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Women's Heart Health: Difference between revisions
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===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). | ||
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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=== | ||
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===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. | ||
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===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== | ||
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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.<cite> | 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. | ||
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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):<cite> | 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==== | ||
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==Case 1:== | ==Case 1:== | ||
{| class="wikitable" cellpadding="0" cellspacing="0" border="1" width=" | {| class="wikitable" cellpadding="0" cellspacing="0" border="1" width="600px" | ||
|- | |- | ||
!colspan="2"|Case 1: 60- year old woman with risk factor (mis)management | !colspan="2"|Case 1: 60- year old woman with risk factor (mis)management | ||
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==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 | ||
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#6 pmid=12575968 | #6 pmid=12575968 | ||
#7 pmid=21159671 | #7 pmid=21159671 | ||
#8 pmid=16908490 | |||
#9 Assessment and Management of cardiovascular risk in women ESC/ESH/2007 | |||
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</biblio> | </biblio> | ||