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Women and Coronary Artery Disease (CAD). Module 2 Risk Factors and Gender Differences. Supported by an unrestricted educational grant from Fujisawa Healthcare, Inc. Gender Differences in Atherosclerosis.

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women and coronary artery disease cad

Women and Coronary Artery Disease (CAD)

Module 2 Risk Factors and Gender Differences

gender differences in atherosclerosis
Gender Differences in Atherosclerosis
  • Women undergoing coronary angiography have more diffuse atherosclerosis measured by IVUS, more total compromised lumen adjusted for BSA throughout the arterial tree compared to men (WISE study)
  • Women and men have similar magnitude of atherosclerosis, but it looks and functions differently, possibly for estrogen-related reasons.
  • A consequence of more diffuse atherosclerosis might be more microvascular disease (limited flow reserve) that is not due to obvious obstructive disease*
  • *C. Noel Bairey-Merz. WISE study data ACC 3/2002
gender differences in atherosclerosis4
Gender Differences in Atherosclerosis
  • 1996 Farb et al: two distinct plaque morphologies in sudden coronary death (SCD)
  • Plaque rupture: thin fibrous cap over a large necrotic core heavily infiltrated by foamy macrophages: 60% of thrombi in SCD
  • Plaque Erosion: thrombus over a base rich in smooth muscle with a proteoglycan-rich matrix (necrotic core is often absent): 40% of thrombi in SCD
  • Farb A, et al. Circulation. 1996
gender differences in atherosclerosis5
Gender Differences in Atherosclerosis
  • 1999 Arbustini et al: Plaque erosion: major substrate for coronary thrombosis in acute myocardial infarction (MI); 291/298 patients (98% with MI) had coronary thrombi at autopsy
  • Of the 25% of this autopsy cohort with plaque erosion: women = 37% and men = 18%
  • Arbustini E, et al. Heart. 1999
gender differences in atherosclerosis6
Gender Differences in Atherosclerosis
  • 1998 Burke et al: effect of risk factors on the mechanism of acute thrombosis and SCD in women (N = 51 women died from SCD)
  • Plaque erosion was highly correlated with cigarette smoking and was the most frequent type of coronary thrombosis seen in women <50 years
  • Plaque rupture: most frequent mode of coronary thrombosis in women >50 years and correlated with elevated serum total cholesterol
  • Burke AP, et al. Circulation. 1998
gender differences in atherosclerosis7
Gender Differences in Atherosclerosis
  • Older women who die suddenly of coronary thrombosis or hypercholesterolemia have plaque rupture in contrast to plaque erosion and have severe coronary arterial stenosis and a large burden of calcium plaque
  • Younger women who die suddenly of coronary thrombosis: cigarette smokers, plaque erosion, relatively little coronary arterial narrowing, and less calcium plaque at autopsy
  • Burke AP, et al. Circulation. 1998
gender differences in atherosclerosis8
Gender Differences in Atherosclerosis
  • Potential explanations
    • Estrogen reduces cellular hypertrophy and enhances vessel wall elasticity, possibly contributing to less lumen intrusion for the same amount of atherosclerosis
    • Estrogen reduces smooth muscle cell migration and lower collagen deposition in response to injury, which may lead to thinner fibrous plaque in women
    • Estrogen and progesterone upregulate degradative collagenases and inflammatory markers (hsCRP)
gender differences in heart attack symptoms
Typical in both sexes

Pain, pressure, squeezing, or stabbing pain in the chest

Pain radiating to neck, shoulder, back, arm, or jaw

Pounding heart, change in rhythm

Difficulty breathing

Heartburn, nausea, vomiting, abdominal pain

Cold sweats or clammy skin

Dizziness

Typical in women

Milder symptoms (without chest pain)

Sudden onset of weakness, shortness of breath, fatigue, body aches, or overall feeling of illness (without chest pain)

Unusual feeling or mild discomfort in the back, chest, arm, neck, or jaw (without chest pain)

Gender Differences in Heart Attack Symptoms
gender differences in emergency department presentation for cad without chest pain
Gender Differences in Emergency Department Presentation for CAD Without Chest Pain

Milner KA, et al. Am J Cardiol. 1999

less common heart attack symptoms in women
Less Common Heart Attack Symptoms in Women
  • Milder symptoms without accompanying chest pain
  • Sudden onset of weakness, shortness of breath, fatigue, body aches, overall feeling of illness
  • Burning sensation in the chest, may be mistaken as heartburn
  • An “unusual” feeling or mild discomfort in the back, chest, arm, neck, or jaw
women and cad

Women and CAD

Which Risk Factors Predispose Women to CAD?

major risk factors for heart disease
Major Risk Factorsfor Heart Disease

Grundy SM, et al. Circulation. 1998; Grundy SM. Circulation. 1999 Braunwald E. N Engl J Med. 1997; Grundy SM, et al. J Am Coll Cardiol. 1999

emerging risk factors
Emerging Risk Factors
  • Lipoprotein (a)
  • Homocysteine
  • Prothrombotic factors
  • Proinflammatory factors
  • Impaired fasting glucose
  • Subclinical atherosclerosis
    • Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease)
    • Abnormal internal or common carotid, ankle-arm index <0.9, coronary Ca2+
correlation of electron beam tomography ebt calcium and low density lipoprotein ldl cholesterol
Correlation of Electron-Beam Tomography (EBT) Calcium and Low Density Lipoprotein (LDL) Cholesterol

r = 0.06, P = 0.49

Hecht. J Am Coll Cardiol. 2001

us adults with high blood pressure 1988 1994
US Adults With High Blood Pressure (1988-1994)

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

predicted cardiac survival by peak systolic blood pressure

1

0.98

P < .001

0.96

0.94

1.5-year survival rates

0.92

0.9

Men

0.88

Women

0.86

50

100

150

200

250

300

Peak systolic blood pressure (mm Hg)

Predicted Cardiac Survival by Peak Systolic Blood Pressure

Shaw LJ. AHA abstract. 2000

us adults with ldl cholesterol of 130 mg dl or higher 1988 1994
US Adults With LDL Cholesterol of 130 mg/dL or Higher (1988-1994)

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

diabetes creates higher risks for women with cad
Diabetes Creates Higher Risks for Women With CAD
  • 65% of diabetics die from heart disease or stroke
  • 4.2 million American women have diabetes
    • Diabetes increases CAD risk 3-fold to 7-fold in women vs 2-fold to 3-fold in men
    • Diabetes doubles the risk of second heart attack in women but not in men
  • Every year, heart disease kills 50,000 more American women than men
  • Statistics are particularly high among African American women

American Heart Association

Centers for Disease Control and Prevention

Manson JE, et al. Prevention of Myocardial Infarction. 1996

lowest survival rates for diabetic women
Lowest Survival Rates for Diabetic Women
  • CAD mortality rates in diabetics, especially women, have not decreased to the same extent as those in the general population
  • In a large cohort referred for coronary disease, diabetic women had the highest mortality rates
    • Estimate of ischemic burden with stress myocardial perfusion imaging significantly improved risk stratification in diabetic women compared with clinical risk alone
    • Stratification by the number of ischemic vessels demonstrated a significant linear increase in cardiac events with escalating ischemic burden (sex-diabetes interaction, P = .016)

Gu K, et al. JAMA. 1999

Giri S, et al. Circulation. 2002

lowest survival rates for diabetic women23
Lowest Survival Rates for Diabetic Women

Giri S, et al. Circulation. 2002

diabetes powerful risk factor for cad in women
Diabetes: Powerful Risk Factor for CAD in Women
  • Framingham Heart Study
    • Women with diabetes mellitus had relative risk of 5.4% for CAD vs women without diabetes
    • Men with diabetes had relative risk of 2.4%
  • Nurses’ Health Study
    • Relative risk of 6.3% for total cardiovascular (CV) mortality
    • Even if women had diabetes for <4 years, their risk of CAD was significantly elevated

Kannel W. Am Heart J. 1987

Manson J, et al. Arch Intern Med. 1991

diabetes mellitus in us higher mortality risk in women
Diabetes Mellitus in US: Higher Mortality Risk in Women

Geiss LS, et al. Diabetes in America (2nd ed). 1995

diabetes high blood sugar
Diabetes: High Blood Sugar
  • Diabetes is a abnormally high level of blood sugar (or glucose) indicating the body’s inability to process glucose
  • ~ 6 million women in the US have physician-diagnosed diabetes
    • ~ 3 million are undiagnosed
  • Risk of death from heart disease is 3 times higher in women with diabetes
  • Diabetes doubles the risk of a second heart attack in women but not in men
gender differences in risk factors diabetes mellitus
Gender Differences in Risk Factors: Diabetes Mellitus
  • Far more powerful coronary risk factor for women than men, negating much of the protective effects of the female sex
  • Nurses Health Study: maturity onset diabetes  3- to 7-fold increase in risk of a CV event
  • The coronary prognosis is substantially worse for diabetic women than diabetic men: diabetic women with MI have doubled the risk of reinfarction and 4-fold likelihood of developing heart failure
  • Coronary revascularization: women diabetics > male diabetics (may be a factor in the less favorable outcome of women)
diabetes a major risk factor for heart disease
Diabetes: A Major Risk Factor for Heart Disease
  • Majority of people with type 2 (adult-onset) diabetes have additional risk factors for heart disease
  • 2 out of 3 people with diabetes die of some type of cardiovascular disease (CVD)
  • Aggressive therapy for diabetes and high blood pressure is usually needed and can reduce your risk of heart disease and its associated complications

Robertson C, RN. 2001; Grundy SM et al. Circulation. 1998; American Heart Association. 2001 Heart and Stroke Statistical Update. 2000; Bakris GL, et al, Am J Kid Dis. 2000

gender differences in risk factors elevated cholesterol
Gender Differences in Risk Factors: Elevated Cholesterol
  • Secondary prevention
    • 4S trial (Scandinavian Simvastatin Survival Study)
    • 4444 men and women with angina or prior MI randomized to placebo or simvastatin
    • 827 women
    • Overall mortality benefit with a 35% reduction in major cardiac events
  • Primary prevention
    • Observational data: decrease in LDL and increase in high density lipoprotein (HDL) reduced CAD risk
      • Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS): women experienced a 46% reduction in first major coronary event with an average 25% reduction in LDL cholesterol
clinical identification of the metabolic syndrome
Clinical Identification of the Metabolic Syndrome
  • Abdominal obesity
    • Men >102 cm (>40 in)
    • Women >88 cm (>35 in)
  • Triglycerides (TG) >150 mg/dL
  • HDL cholesterol
    • Women <50 mg/dL
    • Men <40 mg/dL
  • Blood pressure >130/>85 mm Hg
  • Fasting glucose >110 mg/dL

National Heart, Lung, and Blood Institute

women and cad risk factors
Women and CAD Risk Factors
  • Higher prevalence of avoidable risk factors1
    • ↑ blood cholesterol
    • ↑ physical inactivity
    • ↑ overweight (body mass index, 25.0-29.9)
  • Diabetes is a more powerful risk factor for CAD2
    • 3- to 7-fold in women vs 2- to 3-fold in men
  • ↓ HDL cholesterol levels more predictive of CAD2
  • Women counseled less about nutrition, exercise, and weight control2

1. American Heart Association. 1999 Heart and Stroke Statistical Update. 1998

2. Mosca L, et al. Circulation. 1999

mi or death often first sign of cad
MI or Death Often First Sign of CAD

Levy D, et al. Textbook of Cardiovascular Medicine. 1998

impact of cholesterol levels on risk of death
Impact of Cholesterol Levels on Risk of Death

Neaton JD, et al. Arch Intern Med. 1992

simvastatin survival study significant event reduction in men and women
Simvastatin Survival StudySignificant Event* Reduction in Men and Women

0

-10

-20

Percent risk reduction

P < .00001

P = .01

-30

Women

-34%

Men

n = 3,617

-35%

Women

n = 827

Men

-40

-50

*Includes coronary heart disease (CHD) death; definite or probable nonfatal MI; or

resuscitated cardiac arrest. Simvastatin reduced the risk of heart attacks* as effectively for

women as for men. Because there were only 53 female deaths, the effect of simvastatin on

mortality in women could not be adequately assessed.

The Scandinavian Simvastatin Survival Study. Lancet. 1994

lovastatin reduced the risk of first acute major coronary events in the afcaps trial

Men

n = 5608

Women

n = 997

Older

n = 3180

Smokers

n = 818

Hypertension

n = 1448

Diabetes

n = 155

0

-10

-20

-30

Percent risk reduction

-31%

-37%

-40

-38%

-42%

-50

-46%

-58%

-60

Lovastatin Reduced the Risk of First Acute Major Coronary Events in the AFCAPS Trial
smoking
Smoking
  • Single most preventable cause of death in US
  • Smoking by women causes 150% more deaths from heart disease than lung cancer
  • Women who smoke are 2-6 times more likely to suffer a heart attack
  • Use of birth control pills in smokers compounds cardiac risk
overweight
Overweight

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

overweight and obesity in us adults
Overweight and Obesity in US Adults

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

moderate or vigorous physical activity in us adults

Men

Women

Moderate or Vigorous Physical Activity in US Adults

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

physical inactivity
Physical Inactivity
  • Lack of exercise is a proven risk factor for heart disease
    • A lack of regular physical exercise is a growing epidemic in the US
  • Heart disease is twice as likely to develop in inactive people than in those who are more active
  • Physical activity helps maintain weight, blood pressure, and diabetes
  • Women should exercise to increase heart rate for 20-30 minutes a day, 3-5 times per week
cad risk factors goals
CAD Risk Factors: Goals

Grundy SM, et al. Circulation. 1999. American Heart Association Consensus Panel. Circulation. 1995; The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the National High Blood Pressure Education Program Coordinating Committee. Arch Intern Med. 1997

major risk factors
Major Risk Factors
  • Diabetes mellitus – CHD risk equivalent
  • Cigarette smoking
  • Hypertension (blood pressure >140/90 mm Hg or on anti-hypertensive medications)
  • Low HDL cholesterol (<40 mg/dL)
  • Family history premature CHD (in male first relative <55 years; in female first relative <65 years)
  • Age (men >45 years; women >55 years)
  • High LDL cholesterol (>160 mg/dL)

Risk Categories LDL Goal

CHD or risk equivalent (DM, ASHD) <100

2+ risk factors <130

0-1 risk factor <160

  • CHD risk equivalent = 20% - city of Nashville households w/ female adults (n = 500,000)

Shaw LJ. Am J Managed Care. 2001

National Heart, Lung, and Blood Institute

hormonal effects on ischemia and disease prevalence
Hormonal Effects on Ischemia and Disease Prevalence
  • Premenopause
    • Estrogen has digoxin-like effect:  ST 
  • Post-menopause effect on HRT
    •  ST  - vasodilatory effects of HRT
    • Increase exercise duration/decrease chest pain
  • Women with intact uterus take progestin to protect against uterine malignancies
    • Estrogen and medroxyprogesterone attenuate this effect

Lloyd GW, et al. Heart. 2000; Webb CM, et al. Lancet. 1998;

Morise AP, et al. Am J Cardiol. 1993; Rosano GM, et al. J Am Coll Cardiol. 2000

hormonal effects on ischemia and disease prevalence47
Hormonal Effects on Ischemia and Disease Prevalence
  • Estrogen modulates chest pain syndromes
  • Premenopausal CAD: angina/ischemia variation by menstrual cycle
    • Early follicular phase estradiol and progesterone levels - low < time to ischemia onset
    • Mid-cycle estrogen levels - highest > time to ischemia onset

Lloyd GW, et al. Heart. 2000; Webb CM, et al. Lancet. 1998;

Morise AP, et al. Am J Cardiol. 1993; Rosano GM, et al. J Am Coll Cardiol. 2000

postmenopausal hormone therapy and cardioprotection
Postmenopausal Hormone Therapy and Cardioprotection
  • First randomized trial
  • HERS trial (Heart and Estrogen/Progestin Replacement Study)
    • Secondary CAD prevention trial
    • Randomized trial of placebo vs estrogen and medroxyprogesterone
    • Follow-up = 4 years
    • N = 2,763 women with an intact uterus
    • Outcome measures
      • Primary: nonfatal MI or cardiac death
      • Secondary: unstable angina, coronary revascularization, congestive heart failure

HERS trial. JAMA. 1998.

is there a role for hrt
Is There a Role for HRT?
  • Secondary prevention
    • 1998: HERS
      • 4 years of treatment with conjugated estrogen plus medroxyprogesterone acetate
      • No reduction in the risk of MI and coronary death in women with established CAD

HERS trial. JAMA. 1998.

is there a role for hrt50
Is There a Role for HRT?
  • Secondary prevention
    • 3/2000: Estrogen Replacement and Atherosclerosis trial (ERA)
      • 309 postmenopausal women with CAD
      • Placebo vs conjugated estrogen (.625 mg/day) vs conjugated estrogen (.625 mg/day) with medroxyprogesterone acetate (2.5 mg/day)
      • Angiographic analysis of the diameter of the coronary arteries at the start of the study and 3 years later
  • ERA trial results at follow-up angiography
    • The progression of coronary atherosclerosis was unchanged in the women randomized to either of the estrogen groups

ERA trial. J Am Coll Cardiol. 2001

is there a role for hrt51
Is There A Role for HRT?
  • Primary prevention
    • Women’s Health Initiative
      • 160,000 women:1991-2005
      • Initial results: no cardioprotection attributed to HRT in women on HRT
  • American Heart Association: HRT not recommended for primary or secondary cardioprotection
conclusions

Conclusions

Risk Factor Management

conclusions risk factor management
Conclusions: Risk Factor Management
  • CVD begins in childhood and is strongly associated with major risk factors for heart disease
  • Multiple risk factors require more aggressive management
  • Aggressive risk-factor modification (often with multiple medications) is the most effective strategy for reducing the consequences of heart disease

Berenson GS, et al. N Engl J Med. 1998. Neaton JD, et al. Arch Intern Med. 1992. Kannel WB. in Atherosclerosis and Coronary Artery Disease. 1996. Grundy SM, et al. Circulation. 1999

gender differences in cad risk factors
Gender Differences in CAD Risk Factors
  • Increasing recognition that athersosclerosis is an inflammatory process
  • Ridker PM, et al: A prospective case-controlled study among 28,263 postmenopausal women
    • Among 12 markers of inflammation, C reactive protein was the strongest univariate predictor of the risk of CV events

Ridker PM, et al. N Engl J Med. 2000

diagnosis and management of cad in women
Diagnosis and Management of CAD in Women
  • Gender differences: presentation, manifestation, and diagnosis of CAD
  • Gender differences in mortality
    • 63% of women who die suddenly from CAD had no prior warning symptoms
    • 42% of women vs 24% of men will die within 1 year after MI
  • Thus, early recognition of symptoms and accurate diagnosis of CAD is of great importance
heart disease in women lessons from the past decade
Heart Disease in Women: Lessons From the Past Decade
  • The importance of studying gender-specific aspects of CAD have helped in the following clinical dilemmas:
    • Presentation of CAD: women are older than men
    • Less specific clinical manifestations of CAD in women
    • Greater difficulty in diagnosis: women > men
    • More severe consequences on MI when it occurs in women
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