Cardiovascular Disease in Women: Common Myths
February 7, 2009
Jon W. Wahrenberger, MD FAHA
Disclosures
I have no financial interests to disclose … I wish I did!
I do not specialize in women’s health issues, but about half of my patients are female.
I cannot rule out the influence of my Y-chromosome
As an only son and with 4 sisters I am expected to be sensitive to women’s issues …
….but at any given time at least one of my sisters is annoyed with me about something.
Are women more complicated than men?
Hormones in Men vs. Women
CARDIOVASCULAR DISEASE IS MAINLY A DISEASE OF OLD MEN
Myth 1
More women are dying of CVD than Men
Source: American Heart Association
Cardiovascular disease is the leading cause of death in women
Source: American Heart Association
Although less frequent, CVD occurs in young women
More than35,000 women under the
age of 65 die annually in the US
from CVD
WOMEN DON’T NEED TO WORRY
ABOUT CARDIOVASCULAR DISEASE BEFORE
MENOPAUSE
Myth 2:
Relationship between early menopause and accelerated CVD?
Increasing Risk of CVD
Minimal or no CVD Risk
Menopause
Traditional Paradigm:
Increasing Risk of CVDMenopaus
e
Alternative Paradigm:
Coronary heart disease progresses over decades
Decades of time
Smoking, High Blood Pressure, Elevated
Cholesterol, Diabetes, Inactivity, Obesity
Age, Heredity
The reality: Being premenopausal probably does not protect you from cardiovascular
disease and you should be vigilant at all ages …
HORMONE REPLACEMENT
THERAPY IS DANGEROUS TO THE HEART AND SHOULD
NOT BE TAKEN UNDER ANY
CIRCUMSTANCES
Myth 3:
Estrogen
Critical to reproductive function in men & women
Most produced by ovaries
Some arises from fat, liver, breasts, adrenals
Complex physiologic effects
Changing Estrogen Levels with Age
Estrogen Progesterone
Perimenopausal Symptoms: hot flashes, insomnia, mood changes
Menopausal Physiology: osteoporosis, vaginal mucosal thinning
The GoodThe Good The BadThe Bad
Relief of menopausal symptoms
Reduction in osteoporosis (bone thinning) and fractures
Cardio-protective effects??
Improvement in lipid profile
Breast cancer riskUterine cancer riskComplex
formulation
The Good and Bad of Estrogen Replacement
Women’s Health Initiative
16,608 Post-menopausal
women aged 50-79 with an
intact uterus
Estrogen +Progesterone
Placebo
Study stopped after mean
follow-up of 5.6 years
Hormonal replacement associated with:•Increased heart disease (29% ↑)•Increased stroke (41% ↑)•Increased blood clots •Increased breast cancer (26% ↑)•Reduced colon cancer•Reduced hip fracture
Conclusion: HRT should not be used to prevent disease
in healthy post-menopausal women
WHS: Caveats
Overall mortality was identical in the two groups
Event rates in both groups was low and absolute rates in the estrogen + progesterone group was low - overall risk of treatment is low
Estrogen vs. progesterone influence on outcomes is unknown
Women’s Health Initiative: Estrogen Only Study
10,739 Post-menopausal
women aged 50-79 with previous
hysterectomy
Estrogen Only
Placebo
Study stopped after mean follow-up of
6.8 years
Estrogen replacement associated with:
•9% reduction in heart disease•39% increase stroke •33% increase blood clots •No change in cancer •39% reduction hip fracture
Women’s Health Initiative: Estrogen Only Study
Conclusion: In younger post-menopausal women post hysterectomy, estrogen alone
may be beneficial
Age Group Risk of Coronary Heart Disease
Risk of Stroke
50-59 37% reduction 11% reduction
60-69 6% reduction 62% increase
70-69 13% increase 21% increase
Overall 9% reduction 39% increaseSource: JAMA 2007;297:1477
Oral EstrogenOral Estrogen Transdermal EstrogenTransdermal Estrogen
Large impact on liver metabolism
Increase in inflammatory markers
Increase in protective HDL cholesterol
Bypasses liverNo change in
Inflammatory markers
Reduction in LDLImprovement in
“atherogenic index of plasma”
Reduction in oxidation index
Oral versus Transdermal Estrogen
Estrogen Replacement: The reality
Estrogen therapy is reasonable for the relief of perimenopausal symptoms if started early and tapered after a few years
Estrogen administered transdermally may be less likely to increase risk of blot clots
Estrogen should not be given to reduce CVD risk
VITAMIN SUPPLEMENTATION IS KEY
TO PREVENTING CARDIOVASCULAR DISEASE
IN WOMEN.
Myth 4:
39,876 healthy
women age ≥ 45
Vitamin E600 IU
Placebo
~ 10 years
636 Deaths
615 Deaths
Source: JAMA. 2005;294(1):56-65
B-Vitamins & Health in Women
5442 woman
with CAD or ≥ 3 risk
factors
Folic AcidVit. B6Vit B12
Placebo
~ 7 years
406 Events
390 Events
Source: JAMA. 2008;299(17):2027-2036
The Reality:
Vitamin E and B vitamins are probably safe, but there is no convincing evidence that they need be taken regularly
Some supplements (ephedra) are downright dangerous
Many supplements interact with medicationsThe entire supplement industry is unregulated; the
safety and purity is entirely in the hands of the manufacturer.
IF I’M THIN AND EXERCISE
REGULARLY I SHOULD BE IMMUNE TO
CARDIOVASCULAR DISEASE.
Myth 5:
The Reality:
Inactivity and obesity are just two of many CVD risk factors, and probably not the strongest
Exercise is great but not necessarily enough!
Non-ModifiableNon-Modifiable ModifiableModifiable
Age GenderHeredity
Tobacco UseCholesterolBlood pressureDiabetesPhysical inactivityOverweight
condition
Cardiac Risk Factors
EGGS ARE UNHEALTHY AND SHOULD
NOT BE EATEN.
Myth 6:
The Facts
Egg yolks do contain cholesterolStudies have shown a clear relationship
between serum cholesterol and cardiovascular disease outcomes
Studies have not shown a relationship between egg consumption and health outcomes
What’s in an Egg?
One Medium Egg
Daily Allowance
Daily Allowance if
high risk
213 300 200
213 mgCholesterol
0 mgCholesterol
OK to eat an egg if consistent with overall daily cholesterol limits
MOST WOMEN DO NOT EXPERIENCE CHEST PAIN DURING A HEART ATTACK
– FATIGUE AND SHORTNESS OF BREATH
ARE MUCH MORE COMMON.
Myth 7:
The Facts
Chest discomfort is the most common symptom of a heart attack in both men and women
Women are more likely than men to have additional non-specific symptoms, including: Fatigue Shortness of breath Weakness
Devon, et al. Amer J Critical Care 2008:17(1): 14-24
The Facts
Devon, et al. Amer J Critical Care 2008:17(1): 14-24
The Facts
Location Women (%) Men (%)
Central Chest 75 81
Left chest 57 56
Left arm 40 42
Neck* 37 22
Right chest 37 34
Upper back 34 26
Jaw* 24 12
Devon, et al. Amer J Critical Care 2008:17(1): 14-24
Location of Chest Pain
*Indicates statistically significant difference
The Facts
Location Women (%) Men (%)
Pressure 77 74
Tightness 66 72
Heaviness 58 57
Dull 45 43
Sharp 40 44
Devon, et al. Amer J Critical Care 2008:17(1): 14-24
Quality of Chest Pain
No differences were statistically significant
The Facts
Men and women present relatively similarly with heart attack
For both genders the important point is not to ignore symptoms of a potentially life-threatening condition
CHOCOLATE IS SINFULLY
BAD AND SHOULD BE EATEN ONLY
RARELY
Myth 8
This could be true, but there is some preliminary data to suggest dark chocolate may be beneficial!
Beneficial Effects of Dark Chocolate
Raises protective HDLImproves insulin sensitivityLowers blood pressureImproves endothelial function
ClinicallyRelevant?
Recommended Dose
Rx
Go Red Luncheon Attendee
Dark chocolate, 100 gmDirections: 1 bar dailyDispense 30 day supply
Jon W. Wahrenberger, MD
EXERCISE IS BENEFICIAL
ONLY IF PROLONGED(NO PAIN/NO
GAIN)
Myth 9
Exercise: the facts
There is a dose-response relationship (more is better)
Strenuous exercise is probably better than less strenuous exercise
Several studies have shown that repeated intermittent periods of exercise have a cumulative effect similar to prolonged exercise
Summary
Don’t believe everything you hearWork on traditional risk factors throughout your lifeEggs are OK …. in moderation … as is dark
chocolateOvarian hormone therapy is OK in the young women
with premature or surgical menopause – taper in early 50’s – some data suggest transdermal best
A balanced diet is probably far more helpful than vitamins and supplements
Exercise is beneficial – almost any way you do it!
Questions?