CARDIOVASCULAR HEALTH IN WOMEN
From University of Miami Miller School of Medicine’s Advances in Medicine 2008
Maureen H. Lowery, MD, Professor of Medicine, and Medical Director, Cardiovascular Non-Invasive Diagnostic
Laboratory, University of Miami Miller School of Medicine, Miami, FL
Educational Objectives
| The goal of this program is to provide evidence-based methods for improving cardiovascular health in women.
After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Recognize risk factors for coronary artery disease (CAD) in women.
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| 2. Identify unusual presentations of angina in women with CAD.
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| 3. Describe the treatment of women with CAD.
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| 4. Implement prevention guidelines for CAD in women.
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| 5. Attain management goals for women with established CAD.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning
committee reported nothing to disclose.
Acknowledgements
Dr. Lowery was recorded at Advances in Medicine, sponsored by the University of Miami Miller School of Medicine,
January 14-18, 2008, in Miami, FL. The Audio-Digest Foundation thanks Dr. Lowery and the University of Miami
Miller School of Medicine for their cooperation in the production of this program.
| Introduction: cardiovascular disease (CVD) major cause of death in men and women in United States; number one
cause of these deaths coronary artery disease (CAD); CVD kills more women annually than any cancer and all cancers
combined; decrease in mortality from CVD seen in men over last 2 decades not seen in women; 2001 Institute
of Medicine report found CAD differences between sexes
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| Challenges in women: delay in symptom recognition and treatment; misdiagnosis; lower use of—angiography, revascularization,
aspirin, β-blockers, angiotensin-converting enzyme (ACE) inhibitors, and statins; less
counseling—on risk-factor control; fewer referrals—to cardiac rehabilitation and higher dropout rate; lower
adherence—to proven guidelines
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Historical Perceptions
| Misperceptions: ideas on angina in women shaped by Framingham study, only trial that assessed long-term outcome
of angina without intervention; led to belief that heart disease man’s disease; women underrepresented in
clinical trials on CAD (prevalence of CAD lower in women, especially middle-aged women; studies excluded people
>65 yr of age because of comorbidities)
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| Awareness of CVD risk in women: increased from 1997 to 2005; however, black and Hispanic women at higher
risk and less aware (black, 38% aware; Hispanic, 33%); women less likely to learn of risk from their physicians
than from magazines, television, and newspapers; less counseling than men during office visits—about physical activity,
exercise programs, weight loss, and diet
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| Women’s perceptions of CAD: >50% think cancer (specifically, breast cancer) main threat; some who know
about CAD risk do not think it applies to them; most women now recognize their symptoms may be atypical, but
99% of women have typical chest pain on admission for acute coronary syndrome
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Risk Factors
| Risk factors in women: according to 2006 statistical update from American Heart Association, CAD develops at
earlier age than previously thought; age at menopause now lower; higher prevalence of hypertension, high cholesterol,
and sedentary lifestyle; diabetes (negates female advantage at any age; 3- to 7-fold increase in CAD, compared
to men); low high-density lipoprotein (HDL), especially with high triglycerides; receiving less counseling
about nutrition, exercise, and weight control
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| Diabetes: CAD equivalent; patients at same risk as nondiabetics who had myocardial infarction (MI); higher CVD
mortality and frequency of nonfatal MIs in women than men with diabetes
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| Higher body mass: CAD risk increases with body mass index (BMI) >25 (overweight) and >30 (obese); women
today approaching BMI of 40; intra-abdominal adiposity increases risk
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| Smoking: risk for MI 2 to 6 times higher in women who smoke than men who smoke; MI in young women using
oral contraceptives usually associated with smoking
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| Diagnostic considerations: 63% of women who die suddenly from CAD had no warning; 38% of women, compared
to 25% of men, die within 1 yr after MI
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| Presentation: women present with first symptoms of CAD 10 yr later than men, with first MI 20 yr later than men
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| Framingham findings: angina first manifestation of CAD in 55% of women, compared to 39% of men, but more
men had MI preceded by angina than women; 34% of women and 27% of men had unrecognized MI
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Angina in Women
| Definition of angina: chest pain—pressure-like and retrosternal; provoked by exercise or emotion; relieved by rest
or nitroglycerin within 15 min; if chest pain description—meets 3 of 3 criteria, angina present; 2 of 3, atypical angina;
≤1, noncardiac cause
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| Catheterization: fewer women than men had CAD; women with CAD tended to have less multivessel CAD; angina
less predictive of obstructive CAD in women; Diamond criteria—for calculating pretest probability of CAD;
based on description of chest pain, age of patient, and sex; catheterization found women had less obstructive CAD,
based on criteria
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| Microvascular disease: prevalence in women may explain atypical presentations of CAD; involves small arteries,
branches of epicardial arteries, and endothelial dysfunction; cardiac catheterization (and computed tomographic angiography
[CTA])—look for epicardial stenosis (large plaques) in coronary arteries, not microvascular lesions; microvascular
disease more common in women, diabetics, and old men, and may account for paucity of obstructive
lesions seen in women
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| Further Framingham findings (1977): women with angina had better survival; angina less predictive of MI; angina
did not correlate with epicardial coronary stenosis
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| After developing CAD: women have worse prognosis and mortality; MI in younger woman more likely to be
fatal than in older woman; electrocardiography (ECG) findings atypical; because women older, more overweight,
and more sedentary, they do not perform well on ambulatory stress testing
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| How women experience MI: different from men; some have no chest pain; more likely to have back pain, abdominal
pain, jaw pain, shortness of breath, and nausea and vomiting; these may present alone or with angina
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Treatment
| Treatment: after obstruction documented, women treated same as middle-age men, but without same response and
survival; treatment based on trials with fewer women; after presenting with unstable angina, women receive—less
noninvasive evaluation, stress testing, and coronary angiography, ie, almost no procedures
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| Heart failure: in last 20 yr, women exceeded men in hospital admissions
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| Undertreatment of women: earlier interventions after coronary event more successful; study based on >200,000
patients—≈36,000 women had non-ST segment elevation MI (non-STEMI); after admission with enzyme-positive
acute coronary syndrome, women received less aspirin, heparin, platelet inhibitors, ACE inhibitors, angiography,
and revascularization; after discharge, women not receiving documented therapies shown to decrease morbidity
and mortality in women with CAD; cardiac rehabilitation—women referred less often and more likely to drop out;
women’s behavior after diagnosis—only 15% made significant changes in diet or exercise levels; 20% decreased or
stopped exercising after MI
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Prevention Guidelines
| Evidence-based guidelines (2004): readily available—at www.americanheartassociation.org, or keyword
“women’s heart guidelines”; include prevention therapies shown to be useful in women but underutilized
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| Primary prevention: modification or prevention of risk factors to prevent or delay CAD
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| Secondary prevention: therapies to reduce events and mortality in patients with established CAD
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| “Primary-and-a-half” prevention: in patients with subclinical markers of CAD, eg, increased carotid intimal thickening,
high calcium score on CT of heart
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| Gender-specific guidelines: based on findings in last 10 to 15 yr; hormone therapy ineffective; Global Risk Assessment;
continuum of preclinical assessment
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| Implementing guidelines: determine Framingham risk score; based on—age; sex; total cholesterol and HDL-
cholesterol (HDL-C) levels; blood pressure (BP); presence of diabetes; smoking; stratify 10-yr risk—high; intermediate;
low; required to set LDL-cholesterol (LDL-C) goal
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| 2007 guideline update: recognizes lifetime risk for CAD major cause of death in women; first, stratify women into
high, medium, or low 10-yr risk in order to determine LDL-C goal; then, place women in high-risk or at-risk category
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| Preventive recommendations for all women: smoking cessation; physical activity; healthy weight; healthy
diet
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Management Goals
| A: antiplatelet agents/anticoagulants—ACE inhibitors, or angiotensin receptor blockers for ACE-inhibitor-intolerant;
(ACE inhibitors contraindicated in women who may become pregnant); antianginal agents—nitroglycerin;
β-blockers; calcium-channel blockers may be more effective for angina in women (may have effect on microvascular
disease); ranolazine (Ranexa)—new drug that blocks late sodium channel (seen only in ischemic cells);
shown to treat angina due to microvascular disease; consider in persistent angina after other therapies prove ineffective
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| B: BP control; β-blockers
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| C: cholesterol management; after reaching LDL-C goal, if HDL-C low or non-HDL-C high, add niacin or fibrate
therapy; smoking cessation
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| D: dietary and weight counseling; diabetes management, (hemoglobin A1C <7%)
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| E: exercise; education
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| Role of aspirin: Women’s Health Initiative (WHI) showed 100 mg every other day did not reduce fatal or nonfatal
myocardial events in otherwise healthy women; recommendations—use only in women with documented CAD or
in high-risk category based on Framingham score; stroke—base therapy on individual risk; dosage—81 mg aspirin
sufficient for protection without risk for side effects; alternatives in aspirin-intolerant patients—clopidogrel (Plavix)
acceptable (expensive; bleeding risk); aspirin in other than at-risk healthy women >65 yr of age—consider based
on subclinical data or Framingham score; before starting, evaluate BP and treat when indicated
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| Vitamin E: based on WHI findings, not now recommended; may be considered in older and at-risk women
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| Hormone therapy: of no benefit in preventing or treating CAD
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| Educate: patients and staff
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| Evaluate: fasting lipid and glucose levels; weight; echocardiography if indicated (more normal ejection-fraction
heart failure in women); symptoms—standard stress test when resting ECG normal and patient not high- or intermediate-risk
(in absence of angina or ST-segment shifts that meet diagnostic criteria, patient does not have
CAD); imaging for intermediate- or high-risk patient, even with normal ECG; if woman not ambulatory, chemical
stress test (either nuclear stress test or stress echocardiography [preferred by speaker; besides perfusion,
shows valves, myocardium, diastolic dysfunction, and pulmonary pressures])
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| Calculate: risk based on Framingham score; calculators available at www.nhlbi.nih.gov/guidelines/cholesterol/ index.htm
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| Weight-maintenance goals: BMI <25 (≈18 preferable); waist circumference <35 in (for men, <40 in)
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| Weight-loss goals: make attainable, eg, 1 to 2 lb per wk; 250:250 rule—exercise for extra 250 calories per day; eat
250 fewer calories per day; equals 500 fewer calories per day and 3500 fewer calories per wk, which equals 1 lb
(52 lb per yr)
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| Exercise guidelines: exercise every day; 3 criteria for success—form of exercise patient likes; affordable; convenient;
methods—walk briskly 30 min per day ≥5 days per wk; to lose weight, 60 to 90 min/day; add resistance
training to prevent injury to muscles during aerobic exercise; rehabilitation program—for women with disease
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| Response to resistance: eg, not enough time; “if you don’t find time for exercise, you better find time for disease”
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| ALOHA: say farewell to heart disease; A—assess risk and stratify; L—lifestyle changes; O—other interventions,
acutely in hospital or after discharge; H—highest priority to highest-risk women; A—avoid class III interventions,
eg, hormones, antioxidants, aspirin in low-risk women
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| Patient education: call American Heart Association (888-MY-HEART) or go to Web site (www.americanheart.org)
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Questions and Answers
| Statin therapy: based on risk or high LDL-C; low or intermediate risk—LDL goal <160 mg/dL, then 130 mg/dL;
high risk—LDL goal 100 mg/dL; other benefits—anti-inflammatory; may stop progression of atherosclerosis;
reaching LDL goal— focus on continued patient adherence to therapy; find acceptable alternative therapy if indicated
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| Role of estrogen: before WHI findings, benefits of estrogen replacement therapy thought to derive from improvement
in lipid levels after menopause
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Suggested Reading
Gluckman TJ et al: A practical and evidence-based approach to cardiovascular disease risk reduction. Arch Intern
Med 164:1490, 2004; Grundy SM et al: AHA/ACC scientific statement: Assessment of cardiovascular risk by use
of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association
and the American College of Cardiology. J Am Coll Cardiol 34:1348, 1999; Kyker KA et al: Gender differences
in the presentation and symptoms of coronary artery disease. Curr Womens Health Rep 2:115, 2002; Merz CN
et al: The Women's Ischemia Syndrome Evaluation (WISE) study: protocol design, methodology and feasibility report.
J Am Coll Cardiol 33:1453, 1999; Mosca L et al: AHA/ACC scientific statement: consensus panel statement.
Guide to preventive cardiology for women. American Heart Association/American College of Cardiology. J Am Coll
Cardiol 33:1751, 1999; Mosca L et al: Awareness, perception, and knowledge of heart disease risk and prevention
among women in the United States. American Heart Association Women's Heart Disease and Stroke Campaign Task
Force. Arch Fam Med 9:506, 2000; Reis SE et al: Coronary flow velocity response to adenosine characterizes coronary
microvascular function in women with chest pain and no obstructive coronary disease. Results from the pilot
phase of the Women's Ischemia Syndrome Evaluation (WISE) study. J Am Coll Cardiol 33:1469, 1999; Willett WC
et al: Relative and absolute excess risks of coronary heart disease among women who smoke cigarettes. N Engl J
Med 317:1303, 1987.
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