Unique cardiovascular risk factors in women

Comparing perceptions of leading causes of death in a diverse sample of community-dwelling women in the United States

BACKGROUND

Heart disease is the leading cause of death (LCOD) for women in the United States. However, despite decades of public health campaigns, awareness of heart disease among women, especially those with racial/ethnic minority backgrounds and young women, significantly declined from 2009 to 2019.

OBJECTIVES

The aim of this study was to compare the differences in heart disease awareness as the LCOD among Black, Hispanic, White, and Asian/Other women groups.

METHODS

In this cross-sectional, online survey study, 422 community-dwelling women were analyzed. Heart disease as the LCOD was categorized as the correct answer. We implemented log-linear models via a Poisson regression to estimate unadjusted and adjusted relative risks [RRs] of race in predicting correct knowledge of LCOD.

RESULTS

The mean age was 41.2 (±12.9) years. The sample represents 39.8 % Hispanic, 28.4 % White, 19.9 % Black, 11.9 % Asian/others. After adjusting for age and cardiovascular disease risks, Black and Hispanic women, as compared to White women, had significantly lower awareness of heart disease as the LCOD [(Adjusted RR=0.69, 95 % CI: 0.52, 0.92); (Adjusted RR= 0.78, 95 % CI: 0.78 -0.94), respectively]. Additionally, physical inactivity and hypertension medication intake were significantly associated with this level of awareness (P < 0.5).

CONCLUSION

Lower heart disease awareness in Black and Hispanic women persists. It is crucial to develop more effective approaches to close this disparity. Testing new methods, such as applying artificial intelligence to send more culturally appropriate and personalized messages, is urgently needed to raise women's awareness of their heart disease risk.

Gender disparities in cangrelor usage for the treatment of patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

Cangrelor is a rapid, potent intravenous P2Y12 inhibitor that reduces thrombotic and ischemic events in patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI). This study aimed to investigate gender disparities in Cangrelor usage, efficacy, and safety across gender in patients presenting with acute coronary syndrome (ACS) undergoing PCI.

METHODS

This is an observational retrospective analysis included patients presented with ACS who underwent PCI and received Cangrelor at MedStar Washington Hospital Center (2018-2023). Access to Cangrelor across gender was recorded. The primary safety outcome was in-hospital thrombolysis in myocardial infarction (TIMI) major bleeding, while the primary efficacy outcome was in-hospital major adverse cardiac events (MACE): defined as the composite of in-hospital cardiac death, MI, and stroke. A control group was investigated gender disparities in patients with ACS who did not receive Cangrelor.

RESULTS

A total of 2859 patients with ACS underwent PCI (991 women and 1868 men). Among these patients, women were less likely to receive Cangrelor during PCI compared to men (40.2 % vs. 48 %; P < 0.001). The Cangrelor cohort consisted of 1295 patients (398 women, 897 men), and among those, women had significantly higher rates of in-hospital TIMI major bleeding (3.5 % vs. 0.6 %; P < 0.001) and higher in-hospital MACE (5.0 % vs. 1.3 %; P < 0.001) compared to men. Multivariate modeling after adjusting for differences in baseline characteristics showed that women were associated with increased TIMI major bleeding (OR 4.02, 95 %CI 1.09-14.79; P 0.037), but not in-hospital MACE (OR 2.11, 95 %CI 0.88-5.07; P 0.096). In the non-Cangrelor cohort, there were no significant difference between women and men in TIMI major bleeding (0.8 % vs. 0.9 %, P = 0.865) and MACE (1.5 % vs. 1.6, P = 0.842).

CONCLUSION

In patients presenting with ACS, women who received cangrelor had higher rates of TIMI major bleeding, without an impact on MACE. This may partially explain why women with ACS undergoing PCI receive less cangrelor compared to men. Therefore, increased bleeding events in women receiving cangrelor warrant further investigation.

Preeclampsia as an independent predictor of atherosclerosis progression in women with type 1 diabetes: a 5-year prospective study

BACKGROUND

Preeclampsia (PE) and type 1 diabetes (T1D) are significant risk factors for cardiovascular disease (CVD), but their combined effect on atherosclerosis progression has not been fully explored. This study aimed to evaluate the impact of T1D and PE on the progression of atherosclerosis.

METHODS

Prospective cohort study of 112 women divided into four groups: T1D + /PE + (n = 28), T1D + /PE- (n = 28), T1D-/PE + (n = 28), and T1D-/PE- (n = 28). Participants underwent an initial assessment and a follow-up visit five years later, which included anthropometric evaluation, blood tests, and carotid ultrasound. Atherosclerosis progression was defined as an increase in carotid plaque number or the occurrence of a cardiovascular event (CVE) during follow-up (fatal or non-fatal ischemic heart disease, fatal or non-fatal stroke, and/or heart failure).

RESULTS

A total of 104 women (92.9%) completed the follow-up (54 with T1D, mean age at inclusion 45.2 ± 7.6 years, mean follow-up 5.3 ± 1.2 years). An increase in carotid plaques was identified in 34 women (32.7%), and 3 CVEs (2.9%) occurred. In women with T1D, a history of PE was associated with a twofold increase in atherosclerosis progression (57.7% vs 25.0%, p = 0.015). In multivariate models adjusted for age, T1D and cardiovascular risk factors, PE [OR 4.97 (1.61-15.29), p = 0.005] and PE + T1D [OR 7.69 (1.25-47.29), p = 0.028] were independently associated with atherosclerosis progression.

CONCLUSIONS

PE was a strong independent predictor of atherosclerosis progression over a 5-year follow-up period, with an additive effect in T1D. These findings highlight preeclampsia as a significant CVD risk enhancer in young women with T1D.

Predicting cardiovascular morbidity and mortality with SCORE2 (OP) and Framingham risk estimates in combination with indicators of biological ageing

BACKGROUND AND OBJECTIVE

Previous research assessing whether biological ageing (BA) indicators can enhance the risk assessment of cardiovascular disease (CVD) outcomes beyond established CVD risk indicators, such as Framingham Risk Score (FRS) and Systematic Coronary Risk Evaluation (SCORE2)/SCORE2-Older Persons (OP), is scarce. We explored whether BA indicators, namely the Rockwood Frailty Index (FI) and leukocyte telomere length (TL), improve predictive accuracy of CVD outcomes beyond the traditional CVD risk indicators in general population of middle-aged and older CVD-free individuals.

METHODS

Data included 14 118 individuals from three population-based cohorts: TwinGene, Health 2000 (H2000), and the Helsinki Birth Cohort Study, grouped by baseline age (<70, 70+). The outcomes were incident CVD and CVD mortality with 10-year follow-up. Risk estimations were assessed using Cox regression and predictive accuracies with Harrell's C-index.

RESULTS

Across the three study cohorts and age groups: (i) a higher FI, but not TL, was associated with a higher occurrence of incident CVD (P < .05), (ii) also when considering simultaneously the baseline CVD risk according to FRS or SCORE2/SCORE2-OP (P < .05) (iii) adding FI to the FRS or SCORE2/SCORE2-OP model improved the predictive accuracy of incident CVD. Similar findings were seen for CVD mortality, but less consistently across the cohorts.

CONCLUSIONS

We show robust evidence that a higher FI value at baseline is associated with an increased risk of incident CVD in middle-aged and older CVD-free individuals, also when simultaneously considering the risk according to the FRS or SCORE2/SCORE2-OP. The FI improved the predictive accuracy of CVD outcomes beyond the traditional CVD risk indicators and demonstrated satisfactory predictive accuracy even when used independently.

Women Veterans' Stroke Risk Factors: Identified Prevention Methods and Knowledge Gaps

INTRODUCTION

Stroke is a significant health burden for veterans and the fifth leading cause of death for women. Compared to civilian women, women veterans have significant multimorbid physical and mental health conditions contributing to their stroke risk. This scoping review aimed to synthesize evidence on the stroke risk factors specific to U.S. women veterans and identify any association between risk factors and a delay in prevention and treatment for women veterans.

MATERIALS AND METHODS

This study was approved by the organizational Institutional Review Board. The search strategy was run across 6 databases: MEDLINE and EMBASE via Ovid, Scopus, Web of Science, Cochrane Library, and ClinicalTrials.gov. A total of 1218 records were uploaded to Covidence for screening. Criteria for included studies were peer-reviewed primary research articles written in English about women veterans and cardiovascular disease and stroke risk factors. No restrictions were placed on publication date.

RESULTS

Fourteen articles met the inclusion criteria. Cohorts were 30 years and older. Data originated from national and individual Veterans Affairs studies. Women veterans starting at age 30 have a steadily increasing positive curvilinear association with stroke risk, indicating a need to screen earlier than the recommended age of 45 years. Stroke incidence was higher in veterans with post-traumatic stress disorder, insomnia, restless leg syndrome, traumatic brain injury, constipation with laxative use, egg consumption (2-4 eggs/wk), frailty, and systemic sclerosis. When comparing White veterans and civilian counterparts, Black veterans had a higher incidence of stroke. Ten studies addressed prevention methods. The clinicians should screen and treat women veterans for post-traumatic stress disorder and constipation and consider alternative treatment methods for constipation.

CONCLUSIONS

Empirical literature on this matter is lacking. Examining and understanding the differences in sex, gender, and veteran status, and their association with stroke risk, is warranted. Screening women veterans for post-traumatic stress disorder and for stroke early, at 30 years of age, is recommended.

Lifestyle interventions in later reproductive age women to offset cardiometabolic and bone disease: a scoping review

BACKGROUND

Non-communicable chronic disease is a major contributor to morbidity and mortality with potentially modifiable lifestyle factors. In women, the menopausal transition modifies women's risk of chronic disease, and pregnancy-related complications have been highlighted as female-specific risk factors. Later reproductive years, before onset of menopause, may represent a window of opportunity for promotion of lifestyle modifications. The aim of this scoping review is to investigate which interventions promoting lifestyle modifications in women of later reproductive years may influence cardiometabolic and bone disease.

METHODS

A search of three electronic databases (PubMed, Embase, CINAHL) in the English language was performed in January 2024. Eligible studies included women aged 40-55 participating in interventions focusing on lifestyle modification. Studies reporting outcomes related to cardiometabolic disease, bone disease or body composition were eligible for inclusion.

RESULTS

Improvements in body composition occurred following interventions focusing on aerobic physical activity. Interventions focusing on health promotion and education, incorporating both dietary and physical activity modifications, prevented weight gain and improved cardiometabolic outcomes. Interventions incorporating elements of behavioural theories enhanced patient-motivated lifestyle modifications, with effects on body composition and cardiometabolic outcomes.

CONCLUSIONS

Lifestyle modifications in later reproductive years have the potential to influence cardiometabolic and bone disease. Our findings reinforce the benefits of regular aerobic physical activity, as well as health education, for improving body composition and lipid profile. This information could contribute to the development of clinical guidelines for the prevention of chronic disease.

The association between age at menarche (AAM) and cardiovascular disease (CVD) risk factors in the MASHAD cohort study

Age at menarche may be associated with cardiovascular disease risk factors in different ethnic groups. The purpose of this study was to identify the association of cardiovascular disease (CVD) risk factors with age at menarche (AAM) in Mashhad, the second biggest city in Iran. This was a cross- sectional study based on cohort data of 2353 women (35-65 years) from Mashhad, Iran for whom the age at menarche was reported. Baseline demographic, anthropometric data, and biochemical profiles were also collected. The levels of depression and anxiety were evaluated using a validated Persian version of the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). Multiple logistic regression models were used to examine the association between age at menarche with CVD risk factors. Anthropometric parameters, short stature, prevalence of diabetes, and CVD risk were significantly higher in women who were younger at menarche (AAM) in comparison to women with an older AAM. Women with a menstruating age of 11 years had a significantly higher weight (P < 0.001), higher BMI (P < 0.001), lower waist circumference (WC) (P = 0.004), higher hip circumference (HC) (P < 0.001) and higher waist-to-thigh ratio (WTR) (P < 0.001) than women with an AAM of ≥ 15 years. University-educated women and employed women were most likely to have menarche at ≥ 15 years (P < 0.001 and P = 0.012 respectively. In girls who menstruated at age ≤ 11 years old, the odds of having a BMI > 28.7 kg/m2, WC > 96 cm, HC > 105 cm and WTR > 61.96 were higher than girls who menstruated at 13 years old. The odds of height > 155 cm was higher in girls with menarche age of ≥ 15 than 13 years and the odds of having depression scores greater than 12 was lower in menarche age group of ≥ 15 years. The girls with menstruation age of 12 years had higher odds of having diabetes mellitus and HC > 105 cm than girls with menstruation age of 13 years. The odds of demi span exceeded 74 cm and height > 155 cm were higher in girls with menarche age of 14 than 13 years. AAM may be a useful factor to identify women at greater risk of CVD to implement appropriate preventive measures.

Traditional and Non-Traditional Risk Factors of Acute Coronary Syndrome in Young Women: Evidence from the ANCORS-YW Study

Purpose

Young women are at risk of acute coronary syndrome (ACS). They represent a unique population exposed to traditional cardiovascular risk factors and female sex-specific, non-traditional risk factors. The current study aimed to describe traditional and non-traditional risk factors of ACS in young women from the Middle East.

Patients and Methods

The present study used data from the Jordanian, nationwide, multicenter, case-control study, ANCORS-YW. Bivariate analyses and logistic regression models were used to predict independent risk factors of ACS using adjusted odds ratios (AOR) and 95% confidence intervals (CI).

Results

The study included 572 young women (≤50-years) with a median age of 45-years, divided into an ACS group (n=154, 26.9%) and a control group with no atherosclerotic cardiovascular disease (n=418, 73.1%). The most common presentation of ACS was non-ST-elevation ACS (n=98, 64%). The ACS group, compared to control group, had higher proportions of type-2 diabetes (41.6%vs.11.7%, p<0.001), hypertension (53.9%vs.23.4%, p<0.001), tobacco use (37.7%vs.24.2%, p=0.001), family history of cardiovascular disease (53.2%vs.23.4%, p<0.001), metabolic syndrome (14.3%vs.2.4%, p<0.001), and preterm delivery (24.7%vs.16.7%, p=0.032). ACS group had nonsignificantly greater proportions of hypertensive disorders of pregnancy (29.2%vs.22.7%, p=0.109) and gestational diabetes (15.6%vs.10.3%, p=0.081). Multivariable logistic regression analyses identified five independent predictors of ACS: type-2 diabetes (AOR, 95% CI: 3.45, 1.98─5.99), family history of cardiovascular disease (3.33, 2.15─5.17), tobacco use (2.01, 1.26─3.21), hypertension (1.72, 1.07─2.78), and metabolic syndrome (4.35, 1.72─11.03).

Conclusion

Modifiable risk factors play an important role in ACS risk among young women. Efforts should be made to improve primordial and primary prevention in this population.

Perceived Susceptibility to and Severity of Cardiovascular Disease Is Associated With Intent to Change Behavior Among Women 25-55 Years Old

BACKGROUND

Risk factors for cardiovascular disease (CVD) among young and middle-aged women have increased, whereas CVD knowledge and awareness remain low.

AIMS

The objective of this study was to describe the relationship between the stage of behavior change and awareness, knowledge, and perceptions of CVD among women 25-55 years and identify predictors of the stage of behavior change.

METHODS

A cross-sectional online survey of women ages 25-55 years living in the United States was conducted. Awareness was measured with the question "What is the leading cause of death for women in the United States?" Knowledge, perceptions, and the stage of behavior change were measured with the Heart Disease Fact Questionnaire, Health Beliefs Related to CVD, and Precaution Adoption Process Model instruments, respectively. Chi-square and t tests were used to determine differences between awareness, knowledge, and perceptions based on the stage of behavior change. Multiple logistic regression was used to evaluate the relationship between the stage of behavior change and awareness, knowledge, and perceptions.

RESULTS

A total of 149 primarily minority women (n = 105) were included (mean age = 37.15 ± 7.86 years). The perception of CVD susceptibility was associated with increased intention to change behavior (odds ratio, 1.247; 95% confidence interval, 1.101-1.414; P < .001). The perception of CVD severity was associated with reduced intention to change behavior (odds ratio, 0.809; P = .004).

CONCLUSION

Women who believed they were susceptible to CVD and did not perceive CVD as severe were more likely to report intent to change behavior, suggesting perception of CVD risk is more important than awareness or knowledge. Addressing misperceptions may be a strategy for primary risk reduction.

Sex-based utilization of guideline recommended statin therapy and cardiovascular disease outcomes: Data from a multisite healthcare network primary prevention cohort

Background

In the US, women have similar cardiovascular death rates as men. However, less is known about sex differences in statin use for primary prevention and associated atherosclerotic cardiovascular disease (ASCVD) outcomes.

Methods

Statin prescriptions using electronic health records were examined in patients without ASCVD (myocardial infarction (MI), revascularization or ischemic stroke) between 2013 and 2019. Guideline-directed statin intensity (GDSI) at index (at least moderate intensity, defined per pooled-cohort equation) and follow-up visits were compared between sexes across ASCVD risk groups, defined by the pooled-cohort equation. Cox regression hazard ratios were calculated for statin use and outcomes (myocardial infarction, stroke/transient ischemic attack (TIA), and all-cause mortality) stratified by sex. Interaction terms (statin and sex) were applied.

Results

Among 282,298 patients, (mean age ∼ 50 years) 17.1 % women and 19.5 % men were prescribed any statin at index visit. Time to GDSI was similar between sexes, but the proportion of high-risk women on GDSI at follow-up were lower compared to high-risk men (2-years: 27.7 vs 32.0 %, and 5-years: 47.2 vs 55.2 %, p < 0.05). When compared to GDSI, no statin use was associated with higher risk of MI and ischemic stroke/TIA among both sexes. High-risk women on GDSI had a lower risk of mortality (HR=1.39 [1.22-1.59]) vs. men (HR=1.67 [1.50-1.86]) of similar risk (p value interaction=0.004).

Conclusion

In a large contemporary healthcare system, there was underutilization of statins across both sexes in primary prevention. High-risk women were less likely to remain on GDSI compared to high-risk men. GDSI significantly improved the survival in both sexes regardless of ASCVD risk group. Future strategies to ensure continued use of GDSI, specifically among women, should be explored.

Sex and sex steroids as determinants of cardiovascular risk

There are considerable sex differences regarding the risk of cardiovascular disease (CVD), including arterial hypertension, coronary artery disease (CAD) and stroke, as well as chronic renal disease. Women are largely protected from these conditions prior to menopause, and the risk increases following cessation of endogenous estrogen production or after surgical menopause. Cardiovascular diseases in women generally begin to occur at a later age than in men (on average with a delay of 10 years). Cessation of estrogen production also impacts metabolism, increasing the risk of developing obesity and diabetes. In middle-aged individuals, hypertension develops earlier and faster in women than in men, and smoking increases cardiovascular risk to a greater degree in women than it does in men. It is not only estrogen that affects female cardiovascular health and plays a protective role until menopause: other sex hormones such as progesterone and androgen hormones generate a complex balance that differentiates heart and blood vessel function in women compared to men. Estrogens improve vasodilation of epicardial coronary arteries and the coronary microvasculature by augmenting the release of vasodilating factors such as nitric oxide and prostacyclin, which are mechanisms of coronary vasodilatation that are more pronounced in women compared to men. Estrogens are also powerful inhibitors of inflammation, which in part explains their protective effects on CVD and chronic renal disease. Emerging evidence suggests that sex chromosomes also play a significant role in shaping cardiovascular risk. The cardiovascular protection conferred by endogenous estrogens may be extended by hormone therapy, especially using bioidentical hormones and starting treatment early after menopause.

Ischemic Heart Disease in Women

This review synthesizes the current understanding of ischemic heart disease in women, briefly discussing differences in risk factors, presentation, and treatment. We have underscored the unique clinical phenotype of IHD in women with a higher prevalence of ischemia with non-obstructive coronary arteries. Further research is needed to elucidate the complexities of ischemic heart disease in women, understand the discordance between ischemic burden and clinical symptoms, and optimize treatment strategies.

Cognition is selectively impaired in males with spinal pain: A retrospective analysis of data from the Longitudinal Study of Ageing Danish Twins

Cognitive decline and spinal pain (back pain [BP] and neck pain [NP]) represent a major public health challenge, yet the potential relationship between them remains elusive. A retrospective analysis of the Longitudinal Study of Ageing Danish Twins was performed to determine any potential relationships between BP/NP and cognitive function adjusting for age, sex, educational and socioeconomic status. A total of 4731 adults (2788 females/1943 males) aged 78 ± 6 (SD) years were included in the analysis. We observed a 1-month prevalence of 25% with BP, 21% with NP and 11% for combined BP/NP. While there were no differences in cognition scores for males and females reporting combined BP/NP, compared to those without combined BP/NP (34.38 points [95% confidence interval (CI) = 31.88, 36.88] vs. 35.72 points [95% CI = 35.19, 36.26]; P = 0.180; and 35.72 points [95% CI = 35.19, 36.26] vs. 35.85 points [95% CI = 35.39, 36.31]; P = 0.327; for male and females, respectively), an adjusted analysis revealed that males with combined BP/NP presented with lower cognitive scores compared to males without combined BP/NP (81.26 points [95% CI = 73.80, 88.72] vs. 79.48 points [95% CI = 70.31, 88.66]; P = 0.043). The findings of this hypothesis-generating study may highlight a potential sex-specific association between spinal pain and later-life neurodegeneration.

Incident Cardiovascular Disease in Women With Type 1 or Type 2 Diabetes Following a Hypertensive Disorder of Pregnancy

BACKGROUND

The extent to which a history of hypertensive disorders of pregnancy is associated with incident cardiovascular disease also among women with diabetes is unknown.

METHODS

In this nationwide register-based cohort study, parous women aged 18 to 69 years with a first delivery in the Swedish Medical Birth Register, regardless of diabetic status at that time, and a subsequent clinical visit in the Swedish National Diabetes Register were included. Time to first cardiovascular disease event (myocardial infarction, stroke, or heart failure) before age 70 years by hypertensive disorders of pregnancy history was separately analyzed by diabetes type using Cox regression models that included conventional risk factors.

RESULTS

In total, 1748 (18.9%) of 9230 women with type 1 and 5904 (10.6%) of 55 773 women with type 2 diabetes had their first delivery complicated by a hypertensive disorder of pregnancy. Median time (25-75th percentile) between first delivery and start of follow-up was 3.3 (1.4-13.0) years for women with type 1 and 29.8 (22.4-35.6) years for women with type 2 diabetes. In modeling, the risk for any cardiovascular disease event among women with a history of hypertensive disorders of pregnancy was generally 10% to 20% higher, with main models estimating hazard ratios to 1.20 (95% CI, 0.99-1.47) for women with type 1 and 1.15 (95% CI, 1.02-1.29) for women with type 2 diabetes.

CONCLUSIONS

In women with diabetes, a history of hypertensive disorders of pregnancy was associated with an increased risk of incident cardiovascular disease and should be considered as a risk enhancer.

Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

Associations between hypertension with reproductive and menopausal factors: An integrated women's health programme (IWHP) study

BACKGROUND

Women are less likely to have classic cardiovascular risk factors than men, and events during their reproductive and menopausal years may increase hypertension risk. The aim of this study is to examine woman-specific factors, including menstrual, reproductive and pregnancy complications, in relation to the prevalence of hypertension in mid-life Asian women.

METHODS

This is a cross-sectional study of 1146 healthy women aged 45-69 years, from a multi-ethnic Asian cohort. The women completed an extensive questionnaire that included their sociodemographic details, medical history, lifestyle and physical activity, and reproductive and menopausal history. They also underwent objectively measured physical performance tests and a dual X-ray absorptiometry scan. Hypertension was defined as a systolic BP ≥140 and/or diastolic BP ≥90mm Hg, past diagnosis by a physician, or use of antihypertensive medications. Multivariable logistic regression was used to assess the independent risk factors for hypertension.

RESULTS

The average age of the 1146 women analysed was 56.3 (SD 6.2) years, and 55.2 percent of them were hypertensive. The prevalence of gestational diabetes and gestational hypertension was 12.6% and 9.4%, respectively. Besides age, abnormal menstrual cycle length at 25 years of age (OR:2.35, CI:1.34-4.13), preeclampsia (OR:2.46, CI:1.06-5.74), increased visceral adiposity (OR:4.21, CI:2.28-7.79) and reduced physical performance (OR:2.83, CI:1.46-5.47) were independently associated with hypertension in Asian women.

CONCLUSIONS

Our findings highlight the necessity of including features of menstrual and reproductive history as possible indicators of hypertension risk in cardiovascular disease risk assessment and prevention among Asian women. Reducing visceral adiposity and exercise to improve physical performance may help women avoid developing hypertension.

Closing the gap: cardiovascular disease in women

Cardiovascular disease (CVD) in women remains understudied, under-recognized, underdiagnosed and undertreated. Initiatives such as the Lancet Women and Cardiovascular Disease Commission help to identify sex and gender-related gaps in research, care and outcomes and to guide next steps in addressing them. This article highlights important aspects of the Lancet Commission report and expands on the evidence and proposed strategies for reducing the global burden of CVD in women. Furthermore, the article explores the benefits of cross-specialty collaborations for the treatment and prevention of CVD in women and discusses the impact of gender-related disparities in academic cardiology.

Sex, Gender, and Women's Heart Health: How Women's Heart Programs Address the Knowledge Gap

This article aims to bridge existing knowledge gaps that impact clinical cardiovascular care and outcomes for women in Canada. The authors discuss various aspects of women's heart health, emphasizing the efficacy of multidisciplinary care in promoting women's well-being. The article also identifies the impact of national women's heart health campaigns and the value of peer support in improving outcomes. The article addresses the particular risks that women face, such as pregnancy-related complications and hormone replacement therapy, all of which are associated with cardiovascular events, and highlights the differences in ischemic symptoms between men and women. Despite improvements in acute event outcomes, challenges persist in accessing timely ambulatory care, particularly for women. Canada has responded to these challenges by introducing Women Heart Programs, which offer tailored programs, support groups, and specialized testing. However, these programs remain few in number and are found only in urban settings. Overall, this review identifies sex and gender factors related to women's heart health, underscoring the importance of specialized programs and multidisciplinary care in improving women's cardiovascular health.

Predictive factors of rehabilitation outcomes of perioperative stroke after surgery of the coronary artery and aorta: A pilot study

BACKGROUND

Perioperative stroke is a devastating complication of coronary artery and aortic surgery, resulting in significantly increased mortality and morbidity rates. As such, predicting rehabilitation outcomes after perioperative stroke would be valuable in establishing rehabilitation plans.

OBJECTIVE

To identify prognostic factors of rehabilitation outcomes in perioperative stroke after surgery of the aorta and coronary arteries.

METHODS

This study included patients who experienced perioperative stroke after coronary artery bypass grafting and aortic surgery, and underwent 3-weeks of rehabilitation. Demographic data included age, sex, diagnosis, brain lesions, and Charlson Comorbidity Index (CCI). To identify prognostic factors and the effectiveness of rehabilitation, the Modified Barthel Index (MBI), National Institutes of Health Stroke Scale (NIHSS), Medical Research Council (MRC) sum score, modified Rankin Scale (mRS) score, and Mini-Mental State Examination (MMSE) scores were investigated before and after a three-week rehabilitation period. Spearman rank correlation analyses were performed.

RESULTS

Statistically significant improvements were observed in NIHSS, MBI, and MMSE scores after rehabilitation. Spearman rank correlation analysis revealed a significant correlation between sex, stroke type, and improvement in MRC sum score.

CONCLUSION

The most crucial factors influencing the prognosis of perioperative stroke occurring after coronary artery or aortic surgery included sex and stroke type.

The Menstrual Cycle's Influence on Sleep Duration and Cardiovascular Health: A Comprehensive Review

The menstrual cycle, a fundamental biological process in women, extends its influence beyond reproduction, impacting sleep duration and cardiovascular health. This comprehensive review delves into the intricate connections that bind these three vital aspects of women's health. Beginning with thoroughly exploring the menstrual cycle, we uncover its phases and the dynamic hormonal fluctuations that underlie each stage. We pay special attention to estrogen and progesterone, the primary sex hormones orchestrating the menstrual cycle. With their rhythmic rise and fall, these hormones orchestrate events, affecting sleep duration, sleep patterns, and various indicators of cardiovascular well-being. The review examines how the menstrual cycle influences sleep patterns, exploring the nuanced changes in sleep duration observed throughout menstrual phases. We elucidate the contributing factors, encompassing hormonal fluctuations, the impact of pain and discomfort, and the significance of emotional and psychological factors. All of these elements collectively contribute to variations in sleep quality. Shifting our focus to the cardiovascular system, we investigate the bidirectional relationships between sleep disturbances and cardiovascular conditions, emphasizing the need to address sleep-related issues in the context of cardiovascular risk. The menstrual cycle is analyzed as a pivotal mediator in these intricate connections, exploring how hormonal fluctuations across menstrual phases can influence sleep patterns and cardiovascular health. This analysis provides valuable insights into the complex causality web. As clinical implications emerge, we emphasize the importance of tailoring healthcare strategies for individuals with irregular menstrual cycles. We explore potential interventions, from personalized care and hormone management to lifestyle adjustments, to improve sleep and cardiovascular well-being. In conclusion, this comprehensive review sheds light on the interplay between the menstrual cycle, sleep duration, and cardiovascular health. It underscores the urgent necessity for personalized healthcare approaches and preventive strategies, empowering women to navigate these intricate relationships. Ultimately, through a nuanced understanding of these interactions, we can work towards enhancing women's overall well-being and reducing cardiovascular risk within the context of menstrual cycle-related influences.

Menopause-Biology, consequences, supportive care, and therapeutic options

Menopause is the cessation of ovarian function, with loss of reproductive hormone production and irreversible loss of fertility. It is a natural part of reproductive aging. The physiology of the menopause is complex and incompletely understood. Globally, menopause occurs around the age of 49 years, with geographic and ethnic variation. The hormonal changes of the menopause transition may result in both symptoms and long-term systemic effects, predominantly adverse effects on cardiometabolic and musculoskeletal health. The most effective treatment for bothersome menopausal symptoms is evidence-based, menopausal hormone therapy (MHT), which reduces bone loss and may have cardiometabolic benefits. Evidence-based non-hormonal interventions are also available for symptom relief. Treatment should be individualized with shared decision-making. Most MHT regimens are not regulator approved for perimenopausal women. Studies that include perimenopausal women are needed to determine the efficacy and safety of treatment options. Further research is crucial to improve menopause care, along with research to guide policy and clinical practice.

Cause of Death in Patients with Oropharyngeal Carcinoma by Human Papillomavirus Status: Comparative Data Analysis

BACKGROUND

The incidence of oropharyngeal squamous cell carcinomas (OPSCC) has increased in recent decades, and human papillomavirus (HPV) infection is the main cause of OPSCC. The data regarding causes of death (CODs) are vitally important in informing follow-up strategies and revising treatment strategies to deal with any possible preventable treatment-related COD. However, limited studies have assessed the competing COD by HPV status in patients with OPSCC.

OBJECTIVE

We aimed to analyze the distribution of the competing COD according to HPV status in OPSCC.

METHODS

We retrospectively included stage I-IVB patients with OPSCC from the Surveillance, Epidemiology, and End Results database between 2010 and 2015. The association between HPV status and head and neck cancer-specific mortality (HNCSM), second primary cancer mortality (SPCM), and noncancer-caused mortality (NCCM) were analyzed. The chi-square test, Kaplan-Meier analysis, and Fine and Gray model were used for statistical analysis.

RESULTS

We included 5852 patients in this study and 73.2% (n=4283) of them had HPV-related tumors. A total of 1537 (26.3%) patients died, including 789 (51.3%), 333 (21.7%), and 415 (27%) patients who died from head and neck cancer, second cancer, and noncancer causes, respectively. The 5-year HNCSM, SPCM, NCCM, and overall mortality were 14.7%, 6.5%, 7.7%, and 26.4%, respectively. Those with HPV-positive disease had a lower cumulative incidence of HNCSM (subdistribution hazard ratio [sHR] 0.362, 95% CI 0.315-0.417; P<.001), SPCM (sHR 0.400, 95% CI 0.321-0.496; P<.001), and NCCM (sHR 0.460, 95% CI 0.378-0.560; P<.001) than those with HPV-negative disease. The 5-year risk of HNCSM was 26.9% and 10.7% in those with HPV-negative and HPV-positive disease, respectively (P<.001). The 5-year risk of SPCM was 12.4% and 4.6% in those with HPV-negative and HPV-positive disease, respectively (P<.001). The 5-year risk of NCCM of death was 13.7% and 5.8% in those with HPV-negative and HPV-positive disease, respectively (P<.001). Using the Fine and Gray competing-risks model, our results show that those with HPV-negative tumors had a significantly higher risk of HNCSM (P<.001), SPCM (P<.001), and NCCM (P<.001) than those with HPV-negative tumors.

CONCLUSIONS

HPV-positive OPSCC has a lower NCSM, SPCM, and NCCM as compared to those with HPV-negative OPSCC. HPV positivity is a favorable prognostic factor in the context of overcoming cancer as well as in terms of reducing the risk of other CODs in OPSCC. Our finding supports the need to tailor patient follow-up based on the HPV status of patients with OPSCC.

Measured sodium excretion is associated with cardiovascular outcomes in non-dialysis CKD patients: results from the KNOW-CKD study

Background

There are insufficient studies on the effect of dietary salt intake on cardiovascular (CV) outcomes in chronic kidney disease (CKD) patients, and there is no consensus on the sodium (Na) intake level that increases the risk of CV disease in CKD patients. Therefore, we investigated the association between dietary salt intake and CV outcomes in CKD patients.

Methods

In the Korean cohort study for Outcome in patients with CKD (KNOW-CKD), 1,937 patients were eligible for the study, and their dietary Na intake was estimated using measured 24h urinary Na excretion. The primary outcome was a composite of CV events and/or all-cause death. The secondary outcome was a major adverse cardiac event (MACE).

Results

Among 1,937 subjects, there were 205 (10.5%) events for the composite outcome and 110 (5.6%) events for MACE. Compared to the reference group (urinary Na excretion< 2.0g/day), the group with the highest measured 24h urinary Na excretion (urinary Na excretion ≥ 8.0g/day) was associated with increased risk of both the composite outcome (hazard ratio 3.29 [95% confidence interval 1.00-10.81]; P = 0.049) and MACE (hazard ratio 6.28 [95% confidence interval 1.45-27.20]; P = 0.013) in a cause-specific hazard model. Subgroup analysis also showed a pronounced association between dietary salt intake and the composite outcome in subgroups of patients with abdominal obesity, female, lower estimated glomerular filtration rate (< 60 ml/min per 1.73m2), no overt proteinuria, or a lower urinary potassium-to-creatinine ratio (< 46 mmol/g).

Conclusion

A high-salt diet is associated with CV outcomes in non-dialysis CKD patients.

Experiences with an integrated screening programme targeted at women who had a hypertensive disorder or diabetes in pregnancy in the Netherlands: a qualitative study

OBJECTIVES

Pregnancy is a predictor of women's health later in life. The risk of eventually developing cardiovascular disease (CVD) and/or type 2 diabetes (T2D) increases three to seven times, after pre-eclampsia, hypertension gravidarum or gestational diabetes. The Heart for Women in The Hague project was designed to offer targeted screening to this high-risk population. This research aimed to gather insight regarding the initial experiences of healthcare providers and women with pre-eclampsia, hypertension gravidarum or gestational diabetes.

DESIGN AND SETTING

This study applied a qualitative semistructured interview design using an interview guide based on 'The Consolidated Framework for Implementation Research (CFIR).' Interviews were recorded, transcribed and coded in accordance with the five main CFIR themes. The setting of the study was primary and secondary care in The Hague, the Netherlands. Interviews were carried out from December 2021 until February 2022. The language was Dutch or English.

PARTICIPANTS

Participants (n=13) were women of the target population (n=7) and relevant healthcare professionals (n=6).

RESULTS

Healthcare providers and women were generally positive concerning screening. Healthcare providers agreed that this forgotten group deserves attention and felt that the regional transmural agreement (RTA) provided a clear policy. Women stated that they would like screening to continue and were open-minded regarding lifestyle guidance. Reported barriers included current lack of an easy way of contacting the population after a year, lack of knowledge among the women concerning increased risk, unfamiliarity of new colleagues with the RTA and lack of evidence that screening actually prevents disease.

CONCLUSION

Implementation of screening programmes to prevent or delay the development of CVD and/or T2D after complicated pregnancies will likely improve awareness in both patients and healthcare providers. Healthcare providers considered the RTA important because it concerns a forgotten high-risk population. Future research should focus on the improved effectiveness of tailored interventions to delay or prevent CVD.

Oxidized dietary lipids induce vascular inflammation and atherogenesis in post-menopausal rats: estradiol and selected antihyperlipidemic drugs restore vascular health in vivo

BACKGROUND

Thermoxidation of edible oil through deep fat frying results in the generation of several oxidized products that promote lipid peroxidation and ROS production when eaten. Consumption of thermoxidized oil in post-menopausal conditions where the estrogen level is low contributes to cardiovascular disease. This study evaluates the role of estradiol and antihyperlipidemic agents (AHD) in restoring the vascular health of ovariectomized (OVX) rats fed with thermoxidized palm oil (TPO) and thermoxidized soya oil (TSO) diets.

METHOD

A total of 10 groups of rats (n = 6) were set up for the experiment. Group I (normal control) rats were sham handled while other groups were OVX to bring about estrogen deficient post-menopausal state. Group II (OVX only) was not treated and received normal rat chow. Groups III-X were fed with either TPO or TSO diet for 12 weeks and treated with estradiol (ETD) 0.2 mg/kg/day, atorvastatin (ATV) 10 mg/kg/day, and a fixed-dose combination of ezetimibe and ATV (EZE 3 mg/kg/day + ATV 10 mg/kg/day).

RESULTS

Pro-atherogenic lipids levels were significantly elevated in untreated TSO and TPO groups compared to OVX and sham, resulting in increased atherogenic and Coronary-risk indices. Treatment with Estradiol and AHDs significantly reduced the total cholesterol, triglycerides, low-density lipoprotein cholesterol as well as AI and CRI compared to untreated TSO and TPO groups, whereas TSO and TPO groups showed significant elevation in these parameters compared to Group I values. Moreover, aortic TNF-α levels were extremely elevated in the untreated TSO and TPO compared to Group I. TNF-α levels were significantly reduced in rats treated with AHDs and ETD. Localized oxidative stress was indicated in the aortic tissues of TSO and TPO-fed OVX rats by increased malondialdehyde and decreased glutathione, catalase, and superoxide dismutase levels. This contributed to a depletion in aortic nitric oxide. AHDs and ETD replenished the nitric oxide levels significantly. Histological evaluation of the aorta of TSO and TPO rats revealed increased peri-adventitia fat, aortic medial hypertrophy, and aortic recanalization. These pathologic changes were less seen in AHDs and ETD rats.

CONCLUSION

This study suggests that ETD and AHDs profoundly attenuate oxidized lipid-induced vascular inflammation and atherogenesis through oxidative-stress reduction and inhibition of TNF-α signaling.

Lipid profile screening and ASCVD prevention

INTRODUCTION

Atherosclerotic cardiovascular disease (ASCVD) is the main cause of morbidity and mortality worldwide. Dyslipidemia, in particular elevation of LDL-cholesterol levels (LDL-C), is one of the major cardiovascular risk factors and is characterized by high prevalence and independent unfavorable impact on cardiovascular prognosis; however, because of its asymptomatic course, it often remains undiagnosed. Strategies aimed at early identification of subjects with elevated LDL-C levels may allow early intervention, preventing ASCVD development.

AREAS COVERED

The purpose of this review is to summarize the recommendations of current guidelines by leading scientific authorities on the pros and cons of lipid profile screening programs.

EXPERT OPINION

Systematic assessment of LDL-C levels as part of global cardiovascular risk assessment in all adults is a cornerstone of ASCVD risk prevention. In young adults, adolescents, and children, selective lipid profile screening may be useful to reduce the impact of high cholesterol levels on ASCVD risk in the presence of specific conditions including either family history of early ASCVD or multiple concomitant cardiovascular risk factors. Cascade screening for family members of individuals diagnosed with familial hypercholesterolemia (FH) may be also of great clinical impact. Further evidence is needed to evaluate the cost/benefit ratio of systematic assessment of lipid profile in children, adolescents, and young adults.

Prediction of risk of ischemic heart disease in first-diagnosed systemic lupus erythematosus patients in taiwan: is air pollution exposure a risk factor?

BACKGROUND

Air pollution is a key public health factor with the capacity to induce diseases. The risk of ischemia heart disease (IHD) in those suffering from systemic lupus erythematosus (SLE) from air pollution exposure is ambiguous. This study aimed to: (1) determine the hazard ratio (HR) of IHD after the first-diagnosed SLE and (2) examine the effects of air pollution exposure on IHD in SLE for 12 years.

METHODS

This is a retrospective cohort study. Taiwan's National Health Insurance Research Database and Taiwan Air Quality Monitoring data were used in the study. Cases first diagnosed with SLE in 2006 cases without IHD were recruited as the SLE group. We randomly selected an additional sex-matched non-SLE cohort, four times the size of the SLE cohort, as the control group. Air pollution indices by residence city per period were calculated as the exposure. Life tables and Cox proportional risk models of time-dependent covariance were used in the research.

RESULTS

This study identified patients for the SLE group (n = 4,842) and the control group (n = 19,368) in 2006. By the end of 2018, the risk of IHD was significantly higher in the SLE group than in the control group, and risks peaked between the 6th and 9th year. The HR of incidence IHD in the SLE group was 2.42 times that of the control group. Significant correlations with risk of developing IHD were noted for sex, age, CO, NO₂, PM₁₀, and PM_2.5, of which PM₁₀ exposure had the highest risk of IHD incidence.

CONCLUSIONS

Subjects with SLE were at a higher risk of IHD, especially those in the 6th to 9th year after SLE diagnosis. The advanced cardiac health examinations and health education plan should be recommended for SLE patients before the 6th year after SLE diagnosed.

Cardiovascular and renal health: Preeclampsia as a risk marker

BACKGROUND

Cardiovascular (CVD) and chronic kidney disease (CKD) in women have unique risk factors related to hormonal status and obstetric history that must be taken into account. Pregnancy complications, such as preeclampsia (PE), can reveal a subclinical predisposition for the development of future disease that may help identify women who could benefit from early CVD and CKD prevention strategies.

MATERIALS AND METHODS

Review of PE and its association with future development of CVD and CKD.

RESULTS

Multiple studies have established an association between PE and the development of ischemic heart disease, chronic hypertension, peripheral vascular disease, stroke and CKD. It has not been sufficiently clarified if this relation is a causal one or if it is mediated by common risk factors. Nevertheless, the presence of endothelial dysfunction and thrombotic microangiopathy during pregnancies complicated with PE makes us believe that PE may leave a long-term imprint. Early identification of women who have had a pregnancy complicated by PE becomes a window of opportunity to improve women's health through adequate follow-up and targeted preventive actions. Oxidative stress biomarkers and vascular ultrasound may play a key role in the early detection of this arterial damage.

CONCLUSIONS

The implementation of preventive multidisciplinary targeted strategies can help slow down CVD and CKD's natural history in women at risk through lifestyle modifications and adequate blood pressure control. Therefore, we propose a series of recommendations to guide the prediction and prevention of CVD and CKD throughout life of women with a history of PE.

Evidence for Menopause as a Sex-Specific Risk Factor for Glaucoma

Glaucoma is a leading cause of irreversible blindness worldwide and is characterized by progressive loss of visual function and retinal ganglion cells (RGC). Current epidemiological, clinical, and basic science evidence suggest that estrogen plays a role in the aging of the optic nerve. Menopause, a major biological life event affecting all women, coincides with a decrease in circulating sex hormones, such as estrogen. While 59% of the glaucomatous population are females, sex is not considered a risk factor for developing glaucoma. In this review, we explore whether menopause is a sex-specific risk factor for glaucoma. First, we investigate how menopause is defined as a sex-specific risk factor for other pathologies, including cardiovascular disease, osteoarthritis, and bone health. Next, we discuss clinical evidence that highlights the potential role of menopause in glaucoma. We also highlight preclinical studies that demonstrate larger vision and RGC loss following surgical menopause and how estrogen is protective in models of RGC injury. Lastly, we explore how surgical menopause and estrogen signaling are related to risk factors associated with developing glaucoma (e.g., intraocular pressure, aqueous outflow resistance, and ocular biomechanics). We hypothesize that menopause potentially sets the stage to develop glaucoma and therefore is a sex-specific risk factor for this disease.

Premature stroke and cardiovascular risk in primary Sjögren's syndrome

Introduction

Primary Sjögren's syndrome (pSS) is associated with an increased prevalence of traditional risk factors and cardiovascular diseases (CVDs). The study aimed to identify specific risk factors for CVD in pSS patients.

Methods

PSS patients with and without CVD were compared. All patients fulfilled the EULAR/ACR classification criteria. Patients with CVD presented at least one of the following manifestations: myocardial infarction, transient ischemic attacks, ischemic or hemorrhagic stroke, peripheral artery disease, coronary artery disease, and carotid plaques. Data were collected by a standardized protocol and review of medical records.

Results

61/312 (19.6%) pSS patients presented with CVD. Traditional risk factors such as hypertension, hypercholesterinemia and diabetes (p < 0.05), pSS manifestations, in particular vasculitis (p = 0.033) and Raynaud's phenomenon (p = 0.018) were associated with CVD. Among patients with ischemic events (28/312, 9%), particularly cerebrovascular disease (n = 12/28, 42.9%), correlations with increased EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI) (p = 0.039) and EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI) (p = 0.048) were observed. Age at first cerebrovascular event was 55.2 [48.9-69.6] years. Multivariate analysis confirmed hypertension [odds ratio (OR) 3.7, 95% confidence interval (CI) 1.87-7.18, p < 0.001], hypercholesterinemia (OR 3.1, 95% CI 1.63-5.72, p < 0.001), male gender (OR 0.4, 95% CI 0.17-0.78, p = 0.009), Raynaud's phenomenon (OR 2.5, 95% CI 1.28-4.82, p = 0.007), and CNS involvement (OR 2.7, 95% CI 1.00-7.15, p = 0.048) as independent CVD predictors.

Conclusion

Raynaud's phenomen as well as vasculitis and high ESSDAI have shown a significant association to CVD. PSS patients with cerebrovascular events were younger than expected. Knowledge about risk factors may help clinicians to identify pSS patients at risk for CVD. After diagnosis of pSS, patients should be screened for risk factors such as hypertension and receive appropriate therapy to prevent or at least reduce sequelae such as infarction. However, further investigations are necessary in order to achieve a reliable risk stratification for these patients.

Sex and Gender Determinants of Vascular Disease in the Global Context

Globally, vascular diseases are a leading cause of morbidity and mortality. Many of the most significant risk factors for vascular disease have a gendered dimension, and sex differences in vascular diseases incidence are apparent, worldwide. In this narrative review, we provide a contemporary picture of sex- and gender-related determinants of vascular disease. We illustrate key factors underlying sex-specific risk stratification, consider similarities and sex differences in vascular disease risk and outcomes with comparisons of data from the global North (ie, developed high-income countries in the Northern hemisphere and Australia) and the global South (ie, regions outside Europe and North America), and explore the relationship between country-level gendered inequities in vascular disease risk and the United Nation's gender inequality index. Review findings suggest that the rising incidence of vascular disease in women is partly explained by an increase in the prevalence of traditional risk factors linked to gender-related determinants such as shifting roles and relations related to the double burden of employment and caregiving responsibilities, lower educational attainment, lower socioeconomic status, and higher psychosocial stress. Social isolation partly explained the higher incidence of vascular disease in men. These patterns were apparent across the global North and South. Study findings emphasize the necessity of taking into account sex differences and gender-related factors in the determination of the vascular disease risk profiles and management strategies. As we move toward the era of precision medicine, future research is needed that identifies, validates, and measures gender-related determinants and risk factors in the global South.

Pregnancy Loss and Cardiovascular Diseases in Women: Recent Findings and Potential Mechanisms

PURPOSE OF REVIEW

Pregnancy loss (PL) has been acknowledged by the American Heart Association as a risk factor for cardiovascular diseases (CVD) later in life. This review aims to sum up recent findings (< ~ 5 years), concerning the link between PL and CVD.

RECENT FINDINGS

The association between PL and risk of CVD increased with increasing number of PLs and is inversely correlated to maternal age, indicating that the association concerns euploid PLs. Likely mechanisms leading to PL and an increased risk of CVD include endothelial dysfunction, a pro-inflammatory state, antiphospholipid syndrome, autoimmunity, and genetic predisposition. PL as an independent risk factor for CVD constitutes an obvious gateway for a more targeted approach to future research, prevention, and treatment. Future research should clarify the following questions to which the answers are still unknown: whether PL is (a) directly causing the increased risk of CVD or (b) sharing pathophysiological mechanisms also leading to CVD.

Sex differences in coronary artery bypass grafting-related morbidity and mortality

BACKGROUND

Coronary artery bypass grafting (CABG) is associated with both cardiovascular disease (CVD) and non-CVD traits. In addition, women's prognosis after coronary events and revascularizations is worse than in men. As the course of CVD in women differs from that of men, we performed a phenome-wide analysis on the sex differences in CABG -related morbidity and mortality.

MATERIALS AND METHODS

We performed an untargeted analysis on the sex differences in predictors and outcomes of CABG. We studied a sample of 176,680 FinnGen participants, including 5,950 individuals who underwent CABG (4,988 men and 962 women) and were followed between 1998 and 2019. Over 1,100 different traits were analyzed for both sexes and the results were adjusted with age, smoking status and BMI. Cox proportional hazards models with sex-trait interactions were used to estimate the associations between (1) traits and incident CABG; and (2) CABG and incident traits.

RESULTS

In women, CABG was more strongly related to greater increases in risk of diseases such as hypertension, Alzheimer's, aortic aneurysms, gout, and chronic kidney disease compared to risk increases observed in men (all interaction p-values < 0.03). After CABG, men had 2.5-fold (p = 3.1E-15) and women 6.3-fold (p = 9.4E-08) greater risk of cardiac death compared to same-sex individuals who did not undergo CABG (p for interaction 8.2E-4). Moreover, the risk of death in women remained higher even 12 years after CABG, whereas the long-term risk of death in men was not increased, compared to same-sex individuals who did not undergo CABG.

CONCLUSION

The adverse outcomes after CABG, both quantity and quality, also appear to differ between men and women. In women, CABG is related to greater long-term increases in risk of cardiac death and several other disease states than in men. Consideration should therefore be given to whether women receive adequate long-term post-operative therapy and follow-up as CABG is not associated with equally improved cardiovascular disease prognosis in women than in men.

Trajectories of metabolic parameters after bilateral oophorectomy in premenopausal women

OBJECTIVE

To study the trajectories of metabolic parameters after bilateral oophorectomy.

STUDY DESIGN

This population-based cohort study included a random sample of all premenopausal women who underwent bilateral oophorectomy at or before age 45 years from 1988 to 2007 in Olmsted County, Minnesota, and their age-matched (±1 year) referent women who did not undergo bilateral oophorectomy.

MAIN OUTCOME MEASURES

The medical records of all women were reviewed to collect the metabolic parameters over a 10-year period. We compared three groups of women: 1) referent women (n = 270), 2) women who underwent bilateral oophorectomy and received estrogen therapy (n = 163), and 3) women who underwent bilateral oophorectomy and did not receive estrogen therapy (n = 107).

RESULTS

Over 10 years of follow-up, the three groups had significantly different mean values of diastolic blood pressure, weight, body mass index (BMI), total cholesterol, triglycerides, and high-density lipoprotein cholesterol (HDL-C). However, women with and without bilateral oophorectomy were already different at baseline for hyperlipidemia, systolic blood pressure, weight, and BMI. Nevertheless, the trajectories of change over 10 years were significant for weight (group by time interaction p = 0.03), BMI (p = 0.03), and HDL-C (p = 0.004). The changes occurred primarily in the initial 4-5 years. Women who received estrogen therapy after bilateral oophorectomy were comparable to the referent women with respect to the weight and BMI trends, and they experienced an increase in HDL-C over time.

CONCLUSION

Women who underwent bilateral oophorectomy before menopause experienced unfavorable changes in some metabolic parameters possibly increasing their cardiovascular risk.

Gender-differences in antithrombotic therapy across the spectrum of ischemic heart disease: Time to tackle the Yentl syndrome?

The incidence and clinical presentation of ischemic heart disease (IHD), as well as thrombotic and bleeding risks, appear to differ between genders. Compared with men, women feature an increased thrombotic risk, probably related to an increased platelet reactivity, higher level of coagulation factors, and sex-associated unique cardiovascular risk factors, such as pregnancy-related (i.e., pre-eclampsia and gestational diabetes), gynecological disorders (i.e., polycystic ovary syndrome, early menopause) and autoimmune or systemic inflammatory diseases. At the same time, women are also at increased risk of bleeding, due to inappropriate dosing of antithrombotic agents, smaller blood vessels, lower body weight and comorbidities, such as diabetes and chronic kidney disease. Pharmacological strategies focused on the personalization of antithrombotic treatment may, therefore, be particularly appealing in women in light of their higher bleeding and ischemic risks. Paradoxically, although women represent a large proportion of cardiovascular patients in our practice, adequate high-quality clinical trial data on women remain scarce and inadequate to guide decision-making processes. As a result, IHD in women tends to be understudied, underdiagnosed and undertreated, a phenomenon known as a "Yentl syndrome." It is, therefore, compelling for the scientific community to embark on dedicated clinical trials to address underrepresentation of women and to acquire evidence-based knowledge in the personalization of antithrombotic therapy in women.

Variation in Heart Failure Risk by HIV Severity and Sex in People With HIV Infection

BACKGROUND

HIV is an independent risk factor for heart failure (HF). However, the association of HIV severity with incident HF and the potential interaction with sex are incompletely understood.

SETTING

Integrated health care system.

METHODS

We conducted a cohort study of people with HIV (PWH) and matched people without HIV (PWoH), all aged ≥ 21 years and with no previous HF. Poisson regression was used to compare incident HF by HIV status, with PWH stratified by severity of HIV infection [defined by recent (<6 months) CD4 count, nadir CD4 count, or recent HIV RNA level]. Models were adjusted for sociodemographic characteristics, substance use, and HF risk factors. Analyses were conducted for men and women combined, then by sex.

RESULTS

The study included 38,868 PWH and 386,569 PWoH (mean baseline age = 41.0 ± 10.8 years; 88% men). Compared with PWoH, incident HF risk was higher among PWH with lower recent CD4 [200-499 cells/µL, adjusted rate ratio (aRR) = 1.82, 95% confidence interval (CI) = 1.50 to 2.21 and <200 cells/µL, aRR = 3.26 (2.47 to 4.30)] and a low nadir CD4 [<200 cells/µL, aRR = 1.56 (1.37 to 1.79)] but not among PWH with normal CD4 [≥500 cells/µL, aRR = 1.14 (0.90 to 1.44)]. Higher incident HF risk was observed among PWH at all HIV RNA levels, with greater HF risk at higher HIV RNA levels. The excess HF risk associated with low CD4 (recent or nadir) and high HIV RNA was stronger among women than men (P interactions=0.05, 0.08, and 0.01, respectively).

CONCLUSIONS

Given the association of HIV severity with HF, optimizing HIV treatment and management may be important for HF prevention among PWH.

Quantitative and qualitative features of carotid and coronary atherosclerotic plaque among men and women

Cardiovascular diseases (CVDs), particularly ischemic heart disease (IHD) and stroke, present epidemiologically in a different way among sexes. The reasons of these sex-based differences should be delved into sex-specific cardiovascular (CV) risk factors and different mechanisms of atherosclerotic progression. Imaging techniques of both carotid and coronary atherosclerotic plaques represent a tool to demonstrate sex-related features which might be used to further and better assess CV risk of male and female population. The aim of this review is to evaluate current knowledge on sex-specific qualitative and quantitative plaque features of coronary and carotid atherosclerosis. We also discuss the clinical implication of a sex-based plaque phenotype, evaluated with non-invasive imaging techniques, such as CT-angiography and MRI-angiography, to stratify CV risk.

Identification of an Epigenetic Signature for Coronary Heart Disease in Postmenopausal Women’s PBMC DNA

Menopause is accompanied with an increased risk of cardiovascular disease. DNA methylation may have a significant impact on postmenopausal women's development of coronary heart disease. DNA methylation alterations in peripheral blood mononuclear cells (PBMCs) from women with coronary heart disease and healthy controls were detected using the Illumina Infinium MethylationEPIC BeadChip platform in this work. We employed Sangerbox technology and the GO and KEGG databases to further study the pathogenesis of coronary heart disease in postmenopausal women. After that, we used functional epigenetic module analysis and Cytoscape to remove the hub genes from the protein–protein interaction networks. Five genes (FOXA2, PTRD, CREB1, CTNAP2, and FBN2) were the hub genes. Lipid accumulation, endothelial cell failure, inflammatory responses, monocyte recruitment and aggregation, and other critical biological processes were all influenced by these genes. Finally, we employed methylation-specific PCR to demonstrate that FOXA2 was methylated at a high level in postmenopausal women with coronary heart disease. To better understand coronary heart disease in postmenopausal women's molecular mechanisms, our study examine the major factors contributing to the state of DNA methylation modification, which will help discover novel diagnostic tools and treatment options.

Neurovascular disease in Switzerland: 10-year trends show non-traditional risk factors on the rise and higher exposure in women

BACKGROUND

Effective risk factor modification is the prerequisite to prevent neurovascular disease such as stroke or vascular dementia. Non-traditional vascular risk factors (nt-vrf) including stress significantly add to risk of neurovascular disease arising from traditional vascular risk factors (t-vrf). In order to discover sex-specific changes that may underlie previously reported inclines in the prevalence of neuro- and cardiovascular disease in women, we assessed 10-year trends in the prevalence of vrf in Switzerland.

METHODS

We obtained anonymized data from 22'134 participants (51% women) of the governmental Swiss Health Survey, performed every five years (2007, 2012, and 2017). Epidemiological parameters, t-vrf and nt-vrf were analyzed in a cross-sectional study design.

RESULTS

Over the observation period, the number of women having full-time jobs increased considerably (2007: 38%, 2012: 39%, 2017: 44%). This was accompanied by a substantial rise in the prevalence of nt-vrf in women and men (w/m) including stress at work (2007: not available, 2012: 58%/60%, 2017: 66%/65%), low locus of control (w/m: 2007: 21%/19%, 2012: 22%/19%, 2017: 25%/22%), and sleep disorders (w/m: 2007: 30%/22%, 2012: 28%/20%, 2017: 32%/26%). Amongst t-vrf, only the prevalence of obesity and hypercholesterolemia increased over time in both sexes, while other t-vrf remained stable (hypertension [27%], diabetes [5%]) or decreased (smoking [9.4 cigarettes/day]).

CONCLUSIONS

A rise in women's economic participation alongside a higher affection with nt-vrf in the female Swiss population emphasizes the need to improve vascular risk stratification and implement effective preventive measures for neuro- and cardiovascular disease.

Menopause: a cardiometabolic transition

Menopause is often a turning point for women's health worldwide. Increasing knowledge from experimental data and clinical studies indicates that cardiometabolic changes can manifest at the menopausal transition, superimposing the effect of ageing onto the risk of cardiovascular disease. The menopausal transition is associated with an increase in fat mass (predominantly in the truncal region), an increase in insulin resistance, dyslipidaemia, and endothelial dysfunction. Exposure to endogenous oestrogen during the reproductive years provides women with protection against cardiovascular disease, which is lost around 10 years after the onset of menopause. In particular, women with vasomotor symptoms during menopause seem to have an unfavourable cardiometabolic profile. Early management of the traditional risk factors of cardiovascular disease (ie, hypertension, obesity, diabetes, dyslipidaemia, and smoking) is essential; however, it is important to recognise in the reproductive history the female-specific conditions (ie, gestational hypertension or diabetes, premature ovarian insufficiency, some gynaecological diseases such as functional hypothalamic amenorrhoea, and probably others) that could enhance the risk of cardiovascular disease during and after the menopausal transition. In this Review, the first of a Series of two papers, we provide an overview of the literature for understanding cardiometabolic changes and the management of women at midlife (40-65 years) who are at higher risk, focusing on the identification of factors that can predict the occurrence of cardiovascular disease. We also summarise evidence about preventive non-hormonal strategies in the context of cardiometabolic health.

Pan-risk factor for a comprehensive cardiovascular health management

Cardiovascular diseases (CVDs) have become the leading cause of death in China. CVDs are mainly caused by multiple well-known modifiable risk factors that are affected by socioeconomic and environmental determinants, lifestyle and behavioral choices, and familial and genetic predispositions. With more risk factors proved to be associated with CVD occurrence, the concept "pan-risk factor" is proposed in this review to indicate all discovered and yet-to-be-discovered CVD risk factors for comprehensive primary prevention of CVD. Recognizing more factors and their roles in CVD development and progression is the first step in reducing the ever-increasing burden of CVD. This review is an overview of the pan-risk factor whose associations with CVD outcomes have been established. Along with the accumulation of scientific evidence, an increasing number of risk factors will be discovered and included in the list of pan-risk factors.

Update on Management of Cardiovascular Diseases in Women

Cardiovascular diseases (CVD) have a lower prevalence in women than men; although, a higher mortality rate and a poorer prognosis are more common in women. However, there is a misperception of CVD female risk since women have commonly been considered more protected so that the real threat is vastly underestimated. Consequently, female patients are more likely to be treated less aggressively, and a lower rate of diagnostic and interventional procedures is performed in women than in men. In addition, there are substantial sex differences in CVD, so different strategies are needed. This review aims to evaluate the main gender-specific approaches in CVD.

Evidence base for the management of women with non-ST elevation acute coronary syndrome

According to the Global Burden of Disease study, in 2019, there were an estimated 275.2 million cases of cardiovascular disease (CVD) in women worldwide. Although there was a decrease in the global age-standardised prevalence of CVD in women between 1990 and 2010 (–5.8%), there has been a slight increase (1.0%) since 2010. There were an estimated 6.10 million deaths from CVD in women in 1990, rising to 8.94 million in 2019. Hospital admissions of young women with acute myocardial infarction (AMI) steadily increased from 27% in 1995–1999 to 32% in 2010–2014. Women with AMI compared with men are less likely to receive guideline-indicated pharmacological (aspirin 93.4% vs 94.7%, P2Y12 inhibitors 79.3% vs 86.1% and statins 73.7% vs 77.5%) and revascularisation treatments (angiography (adjusted OR (aOR) 0.71), percutaneous coronary intervention (aOR 0.73)). Women represent <39% of clinical cardiovascular trial participants between 2010 and 2017. Major factors of under-representation in studies included concerns about the burden of participation on health and time. Women were more likely than men to document caring responsibilities as reasons for not participating in a clinical trial. Current clinical practice guidelines recommending risk stratification to guide the appropriateness of an invasive strategy in the context of acute coronary syndrome (ACS) may not be applicable to women given lack of studies specifically evaluating women using contemporary treatment strategies. In our review, we identify significant limitations in the evidence base for the best care of women with ACS, emphasising the need for well-designed clinical trials specifically recruiting women.

Gaps and Disparities in Primary Prevention Statin Prescription During Outpatient Care

The 2018 American College of Cardiology/American Heart Association Guideline on the Management of Blood Cholesterol recommends statin therapy for eligible patients to reduce the risk of atherosclerotic cardiovascular disease (ASCVD). We extracted electronic health record data for patients with at least one primary care or cardiology visit between October 2018 and January 2020 at an urban, academic medical center in New York City. Clinical and demographic data were used to identify patients eligible for primary prevention statin therapy. Statin prescription status was extracted from the electronic health record, and multivariate logistic regression was used to assess the association between statin prescription and age, gender, race, ethnicity, and other clinical and demographic covariables. In 7,550 patients eligible for primary prevention statin therapy, 3,994 (52.9%) were prescribed statins on at least 1 visit. Statin prescription was highest in patients with diabetes mellitus (73.6%) and with a 10-year ASCVD risk ≥20% (60.6%) and was lowest for those with a 10-year ASCVD risk between 5% and 7.5% (18.7%). Compared with those never prescribed statins, patients prescribed statins were less likely to be women, mainly driven by lower statin prescription rates for women with diabetes. In a fully adjusted model, women remained less likely to be prescribed statin therapy (adjusted odds ratios 0.79, 95% confidence interval 0.71 to 0.88). In conclusion, primary prevention statin therapy remains underutilized.