3 Adjusted cumulative incidence Adjusted cumulative incidence Cumulative Incidence of CVD Adjusted for the Competing Risk of Death forMen and Women according to Aggregate Risk Factor (RF) Burden at 50 Years of AgeMenWomen69%≥ 2 major RFs1 major RF≥ 1 Elevated RF≥ 1 Not optimal RFAll optimal RFs50%50%46%39%Adjusted cumulative incidenceAdjusted cumulative incidence36%27%8%5%Attained ageAttained ageLloyd-Jones DM et al., Circulation 2006; 113: 79112640 M3
4 Vi è anche, nelle società occidentali, un’evidente associazione dell’ipertensione con l’età a causa del globale incremento dei valori medi di pressione arteriosa con l’invecchiamento: ciò riguarda soprattutto l’ipertensione sistolica isolata.
5 Distribuzione dei fattori di rischio in Italia in rapporto al sesso (dati Istituto Superiore di Sanità, anno 2003)5
6 CVD Mortality Trends for Males and Females (United States: )Deaths in thousandsYearsMalesFemalesRosamond W et al., Circulation 2007; 115: e6912576 M6
7 Deaths by Cause, Women, Latest Available Year, EU Respiratory disease8%Other cancer12%Injuries and poisoning4%Breast cancer 4%Lung cancer 2%Colo-rectal cancer 3%Other causes20%Stomach cancer 1%Other CVD17%CHD15%Stroke14%European Cardiovascular Disease Statistics, 20006979 M7
8 Acute MI Mortality by Age and Sex SLIDE INFORMATION SOURCE: Vaccarino V. et al. Sex-based differences in early mortality after myocardial infarction. National registry of myocardial infarction 2 participants. N Engl J Med 1999; 341(4):Based on national registry data including 155,565 women and 229,313 men enrolled between June 1994 and January 1998, overall in-hospital mortality during hospitalization for myocardial infarction is 16.7% for women, compared to 11.5% for men(1)Among persons less than 50 years of age, the rate of mortality for women is twice the rate of mortality for men (1).In contrast, for persons over the age of 74 years, there is no statistically significant difference in mortality rates between women and men(1).(1) Vaccarino V. et al. Sex-based differences in early mortality after myocardial infarction. National registry of myocardial infarction 2 participants. N Engl J Med 1999; 341(4):Source: Adapted from Vaccarino N Engl J Med 1999; 341(4):8
9 Prognosis After MI 38% of women die within first year Compared to 25% of men35% of women will have second MI within 6 yearsCompared to 18% of menSLIDE INFORMATION SOURCE: Wenger NK. Cardiovascular health and disease in women problems and prospects. Circulation 2004; 109:Source: Wenger Circulation 2004; 109:9
11 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 menOther Presenting SymptomsUpper abdominal pain, fullness, burning sensationShortness of breathNauseaNeck, back, jaw painAssociationsPrecipitated by exertionPrecipitated by emotional distressSLIDE INFORMATION SOURCES: Charney P. Presenting symptoms and diagnosis of coronary heart disease in women. J Cardiovasc Risk 2002, 9: Goldberg RJ, O’Donnell C, Yarzebski J, et al. Sex differences in symptoms presentation associated with acute myocardial infarction: a population-based perspective. Am Heart J :Coronary artery disease presents more frequently with atypical symptoms in women compared to men (1,2).Gender, race, and other perceptions may affect physicians’ assessment of whether a patient has CHD. Studies using tapes of actresses reading from a script describing CHD symptoms have shown that physicians are less likely to assess CHD in African American women compared to white women and men, and in women with a “hysterical” style compared to those with a more “business-like” presentation(1).(1) Charney P. Presenting symptoms and diagnosis of coronary heart disease in women. J Cardiovasc Risk 2002, 9:(2) Goldberg RJ, O’Donnell C, Yarzebski J, et al. Sex differences in symptoms presentation associated with acute myocardial infarction: a population-based perspective. Am Heart J :Source: Charney Cardiovasc Risk 2002, 9: , Goldberg Am Heart J :11
12 Value of the Exercise ECG in Women 778068707061605040MenWomen3020SLIDE INFORMATION SOURCE: Kwok Y, et al. Meta-analysis of exercise testing to detect coronary artery disease in women..This meta-analysis found that exercise ECG is less accurate in women than in men (1).Mechanisms such as digoxin-like effect of estrogen, different catecholamine response to exercise in women, a higher incidence of mitral valve prolapse, and different chest wall anatomy in women have also been proposed as explanations for accuracy differences (1) .In addition, methods for performing the exercise ECG were developed using men, and the thresholds for abnormal were established almost exclusively in men (1).(1) Kwok Y, et al. Meta-analysis of exercise testing to detect coronary artery disease in women. Am J Cardiol (5):10SensitivitySpecificitySource: Kwok Y, Am J Cardiol (5):12
13 Women Receive Less Interventions to Prevent and Treat Heart Disease Less cholesterol screeningLess lipid-lowering therapiesLess use of heparin, beta-blockers and aspirin during myocardial infarctionFewer referrals to cardiac rehabilitationSLIDE INFORMATION SOURCES: Chandra NC, et al. Observations of the treatment of women in the United States with myocardial infarction; a report from the National Registry of Myocardial Infarction-I. Arch Intern Med 1998; 158: ; Nohria A, et al. Gender differences in coronary artery disease in women: gender differences in mortality after myocardial infarction: why women fare worse than men. Cardiol Clin 1998; 16: Scott LB, Allen JK. Providers perceptions of factors affecting women’s referral to outpatient cardiac rehabilitation programs: an exploratory study. J Cardiopulm Rehab 2004; 24: O’Meara JG, et al. Ethnic and sex differences in the prevalence, treatment, and control of dyslipidemia among hypertensive adults in the GENOA study. Arch Intern Med 2004; 164: Hendrix KH, et al. Ethnic, gender, and age-related differences in treatment and control of dyslipidemia in hypertensive patients. Ethn Dis 2005; 15:11-16.Source: Chandra 1998, Nohria 1998, Scott 2004, O’Meara 2004, Hendrix 200513
24 Focus sulla sindrome metabolica in menopausa 24
25 Age-Specific Prevalence of the Metabolic Syndrome among 8814 US Adults, NHANES III,20-2930-3940-4950-5960-69> 701020304050MenWomenPrevalence (%)Age (years)Ford S et al., JAMA 20022328 G
26 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 teratogeniContraccettivi oraliLa 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 sostitutivaLe informazioni disponibili suggeriscono che gli unici vantaggi della terapia ormonale sostitutiva sono rappresentati da una minor frequenza di fratture ossee e di neoplasiedel colon, mentre è aumentato il rischio di eventi coronarici e tromboembolici, ictus…Linee Guida ESH/ESC 2007
27 Treatment (2) ….Che farmaco usare? Tutti i farmaci antiipertensivi attraversano la placentaDati comparativi tra i diversi farmaci riguardanti sia l’efficacia sia la sicurezza fetale e materna sono ancorainadeguatiACE 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/dieSicuro per madre e feto, blando antiipertensivo.Effetti collaterali: stipsi, depressione, sonnolenza, secchezza fauciLABETALOLO* (alfa 1 bloccante e beta bloccante non selettivo)100 mg x 2/die, max 2.4 g/dieI 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* 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
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