BACKGROUND

It is a myth that coronary artery disease (CAD) is less common

and less severe in women

Myths vs Facts

MYTHS FACTS

Men are more likely to have heart disease

Heart disease is the #1 killer of men and women; 50,000 more women than men die of heart disease every year

Cancer is a bigger threat than heart disease

Nearly twice as many US women die from heart disease and stroke than from all cancers combined

Doctors are aware of women’s risk for heart disease and act accordingly

Undertreatment and underdiagnosis of heart disease in women contributes to excess mortality in women

Cardiovascular disease mortality trends for males and females (United States: 1979–2007).

Wenger N K Circulation. 2012;126:604-611

Copyright © American Heart Association, Inc. All rights reserved.

WOMEN

MEN

Women and CAD Risk Factors

1. American Heart Association. 1999 Heart and Stroke Statistical Update. 1998 2. Mosca L, et al. Circulation. 1999

Higher prevalence of avoidable risk factors1

↑ blood cholesterol, ↑ TG↑ physical inactivity↑ overweight (body mass index, 25.0-29.9)

Diabetes is a more powerful risk factor for CAD2

3- to 7-fold in women vs 2- to 3-fold in men

↓ HDL cholesterol levels more predictive of CAD2

Women counseled less about nutrition, exercise, and weight control2

1. American Heart Association. 1999 Heart and Stroke Statistical Update. 1998 2. Mosca L, et al. Circulation. 1999

A case-control comparison of the relative risk for MI based on sex : the INTERHEART study: Case-control study. Lancet 364:937, 2004

Diabetes is a relatively greater risk factor for CHD in women than in men;

it increases a woman’s risk for CHD by 3-7 fold, with only a

2-3 fold increase in diabetic men

Risk for fatal CHD in diabetic women is 3.5 times higher than in nondiabetic women

Risk in diabetic men is only 2.0 times higher than nondiabetic men)

Huxley R, Barzi F, Woodward M: Excess risk of fatal coronary heart disease associated with diabetes in men and women: Meta-analysis of 37 prospective cohort studies. BMJ 332:73, 2006

Huxley RR,Woodward M. Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies. Lancet. 2011;378:1297–1305

A recent systematic review and meta-analysis involving >2 million people uniformly showed a 25% increased coronary risk among

women smokers than men smokers

• In comparison with their male counterparts, women with angina have a doubled morbidity and mortality.

• Women with stable ischemic heart disease have more MIs than men do.

• Women with CHD, and, in particular, women <50 years of age, have a doubled mortality after MI.

Despite their greater symptom burden of angina and its consequent morbidity and mortality, and despite their older age and

higher risk factor burden, women paradoxically have less severe

obstructive coronary disease at elective angiography than do men

Bairey-Merz CN. The Yentl syndrome is alive and well. Eur Heart J. 2011;32:1313–1315

PARADOX

3 mechanisms proposed :

adverse coronary reactivity, microvascular dysfunction,

plaque erosion/distal micro-embolization

1. Abnormal coronary vasomotion as a prognostic indicator of cardiovascular events in women: results from the National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE). Circulation. 2004 Feb 17; 109(6):722-5.

2. Effect of risk factors on the mechanism of acute thrombosis and sudden coronary death in women. Circulation. 1998 Jun 2; 97(21):2110-6

Angiographic prevalence and pattern of coronary

artery disease in women

Babu EzhumalaiBalachander Jayaraman

JIPMER PUDUCHERRY

AIM

To study the prevalence and pattern of CADin women undergoing CAG

STUDY DESIGN

• Retrospective Analysis• 3 Yr Data• Women With Probable CAD• Discharge Cards And Angio Reports• 2 Groups <55 yrs , >55 yrs• Normal Vs Non-significant Vs Intermediate Vs

Obstructive• SVD Vs DVD Vs TVD

RESULTS

CLINICAL PROFILE OF WOMEN UNDERGOING CORONARY ANGIOGRAM

ANGIOGRAPHIC PROFILE OF WOMEN UNDERGOING CORONARY ANGIOGRAM

DISTRIBUTION OF CORONARY ARTERY DISEASE IN WOMEN UNDERGOING CORONARY ANGIOGRAM

ANALYSIS

• Almost equal number of young (257) and elderly (243)women undergoing angiogram

• ACS presentation 107 vs 107

• Presentation with stable angina was more common in younger 134 vs 104

• Prevalence of OBSTRUCTIVE CAD = 45.4 % , more in elderly 136 vs 91

• Increased prevalence of normal coronaries and non-significant lesions in younger women

• Increased prevalence of multivessel and left main disease in elderly women

DESPITE AN INCREASE IN THE RISKS OF CAD AND INCIDENCE OF ACS AT YOUNGER AGE , YOUNGER FEMALE STILL HAVE LOWER ATHEROSCLEROTIC BURDEN , LESSER PREVALENCE OF OBSTRUCTIVE LESIONS AND BETTER LV FUNCTIONS--- “FEMALE PATTERN CAD”

LIMITATIONS

• USE OF IVUS , OCT, FFR – INTERMEDIATE LESIONS

• NO SMOKERS • AVERAGE AGE

TAKE HOME MESSAGE CVD esp. CAD is by far the biggest health risk for

women.Awareness is still less than it needs to be.Myocardial ischemia has specific sex differencesDespite a lower prevalence of obstructive CAD in

women, women have a higher prevalence of symptoms, ischemia, and mortality relative to men.

Same holds true for young vs older womenWe have to have a better understanding of “MALE

PATTERN VS FEMALE PATTERN IHD”

THANK-YOU