Unique cardiovascular risk factors in women

Challenges in Optimizing Lipid Management in Women

While there are physiologic differences in lipid metabolism in men and women, pharmacologic therapy is very effective in both with similar management strategies recommended in the current guidelines for the management of dyslipidemia. Despite similar guidelines for treatment, studies have shown that women have worse control of dyslipidemia than their male counterparts. This may stem from multiple contributing factors including underestimation of cardiovascular disease risk in women, decreased prescription and utilization of lipid-lowering therapies, decreased medication adherence, and higher risk of statin intolerance, all of which may contribute to lower attainment of lipid targets. Furthermore, heart disease is the leading cause of mortality in women, with heart disease noted an average of 7-10 years later than in men. This has historically led to the misperception that women are protected from heart disease and can be treated less aggressively. In fact, traditional risk factors for atherosclerotic cardiovascular disease often impact risk in women to a greater extent than they do in men. Unique risk factors such as pregnancy-related disorders also contribute to the level of risk and therefore warrant consideration in risk stratification. This review summarizes the efficacy of contemporary lipid-lowering therapies in women versus men and discusses the challenges that arise with lipid management in women along with potential ways to tackle these obstacles.

Interleukin 6 trans-signalling and the risk of future cardiovascular events in men and women

Objective

Pro-inflammatory interleukin 6 (IL6) trans-signalling is associated with increased risk of cardiovascular events (CVEs). Whether this association exists for both sexes is, however, uncertain. Hence, we analysed the risk of CVE associated with IL6 trans-signalling in men and women and investigated if potential interaction between IL6 trans-signalling and sex affects the risk.

Methods

In a prospective cohort of 60-year-old men and women without cardiovascular disease (men=2039, women=2193), subjects were followed for 20 years. To assess the IL6 trans-signalling activity, the proportion between the active binary and inactive ternary IL6 complexes, the binary/ternary ratio (B/T ratio), was estimated. CVE (myocardial infarction, angina pectoris and ischaemic stroke, n=629) risk was analysed with Cox regression, presented as HRs with 95% CIs. B/T ratio was dichotomised, with levels >median representing IL6 trans-signalling. Interaction was analysed on the additive scale and expressed as the synergy index (S). Analyses were adjusted for cardiovascular risk factors.

Results

B/T ratio >median was associated with increased CVE risk in men (HR 1.63; 95% CI 1.32 to 2.01), but not in women (HR 1.21; 95% CI 0.93 to 1.57). There was a significant synergistic interaction (S=1.98; 95% CI 1.15 to 3.42) between the B/T ratio and male sex, the combination increasing the risk by 88%.

Conclusions

Our results suggest differential susceptibility to inflammation mediated by IL6 trans-signalling and subsequent CVE in men and women. The B/T ratio could be considered as a novel biomarker for cardiovascular risk in men, but not in women.

IDO activity forecasts obesity in males and premenopausal females in a 10-year follow-up study:The Cardiovascular Risk in Young Finns Study

BACKGROUND AND AIMS

Indoleamine 2,3-dioxygenase (IDO) is an intracellular enzyme associated with artery wall inflammation. Previous studies have verified correlation between IDO activity and early signs of atherosclerosis especially in females. We aimed to elucidate the relationship between an estimate of IDO activity and atherosclerotic risk factors related to non-alchohol-fatty liver (NAFLD) in a 6- and 10-year follow-up.

METHODS

Estimates of IDO activity along with complete risk factor data were measured from females (n = 506; age 24-39) and males (n = 421; age 24-39) in 2001. Risk factor measurements were conducted again in 2007 and 2011. Statistical examinations were carried out by Pearson correlation and risk ratio analysis.

RESULTS

In females, age-adjusted IDO correlated with body mass index (BMI) (p = 0.0008), waist (p = 0.0009), C-reactive protein (CRP) (p = 0.0014) and logarithmically modified triglycerides (p = 0.0488) in 2007. Correlation remained significant with BMI (p = 0.0007) and waist (p = 0.0063) in 2011. In males, age-adjusted IDO correlated with waist (p = 0.0367) and high-density lipoprotein cholesterol (HDL-C) (p = 0.0489) in 2007. Correlation remained significant with HDL-C (p = 0.0348) in 2011. In risk ratio analysis, relationship between IDO and obesity was confirmed in females after 10 years (RR = 1.026, p = 0.0147, 95% CI) and in males after 6 and 10 years (RR = 1.019, p = 0.0091, 95% CI and RR = 1.015, p = 0.0404, 95% CI, respectively) when the data was adjusted for age and BMI.

CONCLUSIONS

IDO activity correlated with obesity and factors related to NAFLD, namely obesity of visceral type, hypertriglyceridemia and CRP (in females), well-characterized risk factors for diabetes and atherosclerosis in 6- and 10-year follow-up in males and premenopausal females.

Incidence and Risk Factors of Cardio-Cerebrovascular Disease in Korean Menopausal Women: A Retrospective Observational Study using the Korean Genome and Epidemiology Study data

PURPOSE

Cardio-cerebrovascular diseases constitute the most common and fatal disease among menopausal women. However, the risk of cardio-cerebrovascular diseases in menopausal women compared to men has been underestimated, with insufficient related studies. Therefore, we examined the incidence and risk factors of cardio-cerebrovascular diseases among Korean menopausal women.

METHODS

A retrospective observational study design with secondary analysis was conducted using data from the Korean Genome and Epidemiology Study survey. We used the study's data of 1,197 menopausal women, aged 40-64 years, who did not have cardio-cerebrovascular diseases at baseline and their related data from the biennial follow-ups over 14 years. Cardio-cerebrovascular diseases were defined as hypertension, coronary artery disease, or stroke. The incidence of cardio-cerebrovascular diseases was calculated per person-years, and multivariate Cox proportional hazards models were used to determine the predictors of cardio-cerebrovascular diseases during the follow-up period.

RESULTS

Of the 1,197 cases, 264 were early or surgical menopausal women. The overall incidence of cardio-cerebrovascular diseases was 18.75 per 1,000 person-years. Early or surgical menopause (HR = 4.32, p < .001), along with family history of cardiovascular disease (HR = 1.87, p = .024), elevated blood pressure (HR = 1.79, p < .001), abdominal obesity (HR = 1.37, p = .046), or duration of menopause at the same age (HR = 1.01, p = .001), were strong predictors of cardio-cerebrovascular diseases.

CONCLUSION

Based on the results of this study, it is necessary to identify and closely monitor women with early or surgical menopause for cardiovascular and cerebrovascular diseases prevention. Also, prevention of cardio-cerebrovascular diseases through blood pressure and abdominal obesity management is vital for menopausal women.

Incidence of essential hypertension but not echocardiographic abnormalities at four years with a history of preeclampsia with severe features

INTRODUCTION

Women with preeclampsia are more likely to have abnormal echocardiographic parameters at the time of diagnosis and are more likely to have hypertension and other cardiovascular diseases (CVD) later in life. Screening for future CVD in preeclamptic women would assist in appropriately risk stratifying and identifying high risk women for preventive management; however, the timing of screening and the screening factors are unknown.

OBJECTIVE

The objectives of this project are to 1) assess incidence of essential hypertension 4 years after pregnancy in preeclampsia with severe features (PEC) 2) identify predictive echocardiographic variables at the time of PEC diagnosis and 3) assess the rate of echocardiographic abnormalities 4 years after developing PEC.

STUDY DESIGN

This is a prospective longitudinal study observing the incidence of essential hypertension in women within 4 years of a pregnancy complicated by PEC. We further looked at echocardiographic variables at the time of PEC diagnosis and at 4 years after PEC pregnancy in women with and without subsequent incident essential hypertension. The primary outcome measure is the incidence of essential hypertension within 4 years of PEC pregnancy, defined as a systolic blood pressure ≥ 130 mmHg or a diastolic blood pressure ≥ 80 mmHg. Secondary imaging outcomes include the persistence of abnormal echocardiographic parameters. Clinical secondary outcomes are new diagnoses of severe CVD, including coronary artery disease, stroke, arrhythmia, heart failure, or inpatient hospital admission for CVD.

RESULTS

Of the 33 enrolled women with PEC, 48% (16/33) developed incident essential hypertension within 4 years of delivery. These women had thicker left ventricular posterior walls on their initial antenatal echocardiogram when compared to the 52% (17/33) who did not develop hypertension (1.0 cm [0.9-1.1 cm] vs 0.9 cm [0.7-0.9 cm]. p < 0.016). However, these abnormal echocardiographic variables resolved in the 16 women who underwent 4-year follow-up echocardiography.

CONCLUSION

Women who develop PEC have a high incidence of essential hypertension within 4 years of delivery. The group who develops essential hypertension are more likely to have evidence of adverse cardiac remodeling at the time of PEC diagnosis; however, neither group have cardiac echocardiographic abnormalities 4 years postpartum. Because this is a small study, larger long-term cohort studies are needed to confirm these echocardiographic and clinical findings.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Variants translating reduced expression of the beta estrogen receptor gene were associated with increased carotid intima media thickness: A cross-sectional study in late postmenopausal women

There is debate on the role of estrogens in modulating the risk for atherosclerosis in women. Our purpose was to investigate whether the size of the estrogenic impact was independently associated with variation of carotid intima-media thickness (IMT) in healthy late postmenopausal women. The levels of circulating estrogens have been used in previous studies but the influence of SNPs of the estrogen receptors (ER) α and β have not been investigated.We performed a crossed-sectional study of 91 women in a university hospital. We used a double approach in which, in addition to the measurement of estradiol levels by ultrasensitive methods, genetic variants (SNPs) associated with differing expression of the ER α and β genes were assessed. Multivariable analysis was used to examine the association of candidate factors with the value of IMT and plaque detection at both the carotid wall and the sinus.A genotype combination translating reduced gene expression of the ERβ was directly associated with IMT at both the carotid wall (P = .001) and the sinus (P = .002). Other predictors of IMT were the levels of glucose, positively associated with IMT at both the carotid wall (P < .001) and the sinus (P = .001), age positively associated with IMT at the sinus (P = .003), and levels of vitamin D, positively associated with IMT at the carotid wall (P = .04).Poorer estrogenic impact, as concordant with a SNP variant imposing reduced expression of the ERβ, was directly associated with IMT at both the carotid wall and the sinus. Glucose level, vitamin D only for the carotid wall, and age only for the sinus, also emerged as independent factors in the IMT variance.

G protein-coupled estrogen receptor 1: a novel target to treat cardiovascular disease in a sex-specific manner?

As an agonist of the classical nuclear receptors, estrogen receptor-α and -β (NR3A1/2), estrogen has been assumed to inhibit the development of cardiovascular disease in premenopausal women. Indeed, reduced levels of estrogen after menopause are believed to contribute to accelerated morbidity and mortality rates in women. However, estrogen replacement therapy has variable effects on cardiovascular risk in postmenopausal women, including increased serious adverse events. Interestingly, preclinical studies have shown that selective activation of the novel membrane-associated G protein-coupled estrogen receptor, GPER, can promote cardiovascular protection. These benefits are more evident in ovariectomised than intact females or in males. It is therefore possible that selective targeting of the GPER in postmenopausal women could provide cardiovascular protection with fewer adverse effects that are caused by conventional 'receptor non-specific' estrogen replacement therapy. This review describes new data regarding the merits of targeting GPER to treat cardiovascular disease with a focus on sex differences.

Sex differences in mortality in stable patients undergoing vasodilator stress cardiovascular magnetic resonance

OBJECTIVE

We assessed the influence of the ischaemic burden (IB) as derived from vasodilator stress cardiovascular magnetic resonance (CMR) on the risk of death and the effect of revascularisation across sex.

METHODS

We evaluated 6237 consecutive patients with known or suspected chronic coronary syndrome (CCS). Extensive ischaemia was defined as >5 segments with perfusion deficit. Multivariate Cox proportional hazard regression models were used.

RESULTS

A total of 2371 (38.0%) patients were women and 583 (9.3%) underwent CMR-related revascularisation. During a median follow-up of 5.13 years, 687 (11.0%) deaths were reported. We found an adjusted differential effect of CMR-derived IB across sex (p value for interaction=0.039). Women exhibited an adjusted lower risk of death and only equaled men's risk when extensive ischaemia was present. Likewise, CMR-related revascularisation was shown to be differentially associated with the risk of mortality across sex (p value for interaction=0.025). In patients with non-extensive ischaemia, revascularisation was associated with a higher risk of death, with a greater extent in women. At higher IB, revascularisation was associated with a lower risk in men, with more uncertain results in women.

CONCLUSIONS

CMR-derived IB allows predicting the risk of death and gives insight into the potential effect of revascularisation in men and women with CCS. Compared with men, women with non-extensive ischaemia displayed a lower risk and a similar risk with a higher IB. The impact of CMR-related revascularisation on mortality risk was also significantly different according to IB and sex. Further research will be needed to confirm these hypothesis-generating findings.

Sex differences on new-onset heart failure in patients with known or suspected coronary artery disease

AIMS

The impact of sex in patients with CAD has been widely reported, but little is known about the influence of sex on the risk of new-onset HF in patients with known or suspected CAD. We aimed to examine sex-related differences and new-onset heart failure (HF) risk in patients with known or suspected coronary artery disease (CAD) undergoing vasodilator stress cardiac magnetic resonance (CMR).

METHODS AND RESULTS

We prospectively evaluated 5899 consecutive HF-free patients submitted to stress CMR for known or suspected CAD. Ischaemic burden (number of segments with stress-induced perfusion deficit) and left ventricular ejection fraction (LVEF) were assessed by CMR. The association between sex and new-onset HF (including outpatient diagnosis or acute HF hospitalization) was evaluated using a Cox proportional hazards regression model adjusted for competing events [death, myocardial infarction (MI), and revascularization]. A total of 2289 (38.8%) patients were women. During a median follow-up of 4.5 years, 610 (10.3%) patients died, 191 (3.2%) suffered an MI, 905 (15.3%) underwent revascularization, and 314 (5.3%) developed new-onset HF. Unadjusted new-onset HF rates were higher in women than in men (1.25 vs. 0.83 per 100 person-years, P = 0.001). After comprehensive multivariate adjustment, women showed an increased risk of new-onset HF (hazard ratio 1.58, 95% confidence interval 1.18-2.10; P = 0.002). We found a sex-differential effect along the continuum of LVEF (P-value for interaction = 0.007). At lower LVEF, there was an increased risk in both sexes. However, compared with men, the risk of new-onset HF was higher in women with LVEF >55%.

CONCLUSION

Women with known or suspected CAD are at a higher risk of new-onset HF. Further studies are needed to unravel the mechanisms behind these sex-related differences.

The combination of dantrolene and nimodipine effectively reduces 5-HT-induced vasospasms in diabetic rats

Diabetics have a higher risk of developing cerebral vasospasms (CVSP) after subarachnoid hemorrhagic stroke than non-diabetics. Serotonin (5-HT) is one of the key vasoconstrictors released in the hemorrhagic blood and an important contributor to the etiology of CVSP. The combination of the ryanodine receptor blocker dantrolene and the Ca2+ channel blocker nimodipine significantly reduces phenylephrine (PHE)-induced vascular contraction in both diabetic and nondiabetic rats, but the effectiveness of this drug combination in reducing 5-HT-induced contraction is unknown. Dose–response curves for the 5-HT-induced contraction (from 0.1 nM to 100 µM) were performed on aortic rings from diabetic and non-diabetic rats after a 30-min incubation period with dantrolene, nimodipine, and both drugs in combination. In diabetic rats, 10 μM of dantrolene alone failed to reduce 5-HT-induced maximal contraction (E_max), but 50 μM reduced this parameter by 34% (n = 7, p < 0.05). In non-diabetic rats, by contrast, dantrolene did not modify the vascular response to 5-HT. 50 nM of nimodipine alone, however, reduced this parameter by 57% in diabetic rats (n = 10, p < 0.05), and by 34% in non-diabetic rats (n = 10, p < 0.05). In addition, concomitant administration of dantrolene and nimodipine reduced vascular reactivity to a similar extent in both diabetic (~ 60% reduction, n = 10, p < 0.05) and non-diabetic rats (~ 70% reduction, n = 10, p < 0.05). Moreover, the combination of nimodipine with the higher concentration of dantrolene significantly increased the EC₅₀ values for the 5-HT-induced contraction curves in both diabetics (from 10.31 ± 1.17 µM to 19.26 ± 2.82; n = 10, p < 0.05) and non-diabetic rats (5.93 ± 0.54 µM to 15.80 ± 3.24; n = 10, p < 0.05). These results suggest that simultaneous administration of dantrolene and nimodipine has a synergistic effect in reducing 5-HT-induced vascular contraction under both diabetic and non-diabetic conditions. If our findings with rats are applicable to humans, concomitant administration of these drugs may represent a promising alternative for the management of CVSP in both diabetics and non-diabetics.

Positive association of high-density lipoprotein cholesterol with lumbar and femoral neck bone mineral density in postmenopausal women

OBJECTIVE

Experimental studies suggest that lipids affect bone metabolism. We aimed to elucidate whether lipid levels are associated with bone mineral density (BMD) in a cohort of postmenopausal women.

DESIGN

A cross-sectional study of participants in the Chronic Ailment Reduction after MENopause (CARMEN) cohort. Women underwent assessment of clinical and analytical parameters, including fasting lipid levels. BMD was assessed at both lumbar spine and hip. Homogeneity in the cohort was optimized by filtering out a series of confounding variables with a known impact on bone.

MAIN OUTCOME MEASURES

Association of BMD at lumbar spine and femoral neck with lipid levels.

RESULTS

A total of 667 of the 1304 screened women were analyzed. A strong correlation was revealed between total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) in univariate analysis. Multivariate analysis detected a significant positive association of HDL-C with BMD at both spine (p = 0.007) and femoral neck (p = 0.013). Other independent predictors of spine BMD were years since menopause (ysm, negatively associated), and body mass index (BMI) and estradiol, both positively associated with BMD. The other independent variables in the femoral neck were ysm and glucose (negatively associated) and BMI, estradiol, and phosphate, all positively associated with BMD.

CONCLUSION

Levels of HDL-C, but not TC, LDL-C or triglycerides, were positively associated with BMD at both the lumbar spine and femoral neck in a homogeneous cohort of postmenopausal women.

Systemic Oxidative Stress, Aging and the Risk of Cardiovascular Events in the General Female Population

Introduction: Menopause is associated with increased cardiovascular risk, in which oxidative stress plays a pivotal role. Systemic oxidative stress is reflected by decreased levels of free thiols (R-SH, sulfhydryl groups), which are key components of the extracellular antioxidant machinery. In this study, we investigated the relation between serum free thiols as marker of oxidative stress and the female cardiovascular phenotype, as well as potential associations with the risk of cardiovascular (CV) events in pre- and postmenopausal women from the general population.

Methods: Female participants (n = 2,980) of the Prevention of REnal and Vascular ENd-stage Disease (PREVEND) cohort study were included. Serum free thiol concentrations were analyzed for associations with demographic, clinical, biochemical, and gynecological parameters, as well as with menopausal status and, prospectively, with the risk of CV events.

Results: Postmenopausal women had significantly reduced levels of serum free thiols (4.8 ± 1.0 vs. 5.2 ± 1.0 μmol/g, P < 0.001) compared to reproductive women. In multivariable analyses, serum free thiols were significantly associated with menopausal status (OR 0.70 [0.49–0.98], P = 0.039), even when adjusted for potential confounding factors, except for age (P = 0.550). Prospectively, serum free thiols were significantly associated with the risk of CV events (HR 0.52 [0.27–0.97], P = 0.040), even with covariate adjustment, although this disappeared when correcting for age.

Conclusion: In this study, we revealed serum free thiols to be strongly associated with the female cardiovascular phenotype as well as with female risk of CV events, where the influence of age itself seemed to outweigh that of female menopause. Future studies are warranted to further unravel the clinical utility of serum free thiol levels in the context of female cardiovascular risk management.

The risk and added values of the atherosclerotic cardiovascular risk enhancers on prediction of cardiovascular events: Tehran lipid and glucose study

BACKGROUND

In 2013 American College of Cardiology and the American Heart Association released a guideline on the management of atherosclerotic cardiovascular disease (ASCVD) including a composite of death from CVD, non-fatal myocardial infarction, or non-fatal stroke (hard CVD). This guideline recommended a risk score that was calculated using pooled cohort equations (ASCVD-PCE). The guideline was updated in 2018/2019 and further risk discussion was suggested for deciding whether to continue or initiate statin therapy among non-diabetic individuals with ASCVD-PCE score ranged 5-20%. They recommended a risk discussion with considering risk enhancing factors (ASCVD-REFs) including family history of premature CVD, chronic kidney disease, triglycerides ≥ 175 mg/dl, low-density lipoprotein cholesterol (LDL-C) ≥ 160 mg/dl, metabolic syndrome (Mets), and for women premature menopause, and hypertensive disorders of pregnancy (HDP). In the current study, we aimed to examine the predictability of recommended ASCVD-REFs on incident hard CVD in non-diabetic individuals with LDL-C 70-189 mg/dl, with ASCVD-PCE risk 5-20% during 10 and 15-year follow-up.

METHODS

Among a total of 3546 non-diabetic individuals aged 40-75 years, after excluding those with ASCVD-PCE score < 5% and ≥ 20% (n = 2342), 1204 individuals (women = 332) were included. The univariable and multivariable (further adjusted for ASCVD-PCE) Cox regression analysis were used to evaluate the association of each potential ASCVD-REFs with hard CVD. Additionnaly, the role of different components of Mets and a history of gestational diabetes (GDM)/macrosomia was also examined. The predictive ability of each significant ASCVD-REFs, then was evaluated by the discrimination accuracy and risk reclassification index.

RESULTS

During the 10-year follow-up, 73 hard CVD events occurred. Although in univariable analysis, high blood pressure (BP) component of Mets, GDM/macrosomia, and HDP remained as significant ASCVD-REFs, in the multivariable analysis, only the history of HDP (5.35 (1.22-23.38)) and GDM/macrosomia (3.18 (1.05-9.65)) showed independent risks. During the 15-year follow-up, Mets (1.47 (1.05-2.06)) and its components of high waist circumference (1.40 (1.0-1.95)) and high BP (1.52 (1.07-2.15)) significantly increased the risk. These ASCVD-REFs did not improve discrimination or predictive ability.

CONCLUSIONS

In a decade follow-up, only conditions specific for women and in longer follow-up, the presence of Mets perse, and its components of high WC and high BP were shown as significant ASCVD-REFs.

Structure of communities in semantic networks of biomedical research on disparities in health and sexism

Introducción.

Como una iniciativa para mejorar la calidad de la atención sanitaria, en la investigación biomédica se ha incrementado la tendencia centrada en el estudio de las disparidades en salud y sexismo.

Objetivo.

Caracterizar la evidencia científica sobre la disparidad en salud definida como la brecha existente entre la distribución de la salud y el posible sesgo por sexo en el acceso a los servicios médicos.

Materiales y métodos.

Se hizo una búsqueda simultánea de la literatura científica en la base de datos Medline PubMed de dos descriptores fundamentales: Healthcare disparities y Sexism. Posteriormente, se construyó una red semántica principal y se determinaron algunas subunidades estructurales (comunidades) para el análisis de los patrones de organización de la información. Se utilizó el programa de código abierto Cytoscape para el analisis y la visualización de las redes y el MapEquation, para la detección de comunidades. Asimismo, se desarrolló código ex profeso disponible en un repositorio de acceso público.

Resultados.

El corpus de la red principal mostró que los términos sobre las enfermedades del corazón fueron los descriptores de condiciones médicas más concurrentes. A partir de las subunidades estructurales, se determinaron los patrones de información relacionada con las políticas públicas, los servicios de salud, los factores sociales determinantes y los factores de riesgo, pero con cierta tendencia a mantenerse indirectamente conectados con los nodos relacionados con condiciones médicas.

Conclusiones.

La evidencia científica indica que la disparidad por sexo sí importa para la calidad de la atención de muchas enfermedades, especialmente aquellas relacionadas con el sistema circulatorio. Sin embargo, aún se percibe un distanciamiento entre los factores médicos y los sociales que dan lugar a las posibles disparidades por sexo.

State of the Art in Noninvasive Imaging of Ischemic Heart Disease and Coronary Microvascular Dysfunction in Women: Indications, Performance, and Limitations

PURPOSE OF REVIEW

Establishing a diagnosis of ischemic heart disease (IHD) in women, including assessment for coronary microvascular dysfunction (CMD) when indicated, can be challenging. Access to performance of invasive testing when appropriate may be limited, and noninvasive imaging assessments have evolved. This review will summarize the various noninvasive imaging modalities available for the diagnosis of IHD and CMD in women, outlining indications, performance modalities, advantages, and limitations.

RECENT FINDINGS

While stress echocardiography and single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) are widely available and can detect IHD in women, their ability to specifically identify CMD is limited. Novel developments in cardiac magnetic resonance (CMR) imaging, including spectroscopy, and positron emission tomography (PET) have changed the diagnostic landscape. Coronary computed tomographic angiography (CCTA), while unable to diagnose CMD, is developing an emerging role in the risk stratification of ischemic syndromes. Despite the discovery of increased CMD prevalence in symptomatic women and technological advances in diagnostic imaging, practitioners are limited by user expertise and center availability when choosing a diagnostic imaging modality. Knowledge of this evolving field is imperative as it highlights the need for sex-specific assessment of cardiovascular syndromes.

Coronary artery disease and acute coronary syndrome in women

There are important dissimilarities in clinical presentation, aggregation of comorbidities, cardiovascular risk factors and the quality of delivery of medical care among men and women with acute coronary syndrome (ACS). Compared with men, despite the well-known older age and more pronounced frailty, women with ACS present later from symptom onset and are at high bleeding risk after invasive procedures. In addition, autoimmune/inflammatory disease, fibromuscular dysplasia, polycystic ovary, early menopause and history of pre-eclampsia are risk factors preceding ACS among younger women. They more often experience myocardial infarction in the absence of obstructive coronary arteries (MINOCA), which makes diagnosis and treatment of ACS among women more challenging compared with men. Women and men do both benefit from guideline-recommended treatment, although, compared with men, women with ACS have a higher adjusted risk of early death, which equalises between both sexes within the first year. Young women with ACS suffer frequently of depression and present often with MINOCA. Compared with young men, they (young women) have a higher risk of death. Therefore, focusing on young patients with ACS, understanding the particular physiopathology of MINOCA and developing programmes targeting comorbidities and depression-related behavioural risk factors are urgently needed.