Addressing the Bias in Cardiovascular Care: Missed & Delayed Diagnosis of Cardiovascular Disease in Women

Psychosocial distress and health status as risk factors for ten-year major adverse cardiac events and mortality in patients with non-obstructive coronary artery disease

BACKGROUND

We examined the risk of psychosocial distress, including Type D personality, depressive symptoms, anxiety, positive mood, hostility, and health status fatigue and disease specific and generic quality of life for MACE in patients with non-obstructive coronary artery disease (NOCAD).

METHODS

In the Tweesteden mild stenosis (TWIST) study, 546 patients with NOCAD were followed for 10 years to examine the occurrence of cardiac mortality, a major cardiac event, or non-cardiac mortality in the absence of a cardiac event. Cox proportional hazard models were used to examine the impact of psychosocial distress and health status on the occurrence of MACE while adjusting for age, sex, disease severity, and lifestyle covariates.

RESULTS

In total 19% of the patients (mean age baseline = 61, SD 9 years; 52% women) experienced MACE, with a lower risk for women compared to men. Positive mood (HR 0.97, 95%CI 0.95-1.00), fatigue (HR 1.03, 95%CI 1.00-1.06), and physical limitation (HR 0.99, 95%CI 0.98-1.00) were associated with MACE in adjusted models. No significant interactions between sex and psychosocial factors were present. Depressive symptoms were predictive of MACE, but no longer after adjustment.

CONCLUSIONS

In patients with NOCAD fatigue, low positive mood, and a lower physical limitation score were associated with MACE, without marked sex differences. Type D personality, psychosocial factors, and health status were not predictive of adverse outcomes. Reducing psychosocial distress is a valid intervention goal by itself, though it is less likely to affect MACE in patients with NOCAD.

Real-World Evaluation of an Automated Algorithm to Detect Patients With Potentially Undiagnosed Hypertension Among Patients With Routine Care in Hawai'i

BACKGROUND

This real-world evaluation considers an algorithm designed to detect patients with potentially undiagnosed hypertension, receiving routine care, in a large health system in Hawai'i. It quantifies patients identified as potentially undiagnosed with hypertension; summarizes the individual, clinical, and health system factors associated with undiagnosed hypertension; and examines if the COVID-19 pandemic affected detection.

METHODS AND RESULTS

We analyzed the electronic health records of patients treated across 6 clinics from 2018 to 2021. We calculated total patients with potentially undiagnosed hypertension and compared patients flagged for undiagnosed hypertension to those with diagnosed hypertension and to the full patient panel across individual characteristics, clinical and health system factors (eg, clinic of care), and timing. Modified Poisson regression was used to calculate crude and adjusted risk ratios. Among the eligible patients (N=13 364), 52.6% had been diagnosed with hypertension, 2.7% were flagged as potentially undiagnosed, and 44.6% had no evidence of hypertension. Factors associated with a higher risk of potentially undiagnosed hypertension included individual characteristics (ages 40-84 compared with 18-39 years), clinical (lack of diabetes diagnosis) and health system factors (clinic site and being a Medicaid versus a Medicare beneficiary), and timing (readings obtained after the COVID-19 Stay-At-Home Order in Hawai'i).

CONCLUSIONS

This evaluation provided evidence that a clinical algorithm implemented within a large health system's electronic health records could detect patients in need of follow-up to determine hypertension status, and it identified key individual characteristics, clinical and health system factors, and timing considerations that may contribute to undiagnosed hypertension among patients receiving routine care.

A Moderate Walking Test Predicts Survival in Women With Cardiovascular Disease

INTRODUCTION

Cardiovascular disease (CVD) is the principal cause of death in U.S. women. Peak oxygen uptake is strongly related to mortality and CVD. This study aimed to investigate the association between estimated peak oxygen uptake, determined using a moderate 1-km walking test, and all-cause mortality in female patients with stable CVD.

METHODS

Of the 482 women in our registry between 1997 and 2020, we included 430 participants in the analysis (aged 67 [34-88] years). A Cox proportional hazard model was used to determine the variables significantly associated with mortality. On the basis of the peak oxygen uptake estimated using the 1-km walking test, the sample was subdivided into tertiles, and mortality risk was calculated. The discriminatory accuracy of peak oxygen uptake in estimating survival was assessed by receiver operating characteristic curves. All results were adjusted for demographic and clinical covariates.

RESULTS

A total of 135 deaths from any cause occurred over a median of 10.4 years (IQR=4.4-16.4), with an average annual mortality of 4.2%. Estimated peak oxygen uptake was a stronger predictor of all-cause mortality than demographic and clinical variables (c-statistic-0.767; 95% CI=0.72, 0.81; p<0.0001). The survival rate decreased from the highest tertile of fitness to the lowest. Compared with the lowest group, hazard ratios (95% CIs) for the second and third tertiles were 0.55 (0.37, 0.83) and 0.29 (0.16, 0.51), respectively (p for trend <0.0001).

CONCLUSIONS

Higher peak oxygen uptake levels were associated with a lower risk of all-cause mortality. The indirect estimation of peak oxygen uptake using the 1-km walking test is feasible and can be applied for risk stratification among female patients undergoing secondary prevention programs.

A narrative review of heart failure with preserved ejection fraction in breast cancer survivors

Advances in breast cancer (BC) treatment have contributed to improved survival, but BC survivors experience significant short-term and long-term cardiovascular mortality and morbidity, including an elevated risk of heart failure with preserved ejection fraction (HFpEF). Most research has focused on HF with reduced ejection fraction (HFrEF) after BC; however, recent studies suggest HFpEF is the more prevalent subtype after BC and is associated with substantial health burden. The increased HFpEF risk observed in BC survivors may be explained by treatment-related toxicity and by shared risk factors that heighten risk for both BC and HFpEF. Beyond risk factors with physiological impacts that drive HFpEF risk, such as hypertension and obesity, social determinants of health (SDOH) likely contribute to HFpEF risk after BC, impacting diagnosis, management and prognosis.Increasing clinical awareness of HFpEF after BC and screening for cardiovascular (CV) risk factors, in particular hypertension, may be beneficial in this high-risk population. When BC survivors develop HFpEF, treatment focuses on initiating guideline-directed medical therapy and addressing underlying comorbidities with pharmacotherapy or behavioural intervention. HFpEF in BC survivors is understudied. Future directions should focus on improving HFpEF prevention and treatment by building a deeper understanding of HFpEF aetiology and elucidating contributing risk factors and their pathogenesis in HFpEF in BC survivors, in particular the association with different BC treatment modalities, including radiation therapy, chemotherapy, biological therapy and endocrine therapy, for example, aromatase inhibitors. In addition, characterising how SDOH intersect with these therapies is of paramount importance to develop future prevention and management strategies.

Exploring the relationship between self-employment and women’s cardiovascular health

Background

Compared with wage and salary work, self-employment has been linked to more favorable cardiovascular health outcomes within the general population. Women comprise a significant proportion of the self-employed workforce and are disproportionately affected by cardiovascular disease. Self-employed women represent a unique population in that their cardiovascular health outcomes may be related to gender-specific advantages of non-traditional employment. To date, no studies have comprehensively explored the association between self-employment and risk factors for cardiovascular disease among women.

Methods

We conducted a weighted cross-sectional analysis using data from the University of Michigan Health and Retirement Study (HRS). Our study sample consisted of 4624 working women (employed for wages and self-employed) enrolled in the 2016 HRS cohort. Multivariable linear and logistic regression were used to examine the relationship between self-employment and several self-reported physical and mental health risk factors for cardiovascular disease, controlling for healthcare access.

Results

Among working women, self-employment was associated with a 34% decrease in the odds of reporting obesity, a 43% decrease in the odds of reporting hypertension, a 30% decrease in the odds of reporting diabetes, and a 68% increase in the odds of reporting participation in at least twice-weekly physical activity (p < 0.05). BMI for self-employed women was on average 1.79 units lower than it was for women working for wages (p < 0.01).

Conclusions

Employment structure may have important implications for cardiovascular health among women, and future studies should explore the causal relationship between self-employment and cardiovascular health outcomes in this population.

Trial Registration: Not applicable.

ShareHeart: A patient journey map of patients with ischemia and non-obstructive coronary artery disease based on qualitative research

AIMS AND OBJECTIVES

To visualise the health care experiences and needs of patients with ischemia with non-obstructive coronary arteries in a patient journey map. As such, future design challenges can be provided, and it can be used for future healthcare optimization.

BACKGROUND

Ischemia with non-obstructive coronary arteries is a chronic cardiac condition caused by vascular dysfunctions. Ischemia with non-obstructive coronary arteries is often unrecognised, significantly impairs daily functioning, and is more prevalent among women. Patients' experiences remain unexplored, and a clear patient-centered care pathway is lacking.

DESIGN

A qualitative interpretative research design was performed and the standards for reporting qualitative research (SRQR) has been used.

METHODS

In total, 36 women were included and participated in eight semi-structured focus group interviews. Thematic analysis was used, and identified themes were further classified using 'patient journey mapping.' Additionally, Picker's 'eight principles of patient-centered care' were linked to the results and integrated in the patient journey map.

RESULTS

Participants experienced a lack of familiarity with the specific cardiac condition by healthcare providers, repeated hospitalisation, testing and referrals, shortage of specialised cardiologists, and feelings of not being heard. In addition, needs for a multidisciplinary treatment program (including physical and psychological support), better information provision, and an easily accessible contact person were expressed.

CONCLUSIONS

The resulting patient journey map shows how patients experienced and interacted with the current healthcare system. Overall, the results show a complex and long healthcare pathway and important themes for healthcare experiences and needs were identified. Future research could focus on the development and implementation of a patient-centered evidence-based clinical pathway optimising experiences and quality of life.

RELEVANCE TO CLINICAL PRACTICE

The visual tool can help health care professionals, policy makers, and researchers improve healthcare provision which is patient-centered and tailored to the preferences of patients with ischemia with non-obstructive coronary arteries.