1. PERCEPTIONS Vs REALITY:
WOMEN AND HEART DISEASE
Dr.Jayasree.H.Nambiar
DCH,DNB(Paed),DNB(Cardio),FIC(AIMS),FICC.
Consultant Interventional Cardiologist
BMH, Calicut.

2. What is Heart Disease?
• Heart : The most hard-working muscle of our body –
pumps 4-5 liters of blood every minute during rest
• Supplies nutrients and oxygen rich blood to all body
parts, including itself.
• Coronary arteries
surrounding the heart keep it
nourished with blood

3. What is Atherosclerosis?
What is Coronary Artery disease?
• Over time, fatty deposits called plaque build up within
the artery walls. The artery becomes narrow. This is
atherosclerosis
• When this occurs in the coronary arteries, heart does not
get sufficient blood, the condition is called coronary
artery disease, or coronary heart disease

4. What are the symptoms of Coronary
artery disease?
• No symptoms for long period
• Chest pain for short period on exertion
also known as Angina or minor heart
attack
• Myocardial Infarction or major heart
attack-Severe chest pain, death of heart
muscle, heart failure, irregular heart beats
• Sudden Death

6. How Big is the Problem ?
No. 1 killer disease worldwide
12 Million deaths annually.
During last 30 years large declines in
developed countries -rising health
awareness and government
programmes
Alarming increase in developing
countries especially India

7. Why Should I (Indian)
be Worried ?
• Indians More susceptible than any other
ethnic group
– 3.4 times more than Americans
– 6 times more than Chinese
– 20 times more than Japanese
– Occurs even at lower cholesterol levels
• Get the disease at much younger age
- 5-10 years earlier than other communities
• Disease follows more severe and malignant course
– 3 times higher rate of second heart attack and two times
higher mortality than whites

8. Kerala - Statistics
• 110 People die of heart disease daily.
• 38,000 people die of heart attack
every year(ICMR, WHO)
• 50% of total death due to
Cardiovascular disease
• (28% in India)
• ↑se to 2/3 by 2020

9. Kerala – Statistics…
• 87.2Lakhs Hypertensives
• 34.8 Lakhs Diabetes(ICMR-WHO)
• >20 years – 22% Diabetic
36% Hypertensive
66% Cholesterol >200

10. What do we need to
Know?
WOMEN AND HEART
DISEASE

14. Gender Bias in the Treatment of Women
―… The community has
viewed women‘s health almost
with a ‗bikini’ approach,
looking essentially at the
breast and reproductive
system, and almost ignoring
the rest of the woman as part
of women‘s health ….‖

15. Heart Disease is the #1 Killer of
Women
• Coronary heart disease is the
single leading cause of death and
a significant cause of morbidity
among women.
• In 1997 CHD claimed the lives
of 502,938 women (men had less
deaths)
• Since 1984, CVD has killed
more women than men each
year.

16. Death From Breast Cancer or
Heart Disease in Women in the US
US Vital Statistics, 1990

17. CVD Mortality Trends
(1979-1999)
American Heart Association. 2002 Heart and Stroke Statistical Update. 2001
DeathsinThousands

18. In Perspective:
• 1 in ―2‖ women will die
of heart disease.
• 1 in ―25‖ women will die
of breast cancer.

19. Coronary Heart Disease in Women
• Presentation and differences from men
• 2/3 of women who die suddenly have no
previously recognized symptoms.
• Women are more prone to non-cardiac
chest pain…..
• In fact they may experience little or no
squeezing chest pain in the center of the
chest, lightheadedness, fainting, or
shortness of breath with an MI (as seen
on ―ER‖).

20. Not So Straight Forward
• Because of these atypical symptoms, women
seek medical care later than men and are
more likely to be misdiagnosed.
• Women presenting with MI and CAD are
more likely to be older, have a history of DM,
HTN, Hyperlipids, CHF, and unstable angina
than male counterparts.
• Because of these comorbid conditions, there
tends to be diagnostic confusion.

21. Misperceptions and Missed Opportunities
Leading to Access Inequity
• Women were less likely to have an
EKG or be admitted to the telemetry
floors.
• Women are under-diagnosed and
can therefore get a false sense of
security.
• Less aspirin, beta-blockers, statins,
anti arrhythmic treatment, cardiac
cath, PTCA, CABG
• Women were less likely to enroll in
cardiac rehabilitation after an MI or
bypass surgery.

22. CHD Mortality in Younger Women
2.9
4.1
5.7
8.2
10.7
14.4
18.4
21.8
25.3
6.1
7.4
9.5
11.1
13.4
16.6
19.1
21.5
24.2
0
5
10
15
20
25
30
< 50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
DeathduringHospitalization(%)
Men
Women
Figure 1. Rates of death during hospitalization for Myocardial Infarction among w omen and men, according to age. The interaction betw een sex
and age w as significant (P<0.001).
Women under 65 suffer the highest relative sex-specific CHD mortality

23. Women vs Men
• Mortality from CABG-
particularly among younger
women-is double that among
men.
• More women than men die 1
year after an MI.
• CHD is Largely Preventable
• We need to address risk factors
earlier and more aggressively,
thereby reducing women‘s
cardiovascular risk.

24. Women and Heart Disease
Risk Factors

25. What Increases Risk?
• High Cholesterol
• Smoking
• High Blood Pressure
• Diabetes
• Obesity
• Alcohol
• Physical Inactivity

26. • Family history of cardiovascular disease.
• If your parents have cardiovascular disease
(especially if they were diagnosed before age
50), you have an increased risk of developing it.

27. Emerging Risk Factors
• Lipoprotein (a)
• Homocysteine
• Prothrombotic factors
• Proinflammatory factors
• Impaired fasting glucose
• Subclinical atherosclerosis
– Other clinical forms of atherosclerotic disease
(peripheral arterial disease, abdominal aortic
aneurysm, and symptomatic carotid artery disease)
– Abnormal internal or common carotid CIT, ankle-
arm index <0.9, coronary Ca2+

28. Gender Differences in CAD Risk
Factors
• Increasing recognition that atherosclerosis is
an inflammatory process
• Ridker PM, et al: A prospective case-
controlled study among 28,263
postmenopausal women
– Among 12 markers of inflammation, C
reactive protein was the strongest
univariate predictor of the risk of CV
events
Ridker PM, et al. N Engl J Med. 2000

29. CHOLESTEROL

30. CHOLESTEROL ( A TYPE OF FAT)
• Everybody needs cholesterol, it serves a vital
function in the body.
• It circulates in the blood.
• Too much cholesterol can
deposit in the arteries in the
form of plaque and block
them
• No symptoms till heart attack

31. WHERE DOES IT COME FROM ?
• Two sources of
cholesterol: Food
& made in your
body
• Food sources: All
foods containing
animal fat and
meat products
65%
35%

32. GOOD VS. BAD CHOLESTEROL
• LDL cholesterol
– known as bad cholesterol. It has
a tendency to increase risk of
heart disease
– major component of the plaque
that clogs arteries
• HDL cholesterol
– known as the good cholesterol.
Increases with exercise
– helps carry some of the bad
cholesterol out of arteries.

33. Know your Number!
Desirable numbers
• Total Cholesterol < 200;
• LDL < 100
• HDL > 40
• Triglycerides < 200
• Get the levels tested routinely and keep them
under control
• The only thing worse than finding out that you
have one of these conditions is…….NOT finding
out that you have it!!
And that’s not your Mobile Number!

34. Look before your eat
• Eat a variety of fruits and vegetables every
day. (5 servings - they are naturally low in
fat and high in vitamins and minerals and
anti oxidants). Eat colored vegetables and
fruits
• Eat a variety of grain products
• Choose nonfat or low-fat products.
• Use less fat meats- chicken, fish and lean
cuts
 Switch to fat-free milk—toned/skimmed
milk

35. Smoking

36. Cigarette Smoking
• Increases blood pressure
• Decreases HDL
• Damages arteries and blood
cells
• Increases heart attacks
• Cigarette smoke contains
more than 4,000 chemicals,
and 200 of these chemicals
are poisonous

37. Preventable Risk- Smoking
• A. 50% of heart attacks among
women are due to smoking. Smokers
tend to have their first heart attack 10
years earlier than nonsmokers.
• B. If you smoke, you are 4-6x‘s more
likely to suffer a heart attack and
increase your risk of a stroke.
• C. Women who smoke and take
OCP‘s increase their risk of heart
disease 30x‘s.

38. Cigarette Smoking
If you think YOU are smoking the cigarette, you are mistaken…
“It’s the other way round”!

39. SMOKING:
• Stop!!!!!(avg. attempt = 8 times)
• Women who have other smokers
in their household have a 2.5 X's
greater likelihood of relapse.
Circulation 2002:106
• Smoking cessation was
associated with a 36% reduction
in mortality among patients with
CHD.
JAMA 2003:290

40. Quit Smoking
 In just 20 mins after quitting , blood pressure
decreases
 After 24 hrs the chance of heart attack decreases
 Within 1 year of quitting, CHD risk decreases,
within 2 years it reaches the level of a non
smoker.

41. HIGH BLOOD PRESSURE

42. HYPERTENSION
• 65% of all hypertension remains
either undetected or inadequately
treated.
• People who are nor motensive at
55 have a 90% lifetime risk of
developing HTN.
• Prevalence increases with age
and women live longer-
hypertension is more common in
females.
• HTN is more common with OCP
and obesity.

43. CONTROLLING BLOOD PRESSURE
• Adults should have their blood pressure
checked at least once every two years, as
there are no symptoms to tell if you have
high blood pressure
• Optimal levels : 120 /80 mm Hg
• If high
– Modify your lifestyle – Diet, Weight, Exercise,
Salt restriction
– Adhere to the prescribed medication without fail,
to decrease chances of getting heart disease – Do
not stop your medicines without consulting your
doctor, even if the blood pressure becomes
normal

44. Weight Management
 On average, ~ 1/2 to 1mm
decrease in blood pressure for
each pound weight loss in
obese hypertensives (up to
~20# loss)
 Weight reduction can raise
HDL-cholesterol
 Obesity is the major risk for
CHD

45. Exercise
• 30-45 mins of walking
5x‘s/week reduces risk of MI
in females 50%.
• Helps control BP, increases
HDL, decreases body fat, DM
risk, possibly prostate, breast
and uterine cancers.

46. Diabetes

47. Diabetes
• At any given cholesterol level,
diabetic persons have a 2 or 3 x
higher risk of heart attack or stroke
• A diabetic is more likely to die of a
heart attack than a non-diabetic
• ~80% Diabetics die from heart
disease
• Risk of sudden death from a heart
attack for a diabetic is the same as
that of someone who has already had
a heart attack.

48. Diabetes Creates Higher Risks for Women
With CAD
• 65% of diabetics die from heart disease or
stroke
• 4.2 million American women have diabetes
– Diabetes increases CAD risk 3-fold to 7-
fold in women vs 2-fold to 3-fold in men
– Diabetes doubles the risk of second heart
attack in women but not in men
• Every year, heart disease kills 50,000 more
American women than men
• Statistics are particularly high among African
American women American Heart Association
Centers for Disease Control and Prevention
Manson JE, et al. Prevention of Myocardial Infarction. 1996

49. Reported Causes of Death in
People With Diabetes
C

50. Controlling Blood Sugar
• Normal blood sugar:
• Fasting < 100; Post meals <140
• Keep HBA1C < 6.5%
• If high
– Modify your lifestyle – Diet, Weight,
Exercise
– Adhere to the prescribed medication
without fail, to decrease chances of
getting heart disease – Do not stop your
medicines without consulting your
doctor, even if the blood sugar becomes
normal

51. Obesity

52. Obesity
• People who are overweight (10-30 % more than their
normal body weight)
• Obese have 2 to 6 times the risk of developing heart
disease
• Normal Waist Circumference
<88cm in females
< 92cm in males
• Pears or apples?

53. Obesity
A. 1/3 of adult women are obese and its
increasing
B. Active women have a 50% risk
reduction in developing heart disease.

54. Obesity and Coronary Heart Disease Mortality
0
1
2
3
4
5
6
<19 19.0-
21.9
22.0-
24.9
25.0-
26.9
27.0-
28.9
29.0-
31.9
>32.0
Nurses‘ Health Study: Women who never smoked
Relative Risk of Coronary Heart Disease mortality
Body Mass Index (kg/m2)

56. Metabolic Syndrome
Risk Factor Defining Level
Abdominal Obesity Waist Circumference
Men >40 inches
Women >35 inches
TG‘s >150
HDL
Men <40
Women <50
BP >130/85
Fasting Glucose >100 mg/dl

57. Mortality Associated With
Metabolic Syndrome
Lakka H-M et al. JAMA. 2002;288:2709-2716.
18
9
6
8
3
2
0
2
4
6
8
10
12
14
16
18
20
All-cause mortality* CVD mortality* CHD mortality*
Metabolic syndrome
No metabolic syndrome
Mortality(%ofpatients)
2003 PPS®
*Adjusted for known CHD risk factors.
POWERSEARCH PLUG-IN™ 2.0
Copyright © 2001-02 Accent Graphics, Inc.
Slide Source: "R:NDEI-22004 GrantT108ARST095 ARS Case 2 FINAL-Baton Rouge 12-09-03.ppt" <OPEN>
Last Modified: December 9, 2003 2:17:25 PM
Slide Number: 19

58. Alcohol Consumption

59. Alcohol Consumption
In small amounts it acts as a vasodilator-Good!
1-2 drinks
In large amounts it acts as a vasoconstrictor-BAD!
3-4 drinks
This is a very fine line!

60. Physical Inactivity
Increasing physical
activity has been shown to
decrease blood pressure.
Moderate to intense
physical activity for 30-45
minutes on most days of
the week is recommended.

61. Exercise and CVD
Serves several functions in preventing and treating
those at high risk.
Reduces incidence of obesity.
Increases HDL
Lowers LDL and total cholesterol
Helps control diabetes and hypertension
Those at high risk should take part in a
specially supervised program.

62. Exercise, Exercise, Exercise
•Mortality is halved in retired men who
walk more than two miles every day
•Regular exercise can halve the risk of
heart disease, particularly in men who
walk briskly
•Someone who is inactive has as great a
risk of having heart disease as someone
who smokes, has high blood pressure or
has high cholesterol
•Exercise significantly reduces the
chances of diabetes and stroke
•With regular exercise, blood pressure in
those with hypertension is reduced by as
much as 20mms Hg

63. How is cardiovascular disease
associated with menopause?
• After menopause, a woman‘s risk of
cardiovascular disease increases.
• In women who have undergone early
menopause (before age 50) or surgical
menopause, the risk of cardiovascular
disease is also higher, especially when
combined with other risk factors.
• Estrogen helps a woman‘s body protect her
against cardiovascular disease.
• After menopause, cardiovascular disease
becomes more of a risk for women because
of the reduced level of estrogen.

64. Postmenopausal Hormone
Therapy and Cardio protection
• First randomized trial
• HERS trial (Heart and
Estrogen/Progestin
Replacement Study)
– Secondary CAD
prevention trial
– Randomized trial of
placebo vs estrogen
and
medroxyprogesterone
– Follow-up = 4 years
– N = 2,763 women
with an intact uterus
HERS trial. JAMA. 1998.

65. Heart Disease
• There is a continuum of CVD risk, it is not a
―have or have-not‖ condition.
• CHD is less in women who control their risk
factors. JAMA Oct. 6, 2004
• The average age of our population is
increasing and so CHD will remain a major
public health issue.

66. Other Heart Diseases In Women
• RHD & Aortorto arteritis more common in
women
• Congenital heart diseases like ASD more in
women.
• Can cause morbidity & maternal/neonatal
mortality during pregnancy and delivery.
• Needs screening of pregnant women with
Echo/Foetal Echo.

67. “GO RED” Conclusions
Heart disease is a number one killer.
Majority of the causes for heart diseases are
known and can be modified.
Adoption of guidelines for prevention of
cardiovascular diseases can help people to
have a lifelong low level of heart diseases
and stroke.

68. Contd……..
 Chances of Heart disease in women are high
& that is on the increase.
 Most of the risk factors have a higher impact
in women than men.
 Since younger women have a higher mortality
than men(<40yrs) grave implications in
family & society.
 All females should be made aware of this
through educative programmes starting at
school & College levels.

69. Contd…
 Preventive measures save economy & health.
 Girl students be screened for RHD &
Congenital Heart diseases through school
health programmes.
 Separate ‗Women & Child care‘ wings for
Cardiology departments.
 Concessional rate Cardiac check ups for
women.
 Realizing this ‗Cardiac Explosions‘ in women
Govt. schemes on a ‗Go Red‘ Basis!!!.

70. THANK YOU!!!