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Cardiac Disease in Women: How One T hing Can L ead to Another

Cardiac Disease in Women: How One T hing Can L ead to Another. Brattleboro Memorial Hospital May 3, 2014 Sheila M Conley, BSN RN Quality Improvement Associate – Clinical Cardiology. Presentation Goals. Basics of normal circulation Understand Cardiac disease in women

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Cardiac Disease in Women: How One T hing Can L ead to Another

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  1. Cardiac Disease in Women:How One Thing Can Lead to Another Brattleboro Memorial Hospital May 3, 2014 Sheila M Conley, BSN RN Quality Improvement Associate – Clinical Cardiology

  2. Presentation Goals • Basics of normal circulation • Understand Cardiac disease in women • Outline the current system in place to support patients with STEMI in greater Brattleboro area • Emphasize steps every woman can take to minimize risk • Understand where to get additional information

  3. What do you mean: “How one thing leads to another?”

  4. Major Types of Cardiovascular Disease • Plumbing • Coronary Artery Disease • Electrical • Sudden Cardiac Arrest, Pacemakers, ICDs • Structural • Patent Foramen Ovale, Valvular disease • Congenital • These kids are becoming grown ups! • Any combination there of!

  5. Normal Circulation Right Heart de-oxygenated blood is returned to the heart from veins. Right ventricles sends this blood to the lungs via pulmonary arteries for the O2 CO2 exchange. Left heart receives oxygenated blood from pulmonary veins and the left ventricle sends oxygenated blood to the body through the big artery – aorta. First arteries to branch off the aorta are the coronary arteries..

  6. Normal Electrical Conduction

  7. Cardiovascular disease is the leading cause of death in women, outnumbering deaths from all other causes combined. Each year, >500,000 women experience an MI and >250,000 die of CAD. Prevalence of cardiovascular disease in women, including CAD, CHF, stroke, and HTN, exceeds that in men in the population >55 years. Mortality rate from cardiovascular disease in men has declined steadily during the past 20 years. In women, unfortunately, this rate has remained relatively unchanged. Despite the magnitude of the problem, on average only 25% of subjects in most cardiovascular trials are women. The Numbers Please

  8. Evaluation of women with symptoms suggestive of IHD is hampered by the definition of “typical” angina, derived from largely male populations. In a study by Dey et al, 92% of the 7,638 women with presumed ACS presented with chest pain. In women, who had atypical symptoms, dyspnea, N/V, and diaphoresis were the most common symptoms. Women with typical or atypical CP (nonexertional or prolonged discomfort unrelieved by rest) have calculated obstructive CAD probabilities substantially less than that of men. Among those undergoing coronary angiography, as many as 50% of women do not have obstructive CAD. This difference may be largely due to noncardiac chest pain, but it may also represent conditions such as vasospasm, microvascular disease, or stress cardiomyopathy, all of which disproportionally affect women. Symptom Assessment &Prevalence of Ischemia in Women

  9. Although most women with ACS present acutely with chest pain, women may have different warning signs than men. Only about one-third of women experience angina before presentation. Compared with men, women are more likely to complain of shortness of breath, fatigue, and weakness leading up to a diagnosis of an MI. Therefore, the symptoms leading up to cardiovascular disease may in fact be significantly more atypical in women than in men, suggesting the need for heightened vigilance in the CV evaluation of women who have non-anginal symptoms. Atypical warning signs

  10. One factor contributing to relatively greater IHD risk in women is less intensive use of indicated medical therapy (aspirin, beta-blocker, statin, ACEI, therapeutic lifestyle counseling), despite specific guidelines noting their benefit. The Cooperative Cardiovascular Project showed that women received less medical treatment after MI, including 5% that received fewer prescriptions of aspirin at discharge; although they were 5% more likely than men to receive ACE inhibitors, perhaps as the result of Hypertension. A more recent registry indicates that this observation has not changed, with women receiving less (indicated) aspirin at discharge (87.5% vs. 90.4%), beta-blockers (80.5% vs. 82.7%), and statins (55.9% vs. 69.4%) compared with men. Medical Therapy for IHD in Women

  11. Women aren’t the same as men http://www.youtube.com/watch?v=_JI487DlgTA

  12. Heart attacks are not created equally! • STEMI • N-STEMI • Demand ischemia • All “chest pain” aren’t necessarily heart attacks! • Stress induced cardiomyopathy (Takatsubo) • Pericarditis

  13. What is a “STEMI”?

  14. Options for treating STEMI • Mechanical • In the cardiac cath lab, gain arterial access to open the coronary artery within 90/120 minutes of presentation to ED. • Wrist v Groin • Bare metal v Drug eluting • Not risk free but restoring circulation is critical • Medication • Provide clot busting drug IV within 30 minutes of presentation to ED. • Follow by catheterization • Not risk free

  15. Non-PCI capable hospitals STEMI  Transfer to PCI capable hospital • Lytic issues • If no lytic, then hurry up! • Helicopter? Ambulance? NSTEMI ? Transfer • It depends… Communication and process improvements have been key to our success.

  16. Upper CT Valley, ~60 m N and 45 m S on I91 and 30-40 m NW or SE on I89. 20 Referral Hospitals Zone 1 = the local area, APD and VAMC - Primary PCI Zone 1 Option = 5 hospitals that have options in treatment Zone 2 = everyone else – Thrombolytics ~20 Ambulance services 1 Helicopter based at DHMC 1 Helicopter based in Manchester The Region

  17. Ideal STEMI system schematic JACC Vol. 61 No. 4, 2013 January 29, 2013:e78-140

  18. Brattleboro Memorial Hospital is a “Sending Hospital” in the STEMI system Cardiac Caths are not performed at BMH First line treatment is an intravenous Thrombolytic “Clot-buster” that should be given within 30 minutes of presentation to Emergency Department. BMH is considered a “Zone 2 Hospital” in the DHMC STEMI Network because we can’t make a “D2B” of less than 2 hours. Default strategy is Lytic followed by angiography and revascularization.

  19. True STEMI Patients Treated at DHMC May, 2008 - February, 2014 (n=1359)

  20. True STEMI Patients Treated at DHMC May, 2008 - February, 2014 (n=1359) Overall mortality rate is 5%

  21. BMH STEMI Patients Treated at DHMC May, 2008 - February, 2014 (n=79) Entire Registry 50 – 50 % lytic treated

  22. BMH STEMI Patients Treated at DHMC May, 2008 - February, 2014 (n=79)

  23. After the “heart attack” (MI) • 2-3 days in hospital unless there are complications which could cause a longer hospital stay • Labs, additional tests, education • Referral to Cardiac Rehab • Follow up with primary care • Follow up with cardiology

  24. Complications? • Cardiac Catheterization • Dissection • Unable to open the blockage • Access site problems • Acute Kidney Injury/Radiation injury • Heart Function post infarct • Rhythm disturbances • “Pump” or Heart failure

  25. Sudden Cardiac Arrest • This is the situation you hear about with the young athletes, but it can happen to anyone of any age. Typically, it’s a conduction (electrical) defect that can be fixed. It’s important to get it fixed before there is permanent brain damage or cardiac damage. • If this happens, and an AED (Automatic External Defibrilator) is used quickly and effectively, the person will be OK, but will get an ICD. • If the person remains unconscious, they will be placed in a medication induced coma and ‘cooled.” • Therapeutic Hypothermia is the medical term and it can be started by EMS and at Brattleboro Hospital. • It’s thought that slowing down a person’s metabolism can help recover neurological function.

  26. Heart Failure is a scary diagnosis to hear. Tired out Heart • Symptoms include: • Weight gain for more than 2 days in a row • Increased weight of 2-3 pounds/day or 5 pounds in a week • Shortness of breath • Fluid retention, belt is tight or swelling in your feet and legs • Difficulty sleeping/laying flat • Frequent urination at night • Non productive cough • This can be managed with coordinated care!

  27. Get informed Understand what steps you can take to reduce your risk of heart disease. It is never too late to start. Quit Smoking! Get more active Know your numbers Reduce your stress Eat more healthfully You can’t change your genes or the past, but you can affect your future! Google “Just a little heart attack” to see the public service announcement Share it with your friends www.goredforwomen.org/has a lot of this info in small easy to take in chunks Questions? Thank you for the opportunity to speak with you today!

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