Gender inequalities in secondary prevention of cardiovascular disease: a scoping review

BACKGROUND

Despite significant progress in cardiovascular disease (CVD) management, it remains a public health priority and a global challenge. Within the disease process, health care after a cardiovascular event (secondary prevention) is essential to prevent recurrences. Nonetheless, evidence has suggested the existence of gender disparities in CVD management, leaving women in a vulnerable situation. The objective of this study is to identify all available evidence on the existence of gender differences in health care attention after a major adverse cardiovascular event.

METHODS

A scoping review following the structure of PRISMA-ScR was conducted. To define the inclusion criteria, we used Joanna Briggs Institute (JBI) population, concept, context framework for scoping reviews. A systematic search was performed in MEDLINE (PubMed), EMBASE and Cochrane. The methods of this review are registered in the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) (INPLASY202350084).

RESULTS

The initial search retrieved 3,322 studies. 26 articles were identified manually. After the reviewing process, 93 articles were finally included. The main intervention studied was the pharmacological treatment received (n = 61, 66%), distantly followed by guideline-recommended care (n = 26, 28%) and cardiac rehabilitation (CR) referral (n = 16)". Literature described gender differences in care and management of secondary prevention of CVD. Women were less frequently treated with guideline-recommended medications and seem more likely to be non-adherent. When analysing guideline recommendations, women were more likely to make dietary changes, however, men were more likely to increase physical activity. Studies also showed that women had lower rates of risk factor testing and cholesterol goals attainment. Female sex was associated with lower rates of cardiac rehabilitation referral and participation.

CONCLUSIONS

This review allowed us to compile knowledge on the existence of gender inequalities on the secondary prevention of CVD. Additional research is required to delve into various factors influencing therapeutic disparities, referral and non-participation in CR programs, among other aspects, in order to improve existing knowledge about the management and treatment of CVD in men and women. This approach is crucial to ensure the most equitable and effective attention to this issue.

Gender, Tobacco Control Policies, and Persistent Smoking Among Older Adults: A Longitudinal Analysis of 11 European Countries

INTRODUCTION

Little is known about sociodemographic and macro-level predictors of persistent smoking when one has developed a health condition that is likely caused by smoking.

AIMS AND METHODS

We investigate the impact of gender, education, and tobacco control policies (TCPs) on persistent smoking among older Europeans. Respondents (aged 50 +) with a smoking history and at least one smoking-related health condition were pooled from the Survey of Health, Aging and Retirement in Europe (SHARE) and the English Longitudinal Study of Ageing (ELSA) from four waves from 2004 to 2013. We fitted gender-specific logistic regression models with two-way fixed effects (country and year) and tested interaction terms between gender, education, and TCPs.

RESULTS

Although women are less likely to smoke than men, they were more likely to smoke persistently. The effects of education and general TCPs on persistent smoking were significant for women only. Compared to women with low levels of education, those with moderate education (odds ratio [OR] = .63; .49-.82) and high education (OR = .57; .34-.98) are less likely to be persistent smokers. TCPs are associated with a reduced risk of women's persistent smoking (OR = .70; .51-.95) and the association is stronger for those having less education.

CONCLUSIONS

Older women, particularly those with low levels of education, are vulnerable to persistent smoking. TCPs might be effective in reducing persistent smoking for older women, with greater effects for less-educated women. Future studies are needed to understand mechanisms that explain gender differences in responsiveness to TCPs.

IMPLICATIONS

Persistent smoking is a particularly harmful smoking behavior as it is associated with greater risks of comorbidity and mortality. By employing the framework of the multilevel social determinants of health, this study examined the behavior of persistent smoking among older adults in European countries. Women, especially women with low levels of education are vulnerable to persistent smoking. Moreover, TCPs, in general, are significantly related to a reduction in persistent smoking among older women only and the negative association is stronger for those having less education, indicating gender and socioeconomic differences in responsiveness to TCPs.

Sex Differences in Opioid and Psychostimulant Craving and Relapse: A Critical Review

A widely held dogma in the preclinical addiction field is that females are more vulnerable than males to drug craving and relapse. Here, we first review clinical studies on sex differences in psychostimulant and opioid craving and relapse. Next, we review preclinical studies on sex differences in psychostimulant and opioid reinstatement of drug seeking after extinction of drug self-administration, and incubation of drug craving (time-dependent increase in drug seeking during abstinence). We also discuss ovarian hormones' role in relapse and craving in humans and animal models and speculate on brain mechanisms underlying their role in cocaine craving and relapse in rodent models. Finally, we discuss imaging studies on brain responses to cocaine cues and stress in men and women.The results of the clinical studies reviewed do not appear to support the notion that women are more vulnerable to psychostimulant and opioid craving and relapse. However, this conclusion is tentative because most of the studies reviewed were correlational, not sufficiently powered, and not a priori designed to detect sex differences. Additionally, imaging studies suggest sex differences in brain responses to cocaine cues and stress. The results of the preclinical studies reviewed provide evidence for sex differences in stress-induced reinstatement and incubation of cocaine craving but not cue- or cocaine-induced reinstatement of cocaine seeking. These sex differences are modulated in part by ovarian hormones. In contrast, the available data do not support the notion of sex differences in craving and relapse/reinstatement for methamphetamine or opioids in rodent models. SIGNIFICANCE STATEMENT: This systematic review summarizes clinical and preclinical studies on sex differences in psychostimulant and opioid craving and relapse. Results of the clinical studies reviewed do not appear to support the notion that women are more vulnerable to psychostimulant and opioid craving and relapse. Results of preclinical studies reviewed provide evidence for sex differences in reinstatement and incubation of cocaine seeking but not for reinstatement or incubation of methamphetamine or opioid seeking.

Tobacco-related cardiovascular risk in women: New issues and therapeutic perspectives

BACKGROUND

Smoking is the main modifiable risk factor for stroke and myocardial infarction, particularly in women; its prevalence in France is evolving, and new patterns of nicotine consumption have emerged.

AIMS

To present contemporary data on smoking prevalence and the use of electronic cigarettes, and to describe current knowledge of the cardiovascular risk specificities and the effectiveness of withdrawal methods in women.

METHOD

We identified studies by searching the MEDLINE bibliographic database between 1995 and 2020, and the Weekly Epidemiological Bulletin (Bulletin Épidémiologique Hebdomadaire) published by the French health authorities.

RESULT

In recent years, smoking prevalence among French women has decreased overall, except in the oldest age group (aged>55 years). At the same time, the incidence of hospitalization for cardiovascular events has increased worryingly among women smokers aged<65 years. Active smoking in women is associated with an increased risk of premature myocardial infarction, and a risk of stroke that increases with the number of cigarettes consumed per day; it is also responsible for increased cardiovascular events in women taking oestrogen-progestin contraception. Quitting smoking reverses these effects in the long term, and women are just as likely to quit smoking as men.

CONCLUSIONS

Stopping smoking must be a priority objective for women smokers, for primary and secondary prevention, and they should systematically be offered a validated method of cessation or even electronic cigarettes.

Smoking cessation after long-term sick leave due to cancer in comparison with cardiovascular disease: Japan Epidemiology Collaboration on Occupational Health Study

In occupational settings, smokers may take quitting smoking seriously if they experienced long-term sick leave due to cancer or cardiovascular disease (CVD). However, no study has elucidated the smoking cessation rate after long-term sick leave. We examined the smoking cessation rate after long-term sick leave due to cancer and CVD in Japan. We followed 23 survivors who experienced long-term sick leave due to cancer and 39 survivors who experienced long-term sick leave due to CVD who reported smoking at the last health exam before the leave. Their smoking habits before and after the leave were self-reported. Logistic regression was used to calculate adjusted smoking cessation rates. Smoking cessation rate after long-term sick leave due to cancer was approximately 70% and that due to CVD exceeded 80%. The adjusted smoking cessation rate was 67.6% (95% confidence interval [CI]: 47.0, 88.2) for cancer and 80.7% (95% CI: 67.7, 93.8) for CVD. Smoking cessation rate after a longer duration of sick leave (≥60 d) tended to increase for both CVD and cancer. Although any definite conclusion cannot be drawn, the data suggest that smoking cessation rate after long-term sick leave due to CVD is slightly higher than that for cancer.

Association between persistent smoking after a diagnosis of heart failure and adverse health outcomes: A systematic review and meta-analysis

INTRODUCTION

Heart failure (HF) is associated with increased mortality worldwide. Adverse health outcomes in HF are commonly attributed to poor adherence to self-care, including smoking cessation. Smoking is the major modifiable risk factor for HF. Patients have been observed to continue smoking even after diagnosis with HF. Despite the possible association between persistent smoking and adverse health outcomes among HF populations, no consensus has been reached. We aimed to review the literature to determine the association between smoking status after HF diagnosis and adverse health outcomes.

METHODS

A systematic literature search was performed in PubMed, PsycINFO, Web of Science, and Embase. Hand searching was also performed. In total, 9 articles (n=70461) were included in the review for meta-analysis, including seven cohort studies and two cross-sectional studies. Quality was assessed using the modified version of the Newcastle-Ottawa Scale.

RESULTS

Approximately 16% of HF patients continued smoking after HF diagnosis. Persistent smoking increased the hazard ratio (HR) of mortality by 38.4% (HR=1.384; 95% CI: 1.139-1.681) and readmission by 44.8% (HR=1.448; 95% CI: 1.086-1.930). Our review also found that persistent smoking was associated with poor health status, ventricular tachycardia, and arterial stiffness.

CONCLUSIONS

This review highlights the importance of assessment for any history of smoking before and after HF diagnosis. There is a need for smoking cessation programs to be established as crucial components of care for patients with HF. More studies are needed to investigate the possible mechanisms underlying relations among smoking patterns and health consequences.

Persistent smoking after a cardiovascular event: A nationwide retrospective study in Korea

Smoking is a major risk factor of cardiovascular disease (CVD) such as stroke and ischemic heart disease. Prior studies have observed people continued smoking even after being diagnosed with CVD. However, population-level data regarding smoking behavior changes among people who are diagnosed with CVD are still lacking. From the National Health Insurance sample cohort database, we identified 1,700 patients diagnosed as having CVD between 2003 and 2012, and underwent the national health screening examination in the year before and after the CVD event. We found that 486 (28.6%) were smokers before the CVD event. Among them, 240 (49.4%) continued to smoke despite the diagnosis. We observed that a higher smoking amount and longer smoking duration before the diagnosis were associated with persistent smoking. Our finding that approximately 50% of smokers continue smoking even after CVD events supports the need for an assessment of patients' smoking statuses during follow-up after a CVD event and for health-care providers to offer the appropriate smoking cessation interventions to those who continue smoking.

The joint contribution of cardiovascular disease and socioeconomic status to disability retirement: A register linkage study

BACKGROUND

Whether low occupational class amplifies the risk of disability retirement among employees with cardiovascular disease (CVD) is unknown. We examined this issue in two prospective cohort studies.

METHODS

In the Finnish Public Sector Study and the Helsinki Health Study (n=50.799 employees), prevalent CVD (coronary heart disease or stroke, n=1269) was ascertained using records from national health registers, self-reported doctor-diagnosed diseases, and Rose Angina Questionnaire. Data linkage to national pension registers allowed the follow up of disability retirement among the participants for a mean of six years. We analysed the associations of occupational class and CVD with disability retirement using Cox regression, tested interactions between occupational class and prevalent CVD in predicting disability retirement by calculating the Synergy Index, and pooled the results from the two studies using fixed-effect meta-analysis.

RESULTS

Compared with the participants from high occupational class and no CVD, the participants from the low occupational class without CVD had a 2.13-fold (95% CI 1.97-2.30), those with high occupational class and CVD a 2.18-fold (1.73-2.74); and those with both low occupational class and CVD a 4.49-fold (3.83-5.26) risk of disability retirement. A Synergy Index of 1.55 (1.16-2.06) suggested a greater than additive effect for low occupational class and CVD in combination.

CONCLUSIONS

Individuals with both low occupational class and CVD are at a particularly high risk of premature exit from the labour market due to work disability. These findings suggest that better preventive strategies are needed to improve prognosis in this risk group.