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CARDIOVASCULAR DISEASE & WOMEN: A Review of The Evidence. Presented By: Dr. Laurie-Ann Baker, MD, CCFP EM Resident University of Calgary. Objectives. Demystifying the truths and examining the myths Risk Factors The Diagnosis of CAD in Women HRT: What Now… The Bottom Line

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    1. CARDIOVASCULAR DISEASE & WOMEN:A Review of The Evidence

    2. Presented By:Dr. Laurie-Ann Baker, MD, CCFPEM ResidentUniversity of Calgary

    3. Objectives • Demystifying the truths and examining the myths • Risk Factors • The Diagnosis of CAD in Women • HRT: What Now… • The Bottom Line • Current & future research

    4. Fact • Cardiovascular disease, primarily CAD, outnumbers the next 16 causes of death in women combined, including all cancers • Women are 4 to 8 times more likely to die of CVD than of any other disease • CVD will be the leading cause of death for the next 20 years in the developing world

    5. Fact • Since 1980, death from CVD has declined in men but increased in women • The Canadian Cardiovascular Society state that mortality at presentation is twice that of men • It has only been in the last decade that there has been heightened awareness within the health care community that differences between men & women exist

    6. Percentage of total deaths due to CVD by age & sex (Canada 1997)

    7. Risk Factors For Coronary Artery Disease in Women

    8. Diabetes • Increases CAD-related mortality rate in women 3 to 7 times more than in non-diabetic women • Increases CAD-related mortality rate in men 2 to 4 times

    9. DM is a greater predictor of CAD for women than for men • DM reduces women’s life-expectancy advantage • Difference may be due to a particularly deleterious effect of diabetes on lipids and blood pressure in women

    10. Dyslipidemia

    11. Dyslipidemia • After age 50, cholesterol levels plateau in men • Levels of LDL increase an average of 0.05 mmol/L per year between ages 40 and 60 in women • Part of this increase results from declining levels of estrogen

    12. Decreasing estrogen results in the down-regulation of the LDL receptor on the liver • A high LDL level is a strong predictor of CAD risk in women younger than 65 years and a somewhat weaker predictor in women >65 years • Low HDL levels is a stronger predictor of CAD mortality in women than in men particularly after age 65

    13. FRAMINGHAM HEART STUDY: - 8 year risk of heart disease was 7% for women with a total/HDL ratio less than 5 - 12% for those with ratios of 5 to 7 - 20% for those with ratios greater than 7

    14. Further, in another study of 2500 women aged 71 years or older, those with HDL levels <0.9 had a RR of CAD mortality twice that of women with HDL levels of 1.6 or more Elevated triglycerides are also shown to be a significant risk factor in women especially when HDL levels fall below 1.03

    15. * The Air Force / Texas Coronary Atherosclerosis Prevention Study (AFCAPS/ TexCAPS) used drug intervention with a statin in men and women who had average total and LDL levels and slightly low HDL levels. A reduction of primary CV events was demonstrated in both sexes * However, the US / Canadian PREVENT trial (2000) investigators found that women, especially, continue to be under-treated compared to men

    16. Hypertension • Major trials of hypertension treatment, ie. Hypertension Detection & Follow-up Program (HDFP), Systolic Hypertension in the Elderly (SHEP), have included adequate numbers of women and demonstrated benefits of treatment

    17. Women with hypertension have a 4-fold risk of heart disease compared with normotensive women • Men with hypertension have a 3-fold increase in risk • Isolated systolic hypertension in older women has a 30% prevalence in women older than 65 years

    18. Women with hypertension outnumber men with hypertension in the older age groups (due to survival advantage) • Estimated prevalence (BP >140/90 or use of anti-hypertensive) in women older than 45 years is 60% (US statistic)

    19. Smoking

    20. Smoking • The leading preventable cause of CAD in women is cigarette smoking • More than 60% of MI’s in women younger than 50 yrs can be attributed to tobacco use • 21% of all CAD deaths attributable to smoking

    21. The risk in heavy smokers ( > 20 cigarettes per day) is 2 to 4 times higher than in nonsmokers • Light smokers (1-4 cigarettes per day) have double the risk of nonsmokers • Stopping smoking decreases the risk of CAD within months (Nurses’ Health Study found the risk of CAD decrease by 1/3 two years after cessation)

    22. The prevalence of smoking in recent years has dropped in both men and women however women’s rate of cessation is lower than that of men • Almost one fourth of women smoke cigarettes • Greatest increase in the prevalence of smoking is in women aged 65 years or older

    23. Menopause • Natural menopause confers a 3-fold increase in CAD risk • Nurses’ Health Study cohort showed that women under-going bilateral oophorectomy had up to an 8-fold increase in risk of CAD • Of interest, the Nurses’ Health Study showed that early natural menopause was not a risk factor for CAD after adjustment for tobacco exposure

    24. Degree to which estrogen deficiency increases risk of CAD in women remains a subject of debate • Many studies have found the incidence of CAD in postmenopausal women higher than that of pre-menopausal women of the same age range

    25. Although the largest increase in coronary mortality in women coincides with menopause, vital statistics data do not support that menopause, apart from chronological aging increases the risk of CAD • Effects of aging versus estrogen deficiency (menopause state) versus lipid increase

    26. Obesity & Physical Activity

    27. Obesity • Obesity in both men & women has been increasing over the past few decades • Obesity & sedentary lifestyle are interrelated • Obesity is an independent risk factor for all-cause mortality & is associated with DM, hyperlipidemia and hypertension

    28. Obesity in Canada

    29. 30.5% of Canadians between the ages of 20 and 64 are obese (BMI of 27 or greater) • Obesity is the most common metabolic condition in industrialized nations • Total direct cost of obesity in Canada was estimated to be over $1.8 billion (2.4% of the total health care expenditures for all diseases in Canada)

    30. Physical Activity

    31. Physical Activity • Physical inactivity contributes to obesity and is an independent risk factor for MI • Investigators in the Nurses’ Health Study found that 30 to 45 minutes of walking three times weekly reduces the risk of MI by 50% (even in older women)

    32. It is estimated that between 39 and 54% of North American women do not get adequate physical activity • Exercise has been found to reduce the risk of type II DM even in women with obesity and a FHX of DM • HDL levels have shown a dose-response relationship in female runners

    33. The Diagnosis of CAD in Women

    34. Approach to Diagnosis • The perception persists that CAD mainly affects men & is not a serious concern for women • Women develop angina about 10 years later and a first MI about 20 years later than men • Women are more likely to have angina than MI as their initial presentation of CAD

    35. Women tend to have more atypical features when presenting with CAD than do men • Women presenting with acute MI tend to be older and have more co-morbidity • Women are less likely than men to attribute their symptoms to cardiac disease, even in the setting of acute MI

    36. Estimating the Risk • Estimating the likelihood of CAD by assessment of the patient’s clinical characteristics and coronary risk factors is more easily and accurately accomplished in men than in women • As the prevalence of CAD (particularly multi-vessel disease) is lower in women than men (except in older women), the predictive value of any symptom or non-invasive test is lower

    37. The presence of any type of chest pain, whether atypical or typical, is associated with a lower risk of CAD in pre-menopausal women • The likelihood of CAD increases after menopause • Diabetes eliminates the age advantage in women over men and confers a substantially greater CAD mortality than in non-diabetic women • DM is an important predictor of the presence & prognosis of CAD in women

    38. Diagnostic Evaluation • The purpose of performing a clinical evaluation is to identify those at very high risk, who would benefit from immediate coronary angiography, and, in lower-risk patients, to accurately identify those with significant CAD prior to development of acute coronary event

    39. Diagnostic Evaluation • Patients can be classified into high, intermediate or low probability of CAD, by taking into consideration factors such as chest pain types (typical, atypical or nonischemic) and determinants (major, intermediate and minor) or the likelihood of CAD

    40. FEATURES: - Substernal - Squeezing, burning, heavy - Exertional or precipitated by emotion - Promptly relieved by rest or nitroglycerin CLASSIFICATION: - 60-75% prevalence of angiographically significant CAD Classification of Chest Pain(Typical Angina)

    41. FEATURES: - Left chest, abdominal, back, arm, without mid-chest pain - Sharp or fleeting - Unrelated to exercise - Relieved by antacids CLASSIFICATION: - 30-40% prevalence of angiographically significant CAD Classification of Chest Pain(Atypical Angina)

    42. Determinants of the Likelihood of CAD in Women MAJOR - Post menopausal status / age >65 years - Diabetes - Peripheral Vascular Disease

    43. Determinants of the Likelihood of CAD in Women INTERMEDIATE - Hypertension - Smoking - Lipid abnormalities

    44. Determinants of the Likelihood of CAD in Women MINOR - Obesity - Sedentary lifestyle - Family history of CAD - Other risks factors of CAD

    45. Classification According To Their Probability of CAD

    46. HIGH PROBABILITY OF CAD (>80%) * Typical angina and any of: - Post-menopausal status or age >65 - Diabetes - Peripheral Vascular Disease - Two intermediate determinants

    47. HIGH PROBABILITY OF CAD (>80%) * Atypical angina and any of: - Post-menopausal or age >65 and >1 intermediate determinant - Diabetes plus >1 intermediate or minor determinants - Three intermediate or 2 intermediate plus 1 minor determinants

    48. INTERMEDIATE PROBABILITY (20 – 80%) • Typical Angina and 1 intermediate or >2 minor determinants • Atypical Angina and post-menopausal / age >65 • Nonischemic Pain and post-menopausal / age >65 or diabetes and >2 intermediate and/or minor determinants