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

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. Women
CDC 2010

9. MEN
CDC 2010

10. 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

11. 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)

12. 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.

13. CV Risk Factors in Women and Men ( Phase 1)
Sample: M=109, W=77
Smoking
Men Women
Hypertension
Diabetes
Previous MI
Hyperlipidemia

14. 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

15. 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

16. 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

17. 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)

18. 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

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

20. 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

21. Risk Tools Studied
TIMI
CADILLAC
GRACE

22. 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

23. 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

24. 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 , GRACE website

25. GRACE
ACS-STEMI- In Hospital ACS-STEMI Post Discharge month Mortality
Risk Categories
(Tertiles)
GRACE risk score
Probability of Death In-hospital (%)
Low
49-125
<2
Intermediate
2-5
High
>5
Risk Categories
(Tertiles)
GRACE risk score
Probability of Death In-hospital (%)
Low
27-99
<4.4
Intermediate
4.5-11
High

26. 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 in KP NCAL
Sample size: 200 ( Men and Women)
Expected outcome: One of the three scores will be more predictive- C statistic 26

27. 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%

28. 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

29. 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

30. 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

31. 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?

32. 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

33. 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 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