1. Don’t Go Breaking My Heart:
Understanding Heart Disease in Women

2. “Tell a Friend” Campaign
• Raise Awareness
– heart disease is the leading cause
of death in women.
y p
– of the symptoms of heart disease, and
how they may differ in women.
– of the importance of “knowing your
numbers
numbers”
• cholesterol
• blood pressure
• body mass index
• blood sugar.
• Encourage women to talk to their
primary h lth
i healthcare providers about
id b t
heart health.

3. Overview
• Scope of the Problem
• Gender disparities in care?
• Challenges in public awareness
g p
• Challenges in awareness among clinicians
• Gender differences in presentation?
• Reducing CVD risk in women
• Role of postmenopausal HT?

4. Heart Disease: The Leading Cause of Death
for American Women

5. Cardiovascular Disease Mortality Trends
United States: 1979-2001
1979-
Source: CDC/NCHS.

6. Death Rates from Heart Disease per
100,000 Women, 2002 (CDC)

8. Are Women Aware ?
Percentage of women who know that heart
disease i the l di cause of d h i women:
di is h leading f death in
Circulation 2004 109 573 579
Ci l i 2004:109:573-579
50
45
40
35
30
46%
25 34%
20 30%
15
10
5
0
1997 2000 2003

10. Fact or Fiction?
Recent studies show that women perceive heart
disease to the biggest threat to their health?

11. Greatest Health Problem
Mosca, Circulation 2004
40
35
30
25
% 20 1997
15 2000
10 2003
5
0
Breast Cancer Heart
Cancer General Disease

12. Flawed Concept of Women’s Health?
“… The community has viewed women’s
health almost with a ‘bikini’ approach
bikini approach,
looking essentially at the breast and
reproductive system, and almost ignoring the
rest of the woman as part of women’s
f h f ’
health.”
Nanette Wenger, MD
Chief of Cardiology, Grady Hospital
Professor of Medicine, Emory University
Atlanta, G
Atl t Georgia i

13. Perception of Heart Disease Risk Factors
Mosca, Circulation 2004
45
40
Smoking
35 High Cholesterol
30 Family History
25 HTN
% Diabetes
20
15 High Tg
10 Overweight
Lack of exercise
5
0

14. Why The Gender Gap?
• Women present to emergency
rooms or chest pain centers 1- 2
hours later than men.
men
p
• The multiple roles a woman
takes on may delay care because
of her responsibilities to others?
• Women delay care because they
perceive that heart disease is
something that happens to one s
one’s
father, brother, or spouse?

15. Why The Gender Gap?

16. Why The Gender Gap?

17. Why The Gender Gap?
y p
“Vintage” AHA teaching materials!
g g

18. Gap May Extend to Healthcare Professionals
• 2003 survey indicates only 38% of women
have discussed heart health with their
healthcare provider.
provider
• One year death rate for men following a heart
attack is 25%, for women 38%
25% 38%*
– only part of this gap can be explained by
age
• Recommended treatments for heart disease
are less likely to be used in women.
– Aspirin
– Referrals to cardiac rehab programs
– Revascularization
Cholesterol-lowering
– Cholesterol lowering medicines
*Heart Disease & Stroke Statistics 2004 Update (American Heart Association)

19. Fact or Fiction?
The survival rate for women after a heart attack
is the same as for men?

20. Mortality for Women and Men Post-AMI*
j y
and After Adjustment by Risk Score †
50
40 Women
30 Men
(%)
20
10
0
12 24 36 48
Post-AMI
50
40
(%) 30
20
10
0
p
*p<0.001; †p<0.002.
; p 12 24 36 48
After adjustment by risk score

21. CHD Mortality in Younger Women
W ff h highest l i
Women under 65 suffer the hi h relative
d
sex-specific CHD mortality

22. What can you do…..
y
• Seek medical advice for
g g
warning signs
• Act promptly with acute
symptoms
• Seek information related to
your own risk level
• Make appropriate
modifications in lifestyle to
reduce their risk

23. SYMPTOMS OF HEART
DISEASE IN WOMEN

24. Symptoms Of A Heart Attack
• Require immediate action!
– uncomfortable pressure,
fullness, b i or
f ll burning
squeezing sensation in the
chest
– shortness of breath
– nausea, vomiting, dizziness,
sweating
• Symptoms can vary greatly and
may be different in women
than
th men
• You know your body-
y
trust your instincts

25. Differences in Heart Attack Symptoms
Men Women
• Sub-sternal chest pain or
pressure , pp
• Pain in chest, upper back, ,
jaw or neck
• Pain at rest
• Shortness of breath
• Pain down left arm and
shoulder Flu-like
• Fl lik symptoms:
nausea or vomiting, cold
• Weakness sweats
• Fatigue or weakness
• Feelings of anxiety, loss of
appetite, malaise
pp ,

26. Gender Differences in ED Presentation for
CAD Without Chest Pain
48
50
41 Women (n = 90)
40 35
33 32 Men (n = 127)
30
30 26
22 22
19 19
20 14
11
P
Percent of patients
8
10
0
a g n g g in
ne itin io tin ue in a
e st in ig at rp
y sp om g fa at e e
D /v di / F ld
a In ss Sw ou
se i ne h
au /s
N izz rm
D A

27. Women’s Early Warning
Symptoms of Heart Attack
3,
• Published online before print Nov 3 2003
• 515 women with AMI from 5 sites
Prodromal symptoms 1 month b f
• P d l h before AMI
– unusual fatigue (70.7%)
– sleep disturbance (47.8%)
– shortness of breath (42.1%)
– chest discomfort (29.7%)

28. KNOW YOUR RISK
FACTORS FOR HEART
DISEASE

29. Risk Factors for Heart Disease
Non-modifiable Modifiable
• Age • Physical Inactivity
• Family • Psychosocial Factors
history
y
High Blood Pressure
• Hi h Bl d P
• Gender
• Obesity
• Diabetes
• High Cholesterol and
Triglycerides, Low HDL
• Cigarette Smoking
• High fat diet

30. Fact or Fiction?
There is nothing that can be done to reduce
the risk of heart disease in individuals with
strong family history of CHD.

31. “Genetics loads the gun, but
environment pulls the trigger…”
trigger
Judith Stern
Professor of Nutrition and
Internal Medicine
University of California at
Davis

32. Determining Your Risk for HD
• The Framingham Heart Study established major
predisposing risk factors for HD-age, DB, HTN, Smoking,
Dyslipidemia
p p p y prevention
• Important step in primary p
• Estimates 10 yr probability for CHD

33. Framingham Risk Score: Women
Step 1: Age Points Step 4: SBP Points Step 5: Smoking Status Points
Years Points SBP If If Age Age Age Age Age
(mmHg) treated untreated 20-39 40-49 50-59 60-69 70-79
20-34 -7
<120 0 0 Nonsmoker 0 0 0 0 0
35-39 -3
120-129 1 3 Smoker 9 7 4 2 1
40-44 0
45-49 3 130-139
130 139 2 4
140-159 3 5 Step 6: Sum of Points
50-54 6
>160 4 6 Age
55-59 8
Total Cholesterol
60-64 10
HDL-C
65-69 12
Systolic Bl d P
S t li Blood Pressure
70-74 14
Smoking Status
75-79 16
Point Total
Step 2: Total Cholesterol Points
Step 7: 10-year CHD Risk
TC Age Age Age Age Age
(mg/dl) 20-39 40-49 50-59 60-69 70-79
<160 0 0 0 0 0 Point 10-year Point 10-year Point 10-year
Total Risk Total Risk Total Risk
160-199 4 3 2 1 1 <9 <1% 15 3% 22 17%
200-239 8 6 4 2 1 9 1% 16 4% 23 22%
240-279
240 279 11 8 5 3 2 10 1% 17 5% 24 27%
>280 13 10 7 4 2 11 1% 18 6% >25 >30%
12 1% 19 8%
Step 3: HDL-C Points 13 2% 20 11%
HDL-C (mg/dl) Points 14 2% 21 14%
>60 -1
50-59 0
40-49 1
<40 2

34. Guide to Preventive Cardiology in Women
• Women have a low, intermediate, or high risk for
heart attack depending on their “risk factors
risk factors”
p g , gg
• Depending on level of risk, more aggressive
cardiovascular risk reduction strategies are
recommended including lifestyle and
medications

35. WHAT CAN YOU DO TO
REDUCE YOUR RISK OF
HEART DISEASE?

36. Modifiable Risk Factors
• Cigarette Smoking
• Diabetes
p
• Abnormal lipid levels
• High Blood Pressure
Obesity
• Ob i
• Psychosocial factors
• High fat diet
• Physical Inactivity

37. Impact of Multiple Risk Factors in Women
• N EnglJ Med. Stampfer, MJ. 2000:343:16-22
N Engl J Med. Stampfer, MJ. 2000:343:16-22

38. TOBACCO #1 PREVENTABLE RISK
• Female smokers have 2-6 times the risk of sudden
cardiac death than non smokers. The risk is higher for
heavy smokers.
smokers
• Second-hand smoke increases cardiac risk.
• The health benefits of quitting smoking begin
y
immediately.

39. Fact or Fiction?
The fastest growing group of new smokers are
adolescent males

40. Smoking Cessation
Five Keys for Quitting:
1. Get
1 G t ready.
d
2. Get support.
3.
3 Learn new skills and behaviors
behaviors.
4. Get medication and use it correctly.
5.
5 Be prepared for relapse or difficult situations
situations.
www.smokefree.gov
National Quitline: 1-800-QUITNOW

41. Diabetes Prevalence per 100 Adults: 1996

42. Diabetes Prevalence per 100 Adults: 2004

43. Women and Diabetes
• Type 2 diabetes has increased 50% in the
last 10 years.
• 2 of 3 persons with diabetes die of
cardiovascular disease.
• Diabetes increases a woman’s risk of
heart disease 3-7X
(2-3X in men).
• People with diabetes should be treated as
aggressively as those with known heart
disease.
disease
• Diabetes markedly reduces the success
g yp
rate when a woman undergoes bypass
surgery or balloon angioplasty
procedures.

44. Fact or Fiction?
An optimal fasting blood glucose level is
between 100-125

45. American Diabetes Association (ADA)
Guidelines
p g g g/
• Optimal fasting blood sugar 100 mg/dL
• Criteria for diabetes
gg g g
– Fasting glucose 126 mg/dL or higher
– Random glucose 200 mg/dL or higher
• Impaired fasting glucose 100 - 125 mg/dL

46. Lifestyle and Diabetes
• Research shows that diabetes can be
p
prevented by improving diet and physical
y p g p y
activity levels.
l i k for diabetes who f ll a di
• People at risk f di b h follow diet
and exercise plan (with only a modest weight
loss) can decrease their risk of developing
diabetes by almost 50%.

47. The Lipid Profile: Know Your Numbers!
Total <200 mg/dL
Cholesterol
LDL <100mg/dL
g
Low-Density Lipoprotein
Triglycerides
Ti l id <150 mg/dL
/dL
HDL >40 mg/dL for men
/dL f
High-Density Lipoprotein >50 mg/dL for women

48. Fact or Fiction?
The number 1 dietary contributor to elevated
LDL cholesterol is eating foods high in
g g
saturated fats.

49. Therapeutic Lifestyle Changes
Diet
– Minimize dietary intake of saturated fats and trans
fatty acids
f id
– Add plant stanol/sterols and soluble fiber to the diet
Weight
g
– Maintain a desirable body weight and prevent weight
gain
Exercise
– Engage in physical activity to include enough
moderate exercise to expend at least 200
kilocalories/day
• Depending on level of risk, medication may be initiated
along with diet.
diet

50. PCNA’s What’s Missing in CholesterALL
Campaign
“What’s Missing in CholesterALL?”
invites women to become detectives in
investigating all the potential clues to a
healthy cholesterol profile.
PCNA’s brochure, website and toll-free number makes it fun
and interesting for women to search out the culprits of heart
disease.
To receive a free brochure:
Call: 877-HDL-GOAL (877-435-4625)
Visit: htt //
Vi it http://www.pcna.net t
http://www.raiseyourcholesterol.com

51. Recognizing High Blood Pressure
• More men than women have
hypertension until age 55.
yp g
• High blood pressure is more
common in older women
than older men.
p
• A person who has a normal
blood pressure at age 55 has
a 90% lifetime chance of
developing hypertension.
hypertension

52. Blood Pressure: Know you numbers!
Category Systolic BP Diastolic BP
(mmHg)
( H ) (mmHg)
( H )
Normal < 120 < 80
Prehypertension 120-139 80-89
Stage 1 140-159 90-99
Hypertension
Stage 2 > 160 >100
yp
Hypertension
National Heart Lung and Blood Institute – Joint National Committee -7

53. Fact or Fiction?
One in five adult Americans has high blood
p
pressure.

54. Benefits of Lowering Blood Pressure
• Reduces the chance of:
Heart Attack: 20-25 %
Stroke: 35 40 %
35-40
Heart Failure: 50 %
American Heart Association website:
www.americanheart.org

55. Lifestyle Change:
What Difference Does it Make ?
• Weight loss
– (decreases SBP 1.6 mm Hg for each kg lost)
• Dietary Approaches to Stop Hypertension: DASH
diet:
8 14
– (decreases SBP 8-14 mmHg)
• Reducing salt in the diet
– (decreases SBP 2-8 mmHg)
• 30-45 minutes daily aerobic exercise
( g)
– (decreases SBP 4-9 mmHg)
• Limit alcohol
– (decreases SBP 2-4 mm Hg)
• Avoidance of tobacco products

56. Obesity
• Growing epidemic in U.S.
• Increases risk of :
• high blood pressure
p
• lipid abnormalities
• diabetes
• Current focus is on taking
small steps:
• small changes in dietary
patterns
• increasing “incidental”
exercise

57. CHEESEBURGER
20 Years Ago Today
333 calories How many calories are
in today’s cheeseburger?

58. CHEESEBURGER
20 Years Ago Today
333 calories 590 calories
Calorie Difference: 257 calories

59. BMI: Know your numbers!
Classification of Overweight and Obesity by BMI
Obesity Class BMI kg/m 2
Underweight <18.5
<18 5
Normal 18.5–24.9
Overweight 25–29.9
Obesity I 30.0–34.9
II 35.0–39.9
Extreme Obesity
E Ob i III t 40.0

60. Waist Circumference
High Risk
Men > 40 inches
Women > 35 inches

61. Health Benefits of Weight Loss
g
• Decreased cardiovascular risk
• Decreased glucose and insulin levels
• Decreased blood pressure
• Decreased LDL and triglycerides, increased HDL
• y p p
Decreased severity of sleep apnea
• Reduced symptoms of degenerative joint disease
• Improved gynecological conditions

62. National Strategy to Address
y p
Obesity Epidemic
• U.S. Department of Health and
Human Services Initiative
• Small Steps: www.smallstep.gov
• Examples:
• choose fat free over whole milk
• park further from the store and
walk
• share an entrée
• walk to a co-worker’s desk
instead of e-mailing

63. The Metabolic Syndrome
• Certain “risk factors” for heart disease
tend to cluster together and markedly
increase your risk:
– overweight, especially when carried
around the waist
– high blood pressure
– cholesterol abnormalities (low HDL
and high triglycerides)
– elevated blood glucose
• People with these risk factors need to be
treated very aggressively for heart
disease prevention: lifestyle changes are
key!
k !

64. Psychosocial Factors
Stress
Depression

65. Postmenopausal Hormone Therapy
• Postmenopausal HT is
no longer recommended
as a strategy to prevent
heart disease.
• Short term hormone
therapy, ma
therap may still be used
sed
to treat symptoms of
p
menopause - this is a
decision between a
woman and her
healthcare provider.

66. Heart Healthy Diet
• Eat a variety of fruits,
vegetables,
vegetables grains
• Limit foods high in
saturated fat, trans fatty
fat
acid and cholesterol
• Substitute with
unsaturated fat from
vegetables, fish, legumes,
g , , g ,
and nuts
• Limit salt intake

67. Physical Activity
•What is the most common excuse for not
exercising?
Not
N enough time
h i
• What exercise has the lowest dropout rate of
any physical activity?
Walking

68. FITT: The Exercise Prescription
Frequency:
3-5 times per week
Intensity
y
Moderate intensity
Time
30-45 minutes
Type
Low-impact activities

69. Summary
• Know the symptoms of heart disease.
• Know your risk factors for heart disease.
Visit h lth id
• Vi it your healthcare provider:
– Discuss your risk factors
q
– Ask questions about y your heart tests
• Maintain a healthy lifestyle.
• Heart disease is largely preventable.

70. The Red Dress Campaign

71. ... a coworker, a neighbor, a sister
About Women and Heart Disease

72. Preventive Cardiovascular Nurses Association
Healthcare Professionals:
Interested i j i i PCNA?
I d in joining
- Membership includes a 1 year subscription of the Journal
of Cardiovascular Nursing and so much more!
Visit http://www.pcna.net or call (608) 250-2440 for
more i f
information.
i

73. Preventive Cardiovascular Nurses Association
Click below to view:
Printable Resources
And
Framingham Risk Scale

74. Resources
AUGUST 2005
HEART TALK: Nourishing Healthy Hearts
Presented by Preventive Cardiovascular Nurses’ Association and Promise Spread

75. Resources
Websites for Patient Education
Copyright 2005, developed by Jo Ann Carson. Used with permission
Therapeutic Lifestyle Changes - http://www.nhlbi.nih.gov/cgi-
bin/chd/step2intro.cgi
Live Healthier, Live Longer - http://www.nhlbi.nih.gov/chd
Health Heart Handbook for Women -
http://www.nhlbi.nih.gov/health/public/heart/other/hhw/hdbk_wmn.pdf
NHLBI general prevention of heart disease and care for patients -
http://www.nhlbi.nih.gov/chd/index.htm Live Healthier, Live Longer
Portion Distortion - http://hin.nhlbi.nih.gov/portion/
Be Heart Smart (eat foods lower in saturated fat and cholesterol---part of a
series for African-Americans) -
http://www.nhlbi.nih.gov/health/public/heart/other/chdblack/smart.pdf
Heart Healthy Recipes from NHLBI
Keep the Beat -
http://www.nhlbi.nih.gov/health/public/heart/other/ktb_recipebk/ktb_recipeb
k.pdf
“Stay Young at Heart, The Heart Healthy Cooking Way”
http://www.nhlbi.nih.gov/health/public/heart/other/syah/index.htm
“Heart Healthy Home Cooking, African-American Style:” -
http://www.nhlbi.nih.gov/health/public/heart/other/chdblack/cooking.pdf
“Latino Heart Healthy Recipes,” -
http://www.nhlbi.nih.gov/health/public/heart/other/sp_recip.pdf
American Heart Association, http://www.americanheart.org and
http://www.deliciousdecisions.org
National Restaurant Association - http://www.restaurant.org/dineout/nutrition.cfm
Guidance on How to Understand and Use the Nutrition Facts Panel on Food
Labels, US Food and Drug Administration
http://www.cfsan.fda.gov/~dms/foodlab.html
HEART TALK: Nourishing Healthy Hearts Resources
1

76. “Healthy Eating and Physical Activity across Your Lifespan,” provides a four-part
series, including “Better Health for You” (for adults) and “Young at Heart” (older
adults) from the Weight Control Information Network -
http://www.niddk.nih.gov/health/nutrit/nutrit.htm
Aim for a Healthy Weight -
http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/
DASH - http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
DASH Recipes - http://hin.nhlbi.nih.gov/nhbpep_kit/recipes.htm
Reduce Salt and Sodium in Your Diet -
http://www.nhlbi.nih.gov/hbp/prevent/sodium/sodium.htm
Maintaining a Healthy Weight -
http://www.nhlbi.nih.gov/hbp/prevent/h_weight/h_weight.htm
HEART TALK: Nourishing Healthy Hearts Resources
2

77. Registered Dietitian as a Resource
As described in Section III, evidence supports the benefits of referral to the
registered dietitian for lowering serum lipids. The Institute of Medicine describes
the registered dietitian as the nutrition professional uniquely prepared with
academic preparation, clinical training, national examination and continuing
education.
Description of MNT provided by the RD
In general, patients with risk factors for heart disease can benefit from one or
more sessions with the dietitian to address improving lifestyle. but referral to the
registered dietitian (RD) is more important for some patients. Examples of such
patients include:
x Patients with diabetes who need counseling or have never been to the RD
x Patients with genetically elevated triglycerides above 500 mg/dL
x Patients with hypertriglyceridemia who need to increase fat and lower
carbohydrate.
x Patients who wish to defer use of indicated lipid-lowering medications.
x Patients who have difficulty adopting TLC parameters due to dining out,
travel, economic or other restraints.
x Patients with lots of alternative medicine/dietary supplement questions
Tips for Reimbursement for Medical Nutrition Therapy
ƒ The provider should provide written referral to a registered dietitian
ƒ Some registered dietitians are listed by geographic area and area of
expertise at www.eatright.org
ƒ The provider’s order for referral to the dietitian should request Medical
Nutrition Therapy
ƒ Accurate diagnoses should be included
o As of 2005, Medicare specifically covers MNT for diabetes and pre-
dialysis renal disease
o Metabolic syndrome has now been assigned an International
Classification of Disease code (ICD9).
Insurance coverage for MNT varies, but is enhanced when the above listed steps
are included.
HEART TALK: Nourishing Healthy Hearts Resources
3

78. Framingham Risk Score: Women
Step 1: Age Points Step 4: SBP Points Step 5: Smoking Status Points
Years Points SBP If If Age Age Age Age Age
(mmHg) treated untreated 20-39 40-49 50-59 60-69 70-79
20-34 -7
<120 0 0 Nonsmoker 0 0 0 0 0
35-39 -3
120-129 1 3 Smoker 9 7 4 2 1
40-44 0
45-49 3 130-139
130 139 2 4
140-159 3 5 Step 6: Sum of Points
50-54 6
>160 4 6 Age
55-59 8
Total Cholesterol
60-64 10
HDL-C
65-69 12
Systolic Blood Pressure
S t li Bl d P
70-74 14
Smoking Status
75-79 16
Point Total
Step 2: Total Cholesterol Points
Step 7: 10-year CHD Risk
TC Age Age Age Age Age
(mg/dl) 20-39 40-49 50-59 60-69 70-79 Point 10-year Point 10-year Point 10-year
Total Risk Total Risk Total Risk
<160 0 0 0 0 0
<9 <1% 15 3% 22 17%
160-199 4 3 2 1 1
9 1% 16 4% 23 22%
200-239 8 6 4 2 1
10 1% 17 5% 24 27%
240-279
240 279 11 8 5 3 2
11 1% 18 6% >25 >30%
>280 13 10 7 4 2
12 1% 19 8%
13 2% 20 11%
Step 3: HDL-C Points
14 2% 21 14%
HDL-C (mg/dl) Points
>60 -1
50-59 0
40-49 1
<40 2

79. Framingham Risk Score: Men
Step 1: Age Points Step 4: SBP Points Step 5: Smoking Status Points
Years Points SBP If If Age Age Age Age Age
(mmHg) treated untreated 20-39 40-49 50-59 60-69 70-79
20-34 -9
<120 0 0 Nonsmoker 0 0 0 0 0
35-39 -4
120-129 0 1 Smoker 8 5 3 1 1
40-44 0
45-49 3 130-139
130 139 1 2
140-159 1 2 Step 6: Sum of Points
50-54 6
>160 2 3 Age
55-59 8
Total Cholesterol
60-64 10
HDL-C
65-69 11
Systolic Blood Pressure
S t li Bl d P
70-74 12
Smoking Status
75-79 13
Point Total
Step 2: Total Cholesterol Points
Step 7: 10-year CHD Risk
TC Age Age Age Age Age
(mg/dl) 20-39 40-49 50-59 60-69 70-79 Point 10-year Point 10-year Point 10-year
Total Risk Total Risk Total Risk
<160 0 0 0 0 0
<0 <1% 6 2% 13 12%
160-199 4 3 2 1 0
0 1% 7 3% 14 16%
200-239 7 5 3 1 0
1 1% 8 4% 15 20%
240-279
240 279 9 6 4 2 1
2 1% 9 5% 16 25%
>280 11 8 5 3 1
3 1% 10 6% >17 >30%
4 1% 11 8%
Step 3: HDL-C Points
5 2% 12 10%
HDL-C (mg/dl) Points
>60 -1
50-59 0
40-49 1
<40 2