Cardiovascular Disease in Women Module II: Risk Factors

1
Cardiovascular Disease in WomenModule II Risk
Factors
2
Module II Risk Factors

• Traditional Risk Factors
• Evolving Risk Factors

3
Cardiovascular Risk Factors in Women

• Unmodifiable
• Age
• Family History
• Modifiable
• Diabetes
• Dysplipidemia
• Hypertension
• Obesity
• Poor Diet
• Sedentary Lifestyle
• Cigarette Smoking

Source ATP III 2002, Mosca 2007
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Cardiovascular Risk Factors

• Sedentary Lifestyle

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Modifiable Risk Factors Sedentary Lifestyle

• 40 of women report no leisure time physical
  activity
• Exercise is less prevalent among white women
  compared to white men
• African American and Hispanic women have the
  lowest prevalence of leisure time physical
  activity

Source U.S. Surgeon General 1996, Rosamond 2008
6
Estimated Percentage of Americans Age 18 and
Older Who Report Regular Physical Activity 2005
By Race and Sex
Source Rosamond 2008
7
Risk Reduction for CHD Associated with Exercise
in Women
Source Adapted from Manson 1999
8
Cardiovascular Risk Factors

• Cigarette Smoking

9
Relative Risk of Coronary Events for Smokers
Compared to Non-Smokers
Source Adapted from Stampfer 2000
10
Smoking

• The same treatments benefit both women and men
• Women face different barriers to quitting
• Concomitant depression
• Concerns about weight gain

Source Fiore 2000
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Five As

• Ask about tobacco use at every visit
• Advise in a clear and personalized message
• Assess willingness to quit
• Assist to quit
• Offer counseling/support (eg, support groups,
  phone lines)
• Offer pharmacotherapy unless contraindicated
• Arrange follow-up
• For more information http//www.surgeongeneral.go
  v/tobacco/

Source Fiore 2000
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Cardiovascular Risk Factors

• Obesity

13
Obesity Trends Among U.S. AdultsBehavioral Risk
Factor Surveillance System BRFSS, 1990-2006
1998
1990
(BMI 30, or 30 lbs overweight for
5 4 woman)
2006
No Data lt10 1014
1519 2024 2529
30
Source CDC
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Body Mass Index Definition

• BMI weight in kilograms divided by the square
  of the height in meters (kg/m2)
• BMI chart showing BMI based on weight in pounds
  and height in inches available at
  http//www.nhlbi.nih.gov/guidelines/obesity/ob_hom
  e.htm

Source NHLBI
15
Body Weight and CHD Mortality Among Women
P for trend lt 0.001
Source Adapted from Manson 1995
16
Body Weight and CHD Mortality Among Women
P for trend lt 0.001

Source Adapted from Manson 1995
17
Adult Treatment Panel III Guidelines

• Sample menus for different ethnic cultural
  preferences
• Assessment tools
• Counseling tools
• Adherence tips
• Patient handouts

Source ATP III 2002
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Cardiovascular Risk Factors

• Diabetes

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Diabetes

• Diabetes affects 8.8 of all U.S. women age 20
  years or older
• Compared to whites
• African Americans, Latinas, American Indians,
  Asian Americans, and Pacific Islanders have a
  1.5-2.2 times greater prevalence of diabetes

Source CDC, NIDDK 2005
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Diabetes

• 65 of diabetics die of cardiovascular disease
• Diabetics have death rates from heart disease
  that are 2 to 4 times higher than non-diabetics

Source CDC 2003
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Coronary Disease Mortality and Diabetes in Women
Source Adapted from Krolewski 1991
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Race/Ethnicity and Diabetes

• At high risk
• Latinas
• American Indians
• African Americans
• Asian Americans
• Pacific Islanders

Source American Diabetes Association 2001
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Definition of Metabolic Syndrome in Women

• Abdominal obesity - waist circumference gt 35 in.
• High triglycerides 150mg/dL
• Low HDL cholesterol lt 50mg/dL
• Elevated BP 130/85mm Hg
• Fasting glucose 100mg/dL

Source AHA/NHLBI 2005
24
Cardiovascular Risk Factors

• Hypertension

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Treatable Risk Factors Hypertension

• 32 of women in the United States have
  hypertension
• Hypertension is more prevalent among older women
  than older men
• Death from CHD progresses increasingly and
  linearly as blood pressure increases
• For every 20 mmHg systolic or 10 mmHg diagnostic
  increase in blood pressure, risk of death from
  CHD doubles

Source American Heart Association 2004, JNC 7
2004, Rosamond 2008
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Lifestyle Approaches to Hypertension in Women

• Maintain ideal body weight
• Weight loss of as little as 10 lbs reduces blood
  pressure
• DASH eating plan
• Even without weight loss, a diet rich in fruits,
  vegetables, and low fat dairy products can reduce
  blood pressure
• Sodium restriction to 2300 mg/d
• Further restriction to 1500 mg/d may be
  beneficial, especially in African American
  patients
• Increase physical activity
• Limit alcohol to one drink per day
• Alcohol raises blood pressure
• One drink 12 oz beer, 5 oz wine, or 1.5 oz
  liquor

Source JNC VII 2004, Sacks 2001, Mosca 2007
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JNC 7 Report

• Classification of blood pressure
• Treatment algorithms
• Lifestyle strategies
• Antihypertensive drug choices
• Special indications and situations
• Resistant hypertension

Source NIH 2004
28
Trends in Age-adjusted Prevalence of Hypertension
in United States
Source MMWR 2005
29
Hypertension Prevalence Among White and Black
Women in the United States Trends

Source Adapted from Hertz 2005
30
Prevalence of High Blood Pressure by Age and
Race
Source Data from National Vital Statistics
System, Health, United States, 1996-97
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African Americans and Hypertension

• Compared to whites
• African Americans develop hypertension earlier in
  life
• African Americans have much higher average blood
  pressures
• African Americans have a 1.5 times greater risk
  of heart disease death

Source American Heart Association 2008
32
Age-Adjusted 16-Year Incidence of End Stage Renal
Disease by Diastolic Blood Pressure and Race
(MRFIT data)
P e r c e n t
Diastolic Blood Pressure
Source Klag 1997
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DASH Eating Plan

• 78 servings of grains, grain products daily
• 45 servings of vegetables daily
• 45 servings of fruits daily
• 23 servings of low-fat or nonfat dairy foods
  daily
• 2 servings of meats, poultry, fish daily
• 45 servings of nuts, seeds, legumes weekly
• Limited intake of fats, sweets

Source NHLBI 1998
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DASH Diet with Low Sodium Intake in Hypertensive
Individuals Compared to Control Diet with Average
U.S. Sodium Intake
African American Non-African American


Plt.001 from baseline
Source Sacks 2001
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Cardiovascular Risk Factors

• Dyslipidemia

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Approximate and Cumulative LDL Cholesterol
Reduction Achievable By Dietary Modification
Dietary Component Dietary Change Approximate
LDL
Reduction Major Saturated fat lt7 of
calories 8-10 Dietary cholesterol lt200
mg/day 3-5 Weight reduction Lose 10
lbs 5-8 Other LDL-lowering options Viscous
fiber 5-10 g/day 3-5 Plant/sterol 2g/day 6
-15 stanol esters Cumulative
estimate 20-30
Source Adapted from ATP III 2002
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ATP III Full Report

• How to choose a statin
• Dosing regimens
• How to monitor when combining drugs
• Side effect management
• Reprintable nutritional hand-outs
• Menu samples for different cultures
• Adherence strategies/barrier reduction

Source ATP III 2002
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Treatable Risk Factors The Epidemiology of
Cholesterol Levels and Subfractions

• Low HDL more important in women than men
• For every 1 mg/dL increase in HDL 3 decrease in
  CHD risk for women and 2 decrease in CHD risk
  for men
• Total cholesterol/HDL ratio very predictive of
  CHD risk in women
• Triglyceride elevation associated with greater
  atherogenic significance in women than in men

Source Maron 2000
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Treatable Risk Factors Cholesterol Level and
Subfractions

• LDLgt160 mg/dL associated with 3.3-fold elevation
  in risk for women less than 65 years old
• LDL pattern of small, dense particles (more
  atherogenic) present in 25 of population, but
  less frequently seen in women
• Menopausal transition associated with increasing
  proportion of this subfraction

Source Keil 2000, Carr 2000, Hokanson 1996
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Relative Risk of Various Factors for CHD for
Women and Men
2.4
2.5
1.9
2
1.8
Relative Risk
1.6
1.5
1.5
1.4
1.4
1.5
1.3
Men
1.1
Women
1
0.5
0
HTN
CHOL
DM
Obesity
Smoking
Source MMWR 1992
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Cardiovascular Risk Factors

• Poor Diet

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Low Risk Diet is Associated with Lower Risk of
Myocardial Infarction in Women
Relative Risk of MI
Adjusted for other cardiovascular
risk factors
Plt .05 for quintiles 3-5 compared to 1-2
Diet Score by Quintile (1 least vegetables,
fruit, whole grains, fish, legumes)
Source Akesson 2007
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Emerging Risk Factors for CHD

• Pro-inflammatory markers
• C-reactive protein (hs-CRP)
• Fibrinogen
• Hyperhomocysteinemia
• Homocysteine lowering to prevent CHD events has
  been shown to be ineffective or possibly harmful
  in randomized clinical trials

Source ATP III 2002 Mosca 2007
44
Relative Risk of Cardiovascular Events According
to Baseline Levels of hs-CRP in Healthy
Postmenopausal Women
P for trend lt 0.001
Source Ridker 2000
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Fibrinogen Levels and CHD Risk in Women
P for trend lt0.0001
gt3.6
gt2.8, ? 3.1
gt3.1, ? 3.6
? 2.8
Adjusted for age, smoking, BMI, systolic blood
pressure, total cholesterol, HDL, triglycerides,
and educational level
Source Eriksson 1999
46
Relative Risk of Cardiovascular Events According
to Baseline Levels of Homocysteine in Healthy
Postmenopausal Women
P for trend 0.02 (not significant)
µ
µ
µ
µ
Source Ridker 2000
47
The NORVIT Trial Homocysteine Lowering Did Not
Reduce Cardiovascular Events in Women with Prior
MI
Relative Risk of CVD Event
Compared to B12 alone
Compared to placebo


Source Bonaa 2006
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Psychosocial Stressors in Women with CHD The
Stockholm Female Coronary Risk Study

• Among women who were married or cohabitating with
  a male partner, marital stress was associated
  with nearly 3-fold increased risk of recurrent
  CHD events
• Living alone and work stress did not
  significantly increase recurrent CHD events

Source Orth-Gomer 2000
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Depression and CHD Results from the Womens
Health Initiative Study

• Depression is an independent predictor of CHD
  death among women with no history of CHD

Source Wassertheil-Smoller 2004