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Recent surveys of American women reveal that approximately half still do not identify heart disease as the No. 1 cause of death among women. While mortality among men from cardiovascular disease (CVD) has declined steadily as a result of increased screening and detection and effective treatment, the rate among women lags dangerously behind. Paradoxically, the standard tools for 10-year CVD risk stratification have in the past misclassified women who are at intermediate risk, leaving them vulnerable in a time when excellent preventive measures are available. 

 In this podcast, renowned preventive cardiologist and women’s heart health expert Dr. C. Noel Bairey Merz speaks directly to these and other critical issues in advancing CVD detection and prevention in women and offers concrete ideas to help primary care physicians take action in daily clinical care. 



Women and Heart Disease: Incidence, Prevalence, Progress, and the Future

Links to Resources Mentioned in this Podcast 

 Fifteen-Year Trends in Awareness of Heart Disease in Women: Results of a 2012 American  Heart Association National Survey

 Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women 2011 Update : A Guideline From the American Heart Association

 Framingham Risk Score Calculator SI Units 

See Practice Pearls for Primary Care on next page...

Prevention of Heart Disease in Women: Pearls for Primary Care 



 1. Although heart disease remains the leading killer of women, women themselves continue to believe that breast cancer poses the greater mortality threat. Awareness is improving, however, as 53% of women in 2012 identified heart disease as the primary threat, compared with less than 20% two decades ago.

 2. Female CV mortality has fallen along with overall mortality from heart disease. Nonetheless, there is still a gender gap as reduction in mortality from heart disease among men exceeds the rate of reduction among women. 

 3. Women face unique CV risks that primary care physicians need to account for when assessing and managing prevention of CVD in women:
     o  Risk factors unique to women: pregnancy related complication (hypertension, gestational diabetes, eclampsia/pre-eclampsia), autoimmune disease (eg, systemic lupus erythema, rheumatoid arthritis) 
     o  Risk assessment scores: Framingham and Reynolds Risk Scores incorporate gender but may still underestimate the 10-year risk in women, especially since they do not incorporate risk factors unique to women. As stated in the AHA guidelines for the prevention of CVD in women, lifetime risk is a better tool for CVD risk assessment for women 
     o  Hypertension: pregnancy-related hypertensive syndromes (as above) confer a higher CV risk to women.
     o  Every woman with known heart failure should be on optimal medication management (“Magic 4 pills”): aspirin, beta-blocker, statin, ace-inhibitor

 4. Hyperlipidemia, statins and prevention: Treatment of hyperlipidemia is inconsistent among women and primarily varies with age. Data from NHANES suggest that primary care physicians are excellent at controlling and treating elevated cholesterol in the older female population (age 65+ years). These data show, however, that middle-aged and younger women remain undertreated. This may be an artifact of an unexplained reluctance among PCPs to prescribe statins to younger women, which may perhaps be linked to concerns about statin use and pregnancy or potential pregnancy. 
      •  Primary prevention: For some time there was debate about the efficacy of statin therapy for women in primary prevention. This was largely because most statin trials were performed primarily in men and so data on women was underpowered. The 

 was the first study to provide unequivocal evidence that statins are effective in primary prevention in women and should be used.
      •    Secondary Prevention: All women who have had a previous cardiac event, or have established coronary artery disease should be treated with a statin.

 5. Statins should be avoided in women who are pregnant or planning to become pregnant.
  

Podcasts

Female CV mortality lags behind male mortality; lifetime risk assessment, not 10-year risk, is a better estimation tool for women

The patient is a 55-year-old white man with no significant medical history. He has newly diagnosed hypertension: his blood pressure in your office is 152/94 mm Hg.

What agents will you consider for this patient?

Once upon a time, a beta-blocker might have been high on your list. When, if ever, should you consider prescribing these agents?

Here to debate the pros and cons of these agents are Gregory Rutecki, MD, Professor of Medicine at the University of South Alabama, and Bradley Wright, PharmD, at the Auburn University School of Pharmacy and the University of South Alabama.

Dr Rutecki focuses on the negative effects of beta-blockers; warns of the special risks of atenolol; and makes a case for consideration of carvedilol. Dr Wright zeroes in on the role of these agents in patients with a history of MI or congestive heart failure and discusses the possible mortality benefit from beta-blockers in patients with COPD.

Newly diagnosed hypertension in a patient whose blood pressure is 152/94 mm Hg. What agents will you consider for this patient? Beta-blockers? Think again.

The Great Beta-Blocker Debate: The Pros and Cons

• Multivitamins and omega-3s do not protect against heart disease.

• Coronary bypass is significantly more effective than percutaneous coronary intervention with drug-eluting stents for triple-vessel disease in patients with diabetes.

• The polypill enhances patient adherence to multidrug prevention strategies.

• Platelet function monitoring and adjustment of treatment based on results after coronary stenting does not improve clinical outcomes.

These findings made news among the late-breaking clinical trials presented at the American Heart Association’s 2012 Scientific Sessions in Los Angeles last week. These and other study results are also making headlines in the popular media and you may get questions from patients. Here, AHA Chair for the Committee on Scientific Sessions Dr Elliott Antman talks to Cardiology

 host Dr Payal Kohli about study results that may have direct impact on day-to-day primary care practice.


Additional study details are available here:

Strategies for multivessel revascularization in patients with diabetes

A randomized trial of bedside platelet function monitoring to adjust antiplatelet therapy vs Standard of care in patients undergoing drug eluting stent implantation

Omega-3 fatty acids for the prevention of recurrent symptomatic atrial fibrillation: results of a double-blind randomized clinical trial

A randomized trial of a multivitamin (MVM) in the prevention of cardiovascular disease in men

Use of a multidrug pill in reducing cardiovascular events

 host Dr Payal Kohli is a cardiology fellow at the University of California San Francisco, and Dr Antman is Professor of Medicine, Brigham and Women's Hospital, Senior Investigator, TIMI Study Group, and Associate Dean for Clinical/Translational Research at Harvard Medical School, all in Boston, Massachusetts.

Platelet function monitoring and adjustment of treatment based on results after coronary stenting does not improve clinical outcomes . . . and other findings from the AHA Scientific Sessions.

AHA 2012 Highlights: Multivitamins, Omega-3s, the Polypill, and More

Beta-blocker therapy has for decades been the standard of care for patients who have suffered a myocardial infarction (MI). Although there have been no randomized controlled trials of beta-blocker use in patients with stable coronary artery disease (CAD) or with risk factors for coronary disease, extrapolation of the data on post-MI beta-blocker treatment has led to the widespread use of these drugs in this population. A new analysis of data from a large international registry, however, finds that use of beta-blockers in patients with and without a history of CAD does 

 reduce cardiovascular events. The study entitled, 

Beta-blocker use and clinical outcomes in stable outpatients with and without coronary artery disease

 was published online on October 2 in the 

Journal of the American Medical Association

• What assumptions about beta-blocker therapy are addressed in the study?

• Why did beta-blockers not show any benefit in the populations studied?

• What criteria should be used now to determine whether or not a beta-blocker is indicated in different patient types? 

• How should primary care clinicians proceed with patients currently taking beta-blockers?

Discussing the study and providing answers to these and other questions are Cardiology

 host Dr Payal Kohli of the University of California San Francisco and her guest, the first author of the study, Dr Sripal Bangalore. Dr Bangalore is Assistant Professor of Medicine at New York University School of Medicine where he also is the Director of Research for the Cardiac Catheterization Laboratory and Director of the Cardiovascular Outcomes Program.  


(1) The current practice of beta-blocker therapy in patients with risk factors for CAD or with established CAD without a previous acute coronary syndrome (ACS) is a result of extrapolation of data from original studies on the effect of these drugs in post-MI patients. When many of those studies were carried out, the potent medical therapies now routinely used and the practice of revascularization were not standard of care.

(2) This study reports that beta-blockers do not reduce the composite event rate of cardiovascular death/MI/stroke (at a mean follow-up time of 4.5 years) in patients with:
   a. Prior MI (several years after an ACS event)
   b. Known CAD/ischemia on stress testing
   c. Risk factors for CAD
The reason for this lack of efficacy is complex and may include improved use of background therapies, such as statins, aspirin, anti-platelet agents, and revascularization.

(3) Beta-blockers are still strongly indicated in patients with acute MI and patients with heart failure, and they should not be discontinued in these patients. In addition, alternative indications for beta-blocker therapy include migraine therapy, atrial fibrillation rate control, and stable angina. Although beta-blockers may provide symptom relief for these patients, they do not improve overall mortality in these groups.

(4) When determining whether or not to continue beta-blocker therapy for an individual patient, primary care physicians should consider the clinical trial evidence base, the indication for a beta-blocker, and the adverse-effect profile of these medications. It is reasonable to discontinue beta-blocker therapy in patients without another strong indication who fit into 1 of the 3 categories listed in (2), above.


1. Bangalore S, Steg G, Deedwania P, et al; for the REACH Registry Investigators. Beta-blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. 

A new analysis of data from a large international registry finds that use of beta-blockers in patients with and without a history of coronary artery disease does not reduce cardiovascular events.

Atrial Fibrillation

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