Transcript CAD in Women by Dr Sarma

1
Women and
Coronary Artery Disease (CAD)
What do we need to know ?
Dr. R.V.S.N.Sarma, M.D., M.Sc., (Canada)
Consultant Physician and Chest Specialist
Thiruvallur, Chennai
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Myths vs Facts
Myths
Facts
Men are more
likely to have
heart disease
Heart disease is the #1 killer of men and
women; 50,000 more women than men die
of heart disease every year
Cancer is a
bigger threat than
heart disease
Nearly twice as many US women die from
heart disease and stroke than from all
cancers combined
Doctors are aware
of women’s risk for
heart disease and
act accordingly
Undertreatment and underdiagnosis of heart
disease in women contributes to excess
mortality in women
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Women’s Perceptions
of Heart Disease
• 72% of young women (ages 25-40) still consider
cancer to be the greatest threat to women’s health
• Some women know about the risks of heart disease
but do not hear it from their own doctors and do not
“personalize” it
• 65% of women recognize that symptoms may be
“atypical” but do not know classic symptoms
• Most women learn about coronary artery disease
(CAD) from magazines and the Web—not from their
own physicians!
Robinson A. Circulation. 2001
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Gender Bias in the
Treatment of Women
“… The community has viewed women’s health
almost with a ‘bikini’ approach, looking
essentially at the breast and reproductive
system, and almost ignoring the rest of the
woman as part of women’s health ….”
Nanette Wenger, MD
Chief of Cardiology, Grady Hospital
Professor of Medicine, Emory University
Atlanta, Georgia
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Magnitude of the Problem
• 2.5 million women per year in the US are
hospitalized with cardiovascular disease (CVD)
• Deaths from CVD = 500,000/yr
• Leading cause of death in US women: CAD
• >230,000 women die from CAD each year
• 1990: US Congress directed the National
Institutes of Health that women be included in
clinical trials and that gender differences be
evaluated
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Women in Clinical Trials
• Women are underrepresented in
cardiovascular (CV) trials
– Evidence-based CV medicine biased toward men
• Food and Drug Administration/National
Institutes of Health mandate: 50% enrollment
of women
• Women need to be empowered to enroll in
clinical trials for heart disease
– Breast-cancer awareness is a good example
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Publication Bias: Gender
Representation and Negative Studies
• 1966-1994 noninvasive testing literature
– 8% to 27% women
• Lower diagnostic accuracy in women
– High false-positive rates
– Inability to perform maximal stress
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Deaths in Thousands
CVD Mortality Trends (1979-1999)
American Heart Association. 2002 Heart and Stroke Statistical Update. 2001
13
Percent of Population
Prevalence of CVD in the US
90
80
70
60
50
40
30
20
10
0
79.00
70.7
Males
Females
65.2
65.20
51.0
48.10
34.2
28.90
10.4
5.5 4.60
4.20
20-24
25-34
17.4
13.60
35-44
45-54
Ages
55-64
65-74
75+
American Heart Association. 2002 Heart and Stroke Statistical Update. 2001
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Deaths in Thousands
Deaths From CVD and Cancer by Age
and Sex
300,000
250,000
200,000
150,000
100,000
50,000
0
<45
45-64
65-84
>84
Ages
CVD: Males
Cancer: Males
CVD: Females
Cancer: Females
Anderson RN. National Vital Statistics Reports. 2002
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Deaths From CVD (1999)
Congenital
cardiovascular
Rheumatic
fever/rheumatic defects
0.5%
heart disease
0.4%
Diseases of the
arteries
2.0%
High blood
pressure
5.0%
Other
14.9%
Coronary heart
disease
54.5%
Congestive heart
failure
5.9%
Stroke
16.8%
American Heart Association. 2002 Heart and Stroke Statistical Update. 2001
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Health Threats to Women: Perception
vs Reality
1
Perceived health threats
Leading causes of death in women
55%
2
46%
40%
24%
22%
ci
de
n
ts
3%
Ac
eu
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on
i
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Pn
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C
an
C
AD
ta
ck
rt
H
ea
di
rt
at
se
as
e
r
H
ea
Br
ea
st
ca
nc
e
ce
r
C
an
4%
a
4%
2%
1. Gallup survey. 1995
2. American Heart Association. Heart & Stroke Facts. 1996 Statistical Supplement
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Death From Breast Cancer or
Heart Disease in Women in the US
US Vital Statistics, 1990
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Statistics for Women
• 503,927 died of CVD in 1998
– 226,467 from heart attack or other cardiac events
– 97,303 from stroke
• 1 in 5 women has some form of CVD
• 38% of women who have a heart attack die
within 1 year
• 40% of coronary events in women are fatal
– Most occur without prior warning
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Women and
Coronary Artery Disease (CAD)
Risk Factors and Gender Differences
20
Warning Signs and
Symptoms of CAD
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Gender Differences in
Heart Attack Symptoms
Typical in both sexes
Typical in women
• Pain, pressure, squeezing,
or stabbing pain in the chest
• Pain radiating to neck,
shoulder, back, arm, or jaw
• Pounding heart, change in
rhythm
• Difficulty breathing
• Heartburn, nausea, vomiting,
abdominal pain
• Cold sweats or clammy skin
• Dizziness
• Milder symptoms (without
chest pain)
• Sudden onset of weakness,
shortness of breath, fatigue,
body aches, or overall
feeling of illness (without
chest pain)
• Unusual feeling or mild
discomfort in the back, chest,
arm, neck, or jaw (without
chest pain)
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Less Common Heart Attack Symptoms
in Women
• Milder symptoms without accompanying
chest pain
• Sudden onset of weakness, shortness of
breath, fatigue, body aches, overall feeling of
illness
• Burning sensation in the chest, may be
mistaken as heartburn
• An “unusual” feeling or mild discomfort in the
back, chest, arm, neck, or jaw
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Major Risk Factors
for Heart Disease
Modifiable
Nonmodifiable
Emerging Risk Factors
High blood pressure
Family history
Homocysteine
Abnormal cholesterol levels
Age
Elevated lipoprotein (a) levels
Diabetes
Gender
Clotting factors
Cigarette smoking
Markers of inflammation (CRP)
Obesity
Physical inactivity
Grundy SM, et al. Circulation. 1998; Grundy SM. Circulation. 1999
Braunwald E. N Engl J Med. 1997; Grundy SM, et al. J Am Coll Cardiol. 1999
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Emerging Risk Factors
•
•
•
•
•
•
Lipoprotein (a)
Homocysteine
Prothrombotic factors
Proinflammatory factors
Impaired fasting glucose
Subclinical atherosclerosis
– Other clinical forms of atherosclerotic disease (peripheral
arterial disease, abdominal aortic aneurysm, and
symptomatic carotid artery disease)
– Abnormal internal or common carotid CIT, ankle-arm index
<0.9, coronary Ca2+
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Diabetes Creates Higher Risks for
Women With CAD
• 65% of diabetics die from heart disease or stroke
• 4.2 million American women have diabetes
– Diabetes increases CAD risk 3-fold to 7-fold in women vs 2fold to 3-fold in men
– Diabetes doubles the risk of second heart attack in women
but not in men
• Every year, heart disease kills 50,000 more American
women than men
• Statistics are particularly high among African
American women
American Heart Association
Centers for Disease Control and Prevention
Manson JE, et al. Prevention of Myocardial Infarction. 1996
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Lowest Survival Rates for
Diabetic Women
• CAD mortality rates in diabetics, especially women,
have not decreased to the same extent as those in
the general population
• In a large cohort referred for coronary disease,
diabetic women had the highest mortality rates
– Estimate of ischemic burden with stress myocardial
perfusion imaging significantly improved risk stratification in
diabetic women compared with clinical risk alone
– Stratification by the number of ischemic vessels
demonstrated a significant linear increase in cardiac events
with escalating ischemic burden (sex-diabetes interaction,
P = .016)
Gu K, et al. JAMA. 1999
Giri S, et al. Circulation. 2002
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Diabetes: Powerful Risk Factor for
CAD in Women
• Framingham Heart Study
– Women with diabetes mellitus had relative risk of
5.4% for CAD vs women without diabetes
– Men with diabetes had relative risk of 2.4%
• Nurses’ Health Study
– Relative risk of 6.3% for total cardiovascular (CV)
mortality
– Even if women had diabetes for <4 years, their
risk of CAD was significantly elevated
Kannel W. Am Heart J. 1987
Manson J, et al. Arch Intern Med. 1991
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Clinical Identification of the Metabolic
Syndrome
• Abdominal obesity
– Men
– Women
• Triglycerides (TG)
• HDL cholesterol
– Women
– Men
• Blood pressure
• Fasting glucose
>88 cm (>40 in)
>80 cm (>35 in)
>150 mg/dL
<50 mg/dL
<40 mg/dL
>130/>85 mm Hg
>100 mg/dL
National Heart, Lung, and Blood Institute
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Impact of Triglyceride Levels
on Relative Risk of CAD
Framingham Heart Study
Relative Risk (x-fold)
2.5
2.2
Women
Men
2
1.85
1.8
1.45
1.4
1.5
1.2
1
1
0.55
0.65
2.15
1.3
1.25
1.25
300
350
400
1
0.8
0.75
100
150
0.5
0
50
200
250
Castelli WP. Can J Cardiol. 1988
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Women and CAD Risk Factors
• Higher prevalence of avoidable risk factors1
– ↑ blood cholesterol, ↑ TG
– ↑ physical inactivity
– ↑ overweight (body mass index, 25.0-29.9)
• Diabetes is a more powerful risk factor for CAD2
– 3- to 7-fold in women vs 2- to 3-fold in men
• ↓ HDL cholesterol levels more predictive of CAD2
• Women counseled less about nutrition, exercise, and
weight control2
1. American Heart Association. 1999 Heart and Stroke Statistical Update. 1998
2. Mosca L, et al. Circulation. 1999
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MI or Death Often First Sign of CAD
Percentage of patients whose first CAD
diagnosis is MI or death
62%
46%
Men
Women
Levy D, et al. Textbook of Cardiovascular Medicine. 1998
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Smoking
• Single most preventable cause of death in US
• Smoking by women causes 150% more
deaths from heart disease than lung cancer
• Women who smoke are 2-6 times more likely
to suffer a heart attack
• Use of birth control pills in smokers
compounds cardiac risk
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Overweight
Percent of population
Prevalence of Overweight in Americans Aged 20-74 Years
70
60
50
40
30
20
49
55
61
53
51
40
41
42
10
0
Men
1960-1962
Women
1971-1974
1976-1980
1988-1994
American Heart Association. 2002 Heart and Stroke Statistical Update. 2001
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Physical Inactivity
• Lack of exercise is a proven risk factor for heart
disease
– A lack of regular physical exercise is a growing epidemic all
over the world. “We seem to eat much more than what we
burn”
• Heart disease is twice as likely to develop in inactive
people than in those who are more active
• Physical activity helps maintain weight, blood
pressure, and diabetes
• Women should exercise to increase heart rate for
20-30 minutes a day, 3-5 times per week
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Hormonal Effects on Ischemia
and Disease Prevalence
• Premenopause
– Estrogen has digoxin-like effect:  ST 
• Post-menopause effect on HRT
–  ST  - vasodilatory effects of HRT
– Increase exercise duration/decrease chest pain
• Women with intact uterus take progestin to
protect against uterine malignancies
– Estrogen and medroxyprogesterone attenuate this
effect
Lloyd GW, et al. Heart. 2000; Webb CM, et al. Lancet. 1998;
Morise AP, et al. Am J Cardiol. 1993; Rosano GM, et al. J Am Coll Cardiol. 2000
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Hormonal Effects on Ischemia
and Disease Prevalence
• Estrogen modulates chest pain syndromes
• Premenopausal CAD: angina/ischemia variation by
menstrual cycle
– Early follicular phase
estradiol and progesterone levels - low
< time to ischemia onset
– Mid-cycle
estrogen levels - highest
> time to ischemia onset
Lloyd GW, et al. Heart. 2000; Webb CM, et al. Lancet. 1998;
Morise AP, et al. Am J Cardiol. 1993; Rosano GM, et al. J Am Coll Cardiol. 2000
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Postmenopausal Hormone Therapy
and Cardioprotection
• First randomized trial
• HERS trial (Heart and Estrogen/Progestin
Replacement Study)
– Secondary CAD prevention trial
– Randomized trial of placebo vs estrogen and
medroxyprogesterone
– Follow-up = 4 years
– N = 2,763 women with an intact uterus
– Outcome measures
• Primary: nonfatal MI or cardiac death
• Secondary: unstable angina, coronary revascularization,
congestive heart failure
HERS trial. JAMA. 1998.
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Is There a Role for HRT?
• Secondary prevention
– 1998: HERS
• 4 years of treatment with conjugated estrogen plus
medroxyprogesterone acetate
• No reduction in the risk of MI and coronary death in
women with established CAD
HERS trial. JAMA. 1998.
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Is There a Role for HRT?
• Secondary prevention
– 3/2000: Estrogen Replacement and Atherosclerosis trial
(ERA)
• 309 postmenopausal women with CAD
• Placebo vs conjugated estrogen (.625 mg/day) vs conjugated
estrogen (.625 mg/day) with medroxyprogesterone acetate (2.5
mg/day)
• Angiographic analysis of the diameter of the coronary arteries
at the start of the study and 3 years later
• ERA trial results at follow-up angiography
– The progression of coronary atherosclerosis was unchanged
in the women randomized to either of the estrogen groups
ERA trial. J Am Coll Cardiol. 2001
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Is There A Role for HRT?
• Primary prevention
– Women’s Health Initiative. WHI trial
• 160,000 women:1991-2005
• Initial results: no cardioprotection attributed to HRT in
women on HRT
• American Heart Association: HRT not
recommended for primary or secondary
cardioprotection
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Conclusions:
Risk Factor Management
• CVD begins in childhood and is strongly
associated with major risk factors for heart
disease
• Multiple risk factors require more aggressive
management
• Aggressive risk-factor modification (often with
multiple medications) is the most effective
strategy for reducing the consequences of
heart disease
Berenson GS, et al. N Engl J Med. 1998. Neaton JD, et al. Arch Intern Med. 1992. Kannel WB.
in Atherosclerosis and Coronary Artery Disease. 1996. Grundy SM, et al. Circulation. 1999
42
Gender Differences in CAD Risk
Factors
• Increasing recognition that atherosclerosis is
an inflammatory process
• Ridker PM, et al: A prospective casecontrolled study among 28,263
postmenopausal women
– Among 12 markers of inflammation, C reactive
protein was the strongest univariate predictor of
the risk of CV events
Ridker PM, et al. N Engl J Med. 2000
43
Women and
Coronary Artery Disease (CAD)
Diagnosis and Prognosis
44
Diagnosis and Management
of CAD in Women
• Gender differences: presentation,
manifestation, and diagnosis of CAD
• Gender differences in mortality
– 63% of women who die suddenly from CAD had
no prior warning symptoms
– 42% of women vs 24% of men will die within
1 year after MI
• Thus, early recognition of symptoms and
accurate diagnosis of CAD is of great
importance
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Heart Disease in Women: Lessons
From the Past Decade
• The importance of studying gender-specific
aspects of CAD have helped in the following
clinical dilemmas:
– At Presentation of CAD: women are older than
men
– Less specific clinical manifestations of CAD in
women
– Greater difficulty in diagnosis: women > men
– More severe consequences on MI when it occurs
in women
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Screening for Heart Disease
What Tests Should we use to identify
Coronary Heart Disease?
47
Limited Representation of Women in
Studies of CAD Testing
Women
92
100
Percent of patients
Men
78
80
73
60
40
20
22
27
8
0
ECG
Echo
MPI
Adapted from: Shaw LJ, et al. Coronary Artery Disease
in Women: What All Physicians Need to Know. 1999
48
Are There Gender Differences in
Noninvasive Diagnostic Tests?
Is There a Difference in Diagnostic
Accuracy of Noninvasive Tests?
49
Noninvasive Testing Options
Stress
ECG
Stress
Echo
Stress
MPI
EBCT
PET
MRI
50
Noninvasive Testing in
Symptomatic Women
• Stress electrocardiography (ECG)
• Stress echocardiography (ECHO)
• Stress nuclear imaging (MPI)
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Exercise ECG (Treadmill)
• Despite advances in technology, the exercise
ECG remains an important tool in the
diagnosis and prognosis of the patient
suspected of having CAD
• The exercise ECG has an overall sensitivity
of 68% and a specificity of 77% for the
detection of CAD in men
• The sensitivity and specificity of the exercise
ECG in women are about 61% and 70%
respectively
Kwok Y, et al. Am J Cardiol. 1999.
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ECG Testing in Women
Sensitivity and Specificity
Study, Year
Detry et al, 1977
Weiner et al, 1979
Barolsky et al, 1979
Friedman et al, 1982
Guiteras et al, 1982
Hung et al, 1984
No. of
Women
47
580
92
60
112
92
Sensitivity (%) Specificity (%)
80
76
60
32
79
73
63
64
68
41
66
59
Adapted from Heller GV, et al. Nuclear Cardiology: State of the Art and Future Directions. 1998
53
Gender Differences in Exercise
ECG Testing
•  sensitivity in women >65 years
•  specificity in women on hormone
replacement therapy
•  false-positive results due to
autonomic/hormonal influences
• Digoxin like effect of estrogen
Shaw LJ, et al. CAD in Women: What All Physicians Need to Know. 1999
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Diagnosis of Noninvasive Tests in
Women
•
•
•
•
•
ECG
Nuclear perfusion study
ECHO – poor window problem
Dipyridamole injection – MPI,
Stress (Tread mill) Echo –
– Dobutamine infusion Echo –
• Computed tomography
• MR coronary angiography
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Nuclear Imaging in Women
• Myocardial perfusion imaging (MPI)
• Large body of evidence in women
– Gender-specific data available for Tl-201and Tc-99m tracers
– Tc-99m tracers = agent of choice for women due to decrease
attenuation artifacts from breast tissue
– Gated single-photon emission computed tomography
(SPECT) provides post stress ejection fraction and regional
wall motion  helpful to reduce false positives
– IV adenosine/dipyridamole stress provides comparable
overall accuracy in women and men
56
Comparative Test Statistics on
Diagnostic Accuracy in Women
ECG (n = 3721)
Echo (n = 296)
Nuclear (Tl-201) (n = 842)
Nuclear (Gated tech) (n = 100)
Sensitivity
Specificity
61%
86%
78%
84%
70%
79%
64%
94%
Kwok Y, et al. Am J Cardiol. 1999
57
Diagnostic Specificity: Stress Thallium
Tl-201 vs Tc-99m Sestamibi
92%
N = 115, P = .0004
• Perfusion imaging
– Regional blood flow
• Robust evidence in women
21 false +
10 false +
67%
Tl-201
Tc-99m
sestamibi
– Gender-specific data for Tl201 and Tc-99m sestamibi
or teboroxime
– Tc-99m sestamibi is agent
of choice for women
(reduced breast attenuation)
• Gated SPECT
– Post-stress EF and regional
wall motion
– Reduce false-positive tests
• Pharmacologic stress helpful
in older and obese women
Hachamovitch R. et al. J Am Coll Cardiol. 1996;
Amanullah AM, et al. Am J Cardiol. 1997; Taillefer R, et al. J Am Coll Cardiol. 1997
58
Pharmacologic Stress Testing in a
Community Setting: Women vs Men
Percent of patients referred for MPI who underwent exercise stress vs
pharmacologic stress at Mission Internal Medicine Group, Mission Viejo, CA
(4/21/02 to 8/29/02)
Women (n = 243)
Men (n = 375)
Pharmacologic
34%
Pharmacologic
53%
Exercise
47%
Exercise
66%
Data provided by Greg Thomas, MD, Mission Internal Medicine Group
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ECHO Testing in Women
• Overall
– Convenient/readily available1,2
– Avoids ionizing radiation2
– Identifies cardiac structure and left ventricular
function (LVF)
• Sensitivity and specificity vs ECG testing1,2
– Increased sensitivity (79%-88%)
– Increased specificity (77%-86%)
1. Williams MJ, et al. Am J Cardiol. 1994
2. Marwick T, et al. J Am Coll Cardiol. 1995
60
PET Imaging for CAD in Women
Positron Emission Tomography
61
PET Case Study: Patient FF
Stress
Rest
62
PET Case Study: Patient FF
Ischemia of Lateral Wall
63
Electron Beam Computed Tomography
(EBCT)
• Resting study only
• Stationary tungsten target
permits rapid scanning
• Detects coronary
calcification
• Abnormality defined as
presence of any calcium
Courtesy of Howard Lewin, MD, of San Vicente Cardiac
Imaging Center
Diagnostic Accuracy of EBCT
Coronary Calcium Scores by Gender
Subsets
64
100
90
88
88
80
69
Percentage
70
61
60
49
50
48
40
30
20
10
0
Sensitivity
Specificity
Women
Sensitivity
Specificity
Men
Predictive accuracy Predictive accuracy
Women
Men
Devries S, et al. J Am Coll Cardiol. 1995.
Rumberger JA, et al. Circulation. 1995.
Detrano R, et al. Am J Card Imaging. 1996.
65
Technetium-99m SPECT Imaging Predicts
Cardiac Mortality in Women
Ischemia extent and survival by number of vascular territories
Cardiac survival
1.0
0
1
2
0.9
1.0
0 98.5%
1
2
0.9
3
0.8
0.7
0.6
0.8
Women
(n = 3402)
0 0.5 1 1.5 2 2.5 3
Years
80-87%
0.7
3
Men
(n = 4500)
0.6
0
0.5 1
1.5 2
Years
2.5 3
Marwick TH, et al. Am J Med. 1999
hs-CRP, Lipids, and Risk of Future Coronary
Events: Women's Health Study (WHS)
9
8
7
6
5
4
3
2
1
0
4
Quartile of TC:
HDL-C
3
2
1
Ridker PM et al. N Engl J Med 2000;342:836-843.
1
2
3
4
Quartile
of hs-CRP
Risk Factors for Future Cardiovascular
Events: WHS
Lipoprotein(a)
Homocysteine
IL-6
TC
LDL-C
sICAM-1
SAA
Apo B
TC:HDL-C
hs-CRP
hs-CRP + TC:HDL-C
0
1.0
2.0
4.0
6.0
Relative Risk of Future Cardiovascular Events
Ridker PM et al. N Engl J Med 2000;342:836-843.
Women’s Health Initiative:
Trial of Estrogen plus Progestin
 16,608 women randomized
 Conjugated equine estrogens 0.625 mg/d +
medroxyprogesterone acetate 2.5 mg/d vs.
placebo
 Primary outcome: nonfatal MI or CHD death
 Primary adverse outcome: breast cancer
 Stopped early (mean follow-up 5.2 years)
because health risks exceeded benefits
Writing Group for the WHI Investigators. JAMA 2002;288:321-333.
Risks and Benefits of Estrogen/Progestin
on Clinical Outcomes: Women’s Health Initiative
Hazard
Ratio
Nominal
95% CI
Adjusted
95% CI
CHD (MI, coronary death)
1.29
1.02–1.63
0.85–1.97
CABG/PTCA
1.04
0.84–1.28
0.71–1.51
Stroke
1.41
1.07–1.85
0.86–2.31
Venous thromboembolic disease
2.11
1.58–2.82
1.26–3.55
Total CVD
1.22
1.09–1.36
1.00–1.49
Cancer
1.03
0.90–1.17
0.86–1.22
Fractures
0.76
0.69–0.85
0.63–0.92
Death
0.98
0.82–1.18
0.70–1.37
Global index*
1.15
1.03–1.28
0.95–1.39
Outcome
Absolute Excess Risks and Absolute
Risk Reductions per 10,000 PersonYears: Women’s Health Initiative
Difference in risk
per 10,000
person-years
CHD events
+7
Strokes
+8
Pulmonary embolisms
+8
Invasive breast cancer
+8
Colorectal cancers
–6
Hip fractures
–5
Global index
+19
Writing Group for the WHI Investigators. JAMA 2002;288:321-333.
71
Treatment differences
• Thrombolysis – equally effective – Cerebral
hemorrhage risk is more
• Low rates of coronary angiography in women
• Under referral for revascularization procedures
• CABG - > operative mortality 1.9 % v/s 4.6%
• Restenosis after PTCA, or CABG occlusion
rates are more for women - ? Smaller lumen
sizes
72
Summary
•
•
•
•
•
•
•
•
Presentation and symptomatology
Cardiac risk factors – differences
Metabolic syndrome, Obesity – IR – DMII
Dyslipidemia patterns
TMT – lower value
Stress Echo, MPI, Sistemibi, Dobuatamine
CABG, PTCA risks, long term
Above all need for greater clinical suspicion
73
Take-Home Messages
• The majority of risk factors for CAD can be
improved by lifestyle modification.
• Goals for “optimal” levels continue to
decrease with each new guideline version.
• The gap between “average” and “optimal” will
continue to widen unless lifestyle modification
is adopted more successfully.
74
Take-Home Messages
• Diet, exercise (attaining ideal body
weight), and smoking cessation are key
lifestyle changes.
– No “quick-fix”
– Extreme changes are usually not sustainable
– Medications are not an antidote to an
unhealthy lifestyle
75
Take-Home Messages
• Work with your patient to set realistic goals.
• Remember that modest changes in diet,
weight, and exercise can have a big impact
on cardiac risk.
• A heart-healthy lifestyle should be
encouraged from youth, but even changes
later in life lead to important benefits.