Differences in management and outcomes between male and female patients with atherothrombotic disease: results from the REACH Registry in Europe

Long-Term Outcomes of Peripheral Artery Disease in Veterans: Analysis of the Peripheral Artery Disease Long-Term Survival Study (PEARLS)

BACKGROUND

Contemporary research in peripheral artery disease (PAD) remains limited due to lack of a national registry and low accuracy of diagnosis codes to identify patients with PAD.

METHODS

Leveraging a novel natural language processing system that identifies PAD with high accuracy using ankle-brachial index and toe-brachial index values, we created a registry of 103 748 patients with new-onset PAD in the Veterans Health Administration. Study end points include mortality, cardiovascular events (hospitalization for acute myocardial infarction or stroke) and limb events (hospitalization for critical limb ischemia or major amputation) and were identified using Veterans Affairs and non-Veterans Affairs encounters.

RESULTS

The mean age was 70.6 years; 97.3% were male, and 18.5% self-identified as Black. The mean ankle-brachial index value was 0.78 (SD: 0.26) and the mean toe-brachial index value was 0.51 (SD: 0.19). A majority of patients were current (27.1%) or former (30.0%) smokers. Prevalence of hypertension (86.6%), heart failure (22.7%), diabetes (54.8%), chronic kidney disease (23.6%), and chronic obstructive pulmonary disease (35.4%) was high. At 1 year, 9.4% of patients had died. The 1-year incidence of cardiovascular events was 5.6 per 100 patient-years and limb events was 7.0 per 100 patient-years.

CONCLUSIONS

We have successfully launched a registry of >100 000 patients with a new diagnosis of PAD in the Veterans Health Administration, the largest integrated health system in the United States. The incidence of death and clinical events in our cohort is high. Ongoing studies will yield important insights regarding improving care and outcomes in this high-risk group.

Gender Differences and Amputation Risk in Peripheral Artery Disease-A Single-Center Experience

Background and Objectives: Peripheral artery disease (PAD) affects both genders, but the knowledge of clinical and therapeutic aspects particular to each gender has a prognostic value, modulating the risk of amputation and helping to reduce the risk of death or the occurrence of an acute vascular event secondary to optimal management. Materials and Methods: We conducted a retrospective, descriptive study that included 652 patients with PAD who were evaluated at "St. Spiridon" Hospital's Cardiology Department and divided into two groups according to gender: women (100 cases) and men (552 cases). We evaluated demographics, anthropometric data, as well as clinical and paraclinical parameters in the two groups. Results: Men had a lower mean age (p < 0.001), higher mean BMI (p = 0.049) and were more frequent smokers. (p = 0.008). Hypercholesterolemia (p = 0.026), obesity (p = 0.009), concomitant cerebrovascular (p = 0.005) and chronic kidney disease (p = 0.046) were more common in women, while coronary artery disease (p = 0.033) was more common in men. The number of angiographic stenotic lesions (p = 0.037) is a statistically significant parameter in our study, with both genders predominantly associated with stenotic lesions. In addition, directly proportional relationships were found between smoking, uric acid, inflammatory markers, and the number of stenotic lesions and thromboses or the ankle-brachial index (ABI). In the subgroup of men, the number of stenotic and thrombosed lesions positively correlated with the ABI value (p < 0.001). The presence of more than three cardiovascular risk factors (p = 0.001) and serum triglyceride levels (p = 0.019) significantly correlated with the number of angiographically detected lesions. We applied several risk scores (PREVENT III, Finnvasc Score, or GermanVasc risk score) in our study group for prognostic purposes, without showing statistically significant differences between genders. Men, rest pain, gangrene, smoking status, the presence of more than three cardiovascular risk factors, or a serum HDL-cholesterol level below 40 mg/dL (p < 0.001 for all parameters) are independent predictors associated with amputation in our study group. Conclusions: In our study, we demonstrated that several clinical-paraclinical particularities guide the diagnosis, providing the clinician with prognostic and therapeutic tools to choose the optimal management with maximum benefits.

Psychometric Properties of a Brief Version of the Perception of Risk of Heart Disease Scale in an Italian Sample

INTRODUCTION

The number of Italian citizens unaware of their risk of cardiovascular disease it is still very high.

AIM

This study aimed to translate and preliminarily validate a brief Italian version of the Perception of Risk of Heart Disease Scale (PRHDS).

METHODS

PRHDS was culturally adapted to the Italian context. Then, the scale was administered to 772 healthy adults. By randomly dividing the sample into two subsamples, we tested the scale dimensionality through Exploratory Factor Analysis (EFA) followed by Confirmatory Factor Analysis (CFA). Finally, we evaluated internal consistency.

RESULTS

Psychometric properties of the scale were appropriate. EFA and CFA evidenced a unidimensional structure of a brief version of the scale, composed of six items. Internal consistency was adequate.

CONCLUSIONS

Italian version of the brief PRHDS is a promising self-report questionnaire to measure cardiovascular risk perception among Italian adults.

Gender differences in risk factor management and pharmacological treatment among CHD patients: Belgian results of the EUROASPIRE IV and EUROASPIRE V surveys

AIMS

The aim of this study was to provide an up-to-date overview of gender differences or similarities in risk factor control and medical management in the Belgian CHD population.

METHODS

All analyses are based on the ESC EORP EUROASPIRE IV and EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) surveys. Patients between 18 and 80 years old, hospitalised for a first or recurrent coronary event, were included in the survey.

RESULTS

Data were available for 10,519 patients, of which 23.9% were women. Women had a worse risk factor profile compared to men. Women were more physical inactive (OR = 1.31, 95% CI = 1.19-1.44), had a higher prevalence of obesity (OR = 1.37, 95% CI = 1.25-1.50) and had a worse LDL-C control (OR = 1.52, 95% CI = 1.36-1.70). Moreover, women were less likely to use ACE-I/ARBs (OR = 0.84, 95% CI = 0.76-0.94) and statins (OR = 0.79, 95% CI = 0.70-0.90). In addition, little gender differences were found in patients' risk factor awareness, except on cholesterol awareness. Women were more aware about their total cholesterol levels (OR = 1.37, 95% CI = 1.21-1.56).

CONCLUSION

Despite little to no gender differences in the management of CHD patients, women still have a worse risk factor profile, both in Belgian and in other European high-income countries.

In postmenopausal women, lower limb peripheral arterial disease, assessed by ankle-brachial index, may be a strong predictor of cardiovascular risk

BACKGROUND

Lower limb peripheral arterial disease (PAD) is a leading atherosclerotic disease in the elderly. However, awareness of the disease is poor, particularly in women.

METHODS

In this retrospective, cross-sectional study, postmenopausal women referred to our Angiology Division were tested for PAD, defined as an "ankle-brachial index" (ABI) ≤0.9 or ≥1.4 (in the latter case with a "toe-brachial index" <0.7), or a history of lower limb arterial revascularization. Aim of our study was to assess cardiovascular (CV) risk profile in postmenopausal women with and without PAD, and to evaluate the role of PAD and six classic CV risk factors (CVRFs), namely age, current smoking, hypertension, dyslipidaemia, severe chronic renal failure, and diabetes in predicting CV disease (CVD), defined as coronary artery disease and/or cerebrovascular disease.

RESULTS

Overall, 850 patients were included, 39.4% of whom with PAD. Compared with women without PAD, those with PAD were older (75.2 vs 66 years, respectively; p <0.001), and displayed higher rates of other CVRFs (p <0.001 for each). A personal history of CVD was reported in 18.8% of women with PAD and in 6.1% of those without PAD (p <0.001). At multivariate regression analysis, PAD (odds ratio [OR]: 2.15; 95% confidence interval [CI]: 1.33-3.47), and hypertension (OR: 2.20; 95%CI: 1.24-3.88) were the strongest factors associated with CVD presence.

CONCLUSIONS

PAD is a strong marker of CVD in this selected series of postmenopausal women. If confirmed in the general population, PAD screening through ABI calculation may be considered for CV risk assessment in postmenopausal women.

Sex Differences in Peripheral Artery Disease

Peripheral artery disease (PAD) is a prevalent condition that confers substantial morbidity and mortality and remains underdiagnosed as well as undertreated in the overall population. Although PAD prevalence is similar or higher in women compared with men, associations of traditional and nontraditional risk factors with PAD and clinical manifestations of PAD differ by sex and may contribute to delayed or lack of diagnosis in women. Such sex-based differences in the manifestation of PAD may arise from sexual dimorphism in the vascular substrate in health as well as sex variation in the responses to vascular stressors. Despite the availability of proven therapies for improving symptoms and reducing risk of ischemic cardiovascular and limb events among patients with diagnosed PAD, important sex differences in treatment and outcomes have been observed. We provide an overview of current knowledge regarding sex differences in the epidemiology, pathophysiology, clinical presentation, and management of PAD.

Gender differences in cardiovascular risk factor awareness: Results from the ESC EORP EUROASPIRE V Registry

BACKGROUND

Patient risk factor awareness is essential to decrease the risk of recurrent coronary events. The aim of this study was to provide up-to-date evidence on existing gender differences in the patients' knowledge of risk factors and information provided by healthcare professionals.

METHODS

Analyses were based on the cross-sectional ESC EORP EUROASPIRE V survey, including data on CHD patients across 27 European countries. Consecutive patients (18-80 years), hospitalized for a coronary event or surgical procedure, were retrospectively identified. Information on risk factor awareness was collected from medical records, medical examination, and structured questionnaires during the study visit (six months to two years after hospitalization).

RESULTS

Patient information was available for 8261 patients, of which 25.8% were women. Although women with obesity were significantly less aware about their actual (OR = 0.66, CI = 0.52-0.85) and target weight levels (OR = 0.66, CI = 0.54-0.81), no significant gender differences in risk factor awareness were found in disfavour of women. Remarkably, women with hypertension and women with raised low-density lipoprotein cholesterol (LDL-C) levels were even more aware about their target blood pressure levels (OR = 1.21, CI = 1.01-1.46) and actual cholesterol levels (OR = 1.18, CI = 1.02-1.36), respectively. Moreover, there is some indication that women were more informed by a healthcare professional if they had raised CHD risk factor levels.

CONCLUSIONS

Our study showed only few gender differences in disfavour of women in terms of risk factor awareness and information provided by a healthcare professional. Nevertheless, previous EUROASPIRE V findings demonstrated that women still have a poorer risk factor control in secondary CHD prevention.

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.

Prediction of recurrent event in patients with coronary heart disease: the EUROASPIRE Risk Model

AIMS

Most patients with established atherosclerotic cardiovascular disease (CVD) are at very high risk for developing recurrent events. Since this risk varies a lot between patients there is a need to identify those in whom an even more intensive secondary prevention strategy should be envisaged. Using data from the EUROASPIRE IV and V cohorts of coronary heart disease (CHD) patients from 27 European countries, we aimed at developing and internally and externally validating a risk model predicting recurrent CVD events in patients aged < 75 years.

METHODS AND RESULTS

Prospective data were available for 12 484 patients after a median follow-up time of 1.7 years. The primary endpoint, a composite of fatal CVD or new hospitalizations for non-fatal myocardial infarction (MI), stroke, heart failure, coronary artery bypass graft, or percutaneous coronary intervention (PCI), occurred in 1424 patients. The model was developed based on data from 8000 randomly selected patients in whom the association between potential risk factors and the incidence of the primary endpoint was investigated. This model was then validated in the remaining 4484 patients. The final multivariate model revealed a higher risk for the primary endpoint with increasing age, a previous hospitalization for stroke, heart failure or PCI, a previous diagnosis of peripheral artery disease, self-reported diabetes and its glycaemic control, higher non-high-density lipoprotein cholesterol, reduced renal function, symptoms of depression and anxiety and living in a higher risk country. The model demonstrated excellent internal validity and proved very adequate in the validation cohort. Regarding external validity, the model demonstrated good discriminative ability in 20 148 MI patients participating in the SWEDEHEART register. Finally, we developed a risk calculator to estimate risks at 1 and 2 years for patients with stable CHD.

CONCLUSION

In patients with CHD, fatal and non-fatal rates of recurrent CVD events are high. However, there are still opportunities to optimize their management in order to prevent further disease or death. The EUROASPIRE Risk Calculator may be of help to reach this goal.

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-Specific Risks of Major Cardiovascular and Limb Events in Patients With Symptomatic Peripheral Artery Disease

BACKGROUND

Patients with peripheral artery disease (PAD) have a higher risk of major adverse cardiovascular events (MACE) compared with those without PAD.

OBJECTIVES

The aim of this post hoc analysis was to evaluate sex-specific differences in MACE and limb events in the EUCLID (Examining Use of Ticagrelor in PAD) trial.

METHODS

Cox proportional hazards models were used to compare time-to-event outcomes stratified by sex. Covariates were introduced after adjusted model selection.

RESULTS

EUCLID enrolled 13,885 patients with PAD (28% women [n = 3,888]). PAD severity and medical treatment were comparable between sexes, whereas prior lower extremity revascularization was reported less frequently in women (54.8% vs. 57.3%; p = 0.006). Women were older (mean ± SD age: 67.8 ± 8.9 vs. 66.1 ± 8.2 years; p < 0.001) and more likely to have diabetes mellitus (p = 0.004), hypertension, hyperlipidemia, and chronic kidney disease (all p < 0.001). Over a mean follow-up of 30 months, women had a lower risk of MACE (9.5% vs. 11.2%; adjusted hazard ratio: 0.77; 95% confidence interval: 0.68 to 0.88; p < 0.001) and all-cause-mortality (7.6% vs. 9.7%; adjusted hazard ratio: 0.61; 95% confidence interval: 0.53 to 0.71; p < 0.001). In contrast, risk for major adverse limb events (2.6% vs. 3.0%) and hospitalization for acute limb ischemia (1.6% vs. 1.7%) were not different by sex.

CONCLUSIONS

Although women with PAD are at lower risk for MACE and all-cause mortality, risk for limb events was similar between sexes over a mean follow-up of 30 months. Understanding sex-specific differences and dissociation between baseline cardiovascular risk and subsequent cardiovascular events requires further investigation. (A Study Comparing Cardiovascular Effects of Ticagrelor and Clopidogrel in Patients With Peripheral Artery Disease [EUCLID]; NCT01732822).

Gender differences in major adverse cardiovascular outcomes among aged over 60 year-old patients with atherosclerotic cardiovascular disease: A population-based longitudinal study in Taiwan

Atherosclerotic cardiovascular disease (ASCVD) including cerebrovascular disease (CVD), coronary artery disease (CAD), and peripheral arterial disease (PAD), contributes to the major causes of death in the world. Although several studies have evaluated the association between gender and major adverse cardiovascular outcomes in old ASCVD patients, the result is not consistent. Hence, we need a large-scale study to address this issue.This retrospective cohort study included aged over 60 year-old patients with a diagnosis of ASCVD, including CVD, CAD, or PAD, from the database contained in the Taiwan National Health Insurance Bureau during 2001 to 2004. The matched cohort was matched by age, comorbidities, and medical therapies at a 1:1 ratio. A total of 9696 patients were enrolled in this study, that is, there were 4848 and 4848 patients in the matched male and female groups, respectively. The study endpoints included acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, in-hospital mortality, and so on. In multivariate Cox regression analysis in matched cohort, the adjusted hazard ratios (HRs) for female group in predicting acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality were 0.67 (P < .001), 0.73 (P = .0015), 0.78 (P < .001), 0.59 (P < .001), and 0.77 (P = .0007), respectively.In this population-based propensity matched cohort study, age over 60 year-old female patients with ASCVD were associated with lower rates of acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality than male patients. Further prospective studies may be investigated in Taiwan.

Incidence of cardiovascular events in patients with stabilized coronary heart disease: the EUROASPIRE IV follow-up study

The EUROASPIRE surveys (EUROpean Action on Secondary Prevention through Intervention to Reduce Events) demonstrated that most European coronary patients fail to achieve lifestyle, risk factor and therapeutic targets. Here we report on the 2-year incidence of hard cardiovascular (CV) endpoints in the EUROASPIRE IV cohort. EUROASPIRE IV (2012-2013) was a large cross-sectional study undertaken at 78 centres from selected geographical areas in 24 European countries. Patients were interviewed and examined at least 6 months following hospitalization for a coronary event or procedure. Fatal and non-fatal CV events occurring at least 1 year after this baseline screening were registered. The primary outcome in our analyses was the incidence of CV death or non-fatal myocardial infarction, stroke or heart failure. Cox regression models, stratified for country, were fitted to relate baseline characteristics to outcome. Our analyses included 7471 predominantly male patients. Overall, 222 deaths were registered of whom 58% were cardiovascular. The incidence of the primary outcome was 42 per 1000 person-years. Comorbidities were strongly and significantly associated with the primary outcome (multivariately adjusted hazard ratio HR, 95% confidence interval): severe chronic kidney disease (HR 2.36, 1.44-3.85), uncontrolled diabetes (HR 1.89, 1.50-2.38), resting heart rate ≥ 75 bpm (HR 1.74, 1.30-2.32), history of stroke (HR 1.70, 1.27-2.29), peripheral artery disease (HR 1.48, 1.09-2.01), history of heart failure (HR 1.47, 1.08-2.01) and history of acute myocardial infarction (HR 1.27, 1.05-1.53). Low education and feelings of depression were significantly associated with increased risk. Lifestyle factors such as persistent smoking, insufficient physical activity and central obesity were not significantly related to adverse outcome. Blood pressure and LDL-C levels appeared to be unrelated to cardiovascular events irrespective of treatment. In patients with stabilized CHD, comorbid conditions that may reflect the ubiquitous nature of atherosclerosis, dominate lifestyle-related and other modifiable risk factors in terms of prognosis, at least over a 2-year follow-up period.

Evaluation of screening for myocardial ischaemia in women at cardiovascular risk

BACKGROUND

Cardiovascular disease is the primary cause of death in women. Prevention, screening and diagnosis are generally implemented at later stages and less frequently than in men, and provision of treatment is not optimal in women.

AIMS

To assess the relevance of targeted screening for myocardial ischaemia in women with multiple risk factors, and to identify which specific factors target women more effectively.

METHODS

We undertook a prospective observational study with retrospective data collection based on a cohort of symptomatic or asymptomatic women with multiple cardiovascular risk factors. All women underwent non-invasive diagnostic testing through the "Heart, arteries and women", healthcare pathway available at Lille University Hospital, between 1 January 2013 and 30 June 2014.

RESULTS

Screening was positive in 15.7% of the 287 participants. Thirty women had a coronary angiography: of these, 22 (73.3%) had no evidence of obstructive coronary artery disease. The independent predictive factors for positive screening were >5 years since menopause (odds ratio [OR] 3.9; P=0.0016); high-density lipoprotein cholesterol ≤0.5g/dL (OR 2.3; P=0.0356); and body mass index ≥30kg/m² (OR 3.7; P=0.0009). Symptoms were predictive of positive screening (P=0.010), but were mostly atypical. Based on these observations, we developed a clinical coronary score to target screening more efficiently (area under the curve 0.733). Positive screening resulted in low rates of revascularization (16.6%), but a significant increase in the prescription of statins (P=0.002), antiplatelet agents (P<0.0001) and beta-blockers (P=0.024).

CONCLUSION

Screening for myocardial ischaemia among selected women at risk of cardiovascular disease can be useful to improve medical treatment.

Drivers of the Sex Disparity in Statin Therapy in Patients with Coronary Artery Disease: A Cohort Study

BACKGROUND

Women are less likely to be prescribed statins than men. Existing reports explain only a fraction of this difference. We conducted a study to identify factors that account for sex differences in statin therapy among patients with coronary artery disease (CAD).

METHODS AND RESULTS

We retrospectively studied 24,338 patients with CAD who were followed for at least a year between 2000 and 2011 at two academic medical centers. Women (9,006 / 37% of study patients) were less likely to either have initiated statin therapy (81.9% women vs. 87.7% men) or to have persistent statin therapy at the end of follow-up (67.0% women vs. 71.4% men). Women were older (72.9 vs. 68.4 years), less likely to have ever smoked (49.8% vs. 65.6%), less likely to have been evaluated by a cardiologist (57.5% vs. 64.5%) and more likely to have reported an adverse reaction to a statin (27.1% vs. 21.7%) (p < 0.0001 for all). In multivariable analysis, patients with history of smoking (OR 1.094; p 0.017), younger age (OR 1.013 / year), cardiologist evaluation (OR 1.337) and no reported adverse reactions to statins (OR 1.410) were more likely (p < 0.0001 for all) to have persistent statin therapy. Together, these four factors accounted for 90.4% of the sex disparity in persistent statin therapy.

CONCLUSIONS

Several specific factors appear to underlie divergent statin therapy in women vs. men. Identifying such drivers may facilitate programmatic interventions and stimulate further research to overcome sex differences in applying proven interventions for cardiovascular risk reduction.

Gender Disparities in Lipid-Lowering Therapy in Cardiovascular Disease: Insights from a Managed Care Population

BACKGROUND

Numerous studies have documented the strong inverse relationship between low-density lipoprotein cholesterol (LDL-C) levels and atherosclerotic cardiovascular disease (ASCVD). However, women are less likely to be screened for hypercholesterolemia, receive lipid-lowering therapy (LLT), and achieve optimal LDL-C levels.

MATERIALS AND METHODS

Data were extracted from a U.S. administrative claims database between January 2008 and December 2012 for patients with established ASCVD. The earliest date of valid LDL-C value was defined as the index date. Patients were followed for ±12 months from the index date and were stratified by gender, by baseline LDL-C level, and whether they were initially treated with a LLT then propensity score matched by gender using demographic and clinical characteristics. Both descriptive statistics and logistic regression models were used to explore the association of gender with the frequency of LDL-C monitoring, LLT treatment initiation in initially untreated patients, and prescribing patterns in initially treated patients.

RESULTS

A total of 76,414 subjects with established ASCVD were identified; 42% of the sample was women. In the unmatched cohort, 50.3% of men and 32.0% of women were prescribed a preindex statin (p < 0.0001). Among matched patients (n = 51,764), women initially treated with LLT were significantly less likely to receive a prescription for a higher potency LLT. Even among those with LDL-C levels above 160 mg/dL, women were more likely to discontinue LLT, odds ratio (95% confidence interval) 1.8 (1.2-2.3). Female gender and older age were significant predictors of discontinuation, and the potency of the index medication was the strongest predictor of dose titration. Initially untreated women were less likely to initiate LLT treatment than men, irrespective of index LDL-C levels (p < 0.0001).

CONCLUSIONS

The observed disparities further reinforce the need for targeted efforts to reduce the gender gap for secondary prevention in women at high risk of cardiovascular disease.

[Differences in the survival after an episode of stroke treated with thrombolytic therapy. Study Ebrictus]

Objetivo

Investigar la relación entre género y supervivencia después de un episodio de ictus tratado con fibrinólisis.

Diseño

Estudio de cohortes.

Emplazamiento

Atención primaria.

Participantes

Los casos tratados con fibrinólisis por un ictus agudo desde el 1 de abril de 2006 al 13 de septiembre de 2013.

Intervenciones

Seguimiento del estado vital.

Mediciones principales

Riesgos vasculares: escala Framingham, REGICOR, CHA2DS2-VASc, Essen, NIHSS, índice Barthel; densidad de incidencia; análisis de supervivencia por Kaplan-Meier; bivariado entre supervivientes y fallecidos; y multivariante de Cox.

Resultados

Noventa y un pacientes con edad media 68,02 ± 11,9 años. Los hombres tienen mayor riesgo cardiovascular basal. El tiempo medio de seguimiento fue de 2,95 ± 2,33 años. La razón de tasa de incidencias mostró un mayor riesgo en los hombres respecto a las mujeres IR = 3,2 (IC 95%: 1,2-8,0). Los fallecidos en relación con los supervivientes son mayores (p = 0,032); mayor riesgo cardiovascular basal (p = 0,040) y de recidiva de ictus (p < 0,001); mayor severidad del episodio (p = 0,002); y una mayor caída en la puntuación Barthel un año después del ictus (p = 0,016). El porcentaje de muertes es significativamente más alto cuando el paciente es derivado a centros de agudos o de larga estancia (p = 0,006) que cuando se deriva al domicilio, pero solo el género (HR: 1,12; IC 95%: 1,05-1,20) y la prevención cardiovascular secundaria (HR: 0,13; IC 95%: 0,06-0,28) se asociaron con la mortalidad de los pacientes.

Conclusiones

Después de un episodio de ictus tratado con fibrinólisis los hombres tienen un 12% más de riesgo de morir que las mujeres, y la ausencia de prevención cardiovascular secundaria aumenta 7,7 veces el riesgo de mortalidad.

Quality of cardiovascular disease care in Ontario's primary care practices: a cross sectional study examining differences in guideline adherence by patient sex

Background

Women are disproportionately affected by cardiovascular disease, often experiencing poorer outcomes following a cardiovascular event. Evidence points to inequities in processes of care as a potential contributing factor. This study sought to determine whether any sex differences exist in adherence to process of care guidelines for cardiovascular disease within primary care practices in Ontario, Canada.

Methods

This is a secondary analysis of pooled cross-sectional baseline data collected through a larger quality improvement initiative known as the Improved Delivery of Cardiovascular Care (IDOCC). Chart abstraction was performed for 4,931 patients from 84 primary care practices in Eastern Ontario who had, or were at high risk of, cardiovascular disease. Measures examining adherence to guidelines associated with nine areas of cardiovascular care (coronary artery disease, peripheral vascular disease (PVD), stroke/transient ischemic attack, chronic kidney disease, diabetes, dyslipidemia, hypertension, smoking cessation, and weight management) were collected. Multivariable logistic regression analysis was performed to evaluate sex differences, adjusting for age, physician remuneration, and rurality.

Results

Women were significantly less likely to have their lipid profiles taken (OR = 1.17, 95% CI 1.03-1.33), be prescribed lipid lowering medication for dyslipidemia (OR = 1.54, 95% CI 1.20-1.97), and to be prescribed ASA following stroke (OR = 1.56, 95% CI 1.39-1.75). Women with PVD were significantly less likely to be prescribed ACE inhibitors and/or angiotensin receptor blockers (OR = 1.74, 95% CI 1.25-2.41) and lipid lowering medications (OR = 1.95, 95% CI 1.46-2.62) or ASA (OR = 1.59, 95% CI 1.43-1.78). However, women were more likely to have two blood pressure measurements taken and to be referred to a dietician or weight loss program. Male patients with diabetes were less likely to be prescribed glycemic control medication (OR = 0.84, 95% CI 0.74-0.86).

Conclusions

Sex disparities exist in the quality of cardiovascular care in Canadian primary care practices, which tend to favour men. Women with PVD have a particularly high risk of not receiving appropriate medications. Our findings indicate that improvements in care delivery should be made to address these issues, particularly with regard to the prescribing of recommended medications for women, and preventive measures for men.

Cross vascular risk for first and recurrent hospitalised atherothrombosis determined retrospectively from linked data

OBJECTIVES

To determine the sex-specific and age-specific risk ratios for the first-ever and recurrent hospitalisation for cerebrovascular, coronary and peripheral arterial disease in persons with other vascular history versus without other vascular history in Western Australia from 2005to 2007.

DESIGN

Cross-sectional linkage study.

SETTING

Hospitalised population in a representative Australian State.

PARTICIPANTS

All persons aged 34-85 years between 1 January 2005 and 31 December 2007 were hospitalised with a principal diagnosis of atherothrombosis.

DATA SOURCES

Person-linked file of statutory-collected administrative morbidity and mortality records.

MAIN OUTCOME MEASURES

Sex-specific and age-specific risk ratios for the first-ever and recurrent hospitalisations for symptomatic atherothrombosis of the brain, coronary and periphery using a 15-year look-back period lead to the determining of prior events.

RESULTS

Over 3 years, 40 877 (66% men; 55% first-ever) were hospitalised for atherothrombosis. For each arterial territory, age-specific recurrent rates were higher than the corresponding first-ever rates, with the biggest difference seen in the youngest age groups. For all types of first-ever atherothrombosis, the rates were higher in those with other vascular history and the risk ratios declined with an advancing age (trend: all p<0.0001) and remained significantly >1 even for 75-84 years old. However, for recurrent events, the rates were marginally higher in those with other vascular history and no risk ratio age trend was apparent with several not significantly >1 (trend: all p>0.13).

CONCLUSIONS

This study of hospitalised atherothrombosis suggests first-events predominate and that the risk of further events in the same or other arterial territory is very high for all ages and both sexes, accentuating the necessity for an early and sustained active prevention.

Preventing cardiovascular disease in women: how can we do better?

PURPOSE OF REVIEW

This review highlights advances in the primary and secondary prevention of cardiovascular disease (CVD) in women in the preceding 12 months.

RECENT FINDINGS

The American Heart Association (AHA) has recently published guidelines on the prevention of CVD in women, which brought new attention to this important topic. Limited progress has been made regarding an awareness of CVD among women, and modest progress has been made on the creation of health behavior change programs that effectively reduce smoking, increase physical activity and improve nutrition. Preventive therapies have been demonstrated to improve outcomes in women with diagnosed disease, but more research that includes women is required to further assess the benefits of primary preventive strategies and therapies.

SUMMARY

A review of the literature from the past year confirms the recommendations and direction set in the AHA's updated prevention guidelines. This review illuminates promising new directions for practice and the need for future research focused on strategies to advance early and lasting lifestyle changes to promote cardiovascular health and the prevention of CVD. Adoption of and adherence to the guidelines, continued evaluation and publication of effective practice strategies, and ongoing research are critical to improve efforts to prevent CVD in women.

Gender-specific relationships between plasma oxidized low-density lipoprotein cholesterol, total antioxidant capacity, and central adiposity indicators

BACKGROUND

Oxidative stress has a pivotal role in the onset of obesity-related chronic diseases. This study assessed potential gender differences in the associations of adiposity (total vs. central) with oxidative stress markers in healthy young adults.

METHODS

This cross-sectional study enrolled 272 subjects (97 males, 175 females; 22 ± 3 years, body mass index 22.0 ± 2.8 kg/m(2)). Body composition, cardiometabolic and lifestyle features, oxidized low-density lipoprotein cholesterol (ox-LDL) concentrations, plasma total antioxidant capacity (TAC), and glutathione peroxidase (GPx) activity in erythrocytes were determined by validated procedures.

RESULTS

Compared to women, men had statistically higher concentrations of ox-LDL (61.7 vs. 53.5 U/l, p = 0.022). In analyses with the whole sample, those individuals included in the highest tertile of central adiposity indicators (waist circumference, WC, or waist-to-hip ratio, WHR) presented higher ox-LDL and lower TAC values (p < 0.01), while no statistical differences were found across tertiles of total body fat. WHR values were more strongly associated with ox-LDL and TAC concentrations, compared to other adiposity indicators, with higher slopes for women. Sex differences in ox-LDL concentrations were abolished (p > 0.05) after individual pairing of men and women for WC (53.8 vs. 61.6 U/l, p = 0.225) or WHR (56.1 vs. 56.3 U/l, p = 0.471). No differences were found in GPx values concerning gender or adiposity indicators.

CONCLUSIONS

Plasma ox-LDL and TAC values were more strongly influenced by central adiposity indicators (WHR and WC) in women than in men, suggesting that the change of the gynoid to android pattern phenotype among young women could lead to a steeper unfavourable redox status compared to men.

Gender difference in long-term prognosis among patients with cardiovascular disease

BACKGROUND

Differences in prognosis between women and men with atherosclerosis are currently under attention. Previous studies describe contradictory results and are restricted to one cardiovascular bed, while atherosclerosis is a systemic disease. We therefore studied the prognosis of women versus men in the SMART study, a large cohort of patients with clinically manifest atherosclerosis with extensive baseline and follow-up information.

METHODS

5349 patients (1347 women, 4002 men) with at least one type of atherosclerotic vascular disease (coronary artery disease, cerebrovascular disease, peripheral arterial disease or abdominal aortic aneurysm) were included in the SMART study, an ongoing long-term follow-up study. They all received a standardized cardiovascular work-up with a personalized therapy advice. All future cardiovascular events were collected prospectively. All-cause mortality, cardiovascular mortality and cardiovascular outcome (composite of myocardial infarction, stroke and cardiovascular death) were evaluated using Cox regression and expressed as hazard ratios (HR) with 95% confidence intervals (95%CI). Men served as the reference category. Different models were used to adjust for differences in baseline characteristics.

RESULTS

Women and men had a mean age of 60 years and their median follow-up (range) was five years (13.5). The hazard ratios of all-cause mortality, cardiovascular death and cardiovascular outcome were 0.62 (95%CI: 0.51-0.75), 0.59 (95%CI: 0.46-0.75) and 0.73 (95%CI: 0.60-0.87). Neither differences in risk-factor profile nor the different vascular beds involved could explain this advantage.

CONCLUSION

Women with cardiovascular disease who received a similar standardized cardiovascular work-up and personalized therapy advice as men had a favourable long-term outcome.

Triggering of acute myocardial infarction by different means of transportation

BACKGROUND

Prior studies have reported an association between traffic-related air pollution in urban areas and exacerbation of cardiovascular disease. We assess here whether time spent in different modes of transportation can trigger the onset of acute myocardial infarction (AMI).

DESIGN

We performed a case-crossover study. We interviewed consecutive cases of AMI in the KORA Myocardial Infarction Registry in Augsburg, Southern Germany between February 1999 and December 2003 eliciting data on potential triggers in the four days preceding myocardial infarction onset.

RESULTS

A total of 1459 cases with known date and time of AMI symptom onset, who had survived 24 hours after the onset, completed the registry's standard interview on potential triggers of AMI. An association between exposure to traffic and AMI onset 1 hour later was observed (odds ratio: 3.2; 95% confidence interval [CI]: 2.7-3.9, p < 0.001). Using a car was the most common source of traffic exposure; nevertheless, times spent in public transport or on a bicycle were similarly associated with AMI onset 1 hour later. While the highest risk for AMI onset was within 1 hour of exposure to traffic, the elevated risk persisted for up to 6 hours. Women, patients aged 65 years or older, patients not part of the workforce, and those with a history of angina or diabetes exhibited the largest associations between times spent in traffic and AMI onset 1 hour later.

CONCLUSION

The data suggest that transient exposure to traffic regardless of the means of transportation may increase the risk of AMI transiently.

Prevalence of 'borderline' values of cardiovascular risk factors in the clinical practice of general medicine in Italy: results of the BORDERLINE study

INTRODUCTION

The prevalence of patients with 'borderline' levels of cardiovascular risk factors has been rarely investigated, being often reported in studies evaluating abnormal values of these parameters. The BORDERLINE study represents a pilot experience to primarily identify the prevalence of 'high-normal' conditions, such as pre-hypertension, lipid and glucose levels in the upper range of normality in the setting of general practice in Italy.

AIM

The aim of this study was to evaluate the prevalence of patients with 'borderline' values of cardiovascular risk factors in Italy.

METHODS

Involved physicians were asked to evaluate the first 20 outpatients, consecutively seen in June 2009. Data were collected in a study-designed case-report form, in which physicians identified thresholds rather than reported absolute values of several clinical parameters. High-normal values were defined as follows: blood pressure (BP) 130-140/85-90 mmHg; total cholesterol 180-200 mg/dL; low-density lipoprotein cholesterol (LDL-C) 130-150 mg/dL; high-density lipoprotein cholesterol (HDL-C) 30-40 mg/dL in males and 40-50 mg/dL in females; triglycerides 130-150 mg/dL and fasting glucose 100-110 mg/dL.

RESULTS

Fifty-three Italian physicians provided valuable clinical data on 826 individual outpatients, among which 692 (83.7%, 377 women, mean age 60.9 ± 13.2 years, body mass index 26.6 ± 5.0 kg/m2) were included in the present analysis. Prevalence of borderline values of systolic BP and total cholesterol levels were at least comparable with those in the normal limits of the corresponding parameters, whereas prevalence of borderline diastolic BP, LDL-C, HDL-C, triglycerides and fasting glucose levels was significantly lower than that of normal values, but higher than that of abnormal values of the corresponding parameters.

CONCLUSIONS

Using this sample of healthy subjects in the setting of general practice in Italy, our results demonstrated a relatively high prevalence of borderline values of cardiovascular risk factors, which was at least comparable with that of normal, but significantly higher than that of abnormal thresholds. These preliminary findings may prompt more extensive investigations in the area of 'borderline' cardiovascular risk. This information may, in fact, potentially enable the design of more effective prevention strategies in the future to limit the burden of cardiovascular disease in the general population in Italy. Received for publication 4 March 2011; accepted for publication 20 April 2011.