your institution here your institution here cardiovascular disease in women: risk factors
TRANSCRIPT
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YourInstitution
Here
YourInstitution
Here
Cardiovascular DiseaseIn Women: Risk Factors
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Cardiovascular Risk Factors in Women
• Unmodifiable– Age– Family History
• Modifiable– Diabetes – Dyslipidemia– Hypertension– Obesity– Poor Diet– Sedentary Lifestyle– Cigarette Smoking
Source: National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002, Mosca 2007
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Modifiable Risk Factors: Sedentary Lifestyle
• 40% of women report no leisure time physical activity
• Exercise is less prevalent among white women compared to white men
• African American and Hispanic women have the lowest prevalence of leisure time physical activity
Source: U.S. Surgeon General 1999, Rosamond 2008
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Estimated Percentage of Americans Age 18 and Older Who Report Regular
Physical Activity 2005: By Race and Sex
Source: Rosamond 2008
%
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Risk Reduction for CHD Associated with Exercise
in Women
1.00
0.700.75
0.550.50
1.00
0.80
0.65
0.500.58
0.000.100.200.300.400.500.600.700.800.901.001.10
1 2 3 4 5
RelativeRisk
Walking
Any Physical Exercise
5Quintile Group for Activity (MET - hr/wk)
Source: Manson 1999
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Relative Risk of Coronary Events for Smokers Compared to Non-
Smokers
6Source: Adapted from Stampfer 2000
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Smoking
• The same treatments benefit both women and men
• Women face different barriers to quitting– Concomitant depression– Concerns about weight gain
Source: Fiore 2000
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Five A’s
• Ask about tobacco use at every visit• Advise in a clear and personalized message• Assess willingness to quit• Assist to quit• Arrange follow-up
For more information: www.surgeongeneral.gov/tobacco/#clinician
8Source: Fiore 2000,
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1999
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2010
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1999, 2010
9Source: CDC
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Body Mass Index: Definition
• BMI = weight in kilograms divided by the square of the height in meters (kg/m2)
• BMI chart showing BMI based on weight in pounds and height in inches available at http://www.nhlbi.nih.gov/guidelines/obesity
• Downloadable BMI calculator phone applications are available from the National Heart, Lung, & Blood Institute (NHLBI) website above.
10Source: National Heart, Lung, and Blood Institute
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Body Weight and CHD Mortality Among Women
11
P for trend < 0.001
Relative Risk of CHD
Mortality Compared to BMI <19
Source: Adapted from Manson 1995
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Body Weight and CHD Mortality Among Women
12
P for trend <0.001
Relative Risk
of CVD Mortality
Source: Adapted from Manson 1995
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Adult Treatment Panel (ATP) III Guidelines
• Sample menus for different ethnic & cultural preferences
• Assessment tools• Counseling tools• Adherence tips• Patient handouts
Source: National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002
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Diabetes
• Diabetes affects 8.8% of all U.S. women age 20 years or older
• Compared to whites:– African Americans, Latinas, American Indians,
Asian Americans, and Pacific Islanders have a 1.5-2.2 times greater prevalence of diabetes
Source: NIDDK 2005
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Diabetes
• 65% of people with diabetes die of cardiovascular disease
• People with diabetes have death rates from heart disease that are 2 to 4 times higher than people without diabetes
Source: CDC 2011.
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Coronary Disease Mortality and Diabetes in Women
16
0
10
20
30
40
50
60
0 - 3 4 - 7 8 - 11 12 - 15 16 - 19 20 - 23
Duration of Follow-up (yrs)
Women withDiabetes
Women withoutDiabetes
Mortality Rate per 1,000
Source: Krolewski 1991, National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002
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Race/Ethnicity and Diabetes
• At high risk:– Latinas– American Indians– African Americans– Asian Americans– Pacific Islanders
17 Source: American Diabetes Association 2011
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Definition of Metabolic Syndrome in Women
Any 3 of the following:• Abdominal obesity (waist circumference
≥ 35 inches) • High triglycerides ≥ 150 mg/dL• Low HDL cholesterol < 50 mg/dL• Elevated BP ≥ 130/85 mm Hg• Fasting glucose ≥ 100 mg/dL
18Source: Grundy 2005.
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Treatable Risk Factors: Hypertension
• 32% of women in the United States have hypertension
• Hypertension is more prevalent among older women than older men
• Death from CHD progresses increasingly and linearly as blood pressure increases
• For every 20 mm Hg systolic or 10 mm Hg diagnostic increase in blood pressure, risk of death from CHD doubles
Source: Lloyd-Jones 2010, Chobanian 2003, Rosamond 2008
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Lifestyle Approaches to Hypertension in Women
• Maintain ideal body weight- Weight loss of as little as 10 lbs. reduces blood
pressure • DASH (“Dietary Approaches to Stop
Hypertension”) eating plan (low sodium)- Even without weight loss, a low fat diet that is rich in
fruits, vegetables, and low fat dairy products can reduce blood pressure
• Sodium restriction to 1500 mg per day may be beneficial, especially in African American patients
• Increase physical activity• Limit alcohol to one drink per day
- Alcohol raises blood pressure - One drink = 12 oz. beer, 5 oz. wine, or 1.5 oz. liquor
20 Source: Chobanian 2003, Sacks 2001, Mosca 2011
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The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of
High Blood Pressure (JNC 7)
• Classification of blood pressure• Treatment algorithms• Lifestyle strategies• Antihypertensive drug choices• Special indications and situations• Resistant hypertension
Source: Chobanian 2003
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Age-adjusted Prevalence of Hypertension Among Several
Racial/Ethnic Groups in the U.S.
Source: CDC 2005
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Prevalence of Hypertension Among White and Black Women in the
United States
44
24
30
38
0
10
20
30
40
50
1988-1994 1999-2002
Black women
White women
Source: Adapted from Hertz 2005
%
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Prevalence of High Blood Pressure by Age and Race
(2005-2008)
24Source: Data from CDC, National Vital Statistics System, Health, United States, 2005-2008
%
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African Americans and Hypertension
• Compared to whites– African Americans develop hypertension
earlier in life
– African Americans have much higher average blood pressures
– African Americans have a 1.5 times greater risk of death from heart disease
Source: American Heart Association 2008
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“Dietary Approaches to Stop Hypertension” (DASH)
Eating Plan
• 7–8 servings of grains, grain products daily
• 4–5 servings of vegetables daily
• 4–5 servings of fruits daily
• 2–3 servings of low-fat or nonfat dairy foods daily
• ≤ 2 servings of meats, poultry, fish daily
• 4–5 servings of nuts, seeds, legumes weekly
• Limited intake of fats, sweets
26Source: NHLBI 1998, Sacks 2001
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Approximate and Cumulative LDL Cholesterol Reduction
Achievable By Diet and Weight Loss Modifications
Dietary Component Dietary Change Approximate LDL Reduction
Major
Saturated fat < 7% of calories 8-10%
Dietary cholesterol* < 200 mg/day 3-5%
Weight reduction Lose 10 lbs. 5-8%
Other LDL-lowering options
Viscous fiber 5-10 g/day 3-5%
Plant/sterol 2 g/day 6-15%
stanol esters
27Source: Adapted from National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002.
*NOTE: New guideline recommends < 150mg/day
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Adult Treatment Panel (ATP) III Full Report
• How to choose a statin• Dosing regimens• How to monitor when combining drugs• Side effect management• Reprintable nutritional hand-outs• Menu samples for different cultures• Adherence strategies/barrier reduction
Source: National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002.
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Low Risk Diet* is Associated with Lower Risk of Myocardial
Infarction in Women
1.71
1.50
1.281.22
1.001.00
1.20
1.40
1.60
1.80
1 2 3 4 5
29
Diet Score by Quintile* Consumption of vegetables, fruit, whole grains, fish, legumes
1 = little consumption / 5 = high consumption
RelativeRisk of
MI*
*Adjusted for other
cardiovascular
risk factors
Source: Akesson 2007
P <.05 for quintiles 3-5 compared to 1-2
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Emerging Risk Factors for CHD
• Pro-inflammatory markers– High sensitivity C-reactive protein (hs-CRP)– Fibrinogen
• Hyperhomocysteinemia– Homocysteine lowering to prevent CHD
events has been shown to be ineffective or possibly harmful in randomized clinical trials
Source: National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002,; Mosca 2007, Bønaa 2006, Loscalzo 2006
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Relative Risk of CV Events According to Baseline Levels of High sensitivity C-reactive protein (hs-CRP) in Healthy
Postmenopausal Women
2.1 2.1
4.4
1
0
1
2
3
4
5
Median = 0.06 mg/dl Median = 0.19 mg/dl Median = 2.1 mg/dl Median = 4.4 mg/dl
Quartile of Plasma Levels
Relative Risk
P for trend < 0.001Source: National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002, Ridker 2000
(Ref.)
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Fibrinogen Levels and CHD Risk in Women
1.00
1.70
2.19
2.98
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
≤ 2.8 > 2.8, ≤ 3.1 > 3.1, ≤ 3.6 > 3.6
Fibrinogen, g/L
Odds Ratio for
CV Event*
32
*Adjusted for age, smoking, BMI, systolic blood pressure, total cholesterol, HDL, triglycerides, and educational level
P for trend <0.0001
Source: Eriksson 1999
(Ref.)
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Relative Risk of CV Events According to Baseline Levels of Homocysteine in
Healthy Postmenopausal Women
1.1 1.1
2.0
1.0
0.0
0.5
1.0
1.5
2.0
2.5
Median = 8.2 mol/L Median = 10.3 mol/L Median = 12.1 mol/L Median = 15.7 mol/L
Quartile of Plasma Levels
Relative Risk
P for trend = 0.02 (not significant)
Source: Ridker 2000, Bønaa 2006, Loscalzo 2006
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The Norwegian Vitamin Trial (NORVIT): Homocysteine
Lowering Did Not Reduce CV Events in Women with Prior MI
1.07 1.10
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Folic Acid and B12* Folic Acid, B12, and B6**
RelativeRisk of CV Event
*Compared to
B12 aloneSource: Bønaa 2006
**Compared to placebo
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Psychosocial Stressors in Women with CHD: The Stockholm Female
Coronary Risk Study
• Among women who were married or cohabitating with a male partner, marital stress was associated with nearly 3-fold increased risk of recurrent CHD events
• Living alone and work stress did not significantly increase recurrent CHD events
35Source: Orth-Gomer 2000
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Depression and CVD
• Depression is an independent predictor of CHD death among women with no history of CHD
• Screening and treatment for depression has not been shown to improve clinical outcomes, however,
• Depression may reduce adherence to CVD medications, therefore, screening is recommended for women with CVD
36Source: Mosca 2011, Wassertheil-Smoller 2004
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The Heart Truth Professional Education Campaign Website
www.womenshealth.gov/heart-truth
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