Racial and Gender Differences in Cardiovascular Disease Flashcards Preview

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Flashcards in Racial and Gender Differences in Cardiovascular Disease Deck (11):
1

Heart Disease

  • Gender
  • Race
  • Risk factors

  • Gender
    • Leading cause of death, esp in women
    • Accounted for over 290,000 deaths in women in 2009
    • 1 in 4 women will die from it
    • Women are 6x more likely to die of heart disease than breast cancer
    • Incidence in women (>75yo) lags behind men by 5-10 years (65-74yo)
  • Race
    • Black & asian/pacific islander deaths from CHD > white, hispanic, or american indian deaths from CHD
    • Risk factors for CHD: lowest in whites & asians
    • Odds for multiple risk factors: greatest in black & native american women
  • Risk factors
    • 80% of women have >1 risk factor when presenting w/ heart disease
    • Obesity: present in >1/3 of women w/ CHD
    • Diabetes: stronger risk factor for CHD / acute MI in women than men
      • Women have a higher prevalence of diabetes mellitus than men
      • Absolute rates of CVD in diabetes are higher in men than women, but DM accounts for a larger proportion of CVD that occurs in women than men

2

Women vs. Men

  • Cardiac anatomy
  • Cardiac function
  • Physiology
  • Coronary artery size

  • Cardiac anatomy
    • Smaller LV mass, wall thickness, LA dimension, & left end diastolic size
  • Cardiac function
    • Stroke volume: reduced
    • Ejection fraction: slightly higher
    • Pulse: faster
  • Physiology
    • Reduced sympathetic activity
    • Enhanced parasympathetic activity
    • Decreased levels of norepinephrine
  • Coronary artery size
    • Smaller coronary artery size
    • Anything that further reduces teh diameter of the artery (stenosis, spasm, dysfunction) has seroius adverse effects

3

Plaque Distribution, Disruption, & Healing

  • Plaque distribution
    • Men
    • Women
  • Way in which plaque is disrupted
    • Men & older women
    • Younger women
    • Women
  • Way in which atherosclerotic lesions heal
    • Men
    • Women

  • Plaque distribution
    • Men: focal areas of plaque in their coronary arteries w/ single segmental stenosis
    • Women: diffuse plaque buildup & narrowing throughout the length of their coronary arteries
  • Way in which plaque is disrupted
    • Men & older women: plaque rupture
      • Occurs w/ a large necrotic core & disrupted fibrous cap infiltrated by macrophages & lymphocytes
    • Younger women: plaque erosion
      • A fibrous cap is absent at the plaque erosion site
      • The exposed intima consists predominantly of smooth muscle & proteoglycans
    • Women: distal microvascular embolization
      • In the setting of a fatal epicardial thrombosis
  • Way in which atherosclerotic lesions heal
    • Men: negative remodeling
      • Inward remodeling of vasculature & sometimes artery narrowing
    • Women: positive remodeling
      • Outward remodeling away from the lesion

4

Estrogen

  • Effects on cholesterol
  • Effects on endothelial function
  • Effects on women

  • Effects on cholesterol
    • Decrease LDL
    • Increase HDl
    • Increase triglycerides
  • Effects on endothelial function
    • Increase NO availability --> increase vasodilation
    • Increase endothelial growth + decrease smooth muscle growth --> inhibit healthy repsonse to vessel injury
  • Effects on women
    • Estrogen affects women's reproductive & CV systems
    • Women are protected by estrogen when they're younger
    • Menopause --> lose estrogen --> higher risk for heart disease
      • Higher cholesterol & LDL
      • Lower HDL & triglycerides
      • Less vadodilation in response to NO
      • Less inhibition of healthy response to vessel injury

5

Risk Stratification in Women: High Risk

  • Atherosclerotic disease
    • Coronary heart disease
      • Heart attack
      • Blockages in coronary arteries
    • Peripheral arterial disease
      • Peripheral arterial bypass
      • Blockages in vasculature
    • Cerebrovascular disease
      • Stoke
      • Carotid endarterectomy or stenting
    • Abdmoinal aortic aneurysm
  • Diabetes mellitus
  • End stage or chronic kidney disease
  • 10 year Framingham CV disease risk > 10%

6

Risk Stratification in Women: At Risk

  • Cigarette smoking
  • HTN
  • Dyslipidemia
  • FH of premature CVD in a 1st degree relative
  • Obesity
  • Physical inactivity
  • Poor diet
  • Metabolic syndrome (>3)
    • Obesity
    • High triglycerides
    • Low HDL
    • High BP
    • High fasting glucose
  • Advanced subclinical atherosclerosis
  • Poor exercise capacity on treadmill test
  • Systemic autoimmune collagen vascular disease
    • Systemic lupus erythematous
    • Rheumatoid arthritis
  • Pregnancy-induced HTN, gestational diabetes, pre-eclampsia
  • (Thoracic radiation used to treat breast cancer)

7

Risk Stratification in Women: Ideal Risk

  • Total cholesterol < 200
  • BP < 120/80
  • Fasting blood sugar < 100
  • BMI < 25
  • Never smoked or quit > 12 months ago
  • Physicla activity levels at goal
  • Appropriate diet
  • Make up <5% of women

8

Lifestyle Recommendations for Women

  • Smoking cessation
  • Physical activity
  • Low risk diet
  • Depression treatment

  • Smoking cessation
    • Counseling
    • Nicotine replacement (patch, gum, lozenge, inhaler)
    • Pharmacotherapy (buproprion, varenicline)
  • Physical activity
    • Moderate exercise 150 min/week or vigorous exercise 75 min/week
    • Muscle strengthening 2 days/week
    • Moderate to intense activity 60-90 min/day for women needing to lose weight
  • Low risk diet
    • High in vegetables, fruit, whole grains, & fish
    • Low in saturated fats & salts
    • No more than 1 alcoholic drink / day
  • Depression treatment
    • Screen & treat

9

Women & Aspirin

  • Aspirin therapy
  • Clopidogrel
  • Medications that shouldn't be used for prevention of CV disease

  • Aspirin therapy
    • For women w/ a prior history of heart attack or stroke to decreae risk of recurrence
    • Contraversial for stroke/MI prevention in women who are at risk or healthy
      • Beneficial: >65yo, controlled BP, & benefit of prevention > risk of GI bleeding & hemorrhagic stroke
      • Not beneficial: <65yo, low risk or healthy women
  • Clopidogrel
    • For high risk women intolerant or allergic to aspirin
  • Medications that shouldn't be used for prevention of CV disease
    • Antioxidant supplements
    • Folic acid supplements
    • Selective estrogen-receptor modulators (SERMs)
    • Estrogen hormone therapy

10

Acute Coronary Syndrome

  • Most common ACS symptom for both men & women
  • Atypical ACS symptoms in women
  • Gender biases in treating women
  • Deaths within 1 year after first MI
  • Deaths within 5 years after first MI

  • Most common ACS symptom for both men & women
    • Chest pain
  • Atypical ACS symptoms in women
    • Arm, back, shoulder, neck, & jaw pain
    • Shortness of breath
    • Nausea
    • Unexplained fatigue
    • Palpitations
  • Gender biases in treating women
    • Develop more angina, HF, & arrhythmias after a heart attack
    • Less likely to have an EKG, cardiac monitoring, & cardiac enzymes drawn
    • Less cholesterol screening & therapies
    • Less use of heparin, beta blockers, & aspirin during AMI
    • Less antiplatelet therapy for secondary prevention
    • Fewer referrals to cardiac rehabilitation
    • Fewer ICDs
  • Deaths within 1 year after first MI
    • <45yo: women > men
    • 45-64yo: black men > white women > black women > white men
    • >65yo: white & black women > white & black men
  • Deaths within 5 years after first MI
    • <45yo: women > men
    • 45-64yo: black women > black men > white women > white men
    • >65yo: white women > white men

11

Chest Pain w/ "Normal Coronary Arteries"

  • Coronary arteries in men vs. women w/ chest pain
  • Women w/ chest pain & normal coronary arteries
  • Pathophysiology of chest pain w/ normal coronary arteries
  • Treatment of women w/ chest pain & normal coronary arteries

  • Coronary arteries in men vs. women w/ chest pain
    • Men: less likely to have normal coronary arteries
    • Women: more likely to have normal coronary arteries
  • Women w/ chest pain & normal coronary arteries
    • At higher risk & have increased rates of cardiac events
    • Non-CAD women w/ persistent chest pain are more likely to have CV events (non-fatal MIs, strokes, CHF, CV deaths) than those w/o chest pain
  • Pathophysiology of chest pain w/ normal coronary arteries
    • Coronary artery vasospasms
      • Artery spasm --> decreased luminal area --> decreased distal blood flow
    • Endothelial dysfunction
      • Vasoactive stimuli --> abnormal blood flow
      • Increased inflammatory states (high hs-CRP)
      • Reduced substrate of the vasodilator NO
      • Abnormal response to NO or endothelin
      • High levels of endogenous NO inhibitors (asymmetric dimethylarginine, ADMA)
    • Autonomic abnormalities
      • Increased sympathetic tone --> small vessels that are sensitive to vasoconstriction &/or vasospasm
    • Enhanced pain sensitivity
      • Electrical stimulation of atrium & ventricle --> chest pain
      • Injection of contrast media into LAD --> pain
      • Increased activation of regional cerebral cortex during dobutamine stress echo
    • Estrogen deficiency
      • Impaired endothelial dysfunction
      • Poor pain modulation
  • Treatment of women w/ chest pain & normal coronary arteries
    • Aggressive lifestyle changes
    • Risk factor management
    • Low dose aspirin
    • Statin therapy for dyslipidemia