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Scientific Activities - Actividades Científicas

Honorary Committee Lecture

Women and Heart Disease

Mario F. de Camargo Maranhão

Professor of Cardiology
Evangelic School of Medicine and Hospital
University of Paraná School of Medicine
President Elect of the World Heart Federation

Recent studies have shown the high incidence of heart disease in women. In most developed countries, Coronary Heart Disease (CHD) accounts for about one-third in women of all ages, and for 60% of deaths at age 70 or over. CHD mortality in women increases gradually with age and is responsible for approximately 250,000 deaths annually in the United States of America alone. Despite the lower prevalence of CHD in women than in men, currently more women die of CHD, attesting the more adverse outcomes among women.

It is important to note that substantial age-dependency on the occurrence of CHD in women in that in nine aged 45-65 years have clinical manifestations of the disease, in contrast to one in three women older than 65 years of age. CHD brings substantial illness, disability and unfavorable quality of life and prognosis as well as in mortality, and entails a direct health care cost approximating US$ 11 billion annually, and total economic costs about US$ 22 billion each year.

Until recent years, CHD was viewed predominantly as a problem of men, such that only a few preventive, diagnostic, or therapeutic interventions and studies addressed the problem of CHD in women. CHD has increased in prevalence in United States and in most developed countries because of the dramatic aging of their populations, such that more women survive to the age when CHD becomes clinically evident.

Presently, cardiovascular deaths in elderly women exceed those among elderly men, despite the fact that many women do not perceive CHD to be an important part of their illness experience. Elderly women generally fear more breast and endometrial cancer and/or hip fracture than CHD. Notwithstanding, the lifetime risk for post-menopausal women for CHD death approximates 31%, as contrasted to 2.8% for hip fracture and breast cancer, and about 0.7% for endometrial cancer.

Are CHD in women overlooked and underinvestigates ?

The initial manifestation of CHD in women, excluding fatal cases, differ from those in men, since angina, rather than myocardial infarction(MI) is more frequently described as first clinical symptom. Angiographic studies demonstrate that fewer than 50% of women with chest pain have obstructive coronary lesions. For this reason many physicians believe that angina is more benign in women, and chest pain in women is often labeled as of psychogenic origin. However, this view was mostly based on studies carried out in young women, and is no longer valid when the analysis includes older women.

First attacks of MI in women are slightly more frequently fatal than in men. Neverthless, 35% of initial heart attacks are fatal in women compared with 31% in men; 40% of women, as opposed to 13% of men, have reinfarction within the first year of infarction. Women are also more likely to suffer from a stroke after MI. Here, again thye age dependency and the comorbidity factors such as diabetes, hypertension and other chronic diseases play a pivotal role contributory to these poorer outcomes.

There have been attempts to improve both the sensivity and specificity of exercise testing in women using thallium myocardial imaging and radio nucleide ventriculography, and or echo-stress testing. These methods, or a combination of them, seems to provide a higher diagnostic yield than a exercise electrocardiogram alone. However, the non-invasise diagnosis of CHD in women presents problems because the diagnostic criteria have been derived from studies in men, and when applied to women, they yield a higher percentage of false positives.

Once the diagnosis has been correctly established, physicians pursue a less aggressive management approach to CHD in women than men, and women hospitalized for CHD undergo fewer major diagnostic and therapeutic procedures. At least two studies in the US and two other in Europe have called attention to the underdiagnosis and undertreatment of CHD in women. In 1987, a review of series of 49,623 hospital discharges in Massachusetts and 33,159 in Maryland showed that 28% of men underwent and angiography, as opposed to onloy 15% of women, whereas as revascularization was performed in 45% of men and in 27% in women.

Womern with positive radio nucleide exercise tests were referred to a coronary angiographic with much less frequently than men, and women are referred to a coronary artery by-pass surgery at a more advanced stage of the disease or in emergency or urgent situations, resulting in high pre-operative mortality. Similar results were found in another review of thye cases enrolled in a post-infarction trial. Before the MI, women as likely as men to have angina and to have been treated with anti-anginal drugs. Notwithstanding, in spite of women complaints of symptoms consistent with greater funtional disability, they underwent an invasive cardiac procedure half as often as men. Once cardiac catheterization had taken place, by-pass surgery was performed with equal frequency in both genders.

Altough contemporary percutaneous transluminal coronary angioplasty has similar procedures sucess and safety in both genders, women obtain less symptomatic relief, and their long-term survival in less favorable, at least npartly related to older age or the advanced stage of disease. Data from the NHLBI- PTCA Registry defined gender differences for coronary angioplasty in that women who underwent this procedure were older, less likely to have had prior MI, but were more likely to have had heart failure, hypertension and diabetes.

Almost twice as many women as men in the registry were considered either inoperable or at high surgical risk, and more women than men had unstable angina. Four-year follow-up Registry data identified that more women had died in the interval following coronary angioplasty, but there was a comparable occurrence of are more likely to not only have residual angina but to have more severe angina.Not surprisingly, more women than men receiving maintenance anti-anginal medications.

The newer transcathetter revascularization procedures have a lesser sucess rate for women, and a higher complication rate encountered among men both potentially related to the large size of these new devices and the smaller coronary artery size.

It remains unclear wheter the less sucessfull myocardial revascularization procedures for women reflect their older age, their substantial comoborbidity, or if more of these procedures are likely to be performed on an urgent or emergency basis, potentially related to a late recognition of the disease.



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