Transcript Advanced Nursing Practice: Stories from the Field
Evolving Knowledge of Women and Heart Disease
Jo-Ann Eastwood PhD, RN, CCNS, ACNP-BC, FAHA
Magnitude of the Problem
Leading cause of death, mostly due to ischemic heart disease and stroke
Angina is a more common presentation of coronary heart disease in women than in men
Ischemic heart disease in women versus men
Present at older age
Less likely to be diagnosed and treated
Higher cardiovascular mortality
Estimated annual cost for cardiovascular disease in men and women: $400 billion
CVD & Other Causes of Death
More than 1 in 4 women will die of heart disease 1 in 30 women will die of breast cancer
Women are getting the message What is the leading cause of death in women?
We know the answer: Heart Disease!
In 1997, only 30% (less than 1 out of 3) women knew the right answer.
In 2010, 57% of women knew the right answer.
This realization was shared by fewer Black &Hispanic Majority of women believed they couldreduce their risk with multivits, antioxidants or ASA Only 53% said they would call 911 if they had symptoms Mosca, L Circ. Cardiovasc Qual Outcomes 2010;3(2):120-7
Cardiovascular Disease Deaths in the United States (1980-2009)
Women Men 1980 1985 1990 1995 2000 2005 2009 Go AS, et al.
Circulation.
2013;127:e6-e-245.
Gender Differences in Sudden Cardiac Death, Symptoms, and Quality of Life
Sudden cardiac death before arrival at a hospital
Women: 42%
Men: 25%
Symptomatic women versus men
More often have recurrent symptoms requiring hospitalizations
Lower ratings of general well-being and limitations in ability to perform activities of daily living
Shaw LJ, et al.
J Am Coll Cardiol.
2009;54:1561-1571.
Aftermath of CHD
Survivors of ACS have 1.5 – 15 x greater risk of illness and death than general population
Within 6 years of MI: % Men
Recurrent MI:
SCD
HF
Stroke 18 6 22 8 % Women 35 7 46 11
ACC National Cardiovascular Data Registry: In Hospital Mortality
Chest Pain Women Men
P
=0.89
P
<0.0001
P
=0.23
P
=0.14
Black Hispanic Native
.
(n=24,998) (n=3562)
American
In-hospital mortality after coronary angiography.
(n=1251) Among patients with stable chest pain, white women with 1- to 3-vessel CAD had 1.67- to 2.02-fold higher in-hospital mortality than white men (
P
=0.013).
Asian
(n=7823)
White
(n=338,252)
In light of these epidemiologic data, common misunderstandings and a growing awareness of potentially relevant sex differences, the AHA has updated CVD Prevention Guidelines for Women.
SEX MATTERS
Presentation Evaluation and Treatment Benefits and Risks
VIRGO Study: Gender Differences in Symptom Presentation and Perception
Younger patients with MI from 104 US hospitals, 2008-2012 (n=2990)
Age: 18 to 55 years
2:1 female to male enrollment 90% of men and 87% of women presented with chest pain, pressure, tightness, or discomfort
Women presented more additional symptoms More women waited >1 day to seek care than men (55% versus 49%; P<0.05) At time of hospitalization
24% of women said health care provider did not think symptoms were heart related compared with 12% of men (P<0.001) Chest Pain/ Discomfort Radiating Pain Indigestion/ Nausea Shortness of Breath Weakness/ Fatigue Palpitations
Lichtman JH, et al.
Circulation.
2012;126(suppl). Abstract 17831.
Symptoms at MI Presentation
† Patients (%) *
P
<0.05 and †
P
<0.01 versus men.
* † † † * Women (n=2012) Men (n=978)
Women’s Ischemia Syndrome Evaluation (WISE) Study
NHLBI-sponsored 4-center study
Women (>18 years of age) undergoing clinically ordered coronary angiography for suspected myocardial ischemia (n=936)
Myocardial ischemia at non-invasive testing Exclusion criteria
Emergency referral, pregnancy, cardiomyopathy, NYHA class IV CHF, recent acute MI or unstable angina, recent coronary revascularization, significant valvular or congenital heart disease, any contraindication to provocative myocardial stress testing, and any condition likely to affect study retention Objectives
Optimize symptom evaluation and diagnostic testing for ischemic heart disease Explore mechanisms for symptoms and myocardial ischemia in the absence of epicardial coronary artery stenoses Evaluate the influence of reproductive hormones on symptoms and diagnostic test response
Merz CN, et al.
J Am Coll Cardiol.
1999;33:1453-1461.
WISE Study: Estimated Lifetime Costs for Women With Angina
Direct Cardiovascular Costs/Patient
1200000
$1,051,302 $1,001,493 $1,008,780
1000000 800000 600000
$767,288
400000 200000 0
Nonobstructive CAD Shaw LJ, et al.
Circulation.
2006;114:894-904.
1 Vessel CAD 2 Vessel CAD 3 Vessel CAD
Evolving Understanding of Angina in Women
Typical versus atypical angina diagnosis by gender
3225 patients referred to Duke University for evaluation of chest pain with median of 5 Female (n=967) Typical angina (%) Atypical angina (%) 55 34* 28 53
Angina equivalents
Fatigue Lightheadedness Weakness Diaphoresis
− − −
Shortness of breath Nausea Indigestion Coronary patients with angina rate their quality of life lower than those without angina
*
P
<0.05 for comparison across gender. No angina: males (11%) and females (19%).
Abrams J.
Fang JC.
N Engl J Med.
2005;352:2524-2533; Alexander KP, et al.
J Am Coll Cardiol.
1998;32:1657-1664;
Braunwald’s Heart Disease. 9 th Edition
. 2012. Bandu I, et al.
Chest.
1994;105:1009-1012; Stern S.
Circulation.
2002;106:1906-1908; Marquis P, et al.
Eur Heart J
. 1995;16:1554-1560.
Novel Risk Factors in Women
Traditional risk factors and the Framingham risk score may underestimate risk in women Novel risk markers may improve risk detection
Abdominal obesity Metabolic syndrome Low estrogen levels Elevated testosterone levels and polycystic ovary syndrome Elevated C-reactive protein Postmenopause
Clustering of risk factors is common (obesity, hypertension, dyslipidemia)
These risk factors also predict early menopause
Shaw LJ, et al.
J Am Coll Cardiol .
2006;47(suppl):4S-20S.
Shaw LJ, et al.
J Am Coll Cardiol .
2009;54:1561-1575.
SWAN Study. http://www.swanstudy.org. Greenland P, et al.
J Am Coll Cardiol.
2010;56:e50-e103.
Reclassification of Risk in Women Using the Reynolds Risk Score
Ridker PM, et al.
JAMA .
2007;297:611-619.
Reynolds Risk Score calculator: http://www.reynoldsriskscore.org/.
Assessment of Myocardial Ischemia and Obstructive Coronary Disease in Women
Symptoms suggestive of myocardial ischemia
Women have lower rates of obstructive CAD at angiography
Early work by Diamond and Forrester
Women with typical or atypical chest pain symptoms have calculated obstructive CAD probabilities substantially less than men Typical exertional angina in a 55-year-old man has a probability of obstructive CAD of approximately 90% as compared with wide range from 55% to 90% for a 55-year-old woman
This does not address angina equivalents
Chest pain symptoms are less accurate and less precise predictors of obstructive CAD in women
Shaw LJ, et al.
J Am Coll Cardiol.
2006;47(suppl):4S-20S.
Diamond GA, et al.
N Engl J Med
. 1979;300:1350-1358.
Gender Differences in Ischemic Heart Disease in Women
Structural Features (macro- and microvessels)
Smaller size Increased stiffness (fibrosis, remodeling, etc) More diffuse disease More plaque erosion versus rupture Microemboli, rarefaction (drop out), disarray, etc
Functional Features (macro- and micro -vessels)
Endothelial dysfunction
Smooth muscle dysfunction (Raynaud’s, migraine, coronary artery spasm)
Inflammation
−
Plasma markers
−
Vasculitis (Takayasu’s, rheumatoid, SLE, CNSV, giant cell, etc)
Wenger NK.
Curr Cardiol Rep.
2010;12:307:314.
Kramer MC, et al.
J Am Coll Cardiol.
2010;55:122-132.
Shaw LJ, et al.
J Am Coll Cardiol.
2009;54:1561-1575.
Model of Microvascular Angina in Women Shaw LJ, et al.
J Am Coll Cardiol.
2009;54:1561-1571.
Overarching Working Model of Ischemic Heart Disease Pathophysiology in Women Shaw LJ, et al.
J Am Coll Cardiol.
2009;54:1561-1571.
Plaque Erosion and Outward (Positive) Remodeling
Lumen
Plaque erosion and thrombus formation 2x likely in women (men have more plaque rupture)
Thrombus Formation
Outward (positive) remodeling atherosclerotic lesion protrudes outward than impinging on the lumen
Adapted from Bellasi et al, New insights into ischemic heart disease in women. cleveland clinic journal of medicine; 74: 585
What to Tell a Woman When She Doesn’t Want to be a Statistic?
AHA Impact Goal For
All
Americans
20% by 2020 :
Improvement CV health
Reduction in CVD/stroke deaths
Primordial prevention (at all levels of risk)
CVD & associated risk factors develop early in life
Health promotion & disease prevention require all approaches:
Population-level
Individual high risk
Focus on Women
“..defining a women’s risk status and then improving adherence to preventive lifestyle behaviors is the most effective way to lower CVD in women.” Wenger, NK. Clin Cardilol. 2011
Targeting Education - Awareness AND. . .
Prevention
Prevention
Prevention
Prevention
Ideal Health Behaviors such as:
BMI < 25 kg/m2 Blood Glucose < 100mg/dL Waist size < 35” Cholesterol < 200mg/dL Following DASH diet Physical activity at goal level
CVD Risk in Women
Mosca, Circulation 123:1243, 2011
Female – Specific Issues
• • • • • • •
Gender differences in CVD risk factors Tobacco Diabetes and Met Syn Dyslipidemia HTN Fitness
• •
Autoimmune diseases with ↑ CVD risk Rheumatoid Arthritis SLE
• • • • • •
Female specific issues Pregnancy induced HTN Pre-eclampsia Gestational diabetes PCOS
• •
Other Issues for Women Breast cancer therapy effects, Chest radiation
Counseling All Women: Recommended Lifestyle Changes
For all women:
Smoking cessation and avoidance of secondhand smoke
Physical activity
Moderate activity at least 6-7 days a week
Strength training x2/week
DASH-like low-sodium diet
Weight Management
2011 Guidelines: Evidence-based to Effectiveness-based
Benefits and risks observed in clinical practice
Therapies that may have potential benefit Ex. Screening for depression indirectly may impact CVD risk through adherence to prevention therapies or other mechanisms.
Acknowledgement that 10 year risk is not efficacious in women
Targeting Women Throughout the Lifespan
Premenopausal 20-35 yrs Peri menopausal 35-50 yrs Post menopausal >50 yrs
Premenopausal
Initial assessment: Detailed medical and pregnancy-complications hx
Pregnancy:
Early “stress test”? Unique opportunity to assess lifetime CVD risk
“Metabolic syndrome of pregnancy”
Preeclampsia
Postpartum referral for CVD risk assessment
Pregnancy: A Stress Test for Life
Pregnancy stresses maternal carbohydrate, lipid, inflammatory pathways, vascular function
●
Unmasks underlying metabolic, vascular disease •? Pregnancy a screen for later hypertension, diabetes •? Preeclampsia induces damage to vascular endothelium; ? pathway for microvascular dysfunction •? Preeclampsia triggers inflammatory, autoimmune responses •? How can/should preeclampsia, hypertensive disorders of pregnancy (HDP) be incorporated into CV risk assessment for women
Williams, Curr Opin Obstet Gynec 15:465, 2003 Ness, Ann Epidemiol 15:726, 2005 Mosca, Circulation 123:1243, 2011
HDP and Subsequent CV Disease
Compelling evidence for association HDP and future CVD Hypertension Ischemic heart disease Ischemic stroke Thromboembolic disease Heart failure Chronic kidney disease Diabetes mellitus Arrhythmias Hypertension in adolescent life in offspring
Mannisto, Circulation 127:681, 2013
8
Contemporary Recommendations
Pregnancy history integral component of CV risk evaluation for women Women with prior preeclampsia, hypertensive disorders of pregnancy → early, intensive coronary risk intervention Counsel re ↑ CVD risk Counsel re effectiveness of CV risk assessment, reduction in primary prevention CV disease ? Screen as early as 1 year postpartum Guidelines needed for structured follow-up, CV risk management after HDP
Smith, Am J Obstet Gynecol 200:58.e1, 2009 Mosca, Circulation 123:1243, 2011
Perimenopausal
Decrease in exercise > decrease in calorie intake
Weight gain, waist circumference, increase BP
Decreased social interaction d/t:
Mood disorders
Sleep disturbance
Vasomotor symptoms
Changes in work patterns /stress
Alterations in lipid profiles
( ESHRE Capri Workshop Group 2011)
Postmenopausal
Dyslipidemia
Hypertension
Metabolic Syndrome
Lack of exercise
Psychosocial function
Social support
Dysphorias
Higher prevalence of stroke
Dispelling Myths: Confusion Among Women Remains
Observational studies reported HRT effective for symptoms & diseases ie CV and osteoporosis for menopausal women
2 large RCTS HERS and WHI reported no benefits prevention of CVD. WHI found increases Breast CA incidence & CV events in healthy women
Million Women Study- increase in Breast CA with HRT
Dispelling Myths: Confusion Among Women Remains
Hormone therapy should not be used for primary or secondary prevention of CVD
Supplements not useful in preventing CVD
Vitamins E and C
Beta carotene
Folic acid
Aspirin not recommended for healthy women < 65 yrs
Health Disparities
Higher prevalence of risk factors in racial/ethnic groups
HTN → Black women
Diabetes →Hispanic women
Additional socio-economic factors
Inadequate access to healthcare
Reduced access to fresh food/easy availability of fast food
Community characteristics
Challenges: Real World
“I want to eat 5 fruits a day but once I dole out the fruit to the kids there is nothing left”
“It’s not safe in my neighborhood to walk besides I can’t leave the kids”
“I have to use the money I have for healthy groceries to give to the kids to pay for lunch. If they stand in the free lunch line they are teased and embarrassed all day!”
Successes!
“This is the first time my husband’s blood pressure has been down to 120/80 since the 6 th grade” (N’s husband was admitted for a BP of 210/100 last November) “My daughter (14 yo and overweight) watched me choosing good foods to eat and said I want to eat what you’re eating Mommy” “My BP is 138/88 and my doctor says lose 20 lbs! Then I got your message about getting to goal <120/80. I am going back!”
Lessons from the Field
Women may be the key to changing health habits in minority communities
A message that resonates: “Take care of
yourself so you can take care of your family”
If you treat the woman, the family changes
Women need social support
Go where the women are:
Churches, community organizations
Online Resources
Thank-you for your attention!
AHA : Clinical Research Grant Award & to the many LA women who have committed themselves to not becoming a statistic!
Additional References
AHA. http://www.americanheart.org/downloadable/heart/1136818052118Femal es06.pdf.
Go AS, et al. Circulation. 2013;127:e6-e-245.
Wenger NK. Prog Cardiovasc Dis. 2003;46:199-229.
Hemingway H, et al. JAMA. 2006;295:1404-1411.
Daly C, et al. Circulation. 2006;113:490-498 Merz CN, Kelsey SF, Pepine CJ, et al. The Women's Ischemia Syndrome Evaluation (WISE) study: protocol design, methodology and feasibility report. J Am Coll Cardiol. 1999;33:1453-1461 Shaw LJ, et al. J Am Coll Cardiol. 2008;117:1787-1801