Women and Heart Disease

• Cathryn Harbor• Lexington VA• May19,2004

• Sponsored by National Organization for Women

Coronary Artery Disease

Definitions

• Heart Attack: Heart Muscle is damaged because it cant get blood and oxygen.

• Angina: Heart Muscle is deprived of blood flow and oxygen. A charlie horse.

Women get more disease in small blood vessels of the heart

Statistics

• Disease of Arteries is the leading cause of death.

• After menopause women develop heart disease at the same rate as men.

• After menopause, women are 10 times more likely to develop heart disease than to develop breast cancer.

• 40% of people who have a heart attack die of it.

Life Cycle Differences

• Young women develop less disease in the heart arteries than young men.

• After menopause, a woman’s arteries develop disease at a similar rate to men’s.

Heart Disease in Women vs Men

• After menopause women are equally susceptible

• Men have more chest pain.

Women more often have “silent” heart attacks

• Once diagnosed women do worse

Red Flag Symptoms

• Chest Pain or Pressure• Dizziness• Shortness of Breath• Neck Pain unassociated with neck movement • Any Unusual Symptom that occurs with exertion

and resolves with rest• Unexplained Sweats• Nausea

What to do if you have symptoms

• Take an asprin

• Stop any exertion

• Go to the ER if the symptom persists. If it resolves, contact your health care provider.

Known risk factors

• There are more than 80 known risk factors for heart disease

• This means that there is no one cause and no one treatment.

Important Risk Factors

• Smoking• Being overweight• Age• Hypertension• Diabetes • Physical Inactivity• Elevated cholesterols

• Elevated C Reactive Protein

• Elevated Fasting Blood Sugar (90)

• Stress, anxiety, depression

• Elevated homocysteine

Genetic Contribution

• We know that genetics plays a big role• .Genes tell your body how to make

proteins, that is all. To have a genetic problem simply means that you inherit the blueprint for less effective proteins. It does not mean that you inherit heart disease.

• No genetic factors I have found that are not modifiable by environment

The Problem of Choice

• Hard to know what to do.

• Science does not provide clear answers

• Science does not progress rapidly

• What is driving the science?

Women and Heart Health: Choices

• Should I use hormone replacement?

• Should I use medicines to lower my cholesterol?

• Should I change my lifestyle?

Women and Hormones:What We Do Know

• Before menopause women’s risk of heart disease is much lower than men’s.

• After menopause, women’s risk quickly approaches men’s.

• In large surveys women who take estrogen after menopause have less heart disease (nurse’s study).

Evolution of HRT

• Drug companies started producing estrogen from pregnant mare’s urine (Premarin).

• Studies showed that estrogen without progesterone causes uterine cancer.

• Drug companies started making combination packages of estrogen and progestins.

• Because of Patent issues, the progestins the drug companies used were not natural to the body, but synthetic.

Evolution of HRT continued

• Because of the belief, based on good studies, that HRT protects against heart disease, women were told at menopause that they should start premarin to protect their hearts.

• Premarin became the most widely prescribed drug in the country

HERS trial

• 2763 postmenopausal women

• Pre-existing heart disease

• Randomized to placebo or prempro

• 4.1 year study

HERS Trial Results

• In the first year more women on prempro group had more heart attacks than women in the control group

• For the 2nd and 3rd years the groups very similar

• By the 4th year more women in the control group had heart attacks

Impression after HERS Trial

• Starting on HRT after heart disease is established is dangerous at first

• After a few years on HRT estrogen use seems to create no additional risk and possibly to protect women

What Would Explain the Results of HERS?

• We know that estrogen increases women’s chance of forming clots in our blood vessels

• Women in the trial were known to already have diseased arteries.

• Possibly starting a woman on HRT after she has developed heart disease was the problem, since a clot is a bigger problem in a sickened and narrowed artery.

THE WOMEN’S HEALTH INITIATIVE (WHI)

• 16,608 post menopausal women without hysterectomy not currently on HRT

• Randomized to placebo or prempro

• Planned duration 8 years

• Stopped by safety advisory board after 5.3 years: “increased risk of breast cancer without evidence of overall benefit”.

FINDINGS OF WHI

• Breast cancer, heart disease, stroke, lung clots and leg clots are all increased by prempro (in this population). Prempro may have more negative effects than estrogen alone

• Hip fractures and colorectal cancer are reduced by prempro (in this population)

• Prempro increased the risk of hysterectomy

Problems with WHI

• WHI intentionally excluded women with severe menopausal symptoms, though these women are most likely to use HRT.

• Older women not on HRT were studied. Many of them can be presumed to already have heart disease.

• The study was too short to show benefits, if any, of HRT.

What we STILL Don’t Know

• Is there a heart benefit to giving HRT starting right at menopause, before heart disease starts to develop?

• Do other types of estrogen and progesterone have same risks?

• What if lower doses had been used?

• Do older women on hormones need to come off of them?

Take away

• We still do not have enough information to make perfect decisions about putting women on or taking them off estrogen

• Right now the pendulum has swung very far to the no HRT side.

Cholesterol

• People who die of heart attacks have changes in their heart arteries that are made, in part, of cholesterol.

Where Does Cholesterol Come From?

• We thought cholesterol in diet made cholesterol in the body.

• In fact cholesterol is so important that the body makes its own.

• Cholesterol is the result of interactions between carbohydrates, fats and protein in a diet, level of exercise, heredity and hormones.

Cholesterol’s Function

• Important in producing hormones• Forms insulation around nerves to keep

signals moving • Needed to maintain cell membrane fluidity• Has important immune functions (fighting

illness)• Necessary for brain function (thinking)• Important in neurotransmitter production

(mood)

About Cholesterol

• We usually measure three types of cholesterol:

• LDL (bad cholesterol)

• HDL (good cholesterol)

• Triglycerides

Traditional Approach

• Focused on evidence-based medicine

• Five major studies showed impressive risk reduction from using statins (24-39% reduction).

• Drug trials using statins (Lipitor, Pravacol, Baycol, and Zocor, etc demonstrated both a lowering in LDL cholesterol and a lowering of heart attacks.

Statins some more of the issue

• 61-76% of patients treated with statins STILL experience heart attacks.

Lipids and Women

• LDL (Bad Cholesterol) is a good predictor of heart disease in men.

• Simple LDL measurements predict little in women.

• Despite awareness of other modifiable risk factors, we tend to focus on one risk factor (LDL cholesterol) and one therapy (statin drugs)

Tangent about problems with LDL

• LDL is clearly bad, at least for men but there are differences among the types of LDL

• My LDL is 180 yours is 120. Who has the worst problem? We don’t know because

• Answer: It depends on number of cholesterol particles and therefore on the size of the LDL particle.

This Just In

• “Women without coronary artery disease do not benefit from Statin use”.

• For women with known cardiovascular disease, treating hyperlipidemia is effective in reducing fatal and non fatal heart attacks…but “does not affect total mortality”.

Another Big Problem

• Coenzyme Q-10 is a very important anti-oxidant.

• Coenzyme Q-10 is produced in the body, in the same chemical pathway as cholesterol.

• The enzyme, HMG CoA reductase is essential for producing CoQ-10.

• Statin drugs work by disabling this enzyme.

CoQ-10

• Many of unpleasant effects of statin drugs (muscle aches, fatigue) can be reversed by using CoQ-10.

• CoQ-10 has now been demonstrated to be important in treating Parkinson’s disease.

• I believe that everyone on statin drugs should take CoQ-10.

HDL Cholesterol

• HDL (good cholesterol) is very important in women:

• HDL below 50 makes women 2.7 times more likely to die of a heart attack.

Triglycerides

• Triglycerides between 200 and 400 increase risk of heart attack death by 2.4

• Triglycerides above 400 make women 6.9 times more likely to die of heart attacks.

The Metabolic Syndromealso called INSULIN RESISTANCE

• Abnormal cholesterol profiles High TG, low HDL high LDL

• Hypertension

• Type 2 Diabetes

• Coronary artery disease

• Breast, prostate and colon cancer

• Polycystic ovarian disease

Insulin’s Role

• High blood sugar is highly toxic to brain tissue.• When you eat carbohydrates your body turns them into

sugar, glucose.• Insulin rises after you eat carbohydrates to protect your

tissues from excess energy.• Insulin lets excess energy be quickly cleared from the

bloodstream to be stored as triglycerides and cholesterol.

• In the short term, high insulin levels protect your tissues• In the long run, high insulin levels are associated with

many health problems, called the metabolic syndrome.

Triglycerides, Insulin and Diabetes

• Learn and control your triglyceride number• Of all lipid markers, this one is associated

with the effectiveness of your diet and exercise program.

• Triglycerides are where your body stores excess carbohydrate calories

• We have long known that Triglycerides are an important marker for CAD risk in women.

A complex problem without an easy solution

• What’s a girl to do?

How do you protect yourself?

• Lower your risk for heart disease by 70%!

The Lyons Study

• 605 French men and women who had survived heart attacks

• Divided into two groups:– American heart Association Diet (low fat)– Mediterrainian diet:

• Olive oil• Whole grains• More root and green vegetables• More fish and poultry, less red meat

Mediterreanian diet

Lyon s Study Results

• Study was stopped after only 30 months:

• A 70% reduction in deaths from all causes in the group with the Mediterainian diet.

• This was in people who had already had heart attacks!

Changes you can make for risk reduction

• Stop or avoid smoking

• Improve your diet (the LYONS Study)

• Maintain a normal weight

• Exercise

• Consider hormone replacement

• Maintain normal blood pressure

• Reduce stress in your life

• ONE SIZE FITS ALL MEDICINE IS THE BEST FOR THE DRUG COMPANIES.

• It is not necessarily the best for your body

QUESTIONS?

It begins on the first day of medical school and lasts through to retirement…It starts slowly and insidiously, like an addiction, and can end up influencing the very nature of medical decision making and practice…Attempts to influence the judgement of doctors by commercial interests serving the medical industrial complex are nothing if not thorough.

BUT

• In the above studies, not enough women were included to determine the effects of lowering LDL in women

• Level of LDL cholesterol does not correlate well with risk of heart disease

Problems with the system

• Most medical research is payed for by drug companies

• Drug companies need to find drugs that work for large groups of people: one size fits all model

• Not all people are alike: men from women, premenopausal from post menopausal women: one size does not fit all

• Most doctors get their information from drug reps, the marketing agents for the drug industry.

• Drug company information is not intended to be objective. It is a product of spin artists