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Women and CVD When it’s probably not atheroma 11 July 2022 7.30pm BST @Lwnurses #LWN #LearnWithNurses Michaela Nuttall RGN MSc Founder, Learn With Nurses Director, Smart Health Solutions Associate in Nursing, C3 Collaboratingfor Health Chair, Health CareCommittee HEART UK Member, Nurses WorkingParty and Guidelines & Information Trustee, PoTS UKitish and IrishHypertension Society @thisismichaela Women and CVD • Part 1 - When it’s atheroma • Part 2 - When it’s probably not atheroma • Part 3 - Hormones • And of course, the quiz BHF 2020 In the UK more than 100,000 hospital admissions each year are due to heart attacks; that's 280 admissions each day or 1 every 5 minutes. More than 200,000 UK hospital visits each year are due to heart attacks. In the 1960s more than 7 out of 10 heart attacks in the UK were fatal. Today at least 7 out of 10 people survive. Chest pain…. Chest pain refers to pain in the thorax. It can be classified by cause (cardiac or non- cardiac). • Cardiac causes of chest pain include: • Acute coronary syndrome (unstable angina and myocardial infarction). • Stable angina. • Other cardiac causes, such as dissecting thoracic aneurysm, pericarditis, cardiac tamponade, myocarditis, acute congestive cardiac failure, or arrhythmias. https://www.nice.org.uk/guidance/cg95 Non cardiac causes Respiratory causes of chest pain include: • Pulmonary embolus, pneumothorax or tension pneumothorax, community-acquired pneumonia, asthma, or pleural effusion. Other causes of chest pain include: • Gastroenterological causes, such as acute pancreatitis, oesophageal rupture, peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm, or oesophagitis. • Musculoskeletal causes, such as rib fracture, costochondritis, spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction), rheumatoid or psoriatic arthritis, fibromyalgia, or osteoporotic fracture. • Cancer (for example, lung cancer); herpes zoster; Bornholm disease; precordial catch (Texidor twinge); or psychogenic or non-specific chest pain • Postural Tachycardia SyndromeNICE Chest Pain Overview 2020NICE Chest Pain Overview 2020 What percentage of people involved in research about CVD are women? 38.2% 41.1% 42.7% 45.8% 49.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% The average delay between the onset of symptoms and arrival at hospital for men ranges between 1 hour 24 minutes and 3 hours 30 - what is it for women? 1 hour 31 minutes and 5 hours 30 minutes 1 hour 48 minutes and 7 hours 12 minutes 3 hour 48 minutes and 4 hours 12 minutes 7 hour 48 minutes and 12 hours 12 minutes 1 hour 31 minutes and 12 hours 12 minutes 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% What percentage of women get an initial diagnosis which is wrong when having a heart attack? 20% 30% 40% 50% 60% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Why? • Not enough known • Clinicians' perspective • Angiograms not as effective in diagnosis heart disease in women • It might not be ‘traditional’ atheroma (next session) They told me I was just having a panic attack, so I was taken • Lack of inclusion in research to the hospital with no urgency. • InequalitiesBut when it’s not ‘traditional’ atheroma PoTSSCAD (Spontaneous Coronary Artery Dissection) most commonly affects? Men in their 40s & 50s Men in their 60s & 70s Women in their 40s & 50s Women in their 60s & 70s 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%SCAD (Spontaneous Coronary Artery Dissection) most commonly affects? Men in their 40s & 50s Men in their 60s & 70s Women in their 40s & 50s Women in their 60s & 70s 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SCAD • SCAD most commonly occurs between adolescence and late 60s • Many people with SCAD will have few or no traditional risk factors for heart and circulatory disease • 90% of those with SCAD are women • It can often occur during, or soon after, pregnancy • It’s thought that estrogen and progesterone weaken blood vessel walls, making more vulnerable to tearing - SCADhttps://www.saintlukeskc.org/condition/spontaneous-coronary-artery-dissection-scad Symptoms SCAD patients experience different symptoms; the most common are: • Central chest pain • Pain or numbness in one or both arms • Jaw pain • Back pain • Shoulder pain • Nausea • Sweating/clamminess • Difficulty breathing Diagnosis and treatment • ECG (electrocardiogram) Surgical intervention: – although ECGs can • stents, or coronary artery bypass surgery look normal in some SCAD patients Medical management: • Blood tests to assess Aspirin, statins? blood pressure pills and beta blockers Troponin levels • Angiogram Cardiac rehab • CT scan What might increase risk of SCAD? • Abnormalities of the blood So: vessels such as fibromuscular • Number 1 cause of heart attacks dysplasia (FMD) in women under 50 years of age • Inherited connective tissue • Number 1 cause of pregnancy- diseases such as Ehlers-Danlos related heart attacks syndrome or Marfan’s syndrome • Most individuals with SCAD are • Severe high blood pressure young, healthy, and active with • Extreme physical exercise no family history of heart disease • Severe emotional stress Ischaemia with Non-Obstructed Coronary Arteries INOCA • These are conditions where the blood supply to the heart is restricted even when there are no blockages in the coronary arteries. • Patients with INOCA can present at emergency care with symptoms of a heart attack yet are often told there is nothing wrong with their heart, partly because INOCA conditions often do not show up on usual tests, like ECG’s and routine angiograms. • Patients with INOCA can spend many years being sent home from emergency departments without diagnosis, without treatment and without help. Vasospastic angina (Variant/Prinzmetal’s) People experiencing vasospastic angina do not typically have episodes of angina during exercise. • usually occurs while at rest and in the early morning or late at night • is often severe, but can be variable and can also be mild (a sense of unease) • can occur in other locations in the body; the back, shoulders, neck, stomach and arms • can be eased through taking medication • some people can also experience nausea. Triggers • emotional stress • exposure to extremely cold weather or a sudden drop in temperature • hyperventilation • allergic reactions (usually severe reactions that result in histamine release, sometimes referred to as Kounis Syndrome) • inflammation of the coronary artery wall • smoking • some antidepressants • some anti-migraine drugs • use of the drug cocaine • high consumption of alcohol More common in women Especially around the time of menopause Microvascular Angina (syndrome X) • May be more severe and last longer than other types of angina pain • May occur with shortness of breath, sleep problems, fatigue, and lack of energy • Often is first noticed during routine daily activities and times of mental stress Only 5% or coronary arteries are visible on angiogram Diagnosis & treatment • Calcium channel blockers. • Not always diagnosed • Beta blockers. • Lack of awareness • Nitrates like nitroglycerin. • nicorandil, ivabradine and ranolazine • MRI • Low dose imipramine • Stress echocardiography • Hormone replacement therapy (HRT), especially if • Acetylcholine provocation their chest pain is associated with.hot flushes during angiography Support, CBT, HypnotherapyPoTS Summary • Chest pain isn’t always cardiac • Think of what else it might be • The inequalities are vast • It is acknowledged there is a lack of research in women • There is a movement for change, it’s going to take a whileIn summary