myocardial infraction – The Early Career Voice

Practice Change & CME

December 7, 2018March 28, 2019 Mirvat Alasnag, MD

There are many scientific sessions happening around the globe that issue continuous medical education (CME) credits. Although the AHA Scientific Sessions 2018 covered a wide breadth of topics, I took particular interest in how the new Lipid Management Guidelines apply to women. My previous blog ended by citing a clinic encounter with a female patient. When I see how, as a woman cardiologist, I gained a newer perspective on hyperlipidemia, I realize these CME hours don’t capture the actual impact and changes in practice effected by presented data. Most busy clinicians don’t read every page of published guidelines. The lipid guidelines were summarized into ten key take home messages.

These points didn’t include women as a special population. I avail this opportunity to highlight two very different clinic visits: one before AHA Scientific Sessions 2018 & the second soon after it.

October 2018:

This is a 42-year-old female whose cardiovascular risk factors include poorly controlled Type II Diabetes, obesity and hypertension. She suffered an acute inferior myocardial infarction 3 months ago for which primary Percutaneous Intervention was performed with a second-generation drug eluting stent. She was on dual antiplatelet therapy, Lisinopril, Bisoprolol and Atorvastatin 40mg daily. She had not repeated any blood works since discharge (HbA1C 11.1 g/dL & LDL 162 mg/L). Her physical examination was unremarkable aside from weight gain (82 Kg to 85 Kg).

Me: Any chest pain or dyspnea?

She: No

Me: Why did your weight increase?

She: Shrug

Me: Ok I’ll get a dietician and educator to discuss this with you. You need to see your diabetologist. Continue DAPT. We need to drop your LDL, so I’d like to increase the dose of statin.

November 2018:

This is a 45-year-old female whose cardiovascular risk factors include Type II Diabetes, obesity and hypertension. She had a positive myocardial perfusion scan performed for angina. A coronary angiogram revealed non-obstructive coronary artery disease in January 2018. She was on aspirin, oral hypoglycemic agents, Bisoprolol and Atorvastatin 40mg daily. Her HbA1C 8 g/dL & LDL 118 mg/L. Her physical examination was unremarkable (weight 71 Kg).

Me: Any chest pain or dyspnea?

She: No, I’m feeling well.

Me: You’re only 45 years old. How many children do you have? Do you plan on having anymore?

She: Why? Will I have a heart attack if I do?

Me: I’m asking because of the statin. We need to discuss contraception if you aren’t planning anymore or alternatives if you do.

She: How about aspirin? Can I stop it now?

Me: …

As my mentor always told me, “If you don’t know what to look for, you won’t see what you should.” If I wasn’t directed through the AHA Scientific Sessions to search for the topic of women and statin therapy, I would have failed my second patient as I did my first.

But the second encounter sparked a different discussion related to cardiovascular disease prevention in women: What is the role of Aspirin in prevention? This too was discussed at Scientific Sessions 2018.

The Physicians Health Study published in 1989 demonstrated a 44% reduction in myocardial infarctions with aspirin therapy. The evidence for stroke reduction and cardiovascular deaths was inconclusive.¹ The Women’s Health Study published in 2005 demonstrated a 17% reduction in stroke.² This was primarily ischemic with an insignificant increase in hemorrhagic stroke. There was no net effect on fatal and nonfatal myocardial infarctions or overall cardiovascular deaths. The US Preventive Services’ latest statement (see link) recommends low dose aspirin for individuals between 50-59 years with a > 10% 10- year ASCVD risk and a life expectancy of at least 10 years for the primary prevention of cardiovascular disease and colorectal cancer.

Neither of my patients fit the age group; nevertheless, it is worth the pause. Would my second patient qualify in 5 years?

This year three trials on the role of aspirin in prevention were published and all conflict with these recommendations: ASPREE, ASCEND, ARRIVE. ASCEND in particular is relevant to my second patient who is diabetic rendering her ACVD risk > 20%. There was a small reduction in major adverse cardiac events and a significant increase in bleeding.³ How do we reconcile these differences. Subjects in the earlier trials had an important additional risk factor: smoking. The use of statin therapy was also significantly lower in the earlier studies. Perhaps the impact of the two accounts for the conflicting results in the more recent trials.

Is there any role for aspirin in primary prevention? Preliminary data from MESA suggests that high coronary artery calcium score and high plasma lipoprotein (a) may warrant aspirin therapy.⁴

Scientific Sessions offers CME. However, what we take back to our patients is far more…Aspirin or not, Statin or not, CACs or not. All these were thought provoking discussions this year.

I thank both my patients for consenting to using their information in this blog.

REFERENCES:

Steering Committee of the Physicians’ Health Study Research Group. N Engl J Med 1989; 321: 129-35
Ridker P, et al. A Randomized Trial of Low-Dose Aspirin in the Primary Prevention of Cardiovascular Disease in Women. N Engl J Med 2005; 352: 1293-1304.
The ASCEND Study Collaborative Group N Engl J Med 2018; 379: 1529-39.
Chasman D, et al. Polymorphism in the apolipoprotein (a) gene, plasma lipoprotein(a), cardiovascular Disease and Low-dose Aspirin Therapy. Atherosclersosis: 2009 Apr; 203 (2):371-6.

Women’s Health: Premature Coronary Heart Disease In Young Women And Health Disparities – Will Cinderella Make It To The Ball?

April 17, 2018 Tanja Dudenbostel, MD

Every 80 seconds a woman dies from a heart attack or stroke. Once thought to be predominantly a problem of men, coronary heart disease remains the leading cause of morbidity and mortality for women in the US and worldwide. Gender differences have been recognized, but knowledge gaps in gender differences regarding pathophysiology, clinical presentation, diagnosis, and optimal acute and chronic treatment strategies for heart attacks and co-existing or resulting complications such as heart failure are still existing.

Despite stunning improvements in cardiovascular mortality in women in the last two decades, the annual coronary heart disease mortality rate has remained greater for women than for men. The observed narrowing of outcomes between women and men has been attributed to improved therapy for established cardiovascular disease and to primary and secondary preventive interventions. However, women are less likely to receive evidence-based care and have worse outcomes than men and the observed decline in heart attack event rates or heart attack associated deaths in the US in women remains significant higher than in men.

In addition to this unresolved gender gap, we are now facing a new phenotype of premature coronary heart disease. Recent evidence has shown the emergence of unfavorable trends in coronary heart disease and related mortality in younger individuals 35-55 years of age worldwide over the last decade.

While a substantial decline in AMI event rates or MI deaths in the US in the past decade is absent in young women.

Over the last decade, hospitalizations for acute coronary syndrome in women 40-49 years of age have increased all over the world.
Similar, as observed in the general population, young women are more affected than their male counterparts with more hospitalization for heart attacks, 2-fold higher crude 30-day hospital readmissions rate, and higher mortality rates. These unfavorable age and sex-specific trends in coronary heart disease may be attributable to distinct risk factors and an emerging cardiovascular phenotype of increasing obesity, diabetes mellitus, and high fat-salt-sugar consumption rates among young individuals.

Regardless of age, more women than men will die within the first year after they had their first heart attack. Young women who have their first heart attack in their 40s do worse than their male counterparts.

The mechanisms, likely multi-factorial, contributing to excess risk and inferior health among young women remain unclear. Young women are thought to have a different underlying gender-specific biology and disease manifestation and distinctive psychosocial stressors that interfere with health behaviors and interact with biology.

Racially/ethnically diverse young women are more affected by coronary heart disease and have their first heart attack at an even younger age than white women.

Further, ethnically diverse women are less likely to be referred to coronary arteriogram present with their incident AMI at an even younger age than white women, have a higher mortality.

Short-comings in evidence-based care, referral for coronary angiogram, reperfusion strategies, admission to intensive care units are more pronounced in diverse than white non-Hispanic women.

Trends of worse risk profile and higher mortality among younger women persist with continuing reports of excess in-hospital and early and late mortality compared with men.

Clinical and autopsy data point to a different pathophysiology in young women.

From a pathophysiological perspective, there are predominantly 3 major vascular events underlying thrombotic coronary occlusions responsible for myocardial infarction: plaque rupture, plaque erosion, and calcific nodule. Plaque rupture is by far the most common cause, responsible in three quarter of men and in half of women with fatal myocardial infarction.

Autopsy studies have shown that particularly in young women, plaque erosions rather than ruptures are more common. This is of particular interest given that myocardial infarction without obstructive coronary heart disease is more common at younger ages and among women. Further, nonatherosclerotic etiologies of acute coronary syndrome, such as spontaneous coronary artery dissection frequently affects younger women and a recent statement by the American Heart Association provides an overview of the Current State of the Science of Spontaneous Coronary Artery Dissection.

As a physician-scientist who encounters frequently young adults with cardiovascular disease, I am curious what future studies will reveal about this new phenotype of premature coronary artery disease regarding pathophysiology, optimal primary prevention, diagnosis and treatment strategies.

I am also wondering, despite stunning improvements in cardiovascular mortality in women in the last two decades, if we will be able to close the disparity gap in young women with cardiovascular disease and if Cinderella will make it to the ball.

References:

1) Acute Myocardial Infarction in Women. A Scientific Statement From the American Heart Association. Laxmi S. Mehta, Theresa M. Beckie, Holli A. DeVon, Cindy L. Grines, Harlan M. Krumholz, Michelle N. Johnson, Kathryn J. Lindley, Viola Vaccarino, Tracy Y. Wang, Karol E. Watson, Nanette K. Wenger and on behalf of the American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research. Circulation. 2016;133:916-947
2) Ghazi L, Oparil S, Calhoun DA, Lin CP, Dudenbostel T. Distinctive Risk Factors and Phenotype of Younger Patients With Resistant Hypertension: Age Is Relevant. Hypertension. 2017 May;69(5):827-835. PMID: 28348010 PMCID: PMC5402755
3) Hayes SN, Kim ESH, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, Ganesh SK, Gulati R, Lindsay ME, Mieres JH, Naderi S, Shah S, Thaler DE, Tweet MS, Wood MJ; American Heart Association Council on Peripheral Vascular Disease; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; and Stroke Council. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation. 2018 Feb 22.

Tanja Dudenbostel is an Internist, Hypertension Specialist within Cardiology at the University of Alabama at Birmingham where I divide my time as an Assistant Professor between clinical research and seeing patients in cardiology.

Women’s Heart Disease – The Interdisciplinary Road Ahead

March 16, 2018 Tanja Dudenbostel, MD

Every 80 seconds a woman dies from a heart attack or stroke. Once thought to be predominantly found in men, coronary heart disease remains the leading cause of morbidity and mortality for women in the US and worldwide. There have been significant improvements in cardiovascular mortality in women in the last two decades with narrowing of outcomes between women and men which have been attributed to improved therapy for established cardiovascular disease and to primary and secondary preventive interventions. However, women are less likely to receive evidence-based care and have worse outcomes than men. Gender differences have been recognized, but vast knowledge gaps in gender differences regarding pathophysiology, clinical presentation, diagnosis, and optimal acute and chronic treatment strategies for heart attacks and co-existing or resulting complications such as heart failure remain. The AHA Scientific Statement “Acute Myocardial Infarction in Women” provides a comprehensive review of the current evidence.

At the opening plenary session of the American College of Cardiology ACC.18 meeting in Orlando, Florida, the pioneer of women’s cardiology Dr. Nanette Kass Wenger gave her inspiring Simon Dack keynote lecture on Heart Disease & Women titled “Understanding the Journey-The Past, Present and Future of CVD in Women.”

In “Steps on the journey” Dr. Wenger gave a comprehensive review of the early beginnings and showed how far we have come. Some interesting anecdotes were also shared such as that the first women’s heart disease meeting in Iowa in the 1950s was to help women prevent heart attacks in husbands.

Her impactful vision on how to expand the landscape of women’s cardiovascular health research in the next decade struck a nerve with me and made me re-think some of the concepts we are applying in academic cardiology. Dr. Wenger called for an expansion of women’s cardiovascular health research to include social determinants of health as nearly 80% of heart outcomes depend on social factors. Women’s Heart Health is not solely a medical problem and clinical research cannot happen in a vacuum in the hospital. A variety of factors contribute to women’s cardiovascular health and need to be considered for maintenance of health and cure of disease. Women’s Heart Heath needs to be extended. Factors like beliefs and behaviors, the local community, economic, environmental, ethical, legislative/political, public policy – all these social determinants need to be included in heart disease research in women.

My take away for the future was that we cannot longer compartmentalize and that programs focusing on Women’s Heart Heath need to involve all programs available- not only cardiology. It needs to be an interdisciplinary approach to learn more about physiology, psychology and ecology of health for best outcomes and to tackle Women’s Heart Health.

Dr. Wenger quoted the French Victor Hugo in her inspiring lecture.

“There is nothing as powerful as an idea whose time has come.”
Victor Hugo
Histoire d’un crime, 1977