Women and Heart Disease What Is New In 2003

Summer 2003

Women and Heart Disease What Is New In 2003 by Gina Price Lundberg, M.0. FA.CC. 1

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ach year, more women die of card iovascu lar disease than all forms of cancer combined. A quarter of a million women die from cardiovascular disease, mostly from myocardial infarction but about 90,000 of these women are dying from stroke each year. Unfortunately, a poll of patients and physicians in 1994 showed that only 4 percent of women knew that cardiovascular disease was their number one cause of death. Even more concerning is the fact that only onethird of the primary care physicians at that time could identify cardiovascular disease as the number one killer of women. Over the years, women have been concerned about breast cancer and all women can identify what the pink ribbon means. Most women get a mammogram every year because of their concerns about breast cancer and their desire to decrease that risk. However, most women do not even realize that two out of three women will die from cardiovascular disease.

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Since 1994, there has been increasing awareness of cardiovascular disease in women. The American Heart Association has promoted education in women and heart disease since 1995. There are now billboards along the interstate concern ing heart disease and women. There are brochures in your physician's offices and there are commercials on TV. Even Oprah Winfrey has gotten in on the heart disease awareness trend.

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The American College of Card iology and the American Heart Association developed guidel ines for women and heart disease in 1997, increasing physicians awareness. Yet many women still go to the ir physicians with complaints of chest discomfort, sometimes subtle and atypical, but sometimes classic angina, and go undiagnosed. Many women have a myocardial infarction before any diagnosis is made, since half of all patients have no early warning symptoms. Currently, 52 percent of sudden cardiac death occurs in females, so early detection is really the key to saving lives. Some of the problems with diagnosing heart disease in women are that many of the traditional risk factors, the Framingham risk factors, do not identify young women at risk for heart disease and acute myocardial infarct ion. A recent study

showed that less than one-fourth of the women under 55 years old who had a myocardial infarction would have been picked up by traditional risk factors. Half of these women had no risk factors or only one risk factor. And only 18 percent of these women qualified for pharmacotherapy by the NCEP guidelines. Many studies have shown that women are undertreated by their physicians. Women have less exercise stress testing, less nuclear stress test, and are less often referred for cardiac catheterization than age-adjusted males. Fewer women with known coronary artery disease are referred for bypass surgery compared to males with similar disease. Unfortunately, previous card iac catheterization data has led physicians to believe that women with chest pain rarely have coronary artery disease. A woman with typical angina pectoris, meaning she has substernal chest pain that is exacerbated by exertion and relieved with rest or nitroglycerin, still only has about a 70 percent chance of having clinically significant coronary artery disease at cardiac catheterization. (This generally means a stenotic lesion greater than 70 percent.) However, new information from the WISE (Women's Ischemia Syndrome Evaluation) study has shown that many women have diffuse coronary atherosclerosis and small vessel disease. Many women do not respond appropriately given physical or emotional stressors, which still leads to supply/demand mismatch. These women experience the same angina! symptoms and have increased risk and rate of sudden cardiovascular death, myocardial infarction, and stroke.

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women do not even realize that two out of three women will die from cardiovascular disease."

In many women, coronary artery disease presents with increasing fat igue or shortness of breath, particularly with activities that used to be effortless. About 80 percent of women with coronary artery disease will still have substernal chest pain with the quality and characteristics suggestive of angina. It occasionally will radiate to the neck, jaw, either shou lder or either arm. It also can be detected in the epigastric region. It is occasionally associated with diaphoresis and nausea. Many women will mistake angina for indigestion or musculoskeletal pain. When a physician evaluates a www.mag.org

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Journ al of the Medi ca l Association of Georgia

woman with these types of symptoms, it should be considered angina until proven otherwise. Traditional exercise stress testing in females is still a good starting place although many women will have a false pos itive test. Man y insurance companies do not give the patient and the physician the option of starting with imaging, stress testing and so tradition al exercise stress testing must still be used for evaluation in many circumstances. Nuclear stress testing and stress echocardiography are the most sensitive and spec ific in females, primarily because they were standardized in women. The sensitivity and specificity are about the same for a nuclear and echo, but they are highly operator-dependent. The coronary artery risk fac tors that are most concerning in females are diabetes and tobacco use. Diabetes increases the risk of heart disease in a female three to sevenfo ld and is frequently present fo r fi ve years prior to any diagnos is. Eighty percent of diabetics will die from a cardiovascular cause. With the new criteria fo r metabolic syndrome, more women who are insulin-resistant are being diagnosed and treated early. Also , educating young women with gestational diabetes and counseling them on diet and weight loss will help to reduce the numbers of adult diabetics in the future. Tobacco increases a woman 's risk three to fi vefold and is obviously the easiest risk facto r to prevent. Women may need h elp to quit smoking through weaning programs with the nicotine patch or gum or they may desire Zyban. O ther fe males are interested in acupuncture and hypnosis and I would encourage the phys ician to help women with smoking cession in an y way possible. C h olesterol has received the most attention in modifying risk fac tors. Diet and exercise are the foundation fo r th erapy, but the medications currently are very good at reducing the lipid levels. The N C EP guidelines recommend gett ing the LDL below 130 in women with two or more risk fac tors and below 100 in all diabetics and women with known coronary artery disease. The statin drugs are highly effective at reducing LDL. The N C EP guidelines suggest that once a woman h as reach ed her LDL goal, she sh ould begin increas ing h er HDL and reducing h er triglycerides levels as well. An HDL below 40 is quite low in any female and should be above 50 in all females, especially diabetics. Triglycerides should be below 150 in all females. HDL is most increased by estrogen , exercise, and Niacin. Triglycerides are most reduced by G emfibrozil or Fenofibrate. Hyperten sion is also a risk factor that gets a lot of attention because it can be modified with diet, exercise and medications. The new JNC VII G uidelines still recommend diuretics fo r initial hype ~tens ion therapy. However, the Hope study and other studies using angiotensin receptor blockers h ave shown significant reduction in the risk of cardiovascular events. The new guidelines suggest AC E inhibitor or ARB therapy be used in combination with diuretics, especially in diabetic patients or patients with multiple C AD risk factors.

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Family history is commonly a risk factor that will bring patients to medical attention . Primary relatives with initial events of cardiovascular disease prior to the age of 50 in a male and 60 in a female should be considered at significant risk. This is a time when advanced lipid testing may be very useful - not only do abnormal choleste rol leve ls run in fa milies but sometimes the more novel risk factors of lipoprotein( a ) and homocystine can be detected in fa milies. In women with myocardial infa rction prior to 55 years old , 42 percent h ad a famil y history of premature coronary artery disease. Obes ity is quite concerning given that 30 percent of the adult patients these days are obese. Obesity is now considered a body max index (BMI) of greater th an 30. This would be a 5 ft. tall woman who is 140 lbs. We need to encourage our patients to keep a BMI below 25, which is considered ideal health and encourage everyone with a BMI of greater than 30 to get started in an exercise and weight loss program. Sedentary lifestyle is frequently related to hypertension , obesity, and elevated cholesterol leve ls as well as adult-onset diabetes. The current guidelines are three hours of cardiovascular aerobic activity per week, with an additional warm up and cool down. New coronary artery disease risk fac tors are emerging and the high sensitivity C -reactive protein (hsCRP) has probably gotten the most publicity. It h as been on the cover of Time magazine as well as the Wall Street Journal. Many patients walk into the office these days requesting this lab test. The hsCRP is an inflammatory marker and is actually the low end of normal fo r the C-reactive protein lab that was traditionally ordered by rheumatologists. This may be most h elpful in patients who are considered low risk. In a study of patients with low LDL who were told they had low risk of heart disease, about 50 percent of those had an elevated C-reactive protein. An elevated CRP level is a higher risk than an elevated LDL, particularly in females. Prior to telling the patient that she is at low risk by her cholesterol and traditional risk factors, one sh ould consider getting the C -reactive protein to de termine if she is truly low risk. W hen the hsCRP is elevated, implementing asp irin daily and/or a statin would be the treatment of choice. Lipoprotein( a), or Lp(a ), has gotten a lot of publicity over the last 5-10 years, but is not full y understood. Half the patients who h ave this Lp( a ) do not have cardiovascular disease. The Lp( a) is a lipid tail that rides on the LDL particle. When it is present, particularly in the setting of tobacco use, it is highly atherogenic. Ho mocystine is an emerging risk fac tor. Homocystine is associated with increased venous thrombosis and is also associated with increased cardiovascular disease. Homocystine values that are quite high , i. e. over 10, definitel y should be treated with fo lic ac id , Bl 2 and B6. Folic acid is now added to many of the cereals and breads and the American population as a

Summer 2003

whole is getting higher levels of folic acid in their daily diet. The ultrafast CT (or cardiac calcium score) has been highly promoted but can lead to some controversial data. Because the atherosclerotic plaque must have been present somewhere between 5-10 years to calcify, it underestimates coronary disease in young women. A woman who is 60 and has a coronary calcium score of zero can be fairly confident that she did not have any premature coronary artery disease, but a woman at 45 really does not know. The ultrafast CT scan is probably best used in a patient 55-60 with strong family history in order to get more aggressive with risk reduction. Advanced lipid testing is quite helpful in patients with known coronary disease with unremarkable traditional risk factors . Quite often when a patient's HDL is high, then the patient's HDL 2B, which is the protective one, will be low. Also, when the LDL is in the 100-130 mg/di range, patients may be told this is a mild risk. However, if the LDL is Pattern B, this is small, dense and atherogenic. The pattern of LDL can be sh ifted with niacin more so than statin therapy. A lso, niacin will raise the HDL2b along with exercise. Hormone replacement therapy (HRT) is not appropriate for cardiovascular risk reduction. Although HRT reduces LDL and raises HDL, there is no card iovascu lar benefit and the risk

of pulmonary embolus, DVT and breast cancer are concerning. HRT should be based on noncardiac benefits and risks. In summary, there are ·many new and old risk factors and many tests to detect early heart disease in women. Physicians need to be as aggressive in evaluating heart disease in females as we are in males. Physicians need to increase patient awareness of heart disease. By having better informed patients and preventative-minded physicians, our patients will do much better in the future. References 1. Guide to Preventive Cardiology for Women. Circulation, 1999; 99:2480-2484 .

2. AHA Scientific Statement: Cardiovascu lar Disease in Women. Circu lation, 1997; 96:2468-2482. 3. The Women 's lschem ia Syndrome Eval uation (WISE) Study: Protocol Design, Methodology and Feasibility Report. JACC 1999; 33:1453- 1461.

Dr. Gina Lundberg is the Director of The Women's Heart Center, a division of Cardiology of Georgia.

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