Transcript Clinical Evaluation of CAD

Cardiovascular Disease in Women
Joel Niznick MD FRCPC
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Attribution:
Some slides adapted from
Coronary Artery Disease in Women
Muddasir A. Shah, M.D.
Oklahoma University Health
Sciences Center
© Continuing Medical Implementation
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The Heart and Stroke Foundation
Fact Sheet –Women
• Prevalence
– In 2000, 1 in 5 women aged 70 and over were told by a physician
that they had heart problems.
• Mortality (1999 data)
– Coronary artery disease accounted for almost half of all CVD
deaths among women.
– 9,038 women died of stroke (8.5% of all deaths) among women.
– More men than women died from coronary artery disease (23,617
vs. 19,002) and heart attack (11,948 vs. 8,978)
– More women than men died from congestive heart failure (CHF)
(2,646 vs.1,845).
– More women than men died from stroke (9,038 vs. 6,371).
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Risk Factors in Women
The Heart and Stroke Foundation Fact Sheet –Women
Tobacco Smoking
– In 2001, 15% of young women (15-17 yrs) smoked daily.
– In 2001, 16% of women aged 15+ years smoked daily.
Physical Inactivity
– In 2000, 6 in 10 women were physically inactive.
Obesity
– In 2000, 14.2% of women were obese.
High Blood Pressure
– In 2000, 15.7% of women aged 20+ reported having high blood
pressure.
Nutrition: Inadequate Consumption of Vegetables and
Fruit
– Almost 6 in 10 women consumed less than the recommended
amount of vegetables and fruit.
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Figure 4-4
Leading causes of death, number and percentage of
deaths, Canada, 1999
Respiratory (22,026)
10%
Other IHD (21,693)
10%
AMI (20,926)
9.5%
Other (33,240)
15%
Diabetes (6,137)
3%
Infectious Diseases
(2,583)
1%
Cancer (62,606)
29%
All
Cardiovascular
Cerebrovascular
Disease
Disease (15,409)
(78,942)
7%
36%
Other CVD (20,914)
9.5%
Accidents/
Poisoning/ Violence
(13,996)
6%
Total Number of Deaths: 219,530
Cardiovascular (ICD-9 390-459); Respiratory (ICD-9 460-519); Diabetes (ICD-9 250); Cancer (ICD-9 140-239);
Infectious Diseases (ICD-9 001-139); Accidents/Poisonings/Violence (ICD-9 E800-E999)
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Source: Health Canada, using data from Mortality File, Statistics Canada
The Growing Burden of Heart Disease and Stroke in Canada 2003
Figure 4-5 Percentage of total deaths due to cardiovascular diseases
by age group and sex, Canada, 1999
50
Women
Men
Percent
40
30
20
10
0
30-39
40-49
50-59
60-69
70-79
80-89
90+
Women
9.6
13.7
17.8
25.1
34.9
45.0
48.2
Men
9.6
23.0
31.0
33.4
37.4
41.7
43.7
Age Group (years)
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Source: Health Canada, using data from Mortality File, Statistics Canada
The Growing Burden of Heart Disease and Stroke in Canada 2003
Mortality Rates for CVD Declining
Faster in Men than Women
Mortality rate, men, Canada, 1969-1999
Figure 4-7
700
700
600
600
500
500
Rate per 100,000
Rate per 100,000
Figure 4-8
400
300
Mortality rate, women, Canada, 1969-1999
400
300
200
200
100
100
0
0
1969
1974
1979
1984
Cardiovascular Diseases
Ischemic Heart Disease
Acute Myocardial Infarction
Congestive Heart Failure
Source:
1989
1994
1999
Cerebrovascular Disease
Age-standardized to 1991 Canadian Population
Health Canada, using data from Mortality File, Statistics Canada
The Growing Burden of Heart Disease and Stroke in Canada 2003
© Continuing Medical Implementation
1969
1974
1979
1984
Cardiovascular Diseases
Ischemic Heart Disease
Acute Myocardial Infarction
Congestive Heart Failure
1989
1994
1999
Cerebrovascular Disease
Age-standardized to 1991 Canadian Population
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Medical
Implementation
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Source:
Health
Canada, using data from Mortality File,…...bridging
Statistics Canada
The Growing Burden of Heart Disease and Stroke in Canada 2003
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Mortality Rates in Women Expected
to Increase in Next 20 years
Figure 4-9
Number of cardiovascular disease deaths by sex, actual
and projected, Canada, 1950-2025
60,000
50,000
Number
40,000
30,000
20,000
10,000
0
1950
1960
1970
1980
1990
Men-Actual
Women-Actual
2000
2010
2020
Men-Estimate
Women-Estimate
Source: Statistics Canada
The Growing Burden of Heart Disease and Stroke in Canada 2003
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CAD in Women
• Women develop angina about 10 years later and a
first MI about 20 years later than men
• Women are more likely to have angina than MI as
their initial presentation of CAD
• Women presenting with acute MI tend to be older
and have more co-morbidity
• Women are less likely than men to attribute their
symptoms to cardiac disease, even in the setting of
acute MI
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Risk Factors in Women -1
Diabetes Mellitus
• Diabetes mellitus is a more powerful predictor of
CHD risk and prognosis in women than in men
• Diabetes is commonly accompanied by other
cardiovascular risk factors in women
• Diabetes was found to be the only risk factor that
distinguished between those with and without
angiographic CHD
• A history of IDDM is also a strong risk factor in
women for death after MI
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Risk Factors in Women - 2
Hypertension
• The prevalence of hypertension reaches 70 to 80
% in women above age of 70
• Hypertension in women is both a strong predictor
of coronary risk and more commonly seen in those
with CHD
• This increase in risk is also seen in premenopausal women in whom the presence of
hypertension is associated with up to 10 fold
increase in coronary mortality
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Risk Factors in Women - 3
Smoking
• Smoking has been associated with one-half of all coronary
events in women
• Coronary risk is elevated even in women with minimal use
- RR 2.4 for 1.4 cigarettes/day ( Douglas and Ginsburg,
1996 )
• Smoking has a more harmful impact on women than on
men and that risk increases in direct proportion to the
number of cigarettes smoked daily
• Smoking carries a particularly high risk in younger
women, a population likely to contribute substantially to
future burden of CHD
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Risk Factors in Women – 3 cont’d
• Compared with nonsmokers, the incidence of MI was
increased 6-fold in women and 3-fold in men who smoked
at least 20 cigarettes per day
• The risk particularly high in younger women
– the antiestrogenic effect of cigarette smoking may be one possible
explanation for the increased risk of young female smokers
(Njolstad et al, 1996)
• Smoking is also a powerful risk factor for MI in middleaged women than men
• Most of the increased risk induced by smoking dissipates
within 2 to 3 years of cessation of smoking
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Risk Factors in Women – 4
Dyslipidemia
• Low HDL, rather than high LDL cholesterol, is more
predictive of coronary risk in women
• Lipoprotein (a) is a determinant of CHD ( manifested
as angina or MI) in pre-menopausal women and
postmenopausal women under age 66 (OR 5.1 and 2.4,
respectively )
• The total cholesterol concentration appears to be associated
with CHD only in pre-menopausal women or at high levels
• Triglycerides appear to uniquely influence coronary risk in
older women, especially at levels above 400 mg/dl (4.5
mmol/L)
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Influence of Hormonal Status
• CHD is unusual in pre-menopausal women,
particularly in absence of other risk factors
• If pre-menopausal women develop CHD, the
disease tends to be more extensive and diffuse
than in men of the same age
• Surgical menopause, with or without hormone
replacement, carries an added risk of CHD, in
excess of that noted for natural menopause
• The loss of estrogen causes increase in LDL
cholesterol, total cholesterol, TGs and decrease in
HDL cholesterol
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Estrogen Replacement Therapy
(ERT): Benefits and Risks - 1
• Normal menopause ~age 51(95% age 45-55)
• ERT best therapy for peri-menopausal symptoms
– Duration 6 months to 4-5 years
• Observational studies suggested benefit of ERT or
combined estrogen-progestin (HRT) on risk of
CHD and development of osteoporosis
• Women’s Health Initiative (WHI) July 2002
discounted benefit of HRT for cardiac prevention
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ERT and
CV Risk
I in UpToDate,RoseBD (ed),Wellesley,
MAthe2004
Estrogen Replacement Therapy
(ERT): Benefits and Risks - 2
WHI Studies
• Combined estrogen/progestin replacement1
– > 16,000 post menopausal women age 50-79
– Terminated early with average f/u 5.2 years
– Increased risk breast cancer, stroke, CHD (HR 1.24)
and VTE
• Unopposed estrogen trial
– > 11,000 women with prior hysterectomy
– Received unopposed estrogen
– Study discontinued early due to increased risk of stroke
and no projected overall benefit
1
NEJM 2003 Aug 9;349(6):523-341.
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ERT and
CV Risk
I in UpToDate,RoseBD (ed),Wellesley,
MAthe2004
Estrogen Replacement Therapy
(ERT): Benefits and Risks - 3
• HERS I (Heart and Estrogen/Progestin
Replacement Study)
– 2763 post-menopausal women < 80 with CAD
– CEE/progesterone vs placebo – followed for 4
years
– No difference in CHD events overall
– More CHD events in HRT group in year onetrend to benefit in years 4-5
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ERT and
CV Risk
I in UpToDate,RoseBD (ed),Wellesley,
MAthe2004
Estrogen Replacement Therapy
(ERT): Benefits and Risks - 4
• HERS II
– Un-blinded follow-up of 93% patients in HERS
I for 2.7 years
– No ongoing HRT benefit beyond years 4-5
– Over 6.8 years in HERS I & II no benefit of
HRT
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ERT and
CV Risk
I in UpToDate,RoseBD (ed),Wellesley,
MAthe2004
Estrogen Replacement Therapy
(ERT): Recommendations
• Estrogen-progestin therapy should not be prescribed for
primary prevention of CHD.
• Estrogen-progestin therapy should be discontinued if an
acute CHD event occurs, and should not be resumed as a
secondary prevention strategy.
• Unopposed estrogen, although it does not appear to
increase CHD risk, should not be prescribed for primary
prevention because no reduction in CHD risk was observed
in the WHI trial .
• Estrogen or estrogen-progestin therapy should be reserved
for peri-menopausal women with moderate to severe
menopausal symptoms. The lowest estrogen dose that
relieves symptoms should be used for the shortest duration
possible.
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ERT and
CV Risk
I in UpToDate,RoseBD (ed),Wellesley,
MAthe2004
Women Have An Atypical
Clinical Presentation
• Typical retrosternal chest pain less common
• Atypical symptoms and location
–
–
–
–
Resting, nocturnal or stress induced chest pain
Jaw, arm, shoulder, back, epigastric discomfort
Dyspnea, palpitations, presyncope
Fatigue, diaphoresis, nausea
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Gender Bias or Clinical
Conundrum?
• Women who present to the emergency room with
new onset chest pain are approached and
diagnosed less aggressively than men
• Compared to men women are less likely to:
– undergo an EKG, cardiac monitoring or cardiac enzyme
measurement
– to receive a cardiology consult; be admitted to a
coronary care or step down unit
• Women are more likely to receive controlled
substances and anxiolytics in the ER
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Comparison of Men and Women in
Presentation and Outcome
Presentation Comparison
Outcome
Comparison
Angina
W>M
MI morbidity W > M
Atypical CP
W>M
MI Mortality
W > or = M
Silent MI
W>M
CABG Mort.
W > or = M
Death from
MI
W>M
PCI Mortality W > or = M
Sudden death
W>M
False + TMT
W>M
APMI
W<M
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Approach to diagnosis CAD in
Women
•
•
•
•
Classify the type of pain
Assess determinants of likelihood of CAD
Select test based on pre-test probability of CAD
Confirm or deny presence of CAD with TMT,
stress perfusion study or stress echo
• High false positive rate TMT rate in premenopausal females (up to 50%) or low pre-test
likelihood CAD
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Classification of Chest Pain
Typical angina
1. Steady retrosternal component
2. Provoked by exertion or stress
3. Relieved by rest or NTG
Atypical angina
–
2 of 3 criteria
Non-anginal chest pain
–
1 of 3 criteria
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Prevalence of CAD (%) in Symptomatic
Patients According to Age and Sex
Typical angina
Atypical angina
Non anginal
chest pain
AGE
Men
Women
Men
Women
Men
Women
30-39
69.7
25.8
21.8
4.2
5.2
0.8
40-49
87.3
55.2
46.1
13.3
14.1
2.8
50-59
92.0
79.4
58.9
32.4
21.5
8.4
60-69
94.3
90.6
90.6
54.6
28.1
18.6
3 of 3 criteria
2 of 3 criteria
1 of 3 criteria
1) Retrosternal discomfort.2) Provoked by exercise or stress.3) Relieved by rest or NTG
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Determinants of the Likelihood
of CAD in Women
MAJOR
- Post menopausal status /
age >65 years
- Diabetes
- Peripheral Vascular
Disease
INTERMEDIATE
- Hypertension
- Smoking
- Lipid abnormalities
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MINOR
- Obesity
- Sedentary lifestyle
- Family history of CAD
- Other risks factors of
CAD
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Algorithm for Chest Pain
Evaluation in Women
Low Probability of CAD (< 20 %)
– Consider no test
– High likelihood false + result
Intermediate Probability of CAD (20-80%)
– Perfusion imaging or stress echo
High Risk Probability of CAD (> 80%)
– Perfusion imaging or stress echo
– Consider direct angiography
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Comparison of Non-invasive Modalities
in the Diagnosis of CAD in Women
Sensitivity %
Specificity %
TMT
61
70
Stress Thallium
78
64
SPECT MIBI
86
80
Stress Echo
86
70
80 (SVD)
91 (MVD)
79
91
90
Dobutamine Echo
Rubidium PET
Meta-analysis of exercise testing to detect coronary artery disease in
women Kwok Y. Kim C. et al Am J Cardiol 1999. Mar 1:83(5); 660-6.
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Indications for Coronary
Angiography
• High risk stress test
– ECG
– Hemodynamic
• High risk perfusion
study
– Multiple defects
– Severe perfusion
defects
– TID
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•
•
•
•
•
Ongoing symptoms
Unstable angina
Post MI angina
CHF
Vocational indication
– Pilots
– Truck/bus drivers
• Diagnostic uncertainty
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See Diagnostic Testing 2004
Slideshow
Clinical
Clinical Evaluation
Evaluation of
of CAD
CAD
Diagnostic
Diagnostic Testing
Testing
for
for Ischaemia
Ischaemia
Joel Niznick MD FRCPC
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