Women and Heart Disease Mini-Med School Teresa Daniele, M.D., FACC - PDF document

9/24/2019 Women and Heart Disease Mini-Med School Teresa Daniele, M.D., FACC Chief of Cardiology, UCSF-Fresno Associate Professor of Clinical Medicine UCSF Program Director, Adult Cardiovascular Fellowship Director, Center for Women’s Cardiovascular Health Questions to answer today • Why should women worry about heart disease? • What is heart disease? • How is heart disease different in women than men? • What are the risk factors for heart disease? • How can women prevent heart disease? UCSF Fresno Mini Med School 2019 1

9/24/2019 Questions to answer today • Why should women worry about heart disease? • What is heart disease? • How is heart disease different in women than men? • What are the risk factors for heart disease? • How can women prevent heart disease? Heart Disease leading cause of death in women in US 500,000 400,000 Number of 300,000 Deaths 200,000 100,000 0 A B C D E A Total CVD B Cancer C Chronic Lower Respiratory Diseases D Diabetes Mellitus E Alzheimer’s Disease CDC/NCHS. Heart Disease and Stroke Statistics - 2004 Update American Heart Association (AHA) UCSF Fresno Mini Med School 2019 2

9/24/2019 Reynen DJ, Kamigaki AS, Pheatt N, Chaput LA. Th e Burden of Cardiovascular Disease in California: A Report of the California Heart Disease and Stroke Prevention Program. Sacramento, CA: California Department of Public Health, 2007. UCSF Fresno Mini Med School 2019 3

9/24/2019 How long have we known this for? 1970’s 1990’s 1980’s 2000’s UCSF Fresno Mini Med School 2019 4

9/24/2019 Cardiovascular Disease Mortality: U.S. Males and Females 1980-2004 550,000 500,000 Men Women 450,000 400,000 1980 1985 1990 1995 2000 2004 Source: Adapted from Rosamond 2008 UCSF Fresno Mini Med School 2019 5

9/24/2019 Prevalence of Disease by Age UCSF Fresno Mini Med School 2019 6

9/24/2019 Heart disease can be prevented Knowledge = Power Questions to answer today • Why should women worry about heart disease? • What is heart disease? • How is heart disease different in women than men? • What are the risk factors for heart disease? • How can women prevent heart disease? UCSF Fresno Mini Med School 2019 7

9/24/2019 Types of Heart Disease • Coronary atherosclerosis (plaques) • Congestive Heart Failure • Abnormal Heart Rhythms • Cardiac Valve Disease • Congenital Heart Defect Normal Coronary Artery Normal Coronary Artery UCSF Fresno Mini Med School 2019 8

9/24/2019 The Vulnerable Plaque Thin, Vulnerable, Fibrous Cap Large Lipid Core Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671. Characteristics of Unstable and Stable Plaque Unstable Stable Lack of Inflammatory inflammatory cells cells Thin Thick Few More fibrous cap fibrous cap SMCs SMCs Intact Eroded endothelium endothelium Activated macrophages Foam cells Adapted with permission from Libby P. Circulation . 1995;91:2844-2850. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org. UCSF Fresno Mini Med School 2019 9

9/24/2019 Ruptured Plaque with Occlusive Thrombus Formation Thrombus Formation Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671. Questions to answer today • Why should women worry about heart disease? • What is heart disease? • How is heart disease different in women than men? • What are the risk factors for heart disease? • How can women prevent heart disease? UCSF Fresno Mini Med School 2019 10

9/24/2019 Women have more diffuse narrowing of their Women have more diffuse narrowing of their coronary arteries than men coronary arteries than men Men Men Women Women Gender Differences Men: Luminal obstruction Women: Abnormal coronary reactivity Microvascular dysfunction Plaque erosion/distal microembolization UCSF Fresno Mini Med School 2019 11

9/24/2019 Progression of Plaque Disease Progression of Plaque Disease Without Luminal Narrowing Without Luminal Narrowing A A B B V3016 V3016 B A B A C C C C UCSF Fresno Mini Med School 2019 12

9/24/2019 Macro vs. Microvascular Circulation UCSF Fresno Mini Med School 2019 13

9/24/2019 Women’s Early Warning Signs of a Heart Attack • Weeks before Heart Attack (95% of women)  Unusual fatigue (70.7%)  Sleep disturbance (47.8%)  Shortness of breath (42.1%)  Indigestion (39.4%)  Chest pain (29.7 %) • At time of Heart Attack  Shortness of breath (57.9%)  Weakness (54.8%)  Fatigue (42.9%)  Chest pain (57%) McSweeney, JC et al. Circulation 2003; 2619-2623 Questions to answer today • Why should women worry about heart disease? • What is heart disease? • How is heart disease different in women than men? • What are the risk factors for heart disease? • How can women prevent heart disease? UCSF Fresno Mini Med School 2019 14

9/24/2019 Risk factors for Heart disease • Age • Smoking • Family History • Hypertension • Menopause • High cholesterol • Diabetes • Obesity • Physical inactivity • Inflammatory Disease Impact of Hypertension • The risk of heart disease doubles with each increment of 20/10 mm Hg above normal • A 5-10 mm Hg improvement in systolic blood pressure can decrease heart disease risk by 20% • 66% of people with hypertension do not have adequate blood pressure control UCSF Fresno Mini Med School 2019 15

9/24/2019 Hypertension is the most common risk factor for heart disease 100 Percent of Population 83.4 74.0 80 69.2 60.9 55.5 60 46.6 34.1 34.0 40 21.3 18.1 20 11.1 5.8 0 20-34 35-44 45-54 55-64 65-74 75+ Ages Men Women Source: CDC/NCHS and NHLBI. Smoking is the #1 preventable risk factor for heart disease • 2-6 times more likely to have a heart attack • 150% more deaths from cardiac cause than from lung CA • Oral contraceptive users who smoke have significantly higher cardiac risk • 50% reduction in CAD after first year of smoking cessation and in 10-15 yrs, risk of heart disease decreases to the same level of a non-smoker. UCSF Fresno Mini Med School 2019 16

9/24/2019 Relative Risk of Coronary Events for Smokers Compared to Non- Smokers 6 5.48 5 4 3.12 Relative 3 Risk 2 1 1 0 Never Smoked 1-14 Cigarettes per 15 Cigarettes per day day Source: Adapted from Stampfer 2000 UCSF Fresno Mini Med School 2019 17

9/24/2019 Elevated cholesterol levels are a risk factor for heart disease in men and women 5.0 4.0 CHD likelihood 3.0 ratio 2.0 1.0 0.0 Total-C LDL-C Trig. Total-C LDL-C Trig Men Women Framingham Heart Study Elevated Triglyceride levels are associated with greater cardiac risk in women Framingham Heart Study 2.5 2.2 2.15 Women Relative Risk (x-fold) 2 1.85 Men 1.8 1.45 1.4 1.5 1.3 1.25 1.25 1.2 1 1 1 0.8 0.75 0.65 0.55 0.5 0 50 100 150 200 250 300 350 400 Triglyceride levels Triglyceride levels Castelli WP. Can J Cardiol. 1988 UCSF Fresno Mini Med School 2019 18

9/24/2019 Diabetes is a potent risk factor for heart disease • Diabetes is considered a “coronary heart disease equivalent” • Women now make up more than 50% of the diabetic population • Women with diabetes are at 3-7 times greater risk of heart disease than non-diabetic women • Young women who are diabetic lose “gender protection” Source: National Diabetes Fact Sheet, Atlanta, GA, Department of Health and Human Services, Centers for Disease Control and Prevention, 1997. Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI  30, or about 30 lbs. overweight for 5’4” person) 1990 2000 2010 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% UCSF Fresno Mini Med School 2019 19

9/24/2019 Women are more likely to be obese than men Overweight Obese 56.3 Number of persons (in millions) 60 52 50 40 25.6 30 18.7 20 10 0 Men Women Overweight defined as >25 BMI; obese defined as >30 BMI. American Heart Association. 2002 Heart and Stroke Statistical Update American Heart Association. 2002 Heart and Stroke Statistical Update American Heart Association. 2002 Heart and Stroke Statistical Update. 2001 Impact of Weight on Cardiac risk Obesity increases the risk for cardiac disease, hypertension, and diabetes. Being overweight mildly increases the risk of cardiovascular disease, even in young women. Being obese increases the risk fourfold. Central adiposity, defined as a waist size greater than 35 inches in women, is a significant predictor of CHD. (Source: NHLBI) UCSF Fresno Mini Med School 2019 20

9/24/2019 Body Mass Index Evaluation • Body Mass Index formulas Metric formula: (weight in kilograms) (height in meters) x (height in meters) English formula: (weight in pounds) (height in inches) x (height in inches) X 703 • Classification by BMI Overweight >25 but <30 Obese >30 but <40 Extreme Obesity >40 Body Weight and CHD Mortality Among Women 5.8 6 4.6 5 4 Relative Risk 3.1 of CHD Mortality 3 Compared to BMI<19 2 1.4 1 1 1 0 19.0-21.9 22.0-24.9 25.0-26.9 27.0-28.9 29.0-31.9 32 BMI P for trend < 0.001 Source: Adapted from Manson 1995 UCSF Fresno Mini Med School 2019 21