Transcript Power Point Presentation on Estrogen and Heart

Women and Heart Disease
• Cathryn Harbor
• Lexington VA
• May19,2004
• Sponsored by National Organization for Women
Coronary Artery Disease
Definitions
• Heart Attack: Heart Muscle is damaged
because it cant get blood and oxygen.
• Angina: Heart Muscle is deprived of blood
flow and oxygen. A charlie horse.
Women get more disease in small
blood vessels of the heart
Statistics
• Disease of Arteries is the leading cause of
death.
• After menopause women develop heart
disease at the same rate as men.
• After menopause, women are 10 times
more likely to develop heart disease than
to develop breast cancer.
• 40% of people who have a heart attack die
of it.
Life Cycle Differences
• Young women develop less disease in the
heart arteries than young men.
• After menopause, a woman’s arteries
develop disease at a similar rate to men’s.
Heart Disease in Women vs Men
• After menopause women are equally
susceptible
• Men have more chest pain.
Women more often have “silent” heart
attacks
• Once diagnosed women do worse
Red Flag Symptoms
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Chest Pain or Pressure
Dizziness
Shortness of Breath
Neck Pain unassociated with neck movement
Any Unusual Symptom that occurs with exertion
and resolves with rest
• Unexplained Sweats
• Nausea
What to do if you have symptoms
• Take an asprin
• Stop any exertion
• Go to the ER if the symptom persists. If it
resolves, contact your health care
provider.
Known risk factors
• There are more than 80 known risk factors
for heart disease
• This means that there is no one cause and
no one treatment.
Important Risk Factors
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Smoking
Being overweight
Age
Hypertension
Diabetes
Physical Inactivity
Elevated cholesterols
• Elevated C Reactive
Protein
• Elevated Fasting
Blood Sugar (90)
• Stress, anxiety,
depression
• Elevated
homocysteine
Genetic Contribution
• We know that genetics plays a big role
• .Genes tell your body how to make
proteins, that is all. To have a genetic
problem simply means that you inherit the
blueprint for less effective proteins. It
does not mean that you inherit heart
disease.
• No genetic factors I have found that are
not modifiable by environment
The Problem of Choice
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Hard to know what to do.
Science does not provide clear answers
Science does not progress rapidly
What is driving the science?
Women and Heart Health: Choices
• Should I use hormone replacement?
• Should I use medicines to lower my
cholesterol?
• Should I change my lifestyle?
Women and Hormones:
What We Do Know
• Before menopause women’s risk of heart
disease is much lower than men’s.
• After menopause, women’s risk quickly
approaches men’s.
• In large surveys women who take
estrogen after menopause have less heart
disease (nurse’s study).
Evolution of HRT
• Drug companies started producing estrogen
from pregnant mare’s urine (Premarin).
• Studies showed that estrogen without
progesterone causes uterine cancer.
• Drug companies started making combination
packages of estrogen and progestins.
• Because of Patent issues, the progestins the
drug companies used were not natural to the
body, but synthetic.
Evolution of HRT continued
• Because of the belief, based on good
studies, that HRT protects against heart
disease, women were told at menopause
that they should start premarin to protect
their hearts.
• Premarin became the most widely
prescribed drug in the country
HERS trial
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2763 postmenopausal women
Pre-existing heart disease
Randomized to placebo or prempro
4.1 year study
HERS Trial Results
• In the first year more women on prempro
group had more heart attacks than women
in the control group
• For the 2nd and 3rd years the groups very
similar
• By the 4th year more women in the control
group had heart attacks
Impression after HERS Trial
• Starting on HRT after heart disease is
established is dangerous at first
• After a few years on HRT estrogen use
seems to create no additional risk and
possibly to protect women
What Would Explain the Results of
HERS?
• We know that estrogen increases women’s
chance of forming clots in our blood
vessels
• Women in the trial were known to already
have diseased arteries.
• Possibly starting a woman on HRT after
she has developed heart disease was the
problem, since a clot is a bigger problem
in a sickened and narrowed artery.
THE WOMEN’S HEALTH
INITIATIVE (WHI)
• 16,608 post menopausal women without
hysterectomy not currently on HRT
• Randomized to placebo or prempro
• Planned duration 8 years
• Stopped by safety advisory board after 5.3
years: “increased risk of breast cancer
without evidence of overall benefit”.
FINDINGS OF WHI
• Breast cancer, heart disease, stroke, lung
clots and leg clots are all increased by
prempro (in this population). Prempro
may have more negative effects than
estrogen alone
• Hip fractures and colorectal cancer are
reduced by prempro (in this population)
• Prempro increased the risk of
hysterectomy
Problems with WHI
• WHI intentionally excluded women with
severe menopausal symptoms, though
these women are most likely to use HRT.
• Older women not on HRT were studied.
Many of them can be presumed to already
have heart disease.
• The study was too short to show benefits,
if any, of HRT.
What we STILL Don’t Know
• Is there a heart benefit to giving HRT
starting right at menopause, before heart
disease starts to develop?
• Do other types of estrogen and
progesterone have same risks?
• What if lower doses had been used?
• Do older women on hormones need to
come off of them?
Take away
• We still do not have enough information to
make perfect decisions about putting
women on or taking them off estrogen
• Right now the pendulum has swung very
far to the no HRT side.
Cholesterol
• People who die of heart attacks have
changes in their heart arteries that are
made, in part, of cholesterol.
Where Does Cholesterol Come
From?
• We thought cholesterol in diet made
cholesterol in the body.
• In fact cholesterol is so important that the
body makes its own.
• Cholesterol is the result of interactions
between carbohydrates, fats and protein in
a diet, level of exercise, heredity and
hormones.
Cholesterol’s Function
• Important in producing hormones
• Forms insulation around nerves to keep
signals moving
• Needed to maintain cell membrane fluidity
• Has important immune functions (fighting
illness)
• Necessary for brain function (thinking)
• Important in neurotransmitter production
(mood)
About Cholesterol
• We usually measure three types of
cholesterol:
• LDL (bad cholesterol)
• HDL (good cholesterol)
• Triglycerides
Traditional Approach
• Focused on evidence-based medicine
• Five major studies showed impressive risk
reduction from using statins (24-39%
reduction).
• Drug trials using statins (Lipitor, Pravacol,
Baycol, and Zocor, etc demonstrated both
a lowering in LDL cholesterol and a
lowering of heart attacks.
Statins some more of the issue
• 61-76% of patients treated with statins
STILL experience heart attacks.
Lipids and Women
• LDL (Bad Cholesterol) is a good predictor
of heart disease in men.
• Simple LDL measurements predict little in
women.
• Despite awareness of other modifiable risk
factors, we tend to focus on one risk factor
(LDL cholesterol) and one therapy (statin
drugs)
Tangent about problems with LDL
• LDL is clearly bad, at least for men but
there are differences among the types of
LDL
• My LDL is 180 yours is 120. Who has the
worst problem? We don’t know because
• Answer: It depends on number of
cholesterol particles and therefore on the
size of the LDL particle.
This Just In
• “Women without coronary artery disease
do not benefit from Statin use”.
• For women with known cardiovascular
disease, treating hyperlipidemia is
effective in reducing fatal and non fatal
heart attacks…but “does not affect total
mortality”.
Another Big Problem
• Coenzyme Q-10 is a very important antioxidant.
• Coenzyme Q-10 is produced in the body,
in the same chemical pathway as
cholesterol.
• The enzyme, HMG CoA reductase is
essential for producing CoQ-10.
• Statin drugs work by disabling this
enzyme.
CoQ-10
• Many of unpleasant effects of statin drugs
(muscle aches, fatigue) can be reversed
by using CoQ-10.
• CoQ-10 has now been demonstrated to be
important in treating Parkinson’s disease.
• I believe that everyone on statin drugs
should take CoQ-10.
HDL Cholesterol
• HDL (good cholesterol) is very important in
women:
• HDL below 50 makes women 2.7 times
more likely to die of a heart attack.
Triglycerides
• Triglycerides between 200 and 400
increase risk of heart attack death by 2.4
• Triglycerides above 400 make women 6.9
times more likely to die of heart attacks.
The Metabolic Syndrome
also called INSULIN RESISTANCE
• Abnormal cholesterol profiles High TG, low
HDL high LDL
• Hypertension
• Type 2 Diabetes
• Coronary artery disease
• Breast, prostate and colon cancer
• Polycystic ovarian disease
Insulin’s Role
• High blood sugar is highly toxic to brain tissue.
• When you eat carbohydrates your body turns them into
sugar, glucose.
• Insulin rises after you eat carbohydrates to protect your
tissues from excess energy.
• Insulin lets excess energy be quickly cleared from the
bloodstream to be stored as triglycerides and
cholesterol.
• In the short term, high insulin levels protect your tissues
• In the long run, high insulin levels are associated with
many health problems, called the metabolic syndrome.
Triglycerides, Insulin and Diabetes
• Learn and control your triglyceride number
• Of all lipid markers, this one is associated
with the effectiveness of your diet and
exercise program.
• Triglycerides are where your body stores
excess carbohydrate calories
• We have long known that Triglycerides are
an important marker for CAD risk in
women.
A complex problem without an easy
solution
• What’s a girl to do?
How do you protect yourself?
• Lower your risk for heart disease by 70%!
The Lyons Study
• 605 French men and women who had
survived heart attacks
• Divided into two groups:
– American heart Association Diet (low fat)
– Mediterrainian diet:
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Olive oil
Whole grains
More root and green vegetables
More fish and poultry, less red meat
Mediterreanian diet
Lyon s Study Results
• Study was stopped after only 30 months:
• A 70% reduction in deaths from all causes
in the group with the Mediterainian diet.
• This was in people who had already had
heart attacks!
Changes you can make for risk
reduction
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Stop or avoid smoking
Improve your diet (the LYONS Study)
Maintain a normal weight
Exercise
Consider hormone replacement
Maintain normal blood pressure
Reduce stress in your life
• ONE SIZE FITS ALL MEDICINE IS THE
BEST FOR THE DRUG COMPANIES.
• It is not necessarily the best for your body
QUESTIONS?
It begins on the first day of medical school and
lasts through to retirement…It starts slowly and
insidiously, like an addiction, and can end up
influencing the very nature of medical decision
making and practice…Attempts to influence the
judgement of doctors by commercial interests
serving the medical industrial complex are nothing
if not thorough.
BUT
• In the above studies, not enough women
were included to determine the effects of
lowering LDL in women
• Level of LDL cholesterol does not correlate
well with risk of heart disease
Problems with the system
• Most medical research is payed for by drug
companies
• Drug companies need to find drugs that work for
large groups of people: one size fits all model
• Not all people are alike: men from women,
premenopausal from post menopausal women:
one size does not fit all
• Most doctors get their information from drug
reps, the marketing agents for the drug industry.
• Drug company information is not intended to be
objective. It is a product of spin artists