An Update on Gender Disparities in Coronary Heart Disease Care

Estimation and determinants of direct hospitalisation cost for coronary heart disease in a low-middle-income country: evidence from a nationwide study in Iranian hospitals

BACKGROUND

Coronary heart disease (CHD) is the most prevalent type of cardiovascular disease in Iran. This study aims to investigate the estimation and determinants of direct hospitalisation cost for patients with CHD in Iranian hospitals.

METHODS

We identified patients with CHD in Iran in 2019-2020. Data were gathered from the Iran Health Insurance Organisation information systems and the Ministry of Health and Medical Education. This was a cross-sectional prevalence-based study. Generalised linear models were used to find the determinants of hospitalisation cost for patients with CHD. A total of 86 834 patients suffering from CHD were studied.

RESULTS

Mean hospitalisation cost per CHD patient was US$382.90±US$500.72 while the mean daily hospitalisation cost per CHD patient was US$89.71±US$89.99. In-hospital mortality of CHD was 2.52%. Hospitalisation accommodation and medications had the highest share of hospitalisation costs (25.59% and 22.63%, respectively). Men spent 1.12 (95% CI 1.11 to 1.13) times more on hospitalisation costs compared with women, and individuals aged 60 to 69 had hospitalisation costs 1.04 (95% CI 1.02 to 1.06) times higher than those in the 0-49 age range. Patients insured by the Iranian Fund have significantly higher costs 1.17 (95% CI 1.14 to 1.19) than the Rural fund. Hospitalisation costs for patients with CHD who received surgery and angiography were significantly 2.36 (95% CI 2.30 to 2.43) times higher than for patients who did not undergo surgery and angiography.

CONCLUSION

Applying CHD prevention strategies for men and the middle-aged population (50-70 years) is strongly recommended. Prudent use and prescribing of medications will be helpful to reduce hospitalisation cost.

Androgen deficiency in hypopituitary women: its consequences and management

Women with hypopituitarism have various degrees of androgen deficiency, which is marked among those with combined hypogonadotrophic hypogonadism and secondary adrenal insufficiency. The consequences of androgen deficiency and the effects of androgen replacement therapy have not been fully elucidated. While an impact of androgen deficiency on outcomes such as bone mineral density, quality of life, and sexual function is plausible, the available evidence is limited. There is currently no consensus on the definition of androgen deficiency in women and it is still controversial whether androgen substitution should be used in women with hypopituitarism and coexisting androgen deficiency. Some studies suggest beneficial clinical effects of androgen replacement but data on long-term benefits and risk are not available. Transdermal testosterone replacement therapy in hypopituitary women has shown some positive effects on bone metabolism and body composition. Studies of treatment with oral dehydroepiandrosterone have yielded mixed results, with some studies suggesting improvements in quality of life and sexual function. Further research is required to elucidate the impact of androgen deficiency and its replacement treatment on long-term outcomes in women with hypopituitarism. The lack of transdermal androgens for replacement in this patient population and limited outcome data limit its use. A cautious and personalized treatment approach in the clinical management of androgen deficiency in women with hypopituitarism is recommended while awaiting more efficacy and safety data.

Identification of an association between coronary heart disease and ITGB2 methylation in peripheral blood by a case-control study

BACKGROUND

Blood DNA methylation was associated with coronary heart disease (CHD) risk in Caucasians. We investigated the association between DNA methylation in peripheral blood at the reported loci and CHD in the Chinese population.

METHODS

The integrin subunit beta 2 (ITGB2) gene was identified in 196 CHD cases and 184 controls, and its methylation level was determined by mass spectrometry. Logistic regression was used to assess the association.

RESULTS

Hypomethylation of ITGB2 was significantly associated with heart failure CHD and NYHA Ⅰ&Ⅱ CHD patients with minor to medium cardiac function impairment (ITGB2_CpG_11/cg08422803, OR per -10 % methylation = 1.15 and 1.16; p = 0.012 and 0.018 by Bonferroni correction, respectively). Hypomethylation of ITGB2_CpG_11/cg08422803 was a risk factor for CHD in people < 65 years and males (p < 0.05 after Bonferroni correction). The combination of ITGB2 methylation and conventional CHD risk factors could efficiently discriminate CHD, heart failure CHD, NYHA I&II CHD, and myocardial infarction CHD patients from controls (AUC = 0.78, 0.81, 0.80, and 0.81, respectively).

CONCLUSION

Blood-based ITGB2 methylation has the potential as a biomarker for CHD. The combination of ITGB2 methylation and conventional CHD risk factors may improve the risk assessment and detection of CHD.

Risk Factors for Premature Coronary Heart Disease in Women Compared to Men: Systematic Review and Meta-Analysis

Background: We aimed to systematically examine literature on the prevalence of known modifiable and nonmodifiable risk factors for premature coronary heart disease (PCHD) in women compared with men. Materials and Methods: PubMed, CINAHL, Embase, and Web of Science databases were searched. Review protocol is registered in PROSPERO (CRD42020173216). Quality was assessed using the National Heart, Lung, and Blood Institute tool. Review Manager 5.3 was used for meta-analysis. Effect sizes were expressed as odds ratio (OR) and mean differences/standardized mean differences (SMD) with 95% confidence intervals (CIs) for categorical and continuous variables. Results: In this PCHD cohort (age <65 years), the mean age of presentation in women was 3 years older than men. Women had higher total cholesterol (SMD 0.11; 95% CI 0.00 to 0.23) and higher high-density lipoprotein cholesterol (SMD 0.49; 95% CI 0.29 to 0.69). Women were more likely to have hypertension (OR 1.51, 95% CI 1.42 to 1.60), diabetes mellitus (OR 1.78, 95% CI 1.55 to 2.04), obesity (OR 1.33, 95% CI 1.24 to 1.42), metabolic syndrome (OR 3.73, 95% CI 1.60 to 8.69), stroke (OR 1.63, 95% CI 1.51 to 1.77), peripheral vascular disorder (OR 1.67, 95% CI 1.43 to 1.96), and depression (OR 2.29, 95% CI 1.96 to 2.67). Women were less likely to be smokers (OR 0.60, 95% CI 0.55 to 0.66), have reported alcohol intake (OR 0.36, 95% CI 0.33 to 0.40), and reported use of illicit drug (OR 0.32, 95% CI 0.16 to 0.62). Conclusions: Risk factor profile in PCHD has a clear sex difference that supports early, aggressive, holistic, but sex-specific, approach to prevention.

Disparities in Guideline-Recommended Statin Use for Prevention of Atherosclerotic Cardiovascular Disease by Race, Ethnicity, and Gender : A Nationally Representative Cross-Sectional Analysis of Adults in the United States

BACKGROUND

Although statins are a class I recommendation for prevention of atherosclerotic cardiovascular disease and its complications, their use is suboptimal. Differential underuse may mediate disparities in cardiovascular health for systematically marginalized persons.

OBJECTIVE

To estimate disparities in statin use by race-ethnicity-gender and to determine whether these potential disparities are explained by medical appropriateness of therapy and structural factors.

DESIGN

Cross-sectional analysis.

SETTING

National Health and Nutrition Examination Survey from 2015 to 2020.

PARTICIPANTS

Persons eligible for statin therapy based on 2013 and 2018 American College of Cardiology/American Heart Association blood cholesterol guidelines.

MEASUREMENTS

The independent variable was race-ethnicity-gender. The outcome of interest was use of a statin. Using the Institute of Medicine framework for examining unequal treatment, we calculated adjusted prevalence ratios (aPRs) to estimate disparities in statin use adjusted for age, disease severity, access to health care, and socioeconomic status relative to non-Hispanic White men.

RESULTS

For primary prevention, we identified a lower prevalence of statin use that was not explained by measurable differences in disease severity or structural factors among non-Hispanic Black men (aPR, 0.73 [95% CI, 0.59 to 0.88]) and non-Mexican Hispanic women (aPR, 0.74 [CI, 0.53 to 0.95]). For secondary prevention, we identified a lower prevalence of statin use that was not explained by measurable differences in disease severity or structural factors for non-Hispanic Black men (aPR, 0.81 [CI, 0.64 to 0.97]), other/multiracial men (aPR, 0.58 [CI, 0.20 to 0.97]), Mexican American women (aPR, 0.36 [CI, 0.10 to 0.61]), non-Mexican Hispanic women (aPR, 0.57 [CI, 0.33 to 0.82), non-Hispanic White women (aPR, 0.69 [CI, 0.56 to 0.83]), and non-Hispanic Black women (aPR, 0.75 [CI, 0.57 to 0.92]).

LIMITATION

Cross-sectional data; lack of geographic, language, or statin-dose data.

CONCLUSION

Statin use disparities for several race-ethnicity-gender groups are not explained by measurable differences in medical appropriateness of therapy, access to health care, and socioeconomic status. These residual disparities may be partially mediated by unobserved processes that contribute to health inequity, including bias, stereotyping, and mistrust.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Predictors of Readmission after the First Acute Coronary Syndrome and the Risk of Recurrent Cardiovascular Events-Seven Years of Patient Follow-Up

Recurrent hospitalization after acute coronary syndromes (ACS) is common. Identifying risk factors associated with subsequent cardiovascular events and hospitalization is essential for the management of these patients. Our research consisted in observing the outcomes of subjects after they suffered an acute coronary event and identifying the factors that can predict rehospitalization in the first 12 months and the recurrence of another acute coronary episode. Data from 362 patients admitted with ACS during 2013 were studied. Recurrent hospitalizations were retrospectively reviewed from medical charts and electronic hospital archives over a period of seven years. The mean age of the studied population was 64.57 ± 11.79 years, 64.36% of them being males. The diagnosis of ACS without ST elevation was registered in 53.87% of the patients at index hospitalization. More than half had recurrent hospitalization in the first year after the first ACS episode. Patients with lower ejection fraction (39.20 ± 6.85 vs. 42.24 ± 6.26, p < 0.001), acute pulmonary edema during the first hospitalization (6.47% vs. 1.24%, p = 0.022), coexistent valvular heart disease (69.15% vs. 55.90%, p = 0.017), and three-vessel disease (18.90% vs. 7.45%, p = 0.002) were more frequently readmitted in the following twelve months after their first acute coronary event, while those with complete revascularization were less frequently admitted (24.87% vs. 34.78%, p = 0.005). In multiple regression, complete revascularization during the index event (HR = 0.58, 95% CI 0.35-0.95, p = 0.03) and a higher LVEF (left ventricular ejection fraction) (HR = 0.95, 95% CI 0.92-0.988, p = 0.009) remained independent predictors of fewer early readmissions. Complete revascularization of the coronary lesions at the time of the first event and a preserved LVEF were found to be the predictors of reduced hospitalizations in the first year after an acute coronary event.

Why do patients with hypopituitarism still present an increased mortality?

Hypopituitarism is defined as a lack or decreased secretion of one or several pituitary hormones. It can result from diseases of the pituitary gland or from pathologies of the superior regulatory center, i.e. the hypothalamus, thereby decreasing hypothalamic releasing hormones and consequently the pituitary hormones. It is still a rare disease with an estimated prevalence of 30-45 patients/100,000 and an incidence of 4-5/100,000/year. This review summarizes the currently available data with a focus on etiologies of hypopituitarism, evidence on mortality rates in patients with hypopituitarism, temporal trends in mortality , and associated diseases, pathophysiological mechanisms and risk factors that affect mortality risk in these patients.

The outcome of ST-elevation myocardial infarction by sex: a retrospective cohort study

We aimed to compare in-hospital mortality (IHM) of acute myocardial infarction (AMI) between male and females. We assessed the association of sex with IHM after AMI using simple and multivariate cox regression models. Results were presented as crude and adjusted hazard ratios along with their 95% confidence interval (HR; 95% CI). Multivariable Cox regression analysis revealed females had a higher risk of death than males after ST-elevation MI (STEMI) (adjusted HR [95% CI]: 1.64 [1.15-2.36]; p = 0.007). In subgroup analysis by age group, this significantly increased risk was only observed in 50- to 64-year-old females. There were no significant differences between genders after non-STEMI and unspecified MI. Women aged 50 to 64 years had higher IHM after STEMI than men.

Effectiveness of letters to patients with or without Cochrane blogshots on 10-year cardiovascular risk change among women in menopausal transition: 6-month three-arm randomized controlled trial

BACKGROUND

Health information and patient education on lifestyle changes may have a positive effect on the prevention of many chronic conditions, especially cardiovascular diseases (CVDs). We performed a parallel, three-arm randomized controlled trial (RCT) of 6-month educational intervention in a form of letters containing a reminder of the participant's CVD risk with or without Cochrane blogshots to reduce CVD risk among women aged 45-65 with one or more known CVD risk factors.

METHODS

The control group received a letter about their CVD risk at the beginning of the trial. The intervention groups received the initial letter about their CVD risk and remainder letters about their CVD risk every 2 months, with or without Cochrane blogshots: (1) effect of calcium in the prevention of high blood pressure, (2) effect of reducing saturated fat acids in eating habits, and (3) effects of green and black tea in CVD prevention. The primary outcome was CVD risk reduction calculated as the difference between the baseline and 6-month score for a 10-year risk of fatal CVD according to the ACC/AHA guidelines.

RESULTS

After both interventions, CVD risk reduction was significantly higher compared to the control group (P < 0.001, Kruskal-Wallis H test). The number of participants who decreased their CV risk was 29% (20/70) in the control group, 69% (48/70) in the group receiving the reminder letters, and 70% (49/70) in the group receiving the reminder letters and blogshots. The number needed to treat to achieve risk reduction was 2.41 (95% CI = 1.77 to 3.78) for letters with a CVD risk reminder and 2.50 (1.81 to 4.03) for letters with a reminder and a blogshot. The group receiving reminder letters with Cochrane blogshots had a significant change in the category of CVD risk, mainly from high to moderate and from moderate to low CVD risk category.

CONCLUSIONS

A simple and inexpensive intervention method in a form of letters reminding women about their CVD risk with or without providing additional health information in the form of Cochrane blogshots about interventions for important CVD risk factors may be effective in CVD management and could be considered by primary care providers.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04601558. Retrospectively registered on October 19, 2020.

The association between DNA methylation of 6p21.33 and AHRR in blood and coronary heart disease in Chinese population

BACKGROUND

Early detection could significantly improve the prognosis of coronary heart disease (CHD). In-invitro diagnostic technique may provide a solution when sufficient biomarkers could be identified. Pertinent associations between blood-based aberrant DNA methylation and smoking, the pathogenesis of atherosclerosis, and CHD have been robustly demonstrated and replicated, but that studies in Chinese populations are rare. The blood-based methylation of aryl-hydrocarbon receptor repressor (AHRR) cg05575921 and 6p21.33 cg06126421 has been associated with cardiovascular mortality in Caucasians. Here, we aim to investigate whether the AHRR and 6p21.33 methylation in the blood is associated with CHD in the Chinese population.

METHODS

In this case-control study, 180 CHD patients recruited at their first registration in our study center, and 184 controls randomly selected from the people who participated in the annual health examination were enrolled. Methylation intensities of 19 CpG sites, including AHRR cg05575921, 6p21.33 cg06126421, and their flanking CpG sites, were quantified by mass spectrometry. The association between methylation intensities and CHD was estimated by logistic regression analyses adjusted for covariant.

RESULTS

Compared to the controls, lower methylation of 6p21.33_CpG_4.5/cg06126421 was independently associated with increased odds of being a CHD patient (OR per - 10% methylation = 1.42 after adjustment for age, gender, and batch effect; p = 0.032 by multiple testing corrections). No association between blood-based AHRR methylation and CHD was found.

CONCLUSIONS

6p21.33 methylation exhibits a significant association with CHD. The combination of 6p21.33 methylation and conventional risk factors might be an intermediate step towards the early detection of CHD.

Gender gap in annual preventive care services in France

BACKGROUND

In France, screening for cardiovascular risk factors is recommended during annual preventive visits. However, data are lacking on the temporal trend in women's uptake to preventive care services, and in cardiovascular and mortality outcomes. The aim of the study was to investigate the participation and mortality of women in annual preventive care services in a major preventive medicine center in France.

METHOD

Ee conducted repeated cross-sectional studies including a total of 366,270 individuals who had a first examination at the Centre d'Investigations Préventives et Cliniques, France, between January 1992 and December 2011.

FINDINGS

Women's participation was low below 50 years of age, then increases from 50 to 70 years, and is lower for women older than 70 years. The gap in female participation was more pronounced among individuals with high education, low social deprivation, and no depressive symptoms. Compared with the general population, the screened population had significantly lower standardized mortality ratios (SMRs) among both men and women, for all age ranges. Screened women aged 18-49 years showed a lower mortality gain compared with men of the same age; SMRs did not differ significantly by sex for individuals over 50 years.

INTERPRETATION

In this community-based sample, compared with men, women's participation to annual preventive care services was lower, and screened women had a lower mortality gain. Despite the demonstrated benefit of annual check-ups on health, there is a gender gap in adherence to preventive programs and in efficiency of screening programs, especially in the young age range. This gap in cardiovascular disease prevention may result in poorer cardiovascular health in women. Urgent adaptations to overcome this gender gap in preventive screening in France are warranted.

FUNDING

Bamba Gaye is supported by the Fondation Recherche Médicale grant.

Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease

Importance

There is a paucity of data regarding secondary prevention care disparities in women with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD), defined as an ASCVD event at 55 years or younger and 40 years or younger, respectively.

Objective

To evaluate sex-based differences in antiplatelet agents, any statin, high-intensity statin (HIS) therapy, and statin adherence in patients with premature and extremely premature ASCVD.

Design, Setting, and Participants

This was a cross-sectional, multicenter, nationwide VA health care system-based study with patients enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. The study assessed patients who had at least 1 primary care visit in the Veterans Affairs (VA) health care system from October 1, 2014, to September 30, 2015. Participants included 147 600 veteran patients with premature ASCVD, encompassing ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD).

Exposures

Women vs men with premature and extremely premature ASCVD.

Main Outcomes and Measures

Antiplatelet use, any statin use, HIS use, and statin adherence (proportion of days covered [PDC] ≥0.8).

Results

We identified 10 413 women and 137 187 men with premature ASCVD (age ≤55 years) and 1340 women and 8145 men with extremely premature (age ≤40 years) ASCVD. Among patients with premature and extremely premature ASCVD, women represented 7.1% and 14.1% of those groups, respectively. When compared with men, women with premature ASCVD had a higher proportion of African American patients (36.1% vs 23.8%) and lower proportions of Asian patients (0.5% vs 0.7%) and White patients (56.1% vs. 68.1%). In the extremely premature ASCVD group, women had a comparatively higher proportion of African American patients (36.8% vs 23.2%) and lower proportion of White patients (55.0% vs 67.8%) and Asian patients (1.3% vs 1.5%) than men. Among patients with premature IHD, women received less antiplatelet (adjusted odds ratio [AOR], 0.47, 95% CI, 0.45-0.50), any statin (AOR, 0.62; 95% CI, 0.59-0.66), and HIS (AOR, 0.63; 95% CI, 0.59-0.66) therapy and were less statin adherent (mean [SD] PDC, 0.68 [0.34] vs 0.73 [0.31]; β coefficient: -0.02; 95% CI, -0.03 to -0.01) compared with men. Similarly, women with premature ICVD and premature PAD received comparatively less antiplatelet agents, any statin, and HIS. Among patients with extremely premature ASCVD, women also received less antiplatelet therapy (AOR, 0.61; 95% CI, 0.53-0.70), any statin therapy (AOR,0.51; 95% CI, 0.44-0.58), and HIS therapy (AOR, 0.45; 95% CI, 0.37-0.54) than men. There were no sex-associated differences in statin adherence among patients with premature ICVD, premature PAD, or extremely premature ASCVD.

Conclusions and Relevance

This cross-sectional study revealed that women veterans with premature ASCVD and extremely premature ASCVD receive less optimal secondary prevention cardiovascular care in comparison with men. Women with premature ASCVD, particularly those with IHD, were also less statin adherent. Multidisciplinary and patient-centered interventions are needed to improve these disparities in women.

Arterial Hypertension: Individual Therapeutic Approaches-From DNA Sequencing to Gender Differentiation and New Therapeutic Targets

The aim of this paper is to provide an accurate overview regarding the current recommended approach for antihypertensive treatment. The importance of DNA sequencing in understanding the complex implication of genetics in hypertension could represent an important step in understanding antihypertensive treatment as well as in developing new medical strategies. Despite a pool of data from studies regarding cardiovascular risk factors emphasizing a worse prognosis for female patients rather than male patients, there are also results indicating that women are more likely to be predisposed to the use of antihypertensive medication and less likely to develop uncontrolled hypertension. Moreover, lower systolic blood pressure values are associated with increased cardiovascular risk in women compared to men. The prevalence, awareness and, most importantly, treatment of hypertension is variable in male and female patients, since the mechanisms responsible for this pathology may be different and closely related to gender factors such as the renin–angiotensin system, sympathetic nervous activity, endothelin-1, sex hormones, aldosterone, and the immune system. Thus, gender-related antihypertensive treatment individualization may be a valuable tool in improving female patients’ prognosis.

Differences between men and women in the use of preventive medications following a major cardiovascular event: Australian prospective cohort study

Most cardiovascular disease (CVD) events can be prevented with appropriate risk management. Existing evidence suggests women are less likely than men to receive guideline-recommended medications, however data on sex-differences in preventive medication use following a CVD event are lacking. Relative risks (RRs) comparing use of blood pressure- and lipid-lowering medications in men and women at 3-, 6-, 9- and 12-months following hospitalisation for myocardial infarction (MI) or stroke from 2012 to 2017 were quantified using linked data from 8,278 participants enrolled in the Australian 45 and Up Study. Overall, 51% of women and 58% of men were using both blood-pressure- and lipid-lowering medications three months after a MI or stroke event, decreasing to 48% and 53%, respectively, at 12 months after an event. Adjusting for potential confounders, women were 9% less likely than men (RR = 0.91 [95% CI: 0.87, 0.95]) to be using both medications and 19% more likely (RR = 1.19 [95% CI: 1.07, 1.32]) to use neither medication three months after a MI or stroke event. At the 12-month mark, women were 8% less likely (RR = 0.92 [95% CI: 0.88, 0.97]) to be using both medications and 14% more likely (RR = 1.14 [95% CI: 1.03, 1.26]) to use neither medication. Women were consistently less likely to use both preventive medications and more likely to use neither medication at each follow-up time point. Overall, there were major shortfalls in basic preventive medication use post-CVD event and sex disparities are likely to further jeopardise efforts to reduce CVD events in the community.

Sex differences in factors associated with heart failure and diastolic left ventricular dysfunction: a cross-sectional population-based study

BACKGROUND

Although sex differences in cardiovascular diseases are recognised, including differences in incidence, clinical presentation, response to treatments, and outcomes, most of the practice guidelines are not sex-specific. Heart failure (HF) is a major public health challenge, with high health care expenditures, high prevalence, and poor clinical outcomes. The objective was to analyse the sex-specific association of socio-demographics, life-style factors and health characteristics with the prevalence of HF and diastolic left ventricular dysfunction (DLVD) in a cross-sectional population-based study.

METHODS

A random sample of 2001 65-84 year-olds underwent physical examination, laboratory measurements, including N-terminal pro-B-type natriuretic peptide (NT-proBNP), electrocardiography, and echocardiography. We selected the subjects with no missing values in covariates and echocardiographic parameters and performed a complete case analysis. Sex-specific multivariable logistic regression models were used to identify the factors associated with the prevalence of the diseases, multinomial logistic regression was used to investigate the factors associated to asymptomatic and symptomatic LVD, and spline curves to display the relationship between the conditions and both age and NT-proBNP.

RESULTS

In 857 men included, there were 66 cases of HF and 408 cases of DLVD (77% not reporting symptoms). In 819 women, there were 51 cases of HF and 382 of DLVD (79% not reporting symptoms). In men, the factors associated with prevalence of HF were age, ischemic heart disease (IHD), and suffering from three or more comorbid conditions. In women, the factors associated with HF were age, lifestyles (smoking and alcohol), BMI, hypertension, and atrial fibrillation. Age and diabetes were associated to asymptomatic DLVD in both genders. NT-proBNP levels were more strongly associated with HF in men than in women.

CONCLUSIONS

There were sex differences in the factors associated with HF. The results suggest that prevention policies should consider the sex-specific impact on cardiac function of modifiable cardiovascular risk factors.

Gender gap in risk factor control of coronary patients far from closing: results from the European Society of Cardiology EUROASPIRE V registry

AIMS

This study aims to provide an overview on contemporary gender differences in the risk factor control of coronary heart disease (CHD) patients.

METHODS AND RESULTS

Analyses were based on the cross-sectional ESC (European Society of Cardiology) EORP (EurObservational Research Programme) EUROASPIRE V (European Survey of Cardiovascular Disease Prevention and Diabetes) survey including data on CHD patients across 27 European countries. Men and women between 18 and 80 years old, hospitalized for a first or recurrent coronary event were included in the study. Data were available for 8261 patients of which 25.8% women. Overall, women had a worse risk factor control compared with men. Whereas women were more likely to be non-smokers (79.3% vs. 87.2%; P < 0.001), they were less likely to reach recommended levels of physical activity (36.8% vs. 27.5%; P < 0.001), and they were less likely to be non-obese (65.1% vs. 54.3%; P < 0.001). There is indication that risk factors such as smoking behaviour and obesity differed depending on country income level. No gender differences could be observed in blood pressure on target (P > 0.05). Moreover, a lower proportion of women reached low-density lipoprotein cholesterol (LDL-C) target levels (31.4% vs. 22.1%; P < 0.001), and they were less likely to reach glycated haemoglobin (HbA1c) targets if having self-reported diabetes (56.7% vs. 48.6%; P < 0.001).

CONCLUSION

The risk factor control of CHD women is substantial worse compared with men despite little gender differences in cardiovascular medication intake. Further actions are needed to increase the awareness of the worse risk factor control in female CHD patients.

Sex Difference in the Association Between Metabolic Syndrome and Obstructive Coronary Artery Disease: Analysis of Data from the KoRean wOmen'S chest pain rEgistry (KoROSE)

Background: The sex-related impact of metabolic syndrome (MetS) on obstructive coronary artery disease (OCAD) has not been well evaluated. Methods: A total of 1156 patients (62 years and 58% women) with chest pain undergoing invasive coronary angiography (CAG) were recruited from the database of the nation-wide chest pain registry. MetS was defined according to the criteria of the International Diabetes Federation. OCAD was defined as ≥50% stenosis of the left main coronary artery and/or ≥70% stenosis of any other coronary arteries. Results: Women were older than men (65 vs. 59 years, p < 0.001). OCAD (32.0% vs. 30.9%) and MetS (27.8% vs. 27.9%) prevalence rates were similar in both sexes (p > 0.05). The presence of MetS was associated with higher prevalence of OCAD in women (24.5% vs. 47.3%, p < 0.001), but not in men (31.0% vs. 34.3%, p = 0.487). The linear association between the number of components meeting MetS criteria and OCAD prevalence was significant in both sexes (p < 0.001 for each), but it was stronger in women than in men (Chi-square value: 81.9 vs. 14.8, p < 0.001). In a multivariable model, the presence of MetS was independently associated with OCAD in women even after controlling for potential confounders (odds ratio, 1.92; 95% confidence interval, 1.31-2.81; p = 0.001). Conclusions: In patients with chest pain undergoing invasive CAG, the association between the number of components meeting MetS criteria and OCAD prevalence was stronger in women than in men.

High versus Low Mechanical Index Imaging Diagnostic Ultrasound in Patients with Myocardial Infarction: A Therapeutic Application Study

Background

High mechanical index impulse of ultrasound is used for diagnosis of microvascular coronary obstruction and the necrotic area, but an experimental model study suggested that it can restore microvascular and epicardial coronary flow. The purposes of the study were to test the safety and therapeutic efficacy of high acoustic energy diagnostic ultrasound in patients with ST-segment elevation myocardial infarction.

Material/Methods

Patients with ST-segment elevation myocardial infarction subjected to a low (n=199) or high (n=251) mechanical index ultrasound before and after percutaneous coronary interventions and echocardiographic parameters were evaluated. Coronary angiographies were performed for the assessment of culprit vessels. Thrombolysis in myocardial infarction flow grade 1 or 2 were considered as culprit vessels.

Results

Patients diagnosed through low acoustic energy ultrasound reported 235 infarct vessels and patients diagnosed through high acoustic energy ultrasound reported 300 infarct vessels. With respect to low acoustic energy, high acoustic energy reduced the number of culprit vessels at post-percutaneous coronary interventions at 48 hours before hospital discharge (P=0.015) and post-percutaneous coronary interventions at 1-month from the baseline interventions (P=0.043). Also, the maximum% ST-segment resolution and an ejection fraction of the left ventricle was increased and microvascular coronary obstruction in infarct vessels was decreased for both evaluation points. High acoustic energy could not affect heart rate (P=0.133) and oxygen saturation (P=0.079).

Conclusions

High acoustic energy ultrasound is a safe method for diagnosis of ST-segment elevation myocardial infarction and may have therapeutic applications.

Historic and recent trends in county-level coronary heart disease death rates by race, gender, and age group, United States, 1979-2017

Given recent slowing of declines in national all-cause, heart disease, and stroke mortality, examining spatiotemporal distributions of coronary heart disease (CHD) death rates and trends can provide data critical to improving the cardiovascular health of populations. This paper documents county-level CHD death rates and trends by age group, race, and gender from 1979 through 2017. Using data from the National Vital Statistics System and a Bayesian multivariate space-time conditional autoregressive model, we estimated county-level age-standardized annual CHD death rates for 1979 through 2017 by age group (35–64 years, 65 years and older), race (white, black, other), and gender (men, women). We then estimated county-level total percent change in CHD death rates during four intervals (1979–1990, 1990–2000, 2000–2010, 2010–2017) using log-linear regression models. For all intervals, national CHD death rates declined for all groups. Prior to 2010, although most counties across age, race, and gender experienced declines, pockets of increasing CHD death rates were observed in the Mississippi Delta, Oklahoma, East Texas, and New Mexico across age groups and gender, and were more prominent among non-white populations than whites. Since 2010, across age, race, and gender, county-level declines in CHD death rates have slowed, with a marked increase in the percent of counties with increasing CHD death rates (e.g. 4.4% and 19.9% for ages 35 and older during 1979–1990 and 2010–2017, respectively). Recent increases were especially prevalent and geographically widespread among ages 35–64 years, with 40.5% of counties (95% CI: 38.4, 43.1) experiencing increases. Spatiotemporal differences in these long term, county-level results can inform responses by the public health community, medical providers, researchers, and communities to address troubling recent trends.

Gender differences among ischemic heart disease patients enrolled in a cardiac rehabilitation program

BACKGROUND

Cardiac rehabilitation programs reduce cardiovascular events and mortality in ischemic heart disease patients. The aim of this study was to assess gender differences among ischemic heart disease patients enrolled in a cardiac rehabilitation program regarding adherence to the program, as well as, changes in clinical, laboratory, and echocardiographic parameters.

RESULTS

A prospective study that included 30 men and 30 women with stable ischemic heart disease who had been totally revascularized by percutaneous coronary intervention. Patients were enrolled in a 12-week cardiac rehabilitation program. Assessment of demographics, anthropometric measurements, risk factors, and functional capacity was performed. Lipid profile, glycated hemoglobin, and left ventricular ejection fraction were assessed. Assessments were performed at baseline and after completion of the program. Time to enrollment in the program was prolonged for women 39.17 ± 40.49 vs. 19.77 ± 10.26 days (p = 0.014). At baseline, more women were diabetic (p = 0.004), hypertensive (p = 0.02), had a larger waist circumference (p = 0.022), a higher BMI (p = 0.011), and higher HbA1c (p = 0.033). More men were active smokers (p < 0.001). After completion of the program, it was found that men attended 19.1 ± 4.77 (79.6%) sessions compared to 15.7 ± 5.72 (65.4%) sessions for women (p = 0.015). Women had more reduction in diastolic BP - 10.93 ± 8.94 vs. - 5.47 ± 12.57 mmHg (p = 0.058). The magnitude of reduction in resting heart rate was significant in men (p = 0.018) but not in women (p = 0.376). The magnitude of reduction in serum total cholesterol and triglycerides was more in men (p = 0.018 and p = 0.014). Women showed more reduction in HbA1c (p = 0.052).

CONCLUSION

Men are more adherent to cardiac rehabilitation programs. Recruitment of women is significantly delayed. Women have a higher cardiovascular risk burden in the form of prevalence of diabetes, hypertension, and obesity. Completion of a cardiac rehabilitation program causes a reduction in BMI, waist circumference, blood pressure measurements, total cholesterol, triglycerides, LDL-C, HDL-C, HbA1c, and LVEDD with an increase in LVEF in both genders. Men show more reduction in resting HR, total cholesterol, and triglyceride levels while women show more reduction in diastolic BP and HBA1c.

Gender disparities in patient education provided during patient visits with a diagnosis of coronary heart disease

Background:

Cardiovascular disease is the leading cause of death in females in the United States. Prior studies have reported that females receive less patient education and preventive counseling for cardiovascular disease as compared with males. The American Heart Association and others have embarked on several initiatives over the last 20 years to narrow this disparity of care. The primary objective of this study was to determine whether a gender disparity remains in the provision of patient education among patients diagnosed with coronary heart disease, a form of cardiovascular disease. The secondary objective was to determine whether there is an association between the provision of patient education and sociodemographic variables and risk factors.

Methods:

This was a retrospective, cross-sectional, observational study of adults (⩾18 years) diagnosed with coronary heart disease who participated in National Ambulatory Medical Care Survey between the years 2005 and 2014, inclusive. Chi-square tests of independence were performed to address the primary objective. A multivariable logistic regression model was constructed to assess the association between gender and provision of patient education while adjusting for sociodemographic variables and risk factors of interest.

Results:

A total raw survey sample size of 17,332 patient visits meeting the study inclusion/exclusion criteria was utilized. Patients were predominately white, male, non-Hispanic, and ⩾75 years of age. Females had 0.86 times the odds of receiving patient education compared with males (95% confidence interval = 0.78–0.95, p = 0.0024). After adjusting for covariates of interest, gender remained statistically significant in the multivariable logistic model. In addition, the variables “other payer” (vs private insurance), tobacco use, primary care physician type, obesity, hyperlipidemia, and hypertension were found to be statistically significantly associated with the provision of patient education (p < 0.05) in the multivariable analysis.

Conclusion:

In the data analyzed, gender disparities exist, as evidenced by a greater proportion of males receiving patient education than females, among coronary heart disease patients during visits seeking medical care. The acceptability of these findings in terms of overall patient management and treatment goals requires further evaluation.

Upregulation of miR‑423 improves autologous vein graft restenosis via targeting ADAMTS‑7

Coronary artery bypass graft (CABG) is one of the primary methods of treating coronary heart disease (CHD); however, vein graft restenosis is a major limiting factor of the effectiveness of CABG. Emerging evidence has indicated that miR‑423 is associated with vascular diseases. Additionally, upregulation of a disintegrin and metalloproteinase with thrombospondin motifs‑7 (ADAMTS‑7) contributes to neointima formation by promoting the proliferation and migration of vascular smooth muscle cells and inhibiting the proliferation and migration of endothelial cells. The aim of the present study was to examine the effects of miR‑423 target, ADAMTS‑7, on regulating vein graft disease and identify novel biomarkers for use in therapy of vein graft failure (VGF). Aberrant expression of miR‑423 in plasma of patients with CHD prior to and following CABG confirms that miR‑423 may be a suitable target for preventing VGF. Furthermore, a dual‑luciferase reporter gene assay indicated that miR‑423 directly interacted with ADAMTS‑7 and suppressed its expression. Ectopic expression of miR‑423 suppressed ADAMTS‑7, resulting in decreased proliferation and migration rates of human umbilical vein smooth muscle cells by targeting ADAMTS‑7, but resulted in increased proliferation and migration of human umbilical vein endothelial cells in vitro. Overexpression of miR‑423 also enhanced re‑endothelialization and decreased neointimal formation in a rat vein graft model. In conclusion, the results of the present study demonstrated that the miR‑423/ADAMTS‑7 axis may possess potential clinical value for the prevention and treatment of restenosis in patients with CHD following CABG.

Causes of death across categories of estimated glomerular filtration rate: The Stockholm CREAtinine Measurements (SCREAM) project

Introduction

Reduced kidney function increases the risk of death, but there is limited information on causes of death across stages of chronic kidney disease (CKD). We aimed to identify leading causes of death in community-dwelling individuals with differing kidney function.

Methods

Observational analysis from SCREAM, a healthcare utilization cohort of Stockholm, Sweden. We included all individuals who died during 2006–2012 and had one serum creatinine measured in the year prior to death. Using the CKD-EPI formula, we calculated eGFR and stratified individuals according to CKD stages. Causes of death were classified as cardiovascular (CVD), cancer, infection and other, using ICD-10 codes. We compared age- and sex-adjusted differences in the proportions of deaths from each cause.

Results

Out of 89,117 registered deaths, 70,547 (79%) had a recent eGFR estimation and were included in this study. Individuals had a median age of 82 (IRE 62–93) years and 52% were women. The proportions of deaths from CVD increased with lower eGFR, along with the proportion of deaths from infections. Deaths due to diabetes and genito-urinary diseases increased. Deaths due to cancer decreased, but other death causes did not vary. Within CVD causes of death, the proportion of arrhythmias and heart failure increased, but ischemic heart disease and cerebrovascular disease remained stable.

Conclusion

In a region-representative Swedish healthcare extraction, we observe differences regarding specific causes of death across different CKD stages. Increasing patient and provider awareness of this differential pattern of risk may have benefits for patient management, prevention strategies, and health service planning.

Proteomics and multivariate modelling reveal sex-specific alterations in distinct regions of human carotid atheroma

Background

Atherosclerotic lesions are comprised of distinct regions with different proteomic profiles. Men and women develop differences in lesion phenotype, with lesions from women generally being more stable and less prone to rupture. We aimed to investigate the differences in proteomic profiles between sexes, including distinct lesion regions, to identify altered proteins that contribute to these differences observed clinically.

Methods

Carotid endarterectomy samples (ten men/ten women) were obtained, and intraplaque biopsies from three distinct regions (internal control, fatty streak and plaque) were analysed by tandem-mass spectrometry. Multivariate statistical modelling, using orthogonal partial least square-discriminant analysis, was used to discriminate the proteomes between men and women.

Results

Multivariate discriminant modelling revealed proteins from 16 functional groups that displayed sex-specific associations. Additional statistics revealed ten proteins that display region-specific alterations when comparing sexes, including proteins related to inflammatory response, response to reactive oxygen species, complement activation, transport and blood coagulation. Transport protein afamin and blood coagulation proteins antithrombin-III and coagulation factor XII were significantly increased in plaque region from women. Inflammatory response proteins lysozyme C and phospholipase A2 membrane-associated were significantly increased in plaque region from men. Limitations with this study are the small sample size, limited patient information and lack of complementary histology to control for cell type differences between sexes.

Conclusions

This pilot study, for the first time, utilises a multivariate proteomic approach to investigate sexual dimorphism in human atherosclerotic tissue, and provides an essential proteomic platform for further investigations to help understand sexual dimorphism and plaque vulnerability in atherosclerosis.

Electronic supplementary material

The online version of this article (10.1186/s13293-018-0217-3) contains supplementary material, which is available to authorized users.

Sex Difference in Patients With Ischemic Heart Failure Undergoing Surgical Revascularization: Results From the STICH Trial (Surgical Treatment for Ischemic Heart Failure)

BACKGROUND

Female sex is conventionally considered a risk factor for coronary artery bypass grafting (CABG) and has been included as a poor prognostic factor in multiple cardiac operative risk evaluation scores. We aimed to investigate the association of sex and the long-term benefit of CABG in patients with ischemic left ventricular dysfunction enrolled in the prospective STICH trial (Surgical Treatment for Ischemic Heart Failure Study).

METHODS

The STICH trial randomized 1212 patients (148 [12%] women and 1064 [88%] men) with coronary artery disease and left ventricular ejection fraction ≤35% to CABG+medical therapy (MED) versus MED alone. Long-term (10-year) outcomes with each treatment were compared according to sex.

RESULTS

At baseline, women were older (63.4 versus 59.3 years; P=0.016) with higher body mass index (27.9 versus 26.7 kg/m2; P=0.001). Women had more coronary artery disease risk factors (diabetes mellitus, 55.4% versus 37.2%; hypertension, 70.9% versus 58.6%; hyperlipidemia, 70.3% versus 58.9%) except for smoking (13.5% versus 21.8%) and had lower rates of prior CABG (0% versus 3.4%; all P<0.05) than men. Moreover, women had higher New York Heart Association class (class III/IV, 66.2% versus 57.0%), lower 6-minute walk capacity (300 versus 350 m), and lower Kansas City Cardiomyopathy Questionnaire overall summary scores (51 versus 63; all P<0.05). Over 10 years of follow-up, all-cause mortality (49.0% versus 65.8%; adjusted hazard ratio, 0.67; 95% confidence interval, 0.52-0.86; P=0.002) and cardiovascular mortality (34.3% versus 52.3%; adjusted hazard ratio, 0.65; 95% confidence interval, 0.48-0.89; P=0.006) were significantly lower in women compared with men. With randomization to CABG+MED versus MED treatment, there was no significant interaction between sex and treatment group in all-cause mortality, cardiovascular mortality, or the composite of all-cause mortality or cardiovascular hospitalization (all P>0.05). In addition, surgical deaths were not statistically different (1.5% versus 5.1%; P=0.187) between sexes among patients randomized to CABG per protocol as initial treatment.

CONCLUSIONS

Sex is not associated with the effect of CABG+MED versus MED on all-cause mortality, cardiovascular mortality, the composite of death or cardiovascular hospitalization, or surgical deaths in patients with ischemic left ventricular dysfunction. Thus, sex should not influence treatment decisions about CABG in these patients.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Carotid Atheroma From Men Has Significantly Higher Levels of Inflammation and Iron Metabolism Enabled by Macrophages

BACKGROUND AND PURPOSE

Men differ from women in the manifestation of atherosclerosis and iron metabolism. Intraplaque hemorrhage and hemoglobin (Hb) catabolism by macrophages are associated with atherosclerotic lesion instability. The study aims were to investigate sex differences in (1) lesion severity in relation to blood Hb, (2) iron homeostasis in human carotid plaques, and (3) macrophage polarization within atheroma.

METHODS

The carotid artery samples from 39 men and 23 women were immunostained with cell markers for macrophages, smooth muscle cells, ferritin, and TfR1 (transferrin receptor 1), which were further analyzed according to sex in relation to iron, Hb, and lipids in circulation. Additionally, samples of predefined regions from human carotid atherosclerotic lesions, including internal controls, were used for proteomic analysis by mass spectrometry.

RESULTS

Male patients, compared with women, had larger necrotic cores and more plaque rupture, which were associated with higher levels of Hb. Atheroma of male patients had significantly higher levels of Hb in circulation and CD68 macrophages, ferritin, and TfR1 in lesions. CD68 macrophages were significantly correlated with ferritin and TfR1. Plaques from male patients comparatively possessed higher levels of inflammatory macrophage subsets, CD86 (M1) and CD163 (M2), but lower levels of STF (serotransferrin) and HPX (hemopexin).

CONCLUSIONS

Male patients with carotid atheroma had more advanced and ruptured lesions associated with significantly higher levels of inflammatory macrophage infiltration and high iron stores in the blood and in their plaques. These findings help to understand sex differences and iron metabolism in atherosclerosis and factors related to atheroma progression.

Sex differences in risk factor management of coronary heart disease across three regions

Objective

To investigate whether there are sex differences in risk factor management of patients with established coronary heart disease (CHD), and to assess demographic variations of any potential sex differences.

Methods

Patients with CHD were recruited from Europe, Asia, and the Middle East between 2012-2013. Adherence to guideline-recommended treatment and lifestyle targets was assessed and summarised as a Cardiovascular Health Index Score (CHIS). Age-adjusted regression models were used to estimate odds ratios for women versus men in risk factor management.

Results

10 112 patients (29% women) were included. Compared with men, women were less likely to achieve targets for total cholesterol (OR 0.50, 95% CI 0.43 to 0.59), low-density lipoprotein cholesterol (OR 0.57, 95% CI 0.51 to 0.64), and glucose (OR 0.78, 95% CI 0.70 to 0.87), or to be physically active (OR 0.74, 95% CI 0.68 to 0.81) or non-obese (OR 0.82, 95% CI 0.74 to 0.90). In contrast, women had better control of blood pressure (OR 1.31, 95% CI 1.20 to 1.44) and were more likely to be a non-smoker (OR 1.93, 95% CI 1.67 to 2.22) than men. Overall, women were less likely than men to achieve all treatment targets (OR 0.75, 95% CI 0.60 to 0.93) or obtain an adequate CHIS (OR 0.81, 95% CI 0.73 to 0.91), but no significant differences were found for all lifestyle targets (OR 0.93, 95% CI 0.84 to 1.02). Sex disparities in reaching treatment targets were smaller in Europe than in Asia and the Middle East. Women in Asia were more likely than men to reach lifestyle targets, with opposing results in Europe and the Middle East.

Conclusions

Risk factor management for the secondary prevention of CHD was generally worse in women than in men. The magnitude and direction of the sex differences varied by region.

High prevalence of poor fitness among Danish adults, especially among those with high cardiovascular mortality risk

Background

: Poor cardiorespiratory fitness (CRF) is an independent predictor of cardiovascular and all-cause mortality. Yet, our knowledge about the prevalence of poor CRF is limited. We investigated the prevalence of poor CRF among middle-aged Danish adults from a community-based health promotion program, including identification of a subgroup with high cardiovascular mortality risk. This cross-sectional study included 2,253 middle-aged adults, who completed a preventive health check including CRF testing. CRF (ml O 2 /min/kg) was assessed using the Astrand-Ryhming cycle ergometer test. High 10-year cardiovascular mortality risk as defined in the Danish 2016 guidelines was assessed using questionnaires, health examinations, and prescription data from the Danish National Prescription Registry. The prevalence of poor CRF was 51.7% (95% confidence interval [CI] 48.7-54.7) among men and 31.3% (95% CI 28.7-34.1) among women. A total of 216 (19.4%) men and 220 (19.3%) women were identified with a high 10-year cardiovascular mortality risk. Among these, 65.0% of men (95% CI 58.2-71.3) and 44.1% of women (95% CI 37.4-50.9) had poor CRF. Half of men and one third of women participating in a community-based health promotion program were identified with poor CRF. Among high-risk individuals, two thirds of men and almost every second woman had a poor CRF. Our results emphasise the need for effective public health strategies and interventions to increase CRF in the general population and among high-risk individuals in particular in order to improve public health and reduce mortality.

Awareness of Individual Cardiovascular Risk Factors and Self-Perception of Cardiovascular Risk in Women

BACKGROUND

Cardiovascular risk factors (CVRFs) self-perception by women may be inaccurate.

MATERIALS AND METHODS

A questionnaire was completed anonymously Online by women who self-reported their personal CVRF levels including age, weight, contraceptive use, menopausal status, smoking, diet and physical activities. Self-perceived risk was matched to actual cardiovascular risk according to the Framingham score.

RESULTS

Among 5,240 young and middle-aged women with a high educational level, knowledge of personal CVRFs increased with age, from 51-90% for blood pressure (BP), 22-45% for blood glucose and 15-47% for blood cholesterol levels, between 30 and 65 years, respectively. This knowledge was lower for smoking compared with nonsmoking women: 62.5% vs. 74.5% for BP (P < 0.001), 22.7% vs. 33.8% for blood glucose (P < 0.001), 21.9% vs. 32.0% for cholesterol levels (P < 0.001). Knowledge of BP level was reduced among women using an estrogen-progestogen contraception (56.8% vs. 62.1%, P = 0.0031) and even more reduced among smokers (52.2%, P < 0.001). Conversely, women with leisure-time physical or sportive activity (60.5%), were less overweight or obese (22.4% vs. 34.2%, P < 0.001). They reported better knowledge of BP (72.4% vs. 68.3%, P < 0.001), blood cholesterol (31.1% vs. 26.4%, P < 0.001) and glucose levels (32.7% vs. 27.8%, P < 0.001). Self-perceived cardiovascular risk was rated low by 1,279 (20.4%), moderate by 3,710 (63.3%) and high by 893 (16.3%) women. Among 3,386 women tested using the Framingham score, 40.8% were at low, 25.2% at moderate and 33.8% at high risk.

CONCLUSIONS

Knowledge of CVRFs and self-perception of individual risk are inaccurate in women. Educational interventions should be emphasized.

Assessing and Modifying Coronary Artery Disease Risk in Women

OPINION STATEMENT

Despite continued advances in the field, cardiovascular disease remains the leading cause of death in women in the USA with an annual mortality rate that has remained higher for women as compared to men. The factors leading to this sex difference remain incompletely understood. Likely contributors include atypical symptoms at presentation and lack of recognition of cardiovascular risk by women and their providers alike. In addition, women have a higher burden of comorbidities at the time of disease diagnosis and can have differential pathophysiological mechanisms of their acute events. Women also can develop unique cardiovascular risk factors such as preeclampsia and hypertensive disorders of pregnancy. As a result, when women present with symptoms, even atypical, healthcare providers should increase their index level of suspicion for cardiovascular disease. Even after diagnosis, women are less likely to receive guideline-directed medical therapies and be referred for coronary angiography or cardiac rehabilitation. Thus, greater awareness of and research into the aspects of coronary disease that remain unique to women is critical, as women presenting with coronary disease continue to receive disparate care as compared to men. Improvements in awareness and care and new research avenues may reduce the incidence and complications of cardiovascular disease among women.

Mitophagy and Mitochondrial Quality Control Mechanisms in the Heart

PURPOSE OF REVIEW

Mitochondrial homeostasis and quality control are essential to maintenance of cardiac function and a disruption of this pathway can lead to deleterious cardiac consequences.

RECENT FINDINGS

Mitochondrial quality control has been described as a major homeostatic mechanism in cell. Recent studies highlighted that an impairment of mitochondrial quality control in different cell or mouse models is linked to cardiac dysfunction. Moreover, some conditions as aging, genetic mutations or obesity have been associated with mitochondrial quality control alteration leading to an accumulation of damaged mitochondria responsible for increased production of reactive oxygen species, metabolic inflexibility, and inflammation, all of which can have sustained effects on cardiac cell function and even cell death.

SUMMARY

In this review, we describe the major mechanisms of mitochondrial quality control, factors that can impair mitochondrial quality control, and the consequences of disrupted mitochondrial quality control.

Time trends of mortality in patients with non-functioning pituitary adenoma: a Swedish nationwide study

PURPOSE

Patients with non-functioning pituitary adenomas (NFPA), especially women, have increased mortality. The aim of this study was to investigate whether mortality in NFPA patients has changed during the last two decades.

METHODS

This was a nationwide population-based study including 2795 patients (1502 men, 1293 women) diagnosed with NFPA between 1997 and 2011. Patients were identified and followed in Swedish National Health Registries. Standardized mortality ratios (SMRs) with 95 % confidence intervals were calculated for three time periods at first NFPA diagnosis using the general population as reference.

RESULTS

Mean (±SD) age at NFPA diagnosis was 58.9 ± 16.8 years. Mean (range) follow-up time was 8.3 (0-18) years, resulting in 20,517 patient-years at risk. Surgical treatment and radiotherapy were used in 53 and 5 %, respectively. The prevalence of hypopituitarism was 64 % during the first time period of diagnosis and then declined gradually during the study period (P value for trend <0.0001). The use of pituitary surgery and radiotherapy remained stable. In women, mortality was increased for patients diagnosed between 1997 and 2006 but not for those diagnosed between 2007 and 2011. The SMR in men remained stable throughout the study and did not differ from the general population. During the last time period, 2007-2011, the SMR between men and women did not differ.

CONCLUSIONS

While mortality in men with NFPA remains normal and stable during the last two decades, mortality in women has declined. Decreasing prevalence of pituitary insufficiency may be a plausible explanation for this positive development.