Risk factors for coronary heart disease in women

The Spectrum of Familial Hypercholesterolemia (FH) in Saudi Arabia: Prime Time for Patient FH Registry

BACKGROUND

Familial hypercholesterolemia (FH) is a life-threatening inherited condition. Untreated patients have the risk to develop raised plasma levels of cholesterol, atherosclerosis and cardiovascular disease (CVD). If diagnosed and treated early in life, the pathological consequences due to atherosclerosis could be avoided and patients with FH can have an anticipated normal life. Mounting evidence suggests that FH is underdiagnosed and undertreated in all populations. The underlying molecular basis of FH is the presence of mutations in one or more genes in the low-density lipoprotein receptor (LDLR), apolipoprotein B (APOB) or proprotein convertase subtilisin/kexin 9 (PCSK9). However, their prevalence is largely unknown in Saudi Arabia but given the high rates of consanguinity, the prevalence appears to be higher. Furthermore, the high prevalence of obesity and diabetes mellitus in Saudi Arabia increases the vascular disease burden in FH cases by adding additional CVD risk factors.

OBJECTIVE

This article explores the spectrum of FH-causing mutations in the highly consanguineous Saudi community, the need for establishing the Saudi FH registry, the challenges in creating gene databases, and cascade screening.

CONCLUSION

The establishment of FH registry and genetic testing should raise awareness not only among healthcare professionals, but the general population as well. It also helps to provide the best treatment regimen in a cost effective manner to this under-recognised population of FH patients.

Primary Prevention of Atherosclerotic Cardiovascular Disease in Women

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality among women. Despite improvements in cardiovascular disease prevention efforts, there remain gaps in cardiovascular disease awareness among women, as well as age and racial disparities in ASCVD outcomes for women. Disparity also exists in the impact the traditional risk factors confer on ASCVD risk between women and men, with smoking and diabetes both resulting in stronger relative risks in women compared to men. Additionally there are risk factors that are unique to women (such as pregnancy-related factors) or that disproportionally affect women (such as auto-immune disease) where preventive efforts should be targeted. Risk assessment and management must also be sex-specific to effectively reduce cardiovascular disease and improve outcomes among women. Evidence supports the use of statin therapy for primary prevention in women at higher ASCVD risk. However, some pause should be given to prescribing aspirin therapy in women without known ASCVD, with most evidence supporting the use of aspirin for women≥65 years not at increased risk for bleeding. This review article will summarize (1) traditional and non-traditional assessments of ASCVD risk and (2) lifestyle and pharmacologic therapies for the primary prevention of ASCVD in women.

Cardiovascular diseases in pregnancy

BACKGROUND

Cardiovascular diseases arise during 0,2% to 4% of all pregnancies in the industrialized world. In Germany, this type of complication, which is sometimes lethal, affects approximately 30 000 pregnant women per year.

METHODS

We performed a simple literature search in the NCBI databases for publications that appeared from 2008 to 2010 and that contained the search terms "pregnancy" and one of the following: "valvular disease," "endocarditis," "coronary heart disease," "cardiomyopathy," "hypertension," "anticoagulation." We also took consideration of the relevant international medical society guidelines and of the new database of the Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie in Berlin (Embryotox).

RESULTS

There is a rising incidence, not only of hypertension during pregnancy, but also of valvular heart disease during pregnancy. Severe valvular stenosis, particularly mitral stenosis, raises the risk of pulmonary edema and should be treated before pregnancy, by valvuloplasty or surgically. Women with high-grade valvular insufficiency and restricted left-ventricular function are at risk of heart failure. For women with mechanical heart valves, the type of anticoagulation during pregnancy must be discussed on an individual basis. Coumarin derivatives are associated with an elevated risk of hemorrhage as well as coumarin embryopathy; recent studies have shown that the latter risk is low and dose-dependent. Spontaneous dissection of the coronary arteries is best treated by catheter intervention with the implantation of a bare metal stent.

CONCLUSION

Women of child-bearing age who are at risk for, or already have, cardiovascular disease should receive early counseling and treatment, not just from their family physician, but from an interdisciplinary team composed of gynecologists, cardiologists, and, if necessary, cardiac surgeons.

Placental growth factor as short-term predicting biomarker in acute coronary syndrome patients with non-ST elevation myocardial infarction

OBJECTIVES

The relevance of placental growth factor was analyzed at the admission of patients with acute coronary syndrome (ACS) without ST elevation in prognosis of fatal outcome after 30 days.

METHODS

We collected blood samples from 102 ACS patients admitted to the coronary unit with acute chest pain manifesting within the last 12 hours.

RESULTS

In all 102 admitted patients, higher values of placental growth factor (PLGF; >13.2 ng/L, average value) indicated a higher risk of fatal outcome (hazard ratio [HR] 2.28, 95% confidence interval [CI] 1.21- 4.76, P = 0.0125). PLGF is an important independent prognostic marker (adjusted HR 2.35, 95% CI 1.98-4.61, P = 0.1338), and this was shown in a multiparameter model, which involved other statistically important markers of relative risk (age >65, gender, and estimated glomerular filtration rate [eGFR]).

CONCLUSION

PLGF levels measured at 12 hours of symptom onset and 30 days later may independently predict fatal outcome in patients with ACS without ST elevation.

Sex Hormone-Binding Globulin (SHBG), estradiol and breast cancer

The human serum Sex Hormone-Binding Globulin (SHBG) plays an important role in breast cancer pathophysiology and risk definition, since it regulates the bioavailable fraction of circulating estradiol. We here summarize data reported over the years concerning the involvement of SHBG and SHBG polymorphisms in the definition of breast cancer risk. We also report what is known about the direct action of SHBG in breast cancer cells, illustrating its interaction with these cells and the subsequent initiation of a specific intracellular pathway leading to cross-talk with the estradiol-activated pathway and, finally, to the inhibition of several effects of estradiol in breast cancer cells. In conclusion, as a result of its unique property of regulating the estrogen free fraction and cross-talking with the estradiol pathways, by inhibiting estradiol-induced breast cancer cell growth and proliferation, SHBG is associated with a reduced risk of developing the neoplasm after estrogen exposure.

Evaluation of coronary artery disease by computed tomography angiography in patients treated for childhood Hodgkin's lymphoma

PURPOSE To detect pathologies in coronary arteries by computed tomography angiography (CTA) in survivors of childhood Hodgkin's lymphoma who have been treated with radiotherapy and/or cardiotoxic agents. PATIENTS AND METHODS Patients with HL who have been in remission for at least 2 years after completion of therapy were included. CBC, lipid profile, urine analysis, brain natriuretic peptide, troponin-T, creatinine kinase-myocardial band, ECG, telecardiography, echocardiography, and CTA of the patients were performed. Cardiac vascular abnormalities were noted. Results A total of 119 patients were included in the study. In 19 patients (16%), we found coronary artery abnormalities. There was a significant difference between the patients who received mediastinal radiotherapy and those who did not (P = .02). By multivariate analysis, in patients receiving mediastinal radiotherapy the risk of developing a coronary artery abnormality was found to increase 6.8 times compared with patients who did not receive mediastinal radiotherapy (P = .009). Stent implantation was performed in a 28-year-old patient because of critical stenosis in right coronary. In two patients some irregularities were detected both in CTA and conventional angiography, and they remained in close follow-up. A 22-year-old patient whose CTA showed critical stenosis in his left anterior descending artery refused the conventional angiography. CONCLUSION To our knowledge, this is the first large study using CTA for detection of coronary abnormalities in patients treated for HL in pediatric age group. Coronary CTA is a minimally invasive tool for early diagnosis of coronary artery disease in patients who were treated with mediastinal radiotherapy and/or cardiotoxic chemotherapy.

Lifestyle and Risk of Cardiovascular Disease and Type 2 Diabetes in Women: A Review of the Epidemiologic Evidence

Cardiovascular disease is the leading cause of death among both women and men in the United States, accounting for nearly half of all deaths and considerable morbidity. Type 2 diabetes is a major risk factor for cardiovascular disease and one that is particularly potent in women; its prevalence has increased dramatically in recent years. Epidemiologic data indicate that cardiovascular disease and type 2 diabetes share common risk factors and are largely preventable; indeed, findings from the Nurses' Health Study suggest that 74% of cardiovascular disease cases, 82% of coronary heart disease cases, and 91% of diabetes cases in women could be prevented by not smoking, engaging in regular physical activity, maintaining a healthy weight, eating healthier food, and drinking moderate amounts of alcohol. This article reviews lifestyle risk factors and preventive strategies for cardiovascular disease and type 2 diabetes among women.

Sex-related characteristics in hospitalized patients with acute coronary syndromes – the Greek Study of Acute Coronary Syndromes (GREECS)

We studied the sex-specific distribution of various factors in hospitalized patients who presented with acute coronary syndromes (ACS), as well as the annual incidence and the in-hospital and short-term outcomes in males and females. A sample of six hospitals located in Greek urban and rural regions was selected. In these hospitals we recorded almost all nonfatal admissions with a first event of ACS, from October 2003 to September 2004. Sociodemographic, clinical, dietary, and other lifestyle characteristics were recorded. A total of 2,172 patients were included in the study (1,649, 76% male and 523, 24% female). The annual incidence rate was almost three times higher in males than in females (34 per 10,000 males and 10.9 per 10,000 females). The highest frequency of events was observed in winter, in both sexes. Females had higher in-hospital mortality rate as compared to males (5.7% vs 3.2%, P = 0.007), while the 30-day mortality and rehospitalization rate was 17% in male and 16% in female patients. The most common discharged diagnosis for males was Q-wave myocardial infraction (35%), while females were more likely to suffer from unstable angina (42%). Females were older than males, waited longer between seeking and receiving medical advice, and were more likely to have a history of hypertension, obesity, and diabetes mellitus as compared to males. On the other hand, males were more likely to be smokers, to follow a more typical Mediterranean diet, and to be more physically active (P < 0.05). We revealed a sex-related difference in the profile of clinical characteristics and other cardiovascular risk factors in hospitalized patients for ACS.

Long-term effects of tibolone on circulating levels of vascular cell adhesion molecules and E-selectin in postmenopausal women

OBJECTIVE

Adherence of lymphocytes and monocytes to cell adhesion molecules (vascular cell adhesion molecules [VCAMs]) expressed by activated endothelial cells is the first step in the development of atherosclerotic disease. It is known that administration of tibolone for 8 weeks reduces serum levels of VCAMs in postmenopausal women. We evaluated the effects of the administration of tibolone in postmenopausal women for 1 year.

DESIGN

Randomized, placebo-controlled, crossover trial.

SETTING

Healthy volunteers in an academic environment.

PATIENT(S)

Thirty-six healthy women in postmenopause since 1-4 years.

INTERVENTION(S)

Group A received 2.5 mg/d of tibolone and group B received placebo for 12 months; treatment was subsequently crossed over for 1 month.

MAIN OUTCOME MEASURE(S)

Serum concentrations of VCAM-1, intercellular adhesion molecule-1 (ICAM-1), and E-selectin were evaluated at baseline and at 6, 12, and 13 months.

RESULT(S)

Baseline concentration of VCAM-1, ICAM-1, and E-selectin were similar in both groups. At months 6 and 12, mean concentrations of VCAM-1, ICAM-1, and E-selectin decreased significantly in group A but not in group B. At month 13, levels returned to baseline in group A, whereas they decreased significantly in group B.

CONCLUSION(S)

Tibolone causes a rapid and sustained decrease in circulating levels of VCAMs; the effect is lost soon after stopping the treatment. Tibolone induces favorable changes in endothelial function and may exert a direct cardiovascular protective effect in postmenopausal women.

German vegan study: diet, life-style factors, and cardiovascular risk profile

BACKGROUND/AIM

Evaluation of cardiovascular risk profile in 154 German vegans.

METHODS

Cross-sectional study, Germany. Study instruments: 2 FFQ, 2 questionnaires, analyses of fasting venous blood samples.

RESULTS

The total study population had a low BMI (mean: 22.3 kg/m(2)), a moderate blood pressure (mean: 120/75 mm Hg), an extremely low consumption of alcohol (mean: 0.77 g/day) and 96.8% were nonsmokers. Moderate physical activity (PAL) was reported by nearly 50%, whereas 22.7% declared to have a high PAL (>3 h/week). Median triacylglycerol (TG) was 0.81 mmol/l, total cholesterol (TC) was 4.33 mmol/l, HDL was 1.34 mmol/l. The mean TC/HDL-ratio was 3.3. Lipoprotein(a) (Lp(a)) was 8.13 mg/dl, concentrations of >30 mg/dl were prevalent in 25% of the participants. In general, status of folate and pyridoxine were sufficient, while 49.7% showed cobalamin concentrations <150 pmol/l. Plasma homocysteine levels were slightly elevated (median: 12.5 micromol/l). Cobalamin concentration and duration of vegan nutrition were the main determinants of homocysteine in the total study population.

CONCLUSION

Although TC and LDL concentrations were favorable, low HDL and elevated homocysteine and Lp(a) concentrations were unfavorable. Overall, these results confirm the notion that a vegan diet is deficient in vitamin B(12), which may have an unfavorable effect on CHD risk.

The Influence of Gender on Arrhythmias

It is becoming increasingly apparent that there are important gender differences in normal cardiac physiology. These, in turn, could be associated with differences in the type and severity of cardiac arrhythmias. Women have higher resting heart rates than men, probably as a result of a combination of autonomic and intrinsic factors. The clinical significance of this observation is unclear at the present time. Women have a lower incidence of sudden cardiac death, which could be related to the delayed onset of coronary artery disease in women, presumably as a result of the protective effects of female hormones during gestational years. In survivors of sudden cardiac death, there are major gender differences, with fewer women having underlying coronary artery disease and a greater percentage of women having structurally normal hearts. QT interval prolongation and Torsade de Pointes are more common in women, probably on the basis of differences in ion channels between genders. Women appear especially susceptible to Torsades from QT-prolonging drugs such as quinidine or tricyclic antidepressant medications. The mechanisms of paroxysmal supraventricular tachycardia differ between the genders, although therapy seems to be equally efficacious in men and women. Lastly, atrial fibrillation is considerably more common in men. There is also some evidence that it is better tolerated by men.

Mental health issues associated with cardiovascular disease in women

Cardiovascular disease is the leading cause of death in women and men. However, cardiovascular disease and its treatment affect women differently. Much data is emerging regarding the role that mood and anxiety disorders play in the development and prognosis of cardiovascular disease. Pharmacologic treatment of psychiatric disorders can also have direct cardiac effects. The good news is that many more studies are exploring this. However, further research is clearly needed, especially in the area of reproductive hormones and their impact on cardiac disease.

Is there gender bias in the prehospital management of patients with acute chest pain?

OBJECTIVE

Prior emergency department (ED) and inpatient studies have found that women with coronary artery disease are more frequently misdiagnosed and undertreated compared with men. This study was performed to determine whether there is a gender bias in the prehospital management of patients with acute chest pain.

METHODS

This study was performed in a large urban county emergency medical services (EMS) agency with approximately 40,000 patient contacts/year. The study population comprised consecutive patients > or = 45 years old with a chief complaint of atraumatic chest pain. Using chi2 analysis and the unpaired Student's t-test, male and female patient encounters were compared. This study had >80% power (alpha 0.05) to detect a 3% difference between populations.

RESULTS

Data from 2,858 consecutive patient encounters were analyzed, with females comprising 1,508 (53%). Females were significantly older than males (67 +/- 13.1 vs. 62.7 +/- 12.3 years, p < 0.001). Male patients were more likely to receive aspirin (42.3% vs. 35.4%, p < 0.001) and 12-lead electrocardiograms (ECGs) (46.8% vs. 39.3%, p < 0.001) compared with female patients. The rates of transport refusal, oxygen, nitroglycerin, and narcotic administration did not differ between populations.

CONCLUSION

Although females presenting to this urban EMS system with acute chest pain were older, they received significantly less aspirin and fewer 12-lead ECGs in the field. These results suggest strategies must be developed to ensure that appropriate therapy is provided to women presenting to EMS systems with acute cardiac ischemia.

Women and coronary heart disease

Coronary heart disease (CHD) is the leading cause of death in men and women in the United States. The incidence of CHD during midlife is lower in women than men, but the gap narrows with each decade. Because women have a longer life span than men, the absolute numbers of CHD deaths are roughly equal. Effective diagnosis of CHD in women requires the recognition of gender differences in presentation and pathogenesis. Women present with atypical symptoms and are less likely to have adequate primary prevention. This article discusses the differences between men and women in CHD and examines the assessment, diagnosis, and clinical management of CHD in women.

Venous endothelial function in postmenopausal women after six months of tibolone therapy

STUDY OBJECTIVE

To test venous endothelial function in long-term climateric therapy with tibolone.

DESIGN

Measurement of dorsal hand-vein diameter by venous occlusion plethysmography during infusion of norepinephrine (NE), bradykinin (BK), NG-monomethyl L-arginine (L-NMMA) and sodium nitroprusside (SNP).

SETTING

Plethysmography and Menopause Units. University Hospital Valdecilla. Santander. Spain.

PATIENTS

Eleven postmenopausal women having continuous treatment with oral tibolone (2.5 mg/day) for 6 months.

INTERVENTIONS

Three plethysmography studies were made: at baseline, and at three and six months of treatment.

MAIN OUTCOME MEASURES

Dorsal hand-vein diameter measured by venous occlusion plethysmography during infusion of NE, BK, L-NMMA and SNP.

RESULTS

(a) Baseline study: maximum dilation with BK was 54.2+/-10.2%. (b) Three-month study: BK dilation of 71.5+/-11.9%, with a significant increase of 17.3% (P=0.019) compared with baseline. (c) Six-month study: BK dilation of 77.5+/-11.9%, with a significant increase 23.3% (P=0.002) compared with baseline. Maximal vasodilation was reached with SNP in the three studies and L-NMMA infusion has a similar vasoconstrictor response in the three studies.

CONCLUSIONS

Long-term climateric therapy with tibolone improves vein endothelium-dependent vasodilation suggesting a positive impact of this drug on endothelial function.

Effect of menopause on plaque morphologic characteristics in coronary atherosclerosis

BACKGROUND

Coronary artery disease in women appears 10 to 15 years later than in men. To test the hypothesis that the effects of estrogen may manifest themselves as histologic differences in coronary plaques, we examined the hearts of premenopausal and postmenopausal women who died suddenly from coronary artery disease.

METHODS

We studied 51 cases of sudden coronary death and 47 deaths in women who died from noncoronary causes. Coronary deaths were classified on the basis of histologic features. The number of acute plaque ruptures, healed plaque ruptures, vulnerable plaques, and acute plaque erosions were compared between groups. Postmortem values of serum total cholesterol, HDL cholesterol, and thiocyanate were measured, and menopausal status was confirmed by calculating body mass index.

RESULTS

Women older than 50 years of age were much more likely to have a ruptured plaque than were younger, premenopausal women. Plaque rupture was significantly associated with elevated total cholesterol level. In the 51 women who died of coronary disease, the mean number of vulnerable plaques increased significantly as women advanced into the postmenopausal years.

CONCLUSIONS

Our data suggest that estrogen has an anti-inflammatory effect on atherosclerotic plaques, resulting in plaque stabilization. Plaque erosion, the major substrate for thrombosis in premenopausal women, does not appear to be inhibited by estrogen. Because plaque progression may result both from repeated rupture and repeated erosion, a better understanding of the effect of estrogen on atherosclerosis may yield insights into the nature of coronary artery disease.

Heart disease in women. Gender-specific statistics and prevention strategies for a population at risk

For decades, coronary artery disease (CAD) was thought to be primarily a disease of middle-aged men, in whom most research was conducted. But CAD afflicts a diverse patient population, and a major subset of those patients--women--present special diagnostic and therapeutic challenges for the primary care physician. In this article, Dr Rosenfeld provides an overview of CAD in women and discusses its causes and risk factors, prevention strategies, and gender-specific characteristics. She also examines the effect of gender-biased research on the views of both patients and physicians.

Position of the American Dietetic Association and Dietitians of Canada: women's health and nutrition

Within the past 10 years women's health has evolved to a much broader paradigm, beyond reproductive issues. From a physiological perspective, women's health now refers to the prevention, diagnosis, and management of conditions or diseases that may be unique to women, be more prevalent in women, or manifest differently in women than men. Women's health encompasses emotional, social, cultural, spiritual, and physical well-being. It is determined by the social, political, and economic context of women's lives. Nutrition is involved in the etiology or treatment of half of the 10 leading causes of death in women. The incidence of osteoporosis and extremes in body weight are approaching epidemic proportions in women. This position reviews the following health problems: cardiovascular disease, cancer, osteoporosis, weight, and diabetes mellitus. Dietetics professionals are in the perfect position to understand the issues surrounding women's health in order to deliver a message to women that will allow them to make wise decisions regarding their health. Nutrition is a critical component of risk reduction and treatment, and must be included in clinical and preventive services for women. Dietetics professionals must work to increase their knowledge about women's health issues, to promote health and education programs, to influence policy makers, to deliver the highest-quality medical nutrition therapy, and to be proactive in documenting the effectiveness of outcomes-based research.