1. 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

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

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

4. 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 Update. AHA.

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

6. 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 Update. AHA.

7. Rates of Death During Hospitalization Following Myocardial Infarction Among Women and Men According to Age
NRMI-2
N=384,878
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:

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

9. 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:

10. Physician Awareness of CVD Prevention Guidelines by Specialty
Mosca. Circulation 2005;111:

11. Physician Incorporation of CVD Prevention Guidelines by Specialty
Mosca. Circulation 2005;111:

12. Women’s Awareness of Heart Disease
Twelve-Year Follow-up of American Women’s Awareness of CDV Risk ( )
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 with symptoms of MI
Majority cited therapies not evidence-based
Common barriers to prevention were family/caretaking responsibilities
Mosca. CircCardiovasc Qual Outcomes Feb 10 Epub.

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

14. 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

15. 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

16. 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

18. 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

19. 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

20. 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:

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

22. Angiographic Characteristics in BARI
Women Men P Value (n=533) (n=1242)
# significant lesions  1.8 <0.001
# lesions >20%  2.3 <0.001
Myocardial jeopardy Index   24.3 <0.001
Total occlusion (%) <0.001
LVEF < 50% (%) <0.001
Tami-Holland Am J Cardiol 2011;107:

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

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

25. 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