Smoking and sex differences in first manifestation of cardiovascular disease

Socioeconomic Disparities in Women's Cardiovascular Health in the United States and Canada

Cardiovascular disease has been the leading cause of death in the United States and Canada for decades. Although it affects millions of people across a multitude of backgrounds, notable disparities in cardiovascular health are observed among women and become more apparent when accounting for race and socioeconomic status. Although intrinsic sex-specific physiologic differences predispose women to poorer outcomes, social determinants of health (SDOH) and biases at both the individual provider and the larger health care system levels play an equal, if not greater, role. This review examines socioeconomic disparities in women compared with men regarding cardiovascular risk factors, treatments, and outcomes. Although various at-risk subpopulations exist, we highlight the impact of SDOH in specific populations, including patients with disabilities, transgender persons, and South Asian and Indigenous populations. These groups are underrepresented in studies and experience poorer health outcomes owing to structural barriers to care. These findings emphasise the significance of understanding the interplay of different socioeconomic factors and how their stacking can negatively affect women's cardiovascular health. To address these disparities, we propose a multipronged approach to augment culturally sensitive and patient-centred care. This includes increased cardiovascular workforce diversity, inclusion of underrepresented populations into analyses of cardiovascular metrics, and greater utilisation of technology and telemedicine to improve access to health care. Achieving this goal will necessitate active participation from patients, health care administrators, physicians, and policy makers, and is imperative in closing the cardiovascular health gap for women over the coming decades.

Closing the sex gap in cardiovascular mortality by achieving both horizontal and vertical equity

Addressing sex differences and disparities in coronary heart disease (CHD) involves achieving both horizontal and vertical equity in healthcare. Horizontal equity in the context of CHD means that both men and women with comparable health statuses should have equal access to diagnosis, treatment, and management of CHD. To achieve this, it is crucial to promote awareness among the general public about the signs and symptoms of CHD in both sexes, so that both women and men may seek timely medical attention. Women often face inequity in the treatment of cardiovascular disease. Current guidelines do not differ based on sex, but their applications based on gender do differ. Vertical equity means tailoring healthcare to allow equitable care for all. Steps towards achieving this include developing treatment protocols and guidelines that consider the unique aspects of CHD in women. It also requires implementing guidelines equally, when there is not sex difference rather than inequities in application of guideline directed care.

Differences in Risk Factors for Coronary Atherosclerosis According to Sex

Interest in sex differences related to coronary artery disease (CAD) has steadily increased, and the risk factors for CAD show distinct sex differences. For women, cardiovascular risk increases significantly after menopause due to a decrease in estrogen levels. In older individuals, increased arterial stiffness results in a higher pulse pressure, leading to a more common occurrence of isolated systolic hypertension; these changes are more noticeable in women. While the incidence of diabetes is similar in both sexes, women with diabetes face a 50% higher relative risk of fatal coronary heart disease compared to men. Smoking significantly increases the risk of ischemic heart disease in women, particularly those who are younger. The decrease in estrogen in women leads to a redistribution of fat, resulting in increased abdominal obesity and, consequently, an elevated cardiovascular risk. Pregnancy and reproductive factors also have a significant impact on CAD risks in women. Additionally, disparities exist in medical practice. Women are less likely to be prescribed cardioprotective drugs, referred for interventional or surgical treatments, or included in clinical research than men. By increasing awareness of these sex differences and addressing the disparities, we can progress toward more personalized treatment strategies, ultimately improving patient outcomes.

Clinical determinants of ischemic heart disease in Eastern Europe

Cardiovascular inequalities remain pervasive in the European countries. Disparities in disease burden is apparent among population groups based on sex, ethnicity, economic status or geography. To address this challenge, The Lancet Regional Health - Europe convened experts from a broad range of countries to assess the current state of knowledge of cardiovascular disease inequalities across Europe. This report presents the main challenges in Eastern Europe. There were pronounced variations in cardiovascular disease mortality rates across Eastern European countries with a remarkably high disease burden in the North-Eastern Europe. There were also significant differences in access and delivery to healthcare and unmet healthcare needs. Addressing the cardiovascular determinants of health and reducing health disparities in its many dimensions has long been a priority of the European Parliament's work through resolutions and by financing pilot projects. Yet, despite these efforts, few large-scale studies have been conducted to examine the feasibility of reducing cardiovascular disparities in Eastern Europe. There is an urgent need for improved data, measurements, reporting, and comparisons; and for dedicated, collaborative research. There is also a need for a broader understanding of the typology of actions needed to tackle cardiovascular inequalities and a clear political will.

Clinical challenges facing patient participation in cardiac rehabilitation: cigarette smoking

INTRODUCTION

Cardiac rehabilitation (CR) is highly effective at reducing morbidity and mortality. However, CR is underutilized, and adherence remains challenging. In no group is CR attendance more challenging than among patients who smoke. Despite being more likely to be referred to CR, they are less likely to enroll, and much more likely to drop out. CR programs generally do not optimally engage and treat those who smoke, but this population is critical to engage given the high-risk nature of continued smoking in those with cardiovascular disease.

AREAS COVERED

This review covers four areas relating to CR in those who smoke. First, we review the evidence of the association between smoking and lack of participation in CR. Second, we examine how smoking has historically been identified in this population and propose objective screening measures for all patients. Third, we discuss the optimal treatment of smoking within CR. Fourth, we review select populations within those who smoke (those with lower-socioeconomic status, females) that require additional research and attention.

EXPERT OPINION

Smoking poses a challenge on multiple fronts, being a significant predictor of future morbidity and mortality, as well as being strongly associated with not completing the secondary prevention program (CR) that could benefit those who smoke the most.

Sex-based differences in risk of cardiovascular disease development and cardiovascular risk factors among individuals with hypertension: A cross-sectional study from primary care facilities

BACKGROUND

Over the last two decades, the understanding of cardiovascular disease (CVD) has expanded in Asian countries. Despite this progress, there have been limited investigations into sex-based differences in the development of CVD and cardiovascular risk factors (CVRFs).

AIM

We investigated whether males and females with hypertension had different risks of developing CVD and CVRFs.

METHODS

We used a stratified multi-stage sampling design involving 15 primary care centers in Thailand. We recruited 1,448 individuals aged 35-74 years old. The Framingham cardiovascular risk algorithm was used to determine the risk of CVD development.

RESULTS

Female patients were overall more likely to have lower CVD risk scores. However, they demonstrated higher scores in the moderate-risk (p < 0.001) and high-risk (p < 0.001) groups as compared with males. One in four females was at a high risk of developing CVD. Females had higher rates of all CVRFs against males across sub-risk groups, with the highest odds ratio observed in the high-risk group, which persisted after adjusting for covariations. Overall, female patients had higher rates of diabetes, hyperlipidemia, obesity, and abdominal obesity as compared with males. Females in the overall group had a lower prevalence of uncontrolled hypertension than males, in contrast to the high-risk group. Female patients also had a lower prevalence of cigarette smoking and alcohol consumption than males.

CONCLUSION

There is evidence of sex-based differences in the risk of CVD development in hypertensive individuals. The interaction of CVRFs with a high risk of developing CVD was noted in females.

Sex differences in epigenetic age in Mediterranean high longevity regions

Sex differences in aging manifest in disparities in disease prevalence, physical health, and lifespan, where women tend to have greater longevity relative to men. However, in the Mediterranean Blue Zones of Sardinia (Italy) and Ikaria (Greece) are regions of centenarian abundance, male-female centenarian ratios are approximately one, diverging from the typical trend and making these useful regions in which to study sex differences of the oldest old. Additionally, these regions can be investigated as examples of healthy aging relative to other populations. DNA methylation (DNAm)-based predictors have been developed to assess various health biomarkers, including biological age, Pace of Aging, serum interleukin-6 (IL-6), and telomere length. Epigenetic clocks are biological age predictors whose deviation from chronological age has been indicative of relative health differences between individuals, making these useful tools for interrogating these differences in aging. We assessed sex differences between the Horvath, Hannum, GrimAge, PhenoAge, Skin and Blood, and Pace of Aging predictors from individuals in two Mediterranean Blue Zones and found that men displayed positive epigenetic age acceleration (EAA) compared to women according to all clocks, with significantly greater rates according to GrimAge (β = 3.55; p = 1.22 × 10^-12), Horvath (β = 1.07; p = 0.00378) and the Pace of Aging (β = 0.0344; p = 1.77 × 10^-08). Other DNAm-based biomarkers findings indicated that men had lower DNAm-predicted serum IL-6 scores (β = -0.00301, p = 2.84 × 10^-12), while women displayed higher DNAm-predicted proportions of regulatory T cells than men from the Blue Zone (p = 0.0150, 95% Confidence Interval [0.00131, 0.0117], Cohen's d = 0.517). All clocks showed better correlations with chronological age in women from the Blue Zones than men, but all clocks showed large mean absolute errors (MAE >30 years) in both sexes, except for PhenoAge (MAE <5 years). Thus, despite their equal survival to older ages in these Mediterranean Blue Zones, men in these regions remain biologically older by most measured DNAm-derived metrics than women, with the exception of the IL-6 score and proportion of regulatory T cells.

Representational ethical model calibration

Equity is widely held to be fundamental to the ethics of healthcare. In the context of clinical decision-making, it rests on the comparative fidelity of the intelligence - evidence-based or intuitive - guiding the management of each individual patient. Though brought to recent attention by the individuating power of contemporary machine learning, such epistemic equity arises in the context of any decision guidance, whether traditional or innovative. Yet no general framework for its quantification, let alone assurance, currently exists. Here we formulate epistemic equity in terms of model fidelity evaluated over learnt multidimensional representations of identity crafted to maximise the captured diversity of the population, introducing a comprehensive framework for Representational Ethical Model Calibration. We demonstrate the use of the framework on large-scale multimodal data from UK Biobank to derive diverse representations of the population, quantify model performance, and institute responsive remediation. We offer our approach as a principled solution to quantifying and assuring epistemic equity in healthcare, with applications across the research, clinical, and regulatory domains.

Sex-specific risk factors of carotid atherosclerosis progression in a high-risk population of cardiovascular disease

BACKGROUND

The progression of carotid intima-media thickness (cIMT) and plaques are associated with cardiovascular health, especially for high-risk population of cardiovascular disease (CVD).

HYPOTHESIS

Risk factors for atherosclerosis may vary by sex. This study aimed to investigate the sex-specific risk factors of cIMT and plaque progression.

METHODS

We selected subjects who were identified as high-risk population of CVD, and collected their carotid ultrasound data and baseline characteristics. Linear regression and logistic regression analyses were used to identify risk factors for cIMT and plaque progression. Sex-specific risk factors were identified respectively.

RESULTS

A total of 7908 participants were included. The mean age was 57.75 ± 9.45 years and 61.51% were female. During mean follow-up of 1.92 ± 0.89 years, the median annual cIMT change rate was -7.25 μm/year. Seven hundred and fifteen subjects free from plaques at baseline developed plaque. Age, smoking, hypertension, and diabetes were common risk factors for carotid atherosclerosis progression in all participants. Smoking and alcohol drinking were significantly associated with increased cIMT change in women, while hypertension and antihypertensive medication were significant in men. Increased total cholesterol and diabetes were significantly associated with new plaque presence in women, while smoking, increased triglyceride, and dyslipidemia were significant in men (p ˂ .05 for all cases). The association of baseline cIMT and smoking with annual cIMT change rate and increased total cholesterol with new plaque presence were significantly differentiated between both sexes (p for interaction ˂ .05).

CONCLUSIONS

The risk factors for cIMT and plaque progression differed by sex.

No Paradoxical Effect of Smoking Status on Recurrent Cardiovascular Events in Patients Following Percutaneous Coronary Intervention: Thai PCI Registry

Background

"Smoker's paradox" is a controversial phenomenon that describes an unexpectedly favorable short-term outcome of smokers post-percutaneous coronary intervention (PCI). This study aimed to evaluate the effect of smoking status on recurrent major adverse cardiovascular events (MACEs) in patients who recently underwent PCI and to determine whether it was paradoxical.

Methods

This study utilized data from the nationwide Thai PCI registry, enrolling patients during 2018-2019. Our study factor was smoking status, classified as current smokers, ex-smokers, and nonsmokers. The outcome of interest was the time to occurrence of a composite of MACEs (i.e., all-cause death, myocardial infarction (MI), stroke, and unplanned revascularization) evaluated at about 1-year post-PCI. A propensity score (PS) model using inverse probability weighting with regression adjustment was used to estimate the effect of smoking on the occurrence of MACE.

Results

Current smokers, ex-smokers, and non-smokers accounted for 23, 32, and 45% of the 22,741 subjects, respectively. Smokers were younger, more frequently male, and had fewer traditional atherosclerotic risk factors. Current smokers presented more frequently with ST-elevation MIs (STEMIs) and cardiogenic shock (54 and 14.6%, respectively) than non-smokers. MACE rates were 1.9, 1.2, and 1.6 per 100 patients per month in the current smokers, ex-smokers, and non-smokers, respectively. After applying a PS, patients with a history of current smoking and ex-smoking developed the onset of recurrent MACEs significantly sooner than non-smokers, with a median time of 4.4 vs. 4.9 vs. 13.5 months (p < 0.001), respectively.

Conclusions

"Smoker's paradox" was not observed in our patient population. Current smokers and ex-smokers were prone to develop an earlier onset of a post-PCI MACEs than nonsmokers and need a smoke cessation program for further prevention.

Acute Nonatherosclerotic Coronary Thromboembolism Presenting with an Inferior STEMI in a Patient on Oral Contraception

BACKGROUND

Direct coronary embolism in the setting of oral contraceptive pill (OCP) use is a rare adverse effect. It is known for OCP to increase the risk of thrombosis; however, leading to an inferior ST elevated myocardial infarction (STEMI) due to an acute occlusive embolism is a rare entity. Coronary embolism occurs in about 3% of patients with acute coronary syndrome. Case Report. We present a case of a young 41-year-old female with a past medical history significant for dysfunctional uterine bleeding on oral contraceptive pills, who presented to the hospital with chest pain. Her workup was significant for troponin elevation and an electrocardiogram showing inferior ST elevations. The patient was taken emergently to the cardiac catheterization lab. A coronary angiogram revealed a coronary thrombus involving the distal left main and proximal left anterior descending (LAD) with no evidence of atherosclerotic disease. The patient subsequently received anticoagulation therapy leading to complete resolution of symptoms and ST elevations.

CONCLUSION

Coronary embolism is rare and often not considered in the differential of acute coronary syndrome. It is of utmost importance for clinicians to keep a wide differential of nonatherosclerotic causes of STEMI especially when the patient is young, without significant cardiac risk factors.