Perceptions Versus Reality: Women and Heart Disease Ginger

Perceptions Versus Reality: Women and Heart Disease Ginger

Perceptions Versus Reality: Women and Heart Disease Ginger Hook, MSN, RN Overview Heart Disease Discuss Statistics of heart disease Identify risk factors for women and heart disease Discuss evidence-based guidelines for Cardiovascular Disease Prevention in Women Metbolic Syndrome Define MetS

Discuss statistics of MetS Discuss the findings of the ARIC Study Discuss study from Arch Intern Med, 2004 Discuss NHANES II 1976-80, Follow up study Identify Scientific Evidence related to Definition Statistics Statistics

Heart Disease and Stroke First and third leading causes of death in US Accounts for more than 40% of all deaths About 95,000 Americans die of heart disease or stroke each year Amounts to one death every 33 seconds Heart Disease is the leading cause of disability among working adults Age-Adjusted Mortality Heart Disease 300 250

200 150 100 50 0 Lake LaPorte Porter NW IN IN 2002 Deaths per 100,000 Population 2005 Epidemiological Report Northwest Indiana US

Economics 2001 Nationwide cost for all cardiovascular disease was $300 billion Heart disease the cost was $105 billion Stroke, $28 billion Lost productivity due to stroke and heart disease cost mor than $129 billion 2005 Epidemiological Report Northwest Indiana Age-Adjusted Mortality Heart Disease 300 250

200 150 100 50 0 Lake LaPorte Porter NW IN IN 2002 Deaths per 100,00 Population 2005 Epidemiological Report Northwest Indiana US

2005 Epidemiological Report Northwest Indiana Lake LaPorte Porter IN US HP 2010 Diseases of the Heart 264.1 271.7

224.6 246.1 240.8 213.7* Malignant Neoplasms 223.6 198.6 195.3 208.3

193.5 159.9 Chronic Lower Resp Diseases 44.6 52.4 36.6 51.1 43.5

Cerebrovascular Disease 52.7 48.6 45.3 59.4 56.2 Influenza/Pneumonia 13.2

10.8 10.5 21.6 22.6 Diabetes Mellitus 34.2 20.1 25.7

27.3 25.4 15.1* Motor Vehicle Accidents 14.6 19.6 16.9 15.0

15.7 9.2 Intentional Self-Harm 10.6 9.2 12.1 11.9 10.9 5.0

Assault 19.0 8.3 2.4 6.1 6.1 3.0 Sources: Indiana State Department

48.0 Age-Adjusted Mortality All Causes of Death 950 900 850 800 750 Lake LaPorte Porter NW IN IN 2002 Deaths per 100,000 Population US

Women and Heart Disease Heart Disease is the #1 Killer of Women Coronary heart disease is the single leading cause of death and a significant cause of morbidity among American women. In 1997 CHD claimed the lives of 502,938 women (men had less deaths) Since 1984, CVD has killed more American women than men each year. Breast Cancer is the REAL issue! Who cares about heart disease doc

I am more concerned about: BREAST CANCER and lung cancer! In a recent survey, 75% of women identified cancer as their leading cause of death Recent Screening Age 30-40 41-50 51-60 61-70 71-80

80+ Exam Totals 120 100 80 Normal 60 Abnormal 40 20 0 EKG

Echo arm/ankle labs body fat In perspective: 1 in 2 women will die of heart disease. 1 in 25 women will die of breast cancer. Coronary Heart Disease in Women Presentation and differences from men 2/3 of women who die suddenly have

no previously recognized symptoms. Women are more prone to noncardiac chest pain.. In fact they may experience little or no squeezing chest pain in the center of the chest, lightheadedness, fainting, or shortness of breath with an MI (as seen on ER). Nationally: The Problem AWARENESS Perception 67% knowledgeable that chest pain can be heart disease <10% knowledgeable that

SOB, nausea, indigestion can be heart disease Reality chest pain is the presenting symptom in <50% of women Almost half of MIs in women present with SOB, nausea, indigestion, fatigue and shoulder pain Causes of Confusion: Women may experience more

dizziness, nausea, indigestion, and fatigue than men. Women are more likely to have neck, arms, back and shoulder pain. Evidence based information about symptoms suggests a gender focus Women have More atypical Symptoms of MI Source: Milner Am J Cardiol 1999;84:396 Not so straightforward Because of these atypical symptoms, women seek medical care later than men and are more likely to be misdiagnosed.

Women presenting with MI and CAD are more likely to be older, have a history of DM, HTN, Hyperlipids, CHF, and unstable angina than male counterparts. (J Am Coll Cardiol 1997;29) Because of these comorbid conditions, there tends to be diagnostic confusion. Misperceptions and Missed Opportunities Leading to Access Inequity Women were less likely to have an EKG or be admitted to the telemetry floors. Women are under-diagnosed and can therefore get a false sense of security. Less aspirin, beta-blockers, statins, antiarrhythmic treatment, cardiac cath,

PTCA, CABG Women were less likely to enroll in cardiac rehabilitation after an MI or bypass surgery. CHD Mortality in Younger Women Women under 65 suffer the highest relative sex-specific CHD mortality 30 25.3 Death during Hospitalization (%) 25 Men 20 21.8

Women 18.4 24.2 21.5 19.1 16.6 15 13.4 11.1 9.5

10 5 10.7 8.2 7.4 6.1 14.4 5.7 4.1

2.9 0 < 50 50-54 55-59 60-64 65-69 70-74 75-79

80-84 85-89 Figure 1. Rates of death during hospitalization for Myocardial Infarction among w omen and men, according to age. The interaction betw een sex and age w as significant (P<0.001). The Need for Prevention in Women 9,000 US women younger than 45 sustain a heart attack each year. Thus the priority for coronary prevention is substantial for women of all ages. Mortality associated with acute MI among women younger than 65 y/o is almost twice as high among men.

Women vs. Men: Mortality from CABG-particularly among younger women-is double that among men. More women than men die 1 year after an MI. CHD is Largely Preventable We need to address risk factors earlier and more aggressively, thereby reducing womens cardiovascular risk. Women and Heart Disease Risk Factors Non-modifiable Risk Factors Age > 55

CAD rates are 2-3xs higher in postmenopausal women Family history CHD in primary 1st degree relative male<55 or female<65 The #1 Preventable Risk- Smoking A. 50% of heart attacks among women are due to smoking. Smokers tend to have their first heart attack 10 years earlier than nonsmokers. B. If you smoke, you are 4-6xs more likely to suffer a heart attack and increase your risk of a stroke. C. Women who smoke and take OCPs increase their risk of heart disease 30xs.

2. Obesity A. 1/3 of adult women are obese and its increasing B. Active women have a 50% risk reduction in developing heart disease. Increasing Prevalence of Obesity in US Adults Obesity and Coronary Heart Disease Mortality Nurses Health Study: Women who never smoked 6 5 Relative Risk of 4

Coronary 3 Heart Disease mortality 2 1 0 <19 P<0.001 for trend 19.021.9 22.0- 25.0- 27.0- 29.024.9 26.9 28.9 31.9

Body Mass Index (kg/m2) >32.0 Manson JR, et al. N Engl J Med. 1995;333:677-685. Hypertension 65% of all hypertension remains either undetected or inadequately treated. People who are normotensive at 55 have a 90% lifetime risk of developing HTN. Prevalence increases with age and women live longer- hypertension is more common in females. HTN is more common with OCP and obesity.

Risk Factors: Diabetes Diabetes increases the risk of CHD 3-7 Xs in women versus 2-3 Xs in men. Diabetic women who smoke have a 84% higher risk of developing stroke than nonsmokers. 2 of 3 people with diabetes die from CHD or stroke. Reported Causes of Death in People With Diabetes C Cholesterol More than 55 million women

(45million men) have TC>200. Check cholesterol at least once q 5yrs starting at age 20. 36 Million people in the US should be taking a statin according to guidelines, but only 11 million are. Treatments Based on Risk Factors SMOKING: Stop!!!!! (avg. attempt = 8 times) Women who have other smokers in their household have a 2.5 X's greater likelihood of relapse. Circulation 2002:106 Smoking cessation was associated with a 36% reduction in mortality among

patients with CHD. JAMA 2003:290 Women and HTNJNC VII The relationship bet. BP and CV events is continuous, consistent and independent of other risk factors. The higher the BP the greater the chance of MI, CHF, stroke, and kidney disease. Can try to achieve good BP through lifestyle changes. Lifestyle Modification for HTN Modification Recommendatio Expected systolic

reduction n Weight reduction Goal of BMI 18-25 Waist <35inches 5-20 mm Hg per 10kg wt loss DASH Fruits, veges, low-fat dairy products, less fat

8-14 mm Hg Sodium restriction <2.4 g every day 2-8 mm Hg Physical activity 30 mins of aerobic 4xs a week 4-9 mm Hg Reduced EtOH

(1/2 for women) 2-12 oz beer, 1 10oz wine, 3 oz 80proof whiskey in men 2-4 mm Hg Exercise 30-45 mins of walking 5xs/week reduces risk of MI in females 50%. Helps control BP, increases HDL, decreases body fat, DM risk, possibly prostate, breast and uterine cancers. Cholesterol Women at high risk should be

considered for statin therapy regardless of cholesterol-LDL levels. Statin drugs have already surpassed all other classes of medicines in reducing the incidence of the major adverse outcomes of death, MI, and stroke. NEJM 350:15 April 8, 2004 Coronary Heart Disease Whom Do You Treat? How Aggressive should you be? Evidenced-Based Guidelines for Cardiovascular Disease Prevention in Women The AHA Guidelines February 2004

Framingham Heart Study An individualized approach based on cardiovascular risk First-Assess and stratify women into high, intermediate, lower/optimal risk categories. The aggressiveness of treatment should be linked with your risk of having a heart attack or event in the next 10 years- based on the Framingham Heart Study. Framingham Point Score You get points for: Age Total Cholesterol HDL Cholesterol

Smoking Systolic Blood Pressure Add these numbers --you get a 10 yr CHD risk % (category): Risk Stratification - Lower Risk A. Low Risk : 10% or less risk of having a heart attack or dying of heart disease in the next 10 years. May include women with multiple risk factors, Metabolic Syndrome, or 1 or no risk factors. Metabolic Syndrome RISK FACTOR

DEFINING LEVEL Abdominal Obesity Waist Circumference Men Women TGs HDL Men Women BP Fasting Glucose >40 inches >35 inches

>150 <40 <50 >130/85 >100 mg/dl Mortality Associated With Metabolic Syndrome Mortality (% of patients) 20 18 Metabolic syndrome No metabolic syndrome 18

16 14 12 10 8 8 9 6 6 4 3

2 0 POWERSEARCH PLUG-IN 2.0 POWERSEARCH Copyright 2001-02 AccentPLUG-IN Graphics, Inc. 2.0 Copyright 2001-02 Accent Graphics, Inc. All-cause mortality* CVD mortality* 2

CHD mortality* Slide Source: "R:\NDEI-2\2004 Grant\T108\ARS\T095 ARS Case 2 FINAL-Baton Rouge 12-09-03.ppt" Slide Source: "R:\NDEI-2\2004 Grant\T108\ARS\T095 ARS Case 2 FINAL-Baton Rouge 12-09-03.ppt" Last Modified: December 9, 2003 2:17:25 PM Last Modified: December 9, 2003 2:17:25 PM Slide Number: 19 Slide Number: 19 *Adjusted for known CHD risk factors. 2003PPS Lakka H-M et al. JAMA. 2002;288:2709-2716. Intermediate Risk Those with a 10-20% chance of a heart attack in the next 10 yrs.

Pts with the metabolic syndrome, multiple risk factors, marked elevations of a single risk factor, first degree relative with CHD (male<55, female<65) High Risk: >20% You are automatically considered high risk if you have: PAD CRF AAA DM history of stroke Practice Prevention Low Risk Women <10%:

Class I recommendations: Intervention is useful and effective: Lifestyle Interventions Smoking Cessation Physical Activity Heart Healthy Diet- DASH Diet Weight Reduction Treat Individual CVD risk factors Practice Prevention Intermediate Risk Women (10-20%): Smoking Cessation Physical Activity Heart Healthy Diet- DASH Diet Weight

Reduction Control BP and Lipids Class Ila- most scientific evidence favors this type of therapy: ASA Rx-as long as BP is controlled (hemorrhagic stroke) and minimal risk of GI bleed Practice Prevention High Risk Women (>20%): Class I Smoking Cessation Physical Activity/cardiac rehab Heart Healthy Diet- DASH Diet Weight Reduction Control BP and Lipids-statin ASA therapy blocker therapy-esp in all s/p MI

ACE-I or ARBS Glycemic control in DM Heart Disease There is a continuum of CVD risk, it is not a have or have-not condition. CHD is less in women who control their risk factors. JAMA Oct. 6, 2004 The average age of our population is increasing and so CHD will remain a major public health issue. Women and Heart Disease Treatment - Summary 1. Aggressive medical therapy appears particularly effective in women. 2. Women face more adverse outcomes

with revascularization, due to procedural complications, suboptimal gender-based risk Stratification and possibly microvascular disease. 3. Long term revascularization risk reduction and outcomes for women are similarly beneficial to men. EDUCATE!!! Womens main source of information on heart disease: Magazines 45% TV 34% Newspaper 27% MDs 24%

Only 38% of pts in a recent survey said they discussed CHD prevention with their MDs.

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