Women and Cardiovascular Disease Anthony Camuglia MBBS(HonsI), FRACP Interventional and General Cardiologist Mater Hospitals, Brisbane, Australia Princess Alexandra Hospital, Brisbane, Australia Senior Lecturer, University of Queensland, Australia Cardiologist, HeartCare Partners, Brisbane, Australia

Disclosures Medical advisory board member for Boston Scientific (including receiving consulting fees)

Background Most common cause of death in Women Just as for men, mortality rates for cardiovascular disease in women continue to fall Mortality after acute ST elevation MI higher in women than men

Background Women (and doctors) seem less aware of cardiovascular risk compared with other conditions like breast cancer Women develop heart disease around 8 – 10 years later than men Smoking rates in young women of great concern

Modifiable Risk Factors Hypertension Diabetes and the metabolic syndrome Lifestyle factors Especially smoking Dyslipidaemia

Clinical Presentation Conventional wisdom that women more likely to present with ‘atypical’ symptoms Data is somewhat conflicting but is evidence to support this Most women still present with chest pain Need to be aware of non-chest pain symptoms as cause for presentation: chest tightness, shoulder, arm and jaw pain, dyspnoea, ‘heart burn’ or ‘indigestion’ Women often older with more comorbidities at presentation

Two of three: urgent specialist referral. Initial assessment Clinical features ECG Cardiac biomarkers Two of three: urgent specialist referral.

Non-Invasive Assessment Exercise stress test: Non-specific with high false positive rate Exercise Stress Echo: More specific and sensitive, no ionising radiation (Dobutamine Stress Echo if unable to exercise) Myocardial perfusion study: Cannot exclude balanced ischaemia (LMCA or multivessel disease), no information on valvular status, radiation.

Non-Invasive Assessment CT coronary angiography: Currently need a specialist referral for patient to receive rebate Ionising radiation Very sensitive but variable specificity and positive predictive value for significant CAD (highly centre/operator/experience dependent) CT calcium score: Risk stratification tool only, should not be used to assess for CAD in symptomatic patients.

Acute Coronary Syndromes Symptoms with either biomarker elevation or documented ECG changes Women are older at time of presentation with more comorbidities as a result Less likely to be treated with an invasive management strategy but likely to benefit if so treated Less likely to treated with CABG

Acute Coronary Syndrome Women have been shown to be less likely to received appropriate secondary preventative therapies (including statins and ACE inhibitors) Where they are used women benefit from the treatment

Heart Failure Again, women present at an older age than men (in general) More frequently present with HFPEF which has no clear therapy to improve overall mortality (compare this with HF with impaired systolic function).

Hormone Replacement Therapy No role to use HRT as primary or secondary preventative strategy for cardiovascular disease Women < 60 years old without cardiovascular risk factors probably have no significant change in cardiovascular risk with HRT Caution with use of HRT in women > 60 years of age and careful risk assessment and modification

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