Atherosclerotic Cardiovascular Heart Disease in Women Millee Singh DO Non Invasive Cardiology First Coast Heart and Vascular

Overview More than one in three female adults has some form of cardiovascular disease (CVD) Since 1984, the number of CVD deaths for females has exceeded those for males On average Females represented 51.0% of deaths from CVD  In 2010, CVD was the first listed diagnosis of 2.8 million females discharged from short-stay hospitals Most recent data show that 25.1% of bypass and 32.9% of PCI ,31.3% of heart transplant patients were female Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

CVD Male CVD Female Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

Coronary Heart Disease In Women  About 6.6 million females alive today have CHD Of these, 2.6 million have a history of myocardial infarction (MI, or heart attack) Each year new and recurrent MI and fatal CHD will impact an estimated 380,000 women 26% of women age 45 and older who have an initial recognized MI (heart attack) die within a year compared with 19% of men  64% of women who died suddenly of CHD had no previous symptoms Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

Angina Pectoris  More women than men have angina in total numbers (4.1 million vs. 3.7 million)  Angina among non-Hispanic women age 20 and older: 2.8% of non-Hispanic whites 5.4% of non-Hispanic blacks 3.3% of Mexican Americans Each year about 180,000 women over age 45 are diagnosed with stable angina Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

CVD Stroke Lung CA Breast CA Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

Clinical Presentation Women with CHD are generally about 10 years older than men at the time of presentation Although women are generally older than men at presentation, women younger than age 45 years also develop CHD and have a worse prognosis than men The first presentation of CHD may be chest pain, myocardial infarction (MI), heart failure (HF), or sudden cardiac death (SCD) The Framingham Risk Estimation underestimates risk in women -the Reynolds Risk Score, have been developed specifically for use in women Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

SYMPTOMS: CHEST PAIN While differences between women and men -there are more similarities than differences! Chest pain is the most common anginal symptom in both sexes with regard to: Quality of pain (heaviness, pressure) Pattern of radiation Associated symptoms The quality of chest pain (typical versus atypical) is an important predictor of angiographic disease in women Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

Unrecognized/Asymptomatic MI MI in women may go unrecognized, particularly at younger ages and when compared to men: Icelandic study : 13,000 women were followed for 29 years MI that went unrecognized was higher in the younger women (41 versus 24 %) 2003,a report In Circulation ; of 515 women with an acute MI, acute chest pain was absent in 43 % and only 30 % experienced prodromal chest pain 2012 , Jama ; study of over 1,000,000 women and men in the National Registry of Myocardial Infarction (United States) the proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0 versus 30.7 %) McSweeney JC, Cody M, O'Sullivan P, et al. Women's early warning symptoms of acute myocardial infarction. Circulation 2003; 108:2619 Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA 2012; 307:813.

NSTEMI Optimal approach to accurate assessment of risk in women with a non-ST elevation ACS may differ from that in men TACTICS-TIMI 18: Women were more likely to have elevations of hs-CRP, BNP, and less likely to have elevations of troponins and CKMB, than men, despite similar levels of risk Women with any positive marker benefited from an invasive strategy Women with no positive markers benefited from a conservative strategy Men benefited from an invasive strategy when there was biomarker positivity and no differnence in benefit if they were negative Women with unstable angina Without positive biomarkers should be treated conservatively, without early catheterization or use of glycoprotein IIb/IIIa inhibitors

SCD Sudden cardiac death — A 38-year follow-up from the Framingham Heart study

Testing In Women Treadmill stress testing Nuclear stress testing Stress echo CT calcium score Coronary CTA Cardiac catheterization with coronary angiography

How good are the tests? Sen/Spec ETT only (lower than in men) 61% and 70% Stress Nuclear (similar in men) 78% and 64% Stress Echo (similar in men) 86% and 79%

As for CCTA, Where does this stand? ROMICAT trial Women had greater reduction in LOS, lower admission rates, lower radiation doses More normal studies, less obstructive dz Lower radiation doses then a nuclear medicine scan Focal radiation to the breast is present- no confirmed link to increased in Breast CA

Radiation Exposure for Women Courtesy of Ana Barac, MD, ACC HWH 2014

Positive Test ? What next? Women less likely to be referred for further evaluation if they have a positive stress test! Higher incidence of MI or death in these patients have been noted

Cardiac Catheterization Less likely to be referred Higher complication rate than in men Smaller arteries, more bleeding But these pts do better than if no intervention Higher peri-procedural rate of complication but better long-term survival than men

Preventative Measures All Women Exercise Quit smoking Healthy diet BMI <25, waist circumference <35 in. Treat risk factors: HTN, DM, dyslipidemia ASA – look at risk/benefit ratio

DDX Women’s ischemic heart disease (syndrome X, micro vascular disease) Myocarditis Stress-induced cardiomyopathy Coronary dissection

Key Points CAD and CVD are by far the biggest health risks for women Awareness is still less than it needs to be Prevention CAN reduce risk Screening programs are available Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

Key Points Women can present differently, and do worse when they do Women are referred less often for appropriate testing and treatment Women can have more complications from treatment, but still fare better than without treatment