Gender Issues in CVD

Question 0

What are some “cultural” trends that may account for increased CV mortality in women?

Answer 0

Women with MI symptoms wait longer to seek medical attention.
Risk factors not managed as well.
Time to diagnosis is longer.
Tends to affect older, low SES women.

Question 1

How does CAD present differently in angiography in men vs. women?

Answer 1

Women’s atherosclerotic plaques tend to have “positive remodeling” i.e. the lumen diameter doesn’t decrease, making CAD not show up as well on angiography.

Question 2

Age distribution of CVD in women?

Answer 2

Really mostly over age 65.

Might be due to protective effects of estrogen?

Question 3

3 positive effects of estrogen on CV risk factors?

Answer 3

Decreases LDL / increases HDL.
Facilitates NO-mediated vasodilation.
Inhibits inflammatory responses in endothelium.

Question 4

3 negative effects of estrogen on CV risk factors?

Answer 4

Increased TGs.
Increased inflammatory markers, such as CRP.
Increased risk of thrombosis.

Question 5

Is hormone replacement therapy definitively shown to decrease CV risk?

Answer 5

Nope… ambiguous effects. But it definitely increases reproductive cancer risk.

Question 6

How might estrogen increase the risk of plaque rupture?

Answer 6

By upregulating matrix metalloproteases, thinning the fibrous cap.

Question 7

Do women really less frequently present with chest pain when having an MI?

Answer 7

No, that’s not really true. But they do present more frequently vs. men with extra non-specific symptoms (e.g. epigastric pain).

Question 8

Is stress testing less sensitive in women vs. men?

Answer 8

Yes. (70 vs. 77%… that doesn’t seem that huge… but I guess at the population level…)
This is probably related to the fact that women tend to have less coronary occlusion before plaque rupture.
Solution - use more imaging, such as echo, for screening women.

Question 9

How does the total plasma volume change in pregnancy?

How does this compare with the increase in RBC volume?

Answer 9

They both increase enormously, but the RBCs not as much. Relative anemia is normal during pregnancy.

Question 10

How do CO, SV, HR, and total PVR change in pregnancy?

Answer 10

CO (+40%), SV (+30%), and HR (+10%) increase.
TPVR decreases (-30%)

Question 11

Why is aortic stenosis during pregnancy very bad?

Answer 11

The CO really needs to be increased, and in AS, it can’t be.

Question 12

What happens to venous return right after delivery?

Answer 12

It is massively increased, which can lead to frank pulmonary edema if the heart can’t handle it.

Question 13

What is biggest cause of maternal mortality in the US?

Most common causes of this condition in women of childbearing age?

Answer 13

Pulmonary hypertension.

Most commonly due to left->right shunts: VSD, patent ductus arteriosis (PDA), and atrial septal defect (ASD).

Question 14

Recommendation for women of childbearing age with severe pulmonary hypertension?

Answer 14

Tubal ligation, and termination of pregnancy if it occurs.

Question 15

What arrhythmia can further reduce CO in mitral stenosis?

Answer 15

A fib, precipitated by the enlarged atrium.

Question 16

2 ways that pregnancy makes mitral stenosis worse?

Answer 16

Increased HR -> further decreased diastolic filling.

Increased preload -> further dilation of LA -> contractile dysfunction and risk of A Fib.

Question 17

Management of mitral stenosis in pregnancy?

Answer 17

Beta blockers, “judicious” use of diuretics, and if severe, percutaneous balloon dilation (valvuloplasty) of the mitral valve.

Question 18

Are aortic and mitral regurgitation significant problems during pregnancy?

Answer 18

Not really.
One could imagine that the drop in PVR might actually might be beneficial for the AR.
MR can be a problem if severe and complicated by A Fib, PHTN.

Question 19

Review: Pros and cons of mechanical vs. bioprosthetic aortic valve replacement?

Answer 19

Mechanical: must be on warfarin, but they last a long time.
Bioprosthetic: must replaced in about 10 years, but don’t need anticoagulation.
In a women who wants to have children… this is a tough call.

Question 20

What do you do if a woman with a mechanical valve gets pregnant?

Answer 20

Taper of the warfarin, switch to subQ heparin injections, at least for first 13-14 weeks. (there is debate whether or not warfarin should be restarted then)
Heparin does not cross the placenta, and is not associated with fetal loss.
(Taking warfarin while pregnant -> 6% chance of fetal loss.)

Question 21

Dilated cardiomyopathy in pregnancy….

Answer 21

it happens sometimes, increased with pre-eclampsia, multiparity, African-American ethnicity, older age. It reverses itself 50% of the time.
Note that women can’t take ACE-inhibitors /ARBs to help prevent remodeling.