Effect of menopause on plaque morphologic characteristics in coronary atherosclerosis

Sex and stroke risk factors: A review of differences and impact

OBJECTIVES

There is an increase in stroke incidence risk over the lifetime of women, given their longer life expectancy. However, an alarming trend for sex disparities, particularly in certain stroke risk factors, shows a concerning need for focus on sex differences in stroke prevention and treatment for women. In this article, we are addressing sex differences in both traditional and sex-specific stroke risk factors.

METHODS

We searched PubMed from inception to December 2022 for articles related to sex differences and risk factors for stroke. We reviewed full-text articles for relevance and ultimately included 152 articles for this focused review.

RESULTS

Women are at increased risk for stroke from both traditional and non-traditional stroke risk factors. As women age, they have a higher disease burden of atrial fibrillation, increased risk of stroke related to diabetes, worsening lipid profiles, and higher prevalence of hypertension and obesity compared to men. Further, women carry sex hormone-specific risk factors for stroke, including the age of menarche, menopause, pregnancy, and its complications, as well as hormonal therapy. Men have a higher prevalence of tobacco use and atrial fibrillation, as well as an increased risk for stroke related to hyperlipidemia. Additionally, men have sex-specific risks related to low testosterone levels.

CONCLUSIONS

By identifying biological sex-specific risk factors for stroke, developing robust collaborations, researching, and applying the knowledge for risk reduction strategies, we can begin to tailor prevention and reduce the global burden of stroke morbidity and mortality.

Omics Approaches Unveiling the Biology of Human Atherosclerotic Plaques

Atherosclerosis is a chronic inflammatory disease of the arterial wall, characterized by the buildup of plaques with the accumulation and transformation of lipids, immune cells, vascular smooth muscle cells, and necrotic cell debris. Plaques with collagen-poor thin fibrous caps infiltrated by macrophages and lymphocytes are considered unstable because they are at the greatest risk of rupture and clinical events. However, the current histologic definition of plaque types may not fully capture the complex molecular nature of atherosclerotic plaque biology and the underlying mechanisms contributing to plaque progression, rupture, and erosion. The advances in omics technologies have changed the understanding of atherosclerosis plaque biology, offering new possibilities to improve risk prediction and discover novel therapeutic targets. Genomic studies have shed light on the genetic predisposition to atherosclerosis, and integrative genomic analyses expedite the translation of genomic discoveries. Transcriptomic, proteomic, metabolomic, and lipidomic studies have refined the understanding of the molecular signature of atherosclerotic plaques, aiding in data-driven hypothesis generation for mechanistic studies and offering new prospects for biomarker discovery. Furthermore, advancements in single-cell technologies and emerging spatial analysis techniques have unveiled the heterogeneity and plasticity of plaque cells. This review discusses key omics-based discoveries that have advanced the understanding of human atherosclerotic plaque biology, focusing on insights derived from omics profiling of human atherosclerotic vascular specimens.

Compositional plaque progression in women and men with non-obstructive coronary artery disease

Background

In coronary artery disease (CAD), plaque progression and plaque composition are associated with cardiovascular risk. Whether compositional plaque progression in non-obstructive CAD differs between women and men is less studied.

Methods

We included 31 patients (42% women) with chronic non-obstructive CAD from the Norwegian Registry of Invasive Cardiology, undergoing serial coronary computed tomography angiography (CCTA) on clinical indication (median inter-scan interval 1.8 [1.5-2.2] years). We performed quantitative and qualitative plaque analysis of all coronary artery segments.

Results

Women were older compared to men (65 ± 8 years vs. 55 ± 12 years, p = 0.019), while there was no difference in the prevalence of hypertension, diabetes, smoking or statin treatment between groups. At baseline, women had a higher total plaque burden, more calcified plaques, and less fibro-fatty and necrotic core plaques compared to men (all p < 0.05). During follow-up, men showed faster progression of fibro-fatty plaques (4.0 ± 5.4 % per year vs. -0.6 ± 3.1 % per year, p = 0.019) and a greater reduction of fibrous plaques (-7.3 ± 6.1 % per year vs. 2.1 ± 7.2 % per year, p = 0.003) compared to women even after age adjustment. At follow-up, total plaque burden remained higher in women compared to men (24.9 ± 3.3 % vs. 21.1 ± 2.6 %, p = 0.001), while men had an increase in fibro-fatty (21.2 ± 9.3 % vs. 28.6 ± 9.8 %, p = 0.004) and necrotic core plaques (5.6 ± 3.6 % vs. 10.8 ± 7.2 %, p = 0.006), and a decrease in fibrous plaques (69.0 ± 11.9 % vs. 54.7 ± 13.7 %, p < 0.001). Women's plaque composition remained unaltered.

Conclusion

In non-obstructive CAD, serial CCTA demonstrated a higher total plaque burden and a stable plaque composition in women, while men had a faster progression of unstable low-attenuating fibro-fatty plaques.Clinical trial registration: ClinicalTrials.gov: Identifier NCT04009421.

Sex differences in coronary atherosclerosis during the pre- and postmenopausal period: The Tampere Sudden Death Study

BACKGROUND AND AIMS

Women are believed to be protected from coronary heart disease (CHD) by the effects of estrogen but detailed studies on the vessel wall level are missing. We aimed to measure sex differences in atherosclerosis during the premenopausal and postmenopausal periods directly at the coronary arteries.

METHODS

We analyzed statistics for sex differences in CHD mortality in Finland in 2020. Coronary atherosclerosis was measured using computer-assisted morphometry in 10-year age groups of 185 white Caucasian women and 515 men from the Tampere Sudden Death Study.

RESULTS

CHD mortality was rare in both women and men before 50 years of age. After 50 years of age, male mortality increased rapidly, with women reaching equal levels in the oldest age groups. In the autopsy series, there were no differences in fatty streak, fibrotic or calcified plaque areas, nor in the plaque area or stenosis percentage in coronary arteries between premenopausal women and men in the same age group. The plaque area remained 25 % smaller in both coronaries in postmenopausal women aged 51-70 years compared to men. In the oldest postmenopausal group (≥70 years), plaque area reached the level of men. In the postmenopausal period, coronary stenosis in the left anterior descending (LAD) artery remained lower among women.

CONCLUSION

We did not detect any major sex-difference in coronary atherosclerosis in the premenopausal period when women are considered to be protected from CHD. However, in line with CHD mortality statistics, postmenopausal women showed a slower speed of coronary atherosclerosis development compared to men.

The Significance of Coronary Artery Calcification for Percutaneous Coronary Interventions

The prevalence of calcium deposits in coronary arteries grows with age. Risk factors include, e.g., diabetes and chronic kidney disease. There are several underlying pathophysiological mechanisms of calcium deposition. Severe calcification increases the complexity of percutaneous coronary interventions. Invasive techniques to modify the calcified atherosclerotic plaque before stenting have been developed over the last years. They include balloon- and non-balloon-based techniques. Rotational atherectomy has been the most common technique to treat calcified lesions but new techniques are emerging (orbital atherectomy, intravascular lithotripsy, laser atherectomy). The use of intravascular imaging (intravascular ultrasound and optical coherence tomography) is especially important during the procedures in order to choose the optimal strategy and to assess the final effect of the procedure. This review provides an overview of the role of coronary calcification for percutaneous coronary interventions.

Platelet biology and function: plaque erosion vs. rupture

The leading cause of heart disease in developed countries is coronary atherosclerosis, which is not simply a result of ageing but a chronic inflammatory process that can lead to acute clinical events upon atherosclerotic plaque rupture or erosion and arterial thrombus formation. The composition and location of atherosclerotic plaques determine the phenotype of the lesion and whether it is more likely to rupture or to erode. Although plaque rupture and erosion both initiate platelet activation on the exposed vascular surface, the contribution of platelets to thrombus formation differs between the two phenotypes. In this review, plaque phenotype is discussed in relation to thrombus composition, and an overview of important mediators (haemodynamics, matrix components, and soluble factors) in plaque-induced platelet activation is given. As thrombus formation on disrupted plaques does not necessarily result in complete vessel occlusion, plaque healing can occur. Therefore, the latest findings on plaque healing and the potential role of platelets in this process are summarized. Finally, the clinical need for more effective antithrombotic agents is highlighted.

Beyond the Basics: Unraveling the Complexity of Coronary Artery Calcification

Coronary artery calcification (CAC) is mainly associated with coronary atherosclerosis, which is an indicator of coronary artery disease (CAD). CAC refers to the accumulation of calcium phosphate deposits, classified as micro- or macrocalcifications, that lead to the hardening and narrowing of the coronary arteries. CAC is a strong predictor of future cardiovascular events, such as myocardial infarction and sudden death. Our narrative review focuses on the pathophysiology of CAC, exploring its link to plaque vulnerability, genetic factors, and how race and sex can affect the condition. We also examined the connection between the gut microbiome and CAC, and the impact of genetic variants on the cellular processes involved in vascular calcification and atherogenesis. We aimed to thoroughly analyze the existing literature to improve our understanding of CAC and its potential clinical and therapeutic implications.

Age-Stratified Prevalence and Relative Prognostic Significance of Traditional Atherosclerotic Risk Factors: A Report from the Nationwide Registry of Percutaneous Coronary Interventions in Japan

Background The prevalence of traditional atherosclerotic risk factors (TARFs) and their association with clinical profiles or mortality in percutaneous coronary intervention remain unclear. Methods and Results The study analyzed 559 452 patients who underwent initial percutaneous coronary intervention between 2012 and 2019 in Japan. TARFs were defined as male sex, hypertension, dyslipidemia, diabetes, smoking, and chronic kidney disease. We calculated the relative importance according to R2 and machine learning models to assess the impact of TARFs on clinical profile and in-hospital mortality. The relative contribution (RC) of each TARF was defined as the average percentage of the relative importance calculated from these models. The age-specific prevalence of TARFs, except for chronic kidney disease, formed an inverted U-shape with significantly different peaks and percentages. In the logistic regression model and relative risk model, smoking was most strongly associated with acute myocardial infarction (adjusted odds ratio [OR], 1.62 [95% CI, 1.60-1.64]; RC, 47.1%) and premature coronary artery disease (adjusted unstandardized beta coefficient, 2.68 [95% CI, 2.65-2.71], RC, 42.2%). Diabetes was most strongly associated with multivessel disease (adjusted unstandardized beta coefficient, 0.068 [95% CI, 0.066-0.070], RC, 59.4%). The absence of dyslipidemia was most strongly associated with presentation of cardiogenic shock (adjusted OR, 0.62 [95% CI, 0.61-0.64], RC, 34.2%) and in-hospital mortality (adjusted OR, 0.44 [95% CI, 0.41-0.46], RC, 39.8%). These specific associations were consistently observed regardless of adjustment or stratification by age. Conclusions Our analysis showed a significant variation in the age-specific prevalence of TARFs. Further, their contribution to clinical profiles and mortality also varied widely.

Combined Therapy with Anthracyclines and GnRH Analogues for Breast Cancer: Impact on Ischemic Heart Disease

The combination of classic chemotherapy agents like anthracyclines with novel targeted medications has had a positive impact on women's survival from breast cancer. GnRH analogues are primarily employed to temporarily suppress ovarian function in premenopausal women with hormone-receptor-positive (HR+) breast cancer. Despite their benefits, the true degree of their collateral effects has been widely understudied, especially when it comes to ischemic heart disease. This review aims at summarizing the current state of the art on this issue, with particular focus on the risk for cardiotoxicity associated with the combined use of GnRH analogues and anthracyclines.

Female Gene Networks Are Expressed in Myofibroblast-Like Smooth Muscle Cells in Vulnerable Atherosclerotic Plaques

BACKGROUND

Women presenting with coronary artery disease more often present with fibrous atherosclerotic plaques, which are currently understudied. Phenotypically modulated smooth muscle cells (SMCs) contribute to atherosclerosis in women. How these phenotypically modulated SMCs shape female versus male plaques is unknown.

METHODS

Gene regulatory networks were created using RNAseq gene expression data from human carotid atherosclerotic plaques. The networks were prioritized based on sex bias, relevance for smooth muscle biology, and coronary artery disease genetic enrichment. Network expression was linked to histologically determined plaque phenotypes. In addition, their expression in plaque cell types was studied at single-cell resolution using single-cell RNAseq. Finally, their relevance for disease progression was studied in female and male Apoe-/- mice fed a Western diet for 18 and 30 weeks.

RESULTS

Here, we identify multiple sex-stratified gene regulatory networks from human carotid atherosclerotic plaques. Prioritization of the female networks identified 2 main SMC gene regulatory networks in late-stage atherosclerosis. Single-cell RNA sequencing mapped these female networks to 2 SMC phenotypes: a phenotypically modulated myofibroblast-like SMC network and a contractile SMC network. The myofibroblast-like network was mostly expressed in plaques that were vulnerable in women. Finally, the mice ortholog of key driver gene MFGE8 (milk fat globule EGF and factor V/VIII domain containing) showed retained expression in advanced plaques from female mice but was downregulated in male mice during atherosclerosis progression.

CONCLUSIONS

Female atherosclerosis is characterized by gene regulatory networks that are active in fibrous vulnerable plaques rich in myofibroblast-like SMCs.

Sex- and age-related differences in outcomes of patients with acute myocardial infarction: MINOCA vs. MIOCA

AIMS

The aim of the study is to evaluate the impact of sex on acute myocardial infarction (AMI) patients' clinical presentation and outcomes, comparing those with non-obstructive and obstructive coronary arteries (MINOCA vs. MIOCA).

METHODS AND RESULTS

We enrolled 2455 patients with AMI undergoing coronary angiography from January 2017 to September 2021. Patients were divided according to the type of AMI and sex: male (n = 1593) and female (n = 607) in MIOCA and male (n = 87) and female (n = 168) in MINOCA. Each cohort was further stratified based on age (≤/> 70 years). The primary endpoint (MAE) was a composite of all-cause death, recurrent AMI, and hospitalization for heart failure (HF) at follow-up. Secondary outcomes included all-cause and cardiovascular death, recurrent AMI, HF re-hospitalization, and stroke. MINOCA patients were more likely to be females compared with MIOCA ones (P < 0.001). The median follow-up was 28 (15-41) months. The unadjusted incidence of MAE was significantly higher in females compared with males, both in MINOCA [45 (26.8%) vs. 12 (13.8%); P = 0.018] and MIOCA cohorts [203 (33.4%) vs. 428 (26.9%); P = 0.002]. Age was an independent predictor of MAE in both cohorts. Among MINOCA patients, females ≤70 years old had a higher incidence of MAE [18 (23.7%) vs. 4 (5.9%); P = 0.003] compared with male peers, mainly driven by a higher rate of re-hospitalization for HF (P = 0.045) and recurrence of AMI (P = 0.006). Only in this sub-group of MINOCA patients, female sex was an independent predictor of MAE (hazard ratio = 3.09; 95% confidence interval: 1.02-9.59; P = 0.040). MINOCA females ≤70 years old had worse outcomes than MIOCA female peers.

CONCLUSION

MINOCA females ≤70 years old had a significantly higher incidence of MAE, compared with males and MIOCA female peers, likely due to the different pathophysiology of the ischaemic event.

TRIAL REGISTRATION

Data were part of the ongoing observational study 'AMIPE: Acute Myocardial Infarction, Prognostic and Therapeutic Evaluation' (ClinicalTrials.gov Identifier: NCT03883711).

Sex Differences in Coronary Atherosclerotic Phenotype and Healing Pattern on Optical Coherence Tomography Imaging

BACKGROUND

Layered plaque, a signature of previous plaque disruption, is a known predictor of rapid plaque progression. Layered plaque can be identified in vivo by optical coherence tomography. Studies have reported differences in plaque burden between women and men, but sex differences in the pattern of layered plaque are unknown.

METHODS

Preintervention optical coherence tomography images of 533 patients with chronic coronary syndromes were analyzed. Detailed plaque characteristics of layered and nonlayered plaques of the target lesion were compared between men and women.

RESULTS

The prevalence of layered plaque was similar between men (N=418) and women (N=115; 55% versus 54%; P=0.832). In men, more features of plaque vulnerability were identified in layered plaque than in nonlayered plaque: lipid plaque (87% versus 69%; P<0.001), macrophages (69% versus 56%; P=0.007), microvessels (72% versus 39%; P<0.001), and cholesterol crystals (49% versus 30%; P<0.001). No difference in plaque vulnerability between layered and nonlayered plaques was observed in women. Layered plaque in men had more features consistent with previous plaque rupture than in women: interrupted pattern (74% versus 52%; P<0.001) and a greater layer index (1198 [781-1835] versus 943 [624-1477]; P<0.001).

CONCLUSIONS

In men, layered plaques exhibit more features of vascular inflammation and vulnerability as well as evidence of previous plaque rupture, compared with nonlayered plaques, whereas in women, no difference was observed between layered and nonlayered plaques. Vascular inflammation (plaque rupture) may be the predominant mechanism of layered plaque in men, whereas a less inflammatory mechanism may play a key role in women.

REGISTRATION

URL: http://www.

CLINICALTRIALS

gov; Unique Identifier: NCT01110538, NCT04523194.

Activation of estrogen receptor α inhibits TLR4 signaling in macrophages and alleviates the instability of atherosclerotic plaques in the postmenopausal stage

Acute cardiovascular events increase significantly in postmenopausal women. The relationship between estrogen receptor (ER) and plaque stability in the postmenopausal stage remains to be elucidated. We aimed to explore whether ERα activation improves plaque instability in the postmenopausal stage. Here, we report that postmenopausal women showed increased macrophage activation and plaque instability with increased MCP-1, MMP9, TLR4, MYD88 and NF-κB p65 and decreased ERα and TIMP1 expression in the vascular endothelium. Moreover, ovariectomy in LDLR-/- mice resulted in a significant increase in plaque area and necrotic core area, as well as a significant decrease in collagen content and an increase in macrophage accumulation in the artery. Ovariectomy also reduced serum estrogen levels and ERα expression and upregulated TLR4 and MMP9 expression in arteries in LDLR-/- mice. Estrogen or phytoestrogen therapy upregulated the expression level of ERα in ovariectomized mice and increased plaque stability by inhibiting macrophage accumulation and TLR4 signaling. In vitro, LPS incubation of RAW264.7 cells resulted in a significant decrease in ERα and TIMP1 expression and an increase in TLR4 activation, and estrogen or phytoestrogen treatment increased ERα and TIMP1 expression and inhibited TLR4 activation and MMP9 expression in LPS-treated RAW264.7 cells. Compared to control siRNA transfected RAW264.7 cells, TLR4 siRNA promoted TIMP1 expression in RAW264.7 cells with LPS incubation, but did not affect ERα expression in RAW264.7 cells with or without LPS treatment. The ERα inhibitor MPP abolished the regulatory effect of estrogen or phytoestrogen on LPS-induced RAW264.7 cells. In conclusion, the present study demonstrates that decreased ERα expression promotes macrophage infiltration and plaque instability in the postmenopausal stage, and activation of ERα in the postmenopausal stage alleviates atherosclerotic plaque instability by inhibiting TLR4 signaling and macrophage-related inflammation.

Female gene networks are expressed in myofibroblast-like smooth muscle cells in vulnerable atherosclerotic plaques

Women presenting with coronary artery disease (CAD) more often present with fibrous atherosclerotic plaques, which are currently understudied. Phenotypically modulated smooth muscle cells (SMCs) contribute to atherosclerosis in women. How these phenotypically modulated SMCs shape female versus male plaques is unknown. Here, we show sex-stratified gene regulatory networks (GRNs) from human carotid atherosclerotic tissue. Prioritization of these networks identified two main SMC GRNs in late-stage atherosclerosis. Single-cell RNA-sequencing mapped these GRNs to two SMC phenotypes: a phenotypically modulated myofibroblast-like SMC network and a contractile SMC network. The myofibroblast-like GRN was mostly expressed in plaques that were vulnerable in females. Finally, mice orthologs of the female myofibroblast-like genes showed retained expression in advanced plaques from female mice but were downregulated in male mice during atherosclerosis progression. Female atherosclerosis is driven by GRNs that promote a fibrous vulnerable plaque rich in myofibroblast-like SMCs.

Relationship between plasma glutamate and cardiovascular disease risk in Chinese patients with type 2 diabetes mellitus by gender

Objectives

This study aimed to assess the association between plasma glutamate (Glu) and the risk of cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM) and whether this association differs by gender.

Material and methods

We retrieved clinical information on 1032 consecutive patients with T2DM from a same tertiary care center from May 2015 to August 2016. Glu was quantified by liquid chromatography-tandem mass spectrometry analysis. Glu was converted into a categorical variable based on the median concentration in the whole population, while logistic regression was used to obtain the odds ratio (OR) and 95% confidence interval (CI), and the correlation between Glu and various biochemical indices was analyzed.

Results

We found that Glu was positively associated with the risk of CVD in patients with T2DM. This correlation was more significant in women. In T2DM patients, the higher the age, body mass index (BMI), weight and systolic blood pressure (SBP), the lower the glycosylated hemoglobin (HbA1C) concentration and the higher the Glu. In female patients, the correlation between age, weight, BMI, SBP, and plasma Triglycerides (TG), and Glu was also statistically significant.

Conclusion

In conclusion, female T2DM patients with high levels of Glu have a higher risk of developing CVD.

Clinical Outcomes of Different Calcified Culprit Plaques in Patients with Acute Coronary Syndrome

Background: Previous studies have found that coronary artery calcification is closely associated with the occurrence of major adverse cardiac events (MACE). This study aimed to investigate the characteristics and clinical outcomes of different calcified plaques in patients with acute coronary syndrome (ACS) by using optical coherence tomography (OCT). Methods: 258 ACS patients with calcified culprit plaques who underwent OCT-guided stent implantation were enrolled. They were divided into three subtypes based on the calcified plaque morphology, including eruptive calcified nodules, calcified protrusion, and superficial calcific sheet. Results: Compared with superficial calcific sheet and calcified protrusion, eruptive calcified nodules had the greatest calcium burden and a higher rate of stent edge dissection (p < 0.001) and incomplete stent apposition (p < 0.001). In a median follow-up period of 2 years, 39 (15.1%) patients experienced MACE (a composite event of cardiac death, target-vessel myocardial infarction, ischemia-driven revascularization), with a significantly higher incidence in the eruptive calcified nodules group (32.1% vs. 10.1% vs. 13.0%, p = 0.001). A multivariate Cox analysis demonstrated that the eruptive calcified nodules (hazard ratio 3.14; 95% confidence interval, 1.64−6.02; p = 0.001) were an independent predictor of MACE. Conclusions: MACE occurred more frequently in ACS patients with eruptive calcified nodules, and the eruptive calcified nodules were an independent predictor of MACE.

Causes, Angiographic Characteristics, and Management of Premature Myocardial Infarction: JACC State-of-the-Art Review

Among patients presenting with acute myocardial infarction (AMI), the proportion of young individuals has increased in recent years. Although coronary atherosclerosis is less extensive in young patients with AMI, with higher prevalence of single-vessel disease and rare left main involvement, the long-term prognosis is not benign. Young patients with AMI with obstructive coronary artery disease have similar risk factors as older patients except for higher prevalence of smoking, lipid disorders, and family history of premature coronary artery disease, and lower prevalence of diabetes mellitus and hypertension. Smoking cessation is by far the most effective secondary preventive measure. Myocardial infarction with nonobstructive coronary arteries is a relatively common clinical entity (10%-20%) among young patients with AMI, with intravascular and cardiac magnetic resonance imaging being key for diagnosis and potentially treatment. Spontaneous coronary artery dissection is a frequent pathogenetic mechanism of AMI among young women, requiring a high degree of suspicion, especially in the peripartum period.

Sex Differences in Culprit Plaque Characteristics Among Different Age Groups in Patients With Acute Coronary Syndromes

BACKGROUND

Despite the significant decline in cardiovascular mortality in women over the past several decades, sex differences in the underlying pathology of acute coronary syndromes remain poorly understood. Previous postmortem studies have demonstrated sex differences in coronary plaque morphology with a higher prevalence of plaque erosion in young women and more plaque rupture in older women after menopause, whereas men showed no increase in prevalence of plaque rupture with age. However, in vivo data are limited.

METHODS

This study included patients who presented with acute coronary syndrome and underwent preintervention optical coherence tomography imaging of the culprit lesion. The culprit plaque was categorized as plaque rupture, plaque erosion or culprit plaque with calcification, and stratified by age. Features of plaque vulnerability at culprit lesion were also analyzed.

RESULTS

In 1368 patients (women=286), women and men had a similar distribution of culprit plaque morphology (plaque rupture versus plaque erosion). However, significant sex differences were found in the underlying mechanisms of acute coronary syndrome among different age groups: women showed a significant ascending trend with age in plaque rupture (P<0.001) and the features of plaque vulnerability such as lipid plaque (P<0.001), thin-cap fibroatheroma (P=0.005), and microstructures including macrophages, cholesterol crystals, and calcification (P=0.026). No trend was observed in men.

CONCLUSIONS

Age related sex differences in culprit plaque morphology and vulnerability were identified in patients with acute coronary syndrome: prevalence of plaque rupture and vulnerability increased with age in women but not in men.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT01110538 and NCT03479723.

Circadian rhythmicity of the thioredoxin system in cultured murine peritoneal macrophages

Macrophages play a pivotal role in atherosclerosis through a variety of events related to cellular oxidative stress. This process is mainly due to an excessive production of reactive oxygen species whose elimination occurs through antioxidant systems including the thioredoxin (Trx) system. In this paper, we investigated whether the Trx system would exhibit circadian rhythmicity in dexamethasone synchronized cultured macrophages and monitored the impact of the rhythmicity of Trx-1 on markers of atherosclerosis. We found that the clock-related genes BMAL-1, PER-2, CRY-1 and REV ERB α exhibited a robust circadian expression. However, the Trx genes family (Trx-1, Trx-2, TrxR1 and TXNIP) did not exhibit a circadian expression at the mRNA level in spite of the presence of E-box elements within the promoter regions of TrxR1 and TXNIP genes. Nevertheless, both Trx-1 and TXNIP exhibited a circadian expression at the protein level and proteasome inhibition abolished the rhythmicity of Trx-1. Moreover, we found a link between low Trx-1 level and elevated atherogenic markers such as 4-HNE, TNF-α and cholesterol accumulation in macrophages. Our results indicate that the Trx gene family does not exhibit the same circadian regulation and that the presence of E-box elements in the TXNIP promoter is not sufficient to ensure a circadian rhythmicity at the transcriptional level. In addition, since a link was found between a low level of Trx-1 protein during circadian rhythm and high levels of atherogenic markers, administration of Trx-1 at certain time points could be an interesting approach to protect against atherosclerosis development.

Sex Differences in Coronary Atherosclerosis

PURPOSE OF REVIEW

The importance of cardiovascular disease (CVD) in women has long been underestimated. Therefore, we need to understand the impact of sex differences on CVD.

RECENT FINDINGS

Traditional risk factors contribute to coronary artery disease (CAD) differently in women and men. There are female-specific risk factors and comorbid conditions that affect the risk of CAD. Plaque erosion is frequently seen in younger women who smoke, while plaque rupture is common in older women and men who have elevated blood cholesterol. Coronary artery calcification is also different in both sexes. Thus, coronary artery calcification score-based risk stratification in women is challenging. A deeper understanding of the sex differences in the risk factors and plaque morphology of coronary atherosclerosis may lead to improved outcomes of CVD in women.

Obesity and Postmenopausal Hormone Receptor-positive Breast Cancer: Epidemiology and Mechanisms

Obesity is a potential risk for several cancers, including postmenopausal, hormone dependent breast cancers. In this review, we summarize recent studies on the impact of obesity on postmenopausal women's health and discuss several mechanisms that were proposed to increase the risk of breast carcinogenesis.

Predictors of Coronary Plaque Erosion in Current and Non-Current Smokers With ST-Segment Elevation Myocardial Infarction - An Optical Coherence Tomography Study

BACKGROUND

Smoking is an important risk factor of plaque erosion. This study aimed to investigate the predictors of plaque erosion in current and non-current smokers presenting with ST-segment elevation myocardial infarction (STEMI).Methods and Results:A total of 1,320 STEMI patients with culprit plaque rupture or plaque erosion detected by pre-intervention optical coherence tomography were divided into a current smoking group (n=715) and non-current smoking group (n=605). Plaque erosion accounted for 30.8% (220/715) of culprit lesions in the current smokers and 21.2% (128/605) in the non-current smokers. Multivariable analysis showed age <50 years, single-vessel disease and the absence of dyslipidemia were independently associated with plaque erosion rather than plaque rupture, regardless of smoking status. In current smokers, diabetes mellitus (odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.10-0.83; P=0.021) was negatively associated with plaque erosion as compared with plaque rupture. In non-current smokers, minimal lumen area (MLA, OR: 1.37; 95% CI: 1.16-1.62; P<0.001) and nearby bifurcation (OR: 3.20; 95% CI: 1.98-5.16; P<0.001) were positively related to plaque erosion, but not plaque rupture.

CONCLUSIONS

In patients with STEMI, the presence of diabetes mellitus significantly increased the risk of rupture-based STEMI but may not have reduced the risk of plaque erosion-based STEMI in current smokers. Nearby bifurcation and larger MLA were associated with plaque erosion in non-current smokers.

Fibrinogen and a Triad of Thrombosis, Inflammation, and the Renin-Angiotensin System in Premature Coronary Artery Disease in Women: A New Insight into Sex-Related Differences in the Pathogenesis of the Disease

Coronary artery disease (CAD) is the leading cause of morbidity and mortality in women worldwide. Its social impact in the case of premature CAD is particularly devastating. Many differences in the presentation of the disease in women as compared to men, including atypical symptoms, microvascular involvement, and differences in pathology of plaque formation or progression, make CAD diagnosis in women a challenge. The contribution of different risk factors, such as smoking, diabetes, hyperlipidemia, or obesity, may vary between women and men. Certain pathological pathways may have different sex-related magnitudes on CAD formation and progression. In spite of the already known differences, we lack sufficiently powered studies, both clinical and experimental, that assess the multipathogenic differences in CAD formation and progression related to sex in different age periods. A growing quantity of data that are presented in this article suggest that thrombosis with fibrinogen is of more concern in the case of premature CAD in women than are other coagulation factors, such as factors VII and VIII, tissue-type plasminogen activator, and plasminogen inhibitor-1. The rise in fibrinogen levels in inflammation is mainly affected by interleukin-6 (IL-6). The renin-angiotensin (RA) system affects the inflammatory process by increasing the IL-6 level. Unlike in men, in young women, the hypertensive arm of the RA system is naturally downregulated by estrogens. At the same time, estrogens promote the fibrinolytic path of the RA system. In young women, the promoted fibrinolytic process upregulates IL-6 release from leukocytes via fibrin degradation products. Moreover, fibrinogen, whose higher levels are observed in women, increases IL-6 synthesis and exacerbates inflammation, contributing to CAD. Therefore, the synergistic interplay between thrombosis, inflammation, and the RA system appears to have a more significant influence on the underlying CAD atherosclerotic plaque formation in young women than in men. This issue is further discussed in this review. Fibrinogen is the biomolecule that is central to these three pathways. In this review, fibrinogen is shown as the biomolecule that possesses a different impact on CAD formation, progression, and destabilization in women to that observed in men, being more pathogenic in women at the early stages of the disease than in men. Fibrinogen is a three-chain glycoprotein involved in thrombosis. Although the role of thrombosis is of great magnitude in acute coronary events, fibrinogen also induces atherosclerosis formation by accumulating in the arterial wall and enabling low-density lipoprotein cholesterol aggregation. Its level rises during inflammation and is associated with most cardiovascular risk factors, particularly smoking and diabetes. It was noted that fibrinogen levels were higher in women than in men as well as in the case of premature CAD in women. The causes of this phenomenon are not well understood. The higher fibrinogen levels were found to be associated with a greater extent of coronary atherosclerosis in women with CAD but not in men. Moreover, the lysability of a fibrin clot, which is dependent on fibrinogen properties, was reduced in women with subclinical CAD compared to men at the same stage of the disease, as well as in comparison to women without coronary artery atherosclerosis. These findings suggest that the magnitude of the pathological pathways contributing to premature CAD differs in women and men, and they are discussed in this review. While many gaps in both experimental and clinical studies on sex-related differences in premature CAD exist, further studies on pathological pathways are needed.

The risk of carotid plaque instability in patients with metabolic syndrome is higher in women with hypertriglyceridemia

Background

Metabolic syndrome certainly favors growth of carotid plaque; however, it is uncertain if it determines plaque destabilization. Furthermore, it is likely that only some components of metabolic syndrome are associated with increased risk of plaque destabilization. Therefore, we evaluated the effect of different elements of metabolic syndrome, individually and in association, on carotid plaques destabilization.

Methods

A total of 186 carotid endarterectomies from symptomatic and asymptomatic patients were histologically analysed and correlated with major cardiovascular risk factors.

Results

Metabolic syndrome, regardless of the cluster of its components, is not associated with a significant increase in risk of plaque destabilization, rather with the presence of stable plaques. The incidence of unstable plaques in patients with metabolic syndrome is quite low (43.9 %), when compared with that seen in the presence of some risk factors, but significantly increases in the subgroup of female patients with hypertriglyceridemia, showing an odds ratio of 3.01 (95% CI, 0.25–36.30).

Conclusions

Our data may help to identify patients with real increased risk of acute cerebrovascular diseases thus supporting the hypothesis that the control of hypertriglyceridemia should be a key point on prevention of carotid atherosclerotic plaque destabilization, especially in post-menopausal female patients.

Comparison of Carotid Plaque Characteristics Between Men and Women Using Magnetic Resonance Vessel Wall Imaging: A Chinese Atherosclerosis Risk Evaluation Study

BACKGROUND

Carotid vulnerable plaque is a major cause of stroke and differs between men and women. Few studies have investigated the differences in carotid plaque features between sexes in a Chinese population.

PURPOSE

To compare carotid atherosclerotic plaque features between men and women in a Chinese population using magnetic resonance imaging.

STUDY TYPE

Cross-sectional.

SUBJECTS

A total of 567 patients (mean age: 61.5 ± 10.1 years; 404 men) who had recent stroke or transient ischemia attack and atherosclerotic plaque in at least one carotid artery.

FIELD STRENGTH

A 3.0 T.

SEQUENCE

T1- and T2-weighted turbo spin echo, three-dimensional time-of-flight (TOF) fast field echo and magnetization-prepared rapid acquisition gradient echo sequences.

ASSESSMENT

Plaque characteristics including lumen area (LA), wall area (WA), total vessel area (TVA), mean wall thickness (MWT), and mean normalized wall index (NWI); presence of calcification, lipid-rich necrotic core (LRNC), intraplaque hemorrhage (IPH), and fibrous cap rupture (FCR); and percent composition area (%area) were evaluated and compared between men and women.

STATISTICAL TESTS

Independent-sample t test, Mann-Whitney U test, chi-square test, and multiple linear and logistic regressions.

RESULTS

In symptomatic arteries, men had significantly greater LA (46.2 ± 15.6 mm² vs. 40.7 ± 12.9 mm² , P < 0.05), WA (33.9 ± 11.5 mm² vs. 26.3 ± 7.5 mm² , P < 0.05), and TVA (80.1 ± 20.4 mm² vs. 67.0 ± 18.0 mm² , P < 0.05); higher MWT (1.2 ± 0.4 mm vs. 1.0 ± 0.2 mm, P < 0.05); and higher prevalence of LRNC (72.3% vs. 46.0%, P < 0.05) and IPH (18.6% vs. 4.9%, P < 0.05) compared with women. In asymptomatic arteries, men had significantly greater LA (48.3 ± 16.9 mm² vs. 42.1 ± 12.6 mm² , P < 0.05), WA (32.9 ± 11.0 mm² vs. 25.8 ± 6.1 mm² , P < 0.05), and TVA (81.2 ± 22.1 mm² vs. 67.9 ± 16.5 mm² , P < 0.05); higher MWT (1.2 ± 0.3 mm vs. 1.0 ± 0.2 mm, P < 0.05); higher prevalence of LRNC (67.8% vs. 42.9%, P < 0.05), IPH (14.9% vs. 1.2%, P < 0.05), and FCR (6.4% vs. 1.2%, P < 0.05); and higher %LRNC area (24.8 ± 17.2% vs. 17.8 ± 14.1%, P < 0.05) compared with women.

DATA CONCLUSION

Men have similar plaque burden but more vulnerable atherosclerotic plaques compared with women in both symptomatic and asymptomatic carotid arteries in a Chinese population.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: Stage 3.

Sex-Stratified Gene Regulatory Networks Reveal Female Key Driver Genes of Atherosclerosis Involved in Smooth Muscle Cell Phenotype Switching

BACKGROUND

Although sex differences in coronary artery disease are widely accepted with women developing more stable atherosclerosis than men, the underlying pathobiology of such differences remains largely unknown. In coronary artery disease, recent integrative systems biological studies have inferred gene regulatory networks (GRNs). Within these GRNs, key driver genes have shown great promise but have thus far been unidentified in women.

METHODS

We generated sex-specific GRNs of the atherosclerotic arterial wall in 160 women and age-matched men in the STARNET study (Stockholm-Tartu Atherosclerosis Reverse Network Engineering Task). We integrated the female GRNs with single-cell RNA-sequencing data of the human atherosclerotic plaque and single-cell RNA sequencing of advanced atherosclerotic lesions from wild type and Klf4 knockout atherosclerotic smooth muscle cell (SMC) lineage-tracing mice.

RESULTS

By comparing sex-specific GRNs, we observed clear sex differences in network activity within the atherosclerotic tissues. Genes more active in women were associated with mesenchymal cells and endothelial cells, whereas genes more active in men were associated with the immune system. We determined that key drivers of GRNs active in female coronary artery disease were predominantly found in (SMCs by single-cell sequencing of the human atherosclerotic plaques, and higher expressed in female plaque SMCs, as well. To study the functions of these female SMC key drivers in atherosclerosis, we examined single-cell RNA sequencing of advanced atherosclerotic lesions from wild type and Klf4 knockout atherosclerotic SMC lineage-tracing mice. The female key drivers were found to be expressed by phenotypically modulated SMCs and affected by Klf4, suggesting that sex differences in atherosclerosis involve phenotypic switching of plaque SMCs.

CONCLUSIONS

Our systems approach provides novel insights into molecular mechanisms that underlie sex differences in atherosclerosis. To discover sex-specific therapeutic targets for atherosclerosis, an increased emphasis on sex-stratified approaches in the analysis of multi-omics data sets is warranted.

Epidemiological Research Advances in Vascular Calcification in Diabetes

Vascular calcification is the transformation of arterial wall mesenchymal cells, particularly smooth muscle cells (SMCs), into osteoblast phenotypes by various pathological factors. Additionally, vascular transformation mediates the abnormal deposition of calcium salts in the vascular wall, such as intimal and media calcification. Various pathological types have been described, such as calcification and valve calcification. The incidence of vascular calcification in patients with diabetes is much higher than that in nondiabetic patients, representing a critical cause of cardiovascular events in patients with diabetes. Because basic research on the clinical transformation of vascular calcification has yet to be conducted, this study systematically expounds on the risk factors for vascular calcification, vascular bed differences, sex differences, ethnic differences, diagnosis, severity assessments, and treatments to facilitate the identification of a new entry point for basic research and subsequent clinical transformation regarding vascular calcification and corresponding clinical evaluation strategies.

Gender Differences in Endothelial Function and Coronary Vasomotion Abnormalities

Introduction:

Structural and functional abnormalities of coronary microvasculature, referred to as coronary microvascular dysfunction (CMD), have been implicated in a wide range of cardiovascular diseases and have gained growing attention in patients with chest pain with no obstructive coronary artery disease, especially in females. The central mechanisms of coronary vasomotion abnormalities encompass enhanced coronary vasoconstrictive reactivity (ie, coronary spasm), reduced endothelium-dependent and -independent coronary vasodilator capacities, and increased coronary microvascular resistance. The 2 major endothelium-derived relaxing factors, nitric oxide (NO) and endothelium-dependent hyperpolarization (EDH) factors, modulate vascular tone in a distinct vessel size–dependent manner; NO mainly mediates vasodilatation of relatively large, conduit vessels, while EDH factors in small resistance vessels. Endothelium-dependent hyperpolarization–mediated vasodilatation is more prominent in female resistance arteries, where estrogens exert beneficial effects on endothelium-dependent vasodilatation via multiple mechanisms. In the clinical settings, therapeutic approaches targeting NO are disappointing for the treatment of various cardiovascular diseases, where endothelial dysfunction and CMD are substantially involved.

Significance:

In this review, we will discuss the current knowledge on the pathophysiology and molecular mechanisms of endothelial function and coronary vasomotion abnormalities from bench to bedside, with a special reference to gender differences.

Results:

Recent experimental and clinical studies have demonstrated distinct gender differences in endothelial function and coronary vasomotion abnormalities with major clinical implications. Moreover, recent landmark clinical trials regarding the management of stable coronary artery disease have questioned the benefit of percutaneous coronary intervention, supporting the importance of the coronary microvascular physiology.

Conclusion:

Further characterization and a better understanding of the gender differences in basic vascular biology as well as those in cardiovascular diseases are indispensable to improve health care and patient outcomes in cardiovascular medicine.

Global and regional prevalence, burden, and risk factors for carotid atherosclerosis: a systematic review, meta-analysis, and modelling study

BACKGROUND

Estimation of the epidemiological burden of carotid atherosclerosis can serve as a basis for prevention and management of cardiovascular disease. We aimed to provide the first estimation on the prevalence, number of cases, and risk factors for carotid atherosclerosis in the general population globally and regionally.

METHODS

In this systematic review, meta-analysis, and modelling study, we searched PubMed, MEDLINE, Embase, Global Health, and China National Knowledge Infrastructure for articles published from database inception until May 7, 2019, with no language restrictions, for population-based studies that quantified prevalence of carotid atherosclerosis by means of increased carotid intima-media thickness, carotid plaque, and carotid stenosis. Studies were eligible if they included bilaterally scanned carotid arteries using ultrasonography and defined increased carotid intima-media thickness as a thickness of 1·0 mm or more, carotid plaque as a focal carotid intima-media thickness of 1·5 mm or more encroaching into the lumen or at least 0·5 mm or 50% compared with the surrounding carotid intima-media thickness values, and carotid stenosis as 50% or more stenosis. Studies were excluded if the sample was not representative of the general population. We also included studies identified in our previous systematic review and meta-analysis of the prevalence of carotid atherosclerosis in China. We estimated age-specific and sex-specific prevalences of increased carotid intima-media thickness, carotid plaque, and carotid stenosis. We used UN population data to generate the number of people affected in 2000, 2015, and 2020. We did random-effects meta-analyses to assess the effects of risk factors for increased carotid intima-media thickness and carotid plaque. We derived regional numbers of people living with increased carotid intima-media thickness and carotid plaque in 2015 using a risk factors-based model by WHO region. All analyses were done in populations aged 30-79 years due to availability of data. This systematic review and meta-analysis is registered online on PROSPERO, CRD42019134709.

FINDINGS

We identified 8632 articles through our database search, of which 515 were eligible for full-text review, including 37 articles from our previous study, and 59 articles were eligible for inclusion in our systematic review and meta-analysis. Overall, in people aged 30-79 years in 2020, the global prevalence of increased carotid intima-media thickness is estimated to be 27·6% (95% CI 16·9-41·3), equivalent to 1066·70 million affected people and a percentage change of 57·46% from 2000; of carotid plaque is estimated to be 21·1% (13·2-31·5), equivalent to 815·76 million affected people and a percentage change of 58·97% from 2000; and carotid stenosis is estimated to be 1·5% (1·1-2·1), equivalent to 57·79 million affected people and a percentage change of 59·13% from 2000. The prevalence of increased carotid intima-media thickness, carotid plaque, and carotid stenosis increased consistently with age and was higher in men than in women. Current smoking, diabetes, and hypertension were common risk factors for increased carotid intima-media thickness and carotid plaque. In 2015, the Western Pacific region had the largest share of global cases of increased carotid intima-media thickness (317·62 million [33·36%] of 952·13 million affected people) and carotid plaque (240·77 million [33·20%] of 725·25 million), whereas the African region had the smallest share of cases of increased carotid intima-media thickness (59·08 million [6·21%]) and the Eastern Mediterranean region had the smallest share of carotid plaque cases (44·59 million [6·15%]).

INTERPRETATION

A substantial global burden of carotid atherosclerosis exists. Effective strategies are needed for primary prevention and management of carotid atherosclerosis. High-quality epidemiological investigations on carotid atherosclerosis are needed to better address the global burden of carotid atherosclerosis at finer levels.

FUNDING

None.

The age- and sex-specific composition of atherosclerotic plaques in vascular surgery patients

BACKGROUND AND AIMS

The sex- and age-related differences in the composition of iliofemoral atherosclerotic plaques are largely unknown. Therefore, the aim of the current study is to gain insight into plaque composition across strata of age and sex in a large cohort of vascular surgery patients.

METHODS

Peripheral atherosclerotic plaques of patients who underwent iliofemoral endarterectomy (n = 790) were harvested between 2002 and 2014. The plaques were semi-quantitatively analyzed for the presence of lipid cores, calcifications, plaque hemorrhages (PH), collagen, macrophage and smooth muscle cell (SMC) content, and quantitatively for microvessel density. Patients were stratified by age tertiles and sex.

RESULTS

Ageing was independently associated with rupture-prone iliofemoral plaque characteristics, such as higher prevalence of plaque calcifications (OR 1.52 (95%CI:1.03-2.24) p = 0.035) and PH (OR 1.46 (95%CI:1.01-2.09) p = 0.042), and lower prevalence of collagen (OR 0.52 (95%CI:0.31-0.86) p = 0.012) and SMCs (OR 0.59 (95%CI:0.39-0.90) p = 0.015). Sex-stratified data showed that men had a higher prevalence of lipid cores (OR 1.62 (95%CI:1.06-2.45) p = 0.025) and PH (OR 1.62 (95%CI:1.16-2.54) p = 0.004) compared to women. These sex-differences attenuated with increasing age, with women showing an age-related increase in calcifications (p = 0.002), PH (p = 0.015) and decrease in macrophages (p = 0.005). In contrast, men only showed a decrease in collagen (p = 0.043).

CONCLUSIONS

Atherosclerotic iliofemoral plaques derived from men display more rupture-prone characteristics compared to women. Yet, this difference is attenuated with an increase in age, with older women having more rupture-prone characteristics compared to younger women.

Ambient temperature, seasonal influenza and risk of cardiovascular disease in a subtropical area in Southern China

BACKGROUND

Given the regular winter recurrence of influenza epidemics and the biologically plausible association between seasonal influenza and cardiovascular events, researchers assumed a valid and reliable influenza forecast could envision the timing and burden of winter surge in cardiovascular (CVD) hospitalizations. This, however, is well justified only in temperate regions. In this study, we aim to investigate the temporal association between ambient temperature, seasonal influenza and risk of cardiovascular events in a subtropical city.

METHODS

Generalized additive model was used in conjunction with distributed-lag non-linear model of quasi-Poisson family to estimate the association of interest with daily CVD admissions as outcome and daily influenza admissions as predictor, while controlling for meteorological factors (i.e. temperature, relative humidity, wind speed and total rainfall) and respiratory pollutants (i.e. nitrogen dioxide, sulphur dioxide, ozone and PM₁₀). Results were expressed in the form of relative risk (RR).

RESULTS

Using median as the reference value, a U-shaped association was observed between CVD admissions and temperature. A slight decrease in RR was detected mainly towards the lower end of the temperature scale after adjusting for influenza admissions. Risk of CVD admission was found to be positively associated with the number of influenza hospitalization cases; this association remained consistent and statistically significant across subgroups of age except for those aged 5-49 years.

CONCLUSION

The slight reduction in CVD admission risk towards the lower end of the temperature scale after controlling for influenza activity might be attributed to the winter peaks of influenza, meaning that the effect of low temperature on CVD admissions might be partly mediated by influenza infection. In summary, this study reassures us that ambient temperature is independently associated with CVD hospital admissions and offers support for a positive association between seasonal influenza activity and cardiovascular events in Hong Kong.

Age- and Gender-Related Differences in Coronary Lesion Plaque Composition on Optical Coherence Tomography

BACKGROUND

The pathophysiology and chronological course of atherosclerosis seems to be different between men and women due to biological differences, and age and gender differences in plaque composition of coronary lesions remain to be elucidated.Methods and Results:A total of 860 consecutive patients with a median age of 69 years (IQR, 60-78 years) who underwent optical coherence tomography (OCT) of culprit lesions was included. The composition of culprit plaque on OCT was compared between female (n=171) and male (n=689) subjects in younger (<70 years old) and elderly (≥70 years old) patients. In elderly patients, the prevalence of thin-cap fibroatheroma (TCFA) was significantly higher in women than in men (30.6 vs. 15.2%, P<0.001). In younger patients, the prevalence of large calcification was significantly higher in women than in men (60.0 vs. 32.8%, P<0.001). The prevalence of other vulnerable plaque characteristics (i.e., macrophages, microchannels, and spotty calcification), was similar between women and men. Elderly women had a significantly higher prevalence of TCFA (OR, 2.13; 95% CI: 1.33-3.44, P=0.002) than other patients.

CONCLUSIONS

Women had a higher prevalence of TCFA and of large calcification than men in patients ≥70 and <70 years old, respectively. This may facilitate the understanding of gender differences in the pathogenesis of coronary atherosclerosis, and the tailoring of therapy and of prevention according to age and gender.

Coronary artery calcification: recent developments in our understanding of its pathologic and clinical significance

PURPOSE OF REVIEW

Prior investigations have shown the close association between coronary artery calcification (CAC) and total atherosclerotic plaque burden as well as the risk of cardiovascular and all-cause mortality. However, recent pathologic and imaging-based studies suggested that massive dense calcifications are usually associated with stable plaque; whereas, micro calcifications, especially in the thin fibrous cap, are related to vulnerable characteristics. Further, the molecular mechanisms for initiation/progression of vascular calcification are highly complex and still need to be elucidated. In this manuscript, we discuss recent advancement in our understanding of CAC from the basic, pathologic, and clinical perspectives.

RECENT FINDINGS

Research on the relationship between genetic polymorphisms and CAC has been growing and may potentially lead to future precision-based medicine. In basic research field, more attention has been focused on the relationship between inflammation and vascular calcification. Large-scale imaging based studies support the association between statin and calcification progression, maybe one of the ways by which statins prevent cardiovascular events. Nevertheless, the mechanism responsible for this effect is still not fully understood. Optical coherence tomography has improved resolution to detect CAC over traditional CT and may be especially promising for the detection of calcified nodules.

SUMMARY

A better understanding of CAC in all of its forms will advance our understanding of its natural history of atherosclerosis. More work is needed to understand the basic molecular mechanisms responsible for the initiation/progression of CAC, which may eventually lead to the development of effective treatments for atherosclerosis.

Cardiovascular Disease Risk Across a Spectrum of Adverse Plasma Lipid Combinations by Gender and Glycemic Status

High triglycerides (TG), low high-density lipoprotein cholesterol (HDL-C) and high non-HDL-C levels are risk factors for cardiovascular disease (CVD). It is unclear whether the combinations of their adverse changes are related with CVD risk in different gender and diabetes status, particularly in Chinese population. This study aims to evaluate the CVD risk associated with different adverse lipid combinations. A total of 38,989 participants from Chinese Multicenter Longitudinal Health Management Cohorts (mean age 42 years; 62% male) without baseline CVD were followed up for incident CVD from 2007 to 2015. Participants with various combinations of baseline TG, non-HDL-C, and HDL-C levels within- or out of range according to Adult Treatment Panel III were grouped into 8 distinct lipid categories. Cox models estimated the multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of different lipid categories for CVD. After multivariable adjustment, a low level of HDL-C combined with either a high level of non-HDL-C alone or TG alone were associated with increased CVD risk with adjusted HRs (95% CIs) of 1.77 (1.36 to 2.30) and 2.08 (1.30 to 3.34) in male participants. Diabetic participants with high non-HDL-C and low HDL-C levels (adjusted HR 2.93, 95% CI 1.15 to 7.46), and non-diabetic participants with high TG and low HDL-C levels (adjusted HR 1.73, 95% CI 1.33 to 2.26) had greater risk of incident CVD. These relations remained significant when limited analysis to participants with normal LDL-C levels of <3.4 mmol/L, indicating the various combinations of out-of-range lipid profiles other than LDL-C are associated with different CVD risk and the associations depend on gender and glycemic status.

The Influence of Sex on Cardiac Physiology and Cardiovascular Diseases

Cardiovascular disease (CVD) is the leading cause of death world-wide. Most of treatment strategies were based on studies conducted on male patients. Studies have shown that significant differences exist between the two sexes in the development of CVD. There are certain differences between men and women in the structure and physiological functions of the heart such as left ventricular mass index, resting heart rate, and contractile function. Accordingly, the pathological features of the heart such as the extend of hypertrophy, fibrosis, and remodeling are also different. In addition, different genders also affect clinical symptoms, responses to treatment and prognosis in the development of CVD. Therefore, it is important to take these differences into consideration when design treatment options for men and women.

Sex differences in characteristics and outcome in acute coronary syndrome patients in the Netherlands

Background

Sex differences in acute coronary syndrome (ACS) have been reported, but little is known about the situation in the Netherlands.

Methods

This registry is a merge of available data on ACS patients in the electronic data capture systems of 11 centres with 24/7 interventional cardiology services. We included patients >18 years undergoing a cardiac catheterisation between 2010–2012. We evaluated sex differences in clinical and procedural characteristics and 1‑year mortality.

Results

A total of 29,265 ACS patients (8,720 women and 20,545 men) were registered. Women were on average 4.5 years older (68.5 vs 63.0 years, p < 0.001) and had a higher prevalence of hypertension (62.7 vs 49.8%, p < 0.001) and insulin-dependent diabetes mellitus (9.6 vs 6.8%, p < 0.001) than men. Women less often presented with ST-elevation myocardial infarction (43.7% vs 47.6%, p < 0.001) and appeared to have less extensive coronary artery disease than men. Women less often underwent coronary angiography by radial access (52.5 vs 55.9%, p < 0.001). One-year mortality was higher in women than in men (7.3% and 5.6%, p < 0.001). More specific, the relationship between sex and mortality was age-dependent and showed higher mortality in women ≤71 years, but lower mortality in older women compared with men (p-interaction <0.001).

Conclusion

We found differences in clinical and procedural characteristics and outcome between women and men admitted for ACS, which are in line with other Western countries. The limitations of our registry, based on existing local databases, can be overcome by the use of the prospective Netherlands Heart Registry that is currently in development.

Electronic supplementary material

The online version of this article (10.1007/s12471-019-1271-0) contains supplementary material, which is available to authorized users.

Sex-Based Differences in Ten-Year Nationwide Outcomes of Carotid Revascularization

BACKGROUND

We compared the rates of stroke, death, and/or MI between men and women, stratified by symptomatic status and procedure type (carotid endarterectomy [CEA] or carotid artery stent [CAS]).

STUDY DESIGN

Using the Nationwide Inpatient Sample, crude and propensity-matched rates of the composite end point of stroke/death/MI were estimated. Multivariable logistic regression was used to calculate the odds of stroke/death/MI associated with sex.

RESULTS

Between 2005 and 2015, there were 1,242,688 carotid interventions performed (1,083,912 CEA; 158,776 CAS; 515,789 [41.5%] were female patients). Symptomatic admissions comprised 11.3% of the cohort. In-hospital stroke/death/MI rates were more prevalent in men compared with women (4.2% vs 3.9%; p < 0.01). Subgroup analysis revealed symptomatic women vs men had higher rates of stroke after CEA (7.7% vs 6.2%; p < 0.01) and CAS (9.9% vs 7.6%; p < 0.01). Asymptomatic women experienced the same rates of stroke after either CEA (0.3% vs 0.3%; p = 0.051) or CAS (0.4% vs 0.5%; p = 0.09). Propensity-matched logistic regression revealed that symptomatic males vs females had lower odds of stroke after CEA (odds ratio [OR] 0.81; 95% CI 0.72 to 0.91) and CAS (OR 0.72; 95% CI 0.57 to 0.90). Asymptomatic men and women had similar odds of stroke after both CEA (OR 0.95; 95% CI 0.79 to 1.14) and CAS (OR 0.70; 95% CI 0.43 to 1.13).

CONCLUSIONS

This is the largest cohort study to date that demonstrates asymptomatic women undergoing CEA or CAS do not have a higher risk of perioperative stroke, death, or MI. Symptomatic men experience lower rates of stroke after CEA or CAS.

Mechanisms of Sex Disparities in Cardiovascular Function and Remodeling

Epidemiological studies demonstrate disparities between men and women in cardiovascular disease prevalence, clinical symptoms, treatments, and outcomes. Enrollment of women in clinical trials is lower than men, and experimental studies investigating molecular mechanisms and efficacy of certain therapeutics in cardiovascular disease have been primarily conducted in male animals. These practices bias data interpretation and limit the implication of research findings in female clinical populations. This review will focus on the biological origins of sex differences in cardiovascular physiology, health, and disease, with an emphasis on the sex hormones, estrogen and testosterone. First, we will briefly discuss epidemiological evidence of sex disparities in cardiovascular disease prevalence and clinical manifestation. Second, we will describe studies suggesting sexual dimorphism in normal cardiovascular function from fetal life to older age. Third, we will summarize and critically discuss the current literature regarding the molecular mechanisms underlying the effects of estrogens and androgens on cardiac and vascular physiology and the contribution of these hormones to sex differences in cardiovascular disease. Fourth, we will present cardiovascular disease risk factors that are positively associated with the female sex, and thus, contributing to increased cardiovascular risk in women. We conclude that inclusion of both men and women in the investigation of the role of estrogens and androgens in cardiovascular physiology will advance our understanding of the mechanisms underlying sex differences in cardiovascular disease. In addition, investigating the role of sex-specific factors in the development of cardiovascular disease will reduce sex and gender disparities in the treatment and diagnosis of cardiovascular disease. © 2019 American Physiological Society. Compr Physiol 9:375-411, 2019.

The associations of lipids and lipid ratios with stroke: A prospective cohort study

Lipids and lipid ratios have been proven to be associated with cardiovascular disease; however, their relationships with stroke and stroke subtypes had not been fully understood. This study aims to assess the associations of lipids and lipid ratios with type-specific stroke and compare their predictive capacities for stroke occurrence. In this prospective cohort study, a total of 42 005 Chinese participants aged 20 to 80 who were free of stroke at baseline were included and selected into subgroups of stroke subtypes (ischemic, hemorrhagic, and total). Total stroke outcome included a combination of ischemic and hemorrhagic stroke. Over an average follow-up of 3.6 years, 781 participants developed stroke (623 ischemic and 158 hemorrhagic). In men, the highest TC/HDL-C quartile was significantly associated with increased ischemic stroke risk (multivariable-adjusted hazard ratio [HR], 1.52, 95% confidence interval [CI], 1.14-2.03) and total stroke risk (HR, 1.45, 95% CI, 1.12-1.87), and TC/HDL-C had the highest area under the receiver operating characteristic curve (AUC) for predicting ischemic (AUC, 0.868) and total stroke (AUC, 0.874). In women, the highest TG quartile was significantly associated with increased risk of ischemic (HR, 1.99, 95% CI, 1.11-3.59) and total stroke (HR, 1.85, 95% CI, 1.07-3.20), with AUCs of 0.850 and 0.861, respectively. No lipid variables were significantly associated with hemorrhagic stroke in both sex. In conclusion, TC/HDL-C ratio may better predict stroke risk in men, whereas TG was more valuable in predicting stroke risk in women. TC/HDL-C and TG may help to discriminate high stroke risk individuals and serve as potential targets for stroke prevention.

Gender differences in symptom presentation of ST-elevation myocardial infarction - An observational multicenter survey study

BACKGROUND

Symptom presentation has been sparsely studied from a gender perspective restricting the inclusion to ST elevation myocardial infarction (STEMI) patients. Correct symptom recognition is vital in order to promptly seek care in STEMI where fast reperfusion therapy is of utmost importance. Female gender has been found associated with atypical presentation in studies on mixed MI populations but it is unclear whether this is valid also in STEMI.

OBJECTIVES

We assessed whether there are gender differences in symptoms and interpretation of these in STEMI, and if this is attributable to sociodemographic and clinical factors.

METHODS

SymTime was a multicenter observational study including a validated questionnaire and data from medical records. Eligible STEMI patients (n = 532) were enrolled within 24 h after admittance at five Swedish hospitals.

RESULTS

Women were older, more often single and had lower educational level. Chest pain was less prevalent in women (74 vs 93%, p < 0.001), whereas shoulder (33 vs 15%, p < 0.001), throat/neck (34 vs 18%, p < 0.001), back pain (29 versus 12%, p < 0.001) and nausea (49 vs 29%, p < 0.001) were more prevalent. Women less often interpreted their symptoms as of cardiac origin (60 vs 69%, p = 0.04). Female gender was the strongest independent predictor of non-chest pain presentation, odds ratio 5.29, 95% confidence interval 2.85-9.80.

CONCLUSIONS

A striking gender difference in STEMI symptoms was found. As women significantly misinterpreted their symptoms more often, it is vital when informing about MI to the society or to high risk individuals, to highlight also other symptoms than just chest pain.

Stable ischemic heart disease in women: current perspectives

Cardiovascular disease is the leading cause of death in women accounting for 1 in every 4 female deaths. Pathophysiology of ischemic heart disease in women includes epicardial coronary artery, endothelial dysfunction, coronary vasospasm, plaque erosion and spontaneous coronary artery dissection. Angina is the most common presentation of stable ischemic heart disease (SIHD) in women. Risk factors for SIHD include traditional risks such as older age, obesity (body mass index [BMI] >25 kg/m²), smoking, hypertension, dyslipidemia, cerebrovascular and peripheral vascular disease, sedentary lifestyle, family history of premature coronary artery disease, metabolic syndrome and diabetes mellitus, and nontraditional risk factors, such as gestational diabetes, insulin resistance/polycystic ovarian disease, pregnancy-induced hypertension, pre-eclampsia, eclampsia, menopause, mental stress and autoimmune diseases. Diagnostic testing can be used effectively to risk stratify women. Guidelines-directed medical therapy including aspirin, statins, beta-blocker therapy, calcium channel blockers and ranolazine should be instituted for symptom and ischemia management. Despite robust evidence regarding the adverse outcomes seen in women with ischemic heart disease, knowledge gaps exist in several areas. Future research needs to be directed toward a greater understanding of the role of nontraditional risk factors for SIHD in women, gaining deeper insights into the sex differences in therapeutic effects and formulating a sex-specific algorithm for the management of SIHD in women.

Arterial Remodeling After Bioresorbable Scaffolds and Metallic Stents

BACKGROUND

Although previous observational studies have documented late luminal enlargement and expansive remodeling following implantation of a bioresorbable vascular scaffold (BVS), no comparison with metallic stents has been conducted in a randomized fashion.

OBJECTIVES

This study sought to compare vessel remodeling patterns after either Absorb BVS or Xience metallic drug-eluting stent (DES) implantation (Abbott Vascular, Santa Clara, California) and determine the independent predictors of remodeling.

METHODS

In the ABSORB II randomized trial, 383 lesions (n = 359) were investigated by intravenous ultrasound both post-procedure and at 3-year follow-up. According to vessel and lumen area changes over 3 years, we categorized 9 patterns of vessel remodeling that were beyond the reproducibility of lumen and vessel area measurements.

RESULTS

The relative change in mean vessel area was significantly greater with the BVS compared to the DES (6.7 ± 12.6% vs. 2.9 ± 11.5%; p = 0.003); the relative change in mean lumen area was significantly different between the 2 arms (1.4 ± 19.1% vs. -1.9 ± 10.5%, respectively; p = 0.031). Multivariate analysis indicated that use of the BVS, female sex, balloon-artery ratio >1.25, expansion index ≥0.8, previous percutaneous coronary intervention, and higher level of low-density lipoprotein cholesterol were independent predictors of expansive remodeling. Furthermore, in the BVS arm, necrotic core pre-procedure was an independent determinant of expansive remodeling.

CONCLUSIONS

Expansive vessel wall remodeling was more frequent and intense with the BVS than the metallic DES and could be determined by patient baseline characteristics and periprocedural factors. The clinical effect of the observed lumen and vessel remodeling must be investigated in further large clinical studies to optimize the clinical outcome of patients and lesions treated by bioresorbable scaffolds. (ABSORB II Randomized Controlled Trial; NCT01425281).

Age-Specific Sex Differences in Magnetic Resonance Imaging-Depicted Carotid Intraplaque Hemorrhage

BACKGROUND AND PURPOSE

Stroke rates are higher in men compared with women in the fourth through seventh decades of life, and higher rates may result from differences in carotid intraplaque hemorrhage (IPH), an unstable atherosclerotic plaque component. We report age-specific sex differences in the presence of magnetic resonance imaging-depicted carotid IPH.

METHODS

Patients (n=1115) underwent magnetic resonance imaging for carotid IPH between 2005 and 2014. Low-grade carotid stenosis patients (n=906) without prior endarterectomy were eligible for this cross-sectional study.

RESULTS

Of the 906 patients included (mean age±SD in years, 66.98±15.15), 63 (6.95%) had carotid IPH. In men and women, carotid IPH was present in 11.43% (48 of 420) and 3.09% (15 of 486), respectively (P<0.0001). Multivariable logistic regression analysis confirmed greater odds of carotid IPH in men for all ages: 45 to 54 (odds ratio=45.45; 95% confidence interval, 3.43-500), 55 to 64 years (odds ratio=21.74; 95% confidence interval, 3.21-142.86), 65 to 74 years (odds ratio=10.42; 95% confidence interval, 2.91-37.04), and ≥75 years (odds ratio=5.00; 95% confidence interval, 2.31-10.75). Male sex modified the effect of age on the presence of carotid IPH (β=0.074; SE=0.036; P=0.0411).

CONCLUSIONS

Men have greater age-specific odds of magnetic resonance imaging-depicted carotid IPH compared with women. With increasing age post-menopause, the odds of carotid IPH in women becomes closer to that of men. Delayed onset of carotid IPH in women, an unstable plaque component, may partly explain differential stroke rates between sexes, and further studies are warranted.

Assessing and Modifying Coronary Artery Disease Risk in Women

OPINION STATEMENT

Despite continued advances in the field, cardiovascular disease remains the leading cause of death in women in the USA with an annual mortality rate that has remained higher for women as compared to men. The factors leading to this sex difference remain incompletely understood. Likely contributors include atypical symptoms at presentation and lack of recognition of cardiovascular risk by women and their providers alike. In addition, women have a higher burden of comorbidities at the time of disease diagnosis and can have differential pathophysiological mechanisms of their acute events. Women also can develop unique cardiovascular risk factors such as preeclampsia and hypertensive disorders of pregnancy. As a result, when women present with symptoms, even atypical, healthcare providers should increase their index level of suspicion for cardiovascular disease. Even after diagnosis, women are less likely to receive guideline-directed medical therapies and be referred for coronary angiography or cardiac rehabilitation. Thus, greater awareness of and research into the aspects of coronary disease that remain unique to women is critical, as women presenting with coronary disease continue to receive disparate care as compared to men. Improvements in awareness and care and new research avenues may reduce the incidence and complications of cardiovascular disease among women.