Heart Disease in Women

1. 10 Things Every Woman Should Know About Heart Disease Heart Disease in Women Susan P. D’Anna ARNP Clinical Instructor in Medicine Section of Cardiology - DHMC

2. #1 Cardiovascular Disease Is the Number 1 Cause of Death in American Women Myth: • Heart disease is a man’s disease Fact: • Each year heart disease kills more women than men • 38% of women die within one year of suffering a heart attack (compared to 25% of men) CDC National Vital Statistics Report, Vol.49, No., 11 2001 Adapted from the American Heart Association website, 2002

3. Estimated Prevalence of CVD by Age and Gender U.S.: 1988 - 1994 Heart Disease Affects Women in Every Age Group AHA 2003 Heart and Stroke Statistical Update; 2002:8.

4. Women Do Not Perceive Heart Disease as Their Major Health Threat Cancer (net) Cancer (net) Heart Disease Heart Disease Female Perception of TheirGreatest Health Risk 61% Women still fear cancer most 1997 7% 62% 2000 8% 51% 2003 13% Awareness ofLeading Cause of Deathfor Women 50% But, awareness is improving 1997 30% 40% 2000 34% 35% 2003 46% Source: Tracking Women’s Awareness of Heart Disease – AHA National Study; Circulation 2004;109:573-579.

5. Cardiovascular Disease 41% Cancer 22% Source: National Vital Statistics Report, Vol. 50, No. 15, September 16, 2002

7. #2Risk Factors Help Predict Who Is at Risk to Develop Coronary Artery Disease • Age: As women grow older, the chance of developing heart disease increases (especially after the onset of menopause) – The risk of CAD increases 2 to 3 times after menopause • Race: African-American women have a higher risk of death from heart disease than white women women.americanheart.org

8. Cholesterol:Low blood levels of “good” cholesterol (HDL) and high triglycerides are stronger predictors of heart disease death in women than in men

9. Blood Pressure:More than half of all women over 55 have high blood pressure, which increases their risk of heart disease, stroke and other serious conditions • Diabetes:Increases the risk of heart disease 3-7 fold A more powerful risk for heart disease in women than in men Jneid and Thacker, Cleveland Clinic J of Med. 2001: 441-448 women.americanheart.org

10. Why Women Don’t Take Action Against Heart Disease • They don’t put their health as a top priority • They think they’re not old enough to be at risk • They feel too busy to make changes in their lives • They’re already feeling stressed • They don’t have the familial and social support

11. #3 Women’s Experience of Heart Disease Is Different Than Men’s • Women are more likely to die within one year after a heart attack • Women are less likely to survive coronary artery bypass surgery • Women are more likely to experience complications after angioplasty • Women are more likely to have life threatening arrhythmias (irregular heart beats) These differences may be partially due to hormones, a woman’s smaller heart size and advanced age at diagnosis Wenger, N.K., J. Am. Med. Women’s Assoc. 1994:49:181 Wenger, N.K., Int. J. Fertile Women’s Med. 1998; 43:84

12. Traditional Heart Attack Warning Signs • Pressure, burning, squeezing in the center of the chest • Discomfort in one or both arms, shoulders, neck, jaw, stomach, or back • Shortness of breath • Fatigue, cold sweat, nausea, weakness Adapted from the Harvard Medical School website – www.harvard.health.edu

13. Women’s signs are non-specific and more easily overlooked. Symptoms of Coronary Heart Disease Can Differ in Women • Pain in upper back, jaw or neck • Shortness of breath • Flu-like symptoms: nausea or vomiting, cold sweats • Fatigue or weakness • Feelings of anxiety, loss of appetite, discomfort Adapted from the Harvard Medical School website – www.harvard.health.edu

14. Severity of Heart Disease: Men and Women Men Women AHA 2003 Heart and Stroke Statistical update; 2002:12, 14, 17

15. 61 million Americans with CVD 48% are men 52% are women 1 1 Yet, more men are being treated than women 2 3 3 4 4 1. The AHA 2001 Heart and Stroke Statistical Update 3. PTCI: J Am Coll Card 2002 Apr 3; 39(7):1096-103 2. CABG: Ann Thorac Surg 2001 Feb; 71(2):512-20 4. Estimated from internal Guidant records

16. Heart Disease Gender Bias or Sex Difference? • Data used for the care of women derived from studies conducted in middle-aged men • Initial efforts for prevention focused more on men than women • Women and doctors often attribute chest pain in women to noncardiac causes Exploring the Biological Contributions to Human Health-Does Sex Matter: Institute of Medicine 2001

17. Heart DiseaseGender Bias or Sex Difference? • Women tend to have heart attacks later in life than men • Women present more often than men with atypical symptoms • Some diagnostic tests and procedures may not be as accurate in women • Heart disease may be different in women and men Exploring the Biological Contributions to Human Health-Does Sex Matter: Institute of Medicine 2001

18. #4 Heart Attacks Are Caused by Coronary Artery Disease (CAD)

19. Obstructed coronary artery Diffuse narrowing in coronary artery

20. #5 Know Which Tests are More Effective in Women Shaw et al. Card. In Review, 2000: 65-74

21. #6 Estrogen and Menopause May Be Related to Heart Disease • Estrogen increases production of “good” cholesterol (HDL) • As estrogen decreases, women experience lower levels of “good” cholesterol (HDL) and the flexibility in arteries decreases. • Women will live one third of their lives after menopause • Hormone Replacement Therapy (HRT) should not be used for the purpose of reducing the risk of cardiovascular disease in women Jneid and Thacker, Cleveland Clinic J of Med. 2001: 441-448

22. Increased Risk • Heart attack 29% • Breast cancer 26% • Blood clots 2X • Strokes 41% • Dementia • Ovarian Cancer • Strokes • Probable dementia or memory loss* Decreased Risk • Hip fractures 34% • Colorectal cancer 37% • Cancer of uterine lining • Hip fractures No Effect • Quality of life • Number of deaths • Breast cancer • Heart disease Estrogen plus progestin - July 2002 Estrogen alone – March 2004 WHI Had Unexpected Results Source: JAMA 2002; 288:321-333 National Institutes of Health * mdash study shows a trend toward increase in risk

23. CONCLUSIONS of WHI After a 5.2 year follow up: • Health risks exceeded benefits of combined estrogen plus progestin • All-cause mortality was not affected • This regimen should not be initiated or continued for primary prevention of CHD. JAMA 2002; 288:321-333

24. #7 More Research on Women and Heart Disease Is Needed • Historically, women have been under-represented in clinical trials related to heart disease • There is little knowledge regarding the effects of commonly used cardiovascular drugs in women • Practice patterns are based on research in middle-aged men that may not apply to older women • There is limited information regarding therapies used to treat heart disease in the very elderly Evelyn et al. “ Women's Participation in Clinical Trials and Gender-Related Labeling” FDA special report http://www.fda.gov/cder/reports/womens_health/women_clin_trials.htm

25. Enrollment of Women in CVD Trials • 1993 – NIH mandated inclusion of women in federally funded clinical research • Enrollment increasing for women, but with single-sex trials excluded, enrollment rate was 38%, unchanged over time • No change in gender composition of cohorts in majority of studies • Federal efforts have been only moderately successful, mainly due to small number of large single-sex trials • Even when women are included in trials, rarely are the results broken-out NEJM 2000;343-475

26. Representation of Women in Studies of CAD Testing Adapted from Shaw LJ et al. Coronary Artery Disease In Women: What All Physicians Need to Know. 1999;372.

27. Medications – including Aspirin Balloon angioplasty and stenting Heart bypass surgery Pacemakers for slow heart rhythms and defibrillators for rapid heart rhythms #8 There Are a Variety of Options Available to Treat Heart Disease

28. #9 Women Can Take Action to Lower the Risk of Heart Disease • Know your risk factors • Stop smoking • Maintain a healthy body weight • Eat a nutritious balanced diet low in saturated fats • Monitor and manage blood pressure and diabetes • Exercise regularly • Limit alcohol intake • Learn stress management skills • Maintain social relationships • Know the warning signs for heart attack and stroke

29. #10 Women Can Save Lives • If you or someone you knowhasrisk factors for heart disease, adopt a heart healthy lifestyle and discuss a plan of care with your physician • If you experience symptoms of heart attack or stroke, call 911 immediately • LEARN CPR

30. Why Focus on Women’s Cardiovascular Health? • Cardiovascular disease is the largest killer of American women and CVD mortality in women is rising at a disproportionate rate compared to men • The majority of American women are unknowledgeable about their personal risk for CV disease • Changing a woman’s CV risk from higher risk to lower risk with present medical knowledge and tools reduces her chance of coronary events • Women are often decision makers for the family Adapted from American Heart Association and the Nurse’s Health Study

31. The following organizations can provide information on heart disease: * American Heart Association 800-242-8721 http://www.americanheart.org AHA's mission is to reduce disability and death from cardiovascular diseases and cardiovascular diseases and stroke. Several consumer publications are available through AHA, including the AHA Guide to Heart Attack Treatment, Recovery and Prevention. * Health and Human Services Office of Women's Health 1-800-994-WOMAN (96626) http://www.4women.gov OWH investigates a broad spectrum of women's health activities across governmental offices and agencies. It also sponsors the National Information Center, which links the general public to a wide variety of health-care resources and publications, including those related to heart disease. * National Heart, Lung, and Blood Institute 301-592-8573 http://www.4women.gov, www.hearttruth.gov The NHLBI publishes the Healthy Heart Handbook for Women (http://www.nhlbi.nih.gov/health/public/heart/other/hhw/index.htm), which features the latest information on preventing cardiovascular diseases. The publication also helps women develop a personal action plan for reducing the major risk factors. In addition, The Heart Truth website contains helpful information. * American Medical Women's Association http://www.amwa-doc.org/ Mayo Clinic Health Oasis http://www.mayohealth.org/

32. Be a leader in your community for women’s cardiovascular disease through . . . You Can Make a Difference Research Advocacy Awareness