Sex Differences in Cardiac Risk Factors, Perceived Risk, and Health Care Provider Discussion of Risk and Risk Modification Among Young Patients With Acute Myocardial Infarction: The VIRGO Study

Sex-Related Differences in Heart Failure After ST-Segment Elevation Myocardial Infarction

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) complicated by symptoms of acute de novo heart failure is associated with excess mortality. Whether development of heart failure and its outcomes differ by sex is unknown.

OBJECTIVES

This study sought to examine the relationships among sex, acute heart failure, and related outcomes after STEMI in patients with no prior history of heart failure recorded at baseline.

METHODS

Patients were recruited from a network of hospitals in the ISACS-TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry (NCT01218776). Main outcome measures were incidence of Killip class ≥II at hospital presentation and risk-adjusted 30-day mortality rates were estimated using inverse probability of weighting and logistic regression models.

RESULTS

This study included 10,443 patients (3,112 women). After covariate adjustment and matching for age, cardiovascular risk factors, comorbidities, disease severity, and delay to hospital presentation, the incidence of de novo heart failure at hospital presentation was significantly higher for women than for men (25.1% vs. 20.0%, odds ratio [OR]: 1.34; 95% confidence interval [CI]: 1.21 to 1.48). Women with de novo heart failure had higher 30-day mortality than did their male counterparts (25.1% vs. 20.6%; OR: 1.29; 95% CI: 1.05 to 1.58). The sex-related difference in mortality rates was still apparent in patients with de novo heart failure undergoing reperfusion therapy after hospital presentation (21.3% vs. 15.7%; OR: 1.45; 95% CI: 1.07 to 1.96).

CONCLUSIONS

Women are at higher risk to develop de novo heart failure after STEMI and women with de novo heart failure have worse survival than do their male counterparts. Therefore, de novo heart failure is a key feature to explain mortality gap after STEMI among women and men.

Increasing Mortality From Premature Coronary Artery Disease in Women in the Rural United States

Background

Previous reports have described a leveling off of mortality from premature coronary artery disease (CAD). In recent years, the prevalence of cardiovascular risk factors has increased in rural communities and young adults.

Methods and Results

We extracted CAD mortality rates from the Centers for Disease Control and Prevention Wide‐Ranging Online Data for Epidemiologic Research (CDC WONDER) database from 1999 to 2017, focusing on mortality from premature CAD (defined as <65 years of age in women) and urban–rural differences. Variations in mortality rates over time, assessed with Joinpoint regression modeling, are expressed as estimated annual percentage change (95% CI) and stratified by urbanization, sex, age, and race. Age‐adjusted mortality rates decreased for women and men. Stratification by urbanization revealed that premature CAD mortality is stagnating among women in rural areas. However, this stagnation conceals a statistically significant increase in CAD mortality rates since 2009 in women aged 55 to 64 years (estimated annual percentage change: +1.4%; 95% CI, +0.3% to +2.5%) and since 1999 in women aged 45 to 54 years (estimated annual percentage change: +0.6%; 95% CI, +0.2% to 1.0%). Since 1999, mortality has been stagnating in the youngest group (aged 35–44 years; estimated annual percentage change: +0.2%; 95% CI, −0.4% to +0.8%). Stratification by race indicated an increase in mortality rates among white rural women. Premature CAD mortality remains consistently higher in the rural versus urban United States, regardless of sex, race, and age group.

Conclusions

Premature CAD mortality rates have declined over time. However, stratification by sex and urbanization reveals disparities that would otherwise remain concealed: CAD mortality rates have increased among women from rural areas since at least 2009.

The Use of Sex-Specific Factors in the Assessment of Women's Cardiovascular Risk

Cardiovascular disease (CVD) is the leading cause of death among women in the United States. As compared with men, women are less likely to be diagnosed appropriately, receive preventive care, or be treated aggressively for CVD. Sex differences between men and women have allowed for the identification of CVD risk factors and risk markers that are unique to women. The 2018 American Heart Association/American College of Cardiology Multi-Society cholesterol guideline and 2019 American College of Cardiology/American Heart Association guideline on the primary prevention of CVD introduced the concept of risk-enhancing factors that are specific to women and are associated with an increased risk of incident atherosclerotic CVD in women. These factors, if present, would favor more intensified lifestyle interventions and consideration of initiation or intensification of statin therapy for primary prevention to mitigate the increased risk. In this primer, we highlight sex-specific CVD risk factors in women, stress the importance of eliciting a thorough obstetrical and gynecological history during cardiovascular risk assessment, and provide a framework for how to initiate appropriate preventive measures when sex-specific risk factors are present.

Sex Differences in Coronary Artery Calcium and Long-term CV Mortality

PURPOSE OF REVIEW

To summarize differences in plaque depositions, coronary artery calcium (CAC) scoring, and the role of CAC in predicting atherosclerotic cardiovascular disease (ASCVD) mortality in men and women.

RECENT FINDINGS

Women have coronary plaque that is more lipid-rich, dense, and less calcified than their male counterparts. CAC scoring has emerged as a useful tool to quantify ASCVD burden. However, recent evidence favors the use of sex-adjusted CAC cutoffs for women to account for the relatively lower overall CAC burden and therefore risk stratify women appropriately. Several studies have identified CAC distribution patterns in women associated with increased CV mortality, particularly the number of lesions involved, CAC volume, and size. Multiple studies have shown that the pathophysiology and associated risks of ASCVD are different in women when compared with men. CAC scoring is a tool that is widely being used for ASCVD risk stratification. Recent studies have shown that although men have higher CAC burdens, women are more likely to develop plaque erosions with non-calcified plaque that carries a greater risk for cardiovascular events. Providers should be aware of sex-specific CAC patterns carrying increased mortality risk for women, particularly increasing lesion size and number. Given the differences in plaque composition and distribution, revised sex-adjusted CAC scoring is suggested to better risk stratify patients, especially those deemed intermediate risk, and decrease CV mortality.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Words Matter: Sex and Gender as Unique Variables in Research

Sex and gender are not equivalent concepts, even though these 2 variables are often used interchangeably by researchers. The precise use of variables is critical to ensure that research and theoretical work is of the highest quality. This article defines sex and gender and the importance of recognizing both of these variables as being unique and then demonstrates the benefit of measuring both of these variables using the cardiovascular disease literature as an exemplar. Additionally, recommendations for scholars regarding the use of sex and gender in the research and theoretical literature are provided.

Temporal Trends Analysis of the Characteristics, Management, and Outcomes of Women With Acute Coronary Syndrome (ACS): ACS Israeli Survey Registry 2000-2016

Background Cardiovascular disease remains a leading cause of death among women. Despite improvements in the management of patients with acute coronary syndrome (ACS), women with an ACS remain at higher risk. Methods and Results We performed a time-dependent analysis of the management and outcomes of women admitted with ACS who enrolled in the prospective biennial ACS Israeli Surveys between 2000 and 2016. Surveys were divided into 3 time periods (2000-2004, 2006-2010, and 2013-2016). Outcomes included 30-day major adverse cardiac events (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1-year mortality. Overall, 3518 women were admitted with an ACS. Their mean age (70±12 years) was similar among the time periods. Over the time course of the study, more women were admitted with non-ST-elevation ACS (51.9%, 59.6%, and 66.1%, respectively; P<0.001), and statins and percutaneous coronary intervention were increasingly utilized (66%, 91%, 93%, and 42%, 60%, and 68%, respectively; P<0.001 for each). Among women with ST-segment-elevation myocardial infarction, more primary percutaneous coronary interventions were performed (48.5%, 84.7%, and 95.3%, respectively; P<0.001). The rate of 30-day major adverse cardiac events has significantly decreased over the years (24.6%, 18.6%, and 13.5%, respectively; P<0.001). However, 1-year mortality rates declined only from 2000 to 2004 (16.9%, 12.8%, and 12.3%; P=0.007 for the overall difference), and this change was not significant after propensity matching or multivariate analysis. Conclusions Over more than a decade, 30-day major adverse cardiac events have decreased among women with ACS. Advances in pharmacological treatments and an early invasive approach may have accounted for this improvement. However, the lack of further reduction in 1-year mortality rates among women suggests that more measures should be provided in this high-risk population.

Gender Differences in Patient-Reported Outcomes Among Adults With Atherosclerotic Cardiovascular Disease

Background

Atherosclerotic cardiovascular disease (ASCVD) accounts for approximately one third of deaths in women. Although there is an established relationship between positive patient experiences, health‐related quality of life, and improved health outcomes, little is known about gender differences in patient‐reported outcomes among ASCVD patients. We therefore compared gender differences in patient‐centered outcomes among individuals with ASCVD.

Methods and Results

Data from the 2006 to 2015 Medical Expenditure Panel Survey, a nationally representative US sample, were used for this study. Adults ≥18 years with a diagnosis of ASCVD, ascertained by International Classification of Diseases, Ninth Revision (ICD‐9) codes and/or self‐reported data, were included. Linear and logistic regression were used to compare self‐reported patient experience, perception of health, and health‐related quality of life by gender. Models adjusted for demographics, socioeconomic status, and comorbidities. There were 21 353 participants included, with >10 000 (47%‐weighted) of the participants being women, representing ≈11 million female adults with ASCVD nationwide. Compared with men, women with ASCVD were more likely to experience poor patient–provider communication (odds ratio 1.25 [95% confidence interval 1.11–1.41]), lower healthcare satisfaction (1.12 [1.02–1.24]), poor perception of health status (1.15 [1.04–1.28]), and lower health‐related quality of life scores. Women with ASCVD also had lower use of aspirin and statins, and greater odds of ≥2 Emergency Department visits/y.

Conclusions

Women with ASCVD were more likely to report poorer patient experience, lower health‐related quality of life, and poorer perception of their health when compared with men. These findings have important public health implications and require more research towards understanding the gender‐specific differences in healthcare quality, delivery, and ultimately health outcomes among individuals with ASCVD.

Acute myocardial infarction in the young - National Trend Analysis with gender-based difference in outcomes

INTRODUCTION

Although acute myocardial infarction (AMI) is a disease predominantly affecting adults >60 years of age, a significant proportion of the young population who have different risk profiles, are also affected. We undertook a retrospective analysis using National Inpatient Sample (NIS) 2010 to 2014 to evaluate gender differences in characteristics, treatments, and outcomes in the younger AMI population.

METHODS

The NIS 2010-2014 was used to identify all patient hospitalizations with AMI between 18 to <45 years using ICD-9-CM codes. We demonstrated a gender-based difference of in-hospital all-cause mortality, other complications, and revascularization strategies in the overall AMI population and other subgroups of AMI [anterior wall ST-segment elevation MI (STEMI), and non-anterior wall STEMI and non-STEMI (NSTEMI)].

RESULTS

A total of 156,018 weighted records of AMI hospitalizations were identified, of which 111,894 were men and 44,124 were women. Young women had a higher prevalence of anemia, chronic lung disease, obesity, peripheral vascular disease, and diabetes. Conversely, young men had a higher prevalence of dyslipidemia, smoking, and alcohol. Among non-traditional risk factors, women had a higher prevalence of depression and rheumatologic/collagen vascular disease. There was no difference in all-cause in-hospital mortality in women compared to men [2.03% vs 1.48%; OR 1.04, CI (0.84-1.29); P = .68], including in subgroup analysis of NSTEMI, anterior wall STEMI, and non-anterior wall STEMI. Women with AMI were less likely to undergo percutaneous coronary intervention [47.13% vs 61.17%; OR 0.66, 95% CI (0.62-0.70; P < .001] and coronary artery bypass grafting [5.6% vs 6.0%; OR 0.73, 95% CI 0.64-0.83; P < .001] compared to men. Women were also less likely to undergo percutaneous coronary intervention within 24 h of presentation (38.47% vs 51.42%, P < .001).

CONCLUSION

Despite higher baseline comorbidities in young women with AMI, there was no difference in in-hospital mortality in women compared to men. Additional studies are needed to evaluate the impact of gender on clinical presentation, treatment patterns, and outcomes of AMI in young patients.

CLINICAL SIGNIFICANCE

The association of food quality score and cardiovascular diseases risk factors among women: A cross-sectional study

Introduction: Limited studies are available regarding the relationship between Food Quality Score (FQS) and cardiovascular disease (CVD) risk factors. Thus, this study was aimed to investigate the association of FQS with CVD risk factors in women.

Methods: This cross-sectional study was carried out among 368 women aged 20-50 years who randomly selected from health centers across Tehran, Iran. Dietary intake was collected using a reliable and validated food frequency questionnaire (FFQ). The FQS includes vegetables, fruits, whole grains, yogurt, nuts and legumes, coffee, refined grains, desserts and ice cream, sugar-sweetened beverages, red meats, fried food consumed outside the home, processed meats, potato and potato chips. Standard methods were used to assess blood pressure, biochemical and anthropometric measures. Multivariate logistic regression was used to examine the association between FQS and CVD risk factors.

Results: Participant mean age and body mass index (BMI) were 30.7 ± 6.9 years and 24.3 ± 4.0 kg/m2, respectively. After taking potential confounders into account, FQS had no significant association with risk of overweight and obesity [Odds ratio (OR): 1.1, 95% confidence interval (CI): 0.68, 1.8; P = 0.683], diabetes (OR: 0.62, 95% CI: 0.22, 1.74; P = 0.374), metabolic syndrome (OR: 0.36, 95% CI: 0.10, 1.32; P = 0.127), hypercholesterolemia (OR: 0.54, 95% CI: 0.29, 1.01; P= 0.051), or hypertriglyceridemia (OR: 1.63, 95% CI: 0.71, 3.70; P = 0.244).

Conclusion: The results showed that FQS was not significantly associated with CVD risk factors among women. Prospective cohort studies are warranted to confirm our findings.

The Association between Risk Factors and Prodromal Myocardial Infarction Symptoms: A Cross-Sectional Study in Iran

Background

Prodromal symptoms in individuals with risk factors remain challenging, even though myocardial infarction has been noted in research. This study determined the association of risk factors with patients' baseline myocardial infarction related prodromal symptoms.

Methods

In a cross-sectional study, 154 Iranian men and women, mean age 59.62 ± 12.74 years were assessed in 2016-2017. The frequency besides severity of 33 prodromal symptoms and risk factors was assessed using McSweeney Prodromal Myocardial Infarction Symptom Survey.

Results

The main cardiac prodromal symptoms experienced by patients were chest pain/discomfort (n = 99, 64.30%), unusual fatigue (n = 78, 50.60%), and sleep disturbance (n = 33, 20.40%). Women experienced more prodromal symptoms than men (33.26 ± 21.88 vs. 25.48 ± 17.75). Among risk factors, only sex was associated with prodromal symptoms score (P < 0.05).

Conclusion

The frequently experienced prodromal symptoms, i.e., before MI were chest pain/discomfort, unusual fatigue, and sleep disturbance. A crucial finding was the significant association between sex and prodromal symptoms. Identifying prodromal symptoms in patients with risk factors can prevent the incidence of myocardial infarction.

ST-elevation myocardial infarction in a real world population - An observational retrospective study with a sex perspective

BACKGROUND

Mortality after myocardial infarction is higher in women than in men. Data on the association between sex and mortality are conflicting and inconclusive. We evaluated whether there is a sex difference in survival and if sex is associated with the outcome in patients with ST-elevation myocardial infarction (STEMI).

METHODS

We analyzed 3671 STEMI patients. Long-term and 30-day mortality in men and women were compared.

RESULTS

Unadjusted mortality at day 30 was higher in women [221 (8.7%) men died compared to 147 (13.1%) women; p < 0.0001]. After multivariate adjustments, this became insignificant (OR 1.65; 95% CI; 0.81 to 1.40). The long-term, unadjusted mortality was also higher in women [674 (26.3%) men died compared to 382 (34%) women; p < 0.0001]. After multivariable adjustments, female sex (adjusted HR 0.81; 95% CI 0.71 to 0.93; p = 0.002), bleeding (adjusted HR 1.79; 95% CI 1.52 to 2.10; p < 0.0001), renal dysfunction adjusted HR (1.60; 95% CI 1.40 to 1.84; p < 0.0001), hyperlipidemia (adjusted HR 1.61; 95% CI 1.40 to 1.85; p < 0.0001), arterial hypertension (adjusted HR 1.17; 95% CI 1.03 to 1.33; p = 0.015), diabetes (adjusted HR 1.55; 95% CI 1.35 to 1.78; p < 0.0001), age (adjusted HR 1.05; 95% CI 1.04 to 1.06; p < 0.0001), anemia on admission (adjusted HR 1.38; 95% CI 1.23 to 1.58; p < 0.0001), and heart failure (adjusted HR 2.40; 95% CI 2.09 to 2.75; p < 0.0001) predicted long-term mortality.

CONCLUSION

Female sex was associated with a lower risk of dying in the long term. However, risk factors, age, and comorbidities associated with female patients affected the worse outcome.

Sex Differences in Ischemic Heart Disease: Advances, Obstacles, and Next Steps

Evolving knowledge of sex-specific presentations, improved recognition of conventional and novel risk factors, and expanded understanding of the sex-specific pathophysiology of ischemic heart disease have resulted in improved clinical outcomes in women. Yet, ischemic heart disease continues to be the leading cause of morbidity and mortality in women in the United States. The important publication by the Institute of Medicine titled "Women's Health Research-Progress, Pitfalls, and Promise," highlights the persistent disparities in cardiovascular disease burden among subgroups of women, particularly women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment. These important health disparities reflect underrepresentation of women in research, with the resultant unfavorable impact on diagnosis, prevention, and treatment strategies in women at risk for cardiovascular disease. Causes of disparities are multifactorial and related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. Lack of awareness in both the public and medical community, as well as existing knowledge gap regarding sex-specific differences in presentation, risk factors, pathophysiology, and response to treatment for ischemic heart disease, further contribute to outcome disparities. There is a critical need for implementation of sex- and gender-specific strategies to improve cardiovascular outcomes. This review is tailored to meet the needs of a busy clinician and summarizes the contemporary trends, characterizes current sex-specific outcome disparities, delineates challenges, and proposes transformative solutions for improvement of the full spectrum of ischemic heart disease clinical care and research in women.

Contemporary Sex-Based Differences by Age in Presenting Characteristics, Use of an Early Invasive Strategy, and Inhospital Mortality in Patients With Non-ST-Segment-Elevation Myocardial Infarction in the United States

BACKGROUND

Prior studies have reported higher inhospital mortality in women versus men with non-ST-segment-elevation myocardial infarction. Whether this is because of worse baseline risk profile compared with men or sex-based disparities in treatment is not completely understood.

METHODS AND RESULTS

We queried the 2003 to 2014 National Inpatient Sample databases to identify all hospitalizations in patients aged ≥18 years with the principal diagnosis of non-ST-segment-elevation myocardial infarction. Complex samples multivariable logistic regression models were used to examine sex differences in use of an early invasive strategy and inhospital mortality. Of 4 765 739 patients with non-ST-segment-elevation myocardial infarction, 2 026 285 (42.5%) were women. Women were on average 6 years older than men and had a higher comorbidity burden. Women were less likely to be treated with an early invasive strategy (29.4% versus 39.2%; adjusted odds ratio, 0.92; 95% confidence interval, 0.91-0.94). Women had higher crude inhospital mortality than men (4.7% versus 3.9%; unadjusted odds ratio, 1.22; 95% confidence interval, 1.20-1.25). After adjustment for age (adjusted odds ratio, 0.96; 95% confidence interval, 0.94-0.98) and additionally for comorbidities, other demographics, and hospital characteristics, women had 10% lower odds of inhospital mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.89-0.92). Further adjustment for differences in the use of an early invasive strategy did not change the association between female sex and lower risk-adjusted inhospital mortality.

CONCLUSIONS

Although women were less likely to be treated with an early invasive strategy compared with men, the lower use of an early invasive strategy was not responsible for the higher crude inhospital mortality in women, which could be entirely explained by older age and higher comorbidity burden.

Addressing the Gap in Physician Preparedness To Assess Cardiovascular Risk in Women: a Comprehensive Approach to Cardiovascular Risk Assessment in Women

PURPOSE OF REVIEW

Increased recognition of risk factors and improved knowledge of sex-specific presentations has led to improved clinical outcomes for women with cardiovascular disease (CVD) compared to two decades ago. Yet, CVD remains the leading cause of death for women in the USA. Women have unique risk factors for CVD that continue to go under-recognized by their physicians.

RECENT FINDINGS

In a nationwide survey of primary care physicians (PCPs) and cardiologists, only 22% of PCPs and 42% of cardiologists reported being extremely well prepared to assess CVD risk in women. A presidential advisory from the American Heart Association (AHA) and American College of Obstetrics and Gynecologist (ACOG) recommends that cardiologists and obstetricians and gynecologists (Ob/Gyns) collaborate to promote CVD risk identification and reduction throughout a woman's lifetime. We suggest a comprehensive approach to identify unique and traditional risk factors for CVD in women, address the gap in physician knowledge, and improve cardiovascular care for women.

Premature Atherosclerotic Cardiovascular Disease: Trends in Incidence, Risk Factors, and Sex-Related Differences, 2000 to 2016

Background The incidence of atherosclerotic cardiovascular disease has declined in the past 2 decades. However, these benefits may not extend to young patients. The objective of this work was to assess temporal trends in the incidence, risk profiles, sex-related differences, and outcomes in a contemporary population of young patients presenting with coronary artery disease ( CAD ) in British Columbia, Canada. Methods and Results We used a provincial cardiac registry to identify young patients (men aged <50 years, women aged <55 years), with a first presentation of CAD between 2000 and 2016, who had either ≥50% stenosis of ≥1 coronary arteries on angiography or underwent coronary revascularization. A total of 12 519 patients (30% women) met our inclusion criteria. The incidence of CAD remained stable and was higher for men than women (46-53 versus 18-23 per 100 000). Of patients, 92% had at least one traditional cardiovascular risk factor and 67% had multiple risk factors. The prevalence of diabetes mellitus, obesity, and hypertension increased during the study period and was higher for women. Women had fewer emergent procedures and revascularizations. Mortality rates decreased by 31% between 2000 and 2007, then were stable for the remaining 9 years. Mortality was significantly higher for women aged <45 years compared with men. Conclusions The incidence of premature CAD has not declined, and the prevalence of 3 major cardiovascular risk factors increased between 2000 and 2016. The risk burden and mortality rates were worse for women. These data have important implications for the design of strategies to prevent CAD in young adults.

Sex differences in brain activation patterns with mental stress in patients with coronary artery disease

Background

Stress is an important contributor to myocardial ischemia and the progression of coronary artery disease (CAD), and women are more susceptible than men to these effects. Little is known, however, about the neural basis of these sex differences.

Methods

We investigated sex differences in neural correlates of mental stress in a sample of 53 female and 112 male participants (N = 165) with CAD, with and without mental stress-induced myocardial ischemia (MSI), during exposure to mental arithmetic tasks and public speaking stress tasks using high-resolution positron emission tomography (HR-PET) and radiolabeled water imaging of the brain.

Results

Women compared to men had significantly greater activation with stress in the right frontal (BA 9, 44), right parietal lobe (Area 3, 6, 40), right posterior cingulate gyrus (BA 31), bilateral cerebellum, and left temporal/fusiform gyrus (BA 37) and greater deactivation in bilateral anterior cingulate gyrus (BA 24, 32), bilateral medial frontal gyrus (BA 6, 8, 9, 10), right parahippocampal gyrus, and right middle temporal gyrus (BA 21). Women with MSI (but not those without MSI) showed significantly greater activation than men in the right posterior cingulate gyrus (BA 31) and greater deactivation in several frontal and temporal lobe areas.

Conclusion

Men and women with CAD show differences in responses to stress in brain limbic areas that regulate emotion, and these functional responses differ by MSI status. Our results suggest that the cingulate gyrus may be involved in sex differences in MSI.

Electronic supplementary material

The online version of this article (10.1186/s13293-019-0248-4) contains supplementary material, which is available to authorized users.

A Systematic Review and Meta-analysis of the Factors Associated With Nonadherence and Discontinuation of Statins Among People Aged ≥65 Years

Background

Older individuals (aged ≥65 years) are commonly prescribed statins but may experience a range of barriers in adhering to therapy. The factors associated with poor statin adherence and/or discontinuation among this population have not been comprehensively reviewed.

Methods

We conducted a systematic review to identify English articles published through December 12, 2016 that reported factors associated with nonadherence and/or discontinuation of statins among older persons. Data were pooled via random-effects meta-analysis techniques.

Results

Forty-five articles reporting data from more than 1.8 million older statin users from 13 countries were included. The factors associated with increased statin nonadherence were black/non-white race (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.39-1.98), female gender (OR 1.08, 95% CI 1.03-1.13), current smoker (OR 1.12, 95% CI 1.03-1.21), higher copayments (OR 1.38, 95% CI 1.25-1.52), new user (OR 1.58, 95% CI 1.21-2.07), lower number of concurrent cardiovascular medications (OR 1.08, 95% CI 1.06-1.09), primary prevention (OR 1.49, 95% CI 1.40-1.59), having respiratory disorders (OR 1.17, 95% CI 1.12-1.23) or depression (OR 1.11, 95% CI 1.06-1.16), and not having renal disease (OR 1.09, 95% CI 1.04-1.14). The factors associated with increased statin discontinuation were lower income status (OR 1.20, 95% CI 1.06-1.36), current smoker (OR 1.14, 95% CI 1.06-1.23), higher copayment (OR 1.61, 95% CI 1.53-1.70), higher number of medications (OR 1.04, 95% CI 1.01-1.06), presence of dementia (OR 1.18, 95% CI 1.02-1.36), cancer (OR 1.22, 95% CI 1.11-1.33) or respiratory disorders (OR 1.19, 95% CI 1.05-1.34), primary prevention (OR 1.66, 95% CI 1.24-2.22), and not having hypertension (OR 1.13, 95% CI 1.07-1.20) or diabetes (OR 1.09, 95% CI 1.04-1.15).

Conclusion

Interventions that target potentially modifiable factors including financial and social barriers, patients' perceptions about disease risk as well as polypharmacy may improve statin use in the older population.

Particularities of Acute Myocardial Infarction in Young Adults

Coronary heart disease occurs more often in patients over the age of 45. However, recent data shows a growing incidence of coronary events in younger patients also. Young patients with acute myocardial infarction (AMI) represent a relatively small proportion of subjects suffering from an acute ischemic event. However, they represent a subset that is distinguished from elderly patients by a different profile of risk factors, often atypical clinical presentation, and different prognosis. The prevalence of risk factors such as smoking, dyslipidemia, and a family history of coronary events is higher in this group of patients compared to the general population with AMI. Because of an important negative impact on the patients’ psychology, impaired working abilities, and a high socioeconomical burden, myocardial infarction in young patients represents an important cardiovascular pathology. This manuscript aims to present the particularities of AMI occuring at a young age, in comparison with the rest of the population with AMI.

Risk factors for repeat percutaneous coronary intervention in young patients (≤45 years of age) with acute coronary syndrome

Background

The incidences of premature coronary heart disease present a rising trend worldwide. The possible risk factors that may predict the incidence of repeat percutaneous coronary intervention (PCI) in premature acute coronary syndrome (ACS) remains unclear.

Methods

A total of 203 patients ≤45 years with ACS from Chinese PLA General Hospital who have undergone angiography twice were included in this report. Data were collected from medical records of patients during hospitalization. Baseline characteristics which have significant differences in the univariate analysis were enrolled into the multiple logistic regression analysis. According to the odds ratio (OR) of these variables, different values were assigned to build a risk model to predict the possible risk of the premature ACS patients undergoing repeat PCI.

Results

Of the 203 young patients, 88 patients (43.3%) underwent repeat PCI. The intermit time (OR 1.002, (95% CI [1.001–1.002])), diastolic blood pressure of second procedure (OR 0.967, (95% CI [0.938–0.996])), stent diameter (OR 0.352, (95% CI [0.148–0.840])), HbA1C of the first procedure (OR 1.835, (95% CI [1.358–2.479])), and Troponin T of the second procedure (OR 1.24, (95% CI [0.981–1.489])) were significantly associated with the incidence of repeat PCI in patients with premature ACS. An aggregate score between 0 and 6 was calculated based on these cutpoints.

Conclusion

For young patients with premature ACS, risk of undergoing repeat PCI was high. HbA1C was a significant, independent predictor for the incidence of repeat revascularization, and weighed more than traditional lipid profile. The glucose metabolism and disorders in patients with premature ACS should be routinely screened.

Gender/Sex as a Social Determinant of Cardiovascular Risk

The social gradient for cardiovascular disease (CVD) onset and outcomes is well established. The American Heart Association's Social Determinants of Risk and Outcomes of Cardiovascular Disease Scientific Statement advocates looking beyond breakthroughs in biological science toward a social determinants approach that focuses on socioeconomic position, race and ethnicity, social support, culture and access to medical care, and residential environments to curb the burden of CVD going forward. Indeed, the benefits of this approach are likely to be far reaching, enhancing the positive effects of advances in CVD related to prevention and treatment while reducing health inequities that contribute to CVD onset and outcomes. It is disappointing that the role of gender has been largely neglected despite being a critical determinant of cardiovascular health. It is clear that trajectories and outcomes of CVD differ by biological sex, yet the tendency for sex and gender to be conflated has contributed to the idea that both are constant or fixed with little room for intervention. Rather, as distinct from biological sex, gender is socially produced. Overlaid on biological sex, gender is a broad term that shapes and interacts with one's cognition to guide norms, roles, behaviors, and social relations. It is a fluid construct that varies across time, place, and life stage. Gender can interact with biological sex and, indeed, other social determinants, such as ethnicity and socioeconomic position, to shape cardiovascular health from conception, through early life when health behaviors and risk factors are shaped, into adolescence and adulthood. This article will illustrate how gender shapes the early adoption of health behaviors in childhood, adolescence, and young adulthood by focusing on physical activity, drinking, and smoking behaviors (including the influence of role modeling). We will also discuss the role of gender in psychosocial stress with a focus on trauma from life events (childhood assault and intimate partner violence) and work, home, and financial stresses. We conclude by exploring potential biological pathways, with a focus on autonomic functioning, which may underpin gender as a social determinant of cardiovascular health. Finally, we discuss implications for cardiovascular treatment and awareness campaigns and consider whether gender equality strategies could reduce the burden of CVD for men and women at the population level.

Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction: Evidence from the VIRGO Study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients)

BACKGROUND

Some studies report that women are less likely to present with chest pain for acute myocardial infarction (AMI). Information on symptom presentation, perception of symptoms, and care-seeking behaviors is limited for young patients with AMI.

METHODS

We interviewed 2009 women and 976 men aged 18 to 55 years hospitalized for AMI at 103 US hospitals participating in the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients). Structured patient interviews during the index AMI hospitalization were used to collect information on symptom presentation, perception of symptoms, and care-seeking behaviors. We compared patient characteristics and presentation information by sex. Multivariable hierarchical logistic regression was used to evaluate the association between sex and symptom presentation.

RESULTS

The majority of women (87.0%) and men (89.5%) presented with chest pain (defined as pain, pressure, tightness, or discomfort). Women were more likely to present with ≥3 associated symptoms than men (eg, epigastric symptoms, palpitations, and pain or discomfort in the jaw, neck, arms, or between the shoulder blades; 61.9% for women versus 54.8% for men, P<0.001). In adjusted analyses, women with an ST-segment-elevation AMI were more likely than men to present without chest pain (odds ratio, 1.51; 95% confidence interval, 1.03-2.22). In comparison with men, women were more likely to perceive symptoms as stress/anxiety (20.9% versus 11.8%, P<0.001) but less likely to attribute symptoms to muscle pain (15.4% versus 21.2%, P=0.029). Approximately 29.5% of women and 22.1% of men sought medical care for similar symptoms before their hospitalization (P<0.001); however, 53% of women reported that their provider did not think these symptoms were heart-related in comparison with 37% of men (P<0.001).

CONCLUSIONS

The presentation of AMI symptoms was similar for young women and men, with chest pain as the predominant symptom for both sexes. Women presented with a greater number of additional non-chest pain symptoms regardless of the presence of chest pain, and both women and their healthcare providers were less likely to attribute their prodromal symptoms to heart disease in comparison with men.

Cigarette Smoking among Economically Disadvantaged African-American Older Adults in South Los Angeles: Gender Differences

The current study aims to explore gender differences in the risk of cigarette smoking among African-American (AA) older adults who live in economically disadvantaged urban areas of southern Los Angeles. This cross-sectional study enrolled 576 older AA adults (age range between 65 and 96 years) who were residing in Service Planning Area 6 (SPA 6), one of the most economically challenged areas in southern Los Angeles. All participants had cardiometabolic disease (CMD). Data were collected using structured face-to-face interviews. Demographic factors (age and gender), socioeconomic status (educational attainment and financial difficulty), health (number of comorbid medical conditions and depressive symptoms), and health behaviors (current alcohol drinking and current smoking) were measured. Logistic regressions were used to analyze the data without and with interaction terms between gender and current drinking, depressive symptoms, and financial difficulty. AA men reported more smoking than AA women (25.3% versus 9.3%; p < 0.05). Drinking showed a stronger association with smoking for AA men than AA women. Depressive symptoms, however, showed stronger effects on smoking for AA women than AA men. Gender did not interact with financial difficulty with regard to current smoking. As AA older men and women differ in psychological and behavioral determinants of cigarette smoking, gender-specific smoking cessation interventions for AA older adults who live in economically deprived urban areas may be more successful than interventions and programs that do not consider gender differences in determinants of smoking. Gender-tailored smoking cessation programs that address drinking for AA men and depression for AA women may help reduce the burden of smoking in AA older adults in economically disadvantaged urban areas. Given the non-random sampling, there is a need for replication of these findings in future studies.

Factors Affecting Early Mortality and 1-Year Outcomes in Young Women With ST-Segment-Elevation Myocardial Infarction Aged Less Than or Equal to 45 Years

Given that up to 2% of patients with myocardial infarction (MI) are young women, the purpose of this study was to evaluate factors affecting outcomes in young women with ST-segment-elevation myocardial infarction (STEMI) aged less than or equal to 45 years. We evaluated 796 women with STEMI aged less than or equal to 45 years between 2007 and 2014, and mortality was 4.0%. Death occurred more often in women with prehospital sudden cardiac arrest, and severe symptoms of heart failure; less commonly, the women were subjected to percutaneous coronary intervention (PCI), with a higher rate of incomplete revascularization. Beta blockers (BB) and angiotensin converting enzyme inhibitors were frequently used in the survivor group. The independent predictor of 30-day mortality was as follows: inability to undergo PCI (odds ratio [OR] 4.6, 95% confidence interval [CI] 1.45-14.76, P = 0.009), sudden cardiac arrest (OR 4.5, 95% CI 1.5-18.3, P = 0.04). An increase in systolic blood pressure for every 5 mm Hg was associated with lower mortality, OR 0.90, 95% CI 0.76-0.97 in patients without cardiogenic shock (CS) and OR 0.69, 95% CI 0.61-0.78, P < 0.0001 in the group with CS. Predictors for 1-year mortality were the inability to undergo PCI (hazard ratio [HR] 84, 95% CI 1.6-43.1, P = 0.01) and CS (HR 6.97, 95% CI 1.39-34.7, P = 0.01). An increase of 5% in left ventricular ejection fraction reduced the mortality rate for 60% (HR 0.40, 95% CI 0.26-0.63, P < 0.0001) and an increase in systolic blood pressure for every 5 mm Hg reduced mortality for 34% (HR 0.66, 95% CI 0.52-0.84, P = 0.02). Both short- and long-term outcomes in young women aged less than or equal to 45 years with STEMI are good. The strongest predictor for both 30-day and 1-year mortality was the inability to undergo PCI. Suboptimal use of beta blockers and angiotensin converting enzyme inhibitors affect the outcomes in young women. Hypotension in the acute phase of MI increased mortality in young women, independent of coexisting CS.

Acceptance of Online Medical Websites: An Empirical Study in China

As a new type of public health service product, online medical websites (OMWs) are becoming quite popular. OMWs can address patients' basic medical problems remotely and give health guidance online. Compared to traditional hospitals, OMWs are more convenient and inexpensive, they can usually provide a better service for patients with poor medical conditions (especially in rural areas), and they also contribute to the rational distribution of medical resources. Therefore, key factors that affect patients' acceptance of OMWs must be identified to contribute to public health. By integrating perceived risk (PR) and the technology acceptance model (TAM), we proposed a modified TAM and clarified how PR and other factors affect patients' behavioral intention (BI) towards OMWs. A sample of 245 research participants in China took part in this study and the structural equation model (SEM) was used to test our hypotheses. The results revealed that perceived usefulness (PU) is a positive predictor of BI but has no significant effect on attitude (ATT), while perceived ease of use (PEOU) can affect BI through PU and attitude (ATT). Moreover, trust (TRU) was identified as a mediator of PR and PU/PEOU. Also, the doctor⁻patient relationship (DPR) was shown to moderate PR and TRU. In order to increase patients' BI, OMW providers need further innovations to improve patients' TRU and reduce their PR.

Twenty Year Trends and Sex Differences in Young Adults Hospitalized With Acute Myocardial Infarction

BACKGROUND

Sex differences are known to exist in the management of older patients presenting with acute myocardial infarction (AMI). Few studies have examined the incidence and risk factors of AMI among young patients, or whether clinical management differs by sex.

METHODS

The Atherosclerosis Risk in Communities (ARIC) Surveillance study conducts hospital surveillance of AMI in 4 US communities (MD, MN, MS, and NC). AMI was classified by physician review, using a validated algorithm. Medications and procedures were abstracted from the medical record. Our study population was limited to young patients aged 35 to 54 years.

RESULTS

From 1995 to 2014, 28 732 weighted hospitalizations for AMI were sampled among patients aged 35 to 74 years. Of these, 8737 (30%) were young. The annual incidence of AMI hospitalizations increased for young women but decreased for young men. The overall proportion of AMI admissions attributable to young patients steadily increased, from 27% in 1995 to 1999 to 32% in 2010 to 2014 ( P for trend=0.002), with the largest increase observed in young women. History of hypertension (59% to 73%, P for trend<0.0001) and diabetes mellitus (25% to 35%, P for trend<0.0001) also increased among young AMI patients. Compared to young men, young women presenting with AMI were more often black and had a greater comorbidity burden. In adjusted analyses, young women had a lower probability of receiving lipid-lowering therapies (relative risk [RR]=0.87; 95% confidence interval [CI], 0.80-0.94), nonaspirin antiplatelets (RR=0.83; 95% CI, 0.75-0.91), beta blockers (RR=0.96; 95% CI, 0.91-0.99), coronary angiography (RR=0.93; 95% CI, 0.86-0.99) and coronary revascularization (RR = 0.79; 95% CI, 0.71-0.87). However, 1-year all-cause mortality was comparable for women versus men (HR=1.10; 95% CI, 0.83-1.45).

CONCLUSIONS

The proportion of AMI hospitalizations attributable to young patients increased from 1995 to 2014 and was especially pronounced among women. History of hypertension and diabetes among young patients admitted with AMI increased over time as well. Compared with young men, young women presenting with AMI had a lower likelihood of receiving guideline-based AMI therapies. A better understanding of factors underlying these changes is needed to improve care of young patients with AMI.

Age-Specific Sex-Based Differences in Anemia in Patients with Myocardial Infarction

Background: Data are lacking concerning possible age-specific sex-based differences in anemia in myocardial infarction (MI) patients and its association with the outcome. The aim was to assess whether these differences in anemia (on admission and at discharge) in MI patients who underwent percutaneous coronary intervention (PCI) are associated with the outcome. Methods: Data from 5579 MI patients (31.0% women) undergoing PCI at our institution were analyzed. Men and women in different age groups were compared regarding anemia and its association with the 30-day and long-term all-cause mortality. Data were analyzed using descriptive statistics. Results: Women suffered anemia more than men (37.5% vs. 26.8%; p < 0.0001). The prevalence of anemia increased rapidly with age in men but not in women. A J-shaped relationship between age and anemia was found in women. The lower the age, the greater the difference in the prevalence of anemia between the sexes. The difference in the prevalence of anemia at discharge was even more pronounced. Anemia on admission (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.10-1.76; p = 0.005) and at discharge (OR = 2.61; 95% CI = 1.98-3.44; p < 0.0001) predicted a higher 30-day mortality. Women had a better adjusted long-term prognosis (hazard ratio [HR] = 0.78; 95% CI = 0.69-0.87; p < 0.0001) for the total population. Anemia on admission (HR = 1.43; 95% CI = 1.29-1.60; p < 0.0001) and at discharge (HR = 1.96; 95% CI = 1.23-2.21; p < 0.0001) predicted a higher long-term mortality. Conclusion: Younger women with MI suffer anemia more frequently than their male peers. Anemia was associated with a worse outcome. Age-specific sex-based differences in anemia help to explain the increased sex-related mortality in MI patients undergoing PCI.

Hypertension Is an Independent Predictor of Multivessel Coronary Artery Disease in Young Adults with Acute Coronary Syndrome

Background

Risk factors of multivessel coronary artery disease (CAD) among young acute coronary syndrome (ACS) patients remain elusive now.

Methods

This retrospective study analyzed data from 187 consecutive young (age ≤45 years) ACS patients (75 STEMI, 30 NSTEMI, and 72 unstable angina) hospitalized in our hospital from January 2012 to December 2016. Thirty-six young male patients with normal coronary angiography (CAG) findings (no-CAD), who underwent CAG due to suspected chest pain in this period, served as control group. There were 83 patients with single-vessel disease (SVD) and 104 patients with multiple-vessel disease (MVD) among ACS patients. Patients were followed up for a mean of 267±124 days by clinical visit or telephone calls.

Results

All included patients were male. Prevalence of hypertension (57.2% vs. 30.6%, p=0.002) and smoking (70.6% vs. 52.8%, p=0.049) was significantly higher in ACS patients than in no-CAD patients. Prevalence of hypertension (72.1% vs. 38.6%, p<0.001) and body mass index (BMI) were significantly higher in MVD group than in SVD group. Multivariable analysis revealed that hypertension was an independent risk factor for MVD after adjustment for age, gender, BMI, smoking, family history of premature CAD, hyperlipidemia, left ventricular ejection fraction, and brain natriuretic peptide (odds ratio=3.71, 95% confidence interval=1.84-7.46, p<0.001). Rate of major adverse cardiovascular events (MACE) during follow-up (20.2% vs. 4.8%) was significantly higher in MVD group compared with SVD group.

Conclusions

Hypertension is an independent predictor of MVD and MVD is associated with increased MACE rate compared to SVD in young ACS patients during the short-term follow-up.

Stable Ischemic Heart Disease in Women

PURPOSE OF THE REVIEW

Paradoxically, although women have a lower burden of coronary atherosclerosis, they experience more symptoms, more frequent hospitalizations, and a worse prognosis compared to men. This is in part due to biological variations in pathophysiology between the two sexes, and in part related to inadequate understanding of these differences, subconscious referral bias, and suboptimal application of existing women-specific guidelines. We sought to review the contemporary literature and provide an update on risk assessment, diagnosis, and management of IHD in women.

RECENT FINDINGS

IHD in women is often secondary to diffuse non-obstructive atherosclerosis, coronary spasm, inflammation, and endothelial and microvascular dysfunction, and less commonly due to the male pattern of flow-limiting epicardial stenosis. Both IHD patterns likely represent sex-specific manifestations of the same disease process. Additionally, there is a differential expression of risk factors and symptoms between men and women. Application of male-pattern IHD risk factors and presentation to women contributes to under-recognition, under-testing, and under-treatment of IHD in women compared to men. Traditional diagnostic evaluation has focused on detection of epicardial disease, amenable to revascularization. Our improved understanding of sex-specific pathophysiology of IHD has enabled us to also develop tools for detection of microvascular disease. Advances in stress MRI, flow quantification on stress PET, and provocative invasive angiography have filled this void and offer important diagnostic and prognostic information. Despite our improved understanding of sex-specific differences in presentation, risk factors, pathophysiology, diagnostic testing, and management strategies of IHD, women with IHD continue to experience worse outcomes than men. This disparity underscores the need for improved research and understanding of biological sex differences, elimination of subconscious gender bias in referral patterns, and improved application of existing research into clinical practice.

Incidence and mortality of myocardial infarction among Catalonian older adults with and without underlying risk conditions: The CAPAMIS study

BACKGROUND

Population-based data about the epidemiology of acute myocardial infarction is limited. This study investigated incidence and mortality of acute myocardial infarction in older adults with specific underlying chronic conditions and evaluated the influence of these conditions in developing acute myocardial infarction.

DESIGN AND METHODS

This was a population-based cohort study involving 27,204 individuals ≥ 60 years of age in Tarragona (Catalonia, Spain). Data on all cases of hospitalised acute myocardial infarction were collected from 1 December 2008-30 November 2011. Incidence rates and 30-day mortality were estimated according to age, sex, chronic illnesses and underlying conditions. Multivariable Cox regression analysis was used to calculate hazard ratios and to estimate the association between baseline conditions and risk of developing acute myocardial infarction.

RESULTS

The incidence of acute myocardial infarction was 475 per 100,000 person-years. Maximum rates appeared among individuals with history of coronary artery disease (2839 per 100,000), chronic severe nephropathy (1407 per 100,000), atrial fibrillation (1226 per 100,000), chronic heart disease (1149 per 100,000), history of stroke (1147 per 100,000) and diabetes mellitus (914 per 100,000). Thirty-day mortality was 15.3% overall, reaching 31.6% among patients over 80 years. In the multivariable analysis, history of coronary artery disease, age > 70 years, sex male, chronic heart disease, history of stroke, atrial fibrillation, diabetes mellitus and hypertension emerged as significantly associated with an increased risk of acute myocardial infarction.

CONCLUSIONS

The incidence and mortality of acute myocardial infarction remain considerable in our setting. Considering classical major risk factors, diabetes mellitus and hypertension were the underlying conditions most strongly associated with an increased risk in our study population.

Routine blood tests during pregnancy for predicting future increases in risk of cardiovascular morbidity

OBJECTIVE

To examine the association between routine blood tests during pregnancy and future risk of cardiovascular morbidity.

METHODS

The present case-control study was conducted among women who delivered at a teaching hospital in Israel between January 1, 2000, and December 31, 2012. The cohort comprised women who were subsequently hospitalized owing to cardiovascular morbidity (case group) and age-matched non-hospitalized women (control group). Blood levels of creatinine, glucose, potassium, urea, and uric acid were measured during pregnancy. Only women with at least one test result available for all five measurements were included. The relationship between upper quartile blood test values and cardiovascular hospitalization was assessed.

RESULTS

The study included 4115 women (212 in the case group and 3903 in the control group). Three measures were associated with a future risk of cardiovascular morbidity requiring hospitalization: creatinine (hazard ratio [HR] 1.86, 95% confidence interval [CI] 1.37-2.53; P<0.001); potassium (HR 1.48, 95% CI 1.09-2.01; P=0.013), and urea (HR 1.60, 95% CI 1.17-2.19; P=0.003). The number of blood test results in the upper quartile also increased such risk. The HRs for two tests and at least three tests were 1.65 (95% CI 1.06-2.56; P=0.026) and 3.32 (95% CI 2.19-5.04; P<0.001), respectively.

CONCLUSIONS

Future cardiovascular morbidity was predicted by routine blood tests during pregnancy.

Usefulness of Proneurotensin to Predict Cardiovascular and All-Cause Mortality in a United States Population (from the Reasons for Geographic and Racial Differences in Stroke Study)

Cardiovascular disease is a leading cause of death. Proneurotensin is a biomarker associated with the development of cardiovascular disease, cardiovascular mortality, and all-cause mortality. We assessed the association of fasting proneurotensin with mortal events by gender and race (black-white) in a US population. Using a case-cohort subpopulation of the Reasons for Geographic and Racial Differences in Stroke study, fasting proneurotensin was measured on a 1,046-person subcohort and in 651 participants with incident coronary heart disease. Higher proneurotensin was associated with all-cause mortality (hazard ratio [HR] 1.6 per interquartile range, 95% confidence interval [CI] 1.3 to 1.9) and cardiovascular mortality (HR 1.8, 95% CI 1.2 to 2.6). For all-cause and cardiovascular mortality, association was stronger in women (HR 1.9, 95% CI 1.4 to 2.6 and HR 2.5, 95% CI 1.4 to 4.7, respectively) than men (HR 1.4, 95% CI 1.0 to 1.8 and HR 1.4, 95% CI 0.9 to 2.3, respectively), although this difference was not significant. Proneurotensin predicted all-cause mortality in both races and was not predictive of cardiovascular mortality in whites but was in blacks. Proneurotensin was not associated with incident coronary heart disease events. Elevated proneurotensin levels predicted all-cause and cardiovascular mortality in both genders, with a trend toward stronger association in women. Associations were similar in blacks and whites. In conclusion, proneurotensin may be a useful biomarker for all-cause and cardiovascular mortality regardless of race, and it is potentially specific in women.

Mapping the Gaps: Gender Differences in Preventive Cardiovascular Care among Managed Care Members in Four Metropolitan Areas

BACKGROUND

Prior research documents gender gaps in cardiovascular risk management, with women receiving poorer quality routine care on average, even in managed care systems. Although population health management tools and quality improvement efforts have led to better overall care quality and narrowing of racial/ethnic gaps for a variety of measures, we sought to quantify persistent gender gaps in cardiovascular risk management and to assess the performance of routinely used commercial population health management tools in helping systems narrow gender gaps.

METHODS

Using 2013 through 2014 claims and enrollment data from more than 1 million members of a large national health insurance plan, we assessed performance on seven evidence-based quality measures for the management of coronary artery disease and diabetes mellitus, a cardiac risk factor, across and within four metropolitan areas. We used logistic regression to adjust for region, demographics, and risk factors commonly tracked in population health management tools.

FINDINGS

Low-density lipoprotein (LDL) cholesterol control (LDL < 100 mg/dL) rates were 5 and 15 percentage points lower for women than men with diabetes mellitus (p < .0001), and coronary artery disease (p < .0001), respectively. Adjusted analyses showed women were more likely to have gaps in LDL control, with an odds ratio of 1.31 (95% confidence interval, 1.27-1.38) in diabetes mellitus and 1.88 (95% confidence interval, 1.65-2.10) in coronary artery disease.

CONCLUSIONS

Given our findings that gender gaps persist across both clinical and geographic variation, we identified additional steps health plans can take to reduce disparities. For measures where gaps have been consistently identified, we recommend that gender-stratified quality reporting and analysis be used to complement widely used algorithms to identify individuals with unmet needs for referral to population health and wellness behavior support programs.

The design and rationale of SAVE BC: The Study to Avoid CardioVascular Events in British Columbia

Atherosclerotic cardiovascular disease (ASCVD) is highly heritable, particularly when it occurs at a young age. The screening of individuals with premature ASCVD, although often recommended, is not routinely performed. Strategies to address this gap in care are essential. We designed the Study to Avoid CardioVascular Events in British Columbia (SAVE BC) as a prospective, observational study of individuals with a new diagnosis of very premature ASCVD (defined as age ≤ 50 years in males and age ≤ 55 years in females) and their first-degree relatives (FDRs) and spouses. FDRs and spouses will undergo screening for cardiovascular (CV) risk factors and subclinical ASCVD using a structured screening algorithm. All subjects will be followed longitudinally for ≥10 years. The overall goal of SAVE BC is to evaluate the yield of a structured screening program for identifying individuals at risk of premature ASCVD. The primary objectives of SAVE BC are to identify and follow index cases with very premature ASCVD and their FDRs and to determine the diagnostic yield of a structured screening program for these individuals. We will collect data on CV risk factors, medication use, CV events, and healthcare costs in these individuals. SAVE BC will provide insight regarding approaches to identify individuals at risk for premature ASCVD with implications for prevention and treatment in this population.

Are we successfully managing cardiovascular disease in people living with HIV?

PURPOSE OF REVIEW

The aim of this study was to discuss the most recent research in the management of cardiovascular disease (CVD) in people living with HIV (PLWHIV) with a focus on screening, primary and secondary prevention.

RECENT FINDINGS

The cause of CVD in PLWHIV is complex and multifactorial and creates a demand for a multifaceted approach to screening and prevention. Current screening and management of CVD risk factors in PLWHIV is suboptimal, reasons for this are not clear and the data are still scarce both in the primary and secondary preventive setting. There are no optimal routine risk screening tools available to accurately detect early and subclinical disease; PLWHIV are undertreated with preventive drugs such as statins and aspirin and antihypertensives; there are still no programmes that have been shown significantly efficient over time with regards to improved smoking cessation, increased physical activity and optimal diet, and recent reports call for intensified focus on HIV-positive women as a particularly vulnerable subgroup.

SUMMARY

There is a need for further studies investigating barriers to optimal CVD risk factor management in PLWHIV and an increased focus of CVD prevention in HIV-positive women.

Sustained sex-based treatment differences in acute coronary syndrome care: Insights from the American Heart Association Get With The Guidelines Coronary Artery Disease Registry

BACKGROUND

Sex-based differences in acute coronary syndrome (ACS) mortality may attenuate with age due to better symptom recognition and prompt care.

HYPOTHESIS

Age is a modifier of temporal trends in sex-based differences in ACS care.

METHODS

Among 104 817 eligible patients with ACS enrolled in the AHA Get With the Guidelines-Coronary Artery Disease registry between 2003 and 2008, care and in-hospital mortality were evaluated stratified by sex and age. Temporal trends within sex and age groups were assessed for 2 care processes: percentage of STEMI patients presenting to PCI-capable hospitals with a DTB time ≤ 90 minutes (DTB90) and proportion of eligible ACS patients receiving aspirin within 24 hours.

RESULTS

After adjustment for clinical risk factors and sociodemographic and hospital characteristics, 2276 (51.7%) women and 6276 (56.9%) men with STEMI were treated with DTB90 (adjusted OR: 0.85, 95% CI: 0.80-0.91, P < 0.0001 for women vs men). Time trend analysis showed an absolute increase ranging from 24% to 35% in DTB90 rates among both men and women (P for trend <0.0001 for each group), with consistent differences over time across the 4 age/sex groups (3-way P-interaction = 0.93). Despite high rate of baseline aspirin use (87%-91%), there was a 9% to 11% absolute increase in aspirin use over time, also with consistent differences across the 4 age/sex groups (all 3-way P-interaction ≥0.15).

CONCLUSIONS

Substantial gains of generally similar magnitude existed in ACS performance measures over 6 years of study across sex and age groups; areas for improvement remain, particularly among younger women.

Test Selection for Women with Suspected Stable Ischemic Heart Disease

Ischemic heart disease (IHD) is the leading cause of death and disability among women in the United States. Identifying IHD in women presenting with stable symptoms and stratifying their risk for an IHD event can be challenging for providers, with several different tests available. This article is meant to serve as a practical guide for clinicians treating women with potentially ischemic symptoms. Evidence and American Heart Association (AHA) recommendations regarding test selection are reviewed, with a focus on the information to be gained from each test. We outline suggested courses of action to be taken in the case of a positive or negative test. Regardless of the initial test result, clinicians should view a woman's symptom presentation as an opportunity to review and modify her risk of cardiovascular events.

Gender differences in health expenditure determinants: A follow-up study

Researchers' aim was to investigate if patients/physicians characteristics could differently affect males/females health care expenditure. In 2009/2010, a health-related-quality-of-life (HRQL) measure was distributed to 887 general practitioners' (GP) patients in Siena's province-Italy. Severity of diseases was calculated through Cumulative Illness Rating Scale Severity Index (CIRS-SI). Information about GPs' gender and age and patients' gender, age, and socio-economic variables were recorded. 2012 data about pharmaceutical, outpatient and hospital expenditure were obtained. Multivariate regression was carried out. In males, hospital expenditure increased with higher CIRS-SI and female GP whilst in females it was not influenced by any of the variables. Outpatient and pharmaceutical expenditure increased with aging, higher CIRS-SI, and lower HRQL and education, both in males and females. Gender differences in health expenditure determinants emerged for hospital expenditure.

Prevalence and predictors of elevated high-sensitivity C-reactive protein in post-myocardial infarction patients: Insights from the VIRGO and TRIUMPH registries

Elevated high-sensitivity C-reactive protein (hs-CRP) is associated with worse cardiovascular outcomes in patients with acute myocardial infarction (AMI), but little is known about the distribution of hs-CRP levels and predictors of elevated hs-CRP after AMI in the real world. Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) and Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) are prospective AMI registries in the United States that assessed hs-CRP levels 30 days after AMI. TRIUMPH additionally assessed hs-CRP levels at the time of AMI and at 6 months. Hierarchical models were built to examine predictors of elevated hs-CRP (≥2.0 mg/L) at 30 days in both registries and at 6 months after AMI in TRIUMPH. Of 3410 patients in both registries, 58.6% had elevated hs-CRP 30 days after AMI. Patients with elevated hs-CRP at 30 days were more likely to be older, female, obese, smokers, report financial difficulties, and have higher low-density lipoprotein cholesterol levels on admission, diabetes, and hypertension. In TRIUMPH, baseline hs-CRP ≥2 mg/L (n = 1301) was significantly associated with elevated hs-CRP at follow-up (P < 0.001). Similar associations were found in TRIUMPH patients with elevated hs-CRP at 6 months. Our study identified a high prevalence and several patient characteristics associated with elevated hs-CRP at 1 and 6 months after discharge. Further studies to test routine screening after AMI may be warranted to identify higher-risk patients for more aggressive secondary prevention.