女性心脏病

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 Heart and Stroke Statistical Update; CDC/NCHS, AHA CP1138028-9 Deaths (000s) 1979 Years 1982 1986 1990 1994 1998 2001 Males Females Coronary Disease Prevalence NHANES III 1988-94, CDC/NCHS and AHA Incidence rate x 100,000 CP1145262-1 Women Men Overall MI Incidence Annals of Int Med, 2002 CHD Incidence CP1079700-1 1988 vs 1979MI 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 MenArciero AJM 2004 CP1099138-11 May 2003 Death Within First Month Post-MI Olmsted County 1979-1998 CP1053938-6Annals of Int Med, 2002 Overall Men Women 75 1979-83 1984-88 1989-93 1994-98 Sex and MI Mortality CP1165215-5NRMI, Vaccarino: NEJM, 1999 Hospital mortality (%) Overall 30 25 20 15 10 5 0 30 Flegal et al, JAMA, 2002 CP1043203-17 Diabetes and CV Risk in Women Nurses Health Study: Arch Int Med, 2001 RR of CV death DM/no CHD CHD/no DM DM + CHD 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, exposure 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 3% Women who actually: Dont smoke Eat a healthy diet Exercise 30 min/day Are not overweight Use alcohol moderately CP1021901-2 Stampfer et al, NEJM 2000 82% 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 prevalence 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 70% vs 71%* Milner et al: Am J Cardiol, 1999 CP949761-10 Precipitants of Angina Frequency (%) Rest SleepActivity * P0.006 Women Men 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 % Women Men CP926094-1 Dyspnea Nausea Indigestion Dizziness Fatigue Sweating Arm/ Vomiting Fainting shoulder/pain Why? Awareness Risk factors “Atypical” symptoms Treatment 38% 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 after an ED visit for symptoms of unstable angina, the use of cardiac procedures was lower in women, but after taking into account baseline characteristics, men experienced worse outcomes. CP1141913-3 JAMA , 2001 Sex Disparities in MI Treatment US National data CP1074357-7 35,835 pts with NSTEMI- 41% 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 8582 84 86 87 88 89 90 91 92 93 94 95 96 97 98 Year Men, 1056 Women, 765 CP1099138-2Witt, et al; JACC 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 opportunities 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 Manag