1. Gender Sensitive Cardiovascular Health Global Implications

2. Kara Heffron Briseño CHES Spirit of Women Warren Heffron M.D. University of New Mexico

3. Education is not the filling of a pail, but the lighting of a fire. ~Wm Butler Yeats The task of education is not to cut down jungles but to irrigate deserts. ~C.S. Lewis

4. Pop Quiz! What are the top leading causes of death in the world… ….for men? …for women?

5. Quiz Continued Is it really Malaria? Do more women die worldwide from cardiovascular disease than men? Do Doctors know this?

6. How did you do? Cause of Death (WHO) Rate per 100,000 M F 1. Cardiovascular disease 259 278 1a. Ischemic Heart disease 121 110 2. Cerebrovascular disease 81 95 3. Lower respiratory disease 62 62 4. HIV/AIDS 46 43 5. COPD 45 43

8. Objectives At the end of this presentation the participants should: Have an improved understanding of the importance of cardiovascular disease in women and the global impact Be aware of strategies to identify and stratify women into categories of risk for CVD Be able to use evidence based approaches to prevention in patients with hypertension, diabetes, lipid disorders and other risk factors, through education and medical management

9. Objectives Be able to utilize multiple therapies to prevent and manage cardiovascular disease Understand gender related issues to the prevention of cardiovascular disease in women Relate these modalities across cultures and borders raising global awareness

10. Global CVD rates compared to US

11. Source: NCHS and NHLBI. Note: No comparability ratios were applied CVD disease mortality trends for males and females (United States: 1979-2005)

12. Cardiovascular Mortality- Americas  Mortality rates for diseases of the circulatory system have decreased in all countries in the Americas, for both genders. Male decrease > than for females.  This decrease in CV mortality has increased the life expectancy at birth for both genders dramatically (up to 3 years in Canada). Pan American Health Report 2002

13. Women’s Number One Health Threat  CVD kills more women than the next five causes of death combined, including all forms of cancer  In 2005, 1 in 3 female deaths was from CVD as compared to 1 in 30 deaths from breast cancer  Women age 40 and older are less likely than men of that age group to survive a year after their first heart attack American Heart Association, Heart Disease and Stroke Statistics – 2009 Update

14. 14 Racial and Ethnic Groups  Cardiovascular disease is the leading cause of death for African Americans, Latinos, Asian Americans, Pacific Islanders, and American Indians  African American women are at the highest risk for death from heart disease among all racial, ethnic, and gender groups Source: American Heart Association 2004

15. A Total CVD B Cancer C Accidents D Chronic Lower Respiratory Diseases E Mellitus E Diabetes Mellitus F Alzheimer’s Disease Source: NCHS. American Heart Association - Heart Disease and Stroke Statistics 2009 Update. CVD and other major causes of death for all males and females (United States: 2005)

16. Source: NCHS and NHLBI. These data include coronary heart disease, heart failure, stroke and hypertension. Prevalence of CVD in adults age 20 and older by age and sex (NHANES: 2005-2006)

17. Gender and Health Care  Women make primary care decisions in 2/3 of American households.  Women account for 80 cents out of every dollar spent in US drugstores.  Women in American families make 75% of domestic decisions including appointments for physician appointments....most likely the same worldwide Norcross. UCSD

18. Gender Gaps and Health Care  Education gap  Equity, rich get CABG, poor get nothing  Quality gaps  Inadequate medical services  Technology gaps  Transportation gaps Pan American Health Report 2002

19. 19 Women Receive 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  Fewer referrals to cardiac rehabilitation Chandra 1996, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 2005

20. 20 Classification of Recommendations Source: Mosca 2004 Class I: Intervention is useful and effective Class II a: Weight of evidence/opinion is in favor of usefulness/ efficacy Class II b: Usefulness/efficacy is less well established by evidence/opinion Class III: Intervention is not useful/effective and may be harmful Mosca L, et al. Circulation 2007; 115:1481-1501. http://www.circ.ahajournals.orghttp://www.circ.ahajournals.org

21. 21 Cardiovascular Disease Prevention in Women: Current Guidelines  Evaluation of Risk: A general approach – stratify women as high risk, at risk, or at optimal risk  Consider lifetime risk rather than short-term absolute risk  Implement Class I Lifestyle recommendations for all women  Treat HTN, DM, lipid abnormalities  Identify high risk women – highest priority Source: Adapted from Mosca 2007

22. 22 Risk Stratification  CHD equivalent  Diabetes mellitus  Established atherosclerotic disease  Includes many patients with chronic kidney disease, especially ESRD  Major Risk Factors:  Age > 55 years  Smoking  Hypertension, whether or not treated with medication  HDL cholesterol < 40mg/dL (HDL cholesterol ≥ 60mg/dL is a negative risk factor)  Family history of premature CVD Sources: Mosca 2004, ATP III 2002

23. Improving Survival: What Works Globally?  Education of women  Nutrition for women  Family Planning  Immunizations  STD prevention  Malaria prevention  Village outreach health programs Pan American Health Report 2002

24. 24 CHD Risk Equivalents  High Risk > 20% 10-yr risk for CHD events  Established coronary artery disease  Carotid artery stenosis  Peripheral arterial disease  Abdominal aortic aneurysm  Diabetes  Includes many patients with chronic renal disease, especially ESRD Source: Mosca 2004

25. 25 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

26. 26 Lifestyle Interventions  Smoking cessation  Physical activity  Heart healthy diet  Weight reduction/maintenance Source: Mosca 2004

27. 27 Relative Risk of Coronary Events for Smokers Compared to Non-Smokers Source: Adapted from Stampfer 2000

28. 28 Physical Activity  Consistently encourage women to accumulate a minimum of 30 minutes of moderate intensity physical activity on most, or preferably all, days of the week Source: Mosca 2004

29. 29 Risk Reduction for CHD Associated with Exercise in Women Age-Adjusted Relative Risk

30. 30 Body Weight and CHD Mortality Among Women Source: Adapted from Marson 1995

31. 31 Weight Maintenance/ Reduction Goals  BMI between 18.5 and 24.9  Waist circumference < 35 inches  Weight loss goals  10% of body weight over six months or 1-2 pounds weight loss/week  Reduce calories by 500-1,000 per day Source: Mosca 2004, ATP III 2002

32. 32 Diet  For healthy women without elevated LDL:  Healthy food selections:  - Fruits and vegetables-Legumes  -Whole grains-Low-fat protein  -Low-fat or nonfat dairy -Fish  Saturated fats < 10% of calories, < 300mg cholesterol  Limit trans fatty acid intake (main dietary sources are baked goods and fried foods made with partially hydrogenated vegetable oil) Source: Mosca 2004

33. 33 Major Risk Factor Interventions  Blood Pressure  Lipids  Diabetes Source: Mosca 2004

34. 34 Hypertension  Encourage an optimal blood pressure of < 120/80 mm Hg through lifestyle approaches  Pharmacologic therapy is indicated when blood pressure is > 140/90 mm Hg or an even lower blood pressure in the setting of diabetes or target-organ damage (> 130/80 mm Hg)  Thiazide diuretics should be part of the drug regimen for most patients unless contraindicated Source: Mosca 2004

35. 35 ATP III LDL-C Goals Refer to Table: ATP III LDL-C Goals and Cutpoints for TLC and Drug Therapy

36. 36 Diabetes  Recommendation: Lifestyle and pharmacotherapy should be used to achieve near normal HbA1C (<7%) in women with diabetes

37. 37 Coronary Disease Mortality and Diabetes in Women Source: Adapted from Krolewski 1991

38. 38 Race/Ethnicity and Diabetes  At high risk:  Latinas  American Indians  African Americans  Asian Americans  Pacific Islanders

39. 39 Preventive Drug Interventions  Aspirin – High risk women  75-162 mg, or clopidogrel if patient intolerant to aspirin; should be used in high-risk women unless contraindicated  Aspirin – Intermediate risk women  Consider aspirin therapy (75-162 mg) in intermediate- risk women as long as blood pressure is controlled and benefit is likely to outweigh risk of GI side effects Source: Mosca 2004

40. CVD Prevention and Gender Women have opportunities to role model and teach:  Positive health education principles to the family in the home.  Healthy eating, exercise, health screening.  Lead the family health care decisions and education. Pan American Health Report 2002

41. Global Needs Before Cardiovascular Healthcare Carroll Berhorst, MD  Social and Economic Justice  Land Tenure  Agricultural production and marketing  Population control  Malnutrition  Health training  Curative medicine

42. Awareness that CVD is the leading cause of death in women Twelve-Year Follow-Up of American Women's Awareness of Cardiovascular Disease Risk and Barriers to Heart Health Circ Cardiovasc Qual Outcomes published online Feb 10, 2010. Lori Mosca, Heidi Mochari-Greenberger, et al.

43. Awareness of CVD Among Women 54% Of women that know heart disease is the leading cause of death in women 31% of black women and 29% of Hispanic women knew that heart disease was their greatest health risk, compared to 68% among white women 29% Of women that know shortness of breath is a symptom of a heart attack 17% Of women that know chest tightness is a symptom of a heart attack 43 Circ Cardiovasc Qual Outcomes published online Feb 10, 2010. Lori Mosca, Heidi Mochari-Greenberger, et al.

44. 44 Benefits of ASA in Women with Established CAD Source: Adapted from Harpaz 1996

45. 45 Preventive Drug Interventions  Beta-Blockers Should be used indefinitely in all women who have had a myocardialinfarction or who have had chronic ischemic syndromes (unless contraindicated)  Angiotensin-Converting Enzyme Inhibitors Should be used (unless contraindicated) in high-risk women  Angiotensin-Receptor blockers Should be used in high-risk women with clinical evidence of heart failure or an ejection fraction of <40% who are intolerant of ACE inhibitors Source: Mosca 2004

46. 46 Atrial Fibrillation/ Stroke Prevention  Warfarin Among women with chronic or paroxysmal atrial fibrillation, warfarin should be used to maintain the INR at 2.0-3.0 unless they are considered to be at low risk of stroke (<1%/year)  Aspirin 325mg should be used in women with chronic or paroxysmal atrial fibrillation with a contraindication to warfarin or a low risk for stroke (<1%/year) Source: Mosca 2004

47. 47 Depression and Cardiac Rehabilitation  Depression Women with CVD should be evaluated for depression and referred or treated when indicated  Cardiac Rehabilitation Women with a recent acute coronary syndrome or coronary intervention, new onset or chronic angina, should participate in a comprehensive risk education program, such as cardiac rehabilitation, or a physician-guided home or community based program Source: Mosca 2004

48. Awareness does not necessarily equal action Would you call 9-1-1 if you thought you were having symptoms of a heart attack? What would you do if you thought you were having a heart attack? Would you discuss your risk with your doctor? 53% of the women surveyed said they would call 9-1-1 23% reported they would take an aspirin 48% of women reported discussing heart disease with their doctor Circ Cardiovasc Qual Outcomes published online Feb 10, 2010. Lori Mosca, Heidi Mochari-Greenberger, et al.

49. 49 Prevention of Cardiovascular Disease in Women  Assess global risk and stratify into high risk, at risk, or optimal risk  Encourage lifestyle approaches  Treat hypertension, lipid abnormalities, and diabetes  Implement pharmacologic interventions for women at high risk, pharmacologic interventions may be appropriate for some lower risk women  Avoid initiating therapies without benefit, or where risks outweigh benefits Source: Mosca 2007

50. Evidence-Based Guidelines for CVD Prevention in women  Relay heart healthy messages at every patient encounter  Encourage lifestyle approaches  Assess global risk and stratify patients into high risk, at risk, or optimal risk categories  Screen for and treat  Hypertension  Lipid abnormalities  Diabetes

51. Algorithm for CVD Prevention in Women: Mosca, L. et al. Circulation 2007;115:1481-1501

52. Evidence-Based Guidelines for CVD Prevention in women  CVD equivalent  Diabetes mellitus  Established atherosclerotic disease  Includes many patients with chronic kidney disease, especially ESRD  Major Risk Factors:  Age > 55 years  Smoking  Hypertension, whether or not treated with medication  HDL cholesterol < 40mg/dL (HDL cholesterol ≥ 60mg/dL is a negative risk factor)  Family history of premature CVD Mosca 2004, ATP III 2002

53. 53 The Heart Truth Professional Education Campaign Website http://www.womenshealth.gov/hearttruth

54. Additional Resources  The Heart Truth Professional Education Campaign Website: http://www.womenshealth.gov/hearttruth  www.americanheart.org/yourethecure 54