Provider Update
Volume 17, Issue 4
August 2000
Federal Government to Finalize HIPAA Rules
Rules for the Health Insurance Portability and Accountability Act of 1996 - better known as HIPAA - will soon be finalized by
the federal government. This Act encompasses rules developed by the Department of Health and Human Services (HHS) regarding the following
issues:
� Allowing employees to keep their health insurance when they change jobs;
� Establishing national electronic transaction standards governing the security and confidentiality of all electronic health
data;
� Requiring all providers, health insurers, and claims clearinghouses to use national transaction formats and data sets if they electronically transmit data.
Examples of these standardized transaction formats include, but are not limited to, claims transactions, eligibility inquiries, and payment registers/remittance advices. The standard data sets include, but are not limited to, procedure codes, denial codes/error messages, and diagnosis codes.
The final rules developed by HHS for standardized claims transactions and data sets were scheduled to be released by June 30, 2000. The release of transaction and data set rules has been delayed to allow states additional time to submit local codes to the committee for review and approval. Draft versions have been carefully reviewed and the content of transaction and data set rules are clear. However, the privacy and security rules have not been issued. All rules will become effective 26 months after publication in the Federal Register.
Although the final rules have not been released at this time and will not become effective until two years after their release, we want to ensure that providers are aware of this new requirement and that they begin evaluating their systems to guarantee compliance with federal guidelines.
Contact your software vendor to determine what modifications are necessary to ensure your system is compliant with HIPAA's electronic transaction standards. Providers who prefer not to modify their systems may contract with clearinghouses that are HIPAA-compliant to transmit their transactions.
Please familiarize yourself with HIPAA, the specific requirements of each rule and how it will affect you. This information is available on the HCFA website(http://www.hcfa.gov/medicaid/hipaa). This should be done as soon as possible. Please watch for continuing newsletter articles concerning HIPAA compliance in the next several issues of the Provider Update.
Year 2000 CPT Codes May Be Billed
The Year 2000 CPT codes are loaded and may be billed effective for dates of service January 1, 2000 and after.
Code 33140 (Transmyocardial laser revascularization, by thoracotomy) is payable for crossovers only. It may be made payable for Medicaid only claims at a later
date.
Codes 58672 (Laparoscopy, surgical; with fimbrioplasty) and 58673 (Laparoscopy, surgical; with salpingostomy) are payable for only crossovers as these two procedures are associated with the treatment of infertility problems. The Medicaid Program does not cover infertility
procedures.
Some of the codes used in billing for maternity-related anesthesia were deleted and replaced by new codes. You may use these new codes in billing for maternity-related anesthesia effective for dates of service January 1, 2000 and after. The reimbursement amounts did not change. These codes are as follows:
Old Code |
New Code |
62276 |
62318 |
62278 |
62311 |
62279 |
62319 |
Reimbursement for the following codes is limited to 1 per 180 days UNLESS given for reasons OTHER THAN pain control, pain management or the alleviation of chronic pain:
62280 |
64400 |
64415 |
64435 |
64479 |
64520 |
62281 |
64402 |
64417 |
64445 |
64480 |
64530 |
62282 |
64405 |
64418 |
64450 |
64483 |
|
62310 |
64408 |
64420 |
64470 |
64484 |
|
62311 |
64410 |
64421 |
64472 |
64505 |
|
62318 |
64412 |
64425 |
64475 |
64508 |
|
62319 |
64413 |
64430 |
64476 |
64510 |
|
Codes 62274, 62277, 62278, 62279 and 62289 were deleted from the list of codes for which anesthesiologists and CRNAs are paid a flat fee. Added to this list are codes 62310, 62311 and
62319.
Reimbursement for procedure code 77427 (Radiation treatment management, five treatments) is driven by the number placed in the Units column on the HCFA 1500. For example, if the course of therapy totaled 14 treatments, place 14 in the Units column. If the course of therapy totaled 7 treatments, place 7 in the Units column. If the course of therapy consists of only one or two treatments, bill code 77431 rather than code 77427. The fee for each treatment is
$31.28.
Code 90378 (Respiratory Syncytial virus immune globulin) is reimbursed through the Pharmacy Program. Therefore, it is not payable through the Physician
Program.
Code 99173 (Screening test for visual acuity, quantitative, bilateral) is reimbursed via X9007 (Vision Screening) code in the EPSDT Program.
The fees paid for the 2000 codes for dates of service January 1, 2000 through January 31, 2000 will be 7% higher than those paid for dates of services February 1, 2000 through June 30, 2000. Effective July 1, 2000, the fees for all codes previously reduced by 7% are restored. The exceptions will be as follows:
99212 - $30.13 |
99214 - $41.13 |
Z9005 - $33.43 |
99213 - $36.13 |
99215 - $49.63 |
99283 - $35.23 |
If questions arise, please call Kandis Whittington at (225)-342-9490, Tracey Zimmerman at (225)-342-9391 or Ida Duncan at (225)-342-3932.
Electrical Cardioversion
(FIMS# 6063
RA Message 8/1/2000 and 8/8/2000)
Effective for dates of service July 1, 2000 and after, Anesthesia for CPT code 92960 (Electrical Cardioversion) is payable. Claims for CPT code 92960 should be submitted with an Anesthesia Case Unit of 04.
CPT Codes in Non-Pay Status
(FIMS # 6065
RA Message 8/1/2000 and 8/8/2000)
The CPT codes which were discontinued in the Year 2000 issuance of the Current Procedural Terminology will be placed in non-pay status on our files effective for date of service August 15, 2000. Please program your systems accordingly.
Codes Removed from Global Surgery Period Edits
(FIMS # 6003
RA Message 7/11/2000, 7/18/2000)
Chemotherapy Administration Codes 96405, 96406, 96440, 96445, and 96450 were removed from the Global Surgery Period edits effective for dates of service May 1, 2000.
CPT Codes Discontinued
Effective January 1, 2000 CPT procedure code 90744 (Hepatitis Vaccine, ages 11-19) was discontinued. The following procedure codes should be used to bill for hepatitis vaccines with the corresponding ages.
Procedure code 90744 (Hepatitis Vaccine, Pediatric/Adolescent dosage) for recipients 0-19 years of age and procedure code 90746 (Hepatitis Vaccine, Adult dosage) for recipients age 20-21.
DHH Announces Emergency Rules
* Restored back to original date of emergency rules through June 30, 2000
The following emergency rules are effect for dates of service on or after July 1,
2000:
1. Early Periodic Screening Diagnosis and Treatment (EPSDT) KIDMED Services: removes the seven percent (7%) reduction previously made to the reimbursement fees for EPSDT KIDMED
services.
2. Early Periodic Screening Diagnosis and Treatment (EPSDT) Rehabilitation Services: restores the seven percent (7%) reduction previously made to the reimbursement fees for EPSDT rehabilitation
services.
3. Emergency Ambulance Services: removes the seven percent (7%) reduction previously made to the base rate for emergency ambulance
services.
4. Laboratory and Portable X-Ray Services: restores the seven percent (7%) reduction previously made to the reimbursement fees for laboratory and portable x-ray
services.
5. Rehabilitation Centers Services: removes the seven percent (7%) reduction previously made to the reimbursement fees for services provided in rehabilitation
centers.
6. Physician Services: restores the seven percent (7%) reduction previously made to the reimbursement fees for surgery, medicine, evaluation and management, radiology, pathology, and laboratory codes, as well as selected locally-assigned
HCPCs.
7. Early Periodic Screening Diagnosis and Treatment (EPSDT) Dental Services: restores the seven percent (7%) reduction previously made to the reimbursement fees for EPSDT dental services.
8. Mental Health Rehabilitation Services: restores the seven percent (7%) reduction previously made to the reimbursement rates for high need services for adults and children as well as moderate need services for
children.
9. Home Health - Extended Skilled Nursing: increases the reimbursement rate for extended skilled nursing services provided to medically fragile recipients under the age of 21 to $24.50 per
hour.
10. Non-emergency Ambulance Services: restores the base rate for non-emergency ambulance services to the rate that was in effect July 1,
1999.
11. Case Management: restores the seven percent (7%) reduction previously made to the reimbursement rates for Infants and Toddlers, Elderly and Disabled Adult Waiver, HIV, and High Risk Pregnant Women case management
services.
12. Family Planning Clinics: restores the seven percent (7%) reduction previously made to the reimbursement rates for family planning
services.
PUBLIC PROCESS NOTICES:
1. Inpatient Psychiatric Services: restores the seven percent (7%) reduction previously made to the per diem rates for inpatient psychiatric
services.
2. Long Term Hospitals: restores the seven percent (7%) reduction previously made to the per diem rates for long term
hospitals.
3. Private ICFs-MR: restores the seven percent (7%) reduction previously made to the per diem rates for private
ICFs/MR.
4. Private Nursing Facilities: restores the seven percent (7%) reduction previously made to the per diem rates for private nursing
facilities.
5. Outpatient Hospital Rehabilitation Services: restores the seven percent (7%) reduction previously made to the reimbursement rates for outpatient hospital rehabilitation services.
6. Private Hospitals: restores the seven percent (7%) reduction previously made to the per diem rates for private
hospitals.
7. Outpatient Laboratory: restores the seven percent (7%) reduction previously made to outpatient hospital laboratory services.
2000 Unisys Provider Workshops
The focus of the annual Unisys Provider Workshops is to present vital policy and billing information to our Medicaid provider community. Our intent is to create a neutral atmosphere for delivery of the educational materials to the providers in attendance. Due to continuing litigation, provider inquiries regarding the Department's recent spending reduction plan should be addressed to the appropriate Medicaid staff person at his/her office. Contacts and telephone numbers will be available following the
workshops.
Our training format separates basic information from specific program information. The
Basic Medicaid information workshops will cover general Medicaid policy such as standards for participation, recipient eligibility and ID cards, Community Care, third party liability, how to obtain assistance from Unisys, etc.
This information will be presented ONLY in the Basic sessions and will not be repeated in specific program workshops.
All Basic workshop sessions will be identical in content. Providers may choose to attend any of the basic sessions in addition to their specific program, or they may choose to attend only the specific program session for their provider
type.
In each specific program workshop, Unisys staff will discuss recent policy or procedure changes for that specific Medicaid program and will address frequent claim denial causes and solutions.
Community Care policy and procedures will be discussed in the following workshops: Basic, Professional, KIDMED, RHC/FQHC, and
Hospital.
A new Eligibility workshop geared toward the new LaCHIP eligibility category and EPSDT services availability and access is being offered this year. Anyone who services EPSDT recipients is encouraged to
attend.
Hospital training and precertification training are being held as separate sessions this year. Personnel from the Utilization Review Department of each hospital and those involved in precertification for inpatient admissions, including hospital case managers who do precertification, should attend the Precertification workshop which will address precertification. The Basic Hospital workshop will focus on hospital policy in general and on billing policies and
procedures.
Pharmacy training will not be held with these workshops this year. Pharmacy providers will be notified of other arrangements for training as that information becomes available. However, pharmacy providers who also provide services through the DME program may wish to attend the DME
workshop.
Due to space limitations, only personnel involved in billing should attend (with the exception of the precertification workshop). Attendees should arrive 15 - 20 minutes early to register.
REMEMBER,
� Each person MUST have his or her provider name and Medicaid provider ID number in order to register and
attend
� Providers are required to have a valid Medicaid provider ID number for each specific program workshop
attended.
Medicaid Programs for discussion at the workshops include:
1. Basic Medicaid Information: All providers may attend. Basic Medicaid information will be presented, including standards for participation, recipient eligibility and ID cards, Community Care, third party liability, remittance advice review, how to obtain assistance from Unisys, Provider Relations information, common generic denial reasons and methods of correction, etc. This information will not be repeated in any of the specific program workshops listed
below.
2. Eligibility: All providers may attend.
3. Professional: Physicians, Labs, Optometrists, Chiropractors, Ambulatory Surgery Centers, Optical Suppliers, Nurse Practitioners, Audiologists, Nurse Midwives, CRNAs, Hemodialysis (supervision ONLY), and Mental Health
Clinics.
4. Hospital: Acute, Rehabilitation, Long Term, Free-standing Psych, and Distinct Part Psych hospitals. Hospital policy and billing issues will be
presented.
5. Precertification: Hospital Utilization Review or other personnel involved in obtaining precertification. Precertification workshops will include policy and procedures specific to precertification (not
billing).
6. Long Term Care: Nursing and ICF/MR Facilities and Hospice
Services.
7. Mental Health Rehabilitation Agencies: Workshops will be held in Alexandria, New Orleans, Ruston, and Lafayette
ONLY.
8. Home Health Agencies and Free-standing Rehabilitation Centers:
Home Health providers who are also DME providers should attend both the Home Health and DME
sessions.
9. Durable Medical Equipment (DME) Suppliers: Pharmacists who also provide services through the DME program providers may wish to attend this
workshop.
10. Dental: EPSDT and Adult and Oral Surgery. Dental training will be offered ONLY in New Orleans and ONLY in conjunction with the 51st Annual New Orleans Dental
Conference.
11. Ambulance Transportation: Ambulance providers only--does not include non-emergency non-ambulance
transportation.
12. Non-emergency Medical Transportation: Non-emergency non-ambulance providers only--does not include ambulance
transportation.
13. EPSDT: EPSDT Health Services (school boards and Early Intervention Centers
ONLY).
14. Federally Qualified Health Centers and Rural Health
Clinics
15. KIDMED
16. Case Management: Contract case management providers and targeted case management providers. Waiver providers may also attend this session for informational purposes.
This session will be held in New Orleans, Ruston, and Lafayette ONLY. THIS SESSION IS NOT FOR HOSPITAL CASE
MANAGERS.
17. Waiver: PCA and Elderly waiver providers, EPSDT PCS providers and Adult Day Health Center providers should attend. Case management providers (this does not include hospital case managers) may also attend this session for informational purposes.
This session will be held in New Orleans, Ruston, and Lafayette ONLY. MR/DD Waiver training is being conducted separately by the DHH Division of Home and Community Based Waiver
Services.
Please refer to the following list for dates (Day 1 and Day 2) and times at each workshop location.
Note that there may be more than one session held at the same time. There is no pre-registration required. Please direct any questions concerning the workshops to Unisys Provider Relations at 800/473-2783 or 504/924-5040. Meeting sites should be contacted for directions or sleeping accommodations ONLY!
DO NOT contact the meeting sites with questions related to the workshops!
2000 Unisys Provider Workshop Schedule
CITY
|
DAY, DATE, TIME, AND SESSION
|
|
Baton Rouge
|
Tuesday, September 12
|
Wednesday, September 13
|
Room Name
|
Auditorium
|
Classroom 3
|
Main Auditorium
|
Classroom 3
|
LA
State Police Training Academy
7901
Independence Blvd. Baton Rouge, LA
|
Basic � 8:30 � 10:30
Eligibility � 11:00 � 12:30
Professional
� 1:30 � 3:30
KIDMED
� 3:45 � 5:15
|
EPSDT � 8:30 � 9:30
Hospital � 10:00 � 12:00
Precert � 12:15 � 2:15
Basic � 2:45 � 4:45
|
Basic � 8:30 � 10:30
Eligibility � 10:45 � 12:15
Basic � 1:00 � 3:00
DME � 3:30 � 5:00
|
RHC/FQHC � 8:30 � 9:30
LTC � 10:00 �11:00
Home Health/Rehab �11:30 � 1:30
Ambulance � 2:00 � 3:30
NEMT � 4:00 � 5:00
|
Slidell
|
Thursday, September 14
|
|
Room Name
|
John Wesley Center
|
Genesis Hall
|
Aldersgate
United Methodist Church
360
Robert Blvd.
Slidell,
LA
|
Basic � 8:30 � 10:30
Eligibility � 11:00 � 12:30
Professional� 1:30 � 3:30
|
Hospital� 1:00 � 3:00
Precert� 3:00 � 5:00
|
Alexandria
|
Tuesday, September 19
|
Wednesday, September 20
|
Thursday, September 21
|
Room Name
|
Claiborne
|
Livingston
|
Claiborne
|
Livingston
|
Claiborne
|
Hotel
Bentley
200
DeSoto
Alexandria,
LA
|
Basic � 8:30 � 10:30
Eligibility � 10:45 � 12:15
Professional � 1:30 � 3:30
KIDMED � 4:00 �5:30
|
EPSDT � 8:30 � 9:30
Hospital � 10:00 � 12:00
Precert � 12:15 � 2:15
Basic � 2:45 � 4:45
|
Basic � 8:30 � 10:30
Eligibility � 10:45 � 12:15
Basic � 1:00 � 3:00
MHR � 3:30 � 4:30
|
RHC/FQHC � 8:30 � 9:30
LTC � 10:00 � 11:00
Home Health/Rehab �1:00 � 3:00
DME � 3:30 � 5:00
|
Basic � 8:30 � 10:30
Eligibility � 10:45 � 12:15
Ambulance � 1:00 � 2:30
NEMT � 3:00 � 4:00
|
Houma
|
Tuesday, September 26
|
|
Room Name
|
Ballroom
|
Ramada
Inn
1400
W. Tunnel Blvd.
Houma,
LA
|
Basic � 8:00 � 10:00
Eligibility� 10:15 � 11:45
Professional� 12:00 � 1:45
Hospital� 2:00 � 3:30
Precert�
3:30 � 5:00
|
New Orleans
|
Wednesday, September 27
|
Thursday, September 28
|
Friday, September 29
|
Room Name
|
Pontchartrain B
|
Rivertown
|
Rivertown
|
Rivertown
|
Rivertown
|
Rivertown
|
Pontchartrain
Center
4545
Williams Blvd.
Kenner,
LA
|
Basic � 8:30 � 10:30
Eligibility � 11:00 � 12:30
Professional � 1:30 � 3:30
KIDMED � 4:00 �5:30
|
EPSDT � 8:30 � 9:30
Hospital � 10:00 � 12:00
Precert � 12:15 � 2:15
Basic � 2:45 � 4:45
|
Basic � 8:30 � 10:30
Eligibility � 11:00 � 12:30
Basic � 1:00 � 3:00
MHR � 3:30 � 4:30
|
RHC/FQHC � 8:30 � 9:30
LTC � 10:00 � 11:00
Home Health/Rehab �1:00 � 3:00
DME � 3:30 � 5:00
|
Basic � 8:30 � 10:30
Eligibility � 11:00 � 12:30
Basic � 1:30 � 3:30
|
Case Management� 8:30 � 9:30
Waiver � 10:00 � 11:30
Ambulance � 12:30 � 2:00
NEMT � 2:30 � 3:30
|
|
|
|
|
|
|
|
|
|
New Orleans
|
Friday, September 29
|
|
Ernest
Morial Convention Center
900 Convention Center Blvd.
New
Orleans, LA
|
Dental � 8:30 � 11:00
|
The
only dental training session offered this year will be held in
conjunction with the 51st Annual New Orleans Dental Conference.
|
Monroe
|
Monday, October 2
|
Tuesday, October 3
|
Room Name
|
Bonaparte/Jackson
|
New Orleans
|
Bonaparte/Jackson
|
New Orleans
|
Holiday
Inn Holidome
1051
US Hwy. 165 Bypass at
I-20
Monroe,
LA
|
Basic - 8:30 � 10:30
Eligibility � 10:45 � 12:15
Professional � 1:30 � 3:30
KIDMED � 3:45 � 5:15
|
EPSDT � 8:30 � 9:30
Hospital � 10:00 � 12:00
Precert � 12:15 � 2:15
Basic � 2:45 � 4:45
|
Basic � 8:30 � 10:30
Eligibility � 10:45 � 12:15
Basic � 1:15 � 3:15
DME � 3:30 � 5:00
|
RHC/FQHC � 8:00 � 9:00
LTC � 9:30 �10:30
Home Health/Rehab �11:00 � 1:00
Ambulance � 1:30 � 3:00
NEMT � 3:30 � 4:30
|
Ruston
|
Wednesday, October 4
|
|
Room Name
|
222-223
|
224
|
LA
Tech University Student Center
Wisteria
Dr. (on campus)
Ruston,
LA
|
Basic � 8:30 � 10:30
Eligibility� 10:45 � 12:15
Ambulance � 1:00 � 2:30
NEMT � 2:45 � 3:45
RHC/FQHC � 4:00 � 5:00
|
MHR � 12:30 � 1:30
Case Management� 2:00 � 3:00
Waiver� 3:30 � 5:00
|
|
|
|
|
|
|
Shreveport
|
Thursday, October 5
|
Friday, October 6
|
Room Name
|
Pavilion 3
|
Pavilion 4
|
Pavilion 3
|
Pavilion 4
|
Holiday
Inn
102
Lake St.
Shreveport,
LA
|
Basic � 8:30 � 10:30
Eligibility � 10:45 � 12:15
Professional � 1:30 � 3:30
KIDMED � 3:45 � 5:15
|
EPSDT � 8:30 � 9:30
Hospital � 10:00 � 12:00
Precert � 12:15 � 2:15
Basic � 2:45 � 4:45
|
Basic � 8:30 � 10:30
Eligibility � 10:45 � 12:15
Basic � 1:00 � 3:00
DME � 3:30 � 5:00
|
RHC/FQHC � 8:00 � 9:00
LTC � 9:30 � 10:30
Home Health/Rehab �11:00 � 1:00
Ambulance � 1:30 � 3:00
NEMT � 3:30 � 4:30
|
Lafayette
|
Tuesday, October 17
|
Wednesday, October 18
|
Thursday, October 19
|
Room Name
|
Acadia/Iberia
|
Scandals
|
The Courtyard
|
St. Mary/St. Martin
|
The Courtyard
|
St. Mary/St. Martin
|
Hotel
Acadiana
1801
W. Pinhook Rd.
Lafayette,
LA
|
Basic � 8:30 � 10:30
Eligibility � 11:00 � 12:30
Professional � 1:30 � 3:30
KIDMED � 4:00 �5:30
|
EPSDT � 8:30 � 9:30
Hospital � 10:00 � 12:00
Precert � 12:15 � 2:15
Basic � 2:45 � 4:45
|
Basic � 8:30 � 10:30
Eligibility � 11:00 � 12:30
Basic � 1:30 � 3:30
MHR � 4:00 � 5:00
|
RHC/FQHC � 8:30 � 9:30
LTC � 10:00 � 11:00
Home Health/Rehab �1:00 � 3:00
DME � 3:30 � 5:00
|
Basic � 8:30 � 10:30
Eligibility � 11:00 � 12:30
Basic � 1:30 � 3:30
|
Case Management � 8:30 � 9:30
Waiver � 10:00 � 11:30
Ambulance � 12:30 � 2:00
NEMT � 2:30 � 3:30
|
Lake Charles
|
Tuesday, October 24
|
Wednesday, October 25
|
Room Name
|
Exhibition Hall
|
Exhibition Hall
|
Exhibition Hall
|
Exhibition Hall
|
Lake
Charles Civic Center � Exhibition Hall (first floor)
900
Lakeshore Dr.
Lake
Charles, LA
|
Basic � 8:30 � 10:30
Eligibility � 11:00 � 12:30
Professional � 1:30 � 3:30
KIDMED � 3:45 � 5:15
|
EPSDT � 8:30 � 9:30
Hospital � 10:00 � 12:00
Precert � 12:15 � 2:15
Basic � 2:45 � 4:45
|
Basic � 8:30 � 10:30
Eligibility � 11:00 � 12:30
Basic � 1:00 � 3:00
DME � 3:30 � 5:00
|
RHC/FQHC � 8:00 � 9:00
LTC � 9:30 � 10:30
Home Health/Rehab �11:00 � 1:00
Ambulance � 1:30 � 3:00
NEMT � 3:30 � 4:30
|
|
|
|
|
|
|
|
|
|
Louisiana Drug Utilization Review (LADUR) Education
Cardiovascular Disease in Women
By: J. Christopher Lynch, Pharm.D. University of Louisiana at Monroe College of Pharmacy
Issues...
� Appropriate coronary artery disease prevention and treatment in women is
needed.
� There are numerous misconceptions about coronary risk in
women.
� Women and men differ in the initial presentation and progression of coronary disease.
Introduction
Coronary artery disease (CAD) is the number one killer of postmenopausal
women1. Unfortunately, misconceptions regarding women's coronary risk abound among both health care professionals and lay people. The purpose of this review is to reinforce the need for appropriate coronary artery disease prevention and treatment in women through the clinical application of available
research.
Background
Despite an overall decrease in cardiovascular mortality in the United States, this decrease is less in women than in men, and markedly less in African-American
women2. With the aging of the population, the incidence of CAD in women becomes greater with each generation. In 1994, cardiovascular disease was responsible for 45% of all deaths in women, and it is estimated that 1 in 2 women will die from heart disease or stroke by the end of the century. To put this into perspective, an average woman is 12-13 times more likely to die from CAD than from breast cancer, a disease often listed as a woman's number one perceived health
risk2.
Women differ from men in the initial presentation and progression of coronary disease. Women typically experience onset of CAD about 10 years later than men; however this delay of onset often disappears if the woman also has diabetes or renal disease. A first myocardial infarction (M.I.) typically occurs approximately 20 years later in a woman than in a man, but it is more likely to be fatal; and women exhibit more atypical symptoms of an MI, including neck pain, shoulder pain or nausea and
vomiting3. Also, chest pain in women is less predictive of heart disease than in men; while more women experience chest pain, fewer exhibit evidence of coronary disease upon further testing. The age differences in the onset and progression of CAD in men and women may also be due to the benefit women gain from the effects of estrogen, which will be discussed separately.
The major determinants of CAD in women are age and menopausal status. Other strong risk factors include cigarette smoking, hypertension, hyperlipidemia, diabetes, obesity and sedentary lifestyle. Postmenopausal women are more likely than their male counterparts to have several of these risks, including hyperlipidemia, hypertension, obesity and
diabetes4. Incidences of these risks vary with racial groups, with African-American women carrying a disproportionately high burden of all of these major risk factors. African-American women are also less likely to be treated appropriately for many of these
risks.
Hypertension
Women share the cardiovascular risk of hypertension with men, but the lack of adequate treatment of the disease may be of particular concern to women. Among adult women in the United States, it is estimated that 60% of white women and 79% of black women have
hypertension5. Other data suggest that men and women are both heavily under-treated for hypertension, with 50% of hypertensive patients receiving treatment and only 20% of patients being controlled
adequately6. The Systolic Hypertension in the Elderly Program (SHEP) which had a large proportion of female subjects, demonstrated a 25% reduction in CHD and a 36% reduction in stroke among patients whose hypertension was effectively
treated7. Drug therapy in non-reproductive women need not differ from
men8, while the teratogenecity of drug therapy should be considered in women who may conceive.
Isolated systolic hypertension is of particular concern to postmenopausal women, and may affect up to 30% of this population. Unfortunately, adequate control of isolated systolic hypertension appears to be worse than of primary hypertension, despite the persuasive demonstration of benefit of treating this disease. Low dose thiazide diuretics remain the treatment of choice for isolated systolic
hypertension.
Hyperlipidemia
Women also share men's increased risk for CHD in the presence of hyperlipidemia. Unfortunately, few of the large randomized trials that demonstrated CAD risk reduction with reduced LDL cholesterol levels included women participants. The Scandinavian Simvastatin Survival Study (4S Study) included a subgroup of female participants, and demonstrated a benefit in coronary health which was comparable to
men9. Women under the age of 65 have a definite association between increased total cholesterol (>240mg/dl) and CHD mortality, but this association is either lost or blunted in older women. LDL cholesterol levels are a weak predictor of coronary events in younger women, but are a powerful predictor of MI's in postmenopausal women
10.
A low serum HDL, however, remains as a strong predictor of CHD mortality in women of all ages, and has a much stronger association with disease in women than in
men2. A recent study to assess the compliance of women with hyperlipidemia with NCEP guidelines, revealed that 63% of women with a goal LDL of <130 did not meet that goal, and 91% of women with a goal LDL of <100 did not meet that
goal11.
Unlike men, women seem to be at increased risk for CAD in the presence of
hypertriglyceridemia12. Hypertriglyceridemia may be associated with high LDL cholesterol levels, or may present as isolated hypertriglyceridemia, especially in women with diabetes. Low HDL cholesterol levels are also a predictor of coronary disease in women, particularly in women older than age 65
13.
In a large trial to assess prescribing of lipid lowering therapies in patients with pre-existing CAD, researchers found a startling discrepancy between men and women patients. Between 1994 and 1997, in a period when the prescribing of lipid-lowering drugs in men with CAD rose from 42% to 54% of appropriate men, the percentage for women fell from 38% to
35%14. As the pool of data on the benefit of lipid control in this high-risk population grows, this neglect of female patients becomes very
troubling.
Antiplatelet
Current recommendations for the use of aspirin for the primary or secondary prevention of myocardial infarction are almost exclusively derived from studies conducted in men, with recommendations for women being extrapolated from these data. A meta-analysis of randomized trials of aspirin in secondary MI prevention, aspirin therapy imparts about a 25% reduction in the risk for subsequent cardiovascular events in both men and
women15. A recent study conducted solely in women demonstrated aspirin therapy to be an independent predictor of reduced cardiovascular mortality, and found its use to be of particular benefit in women who were diabetic, symptomatic (chest pains) or had a previous
MI16. Despite evidence of benefit of aspirin in women with existing CAD, fewer women than men with a previous M.I. are prescribed aspirin
therapy17.
Many questions about the use of aspirin in normal risk women will remain unanswered until the data from the Women's Health Study, which is addressing this question, becomes available around 2007. Until more data are available, it is rational for practitioners to consider aspirin prophylaxis to be effective in preventing recurrent M.I.s and to discuss the risks versus benefits of aspirin therapy with women having no history of coronary
events.
Estrogen replacement
Primary prevention
In retrospective studies, postmenopausal hormone replacement therapy (HRT) has consistently been found to reduce a woman's risk of CAD by 35 to
50%18,19. Perhaps due to the low overall incidence of diseases that are worsened by estrogen, hormone replacement therapy has been associated with reduced mortality from all causes combined, and has been proposed as a standard of care in countries were heart disease is the leading cause of death among women. Recent analysis of available data resulted in the suggestion that in a woman with no unusual risk for heart disease, cancer or osteoporosis would gain an additional one to three years of life by taking hormone replacement
therapy20.
There are multiple reasons for estrogen's positive effects on coronary health. It is estimated that 25-35% of the beneficial effect of estrogen is due to direct effects on plasma lipids; estrogen has been shown to decrease LDL (10-15%), and increase HDL (15-20%). The remaining 65-75% of estrogen's cardioprotective ability stems from resultant increases in insulin sensitivity and vascular dilation, and decreases in fibrinogen levels and coronary artery LDL cholesterol
uptake21.
Unfortunately, estrogen replacement may also cause a dramatic rise in plasma triglycerides, which can be especially dangerous in diabetic women. Transdermal estrogen replacement may lose most of the beneficial effects on plasma lipids, but should maintain the majority of estrogen's protective effect on the heart.
Definitive evidence for the role of HRT in the primary prevention of CAD will be provided upon the completion of the NIH's ongoing Women's Health Initiative
trial22. The study is designed to assess the impact of HRT, diet, and calcium and vitamin D supplementation on the overall morbidity and mortality of postmenopausal women. Initial results of this prospective, randomized trial should be available in 2005.
Secondary prevention
The role of HRT in the prevention of secondary coronary events has been put into question by the recently published Heart and Estrogen/progestin Replacement Study
(HERS)23. While many observational studies had suggested a beneficial effect of HRT in women with previous coronary
disease24, the HERS Trial was the first to prospectively research this issue. In a classic case of experiment over observation, the HERS Trial confounded previous epidemiologic studies by demonstrating no benefit of HRT in preventing second coronary events in this high risk group.
Explanations for the difference between observational studies and the HERS Trial are numerous. It is widely believed that women with healthy behaviors are more likely to start and continue HRT, allowing peripheral cardiovascular factors; such as physical exercise, diet and smoking status; to weigh heavily in epidemiological data. This "prevention bias" makes the interpretation of any observational study difficult to apply universally.
While the HERS Trial did demonstrate a beneficial effect on plasma lipids by HRT, this benefit did not translate into decreased recurrences of cardiovascular events within the 4-year course of the study. There was a positive trend in cardiovascular outcomes over the course of the study in women treated with HRT, but it is dangerous to extrapolate this data beyond the scope of the study.
Care should be taken to apply the HERS Trial only to the relatively small number of postmenopausal women with established CAD. Estrogen should not be initiated for the sole purpose of secondary prevention of CAD. However, given the pattern of CHD events in women receiving HRT and the evidence for the benefit of prolonged treatment with estrogen, HRT should not be discontinued in women with established coronary disease who are currently receiving
HRT.
Conclusion
All health care professionals share the responsibility of increasing awareness of cardiovascular health in women. The simple recognition that cardiovascular disease is the number one killer of postmenopausal women could be a strong agent for change if it were widely recognized. All health care professionals should consider implementing organized education efforts, consisting of opportunistic counseling, identification of high-risk patients, and group or community education programs. It can be hoped that increased application of CAD prevention modalities will decrease the discrepancy that exists between men and women in this area.
References:
1. Hennekens CH. Risk factors for coronary heart disease in women. Cardiol Clin 1998;
16:1-8.
2. Mosca L, Manson JE, Sutherland SE, et al. Cardiovascular disease in women. A statement for healthcare professionals from the American Heart Association. Circulation.
1997;96:2468-82.
3. Schenck-Gustafsson K. Risk factors for cardiovascular disease in women: assessment and management. European Heart Journal. 1996; 17(Supplement
D):2-8.
4. Castelli WP. Epidemiology of coronary heart disease: The Framingham Study. Am J Med. 1984;27 (suppl
2A):4-12.
5. Mosca L, Manson JE, Sutherland SE, et al. Cardiovascular disease in women. A statement for healthcare professionals from the American Heart Association. Circulation.
1997;96:2468-82.
6. Mosca L, Manson JE, Sutherland SE, et al. Cardiovascular disease in women. A statement for healthcare professionals from the American Heart Association. Circulation.
1997;96:2468-82.
7. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA. 1991;
265:3255-3262.
8. National High Blood Pressure Education Program Working Group. National High Blood Pressure Education Program working group report on hypertension in the elderly. Hypertension.
1994;23:275-285.
9. Scandinavian Simvastatin Survival Study Group: Randomized trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (4S). Lancet
1994;344:1383-89.
10. Zimetbaum P, Frisham WH, Osi WL, et al. Plasma lipids and lipoproteins and the incidence of cardiovascular disease in the very elderly. The Bronx Aging Study. Arterioscler Thromb Vac Biol.
1992;12:416-23.
11. Schrott HG, Bittner V, Vittinghoff E, et al. Adherence to national cholesterol education program treatment goals in postmenopausal women with heart disease. The Heart and Estrogen/progestin Replacement Study (HERS). JAMA.
1997;277:1281-6.).
12. Austin MA, Hokanson JE, Edwards KL. Hypertriglyceridemia as a cardiovascular risk factor. Am J Cardiol
1998;81(4A):7B-12B.
13. Manolio TA, Pearson TA, Wenger NK, et al. Cholesterol and heart disease in older persons and women: Review of an NHLBI workshop. Ann Epidemiol
1992;2:161-176.
14. Miller M; Byington R; Hunninghake D; Pitt B; Furberg CD. Sex bias and underutilization of lipid-lowering therapy in patients with coronary artery diseaseat academic medical centers in the United States and Canada. Prospective Randomized Evaluation of the Vascular effects of Norvasc Trail (Prevent) Investigators. Arch Intern Med 2000 Feb 14; 160 (3) : 343-7.
15. Antiplatelet Trialists' Collaboration: Collaborative overview of randomized trials of antiplatelet therapy:I. Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 308:81-106,
1994.
16. Harpaz D, Benderly M, Goldbourt U, et al. Effect of aspirin on mortality in women with symptomatic or silent myocardial ischemia. Isreali BIP Study Group. Am J Cardiol.
1996;78:1215-9.
17. Mclaughlin TJ, Soumerai SB, Willison DDJ, et al. Adherence to national guidelines for drug therapy of suspected acute myocardial infarction: Evidence of undertreatment in women and the elderly. Arch Intern Med
1996;156:799-805.
18. Stampfer MJ, Coldtiz GA. Estrogen replacement therapy and coronary heart disease: a quantitative assessment of the epidemiologic evidence. Prev Med.
1991;20:47-63.
19. Grady D, Rubin SM, Petitti DB, et al. Hormone therapy to prevent disease and prolong life in postmenopausal women. Ann Intern Med.
1992;117:1016-1037.
20. Col NF, Eckman MH, Karas RH, et al. Patient-specific decisions about hormone replacement therapy in postmenopausal women. JAMA.
1997;277:1140-47.
21. Clarkson TB, Anthony MS. Effects on the cardiovascular system: basic aspects. In: Lindsay R, Dempster DW, Jordan VC, eds. Estrogen and Antiestrogens. Philadelphia, PA: Lippencott-Raven;
1997:89-118.
22. The Women's Health Initiative Study Group. Design of the Women's Health Initiative clinical trial and observational study. Control Clin Trials.
1998;19:61-109.
23. Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. JAMA.
1998;280:605-613.
24. Newton KM, LaCroix AZ, McKnight B, et al. Estrogen replacement therapy and prognosis after first myocardial infarction. Am J Epidemiol. 1997; 145:269-277.