Tenth International Symposium
HEART FAILURE & Co.
CARDIOLOGY SCIENCE UPDATE
FEMALE DOCTORS SPEAKING
ON FEMALE DISEASES
Milano
9 - 10 aprile 2010
C. Giannattasio
Prevalence of Cardiovascular Disease in
Americans Age 20 and Older by Age and Sex
NHANES III: 1988-94
Source: © American Heart Association 2004
Cumulative Incidence of CVD Adjusted for the Competing Risk of Death for
Men and Women according to Aggregate Risk Factor (RF) Burden at 50 Years of Age
Men
Women
0.7
69%
0.6
50%
0.5
46%
0.4
36%
0.3
0.2
0.1
Adjusted cumulative incidence
Adjusted cumulative incidence
0.7
≥ 2 major RFs
1 major RF
≥ 1 Elevated RF
≥ 1 Not optimal RF
All optimal RFs
0.6
0.5
50%
0.4
39%
0.3
27%
0.2
0.1
8%
5%
0
0
50
60
70
80
Attained age
12640 M
90
50
60
70
80
90
Attained age
Lloyd-Jones DM et al., Circulation 2006; 113: 791
Distribuzione dei fattori di rischio
in Italia in rapporto al sesso
(dati Istituto Superiore di Sanità, anno 2003)
CVD Mortality Trends for Males and Females
(United States: 1979-2004)
Deaths in thousands
550
500
450
400
79
85
95
Years
Males
12576 M
Females
Rosamond W et al., Circulation 2007; 115: e69
Deaths by Cause, Women, Latest Available Year, EU
Other cancer
12%
Respiratory disease
8%
Injuries and poisoning
4%
Breast cancer 4%
Lung cancer 2%
Colo-rectal cancer 3%
Stomach cancer 1%
Other causes
20%
Other CVD
17%
Stroke
14%
6979 M
CHD
15%
European Cardiovascular Disease Statistics, 2000
Acute MI Mortality by Age and Sex
30
25
Men
Women
20
Death During
Hospitalization
(%)
15
10
5
0
<50
50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
Age
Source: Adapted from Vaccarino N Engl J Med 1999; 341(4): 217-225
Prognosis After MI
 38% of women die within first year
 Compared to 25% of men
 35% of women will have second MI
within 6 years
 Compared to 18% of men
Source: Wenger Circulation 2004; 109:558-560
L’infarto nella donna giovane
10
Diagnosis of Coronary Artery
Disease in Women
• Chest pain is experienced by most women with CHD,
but non-chest pain presentations are more common in
women than men
• Other Presenting Symptoms
– Upper abdominal pain, fullness, burning sensation
– Shortness of breath
– Nausea
– Neck, back, jaw pain
• Associations
– Precipitated by exertion
– Precipitated by emotional distress
Source: Charney Cardiovasc Risk 2002, 9:303-307, Goldberg Am Heart J 1998. 136:189-195
Value of the Exercise ECG in Women
80
70
77
70
68
61
60
50
Men
Women
40
30
20
10
0
Sensitivity
Source: Kwok Y, Am J Cardiol 1999. 83(5):660-666
Specificity
Women Receive Less Interventions
to Prevent and Treat Heart Disease
• Less cholesterol screening
• Less lipid-lowering therapies
• Less use of heparin, beta-blockers
and aspirin during myocardial
infarction
• Fewer referrals to cardiac
rehabilitation
Source: Chandra 1998, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 2005
Mortality in Recent Cohort Studies of Patients Hospitalized
with Heart Failure according to LVEF
90
Reduced LVEF
Preserved LVEF
80
70
% death
60
50
40
30
20
10
0
0
1
2
3
4
5
6
Follow-up (years)
11368 M
Hogg et al., JACC 2004; 43: 317
Processes Underlying Diastolic Dysfunction
Blood Vessels
Hypertension
Aging
Atherosclerosis
Diabetes
Hypertrophy
Fibrosis
Altered elastin & collagen
calcification
Endothelial dysfunction
Loss of compliance
Myocardium
Hypertrophy (LVH)
Fibrosis
Cellular dysfunction
Ischemia
Increased stiffness
Impaired relaxation
Diastolic Dysfunction
Heart Failure with Preserved Systolic Function
9421 M
18
21
Coronary Risk Chart
Non-smoker
mg/dl150 200
mmol/l 4
5
250
6
7
Smoker
300
mg/dl150 200
8
mmol/l 4
5
250
6
7
Non-smoker
300
age
70
140
120
180
age
160
60
SBP (mmHg)
140
120
180
160
age
140
50
120
180
age
160
40
140
mg/dl150 200
8
180
160
WOMEN
Risk of Coronary Heart Disease
120
mmol/l 4
5
250
6
7
Smoker
300
mg/dl 150 200
8
mmol/l 4
180
180
160
160
140
140
120
120
180
180
160
160
140
140
120
120
180
180
160
160
age
140
140
120
120
50
180
180
160
160
140
140
120
120
5
250
6
7
300
8
180
age
160
70
140
120
180
age
160
60
140
120
180
160
140
120
180
age
160
40
140
120
10 Year Risk Level
180
180
age
160
160
30
140
140
120
120
mmol/l 4
5
mg/dl150 200
6
7
250
8
300
Cholesterol
5334 M
mmol/l 4
5
mg/dl150 200
6
7
250
8
300
Cholesterol
180
Very high
High
Moderate
Mild
Low
over 40%
20% to 40%
10% to 20%
5% to 10%
under 5%
180
age
160
160
30
140
140
120
120
mmol/l 4
5
mg/dl150 200
6
7
250
8
300
Cholesterol
mmol/l 4
5
mg/dl150 200
6
7
250
8
300
Cholesterol
SBP (mmHg)
MEN
Risk of Coronary Heart Disease
Staessen JA, 1983 AM J Edipemiol
Focus sulla sindrome metabolica in
menopausa
Age-Specific Prevalence of the Metabolic Syndrome
among 8814 US Adults, NHANES III, 1988-1994
50
Men
Prevalence (%)
40
Women
30
20
10
0
20-29
30-39
40-49
50-59
60-69
> 70
Age (years)
2328 G
Ford S et al., JAMA 2002
Terapia dell’ipertensione nella donna
--I benefici del trattamento antipertensivo sono simili nei due sessi. È tuttavia
sconsigliato l’impiego di ACE-inibitori e sartani nelle donne durante il periodo
fertile e la gestazione per i potenziali effetti teratogeni
Contraccettivi orali
La terapia con contraccettivi orali a basso contenuto di estrogeni si associa ad
un incremento del rischio di ipertensione,ictus e infarto del miocardio……
Terapia ormonale sostitutiva
Le informazioni disponibili suggeriscono che gli unici vantaggi della terapia
ormonale sostitutiva sono rappresentati da una minor frequenza di fratture
ossee e di neoplasie
del colon, mentre è aumentato il rischio di eventi coronarici e tromboembolici,
ictus…
Linee Guida ESH/ESC 2007
Treatment (2)
….Che farmaco usare?
Tutti i farmaci antiipertensivi attraversano la placenta
Dati comparativi tra i diversi farmaci riguardanti sia l’efficacia sia la sicurezza fetale e materna sono ancora
inadeguati
ACE inibitori e ARB controindicati perché teratogeni: stopparli anche nelle donne fertili che stanno programmando
una gravidanza!

METILDOPA (simpaticolitico centrale).
Aldomet os 250 mg x 2/die, max 3 g/die
Sicuro per madre e feto, blando antiipertensivo.
Effetti collaterali: stipsi, depressione, sonnolenza, secchezza fauci

LABETALOLO* (alfa 1 bloccante e beta bloccante non selettivo)
100 mg x 2/die, max 2.4 g/die
I beta bloccanti cardioselettivi Beta1 (atenololo) possono ridurre la crescita fetale e placentare.
I beta bloccanti non selettivi (propranololo) possono interferire con il rilassamento miometriale (processo beta2 relato)

Calcio antagonisti (Adalat* 30-90 mg/die max 120 mg/die)
Sicuri per madre e feto, sebbene non esistano molti studi per Ca antagonisti non diidropiridinici (verapamil, diltiazem),
ed amlodipina. Maggiori informazioni per nifedipina
* Consigliati anche durante l’allattamento