Η στεφανιαία νόσος στις γυναίκες Υπάρχουν διαφορές και ποιες από τους άνδρες ΤΣΑΓΑΛΟΥ ΕΛΕΥΘΕΡΙΑ Θεραπευτική Κλινική Πανεπιστημίου Αθηνών
Τα καρδιαγγειακά νοσήματα αποτελούν μια κατεξοχήν ανδρική ασθένεια Οι γυναίκες έχουν λιγότερους παράγοντες κινδύνου, με παράλληλη ισχυρή προστασία από τα οιστρογόνα Απασχολούν τις υπηρεσίες υγείας με ασαφή ενοχλήματα και ψευδώς θετικές δοκιμασίες για μυοκαρδιακή ισχαιμία Όταν εμφανίζουν στεφανιαία νόσο, έχουν υψηλότερη θνητότητα σε σχέση με τους άνδρες
Curr Probl Cardiol 2012;37:450-526
Males, Females and Cardiovascular Disease Circulation 2012;125:188-197
Trends in Mortality Rates From Coronary Heart Disease J Am Coll Cardiol 2007;50: 2128 32
Age specific mortality rates J Am Coll Cardiol 2007;50: 2128 32
Γιατί υποτιμάται η στεφανιαία νόσος στις γυναίκες????
Γιατί πρόκειται εν πολλοίς για μια διαφορετική ασθένεια Διαφορετικοί παράγοντεσ κινδφνου Διαφορετικζσ κλινικζσ εκδηλώςεισ ΔΙΑΦΟΡΕΣΙΚΑ ΑΓΓΕΙΟΓΡΑΦΙΚΑ ΕΤΡΗΜΑΣΑ ΠΑΡΟΜΟΙΑ ΚΑΚΗ ΠΡΟΓΝΩΗ
Traditional risk factors cigarette smoking is increasingly more prevalent in young adult women who often cite weightmanagement as a reason for smoking obesity is prevalent in one-third of women greater blood cholesterol levels hypertriglyceridemia is a more potent independent risk factor diabetic women have significantly greater rates of IHD mortality
Novel risk factors Greater mean C-reactive protein Disruption of ovulatory cycling Functional hypothalamic amenorrhea Polycystic ovarian syndrome Pregnancy associated factors pregnancy-associated remodeling of the coronary arteries pregnancy-induced hypertension gestational diabetes
Prediction of IHD risk Framingham Risk Score classifies 90% of women as low risk, with very few assigned a high-risk status before the age of 70 The Reynolds risk score 0.0799 age 3.137 + natural logarithm (systolic blood pressure) 0.180 + natural logarithm (hscrp) 1.382 + natural logarithm (total cholesterol) 1.172 natural logarithm (high-density lipoprotein cholesterol) + 0.134 hemoglobin A1c (%) (if diabetic) + 0.818 (if current smoker) + 0.438 (if family history of premature MI)
ANGINA
Angina Prevalence Circulation 2008;117:1526-1536
Cardiac catheterization results of women with angina WISE study 100 80 60 40 20 0 Nonobstructive 1 vessel 2 vessel 3 vessel Circulation 2006;114:894-904
Standardized Mortality Ratios for patients suffering from angina JAMA. 2006;295:1404-1411
Five year primary event rates ( nonfatal MI, hospitalization for CHF, stroke, or cardiovascular death) Arch Intern Med. 2009 ; 169(9): 843 850
IVUS imaging in a woman with angiographically normal coronary arteries
Relationship between the number of risk factors and percent atheroma volume J Interven Cardiol 2010;23:511 519
Coronary microvascular dysfunction DEFINITION abnormal coronary microvascular resistance that is clinically evident as an inappropriate coronary blood flow response, impaired myocardial perfusion, and/or myocardial ischemia that cannot be accounted for by abnormalities in the epicardial coronary arteries Heart Lung Circ 2009;18:19-27
Coronary flow reserve
Coronary flow reserve and event-free survival J Am Coll Cardiol 2010;55:2825 32
Acute coronary events
Males, Females and Cardiovascular Disease Circulation 2012;125:188-197
Age distribution JAMA 2012;308(10):998-1006
Χαρακτηριστικά γυναικών με οξέα στεφανιαία σύνδρομα Μεγαλύηερη ηλικία Μικρόηερο θορηίο προηγούμεμης ζηεθαμιαίας μόζοσ Περιζζόηεροι παράγομηες κιμδύμοσ Περιζζόηερη αμαιμία Περιζζόηερη μεθρική αμεπάρκεια
Women s major symptoms before a heart attack include Unusual fatigue 70% Sleep disturbance 48% Shortness of breath 42% Indigestion 39% Anxiety 35% Most frequent symptoms during the heart attack include Shortness of breath 58% Weakness 55% Unusual fatigue 43% Cold sweat 39% Dizziness 39% Curr Probl Cardiol 2012;37:450-526
Symptoms of Myocardial Ischemia in Women JAMA 2012;307(8):813-822
Hospital mortality by chest pain upon presentation, age and sex JAMA 2012;307(8):813-822
Angiographic data in women and men presenting with ACS JAMA 2009 August 26; 302(8): 874 882
Angiographic data in women and men presenting with STEMI, NSTEMI or unstable angina JAMA. 2009 August 26; 302(8): 874 882
40% of women with ACS and non-obstructive CAD present with ruptured or ulcerated plaques
Unadjusted and multivariable adjusted 30-day mortality models in women versus men JAMA 2009 August 26; 302(8): 874 882
Differences in initial and early management Circulation 2012 Oct 30;126(18):2184-9
Differences in mortality Circulation 2012 Oct 30;126(18):2184-9
Conclusions Coronary/ischemic heart disease has specific sex differences. Novel risk factors Greater prevalence of ischemia Greater symptoms burden Less obstructive CAD microvascular angina a new entity
Conclusions New models linking these findings with symptoms, ischemia, and adverse outcomes should be tested
Conclusions Younger women are presenting with ACS Atypical symptoms are quite frequent If diagnosed and treated as aggressively as men might have better long term prognosis
Σας ευχαριστώ
Delays in emergency care for cardiac symptoms Circ Cardiovasc Qual Outcomes 2009;2:9-1 A greater proportion of women die before hospital arrival Natl Vital Stat Rep 2000;48:1-105 Underutilization of evidence-based therapies European Heart Journal (2011) 32, 1337 1344
Secondary prevention medication prescription between nonobstructive and obstructive CAD patients with ACS Circ Cardiovasc Qual Outcomes 2010;3:632-641
Conclusions
A total mess!!!!! Dissociation between symptoms---ecg Findings---Coronary angiography findings typical cardiac symptoms is based primarily on the experience of white, middle-aged men, with deviations called atypical.
Assessment of myocardial ischemia Electrocardiograph (stress ECG test) Positron emission tomography (metabolic tracers) Magnetic resonance spectroscopy Transmyocardial metabolic studies Myocardial perfusion techniques Myocardial scintigraphy Positron emission tomography (blood flow tracers) Magnetic resonance imaging Contrast echocardiography Angiographic myocardial blush Coronary blood flow techniques Coronary sinus thermodilution Intracoronary Doppler flowire Angiographic frame count Doppler echocardiography