Racial and Gender Differences in Cardiovascular Disease

Question 1

Heart Disease

• Gender
• Race
• Risk factors

Answer 1

• Gender
  
  • Leading cause of death, esp in women
  • Accounted for over 290,000 deaths in women in 2009
  • 1 in 4 women will die from it
  • Women are 6x more likely to die of heart disease than breast cancer
  • Incidence in women (>75yo) lags behind men by 5-10 years (65-74yo)
• Race
  
  • Black & asian/pacific islander deaths from CHD > white, hispanic, or american indian deaths from CHD
  • Risk factors for CHD: lowest in whites & asians
  • Odds for multiple risk factors: greatest in black & native american women
• Risk factors
  
  • 80% of women have >1 risk factor when presenting w/ heart disease
  • Obesity: present in >1/3 of women w/ CHD
  • Diabetes: stronger risk factor for CHD / acute MI in women than men
    
    • Women have a higher prevalence of diabetes mellitus than men
    • Absolute rates of CVD in diabetes are higher in men than women, but DM accounts for a larger proportion of CVD that occurs in women than men

Question 2

Women vs. Men

• Cardiac anatomy
• Cardiac function
• Physiology
• Coronary artery size

Answer 2

• Cardiac anatomy
  
  • Smaller LV mass, wall thickness, LA dimension, & left end diastolic size
• Cardiac function
  
  • Stroke volume: reduced
  • Ejection fraction: slightly higher
  • Pulse: faster
• Physiology
  
  • Reduced sympathetic activity
  • Enhanced parasympathetic activity
  • Decreased levels of norepinephrine
• Coronary artery size
  
  • Smaller coronary artery size
  • Anything that further reduces teh diameter of the artery (stenosis, spasm, dysfunction) has seroius adverse effects

Question 3

Plaque Distribution, Disruption, & Healing

• Plaque distribution
  
  • Men
  • Women
• Way in which plaque is disrupted
  
  • Men & older women
  • Younger women
  • Women
• Way in which atherosclerotic lesions heal
  
  • Men
  • Women

Answer 3

• Plaque distribution
  
  • Men: focal areas of plaque in their coronary arteries w/ single segmental stenosis
  • Women: diffuse plaque buildup & narrowing throughout the length of their coronary arteries
• Way in which plaque is disrupted
  
  • Men & older women: plaque rupture
    
    • Occurs w/ a large necrotic core & disrupted fibrous cap infiltrated by macrophages & lymphocytes
  • Younger women: plaque erosion
    
    • A fibrous cap is absent at the plaque erosion site
    • The exposed intima consists predominantly of smooth muscle & proteoglycans
  • Women: distal microvascular embolization
    
    • In the setting of a fatal epicardial thrombosis
• Way in which atherosclerotic lesions heal
  
  • Men: negative remodeling
    
    • Inward remodeling of vasculature & sometimes artery narrowing
  • Women: positive remodeling
    
    • Outward remodeling away from the lesion

Question 4

Estrogen

• Effects on cholesterol
• Effects on endothelial function
• Effects on women

Answer 4

• Effects on cholesterol
  
  • Decrease LDL
  • Increase HDl
  • Increase triglycerides
• Effects on endothelial function
  
  • Increase NO availability –> increase vasodilation
  • Increase endothelial growth + decrease smooth muscle growth –> inhibit healthy repsonse to vessel injury
• Effects on women
  
  • Estrogen affects women’s reproductive & CV systems
  • Women are protected by estrogen when they’re younger
  • Menopause –> lose estrogen –> higher risk for heart disease
    
    • Higher cholesterol & LDL
    • Lower HDL & triglycerides
    • Less vadodilation in response to NO
    • Less inhibition of healthy response to vessel injury

Question 5

Risk Stratification in Women: High Risk

Answer 5

• Atherosclerotic disease
  
  • Coronary heart disease
    
    • Heart attack
    • Blockages in coronary arteries
  • Peripheral arterial disease
    
    • Peripheral arterial bypass
    • Blockages in vasculature
  • Cerebrovascular disease
    
    • Stoke
    • Carotid endarterectomy or stenting
  • Abdmoinal aortic aneurysm
• Diabetes mellitus
• End stage or chronic kidney disease
• 10 year Framingham CV disease risk > 10%

Question 6

Risk Stratification in Women: At Risk

Answer 6

• Cigarette smoking
• HTN
• Dyslipidemia
• FH of premature CVD in a 1st degree relative
• Obesity
• Physical inactivity
• Poor diet
• Metabolic syndrome (>3)
  
  • Obesity
  • High triglycerides
  • Low HDL
  • High BP
  • High fasting glucose
• Advanced subclinical atherosclerosis
• Poor exercise capacity on treadmill test
• Systemic autoimmune collagen vascular disease
  
  • Systemic lupus erythematous
  • Rheumatoid arthritis
• Pregnancy-induced HTN, gestational diabetes, pre-eclampsia
• (Thoracic radiation used to treat breast cancer)

Question 7

Risk Stratification in Women: Ideal Risk

Answer 7

• Total cholesterol < 200
• BP < 120/80
• Fasting blood sugar < 100
• BMI < 25
• Never smoked or quit > 12 months ago
• Physicla activity levels at goal
• Appropriate diet
• Make up <5% of women

Question 8

Lifestyle Recommendations for Women

• Smoking cessation
• Physical activity
• Low risk diet
• Depression treatment

Answer 8

• Smoking cessation
  
  • Counseling
  • Nicotine replacement (patch, gum, lozenge, inhaler)
  • Pharmacotherapy (buproprion, varenicline)
• Physical activity
  
  • Moderate exercise 150 min/week or vigorous exercise 75 min/week
  • Muscle strengthening 2 days/week
  • Moderate to intense activity 60-90 min/day for women needing to lose weight
• Low risk diet
  
  • High in vegetables, fruit, whole grains, & fish
  • Low in saturated fats & salts
  • No more than 1 alcoholic drink / day
• Depression treatment
  
  • Screen & treat

Question 9

Women & Aspirin

• Aspirin therapy
• Clopidogrel
• Medications that shouldn’t be used for prevention of CV disease

Answer 9

• Aspirin therapy
  
  • For women w/ a prior history of heart attack or stroke to decreae risk of recurrence
  • Contraversial for stroke/MI prevention in women who are at risk or healthy
    
    • Beneficial: >65yo, controlled BP, & benefit of prevention > risk of GI bleeding & hemorrhagic stroke
    • Not beneficial: <65yo, low risk or healthy women
• Clopidogrel
  
  • For high risk women intolerant or allergic to aspirin
• Medications that shouldn’t be used for prevention of CV disease
  
  • Antioxidant supplements
  • Folic acid supplements
  • Selective estrogen-receptor modulators (SERMs)
  • Estrogen hormone therapy

Question 10

Acute Coronary Syndrome

• Most common ACS symptom for both men & women
• Atypical ACS symptoms in women
• Gender biases in treating women
• Deaths within 1 year after first MI
• Deaths within 5 years after first MI

Answer 10

• Most common ACS symptom for both men & women
  
  • Chest pain
• Atypical ACS symptoms in women
  
  • Arm, back, shoulder, neck, & jaw pain
  • Shortness of breath
  • Nausea
  • Unexplained fatigue
  • Palpitations
• Gender biases in treating women
  
  • Develop more angina, HF, & arrhythmias after a heart attack
  • Less likely to have an EKG, cardiac monitoring, & cardiac enzymes drawn
  • Less cholesterol screening & therapies
  • Less use of heparin, beta blockers, & aspirin during AMI
  • Less antiplatelet therapy for secondary prevention
  • Fewer referrals to cardiac rehabilitation
  • Fewer ICDs
• Deaths within 1 year after first MI
  
  • _<_45yo: women > men
  • 45-64yo: black men > white women > black women > white men
  • _>_65yo: white & black women > white & black men
• Deaths within 5 years after first MI
  
  • _<_45yo: women > men
  • 45-64yo: black women > black men > white women > white men
  • _>_65yo: white women > white men

Question 11

Chest Pain w/ “Normal Coronary Arteries”

• Coronary arteries in men vs. women w/ chest pain
• Women w/ chest pain & normal coronary arteries
• Pathophysiology of chest pain w/ normal coronary arteries
• Treatment of women w/ chest pain & normal coronary arteries

Answer 11

• Coronary arteries in men vs. women w/ chest pain
  
  • Men: less likely to have normal coronary arteries
  • Women: more likely to have normal coronary arteries
• Women w/ chest pain & normal coronary arteries
  
  • At higher risk & have increased rates of cardiac events
  • Non-CAD women w/ persistent chest pain are more likely to have CV events (non-fatal MIs, strokes, CHF, CV deaths) than those w/o chest pain
• Pathophysiology of chest pain w/ normal coronary arteries
  
  • Coronary artery vasospasms
    
    • Artery spasm –> decreased luminal area –> decreased distal blood flow
  • Endothelial dysfunction
    
    • Vasoactive stimuli –> abnormal blood flow
    • Increased inflammatory states (high hs-CRP)
    • Reduced substrate of the vasodilator NO
    • Abnormal response to NO or endothelin
    • High levels of endogenous NO inhibitors (asymmetric dimethylarginine, ADMA)
  • Autonomic abnormalities
    
    • Increased sympathetic tone –> small vessels that are sensitive to vasoconstriction &/or vasospasm
  • Enhanced pain sensitivity
    
    • Electrical stimulation of atrium & ventricle –> chest pain
    • Injection of contrast media into LAD –> pain
    • Increased activation of regional cerebral cortex during dobutamine stress echo
  • Estrogen deficiency
    
    • Impaired endothelial dysfunction
    • Poor pain modulation
• Treatment of women w/ chest pain & normal coronary arteries
  
  • Aggressive lifestyle changes
  • Risk factor management
  • Low dose aspirin
  • Statin therapy for dyslipidemia