1、,Heart Disease In Women 2005 Great Wall Meeting Beijing,Vronique L. Roger, MD, MPH Professor of Medicine Mayo Clinic College of Medicine,Outline,The growing burden of heart disease in women Mortality Prevalence-Incidence Outcome Explanations for disparities Action plan,Cardiovascular Deaths-US,2004
2、Heart and Stroke Statistical Update; CDC/NCHS, AHA,CP1138028-9,Deaths (000s),1979,Years,1982,1986,1990,1994,1998,2001,Females,Coronary Disease Prevalence NHANES III 1988-94, CDC/NCHS and AHA,Incidence rate x 100,000,CP1145262-1,MI Incidence,Annals of Int Med, 2002,CHD Incidence,CP1079700-1,1988 vs 1
3、979,MI 40 years 60 years 80 years MI/SCD 40 years 60 years 80 years Any CHD 40 years 60 years 80 years,1998 vs 1988,Women,Men,Arciero AJM 2004,CP1099138-11,May 2003,Death Within First Month Post-MI,Olmsted County 1979-1998,CP1053938-6,Annals of Int Med, 2002,Overall,Men,Women,75,75,1979-83,1984-88,1
4、989-93,1994-98,Sex and MI Mortality,CP1165215-5,NRMI, Vaccarino: NEJM, 1999,Hospital mortality (%),Overall,30 25 20 15 10 5 0,Burden of heart disease in women,CHD is more prevalent in older women Incidence of all CHD declined among men and younger persons, NOT in women Burden of CHD displaced toward
5、s women, who have worst outcomes,Why?,Why?,Awareness Risk factors “Atypical” symptoms Treatment,2003 AHA Survey,13%,U.S. women think heart disease is their greatest health threat 51% believe it is cancer,CP1021901-2,Misperception = Missed opportunities for prevention,Perceived Leading Cause of Death
6、 in Women,CP1165215-2,AHA Survey, Mosca: Circulation, 2004,%,Breast cancer,Cancer (any),Heart disease,Unsure,White,Cause of Death in Women,AHA Statistical Update, 2004,Deaths (thousands),Heart disease,Cancer,COPD,Influenza,Diabetes,Other,Cerebro- vascular disease,Breast Cancer,CP992570-6,CP1110520-1
7、,CP1110520-2,“If a woman doesnt think she can have heart disease, notes Dr. George Sopko of the NHLBI, shes not going to interpret her symptoms as heart disease even if her symptoms are the same as a mans.“,Why?,Awareness Risk factors “Atypical” symptoms Treatment,Smoking Rates and Risk of MI in Wom
8、en,CP1165215-14,WHO-MONICA 32 populations/21 countries Mahonen: Tobacco Control, 2004,%,35-39,Non-fatal MI Population,RR=5.3 (CI 3.2-8.7) Attributable risk = 55%,40-44,45-49,50-54,55-59,60-64,Age,Increasing obesity BMI30,Flegal et al, JAMA, 2002,CP1043203-17,Diabetes and CV Risk in Women,Nurses Heal
9、th Study: Arch Int Med, 2001,RR of CV death,n=120,000 women age 30-55, 20-yr F-U.,CP1138028-2,“50% of patients with CHD have no identifiable, conventional risk factors.”*,*Smoking, DM, BP, cholesterol,Myth,Reality,Greenland et al, JAMA 2003 -Chic. Heart Assoc, MRFIT, Framingham -Before CHD event, ex
10、posure to 1 RF in 87-100% of cases,Khot et al, JAMA 2003 -14 clinical trials (GUSTO, PURSUIT) Before CHD event, exposure to 1 RF in 80-90% of cases 90% of women 45 years old with MI had 1 risk factor and 80% were current smokers,Stampfer et al, NEJM 2000,Women who actually: Dont smoke Eat a healthy
11、diet Exercise 30 min/day Are not overweight Use alcohol moderately,CP1021901-2,Stampfer et al, NEJM 2000,CV events prevented if ALL women: Did not smoke Ate a healthy diet Exercised 30 min/day BMI 25 Used alcohol moderately,CP1021901-2,Summary,The adoption of Western lifestyle and the growing preval
12、ence of risk factors will lead to similar trends in all countries,Why?,Awareness Risk factors “Atypical” symptoms Treatment,*Women vs men reporting chest pain as a symptom of acute coronary ischemia/infarction,Milner et al: Am J Cardiol, 1999,CP949761-10,Precipitants of Angina,Frequency (%),Rest,Sle
13、ep,Activity,P0.006,Mental stress,Pepine et al: AJC, 1994,CP981765-5,Symptoms of Acute CHD in Patients Without Chest Pain,Milner et al: Am J Cardiol, 1999,%,CP926094-1,Dyspnea Nausea Indigestion Dizziness Fatigue Sweating Arm/ Vomiting Fainting shoulder/pain,Why?,Awareness Risk factors “Atypical” sym
14、ptoms Treatment,CP1021901-10,Women whose doctor discussed heart disease prevention,2003 AHA Survey Mosca, Circulation 2005,*MDs systematically underestimate CVD risk and in women vs. men,CP1141913-3,JAMA , 2001,Sex Disparities in MI Treatment US National data,CP1074357-7,35,835 pts with NSTEMI- 41%
15、women Women - DM, HTN, age, CAD events Early ASA, heparin, GPIIb-IIIa, ACE-I Revascularizations (CABG 41%) Discharge ASA, blocker, ACE-I, statins Death, MI, CHF,Blomkains, JACC 2004 CRUSADE NSTEMI database,MIs (%),83,85,82,84,86,87,88,89,90,91,92,93,94,95,96,97,98,Year,CP1099138-2,Witt, et al; JACC
16、2004; 44: 988-96,Secondary prevention after MI in our practice 1821 persons with MI, participation 55%,Summary of treatment differences,In every circumstance, sex disparities in treatment have been documented Women are less likely to get aggressive treatment than men These disparities identify oppor
17、tunities for improvement,ACTION PLAN,Mosca, Circulation. 2004;109:672 693,CP1170099-24,CVD Prevention Womens Guideline Resources,Framingham CHD risk score ADA (diabetes) JNC VII (HTN) DASH (HTN) NCEP-ATP III (lipids) NHLBI Obesity Management Surgeon Generals Report (tobacco),americanheart.org acc.org,CP1170099-33,We need to:,Address identified evidence gaps Disseminate guidelines broadly Non-CV professional publications Increase public awareness,
