Sex-Specific Plaque Signature: Uniqueness of Atherosclerosis in Women

Investigating the Effects and Mechanisms of Combined Vitamin D and K Supplementation in Postmenopausal Women: An Up-to-Date Comprehensive Review of Clinical Studies

Aging is a complex process and a significant risk factor for chronic diseases. Menopause, a component of aging in women, is associated with several important cardiometabolic conditions including metabolic syndrome, osteoporosis, and cardiovascular diseases. Menopausal women could benefit from preventative strategies that may decrease morbidity and mortality and improve their quality of life. Vitamins D and K are essential nutrients required for bone health, immune function, and reducing cardiovascular risks, yet their synergistic effect is less understood in aging women. This is the first comprehensive review to summarize the evidence found in randomized clinical trials of the beneficial effects of vitamin D and K co-treatment in postmenopausal women. In our literature search across key electronic databases such as Cochrane, PubMed, and Ovid, we identified 31 pertinent studies. Overall, significant findings indicate that the combined intake of vitamins D and K may positively affect cardiovascular and bone health in postmenopausal women, emphasizing the importance of maintaining a healthy diet rich in vegetables and fermented dairy products. Given the challenges in obtaining all necessary nutrients solely through the diet, vitamin D and K supplements are recommended for postmenopausal women to promote healthy aging and well-being.

Cardiovascular disease prevention in women - the current state in 2023

PURPOSE OF REVIEW

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality for women globally. The purpose of this review is to provide an updated overview of CVD prevention in women, focusing on what is currently understood about female-specific or female-predominant CVD risk factors and the importance of tailored strategies for risk assessment and medical interventions.

RECENT FINDINGS

Recent studies have demonstrated the need to account for risk factors specific to women in current risk assessment models for CVD, including early menarche, polycystic ovary syndrome, adverse pregnancy outcomes, early menopause, and chronic inflammatory conditions. Incorporation of these findings has led to advancements in sex-specific guidelines, diagnostic tools, and treatment approaches that have led to improvement in the precision of CVD prevention strategies. At-risk women benefit similarly to lipid-lowering and other preventive therapies as men but are less likely to be treated.

SUMMARY

CVD prevention in women has made substantial progress over the past decade, marked by increasing awareness among clinicians, improved understanding of sex-specific risk-enhancing factors, and incorporation of sex-specific guidelines for management. However, there remain knowledge gaps that warrant ongoing efforts to optimize CVD prevention strategies in women, which will ultimately lead to improved cardiovascular health outcomes.

CYP4V2 rs56413992 C > T was associated with the risk of coronary heart disease in the Chinese Han population: a case-control study

PURPOSE

The research aimed to detect the association between single nucleotide polymorphisms (SNPs) in CYP4V2 gene and coronary heart disease (CHD) risk.

METHODS

This case-control study included 487 CHD subjects and 487 healthy individuals. Logistic regression was performed to analyze the connection between five SNPs in CYP4V2 (rs1398007, rs13146272, rs3736455, rs1053094, and rs56413992) and CHD risk, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to evaluate the connection.

RESULTS

As a result, we found that rs56413992 T allele (OR = 1.36, 95% CI = 1.09-1.70, p = 0.007) and CT genotype (OR = 1.40, 95% CI = 1.06-1.83, p = 0.017) were significantly associated with an increased risk of CHD in the overall analysis. Precisely, rs56413992 was linked to an elevated risk of CHD in people aged > 60, males, smokers and drinkers. The study also indicated that rs1398007 was linked to an increased CHD risk in drinkers. In addition, rs1053094 was correlated with a decreased risk of CHD complicated with diabetes mellitus (DM), and rs1398007 was correlated with a decreased risk of CHD complicated with hypertension (HTN).

CONCLUSION

This study was the first to experimentally demonstrate that CYP4V2 rs56413992 was associated with the risk of CHD, which will provide a certain reference for revealing the pathogenesis of CHD.

Sex differences in diagnostic modalities of atherosclerosis in the macrocirculation

Asymptomatic atherosclerosis begins early in life and may progress in a sex-specific manner to become the major cause of cardiovascular morbidity and death. As diagnostic tools to evaluate atherosclerosis in the macrocirculation, we discuss imaging methods (in terms of computed tomography, positron emission tomography, intravascular ultrasound, magnetic resonance imaging, and optical coherence tomography), along with derived scores (Agatston, Gensini, Leaman, Syntax), and also hemodynamic indices of vascular stiffness (including flow-mediated dilation, shear stress, pulse pressure, augmentation index, arterial distensibility), assessment of plaque properties (composition, erosion, rupture), stenosis measures such as fractional flow reserve. Moreover, biomarkers including matrix metalloproteinases, vascular endothelial growth factors and miRNAs, as well as the impact of machine learning support, are described. Special attention is given to age-related aspects and sex-specific characteristics, along with clinical implications. Knowledge gaps are identified and directions for future research formulated.

Sex-specific differences in cardiovascular risk factors and implications for cardiovascular disease prevention in women

Cardiovascular disease (CVD) is the leading cause of mortality for women globally. Sex differences exist in the relative risks conferred by traditional CVD risk factors, including diabetes, hypertension, obesity, and smoking. Additionally, there are female-specific risk factors, including age of menarche and menopause, polycystic ovary syndrome, infertility and the use of assisted reproductive technology, spontaneous pregnancy loss, parity, and adverse pregnancy outcomes, as well as female-predominant conditions such as autoimmune diseases, migraines, and depression, that enhance women's cardiovascular risk across the lifespan. Along with measurement of traditional risk factors, these female-specific factors should also be ascertained as a part of cardiovascular risk assessment to allow for a more comprehensive overview of the risk for developing cardiometabolic disorders and CVD. When present, these factors can identify women at elevated cardiovascular risk, who may benefit from more intensive preventive interventions, including lifestyle changes and/or pharmacotherapy such as statins. This review describes sex differences in traditional risk factors and female-specific/female-predominant risk factors for CVD and examines the role of coronary artery calcium scores and certain biomarkers that can help further risk stratify patients and guide preventive recommendations.

The sex-associated burden of atherosclerotic cardiovascular diseases: an update on prevention strategies

Cardiovascular diseases (CVDs) are the main cause of morbidity, mortality and disability worldwide. Strong evidence exists that the interplay of sex/gender with age plays a specific and relevant role in the pathophysiology of atherosclerosis and its clinical presentation. As several knowledge gaps are still present regarding this relationship, novel research evidence needs to be obtained, also by increasing women participation to clinical studies. Moreover, the age-related discrimination, or ageism, should also be counteracted since it represents a major limit for access to care for older persons of both sexes. Diagnostic and prevention protocols for CVD management should then be improved according to these considerations, along with innovative biomedical and communication strategies.

Cardiac-Specific Expression of Cre Recombinase Leads to Age-Related Cardiac Dysfunction Associated with Tumor-like Growth of Atrial Cardiomyocyte and Ventricular Fibrosis and Ferroptosis

Transgenic expression of Cre recombinase driven by a specific promoter is normally used to conditionally knockout a gene in a tissue- or cell-type-specific manner. In αMHC-Cre transgenic mouse model, expression of Cre recombinase is controlled by the myocardial-specific α-myosin heavy chain (αMHC) promoter, which is commonly used to edit myocardial-specific genes. Toxic effects of Cre expression have been reported, including intro-chromosome rearrangements, micronuclei formation and other forms of DNA damage, and cardiomyopathy was observed in cardiac-specific Cre transgenic mice. However, mechanisms associated with Cardiotoxicity of Cre remain poorly understood. In our study, our data unveiled that αMHC-Cre mice developed arrhythmias and died after six months progressively, and none of them survived more than one year. Histopathological examination showed that αMHC-Cre mice had aberrant proliferation of tumor-like tissue in the atrial chamber extended from and vacuolation of ventricular myocytes. Furthermore, the αMHC-Cre mice developed severe cardiac interstitial and perivascular fibrosis, accompanied by significant increase of expression levels of MMP-2 and MMP-9 in the cardiac atrium and ventricular. Moreover, cardiac-specific expression of Cre led to disintegration of the intercalated disc, along with altered proteins expression of the disc and calcium-handling abnormality. Comprehensively, we identified that the ferroptosis signaling pathway is involved in heart failure caused by cardiac-specific expression of Cre, on which oxidative stress results in cytoplasmic vacuole accumulation of lipid peroxidation on the myocardial cell membrane. Taken together, these results revealed that cardiac-specific expression of Cre recombinase can lead to atrial mesenchymal tumor-like growth in the mice, which causes cardiac dysfunction, including cardiac fibrosis, reduction of the intercalated disc and cardiomyocytes ferroptosis at the age older than six months in mice. Our study suggests that αMHC-Cre mouse models are effective in young mice, but not in old mice. Researchers need to be particularly careful when using αMHC-Cre mouse model to interpret those phenotypic impacts of gene responses. As the Cre-associated cardiac pathology matched mostly to that of the patients, the model could also be employed for investigating age-related cardiac dysfunction.

The Role of Imaging in Preventive Cardiology in Women

PURPOSE OF REVIEW

The prevalence of CVD in women is increasing and is due to the increased prevalence of CV risk factors. Traditional CV risk assessment tools for prevention have failed to accurately determine CVD risk in women. CAC has shown to more precisely determine CV risk and is a better predictor of CV outcomes. Coronary CTA provides an opportunity to determine the presence of CAD and initiate prevention in women presenting with angina. Identifying women with INOCA due to CMD with use of cPET or cMRI with MBFR is vital in managing these patients. This review article outlines the role of imaging in preventive cardiology for women and will include the latest evidence supporting the use of these imaging tests for this purpose.

RECENT FINDINGS

CV mortality is higher in women who have more extensive CAC burden. Women have a greater prevalence of INOCA which is associated with higher MACE. INOCA is due to CMD in most cases which is associated with traditional CVD risk factors. Over half of these women are untreated or undertreated. Recent study showed that stratified medical therapy, tailored to the specific INOCA endotype, is feasible and improves angina in women. Coronary CTA is useful in the setting of women presenting with acute chest pain to identify CAD and initiate preventive therapy. CAC confers greater relative risk for CV mortality in women versus (vs.) men. cMRI or cPET is useful to assess MBFR to diagnose CMD and is another useful imaging tool in women for CV prevention.

Gender Medicine in Clinical Radiology Practice

Gender Medicine is rapidly emerging as a branch of medicine that studies how many diseases common to men and women differ in terms of prevention, clinical manifestations, diagnostic-therapeutic approach, prognosis, and psychological and social impact. Nowadays, the presentation and identification of many pathological conditions pose unique diagnostic challenges. However, women have always been paradoxically underestimated in epidemiological studies, drug trials, as well as clinical trials, so many clinical conditions affecting the female population are often underestimated and/or delayed and may result in inadequate clinical management. Knowing and valuing these differences in healthcare, thus taking into account individual variability, will make it possible to ensure that each individual receives the best care through the personalization of therapies, the guarantee of diagnostic-therapeutic pathways declined according to gender, as well as through the promotion of gender-specific prevention initiatives. This article aims to assess potential gender differences in clinical-radiological practice extracted from the literature and their impact on health and healthcare. Indeed, in this context, radiomics and radiogenomics are rapidly emerging as new frontiers of imaging in precision medicine. The development of clinical practice support tools supported by artificial intelligence allows through quantitative analysis to characterize tissues noninvasively with the ultimate goal of extracting directly from images indications of disease aggressiveness, prognosis, and therapeutic response. The integration of quantitative data with gene expression and patient clinical data, with the help of structured reporting as well, will in the near future give rise to decision support models for clinical practice that will hopefully improve diagnostic accuracy and prognostic power as well as ensure a more advanced level of precision medicine.

Smoking and combined oral contraceptives should be considered as an independent variable in sex and gender-oriented studies

The influence of sex combined with smoking and combined oral contraceptives (COC) use on atherogenic indexes is scarcely studied. Thus, traditional lipid parameters were measured, and non-traditional atherogenic indexes were calculated in a young and healthy population of men, COC-free women, and COC users. Total cholesterol (TChol), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and HDL/LDL ratio were lower in men, while triglycerides (TG)/HDL ratio, atherogenic index of plasma (AIP), Castelli's Risk Index I (CRII) and CRI-II, atherogenic coefficient (AC), creatinine, creatinine clearance, and estimated glomerular filtration rate (eGFR) were higher in men. The use of COC modified TChol, HDL, TG, TG/HDL, and AIP which had significantly higher values in COC users. In addition, TG were also increased in COC users in comparison with men. Smoking reduced sexually divergent parameters: BMI, TG, HDL/LDL, TG/HDL, AIP, CRII, CRI-II, and AC became similar among the three cohorts, losing the reported sex differences. Smoking also reduced differences in TChol, HDL, TG, and AIP between COC-free women and COC users, but it does not affect CRII, CRI-II, creatinine, creatinine clearance, and eGFR, underlining that COC users and COC-free women have to be considered two different populations. Our results represent a complex landscape suggesting that for both sexes smoking should be an independent variable in medical studies. Moreover, in women, the use of COC evidenced two different cohorts. Thus, more variables should be considered during a single study indicating that sex, smoking, and COC should be studied together to get a picture of the real-life context.

Maternal high-fat diet promotes calcified atherosclerotic plaque formation in adult offspring by enhancing transformation of VSMCs to osteochondrocytic-like phenotype

Aim

Maternal high-fat diet (HFD) is associated with the development of cardiovascular disease (CVD) in adult offspring. Atherosclerotic vascular calcification is well documented in patients with CVD. We examined the effect of maternal HFD on calcified plaque formation.

Methods and results

Seven-week-old female apo-E^−/− mice (C57BL6/J) were nourished either an HFD or a normal diet (ND) a week before mating, and during gestation and lactation. Offspring of both the groups were fed a high-cholesterol diet (HCD) from 8 weeks of age. Osteogenic activity of the thoracic aorta, assessed using an ex vivo imaging system, was significantly increased after 3 months of HCD in male offspring of HFD-fed dams (O-HFD) as compared with those of ND-fed dams (O-ND). Alizarin-red-positive area in the aortic root was significantly increased after 6 months of HCD in male O-HFD as compared to that of O-ND. Plaque size and Oil Red O-positive staining were comparable between the two groups. Primary cultured vascular smooth muscle cells (VSMCs) of the thoracic aorta were treated with phosphate and interleukinL-1β (IL-1β) to transform them into an osteochondrocytic-like phenotype. Intracellular calcium content and alkaline phosphatase activity were markedly higher in the VSMCs of O-HFD than in O-ND. IL-1β concentration in the supernatant of bone marrow-derived macrophages was markedly higher in O-HFD than in O-ND.

Conclusion

Our findings indicate that maternal HFD accelerates the expansion of atherogenic calcification independent of plaque progression. In vitro phosphate- and IL-1β-induced osteochondrocytic transformation of VSMCs was augmented in O-HFD. Inhibition of VSMCs, skewing toward osteochondrocytic-like cells, might be a potential therapeutic strategy for preventing maternal HFD-associated CVD development.

Cardiac CT angiography in current practice: An American society for preventive cardiology clinical practice statement✰

In this clinical practice statement, we represent a summary of the current evidence and clinical applications of cardiac computed tomography (CT) in evaluation of coronary artery disease (CAD), from an expert panel organized by the American Society for Preventive Cardiology (ASPC), and appraises the current use and indications of cardiac CT in clinical practice. Cardiac CT is emerging as a front line non-invasive diagnostic test for CAD, with evidence supporting the clinical utility of cardiac CT in diagnosis and prevention. CCTA offers several advantages beyond other testing modalities, due to its ability to identify and characterize coronary stenosis severity and pathophysiological changes in coronary atherosclerosis and stenosis, aiding in early diagnosis, prognosis and management of CAD. This document further explores the emerging applications of CCTA based on functional assessment using CT derived fractional flow reserve, peri‑coronary inflammation and artificial intelligence (AI) that can provide personalized risk assessment and guide targeted treatment. We sought to provide an expert consensus based on the latest evidence and best available clinical practice guidelines regarding the role of CCTA as an essential tool in cardiovascular prevention - applicable to risk assessment and early diagnosis and management, noting potential areas for future investigation.

The Diabetes-Cardiovascular Connection in Women: Understanding the Known Risks, Outcomes, and Implications for Care

PURPOSE OF REVIEW

Cardiovascular disease (CVD) complications constitute about 50-70% of mortality in people with diabetes. However, there remains a persistently greater relative increase in CVD morbidity and mortality in women with diabetes than in their male counterparts. This review presents recent evidence for the risks, outcomes, and management implications for women with diabetes.

RECENT FINDINGS

Compared to men, women have higher BMI and more adverse cardiovascular risk profile at time of diabetes diagnosis with greater risk for coronary heart disease, stroke, vascular dementia, and heart failure. Pregnancy-specific risk factors of gestational diabetes and pre-eclampsia are associated with future type 2 diabetes (T2D) and CVD. Women with T2D may experience greater benefits than men from GLP-1 receptor agonists. Women with diabetes are at greater relative risk for CVD complications than men, with poorer outcomes, superimposed on preexisting gender disparities in social determinants of health, lower likelihood of being offered cardioprotective interventions, and enrollment in trials. Further research and the utilization of SGLT-2 inhibitors, GLP-1 receptor agonists, and other CVD prevention strategies will help reduce morbidity and mortality.

Improving the enrollment of women and racially/ethnically diverse populations in cardiovascular clinical trials: An ASPC practice statement

Cardiovascular disease (CVD) remains the leading cause of death for both women and men worldwide. In the United States (U.S.), there are significant disparities in cardiovascular risk factors and CVD outcomes among racial and ethnic minority populations, some of whom have the highest U.S. CVD incidence and mortality. Despite this, women and racial/ethnic minority populations remain underrepresented in cardiovascular clinical trials, relative to their disease burden and population percentage. The lack of diverse participants in trials is not only a moral and ethical issue, but a scientific concern, as it can limit application of future therapies. Providing comprehensive demographic data by sex and race/ethnicity and increasing representation of diverse participants into clinical trials are essential in assessing accurate drug response, safety and efficacy information. Additionally, diversifying investigators and clinical trial staff may assist with connecting to the language, customs, and beliefs of study populations and increase recruitment of participants from diverse backgrounds. In this review, a working group for the American Society for Preventive Cardiology (ASPC) reviewed the literature regarding the inclusion of women and individuals of diverse backgrounds into cardiovascular clinical trials, focusing on prevention, and provided recommendations of best practices for improving enrollment to be more representative of the U.S. society into trials.

Secondary Prevention of Cardiovascular Disease in Women: Closing the Gap

Cardiovascular disease (CVD) remains the leading cause of death in women globally. Younger women (<55 years of age) who experience MI are less likely to receive guideline-directed medical therapy (GDMT), have a greater likelihood of readmission and have higher rates of mortality than similarly aged men. Women have been under-represented in CVD clinical trials, which limits the generalisability of results into practice. Available evidence indicates that women derive a similar benefit as men from secondary prevention pharmacological therapies, such as statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, icosapent ethyl, antiplatelet therapy, sodium–glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists. Women are less likely to be enrolled in cardiac rehabilitation programs than men. Mitigating risk and improving outcomes is dependent on proper identification of CVD in women, using appropriate GDMT and continuing to promote lifestyle modifications. Future research directed at advancing our understanding of CVD in women will allow us to further develop and tailor CVD guidelines appropriate by sex and to close the gap between diagnoses, treatment and mortality.