Bệnh tim mạch ở phụ nữ mãn kinh PGS nguyễn thị dung

BỆNH TIM MẠCH Ở PHỤ NỮ MÃN KINH PGS.TS.Nguyễn Thị Dung Bộ môn Nội – ĐHY Hải Phòng Chủ Tịch Hội Tim Mạch Hải Phòng Heart Disease The leading killer of women at all ages Although less frequent, CVD occurs in young women More than 35,000 women under the age of 65 die annually in the US from CVD Women and heart disease: What’s new ? Hormones in Men vs Women Estrogen • Critical to reproductive function in men & women • Most produced by ovaries • Some arises from fat, liver, breasts, adrenals • Complex physiologic effects Association Française pour l'Etude de la Ménopause Relationship between early menopause and accelerated CVD ? Traditional Paradigm: Menopause Minimal or no CVD Risk Increasing Risk of CVD Alternative Paradigm: Increasing Risk of CVD Menopause Définition de la ménopause ● Absence de règles depuis au moins 12 mois (au bout de mois déjà on peut se dire que…) L’âge moyen de la ménopause reste constant dans le monde : 50 51 ans ● Symptômes associés: sueurs, bouffées de chaleur, troubles de l’humeur…Intérêt limité des dosages hormonaux ● En 2004 en France 10 millions de femmes ménopausées 300 000 500 000 nouvelles femmes par an ● Espérance de vie des femmes : 83 ans (60 en 1900) ● Accompagner les femmes durant cette période pouvant durer …10 ans ● 50% de la population féminine française sera concernée dans 20 ans Les signes cliniques varient, d’une femme l’autre, d’un pays l’autre, d’une culture l’autre Séminaire femme 2008 Vers la fin du travail des ovaires… Ménopause Pré-ménopause ans Post-ménopause an Périménopause(52 ± năm) Quanh MK: Khoảng thời gian chuyển tiếp từ GĐ sinh sản sang GĐ sinh sản séminaire femme 2008 10 thiểu Estrogen progesteron) Women’s Health Initiative: Estrogen Only Study Age Group Risk of Coronary Heart Disease Risk of Stroke 50-59 37% reduction 11% reduction 60-69 6% reduction 62% increase 70-69 13% increase 21% increase Overall 9% reduction 39% increase Conclusion: In younger post-menopausal women post hysterectomy, estrogen alone may be beneficial Women’s Health Initiative: Estrogen Only Study 10,739 Postmenopausal women aged 50-79 with previous hysterectomy Estrogen Only Study stopped after mean follow-up of 6.8 years Placebo Estrogen replacement associated with: •9% reduction in heart disease •39% increase stroke •33% increase blood clots •No change in cancer •39% reduction hip fracture Source: JAMA 2007;297:1477 Women’s Health Initiative 16,608 Postmenopausal women aged 50-79 with an intact uterus Estrogen + Progesterone Study stopped after mean followup of 5.6 years Placebo Hormonal replacement associated with: •Increased heart disease (29% ↑) •Increased stroke (41% ↑) •Increased blood clots •Increased breast cancer (26% ↑) •Reduced colon cancer •Reduced hip fracture Conclusion: HRT should not be used to prevent disease in healthy postmenopausal women NIH What they found, somewhat surprisingly, is that while HRT did improve symptoms and reduce hip fractures due to osteoporosis, it actually did a bunch of bad things, including INCREASING the risk of heart disease, stroke, blood clots and cancer The conclusion was clearly that HRT should not be used to prevent cardiovascular disease Source: JAMA 2007;297:1477 Estrogen Replacement: The reality • Estrogen therapy is reasonable for the relief of perimenopausal symptoms if started early and tapered after a few years • Estrogen administered transdermally may be less likely to increase risk of blot clots • Estrogen should not be given to reduce CVD risk 2008 Association Française pour l'Etude de la Ménopause es XXIV Journées Les recommandations de l’AFEM (1) ● Le THM reste le traitement de référence des troubles cliniques de la ménopause, avec une information objective des bénéfices/risques pour la patiente ●Le risque relatif de cancers ne doit pas être un obstacle si cette prescription est justifiée ●Un antécédent personnel de cancer du sein est une contreindication ● En cas d’hystérectomie, œstrogènes seuls ● Pas de THM chez une patiente haut risque cardio vasculaire  ● N’est pas protecteur cardiovasculaire mais augmente l’incidence des thromboses veineuses 33 Séminaire femme 2008 Les recommandations de l’AFEM(2) Si on prescrit un traitement hormonal ● INFORMER les patientes ● Durée conseillée maximale de ans ● Dosage : la dose minimale efficace ● Avant de prescrire le traitement, rechercher :  Antécédents personnels et familiaux Examen clinique : TA, poids, Bilan cardio- vasculaire Palpation mammaire.examen gynécologique (seins, frottis)  Evaluation du risque cardio-vasculaire ● Information du sur-risque relatif de cancer du sein pour celles qui ont plus de 65 ans et prennent un traitement hormonal depuis plus de ans Séminaire femme 2008 Contre-indications       Cancer du sein de la patiente (connu ou suspecté) Cancers de l’endomètre connus ou suspectés Accidents thrombo-emboliques veineux évolutifs ou récidivants Accidents thrombo-emboliques artériels Affections hépatiques chroniques ou aigües (attendre normalisation des transaminases) Hémorragies génitales sans diagnostic établi séminaire femme 2008 35 Summary ● Heart Disease is the leading cause of death in women ● Most risk factors are the same for men and women, but women are at particularly high risk if they have diabetes mellitus Gender specific risks are menopause and intake of birth control pills while smoking ● Diagnosis of Heart Disease in women is very difficult since many women have atypical symptoms such as shortness of breath and extreme fatigue ● Prevention of heart disease is crucial ● Almost 50 % of heart disease problems can be avoided by lifestyle changes ● Ineffective interventions such as antioxidants and hormone replacement therapy should be avoided Women Making a Change Formes combinées séminaire femme 2008 38 Œstrogènes du THM séminaire femme 2008 39 Progestatifs et THS séminaire femme 2008 40 Perimenopause Mosca L et al Circulation 2004;109:672-693 and Circulation 2007; 115: 1481-1501 [...]... Metabolic Syndrome     Risk Factor, Disease, or Outcome Risk • Triglycerides  Diabetes Mellitus  • Obesity (BMI >30)*** Waist Circumference >35” –   ***Obesity ~25% of women - BMI >30, Less leisure-time physical activity - Greater functional decline - Adapted from Bellasi et al, New insights into ischemic heart disease in women cleveland clinic journal of medicine; 74: 585-594, 2004 WHI, Million... Signs of a Heart Attack • Weeks before Heart Attack (95% of women)      Unusual fatigue (70.7%) Sleep disturbance (47.8%) Shortness of breath (42.1%) Indigestion (39.4%) Chest pain (29.7 %) • At time of Heart Attack     Shortness of breath (57.9%) Weakness (54.8%) Fatigue (42.9%) Chest pain (57%) McSweeney, JC et al Circulation 2003; 2619-2623 Women have smaller coronary arteries • After correcting... 1999:164-167 Cardiovascular Disease Deaths: Trends for Males and Females United States: 1979-2001 Source: CDC/NCHS © AHA, 2004 AHA Guidelines for CVD Prevention in Women: Blood Pressure • Encourage an optimal blood pressure of