perceptions versus reality: women and heart disease ginger hook, msn, rn
TRANSCRIPT
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Perceptions Versus Reality:Women and Heart Disease
Ginger Hook, MSN, RN
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Overview
• Heart Disease– Discuss Statistics of
heart disease– Identify risk factors for
women and heart disease
– Discuss evidence-based guidelines for Cardiovascular Disease Prevention in Women
• Metbolic Syndrome– Define MetS– Discuss statistics of
MetS– Discuss the findings of
the ARIC Study
– Discuss study from Arch Intern Med, 2004
– Discuss NHANES II 1976-80, Follow up study
– Identify Scientific Evidence related to Definition
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Statistics
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Statistics
• Heart Disease and Stroke – First and third leading causes of death in
US– Accounts for more than 40% of all
deaths
• About 95,000 Americans die of heart disease or stroke each year– Amounts to one death every 33 seconds
• Heart Disease is the leading cause of disability among working adults
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Age-Adjusted Mortality
0
50
100
150
200
250
300
Lake LaPorte Porter NW IN IN US
2002 Deaths per 100,000 Population
Heart Disease
2005 Epidemiological Report – Northwest Indiana
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Economics
• 2001• Nationwide cost for all cardiovascular
disease was $300 billion• Heart disease the cost was $105
billion• Stroke, $28 billion• Lost productivity due to stroke and
heart disease cost mor than $129 billion
2005 Epidemiological Report – Northwest Indiana
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0
50
100
150
200
250
300
Lake LaPorte Porter NW IN IN US
2002 Deaths per 100,00 Population
Heart Disease
Age-Adjusted Mortality
2005 Epidemiological Report – Northwest Indiana
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Lake LaPorte Porter IN US HP
2010
Diseases of the Heart 264.1 271.7 224.6 246.1 240.8 213.7*
Malignant Neoplasms 223.6 198.6 195.3 208.3 193.5 159.9
Chronic Lower Resp Diseases
44.6 52.4 36.6 51.1 43.5
Cerebrovascular Disease
52.7 48.6 45.3 59.4 56.2 48.0
Influenza/Pneumonia 13.2 10.8 10.5 21.6 22.6
Diabetes Mellitus 34.2 20.1 25.7 27.3 25.4 15.1*
Motor Vehicle Accidents
14.6 19.6 16.9 15.0 15.7 9.2
Intentional Self-Harm 10.6 9.2 12.1 11.9 10.9 5.0
Assault 19.0 8.3 2.4 6.1 6.1 3.0
2005 Epidemiological Report – Northwest Indiana
Sources: Indiana State Department
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Age-Adjusted Mortality
750
800
850
900
950
Lake LaPorte Porter NW IN IN US
2002 Deaths per 100,000 Population
All Causes of Death
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Women and Heart Disease
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Heart Disease is the #1 Killer of Women
• Coronary heart disease is the single leading cause of death and a significant cause of morbidity among American women.
• In 1997 CHD claimed the lives of 502,938 women (men had less deaths)
• Since 1984, CVD has killed more American women than men each year.
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“Breast Cancer is the REAL issue!”
• Who cares about heart disease doc…I am more concerned about:
BREAST CANCER and lung cancer!”
• In a recent survey, 75% of women identified cancer as their leading cause of death…
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Exam Totals
0
20
40
60
80
100
120
EKG Echo arm/ankle labs body fat
Normal
Abnormal
Age
30-40
41-50
51-60
61-70
71-80
80+
Recent Screening
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In perspective:
• 1 in 2 women will die of heart disease.
• 1 in 25 women will die of breast cancer.
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Coronary Heart Disease in Women
• Presentation and differences from men
• 2/3 of women who die suddenly have no previously recognized symptoms.
• Women are more prone to non-cardiac chest pain…..
• In fact they may experience little or no squeezing chest pain in the center of the chest, lightheadedness, fainting, or shortness of breath with an MI (as seen on “ER”).
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Nationally: The Problem – AWARENESS
• Perception• 67%
knowledgeable that chest pain can be heart disease
• <10% knowledgeable that SOB, nausea, indigestion can be heart disease
• Reality• chest pain is the
presenting symptom in <50% of women
• Almost half of MIs in women present with SOB, nausea, indigestion, fatigue and shoulder pain
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Causes of Confusion:
• Women may experience more dizziness, nausea, indigestion, and fatigue than men.
• Women are more likely to have neck, arms, back and shoulder pain.
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Evidence based information about symptoms suggests a gender focus
Women have More atypical Symptoms of MI
Source: Milner Am J Cardiol 1999;84:396
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Not so straightforward
• Because of these atypical symptoms, women seek medical care later than men and are more likely to be misdiagnosed.
• Women presenting with MI and CAD are more likely to be older, have a history of DM, HTN, Hyperlipids, CHF, and unstable angina than male counterparts.
(J Am Coll Cardiol 1997;29)
• Because of these comorbid conditions, there tends to be diagnostic confusion.
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Misperceptions and Missed Opportunities Leading to Access Inequity
• Women were less likely to have an EKG or be admitted to the telemetry floors.
• Women are under-diagnosed and can therefore get a false sense of security.
• Less aspirin, beta-blockers, statins, antiarrhythmic treatment, cardiac cath, PTCA, CABG
• Women were less likely to enroll in cardiac rehabilitation after an MI or bypass surgery.
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CHD Mortality in Younger Women
2.94.1
5.7
8.2
10.7
14.4
18.4
21.8
25.3
6.17.4
9.5
11.1
13.4
16.6
19.1
21.5
24.2
0
5
10
15
20
25
30
< 50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
Dea
th d
urin
g H
ospi
taliz
atio
n (%
) Men
Women
Figure 1. Rates of death during hospitalization for Myocardial Infarction among w omen and men, according to age. The interaction betw een sex and age w as signif icant (P<0.001).
Women Women underunder 65 suffer the highest relative sex-specific CHD mortality 65 suffer the highest relative sex-specific CHD mortality
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The Need for Prevention in Women
• 9,000 US women younger than 45 sustain a heart attack each year.
• “Thus the priority for coronary prevention is substantial for women of all ages.”
• Mortality associated with acute MI among women younger than 65 y/o is almost twice as high among men.
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Women vs. Men:
• Mortality from CABG-particularly among younger women-is double that among men.
• More women than men die 1 year after an MI.
• CHD is Largely Preventable• We need to address risk factors earlier
and more aggressively, thereby reducing women’s cardiovascular risk.
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Women and Heart Disease
Risk Factors
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Non-modifiable Risk Factors
• Age > 55
– CAD rates are 2-3x’s higher in postmenopausal women
• Family history
– CHD in primary 1st degree relative male<55 or female<65
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The #1 Preventable Risk- Smoking
• A. 50% of heart attacks among women are due to smoking. Smokers tend to have their first heart attack 10 years earlier than nonsmokers.
• B. If you smoke, you are 4-6x’s more likely to suffer a heart attack and increase your risk of a stroke.
• C. Women who smoke and take OCP’s increase their risk of heart disease 30x’s.
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2. Obesity
A. 1/3 of adult women are obese and its increasing
B. Active women have a 50% risk reduction in developing heart disease.
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Increasing Prevalence of Obesity in US Adults
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Obesity and Coronary Heart Disease Mortality
0
1
2
3
4
5
6
<19 19.0-21.9
22.0-24.9
25.0-26.9
27.0-28.9
29.0-31.9
>32.0
Nurses’ Health Study: Women who never smoked
RelativeRisk of CoronaryHeart Diseasemortality
Body Mass Index (kg/m2)
P<0.001 for trendManson JR, et al. N Engl J Med. 1995;333:677-685.
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Hypertension
• 65% of all hypertension remains either undetected or inadequately treated.
• People who are normotensive at 55 have a 90% lifetime risk of developing HTN.
• Prevalence increases with age and women live longer- hypertension is more common in females.
• HTN is more common with OCP and obesity.
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Risk Factors: Diabetes
• Diabetes increases the risk of CHD 3-7 X’s in women versus 2-3 X’s in men.
• Diabetic women who smoke have a 84% higher risk of developing stroke than nonsmokers.
• 2 of 3 people with diabetes die from CHD or stroke.
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Reported Causes of Death in People With Diabetes
C
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Cholesterol
• More than 55 million women (45million men) have TC>200.
• Check cholesterol at least once q 5yr’s starting at age 20.
• 36 Million people in the US should be taking a statin according to guidelines, but only 11 million are.
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Treatments Based on Risk Factors
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SMOKING:
• Stop!!!!! (avg. attempt = 8 times)• Women who have other smokers in
their household have a 2.5 X's greater likelihood of relapse. Circulation 2002:106
• Smoking cessation was associated with a 36% reduction in mortality among patients with CHD.
JAMA 2003:290
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Women and HTN—JNC VII
• The relationship bet. BP and CV events is continuous, consistent and independent of other risk factors.
• The higher the BP the greater the chance of MI, CHF, stroke, and kidney disease.
• Can try to achieve good BP through lifestyle changes.
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Lifestyle Modification for HTN
Modification Recommendation
Expected systolic reduction
Weight reduction Goal of BMI 18-25
Waist <35inches5-20 mm Hg per 10kg wt loss
DASH Fruits, veges, low-fat dairy products, less fat
8-14 mm Hg
Sodium restriction
<2.4 g every day 2-8 mm Hg
Physical activity 30 mins of aerobic 4x’s a week
4-9 mm Hg
Reduced EtOH
(1/2 for women)
2-12 oz beer, 1 10oz wine, 3 oz 80proof whiskey in men
2-4 mm Hg
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Exercise
• 30-45 mins of walking 5x’s/week reduces risk of MI in females 50%.
• Helps control BP, increases HDL, decreases body fat, DM risk, possibly prostate, breast and uterine cancers.
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Cholesterol
• Women at high risk should be considered for statin therapy regardless of cholesterol-LDL levels.
• Statin drugs have already surpassed all other classes of medicines in reducing the incidence of the major adverse outcomes of death, MI, and stroke.
NEJM 350:15 April 8, 2004
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Coronary Heart Disease
Whom Do You Treat?How Aggressive should you be?
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Evidenced-Based Guidelines for Cardiovascular Disease
Prevention in WomenThe AHA Guidelines
February 2004
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Framingham Heart Study
• An individualized approach based on cardiovascular risk-
• First-Assess and stratify women into high, intermediate, lower/optimal risk categories.
• The aggressiveness of treatment should be linked with your risk of having a heart attack or event in the next 10 years- based on the Framingham Heart Study.
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Framingham Point Score
• You get points for:• Age
• Total Cholesterol • HDL Cholesterol• Smoking
• Systolic Blood Pressure
• Add these numbers --you get a 10 yr CHD risk % (category):
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Risk Stratification - Lower Risk
• A. Low Risk : 10% or less risk of having a heart attack or dying of heart disease in the next 10 years.
• May include women with multiple risk factors, Metabolic Syndrome, or 1 or no risk factors.
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Metabolic Syndrome
RISK FACTOR DEFINING LEVEL
Abdominal Obesity Waist Circumference
Men >40 inches
Women >35 inches
TG’s >150
HDL
Men <40
Women <50
BP >130/85
Fasting Glucose >100 mg/dl
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Mortality Associated With Metabolic Syndrome
Lakka H-M et al. JAMA. 2002;288:2709-2716.
18
9
6
8
32
0
2
4
6
8
10
12
14
16
18
20
All-cause mortality* CVD mortality* CHD mortality*
Metabolic syndrome
No metabolic syndrome
Mo
rtal
ity
(% o
f p
atie
nts
)
2003 PPS®
*Adjusted for known CHD risk factors.
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Intermediate Risk
• Those with a 10-20% chance of a heart attack in the next 10 yrs.
• Pts with the metabolic syndrome, multiple risk factors, marked elevations of a single risk factor, first degree relative with CHD (male<55, female<65)
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High Risk: >20%
• You are automatically considered high risk if you have:
• PAD
• CRF
• AAA
• DM
• history of stroke
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Practice Prevention
• Low Risk Women <10%:• Class I recommendations: Intervention is
useful and effective:• Lifestyle Interventions”
Smoking CessationPhysical ActivityHeart Healthy Diet- DASH DietWeight ReductionTreat Individual CVD risk factors
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Practice Prevention
• Intermediate Risk Women (10-20%):Smoking Cessation
Physical Activity Heart Healthy Diet- DASH Diet Weight ReductionControl BP and Lipids
• Class Ila- most scientific evidence favors this type of therapy:
ASA Rx-as long as BP is controlled (hemorrhagic stroke) and minimal risk of GI bleed
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Practice Prevention
• High Risk Women (>20%): Class ISmoking CessationPhysical Activity/cardiac rehab
Heart Healthy Diet- DASH DietWeight ReductionControl BP and Lipids-statinASA therapyblocker therapy-esp in all s/p MIACE-I or ARBS
Glycemic control in DM
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Heart Disease
• There is a continuum of CVD risk, it is not a “have or have-not” condition.
• CHD is less in women who control their risk factors. JAMA Oct. 6, 2004
• The average age of our population is increasing and so CHD will remain a major public health issue.
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Women and Heart Disease –Treatment - Summary
1. Aggressive medical therapy appears particularly effective in women.
2. Women face more adverse outcomes with revascularization, due to procedural complications, suboptimal gender-based risk Stratification and possibly microvascular disease.
3. Long term revascularization risk reduction and outcomes for women are similarly beneficial to men.
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EDUCATE!!!
• Women’s main source of information on heart disease:
Magazines 45%TV 34%Newspaper 27%MD’s 24%
• Only 38% of pts in a recent survey said they discussed CHD prevention with their MD’s.