Sex-, Gender en Hart en vaatziekten: Je kunt er in de opleiding niet vroeg genoeg aandacht aan geven angela.maas@radboudumc.nl www.hartvoorvrouwen.nl 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 bedrijven Regelmatig presentaties nascholingen MSD Sponsoring of onderzoeksgeld nvt Honorarium of andere (financiële) vergoeding Aandeelhouder Andere relatie, namelijk:
Every Cell Has a Sex: X and Y and the Future of Health Care
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
Mechanisms contributing to sex differences throughout life: Ventura-Clapier R et al. Cardiovasc Res 2017
Systemic inflammation in ischemic heart disease Inflammation holy grail Libby P et al JACC 2017
Sex bias in infectious diseases, inflammatory diseases and cancer Klein SL et al. Nat Reviews Immunology 2016
Sex hormones (m/f) over life-time: young men higher pro-inflammatory state, reverses after menopause Ober C et al. Nat Rev Genetics 2008
Risk factors
British Medical Journal 14th April 1973
1991
Mortality Europe (WHO, EHJ 2016) IHD 19% Stroke 9% Other CVD 12% IHD 20% Stroke 14% Other CVD 15%
Volkskrant 9 Januari 2018
Boek Hartschade, april 2018
Crea F, et al. EHJ 2013
% normal CAG in stable angina pectoris: database Sweden, findings at heartcath, N=12200 % Johnston N, Schenck-Gustafsson K, et al. Eur Heart J 2011
IVUS in women with angina and non-obstructive CAD (NOCAD): Khuddus MA, et al. J Interven Cardiol 2010;23:511 9 atherosclerosis
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 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
(= NOCAD) Berry C. Circulation 2017
Myocardial infarction with no-obstructive coronary arteries (MINOCA) Pasupathy S, et al. Circ J 2016; 80: 11-16.
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
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
Broken Heart syndrome: 9-10 x more often in women (>60 yrs) compared to men Tako-Tsubo CMP
Broken Heart syndrome: 9-10 x more often in women (>60 yrs) compared to men Tako-Tsubo CMP
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 ---------------------------- 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: 24-34. ageing
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
CMD: abnormal vasodilatation and/or increased vasoconstriction Crea F, Camici 2014
Concept of Coronary Microvascular Dysfunction Herrmann J. Trends Cardiovasc Med 2015
Frailty, Thy Name Is Woman Syndrome of Women with HFpEF Hypertension diabetes Pedrotty DM et al. Circ Cardiovasc Qual Outcomes 2015
Eur J Preventive Cardiol 2016; 23 (17): 1863-79.
Long-term CVD consequences of preeclampsia
Nerenberg K, et al. Canadian J Cardiol 2014
2016 European guidelines CVD prevention in clinical practice: Piepolo MF et al. Eur Heart J 2016
teens adolescence forties fifties teens Elias-Smale SE et al. Maturitas 2015
Dutch awareness campaign, April 2016: Treat me like a Lady www.hartvoorvrouwen.nl Radboud Women s Heart Center
info@hartvoorvrouwen www.hartvoorvrouwen.nl @Hartvoorvrouwen Radboud Women s Heart Center