Radboud Women s Heart Center

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Hendrik Adam
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1 Sex-, Gender en Hart en vaatziekten: Je kunt er in de opleiding niet vroeg genoeg aandacht aan geven AIOS 25 Mei 2018 Radboud Women s Heart Center

Disclosure belangen spreker NAAM AIOS cursus Vasculaire Geneeskunde 24/25 mei 2018 (potentiële) Belangenverstrengeling Voor bijeenkomst mogelijk relevante relaties met

2 Disclosure belangen spreker NAAM AIOS cursus Vasculaire Geneeskunde 24/25 mei 2018 (potentiële) Belangenverstrengeling Voor bijeenkomst mogelijk relevante relaties met bedrijven Regelmatig presentaties nascholingen MSD Sponsoring of onderzoeksgeld nvt Honorarium of andere (financiële) vergoeding Aandeelhouder Andere relatie, namelijk:

3 Every Cell Has a Sex: X and Y and the Future of Health Care

4 Sex differences exist in the whole genome analysis and are mainly overlooked NIH ordered m/f balance in cell and animal research: XY XX Nature 2014

5 Mechanisms contributing to sex differences throughout life: Ventura-Clapier R et al. Cardiovasc Res 2017

7 Systemic inflammation in ischemic heart disease Inflammation holy grail Libby P et al JACC 2017

8 Sex bias in infectious diseases, inflammatory diseases and cancer Klein SL et al. Nat Reviews Immunology 2016

9 Sex hormones (m/f) over life-time: young men higher pro-inflammatory state, reverses after menopause Ober C et al. Nat Rev Genetics 2008

10 Risk factors

12 British Medical Journal 14th April 1973

13 1991

14 Mortality Europe (WHO, EHJ 2016) IHD 19% Stroke 9% Other CVD 12% IHD 20% Stroke 14% Other CVD 15%

15 Volkskrant 9 Januari 2018

17 Boek Hartschade, april 2018

19 Crea F, et al. EHJ 2013

20 % normal CAG in stable angina pectoris: database Sweden, findings at heartcath, N=12200 % Johnston N, Schenck-Gustafsson K, et al. Eur Heart J 2011

21 IVUS in women with angina and non-obstructive CAD (NOCAD): Khuddus MA, et al. J Interven Cardiol 2010;23:511 9 atherosclerosis

22 Patterns of vascular ageing in men and women

Feminine pattern of IHD: smaller diameter coronary arteries less stenoses epicardial coronary arteries (NOCAD)(< 65 yrs) diffuse pattern atherosclerosis less

23 Feminine pattern of IHD: smaller diameter coronary arteries less stenoses epicardial coronary arteries (NOCAD)(< 65 yrs) diffuse pattern atherosclerosis less calcification, more soft plaques more vascular dysfunction (also after PCI and CABG) clinical prognosis not better diffuse atherosclerosis focal stenosis Gould 1999, Shaw LJ et al 2009

24 (= NOCAD) Berry C. Circulation 2017

25 Myocardial infarction with no-obstructive coronary arteries (MINOCA) Pasupathy S, et al. Circ J 2016; 80:

26 Classic type I ACS Sex-specific aspects of ACS Type II ACS SCAD: >> 90 % women 25% FMD Blank spots in guidelines & lack of gender-balance Note: chronic TTC-variants in PTSS

27 Age-distribution SCAD (>> 90% women) Indication statins?? no guidelines yet for SCAD patients Use of DAPT in premenopausal women may cause severe uterine bleeding AHA and ESC position paper released in 2018 Saw J et al. JACC 2017

28 Broken Heart syndrome: 9-10 x more often in women (>60 yrs) compared to men Tako-Tsubo CMP

29 Broken Heart syndrome: 9-10 x more often in women (>60 yrs) compared to men Tako-Tsubo CMP

30 Different symptoms in stable/unstable IHD among men/women and in various age-groups Typical AP Crescendo/decrescendo pattern of symptoms in type II ACS Typical AP + HFpEF symptoms

Development ischemic heart disease in women: premenopause low risk 45-65 years low- intermediate risk older age high risk risk factor assessment obstructive CAD ----------------------------

31 Development ischemic heart disease in women: premenopause low risk years low- intermediate risk older age high risk risk factor assessment obstructive CAD non-obstructive CAD functional CAD, type II ACS less obstructive CAD than in men outward remodelling microvascular coronary disease Regitz-Zagrosek V et al Eur Heart J 2016; 37: ageing

32 Type 1 - coronary microvascular disease (CMD) precursor abnormalities larger coronary arteries In 50% women with chest pain at middleage (WISE) Bairey Merz CN, et al 2006 Persistent symptoms adverse prognosis Johnson BD, et al 2006

33 CMD: abnormal vasodilatation and/or increased vasoconstriction Crea F, Camici 2014

34 Concept of Coronary Microvascular Dysfunction Herrmann J. Trends Cardiovasc Med 2015

35 Frailty, Thy Name Is Woman Syndrome of Women with HFpEF Hypertension diabetes Pedrotty DM et al. Circ Cardiovasc Qual Outcomes 2015

37 Eur J Preventive Cardiol 2016; 23 (17):

38 Long-term CVD consequences of preeclampsia

39 Nerenberg K, et al. Canadian J Cardiol 2014

40 2016 European guidelines CVD prevention in clinical practice: Piepolo MF et al. Eur Heart J 2016

41 teens adolescence forties fifties teens Elias-Smale SE et al. Maturitas 2015

42 Dutch awareness campaign, April 2016: Treat me like a Lady Radboud Women s Heart Center

43 Radboud Women s Heart Center

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