Relation of the Number of Parity to Left Ventricular Diastolic Function in Pregnancy

Exploring Sirtuins: New Frontiers in Managing Heart Failure with Preserved Ejection Fraction

With increasing research, the sirtuin (SIRT) protein family has become increasingly understood. Studies have demonstrated that SIRTs can aid in metabolism and affect various physiological processes, such as atherosclerosis, heart failure (HF), hypertension, type 2 diabetes, and other related disorders. Although the pathogenesis of HF with preserved ejection fraction (HFpEF) has not yet been clarified, SIRTs have a role in its development. Therefore, SIRTs may offer a fresh approach to the diagnosis, treatment, and prevention of HFpEF as a novel therapeutic intervention target.

Heart Failure Preserved Ejection Fraction in Women: Insights Learned from Imaging

While the prevalence of heart failure, in general, is similar in men and women, women experience a higher rate of HFpEF compared to HFrEF. Cardiovascular risk factors, parity, estrogen levels, cardiac physiology, and altered response to the immune system may be at the root of this difference. Studies have found that in response to increasing age and hypertension, women experience more concentric left ventricle remodeling, more ventricular and arterial stiffness, and less ventricular dilation compared to men, which predisposes women to developing more diastolic dysfunction. A multi-modality imaging approach is recommended to identify patients with HFpEF. Particularly, appreciation of sex-based differences as described in this review is important in optimizing the evaluation and care of women with HFpEF.

Sex matters: the frequently overlooked importance of considering sex in computational models

Personalised medicine and the development of a virtual human or a digital twin comprises visions of the future of medicine. To realise these innovations, an understanding of the biology and physiology of all people are required if we wish to apply these technologies at a population level. Sex differences in health and biology is one aspect that has frequently been overlooked, with young white males being seen as the "average" human being. This has not been helped by the lack of inclusion of female cells and animals in biomedical research and preclinical studies or the historic exclusion, and still low in proportion, of women in clinical trials. However, there are many known differences in health between the sexes across all scales of biology which can manifest in differences in susceptibility to diseases, symptoms in a given disease, and outcomes to a given treatment. Neglecting these important differences in the development of any health technologies could lead to adverse outcomes for both males and females. Here we highlight just some of the sex differences in the cardio-respiratory systems with the goal of raising awareness that these differences exist. We discuss modelling studies that have considered sex differences and touch on how and when to create sex-specific models. Scientific studies should ensure sex differences are included right from the study planning phase and results reported using sex as a biological variable. Computational models must have sex-specific versions to ensure a movement towards personalised medicine is realised.

Multiple Prior Live Births Are Associated With Cardiac Remodeling and Heart Failure Risk in Women

OBJECTIVE

Greater parity has been associated with cardiovascular disease risk. We sought to find whether the effects on cardiac remodeling and heart failure risk are clear.

METHODS

We examined the association of number of live births with echocardiographic measures of cardiac structure and function in participants of the Framingham Heart Study (FHS) using multivariable linear regression. We next examined the association of parity with incident heart failure with preserved (HFpEF) or reduced (HFrEF) ejection fraction using a Fine-Gray subdistribution hazards model in a pooled analysis of n = 12,635 participants in the FHS, the Cardiovascular Health Study, the Multi-Ethnic Study of Atherosclerosis, and Prevention of Renal and Vascular Endstage Disease. Secondary analyses included major cardiovascular disease, myocardia infarction and stroke.

RESULTS

Among n = 3931 FHS participants (mean age 48 ± 13 years), higher numbers of live births were associated with worse left ventricular fractional shortening (multivariable β -1.11 (0.31); P = 0.0005 in ≥ 5 live births vs nulliparous women) and worse cardiac mechanics, including global circumferential strain and longitudinal and radial dyssynchrony (P < 0.01 for all comparing ≥ 5 live births vs nulliparity). When examining HF subtypes, women with ≥ 5 live births were at higher risk of developing future HFrEF compared with nulliparous women (HR 1.93, 95% CI 1.19-3.12; P = 0.008); by contrast, a lower risk of HFpEF was observed (HR 0.58, 95% CI 0.37-0.91; P = 0.02).

CONCLUSIONS

Greater numbers of live births are associated with worse cardiac structure and function. There was no association with overall HF, but a higher number of live births was associated with greater risk for incident HFrEF.

Diastolic dysfunction and sex-specific progression to HFpEF: current gaps in knowledge and future directions

Diastolic dysfunction of the left ventricle (LVDD) is equally common in elderly women and men. LVDD is a condition that can remain latent for a long time but is also held responsible for elevated left ventricular filling pressures and high pulmonary pressures that may result in (exercise-induced) shortness of breath. This symptom is the hallmark of heart failure with preserved ejection fraction (HFpEF) which is predominantly found in women as compared to men within the HF spectrum. Given the mechanistic role of LVDD in the development of HFpEF, we review risk factors and mechanisms that may be responsible for this sex-specific progression of LVDD towards HFpEF from an epidemiological point-of-view and propose future research directions.

Sex differences in heart failure with preserved ejection fraction: From traditional risk factors to sex-specific risk factors

Heart failure with preserved ejection fraction has a higher prevalence in women versus men. There are several proposed mechanisms to explain this sex discrepancy including differences in cardiovascular adaptation to comorbidities and potential underlying etiologic mechanisms. In this review, we summarize sex differences in traditional risk factors, such as obesity, diabetes, hypertension, and coronary artery disease, which contribute to the development of heart failure with preserved ejection fraction in women. Furthermore, we explore female-specific risk factors, such as sex hormones, adverse pregnancy outcomes, and other reproductive factors, which may explain the predominance of heart failure with preserved ejection fraction in women. Beyond sex differences in risk factors, there are also significant sex differences in outcomes with women reporting lower quality of life but overall better survival versus men. Finally, while treatment options for patients with heart failure with preserved ejection fraction are still limited, sex differences have also been reported for the available therapies, with suggestion of preferential benefit of specific heart failure with preserved ejection fraction therapies in women. Further work is required to better understand sex differences in heart failure with preserved ejection fraction, including deeper understanding of pathophysiological mechanisms, derivation of more accurate risk stratification models, and increased representation of women in clinical trials.

Prolongation of QTc interval due to increased parity and great grand multiparity

Women are more prone to cardiac arrhythmias. Increased exposure to sex hormones may alter the ventricular repolarisation of the heart as the parity number increases. In this study, we aim to investigate the effect of parity number to electrocardiographic parameters. A total of 205 adult women were included for the study. Nulliparous (NP), primiparous (PP), multiparous (MP), grand multiparous (GMP) and great grand multiparous (GGMP) women constituted the study population. Increased parity has positive correlation with QTc interval (p=.000, r = 0.303). GGMP has significantly higher QTc compared to NP, PP, MP and GMP (p=.001, p=.000, p=.004 and p=.007, respectively). GGMP and parity have explanatory power on QTc (p=.019 and p=.020, respectively). Parity and GGMP affect cardiac repolarisation and prolong the QTc interval most probably due to repeated exposure to sex hormones. This study showed that GGMP and parity are independent risk factors for QTc interval prolongation.Impact StatementWhat is already known on this subject? Increased exposure to sex hormones may alter the ventricular repolarisation of the heart as the parity number increases. Previous studies showed that increased parity (up to 7) deteriorates ventricular diastolic functions, prolongs QTc interval and these conditions cause cardiovascular diseases.What do the results of this study add? In this study, we added great grand multiparity (10 or more parity) (GGMP) group that have never been studied before. We found that GGMP has much more impact on QTc prolongation than fewer parity groups and this result shows us that GGMP deteriorates ventricular functions more.What are the implications of these findings for clinical practice and/or further research? These results show us that women should be discouraged from having more delivery. Also, women with a pregnancy history of five and more (grand multiparity) should be evaluated with an electrocardiography and a cardiology consultation should be performed before re-conception. In the future, larger prospective studies are needed on this subject. In addition, other electrocardiographic parameters (QRS-T angle and Tpe/QTc in electrocardiography, etc.) that related with diastolic functions should be evaluated for comparison of GGMP and non-GGMP populations in future studies.

Recurrent births (multiparity) lead to permanent changes in cardiac structure

AIM

Although the effects of pregnancy on the cardiovascular system have been covered by many studies, permanent changes in the hearts of multiparous women have not been investigated. This study therefore aimed to examine the permanent structural changes in the cardiac structure of multiparous women via transthoracic echocardiography (TTE).

METHOD

This case-control study included 366 females who had given birth to 1-21 children, and 218 females with no previous deliveries. Anamnesis, physical examination, electrocardiography (ECG), TTE, and exercise stress tests were used to determine whether the cases had additional systemic pathologies. The structural cardiac parameters of all cases were recorded with TTE.

RESULTS

The study revealed that LV mass, LV mass index, left ventricular end diastolic volume (LVEDV), left ventricular end diastolic volume index (LVEDVI) were observed higher in women with five or more deliveries when compared to nulliparous women. On the other hand, ejection fraction (EF) was significantly lower in the same group. Receiver operating curve (ROC) analysis demonstrated that the prediction sensitivity for the presence of eccentric hypertrophy was 74% among women who had given >10.5 births, and its specificity was 97.8% (AUC: 0.949, 95% CI 0.905-0.993; p < 0.0001).

CONCLUSION

The results showed that women with recurrent births had increased left ventricular end diastolic volume, left ventricular total mass in myocardium and decreased EF due to increased end diastolic volume. The results also showed delivering at frequent intervals (especially the birth of 11 or more) may be one of the causes of eccentric hypertrophy, in women of the low-to-middle income countries.

Echocardiographic Assessments for Peripartum Cardiac Events in Pregnant Women with Low-Risk Congenital Heart Disease

This retrospective cohort study aimed to explore the relationship between temporal changes in the cardiac function and peripartum cardiac events in pregnant women with low-risk congenital heart disease.We performed echocardiography at early and late pregnancy and postpartum in 76 pregnant women with low-risk congenital heart disease, and compared echocardiographic parameters between subjects with and without peripartum cardiac events. Median age at delivery was 27 (range, 24-31) years. The ZAHARA and CARPREG II scores suggested that most women were found to be at low-risk for pregnancy. Fifteen subjects had cardiac events that included heart failure in 10, arrhythmia in 4, and pulmonary hypertension in one subject. The left ventricular and atrial volumes significantly increased from early pregnancy toward late pregnancy, and the E/A ratio and global longitudinal strain significantly decreased from early pregnancy toward late pregnancy. The left atrial volume (67 [53-79] versus 45 [35-55] mL, P = 0.002) and plasma brain natriuretic peptide level (58 [36-123] versus 34 [18-48] pg/mL, P = 0.026) at late pregnancy were significantly higher in subjects with cardiac events than in those without cardiac events.An increase in the left atrial volume followed by mild left ventricular diastolic dysfunction is related to peripartum cardiac events in women with congenital heart disease who are at low risk for cardiac events during pregnancy.

The correlation between maternal age, parity, cardiac diastolic function and occurrence rate of pre-eclampsia

To evaluate the effect of age and parity on maternal cardiac diastolic function in second trimester among pregnant women with normal left ventricular ejection fraction. To analyze the correlation between impaired diastolic function and pre-eclampsia. It had been suggested that maternal cardiac adaptations during pregnancy differed between nulliparous and primiparous women and also varied according to age. Impaired cardiac function may precede pre-eclampsia. Therefore, we examined the effects of parity and age on cardiac diastolic function during pregnancy and whether impaired diastolic function during the second trimester correlates with pre-eclampsia. Women with singleton pregnancies at 13 + 0 to 27 + 6 weeks’ gestation and left ventricular ejection fraction (LVEF) ≥ 50% were retrospectively identified. Diastolic function parameters were assessed using transthoracic echocardiography. Pre-eclampsia was identified from medical records. The effect of age and parity on maternal cardiac diastolic function as well as the correlation between impaired diastolic function and occurrence rate of pre-eclampsia were examined. 376 pregnant women were included (median age: 30 years; median gestational age: 14 weeks; 171 primiparous women). LVEF was 66%. Impaired cardiac diastolic function was seen in 7.8% of pregnant women < 35 years compared with 28.6% of those ≥ 35 years (p = 0.000). ROC curve showed women with maternal age over 32 began to have a higher rate of impaired cardiac diastolic function (AUC = 0.704, p = 0.000, sensitivity = 54.5%, specificity = 75.3%). There was no difference in diastolic function indices between maternal women grouped by parity. Higher maternal age was an independent risk factor of declining Em (p < 0.05). Em < 13 cm/s was significantly associated with pre-eclampsia occurrence (HR 8.56; 95% CI 3.40–21.57) after being adjusted for confounders. Maternal age is an independent risk factor for diastolic function decline. There is no difference in cardiac diastolic function between nulliparous women and primiparous women. Pre-eclampsia occurrence is significantly higher in patients with impaired diastolic function at mid-gestation. The application of risk grading using diastolic function at mid-gestation may improve the survival outcomes of pregnant women.

Reference values for 2-dimensional and M-mode echocardiography in Friesian and Warmblood horses

BACKGROUND

Echocardiographic reference intervals for Friesian horses are poorly described.

OBJECTIVES

To obtain reference intervals for echocardiographic measurements in Friesians and compare these with Warmbloods.

ANIMALS

One hundred healthy adult Friesians and 100 healthy adult Warmblood horses.

METHODS

Cross-sectional study. Two-dimensional and M-mode echocardiographic images were obtained. Echocardiographic measurements, including size, area, and volumetric measurements of left atrium, left and right ventricle, aorta, and pulmonary artery, were performed. Measurements were compared between the 2 breeds using an independent samples t test with Bonferroni correction for multiple comparisons.

RESULTS

Reference ranges for standard echocardiographic measurements in Friesians were obtained. Several left ventricular measurements were significantly smaller in Friesians compared to Warmbloods, such as the left ventricular end-diastolic volume using the 4-chamber modified Simpsons' method (99.85% confidence interval for the difference [CI] = -245 to -63). Also the right ventricular end-diastolic and peak-systolic internal diameter were smaller in Friesians (99.85% CI = -1.33 to -0.6 and 99.85% CI = -1.54 to -0.76, respectively). Fractional shortening (99.85% CI = 0.61-6) and ejection fraction (99.85% CI = 0.21-4.6) were significantly larger. No structural effects of systemic hypertension, such as concentric hypertrophy, were detected.

CONCLUSIONS AND CLINICAL IMPORTANCE

Our study provides reference intervals for echocardiographic measurements in Friesians useful in a clinical setting. In general, the left ventricular dimensions in Friesians were significantly smaller compared to Warmbloods, emphasizing the need for breed-specific reference intervals.

Coexisting Morbidities in Heart Failure: No Robust Interaction with the Left Ventricular Ejection Fraction

PURPOSE OF REVIEW

Heart failure (HF) patients often present with multiple coexisting morbidities. In this review, we contend that coexisting morbidities are highly prevalent and clinically important regardless of the left ventricular ejection fraction (LVEF).

RECENT FINDINGS

Multimorbidity is prevalent in the ambulatory subjects of the community and increases with age. Differences in the prevalence of coexisting morbidities between HF with preserved LVEF (> 50%), mid-range LVEF (40-50%), and reduced LVEF (< 40%) are either not demonstrable or whenever present are small and unrelated to morbidity and mortality. The constellation of coexisting morbidities together with the disease modifiers (age, sex, genes, other) defines the HF phenotype and outcome. There is no robust evidence supporting an interaction in HF patients between the prevalence and clinical significance of coexisting morbidities and the LVEF.

Multiparity, Brain Atrophy, and Cognitive Decline

Background

Multiparity – grand multiparity (i.e., five or more childbirths) in particular – has been reported to have an association with increased risk of Alzheimer’s disease (AD) dementia or related cognitive decline in women. However, the pathological links underlying this relationship are still unknown. This study was conducted to examine the relationships of multiparity with cerebral amyloid-beta (Aβ) deposition, brain atrophy, and white matter hyperintensities (WMHs).

Methods

In this study, total of 237 older women with 148 cognitively normal and 89 mild cognitive impairment from the Korean Brain Aging Study for Early Diagnosis and Prediction of Alzheimer’s Disease (KBASE) were included. Participants underwent clinical and neuropsychological assessments in addition to ¹¹C-labeled Pittsburgh Compound B positron emission tomography, and magnetic resonance imaging. The associations of parity with Aβ deposition, hippocampal volume, cortical volume, WMH volume and mini-mental status examination (MMSE) score were examined.

Results

Participants with grand multiparity showed significantly reduced adjusted hippocampal volume, spatial pattern of atrophy for recognition of AD volume and spatial pattern of atrophy for recognition of brain aging volume even after controlling for potential confounders. Furthermore, MMSE score was also significantly lower in this group. In contrast, grand multiparity did not show any association with global Aβ retention, Aβ positivity rate, or WMH volume, regardless of covariates.

Conclusion

Our findings suggest that grand multiparity contributes to cognitive decline or increased dementia risk in older women by aggravating amyloid-independent hippocampal or cortical atrophy.

The effect of parity on exercise physiology in women with heart failure with preserved ejection fraction

Aims

Women are overrepresented amongst patients with heart failure with preserved ejection fraction (HFpEF); however, the underpinning mechanism for this asymmetric distribution is unclear. Pregnancy represents a potential gender‐specific risk factor for HFpEF. It leads to significant physiological adaption, and increasing parity has been associated with some cardiovascular risk. We sought to examine the relationship between prior parity with the rest and exercise haemodynamic and echocardiographic profile of women with HFpEF.

Methods and results

Patients referred for assessment of exertional dyspnoea and confirmed to have a haemodynamic and clinical profile consistent with HFpEF were included. Detailed evaluation consisted of rest and exercise right heart catheterization and echocardiography. A socio‐economic and obstetric history was also documented. Fifty‐eight women were assessed and categorized as having either 0–2 births or ≥3 births, dividing the cohort equally. Women with ≥3 births achieved a lower symptom‐limited workload than those with 0–2 births [38 (24–51) vs. 46 (31–68) W, P = 0.04]. Women with ≥3 births had a greater rise in pulmonary capillary wedge pressure indexed to workload with exercise [0.5 (0.3–0.8) vs. 0.3 (0.2–0.5) mmHg/W, P = 0.03], paralleled by a greater rise in right atrial pressure [10 (8–12) vs. 7 (3–11), P = 0.01]. Pulmonary vascular resistance was also higher in women with ≥3 births [1.9 (1.6–2.4) vs. 1.6 (1.4–1.9) mmHg/L/min rest, P = 0.046, and 1.9 (2.4–2.4) vs. 1.4 (1–1.8) mmHg/L/min exercise, P = 0.024]. Left ventricular ejection fraction was lower at rest [60 (57–61) vs. 63 (60–66), P = 0.008] and during exercise [65 (62–67) vs. 68 (66–70), P = 0.038] in women with higher parity.

Conclusions

Higher parity is associated with greater impairments in multiple physiologic parameters of HFpEF severity in women, including diastolic reserve, pulmonary vascular resistance, and systolic dysfunction.

Sex differences in heart failure

The overall lifetime risk of heart failure (HF) is similar between men and women, however, there are marked sex differences in the landscape of this condition that are both important and under-recognized. Men are predisposed to HF with reduced ejection fraction (HFrEF), whereas women predominate in HF with preserved ejection fraction (HFpEF). Sex differences are also notable in the penetrance of genetic cardiomyopathies, risk factors, e.g. breast cancer which may be associated with cancer treatment-induced cardiomyopathy, as well as sex-specific conditions such as peripartum cardiomyopathy (PPCM). This review outlines the key sex differences with respect to clinical characteristics, pathophysiology, and therapeutic responses to HF treatments. Finally, we address important differences in the prognosis of HF. A central hypothesis is that the higher risk of HFrEF in men compared to women may be attributable to their predisposition to macrovascular coronary artery disease and myocardial infarction, whereas coronary microvascular dysfunction/endothelial inflammation has been postulated to play a key role in HFpEF and maybe the common link among HF syndromes that women are predisposed to Takotsubo cardiomyopathy, PPCM, and breast cancer radiotherapy-induced cardiomyopathy. Under-pinning current sex disparities in HF, there is a paucity of women recruited to HF clinical trials (20–25% of cohorts) and thus treatment guidelines are predominantly based on male-derived data. Large gaps in knowledge exist in sex-specific mechanisms, optimal drug doses for women and sex-specific criteria for device therapy.

Sex Differences in Cardiovascular Pathophysiology: Why Women Are Overrepresented in Heart Failure With Preserved Ejection Fraction

Consistent epidemiological data demonstrate that patients with heart failure with preserved ejection fraction (HFpEF) are more likely to be women than men. Exploring mechanisms behind this sex difference in heart failure epidemiology may enrich the understanding of underlying HFpEF pathophysiology and phenotypes, with the ultimate goal of identifying therapeutic approaches for the broader HFpEF population. In this review we evaluate the influence of sex on the key domains of cardiac structure and function, the systemic and pulmonary circulation, as well as extracardiac factors and comorbidities that may explain the predisposition of women to HFpEF. We highlight the potential role of factors exclusive to or more prevalent in women such as pregnancy, preeclampsia, and iron deficiency. Finally, we discuss existing controversies and gaps in knowledge, as well as the clinical importance of known sex differences in the context of the potential need for sex-specific diagnostic criteria, improved risk stratification models, and targeted therapies.

Effects of multiparity on left ventricular diastolic dysfunction in women: cross-sectional study of the KoRean wOmen'S chest pain rEgistry (KoROSE)

OBJECTIVES

To investigate the association between left ventricular (LV) diastolic dysfunction and multiparity in patients with suspected coronary artery disease (CAD).

DESIGN

Cross-sectional study.

SETTING

Linked secondary and tertiary care records from 29 cardiac centres which participated in KoRean wOmen'S chest pain rEgistry.

PARTICIPANTS

960 women with suspected CAD who underwent invasive coronary angiography from February 2011 to May 2017. The patients were classified by parity number, as follows: low-parity, 0 to <3; multiparity, ≥3 pregnancies.

MAIN OUTCOME MEASURE

Prevalence of LV diastolic dysfunction.

RESULTS

There were 302 and 658 low-parity and multiparity patients, respectively. The prevalence of LV diastolic dysfunction was significantly higher in the multiparity than in the low-parity group. The multiparity group had significantly lower E and e´ septal velocities and E/A ratio, and had a significantly higher E/e´ ratio and right ventricular systolic pressure, which are parameters of LV diastolic dysfunction, than the low-parity group. The prevalence of CAD was significantly higher in the multiparity than in the low-parity group. Receiver operating characteristic curve analysis identified a parity of 2.5 as the cut-off for predicting LV diastolic dysfunction (area under the curve, 0.66; sensitivity, 74.1%; specificity, 52.0%; 95% CI 0.607 to 0.706; p<0.001). After adjustment for confounding factors, multivariate regression analysis showed that multiparity had a 1.80-fold increased risk for LV diastolic dysfunction (OR 1.80, 95% CI 1.053 to 3.081, p=0.032).

CONCLUSIONS

The prevalence of LV diastolic dysfunction was higher in multiparity than in low-parity women with suspected CAD. Multiparity was an independent risk factor for LV diastolic dysfunction. LV diastolic dysfunction should be evaluated in multiparous women for the risk of subsequent cardiovascular disease and facilitate the initiation of appropriate treatment.