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	James L. Holly, M.D.

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Your Life Your Health - Women and Heart Disease: Hormone Usage

James L. Holly,M.D.

March 01, 2005

Cardiology Review March 2005, Vol 22 No 3

CAD remains the number one cause of death among women.
CAD deaths in women exceeds that of men.
CAD deaths in women exceed the next seven causes of death combined.
Women still consider breast cancer as their greatest health threat.
For every one woman who dies of breast cancer, twelve will die of heart disease.
Reasons for the above:
1. Women are les likely than men to have classic angina.
2. Women have a greater likelihood of presenting with angina induced by rest, sleep and mental stress.
Women with MI are at higher risk for dying than men.
Women undergoing coronary bypass graph have higher mortality rates than men.

Angina

First described in 1772 by Heberden.
Woman more often report a "tightness" in the chest.
Women more than men will describe other symptoms:
1. throat pain
2. jaw pain
3. neck pain
4. back pain
5. nausea
6. shortness of breath
Differences in symptoms may be due to the pathophysiology and mechanisms of coronary disease.
1. Woman may be may be more prone to silent ischemia
2. Symptoms drive referral for further testing

Management of patients with stable angina

There is no distinction between men and women.
Treatment
1. Aspirin
2. Lipid-lowering agents
3. ARBs
4. Beta Blockers

Management of patients with unstable angina and non-ST-segment elevation MI

Women should be treated like men
Aspirin and Plavix
Indications for noninvasive and invasive testing are similar
In one study, women:
1. Were more likely to have unstable angina
2. Were older
3. Had a higher incidence of CHF
4. Different risk profile than men
5. Death and MI at30 days were significantly lower in women than in men with unstable angina, in part because women with unstable angina had less extensive CAD than men.
Glycoprotein IIb/IIIa Inhibitors
1. In women there has been controversy over the use of glycoprotein inhibitors
2. Recent study concluded that they reduced cardiac complication in men and women with a definite diagnosis of CAD and increased troponin concentrations.
Revascularization
1. The Thrombolysis in Myocardial Infarction (TIMI) III study showed that women were less likely than men to undergo revascularization.
2. Probably due to lower incidence of multivessel disease in women.
3. Men and women have a similar 5-year survival after PTCA or CABG.

Management of patients with ST-Segment Elevation MI

Outcomes have improved for women with primary revascularization.
Women still have a higher mortality.
ACC/AHA guidelines - all patients with SET elevation MI should undergo rapid evaluation for reperfusion therapy.

Hormone Therapy

Observational studies have suggested that hormones reduce CAD risk but randomized clinical trials have not shown that promise.
1. The Heart and Estrogen/Progestin Replacement Study showed an increase in cardiac events in the first year of treatment for women with known CAD who were randomly assigned to receive combined CEE plus progestin with no effect over longer follow-up.
2. Women's Health Initiative (WHI), the estrogen/progestin trail was stopped because of stroke risk.
For post menopausal women, non hormone interventions offer the most promise for reducing morbidity and mortality from cardiovascular disease.
Increased and persistent stroke risk among women on Conjugated Equine Estrogens (CEE).
Risk of DVT and pulmonary embolism was increased with treatment with CEE.
Risk of breast cancer tended to be lower.
Neither CEE nor estrogen plus progestin was cardio-protective.
No estrogen therapy or estrogen-progestin therapy regimen should be used for primary or secondary prevention of CHD. (North American Menopause Society)

Other Articles in the Cardiovascular Disease in Women Series

	Women and Heart Disease: Congestive Heart Failure Women and Heart Disease: Primary Prevention Women and Heart Disease: Testing Guidelines Women and Heart Disease: Hormone Replacement Therapy Women and Heart Disease: It can be prevented!

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