Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies

Tobacco Use and Tobacco Dependence Management

Tobacco use is a major public health problem and the leading cause of preventable deaths in the United States and worldwide. Tobacco dependence determines tobacco use and is largely due to nicotine addiction. Such dependence is a disease resulting in a strong desire or compulsion to take tobacco, with difficulty in cessation of tobacco, along with persistent use despite overtly harmful consequences.

Sex effects in predictors of smoking abstinence and neuropsychiatric adverse events in the EAGLES trial

Significance There are sex effects in abstinence outcomes across all smoking cessation medications, but there is limited information regarding sex effects on cessation-related neuropsychiatric adverse events (NPSAEs) or interactions with psychiatric status.

METHODS

Secondary analysis of data from EAGLES of 8144 adults who smoke cigarettes randomized to varenicline, bupropion, nicotine patch or placebo. Design characteristics included region (within/outside US), psychiatric cohort (absent/present), and treatment. Baseline variables included demographics, smoking history, prior use of study treatments, lifetime suicide-related history, and prior psychiatric co-morbidities and medication use. Design characteristics were forced into logistic regressions models, and then interactions among sex, design elements, and baseline characteristics were evaluated for NPSAEs and 6-month cessation outcomes.

RESULTS

Findings demonstrated a significant interaction of sex and race (p < 0.02); Black women were more likely to report NPSAEs than Black men. For cessation outcomes, there were no significant interactions with psychiatric cohort and sex. Women vs men with higher baseline levels of smoking had lower odds of continuous abstinence. Women vs men who used varenicline previously had lower odds of continuous abstinence. For 6-month point prevalence, sex interacted with baseline cigarettes per day (p < 0.01) similar to the interaction for continuous abstinence. Sex interacted with medication (p < 0.03), such that women vs men had relatively greater success at achieving point prevalence abstinence on varenicline.

CONCLUSIONS

Overall, results demonstrated important sex and racial differences in the incidence of NPSAEs, but psychiatric status did not interact with sex on cessation outcomes. Findings did support prior work demonstrating relative increased efficacy of varenicline for women.

Addressing Cardiovascular Risk Across the Arc of a Woman's Life: Sex-Specific Prevention and Treatment

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in women in the United States of America. Despite this, women are underdiagnosed, less often receive preventive care, and are undertreated for CVD compared to men. There has been an increase in sex-specific risk factors and treatments over the past decade; however, sex-specific recommendations have not been included in the guidelines. We aim to highlight recent evidence behind the differential effect of traditional risk factors and underscore sex-specific risk factors with an intention to promote awareness, improve risk stratification, and early implementation of appropriate preventive therapies in women.

RECENT FINDINGS

Women are prescribed fewer antihypertensives and lipid-lowering agents and receive less cardiovascular care as compared to men. Additionally, pregnancy complications have been associated with increased cardiovascular mortality later in life. Findings from the ARIC study suggest that there is a perception of lower risk of cardiovascular disease in women. The SWEDEHEART study which investigated sex differences in treatment, noted a lower prescription of guideline-directed therapy in women. Women are less likely to be prescribed statin medications by their providers in both primary and secondary prevention as they are considered lower risk than men, while also being more likely to decline and discontinue treatment. A woman's abnormal response to pregnancy may serve as her first physiological stress test which can have implications on her future cardiovascular health. This was supported by the CHAMPs study noting a higher premature cardiovascular risk after maternal complications. Adverse pregnancy outcomes have been associated with a 1.5-4.0 fold increase in future cardiovascular events in multiple studies. In this review, we highlight the differences in traditional risk factors and their impact on women. Furthermore, we address the sex-specific risk factors and pregnancy-associated complications that increase the risk of CVD in women. Adherence to GDMT may have implications on overall mortality in women. An effort to improve early recognition of CVD risk with implementation of aggressive risk factor control and lifestyle modification should be emphasized. Future studies should specifically report on differences in outcomes between males and females. Increased awareness and knowledge on sex-specific risks and prevention are likely to lower the prevalence and improve outcomes of CVD in women.

Between-Sex Differences in Risk Factors for Cardiovascular Disease among Patients with Myocardial Infarction-A Systematic Review

Between-sex differences in the presentation, risk factors, management, and outcomes of acute myocardial infarction (MI) are well documented. However, as such differences are highly sensitive to cultural and social changes, there is a need to continuously re-evaluate the evidence. The present contemporary systematic review assesses the baseline characteristics of men and women presenting to secondary, tertiary, and quaternary centres with acute myocardial infarction (MI). Over 1.4 million participants from 18 studies, including primary prospective, cross sectional and retrospective observational studies, as well as secondary analysis of registry data are included in the study. The study showed that women were more likely than men to have a previous diagnosis of diabetes, hypertension, cerebrovascular disease, and heart failure. They also had lower odds of presenting with previous ischaemic heart disease and angina, dyslipidaemia, or a smoking history. Further work is necessary to understand the reasons for these differences, and the role that gender-specific risk factors may have in this context. Moreover, how these between-gender differences are implicated in management and outcomes also requires further work.

[Sex-specific differences of special tumor diseases]

BACKGROUND

Numerous data show that sex and gender have gained increasing importance in precision medicine as relevant modulators of specific oncological and hematological diseases. The purpose of this article is to provide a summary of the current state of knowledge on sex differences in the incidence and outcome of specific malignancies and to further elucidate possible underlying causes.

MATERIAL AND METHODS

Evaluation and discussion of basic research studies, meta-analyses, and clinical trials.

RESULTS

There are significant sex-specific differences in the incidence, response rates, and mortality for a variety of oncological diseases. For the most part, men have poorer outcomes, whereas women have higher treatment-associated toxicities and distinct presentations at younger ages. Hormonal, immunological, and pharmacological causes are suspected.

CONCLUSION

Advanced patient-individualized treatment in oncology and hematology will be measured in the future by the implementation of the existing relevant sex differences in the clinical practice and further investigations on underlying mechanisms in studies in order to guarantee and to optimize the best possible treatment for oncological patients in the future.

A Woman's Heart: Improving Uptake and Awareness of Cardiovascular Screening for Middle-Aged Populations

Mid-life, the years leading up to and following the menopause transition, in women is accompanied by a change in cardiometabolic risk factors, including increases in body weight, changes in body composition, a more insulin-resistant state, and a shift towards a more atherogenic dyslipidemia pattern. Cardiovascular disease (CVD) risk assessment should be performed continually throughout the lifespan, as risk is not stagnant and can change throughout the life course. However, mid-life is a particularly important time for a woman to be evaluated for CVD risk so that appropriate preventive strategies can be implemented. Along with assessing traditional risk factors, ascertainment of a reproductive history is an integral part of a comprehensive CVD risk assessment to recognize unique female-specific or female-predominant factors that modify a woman's risk. When there is uncertainty about CVD risk and the net benefit of preventive pharmacotherapy interventions (such as statins), measuring a coronary artery calcium score can help further refine risk and guide shared decision-making. Additionally, there should be heightened sensitivity around identifying signs and symptoms of ischemic heart disease in women, as these may present differently than in men. Ischemia from coronary microvascular disease and/or vasospasm may be present even without obstructive coronary artery disease and is associated with a heightened risk for major cardiovascular events and reduced quality of life. Therefore, correctly identifying CVD in women and implementing preventive and treatment therapies is paramount. Unfortunately, women are underrepresented in cardiovascular clinical trials, and more data are needed about how to best incorporate novel and emerging risk factors into CVD risk assessment. This review outlines an approach to CVD screening and risk assessment in women using several methods, focusing on the middle-aged population.

Impact of modifiable risk factors on prediction of 10-year cardiovascular disease utilizing framingham risk score in Southwest Iran

BACKGROUND

This cohort study was conducted to examine the association between modifiable risk factors, including hypertension, smoking, physical activity, diabetes, cholesterol, and high-density lipoprotein with Framingham risk score in the prediction of 10-year-risk of cardiovascular diseases (CVD) between men and women in an Arab community of Southwest Iran, Hoveyzeh.

MATERIALS AND METHODS

A total of 8,526 people aged 35-70 participated in this cohort study. Framingham was used to estimate the 10-year risk of CVD. Also, the linear regression models were used to assess the relationship between modifiable risk factors and the 10-year risk of CVD. Finally, the area under the receiver operating characteristic curve (AUC) was used to measure the ability of modifiable risk factors to predict the 10-year risk of CVD.

RESULTS

Our results of linear regression models showed that hypertension, smoking, PA, diabetes, cholesterol, and HDL were independently associated with the CVD risk in men and women. Also, AUC analysis showed that hypertension and diabetes have the largest AUC in men 0.841; 0.778 and in women 0.776; 0.715, respectively. However, physical activity had the highest AUC just in women 0.717.

CONCLUSION

Hypertension and diabetes in both gender and physical activity in women are the most important determinant for the prediction of CVD risk in Hoveyzeh. Our cohort study may be useful for adopting strategies to reduce CVD progression through lifestyle changes.

Workplace socioeconomic characteristics and coronary heart disease: a nationwide follow-up study

OBJECTIVES

Important gaps in previous research include a lack of studies on the association between socioeconomic characteristics of the workplace and coronary heart disease (CHD).We aimed to examine two contextual factors in association with individuals' risk of CHD: the mean educational level of all employees at each individual's workplace (education_work) and the neighbourhood socioeconomic characteristics of each individual's workplace (neighbourhood SES_work).

DESIGN

Nationwide follow-up/cohort study.

SETTING

Nationwide data from Sweden.

PARTICIPANTS

All individuals born in Sweden from 1943 to 1957 were included (n=1 547 818). We excluded individuals with a CHD diagnosis prior to 2008 (n=67 619), individuals without workplace information (n=576 663), individuals lacking residential address (n=4139) and individuals who had unknown parents (n=7076). A total of 892 321 individuals were thus included in the study (426 440 men and 465 881 women).

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome variable was incident CHD during follow-up between 2008 and 2012. The association between education_work and neighbourhood SES_work and the outcome was explored using multilevel and cross-classified logistic regression models to determine ORs and 95% CIs, with individuals nested within workplaces and neighbourhoods. All models were conducted in both men and women and were adjusted for age, income, marital status, educational attainment and neighbourhood SES_residence.

RESULTS

Low (vs high) education_work was significantly associated with increased CHD incidence for both men (OR 1.29, 95% CI 1.23 to 1.34) and women (OR 1.38, 95% CI 1.29 to 1.47) and remained significant after adjusting for potential confounders. These findings were not replicable for the variable neighbourhood SES_work.

CONCLUSIONS

Workplace socioeconomic characteristics, that is, the educational attainment of an individual's colleagues, may influence CHD risk, which represents new knowledge relevant to occupational health management at workplaces.

Who benefits from green spaces? Surrounding greenness and incidence of cardiovascular disease in a population-based electronic medical records cohort in Madrid

The objective was to study the association between surrounding greenness and the incidence of cardiovascular diseases (CVD) with a four years follow-up in almost half a million high CVD-risk women and men, as well as its differential effect by area-level deprivation in Madrid. We analyzed 2015-2018 primary healthcare electronic medical records for 437,513 high CVD risk individuals representing more than 95% of the population of that age range residing in Madrid. The outcome variable was any cardiovascular event. We measured surrounding residence greenness at 200 m, 300 m, 500 m, and 1000 m through the Normalized Difference Vegetation Index (NDVI). We assessed socioeconomic deprivation through a census-based deprivation index. We estimated the 4-year relative risk of CVD by an increase in 0.1 units of NDVI and then stratified the models by quintiles of deprivation (Q5 the most deprived). We found that for every increase in 0.1 units of NDVI at 1000 m there was a 16% decrease in CVD risk (RR = 0.84 95% CI 0.75-0.94). CVD risk for the remaining distance exposures (at 200 m, 300 m, and 500 m) were none statistically significant. In general, the protective effect of green spaces was present in medium-deprivation areas and males, but the associations were inconsistent across deprivation levels. This study highlights the relevance of evaluating the interaction between physical and social urban components to further understand possible population prevention approaches for cardiovascular diseases. Future studies should focus on the mechanisms of context-specific interactions between social inequalities and green spaces' effects on health.

Sex-related differences in outcome after left atrial appendage occlusion: Insights from Europe and the EWOLUTION registry

BACKGROUND

Women with atrial fibrillation (AF) generally experience worse symptoms, poorer quality of life, and have a higher risk of stroke and death. There is limited availability of sex-related differences regarding left atrial appendage occlusion (LAAO).

AIMS

The aim of this study was to evaluate the sex-related differences in patients undergoing LAAO in EWOLUTION.

METHODS

A total of 1025 patients scheduled for elective LAAO therapy employing the WATCHMAN Gen 2.5 prospectively consented for participation; 1005 patients received a successful implant and were followed for 2 years. As we detected sex-related differences in baseline data we performed a propensity score matching. The primary endpoint is a combined endpoint of survival free from mortality, major bleeding, ischemic stroke, transitory ischemic attack (TIA) and systemic embolization (SE) up to 2-year clinical follow-up. Secondary Endpoints were periprocedural data and overall 2-year survival.

RESULTS

Women were older but had less often vascular disease and hemorrhagic stroke. There was no sex-related significant difference after LAAO at 2 years in the combined endpoint of survival free from mortality, major bleeding, ischemic stroke, TIA, and SE (female vs. male: 79% vs.76%, p = 0.24) or in overall survival (female vs. male: 85% vs. 82%, p = 0.16). Procedural data showed a higher sealing rate after the implantation in women (complete sealing female 94% vs. male 90%, p = 0.033), significantly more pericardial effusions (female 1.2% vs. male 0.2%, p = 0.031) and a similar periprocedural risk profile.

CONCLUSIONS

Females undergoing LAAO differ in various baseline variables, but after adjustment, we observed similar safety and efficacy of LAAO with no significant difference in long-term outcomes between women and men.

Clinical challenges facing patient participation in cardiac rehabilitation: cigarette smoking

INTRODUCTION

Cardiac rehabilitation (CR) is highly effective at reducing morbidity and mortality. However, CR is underutilized, and adherence remains challenging. In no group is CR attendance more challenging than among patients who smoke. Despite being more likely to be referred to CR, they are less likely to enroll, and much more likely to drop out. CR programs generally do not optimally engage and treat those who smoke, but this population is critical to engage given the high-risk nature of continued smoking in those with cardiovascular disease.

AREAS COVERED

This review covers four areas relating to CR in those who smoke. First, we review the evidence of the association between smoking and lack of participation in CR. Second, we examine how smoking has historically been identified in this population and propose objective screening measures for all patients. Third, we discuss the optimal treatment of smoking within CR. Fourth, we review select populations within those who smoke (those with lower-socioeconomic status, females) that require additional research and attention.

EXPERT OPINION

Smoking poses a challenge on multiple fronts, being a significant predictor of future morbidity and mortality, as well as being strongly associated with not completing the secondary prevention program (CR) that could benefit those who smoke the most.

Impact of puberty, sex determinants and chronic inflammation on cardiovascular risk in young people

Worrying trends of increased cardiovascular disease (CVD) risk in children, adolescents and young people in the Modern Era have channelled research and public health strategies to tackle this growing epidemic. However, there are still controversies related to the dynamic of the impact of sex, age and puberty on this risk and on cardiovascular health outcomes later in life. In this comprehensive review of current literature, we examine the relationship between puberty, sex determinants and various traditional CVD-risk factors, as well as subclinical atherosclerosis in young people in general population. In addition, we evaluate the role of chronic inflammation, sex hormone therapy and health-risk behaviours on augmenting traditional CVD-risk factors and health outcomes, ultimately aiming to determine whether tailored management strategies for this age group are justified.

Cardiac Imaging in Women with Ischemic Heart Disease

Cardiac diseases are the main cause of death for both sexes worldwide. Treatment varies widely according to the sex of a patient, as there are differences in physiopathology, epidemiology, clinical presentation and management. However, women have been largely excluded from research studies in this field. At present, differences are starting to be recognized and more attention is being paid to the identification of female-specific (or emergent) atherosclerotic risk factors. Diagnostic testing also merits attention because cardiac imaging offers important information to help diagnosis and guide cardiac disease management. In this sense, multimodal imaging should be used with the most cost-effective approach, integrating this information into the clinical sphere according to the pretest probability of the disease. In this review, we address sex-specific features of ischemic heart disease that should be considered in the clinical assessment of women, as well as the value of different imaging techniques (including technical and clinical aspects) for management of women with ischemic heart disease, and identify future areas of action concerning ischemic heart disease in women.

Development of Dependence in Smokers and Rodents With Voluntary Nicotine Intake: Similarities and Differences

INTRODUCTION

Smoking and vaping throughout adolescence and early adulthood lead to nicotine dependence. Nicotine withdrawal is associated with somatic and affective withdrawal symptoms that contribute to smoking and relapse. Affective nicotine withdrawal symptoms in humans include craving for cigarettes, depression, anxiety, trouble sleeping, and cognitive deficits.

METHODS

Herein, we review clinical studies that investigated nicotine dependence in people who smoke or vape. We also discuss studies that investigated the development of dependence in animals with oral nicotine intake, nicotine aerosol self-administration, and intravenous nicotine self-administration.

RESULTS

Clinical studies report that adolescents who smoke daily develop nicotine dependence before those who smoke infrequently, but ultimately all smokers become dependent in adulthood. Preclinical studies indicate that rats that self-administer nicotine also become dependent. Rats that self-administer nicotine display somatic withdrawal signs and affective withdrawal signs, including increased anxiety and depressive-like behavior, cognitive deficits, and allodynia. Most nicotine withdrawal signs were observed in rodents with daily (7 days/week) or intermittent long access (23-hour) to nicotine. Clinical smoking studies report symptoms of nicotine dependence in adolescents of both sexes, but virtually all preclinical nicotine self-administration studies have been done with adult male rats.

CONCLUSIONS

The role of sex and age in the development of dependence in nicotine self-administration studies remains under-investigated. However, the role of sex and age in nicotine withdrawal has been thoroughly evaluated in studies in which nicotine was administered noncontingently. We discuss the need for volitional nicotine self-administration studies that explore the gradual development of dependence during adolescence and adulthood in rodents of both sexes.

IMPLICATIONS

The reviewed clinical studies investigated the development of nicotine dependence in male and female adolescent and young adult smokers and vapers. These studies indicate that most adolescent smokers and vapers gradually become nicotine dependent. Preclinical studies with rodents show that nicotine intake in widely used self-administration models also leads to dependence. However, almost all animal studies that investigated the development of nicotine dependence have been conducted with adult male rats. To better model smoking and vaping, it is important that nicotine intake in rats or mice starts during adolescence and that both sexes are included.

Epidemiology and trends in stroke mortality in the USA, 1975-2019

BACKGROUND

Whether changes in stroke mortality are affected by age distribution and birth cohorts, and if the decline in stroke mortality exhibits heterogeneity by stroke type, remains uncertain.

METHODS

We undertook a sequential time series analysis to examine stroke mortality trends in the USA among people aged 18-84 years between 1975 and 2019 (n = 4 332 220). Trends were examined for overall stroke and by ischaemic and haemorrhagic subtypes. Mortality data were extracted from the US death files, and age-sex population data were extracted from US census. Age-standardized stroke mortality rates and incidence rate ratio (IRR) with 95% confidence interval [CI] were derived from Poisson regression models.

RESULTS

Age-standardized stroke mortality declined for females from 87.5 in 1975 to 30.9 per 100 000 in 2019 (IRR 0.27, 95% CI 0.26, 0.27; average annual decline -2.78%, 95% CI -2.79, -2.78). Among males, age-standardized mortality rate declined from 112.1 in 1975 to 38.7 per 100 000 in 2019 (RR 0.26, 95% CI 0.26, 0.27; average annual decline -2.80%, 95% CI -2.81, -2.79). Stroke mortality increased sharply with advancing age. Decline in stroke mortality was steeper for ischaemic than haemorrhagic strokes.

CONCLUSIONS

Stroke mortality rates have substantially declined, more so for ischaemic than haemorrhagic strokes.

Cumulative tobacco consumption has a dose-dependent effect on atheromatosis burden and improves severe atheromatosis prediction in asymptomatic middle-aged individuals: The ILERVAS study

BACKGROUND AND AIMS

Sex-specific impact of cumulative tobacco consumption (CTC) on atheromatosis extension and total plaque area remains unknown. We aimed to determine the impact of CTC in atheromatosis localization and burden.

METHODS

We performed a cross-sectional analysis in 8330 asymptomatic middle-aged individuals. 12-territory vascular ultrasounds in carotid and femoral arteries were performed to detect atheromatous plaque presence and to measure total plaque area. Adjusted regressions and conditional predictions by smoking habit or CTC (stratified in terciles as low (≤13.53), medium (13.54-29.3), and high (>29.3 packs-year)) were calculated. Severe atheromatosis (SA, ≥3 territories with atheroma plaque) was predicted with the Systematic COronary Risk Evaluation 2 (SCORE2) model. The improvement of SA prediction after adding CTC was evaluated.

RESULTS

CTC was associated with an increased risk of atheromatosis, stronger in femoral than in carotid artery, but similar in both sexes. A dose-dependent effect of CTC on the number of territories with atheroma plaque and total plaque area was observed. Addition of CTC to the SCORE2 showed a higher sensitivity, accuracy, and negative predictive value in males, and a higher specificity and positive predictive value in females. In both sexes, the new SCORE2-CTC model showed a significant increase in AUC (males: 0.033, females: 0.038), and in the integrated discrimination index (males: 0.072; females: 0.058, p < 0.001). Age and CTC were the most important clinical predictors of SA in both sexes.

CONCLUSIONS

CTC shows a dose-dependent association with atheromatosis burden, impacts more strongly in femoral arteries, and improves SA prediction.

Sex differences in care complexity and cost of cardiac-related procedures as a basis for improving hospital payments systems

In this study, we estimate sex differences in care complexity and cost of cardiac-related procedures in order to demonstrate the importance of sex as a risk adjuster in a hospital payment system. We use individual visit-level data for all adult Israelis who underwent either heart valve surgery (HVS) or coronary artery bypass graft surgery (CABG) during the period 2014-2018 in publicly funded hospitals. We find that women undergoing a cardiac-related procedure are more likely to die during hospitalization, they have longer hospital stays, and overall, they are more likely to be care-complex than men. Furthermore, the cost of the surgery itself is higher for women than for men in the case of HVS (though not CABG), and the cost of the post-operative hospital stay is higher in the case of CABG (though not HVS). It is concluded that sex differences should be considered in the calculation of payment for cardiac-related procedures in order to reduce incentives for selection and reduce unwarranted variation in cardiac-care utilization and medical practice.

Mortality risk factors in community-dwelling, subjectively healthy, Swiss older adults: update after 8-years follow-up

BACKGROUND

Worldwide population is ageing, but little is known regarding risk factors associated with increased mortality in subjectively healthy, community-dwelling older adults. We present the updated results of the longest follow-up carried out on Swiss pensioners and we provide results on potential risk factors associated with mortality before the onset of the COVID-19 pandemic.

MATERIALS AND METHODS

Within the SENIORLAB study, we collected demographic data, anthropometric measures, medical history, and laboratory parameters of 1467 subjectively healthy, community-dwelling, Swiss adults aged ≥ 60 years over a median follow-up of 8.79 years. The variables considered in the multivariable Cox-proportional hazard model for mortality during follow-up were selected based on prior knowledge. Two separate models for males and females were calculated; moreover, we fitted the old model obtained in 2018 to the complete follow-up data to highlight differences and similarities.

RESULTS

The population sample included 680 males and 787 females. Age of participants ranged between 60 and 99 years. We experienced 208 deaths throughout the entire follow-up period; no patients were lost at follow-up. The Cox-proportional hazard regression model included female gender, age, albumin levels, smoking status, hypertension, osteoporosis and history of cancer within predictors of mortality over the follow-up period. Consistent findings were obtained also after gender stratification. After fitting the old model, female gender, hypertension, and osteoporosis still showed statistically significant independent associations with all-cause mortality.

CONCLUSIONS

Understanding the predictors of a healthy survival can improve the overall quality of life of the ageing population and simultaneously reduce their global economic burden.

TRIAL REGISTRATION

The present study was registered in the International Standard Randomized Controlled Trial Number registry: https://www.isrctn.com/ISRCTN53778569 (registration date: 27/05/2015).

Smoking Increases the Risk of Hepatocellular Carcinoma and Cardiovascular Disease in Patients with Metabolic-Associated Fatty Liver Disease

The association of smoking with hepatocellular carcinoma (HCC) or cardiovascular disease (CVD) has been reported, but the study of its relationship with metabolic-associated fatty liver disease (MAFLD) is limited. We aimed to investigate the effect of smoking on the incidence of HCC or CVD in MAFLD patients. Using the Korean nationwide health screening database, we analyzed subjects between 2001 and 2015. A total of 283,088 subjects including 110,863 MAFLD patients and 172,225 controls were analyzed. Smoking status was divided by non-smoker, ex-smoker, or current smoker. In the follow-up period, a total of 2903 (1.0%) subjects developed HCC, and the MAFLD group (1723, 1.6%) had a significantly higher incidence than the control group (1180, 0.7%). In the MAFLD group, current smokers showed significantly higher risk of HCC compared to non-smokers (adjusted HR 1.24, 95% CI 1.08-1.41), whereas the control group did not (adjusted HR 1.07, 95% CI 0.89-1.30). A total of 18,984 (6.7%) patients developed CVD, and the incidence was significantly higher in the MAFLD group (8688, 7.8%) than in the control group (10,296, 6.0%), similar to HCC. The risk of CVD in current smokers increased by 22% compared to non-smokers in the MAFLD group (adjusted HR 1.22, 95% CI 1.15-1.30) and by 21% (adjusted HR 1.21, 95% CI 1.13-1.29) in the control group. Based on sex stratification, men showed increased incidence of both HCC and CVD by smoking, whereas women had only increased risk of CVD. Smoking significantly increases the incidence of HCC and CVD in MAFLD patients; thus, it is highly recommended to quit smoking completely in the population with MAFLD.

3,4-benzopyrene aggravates myocardial ischemia-reperfusion injury-induced pyroptosis through inhibition of autophagy-dependent NLRP3 degradation

Polycyclic aromatic hydrocarbons (PAHs) are produced during combustion of organic matter, such as during cigarette smoking, and they exist widely in the environment. Exposure to 3,4-benzo[a]pyrene (BaP), as the most widely studied PAHs, relates to many cardiovascular diseases. However, the underlying mechanism of its involvement remains largely unclear. In this study, we developed a myocardial ischemia-reperfusion (I/R) injury mouse model and an oxygen and glucose deprivation-reoxygenation H9C2 cell model to evaluate the effect of BaP in I/R injury. After BaP exposure, the expression of autophagy-related proteins, the abundance of NLRP3 inflammasomes, and the degree of pyroptosis were measured. Our results show that BaP aggravates myocardial pyroptosis in a autophagy-dependent manner. In addition, we found that BaP activates the p53-BNIP3 pathway via the aryl hydrocarbon receptor to decrease autophagosome clearance. Our findings present new insights into the mechanisms underlying cardiotoxicity and reveal that the p53-BNIP3 pathway, which is involved in autophagy regulation, is a potential therapeutic target for BaP-induced myocardial I/R injury. Because PAHs are omnipresent in daily life, the toxic effects of these harmful substances should not be underestimated.

HbA1c is a predictive factor of severe coronary stenosis and major adverse cardiovascular events in patients with both type 2 diabetes and coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is not only a macrovascular complication of type 2 diabetes mellitus (T2DM). Cardiovascular disease (CVD) is one of the leading causes of mortality among individuals with T2DM. Reducing the risk of adverse cardiovascular events (MACE) is crucial for the management of patients with CHD. This study aimed to investigate the effect of glycemic control on CHD severity and 3-point MACE (3p-MACE) risk in patients with T2DM and CHD.

METHODS

681 patients with both T2DM and CHD throughout October 2017 and October 2021 who were hospitalized in the second affiliated hospital of Nanchang university were included. A total of 300 patients were eventually enrolled in this retrospective cohort research. The severity of CHD in these patients was assessed, and the primary outcome during follow-up was recorded, with the primary result being the 3-point major adverse cardiovascular event (3p-MACE). The correlation between baseline glycated hemoglobin A1c (b-HbA1c) and the severity of CHD was evaluated by logistic regression analysis. The effect of b-HbA1c and follow-up HbA1c (f-HbA1c) levels on the risk of 3p-MACE were investigated by cox regression analysis.

RESULTS

b-HbA1c was positively correlated with the severity of CHD (r = 0.207, p = 0.001), and patients with b-HbA1c > 9% were more likely to have severe CHD. The HRs for b-HbA1c and f-HbA1c on the risk of 3p-MACE were 1.24 (95% CI 0.94-1.64, p = 0.123) and 1.32 (95% CI 1.02-1.72, p = 0.036), respectively. Patients with f-HbA1c   ≥8.6% had a higher risk of 3p-MACE than f-HbA1c < 8.6% (HR = 1.79, 95% CI 1.16-2.79, p = 0.009).

CONCLUSION

In patients with both T2DM and CHD, b-HbA1c was an independent predictive factor of severe CHD. f-HbA1c was an independent predictive factor of 3p-MACE. Having the f-HbA1c below 8.6% significantly reduced the risk of 3p-MACE.

Overall Clinical Features of Type 2 Diabetes Mellitus With Respect to Gender

Introduction Since patients with type 2 diabetes are frequently misdiagnosed, provided inappropriate management, or poorly controlled, it is important to comprehend the wide range of clinical signs and symptoms associated with diabetes. Therefore, this study evaluated the overall clinical manifestations of patients with type 2 diabetes patients with respect to gender. Methods This was a multicenter, cross-sectional study that was conducted at various hospitals, using a non-probability sampling technique. The duration of the study was about six months, from January 1, 2022 to June 30, 2022. The study included 590 type 2 diabetes patients, ranging in age from 35 to 70 years. Age, gender, socioeconomic status, health status, co-morbidities, and diabetes symptoms were documented. A chi-square was applied to determine the association between overall symptoms associated with type 2 diabetes and gender. An independent t-test was applied to determine the significance level between means of demographic parameters. Results The study findings showed that out of 590 patients with diabetes, 310 (52.5%) were males and 280 (47.5%) were females. The male and female mean ages were 57.46±14.93 and 50.38±14.85 years, respectively, with a statistically significant gender difference (p<0.001). The prevalence of renal manifestation in type 2 patients with diabetes revealed a significant relationship (p<0.05) for both genders. The prevalence of ocular manifestations revealed a significant relationship with both genders (p<0.05) in terms of distortion and blurred vision. The prevalence of ocular manifestations revealed a significant relationship observed with both genders (p<0.05) in terms of shortness of breath, dyspnea severity, and severity of chest pain. Conclusion This study concluded that women with type 2 diabetes mellitus have a significantly higher frequency of muscular pain, urinary symptoms, neurological symptoms, and dermatological manifestations than men. In contrast, respiratory symptoms were significantly more pronounced in males than in females. The presence of comorbidities such as dyslipidemia significantly increased the probability of developing type 2 diabetes in both genders.

Association between major adverse cardiovascular events and pentraxin-3 in patients who have undergone coronary computed tomography angiography: from the FU-CCTA registry

Chronic vasculitis is considered to be associated with future cardiovascular events. Here, we present major cardiovascular events (MACEs) in patients who underwent coronary computed tomography angiography (CCTA) for screening for coronary artery disease (CAD), and the association between MACEs and the inflammation marker pentraxin (PTX)-3 or highly sensitive C-reactive protein (hsCRP). The patients who underwent CCTA for the purpose of screening for CAD at Fukuoka University Hospital (FU-CCTA registry), 456 patients with suspected CAD or at least one cardiovascular risk factor were followed for up to 5 years. The levels of PTX-3 and hsCRP in blood were measured at the time of CCTA, and the patients were divided into two groups according to the presence (MACEs group) or absence (non-MACEs group) of MACEs. There were no differences in PTX-3 or hsCRP between the MACEs (-) and MACEs ( +) groups in all patients. A multivariate analysis related to the presence or absence of MACEs by logistic regression analysis of inflammation factors (PTX-3 and hsCRP) in addition to conventional risk factors as independent variables was performed. PTX-3 was a predictor of MACEs in males, whereas smoking, but not PTX-3, was a predictor of MACEs in females. PTX-3 could be a predictor of MACEs in males, but not females.

Risk factor clustering in men and women with CHD in the Southern Cone of Latin America

Background

Presence of multiple risk factors (RF) increases the risk for cardiovascular morbidity and mortality, and this is especially important in patients with coronary heart disease (CHD). The current study investigates sex differences in the presence of multiple cardiovascular RF in subjects with established CHD in the southern Cone of Latin America.

Methods

We analyzed cross-sectional data from the 634 participants aged 35-74 with CHD from the community-based CESCAS Study. We calculated the prevalence for counts of cardiometabolic (hypertension, dyslipidemia, obesity, diabetes) and lifestyle (current smoking, unhealthy diet, low physical activity, excessive alcohol consumption) RF. Differences in RF number between men and women were tested with age-adjusted Poisson regression. We identified the most common RF combinations among participants with ≥4 RF. We performed a subgroup analysis by educational level.

Results

The prevalence of cardiometabolic RF ranged from 76.3% (hypertension) to 26.8% (diabetes), and the prevalence of lifestyle RF from 81.9% (unhealthy diet) to 4.3% (excessive alcohol consumption). Obesity, central obesity, diabetes and low physical activity were more common in women, while excessive alcohol consumption and unhealthy diet were more common in men. Close to 85% of women and 81.5% of men presented with ≥4 RF. Women presented with a higher number of overall (relative risk (RR) 1.05, 95% CI 1.02-1.08) and cardiometabolic RF (1.17, 1.09-1.25). These sex differences were found in participants with primary education (RR women overall RF 1.08, 1.00-1.15, cardiometabolic RF 1.23, 1.09-1.39), but were diluted in those with higher educational attainment. The most common RF combination was hypertension/dyslipidemia/obesity/unhealthy diet.

Conclusion

Overall, women showed a higher burden of multiple cardiovascular RF. Sex differences persisted in participants with low educational attainment, and women with low educational level had the highest RF burden.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Predictors for quitting smoking in smoking cessation clinics among female smokers in China

INTRODUCTION

The number of cessation clinics in China have been increasing ever since the Chinese government supported the establishment of smoking cessation clinics (SCCs) in each province in 2014. Many studies have examined smoking cessation behaviors among male smokers, but few of female smokers. This study aimed to understand female smokers' quitting behaviors in SCCs and identify predictors of successful cessation.

METHODS

This study used data of the SCCs Platform in China from 2018 to 2020. The self-reported 7-day point prevalence of abstinence rate (PPAR) at 1 month and at 3 months follow-up and the continuous abstinence rate (CAR) at 3 months follow-up are reported based on smokers' characteristics and intention to treat analysis. A multiple logistic regression model was used to identify predictors of continuous abstinence at 3 months follow-up.

RESULTS

The 7-day PPAR of female outpatients in SCCs was 29.20% at 1 month follow-up and 28.36% at 3 months follow-up. The CAR at 3 months follow-up was 19.88%. Female smokers who were prepared to quit within 7 days (AOR=2.86; 95% CI: 1.53-5.32), today (AOR=4.01; 95% CI: 2.35-6.85), had started to quit (AOR=7.11; 95% CI: 4.12-12.27), and used a combination of counseling and drugs (AOR=2.41; 95% CI: 1.73-3.35) were more likely to quit smoking. Associated with lower quitting rates were: living in the central region of China (AOR=0.47; 95% CI: 0.31-0.73) and the west region (AOR=0.48; 95% CI: 0.31-0.73); being aged 30-39 years (AOR=0.39; 95% CI: 0.23-0.64), and 40-49 years (AOR=0.41; 95% CI:0.24-0.69); being unemployed (AOR=0.64; 95% CI: 0.45-0.91); having a fair perceived health status at the first visit (AOR=0.65; 95% CI: 0.47-0.91) and a poor one (AOR=0.37; 95% CI: 0.21-0.64); having a moderate nicotine dependence (AOR=0.64; 95% CI: 0.44-0.92) and a severe one (AOR=0.50; 95% CI: 0.34-0.72).

CONCLUSIONS

In our study, the region of residence, age, employment, perceived health status, Fagerström test for nicotine dependence (FTND), readiness to quit, and intervention model were independent predictors of quitting for female smokers. Improving the motivation to quit, providing intensive psychological interventions and equipping SCCs with cessation medication would assist female smokers to quit.

Degree of Joint Risk Factor Control and Incident Heart Failure in Hypertensive Patients

BACKGROUND

Heart failure (HF) is a major complication in patients with hypertension.

OBJECTIVES

This study aimed to investigate the extent to which joint risk factor control could attenuate hypertension-related excess risk of HF.

METHODS

The study included a total of 75,293 participants with diagnosed hypertension from the UK Biobank and matched with 256,619 nonhypertensive control subjects, followed up until May 31, 2021. The degree of joint risk factor control was assessed on the basis of the major cardiovascular risk factors, including blood pressure, body mass index, low-density lipoprotein cholesterol, hemoglobin A1c, albuminuria, smoking, and physical activity. The Cox proportional hazards models were used to estimate associations between the degree of risk factor control and risk of HF.

RESULTS

Among hypertensive patients, joint risk factor control showed an association with a stepwise reduction of incident HF risk. Each additional risk factor control was related to a 20% lower risk, and the optimal risk factor control (controlling ≥6 risk factors) was associated with a 62% lower risk (HR: 0.38; 95% CI: 0.31-0.45). In addition, the study found that the hypertension-related excess risk of HF among participants jointly controlling ≥6 risk factors were even lower than in nonhypertensive control subjects (HR: 0.79; 95% CI: 0.67-0.94). The protective associations of joint risk factor control and risk of incident HF were broadly stronger among men than women and among medication users than nonusers (P for interaction < 0.05).

CONCLUSIONS

The joint risk factor control is associated with a lower risk of incident HF in an accumulative and sex-specific manner. Optimal risk factor control may eliminate hypertension-related excess risk of HF.

Assessment of Cardiovascular Risk in Women: Progress so Far and Progress to Come

Cardiovascular disease is the leading cause of death in women worldwide. Nonetheless, there exist several uncertainties in the prediction, diagnosis, and treatment of cardiovascular disease in women. A cornerstone in the prediction of cardiovascular disease is the implementation of risk scores. A variety of pregnancy- and reproductive-factors have been associated with lower or higher risk of cardiovascular disease. Consequently, the question has been raised, whether these female-specific factors also provide added value to cardiovascular risk prediction. In this review, we provide an overview of the existing literature on sex differences in the association of established cardiovascular risk factors with cardiovascular disease and the relation between female-specific factors and cardiovascular risk. Furthermore, we systematically reviewed the literature for studies that assessed the added value of female-specific factors beyond already established cardiovascular risk factors. Adding female-specific factors to models containing established cardiovascular risk factors has led to little or no significant improvement in the prediction of cardiovascular events. However, analyses primarily relied on data from women aged ≥40 years. Future investigations are needed to quantify whether pregnancy-related factors improve cardiovascular risk prediction in young women in order to support adequate treatment of risk factors and enhance prevention of cardiovascular disease in women.

The drospirenone (DRSP)-only pill: clinical implications in the daily use

OBJECTIVES

Progestins used in contraception are either components of combined hormonal contraceptives or are used as a single active ingredient. Progestins are highly effective in long-term contraception and have a very good safety profile with very few contraindications.

METHODS

An oestrogen-free ovulation inhibitor POP has been authorised in the USA and the EU. It contains 4 mg of drospirenone (DRSP). The hormone administration regimen of 24 days followed by a 4-day hormone-free period was chosen to improve bleeding control and to maintain oestradiol concentrations at early follicular- phase levels, preventing oestrogen deficiency.

RESULTS

Clinical trials have demonstrated high contraceptive effectiveness, a very low risk of cardiovascular risk events and a favourable bleeding pattern. Due to the long half-life of DRSP (30-34 h), the effectiveness is maintained even in case of a forgotten pill on a single occasion. Studies involving deliberate 4 days in one cycle 24-hour delays in taking a pill have demonstrated that ovulation inhibition is maintained if a single pill is missed.

CONCLUSIONS

This review article will describe the clinical impact in the daily use of the 4 mg DRSP only pill and the resulting data on the effectiveness and safety of this hormonal contraceptive.

Smoking and diabetes: sex and gender aspects and their impact on vascular diseases

Smoking and diabetes mellitus (DM) have been identified as two major cardiovascular risk factors for many years. In the field of cardiovascular diseases, considering sex differences, or gender differences, or both has become an essential element in moving toward equitable and quality healthcare. We reviewed the impact of sex or gender on the link between smoking and DM. The risk of type 2 DM (T2DM) due to smoking has been established in both sexes at the same level. As is the case in the general population, the prevalence of smoking in those with DM is higher in men than in women, although the decrease in smoking observed in recent years is more pronounced in men than in women. Regarding chronic DM complications, smoking is an independent risk factor for all-cause mortality, as well as macrovascular and microvascular complications, in both sexes. Nevertheless, in T2DM, the burden of smoking appears to be greater in women than in men for coronary heart disease morbidity, women having a 50% higher risk of fatal coronary event. Women are more dependent to nicotine, cumulate psychosocial barriers to quitting smoking, and are more likely to gain weight, which might make it more difficult for them to quit smoking. Smoking cessation advice and treatments should take into account gender differences to improve the success and long-term maintenance of abstinence in people with and without DM. This might include interventions that address emotions and stress in women or designed to reach specific populations of men.

The contribution of smoking to differences in cardiovascular disease incidence between men and women across six ethnic groups in Amsterdam, the Netherlands: The HELIUS study

It is unclear to what extent differences in cardiovascular disease (CVD) risk between men and women are explained by differences in smoking, and whether this contribution to risk is consistent across ethnic groups. In this prospective study, we determined the contribution of smoking to differences in CVD incidence between men and women, also in various ethnic groups. We linked baseline data of 18,058 participants of six ethnic groups from the HELIUS study (Amsterdam, the Netherlands) to CVD incidence data, based on hospital admission and death records from Statistics Netherlands (2013-2019). The contribution of smoking to CVD incidence, as estimated by the population attributable fraction, was higher in men than in women, overall (24.1% versus 15.6%) and across most ethnic groups. Among Dutch participants, however, the contribution of smoking was higher among women (21.0%) than men (16.2%). Using Cox regression analyses, we observed that differences in smoking prevalence explained 22.0% of the overall lower hazard for CVD in women compared to men. Smoking contributed minimally to the lower hazards for CVD in women among participants of Dutch (0%), Ghanaian (4.9%) and Moroccan origin (0%), but explained 28.6% and 48.6% of the lower hazards in women in South-Asian Surinamese and African Surinamese groups, respectively. While smoking prevention and cessation may lead to lower CVD incidence in most groups of men and women, it may not substantially reduce disparities in CVD risk between men and women in most ethnic groups.

Sex-Linked Biology and Gender-Related Research Is Essential to Advancing Hearing Health

There is robust evidence that sex (biological) and gender (behavioral/social) differences influence hearing loss risk and outcomes. These differences are noted for animals and humans-in the occurrence of hearing loss, hearing loss progression, and response to interventions. Nevertheless, many studies have not reported or disaggregated data by sex or gender. This article describes the influence of sex-linked biology (specifically sex-linked hormones) and gender on hearing and hearing interventions, including the role of sex-linked biology and gender in modifying the association between risk factors and hearing loss, and the effects of hearing loss on quality of life and functioning. Most prevalence studies indicate that hearing loss begins earlier and is more common and severe among men than women. Intrinsic sex-linked biological differences in the auditory system may account, in part, for the predominance of hearing loss in males. Sex- and gender-related differences in the effects of noise exposure or cardiovascular disease on the auditory system may help explain some of these differences in the prevalence of hearing loss. Further still, differences in hearing aid use and uptake, and the effects of hearing loss on health may also vary by sex and gender. Recognizing that sex-linked biology and gender are key determinants of hearing health, the present review concludes by emphasizing the importance of a well-developed research platform that proactively measures and assesses sex- and gender-related differences in hearing, including in understudied populations. Such research focus is necessary to advance the field of hearing science and benefit all members of society.

2021 EULAR recommendations regarding lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases

OBJECTIVES

A European League Against Rheumatism taskforce was convened to review the literature and develop recommendations on lifestyle behaviours for rheumatic and musculoskeletal diseases (RMDs).

METHODS

Six lifestyle exposures (exercise, diet, weight, alcohol, smoking, work participation) and seven RMDs (osteoarthritis, rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis, systemic lupus erythematosus, systemic sclerosis, gout) were considered. The taskforce included health professionals in rheumatology, geriatricians, epidemiologists, public health experts, people with RMDs and exposure domain experts. Systematic reviews were conducted to gather available evidence, from which recommendations were developed.

RESULTS

Five overarching principles and 18 specific recommendations were defined based on available evidence. The overarching principles define the importance of a healthy lifestyle, how lifestyle modifications should be implemented, and their role in relation to medical treatments. Exercise recommendations highlight the safety and benefits of exercise on pain and disability, particularly among people with osteoarthritis and axial spondyloarthritis. The diet recommendations emphasise the importance of a healthy, balanced diet for people with RMDs. People with RMDs and health professionals should work together to achieve and maintain a healthy weight. Small amounts of alcohol are unlikely to negatively affect the outcomes of people with RMDs, although people with rheumatoid arthritis and gout may be at risk of flares after moderate alcohol consumption. Smokers should be supported to quit. Work participation may have benefits on RMD outcomes and should be discussed in consultations.

CONCLUSIONS

These recommendations cover a range of lifestyle behaviours and can guide shared decision making between people with RMDs and health professionals when developing and monitoring treatment plans.

Gender Differences Among Out-of-School Korean Adolescents in a Counselor-Visiting Smoking Cessation Program

ABSTRACT

The purpose of this study was to explore the determinants of self-reported smoking cessation among out-of-school Korean adolescents who participated in a counselor-visiting smoking cessation program. This retrospective descriptive study analyzed data from the Korea Health Promotion Institute. Participants were enrolled between June 1, 2015, and December 31, 2017, at a regional smoking cessation center in a counselor-visiting smoking cessation program for out-of-school adolescents. Participants consisted of 807 adolescents (70.3% male) with a mean age of 16.9 ± 1.2 years. Multiple logistic regression analysis showed that female gender (OR = 1.54-1.92), cohort year 2016 (OR = 1.69-1.90), smoking more than half a pack a day (OR = 0.44-0.50), strong motivation to quit (OR = 1.44), and number of counseling in person (OR = 1.97-2.10) were statistically significant independent contributors to quitting, based on follow-up assessments at 4 weeks, 12 weeks, and 6 months. This study explored smoking cessation outcomes of a government-driven smoking cessation program that targeted out-of-school adolescents and identified several risk factors that affect a successful outcome. More research is necessary to evaluate the efficacy of such smoking cessation programs for marginalized or understudied populations.

Sex-specific and age-specific incidence of ischaemic heart disease, atrial fibrillation and heart failure in community patients with chronic obstructive pulmonary disease

OBJECTIVE

To estimate the incidence of ischaemic heart disease, atrial fibrillation and heart failure in community patients with or without chronic obstructive pulmonary disease (COPD).

METHODS

For this population-based study, we used primary care data of the Julius General Practitioners' Network. Eligible participants were aged 40-80 years old and contributed data between January 2014 and February 2019. Participants were divided into groups according to COPD status and were followed up for new ischaemic heart disease, atrial fibrillation and/or heart failure. Age-specific and sex-specific incidence and incidence rate ratios were calculated for patients with and without COPD.

RESULTS

Mean follow-up was 3.9 years, 6223 patients were included in the COPD group, and 137 028 individuals in the background group without COPD. Incidence rates of all three heart diseases increased with age and were higher in males, independent of presence of COPD. Incidence rate ratios for patients with COPD, adjusted for age and sex, were 1.69 (95% CI 1.49 to 1.92) for ischaemic heart disease, 1.56 (95% CI 1.38 to 1.77) for atrial fibrillation and 2.96 (95% CI 2.58 to 3.40) for heart failure.

CONCLUSION

The incidence of all major cardiovascular diseases is higher in patients with COPD, with the highest incidence rate ratio observed for heart failure.

Diastolic dysfunction and sex-specific progression to HFpEF: current gaps in knowledge and future directions

Diastolic dysfunction of the left ventricle (LVDD) is equally common in elderly women and men. LVDD is a condition that can remain latent for a long time but is also held responsible for elevated left ventricular filling pressures and high pulmonary pressures that may result in (exercise-induced) shortness of breath. This symptom is the hallmark of heart failure with preserved ejection fraction (HFpEF) which is predominantly found in women as compared to men within the HF spectrum. Given the mechanistic role of LVDD in the development of HFpEF, we review risk factors and mechanisms that may be responsible for this sex-specific progression of LVDD towards HFpEF from an epidemiological point-of-view and propose future research directions.

Smoking and combined oral contraceptives should be considered as an independent variable in sex and gender-oriented studies

The influence of sex combined with smoking and combined oral contraceptives (COC) use on atherogenic indexes is scarcely studied. Thus, traditional lipid parameters were measured, and non-traditional atherogenic indexes were calculated in a young and healthy population of men, COC-free women, and COC users. Total cholesterol (TChol), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and HDL/LDL ratio were lower in men, while triglycerides (TG)/HDL ratio, atherogenic index of plasma (AIP), Castelli's Risk Index I (CRII) and CRI-II, atherogenic coefficient (AC), creatinine, creatinine clearance, and estimated glomerular filtration rate (eGFR) were higher in men. The use of COC modified TChol, HDL, TG, TG/HDL, and AIP which had significantly higher values in COC users. In addition, TG were also increased in COC users in comparison with men. Smoking reduced sexually divergent parameters: BMI, TG, HDL/LDL, TG/HDL, AIP, CRII, CRI-II, and AC became similar among the three cohorts, losing the reported sex differences. Smoking also reduced differences in TChol, HDL, TG, and AIP between COC-free women and COC users, but it does not affect CRII, CRI-II, creatinine, creatinine clearance, and eGFR, underlining that COC users and COC-free women have to be considered two different populations. Our results represent a complex landscape suggesting that for both sexes smoking should be an independent variable in medical studies. Moreover, in women, the use of COC evidenced two different cohorts. Thus, more variables should be considered during a single study indicating that sex, smoking, and COC should be studied together to get a picture of the real-life context.

Occupational exposure to respirable crystalline silica and acute myocardial infarction among men and women in Sweden

OBJECTIVES

Occupational exposure to respirable crystalline silica (RCS) is common. The study aimed to assess the risk for acute myocardial infarction (AMI) after long-term exposure to RCS and to explore differences in risk between men and women.

METHODS

The cohort included all manual workers identified from the Swedish National Census in 1980 using data on job titles and demography altogether from five censuses from 1960 to 1990, in total 605 246 men and 480 607 women. Information on AMI was obtained from nationwide registers from 1992 to 2006. Exposure to RCS was assessed with a job-exposure matrix. HRs and 95% CIs were estimated by Cox regression, adjusted for age, socioeconomic status and urbanisation index.

RESULTS

Among manual workers ever exposed to RCS, the adjusted risk of AMI was HR 1.29 (95% CI 1.15 to 1.46) in women, and HR 1.02 (95% CI 1.00 to 1.04) in men. In the highest quartile of cumulative exposure, the risk of AMI was HR 1.66 (95% CI 1.27 to 2.18) for women, and HR 1.06 (95% CI 1.03 to 1.10) for men, respectively. The risk of AMI increased with cumulative exposure to RCS both in women (p=0.001) and in men (p=0.016). An interaction analysis showed that the relative risk from exposure to RCS was statistically significantly lower in men than in women at similar exposure levels.

CONCLUSIONS

Occupational exposure to RCS was related to the risk of AMI. Women were more sensitive to exposure to RCS than men.

Sex difference after acute myocardial infarction patients with a history of current smoking and long-term clinical outcomes: Results of KAMIR Registry

BACKGROUND

The contribution of sex as an independent risk factor for cardiovascular disease still remains controversial. The present study investigated the impact of sex on long-term clinical outcomes in Korean acute myocardial infarction (AMI) patients with a history of current smoking on admission after drug-eluting stents (DESs).

METHODS

A total of 12,565 AMI patients (male: n = 11,767 vs. female: n = 798) were enrolled. Major adverse cardiac events (MACEs) comprising all-cause death, recurrent myocardial infarction (Re-MI), and any repeat revascularization were the primary outcomes that were compared between the two groups. Probable or definite stent thrombosis (ST) was the secondary outcome.

RESULTS

After adjustment, the early (30 days) cumulative incidences of MACEs (adjusted hazard ratio [aHR]: 1.457; 95% confidence interval [CI]: 1.021-2.216; p = 0.035) and all-cause death (aHR: 1.699; 95% CI: 1.074-2.687; p = 0.023) were significantly higher in the female group than in the male group. At 2 years, the cumulative incidences of all-cause death (aHR: 1.561; 95% CI: 1.103-2.210; p = 0.012) and Re-MI (aHR: 1.800; 95% CI: 1.089-2.974; p = 0.022) were significantly higher in the female group than in the male group. However, the cumulative incidences of ST were similar between the two groups (aHR: 1.207; 95% CI: 0.583-2.497; p = 0.613).

CONCLUSIONS

The female group showed worse short-term and long-term clinical outcomes compared with the male group comprised of Korean AMI patients with a history of current smoking after successful DES implantation. However, further studies are required to confirm these results.

Impact of the natural hormonal milieu on ventral striatal responses to appetitive cigarette smoking cues: A prospective longitudinal study

Background

The female sex hormones estradiol (E) and progesterone (P) galvanize the ventral striatal reward pathway. E elevates ventral striatal dopamine and accelerates drug-cued reinstatement, while P has opposing 'protective' effects on drug-related behavior. We hypothesize that women may exhibit greater ventral striatal responses to smoking cues (SCs) during the late follicular phase of the menstrual cycle (MC) when E is high and unimpeded by P, and reduced responses during the late luteal phase when P is high.

Methods

To test our hypothesis, 24 naturally cycling cigarette-dependent women completed functional magnetic resonance (fMRI) sessions over the course of 3 MCs at select time points to reflect the early follicular (low E and P; LEP, control condition), late follicular (high E, low P; HE) and mid-luteal (high E, high P; HEP) MC phases. During fMRI sessions (counterbalanced by phase), women were exposed to a SC versus nonSC audio-visual clip. Ovulation was verified for each MC, and hormone levels were acquired prior to sessions.

Results

Contrasts within conditions showed that ventral striatal brain responses to SCs versus nonSCs were negligible during LEP and greater during HE (p=0.009) and HP (p=0.016). Contrasts across conditions showed that HE and HEP had greater responses than LEP (p=0.005), and HE had greater responses than HEP (p=0.049).

Conclusions

Results support and extend our retrospective cross-sectional study of the influence of the hormonal milieu on SC reactivity. Results are clinically relevant as they may guide novel, hormonally-informed and immediately translatable treatment strategies that can potentially reduce relapse in naturally cycling women.

Longitudinal Changes in Smoking Habits in Women and Subsequent Risk of Cancer

INTRODUCTION

This study investigated the association between longitudinal smoking habit changes and cancer risk in a cohort of Korean women.

METHODS

Study population included women aged ≥40 years who underwent 2 biennial cancer screenings (2009-2010 and 2011-2012) and were followed up until 2020. This analysis was conducted in 2021. On the basis of changes in smoking habits, participants were grouped into sustained nonsmokers, sustained quitters, new quitters, relapsers, smoking initiators, and sustained smokers. Outcomes included incident cancer cases, smoking-related cancers, and specific cancer sites.

RESULTS

Of 3,051,946 women, the mean age was 54.8 years, and the median follow-up was 8.9 years. Compared with sustained nonsmokers, other groups had a significantly increased risk of cancer and smoking-related cancers: sustained quitters (adjusted hazard ratio=1.05; 95% CI=1.01, 1.09), new quitters (adjusted hazard ratio=1.12; 95% CI=1.07, 1.17), and sustained smokers (adjusted hazard ratio=1.14; 95% CI=1.09, 1.19). A significantly increased risk of lung, stomach, liver, and pancreas cancers was found in sustained smokers and new quitters. Relapsers/smoking initiators showed a higher risk of liver, lung, and breast cancer than sustained nonsmokers, but the strength of their corresponding adjusted hazard ratio was generally lower than that of sustained smokers. The hazard ratio of cancer risk was 0.92 (95% CI=0.87, 0.97) among sustained quitters and 0.97 (95% CI=0.91, 1.03) among new quitters relative to that among sustained smokers.

CONCLUSIONS

This study found a significant association between changes in smoking behavior and cancer risk. These findings suggest that smoking cessation is critical for cancer prevention in women.

UK women smokers' experiences of an age-progression smoking cessation intervention: Thematic analysis of accounts

Objectives

Appearance-related interventions to promote healthy behaviour have been found effective to communicate health risks. The current study aimed to explore women smokers' experiences of age-progression software showing the effects of smoking on the face.

Methods

A qualitative design was implemented, utilizing both individual interviews and focus groups within a critical realist framework. Fifteen, 19-52 year-old women smokers were administered an age-progression intervention. All participants responded to the intervention, engaged in semi-structured interviews, and were invited back to attend one of three focus groups. Data were analysed using inductive thematic analysis.

Results

Four main themes were identified: Health versus Appearance, Shock Reaction, Perceived Susceptibility, and Intention to Quit. Participants found the intervention useful, voicing need for a comprehensive approach that includes both appearance and health. Despite increases in appearance-based apps which could diminish impact, women's accounts of shock induced by the aged smoking-morphed images were similar to previous work conducted more than ten years previously.

Conclusions

The study provides novel insights in how women smokers currently perceive, and react to, an age-progression intervention for smoking cessation.

Innovation

Findings emphasise the implementation of this intervention type accompanied by health information in a range of patient settings.

Women at heart: Introducing gender cardio-oncology

As cardio-oncology imposed itself as the reference specialty for a comprehensive cardiovascular approach to all patients with cancer, a more specific and careful cardiac evaluation of women entering their journey into cancer care is needed. Gender medicine refers to the study of how sex-based biological and gender-based socioeconomic and cultural differences influence people's health. Gender-related aspects could account for differences in the development, progression, and clinical signs of diseases as well as in the treatment of adverse events. Gender also accounts for major differences in access to healthcare. As for medicine and healthcare in general, gender-related characteristics have gained significance in cardio-oncology and should no longer be neglected in both clinical practice and research. We aimed to review the most relevant cardiovascular issues in women related to the cardio-oncology approach to offer a specific gender-related point of view for clinicians involved in the care process for both cancer and cardiovascular disease.

Cardiovascular Risk Among Patients Who Smoke: Risk Profiles and Differences by Sex

INTRODUCTION

Smoking is particularly harmful to the cardiovascular system, and smoking-cessation is a key target for cardiovascular prevention. From a large nationwide database on subjects who visited smoking-cessation services, this study assessed the profile and abstinence rate comparing female with male smokers at high cardiovascular risk.

METHODS

This was an observational study from the French smoking-cessation services cohort (French national cohort Consultations de Dépendance Tabagique) between 2001 and 2018. Inclusion criteria were being aged ≥18 years and having ≥1 cardiovascular risk factor. Abstinence was self-reported (stopping cigarettes or other tobacco products use ≥28 consecutive days) and confirmed by exhaled carbon monoxide <10 parts per million. Analysis was conducted in 2021.

RESULTS

Among 36,864 people who smoke, 15,407 (42%) were women. Women were 3 years younger (48 vs 51 years, p<0.001) and more educated (≥high school diploma: 54% vs 45%, p<0.001) than men. The burden of cardiovascular risk factors was slightly lower in women than in men and, for hypercholesterolemia, hypertension, diabetes, and cardiovascular diseases, were half as frequent in women as they were in men (16% vs 32%, p<0.001). However, women suffered more often from obesity, respiratory diseases, and anxiety‒depression symptoms (53% vs 39%, p<0.001). Finally, although women were less nicotine dependent, their abstinence rate was slightly lower (52.6% vs 55.2%, p<0.001).

CONCLUSIONS

Women who smoked had a high burden of risk factors, especially obesity and elevated rates of lung diseases, and a lower abstinence rate, with more common anxiety‒depression symptoms. Men who smoked had a higher prevalence of cardiovascular disease, higher nicotine dependence, and coaddictions. These findings highlight the need to strengthen cardiovascular prevention strategies through comprehensive sex-tailored smoking-cessation interventions.

Association of mental distress with chronic diseases in 1.9 million individuals: A population-based cross-sectional study

OBJECTIVE

Mental distress has a high global prevalence and is associated with poor health outcomes. This study aimed to estimate the relationship between mental distress and the risk of 10 chronic diseases using data from the Behavioral Risk Factor Surveillance System (BRFSS).

METHODS

Cross-sectional data from the 2013, 2014, 2015, 2016 and 2017 BRFSS were analyzed. The association between mental distress based on the number of days of poor mental health and the risk of 10 chronic diseases, namely obesity, diabetes, asthma, chronic obstructive pulmonary disease (COPD), arthritis, kidney disease, coronary heart disease (CHD), stroke, skin cancer, and other cancers, were assessed by logistic regression models to calculate odds ratios and 95% confidence intervals. Subgroup analyses stratified by age and sex were also conducted.

RESULTS

Positive associations between mental distress and chronic diseases were observed. We also found a dose-response gradient between mental distress levels and the risk of all chronic diseases except skin cancer. In respondents aged 18-44 years reporting ≥23 days/month of mental distress, there has the largest odds ratio between mental distress levels and each chronic disease. Moreover, mental distress was associated with higher risks of obesity and arthritis in women relative to men.

CONCLUSIONS

Mental distress was positively associated with chronic diseases. Age and sex are crucial in this relationship. Further studies with longitudinal data are needed to clarify the direction of this association.