The influence of sex on left ventricular remodeling in arterial hypertension

Association of 20-Year Longitudinal Depressive Symptoms With Left Ventricular Geometry Outcomes in the Coronary Artery Risk Development in Young Adults Study: A Role for Androgens?

OBJECTIVE

Depression is a risk factor for coronary heart disease and left ventricular hypertrophy (LVH) is a potent predictor of coronary heart disease events. Whether depression is associated with LVH has received limited investigation. This study assessed cross-sectional and 20-year longitudinal associations of depressive symptoms with LVH outcomes after accounting for important known confounders.

METHODS

From 5115 participants enrolled in 1985-1986 in the Coronary Artery Risk Development in Young Adults Study, 2533 had serial measures of depressive symptoms and subsequent echocardiography to measure normal LV geometry, concentric remodeling, and LVH. The primary exposure variable was trajectories of the Center for Epidemiologic Studies Depression (CES-D) scale score from 1990-1991 to 2010-2011. Multivariable polytomous logistic regression was used to assess associations of trajectories with a composite LV geometry outcome created using echocardiogram data measured in 2010-2011 and 2015-2016. Sex-specific conflicting results led to exploratory models that examined potential importance of testosterone and sex hormone-binding globulin.

RESULTS

Overall CES-D and Somatic subscale trajectories had significant associations with LVH for female participants only. Odds ratios for the subthreshold (mean CES-D ≈ 14) and stable (mean CES-D ≈ 19) groups were 1.49 (95% confidence interval = 1.05-2.13) and 1.88 (95% confidence interval = 1.16-3.04), respectively. For female participants, sex hormone-binding globulin was inversely associated with LVH, and for male participants, bioavailable testosterone was positively associated with concentric geometry.

CONCLUSIONS

Findings from cross-sectional and longitudinal regression models for female participants, but not male ones, and particularly for Somatic subscale trajectories suggested a plausible link among depression, androgens, and LVH. The role of androgens to the depression-LVH relation requires additional investigation in future studies.

Dynamic Evolution of Cardiac Function and Glucose and Lipid Metabolism in Ovariectomized Rats and the Intervention Effect of Erxian Decoction

Aims

Abnormal changes in cardiac function have been reported in menopausal women, but there are few clinical studies on this topic. Erxian decoction (EXD) is a classic prescription that is widely used in the treatment of female menopausal diseases. The purpose of this study was to investigate the dynamic evolution of cardiac function and glucose and lipid metabolism in ovariectomized (OVX) rats and the intervention effect of EXD.

Materials and Methods

The OVX climacteric rat model was established by bilateral ovariectomy. After successful modeling, the rats were randomly divided into four groups: the sham operation (SHAM) group (equal volumes of purified water), OVX group (equal volumes of purified water), estradiol (E₂) group (1.8 × 10^-4 g/kg), and EXD group (9 g/kg). Each group of rats was treated for 16 weeks. At the 4^th, 8^th, 12^th, and 16^th weeks after treatment, the cardiac function of the rats in each group was evaluated by ultrasound. The coaxial method was used to measure blood pressure (BP). Serum endothelin-1 (ET-1) and angiotensin-2 (Ang II) levels were determined by the enzyme-linked immunosorbent assay (ELISA). The strip method was used to measure fasting blood glucose (FBG). The serum total cholesterol (TC) and triglyceride (TG) levels of rats were measured with the oxidase method. Direct methods were used to measure serum high-density lipoprotein (HDL-C) and low-density lipoprotein (LDL-C) levels. At week 16 of dosing, serum E₂ levels were determined by E₂ radioimmunoassay. The myocardium and uterus of the rats in each group were stained with HE (hematoxylin-eosin). The ultrastructure of the rat myocardium was observed by electron microscopy.

Results

After the 16^th week of treatment, the serum E₂ level decreased (P < 0.05), and the uterus was atrophied in OVX rats. The cardiac ejection fraction (EF%) decreased at 4 weeks after treatment, and systolic and diastolic function decreased after 12 weeks. After the 16^th week, the EF%, which reflects the "pump" function of the heart, decreased significantly (P < 0.05 or P < 0.01). At the 4^th, 8^th, 12^th, and 16^th weeks of treatment, the systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean pressure (MBP) of the rats in the OVX group increased with time (P < 0.05 or P < 0.01). The serum ET-1 and Ang II levels of rats in the OVX group increased (P < 0.05 or P < 0.01). In the OVX group, FBG was increased (P < 0.05 or P < 0.01), and blood lipids, especially LDL-C, were significantly increased (P < 0.05 or P < 0.01). After the 16^th week of treatment, the myocardial tissue of OVX rats showed obvious pathological changes. EXD significantly increased serum E₂ levels (P < 0.01), decreased ET-1 and Ang II levels (P < 0.01), reduced the cardiac function risk factors BP, FBG, and blood lipids, and significantly improved cardiac function and structural changes in OVX rats (P < 0.05 or P < 0.01).

Conclusions

EXD can improve abnormal cardiac structure and function in OVX rats.

Sex Differences in Molecular Mechanisms of Cardiovascular Aging

Cardiovascular disease (CVD) is still the leading cause of illness and death in the Western world. Cardiovascular aging is a progressive modification occurring in cardiac and vascular morphology and physiology where increased endothelial dysfunction and arterial stiffness are observed, generally accompanied by increased systolic blood pressure and augmented pulse pressure. The effects of biological sex on cardiovascular pathophysiology have long been known. The incidence of hypertension is higher in men, and it increases in postmenopausal women. Premenopausal women are protected from CVD compared with age-matched men and this protective effect is lost with menopause, suggesting that sex-hormones influence blood pressure regulation. In parallel, the heart progressively remodels over the course of life and the pattern of cardiac remodeling also differs between the sexes. Lower autonomic tone, reduced baroreceptor response, and greater vascular function are observed in premenopausal women than men of similar age. However, postmenopausal women have stiffer arteries than their male counterparts. The biological mechanisms responsible for sex-related differences observed in cardiovascular aging are being unraveled over the last several decades. This review focuses on molecular mechanisms underlying the sex-differences of CVD in aging.

Association of Office and Ambulatory Blood Pressure with Left Ventricular Structure and Function in Hypertensive Patients

Objective

Methods

Results

Conclusion

Influences of achieved SBP on age and sex-related left ventricular structural alteration in community hypertensive populations

OBJECTIVE

To evaluate age and sex-related left ventricular (LV) structural alteration in community hypertensive populations, and to explore whether achieved systolic blood pressure (SBP) (<120, < 130 and <140 mmHg) would modify the association between age and sex with LV structural alteration.

METHOD

A total of 1419 community hypertensive people (mean age 61 years, women 50.5%) without cardiovascular disease and left ventricular hypertrophy (LVH) at baseline were included. LV structural measures were assessed using transthoracic echocardiography at baseline and at follow-up. Age and sex-related LV structural alteration was evaluated using linear and Cox regression analysis as appropriate.

RESULTS

Per 10 years increase in age was associated with positive alteration of LV mass (LVM) index (coefficient-β: 2.63) and LV mass-to-volume (LVMV) ratio (coefficient-β: 0.04). Female sex was associated with positive alteration of LVM index (coefficient-β: 4.87) and LVMV ratio (coefficient-β: 0.05). After a median follow-up of 4 years, compared to men, women had a higher rate of LVH (36.8% vs. 11.5%, P < 0.001). The association between age and incident LVH was nonsignificant when achieved SBP <120 mmHg. The association between female sex and LVM index alteration was nonsignificant when achieved SBP <120 mmHg and <130 mmHg.

CONCLUSION

Age and female sex were associated with a phenotype of LV remodeling which was featured by increased LVM index and concentric remodeling. Women had a higher risk of developing LVH. A lower achieved SBP conferred greater effects on mitigating age and sex-related LV structural alteration.

VIDEO ABSTRACT

http://links.lww.com/HJH/B907.

Hypertension in Women: A South-Asian Perspective

Introduction

Hypertension is an important contributor to cardiovascular disease related morbidity and mortality. Despite the magnitude of its negative impact on cardiovascular outcomes, treatment and control of hypertension remain suboptimal in both men and women.

Materials and Methods

Numerous databases, i.e., PubMed, ScienceDirect, etc., were searched using keywords to identify relevant studies to our narrative review. The findings from the most pertinent articles were summarized and integrated into our narrative review on hypertension in women.

Results

The pathophysiology of essential hypertension is still being delineated in both men and women; there are multiple sex specific factors in association with the development of hypertension in women, including age, combined oral contraceptives (COCs), polycystic ovarian syndrome (PCOS), preeclampsia, etc. There are several sex specific considerations in antihypertensives drug choices.

Discussion

Despite the magnitude of its negative impact on cardiovascular outcomes, treatment and control of hypertension remain suboptimal in women. Medical treatment and adherence is uniquely challenging for South Asian women due to a variety of socio-cultural-economic factors. Further research is warranted to identify optimal sex-specific treatment options that will improve the control of hypertension and decrease the risk of subsequent cardiovascular disease in both genders.

Underrepresentation of women in cardiac imaging trials: A review

Inclusion and equal representation of women in cardiovascular imaging trials are essential to provide insight into the factors impacting women's heart health and outcomes. Despite heart disease being the leading cause of mortality for women in the United States, women have been underrepresented in cardiovascular clinical trials, including imaging trials. Research demonstrates that women have key sex-specific differences in the pathophysiology of cardiovascular disease, the evolution of disease state, and disease manifestation (Solimene, 2010; Nevsky et al., 2011 [1,2]). This understanding and acknowledgment come decades after clinical providers have extrapolated data from cardiovascular disease clinical trials conducted primarily on Caucasian men, assuming the data were generalizable to sex, race, and ethnicity. The current cardiology society guidelines, which recommend optimal medical therapies for various cardiovascular diseases, are based on trials predominantly focused on men rather than women. Sex-based research, governmental and institutional task forces, and policies on gender equity have made inroads into the disproportionate number of women's enrollment in clinical research. The National Institutes of Health in the 1990s set forth requirements on incorporating women and minorities in research, including clinical trials (Mastroianni et al., 1994; Mieres et al., 2014 [3,4]). Continued progress is imperative to improve the gap in the number of women enrolled in clinical research trials.

Reducing Cardiac Injury during ST-Elevation Myocardial Infarction: A Reasoned Approach to a Multitarget Therapeutic Strategy

The significant reduction in ‘ischemic time’ through capillary diffusion of primary percutaneous intervention (pPCI) has rendered myocardial-ischemia reperfusion injury (MIRI) prevention a major issue in order to improve the prognosis of ST elevation myocardial infarction (STEMI) patients. In fact, while the ischemic damage increases with the severity and the duration of blood flow reduction, reperfusion injury reaches its maximum with a moderate amount of ischemic injury. MIRI leads to the development of post-STEMI left ventricular remodeling (post-STEMI LVR), thereby increasing the risk of arrhythmias and heart failure. Single pharmacological and mechanical interventions have shown some benefits, but have not satisfactorily reduced mortality. Therefore, a multitarget therapeutic strategy is needed, but no univocal indications have come from the clinical trials performed so far. On the basis of the results of the consistent clinical studies analyzed in this review, we try to design a randomized clinical trial aimed at evaluating the effects of a reasoned multitarget therapeutic strategy on the prevention of post-STEMI LVR. In fact, we believe that the correct timing of pharmacological and mechanical intervention application, according to their specific ability to interfere with survival pathways, may significantly reduce the incidence of post-STEMI LVR and thus improve patient prognosis.

Preclinical cardiac disease in women and men with primary aldosteronism

PURPOSE

We tested the sex-specific associations between primary aldosteronism (PA), left ventricular (LV) hypertrophy and LV systolic myocardial function.

MATERIAL AND METHODS

Conventional and speckle tracking echocardiography was performed in 109 patients with PA and 89 controls with essential hypertension (EH). LV hypertrophy was identified if LV mass index exceeded 47.0 g/m^2.7 in women and 50.0 g/m^2.7 in men. LV systolic myocardial function was assessed by global longitudinal strain (GLS) and midwall shortening.

RESULTS

PA patients had higher prevalence of LV hypertrophy (52 vs. 21%, p < 0.001) than EH patients in both sexes, while GLS did not differ by sex or hypertension aetiology. In multivariable analyses, presence of LV hypertrophy was associated with PA and obesity in both sexes, while lower systolic myocardial function, whether measured by GLS or midwall shortening, was not associated with PA, but primarily with higher body mass index and LV mass index, respectively, in both sexes (all p < 0.05).

CONCLUSION

Having PA was associated with higher prevalence of LV hypertrophy both in women and men, compared to EH. PA was not associated with LV systolic myocardial function in either sex.

Modified Cornell electrocardiographic criteria in the assessment of left ventricular hypertrophy geometry of patients with essential hypertension

To evaluate the value of modified Cornell electrocardiographic criteria in the assessment of left ventricular hypertrophy (LVH) for patients with essential hypertension. A total of 381 patients with essential hypertension diagnosed in our hospital were selected. Using the left ventricle (LV) geometric patterns classified by the American Society of Echocardiography (ASE), we examined the distribution of the modified Cornell criteria of Ravl + S_D (the deepest S wave in 12‐lead ECG) in different geometric patterns and analyzed the correlation of modified Cornell criteria with changes in the LV geometric patterns using multiple linear regression analysis. The distribution of modified Cornell criteria, Sokolow‐Lyon criteria (RV5/V6 + SV1), and Cornell criteria (Ravl + SV3) in gender‐specific hypertensive geometric patterns were significantly different (P ≤ .01 for all). The voltage of Ravl + S_D in male patients showed an increase trend in the normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH) groups, and this increase trend was significantly in the unadjusted model and the adjusted model. The voltages of Ravl + SV3 and RV5/V6 + SV1 of male patients in CR, CH and RH groups showed a gradual increase trend, but the increase trend in CR group has no statistical significance compared to that in NG group (P ≥ .05). The voltages of Ravl + S_D, RV5/V6 + SV1, and Ravl + SV3 in female patients in CR, CH and EH groups showed a trend of increase after decrease in the adjusted model. In conclusion, the modified Cornell criteria could dynamically reflect left ventricular hypertensive geometry of male patients.

Sex-Related Differences in the Impact of Systemic Hypertension on Left Ventricular Remodeling in Patients with Hypertrophic Obstructive Cardiomyopathy

BACKGROUND

The clinical condition of hypertrophic obstructive cardiomyopathy (HOCM) and concomitant systemic hypertension is growing more and more prevalent, and it brings about a challenging diagnostic and therapeutic dilemma. However, whether systemic hypertension has an impact on HOCM, and whether sex-related differences exist in this impact, remains unclear.

METHODS

A total of 453 HOCM patients (age 48.7 ± 12.8 years, 252 [55.6%] males) were recruited in this study. There were 150 patients (33.1%, 81 males and 69 females) with a history of controlled systemic hypertension. Cardiac magnetic resonance (CMR) imaging was performed in all patients. Left ventricular (LV) remodeling index (LVRI) was determined by CMR. LVRI >1.3 g/mL was defined as pathological LV remodeling.

RESULTS

Men had significantly greater LVRI (1.40 ± 0.54 vs. 1.15 ± 0.38 g/mL, p < 0.001) and LVRI >1.3 g/mL (p = 0.002), compared with women. The incidence of syncope and 5-year sudden cardiac death risk score were significantly lower in HOCM with hypertension than those without hypertension. LVRI (p = 0.003) and LVRI >1.3 g/mL (p = 0.007) were significantly smaller in males with hypertension, but not in females with hypertension. However, log cardiac troponin I and log N-terminal pro-B-type natriuretic peptide were positively correlated with LVRI in men and women. On multivariable logistic analysis, hypertension (OR 0.172, 95% CI 0.056-0.528, p = 0.002) remained an independent determinant of pathological LV remodeling in males, whereas not in females.

CONCLUSIONS

There were significant sex differences in the impact of systemic hypertension on LV remodeling in patients with HOCM. Controlled systemic hypertension may contribute to improving LV remodeling in male patients with HOCM, but not in females.