Cardiovascular Risk Assessment in Women Elizabeth Scruth RN MN MPH CCNS CCRN PhD (c) September 2011

Program of Research Undertaken as part of PhD research St Vincent's Cardiovascular Nursing Research Center- Melbourne Australia Combined medical and nursing research center- 60 researchers Professor of Nursing and Professor of Medicine- Interventional Cardiologist –directors of the center

Acknowledgement of Supervisors Professor Worrall-Carter- Nursing Director of SVCNR Professor Michelle Campbell- Dean of Nursing School at ACU Dr Karen Page- A/Professor-ACU Professor Robert Whit bourn- MD- Medical Director of SVCNR/Director of Cardiac Catheter Labs/CCU at St Vincent's Public Hospital in Melbourne Eugene Cheng MD- Kaiser Permanente

Grants for Research PhD : Australian Government –fully funded Statistical Analysis: DOR KP- through community funds Quality Outcomes in CV and Stroke Research conference 2011 in DC- expenses paid by Australian Government

Cardiovascular Risk in Women Phases of Research Phase One Primary Risk Assessment Phase Two Secondary Risk Assessment Phase Three/Four Follow up from phase two Adherence to evidence based guidelines in women 5

Overview of Presentation The global burden of CVD Assessing cardiovascular risk Limitations of current cardiovascular risk prediction tools- secondary Comparison of cardiovascular risk tools Utilization of evidence based guidelines (part of post doctoral studies)

Background Cardiovascular disease (CVD); number one cause of mortality for both genders In the USA 1 in 3 people have CVD; one death every minute CVD accounts for 18% of the total burden of disability adjusted life years Cost in 2010 ( estimate) 510 billion Risk factors different in men and women 2 in 3 males and 1 in 2 females at age 40 have CVD so prevention is important Centres for Disease Control (CDC) (2011): Heart Disease and Stroke Statistics: 2010 AHA Update

Women CDC 2010

MEN CDC 2010

Risk Factors for CVD - Men Personal history of CVD Hypertension Age over 55 Inactivity Peripheral vascular disease Dyslipidemia Family history of CVD Smoking Diabetes Mellitus 10 American Heart Association (2008), (2010): Johannes & Bairey Merz (2011) Cardiology in Review 19;76-80

Risk Factors for CVD -Women Personal history of CVD Hypertension Age over 55 Inactivity Peripheral vascular disease Dyslipidemia Family history of CVD Smoking Diabetes Mellitus 90% of all cardiac events occur with only one elevated risk factor 11 American Heart Association (2008): Mosca et al (2007)

Risk Factors for CVD -Women Hypertension Mortality for HTN higher in women; differences of 20 mm Hg systolic and 10 mm Hg diastolic pressure in women are associated with a 2 fold increase in mortality. Systolic more than diastolic predicts mortality Both of these risk factors are more prevalent in women than men upon presentation with their first myocardial infarction Diabetes Mellitus 90% of all cardiac events occur with only one elevated risk factor 12 American Heart Association (2008), (2010): Johannes & Bairey Merz (2011) Cardiology in Review 19;76-80.

CV Risk Factors in Women and Men ( Phase 1) Sample: M=109, W=77 Smoking Men Women 20 39 Hypertension 56 54 Diabetes 26 22 Previous MI 3 5 Hyperlipidemia 69 52

Cardiovascular Risk Cardiovascular risk assessment: The basis for prevention (American Heart Association Guidelines updated in 2011 for preventing CVD in women) Go Red for Women Campaign Originated in the USA 14

What the literature reveals Accurate risk assessment of CVD is vital for the prevention of CVD and tailoring therapeutic strategies for ACS Many aspects of risk assessment are poorly understood by healthcare providers Primary (initial) and secondary (at time of ACS) cardiac risk assessment tools need further study as new diagnostic and technology emerges

Secondary cardiac risk assessment tools- need to be utilized more Current primary cardiac risk assessment tools studied mainly in white men and women- ethnic groups? Secondary cardiac risk assessment tools- need to be utilized more 38.2 million women with CVD in the USA Evidence based guidelines for the prevention and treatment of CVD are not utilized fully despite proven benefits American Heart Association (2008), (2010): Johannes & Bairey Merz (2011) Cardiology in Review 19;76-80

Primary CVD Risk Assessment Assessing the risk of CVD requires the synthesis of multiple risk factors into a multivariate profile Framingham risk score (10 year risk) Age, HT, smoking, hyperlipidemia Reynolds risk score (10 year risk) 35 risk factors including traditional and novel risk factors SCORE risk system (10 year risk) Age, gender, SBP, total cholesterol, HDL cholesterol and smoking ( estimates 10 year risk of any first atherosclerotic event- not just coronary heart disease related deaths)

Limitations Framingham study failed to explain 50% of cardiovascular events Framingham risk factors: women have a cardiac event in the absence of these Reynolds: Only predicts 10 year risk of cardiac events and studies to date mainly conducted on white women

SCORE risk system unique: separate risk scores for high risk and low risk regions of Europe validated only on European populations

Secondary Risk Estimation Early risk stratification at the time of an ACS plays a pivotal role Different scores are available based on initial presentation and history Scores assist in determining short and long term outcomes after an ACS

Risk Tools Studied TIMI CADILLAC GRACE

TIMI Risk Tool Risk factors Points (0-14) Age 65-74 >75 2 3 DM/HT or angina 1 Systolic blood pressure <100 HR >100 Killip class II-IV Weight<67kg Anterior MI or LBBB Time to treatment >4 hours High Risk > 8 points/Moderate Risk 6 – 7 points/Low Risk 0-5 points Morrow, D. A., Antman, K. M., Charlesworth, A. et al 2000

CADILLAC risk score for 30-day and one-year mortality after primary percutaneous coronary intervention for ST elevation myocardial infarction Risk Factor Points (0-18) LVEF <40 percent 4 Killip class 2/3 3 Renal insufficiency (estimated creatinine clearance <60 mL/min) TIMI flow grade after PCI of 0 to 2 2 Age >65 years Anemia ( hematocrit <39 percent in men and <36 percent in women) Triple vessel disease Risk Score 30-day mortality One-year mortality Low risk score 0 to 2) 0.1 to 0.2 percent 0.8 to 0.9 percent Intermediate risk (score 3 to 5) 1.3 to 1.9 percent 4.0 to 4.5 percent High risk (score >6) 6.6 to 8.1 percent 12.4 to 13.2 percent Halkin, A., Sing, M., Nikolsky, E., Grines, C. L., Tcheng, J. E., Garcia, E. el al 2005

GRACE Risk Tool Risk factors Points (0-372) Age 0 to 100 Killip class 0-59 Systolic blood pressure 0-58 Presence of ST segment deviation 28 Cardiac arrest during presentation 39 Serum creatinine concentration 1-28 Presence of elevated serum cardiac biomarkers 14 Heart rate 0-46 Steg, Goldberg, Gore et al. 2002 , GRACE website

GRACE ACS-STEMI- In Hospital ACS-STEMI Post Discharge- 6 month Mortality Risk Categories (Tertiles) GRACE risk score Probability of Death In-hospital (%) Low 49-125 <2 Intermediate 126-154 2-5 High 155-319 >5 Risk Categories (Tertiles) GRACE risk score Probability of Death In-hospital (%) Low 27-99 <4.4 Intermediate 100-127 4.5-11 High 128-263

Comparing the Risk Tools Aim: Compare and contrast the secondary cardiovascular risk assessment tools TIMI, GRACE and CADILLAC used at the time of ACS in women to determine predictability in women and Men Research method: Retrospective descriptive design: TIMI, GRACE and CADILLAC scores will be calculated on admission and cases followed for 12 months. Men and women admitted with ACS (STEMI) from 2008-2009 in KP NCAL Sample size: 200 ( Men and Women) Expected outcome: One of the three scores will be more predictive- C statistic 26

Preliminary Analysis of Research – Unpublished data W=77, M=109 Type of MI on presentation: Anterior MI= M(49) F(28) Inferior MI = M(60) F(47) Lateral MI = M(0) F(2) Anterior MI =41.40%, Inferior MI=57.53%, Lateral MI=1.08%

Coronary Artery Disease- Women CAD Frequency Percent Cumulative Frequency Cumulative Percent Multiple Vessel Disease 56 72.73 Single Vessel Disease 21 27.7 77 100

Analysis of Secondary CV Risk Tools EVENTS CADILLAC C Statistic GRACE TIMI MCE 0.718 0.680 0.632 NMCE 0.642 0.624 0.668 MCE ( 1 year) 0.649 0.539 0.566 NMCE ( 1 year) 0.619 0.547 0.604 Death in hospital 0.860 0.645 0.853 Death at 1 year 0.806 0.763

Ideal Cardiovascular Health for men and women Total cholesterol: less than 200 mg/dL HDL cholesterol- 60mg/dL and above BP- Systolic 120 or below, diastolic 80 or below BMI - Normal 18.5 to 25.0 Exercise- 150 minutes per week Heart healthy diet

Publications Publications related to PhD studies: Currently under review Worrall-Carter, L., Ski, C., Scruth, E., Campbell, M., Page, K. Assessing Cardiovascular Risk In Women. Journal of Health and Sciences ( Accepted for Publication August 2011) Manuscripts ready for submission: Scruth, E., Worrall-Carter, L., Page, K., Cheng, E., Campbell, M. Risk determination after PCI for ACS: review of the commonly used risk prediction tools for the Clinical Nurse Specialist. Currently being reviewed by Clinical Nurse Specialist Journal Scruth, E., Worrall-Carter, L., Rolley, J., Page, K.. Psychometric properties of secondary risk prediction tools used after PCI for STEMI. Being submitted to European Journal of CV Nurisng Manuscripts currently being developed for submission: 1. Assessing a profile of cardiovascular Risk in men and women with STEMI 2. Secondary cardiovascular risk tools: A comparison of the tools in men and women post PCI for STEMI 3. A follow up of patients one year after PCI for STEMI: Do secondary cardiovascular risk tools accurately predict events?

Cardiac Publications not related to PhD studies Scruth. E., Haynes. A.. Cardiovascular Disease: Chapter in Thelan’s Critical Care Nursing: Diagnosis and Management (October 2009) Scruth. E. Cardiogenic Shock: Chapter in Manual of Critical Care Nursing- Nursing Interventions and Collaborative Management. (2011) Baird;Bethel Scruth, E. Haynes, A. Review of Cardiovascular Disease: Chapter in Priorities in Critical Care ( Due out late 2011). Scruth, E. Cheng. E. (2006). Measuring Cardiac Output. Contemporary Critical Care

Critical Care Publications not related to PhD studies Cheng, E. Jaramillo. K., Scruth, E., Cheng, E. (2009). Prolonged Paralysis and apnoea after receiving neuromuscular blocking agent: what nurses need to know. Accepted for publication March 2009. American Journal of Critical Care Nursing Scruth, E., Read. J., Cheng. E. (2007). Collaboration between the ICU Manager, Clinical Nurse Specialist and the Medical Director. Journal of Critical Care Nursing Read, J., Scruth E. (2006). Collaboration in the ICU: Use of Advisory Councils. Journal of Critical Care Nursing Cheng, E. Scruth E., Guitterrez, V., Chassy, Patel. D. (2006). Introducing the use of end tidal CO2 to determine feeding tube placement in a community hospital. Journal of Critical Care Medicine