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Women and Coronary Heart Disease

BIOL122 A2 Group Presentation
by

Sarah Buckland

on 17 September 2013

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Transcript of Women and Coronary Heart Disease

Women and Coronary Heart Disease
Women and Coronary Heart Disease
By Michelle, Bek & Sarah.
Aetiology
Clinical Manifestations
Treatment
Hormone Replacement
Therapy
Epidemiology
Coronary Heart Disease?
Risk Factors
Seeking Medical Assistance: Gender Differences



Class Activity
Coronary Heart Disease (CHD) is the most common form of Cardiovascular Disease. It is a condition caused by atherosclerosis that reduces the blood flow through the coronary arteries to the heart muscle, and typically results in chest pain or heart damage. CHD can lead to many other complications, such as angina pectoris, myocardial infarction, and Congestive Heart Failure (CHF).
Also known as: Ischaemic Heart Disease or Coronary Artery Disease (CAD).
What is Cardiovascular
Disease?
Cardiovascular Disease (CVD) includes all diseases or conditions of the heart or blood vessels.
The main types in Australia are:
- Coronary Heart Disease (CHD)
- Congestive Heart Failure (CHF)
- Stroke
- Congenital Heart Disease
- Rheumatic Heart Disease
- Peripheral Vascular Disease
Congestive Heart Failure
Congestive Heart Failure (CHF) is a condition in which the heart is unable to pump blood at an adequate rate or in adequate volume, and is unable to maintain adequate supply of blood in the tissues. Also known as Congestive Cardiac Failure (CCF).
- Atherosclerosis
- Imbalance between oxygen supply and demand
- Increased oxygen demands
- Inadequate oxygen transport

- Oestrogen plays a significant role in the aetiology of CVD in women

- smoking (active and passive)
- high blood cholesterol
- high blood pressure
- diabetes mellitus
- physical inactivity
- overweight/obese
- stress
- depression, social isolation and lack of quality support
Risk Factors
Non-modifiable
- increasing age
- family history of CHD
Modifiable
CVDs have been the leading cause of death in Australia since 2000, for both men and women.
At what age are women dying?
CVD death rates increase significantly with age.
The highest CVD death rates occurred in those aged 85 and over.
Image Source: (AIHW, 2011)
- Coronary heart disease, stroke, heart failure
and other heart diseases are the three leading
causes of death among Australian women

- CVD causes 1 in 3 deaths in women

- CVD is responsible for more than 25% of premature death among women

- CVDs are in the top 10 causes of disability for women

- 1 in 5 Australian women (approx. 2million women) have CVD
226,000 have coronary heart disease
168,000 have had a stroke
176,000 have heart failure
Australian Statistics:
Death rates after first MI contrasted
Pathogenesis
- 75% or greater atherosclerotic reduction in lumen or one or more major coronary vessels (critical stenosis)

> Gender differences explained by effects of oestrogen


Angina pectoris is chest pain caused by myocardial ischaemia, which usually precedes a myocardial infarction (MI). Symptoms of an MI can present atypically in women than they do in men.

Men "classic" symptoms:
• severe crushing chest pain
• pulse rapid and weak
• dyspnoea due to pulmonary congestion and oedema
• massive MIs can cause cardiogenic shock
• “silent MIs”
• dysrhythmias
How are women different?
Upper shoulder or back pain
Jaw pain or pain spreading to the jaw
Pressure or pain in the center of the chest
Indigestion (vomiting, nausea)
Light headedness
Pain that spread to the arm
Unusual fatigue for several days

Pharmacological Treatment
Lifestyle Treatment
Hormone replacement therapy (HRT) involves the use of exogenous oestrogen.
HRT is used for relief of menopausal symptoms, but it is also associated with several unwanted adverse effects and significant health risks.
Oestrogen-Only vs. Combination Therapy
For women with an intact uterus, oestrogen-only therapy (ERT) has the potential to cause proliferation of endometrial cells and hence increases the risk of developing endometrial cancer.
Therefore, it is advised that women with an intact uterus be given a combination therapy which includes progestogen also (EPRT).

Combination therapies include:
- Continuous Combined HRT - involves taking oestrogen and progesterone daily, usually indicated for women who haven't had a period for at least 12 months
- Cyclical Combined HRT - involves taking oestrogen daily and only adding progesterone for 10-14 days each month
Routes of delivery
HRT is available in the following forms:
- oral tablet
- vaginal tablet
- transdermal patch
- transdermal gel
- injection
- pessaries
- vaginal cream
Action of Liver
Recommendations of Use
Provides relief for menopausal symptoms:
- hot flushes
- sleep disturbances
- night sweats

Reduces some health risks:
- bowel cancer
- bone fractures

Causes several unwanted adverse effects:
- bleeding
- weight gain
- headaches
- nausea
- breast tenderness
- fluid retention
Increases several health risks:
- breast cancer
- abnormal mammogram
- stroke
- thrombosis
- spotting or the return of periods

No effect on:
- uterine cancer
- ovarian cancer
- mental health
- general health

Research is unclear regarding:
- cardiovascular risks
- memory loss and dementia
- improvements to hair and skin
Cardiovascular Risks
The literature is unclear in regards to the risk of HRT upon cardiovascular conditions.

- An existing high quality systematic review found no association between HRT and CVD incidence/death, in women with no prior CVD

Spot risk factors?
Spot clinical manifestations/symptoms?

Death rate after first MI (Myocardial Infarction) of women is higher than men. Also it noticeably increases within the first 5 years.
Treatment differences in Accident & Emergency Department
There has been some studies regarding
treatment differences towards patients experiencing MI symptoms, who visited A&E departments. These differences are to due to various reasons, in particular the patients' gender.
Diagnosis in A&E
Blood test
Echocardiogram
ECG (Electrocardiogram)

CCU, coronary care unit;
PTCA, percutaneous transluminal coronary angioplasty.
Image source (O'Donnell, 2005).
Reasons for non-administration
of thrombolytic therapy
Women waited longer for thrombolysis, with a median ‘door to needle’ time of 70 minutes in comparison with 52 minutes for men. Men were more likely to receive their treatment within the recommended 30-minute time.
How long does it take?
Why?
Takes longer for women to seek for help.
- women tend to call GP, rather than
call for immediate help
Vague or ambiguous symptoms
Women are generally older when they
develop MI
Health professionals generally consider
the male patient to be at higher risk
Aspirin: Keeps blood clots from forming
by preventing blood platelets from
sticking together.
Thrombolysis: a procedure that
involves injecting a clot-dissolving
agent to restore blood flow in a
coronary artery.
Likely Treatments in
A&E department
Data Source: (O'Donnell, 2005)
Data Source: (NHMRC, 2004) and (NHMRC, 2005)
Data Source: (Heart Healthy Women, 2013)
- There is some evidence which indicates that oestrogen-only HRT reduces the risk of CVD, in women with no prior CVD

- There is evidence which indicates no association between oestrogen-only or combined HRT and risk of CVD death, in women with existing CVD
- postmenopause (low levels of oestrogen)
Image Source: (The Heart Foundation, 2013)
Image Source: (The Heart Foundation, 2013)
Image Source: (The Heart Foundation, 2013)
Image Source: (The Heart Foundation, 2013)
By Michelle, Bek and Sarah
Oral HRT tablets:
- require higher dose
- high hepatic first pass effect
- reduces bioavailability of hormones
- may render hormones ineffective
- liver may become overworked

Dermal HRT (such as patches and creams):
- generally better choice
- absorb very well across skin
- absorbed directly in bloodstream
- easier to adjust dose if necessary when using creams

Every woman is individual, and so requires a therapy which balances her unique hormonal and metabolic needs.
Liver Disease:
- severe liver disease may slow metabolism of hormones
- more adverse effects
Thrombolysis
Chance of surviving and recovering from
MI is greater if a thrombolytic drug is administered within 12 hours after the
onset of heart attack.

Ideally, the patient should receive
thrombolytic medications within the
first 30 minutes after arriving
at the hospital.
Blood Vessels

• Increase blood flow by binding to endothelium receptors to stimulates the release of nitric oxide, causing vasodilation
• Up-regulation of vasodilatory substances and down-regulation of the vasoconstrictor molecules
• Inhibits platelet activation and directly inhibits smooth muscle cell migration and proliferation

Lipids & Atherosclerosis
• Lower plasma low-density lipoprotein (LDL) cholesterol levels and higher high-density lipoprotein (HDL) cholesterol levels
• Complex metabolism of lipoproteins in the arterial wall, impede the atherosclerotic plaque.
• Inhibits platelet aggregation, myointimal proliferation, reduces lipoprotein-induced arterial smooth muscle cell proliferation, collagen and elastin production, and increases arterial smooth muscle prostacyclin production and inhibition of foam cell formation

Blood Clotting
• Oral contraceptives - increased risk for venous and arterial thrombosis.
• Accelerate blood clotting and platelet aggregation
• Reduces plasma concentrations of fibrinogen and the anticoagulants anti-thrombin and protein S.
• Concentrations of coagulation factors usually remain within the normal range. May result in synergistic or opposing effects on the risk of venous thrombosis.
• Usually only a threat to susceptible women.

Healthy eating

Regular exercise

Maintain a healthy BMI

Do not smoke

Reduce stress
• Cholesterol-modifying medications
• Opioids
• Beta blockers
• Anti-platelet drugs, fibrinolytics, anticoagulants:
• Vasodilators
• ACE inhibitors and ARBs
• Calcium channel blockers
Drugs
Surgical Procedures

Angiography
: an X-ray of the coronary arteries is taken to see if they are narrowed or blocked.
• Angioplasty and stent placement: insertion of a catheter into the narrowed part of your artery.
• Coronary artery bypass surgery: creation a graft to bypass blocked coronary arteries using a vessel from another part of your body.

• Men are more likely to seek assistance due to high public circulation of typical male cardiac symptoms
• Studies indicate that women tend to complain less about their cardiac symptoms then men.
Don’t necessarily experience angina pain and experience different symptoms to heart attacks and acute coronary syndrome.
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