Women's Heart Health: Difference between revisions

Cardiovascular disease (CVD) is the leading cause of death in women worldwide. According to the Global Burden of disease CVD caused almost 32% of deaths in women worldwide vs. 27% in men(AHA: statistical fact sheet june 2010). In Europe 54% of al female deaths are from CVD vs. 43% men (British heart Foundation/heartstats.). After at least two decades of growing awareness regarding sex differences in coronary artery disease, the evolving knowledge of the clinical consequences is emerging. Although recent  reports document decreases in CHD mortality for women, reductions lag behind those realized for men (2 Heron MP, Hoyert DL, Xu J, Scott C, Tejada-Vera B. Deaths: preliminary data for 2006. Natl Vital Stat Rep 2008;56:1–52). Another worrying fact is that we see a mortality increase among younger women (3. Ford ES, Capewell S. Coronary heart disease mortality among Young adults in the U.S. from 1980 through 2002: concealed leveling of mortality rates. J Am Coll Cardiol 2007;50:2128 –32.),

3).

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 wel understood.   

Smoking is the single most important preventable cause of IHD in women. It

is a relatively large risk factor for myocardial infarction in women under the age of 55 when compared to men. Smoking enhances the inflammatory process, activates the coagulation system en promotes LDL oxidation. Smoking leads to down-regulation of the estrogen receptor in the endothelial wall leading to endothelial dysfunction and atherosclerosis.The combination of smoking and the use of oral contraceptives has a synergistic effect by inducing endothelial dysfunction and activation of the coagulation system. After cessation the risk declines rapidly.

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( AMp29/ref16). Low HDL and high triglycerides seems to be more important risk factors in women than in men. Data form the Nurses Health Study shows that HDL was the lipid parameter that best discriminated the risk of ischemic heart disease (VACC ref 24).

Obesity is an important risk factor for diabetes, hypertension and cardiovascular disease. There is a gradient of coronary risk with increasing overweight, with the heaviest category of women having a four-fold increased risk for CVD compared with lean women. Around menopause there is a shift from gynoid fat distribution to android. This central obesity in women leads more than in men to the metabolic syndrome, with an increased relative risk of insulin resistance, dyslipidemia and hypertension.  

Diabetes is associated with a higher risk for ischemic heart disease in women than in men (RR2.0). This is partly due to a higher rate of coexisting risk factors in women with diabetes compared to men. Another important factor is that diabetes is more difficult to treat since less women reach treatment goals when compared to men. In women diabetes is a independent risk factor for developing heart failure. Diabetes during pregnancy has a 7-12 fold risk for developing diabetes later in life.

In an effort to make a more accurate estimation of cardiovascular risk, more than 100 new risk markers have been proposed. There is however a slight resistance to use these markers since the lack of evidence that they really make risk estimation more accurate. A recent summary of systematic reviews conducted for the United states Preventive Services Task force has reviewed the evidence of 9 novel risk factors (Table 1). Of the risk markers evaluated C-reactive protein was the best candidate for screening, however, evidence is still lacking to recommend routine use. The Reynolds Risk score, which is a risk score specifically designed for women, incorporated CRP which reclassified 15 % of the intermediate risk women to high risk.

Data form 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 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.  

Many women appear healthy wit hno symptoms of CVD nevertheless, they are potentially at increased risk

‘body weight

The clinical presentation of cardiac complaints differ between men and women. Female patients as well as their treating physicians often do not recognize or interpret their complaints as heart problems. Women present less typical as what we are used when men present with heart problems. Typical symptoms, as we have learned from our male patients, such as heavy pressure on the chest which radiates to the left arm or the jaws are often absent in women. Women more often present with complaints such as “tightness” , “out of breath” en “tiredness”. When women get older (>60 yrs) and the risk of obstructive coronary artery disease rises, the clinical presentation becomes more typical (substernal pain, with radiation to jaw and/or left arm).  

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.(Eur.H J/2006;27:2285-93).  

Chest pain complaints in women should always be related to their risk factor profile. It should also be noted that in women, very often chest pain is related to not well regulated hypertension. Blood pressure changes increase vascular wall pressure of the coronary arteries which translates in chest discomfort often at rest. In addition hypertension more often leads to diastolic dysfunction in women en hypertrophy which can result in chest pain. A small dose of nitrates can be effective.

*Explain importance of a varied diet and the need to adjust energy intake to achieve And maintain ideal body weight.

====Obesity:TARGET: Body Mass Index < 25 kg.m2 or waist circumference < 88====

*Explain that by consuming 500-1000 calories/day less than required to maintain het current weight, she can lode about 500 grams/week and ultimately achieve weight loss of 5-15%

The initation or continuation of hormone replacement therapy should be decided according to the individual patient. Given the many potentially beneficial effects of estrogens on cardiovascular physiology, much expectation was placed on hormone therapy for CVD prevention. However several studies did not support benificial effects of hormone therapy and in the WHI study (womens health initiative) the study was terminated due to a small increase in CVD.  In a woman < 60 years, who recently menopaused with menopausal symptoms and without CVD, the initiation of replacement therapy does not cause early harm. If a women is at increased risk, HRT therapy is safe to use in the younger women with indications. It should be notes however, that HRT should not be initiated solely for the prevention of cardiovascular disease and should not be regarded as a substitute for antihypertensive treatment.

|colspan="2"|Patient presented at the emergency room with atypical complaints. She was nauseaus had a burning sensation on het chest. She had consulted her GP several times with atypical chest pain. No further action was taken then.

|Several weeks of extreme tiredness, burning chestpains, not related to excercise.

|'''Riskfactors:'''  

|Her father had his First heart atack at age 50. She had hypertension during both pregnancies.Menopausa She menopaused at age 46 with a lot of menopausal complaints such as flushes. She had a smoking history of 10 years.,

|BMI=26, bloodpressure: 180/100 mmHg, pulse: 80 r.a., normal heart sounds, grade II/VI systolic murmur.  

|ECG showed T-wave inversion in the precordial leads. Cardiac enzymes were positive. Cardiac catheterization showed an 80% stenosis of the left main coronary artery. The echocardiogram show wall segment disorders of the anterior wall and a grad II mitral valave insufficiency.

|She received PTCA of the left main en her lipid profile and bloodpressure was treated. She recovered and is doing well.  

*Atypical presenttion of acute coronary syndrome

|colspan="2"|Patient is referred for a second opionion to the cardiologist with complaints of tiredness and chestpain. She was evaluated 3 months earlier with chestpain. Cardiovascualr analysis then showed no cardiac pathology.  

|Patient, who runs every week 10 kilometers, complains that she noticed shortness of breath and tiredness during her weekly run which she describes as abnormal. During running she has no chestpain. She does however experience chestpain, which she describes as “heavy”feeling on the chest, when there is an abrupt change of temperature. Als slight radiation to the left arm.

|'''Riskfactors:'''  

|Menopausal, positive family history, smoking history (she quit 15 years ago ), obstetric history normal, Alcohol consumption: 2U/day

|BMI=26, bloodpressure: 145/90 mmHg, pulse: 70 r.a., normal heart sounds, no murmurs.  

|ECG and exercise stress test were completely normal. Vascular scanning of the carotis arteries showed moderatie plaqueformation in de the carotid bulb.  No chestpain during excercise. Myocardial perfusion scan showed ischemia in the inferior segments of the heart. Cardiac catheterization: vessel wall irregularities in all coronary arteries, no significant obstructions.

|Bloodpressure and lipidprofiles was optimized with ACE inhibition and a statine. She was advised to lose weight and drink less alcohol with regard to her elevated triglycerides. She received a low dose b-blokker and was without complaints within 3 months.

*Risk factors should always be optimized, bloodpressure en lipide profile was inadequate