Twelve-year follow-up of American women's awareness of cardiovascular disease risk and barriers to heart health

Relation of serum uric acid to severity and progression of coronary artery calcium in postmenopausal White and Filipino women (from the Rancho Bernardo study)

Elevated serum uric acid (UA) is associated with cardiovascular disease (CVD) but its association with coronary artery calcium (CAC) is inconsistent. This study examined ethnic differences in the association of UA levels with CAC severity and progression. Participants included 202 white and 166 Filipino postmenopausal women without known CVD. White women originated from the Rancho Bernardo cohort study, whereas Filipino women were convenience sampled from comparable localities. Baseline UA levels and CVD risk factors were measured in 1995 to 1999. CAC was assessed by electron beam computed tomography (EBCT) in 2000 to 2002 (EBCT1) and repeated in 2005 to 2007 (EBCT2). EBCT1 CAC density scores were categorized by severity: minimal 0 to 10, mild 11 to 100, moderate 101 to 399, and severe ≥400. Progression was defined as CAC volume score increases of ≥2.5 mm3 between scans. White women were older at baseline than Filipinas (64.6 vs 59.3 years, p<0.001). Filipinas had increased UA levels (235.8 vs 294.2 μmol/L, p<0.001), diabetes (35.5% vs 5.2%, p<0.001), hypertension (69.6% vs 45.2%, p<0.001), and statin use (32.8% vs 18.7%, p=0.002). CAC severity did not vary by ethnicity (p=0.502), but Filipinas experienced more CAC progression than whites (53.0% vs 39.1%, p=0.016). Adjustment for CVD risk factors identified a positive association between UA levels and increasing CAC severity at EBCT1 in Filipinas (odds ratio [OR] 1.34, 95% confidence interval [CI] 1.05 to 1.71) but not whites (OR 0.94, 95% CI 0.71 to 1.25). Higher UA levels predicted CAC progression in both cohorts (OR 1.26, 95% CI 1.02 to 1.56). In conclusion, these results support use of UA as an ethnicity-specific marker of CAC severity and as a marker of CAC progression among postmenopausal women.

Sex differences in cardiovascular outcomes, pharmacological treatments and indicators of care in patients with newly diagnosed diabetes: Analyses on administrative database

BACKGROUND

The impact of diabetes on cardiovascular disease in both sexes is known, but the specifics have not been fully clarified. We investigated whether sex-related differences exist in terms of management and hospitalization in patients with newly diagnosed diabetes.

METHODS

We examined the rates of hospitalization for cardiovascular causes, mortality, treatments and management of patients with diabetes compared to subjects without, from administrative database. Interaction between sex and diabetes on clinical outcomes were calculated using a Cox regression model. Pharmacological treatments and recommended examinations by sex were calculated using logistic regression.

RESULTS

From 2002 to 2006, 158,426 patients with diabetes and 314,115 subjects without were identified and followed up for a mean of 33 months (± 17.5). Diabetes confers a higher risk for all clinical outcomes. Females with diabetes have a risk profile for hospitalization for coronary heart disease comparable to males without (4.6% and 5.3%). Interaction between sex and diabetes shows that females with diabetes had an added 19% higher risk of total death (95% CI 1.13-1.24). No differences were observed in hospitalizations, although females with diabetes were less likely to undergo revascularization after myocardial infarction. Females received cardiovascular prevention drugs less frequently than males and had a slight tendency to get fewer examinations.

CONCLUSION

Diabetes is linked to a higher increase of mortality in females relative to males. This might reflect sex differences in the use of revascularization procedures or therapeutic regimens. Closer attention and implementation of standard care for females are necessary from the onset of diabetes.

Health behaviors among breast, prostate, and colorectal cancer survivors: a US population-based case-control study, with comparisons by cancer type and gender

PURPOSE

The aim of this study is to compare health behaviors between breast, prostate, female, and male colorectal cancer survivors to noncancer controls, stratified by short- and long-term survivors, and between cancer types and genders.

METHODS

A 3:1 population-based sample of breast (6,259), prostate (3,609), female colorectal (1,082), and male colorectal (816) cancer survivors from the 2009 Behavioral Risk Factor Surveillance System survey were matched to noncancer controls on age, gender, race/ethnicity, income, insurance, and region of the US. The likelihood of flu immunization, physical check-up, cholesterol check, body mass index (BMI), physical activity, diet (5-A-Day), smoking, and alcohol use were compared between groups using binomial logistic regression models.

RESULTS

Short-term breast cancer survivors were significantly more likely to meet multiple behavioral recommendations, than controls, but the likelihood decreased in the long term. Breast and female colorectal cancer survivors were up to 2.27 (95 % CI 1.90, 2.71) and 1.89 times more likely (95 % CI 1.60, 2.24) to meet the 5-A-Day and BMI recommendations, up to 0.54 times less likely (95 % CI 0.46, 0.64) to drink any alcohol, but were 0.68 times less likely (95 % CI 0.49, 0.95) to meet the physical activity recommendation, compared to prostate and male colorectal cancer survivors.

CONCLUSIONS

Some cancer survivors may engage in better health behaviors shortly after diagnosis, but the majority of cancer survivors do not have better health behaviors than individuals without a history of cancer. However, a consistent pattern of behavioral differences exist between male and female cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Gender differences in health behaviors among cancer survivors may be influenced by perceptions of masculinity/femininity and disease risk. Ongoing health behavioral promotion and disease prevention efforts could be improved by addressing these perceptions.

Community-level cardiovascular risk factors impact geographic variation in cardiovascular disease hospitalizations for women

Prior work has shown significant geographic variation in cardiovascular (CV) risk factors including metabolic syndrome, obesity, and hypercholesterolemia. However, little is known about how variations in CV risk impact cardiovascular disease (CVD)-related hospitalizations. Community-level CV risk factors (hypertension, dyslipidemia, hyperglycemia, and elevated waist circumference) were assessed from community-wide health screenings sponsored by Sister to Sister (STS) from 2008 to 2009 in 17 major US cities. Using data from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (HCUP-NIS), CVD hospitalizations were identified based on ICD-9 codes for acute myocardial infarction (AMI), congestive heart failure (CHF), and stroke. We linked STS data with HCUP-NIS hospitalizations based on common cities and restricted the analysis to women discharged from hospitals inside the STS cities. Using hierarchical models with city as the random intercept, we assessed the impact of city-specific CV risk factors on between-city variance of AMI, CHF, and stroke. Analyses were also adjusted for patient age and clinical comorbidities. Our analysis yielded a total of 742,445 all-cause discharges across 70 hospitals inside of 13 linked cities. The overall city-specific range proportion of AMI, CHF, and stroke hospitalizations were 1.13 % (0.75-1.59 %), 2.57 % (1.44-3.92 %), and 1.24 % (0.66-1.84 %), respectively. After adjusting for city-specific CV risk factors, between-city variation was no longer statistically significant for all CVD conditions explored. In conclusion, we found that geographic variations in AMI, CHF, and stroke hospitalizations for women may be partially explained by community-level CV risk factors. This finding suggests that interventions to reduce CVD should be tailored to the unique risk profile and needs of high-risk communities.

Peripheral artery disease is a coronary heart disease risk equivalent among both men and women: results from a nationwide study

AIMS

Lower extremity peripheral artery disease (PAD) has been proposed as a 'coronary heart disease (CHD) risk equivalent'. We aimed to examine whether PAD confers similar risk for mortality as incident myocardial infarction (MI) and whether risk differs by gender.

METHODS

Using nationwide Danish administrative registries (2000-2008), we identified patients aged ≥40 years with incident PAD (PAD only, n = 35,628), incident PAD with a history of MI (PAD + MI, n = 7029), and incident MI alone (MI alone, n = 71,115).

RESULTS

Patients with PAD only tended to be younger, female, and have less comorbidity than the other groups. During follow up (median 1051 d, IQR 384-1938), we found that MI-alone patients had greater risk of adverse outcomes in the acute setting (first 90 d); however, the PAD-only and PAD + MI groups had higher long-term mortality at 7 years than those with MI alone (47.8 and 60.4 vs. 36.4%, respectively; p < 0.0001). After adjustment, the PAD-only and PAD + MI groups had a higher long-term risk for mortality [hazard ratio (HR) 1.47, 95% confidence interval (CI) 1.44-1.51; and HR 1.65, 95% CI 1.58-1.72, respectively], cardiovascular mortality (HR 1.30, 95% CI 1.26-1.34; and HR 1.71, 95% CI 1.62-1.80, respectively), and composite of death, MI, and ischaemic stroke, 95% CI HR, 1.38, 95% CI 1.36-1.42; and HR 1.68, 95% CI 1.61-1.75, respectively). The greater long-term risks of PAD were seen for both women and men.

CONCLUSIONS

Both women and men with incident PAD have greater long-term risks of total and cardiovascular mortality vs. those with incident MI. PAD should be considered a CHD risk equivalent, warranting aggressive secondary prevention.

Hemodynamic and hormonal patterns of untreated essential hypertension in men and women

BACKGROUND

Knowledge of hemodynamic factors accounting for the development of hypertension should help to tailor therapeutic approaches and improve blood pressure control. Few data exist regarding sex differences of hemodynamic factors contributing to hypertension progression among patients with untreated nondiabetic stage I and II prehypertension (PreHyp) as defined by the Joint National Committee-7 guidelines (JNC-7).

METHODS

We utilized noninvasive impedance cardiography, applanation tonometry and plasma measures of angiotensin II, angiotensin (1-7), serum aldosterone, high-sensitivity C-reactive protein (hs-CRP) and cytokine biomarkers of inflammation to characterize the hemodynamic and hormonal profile of 100 patients with untreated hypertension (39 women).

RESULTS

Despite there being no differences between women and men in terms of office blood pressure, heart rate and body mass index, men demonstrated lower values of pulse pressure, systemic vascular resistance, brachial artery pulse wave velocity and augmentation index. In each of the three hypertension categories, the increased blood pressure in men was associated with significant augmentations in stroke volume and cardiac output compared with women. Sex-related hemodynamic differences were associated in women with higher plasma levels of leptin, hs-CRP, plasma angiotensin II and serum aldosterone, and no differences in the serum concentrations of cytokinins. In women but not men, hs-CRP correlated with plasma concentrations of transforming growth factor β1 (TGFβ1) and body weight; in addition, plasma TGFβ1 correlated with levels of serum vascular cell adhesion molecule 1.

CONCLUSION

The impact of sex differences in the hemodynamic factors accounting for the elevation in arterial pressure in subjects with essential hypertension has been poorly characterized or this information is not available. We suggest that this gap in knowledge may adversely influence choices of drug treatment since our study shows for the first time significant differences in the hemodynamic and hormonal mechanisms accounting for the increased blood pressure in women compared to men.

Gender, socioeconomic and ethnic/racial disparities in cardiovascular disease: a time for change

Cardiovascular disease (CVD) mortality rates have declined steadily over the past few decades but gender, socioeconomic and ethnic/racial disparities have not. These disparities impede cardiovascular health care reaching all those in need. The origins of disparities in CVD are numerous and wide-ranging, having largely evolved from inequalities in society. Similarly, disparities in CVD, interventions and outcomes will also vary depending on the minority or disadvantaged group. For this reason, strategies aimed at reducing such disparities must be stratified according to the target group, while keeping in mind that these groups are not mutually exclusive. There is a pressing need to move beyond what can be inferred from traditional cardiovascular risk factor profiling toward implementation of interventions designed to address the needs of these populations that will eventuate in a reduction of disparities in morbidity and mortality from CVD. This will require targeted and sustainable actions. Only by ensuring timely and equitable access to care for all through increased awareness and active participation can we start to close the gap and deliver appropriate, acceptable and just care to all, regardless of gender, socioeconomic status or ethnicity/race.

Cardiovascular disease knowledge and weight perception among Hispanic and non-Hispanic white women

BACKGROUND

While knowledge of cardiovascular disease (CVD) has improved, it remains low among minority women, thereby contributing to disparities and posing health challenges. Moreover, substantial numbers of women do not recognize that excess weight imposes CVD risk and increases morbidity and decreases survival. In order to test the hypothesis that CVD knowledge is reduced among overweight and obese women, CVD knowledge and weight perception was compared among Hispanic and non-Hispanic white (NHW) women.

METHODS

Data from 382 Hispanic and 301 NHW women, participants in the Heart Health in Action database (n=829), were analyzed from a structured behavioral risk factor surveillance system (BRFSS) questionnaire to assess demographics, risk factors, and CVD knowledge. Multivariable logistic regression analysis was utilized to test for differences between Hispanic and NHW women regarding knowledge with covariates of age, education, and body mass index (BMI).

RESULTS

Hispanics (27%) were less likely than NHW (88%) to correctly identify the leading cause of death among women, (p<0.0001). Years living in the United States did not relate to the percentage of respondents who correctly identified the leading cause of death among women or knew the symptoms of a heart attack. Differences between Hispanic and NHW remained significant after adjustment for age, education, and BMI (p<0.0001). Hispanics (69.4%) were less likely than NHW (82.9 %) to correctly estimate weight (p<0.0001). Underestimation of weight was greater among Hispanics (24.8%) than NHW (5.0%); 48.5% of overweight Hispanic participants versus 12.7% of overweight NHW participants underestimated weight (p<0.0001) and 17.2% of obese Hispanic versus 0% of NHW obese participants (p=0.001) underestimated weight. The percentage underestimating the silhouette corresponding to their weight was related to years in the United States: 29.3% for<10 years, 38.3% with 10-19 years, and 49.3% with ≥20 years (p=0.01 for trend).

CONCLUSIONS

Effective prevention strategies for at-risk populations need to target CVD knowledge and awareness among overweight and obese Hispanic women.

Motivational interviewing to reduce cardiovascular risk in African American and Latina women

Cardiovascular disease (CVD) is the leading cause of death for women, and disproportionally so for African American and Latina women. CVD is largely preventable and many risks can be attributable to health behaviors, implementing and sustaining positive health behaviors is a challenge. Motivational interviewing is one promising intervention for initiating behavior change. The purpose of this review was to identify, synthesize, and critically analyze the existing literature on the use of motivational interviewing as a behavioral intervention to reduce CVD risk among African American and Latina women. Seven studies were identified that met inclusion criteria. Results of this review suggest that motivational interviewing has mixed results when used to reduce cardiovascular risk factors in African American and Latina women. More research using a standardized motivational interviewing approach is needed to definitively determine if it is an effective behavioral intervention to reduce CVD risk when used in populations of African American and Latina women.

The burden of uterine fibroids for African-American women: results of a national survey

BACKGROUND

Uterine fibroids have a disproportionate impact on African-American women. There are, however, no data to compare racial differences in symptoms, quality of life, effect on employment, and information-seeking behavior for this disease.

METHODS

An online survey was conducted by Harris Interactive between December 1, 2011 and January 16, 2012. Participants were U.S. women aged 29-59 with symptomatic uterine fibroids. African-American women were oversampled to allow statistical comparison of this high-risk group. Bivariate comparison of continuous and categorical measures was based on the t-test and the Chi-squared test, respectively. Multivariable adjustment of risk ratios was based on log binomial regression.

RESULTS

The survey was completed by 268 African-American and 573 white women. There were no differences between groups in education, employment status, or overall health status. African-American women were significantly more likely to have severe or very severe symptoms, including heavy or prolonged menses (RR=1.51, 95% CI 1.05-2.18) and anemia (RR=2.73, 95% CI 1.47-5.09). They also more often reported that fibroids interfered with physical activities (RR=1.67, 95% CI 1.20-2.32) and relationships (RR=2.27, 95% CI 1.23-4.22) and were more likely to miss days from work (RR=1.77, 95% CI 1.20-2.61). African-American women were more likely to consult friends and family (36 vs. 22%, P=0.004) and health brochures (32 vs. 18%, P<0.001) for health information. Concerns for future fertility (RR=2.65, 95% CI 1.93-3.63) and pregnancy (RR=2.89, 95% CI 2.11-3.97) following fibroid treatments were key concerns for black women.

CONCLUSIONS

African-American women have more severe symptoms, unique concerns, and different information-seeking behavior for fibroids.

Ischemic heart disease in women

Cardiovascular disease is the leading cause of death in women. Although overall mortality from coronary heart disease (CHD) has decreased, there are subsets of patients, particularly young women, in whom the mortality rate has increased. Underlying sex differences in CHD may be an explanation. Women have more frequent symptoms, more ischemia, and higher mortality than men, but less obstructive coronary artery disease (CAD). Despite this, traditional risk factor assessment has been ineffective in risk stratifying women, prompting the emergence of novel markers and prediction scores to identify a population at risk. Sex differences in manifestations and the pathophysiology of CHD also have led to differences in the selection of diagnostic testing and treatment options for women, having profound effects on outcomes. The frequent finding of nonobstructive CAD in women with ischemia suggests microvascular dysfunction as an underlying cause; therefore, coronary reactivity and endothelial function testing may add to diagnostic accuracy in female patients. In spite of evidence that women benefit from the same therapies as men, they continue to receive less-aggressive therapy, which is reflected in higher healthcare resource utilization and adverse outcomes. More sex-specific research is needed in the area of symptomatic nonobstructive CAD to define the optimal therapeutic approach.

Presentation, management, and outcomes of ischaemic heart disease in women

Scientific interest in ischaemic heart disease (IHD) in women has grown considerably over the past 2 decades. A substantial amount of the literature on this subject is centred on sex differences in clinical aspects of IHD. Many reports have documented sex-related differences in presentation, risk profiles, and outcomes among patients with IHD, particularly acute myocardial infarction. Such differences have often been attributed to inequalities between men and women in the referral and treatment of IHD, but data are insufficient to support this assessment. The determinants of sex differences in presentation are unclear, and few clues are available as to why young, premenopausal women paradoxically have a greater incidence of adverse outcomes after acute myocardial infarction than men, despite having less-severe coronary artery disease. Although differential treatment on the basis of patient sex continues to be described, the extent to which such inequalities persist and whether they reflect true disparity is unclear. Additionally, much uncertainty surrounds possible sex-related differences in response to cardiovascular therapies, partly because of a persistent lack of female-specific data from cardiovascular clinical trials. In this Review, we assess the evidence for sex-related differences in the clinical presentation, treatment, and outcome of IHD, and identify gaps in the literature that need to be addressed in future research efforts.

Anginal symptoms, coronary artery disease, and adverse outcomes in Black and White women: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study

BACKGROUND

Black women are less likely to be evaluated and treated for anginal symptoms, despite a higher premature cardiac mortality rate compared to white women. Our objective was to compare angina symptoms in black versus white women regarding (1) angina symptoms characterization; (2) relationship with obstructive coronary artery disease (CAD); and (3) relationship with subsequent mortality.

METHODS

A cohort of 466 women (69 black and 397 white) undergoing coronary angiography for suspected ischemia and without prior history of CAD completed symptom checklists. Four symptom clusters (CHEST, UPPER, STOMACH, and TYPICAL TRIGGERS) were derived by factor analysis. All angiograms were analyzed by core lab. Mortality data over 10 years were obtained from National Death Index.

RESULTS

(1) Black women had lower mean CHEST cluster scores (0.60±0.30 vs. 0.73±30, p=0.002), but higher STOMACH scores (0.41±0.25 vs. 0.30±0.25, p=0.011) than white women. (2) Prevalence and severity of CAD did not differ in black and white women and was not predicted by symptom cluster scores. (3) All-cause mortality rates were 24.9% in blacks versus 14.5% in whites, p=0.007; and cardiovascular mortality 22.5% vs.8.8%, p=0.001. Symptom clusters were not predictive of adverse events in white women. However, black women with a low TYPICAL score had significantly higher mortality compared to those with a high TYPICAL score (43% vs. 10%, p=0.006).

CONCLUSIONS

Among women undergoing coronary angiography, black women report fewer chest-related and more stomach-related symptoms, regardless of presence or severity of CAD, and these racial symptom presentation differences are linked with the more adverse prognosis observed in the black women. Atypical symptom presentation may be a barrier to appropriate and timely diagnosis and treatment and contribute to poorer outcomes for black women.

A novel program focused on women survivors who were enrolled in a cardiac arrest pathway

The number of cases of out-of-hospital cardiac arrest is estimated to be 300,000/year in the United States. Two landmark studies published in 2002 demonstrated that therapeutic hypothermia decreased mortality and improved neurological outcome after out-of-hospital cardiac arrest. Our institutional pathway for the management of survivors of cardiac arrest stresses teamwork involving multiple disciplines, including cardiology, critical care, nursing, neurology, infectious diseases, physical therapy, social work, and pastoral care. Involvement of the patients' families is critical in the understanding of the process and in the decision making and goals of care when neurological prognosis is poor. In a unique approach, we have included the survivors in the process. Our approach to quality improvement includes a yearly conference incorporating the voices of survivors and families. This conference serves as a means to review our experience, educate clinicians, involve all healthcare providers in the outcome, and provide a model of communication and professionalism to trainees. During review of our experience, we noted the small number of women undergoing therapeutic hypothermia, accounting for only 21% of all patients undergoing this therapy after cardiac arrest. This led to a conference that focused on cardiac disease and cardiac arrest in women.

Characterization of vascular disease risk in postmenopausal women and its association with cognitive performance

OBJECTIVES

While global measures of cardiovascular (CV) risk are used to guide prevention and treatment decisions, these estimates fail to account for the considerable interindividual variability in pre-clinical risk status. This study investigated heterogeneity in CV risk factor profiles and its association with demographic, genetic, and cognitive variables.

METHODS

A latent profile analysis was applied to data from 727 recently postmenopausal women enrolled in the Kronos Early Estrogen Prevention Study (KEEPS). Women were cognitively healthy, within three years of their last menstrual period, and free of current or past CV disease. Education level, apolipoprotein E ε4 allele (APOE4), ethnicity, and age were modeled as predictors of latent class membership. The association between class membership, characterizing CV risk profiles, and performance on five cognitive factors was examined. A supervised random forest algorithm with a 10-fold cross-validation estimator was used to test accuracy of CV risk classification.

RESULTS

The best-fitting model generated two distinct phenotypic classes of CV risk 62% of women were "low-risk" and 38% "high-risk". Women classified as low-risk outperformed high-risk women on language and mental flexibility tasks (p = 0.008) and a global measure of cognition (p = 0.029). Women with a college degree or above were more likely to be in the low-risk class (OR = 1.595, p = 0.044). Older age and a Hispanic ethnicity increased the probability of being at high-risk (OR = 1.140, p = 0.002; OR = 2.622, p = 0.012; respectively). The prevalence rate of APOE-ε4 was higher in the high-risk class compared with rates in the low-risk class.

CONCLUSION

Among recently menopausal women, significant heterogeneity in CV risk is associated with education level, age, ethnicity, and genetic indicators. The model-based latent classes were also associated with cognitive function. These differences may point to phenotypes for CV disease risk. Evaluating the evolution of phenotypes could in turn clarify preclinical disease, and screening and preventive strategies. ClinicalTrials.gov NCT00154180.

Accounting for clinical action reduces estimates of gender disparities in lipid management for diabetic veterans

BACKGROUND

Women with diabetes have higher low-density lipoprotein (LDL) levels than men, resulting in apparent disparities between genders on quality indicators tied to LDL thresholds.

OBJECTIVE

To investigate whether gender disparities persist when accounting for clinical action with statins or cardiovascular risk.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Veterans Health Administration patients (21,780 women and 646,429 men) aged 50-75 with diabetes.

MAIN MEASURES

Threshold measure: LDL < 100 mg/dL; clinical action measure: LDL < 100 mg/dL; or LDL ≥ 100 mg/dL and the patient was prescribed a moderate or high-dose statin at the time of the test; or LDL ≥ 100 mg/dL and the patient received other appropriate clinical action within 90 days; adherence: continuous multiple interval measure of gaps in dispensed medication (CMG).

KEY RESULTS

Women were much less likely to have LDL < 100 mg/dL than were men (55 % vs. 68 %). This disparity narrowed from 13 % to 6 % for passing the clinical action measure (79 % vs. 85 %). These gender differences persisted among those with ischemic heart disease (IHD). Women had a lower odds of passing the clinical action measure (odds ratio 0.68, 95 % confidence interval 0.66-0.71). Among those with IHD, the gender gap increased with age. Differences in pass rates were explained by women's higher LDL levels, but not by their slightly worse adherence (3 % higher CMG).

CONCLUSIONS

Women and men veterans receive more similar quality of care for lipids in diabetes than previously indicated. Less reassuringly, the remaining gender differences appear to be as common in women at high cardiovascular risk as in those at low risk. Rather than focus on simply improving LDL levels in all women with diabetes, future efforts should ensure that patients with high cardiovascular risk are appropriately treated with statins when clinically indicated, feasible, and concordant with patient preferences.

Gender disparity in cardiovascular disease: bias or biology?

This article addresses gender disparity in cardiovascular disease, with selected examples used to explore whether these disparities represent bias, biology or both. Gender-specific basic and clinical cardiovascular research is needed to address these issues, with rigorous application required for the emerging knowledge. These explorations offer promise to improve cardiovascular outcomes for women and are the basis for the application of gender-based evaluation of pathophysiology, clinical presentations, preventive interventions, diagnostic strategies, therapies and outcomes of cardiovascular disease in women.

Sex differences in the effectiveness of early coronary computed tomographic angiography compared with standard emergency department evaluation for acute chest pain: the rule-out myocardial infarction with Computer-Assisted Tomography (ROMICAT)-II Trial

BACKGROUND

We evaluate sex-based differences in the effectiveness of early cardiac computed tomographic angiography (CCTA) and standard emergency department (ED) evaluation in patients with acute chest pain.

METHODS AND RESULTS

In the Rule-Out Myocardial Infarction With Computer-Assisted Tomography (ROMICAT)-II multicenter, controlled trial, we randomized 1000 patients (47% women) 40 to 74 years of age with symptoms suggestive of acute coronary syndrome to an early CCTA or standard ED evaluation. In this prespecified analysis, women in the CCTA arm had a greater reduction in length of stay, lower hospital admission rates, and lesser increased cumulative radiation dose than men in a comparison of ED strategies (P for interaction ≤0.02). Although women had lower acute coronary syndrome rates than men (3% versus 12%; P<0.0001), sex differences in length of stay persisted after adjustment for baseline differences, including acute coronary syndrome rate (P for interaction <0.03). Length of stay was similar between sexes with normal CCTA findings (P=0.11). There was no missed acute coronary syndrome for either sex. No difference was observed in major adverse cardiac events between sexes and ED strategies (P for interaction =0.39). Women had more normal CCTA examinations than men (58% versus 37%; P<0.0001), less obstructive coronary disease by CCTA (5% versus 17%; P=0.0001), but similar normalcy rates for functional testing (P=0.65). Men in the CCTA arm had the highest rate of invasive coronary angiography (18%), whereas women had comparable low 5% rates regardless of ED strategy.

CONCLUSIONS

This trial provides data supporting an early CCTA strategy as an attractive option in women presenting to the ED with symptoms suggestive of acute coronary syndrome. The findings may be explained by lower CAD prevalence and severity in women than men.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT01084239.

Coronary artery disease in women: a 2013 update

Coronary artery disease (CAD) is a leading cause of death of women and men worldwide. CAD's impact on women traditionally has been underappreciated due to higher rates at younger ages in men. Microvascular coronary disease disproportionately affects women. Women have unique risk factors for CAD, including those related to pregnancy and autoimmune disease. Trial data indicate that CAD should be managed differently in women. In this review, we will examine risk assessment for CAD in women, CAD's impact on women, as well as CAD's female-specific presentation and management strategies.

Gender and racial disparities in adherence to statin therapy: a meta-analysis

BACKGROUND

Significant disparities exist in cardiovascular outcomes based on race/ethnicity and gender. Rates of evidence-based medication use and long-term medication adherence also appear to be lower in racial subgroups and women but have been subject to little attention. Our objective was to evaluate the effect of race/ethnicity and gender on adherence to statin therapy for primary or secondary prevention.

METHODS AND RESULTS

Studies were identified through a systematic search of MEDLINE, EMBASE, ClinicalTrials.gov, and the Cochrane Database of Systematic Reviews (through April 1, 2010) and manual examination of references in selected articles. Studies reporting on adherence to statins by men and women or patients of white and nonwhite race were included. Information on study design, adherence measurement, duration, geographic location, sample size, and patient demographics was extracted using a standardized protocol. From 3,022 potentially relevant publications, 53 studies were included. Compared with men, women had a 10% greater odds of nonadherence (odds ratio 1.10, 95% confidence interval [CI], 1.07-1.13). Nonwhite race patients had a 53% greater odds of nonadherence than white race patients (odds ratio 1.53, 95% CI 1.25-1.87). There was significant heterogeneity in the pooled estimate for gender (I(2) 0.95, P value for heterogeneity <.001) and race (I(2) 0.98, P value for heterogeneity <.001). The overall results remained unchanged in those subgroups that had significantly less heterogeneity.

CONCLUSIONS

Among patients prescribed statins, women and nonwhite patients are at increased risk for nonadherence. Further research is needed to identify interventions best suited to improve adherence in these populations.

Injury or activity-related pain sustained by a population of at-risk women during a 6-month exercise program

BACKGROUND

Exercise provides numerous cardiovascular (CV) benefits to women; however, identifying women who are likely to sustain musculoskeletal injury or discomfort is important when tailoring exercise activities.

PURPOSE

To evaluate factors associated with the incidence of injury in women at risk for CV disease (CVD) during their participation in a structured exercise intervention for primary CVD prevention.

STUDY DESIGN

Retrospective comparative study.

METHODS

Baseline anthropometric measures, CV efficiency (via standardized submaximal treadmill testing), and questionnaire-based assessments of functional capacity (Duke Activity Status Index [DASI]), daytime sleepiness (Epworth Sleepiness Scale), and depression (9-item Patient Health Questionnaire) were compared between participants sustaining an injury or experiencing persistent pain, regardless of cause, with those reporting no such events.

RESULTS

Of 117 women enrolled in the study, 27 (23%) experienced an injury or activity-related musculoskeletal pain during the program (injured group). Baseline characteristics for the entire group were: age, 57.3 years; weight, 203 lb; body mass index, 34.8 kg/m 2 ; and waist circumference, 39.9 in. Characteristics did not differ significantly between the injured and non-injured groups for baseline demographics (P > 0.05), but obesity incidence (body mass index ≥ 30 kg/m 2 ) was more prevalent in the injured group (P = 0.02). On univariate analysis, 9-item Patient Health Questionnaire depression scores were higher for injured participants (5.6 vs 4.1, P = 0.16) and DASI activity scores were significantly lower for injured participants (31.3 vs 41.0, P = 0.004) despite there being no significant difference in baseline exercise capacity, expressed as metabolic equivalents (8.1 vs 7.5, P = 0.20) between groups. The DASI score was an independent predictor of injury by multivariate analysis (P = 0.0092).

CONCLUSION

Women study participants who were injured or experienced activity-related pain during a 6-month structured exercise intervention (injured group) had similar waist measurements, lipid/lipoprotein level profiles, and hemodynamic responses compared with women study participants who were event free (non-injured group); however, injured-group participants were more obese, more depressed, and reported lower functional capacity. Women who have the characteristics of the injured-group participants may be at greater risk for activity-induced injury when participating in exercise-based prevention programs for CV health.

"Missing pieces": exploring cardiac risk perceptions in older women

Approximately 95% of older women have factors that put them at risk for developing cardiovascular disease, but research indicates many do not perceive themselves to be at risk. We examined older women's perceived risk for coronary heart disease (CHD) and the factors influencing their perceptions. We conducted a descriptive, qualitative study using in-depth, individual interviews and quantitative measures to assess perceived risk and risk factors. Twenty-four older African American and Caucasian women had a mean 4.46 cardiac risk factors but perceived their own CHD risk as unrealistically low at 1.95 cm (SD = 1.57, on 0-to-8 cm visual analogue scale). Narrative data clustered in themes that represented a lack of fact-based information and multiple misconceptions about CHD and prevention. Major improvements in CHD health are only achievable if risk factors are prevented. This research suggests older women have substantial needs for consistent CHD information and prevention guidance.

Fifteen-year trends in awareness of heart disease in women: results of a 2012 American Heart Association national survey

BACKGROUND

The purpose of this study was to evaluate trends in awareness of cardiovascular disease (CVD) risk among women between 1997 and 2012 by racial/ethnic and age groups, as well as knowledge of CVD symptoms and preventive behaviors/barriers.

METHODS AND RESULTS

A study of awareness of CVD was conducted by the American Heart Association in 2012 among US women >25 years of age identified through random-digit dialing (n=1205) and Harris Poll Online (n=1227), similar to prior American Heart Association national surveys. Standardized questions on awareness were given to all women; additional questions about preventive behaviors/barriers were given online. Data were weighted, and results were compared with triennial surveys since 1997. Between 1997 and 2012, the rate of awareness of CVD as the leading cause of death nearly doubled (56% versus 30%; P<0.001). The rate of awareness among black and Hispanic women in 2012 (36% and 34%, respectively) was similar to that of white women in 1997 (33%). In 1997, women were more likely to cite cancer than CVD as the leading killer (35% versus 30%), but in 2012, the trend reversed (24% versus 56%). Awareness of atypical symptoms of CVD has improved since 1997 but remains low. The most common reasons why women took preventive action were to improve health and to feel better, not to live longer.

CONCLUSIONS

Awareness of CVD among women has improved in the past 15 years, but a significant racial/ethnic minority gap persists. Continued effort is needed to reach at-risk populations. These data should inform public health campaigns to focus on evidenced-based strategies to prevent CVD and to help target messages that resonate and motivate women to take action.

Cardiovascular disease in women

Gender-specific data focused on cardiovascular disease (CVD) are becoming increasingly available. This is of great importance, given that CVD has become the number 1 killer of women, and unlike for men, mortality rates do not seem to be declining. Many factors are cited as the causes of sex-based differences, including delays in recognizing symptoms, underutilization of diagnostic tests and treatments, as well as anatomic, physiological, and genetic factors. Evidence of fundamental biological differences in vascular function and the underlying pathologic processes is only beginning to elucidated, motivated by growing evidence of differences in clinical presentations and outcomes between men and women. The good news is that we are starting to see improvements in outcomes for women, such as after coronary revascularization; decrease in complication rates with the advent of new techniques, such as radial access for cardiac catheterizations; as well as increased participation of women in clinical trials. The underlying mechanisms of ischemic heart disease remain to be elucidated, and will help guide therapy and ultimately may explain the higher prevalence of : subendocardial myocardial infarctions, spontaneous arterial dissections, plaque erosion, increased vasospastic disorders, such as coronary microvascular disease, and pulmonary hypertension in women compared with men. We have made great progress in understanding gender-related differences in CVDs, but much remains to be done to optimize the prevention of CVD for both men and women.

Women at risk for cardiovascular disease lack knowledge of heart attack symptoms

BACKGROUND

It is not known whether cardiovascular disease (CVD) risk level is related to knowledge of the leading cause of death of women or heart attack symptoms.

HYPOTHESIS

Women with higher CVD risk estimated by Framingham Risk Score (FRS) or metabolic syndrome (MS) have lower CVD knowledge.

METHODS

Women visiting primary care clinics completed a standardized behavioral risk questionnaire. Blood pressure, weight, height, waist size, fasting glucose, and lipid profile were assessed. Women were queried regarding CVD knowledge.

RESULTS

Participants (N = 823) were Hispanic women (46%), non-Hispanic white (37%), and non-Hispanic black (8%). FRS was determined in 278: low (63%), moderate (29%), and high (8%); 24% had ≥3 components of MS. The leading cause of death was answered correctly by 54%, heart attack symptoms by 67%. Knowledge was lowest among racial/ethnic minorities and those with less education (both P< 0.001). Increasing FRS was inversely associated with knowing the leading cause of death (low 72%, moderate 68%, high 45%, P = 0.045). After multivariable adjustment, moderate/high FRS was inversely associated with knowing symptoms (moderate odds ratio [OR] 0.52, 95% confidence interval [CI]: 0.28-0.98; high OR 0.29, 95% CI: 0.11-0.81), but not the leading cause of death. MS was inversely associated with knowing the leading cause of death (P< 0.001) or heart attack symptoms (P = 0.018), but not after multivariable adjustment.

CONCLUSIONS

Women with higher FRS were less likely to know heart attack symptoms. Efforts to target those at higher CVD risk must persist, or the most vulnerable may suffer disproportionately, not only because of risk factors but also inadequate knowledge.

Protective cardiovascular and renal actions of vitamin D and estrogen

Both basic science and clinical studies support the concept that vitamin D deficiency is involved in the pathogenesis of cardiovascular and renal diseases through its association with diabetes, obesity, and hypertension. Understanding the underlying mechanisms may provide a rationale for advocating adequate intake of vitamin D and calcium in all populations, thereby preventing many chronic diseases. This review explores the effect of vitamin D deficiency in the development of cardiovascular and renal diseases, and the role of vitamin D supplementation on cardiovascular outcomes. In addition, it highlights the importance of vitamin D intake for the prevention of adverse long-term health consequences, and in ways to facilitate the management of cardiovascular disease. This is particularly true for African American and postmenopausal women, who are at added risk for cardiovascular disease. We suggest that the negative cardiovascular effects of low vitamin D in postmenopausal women could be improved by a combined treatment of vitamin D and sex steroids acting through endothelium-dependent and/or -independent mechanisms, resulting in the generation of nitric oxide and calcitonin gene-related peptide (CGRP).

High prevalence of metabolic syndrome in young Hispanic women: findings from the national Sister to Sister campaign

BACKGROUND

Hispanics are the fastest growing segment of the U.S. population and have a higher prevalence of cardiometabolic risk factors as compared with non-Hispanic whites. Further data suggests that Hispanics have undiagnosed complications of metabolic syndrome, namely diabetes mellitus, at an earlier age. We sought to better understand the epidemiology of metabolic syndrome in Hispanic women using data from a large, community-based health screening program.

METHODS

Using data from the Sister to Sister: The Women's Heart Health Foundation community health fairs from 2008 to 2009 held in 17 U.S. cities, we sought to characterize how cardiometabolic risk profiles vary across age for women by race and ethnicity. Metabolic syndrome was defined using the updated National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines, which included three or more of the following: Waist circumference ≥35 inches, triglycerides ≥150 mg/dL, high-density lipoprotein (HDL) <50 mg/dL, systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥85 mmHg, or a fasting glucose ≥100 mg/dL.

RESULTS

A total of 6843 community women were included in the analyses. Metabolic syndrome had a prevalence of 35%. The risk-adjusted odds ratio for metabolic syndrome in Hispanic women versus white women was 1.7 (95% confidence interval, 1.4, 2.0). Dyslipidemia was the strongest predictor of metabolic syndrome among Hispanic women. This disparity appeared most pronounced for younger women. Additional predictors of metabolic syndrome included black race, increasing age, and smoking.

CONCLUSIONS

In a large, nationally representative sample of women, we found that metabolic syndrome was highly prevalent among young Hispanic women. Efforts specifically targeted to identifying these high-risk women are necessary to prevent the cardiovascular morbidity and mortality associated with metabolic syndrome.

Cardiovascular disease prevention in women: a rapidly evolving scenario

The past decade has witnessed a long overdue recognition of the importance of CVD in women, accompanied by an increasing awareness of gender differences in risk factors, natural history, preventive strategies, treatment, and prognosis of CVD. Reflecting the disease burden and the specific aspects of CVD in women, the American Heart Association has developed women-specific evidence-based guidelines and consensus documents for CVD prevention. The most recent update of these guidelines, published in 2011, is a milestone in the field and shows the rapidly evolving scenario of CVD prevention in women. We discuss some novel aspects of the 2011 update. The new guidelines change the focus from evidence-based to effectiveness-based, with consideration of both benefits and harms/costs of preventive interventions. The guidelines also introduce "ideal cardiovascular health" as the lowest category of risk, which implies the need of communitywide preventive, educational and policy initiatives to promote healthy lifestyles in the general population. Furthermore, the guidelines emphasize long-term overall CVD risk rather than short-term coronary risk. We also address several barriers and open questions in the evaluation and implementation of these guidelines, including how to increase the small proportion of women with ideal cardiovascular health; how to increase implementation and compliance with the recommendations; how to provide effectiveness-based recommendations for lifetime prevention goals based on short-term trials; how to obtain the best possible evidence in women; how to identify subgroups of women with different cardiovascular risk profiles or who may require tailored preventive strategies; and how to adapt current guidelines to international settings, particularly to low- and middle-income countries.

Associations of cardiorespiratory fitness and fatness with metabolic syndrome in rural women with prehypertension

BACKGROUND

This study investigated the associations of fitness and fatness with metabolic syndrome in rural women, part of a recognized US health disparities group.

METHODS

Fitness, percentage body fat, BMI, and metabolic syndrome criteria were assessed at baseline in 289 rural women with prehypertension, ages 40-69, enrolled in a healthy eating and activity community-based clinical trial for reducing blood pressure.

RESULTS

Ninety (31%) women had metabolic syndrome, of which 70% were obese by BMI (≥30 kg/m²), 100% by percentage body fat (≥30%), and 100% by revised BMI standards (≥25 kg/m²) cited in current literature. Hierarchical logistic regression models, adjusted for age, income, and education, revealed that higher percentage body fat (P < 0.001) was associated with greater prevalence of metabolic syndrome. Alone, higher fitness lowered the odds of metabolic syndrome by 7% (P < 0.001), but it did not lower the odds significantly beyond the effects of body fat. When dichotomized into "fit" and "unfit" groups, women categorized as "fat" had lower odds of metabolic syndrome if they were "fit" by 75% and 59%, for percentage body fat and revised BMI, respectively.

CONCLUSION

Among rural women with prehypertension, obesity and fitness were associated with metabolic syndrome. Obesity defined as ≥25 kg/m² produced results more consistent with percentage body fat as compared to the ≥30 kg/m² definition.

Cardiac rehabilitation for women across the lifespan

Cardiac rehabilitation improves function and compliance and also reduces morbidity and mortality in female and male cardiovascular disease patients but remains significantly underutilized. At every age, and especially in their senior years, female cardiovascular disease patients are under-referred relative to men. Lack of standardized referral processes, misconceptions by physicians and patients, and idiosyncrasies of female pathophysiology contribute to this pattern. Moreover, confounding factors of age, socioeconomic status, and sex-specific roles and responsibilities exacerbate the problem. This review summarizes barriers to cardiac rehabilitation for female cardiac patients, and highlights opportunities for increased participation and benefit.

Atherosclerosis: from biology to pharmacological treatment

A recent explosion in the amount of cardiovascular risk has swept across the globe. Primary prevention is the preferred method to lower cardiovascular risk. Lowering the prevalence of obesity is the most urgent matter, and is pleiotropic since it affects blood pressure, lipid profiles, glucose metabolism, inflammation, and atherothrombotic disease progression. Given the current obstacles, success of primary prevention remains uncertain. At the same time, the consequences of delay and inaction will inevitably be disastrous, and the sense of urgency mounts. Pathological and epidemiological data confirm that atherosclerosis begins in early childhood, and advances seamlessly and inexorably throughout life. Risk factors in childhood are similar to those in adults, and track between stages of life. When indicated, aggressive treatment should begin at the earliest indication, and be continued for many years. For those patients at intermediate risk according to global risk scores, C-reactive protein, coronary artery calcium, and carotid intima-media thickness are available for further stratification. Using statins for primary prevention is recommended by guidelines, is prevalent, but remains under prescribed. Statin drugs are unrivaled, evidence-based, major weapons to lower cardiovascular risk. Even when low density lipoprotein cholesterol targets are attained, over half of patients continue to have disease progression and clinical events. Though clinical evidence is incomplete, altering or raising the blood high density lipoprotein cholesterol level continues to be pursued. The aim of this review is to point out the attention of key aspects of vulnerable plaques regarding their pathogenesis and treatment.

Managing metabolic syndrome in women

Cardiovascular disease (CVD) death rates in women in the United States are rising. This is attributed to the obesity epidemic and its contribution to cardiometabolic risk. Various gender-related factors and strategies must be considered to effectively manage metabolic syndrome in women and improve outcomes.

Why do older adult women fall short of the recommended follow-up care for coronary artery disease?

BACKGROUND

Many women with coronary artery disease (CAD), commonly referred to as coronary heart disease, do not receive an annual office visit to manage their disease. We set out to determine what barriers factor into women not receiving an office visit to manage their disease.

METHODS

A purposive sample of 26 eligible women (≥65 years of age) diagnosed with CAD completed in-depth, qualitative interviews. Systematic analysis of the content of interviews was performed on transcripts from these interviews. Participants with an AARP Medicare Supplement Insurance Plan insured by UnitedHealthcare insurance company that did not receive an annual office visit were eligible. In addition, we surveyed 100 physicians to obtain their thoughts about why women may not schedule at least one annual visit to manage their CAD.

RESULTS

The most common barriers identified were skepticism of heart problems, having to take the initiative to schedule the appointment, and dealing with seemingly more pressing health problems. Many of these barriers identified were substantiated in a survey of physicians that treat women with CAD, but the relative rankings of the importance of these problems differed somewhat.

CONCLUSIONS

Many women were skeptical about their heart health and often lacked the initiative to schedule a follow-up appointment. Most agreed that they would make an appointment if contacted by their doctor's office. Many of these women were receptive to the idea of receiving educational information by mail. Active involvement by doctors' offices to schedule appointments may help improve care, as might mail-based reminders.

Food, class, and health: the role of the perceived body in the social reproduction of health

The association between social class and cardiovascular health is complex, involving a constant interplay of factors as individuals integrate external information from the media, health care providers, and people they know with personal experience to produce health behaviors. This ethnographic study took place from February 2008 to February 2009 to assess how cardiovascular health information circulating in Kansas City influenced a sample of 55 women in the area. Participants were primarily Caucasian (n = 41) but diverse in terms of age, income, and education. Themes identified in transcripts showed women shared the same idea of an ideal body, young and thin, and associated this perception with ideas about good health, intelligence, and morality. Transcript themes corresponded to those found at health events and in the media that emphasized individual control over determinants of disease. Women's physical appearance and health behaviors corresponded to class indicators. Four categories were identified to represent women's shared beliefs and practices in relation to class, cardiovascular disease, and obesity. Findings were placed within an existing body of social theory to better understand how cardiovascular health information and women's associated beliefs relate to health inequality.

Women's cardiovascular health: perspectives from South-East Asia

Cardiovascular disease (CVD) is an under-recognized major health problem among women in South-East Asia. The prevalence of cardiovascular risk factors such as hypertension, diabetes mellitus, dyslipidemia, physical inactivity, and being overweight or obese has shown a significantly increasing trend among women in the region, with the exception of Singapore. The problem is compounded by low awareness that CVD is a health problem for women as well as for men, by misconceptions about the disease, and by the lack of suitable, locally available health literature. Efforts have been made by the national heart associations and other organizations to increase heart health awareness and promote healthy lifestyles. Singapore initiated these prevention programs in the early 1990s and has been successful in reducing the prevalence of cardiovascular risk factors. The governments of the region, in accordance with the Noncommunicable Disease Alliance, have begun implementing appropriate preventive strategies and improving health-delivery systems. However, psychological, social, and cultural barriers to cardiovascular health awareness in women need to be addressed before these programs can be fully and successfully implemented.

Racial/ethnic and age differences in women's awareness of heart disease

BACKGROUND

The purpose of this study was to examine differences in awareness of heart disease among women according to race/ethnicity by age group, adjusted for confounders.

METHODS

American Heart Association (AHA) National Surveys conducted in 2006 (n=1005) and 2009 (n=1142) were pooled using common variables (n=2147) and reweighted to reflect the 2010 United States Census. Surveys comprised standardized, interviewer-assisted demographic and awareness questions. Associations between racial/ethnic group and heart disease awareness stratified by age were assessed by weighted chi-square statistics; logistic regression was used for multivariable adjustment.

RESULTS

Black and Hispanic women were 66% less likely than white women to be aware that heart disease is the leading cause of death in women (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.23-0.50) after multivariable adjustment for significant confounders. The percent aware among white women was 65%; awareness did not differ between black and Hispanic women (37% vs. 38%). Other significant multivariable predictors included <high school education (OR 0.37, 95% CI 0.22-0.62) and income <$35,000/year (OR 0.56, 95% CI 0.41-0.77). Younger women (age<55 years) were less likely to be aware that heart disease is the leading cause of death in women (OR 0.66, 95% CI 0.50-0.87) and were less likely to report being very well/well informed about heart disease (OR 0.53, 95% CI 0.41-0.68) compared to older women (age≥55 years). Awareness of heart attack signs, such as shortness of breath (34%), nausea (15%), and fatigue (7%), was low among all women.

CONCLUSIONS

Racial/ethnic minority status and age<55 years were significant risk factors for lower heart disease awareness among women, suggesting these groups should be targeted for educational programs. Awareness of heart attack signs was low among all subgroups of women.