1 . The economic cost of CHD for 2015 was estimated to be
| A) | | $402 million. |
| B) | | $42 billion. |
| C) | | $103 billion. |
| D) | | $351.2 billion. |
OVERVIEW OF WOMEN AND CHD
The older adult population is changing the demography of CHD
in the United States. In 2018, 16% of the U.S. population was 65 years of age and older
[5]. This number is projected to grow to
20% of the U.S. population (approximately 72 million people) by 2030 [6]. Individuals who are 85 years of age and
older are the most rapidly growing subgroup of older adults. Approximately 6.3 million
Americans are 85 years of age and older, with a projected increase to more than 19 million
expected by 2060 [7,8]. These trends will clearly influence the
diagnosis and treatment of CHD in women. For the year 2015, the total economic cost of this
health problem in the United States was estimated to be $351.2 billion [3]. Given the fact that the incidence of CHD in
women increases with age, coupled with the projected increase in the older population, this
economic burden will continue to grow.
2 . Among American women, CHD is the
| A) | | leading cause of death. |
| B) | | second most common cause of death. |
| C) | | third most common cause of death. |
| D) | | fourth most common cause of death. |
OVERVIEW OF WOMEN AND CHD
CHD is the leading cause of death in American women [9]. Although the risk of breast cancer has been
the focus of intense media coverage for several years, CHD is responsible for more deaths
among women in the United States each year than all forms of cancer, including breast cancer
[9]. However, CHD mortality has been
declining for men and women since 1979. In a 1979–2011 analysis, mortality rates declined
consistently for adults older than 65 years of age, with steep declines observed between
2000 and 2011. While adults younger than 55 years of age showed initial declines in
mortality, these improvements eventually plateaued, with younger women experiencing the
least improvement [345]. The rate of CHD
death increased 6% from 2011 to 2017 [10].
In 2019, CHD was the cause of death in 420,812 women, representing 48.1% of all CHD deaths
[1].
3 . Compared to men, women's sex-specific anatomic differences include
| A) | | a lower percentage of body fat. |
| B) | | larger diameter coronary arteries. |
| C) | | larger heart and thoracic cavity. |
| D) | | higher resting EF and stroke volume. |
CARDIOVASCULAR RISK PROFILE IN WOMEN
Several anatomic and physiologic differences exist in the
cardiovascular system of women compared to men. Because women's bodies are generally smaller
in stature, the female heart and thoracic cavity are smaller and lighter. A woman's heart
weighs approximately 229 grams, whereas a man's heart weighs 285 grams. The female heart
also has smaller coronary arteries than a man's heart. The right coronary artery appears to
be more dominant in women [1,17,18,19,20].
In addition to anatomic differences in male and female
cardiovascular systems, research indicates that women may deposit plaque differently than
men. The Women's Ischemia Syndrome Evaluation (WISE) Study, supported by the National Heart,
Lung, and Blood Institute, evaluated sex differences in the presentation and treatment of
obstructive CHD [21,22]. Researchers found that women's
atherosclerotic plaque deposition was more diffuse than men's. This physiologic difference
results in scalloping or artery irregularities, rather than the large, obstructive blockages
that are commonly associated with CHD and MI. A 2019 study also analyzed plaque
characteristics in male and female patients with suspected CHD. A total of 1,050 patients
were matched for sex, age, and known coronary risk factors. All patients underwent CT
angiography analysis to assess for stenosis, plaque types (i.e., noncalcified, mixed, or
calcified), and high-risk plaque features [23]. The men had significantly more plaques and a larger proportion of calcified plaques,
whereas women had more mixed and noncalcified plaques. These findings support the need for a
differentiated plaque analysis to improve the accuracy of risk stratification for both sexes
[23].
Microvessels and vasodilator response also appear to be
impaired more frequently in the female population. These less obvious changes are more
difficult to detect from a traditional angiogram and may result in different symptoms. These
characteristics may partially account for the differences in presentation and subsequent
treatment of CHD in women.
On the electrocardiogram (ECG), women's resting heart rate is
higher, PR and QRS intervals tend to be shorter, and the amplitude of the R, S, and T waves
across the precordium are smaller. Left ventricular end-diastolic pressure and volume are
also lower in women, yet stroke volume and resting ejection fractions (EF) tend to be higher
in women than in men [24]. Up to 30% of
women with normal coronary arteries do not have an increase in EF with exercise, a finding
that has important implications for exercise testing [1,17,19,25,26,27].
Hematologic differences also exist. Women's hematocrit and
blood volumes tend to be lower, along with their oxygen-carrying capacity. Cholesterol
levels tend to rise in women around 55 years of age; however, the natural estrogens of
perimenopause are believed to provide protection against CHD by conferring beneficial
effects to the lipid profile. It has also been suggested that estrogen receptors located
within the walls of blood vessels may affect the proliferation of smooth muscle cells,
reduce platelet aggregation, and alter the degradation of collagen and elastin [22,28,29].
The last anatomic and physiologic difference between men and
women is body fat percentage. The percentage of body fat is higher in women and may be
distributed differently. Women who have a large waist, also referred to as abdominal obesity
or central adiposity, tend to have an increased risk of an MI at an earlier age [19,20,28]. Studies have
suggested that, in particular, waist-to-hip ratio measures of abdominal adiposity may be
strong indicators of mortality in women [30,31,32]. Other studies have indicated that waist-to-height ratio may be an
accurate predictor of CHD in women [33,34]. Patterns of fat distribution and
associated cardiovascular health risks will be discussed in further detail in the following
section on traditional coronary risk factors. Table 2
summarizes how women's physiologic profile differs from men's.
4 . Compared with the risk level of a man the same age with comparable risk factors, a premenopausal woman's risk of a coronary event is
| A) | | 10%. |
| B) | | 25%. |
| C) | | 50%. |
| D) | | 80%. |
CARDIOVASCULAR RISK PROFILE IN WOMEN
Traditional cardiovascular risk factors increase the
likelihood of the development of CHD in both men and women. However, the weight given to
these risk factors may not be the same between the sexes. Furthermore, the traditional
diagnostic tests, which generally focus on obstructive disease, are not as effective in
women as compared to men [21]. At comparable
levels of cardiovascular risk factors, the risk of a cardiac event in a premenopausal woman
is 50% the risk level for a man the same age. The relative protection of women from CHD may
be due to better tolerance of cardiovascular risk factors, as well as hormonal and metabolic
differences [21,35].
5 . Hyperlipidemia, hypertension, and cigarette smoking are what type of CHD risk factors?
| A) | | Alterable |
| B) | | Nonalterable |
| C) | | Gender or sex-specific |
| D) | | Both A and C |
CARDIOVASCULAR RISK PROFILE IN WOMEN
Again, alterable cardiovascular risk factors require the
most attention when counseling female patients. These factors include smoking,
hypertension, hyperlipidemia, diabetes, obesity, metabolic syndrome, sedentary lifestyle,
obstructive sleep apnea, and psychosocial wellness.
6 . Which of the following groups are at an increased risk of developing hypertension?
| A) | | Black women |
| B) | | Pregnant women |
| C) | | Postmenopausal women |
| D) | | All of the above |
CARDIOVASCULAR RISK PROFILE IN WOMEN
Like smoking, hypertension is a powerful independent risk
factor for the development of CHD in men and women. Compared with men, hypertension is
twice as prevalent in women with CHD. Additionally, women with hypertension have three to
four times the risk of developing CHD than women with normal blood pressure [56]. Among non-Hispanic Black women,
hypertension tends to occur at an earlier age, be more severe and treated less adequately,
and result in more significant morbidity and mortality rates. More than 57.6% of
non-Hispanic Black women in the United States have hypertension, compared with 40.5% of
White women [1]. In addition to Black
women, pregnant women and postmenopausal women older than 65 years of age are also at high
risk for developing hypertension [57].
7 . Effects of obesity on metabolic processes include
| A) | | decrease in uric acid levels. |
| B) | | reduction of blood pressure. |
| C) | | decrease in triglyceride levels. |
| D) | | alteration of glucose tolerance. |
CARDIOVASCULAR RISK PROFILE IN WOMEN
Obesity is another traditional risk factor. In 2016, 39.8%
of U.S. adults were obese, an incidence that has greatly increased in the last 20 years
[74,75]. As of 2018, every state had a prevalence of obesity greater than 20%.
Twenty-two states reported an obesity prevalence of 30% to 35%, and nine states reported
rates greater than 35% prevalence [75].
If a woman is 30% overweight, she is at increased risk for
developing an MI, heart failure, stroke, and even death. Mild-to-moderate obesity (i.e.,
5% to 15% overweight) may also be detrimental. Women who are overweight have a two to
three times greater risk of an MI compared to lean women [77]. Fluctuations in weight may also impact a
women's overall risk for metabolic syndrome and CHD [78]. Like the other cardiovascular risk factors, CHD risk increases with
certain risk factor combinations, such as obesity and smoking [20,36,42,48,79]. Obesity unfavorably influences other metabolic processes, including
elevation of blood pressure, triglyceride, and uric acid levels; reduction of HDL
cholesterol; and alteration of glucose tolerance and insulin sensitivity [20].
8 . Which of the following psychosocial factors is predictive of CHD?
| A) | | Stress |
| B) | | Anger |
| C) | | Cynicism |
| D) | | Depression |
CARDIOVASCULAR RISK PROFILE IN WOMEN
Psychosocial CHD risk factors include stress/anxiety,
anger/hostility, cynicism, depression, and social isolation While single psychosocial risk
factors are generally unrelated to level of CHD or its progression, depression is
predictive of CHD [358]. Two times more
prevalent in women than men, depression increases women's CHD risk by at least 50%. As a
powerful risk factor, depression has been associated with early-onset MI, especially in
younger and middle-aged women [338,358]. Additionally, social isolation
increases with age. New evidence demonstrates such isolation is a risk factor for heart
failure independent of traditional cardiovascular risk factors. Social isolation may
influence heart failure risk by inducing a negative psychological state that reduces
protective hormones, leading to adverse effects on the heart, blood pressure, and blood
vessel wall repair, as well as immune function. As socially isolated individuals lack
social support, they may also experience more stress and depression, influencing their
engagement in health-promotion activities [357].
9 . At the time of menopause
| A) | | LDL decreases. |
| B) | | HDL increases. |
| C) | | estrogen levels decrease. |
| D) | | blood vessels become more flexible. |
CARDIOVASCULAR RISK PROFILE IN WOMEN
At the time of menopause, serum estrogen levels decrease.
The absence of estrogen increases a postmenopausal woman's vulnerability to CHD due to the
effects on lipoprotein metabolism. These changes include a decrease in HDL levels and an
increase in LDL levels. In addition, blood vessels become less flexible due to the
reduction in circulating estrogen after menopause [107]. Premature menopause enhances this risk for women [340].
10 . As a general guideline, cholesterol screening in adults should initially be done when a patient is
| A) | | 15 years of age. |
| B) | | 20 years of age. |
| C) | | 30 years of age. |
| D) | | 40 years of age. |
Primary prevention begins in youth and early adulthood with
general screening of family history of CHD and cardiovascular risk factors. This is also an
opportunity to reinforce lifelong heart healthy habits. With regard to total cholesterol,
the initial screen in adults should be done at 20 years of age and followed up thereafter
every five years. With female patients, obstetrician/gynecologists play a key role in this
screening process. If cholesterol levels are greater than 200 mg/dL, additional testing of
lipoproteins, specifically HDL and LDL, and annual checks are warranted [73].
11 . Guidelines for cardiac nutrition should emphasize that approximately what percentage of daily calories should come from saturated fat?
| A) | | Less than 7% |
| B) | | 25% |
| C) | | 30% |
| D) | | 50% |
CLINICAL RECOMMENDATIONS FOR PRIMARY CHD PREVENTION IN WOMEN
| Lifestyle Interventions |
| Cigarette smoking |
| Women should not smoke and should avoid environmental tobacco
smoke. | | Provide counseling, nicotine replacement, and other pharmacotherapy as
indicated in conjunction with a behavioral program or formal smoking cessation
program (Class I, Level B). |
|
| Dietary intake | Women should consume a diet rich in fruits and vegetables (5 servings/day),
whole-grain, high-fiber foods, nuts and legumes, low-fat dairy products and omega-3
fatty acids (in the form of oily fish at least twice a week); limit sweets,
sugar-sweetened beverages, red meats, saturated fat (<7% of total energy intake),
cholesterol <150 mg/d, alcohol intake no more than 1 drink per day, sodium intake
<1,500 mg/d (approximately 1 tsp salt); and avoid consumption of trans fatty
acids (Class I, Level B). |
| Weight maintenance/reduction | Women should maintain or lose weight through an appropriate balance of caloric
intake, physical activity, and formal behavioral programs when indicated to
maintain/achieve a body mass index (BMI) between 18.5 and 24.9 kg/m2 and a waist
circumference ≤35 in (Class I, Level B). |
| Physical activity |
| Women should accumulate at least 150 minutes/week of moderate exercise, 75
minutes/week of vigorous exercise, or an equivalent combination of moderate- and
vigorous-intensity aerobic physical activity. Aerobic activity should be
performed in episodes of at least 10 minutes, preferably spread throughout the
week (Class I, Level B). | | Women should be advised of additional cardiovascular benefits by
increasing moderate-intensity aerobic physical activity to 5 hours/week, 2.5
hours/week of vigorous-intensity physical activity, or an equivalent combination
of both (Class I; Level of Evidence B). | | Women should engage in muscle-strengthening activities involving all major
muscle groups on ≥2 days/week (Class I; Level of Evidence B). | | Women who need to lose weight or sustain weight loss should accumulate a
minimum of 60 to 90 minutes of at least moderate-intensity physical activity
(e.g., brisk walking) on most (and preferably all) days of the week (Class I,
Level B). |
|
| Major Risk Factor Interventions |
| Blood pressure—optimal level and lifestyle | Encourage an optimal blood pressure of <120/80 mm Hg through lifestyle
approaches such as weight control, increased consumption of fresh fruits, vegetables
and low-fat dairy products, sodium restriction, increased physical activity, and
alcohol moderation (Class I, Level B). |
| Lipid and lipoprotein levels—optimal levels and lifestyle | Lifestyle approaches should be encouraged to achieve the following levels of
lipids and lipoproteins: LDL <100 mg/dL, HDL >50 mg/dL, triglycerides <150
mg/dL, and non-HDL (total cholesterol minus HDL cholesterol) <130 mg/dL (Class I,
Level B). |
| Diabetes | Lifestyle and pharmacotherapy should be used in women with diabetes to achieve
a HbA1c <7% without significant hypoglycemia (Class IIa, Level B). |
| Preventive Drug Interventions |
| Omega 3 fatty acid supplementation | Capsule form (e.g., eicosapentaenoic acid [EPA] 1,800 mg/d) may be considered
with hypercholesterolemia and/or hypertriglyceridemia. Note: Fish oil dietary
supplements may have widely variable amounts of EPA and DHA (likely the only active
ingredients) (Class IIb, Level B). |
| Blood pressure—pharmacotherapy | Pharmacotherapy is indicated when blood pressure is ≥140/90 mm Hg or ≥130/80 mm
Hg) in women with diabetes or chronic kidney disease. Thiazide diuretics should be
part of the drug regimen for most women (unless contraindicated) or if there are
compelling indications for other agents in specific vascular diseases. |
| Aspirin or clopidogrel |
| High-risk women: Aspirin therapy
(75–325 mg/d) should be used (unless contraindicated) (Class I, Level A). If a
high-risk woman is intolerant of aspirin therapy, clopidogrel should be
substituted (Class I, Level B). | | Women with diabetes: Aspirin therapy
(75–325 mg/d) is reasonable (unless contraindicated) (Class IIa, Level
B). | | Women 40 to 59 years of age with an estimated
10-year cardiovascular risk of at least 10% per ACC/AHA equations:
The net benefit is small and should be considered through shared
decision-making. | | Women 60 to 69 years of age with at least 20%
10-year cardiovascular risk or with diabetes and an estimated risk of at least
10%: Aspirin therapy should be considered in the context of no
excess risk of bleeding and shared decision-making (USPSTF Grade C). |
|
| Class III Interventions (Not Useful/Effective and
May Be Harmful) |
| Antioxidant supplements | Antioxidant vitamin supplements (e.g., vitamin E, C, and beta carotene) should
not be used for primary CHD prevention (Class III, Level A). |
| Folic acid | Folic acid, with or without B6 and B12 supplementation, should not be used for
primary CHD prevention (Class III, Level A). |
| Aspirin for MI in women <65 years of age | Routine use of aspirin therapy in healthy women is not advised (Class III,
Level B; USPSTF Grade D). |
| Hormone replacement therapy | Hormone therapy and selective estrogen-receptor modulators should not be used
for primary CHD prevention (Class III, Level A). |
12 . Lifestyle changes that may assist in achieving healthy blood pressure include
| A) | | weight control. |
| B) | | physical activity. |
| C) | | moderate alcohol intake. |
| D) | | All of the above |
CLINICAL RECOMMENDATIONS FOR PRIMARY CHD PREVENTION IN WOMEN
| Lifestyle Interventions |
| Cigarette smoking |
| Women should not smoke and should avoid environmental tobacco
smoke. | | Provide counseling, nicotine replacement, and other pharmacotherapy as
indicated in conjunction with a behavioral program or formal smoking cessation
program (Class I, Level B). |
|
| Dietary intake | Women should consume a diet rich in fruits and vegetables (5 servings/day),
whole-grain, high-fiber foods, nuts and legumes, low-fat dairy products and omega-3
fatty acids (in the form of oily fish at least twice a week); limit sweets,
sugar-sweetened beverages, red meats, saturated fat (<7% of total energy intake),
cholesterol <150 mg/d, alcohol intake no more than 1 drink per day, sodium intake
<1,500 mg/d (approximately 1 tsp salt); and avoid consumption of trans fatty
acids (Class I, Level B). |
| Weight maintenance/reduction | Women should maintain or lose weight through an appropriate balance of caloric
intake, physical activity, and formal behavioral programs when indicated to
maintain/achieve a body mass index (BMI) between 18.5 and 24.9 kg/m2 and a waist
circumference ≤35 in (Class I, Level B). |
| Physical activity |
| Women should accumulate at least 150 minutes/week of moderate exercise, 75
minutes/week of vigorous exercise, or an equivalent combination of moderate- and
vigorous-intensity aerobic physical activity. Aerobic activity should be
performed in episodes of at least 10 minutes, preferably spread throughout the
week (Class I, Level B). | | Women should be advised of additional cardiovascular benefits by
increasing moderate-intensity aerobic physical activity to 5 hours/week, 2.5
hours/week of vigorous-intensity physical activity, or an equivalent combination
of both (Class I; Level of Evidence B). | | Women should engage in muscle-strengthening activities involving all major
muscle groups on ≥2 days/week (Class I; Level of Evidence B). | | Women who need to lose weight or sustain weight loss should accumulate a
minimum of 60 to 90 minutes of at least moderate-intensity physical activity
(e.g., brisk walking) on most (and preferably all) days of the week (Class I,
Level B). |
|
| Major Risk Factor Interventions |
| Blood pressure—optimal level and lifestyle | Encourage an optimal blood pressure of <120/80 mm Hg through lifestyle
approaches such as weight control, increased consumption of fresh fruits, vegetables
and low-fat dairy products, sodium restriction, increased physical activity, and
alcohol moderation (Class I, Level B). |
| Lipid and lipoprotein levels—optimal levels and lifestyle | Lifestyle approaches should be encouraged to achieve the following levels of
lipids and lipoproteins: LDL <100 mg/dL, HDL >50 mg/dL, triglycerides <150
mg/dL, and non-HDL (total cholesterol minus HDL cholesterol) <130 mg/dL (Class I,
Level B). |
| Diabetes | Lifestyle and pharmacotherapy should be used in women with diabetes to achieve
a HbA1c <7% without significant hypoglycemia (Class IIa, Level B). |
| Preventive Drug Interventions |
| Omega 3 fatty acid supplementation | Capsule form (e.g., eicosapentaenoic acid [EPA] 1,800 mg/d) may be considered
with hypercholesterolemia and/or hypertriglyceridemia. Note: Fish oil dietary
supplements may have widely variable amounts of EPA and DHA (likely the only active
ingredients) (Class IIb, Level B). |
| Blood pressure—pharmacotherapy | Pharmacotherapy is indicated when blood pressure is ≥140/90 mm Hg or ≥130/80 mm
Hg) in women with diabetes or chronic kidney disease. Thiazide diuretics should be
part of the drug regimen for most women (unless contraindicated) or if there are
compelling indications for other agents in specific vascular diseases. |
| Aspirin or clopidogrel |
| High-risk women: Aspirin therapy
(75–325 mg/d) should be used (unless contraindicated) (Class I, Level A). If a
high-risk woman is intolerant of aspirin therapy, clopidogrel should be
substituted (Class I, Level B). | | Women with diabetes: Aspirin therapy
(75–325 mg/d) is reasonable (unless contraindicated) (Class IIa, Level
B). | | Women 40 to 59 years of age with an estimated
10-year cardiovascular risk of at least 10% per ACC/AHA equations:
The net benefit is small and should be considered through shared
decision-making. | | Women 60 to 69 years of age with at least 20%
10-year cardiovascular risk or with diabetes and an estimated risk of at least
10%: Aspirin therapy should be considered in the context of no
excess risk of bleeding and shared decision-making (USPSTF Grade C). |
|
| Class III Interventions (Not Useful/Effective and
May Be Harmful) |
| Antioxidant supplements | Antioxidant vitamin supplements (e.g., vitamin E, C, and beta carotene) should
not be used for primary CHD prevention (Class III, Level A). |
| Folic acid | Folic acid, with or without B6 and B12 supplementation, should not be used for
primary CHD prevention (Class III, Level A). |
| Aspirin for MI in women <65 years of age | Routine use of aspirin therapy in healthy women is not advised (Class III,
Level B; USPSTF Grade D). |
| Hormone replacement therapy | Hormone therapy and selective estrogen-receptor modulators should not be used
for primary CHD prevention (Class III, Level A). |
13 . Exercise increases
| A) | | HDL levels. |
| B) | | total cholesterol levels. |
| C) | | risk of thromboembolism. |
| D) | | All of the above |
Reports on physical activity and CHD in women have been
conflicting. While some studies have found no reduction in CHD risk, many other studies
have demonstrated lower all-cause mortality in women and men with higher levels of
fitness. A study published in 2001 reported that even light-to-moderate amounts of
exercise (i.e., at least one hour of walking a week) were associated with a lowered risk
of CHD in women [297]. This correlation
extended to women with heightened risk for CHD, including those who were overweight, had
high cholesterol, or smoked.
14 . The Nurse's Health Study demonstrated that low-dose aspirin is associated with what percentage reduction in heart attack risk in women?
As with men, low-dose aspirin therapy may play a role in
the primary prevention of CHD in women. Aspirin works as a thromboxane inhibitor keep
blood platelets from sticking together and forming clots [281]. The NHS demonstrated a 32% reduction in
risk of first MI in women who took low-dose aspirin (i.e., one to six aspirin per week)
[303]. While low-dose aspirin may be
associated with a somewhat lower cardiovascular and total mortality rate in women, its
cardioprotective role is not without limitations. The benefit of such therapy should be
weighed against the risk of hemorrhagic stroke and gastrointestinal bleeding [304]. In 2022, the U.S. Preventive Services
Task Force issued updated guidance regarding the use of aspirin for cardioprotection [304]. They recommend against initiating
low-dose aspirin use for the primary prevention of cardiovascular disease in adults 60
years or older. The decision to initiate low-dose aspirin use for the primary prevention
of cardiovascular disease in adults 40 to 59 years of age who have a 10% or greater
10-year risk should be an individual one. Evidence indicates that the net benefit of
aspirin use in this group is small. Persons who are not at increased risk for bleeding and
are willing to take low-dose aspirin daily are more likely to benefit [304].
15 . Noncoronary causes of anginal-type symptoms in women include
| A) | | pericarditis. |
| B) | | gallbladder disease. |
| C) | | mitral valve prolapse. |
| D) | | All of the above |
The diagnosis of CHD is a more complex process in women for
two primary reasons: age at presentation and differences in presenting symptoms. As noted,
women are typically 5 to 10 years older than men when presenting with CHD, which may be due
either to delays in diagnosis or presentation. When women do present, other conditions, such
as osteoporosis, diabetes, or hypertension, as well as the provider's interpretation of the
woman's chest pain, may obscure the indications of disease. Noncoronary causes of chest pain
are also more prevalent in the female population. Chest pain in women is frequently
accompanied by abdominal pain, dyspnea, nausea, fatigue, and greater functional disability
[138,139,140]. Additionally, a
variety of intrathoracic and extrathoracic structures may cause symptoms localizing to the
chest, such as mitral valve prolapse, pericarditis, or gallbladder disease. Therefore, the
differential diagnosis of chest pain must include a number of conditions to prevent a
false-positive diagnosis of CHD in women [140,141]. Table
5 outlines the differential diagnosis to first rule out the
most critical problems.
16 . In the diagnosis of CHD in women, clinical history and physical examination
| A) | | provide a high level of disease likelihood. |
| B) | | have limited value and often require further diagnostic tests. |
| C) | | do not provide useful information regarding symptoms of advanced disease. |
| D) | | have limited value for women older than 70 years of age with definite angina. |
To further complicate the picture, the clinical history and
physical exam have limited value in women older than 65 years of age with definite angina
[139]. The history and physical exam do
provide information on the occurrence of prior events and risk factors and also uncover
symptoms of more advanced disease. However, these diagnostic clues often only partially
indicate disease likelihood, which makes further diagnostic tests important and necessary
[139,145,146]. The presence of
new physical assessment findings, such as dysrhythmias, mitral regurgitation, a fourth heart
sound (atrial gallop), or bibasilar crackles, increases the chances of a positive diagnosis
of CHD [147]. The diagnosis is also favored
by the presence of other cardiovascular risk factors or by ECG changes at rest or during
anginal episodes [147].
17 . Which of the following noninvasive tests for CHD is considered controversial in women?
| A) | | Resting ECG |
| B) | | Exercise ECG |
| C) | | Exercise echocardiogram |
| D) | | Nuclear medicine stress test |
Exercise ECG (also referred to as the stress test or
exercise treadmill test) may not be as accurate in the diagnosis of CHD in women as in men
[347]. However, the ACCF and the AHA
recommend the routine use of the exercise ECG (when combined with traditional analysis of
ST-segment and heart rate changes) for evaluating suspected CHD in women who have a normal
resting ECG and good exercise tolerance [150]. Women with nonobstructive disease and stress test abnormalities are
no longer defined as having a false-positive test. Instead, their test is classified as
abnormal, and they are noted as being at an elevated risk of obstructive CHD [150]. A test result that is clearly negative
has been found to be equally reliable in both women and men [141]. Better diagnostic results are seen in
women with multivessel involvement versus single vessel or no disease. With multivessel
disease, an overall accuracy of 84% has been reported [150].
Even in women with CHD, the accuracy of using exercise ECG
for diagnosis alone is not recommended. When test results are clearly positive or not
clearly positive or negative, additional risk stratification with cardiac imaging is
recommended [150]. The ACCF/AHA have
recommended cardiac imaging for symptomatic women with established CHD, women who have an
indeterminate or intermediate-risk exercise ECG test, and women with an intermediate-risk
Duke treadmill score. Cardiac imaging has also been recommended for women with diabetes,
metabolic syndrome, and polycystic ovary syndrome because of their increased risk of
cardiovascular death [122,150].
18 . With nuclear myocardial perfusion scans
| A) | | a tracer is injected and myocardial blood flow is evaluated. |
| B) | | a two-dimensional image is used to assess synergy of myocardial contraction. |
| C) | | red blood cells are labeled in vivo and gated images of blood flow are recorded. |
| D) | | None of the above |
The nuclear medicine myocardial perfusion scan is another
noninvasive test that may be used in women. At peak exercise, a small amount of
radioactive tracer is injected and a series of images of myocardial blood flow are then
evaluated. Normal myocardial blood flow is indicated by a homogeneous distribution of
thallium throughout the myocardium, while myocardial ischemia and/or infarction is
suggested by either a transient or persistent defect in tracer uptake. Compared with
exercise ECG, nuclear medicine perfusion tests have better accuracy with fewer
false-positive results in women, especially in patients with multivessel disease [141,151,152,153].
19 . Major drawbacks associated with cardiac catheterization include all of the following, EXCEPT:
| A) | | Cost |
| B) | | Invasiveness |
| C) | | Potential for complications |
| D) | | Relative inaccuracy in diagnosing CHD |
Coronary angiogram is the definitive diagnostic test to
detect CHD despite major drawbacks, such as its invasive nature, cost, and potential
complications [11]. While the number of
catheterizations performed on women has increased, men are more likely to be referred for
catheterization than women, possibly because women may be at greater risk of adverse
events after angiogram, including death [167,168,169,170]. One study found that men were 40% more likely to undergo angiography
than women, despite angiography data indicating women have more functional impairment and
unstable symptoms than men [171,172].
20 . In women, CHD most commonly presents as
| A) | | angina. |
| B) | | sudden death. |
| C) | | myocardial infarction. |
| D) | | heart failure. |
CLINICAL MANIFESTATIONS OF CHD IN WOMEN
After menopause, the clinical manifestations of CHD increase
in women. The most common CHD manifestation in both men and women is angina [178]. Approximately 9.1 million women in the
United States are currently living with CHD; 35,000 are younger than 65 years of age, and 4
million suffer from angina [1,56]. The basic forms of angina include stable
angina, unstable angina, and variations of angina. In terms of incidence, stable angina
occurs more frequently in women in the United States than in men, with an estimated
female-to-male ratio of 1.7:1 [178,179].
21 . Women with what type of angina have the greatest likelihood of three-vessel or left main CHD?
| A) | | No |
| B) | | Stable |
| C) | | Variant |
| D) | | Unstable |
CLINICAL MANIFESTATIONS OF CHD IN WOMEN
Stable anginal episodes often worsen and become more severe,
leading to unstable angina. Unstable angina is a type of chest pain that radiates more
widely, may occur at rest, and is difficult to relieve. Women who suffer from unstable
angina have the greatest likelihood of significant coronary artery stenosis and three-vessel
or left main CHD. Consequently, these women are at greatest risk to experience more serious
cardiac events, such as an MI or sudden cardiac death [180].
22 . Microvascular angina
| A) | | may be due to a hormonal imbalance related to estrogen deficiency. |
| B) | | does not respond to beta blockers, calcium channel blockers, or nitrates. |
| C) | | may be due to decreased sensitivity in the nerves leading to the heart, esophagus, and chest. |
| D) | | is associated with an increased likelihood of significant CHD compared to other forms of angina. |
CLINICAL MANIFESTATIONS OF CHD IN WOMEN
By definition, microvascular angina is characterized by the
presence of angiographically normal coronary arteries. In women with this syndrome, plaque
accumulates in very small arteries of the heart, causing arterial narrowing, reduced oxygen
flow to the heart, and pain that may be similar to that experienced by patients with blocked
major coronary arteries. As noted, the difficulty with microvascular angina is that plaque
does not appear when using standard tests. Rather, PET scan or magnetic resonance imaging
are the primary diagnostic tools, as discussed [347]. The exact etiologic mechanism of microvascular angina is not known. It
has been speculated that up to 80% of cases may be due to hypersensitivity in the nerves
that lead to the heart, esophagus, and chest, making women acutely aware of sensations in
their heart. Another possibility is that the syndrome is caused by a disorder of the small
blood vessels that feed the heart, wherein the vessels fail to dilate in response to
physical and/or emotional stress. The syndrome could also be due to a hormonal imbalance
induced by a deficiency of estrogen. Women with this type of angina have less of a
likelihood of significant CHD, and therefore a better prognosis, compared to other forms of
angina. However, these women are still at risk of suffering an MI or, at a minimum, of
experiencing a reduced quality of life [183,184,185,186]. Many women respond
to risk factor modification through cardiac rehabilitation and to pharmacotherapy with beta
blockers, calcium channel blockers, and nitrates.
23 . Which of the following cardiac symptoms is more common in women than in men?
| A) | | Jaw pain |
| B) | | Cold sweats |
| C) | | Chest discomfort |
| D) | | Pain that spreads |
CLINICAL MANIFESTATIONS OF CHD IN WOMEN
Women may complain of classic substernal pain or have
variations in their chest pain syndromes for reasons that are not completely understood.
Women frequently report pain centered in the chest, pain in one or both arms, pain in the
neck and/or jaw, or pain centered in the back and/or shoulders. Women also frequently
report nausea, back pain, dizziness, generalized fatigue, shortness of breath, and
palpitations [139,145,187,189,190]. Recognition of these sex differences in
symptom reporting may result in more prompt and accurate diagnosis and treatment, as well
as preventable deaths.
24 . Which of the following is a factor that places women at increased risk for silent MIs and/or sudden cardiac death?
| A) | | Diabetes |
| B) | | Older age |
| C) | | Hypertension |
| D) | | All of the above |
CLINICAL MANIFESTATIONS OF CHD IN WOMEN
Unrecognized or silent MIs are more frequent in women (54%)
than men (33%), accounting for more than 50% of all infarctions in women 55 years of age and
older [201]. Factors that place women at
increased risk include older age, hypertension, and diabetes [201]. As mentioned previously, sudden cardiac
death generally occurs about 5 to 10 years later in women compared to men.
25 . Which of the following explains why cardiac enzyme elevations may be lower in women than in men?
| A) | | Smaller body size of women |
| B) | | Smaller thoracic cavity in men |
| C) | | Decreased sensitivity in women |
| D) | | Lower false-positive rates in women |
CLINICAL MANIFESTATIONS OF CHD IN WOMEN
Accurate diagnosis of myocardial injury and/or infarction is
aided by measurement of serial cardiac enzymes [166]. Due to smaller body size, enzyme elevations may not be as high in women
as those seen in men. This information is important to know when analyzing and interpreting
enzyme rises in female patients presenting with cardiac symptoms. Further research is needed
to explore sex-specific cardiac enzyme activity patterns [19].
26 . Which of the following complications occur more frequently in women post-MI than in men?
| A) | | Stroke |
| B) | | Heart block |
| C) | | Supraventricular dysrhythmias |
| D) | | None of the above |
CLINICAL MANIFESTATIONS OF CHD IN WOMEN
Heart failure tends to be more severe in women despite
their higher left-ventricular EF and less severe ventricular dysfunction, perhaps due to the
adverse effects of diabetes and hypertension on left ventricular diastolic function [11,19,35,338]. Furthermore, the incidence of
supraventricular and ventricular dysrhythmias, as well as heart block, appears to be similar
in women and men [56,338]. However, more ventricular dysrhythmias
have been reported in young women with MI who use hormonal contraceptives. Women also have a
much higher risk of stroke post-MI and death from stroke compared with men [56].
27 . Compared with other women post-MI, young women who use hormonal contraceptives are at an increased risk for
| A) | | stroke. |
| B) | | heart block. |
| C) | | ventricular dysrhythmias. |
| D) | | supraventricular dysrhythmias. |
CLINICAL MANIFESTATIONS OF CHD IN WOMEN
Heart failure tends to be more severe in women despite
their higher left-ventricular EF and less severe ventricular dysfunction, perhaps due to the
adverse effects of diabetes and hypertension on left ventricular diastolic function [11,19,35,338]. Furthermore, the incidence of
supraventricular and ventricular dysrhythmias, as well as heart block, appears to be similar
in women and men [56,338]. However, more ventricular dysrhythmias
have been reported in young women with MI who use hormonal contraceptives. Women also have a
much higher risk of stroke post-MI and death from stroke compared with men [56].
28 . Women are less likely to receive thrombolytic therapy in the treatment of MI due to
| A) | | medical contraindications. |
| B) | | advanced age at time of MI. |
| C) | | delayed arrival at the hospital. |
| D) | | All of the above |
THERAPEUTIC INTERVENTIONS
Thrombolytic therapy is frequently given to patients
within the first six hours of presenting with possible cardiac symptoms. It has proved
beneficial in restoring vessel patency and improving clinical outcomes in both men and
women (i.e., 25% to 30% reduction in short-term mortality) [209,216]. However, women are less likely to receive thrombolysis to restore
vessel patency in the management of acute MI for several reasons, including advanced age,
delayed arrival at the hospital, and medical contraindications [216]. Even in those eligible, women are less
likely to receive thrombolytic therapy [217]. The Gruppo Italiano per lo Studio della Streptochinasi
nell'infarto Miocardico (GISSI-1) first validated streptokinase as an
effective therapy and reported a significant reduction in the 21-day mortality in women
who received IV streptokinase within six hours post-MI. Despite these promising outcomes,
treated women's mortality rates remain higher than men's [217,218,338]. The AHA
recommends thrombolytic therapy be used at non-PCI centers when a significant delay to
performing a primary PCI within 120 minutes of first medical contact is anticipated [338].
29 . What is the treatment of choice for patients with single-vessel CHD?
| A) | | Thrombolytic therapy |
| B) | | Percutaneous coronary intervention (PCI) |
| C) | | Internal mammary artery (IMA) graft surgery |
| D) | | Coronary artery bypass graft (CABG) surgery |
THERAPEUTIC INTERVENTIONS
PCI is the treatment of choice for patients with
single-vessel disease [207]. It offers
patients a lower 30-day mortality rate compared with thrombolytic therapy [338]. An estimated 35% of PCIs in the United
States are performed in women [208]. At
the time this procedure was first performed, women tended to be on average nine years
older than men, with more cardiovascular risk factors and severe unstable angina [208]. However, angiographically documented
CHD has not been found to be more extensive in women compared to men [209]. On a per-lesion basis, angiographic
success rates have been found to be similar between men (88%) and women (89%), as were
clinical success rates [209,210]. Determinants of PCI success include
lesion-specific angiographic features, such as the severity of stenosis, coronary
calcification, and intralesional thrombosis-factors that are not influenced by either age
or sex [211]. In treating left anterior
descending disease, CABG surgery is an attractive option due to the high rate of post-PCI
restenosis [208].
30 . All of the following factors place female patients with CHD at increased surgical risk compared with men, EXCEPT:
| A) | | Older age |
| B) | | More unstable angina |
| C) | | Greater number of comorbidities |
| D) | | Greater number of diseased arteries |
THERAPEUTIC INTERVENTIONS
The Coronary Artery Surgery Study (CASS) investigated
2,800 women and 5,300 men who were experiencing severe enough chest pain to warrant a
coronary angiogram. This study revealed a number of differences in the preoperative status
of men and women. As discussed earlier, women were found to be at increased surgical risk
because they tend to be older, have more unstable angina, frequent cardiac enlargement on
chest x-ray, severe mitral regurgitation, and more symptoms and comorbidities, such as
hypertension, diabetes, and heart failure. Factors that place women at lower risk include
they tend to have fewer diseased arteries and less myocardial damage. In other words,
women generally have better EFs and ventricular wall motion, as well as less left main
stenosis and three-vessel disease [11,19,26,27,35]. It has been suggested these differences
in preoperative status may be less related to sex than to delays in the initial diagnosis
and treatment of symptomatic CHD in women. This delay translates into an older age and
more frequent comorbidity in women at surgical presentation [219,220].
31 . Surgical intervention referral patterns in women with CHD indicate that women are most often referred
| A) | | earlier than men. |
| B) | | on an elective basis. |
| C) | | based on a positive exercise ECG. |
| D) | | for symptoms of unstable angina and/or heart failure. |
THERAPEUTIC INTERVENTIONS
CABG surgery continues to be the criterion standard in the
treatment of multi-vessel CHD in both men and women. However, women tend to be referred
for surgery much later in relation to men. In one study, fewer women with symptoms were
referred for angiogram, and men underwent CABG four times as often as women. Women were
referred more for symptoms of unstable angina, heart failure, and post-MI angina, while
men were referred on the basis of a positive exercise ECG [19,26]. As a result, women are more likely to have surgery on an emergency
basis, with potentially fewer techniques available to the surgeon, rather than on an
elective basis, as is common in men. For example, the use of left internal mammary artery
(LIMA) grafts is accepted as the criterion standard for surgical revascularization. Many
studies have demonstrated better long-term patency rates and survival in patients
undergoing CABG with LIMA [223,224]. The benefit of LIMA grafts has been
observed consistently regardless of age, sex, stenosis severity, or LV function. Although
a number of risk factors have been identified to result in LIMA graft failure, they are
less common than for other grafts [224].
Nevertheless, the risk-to-benefit question is of increasing importance as the proportion
of high-risk subgroups continues to rise [223,225].
32 . During the first four weeks of recovery post-CABG surgery, women were more likely than men to report
| A) | | fatigue. |
| B) | | numbness. |
| C) | | incisional pain. |
| D) | | negative emotions. |
THERAPEUTIC INTERVENTIONS
An interesting study compared the symptoms experienced by
men and women during the first four weeks of recovery post-CABG surgery. Women reported
numbness and discomfort in their breasts, while men reported more fatigue, incisional
pain, and negative emotions. Both men and women felt their recovery emotions were related
to their social roles and circumstances [225]. For instance, women were concerned and anxious about who would care
for them during their home recovery, as they tended to be older and live alone. In
contrast, men were more concerned first with their immediate physical recovery symptoms
and secondly with return to work issues [233]. Researchers have noted that women tend to find strength for the
postoperative recovery phase from their own spirituality and relationships with others,
especially their families, friends, and social networks [234]. One study found that women's primary
concerns shifted over the course of one year after CABG surgery [235]. In the first postoperative month, women
were most concerned with issues related to future plans, such as progress in recovery and
resuming their lifestyle. By one year after surgery, women were most concerned about diet,
and more than half of the women were exercising more.
33 . Women are reported to drop out of formal cardiac rehabilitation programs due to
| A) | | positive family support. |
| B) | | responsibilities at home. |
| C) | | decreasing cardiac symptoms. |
| D) | | lack of need for admission to transitional care. |
THERAPEUTIC INTERVENTIONS
A number of factors account for the lower program completion
rates among women. These factors include family commitments, financial concerns such as
insurance barriers, and lack of spousal support. Other reasons for decreased program
attendance in both men and women include transportation problems, distance, cost, work
conflicts, medical reasons, and having a sense of personal control over their condition
[238,243]. Societal barriers, such as low education, may also impede enrollment in
a rehabilitation program [244]. However,
women's attendance at cardiac rehabilitation programs is more often affected by medical
reasons compared to men, with complaints of increased angina and other associated symptoms,
comorbidities such as arthritis and peripheral vascular disease, and/or a need for admission
to transitional care postdischarge. This trend may be due to the presence of more
cardiovascular risk factors and increasing cardiac symptoms in women [26,241,245]. On the other hand,
men usually receive more family support and are accompanied by their spouse to cardiac
rehabilitation programs more often than women, a finding that may partially explain women's
higher dropout rates.
34 . Assessment to determine which women are at an increased risk for not participating in cardiac rehabilitation program should include all of the following, EXCEPT:
| A) | | Marital status |
| B) | | Psychologic state |
| C) | | Functional status |
| D) | | Socioeconomic status |
THERAPEUTIC INTERVENTIONS
Nurse-led coordination of care after hospital discharge may
have a role in improving rehabilitation uptake [248]. Some experts advocate giving nurses more responsibility to educate and
motivate women to complete their recovery by participating in outpatient cardiac
rehabilitation [249]. By assessing each
woman prior to discharge, those women who are at increased risk for not participating may be
identified and targeted for follow-up. This assessment should include a woman's
psychological state, namely anxiety and depression, as well as other factors like functional
status; education, employment and socioeconomic status; and availability of social
support.
35 . Which of the following areas should be covered in patient education for women with CHD?
| A) | | Disease process |
| B) | | Cardiac medications |
| C) | | Risk-factor modification |
| D) | | All of the above |
IMPLICATIONS FOR NURSING PRACTICE
Patient education for women with CHD should incorporate
several components, including the disease process, diagnostic tests, medications, the
recovery process, and risk-factor modification. In relation to the disease process, female
patients should be taught symptom recognition and early treatment of complications. The
positive long-term outcomes of women with angina and post-PCI and CABG surgery should be
stressed when counseling patients regarding the recovery process. Medication teaching
should include a description of the action and effects of the cardiac medication, along
with the dosage, frequency, and possible side effects. The nurse may also act as a patient
advocate with regard to diagnostic testing. Attempt to ensure that the appropriate
diagnostic tests and treatment procedures are provided to the patient. Finally, risk
factor modification enhances the patient's progress and quality of life [271].
36 . Which of the following is recommended for the primary or secondary prevention of CHD?
| A) | | Folic acid |
| B) | | Beta blockers |
| C) | | Antioxidant supplements |
| D) | | Hormone replacement therapy |
IMPLICATIONS FOR NURSING PRACTICE
CLINICAL RECOMMENDATIONS FOR SECONDARY CHD PREVENTION IN WOMEN
| Blood Pressure |
| Beta blockers |
| All women after MI or acute coronary syndrome with
normal left ventricular function: Beta blockers should be used for
up to 12 months (unless contraindicated): (Class I, Level A). | | Women with left ventricular failure:
Long-term beta-blocker therapy should be used indefinitely (unless
contraindicated) (Class I, Level A) and may be considered in other women with
coronary or vascular disease and normal left ventricular function (Class IIb,
Level C). |
|
| ACE inhibitors | Women after MI and in those with clinical evidence of
heart failure or an LVEF ≤40% or with diabetes: ACE inhibitors should
be used (unless contraindicated) (Class I, Level A). |
| ARBs | Women after MI and in those with clinical evidence of
heart failure or an LVEF ≤40% or with diabetes who are intolerant of ACE
inhibitors: ARBs should be used (Class I, Level B). |
| Aldosterone blockade | After MI in women without significant hypotension,
renal dysfunction or hyperkalemia who are already receiving therapeutic doses of
an ACE inhibitor and beta blocker and have LVEF ≤40% with symptomatic heart
failure: Use aldosterone blockade (Class I, Level B). |
| Lipids |
| Pharmacotherapy for high-risk women | Very-high-risk women with CHD plus multiple major risk
factors, severe and poorly controlled risk factors or diabetes to achieve an LDL
<100 mg/dL (Class I, Level A), and women with other atherosclerotic CHD or
diabetes or 10-year absolute risk >20%: Utilize LDL-lowering drug
therapy simultaneously with lifestyle therapy (Class I, Level B). |
| Pharmacotherapy for low HDL, or elevated non-HDL, high-risk women | Very-high-risk women with CHD who may require an
LDL-lowering drug combination: Utilize niacin or fibrate therapy when
HDL is low or non-HDL is elevated in high-risk women after LDL goal is reached
(reduction to <70 mg/dL is reasonable) (Class IIa, Level B). |
| Pharmacotherapy for low HDL or elevated non-HDL, other at-risk women | Women with multiple risk factors and a 10-year absolute
risk 10% to 20%: Consider niacin or fibrate therapy when HDL is low
(<50 mg/dL) or non-HDL is elevated (>130 mg/dL) after LDL goal is reached
(Class IIb, Level B). |
| Pharmacotherapy for other at-risk women |
| Women with or without CHD risk factors on
lifestyle therapy: Utilize LDL-lowering therapy if LDL ≥190 mg/dL
(Class I, Level B). | | Women with multiple risk factors even if 10-year
absolute risk is <10%: Utilize LDL-lowering therapy if LDL level
is>160 mg/dL with lifestyle therapy (Class I, Level B). | | Women older than 60 years of age with an estimated
CHD risk 10%: Statins could be considered if hs-CRP is >2 mg/dL
after lifestyle modification and no acute inflammatory process is present (Class
IIb, Level B). | | Women with multiple risk factors and 10-year
absolute risk 10% to 20%: Utilize LDL-lowering therapy if LDL is
≥130 mg/dL with lifestyle therapy (Class I, Level B). |
|
| Antiplatelet Therapy |
| Aspirin or clopidogrel |
| High risk women: Aspirin therapy
(75–325 mg/d)a should be used (unless
contraindicated) (Class I, Level A). If intolerant of aspirin therapy,
clopidogrel should be substituted (Class I, Level B). | | Women with diabetes: Aspirin therapy
(75–325 mg/d) is reasonable (unless contraindicated) (Class IIa, Level
B). |
|
| Class III Interventions (Not Useful/Effective and
May Be Harmful) |
| Menopausal therapy | Hormone therapy and selective estrogen-receptor modulators should not be used
for secondary CHD prevention (Class III, Level A). |
| Antioxidant supplements | Antioxidant vitamin supplements (e.g., vitamin E, C, and beta carotene) should
not be used for secondary CHD prevention (Class III, Level A). |
| Folic acid | Folic acid, with or without B6 and B12 supplementation, should not be used for
secondary CHD prevention (Class III, Level A). |
| Lifestyle Interventions |
| Cardiac rehabilitation | Women with a recent acute coronary syndrome or coronary
intervention, new-onset or chronic angina, recent cerebrovascular event, or
peripheral arterial disease (Class I, Level A), or current/prior symptoms of heart
failure and a left ventricular EF (LVEF) <35%: Comprehensive
risk-reduction regimen, such as cardiovascular or stroke rehabilitation or a
physician-guided home- or community-based exercise training program should be
recommended (Class I, Level B). |
| aAfter PCI with stent
placement or CABG surgery within previous year and in women with noncoronary forms
of CHD, use current guidelines for aspirin and clopidogrel. |
37 . Women have formerly been excluded from large-scale clinical trials related to CHD due to
| A) | | lack of other health problems. |
| B) | | risks to the fetus during childbearing years. |
| C) | | Both A and B |
| D) | | None of the above |
IMPLICATIONS FOR FURTHER RESEARCH
Women of reproductive age have been excluded from
cardiovascular studies due to the possible risks to any potential fetus, while older women
have been excluded because they often have multiple health problems that may create health
risks or confuse the research findings. As a result, women have had restrictions in clinical
care, such as the underutilization of thrombolytic therapy for the management of evolving
MIs. Age-based exclusions of women from clinical trials on invasive diagnostic or
therapeutic techniques have also limited the participation of women [7,325,326].
38 . Difficulties regarding the current base of research related to CHD include
| A) | | the small sample sizes. |
| B) | | no major initiatives have been instituted to study the subject. |
| C) | | the results of studies on women are used to diagnose and treat men. |
| D) | | None of the above |
IMPLICATIONS FOR FURTHER RESEARCH
Additionally, sample sizes of existing studies have
traditionally been too small to either evaluate effects or draw conclusions about care for
women. As a result, the findings of studies conducted with men, as well as with younger
populations, have been used to diagnose and treat women and older adults. In other words,
studies done on men were driving clinical practice with female patients. Yet, research
indicates that differences exist in cardiovascular risk factors, disease presentation,
diagnosis, and response of women to various CHD treatments [122,327].
At the federal level, two major initiatives have been
instituted to expand the base of research related to women-specific health issues. The NIH
has mandated investigators include women and minorities in clinical research populations for
health-related studies. At the very least, the investigator must adequately justify any
decisions to exclude potential subjects from these studies [328]. A second factor that has influenced the
research base related to women's health is the development of the NIH Interdisciplinary
Women's Health Research Center, formed to encourage studies related to issues affecting
women's health [329]. In a 2016 AHA
Scientific Statement, Mehta and colleagues discuss the need to develop strategies to
increase the inclusion of women of all ages in clinical cardiovascular research [338]. Examples of possible strategies include
raising the mandatory inclusion rates and requiring sex-stratified data reporting.
39 . The Women's Health Initiative addresses all of the following major health issues of women, EXCEPT:
| A) | | Cancer |
| B) | | Osteoporosis |
| C) | | CHD |
| D) | | Contraception |
IMPLICATIONS FOR FURTHER RESEARCH
The Women's Health Initiative (WHI), a 15-year study of
160,000 women, was undertaken as the largest NIH clinical trial to answer questions
regarding postmenopausal women's health. The WHI specifically addressed the major health
problems of menopausal women, including CHD, cancer, and osteoporosis [330]. In relation to CHD, the WHI studied the
effects of low-fat diets for prevention as well as the risks and benefits of hormone
replacement therapy [330]. As discussed, the
WHI trials investigated both combination (estrogen plus progestin) and unopposed estrogen
hormone therapy. Both trials were cut short prior to the projected completion dates. In July
2002, the WHI halted the combination therapy trials due to a significantly increased
incidence of breast cancer. In February 2004, the unopposed estrogen study was stopped when
researchers determined that the heightened risk of stroke was unacceptable to continue the
trial. In the case of the combination hormone study, researchers found an increased risk for
MI, stroke, and venous thromboembolism. The estrogen-only study resulted in increased risk
of stroke and venous thromboembolism, but no difference in the risk of MI [316,317]. There is some controversy regarding the trials' designs and whether the
findings are universally applicable [331,332]. However, the FDA continues to
recommend against the routine use of hormone replacement therapy as preventive treatment for
CHD in postmenopausal women [333].
40 . Further research studies are needed on
| A) | | the clinical course of women with CHD. |
| B) | | the impact of CHD on the patient and family. |
| C) | | which strategies are most effective in helping women of various age groups in reducing their cardiovascular risk factors. |
| D) | | All of the above |
IMPLICATIONS FOR FURTHER RESEARCH
Beyond the large NIH trials that have been initiated, other
research by various disciplines is needed about women and CHD. This research involves asking
questions such as those listed in Table 8, related to
cardiovascular risk factors, the impact of CHD on the patient and family, the clinical
course of women with CHD, and intervention studies. For instance, why do women fail to
receive diagnostic studies or therapeutic interventions to the same extent that men do? Many
studies have shown less active or aggressive diagnosis and management of CHD in women. Fewer
women with positive noninvasive cardiac tests are catheterized and fewer women have
revascularization by either PCI or CABG surgery compared to men [122,205,225,334]. The question remains: Are men
overtreated, or are women undertreated?
