Myths
Facts
Men are more
likely to have
heart disease
Heart disease is the #1 killer of men and
women; 50,000 more women than men die
of heart disease every year
Cancer is a
bigger threat than
heart disease
Nearly twice as many US women die from
heart disease and stroke than from all
cancers combined
Doctors are aware
of women’s risk for
heart disease and
act accordingly
Undertreatment and underdiagnosis of heart
disease in women contributes to excess
mortality in women
“… The community has viewed women’s
health almost with a ‘bikini’ approach,
looking essentially at the breast and
reproductive system, and almost ignoring
the rest of the woman as part of women’s
health ….”
Nanette Wenger, MD
Chief of Cardiology, Grady Hospital
Professor of Medicine, Emory University
Atlanta, Georgia

2.5 million women per year in the US are
hospitalized with cardiovascular
disease (CVD)

Deaths from CVD = 500,000/yr

Leading cause of death in US women:
CAD

1990: US Congress directed the National
Institutes of Health that women be
included in clinical trials and that gender
differences be evaluated

1 in 5 women has some form of CVD

38% of women who have a heart attack
die within 1 year

40% of coronary events in women are
fatal
› Most occur without prior warning
Deaths in Thousands
American Heart Association. 2002 Heart and Stroke Statistical Update. 2001
Typical in both sexes







Pain, pressure, squeezing,
or stabbing pain in the
chest
Pain radiating to neck,
shoulder, back, arm, or jaw
Pounding heart, change in
rhythm
Difficulty breathing
Heartburn, nausea,
vomiting, abdominal pain
Cold sweats or clammy skin
Dizziness
Typical in women



Milder symptoms (without
chest pain)
Sudden onset of weakness,
shortness of breath, fatigue,
body aches, or overall
feeling of illness (without
chest pain)
Unusual feeling or mild
discomfort in the back,
chest, arm, neck, or jaw
(without chest pain)
Percent of Population
90
80
70
60
50
40
30
20
10
0
79.00
70.7
Males
Females
65.2
65.20
51.0
48.10
34.2
28.90
10.4
5.5 4.60
4.20
20-24
25-34
17.4
13.60
35-44
45-54
Ages
55-64
65-74
75+
American Heart Association. 2002 Heart and Stroke Statistical Update. 2001
More than35,000
women under the
age of 65 die
annually in the US
from CVD
72% of young women (ages 25-40) still consider
cancer to be the greatest threat to women’s
health
 Some women know about the risks of heart disease
but do not hear it from their own doctors and do
not “personalize” it

Robinson A. Circulation. 2001
 65%
of women recognize that
symptoms may be “atypical” but do
not know classic symptoms
 Most women learn about coronary
artery disease (CAD) from magazines
and the Web—not from their own
physicians!
1
Perceived health threats
Leading causes of death in women
55%
2
46%
40%
24%
22%
ci
de
n
ts
3%
Ac
eu
m
on
i
PD
Pn
C
O
ce
r
C
an
C
AD
ta
ck
rt
H
ea
di
rt
at
se
as
e
r
H
ea
Br
ea
st
ca
nc
e
ce
r
C
an
4%
a
4%
2%
1. Gallup survey. 1995
2. American Heart Association. Heart & Stroke Facts. 1996 Statistical Supplement
US Vital Statistics, 1990
Traditional Paradigm:
Menopaus
e
Minimal or no CVD Risk Increasing Risk of CVD
Alternative Paradigm:
Increasing Risk of CVD
Menopaus
e
Decades of time
The reality: Being premenopausal probably
High Blood Pressure,
does not protect youSmoking,
from cardiovascular
Age, Heredity
Cholesterol,
disease
and you should Diabetes,
beElevated
vigilant
at all ages …
Inactivity, Obesity




Critical to
reproductive
function in men &
women
Most produced by
ovaries
Some arises from fat,
liver, breasts,
adrenals
Complex physiologic
effects

Secondary prevention
› 1998: HERS
 4 years of treatment with conjugated estrogen
plus medroxyprogesterone acetate
 No reduction in the risk of MI and coronary
death in women with established CAD
HERS trial. JAMA. 1998.

Secondary prevention
› 3/2000: Estrogen Replacement and Atherosclerosis trial
(ERA)
 309 postmenopausal women with CAD
 Placebo vs conjugated estrogen (.625 mg/day) vs conjugated
estrogen (.625 mg/day) with medroxyprogesterone acetate
(2.5 mg/day)
 Angiographic analysis of the diameter of the coronary arteries
at the start of the study and 3 years later

ERA trial results at follow-up angiography
› The progression of coronary atherosclerosis was
unchanged in the women randomized to either of the
estrogen groups
ERA trial. J Am Coll Cardiol.
2001
16,608 Postmenopausal
women aged 5079 with an intact
uterus
Estrogen +
Progesterone
Placebo
Hormonal replacement associated with:
•Increased heart disease (29% ↑)
•Increased stroke (41% ↑)
•Increased blood clots
•Increased breast cancer (26% ↑)
•Reduced colon cancer
•Reduced hip fracture
Study stopped
after mean followup of 5.6 years
RCOG UPDATE (11 June 2013): The British Menopause
Society (BMS) and Women’s Health Concern recently
published a literature review
In summary, their key recommendations are:
 The decision whether to use HRT should be made by
each woman having been given sufficient
information by her healthcare professional, including
information about complementary therapies and
lifestyle and dietary changes.
 HRT dosage, regimen and duration should be
individualised, with an annual evaluation of the pros
and cons


Arbitrary limits should not be placed on
the duration of usage of HRT; if symptoms
persist, the benefits of hormone therapy
usually outweigh the risks.

HRT prescribed before the age of 60 has
a favourable benefit/risk profile.

It is imperative that women with
Premature Ovarian Insufficiency (POI)
are encouraged to use HRT at least until
the average age of the menopause.

If HRT is to be used in women over 60
years of age, lower doses should be
started, preferably with a transdermal
route of administration.
60
50
40
Mortality
Rate per
1,000
30
Women with
Diabetes
20
Women without
Diabetes
10
0
0-3
4-7
8 - 11 12 - 15 16 - 19 20 - 23
Duration of Follow-up (yrs)
Sources: Krolewski 1991, National Cholesterol Education Program (NCEP) Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002.
33

65% of diabetics die from heart disease or stroke

4.2 million American women have diabetes
› Diabetes increases CAD risk 3-fold to 7-fold in women vs 2-
fold to 3-fold in men
› Diabetes doubles the risk of second heart attack in
women but not in men
American Heart Association
Centers for Disease Control and Prevention
Manson JE, et al. Prevention of Myocardial Infarction. 1996

Framingham Heart Study
› Women with diabetes mellitus had relative
risk of 5.4% for CAD vs women without
diabetes
› Men with diabetes had relative risk of 2.4%

Nurses’ Health Study
› Relative risk of 6.3% for total cardiovascular
(CV) mortality
› Even if women had diabetes for <4 years,
their risk of CAD was significantly elevated
Kannel W. Am Heart J. 1987
Manson J, et al. Arch Intern Med. 1991

Abdominal obesity
› Men
› Women


Triglycerides
HDL cholesterol
› Women
› Men


Blood pressure
Fasting glucose
>88 cm (>40 in)
>80 cm (>35 in)
(TG)
>150 mg/dL
<50 mg/dL
<40 mg/dL
>130/>85 mm Hg
>100 mg/dL
National Heart, Lung, and Blood Institute
Framingham Heart Study
Relative Risk (x-fold)
2.5
2.2
Women
Men
2
1.85
1.8
1.45
1.4
1.5
1.2
1
1
0.55
0.65
2.15
1.3
1.25
1.25
300
350
400
1
0.8
0.75
100
150
0.5
0
50
200
250
Castelli WP. Can J Cardiol. 1988
Single most preventable cause of death
in US
 Smoking by women causes 150% more
deaths from heart disease than lung
cancer
 Women who smoke are 2-6 times more
likely to suffer a heart attack


Nurses’ Health Study: Even a few
cigarettes a day correlated with a
greater risk of CVD or fatal MI

About one-quarter of all women smoke;
prevalence greatest among
postmenopausal women
39

Younger women who smoke probably
cancel out any premenopausal
protection

Women who take oral contraceptives
and smoke are more likely to have an MI
or stroke than those who take the pill but
don’t smoke

Puts a woman at greater risk for CVD
and poorer outcomes

Depression also may increase risk or
defer her from seeking medical help

Consider screening women with CAD for
depression and refer for treatment as
needed
41

Lack of exercise is a proven risk factor for heart
disease
› A lack of regular physical exercise is a growing
epidemic all over the world. “We seem to eat
much more than what we burn”

Heart disease is twice as likely to develop in
inactive people than in those who are more active
 Physical
activity helps maintain
weight, blood pressure, and diabetes
 Women
should exercise to increase
heart rate for 20-30 minutes a day, 3-5
times per week

Women are underrepresented in
cardiovascular (CV) trials
› Evidence-based CV medicine biased
toward men
Food and Drug Administration/National
Institutes of Health mandate: 50%
enrollment of women
 Women need to be empowered to
enroll in clinical trials for heart disease

› Breast-cancer awareness is a good example

Coronary MVD is heart disease that
affects the heart's tiny arteries. This
disease is also called cardiac syndrome
X or nonobstructive CHD. In coronary
MVD, the walls of the heart's tiny arteries
are damaged or diseased.

Women are more likely than men to
have coronary MVD. Many researchers
think that a drop in estrogen levels during
menopause combined with other heart
disease risk factors causes coronary
MVD.

Although death rates from heart disease
have dropped in the last 30 years, they
haven't dropped as much in women as
in men. This may be the result of
coronary MVD.
Stress
Rest





Thrombolysis – equally effective – Cerebral
hemorrhage risk is more
Low rates of coronary angiography in
women
Under referral for revascularization
procedures
CABG - > operative mortality 1.9 % v/s 4.6%
Restenosis after PTCA, or CABG occlusion
rates are more for women - ? Smaller lumen
sizes
Women have higher hospital readmission
rates for unstable angina, reinfarction,
heart failure, ventricular tachycardia,
and ventricular fibrillation.
 Main goals: Reduce risk and restore
functional capacity

51
parameter
Changes at various times (weeks)
5
12
20
24
32
38
HR
↑
↑↑↑
↑↑↑
↑↑↑
↑↑↑↑
↑↑↑↑
SBP
↔
↓
↓
↔
↑
↑↑
DBP
↔
↓
↓↓
↓
↔
↑↑
↑↑↑↑↑
↑↑↑↑↑↑
↑↑↑↑↑↑
↑↑↑↑↑
SV
↑
↑↑↑↑↑
CO
↑↑
↑↑↑↑↑↑
↑↑↑↑↑↑↑
↑↑↑↑↑↑↑
↑↑↑↑↑↑↑
↑↑↑↑↑↑↑
SVR
↓↓
↓↓↓↓↓
↓↓↓↓↓↓
↓↓↓↓↓↓
↓↓↓↓↓↓
↓↓↓↓↓
LV EF
↑
↑↑
↑↑
↑↑
↑
↑
↑ ≤ 5%; ↑↑ 6-10%; ↑↑↑ 11-15%; ↑↑↑↑ 16-20%; ↑↑↑↑↑ 21-30%; ↑↑↑↑↑↑ > 30%, ↑↑↑↑↑↑↑ > 40%.

Plasma volume ↑ 50% (20100%).
“Physiologic anemia of
pregnancy”.
 Estrogen-mediated
stimulation of the RAS.
 Role of other hormones

›
deoxycorticosterone,
prostaglandins, estrogen,
prolactin, placental lactogen,
GH, ACTH, ANP
From Pitkin RM, Nutritional support in obstetrics and gynecology. Clin Obstet Gynecol 1976;19:489
CVD
Mortality
per
100,000
Women
HTN – Hypertension
GDM – Gestational Diabetes
PCOS – Polycystic Ovary Syndrome
Source: Adapted from “CVD Prevention and the Primary Care Partnership”, Deborah Ehrenthal, MD, FACP
55
Anxiety, pain, uterine contraction.
 Oxygen consumption ↑ threefold.
 ↑ CO during labor (↑ SV and ↑ HR).
 ↑ SBP & DBP (especially 2nd stage)


Those changes are influenced by the
form of anesthesia and analgesia.
Increase in venous return
(relief of caval compression)
Blood shifting “auto-transfusion”
(from the contracting uterus to the
systemic circulation)
Increase in effective blood volume
Blood loss
during
delivery
Substantial increase in LV filling pressure, SV and CO
Clinical deterioration
• HR and CO return to pre-labor values within 1 hour. MAP and SV within 24 hours.
• Hemodynamic adaptation persists post partum and return to pre-pregnancy
values
within 12-24 weeks after delivery.
Before conception
History
Exercise capacity
Current or past evidence of HF
Associated arrhythmias
Physical exam
Cardiac Hemodynamics
Severity of heart disease, PA pressures
Echo, MRI.
Exercise testing
Useful if the history is inadequate to allow assessment of functional capacity
During pregnancy
Evaluate once each trimester and whenever there is change in symptoms
Multidisciplinary approach, Fetal Echo
During Labor & Delivery
Multidisciplinary approach (Obstetrician, Cardiologist, Anesthesiologist)
Tailor management to specific needs
Reimold, S. C. et al. N Engl J Med 2003;349:52-59
Pulmonary HTN and Eisenmenger’s
syndrome.
 Symptomatic obstructive cardiac lesions:

› AS, PS, uncorrected coarctation of the
aorta.
Marfan’s Syndrome with dilated aortic
root.
 Systemic ventricular dysfunction (LVEF <
40%).
 Severe cyanotic heart disease.
 Patients with prosthetic valves.
 Significant uncorrected CHD.

Lesion
Maternal
death rate (%)
• Severe Pulmonary Hypertension
50
• Severe obstructive lesions:
AS,PS, HOCM, Coarctation.
17
• Systemic Ventricular Dysfunction,
NYHA class III or IV
7

The prevalence of clinically
significant maternal heart
disease is low (<1%)1.

Its presence increases the risk
of adverse maternal, fetal,
and neonatal outcomes2.
1.
2.
Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in
women with heart disease. Circulation 2001;104:515-521.
Siu SC, Colman JM, Sorensen S, et al. Adverse neonatal and cardiac outcomes are more common
in pregnant women with cardiac disease. Circulation 2002;105:2179-2184.

Preeclampsia (pre-e-KLAMP-se-ah) is a
condition that develops during
pregnancy. The two main signs of
preeclampsia are a rise in blood pressure
and excess protein in the urine.

These signs usually occur during the
second half of pregnancy and go away
after delivery. However, your risk of
developing high blood pressure later in
life increases after having preeclampsia.

Preeclampsia also is linked to an
increased lifetime risk of heart disease,
including CHD, heart attack, and heart
failure. (Likewise, having heart disease
risk factors, such as diabetes or obesity,
increases your risk for preeclampsia.)

If you had preeclampsia during
pregnancy, you're twice as likely to
develop heart disease as women who
haven't had the condition. You're also
more likely to develop heart disease
earlier in life.

Severe AS is poorly tolerated.
› AVA < 0.7 cm2, Mean PG > 50 mmHg.
› Mortality up to 17%.

Symptomatic patients or Mean gradient >
50 mmHg
 → Delay conception until after surgical
or interventional correction.
 Consider balloon valvuloplasty, Ross
procedure, tissue valve (no need for
anticoagulation).

Symptomatic patients before end of 1st
trimester
 Terminate pregnancy.
 Β-Blockade, Bed rest.
 Palliative aortic balloon valvuloplasty or
AVR.
 Early Delivery.
Reimold, S. C. et al. N Engl J Med 2003;349:52-59
Hameed A, et al. The effects of valvular
heart disease on maternal and fetal
outcome of pregnancy. J Am Coll Cardiol
2001;37:893-9.
Warfarin
Heparin
Crosses the placenta.
↑early abortion,
prematurity, and
embryopathy when used in
1st trimester (6th–12th weeks).
 CNS & Eye abnormalities
(2nd & 3rd trimester).
 Bleeding in the fetus
(especially at delivery)
› Should be stopped
before delivery.





Does not cross the
placenta
No teratogenicity
No fetal bleeding


Twice daily SC injection
Risk of osteoporosis
›
›


<2% symptomatic fractures.
but 30% decrease in bone
density.
Risk for thrombocytopenia
↑↑ Risk of thrombosis

Antibiotic prophylaxis at the time of delivery is not
recommended for patients expected to have
uncomplicated vaginal delivery or cesarian
section, unless clinically overt infection is present 1,2

Patients at high risk for endocarditis may receive
antibiotics at the discretion of their physician2:
› Those with prosthetic heart valves.
› Previous IE.
1 Sugrue D, Troy P, McDonald D. Antibiotic prophylaxis against infective endocarditis after normal delivery -- is it necessary? Br Heart J 1980;44:499-502.
2 Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA

Most women with heart disease can
have a pregnancy proper care.

Pre-pregnancy evaluation mandatory.

High-risk cases benefit from combined
high-risk OB and cardiac care in the
same center.