CVD in Women - Malmsten

Question 1

What is the largest killer of women (In the US)?

How do women’s expectations of illness compare?

Answer 1

Heart disease.

Improving, but still skewed. Breast cancer incidence overstated.

Question 2

Give some examples of how physicians’ perceptions can reduce quality of CVD care in women.

How do women’s own perceptions contribute to this?

Answer 2

Women are less likely to be referred for testing or surgery, are less likely to receive medication, and are referred later.

Women are more likely to delay seeking care, may have been misinformed about their symptoms, and may not recognize the atypical signs.

Question 3

Try to recall some of the 9 major risk factors for MI found in the INTERHEART study.

Answer 3

High cholesterol

Smoking

High waist-hip ratio

Hypertension

Diabetes

Low physcial activity

Low/no alcohol use

Bad diet

Stress

Question 4

How can stress contribute to heart disease?

Answer 4

Stress (eg marital) increases CAD risk. Cynicism worsens outcomes, optimism & stress reduction improves it.

Also, Takotsubo cardiomyopathy.

Question 5

What interventions are not indicated for the prevention of CVD in women?

(I’m not talking about pregnancy contraindications, that’ll be later)

Answer 5

Estrogen replacement therapy

Antioxidant supplements

Folic acid supplements

Aspirin (this is contradicted later)

Question 6

What is Framingham risk?

What are some problems with it?

Answer 6

Framingham risk is a 10-year risk calculation for CVD.

May lull patients & physicians into false sense of security. Lifetime risk is more relevant.

Question 7

What characteristics feature in women at high risk for CVD?

There’s quite a few; emphasis on the women-specific ones.

Answer 7

CAD, CVD, PAD, AAA, ESRD, DM, Framingham risk >10%, smoking, hypertension, elevated lipids, obesity, poor diet, inactivity, family history, metabolic syndrome, poor exercise capacity, atherosclerosis, collagen vascular disease.

Pre-eclampsia, gestational diabetes or hypertension

Question 8

Besides gestational diabetes, hypertension, and eclampsia, what are some other signs in pregnancy that imply future CVD risk?

Answer 8

Decreased EF, stenotic valvular lesions, heart failure, pulmonary HTN.

Question 9

How does PCOS affect a woman’s risk for CVD?

What about timing of menarche/menopause?

Answer 9

Elevated; screen for MBS, hyperlipidemia, etc.

Early menarche/menopause increases CVD risk.

Question 10

Two major lifestyle modifications to reduce CVD risk include smoking cessation and increasing physical activity. Try to recall some of the specific guidelines.

Answer 10

Smoking: Stop smoking, avoid environmental smoke, pursue nicotine replacement pharmacotherapy and counseling as needed.

Exercise: 150min moderate / 75min vigorous per week. More benefit with more exercise, more needed for weight loss. Wt training 2/wk. Goal: Waist size <35in, BMI <25.

Question 11

When is cardiac rehab indicated?

Answer 11

Following recent coronary event, angina, stroke, PAD, or in heart failure with decreased ejection fraction.

Question 12

How do treatment indications for hypertension in women differ from that of men?

Answer 12

Not much; still give thiazides, as well as ACE-Is/ARBs/beta-blockers in high risk cases.

Exception: No ACE-Is/ARBs in pregnant or potentially pregnant women.

Question 13

How does statin use and treatment goals differ in women from men?

Answer 13

Higher goal HDL (50 rather than 40)

Contraindicated in pregnancy (stop 3 months prior)

Question 14

What anticoagulants are indicated as preventive treatments in women?

Answer 14

Aspirin (for CHD, DM, stroke, and maybe stroke <65yrs)

Thienopyridines if aspirin is poorly tolerated.

Warfarin for women with a-fib but NOT IF CHILDBEARING

Dabigatran (alternative for some patients)

Question 15

When is beta-blocker use indicated?

Answer 15

Following MI/ACS. Long-term if LV function is lost, or with ongoing CAD/vascular disease.

Question 16

What anti-hypertensives are safe for pregnancy?

Answer 16

Methyldopa

Hydralazine

Labetalol

Nifedipine

Question 17

Describe the presentation of stress-induced cardiomyopathy.

Answer 17

Presents likek a STEMI but with normal coronaries. Must be diagnosed by exclusion of other possibilities. Preceded by stressful event.

More common in women than men.

Question 18

Women die (more/less) often than men from CVD, perhaps because their presentation is ____. They are more likely to develop ____ cardiomyopathy. Their unique risk factors include ____. Drugs such as ____ should be avoided in pregnancy.

Answer 18

Women die more often than men from CVD, perhaps because their presentation is more atypical. They are more likely to develop Takotsubo/stress-induced cardiomyopathy. Their unique risk factors include PCOS, Pre-eclampsia, and gestational diabetes. Drugs such as ACE-I/ARBs and statins should be avoided in pregnancy.