Cardiovascular Disease in Women Module II: Risk Factors

Module II: Risk Factors  Traditional Risk Factors  Evolving Risk Factors

Cardiovascular Risk Factors in Women  Unmodifiable  Age  Family History  Modifiable  Diabetes  Dysplipidemia  Hypertension  Obesity  Poor Diet  Sedentary Lifestyle  Cigarette Smoking Source: ATP III 2002, Mosca 2007

Cardiovascular Risk Factors  Sedentary Lifestyle

Modifiable Risk Factors: Sedentary Lifestyle  40% of women report no leisure time physical activity  Exercise is less prevalent among white women compared to white men  African American and Hispanic women have the lowest prevalence of leisure time physical activity Source: U.S. Surgeon General 1996, Rosamond 2008

Estimated Percentage of Americans Age 18 and Older Who Report Regular Physical Activity 2005: By Race and Sex Source: Rosamond 2008

Risk Reduction for CHD Associated with Exercise in Women Source: Adapted from Manson 1999

Cardiovascular Risk Factors  Cigarette Smoking

Relative Risk of Coronary Events for Smokers Compared to Non-Smokers Source: Adapted from Stampfer 2000

Smoking  The same treatments benefit both women and men  Women face different barriers to quitting  Concomitant depression  Concerns about weight gain Source: Fiore 2000

Five A’s  Ask about tobacco use at every visit  Advise in a clear and personalized message  Assess willingness to quit  Assist to quit  Offer counseling/support (eg, support groups, phone lines)  Offer pharmacotherapy unless contraindicated  Arrange follow-up  For more information: Source: Fiore 2000

Cardiovascular Risk Factors  Obesity

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Obesity Trends* Among U.S. Adults Behavioral Risk Factor Surveillance System BRFSS, (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) Source: CDC

Body Mass Index: Definition  BMI = weight in kilograms divided by the square of the height in meters (kg/m2)  BMI chart showing BMI based on weight in pounds and height in inches available at: Source: NHLBI

Body Weight and CHD Mortality Among Women P for trend < Source: Adapted from Manson 1995

Body Weight and CHD Mortality Among Women P for trend < ≥ Source: Adapted from Manson 1995

Adult Treatment Panel III Guidelines  Sample menus for different ethnic & cultural preferences  Assessment tools  Counseling tools  Adherence tips  Patient handouts Source: ATP III 2002

Cardiovascular Risk Factors  Diabetes

Diabetes  Diabetes affects 8.8% of all U.S. women age 20 years or older  Compared to whites:  African Americans, Latinas, American Indians, Asian Americans, and Pacific Islanders have a times greater prevalence of diabetes Source: CDC, NIDDK 2005

Diabetes  65% of diabetics die of cardiovascular disease  Diabetics have death rates from heart disease that are 2 to 4 times higher than non-diabetics Source: CDC 2003

Coronary Disease Mortality and Diabetes in Women Source: Adapted from Krolewski 1991

Race/Ethnicity and Diabetes  At high risk:  Latinas  American Indians  African Americans  Asian Americans  Pacific Islanders Source: American Diabetes Association 2001

Definition of Metabolic Syndrome in Women  Abdominal obesity - waist circumference > 35 in.  High triglycerides ≥ 150mg/dL  Low HDL cholesterol < 50mg/dL  Elevated BP ≥ 130/85mm Hg  Fasting glucose ≥ 100mg/dL Source: AHA/NHLBI 2005

Cardiovascular Risk Factors  Hypertension

Treatable Risk Factors: Hypertension  32% of women in the United States have hypertension  Hypertension is more prevalent among older women than older men  Death from CHD progresses increasingly and linearly as blood pressure increases  For every 20 mmHg systolic or 10 mmHg diagnostic increase in blood pressure, risk of death from CHD doubles Source: American Heart Association 2004, JNC , Rosamond 2008

Lifestyle Approaches to Hypertension in Women Source: JNC VII 2004, Sacks 2001, Mosca 2007  Maintain ideal body weight  Weight loss of as little as 10 lbs reduces blood pressure   DASH eating plan  Even without weight loss, a diet rich in fruits, vegetables, and low fat dairy products can reduce blood pressure   Sodium restriction to 2300 mg/d  Further restriction to 1500 mg/d may be beneficial, especially in African American patients   Increase physical activity   Limit alcohol to one drink per day  Alcohol raises blood pressure  One drink = 12 oz beer, 5 oz wine, or 1.5 oz liquor

JNC 7 Report  Classification of blood pressure  Treatment algorithms  Lifestyle strategies  Antihypertensive drug choices  Special indications and situations  Resistant hypertension Source: NIH 2004

Trends in Age-adjusted Prevalence of Hypertension in United States Source: MMWR 2005

Hypertension Prevalence Among White and Black Women in the United States: Trends Source: Adapted from Hertz 2005 %

Prevalence of High Blood Pressure by Age and Race Source: Data from National Vital Statistics System, Health, United States,

African Americans and Hypertension  Compared to whites  African Americans develop hypertension earlier in life  African Americans have much higher average blood pressures  African Americans have a 1.5 times greater risk of heart disease death Source: American Heart Association 2008

Age-Adjusted 16-Year Incidence of End Stage Renal Disease by Diastolic Blood Pressure and Race (MRFIT data) Source: Klag 1997 PercentPercent Diastolic Blood Pressure

DASH Eating Plan  7–8 servings of grains, grain products daily  4–5 servings of vegetables daily  4–5 servings of fruits daily  2–3 servings of low-fat or nonfat dairy foods daily  ≤ 2 servings of meats, poultry, fish daily  4–5 servings of nuts, seeds, legumes weekly  Limited intake of fats, sweets Source: NHLBI 1998

DASH Diet with Low Sodium Intake in Hypertensive Individuals Compared to Control Diet with Average U.S. Sodium Intake African American Non-African American * P<.001 from baseline * Source: Sacks 2001 *

Cardiovascular Risk Factors  Dyslipidemia

Approximate and Cumulative LDL Cholesterol Reduction Achievable By Dietary Modification Dietary Component Dietary Change Approximate LDL Reduction Major Saturated fat<7% of calories8-10% Dietary cholesterol<200 mg/day3-5% Weight reductionLose 10 lbs5-8% Other LDL-lowering options Viscous fiber5-10 g/day3-5% Plant/sterol2g/day6-15% stanol esters Cumulative estimate20-30% Source: Adapted from ATP III 2002

ATP III Full Report Source: ATP III 2002  How to choose a statin  Dosing regimens  How to monitor when combining drugs  Side effect management  Reprintable nutritional hand-outs  Menu samples for different cultures  Adherence strategies/barrier reduction

Treatable Risk Factors: The Epidemiology of Cholesterol Levels and Subfractions  Low HDL more important in women than men  For every 1 mg/dL increase in HDL 3% decrease in CHD risk for women and 2% decrease in CHD risk for men  Total cholesterol/HDL ratio very predictive of CHD risk in women  Triglyceride elevation associated with greater atherogenic significance in women than in men Source: Maron 2000

Treatable Risk Factors: Cholesterol Level and Subfractions  LDL>160 mg/dL associated with 3.3-fold elevation in risk for women less than 65 years old  LDL pattern of small, dense particles (more atherogenic) present in 25% of population, but less frequently seen in women  Menopausal transition associated with increasing proportion of this subfraction Source: Keil 2000, Carr 2000, Hokanson 1996

Source: MMWR 1992 Relative Risk HTNCHOLDMObesitySmoking Men Women Relative Risk of Various Factors for CHD for Women and Men

Cardiovascular Risk Factors  Poor Diet

Low Risk Diet is Associated with Lower Risk of Myocardial Infarction in Women Diet Score by Quintile (1= least vegetables, fruit, whole grains, fish, legumes) Relative Risk of MI* *Adjusted for other cardiovascular risk factors Source: Akesson 2007 P<.05 for quintiles 3-5 compared to 1-2

Emerging Risk Factors for CHD  Pro-inflammatory markers  C-reactive protein (hs-CRP)  Fibrinogen  Hyperhomocysteinemia  Homocysteine lowering to prevent CHD events has been shown to be ineffective or possibly harmful in randomized clinical trials Source: ATP III 2002; Mosca 2007

Relative Risk of Cardiovascular Events According to Baseline Levels of hs-CRP in Healthy Postmenopausal Women P for trend < Source: Ridker 2000

Fibrinogen Levels and CHD Risk in Women *Adjusted for age, smoking, BMI, systolic blood pressure, total cholesterol, HDL, triglycerides, and educational level  2.8 >2.8,  3.1 >3.1,  3.6 >3.6 Source: Eriksson 1999 P for trend <0.0001

Relative Risk of Cardiovascular Events According to Baseline Levels of Homocysteine in Healthy Postmenopausal Women P for trend = 0.02 (not significant) μμμ μ Source: Ridker 2000

The NORVIT Trial: Homocysteine Lowering Did Not Reduce Cardiovascular Events in Women with Prior MI Relative Risk of CVD Event *Compared to B12 alone Source: Bonaa 2006 * ** **Compared to placebo

Psychosocial Stressors in Women with CHD: The Stockholm Female Coronary Risk Study  Among women who were married or cohabitating with a male partner, marital stress was associated with nearly 3-fold increased risk of recurrent CHD events  Living alone and work stress did not significantly increase recurrent CHD events Source: Orth-Gomer 2000

Depression and CHD: Results from the Women’s Health Initiative Study  Depression is an independent predictor of CHD death among women with no history of CHD Source: Wassertheil-Smoller 2004