Cardiovascular Disease in Women

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Cardiovascular Disease in Women

• Dr Ghada Mikhail
• Consultant Cardiologist
• St Marys Hospital Trust

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Death By Cause - Women 2004 UK

• CVD is responsible for
• 36 of deaths in women
• (37 in men)
• Higher than deaths from
• all cancers combined
• Breast CA is responsible
• for 4 deaths in women
• Deaths from CVS is almost 9 times higher
• than deaths from breast cancer.

BHF 2006 heartstats.org
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Death By Cause - Women 2004 Europe
CVD is responsible for 55 of deaths in
women (43 in men) 18 x mortality compared
to Breast cancer
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Age specific death rates from CHD, women,
1968-2003., UK, plotted as a percentage of the
rate in 1968
In women 50 (50 in men) fall in death rates in
those aged 55-64yrs 32 (35 in
men) fall in death rates in those aged 35-44 yrs
BHF 2005 heartstats.org
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Age standardised coronary event rates, women aged
34-65 MONICA-WHO (MONitoring trends and
determinants In CArdiovascular disease)
BHF 2005 heartstats.org
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• Many women lack the basic awareness that CVD is
  their leading cause of death
• Health care professionals- Mx remains a challenge
• Research- women are underrepresented in clinical
  studies

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CVD in Women under-diagnosed, under-treated and
under-researched

• Gender Differences
• Presentation
• Investigation
• Treatment
• Prognosis

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• Risk Factors
• Age
• Smoking
• Diabetes Mellitus
• Hypertension (LVH)
• Hyperlipidaemia (especially HDL,TG in women)
• Family History of CHD
• Homocysteine
• CRP
• Menopause
• Sedentary Lifestyle
• Biggest Risk factor is the misconception that
  CHD is a Mans Disease
• AHA and ACC guidelines for gender specific risk
  assessment
• - guidelines for
  primary and secondary prevention
• ESC
• BCS- guidelines in progress

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Euro Heart Survey of Angina n3779
North n 521
Mediterranean n966 Central
n1341 West n951
Caroline Daly ESC 2005
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Caroline Daly ESC 2005
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Caroline Daly ESC 2005
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Caroline Daly ESC 2005
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Effect of gender on risk of death/MI
Multivariate HR adjusted for age, DM, LV function
and severity of CAD
Caroline Daly 2005
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• Coronary Revascularisation PCI/CABG
• At the time of presentation with CAD, women are
  older and have more
• co-morbid factors
• Increased co-morbid factors
• Older
• Smaller in size
• Hypertension
• Diabetes mellitus
• Hypercholesterolaemia
• Peripheral vascular disease
• Congestive cardiac failure (diastolic
  dysfunction)

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• Coronary Revascularisation- PCI/CABG
• Smaller vessel size
• Coronary lesion distribution and morphology is
  similar
• Women tend to have more ostial vessel disease
• Women receive less IMA conduits than men
• Stent usage is less
• Use of GPIIb/IIIa is less in women
• Higher incidence of urgent procedures

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• Coronary Revascularisation- PCI/CABG
• Higher mortality rate
• In-hospital mortality x 2 times higher for CABG
• Increased mortality in younger women (? Ovarian
  dysfunction,
• ? Abnormalities of oestrogen receptors )
• Higher vascular (stroke, groin) complications
• Higher bleeding and renal complications in women
• At 5 years after CABG and PCI- survival similar
  for men women

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TAXUS IV Gender Analysis

• TAXUS IV n 1,314
• 662 patients (187 28.2 women) randomised to
  TAXUS
• 652 patients (180 27.2 women) randomised to
  BMS
• Primary endpoint
• Rate of ischemia-driven target vessel
  revascularisation at 9 months
• Key Secondary Endpoints
• MACE
• Angiographic (QCA) endpoints pre-specified in 732
  patients
  Lanskey et al JACC 2005
• 
  
  

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TAXUS IV- Female Group MACE at 1 Year
Control (N180)
TAXUS (N187)
Patients ()
Cardiac death
MI
TLR
TVR
MACE
Lanskey et al JACC 2005

MC
Morice Euro PCR 2005
No stent thrombosis in either group at 1 year
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TAXUS IV- Female Group Angiographic Results at 9
months
Control (N72)
TAXUS (N81)
MLD
Late Loss
Late Loss
MLD
mm
mm
In-stent
AnalysisSegment
AnalysisSegment
In-stent
Significant improvement in outcomes for MLD and
Late Loss in TAXUS compare to Control
Lanskey et al JACC 2005
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TAXUS IV- Female Group Angiographic Results at 9
months
Control (N72)
TAXUS (N81)
Diameter Stenosis
Diameter Stenosis
Restenosis


In-stent
AnalysisSegment
In-stent
AnalysisSegment
Restenosis was significantly reduced with the
TAXUS stent
Lanskey et al JACC 2005
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TAXUS IV Gender Analysis

• Women older, hypertension, diabetes, renal
  impairement, unstable angina, heart failure
• Women- higher unadjusted 1 year rates of TLR
  (7.6 vs 3.2, p0.03)
• Female gender - not an independent predictor of
  TLR or TVR

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M Leon ACC 2005
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Experience in Milan
Baseline Patient Characteristics (I)
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Experience in Milan
Baseline Patient Characteristics (II)
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Experience in Milan
In-Hospital and 30-days Outcomes
excluding peri-procedural MI
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Clinical Outcomes at 1 year
Median clinical follow-up 13.9 months (IQR
11.5-17.5)
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AMI

• Women
• Older (approx 20 yrs)
• Higher incidence of risk factors
• Increased incidence in young women (lt45 yrs)
• Present more often with angina rather than AMI
• Present more often with NSTEMI than with STEMI
• Higher proportion of silent AMI (? older,
  diabetes, less awareness)
• Present later to hospital with AMI (? atypical
  symptoms, less awareness, mans disease)

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AMI

• Women have higher rate of complications
• - cardiogenic shock
• - congestive cardiac failure
• - reinfarction
• - peripheral bleeding
• - stroke
• Higher risk of cerebral bleeding with
  thrombolysis
• Higher early mortality than men
• Gender is an independent risk factor for
  mortality in AMI
• Mortality rate in younger women (lt45 years) is
  over twice that in men
• Late presentation to hospital
• Less aggressively treated

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CABG

• Complications
• Stroke
• Post operative haemorrhage
• Prolonged mechanical ventilation
• Post-operative renal failure
• Cardiac failure

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• Coronary Revascularisation- PCI/CABG
• Earlier detection of CAD by non-invasive imaging
• Wider use of stents
• Role of drug eluting stents
• Increasing use of GIIb/IIIa inhibitors
• Off-pump bypass surgery
• Minimal access procedures
• Research Studies / Trials

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• Women are evaluated less intensively and are
  undertreated
• Women under-represented in research studies
• Better awareness
• Appropriate access to diagnosis treatment
• Earlier more aggressive control of risk factors

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• AWARENESS

HEALTH CARE PROFESSIONALS GENERAL PUBLIC

• Education /Scientific Meetings
• Research

• Education / Scientific Meetings
• Research

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• Scientific Initiatives Awareness Campaigns
• Go Red Campaign AHA
• Heart Truth Campaign-
• NHLBI

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European Society of Cardiology 2005
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UK Scientific Public Awareness Campaign
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CVD in Women- Healthcare Professionals

• Primary Care- GPs
• General Physicians
• Cardiologists
• Nursing staff- chest pain nurses
• Dept of Health
• BCS / BCIS
• Cardiac Networks
• CHD Leads
• Nursing Leads

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CVD in Women- Healthcare Professionals

• Symposium on CVD in Women- Friday 7th July
• Recommendations
• Consensus Statement
• Working Group of BCS
• Research

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CVD in Women- General Public

• Symbol
• Website- heratheart.org.uk

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CVD in Women- General Public

• Posters
• Patient Leaflets

Endorsed by BCS
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