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Men are from Mars, Women are from Venus

Men are from Mars, Women are from Venus. Gender Differences in Cardiac and Vascular Disease. Karen Reinhard ACNP, Cardiothoracic Surgery University of Arizona Health Network September 15, 2012. Objectives.

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Men are from Mars, Women are from Venus

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  1. Men are from Mars,Women are from Venus Gender Differences in Cardiac and Vascular Disease Karen Reinhard ACNP, Cardiothoracic Surgery University of Arizona Health Network September 15, 2012

  2. Objectives • Discuss differences with regard to vascular and cardiac disease in women as it relates to : • Awareness, incidence, prevalence, outcomes • Research • Pathophysiology • Clinical presentation • Prevention and intervention • Identify • Strategies to assess/stratify risk • Lifestyle approaches to prevention • EBP guidelines for prevention based on 2011 AHA Guidelines for Prevention of CVD in Women

  3. Definitions • CVD • Cardiovascular Disease • CVA • Ischemic/embolic stroke • CHD or CAD • Coronary Heart/Artery Disease • PAD • Peripheral Arterial Disease

  4. Peripheral Vascular Disease • Venous • Venous Thromboembolism (VTE) • DVT and PE • Occurs in 1-3/1000 people in the general population • Risk Factors • Obesity • 2-3 x risk • Unique risk factors for women • Pregnancy • 4 to 5-fold increase • Oral contraceptives Caprini, 2005; White, 2003; James; 2009

  5. Awareness • In a study conducted by the AHA in 1997, only 7% of women thought CVD was their greatest health risk • In a follow-up survey in 2003, almost half of the women identified CVD as a leading cause of death and 13% thought it was their leading health problem Mosca, Ferris, Fabunmi, & Robertson, 2004

  6. Awareness • Health care provider awareness • On-line, cross-sectional study of 500 physicians • Lower perceived risk of CVD for women • Awareness/implementation of prevention guidelines varied by specialty • OB/Gyn substantially less aware • 67% of the OB/Gyn’s identified themselves as the PCP for their patient’s Mosca,.L. et al. , 2005

  7. Awareness Prevalence Awareness Hirsch, AT et al., 2007

  8. Why is it important? Deaths due to diseases of the heart - United States: 1900–2007 Roger, V.L. et al., 2011

  9. Why is it important? Roger, V.L. et al., 2011

  10. Why is it important? Cardiovascular Disease Mortality – U.S. Males and Females, 1980 - 2004 Rosamond W, et al., 2008

  11. Why is it important? Annual # of U.S. Adults Diagnosed with MI and Fatal CHD by Age/Sex: 1987 - 2004 Rosamond W, et al., 2008

  12. Why is it important? Rosamond W, et al., 2008

  13. Women as CaregiversAfter a Stroke • Stroke will affect 4 out of 5 families over the course of a lifetime • More than half (59-75%) of all family caregivers in the United States are women • The average caregiver is a married 46-year-old working woman earning $36,000 per year http://www.stroke.org/site/PageServer?pagename=WOMCOMP

  14. PAD and Women • Patients with symptomatic PAD alone had nearly one-third more major cardiovascular events than patients with CAD alone, and over 75% more than patients with Cerebrovascular Disease alone.  • Although the age-dependent prevalence of PAD in adult women is lower than for men, the total population burden of PAD appears to be higher Hirsch et al., 2012

  15. PAD and Women • Women with PAD have faster functional decline and greater mobility loss than men with PAD • Trend exists that suggests higher CVD events for women than for men with ABI < 0.9 Hirsch et al., 2012; McDermott et al., 2011

  16. Risk Factors • The same risk factors exist for men and women BUT risk factors for CVD behave differently in men and women • Magnitude and type of contribution • Magnitude for developing CVD related to smoking is somewhat greater in women • Relative risk of CHD in women with DM is 2x that of men Nauman, 2010

  17. Risk Factors • Some possible, unique risk factors • Pregnancy • Pre-eclampsia • Hormone replacement therapy/Oral contraceptives • Other suggested risk factors…… • Metabolic Syndrome, anemia, hsCRP, autoimmune disease Bellamy, L., Casas, J., Hingorani, A.D., Williams, D.J., 2007

  18. Disease Development • Different pathophysiology is suggested by…. • Women show less obstructive CHD compared to men with the same degree of • Syndrome of chest pain without obstructive coronary artery disease (CAD) is distinctly more common in women than in men • Women, show higher rates of adverse outcomes after acute myocardial infarction than men

  19. Clinical Presentation

  20. Clinical Presentation • Stroke symptoms include: • SUDDEN numbness or weakness of face, arm or leg - especially on one side of the body. • SUDDEN confusion, trouble speaking or understanding. • SUDDEN trouble seeing in one or both eyes. • SUDDEN trouble walking, dizziness, loss of balance or coordination. • SUDDEN severe headache with no known cause. http://www.stroke.org/site/PageServer?pagename=WOMSYMP

  21. Clinical Presentation • A study conducted at the University of Michigan interviewed patients presenting with ischemic stroke or TIA during the period January 2005 through December 2007 concluded that women were 1.42 times more likely to present with “non-traditional” symptoms than men, symptoms such as… • Pain • Lightheadedness • Headaches • Mental status changes — disorientation, confusion, or loss of consciousness http://www.stroke.org/site/PageServer?pagename=WOMSYMP

  22. Clinical Presentation • Other unique symptoms women may describe with CVA: • Sudden face and limb pain • Sudden hiccups • Sudden nausea • Sudden general weakness • Sudden chest pain • Sudden shortness of breath • Sudden palpitations http://www.stroke.org/site/PageServer?pagename=WOMSYMP

  23. Clinical Presentation • Symptoms of a heart attack include • Pain or discomfort in the jaw, neck, or back • Feeling weak, light-headed, or faint • Chest pain or discomfort • Pain or discomfort in arms or shoulder • Shortness of breath http://www.cdc.gov/heartdisease/signs_symptoms.htm

  24. Clinical Presentation • Women with ACS are more likely than men to present with “atypical” symptoms including • Dyspnea • Shortness of breath • Indigestion • Middle or upper back pain • Nausea/vomiting • Unexplained weakness and fatigue • Sense of doom Finks, S., 2010

  25. Clinical Presentation • Symptoms of PAD include • Intermittent claudication • Cramping, aching, numbness, tiredness, weakness, or burning in buttock, thigh, calf or foot occurring with walking • Skin may appear pale and feel cool to the touch • Foot/toe pain or tingling that does not go away with rest, pain may be worse when the leg is elevated and improve when leg is dependent position • A feeling that the hip or leg is "giving out" during walking • Skin wounds or ulcers of legs or feet that heal slowly or do not heal at all Women and vascular disease, 2012; http://www.hearthealthywomen.org/cardiovascular-disease/featured/pad-legs.html

  26. Prevention • First published guidelines for prevention of cardiovascular disease in women were in 1999 by the American Heart Association • Updated in 2004 and 2007 • Most recent updates were published in 2011

  27. ALOHA: Five-step approach to prevention • Assess and stratify women into high risk, at risk, and ideal CV health • Lifestyle approaches recommended for all women • Other CVD interventions • Treatment of HTN, DM, lipid abnormalities • Highest priority is for high risk patients • Avoid initiating therapies that lack benefit or where risk > benefit

  28. Risk Stratification • Estimating the probability of experiencing a coronary artery disease event during a 10-year period • Historically used is the FRAMINGHAM RISK SCORE • A FRS score of greater than 20% can accurately identify a woman at high risk • BUT….a lower score potentially underestimates a woman’s true risk of a CVD event • Other methods • AHA Primary Prevention of CVD in Women Guidelines • Reynolds Risk Score • Recalibrated FRS Finks, S., 2010

  29. Risk Stratification • AHA classification of CVD risk in women (2011) • High Risk • DM or documented atherosclerotic disease (CVA, CHD, PAD, AAA) • Includes those with CKD, FRS > 20% • At Risk • > 1 major risk factors for CVD • Tobacco abuse, HTN, HLD, family hx, obesity, physical inactivity, poor diet • Metabolic Syndrome • Evidence of subclinical CAD • Ideal Cardiovascular Health • No risk factors • Healthy lifestyle

  30. Prevention/Intervention • Lifestyle interventions • Smoking cessation • Physical activity • Weight reduction/maintenance • Heart healthy diet Mosca L, Benjamin EJ, Berra K, et al., 2011

  31. Relative Risk of Coronary Events for Smokers Compared to Non-Smokers Stampfer, MJ, et al., 2000

  32. Risk Reduction for CHD Associated with Exercise in Women Manson JE, et al., 1999

  33. Body Weight and CHD Mortality Among Women P for trend < 0.001 Manson JE, et al., 1995

  34. Weight Reduction/Maintenance • Women should maintain or lose weight through an appropriate balance of physical activity, calorie intake, and formal behavioral programs when indicated to maintain: • BMI between 18.5 and 24.9 kg/m² • Waist circumference < 35 inches Mosca L, Benjamin EJ, Berra K, et al., 2011

  35. Low Risk Diet is Associated with Lower Risk of Myocardial Infarction in Women Relative Risk of MI* *Adjusted for other cardiovascular risk factors P< .05 for quintiles 3-5 compared to 1-2 Diet Score by Quintile (1= least vegetables, fruit, whole grains, fish, legumes) Akesson A, et al., 2007

  36. Major Risk Factor Interventions Blood Pressure Lipids Diabetes Mosca L, Benjamin EJ, Berra K, et al., 2011

  37. Blood Pressure • Relationship between BP and CV events is continuous, consistent, and independent of other risk factors • Can reduce BP with lifestyle modifications • Weight reduction – 5-20 mmHg/10kg weight loss • DASH – 8-14 mmHg • Sodium restriction – 2-8 mmHg • Physical activity – 4-9 mmHg • Reduced EToH – 2-4 mmHg Mosca L, Benjamin EJ, Berra K, et al., 2011

  38. Lipids • Optimal levels of lipids and lipoproteins in women are as follows (these should be encouraged in all women with lifestyle approaches): • LDL < 100mg/dL • HDL > 50m/dL • Triglycerides < 150mg/d • Non-HDL (total cholesterol minus HDL) < 130mg/d • Goals and target for initiation of treatment based on risk stratification Mosca L, Benjamin EJ, Berra K, et al., 2011

  39. Diabetes • Treatment of hyperglycemia has been shown to reduce or delay complications of diabetes such as retinopathy, neuropathy, and nephropathy • Keep HBA1C < 7% Mosca L, Benjamin EJ, Berra K, et al., 2011

  40. Summary • CVD is largely preventable • CVD which includes CVA, CHD/CAD and PAD is a significant and under recognized health issue for women • CVD may have different pathophysiology in women • Women with CVD may have different clinical signs and symptoms • Women may respond differently to intervention • Recommend healthy lifestyle changes for all women • Identify those at risk, and implement prevention strategies

  41. Thank You!Have a great weekend

  42. References • About the heart truth. (2012, February 29). Retrieved from http://www.nhbli.nih.gov/educational/hearttruth/about/index.htm • Caprini, J. A. (2005). Risk factors for venousthromboembolism. The American Journal of Medicine: Continuing Medical Education Series, Retrieved from http://www.venousdisease.com/Publications/Update on risk factors-caprini.pdf • Finks, S. (2010). Cardiovascular disease in women. In Pharmacotherapy Self-Assessment Program: Cardiology (7 ed., Vol. 1, pp. 179-199). American College of Clinical Pharmacy. • Hayes, S.N. (2006). Preventing Cardiovascular Disease in Women. American Family Physician, 74(8), 1331-1340. • Hirsch, A.T., Murphy, T.P., Lovell, M.B., Twillman, G., Treat-Jacobson, D., Harwood, E.M., Mohler, E.R., …Criqui, M.H. (2007). Gaps in Public Knowledge of Peripheral Arterial Disease: The First National PAD Public Awareness Survey. Circulation, 116, 2086-2094. • James, A.H. (2009). Venous Thromboembolism in Pregnancy. Arteriosclerosis, Thrombosis & Vascular Biology. 29(3), 326-331. • Mosca, L., Appel, L.J., Benjamin, E.J., Berra, K., Chandra-Strobos, N., Fabunmi, R.P., Grady, D., … Williams, C.L. (2004). Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women. Circulation, 109, 672-693. • Mosca, L., Banka, C.L., Benjamin, E.J., Berra, K., Bushnell, C., Dolor, R.J., Ganiats, T.G,…Wenger, N.K. (2007). Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. Circulation, 115, 1481-1501. • Mosca, L., Barrett-Connor, E., & Wenger, N. (2011). Sex/gender differences in cardiovascular disease prevention: What a difference a decade makes. Circulation, 124, 2145-2154. • Mosca, L., Benjamin, E., Berra, K., Bezanson, J., Dolor, R., Lloyd-Jones, D., Newby, L., … Zhao, D. (2011). Effectiveness-based guidelines for the prevention of cardiovascular disease in women - 2011 update. Circulation, 123, 1243-1262. • Mosca, L., Linfante, A.H., Benjamin, E.J., Berra, K., Hayes, S.N., Walsh, W., Fabunmi, R.P. … Simpson, S.L. (2005). National Study of Physician Awareness and Adherence to Cardiovascular Disease Prevention Guidelines. Circulation, 111, 499-510. • Mosca, L., Ferris, A., Fabunmi, R., Robertson, R.M. (2003) Tracking women’s awareness of heart disease: an American Heart Association study. Circulation, 109, 573-579. • Roger, V.L., Go, A.S., Lloyd-Jones, D.M., Adams, R.J., Berry, J.D., Brown, T.M., Carnethon, M.R., … Wylie-Rosett, J. (2011). Heart Disease and Stroke Statistics – 2011 Update: A Report From the American Heart Association. Circulation, 123, e18-e209. • White, R.H. (2003). The Epidemiology of Venous Thromboembolism. Circulation, 107, I4-I8.

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