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IޟrpyϺHEM< a5| yN5&P$s_Я"^>/픲_gz#yu>q^I>Olb_pWkK}Hy:[w}J_}\Y/'M_,'~>c獜MIOFo);oΖ:|݌7-q*# Ư'w>R^izYY\/?{a#Ǔw{Ls_ǼzHy1/^~Bc'/_40^U4._; gHUqsaEJO>cg1,o}˲u^zl_}>ww/Cifdm4ٓZnrPG5j~88~|keb[7~zk}z~}M4#*wwcۀE$sPӫ-15wԓc|с4kΗ-3kww`[\58OP˃:ԓ\mW&<#c2Ug{ ϗG _9G򝪿,ha6Ji֧ߝ9$giߵe{uG^> aXצs[1Hbބ"$թs=w_O& WWA"$zVK0{2ǚpˆ{ 0AA@auʚ;2Nʚ;g4EdEd 0@ppp@ <4!d!dqt 0$0~<4ddddqt 0$0~<4ddddqt 0$0~P 0___PPT10 ___PPT9xB`? % +Cardiovascular Disease in Women (Joel Niznick MD FRCPCXR%Attribution: Some slides adapted from&&(LGbThe Heart and Stroke Foundation Fact Sheet  Women 21(Prevalence In 2000, 1 in 5 women aged 70 and over were told by a physician that they had heart problems. Mortality (1999 data) Coronary artery disease accounted for almost half of all CVD deaths among women. 9,038 women died of stroke (8.5% of all deaths) among women. More men than women died from coronary artery disease (23,617 vs. 19,002) and heart attack (11,948 vs. 8,978) More women than men died from congestive heart failure (CHF) (2,646 vs.1,845). More women than men died from stroke (9,038 vs. 6,371).  Z_ZZZZ _  MHRisk Factors in Women The Heart and Stroke Foundation Fact Sheet  Women "I$3Tobacco Smoking In 2001, 15% of young women (15-17 yrs) smoked daily. In 2001, 16% of women aged 15+ years smoked daily. Physical Inactivity In 2000, 6 in 10 women were physically inactive. Obesity In 2000, 14.2% of women were obese. High Blood Pressure In 2000, 15.7% of women aged 20+ reported having high blood pressure. Nutrition: Inadequate Consumption of Vegetables and Fruit Almost 6 in 10 women consumed less than the recommended amount of vegetables and fruit. PkPP1PP$PPFP:PXPPj1$  F  :XNEOFPI:Mortality Rates for CVD Declining Faster in Men than Women;;(QJ>Mortality Rates in Women Expected to Increase in Next 20 years??(D; CAD in WomendWomen develop angina about 10 years later and a first MI about 20 years later than men Women are more likely to have angina than MI as their initial presentation of CAD Women presenting with acute MI tend to be older and have more co-morbidity Women are less likely than men to attribute their symptoms to cardiac disease, even in the setting of acute MI eZeYPRisk Factors in Women -1|Diabetes Mellitus Diabetes mellitus is a more powerful predictor of CHD risk and prognosis in women than in men Diabetes is commonly accompanied by other cardiovascular risk factors in women Diabetes was found to be the only risk factor that distinguished between those with and without angiographic CHD A history of IDDM is also a strong risk factor in women for death after MI >PkPjZQRisk Factors in Women - 2dHypertension The prevalence of hypertension reaches 70 to 80 % in women above age of 70 Hypertension in women is both a strong predictor of coronary risk and more commonly seen in those with CHD This increase in risk is also seen in pre-menopausal women in whom the presence of Hypertension is associated with up to 10 fold increase in coronary mortality 4 PXP X[SRisk Factors in Women - 3Smoking Smoking has been associated with one-half of all coronary events in women Coronary risk is elevated even in women with minimal use - RR 2.4 for 1.4 cigarettes/day ( Douglas and Ginsburg, 1996 ) Smoking has a more harmful impact on women than on men and that risk increases in direct proportion to the number of cigarettes smoked daily Smoking carries a particularly high risk in younger women, a population likely to contribute substantially to future burden of CHD LPP\T@Risk Factors in Women  3 cont d!!(Compared with nonsmokers, the incidence of MI was increased 6-fold in women and 3-fold in men who smoked at least 20 cigarettes per day The risk particularly high in younger women the antiestrogenic effect of cigarette smoking may be one possible explanation for the increased risk of young female smokers (Njolstad et al, 1996) Smoking is also a powerful risk factor for MI in middle-aged women than men Most of the increased risk induced by smoking dissipates within 2 to 3 years of cessation of smoking fZZZ,m]U2Risk Factors in Women  4Dyslipidemia Low HDL, rather than high LDL cholesterol, is more predictive of coronary risk in women Lipoprotein (a) is a determinant of CHD ( manifested as angina or MI) in pre-menopausal women and postmenopausal women under age 66 (OR 5.1 and 2.4, respectively ) The total cholesterol concentration appears to be associated with CHD only in pre-menopausal women or at high levels Triglycerides appear to uniquely influence coronary risk in older women, especially at levels above 400 mg/dl J PPP RDInfluence of Hormonal StatusCHD is unusual in pre-menopausal women, particularly in absence of other risk factors If pre-menopausal women develop CHD, the disease tends to be more extensive and diffuse than in men of the same age Surgical menopause, with or without hormone replacement, carries an added risk of CHD, in excess of that noted for natural menopause The loss of estrogen causes increase in LDL cholesterol, total cholesterol, TGs and decrease in HDL cholesterol $P"E<.Women Have An Atypical Clinical Presentation //(Typical retrosternal chest pain less common Atypical symptoms and location Resting, nocturnal or stress induced chest pain Jaw, arm, shoulder, back, epigastric discomfort Dyspnea, palpitations, presyncope Fatigue, diaphoresis, nausea 6KK,  MSK"Gender Bias or Clinical Conundrum?##(Women who present to the emergency room with new onset chest pain are approached and diagnosed less aggressively than men Compared to men women are less likely to: undergo an EKG, cardiac monitoring or cardiac enzyme measurement to receive a cardiology consult; be admitted to a coronary care or step down unit Women are more likely to receive controlled substances and anxiolytics in the ER XZZRZQs  VM7Comparison of Men and Women in Presentation and Outcome88(&Approach to diagnosis CAD in Women -1-''(*Classify the type of pain Assess determinants of likelihood of CAD Select test based on pre-test probability of CAD Confirm or deny presence of CAD with TMT, stress perfusion study or stress echo High false positive rate TMT rate in pre-menopausal females (up to 50%) or low pre-test likelihood CAD++TBClassification of Chest PainTypical angina Steady retrosternal component Provoked by exertion or stress Relieved by rest or NTG Atypical angina 2 of 3 criteria Non-anginal chest pain 1 of 3 criteria ZW ZZZZZ Z ZZW  I@GPrevalence of CAD (%) in Symptomatic Patients According to Age and SexHH F=.Determinants of the Likelihood of CAD in WomenMAJOR - Post menopausal status / age >65 years - Diabetes - Peripheral Vascular Disease INTERMEDIATE - Hypertension - Smoking - Lipid abnormalities PZV 2 _MINOR - Obesity - Sedentary lifestyle - Family history of CAD - Other risks factors of CAD 0_ZZYJA,Algorithm for Chest Pain Evaluation in WomenLow Probability of CAD (< 20 %) Consider no test High likelihood false + result Intermediate Probability of CAD (20-80%) Perfusion imaging or stress echo High Risk Probability of CAD (> 80%) Perfusion imaging or stress echo Consider direct angiography  Z0Z)Z!Z%Z>Z 0 ! > ^OFComparison of Non-invasive Modalities in the Diagnosis of CAD in WomenGG$?6$Indications for Coronary Angiography%%(mHigh risk stress test ECG Hemodynamic High risk perfusion study Multiple defects Severe perfusion defects TIDL.. yOngoing symptoms Unstable angina Post MI angina CHF Vocational indication Pilots Truck/bus drivers Diagnostic uncertainty6JJWN%See Diagnostic Testing 2004 Slideshow&&(/K  ` ` ̙33` 333MMM` ff3333f` f` f` 3>?" dd@,|?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> 0 ^(     N ))?" `  T Click to edit Master title style! !$  0| "  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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ZB ;` s *1 ?YY`B <` 01 ?ZB =` s *1 ?''1 ZB >` s *1 ?  1 ZB ?` s *1 ?1 `B B` 01 ?`B C` 0o ?`B D` 0o ?`B ` 01 ?k`B ` 01 ?H ` 0޽h ? ̙33  &0P(  P~ P s *  `   ~ P s *    r P S Ȃ p   H P 0޽h ? ffD3fy___PPT10Y+D=' = @B +  d0(  dx d c $` ` 0   x d c $   H d 0޽h ? ̙33t  $**(  x  c $j1  `  1  v # #"2& DDDDDDDDvD  <o1? v Meta-analysis of exercise testing to detect coronary artery disease in women Kwok Y. Kim C. et al Am J Cardiol 1999. Mar 1:83(5); 660-6. @`  <'1?py   L90 @`  <]1?y p  L91 @`  6e1?y   T Rubidium PET   @`  <40?pF y  L79 @`   <0?F py  \80 (SVD) 91 (MVD) @`   60?F y  WDobutamine Echo @`   <X0?p F  L70 @`   <0? pF  L86 @`   60? F  S Stress Echo   @`  <0?p  L80 @`  < ?p  L86 @`  6 ?  R SPECT MIBI   @`  < ?pz L64 @`  <+U?zp L78 @`  6H0U?z WStress Thallium @`  <@:U?p6z L70 @`  <7U?6pz L61 @`  6XKU?6z KTMT @`  6`U?p6 U Specificity % @`  6U?p6 U Sensitivity % @`  <A?6 > @`ZB  s *1 ?ZB  s *1 ?66ZB  s *1 ?zzZB  s *1 ?ZB  s *1 ?  ZB  s *1 ?F F ZB   s *1 ?y y `B ! 01 ?  `B " 0o ?vvZB # s *1 ? 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Mortality (1999 data) Coronary artery disease accounted for almost half of all CVD deaths among women. 9,038 women died of stroke (8.5% of all deaths) among women. More men than women died from coronary artery disease (23,617 vs. 19,002) and heart attack (11,948 vs. 8,978) More women than men died from congestive heart failure (CHF) (2,646 vs.1,845). More women than men died from stroke (9,038 vs. 6,371).  Z_ZZZZ _  MHRisk Factors in Women The Heart and Stroke Foundation Fact Sheet  Women "I$3Tobacco Smoking In 2001, 15% of young women (15-17 yrs) smoked daily. In 2001, 16% of women aged 15+ years smoked daily. Physical Inactivity In 2000, 6 in 10 women were physically inactive. Obesity In 2000, 14.2% of women were obese. High Blood Pressure In 2000, 15.7% of women aged 20+ reported having high blood pressure. Nutrition: Inadequate Consumption of Vegetables and Fruit Almost 6 in 10 women consumed less than the recommended amount of vegetables and fruit. PkPP1PP$PPFP:PXPPj1$  F  :XNEOFPI:Mortality Rates for CVD Declining Faster in Men than Women;;(QJ>Mortality Rates in Women Expected to Increase in Next 20 years??(D; CAD in WomendWomen develop angina about 10 years later and a first MI about 20 years later than men Women are more likely to have angina than MI as their initial presentation of CAD Women presenting with acute MI tend to be older and have more co-morbidity Women are less likely than men to attribute their symptoms to cardiac disease, even in the setting of acute MI eZeYPRisk Factors in Women -1|Diabetes Mellitus Diabetes mellitus is a more powerful predictor of CHD risk and prognosis in women than in men Diabetes is commonly accompanied by other cardiovascular risk factors in women Diabetes was found to be the only risk factor that distinguished between those with and without angiographic CHD A history of IDDM is also a strong risk factor in women for death after MI >PkPjZQRisk Factors in Women - 2dHypertension The prevalence of hypertension reaches 70 to 80 % in women above age of 70 Hypertension in women is both a strong predictor of coronary risk and more commonly seen in those with CHD This increase in risk is also seen in pre-menopausal women in whom the presence of Hypertension is associated with up to 10 fold increase in coronary mortality 4 PXP X[SRisk Factors in Women - 3Smoking Smoking has been associated with one-half of all coronary events in women Coronary risk is elevated even in women with minimal use - RR 2.4 for 1.4 cigarettes/day ( Douglas and Ginsburg, 1996 ) Smoking has a more harmful impact on women than on men and that risk increases in direct proportion to the number of cigarettes smoked daily Smoking carries a particularly high risk in younger women, a population likely to contribute substantially to future burden of CHD LPP\T@Risk Factors in Women  3 cont  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~%Root EntrydO)PdJf!Pictures=BCurrent User5SummaryInformation(XUPowerPoint Document("kyDocumentSummaryInformation8Bitmap Image Paint.Picture0Bitmap Image`/ 0DTimes New Roman 0 0DSymbolew Roman 0 0@ .  @n?" dd@  @@`` , $ |  E+  +E I QRSTWXZ\^_`ab f hjmn+pqrtuvwxzb$aƑ*E26"$(Sl|r}L6"$UaP:|nZ$$$$$$$$$$$$$$$$$$$$2$Qcï$C !b2$U/iV.${zdm"$.>s[1Hbބ"$թs=w_O& WWA"$zVK0{2ǚpˆ{ 0AA@auʚ;2Nʚ;g47d7d  0 ppp@ <4!d!dLqt 0<4ddddLqt 0<4ddddLqt 0P 0___PPT10 ___PPT9xB`? %4Cardiovascular Disease in Women (Joel Niznick MD FRCPCXR%Attribution: Some slides adapted from&&(LGbThe Heart and Stroke Foundation Fact Sheet  Women 21(Prevalence In 2000, 1 in 5 women aged 70 and over were told by a physician that they had heart problems. Mortality (1999 data) Coronary artery disease accounted for almost half of all CVD deaths among women. 9,038 women died of stroke (8.5% of all deaths) among women. More men than women died from coronary artery disease (23,617 vs. 19,002) and heart attack (11,948 vs. 8,978) More women than men died from congestive heart failure (CHF) (2,646 vs.1,845). More women than men died from stroke (9,038 vs. 6,371).  Z_ZZZZ _  MHRisk Factors in Women The Heart and Stroke Foundation Fact Sheet  Women "I$3Tobacco Smoking In 2001, 15% of young women (15-17 yrs) smoked daily. In 2001, 16% of women aged 15+ years smoked daily. Physical Inactivity In 2000, 6 in 10 women were physically inactive. Obesity In 2000, 14.2% of women were obese. High Blood Pressure In 2000, 15.7% of women aged 20+ reported having high blood pressure. Nutrition: Inadequate Consumption of Vegetables and Fruit Almost 6 in 10 women consumed less than the recommended amount of vegetables and fruit. PkPP1PP$PPFP:PXPPj1$  F  :XNEOFPI:Mortality Rates for CVD Declining Faster in Men than Women;;(QJ>Mortality Rates in Women Expected to Increase in Next 20 years??(D; CAD in WomendWomen develop angina about 10 years later and a first MI about 20 years later than men Women are more likely to have angina than MI as their initial presentation of CAD Women presenting with acute MI tend to be older and have more co-morbidity Women are less likely than men to attribute their symptoms to cardiac disease, even in the setting of acute MI eZeYPRisk Factors in Women -1|Diabetes Mellitus Diabetes mellitus is a more powerful predictor of CHD risk and prognosis in women than in men Diabetes is commonly accompanied by other cardiovascular risk factors in women Diabetes was found to be the only risk factor that distinguished between those with and without angiographic CHD A history of IDDM is also a strong risk factor in women for death after MI >PkPjZQRisk Factors in Women - 2dHypertension The prevalence of hypertension reaches 70 to 80 % in women above age of 70 Hypertension in women is both a strong predictor of coronary risk and more commonly seen in those with CHD This increase in risk is also seen in pre-menopausal women in whom the presence of Hypertension is associated with up to 10 fold increase in coronary mortality 4 PXP X[SRisk Factors in Women - 3Smoking Smoking has been associated with one-half of all coronary events in women Coronary risk is elevated even in women with minimal use - RR 2.4 for 1.4 cigarettes/day ( Douglas and Ginsburg, 1996 ) Smoking has a more harmful impact on women than on men and that risk increases in direct proportion to the number of cigarettes smoked daily Smoking carries a particularly high risk in younger women, a population likely to contribute substantially to future burden of CHD LPP\T@Risk Factors in Women  3 cont d!!(Compared with nonsmokers, the incidence of MI was increased 6-fold in women and 3-fold in men who smoked at least 20 cigarettes per day The risk particularly high in younger women the antiestrogenic effect of cigarette smoking may be one possible explanation for the increased risk of young female smokers (Njolstad et al, 1996) Smoking is also a powerful risk factor for MI in middle-aged women than men Most of the increased risk induced by smoking dissipates within 2 to 3 years of cessation of smoking fZZZ,m]U2Risk Factors in Women  4Dyslipidemia Low HDL, rather than high LDL cholesterol, is more predictive of coronary risk in women Lipoprotein (a) is a determinant of CHD ( manifested as angina or MI) in pre-menopausal women and postmenopausal women under age 66 (OR 5.1 and 2.4, respectively ) The total cholesterol concentration appears to be associated with CHD only in pre-menopausal women or at high levels Triglycerides appear to uniquely influence coronary risk in older women, especially at levels above 400 mg/dl J PPP RDInfluence of Hormonal StatusCHD is unusual in pre-menopausal women, particularly in absence of other risk factors If pre-menopausal women develop CHD, the disease tends to be more extensive and diffuse than in men of the same age Surgical menopause, with or without hormone replacement, carries an added risk of CHD, in excess of that noted for natural menopause The loss of estrogen causes increase in LDL cholesterol, total cholesterol, TGs and decrease in HDL cholesterol $P"_V:Estrogen Replacement Therapy (ERT): Benefits and Risks - 1;;(Normal menopause ~age 51(95% age 45-55) ERT best therapy for peri-menopausal symptoms Duration 6 months to 4-5 years Observational studies suggested benefit of ERT or combined estrogen-progestin (HRT) on risk of CHD and development of osteoporosis Women s Health Initiative (WHI) July 2002 discounted benefit of HRT for cardiac prevention<VV`W:Estrogen Replacement Therapy (ERT): Benefits and Risks - 2;;(~WHI Studies Combined estrogen/progestin replacement1 > 16,000 post menopausal women age 50-79 Terminated early with average f/u 5.2 years Increased risk breast cancer, stroke, CHD (HR 1.24) and VTE Unopposed estrogen trial > 11,000 women with prior hysterectomy Received unopposed estrogen Study discontinued early due to increased risk of stroke and no projected overall benefit P+PPPP (    ~aY3Estrogen Replacement Therapy (ERT): Recommendations44(}Estrogen-progestin therapy should not be prescribed for primary prevention of CHD. Estrogen-progestin therapy should be discontinued if an acute CHD event occurs, and should not be resumed as a secondary prevention strategy. Unopposed estrogen, although it does not appear to increase CHD risk, should not be prescribed for primary prevention because no reduction in CHD risk was observed in the WHI trial . Estrogen or estrogen-progestin therapy should be reserved for peri-menopausal women with moderate to severe menopausal symptoms. The lowest estrogen dose that relieves symptoms should be used for the shortest duration possible. ,~P"YE<.Women Have An Atypical Clinical Presentation //(Typical retrosternal chest pain less common Atypical symptoms and location Resting, nocturnal or stress induced chest pain Jaw, arm, shoulder, back, epigastric discomfort Dyspnea, palpitations, presyncope Fatigue, diaphoresis, nausea 6KK,  MSK"Gender Bias or Clinical Conundrum?##(Women who present to the emergency room with new onset chest pain are approached and diagnosed less aggressively than men Compared to men women are less likely to: undergo an EKG, cardiac monitoring or cardiac enzyme measurement to receive a cardiology consult; be admitted to a coronary care or step down unit Women are more likely to receive controlled substances and anxiolytics in the ER XZZRZQs  VM7Comparison of Men and Women in Presentation and Outcome88(&Approach to diagnosis CAD in Women -1-''(*Classify the type of pain Assess determinants of likelihood of CAD Select test based on pre-test probability of CAD Confirm or deny presence of CAD with TMT, stress perfusion study or stress echo High false positive rate TMT rate in pre-menopausal females (up to 50%) or low pre-test likelihood CAD++TBClassification of Chest PainTypical angina Steady retrosternal component Provoked by exertion or stress Relieved by rest or NTG Atypical angina 2 of 3 criteria Non-anginal chest pain 1 of 3 criteria ZW ZZZZZ Z ZZW  I@GPrevalence of CAD (%) in Symptomatic Patients According to Age and SexHH F=.Determinants of the Likelihood of CAD in WomenMAJOR - Post menopausal status / age >65 years - Diabetes - Peripheral Vascular Disease INTERMEDIATE - Hypertension - Smoking - Lipid abnormalities PZV 2 _MINOR - Obesity - Sedentary lifestyle - Family history of CAD - Other risks factors of CAD 0_ZZYJA,Algorithm for Chest Pain Evaluation in WomenLow Probability of CAD (< 20 %) Consider no test High likelihood false + result Intermediate Probability of CAD (20-80%) Perfusion imaging or stress echo High Risk Probability of CAD (> 80%) Perfusion imaging or stress echo Consider direct angiography  Z0Z)Z!Z%Z>Z 0 ! > ^OFComparison of Non-invasive Modalities in the Diagnosis of CAD in Women     "#$&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}GG$?6$Indications for Coronary Angiography%%(mHigh risk stress test ECG Hemodynamic High risk perfusion study Multiple defects Severe perfusion defects TIDL.. yOngoing symptoms Unstable angina Post MI angina CHF Vocational indication Pilots Truck/bus drivers Diagnostic uncertainty6JJWN%See Diagnostic Testing 2004 Slideshow&&(/K  p@(  r  S   `   r  S h73     s * "``Z >ERT and CV Risk I in UpToDate,RoseBD (ed),Wellesley, MA 2004 ?(2?,  H  0޽h ? ̙33___PPT10i.P-+D=' = @B +m  |(  r  S g  `   r  S @k     0p l"1 NEJM 2003 Aug 9;349(6):523-341. .# 2"  s *Pn"``Z >ERT and CV Risk I in UpToDate,RoseBD (ed),Wellesley, MA 2004 ?(2?,  H  0޽h ? ̙33___PPT10i.@j+D=' = @B +  @(  r  S @n  `  n r  S      s *=n"``Z >ERT and CV Risk I in UpToDate,RoseBD (ed),Wellesley, MA 2004 ?(2?,  H  0޽h ? ̙33___PPT10i.p7+D=' = @B +x.  --pF`/-(  `x ` c $0 .  `  . w,  ` #"2&rsrrrsrr ` <q?Y1  Y1 of 3 criteria @` ` <D}? 1 Y Y2 of 3 criteria @` ` <x?k1  Y3 of 3 criteria @` ` <x+?1 k > @` ` <(? W1) Retrosternal discomfort.2) Provoked by exercise or stress.3) Relieved by rest or NTGXX @`  ` <ğ? 1  N18.6 @`  ` <?Y 1  N28.1 @`  ` <h? Y1  N54.6 @`  ` <L? 1  N90.6 @`  ` <Þ?' 1  N90.6 @` ` <˞?k '1  N94.3 @` ` 6p՞? k1  M60-69 @` ` <ݞ?L   M8.4 @` ` <?YL   N21.5 @` ` <? L Y  N32.4 @` ` <? L  N58.9 @` ` <?'L  N79.4 @` ` < ?kL '  N92.0 @` ` 6,?L k  M50-59 @` ` < ?L  M2.8 @` ` <?YL  N14.1 @` ` <(? YL  N13.3 @` ` <7?  L  N46.1 @` ` <@?' L  N55.2 @` ` <I?k'L  N87.3 @` ` 6R?kL  M40-49 @` ` <[?h M0.8 @` ` <d?Yh M5.2 @`  ` <m? hY M4.2 @` !` <v? h  N21.8 @` "` <?'h  N25.8 @` #` <?kh' N69.7 @` $` 6?hk M30-39 @` %` <?h OWomen @` &` <ģ?Yh MMen @` '` <̬? Yh OWomen @` (` <Ե?  h MMen @` )` <ܾ?' h OWomen @` *` <ǟ?k'h MMen @` +` 6П?kh KAGE @` ,` 6ҟ?Y `Non anginal chest pain @` -` 6x? Y YAtypical angina @` .` 6`ܟ?k  XTypical angina @` /` <?k > @`ZB 0` s *1 ?kZB 1` s *1 ?ZB 2` s *1 ?hhZB 3` s *1 ?ZB 4` s *1 ?L L ZB 5` s *1 ?  ZB 6` s *1 ?1 1 `B 7` 0o ?ZB 8` s *1 ?ZB 9` s *1 ?kkZB :` s *1 ?  ZB ;` s *1 ?YY`B <` 01 ?ZB =` s *1 ?''1 ZB >` s *1 ?  1 ZB ?` s *1 ?1 ZB B` s *1 ?k`B D` 0o ?`B ` 01 ?kZB ` s *1 ?1 `B ` 01 ?1 `B C` 0o ?`B ` 01 ?kH ` 0޽h ? ̙33y___PPT10Y+D=' = @B +r IxH_0<b@D@ vaC( "  [Bitmap Image Paint.Pi ՜.+,0    On-screen ShowOttawacvcentreky  #Times New RomanSymbolCMI copyright template Bitmap Image Cardiovascular Disease in Women&Attribution: Some slides adapted from2The Heart and Stroke Foundation Fact Sheet WomenIRisk Factors in Women The Heart and Stroke Foundation Fact Sheet Women Slide 5Slide 6;Mortality Rates for CVD Declining Faster in Men than Women?Mortality Rates in Women Expected to Increase in Next 20 years CAD in WomenRisk Factors in Women -1Risk Factors in Women - 2Risk Factors in Women - 3!Risk Factors in Women 3 contdRisk Factors in Women 4Influence of Hormonal Status;Estrogen Replacement Therapy (ERT): Benefits and Risks - 1;Estrogen Replacement Therapy (ERT): Benefits and Risks - 2;Estrogen Replacement Therapy (ERT): Benefits and Risks - 3;Estrogen Replacement Therapy (ERT): Benefits and Risks - 44Estrogen Replacement Therapy (ERT): Recommendations/Women Have An Atypical Clinical Presentation #Gender Bias or Clinical Conundrum?8Comparison of Men and Women in Presentation and Outcome$Approach to diagnosis CAD in Women Classification of Chest PainHPrevalence of CAD (%) in Symptomatic Patients According to Age and Sex/Determinants of the Likelihood of CAD in Women-Algorithm for Chest Pain Evaluation in WomenGComparison of Non-invasive Modalities in the Diagnosis of CAD in Women%Indications for Coronary Angiography&See Diagnostic Testing 2004 Slideshow _GyfNiznickNiznick Fonts UsedDesign TemplateEmbedded OLE Servers Slide Titles d!!(Compared with nonsmokers, the incidence of MI was increased 6-fold in women and 3-fold in men who smoked at least 20 cigarettes per day The risk particularly high in younger women the antiestrogenic effect of cigarette smoking may be one possible explanation for the increased risk of young female smokers (Njolstad et al, 1996) Smoking is also a powerful risk factor for MI in middle-aged women than men Most of the increased risk induced by smoking dissipates within 2 to 3 years of cessation of smoking fZZZ,m]U2Risk Factors in Women  4Dyslipidemia Low HDL, rather than high LDL cholesterol, is more predictive of coronary risk in women Lipoprotein (a) is a determinant of CHD ( manifested as angina or MI) in pre-menopausal women and postmenopausal women under age 66 (OR 5.1 and 2.4, respectively ) The total cholesterol concentration appears to be associated with CHD only in pre-menopausal women or at high levels Triglycerides appear to uniquely influence coronary risk in older women, especially at levels above 400 mg/dl J PPP RDInfluence of Hormonal StatusCHD is unusual in pre-menopausal women, particularly in absence of other risk factors If pre-menopausal women develop CHD, the disease tends to be more extensive and diffuse than in men of the same age Surgical menopause, with or without hormone replacement, carries an added risk of CHD, in excess of that noted for natural menopause The loss of estrogen causes increase in LDL cholesterol, total cholesterol, TGs and decrease in HDL cholesterol $P"_V:Estrogen Replacement Therapy (ERT): Benefits and Risks - 1;;(Normal menopause ~age 51(95% age 45-55) ERT best therapy for peri-menopausal symptoms Duration 6 months to 4-5 years Observational studies suggested benefit of ERT or combined estrogen-progestin (HRT) on risk of CHD and development of osteoporosis Women s Health Initiative (WHI) July 2002 discounted benefit of HRT for cardiac prevention<VV`W:Estrogen Replacement Therapy (ERT): Benefits and Risks - 2;;(~WHI Studies Combined estrogen/progestin replacement1 > 16,000 post menopausal women age 50-79 Terminated early with average f/u 5.2 years Increased risk breast cancer, stroke, CHD (HR 1.24) and VTE Unopposed estrogen trial > 11,000 women with prior hysterectomy Received unopposed estrogen Study discontinued early due to increased risk of stroke and no projected overall benefit P+PPPP (    ~aY3Estrogen Replacement Therapy (ERT): Recommendations44(}Estrogen-progestin therapy should not be prescribed for primary prevention of CHD. Estrogen-progestin therapy should be discontinued if an acute CHD event occurs, and should not be resumed as a secondary prevention strategy. Unopposed estrogen, although it does not appear to increase CHD risk, should not be prescribed for primary prevention because no reduction in CHD risk was observed in the WHI trial . Estrogen or estrogen-progestin therapy should be reserved for peri-menopausal women with moderate to severe menopausal symptoms. The lowest estrogen dose that relieves symptoms should be used for the shortest duration possible. ,~P"YE<.Women Have An Atypical Clinical Presentation //(Typical retrosternal chest pain less common Atypical symptoms and location Resting, nocturnal or stress induced chest pain Jaw, arm, shoulder, back, epigastric discomfort Dyspnea, palpitations, presyncope Fatigue, diaphoresis, nausea 6KK,  MSK"Gender Bias or Clinical Conundrum?##(Women who present to the emergency room with new onset chest pain are approached and diagnosed less aggressively than men Compared to men women are less likely to: undergo an EKG, cardiac monitoring or cardiac enzyme measurement to receive a cardiology consult; be admitted to a coronary care or step down unit Women are more likely to receive controlled substances and anxiolytics in the ER XZZRZQs  VM7Comparison of Men and Women in Presentation and Outcome88(#Approach to diagnosis CAD in Women $$(*Classify the type of pain Assess determinants of likelihood of CAD Select test based on pre-test probability of CAD Confirm or deny presence of CAD with TMT, stress perfusion study or stress echo High false positive rate TMT rate in pre-menopausal females (up to 50%) or low pre-test likelihood CAD++TBClassification of Chest PainTypical angina Steady retrosternal component Provoked by exertion or stress Relieved by rest or NTG Atypical angina 2 of 3 criteria Non-anginal chest pain 1 of 3 criteria ZW ZZZZZ Z ZZW  I@GPrevalence of CAD (%) in Symptomatic Patients According to Age and SexHH F=.Determinants of the Likelihood of CAD in WomenMAJOR - Post menopausal status / age >65 years - Diabetes - Peripheral Vascular Disease INTERMEDIATE - Hypertension - Smoking - Lipid abnormalities PZV 2 _MINOR - Obesity - Sedentary lifestyle - Family history of CAD - Other risks factors of CAD 0_ZZYJA,Algorithm for Chest Pain Evaluation in WomenLow Probability of CAD (< 20 %) Consider no test High likelihood false + result Intermediate Probability of CAD (20-80%) Perfusion imaging or stress echo High Risk Probability of CAD (> 80%) Perfusion imaging or stress echo Consider direct angiography  Z0Z)Z!Z%Z>Z 0 ! > ^OFComparison of Non-invasive Modalities in the Diagnosis of CAD in WomenGG$?6$Indications for Coronary Angiography%%(mHigh risk stress test ECG Hemodynamic High risk perfusion study Multiple defects Severe perfusion defects TIDL.. yOngoing symptoms Unstable angina Post MI angina CHF Vocational indication Pilots Truck/bus drivers Diagnostic uncertainty6JJWN%See Diagnostic Testing 2004 Slideshow&&(/K  `6(  ~  s *H%  `   x  c $  p@  H  0޽h ? @ ff3Ιd332zy___PPT10Y+D=' = @B +rDwL  wӼaC( "  \Bitmap Image Paint.Picture0Bitmap Image`/ 0DTimes New Roman 0 0DSymbolew Roman 0 0@ .  @n?" dd@  @@`` , $ |   E+  +E I QRSTWXZ\^_`ab f hjmn+pqrtuvwxzb$aƑ*E26"$(Sl|r}L6"$UaP:|nZ$$$$$$$$$$$$$$$$$$$$2$Qcï$C !b2$U/iV.${zdm"$.>s[1Hbބ"$թs=w_O& WWA"$zVK0{2ǚpˆ{ 0AA@auʚ;2Nʚ;g45d5d  0ppp@ <4!d!dLqt 0<4ddddLqt 0<4ddddLqt 0P 0___PPT10 ___PPT9xB`? %4Cardiovascular Disease in Women (Joel Niznick MD FRCPCXR%Attribution: Some slides adapted from&&(LGbThe Heart and Stroke Foundation Fact Sheet  Women 21(Prevalence In 2000, 1 in 5 women aged 70 and over were told by a physician that they had heart problems. Mortality (1999 data) Coronary artery disease accounted for almost half of all CVD deaths among women. 9,038 women died of stroke (8.5% of all deaths) among women. More men than women died from coronary artery disease (23,617 vs. 19,002) and heart attack (11,948 vs. 8,978) More women than men died from congestive heart failure (CHF) (2,646 vs.1,845). More women than men died from stroke (9,038 vs. 6,371).  Z_ZZZZ _  MHRisk Factors in Women The Heart and Stroke Foundation Fact Sheet  Women "I$3Tobacco Smoking In 2001, 15% of young women (15-17 yrs) smoked daily. In 2001, 16% of women aged 15+ years smoked daily. Physical Inactivity In 2000, 6 in 10 women were physically inactive. Obesity In 2000, 14.2% of women were obese. High Blood Pressure In 2000, 15.7% of women aged 20+ reported having high blood pressure. Nutrition: Inadequate Consumption of Vegetables and Fruit Almost 6 in 10 women consumed less than the recommended amount of vegetables and fruit. PkPP1PP$PPFP:PXPPj1$  F  :XNEOFPI:Mortality Rates for CVD Declining Faster in Men than Women;;(QJ>Mortality Rates in Women Expected to Increase in Next 20 years??(D; CAD in WomendWomen develop angina about 10 years later and a first MI about 20 years later than men Women are more likely to have angina than MI as their initial presentation of CAD Women presenting with acute MI tend to be older and have more co-morbidity Women are less likely than men to attribute their symptoms to cardiac disease, even in the setting of acute MI eZeYPRisk Factors in Women -1|Diabetes Mellitus Diabetes mellitus is a more powerful predictor of CHD risk and prognosis in women than in men Diabetes is commonly accompanied by other cardiovascular risk factors in women Diabetes was found to be the only risk factor that distinguished between those with and without angiographic CHD A history of IDDM is also a strong risk factor in women for death after MI >PkPjZQRisk Factors in Women - 2cHypertension The prevalence of hypertension reaches 70 to 80 % in women above age of 70 Hypertension in women is both a strong predictor of coronary risk and more commonly seen in those with CHD This increase in risk is also seen in pre-menopausal women in whom the presence of hypertension is associated with up to 10 fold increase in coronary mortality 4 PWP W[SRisk Factors in Women - 3Smoking Smoking has been associated with one-half of all coronary events in women Coronary risk is elevated even in women with minimal use - RR 2.4 for 1.4 cigarettes/day ( Douglas and Ginsburg, 1996 ) Smoking has a more harmful impact on women than on men and that risk increases in direct proportion to the number of cigarettes smoked daily Smoking carries a particularly high risk in younger women, a population likely to contribute substantially to future burden of CHD LPP\T@Risk Factors in Women  3 cont d!!(Compared with nonsmokers, the incidence of MI was increased 6-fold in women and 3-fold in men who smoked at least 20 cigarettes per day The risk particularly high in younger women the antiestrogenic effect of cigarette smoking may be one possible explanation for the increased risk of young female smokers (Njolstad et al, 1996) Smoking is also a powerful risk factor for MI in middle-aged women than men Most of the increased risk induced by smoking dissipates within 2 to 3 years of cessation of smoking fZZZ,m]U2Risk Factors in Women  4Dyslipidemia Low HDL, rather than high LDL cholesterol, is more predictive of coronary risk in women Lipoprotein (a) is a determinant of CHD ( manifested as angina or MI) in pre-menopausal women and postmenopausal women under age 66 (OR 5.1 and 2.4, respectively ) The total cholesterol concentration appears to be associated with CHD only in pre-menopausal women or at high levels Triglycerides appear to uniquely influence coronary risk in older women, especially at levels above 400 mg/dl J PPP RDInfluence of Hormonal StatusCHD is unusual in pre-menopausal women, particularly in absence of other risk factors If pre-menopausal women develop CHD, the disease tends to be more extensive and diffuse than in men of the same age Surgical menopause, with or without hormone replacement, carries an added risk of CHD, in excess of that noted for natural menopause The loss of estrogen causes increase in LDL cholesterol, total cholesterol, TGs and decrease in HDL cholesterol $P"_V:Estrogen Replacement Therapy (ERT): Benefits and Risks - 1;;(Normal menopause ~age 51(95% age 45-55) ERT best therapy for peri-menopausal symptoms Duration 6 months to 4-5 years Observational studies suggested benefit of ERT or combined estrogen-progestin (HRT) on risk of CHD and development of osteoporosis Women s Health Initiative (WHI) July 2002 discounted benefit of HRT for cardiac prevention<VV`W:Estrogen Replacement Therapy (ERT): Benefits and Risks - 2;;(~WHI Studies Combined estrogen/progestin replacement1 > 16,000 post menopausal women age 50-79 Terminated early with average f/u 5.2 years Increased risk breast cancer, stroke, CHD (HR 1.24) and VTE Unopposed estrogen trial > 11,000 women with prior hysterectomy Received unopposed estrogen Study discontinued early due to increased risk of stroke and no projected overall benefit P+PPPP (    ~aY3Estrogen Replacement Therapy (ERT): Recommendations44(}Estrogen-progestin therapy should not be prescribed for primary prevention of CHD. Estrogen-progestin therapy should be discontinued if an acute CHD event occurs, and should not be resumed as a secondary prevention strategy. Unopposed estrogen, although it does not appear to increase CHD risk, should not be prescribed for primary prevention because no reduction in CHD risk was observed in the WHI trial . Estrogen or estrogen-progestin therapy should be reserved for peri-menopausal women with moderate to severe menopausal symptoms. The lowest estrogen dose that relieves symptoms should be used for the shortest duration possible. ,~P"YE<.Women Have An Atypical Clinical Presentation //(Typical retrosternal chest pain less common Atypical symptoms and location Resting, nocturnal or stress induced chest pain Jaw, arm, shoulder, back, epigastric discomfort Dyspnea, palpitations, presyncope Fatigue, diaphoresis, nausea 6KK,  MSK"Gender Bias or Clinical Conundrum?##(Women who present to the emergency room with new onset chest pain are approached and diagnosed less aggressively than men Compared to men women are less likely to: undergo an EKG, cardiac monitoring or cardiac enzyme measurement to receive a cardiology consult; be admitted to a coronary care or step down unit Women are more likely to receive controlled substances and anxiolytics in the ER XZZRZQs  VM7Comparison of Men and Women in Presentation and Outcome88(#Approach to diagnosis CAD in Women $$(*Classify the type of pain Assess determinants of likelihood of CAD Select test based on pre-test probability of CAD Confirm or deny presence of CAD with TMT, stress perfusion study or stress echo High false positive rate TMT rate in pre-menopausal females (up to 50%) or low pre-test likelihood CAD++TBClassification of Chest PainTypical angina Steady retrosternal component Provoked by exertion or stress Relieved by rest or NTG Atypical angina 2 of 3 criteria Non-anginal chest pain 1 of 3 criteria ZW ZZZZZ Z ZZW  I@GPrevalence of CAD (%) in Symptomatic Patients According to Age and SexHH F=.Determinants of the Likelihood of CAD in WomenMAJOR - Post menopausal status / age >65 years - Diabetes - Peripheral Vascular Disease INTERMEDIATE - Hypertension - Smoking - Lipid abnormalities PZV 2 _MINOR - Obesity - Sedentary lifestyle - Family history of CAD - Other risks factors of CAD 0_ZZYJA,Algorithm for Chest Pain Evaluation in WomenLow Probability of CAD (< 20 %) Consider no test High likelihood false + result Intermediate Probability of CAD (20-80%) Perfusion imaging or stress echo High Risk Probability of CAD (> 80%) Perfusion imaging or stress echo Consider direct angiography  Z0Z)Z!Z%Z>Z 0 ! > ^OFComparison of Non-invasive Modalities in the Diagnosis of CAD in WomenGG$?6$Indications for Coronary Angiography%%(mHigh risk stress test ECG Hemodynamic High risk perfusion study Multiple defects Severe perfusion defects TIDL.. yOngoing symptoms Unstable angina Post MI angina CHF Vocational indication Pilots Truck/bus drivers Diagnostic uncertainty6JJWN%See Diagnostic Testing 2004 Slideshow&&(/K}  $(  r  S X  `  X r  S X  X H  0޽h ? ̙33___PPT10i.eZ=+D=' = @B +}  `$(  r  S d=X  `  X r  S 8>X  X H  0޽h ? ̙33___PPT10i.C9+D=' = @B +?#  V"N"6!(  r  S X  `  X 4! c  #"2&DDDDDDDDc X & <LX?c @ @` % <@X?@ c @ @` $ <@X?x@ c OW < M @` # <LX?xc ^ APMI" @` " <X?  @ @` ! <X?@  @ @`   <X?x @  OW > M @`  <\? x S False + TMT   @`  <|X?   @ @`  <\?@   @ @`  <|\?x @  OW > M @`  <(\? x  T Sudden death   @`  <*\?   R W > or = M   @`  <0;\?@   U PCI Mortality @`  <TD\?x @  OW > M @`  <4F\? x  U Death from MI @`  <V\?N  R W > or = M   @`  <_\?@ N  R CABG Mort.   @`  <h\?xN@  OW > M @`  <q\?Nx  Q Silent MI   @`  <s\? N R W > or = M   @`  <t\?@ N T MI Mortality   @`  <\?x @ N OW > M @`  <Ԗ\? xN S Atypical CP   @`  <P\?  MW > M @`   <\?@   T MI morbidity   @`   <\?x@  OW > M @`   <\?x  NAngina @`   6L\? R Comparison   @`   6\?@  OOutcome @`  6@\?x@  R Comparison   @`  6\?x T Presentation   @``B ' 01 ?ZB ( s *1 ?ZB ) s *1 ?  ZB * s *1 ?NNZB + s *1 ?  ZB , s *1 ?  ZB - s *1 ? @ ZB . s *1 ?@ `B 0 01 ?cZB 1 s *1 ?xxcZB 2 s *1 ?@ @ cZB 3 s *1 ? ZB  s *1 ? cZB  s *1 ? c`B 4 01 ? ZB  s *1 ?@  ZB  s *1 ?@ ZB  s *1 ?@ cc`B / 01 ?c@ cH  0޽h ? ̙33___PPT10i.j+D=' = @B +r V&Z]M m(aMG( "  ]Bitmap Image Paint.Picture0Bitmap Image`/ 0DTimes New Roman 0 0DSymbolew Roman 0 0@ .  @n?" dd@  @@`` < 4 ~" E+  +E I QRSTWXZ\^_`ab f hjmn+pqrtuvwxz{|b$aƑ*E26"$(Sl|r}L6"$UaP:|nZ$$$$$$$$$$$$$$$$$$$$2$Qcï$C !b2$U/iV.${zdm"$.>s[1Hbބ"$թs=w_O& WWA"$zVK0{2ǚpˆ{ 0AA@auʚ;2Nʚ;g45d5d  0ppp@ <4!d!dLqt 0xf<4ddddLqt 0xf<4ddddLqt 0xfP 0___PPT10 ___PPT9xB`? %8Cardiovascular Disease in Women (Joel Niznick MD FRCPCXR%Attribution: Some slides adapted from&&(LGbThe Heart and Stroke Foundation Fact Sheet  Women 21(Prevalence In 2000, 1 in 5 women aged 70 and over were told by a physician that they had heart problems. Mortality (1999 data) Coronary artery disease accounted for almost half of all CVD deaths among women. 9,038 women died of stroke (8.5% of all deaths) among women. More men than women died from coronary artery disease (23,617 vs. 19,002) and heart attack (11,948 vs. 8,978) More women than men died from congestive heart failure (CHF) (2,646 vs.1,845). More women than men died from stroke (9,038 vs. 6,371).  Z_ZZZZ _  MHRisk Factors in Women The Heart and Stroke Foundation Fact Sheet  Women "I$3Tobacco Smoking In 2001, 15% of young women (15-17 yrs) smoked daily. In 2001, 16% of women aged 15+ years smoked daily. Physical Inactivity In 2000, 6 in 10 women were physically inactive. Obesity In 2000, 14.2% of women were obese. High Blood Pressure In 2000, 15.7% of women aged 20+ reported having high blood pressure. Nutrition: Inadequate Consumption of Vegetables and Fruit Almost 6 in 10 women consumed less than the recommended amount of vegetables and fruit. PkPP1PP$PPFP:PXPPj1$  F  :XNEOFPI:Mortality Rates for CVD Declining Faster in Men than Women;;(QJ>Mortality Rates in Women Expected to Increase in Next 20 years??(D; CAD in WomendWomen develop angina about 10 years later and a first MI about 20 years later than men Women are more likely to have angina than MI as their initial presentation of CAD Women presenting with acute MI tend to be older and have more co-morbidity Women are less likely than men to attribute their symptoms to cardiac disease, even in the setting of acute MI eZeYPRisk Factors in Women -1|Diabetes Mellitus Diabetes mellitus is a more powerful predictor of CHD risk and prognosis in women than in men Diabetes is commonly accompanied by other cardiovascular risk factors in women Diabetes was found to be the only risk factor that distinguished between those with and without angiographic CHD A history of IDDM is also a strong risk factor in women for death after MI >PkPjZQRisk Factors in Women - 2cHypertension The prevalence of hypertension reaches 70 to 80 % in women above age of 70 Hypertension in women is both a strong predictor of coronary risk and more commonly seen in those with CHD This increase in risk is also seen in pre-menopausal women in whom the presence of hypertension is associated with up to 10 fold increase in coronary mortality 4 PWP W[SRisk Factors in Women - 3Smoking Smoking has been associated with one-half of all coronary events in women Coronary risk is elevated even in women with minimal use - RR 2.4 for 1.4 cigarettes/day ( Douglas and Ginsburg, 1996 ) Smoking has a more harmful impact on women than on men and that risk increases in direct proportion to the number of cigarettes smoked daily Smoking carries a particularly high risk in younger women, a population likely to contribute substantially to future burden of CHD LPP\T@Risk Factors in Women  3 cont d!!(Compared with nonsmokers, the incidence of MI was increased 6-fold in women and 3-fold in men who smoked at least 20 cigarettes per day The risk particularly high in younger women the antiestrogenic effect of cigarette smoking may be one possible explanation for the increased risk of young female smokers (Njolstad et al, 1996) Smoking is also a powerful risk factor for MI in middle-aged women than men Most of the increased risk induced by smoking dissipates within 2 to 3 years of cessation of smoking fZZZ,m]U2Risk Factors in Women  4Dyslipidemia Low HDL, rather than high LDL cholesterol, is more predictive of coronary risk in women Lipoprotein (a) is a determinant of CHD ( manifested as angina or MI) in pre-menopausal women and postmenopausal women under age 66 (OR 5.1 and 2.4, respectively ) The total cholesterol concentration appears to be associated with CHD only in pre-menopausal women or at high levels Triglycerides appear to uniquely influence coronary risk in older women, especially at levels above 400 mg/dl (4.5 mmol/L) J PPP RDInfluence of Hormonal StatusCHD is unusual in pre-menopausal women, particularly in absence of other risk factors If pre-menopausal women develop CHD, the disease tends to be more extensive and diffuse than in men of the same age Surgical menopause, with or without hormone replacement, carries an added risk of CHD, in excess of that noted for natural menopause The loss of estrogen causes increase in LDL cholesterol, total cholesterol, TGs and decrease in HDL cholesterol $P"_V:Estrogen Replacement Therapy (ERT): Benefits and Risks - 1;;(Normal menopause ~age 51(95% age 45-55) ERT best therapy for peri-menopausal symptoms Duration 6 months to 4-5 years Observational studies suggested benefit of ERT or combined estrogen-progestin (HRT) on risk of CHD and development of osteoporosis Women s Health Initiative (WHI) July 2002 discounted benefit of HRT for cardiac prevention<VV`W:Estrogen Replacement Therapy (ERT): Benefits and Risks - 2;;(~WHI Studies Combined estrogen/progestin replacement1 > 16,000 post menopausal women age 50-79 Terminated early with average f/u 5.2 years Increased risk breast cancer, stroke, CHD (HR 1.24) and VTE Unopposed estrogen trial > 11,000 women with prior hysterectomy Received unopposed estrogen Study discontinued early due to increased risk of stroke and no projected overall benefit P+PPPP (    ~bZ:Estrogen Replacement Therapy (ERT): Benefits and Risks - 3;;(HERS I (Heart and Estrogen/Progestin Replacement Study) 2763 post-menopausal women < 80 with CAD CEE/progesterone vs placebo  followed for 4 years No difference in CHD events overall More CHD events in HRT group in year one-trend to benefit in years 4-5&88c[:Estrogen Replacement Therapy (ERT): Benefits and Risks - 4;;(HERS II Un-blinded follow-up of 93% patients in HERS I for 2.7 years No ongoing HRT benefit beyond years 4-5 Over 6.8 years in HERS I & II no benefit of HRT&aY3Estrogen Replacement Therapy (ERT): Recommendations44(}Estrogen-progestin therapy should not be prescribed for primary prevention of CHD. Estrogen-progestin therapy should be discontinued if an acute CHD event occurs, and should not be resumed as a secondary prevention strategy. Unopposed estrogen, although it does not appear to increase CHD risk, should not be prescribed for primary prevention because no reduction in CHD risk was observed in the WHI trial . Estrogen or estrogen-progestin therapy should be reserved for peri-menopausal women with moderate to severe menopausal symptoms. The lowest estrogen dose that relieves symptoms should be used for the shortest duration possible. ,~P"YE<.Women Have An Atypical Clinical Presentation //(Typical retrosternal chest pain less common Atypical symptoms and location Resting, nocturnal or stress induced chest pain Jaw, arm, shoulder, back, epigastric discomfort Dyspnea, palpitations, presyncope Fatigue, diaphoresis, nausea 6KK,  MSK"Gender Bias or Clinical Conundrum?##(Women who present to the emergency room with new onset chest pain are approached and diagnosed less aggressively than men Compared to men women are less likely to: undergo an EKG, cardiac monitoring or cardiac enzyme measurement to receive a cardiology consult; be admitted to a coronary care or step down unit Women are more likely to receive controlled substances and anxiolytics in the ER XZZRZQs  VM7Comparison of Men and Women in Presentation and Outcome88(#Approach to diagnosis CAD in Women $$(*Classify the type of pain Assess determinants of likelihood of CAD Select test based on pre-test probability of CAD Confirm or deny presence of CAD with TMT, stress perfusion study or stress echo High false positive rate TMT rate in pre-menopausal females (up to 50%) or low pre-test likelihood CAD++TBClassification of Chest PainTypical angina Steady retrosternal component Provoked by exertion or stress Relieved by rest or NTG Atypical angina 2 of 3 criteria Non-anginal chest pain 1 of 3 criteria ZW ZZZZZ Z ZZW  I@GPrevalence of CAD (%) in Symptomatic Patients According to Age and SexHH F=.Determinants of the Likelihood of CAD in WomenMAJOR - Post menopausal status / age >65 years - Diabetes - Peripheral Vascular Disease INTERMEDIATE - Hypertension - Smoking - Lipid abnormalities PZV 2 _MINOR - Obesity - Sedentary lifestyle - Family history of CAD - Other risks factors of CAD 0_ZZYJA,Algorithm for Chest Pain Evaluation in WomenLow Probability of CAD (< 20 %) Consider no test High likelihood false + result Intermediate Probability of CAD (20-80%) Perfusion imaging or stress echo High Risk Probability of CAD (> 80%) Perfusion imaging or stress echo Consider direct angiography  Z0Z)Z!Z%Z>Z 0 ! > ^OFComparison of Non-invasive Modalities in the Diagnosis of CAD in WomenGG$?6$Indications for Coronary Angiography%%(mHigh risk stress test ECG Hemodynamic High risk perfusion study Multiple defects Severe perfusion defects TIDL.. yOngoing symptoms Unstable angina Post MI angina CHF Vocational indication Pilots Truck/bus drivers Diagnostic uncertainty6JJWN%See Diagnostic Testing 2004 Slideshow&&(/K}  `$(  r  S h  `  h r  S `h  h H  0޽h ? ̙33___PPT10i.C9+D=' = @B +@  @(  r  S qX  `  h r  S      s *"``Z >ERT and CV Risk I in UpToDate,RoseBD (ed),Wellesley, MA 2004 ?(2?,  H  0޽h ? ̙3380___PPT10.jD@  @(  r  S <  `  h r  S      s *d "``Z >ERT and CV Risk I in UpToDate,RoseBD (ed),Wellesley, MA 2004 ?(2?,  H  0޽h ? ̙3380___PPT10.0Sr(]pb ru@ (#yc