Sex differences in cardiovascular disease - Impact on care and outcomes

Circulating mitochondrial biomarkers in acute coronary syndrome

Background

Acute coronary syndrome (ACS) is the leading cause of mortality in developed countries. Mitochondrial dysfunction is a hallmark of various cardiometabolic diseases, including ACS. Emerging evidence suggests that evaluating mitochondrial biomarkers in plasma may offer valuable insights into the pathophysiology and management of these conditions. The present study aims to analyse the effect of ACS, sex and their interaction on plasma levels of mitochondrial markers, such as peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α), mitochondrial open reading frame of the 12S rRNA type-c (MOTS-c) and citrate syntetase (CS).

Methods

A total of 18 ACS patients (8 women and 10 men) and 20 controls (8 women and 12 men) were included in this study. Venous blood samples were collected from participants after a 12-h overnight fast. Plasma levels of mitochondrial PGC-1α, MOTS-c and CS were measured.

Results

ACS significantly reduced plasma levels of PGC-1α and MOTS-c. Sex did not shown a significant effect on these markers. Additionally, MOTS-c positively correlated with the first troponin and hemoglobin, PGC-1α negatively correlated with glucose and positively with HDL-cholesterol, and CS showed negative correlations with NT-proBNP, C-reactive protein, and hemoglobin.

Conclusion

Mitochondria markers, MOTS-c and PGC-1α, are altered in ACS patients, with no observed sex differences. These findings represent an initial step toward integrating personalized medicine into the clinical management of ACS. Nonetheless, further studies are required to fully elucidate the role of these markers in this pathology.

Thermoneutral-housed rats demonstrate impaired perivascular adipose tissue and vascular crosstalk

OBJECTIVE

Vascular pathology, characterized by impaired vasoreactivity and mitochondrial respiration, differs between the sexes. Housing rats under thermoneutral (TN) conditions causes vascular dysfunction and perturbed metabolism. We hypothesized that thoracic perivascular adipose tissue (tPVAT), a vasoregulatory adipose depot known to have a brown adipose tissue (BAT) phenotype, remodels to a mainly white adipose (WAT) phenotype in rats housed at TN, driving diminished vasoreactivity in a sex-dependent manner.

METHODS

Male and female Wistar rats were housed at either room temperature (RT) or TN. We measured changes in tPVAT morphology, vasoreactivity in vessels with intact tPVAT or transferred to tPVAT of the oppositely-housed animal, vessel stiffness, vessel mitochondrial respiration and cellular signaling.

RESULTS

Remodeling of tPVAT was observed in rats housed at TN; animals in this environment showed tPVAT whitening and displayed diminished aortae vasodilation ( P  < 0.05), different between the sexes. Juxtaposing tPVAT from RT rats onto aortae from TN rats in females corrected vasodilation ( P  < 0.05); this did not occur in males. In aortae of all animals housed at TN, mitochondrial respiration was significantly diminished in lipid substrate experiments ( P  < 0.05), and there was significantly less expression of phosphorylated endothelial nitric oxide synthase (peNOS) ( P  < 0.001).

CONCLUSIONS

These data are consistent with TN-induced remodeling of tPVAT, notably associated with sex-specific blunting of vasoreactivity, diminished mitochondrial respiration, and altered cellular signaling.

Burden of cardiovascular hospitalizations and in-hospital mortality in Greece: national trends over five years

OBJECTIVE

Nationwide epidemiological studies provide crucial insights into the burden of prevalent and emerging diseases, guiding the development of targeted health policies. This study analyzes trends in cardiovascular disease (CVD) hospitalizations and in-hospital mortality in Greece.

METHODS

Anonymized data were retrieved from the Hellenic Statistical Authority to calculate hospitalization rates (HRs) per 100,000 population and in-hospital mortality for cardiovascular (CV) sub-causes from 2013 to 2017. The statistical significance of temporal trends was assessed using generalized linear models in Python.

RESULTS

From 2013 to 2017, HRs increased by 9.2% for myocardial infarctions (MIs), 34.5% for heart failure (HF), 12.3% for stroke, 62.7% for cardiac arrest, and 36.6% for pulmonary embolism. In 2017, CVDs were the leading cause of hospitalization (14%) with a HR of 1942.4 per 100,000 population, with HF being the leading CV sub-cause of hospitalization (12%). HF together with stroke, atrial fibrillation/flutter (AF/Af), and coronary artery disease represented over 60% of all CV hospitalizations. While coronary artery disease was more prevalent in the male population, HF, strokes, and AF/Af were the primary CV sub-causes in the female population. HRs were higher in the male population for most CV sub-causes. Higher in-hospital mortality was found in the female population across all major CV sub-causes.

CONCLUSION

This study demonstrated significant shifts in the burden of CV sub-causes in Greece, with increasing HRs for MIs and HF. These findings highlight the need for optimization of guideline implementation, and development of specialized CV units and cardiogeriatric centers to address the challenges posed by the aging population.

Chest pain in a multi-ethnic population: A community-based study on sex differences in chest pain prevalence and care contacts

Objective

While chest pain is a common symptom, its prevalence among women and men across ethnic groups is unknown. Moreover, how chest pain is associated with general practitioner (GP) and cardiologist visits in women and men across ethnic groups, remains to be determined.

Design

We used baseline data on 12423 women and 9071 men from the multi-ethnic HELIUS cohort (Amsterdam, the Netherlands; 2011-2015). Using logistic regressions, we studied sex differences in chest pain prevalence across ethnic groups. Next, in those who reported chest pain in the past two years (henceforth; recent chest pain), we studied sex differences in GP, cardiologist, and any specialists visits, in total and by ethnicity. Analyses were adjusted for age, ethnicity (in the total population), socioeconomic factors, associated symptoms, clinical parameters, and lifestyle factors.

Results

Across most ethnic groups, women were more likely than men to report lifetime (33 % vs 29 %, p < .001) and recent chest pain (4.5 % vs 2.7 %, p = .001). In those with recent chest pain, women were more likely to have visited a GP, yet less likely to have visited a cardiologist, but not any specialist, compared to men. These differences were also observed in several sensitivity analyses, including in those with symptoms suggestive of typical Angina Pectoris.

Conclusion

Chest pain is more commonly reported in women than men across most ethnic groups. While men were less likely to have visited a GP than women, women were less likely to have visited a cardiologist. Combined, this suggests delays in care may occur at different points in the care trajectory for women and men.

Remote organ cancer induces kidney injury, inflammation, and fibrosis and adversely alters renal function

Approximately 30% of the patients with cancer experience kidney complications, which hinder optimal cancer management, imposing a burden on patients' quality of life and the healthcare system. The etiology of kidney complications in patients with cancer is often attributed to oncological therapies. However, the direct impact of cancer on kidney health is underestimated. Our previous study demonstrated that metastatic lung cancer adversely alters the kidney and exacerbates chemotherapy-induced nephrotoxicity, indicating lung cancer-kidney crosstalk. The current study examines whether this phenomenon is specific to the employed cancer model. Female and male mice of various strains were injected with different cell lines of remote organ cancer, and their kidney tissues were analyzed for toxicity and fibrosis. The impact of cancer on the kidney varied by cancer type. Breast cancer and specific subtypes of lung cancer, including KRAS- and epidermal growth factor receptor (EGFR)-mutant cancer, pathologically altered kidney physiology and function in a manner dependent on the metastatic potential of the cell line. This was independent of mouse strain, sex, and cancer cell line origin. Moreover, tumor DNA was not detected in the renal tissue, excluding metastases to the kidney as a causative factor for the observed pathological alterations. Lewis lung carcinoma and B16 melanoma did not cause nephrotoxicity, regardless of the tumor size. Our results confirm cancer-kidney crosstalk in specific cancer types. In the era of precision medicine, further research is essential to identify at-risk oncology populations, enabling early detection and management of renal complications.NEW & NOTEWORTHY Patients with cancer frequently experience kidney complications, often attributed to antineoplastic therapies. This emphasis on therapy-induced nephrotoxicity has led to the underestimation of the impact of cancer on the kidney. Our study demonstrates that distant organ cancer is sufficient to induce nephrotoxicity, highlighting the existence of cancer-kidney crosstalk. Our findings underscore a gap in our understanding of renal complications in patients with cancer and provide a rationale for identifying the underlying mechanisms for the development of nephroprotective agents.

Demographics and regional trends of ischemic heart disease-related mortality in older adults in the United States, 1999-2020

BACKGROUND

Ischemic heart disease (IHD) has a significant impact on public health and healthcare expenditures in the United States (US).

METHODS

We used data from the CDC WONDER database from 1999-2020 to identify trends in the IHD-related mortality of patients ≥ 75 years in the US. AAMRs per 100,000 population and APC were calculated and categorized by year, sex, race, and geographic divisions.

RESULTS

Between 1999 and 2020, a total of 8,124,568 IHD-related deaths were recorded. Notable declines in AAMR were observed from 1999 to 2014 (APC: -3.86) and from 2014 to 2018 (APC: -2.55), with an overall increase from 2018 to 2020 (APC: 3.76). Older men consistently demonstrated higher AAMRs than older females, with AAMRs for both sexes decreasing steadily from 1999 to 2018 and increasing in 2020. When stratified by race/ethnicity, Whites (1931.7) had the highest AAMR, followed by Blacks (1836.5), American Indians (1510.5), Hispanics (1464.4), and Asians (1093.6). Furthermore, nonmetropolitan areas (2015.2) showed greater AAMRs than metropolitan areas (1841.8). The ≥ 85-year group consistently exhibited higher IHD-related mortality rates compared to the 75-84 years group. In comparison, the older group [≥75 years] (1873.0) consistently exhibited higher IHD-related AAMRs than the younger group [<75 years] (64.0) throughout the study, showing a significant disparity. Chronic IHD (1552.0) consistently showed the highest AAMRs throughout the study, surpassing myocardial infarction (515.6), other ischemic heart diseases (24.0), and angina pectoris (5.6).

CONCLUSION

Targeted interventions and resource allocation are crucial for areas with high IHD-related mortality. Public health policies should address demographic and geographical disparities, with further research for effective strategies.

Schistosoma mansoni antigen induced innate immune memory features mitochondrial biogenesis and can be inhibited by ovarian produced hormones

We have previously identified that S. mansoni infection induces a unique form of myeloid training that protects male but not female mice from high fat diet induced disease. Here we demonstrate that ovarian derived hormones account for this sex specific difference. Ovariectomy of females prior to infection permits metabolic reprogramming of the myeloid lineage, with BMDM exhibiting carbon source flexibility for cellular respiration, and mice protected from systemic metabolic disease. The innate training phenotype of infection can be replicated by in vivo injection of SEA, and by exposure of bone marrow to SEA in culture prior to macrophage differentiation (Day 0). This protective phenotype is linked to increased chromatin accessibility of lipid and mitochondrial pathways in BMDM including Nrf1 and Tfam, as well as mitochondrial biogenesis. This work provides evidence that S. mansoni antigens induce a unique form of innate training inhibited by ovarian-derived hormones in females.

Sex hormone-dependent host-microbiome interactions and cardiovascular risk (XCVD): design of a longitudinal multi-omics cohort study

INTRODUCTION

Cardiovascular diseases (CVDs) present differently in women and men, influenced by host-microbiome interactions. The roles of sex hormones in CVD outcomes and gut microbiome in modifying these effects are poorly understood. The XCVD study examines gut microbiome mediation of sex hormone effects on CVD risk markers by observing transgender participants undergoing gender-affirming hormone therapy (GAHT), with findings expected to extrapolate to cisgender populations.

METHODS AND ANALYSES

This observational, longitudinal cohort study includes baseline, 1- and 2-year follow-ups with transgender participants beginning GAHT. It involves comprehensive phenotyping and microbiome genotyping, integrating computational analyses of high-dimensional data. Microbial diversity will be assessed using gut, skin, and oral samples via 16S rRNA and shotgun metagenomic sequencing of gut samples. Blood measurements will include sex hormones, CVD risk markers, cardiometabolic parameters, cytokines, and immune cell counts. Hair samples will be analysed for cortisol. Participants will complete online questionnaires on physical activity, mental health, stress, quality of life, fatigue, sleep, pain, and gender dysphoria, tracking medication use and diet to control for confounders. Statistical analyses will integrate phenomic, lifestyle, and multi-omic data to model health effects, testing gut microbiome mediation of CVD risk as the endocrine environment shifts between that typical for cisgender men to women and vice versa.

ETHICS AND DISSEMINATION

The study adheres to Good Clinical Practice and the Declaration of Helsinki. The protocol was approved by the Charité Ethical Committee (EA1/339/21). Signed informed consent will be obtained. Results will be published in peer-reviewed journals and conferences and shared as accessible summaries for participants, community groups, and the public, with participants able to view their data securely after public and patient involvement review for accessibility.

TRIAL REGISTRATION NUMBER

The XCVD study was registered on ClinicalTrials.gov (NCT05334888) as 'Sex-differential host-microbiome CVD risk - a longitudinal cohort approach (XCVD)" on 4 April 2022. Data set link can be found at https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05334888.

Regional and socioeconomic disparities in calcium scans

INTRODUCTION

Disparities in cardiovascular care are well recognized, with socioeconomic status being one of the strongest determinants of cardiovascular disease outcomes. This study evaluates whether these disparities translate to coronary artery calcium (CAC) scan utilization. Specifically, we aim to describe regional variation and socioeconomic variables that impact CAC utilization across the United States relative to the prevalence of coronary artery disease (CAD) and related comorbidities.

METHODS

This cross-sectional study integrates county-level CAC utilization with CAD prevalence and publicly available socioeconomic variables including self-identified ethnicity, education, and adjusted gross income. CAC utilization rates were sourced from 2022 hospital commercial claims, outpatient Medicare service claims, and independent imaging center claims. Heart disease prevalence and socioeconomic variables were extracted from the Centers for Disease Control and Prevention and the National Center for Chronic Disease Prevention and Health Promotion. Adjusted gross income per capita was gathered from Internal Revenue Service data.

RESULTS

CAC utilization was evaluated across 808 counties within the United States, representing 600,379 claims. Median utilization was 1.62 scans per 1,000 persons with a range of 0.03 to 104.39. The West had the highest CAC scan utilization rate (median 3.09 scans per 1,000 persons) with a CAD prevalence of 548 per 100,000 persons. In contrast, the Midwest had the lowest utilization rate (median 1.24 scans per 1,000 persons) with a CAD prevalence of 635 per 100,000 persons. Socioeconomic factors that favor higher CAC utilization include a larger density of White/Caucasian ethnicity (p = 0.007) and a higher adjusted gross income per capita (p = 0.006). Counties with the lowest rates of CAC utilization have a higher population of African Americans (p <0.001) and a higher proportion of females (p <0.001).

CONCLUSION

This analysis highlights regional and socioeconomic differences in CAC utilization in the United States. Under-represented ethnicities such as African Americans have among the lowest rates of CAC utilization despite having a higher burden and mortality from heart disease. Discordance between CAC utilization, heart disease prevalence and socioeconomic status reveals a need for targeted interventions and policies aimed at mitigating structural barriers that perpetuate health inequities.

Systematic Review of Sex-specific High Sensitivity Cardiac Troponin I and T Thresholds

PURPOSE

High-sensitivity cardiac troponin I (hs-cTnI) and T (hs-cTnT) have been demonstrated to have lower sex-specific 99th percentiles in healthy females. However, these sex-specific thresholds are not widely adopted in clinical practice which could lead to underdiagnosis of acute myocardial infarction in females. We conducted a systematic review to explore sex-specific 99th percentiles for hs-cTnI and hs-cTnT from healthy reference populations.

METHODS

The principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to complete this systematic review. We used PubMed and OVID EMBASE to search for original studies published between November 2017 and November 2021 that included reference populations used to establish the 99th percentiles of hs-cTnI and hs-cTnT with the following inclusion criteria: adults; English language; samples taken as part of a healthy, reference population; studies using high-sensitivity troponin assay; and sample size > 300. Studies were excluded if the reference population sample size was < 300, if a conventional troponin assay was used, or if they did not include independently derived, sex-specific 99th percentiles. Data was extracted from the studies through Covidence to perform a qualitative data synthesis. Female-specific, male-specific, and overall 99th percentiles for hs-cTn were compared.

FINDINGS

We reviewed 131 articles of which 19 met inclusion criteria. These 19 studies derived sex-specific 99th percentiles for 11 different hs-cTnI assays and 9 different hs-cTnT assays. More than 90% (13 of 14 studies) of hs-cTnI assays found lower female 99th percentiles compared to male and to overall 99th percentiles. One study included nine different hs-cTnI assays, of which only one assay resulted in a higher female 99th percentile compared to male and to overall 99th percentiles. Eight of nine hs-cTnT studies (88.9%) found lower female 99th percentiles compared to male and to overall 99th percentiles.

IMPLICATIONS

The data shows significantly lower 99th percentiles in females compared to 99th percentiles in males and overall. Incorporating these sex-specific 99th percentile cut-offs into clinical practice could lead to increased diagnosis and potentially better outcomes for females presenting with acute myocardial infarction.

Sex differences in chronic kidney disease-related complications and mortality across levels of glomerular filtration rate

BACKGROUND

Chronic kidney disease (CKD) is a growing global health concern. Recent research has indicated sex disparities in CKD-related complications, yet the impact of sex differences on critical kidney function levels that trigger these complications and mortality remains inadequately documented.

METHODS

We investigated sex-specific disparities in CKD-related complications and mortality according to estimated glomerular filtration rate (eGFR) levels. We analyzed National Health and Nutrition Examination Survey (NHANES) data spanning from 1999 to 2018, including adult participants with an eGFR of 15-150 mL/min/1.73 m2. The outcomes were CKD-related complications [hypertension, anaemia, cardiovascular (CV) diseases, acidosis, hyperphosphatemia, hyperparathyroidism] and all-cause and cause-specific mortality (CV mortality and non-CV mortality). Sex-stratified multivariable logistic and Cox regression models yielded odds ratios and hazard ratios for the relationship between eGFR categories and outcomes. Sex-stratified natural splines were used to explore the relationship between continuous eGFR and outcomes and identified eGFR thresholds of statistical significance.

RESULTS

The study included 49 558 participants (50.3% women, 49.7% men). Multivariable logistic regression demonstrated a significant eGFR association with all CKD-related complications, exhibiting a linear trend across eGFR categories. Modelling eGFR as a natural spline revealed varied significance thresholds between sexes for anaemia and hyperparathyroidism. Additionally, the eGFR-hyperphosphatemia association was more pronounced in men. We observed substantial but not statistically significant differences between men and women in the thresholds of statistical significance for CV (significance appeared at a higher eGFR in men) and non-CV mortality (significance appeared at a higher eGFR in women).

CONCLUSIONS

Research shows sex disparities in most CKD-related complications. Men develop anaemia and hyperparathyroidism earlier; women show a steeper anaemia increase. Men have higher CV mortality risk. As eGFR decreased, men faced a higher risk of CV mortality at a higher eGFR threshold than women.

A gender perspective on diet, microbiome, and sex hormone interplay in cardiovascular disease

A unique interplay between body and environment embeds and reflects host-microbiome interactions that contribute to sex-differential disease susceptibility, symptomatology, and treatment outcomes. These differences derive from individual biological factors, such as sex hormone action, sex-divergent immune processes, X-linked gene dosage effects, and epigenetics, as well as from their interaction across the lifespan. The gut microbiome is increasingly recognized as a moderator of several body systems that are thus impacted by its function and composition. In humans, biological sex components further interact with gender-specific exposures such as dietary preferences, stressors, and life experiences to form a complex whole, requiring innovative methodologies to disentangle. Here, we summarize current knowledge of the interactions among sex hormones, gut microbiota, immune system, and vascular health and their relevance for sex-differential epidemiology of cardiovascular diseases. We outline clinical implications, identify knowledge gaps, and place emphasis on required future studies to address these gaps. In addition, we provide an overview of the caveats associated with conducting cardiovascular research that require consideration of sex/gender differences. While previous work has inspected several of these components separately, here we call attention to further translational utility of a combined perspective from cardiovascular translational research, gender medicine, and microbiome systems biology.

Female Specific Restrictive Cardiomyopathy and Metabolic Dysregulation in transgenic mice expressing a Peptide of the Amino-Terminus of GRK2

Cardiovascular disease and heart failure are a major health challenge, with sex differences in pathophysiology and treatment responses critically influencing patient outcomes. G protein-coupled receptor (GPCR) kinase 2 (GRK2) is a pivotal regulator of cellular signaling whose elevation is a hallmark of heart failure progression. Its complex network of protein interactions impact a wide range of physiological and pathophysiological processes including cardiac function. In this study, we examined the effects of cardiac-restricted expression of an amino-terminal peptide of GRK2 (βARKnt) in female mice subjected to acute and chronic pressure overload. Our findings reveal that that βARKnt affects hypertrophy development and cardiac function differently in female mice than in males, leading to a transition to heart failure not observed in control females or βARKnt males. Notably, the βARKnt female mice exhibited baseline hypertrophy with distinct left atrial morphology, increased fibrosis, and immune cell infiltration compared to the controls, which progressed under chronic stress, indicating adverse cardiac remodeling. Furthermore, βARKnt female mice, unlike males, exhibit impaired tissue respiration following acute pressure overload and altered glucose sensitivity and insulin tolerance, highlighting significant remodeling of cardiac and systemic metabolism.

The complexity of cardiovascular risk in women. Descriptive review

OBJECTIVES

Cardiovascular diseases (CVD) are the greatest threat to the health of women and is the leading cause of death amongst women globally; however, cardiovascular disease in women remains understudied, under-recognized, underdiagnosed, and undertreated. The aim of this descriptive review is to summarize the existing problem and to identify the knowledge gaps in cardiovascular disease research, prevention, treatment, and access to care for women.

MATERIAL AND METHODS

This is a descriptive review of the literature based on numerous articles published in peer-reviewed journals since the beginning of this century related to the spectrum of cardiovascular disease in women.

RESULTS

There are several obstacles to improve cardiovascular disease outcomes in women. One of them is the lack of reliable, effective screening modalities since her participation in clinical trial is quite low. Other concern is the complexity of the female organism with several hormonal changes during her life and the hemodynamics stress during pregnancy. Moreover, in the last stage of their life several cardiometabolic risk factor may appear, most of them not recognized by the health team in primary care attention.

DISCUSSION

Effective strategies are required to address inequalities in the diagnosis, treatment and prevention of heart disease in women; to advance innovative solutions for early detection and oriented management; to clarify the underlying biological mechanisms that contribute to sex-specific differences in outcomes; and finally, reduce the global burden of cardiovascular disease in women.

Network analysis to examine sex differences linked to emotional well-being in cardiovascular disease

Psychosocial dimensions are essential to guarantee an optimal approach to improve emotional well-being in patients with cardiovascular disease (CVD). There is evidence of sex differences regarding these dimensions. Thus, the connections between them are crucial to implement personalized therapies. Network model analyses were conducted on data from 593 CVD patients. The models included scores from the Hospital Anxiety and Depression Scale (HADS), positive (PA) and negative affect (NA), positivity (PS), satisfaction of life (SLS), social support (SS), self-efficacy on emotion regulation (RESE), cardiac self-efficacy (CSE) and the Short Form-12 Health Survey. The main sex differences were found in: PA-PS (p = 0.03), SS-RESE (p = 0.04), for which the positive associations are stronger for men than for women and PA-RESE (p < 0.01) for which the positive association is stronger for women than for men. These nuances should be considered to implement tailored and integrative therapies for each CVD patient.

Sex-Specific Functional Status Decline and Outcomes in Mild-to-Moderate Aortic Stenosis: Results From the PROGRESSA Study

Background

Little is known about the effect of sex on functional status decline in aortic valve stenosis (AS) patients.

Objectives

The purpose of this study was to examine the changes in functional status according to sex in patients with mild-to-moderate AS and its association with the composite of death or aortic valve replacement (AVR).

Methods

We included patients with mild-to-moderate AS prospectively recruited in the PROGRESSA (Metabolic Determinants of the Progression of Aortic Stenosis) study (NCT01679431). Functional status was assessed using the New York Heart Association classification and the Duke Activity Status Index (DASI).

Results

A total of 244 patients (mean age 64 ± 14 years, 29% women) were included. The mean follow-up was 4.3 ± 2.4 years. Women with intermediate-to-fast AS progression rate (median change in peak aortic jet velocity ≥0.11 m/s/year) had significantly faster decline in DASI score compared to men with similar progression rate (P < 0.05). In linear mixed analysis adjusted for several clinical and echocardiographic factors, female sex and change in peak aortic jet velocity remained strongly associated with the worsening of New York Heart Association class and the decline of DASI score (all, P < 0.001). The composite of death or AVR occurred in 115 patients (16 deaths and 99 AVRs). In multivariable Cox regression analyses, functional status decline during follow-up remained significantly associated with the composite of death or AVR (HR: 2.13; 95% CI: 1.22-3.73; P = 0.008).

Conclusions

In patients with mild-to-moderate AS at baseline, intermediate-to-fast progression rate of AS was associated with a more rapid decline of functional status during follow-up, particularly in women. Functional status decline during follow-up was strongly associated with the incidence of death or AVR, with comparable effect in both women and men.

Exploring the trend of age-standardized mortality rates from cardiovascular disease in Malaysia: a joinpoint analysis (2010-2021)

INTRODUCTION

Cardiovascular disease (CVD) is a major health concern worldwide, particularly in low- and middle-income countries. The COVID-19 pandemic that emerged in late 2019 may have had an impact on the trend of CVD mortality. This study aimed to investigate the trend and changes in CVD mortality rates in Malaysia, using age-standardized mortality rates (ASMR) from 2010 to 2021.

METHODS

The Malaysian population and mortality data from 2010 to 2021 were obtained from the Department of Statistics Malaysia (DOSM). ASMRs from CVD per 100,000 population were calculated based on the World Health Organization (2000-2025) standard population using the direct method. The ASMRs were computed based on sex, age groups (including premature mortality age, 30-69 years), and CVD types. The annual percent change (APC) and average annual percent change (AAPC) of the ASMR with corresponding 95% confidence intervals (95% CI) were estimated from joinpoint regression model using the Joinpoint Regression Program, Version 4.9.1.0.

RESULTS

Throughout the study period (2010-2021), ASMRs for CVD exhibited an increase from 93.1 to 147.0 per 100,000, with an AAPC of 3.6% (95% CI: 2.1 to 5.2). The substantial increase was observed between 2015 and 2018 (APC 12.6%, 95% CI: 5.4%, 20.3%), with significant changes in both sexes, and age groups 50-69, 70 years and over, and 30-69 (premature mortality age). Notably, the ASMR trend remained consistently high in the premature mortality age group across other age groups, with males experiencing higher rates than females. No significant changes were detected before or after the COVID-19 pandemic (between 2019 and 2021), except for females who died from IHD (10.3% increase) and those aged 0-4 (25.2% decrease).

CONCLUSION

Overall, our analysis highlights the persistently high burden of CVD mortality in Malaysia, particularly among the premature mortality age group. These findings underscore the importance of continued efforts to address CVD risk factors and implement effective prevention and management strategies. Further research is needed to fully understand the impact of the COVID-19 pandemic on CVD mortality rates and to inform targeted interventions to reduce the burden of CVD in Malaysia.

Breastfeeding duration is associated with favorable body composition and lower glycoprotein acetyls in later life

OBJECTIVE

The aim of the present study was to investigate associations between lifetime breastfeeding behaviors and cardiovascular risk in later reproductive years.

METHOD

This was a prospective 10-year longitudinal cohort study of 168 parous women. Health, lifestyle and infant feeding questionnaires, blood samples, anthropometry and body composition were collected. Cardiovascular risk was estimated using QRISK®3 and hierarchical multiple linear regression analysis performed.

RESULTS

Mean age was 42.4 years (SD 3.8; range 31-50) and 98.7% (n = 156/158) were premenopausal. Ever breastfeeding rates were 72.6% (n = 122/168) and 37.5% (n = 63/168) lifetime ≥12 months breastfeeding duration. Median durations were 5.5 weeks for exclusive breastfeeding (IQR 35.8; range 0-190) and 30.5 weeks for any breastfeeding (IQR 84.0; range 0-488). Breastfeeding duration was not associated with QRISK®3 scores in adjusted models. Lower glycoprotein acetyls were associated with ever breastfeeding (P = 0.03), and lifetime breastfeeding ≥12 months (P = 0.001). Lifetime breastfeeding ≥12 months and longer exclusive breastfeeding were associated with lower fat mass index (P = 0.03, P = 0.01), tissue percentage fat (P = 0.02, P = 0.009) and visceral adipose tissue volume (P = 0.04, P = 0.025) after correcting for confounders including body mass index.

CONCLUSION

Longer breastfeeding is associated with favorable body composition and lower glycoprotein acetyls, a novel inflammatory biomarker associated with cardiometabolic risk. Breastfeeding is a low-cost, health promoting behavior for women and infants. Pregnant women, especially those at higher risk of cardiovascular disease, should be counseled about the potential benefits of exclusive and longer breastfeeding duration.

Maternal-fetal dyad beyond the phenomenology of pregnancy: from primordial cardiovascular prevention on out, do not miss this boat!

Pregnancy represents a stress test for every woman's cardiovascular (CV) system, and a pre-existing maternal unfavorable cardio-metabolic phenotype can uncover both adverse pregnancy outcomes and the subsequent development of cardiovascular disease (CVD) risk factors during and after pregnancy. Moreover, the maternal cardiac and extracardiac environment can affect offspring's cardiovascular health through a complex mechanism called developmental programming, in which fetal growth can be influenced by maternal conditions. This interaction continues later in life, as adverse developmental programming, along with lifestyle risk factors and genetic predisposition, can exacerbate and accelerate the development of CV risk factors and CVD in childhood and adolescence. The aim of this narrative review is to summarize the latest evidences regarding maternal-fetal dyad and its role on primordial, primary and secondary CV prevention.

Teaching gender medicine can enhance the quality of healthcare

Teaching gender and sex differences is fundamental in medical classes because it has a strong impact in reducing disparity in treatment, in defining effective and personalized therapies that respect the different physiology and pathophysiology of women. Furthermore, it is the prerequisite for the pharmacoequity.

Women's reproductive risk score and healthy lifestyle modification in cardiovascular disease: Findings from the UK Biobank

BACKGROUND AND AIMS

Reproductive risk factors are associated with increased risk of cardiovascular disease (CVD) in women. However, the combined effects of the composite reproductive risk factors on CVD are unknown. This study was performed to construct a reproductive risk score (RRS) to measure reproductive status, examine the association between RRS and CVD, and explore the modification effect of healthy lifestyle on the association in women in the UK Biobank cohort.

METHODS

The RRS was constructed in 74,141 female participants with data about the items derived for the RRS in the UK Biobank. The RRS was derived from 17 baseline variables, all of which indicated women's reproductive health status. We defined four categories of RRS status: low-risk group (score 0-1); low-intermediate group (score 2-3); high-intermediate group (score 4-5); and high-risk group (score 6-13). We also constructed a healthy lifestyle score (HLS) with five related factors, and categorized into unhealthy lifestyle group (score: 0-1), intermediate lifestyle group (score: 2-3) and healthy lifestyle group (score: 4-5).

RESULTS

Each point increase in the RRS was associated with a 22 % higher risk of CVD (adjusted hazard ratio (aHR): 1.22; 95 % confidence interval (CI): 1.16 to 1.28), 23 % higher risk of IHD (1.23; 1.17 to 1.31) and 19 % higher risk of stroke (1.19; 1.07 to 1.32). The percentage population-attribution risks (PAR%) were 16 % (95 % CI: 8 to 24) for CVD, 15 % (95 % CI: 6 to 24) for IHD and 18 % (95 % CI: 1 to 33) for stroke. A healthy lifestyle significantly attenuated RRS associations with the incidence of CVD and IHD. The attributable proportions due to additive interaction (p < 0.001) between RRS and HLS were 0.14 (95 % CI: 0.07 to 0.22) for CVD and 0.15 (95 % CI: 0.09 to 0.23) for IHD, respectively.

CONCLUSIONS

High RRS was associated with increased risks of CVD, IHD and stroke in female participants in the UK Biobank. The early-stage identification of women with reproductive risk using synthesised indicators and appropriate healthy lifestyle interventions could be useful for the prevention of early CVD and the extension of healthy active life expectancy.

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

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

Exploring sex variations in the incidence of cardiovascular events: a counterfactual decomposition analysis

BACKGROUND

Some cardiovascular risk factors (CVRFs) that occur differently in men and women can be addressed to reduce the risk of suffering a major adverse cardiovascular event (MACE). Furthermore, the development of MACE is highly influenced by social determinants of health. Counterfactual decomposition analysis is a new methodology that has the potential to be used to disentangle the role of different factors in health inequalities. This study aimed to assess sex differences in the incidence of MACE and to estimate how much of the difference could be attributed to the prevalence of diabetes, hypertension, hypercholesterolaemia and socioeconomic status (SES).

METHODS

Descriptive and counterfactual analyses were conducted in a population of 278 515 people with CVRFs. The contribution of the causal factors was estimated by comparing the observed risk ratio with the causal factor distribution that would have been observed if men had been set to have the same factor distribution as women. The study period was between 2018 and 2021.

RESULTS

The most prevalent CVRF was hypercholesterolaemia, which was similar in both sexes, while diabetes was more prevalent in men. The incidence of MACE was higher in men than in women. The main causal mediating factors that contributed to the sex differences were diabetes and SES, the latter with an offsetting effect.

CONCLUSIONS

This result suggests that to reduce the MACE gap between sexes, diabetes prevention programmes targeting men and more gender-equal salary policies should be implemented.

Exploring the sex difference in cardiovascular risk during growth hormone therapy in adults

OBJECTIVE

Given the previously identified sex differences in cardiovascular (CV) morbidity and mortality in patients with growth hormone deficiency (GHD) receiving GH replacement therapy (GHRT), our aim is to investigate sex-specific differences in the efficacy of (long-term) GHRT on CV risk profile and disease in subjects with GHD. Our hypothesis is that women will experience less beneficial effects than men.

DESIGN

Retrospective nationwide cohort study.

METHODS

We compared all men (n = 1335) and women (n = 1251) with severe GHD registered in the Dutch National Registry of GH Treatment in Adults database with respect to CV risk profile and morbidity at baseline and during follow-up.

RESULTS

Men had a more unfavourable CV risk profile at baseline. During the first years of GHRT, the reduction in waist circumference, waist-to-hip ratio, total cholesterol, and triglyceride levels was greater in men than in women (all P < .05). Between-sex differences in effects during later follow-up were less clear. No sex differences were found in the risk of developing non-fatal cardiovascular or cerebrovascular diseases during GHRT.

CONCLUSIONS

Our results suggest that men with GHD did indeed experience more beneficial effects of GHRT on body composition and lipoprotein metabolism than women, at least in the early years of treatment. Also, the more unfavourable CV risk profile at baseline in men did not translate into a sex difference in the risk of developing CV and cerebrovascular morbidity during GHRT.

Cardiovascular and renal outcomes of glucagon-like peptide 1 receptor agonists among patients with and without type 2 diabetes mellitus: A meta-analysis of randomized placebo-controlled trials

Background

Multiple cardiovascular outcomes trials (CVOTs) have shown the efficacy of GLP-1RAs in reducing major adverse cardiovascular events (MACEs) for high-risk patients. However, some CVOTs failed to demonstrate cardiovascular benefits.

Objectives

We analyzed the impact of GLP-1RA on cardiovascular and renal outcomes in patients with or without T2DM, with subgroup analysis based on sex, estimated glomerular filtration rate (eGFR), body mass index (BMI), and history of cardiovascular disease (CVD).

Methods

A comprehensive database search for placebo-controlled RCTs on GLP-1RA treatment was conducted until April 2024. Data extraction and quality assessment were carried out, employing a robust statistical analysis using a random effects model to determine outcomes with log odds ratios and 95 % confidence intervals (CIs).

Results

A total of 13 CVOTs comprising 83,258 patients were included. GLP-1RAs significantly reduced MACE (OR 0.86, 95 % CI: 0.80 to 0.94, p < 0.01) all-cause mortality OR 0.87, 95 % CI: 0.82 to 0.93, p < 0.001, CV mortality (OR 0.87, 95 % CI: 0.81 to 0.94, p < 0.001), stroke (fatal: OR 0.74, 95 % CI: 0.56 to 0.96, p = 0.03; non-fatal: OR 0.87, 95 % CI: 0.79 to 0.96, p = 0.005), coronary revascularization (OR 0.86, 95 % CI: 0.74 to 0.99, p = 0.023), and composite kidney outcome (OR 0.76, 95 % CI: 0.67 to 0.85, p < 0.001. GLP-1RA significantly reduced MACE in both sexes. Furthermore, GLP-1RA reduced MACE regardless of CVD history, BMI, and eGFR level.

Conclusion

Significant reductions in MACE, overall and CV mortality, stroke, coronary revascularization, and composite kidney outcome with GLP-1RA treatment were noted across all subgroups.

Sex-Based Mechanisms of Cardiac Development and Function: Applications for Induced-Pluripotent Stem Cell Derived-Cardiomyocytes

Males and females exhibit intrinsic differences in the structure and function of the heart, while the prevalence and severity of cardiovascular disease vary in the two sexes. However, the mechanisms of this sex-based dimorphism are yet to be elucidated. Sex chromosomes and sex hormones are the main contributors to sex-based differences in cardiac physiology and pathophysiology. In recent years, the advances in induced pluripotent stem cell-derived cardiac models and multi-omic approaches have enabled a more comprehensive understanding of the sex-specific differences in the human heart. Here, we provide an overview of the roles of these two factors throughout cardiac development and explore the sex hormone signaling pathways involved. We will also discuss how the employment of stem cell-based cardiac models and single-cell RNA sequencing help us further investigate sex differences in healthy and diseased hearts.

Perivascular adipose tissue remodeling impairs vasoreactivity in thermoneutral-housed rats

Objective

Vascular pathology, characterized by impaired vasoreactivity and mitochondrial respiration, differs between the sexes. Housing rats under thermoneutral (TN) conditions causes vascular dysfunction and perturbed metabolism. We hypothesized that perivascular adipose tissue (PVAT), a vasoregulatory adipose depot with brown adipose tissue (BAT) phenotype, remodels to a white adipose (WAT) phenotype in rats housed at TN, driving diminished vasoreactivity in a sex-dependent manner.

Methods

Male and female Wistar rats were housed at either room temperature (RT) or TN. Endpoints included changes in PVAT morphology, vasoreactivity in vessels with intact PVAT or transferred to PVAT of the oppositely-housed animal, vessel stiffness, vessel mitochondrial respiration and cellular signaling.

Results

Remodeling of PVAT was observed in rats housed at TN; animals in this environment showed PVAT whitening and displayed diminished aortae vasodilation (p<0.05), different between the sexes. Juxtaposing PVAT from RT rats onto aortae from TN rats in females corrected vasodilation (p<0.05); this did not occur in males. In aortae of all animals housed at TN, mitochondrial respiration was significantly diminished in lipid substrate experiments (p<0.05), and there was significantly less expression of peNOS (p<0.001).

Conclusions

These data are consistent with TN-induced remodeling of PVAT, notably associated with sex-specific blunting of vasoreactivity, diminished mitochondrial respiration, and altered cellular signaling.

Cross-sectional and longitudinal associations of Iron biomarkers and cardiovascular risk factors in pre- and postmenopausal women: leveraging repeated measurements to address natural variability

BACKGROUND

The association between iron biomarkers and cardiovascular disease risk factors (CVD-RFs) remains unclear. We aimed to (1) evaluate the cross-sectional and longitudinal associations between iron biomarkers (serum ferritin, transferrin saturation (TSAT), transferrin) and CVD-RFs among women, and (2) explore if these associations were modified by menopausal status.

METHOD

Cross-sectional and longitudinal analyses including 2542 and 1482 women from CoLaus cohort, respectively. Multiple linear regression and multilevel mixed models were used to analyse the associations between Iron biomarkers and CVD-RFs. Variability of outcomes and iron markers between surveys was accessed using intraclass correlation (ICC).

RESULTS

After multivariable adjustment, elevated serum ferritin levels were associated with increased insulin and glucose levels, while higher transferrin levels were linked to elevated glucose, insulin and total cholesterol, and systolic and diastolic blood pressure (p < 0.05). No association was observed between CVD-RFs and TSAT (p > 0.05). Iron biomarkers demonstrated low reliability across reproductive stages but exhibited stronger associations in the perimenopausal group. In longitudinal analysis, we found association only for transferrin with lower glucose levels [β = - 0.59, 95% CI (- 1.10, - 0.08), p = 0.02] and lower diastolic blood pressure [β = - 7.81, 95% CI (- 15.9, - 0.56), p = 0.04].

CONCLUSION

In cross-sectional analysis, transferrin was associated with several CVD-RFs, and the associations did not change according to menopausal status. Conversely, in the longitudinal analyses, changes in transferrin were associated only with lower glucose and diastolic blood pressure levels. These differences might stem from the substantial longitudinal variation of iron biomarkers, underscoring the need for multiple iron measurements in longitudinal analyses.

Low income and education are associated with greater ASCVD risk scores among adults in the US

Introduction

Social determinants of health (SDOH) are fundamental causes of poor cardiovascular health, yet cardiovascular disease (CVD) risk assessment tools exclude SDOH. Our objective was to determine whether SDOH are independently associated with CVD risk in US adults.

Methods

Utilizing the National Health and Nutrition Examination Survey (NHANES), we combined years 1999-2018 and included participants aged 40-79 without history of CVD and with information to calculate CVD risk (n = 21,694). Ten-year risk of atherosclerotic CVD (ASCVD) was calculated using the American Heart Association/American College of Cardiology (AHA/ACC) pooled cohort equations. We used linear regression models to estimate the association between SDOH and ASCVD risk, after adjusting for demographic factors. All analyses accounted for the complex survey design.

Results

Mean age was 54.7 years, with 52.7 % female, 73.8 % non-Hispanic White, 9.4 % non-Hispanic Black, and 10.7 % Hispanic. From adjusted models, compared with an income of ≥ $75 K, ASCVD risk was greater by 3.06 (95 % CI: 2.65, 3.47) among those with income < $25 K, by 1.55 (95 % CI: 1.21, 1.89) among those with income $25 K-<$55 K, and by 1.20 (95 % CI: 0.84, 1.56) among those with income $55 K-<$75 K. Compared to college graduates, ASCVD risk was greater by 3.09 (95 % CI: 2.56, 3.62) among those with less than a high school education, by 1.65 (95 % CI: 1.31, 200) among those who were high school graduates, and by 1.41 (95 % CI: 1.11, 1.72) among those with some college education.

Conclusion

We found strong graded associations between lower income and lower educational attainment with greater CVD risk.

Gender Disparities in Cardiovascular Disease and Their Management: A Review

Worldwide, cardiovascular diseases (CVDs) are still the primary cause of death, and there are notable differences between sexes when it comes to symptoms/course and treatment. Due to evolving healthcare technologies, significant progress has been made in understanding CVDs. Hence, it is evident that gender disparities exist in the clinical presentation, prevalence, management, outcomes, and risk factors, including biological, behavioral, and sociocultural factors. This narrative review is designed to provide a generalized idea of gender disparities in CVDs. It aims to provide insights to prove the role of hormonal influences, genetic predispositions, and the difference in physiological outcomes owing to different genders. This review explores subtle distinctions in CVD across genders, including changes in structure, biology, and hormones that affect how illness presents and progresses. Lifestyle variables also influence sociocultural factors and gender disparities in risk profiles. Traditional risk factors, diabetes mellitus (DM), cholesterol levels, and smoking may have different weights and relevance in men and women. Moreover, age and other conventional risk variables have distinct effects on gender. Treatment efficacy may be impacted by the expression of gender-specific factors, emphasizing the necessity for customized strategies. Development of CVDs can be delayed or prevented, and its consequences can be lessened with the early identification and effective management of gender-specific factors. More investigation is necessary to clarify complex interactions between structural, biochemical, and hormonal aspects across genders in order to maximize treatment results and reduce the burden of CVDs.

The Impact of Stress and Social Determinants on Diet in Cardiovascular Prevention in Young Women

The prevention of cardiovascular diseases is a fundamental pillar for reducing morbidity and mortality caused by non-communicable diseases. Social determinants, such as socioeconomic status, education, neighborhood, physical environment, employment, social support networks, and access to health care, play a crucial role in influencing health outcomes and health inequities within populations. Social determinants and stress in women are interconnected factors that can significantly impact women's health and well-being. Pregnancy is a good time to engage young women and introduce them to beneficial behaviors, such as adopting essential life skills, especially diet, and learning stress management techniques. Stress influences diet, and women are more likely to engage in unhealthy eating behaviors such as emotional eating or coping with stress with food. Strong action is needed to improve women's lifestyle starting at a young age considering that this lays the foundation for a lower cardiovascular risk in adults and the elderly. The objective of this review is to examine cardiovascular primary prevention in young healthy women, focusing particularly on unresolved issues and the influence of social determinants, as well as the correlation with stressors and their influence on diet.

Psychological Health and Ischemic Heart Disease in Women: A Review of Current Evidence and Clinical Considerations across the Healthspan

PURPOSE OF REVIEW

Psychological health encompasses a constellation of negative and positive factors-i.e., psychosocial stress, depression, anxiety, trauma, loneliness and social isolation, anger and hostility, optimism, and a sense of purpose. This narrative review presents current evidence at the intersection of psychological health, risk of ischemic heart disease (IHD), and IHD-related outcomes, with an emphasis on associations in women.

RECENT FINDINGS

For women, relations between psychological health and IHD reflect important sex and gender differences in biological and psychosocial factors. Although efforts devoted to understanding psychological health and IHD risk have varied by psychological factor-scientific evidence is strongest for psychosocial stress and depression, while anxiety, trauma, and positive psychological factors warrant more investigation-less optimal psychological health is consistently associated with an earlier and greater risk of IHD morbidity and mortality in women. Still, many past prospective studies of psychological factors and IHD risk had a limited representation of women, did not include analyses by sex, or failed to account for other influential, sex-specific factors. Thus, there are multiple pathways for further, rigorous investigation into psychological health-IHD associations, mechanisms, and empirically supported psychological interventions to mitigate IHD risk among women. Given the robust evidence linking psychological health with women's risk for IHD, implementing routine, brief, psychological screening is recommended. Significant life events, developmental milestones specific to women, and IHD diagnoses or events could cue further psychological assessment and referral, efforts which will mutually strengthen the evidence for integrated psychological and IHD care and delivery of such care to this vulnerable group.

Measurements of Postmenopausal Serum Estradiol Levels and Cardiovascular Events: A Systematic Review

Background

Cardiovascular disease (CVD) is the leading cause of death among female patients and its likelihood increases following menopause. However, whether estradiol levels are related to CVD remains unknown. We aimed to determine the association between serum estradiol levels and cardiovascular (CV) events in postmenopausal females.

Methods

Electronic databases (MEDLINE, Embase) were searched systematically from inception to October 2022. Studies were eligible for inclusion if they included the following: (i) postmenopausal females; (ii) examination of the association between total serum estradiol levels and CV events (CV mortality, CVD, coronary heart disease, myocardial infarction, stroke, venous thromboembolism, heart failure, and CV hospitalization); (iii) original data (randomized controlled trial, quasi-experimental, cohort, case-control, or cross-sectional study). A narrative synthesis was completed because the data were not amenable to meta-analysis.

Results

Of the 9026 citations retrieved, 8 articles were included, representing a total of 5635 women. The risk-of-bias was fair, and considerable heterogeneity was present. In those not using menopausal hormone therapy, 3 studies demonstrated mixed results between estradiol levels and risk of coronary heart disease, and 1 study showed that higher estradiol levels were associated with an increased risk of myocardial infarction. No significant associations were present between estradiol levels and the remaining events (ie, CV mortality, heart failure, CVD, and stroke).

Conclusions

The association between serum estradiol levels and CV events in postmenopausal females remains unclear. Further studies assessing this association are warranted, given the elevated CVD risk in this population.

Cardiovascular risk, social vigilance, and stress profiles of male law enforcement officers versus civilians

This study examined the cardiovascular disease (CVD) risk profiles of male law enforcement officers (LEOs) and civilians. CVD risk profiles were based on data collected using traditional objective (e.g., resting BP, cholesterol), novel objective (e.g., ambulatory BP) and self-report measures (e.g., EMA social vigilance). A subset of male LEOs (n = 30, M age = 41.47, SD = 8.03) and male civilians (n = 120, M age = 40.73, SD = 13.52) from a larger study were included in analyses. Results indicated LEOs had significantly higher body mass index [BMI], 31.17 kg/m2 versus 28.87 kg/m2, and exhibited significantly higher trait and state social vigilance across multiple measures, whereas perceived stress was higher among civilians. Findings highlight the need for future research examining CVD risk associated with occupational health disparities, including attributes of individuals entering certain professions as well as experiential and environmental demands of the work.

Sex-disparities in chest pain workup: a retrospective cohort review of a university based clinical decision pathway

BACKGROUND

Females have historically lower rates of cardiovascular testing when compared to males. Clinical decision pathways (CDP) that utilize standardized risk-stratification methods may balance this disparity. We sought to determine whether clinical decision pathways could minimize sex-based differences in the non-invasive workup of chest pain in the emergency department (ED). Moreover, we evaluated whether the HEART score would minimize sex-based differences in risk-stratification.

METHODS

We conducted a retrospective cohort review of adult ED encounters for chest pain where CDP was employed. Primary outcome was any occurrence of non-invasive imaging (coronary CTA, stress imaging), invasive testing, intervention (PCI or CABG), or death. Secondary outcomes were 30-day major adverse cardiac events (MACE). We stratified HEART scores and primary/secondary outcomes by sex.

RESULTS

A total of 1078 charts met criteria for review. Mean age at presentation was 59 years. Females represented 47% of the population. Low, intermediate, and high-risk patients as determined by the HEART score were 17%, 65%, and 18% of the population, respectively, without any significant differences between males and females. Non-invasive testing was similar between males and females when stratified by risk. Males categorized as high risk underwent more coronary angiogram (33% vs. 16%, p = 0.01) and PCI (18% vs. 8%, p = 0.04) than high risk females, but this was not seen in patients categorized as low or intermediate risk. Males experienced more MACE than females (8% vs. 3%, p = 0.001).

CONCLUSIONS

We identified no sex-based differences in risk-stratification or non-invasive testing when the CDP was used. High risk males, however, underwent more coronary angiogram and PCI than high risk females, and consequently males experienced more overall MACE than females. This disparity may be explained by sex-based differences in the pathophysiology driving each patient's presentation.

The interplay between sex, time of day, fasting status, and their impact on cardiac mitochondrial structure, function, and dynamics

Mitochondria morphology and function, and their quality control by mitophagy, are essential for heart function. We investigated whether these are influenced by time of the day (TOD), sex, and fed or fasting status, using transmission electron microscopy (EM), mitochondrial electron transport chain (ETC) activity, and mito-QC reporter mice. We observed peak mitochondrial number at ZT8 in the fed state, which was dependent on the intrinsic cardiac circadian clock, as hearts from cardiomyocyte-specific BMAL1 knockout (CBK) mice exhibit different TOD responses. In contrast to mitochondrial number, mitochondrial ETC activities do not fluctuate across TOD, but decrease immediately and significantly in response to fasting. Concurrent with the loss of ETC activities, ETC proteins were decreased with fasting, simultaneous with significant increases of mitophagy, mitochondrial antioxidant protein SOD2, and the fission protein DRP1. Fasting-induced mitophagy was lost in CBK mice, indicating a direct role of BMAL1 in regulating mitophagy. This is the first of its kind report to demonstrate the interactions between sex, fasting, and TOD on cardiac mitochondrial structure, function and mitophagy. These studies provide a foundation for future investigations of mitochondrial functional perturbation in aging and heart diseases.

Consideration of Gender in Cardiovascular Disease Prevention and Management

According to the World Health Organization, heart disease is the leading cause of death worldwide, accounting for approximately 17.9 million deaths annually. Although both men and women experience heart disease, there are notable differences in pathophysiology, evaluation, and pharmacologic management related to biological sex and gender. Men are more likely to develop heart disease at younger ages with more severe presentations. Women usually develop heart disease later in life and have more subtle symptoms, including microvascular involvement. It is essential that providers are aware of gender disparities, social determinants, and modifiable risk factors in prevention of heart disease.

Sex-Related Differences in the Prevalence of Classical, Non-Classical Risk Factors and Management of the Chronic Coronary Syndrome

(1) Background: Coronary artery disease (CAD) remains the leading cause of death in both sexes. The male sex is considered a classical atherosclerosis risk factor, whereas females should be protected by hormonal effects until menopause. Although there are known differences in the development, type, and prognosis of chronic coronary syndrome (CCS) between both sexes, there are no differences in approach in the guidelines. (2) Methods: The sex-related differences in CAD risk factors, treatment, echocardiographic, and angiographic results were assessed among 3291 patients with CCS. (3) Results: Women were older and had a higher prevalence of hypertension, dyslipidaemia, and diabetes mellitus than men. Women were more often treated conservatively than men. There was no difference in the use of beta-blockers and statins among the sexes. The LDL cholesterol goal was less frequently reached by women. Women were treated less often with aspirin than men, but they were treated more often with angiotensin receptor blockers than men. The left ventricle ejection fraction was higher among females. The number of obstructed vessels was higher in men. (4) Conclusions: Women may be more exposed to the risk factors of CAD than men. Men are diagnosed with CAD earlier, and their prevention and therapy are more efficient.

Best practices to promote rigor and reproducibility in the era of sex-inclusive research

To enhance inclusivity and rigor, many funding agencies and journals now mandate the inclusion of females as well as males in biomedical studies. These mandates have enhanced generalizability and created unprecedented opportunities to discover sex differences. However, education in sound methods to consider sex as a subgroup category has lagged behind, resulting in a problematic literature in which study designs, analyses, and interpretations of results are often flawed. Here, we outline best practices for complying with sex-inclusive mandates, both for studies in which sex differences are a primary focus and for those in which they are not. Our recommendations are organized within the "4 Cs of Studying Sex to Strengthen Science: Consideration, Collection, Characterization and Communication," a framework developed by the Office of Research on Women's Health at the National Institutes of Health in the United States. Following these guidelines should help researchers include females and males in their studies while at the same time upholding high standards of rigor.

Characteristics of women with ischemic sudden cardiac death

BACKGROUND

Sudden cardiac death (SCD) is a significant mode of death causing 15-20% of all deaths in high-income countries. Coronary artery disease (CAD) is the most common cause of SCD in both sexes, and SCD is often the first manifestation of underlying CAD in women. This case-control study aimed to determine the factors associated with SCD due to CAD in women.

METHODS

The study group consisted of women with CAD-related SCD (N = 888) derived from the Fingesture study conducted in Northern Finland from 1998 to 2017. All SCDs underwent medicolegal autopsy. The control group consisted of women with angiographically verified CAD without SCD occurring during the 5-year-follow-up (N = 610). To compare these groups, we used medical records, autopsy findings, echocardiograms, and electrocardiograms (ECGs).

RESULTS

Subjects with SCD were older (73.2 ± 11.3 vs. 68.8 ± 8.0, p < 0.001) and were more likely to be smokers or ex-smokers (37.1% vs. 27.6%, p = 0.045) compared to control patients. The proportion of subjects with prior myocardial infarction (MI) was higher in controls (46.9% vs. 41.4% in SCD subjects, p = 0.037), but in contrast, SCD subjects were more likely to have underlying silent MI (25.6% vs. 2.4% in CAD controls, p < 0.001). Left ventricular hypertrophy (LVH) was more common finding in SCD subjects (70.9% vs. 55.1% in controls, p < 0.001). Various electrocardiographic abnormalities were more common in subjects with SCD, including higher heart rate, atrial fibrillation, prolonged QTc interval, wide or fragmented QRS complex and early repolarization. The prevalence of Q waves and T inversions did not differ between the groups.

CONCLUSIONS

Underlying LVH and previous MI with myocardial scarring are common and often undiagnosed in women with CAD-related SCD. These results suggest that untreated CAD with concomitant myocardial disease is an important factor in SCD in women.

The role of sex and gender in hypertension

Hypertension (HTN) is a critical primary modifiable risk factor for the development of cardiovascular diseases, with recognized sex-based differences. While sex refers to one's biological genetic makeup and attributes, gender encompasses the individual's psycho-socio-cultural characteristics, including their environment and living conditions. The impact of each gendered variable may differ amongst men and women with respect to HTN. Applying a sex and gender-based lenses to inform our understanding of HTN has the potential to unveil important contributors of HTN-related cardiovascular outcomes. For instance, increased life stressors, work related anxiety and depression, typically have more pronounced effect on women than men with HTN. The impact of social surrounding including marital status and social support on HTN also differs amongst men and women. While married men are less likely to have higher blood pressure, single women, and those who never married are less likely to have HTN. Additionally, the beneficial role of social support is more pronounced in more historically marginalized cultural groups compared to majority. Finally, socioeconomic status, including education level and income have a linear and inverse relationship in blood pressure control in more resource-rich countries. The aim of this review is to summarize how sex and gender interact in shaping the clinical course of HTN demonstrating the importance of both sex and gender in HTN risk and its treatment. Hence, when investigating the role of gendered factors in HTN it is imperative to consider cultural, and social settings. In this narrative we found that employment and education play a significant role in manifestation and control of HTN particularly in women.

Association between the number of pregnancies and cardiac target organ damages: a cross-sectional analysis of data from the Korean women's chest pain registry (KoROSE)

BACKGROUND

Pregnancy increases long-term cardiovascular risk after childbirth, but the mechanisms are unclear. This study was performed to investigate the association between the number of pregnancies and several cardiac target organ damage (TOD) in middle-aged and elderly women.

METHODS

Using the database of the nation-wide registry, a total of 1,137 women (mean age 63.0 ± 10.9 years) with stable chest pain undergoing invasive coronary angiography (CAG) were analyzed. Information on the number of pregnancies was obtained through a questionnaire. Obstructive coronary artery disease (CAD), left ventricular (LV) mass index (LVMI) and LV septal annular (e') velocity were assessed as indicators of cardiac TOD.

RESULTS

Women with higher number of pregnancies (≥ 3) were older (66.3 ± 9.6 vs. 57.4 ± 10.7 years; P < 0.001), had more cardiovascular risk factors, and took more cardiovascular medications than those with lower number of pregnancies (< 3). In multivariable analyses, higher number of pregnancies (≥ 3) was associated with obstructive CAD (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.21-2.17; P = 0.001), a higher LVMI (> 95 g/m²) (OR, 1.46; 95% CI, 1.08-1.98; P = 0.013) and a lower septal e' velocity (< 7 cm/s) (OR, 1.55; 95% CI, 1.12-2.14; P = 0.007) even after controlling for potential confounders. As the number of pregnancies increased, the prevalence of CAD and LVMI increased, and the septal e' velocity gradually decreased (P < 0.001 for each).

CONCLUSIONS

In women with chest pain undergoing invasive CAG, higher number of pregnancies was associated with multiple cardiac TOD. Parity information should be checked when assessing a woman's cardiovascular risk.

Surgical revascularization in women: focus on factors worsening the prognosis

In recent years, there has been an increase in the number of women undergoing coronary artery bypass grafting (CABG). Although the evidence of gender effects on outcomes is controversial, a number of publications have reported less favorable outcomes of CABG in women. The aim of this paper was to review the literature regarding factors that worsen short- and long-term prognosis in women undergoing surgical myocardial revascularization.

Gender differences in early outcomes of CABG are largely explained by gender distribution of baseline clinical characteristics. Women, compared to men, undergo CABG at an older age and have a worse profile of cardiovascular disease (CVD) risk factors (RF), comorbidity burden, structural and functional cardiac pathology, and coronary lesions. In women, complete myocardial revascularization is less frequent than in men, venous shunts are used more frequently, and the left internal mammary artery is less frequently used as a conduit. In addition to the baseline characteristics, higher incidence of perioperative myocardial infarction (MI), higher prevalence of anxiety and depression, lower quality of life and social adaptation after CABG, and lower involvement of women in rehabilitation programs, compared to men, may contribute to a less favorable long-term prognosis after CABG in women.

There is a need for more information for physicians about the specifics of CVDs and anatomical and surgical aspects of CABG in women. It is also necessary to raise patients’ awareness of RF correction and to involve them in educational technologies. Recommendations for diagnosis and treatment of CVDs should be developed taking into account gender. Further research is also required to develop and implement sex-specific models for predicting surgical risks. Long-term follow-up is appropriate in women with recent MI and a history of diabetes mellitus. To further improve clinical outcomes of CABG in women, development of approaches that facilitate more complete revascularization and reduce the incidence of perioperative complications, such as MI and pneumonia, is needed. More answers to questions regarding gender differences in long-term outcomes of CABG may be obtained by analyzing further studies involving a larger number of female patients.

Low defensive cardiac reactivity as a physiological correlate of psychopathic fearlessness: Gender differences

Affective/interpersonal features of psychopathy have been consistently associated with diverse psychophysiological indicators of low threat sensitivity, suggesting an underlying deficit in the reactivity of the brain's defensive motivational system. This study examined the Cardiac Defense Response (CDR) -a complex pattern of heart rate changes in response to an aversive, intense, and unexpected stimulus- and its second accelerative component (A2), as a new physiological indicator of the fearlessness trait component of psychopathy. The differential contribution of dispositional fearlessness, externalizing proneness, and coldheartedness to the CDR pattern elicited during a defense psychophysiological test was examined in a mixed-gender sample of 156 undergraduates (62% women) assessed by the Psychopathic Personality Inventory-Revised (PPI-R). Higher PPI-R Fearless Dominance scores were related to lower heart rate changes throughout the CDR in women, but not in men. Further analyses on scales conforming the fearless dominance factor revealed that the hypothesized reduced A2 was specifically related to higher PPI-R Fearlessness scores only in women. Our findings provide initial evidence for the utility of the A2 to better understand the physiological aspects of fearlessness tendencies and its potential distinct manifestations across genders.

The burden of premature mortality from cardiovascular diseases: A systematic review of years of life lost

INTRODUCTION

Premature mortality refers to deaths that occur before the expected age of death in a given population. Years of life lost (YLL) is a standard parameter that is frequently used to quantify some component of an "avoidable" mortality burden.

OBJECTIVE

To identify the studies on premature cardiovascular disease (CVD) mortality and synthesise their findings on YLL based on the regional area, main CVD types, sex, and study time.

METHOD

We conducted a systematic review of published CVD mortality studies that reported YLL as an indicator for premature mortality measurement. A literature search for eligible studies was conducted in five electronic databases: PubMed, Scopus, Web of Science (WoS), and the Cochrane Central Register of Controlled Trials (CENTRAL). The Newcastle-Ottawa Scale was used to assess the quality of the included studies. The synthesis of YLL was grouped into years of potential life lost (YPLL) and standard expected years of life lost (SEYLL) using descriptive analysis. These subgroups were further divided into WHO (World Health Organization) regions, study time, CVD type, and sex to reduce the effect of heterogeneity between studies.

RESULTS

Forty studies met the inclusion criteria for this review. Of these, 17 studies reported premature CVD mortality using YPLL, and the remaining 23 studies calculated SEYLL. The selected studies represent all WHO regions except for the Eastern Mediterranean. The overall median YPLL and SEYLL rates per 100,000 population were 594.2 and 1357.0, respectively. The YPLL rate and SEYLL rate demonstrated low levels in high-income countries, including Switzerland, Belgium, Spain, Slovenia, the USA, and South Korea, and a high rate in middle-income countries (including Brazil, India, South Africa, and Serbia). Over the past three decades (1990-2022), there has been a slight increase in the YPLL rate and the SEYLL rate for overall CVD and ischemic heart disease but a slight decrease in the SEYLL rate for cerebrovascular disease. The SEYLL rate for overall CVD demonstrated a notable increase in the Western Pacific region, while the European region has experienced a decline and the American region has nearly reached a plateau. In regard to sex, the male showed a higher median YPLL rate and median SEYLL rate than the female, where the rate in males substantially increased after three decades.

CONCLUSION

Estimates from both the YPLL and SEYLL indicators indicate that premature CVD mortality continues to be a major burden for middle-income countries. The pattern of the YLL rate does not appear to have lessened over the past three decades, particularly for men. It is vitally necessary to develop and execute strategies and activities to lessen this mortality gap.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021288415.

Does the addition of serum antimüllerian hormone concentrations to the Framingham Risk Score and Pooled Cohort Equations improve the prediction of cardiovascular disease?

The present study revealed that the addition of serum antimüllerian hormone concentrations to Framingham Risk Score and Pooled Cohort Equations could potentially improve the risk prediction of cardiovascular disease.

Objective

The current study aimed to examine the added value of serum antimüllerian hormone (AMH) concentration to the Framingham Risk Score (FRS) and Pooled Cohort Equations (PCE) in predicting the risk of cardiovascular disease (CVD) in women of reproductive age.

Methods

Women 30 years and older were considered eligible for this population-based prospective study. The univariate and multivariate Cox proportional hazard models were used to evaluate the association between the serum concentrations of AMH and the risk of CVD.

Results

In the enhanced model, which integrated AMH into FRS and PCE and was adjusted for family history of premature CVD, AMH showed a significant association with the risk of CVD during a 19-year follow-up of 800 women (hazard ratio, 0.77 [95% CI, 0.60-0.99] and hazard ratio, 0.64 [95% CI, 0.48-0.84], respectively). According to the likelihood-ratio test, the addition of AMH measurements to FRS and PCE could significantly improve the risk prediction of CVD (P = 0.02 and P < 0.001, respectively); however, the integration of this biomarker did not improve the classification of risk categories.

Conclusions

The present findings revealed that the addition of serum AMH concentrations to FRS and PCE could potentially improve the risk prediction of CVD.

Sex differences in cardiovascular disease and dysregulation in Down syndrome

This meta-analysis, which consisted of a scoping review and retrospective medical record review, is focused on potential sex differences in cardiovascular diseases in patients with Down syndrome. We limited our review to peer-reviewed, primary articles in the English language, in the PubMed and Web of Science databases from 1965 to 2021. Guidelines for scoping reviews were followed throughout the process. Four categorical domains were identified and searched using additional keywords: 1) congenital heart disease, 2) baseline physiology and risk factors, 3) heart disease and hypertension, and 4) stroke and cerebrovascular disease. Articles were included if they reported male and female distinct data, participants with Down syndrome, and one of our keywords. The retrospective medical record review was completed using 75 participating health care organizations to identify the incidence of congenital and cardiovascular diseases and to quantify cardiovascular risk factors in male and female patients. Female patients with Down syndrome are at higher risk of hypertension, ischemic heart disease, and cerebrovascular disease. The risk of congenital heart disease is higher in males with Down syndrome at all ages included in our analyses. Some of the male-to-female sex differences in cardiovascular disease risk in the general patient population are not present, or reversed in the Down syndrome population. This information should be considered for future investigations and ongoing patient care.NEW & NOTEWORTHY In patients with Down syndrome (DS), CHD is the leading cause of death <20 yr old and cardiovascular disease is a leading cause of death in individuals >20 yr old. Men with DS live longer than women. It is unknown if sex differences are present in cardiovascular disease and dysregulation in DS across the lifespan. We observed higher risk of hypertension, ischemic heart disease, and cerebrovascular disease in females and a higher risk of CHD in males with DS.

Gender medicine: effects of sex and gender on cardiovascular disease manifestation and outcomes

Despite a growing body of evidence, the distinct contributions of biological sex and the sociocultural dimension of gender to the manifestations and outcomes of ischaemic heart disease and heart failure remain unknown. The intertwining of sex-based differences in genetic and hormonal mechanisms with the complex dimension of gender and its different components and determinants that result in different disease phenotypes in women and men needs to be elucidated. The relative contribution of purely biological factors, such as genes and hormones, to cardiovascular phenotypes and outcomes is not yet fully understood. Increasing awareness of the effects of gender has led to efforts to measure gender in retrospective and prospective clinical studies and the development of gender scores. However, the synergistic or opposing effects of sex and gender on cardiovascular traits and on ischaemic heart disease and heart failure mechanisms have not yet been systematically described. Furthermore, specific considerations of sex-related and gender-related factors in gender dysphoria or in heart-brain interactions and their association with cardiovascular disease are still lacking. In this Review, we summarize contemporary evidence on the distinct effects of sex and gender as well as of their interactions on cardiovascular disease and how they favourably or unfavourably influence the pathogenesis, clinical manifestations and treatment responses in patients with ischaemic heart disease or heart failure.

Sex chromosome mechanisms in cardiac development and disease

Many human diseases, including cardiovascular disease, show differences between men and women in pathology and treatment outcomes. In the case of cardiac disease, sex differences are exemplified by differences in the frequency of specific types of congenital and adult-onset heart disease. Clinical studies have suggested that gonadal hormones are a factor in sex bias. However, recent research has shown that gene and protein networks under non-hormonal control also account for cardiac sex differences. In this review, we describe the sex chromosome pathways that lead to sex differences in the development and function of the heart and highlight how these findings affect future care and treatment of cardiac disease.