CHEST PAIN IN WOMEN Chest Pain in Women

CHEST PAIN IN WOMEN Chest Pain in Women: Think Heart First ! Alice K. Jacobs, M. D. Boston University Medical Center Boston , MA CRT 2012

Disclosure Information FINANCIAL DISCLOSURE: Research Support: Abbott Vascular UNLABELED/UNAPPROVED USES DISCLOSURE: None

CHEST PAIN IN WOMEN Prevalence of Cardiovascular Disease in Americans Percent of Population NNHANES 2005 -2008 20 -39 40 -59 60 -79 > 80 Age (Years) Heart Disease and Stroke Statistics. 2012 Update. AHA.

CHEST PAIN IN WOMEN Deaths in Thousands Leading Causes of Death for Men and Women United States: 2008 A B A. Total CVD D. Respiratory B. Cancer E. Diabetes C. Accidents F. Alzheimer C Men D E F A B D F C E Women Heart Disease and Stroke Statistics. 2012 Update. AHA.

CHEST PAIN IN WOMEN Cardiovascular Disease Mortality Trends United States: 1979 -2008 Heart Disease and Stroke Statistics. 2012 Update. AHA.

CHEST PAIN IN WOMEN Incidence in Thousands Annual Incidence of Myocardial Infarction or Fatal CHD 1984 -2004 35 -44 45 -64 65 -74 75 Ages in Years Heart Disease and Stroke Statistics. 2012 Update. AHA.

CHEST PAIN IN WOMEN Rates of Death During Hospitalization Following Myocardial Infarction Among Women and Men According to Age NRMI-2 N=384, 878 1994 -1998 Vaccarino. N Engl J Med 1999; 341: 217 -225.

CHEST PAIN IN WOMEN In-hospital Mortality (%) In-Hospital Mortality Rates in Women and Men with Myocardial Infarction in GWTG OR 1. 12 (95% CI 1. 02 -1. 23) P=0. 015 OR 1. 04 (95% CI 0. 99 -1. 10) P=0. 10 10. 2 8. 2 5. 7 Overall MI Cohort 5. 5 STEMI Subpopulation Jneid. Circulation. 2008; 118: 2803 -2810.

CHEST PAIN IN WOMEN National Online Physician Survey (500 Physicians) More women than men die each year from cardiovascular disease: • Primary Care Physicians – 8% • OB/GYNs – 13% • Cardiologists – 17% Mosca. Circulation 2005; 111: 499 -510.

CHEST PAIN IN WOMEN Physician Awareness of CVD Prevention Guidelines by Specialty Mosca. Circulation 2005; 111: 499 -510.

CHEST PAIN IN WOMEN Physician Incorporation of CVD Prevention Guidelines by Specialty Mosca. Circulation 2005; 111: 499 -510.

CHEST PAIN IN WOMEN Women’s Awareness of Heart Disease Twelve-Year Follow-up of American Women’s Awareness of CDV Risk (1997 -2009) • Awareness of heart disease as the #1 killer of women has increased from 30% to 54% awareness. • African American and Hispanic women significantly less aware than White woman • 53% of women would call 9 -1 -1 with symptoms of MI • Majority cited therapies not evidence-based • Common barriers to prevention were family/caretaking responsibilities Mosca. Circ. Cardiovasc Qual Outcomes. 2010 Feb 10 Epub.

CHEST PAIN IN WOMEN Time from ACS Symptom Onset to Presentation by Sex 2002 -2007 AHA & NHLBI Awareness Campaigns Diercks. Am Heart J 2010; 160: 80 -87.

CHEST PAIN IN WOMEN Clinical Recognition of CAD Typical symptoms both sexes ü Pressure, heaviness, squeezing in chest ü Discomfort radiating to neck, jaw, back shoulder ü “Pounding” heart, change in rhythm ü Difficulty breathing ü Indigestion, nausea, vomiting, epigastric pain ü Sweating, clammy skin ü Dizziness WISE Investigators. JACC. 2008

CHEST PAIN IN WOMEN Clinical Recognition of CAD Symptoms more common in women ü Milder symptoms without chest discomfort ü Sudden onset weakness, SOB, fatigue, overall “unwell” ü Unusual feeling or mild discomfort in back, chest, arm, neck, jaw WISE Investigators. JACC. 2008

CHEST PAIN IN WOMEN Likelihood of ACS UA/NSTEMI Guidelines 2007 High Intermediate Low History Chest, left arm Chest or left arm pain; known CAD pain; >70 years; male; diabetes; vascular disease Exam MR murmur, Vascular disease Chest discomfort hypotension, with palpation diaphoresis, CHF ECG ST-segment Q waves; ST change ≥ 1 mm; T depression 0. 5 wave inversion 1 mm T waves flat or inversion <1 mm; Normal Cardiac Markers Elevated Normal Probable ischemic symptoms in absence of intermediate likelihood; cocaine

CHEST PAIN IN WOMEN

CHEST PAIN IN WOMEN Intermediate Likelihood Women with Atypical or Typical Chest Pain Symptoms Normal Rest ECG and Able to Exercise Diabetes, Abnormal Rest ECG, or Questionable Exercise Capacity Exercise Treadmill Testing Stress Cardiac Imaging Low post. ETT likelihood Int Risk TM Able to exercise or h/o symptoms with low-level exercise Exercise Stress Risk factor modification +/or Anti. Ischemic Rx Normal or mildly abnormal with normal LV function Mieres. Circulation. 2005. Unable to Exercise (orthopedic reasons, CVA, LBBB, etc. ) Pharmacologic Stress Moderately or severely abnormal or reduced EF Cardiac catheterization

CHEST PAIN IN WOMEN Angina in Women ü Higher prevalence in women than men ü Women more likely to present with angina; men more likely to present with MI ü Women with more angina for same extent of epicardial disease ü Women with angina without obstructive CAD worse prognosis

CHEST PAIN IN WOMEN Sex Ratios in Angina Prevalence 74 reports 31 countries Women n=13, 331 Men n=11, 511 Rose Angina Hemingway. Circulation 2008; 117: 1526 -1536.

CHEST PAIN IN WOMEN Sex Differences in Symptoms in Patients with Diabetes and CAD in BARI No Symptoms Anginal Equivalent Angina Tami-Holland Am J Cardiol 2011; 107: 980 -985.

CHEST PAIN IN WOMEN Angiographic Characteristics in BARI Women (n=533) Men P Value (n=1242) # significant lesions 2. 3 1. 7 2. 7 1. 8 <0. 001 # lesions >20% 4. 3 2. 2 4. 8 2. 3 <0. 001 Myocardial jeopardy Index 42. 5 24. 3 47. 9 24. 3 <0. 001 Total occlusion (%) 29 42 <0. 001 LVEF < 50% (%) 11 19 <0. 001 Tami-Holland Am J Cardiol 2011; 107: 980 -985.

CHEST PAIN IN WOMEN Cardiac Non-CHD Causes of Chest Pain in Women ü Syndrome X of Microvascular Disease ü Stress-induced Cardiomyopathy ü Spontaneous coronary artery dissection

CHEST PAIN IN WOMEN Cardiac Non-CHD and Non-Cardiac Causes of Chest Pain ü Aortic dissection ü Pericarditis ü Pulmonary ü Gastro-intestinal ü Musculoskeletal ü Other (referred pain, shingles)

CHEST PAIN IN WOMEN Current Initiatives © Go Red For Women © Heart Truth Campaign © Women. Heart © Society for Women’s Health Research (SWHR) © FDA Office of Women’s Health © Cardiovascular Research Foundation