Cardiovascular Disease in Women: Common Myths

1. Cardiovascular Disease in Women: Common Myths Jon W. Wahrenberger, MD FAHA February 7, 2009

2. Disclosures • I have no financial interests to disclose … I wish I did! • I do not specialize in women’s health issues, but about half of my patients are female. • I cannot rule out the influence of my Y-chromosome • As an only son and with 4 sisters I am expected to be sensitive to women’s issues … ….but at any given time at least one of my sisters is annoyed with me about something.

3. Are women more complicated than men?

4. Hormones in Men vs. Women

5. Myth 1 Cardiovascular disease is mainly a disease of old men

6. More women are dying of CVD than Men Source: American Heart Association

7. Cardiovascular disease is the leading cause of death in women Source: American Heart Association

8. Although less frequent, CVD occurs in young women More than35,000 women under the age of 65 die annually in the US from CVD

9. Myth 2: Women don’t need to worry about cardiovascular disease before menopause

10. Relationship between early menopause and accelerated CVD? Traditional Paradigm: Menopause Increasing Risk of CVD Minimal or no CVD Risk Alternative Paradigm: Increasing Risk of CVD Menopause

11. Coronary heart disease progresses over decades Decades of time The reality: Being premenopausal probably does not protect you from cardiovascular disease and you should be vigilant at all ages … Age, Heredity Smoking, High Blood Pressure, Elevated Cholesterol, Diabetes, Inactivity, Obesity

12. Myth 3: Hormone replacement therapy is dangerous to the heart and should not be taken under any circumstances

13. Estrogen • Critical to reproductive function in men & women • Most produced by ovaries • Some arises from fat, liver, breasts, adrenals • Complex physiologic effects

14. Changing Estrogen Levels with Age Estrogen Progesterone Perimenopausal Symptoms: hot flashes, insomnia, mood changes Menopausal Physiology: osteoporosis, vaginal mucosal thinning

15. The Good and Bad of Estrogen Replacement The Good The Bad • Relief of menopausal symptoms • Reduction in osteoporosis (bone thinning) and fractures • Cardio-protective effects?? • Improvement in lipid profile • Breast cancer risk • Uterine cancer risk • Complex formulation

16. Women’s Health Initiative Estrogen + Progesterone 16,608 Post-menopausal women aged 50-79 with an intact uterus Study stopped after mean follow-up of 5.6 years Placebo • Hormonal replacement associated with: • Increased heart disease (29% ↑) • Increased stroke (41% ↑) • Increased blood clots • Increased breast cancer (26% ↑) • Reduced colon cancer • Reduced hip fracture Conclusion: HRT should not be used to prevent disease in healthy post-menopausal women

17. WHS: Caveats • Overall mortality was identical in the two groups • Event rates in both groups was low and absolute rates in the estrogen + progesterone group was low - overall risk of treatment is low • Estrogen vs. progesterone influence on outcomes is unknown

18. Women’s Health Initiative: Estrogen Only Study 10,739 Post-menopausal women aged 50-79 with previous hysterectomy Estrogen Only Study stopped after mean follow-up of 6.8 years Placebo • Estrogen replacement associated with: • 9% reduction in heart disease • 39% increase stroke • 33% increase blood clots • No change in cancer • 39% reduction hip fracture

19. Women’s Health Initiative: Estrogen Only Study Source: JAMA 2007;297:1477 Conclusion: In younger post-menopausal women post hysterectomy, estrogen alone may be beneficial

20. Oral versus Transdermal Estrogen Oral Estrogen Transdermal Estrogen • Large impact on liver metabolism • Increase in inflammatory markers • Increase in protective HDL cholesterol • Bypasses liver • No change in Inflammatory markers • Reduction in LDL • Improvement in “atherogenic index of plasma” • Reduction in oxidation index

21. Estrogen Replacement: The reality • Estrogen therapy is reasonable for the relief of perimenopausal symptoms if started early and tapered after a few years • Estrogen administered transdermally may be less likely to increase risk of blot clots • Estrogen should not be given to reduce CVD risk

22. Myth 4: Vitamin supplementation is key to preventing cardiovascular disease in women.

23. Vitamin E600 IU 636 Deaths 39,876 healthy women age ≥ 45 ~ 10 years 615 Deaths Placebo Source: JAMA. 2005;294(1):56-65

24. B-Vitamins & Health in Women Folic AcidVit. B6Vit B12 406 Events 5442 woman with CAD or ≥ 3 risk factors ~ 7 years 390 Events Placebo Source: JAMA. 2008;299(17):2027-2036

25. The Reality: • Vitamin E and B vitamins are probably safe, but there is no convincing evidence that they need be taken regularly • Some supplements (ephedra) are downright dangerous • Many supplements interact with medications • The entire supplement industry is unregulated; the safety and purity is entirely in the hands of the manufacturer.

26. Myth 5: If I’m thin and exercise regularly I should be immune to cardiovascular disease.

27. The Reality: • Inactivity and obesity are just two of many CVD risk factors, and probably not the strongest • Exercise is great but not necessarily enough!

28. Cardiac Risk Factors Non-Modifiable Modifiable • Age • Gender • Heredity • Tobacco Use • Cholesterol • Blood pressure • Diabetes • Physical inactivity • Overweight condition

29. Myth 6: Eggs are unhealthy and should not be eaten.

30. The Facts • Egg yolks do contain cholesterol • Studies have shown a clear relationship between serum cholesterol and cardiovascular disease outcomes • Studies have not shown a relationship between egg consumption and health outcomes

31. What’s in an Egg? 213 mgCholesterol 0 mgCholesterol OK to eat an egg if consistent with overall daily cholesterol limits

32. Myth 7: Most women do not experience chest pain during a heart attack – fatigue and shortness of breath are much more common.

33. The Facts • Chest discomfort is the most common symptom of a heart attack in both men and women • Women are more likely than men to have additional non-specific symptoms, including: • Fatigue • Shortness of breath • Weakness Devon, et al. Amer J Critical Care 2008:17(1): 14-24

34. The Facts Devon, et al. Amer J Critical Care 2008:17(1): 14-24

35. The Facts Location of Chest Pain *Indicates statistically significant difference Devon, et al. Amer J Critical Care 2008:17(1): 14-24

36. The Facts Quality of Chest Pain No differences were statistically significant Devon, et al. Amer J Critical Care 2008:17(1): 14-24

37. The Facts • Men and women present relatively similarly with heart attack • For both genders the important point is not to ignore symptoms of a potentially life-threatening condition

38. Myth 8 Chocolate is sinfully bad and should be eaten only rarely This could be true, but there is some preliminary data to suggest dark chocolate may be beneficial!

39. Beneficial Effects of Dark Chocolate • Raises protective HDL • Improves insulin sensitivity • Lowers blood pressure • Improves endothelial function Clinically Relevant?

40. Recommended Dose Rx Go Red Luncheon Attendee Dark chocolate, 100 gm Directions: 1 bar dailyDispense 30 day supply Jon W. Wahrenberger, MD

41. Myth 9 Exercise is beneficial only if prolonged (No Pain/No Gain)

42. Exercise: the facts • There is a dose-response relationship (more is better) • Strenuous exercise is probably better than less strenuous exercise • Several studies have shown that repeated intermittent periods of exercise have a cumulative effect similar to prolonged exercise

43. Summary • Don’t believe everything you hear • Work on traditional risk factors throughout your life • Eggs are OK …. in moderation … as is dark chocolate • Ovarian hormone therapy is OK in the young women with premature or surgical menopause – taper in early 50’s – some data suggest transdermal best • A balanced diet is probably far more helpful than vitamins and supplements • Exercise is beneficial – almost any way you do it!

44. Questions?