Heart Disease in Women
10 Things
Every Woman Should Know About
Heart Disease
Susan P. D’Anna ARNP
Clinical Instructor in Medicine
Section of Cardiology - DHMC
#1 Cardiovascular Disease Is the Number 1
Cause of Death in American Women
Myth:
♥ Heart disease is a man’s
disease
Fact:
 Each year heart disease kills
more women than men
 38% of women die within one
year of suffering a heart attack
(compared to 25% of men)
CDC National Vital Statistics Report, Vol.49, No., 11 2001
Adapted from the American Heart Association website, 2002
Heart Disease Affects Women in Every
Age Group
Estimated Prevalence of CVD by Age and Gender
U.S.: 1988 - 1994
AHA 2003 Heart and Stroke Statistical Update; 2002:8.
Women Do Not Perceive Heart Disease
as Their Major Health Threat
Female Perception of Their Greatest Health Risk
Women still
fear cancer
most
1997
2000
2003
61%
7%
62%
8%
51%
13%
Cancer (net)
Heart Disease
Awareness of Leading Cause of Death for Women
But,
awareness is
improving
1997
2000
2003
50%
30%
40%
34%
35%
46%
Cancer (net)
Heart Disease
Source: Tracking Women’s Awareness of Heart Disease – AHA National Study; Circulation 2004;109:573-579.
All CVD 40.9%
All Cancers 21.8%
Lung Cancer 5.3%
Chronic lower respiratory diseases 5.1%
Breast Cancer 3.4%
Diabetes 3.1%
Influenza and pneumonia
Alzheimers 2.9%
Accidents 2.8%
Colon Cancer 2.4%
Nephritis 1.6%
Septicema 1.4%
Chronic liver disease and cirrhosis 0.8%
Pneumonitis due to solids and liquid 0.7%
Parkinson's .06%
Intentional Self harm 0.5%
Assault 0.3%
Cancer 22%
HIV 0.3%
Source: National Vital Statistics Report, Vol. 50, No. 15, September 16, 2002
#2 Risk Factors Help Predict Who Is at Risk to
Develop Coronary Artery Disease
 Age: As women grow older, the chance
of developing heart disease increases
(especially after the onset of
menopause) – The risk of CAD
increases 2 to 3 times after
menopause
 Race: African-American women have a
higher risk of death from heart disease
than white women
women.americanheart.org
 Cholesterol:
Low blood levels of “good”
cholesterol (HDL) and high
triglycerides are stronger
predictors of heart disease
death in women than in men
 Blood Pressure: More than half of all women
over 55 have high blood
pressure, which increases their
risk of heart disease, stroke and
other serious conditions
 Diabetes:
Increases the risk of heart
disease 3-7 fold
A more powerful risk for heart
disease in women than in men
Jneid and Thacker, Cleveland Clinic J of Med. 2001: 441-448
women.americanheart.org
Why Women Don’t Take Action Against Heart
Disease
 They don’t put their health as a top priority
 They think they’re not old enough to be at risk
 They feel too busy to make changes in their
lives
 They’re already feeling stressed
 They don’t have the familial and social
support
#3 Women’s Experience of Heart Disease
Is Different Than Men’s
 Women are more likely to die within one
year after a heart attack
 Women are less likely to survive
coronary artery bypass surgery
 Women are more likely to experience
complications after angioplasty
 Women are more likely to have life
threatening arrhythmias (irregular heart
beats)
These differences may be partially due to
hormones, a woman’s smaller heart size and
advanced age at diagnosis
Wenger, N.K., J. Am. Med. Women’s Assoc. 1994:49:181 Wenger, N.K., Int. J. Fertile
Women’s Med. 1998; 43:84
Traditional Heart Attack Warning
Signs
 Pressure, burning, squeezing in the
center of the chest
 Discomfort in one or both arms,
shoulders, neck, jaw, stomach, or back
 Shortness of breath
 Fatigue, cold sweat, nausea, weakness
Adapted from the Harvard Medical School website – www.harvard.health.edu
Symptoms of Coronary Heart
Disease Can Differ in Women
 Pain in upper back, jaw or neck
 Shortness of breath
 Flu-like symptoms: nausea or vomiting,
cold sweats
 Fatigue or weakness
 Feelings of anxiety, loss of appetite,
discomfort
Women’s signs are non-specific and
more easily overlooked.
Adapted from the Harvard Medical School website – www.harvard.health.edu
Severity of Heart Disease: Men and Women
Deaths within one year of 1st MI
Sudden deaths with no previous
symptoms
Within six years of recognized
MI, percent who will:




have another MI
have a stroke
experience SCD
be disabled with heart failure
AHA 2003 Heart and Stroke Statistical update; 2002:12, 14, 17
Men
Women
25%
38%
50%
63%
18%
8%
7%
22%
35%
11%
6%
46%
61 million Americans with CVD
48% are men
Yet, more
men are
being
treated than
women
PTCI
2
CABG
PTA
Brady
Tachy
1
52% are women
65%
35%
3
65%
35%
3
65%
35%
4
4
Heart Failure
1. The AHA 2001 Heart and Stroke Statistical Update
2. CABG: Ann Thorac Surg 2001 Feb; 71(2):512-20
53%
47%
77%
80%
23%
20%
3. PTCI: J Am Coll Card 2002 Apr 3; 39(7):1096-103
4. Estimated from internal Guidant records
1
Men
Women
Heart Disease
Gender Bias or Sex Difference?
 Data used for the care of women
derived from studies conducted in
middle-aged men
 Initial efforts for prevention focused
more on men than women
 Women and doctors often attribute
chest pain in women to noncardiac
causes
Exploring the Biological Contributions to Human Health-Does Sex
Matter: Institute of Medicine 2001
Heart Disease
Gender Bias or Sex Difference?
 Women tend to have heart attacks later in life
than men
 Women present more often than men with
atypical symptoms
 Some diagnostic tests and procedures may
not be as accurate in women
 Heart disease may be different in women and
men
Exploring the Biological Contributions to Human Health-Does Sex
Matter: Institute of Medicine 2001
#4 Heart Attacks Are Caused by Coronary Artery
Disease (CAD)
Obstructed
coronary
artery
Diffuse
narrowing in
coronary
artery
#5 Know Which Tests are More Effective in Women
Other
Names
Test
Fasting Lipid Profile
Electrocardiogram
Description
Measures total, “good” (HDL) and “bad” (LDL),
levels of cholesterol
ECG or EKG
Stress Test
Measures electrical impulses of heart
Tests function of heart during strenuous
physical exercise
Echocardiogram
Echo
Uses ultrasound waves to evaluate heart
structure and function
Nuclear Imaging
Thallium,
Sestamibi,
MUGA scan
Uses radioactive isotope injected into blood
stream to evaluate heart function
Cardiac
Catheterization
Angiogram
“cath”
Used to diagnose coronary artery
disease(CAD). An invasive procedure in which
tubes are inserted through blood vessels, dye is
injected and x-rays of the heart are taken
Shaw et al. Card. In Review, 2000: 65-74
#6 Estrogen and Menopause May Be
Related to Heart Disease
 Estrogen increases production of “good” cholesterol
(HDL)
 As estrogen decreases, women experience lower
levels of “good” cholesterol (HDL) and the flexibility
in arteries decreases.
 Women will live one third of their lives after
menopause
 Hormone Replacement Therapy (HRT) should not
be used for the purpose of reducing the risk of
cardiovascular disease in women
Jneid and Thacker, Cleveland Clinic J of Med. 2001: 441-448
Increased Risk
Decreased Risk
No Effect
Estrogen plus progestin - July 2002






Heart attack
Breast cancer
Blood clots
Strokes
Dementia
Ovarian Cancer
29%
26%
2X
41%



Hip fractures
34%
Colorectal cancer 37%
Cancer of uterine lining


Quality of life
Number of deaths


Breast cancer
Heart disease
Estrogen alone – March 2004



Strokes
Probable dementia or
memory loss*
Source: JAMA 2002; 288:321-333
Hip fractures
WHI Had Unexpected Results
National Institutes of Health
* mdash study shows a trend toward increase in risk
CONCLUSIONS of WHI
After a 5.2 year follow up:
 Health risks exceeded benefits of
combined estrogen plus progestin
 All-cause mortality was not affected
 This regimen should not be initiated
or continued for primary prevention of
CHD.
JAMA 2002; 288:321-333
#7 More Research on Women and Heart
Disease Is Needed
 Historically, women have been under-represented in
clinical trials related to heart disease
 There is little knowledge regarding the effects of
commonly used cardiovascular drugs in women
 Practice patterns are based on research in middleaged men that may not apply to older women
 There is limited information regarding therapies used
to treat heart disease in the very elderly
Evelyn et al. “ Women's Participation in Clinical Trials and Gender-Related Labeling” FDA special report
http://www.fda.gov/cder/reports/womens_health/women_clin_trials.htm
Enrollment of Women in CVD Trials
 1993 – NIH mandated inclusion of women in
federally funded clinical research
 Enrollment increasing for women, but with singlesex trials excluded, enrollment rate was 38%,
unchanged over time
 No change in gender composition of cohorts in
majority of studies
 Federal efforts have been only moderately
successful, mainly due to small number of large
single-sex trials
 Even when women are included in trials, rarely
are the results broken-out
NEJM 2000;343-475
Representation of Women in Studies of
CAD Testing
% of Patients
91
ECG
79
ECHO
MPI
9
21
72
28
Men
Women
Adapted from Shaw LJ et al. Coronary Artery Disease In Women: What All Physicians Need to Know. 1999;372.
#8 There Are a Variety of Options
Available to Treat Heart Disease
 Medications – including Aspirin
 Balloon angioplasty and stenting
 Heart bypass surgery
 Pacemakers for slow heart rhythms and
defibrillators for rapid heart rhythms
#9 Women Can Take Action to Lower the
Risk of Heart Disease
1. Know your risk factors
2. Stop smoking
3. Maintain a healthy body weight
4. Eat a nutritious balanced diet low in saturated fats
5. Monitor and manage blood pressure and diabetes
6. Exercise regularly
7. Limit alcohol intake
8. Learn stress management skills
9. Maintain social relationships
10. Know the warning signs for heart attack and stroke
#10 Women Can Save Lives
 If you or someone you know has risk factors
for heart disease, adopt a heart healthy
lifestyle and discuss a plan of care with your
physician
 If you experience symptoms of heart attack or
stroke, call 911 immediately
 LEARN CPR
Why Focus on Women’s
Cardiovascular Health?
Adapted from American Heart Association
and the Nurse’s Health Study
 Cardiovascular disease is
the largest killer of
American women and CVD
mortality in women is
rising at a disproportionate
rate compared to men
 The majority of American
women are
unknowledgeable about
their personal risk for CV
disease
 Changing a woman’s CV
risk from higher risk to
lower risk with present
medical knowledge and
tools reduces her chance of
coronary events
 Women are often decision
makers for the family
The following organizations can provide information on heart disease:
* American Heart Association
800-242-8721
http://www.americanheart.org
AHA's mission is to reduce disability and death from cardiovascular diseases and cardiovascular diseases and stroke. Several
consumer publications are available through AHA, including the AHA Guide to Heart Attack Treatment, Recovery and
Prevention.
* Health and Human Services
Office of Women's Health
1-800-994-WOMAN (96626)
http://www.4women.gov
OWH investigates a broad spectrum of women's health activities across governmental offices and agencies. It also sponsors
the National Information Center, which links the general public to a wide variety of health-care resources and
publications, including those related to heart disease.
* National Heart, Lung, and Blood Institute
301-592-8573
http://www.4women.gov, www.hearttruth.gov
The NHLBI publishes the Healthy Heart Handbook for Women
(http://www.nhlbi.nih.gov/health/public/heart/other/hhw/index.htm), which features the latest information on
preventing cardiovascular diseases. The publication also helps women develop a personal action plan for reducing the
major risk factors. In addition, The Heart Truth website contains helpful information.
* American Medical Women's Association
http://www.amwa-doc.org/
Mayo Clinic Health Oasis
http://www.mayohealth.org/
You Can Make a Difference
Be a leader in your
community for women’s
cardiovascular disease
through . . .
Research
Advocacy
Awareness