Cardiovascular Disease in Women

Objectives

• Discuss strategies to assess and stratify women into high risk, at risk, and ideal health categories for cardiovascular disease (CVD)
• Summarize lifestyle approaches to the prevention of CVD in women
• Review American Heart Association (AHA) 2011 Guidelines approaches to CVD prevention for patients with hypertension, lipid abnormalities, and diabetes, with a focus on effectiveness in practice
• Review AHA 2011 Guidelines approach to pharmacological intervention for women at risk for cardiovascular events
• Summarize commonly used therapies that should not be initiated for the prevention or treatment of CVD, because they lack benefit or because risks outweigh benefits

Coronary heart disease is the leading cause of death for all women. The following table shows deaths per 100,000. African American women have higher death rates for CHD, stroke and lung cancer than white, Hispanic or Asian women.

	CHD	Stroke	Lung Cancer	Breast Cancer
Black/African American	130.0	57.0	39.0	32.2
White	101.5	41.0	41.3	23.0
Hispanic	84.5	32.3	14.1	14.8
Asian	58.9	34.9	18.1	11.7

SOURCES:
(1) Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P, Stafford R, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. (2010). Executive summary: Heart disease and stroke statistics-2010 update. A report from the American Heart Association. Circulation, 121, 948-954.
(2) Centers for Disease Control and Prevention, National Center for Health Statistics, Health Data Interactive, 2005-2007. Available at: http://www.cdc.gov/nchs/hdi.htm.
The chart below shows the number of U.S. men and women diagnosed with myocardial infarction and fatal CHD by age. Although women in general present at later ages than men, over 10,000 reproductive age women per year are diagnosed with myocardial infarction or suffer fatal CHD.

	Age 35-44	Age 45-64	Age 65-74	Age 75+
Men	30,000	265,000	180,000	235,000
Women	10,000	95,000	95,000	290,000

SOURCE:
(1) Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, Hailpern SM, Ho M, Howard V, Kissela B, Kittner S, Lloyd-Jones D, McDermott M, Meigs J, Moy C, Nichol G, O’Donnell C, Roger V, Sorlie P, Steinberger J, Thom T, Wilson M, Hong Y, for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee (2008). AHA Statistical Update, Heart Disease and Stroke Statistics—2008 Update, A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 117, e25-e146.
The chart below shows the number of U.S. cardiovascular disease deaths from 1980-2007. While the number of CVD-related deaths in males has been steadily declining over the past 15-20 years, cardiovascular deaths for women remained flat or increased slightly during the 1980s and 1990s. The number of deaths for women has exceeded those for men over the past 20 years.

	1985	1990	1995	2000	2007
Men	487,000	445,000	452,000	440,000	391,886
Women	495,000	475,000	503,000	506,000	421,918

SOURCES:
(1) Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, Hailpern SM, Ho M, Howard V, Kissela B, Kittner S, Lloyd-Jones D, McDermott M, Meigs J, Moy C, Nichol G, O’Donnell C, Roger V, Sorlie P, Steinberger J, Thom T, Wilson M, Hong Y, for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee (2008). AHA Statistical Update, Heart Disease and Stroke Statistics—2008 Update, A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 117, e25-e146.
(2) Roger VL, Go AS, Lloyd-Jones DM, et al. (2011). Heart disease and stroke statistics--2011 update: A report from the American Heart Association. Circulation, 123(4), e18-209.
Cultural Competency: Considering the Diversity of Patients

• In addition to race/geographic/ethnic origin, other facets of diversity should be considered, including:
• Age, language, culture, literacy, disability, frailty, socioeconomic status, occupational status, and religious affiliation
• The root causes of disparities include variations and lack of understanding of health beliefs, cultural values and preferences, and patients’ inability to communicate symptoms in a language other than their own
• Clinicians also should be familiar with patients’ socioeconomic status, which may make attaining a healthy lifestyle and using medications more difficult

SOURCE:
(1) Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, Newby LK, Piña IL, Roger VL, Shaw LJ, Zhao D, Beckie TM, Bushnell C, D'Armiento J, Kris-Etherton PM, Fang J, Ganiats TG, Gomes AS, Gracia CR, Haan CR, Jackson EA, Judelson DR, Kelepouris E, Lavie CJ, Moore A, Nussmeier NA, Ofili E, Oparil S, Ouyang P, Pinn VW, Sherif K, Smith SC, Sopko G, Chandra-Strobos N, Urbina EM, Vaccarino V, Wenger NK. (2011). Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 Update: A Guideline From the American Heart Association. Circulation, 123, 1243-1262.
Women Receive Fewer Interventions to Prevent and Treat Heart Disease

• Less cholesterol screening
• Fewer lipid-lowering therapies
• Less use of heparin, beta-blockers and aspirin during myocardial infarction
• Less antiplatelet therapy for secondary prevention
• Fewer referrals to cardiac rehabilitation
• Fewer implantable cardioverter-defibrillators compared to men with the same recognized indications

SOURCES:
(1) Chandra NC, et al. (1998). Observations of the treatment of women in the United States with myocardial infarction: A report from the National Registry of Myocardial Infarction-I. Archives of Internal Medicine, 158, 981-988.
(2) Nohria A, et al. (1998). Gender differences in coronary artery disease in women: Gender differences in mortality after myocardial infarction: Why women fare worse than men. Cardiology Clinics, 16, 45-57.
Scott LB, Allen JK. (2004). Providers perceptions of factors affecting women’s referral to outpatient cardiac rehabilitation programs: an exploratory study. Journal of Cardiopulmonary Rehabilitation, 24, 387-391.
(3) O’Meara JG, et al. (2004). Ethnic and sex differences in the prevalence, treatment, and control of dyslipidemia among hypertensive adults in the GENOA study. Archives of Internal Medicine, 164, 1313-1318.
(4) Hendrix KH, et al. (2005). Ethnic, gender, and age-related differences in treatment and control of dyslipidemia in hypertensive patients. Ethnicity & Disease, 15, 1-16.
(5) Hernandez AF, et al. (2007). Sex and racial differences in the use of implantable cardioverter-defibrillators among patients hospitalized with heart failure. Journal of the American Medical Association, 298, 1535-1532.
(6) Hernandez AF, et al. (2007). Sex and racial differences in the use of implantable cardioverter-defibrillators among patients hospitalized with heart failure. Journal of the American Medical Association, 298, 1535-1532.
(7) Cho L, et al. (2008). Gender differences in utilization of effective cardiovascular secondary prevention: a Cleveland Clinic Prevention Database study. Journal of Womens Health, 17, 1-7.
Educate Patients About the Warning Symptoms of a Heart Attack

• Chest pain, discomfort, pressure or squeezing are the most common symptoms for men and women
• Women are somewhat more likely than men to experience other heart attack symptoms, including:
• Unusual upper body pain or discomfort in one or both arms, the back, shoulder, neck, jaw, or upper part of the stomach
• Shortness of breath
• Nausea/Vomiting
• Unusual or unexplained fatigue (which may be present for days)
• Breaking out in a cold sweat
• Light-headedness or sudden dizziness
• If any of these symptoms occur, call 9–1–1 for emergency medical care.

SOURCES:
(1) Mosca L, Mochari-Greenberger H, Dolor RJ, Newby LK, Robb K. (2010). Twelve-Year follow-up of American Women’s Awareness of Cardiovascular Disease (CVD) Risk and Barriers to Heart Health. Circulation: Cardiovascular & Quality Outcomes, 3,120-127.
(2) Act in Time Heart Attack Awareness Messages – DHHS Office on Women’s Health, 2011.
Encourage Patients To Make The Call. Don’t Miss a Beat

• Only 53% of women said they would call 9-1-1 if experiencing the symptoms of a heart attack
• However, 79% said they would call 9-1-1 if someone else was having a heart attack
• For themselves, 46% of women would do something other than call 9-1-1—such as take an aspirin, go to the hospital, or call the doctor

SOURCES:
(1) Mosca L, Mochari-Greenberger H, Dolor RJ, Newby LK, Robb K. (2010). Twelve-Year follow-up of American Women’s Awareness of Cardiovascular Disease (CVD) Risk and Barriers to Heart Health. Circulation: Cardiovascular & Quality Outcomes, 3,120-127.
(2) Act in Time Heart Attack Awareness Messages – DHHS Office on Women’s Health, 2011.
2011 Update: Guidelines for the Prevention of Cardiovascular Disease in Women
Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women-2011 update: A guideline from the American Heart Association. Circulation. 2011. www.circulation.org.
SOURCES:
(1) Mosca L, et al. (2004). Evidence-based guidelines for cardiovascular disease prevention in women. Circulation, 109, 672-693.
(2) Mosca L, et al. (2007). Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation, 115, 1481-501.
(3) Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, Newby LK, Piña IL, Roger VL, Shaw LJ, Zhao D, Beckie TM, Bushnell C, D'Armiento J, Kris-Etherton PM, Fang J, Ganiats TG, Gomes AS, Gracia CR, Haan CR, Jackson EA, Judelson DR, Kelepouris E, Lavie CJ, Moore A, Nussmeier NA, Ofili E, Oparil S, Ouyang P, Pinn VW, Sherif K, Smith SC, Sopko G, Chandra-Strobos N, Urbina EM, Vaccarino V, Wenger NK. (2011). Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 Update: A Guideline From the American Heart Association. Circulation, 123, 1243-1262.
Evidence-based guidelines for the prevention of cardiovascular disease in women developed in 2004, updated in 2007, and updated again in 2011. For the original 2004 guidelines, over 1,270 articles were screened by the panel, and 400 articles were included for evidence tables. The summary evidence used by the expert panel in 2011 can be obtained online as a Data Supplement at http://circ.ahajournals.org.
Calculate 10-Year Cardiovascular Disease (CVD) Risk using either lipids or BMI at www.framinghamheartstudy.org/risk/gencardio.html#
Stratify Patients with the following conditions as High Risk:

• Documented atherosclerotic disease, including
• clinically manifest coronary heart disease
• clinically manifest peripheral arterial disease
• clinically manifest cerebrovascular disease
• abdominal aortic aneurysm
• Diabetes mellitus
• End-stage or chronic kidney disease
• 10-year Framingham cardiovascular disease risk ≥ 10% [new in 2011]

SOURCES:
(1) Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, Newby LK, Piña IL, Roger VL, Shaw LJ, Zhao D, Beckie TM, Bushnell C, D'Armiento J, Kris-Etherton PM, Fang J, Ganiats TG, Gomes AS, Gracia CR, Haan CR, Jackson EA, Judelson DR, Kelepouris E, Lavie CJ, Moore A, Nussmeier NA, Ofili E, Oparil S, Ouyang P, Pinn VW, Sherif K, Smith SC, Sopko G, Chandra-Strobos N, Urbina EM, Vaccarino V, Wenger NK. (2011). Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 Update: A Guideline From the American Heart Association. Circulation, 123, 1243-1262.
(2) National Heart Lung and Blood Institute, “What Are the Signs and Symptoms of Coronary Artery Disease?” Retrieved from http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_SignsAndSymptoms.html.
The major change in the 2011 guidelines for the definition of “high risk patients” is to identify “high risk patients” as those at 10% or higher risk of a CVD event within 10 years.  The previous definition specified a 20% or higher risk.
Stratify Patients as At Risk if they have ≥ 1 of the following risk factors for CVD, including (but not limited to):

• Cigarette smoking
• Hypertension: SBP ≥ 120 mm Hg, DBP ≥ 80 mm Hg or treated
• Dyslipidemia
• Family history of premature CVD in a 1 st degree relative (CVD at < 55 years in a male relative, or < 65 years in a female relative)
• Obesity, especially central obesity
• Physical inactivity
• Poor diet
• Metabolic syndrome
• Advanced subclinical atherosclerosis
• Poor exercise capacity on treadmill test and/or abnormal heart rate recovery after stopping exercise
• Systemic autoimmune collagen-vascular disease (e.g. lupus, rheumatoid arthritis) [new in 2011]
• A history of pregnancy-induced hypertension, gestational diabetes, preeclampsia [new in 2011]

SOURCE:
Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, Newby LK, Piña IL, Roger VL, Shaw LJ, Zhao D, Beckie TM, Bushnell C, D'Armiento J, Kris-Etherton PM, Fang J, Ganiats TG, Gomes AS, Gracia CR, Haan CR, Jackson EA, Judelson DR, Kelepouris E, Lavie CJ, Moore A, Nussmeier NA, Ofili E, Oparil S, Ouyang P, Pinn VW, Sherif K, Smith SC, Sopko G, Chandra-Strobos N, Urbina EM, Vaccarino V, Wenger NK. (2011). Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 Update: A Guideline From the American Heart Association. Circulation, 123, 1243-1262.
The 2011 guidelines added systemic autoimmune collagen-vascular disease (e.g. lupus, rheumatoid arthritis) and a history of pregnancy-induced hypertension, gestational diabetes, and preeclampsia to the risk classification.