Sex differences in risk factors for myocardial infarction: cohort study of UK Biobank participants

Sex differences in primary malignant cardiac tumors: A multi-institutional cohort study from National Cancer Database

INTRODUCTION

Despite the significant clinical importance of sex among factors affecting cancer progression and survival, it remains one of the least studied factors. Therefore, we sought to examine these differences in relation to primary malignant cardiac tumors (PMCTs) using a national data set.

METHODS

The 2004-2017 National Cancer Database was queried for patients with PMCTs. Annual trend of females' percent was assessed. Overall survival predictors were evaluated with Kaplan-Meier and Cox-regression. Subgroup analysis was done based on histology, comorbidity index, race, insurance, and surgical treatment.

RESULTS

PMCTs were identified in 736 patients (median age 52, female [47.8%]). Most of them were high-grade (49.2%). About 60% underwent surgery. Angiosarcoma (43%), fibrosarcoma (5.2%), and leiomyosarcoma (5.2%) were the most common pathologies. Based on multivariate Cox-regression, higher income, higher comorbidity index, angiosarcoma, and Stage III/IV were associated with higher late mortality, while year of diagnosis and use of surgery or chemotherapy were associated with lower mortality. Among the surgical group, age, higher income, higher comorbidity index, angiosarcoma, and Stage III/IV were independent predictors of higher late mortality, while private insurance and year of diagnosis were associated with lower late mortality. No difference was seen between males and females in 30-day and late mortality (p = .71). Subgroup analysis based on Cox-regression showed no differences in late mortality between males and females.

CONCLUSION

PMCTs have poor overall survival. Surgery and chemotherapy were associated with longer survival benefits. On the contrary, the associated risk factors for mortality were advanced age, higher comorbidity index, angiosarcoma histology, and Stage III/IV.

Waiting for JAK inhibitor safety data

The US Food and Drug Administration (FDA) has recently added a new 'black box warning' on all currently approved Janus kinase (JAK) inhibitors indicated for the treatment of arthritis and other inflammatory conditions based on results from the ORAL Surveillance study of tofacitinib versus tumour necrosis factor alpha inhibitors in rheumatoid arthritis. This is a warning difficult to ignore because the data, being from a randomised controlled trial, are of high fidelity and hard to reproach. It is especially problematic because safety data for all the other JAK inhibitors will be pending for several years. So how might we proceed, without being bound by our stasis? The lack of absolute certainty seems to require a pragmatic approach to the routine care use of JAK inhibitors. The patients who were at greatest risk were older and had other risk factors for the corresponding adverse events, in keeping with effect modification. This highlights the need to focus on risk stratification when tailoring therapy. In this viewpoint, we propose a simple illustration to guide clinical decision-making. First, identify general risk factors for venous thromboembolic event (VTE), major adverse cardiac event (MACE) and cancer (age>65 years and smoking) and whether there is a previous history of VTE, MACE or cancer. Then, evaluate risk based on the number of other risk factors for VTE and the number of other risk factors for MACE. Ultimately, 'treat-to-target' will in the end always be 'treat-to-agreement'. As we have done in the past, and will do in the future, the optimal treatment strategy will have to be tailored based on individual patient risk factors and preferences in a shared-decision process.

The Association of Smoking with Hospitalization and Mortality Differs According to Sex in Patients with Heart Failure Following Myocardial Infarction

Background: Smoking has been associated with higher morbidity and mortality following myocardial infarction (MI), but reports of the impact on morbidity and mortality for females and elderly patients experiencing MI complicated with left ventricular dysfunction or overt heart failure are limited. Materials and Methods: In an individual patient data meta-analysis of high-risk MI patients, the association of smoking with hospitalizations and death were investigated. Weighted Cox proportional hazard modeling were used to study the risks of smoking on adjudicated endpoints among different sex and age categories. Results: Twenty-eight thousand seven hundred thirty-five patients from the CAPRICORN, EPHESUS, OPTIMAAL, and VALIANT trials were assessed. After weighting, smokers (N = 18,148) were unfrequently women (29.2%) and a minority were above ≥80 years (9.8%). Smoking was significantly more associated with all-cause hospitalizations in women (hazard ratio [HR] 1.24; 95% confidence interval [95% CI] 1.16-1.32) than in men (HR = 1.10; 95% CI 1.05-1.16) resulting in a significant interaction between smoking and sex (p = 0.005). Smoking was predictive of all-cause mortality homogenously across age categories (p for interaction = 0.25) and sex (p for interaction = 0.58). Conclusions: The influence of smoking on morbidity differed according to sex following high-risk MI. The deleterious impact of smoking on hospitalization appeared particularly potent in women, which should further reinforce preventive strategies in females.

Sex-specific associations of adiposity with cardiometabolic traits in the UK: A multi-life stage cohort study with repeat metabolomics

BACKGROUND

Sex differences in cardiometabolic disease risk are commonly observed across the life course but are poorly understood and may be due to different associations of adiposity with cardiometabolic risk in females and males. We examined whether adiposity is differently associated with cardiometabolic trait levels in females and males at 3 different life stages.

METHODS AND FINDINGS

Data were from 2 generations (offspring, Generation 1 [G1] born in 1991/1992 and their parents, Generation 0 [G0]) of a United Kingdom population-based birth cohort study, the Avon Longitudinal Study of Parents and Children (ALSPAC). Follow-up continues on the cohort; data up to 25 y after recruitment to the study are included in this analysis. Body mass index (BMI) and total fat mass from dual-energy X-ray absorptiometry (DXA) were measured at mean age 9 y, 15 y, and 18 y in G1. Waist circumference was measured at 9 y and 15 y in G1. Concentrations of 148 cardiometabolic traits quantified using nuclear magnetic resonance spectroscopy were measured at 15 y, 18 y, and 25 y in G1. In G0, all 3 adiposity measures and the same 148 traits were available at 50 y. Using linear regression models, sex-specific associations of adiposity measures at each time point (9 y, 15 y, and 18 y) with cardiometabolic traits 3 to 6 y later were examined in G1. In G0, sex-specific associations of adiposity measures and cardiometabolic traits were examined cross-sectionally at 50 y. A total of 3,081 G1 and 4,887 G0 participants contributed to analyses. BMI was more strongly associated with key atherogenic traits in males compared with females at younger ages (15 y to 25 y), and associations were more similar between the sexes or stronger in females at 50 y, particularly for apolipoprotein B-containing lipoprotein particles and lipid concentrations. For example, a 1 standard deviation (SD) (3.8 kg/m2) higher BMI at 18 y was associated with 0.36 SD (95% confidence interval [CI] = 0.20, 0.52) higher concentrations of extremely large very-low-density lipoprotein (VLDL) particles at 25 y in males compared with 0.15 SD (95% CI = 0.09, 0.21) in females, P value for sex difference = 0.02. By contrast, at 50 y, a 1 SD (4.8 kg/m2) higher BMI was associated with 0.33 SD (95% CI = 0.25, 0.42) and 0.30 SD (95% CI = 0.26, 0.33) higher concentrations of extremely large VLDL particles in males and females, respectively, P value for sex difference = 0.42. Sex-specific associations of DXA-measured fat mass and waist circumference with cardiometabolic traits were similar to findings for BMI and cardiometabolic traits at each age. The main limitation of this work is its observational nature, and replication in independent cohorts using methods that can infer causality is required.

CONCLUSIONS

The results of this study suggest that associations of adiposity with adverse cardiometabolic risk begin earlier in the life course among males compared with females and are stronger until midlife, particularly for key atherogenic lipids. Adolescent and young adult males may therefore be high priority targets for obesity prevention efforts.

Does Gender Influence the Effectiveness and Safety of Insulin Glargine 300 U/ml in Patients with Uncontrolled Type 2 Diabetes? Results from the REALI European Pooled Analysis

INTRODUCTION

Gender differences in risk factors and treatment outcomes for type 2 diabetes mellitus (T2DM) may exist. We used the REALI European database to investigate whether there were gender-specific differences in baseline characteristics and clinical outcomes among patients with inadequately controlled T2DM initiated on insulin glargine 300 U/ml (Gla-300).

METHODS

Data were pooled from 14 multicentre, prospective, interventional and non-interventional studies. Impact of gender on glycaemic control, insulin dose, body weight and hypoglycaemia was evaluated after 12 and 24 weeks of Gla-300 treatment.

RESULTS

Women (N = 3857) were older than men (N = 4376) (median age, 65.0 versus 63.0 years), with greater mean body mass index (32.5 versus 31.6 kg/m²) and lower median estimated glomerular filtration rate (77.5 versus 84.0 ml/min/1.73 m²). Peripheral arterial disease and a history of myocardial infarction were more frequent in men (20.1% versus 11.7% and 12.0% versus 5.8%, respectively). At baseline, mean haemoglobin A1c (HbA1c) was 8.74% in men and 8.79% in women. Least square (LS) mean (95% CI) reduction in HbA1c from baseline to week 24 was - 1.17% (- 1.21 to - 1.13) in men and - 1.07% (- 1.11 to - 1.02) in women, resulting in a LS mean difference of - 0.10% (- 0.15 to - 0.05; p < 0.0001). At 24 weeks, 21.6% of women and 27.2% of men achieved target HbA1c of < 7.0% (p < 0.001; chi-square). Reported incidence for symptomatic (8.5% versus 8.7%) and severe (0.3% versus 0.5%) any-time-of-the-day or symptomatic (2.4% versus 1.8%) and severe (0.1% versus 0.2%) nocturnal hypoglycaemia was overall low and comparable between men and women. Changes in daily Gla-300 dose and body weight were also similar.

CONCLUSION

Despite some gender differences in baseline characteristics, Gla-300 treatment improved glycaemic control, with overall low hypoglycaemia incidences in both men and women. However, women had statistically significantly lower HbA1c reductions than men, although these differences were clinically modest.

TrpNet: Understanding Tryptophan Metabolism across Gut Microbiome

Crosstalk between the gut microbiome and the host plays an important role in animal development and health. Small compounds are key mediators in this host–gut microbiome dialogue. For instance, tryptophan metabolites, generated by biotransformation of tryptophan through complex host–microbiome co-metabolism can trigger immune, metabolic, and neuronal effects at local and distant sites. However, the origin of tryptophan metabolites and the underlying tryptophan metabolic pathway(s) are not well characterized in the current literature. A large number of the microbial contributors of tryptophan metabolism remain unknown, and there is a growing interest in predicting tryptophan metabolites for a given microbiome. Here, we introduce TrpNet, a comprehensive database and analytics platform dedicated to tryptophan metabolism within the context of host (human and mouse) and gut microbiome interactions. TrpNet contains data on tryptophan metabolism involving 130 reactions, 108 metabolites and 91 enzymes across 1246 human gut bacterial species and 88 mouse gut bacterial species. Users can browse, search, and highlight the tryptophan metabolic pathway, as well as predict tryptophan metabolites on the basis of a given taxonomy profile using a Bayesian logistic regression model. We validated our approach using two gut microbiome metabolomics studies and demonstrated that TrpNet was able to better predict alterations in in indole derivatives compared to other established methods.

Selection of 51 predictors from 13,782 candidate multimodal features using machine learning improves coronary artery disease prediction

Current cardiovascular risk assessment tools use a small number of predictors. Here, we study how machine learning might: (1) enable principled selection from a large multimodal set of candidate variables and (2) improve prediction of incident coronary artery disease (CAD) events. An elastic net-based Cox model (ML4HEN-COX) trained and evaluated in 173,274 UK Biobank participants selected 51 predictors from 13,782 candidates. Beyond most traditional risk factors, ML4HEN-COX selected a polygenic score, waist circumference, socioeconomic deprivation, and several hematologic indices. A more than 30-fold gradient in 10-year risk estimates was noted across ML4HEN-COX quintiles, ranging from 0.25% to 7.8%. ML4HEN-COX improved discrimination of incident CAD (C-statistic = 0.796) compared with the Framingham risk score, pooled cohort equations, and QRISK3 (range 0.754-0.761). This approach to variable selection and model assessment is readily generalizable to a broad range of complex datasets and disease endpoints.

Sex Differences in Cumulative Exposure to Metabolic Risk Factors Before Hypertension Onset: The Cohort of the Tehran Lipid and Glucose Study

Background

Previous studies have shown a sex difference in the association between hypertension and cardiovascular disease; however, the precise mechanism remains unclear. Because there are strong associations between metabolic risk factors (MRFs) and hypertension, a sex‐specific analysis of MRFs before hypertension onset could offer new insights and expand our understanding of sex differences in cardiovascular disease. We evaluated cumulative exposure to major MRFs and rate of change of those factors, including body mass index, waist circumference, systolic blood pressure, diastolic blood pressure, fasting plasma glucose, total cholesterol, triglycerides, and high‐density lipoprotein cholesterol among individuals who did and did not develop hypertension at follow‐up.

Methods and Results

We included 5374 participants (2191 men) initially without hypertension with age range of 20–50 years at baseline who participated in the Tehran Lipid and Glucose Study, and had been examined at least 3 times during the study period (1999–2018). In both sexes, the cumulative exposure to all MRFs (except for fasting plasma glucose and high‐density lipoprotein cholesterol in men) were higher in those who developed hypertension, compared with those who did not develop hypertension. However, women experienced greater cumulative exposure to major MRFs, compared with their male counterparts. Also, they experienced a faster increase in waist circumference, systolic blood pressure, diastolic blood pressure, and high‐density lipoprotein cholesterol than men. Furthermore, rapid increase in systolic blood pressure began earlier in women than men, at the age of 30 years. We also found that those men who developed hypertension experienced unfavorable change in major MRFs during young adulthood (<50 years of age).

Conclusions

Women exhibited more metabolic disturbances than men before onset of hypertension, which may explain the stronger impact of hypertension for major types of cardiovascular disease in women, compared with men.

Guidelines for in vivo mouse models of myocardial infarction

Despite significant improvements in reperfusion strategies, acute coronary syndromes all too often culminate in a myocardial infarction (MI). The consequent MI can, in turn, lead to remodeling of the left ventricle (LV), the development of LV dysfunction, and ultimately progression to heart failure (HF). Accordingly, an improved understanding of the underlying mechanisms of MI remodeling and progression to HF is necessary. One common approach to examine MI pathology is with murine models that recapitulate components of the clinical context of acute coronary syndrome and subsequent MI. We evaluated the different approaches used to produce MI in mouse models and identified opportunities to consolidate methods, recognizing that reperfused and nonreperfused MI yield different responses. The overall goal in compiling this consensus statement is to unify best practices regarding mouse MI models to improve interpretation and allow comparative examination across studies and laboratories. These guidelines will help to establish rigor and reproducibility and provide increased potential for clinical translation.

Trends of Sex Differences in Clinical Outcomes After Myocardial Infarction in the United States

BACKGROUND

Female patients have been shown to experience worse clinical outcomes after acute myocardial infarction (AMI) compared with male patients. However, it is unclear what trend these differences followed over time.

METHODS

Data from patients hospitalized with AMI between 2004 and 2015 in the National Inpatient Sample were retrospectively analyzed, stratified according to sex. Multivariable logistic regression analyses were performed to examine the adjusted odds ratios (aORs) of invasive management and in-hospital outcomes according to sex. The Mantel-Haenszel extension of the χ2 test was performed to examine the trend of management and in-hospital outcomes over the study period.

RESULTS

Of 7,026,432 AMI hospitalizations, 39.7% (n = 2,789,494) were women. Overall, women were older (median: 77 vs 70 years), with a higher prevalence of risk factors such as diabetes, hypertension, and depression. Women were less likely to receive coronary angiography (aOR, 0.92; 95% confidence interval [CI], 0.91-0.93) and percutaneous coronary intervention (aOR, 0.82; 95% CI, 0.81-0.83) compared with men. Odds of all-cause mortality were higher in women (aOR, 1.03; 95% CI, 1.02-1.04; P < 0.001) and these rates have not narrowed over time (2004 vs 2015: aOR, 1.07 [95% CI, 1.04-1.09] vs 1.11 [95% CI, 1.07-1.15), with similar observations recorded for major adverse cardiovascular and cerebrovascular events.

CONCLUSIONS

In this temporal analysis of AMI hospitalizations over 12 years, we showed lower receipt of invasive therapies and higher mortality rates in women, with no change in temporal trends. There needs to be a systematic and consistent effort toward exploring these disparities to identify strategies to mitigate them.

Are sex disparities in COVID-19 a predictable outcome of failing men's health provision?

The COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus, has taken a catastrophic toll on society, health-care systems and the economy. Notably, COVID-19 has been shown to be associated with a higher mortality rate in men than in women. This disparity is likely to be a consequence of a failure to invest in men’s health, as it has also been established that men have a lower life expectancy and poorer outcomes from non-communicable diseases than women. A variety of biological, social and economic factors have contributed to the sex disparities in mortality from COVID-19. A streamlined men’s health programme — with the urologist as the gatekeeper of men’s health — is needed to help prevent future tragedies of this nature.

COVID-19 has been shown to be associated with a higher mortality rate in men than in women. In this Perspectives article, the authors posit that this disparity is due to a failure to invest in men’s health and discuss the biological, social and economic factors that have contributed to the sex disparities in mortality from COVID-19, as well as considering how a streamlined men’s health programme with the urologist in a central role could address these issues.

Hypertension in Women: Should There be a Sex-specific Threshold?

Conventionally, hypertension is defined by the same blood pressure (BP) threshold (systolic BP ≥140 and/or diastolic BP ≥90 mmHg) in both women and men. Several studies have documented that women with hypertension are more prone to develop BP-associated organ damage and that high BP is a stronger risk factor for cardiovascular disease (CVD) in women than men. While healthy young women have lower BP than men, a steeper increase in BP is found in women from the third decade of life. Studies have documented that the BP-attributable risk for acute coronary syndromes (ACS), heart failure and AF increases at a lower level of BP in women than in men. Even high normal BP (130–139/80–89 mmHg) is associated with an up to twofold higher risk of ACS during midlife in women, but not in men. Whether sex-specific thresholds for definition of hypertension would improve CVD risk detection should be considered in future guidelines for hypertension management and CVD prevention.

Social deprivation as a risk factor for COVID-19 mortality among women and men in the UK Biobank: nature of risk and context suggests that social interventions are essential to mitigate the effects of future pandemics

OBJECTIVES

To investigate sex differences in the effects of social deprivation on COVID-19 mortality and to place these effects in context with other diseases.

DESIGN

Prospective population-based study.

SETTING

UK Biobank.

PARTICIPANTS

501 865 participants (54% women).

MAIN OUTCOME MEASURE

COVID-19 as the underlying cause of death.

RESULTS

Of 472 946 participants alive when COVID-19 was first apparent in the UK (taken as 1 February 2020), 217 (34% women) died from COVID-19 over the next 10 months, resulting in an incidence, per 100 000 person years, of 100.65 (95% CI 79.47 to 121.84) for women and 228.59 (95% CI 194.88 to 262.30) for men. Greater social deprivation, quantified using the Townsend Deprivation Score, was associated with greater risk of fatal COVD-19. Adjusted for age and ethnicity, HRs for women and men, comparing those in the most with the least deprived national fifths, were 3.66 (2.82 to 4.75) for women and 3.00 (2.46 to 3.66) for men. Adjustments for key baseline lifestyle factors attenuated these HRs to 2.20 (1.63 to 2.96) and 2.62 (2.12 to 3.24), respectively. There was evidence of a log-linear trend in the deprivation-fatal COVID-19 association, of similar magnitude to the equivalent trends for the associations between deprivation and fatal influenza or pneumonia and fatal cardiovascular disease. For all three causes of death, there was no evidence of a sex difference in the associations.

CONCLUSIONS

Higher social deprivation is a risk factor for death from COVID-19 on a continuous scale, with two to three times the risk in the most disadvantaged 20% compared with the least. Similarities between the social gradients in COVID-19, influenza/pneumonia and cardiovascular disease mortality, the lack of sex differences in these effects, and the partial mediation of lifestyle factors suggest that better social policies are crucial to alleviate the general medical burden, including from the current, and potential future, viral pandemics.

Sex-related differences in ventricular remodeling after myocardial infarction

The epidemiology, clinical features and outcome of myocardial infarction (MI) display significant differences between men and women. Prominent sex differences have also been suggested in left ventricular (LV) remodeling after MI. Ventricular remodeling refers to a deterioration of LV geometry and function often leading to heart failure (HF) development and an increased risk of adverse cardiovascular events. Women have a lower propensity to the acquisition of a spherical geometry and LV dysfunction. These differences can be attributed at least partially to a lower frequency of transmural infarction and smaller areas of microvascular obstruction in women, as well as to a less prominent activation of neuroendocrine systems and apoptotic, inflammatory and profibrotic pathways in women. Estrogens might play a role in this difference, which could partially persist even after the menopause because of a persisting intramyocardial synthesis of estrogens in women. Conversely, androgens may exert a detrimental influence. Future studies should better clarify sex differences in the predictors, clinical correlates, prognostic impact and disease mechanisms of remodeling, as well as the existence of sex-specific therapeutic targets. This research effort should hopefully allow to optimize the treatment of MI during the acute and post-acute phase, possibly through different therapeutic strategies in men and women, with the goal of reducing the risk of HF development and improving patient outcome.

Smoking and sex differences in first manifestation of cardiovascular disease

BACKGROUND AND AIMS

An increasing proportion of women believe that smoking few cigarettes daily substantially reduces their risk of developing cardiovascular (CV) related disorders. The effect of low intensity smoking is still largely understudied. We investigated the relation among sex, age, cigarette smoking and ST segment elevation myocardial infarction (STEMI) as initial manifestation of CV disease.

METHODS

We analyzed data of 50,713 acute coronary syndrome patients with no prior manifestation of CV disease from the ISACS-Archives (NCT04008173) registry. We compared the rates of STEMI in current smokers (n = 11,530) versus nonsmokers (n = 39,183).

RESULTS

In the young middle age group (<60 years), there was evidence of a more harmful effect in women compared with men (RR ratios: 1.90; 95% CI: 1.69-2.14 versus 1.68; 95% CI: 1.56-1.80). This association persisted even in women who smoked 1 to 10 packs per year (RR ratios: 2.02; 95% CI: 1.65 to 2.48 versus 1.38; 95% CI: 1.22 to 1.57). In the older group, rates of STEMI were similar for women and men (RR ratios: 1.36; 95% CI: 1.22-1.53 versus 1.39; 95% CI: 1.28-1.50). STEMI was associated with a twofold higher 30-day mortality rate in young middle age women compared with men of the same age (odds ratios, 5.54; 95% CI, 3.83-8.03 vs. 2.93; 95% CI, 2.33-3.69).

CONCLUSIONS

Low intensity smoking provides inadequate protection in young - middle age women as they still have a substantially higher rate of STEMI and related mortality compared with men even smoking less than 10 packs per year. This finding is worrying as more young - middle age women are smoking, and rates of smoking among young-middle age men continue to fall.

Gender Differences in Diabetic Kidney Disease: Focus on Hormonal, Genetic and Clinical Factors

Diabetic kidney disease (DKD) is one of the most serious complications of both type 1 (T1DM) and type 2 diabetes mellitus (T2DM). Current guidelines recommend a personalized approach in order to reduce the burden of DM and its complications. Recognizing sex and gender- differences in medicine is considered one of the first steps toward personalized medicine, but the gender issue in DM has been scarcely explored so far. Gender differences have been reported in the incidence and the prevalence of DKD, in its phenotypes and clinical manifestations, as well as in several risk factors, with a different impact in the two genders. Hormonal factors, especially estrogen loss, play a significant role in explaining these differences. Additionally, the impact of sex chromosomes as well as the influence of gene-sex interactions with several susceptibility genes for DKD have been investigated. In spite of the increasing evidence that sex and gender should be included in the evaluation of DKD, several open issues remain uncovered, including the potentially different effects of newly recommended drugs, such as SGLT2i and GLP1Ras. This narrative review explored current evidence on sex/gender differences in DKD, taking into account hormonal, genetic and clinical factors.

Sex differences in the association between major cardiovascular risk factors in midlife and dementia: a cohort study using data from the UK Biobank

BACKGROUND

Sex differences in major cardiovascular risk factors for incident (fatal or non-fatal) all-cause dementia were assessed in the UK Biobank. The effects of these risk factors on all-cause dementia were explored by age and socioeconomic status (SES).

METHODS

Cox proportional hazards models were used to estimate hazard ratios (HRs) and women-to-men ratio of HRs (RHR) with 95% confidence intervals (CIs) for systolic blood pressure (SBP) and diastolic blood pressure (DBP), smoking, diabetes, adiposity, stroke, SES and lipids with dementia. Poisson regression was used to estimate the sex-specific incidence rate of dementia for these risk factors.

RESULTS

502,226 individuals in midlife (54.4% women, mean age 56.5 years) with no prevalent dementia were included in the analyses. Over 11.8 years (median), 4068 participants (45.9% women) developed dementia. The crude incidence rates were 5.88 [95% CI 5.62-6.16] for women and 8.42 [8.07-8.78] for men, per 10,000 person-years. Sex was associated with the risk of dementia, where the risk was lower in women than men (HR = 0.83 [0.77-0.89]). Current smoking, diabetes, high adiposity, prior stroke and low SES were associated with a greater risk of dementia, similarly in women and men. The relationship between blood pressure (BP) and dementia was U-shaped in men but had a dose-response relationship in women: the HR for SBP per 20 mmHg was 1.08 [1.02-1.13] in women and 0.98 [0.93-1.03] in men. This sex difference was not affected by the use of antihypertensive medication at baseline. The sex difference in the effect of raised BP was consistent for dementia subtypes (vascular dementia and Alzheimer's disease).

CONCLUSIONS

Several mid-life cardiovascular risk factors were associated with dementia similarly in women and men, but not raised BP. Future bespoke BP-lowering trials are necessary to understand its role in restricting cognitive decline and to clarify any sex difference.

Are there sex differences in the effect of type 2 diabetes in the incidence and outcomes of myocardial infarction? A matched-pair analysis using hospital discharge data

BACKGROUND

To analyze incidence, use of therapeutic procedures, and in-hospital outcomes in patients with ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) according to the presence of type 2 diabetes (T2DM) in Spain (2016-2018) and to investigate sex differences.

METHODS

Using the Spanish National Hospital Discharge Database, we estimated the incidence of myocardial infarctions (MI) in men and women with and without T2DM aged ≥ 40 years. We analyzed comorbidity, procedures, and outcomes. We matched each man and woman with T2DM with a non-T2DM man and woman of identical age, MI code, and year of hospitalization. Propensity score matching was used to compare men and women with T2DM.

RESULTS

MI was coded in 109,759 men and 44,589 women (30.47% with T2DM). The adjusted incidence of STEMI (IRR 2.32; 95% CI 2.28-2.36) and NSTEMI (IRR 2.91; 95% CI 2.88-2.94) was higher in T2DM than non-T2DM patients, with higher IRRs for NSTEMI in both sexes. The incidence of STEMI and NSTEMI was higher in men with T2DM than in women with T2DM. After matching, percutaneous coronary intervention (PCI) was less frequent among T2DM men than non-T2DM men who had STEMI and NSTEMI. Women with T2DM and STEMI less frequently had a code for PCI that matched that of non-T2DM women. In-hospital mortality (IHM) was higher among T2DM women with STEMI and NSTEMI than in matched non-T2DM women. In men, IHM was higher only for NSTEMI. Propensity score matching showed higher use of PCI and coronary artery bypass graft and lower IHM among men with T2DM than women with T2DM for both STEMI and NSTEMI.

CONCLUSIONS

T2DM is associated with a higher incidence of STEMI and NSTEMI in both sexes. Men with T2DM had higher incidence rates of STEMI and NSTEMI than women with T2DM. Having T2DM increased the risk of IHM after STEMI and NSTEMI among women and among men only for NSTEMI. PCI appears to be less frequently used in T2DM patients After STEMI and NSTEMI, women with T2DM less frequently undergo revascularization procedures and have a higher mortality risk than T2DM men.

Cardiovascular Safety Profile of Romosozumab: A Pharmacovigilance Analysis of the US Food and Drug Administration Adverse Event Reporting System (FAERS)

Background: Cardiovascular safety concerns for major cardiovascular events (MACE) were raised during the clinical trials of romosozumab. We aimed to evaluate the cardiovascular safety profile of romosozumab in a large pharmacovigilance database. Methods: All cases reported between January 2019 and December 2020 where romosozumab was reported were extracted from the Food and Drug Administration Adverse Event Reporting System (FAERS). The outcome of interest was MACE (myocardial infarction (MI), stroke, or cardiovascular death). A disproportionality analysis was conducted by estimating the reporting odds ratios (RORs) and 95% confidence intervals. Disproportionality analyses were stratified by sex and reporting region (US, Japan, other). Results: Of the 1995 eligible cases with romosozumab, the majority (N = 1188; 59.5%) originated from Japan. Overall, 206 suspected MACE reports were identified, of which the majority (n = 164; 13.8%) were from Japan, and 41 (5.2%) were from the United States (US). Among Japanese reports, patients were older and more frequently male than reports from the US. Similarly, cases with a reported MACE were older and had higher reports of cardioprotective drugs than those without cardiovascular events. Elevated reports for MACE (ROR 4.07, 95% CI: 2.39–6.93) was identified overall, which was primarily driven by the significant disproportionality measures in the Japanese reports. Conclusions: The current pharmacovigilance study identified a potential signal for elevated MACE, particularly in Japan. The results support the current safety warnings from the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) to avoid use in high-risk patients.

Sex Disparities in Cardiovascular Risk Factor Assessment and Screening for Diabetes-Related Complications in Individuals With Diabetes: A Systematic Review

Background

Insight in sex disparities in the detection of cardiovascular risk factors and diabetes-related complications may improve diabetes care. The aim of this systematic review is to study whether sex disparities exist in the assessment of cardiovascular risk factors and screening for diabetes-related complications.

Methods

PubMed was systematically searched up to April 2020, followed by manual reference screening and citations checks (snowballing) using Google Scholar. Observational studies were included if they reported on the assessment of cardiovascular risk factors (HbA1c, lipids, blood pressure, smoking status, or BMI) and/or screening for nephropathy, retinopathy, or performance of feet examinations, in men and women with diabetes separately. Studies adjusting their analyses for at least age, or when age was considered as a covariable but left out from the final analyses for various reasons (i.e. backward selection), were included for qualitative analyses. No meta-analyses were planned because substantial heterogeneity between studies was expected. A modified Newcastle-Ottawa Quality Assessment Scale for cohort studies was used to assess risk of bias.

Results

Overall, 81 studies were included. The majority of the included studies were from Europe or North America (84%).The number of individuals per study ranged from 200 to 3,135,019 and data were extracted from various data sources in a variety of settings. Screening rates varied considerably across studies. For example, screening rates for retinopathy ranged from 13% to 90%, with half the studies reporting screening rates less than 50%. Mixed findings were found regarding the presence, magnitude, and direction of sex disparities with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, with some evidence suggesting that women, compared with men, may be more likely to receive retinopathy screening and less likely to receive foot exams.

Conclusion

Overall, no consistent pattern favoring men or women was found with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, and screening rates can be improved for both sexes.

Stage 1 hypertension by the 2017 American College of Cardiology/American Heart Association hypertension guidelines and risk of cardiovascular disease events: systematic review, meta-analysis, and estimation of population etiologic fraction of prospective cohort studies

BACKGROUND

Epidemiological studies reported an inconsistent association between stage 1 hypertension (SBP 130-139 mmHg or DBP 80-89 mmHg) defined by the 2017 American College of Cardiology/American Heart Association hypertension guidelines and cardiovascular disease (CVD) events. In addition, the proportion of CVD events that could be prevented with effective control of stage 1 hypertension is unknown.

OBJECTIVES

To assess the association between stage 1 hypertension and CVD events and estimate the population etiologic fraction.

METHODS

PubMed, Embase, and Web of Science databases were searched from 1 January 2017 to 22 September 2019. Normal BP was considered SBP less than 120 mmHg and DBP less than 80 mmHg. Hazard ratios and 95% confidence intervals (95% CIs) were pooled by using a random-effects model.

RESULTS

We included 11 articles (16 studies including 3 212 447 participants and 65 945 events) in the analysis. Risk of CVD events was increased with stage 1 hypertension versus normal BP (hazard ratio 1.38, 95% CI 1.28-1.49). On subgroup analyses, stage 1 hypertension was associated with coronary heart disease (CHD) (hazard ratio 1.30, 95% CI 1.20-1.41), stroke (1.39, 1.27-1.52), CVD morbidity (1.42, 1.32-1.53), and CVD mortality (1.34, 1.05-1.71). The population etiologic fraction for the association of CVD events, CHD, stroke, CVD morbidity, and CVD mortality with stage 1 hypertension was 12.90, 10.48, 12.71, 14.03, and 11.69%, respectively.

CONCLUSION

Stage 1 hypertension is associated with CVD events, CVD morbidity, CVD mortality, CHD, and stroke. Effective control of stage 1 hypertension could prevent more than 10% of CVD events.

The effectiveness of planned discharge education on health knowledge and beliefs in patients with acute myocardial infarction: a randomized controlled trial

BACKGROUND

To the best of our knowledge, no other studies investigated acute myocardial infarction patients' beliefs and knowledge level after the discharge education.

AIMS

The aim of the study was to investigate the effectiveness of planned discharge education on the beliefs and knowledge levels of CVD risk factors, medication compliance, dietary compliance, and individual follow-up in patients with acute myocardial infarction (AMI).

METHODS

A double-blind randomized controlled study was carried out with 100 AMI patients. All participants were randomly assigned to the intervention (n = 50) and control groups (n = 50). The first evaluation of all participants in both groups was on the day of discharge. Both groups were re-evaluated after 4 weeks. Patients' beliefs on medication, diet, and individual monitoring were assessed by the Beliefs about Medication Compliance Scale (BMCS), the Beliefs about Dietary Compliance Scale (BDCS), and the Beliefs about Individual Follow-up Scale (BIFS), respectively. The knowledge of CVD risk factors was questioned with the Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) Scale.

RESULTS

The mean age of the patients was 59.10 ± 9.38 years in the intervention group and 58.86 ± 9.19 in the control group. After the planned discharge education, beliefs and knowledge levels of CVD risk factors, medication compliance, dietary compliance, and individual follow-up were significantly increased compared with the control group.

CONCLUSION

Planned discharge education had a positive effect on the knowledge level of cardiovascular diseases risk factors, drug compliance, nutritional compliance, and individual follow-up in patients with acute myocardial infarction.

Characterisation, identification, clustering, and classification of disease

The importance of quantifying the distribution and determinants of multimorbidity has prompted novel data-driven classifications of disease. Applications have included improved statistical power and refined prognoses for a range of respiratory, infectious, autoimmune, and neurological diseases, with studies using molecular information, age of disease incidence, and sequences of disease onset ("disease trajectories") to classify disease clusters. Here we consider whether easily measured risk factors such as height and BMI can effectively characterise diseases in UK Biobank data, combining established statistical methods in new but rigorous ways to provide clinically relevant comparisons and clusters of disease. Over 400 common diseases were selected for analysis using clinical and epidemiological criteria, and conventional proportional hazards models were used to estimate associations with 12 established risk factors. Several diseases had strongly sex-dependent associations of disease risk with BMI. Importantly, a large proportion of diseases affecting both sexes could be identified by their risk factors, and equivalent diseases tended to cluster adjacently. These included 10 diseases presently classified as "Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified". Many clusters are associated with a shared, known pathogenesis, others suggest likely but presently unconfirmed causes. The specificity of associations and shared pathogenesis of many clustered diseases provide a new perspective on the interactions between biological pathways, risk factors, and patterns of disease such as multimorbidity.

Sex specificities of medical and social parameters in patients with coronary artery disease with different severity of depression

Aim. To determine the sex specificities of medical and social parameters in patients hospitalized due to coronary artery disease (CAD), class II, III, IV angina, aged 35-60 years and assess the significance of their relationship with different levels of depression.

Material and methods. The study involved 312 patients aged 35-60 with documented CAD, class II, III, IV angina. Two comparison groups were identified: group I — 138 patients (men, 81; women, 57) with CAD and without depression (mean age, 47,8±4,6 years); group II — 174 patients (men, 60; women, 105) with CAD and depression (mean age, 48,3±5,3 years). Medical and social data, the severity of depression and distress tolerance, psychological status and quality of life was assessed. Statistical analysis was carried out, which are presented as the mean and standard error of the mean (M±m). The odds ratio (OR) and 95% confidence interval (CI) were calculated. Differences were considered significant at p<0,05.

Results. The prevalence of depression among patients with CAD was 55,77%, while women were 1,5 times more likely to suffer it than men. Depression was significantly associated with hyperglycemia, hypercholesterolemia, and class III-IV angina, regardless of sex. Class III and IV angina prevailed in women, while class II angina — in men (OR, 2,16; 95% CI, 1,37-3,41, p<0,001)). Women were more prone to degree II-III disability (group II, 26,67%; group I 8,77%; p=0,008), compared with men (group II, 27,54%; group I, 11,11%; p=0,012). Sedentary lifestyle was also associated to a greater extent with the female sex than with the male (OR, 2,89, 95% CI, 1,46-5,70, p=0,003; OR, 2,31, 95% CI, 1,19-4,48; p=0,014, respectively). Both men and women showed a significant association of depression with atherosclerosis (p<0,001), however, sex differences did not reach significance. Indicators such as lack of job and higher education, as well as smoking and arrhythmias were characteristic of both sexes, but had a greater impact on the mental condition of men (p=0,002, p<0,001, p=0,0014 and p=0,01, respectively). For men, the relationship of depression with diabetes (8,7 vs 0%; p=0,008), obesity (42,03 vs 19,75%; p=0,004), subordinate status (82,61 vs 64,2%; p=0,016) and unmarried status (60,87 vs 40,74%; p=0,02).

Conclusion. There are significant differences in factors contributing to depression in different sex groups. The association of depression with CAD has an adverse effect on the physical and psychological health of both males and females. At the same time, women are more prone to mental disorders than men. It is necessary to further study the sex characteristics of medical and social parameters in order to personalize treatment methods.

The Population-Attributable Fraction for Premature Mortality Due to Cardiovascular Disease Associated With Stage 1 and 2 Hypertension Among Japanese

BACKGROUND

Our aim was to assess how the population-attributable fraction (PAF) for premature mortality due to cardiovascular disease (CVD) associated with hypertension changes if blood pressure (BP) thresholds for hypertension were lowered from systolic/diastolic BP ≥140/90 mm Hg to ≥130/80 mm Hg, as defined using the 2017 American College of Cardiology/American Heart Association blood pressure guideline.

METHODS

Analyses were conducted using a database of participants who underwent a national health checkup examination started in 2008 in Japan (n = 510,238; mean age, 59.6 ± 8.1 years; 42% men). Each participant was categorized as having normal or elevated BP, or stage 1 or 2 hypertension according to the guideline. Data on premature mortality due to CVD occurring before age 70 years were available through March 2015.

RESULTS

Over a median follow-up of 3.4 years, 739 deaths from CVD occurred. After multivariable adjustment, hazard ratios for premature CVD mortality for elevated BP, stage 1 hypertension, and stage 2 hypertension vs. normal BP were 1.02 (95% confidence interval, 0.72, 1.44), 1.33 (1.02, 1.75), and 2.41 (1.90, 3.05), respectively. The PAF associated with stage 1 and 2 hypertension was 4.4% and 39.4%, respectively.

CONCLUSIONS

In the current nationwide study of Japanese adults, stage 1 and 2 hypertension were associated with an increased risk for premature CVD mortality. The PAF for premature CVD mortality associated with hypertension increased by 4.4% if BP thresholds for hypertension were lowered from systolic/diastolic BP ≥140/90 to ≥130/80 mm Hg.

The Importance of Gender to Understand Sex Differences in Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. There is robust evidence of heterogeneity in underlying mechanism, manifestation, prognosis, and response to treatment of CVD between male and female patients. Gender, which refers to the socially constructed roles, behaviours, expressions, and identities of individuals, is an important determinant of CV health, and its consideration might help in attaining a broader understanding of the observed sex differences in CVD. Established risk factors such as hypertension, dyslipidemia, diabetes mellitus, obesity, and smoking are well known to contribute to CVD. However, despite the differences in CVD risk between male and female, most studies looking into the magnitude of effect of each risk factor have traditionally focused on male subjects. While biological sex influences disease pathophysiology, the psycho-socio-cultural construct of gender can further interact with this effect. Behavioural, psychosocial, personal, cultural, and societal factors can create, repress, or strengthen underlying biological CV health differences. Although mechanisms of action are largely unclear, it is suggested that gender-related factors can further exacerbate the detrimental effect of established risk factors of CVD. In this narrative review, we explore the current literature investigating the role of gender in CV risk and its impact on established risk factors as a fundamental step toward precision medicine.

Isolated systolic and diastolic hypertension by the 2017 American College of Cardiology/American Heart Association guidelines and risk of cardiovascular disease: a large prospective cohort study

OBJECTIVE

The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guidelines lowered the hypertension threshold from a SBP/DBP level of at least 140/90 mmHg to at least 130/80 mmHg. The cardiovascular impact of isolated systolic hypertension (ISH) and isolated diastolic hypertension (IDH) under the new definition remains unclear.

METHODS

We used data from the UK Biobank study, which is a prospective population-based cohort study. Participants were categorized into five groups: normal BP, normal high BP, ISH, IDH and systolic and diastolic hypertension. The primary endpoint for this study was the composite of nonfatal myocardial infarction (MI), nonfatal ischaemic stroke, nonfatal haemorrhagic stroke and cardiovascular disease (CVD) death. We also explored the results for the above-mentioned CVD outcomes separately. Baseline BP measurements were obtained twice after the participant had been at rest for at least 5 min in a seated position.

RESULTS

We included 385 955 participants who were not taking antihypertensive medications, were free of CVD at baseline and had available data on BP measurements. During a median follow-up of 8.1 years, 8959 CVD events were recorded, including 4729 nonfatal MIs, 2287 nonfatal ischaemic strokes, 813 nonfatal haemorrhagic strokes, and 1826 CVD deaths. According to the hypertension threshold of at least 130/80 mmHg by the American College of Cardiology/American Heart Association guidelines, both ISH (hazard ratio 1.39; 95% confidence interval 1.27, 1.15) and IDH (hazard ratio 1.28; 95% confidence interval 1.15, 1.43) were significantly associated with a higher overall CVD risk than normal BP. ISH was associated with most CVD risk, except for ischaemic stroke, while the excess CVD risk associated with IDH appeared to be driven mainly by MI and CVD death. We found heterogeneity by sex and age regarding the effects of IDH on overall CVD risk, with significant associations in younger adults (age <60 years) and women and null associations in men and older adults (age ≥60 years).

CONCLUSION

ISH was associated with the risk of most CVD events, while the association between IDH and CVD risk was mainly driven by MI incidence and CVD death. Further research is needed to identify participants with IDH who have a particular risk for developing CVD.

Age-Stratified Sex-Related Differences in the Incidence, Management, and Outcomes of Acute Myocardial Infarction

OBJECTIVE

To assess the impact of female sex on the incidence, management, and outcomes of myocardial infarction (MI) in different age groups.

METHODS

Patients admitted with ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI), between January 1, 2003, and December 31, 2015, were identified in the National Inpatient Sample. We compared STEMI and NSTEMI rates, management patterns, and in-hospital morbidity and mortality in men and women stratified into 4 age groups (<45, 45 to 64, 65 to 84, and ≥85 years of age).

RESULTS

A total of 6,720,639 weighted hospitalizations for MI (79.8% NSTEMI, and 20.2% STEMI) were included. The incidence rate of hospitalizations for MI was lower in women than men across all age groups. Women were less likely than men to undergo coronary angiography, revascularization, or to use circulatory-support devices. These differences were consistent across all age groups. Adjusted odds of death for women (vs men) varied by age: odds ratio (95% confidence interval) 1.08 (0.97 to 1.20), 1.05 (1.02 to 1.08), 0.92 (0.91 to 0.94), and 0.86 (0.85 to 0.88) for NSTEMI, and 1.15 (1.04 to 1.27), 1.22 (1.18 to 1.26), 1.09 (1.06 to 1.11), and 0.97 (0.94 to 0.99), for STEMI, in age groups (<45, 45 to 64, 65 to 84, and ≥85), respectively. The magnitude of differences in complications between men and women was higher in younger and middle-age patients.

CONCLUSION

Compared with men, women have lower incidence of MI and less likelihood of undergoing invasive treatment regardless of age. However, post-MI outcomes are age specific. The negative impact of female sex on most outcomes was most pronounced in young and middle-aged women.

Sex Differences in the Risk of Coronary Heart Disease Associated With Type 2 Diabetes: A Mendelian Randomization Analysis

OBJECTIVE

Observational studies have demonstrated that type 2 diabetes is a stronger risk factor for coronary heart disease (CHD) in women compared with men. However, it is not clear whether this reflects a sex differential in the causal effect of diabetes on CHD risk or results from sex-specific residual confounding.

RESEARCH DESIGN AND METHODS

Using 270 single nucleotide polymorphisms (SNPs) for type 2 diabetes identified in a type 2 diabetes genome-wide association study, we performed a sex-stratified Mendelian randomization (MR) study of type 2 diabetes and CHD using individual participant data in UK Biobank (251,420 women and 212,049 men). Weighted median, MR-Egger, MR-pleiotropy residual sum and outlier, and radial MR from summary-level analyses were used for pleiotropy assessment.

RESULTS

MR analyses showed that genetic risk of type 2 diabetes increased the odds of CHD for women (odds ratio 1.13 [95% CI 1.08-1.18] per 1-log unit increase in odds of type 2 diabetes) and men (1.21 [1.17-1.26] per 1-log unit increase in odds of type 2 diabetes). Sensitivity analyses showed some evidence of directional pleiotropy; however, results were similar after correction for outlier SNPs.

CONCLUSIONS

This MR analysis supports a causal effect of genetic liability to type 2 diabetes on risk of CHD that is not stronger for women than men. Assuming a lack of bias, these findings suggest that the prevention and management of type 2 diabetes for CHD risk reduction is of equal priority in both sexes.

Sex and ethnic differences in the cardiovascular complications of type 2 diabetes

Diabetes mellitus represents a global health concern affecting 463 million adults and is projected to rapidly rise to 700 million people by 2045. Amongst those with type 2 diabetes (T2D), there are recognised differences in the impact of the disease on different sex and ethnic groups. The relative risk of cardiovascular complications between individuals with and without T2D is higher in females than males. People of South Asian heritage are two to four times more likely to develop T2D than white people, but conversely not more likely to experience cardiovascular complications. Differences in the pathophysiological responses in these groups may identify potential areas for intervention beyond glycaemic control. In this review, we highlight key differences of diabetes-associated cardiovascular complications by sex and ethnic background, with a particular emphasis on South Asians. Evidence assessing therapeutic efficacy of new glucose lowering drugs in minority groups is limited and many major cardiovascular outcomes trials do not report ethnic specific data. Conversely, lifestyle intervention and bariatric surgery appear to have similar benefits regardless of sex and ethnic groups. We encourage future studies with better representation of women and ethnic minorities that will provide valuable data to allow better risk stratification and tailored prevention and management strategies to improve cardiovascular outcomes in T2D.

Nonalcoholic steatohepatitis: the role of peroxisome proliferator-activated receptors

The increasing epidemic of obesity worldwide is linked to serious health effects, including increased prevalence of type 2 diabetes mellitus, cardiovascular disease and nonalcoholic fatty liver disease (NAFLD). NAFLD is the liver manifestation of the metabolic syndrome and includes the spectrum of liver steatosis (known as nonalcoholic fatty liver) and steatohepatitis (known as nonalcoholic steatohepatitis), which can evolve into progressive liver fibrosis and eventually cause cirrhosis. Although NAFLD is becoming the number one cause of chronic liver diseases, it is part of a systemic disease that affects many other parts of the body, including adipose tissue, pancreatic β-cells and the cardiovascular system. The pathomechanism of NAFLD is multifactorial across a spectrum of metabolic derangements and changes in the host microbiome that trigger low-grade inflammation in the liver and other organs. Peroxisome proliferator-activated receptors (PPARs) are a group of nuclear regulatory factors that provide fine tuning for key elements of glucose and fat metabolism and regulate inflammatory cell activation and fibrotic processes. This Review summarizes and discusses the current literature on NAFLD as the liver manifestation of the systemic metabolic syndrome and focuses on the role of PPARs in the pathomechanisms as well as in the potential targeting of disease.

Differential association of metabolic syndrome and low-density lipoprotein cholesterol with incident cardiovascular disease according to sex among Koreans: a national population-based study

AIMS

To investigate sex differences in the association of metabolic syndrome (MetS) and/or low-density lipoprotein cholesterol (LDL-C) with the incidence of cardiovascular and cerebrovascular disease (CCVD).

METHODS AND RESULTS

A total of 4 702 458 individuals, aged between 40 and 70, without a previous diagnosis of CCVD, underwent at least two health screenings between 2009 and 2011. Of them, 4 193 878 individuals (48.6% women) fulfilled the study requirements. The main outcome measured was the incidence of CCVD. By the end of 2017, 68 921 CCVD events occurred. Men in high LDL-C only, MetS only, and both MetS and high LDL-C groups had higher risks of CCVD. Women in MetS only and both MetS and high LDL-C groups, but not those in high LDL-C only group, had higher risks of CCVD than those in the reference group. The effect of the interaction between the presence of MetS and high LDL-C levels on the primary outcome was found among women (P for interaction 0.016) but not among men (P for interaction 0.897). A combination of MetS and LDL-C > 3.4 mmol/L increased the risk of CCVD as compared to MetS or LDL-C > 3.4 mmol/L alone in both men and women.

CONCLUSIONS

Metabolic syndrome confers an increased risk of CCVD irrespective of sexes; LDL-C > 3.4 mmol/L alone has a greater influence on CCVD occurrence in men than in women. Metabolic syndrome and high LDL-C beget a synergistically detrimental impact on the incidence of CCVD in both men and women. Treatment of dyslipidaemia and metabolic syndrome should be tailored according to patient characteristics.

Sex and gender differences in anesthesia: Relevant also for perioperative safety?

Sex (a biological determination) and gender (a social construct) are not interchangeable terms and both impact perioperative management and patient safety. Sex and gender differences in clinical phenotypes of chronic illnesses and risk factors for perioperative morbidity and mortality are relevant for preoperative evaluation and optimization. Sex-related differences in physiology, as well as in pharmacokinetics and pharmacodynamics of anesthetic drugs may influence the anesthesia plan, the management of pain, postoperative recovery, adverse effects, patient satisfaction, and outcomes. Further studies are needed to characterize outcome differences between men and women in non-cardiac, cardiac, and transplantation surgery in order to individualize perioperative management and improve patient safety. Transgender patients represent a vulnerable population who need special perioperative care. Gender balance increases team performance and may improve perioperative outcomes.

Assessing cardiovascular disease risk factor screening inequalities in India using Lot Quality Assurance Sampling

Background

Cardiovascular diseases (CVDs) are the leading cause of mortality in India. India has rolled out Comprehensive Primary Health Care (CPHC) reforms including population based screening for hypertension and diabetes, facilitated by frontline health workers. Our study assessed blood pressure and blood sugar coverage achieved by frontline workers using Lot Quality Assurance Sampling (LQAS).

Methods

LQAS Supervision Areas were defined as catchments covered by frontline workers in primary health centres in two districts each of Uttar Pradesh and Delhi. In each Area, 19 households for each of four sampling universes (males, females, Above Poverty Line (APL) and Below Poverty Line (BPL)) were visited using probability proportional to size sampling. Following written informed consent procedures, a short questionnaire was administered to individuals aged 30 or older using tablets related to screening for diabetes and hypertension. Using the LQAS hand tally method, coverage across Supervision Areas was determined.

Results

A sample of 2052 individuals was surveyed, median ages ranging from 42 to 45 years. Caste affiliation, education levels, and occupation varied by location; the sample was largely married and Hindu. Awareness of and interaction with frontline health workers was reported in Uttar Pradesh and mixed in Delhi. Greater coverage of CVD risk factor screening (especially blood pressure) was seen among females, as compared to males. No clear pattern of inequality was seen by poverty status; some SAs did not have adequate BPL samples. Overall, blood pressure and blood sugar screening coverage by frontline health workers fell short of targeted coverage levels at the aggregate level, but in all sites, at least one area was crossing this threshold level.

Conclusion

CVD screening coverage levels at this early stage are low. More emphasis may be needed on reaching males. Sex and poverty related inequalities must be addressed by more closely studying the local context and models of service delivery where the threshold of screening is being met. LQAS is a pragmatic method for measuring program inequalities, in resource-constrained settings, although possibly not for spatially segregated population sub-groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05914-y.

Contemplating on the Etiology of COVID-19 Severity and Mortality Sex Differences

COVID-19 displays a sex-biased behavior with a higher rate of intensity and mortality in men. In that sense, COVID-19 deflects-off the typical trend of many viral infections which are characterized by a higher rate of intensity and prevalence in males, yet a higher female mortality rate. Severity and mortality rates of COVID-19 are associated with several underlying diseases, which exhibit significant self-sufficient male-biased dimorphism, thus are at times hypothesized to be the ones responsible to tilt mortality balance toward higher men death in COVID-19. Yet, similar comorbidities prevail in other viral infections, raising curiosity to what makes COVID-19 unique? The answer may lay in the involvement of renin-angiotensin system and ACE2 receptor in COVID-19 progression, 2 players which are significant contributors to the fatality of COVID-19. A structured difference is evident in the expression and function of RAS and ACE2 between the sexes, presumably tipping over mortality rate tendency toward male-risk factor.

Age and Sex Influence Mitochondria and Cardiac Health in Offspring Exposed to Maternal Glucolipotoxicity

Infants of diabetic mothers are at risk of cardiomyopathy at birth and myocardial infarction in adulthood, but prevention is hindered because mechanisms remain unknown. We previously showed that maternal glucolipotoxicity increases the risk of cardiomyopathy and mortality in newborn rats through fuel-mediated mitochondrial dysfunction. Here we demonstrate ongoing cardiometabolic consequences by cross-fostering and following echocardiography, cardiomyocyte bioenergetics, mitochondria-mediated turnover, and cell death following metabolic stress in aged adults. Like humans, cardiac function improves by weaning with no apparent differences in early adulthood but declines again in aged diabetes-exposed offspring. This is preceded by impaired oxidative phosphorylation, exaggerated age-related increase in mitochondrial number, and higher oxygen consumption. Prenatally exposed male cardiomyocytes have more mitolysosomes indicating high baseline turnover; when exposed to metabolic stress, mitophagy cannot increase and cardiomyocytes have faster mitochondrial membrane potential loss and mitochondria-mediated cell death. Details highlight age- and sex-specific roles of mitochondria in developmentally programmed adult heart disease.

•

Fetal exposures disrupt mitochondria, bioenergetics, & cardiac function at birth

•

First, bioenergetics & function improve until greater reliance on OXPHOS with age

•

At 6MO, poor respiration incites biogenesis & mitophagy, and then functional decline

•

Fetal exposures cause faster mitochondria-mediated cell death in aged adult hearts

Women's health in The BMJ: a data science history

OBJECTIVE

To determine how the representation of women's health has changed in clinical studies over the course of 70 years.

DESIGN

Observational study of 71 866 research articles published between 1948 and 2018 in The BMJ.

MAIN OUTCOME MEASURES

The incidence of women-specific health topics over time. General linear, additive and segmented regression models were used to estimate trends.

RESULTS

Over 70 years, the overall odds that a word in a BMJ research article was 'woman' or 'women' increased by an annual factor of 1.023, but this rate of increase varied by clinical specialty with some showing little or no change. The odds that an article was about some aspect of women-specific health increased much more slowly, by an annual factor of 1.004. The incidence of articles about particular areas of women-specific medicine such as pregnancy did not show a general increase, but rather fluctuated over time. The incidence of articles making any mention of women, gender or sex declined between 1948 and 2005, after which it rose steeply so that by 2018 few papers made no mention of them at all.

CONCLUSIONS

Over time women have become ever more prominent in BMJ research articles. However, the importance of women-specific health topics has waxed and waned as researchers responded ephemerally to medical advances, public health programmes, and sociolegal changes. The appointment of a woman editor-inchief in 2005 may have had a dramatic effect on whether women were mentioned in research articles.

Sex differences in the association between major risk factors and the risk of stroke in the UK Biobank cohort study

Objective

To determine whether there are sex differences in the association between risk factors and incident stroke, including stroke subtypes.

Methods

A total of 471,971 (56% women) UK Biobank participants without a history of cardiovascular disease were included. During 9 years of follow-up, 4,662 (44% women) cases of stroke were recorded. Cox models yielded adjusted hazard ratios (HRs) and women-to-men ratios of HRs (RHRs) for stroke associated with 7 risk factors.

Results

The incidence rate per 10,000 person-years was 8.66 (8.29–9.04) in women and 13.96 (13.44–14.50) in men for any stroke, 6.06 (5.75–6.38) in women and 11.35 (10.88; 11.84) in men for ischemic stroke, and 1.56 (1.41–1.73) in women and 2.23 (2.02–2.45) in men for hemorrhagic stroke. The association between increases in blood pressure, body anthropometry, and lipids, diabetes, and atrial fibrillation and any stroke was similar between men and women. Hypertension, smoking, and a low socioeconomic status were associated with a greater HR of any stroke in women than men; the RHRs were 1.36 (1.26–1.47), 1.18 (1.02–1.36), and 1.17 (1.03–1.33), respectively. Diabetes was associated with a higher HR of ischemic stroke in women than men (RHR 1.25 [1.00–1.56]). Atrial fibrillation was associated with a higher HR of hemorrhagic stroke in women than men (RHR 2.80 [1.07–7.36]).

Conclusion

Several risk factors are more strongly associated with the risk of any stroke or stroke subtypes in women compared with men. Despite this, the incidence of stroke remains higher among men than women.

Sex-specific associations between cardiovascular risk factors and myocardial infarction in patients with type 2 diabetes: The ADVANCE-ON study

AIM

To examine possible sex differences in the excess risk of myocardial infarction (MI) consequent to a range of conventional risk factors in a large-scale international cohort of patients with diabetes, and to quantify these potential differences both on the relative and absolute scales.

MATERIALS AND METHODS

Eleven thousand and sixty-five participants (42% women) with type 2 diabetes in the ADVANCE trial and its post-trial follow-up study, ADVANCE-ON, were included. Cox regression models were used to estimate hazard ratios (HRs) for associations between risk factors and MI (fatal and non-fatal) by sex, and the women-to-men ratio of HRs (RHR).

RESULTS

Over a median of 9.6 years of follow-up, 719 patients experienced MI. Smoking status, smoking intensity, higher systolic blood pressure (SBP), HbA1c, total and LDL cholesterol, duration of diabetes, triglycerides, body mass index (BMI) and lower HDL cholesterol were associated with an increased risk of MI in both sexes. Furthermore, some variables were associated with a greater relative risk of MI in women than men: RHRs were 1.75 (95% CI: 1.05-2.91) for current smoking, 1.53 (1.00-2.32) for former smoking, 1.18 (1.02-1.37) for SBP, and 1.13 (95% CI, 1.003-1.26) for duration of diabetes. Although incidence rates of MI were higher in men (9.3 per 1000 person-years) compared with women (5.8 per 1000 person-years), rate differences associated with risk factors were greater in women than men, except for HDL cholesterol and BMI.

CONCLUSIONS

In patients with type 2 diabetes, smoking, higher SBP and longer duration of diabetes had a greater relative and absolute effect in women than men, highlighting the importance of routine sex-specific approaches and early interventions in women with diabetes.

Trends in Recurrent Coronary Heart Disease After Myocardial Infarction Among US Women and Men Between 2008 and 2017

BACKGROUND

Rates for recurrent coronary heart disease (CHD) events have declined in the United States. However, few studies have assessed whether this decline has been similar among women and men.

METHODS

Data were used from 770 408 US women and 700 477 US men <65 years of age with commercial health insurance through MarketScan and ≥66 years of age with government health insurance through Medicare who had a myocardial infarction (MI) hospitalization between 2008 and 2017. Women and men were followed up for recurrent MI, recurrent CHD events (ie, recurrent MI or coronary revascularization), heart failure hospitalization, and all-cause mortality (Medicare only) in the 365 days after MI.

RESULTS

From 2008 to 2017, age-standardized recurrent MI rates per 1000 person-years decreased from 89.2 to 72.3 in women and from 94.2 to 81.3 in men (multivariable-adjusted P interaction by sex <0.001). Recurrent CHD event rates decreased from 166.3 to 133.3 in women and from 198.1 to 176.8 in men (P interaction <0.001). Heart failure hospitalization rates decreased from 177.4 to 158.1 in women and from 162.9 to 156.1 in men (P interaction=0.001). All-cause mortality rates decreased from 403.2 to 389.5 in women and from 436.1 to 417.9 in men (P interaction=0.82). In 2017, the multivariable-adjusted rate ratios comparing women with men were 0.90 (95% CI, 0.86-0.93) for recurrent MI, 0.80 (95% CI, 0.78-0.82) for recurrent CHD events, 0.99 (95% CI, 0.96-1.01) for heart failure hospitalization, and 0.82 (95% CI, 0.80-0.83) for all-cause mortality.

CONCLUSIONS

Rates of recurrent MI, recurrent CHD events, heart failure hospitalization, and mortality in the first year after an MI declined considerably between 2008 and 2017 in both men and women, with proportionally greater reductions for women than men. However, rates remain very high, and rates of recurrent MI, recurrent CHD events, and death continue to be higher among men than women.

Gender Differences in Residual Risk Factors for Major Adverse Cardiovascular Events Following ACS and How to Bridge the Gap

PURPOSE OF REVIEW

The review aims to describe the differences between men and women in those factors that can influence a worse prognosis in women after an acute cardiovascular event.

RECENT FINDINGS

Women adequately treated with current evidence-based medications for acute myocardial infarction and for conventional cardiovascular risk factors, such as hypertension, diabetes, smoking, and dyslipidemia, still have an extra risk of death compared with men. Additional factors that increase the risk of poor prognosis for the index event have been identified. The residual risk can be due to factors affecting the prognosis of the women from outside (they are external to the patient's body) and also to factors that, on the contrary, belong to the female body (female being/female sex). The review will give an update on those residual risk factors, including young age, vulnerability for de novo heart failure, time from symptom onset to treatment, heath care delivered during the weekend, and depression, which generally negatively influence the outcome of women with an acute myocardial infarction.

Sex differences in the association between childhood maltreatment and cardiovascular disease in the UK Biobank

OBJECTIVES

To assess and compare associations between childhood maltreatment and cardiovascular disease (CVD) in men and women in the UK. In secondary analyses, we also explored possible age differences and associations with early onset CVD (<50 years).

METHODS

We included 157 311 participants from the UK Biobank who had information on physical, sexual or emotional abuse, emotional or physical neglect. CVD outcomes were defined as any CVD, hypertensive disease, ischaemic heart disease (IHD) and cerebrovascular disease. These were extracted from self-report, blood pressure measurements, hospital register and death register. The associations between maltreatment and CVD were assessed using Poisson regression with robust variance to estimate risk ratios, stratified by sex and adjusted for socioeconomic and demographic factors.

RESULTS

All types of maltreatment were associated with increased risk of CVD and IHD in both sexes. Additionally, in women all types of maltreatment were associated with higher risk of hypertensive disease, and all, except emotional neglect, were associated with cerebrovascular disease. In men, all but sexual abuse, were associated with higher risk of hypertensive disease, and all, except physical and sexual abuse, were associated with cerebrovascular disease. Associations were generally stronger in women, and individuals who were younger at baseline had stronger associations of childhood maltreatment with any CVD and IHD, but age differences were less evident when only early onset CVD was considered.

CONCLUSIONS

Childhood maltreatment was consistently associated with CVD and stronger associations were generally observed in women and seemed to be stronger for early onset CVD.

Diabetes, Glycated Hemoglobin, and the Risk of Myocardial Infarction in Women and Men: A Prospective Cohort Study of the UK Biobank

OBJECTIVE

Diabetes has shown to be a stronger risk factor for myocardial infarction (MI) in women than men. Whether sex differences exist across the glycemic spectrum is unknown. We investigated sex differences in the associations of diabetes status and glycated hemoglobin (HbA1c) with the risk of MI.

RESEARCH DESIGN AND METHODS

Data were used from 471,399 (56% women) individuals without cardiovascular disease (CVD) included in the UK Biobank. Sex-specific incidence rates were calculated by diabetes status and across levels of HbA1c using Poisson regression. Cox proportional hazards analyses estimated sex-specific hazard ratios (HRs) and women-to-men ratios by diabetes status and HbA1c for MI during a mean follow-up of 9 years.

RESULTS

Women had lower incidence rates of MI than men, regardless of diabetes status or HbA1c level. Compared with individuals without diabetes, prediabetes, undiagnosed diabetes, and previously diagnosed diabetes were associated with an increased risk of MI in both sexes. Previously diagnosed diabetes was more strongly associated with MI in women (HR 2.33 [95% CI 1.96; 2.78]) than men (1.81 [1.63; 2.02]), with a women-to-men ratio of HRs of 1.29 (1.05; 1.58). Each 1% higher HbA1c, independent of diabetes status, was associated with an 18% greater risk of MI in both women and men.

CONCLUSIONS

Although the incidence of MI was higher in men than women, the presence of diabetes is associated with a greater excess relative risk of MI in women. However, each 1% higher HbA1c was associated with an 18% greater risk of MI in both women and men.

Sex Disparities in Myocardial Infarction: Biology or Bias?

Women have generally worse outcomes after myocardial infarction (MI) compared to men. The reasons for these disparities are multifactorial. At the beginning is the notion-widespread in the community and health care providers-that women are at low risk for MI. This can impact on primary prevention of cardiovascular disease in women, with lower use of preventative therapies and lifestyle counselling. It can also lead to delays in presentation in the event of an acute MI, both at the patient and health care provider level. This is of particular concern in the case of ST elevation MI (STEMI), where "time is muscle". Even after first medical contact, women with acute MI experience delays to diagnosis with less timely reperfusion and percutaneous coronary intervention (PCI). Compared to men, women are less likely to undergo invasive diagnostic testing or PCI. After being diagnosed with a STEMI, women receive less guideline-directed medical therapy and potent antiplatelets than men. The consequences of these discrepancies are significant-with higher mortality, major cardiovascular events and bleeding after MI in women compared to men. We review the sex disparities in pathophysiology, risk factors, presentation, diagnosis, treatment, and outcomes for acute MI, to answer the question: are they due to biology or bias, or both?

Sex and gender: modifiers of health, disease, and medicine

Clinicians can encounter sex and gender disparities in diagnostic and therapeutic responses. These disparities are noted in epidemiology, pathophysiology, clinical manifestations, disease progression, and response to treatment. This Review discusses the fundamental influences of sex and gender as modifiers of the major causes of death and morbidity. We articulate how the genetic, epigenetic, and hormonal influences of biological sex influence physiology and disease, and how the social constructs of gender affect the behaviour of the community, clinicians, and patients in the health-care system and interact with pathobiology. We aim to guide clinicians and researchers to consider sex and gender in their approach to diagnosis, prevention, and treatment of diseases as a necessary and fundamental step towards precision medicine, which will benefit men's and women's health.