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30
25.3
25 24.2
Death during Hospitalization (%)
21.8 21.5
Men Women
20 19.1
18.4
16.6
15 14.4
13.4
11.1
10.7
9.5
10
8.2
7.4
6.1
5.7
5 4.1
2.9
0
< 50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
Figure 1. Rates of death during hospitalization for Myocardial Infarction among women and men, according to age. The interaction between sex and age
was significant (P<0.001).
3
2.5
2 Pre-menopausal
Post-menopausal
1.5
1
0.5
0
40-44 45-49 50-54
Gender differences in symptoms
90
% chance of angiographic CAD
80
70
60
50 Women
40 Men
30
20
10
0
Typical angina
Women’s Symptoms
• Prodromal • Acute
– Unusual fatigue 70% – Shortness of breath 58%
– Sleep disturbance 48% – Weakness 55%
– Shortness of breath 42% – Unusual fatigue 43%
– Indigestion 39% – Cold sweat 39%
– Anxiety 35% – Dizziness 39%
– 43% did NOT have chest
pain
Diastolic Dysfunction
• Heart Failure with Preserved Ejection Fraction
“HFPEF”
– Ventricular Hypertrophy
– Constrictive/Restrictive
– Diabetic
• Ischemia
• Dilated Cardiomyopathy
Incidence of Hypertension
80
70
60
50
% of population
40 Women
Men
30
20
10
0
35-44 45-54 55-64 65-74 75+
Age
Adapted from AHA 1999
Hypertension
A Risk Factor for Cardiovascular Disease
Coronary Peripheral artery Cardiac
disease Stroke disease failure
50
45.4
Biennial 40 Normotensive
age- Hypertensive
adjusted 30
rate per 22.7 21.3
1000 20
subjects 12.4 13.9
9.5 9.9
10 6.2 7.3 6.3
3.3 5.0 3.5
2.4 2.0 2.1
0
Men Women Men Women Men Women Men Women
Risk ratio: 2.0 2.2 3.8 2.6 2.0 3.7 4.0 3.0
converting enzyme
AT II receptor
antagonists
receptor
Aldosterone
vasoconstriction aldosterone antagonists
cell hypertrophy
receptor
Efficacy of beta
blockers
Greater benefit in
women vs men
Pharmacologic therapy
• Ace inhibitors
– Mortality benefit in symptomatic women
• ARB
– Similar effect on women and men
• Digoxin
– Increased mortality in women
• Aldosterone antagonists
– Reduced mortality in women
ICD
Trial data
• SCD-HEFT
– No mortality benefit seen (23% women)
• MADIT-II
– Benefit for women (16% enrolled)
• 5 trial metaanalysis
– HR 1.01
• Including COMPANION
– HR 0.78 (p=ns)
• Sudden death less common
Cardiac Resynchronization Therapy
CRT
• NYHA Class II, III and IV
• LV systolic dysfunction
• QRS wide
• Improves survival
• Lower hospitalizations
• Reduces symptoms
• More LV volume
– reduction, increase EF
Barsheshet et al. Nat Rev Cardiol. 2012;online
Summary
• Heart failure types more common in women
– Diastolic HF, Takotsubo CM, pregnancy
• Compared to men, women have differences
in cardiovascular:
– Physiology
– Etiology of disease, heart failure
– Response to therapy