The leading cause of death in women, female heart disease looks different, affects Black women disproportionately, and has less-known risk factors – some associated with pregnancy complications or menopause. Cardiologist Jie Yang, MD, breaks down the evidence by age group and offers actionable steps for helping patients lower their risk. Bonus: Learn when to suspect microvascular disease.
let the topic for today would be cardiovascular disease and woman. And um when I was first asked to give this talk I thought wow that's a huge huge topic. So um I decided that what we could do is um specifically um go for uh preventative side of things. And then um after that if we have time we can talk a little bit more about the kind of more acute issues given the group of physicians that I'm talking to today. So my outline would be to first review the disparities um of cardiovascular disease and treatment of cardiovascular disease in women. And then talk more about the sex specific risk factors that enhance cardiovascular risk and go over kind of more in depth microvascular disease. Because I think that that is a topic that we are under. Um recognizing. So the first thing of um which I'm sure you are all aware is that cardiovascular disease risk is underappreciated and woman. So I took this infographic from an A. C. C. Um advertisement on women in cardiology. And the idea is that unfortunately one out of four deaths for women are from cardiovascular disease. Um Specifically um stroke and M. I. Together. Um But it's not something that women tend to realize that they are at risk for. And I think one of the it tolls of this lack of recognition is that women have a higher morbidity and mortality in both Am I? Um And even when they are recognized as having a problem when they undergo cabbage or when they're treated for heart failure and angina they just tend to have more higher um higher morbidity and mortality overall. Um We do also know that in comparison to men, women are much less likely to receive the goal directed medical therapy or inappropriate intensification of therapy. So starting from the left. Unfortunately there are lower rates of use of ace inhibitors and arms. Post Emmy, fewer women achieve door to balloon time of less than 90 minutes. There's a lower rate of diagnostic testing or specialty care fewer. Um Women undergo revascularization procedures. Um And on the right we have lower rates of um oral anticoagulants, nation, lower statin, lower goal directed medical therapy for statins and higher rate of death from high blood pressure unfortunately. And so it's a combination of everything in terms of unfortunately the whole spectrum of cardiovascular care. Unfortunately there tends to be again, so unfortunately the other thing that we should be aware of is that there is a racial disparity as well, fortunately black women are disproportionately affected. Um and when we look at this by the numbers unfortunately, um cardiovascular disease kills at least 50,000 African American women annually and unfortunately they tend to be affected at a much younger age group. Um an age range than um uh non African American women. Um so in the ages of 20 and older, 49% have some form of cardiovascular disease. The vast majority of those patients have hypertension and that's difficult to control. Only one in five African American woman actually believes that she is personally at risk, unfortunately, and only 52% of African American women are actually aware of the signs and symptoms of a heart attack. Only 36% know that their heart disease is their greatest risk. And then more than 40% of non hispanic blacks have high blood pressure, which is really unfortunately, kind of the probably one of the driving factors for this disparity in terms of their overall outcomes. Um we do also know that african american women are 40% more likely to die from heart disease than non hispanic white females and that black women unfortunately have this kind of 20 points higher blood pressure, um 60% more often than white females. So when we are looking at the risk factors for a patient coming in who is female, obviously we're going to look at the traditional risk factors that there are some emerging nontraditional um atherosclerotic cardiovascular disease risk factors as well and we'll get into them a little bit further. First thing of course, is to say that the traditional risk factors remain fundamental. You know obviously um family history. So unfortunately family history is actually a stronger risk factor for women um than it is for men. Interestingly enough, um diabetes um for whatever reason, um there is earlier occurrence and higher mortality of cardiovascular disease in diabetic women versus men. They also have lower revascularization rates, higher risk of developing heart failure and higher incidence of stroke. And um unfortunately diabetic women tend to also be have more communication symptoms compared to diabetic men. For hypertension. They have higher prevalence um in women over age 60 then and then for hypertension and generally less well controlled And then of course for display academia among women, it is the highest risk factor. And unfortunately at the Roma regression and um unfortunately at the Roma regression and LDL lowering, it can actually be greater for women on statins. But unfortunately in the the media there's this um there there is some concern or at least patients have a concern that statins are not effective in women. So I've actually had patients tell me, well I don't want to staten you know, I've heard that it doesn't work for women, it only works for men. And so that's actually not true. Um and I'll talk about that a little bit further, you know, later slide obesity unfortunately disproportionately affects women and the sedentary lifestyle for whatever reason, the prevalence of a sedentary lifestyle is higher among women Um and smoking as well. So interestingly when they do they do prospective studies or retro excuse me, retrospective studies with women, they have a 25% increased risk for development of coronary artery disease. They think specifically from just smoking rather than in men. So overall, the traditional risk factors still remained fundamental and obviously um things that you guys are looking at on a daily basis. And then let's talk more in depth now about the what we would consider less traditional risk factors. So the first three on the top here, the preterm delivery, hypertensive disorders of pregnancy and gestational diabetes are all pregnancy related risk factors. And what's really interesting is that we have a very, very fresh, I would say hot off the press. Um h a statement about this. So they basically um was led by my colleague Bishopric here at UCSF. And they wrote a scientific statement talking about adverse pregnancy outcomes and cardiovascular risk. Um and the unique opportunities we have for cardiovascular disease prevention and women early on here is a very complex, complicated slide. But basically saying that um these adverse pregnancy outcomes which include hypertensive disorders of pregnancy such as preeclampsia, gestational diabetes, um um Preterm delivery, small for gestational age, placental abruption or miscarriage or stillbirth. Each of these increases the odds ratio of have a women having cardiovascular disease later on in life, anything from 1 1.6 odds ratio to as high as perhaps 2.74 for patients with severe pre eclampsia. Um Not surprisingly, unfortunately, the racial and ethnic disparities and pregnancy complications are there. And for non hispanic black women, they have increased risk for hypertensive disorders of pregnancy, which you probably probably don't realize, but also increased risk for gestational diabetes, miscarriage, stillbirth, Preterm delivery et cetera. The case vitality rate for preeclampsia is unfortunately 2.7% higher times higher, not percent, 2.7 times higher among black women than white women. And it's not all because of, unfortunately, it is not all because of their established risk factors. So there's a heart study called the Bogalusa Heart Study which is out of university, um out of Tulane. And I basically talks about how they were able to balance the risk factors for black women and white women. And yet still, in terms of looking at the racial disparities, black women still had worsened outcomes, which suggests that there is a systemic problem in terms of our care, possibly from implicit bias or some other uh problem. But it's not only do black women start off with a disadvantage in terms of risk factors, there is also some sort of uh process that is wrong in terms of how their care goes because even with the risk factors balanced out, there is still a problem there. And then The other thing that is unfortunate is that when we look at these cohort studies on women's health in terms of pregnancy outcomes, the best majority of them unfortunately are white women about 95% or about fortunately, there is one study called the black Women's Health Study that's out of boston University, it's the largest cohort study of black women in United States and it has the potential to really examine the strength of these relationships of care and risk factors among black women. Um And so it's a really interesting um process. But you can actually have your patients referred to be part of the study because it's it's like an ongoing health study. So that's something to consider if they're your patients are interested. Um The other thing to know is aside from the uh the pregnancy outcome disadvantages from all of the adverse outcomes. One good thing is that breastfeeding and lactation can benefit women in the postpartum setting. And so that's something that we can encourage something we can actually do um to help our patients because we do know that lactating women actually have lower fasting, glucose triglycerides, insulin resistance, um lower blood pressure and we don't have to go through the whole entire study. But they tend to um have better outcomes in the long run if they're able to um do breastfeeding at least for six months and possibly even up to a year. And in terms of pharmacology ropy, there's not too much. We do know that low dose aspirin is effective in reducing development of pre eclampsia. And so that's recommended. Um There are some studies that show that matt foreman um can be helpful in reducing diabetes incidents in patients who have gestational diabetes. So that can be helpful as well. Um And so that leads to the question. Should we ask all of our patients when we're doing our general cardiovascular risk stratification about these adverse pregnancy outcomes? And the H. A. Statement says whereas no clinical trials have specifically to the use of statins for cardiovascular prevention in women with a history of these adverse pregnancy outcomes, They actually um the 2018 American Heart Association treatment guidelines for cholesterol, they classify gestational diabetes preeclampsia, preterm birth and birth of a small for gestational age, infant as risk enhancers. And that these should be discussed with the patient on deciding whether to initiate statins for primary prevention. Um So so that would be um my slides for the adverse pregnancy outcomes section. Let's jump a little bit to other conditions that women are more are predominantly affect women. That also put patients at risk. So um lupus unfortunately has a 9 to 1 sex ratio and it has an increased fire risk nine to perhaps even 50 fold due to the inflammation lupus is um one of these things that we don't consider in regard to our cardiovascular scoring systems, but we do know that patients with lupus and rheumatoid arthritis, which is probably kind of more obvious um have a significant increase risk of coronary artery disease and then the other inflammatory disorders such as thyroid disorders, inflammatory bowel disease crisis. All those um increase the risk of endothelial dysfunction as well. So patients with breast cancer unfortunately get radiotherapy exposure and then puts them at risk for premature coronary disease. It's worse if it's directed toward the left breast. Um And so these patients, it has been recommended previously that they should receive like a functional non invasive stress test within 5 to 10 years of completion of their chests, radiation therapy specifically if they're having symptoms of dystonia etcetera. There are also low dose acute, sub acute and late cardio toxicity associated with the chemotherapy related to breast cancer, which can be a whole another talk on its own. Um But obviously this is something that affects women um and and can be very cardio toxic in terms of migraines. Migraines actually especially sorry, especially migraines with aura are linked to increase cardiovascular and cerebrovascular events in the women's health study. So there are patients with migraines who are more likely to have these as fast as well. And so this is something that I think we should keep in mind when you're talking to your patient In regards to patients with Pecos, that's also something that we can consider. So, Pecos patients are at 19% higher risk of developing cardiovascular disease um than other women who do not have cardiovascular disease between the ages of 30 and 40s. Um in depression of course, um, it's really interesting. It it actually does increase your cardiovascular disease risk, but it's actually a smaller increase than other traditional risk factors. I put this light in here because obviously menopause and cardiovascular disease is are related to each other. Um one of the things that we need to really think about is um, the use of hormone replacement therapy and this is definitely something that is not as much in my field, but as much, much more in the primary care field. And I'm sure that you guys are all aware of all the studies talking about um the fact that hormone replacement therapy previously used to be thought of as possibly having some cardiovascular benefit, but after the women's health initiative and the hearse trials been noted not to have any benefit, but then more recently or but then the elite trial came out and there was some thought that perhaps early initiation of hormone replacement therapy In women less than six years of age or within 10 years of menopause was thought to be associated with some reduced risk. And so they're still um a little bit of thought there that maybe early onset, different forms of use of hormone replacement therapy could be useful at this point. There's there's um not too much or momentum in this category of of of of of discussion. Um So what I usually do. Um and this is what uh from the european society actually is to think of it as like a timeline. And so when you think of patients um at each point in their lives, um what they're possible risks are and they kind of just keep acting up unfortunately. So when they're in their teens, you could say early and late mentor can make a difference. Um, migraines and then in there um teams to adolescents, reproductive disorders. And then when they hit their forties, um they may have early menopause or premature hypertension, metabolic syndromes, etcetera. And then further on in their fifties, they might have type one micro vascular disease or persistent nasal motor symptoms after menopause or a young stroke. So these are the patients that you're trying to make sure that if they have these early on in life that you can help prevent future cardiovascular disease. Um This is from the A. J. And they're they're kind of step one through four in reducing cardiovascular disease in women. So they um would like us to screen for these sex specific risk factors which we talked about and then step to assess for the traditional risk factors and then begin aggressive management um which you guys are all aware of with controlling blood pressure cholesterol, reduce sugar, um Stay active, stay healthy and then set for also of course to use the tenure A CVD. Risk lifetime risk assessment with some caveats and of course discussed with the patient. So I went after this step. Of course. Then it's the discussion of whether we should start statin therapy or not. And like I said before, patients told me that they didn't want status because they were they were told somewhere or thought that they were ineffective in women. So that's not true. There was this huge trial done a long time ago, the cholesterol treatment, trialist collaboration Like 134,000 participants and they gave them statins and they found that uh, there were similar effects in statin therapy and reduction of cardiovascular event and mortality in both men and women. I'm okay. And then in regards to seeing someone in the clinic and discussing prevention and going through prevention, One of the things is that sometimes patients will actually say, hey, I have symptoms and are these symptoms heart disease or coronary disease. And I think I see this a lot that women, there are women who don't know. And so they come to see me and they say, I have this, I have that, you know, what is it? Um So in terms of heart attack symptoms and every, I think we all know this that women present differently than that. So if you're sitting in a clinic and they're acutely having any of these symptoms, definitely, you want to kind of think maybe there is a possibility that this is a heart attack if it's not going away. So any nausea or vomiting, excuse me. Um any nausea or vomiting and any jaw or neck or upper black back pain, any chest pain. Um but not always not women and even men don't always have chest pain, um any upper chest or upper abdomen discomfort, shortness of breath. Um certainly I think a B or fainting is, sometimes I open this, they create that generally with a heart attack, but it can be related. Um and then indigestion. And sometimes women present kind of just very, very tired. I'm just very, very tired and this is an acute onset. If it's acute onset and it's just not normal, it doesn't go away. Then I tell patients yes than than go to the emergency room to get evaluated because you'd rather you know, be wrong then this acute in mind in terms of stable angina. The things that um we see are squeezing a sensation, chest tightness, radiation again to the chest, to the jaw, to the armpits um lasting longer than a few minutes and crescendo de crescendo kind of character. Shortness of breath, definitely mental stress related symptoms seem to be more so in women, an extreme tiredness, often after an internet episode. Those are probably more kind of typical. What we would say is maybe a female specific symptom apology um and then which would merit an evaluation? Um atypical would be if they have kind of both typical atypical symptoms. You know, the patients who have symptoms with exertion but also without exertion. Um And then the non angel chest pain would be kind of um It always only happens when they're at rest or there's kind of one other criteria that doesn't seem to meet. Um um Symptomology here and this is obviously very, very broad and obviously very, very difficult. And so because women tend to be poorly recognized in terms of their cardiovascular risk, I do think it's always kind of um better to send them to us for further evaluation if necessary so that we can kind of get things started and consider a stress test or further evaluation and that's it there. That's very interesting about the ischemic heart disease in women um is that it's different than in men. Um Men tend to have a very focal kind of cyanosis pattern, whereas women tend to have a more diffused atherosclerotic pattern. Women also unfortunately have smaller coronary arteries and so it um leads to kind of a more diffused smaller coronary arteries and less stone ah tick but more just kind of um diffuse plaque um When this occurs it's a lot harder. Um to just say I'm going to go in there and I'm gonna stent this, you know 90% lesion because it's so diffuse and so to treat that is a little bit more complex. The other thing that women have our you know is microvascular disease. It it's much much more common in women than in men. So here's like a beautiful picture of the micro vasculature. So basically all of these arteries and arterials that are actually in the small, small, small, small, even smaller spaces that go into the actual myocardial um versus the epic cardio blood vessels. And so women tend to have this kind of micro vascular disease and intends to be missed. Because if they come to you and they say I have exertion, all angina symptoms and you do a cardiovascular um stress echo, for example, or or even a nuclear. Well, we're looking with or on Trafico nuclear, it's going to be positive if there is obstructive lesion in the epic cardio arteries, right? But if it's microvascular disease, it will be possibly completely normal. But they can still have micro vascular disease. Usually if they have significant microvascular disease, there may be some very um subtle while motion abnormalities, but they can be missed. And so if a patient comes to you and they say that they have a variable threshold of activity that provokes the angina, meaning sometimes they can walk up a hill but sometimes it doesn't they don't they can't before they have the chest pain. Or if the duration kind of persons for a for a few minutes and then um uh after effort is interrupted, meeting if they walk up the hill and then it it takes more than a few minutes before the symptoms go away. And if they have kind of a slow and not a very good response to nitrates, it's possible that they have micro vascular disease. The other thing is that low heart rate activities such as mental arousal or basically emotional distress or palpitations are more likely to trigger angina in micro vascular disease and lovely. These patients tend to just feel very, very tired all the time. So that's a possibility. And what can we do to how do we diagnose microvascular disease? This is not that easy, but the probably the best validated modality for evaluating for micro vascular disease would be cardiac pet. Um And cardiac pet specifically in 13 ammonia pet is probably the most validated um suspect which is the nuclear mp that we generally get. It's not very useful um at all. And it's pretty limited utility. And then you could consider cardiac M. R. But it's not very well validated right now and it's really expensive. And from a prognostic risk perspective that data is limited. So usually if it's someone that I'm really suspicious as micro vascular disease and I would order a cardiac and what do I do for treatment? So the first thing is aggressive risk Matthew modification, which were already usually doing and then I can try some sublingual natural western. If that does not work, then the other medications that we usually use for angina can be utilized. So um it's interesting rednecks is seems to have pretty uh in small studies, pretty significant benefits. So you can try run exa and beta blockers and calcium channel blockers have some benefit. And lastly some patients really do well with low dose in it for me. But I honestly um this was there were a couple of studies on this but it's not constant, it's not a very common usage but I've seen it um seen it a couple times Um and enter transition in women especially Perry Pardon? You have to consider there is possibility of scat so spontaneous coronary dissection where you basically have a dissection in your little coronary vessels and that's unfortunately predominantly women 80% average age 42 years. Um It's usually associated onboard questions rights related to peri partum but it can actually happen just spontaneously not related, anything to pregnancy at all and we still don't really know what, we don't really have a good sense of it yet. Um The classic presentation is always like kind of a very young healthy women without any traditional A. S. CVD risk factors. And then it kind of has sudden hcs. Um it usually does have some recurrent 10 year, 20% recurrence and you just have to be really suspicious of it because one of the things that can happen is that when you go in and Kathy's patients who are having um then you're in semi, especially if it's an n steamy um when you catch them, they might have the flap may have actually been pushed back by the force of your injection and you may not actually see the coronary dissection plane is it's so small and so a lot of, there are times when patients who have scared um it's missed. So it's for good practitioner um It's just something to be aware of and to be suspicious of because one of the things that needs to be done for patients with scott is that they should be screened for fiber muscular dysplasia because there's a pretty significant overlap there. Um And that screening includes um vascular like either C. T. Or M. R. C. T. A. Or M. R. A. For their brain to look for any aneurysms and then basically basis goal all the way to tell this um of uh C. T. Angio to look for any vascular problems and to see if they have fiber vascular display shin. Um The next uh topic would be taxable which is very common in post menopausal women or at least most commonly noted in postmenopausal women. And we all know it's preceded by emotional or physical stressors and generally improves with beta blockers with a generally good prognosis um which is um typically seen here with a pickle dilation, which improves after a few days. It can be very difficult sometimes to identify the specific stressor that caused this problem. Um and so, but the classic finding is that the cath is negative and when the patient gets a repeat echo within a short time span, everything reverts back to normal. And then the assumption is it was a stress cardiomyopathy. And I think lastly, the thing to talk about is heart failure with preserved ejection fraction, which is twice as likely to occur in women than in men. Um and we think that this is probably because microvascular endothelial dysfunction is part of the ideology for half deaf and also because, like we talked about previously, women tend to have higher blood pressure than then. And this is a very poorly understood um entity unfortunately possibly because it's so diverse. Like I think a lot of different kinds of cardiomyopathy get thrown into the bucket for half path. And so it's not always clear exactly um the genotype that is is um is noted. And so I think when we do studies on these patients with Half Path it can be um it can be somewhat heterogeneous what the findings are. Um But fortunately um there may be good news in the home front for Half Path. There may be a medication and S. G. L. T. Two inhibitor may possibly uh the publication that's coming out very soon. There may be some good news that there is something we can do for these patients with half past. And so in summary heart disease is the leading cause of death in women. Unfortunately, black women are most vulnerable into early cardiovascular disease and have poor long term outcomes and then adverse outcomes in pregnancy, increased cardiovascular risk. And there's something we should consider in our screening. Uh and then there are, of course the several conditions which we mentioned that increased cardiovascular risk um that are predominantly affecting women, um, and that women also have a different pattern of ischemic heart disease than men, including micro vascular disease, which should be included on your different
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