acute myocardial infarction in women
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Acute Myocardial Infarction in Women
PresenterDR PRAVEEN GUPTA
Moderator DR AJIT ANANTHAKRISHNA
PILLAI
Date -17/02/2016
Department of Cardiology,JIPMER
Pondicherry, India
Cardiovascular disease (CVD)
Leading cause of mortality,
Understudied
Underdiagnosed
Undertreated
Annual CVD mortality remained greater
Women living with & dying of CVD are larger than men
Cardiovascular disease (CVD)
Different plaque characteristics
Greater role of microvascular disease
Less severe obstructive disease of epicardial coronary
arteries
Prevalence of AMI
6.6 million US women
< 1 year of a first AMI, 26% of women and 19% of men will
die
< 5 years of a first AMI, more women than men will die (47%
of women and 36% of men), have heart failure (HF), or suffer
from a stroke
Prevalence of AMI
Characterstics of CAD in Women
Higher prevalence Diabetes mellitus (DM) HF Hypertension Depression Renal dysfunction NSTEMI and nonobstructive CAD
Characterstics of CAD in Women
Spontaneous coronary artery dissection (SCAD)
Coronary artery spasm (CAS) Longer hospitalizations Higher in-hospital mortality Bleeding complications
Pathophysiology of AMI
Coronary Artery Spasm
OCT showing Coronary plaque
Representative Case of OCT-Defined Erosion(A) Coronary angiography shows nonsignificant stenosis in mid-left anterior descending coronary artery.(B) Intracoronary ergonovine injection resulted in complete occlusion. (C) This normalized with 200 μg of intracoronary nitroglycerin administration. (E, F) Optical coherence tomography (OCT) revealed a red thrombus with high backscattering protrusion mass with signal-free shadowing. (D to F) An intact fibrous cap and an irregular luminal surface are visible. Asterisk indicates the total occlusion site by ergonovine provocation test and arrows indicate the sites of OCT findings after nitroglycerine injection.
J Am Coll Cardiol Img. 2015;8(9):1059-1067. doi:10.1016/j.jcmg.2015.03.010
Plaque Rupture and Erosion
Spontaneous Coronary Artery Dissection
Rare cause of AMI Suspect in young
woman Prevalence 0.2% to
4%
Associated with Peripartum and Postpartum status Oral contraceptive use Exercise Connective tissue
disorders vasculitides
A, Distal normal left anterior descending (LAD) artery. The intact normal arterial wall was shown well by both modalities (arrow on optical coherence tomography [OCT] image. B, Distal dissection. Intravascular ultrasound (IVUS) images showing intramural hematoma and luminal compression, but it was unable to demonstrate the intimal flap. OCT showed clearly the distal exit point of the dissection with the intimal flap and communication between the intramural hematoma and true lumen (arrow). C, Mid-LAD dissection. A large crescent-shaped eccentric hematoma (*). IVUS showed well the inner lumen (thick arrow) and external vessel reference (thin arrow); OCT showed the hematoma compression and demonstrated the integrity of an otherwise disease-free intima but did not reveal the vessel reference diameter as clearly as IVUS. D, Normal proximal LAD. OCT measurement of reference lumen
area and diameter for stent sizing are shown. Circ Cardiovasc Interv. 2011 Apr 1;4(2):e5-7. doi: 10.1161/CIRCINTERVENTIONS.110.959593
Clinical Presentation
Atypical chest pain
Angina equivalent-dyspnea, weakness, fatigue, and indigestion
Lead to misdiagnosis, delayed revascularization, & higher
AMI mortality rates
Atypical Symptoms
Chest pain: sharp, pleuritic, burning, aching, soreness,
Unusual fatigue
Unusual shortness of breath
Upper back/chest pain
Neck, jaw, arm, shoulder, back, epigastric pain
Flu-like symptoms
Atypical Symptoms
Dizziness
Generalized scared/anxiety feeling
Generalized weakness
Indigestion
Palpitations
Delay in seeking treatment for AMI
Due to lack of awareness of risk Passivity Inaccurate symptom attributionBarriers to selfcareOlder ageLower education and socioeconomic levels A history of angina
Delay in seeking treatment for AMI
DM
Hypertension
HF
Dyslipidemia
Living alone
Interpreting symptoms as
nonurgent
Temporary, consulting with
a physician or family
member
Fear
Embarrassment
VIRGO study
Women fail to assess their risk of heart disease
Women -limited access to preventive cardiac care before AMI
J Am Heart Assoc. 2014;3:e001252 doi:10.1161/JAHA.114.001252
Treatment of AMI
Less frequently referred for appropriate treatment More Mechanical complications & HF Ventricular arrhythmias occur at similar rates. More favorable outcome with PCI compared with
thrombolytic therapy
STEMI Revascularization Thrombolytic Therapy
Higher morbidity and mortality
GUSTO trial –More complications such as shock, HF,
reinfarction, recurrent ischemia, bleeding, and stroke
(ASSENT-2) trial- Increased risk of reinfarction Multiple relative contraindications age, hypertension, and
small body size Beneficial and reduce mortality and morbidity
Primary PCI
Benefit the most GUSTO II-B angioplasty-56
deaths in women/42 deaths in men/ 1000
Vascular complications & the need for blood transfusions occur more in women
Female sex-Independent predictor of bleeding
DES- reduced death or MI and reduced target vessel revascularization
CABG Surgery
Older and sicker
Increased risk of in-
hospital mortality
Less likely to receive IMA
graft
More renal failure,
neurological complications,
and postoperative MI
NSTEMI Revascularization
More complications bleeding HF, shock renal failure Reinfarction stroke readmission benefit from invasive managment
Medical Therapies Same as in men
Consideration of weight & renal
dosing
HRT should not be given
Antioxidant vitamin supplements
should not be used
Aspirin & Clopidogrel reduced
the risk of a major coronary
event
Medical Therapies
Prasugrel
Ticagrelor
Glycoprotein IIb/IIIa
inhibitor
Low-molecularweight
heparins Bivalirudin Fondaparinux
Medical Therapies
Nonselective β-blockers should be avoided in patients whose AMI is due to
coronary arterial vasospasm
ACE inhibitor improved survival in women
ACE inhibitors and ARBs are pregnancy category C for the first trimester
& category D during the second and third trimesters
Benefit from lipid-lowering therapy
Statins are pregnancy category X, avoid during pregnancy
Aldosterone antagonist in the absence of contraindications
Nonpharmacological TreatmentCardiac Rehabilitation Referral and
Participation
Class I recommendation
SAFE-PCIStudy of Access Site for Enhancement of PCI
for Women Trial of specific PCI access strategies
that was exclusive to women
Reductions in bleeding or vascular
complications with the radial access
J Am Coll Cardiol Intv. 2014;7(8):857-
867. doi:10.1016/j.jcin.2014.04.007
Take Home Message
CVD is an equal-opportunity killer, Sex differences occur in the pathophysiology &
clinical presentation of MI & affect treatment delays.
Recommended perfusion therapies for AMI in women are similar to those in men,
Bleeding risks & other complications remain greater
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