Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Noise exposure and risk of myocardial infarction incidence and mortality: a dose-response meta-analysis

The strength and shape of the dose-response relationship between different types of noise and myocardial infarction (MI) remain unclear. Therefore, we aimed to summarize the evidence of the association between various types of noise and MI incidence and mortality through a dose-response meta-analysis. We performed a systematic search of the PubMed, Embase, and Web of Science databases up to December 19, 2021. The generalized least-squares method and restricted cubic splines were used to assess the potential linear and nonlinear dose-response relationships between noise exposure and the risk of MI events. Twenty observational studies with 34 reports met the eligibility criteria. In the linear models, the pooled relative risk and corresponding 95% confidence interval (CI) for MI incidence was 1.04 (95% CI: 1.02 - 1.05), and the MI mortality was 1.02 (95% CI: 1.02 - 1.03) for each 10 dB(A) increase in noise exposure. In addition, we observed an approximately J-shaped dose-response relationship between noise and MI mortality (P_nonlinearity = 0.0037), whereas the threshold for the statistical impact of noise on MI mortality may be 42 dB(A). Our findings support the notion that various types of noise exposure have a positive dose-response relationship with the risk of MI incidence and mortality.

New Perspectives on Sex Steroid and Mineralocorticoid Receptor Signaling in Cardiac Ischemic Injury

The global burden of ischemic heart disease is burgeoning for both men and women. Although advances have been made, the need for new sex-specific therapies targeting key differences in cardiovascular disease outcomes in men and women remains. Mineralocorticoid receptor directed treatments have been successfully used for blood pressure control and heart failure management and represent a potentially valuable therapeutic option for ischemic cardiac events. Clinical and experimental data indicate that mineralocorticoid excess or inappropriate mineralocorticoid receptor (MR) activation exacerbates ischemic damage, and many of the intracellular response pathways activated in ischemia and subsequent reperfusion are regulated by MR. In experimental contexts, where MR are abrogated genetically or mineralocorticoid signaling is suppressed pharmacologically, ischemic injury is alleviated, and reperfusion recovery is enhanced. In the chronic setting, mineralocorticoid signaling induces fibrosis, oxidative stress, and inflammation, which can predispose to ischemic events and exacerbate post-myocardial infarct pathologies. Whilst a range of cardiac cell types are involved in mineralocorticoid-mediated regulation of cardiac function, cardiomyocyte-specific MR signaling pathways are key. Selective inhibition of cardiomyocyte MR signaling improves electromechanical resilience during ischemia and enhances contractile recovery in reperfusion. Emerging evidence suggests that the MR also contribute to sex-specific aspects of ischemic vulnerability. Indeed, MR interactions with sex steroid receptors may differentially regulate myocardial nitric oxide bioavailability in males and females, potentially determining sex-specific post-ischemic outcomes. There is hence considerable impetus for exploration of MR directed, cell specific therapies for both women and men in order to improve ischemic heart disease outcomes.

Sex-Based Differences in Outcomes Following Peripheral Artery Revascularization: Insights From VOYAGER PAD

Background

Despite high female prevalence of peripheral artery disease (PAD), little is known about sex‐based outcomes after lower extremity revascularization (LER) for symptomatic PAD. The effects of rivaroxaban according to sex following LER have not been fully reported.

Methods and Results

In VOYAGER PAD (Vascular Outcomes Study of ASA [acetylsalicylic acid] Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for Peripheral Artery Disease), low‐dose rivaroxaban versus placebo on a background of aspirin reduced the composite primary efficacy outcome of cardiovascular and limb events in patients with PAD undergoing LER. Unplanned index limb revascularization was prespecified and prospectively ascertained. The primary safety outcome was Thrombolysis in Myocardial Infarction major bleeding. Analyses of outcomes and treatment effects by sex were performed using Cox proportional hazards models. Among 6564 randomly assigned patients followed for a median of 28 months, 1704 (26.0%) were women. Among patients administered placebo, women were at similar risk for the primary efficacy outcome (hazard ratio [HR], 0.90; [95% CI, 0.74–1.09]; P=0.29) as men, while female sex was associated with a trend toward higher risk of unplanned index limb revascularization (HR, 1.18; [95% CI, 1.00–1.40]; P=0.0499). Irrespective of sex, effects of rivaroxaban were consistent for the primary efficacy outcome (P‐interaction=0.22), unplanned index limb revascularization (P‐interaction=0.64), and bleeding (P‐interaction=0.61). Women were more likely than men to discontinue study treatment (HR, 1.13; [95% CI, 1.03–1.25]; P=0.0099).

Conclusions

Among >1700 women with PAD undergoing LER, women and men were at similar risk for the primary outcome, but a trend for greater risk of unplanned index limb revascularization among women was observed. Effects of rivaroxaban were consistent by sex, though women more often discontinued treatment. Better understanding of sex‐based outcomes and treatment adherence following LER is needed.

Registration

URL: http://clinicaltrials.gov; Unique identifier: NCT02504216.

Sex-Specific Differences in Clinical Outcomes After Percutaneous Coronary Intervention: Insights from the TAILOR-PCI Trial

Background TAILOR-PCI (Tailored Antiplatelet Initiation to Lessen Outcomes due to decreased Clopidogrel Response After Percutaneous Coronary Intervention) studied genotype-guided selection of antiplatelet therapy after percutaneous coronary intervention versus conventional therapy with clopidogrel. The presence of CYP2C19 loss-of-function alleles in patients treated with clopidogrel may be associated with increased risk for ischemic events. We report a prespecified sex-specific analysis of genotyping and associated cardiovascular outcomes from this study. Methods and Results Associations between sex and major adverse cardiac events (MACE: cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia) and Bleeding Academic Research Consortium (BARC) bleeding at 12 months were analyzed using Cox proportional-hazards models. Among 5276 randomized patients, loss-of-function carriers were observed in ≈36% of both sexes, and >80% of carriers were heterozygotes. At 12 months, after adjustment for baseline differences, risks of MACE (HR , 1.28 [0.97 to 1.68]; P=0.088) and BARC bleeding (hazard ratio [HR], 1.36 [0.91 to 2.05]; P=0.14) were comparable among women and men. There were no significant interactions between sex and treatment strategy for MACE interaction P value (P_int=0.59) or BARC bleeding (P_int=0.47) nor for sex and genotype (MACE P_int=0.15, and BARC bleeding P_int=0.60). Conclusions CYP2C19 loss-of-function alleles were present in ≈1 in 3 women and men. Women had similar adjusted risks of MACE and bleeding as men following percutaneous coronary intervention. Genotype-guided therapy did not significantly reduce the risk of MACE or bleeding relative to conventional therapy for both sexes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01742117.

Analytical Considerations in Deriving 99th Percentile Upper Reference Limits for High-Sensitivity Cardiac Troponin Assays: Educational Recommendations from the IFCC Committee on Clinical Application of Cardiac Bio-Markers

The International Federation of Clinical Chemistry Committee on Clinical Application of Cardiac Bio-Markers provides evidence-based educational documents to facilitate uniform interpretation and utilization of cardiac biomarkers in clinical laboratories and practice. The committee's goals are to improve the understanding of certain key analytical and clinical aspects of cardiac biomarkers and how these may interplay in clinical practice. Measurement of high-sensitivity cardiac troponin (hs-cTn) assays is a cornerstone in the clinical evaluation of patients with symptoms and/or signs of acute cardiac ischemia. To define myocardial infarction, the Universal Definition of Myocardial Infarction requires patients who manifest with features suggestive of acute myocardial ischemia to have at least one cTn concentration above the sex-specific 99th percentile upper reference limit (URL) for hs-cTn assays and a dynamic pattern of cTn concentrations to fulfill the diagnostic criteria for MI. This special report provides an overview of how hs-cTn 99th percentile URLs should be established, including recommendations about prescreening and the number of individuals required in the reference cohort, how statistical analysis should be conducted, optimal preanalytical and analytical protocols, and analytical/biological interferences or confounds that can affect accurate determination of the 99th percentile URLs. This document also provides guidance and solutions to many of the issues posed.

Trends in Inequities in the Treatment of and Outcomes for Women and Minorities with Myocardial Infarction

STUDY OBJECTIVE

To test whether the differences across sex and race in the treatment of and outcomes for ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) have changed over a recent decade.

METHODS

We conducted a retrospective analysis of patients with a diagnosis of STEMI or NSTEMI in California from 2005 to 2015 using the Office of State Health Planning and Development dataset. Using multivariable linear regression with county-fixed effects, we measured the baseline and change over time in the proportions of patients with STEMI or NSTEMI who underwent appropriately-timed coronary angiography (day of admission and within 3 days of admission, respectively) and survived at 1 year according to sex and race (Asian, Black, Hispanic, and White) and adjusting for comorbidities, payor, and hospital characteristics.

RESULTS

We analyzed 159,068 STEMI and 294,068 NSTEMI presentations. In 2005, 50.0% of 12,329 men and 35.7% of 6,939 women with STEMI and 45.0% of 14,379 men and 33.1% of 10,674 women with NSTEMI underwent timely angiography. In 2015, 76.7% of 6,257 men and 66.8% of 2,808 women with STEMI underwent timely angiography and 56.3% of 13,889 men and 45.9% of 9,334 women with NSTEMI underwent timely angiography. In 2005, 1-year survival was 82.3% for men and 69.6% for women after STEMI; in 2013, 1-year survival was 88.1% for men and 79.1% for women. In the multivariable model, the baseline difference was 1.1 percentage points (95% confidence interval [CI] 0.2 to 1.9), and survival increased for women compared with men by 0.3 percentage points per year (95% CI 0.2 to 0.5). In 2005, 46.0% (5,878) of 12,789 White patients and 31.2% (330) of 1,057 Black patients with STEMI underwent timely angiography; in 2015 75.2% of 3,928 White patients and 69.2% of 522 Black patients underwent timely angiography for STEMI. In the multivariable model, this difference was 6.4 percentage points at baseline (95% CI 4.5 to 8.3), and the probability of undergoing timely angiography for Black patients increased by 0.3 percentage points per year (95% CI -0.1 to 0.6).

CONCLUSION

Despite overall improvements in the treatment of and outcomes for STEMI and NSTEMI, disparities persist in the treatment of and outcomes for both the conditions, particularly for women.

Intimate Relationships and Coronary Heart Disease: Implications for Risk, Prevention, and Patient Management

PURPOSE OF REVIEW

Research and clinical services addressing psychosocial aspects of coronary heart disease (CHD) typically emphasize individuals, focusing less on the context of intimate relationships such as marriage and similar partnerships. This review describes current evidence regarding the role of intimate relationships in the development, course, and management of CHD.

RECENT FINDINGS

Having an intimate partner is associated with reduced risk of incident CHD and a better prognosis among patients, but strain (e.g., conflict) and disruption (i.e., separation, divorce) in these relationships are associated with increased risk and poor outcomes. These associations likely reflect mechanisms involving health behavior and the physiological effects of emotion and stress. Importantly, many other well-established psychosocial risk and protective factors (e.g., low SES, job stress, depression, and optimism) are strongly related to the quality of intimate relationships, and these associations likely contribute to the effects of those other psychosocial factors. For better or worse, intimate partners can also affect the outcome of efforts to alter health behaviors (physical activity, diet, smoking, and medication adherence) central in the prevention and management CHD. Intimate partners also influence-and are influenced by-stressful aspects of acute coronary crises and longer-term patient adjustment and management. Evidence on each of these roles of intimate relationships in CHD is considerable, but direct demonstrations of the value of couple assessments and interventions are limited, although preliminary research is promising. Research needed to close this gap must also address issues of diversity, disparities, and inequity that have strong parallels in CHD and intimate relationships.

Sex Differences in Culprit Plaque Characteristics Among Different Age Groups in Patients With Acute Coronary Syndromes

BACKGROUND

Despite the significant decline in cardiovascular mortality in women over the past several decades, sex differences in the underlying pathology of acute coronary syndromes remain poorly understood. Previous postmortem studies have demonstrated sex differences in coronary plaque morphology with a higher prevalence of plaque erosion in young women and more plaque rupture in older women after menopause, whereas men showed no increase in prevalence of plaque rupture with age. However, in vivo data are limited.

METHODS

This study included patients who presented with acute coronary syndrome and underwent preintervention optical coherence tomography imaging of the culprit lesion. The culprit plaque was categorized as plaque rupture, plaque erosion or culprit plaque with calcification, and stratified by age. Features of plaque vulnerability at culprit lesion were also analyzed.

RESULTS

In 1368 patients (women=286), women and men had a similar distribution of culprit plaque morphology (plaque rupture versus plaque erosion). However, significant sex differences were found in the underlying mechanisms of acute coronary syndrome among different age groups: women showed a significant ascending trend with age in plaque rupture (P<0.001) and the features of plaque vulnerability such as lipid plaque (P<0.001), thin-cap fibroatheroma (P=0.005), and microstructures including macrophages, cholesterol crystals, and calcification (P=0.026). No trend was observed in men.

CONCLUSIONS

Age related sex differences in culprit plaque morphology and vulnerability were identified in patients with acute coronary syndrome: prevalence of plaque rupture and vulnerability increased with age in women but not in men.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT01110538 and NCT03479723.

The association of biological sex and long-term outcomes in patients with acute dyspnea at the emergency department

BACKGROUND AND IMPORTANCE

Marked differences have been described between women and men in disease prevalence, clinical presentation, response to treatment and outcomes. However, such data are scarce in the acutely ill. An awareness of differences related to biological sex is essential for the success of clinical care and outcomes in patients presenting with acute dyspnea, the most frequent cause of emergency department (ED) admission.

OBJECTIVES

The aim of the present study was to assess the effect of biological sex on 1-year all-cause mortality in patients presenting with acute dyspnea to the ED.

DESIGN, SETTINGS AND PARTICIPANTS

Consecutive adult patients presenting with acute dyspnea in two Lithuanian EDs were included. Clinical characteristics, laboratory data and medication use at discharge were collected. Follow-up at 1 year was performed via national data registries.

OUTCOMES MEASURE AND ANALYSIS

The primary outcome of the study was 1-year all-cause mortality. Hazard ratios (HRs) for 1-year mortality according to biological sex were calculated using a Cox proportional hazards regression model, with and without adjustment for the following confounders: age, systolic blood pressure, creatinine, sodium and hemoglobin.

MAIN RESULTS

A total of 1455 patients were included. Women represented 43% of the study population. Compared to men, women were older [median (interquartile range [IQR]) age 74 (65-80) vs. 68 (59-77) years, P < 0.0001]. The duration of clinical signs before admission was shorter for women [median (IQR) duration 4 (1-14) vs. 7(2-14) days, P = 0.006]. Unadjusted 1-year all-cause mortality was significantly lower in women (21 vs. 28%, P = 0.001). Adjusted HR of 1-year all-cause mortality was lower in women when compared to men [HR 0.68 (0.53-0.88), P = 0.0028]. Additional sensitivity analyses confirmed the survival benefit for women in subgroups including age greater and lower than 75 years, the presence of comorbidities and causes of dyspnea (cardiac or noncardiac).

CONCLUSION

Women have better 1-year survival than men after the initial ED presentation for acute dyspnea. Understanding the biological sex-related differences should lead toward precision medicine, and improve clinical decision-making to promote gender equality in health.

Development and Validation of a Novel Risk Stratification Model for Slow-Flow/No-Reflow During Primary Percutaneous Coronary Intervention (the RK-SF/NR Score)

In this study, we developed and validated a novel risk stratification model to predict slow-flow/no-reflow (SF/NR) during the primary percutaneous coronary intervention (PCI), namely the RK-SF/NR score. A total of 1,711 consecutive patients with ST-segment elevation myocardial infarction (STEMI) undergone primary PCI. A novel risk stratification model was developed in the development dataset and tested in the validation dataset. The overall incidence rate of SF/NR during the procedure was 28.8% (493/1,711). The final solution consisted of 9 variables: female gender (points = 2), total ischemic time ≥8 hours (points = 1), cardiac arrest at presentation (points = 2), left ventricular end-diastolic pressure ≥24 mm Hg (points = 3), left ventricular ejection fraction ≤30% (points = 2), culprit proximal left anterior descending artery (points = 3), thrombus grade ≥4 (points = 6), preprocedure thrombolysis in myocardial infarction (TIMI) 0 flow (points = 2), and lesion length ≥35 mm (points = 3). In the validation set, the area under the curve the RK-SF/NR score was 0.775 (0.722 to 0.829) and a score ≥10 has sensitivity of 77.9% (68.2% to 85.8%), negative predictive value of 87.3% (82.3% to 91.0%), specificity of 62.6% (56.0% to 68.9%), and positive predictive value of 46.3% (41.4% to 51.2%). In conclusion, RK-SF/NR score had shown good discriminating power for predicting SF/NR during primary PCI with good sensitivity and negative predictive value. Hence, the proposed model can have good clinical utility for screening patients at high risk of developing SF/NR during primary PCI.

Sex and Race Differences in the Evaluation and Treatment of Young Adults Presenting to the Emergency Department With Chest Pain

Background Acute myocardial infarctions are increasingly common among young adults. We investigated sex and racial differences in the evaluation of chest pain (CP) among young adults presenting to the emergency department. Methods and Results Emergency department visits for adults aged 18 to 55 years presenting with CP were identified in the National Hospital Ambulatory Medical Care Survey 2014 to 2018, which uses stratified sampling to produce national estimates. We evaluated associations between sex, race, and CP management before and after multivariable adjustment. We identified 4152 records representing 29 730 145 visits for CP among young adults. Women were less likely than men to be triaged as emergent (19.1% versus 23.3%, respectively, P<0.001), to undergo electrocardiography (74.2% versus 78.8%, respectively, P=0.024), or to be admitted to the hospital or observation unit (12.4% versus 17.9%, respectively, P<0.001), but ordering of cardiac biomarkers was similar. After multivariable adjustment, men were seen more quickly (hazard ratio [HR], 1.15 [95% CI, 1.05-1.26]) and were more likely to be admitted (adjusted odds ratio, 1.40 [95% CI, 1.08-1.81]; P=0.011). People of color waited longer for physician evaluation (HR, 0.82 [95% CI, 0.73-0.93]; P<0.001) than White adults after multivariable adjustment, but there were no racial differences in hospital admission, triage level, electrocardiography, or cardiac biomarker testing. Acute myocardial infarction was diagnosed in 1.4% of adults in the emergency department and 6.5% of admitted adults. Conclusions Women and people of color with CP waited longer to be seen by physicians, independent of clinical features. Women were independently less likely to be admitted when presenting with CP. These differences could impact downstream treatment and outcomes.

Sex-Specific Risk Factors Associated With First Acute Myocardial Infarction in Young Adults

IMPORTANCE

An increasing proportion of people in the US hospitalized for acute myocardial infarction (AMI) are younger than 55 years, with the largest increase in young women. Effective prevention requires an understanding of risk factors associated with risk of AMI in young women compared with men.

OBJECTIVES

To assess the sex-specific associations of demographic, clinical, and psychosocial risk factors with first AMI among adults younger than 55 years, overall, and by AMI subtype.

DESIGN, SETTING, AND PARTICIPANTS

This study used a case-control design with 2264 patients with AMI, aged 18 to 55 years, from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study and 2264 population-based controls matched for age, sex, and race and ethnicity from the National Health and Nutrition Examination Survey from 2008 to 2012. Data were analyzed from April 2020 to November 2021.

EXPOSURES

A wide range of demographic, clinical, and psychosocial risk factors.

MAIN OUTCOMES AND MEASURES

Odds ratios (ORs) and population attributable fractions (PAF) for first AMI associated with demographic, clinical, and psychosocial risk factors.

RESULTS

Of the 4528 case patients and matched controls, 3122 (68.9%) were women, and the median (IQR) age was 48 (44-52) years. Seven risk factors (diabetes [OR, 3.59 (95% CI, 2.72-4.74) in women vs 1.76 (1.19-2.60) in men], depression [OR, 3.09 (95% CI, 2.37-4.04) in women vs 1.77 (1.15-2.73) in men], hypertension [OR, 2.87 (95% CI, 2.31-3.57) in women vs 2.19 (1.65-2.90) in men], current smoking [OR, 3.28 (95% CI, 2.65-4.07) in women vs 3.28 (2.65-4.07) in men], family history of premature myocardial infarction [OR, 1.48 (95% CI, 1.17-1.88) in women vs 2.42 (1.71-3.41) in men], low household income [OR, 1.79 (95% CI, 1.28-2.50) in women vs 1.35 (0.82-2.23) in men], hypercholesterolemia [OR, 1.02 (95% CI, 0.81-1.29) in women vs 2.16 (1.49-3.15) in men]) collectively accounted for the majority of the total risk of AMI in women (83.9%) and men (85.1%). There were significant sex differences in risk factor associations: hypertension, depression, diabetes, current smoking, and family history of diabetes had stronger associations with AMI in young women, whereas hypercholesterolemia had a stronger association in young men. Risk factor profiles varied by AMI subtype, and traditional cardiovascular risk factors had higher prevalence and stronger ORs for type 1 AMI compared with other AMI subtypes.

CONCLUSIONS AND RELEVANCE

In this case-control study, 7 risk factors, many potentially modifiable, accounted for 85% of the risk of first AMI in young women and men. Significant differences in risk factor profiles and risk factor associations existed by sex and by AMI subtype. These findings suggest the need for sex-specific strategies in risk factor modification and prevention of AMI in young adults. Further research is needed to improve risk assessment of AMI subtypes.

Sex differences in outcomes of transcatheter edge-to-edge repair with MitraClip: A meta-analysis

BACKGROUND

Transcatheter edge-to-edge repair (TEER) with MitraClip improves outcomes among select patients with moderate-to-severe and severe mitral regurgitation; however, data regarding sex-specific differences in the outcomes among patients undergoing TEER are limited.

METHODS

An electronic search of the PubMed, Embase, Central, and Web of Science databases for studies comparing sex differences in outcomes among patients undergoing TEER was performed. Summary estimates were primarily conducted using a random-effects model.

RESULTS

Eleven studies with a total of 24,905 patients (45.6% women) were included. Women were older and had a lower prevalence of comorbidities, including diabetes, chronic kidney disease, and coronary artery disease. There was no difference in procedural success (odds ratio [OR]: 0.75, 95% confidence interval [CI]: 0.55-1.05) and short-term mortality (i.e., up to 30 days) between women and men (OR: 1.16, 95% CI: 0.97-1.39). Women had a higher incidence of periprocedural bleeding and stroke (OR: 1.34, 95% CI: 1.15-1.56) and (OR: 1.57, 95% CI: 1.10-2.25), respectively. At a median follow-up of 12 months, there was no difference in mortality (OR: 0.98, 95% CI: 0.89-1.09) and heart failure hospitalizations (OR: 1.07, 95% CI: 0.68-1.67). An analysis of adjusted long-term mortality showed a lower incidence of mortality among women (hazards ratio: 0.77, 95% CI: 0.67-0.88).

CONCLUSIONS

Despite a lower prevalence of baseline comorbidities, women undergoing TEER with MitraClip had higher unadjusted rates of periprocedural stroke and bleeding as compared with men. There was no difference in unadjusted procedural success, short-term or long-term mortality. However, women had lower adjusted mortality on long-term follow-up. Future high-quality studies assessing sex differences in outcomes after TEER are needed to confirm these findings.

Pre-transplantation of Bone Marrow Mesenchymal Stem Cells Amplifies the Therapeutic Effect of Ultrasound-Targeted Microbubble Destruction-Mediated Localized Combined Gene Therapy in Post-Myocardial Infarction Heart Failure Rats

Although stem cell transplantation and single-gene therapy have been intensively discussed separately as treatments for myocardial infarction (MI) hearts and have exhibited ideal therapeutic efficiency in animal models, clinical trials turned out to be disappointing. Here, we deliver sarcoplasmic reticulum Ca²⁺-ATPase 2a (SERCA2a) and connexin 43 (Cx43) genes simultaneously via an ultrasound-targeted microbubble destruction (UTMD) approach to chronic MI hearts that have been pre-treated with bone marrow mesenchymal stem cells (BMSCs) to amplify cardiac repair. First, biotinylated microbubbles (BMBs) were fabricated, and biotinylated recombinant adenoviruses carrying the SERCA2a or Cx43 gene were conjugated to the surface of self-assembled BMBs to form SERCA2a-BMBs, Cx43-BMBs or dual gene-loaded BMBs. Then, the general characteristics of these bubbles, including particle size, concentration, contrast signal and gene loading capacity, were examined. Second, a rat myocardial infarction model was created by ligating the left anterior descending coronary artery and injecting BMSCs into the infarct and border zones. Four weeks later, co-delivery of SERCA2a and Cx43 genes to the infarcted heart were delivered together to the infarcted heart using the UTMD approach. Cardiac mechano-electrical function was determined 4 wk after gene transfection, and the infarcted hearts were collected for myocardial infarct size measurement and detection of expression of SERCA2a, Cx43 and cardiac-specific markers. Finally, to validate the role of BMSC transplantation, MI rats transplanted or not with BMSCs were transfected with SERCA2a and Cx43, and the cardiac mechano-electrical function of these two groups of rats was recorded and compared. General characteristics of the self-assembled gene-loaded BMBs were qualified, and the gene loading rate was satisfactory. The self-assembled gene-loaded BMBs were in microscale and exhibit satisfactory dual-gene loading capacity. High transfection efficiency was achieved under ultrasound irradiation in vitro. In addition, rats in which SERCA2a and Cx43 were overexpressed simultaneously had the best contractile function and electrical stability among all experimental groups. Immunofluorescence assay revealed that the levels of SERCA2a and/or Cx43 proteins were significantly elevated, especially in the border zone. Moreover, compared with rats that did not receive BMSCs, rats pre-treated with BMSCs have better mechano-electrical function after transfection with SERCA2a and Cx43. Collectively, we report a promising cardiac repair strategy for post-MI hearts that exploits the providential advantages of stem cell therapy and UTMD-mediated localized co-delivery of specific genes.

Sex Differences in Cardiovascular Risk Associated With Long-Term PM2.5 Exposure: A Systematic Review and Meta-Analysis of Cohort Studies

Background

Established evidence suggests risks of developing cardiovascular disease are different by sex. However, it remains unclear whether associations of PM_2.5 with cardiovascular risk are comparable between women and men. The meta-analysis aimed to examine sex differences in associations of ischemic heart disease (IHD) and stroke with long-term PM_2.5 exposure.

Methods

PubMed, EMBASE and Cochrane Library were searched until May 2, 2021. We included cohort studies reporting sex-specific associations of long-term PM_2.5 exposure (e.g., ≥1 year) with IHD and stroke. The primary analysis was to estimate relative risk (RR) of PM_2.5-outcome in women and men separately, and the additional women-to-men ratio of RR (RRR) was explored to compare sex differences, using random-effect models.

Results

We identified 25 eligible studies with 3.6 million IHD and 1.3 million stroke cases among 63.7 million participants. A higher level of PM_2.5 exposure was significantly associated with increased risk of IHD in both women (RR = 1.21; 95% CI, 1.15–1.27) and men (RR = 1.12; 95% CI, 1.07–1.17). The women-to-men RRR of IHD was 1.05 (95% CI, 1.02–1.08) per 10 μg/m³ increment in PM_2.5 exposure, indicating significant excess risk of IHD in women. The significant risks of stroke associated with PM_2.5 were obtained in both women (RR = 1.11; 95% CI, 1.08–1.13) and men (RR = 1.11; 95% CI, 1.07–1.14), but no significant women-to-men RRR was observed in stroke (RRR = 1.00; 95% CI, 0.96–1.04).

Conclusions

The study identified excess risk of IHD associated with long-term PM_2.5 exposure in women. The findings would not only have repercussions on efforts to precisely evaluate the burden of IHD attributable to PM_2.5, but would also provide novel clues for cardiovascular risk prevention accounting for sex-based differences.

No sex-related differences in infarct size, no-reflow and protection by ischaemic preconditioning in Göttingen minipigs

Aims

Female sex has been proposed to be cardioprotective per se. Studies with myocardial ischaemia/reperfusion and infarct size as endpoint have demonstrated cardioprotection in female, castrated male and male pigs. These studies are difficult to compare, given the different pig strains, models, durations of ischaemia and methods of infarct size quantification. The few studies using both female and male pigs reported no differences in infarct size and cardioprotection. We therefore prospectively compared infarct size in Göttingen minipigs undergoing ischaemia/reperfusion (I/R) without and with ischaemic preconditioning (IPC) between female, castrated male and male pigs.

Methods and Results

In a prospective, randomised approach, 28 Göttingen open-chest, anaesthetised minipigs underwent 60 min ischaemia by distal left anterior descending artery (LAD) occlusion and 180 min reperfusion without and with IPC by 3 cycles of 5 min LAD occlusion/10 min reperfusion. Infarct size with I/R was not different between female, castrated male and male pigs (45±8 vs. 45±13 vs. 41±9% area at risk), as was the reduction in infarct size with IPC (25±11 vs. 30±8 vs. 19±10% area at risk). Also, the area of no-reflow was not different between female, castrated male and male pigs with I/R (57±13 vs. 35±7 vs. 47±26% infarct size) or IPC (4±10 vs.12±20 vs. 0±0% infarct size). Phosphorylation of signal transducer and activator of transcription 3 was increased at 10 min reperfusion by IPC but not by I/R to the same extent in female, castrated male and male pigs (198±30 vs. 230±165 vs. 179±107% of baseline).

Conclusion

Our data do not support the notion of sex- or castration-related differences in infarct size, coronary microvascular injury and cardioprotection by ischaemic preconditioning.

Translational perspective

The translation of successful preclinical studies on cardioprotection to the benefit of patients with reperfused myocardial infarction has been difficult. The difficulties have been attributed to confounders such as co-morbidities and co-medications which patients typically have but animals don´t, but also to age and sex. Notably, female sex has been considered as protective per se. We have now, using our established and clinically relevant pig model of reperfused acute myocardial infarction and ischaemic preconditioning as the most robust cardioprotective intervention looked for sex-related differences of infarct size, no-reflow and cardioprotection by ischaemic preconditioning in a prospectively powered approach but found none such difference.

Sex Difference Trend in 5-Year Mortality Among Patients With Coronary Artery Disease: A 24,432 Chinese Cohort Study From 2007 to 2014

Background

The sex difference trend of short-term mortality in coronary artery disease (CAD) is narrowing, which has been reported in the previous studies. However, no studies assess the sex difference temporal trends of CAD mortality in China especially long-term mortality trend.

Methods

Based on the registry at Guangdong Provincial People's Hospital which is the largest cardiovascular center in South China, this retrospective cohort study included 24,432 hospitalized patients with CAD confirmed by coronary angiography from January 2007 to December 2014. Women and men were followed for 1-year and 5-year all-cause mortality.

Results

From 2007 to 2014, 5-year age-standardized mortality increased from 10.0 to 11.7% in men (p for trend < 0.001) and from 11.5 to 8.1% in women (p for trend = 0.99). The multivariable-adjusted hazard ratios (95% CI), which compare women with men, were from 1.02 (0.39–2.67) to 0.66 (0.39–1.12) for 1-year all-cause mortality and 1.23 (0.64–2.36) to 0.59 (0.44–0.79) for 5-year all-cause mortality (p for trend = 0.04).

Conclusion

Our study found that the mortality risk among men and women was similar in the 1-year prognosis of CAD, and there was no significant downward trend. In the 5-year long-term prognosis of CAD, the mortality risk among men continued to rise, while women had reached the peak, which means that the mortality risk continues to be higher among men than women.

Age stratified sex-related differences in incidence, management, and outcomes of cardiogenic shock

BACKGROUND

There is a lack of data on age-stratified sex differences in the incidence, treatment, and outcomes of cardiogenic shock (CS). We sought to study these differences from a contemporary database.

METHODS

Patients admitted with CS (2004-2018) were identified from the United States National Inpatient Sample. We compared CS (acute myocardial infarction-related cardiogenic shock [AMI-CS] and non-acute myocardial infarction-related cardiogenic shock [Non-AMI-CS]) incidence, management, and outcomes in males and females, stratified into four age groups (20-44, 45-64, 65-84, and ≥85 years of age). Propensity score matching (PSM) was used for adjustment.

RESULTS

A total of 1,506,281 weighted hospitalizations for CS were included (AMI-CS, 39%; Non-AMI-CS, 61%). Across all age groups, females had a lower incidence of CS compared with males. After PSM and among the AMI-CS cohort, higher mortality among females compared with males was observed in the age groups 45-64 (28.5% vs. 26.3%) and 65-84 years (39.3% vs. 37.9%) (p < 0.01, for all). Among the Non-AMI-CS cohort, higher mortality among females compared with males was observed in the age groups 20-44 (33.5% vs. 30.5%), 45-64 (35.1% vs. 31.9%), and 65-84 years (41.7% vs. 40.3%) (p < 0.01, for all). Similar age-dependent differences in the management of CS were also observed between females and males.

CONCLUSIONS

Females have a lower incidence of CS regardless of age. Significant disparities in the management and outcomes of CS were observed based on sex. However, these disparities varied by age and etiology of CS (AMI-CS vs. Non-AMI-CS) with pronounced disparity among females in the age range of 45-84 years.

Risk Factors for Coronary Heart Disease Among Lebanese Women: A Case–Control Study

Purpose

Women are increasingly concerned by coronary heart disease (CHD), with peculiarities of their own, particularly concerning risk factors. The aim of the study was to assess the risk factors for CHD in Lebanese women over forty.

Patients and Methods

A case–control study was carried out in 6 hospitals in Beirut and Mount-Lebanon, from December 2018 to December 2019 including 1500 patients (1200 controls and 300 cases). Women were stratified into pre- and post-menopausal groups. Personal and medical data were collected from hospital records and during an interview where validated questionnaires were used. Binary logistic regressions were performed to investigate potential predictors of CHD in the 2 groups.

Results

In post-menopausal women, dyslipidemia (adjusted odds ratio [aOR], 3.018; 95% confidence interval, 2.102–4.332), hypertension (aOR: 2.449, [1.386–4.327]), a family history of CHD (aOR: 2.724, [1.949–3.808]), cigarette smoking (aOR: 2.317, [1.574–3.410]) and common non-rheumatic joint pain (aOR: 1.457, [1.053–2.016]) were strongly associated with CHD. Conversely, living in Mount Lebanon seemed protective, compared to Beirut (aOR: 0.589, [0.406–0.854]), as well as having a moderate monthly income (aOR: 0.450, [0.220–0.923]), adhering to a Mediterranean diet (aOR: 0.965, [0.936–0.994]), and practicing physical activity [PA] (aOR: 0.396, [0.206–0.759] and 0.725, [0.529–0.992], respectively for high and moderate vs low PA). In pre-menopausal women, dyslipidemia (aOR: 6.938, [1.835–26.224]), hypertension (aOR: 6.195, [1.318–29.119]), family histories of dyslipidemia (aOR: 6.143, [1.560–24.191]) and CHD (aOR: 4.739, [1.336–16.805]) reached statistical significance.

Conclusion

The identification of factors associated with CHD in women, some of which are frequent and trivialized in post-menopause, underlines the need to put in place specific and dedicated CHD prevention strategies in women.

The presentation of spontaneous coronary artery dissection in the emergency department: Signs and symptoms in an unsuspecting population

OBJECTIVES

Spontaneous coronary artery dissection (SCAD) has emerged as a common cause of acute coronary syndrome (ACS) in young women, although it is rarely discussed in the differential diagnosis for chest pain in the emergency department (ED). In a population otherwise considered low risk for myocardial infarction, there is a danger of incomplete workup and missed diagnosis. In this study, we aim to describe the clinical presentation of those who present to the ED with SCAD to increase awareness of this potentially fatal diagnosis among emergency practitioners.

METHODS

Data were queried from the Mayo Clinic "Virtual" Multicenter SCAD Registry, a large multisite international disease registry. The registry includes demographic information as well as data from both medical records and surveys administered following the SCAD event. Symptom presentation was abstracted from survey narrative responses. Data analysis was performed using descriptive statistics.

RESULTS

Of 1196 subjects included, chest pain was reported during initial SCAD event in 95.7%. Most common chest symptoms descriptors were pain, pressure/weight, and tightness, with radiation most often in one or both arms/shoulders. Other common symptoms included nausea, shortness of breath, and diaphoresis. Most common electrocardiogram (ECG) findings reported were ST elevation, T-wave abnormality, and normal ECG. Initial troponin values were within normal range in 20.1% of patients.

CONCLUSION

With young healthy women often considered "low risk" for ACS, it is important to understand that SCAD is a cause of ACS, and familiarity with presentation can improve awareness among emergency physicians. Our data can provide insight in helping to identify young women who present with chest pain due to SCAD so they can be appropriately evaluated.

Gender-Based Long-Term Outcomes After Revascularization for Three-Vessel Coronary Disease: A Propensity Score-Matched Analysis of a Large Cohort

Objective

To investigate the impact of gender on long-term outcomes after revascularization in patients with three-vessel disease (TVD), a severe and challenging subtype of coronary artery disease.

Methods

This was a single center retrospective cohort study. A total of 3776 patients with TVD who underwent revascularization between 2013 and 2018 were analyzed and were divided into the female group (n = 1039, 27.5%) and the male group (n = 2737, 72.5%). We performed a 1:2 propensity score matching (PSM) to balance the baseline characteristics, and a total of 1506 (504 matched pairs) patients were created after undertaking PSM. The primary outcome was the frequency of major adverse cardiac and cerebrovascular events (MACCE) including all-cause death, myocardial infarction, repeat revascularization, stroke, and readmission for angina pectoris or heart failure. The secondary outcome was the incidence of all-cause death.

Results

Through 2.4-year follow-up, no significant differences in MACCE (25.8% vs 27.5%, p = 0.279) and all-cause death (2.1% vs 2.2%, p = 0.888) were observed between the two cohorts. Similar results as with the early detection were obtained in propensity-matched patients. Multivariable analysis revealed that female gender (hazard ratio 0.99, 95% confidence interval 0.88–1.17, p = 0.820) was not an independent predictor of MACCE but percutaneous coronary intervention (compared with coronary artery bypass graft surgery), hypertension, diabetes mellitus, atrial fibrillation, left main trunk involvement and left ventricular ejection fraction ≤40% were independently associated with a higher MACCE rate in these patients.

Conclusion

For patients with TVD after coronary revascularization, there were no gender-based differences in the long-term outcomes and female gender was not an independent predictor of MACCE.

Meta-analysis of the association between Apolipoprotein E polymorphism and risks of myocardial infarction

BACKGROUND

Myocardial infarction (MI) remains the leading cause of death and disability among cardiovascular diseases worldwide. Studies show that elevated low-density lipid protein cholesterol (LDL-C) levels confer the highest absolute risk of MI, and Apolipoprotein E (ApoE) is implicated in regulating levels of triglycerides (TGs), cholesterol, and LDL-C. Our study aimed to evaluate the association between APOE polymorphism and MI, and to provide evidence for the etiology of MI.

METHODS

Case-control studies on the association between APOE polymorphisms and the risk of myocardial infarction were included by searching PubMed, Web of Science, and CNKI, and this meta-analysis was written in accordance with PRISMA guideline statement. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using either random-effects or fixed-effects models by R software.

RESULTS

A total of 33 eligible articles involving 13,706 cases and 14,817 controls were finally selected. The pooled analysis based on the total eligible articles showed that the risk of MI was associated with ApoE epsilon 2 and epsilon 4 alleles. The results showed that patients with MI had a low frequency of the ε2 allele (OR 0.74, 95% CI 0.64-0.86) and a high frequency of the ε4 allele (OR 1.24, 95% CI 1.09-1.42).

CONCLUSIONS

APOE ε2-involved genotypes may be protective factors for MI; in contrast, ε4-involved genotypes (ε4/ε3 vs. ε3/ε3, and ε4/ε4 vs. ε3/ε3) may be risk factors for MI.

ST-Segment Elevation Myocardial Infarction: Sex Differences in Incidence, Etiology, Treatment, and Outcomes

PURPOSE

Although there have been marked improvements in the standard of care for treatment of ST-elevation myocardial infarction, women, especially younger women, continue to have significantly worse outcomes than men.

RECENT FINDINGS

This review highlights the current sex differences in presentation, etiology, treatment, and outcomes among these patients in order to make providers aware of the heterogeneous entities that cause ST-elevation myocardial infarction particularly in women and of disparities in treatment that lead to poorer outcomes in women. Furthermore, it emphasizes evidence-based strategies including standardized protocols for early revascularization, mechanical circulatory support, and access methodology that can reduce sex-based disparities in treatments and outcomes.

Contemporary sex differences in mortality among patients with ST-segment elevation myocardial infarction: a systematic review and meta-analysis

OBJECTIVES

To assess the effect of sex differences on short-term and long-term mortality among patients with ST-segment elevation myocardial infarction (STEMI).

DESIGN

Systematic review and meta-analysis of contemporary available evidence.

SETTING

PubMed, Embase and Cochrane Library were searched for relevant studies reporting sex-specific outcomes among patients with STEMI published between 1 January 2010 and 1 August 2020. Risk ratios (RRs) and 95% CIs were measured using DerSimonian and Laird random-effects model. Sensitivity analyses were performed and publication bias was also checked. All statistical analyses were performed using STATA V.15.0.

PARTICIPANTS

Studies providing data about short-term or long-term mortality stratified by sex in patients with STEMI were included. Only study conducted in last 10 years were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause death at short-term (in-hospital or 30 days) and long-term (at least 12 months) follow-up.

RESULTS

A total of 15 studies involving 128 585 patients (31 706 (24.7%) female and 96 879 (75.3%) male) were included. In the unadjusted analyses, female were at a higher risk of short-term mortality (RR, 1.73; 95% CI 1.53 to 1.96, p<0.001, I²=77%) but not long-term mortality (RR, 1.23; 95% CI 0.89 to 1.69, p=0.206, I²=77.5%). When adjusted effect estimates from individual studies were used in meta-analysis, the association between female and higher risk of short-term mortality remained significant (RR, 1.24; 95% CI 1.11 to 1.38, p<0.001, I²=39.6%). And adjusted long-term mortality was also similar between female and male (RR, 1.11; 95% CI 0.42 to 1.80, p=0.670, I²=74.5%).

CONCLUSIONS

An increased short-term but not long-term mortality was found in female with STEMI. After adjustment for baseline cardiovascular risk factors and clinical profiles, short-term mortality remains higher in female with STEMI compared with male, indicating the need for further improvements in management in female patients.

Sex Difference in the Case Fatality of Older Myocardial Infarction Patients

BACKGROUND

The female sex is associated with poorer outcomes after myocardial infarction (MI), although current evidence in older patients is limited and mixed. We sought to evaluate sex-based differences in outcome after MI in older patients.

METHOD

Consecutive older (≥70 years) all-comer patients with out-of-hospital MI admitted to 20 hospitals in Finland between 2005 and 2014 were studied using national registries (n = 40 654, mean age 80 years, 50% women). The outcome of interest was death within 1 year after MI. Differences between sexes (age, baseline features, medication, comorbidities, revascularization, and treating hospital) were balanced by inverse probability weighting.

RESULTS

Adjusted all-cause case fatality was lower in women than in men at 30 days (16.0% vs 19.0%, respectively) and at 1 year (27.7% vs 32.4%, respectively) after MI (hazard ratio: 0.83; confidence interval [CI]: 0.80-0.86; p < .0001). Excess 1-year case fatality after MI compared to the corresponding general population was 22.1% (CI: 21.4%-22.8%) in women and 24.1% (CI: 23.4%-24.9%) in men. Women had a lower adjusted hazard of death after MI in subgroups of patients aged 70-79 years and ≥80 years, patients with and without ST elevation MI, revascularized and non-revascularized patients, patients with and without atrial fibrillation, and patients with and without diabetes. The sex difference in case fatality remained similar during the study period.

CONCLUSIONS

Older women were found to have a lower hazard of death after an out-of-hospital MI when compared to older men with similar features and treatments. This finding was consistent in several subgroups.

The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 5: Sex- and Gender-Unique Manifestations of Cardiovascular Disease

This Atlas chapter summarizes sex- and some gender-associated, and unique aspects and manifestations of cardiovascular disease (CVD) in women. CVD is the primary cause of premature death in women in Canada and numerous sex-specific differences related to symptoms and pathophysiology exist. A review of the literature was done to identify sex-specific differences in symptoms, pathophysiology, and unique manifestations of CVD in women. Although women with ischemic heart disease might present with chest pain, the description of symptoms, delay between symptom onset and seeking medical attention, and prodromal symptoms are often different in women, compared with men. Nonatherosclerotic causes of angina and myocardial infarction, such as spontaneous coronary artery dissection are predominantly identified in women. Obstructive and nonobstructive coronary artery disease, aortic aneurysmal disease, and peripheral artery disease have worse outcomes in women compared with men. Sex differences exist in valvular heart disease and cardiomyopathies. Heart failure with preserved ejection fraction is more often diagnosed in women, who experience better survival after a heart failure diagnosis. Stroke might occur across the lifespan in women, who are at higher risk of stroke-related disability and age-specific mortality. Sex- and gender-unique differences exist in symptoms and pathophysiology of CVD in women. These differences must be considered when evaluating CVD manifestations, because they affect management and prognosis of cardiovascular conditions in women.

The evolving role of coronary computed tomography in understanding sex differences in coronary atherosclerosis

Our understanding of sex differences in subclinical atherosclerosis and plaque composition and characteristics have greatly improved with the use of coronary computed tomography (CCTA) over the past years. CCTA has emerged as an important frontline diagnostic test for women, especially as we continue to understand the impact of non-obstructive atherosclerosis as well as diffuse, high risk plaque as precursors of acute cardiac events in women. Based on its ability to identify complex plaque morphology such as low attenuation plaque, high risk non calcified plaque, positive remodeling, fibrous cap, CCTA can be used to assess plaque characteristics. CCTA can avoid false positive of other imaging studies, if included earlier in assessment of ischemic symptoms. In the contemporary clinical setting, CCTA will prove useful in further understanding and managing cardiovascular disease in women and those without traditional obstructive coronary disease.

Sex Differences in Baseline Characteristics Do Not Predict Early Outcomes after Percutaneous Coronary Intervention: Results from the Australian GenesisCare Cardiovascular Outcomes Registry (GCOR)

OBJECTIVE

The effect of baseline differences between men and women on early outcomes after percutaneous coronary intervention (PCI).

DESIGN, SETTING, PARTICIPANTS

This is an observational study of all participants in the GenesisCare Cardiovascular Outcomes Registry, undergoing PCI. The registry holds data for both emergency and elective procedures. Data was collected on 10,989 consecutive patients from 12 Australian Private Hospitals, including baseline demographics, co-morbidities, risk factors, PCI procedures, and lesion characteristics.

MAIN OUTCOME MEASURES

Outcome was measured for complications (in-hospital death, peri-procedural myocardial infarctions, and bleeding events), at discharge and at 30-days for death, myocardial infarction, target lesion revascularisation (TLR), major adverse cardiac events (MACE), and unplanned readmissions.

RESULTS

Women represented 23% of the study population, were significantly older, with a higher rate of hypertension and hyperlipidaemia. Heart failure was more common in women and was associated with a significantly higher average ejection fraction than in men. Women had a lower rate of pre-existing coronary artery disease (CAD), had less complex CAD, and needed fewer stents. Periprocedural complications were similar, but major bleeding was more common in women. The 30-day outcome was similar between men and women for death, myocardial infarction, target lesion revascularisation (TLR), major adverse cardiovascular events (MACE), and unplanned readmissions.

CONCLUSIONS

Although significant differences were observed between women and men in both clinical presentation and complexity of disease, the 30-day outcome was similar for death and MACE. Women had a higher rate of major bleeding events, and lower adherence to statins and dual antiplatelet therapy (DAPT).

Construction of a femininity score in the UK Biobank and its association with angina diagnosis prior to myocardial infarction

Gender captures social components beyond biological sex and can add valuable insight to health studies in populations. However, assessment of gender typically relies on questionnaires which may not be available. The aim of this study is to construct a gender metric using available variables in the UK Biobank and to apply it to the study of angina diagnosis. Proxy variables for femininity characteristics were identified in the UK Biobank and regressed on sex to construct a composite femininity score (FS) validated using tenfold cross-validation. The FS was assessed as a predictor of angina diagnosis before incident myocardial infarction (MI) events. The FS was derived for 315,937 UK Biobank participants. In 3059 individuals with no history of MI at study entry who had an incident MI event, the FS was a significant predictor of angina diagnosis prior to MI (OR 1.24, 95% CI 1.10-1.39, P < 0.001) with a significant sex-by-FS interaction effect (P = 0.003). The FS was positively associated with angina diagnosis prior to MI in men (OR 1.37, 95% CI 1.19-1.57, P < 0.001), but not in women. We have provided a new tool to conduct gender-sensitive analyses in observational studies, and applied it to study of angina diagnosis prior to MI.

Gender Differences in All-Cause Mortality after Acute Myocardial Infarction: Evidence for a Gender-Age Interaction

Gender difference studies in mortality after acute myocardial infarction (AMI) have shown inconsistent results. A total of 13,104 patients from the KAMIR-NIH between November 2011 and December 2015 were classified into young (n = 3837 [29.3%]) and elderly (n = 9267 [70.7%]) patients. For the study, women <65 and men <55 years of age were considered “young”. In the adjusted model of the entire cohort, there was no significant difference in three-year all-cause mortality between women and men (17.8% vs. 10.3%; adjusted hazard ratio [HR], 0.953; 95% confidence interval [CI], 0.799–1.137). However, when the entire cohort was subdivided into two age groups, young women showed an 84.3% higher mortality rate than young men (adjusted HR, 1.843; 95% CI, 1.098–3.095). Contrariwise, elderly women patients had a 20.4% lower hazard of mortality compared with elderly men (adjusted HR, 0.796; 95% CI, 0.682–0.929). The interaction of gender with age was significant, even after multiple adjustments (adjusted p for interaction = 0.003). The purpose of this study was to assess whether gender differences depend on the patients’ age. Based on our analysis, higher mortality of young women remains even in the contemporary era of AMI. A better understanding of the mechanisms underlying these differences is warranted.

LncRNA HOTTIP Knockdown Attenuates Acute Myocardial Infarction via Regulating miR-92a-2/c-Met Axis

Increasing investigations have focused on long non-coding RNAs (lncRNAs) in various human diseases, including acute myocardial infarction (AMI). Although lncRNA HOTTIP has been identified to play an important role in coronary artery diseases, its role and specific mechanism in AMI remain unclear. To investigate the potential role of HOTTIP in MI, HOTTIP expression in hypoxia-treated cardiomyocytes and myocardial tissues of MI mice was evaluated. The potential targets of HOTTIP and miR-92a-2 were predicted using Starbase and Targetscan. To further determine the cardio-protective effects of HOTTIP in vivo, si-HOTTIP and miR-92a-2 mimics were individually or co-injected into mice through intramyocardial injection. Moreover, their roles were further confirmed in rescue experiments. HOTTIP was significantly upregulated in ischemic myocardium of MI mice and hypoxia-induced cardiomyocytes. Moreover, HOTTIP knockdown markedly promoted cardiomyocyte growth and inhibited cardiomyocyte apoptosis in vitro. Luciferase reporter assay showed that HOTTIP could directly sponge miR-92a-2 to negatively regulate miR-92a-2 expression. In addition, c-Met was identified as a direct target of miR-92a-2, and their correlation was confirmed by luciferase reporter assay. MiR-92a-2 overexpression significantly enhanced the protective effect of HOTTIP knockdown against AMI through partially inhibiting c-Met expression. Our results demonstrated that HOTTIP downregulation attenuated AMI progression via the targeting miR-92a-2/c-Met axis and suggested that HOTTIP might be a potential therapeutic target for AMI.

A Primer on Incorporating Sex as a Biological Variable into the Conduct and Reporting of Basic and Clinical Research Studies

The recent move to require sex as a biological variable (SABV), which includes gender, into the reporting of research published by the American Journal of Physiology - Heart and Circulatory Physiology follows a growing, and much-needed, trend by journals. Understandably, there is concern over how to do this without adding considerable work, especially if one's primary research focus is not on elucidating sex/gender differences. The purpose of this article is to provide additional guidance and examples on how to incorporate SABV into the conduct and reporting of basic and clinical research. Using examples from our research, which includes both studies focused and not focused on sex/gender differences, we offer suggestions for how to incorporate SABV into basic and clinical research studies.

A Systematic Review of Wearable Sensors for Monitoring Physical Activity

This article reviews the use of wearable sensors for the monitoring of physical activity (PA) for different purposes, including assessment of gait and balance, prevention and/or detection of falls, recognition of various PAs, conduction and assessment of rehabilitation exercises and monitoring of neurological disease progression. The article provides in-depth information on the retrieved articles and discusses study shortcomings related to demographic factors, i.e., age, gender, healthy participants vs patients, and study conditions. It is well known that motion patterns change with age and the onset of illnesses, and that the risk of falling increases with age. Yet, studies including older persons are rare. Gender distribution was not even provided in several studies, and others included only, or a majority of, men. Another shortcoming is that none of the studies were conducted in real-life conditions. Hence, there is still important work to be done in order to increase the usefulness of wearable sensors in these areas. The article highlights flaws in how studies based on previously collected datasets report on study samples and the data collected, which makes the validity and generalizability of those studies low. Exceptions exist, such as the promising recently reported open dataset FallAllD, wherein a longitudinal study with older adults is ongoing.

Associations Between Blood Pressure and Accelerated DNA Methylation Aging

Background

Individuals of the same chronological age may exhibit diverse susceptibilities to death. However, few studies have investigated the associations between blood pressure and the accelerated aging.

Methods and Results

A cross‐sectional study was conducted in 288 adults aged ≥50 years. We assessed the DNA methylation‐based measures of biological age using CpG sites on the Illumina HumanMethylationEPIC BeadChip. Epigenetic age acceleration metrics were derived by regressing residuals (ΔAge) and ratios (aging rate) of DNA methylation age on chronological age. Dose‐response relationships between blood pressure and epigenetic age acceleration were quantified using multiple linear regression and restricted cubic regression models. We found that each 10–mm Hg increase in systolic blood pressure was associated with 0.608 (95% CI, 0.231–0.984) years increase in ΔAge and 0.007 (95% CI, 0.002–0.012) increase in aging rate; meanwhile, for pulse pressure, the increase was 1.12 (95% CI, 0.625–1.61) years for ΔAge and 0.013 (95% CI, 0.007–0.020) for aging rate. Subgroup analysis showed that the significant associations of systolic blood pressure and pulse pressure with epigenetic age acceleration appeared to be limited to women, although interactions between blood pressure and sex were not significant (P values for interaction >0.05). The combination of women and hypertension was associated with a much higher increase in ΔAge (β [95% CI], 4.05 [1.07–7.02]) and aging rate (β [95% CI], 0.047 [0.008–0.087]), compared with male participants without hypertension.

Conclusions

Our findings suggested that high systolic blood pressure and pulse pressure were associated with the epigenetic age acceleration, providing important clues for relationships between blood pressure and epigenetic aging.

Sex Difference in the Association between Lipid Profile and Incident Cardiovascular Disease among Young Adults

AIM

Using a nationwide epidemiological database, we sought to examine whether there was a sex difference in the association between lipid profiles and subsequent cardiovascular disease (CVD) in young adults.

METHODS

Medical records of 1,909,362 young adults (20-49 years old) without a prior history of CVD and not taking lipid-lowering medications were extracted. We conducted multivariable Cox regression analyses to identify the association between the number of abnormal lipid profiles and incident CVD.

RESULTS

After a mean follow-up of 3.4±2.6 years, myocardial infarction (MI), angina pectoris (AP), stroke, and heart failure (HF) developed in 2,575 (0.1%), 26,006 (1.4%), 10,748 (0.6%), and 24,875 (1.3%) subjects, respectively. The incidence of MI, AP, and HF increased with the number of abnormal lipid profiles in both men and women, whereas the incidence of stroke increased with the number of abnormal lipid profiles only in men but not in women. Multivariable adjusted hazard ratios (HRs) for MI per 1-point higher abnormal lipid profile were 1.57 (95% confidence interval [CI] 1.49-1.65) in men and 1.25 (95% CI 1.07-1.47) in women. HRs for AP, stroke, and HF per 1-point higher abnormal lipid profile were 1.14 (95% CI 1.12-1.16), 1.06 (95% CI 1.02-1.09), and 1.10 (95% CI 1.08-1.12) in men and 1.18 (95% CI 1.13-1.23), 1.09 (95% CI 1.03-1.16), and 1.10 (95% CI 1.05-1.14) in women.

CONCLUSION

Our analysis demonstrated an association between the number of abnormal lipid profiles and incident CVD in both men and women. The association between the number of abnormal lipid profiles and incident MI was pronounced in men.

Sex-specific differences in trimethylamine N-oxide (TMAO) concentrations before and after cardiac rehabilitation in acute myocardial infarction patients

Trimethylamine N-oxide (TMAO) is a biomarker of cardiovascular risk and may enhance the progression of atherosclerosis. The aim of the study was to determine whether there are sex-specific differences in TMAO concentrations before and after cardiac rehabilitation in acute myocardial infarction (AMI) patients. A total of 56 participants [45/56 (80.4 %) males, 11/56 (19.6 %) females] were drawn from AMI inpatients hospitalized at the Division of Cardiology, Medical University of Graz, Austria. For the assessment of TMAO, serum samples were collected within the first day after hospital admission due to AMI and at the start and end of cardiac rehabilitation. Shortly after hospital admission due to AMI, females had significantly higher TMAO blood concentrations than males. These initially high TMAO levels remained almost unchanged in the female AMI patients until the start of cardiac rehabilitation and only reached the lower TMAO concentrations observed in the male patients after rehabilitation [female patients: TMAO (acute myocardial infarction) = 5.93 μmol/L (SE = 1.835); TMAO (start of rehabilitation) = 5.68 μmol/L (SE = 1.217); TMAO (end of rehabilitation) = 3.89 μmol/L (SE = 0.554); male patients: TMAO (acute myocardial infarction) = 3.02 μmol/L (SE = 0.255), TMAO (start of rehabilitation) = 3.91 μmol/L (SE = 0.346), TMAO (end of rehabilitation) = 4.04 μmol/L (SE = 0.363)]. After AMI, women might be at higher cardiovascular risk due to persistently higher levels of TMAO. High TMAO levels in women might decrease after cardiac rehabilitation due to cardiac rehabilitation-associated lifestyle modifications. These lifestyle modifications after AMI might also prevent increases in TMAO concentrations in men.

Parkinson's disease protein 7 protected against oxidative stress of myocardial infarction direct through p47phox and nicotinamide adenine dinucleotide phosphate oxidase 4

In the present study, we aimed to investigate the role and mechanism of Parkinson's disease protein 7 (Park7) in myocardial infarction (MI). The Park7 expression in the serum and tissues was down-regulated in mice with MI. Recombinant Park7 protein protected against MI-induced injury and reduced oxidative stress in mice model. Conversely, knockout Park7 increased injury of MI and promoted oxidative stress in MI mice model. In embryonic rat cardiac myoblasts H9c2 cells, over-expression of Park7 reduced reactive oxygen species (ROS)-induced oxidative stress, while down-regulation of Park7 increased ROS-induced oxidative stress. Park7 combined nicotinamide adenine dinucleotide phosphate (NADPH) oxidase cytoplasmic subunit p47phox protein had direct effect on inducing NADPH activator. The inhibition of p47phox reduced the effects of Park7 in ROS production of H₂O₂-treated H9c2 cells. The regulation of NADPH participated in the effects of Park7 on ROS production of in both MI mice model and H₂O₂-treated H9c2 cells. Our data demonstrated that Park7 protects against oxidative stress in MI model direct through p47phox and NADPH oxidase 4.

Targeting angiogenesis in myocardial infarction: Novel therapeutics (Review)

Acute myocardial infarction (AMI) remains the main cause of mortality worldwide. Despite surgery and medical treatment, the non-regeneration of dead cardiomyocytes and the limited contractile ability of scar tissue can lead to heart failure. Therefore, restoring blood flow in the infarcted area is important for the repair of myocardial injury. The objective of the present review was to summarize the factors influencing angiogenesis after AMI, and to describe the application of angiogenesis for cardiac repair. Collectively, this review may be helpful for relevant studies and to provide insight into future therapeutic applications in clinical practice.

Comparison of Lean Mass in Women With and Without Heart Disease

PURPOSE

This proof-of-concept study compared lean mass (LM) between women with heart disease (HD) and without HD.

METHODS

Fifty-six community-dwelling women were pair-matched by age. Heart disease was defined using criteria from the US Behavioral Risk Factor Surveillance System. Body composition was measured using multifrequency bioelectrical impedance analysis. Relative LM was calculated against height (kg/m2) as the lean mass index (LMI). Sarcopenia was defined as an LMI <15.0 kg/m2. Strength was measured with a handgrip dynamometer, arm curl test, and chair stand test.

RESULTS

Those with HD had significantly less absolute (38.2 ± 0.8 vs 43.5 ± 1.0 kg; P < .001) and relative (15.3 ± 0.3 vs 16.2 ± 0.3 kg/m2, P = .015) LM compared with those without HD. Body mass was significantly greater for those without HD (76.1 ± 2.1 vs 68.4 ± 2.1 kg; P = .013) and there were no differences in fat mass. Upper body strength was significantly less and lower body strength was diminished but not significantly different in those with HD compared to those without HD (handgrip: P = .016; arm curl: P < .001; chair stand: P = .066).

CONCLUSIONS

In this group of community-dwelling women, those who reported a diagnosis of HD had significantly less LM than those without HD. Although neither group was classified as sarcopenic, women with HD were at greater risk due to lower relative LM. Based on our findings, during cardiac rehabilitation clinicians should counsel women regarding resistance exercise for maintenance of LM in addition to strength.

Farrerol Alleviates Myocardial Ischemia/Reperfusion Injury by Targeting Macrophages and NLRP3

Myocardial ischemia/reperfusion (I/R) injury is associated with high mortality and morbidity, however, it has no curative treatment. Farrerol (FA), an active compound extracted from rhododendron, has antibacterial, anti-inflammatory, and antioxidant activities, but its effect and mechanism of FA in I/R injury remain unclear. Here, we found that FA alleviated myocardial I/R in vivo, and decreased the secretion of myocardial injury factors (CK-MB, LDH, troponin-1, and NT-proBNP) while inhibiting the release of inflammatory factors (IL-1β, IL-6, and TNF-α). FA could also alleviate excessive oxidative stress by elevating the level of antioxidant enzymes and reducing oxidation products; and decreased reduced the expression of apoptosis-associated proteins (cleaved caspase-3, Bax, and Bcl-2). However, inhibiting the autophagic pathway or knocking out the Nrf2 gene did not eliminate the myocardial protective effect of FA, but interestingly, macrophage clearance and Nlrp3 deficiency effectively blocked the myocardial protective effect of FA. In addition, FA suppressed NLRP3 inflammasome activation by interfering with NLRP3 and NEK7. In conclusion, these results support drug-targeted macrophage therapy for myocardial I/R and indicate that FA may be used as an immunomodulator in clinical therapy for myocardial I/R.

Cardiac rehabilitation - The answer for the second chance

In the United States and worldwide, the leading cause of death in females is cardiovascular disease (CVD). However, compared to males, females have overall higher mortality rates, especially within the first few years of having an acute myocardial infarction (AMI). Despite the increased awareness of CVD in females and established benefits of cardiac rehabilitation (CR) programs, there is still delayed initiation of care, under-recognition of atypical presentations of angina in females, under referral of females to CR, and under-representation of females in CVD trials. In this paper, we will investigate the barriers to female participation in CR, explore the fundamental differences in physiology between males and females, and current limitations in CVD trials where females are under-represented. Finally, we aim to provide potential methods to increase enrollment of females in CR and CR related trials.

Sex disparities in in-hospital outcomes of left ventricular aneurysm complicating acute myocardial infarction: A United States nationwide analysis

Background

Previous studies have reported sex-specific differences in the presentation, mechanisms, and outcomes of acute myocardial infarction (AMI). We assessed differences between women and men in the incidence and in-hospital outcomes of left ventricular (LV) aneurysm complicating AMI.

Methods

Hospitalizations for AMI with LV aneurysm were identified retrospectively in the National Inpatient Sample (NIS) from 2001 to 2017. Incidence and trends in in-hospital mortality, complications, length of stay and costs were analyzed in women and men.

Results

A total of 16,334 AMI hospitalizations with concomitant LV aneurysm were identified including 6994 (42.8%) women and 9340 (57.2%) men. Among these hospitalizations, women had a higher incidence of LV aneurysm compared to men (0.16% vs. 0.14%; p < 0.001). Unadjusted in-hospital mortality was higher in women than men (12.7% vs. 7.2%; p < 0.001). After adjusting for demographic and baseline characteristics and excluding inter-hospital transfers, women with AMI complicated by LV aneurysm had 49% greater odds of in-hospital mortality than men (OR 1.49, 95% confidence interval 1.06-2.10, p = 0.02). Women with LV aneurysm were less likely than men to undergo percutaneous coronary intervention (28.5% vs. 35.4%; p < 0.001), bypass surgery (15.8% vs. 25.1%; p < 0.001), coronary atherectomy (0.8% vs. 1.9%; p = 0.009) and LV aneurysm surgery (7.8% vs. 11.1%; p = 0.001).

Conclusions

In this large population-based cohort study, women had a slightly higher incidence but dramatically higher in-hospital mortality associated with LV aneurysm complicating AMI compared to men. Further research is necessary to validate strategies to ensure that women receive guideline-directed therapy for AMI and LV aneurysm to address the sex disparity in mortality.

Preterm Delivery and Long-term Risk of Hypertension in Women

Importance

Preterm delivery has been associated with future cardiometabolic disorders in women. However, the long-term risks of chronic hypertension associated with preterm delivery and whether such risks are attributable to familial confounding are unclear. Such knowledge is needed to improve long-term risk assessment, clinical monitoring, and cardiovascular prevention strategies in women.

Objective

To examine the long-term risks of chronic hypertension associated with preterm delivery in a large population-based cohort of women.

Design, Setting, and Participants

This national cohort study assessed all 2 195 989 women in Sweden with a singleton delivery from January 1, 1973, to December 31, 2015. Data analyses were conducted from March 8, 2021, to August 20, 2021.

Exposures

Pregnancy duration identified from nationwide birth records.

Main Outcomes and Measures

New-onset chronic hypertension identified from primary care, specialty outpatient, and inpatient diagnoses using administrative data. Cox proportional hazards regression was used to compute hazard ratios (HRs) while adjusting for preeclampsia, other hypertensive disorders of pregnancy, and other maternal factors. Cosibling analyses were assessed for potential confounding by shared familial (genetic and/or environmental) factors.

Results

In 46.1 million person-years of follow-up, 351 189 of 2 195 989 women (16.0%) were diagnosed with hypertension (mean [SD] age, 55.4 [9.9] years). Within 10 years after delivery, the adjusted HR for hypertension associated with preterm delivery (gestational age <37 weeks) was 1.67 (95% CI, 1.61-1.74) and when further stratified was 2.23 (95% CI, 1.98-2.52) for extremely preterm (22-27 weeks of gestation), 1.85 (95% CI, 1.74-1.97) for moderately preterm (28-33 weeks of gestation), 1.55 (95% CI, 1.48-1.63) for late preterm (34-36 weeks of gestation), and 1.26 (95% CI, 1.22-1.30) for early-term (37-38 weeks of gestation) compared with full-term (39-41 weeks of gestation) delivery. These risks decreased but remained significantly elevated at 10 to 19 years (preterm vs full-term delivery: adjusted HR, 1.40; 95% CI, 1.36-1.44), 20 to 29 years (preterm vs full-term delivery: adjusted HR, 1.20; 95% CI, 1.18-1.23), and 30 to 43 years (preterm vs full-term delivery: adjusted HR, 95% CI, 1.12; 1.10-1.14) after delivery. These findings were not explained by shared determinants of preterm delivery and hypertension within families.

Conclusions and Relevance

In this large national cohort study, preterm delivery was associated with significantly higher future risks of chronic hypertension. These associations remained elevated at least 40 years later and were largely independent of other maternal and shared familial factors. Preterm delivery should be recognized as a lifelong risk factor for hypertension in women.

Menopausal Hormone Replacement Therapy and Reduction of All-Cause Mortality and Cardiovascular Disease: It Is About Time and Timing

ABSTRACT

The totality of evidence indicates menopausal hormone replacement therapy (HRT) effects are determined by timing of initiation according to age and/or time since menopause, underlying health of target tissue, and duration of therapy. Initiated in women at younger than 60 years and/or at or near menopause, HRT significantly reduces all-cause mortality and cardiovascular disease (CVD), whereas other primary CVD prevention therapies such as lipid-lowering fail to do so. The magnitude and type of HRT-associated risks, including breast cancer, stroke, and venous thromboembolism, are rare (<10 events/10,000 women), not unique to HRT, and comparable with other medications. Hormone replacement therapy is a sex-specific and time-dependent primary CVD prevention therapy that concomitantly reduces all-cause mortality, as well as other aging-related diseases with an excellent risk profile. Keeping in mind that prevention strategies must be personalized, health care providers and patients can use cumulated HRT data in making clinical decisions concerning chronic disease prevention including CVD and mortality reduction.