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Aikens RC, Chen JH, Baiocchi M, Simard JF. Feedback Loop Failure Modes in Medical Diagnosis: How Biases Can Emerge and Be Reinforced. Med Decis Making 2024:272989X241248612. [PMID: 38738479 DOI: 10.1177/0272989x241248612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
BACKGROUND Medical diagnosis in practice connects to research through continuous feedback loops: Studies of diagnosed cases shape our understanding of disease, which shapes future diagnostic practice. Without accounting for an imperfect and complex diagnostic process in which some cases are more likely to be diagnosed correctly (or diagnosed at all), the feedback loop can inadvertently exacerbate future diagnostic errors and biases. FRAMEWORK A feedback loop failure occurs if misleading evidence about disease etiology encourages systematic errors that self-perpetuate, compromising future diagnoses and patient care. This article defines scenarios for feedback loop failure in medical diagnosis. DESIGN Through simulated cases, we characterize how disease incidence, presentation, and risk factors can be misunderstood when observational data are summarized naive to biases arising from diagnostic error. A fourth simulation extends to a progressive disease. RESULTS When severe cases of a disease are diagnosed more readily, less severe cases go undiagnosed, increasingly leading to underestimation of the prevalence and heterogeneity of the disease presentation. Observed differences in incidence and symptoms between demographic groups may be driven by differences in risk, presentation, the diagnostic process itself, or a combination of these. We suggested how perceptions about risk factors and representativeness may drive the likelihood of diagnosis. Differing diagnosis rates between patient groups can feed back to increasingly greater diagnostic errors and disparities in the timing of diagnosis and treatment. CONCLUSIONS A feedback loop between past data and future medical practice may seem obviously beneficial. However, under plausible scenarios, poorly implemented feedback loops can degrade care. Direct summaries from observational data based on diagnosed individuals may be misleading, especially concerning those symptoms and risk factors that influence the diagnostic process itself. HIGHLIGHTS Current evidence about a disease can (and should) influence the diagnostic process. A feedback loop failure may occur if biased "evidence" encourages diagnostic errors, leading to future errors in the evidence base.When diagnostic accuracy varies for mild versus severe cases or between demographic groups, incorrect conclusions about disease prevalence and presentation will result without specifically accounting for such variability.Use of demographic characteristics in the diagnostic process should be done with careful justification, in particular avoiding potential cognitive biases and overcorrection.
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Affiliation(s)
- Rachael C Aikens
- Biomedical Informatics Program, Stanford University, Stanford, CA, USA
- Mathematica, Princeton, NJ, USA
| | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Stanford School of Medicine, Stanford, CA, USA
- Division of Hospital Medicine, Stanford School of Medicine, Stanford, CA, USA
| | - Michael Baiocchi
- Biomedical Informatics Program, Stanford University, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Julia F Simard
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
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Parvand M, Ghadiri S, Théberge E, Comber L, Mullen KA, Bhalla NP, Johnson D, McKinley G, Sedlak TL. Sex, Gender, and Women's Heart Health: How Women's Heart Programs Address the Knowledge Gap. CJC Open 2024; 6:442-453. [PMID: 38487062 PMCID: PMC10935996 DOI: 10.1016/j.cjco.2023.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/15/2023] [Indexed: 03/17/2024] Open
Abstract
This article aims to bridge existing knowledge gaps that impact clinical cardiovascular care and outcomes for women in Canada. The authors discuss various aspects of women's heart health, emphasizing the efficacy of multidisciplinary care in promoting women's well-being. The article also identifies the impact of national women's heart health campaigns and the value of peer support in improving outcomes. The article addresses the particular risks that women face, such as pregnancy-related complications and hormone replacement therapy, all of which are associated with cardiovascular events, and highlights the differences in ischemic symptoms between men and women. Despite improvements in acute event outcomes, challenges persist in accessing timely ambulatory care, particularly for women. Canada has responded to these challenges by introducing Women Heart Programs, which offer tailored programs, support groups, and specialized testing. However, these programs remain few in number and are found only in urban settings. Overall, this review identifies sex and gender factors related to women's heart health, underscoring the importance of specialized programs and multidisciplinary care in improving women's cardiovascular health.
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Affiliation(s)
- Mahraz Parvand
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Siavash Ghadiri
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Emilie Théberge
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Lisa Comber
- Ottawa Heart Institute Research Corporation (OHIRC), Ottawa, Ontario, Canada
| | - Kerri-Anne Mullen
- Ottawa Heart Institute Research Corporation (OHIRC), Ottawa, Ontario, Canada
| | | | - Denise Johnson
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gayl McKinley
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tara L. Sedlak
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
- British Columbia Women's Hospital, Vancouver, British Columbia, Canada
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Perera S, Aslam A, Burgess S, Castles AV, Segan L, Mukherjee S, Beale AL, Gutman SJ, Biswas S, Leet A, Zaman S. Gender Differences in Medical Student Perceptions of a Career in Cardiology. Heart Lung Circ 2023; 32:1250-1256. [PMID: 37414678 DOI: 10.1016/j.hlc.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 04/29/2023] [Accepted: 05/18/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Worldwide, the cardiology profession has an under-representation of women. We assessed medical students' perceptions of cardiology as a career choice with the aim of identifying barriers to gender diversity. METHOD An anonymous survey was distributed to medical students studying at three Australian medical universities. Questions pertained to demographics, year and stage of medical training, desire to pursue cardiology, and perceived barriers to a cardiology career. Results were analysed according to identified gender and desire to pursue or not pursue a cardiology career. Multivariable logistic regression evaluated for independent associations. The primary outcome were barriers identified to pursuing a career in cardiology. RESULTS From 127 medical student respondents (86.6% female, mean age 25.9±4.8 years), 37.0% stated they wanted to pursue a career in cardiology (39.1% of women versus 23.5% of men, p=0.54). The top four perceived barriers to a cardiology career included: poor work-life balance (92/127, 72.4%), physician training process (63/127, 49.6%), on-call requirements (50/127, 39.4%) and lack of flexibility (49/127, 38.6%), with no gender differences. Women were more likely to report gender-related barriers (37.3% versus 5.9%, p=0.01) and less likely to identify procedural aspects as a barrier (5.5% women versus 29.4% men, p=0.001). Students in their pre-clinical years were more likely to want a career in cardiology (odds ratio 3.0, 95% confidence interval 1.2-7.7, p=0.02). CONCLUSIONS A high proportion of female and male medical students want to pursue a career in cardiology with both genders identifying major barriers of poor work-life balance, lack of flexibility, on-call requirements and the training process.
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Affiliation(s)
| | - Anum Aslam
- Monash Health, Melbourne, Vic, Australia; Western Health, Melbourne, Vic, Australia
| | - Sonya Burgess
- Department of Medicine, The University of New South Wales, Sydney, NSW, Australia; Department of Cardiology, Nepean Hospital, Sydney, NSW, Australia
| | - Anastasia Vlachadis Castles
- Department of Cardiology, The Northern Hospital, Melbourne, Vic, Australia; Austin Clinical School, Department of Medicine, The University of Melbourne, Melbourne, Vic, Australia
| | - Louise Segan
- Department of Cardiology, Barwon Health, Melbourne, Vic, Australia; Clinical Research, Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Swati Mukherjee
- Department of Cardiology, Cabrini Health, Melbourne, Vic, Australia
| | - Anna L Beale
- Monash Health, Melbourne, Vic, Australia; Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Sarah J Gutman
- Monash Health, Melbourne, Vic, Australia; Clinical Research, Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Sinjini Biswas
- Department of Cardiology, Cabrini Health, Melbourne, Vic, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Angeline Leet
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Sarah Zaman
- School of Clinical Sciences Monash Health, Monash Cardiovascular Research Centre, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia.
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Marschner S, Mukherjee S, Watts M, Min H, Beale AL, O'Brien J, Juneja A, Tremmel JA, Zaman S. Prevention of Cardiovascular Disease in Women With Pregnancy-Related Risk Factors: A Prospective Women's Heart Clinic Study. J Am Heart Assoc 2023; 12:e030015. [PMID: 37642017 PMCID: PMC10547318 DOI: 10.1161/jaha.123.030015] [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: 02/27/2023] [Accepted: 06/20/2023] [Indexed: 08/31/2023]
Abstract
Background Hypertensive disorders of pregnancy, gestational diabetes, and having a small-for-gestational-age baby are known to substantially increase a woman's risk of cardiovascular disease. Despite this, evidence for models of care that mitigate cardiovascular disease risk in women with these pregnancy-related conditions is lacking. Methods and Results A 6-month prospective cohort study assessed the effectiveness of a multidisciplinary Women's Heart Clinic on blood pressure and lipid control in women aged 30 to 55 years with a past pregnancy diagnosis of hypertensive disorders of pregnancy, gestational diabetes, or a small-for-gestational age baby in Melbourne, Australia. The co-primary end points were (1) blood pressure <140/90 mm Hg or <130/80 mm Hg if diabetes and (2) total cholesterol to high-density lipoprotein cholesterol ratio <4.5. The study recruited 156 women with a mean age of 41.0±4.2 years, 3.9±2.9 years from last delivery, 68.6% White, 20.5% South/East Asian, and 80.5% university-educated. The proportion meeting blood pressure target increased (69.2% to 80.5%, P=0.004), with no significant change in lipid targets (80.6% to 83.7%, P=0.182). Systolic blood pressure (-6.9 mm Hg [95% CI, -9.1 to -4.7], P<0.001), body mass index (-0.6 kg/m2 [95% CI, -0.8 to -0.3], P<0.001), low-density lipoprotein cholesterol (-4.2 mg/dL [95% CI, -8.2 to -0.2], P=0.042), and total cholesterol (-4.6 mg/dL [95% CI, -9.1 to -0.2] P=0.042) reduced. Heart-healthy lifestyle significantly improved with increased fish/olive oil (36.5% to 51.0%, P=0.012), decreased fast food consumption (33.8% to 11.0%, P<0.001), and increased physical activity (84.0% to 92.9%, P=0.025). Conclusions Women at high risk for cardiovascular disease due to past pregnancy-related conditions experienced significant improvements in multiple cardiovascular risk factors after attending a Women's Heart Clinic, potentially improving long-term cardiovascular disease outcomes. Registration URL: https://www.anzctr.org.au; Unique identifier: ACTRN12622000646741.
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Affiliation(s)
- Simone Marschner
- Westmead Applied Research Centre, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Swati Mukherjee
- Department of CardiologyCabrini HealthMelbourneAustralia
- Department of CardiologyAlfred HospitalMelbourneAustralia
- Faculty of Medicine, Nursing & Health SciencesMonash UniversityMelbourneAustralia
| | - Monique Watts
- Department of CardiologyAlfred HospitalMelbourneAustralia
- Faculty of Medical EducationUniversity of MelbourneMelbourneAustralia
| | - Haeri Min
- Westmead Applied Research Centre, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Anna L. Beale
- Department of CardiologyAlfred HospitalMelbourneAustralia
| | | | - Aashima Juneja
- Department of MedicineThe Northern HospitalMelbourneAustralia
| | - Jennifer A. Tremmel
- Department of Medicine (Cardiovascular)Stanford University School of MedicineStanfordCA
| | - Sarah Zaman
- Westmead Applied Research Centre, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
- School of Clinical Sciences at Monash HealthMonash UniversityMelbourneAustralia
- Department of CardiologyWestmead HospitalSydneyAustralia
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Heaney RM, Zaki-Metias KM, McKee H, Wang H, Ogunde B, Yong-Hing CJ, Freitas V, Ghai S, Seely JM, Nguyen ET. Correlation Between Breast Arterial Calcifications and Higher Cardiovascular Risk: Awareness and Attitudes Amongst Canadian Radiologists Who Report Mammography. Can Assoc Radiol J 2023; 74:582-591. [PMID: 36541871 DOI: 10.1177/08465371221140347] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Breast arterial calcification (BAC) on mammography correlates with increased cardiovascular risk. Reporting BAC is not standard practice. Our study evaluates the awareness of Canadian radiologists who report mammography of the clinical significance of BAC and their attitudes towards reporting BAC compared to their European and American counterparts. Methods: Following local institutional ethics approval, a 25 question survey (SurveyMonkey) was disseminated to Canadian radiologists via provincial and national society email lists. Responses were collected over 5 weeks (April-June 2022). Results: One hundred and eighty-six complete responses were collected. Sixty percent (112/186) were aware of the association between BAC and cardiovascular risk and 16% (29/186) document its presence in mammogram reports. Thirty five percent (65/186) occasionally document BAC if severe or in a young patient. Four percent (7/186) had local departmental guidelines on BAC reporting and 82% (153/186) agreed there is a need for national BAC reporting guidelines. Fewer Canadian radiologists were aware of the association between BAC and cardiovascular risk compared to European radiologists (60% vs 81%), report the presence of BAC compared to both European (15% vs 62%) and American (15% vs 35%) radiologists, and inform the patient of the presence of BAC compared to European radiologists (1% vs 46%). Conclusion: Canadian radiologists who report mammography were less aware of the association between BAC and cardiovascular risk than their European and American counterparts and were less likely to document the presence of BAC. Given the correlation of BAC with increased cardiovascular event risk, there is increased need for awareness as well as national BAC reporting guidelines.
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Affiliation(s)
- Roisin M Heaney
- Joint Department of Medical Imaging, Toronto General Hospital, Toronto, ON, Canada
| | - Kaitlin M Zaki-Metias
- Department of Radiology, Trinity Health Oakland Hospital/Wayne State University School of Medicine, Pontiac, MI, USA
| | - Hayley McKee
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Huijuan Wang
- Department of Radiology, Trinity Health Oakland Hospital/Wayne State University School of Medicine, Pontiac, MI, USA
| | - Barakat Ogunde
- Department of Radiology, Trinity Health Oakland Hospital/Wayne State University School of Medicine, Pontiac, MI, USA
| | - Charlotte J Yong-Hing
- Diagnostic Imaging, BC Cancer, Vancouver, BC, Canada
- Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Vivianne Freitas
- Joint Department of Medical Imaging, Princess Margaret Hospital, Toronto, ON, Canada
| | - Sandeep Ghai
- Joint Department of Medical Imaging, Princess Margaret Hospital, Toronto, ON, Canada
| | - Jean M Seely
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Elsie T Nguyen
- Joint Department of Medical Imaging, Toronto General Hospital, Toronto, ON, Canada
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Stranges TN, Namchuk AB, Splinter TFL, Moore KN, Galea LAM. Are we moving the dial? Canadian health research funding trends for women's health, 2S/LGBTQ + health, sex, or gender considerations. Biol Sex Differ 2023; 14:40. [PMID: 37322516 PMCID: PMC10273719 DOI: 10.1186/s13293-023-00524-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/31/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Sex and gender impacts health outcomes and disease risk throughout life. The health of women and members of the Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer or Questioning (2S/LGBTQ +) community is often compromised as they experience delays in diagnosis. Distinct knowledge gaps in the health of these populations have prompted funding agencies to mandate incorporation of sex and gender into research. Sex- and gender-informed research perspectives and methodology increases rigor, promotes discovery, and expands the relevance of health research. Thus, the Canadian Institutes of Health Research (CIHR) implemented a sex and gender-based analysis (SGBA) framework recommending the inclusion of SGBA in project proposals in 2010 and then mandating the incorporation of SGBA into grant proposals in 2019. To examine whether this mandate resulted in increased mention of sex or gender in funded research abstracts, we searched the publicly available database of grant abstracts funded by CIHR to analyze the percentage of abstracts that mentioned sex or gender of the population to be studied in the funded research. To better understand broader health equity issues we also examined whether the funded grant abstracts mentioned either female-specific health research or research within the 2S/LGBTQ + community. RESULTS We categorized a total of 8,964 Project and Operating grant abstracts awarded from 2009 to 2020 based on their study of female-specific or a 2S/LGBTQ + populations or their mention of sex or gender. Overall, under 3% of grant abstracts funded by CIHR explicitly mentioned sex and/or gender, as 1.94% of grant abstracts mentioned sex, and 0.66% mentioned gender. As one of the goals of SGBA is to inform on health equity and understudied populations with respect to SGBA, we also found that 5.92% of grant abstracts mentioned female-specific outcomes, and 0.35% of grant abstracts focused on the 2S/LGBTQ + community. CONCLUSIONS Although there was an increased number of funded grants with abstracts that mentioned sex and 2S/LGBTQ + health across time, these increases were less than 2% between 2009 and 2020. The percentage of funded grants with abstracts mentioning female-specific health or gender differences did not change significantly over time. The percentage of funding dollars allocated to grants in which the abstracts mentioned sex or gender also did not change substantially from 2009 to 2020, with grant abstracts mentioning sex or female-specific research increasing by 1.26% and 3.47%, respectively, funding allocated to research mentioning gender decreasing by 0.49% and no change for 2S/LGBTQ +-specific health. Our findings suggest more work needs to be done to ensure the public can evaluate what populations will be examined with the funded research with respect to sex and gender to advance awareness and health equity in research.
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Affiliation(s)
- Tori N. Stranges
- Women’s Health Research Cluster, University of British Columbia, Vancouver, BC Canada
- School of Health and Exercise Sciences, University of British Columbia, Okanagan, Kelowna, BC Canada
| | - Amanda B. Namchuk
- Women’s Health Research Cluster, University of British Columbia, Vancouver, BC Canada
- Graduate Program in Neuroscience, University of British Columbia, Vancouver, BC Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC Canada
| | | | - Katherine N. Moore
- Women’s Health Research Cluster, University of British Columbia, Vancouver, BC Canada
| | - Liisa A. M. Galea
- Women’s Health Research Cluster, University of British Columbia, Vancouver, BC Canada
- Graduate Program in Neuroscience, University of British Columbia, Vancouver, BC Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC Canada
- Centre for Addiction and Mental Health, Toronto, ON Canada
- Department of Psychiatry, University of Toronto, Toronto, ON Canada
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Tegg NL, Desmarais OH, Lindsay MP, McDermott S, Mulvagh SL, Desbiens MM, Norris CM. A Survey of Female-Specific Cardiovascular Protocols in Emergency Departments in Canada. CJC Open 2023; 5:107-111. [PMID: 36880067 PMCID: PMC9984888 DOI: 10.1016/j.cjco.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background Cardiovascular diseases (CVD) remain the leading cause of death for women. However, systematic inequalities exist in how women experience clinical cardiovascular (CV) policies, programs, and initiatives. Methods In collaboration with the Heart and Stroke Foundation of Canada, a question regarding female-specific CV protocols in an emergency department (ED), or an inpatient or ambulatory care area of a healthcare site was sent via e-mail to 450 healthcare sites in Canada. Contacts at these sites were established through the larger initiative-the Heart Failure Resources and Services Inventory-conducted by the foundation. Results Responses were received from 282 healthcare sites, with 3 sites confirming the use of a component of a female-specific CV protocol in the ED. Three sites noted using sex-specific troponin levels in the diagnosis of acute coronary syndromes; 2 of the sites are participants in the hs-cTn-Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women (CODE MI) trial. One site reported the integration of a female-specific CV protocol component into routine use. Conclusions We have identified an absence of female-specific CVD protocols in EDs that may be associated with the identified poorer outcomes in women impacted by CVD. Female-specific CV protocols may serve to increase equity and ensure that women with CV concerns have access to the appropriate care in a timely manner, thereby helping to mitigate some of the current adverse effects experienced by women who present to Canadian EDs with CV symptoms.
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Affiliation(s)
- Nicole L Tegg
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Susanna McDermott
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Colleen M Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.,Heart Health and Stroke Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada.,Faculty of Medicine, School of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
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Cardiovascular Risk Screening among Women Veterans: Identifying Provider and Patient Barriers and Facilitators to Develop a Clinical Toolkit. Womens Health Issues 2022; 32:284-292. [PMID: 35115227 DOI: 10.1016/j.whi.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 11/15/2021] [Accepted: 12/09/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Cardiovascular (CV) disease is the leading cause of death among women in the United States, making CV risk screening and management a women's health priority. Objectives were to elicit barriers and facilitators to CV risk identification and reduction among women veterans, and iteratively cocreate clinical tools to identify CV risk factors and promote goal-setting for lifestyle changes. METHODS We conducted three exploratory focus groups with 21 Veterans Health Administration primary care team members and piloted patient CV screeners with brief interviews with 19 patients from two Veterans Health Administration women's clinics to inform toolkit development. We then conducted two focus groups and one interview for feedback from a total of 12 staff on the proposed toolkit components. Transcripts were summarized, and a matrix analysis was used to synthesize qualitative findings. RESULTS Provider-identified barriers included difficulties disseminating CV information in clinic, limited patient knowledge, and lack of organized resources for provider communication and available referrals. Women's complex health needs were notable challenges to CV risk reduction. Facilitators included having a single place to track patient CV risks (e.g., an electronic template note), a patient screening worksheet, and aids to complete referrals. Patient-identified barriers included difficulties balancing health, finances, and physical and mental health concerns. Facilitators included resources for accountability and gender-specific information about CV risks and complications. Providers requested easy, accessible tools in the electronic record with gender-specific CV data and resources linked. Patients requested lifestyle change supports, including trustworthy sources vetted by providers. CONCLUSIONS Iteratively eliciting end-users' perspectives is critical to developing user-friendly, clinically relevant tools. CV risk reduction among women veterans will require multilevel tools and resources that meet providers' and women's needs.
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Adedinsewo DA, Pollak AW, Phillips SD, Smith TL, Svatikova A, Hayes SN, Mulvagh SL, Norris C, Roger VL, Noseworthy PA, Yao X, Carter RE. Cardiovascular Disease Screening in Women: Leveraging Artificial Intelligence and Digital Tools. Circ Res 2022; 130:673-690. [PMID: 35175849 PMCID: PMC8889564 DOI: 10.1161/circresaha.121.319876] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease remains the leading cause of death in women. Given accumulating evidence on sex- and gender-based differences in cardiovascular disease development and outcomes, the need for more effective approaches to screening for risk factors and phenotypes in women is ever urgent. Public health surveillance and health care delivery systems now continuously generate massive amounts of data that could be leveraged to enable both screening of cardiovascular risk and implementation of tailored preventive interventions across a woman's life span. However, health care providers, clinical guidelines committees, and health policy experts are not yet sufficiently equipped to optimize the collection of data on women, use or interpret these data, or develop approaches to targeting interventions. Therefore, we provide a broad overview of the key opportunities for cardiovascular screening in women while highlighting the potential applications of artificial intelligence along with digital technologies and tools.
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Affiliation(s)
- Demilade A. Adedinsewo
- Department of Cardiovascular Medicine (D.A.A., A.W.P., S.D.P.), Mayo Clinic, Jacksonville, FL
| | - Amy W. Pollak
- Department of Cardiovascular Medicine (D.A.A., A.W.P., S.D.P.), Mayo Clinic, Jacksonville, FL
| | - Sabrina D. Phillips
- Department of Cardiovascular Medicine (D.A.A., A.W.P., S.D.P.), Mayo Clinic, Jacksonville, FL
| | - Taryn L. Smith
- Division of General Internal Medicine (T.L.S.), Mayo Clinic, Jacksonville, FL
| | - Anna Svatikova
- Department of Cardiovascular Diseases (A.S.), Mayo Clinic, Phoenix, AZ
| | - Sharonne N. Hayes
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
| | - Sharon L. Mulvagh
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada (S.L.M.)
| | - Colleen Norris
- Cardiovascular Health and Stroke Strategic Clinical Network, Edmonton, Canada (C.N.)
| | - Veronique L. Roger
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
- Department of Quantitative Health Sciences (V.L.R.), Mayo Clinic, Rochester, MN
- Epidemiology and Community Health Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD (V.L.R.)
| | - Peter A. Noseworthy
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y.), Mayo Clinic, Rochester, MN
| | - Rickey E. Carter
- Department of Quantitative Health Sciences (R.E.C.), Mayo Clinic, Jacksonville, FL
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Austin RR, Mathiason MA, Lu SC, Lindquist RA, McMahon SK, Pieczkiewicz DS, Monsen KA. Toward Clinical Adoption of Standardized mHealth Solutions: The Feasibility of Using MyStrengths+MyHealth Consumer-Generated Health Data for Knowledge Discovery. Comput Inform Nurs 2022; 40:71-79. [PMID: 35115437 DOI: 10.1097/cin.0000000000000862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Robin R Austin
- Author Affiliations: School of Nursing, University of Minnesota (Dr Austin, Ms Mathiason, Dr Lindquist, Dr McMahon, and Dr Monsen), Minneapolis; MD Anderson Cancer Center, University of Texas (Dr Lu), Austin; and Institute for Health Informatics, University of Minnesota (Drs Pieczkiewicz and Monsen), Minneapolis
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Gulati M, Hendry C, Parapid B, Mulvagh SL. Why We Need Specialised Centres for Women's Hearts: Changing the Face of Cardiovascular Care for Women. Eur Cardiol 2022; 16:e52. [PMID: 35024054 PMCID: PMC8728884 DOI: 10.15420/ecr.2021.49] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/19/2021] [Indexed: 11/05/2022] Open
Abstract
Although cardiovascular disease (CVD) is the leading cause of mortality in women globally, cardiovascular care for women remains suboptimal, with poorer outcomes than for men. During the past two decades, there has been an incremental increase in research and publications on CVD in women, addressing sex-specific risk factors, symptoms, pathophysiology, treatment, prevention and identification of inequities in care. Nonetheless, once women have manifested CVD, they continue to have increasingly worse outcomes than men. An approach to addressing these global disparities has been the worldwide establishment of specialised centres providing cardiovascular care for women. These women’s heart centres (WHCs) allow a comprehensive approach to the cardiovascular care of women across the lifespan. The purpose of this article is to define the need for and role of these specialised centres by outlining sex-specific gaps in CVD care, and to provide guidance on components within WHCs that may be considered when establishing such programmes.
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Affiliation(s)
- Martha Gulati
- Division of Cardiology, University of Arizona Phoenix, AZ, US
| | - Cara Hendry
- Manchester Heart Institute, Manchester University Hospital NHS Trust Manchester, UK
| | | | - Sharon L Mulvagh
- Division of Cardiology, Department of Medicine, Dalhousie University Halifax, Nova Scotia, Canada.,Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, US
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12
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Mulvagh SL, Mullen KA, Nerenberg KA, Kirkham AA, Green CR, Dhukai AR, Grewal J, Hardy M, Harvey PJ, Ahmed SB, Hart D, Levinsson AL, Parry M, Foulds HJ, Pacheco C, Dumanski SM, Smith G, Norris CM. The Canadian Women’s Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women — Chapter 4: Sex- and Gender-Unique Disparities: CVD Across the Lifespan of a Woman. CJC Open 2021; 4:115-132. [PMID: 35198930 PMCID: PMC8843896 DOI: 10.1016/j.cjco.2021.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 09/13/2021] [Indexed: 02/09/2023] Open
Abstract
Women have unique sex- and gender-related risk factors for cardiovascular disease (CVD) that can present or evolve over their lifespan. Pregnancy-associated conditions, polycystic ovarian syndrome, and menopause can increase a woman’s risk of CVD. Women are at greater risk for autoimmune rheumatic disorders, which play a role in the predisposition and pathogenesis of CVD. The influence of traditional CVD risk factors (eg, smoking, hypertension, diabetes, obesity, physical inactivity, depression, anxiety, and family history) is greater in women than men. Finally, there are sex differences in the response to treatments for CVD risk and comorbid disease processes. In this Atlas chapter we review sex- and gender-unique CVD risk factors that can occur across a woman’s lifespan, with the aim to reduce knowledge gaps and guide the development of optimal strategies for awareness and treatment.
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13
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Austin RR, Mathiason MA, Lindquist RA, McMahon SK, Pieczkiewicz DS, Monsen KA. Understanding Women's Cardiovascular Health Using MyStrengths+MyHealth: A Patient-Generated Data Visualization Study of Strengths, Challenges, and Needs Differences. J Nurs Scholarsh 2021; 53:634-642. [PMID: 33998130 DOI: 10.1111/jnu.12674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this data visualization study was to identify patterns in patient-generated health data (PGHD) of women with and without Circulation signs or symptoms. Specific aims were to (a) visualize and interpret relationships among strengths, challenges, and needs of women with and without Circulation signs or symptoms; (b) generate hypotheses based on these patterns; and (c) test hypotheses generated in Aim 2. DESIGN The design of this visualization study was retrospective, observational, case controlled, and exploratory. METHODS We used existing de-identified PGHD from a mobile health application, MyStrengths+MyHealth (N = 383). From the data, women identified with Circulation signs or symptoms (n = 80) were matched to an equal number of women without Circulation signs or symptoms. Data were analyzed using data visualization techniques and descriptive and inferential statistics. FINDINGS Based on the patterns, we generated nine hypotheses, of which four were supported. Visualization and interpretation of relationships revealed that women without Circulation signs or symptoms compared to women with Circulation signs or symptoms had more strengths, challenges, and needs-specifically, strengths in connecting; challenges in emotions, vision, and health care; and needs related to info and guidance. CONCLUSIONS This study suggests that visualization of whole-person health including strengths, challenges, and needs enabled detection and testing of new health patterns. Some findings were unexpected, and perspectives of the patient would not have been detected without PGHD, which should be valued and sought. Such data may support improved clinical interactions as well as policies for standardization of PGHD as sharable and comparable data across clinical and community settings. CLINICAL RELEVANCE Standardization of patient-generated whole-person health data enabled clinically relevant research that included the patients' perspective.
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Affiliation(s)
- Robin R Austin
- Assistant Professor, University of Minnesota, School of Nursing, Minneapolis, MN, USA
| | | | - Ruth A Lindquist
- Professor Emeriti, University of Minnesota, School of Nursing, Minneapolis, MN, USA
| | - Siobhan K McMahon
- Associate Professor, University of Minnesota, School of Nursing, Minneapolis, MN, USA
| | - David S Pieczkiewicz
- Clinical Associate Professor, University of Minnesota, Institute for Health Informatics, Minneapolis, MN, USA
| | - Karen A Monsen
- Professor, University of Minnesota, School of Nursing and Institute for Health Informatics, Minneapolis, MN, USA
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14
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Lüscher TF, Miller VM, Bairey Merz CN, Crea F. Diversity is richness: why data reporting according to sex, age, and ethnicity matters. Eur Heart J 2021; 41:3117-3121. [PMID: 32531027 DOI: 10.1093/eurheartj/ehaa277] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/06/2020] [Indexed: 01/03/2023] Open
Affiliation(s)
- Thomas F Lüscher
- Heart Division, Royal Brompton and Harefield Hospitals and National Heart and Lung Institute, Imperial College, London SW3 6NP, UK.,Center for Molecular Cardiology, University of Zurich, CH-8952 Schlieren-Zurich, Switzerland
| | - Virginia M Miller
- Department of Physiology, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Filippo Crea
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, I-00168 Rome, Italy
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15
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Suthahar N, Meems LMG, van Veldhuisen DJ, Walter JE, Gansevoort RT, Heymans S, Schroen B, van der Harst P, Kootstra-Ros JE, van Empel V, Mueller C, Bakker SJL, de Boer RA. High-Sensitivity Troponin-T and Cardiovascular Outcomes in the Community: Differences Between Women and Men. Mayo Clin Proc 2020; 95:1158-1168. [PMID: 32498772 DOI: 10.1016/j.mayocp.2020.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/14/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate associations of high-sensitivity cardiac troponin-T (cTnT) with cardiovascular disease (CVD), heart failure (HF), and mortality in community-dwelling women and men. PARTICIPANTS AND METHODS A total of 8226 adults from the Prevention of Renal and Vascular End-stage Disease (PREVEND) cohort (1997-1998) were enrolled in a prospective observational study (mean age: 49 years; 50.2% women). Sex-specific associations of cTnT levels with future clinical outcomes were evaluated using adjusted Cox-regression models. RESULTS Measurable cTnT levels (≥3 ng/L) were detected in 1102 women (26.7%) and in 2396 men (58.5%). Baseline cTnT levels were associated with a greater risk of developing CVD in women than men [Hazard ratio (HRwomen), 1.48 per unit increase in log2-cTnT; 95% CI, 1.21 to 1.81 vs HRmen, 1.20; 95% CI, 1.07 to 1.35; Pinteraction<.001]. Similar sex-related differences were observed for HF (Pinteraction= .005) and mortality (Pinteraction= .008). Further, compared with referent category (cTnT <3 ng/L), women with cTnT levels greater than or equal to 6 ng/L had a significantly increased risk for CVD (HR, 2.30; 95% CI, 1.45 to 3.64), HF (HR, 2.86; 95% CI, 1.41 to 5.80), and mortality (HR, 2.65; 95% CI, 1.52 to 4.61), whereas men with cTnT levels greater than or equal to 6 ng/L had a significantly increased risk only for CVD (HR, 1.51; 95% CI, 1.07 to 2.13). CONCLUSION Baseline cTnT levels were associated with future CVD, HF, and mortality in both sexes, and these associations were stronger in women. Future studies are needed to determine the value of cTnT in early diagnosis of CVD, particularly in women.
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Affiliation(s)
- Navin Suthahar
- University of Groningen, University Medical Center Groningen, Department of Cardiology, the Netherlands.
| | - Laura M G Meems
- University of Groningen, University Medical Center Groningen, Department of Cardiology, the Netherlands
| | - Dirk J van Veldhuisen
- University of Groningen, University Medical Center Groningen, Department of Cardiology, the Netherlands
| | - Joan E Walter
- Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Ron T Gansevoort
- University of Groningen, University Medical Center Groningen, Division of Nephrology, Department of Internal Medicine, the Netherlands
| | - Stephane Heymans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, the Netherlands
| | - Blanche Schroen
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, the Netherlands
| | - Pim van der Harst
- University of Groningen, University Medical Center Groningen, Department of Cardiology, the Netherlands
| | - Jenny E Kootstra-Ros
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, the Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, the Netherlands
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
| | - Stephan J L Bakker
- University of Groningen, University Medical Center Groningen, Division of Nephrology, Department of Internal Medicine, the Netherlands
| | - Rudolf A de Boer
- University of Groningen, University Medical Center Groningen, Department of Cardiology, the Netherlands
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16
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Norris CM, Yip CYY, Nerenberg KA, Clavel M, Pacheco C, Foulds HJA, Hardy M, Gonsalves CA, Jaffer S, Parry M, Colella TJF, Dhukai A, Grewal J, Price JAD, Levinsson ALE, Hart D, Harvey PJ, Van Spall HGC, Sarfi H, Sedlak TL, Ahmed SB, Baer C, Coutinho T, Edwards JD, Green CR, Kirkham AA, Srivaratharajah K, Dumanski S, Keeping‐Burke L, Lappa N, Reid RD, Robert H, Smith G, Martin‐Rhee M, Mulvagh SL. State of the Science in Women's Cardiovascular Disease: A Canadian Perspective on the Influence of Sex and Gender. J Am Heart Assoc 2020; 9:e015634. [PMID: 32063119 PMCID: PMC7070224 DOI: 10.1161/jaha.119.015634] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | | | - Kara A. Nerenberg
- Department of Medicine/Division of General Internal MedicineUniversity of CalgaryAlbertaCanada
| | | | | | | | - Marsha Hardy
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | | | - Shahin Jaffer
- Department of Medicine/Community Internal MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoOntarioCanada
| | - Tracey J. F. Colella
- University Health Network/Toronto Rehab Cardiovascular Prevention and Rehabilitation ProgramTorontoOntarioCanada
| | - Abida Dhukai
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoOntarioCanada
| | - Jasmine Grewal
- Division of CardiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Jennifer A. D. Price
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoOntarioCanada
- Women's College Research InstituteWomen's College HospitalTorontoOntarioCanada
| | - Anna L. E. Levinsson
- Montreal Heart InstituteMontrealQuebecCanada
- Beaulieu‐Saucier Université de Montréal Pharmacogenomics CentreMontrealQuebecCanada
- Faculty of MedicineUniversité de MontréalMontrealQuebecCanada
| | - Donna Hart
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Paula J. Harvey
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
- Women's College Research Institute and Division of CardiologyDepartment of Medicine Women's College HospitalUniversity of TorontoOntarioCanada
| | | | - Hope Sarfi
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Tara L. Sedlak
- Leslie Diamond Women's Heart CentreVancouver General HospitalUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Sofia B. Ahmed
- Department of Medicine and Libin Cardiovascular InstituteUniversity of CalgaryAlbertaCanada
| | - Carolyn Baer
- Division of General Internal MedicineDepartment of MedicineMoncton HospitalDalhousie UniversityHalifaxNova ScotiaCanada
| | - Thais Coutinho
- Division of Cardiac Prevention and RehabilitationDivision of Cardiology and Canadian Women's Heart Health CentreUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | - Jodi D. Edwards
- School of Epidemiology and Public HealthUniversity of Ottawa and University of Ottawa Heart InstituteOttawaOntarioCanada
| | - Courtney R. Green
- Society of Obstetricians and Gynaecologists of CanadaOttawaOntarioCanada
| | - Amy A. Kirkham
- Department of Biomedical EngineeringUniversity of AlbertaEdmontonAlbertaCanada
| | - Kajenny Srivaratharajah
- Division of General Internal MedicineDepartment of MedicineMcMaster UniversityHamiltonOntarioCanada
| | | | | | - Nadia Lappa
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Robert D. Reid
- Division of Cardiac Prevention and RehabilitationDivision of Cardiology and Canadian Women's Heart Health CentreUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | - Helen Robert
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Graeme Smith
- Department of Obstetrics and GynecologyKingston Health Sciences CentreQueen's UniversityKingstonOntarioCanada
| | | | - Sharon L. Mulvagh
- Division of CardiologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
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17
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Amorim TV, Souza ÍEDO, Salimena AMDO, Queiroz ABA, Elias EA. Women with cardiopathy in the context of reproductive planning: contributions of phenomenological hermeneutics. ESCOLA ANNA NERY 2020. [DOI: 10.1590/2177-9465-ean-2019-0164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: To analyze the existential movement of women with heart diseases in the context of Reproductive Planning. Method: Qualitative with Heideggerian phenomenological approach. Seventeen participants with heart disease and with recent experience of pregnancy at a reference institution for maternal risk participated in the study, through the phenomenological interview. Results: Two units of meanings emerged in the hermeneutical analysis: To be more attentive and concerned with the treatment because the problem remains the same; Expressing that they don´t want to get pregnant anymore because they´ve reached the limit and to seek planning in doing the tubal ligation. Conclusion and implications for practice: The unveiling of the existential movement made it possible to understand that, although the participants felt secure with the institutional follow-up of high-risk pregnancies, this proved to be insufficient with regard to Reproductive Planning. It stands out the necessary consideration by nurses and other health professionals that this planning is an important set of actions to identify and modify risks in women with heart diseases in the perspective of better perinatal outcomes. It is necessary to advance in the comprehension of the subjective aspects of the woman and the couple through the dialogue, besides the permanent education work of the whole team.
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18
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Women With Nonalcoholic Fatty Liver Disease Lose Protection Against Cardiovascular Disease: A Longitudinal Cohort Study. Am J Gastroenterol 2019; 114:1764-1771. [PMID: 31577570 PMCID: PMC6832850 DOI: 10.14309/ajg.0000000000000401] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Cardiovascular (CV) disease is the top cause of mortality in patients with nonalcoholic fatty liver disease (NAFLD). Female sex is protective against CV disease. We aimed to determine whether female sex remains a protective factor against CV disease (myocardial infarction, angina, and stroke) in NAFLD. METHODS We identified all adults diagnosed with NAFLD in Olmsted County, Minnesota, between 1997 and 2014 and selected an age- and sex-matched (1:4) referent cohort from the general population. NAFLD was ascertained using a code-based algorithm with high validity tested by medical record review. The impact of female sex on incident CV events was examined using Cox proportional hazards regression analysis stratified by standard clinical risk factors. RESULTS A total of 3,869 NAFLD and 15,209 age- and sex-matched referent subjects were identified. After a median follow-up time of 7 (range 1-20) years, 3,851 CV events were recorded. Female sex was protective for ischemic CV events in the general population (hazard ratio = 0.71, 95% confidence interval 0.62-0.80, P < 0.001), but the impact was significantly diminished among those with NAFLD (hazard ratio = 0.90, 95% confidence interval 0.74-1.08, P = 0.25), even after stratification by time-dependent CV risk factors and control for diagnostic testing (liver enzymes and ultrasound) during routine medical evaluations, as a surrogate of access to care. Among those with NAFLD, excess events were higher in women than in men: CV disease (18% vs 9%) and mortality (9% vs 6%). DISCUSSION Women with NAFLD lose the CV protection conferred by the female sex, and their risk is underestimated by current estimating methods in clinical practice.
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19
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Aggarwal NR, Patel HN, Mehta LS, Sanghani RM, Lundberg GP, Lewis SJ, Mendelson MA, Wood MJ, Volgman AS, Mieres JH. Sex Differences in Ischemic Heart Disease: Advances, Obstacles, and Next Steps. Circ Cardiovasc Qual Outcomes 2019; 11:e004437. [PMID: 29449443 DOI: 10.1161/circoutcomes.117.004437] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Evolving knowledge of sex-specific presentations, improved recognition of conventional and novel risk factors, and expanded understanding of the sex-specific pathophysiology of ischemic heart disease have resulted in improved clinical outcomes in women. Yet, ischemic heart disease continues to be the leading cause of morbidity and mortality in women in the United States. The important publication by the Institute of Medicine titled "Women's Health Research-Progress, Pitfalls, and Promise," highlights the persistent disparities in cardiovascular disease burden among subgroups of women, particularly women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment. These important health disparities reflect underrepresentation of women in research, with the resultant unfavorable impact on diagnosis, prevention, and treatment strategies in women at risk for cardiovascular disease. Causes of disparities are multifactorial and related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. Lack of awareness in both the public and medical community, as well as existing knowledge gap regarding sex-specific differences in presentation, risk factors, pathophysiology, and response to treatment for ischemic heart disease, further contribute to outcome disparities. There is a critical need for implementation of sex- and gender-specific strategies to improve cardiovascular outcomes. This review is tailored to meet the needs of a busy clinician and summarizes the contemporary trends, characterizes current sex-specific outcome disparities, delineates challenges, and proposes transformative solutions for improvement of the full spectrum of ischemic heart disease clinical care and research in women.
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Affiliation(s)
- Niti R Aggarwal
- From Division of Cardiovascular Medicine, Department of Medicine and Radiology, the University of Wisconsin School of Medicine & Public Health, Madison (N.R.A.); Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL (H.N.P., R.M.S., A.S.V.); Division of Cardiology, Department of Internal Medicine, The Ohio State University, Columbus (L.S.M.); Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (G.P.L.); Division of Cardiology, The Oregon Clinic, Portland, OR (S.J.L.); Department of Medicine, Division of Cardiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL (M.A.M.); Division of Cardiology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA (M.J.W.); and Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, New York (J.H.M.).
| | - Hena N Patel
- From Division of Cardiovascular Medicine, Department of Medicine and Radiology, the University of Wisconsin School of Medicine & Public Health, Madison (N.R.A.); Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL (H.N.P., R.M.S., A.S.V.); Division of Cardiology, Department of Internal Medicine, The Ohio State University, Columbus (L.S.M.); Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (G.P.L.); Division of Cardiology, The Oregon Clinic, Portland, OR (S.J.L.); Department of Medicine, Division of Cardiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL (M.A.M.); Division of Cardiology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA (M.J.W.); and Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, New York (J.H.M.)
| | - Laxmi S Mehta
- From Division of Cardiovascular Medicine, Department of Medicine and Radiology, the University of Wisconsin School of Medicine & Public Health, Madison (N.R.A.); Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL (H.N.P., R.M.S., A.S.V.); Division of Cardiology, Department of Internal Medicine, The Ohio State University, Columbus (L.S.M.); Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (G.P.L.); Division of Cardiology, The Oregon Clinic, Portland, OR (S.J.L.); Department of Medicine, Division of Cardiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL (M.A.M.); Division of Cardiology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA (M.J.W.); and Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, New York (J.H.M.)
| | - Rupa M Sanghani
- From Division of Cardiovascular Medicine, Department of Medicine and Radiology, the University of Wisconsin School of Medicine & Public Health, Madison (N.R.A.); Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL (H.N.P., R.M.S., A.S.V.); Division of Cardiology, Department of Internal Medicine, The Ohio State University, Columbus (L.S.M.); Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (G.P.L.); Division of Cardiology, The Oregon Clinic, Portland, OR (S.J.L.); Department of Medicine, Division of Cardiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL (M.A.M.); Division of Cardiology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA (M.J.W.); and Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, New York (J.H.M.)
| | - Gina P Lundberg
- From Division of Cardiovascular Medicine, Department of Medicine and Radiology, the University of Wisconsin School of Medicine & Public Health, Madison (N.R.A.); Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL (H.N.P., R.M.S., A.S.V.); Division of Cardiology, Department of Internal Medicine, The Ohio State University, Columbus (L.S.M.); Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (G.P.L.); Division of Cardiology, The Oregon Clinic, Portland, OR (S.J.L.); Department of Medicine, Division of Cardiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL (M.A.M.); Division of Cardiology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA (M.J.W.); and Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, New York (J.H.M.)
| | - Sandra J Lewis
- From Division of Cardiovascular Medicine, Department of Medicine and Radiology, the University of Wisconsin School of Medicine & Public Health, Madison (N.R.A.); Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL (H.N.P., R.M.S., A.S.V.); Division of Cardiology, Department of Internal Medicine, The Ohio State University, Columbus (L.S.M.); Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (G.P.L.); Division of Cardiology, The Oregon Clinic, Portland, OR (S.J.L.); Department of Medicine, Division of Cardiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL (M.A.M.); Division of Cardiology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA (M.J.W.); and Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, New York (J.H.M.)
| | - Marla A Mendelson
- From Division of Cardiovascular Medicine, Department of Medicine and Radiology, the University of Wisconsin School of Medicine & Public Health, Madison (N.R.A.); Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL (H.N.P., R.M.S., A.S.V.); Division of Cardiology, Department of Internal Medicine, The Ohio State University, Columbus (L.S.M.); Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (G.P.L.); Division of Cardiology, The Oregon Clinic, Portland, OR (S.J.L.); Department of Medicine, Division of Cardiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL (M.A.M.); Division of Cardiology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA (M.J.W.); and Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, New York (J.H.M.)
| | - Malissa J Wood
- From Division of Cardiovascular Medicine, Department of Medicine and Radiology, the University of Wisconsin School of Medicine & Public Health, Madison (N.R.A.); Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL (H.N.P., R.M.S., A.S.V.); Division of Cardiology, Department of Internal Medicine, The Ohio State University, Columbus (L.S.M.); Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (G.P.L.); Division of Cardiology, The Oregon Clinic, Portland, OR (S.J.L.); Department of Medicine, Division of Cardiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL (M.A.M.); Division of Cardiology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA (M.J.W.); and Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, New York (J.H.M.)
| | - Annabelle S Volgman
- From Division of Cardiovascular Medicine, Department of Medicine and Radiology, the University of Wisconsin School of Medicine & Public Health, Madison (N.R.A.); Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL (H.N.P., R.M.S., A.S.V.); Division of Cardiology, Department of Internal Medicine, The Ohio State University, Columbus (L.S.M.); Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (G.P.L.); Division of Cardiology, The Oregon Clinic, Portland, OR (S.J.L.); Department of Medicine, Division of Cardiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL (M.A.M.); Division of Cardiology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA (M.J.W.); and Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, New York (J.H.M.)
| | - Jennifer H Mieres
- From Division of Cardiovascular Medicine, Department of Medicine and Radiology, the University of Wisconsin School of Medicine & Public Health, Madison (N.R.A.); Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL (H.N.P., R.M.S., A.S.V.); Division of Cardiology, Department of Internal Medicine, The Ohio State University, Columbus (L.S.M.); Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (G.P.L.); Division of Cardiology, The Oregon Clinic, Portland, OR (S.J.L.); Department of Medicine, Division of Cardiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL (M.A.M.); Division of Cardiology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA (M.J.W.); and Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, New York (J.H.M.)
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Laughlin-Tommaso SK, Fuchs EL, Wellons MF, Lewis CE, Calderon-Margalit R, Stewart EA, Schreiner PJ. Uterine Fibroids and the Risk of Cardiovascular Disease in the Coronary Artery Risk Development in Young Adult Women's Study. J Womens Health (Larchmt) 2019; 28:46-52. [PMID: 30412447 PMCID: PMC6343187 DOI: 10.1089/jwh.2018.7122] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Uterine fibroids, the most common reproductive tract tumor in women, have been associated with hypertension and atherosclerotic cardiovascular disease (CVD). Prior studies of fibroids and CVD have examined the subset of women with symptomatic fibroids who undergo hysterectomy, itself a risk factor for CVD. We aimed to study the risk of subclinical CVD, as determined by coronary artery calcification (CAC), carotid intima media thickness (CIMT), and left ventricular (LV) mass, in women with ultrasound-diagnosed uterine fibroids. MATERIALS AND METHODS Participants were 972 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a cohort recruited in 1985-1986. CARDIA screened black and white women aged 35-49 years by ultrasound for fibroids at 16 years of follow-up (2002-2004). Demographics and CVD risk factors were collected in 2000-2001 at 15 years of follow-up (baseline for this analysis). Women were tested at years 15, 20, and 25 for CAC, at year 20 for CIMT, and at year 25 for echocardiographic LV mass. Multivariable logistic regression was used to estimate the odds of CAC, CIMT, and LV mass. RESULTS Fifty-two percent of women had fibroids (61.7% in black, 38.3% in white women). Most CVD risk factors were more common in women with fibroids. Adjusted odds of subclinical CVD, such as elevated CIMT and elevated LV mass, were not different for women with fibroids compared with those without (CIMT odds ratio [OR] = 1.03; confidence interval [95% CI] 0.7-1.5 and LV mass OR = 1.14; 95% CI 0.77-1.68), when adjusted for confounders. CONCLUSIONS Although women with fibroids had more CVD risk factors, presence of fibroids was not associated with subclinical CVD.
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Affiliation(s)
- Shannon K. Laughlin-Tommaso
- Division of Gynecology, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Erika L. Fuchs
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Melissa F. Wellons
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cora E. Lewis
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Elizabeth A. Stewart
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Pamela J. Schreiner
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota
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21
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Medina-Inojosa JR, Vinnakota S, Garcia M, Arciniegas Calle M, Mulvagh SL, Lopez-Jimenez F, Bhagra A. Role of Stress and Psychosocial Determinants on Women's Cardiovascular Risk and Disease Development. J Womens Health (Larchmt) 2018; 28:483-489. [PMID: 30457922 DOI: 10.1089/jwh.2018.7035] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The notion that cardiovascular disease (CVD) primarily occurs in men is slowly disappearing. More women than men die of CVD every year, and when women survive, the burden and consequences are worse than in men. Markers of stress and other psychosocial factors have been associated with poor outcomes. Multiple studies have demonstrated sex-based differences in the vascular and endothelial responses to mental stress. Psychosocial stressors were also found to be independent risk factors for the development and progression of CVD. This review arises from accumulating evidence suggesting that psychological well-being may improve cardiac-related outcomes, independent of cardiac risk factors. Despite the fact that positive physician-patient engagement is likely to play a critical role in promoting positive psychological traits and healthy behaviors, current physician awareness and advocacy are rather suboptimal, despite active awareness campaigns such as the American Heart Association's Go Red for Women®. There is a need to further study the role and management of stress as a CVD risk factor, especially in women, who are disproportionately affected.
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Affiliation(s)
- Jose R Medina-Inojosa
- 1 Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shravya Vinnakota
- 2 Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mariana Garcia
- 1 Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Maria Arciniegas Calle
- 1 Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sharon L Mulvagh
- 1 Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.,3 Division of Cardiology, Nova Scotia Health Authority, Dalhousie University, Halifax, Canada
| | - Francisco Lopez-Jimenez
- 1 Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anjali Bhagra
- 2 Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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22
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Adigun RO, Boler AN, Mankad R. Disparities in Cardiac Care of Women: Current Data and Possible Solutions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:87. [PMID: 30242773 DOI: 10.1007/s11936-018-0688-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease remains the leading cause of death in women. The goal of this review is to address known disparities in cardiovascular care with regard to diagnosis and treatment of heart disease in women. RECENT FINDINGS Gender-specific differences in regard to the incidence, treatment, and outcomes of common cardiovascular pathology are increasingly recognized. Particular attention to ischemic heart disease, arrhythmia, congestive heart failure, and structural heart disease are reviewed in this article. There is a clear racial and ethnic discrepancy among women which is particularly concerning with a progressively diverse patient population. Medical and surgical treatment differences between men and women must be addressed by providers in order to optimize long-term outcomes among all patients. Understanding the unique cardiovascular risk profile and barriers to optimal treatment outcomes in women is imperative to eliminate the current disparities in cardiovascular disease.
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Affiliation(s)
- Rosalyn O Adigun
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA
| | - Amber N Boler
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA
| | - Rekha Mankad
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA.
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24
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Lundberg GP, Mehta LS, Volgman AS. Specialized Care for Women: the Impact of Women's Heart Centers. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:76. [PMID: 30091012 DOI: 10.1007/s11936-018-0656-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF THE REVIEW Cardiovascular disease (CVD) has been and remains the leading cause of mortality in women in the United States. For decades, more women died every year of CVD compared to men. Heart centers for women (HCW) are developed in response to the need for greater patient and physician awareness of CVD in women and to conduct sex-specific research in women. Today, many HCW provide multispecialty and focused areas of cardiovascular care for women. HCW provide their female patients with expertise over the many stages of a woman's life. And HCW partner with national organizations to advance research and education through specialized and focused care for women. The purpose of this review is to review the historical development of heart centers for women and discuss the types of care they provide for women. RECENT FINDINGS Mortality rates from cardiovascular disease in women are finally reaching the levels of men after decades of focus on awareness, prevention, and evidence-based guideline-directed care for women. Heart centers for women have evolved to provide subspecialty and comprehensive care for women that includes education and research. Heart centers for women are partnering with many other disease-based and patient advocacy organizations to provide care for all women at all stages of life. Alarmingly, there has been increasing CVD mortality in both men and women recently.
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Affiliation(s)
- Gina P Lundberg
- Emory Women's Heart Center, Emory University School of Medicine, Atlanta, GA, USA.
| | - Laxmi S Mehta
- Women's Cardiovascular Program, The Ohio State University, Columbus, OH, USA
| | - Annabelle S Volgman
- Rush Heart Center for Women, Rush University Medical Center, Chicago, IL, USA
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25
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Hayes SN, Kim ESH, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, Ganesh SK, Gulati R, Lindsay ME, Mieres JH, Naderi S, Shah S, Thaler DE, Tweet MS, Wood MJ. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e523-e557. [PMID: 29472380 PMCID: PMC5957087 DOI: 10.1161/cir.0000000000000564] [Citation(s) in RCA: 695] [Impact Index Per Article: 115.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.
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27
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Miller VM, Harman SM. An update on hormone therapy in postmenopausal women: mini-review for the basic scientist. Am J Physiol Heart Circ Physiol 2017; 313:H1013-H1021. [PMID: 28801526 PMCID: PMC5792205 DOI: 10.1152/ajpheart.00383.2017] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/03/2017] [Accepted: 08/09/2017] [Indexed: 02/03/2023]
Abstract
The worlds of observational, clinical, and basic science collided in 2002 with the publication of results of the Women's Health Initiative (WHI), a large-scale, prospective, blinded, randomized-controlled trial designed to provide evidence regarding use of hormone treatment to prevent cardiovascular disease in menopausal women. The results of the WHI dramatically changed clinical practice, negatively impacted funding for hormone research, and left scientists to unravel the "why" of the results. Now over a decade and a half since the initial publication of the WHI results, basic and clinical scientists often do not interpret the results of the WHI with the precision needed to move the science forward. This review will 1) describe the historical background leading up to the WHI, 2) list the outcomes from the WHI, and put them in perspective with results of subsequent analysis of the WHI data and results from other prospective menopausal hormone treatment trials addressing cardiovascular effects of menopausal hormone use, and 3) articulate how the collective results are influencing current clinical care with the intent to provide guidance for designing and evaluating relevant new hormonal studies.
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Affiliation(s)
- Virginia M. Miller
- 1Departments of Surgery and Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; and
| | - S. Mitchell Harman
- 2Kronos Longevity Research Institute and the Phoenix Veterans Administration Health Care System, Phoenix, Arizona
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Faubion SS, Kapoor E, Kling JM, Kuhle CL, Sood R, Rullo JE, Thielen JM, Shuster LT, Rocca WA, Hilsaca KSF, Mara KC, Schroeder DR, Miller VM. Data Registry on Experiences of Aging, Menopause, and Sexuality (DREAMS): A cohort profile. Maturitas 2017; 107:44-49. [PMID: 29169579 DOI: 10.1016/j.maturitas.2017.09.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 09/27/2017] [Accepted: 09/29/2017] [Indexed: 12/12/2022]
Abstract
The Women's Health Clinic (WHC) at Mayo Clinic in Rochester, Minnesota, has provided consultative care to women with menopausal and sexual health concerns since 2005. Clinical information on the 8688 women seen in the WHC through May 2017 who gave consent for the use of their medical records in research is contained in the Data Registry on Experiences of Aging, Menopause, and Sexuality (DREAMS). Initially, DREAMS was created to improve the clinical care of women, but it has become a valuable research tool. About 25% of the DREAMS women have been seen in the WHC 2 or more times, allowing for passive longitudinal follow-up. Additionally, about 25% of the DREAMS women live in the 27-county region included in the expanded Rochester Epidemiology Project medical records linkage system, providing additional information on those women. The cohort has been used to investigate associations between: caffeine intake and vasomotor symptom bother; recent abuse (physical, sexual, verbal, and emotional) and menopausal symptoms; specific menopausal symptoms and self-reported view of menopause; and obstructive sleep apnea risk and vasomotor symptom severity and the experience of vasomotor symptoms in women older than 60 years. A study nearing completion describes a clinical series of over 3500 women presenting for sexual health consultation by sexual function domain and by decade of life. Other studies under way are determining correlates with sexual health and dysfunction. Planned studies will investigate associations between the experience with menopause and the risk of disease.
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Affiliation(s)
- Stephanie S Faubion
- Women's Health Clinic, Division of General Internal Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Ekta Kapoor
- Women's Health Clinic, Division of General Internal Medicine, Mayo Clinic, Rochester, MN, United States; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, United States
| | - Juliana M Kling
- Division of Women's Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, United States
| | - Carol L Kuhle
- Women's Health Clinic, Division of General Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Richa Sood
- Women's Health Clinic, Division of General Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jordan E Rullo
- Women's Health Clinic, Division of General Internal Medicine, Mayo Clinic, Rochester, MN, United States; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Jacqueline M Thielen
- Women's Health Clinic, Division of General Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Lynne T Shuster
- Women's Health Clinic, Division of General Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Walter A Rocca
- Division of Epidemiology, Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Virginia M Miller
- Women's Health Research Center, and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
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Jayachandran M, Garovic VD, Mielke MM, Bailey KR, Lahr BD, Miller VM. Characterization of intravascular cellular activation in relationship to subclinical atherosclerosis in postmenopausal women. PLoS One 2017; 12:e0183159. [PMID: 28910282 PMCID: PMC5598935 DOI: 10.1371/journal.pone.0183159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/31/2017] [Indexed: 02/02/2023] Open
Abstract
Objective Mechanisms and interactions among intravascular cells contributing to development of subclinical atherosclerosis are poorly understood. In women, both menopausal status and pregnancy history influence progression of atherosclerosis. This study examined activation and interactions among blood elements with subclinical atherosclerosis in menopausal women with known pregnancy histories. Methods Carotid intima-media thickness (CIMT), as a marker of subclinical atherosclerosis, was measured using B-mode ultrasound in age- and parity-matched women [40 with and 40 without a history of preeclampsia] 35 years after the index pregnancy. Interactions among intravascular cells (38 parameters) were measured by flow cytometry in venous blood. Data analysis was by principal component which retained 7 independent dimensions accounting for 63% of the variability among 38 parameters. Results CIMT was significantly greater in women with a history of preeclampsia (P = 0.004). Platelet aggregation and platelet interactions with granulocytes and monocytes positively associated with CIMT in postmenopausal women independent of their pregnancy history (ρ = 0.258, P< 0.05). However, the association of the number of platelets, platelet activation and monocyte-platelet interactions with CIMT differed significantly depending upon pregnancy history (test for interaction, P<0.001). Conclusion Interactions among actived intravascular cells and their association with subclinical atherosclerosis differ in women depending upon their pregnancy histories.
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Affiliation(s)
- Muthuvel Jayachandran
- Departments of Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
- Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Vesna D. Garovic
- General Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Michelle M. Mielke
- Health Science Research, Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, United States of America
- Neurology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Kent R. Bailey
- Health Science Research, Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, United States of America
- Health Science Research, Division of Biostatistics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Brian D. Lahr
- Health Science Research, Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, United States of America
- Health Science Research, Division of Biostatistics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Virginia M. Miller
- Departments of Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
- Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
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30
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Charting the Course for Women's Heart Health in Canada: Recommendations From the First Canadian Women's Heart Health Summit. Can J Cardiol 2017. [DOI: 10.1016/j.cjca.2017.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Resurrección DM, Motrico E, Rigabert A, Rubio-Valera M, Conejo-Cerón S, Pastor L, Moreno-Peral P. Barriers for Nonparticipation and Dropout of Women in Cardiac Rehabilitation Programs: A Systematic Review. J Womens Health (Larchmt) 2017; 26:849-859. [PMID: 28388314 DOI: 10.1089/jwh.2016.6249] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is a major health problem worldwide. Cardiac rehabilitation (CR) programs are effective in reducing mortality and improving the quality of life of patients with CVD. Women are under-represented in CR and have a higher dropout rate than men. We aimed to systematically review the literature on barriers perceived by women with CVD affecting their nonparticipation in and/or dropping out from CR programs. METHODS Systematic review was done using MEDLINE, Embase, Scopus, Open Grey, and Cochrane Database from inception to September 2016. Search terms included (1) heart disease and other cardiac conditions, (2) CR and secondary prevention, and (3) nonparticipation in and/or dropout. Databases were searched following the "participants, interventions, comparisons, outcomes, and study design" method. RESULTS A total of 24 studies (17 descriptive, 6 qualitative, and 1 randomized controlled trial) reporting several barriers were grouped into five broad categories: intrapersonal barriers (self-reported health, health beliefs, lack of time, motivation, and religious reasons); interpersonal barriers (lack of family/social support and work conflicts); logistical barriers (transport, distance, and availability of personal/community resources); CR program barriers (services offered, group format, exercise component, and CR sessions); and health system barriers (lack of referral, cost, negative experiences with the health system, and language). We found differences between the barriers related to nonparticipation in and dropout from CR programs. CONCLUSIONS Women reported multilevel barriers for nonparticipation in and dropout from CR programs. Future clinical guidelines should evaluate and eliminate these barriers to improve adherence to CR programs in women. In addition, understanding the barriers for nonparticipation and dropout may be beneficial for future intervention trials.
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Affiliation(s)
| | - Emma Motrico
- 1 Departamento de Psicología, Universidad Loyola Andalucía , Sevilla, Spain .,2 Primary Care Prevention and Health Promotion Research Network (RedIAPP) , Barcelona, Spain
| | - Alina Rigabert
- 1 Departamento de Psicología, Universidad Loyola Andalucía , Sevilla, Spain
| | - Maria Rubio-Valera
- 2 Primary Care Prevention and Health Promotion Research Network (RedIAPP) , Barcelona, Spain .,3 Research and Development Unit , Fundació Sant Joan de Déu, Barcelona, Spain
| | - Sonia Conejo-Cerón
- 4 Instituto de Investigación Biomédica de Málaga (IBIMA) , Málaga, Spain
| | - Luis Pastor
- 5 Hospital Nuestra Señora de Valme , Sevilla, Spain
| | - Patricia Moreno-Peral
- 2 Primary Care Prevention and Health Promotion Research Network (RedIAPP) , Barcelona, Spain .,4 Instituto de Investigación Biomédica de Málaga (IBIMA) , Málaga, Spain
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Fonseca MIH, da Silva IT, Ferreira SRG. Impact of menopause and diabetes on atherogenic lipid profile: is it worth to analyse lipoprotein subfractions to assess cardiovascular risk in women? Diabetol Metab Syndr 2017; 9:22. [PMID: 28405227 PMCID: PMC5384156 DOI: 10.1186/s13098-017-0221-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 03/26/2017] [Indexed: 01/13/2023] Open
Abstract
Cardiovascular disease is the leading cause of death in women at advanced age, who are affected a decade later compared to men. Cardiovascular risk factors in women are not properly investigated nor treated and events are frequently lethal. Both menopause and type 2 diabetes substantially increase cardiovascular risk in the female sex, promoting modifications on lipid metabolism and circulating lipoproteins. Lipoprotein subfractions suffer a shift after menopause towards a more atherogenic lipid profile, consisted of hypertriglyceridemia, lower levels of both total high density lipoprotein (HDL) and its subfraction HDL2, but also higher levels of HDL3 and small low-density lipoprotein particles. This review discusses the impact of diabetes and menopause to the lipid profile, challenges in lipoprotein subfractions determination and their potential contribution to the cardiovascular risk assessment in women. It is still unclear whether lipoprotein subfraction changes are a major driver of cardiometabolic risk and which modifications are predominant. Prospective trials with larger samples, methodological standardizations and pharmacological approaches are needed to clarify the role of lipoprotein subfractions determination on cardiovascular risk prediction and intervention planning in postmenopausal women, with or without DM.
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Affiliation(s)
- Marília Izar Helfenstein Fonseca
- Department of Epidemiology, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP 01246-904 Brazil
| | - Isis Tande da Silva
- Department of Nutrition, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP 01246-904 Brazil
| | - Sandra Roberta G. Ferreira
- Department of Epidemiology, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP 01246-904 Brazil
- Department of Nutrition, School of Public Health, University of São Paulo, Av. Dr. Arnaldo, 715, São Paulo, SP 01246-904 Brazil
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Abstract
Atherosclerosis is the main cause of death in men and women. This so-called "hardening of the arteries" results from advanced atherogenesis, the accumulation and death of subendothelial fat-laden macrophages (vascular plaque). The macrophages are attracted as the result of signals from injured vessels recruiting and activating cells to quell the injury by inflammation. Among the recruited cells are circulating monocytes that may be captured by the formation of neural cell adhesion molecule (nCAM) tethers between the monocytes and vascular endothelium; the tethers are dependent on electrostatic binding between distal segments of apposed nCAM molecules. The capture of monocytes is followed by their entry into the subendothelial area as macrophages, many of which will remain and become the fat-laden foam cells in vascular plaque. Neural cell adhesion molecules are subject to sialylation that blocks their electrostatic binding. We showed that estradiol-induced nCAM sialylases are present in vascular endothelial cells and tested whether sex steroid pretreatment of human vascular endothelium could inhibit the capture of monocytes. Using in vitro techniques, pretreatment of human arterial endothelial cells with estradiol, testosterone, dehydroepiandrosterone and dihydrotestosterone all induced sialylation of endothelial cells and, in a dose-response manner, reduced the capture of monocytes. Steroid hormones are protective against atherogenesis and its sequellae. Sex steroid depletion is associated with atherosclerosis. Based on this knowledge plus our results using sex steroid pretreatment of endothelial cells, we propose that the blockade of the initial step in atherogenesis by sex steroid-induced nCAM sialylation may be crucial to hormonal prevention of atherosclerosis.
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Affiliation(s)
- Frederick Naftolin
- Department of Obstetrics and Gynecology, New York University, New York, NY, USA
| | - Holly Mehr
- Department of Obstetrics and Gynecology, New York University, New York, NY, USA
| | - Ahmed Fadiel
- Department of Obstetrics and Gynecology, New York University, New York, NY, USA
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Qin J, Le Y, Froogh G, Kandhi S, Jiang H, Luo M, Sun D, Huang A. Sexually dimorphic adaptation of cardiac function: roles of epoxyeicosatrienoic acid and peroxisome proliferator-activated receptors. Physiol Rep 2016; 4:4/12/e12838. [PMID: 27354541 PMCID: PMC4923237 DOI: 10.14814/phy2.12838] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/27/2016] [Indexed: 01/01/2023] Open
Abstract
Epoxyeicosatrienoic acids (EETs) are cardioprotective mediators metabolized by soluble epoxide hydrolase (sEH) to form corresponding diols (DHETs). As a sex‐susceptible target, sEH is involved in the sexually dimorphic regulation of cardiovascular function. Thus, we hypothesized that the female sex favors EET‐mediated potentiation of cardiac function via downregulation of sEH expression, followed by upregulation of peroxisome proliferator‐activated receptors (PPARs). Hearts were isolated from male (M) and female (F) wild‐type (WT) and sEH‐KO mice, and perfused with constant flow at different preloads. Basal coronary flow required to maintain the perfusion pressure at 100 mmHg was significantly greater in females than males, and sEH‐KO than WT mice. All hearts displayed a dose‐dependent decrease in coronary resistance and increase in cardiac contractility, represented as developed tension in response to increases in preload. These responses were also significantly greater in females than males, and sEH‐KO than WT. 14,15‐EEZE abolished the sex‐induced (F vs. M) and transgenic model‐dependent (KO vs. WT) differences in the cardiac contractility, confirming an EET‐driven response. Compared with M‐WT controls, F‐WT hearts expressed downregulation of sEH, associated with increased EETs and reduced DHETs, a pattern comparable to that observed in sEH‐KO hearts. Coincidentally, F‐WT and sEH‐KO hearts exhibited increased PPARα expression, but comparable expression of eNOS, PPARβ, and EET synthases. In conclusion, female‐specific downregulation of sEH initiates an EET‐dependent adaptation of cardiac function, characterized by increased coronary flow via reduction in vascular resistance, and promotion of cardiac contractility, a response that could be further intensified by PPARα.
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Affiliation(s)
- Jun Qin
- Department of Physiology, New York Medical College, Valhalla, New York Department of GI Surgery, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Yicong Le
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Ghezal Froogh
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Sharath Kandhi
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Houli Jiang
- Department of Pharmacology, New York Medical College, Valhalla, New York
| | - Meng Luo
- Department of GI Surgery, Shanghai Ninth People's Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Dong Sun
- Department of Physiology, New York Medical College, Valhalla, New York
| | - An Huang
- Department of Physiology, New York Medical College, Valhalla, New York
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