Post on 20-Aug-2018
transcript
Current Trends in Cardiovascular Disease in
Women
Dr Robert Chan
“The Community has viewed women’s health almost with a ‘bikini’ approach, looking essentially at the breast and the reproductive system, and almost ignoring the rest….”
Prof Nanette Wenger
Cardiovascular Disease in Women
Synopsis • Primary prevention • Presentation • Diagnosis • Conditions predominantly affecting women • Gender differences in management • Percutaneous coronary intervention
Primary Prevention of Cardiovascular Disease
• Quitting smoking and avoiding passive smoking • Healthy diet and lifestyle • Address obesity with attention to waist (<80cm) and BMI • Knowledge of family history of cardiovascular and lipid
disorders • Appropriate blood pressure management in those with
hypertension • Optimal glycaemic control in diabetics • Appropriate use of aspirin, statin and hormone therapy
Aspirin for Primary Prevention
The Women’s Health Study 39,876 women > 45 (mean age 55) were randomised to 100mg of aspirin second daily or placebo and followed up for 10 years. • Myocardial infarction: RR1.02, 95% CI 0.84-1.25, p=0.83 • CV death: RR0.95, 95% CI 0.74-1.22, p=0.68 • Ischaemic stroke: RR0.76, 95% CI 0.63-0.93, p=0.009 • Haemorrhagic stroke: RR1.24, 95% CI 0.82-1.87, p=0.31 • GI bleeding: RR1.4, 95% CI1.07-1.83, p=0.02 Subgroup of women > 65: • Myocardial infarction: RR0.66, 95% CI 0.44-0.97, p=0.04 • Composite end pt: RR0.74, 95% CI 0.59-0.92, p=0.008
Indications of Aspirin for Primary Prevention
• Prevention of ischaemic stroke in women age 55 to 79 • Prevention of myocardial infarction in women age > 65 or
at high risk
Statins for Primary Prevention • Women were under-represented in earlier statin trials • In JUPITER trial, women with no known coronary
disease, CRP > 2mg/L and LDL cholesterol < 3.4mmol/L who received rosuvastatin had a 46% reduction in MI, stroke, hospitalisation for unstable angina, or cardiovascular mortality
Statin Trials in Women
Kos$s WJ et al JACC 2012
Adverse Effects of Statins • Myopathy • Increased incidence of diabetes • Cognitive impairment • Abnormal liver enzymes
Indications of Statin for Primary Prevention
• Women at high risk of cardiovascular disease (diabetics aged > 60 or with microalbuminuria, moderate to severe chronic kidney disease, familial hypercholesterolaemia, systolic BP > 180mmHg, total cholesterol > 7.5mmol/L, Aboriginal and Torres Strait Islanders aged > 74, high risk according to CVD risk charts)
• Consider benefits vs potential or actual adverse effects from treatment
CT Coronary Calcium Score • Measures calcification of
coronary atherosclerosis • Ideal age range 45 to 70 • No contrast involved • Radiation exposure
(1-2mSv, background 2mSv per year, mammogram 0.7mSv)
• Score compared with age and gender match cohort
• No medicare rebate
Multi-Ethnic Study of Atherosclerosis • > 4000 non-diabetic subjects not on aspirin undergoing
CT calcium scoring and followed-up (average 7.6 years)
CHD events include non-‐fatal MI, resuscitated cardiac arrest and CHD death CVD events include CHD events and fatal and non-‐fatal stroke
CV Risk based on CT Calcium Score
Coronary Calcium Score Increase in Annual Event Rate
1-‐100 2.1x
100-‐400 5.4x (moderate risk)
>400 10x (high risk)
Pletcher MJ et al. Arch Intern Med 2004;164:1285-‐92
Risk Stratification complemented by CT • Allow “auditing” of the biological effects of risk factors • CT coronary calcium score > 100 suggests a net benefit
from aspirin regardless of conventional guidelines • In a study of patients with chest pain presenting to ED
who subsequently underwent CTCA (ROMICAT 1), 20% of subjects with obstructive coronary disease and 40% with non-obstructive coronary disease were not identified as candidates for statin based on conventional guidelines
Hormone Therapy • Either oestrogen + progestin, or oestrogen alone used to
treat menopausal symptoms and prevent osteoporosis • Women’s Health Study showed a trend towards a
greater risk of cardiovascular disease in combination therapy, especially those who started treatment > 9 years after onset of menopause
• Other studies found increased risk of stroke and DVT • Women who are on hormone therapy should cease
treatment after acute coronary events • Should consider age (65), duration of menopause, risk
profile, menopausal symptoms and bone health
Presenting Symptoms • In patients with acute coronary syndrome, more women
present with atypical symptoms including dyspnoea, nausea and vomiting, fatigue and diaphoresis
• Most women with coronary heart disease still present with typical symptoms
Stress Testing • Exercise stress ECG testing has a higher false-positive
rate in women and ST depression on ECG is not related to adverse outcome
• Exercise nuclear myocardial perfusion study can give false-positive results because of breast attenuation artefacts
• Exercise echocardiogram can be affected by poor acoustic windows related to large breast
CT Coronary Angiogram
Radiation Exposure in CTCA
CTCA
• Microvascular Angina (Syndrome X) • Stress (Takotsubo) Cardiomyopathy • Spontaneous Coronary Artery Dissection
Conditions Disproportionately Affecting Women
Microvascular Angina (Syndrome X)
• Peri- and post-menopausal women account for 70% of patients presenting with chest pain and raised cardiac enzymes but no angiographic evidence of coronary disease
• Possibly related to ischaemia at a microvascular level • Some patients have objective evidence of stress induced
myocardial ischaemia during stress testing • May have worse cardiovascular outcome • Treated by lifestyle modifications, anti-anginal agents,
ACEI, statin, analgesia
Takotsubo Cardiomyopathy • “Broken heart syndrome” • Precipitated by sudden emotional or physical stress • Signs and symptoms of myocardial infarction without
demonstrable epicardial coronary disease • Typical apical ballooning appearance during left
ventriculogram resembling a Japanese fishing pot used to trap octopuses
• Majority of cases are in post-menopausal women • Supportive treatment and risk factor management • Favourable prognosis and recurrence rare
Stress (Takotsubo) Cardiomyopathy
Spontaneous Coronary Artery Dissection
• Rare cause of acute coronary syndrome • Predominantly in young healthy women (age 30-45) • 70% cases are in women 30% of whom during
pregnancy, possibly related to hormonal changes, increased cardiac output and shear stress, and heightened inflammatory response
• Diagnosed by cardiac catheterisation and coronary angiography
• Treatment ranges from medical management to coronary artery bypass graft surgery
• 2 year survival 95%, 10 year recurrence rate 10% • Associated with fibromuscular dysplasia (renal, carotid)
Fibromuscular Dysplasia
Gender Differences in Management • Women with heart disease tend to be smaller, lighter,
older and have more co-morbidities such as diabetes and hypertension
• Women with acute coronary syndrome are more likely to be managed medically
• Women receive less aggressive medical therapy, less intense secondary prevention treatment, and less often referred to cardiac rehabilitation
• Lower quality of life score and slower recovery
Percutaneous Coronary Intervention in Women
• Women have smaller coronary, femoral and radial arteries
• More prone to radial artery spasm • Higher risk of stroke during cardiac catheterisation • Increased bleeding risk (2-10x), often related to access
site complications • Partly overcome by adoption of radial artery approach,
use of vascular closure devices and less intense anti-coagulants
• Bleeding complications may be related to vascular fragility influenced by oestrogen, and menopause associated changes in coagulation and fibrinolysis
Radial vs Femoral Access • A recent trial examining >1000 women undergoing
diagnostic catheterisation or coronary intervention • Those with radial access had significant less bleeding
and vascular complications (0.6% vs 1.7%) with 6.7% cross-over, more women preferred radial access
• Another longitudinal study of 35,000 trans-femoral cases, vascular complications of 0.2% in diagnostic catheterisation and 1% for coronary intervention
• Personal trans-femoral experience: complication 0.1% • Caveats: radial artery occlusion (1-10%), permanent
loss of a conduit for bypass grafting and arteriovenous fistula, increased radiation exposure
Key Messages • Aspirin appears to be less beneficial in women than in men in
primary prevention of coronary heart disease • Statin remains beneficial in primary prevention in high risk women • Hormonal therapy is not recommended for cardiovascular disease
prevention • Although some women with acute coronary syndromes have
atypical presentation, most women present with typical symptoms • Accuracy of stress tests may be compromised in women, CTCA may
be an alternative • Certain heart conditions occur predominantly in women • Women with acute coronary syndromes should be treated
aggressively but stable patients can be managed conservatively initially
• Percutaneous coronary intervention techniques can be modified in women to minimise complications