Boston University Medical Center Boston , MA Chest Pain in Women: Think Heart First ! Alice K. Jacobs, M.D. Boston University Medical Center Boston , MA CRT 2012

Disclosure Information FINANCIAL DISCLOSURE: Research Support: Abbott Vascular UNLABELED/UNAPPROVED USES DISCLOSURE: None

Prevalence of Cardiovascular Disease in Americans NNHANES 2005-2008 Percent of Population > 80 20-39 40-59 60-79 Age (Years) Heart Disease and Stroke Statistics. 2012 Update. AHA.

Leading Causes of Death for Men and Women United States: 2008 A. Total CVD B. Cancer C. Accidents D. Respiratory E. Diabetes F. Alzheimer Deaths in Thousands A B C D E F A B D F C E Men Women Heart Disease and Stroke Statistics. 2012 Update. AHA.

Cardiovascular Disease Mortality Trends United States: 1979-2008 Heart Disease and Stroke Statistics. 2012 Update. AHA.

Annual Incidence of Myocardial Infarction or Fatal CHD 1984-2004 Incidence in Thousands 35-44 45-64 65-74 75 Ages in Years Heart Disease and Stroke Statistics. 2012 Update. AHA.

Rates of Death During Hospitalization Following Myocardial Infarction Among Women and Men According to Age NRMI-2 N=384,878 1994-1998 Figure 1. Rates of Death during Hospitalization for Myocardial Infarction among Women and Men, According to Age. The interaction between sex and age was significant (P Vaccarino. N Engl J Med 1999;341:217-225.

In-Hospital Mortality Rates in Women and Men with Myocardial Infarction in GWTG OR 1.12 (95% CI 1.02-1.23) P=0.015 OR 1.04 (95% CI 0.99-1.10) P=0.10 10.2 In-hospital Mortality (%) 8.2 5.7 5.5 Overall MI Cohort STEMI Subpopulation Jneid. Circulation. 2008;118:2803-2810.

National Online Physician Survey (500 Physicians) More women than men die each year from cardiovascular disease: Primary Care Physicians – 8% OB/GYNs – 13% Cardiologists – 17% Mosca. Circulation 2005;111:499-510.

Physician Awareness of CVD Prevention Guidelines by Specialty Mosca. Circulation 2005;111:499-510.

Physician Incorporation of CVD Prevention Guidelines by Specialty Mosca. Circulation 2005;111:499-510.

Women’s Awareness of Heart Disease Twelve-Year Follow-up of American Women’s Awareness of CDV Risk (1997-2009) Awareness of heart disease as the #1 killer of women has increased from 30% to 54% awareness. African American and Hispanic women significantly less aware than White woman 53% of women would call 9-1-1 with symptoms of MI Majority cited therapies not evidence-based Common barriers to prevention were family/caretaking responsibilities Mosca. CircCardiovasc Qual Outcomes. 2010 Feb 10 Epub.

Time from ACS Symptom Onset to Presentation by Sex 2002-2007 AHA & NHLBI Awareness Campaigns Diercks. Am Heart J 2010;160:80-87.

Clinical Recognition of CAD Typical symptoms both sexes Pressure, heaviness, squeezing in chest Discomfort radiating to neck, jaw, back shoulder “Pounding” heart, change in rhythm Difficulty breathing Indigestion, nausea, vomiting, epigastric pain Sweating, clammy skin Dizziness WISE Investigators. JACC. 2008

Clinical Recognition of CAD Symptoms more common in women Milder symptoms without chest discomfort Sudden onset weakness, SOB, fatigue, overall “unwell” Unusual feeling or mild discomfort in back, chest, arm, neck, jaw WISE Investigators. JACC. 2008

Likelihood of ACS UA/NSTEMI Guidelines 2007 High Intermediate Low History Chest, left arm pain; known CAD Chest or left arm pain; >70 years; male; diabetes; vascular disease Probable ischemic symptoms in absence of intermediate likelihood; cocaine Exam MR murmur, hypotension, diaphoresis, CHF Vascular disease Chest discomfort with palpation ECG ST-segment change ≥ 1mm; T wave inversion Q waves; ST depression 0.5-1mm T waves flat or inversion <1mm; Normal Cardiac Markers Elevated

Normal Rest ECG and Able to Exercise Intermediate Likelihood Women with Atypical or Typical Chest Pain Symptoms Normal Rest ECG and Able to Exercise Diabetes, Abnormal Rest ECG, or Questionable Exercise Capacity Exercise Treadmill Testing Stress Cardiac Imaging Low post-ETT likelihood Int Risk TM Able to exercise or h/o symptoms with low-level exercise Unable to Exercise (orthopedic reasons, CVA, LBBB, etc.) Exercise Stress Pharmacologic Stress Risk factor modification +/or Anti-Ischemic Rx Normal or mildly abnormal with normal LV function Moderately or severely abnormal or reduced EF Cardiac catheterization Mieres. Circulation. 2005.

Angina in Women Higher prevalence in women than men Women more likely to present with angina; men more likely to present with MI Women with more angina for same extent of epicardial disease Women with angina without obstructive CAD worse prognosis

Sex Ratios in Angina Prevalence 74 reports 31 countries Women n=13,331 Men n=11,511 Rose Angina Figure 2. Sex ratios in Rose angina prevalence ([PR] 95% CIs) ordered by study weight and pooled estimate from a random-effects model. Numbers in parentheses denote patients’ ages or year of study. Hemingway. Circulation 2008;117:1526-1536.

Sex Differences in Symptoms in Patients with Diabetes and CAD in BARI No Symptoms Anginal Equivalent Angina Tami-Holland Am J Cardiol 2011;107:980-985.

Angiographic Characteristics in BARI Women Men P Value (n=533) (n=1242) # significant lesions 2.31.7 2.71.8 <0.001 # lesions >20% 4.32.2 4.8 2.3 <0.001 Myocardial jeopardy Index 42.524.3 47.9  24.3 <0.001 Total occlusion (%) 29 42 <0.001 LVEF < 50% (%) 11 19 <0.001 Tami-Holland Am J Cardiol 2011;107:980-985.

Cardiac Non-CHD Causes of Chest Pain in Women Syndrome X of Microvascular Disease Stress-induced Cardiomyopathy Spontaneous coronary artery dissection

Cardiac Non-CHD and Non-Cardiac Causes of Chest Pain Pulmonary Gastro-intestinal Musculoskeletal Other (referred pain, shingles) Aortic dissection Pericarditis

Current Initiatives Go Red For Women Heart Truth Campaign WomenHeart Society for Women’s Health Research (SWHR) FDA Office of Women’s Health Cardiovascular Research Foundation