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