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Cardiovascular DiseaseIn Women: Risk Factors

Cardiovascular Risk Factors in Women

• Unmodifiable– Age– Family History

• Modifiable– Diabetes – Dyslipidemia– Hypertension– Obesity– Poor Diet– Sedentary Lifestyle– Cigarette Smoking

Source: National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002, Mosca 2007

Modifiable Risk Factors: Sedentary Lifestyle

• 40% of women report no leisure time physical activity

• Exercise is less prevalent among white women compared to white men

• African American and Hispanic women have the lowest prevalence of leisure time physical activity

Source: U.S. Surgeon General 1999, Rosamond 2008

Estimated Percentage of Americans Age 18 and Older Who Report Regular

Physical Activity 2005: By Race and Sex

Source: Rosamond 2008

%

Risk Reduction for CHD Associated with Exercise

in Women

1.00

0.700.75

0.550.50

1.00

0.80

0.65

0.500.58

0.000.100.200.300.400.500.600.700.800.901.001.10

1 2 3 4 5

RelativeRisk

Walking

Any Physical Exercise

5Quintile Group for Activity (MET - hr/wk)

Source: Manson 1999

Relative Risk of Coronary Events for Smokers Compared to Non-

Smokers

6Source: Adapted from Stampfer 2000

Smoking

• The same treatments benefit both women and men

• Women face different barriers to quitting– Concomitant depression– Concerns about weight gain

Source: Fiore 2000

Five A’s

• Ask about tobacco use at every visit• Advise in a clear and personalized message• Assess willingness to quit• Assist to quit• Arrange follow-up

For more information: www.surgeongeneral.gov/tobacco/#clinician

8Source: Fiore 2000,

1999

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults

BRFSS, 1990, 1999, 2010

9Source: CDC

Body Mass Index: Definition

• BMI = weight in kilograms divided by the square of the height in meters (kg/m2)

• BMI chart showing BMI based on weight in pounds and height in inches available at http://www.nhlbi.nih.gov/guidelines/obesity

• Downloadable BMI calculator phone applications are available from the National Heart, Lung, & Blood Institute (NHLBI) website above.

10Source: National Heart, Lung, and Blood Institute

Body Weight and CHD Mortality Among Women

11

P for trend < 0.001

Relative Risk of CHD

Mortality Compared to BMI <19

Source: Adapted from Manson 1995

Body Weight and CHD Mortality Among Women

12

P for trend <0.001

Relative Risk

of CVD Mortality

Source: Adapted from Manson 1995

Adult Treatment Panel (ATP) III Guidelines

• Sample menus for different ethnic & cultural preferences

• Assessment tools• Counseling tools• Adherence tips• Patient handouts

Source: National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002

Diabetes

• Diabetes affects 8.8% of all U.S. women age 20 years or older

• Compared to whites:– African Americans, Latinas, American Indians,

Asian Americans, and Pacific Islanders have a 1.5-2.2 times greater prevalence of diabetes

Source: NIDDK 2005

Diabetes

• 65% of people with diabetes die of cardiovascular disease

• People with diabetes have death rates from heart disease that are 2 to 4 times higher than people without diabetes

Source: CDC 2011.

Coronary Disease Mortality and Diabetes in Women

16

0

10

20

30

40

50

60

0 - 3 4 - 7 8 - 11 12 - 15 16 - 19 20 - 23

Duration of Follow-up (yrs)

Women withDiabetes

Women withoutDiabetes

Mortality Rate per 1,000

Source: Krolewski 1991, National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002

Race/Ethnicity and Diabetes

• At high risk:– Latinas– American Indians– African Americans– Asian Americans– Pacific Islanders

17 Source: American Diabetes Association 2011

Definition of Metabolic Syndrome in Women

Any 3 of the following:• Abdominal obesity (waist circumference

≥ 35 inches) • High triglycerides ≥ 150 mg/dL• Low HDL cholesterol < 50 mg/dL• Elevated BP ≥ 130/85 mm Hg• Fasting glucose ≥ 100 mg/dL

18Source: Grundy 2005.

Treatable Risk Factors: Hypertension

• 32% of women in the United States have hypertension

• Hypertension is more prevalent among older women than older men

• Death from CHD progresses increasingly and linearly as blood pressure increases

• For every 20 mm Hg systolic or 10 mm Hg diagnostic increase in blood pressure, risk of death from CHD doubles

Source: Lloyd-Jones 2010, Chobanian 2003, Rosamond 2008

Lifestyle Approaches to Hypertension in Women

• Maintain ideal body weight- Weight loss of as little as 10 lbs. reduces blood

pressure • DASH (“Dietary Approaches to Stop

Hypertension”) eating plan (low sodium)- Even without weight loss, a low fat diet that is rich in

fruits, vegetables, and low fat dairy products can reduce blood pressure

• Sodium restriction to 1500 mg per day may be beneficial, especially in African American patients

• Increase physical activity• Limit alcohol to one drink per day

- Alcohol raises blood pressure - One drink = 12 oz. beer, 5 oz. wine, or 1.5 oz. liquor

20 Source: Chobanian 2003, Sacks 2001, Mosca 2011

The Seventh Report of the Joint National Committee on Prevention, Detection,

Evaluation, and Treatment of

High Blood Pressure (JNC 7)

• Classification of blood pressure• Treatment algorithms• Lifestyle strategies• Antihypertensive drug choices• Special indications and situations• Resistant hypertension

Source: Chobanian 2003

Age-adjusted Prevalence of Hypertension Among Several

Racial/Ethnic Groups in the U.S.

Source: CDC 2005

Prevalence of Hypertension Among White and Black Women in the

United States

44

24

30

38

0

10

20

30

40

50

1988-1994 1999-2002

Black women

White women

Source: Adapted from Hertz 2005

%

Prevalence of High Blood Pressure by Age and Race

(2005-2008)

24Source: Data from CDC, National Vital Statistics System, Health, United States, 2005-2008

%

African Americans and Hypertension

• Compared to whites– African Americans develop hypertension

earlier in life

– African Americans have much higher average blood pressures

– African Americans have a 1.5 times greater risk of death from heart disease

Source: American Heart Association 2008

“Dietary Approaches to Stop Hypertension” (DASH)

Eating Plan

• 7–8 servings of grains, grain products daily

• 4–5 servings of vegetables daily

• 4–5 servings of fruits daily

• 2–3 servings of low-fat or nonfat dairy foods daily

• ≤ 2 servings of meats, poultry, fish daily

• 4–5 servings of nuts, seeds, legumes weekly

• Limited intake of fats, sweets

26Source: NHLBI 1998, Sacks 2001

Approximate and Cumulative LDL Cholesterol Reduction

Achievable By Diet and Weight Loss Modifications

Dietary Component Dietary Change Approximate LDL Reduction

Major

Saturated fat < 7% of calories 8-10%

Dietary cholesterol* < 200 mg/day 3-5%

Weight reduction Lose 10 lbs. 5-8%

Other LDL-lowering options

Viscous fiber 5-10 g/day 3-5%

Plant/sterol 2 g/day 6-15%

stanol esters

27Source: Adapted from National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002.

*NOTE: New guideline recommends < 150mg/day

Adult Treatment Panel (ATP) III Full Report

• How to choose a statin• Dosing regimens• How to monitor when combining drugs• Side effect management• Reprintable nutritional hand-outs• Menu samples for different cultures• Adherence strategies/barrier reduction

Source: National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002.

Low Risk Diet* is Associated with Lower Risk of Myocardial

Infarction in Women

1.71

1.50

1.281.22

1.001.00

1.20

1.40

1.60

1.80

1 2 3 4 5

29

Diet Score by Quintile* Consumption of vegetables, fruit, whole grains, fish, legumes

1 = little consumption / 5 = high consumption

RelativeRisk of

MI*

*Adjusted for other

cardiovascular

risk factors

Source: Akesson 2007

P <.05 for quintiles 3-5 compared to 1-2

Emerging Risk Factors for CHD

• Pro-inflammatory markers– High sensitivity C-reactive protein (hs-CRP)– Fibrinogen

• Hyperhomocysteinemia– Homocysteine lowering to prevent CHD

events has been shown to be ineffective or possibly harmful in randomized clinical trials

Source: National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002,; Mosca 2007, Bønaa 2006, Loscalzo 2006

Relative Risk of CV Events According to Baseline Levels of High sensitivity C-reactive protein (hs-CRP) in Healthy

Postmenopausal Women

2.1 2.1

4.4

1

0

1

2

3

4

5

Median = 0.06 mg/dl Median = 0.19 mg/dl Median = 2.1 mg/dl Median = 4.4 mg/dl

Quartile of Plasma Levels

Relative Risk

P for trend < 0.001Source: National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) 2002, Ridker 2000

(Ref.)

Fibrinogen Levels and CHD Risk in Women

1.00

1.70

2.19

2.98

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

≤ 2.8 > 2.8, ≤ 3.1 > 3.1, ≤ 3.6 > 3.6

Fibrinogen, g/L

Odds Ratio for

CV Event*

32

*Adjusted for age, smoking, BMI, systolic blood pressure, total cholesterol, HDL, triglycerides, and educational level

P for trend <0.0001

Source: Eriksson 1999

(Ref.)

Relative Risk of CV Events According to Baseline Levels of Homocysteine in

Healthy Postmenopausal Women

1.1 1.1

2.0

1.0

0.0

0.5

1.0

1.5

2.0

2.5

Median = 8.2 mol/L Median = 10.3 mol/L Median = 12.1 mol/L Median = 15.7 mol/L

Quartile of Plasma Levels

Relative Risk

P for trend = 0.02 (not significant)

Source: Ridker 2000, Bønaa 2006, Loscalzo 2006

The Norwegian Vitamin Trial (NORVIT): Homocysteine

Lowering Did Not Reduce CV Events in Women with Prior MI

1.07 1.10

0.00

0.20

0.40

0.60

0.80

1.00

1.20

Folic Acid and B12* Folic Acid, B12, and B6**

RelativeRisk of CV Event

*Compared to

B12 aloneSource: Bønaa 2006

**Compared to placebo

Psychosocial Stressors in Women with CHD: The Stockholm Female

Coronary Risk Study

• Among women who were married or cohabitating with a male partner, marital stress was associated with nearly 3-fold increased risk of recurrent CHD events

• Living alone and work stress did not significantly increase recurrent CHD events

35Source: Orth-Gomer 2000

Depression and CVD

• Depression is an independent predictor of CHD death among women with no history of CHD

• Screening and treatment for depression has not been shown to improve clinical outcomes, however,

• Depression may reduce adherence to CVD medications, therefore, screening is recommended for women with CVD

36Source: Mosca 2011, Wassertheil-Smoller 2004

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