WOMEN AND CARDIOVASCULAR

DISEASE4th Annual Lourdes Cardiology

Services Symposium: Cardiology for the Primary Care Physician

Rozy Dunham, MD, FACC

Man’s Disease?

Heart disease is the leading cause of death for women in the U.S.

1 in 3 women dies of heart disease, only 1 in 31 of breast cancer

26% of women >45yo who have an initial MI die within one year compared to 19% of men

Women are more likely to describe chest pain that is sharp, burning, and more frequently have pain in the neck, jaw, throat, abdomen, or back

In 2004, <50% of women recognized heart disease as the #1 killer

In 2011, only 53% of women said they would call 911 first if they thought they were having a heart attack

Go Red For Women 2004

Objectives

Recognize the impact of cardiovascular disease in women (CHD and Stroke)

Recognize the presentation of heart disease can be different in women as compared to men

Identify risk factors unique to women for both CHD and Stroke

Recognize treatments that are NOT beneficial for CVD prevention in women

Guidelines

1999- First female specific guidelines for heart disease prevention

2004- Evidence Based Guidelines for Cardiovascular Disease Prevention in Women

2011-Effectiveness Based Guidelines for Cardiovascular Disease Prevention in Women

2014- Guidelines for the Prevention of Stroke in Women; a statement from the AHA and ASA

2004 Guidelines

Written in the wake of the Women’s Health Initiative and HERS trial

Need for strategies to prevent heart disease in women

2004 Guidelines

Assess and stratify women into high, intermediate, lower, or optimal risk categories

Lifestyle approaches to prevent CVD for all women and a top priority (smoking cessation, regular exercise, weight management, and heart healthy diet)

Other CVD risk-reducing interventions (BP management, lipid management, DM management)

Higher priority for therapy for highest risk patients Avoid Class III interventions (not beneficial, may

be harmful)

Spectrum of Risk

Based on the Framingham Risk Score No such thing as NO risk High Risk (>20%):

Established CHD Cerebrovascular disease Peripheral arterial disease AAA DM CKD

Intermediate Risk (10-20%): Subclinical CHD (coronary Ca) Metabolic syndrome Multiple risk factors (smoking, HTN, HPL, obesity,

poor diet, physical inactivity) Autoimmune collagen vascular disease (SLE, RA) Family history of early onset CVD History of preeclampsia, gestational DM, or

pregnancy induced HTN)

Lower Risk (<10%): Multiple risk factors, metabolic syndrome, or 1 or

no risk factors

Optimal Risk (<10%): Optimal levels of risk factors and heart healthy

lifestyle (ideal lipids, HTN, blood glucose, BMI, non-smoker, physically activity, healthy diet)

Lifestyle Interventions

Recommended for ALL women Smoking cessation Physical activity (30 minutes of moderate-

intensity exercise most days of the week) Cardiac rehab Heart healthy diet Weight maintenance/reduction (BMI 18.5-24.9

kg/m2; waist circumference <35 in.) Psychosocial Factors Omega 3 fatty-acid supplementation in high

risk patients

Other Interventions

Optimal BP <120/80 Lipid Management DM management

Preventive Drug Interventions

ASA for high or intermediate risk patients, or clopidogrel if intolerant of ASA

Beta Blockers in women with h/o MI ACE in high risk women ARB in high risk women intolerant of ACE Warfarin/ASA for a.fib a stroke prevention

Class III Interventions

Hormone Therapy (combined estrogen/progestin or unopposed estrogen) should NOT be used for CVD prevention

Antioxidant supplements ASA for lower risk patients

Effectiveness Based Guidelines-2011 Update

Reversing a trend over the last 40 years, CHD death rates in US women 35-54yo appear to be increasing, likely due to the obesity epidemic

Death rates higher in black vs. white women

Leading cause of death in women in every major developed country

Flow diagram for CVD preventive care in women.

Mosca L et al. Circulation. 2011;123:1243-1262

Copyright © American Heart Association, Inc. All rights reserved.

2011 Update

Did not endorse routine use of high-sensitivity CRP for screening purposes

Did discuss unique opportunities to assess a women’s risk, like at time of pregnancy

Preeclampsia may be an early indicator of CVD risk

Class III Interventions

Hormone therapy, including selective estrogen-receptor modulators, should not be used for primary or secondary prevention of CVD

Antioxidant supplements (vitamin E, C, and beta carotene) should not be used for primary or secondary prevention of CVD

Folic Acid with or without B6 and B12 supplementation should not be used for primary or secondary prevention of CVD

Routine use of ASA for prevention of MI in healthy women <65 yo (ASA can be useful in women >65yo if BP controlled and benefit for ischemic stroke prevention and MI prevention is likely to outweigh risk of GIB and hemmorhagic stroke)

Guidelines for the Prevention of Stroke in Women

February 2014 Stroke accounts for a higher proportion of CVD

events than CHD in women (opposite for men) Lifetime risk of stroke higher in women, mostly

because women live longer 53.5% of new or recurrent strokes occur

among women In 2010, 60% of deaths related to stroke were

in women Majority are ischemic strokes vs. hemorrhagic Risk factors unique to women

Risk FactorSex-Specific Risk

Factors

Risk Factors That Are

Stronger or More Prevalent in

Women

Risk Factors With Similar

Prevalence in Men and Women

but Unknown Difference in

Impact

Pregnancy XPreeclampsia XGestational diabetes

X

Oral contraceptive use

X

Postmenopausal hormone use

X

Changes in hormonal status

X

Migraine with aura

X

Atrial fibrillation XDiabetes mellitus

X

Hypertension XPhysical inactivity

X

Age XPrior cardiovascular disease

X

Obesity XDiet XSmoking XMetabolic syndrome

X

Depression XPsychosocial stress

X

Stroke In Pregnancy

Preeclampsia/eclampsia and pregnancy-induced HTN

Continue to be at high risk for stroke even after birth

ACOG recommends treatment of severe HTN in pregnancy (systolic BP >160 mmHg or diastolic BP>110 mmHg)

Labetolol is first-line therapy AVOID atenolol, ACE, and ARB

Hypertension

History of preeclampsia, eclampsia, pregnancy induced HTN, gestational DM all are associated with a higher risk of CVD and stroke beyond the childbearing years

In one 2012 study, 18.2 % of women with a history of preeclampsia vs. 1.7 % of women with uncomplicated pregnancies had a CVD event in 10 years

Recommendations

Women with chronic primary or secondary HTN or previous pregnancy related HTN should take a low dose ASA from the 12th week of gestation until delivery

Calcium supplementation (>1g/day) should be considered for women with low dietary intake of calcium to prevent preeclampsia

Severe HTN in pregnancy should be treated Consider treatment of moderate HTN Atenolol, ACE, ARB contraindicated After birth, women with chronic HTN should continue to be

treated and monitored for post-partum preeclampsia Because of increased risk of future HTN and stroke 1-30

years after delivery in women with a history of preeclampsia, it is reasonable to evaluate and treat for HTN, obesity, smoking, and dyslipidemia

Cerebral Venous Thrombosis

Thrombus formation in >1 of the venous sinuses

0.5%-1% of all strokes >70% of cases in women 2 major risk factors include oral

contraceptive use and pregnancy

Recomendations

Screen and test for prothrombotic conditions Warfarin for 3-6 months in provoked CVT 6-12 months in unprovoked CVT Indefinite anticoagulation for recurrent CVT In CVT with pregnancy, LMWH throughout

pregnancy and >6 weeks post-partum Future pregnancy not contraindicated Women with a history of CVT can be treated

prophylactically with LMWH during future pregnancies

Oral Contraceptive Use

2.75 fold increase in ischemic stroke with any OC use

Progestogen only OCs revealed no significant increased risk

Overall slightly increased risk of hemorrhagic stroke

Increased risk with obesity, HPL, smoking, HTN, migraine headaches and OC use

Recommendations

OCs may be harmful in women with additional risk factors (smoking, prior thromboembolic events)

Among OC users, aggressive therapy of stroke risk factors reasonable

Routine screening for prothrombotic mutations before initiation of OC is NOT useful

Measurement of BP before initiation of OC is recommended

Menopause and Post Menopausal HT

Data seems to suggest increased risk of stroke with earlier onset of menopause (before age 42) although evidence is inconsistent

Studies of HT for primary and secondary prevention of stroke have been negative

HERS, WEST, and WHI HT does not reduce stroke risk and may

increase risk

Recommendations

HT (conjugated equine estrogen with or without medroxyprogesterone) should not be used for primary or secondary prevention of stroke in post-menopausal women

SERMs, such as raloxifene, tamoxifen, or tibolone, should not be used for prevention of stroke

Migraine With Aura

Women are 4 times more likely than men to have migraines

Migraine with aura is associated with double the risk for ischemic stroke

This association is higher in women than men

Risk increases even more with smoking and OC use

Recommendations

Treatment to reduce migraine frequency is reasonable as there is an association between higher migraine frequency and stroke risk

Evidence is lacking that treatment reduced risk of first stroke

Strongly recommend smoking cessation in women with migraine and aura

Obesity, metabolic syndrome, and lifestyle factors

Prevalence of obesity higher in women than in men

Recommendation are same for men and women: regular physical activity, moderate alcohol consumption, abstention from smoking, and healthy diet

Atrial Fibrillation

AF increases with age and women have greater life expectancy

60% of AF patients >75yo are women Risk stratification : CHADS2 and

CHA2DS2-VASc score Female sex is an independent predictor of

stroke in AF

Recommendations

Risk stratify patients Considering the increased prevalence of AF

with age and the higher risk of stroke in elderly women with AF, active screening (age >75) in primary care settings is appropriate

Oral AC in women <65yo with AF alone and no other risk factors is not recommended (CHADS2=0, CHA2DS2-VASc=1). Antiplatelet therapy is a reasonable option

New oral anticoagulants are a useful alternative to warfarin in appropriate patients

Strategies For Prevention of Stroke in Women

Management of carotid disease (symptomatic or asymptomatic) same as for men

ASA therapy in women with DM, high-risk patients, and women >65yo if benefit is likely to outweigh the risk

Conclusions

Many gaps remain in our knowledge regarding sex differences in CVD and prevention

More awareness among women Sex specific risk scores necessary More women need to be represented in

clinical trials of CVD Until then, management remains

essentially the same as for men (ASA)