Women and Heart Disease

Olga Toleva, MD, MPH, FRCPC, CCFPAssistant Professor

Interventional Cardiologist St. Boniface Hospital

Winnipeg, MB

13 Feb 2019

WEAR RED CANADA - MANITOBA

Introduction• Women have different symptom profile

• Research was mostly based on men there was minimal participation of women in randomized trials

• Key signs of heart attack in women: 2/3 will have atypical symptoms

• Women seek help less and give priority to family members and children

CBC Radio- April 25, 2015 Terry MacLeod interviewedDr. Noel Bairey Merz Director of Barbra Streisand Women's Heart Center

Door-to-balloon time for patients initially presenting to an emergency departmentfrom April 2012-September 2016 within the Winnipeg Regional Healthcare Association

Courtesy of Dr. David Allen and Brett Hiebert- Analysis on STEMI data in WRHA

Acute myocardial infarction

Clinical presentations

• Acute coronary syndrome unstable angina

• NSTEMI

• STEMI

• Sudden cardiac death

Symptoms and Signs

• Crushing chest pain

• Severe shortness of breath

• Chest pain radiating to the arms

• Jaw pain

• Profuse sweating

• Chest pressure

• Shortness of breath

• Arm pain / burning only

• Nausea or stomach pain

• Back, neck, jaw pain

• Fatigue

• Sweating

Men Women

Cardiac catheterization

Coronary stent

Chest pain and MI in Women

• Smoking

• High cholesterol

• Diabetes

• Hypertension

• Family history of MI

• Postmenopausal

• Spontaneous coronary dissection

• Coronary artery spasm

• Broken heart syndrome

• INCA with normal coronaries MVD

• MINOCA

• MINCA

Atherosclerosis “Normal “ coronaries

Non atherosclerotic causes of MI

Spontaneous coronary artery dissection (SCAD

CJC 2013;9:1027-1033. Cath & Cardiov Interv 2017

~3% of all ACS

90% of SCAD is in women

- In women <50yrs with ACS, as high as 25% have SCAD- In patients with SCAD, 25% present as STEMI

Clinical features that raise suspicion for SCAD

• Myocardial infarction in women younger 50 years of age• Absence of traditional cardiac risk factors• No evidence of coronary atherosclerosis on angiography• Peripartum state• Hx of fibro muscular dysplasia• Hx of connective tissue disorder i.e. Ehler Danlos, Lois

Deitz, Cystic medial necrosis or systemic inflammatory condition - Polyarteritis nodosa, Churg-Strauss syndrome, Rheumatoid arthritis, sarcoidosis

• Recent intensive exercise or emotional stress

Coronary Angiogram Classification of Spontaneous Coronary Artery Dissection J. SawCatheterization and Cardiovascular Interventions 84:1115–1122 (2014)

OMTrueLumen

OMFalseLumen

Optical Coherence Tomography catheter

Imaging of the coronary

Stenting of the artery

Management

• Conservative management -unless proximal or ongoing symptoms

• Benefit from cardiac rehabilitation

– Avoid isometric/extreme exercise

• Recurrence - 5-20%

• Prognosis - 2yr survival 95%

CJC 2013;9:1027-1033. BMJ 2017;0:1-9. doi:10.1136/heartjnl-2016-310320

VanSCAD2019Saw J, et al. JACC 2017 Aug;70(9):1148-58. Saw J, et al. JACC 2016;68:297-312. Hayes et al, Circulation 2018;137:e523-e557.

(%/yr)Median FU 3.1yr

Strategies to Prevent Recurrent SCAD

• Beta-blockers to reduce arterial shear stress (dP/dT)

• Optimal management of hypertension

• Reduce potential precipitating triggers:

• Emotional stress: psychosocial support, peer-group support

• Physical stress: avoid heavy weight lifting(<30-50 pounds), avoid competitive sports, participate in Cardiac Rehab Program

• Avoid hormonal therapies, sympatho-mimetic drugs, intense coughing/ retching/vomiting/bowel straining (Valsalva-type activities), future pregnancy

Anterior STEMI

• 55 F with chest pain after argument with her husband.

• No cardiac risk factors.

• Transferred to the Cath lab for emergency angiogram

• There were no coronary artery stenosis, but LV gram was consistent with apical ballooning.

Tako Tsubo cardiomyopathy

Takotsubo (Stress) Cardiomyopathy Scott W. Sharkey, John R. Lesser and Barry J. MaronCirculation. 2011;124:e460-e462 doi: 10.1161/CIRCULATIONAHA.111.052662

Management

• The LV dysfunction is transient and complete recovery is expected between 3-7 days to 4 weeks.

• Repeat imaging ECHO is recommended to confirm recovery of LV function.

• Etiology is believed to be based on adrenaline surge in the blood stream that causes generalized microvascular spasm and affects the myocardial circulation.

Takotsubo (Stress) Cardiomyopathy Scott W. Sharkey, John R. Lesser and Barry J. MaronCirculation. 2011;124:e460-e462 doi: 10.1161/CIRCULATIONAHA.111.052662

Conclusions

• Coronary artery disease is seen in women with traditional cardiac risk factors or in perimenopausal age.

• We now know that the same is true for Microvasculardysfunction

• Acute MI should be of concern in women of all age groups when presenting with chest pain syndromes.

• Immediate ECG and cardiac markers should be obtained to exclude acute coronary syndrome.

• High index of suspicion to achieve early diagnosis in women will improve their survival from acute coronary syndromes and ischemia related cardiac death.

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Your Manitoba Team