MDNews - Greater Kansas

ON FEB. 6 — Go Red Day — we drew attention to heart disease, the leading cause of death for women. About one in three women dies from heart disease. 1 Tragically, the rates of death from coronary artery disease (CAD) continue to increase in women younger than 55. However, awareness of the importance of heart disease in women is improving. According to a 2012 American Heart Association national survey, 56 percent of women were aware that heart disease is the leading cause of death for women, compared with only 30 percent in 1997. 2 Women often suffer worse consequences from heart disease compared with men. Among individuals with a history of a heart attack at younger than age 50, women's mortality rate is twice that of men. 3 Women also experience higher rates of angina and recurrent hospitalizations. 4 Additional dis- parity exists between the number of women and men who experience sudden cardiac death before reaching a hospital, with 52 percent of women and 42 percent of men dying before arrival. Paradoxically, women have less anatomi- cal obstructive CAD despite their higher rates of angina. 5 Moreover, "symptomatic women undergoing coronary angiography have less extensive, less severe CAD, despite being older with a greater risk factor burden, compared to men," and "despite relatively less CAD, women have a more adverse prognosis compared to men." 6 The term "female-specific ischemic heart disease" is a more appropriate description than CAD and includes heart disease secondary to microvascular dysfunction, plaque erosion and abnormal coronary reactivity, which are often seen in women. Among women with chest pain, normal angiograms and endothelial dysfunction, a 10-year follow-up found 30 percent developed Awareness of Heart Disease in Women obstructive CAD, emphasizing the fact that a prognosis of nonobstructive CAD cannot be viewed as benign. According to the Dallas Heart Study, "angina was not related to atherosclerosis measured by coro- nary calcium score but was related to risk factors [such as] obesity, insulin resistance [and] serum inflammatory markers … ." In this study, 29 percent of women had angina in the absence of atherosclerosis. In treating women with chest pain and nonobstructive disease, therapies should be directed at improving endothelial function, including use of statins, beta blockers and angiotensin-converting enzyme inhibitors. Exercise improves symptoms, 7 and Ranolazine has shown improvement in anginal symptoms in women with ischemia and nonobstructive CAD. 8 The Reynolds Risk Score, which includes high-sensitivity C-reactive protein and fam- ily history, better risk-stratifies women than the Framingham Risk Score, which under- estimates cardiovascular risk in women. 9 Assessment of a CT calcium score also improves risk prediction in women, with the presence of any coronary calcium being asso- ciated with a six-fold greater risk of CAD. 10 The 2011 Effectiveness-Based Guidelines for the Prevention of Coronary Artery Disease in Women classifies women into three categories based on risk factors — high risk, at risk and optimal risk. In addition to traditional risk factors, factors such as poor diet, elevated calcium score, autoimmune diseases like systemic lupus erythematosus or rheumatoid arthritis, preeclampsia, and gestational diabetes automatically classify women into the at-risk category. 11 Various factors contribute to women's higher mortality from acute coronary syndrome: Women are often less likely to receive aspirin, heparin and beta blockers and to undergo timely coronary intervention. They experience higher rates of bleeding after procedures. Women are also less likely to seek rapid and appropriate care when symptoms start and present to the emergency room an average of an hour later than men. 12 Further research should be conducted to determine diagnostic and therapeutic approaches that will enhance outcomes for women. Shilpa K shat r iya, MD, pract ices at Heartland Cardiology. For more information or to reach her, please call 316-686-5300 or visit heartlandcardiology.com. References 1. Centers for Disease Control and Prevention, 1999 2. Mosca L et al. Fifteen-year trends in awareness of heart disease in women: results of a 2012 American Heart Association national survey. CIRC 2013;127:1254–1263. 3. Vaccarino V et al. Sex-based differences in early mortality after myocardial infarction. NRMI-2. N Engl J Med 1999; 341:217–25. 4. Hemingway H et al. Prevalence of angina in women versus men: a systematic review and meta-analysis of international variations across 31 countries. CIRC 2008; 117:1526–36. 5. Merz CB et al. Ischemic heart disease in women: insights from the NHLBI-sponsored Women's Ischemic Syndrome Evaluation (WISE) study. Part II. JACC 2006;47 Suppl:21–9. 6. Lichtlen PR et al. Long-term prognosis of patients with angina-like chest pain and normal coronary angio- graphic findings. JACC 1995;25:1013– 8). 7. Eriksson BE et al. Physical training in Syndrome X: physical training counteracts deconditioning and pain in Syndrome X. JACC 2000;36:1619–25. 8. Mehta PK et al. Ranolazine improves angina in women with evidence of myocardial ischemia but no obstructive coronary artery disease. JACC Img 2011;4:514–22). 9. Wenger NK. The Reynolds Risk Score: improved accuracy for cardiovascular risk prediction in women? Nat Clin Pract Cardiovasc Med 2007;4:366–7. 10. Lakoski SG et al. Coronary artery calcium scores and risk for cardiovascular events in women classified as "low risk" based on Framingham risk score: the MESA. Arch Intern Med 2007; 167:2437– 42). 11. Mosca et al. Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women. CIRC 2011 March 22; 123(11): 1243–1262. 12. Blomkalns AL et al. Gender disparities in the diagnosis and treatment of non ST-segment elevation acute coronary syndromes: large-scale observations from the CRUSADE National Quality Improvement Initiative. JACC 2005;45:832–7). By Shilpa Kshatriya, MD By Shilpa Kshatriya, MD SPECI A L FE AT UR E Greater Kansas | 1 1 M D N E W S . 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