Cardiovascular Disease in Women Module V: Prognosis and Treatment Outcomes

Women Received Less Interventions to Prevent and Treat Heart Disease  Less cholesterol screening  Less lipid-lowering therapies  Less use of heparin, beta-blockers and aspirin during myocardial infarction  Less antiplatelet therapy for secondary prevention  Fewer referrals to cardiac rehabilitation  Fewer implantable cardioverter-defibrillators compared to men with the same recognized indications Sources: Chandra 1998, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 2005, Chou 2007, Hernandez 2007, Cho 2008

Prognosis After MI  38% of women die within first year  Compared to 25% of men  35% of women will have second MI within 6 years  Compared to 18% of men Source: Wenger 2004

Prognosis  Women < 65 yrs have 2 X mortality rate after MI compared to men of same age  After MI, women have significantly higher rates of:  Depression  Physical disability  After CABG, women have significantly higher rates of:  Hospital readmission  Reduced mental health and physical functioning Source: Vaccarino 1999, Ades 2002, Lauzon 2003, Vaccarino 2003

Undertreatment of MI in Women  Compared with men:  Less emergent thrombolysis  Less acute catheterization and angioplasty  Less acute surgical revascularization  Less use of heparin, beta-blockers, and aspirin Source: Chandra 1998, Nohria 1998

Cardiac Rehabilitation for Women  Cardiac rehabilitation programs benefit both men and women  Participation rates for eligible women are 15-20%, compared to 25-31% for eligible men  Women are more likely to drop out after beginning cardiac rehabilitation  Healthcare providers are less likely to encourage rehabilitation for female patients Source: Scott 2004

Benefits of ASA in Women with Established CAD * P = **P = * ** Source: Adapted from Harpaz 1996

Addition of Clopidogrel to Aspirin and Fibrinolytic Therapy for MI with ST-Segment Elevation in Women P < 0.05; reduction in odds = 38% Source: Sabatine 2005

Gender Gap in Dyslipidemia Treatment  Significantly more men than women have annual cholesterol measurements  Significantly more men than women receive effective lipid-lowering therapy  African Americans receive less lipid-lowering treatment compared to whites Source: O’Meara 2004, Hendrix 2005, Chou 2007, Cho 2008

Meta-Analysis of 11 Clinical Trials of Statin Therapy Including 15,917 Women with Known CHD CHD Events Non-Fatal MI CHD Mortality Source: Grady 2003.

Simvastatin and Gender Risk for CHD and Mortality *P <0.05 Source: Scandinavian Simvastatin Survival Study Group 1994

Heart Protection Study: Major Findings  Randomized, placebo-controlled trial of over 20,000 patients at risk for CVD  Statin treatment reduced the risk of heart attacks and strokes by at least one third, as well as reducing the need for arterial surgery, angioplasty and amputations.  Major CV events were reduced in women (5082 enrolled) as well as men, and in all age groups, across all cholesterol levels. Source: HPS Writing Group, Lancet 2002

Primary Prevention of CHD Events with Statin Treatment: AFCAPS/TexCAPS Relative Risk of First Major Coronary Events P < compared to placebo Source: Downs 1998

Implanted Cardioverter Defibrillator (ICD) Therapy in Women  Women appear to have a lower incidence of sudden cardiac death then men  Women present more frequently with ventricular fibrillation than men  Women have similar survival rates after ICD implantation compared to men  In a study of hospitals participating in a heart failure quality improvement program, women received fewer implantable cardioverter-defibrillators compared to men with the same recognized indications Source: Pires 2002, Hernandez 2007

Adjusted Odds for Use of Implantable Cardioverter-Defibrillator According to Guidelines by Race and Sex *P <0.05 compared with white men Source: Adapted from Hernandez 2007 * * *

Interventional Procedures and Surgery  Higher complication and death rates  Smaller artery size  More co-existing illnesses (older at presentation)  Higher rates of diabetes  More urgent and emergent presentations  Higher incidence of congestive heart failure in women from diastolic dysfunction Source: Jacobs 2003

Coronary Revascularization in Women Compared to Men  Increased use of PTCA compared to stents, because of smaller vessel size  Decreased rates of glycoprotein IIb/IIIa inhibitor use, possibly because of increased bleeding complications in women  Higher in-hospital mortality for CABG and PCI  Higher rates of vascular complications  Higher transfusion rates Source: Jacobs 2003

Revascularization Outcomes in Women: Improvements in Recent Years  NHLBI registry data shows improved clinical success rates and lower major complication rates for women undergoing PTCA  Retrospective data suggest that women have lower mortality rates when undergoing off-pump CABG, compared to standard CABG Source: Jacobs 1997, Petro 2000

Sex Differences for In-Hospital Mortality After CABG: Higher Mortality in Younger Women P for interaction between sex and age = ≥ Source: Adapted from Vaccarino 2002

CABG Outcomes in Women: A Vicious Cycle Perception: Higher post-operative morbidity/mortality in women Prompt referral for CABG discouraged in women Women referred at later stages of disease, w/ more comorbidities Higher operative risk for women Fewer long-term benefits for women Source: Adapted from Vaccarino 2003