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López-Palop R, Carrillo P, Lozano Í. Impact of Sex in the Incidence of Heart Failure in Patients with Chronic Coronary Syndrome. Curr Heart Fail Rep 2024:10.1007/s11897-024-00663-z. [PMID: 38703306 DOI: 10.1007/s11897-024-00663-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE OF REVIEW This review examines the available evidence concerning the incidence of heart failure in patients with chronic coronary syndrome, with a focus on gender differences. RECENT FINDINGS The incidence of heart failure in the context of chronic coronary syndrome presents conflicting data. Most of the available information stems from studies involving stable patients' post-acute coronary syndrome, revealing a wide range of incidence rates, from less than 3% to over 20%, observed over 5 years of follow-up. Regarding the gender differences in heart failure incidence, there is no consensus about whether women exhibit a higher incidence, particularly in the presence of evidence of obstructive coronary artery disease. However, in cases where obstructive coronary artery disease is absent, women may face a more unfavourable prognosis due to a higher prevalence of microvascular disease and heart failure with preserved ventricular function. The different profile of ischaemic heart disease in women difficult to establish differences in prognosis independently associated with female sex. Targeted investigations are essential to discern the incidence of heart failure in chronic coronary syndrome and explore potential gender-specific associations.
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Affiliation(s)
- Ramón López-Palop
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Murcia-Cartagena s/n. 30120, Murcia, Spain.
| | - Pilar Carrillo
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Murcia-Cartagena s/n. 30120, Murcia, Spain
| | - Íñigo Lozano
- Servicio de Cardiología, Hospital Universitario de Cabueñes, Gijón, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo, Spain
- Universidad de Oviedo, Oviedo, Spain
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2
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Wong YL, Yu M, Chong C, Yang D, Xu D, Lee ML, Hsu W, Wong TY, Cheng C, Cheung CY. Association between deep learning measured retinal vessel calibre and incident myocardial infarction in a retrospective cohort from the UK Biobank. BMJ Open 2024; 14:e079311. [PMID: 38514140 PMCID: PMC10961540 DOI: 10.1136/bmjopen-2023-079311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/19/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Cardiovascular disease is a leading cause of global death. Prospective population-based studies have found that changes in retinal microvasculature are associated with the development of coronary artery disease. Recently, artificial intelligence deep learning (DL) algorithms have been developed for the fully automated assessment of retinal vessel calibres. METHODS In this study, we validate the association between retinal vessel calibres measured by a DL system (Singapore I Vessel Assessment) and incident myocardial infarction (MI) and assess its incremental performance in discriminating patients with and without MI when added to risk prediction models, using a large UK Biobank cohort. RESULTS Retinal arteriolar narrowing was significantly associated with incident MI in both the age, gender and fellow calibre-adjusted (HR=1.67 (95% CI: 1.19 to 2.36)) and multivariable models (HR=1.64 (95% CI: 1.16 to 2.32)) adjusted for age, gender and other cardiovascular risk factors such as blood pressure, diabetes mellitus (DM) and cholesterol status. The area under the receiver operating characteristic curve increased from 0.738 to 0.745 (p=0.018) in the age-gender-adjusted model and from 0.782 to 0.787 (p=0.010) in the multivariable model. The continuous net reclassification improvements (NRIs) were significant in the age and gender-adjusted (NRI=21.56 (95% CI: 3.33 to 33.42)) and the multivariable models (NRI=18.35 (95% CI: 6.27 to 32.61)). In the subgroup analysis, similar associations between retinal arteriolar narrowing and incident MI were observed, particularly for men (HR=1.62 (95% CI: 1.07 to 2.46)), non-smokers (HR=1.65 (95% CI: 1.13 to 2.42)), patients without DM (HR=1.73 (95% CI: 1.19 to 2.51)) and hypertensive patients (HR=1.95 (95% CI: 1.30 to 2.93)) in the multivariable models. CONCLUSION Our results support DL-based retinal vessel measurements as markers of incident MI in a predominantly Caucasian population.
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Affiliation(s)
- Yiu Lun Wong
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Marco Yu
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Crystal Chong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
| | - Dawei Yang
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Dejiang Xu
- School of Computing, National University of Singapore, Singapore
| | - Mong Li Lee
- School of Computing, National University of Singapore, Singapore
| | - Wynne Hsu
- School of Computing, National University of Singapore, Singapore
| | - Tien Y Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Tsinghua Medicine, Tsinghua University, Beijing, China
| | - Chingyu Cheng
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
- Centre for Innovation and Precision Eye Health; and Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Carol Y Cheung
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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3
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van Rosendael SE, Bax AM, Lin FY, Achenbach S, Andreini D, Budoff MJ, Cademartiri F, Callister TQ, Chinnaiyan K, Chow BJW, Cury RC, DeLago AJ, Feuchtner G, Hadamitzky M, Hausleiter J, Kaufmann PA, Kim YJ, Leipsic JA, Maffei E, Marques H, de Araújo Gonçalves P, Pontone G, Raff GL, Rubinshtein R, Villines TC, Chang HJ, Berman DS, Min JK, Bax JJ, Shaw LJ, van Rosendael AR. Sex and age-specific interactions of coronary atherosclerotic plaque onset and prognosis from coronary computed tomography. Eur Heart J Cardiovasc Imaging 2023; 24:1180-1189. [PMID: 37165981 PMCID: PMC10445263 DOI: 10.1093/ehjci/jead094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/21/2023] [Accepted: 04/05/2023] [Indexed: 05/12/2023] Open
Abstract
AIMS The totality of atherosclerotic plaque derived from coronary computed tomography angiography (CCTA) emerges as a comprehensive measure to assess the intensity of medical treatment that patients need. This study examines the differences in age onset and prognostic significance of atherosclerotic plaque burden between sexes. METHODS AND RESULTS From a large multi-center CCTA registry the Leiden CCTA score was calculated in 24 950 individuals. A total of 11 678 women (58.5 ± 12.4 years) and 13 272 men (55.6 ± 12.5 years) were followed for 3.7 years for major adverse cardiovascular events (MACE) (death or myocardial infarction). The age where the median risk score was above zero was 12 years higher in women vs. men (64-68 years vs. 52-56 years, respectively, P < 0.001). The Leiden CCTA risk score was independently associated with MACE: score 6-20: HR 2.29 (1.69-3.10); score > 20: HR 6.71 (4.36-10.32) in women, and score 6-20: HR 1.64 (1.29-2.08); score > 20: HR 2.38 (1.73-3.29) in men. The risk was significantly higher for women within the highest score group (adjusted P-interaction = 0.003). In pre-menopausal women, the risk score was equally predictive and comparable with men. In post-menopausal women, the prognostic value was higher for women [score 6-20: HR 2.21 (1.57-3.11); score > 20: HR 6.11 (3.84-9.70) in women; score 6-20: HR 1.57 (1.19-2.09); score > 20: HR 2.25 (1.58-3.22) in men], with a significant interaction for the highest risk group (adjusted P-interaction = 0.004). CONCLUSION Women developed coronary atherosclerosis approximately 12 years later than men. Post-menopausal women within the highest atherosclerotic burden group were at significantly higher risk for MACE than their male counterparts, which may have implications for the medical treatment intensity.
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Affiliation(s)
- Sophie E van Rosendael
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - A Maxim Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Fay Y Lin
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, Zena and Michael A. Wiener Cardiovascular Institute, and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, New York, NY, USA
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen Medizinische Klinik 2-Kardiologie und Angiologie, Ulmenweg 18, 91054 Erlangen, Germany
| | - Daniele Andreini
- Division of Cardiology and Cardiac Imaging, IRCCS Galeazzi Sant'Ambrogio, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Matthew J Budoff
- Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, CA
| | | | - Tracy Q Callister
- Department of Cardiology, Tennessee Heart and Vascular Institute, 353 New Shackle Island Rd Hendersonville, TN 37075, USA
| | - Kavitha Chinnaiyan
- Department of Cardiology, William Beaumont Hospital, 3535 W 13 Mile Rd #742, Royal Oak, MI 48073, USA
| | - Benjamin J W Chow
- Department of Medicine and Radiology, University of Ottawa, 40 Ruskin St, Ottawa, ON K1Y 4W7, Canada
| | - Ricardo C Cury
- Department of Radiology, Miami Cardiac and Vascular Institute, 8900 N Kendall Dr, Miami, FL 33176, USA
| | - Augustin J DeLago
- Capitol Cardiology Associate, 7 Southwoods Blvd, Albany, NY 12211, USA
| | - Gudrun Feuchtner
- Department of Radiology, Medical University of Innsbruck, Christoph-Probst-Platz 1, Innrain 52 A, Fritz-Pregl-Straße 3, 6020 Innsbruck, Austria
| | - Martin Hadamitzky
- Department of Radiology and Nuclear Medicine, German Heart Center Munich, Lazarettstraße 36, 80636 München, Germany
| | - Joerg Hausleiter
- Department of Radiology, Medizinische Klinik I der Ludwig-Maximilians-Universität München, Ziemssenstraße 1, 80336 München, Germany
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital of Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Yong-Jin Kim
- Department of Medicine, Seoul National University Hospital, Jongno-gu, Seoul 03080, South Korea
| | - Jonathon A Leipsic
- Department of Medicine and Radiology, University of British Columbia, 1081 Burrard Street Vancouver, BC V6Z 1Y6, Canada
| | - Erica Maffei
- Department of Radiology, Fondazione Monasterio (FTGM)-CNR, Pisa, Italy
| | - Hugo Marques
- UNICA, Cardiovascular Imaging Unit, Hospital da Luz Lisboa, Av. Lusíada 100, 1500-650 Lisboa, Portugal
- Católica Medical School, Estr. Octávio Pato, 2635-631 Rio de Mouro, Portugal
- Católica Biomedical Research Center, R. Q.ta Grande 6 2780, 2780-156 Oeiras, Portugal
| | - Pedro de Araújo Gonçalves
- UNICA, Cardiovascular Imaging Unit, Hospital da Luz Lisboa, Av. Lusíada 100, 1500-650 Lisboa, Portugal
- Nova Medical School, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal
| | - Gianluca Pontone
- Division of Cardiology and Cardiac Imaging, IRCCS Galeazzi Sant'Ambrogio, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Gilbert L Raff
- Department of Cardiology, William Beaumont Hospital, 3535 W 13 Mile Rd #742, Royal Oak, MI 48073, USA
| | - Ronen Rubinshtein
- Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Todd C Villines
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Hyuk-Jae Chang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea
| | - Daniel S Berman
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | | | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, Zena and Michael A. Wiener Cardiovascular Institute, and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, New York, NY, USA
| | - Alexander R van Rosendael
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Ong P, Hubert A, Schwidder M, Beltrame JF. Coronary Spasm: Ethnic and Sex Differences. Eur Cardiol 2023; 18:e43. [PMID: 37456767 PMCID: PMC10345948 DOI: 10.15420/ecr.2023.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/29/2023] [Indexed: 07/18/2023] Open
Abstract
Coronary spasm (CS), which may occur at the epicardial (focal or diffuse spasm) and/or microvascular (microvascular spasm) level, is a well-established cause of myocardial ischaemia, in particular in patients with anginal chest pain despite unobstructed coronary arteries. The diagnosis of CS can be confirmed during coronary angiography by an additional provocation test with vasoactive substances such as acetylcholine. Due to partially inconsistent data from large clinical studies, especially between Asian and white CS patients, ethnic differences concerning the prevalence and angiographic patterns of CS seem to exist. Furthermore, several studies in patients with coronary vasomotor disorders pointed towards differences among male and female CS patients. This article gives an overview of ethnic- and sex-related differences in patients with CS.
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Affiliation(s)
- Peter Ong
- Robert-Bosch-Krankenhaus, Department of Cardiology and AngiologyStuttgart, Germany
| | - Astrid Hubert
- Robert-Bosch-Krankenhaus, Department of Cardiology and AngiologyStuttgart, Germany
| | - Maike Schwidder
- Robert-Bosch-Krankenhaus, Department of Cardiology and AngiologyStuttgart, Germany
| | - John F Beltrame
- The Queen Elizabeth HospitalAdelaide, Australia
- Discipline of Medicine, University of AdelaideAdelaide, Australia
- Central Adelaide Local Health NetworkAdelaide, Australia
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5
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Vijayalakshmi IB, Nemani L, Kher M, Kumar A. The Gamut of Coronary Artery Disease in Indian Women. INDIAN JOURNAL OF CARDIOVASCULAR DISEASE IN WOMEN 2023. [DOI: 10.25259/mm_ijcdw_404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Coronary artery disease is the leading cause of death among women. Majority of women suffering from CAD have one or more risk factors for CAD in their parents. Women are at higher risk for cardiac events with respect to traditional risk factors including dyslipidemia, hypertension, diabetes, and smoking. Menopause, pregnancy complications, inflammation, anemia, migraines, and depression are important sex-specific novel risk factors for CVD, and it is important that clinicians should be aware of these risks to design strategies for prevention. Education, self-awareness in women, and timely recognition of CAD in women with lifestyle modifications and timely intervention result in better outcomes.
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Affiliation(s)
- I. B. Vijayalakshmi
- Department of Pediatric Cardiology, Super Specialty Hospital (Pradhana Mantri Swasthya Suraksha Yojana), Bengaluru Medical College and Research Institute, Bengaluru, Karnataka, India,
| | - Lalita Nemani
- Department of Cardiology, Nizams Institute of Medical Sciences, Punjagutta, Hyderabad, India,
| | - Monica Kher
- Department of Cardiology, Aster Hospital, Doha, Qatar,
| | - Achukatla Kumar
- Department of Health Research, ICMR, Port Blair, Andaman and Nicobar Islands, India,
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6
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Wolter NL, Jaffe IZ. Emerging vascular cell-specific roles for mineralocorticoid receptor: implications for understanding sex differences in cardiovascular disease. Am J Physiol Cell Physiol 2023; 324:C193-C204. [PMID: 36440858 PMCID: PMC9902217 DOI: 10.1152/ajpcell.00372.2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/04/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
As growing evidence implicates extrarenal mineralocorticoid receptor (MR) in cardiovascular disease (CVD), recent studies have defined both cell- and sex-specific roles. MR is expressed in vascular smooth muscle (SMC) and endothelial cells (ECs). This review integrates published data from the past 5 years to identify novel roles for vascular MR in CVD, with a focus on understanding sex differences. Four areas are reviewed in which there is recently expanded understanding of the cell type- or sex-specific role of MR in 1) obesity-induced microvascular endothelial dysfunction, 2) vascular inflammation in atherosclerosis, 3) pulmonary hypertension, and 4) chronic kidney disease (CKD)-related CVD. The review focuses on preclinical data on each topic describing new mechanistic paradigms, cell type-specific mechanisms, sexual dimorphism if addressed, and clinical implications are then considered. New data support that MR drives vascular dysfunction induced by cardiovascular risk factors via sexually dimorphic mechanisms. In females, EC-MR contributes to obesity-induced endothelial dysfunction by regulating epithelial sodium channel expression and by inhibiting estrogen-induced nitric oxide production. In males with hyperlipidemia, EC-MR promotes large vessel inflammation by genomic regulation of leukocyte adhesion molecules, which is inhibited by the estrogen receptor. In pulmonary hypertension models, MRs in EC and SMC contribute to distinct components of disease pathologies including pulmonary vessel remodeling and RV dysfunction. Despite a female predominance in pulmonary hypertension, sex-specific roles for MR have not been explored. Vascular MR has also been directly implicated in CKD-related vascular dysfunction, independent of blood pressure. Despite these advances, sex differences in MR function remain understudied.
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Affiliation(s)
- Nicole L Wolter
- Molecular Cardiology Research Institute, https://ror.org/002hsbm82Tufts Medical Center, Boston, Massachusetts
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts
| | - Iris Z Jaffe
- Molecular Cardiology Research Institute, https://ror.org/002hsbm82Tufts Medical Center, Boston, Massachusetts
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7
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Rudnicka AR, Welikala R, Barman S, Foster PJ, Luben R, Hayat S, Khaw KT, Whincup P, Strachan D, Owen CG. Artificial intelligence-enabled retinal vasculometry for prediction of circulatory mortality, myocardial infarction and stroke. Br J Ophthalmol 2022; 106:1722-1729. [PMID: 36195457 PMCID: PMC9685715 DOI: 10.1136/bjo-2022-321842] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/03/2022] [Indexed: 02/02/2023]
Abstract
AIMS We examine whether inclusion of artificial intelligence (AI)-enabled retinal vasculometry (RV) improves existing risk algorithms for incident stroke, myocardial infarction (MI) and circulatory mortality. METHODS AI-enabled retinal vessel image analysis processed images from 88 052 UK Biobank (UKB) participants (aged 40-69 years at image capture) and 7411 European Prospective Investigation into Cancer (EPIC)-Norfolk participants (aged 48-92). Retinal arteriolar and venular width, tortuosity and area were extracted. Prediction models were developed in UKB using multivariable Cox proportional hazards regression for circulatory mortality, incident stroke and MI, and externally validated in EPIC-Norfolk. Model performance was assessed using optimism adjusted calibration, C-statistics and R2 statistics. Performance of Framingham risk scores (FRS) for incident stroke and incident MI, with addition of RV to FRS, were compared with a simpler model based on RV, age, smoking status and medical history (antihypertensive/cholesterol lowering medication, diabetes, prevalent stroke/MI). RESULTS UKB prognostic models were developed on 65 144 participants (mean age 56.8; median follow-up 7.7 years) and validated in 5862 EPIC-Norfolk participants (67.6, 9.1 years, respectively). Prediction models for circulatory mortality in men and women had optimism adjusted C-statistics and R2 statistics between 0.75-0.77 and 0.33-0.44, respectively. For incident stroke and MI, addition of RV to FRS did not improve model performance in either cohort. However, the simpler RV model performed equally or better than FRS. CONCLUSION RV offers an alternative predictive biomarker to traditional risk-scores for vascular health, without the need for blood sampling or blood pressure measurement. Further work is needed to examine RV in population screening to triage individuals at high-risk.
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Affiliation(s)
| | - Roshan Welikala
- Faculty of Science, Engineering and Computing, Kingston University, Kingston-Upon-Thames, UK
| | - Sarah Barman
- Faculty of Science, Engineering and Computing, Kingston University, Kingston-Upon-Thames, UK
| | - Paul J Foster
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, University College London, London, UK
| | - Robert Luben
- MRC Epidemiology Unit, Cambridge University, Cambridge, UK
| | - Shabina Hayat
- Department of Psychiatry, Cambridge Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Kay-Tee Khaw
- MRC Epidemiology Unit, Cambridge University, Cambridge, UK
| | - Peter Whincup
- Population Health Research Institute, St George's University of London, London, UK
| | - David Strachan
- Population Health Research Institute, St George's University of London, London, UK
| | - Christopher G Owen
- Population Health Research Institute, St George's University of London, London, UK
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8
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Hanssen H, Streese L, Vilser W. Retinal vessel diameters and function in cardiovascular risk and disease. Prog Retin Eye Res 2022; 91:101095. [PMID: 35760749 DOI: 10.1016/j.preteyeres.2022.101095] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 12/13/2022]
Abstract
In the last two decades evidence has gradually accumulated suggesting that the eye may be a unique window for cardiovascular risk stratification based on the assessment of subclinical damage of retinal microvascular structure and function. This can be facilitated by non-invasive analysis of static retinal vessel diameters and dynamic recording of flicker light-induced and endothelial function-related dilation of both retinal arterioles and venules. Recent new findings have made retinal microvascular biomarkers strong candidates for clinical implementation as reliable risk predictors. Beyond a review of the current evidence and state of research, the article aims to discuss the methodological benefits and pitfalls and to identify research gaps and future directions. Above all, the potential use for screening and treatment monitoring of cardiovascular disease risk are highlighted. The article provides fundamental comprehension of retinal vessel imaging by explaining anatomical and physiological essentials of the retinal microcirculation leading to a detailed description of the methodological approach. This allows for better understanding of the underlying retinal microvascular pathology associated with the prevalence and development of cardiovascular disease. A body of new evidence is presented on the clinical validity and predictive value of retinal vessel diameters and function for incidence cardiovascular disease and outcome. Findings in children indicate the potential for utility in childhood cardiovascular disease prevention, and the efficacy of exercise interventions highlight the treatment sensitivity of retinal microvascular biomarkers. Finally, coming from the availability of normative data, solutions for diagnostic challenges are discussed and conceptual steps towards clinical implementation are put into perspective.
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Affiliation(s)
- Henner Hanssen
- Department of Sport, Exercise and Health, Preventive Sports Medicine and Systems Physiology, Medical Faculty, University of Basel, Switzerland.
| | - Lukas Streese
- Department of Sport, Exercise and Health, Preventive Sports Medicine and Systems Physiology, Medical Faculty, University of Basel, Switzerland
| | - Walthard Vilser
- Institute of Biomedical Engineering and Informatics, Ilmenau University of Technology, Ilmenau, Germany; Neonatology and Pediatric Intensive Care Unit, Department of Pediatrics, Jena University Hospital, Jena, Germany
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9
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Choi D, Choi S, Kim KH, Kim K, Chang J, Kim SM, Kim SR, Cho Y, Lee G, Son JS, Park SM. Combined Associations of Physical Activity and Particulate Matter With Subsequent Cardiovascular Disease Risk Among 5‐Year Cancer Survivors. J Am Heart Assoc 2022; 11:e022806. [PMID: 35491990 PMCID: PMC9238603 DOI: 10.1161/jaha.121.022806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The combined associations of physical activity and particulate matter (PM) with subsequent cardiovascular disease (CVD) risk is yet unclear. Methods and Results The study population consisted of 18 846 cancer survivors who survived for at least 5 years after initial cancer diagnosis from the Korean National Health Insurance Service database. Average PM levels for 4 years were determined in administrative district areas, and moderate‐to‐vigorous physical activity (MVPA) information was acquired from health examination questionnaires. A multivariable Cox proportional hazards model was used to evaluate the risk for CVD. Among patients with low PM with particles ≤2.5 µm (PM2.5; (19.8–25.6 μg/m3) exposure, ≥5 times per week of MVPA was associated with lower CVD risk (adjusted hazard ratio [aHR], 0.77; 95% CI, 0.60–0.99) compared with 0 times per week of MVPA. Also, a higher level of MVPA frequency was associated with lower CVD risk (P for trend=0.028) among cancer survivors who were exposed to low PM2.5 levels. In contrast, ≥5 times per week of MVPA among patients with high PM2.5 (25.8–33.8 μg/m3) exposure was not associated with lower CVD risk (aHR, 0.98; 95% CI, 0.79–1.21). Compared with patients with low PM2.5 and MVPA ≥3 times per week, low PM2.5 and MVPA ≤2 times per week (aHR, 1.26; 95% CI, 1.03–1.55), high PM2.5 and MVPA ≥3 times per week (aHR, 1.34; 95% CI, 1.07–1.67), and high PM2.5 and MVPA ≤2 times per week (aHR, 1.38; 95% CI, 1.12–1.70) was associated with higher CVD risk. Conclusions Cancer survivors who engaged in MVPA ≥5 times per week benefited from lower CVD risk upon low PM2.5 exposure. High levels of PM2.5 exposure may attenuate the risk‐reducing effects of MVPA on the risk of CVD.
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Affiliation(s)
- Daein Choi
- Department of Medicine Mount Sinai Beth IsraelIcahn School of Medicine at Mount Sinai New York NY
| | - Seulggie Choi
- Department of Biomedical Sciences Seoul National University Graduate School Seoul South Korea
| | - Kyae Hyung Kim
- Department of Family Medicine Seoul National University Hospital Seoul South Korea
| | - Kyuwoong Kim
- Division of Cancer Control and Policy National Cancer Control InstituteNational Cancer Center Goyang South Korea
| | - Jooyoung Chang
- Department of Biomedical Sciences Seoul National University Graduate School Seoul South Korea
| | - Sung Min Kim
- Department of Biomedical Sciences Seoul National University Graduate School Seoul South Korea
| | - Seong Rae Kim
- Department of Dermatology Seoul National University Hospital Seoul South Korea
| | - Yoosun Cho
- Total Healthcare CenterKangbuk Samsung HospitalSungkyunkwan University School of Medicine Seoul South Korea
| | - Gyeongsil Lee
- Department of Biomedical Sciences Seoul National University Graduate School Seoul South Korea
- Department of Family Medicine Seoul National University Hospital Seoul South Korea
| | - Joung Sik Son
- Department of Family Medicine Korea University Guro Hospital South Korea
| | - Sang Min Park
- Department of Biomedical Sciences Seoul National University Graduate School Seoul South Korea
- Department of Family Medicine Seoul National University Hospital Seoul South Korea
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Mansour M, Radaideh Q, Alaiwah MN, Alnimer Y, Devabhaktuni SR, Dhar G, Vallurupalli S, Michos ED, Newby DE, Williams MC, Fudim M, Al'Aref SJ. Major adverse cardiac events in symptomatic women with non-obstructive CAD on coronary CTA: pooled analysis from PROMISE and SCOT-HEART. Int J Cardiovasc Imaging 2022; 38:683-693. [PMID: 34628593 PMCID: PMC8930619 DOI: 10.1007/s10554-021-02429-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022]
Abstract
The presence of non-obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CTA) has been associated with the occurrence of major adverse cardiac events (MACE). However, factors associated with the development of MACE in symptomatic women with non-obstructive CAD on coronary CTA have not been fully elucidated. We sought to examine the influence of risk factors and coronary artery calcification on MACE in symptomatic women with non-obstructive CAD on coronary CTA. Women from PROMISE and SCOT-HEART trials with none or non-obstructive CAD on coronary CTA comprised the study cohort. Baseline characteristics and clinical presentation were assessed. Survival analysis using Kaplan-Meier curves was done to compare outcomes stratified by the atherosclerotic cardiovascular disease (ASCVD) risk score and the Agatston score. The primary endpoint was a composite of all-cause mortality, myocardial infarction, and revascularization. 2597 women had non-obstructive CAD or normal coronary CTA, with a median follow-up of 32 months. Compared to women without MACE, women with MACE had lower high-density lipoprotein cholesterol (HDL-C) levels and higher mean ASCVD risk scores. Further, women with non-obstructive CAD and ASCVD ≥ 7.5% had higher risk of MACE than those with ASCVD < 7.5% [3.2% vs. 1.1%, adjusted HR (aHR) of 3.1 (95% CI 1.32, 7.23), P-value 0.009]. The Agatston calcium score, on the other hand, was not independently associated with MACE among this population of symptomatic women. Symptomatic women with non-obstructive CAD on coronary CTA are at higher risk for MACE, with the ASCVD risk score being independently associated with the occurrence of adverse events.
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Affiliation(s)
- Munthir Mansour
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Qais Radaideh
- Division of Internal Medicine, Department of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Malek N Alaiwah
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Yanal Alnimer
- Department of Medicine, Tappahannock Hospital, Virginia Commonwealth University, Richmond, VA, USA
| | - Subodh R Devabhaktuni
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Gaurav Dhar
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Srikanth Vallurupalli
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Subhi J Al'Aref
- Division of Cardiology, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA.
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11
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Schamroth Pravda N, Karny-Rahkovich O, Shiyovich A, Schamroth Pravda M, Rapeport N, Vaknin-Assa H, Eisen A, Kornowski R, Porter A. Coronary Artery Disease in Women: A Comprehensive Appraisal. J Clin Med 2021; 10:jcm10204664. [PMID: 34682787 PMCID: PMC8541551 DOI: 10.3390/jcm10204664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/02/2021] [Accepted: 10/09/2021] [Indexed: 01/16/2023] Open
Abstract
Coronary artery disease (CAD) is a significant cause of illness and death amongst women. The pathophysiology, manifestations, and outcomes of CVD and CAD differ between sexes. These sex differences remain under-recognized. The aim of this review is to highlight and raise awareness of the burden and unique aspects of CAD in women. It details the unique pathophysiology of CAD in women, cardiovascular risk factors in women (both traditional and sex-specific), the clinical presentation of CAD in women, and the range of disease in obstructive and non-obstructive CAD in women.
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Affiliation(s)
- Nili Schamroth Pravda
- Department of Cardiology, Rabin Medical Center, Petach Tikva 49100, Israel; (O.K.-R.); (A.S.); (H.V.-A.); (A.E.); (R.K.); (A.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 39040, Israel
- Correspondence: ; Tel.: +972-544476243
| | - Orith Karny-Rahkovich
- Department of Cardiology, Rabin Medical Center, Petach Tikva 49100, Israel; (O.K.-R.); (A.S.); (H.V.-A.); (A.E.); (R.K.); (A.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 39040, Israel
| | - Arthur Shiyovich
- Department of Cardiology, Rabin Medical Center, Petach Tikva 49100, Israel; (O.K.-R.); (A.S.); (H.V.-A.); (A.E.); (R.K.); (A.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 39040, Israel
| | | | | | - Hana Vaknin-Assa
- Department of Cardiology, Rabin Medical Center, Petach Tikva 49100, Israel; (O.K.-R.); (A.S.); (H.V.-A.); (A.E.); (R.K.); (A.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 39040, Israel
| | - Alon Eisen
- Department of Cardiology, Rabin Medical Center, Petach Tikva 49100, Israel; (O.K.-R.); (A.S.); (H.V.-A.); (A.E.); (R.K.); (A.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 39040, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petach Tikva 49100, Israel; (O.K.-R.); (A.S.); (H.V.-A.); (A.E.); (R.K.); (A.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 39040, Israel
| | - Avital Porter
- Department of Cardiology, Rabin Medical Center, Petach Tikva 49100, Israel; (O.K.-R.); (A.S.); (H.V.-A.); (A.E.); (R.K.); (A.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 39040, Israel
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12
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Gewalt S, Lahu S, Ndrepepa G, Pellegrini C, Bernlochner I, Neumann FJ, Menichelli M, Morath T, Witzenbichler B, Wöhrle J, Hoppe K, Richardt G, Laugwitz KL, Schunkert H, Kastrati A, Schüpke S, Mayer K. Efficacy and Safety of Ticagrelor Versus Prasugrel in Women and Men with Acute Coronary Syndrome: A Pre-specified, Sex-Specific Analysis of the ISAR-REACT 5 Trial. J Atheroscler Thromb 2021; 29:747-761. [PMID: 33867409 PMCID: PMC9135658 DOI: 10.5551/jat.62776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Aim: Sex-specific analyses of direct head-to-head comparisons between newer P2Y12 inhibitors are limited. This study was conducted to assess the efficacy and safety of ticagrelor versus prasugrel in women and men with acute coronary syndromes (ACS) planned for an invasive strategy.
Methods: This pre-specified analysis of the ISAR-REACT 5 trial included 956 women and 3,062 men with ACS randomly assigned to either ticagrelor or prasugrel. The primary endpoint was the 12-month incidence of death, myocardial infarction, or stroke; the safety endpoint was the 12-month incidence of bleeding (type 3–5 according to the Bleeding Academic Research Consortium [BARC]).
Results: The primary endpoint occurred in 42 women (8.9%) in the ticagrelor group and 39 women (8.3%) in the prasugrel group (hazard ratio [HR]=1.10, 95% confidence interval [CI] 0.71–1.70,P=0.657) and in 142 men (9.4%) in the ticagrelor group and 98 men (6.5%) in the prasugrel group (HR=1.47 [1.13–1.90],P=0.004;P for interaction [Pint]=0.275). BARC type 3–5 bleeding occurred in 36 women (9.7%) in the ticagrelor group and 34 women (9.7%) in the prasugrel group (HR=1.04 [0.65–1.67],P=0.856) and in 59 men in the ticagrelor group (4.4%) and 46 men (3.6%) in the prasugrel group (HR=1.24 [0.85–1.83],P=0.266; Pint=0.571).
Conclusions: Although there was no significant interaction between sex and treatment effect of study drugs, the superior efficacy of prasugrel was more evident among men. No difference in bleeding between the two study groups was seen for both women and men.
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Affiliation(s)
- Senta Gewalt
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | - Shqipdona Lahu
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | - Costanza Pellegrini
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance.,Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg · Bad Krozingen
| | | | - Tanja Morath
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | | | - Jochen Wöhrle
- Department of Cardiology, Medical Campus Lake Constance
| | - Katharina Hoppe
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | | | - Karl-Ludwig Laugwitz
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance.,Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance
| | - Katharina Mayer
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
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13
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Greco A, Capodanno D. Differences in coronary artery disease and outcomes of percutaneous coronary intervention with drug-eluting stents in women and men. Expert Rev Cardiovasc Ther 2021; 19:301-312. [PMID: 33706641 DOI: 10.1080/14779072.2021.1902806] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Despite common perceptions, coronary artery disease (CAD) is not a male-specific condition, and sex-based differences do occur in many aspects, including clinical outcomes after percutaneous coronary intervention (PCI) with stent implantation. New-generation drug-eluting stents (DES) significantly improved post-PCI outcomes. However, no sex-specific guidelines on PCI and the use of DES are available as current evidence was derived from clinical trials enrolling predominantly male patients. AREAS COVERED This review aims at exploring sex-based disparities in CAD characteristics and manifestations, and comparing PCI outcomes and the efficacy and safety profiles of DES according to sex. In addition, a critical approach to trials' interpretation with an analysis of sources of bias is provided to inform future research and clinical practice. EXPERT OPINION Sex gap in clinical outcomes after PCI with DES implantation is narrowing due to improved performances of new-generation DES. However, scientific research and biomedical engineering are striving to optimize DES profiles and generate new iterations of devices. At the same time, gender initiatives and sex-specific trials are accruing to overcome current issues in the field. Advances in these areas will foster improvements in early and long-term clinical outcomes of both women and men.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - S. Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - S. Marco", University of Catania, Catania, Italy
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14
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Geraghty L, Figtree GA, Schutte AE, Patel S, Woodward M, Arnott C. Cardiovascular Disease in Women: From Pathophysiology to Novel and Emerging Risk Factors. Heart Lung Circ 2021; 30:9-17. [DOI: 10.1016/j.hlc.2020.05.108] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/05/2020] [Accepted: 05/24/2020] [Indexed: 12/12/2022]
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15
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Salle L, Denis M, Feron F, Dillinger JG, Henry P, Gautier JF, Kevorkian JP. Impact of BMI on prevalence of coronary atherosclerotic lesions in non-smoking premenopausal diabetic women: A monocentric study. DIABETES & METABOLISM 2020; 47:101218. [PMID: 33359315 DOI: 10.1016/j.diabet.2020.101218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/10/2020] [Accepted: 12/14/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Laurence Salle
- Department of Endocrinology and Diabetology, Limoges University Hospital Centre, 2, Avenue Martin Luther King, 87042 Limoges Cedex, France.
| | - Margot Denis
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
| | - Florine Feron
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
| | - Jean-Guillaume Dillinger
- Department of Cardiology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
| | - Patrick Henry
- Department of Cardiology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
| | - Jean-François Gautier
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
| | - Jean-Philippe Kevorkian
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
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16
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Mohadjer A, Brown G, Shah SR, Nallapati C, Waheed N, Bavry AA, Park K. Sex-Based Differences in Coronary and Structural Percutaneous Interventions. Cardiol Ther 2020; 9:257-273. [PMID: 32440761 PMCID: PMC7584690 DOI: 10.1007/s40119-020-00176-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Indexed: 02/06/2023] Open
Abstract
In the current state of interventional cardiology, the ability to offer advanced therapies to patients who historically were not surgical candidates has grown exponentially in the last few decades. As therapies have expanded in complex coronary and structural interventions, the nuances of treating certain populations have emerged. In particular, the role of sex-based anatomic and outcome differences has been increasingly recognized. As guidelines for cardiovascular prevention and treatment for certain conditions may vary by sex, therapeutic interventions in the structural and percutaneous coronary areas may also vary. In this review, we aim to discuss these differences, the current literature available on these topics, and areas of focus for the future.
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Affiliation(s)
- Ashley Mohadjer
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Garrett Brown
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
- Division of Cardiovascular Medicine, University of South Florida, Tampa, FL, USA
| | - Syed R Shah
- Department of Internal Medicine, North Florida Regional Medical Center, University of Central Florida (Gainesville), Gainesville, FL, USA
| | - Charishma Nallapati
- Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Nida Waheed
- Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Anthony A Bavry
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA.
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17
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Research progress regarding the diagnosis and treatment of mental stress-induced myocardial ischemia. Anatol J Cardiol 2020; 24:126-136. [PMID: 32870175 PMCID: PMC7585978 DOI: 10.14744/anatoljcardiol.2020.69447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Myocardial ischemia resulting from psychological stress [mental stress-induced myocardial ischemia (MSIMI)] refers to the condition wherein psychosocial and psychological stimulations cause myocardial ischemia in patients with coronary heart disease, which is different from drug-induced myocardial ischemia. Therefore, this condition often escapes diagnosis, portends clinical risk, and affects the quality of life of MSIMI survivors. MSIMI is closely related to the poor prognosis of cardiovascular diseases, especially in young women, according to recent randomized, controlled trials (RCTs) on MSIMI. These RCTs involved different sample sizes, interventional measures, and detection techniques. Moreover, differences exist regarding the prevalence rate, distribution characteristics, possible pathogenesis, and clinical significance. Nevertheless, currently, the diagnostic criteria, pathogenesis, and treatment of MSIMI are still in the clinical exploration stage. Hence, considering recent RCTs, this paper summarizes the research status of MSIMI from the aspects of pathogenesis, diagnosis, and treatment strategies to provide a theoretical basis for the follow-up diagnostic methods and treatment guidelines for MSIMI.
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18
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Lin GM, Colangelo LA, Klein BEK, Cotch MF, Wong TY, Cheung CY, Heckbert SR, Alonso A, Kwon Y, Kronmal RA, Lloyd-Jones DM, Liu K. Association of Retinal Microvascular Signs with Incident Atrial Fibrillation: The Multi-Ethnic Study of Atherosclerosis. Ophthalmol Retina 2020; 5:78-85. [PMID: 32565383 DOI: 10.1016/j.oret.2020.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Microvascular diseases may contribute to the occurrence of atrial fibrillation (AF). Retinal microvascular signs that are similar to other microvasculature in the body and can be visualized directly via ophthalmoscopy may provide insights into such a relationship. DESIGN Prospective, longitudinal, multiethnic study. PARTICIPANTS We examined the association between retinal microvascular signs and incident AF in 4994 participants 47 to 86 years of age and free of prior AF who underwent fundus photography from 2002 through 2004 and were followed up through 2015 in the Multi-Ethnic Study of Atherosclerosis (MESA). METHODS Retinal microvascular signs evaluated include central retinal arteriolar equivalent and central retinal venular equivalent (CRVE) and presence of any retinopathy signs (e.g., retinal microaneurysms or hemorrhages). A multivariate Cox regression analysis was used to determine the relationship while adjusting for traditional risk factors, alcohol intake, body mass index, diabetes status, chronic kidney disease status, hemoglobin A1c level, C-reactive protein level, medications, and prevalent cardiovascular diseases or heart failure. MAIN OUTCOME AND MEASURES Incident AF events were identified using 12-lead electrocardiographic findings, hospital discharge records, and Medicare claims data. RESULTS During a median follow-up of 14.1 years, 643 AF events were identified. No association was found between any retinal microvascular signs and incident AF except for retinal focal arteriolar narrowing (hazard ratio, 1.75; 95% confidence interval, 1.06-2.87) in the overall population. However, in the subgroup analyses by gender, wider CRVE was associated with a higher risk of incident AF in women, but not in men (hazard ratio for every 10-μm increase in CRVE, 1.08 [95% confidence interval, 1.01-1.15] and 0.97 [95% confidence interval, 0.92-1.03], respectively; P = 0.041 for interaction). CONCLUSIONS No consistent pattern of association was found between retinal microvascular signs and incident AF. We observed an association in women, but not in men, of wider retinal venular calibers with incidence of AF. The reasons for a possible interaction are incompletely understood.
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Affiliation(s)
- Gen-Min Lin
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois; Department of Medicine, Hualien Armed Forces General Hospital, Hualien, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
| | - Laura A Colangelo
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Barbara E K Klein
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Mary Frances Cotch
- Division of Epidemiology and Clinical Applications, NIH Intramural Research Program, National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Tien Y Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Duke-NUS Medical School, National University of Singapore, Singapore, Republic of Singapore
| | - Carol Y Cheung
- Department of Ophthalmology and Visual Sciences, Chinese University of Hong Kong, Hong Kong, China
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Younghoon Kwon
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Richard A Kronmal
- Department of Biostatistics, University of Washington, Seattle, Washington
| | | | - Kiang Liu
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
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19
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Ghare MI, Tirziu D, Abbott JD, Altin E, Yang Y, Ng V, Grines C, Lansky A. Sex-Specific Outcomes in Cardiovascular Device Evaluations. J Womens Health (Larchmt) 2020; 29:1246-1255. [PMID: 32543268 DOI: 10.1089/jwh.2019.8068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Females have historically been underrepresented in cardiovascular device trials. As a result, differences in outcomes for males and females are not possible to be determined in subanalyses. Materials and Methods: Against a backdrop of troubling trends in cardiovascular outcomes for females, we provide a narrative review on the differences in outcomes observed in females undergoing device evaluations in multiple fields of cardiovascular medicine, including coronary revascularization, structural heart disease, and heart failure. We also review predictors of cardiovascular trial nonparticipation as it may provide avenues by which female enrollment in cardiovascular device trials can be improved. Results: Advances have been made in structural heart therapy, where female representation in transcatheter aortic valve replacement studies was nearly 50%. For other indications, coronary revascularization and heart failure, there was clearly a disparity in female recruitment. On average, female representation was 25% in major clinical trials evaluating drug eluting stents, implantable cardioverter defibrillators, cardiac resynchronization defibrillators, and ventricular assist devices. As a result, the best treatment recommendations for females in these fields are currently guided by outcomes evaluated primarily in males. Conclusions: Female enrollment in device clinical trials for coronary revascularization and heart failure has lagged, leaving uncertainty in making benefit/risk assessments of device therapy. The predictors of female nonparticipation in clinical trials can inform a comprehensive strategy to facilitate and enrich the enrollment of females in cardiovascular device trials. This is critical to ensure that sex differences can be considered in treatment selection, so that patients can receive the best available care.
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Affiliation(s)
- Mohammed Imran Ghare
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniela Tirziu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jinnette Dawn Abbott
- Department of Medicine, Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Elissa Altin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yiping Yang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Vivian Ng
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York, USA
| | - Cindy Grines
- Northside Cardiovascular Institute, Atlanta, Georgia, USA
| | - Alexandra Lansky
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Barts Heart Center, St Bartholomew's Hospital and William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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20
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Manzo-Silberman S. Percutaneous coronary intervention in women: is sex still an issue? Minerva Cardioangiol 2020; 68:393-404. [PMID: 32326680 DOI: 10.23736/s0026-4725.20.05203-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Coronary artery disease among women presents differences in terms of clinical presentation and pathophysiology. To date, women present worse prognoses with more events and higher mortality rate. One the one hand, they are less likely addressed for invasive therapy. One the other hand, revascularization procedures, whether by bypass or by percutaneous coronary intervention, are associated with higher rates of complications and poorer prognosis. Despite higher risk factor burden and comorbidity, women are less affected by obstructive disease and plaque characteristics are more favorable than among men. Abnormalities of endothelial function and micro vascular flow reserve could explain part of the high prevalence of symptoms of angina observed among women. Due to the worse prognosis of microvascular dysfunction, particularly in women, proper diagnosis is mandatory and deserve invasive management. Outcome following ST elevation myocardial infarction is still more severe among women with higher in-hospital mortality, but sex discrepancies are observed even in elective percutaneous coronary intervention. However, improvement of techniques, drugs and devices benefited to both men and women and tend to decrease gender gap. Especially, changes in the design of newer-generation drug-eluting stents (DES) may be particularly important for women. Female sex remains a potent predictor of higher risk of bleeding and vascular complication; thus important efforts should be promoted to develop bleeding avoidance strategies. Sex-based differences still deserve dedicated investigations in terms of physiopathology, particular hormonal impacts, and specific responses to drugs and devices.
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Affiliation(s)
- Stéphane Manzo-Silberman
- Service of Cardiology, Lariboisière University Hospital, Paris, France - .,UMRS 942, University of Paris, Paris, France -
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21
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Association between Post-Diagnosis Particulate Matter Exposure among 5-Year Cancer Survivors and Cardiovascular Disease Risk in Three Metropolitan Areas from South Korea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17082841. [PMID: 32326144 PMCID: PMC7215375 DOI: 10.3390/ijerph17082841] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 12/20/2022]
Abstract
Cancer survivors are at an increased risk for cardiovascular disease (CVD). However, the association between particulate matter (PM) and CVD risk among cancer survivors (alive >5 years since diagnosis) is unclear. We investigated the risk of CVD among 40,899 cancer survivors within the Korean National Health Insurance Service database. Exposure to PM was determined by assessing yearly average PM levels obtained from the Air Korea database from 2008 to 2011. PMs with sizes <2.5 (PM2.5), <10 (PM10), or 2.5-10 (PM2.5-10) μm in diameter were compared, with each PM level exposure further divided into quintiles. Patients were followed up from January 2012 to date of CVD event, death, or December 2017, whichever came earliest. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CVD were calculated using Cox proportional hazards regression by PM exposure levels. Compared with cancer survivors in the lowest quintile of PM2.5 exposure, those within the highest quintile had a greater risk for CVD (aHR 1.31, 95% CI 1.07-1.59). Conversely, increasing PM10 and PM2.5-10 levels were not associated with increased CVD risk (p for trend 0.078 and 0.361, respectively). Cancer survivors who reduce PM2.5 exposure may benefit from lower risk of developing CVD.
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Abstract
PURPOSE OF REVIEW To summarize differences in plaque depositions, coronary artery calcium (CAC) scoring, and the role of CAC in predicting atherosclerotic cardiovascular disease (ASCVD) mortality in men and women. RECENT FINDINGS Women have coronary plaque that is more lipid-rich, dense, and less calcified than their male counterparts. CAC scoring has emerged as a useful tool to quantify ASCVD burden. However, recent evidence favors the use of sex-adjusted CAC cutoffs for women to account for the relatively lower overall CAC burden and therefore risk stratify women appropriately. Several studies have identified CAC distribution patterns in women associated with increased CV mortality, particularly the number of lesions involved, CAC volume, and size. Multiple studies have shown that the pathophysiology and associated risks of ASCVD are different in women when compared with men. CAC scoring is a tool that is widely being used for ASCVD risk stratification. Recent studies have shown that although men have higher CAC burdens, women are more likely to develop plaque erosions with non-calcified plaque that carries a greater risk for cardiovascular events. Providers should be aware of sex-specific CAC patterns carrying increased mortality risk for women, particularly increasing lesion size and number. Given the differences in plaque composition and distribution, revised sex-adjusted CAC scoring is suggested to better risk stratify patients, especially those deemed intermediate risk, and decrease CV mortality.
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Affiliation(s)
- Allison Bigeh
- Department of Medicine, Division of Cardiology at the University of Arizona, Phoenix, AZ, USA
| | - Chandana Shekar
- Department of Medicine, Division of Cardiology at the University of Arizona, Phoenix, AZ, USA
| | - Martha Gulati
- Department of Medicine, Division of Cardiology at the University of Arizona, Phoenix, AZ, USA.
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Zhang X, Zhao H, Chow WH, Bixby M, Durand C, Markham C, Zhang K. Population-Based Study of Traffic-Related Air Pollution and Obesity in Mexican Americans. Obesity (Silver Spring) 2020; 28:412-420. [PMID: 31797571 DOI: 10.1002/oby.22697] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 10/01/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The purpose of this study was to assess the cross-sectional association between residential exposure to traffic-related air pollution and obesity in Mexican American adults. METHODS A total of 7,826 self-reported Mexican Americans aged 20 to 60 years old were selected from the baseline survey of the MD Anderson Mano-a-Mano Mexican American Cohort. Concentrations of traffic-related particulate matter with aerodynamic diameter < 2.5 μm were modeled at geocoded residential addresses using a dispersion models. The residential proximity to the nearest major road was calculated using a Geographic Information System. Linear and logistic regression models were used to estimate the adjusted associations between exposure and obesity, defined as BMI ≥ 30. RESULTS More than half (53.6%) of the study participants had BMI ≥ 30, with a higher prevalence in women (55.0%) than in men (48.8%). Overall higher traffic-related air pollution exposures were associated with lower BMI in men but higher BMI in women. By stratifying for those who lived in a 0- to 1,500-m road buffer, the one-interquartile-range (685.1 m) increase of distance to a major road had a significant association with a 0.58-kg/m2 lower BMI (95% CI: -0.92 to -0.24) in women. CONCLUSIONS Exposure to intensive traffic is associated with increased risk of obesity in Mexican American women.
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Affiliation(s)
- Xueying Zhang
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Hua Zhao
- Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University Richmond, Virgnia, USA
| | - Wong-Ho Chow
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Moira Bixby
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Casey Durand
- Department of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christine Markham
- Department of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Kai Zhang
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Southwest Center for Occupational and Environmental Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Residual angina in female patients after coronary revascularization. Int J Cardiol 2019; 286:208-213. [DOI: 10.1016/j.ijcard.2019.01.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/04/2019] [Accepted: 01/10/2019] [Indexed: 11/20/2022]
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Sex differences in coronary artery plaque composition detected by coronary computed tomography: quantitative and qualitative analysis. Neth Heart J 2019; 27:272-280. [PMID: 30734147 PMCID: PMC6470243 DOI: 10.1007/s12471-019-1234-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Sex differences in the calculation of coronary heart disease risk have been analysed extensively. However, data on coronary plaque morphology diverge. We analysed plaque characteristics in patients with suspected coronary artery disease (CAD) and defined prognostic factors using coronary computed tomography angiography (CCTA). Methods A total of 6,050 consecutive patients underwent CCTA and were enrolled in the registry. Patients with known CAD were excluded. The patients were propensity score matched (1:1 male:female) for age and known coronary risk factors. Coronary arteries were evaluated for stenosis, plaque types (non-calcified, mixed and calcified) and high-risk plaque features (napkin-ring sign, low-attenuation plaque, spotty calcifications, positive remodelling). Clinical follow-up was performed. Results A total of 1,050 patients (525 female, 525 male) in matched cohorts were selected for analysis. CCTA showed significantly higher calcium scores for males (mean 180.5 vs 67.8 AU, p < 0.0001) and a higher rate of CAD (66.0% vs 34.1%, p < 0.0001). In a total of 16,800 segments, males had significantly more plaques (861 vs 752, p < 0.0001) with a significantly larger proportion of calcified plaques, while females had more mixed and non-calcified plaques (33.5% vs 24.4%, p = 0.006 and 24.1% vs 13.6%, p = 0.22, respectively). After a mean follow-up of 5.6 years, major adverse cardiac event (MACE) rate was 5.3% in male and 1.9% in female patients (p < 0.05). The relative odds ratio for high-risk plaque features to predict MACE was higher in females. Conclusion Based on a higher relative risk for women with high-risk plaque features, the findings of our study support the increased importance of a differentiated qualitative plaque analysis to improve the risk stratification for both sexes.
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Ferdinand KC, Samson R. Nonobstructive Coronary Artery Disease in Women: Risk Factors and Noninvasive Diagnostic Assessment. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2019. [DOI: 10.15212/cvia.2017.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Chyou AC, Klein BEK, Klein R, Barr RG, Cotch MF, Praestgaard A, Wong TY, Lima J, Bluemke DA, Kawut S. Retinal vascular changes and right ventricular structure and function: the MESA-Right Ventricle and MESA-Eye studies. Pulm Circ 2018; 9:2045894018819781. [PMID: 30622700 PMCID: PMC6304712 DOI: 10.1177/2045894018819781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/21/2018] [Indexed: 11/16/2022] Open
Abstract
Retinal vessel diameters have been associated with left ventricular morphology
and function but their relationship with the right ventricle (RV) has not been
studied. We hypothesized that wider retinal venules and narrower retinal
arterioles are associated with RV morphology and function. RV end-diastolic mass
(RVEDM), end-diastolic volume (RVEDV), end-systolic volume (RVESV), stroke
volume (RVSV), and ejection fraction (RVEF) were assessed using cardiac magnetic
resonance imaging (MRI) scans of 4204 participants without clinical
cardiovascular disease at the baseline examination; retinal photography was
obtained at the second examination. Mean diameters of retinal arterioles and
venules were measured and summarized as central retinal vein and artery
equivalents (“veins” and “arteries,” respectively). After adjusting for
covariates, wider veins were associated with greater RVEDM and RVEDV in women
(P = 0.04 and P = 0.02, respectively),
whereas there was an inverse association with RVEDV in men
(P = 0.02). In both sexes, narrower arteries were associated
with lower RVEDM (P < 0.001 in women and
P = 0.002 in men) and smaller RVEDV
(P < 0.001 in women and P = 0.04 in men) in
adjusted models. Narrower arteries were also associated with lower RVEF in men
but this was of borderline significance after adjusting for the LVEF
(P = 0.08). Wider retinal venular diameter was associated
with sex-specific changes in RVEDM and RVEDV in adults without clinical
cardiovascular disease. Narrower retinal arteriolar diameter was associated with
significantly lower RVEDM and smaller RVEDV in both sexes.
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Affiliation(s)
- Anthony C Chyou
- Division of Cardiology and the Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York City, NY, USA
| | - Barbara E K Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ronald Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - R Graham Barr
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York City, NY, USA
| | - Mary Frances Cotch
- National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Amy Praestgaard
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tien Y Wong
- Singapore Eye Research Institute, National University of Singapore, Singapore, Republic of Singapore
| | - Joao Lima
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David A Bluemke
- National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, MD, USA
| | - Steven Kawut
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Nicholls SJ, Tuzcu EM, Wolski K, Johnson BD, Sopko G, Sharaf BL, Pepine CJ, Nissen SE, Bairey Merz CN. Extent of coronary atherosclerosis and arterial remodelling in women: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation. Cardiovasc Diagn Ther 2018; 8:405-413. [PMID: 30214855 PMCID: PMC6129832 DOI: 10.21037/cdt.2018.04.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 03/16/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Information regarding the pathogenesis of ischemic heart disease (IHD) in women is limited. Sex-specific responses to atherosclerosis and coronary arterial remodelling in women versus men have been hypothesized, but limited study exists. METHODS Case-matched study of 174 women with suspected ischemia referred for coronary angiography: 87 with non-obstructive coronary artery disease (CAD) (no luminal diameter stenosis >20% in any coronary artery) and 87 age and ethnicity matched women with obstructive CAD. Groups were compared with regard to atheroma burden and coronary arterial remodelling assessed by coronary artery intravascular ultrasound (IVUS). RESULTS IVUS revealed more extensive atheroma with obstructive CAD vs. those without obstructive CAD, with greater percent atheroma volume (PAV) (36.1%±9.8% vs. 25.4%±9.1%, P<0.0001), total atheroma volume (TAV) (140.8±58.7 vs. 98.8±46.9 mm3, P<0.0001) and percentage of images containing plaque (70.0%±30.5% vs. 35.7%±32.6%, P<0.0001). Adjusting for risk factors, PAV (35%±1% vs. 28%±1%, P=0.0008), TAV (131±7 vs. 115±7 mm3, P=0.110) and percentage of images containing plaque (66%±4% vs. 45%±5%, P=0.0008) remained greater with obstructive CAD. Obstructive CAD was associated with smaller lumen volumes (251.9±92.8 vs. 289.7±91.8 mm3, P=0.005), but surprisingly, the external elastic membrane (EEM) volume was very similar comparing the groups (392.7±128.1 vs. 388.6±113.7 mm3, P=0.910). CONCLUSIONS Our findings suggest that women referred to angiography for suspected ischemia, have differing patterns of coronary arterial response to injury with regard to accumulation of atherosclerosis and compensatory remodelling related to the presence and absence of obstructive CAD. Preservation and cultivation of compensatory arterial remodelling may be a novel CAD therapeutic target.
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Affiliation(s)
- Stephen J. Nicholls
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | | | | | - B. Delia Johnson
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - George Sopko
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
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Hatleberg CI, Ryom L, El‐Sadr W, Mocroft A, Reiss P, De Wit S, Dabis F, Pradier C, d'Arminio Monforte A, Kovari H, Law M, Lundgren JD, Sabin CA. Gender differences in the use of cardiovascular interventions in HIV-positive persons; the D:A:D Study. J Int AIDS Soc 2018; 21:e25083. [PMID: 29509305 PMCID: PMC5839235 DOI: 10.1002/jia2.25083] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 01/29/2018] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION There is paucity of data related to potential gender differences in the use of interventions to prevent and treat cardiovascular disease (CVD) among HIV-positive individuals. We investigated whether such differences exist in the observational D:A:D cohort study. METHODS Participants were followed from study enrolment until the earliest of death, six months after last visit or February 1, 2015. Initiation of CVD interventions [lipid-lowering drugs (LLDs), angiotensin-converting enzyme inhibitors (ACEIs), anti-hypertensives, invasive cardiovascular procedures (ICPs) were investigated and Poisson regression models calculated whether rates were lower among women than men, adjusting for potential confounders. RESULTS Women (n = 12,955) were generally at lower CVD risk than men (n = 36,094). Overall, initiation rates of CVD interventions were lower in women than men; LLDs: incidence rate 1.28 [1.21, 1.35] vs. 2.40 [2.34, 2.46]; ACEIs: 0.88 [0.82, 0.93] vs. 1.43 [1.39, 1.48]; anti-hypertensives: 1.40 [1.33, 1.47] vs. 1.72 [1.68, 1.77] and ICPs: 0.08 [0.06, 0.10] vs. 0.30 [0.28, 0.32], and this was also true for most CVD interventions when exclusively considering periods of follow-up for which individuals were at high CVD risk. In fully adjusted models, women were less likely to receive CVD interventions than men (LLDs: relative rate 0.83 [0.78, 0.88]; ACEIs: 0.93 [0.86, 1.01]; ICPs: 0.54 [0.43, 0.68]), except for the receipt of anti-hypertensives (1.17 [1.10, 1.25]). CONCLUSION The use of most CVD interventions was lower among women than men. Interventions are needed to ensure that all HIV-positive persons, particularly women, are appropriately monitored for CVD and, if required, receive appropriate CVD interventions.
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Affiliation(s)
- Camilla I Hatleberg
- Department of Infectious Diseases Section 2100CHIPUniversity of CopenhagenFinsencentretRigshospitaletCopenhagenDenmark
| | - Lene Ryom
- Department of Infectious Diseases Section 2100CHIPUniversity of CopenhagenFinsencentretRigshospitaletCopenhagenDenmark
| | - Wafaa El‐Sadr
- ICAP‐Columbia University and Harlem HospitalNew YorkNYUSA
| | | | - Peter Reiss
- Academic Medical CenterDepartment of Global Health and Division of Infectious DiseasesUniversity of AmsterdamHIV Monitoring FoundationAmsterdamThe Netherlands
| | - Stephane De Wit
- Division of Infectious DiseasesSaint Pierre University HospitalUniversité Libre de BruxellesBrusselsBelgium
| | - Francois Dabis
- CHU de Bordeaux and INSERM U897Université de BordeauxTalenceFrance
| | | | - Antonella d'Arminio Monforte
- Dipartimento di Scienze della SaluteClinica di Malattie Infettive e TropicaliAzienda Ospedaliera‐Polo Universitario San PaoloMilanItaly
| | - Helen Kovari
- Division of infectious diseases and hospital epidemiologyUniversity hospital ZurichUniversity of ZurichZurichSwitzerland
| | | | - Jens D Lundgren
- Department of Infectious Diseases Section 2100CHIPUniversity of CopenhagenFinsencentretRigshospitaletCopenhagenDenmark
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Madonis SM, Skelding KA, Roberts M. Management of acute coronary syndromes: special considerations in women. Heart 2018; 103:1638-1646. [PMID: 28970234 DOI: 10.1136/heartjnl-2016-309938] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 06/07/2017] [Accepted: 07/02/2017] [Indexed: 01/18/2023] Open
Affiliation(s)
- Stephanie M Madonis
- Department of General Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Kimberly A Skelding
- Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Madhur Roberts
- Department of Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
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Kenkre TS, Malhotra P, Johnson BD, Handberg EM, Thompson DV, Marroquin OC, Rogers WJ, Pepine CJ, Bairey Merz CN, Kelsey SF. Ten-Year Mortality in the WISE Study (Women's Ischemia Syndrome Evaluation). Circ Cardiovasc Qual Outcomes 2017; 10:e003863. [PMID: 29217675 PMCID: PMC5728666 DOI: 10.1161/circoutcomes.116.003863] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 09/18/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND The WISE study (Women's Ischemia Syndrome Evaluation) was a prospective cohort study of 936 clinically stable symptomatic women who underwent coronary angiography to evaluate symptoms and signs of ischemia. Long-term mortality data for such women are limited. METHODS AND RESULTS Obstructive coronary artery disease (CAD) was defined as ≥50% stenosis on angiography by core laboratory. We conducted a National Death Index search to assess the mortality of women who were alive at their final WISE contact date. Death certificates were obtained. All deaths were adjudicated as cardiovascular or noncardiovascular by a panel of WISE cardiologists masked to angiographic data. Multivariate Cox proportional hazards regression was used to identify significant independent predictors of mortality. At baseline, mean age was 58±12 years; 176 (19%) were non-white, primarily black; 25% had a history of diabetes mellitus, 59% hypertension, 55% dyslipidemia, and 59% had a body mass index ≥30. During a median follow-up of 9.5 years (range, 0.2-11.5 years), a total of 184 (20%) died. Of these, 115 (62%) were cardiovascular deaths; 31% of all cardiovascular deaths occurred in women without obstructive CAD (<50% stenosis). Independent predictors of mortality were obstructive CAD, age, baseline systolic blood pressure, history of diabetes mellitus, history of smoking, elevated triglycerides, and estimated glomerular filtration rate. CONCLUSIONS Among women referred for coronary angiography for signs and symptoms of ischemia, 1 in 5 died from predominantly cardiac pathogeneses within 9 years of angiographic evaluation. A majority of the factors contributing to the risk of death seem to be modifiable by existing therapies. Of note, 1 in 3 of the deaths in this cohort occurred in women without obstructive CAD, a condition often considered benign and without guideline-recommended treatments. Clinical trials are needed to provide treatment guidance for the group without obstructive CAD.
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Affiliation(s)
- Tanya S Kenkre
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.).
| | - Pankaj Malhotra
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - B Delia Johnson
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Eileen M Handberg
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Diane V Thompson
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Oscar C Marroquin
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - William J Rogers
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Carl J Pepine
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - C Noel Bairey Merz
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
| | - Sheryl F Kelsey
- From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (T.S.K., B.D.J., O.C.M., S.F.K.); Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA (P.M., C.N.B.M.); Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville (E.M.H., C.J.P.); Division of Cardiology, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA (D.V.T.); Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (O.C.M.); and Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham (W.J.R.)
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Takagi C, Ono K, Matsuo H, Nagano N, Nojima Y. Higher reticulocyte counts are associated with higher mortality rates in hemodialysis patients: a retrospective single-center cohort study. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-016-0084-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Leclercq F. [Cardiovascular disease in women in 2017]. REVUE DE L'INFIRMIÈRE 2017; 66:16-19. [PMID: 28865690 DOI: 10.1016/j.revinf.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
From an anatomical, physiological and clinical point of view, cardiovascular diseases in women are specific. Long considered as being less exposed to these risks, women are nevertheless victims of coronary disease, which remains, in developed countries, the leading cause of death in women. The situation is all the more concerning given that the number of young women presenting risk factors is constantly rising. Encouraging female patients to become players in their health care with regard to this pathology is especially important given that effective treatments exist which can improve the prognosis.
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Affiliation(s)
- Florence Leclercq
- Département de cardiologie, CHU de Montpellier, 371 avenue du Doyen Gaston-Giraud, 34090 Montpellier, France.
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Worrall-Carter L, MacIsaac A, Scruth E, Rahman MA. Gender difference in the use of coronary interventions for patients with acute coronary syndrome: Experience from a major metropolitan hospital in Melbourne, Australia. Aust Crit Care 2017; 30:3-10. [DOI: 10.1016/j.aucc.2016.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/20/2016] [Accepted: 03/28/2016] [Indexed: 01/11/2023] Open
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36
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Tan YC, Sinclair H, Ghoorah K, Teoh X, Mehran R, Kunadian V. Gender differences in outcomes in patients with acute coronary syndrome in the current era: A review. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:51-60. [PMID: 26450783 DOI: 10.1177/2048872615610886] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Coronary heart disease is the most common cause of death worldwide. In the United Kingdom in 2010, over 80,000 deaths were attributed to coronary heart disease, and one in 10 female deaths were due to coronary heart disease. Acute coronary syndrome, a subset of coronary heart disease, was responsible for 175,000 inpatient admissions in the United Kingdom in 2012. While men have traditionally been considered to be at higher risk of acute coronary syndrome, various studies have demonstrated that women often suffer from poorer outcomes following an adverse cardiovascular event. This gap is gradually narrowing with the introduction of advanced interventional strategies and pharmacotherapy. However, a better understanding of these differences is of crucial importance for the improvement of the pharmacological and interventional management of acute coronary syndrome and for the development of possible new gender-specific diagnostic and therapeutic options. The goals of this review are to evaluate gender differences in outcomes in patients with acute coronary syndrome in the current era and identify potential mechanisms behind these differences in outcomes following percutaneous coronary intervention.
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Affiliation(s)
- Ying C Tan
- 1 Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, UK
| | - Hannah Sinclair
- 1 Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, UK.,2 Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Kuldeepa Ghoorah
- 2 Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Xuyan Teoh
- 1 Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, UK
| | | | - Vijay Kunadian
- 1 Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, UK.,2 Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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Wanha W, Kawecki D, Roleder T, Pluta A, Marcinkiewicz K, Morawiec B, Kret M, Pawlowski T, Smolka G, Ochala A, Wojakowski W. Gender differences and bleeding complications after PCI on first and second generation DES. SCAND CARDIOVASC J 2016; 51:53-60. [PMID: 27471987 DOI: 10.1080/14017431.2016.1219044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The aim of this study was to evaluate gender differences in the long-term clinical outcomes and safety of patients treated with first- and second generation DES. METHODS The Katowice-Zabrze Registry included 1916 consecutive patients treated with either first or second generation DES. We evaluated major adverse cardiac and cerebrovascular events (MACCE) [composite of death, myocardial infarction (MI), stroke and target vessel revascularization (TVR)] at 12-month follow-up. Safety end point was bleeding complications and stent thrombosis. RESULTS Registry included [unstable angina (UA) 1500(78%), non-ST-segment elevation myocardial infarction (NSTEMI) 285 (15%), ST-segment elevation myocardial infarction/left bundle branch block (STEMI/LBBB) 131 (7%)]. There were 35.5% females and 64.5% males. Women were older and had higher prevalence of comorbidities. Males more often had multivessel disease and higher Syntax score when comparable to females. We did not observed difference in acute and subacute stent thrombosis in our data, however, females had more in-hospital bleeding complications. Univariable Cox regression analysis revealed that women had similar outcomes when compared to men in terms of a risk of death, MI, TVR, stroke and MACCE at 1-year follow-up. There were no differences between males and females in MACCE when first- and second generation DES were analyzed separately. CONCLUSION Despite higher risk profile, women treated with DES have similar outcomes as males in 1-year follow-up. However there is, an increased risk of in-hospital bleedings in women.
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Affiliation(s)
- Wojciech Wanha
- a Third Division of Cardiology , Medical University of Silesia , Katowice , Poland
| | - Damian Kawecki
- b Division of Cardiology , Medical University of Silesia , Zabrze , Poland
| | - Tomasz Roleder
- a Third Division of Cardiology , Medical University of Silesia , Katowice , Poland
| | - Aleksandra Pluta
- a Third Division of Cardiology , Medical University of Silesia , Katowice , Poland
| | - Kamil Marcinkiewicz
- a Third Division of Cardiology , Medical University of Silesia , Katowice , Poland
| | - Beata Morawiec
- b Division of Cardiology , Medical University of Silesia , Zabrze , Poland
| | - Mariusz Kret
- c Department of Cardiology , Specialistic Hospital , Tarnow , Poland
| | - Tomasz Pawlowski
- a Third Division of Cardiology , Medical University of Silesia , Katowice , Poland
| | - Grzegorz Smolka
- a Third Division of Cardiology , Medical University of Silesia , Katowice , Poland
| | - Andrzej Ochala
- a Third Division of Cardiology , Medical University of Silesia , Katowice , Poland
| | - Wojciech Wojakowski
- a Third Division of Cardiology , Medical University of Silesia , Katowice , Poland
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38
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Zhou X, Teng B, Mustafa SJ. Sex Difference in Coronary Endothelial Dysfunction in Apolipoprotein E Knockout Mouse: Role of NO and A2A Adenosine Receptor. Microcirculation 2016. [PMID: 26201383 DOI: 10.1111/micc.12222] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Sex plays an important role in the pathophysiology of cardiovascular diseases. This study aims to investigate how sex impacts on the coronary flow regulation during atherosclerosis. METHODS ApoE KO mouse fed with western diet were used for atherosclerosis model. Coronary RH and flow response were measured using Langendorff-perfused isolated hearts. RESULTS Coronary RH and A23187-induced NO-dependent flow increases were significantly reduced in female (by ~28% and 48%, respectively), but not in male atherosclerotic mice. However, SNP-induced coronary vasodilation remains intact in both sexes of ApoE KO mice. L-NAME (NOS inhibitor) reduced baseline flow and RH to a lesser extent in ApoE KO (by ~19% and 31%) vs. WT (~30% and 59%, respectively), and abolished the sex difference in RH. In contrast, SCH58261 (a selective A2A AR antagonist) reduced the baseline flow and RH to a greater extent in atherosclerotic mice, but did not affect the sex difference. Immunofluorescent staining of coronary arteries showed a similar A2A AR upregulation in both sexes of ApoE KO mice. CONCLUSIONS Our results suggest that during atherosclerosis, female mice are more susceptible to NO-dependent endothelial dysfunction and the upregulation of A2A AR may serve as a compensatory mechanism to counteract the compromised endothelial function.
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Affiliation(s)
- Xueping Zhou
- Department of Physiology and Pharmacology, West Virginia University, Morgantown, West Virginia, USA.,Center for Cardiovascular and Respiratory Sciences and West Virginia Clinical & Translational Science Institute, Morgantown, West Virginia, USA
| | - Bunyen Teng
- Department of Physiology and Pharmacology, West Virginia University, Morgantown, West Virginia, USA.,Center for Cardiovascular and Respiratory Sciences and West Virginia Clinical & Translational Science Institute, Morgantown, West Virginia, USA
| | - S J Mustafa
- Department of Physiology and Pharmacology, West Virginia University, Morgantown, West Virginia, USA.,Center for Cardiovascular and Respiratory Sciences and West Virginia Clinical & Translational Science Institute, Morgantown, West Virginia, USA
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Saldarriaga C, Bedoya L, Gómez L, Hurtado L, Mejía J, González N. Conocimiento del riesgo de presentar un infarto de miocardio y las barreras para el acceso al estilo de vida saludable. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2015.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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40
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Baldassarre LA, Raman SV, Min JK, Mieres JH, Gulati M, Wenger NK, Marwick TH, Bucciarelli-Ducci C, Bairey Merz CN, Itchhaporia D, Ferdinand KC, Pepine CJ, Walsh MN, Narula J, Shaw LJ. Noninvasive Imaging to Evaluate Women With Stable Ischemic Heart Disease. JACC Cardiovasc Imaging 2016; 9:421-35. [PMID: 27056162 PMCID: PMC5486953 DOI: 10.1016/j.jcmg.2016.01.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/20/2016] [Accepted: 01/21/2016] [Indexed: 12/18/2022]
Abstract
Declines in cardiovascular deaths have been dramatic for men but occur significantly less in women. Among patients with symptomatic ischemic heart disease (IHD), women experience relatively worse outcomes compared with their male counterparts. Evidence to date has failed to adequately explore unique female imaging targets and their correlative signs and symptoms of IHD as major determinants of IHD risk. We highlight sex-specific anatomic and functional differences in contemporary imaging and introduce imaging approaches that leverage refined targets that may improve IHD risk prediction and identify potential therapeutic strategies for symptomatic women.
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Affiliation(s)
| | - Subha V Raman
- The Ohio State University College of Medicine, Columbus, Ohio
| | - James K Min
- Weill Cornell Medical College, New York, New York
| | | | - Martha Gulati
- The University of Arizona College of Medicine, Tucson, Arizona
| | | | | | | | | | - Dipti Itchhaporia
- Hoag Memorial Hospital Presbyterian Hospital, Newport Beach, California
| | | | - Carl J Pepine
- University of Florida College of Medicine, Gainesville, Florida
| | | | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Leslee J Shaw
- Emory University School of Medicine, Atlanta, Georgia.
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41
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Kok MM, van der Heijden LC, Sen H, Danse PW, Löwik MM, Anthonio RL, Louwerenburg JHW, de Man FHAF, Linssen GCM, IJzerman MJ, Doggen CJM, Maas AHEM, Mehran R, von Birgelen C. Sex Difference in Chest Pain After Implantation of Newer Generation Coronary Drug-Eluting Stents: A Patient-Level Pooled Analysis From the TWENTE and DUTCH PEERS Trials. JACC Cardiovasc Interv 2016; 9:553-61. [PMID: 26947384 DOI: 10.1016/j.jcin.2015.10.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 01/01/2015] [Accepted: 10/22/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVES This study sought to assess sex differences in chest pain after percutaneous coronary intervention (PCI) with newer generation drug-eluting stents (DES). BACKGROUND Sex-based data on chest pain after PCI with DES are scarce. METHODS The authors performed a patient-level pooled analysis of the TWENTE and DUTCH PEERS randomized trials, in which patients were treated with newer generation permanent polymer-coated DES. At 1 and 2 years, clinical follow-up was available in 99.8% and patient-reported chest pain data in 94.1% and 93.6%, respectively. RESULTS Among all 3,202 patients, the 871 (27.2%) women were older (67.5 ± 10.2 years vs. 62.8 ± 10.6 years; p < 0.001) and had more cardiovascular risk factors: diabetes (24.2% vs. 17.8%; p < 0.001), hypertension (63.6% vs. 51.6%; p < 0.001), and positive family history (54.5% vs. 50.1%; p = 0.03). At 1- and 2-year follow-up, women reported more clinically relevant chest pain (16.3% vs. 10.5%; p < 0.001, and 17.2% vs. 11.1%; p < 0.001, respectively). Multivariate analysis demonstrated that female sex independently predicted clinically relevant chest pain at 1- and 2-year follow-up both during daily activities and at minimum physical exertion/at rest (1 year adjusted odds ratio [OR]: 1.7; 95% confidence interval [CI]: 1.2 to 2.4; p = 0.002; and adjusted OR: 1.8; 95% CI: 1.3 to 2.5; p < 0.001; 2-year adjusted OR: 1.8; 95% CI: 1.3 to 2.6; p < 0.001; and adjusted OR: 1.7; 95% CI: 1.3 to 2.3; p = 0.001). Nevertheless, the 2-year rates of death, myocardial infarction, revascularization, stent thrombosis, and various composite clinical endpoints were similar for both sexes. CONCLUSIONS Although the incidence of adverse cardiovascular events was low and similar for both sexes, women showed a statistically significantly higher prevalence of clinically relevant chest pain, which might be largely related to mechanisms other than epicardial coronary obstruction.
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Affiliation(s)
- Marlies M Kok
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Liefke C van der Heijden
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Hanim Sen
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Peter W Danse
- Department of Cardiology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Marije M Löwik
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - J Hans W Louwerenburg
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Frits H A F de Man
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Gerard C M Linssen
- Department of Cardiology, Ziekenhuisgroep Twente, Almelo and Hengelo, the Netherlands
| | - Maarten J IJzerman
- Health Technology and Services Research, MIRA, Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Carine J M Doggen
- Health Technology and Services Research, MIRA, Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Angela H E M Maas
- Chair of Cardiology for Women, Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Heart, Mount Sinai Medical Center, New York, New York
| | - Clemens von Birgelen
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Health Technology and Services Research, MIRA, Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands.
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Izadnegahdar M, Mackay M, Lee MK, Sedlak TL, Gao M, Bairey Merz CN, Humphries KH. Sex and Ethnic Differences in Outcomes of Acute Coronary Syndrome and Stable Angina Patients With Obstructive Coronary Artery Disease. Circ Cardiovasc Qual Outcomes 2016; 9:S26-35. [DOI: 10.1161/circoutcomes.115.002483] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Dean J, Cruz SD, Mehta PK, Merz CNB. Coronary microvascular dysfunction: sex-specific risk, diagnosis, and therapy. Nat Rev Cardiol 2015; 12:406-14. [PMID: 26011377 DOI: 10.1038/nrcardio.2015.72] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cardiovascular disease is the leading cause of death worldwide. In the presence of signs and symptoms of myocardial ischaemia, women are more likely than men to have no obstructive coronary artery disease (CAD). Women have a greater burden of symptoms than men, and are often falsely reassured despite the presence of ischaemic heart disease because of a lack of obstructive CAD. Coronary microvascular dysfunction should be considered as an aetiology for ischaemic heart disease with signs and symptoms of myocardial ischaemia, but no obstructive CAD. Coronary microvascular dysfunction is defined as impaired coronary flow reserve owing to functional and/or structural abnormalities of the microcirculation, and is associated with an adverse cardiovascular prognosis. Therapeutic lifestyle changes as well as antiatherosclerotic and antianginal medications might be beneficial, but clinical outcome trials are needed to guide treatment. In this Review, we discuss the prevalence, presentation, diagnosis, and treatment of coronary microvascular dysfunction, with a particular emphasis on ischaemic heart disease in women.
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Affiliation(s)
- Jenna Dean
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Sherwin Dela Cruz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Puja K Mehta
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
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44
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Lee PH, Park DW. Sex differences in clinical outcomes following coronary revascularization. Interv Cardiol 2015. [DOI: 10.2217/ica.15.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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45
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Moshki M, Zareie M, Hashemizadeh H. Sex differences in Acute Myocardial Infarction. Nurs Midwifery Stud 2015; 4:e22395. [PMID: 25830154 PMCID: PMC4377526 DOI: 10.17795/nmsjournal22395] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 10/12/2014] [Accepted: 01/01/2015] [Indexed: 11/25/2022] Open
Affiliation(s)
- Mahdi Moshki
- Social Development and Health Promotion Research Center, Department of Public Health, School of Health, Gonabad University of Medical Sciences, Gonabad, IR Iran
| | - Mohammad Zareie
- Nursing Department, Shirvan Nursing Faculty, North Khorasan University of Medical Sciences, Bojnurd, IR Iran
| | - Haydeh Hashemizadeh
- Social Development and Health Promotion Research Center, Department of Public Health, School of Health, Gonabad University of Medical Sciences, Gonabad, IR Iran
- Department of Nursing, Quchan Branch, Islamic Azad University, Quchan, IR Iran
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46
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Ahmadi A, Soori H, Sajjadi H, Nasri H, Mehrabi Y, Etemad K. Current status of the clinical epidemiology of myocardial infarction in men and women: a national cross-sectional study in iran. Int J Prev Med 2015; 6:14. [PMID: 25789146 PMCID: PMC4362287 DOI: 10.4103/2008-7802.151822] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 12/01/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Cardiovascular disease is the main reason for mortality in men and women. Clinical epidemiology of myocardial infarction (MI) in men and women has not been yet studied in Iran, one of the largest Middle East countries in South-Western Asia. This study was conducted to determine the clinical epidemiology of MI in men and women in Iran. METHODS This hospital-based, cross-sectional study used the data of 20,750 MI patients in Iran in 2012 (the codes I22, I21, I24, and I25.2). Univariate comparisons used Chi-square test for categorical variables and t-test for continuous variables. P < 0.05 was considered as significant. RESULTS Totally, 20,750 MI patients (15,033 men and 5,717 women) with age range of 13-106 (mean; 61.2 ± 13.4) years were enrolled. Only 9 (0.04%) patients (8 men and 1 woman) were ≤18 years (mean age: 14.8 ± 1.9), out of whom only two men were diabetic. 22.2% (18% men and 33.4% women) of the patients had diabetes, 26.2% (28.5% men and 20.1% women) were smoker and 35.5% (28.6% men and 53.7% women) had hypertension. ST-segment elevation MI incidence was 2.8 times higher in men than women. Left bundle branch block was significantly more prevalent in men than women. Men used percutaneous coronary intervention more frequently than women did. No difference in coronary artery bypass graft was noted between men and women. Mortality incidence was approximately twice higher in men than women. The prevalence of chest pain was higher in women than men. CONCLUSIONS The MI incidence pattern, mortality from MI, and risk factors prevalence are significantly different between men and women in Iran. More emphasis on these issues in training people and healthcare professionals seems to contribute partially to patients' timely referring to health care centers and preventing MI-associated mortalities.
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Affiliation(s)
- Ali Ahmadi
- Department of Epidemiology and Biostatistics, School of Public Health, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Hamid Soori
- Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Homeira Sajjadi
- Social Determinants of Health Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Islamic Republic of Iran
| | - Hamid Nasri
- Department of Nephrology, Division of Nephropathology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Yadollah Mehrabi
- Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Koorosh Etemad
- Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Ladwig KH, Waller C. [Gender-specific aspects of coronary heart disease]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2014; 57:1083-91. [PMID: 25112950 DOI: 10.1007/s00103-014-2020-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The total number of deaths from cardiovascular diseases (CVD) is greater for women than for men, although the mean age at manifestation of CVD is about 10 years older. However, the annual number of cases treated for CVD in acute hospital settings in men exceeds that of women by 50 %. Remarkable gender differences exist in terms of morphological and physiological conditions (e.g. mean coronary vessel diameter; ability to adapt to protective exercise-induced myocardial hypertrophy), as well as of the frequency and clinical significance of somatic risk factors (e.g. smoking). Female body weight increases after menopause and the body shape assumes a more android fat distribution. Women report higher levels of unspecific and affective symptoms. They suffer more from anxiety and depression than men; however, the secondary impact on CVD onset may be less pronounced. The post-acute CVD course is more complicated in women, mainly because they are older and suffer more from multi-morbidity. Whilst male CVD patients aim for a rapid recovery, physical fitness and an increased life expectancy, female patients seek relief from everyday challenges, the maintenance of their independence and emotional support.
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Affiliation(s)
- K-H Ladwig
- Institut für Epidemiologie, Helmholtz Zentrum München, Deutsches Forschungszentrum für Gesundheit und Umwelt, Institut für Epidemiologie-II, Mental Health Research Unit, Ingolstädter Landstr. 1, 85764, Neuherberg, Deutschland,
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Kuruvilla S, Kramer CM. Coronary microvascular dysfunction in women: an overview of diagnostic strategies. Expert Rev Cardiovasc Ther 2014; 11:1515-25. [PMID: 24160578 DOI: 10.1586/14779072.2013.833854] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Coronary microvascular dysfunction (CMD) also known as syndrome X, is characterized by typical anginal symptoms, evidence of myocardial ischemia on non-invasive testing and normal to minimal coronary disease on coronary angiography. It has a female preponderance and has been detected in up to 50% of women presenting with chest pain symptoms. Definitive diagnosis of CMD is critical as recent evidence suggests that women with this condition are at increased risk of cardiovascular events in the future. Invasive coronary reactivity testing on coronary angiography is considered to be the 'gold standard' for diagnosis of CMD. Non-invasive imaging techniques such as PET and cardiac magnetic resonance hold promise for detection of CMD in the future.
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Affiliation(s)
- Sujith Kuruvilla
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, VA, USA and
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Sedlak TL, Lee M, Izadnegahdar M, Merz CNB, Gao M, Humphries KH. Sex differences in clinical outcomes in patients with stable angina and no obstructive coronary artery disease. Am Heart J 2013; 166:38-44. [PMID: 23816019 DOI: 10.1016/j.ahj.2013.03.015] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 03/26/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND We comparatively evaluated clinical outcomes in men and women presenting with stable angina with no coronary artery disease (CAD), nonobstructive CAD, and obstructive CAD on coronary angiography. METHODS We studied all patients ≥20 years with stable angina, undergoing coronary angiography in British Columbia, Canada, from July 1999 to December 2002 (n = 13,695) with maximum follow-up to 3 years. No CAD, nonobstructive CAD, and obstructive CAD were defined as 0%, 1% to 49%, and ≥50% luminal narrowing in any epicardial coronary artery, respectively. Freedom from major adverse cardiac events (MACEs), which included the combined end points of all-cause mortality, nonfatal acute myocardial infarction, nonfatal stroke, and heart failure admissions, was estimated using the Kaplan-Meier method. Hazard ratios (HRs) and 95% CIs for MACE were estimated up to 3 years postcatheterization and compared between sex and CAD groups. RESULTS Within the first year, women with nonobstructive CAD had a higher risk of MACE than men with nonobstructive CAD (adjusted HR 2.43, 95% CI 1.08-5.49). Furthermore, women with nonobstructive CAD had a 2.55-fold higher risk of MACE than women with no CAD (95% CI 1.33-4.88). In contrast, men with nonobstructive CAD had a similar risk as men with no CAD (adjusted HR 0.61, 95% CI 0.26-1.45). The differences in MACE according to extent of CAD were not evident in the longer term. CONCLUSIONS Women with stable angina and nonobstructive CAD are 3 times more likely to experience a cardiac event within the first year of cardiac catheterization than men. A prospective trial to examine the impact of medical therapy on MACE in patients with nonobstructive CAD is warranted.
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Zoghbi WA, Arend TE, Oetgen WJ, May C, Bradfield L, Keller S, Ramadhan E, Tomaselli GF, Brown N, Robertson RM, Whitman GR, Bezanson JL, Hundley J. 2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation 2013; 127:e663-828. [DOI: 10.1161/cir.0b013e31828478ac] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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