 Hi, everyone. My name is Lorraine Cornwell. I'm one of the cardiac surgeons over at the Michael E. DeBakey VA Medical Center, and I'd like to talk to you today about heart disease in women, particularly focusing on heart surgery. As I'm one of the heart surgeons, and I'm one of the few women in heart surgery. I thought this was an apropos topic for today. As you all here probably know, heart disease is the number one killer of all women. There has been an increase in awareness over the past decades, but only about half of women recognize that heart disease is their number one killer. And this is, you know, a large number of women that die every year with heart disease. There were nearly 300,000 women that died of heart disease in 2017, for instance. The breakdown of cardiovascular death, the majority is due to coronary heart disease. That's around 43%. But there's also a smattering of other type of diseases, for instance, stroke, heart failure, high blood pressure peripheral vascular disease, and then of course the other category. And heart disease is very prevalent in US adults. There's about 81 million US adults, one in three that live with heart disease presently, and around 43 million of those are women. And cardiovascular disease does account for about 38% of all female deaths presently, and more than half of the women who die suddenly from cardiovascular disease had no prior symptoms. When you look at the causes of death worldwide, I thought this graph was very interesting. It's female on the left side versus male on the right. And that lighter blue is cardiovascular deaths. And you can see with age on the y axis here as age increases, the number of deaths increases in women versus men with females dying at an older age, but from the same condition, that's what we see is that women tend to contract the disease a little later in life, but are equally at risk from dying from cardiovascular disease. So as you know, other women who die each year, one in three are dying from cardiovascular disease. So this is important to know, important to relate to our patients, our families. And we can change these statistics because we can make the right choices for our hearts. Cardiovascular disease is largely preventable. So I wanted to talk particularly about coronary heart disease and women. That's the coronary artery atherosclerosis. That's the most common cause of cardiovascular disease. It does vary in prevalence with race and ethnicity, particularly in black women, but also white and Hispanic women have around a 6% prevalence of coronary heart disease in age over 20, a little bit less so in Asian women. There has been noted an increasing incidence of MI and young women recently. That's myocardial infarction or heart attack, and with higher mortality rates. The diagnosis in women can be difficult because sometimes there are atypical symptoms such as shortness of breath or extreme fatigue rather than the crushing chest pain that's often diagnosed in textbooks. However, the risk factors for both men and women are relatively similar. There's controllable risk factors such as cholesterol, blood pressure, the physical inactivity, being overweight or obese, the diabetes and smoking, and some uncontrollable risk factors such as age, heredity and race. Some of these can be modified though and these are the ones to focus on. There's also one of the big risk factors for heart diseases, the metabolic syndrome, which is related to body shape. The bad fat tends to be that central obesity with increased abdominal circumference, whereas a more pear shape is a better distribution of fat. When you compare men versus women, women do have excess risk from menopause, from hormonal changes, including birth control pills, especially in combination with smoking. And there is increased risk with diabetes, polycystic ovaries, and pregnancy induced hypertension for women. Women are also at higher risk for coronary heart disease if they also have blockage of carotid arteries, peripheral vascular circulation, problems with the legs, abdominal aneurysms, diabetes, or chronic kidney disease. As we said, the incidence of heart disease does increase in women as they get older. You can see the rate greatly goes up over age 65. So the best time to evaluate for risk factors and work on prevention are in these younger years when women are less than 65. When we think about the risk factors, perhaps the most important risk factor for coronary heart disease is this misperception that coronary heart disease is a man's disease. This misperception has led to great inequities in the treatment of women with coronary heart disease. What we've seen from many research studies is that there does seem to be a delay in care for women that present with chest pain, for instance. Women that present to an ER with chest pain are less likely to be triaged as an emergency. They tend to have a longer wait time. They're less likely to have an EKG placed, and this is all just compared to men who present with chest pain in the same cohort, less likely to be placed on a cardiac monitor, less likely to be seen by specialists and less likely to be admitted for observation. It's unknown why this is the case. Why are these disparities present between women and men who present with chest pain or with even a clear heart attack? It may be partly because the clinical presentation does vary. Women more often present with shortness of breath or weakness or an unusual fatigue, cold sweat, dizziness, lightheadedness, nausea, discomfort in the upper body and the arms feeling heavy or weak. The chest discomfort may be minimized by the clinicians that are seeing the patient if they just aren't thinking about coronary heart disease when a woman presents with these problems. So I wanted to talk through a case presentation. A 37 year old white female with diabetes for about six years presented to her family doctor. She had no other cardiovascular risk factors and was a non-smoker. July 7 presented to the family doctor with left sided shoulder pain for about three weeks. Pain got worse with walking or climbing stairs. The symptoms were felt to be thought to an inflamed shoulder at that time and ibuprofen was prescribed. Then July 11, the same patient comes to the emergency room. The left side shoulder pain had gotten worse. Also, the woman had increased shortness of breath when walking her dogs or doing any activities. She had the diagnosis of shoulder arthritis was given to her again and she was discharged home on the same day. Two days later, July 13, back to the emergency room, this time excruciating shoulder pain, shortness of breath and sweating and finally an EKG was done and revealed a myocardial infarction or heart attack. So the patient was sent then for emergency heart catheterization. So why the delay? Why does this tend to happen? Symptoms can be unusual in women. Silent myocardial infarction is more common in women versus men. Some of the diagnostic texts are a little less accurate. For instance, nuclear stress tests can have more false positives in women. And it's seen in many research studies that women are less likely to receive cardiac catheterization, which is the gold standard for diagnosing heart disease. Percutaneous coronary intervention or stents, thrombolytics as a form of treatment and also less likely to receive heart surgery. So what we see is that women, as we said, tend to present at an older age with myocardial infarction and tend to have a higher comorbidity rate, meaning they have more risk factors at the time they present. They also have a higher complication rate with the myocardial infarction and also with procedures that are performed. Therefore they have a higher mortality, longer hospitalization and higher readmission rate. But what we do see is that women benefit as much from these treatments as men do, yet they haven't been well studied in research as of this point in time. So recognition is key and more research is needed. So I like this cartoon because the doctor saying we have studies of fruit flies, mice, hamsters, frogs, monkeys and men with this condition. But medical research using women as subjects just never occurred to anybody. And that's often the case. We see large research studies which are done mostly on male subjects and this information is then attempted to be extrapolated to women, but we may not be the same as men. So how do we diagnose coronary heart disease? Cardiac catheterization is the gold standard. Here we see a left main, which looks okay. Left anterior descending looks reasonable, but the circumflex here has an acute ruptured plaque. And this is after percutaneous coronary intervention, better flow through the circumflex vessel. So as I said, cardiac catheterization also known as coronary arteriography or angiography is the gold standard. It defines that coronary anatomy and flow. How do we define a significant stenosis? That's going to be a left main like here. The left main is very tightly stenotic in that picture. Anything more than 50% stenotic is considered significant or more than 70% in any of the other vessels. And although we can see the anatomy well, it doesn't always distinguish between a stable plaque versus a vulnerable plaque that's going to cause myocardial infarction. And it's also not a reliable indicator of the functional significance of that stenosis. For this, we need a functional flow reserve or an FFR test, which is also done with catheters in the coronary vessels. Now, as the number of vessels disease increases, there is a worse survival, which correlates with those numbers of vessels disease. Normal coronary arteries, 90%, 91% 12 year survival in this cast registry. And it goes down one vessel disease, 74% to 40% for triple vessel disease. So it is the triple vessel disease that is is the main problem. Now coronary artery disease can be different in women. We see in men, a blockage of the coronary artery will tend to be vocally stenotic just one area, whereas blockage in a female coronary artery may exist up and down the vessel and the vessels may be smaller in caliber as well. So what about the diagnosis and treatment of disease in the US? As we said, cardiovascular disease is highly prevalent and coronary heart disease has a very high costly treatment rate. We have made a difference though in the number of deaths attributable to heart disease in the US. Over the last decade, there was a decline in deaths attributable to heart disease and this was likely partly epidemiologic changes in the population and changes in smoking rates, for instance, but also some element of improvement in therapeutics. So the therapeutics for advanced coronary disease are along two lines, generally coronary stents versus bypass surgery. And I wanted to go over a little bit about the stents which are placed in through small catheters inside the vessel, pushing the plaque to the sidewall versus bypass surgery, which actually goes entirely around the blockages and is done through largely through autonomies or open heart surgery. The trends in these cardiovascular procedures over time has been interesting. When cardiac catheterization and stenting first became popularized in the late 90s and early 2000s, the rates went the highest they've been and slowly declined over time. The blue curve is the cardiac catheterization. Green is the PTCA or percutaneous coronary intervention PCI rate, which did start to decline after the early 2000s to lower rates more recently. If you look at coronary artery bypass grafting in the red, when stenting became more popularized, coronary bypass grafting decreased. So bypass surgery was over 600,000 cases in the late 90s in the U.S. Now is down to around 400,000 cases, but has remained steady over the last few years. This use of advanced therapeutics between women and men. This is a big question, which I believe needs to be researched more extensively. There are definite disparities documented. Women are less likely to receive either revascularization with either stenting or cabbage. They're also less likely to receive some of the advanced therapeutics like multiple arterial grafts. Women tend to have a higher rate of comorbidities at diagnosis in an older age so it's unclear whether practitioners, doctors, surgeons decide that the female patient is not a candidate for some of these therapeutics, or whether there is some innate bias going on. There is certainly a difference in disease between males and females, as we discussed, and the complications do remain higher in women, but they need to be studied more extensively and we need to try to make some sense of why this is occurring. So what about the treatment with coronary stents? Here you see these are the tiny little mesh-like tubes that are placed inside the vessel. Once inside the proper position, a balloon is blown up in order to push the stent against the wall and push the plaque against the wall. You guys probably have already seen such images of a catheter being placed across the coronary blockage, balloon inflated, and then deflated again showing the stent in place. And here is a CAT scan showing the metallic nature of a stent in position. What about coronary artery bypass? This is the alternative with more advanced disease. Bypass surgery is recommended, especially with triple vessel disease. So here we see coronary artery bypass grafts performed with vein. I like this animation because it shows both the blockage. Here's a right coronary artery blockage and a vein bypass graft placed from the aorta to the coronary around that blockage to give better blood flow past the vessel. So the distal anastomosis is far out on the vessel, past all the blockage, and that gives better blood flow to the entire vessel. Whereas a stent would only be treating one place at a time. So what are the guidelines for using cabbage versus stents? These are guidelines from the ACC and AHA. Class one means that cabbage is recommended and is proven to be beneficial in unprotected left main coronary disease, triple vessel disease. And in two vessel disease, as long as the proximal LED also has disease. It's also reasonable with lesser coronary disease in certain circumstances. So why is cabbage given a class 1A for those indications versus stenting? The reason is with triple vessel disease or left main, there's a divergence of the survival curves with time. It increases the survival advantage and also freedom from need for repeat procedures, repeat revascularization. And it increases over time, these curves, verge as you get past a year, two years, three years, if you get to five or 10 years, those curves continue to diverge. So why is cabbage better than PCI? And the answer is anatomically. Atomically, most of that atherosclerosis atheroma is located in the proximal coronary arteries. So in cabbage, the graphs are to the mid coronary vessel. So you're treating the culprit lesion, regardless of the complexity of lesions, and it protects against future culprit lesions. So it's revascularizing that entire circulation. So if you look at a typical stent versus a typical cabbage case, remember, cabbage is for diffuse disease or for multi arterial disease. So a typical cabbage case is like this where you see disease up and down the vessels, whereas a typical PCI case would be just one lesion that's then going to be stented with that percutaneous coronary intervention. And the details about coronary artery bypass grafting was developed in the 60s. This was shortly after the cardiopulmonary bypass machine was developed. As you all here are here to discuss perfusion techniques today. You know, this revolutionized the treatment of coronary heart disease. Cabbage is the most commonly performed open heart operation. As we said, right now there's about 400,000 in the US yearly. The outcomes are excellent, both short and long term outcomes. The mortality is less than 3% and continues to decrease. So here we are performing open heart surgery. This is through a median sternotomy. And you can see, when you open the sternum and open the pericardium, the heart and the major structures are right under the sternum. We've got the ascending aorta, right atrium, right ventricle, pulmonary artery. The left ventricle is posterior. So what we do, most of you in the audience would have seen this or know this already, but it's interesting to see the pictures. We have two tubes, one into the ascending aorta, that's the aorta cannula, large one into the right atrium advancing into the inferior vena cava to drain the heart. And then we place cardioplesia cannula is a retrograde and an integrate in the ascending aorta. And then of course, you guys have seen this, the cardiopulmonary bypass machine is used. So we drain the blood from the patient's body oxygenate pump it back. This enables us to stop the heart in order to do bypass surgery. Traditional bypass is with the saponis vein removed from the leg and we reverse the vein to avoid the problem of the valves and so it to the vessel beyond the blockage. The big innovation though was the use of the internal mammary artery or internal thoracic artery, the left internal thoracic artery to the left anterior descending artery graft visualized here was a huge innovation to improving long term patency of the graphs to the heart and improving long term survival. Women are less likely to receive mammary grafts and less likely to receive multiple arterial grafts. Again, unknown why particularly bilateral internal mammary grafts, where both the right and left are used perhaps there is a concern among surgeons that women will have issues with wound healing with the breast tissue not getting enough blood flow after taking both of those arteries. It's unclear more research is needed. What about off pump cabbage off pump cabbage in the early 2000s was thought to be a huge innovation we were able to figure out how to do bypass surgery without using the heart loan machine. And for this, we use a stabilizer it's little suction cups that are placed right around the coronary artery, and then silastic tapes to control the blood flow in the artery. We still open these tiny vessels, and then perform bypass is to the vessels in the similar manner. Use of off pump peaked in the early 2000s at 24% in 2004, but has decreased since that time as more studies come out that there's minimal advantage to using off pump and greatly increased technical difficulty. The potential advantage could be in high risk cases, and possibly in women. Also in patients that have renal failure and for other anatomic considerations such as severe atherosclerosis or porcelain aorta calcified plaque in the ascending order where cross clamps and cannulas will not be feasible. Some of the benefits also may be reduced hospital stay and reduce blood transfusion. So here we are performing an off pump bypass you can see the the vessels are tiny, and the stabilizer is just pushing against the heart to keep that small area of heart stable while we try to do the graph. So why do we do coronary artery bypass crafting. I like showing this patients cardiac catheterization because what we have here is a problem. Here's a patient who had coronary disease developed about 10 years prior to this cardiac cat. Here you see the wires in place from bypass surgery. 10 years prior, and you see a problem when they inject the left main there is very little flow to the vessels of the heart this is not enough to sustain life. So what's the solution. Here's the graft left internal memory already to left anterior descending raft that is keeping that entire patients heart with reasonable cardiac blood flow. So that has saved the patient's life. So what treatment would you choose for left main or triple vessel coronary disease. I hope I've convinced you so far this is a no brainer. It's going to be coronary artery bypass crafting as the best long lasting solution for severe coronary heart disease, especially triple vessel and left main. So what we do at the Mike Lee to bake you via medical center where I work. We use a heart team concept. And this is commonly considered to be standard of care now we discourage just ad hoc PCI which means that patients on the table, and the cardiologist decides to throw a stenton. We try to allow time for the patient to digest the information regarding the treatment and then tailor the procedure to the patient and not the patient to the procedure. So, in looking at cabbage at the, at the VA and elsewhere in the country this is extensively tracked. The mortality is very low at this point in time. Every single cabbage is tracked by a database is STS database for most of the hospitals and the basket database for the VA. The public reporting of outcomes is is readily evident to that has helped improve transparency and quality of care for for bypass surgery. Now what should we do with the information that these reports have found poor outcomes in women, we have older age and more comorbidities and women at the time of surgery, worse complication rates and worse mortality. Even when the women are matched with the propensity matching or the multivariable analysis on some of these studies, the complications are higher in women. So, I believe strongly we have to study the effect of these therapeutics in women more widely. Women are less likely to receive not only the PCI or cabbage like we discussed, but they're less likely to receive valve surgery to have your surgical aortic replacements for aortic valve stenosis. They're less likely to receive advanced heart failure therapy such as ventricular assist device and heart transplant less likely to receive cardiac rehab after presenting with an MI or after cardiac surgery. They're less likely to be included in research protocols. And all of this is not even to mention how sex disparities affect the women working in the medical field such as in my field cardiac surgery. There are cardiac fields such as profusionists. There is a big disparity in how we are treated how we are paid. And this is something that we need to band together for as well. Getting back to how to beat heart disease. You have to choose heart health, eat healthy exercise. These are messages to get to our family and friends lose any excess weight. You know, make sure women know that they're just at risk for heart disease as men are. And we joke about the heart attack on the plate. And this is the type of food that we tend to eat as Americans, but we need to encourage each other to choose to eat more healthily. Also, choose to know your risk. Family and friends can find out on with online tools for the go read campaign from the American heart about their risk factors, their heart health and encourage the dialogue with their physicians. They can empower themselves by visiting the website learning the risk for heart disease and talking with their family and friends. I do think we in the medical profession need to work towards improving health care delivery for women. We need to look towards early modification of risk factors, early identification of disease. Making sure women get treated appropriately when they do present with cardiovascular disease. And we need to work on increasing the enrollment of women in research. These research studies are critical to know how to treat women in the future. The increased rates of complications and mortality in women versus men have got to be addressed and improved. So, in summary, the prevention of heart disease is crucial. Almost 50% of heart disease problems can be avoided by lifestyle changes. We can improve our health care diagnostics and therapeutics for coronary heart disease and women. And we can increase research on heart health in women. So I'd like to thank everyone for paying attention and coming today to this conference. I'd like to thank the veterans and our patients for allowing us the privilege, the great privilege of treating them. And I'd like to thank the heart team. Everyone have a great day. Thank you.