Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies

QUIET WARRIOR - Rationale and design: An ancillary study to the Women's IschemiA TRial to Reduce Events in Nonobstructive CAD (WARRIOR)

Background

Cardiovascular disease is the leading cause of death among women in the US, predominantly due to ischemic heart disease (IHD). There is a notable deficiency in therapies tailored for IHD in women, who often present with variable symptoms that delay diagnosis and treatment. In many cases, coronary angiography does not reveal obstructive coronary artery disease (CAD) despite increased risk for major adverse cardiac events (MACE) compared with sex and age-matched asymptomatic cohorts.

Objectives

The Women's IschemiA TRial to Reduce Events in Nonobstructive CAD (WARRIOR) evaluates intensive medical treatment for women with Ischemia with No Obstructive Coronary Arteries (INOCA). The QUIET WARRIOR sub-study aims to improve predictive tools for adverse outcomes by detailed analysis of Coronary Computed Tomography Angiography (CCTA) data and biorepository samples. These data will also uncover pathophysiological mechanisms associated with angina and MACE, improving predictive tools for symptomatic women with INOCA.

Methods

This ancillary study will analyze CCTA images from 600 WARRIOR subjects. It will assess clinical, social, and coronary artery variables, including plaque characteristics and markers of inflammation. Advanced imaging techniques and machine-learning models will be employed to quantify plaque features and predict clinical outcomes.

Expected results

The study aims to elucidate associations between CCTA-derived plaque characteristics, ischemic symptoms, and MACE. Anticipated findings include correlations of specific plaque attributes with angina severity and novel insights into inflammatory markers. Socioeconomic variables will also be examined for their impact on cardiovascular risk.

Conclusion

The QUIET WARRIOR sub-study will advance the understanding of INOCA in women, integrating clinical, imaging, and socioeconomic data to enhance risk prediction and guide personalized therapeutic strategies. This research will address critical gaps in managing nonobstructive CAD, promoting more equitable cardiovascular care.

Coronary Microvascular Dysfunction and Vasospastic Angina-Pathophysiology, Diagnosis and Management Strategies

Coronary artery disease is one of the leading public health problems in the world in terms of mortality and economic burden from the disease. Traditionally, the focus of research and clinical pathways leading to the diagnosis and treatment of coronary artery disease was on the more common variant of the disease resulting from atherosclerosis in the epicardial coronary arteries. However, coronary microvasculature, representing the vast majority of the total heart circulation, has the greatest influence on overall coronary resistance and, therefore, blood flow. Coronary microvascular dysfunction (CMD), characterized by structural or functional abnormalities in the microvasculature, significantly impacts myocardial perfusion. Endothelial dysfunction results in inadequate coronary dilation during exercise or spontaneous spasm in the microvasculature or epicardial arteries. A significant proportion of people presenting for coronary angiography in the context of angina have unobstructed epicardial coronary arteries yet are falsely reassured about the benign nature of their condition. Meanwhile, increasing evidence indicates that patients diagnosed with CMD as well as vasospastic angina (VSA) face an increased risk of Major Adverse Cardiovascular Events (MACEs), including death. The aim of this review is to outline the current practice with regard to invasive and non-invasive methods of CMD and VSA diagnosis and assess the evidence supporting the existing treatment strategies. These include endotype-specific pharmacological therapies, a holistic approach to lifestyle modifications and risk factor management and novel non-pharmacological therapies. Furthermore, the review highlights critical gaps in research and suggests potential areas for future investigation, to improve understanding and management of these conditions.

Sex differences in associations of daily stair climbing, genetic predisposition, and risk of cardiovascular disease among 389,973 UK adults

OBJECTIVES

This study aimed to determin the sex differences in associations between daily stair climbing with cardiovascular disease (CVD) risk, and the role of genetic predisposition.

STUDY DESIGN

This study is a prospective cohort study from the UK Biobank.

METHODS

A total of 389,973 adults (mean age of 55.7 years, 45.2 % men) from the UK Biobank were analyzed. The frequency of daily stair climbing was self-reported via questionnaires, and the polygenetic risk score (PRS) of CVD was measured to assess genetic predisposition. Cox proportional hazards regression was used to predict CVD risk.

RESULTS

During a median follow-up of 13.7 years, 57,704 cases were recorded. Compared with the no stair climbing group, both sexes achieved a peak CVD benefit at 11-15 times/day of stair climbing (hazard ratio (HR) 95 % confidence intervals (CI) 0.92 [0.88-0.98] for male, HR 95 % CI 0.86 [0.82-0.90] for female). In the joint analyses, 11-15 times/day of stair climbing was significantly associated with a 12 % lower CVD risk even in the high PRS group of women. For males, 11-15 times/day of stair climbing was significantly associated with CVD risk only in intermediate and high PRS groups, but not in the low PRS group. Results were consistent in subgroup analyses stratified by age.

CONCLUSIONS

Our study demonstrated the negative associations of daily stair climbing with CVD risk were more pronounced in females than in males, and these associations were independent of disease susceptibility to CVD only in females. These findings highlight stair climbing as a low-cost intervention strategy for preventing CVD, especially in females.

Genetic Insights Into Coronary Microvascular Disease

Coronary microvascular disease (CMVD) affects the coronary pre-arterioles, arterioles, and capillaries and can lead to blood supply-demand mismatch and cardiac ischemia. CMVD can present clinically as ischemia or myocardial infarction with no obstructive coronary arteries (INOCA or MINOCA, respectively). Currently, therapeutic options for CMVD are limited, and there are no targeted therapies. Genetic studies have emerged as an important tool to gain rapid insights into the molecular mechanisms of human diseases. For example, coronary artery disease (CAD) genome-wide association studies (GWAS) have enrolled hundreds of thousands of patients and have identified > 320 loci, elucidating CAD pathogenic pathways and helping to identify therapeutic targets. Here, we review the current landscape of genetic studies of CMVD, consisting mostly of genotype-first approaches. We then present the hypothesis that CAD GWAS have enrolled heterogenous populations and may be better characterized as ischemic heart disease (IHD) GWAS. We discuss how several of the genetic loci currently associated with CAD may be involved in the pathogenesis of CMVD. Genetic studies could help accelerate progress in understanding CMVD pathophysiology and identifying putative therapeutic targets. Larger phenotype-first genomic studies into CMVD with adequate sex and ancestry representation are needed. Given the extensive CAD genetic and functional validation data, future research should leverage these loci as springboards for CMVD genomic research.

Factors Influencing Drug Prescribing for Patients With Hospitalization History in Circulatory Disease-Patient Severity, Composite Adherence, and Physician-Patient Relationship: Retrospective Cohort Study

BACKGROUND

With countries promoting generic drug prescribing, their growth may plateau, warranting further investigation into the factors influencing this trend, including physician and patient perspectives. Additional strategies may be needed to maximize the switch to generic drugs while ensuring health care system sustainability, focusing on factors beyond mere low cost. Emphasizing affordability and clarifying other prescription considerations are essential.

OBJECTIVE

This study aimed to provide initial insights into how patient severity, composite adherence, and physician-patient relationships impact generic switching.

METHODS

This study used a long-term retrospective cohort design by analyzing data from a national health care database. The population included patients of all ages, primarily older adults, who required primary-to-tertiary preventive actions with a history of hospitalization for cardiovascular diseases (ICD-10 [International Statistical Classification of Diseases, Tenth Revision]) from April 2014 to March 2018 (4 years). We focused on switching to generic drugs, with temporal variations in clinical parameters as independent variables. Lifestyle factors (smoking and drinking) were also considered. Adherence was measured as a composite score comprising 11 elements. The physician-patient relationship was established based on the interval between physician change and prescription. Logistic regression analysis and propensity score matching were used, along with complementary analysis of physician-patient relationships, proportion of days covered, and adherence for a subset of the population.

RESULTS

The study included 48,456 patients with an average follow-up of 36.1 (SD 8.8) months. The mean age was 68.3 (SD 9.9) years; BMI, 23.4 (SD 3.4) kg/m2; systolic blood pressure, 131.2 (SD 15) mm Hg; low-density lipoprotein cholesterol level, 116.6 (SD 29.3) mg/dL; hemoglobin A1c (HbA1c), 5.9% (SD 0.8%); and serum creatinine level, 0.9 (SD 0.8) mg/dL. Logistic regression analysis revealed significant associations between generic switching and systolic blood pressure (odds ratio [OR] 0.996, 95% CI 0.993-0.999), serum creatinine levels (OR 0.837, 95% CI 0.729-0.962), glutamic oxaloacetic transaminase levels (OR 0.994, 95% CI 0.990-0.997), proportion of days covered score (OR 0.959, 95% CI 0.948-0.97), and adherence score (OR 0.910, 95% CI 0.875-0.947). In addition, generic drug rates increased with improvements in the HbA1c level band and smoking level (P<.01 and P<.001). The group with a superior physician-patient relationship after propensity score matching had a significantly higher rate of generic drug prescribing (51.6%, SD 15.2%) than the inferior relationship group (47.7%, SD17.7%; P<.001).

CONCLUSIONS

Although physicians' understanding influences the choice of generic drugs, patient condition (severity) and adherence also impact this decision. For example, improved creatinine levels are associated with generic drug choice, while stronger physician-patient relationships correlate with higher rates of generic drug use. These findings may contribute to the appropriate prescription of pharmaceuticals if the policy diffusion of generic drugs begins to slow down. Thus, preventing serious illness while building trust may result in clinical benefits and positive socioeconomic outcomes.

Clinical features, myocardial injury and systolic impairment in acute myocarditis

OBJECTIVE

Cardiovascular magnetic resonance (CMR) is increasingly used in the diagnosis of myocarditis, with myocardial injury and systolic dysfunction playing key roles in the prognosis of this clinical setting. The clinical determinants of myocardial injury and systolic impairment in acute myocarditis are poorly defined. The aim of the current study is to assess the association of laboratory markers, late gadolinium enhancement (LGE) and left ventricular ejection fraction (LVEF) in patients with acute myocarditis.

METHODS

We completed a retrospective cohort study from a tertiary referral centre in London with CMR and acute myocarditis. Cases with cardiomyopathy were excluded. Missing data was imputed for selected clinical variables. We evaluated the association between peak troponin and LGE extent and LVEF. We adjusted the models for age, sex and time to CMR with a sensitivity analysis adjusting for body mass index and cardiovascular risk factors including hypertension, dyslipidaemia, diabetes mellitus and smoking.

RESULTS

127 patients had abnormal T2-weighted imaging/mapping results with 118 (93%) presenting with chest pain and/or shortness of breath. Left ventricular LGE was identified in 118 (93%) patients and LVEF was 58±11%. The median time from the peak troponin to CMR was 1 day (IQR 0-6 days). The highest tertile of peak troponin was associated with more LGE (incident rate ratio 1.33, 95% CI: 1.07 to 1.64) and a lower LVEF (coefficient -5.3%, 95% CI: -9.5% to -1.1%). Diabetes was also associated with more LGE (incident rate ratio 1.90, 95% CI: 1.37 to 2.61) and lower LVEF (coefficient -8.9%, 95% CI: -14.7% to -1.8%).

CONCLUSIONS

Peak troponin is associated with more LGE and a lower LVEF even after accounting for demographics and comorbidities. Myocardial injury and systolic dysfunction play key roles in prognosis and future work incorporating clinical features into a risk prediction model may enable better risk stratification in acute myocarditis.

Prediction of Major Adverse Coronary Events Using the Coronary Risk Score in Women

Purpose To establish a COronary Risk Score in WOmen (CORSWO) to predict major adverse coronary events (MACE). Materials and Methods This retrospective analysis included 2226 female individuals (mean age, 66.7 years ± 11.6 [SD]) from a cohort of 25 943 consecutive patients referred for clinical gated SPECT myocardial perfusion imaging (gSPECT MPI). During the follow-up (mean, 4 years ± 2.7) after gSPECT MPI, occurrence of MACE (unstable angina requiring hospitalization, nonfatal myocardial infarction, coronary revascularization, cardiac death) was assessed. The patients were divided into training (n = 1460) and validation (n = 766) groups. To obtain the predictor model, multiple Cox regression analyses were performed. Results In the training group, 148 female individuals had MACE (2.6% per year). The best model (area under the receiver operating characteristic curve [AUC]: 0.80 [95% CI: 0.74, 0.83]; Brier score: 0.08) to predict MACE in female individuals included the following variables: age older than 69 years (hazard ratio [HR]: 1.58, P = .01), diabetes mellitus (HR: 1.47, P = .03), pharmacologic test (HR: 1.63, P = .01), ST-segment depression (≥1 mm) (HR: 2.02, P < .001), myocardial ischemia greater than 5% (HR: 2.21, P < .001), perfusion defect at rest greater than 9% (HR: 1.96, P = .009), perfusion defect at stress greater than 6% (HR: 1.63, P = .03), and end-systolic volume index greater than 15 mL (HR: 2.04, P < .001). During validation, the model achieved moderate performance (AUC: 0.78 [95% CI: 0.70, 0.83]). CORSWO obtained from these variables allowed for stratification of female individuals into four risk levels: low (score: 0-3, HR: 1), moderate (score: 4-6, HR: 1.58), high (score: 7-11, HR: 4.13), and very high (score: >11, HR: 13.87). The high and very high risk levels (HR: 5.29) predicted MACE in female individuals, with excellent performance (AUC: 0.78 [95% CI: 0.72, 0.80]). Conclusion With clinical, stress test, and gSPECT MPI variables, CORSWO effectively stratified female individuals according to coronary risk and was able to detect those with high and very high risk. Keywords: SPECT, Cardiac, Coronary Arteries, Women, Risk Stratification, Cardiac Event, CORSWO, MACE, Gated SPECT Supplemental material is available for this article. ©RSNA, 2024.

Sex differences of sequential changes in coronary blood flow and microvascular function in patients with suspected angina

AIMS

This study evaluated the sex differences of sequential changes in coronary blood flows and microvascular function in patients with suspected angina but with no obstructed coronary arteries.

METHODS

A total of 202 consecutive patients who experienced chest pain but had no significant coronary artery stenosis and who underwent adenosine stress echocardiography were included in the study. Coronary blood flow (CBF) velocities were measured at 1, 2, and 3 min after adenosine infusion.

RESULTS

The mean age was 61 years, and 138 (68%) were women. Approximately 40% of patients had coronary microvascular dysfunction (CMD, coronary flow velocity reserve < 2.3), with women exhibiting higher CMD prevalence. The left ventricular (LV) mass index was similar between men and women, while women exhibited higher baseline rate pressure products (RPP). At baseline, coronary blood flow velocities were similar between the sexes. However, CBF velocities in women gradually increased during the examination; and in men, the increase was abrupt and steep during the early stages of examination (p = 0.015 for interaction between time and sex), even with similar RPP in stress. Coronary flow velocity reserve was steadily lower in women compared to men (1 min, 2.09 ± 0.86 vs 2.44 ± 0.87; 2 min, 2.39 ± 0.72 vs 2.63 ± 0.85; 3 min, 2.45 ± 0.70 vs 2.68 ± 0.73).

CONCLUSIONS

In patients with suspected angina but with no obstructed coronary arteries, CMD was especially prevalent among women. Women exhibited higher oxygen consumption, while exhibiting slower and gradual increases in CBF velocities. Conversely, men exhibited faster and steeper increases in CBF velocities even with similar RPP in stress.

Factors Associated With the Development of Heart Failure Following Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

Acute coronary syndrome (ACS) remains a major global health burden, encompassing a spectrum of conditions from unstable angina to acute myocardial infarction. Despite advancements in early detection and management, ACS is often complicated by the development of heart failure. This systematic review and meta-analysis aimed to identify factors associated with the development of heart failure following acute coronary syndrome. A comprehensive search was conducted across PubMed, Embase, Cochrane Library, and Web of Science from January 2018 to November 2024. Studies evaluating clinical or biochemical predictors of heart failure development in adult patients with acute coronary syndrome were included. Out of the initially identified studies, nine studies met the inclusion criteria. The Newcastle-Ottawa Scale was used to assess the quality of included studies, with most studies demonstrating high quality. The pooled analysis revealed that older age, female sex, diabetes, hypertension, chronic obstructive pulmonary disease, atrial fibrillation, multivessel coronary disease, and reduced left ventricular ejection fraction were significant predictors of heart failure development following acute coronary syndrome. The presence of atrial fibrillation emerged as the strongest predictor, followed by reduced left ventricular ejection fraction and chronic obstructive pulmonary disease. While complete revascularization showed a protective trend, this association did not reach statistical significance. The findings were limited by the predominantly retrospective nature of included studies and heterogeneity in the assessment of certain risk factors. Future research should focus on prospective studies with larger cohorts and comprehensive evaluation of additional factors such as treatment delays and revascularization strategies. Understanding these predictors can facilitate early risk stratification and guide targeted interventions, potentially improving outcomes for patients with acute coronary syndrome.

Acute Intermittent Porphyria in an Adolescent Patient: Diagnostic and Treatment Challenges

Acute intermittent porphyria (AIP) is a rare inherited metabolic disorder caused by decreased activity of the enzyme porphobilinogen deaminase in the heme synthesis pathway. This leads to the accumulation of toxic porphyrin precursors, such as porphobilinogen and δ-aminolevulinic acid. Clinical manifestations typically include episodic bouts of severe neurovisceral pain and autonomic dysfunction. These events have various triggers, including fasting, dehydration, hormonal fluctuations, and certain medications, while treatment involves dextrose infusions for mild attacks and intravenous hemin for severe cases. This case highlights a 17-year-old female patient with numerous prior presentations to the healthcare system for intense bouts of abdominal pain, vomiting, and seizure-like activity who was ultimately diagnosed with AIP. Her course was complicated by diagnostic delays and challenges managing severe refractory pain requiring prolonged courses of hemin in addition to a multimodal pain plan. This case highlights the diagnostic complexities and treatment challenges that patients with AIP face when navigating this challenging clinical syndrome and identifies an opportunity for increased awareness to guide the testing and treatment for AIP.

Coronary Microvascular Dysfunction: Searching the Strongest Imaging Modality in Different Scenarios

Coronary microvascular dysfunction is a clinical condition very diffuse in many different settings. Often the diagnosis can be very tricky, and choosing the proper diagnostic strategy can be fundamental for reaching the goal. The aim of this review is to evaluate the properties and the feasibility of our tests in specific scenarios by looking at the performances of each methodology reported in the literature.

Engaging women in decision-making about their heart health: a literature review with patients' perspective

Cardiovascular disease (CVD) remains the leading cause of death globally. Although the burden of CVD risk factors tends to be lower in women, they remain at higher risk of developing complications when affected by these risk factors. There is still a lack of awareness surrounding CVD in women, both from a patient's and a clinician's perspective, especially among visible minorities. However, women who are informed about their heart health and who engage in decision-making with their healthcare providers are more likely to modify their lifestyle, and improve their CVD risk. A patient-centered care approach benefits patients' physical and mental health, and is now considered gold-standard for efficient patient care. Engaging women in their heart health will contribute in closing the gap of healthcare disparities between men and women, arising from sociocultural, socioeconomic, and political factors. This comprehensive review of the literature discusses the importance of engaging women in decision-making surrounding their heart health and offers tools for an effective and culturally sensitive patient-provider relationship.

Evaluating Ischemic Heart Disease in Women: Focus on Angina With Nonobstructive Coronary Arteries (ANOCA)

Ischemic heart disease (IHD) is common in women, and cardiovascular disease is a leading cause of morbidity and mortality. While obstructive coronary artery disease is the most common form of IHD, millions of women suffer from angina with nonobstructive coronary arteries (ANOCA), an umbrella term encompassing multiple nonatherosclerotic disorders of the coronary tree. The underlying pathology leading to ischemia in these syndromes may be challenging to diagnose, leaving many women without a diagnosis despite persistent symptoms that impact quality of life and adversely affect long-term cardiovascular prognosis. In the last decade, there have been significant advances in the recognition and diagnostic evaluation of ANOCA. Despite these advances, the standard approach to evaluating suspected IHD in women continues to focus predominantly on the assessment of atherosclerotic coronary artery disease, leading to missed opportunities to accurately diagnose and treat underlying coronary vasomotor disorders. The goal of this review is to describe advances in diagnostic testing that can be used to evaluate angina in women and present a pragmatic diagnostic algorithm to guide evaluation of ANOCA in symptomatic patients. The proposed approach for the assessment of ANOCA is consistent with prior expert consensus documents and guidelines but is predicated on the medical interview and pretest probability of disease to inform a personalized diagnostic strategy.

Inequalities in cardiovascular disease among elderly Indians: A gender perspective analysis using LASI wave-I (2017-18)

BACKGROUND

While Cardiovascular disease (CVD) affects both men and women, emerging evidence suggests notable gender differentials in disease prevalence. This study aims to explore and analyse the gender differentials in CVD disease prevalence in India.

METHODS

The present study utilizes data from first wave of the nationally representative survey "Longitudinal Ageing Study in India" (LASI, WAVE-I, 2017-18) with the eligible sample size of 31,464 individuals aged 60 years and above. Logistic regression analysis was used to understand risk of CVD by demographic characteristics. Factors contribution to gender differences in CVD prevalence was examined using a non-linear Fairlie decomposition.

RESULTS

The prevalence of CVD was lower in men (31.06%) compared to women (38.85%). Women have a 33% higher likelihood of CVD compared to men (OR: 1.33; 95% CI: 1.25-1.42). Lack of education also confers a lower risk, more pronounced in women with no schooling (OR: 0.81; 95% CI: 0.7-0.94) compared to men (OR: 0.52; 95% CI: 0.47-0.58). Morbidity influences CVD presence more among women than men, with individuals suffering from three or more diseases having markedly increased odds (Men: OR: 3.89; 95% CI: 3.54-4.3, Women: OR: 6.97; 95% CI: 6.48-10.11). Smoking accounted increase in (20.52%) the gender gap while years of schooling dramatically lessened the gender gap (-46.30%).

CONCLUSION

Result show gender differential in CVD prevalence and underlying risk factors, underscoring the need for gender-specific preventive strategies and interventions. Our findings highlight the importance of refined approach to cardiovascular health that considers the complex interplay of biological, social, and environmental determinants.

Multimodality assessment of the coronary microvasculature with TIMI frame count versus perfusion PET highlights coronary changes characteristic of coronary microvascular disease

Background

The diagnosis of coronary microvascular disease (CMVD) remains challenging. Perfusion PET-derived myocardial blood flow (MBF) reserve (MBFR) can quantify CMVD but is not widely available. Thrombolysis in Myocardial Infarction (TIMI) frame count (TFC) is an angiography-based method that has been proposed as a measure of CMVD. Here, we compare TFC and PET-derived MBF measurements to establish the role of TFC in assessing for CMVD. We use coronary modeling to elucidate the relationship between MBFR and TFC and propose TFC thresholds for identifying CMVD.

Methods

In a cohort of 123 individuals (age 58 ± 12.1, 63% women, 41% Caucasian) without obstructive coronary artery disease who had undergone perfusion PET and coronary angiography for clinical indications, we compared TFC and perfusion PET parameters using Pearson correlation (PCC) and linear regression modeling. We used mathematical modeling of the coronary circulation to understand the relationship between these parameters and performed Receiver Operating Curve (ROC) analysis.

Results

We found a significant negative correlation between TFC and MBFR. Sex, race and ethnicity, and nitroglycerin administration impact this relationship. Coronary modeling showed an uncoupling between TFC and flow in epicardial vessels. In ROC analysis, TFC performed well in women (AUC 0.84-0.89) and a moderately in men (AUC 0.68-0.78).

Conclusions

We established an inverse relationship between TFC and PET-derived MBFR, which is affected by patient selection and procedural factors. TFC represents a measure of the volume of the epicardial coronary compartment, which is increased in patients with CMVD, and performs well in identifying women with CMVD.

Cardiovascular Imaging in Women

Multimodality cardiovascular imaging is a cornerstone diagnostic tool in the diagnosis, risk stratification, and management of cardiovascular diseases, whether those involving the coronary tree, myocardial, or pericardial diseases in general and particularly in women. This manuscript aims to shed some light and summarize the very features of cardiovascular disease in women, explore their unique characteristics and discuss the role of cardiovascular imaging in ischemic heart disease and cardiomyopathies. The role of four imaging modalities will be discussed including nuclear medicine, echocardiography, noninvasive coronary angiography, and cardiac magnetic resonance.

Arterial Stiffness Changes in Adult Cancer Patients Receiving Anticancer Chemotherapy: A Real-World Bicentric Experience

Background Chemotherapy correlates to acute and long-term cardiotoxicity, is reflected clinically by myocardial and vascular endothelial dysfunction, and can cause cardiovascular complications. Thus, early diagnosis of cardiovascular disease in cancer patients undergoing anti-cancer treatment is necessary to enhance long-term survival. Our principal objective in this study was to discern the impact of specific anti-cancer chemotherapeutics and biologics on arterial stiffness alterations before and after the administration. Methods Conducted at Mustafa Bacha University Hospital, Algeria, the study focused on arterial stiffness in anti-cancer chemotherapy patients. Assessments included blood pressure, diabetes, and dyslipidemia, with precise measurements using validated systems, particularly pulse wave velocity (PWV). Various chemotherapy protocols were applied, and statistical analysis with R software (R Foundation for Statistical Computing, Vienna, Austria) maintained a significance level of p=0.05. Key outcomes centered on carotid-femoral PWV and secondary endpoints such as central and peripheral pressures and pulse pressure (PP). Univariate and bivariate analyses were conducted using appropriate statistical tests.  Results A comparative prospective observational study was completed on 58 patients (34 women and 24 men; mean age: 52.64 +/- 12.12 years) treated with anti-cancer chemotherapy agents. Our evaluation included a complete clinical exam, electrocardiogram, Doppler echocardiography, and applanation tonometry with arterial stiffness measurement using PWV. Patients presented significantly higher levels of carotid-femoral PWV, regardless of the chosen chemotherapy protocol, with no return to the initial level after one year of stopping treatment (p-value < 0.01). Moreover, this increase was more significant in patients with diabetes and hypertension and patients treated with monoclonal antibodies or intercalants.  Conclusion This prospective study shows that chemotherapy patients have elevated arterial stiffness, emphasizing the need to assess PWV and monitor cardiovascular risk factors. PP measurement with PWV could improve risk management.

Gender Bias in Diagnosis, Prevention, and Treatment of Cardiovascular Diseases: A Systematic Review

Cardiovascular disease (CVDs) has been perceived as a 'man's disease', and this impacted women's referral to CVD diagnosis and treatment. This study systematically reviewed the evidence regarding gender bias in the diagnosis, prevention, and treatment of CVDs. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. We searched CINAHL, PubMed, Medline, Web of Science, British Nursing Index, Scopus, and Google Scholar. The included studies were assessed for quality using risk bias tools. Data extracted from the included studies were exported into Statistical Product and Service Solutions (SPSS, v26; IBM SPSS Statistics for Windows, Armonk, NY), where descriptive statistics were applied. A total of 19 studies were analysed. CVDs were less reported among women who either showed milder symptoms than men or had their symptoms misdiagnosed as gastrointestinal or anxiety-related symptoms. Hence, women had their risk factors under-considered by physicians (especially by male physicians). Subsequently, women were offered fewer diagnostic tests, such as coronary angiography, ergometry, electrocardiogram (ECG), and cardiac enzymes, and were referred to less to cardiologists and/or hospitalisation. Furthermore, if hospitalised, women were less likely to receive a coronary intervention. Similarly, women were prescribed cardiovascular medicines than men, with the exception of antihypertensive and anti-anginal medicines. When it comes to the perception of CVD, women considered themselves at lower risk of CVDs than men. This systematic review showed that women were offered fewer diagnostic tests for CVDs and medicines than men and that in turn influenced their disease outcomes. This could be attributed to the inadequate knowledge regarding the differences in manifestations among both genders.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations

This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.

Sex Differences in Red Blood Cell Transfusions and 30-Day Mortality in Cardiac Surgery: A Single Center Observational Study

In cardiac surgery, women have higher short-term mortality and a higher risk of receiving red blood cell (RBC) transfusions than men. This study's aim was to evaluate possible sex differences in RBC transfusions in cardiac surgery and their association with preoperative hemoglobin levels, body mass index, and 30-day mortality. A single-center retrospective study was conducted with 1583 patients (1181 men and 402 women) undergoing cardiac surgery. A total of 64.4% of the women and 33.0% of the men received an RBC transfusion. In a multivariable analysis, female sex was an independent predictor of RBC transfusion (OR 3.88, 95% CI 2.95-5.11, p < 0.001). Other independent predictors of RBC transfusion were age, preoperative hemoglobin level, and body mass index. The women were more likely to receive RBC transfusions than the men, regardless of the type of cardiac surgery. Decreased transfusion risk was found in all higher-than-normal weight categories in the women, but only in the severe obesity category in the men. Preoperative hemoglobin was similarly associated with RBC transfusion in the men and women. The crude 30-day mortality rate was higher in the women than in the men (2.5% vs. 0.9%, p = 0.018). In both sexes, RBC transfusion was associated with an increased probability of death within 30 days.

Optimal P2Y12 inhibitor durations in older men and older women following an acute myocardial infarction: A nationwide cohort study using Medicare data

Study objective

Identify optimal P2Y12 inhibitor durations balancing ischemic-benefit and bleeding-risk outcomes after acute myocardial infarction (AMI) in older men and women.

Design

Observational retrospective cohort with 2 years of follow-up, using clone-censor-weight marginal structural models to emulate randomization.

Setting

20 % sample of US Medicare administrative claims data.

Participants

P2Y12 inhibitor new users ≥66 years old following 2008-2013 AMI hospitalization.

Exposures

12- to 24-month P2Y12 inhibitor durations in 1-month intervals.

Main outcome measures

Effectiveness outcome (composite of all-cause mortality, recurrent AMI, ischemic stroke), safety outcome (hospitalized bleed), and negative control outcome (heart failure hospitalization).

Results

Of 28,488 P2Y12 inhibitor new users, 51 % were female, 50 % were > 75 years old, 88 % were White/non-Hispanic, and 93 % initiated clopidogrel. Negative control outcome results for 16- through 24-month durations appeared most likely to meet assumptions of no unmeasured confounding. Compared to men taking 24-month therapy, men taking 16-month therapy had higher 2-year risks of the composite effectiveness outcome (relative risk [RR] = 1.08; 95 % confidence interval [95%CI]:1.00-1.15) with similar bleeding risks (RR = 0.98; 95%CI:0.85-1.13). Compared to women taking 24-month therapy, women taking 16-month therapy had similar 2-year risks of the composite effectiveness outcome (RR = 0.98; 95%CI:0.92-1.04) and lower bleeding risks (RR = 0.88; 95%CI:0.80-0.96).

Conclusions

Older men taking 24-month P2Y12 inhibitor therapy had the lowest composite effectiveness outcome risk with no increased bleeding risk compared to shorter durations. Women taking 16-month versus 24-month P2Y12 inhibitor therapy had similar composite effectiveness outcome risks but a substantially lower hospitalized bleeding risk, suggesting durations beyond 15-17 months lacked benefit while increasing bleeding risk.

Sex differences in prevalence and outcomes of the different endotypes of chronic coronary syndrome in symptomatic patients undergoing invasive coronary angiography: Insights from the global ILIAS invasive coronary physiology registry

BACKGROUND AND AIMS

The management of chronic coronary syndrome (CCS) is informed by studies predominantly including men. This study investigated the relationship between patients sex and different endotypes of CCS, including sex-specific clinical outcomes.

METHODS

In patients with CCS undergoing coronary angiography, invasive Fractional Flow Reserve (FFR) and Coronary Flow Reserve (CFR) were measured. Patients were stratified into groups: 1) obstructive coronary artery disease (oCAD) (FFR≤0.80, no revascularization), 2) undergoing revascularization, 3) non-obstructive coronary artery disease with coronary microvascular dysfunction (CMD) (FFR>0.80, CFR≤2.5), and 4) non-obstructive coronary artery disease without CMD (FFR>0.80 and CFR>2.5).

RESULTS

1836 patients (2335 vessels) were included, comprising 1359 (74.0%) men and 477 (26.0%) women. oCAD was present in 14.1% and was significantly less prevalent in women than in men (10.3% vs 15.5%, respectively p < 0.01). Revascularization was present in 30.9% and was similarly prevalent in women and men (28.2% vs. 31.9%, respectively p = 0.13). CMD was present in 24.2% and was significantly more prevalent in women than men (28.6% vs 22.6%, respectively p < 0.01). Normal invasive measurements were found in 564 patients (33.0% women vs 30.0% men, p = 0.23). Male sex was associated with an increased risk of target vessel failure compared to women (HR.1.89, 95% CI 1.12-3.18, p = 0.018), regardless of CCS-endotype.

CONCLUSIONS

Sex differences exist in the prevalence and outcomes of different endotypes of CCS in symptomatic patients undergoing invasive coronary angiography. In particular, oCAD (and subsequent revascularization) were more prevalent in men. Conversely, CMD was more prevalent in women. Overall, men experienced a worse cardiovascular outcome compared to women, independent of any specific CCS endotype.

Large-scale characterization of gender differences in diagnosis prevalence and time to diagnosis

We carry out an analysis of gender differences in patterns of disease diagnosis across four large observational health datasets and find that women are routinely older when first assigned most diagnoses. Among 112 acute and chronic diseases, women experience longer lengths of time between symptom onset and disease diagnosis than men for most diseases regardless of metric used, even when only symptoms common to both genders are considered. These findings are consistent for patients with private as well as government insurance. Our analysis highlights systematic gender differences in patterns of disease diagnosis and suggests that symptoms of disease are measured or weighed differently for women and men. Data and code leverage the open-source common data model and analytic code and results are publicly available.

The Impact of Sex on Cardiogenic Shock Outcomes Following ST Elevation Myocardial Infarction

BACKGROUND

Cardiogenic shock (CS) remains the leading cause of ST elevation myocardial infarction (STEMI)-related mortality. Contemporary studies have shown no sex-related differences in mortality.

METHODS

STEMI-CS patients undergoing primary percutaneous coronary intervention (PPCI) were included based on a dedicated prospective STEMI database. We compared sex-specific differences in CS characteristics at baseline, during hospitalization, and in subsequent clinical outcomes. Endpoints included all-cause mortality and major adverse cardiac events (MACE).

RESULTS

Of 3202 consecutive STEMI patients, 210 (6.5%) had CS, of which 63 (30.0%) were women. Women were older than men (73.2 vs. 65.5% y, p < 0.01), and more had hypertension (68.3 vs. 52.8%, p = 0.019) and diabetes (38.7 vs. 24.8%, p = 0.047). Fewer were smokers (13.3 vs. 41.2%, p < 0.01), had previous PCI (9.1 vs. 22.3% p = 0.016), or required IABP (35.3 vs. 51.1% p = 0.027). Women had higher rates of mortality (53.2 vs. 35.3% in-hospital, p = 0.01; 61.3 vs. 41.9% at 1 month, p = 0.01; and 73.8 vs. 52.6% at 3 years, p = 0.05) and MACE (60.6 vs. 41.6% in-hospital, p = 0.032; 66.1 vs. 45.6% at 1 month, p = 0.007; and 62.9 vs. 80.3% at 3 years, p = 0.015). After multivariate adjustment, female sex remained an independent factor for death (HR-2.42 [95% CI 1.014-5.033], p = 0.042) and MACE (HR-1.91 [95% CI 1.217-3.031], p = 0.01).

CONCLUSIONS

CS complicating STEMI is associated with greater short- and long-term mortality and MACE in women. Sex-focused measures to improve diagnosis and treatment are mandatory for CS patients.

Sex Differences in Clinical Characteristics and Outcomes After Myocardial Infarction With Low Ejection Fraction: Insights From PARADISE-MI

Background Studies demonstrated sex differences in outcomes following acute myocardial infarction, with women more likely to develop heart failure (HF). Sacubitril/valsartan has been shown to reduce cardiovascular death and HF hospitalizations in patients with HF with reduced ejection fraction. Methods and Results A total of 5661 patients (1363 women [24%]) with acute myocardial infarction complicated by reduced left ventricular ejection fraction (≤40%), pulmonary congestion, or both and ≥1 of 8 risk-augmenting factors were randomized to receive sacubitril/valsartan or ramipril. The primary outcome was cardiovascular death or incident HF. Baseline characteristics, clinical outcomes, and safety events were compared according to sex, a prespecified subgroup. Female participants were older and had more comorbidities. After multivariable adjustment, women and men were at similar risks for cardiovascular death or all-cause death. Women were more likely to have first HF hospitalization (hazard ratio [HR], 1.34 [95% CI, 1.05-1.70]; P=0.02) and total HF hospitalizations (HR, 1.39 [95% CI, 1.05-1.84]; P=0.02). Sex did not significantly modify the treatment effect of sacubitril/valsartan compared with ramipril on the primary outcome (P for interaction=0.11). Conclusions In contemporary patients who presented with reduced left ventricular ejection fraction, pulmonary congestion, or both, following acute myocardial infarction, women had a higher incidence of HF during follow-up. Sex did not modify the treatment effect of sacubitril/valsartan relative to ramipril. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02924727.

Advances in Coronary Computed Tomographic Angiographic Imaging of Atherosclerosis for Risk Stratification and Preventive Care

The diagnostic evaluation of coronary artery disease is undergoing a dramatic transformation with a new focus on atherosclerotic plaque. This review details the evidence needed for effective risk stratification and targeted preventive care based on recent advances in automated measurement of atherosclerosis from coronary computed tomography angiography (CTA). To date, research findings support that automated stenosis measurement is reasonably accurate, but evidence on variability by location, artery size, or image quality is unknown. The evidence for quantification of atherosclerotic plaque is unfolding, with strong concordance reported between coronary CTA and intravascular ultrasound measurement of total plaque volume (r >0.90). Statistical variance is higher for smaller plaque volumes. Limited data are available on how technical or patient-specific factors result in measurement variability by compositional subgroups. Coronary artery dimensions vary by age, sex, heart size, coronary dominance, and race and ethnicity. Accordingly, quantification programs excluding smaller arteries affect accuracy for women, patients with diabetes, and other patient subsets. Evidence is unfolding that quantification of atherosclerotic plaque is useful to enhance risk prediction, yet more evidence is required to define high-risk patients across varied populations and to determine whether such information is incremental to risk factors or currently used coronary computed tomography techniques (eg, coronary artery calcium scoring or visual assessment of plaque burden or stenosis). In summary, there is promise for the utility of coronary CTA quantification of atherosclerosis, especially if it can lead to targeted and more intensive cardiovascular prevention, notably for those patients with nonobstructive coronary artery disease and high-risk plaque features. The new quantification techniques available to imagers must not only provide sufficient added value to improve patient care, but also add minimal and reasonable cost to alleviate the financial burden on our patients and the health care system.

Inflammation biomarkers are associated with the incidence of cardiovascular disease: a meta-analysis

Background

Inflammation is a risk factor for cardiovascular disease (CVD), and particular inflammatory parameters can be used to predict the incidence of CVD. The aim of this study was to assess the association between fibrinogen (FIB), interleukin-6 (IL-6), C-reactive protein (CRP) and galectin-3 (Gal-3) and the risk of cardiovascular disease using meta-analysis.

Methods

PubMed, Embase, Scopus, and Web of Science databases were searched with the appropriate strategies to identify observational studies relevant to this meta-analysis. A random-effects model was used to combine inflammation factor-associated outcomes and cardiovascular disease outcomes, except in the case of galectin-3, where a fixed-effects model was used because of less heterogeneity. Location, age, type of cardiovascular disease, and sample size factors were used to explore heterogeneity in stratification and metaregression for subgroup analysis. A case-by-case literature exclusion approach was used for sensitivity analysis. The funnel plot and Begg's test were combined to assess publication bias.

Results

Thirty-three papers out of 11,456 were screened for inclusion in the analysis. Four inflammation biomarkers were significantly associated with the development of CVD: FIB (OR: 1.21, 95% CI: 1.15-1.27, P < 0.001; HR: 1.04, 95% CI: 1.00-1.07, P < 0.05), IL-6 (HR: 1.16, 95% CI: 1.10-1.22, P < 0.001), CRP (OR: 1.25, 95% CI: 1.15-1.35, P < 0.001; HR: 1.20, 95% CI: 1.14-1.25, P < 0.001) and Gal-3 (HR: 1.09, 95% CI: 1.05-1.14, P < 0.001). Location factors help explain the source of heterogeneity, and there is publication bias in the Gal-3 related literature.

Conclusion

Taken together, the current research evidence suggests that high levels of fibrinogen, interleukin-6, C-reactive protein and galectin-3 are risk factors for cardiovascular disease and can be used as biomarkers to predict the development of cardiovascular disease to some extent.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42023391844.

Sex Differences in Heart Failure: What Do We Know?

Heart failure (HF) remains an important global health issue, substantially contributing to morbidity and mortality. According to epidemiological studies, men and women face nearly equivalent lifetime risks for HF. However, their experiences diverge significantly when it comes to HF subtypes: men tend to develop HF with reduced ejection fraction more frequently, whereas women are predominantly affected by HF with preserved ejection fraction. This divergence underlines the presence of numerous sex-based disparities across various facets of HF, encompassing aspects such as risk factors, clinical presentation, underlying pathophysiology, and response to therapy. Despite these apparent discrepancies, our understanding of them is far from complete, with key knowledge gaps still existing. Current guidelines from various professional societies acknowledge the existence of sex-based differences in HF management, yet they are lacking in providing explicit, actionable recommendations tailored to these differences. In this comprehensive review, we delve deeper into these sex-specific differences within the context of HF, critically examining associated definitions, risk factors, and therapeutic strategies. We provide a specific emphasis on aspects exclusive to women, such as the impact of pregnancy-induced hypertension and premature menopause, as these unique factors warrant greater attention in the broader HF discussion. Additionally, we aim to clarify ongoing controversies and knowledge gaps pertaining to the pharmacological treatment of HF and the sex-specific indications for cardiac implantable electronic devices. By shining a light on these issues, we hope to stimulate a more nuanced understanding and promote the development of more sex-responsive approaches in HF management.

The association of sex-specific hormones with coronary artery plaque characteristics from Miami Heart (MiHeart) study

Objective

The association of sex-specific hormones with coronary computed tomography angiography(CCTA)-based plaque characteristics in women without cardiovascular disease is not well understood. We investigated the association of sex-specific hormones with coronary artery plaque characteristics in a contemporary multiracial cohort with no clinical coronary artery disease (CAD).

Methods

In this cross-sectional analysis, we utilized data from 2,325 individuals with no clinical CAD from the Miami Heart (MiHeart) study. Multivariable logistic regression models were used to investigate the association of sex hormones: sex hormone binding globulin (SHBG), dehydroepiandrosterone (DHEA), free and total testosterone, estradiol, with plaque characteristics among women and men.

Results

Of the 1,155 women, 34.2% had any plaque and 3.4% had any high-risk plaque features (HRP) while among men (n = 1170), 63.1% had any plaque and 10.4% had HRP. Among women, estradiol and SHBG were associated with lower odds of any plaque after adjusting for age and race-ethnicity (estradiol OR per SD increase: 0.87, 95%CI: 0.76-0.98; SHBG OR per SD increase: 0.82, 95%CI: 0.72-0.93) but the significance did not persist after adjustment of cardiovascular risk factors. High free testosterone was associated with higher odds of HRP (aOR:3.48, 95%CI:1.07-11.26) but null associations for the other sex hormones with HRP, in the context of limited sample size. Among men, there were no significant associations between sex-specific hormones and plaque or HRP.

Conclusion

Among young to middle-aged women with no clinical CAD, increasing estradiol and SHBG were associated with lower odds of any plaque and higher free testosterone was associated with HRP. Larger cohorts may be needed to validate this.

Significance of coronary artery calcification for predicting major adverse cardiovascular events: results from the NADESICO study in Japan

BACKGROUND

We aimed to determine the usefulness and sex differences of assessment of coronary artery calcification (CAC) with cardiovascular risk factors and major adverse cardiovascular events (MACE) in Japanese patients.

METHODS

In a nationwide, multicenter, prospective cohort study, 1187 patients with suspected coronary artery disease who underwent coronary computed tomography were enrolled. MACE included cardiovascular death, myocardial infarction, stroke, revascularization, and hospitalization for unstable angina, heart failure, or aortic disease. The concordance (C)-statistics were used to assess the relationships among the Suita risk score, CAC score, and incident MACE, with emphasis on sex differences.

RESULTS

The final analysis included 982 patients (mean age, 64.7 ± 6.6 years; 53.9 % male patients). MACE developed in 65 male and 21 female patients during a median follow-up of 1480 days. The C-statistics calculated using Suita score for MACE were 0.650, 0.633, and 0.569 in overall, male, and female patients, respectively. In overall patients, the C-statistic significantly increased in combined models of Agatston CAC scores of ≥100, 200, 300, or 400 and the Suita score. In each sex, the C-statistics significantly increased in the model that added an Agatston CAC score of ≥100 and ≥ 200 (+0.049 and + 0.057) in male patients, and ≥ 400 (+0.119) in females, respectively.

CONCLUSIONS

Adding assessment of Agatston CAC scores to Suita score was useful to improve the predictive ability for future MACE in Japanese patients. Agatston CAC scores of ≥100 or 200 in male and ≥ 400 in female patients in addition to Suita score improved the MACE risk prediction.

Coronary Microvascular Spasm: Clinical Presentation and Diagnosis

Professor Maseri pioneered the research and treatment of coronary vasomotion abnormalities represented by coronary vasospasm and coronary microvascular dysfunction (CMD). These mechanisms can cause myocardial ischaemia even in the absence of obstructive coronary artery disease, and have been appreciated as an important aetiology and therapeutic target with major clinical implications in patients with ischaemia with non-obstructive coronary artery disease (INOCA). Coronary microvascular spasm is one of the key mechanisms responsible for myocardial ischaemia in patients with INOCA. Comprehensive assessment of coronary vasomotor reactivity by invasive functional coronary angiography or interventional diagnostic procedure is recommended to identify the underlying mechanisms of myocardial ischaemia and to tailor the best treatment and management based on the endotype of INOCA. This review highlights the pioneering works of Professor Maseri and contemporary research on coronary vasospasm and CMD with reference to endothelial dysfunction, Rho-kinase activation and inflammation.

Gender Differences in Epicardial Adipose Tissue and Plaque Composition by Coronary CT Angiography: Association with Cardiovascular Outcome

Background: To investigate gender differences in epicardial adipose tissue (EAT) and plaque composition by coronary CT angiography (CCTA) and the association with cardiovascular outcome. Methods: Data of 352 patients (64.2 ± 10.3 years, 38% female) with suspected coronary artery disease (CAD) who underwent CCTA were retrospectively analyzed. EAT volume and plaque composition from CCTA were compared between men and women. Major adverse cardiovascular events (MACE) were recorded from follow-up. Results: Men were more likely to have obstructive CAD, higher Agatston scores, and a larger total and non-calcified plaque burden. In addition, men displayed more adverse plaque characteristics and EAT volume compared to women (all p < 0.05). After a median follow-up of 5.1 years, MACE occurred in 8 women (6%) and 22 men (10%). In multivariable analysis, Agatston calcium score (HR 1.0008, p = 0.014), EAT volume (HR 1.067, p = 0.049), and low-attenuation plaque (HR 3.82, p = 0.036) were independent predictors for MACE in men, whereas only low-attenuation plaque (HR 2.42, p = 0.041) showed predictive value for events in women. Conclusion: Women demonstrated less overall plaque burden, fewer adverse plaque characteristics, and a smaller EAT volume compared to men. However, low-attenuation plaque is a predictor for MACE in both genders. Thus, a differentiated plaque analysis is warranted to understand gender differences of atherosclerosis to guide medical therapy and prevention strategies.

Sex-related differences in coronary vasomotor disorders: Comparisons between Western and Japanese populations

Sex-related differences in the prevalence of cardiac disorders have been elucidated beyond races. Angina/ischemia with nonobstructive coronary artery disease (AINOCA) is often observed in females. Coronary microvascular dysfunction (CMD) and coronary epicardial spasm (CES) are the principal cause of AINOCA. The clinical outcomes of Western patients with CMD were less satisfactory than expected, while the prognosis of Japanese patients with CES treated with medications including calcium channel blockers was favorable. However, the incidence and clinical features of coronary spasm endotypes were different between Western and Japanese populations. Furthermore, sex-related differences in the clinical manifestations and outcomes of patients with different spasm endotypes remain uncertain beyond race. In this article, we will review the sex differences in Japanese AINOCA patients with coronary vasomotor disorders, including CMD and CES, and compare them with those of Western patients.

Longitudinal Strain Analysis and Correlation with TIMI Frame Count in Patients with Ischemia with No Obstructive Coronary Artery (INOCA) and Microvascular Angina (MVA)

Background: The aim of the study is to evaluate the subclinical alterations of cardiac mechanics detected using speckle-tracking echocardiography and compare these data with the coronary angiography indices used during coronary angiography in a population of patients diagnosed with ischemia with no obstructive coronary artery (INOCA) and microvascular angina (MVA). Methods: The study included 85 patients admitted to our center between November 2019 and January 2022 who were diagnosed with INOCA compared with a control group of 70 healthy patients. A collection of anamnestic data and a complete cardiovascular physical examination, and echocardiogram at rest with longitudinal strain were performed for all patients. Furthermore, the TIMI frame count (TFC) for the three coronary vessels was calculated according to Gibson's indications. All parameters were compared with a control population with similar characteristics. Results: Patients with INOCA compared to the control population showed statistically significant changes in the parameters assessed on the longitudinal strain analysis. In particular, patients with INOCA showed statistically significant changes in GLS (-16.71) compared to the control population (-19.64) (p = 0.003). In patients with INOCA, the total TIMI frame count (tTFC) correlated with the GLS value with a correlation coefficient of 0.418 (p = 0.021). Conclusions: In patients with angina, documented myocardial ischemia, the absence of angiographically significant stenosis (INOCA) and LVEF > 50%, the prevalence of microvascular dysfunction documented by TFC was extremely represented. A statistically significant reduction in GLS was observed in these patients. TFC and longitudinal strain, therefore, appear to be two reliable, sensitive and easily accessible methods for the study of alterations in coronary microcirculation and the characterization of patients with INOCA and microvascular angina.

[Angina Pectoris and the Importance of Coronary Microcirculation in Practice]

Angina Pectoris and the Importance of Coronary Microcirculation in Practice Abstract. Microvascular angina is a common manifestation of coronary microvascular dysfunction, particulary prevalent in post-menopausal women above the age of 50 and associated with impaired quality of life and poor clinical outcomes. However, microvascular angina remains largely undetected given the underuse of diagnostic tools for the assessment of coronary microvascular function. As a consequence, many of these patients suffering from coronary microvascular dysfunction fail to receive the appropriate medical treatment and remain in the long term symptomatic. Invasive coronary catheterization with measurement of coronary flow reserve and intracoronary acetylcholine provocation testing allows for the assessment of coronary microvascular dysfunction, and a therapy targeting specific physiological pathways can be implemented. A targeted therapy includes lifestyle modifications, secondary prevention measures, and anti-anginal medication. Ongoing clinical research in the field is expected to deliver novel diagnostic and therapeutic concepts for an improved management of patients with coronary microvascular disease.

Temporal Changes in Extracellular Vesicle Hemostatic Protein Composition Predict Favourable Left Ventricular Remodeling after Acute Myocardial Infarction

The subset of plasma extracellular vesicles (EVs) that coprecipitate with low-density lipoprotein (LDL-EVs) carry coagulation and fibrinolysis pathway proteins as cargo. We investigated the association between LDL-EV hemostatic/fibrinolysis protein ratios and post-acute myocardial infarction (post-AMI) left ventricular (LV) remodeling which precedes heart failure. Protein concentrations of von Willebrand factor (VWF), SerpinC1 and plasminogen were determined in LDL-EVs extracted from plasma samples obtained at baseline (within 72 h post-AMI), 1 month and 6 months post-AMI from 198 patients. Patients were categorized as exhibiting adverse (n = 98) or reverse (n = 100) LV remodeling based on changes in LV end-systolic volume (increased or decreased ≥15) over a 6-month period. Multiple level longitudinal data analysis with structural equation (ML-SEM) model was used to assess predictive value for LV remodeling independent of baseline differences. At baseline, protein levels of VWF, SerpinC1 and plasminogen in LDL-EVs did not differ between patients with adverse versus reverse LV remodeling. At 1 month post-AMI, protein levels of VWF and SerpinC1 decreased whilst plasminogen increased in patients with adverse LV remodeling. In contrast, VWF and plasminogen decreased whilst SerpinC1 remained unchanged in patients with reverse LV remodeling. Overall, compared with patients with adverse LV remodeling, higher levels of SerpinC1 and VWF but lower levels of plasminogen resulted in higher ratios of VWF:Plasminogen and SerpinC1:Plasminogen at both 1 month and 6 months post-AMI in patients with reverse LV remodeling. More importantly, ratios VWF:Plasminogen (AUC = 0.674) and SerpinC1:Plasminogen (AUC = 0.712) displayed markedly better prognostic power than NT-proBNP (AUC = 0.384), troponin-I (AUC = 0.467) or troponin-T (AUC = 0.389) (p < 0.001) to predict reverse LV remodeling post-AMI. Temporal changes in the ratios of coagulation to fibrinolysis pathway proteins in LDL-EVs outperform current standard plasma biomarkers in predicting post-AMI reverse LV remodeling. Our findings may provide clinical cues to uncover the cellular mechanisms underpinning post-AMI reverse LV remodeling.

Heart failure as a complication of myocardial infarction: rational therapy. Case report

Heart failure (HF) is still a frequent complication of myocardial infarction. Timely identification of subjects at risk for HF development and early initiation of guideline-directed HF therapy in these patients, can decrease the HF burden. This article aims at summarizing clinical data on established pharmacological therapies in treating post-MI patients with left ventricular systolic dysfunction and signs and symptoms of HF.

Sex difference after acute myocardial infarction patients with a history of current smoking and long-term clinical outcomes: Results of KAMIR Registry

BACKGROUND

The contribution of sex as an independent risk factor for cardiovascular disease still remains controversial. The present study investigated the impact of sex on long-term clinical outcomes in Korean acute myocardial infarction (AMI) patients with a history of current smoking on admission after drug-eluting stents (DESs).

METHODS

A total of 12,565 AMI patients (male: n = 11,767 vs. female: n = 798) were enrolled. Major adverse cardiac events (MACEs) comprising all-cause death, recurrent myocardial infarction (Re-MI), and any repeat revascularization were the primary outcomes that were compared between the two groups. Probable or definite stent thrombosis (ST) was the secondary outcome.

RESULTS

After adjustment, the early (30 days) cumulative incidences of MACEs (adjusted hazard ratio [aHR]: 1.457; 95% confidence interval [CI]: 1.021-2.216; p = 0.035) and all-cause death (aHR: 1.699; 95% CI: 1.074-2.687; p = 0.023) were significantly higher in the female group than in the male group. At 2 years, the cumulative incidences of all-cause death (aHR: 1.561; 95% CI: 1.103-2.210; p = 0.012) and Re-MI (aHR: 1.800; 95% CI: 1.089-2.974; p = 0.022) were significantly higher in the female group than in the male group. However, the cumulative incidences of ST were similar between the two groups (aHR: 1.207; 95% CI: 0.583-2.497; p = 0.613).

CONCLUSIONS

The female group showed worse short-term and long-term clinical outcomes compared with the male group comprised of Korean AMI patients with a history of current smoking after successful DES implantation. However, further studies are required to confirm these results.

Bibliometric and visual analysis of coronary microvascular dysfunction

Background

Coronary microvascular dysfunction (CMD) may play an important role in various cardiovascular diseases, including HFpEF and both obstructive and non-obstructive coronary artery disease (CAD). To date, there has been no bibliometric analysis to summarize this field. Here, we aim to conduct a bibliometric analysis of CMD to determine the current status and frontiers in this field.

Materials and methods

Publications about CMD were taken from the Web of Science Core Collection database (WOSCC). WOSCC's literature analysis wire, the VOSviewer 1.6.16, and CiteSpace 5.1.3 were used to conduct the analysis.

Results

A total of 785 publications containing 206 reviews and 579 articles are included in the sample. The leading authors are Iacopo Olivotto, Paolo G. Camici, and Carl J. Pepine. The most productive institutions are the University of Florence, Cedars Sinai Medical Center, and Harvard University. The most productive countries are the USA, Italy, and England. There are a total of 237 journals that contribute to this field, and the leading journals in our study were the International Journal of Cardiology, the European Heart Journal and the JACC. From 2012 to 2021, the top three most-cited articles focused on the association between HFpEF and CMD. The important keywords are heart failure, hypertrophic cardiomyopathy, chest pain, women, coronary flow reserve (CFR), endothelial dysfunction and prognostic value. "Positron emission tomography" shows the strongest burst strength, followed by "blow flow" and "artery." The keywords that started to burst from 2015 are particularly emphasized, including "heart failure," "coronary flow reserve," and "management."

Conclusion

Studies about CMD are relatively limited, and the largest contribution comes from the USA, Italy and England. More studies are needed, and publications from other countries should be enhanced. The main research hotspots in the CMD field include CMD in patients with HFpEF, sex differences, the new methods of diagnosis for CMD, and the effective treatment of CMD. Attention should be given to CMD in patients with HFpEF, and untangling the association between CMD and HFpEF could be helpful in the development of physiology-stratified treatment for patients with CMD and HFpEF.

Ventricular arrhythmias in acute myocardial ischaemia-Focus on the ageing and sex

Annually, approximately 17 million people die from cardiovascular diseases worldwide, half of them suddenly. The most common direct cause of sudden cardiac death is ventricular arrhythmia triggered by an acute coronary syndrome (ACS). The study summarizes the knowledge of the mechanisms of arrhythmia onset during ACS in humans and in animal models and factors that may influence the susceptibility to life-threatening arrhythmias during ACS with particular focus on the age and sex. The real impact of age and sex on the arrhythmic susceptibility within the setting of acute ischaemia is masked by the fact that ACSs result from coronary artery disease appearing with age much earlier among men than among women. However, results of researches show that in ageing process changes with potential pro-arrhythmic significance, such as increased fibrosis, cardiomyocyte hypertrophy, decrease number of gap junction channels, disturbances of the intracellular Ca²⁺ signalling or changes in electrophysiological parameters, occur independently of the development of cardiovascular diseases and are more severe in male individuals. A review of the literature also indicates a marked paucity of research in this area in female and elderly individuals. Greater awareness of sex differences in the aging process could help in the development of personalized prevention methods targeting potential pro-arrhythmic factors in patients of both sexes to reduce mortality during the acute phase of myocardial infarction. This is especially important in an era of aging populations in which women will predominate due to their longer lifespan.

MINOCA: One Size Fits All? Probably Not—A Review of Etiology, Investigation, and Treatment

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of conditions that include both atherosclerotic (coronary plaque disruption) and non-atherosclerotic (spontaneous coronary artery dissection, coronary artery spasm, coronary artery embolism, coronary microvascular dysfunction, and supply–demand mismatch) causes resulting in myocardial damage that is not due to obstructive coronary artery disease. Failure to identify the underlying cause may result in inadequate and inappropriate therapy in these patients. The cornerstone of managing MINOCA patients is to identify the underlying mechanism to achieve the target treatment. Intravascular imaging is able to identify different morphologic features of coronary plaques, while cardiac magnetic resonance is the gold standard for detection of myocardial infarction in the setting of MINOCA. In this review, we summarize the relevant clinical issues, contemporary diagnosis, and treatment options of MINOCA.

Age-dependent and sex-dependent differences in mortality from influenza-associated cardiovascular diseases among older adults in Shanghai, China: a population-based study

OBJECTIVES

Influenza epidemics lead to substantial morbidity and mortality among older adults. This study aimed to analyse and assess the age-specific and sex-specific differences in mortality rates for cardiovascular disease (CVD) associated with influenza in older adults.

DESIGN

We obtained weekly data on mortality from CVD in adults≥60 years, categorised into five age groups. We used a quasi-Poisson model and adjusted for long-term and seasonal trends and absolute humidity as confounding factors. The male-to-female ratio (M/F ratio) was an indicator for assessing sex differences.

SETTING

Shanghai, China.

PARTICIPANT

We analysed 440 107 CVD deaths in adults aged ≥60 years, including 44 913 cases positive for influenza and 1 927 487 outpatient visits for influenza-like illness from 2010 to 2019.

MAIN OUTCOME MEASURES

Age-specific and sex-specific excess CVD mortality rates in older adults for various combinations of CVDs and influenza viruses.

RESULTS

Variations were observed in the excess mortality from CVD, ischaemic heart disease (IHD) and stroke depending on the influenza types/subtypes in different age and sex categories. The ≥85 years group had the highest excess mortality rates per 100 000 persons for CVD, IHD and stroke, while influenza A (H3N2) virus accounted for the highest mortality from CVD, IHD and stroke in people aged ≥65 years. Older men had a significantly lower influenza-associated IHD mortality rate than women, with an M/F ratio of 0.77 (p<0.05).

CONCLUSIONS

Excess mortality rates for CVDs associated with influenza increased with age in older adults. The risk for influenza-associated IHD mortality was significantly higher in older women than men. Our findings will help implement targeted health strategies, including the promotion of influenza vaccination and early therapeutic intervention for the older population with CVD, to curb the influenza burden effectively.

Statins in High Cardiovascular Risk Patients: Do Comorbidities and Characteristics Matter?

Atherosclerotic cardiovascular disease (ASCVD) morbidity and mortality are decreasing in high-income countries, but ASCVD remains the leading cause of morbidity and mortality in high-income countries. Over the past few decades, major risk factors for ASCVD, including LDL cholesterol (LDL-C), have been identified. Statins are the drug of choice for patients at increased risk of ASCVD and remain one of the most commonly used and effective drugs for reducing LDL cholesterol and the risk of mortality and coronary artery disease in high-risk groups. Unfortunately, doctors tend to under-prescribe or under-dose these drugs, mostly out of fear of side effects. The latest guidelines emphasize that treatment intensity should increase with increasing cardiovascular risk and that the decision to initiate intervention remains a matter of individual consideration and shared decision-making. The purpose of this review was to analyze the indications for initiation or continuation of statin therapy in different categories of patient with high cardiovascular risk, considering their complexity and comorbidities in order to personalize treatment.

Sex and gender differences in dementia

The dementia landscape has undergone a striking paradigm shift. The advances in understanding of neurodegeneration and proteinopathies has changed our approach to patients with cognitive impairment. Firstly, it has recently been shown that the various proteinopathies that are the cause of the dementia begin to build up long before the appearance of any obvious symptoms. This has cemented the idea that there is an urgency in diagnosis as it occurs very late in the pathophysiology of these diseases. Secondly, that accurate diagnosis is required to deliver targeted therapies, that is precision medicine. With this latter point, the realization that various factors of a person need to be considered as they may impact the presentation and progression of disease has risen to the forefront. Two of these factors aside from race and age are biological sex and gender (social construct), as both can have tremendous impact on manifestation of disease. This chapter will cover what is known and remains to be known on the interaction of sex and gender with some of the major causes of dementia.

Identifying and Investigating Ambulatory Care Sequences Before Invasive Coronary Angiography

BACKGROUND

The concept of care pathways is widely used to provide efficient, timely, and evidence-based medical care. Recently, the investigation of actual empirical patient pathways has gained attention. We demonstrate the usability of State Sequence Analysis (SSA), a data mining approach based on sequence clustering techniques, on comprehensive insurance claims data from Germany to identify empirical ambulatory care sequences. We investigate patients with coronary artery disease before invasive coronary angiography (CA) and compare identified patterns with guideline recommendations. This patient group is of particular interest due to high and regionally varying CA rates.

METHODS

Events relevant for the care of coronary artery disease patients, namely physician consultations and medication prescriptions, are identified based on medical guidelines and combined to define states. State sequences are determined for 1.5 years before CA. Sequence similarity is defined for clustering, using optimal matching with theory-informed substitution costs. We visualize clusters, present descriptive statistics, and apply logistic regression to investigate the association of cluster membership with subsequent undesired care events.

RESULTS

Five clusters are identified, the included patients differing with respect to morbidity, urbanity of residential area, and health care utilization. Clusters exhibit significant differences in the timing, structure, and extent of care before CA. When compared with guideline recommendations, 3 clusters show signs of care deficits.

CONCLUSIONS

Our analyses demonstrate the potential of SSA for exploratory health care research. We show how SSA can be used on insurance claims data to identify, visualize, and investigate care patterns and their deviations from guideline recommendations.