002. Vol. 11. No.3.