733
edits
Women's Heart Health: Difference between revisions
Jump to navigation
Jump to search
→Which patients can be managed for global cardiovascular risk by a menopause physician?
No edit summary |
|||
| (10 intermediate revisions by 2 users not shown) | |||
| Line 9: | Line 9: | ||
In general cardiovascular events among women appear approximately 7-10 years later in women than in men. The lower incidence of CVD in premenopausal women compared with men of similar age and the menopause associated increase in CVD have long suggested that estrogens underlie a protective effect on the cardiovascular system for women. | In general cardiovascular events among women appear approximately 7-10 years later in women than in men. The lower incidence of CVD in premenopausal women compared with men of similar age and the menopause associated increase in CVD have long suggested that estrogens underlie a protective effect on the cardiovascular system for women. | ||
It is known that estrogens improve the arterial wall response to injury and inhibit the development of atherosclerosis by promoting re-endotheliazation, inhibiting smooth muscle cell proliferation, and matrix deposition following vascular injury. | It is known that estrogens improve the arterial wall response to injury and inhibit the development of atherosclerosis by promoting re-endotheliazation, inhibiting smooth muscle cell proliferation, and matrix deposition following vascular injury.<cite>5</cite> | ||
Estrogens also decrease systemic vascular resistance, improve coronary and peripheral endothelial function and prevent coronary artery spasm in women with and without atherosclerosis. Pre-menopausal women with hormonal imbalances and estrogen deficiencies have a higher risk of developing premature atherosclerosis | Estrogens also decrease systemic vascular resistance, improve coronary and peripheral endothelial function and prevent coronary artery spasm in women with and without atherosclerosis. Pre-menopausal women with hormonal imbalances and estrogen deficiencies have a higher risk of developing premature atherosclerosis.<cite>6</cite> | ||
==Gender Differences in the Pathofysiology of Atherosclerosis== | ==Gender Differences in the Pathofysiology of Atherosclerosis== | ||
| Line 25: | Line 25: | ||
===Microvascular angina pectoris=== | ===Microvascular angina pectoris=== | ||
[[File:Differences_in_coronary_artery_disease_by_gender.svg|thumb|400px|right]] | |||
This paradoxical difference, where women have lower rates of anatomical CAD but more symptoms, ischemia, and adverse outcomes, appears linked to abnormal coronary reactivity that includes microvascular dysfunction. Symptoms as the result of microvascular dysfunction should be called microvascular angina. Abnormal coronary reactivity is often the result of diffuse (microvascular) atherosclerosis which is often seen in women, in contrast to the obstructive atherosclerosis which is more common in men (figure 2). | This paradoxical difference, where women have lower rates of anatomical CAD but more symptoms, ischemia, and adverse outcomes, appears linked to abnormal coronary reactivity that includes microvascular dysfunction. Symptoms as the result of microvascular dysfunction should be called microvascular angina. Abnormal coronary reactivity is often the result of diffuse (microvascular) atherosclerosis which is often seen in women, in contrast to the obstructive atherosclerosis which is more common in men (figure 2). | ||
| Line 33: | Line 34: | ||
It is this combination of non-obstructive cardiovascular disease with loss of endothelial function in the epicardial and microvascular beds which can lead to chest pain which is not well understood. | It is this combination of non-obstructive cardiovascular disease with loss of endothelial function in the epicardial and microvascular beds which can lead to chest pain which is not well understood. | ||
For women with evidence of ischemia but no obstructive CAD, anti-anginal and anti-ischemic therapies can improve symptoms, endothelial function, and quality of life; however, trials evaluating impact on adverse outcomes are needed. Women experience more adverse outcomes compared with men because obstructive CAD remains the current focus of therapeutic strategies. Continued research is indicated to devise therapeutic regimens to improve symptom burden and reduce risk in women with ischemic heart disease. | For women with evidence of ischemia but no obstructive CAD, anti-anginal and anti-ischemic therapies can improve symptoms, endothelial function, and quality of life; however, trials evaluating impact on adverse outcomes are needed. Women experience more adverse outcomes compared with men because obstructive CAD remains the current focus of therapeutic strategies. Continued research is indicated to devise therapeutic regimens to improve symptom burden and reduce risk in women with ischemic heart disease. | ||
===Syndrome X=== | ===Syndrome X=== | ||
| Line 43: | Line 44: | ||
==Risk Factors== | ==Risk Factors== | ||
Risk estimates associated with traditional cardiovascular risk factors are overall similar in women and men across various regions of the World. However, the increased risk associated with hypertension and diabetes and the protective effect of exercise and alcohol appear to be larger in women than in men | Risk estimates associated with traditional cardiovascular risk factors are overall similar in women and men across various regions of the World. However, the increased risk associated with hypertension and diabetes and the protective effect of exercise and alcohol appear to be larger in women than in men.<cite>7</cite> It is also important to make a difference between pre and post menopausal status. Table 1 gives an overview of the global cardiovascular risk factors in women | ||
===Smoking=== | ===Smoking=== | ||
| Line 49: | Line 50: | ||
===Hypertension=== | ===Hypertension=== | ||
Hypertension is a highly prevalent risk factor that becomes more common in women then in men and is particularly prevalent among black women | Hypertension is a highly prevalent risk factor that becomes more common in women then in men and is particularly prevalent among black women.<cite>7</cite> After menopause the renine activity in plasma increases which leads to sodium retention. By the age of 60 almost 50% of all women have clinically manifest hypertension, defined as a systolic blood pressure > 140 mmHg and a diastolic blood pressure of 90 mmHg.<cite>6</cite> Hypertension in women compared to men more often leads to CVA, left ventricular hypertrophy en diastolic dysfunction. The structural changes of the myocardium can become clinical manifest by dyspnea, supraventricular tachycardia such as atrial fibrillation, angina due to endothelial dysfunction. Slightly elevated blood pressure leads in women more then in men to endothelial dysfunction.<cite>6</cite> Hypertension is 2 to 3 times more common in women taking oral contraceptives, especially among obese and older women. Blood pressure lowering strategies have demonstrated to reduce the risk of ischemic heart disease and stroke | ||
===Dyslipidemia=== | ===Dyslipidemia=== | ||
In women there is a stronger fluctuation of lipid levels throughout life. Due to hormonal changes total and LDL cholesterol levels increase with an average of 10-14% after menopause | In women there is a stronger fluctuation of lipid levels throughout life. Due to hormonal changes total and LDL cholesterol levels increase with an average of 10-14% after menopause.<cite>6</cite> Low HDL and high triglycerides seems to be more important risk factors in women than in men. Data from the Nurses Health Study shows that HDL was the lipid parameter that best discriminated the risk of ischemic heart disease.<cite>7</cite> | ||
Hypertriglyceridemia is associated with a 37% increase in CVD risk in women compared to 14% in men | Hypertriglyceridemia is associated with a 37% increase in CVD risk in women compared to 14% in men.<cite>7</cite> The dynamic changes of the lipidprofiles due to age and menopausal status play an important role in the prevention of cardiovascular disease in women. | ||
===Obesity=== | ===Obesity=== | ||
| Line 62: | Line 63: | ||
===Women specific risk factors=== | ===Women specific risk factors=== | ||
Estrogens improve the arterial wall response to injury and inhibit the development of atherosclerosis by promoting re-endotheliazation, inhibiting smooth muscle cell proliferation and matrix deposition following vascular injury. They also have a vasodilative effect. Premenopausal women with hormonal dysfunction and estrogen deficiency have a higher risk for developing premature atherosclerosis | Estrogens improve the arterial wall response to injury and inhibit the development of atherosclerosis by promoting re-endotheliazation, inhibiting smooth muscle cell proliferation and matrix deposition following vascular injury. They also have a vasodilative effect. Premenopausal women with hormonal dysfunction and estrogen deficiency have a higher risk for developing premature atherosclerosis.<cite>6</cite> The polycystic ovarian syndrome, a condition also known as PCOS have a high risk for developing the metabolic syndrome and type 2 diabetes and are therefore an at risk population. Also women with premature ovarian failure (menopause before the age of 40) have a higher risk for developing CVD. | ||
=== “Novel” risk factors=== | === “Novel” risk factors=== | ||
| Line 68: | Line 69: | ||
===Depression & Acute stress=== | ===Depression & Acute stress=== | ||
[[File:takotsubo.svg|thumb|400px|Takotsubo cardiomyopathy]] | |||
Data from the INTERHEART study shows, that particular in women the combined exposure psychological risk factors such as depression, chronic emotional distress and acute stress such as major live events, are significantly associated with acute myocardial infarction (OR 2.6 in men and 3.5 in women). A stress-induced condition known as “Takotsubo cardiomyopathy” is almost exclusively seen among women. Due to severe emotional stress these women present with symptoms mimicking acute myocardial infarction. Also the ECG and echocardiogram show all the signs of infarction. However the CAG is often normal with no signs of coronary obstruction. The severe impaired left ventricular function usually normalizes completely after a couple of months. | Data from the INTERHEART study shows, that particular in women the combined exposure psychological risk factors such as depression, chronic emotional distress and acute stress such as major live events, are significantly associated with acute myocardial infarction (OR 2.6 in men and 3.5 in women). A stress-induced condition known as “Takotsubo cardiomyopathy” is almost exclusively seen among women. Due to severe emotional stress these women present with symptoms mimicking acute myocardial infarction. Also the ECG and echocardiogram show all the signs of infarction. However the CAG is often normal with no signs of coronary obstruction. The severe impaired left ventricular function usually normalizes completely after a couple of months. | ||
==Risk Factor Assessment== | ==Risk Factor Assessment== | ||
===Which risk factors should be assessed?=== | ===Which risk factors should be assessed?=== | ||
Global cardiovascular risk should be assessed in | Global cardiovascular risk should be assessed in '''ALL''' women in menopause consulting the physician. | ||
Many women appear healthy with no symptoms of CVD nevertheless, they are potentially at increased risk | Many women appear healthy with no symptoms of CVD nevertheless, they are potentially at increased risk | ||
| Line 99: | Line 101: | ||
===Which patients can be managed for global cardiovascular risk by a menopause physician?=== | ===Which patients can be managed for global cardiovascular risk by a menopause physician?=== | ||
*A | [[File:cardiologist_menopause_physician.svg|thumb|400px|right]] | ||
*A woman with a high-risk profile or overt cardiovascular disease requires intensive management including drug therapy | |||
*Collaboration with a cardiovascular specialist is essential if global cardiovascular risk is high, or if cardiovascular disease is present. | *Collaboration with a cardiovascular specialist is essential if global cardiovascular risk is high, or if cardiovascular disease is present. | ||
==Clinical Presentation== | ==Clinical Presentation== | ||
| Line 111: | Line 112: | ||
Women who are diagnosed with non cardiac chest pain have twofold increased risk to develop a coronary event in the next 5-7 years and have a four times higher risk for re-hospitalization. This implicates that diagnostic testing is limited and that women should be more aggressively treated for their risk factors. | Women who are diagnosed with non cardiac chest pain have twofold increased risk to develop a coronary event in the next 5-7 years and have a four times higher risk for re-hospitalization. This implicates that diagnostic testing is limited and that women should be more aggressively treated for their risk factors. | ||
Chest pain syndromes are more common in women then in men and are less related to the presence of atherosclerosis in the epicardial coronary arteries. | Chest pain syndromes are more common in women then in men and are less related to the presence of atherosclerosis in the epicardial coronary arteries.<cite>8</cite> | ||
There are no gender-specific criteria for the interpretation of ECG’s. Non specific ECG changes at rest, a lower exercise capacity and a smaller vessel size contribute to the lower sensitivity and specificity of non-invasive testing in women. At younger ages, endogenous estrogen level scan induce ECG changes mimicking ischemia. | There are no gender-specific criteria for the interpretation of ECG’s. Non specific ECG changes at rest, a lower exercise capacity and a smaller vessel size contribute to the lower sensitivity and specificity of non-invasive testing in women. At younger ages, endogenous estrogen level scan induce ECG changes mimicking ischemia. | ||
| Line 120: | Line 121: | ||
Symptom management in patients with non-obstructive cardiovascular disease is a challenge. Important to differentiate between vasospastic forms and complaints related to endothelial dysfunction. Table 2 gives an overview of current treatment options. | Symptom management in patients with non-obstructive cardiovascular disease is a challenge. Important to differentiate between vasospastic forms and complaints related to endothelial dysfunction. Table 2 gives an overview of current treatment options. | ||
Lifestyle behaviors can prevent and reduce the risk of getting heart disease and should therefore be primary focus in the GP-practice. Strategies adapt health lifestyle changes are listed below Adapted from Assessment and Management of cardiovascular risk in women ESC/ESH/2007): | Lifestyle behaviors can prevent and reduce the risk of getting heart disease and should therefore be primary focus in the GP-practice. Strategies adapt health lifestyle changes are listed below Adapted from Assessment and Management of cardiovascular risk in women ESC/ESH/2007):<cite>9</cite> | ||
====Smoking: TARGET: permanently stop smoking all forms of tobacco==== | ====Smoking: TARGET: permanently stop smoking all forms of tobacco==== | ||
| Line 175: | Line 176: | ||
*Prevention and reduction of cardiovascular disease as early as possible must be a priority | *Prevention and reduction of cardiovascular disease as early as possible must be a priority | ||
== | ==Case 1:== | ||
{| class="wikitable" cellpadding="0" cellspacing="0" border="1" width=" | {| class="wikitable" cellpadding="0" cellspacing="0" border="1" width="600px" | ||
|- | |- | ||
!colspan="2"| | !colspan="2"|Case 1: 60- year old woman with risk factor (mis)management | ||
|- | |- | ||
|colspan="2"|Patient presented at the emergency room with atypical complaints. She was nauseaus had a burning sensation in the chest. She had consulted her GP several times with atypical chest pain. No further action was taken then. | |colspan="2"|Patient presented at the emergency room with atypical complaints. She was nauseaus had a burning sensation in the chest. She had consulted her GP several times with atypical chest pain. No further action was taken then. | ||
| Line 209: | Line 210: | ||
==Case 2:== | ==Case 2:== | ||
{| class="wikitable" cellpadding="0" cellspacing="0" border="1" width=" | {| class="wikitable" cellpadding="0" cellspacing="0" border="1" width="600px" | ||
|- | |- | ||
!colspan="2"|Case 2: 52-year old woman with microvascular disease | !colspan="2"|Case 2: 52-year old woman with microvascular disease | ||
| Line 242: | Line 243: | ||
==References== | ==References== | ||
<biblio> | <biblio> | ||
#1 | #1 pmid=20019324 | ||
#2 [http://www.bhf.org.uk/publications/view-publication.aspx?ps=1001443 European cardiovascular disease statistics 2008 | #2 [http://www.bhf.org.uk/publications/view-publication.aspx?ps=1001443 Steven Allender, Peter Scarborough, Viv Peto and Mike Rayner. ''European cardiovascular disease statistics 2008''. British Heart Foundation Health Promotion Research Group.] | ||
#3 | #3 pmid=19788058 | ||
#4 pmid=18036449 | #4 pmid=18036449 | ||
#5 pmid=12575968 | #5 pmid=20160161 | ||
#6 pmid=12575968 | |||
#7 pmid=21159671 | |||
#8 pmid=16908490 | |||
#9 Assessment and Management of cardiovascular risk in women ESC/ESH/2007 | |||
</biblio> | </biblio> | ||