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Kim HL. Differences in Risk Factors for Coronary Atherosclerosis According to Sex. J Lipid Atheroscler 2024; 13:97-110. [PMID: 38826179 PMCID: PMC11140242 DOI: 10.12997/jla.2024.13.2.97] [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: 10/18/2023] [Revised: 11/13/2023] [Accepted: 11/29/2023] [Indexed: 06/04/2024] Open
Abstract
Interest in sex differences related to coronary artery disease (CAD) has steadily increased, and the risk factors for CAD show distinct sex differences. For women, cardiovascular risk increases significantly after menopause due to a decrease in estrogen levels. In older individuals, increased arterial stiffness results in a higher pulse pressure, leading to a more common occurrence of isolated systolic hypertension; these changes are more noticeable in women. While the incidence of diabetes is similar in both sexes, women with diabetes face a 50% higher relative risk of fatal coronary heart disease compared to men. Smoking significantly increases the risk of ischemic heart disease in women, particularly those who are younger. The decrease in estrogen in women leads to a redistribution of fat, resulting in increased abdominal obesity and, consequently, an elevated cardiovascular risk. Pregnancy and reproductive factors also have a significant impact on CAD risks in women. Additionally, disparities exist in medical practice. Women are less likely to be prescribed cardioprotective drugs, referred for interventional or surgical treatments, or included in clinical research than men. By increasing awareness of these sex differences and addressing the disparities, we can progress toward more personalized treatment strategies, ultimately improving patient outcomes.
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Affiliation(s)
- Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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Huang S, Li Y, Jiang L, Ren Y, Wang J, Shi K, Yan WF, Qian WL, Yang ZG. Impact of Type 2 Diabetes Mellitus on Epicardial Adipose Tissue and Myocardial Microcirculation by MRI in Postmenopausal Women. J Magn Reson Imaging 2022; 56:1404-1413. [PMID: 35179821 DOI: 10.1002/jmri.28121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) often occurs conjunctly with the menopausal transition in female patients. In addition, epicardial adipose tissue (EAT) has an unfavorable impact on the myocardium and coronary arteries under the influence of metabolic disorders. PURPOSE To investigate the impact of T2DM on EAT and myocardial microvascular function in postmenopausal women. STUDY TYPE Retrospective. POPULATION One-hundred sixty-one postmenopausal women divided into three groups: newly diagnosed (≤5 years) T2DM (n = 56, 58.6 ± 7.7 years), long-term (>5 years) T2DM (n = 57, 61.9 ± 7.9 years), and healthy controls (n = 48, 59.4 ± 7.4 years). FIELD STRENGTH/SEQUENCE 3.0 T; balanced steady-state free precession and inversion recovery prepared echo-planar sequences. ASSESSMENT EAT volume was quantified by delineating the epicardial border and the visceral layer of pericardium on the short-axis cine stacks. Perfusion parameters including upslope, maximum signal intensity (MaxSI) and time to maximum signal intensity (TTM) were derived from the first-pass perfusion signal intensity-time curves. STATISTICAL TESTS One-way analysis of variance, Pearson's and Spearman correlation, and multivariable linear regression. Two-sided P < 0.05 was considered statistically significant. RESULTS EAT volume was significantly increased in diabetic postmenopausal women compared to the controls (48.4 ± 13.4 mL/m2 [newly diagnosed T2DM] vs. 58.4 ± 17.3 mL/m2 [long-term T2DM] vs. 35.8 ± 12.3 mL/m2 [controls]). Regarding perfusion parameters, upslope and MaxSI were significantly reduced (2.6 ± 1.0 [newly diagnosed T2DM] vs. 2.1 ± 0.8 [long-term T2DM] vs. 3.6 ± 1.3 [controls]; and 21.4 ± 6.9 [newly diagnosed T2DM] vs. 18.7 ± 6.4 [long-term T2DM] vs. 28.4 ± 8.6 [controls]), whereas TTM was significantly increased in the T2DM groups compared to the control group (23.6 ± 8.7 [newly diagnosed T2DM] vs. 27.1 ± 9.4 [long-term T2DM] vs. 21.4 ± 6.0 [controls]). Multivariable analysis (adjusted coefficient of determination [R2 ] = 0.489) showed that EAT volume (β = -0.610) and menopausal age (β = 0.433) were independently correlated with decreased perfusion upslope. DATA CONCLUSION Diabetic postmenopausal women had significantly higher EAT volume and more impaired microcirculation compared to the controls. Increased EAT volume and earlier menopausal age were independently associated with microvascular dysfunction in these patients. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY STAGE: 3.
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Affiliation(s)
- Shan Huang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuan Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Jiang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Ren
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jin Wang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ke Shi
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei-Feng Yan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wen-Lei Qian
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhi-Gang Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Wen J, Shuai W, Ding T, Feng Y, Zhang J, Wang S. Reproductive risk factors for angiographic obstructive coronary artery disease among postmenopausal women. Menopause 2020; 27:1403-1410. [PMID: 32769758 DOI: 10.1097/gme.0000000000001616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Reproductive factors are female-specific coronary artery disease (CAD) risk factors. However, the importance of reproductive factors in angiographic obstructive CAD in postmenopausal women remains uncertain. This study aimed to compare reproductive factors between postmenopausal women with no apparent CAD, nonobstructive CAD, and obstructive CAD and identify reproductive risk factors for obstructive CAD. METHODS In this hospital-based cross-sectional study, 1,474 postmenopausal women, admitted with chest pain and referred for invasive coronary angiography were enrolled between April 2013 and October 2018. RESULTS Adjusted odds ratio (95% CI) for obstructive CAD were 1.81 (1.03-3.17) for multigravidity (three or more pregnancies), 1.77 (1.14-2.76) for early menopause (≤40 y old), and 1.72 (1.26-2.35) for short reproductive life span (≤30 y). Each additional year in age at menopause or reproductive life span was associated with a 4% reduction in obstructive CAD risk in postmenopausal women (odds ratio, 0.96; 95% CI, 0.94-0.99; P = 0.011). The other reproductive factors, including parity, age at first birth, spontaneous abortion, induced abortion, stillbirth, hypertensive disorders of pregnancy, gestational diabetes mellitus, and age at menarche, were not correlated with obstructive CAD risk in postmenopausal women. CONCLUSIONS Multigravidity (three or more pregnancies), early menopause, and a shorter reproductive life span were independent risk factors of angiographic obstructive CAD among postmenopausal women, which suggested that pregnancy and ovarian function may be important for the early identification and prevention of increased risk of female angiographic obstructive CAD.
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Affiliation(s)
- Jingyi Wen
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Wei Shuai
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute of Wuhan University, and Hubei Key Laboratory of Cardiology, Wuhan, Hubei, P.R. China
| | - Ting Ding
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Yanzhi Feng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Jinjin Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Shixuan Wang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
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Mishra SR, Chung HF, Waller M, Mishra GD. Duration of estrogen exposure during reproductive years, age at menarche and age at menopause, and risk of cardiovascular disease events, all-cause and cardiovascular mortality: a systematic review and meta-analysis. BJOG 2020; 128:809-821. [PMID: 32965759 DOI: 10.1111/1471-0528.16524] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Little is known about the estrogen exposure measurement and mutual effect of age at menarche and age at menopause in the risk of cardiovascular disease (CVD) events. OBJECTIVES To evaluate estrogen exposure measurement and describe mutual effect of age at menarche and age at menopause in the risk of CVD events. SEARCH STRATEGY Systematic review of literature in PubMed, Embase and Web of Science for studies published up to 28 June 2020. SELECTION CRITERIA Observational studies related to estrogen exposure measurement, including mutual effect of age at menarche and age at menopause and risk of CVD events. DATA COLLECTION AND ANALYSIS Synthesis of evidence was conducted by reviewing individual estimates, followed by meta-analysis. The study received no external funding. MAIN RESULTS A total of 75 studies were included in synthesis of evidence, of which 17 studies were included in meta-analysis. Reproductive lifespan (age at menopause - age at menarche), endogenous estrogen exposure and total estrogen exposure were used for estrogen exposure measurement. Reproductive lifespan was by far the most commonly used method for estrogen exposure measurement. A shorter reproductive lifespan was associated with a higher risk of CVD events; the pooled relative risk (95% CI) was 1.31 (1.25-1.36) for stroke events. Robust epidemiological studies with measurement of estrogen exposure and associated health risk would strengthen the evidence. CONCLUSIONS Reproductive lifespan was the most commonly used method for estrogen exposure measurement in epidemiological studies. A shorter reproductive lifespan was associated with a higher risk of CVD events, particularly stroke. TWEETABLE ABSTRACT A systematic review and meta-analysis found that women with a shorter reproductive lifespan have a higher risk of stroke events.
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Affiliation(s)
- S R Mishra
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - H-F Chung
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - M Waller
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - G D Mishra
- School of Public Health, The University of Queensland, Brisbane, Australia
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Ramesh S, James MT, Holroyd-Leduc JM, Wilton SB, Seely EW, Hemmelgarn BR, Tonelli M, Wheeler DC, Ahmed SB. Estradiol and mortality in women with end-stage kidney disease. Nephrol Dial Transplant 2020; 35:1965-1972. [PMID: 32865207 DOI: 10.1093/ndt/gfaa126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 04/02/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Young women with end-stage kidney disease (ESKD) have early menopause compared with women in the general population and the highest mortality among the dialysis population. We hypothesized that low estrogen status was associated with death in women with ESKD. METHODS We measured estradiol and sex hormone levels in female ESKD patients initiating hemodialysis from 2005 to 2012 in four Canadian centers. We divided women into quintiles based on estradiol levels and tested for associations between the estradiol level and cardiovascular (CV), non-CV and all-cause mortality. Participants were further dichotomized by age. RESULTS A total of 482 women (60 ± 15 years of age, 53% diabetic, estradiol 116 ± 161 pmol/L) were followed for a mean of 2.9 years, with 237 deaths (31% CV). Estradiol levels were as follows (mean ± standard deviation): Quintile 1: 19.3 ± 0.92 pmol/L; Quintile 2: 34.6 ± 6.6 pmol/L; Quintile 3: 63.8 ± 10.6 pmol/L; Quintile 4: 108.9 ± 19.3; Quintile 5: 355 ± 233 pmol/L. Compared with Quintile 1, women in Quintiles 4 and 5 had significantly higher adjusted all-cause mortality {hazard ratio [HR] 2.12 [95% confidence interval (CI) 1.38-3.25] and 1.92 [1.19-3.10], respectively}. Similarly, compared with Quintile 1, women in Quintile 5 had higher non-CV mortality [HR 2.16 (95% CI 1.18-3.96)]. No associations were observed between estradiol levels and CV mortality. When stratified by age, higher quintiles were associated with greater all-cause mortality (P for trend <0.001) and non-CV mortality (P for trend = 0.02), but not CV mortality in older women. CONCLUSIONS In women with ESKD treated with hemodialysis, higher estradiol levels were associated with greater all-cause and non-CV mortality. Further studies are required to determine the mechanism for the observed increased risk.
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Affiliation(s)
- Sharanya Ramesh
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T James
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, affiliated with University of Calgary and Alberta Health Services, Calgary, Alberta, Canada.,Cumming School of Medicine, Alberta Kidney Disease Network, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Jayna M Holroyd-Leduc
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Stephen B Wilton
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, affiliated with University of Calgary and Alberta Health Services, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Ellen W Seely
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA, USA
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, affiliated with University of Calgary and Alberta Health Services, Calgary, Alberta, Canada.,Cumming School of Medicine, Alberta Kidney Disease Network, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada.,Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Cumming School of Medicine, Alberta Kidney Disease Network, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada.,Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta, Canada
| | - David C Wheeler
- Department of Nephrology, University College London, London, UK
| | - Sofia B Ahmed
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, affiliated with University of Calgary and Alberta Health Services, Calgary, Alberta, Canada.,Cumming School of Medicine, Alberta Kidney Disease Network, Calgary, Alberta, Canada
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6
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Maifrino LBM, Lima NEAD, Marques MR, Cardoso CG, Souza LBD, Tomé TDC, Quintana HT, Oliveira FD, Reis BDCAA, Fonseca FLA. Evaluation of Collagen Fibers, MMP2, MMP9, 8-OHdG and Apoptosis in the Aorta of Ovariectomized LDL Knockout Mice Submitted to Aerobic Exercise. Arq Bras Cardiol 2018; 112:180-188. [PMID: 30570072 PMCID: PMC6371828 DOI: 10.5935/abc.20180263] [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] [Received: 12/09/2017] [Accepted: 07/23/2018] [Indexed: 11/20/2022] Open
Abstract
Background In menopause, there is greater cellular exposure to oxidative stress, related
to the decreased antioxidative effects of estrogen. These metabolic changes
favor the progression of cardiovascular diseases, such as atherosclerosis.
Abnormal function of the aorta - the most important artery - is associated
with many cardiovascular diseases. Collagen, especially types I and III, is
one of the most important aortic wall components and it can be affected by
many factors, including menopause. The 8-OHdG is one of the main markers of
DNA oxidative damage induced by reactive oxygen species (ROS). Objective We aimed to investigate effects of moderate aerobic training on the ascending
aorta of LDL-knockout (LDL-KO) and ovariectomized female mice. Methods A total of 15 C57BL/6 mice and 15 LDL-KO mice were divided into experimental
groups. The thickness and volume density of types I and III collagen fibers
were performed by morphoquantitative analysis, whereas the MMP-2 and MMP-9
and 8-OHdG were detected by immunohistochemistry and apoptosis was detected
by the TUNEL assay. The significance level for all tests was p <
0.05. Results Exercise causes an increase in the thickness of the aorta in LDL-KO groups,
particularly accentuated in the ovariectomized groups. The type I collagen
fibers showed an increase in volume density influenced by training in both
Control groups and in the LDL-KO group. Type III collagen density decreased
in both groups. The MMP-2 showed moderade immunostaining in the tunica media
in LDL-KO groups, which did not occur in the control groups and the MMP-9
stained irregularly in all tissues. The marker 8-OhdG was stronger in the
exercise training groups. Additionally, the ovariectomy, the exercise
training and the LDL-KO treatments increased apoptosis. Conclusion These results suggest that moderate-intensity aerobic exercise in
ovariectomized mice associated to an increase in LDL rate possibly increases
oxidative stress and apoptosis induction.
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Affiliation(s)
| | | | | | | | - Lidiane B de Souza
- Departamento de Biociências da Universidade Federal de São Paulo, São Paulo, SP - Brazil
| | | | | | - Flavia de Oliveira
- Departamento de Biociências da Universidade Federal de São Paulo, São Paulo, SP - Brazil
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Analysis of traditional and emerging risk factors in premenopausal women with coronary artery disease: A pilot-scale study from North India. Mol Cell Biochem 2017; 432:67-78. [PMID: 28337704 DOI: 10.1007/s11010-017-2998-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 03/04/2017] [Indexed: 12/17/2022]
Abstract
Premenopausal women are known to have less heart disease than their menopausal counterparts and men. However, there is a rising prevalence of coronary artery disease (CAD) in premenopausal females, which necessitates determination of risk factors that negate the effects of hormonal protection. There are few studies describing the prevalence of traditional and emerging risk factors in premenopausal women with CAD. Thus, our objective was to explore the prevalence of traditional and emerging risk factors and features of coronary lesions in premenopausal women with CAD in an Indian population. Forty premenopausal female patients with angiographically proven CAD and undergoing treatment with conventional therapies and 40 age-matched premenopausal females without any evidence of CAD were enrolled. Premenopausal females with CAD most commonly had the single-vessel CAD and the left anterior descending artery was most commonly involved. The prevalence of hypertension, diabetes, obesity, metabolic syndrome, family history of CAD and 10-year risk score was higher in premenopausal females with CAD than controls. Even after treatment with conventional therapies, premenopausal women with CAD had dyslipidemia and significantly elevated levels of emerging risk factors such as ApoB, ApoB/ApoA1 ratio, hsCRP, lipoprotein (a), uric acid, T4, fibrinogen, and total leukocyte count as compared to controls (p < 0.05). Further, they had significantly lower levels of HDL-C, and Apolipoprotein A1 and T3 which are protective markers for vascular risk. Multivariate regression analysis demonstrated that low levels of Apo A1 and high levels of fibrinogen, hsCRP and TG drive the vascular risk, and therefore these factors should be considered as candidates for better diagnosis, early detection, and intervention of CAD in premenopausal women.
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Kim HL, Kim MA, Shim WJ, Park SM, Kim YH, Na JO, Shin MS, Kim YJ, Yoon HJ, Shin GJ, Cho Y, Kim SE, Hong KS, Cho KI. Reproductive Factors Predicting Angiographic Obstructive Coronary Artery Disease: The KoRean wOmen'S Chest Pain rEgistry (KoROSE). J Womens Health (Larchmt) 2016; 25:443-8. [DOI: 10.1089/jwh.2015.5381] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hack-Lyoung Kim
- Seoul National University Boramae Medical Center, Seoul, Korea
| | - Myung-A Kim
- Seoul National University Boramae Medical Center, Seoul, Korea
| | - Wan-Joo Shim
- Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea
| | - Seong Mi Park
- Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea
| | - Yong Hyun Kim
- Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea
| | - Jin Oh Na
- Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea
| | - Mi Seung Shin
- Gachon Medical School Gil Medical Center, Incheon, Korea
| | - Yong-Jin Kim
- Seoul National University Hospital, Seoul, Korea
| | - Hyun Ju Yoon
- Chonnam National University Hospital, Gwangju, Korea
| | - Gil Ja Shin
- Ewha Womans University Hospital, Seoul, Korea
| | | | - Sung-Eun Kim
- Hallym University Medical Center, Seoul and Chuncheon, Korea
| | - Kyung-Soon Hong
- Hallym University Medical Center, Seoul and Chuncheon, Korea
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Kiely C, Rocha J, O'Connor E, O'Shea D, Green S, Egaña M. Influence of menopause and Type 2 diabetes on pulmonary oxygen uptake kinetics and peak exercise performance during cycling. Am J Physiol Regul Integr Comp Physiol 2015; 309:R875-83. [PMID: 26269520 DOI: 10.1152/ajpregu.00258.2015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 08/11/2015] [Indexed: 02/02/2023]
Abstract
We investigated if the magnitude of the Type 2 diabetes (T2D)-induced impairments in peak oxygen uptake (V̇O2) and V̇O2 kinetics was affected by menopausal status. Twenty-two women with T2D (8 premenopausal, 14 postmenopausal), and 22 nondiabetic (ND) women (11 premenopausal, 11 postmenopausal) matched by age (range = 30-59 yr) were recruited. Participants completed four bouts of constant-load cycling at 80% of their ventilatory threshold for the determination of V̇O2 kinetics. Cardiac output (CO) (inert gas rebreathing) was recorded at rest and at 30 s and 240 s during two additional bouts. Peak V̇O2 was significantly (P < 0.05) reduced in both groups with T2D compared with ND counterparts (premenopausal, 1.79 ± 0.16 vs. 1.55 ± 0.32 l/min; postmenopausal, 1.60 ± 0.30 vs. 1.45 ± 0.24 l/min). The time constant of phase II of the V̇O2 response was slowed (P < 0.05) in both groups with T2D compared with healthy counterparts (premenopausal, 29.1 ± 11.2 vs. 43.0 ± 12.2 s; postmenopausal, 33.0 ± 9.1 vs. 41.8 ± 17.7 s). At rest and during submaximal exercise absolute CO responses were lower, but the "gains" in CO larger (both P < 0.05) in both groups with T2D. Our results suggest that the magnitude of T2D-induced impairments in peak V̇O2 and V̇O2 kinetics is not affected by menopausal status in participants younger than 60 yr of age.
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Affiliation(s)
- Catherine Kiely
- School of Medicine, Department of Physiology, Trinity College Dublin, Dublin, Ireland
| | - Joel Rocha
- School of Medicine, Department of Physiology, Trinity College Dublin, Dublin, Ireland
| | - Eamonn O'Connor
- School of Medicine, Department of Physiology, Trinity College Dublin, Dublin, Ireland
| | - Donal O'Shea
- Endocrinology, St. Columcille's and St. Vincent's Hospitals, Dublin, Ireland; and
| | - Simon Green
- School of Science and Health and School of Medicine, University of Western Sydney, Sydney, Australia
| | - Mikel Egaña
- School of Medicine, Department of Physiology, Trinity College Dublin, Dublin, Ireland;
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Ibrahim RM, Hamdan NS, Mahmud R, Imam MU, Saini SM, Rashid SNA, Abd Ghafar SA, Latiff LA, Ismail M. A randomised controlled trial on hypolipidemic effects of Nigella Sativa seeds powder in menopausal women. J Transl Med 2014; 12:82. [PMID: 24685020 PMCID: PMC4013060 DOI: 10.1186/1479-5876-12-82] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 03/04/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The risk of cardiovascular diseases (CVD) is increased tremendously among menopausal women, and there is an increasing demand for alternative therapies for managing factors like dyslipidemia that contribute to CVD development. METHODS In this study, Nigella sativa was evaluated for its hypolipidemic effects among menopausal women. In a randomised trial, hyperlipidemic menopausal women were assigned to treatment (n=19) or placebo groups (n=18), and given N. sativa or placebo for two months after their informed consents were sought. At baseline, blood samples were taken and at one month intervals thereafter until one month after the end of the study. RESULTS The results showed that N. sativa significantly improved lipid profiles of menopausal women (decreased total cholesterol, low density lipoprotein cholesterol and triglyceride, and increased high density lipoprotein cholesterol) more than the placebo treatment over 2 months of intervention. One month after cessation of treatment, the lipid profiles in the N. sativa-treated group tended to change towards the pretreatment levels. CONCLUSIONS N. sativa is thought to have multiple mechanisms of action and is cost-effective. Therefore, it could be used by menopausal women to remedy hypercholesterolemia, with likely more benefits than with single pharmacological agents that may cause side effects. The use of N. sativa as an alternative therapy for hypercholesterolemia could have profound impact on the management of CVD among menopausal women especially in countries where it is readily available.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Maznah Ismail
- Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor Darul Ehsan, Malaysia.
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Hsieh CH, Chiou WY, Lee CC, Lee MS, Lin HY, Su YC, Hung SK. Factors affecting myocardial infarction in cervical cancer patients: a population-based study. J Clin Med Res 2013; 5:467-74. [PMID: 24171059 PMCID: PMC3808265 DOI: 10.4021/jocmr1591w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2013] [Indexed: 11/04/2022] Open
Abstract
Background Radiotherapy (RT) or concurrent chemoradiation therapy has been suggested to increase the risk of coronary heart disease for cervical cancer patients, but the results of studies have been inconsistent. Therefore, we aimed to investigate the factors which influence the risk of developing myocardial infarction (MI) in cervical cancer patients with a large, nationwide cohort. Methods The study analyzed data from the 1996 to 2010 National Health Insurance Research Database provided by the National Health Research Institutes in Taiwan. The assessed number of patients with cervical cancer with radiotherapy only, surgery with bilateral oophorectomy only, and with appendectomy were 308, 323 and 229, respectively. The Kaplan-Meier method and the Cox proportional hazards model were used to assess the risk of myocardial infarction. Results The adjusted hazard ratio for cervical cancer in patients with MI was 1.97 (95% CI, 0.97 - 3.91; P = 0.05) for the group that received RT alone, and 2.13 (95% CI, 1.11 - 3.75; P = 0.01) for the surgery group when compared with controls. The more risk comorbidities they have, the higher the risk of myocardial infarction would be for the patients. Conclusion The incidence of MI was significantly higher among cervical cancer patients with RT alone or surgery with bilateral oophorectomy alone than among general populations. RT might be as a factor to increase risk as bilateral oophorectomy. Whether RT itself triggers menopause or impairs the ovarian hormone production that increases the risk of MI needs to be further investigated.
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Affiliation(s)
- Chen-Hsi Hsieh
- Department of Radiation Oncology, Far Eastern Memorial Hospital, Taipei, Taiwan ; Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan ; Institute of Traditional Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan ; These authors contributed equally to this work
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Crandall CJ, Barrett-Connor E. Endogenous sex steroid levels and cardiovascular disease in relation to the menopause: a systematic review. Endocrinol Metab Clin North Am 2013; 42:227-53. [PMID: 23702399 DOI: 10.1016/j.ecl.2013.02.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Heart disease remains a major cause of death among women in the United States. This article focuses on physiologic endogenous estrogen levels with a systematic review of literature related to endogenous sex steroid levels and coronary artery disease (CAD) among postmenopausal women with natural or surgical menopause. There is adequate reason to seek evidence for associations of circulating estrogen levels and CAD. In the future, even if ovarian senescence-associated hormonal changes are confirmed to be associated with CAD in cohort studies of postmenopausal women, there may be other components explaining the gender differences in CAD patterns.
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Affiliation(s)
- Carolyn J Crandall
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA 90024, USA.
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Cremonini E, Bonaccorsi G, Bergamini CM, Castaldini C, Ferrazzini S, Capatti A, Massari L, Romani A, Marci R, Fila E, Ferrari C, Cervellati C. Metabolic transitions at menopause: In post-menopausal women the increase in serum uric acid correlates with abdominal adiposity as assessed by DXA. Maturitas 2013; 75:62-6. [DOI: 10.1016/j.maturitas.2013.01.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 01/11/2013] [Accepted: 01/21/2013] [Indexed: 01/26/2023]
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14
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Diabetes abrogates sex differences and aggravates cardiometabolic risk in postmenopausal women. Cardiovasc Diabetol 2013; 12:61. [PMID: 23570342 PMCID: PMC3626922 DOI: 10.1186/1475-2840-12-61] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 03/30/2013] [Indexed: 01/14/2023] Open
Abstract
Background The aim of this study is to evaluate the effect of gender and menopause in cardiometabolic risk in a type 2 diabetes mellitus (T2DM) population, based on classical and non-traditional markers. Methods Seventy four volunteers and 110 T2DM patients were enrolled in the study. Anthropometric data, blood pressure, body mass index (BMI), waist circumference (WC) and the following serum markers were analyzed: glucose, Total-c, TGs, LDL-c, Oxidized-LDL, total HDL-c and large and small HDL-c subpopulations, paraoxonase 1 activity, hsCRP, uric acid, TNF-α, adiponectin and VEGF. Results Non-diabetic women, compared to men, presented lower glycemia, WC, small HDL-c, uric acid, TNF-α and increased large HDL-c. Diabetes abrogates the protective effect of female gender, since diabetic women showed increased BMI, WC, small HDL-c, VEGF, uric acid, TNF-α and hsCRP, as well as reduced adiponectin, when compared with non-diabetic. In diabetic females, but not in males, WC is directly and significantly associated with TNF-α, VEGF, hsCRP and uric acid; TNF-α is directly associated with VEGF and hsCRP, and inversely with adiponectin. Postmenopausal females presented a worsen cardiometabolic profile, viewed by the increased WC, small HDL-c, VEGF, uric acid, TNF-α and hsCRP. In this population, WC is directly and significantly associated with TNF-α, VEGF, hsCRP; TNF-α is directly associated with VEGF; and uric acid is inversely associated with large HDL-c and hsCRP with adiponectin, also inversely. Conclusions Diabetes abrogates the protective effect of gender on non-diabetic women, and postmenopausal diabetic females presented worsen cardiometabolic risk, including a more atherogenic lipid sketch and a pro-inflammatory and pro-angiogenic profile. The classical cardiovascular risk factors (CVRFs) fail to completely explain these differences, which are better clarified using “non-traditional” factors, such as HDL-c subpopulations, rather than total HDL-c content, and markers of inflammation and angiogenesis, namely TNF-α, hsCRP, uric acid and VEGF. Multi-therapeutic intervention, directed to obesity, atherogenic lipid particles and inflammatory mediators is advisory in order to efficiently prevent the serious diabetic cardiovascular complications.
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Brenner R, Weilenmann D, Maeder MT, Jörg L, Bluzaite I, Rickli H, De Pasquale G, Ammann P. Clinical characteristics, sex hormones, and long-term follow-up in Swiss postmenopausal women presenting with Takotsubo cardiomyopathy. Clin Cardiol 2012; 35:340-7. [PMID: 22488168 DOI: 10.1002/clc.21986] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Revised: 02/27/2012] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The overwhelming majority of patients with stress cardiomyopathy (SC) are postmenopausal women, suggesting an important pathophysiologic role of the female sex hormones. Preliminary data suggest that myocardial stunning might be provoked by estrogen deficiency. HYPOTHESIS We hypothesized that, compared with age- and gender-matched patients with myocardial infarction (MI) or patients with normal coronary arteries, patients with SC would exhibit altered levels of sex hormones. Furthermore, we aimed to describe the clinical course and the pattern of sex hormones of the SC patients during long-term follow-up. METHODS Blood samples obtained on hospital admission were analyzed for estradiol (E2), progesterone (P), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) in women with SC (n = 17), age-matched women with acute MI (n = 16), and women with normal coronary arteries (n = 15). Six years after the initial event, SC patients underwent a clinical and echocardiographic follow-up and reassessment of sex hormones. RESULTS Estrogen concentrations at hospital admission were significantly higher in the SC group compared with the MI and the control groups, with no difference in P, FSH, and LH concentrations. Follow-up E2 after 6 years in SC patients was lower than during the acute SC episode. Follow-up P in these patients was lower than P in the MI and control groups during the acute event, with a similar trend for E2. After a median follow-up of 6.4 years, 1 sudden cardiac death occurred and 2 patients suffered from SC recurrence. CONCLUSIONS During the acute event, E2 concentrations are elevated in postmenopausal SC patients compared with women with acute MI or with normal coronary arteries. The higher E2 concentrations might have exerted atheroprotective effects and thus diverted the stress response to SC rather than MI. Recurrence and/or sudden cardiac death remains a potential risk of SC.
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Affiliation(s)
- Roman Brenner
- Department of Cardiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
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Gallicchio L, MacDonald R, Wood B, Rushovich E, Helzlsouer KJ. Menopausal-type symptoms among breast cancer patients on aromatase inhibitor therapy. Climacteric 2011; 15:339-49. [PMID: 22191462 DOI: 10.3109/13697137.2011.620658] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To examine self-reported menopausal-type symptoms among breast cancer patients on aromatase inhibitors (AIs) compared to women of the same age who had not been diagnosed with cancer, and to determine whether the percentage of breast cancer patients experiencing these symptoms changed over the first 6 months of AI treatment. METHODS Data from a 6-month cohort study of 100 breast cancer patients initiating AI therapy and of 200 women of a similar age without a history of cancer were analyzed. At baseline (prior to the initiation of AI therapy among the breast cancer patients), 3 months, and 6 months, a comprehensive questionnaire was administered to participants that ascertained data on the experiencing of specific menopausal-type symptoms. RESULTS The data showed statistically significant increases in the prevalence of certain symptoms from baseline to either follow-up point among the breast cancer patients; these symptoms included hot flushes, night sweats, pain during intercourse, hair loss, forgetfulness, depression, difficulty falling asleep, and interrupted sleep. Additionally, breast cancer patients were more likely than the women in the comparison group to report the new onset of many of these same symptoms during the follow-up time period. CONCLUSIONS Because bothersome symptoms and side-effects are a major reason for discontinuation and non-adherence to treatment, symptoms should be monitored and addressed by oncologists so that the breast cancer patient can maintain her quality of life and remain adherent to the treatment schedule.
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Affiliation(s)
- L Gallicchio
- The Prevention and Research Center, Weinberg Center for Women's Health & Medicine, Mercy Medical Center, 227 St. Paul Place, Baltimore, MD 21202, USA
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Inflammatory response of coronary artery disease postmenopausal women is associated with the IVS1-397T > C estrogen receptor α polymorphism. Clin Immunol 2009; 130:355-64. [DOI: 10.1016/j.clim.2008.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 09/02/2008] [Accepted: 09/17/2008] [Indexed: 01/09/2023]
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The importance of the (TAAAA)n alleles at the SHBG gene promoter for the severity of coronary artery disease in postmenopausal women. Menopause 2008; 15:461-8. [PMID: 18188141 DOI: 10.1097/gme.0b013e31814faf41] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Androgen may be detrimental in the development of coronary artery disease (CAD) in women. We investigated possible associations between the (TAAAA)n polymorphism of sex hormone-binding globulin (SHBG) gene promoter, which influences transcriptional efficiency of the SHBG gene and the severity of CAD in women. DESIGN In this prospective clinical study, 146 postmenopausal women (46-88 y) undergoing coronary angiography were studied. CAD severity, history of angina and myocardial infarction, and reproductive history were recorded and hormonal parameters measured. According to the number of SHBG gene promoter repeat polymorphisms, participants were classified into short (seven or fewer), medium length (eight), and long repeat (nine or more) allele groups. RESULTS Significant CAD was more prevalent in the long repeat allele carrier group: 65% of the participants with three vessels with severe stenosis belonged to the long repeat allele group, whereas only 37% of participants with mild CAD belonged to this group (P=0.01). A history of angina and prevalence of hyperlipidemia was more frequent in the long repeat allele group (P<0.05). Calculated free testosterone levels were higher in the long repeat allele groups (P<0.05), whereas SHBG levels tended to be lower (P=0.06). SHBG levels correlated inversely with body mass index and waist circumference (P<0.05). CONCLUSIONS Longer (TAAAA)n repeats in the SHBG gene promoter are associated with more severe CAD in women undergoing coronary angiography, a finding not previously reported. This association may reflect the lifelong tissue exposure to higher free androgens and supports the adverse cardiovascular effect of androgenic exposure in this highly selected group of women.
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L'hermite M, Simoncini T, Fuller S, Genazzani AR. Could transdermal estradiol + progesterone be a safer postmenopausal HRT? A review. Maturitas 2008; 60:185-201. [PMID: 18775609 DOI: 10.1016/j.maturitas.2008.07.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 07/10/2008] [Accepted: 07/21/2008] [Indexed: 12/26/2022]
Abstract
Hormone replacement therapy (HRT) in young postmenopausal women is a safe and effective tool to counteract climacteric symptoms and to prevent long-term degenerative diseases, such as osteoporotic fractures, cardiovascular disease, diabetes mellitus and possibly cognitive impairment. The different types of HRT offer to many extent comparable efficacies on symptoms control; however, the expert selection of specific compounds, doses or routes of administration can provide significant clinical advantages. This paper reviews the role of the non-oral route of administration of sex steroids in the clinical management of postmenopausal women. Non-orally administered estrogens, minimizing the hepatic induction of clotting factors and others proteins associated with the first-pass effect, are associated with potential advantages on the cardiovascular system. In particular, the risk of developing deep vein thrombosis or pulmonary thromboembolism is negligible in comparison to that associated with oral estrogens. In addition, recent indications suggest potential advantages for blood pressure control with non-oral estrogens. To the same extent, a growing literature suggests that the progestins used in association with estrogens may not be equivalent. Recent evidence indeed shows that natural progesterone displays a favorable action on the vessels and on the brain, while this might not be true for some synthetic progestins. Compelling indications also exist that differences might also be present for the risk of developing breast cancer, with recent trials indicating that the association of natural progesterone with estrogens confers less or even no risk of breast cancer as opposed to the use of other synthetic progestins. In conclusion, while all types of hormone replacement therapies are safe and effective and confer significant benefits in the long-term when initiated in young postmenopausal women, in specific clinical settings the choice of the transdermal route of administration of estrogens and the use of natural progesterone might offer significant benefits and added safety.
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Affiliation(s)
- Marc L'hermite
- Department of Gynecology and Obstetrics, Université Libre de Bruxelles, Bruxelles, Belgium.
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Saltiki K, Cimponeriu A, Lili K, Peppa M, Anastasiou E, Alevizaki M. Severity of coronary artery disease in postmenopausal diabetic women. Hormones (Athens) 2008; 7:148-55. [PMID: 18477552 DOI: 10.1007/bf03401506] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Coronary artery disease (CAD) risk increases in women after the menopause. The aim of this study was to determine the effect of diabetes on the severity of CAD in postmenopausal women undergoing coronary angiography. DESIGN 180 postmenopausal women underwent coronary angiography for suspected CAD. CAD severity was assessed by the number of arteries (0-3) with >50% stenosis in the angiography. Forty-four women had type 2 diabetes mellitus (T2DM). Predisposing risk factors and biochemical and hormonal parameters were recorded. The diabetic women were older (p=0.014), had higher BMI and waist circumference (p<0.001), higher prevalence of hypertension (p=0.002), higher levels of triglycerides, uric acid and higher HOMA-Insulin Resistance Index (p=0.009). RESULTS The women with diabetes had a higher prevalence of severe stenosis in the angiography: T2DM: 0-vessels 25%, 1-vessel disease 18.2%, 2-vessels disease 22.7%, 3-vessels disease 34.1%, vs. 49.2%, 23.5%, 22.1%, 5.1% in the non-diabetic women, respectively (p<0.001). Binary logistic regression analysis showed that T2DM was a significant predictor of severe CAD (>or=3 vessel disease) independently of age, family history of T2DM, BMI, time since menopause, hypertension and hypercholesterolemia. Women with T2DM also had lower sex hormone binding globulin (SHBG, p=0.010) levels compared to non-diabetic women. CONCLUSIONS Diabetic postmenopausal women develop more severe CAD compared to non-diabetic women. This association is independent of other predisposing factors and suggests an independent effect of T2DM on the atherosclerotic process, at least in women after menopause.
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Affiliation(s)
- Katerina Saltiki
- Endocrine Unit, Evgenidion Hospital and Department of Clinical Therapeutics, Alexandra University Hospital, Athens, Greece.
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Belkacémi Y, Laharie-Mineur H, Gligorov J, Azria D. Bénéfice et risques potentiels de l'association du trastuzumab à la chimiothérapie et à la radiothérapie dans le cancer du sein non métastatique. Cancer Radiother 2007; 11:266-75. [PMID: 17644449 DOI: 10.1016/j.canrad.2007.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Revised: 04/02/2007] [Accepted: 04/20/2007] [Indexed: 11/20/2022]
Abstract
Trastuzumab (Herceptin) is the first humanised monoclonal antibody targeting the HER2 antigen in breast cancer. HER2 receptor has been individualised 20 years ago. During the past 10 years, trastuzumab administration has radically modified the prognosis of the patients that are treated for HER2 positive breast cancer. Its efficacy has been demonstrated in the metastatic and adjuvant settings. While, trastuzumab based-regimens became the standard of care in the treatment of HER2/neu positive breast cancer, the optimal combination (concurrently or sequentially) to chemotherapy and radiation therapy is still unknown. Indeed, while the concurrent administration of trastuzumab and anthracyclines is not recommended because of a high risk of cardiac toxicity, there is no published data on the best sequence of trastuzumab and radiation therapy administration, particularly when internal mammary chain is involved. The benefit/risk ratio of the concurrent and sequential administration of trastuzumab with chemotherapy and radiation therapy will be discussed in this review.
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MESH Headings
- Animals
- Anthracyclines/administration & dosage
- Anthracyclines/adverse effects
- Anthracyclines/therapeutic use
- Antibiotics, Antineoplastic/administration & dosage
- Antibiotics, Antineoplastic/adverse effects
- Antibiotics, Antineoplastic/therapeutic use
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols
- Breast Neoplasms/drug therapy
- Breast Neoplasms/genetics
- Breast Neoplasms/metabolism
- Breast Neoplasms/mortality
- Breast Neoplasms/radiotherapy
- Combined Modality Therapy
- Disease Models, Animal
- Female
- Follow-Up Studies
- Heart/drug effects
- Humans
- Multicenter Studies as Topic
- Radiotherapy Dosage
- Radiotherapy, Adjuvant
- Randomized Controlled Trials as Topic
- Receptor, ErbB-2
- Retrospective Studies
- Risk Assessment
- Risk Factors
- Time Factors
- Trastuzumab
- Treatment Outcome
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Affiliation(s)
- Y Belkacémi
- Département d'oncologie-radiothérapie, CLCC Oscar-Lambret, université de Lille-II, 3, rue Frédéric-Combemale, 59020 Lille, France.
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