Women smokers face tougher odds than men after a heart attack

Women who smoke have heart attacks at younger ages and are more likely than men to suffer complications months after a cardiac event, according to a new University of Michigan Cardiovascular Center study.

Elizabeth Jackson, M.D., M.P.H., cardiologist at the University of Michigan Cardiovascular Center

Although fewer women than men smoke in the United States, the gender gap is decreasing and the U-M findings suggest the toll of smoking is greater on women’s health.

“Smoking is not good for men or women but our analysis shows that women who smoke do worse six months after a heart attack than men,” says senior study author Elizabeth Jackson, M.D., M.P.H., cardiologist at the U-M Cardiovascular Center. “We were not able to look at the basic biological mechanisms that would account for this, but other studies can give us some ideas.

“The ideologies of acute coronary syndrome may be different and the atherosclerotic burden greater for women,” Jackson says.

Smoking reduces circulation by narrowing the blood vessels and contributes to an atherosclerotic build-up of plaque in the arteries. Cigarette smokers are two to four times more likely to develop heart disease than non-smokers.

Jackson, a member of the U-M Women’s Heart Program team, and lead author Michael Howe, M.D., a cardiology fellow at the U-M Health System, conducted a study to examine smoking status of patients during and six months after an acute coronary syndrome event, such as a heart attack.

They used the U-M Health System’s acute coronary event registry which has data on 3,588 patients admitted to the U-M Medical Center from Jan. 1, 1999 to Dec. 31, 2006 with a diagnosis of ACS.

A reported 24 percent of patients were actively smoking. Male smokers were nine years younger than non-smoking men when admitted for their cardiac event. Women smokers were 13 years younger than non-smoking women when admitted.

Among smokers, gender was a significant factor for risk of complications after a heart attack. Six months after their cardiac event, 13.5 percent of female smokers needed emergency treatment to restore blood flow compared to 4.4 percent of male smokers who needed an unscheduled revascularization.

“The differences in outcomes among women smokers may reflect inherent biological differences between genders, or possibly less aggressive medical management of women that’s been described by other investigators,” Howe says. “Either way, it clearly emphasizes the need for increased physician awareness and vigilance, in women in particular, after an acute coronary event.”

The good news is that by quitting smoking, the risk of heart disease and stroke can be cut in half just one year later and continues to decline until it’s as low as a nonsmoker’s risk, according to the American Heart Association.

The gender differences study was published online ahead of print in the American Journal of Cardiology.

A Focus on Prevention, Early Detection During Breast Cancer Awareness Month

Washington, DC — Breast cancer consistently tops the list of health concerns for many women and fear of developing the disease can be a tremendous source of anxiety. Fortunately, preventive measures can reduce a woman’s risk of breast cancer and early detection can improve her chances of survival. During National Breast Cancer Awareness Month in October, The American College of Obstetricians and Gynecologists (The College) urges women to move beyond fear and into action by reducing personal breast cancer risk factors, having regular mammograms, and tuning in to breast changes that warrant further assessment.

Breast cancer remains the second leading cause of cancer death among women after lung cancer. In 2011, it is estimated that more than 230,000 women will be diagnosed with breast cancer and more than 39,000 women will die from it. While these figures are alarming, there is much good news.

“There’s still a lot more to be done in the fight against breast cancer, but we have come a long way,” said James N. Martin, Jr, MD, president of The College. “Advances in early detection and improved treatments have led to a steady decrease in breast cancer-related deaths since the 1990s. The 2.5 million breast cancer survivors in the US serve as proof that more women are beating breast cancer than ever before. Women diagnosed with breast cancer also have a wider variety of breast-conserving treatments and reconstruction options to consider. And an increasing body of research suggests that women can make a difference in preventing or detecting cancer early.”

Being a woman and getting older are the two main, non-modifiable risk factors for breast cancer. Family history, personal history of certain cancers, no pregnancies or first pregnancy later in life, beginning menstrual periods before age 12 or menopause after age 55, obesity, heavy alcohol intake (defined as more than seven drinks per week), and use of some types of hormone therapy can also increase a woman’s risk. A woman’s individual risk factors can help guide her efforts in preventing cancer.

“There’s a reason why so many doctors preach the gospel of living a healthy lifestyle. In addition to lowering the risk of breast cancer, it can have a significant impact on a woman’s risk for many cancers and other illnesses, such as diabetes and heart disease,” Dr. Martin said. The American Institute for Cancer Research estimates that almost 40 percent of the breast cancer cases in the US—about 70,000 cases a year—could be prevented if women maintained a healthy weight, exercised, and limited the amount of alcohol they drink. Getting 30-90 minutes of exercise on most days, consuming a well-balanced diet, and drinking less than one alcoholic drink per day is a great start for most women.

Women should also take family history into account. Roughly 20 percent of women with breast cancer have close relatives such as siblings, parents, or grandparents who have also had the disease. Women with a strong family history should talk to their doctor about interventions such as beginning mammography before age 40 and prophylactic medication therapy or surgery to reduce their risk.

In some instances, women who’ve done everything that they can to avoid breast cancer still develop the disease. This is why regular mammography screening is so critical. “We know that mammograms are central to early detection in all women, regardless of risk factors,” Dr. Martin said. Mammograms can detect changes in the breast as small as a pinhead, often one to two years earlier than when a lump can be felt and before the cancer has spread to other parts of the body. The five-year survival rate for cancer caught at this stage is 98 percent, a compelling reason to get screened. The College recommends that women 40 and older be offered annual mammograms. Clinical breast exams performed by a physician are also recommended yearly for women 40 and over and every one to three years among women ages 20-39.

Nearly one half of all cases of breast cancer in women 50 years and older and more than 70% of cases in women younger than 50 years are discovered by women themselves, frequently unintentionally. Instead of traditional breast self-exams, The College now recommends that women develop breast self-awareness, meaning that they become more familiar with what’s normal for their breasts and better able to detect changes. Women who experience changes such as lumps in the breast or underarm, dimpling, breast pain, redness or thickening of the nipple or breast skin, or anything else that looks or feels different should quickly report them to their doctor.

“Awareness of and commitment to doing what’s best for your body can make a big difference in your health,” Dr. Martin said. “Do what you can to reduce your risk, because your actions do make a difference.”

To learn more about taking control of your breast health, The College’s “Spotlight on Breast Cancer” is available online.

NHS told to improve care of pregnant women carrying twins or triplets

The NHS has been told to improve its care of pregnant women carrying twins or triplets in order to reduce the significant medical risks involved for both mothers-to-be and their babies.

The National Institute for Health and Clinical Excellence, which sets standards for the NHS, has issued its first guidance on how health professionals should manage multiple births after discovering wide variations in the quality of care provided by different parts of the NHS.

Improvements and new procedures are needed in order to give women who conceive twins or triplets better and more consistent care, minimise the number of unnecessary caesarean deliveries among them and reduce the number of twins and triplets who require specialist care at birth.

About 11,000 women a year in England and Wales give birth to twins, triplets or, more rarely, four babies or more simultaneously. Multiple births account for 3% of the 700,000 live births a year.

The number of women giving birth to two or more babies at the same time rose from 10 per 1,000 in 1980 to 16 per 1,000 in 2009, mainly due to the increased use of assisted reproduction, especially IVF.

Mothers with a multiple pregnancy need specialist care in order to safeguard against the many problems and complications that can affect the mother or babies.

While many women carrying twins or triplets will experience a straightforward pregnancy, such patients are known to be at much greater risk of miscarriage, anaemia, hypertension, vaginal bleeding, premature birth and needing an assisted delivery or caesarean.

For example, while 4.8 per 1,000 of every pregnancy involving a single child end in stillbirth, 11.2 per 1,000 of those involving twins end in stillbirth, as do 27.9 per 1,000 of those involving triplets.

Babies of multiple births, meanwhile, are similarly at higher risk of poor outcomes including being born prematurely, having a low birthweight, admission to a neonatal intensive care unit, congenital malformations, cerebral palsy and impaired physical and cognitive development.

In its guidance released on Wednesday, Nice recommends that all women having an uncomplicated twin or triplet pregnancy should be cared for by a multidisciplinary team of medical experts who are experienced in such pregnancies, including obstetricians, midwives and ultrasonographers as well as a mental health professional, infant feeding specialist, dietitian and women’s health physiotherapist.

They should also undergo a risk assessment before the birth to establish whether the babies are identical siblings, where they come from the same egg and share one placenta, or have a placenta each, and undergo careful management from then on.

Identical siblings in utero involve a much higher risk of stillbirth, foetal complications and a condition called twin to twin transfusion syndrome.

Woman carrying multiple foetuses should also be given ultrasound scans in the first three months, more antenatal visits and monitoring of their babies for signs of intrauterine growth restriction after they are 20 weeks’ pregnant.

“We know there is a real clinical need for this guideline because NHS antenatal care for women expecting twins or triplets appears to vary considerably across England and Wales”, said Dr Fergus Macbeth, the director of Nice’s centre for clinical practice.

“For example, not all women with multiple pregnancies are cared for in dedicated settings such as ‘twin clinics’ or by multidisciplinary teams of healthcare professionals. This can lead to higher than necessary rates of assisted birth and caesarean sections and also means that women are not appropriately assessed for possible risks during pregnancy.”

Macbeth added: “Although many women will have a normal pregnancy and birth, it is well known that there are higher risks involved for these types of pregnancy and so it is important to get it right. We hope this guideline will set the standard of high-quality care, which should be provided to all women pregnant with twins or triplets.

“Implementing these clear recommendations will help women to feel supported and well looked after at a time when they can be feeling anxious.”

Keith Reed, chief executive of the charity Twins and Multiple Births Association (Tamba), said: “Sadly the care some expectant multiple birth mothers currently receive does not meet their needs. These important guidelines are a landmark in the antenatal care of multiples.

“They will undoubtedly produce better clinical outcomes as well as reducing anxiety for those women who have been told their pregnancies are ‘high risk’.”

Jane Denton, director of the Multiple Births Foundation, said the new standards would “transform” care.

“The news of a twin or triplet pregnancy is often a great shock for parents and the risk of complications during the pregnancy and preterm birth, as well as the practical and financial implications for the family, can cause great anxiety.

“Although much of the care at present is very good, there are many inconsistencies … these recommendations address all of these concerns and will give mothers confidence that they are receiving the highest standard of care.