Coronary Heart Disease in Women: Prevention - Diagnosis - Therapy

219 Pages·2003·2.266 MB·English

by  Elisabeth von der Lohe MD (auth.)

Elisabeth von der Lohe
Coronary Heart Disease in Women
Springer-Verlag Berlin Heidelberg GmbH
Elisabeth von der Lohe
Coronary
Heart Disease
in Women
Prevention • Diagnosis • Therapy
With 37 Figures and 34 Tables
123
Elisabeth von der Lohe MD
Associate Professor of Clinical Medicine (Cardiology)
Chief of Cardiology,Wishard Health Services
Krannert Institute of Cardiology,Indiana University
Clarian Cardiovascular Center
1800 N Senate Blvd B 400
Indianapolis,IN 46202,USA
e-mail:[email protected]
ISBN 978-3-540-00128-7 ISBN 978-3-642-55553-4 (eBook)
DOI 10.1007/978-3-642-55553-4
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V
Foreword
Until recently coronary artery disease was thought to be primarily a dis-
ease in men.This misconception has led to a great deal ofmisunderstand-
ing and mismanagement ofwomen who have coronary heart disease.We
now know that coronary heart disease is a major problem in women.Not
only is the frequency of coronary artery disease in women higher than
previously recognized,but in women this disease also has some unique
management differences that must be understood.This book is appropri-
ate,timely,and necessary,as physicians are responsible for our increasing-
ly aging population;thus,it is important to know the issues that relate to
women and coronary heart disease.The differences between men and
women in patients with coronary heart disease are quite numerous and
profound.
Dr.von der Lohe discusses these differences and the appropriate man-
agement in depth.Our knowledge is changing rapidly,and it is essential
for clinicians to be kept up-to-date as to how best to manage women who
suffer from this problem.Dr.von der Lohe is a very appropriate person to
address this issue since she not only runs a women’s health clinic,but also
is actively involved in the most frequently used diagnostic and therapeu-
tic efforts at managing coronary artery disease,namely,echocardiography
and both diagnostic and interventional cardiac catheterization.
I am honored to have been asked to write this introduction.I am cer-
tain that this text will go a long way toward improving our understanding
and management ofwomen with coronary heart disease.
Harvey Feigenbaum
Distinguished Professor ofMedicine
Director,Echocardiography Laboratories
Indiana University School ofMedicine
Senior Research Associate
Indianapolis,Indiana,United States
VII
Preface
Coronary artery disease has stereotypically been characterized as a men’s
disease.
The fact is,however, that as many women as men die from coronary
artery disease each year in the United States.In women 75 years ofage or
older,it is even the leading cause ofdeath.Women tend to be older at the
time when the diagnosis ofcoronary artery disease is made,and,on aver-
age, a myocardial infarct strikes about 20 years later in women than in
men.The increase in the incidence of coronary artery disease with age
correlates with the decline in the serum estrogen levels in women enter-
ing menopause.Because many women now live 40 years or more beyond
the onset of menopause, coronary artery disease in aging women will
most certainly play a predominant role in future medicine. Not many
physicians have realized its growing significance.Increasing awareness of
these epidemiological changes will help improve health care for women
with coronary artery diease.
Basic research over the past two decades or so has revealed funda-
mental differences in cardiovascular physiology between men and
women. These findings led to the introduction of gender-specific ap-
proaches to diagnosis and treatment ofcoronary artery disease in clinical
practice,and also caused an increase in the percentage ofwomen that are
included in clinical studies.Whereas 4 years ago only one quarter ofstudy
participants were females,this number has now risen to approximately
40 % and will most likely reach the 50 % mark over the course ofthe next
decade.In the meantime,more and more programs for Women’s Health
have been established throughout the United States,specializing in pre-
vention,diagnosis,and treatment ofcoronary artery diease in women.As
director ofa Women’s Health Program and practicing interventional car-
diologist,I was repeatedly asked to give seminars on cardiovascular dis-
ease in women.Based on this experience and following a suggestion by
Dr.Udo K.Lindner,former at Springer-Verlag,editorial director,I came
up with this textbook,which summarizes gender-specific differences in
prevention, diagnosis and therapy of coronary artery disease. Special
emphasis was placed on giving an account of current strategies for pre-
vention ofcoronary artery disease and on discussing the current contro-
versies in hormone replacement therapy.
Elisabeth von der Lohe
Indianapolis,February 2003
IX
Contents
1 Epidemiology
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Gender-Specific Mortality Rates . . . . . . . . . . . . . . . . . . . 3
Morbidity and Mortality with Respect to Age and Gender . . . . . 4
Perception. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Mortality in Myocardial Infarction:
Comparison Between Women and Men . . . . . . . . . . . . . . . 6
International Comparisons . . . . . . . . . . . . . . . . . . . . . . 7
The “MONItoring Cardiovascular Disease”
Project of the WHO (WHO MONICA Project). . . . . . . . . . . . 10
2 Cardiovascular Risk Factors
and the Development
of Coronary Heart Disease in Women
Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Dyslipidemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Lipoprotein (a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Insulin Resistance and Polycystic Ovary Syndrome . . . . . . . 21
Family History of Coronary Heart Disease
or Genetic Disposition . . . . . . . . . . . . . . . . . . . . . . . . . 23
Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
X Contents
Sedentary Lifestyle . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Homocysteine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
High sensitivity C-reactive Protein. . . . . . . . . . . . . . . . . . 27
Risk Factors Unique to Women . . . . . . . . . . . . . . . . . . . . 28
Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Oral Contraception. . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3 Pathophysiology
of Coronary Heart Disease
and the Effects of Estrogen
Basics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Plaque Formation and Significance ofPlaques in CHD. . . . . . . 36
Effects of Estrogen. . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Effect ofEstrogen on Vascular Reactivity
and Endothelial Function . . . . . . . . . . . . . . . . . . . . . . . 39
Effect ofEstrogen on Lipid Metabolism . . . . . . . . . . . . . . . 41
Antioxidative Effect ofEstrogen . . . . . . . . . . . . . . . . . . . 42
Effect ofEstrogen on Inflammation . . . . . . . . . . . . . . . . . 43
Effect ofEstrogen on Hemostasis. . . . . . . . . . . . . . . . . . . 43
4 Stable Angina
Definition and Pathophysiology of Angina Pectoris. . . . . . . 48
Diagnosis Based on Symptoms. . . . . . . . . . . . . . . . . . . . 49
Prinzmetal’s or Variant Angina . . . . . . . . . . . . . . . . . . . . 50
Syndrome X. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Diagnostic Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . 52
Electrocardiogram. . . . . . . . . . . . . . . . . . . . . . . . . . . 52
XI
Contents
Stress Testing,Including Stress Echocardiography
and Nuclear Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . 52
Determination ofPretest Probability for CHD. . . . . . . . . . 52
Selection ofStress Test . . . . . . . . . . . . . . . . . . . . . . . 53
Stress ECG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Nuclear Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Stress Echocardiography. . . . . . . . . . . . . . . . . . . . . . 56
Pharmacological Stress Tests. . . . . . . . . . . . . . . . . . . . 58
Electron Beam Computed Tomography . . . . . . . . . . . . . . . 61
Magnetic Resonance Imaging. . . . . . . . . . . . . . . . . . . . . 61
Diagnostic Cardiac Catheterization. . . . . . . . . . . . . . . . . . 61
Gender Differences in the Use ofDiagnostic Cardiac
Catheterizations and Percutaneous Coronary Intervention . . . . 62
Medical Management. . . . . . . . . . . . . . . . . . . . . . . . . . 64
Beta-blockers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Nitrate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Calcium Channel Blockers. . . . . . . . . . . . . . . . . . . . . . . 66
Percutaneous Coronary Intervention for Stable Angina . . . 67
Gender-Specific Success and Complication Rates
for Balloon Angioplasty . . . . . . . . . . . . . . . . . . . . . . . . 69
Gender-Specific Success and Complication Rates
for Coronary Intervention with Stent Implantation. . . . . . . . . 71
Restenosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Rotablator Therapy,Directional Coronary Atherectomy,
Laser Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Multivessel Coronary Intervention – When PCI?
When Bypass Surgery?. . . . . . . . . . . . . . . . . . . . . . . . . 75
5 Acute Myocardial Infarction
Progression from Stable Coronary Heart Disease
to Myocardial Infarction . . . . . . . . . . . . . . . . . . . . . . . . 84
Epidemiology of Acute Myocardial Infarction. . . . . . . . . . . 85
Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87