Women and Cardiovascular Disease Update October 17 2019

Women and Cardiovascular Disease Update October 17 2019

Women and Cardiovascular Disease Update October 17 2019 Margo M. Vassar, MD, FACC No Disclosures

Remote sites, please mute your microphones during the presentation Learning Objectives 1. Learn differences in the patterns of cardiac disease between men and women

2. Shortcomings in our current system in respect to women's cardiovascular wellness 3. Explore some disease processes of greater importance in women But first, about you Primary care?

Subspeciality practice? Hospital practice? Surgical? Research Patient S.C. 67 y/o female

Admitted with one day dyspnea, new AKI CVA six years prior, known HTN, Chol ASA, statin, BB, ACE-I, DM No prior echo Patient C.M. 73 y/o female

MMP- Asthma, HTN, Chol, DM, Past tob, anxiety, husband known CAD Cath 17 years prior- calcium Home meds- ASA, statin, PRN nitro Two days of chest discomfort NSTEMI found after phone request for more

nitro Patient M.B. 56 y/o female DM, Chol, poor medical compliance and cardiac work up at OSH

Presented with dyspnea, afib RVR with spontaneous return to NSR Abnormal Lexiscan with regional abnormalities History

History I have seen nearly a hundred people under this disorder(angina pectoris), of which number there have been three women... All the rest were men near or past the fiftieth year of their age

Heberden, W. 1772. Some account of a disorder of the breast. Medical Transactions. The Royal College of Physicians of London. 2: 59-67. American Heart Association 1960s American Heart Association

conference on women and cardiovascular disease How Can I Help My Husband Cope with Heart Disease? Introduction of the American Heart

Associations Prudent Diet in a public education pamphlet The Way to a Mans Heart. First wave Acknowledgment that heart disease occurs in

in a significant way women Landmark Studies Veterans Administration Cooperative Study

(1974) Multiple Risk Factor Intervention Trial (1976) Physicians Health Study (1989) Yentl

Yentl Syndrome The male normal is the global gold standard Women must normalize to the male standard to be recognized Typical Angina vs Atypical Angina inherit bias in language used

First changes seen Acknowledgment that heart disease occurs in women Very skewed/limited perception of what heart disease is

Women still had other higher health priorities with myths and misconceptions ~ 20 years later. Perceptions Some Myths include

Breast cancer is the number one killer of women I dont have any symptoms/minimize I'm too young (both genders) Heart disease does/doesn't run in

my family, so it's out of my hands Womens Heart Disease Awareness Study Womens Heart Disease Awareness Study https://doi.org/10.1161/CIR.0b013e318287cf2fCirculation. 2013;CIR.0b013e318287cf2f

Heart disease in women Coronary artery disease is the number one killer of women in America One in four women who die in the United States each year die from heart disease

Heart diseases cause almost twice as many deaths among women as all forms of cancer combined More than one in three female adults in the United States has some form of cardiovascular disease. Females represent more than half of deaths from cardiovascular disease. Sixty-four percent of women who die suddenly of

coronary artery disease had no previous symptoms Heart disease in women Coronary artery disease is the number one killer of women in America, one in four women who die in the United States each year die from heart disease

Heart diseases cause almost twice as many deaths among women as all forms of cancer combined More than one in three female adults in the United States has some form of cardiovascular disease. Females represent more than half of deaths from cardiovascular disease. Sixty-four percent of women who die suddenly of

coronary artery disease had no previous symptoms HFpEF main risks- HTN, age, and female sex Next Wave Awareness of the differences between men and women qualitatively and quantitatively

AMI presentation A woman having a heart attack may experience the same symptoms as a man, but she may also experience: Nausea or indigestion

Extreme fatigue Weakness or dizziness Loss of appetite Coughing Heart palpitations Back pain

AMI cont Symptoms can occur suddenly or develop over hours, days or weeks. Women having MI may attribute them to other factors and are more likely to die uninformed about the symptoms, ignoring symptoms, or reluctance to seek prompt

medical attention Not seeking help when symptoms of a heart attack occur can lead to permanent damage or even death Any good news Not yet

Women are Older at initial presentation More likely to die in the 1st year after 1st heart attack More likely to have a 2nd heart attack Sicker with a heart attack

More likely to ignore symptoms Present later in course leading to further complications Multi-center observational registry VIRGO

Young (<50) AMI female patients matched to young men Coding/charting explored Less hyperlipidia among women (statin Rx) More overweight Dx however less by actual BMI

VIRGO Objectification of women by healthcare professionals More likely to be advised on weight loss and not validated risk factors

If you dont check for hyperlipidemia, your patient will never have it Women found to delay office visits to try to lose more weight first

If your patient doesnt show, they cant get diagnosed WISE Symptom Recognition Diagnostic testing

Reproductive hormonal status WISE 65% women with ischemia presented with

atypical symptoms The investigators want to specifically study 375 female patients who have signs or symptoms suggestive of heart disease but don't have obstructive coronary artery disease Comparing coronary angiography with

cardiac MRI Estimated Study Completion Date - August 31, 2020 Pregnancy Pregnancy

Heathy pregnancy is a great stress test! Physiologic 50% increase in cardiac output Increased risk for coronary artery dissection during pregnancy and postpartum period As maternal age increases so does risk for ACS

Dont forget pulmonary embolism Pregnancy (cont) HTN seen in up to 20% of pregnancies, goal <140/90 Women with Gestational Hypertension of PreEclampsia are at twofold increased risk for

CV disease Aggressive risk factor screening No specific genetic tests No serial echo or prophylactic aspirin indicated Peripartum Cardiomyopathy Risks include increased maternal age, multiparous

status, multi-fetal gestation, African descent, h/o HTN/Pre-eclampsia, cocaine abuse Conventional therapies including Beta-blockers and ACE-I started post partum once hemodynamically stable (ACE-I ok in lactation) Treat aggressively, refer for advanced therapies

early Consider anticoagulation Rule of 1/3s Research still ongoing Valve Disease in pregnancy Regurgitant lesions typically well tolerated

Mitral stenosis- diuresis and rate control first tier, valvuloplasty if regurgitation only mildmoderate Aortic stenosis few options, try to address first. Keep in mind Ross procedure Increased throbotic events with mechanical valves

Spontaneous Coronary Artery Dissection Spontaneous Coronary Artery Dissection SCAD

Not atherosclerosis Average age 42 years ~80% female, ~10-20% peripartum Low CVD risk factors when compared to ACS controls 1-4% of all ACS

#1 cause of peripartum MI, 10-30% of MI in women <50 Tweet et al, Circ 2012; Lettieri, AJC 2015; Nishiguchi Eur Heart J 2013

SCAD Potential risk factors- fibromuscular dysplasia, postpartum/pregnancy, extreme emotion or exercise, connective tissue dz, coronary tortuosity, family history Treatment presumptively conservative

unless occlusion- ASA, Statin if indicated, BB/ ACEI if indicated, Nitrates/CCB for chest pain SCAD Microvascular Disease

Microvascular Disease http://www.health.harvard.edu/staying-healthy/new-view-of-heart-disease-in-women Micro vs Macro Microvascular Disease

Macrovascular Disease Diffuse discomfort, Crushing CP radiating, fatigue, DOE

Constricted vessels Function vascular imaging, stress test Antihypertensive, Statins, ?antinflamatory cold sweat, nausea

Isolated/Culprit plaque Stress test, angiography Angioplasty/Stenting, bypass surgery, statin Good news on Microvascular Dz It responds to GDMT

Statins and aspirin unless contraindicated Betablockers, CCB, nitrates Cardiac rehab LIFESTYLE MODIFICATION Microvascular disease

Bugiardini, Bairey Merz, JAMA 2005:293:477-84 Rheumatoid Disease Ther AdvMusculoskelet Dis. 2016 Jun; 8(3): 86 101

Rheumatoid Disease 50% premature deaths due to CV disease Effect of CV risk comparable to diabetes/IR Chronic inflammatory state + Sedentary Traditional risk calculators underestimate RA NSAIDS controversial, glucocorticoids

generally associated with increased CV risk anti-TNF- therapy can exacerbate HF Rheumatoid Disease manifestations Increase atherosclerotic dz Valvular heart disease, arrhythmia, pericarditis

and endocarditis Increased risk of HF *** Myocarditis and microvascular disease Sed Rate, RF, ACPA and CRP - positively associated with increased atherogenicity and CV events RF and ANA - increased risk for myocardial

infarction, heart failure and vascular disease REGARDLESS OF presence of rheumatic disease Fibromuscular Dysplasia Fibromuscular Dysplasia Keep in mind in cases of difficult to control

Hypertension Abnormal development or growth of cells in the walls of the bodys arteries, particularly the renal arteries, ~10 familiar Most common in premenopausal women younger than age 50

Treatment aggressive multi Rx antihypertensives If failure of medical tx, consider angioplasty vs bypass, typically no stenting More to come Electrophysiology differences (CRT, LBBB) Hormonal effects on lipids

Psycho social differences Depression/Stress/Impact of history of abuse Differences in valve surgery referral Fibromuscular Dysplasia Differences in antithrombotic metabolism Patient S.C.

67 y/o female Admitted with one day dyspnea, new AKI CVA six years prior, known HTN, Chol ASA, statin, BB, ACE-I, DM No prior echo Patient S.C.

67 y/o female Admitted with one day dyspnea, new AKI CVA six years prior, known HTN, Chol, inconsistent History ASA, statin, BB, ACE-I, DM No prior echo

HFpEF, 3 Vessel CAD- CABG workup Patient C.M. 73 y/o female MMP- Asthma, HTN, Chol, DM, Past tob, anxiety husband known CAD

Cath 17 years prior- calcium Home meds- ASA, statin, PRN nitro Two days of chest discomfort NSTEMI found after request for more nitro Patient C.M. 73 y/o female

MMP- Asthma, HTN, Chol, DM, Past tob, anxiety, husband known CAD Cath 17 years prior- calcium Home meds- ASA, statin, PRN nitro Two days of chest discomfort NSTEMI found after request for more nitro

PCI to LAD Didnt recognize/minimized symptoms Patient M.B. 56 y/o female DM, Chol, poor medical compliance and

cardiac work up at OSH Presented with dyspnea, afib RVR with spontaneous return to NSR Abnormal Lexiscan with regional abnormalities Patient M.B.

56 y/o female DM, Chol, poor medical compliance and cardiac work up at OSH Presented with dyspnea, afib RVR with spontaneous return to NSR Abnormal Lexiscan with regional

abnormalities Microvacsular disease, still did not know she had any sort of heart disease Mahalo

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