Recognizing Women at Risk for Developing Coronary Heart Disease

Jean McSweeney, PhD, RN, FAHA, FAAN Interim Dean, Associate Dean for Research College of Nursing University of Arkansas for Medical Sciences

Key Facts Cardiovascular Diseases

(CVDs)

In 2008, 17.5 million people died from CVDs, (31% of global deaths) 7.4 million deaths due to CHD By 2030, almost 23.3 million will die from CVDs

–

Economic impact in billions

WHO; CVD Fact sheet, (2013); AHA Heart Disease Statistics - Update. (2015).

CVD Mortality Trends for Males & Females (United States: 1979 –2011).

Source: NCHS, NHLBI.

Dariush Mozaffarian et al., Circulation. 2015;131:e29-e322.

100 90 80 70 60 50 40 30 20 10 0 Prevalence of CVD in Adults ≥ 20 Years of Age (NHANES : 2009 –2012). 11,9 10 40,5 35,5 69,1 67,9 84,7 85,9 Men Women 20-39 40-59 60-79 80+

Dariush Mozaffarian et al., Circulation. 2015;131:e29-e322.

Incidence of MI or Fatal CHD by Age, Sex, & Race (Atherosclerosis Risk in Communities Surveillance: 2005 –2011).

Source:NHLBI, Dariush Mozaffarian et al., Circulation. 2015;131:e29-e322

Leading Causes of Death: Females (2010)

NCHS and NHLBI. (2013)

Contributing Factor to Disparities in Mortality Rates for CVD Women are generally about 7 years older than men when they present with MI Entered menopause and lost the benefit of estrogen Women tend to have more co-morbid conditions at time of diagnosis

– – –

diabetes systolic hypertension obesity Lack of symptom recognition of CHD and MI in women contributes to disparities

Lloyd-Jones et al., (2009).

Women’s Awareness of Heart Disease as # 1 Cause of Death

Lori Mosca et al. Circulation. 2013;CIR.0b013e318287cf2f

Impact of CHD in Women as Compared to Men

After MI 26% women > 45 as compared to 19% men die within 1 year If women under age 50 at time of MI, twice as likely to be fatal as in men of comparable age After MI, 46% women as compared to 22% are disabled within 6 years

AHA, Women’s Health (2011), (2014).

Impact of CHD in Women as Compared to Men

(Cont.) More CHD symptoms More physical limitations after event; especially young and mid-life Have less obstructive CHD when referred for revascularization More microvascular disease Lower levels of biomarkers of cardiac necrosis

Go, A. S., Mozaffarian, D., Roger, V. r. L., Benjamin, E. J., Berry, J. D., Borden, W. B. et al. (2013). Heart Disease and Stroke Statistics 2013 Update: A Report From the American Heart Association.

Circulation, 127

(1), e6-e245.

Vaccarino, V. (2010). Ischemic heart disease in women: Many questions, few facts.

Circ Cardiovasc Qual Outcomes, 3(

2), 111-5.

Sex Differences in Cardiovascular System

After the reproductive system, the CV system has the most sex- based differences Women have smaller coronary arteries, more breast tissue, impacts diagnostic test results Differences between sexes in hematocrit and estrogen levels, frequency of mitral valve prolapse, left ventricular hypertrophy, and myocardial blood flow

Sweitzer & Douglas, (2005); Hravnak et al., (2007); McSweeney & Lefler, (2007); Institute of Medicine. (2002).

Unequal treatment: Confronting racial and ethnic disparities in health care

Institute of Medicine.

Delay in Seeking Treatment for MI Profile of delayers

– – – – – –

Older age Female African American race Low socioeconomic status Low awareness of symptoms History of comorbidities

Moser et al., (2006). Reducing delay in seeking treatment by patients with Acute Coronary Syndrome & Stroke.

Circulation,

114:168-182.

Consequences of Delay in Seeking MI Treatment

Treatment is time dependent

–

7-fold decrease in mortality if treated within 70 minutes of symptom onset 250,000 die annually before reaching the hospital Average delay 2 - 4 hours

–

Minority populations delay longer

Mosca, et al., (2010). Twelve-year follow-up of American women's awareness of cardiovascular disease risk and barriers to heart health.

Circ Cardiovascular Quality Outcomes, 3

(2), 118-9.

Lack of Symptom Identification

If CP is not chief symptom, more likely to be misdiagnosed Twice as likely to die after misdiagnosis compared to those diagnosed with MI Women < 55 years old or minorities with shortness of breath as chief complaint are most misdiagnosed Little is known about women’s symptoms or possible racial differences in symptoms Need to address factors that shape women’s symptom presentation

AHRQ, (2005); Dracup, (2007).

Why Do Women’s Risks Remain High?

Fail to discuss risk factor modification with every health care encounter

– –

Clinic Hospital Inadequate education R/T gender racial differences

– –

All heath care providers Public

Roger et al., - Update. (2012).

Modifiable Risk Factors for CHD in Women in the U.S.

35 30 25 27.2

30,8 29,9 23,7 27,8 28 25,6 26,2 27,1 26,3 23,4 24 20 20,7 21,2 17,2 15 10 5 0 High Blood Pressure Obese Inactive Fruits & Veggies Smoking U.S. 2006-08 U.S. 2009-11 U.S. 2013 Kaiser Family State Health (2006-08) and BRFSS Prevalence and Trends Data (2009-2013).

Prevalence* of Self-Reported Obesity Among U.S. Adults by State & Territory , (BRFSS, 2013) *Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

2011

2012 2013

Source: Behavioral Risk Factor Surveillance System, CDC.

Heart Disease Risk Factor “Multiplier Effect” in Midlife Women

Association of Sleep Duration with CHD Mortality: Risk Factor?

Substantial gender differences with women more susceptible to adverse cardiac effects of short sleep

–

Women with <5 hr sleep 2.3 X more likely to have fatal event than those >7 hr

– –

No elevated risk in men Reduced sleep in women associated with incident hypertension but not in men

Patel S, et al., (2009). Association of Sleep Duration with Mortality from Cardiovascular Disease and Other Causes for Japanese Men and Women.

Sleep

; 32:295-301.

Cappuccio FP, et al., (2007). Gender-Specific Associations of Short Sleep Duration With Prevalent and Incident Hypertension. The Whitehall II Study.

Hypertension

; 50:694-701.

Exposure to Particulate Matter – Risk Factor?

CVD risks associated with exposure to particulate matter in air pollution

–

Automobile exhaust Living close to heavily trafficked freeways has been linked to increases in coronary artery calcification, a potent risk factor for MI Particulates set in place a series of responses triggering a systemic inflammatory response and is dose dependent

Brook et al., (2010); American Heart Association. (2007).

Oral Contraceptive Hormones

Assess women > 35 CHD for CHD risks prior to presenting oral contraceptives Especially important if current smokers, with known or uncontrolled HTN or a history of migraine headaches Contraceptives HDL, LDL, BP, worsen glucose tolerance

Shufelt & Bairey Merz, (2009).

Hormone Replacement Therapy (HRT) Controversy continues about the impact of HRT on the development of CHD One study examined the influence of the timing of HRT on the development of CVD. They concluded that the timing of initiating HRT is an important variable:

–

Women who initiated HRT closer to onset of menopause had an risk of developing CHD than did those more distant

Rossouw et al., (2007).

To Make Diagnosis of CHD in Women Identify risk factors Assess for prodromal symptoms (PS) Implement primary & secondary prevention measures

Following Content Based on the Following Publication McSweeney, J., O’Sullivan, P., Cleves, M., Lefler, L., Cody, M., Moser, D., Dunn, K., Kovacks, M., Crane, P., Ramer, L., Messmer, P., Garvin, B., & Zaho, W. (2010). Racial differences in women’s prodromal and acute myocardial infarction symptoms.

American Journal of Critical Care, 19,(1), 63-73.

Research Supported by the

National Institutes of Health MI Symptoms in Women: Disparities in Women of C o l o r PI: Jean C. McSweeney , NIH: NINR,1 R01 NR05265

Purpose & Recruitment

Describe and compare ethnic differences in prodromal and acute myocardial infarction (AMI) symptoms Recruited from 15 sites nation-wide Rural and urban, large and small medical centers in AR, CA, FL, NC, LA, OH, SC, TX

Methods

Descriptive Retrospective Survey, (4-6 months post-MI) Blessed Cognitive Screen McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS©)

–

33 Prodromal and 37 Acute symptoms, RF & comorbidities

McSweeney, O'Sullivan, Cody, & Crane. (2003).

Data Base

1270 women

–

43% black, 42% white and 15% Hispanic All women were >21 years of age and 4-6 months post-MI hospitalization White women oldest, most educated and had highest income

Prodromal Symptoms

N= 1270 95% (n=1239) reported at least 1 Unusual fatigue most frequent (73%, n=930) Significant (p<.01) ethnic differences in frequency of reporting 17 of 33 prodromal symptoms

Prodromal Symptoms

and Mean Scores (p<.001) 5.86

† 60.1

†

Superscripts that differ indicate significant post hoc differences at P<.003

10 Most Frequent Prodromal Symptoms 80 70 60 50 40 30 20 10 0

* * † * †

Fatigue Sleep Black Anxiety Hispanic SOB White Indig.

Superscripts that differ indicate significant post hoc differences at P<.003

10 Most Frequent Prodromal Symptoms (cont.) 45 40 15 10 5 0 35 30 25 20

*

†

*

† †

*

†

*

†

*

† Hrt Race Vision Black Chest P/D Hispanic Thinking White Appetite Superscripts that differ indicate significant post hoc differences at P<.003

% of Women Reporting a Symptom in the Prodromal Phase Reporting the Same Symptom in the Acute Phase

Cluster Analysis of Women’s Prodromal and Acute Myocardial Infarction Symptoms McSweeney, J., Cleves, M., Zhao, W., Lefler, L., & Yang, S. (2010). Cluster analysis of women’s prodromal and acute myocardial Infarction symptoms by race and other characteristics.

Journal of Cardiovascular Nursing,

25(4), 311 - 322.

Step 1

Three clusters were identified the prodromal symptoms

–

Each contained women with increasing frequency and severity of symptoms

Prodromal Symptom Clusters

Cluster

1 (N=552) 2 (N=435) 3 (N=283)

High probability (70-100%)

Very tired, unusual fatigue Sleep disturbance Very tired, unusual fatigue Sleep disturbance Anxious Shortness of breath Arms weak/heavy Hand/arms tingling

Medium probability (40-70%)

Very tired, unusual fatigue Anxious Heart racing Shortness of breath Frequent indigestion Change in thinking/remembering Any chest pain/discomfort Cough Heart racing Difficulty breathing during night Loss of appetite Frequent indigestion Arms ache Numbness or burning in hands/fingers Vision problems Change in thinking/remembering

Step 2: Examine the Association Between Women’s Characteristics & Clusters

Six of ten characteristics were strongly associated with the clusters:

–

Age, race, BMI, personal history of heart disease, diabetes and smoking status

Characteristics of Women within Clusters: Prodromal Symptoms

Prodromal Summary

Chest pain/discomfort was not identified as a primary prodromal symptom African-American women <50 years were more likely to complain of frequent and intense symptoms compared to other women

Clinical Application: Prevention

Earlier and more aggressive measures needed to identify, control, and eliminate risk factors Further gender-specific research to develop evidence-based practice Need to change our focus from treatment to prevention and early treatment to delay progression Evidence based tailored, gender-specific education for women and HC professionals

Lifestyle Interventions

Cigarette smoking

–

Providers must advise not to smoke and to avoid environmental tobacco smoke Physical activity

– –

Accumulate at least 150 min/wk of moderate exercise, 75 min/wk of vigorous exercise, or equivalent performed in 10 minute bouts/ week Muscle-strengthening activities Cardiac rehabilitation

–

Recommended to women with ACS, after revascularization, or angina

Mosca et al., Guidelines for the Prevention of CVD in Women - Update (2011).

Lifestyle Interven tions

(cont.) Physical activity

‒

Accumulate at least 150 min/wk of moderate exercise, 75 min/wk of vigorous exercise, or equivalent performed in 10 minute bouts/ week

‒

Muscle-strengthening activities

‒

Cardiac rehabilitation Many insurers will pay costs, (ex) silver sneakers

‒

Unsafe neighborhoods detriment

Mosca et al., Guidelines for the Prevention of CVD in Women – Update (2011).

Specific Dietary Intake Recommendations for Women

Nutrient

Fruits & Vegetables Fish Fiber Whole grains Sugar Nuts, legumes, and seeds Saturated fat Cholesterol Alcohol Sodium

Serving

>4.5 cups/d 2/wk 30 g/d (1.1 g/10 g carbohydrate) 3/d <5/wk (<450 kcal/wk from sugar sweetened beverages >4/wk <7% total energy intake <150 mg/d <1/d <1500 mg/d Mosca et al., Guidelines for the Prevention of CVD in Women – Update (2011).

Summary: Projected Results of Prevention

78% of all adults alive in U.S. today (20-80 years old) are candidates for modification of at least 1 CHD risk factor If implemented, estimate MI’s could be reduced by 63%

–

Smoking cessation most cost saving intervention Could save over 36 million worldwide

Kahn, R., Robertson, M., Smith, R., & Eddy, D. (2008). The impact of reducing the burden of cardiovascular disease,

Circulation

.

Questions