There are gender differences in cardiovascular disease

1
There are gender differences in cardiovascular
disease

• Alberto Lombardi, MD
• Italian Heart Foundation - IHF
• Giovanni Lorenzini Medical Science Foundation
  FGL
• Milan 2009.02.14

2
There are gender differences in cardiovascular
disease

• Definition
• The concept of Gender refers to a complex
  interrelation and integration of sex as a
  biological and functional marker of the human
  body and psychological and cultural behaviour
  (due to ethnical, social, and religious
  background).
• Gender Medicine focuses on the impact of the
  gender on human physiology, pathophysiology, and
  clinical features of diseasespathophysiology, and
  clinical features of diseases.
• www.gendermedicine.org

3
There are gender differences in cardiovascular
disease

• scenario

4
There are gender differences in cardiovascular
disease scenario

• Inhabitants 59.619.290 m
  28.949.747 w 30.669.543
• Life expectancy
  m 77.8 w 83.7
• Life expectancy at 50 years of age
  m 30.37 w 35.31
• Healthy life years at 50 years of age
  m 20.63 w 20.86
• N. GPs 47.061
• N. Pharmacies 16.000
• N. Physicians in Cardiology Departments
  6.915
• N. Nurses in Cardiology Departments
  15.331
• N. Cardiology beds 7.970
  697 dh
• N. Heart Surgery beds 1.968
  43 dh
• N. ICUs 411
• N. PCIs 98.824 ( 12
  2003/2002)
• Cardiology Performances 14.590.269
  
• Number of stroke units
  68
• Lancet 20083722124-31 G It Card 2008 SS
  5-83 Italia in Cifre 2008

5
There are gender differences in cardiovascular
disease CVD Mortality in US Women Is Not
Declining
494,000
434,000
NCEP ATP II
NCEP ATP III
NCEP ATP I
AHA. Heart Disease and Stroke Statistics2005
Update. Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in
Adults. JAMA. 20012852486-2497.
6
There are gender differences in cardiovascular
disease Causes of death in women - Italy
Gastrointestinal
disease
Percentage of death in Italy in 2001 From
ISTAT - elaboration ISTISAN 95/34, modified
Trauma
Respiratory disease
Cancer
Cardio cerebro-
CVD
CHD
vascular disease
Death ()
0
25
50
75
100
7
There are gender differences in cardiovascular
disease scenariohttp//www.ministerosalute.it/pr
ogrammazione/sdo/ric_informazioni/sceltadrg.jsp
8
Mortalità intraospedaliera dopo infarto
miocardico, in uomini e donne di differenti
classi di età le donne, fino ai 70 anni di età,
hanno una maggiore letalità dei loro coetanei
maschi
Men
Women
30
25
20
Death during Hospitalization,
15
10
5
0
lt50
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
Age, years
Sex-based Differences in Early Mortality after
Myocardial Infarction. Vaccarino V N Engl J Med
1999
9
There are gender differences in cardiovascular
disease scenario

• Global NHS budget 2008
• public 107 billion private 20 billion
• Economic investments on CVD
• Health Care costs 13.8 Bill (2006)
  Indirect Costs 8.0 billion (2006)
• Global Pharmaceutical budget (2007)
• public 12.7 billion and private 6.0
  billion
• Drugs Investments in CVD (outpatients) (2007)
  5.1 billion
• Statins 1.017 million
• ACE-I 653 million
• ACEI Diur 574 million
• Ca A 574 million
• beta-Blockers 245 million
• European CVD Statistics 2008 . OSMED 2008

10
There are gender differences in cardiovascular
disease scenario

• 250.000 yearly deaths for CCVD women (55) men
  (45)
• An equal number of people is suffering from
  disabilities due to CCVD
• In the next 10 years from now (if the trend
  continues)
• around 2.4 million (1.3 million women and 1.1
  million men) will die
• In the next 10 years from now the direct and
  indirect costs of the CCVD in will accumulate
  200 billion!

11
There are gender differences in cardiovascular
disease

• Aging
• The age is considered an independent risk factor
  of cardiovascular disease.
• The correlation between age and occurrence of
  cardiovascular disease (MI and Stroke) is largely
  confirmed. At hospital admission for MI are
  prevalent men until the age of 65 years, but are
  equally prevalent in men and women 66-75 years
  years, and become prevalent in women aged over 75
  years.

12
There are gender differences in cardiovascular
disease

• In women it is possible to watch a reduced use of
  revascularization procedures
• NEJM 2007 356 898-1009
  Circulation 2007 115 833-39
• In women the mortality is increased after MI
• 
  Arch intern Med 1998 158
  981-988

13
There are gender differences in cardiovascular
disease

• Women have smaller arteries and less adaptable to
  the flow
• 
  Am Heart J 2000139
  649-653
• With age or diabetes, this difference is
  accentuated
• 
  Hypertension 2004 44 67-71

14
Women are different Know the signs of a heart
attack

• More likely for women
• Unexplained weakness or fatigue
• Anxiety or unusual nervousness
• Indigestion or gas-like pain
• For men and women alike
• Feeling of heaviness or pressure-like chest pain
  between the breasts or beneath the breastbone
• Discomfort/pain between the shoulder blades or in
  the neck, jaw or stomach

15
The timing hypothesis differential effects of
HRT on early and later stages of atherosclerotic
disease
M. E. Mendelsohn et al., Science 2005 308
1583 -1587
16
AHA Guidelines for CVD Prevention in Women Class
I Recommendations

• All levels of risk (based on Framingham)
• Smoking cessation
• Physical activity
• Heart-healthy diet
• Weight maintenance/reduction
• Intermediate risk (10-20), add
• Lipid control
• Aspirin
• High risk (gt20), add
• Lipid control
• Aspirin
• Control of HTN with ?-blocker and ACE inhibitor
• Glycemic control

Mosca L, et al. Circulation. 2004109672-693
17
AHA Womens Guidelines for Lipid Management

• Initiate TLC for all women, regardless of risk
  level

• Intermediate Risk
• Initiate statin if LDL-C 130 mg/dL on TLC
• Initiate niacin or fibrate for low HDL-C, after
  LDL-C goal is reached
• Initiate niacin or fibrate for high nonHDL-C,
  after LDL-C goal is reached

• High Risk
• Initiate statin if LDL-C 100 mg/dL concomitant
  with TLC
• Initiate niacin or fibrate for low HDL-C
• Initiate niacin or fibrate for high nonHDL-C

Mosca L, et al. Circulation. 2004109672-693
18
Drugs for Cardiovascular Disease Prevention in
WomenImplications of the AHA Guidelines 2007
Update

• Initiate TLC for all women

• LDL
• Initiate statin if LDL-C 130 mg/dL on TLC with
  risk 10-20
• Initiate statin if LDL-C 160 mg/dL on TLC with
  risk lt 10
• Initiate statin if LDL-C 160 mg/dL on TLC with
  or without other risk factors

• HDL
• Initiate niacin or fibrate for low HDL-C or non
  HDL-C is elevated in high risk women after LDL-C
  is reached
• Consider niacin or fibrate for low HDL-C or non
  HDL-C is elevated in high risk women with
  multiple risk factors and a 10 year absolute risk
  10-20, after LDL-C is reached

Nanette Wenger, et al. Drugs 200868(3)339-358
19
There are gender differences in cardiovascular
disease CHD in Women

• Much research in past 20 years on diagnosis and
  treatment of CHD excluded or underrepresented
  women
• Only 20 of studies including women published
  sex-specific findings
• Tests and therapies used to treat CHD in women
  based on studies conducted primarily in men

Stanford-UCSF Evidence-based Practice Center.
Profile, November 2002. Agency for Healthcare
Quality and Research, Rockville, MD.
http//www.ahrq.gov/clinic/epc/ucsfepc.htm
20
There are gender differences in cardiovascular
disease Il genere donna negli studi europei
S. Priori, Policy Conference on CVD in Women
21
Efficacy and safety of cholesterol-lowering
treatment prospective meta-analysis of data from
90 056 participants in 14 randomised trials of
statins
Lancet 2005, 3661267-1278
22
There are gender differences in cardiovascular
disease The influence of gender on the effects
of aspirin in preventing myocardial
infarction Gender accounts for a substantial
proportion of the variability in the efficacy of
aspirin in reducing MI rates across these trials,
and supports the notion that women might be less
responsive to aspirin than men.

Todd Yerman, Wen Q Gan and Don D Sin

BMC Medicine 2007,
529
23
Le donne e la conoscenza delle malattie
cardiovascolari
Dm1 Quali, tra le seguenti malattie, Le incutono
maggiori timori?
Base 1000 donne over 50 anni
Dipartimento Studi Socio Sanitari
24
Le donne e la conoscenza delle malattie
cardiovascolari
Dm 2 Tra le malattie cardiovascolari, quali
considera i principali fattori di rischio per il
cuore?
Base 1000 donne over 50 anni
Dipartimento Studi Socio Sanitari
25
There are gender differences in cardiovascular
disease

• There is evidence that cardiovascular diseases
  are largely preventable. A simultaneous reduction
  of high cholesterol, of hypertension, obesity and
  use of tobacco can reduce by 50 the incidence of
  cardiovascular disease.
• 
  NEJM 2007m
  3562388-98