Sex differences in coronary heart disease risk factors: rename it ischaemic heart disease!

Number of Pregnancies and Risk of Atherosclerotic Cardiovascular Disease in Postmenopausal Women: A Cross-Sectional Study of NHANES from 1999 to 2018

Background: Atherosclerotic cardiovascular disease (ASCVD) remains the most common cause of death in women. Pregnancy is an exposure unique to women leading to significant changes in maternal cardiovascular function. However, studies of the relationship between the number of pregnancies and ASCVD are rare. We aimed to clarify the association between the number of pregnancies and ASCVD. Methods: In this cross-sectional study, we used publicly available data from the National Health and Nutrition Examination Survey from 1999 to 2018. The number of pregnancies was divided into 0 (reference), 1, 2-3, 4-5, or ≥6, to create more stable estimates. A multiple logistic regression approach was used to examine the correlation between pregnancy and ASCVD in women aged 45 years or older who reported no menstruation in the past 12 months due to menopause, as well as in those aged 55 years or older, encompassing various age groups. We also separately estimated the association between the exposure of pregnancy and individual components of ASCVD. Results: In this study, age-adjusted data showed that women with six or more pregnancies had a doubled risk (odds ratio [OR]: 2.07) of ASCVD. The risk remained elevated at 1.69 times in women with four to five pregnancies and further increased to 1.90 times in women with six or more pregnancies, after adjusting for social factors. Similar patterns were observed when considering reproductive health and cardiovascular risk factors. Across the full population, every model that accounted for these variables consistently indicated that with an increasing number of pregnancies, we observed higher ORs for ASCVD risk (all p values <0.05). Conclusions: A higher number of pregnancies was associated with a higher risk of ASCVD after menopause, especially among women aged 45-64 years. Moreover, this association is particularly significant in the risk of stroke, cardiovascular heart disease, and heart attack.

Burden of ischemic heart disease in the Middle East and North Africa (MENA) and attributable risk factors: An epidemiological analysis from 1990 to 2019

Introduction

Despite the burden of ischemic heart disease (IHD), there remains a paucity of research on the incidence, mortality, and burden of this condition in the Middle East and North Africa (MENA) regions. This study aimed to evaluate the epidemiology and the risk factors associated with IHD in the MENA region.

Methods

This study was performed based on the GBD study 2019 data. We retrieved the data related to the epidemiology and burden of IHD, including prevalence, incidence, years of life lost due to premature death (YLLs), years lived with disability (YLDs), and mortality at the global level and in MENA countries across years and sexes.

Results

IHD accounted for approximately 2.55 million (95 % UI 2.29-2.83) incident cases in MENA in 2019, with an age-standardized incidence rate of 613.87 (95 % UI 555.84-675.16) per 100 000 people, which has decreased by 9 % between 1990 and 2019. IHD accounted for 11.01 % of DALYs causes in MENA in 2019, an increase of 68 % compared to 1990. The DALYs rate from IHD increased with age in both men and women and was higher in men than in women in all age groups, except 85-89 years age-group, in 2019.

Conclusion

The age-standardized prevalence and incidence of IHD are decreasing in MENA. However, this reduction is lower than the global level, which can be due to a weaker performance of the countries in the region in reducing the prevalence and incidence of the disease compared to the global average.

Assessing Global, Regional, and National Time Trends and Associated Risk Factors of the Mortality in Ischemic Heart Disease Through Global Burden of Disease 2019 Study: Population-Based Study

BACKGROUND

Ischemic heart disease (IHD) is the leading cause of death among noncommunicable diseases worldwide, but data on current epidemiological patterns and associated risk factors are lacking.

OBJECTIVE

This study assessed the global, regional, and national trends in IHD mortality and attributable risks since 1990.

METHODS

Mortality data were obtained from the Global Burden of Disease 2019 Study. We used an age-period-cohort model to calculate longitudinal age curves (expected longitudinal age-specific rate), net drift (overall annual percentage change), and local drift (annual percentage change in each age group) from 15 to >95 years of age and estimate cohort and period effects between 1990 and 2019. Deaths from IHD attributable to each risk factor were estimated on the basis of risk exposure, relative risks, and theoretical minimum risk exposure level.

RESULTS

IHD is the leading cause of death in noncommunicable disease-related mortality (118.1/598.8, 19.7%). However, the age-standardized mortality rate for IHD decreased by 30.8% (95% CI -34.83% to -27.17%) over the past 30 years, and its net drift ranged from -2.89% (95% CI -3.07% to -2.71%) in high sociodemographic index (SDI) region to -0.24% (95% CI -0.32% to -0.16%) in low-middle-SDI region. The greatest decrease in IHD mortality occurred in the Republic of Korea (high SDI) with net drift -6.06% (95% CI -6.23% to -5.88%), followed by 5 high-SDI nations (Denmark, Norway, Estonia, the Netherlands, and Ireland) and 2 high-middle-SDI nations (Israel and Bahrain) with net drift less than -5.00%. Globally, age groups of >60 years continued to have the largest proportion of IHD-related mortality, with slightly higher mortality in male than female group. For period and birth cohort effects, the trend of rate ratios for IHD mortality declined across successive period groups from 2000 to 2004 and birth cohort groups from 1985 to 2000, with noticeable improvements in high-SDI regions. In low-SDI regions, IHD mortality significantly declined in female group but fluctuated in male group across successive periods; sex differences were greater in those born after 1945 in middle- and low-middle-SDI regions and after 1970 in low-SDI regions. Metabolic risks were the leading cause of mortality from IHD worldwide in 2019. Moreover, smoking, particulate matter pollution, and dietary risks were also important risk factors, increasingly occurring at a younger age. Diets low in whole grains and legumes were prominent dietary risks in both male and female groups, and smoking and high-sodium diet mainly affect male group.

CONCLUSIONS

IHD, a major concern, needs focused health care attention, especially for older male individuals and those in low-SDI regions. Metabolic risks should be prioritized for prevention, and behavioral and environmental risks should attract more attention to decrease IHD mortality.

Sexual Dimorphism in Cardiovascular Biomarkers: Clinical and Research Implications

Sex-based differences in cardiovascular disease presentation, diagnosis, and response to therapies are well established, but mechanistic understanding and translation to clinical applications are limited. Blood-based biomarkers have become an important tool for interrogating biologic pathways. Understanding sexual dimorphism in the relationship between biomarkers and cardiovascular disease will enhance our insights into cardiovascular disease pathogenesis in women, with potential to translate to improved individualized care for men and women with or at risk for cardiovascular disease. In this review, we examine how biologic sex associates with differential levels of blood-based biomarkers and influences the effect of biomarkers on disease outcomes. We further summarize key differences in blood-based cardiovascular biomarkers along central biologic pathways, including myocardial stretch/injury, inflammation, adipose tissue metabolism, and fibrosis pathways in men versus women. Finally, we present recommendations for leveraging our current knowledge of sex differences in blood-based biomarkers for future research and clinical innovation.

Anxiety Disorders Are Associated With Coronary Endothelial Dysfunction in Women With Chest Pain and Nonobstructive Coronary Artery Disease

Background

Anxiety disorders are the most prevalent mental disorders and are an emerging risk factor for coronary artery disease and its complications. We determine the relationship between having a clinical diagnosis of an anxiety disorder and coronary endothelial dysfunction (CED) using invasive coronary reactivity testing across both sexes.

Methods and Results

Patients presenting with chest pain and nonobstructive coronary artery disease (stenosis <40%) at coronary angiography underwent an invasive assessment of CED. Patients were categorized as having a clinical diagnosis of an anxiety disorder at the time of coronary angiography by chart review. The frequency of CED was compared between patients with versus without an anxiety disorder and after stratifying patients by sex. Between 1992 and 2020, 1974 patients (mean age, 51.3 years; 66.2% women) underwent invasive coronary reactivity testing, of which 550 (27.9%) had a documented anxiety disorder at the time of angiography. There was a significantly higher proportion of patients with any type of CED in those with an anxiety disorder in all patients (343 [62.7%] versus 790 [56.4%]; P=0.011) that persisted in women but not in men. After adjusting for covariables, anxiety was significantly associated with any CED among all patients (odds ratio [95% CI], 1.36 [1.10–1.68]; P=0.004), and after stratifying by sex in women but not in men.

Conclusions

Anxiety disorders are significantly associated with CED in women presenting with chest pain and nonobstructive coronary artery disease. Thus, CED may represent a mechanism underpinning the association between anxiety disorders and coronary artery disease and its complications, highlighting the role of anxiety as a potential therapeutic target to prevent cardiovascular events.

Sex hormones, vascular factors and cognition

After more than a century of research, we have failed to develop a pharmacological prevention or cure for dementia. There are strong indicators that sex hormones influence cognition. In this paper we discuss the role of these hormones at the intersection between vascular disease and dementia, in light of the mounting literature covering the shared risk factors, pathological features alongside the timeline of hormonal change with the evolution of vascular and neurodegenerative disease. Interactive risk factors and the role of inflammation over the duration of disease evolution are highlighted. Our summary tables assessing the impact of estrogen-based hormone therapy on cognition over the past 45 years illustrate the effort expended to determine the ideal age for intervention and the type, dose, administration, and duration of therapy that might improve or protect cognition as well as alleviate menopausal symptoms. As the prevalence of dementia is rising and is higher in women, it is crucial we advance our knowledge from the "inconclusive" position statement on menopausal hormone therapy of the US Preventive Services Task Force.

Sex- and Gender-Stratified Risks of Psychological Factors for Incident Ischemic Heart Disease: Systematic Review and Meta-Analysis

Background

Psychological factors are associated with an increased risk of developing ischemic heart disease (IHD). Women more often report psychological factors, and sex and gender differences are present in IHD. In this meta‐analysis we examine the risks of psychological factors for IHD incidence in women and men. We hypothesize that a broad range of psychological factors are related to a higher risk for incident IHD, with a higher risk for women.

Methods and Results

PubMed, EMBASE, and PsycINFO were searched for studies assessing the risk between psychological factors and incident IHD. Psychological factors included depression, anxiety or panic disorder, social support, hostility, anger, personality (type D), type A behavior pattern, posttraumatic stress disorder, and psychological distress. In the primary analyses, 62 studies (77 separate reports) that included 2 145 679 women and 3 119 879 men and reported confounder‐adjusted hazard ratios or relative risks were included. Pooled effect confounder‐adjusted estimates from random‐effects models showed that psychological factors (all combined) were associated with incident IHD in women (hazard ratio: 1.22; 95% CI, 1.14–1.30) and men (hazard ratio: 1.25; 95% CI, 1.19–1.31). No sex and gender differences were found for these pooled effect estimates (P=0.547).

Conclusions

Psychological factors are associated with incident IHD in both women and men, but no significant differences were observed between women and men. IHD is predominantly being studied as obstructive coronary artery disease, which is more prevalent in men. Data are needed on psychological predictors and other manifestations of IHD such as coronary microvascular disease, which is more common in women.

Gender Differences in Patient-Reported Outcomes Among Adults With Atherosclerotic Cardiovascular Disease

Background

Atherosclerotic cardiovascular disease (ASCVD) accounts for approximately one third of deaths in women. Although there is an established relationship between positive patient experiences, health‐related quality of life, and improved health outcomes, little is known about gender differences in patient‐reported outcomes among ASCVD patients. We therefore compared gender differences in patient‐centered outcomes among individuals with ASCVD.

Methods and Results

Data from the 2006 to 2015 Medical Expenditure Panel Survey, a nationally representative US sample, were used for this study. Adults ≥18 years with a diagnosis of ASCVD, ascertained by International Classification of Diseases, Ninth Revision (ICD‐9) codes and/or self‐reported data, were included. Linear and logistic regression were used to compare self‐reported patient experience, perception of health, and health‐related quality of life by gender. Models adjusted for demographics, socioeconomic status, and comorbidities. There were 21 353 participants included, with >10 000 (47%‐weighted) of the participants being women, representing ≈11 million female adults with ASCVD nationwide. Compared with men, women with ASCVD were more likely to experience poor patient–provider communication (odds ratio 1.25 [95% confidence interval 1.11–1.41]), lower healthcare satisfaction (1.12 [1.02–1.24]), poor perception of health status (1.15 [1.04–1.28]), and lower health‐related quality of life scores. Women with ASCVD also had lower use of aspirin and statins, and greater odds of ≥2 Emergency Department visits/y.

Conclusions

Women with ASCVD were more likely to report poorer patient experience, lower health‐related quality of life, and poorer perception of their health when compared with men. These findings have important public health implications and require more research towards understanding the gender‐specific differences in healthcare quality, delivery, and ultimately health outcomes among individuals with ASCVD.

Sex Differences in Ischemic Heart Disease: Advances, Obstacles, and Next Steps

Evolving knowledge of sex-specific presentations, improved recognition of conventional and novel risk factors, and expanded understanding of the sex-specific pathophysiology of ischemic heart disease have resulted in improved clinical outcomes in women. Yet, ischemic heart disease continues to be the leading cause of morbidity and mortality in women in the United States. The important publication by the Institute of Medicine titled "Women's Health Research-Progress, Pitfalls, and Promise," highlights the persistent disparities in cardiovascular disease burden among subgroups of women, particularly women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment. These important health disparities reflect underrepresentation of women in research, with the resultant unfavorable impact on diagnosis, prevention, and treatment strategies in women at risk for cardiovascular disease. Causes of disparities are multifactorial and related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. Lack of awareness in both the public and medical community, as well as existing knowledge gap regarding sex-specific differences in presentation, risk factors, pathophysiology, and response to treatment for ischemic heart disease, further contribute to outcome disparities. There is a critical need for implementation of sex- and gender-specific strategies to improve cardiovascular outcomes. This review is tailored to meet the needs of a busy clinician and summarizes the contemporary trends, characterizes current sex-specific outcome disparities, delineates challenges, and proposes transformative solutions for improvement of the full spectrum of ischemic heart disease clinical care and research in women.

Gender differences in the factors predicting initial engagement at cardiac rehabilitation

Objective

To determine whether there are gender differences in the factors that predict attendance at the initial cardiac rehabilitation baseline assessment (CR engagement) after referral.

Methods

Using data from the National Audit of Cardiac Rehabilitation, we analysed data on 95 638 patients referred to CR following a cardiovascular diagnosis/treatment between 2013 and 2016. Eighteen factors that have been shown in previous research to be important predictors of CR participation were investigated and grouped into four categories: sociodemographic factors, cardiac risk factors, patient medical status and service-level factors. Logistic binary regression models were built for male patients and female patients, assessing the likelihood for CR engagement. Each included predictors such as age, number of comorbidities and social deprivation score.

Results

There were no important differences in the factors that predict the likelihood of CR engagement in men and women. Seven factors associated with a reduced probability of CR engagement, and eight factors associated with increased probability, were identified. Fourteen of the 15 factors identified as predicting the likelihood for engagement/non-engagement were the same for both men and women. Increasing age, being South Asian or non-white ethnicity (other than Black) and being single were all associated with a reduced likelihood of attending an initial CR baseline assessment in both men and women. Male patients with diabetes were 11% less likely to engage with CR; however, there was no significant association in women. Results showed that the overwhelmingly important determinant of CR engagement observed in both men and women was receiving an invitation to attend an assessment session (OR 4.223 men/4.033women; p<0.05).

Conclusions

Consideration of gender differences in predictors of CR uptake should probably be more nuanced and informed by the stage of the patient care pathway.