Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association. Writing Group

Ten reasons to screen women at risk of lung cancer

This opinion piece reviews major reasons for promoting lung cancer screening in at-risk women who are smokers or ex-smokers, from the age of 50. The epidemiology of lung cancer in European women is extremely worrying, with lung cancer mortality expected to surpass breast cancer mortality in most European countries. There are conflicting data as to whether women are at increased risk of developing lung cancer compared to men who have a similar tobacco exposure. The sharp increase in the incidence of lung cancer in women exceeds the increase in their smoking exposure which is in favor of greater susceptibility. Lung and breast cancer screening could be carried out simultaneously, as the screening ages largely coincide. In addition, lung cancer screening could be carried out every 2 years, as is the case for breast cancer screening, if the baseline CT scan is negative.As well as detecting early curable lung cancer, screening can also detect coronary heart disease and osteoporosis induced by smoking. This enables preventive measures to be taken in addition to smoking cessation assistance, to reduce morbidity and mortality in the female population. Key points • The epidemiology of lung cancer in European women is very worrying.• Lung cancer is becoming the leading cause of cancer mortality in European women.• Women benefit greatly from screening in terms of reduced risk of death from lung cancer.

Associations between body composition and cardiovascular disease risk in pre- and postmenopausal women

BACKGROUND

Menopause transition is a critical phase of women's life since body composition and cardiovascular risk factors begin to change during this period. This study investigated the associations between body composition and cardiovascular disease risk (CVDR) in pre (PrMW) and postmenopausal women (PMW).

METHODS

A community-based cross-sectional study involving 184 PrMW and 166 PMW, selected randomly from Bope-Poddala area in Galle, Sri Lanka was carried out. Total-body fat mass (TBFM, kg), total body skeletal muscle mass (TBSMM, kg), total body bone mineral density (TBBMD, g/cm2) and total body bone mineral content (TBBMC, g) were measured with total body DXA scanner and they were taken as indices of body composition. CVDR was evaluated using Framingham risk score (FRS%) and individual CVDR factors, such as systolic blood pressure (SBP, mmHg), diastolic blood pressure (DBP, mmHg), fasting blood sugar (FBS, mg/dl), total cholesterol, (TC, mg/dl), tryglycerides (TG, mg/dl), high-density lipoprotein (HDL, mg/dl) and low-density lipoprotein (LDL, mg/dl). Correlations between indices of body composition and CVDR factors were assessed with adjusted partial correlation (adjusted for socio-demographic and gynecologic status, age, daily calorie consumption and physical activity level).

RESULTS

Mean(SD) age of PrMW and PMW were 42.4(6.0) and 55.8(3.8) years respectively. TBFM correlated with SBP and DBP (r range; 0.15 to 0.21) and TBSMM correlated with SBP, DBP and HDL (r range; - 0.24 to 0.17) only in PrMW (p < 0.05). TBBMD correlated only with FBS in PMW (r; - 0.21, p = 0.01). TBBMC did not show correlations with CVDR factors (p > 0.05). Body composition indices did not show correlations with total CVDR estimated by FRS and in both groups of women (p > 0.05).

CONCLUSIONS

Both SBP and DBP are associated with FM and SMM in different ways among PrMW. This association, however, was not seen among PMW. FBS is associated with BMD only in PMW.

Reproduction as a window to future health in women

Cultivating awareness for reproduction as a window to future health presents an opportunity for early identification and modification of risk factors that can affect both individual and population-level morbidity and mortality. Infertility could serve as both a window into future health as well as a pathway to future pathology. The underlying mechanisms of infertility may share common pathways with long-term risk for health and well-being. Making this identification early in the disease process may improve opportunities for intervention, and deepen our understanding of long-term risk. Additionally, fertility treatments may increase individual risk. Only by making these associations and designing studies to understand how disease and treatment risk impact health can we truly fulfill our goal of building healthy families. The aim of this review is to discuss the short-term impact of fertility challenges and treatment, long-term associations of infertility with morbidity and mortality, and the role of parity in modifying these risk associations.

Differential Patterns and Outcomes of 20.6 Million Cardiovascular Emergency Department Encounters for Men and Women in the United States

Background We describe sex-differential disease patterns and outcomes of >20.6 million cardiovascular emergency department encounters in the United States. Methods and Results We analyzed primary cardiovascular encounters from the Nationwide Emergency Department Sample between 2016 and 2018. We grouped cardiovascular diagnoses into 15 disease categories. The sample included 48.7% women; median age was 67 (interquartile range, 54-78) years. Men had greater overall baseline comorbidity burden; however, women had higher rates of obesity, hypertension, and cerebrovascular disease. For women, the most common emergency department encounters were essential hypertension (16.0%), hypertensive heart or kidney disease (14.1%), and atrial fibrillation/flutter (10.2%). For men, the most common encounters were hypertensive heart or kidney disease (14.7%), essential hypertension (10.8%), and acute myocardial infarction (10.7%). Women were more likely to present with essential hypertension, hypertensive crisis, atrial fibrillation/flutter, supraventricular tachycardia, pulmonary embolism, or ischemic stroke. Men were more likely to present with acute myocardial infarction or cardiac arrest. In logistic regression models adjusted for baseline covariates, compared with men, women with intracranial hemorrhage had higher risk of hospitalization and death. Women presenting with pulmonary embolism or deep vein thrombosis were less likely to be hospitalized. Women with aortic aneurysm/dissection had higher odds of hospitalization and death. Men were more likely to die following presentations with hypertensive heart or kidney disease, atrial fibrillation/flutter, acute myocardial infarction, or cardiac arrest. Conclusions In this large nationally representative sample of cardiovascular emergency department presentations, we demonstrate significant sex differences in disease distribution, hospitalization, and death.

Prevalence of cardiovascular diseases in relation to total bone mineral density and prevalent fractures: A population-based cross-sectional study

BACKGROUND AND AIM

We aimed to explore the relationship between total BMD and prevalent fractures and the risk of CVD in a female population in the United States (US).

METHODS AND RESULTS

We undertook cross-sectional analyses of a female population participating in the US National Health and Nutrition Examination Survey (NHANES). Generalized linear models and restricted cubic spline curves were used to examine the association between total BMD and CVD. Subgroup analyses were also undertaken. A total of 13,707 women were enrolled. The restricted cubic spline curve revealed a linear and negative association between total BMD and CVD. The inflection point for the curve was identified at total BMD = 1.085 g/cm². A negative relationship between total BMD and the prevalence of individual CVDs (angina and stroke) was noted (P < 0.05). In subgroup analyses stratified by race/ethnicity, hypertension, diabetes mellitus, and physical activity, a negative association existed in women who were non-Hispanic White, without hypertension, without diabetes mellitus, and who never participated in physical activity, respectively. In subgroup analyses stratified by age, this association also differed based on age. In addition, participants without history of fracture had significant lower probability of experiencing individual CVDs (angina pectoris, heart attack, and stroke) compared with those with history of fracture.

CONCLUSIONS

We revealed a reduced prevalence of CVD associated with increased total BMD in a female population in the US. CVD risk decreased significantly if total BMD >1.085 g/cm². Additionally, fracture-free individuals had much reduced odds of developing CVD.

Sex-dependent vulnerability of fetal nonhuman primate cardiac mitochondria to moderate maternal nutrient reduction

Poor maternal nutrition in pregnancy affects fetal development, predisposing offspring to cardiometabolic diseases. The role of mitochondria during fetal development on later-life cardiac dysfunction caused by maternal nutrient reduction (MNR) remains unexplored. We hypothesized that MNR during gestation causes fetal cardiac bioenergetic deficits, compromising cardiac mitochondrial metabolism and reserve capacity. To enable human translation, we developed a primate baboon model (Papio spp.) of moderate MNR in which mothers receive 70% of control nutrition during pregnancy, resulting in intrauterine growth restriction (IUGR) offspring and later exhibiting myocardial remodeling and heart failure at human equivalent ∼25 years. Term control and MNR baboon offspring were necropsied following cesarean-section, and left ventricle (LV) samples were collected. MNR adversely impacted fetal cardiac LV mitochondria in a sex-dependent fashion. Increased maternal plasma aspartate aminotransferase, creatine phosphokinase (CPK), and elevated cortisol levels in MNR concomitant with decreased blood insulin in male fetal MNR were measured. MNR resulted in a two-fold increase in fetal LV mitochondrial DNA (mtDNA). MNR resulted in increased transcripts for several respiratory chain (NDUFB8, UQCRC1, and cytochrome c) and adenosine triphosphate (ATP) synthase proteins. However, MNR fetal LV mitochondrial complex I and complex II/III activities were significantly decreased, possibly contributing to the 73% decreased ATP content and increased lipid peroxidation. MNR fetal LV showed mitochondria with sparse and disarranged cristae dysmorphology. Conclusion: MNR disruption of fetal cardiac mitochondrial fitness likely contributes to the documented developmental programming of adult cardiac dysfunction, indicating a programmed mitochondrial inability to deliver sufficient energy to cardiac tissues as a chronic mechanism for later-life heart failure.

Ischemic Etiology and Prognosis in Men and Women with Acute Heart Failure

Coronary heart disease is common in heart failure (HF). Our aim was to determine the impact of ischemic etiology on prognosis among men and women with HF. This study is a prospective national multicenter registry. The primary endpoint was 12-month mortality. Patients with HF and ischemic heart disease were stratified according to sex. A total of 1830 patients were enrolled of which 756 (41.3%) were women. Ischemic etiology was more common in men (446 (41.6%)) than in women (167 (22.2%)). Among patients with ischemic HF, diabetes was more frequent in women than in men. Ischemic etiology was not associated with higher mortality risk, and this was true for women (Hazard Ratio [HR] 1.51, 95% Confidence Interval [CI] 0.98–2.32; p = 0.61) and men (HR 1.14, 95% CI 0.81–1.61; p = 0.46), p-value for interaction: 0.067. Mortality/readmission risk in ischemic HF increased in men with previous readmissions (HR 1.15, 95% CI 1.02–1.29; p = 0.022), chronic obstructive pulmonary disease (HR1.20, 95% CI 1.02–1.41; p = 0.026) and in women with diabetes (HR 2.23, 95% CI 1.05–4.47; p = 0.035). Ischemic etiology was not associated with mortality in HF patients. In ischemic HF, the variables associated with a poor prognosis were diabetes in women and previous readmissions and chronic obstructive pulmonary disease in men.

Go Red for Women Strategically Focused Research Network: Summary of Findings and Network Outcomes

The Go Red for Women movement was initiated by the American Heart Association (AHA) in the early 2000s to raise awareness concerning cardiovascular disease (CVD) risk in women. In 2016, the AHA funded 5 research centers across the United States to advance our knowledge of the risks and presentation of CVD that are specific to women. This report highlights the findings of the centers, showing how insufficient sleep, sedentariness, and pregnancy-related complications may increase CVD risk in women, as well as presentation and factors associated with myocardial infarction with nonobstructive coronary arteries and heart failure with preserved ejection fraction in women. These projects were augmented by collaborative ancillary studies assessing the relationships between various lifestyle behaviors, including nightly fasting duration, mindfulness, and behavioral and anthropometric risk factors and CVD risk, as well as metabolomic profiling of heart failure with preserved ejection fraction in women. The Go Red for Women Strategically Focused Research Network enhanced the evidence base related to heart disease in women, promoting awareness of the female-specific factors that influence CVD.

Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association

Cardiovascular disease (CVD) is the leading cause of death in women, who have a notable increase in the risk for this disease after menopause and typically develop coronary heart disease several years later than men. This observation led to the hypothesis that the menopause transition (MT) contributes to the increase in coronary heart disease risk. Over the past 20 years, longitudinal studies of women traversing menopause have contributed significantly to our understanding of the relationship between the MT and CVD risk. By following women over this period, researchers have been able to disentangle chronological and ovarian aging with respect to CVD risk. These studies have documented distinct patterns of sex hormone changes, as well as adverse alterations in body composition, lipids and lipoproteins, and measures of vascular health over the MT, which can increase a woman's risk of developing CVD postmenopausally. The reported findings underline the significance of the MT as a time of accelerating CVD risk, thereby emphasizing the importance of monitoring women's health during midlife, a critical window for implementing early intervention strategies to reduce CVD risk. Notably, the 2011 American Heart Association guidelines for CVD prevention in women (the latest sex-specific guidelines to date) did not include information now available about the contribution of the MT to increased CVD in women. Therefore, there is a crucial need to discuss the contemporary literature on menopause and CVD risk with the intent of increasing awareness of the significant adverse cardiometabolic health-related changes accompanying midlife and the MT. This scientific statement provides an up-to-date synthesis of the existing data on the MT and how it relates to CVD.

Challenges and Opportunities for the Prevention and Treatment of Cardiovascular Disease Among Young Adults: Report From a National Heart, Lung, and Blood Institute Working Group

Improvements in cardiovascular disease (CVD) rates among young adults in the past 2 decades have been offset by increasing racial/ethnic and gender disparities, persistence of unhealthy lifestyle habits, overweight and obesity, and other CVD risk factors. To enhance the promotion of cardiovascular health among young adults 18 to 39 years old, the medical and broader public health community must understand the biological, interpersonal, and behavioral features of this life stage. Therefore, the National Heart, Lung, and Blood Institute, with support from the Office of Behavioral and Social Science Research, convened a 2-day workshop in Bethesda, Maryland, in September 2017 to identify research challenges and opportunities related to the cardiovascular health of young adults. The current generation of young adults live in an environment undergoing substantial economic, social, and technological transformations, differentiating them from prior research cohorts of young adults. Although the accumulation of clinical and behavioral risk factors for CVD begins early in life, and research suggests early risk is an important determinant of future events, few trials have studied prevention and treatment of CVD in participants <40 years old. Building an evidence base for CVD prevention in this population will require the engagement of young adults, who are often disconnected from the healthcare system and may not prioritize long-term health. These changes demand a repositioning of existing evidence-based treatments to accommodate new sociotechnical contexts. In this article, the authors review the recent literature and current research opportunities to advance the cardiovascular health of today's young adults.

Reducing Cardiovascular Disease Risk in Women Beyond Statin Therapy: New Insights 2020

Management of residual and persistent cardiovascular disease (CVD) risk among statin-treated individuals has emerged as an important preventive strategy. The purpose of this article is to review the unique landscape of CVD in women and relevant prior prevention trials, and to discuss how the recent results of the Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) might apply to the contemporary management of CVD risk among statin-treated women. Women have unique risk factors that may impact CVD and its prevention. Historically, women have been underrepresented in CVD trials, posing a challenge to development of clinical recommendations for women. Low-density lipoprotein cholesterol-targeting treatments have demonstrated CVD risk reduction, with comparable effects in both sexes. In contrast, triglyceride-lowering treatments (niacin, fenofibrate, and omega-3 fatty acids) have reported mixed findings for CVD risk reduction. Recent clinical trials of combination omega-3 fatty acids (docosahexaenoic acid/eicosapentaenoic acid [EPA]) have not found significant CVD risk reduction. The recently published REDUCE-IT study found that icosapent ethyl, an EPA-only omega-3 fatty acid, in combination with statins, significantly reduced CVD events in high-risk patients. The icosapent ethyl group had a significantly lower occurrence of the primary composite CVD endpoint (17.2%) than the placebo group (22.0%; hazard ratio 0.75; 95% confidence interval 0.68-0.83; p < 0.001). CVD risk reduction with icosapent ethyl treatment was comparable between women and men (p for interaction, 0.33). Data from REDUCE-IT suggest women benefit similarly to men with respect to icosapent ethyl, a novel therapy for prevention of CVD.

The Placenta as a Window to Maternal Vascular Health

Cardiovascular disease remains the leading killer of women, with sex-specific manifestation, mechanisms, and morbidity. Preeclampsia, fetal growth restriction, and a subset of preterm births demonstrate aberrancies in the maternal vessels supplying the placenta and damage to the placental parenchyma consistent with hypoxic/ischemic or oxidative injury. This constellation of findings, maternal vascular malperfusion (MVM) lesions, may hold the key to understanding and identifying the elevated risk for early cardiovascular disease in women who experience adverse pregnancy outcomes. This intriguing possibility has only begun to be examined, but accumulating evidence is compelling and is reviewed here.

Prime Time Sister Circles(®)II: Evaluating a Culturally Relevant Intervention to Decrease Psychological and Physical Risk Factors for Chronic Disease in Mid-Life African American Women

PURPOSE

This article presents the results of two evaluation studies of the Prime Time Sister Circles(®) (PTSC). The PTSC is a gender, cultural, and age specific, curriculum-based, low-cost, short-term, replicable support group approach aimed at reducing key modifiable health risk factors for chronic illnesses in midlife African American women.

METHODS

Study 1 includes an evaluation of 31 PTSCs (N=656 women) documenting changes in psychological and attitudinal outcomes (health satisfaction, health locus of control), behavioral outcomes (healthy eating patterns, physical activity, stress management), and clinical outcomes (weight, BMI, blood pressure, non-fasting blood sugar). Study 2 includes evaluation of a subset of the PTSC sites (N=211 women) with comparison (N=55 women) data from those same locations.

RESULTS

Study 1 showed significant changes (p<.0001) in the PTSC women's reports of (lower) stress, (higher) health locus of control, (increased) health satisfaction, (increased) physical activity, and (healthier) eating patterns. The PTSC women demonstrated a significant weight reduction at posttest (p <.0001) and had slightly better clinical outcomes in BMI, hypertension, and non-fasting blood sugar. Results document the sustainability of selected changes over a six-month period. Findings from the Study 2 strengthen the effectiveness claims of the PTSC intervention with significant changes for the PTSC women on selected outcomes and little changes for the comparison women.

CONCLUSIONS

Results reaffirm findings regarding the effectiveness of the PTSC, as originally reported in Gaston, Porter, and Thomas (2007) and extends the credibility of findings by examining participants' clinical outcomes in addition to self-reports.

Astragalus Membranaceus Improving Asymptomatic Left Ventricular Diastolic Dysfunction in Postmenopausal Hypertensive Women with Metabolic Syndrome: A Prospective, Open-Labeled, Randomized Controlled Trial

Background:

Postmenopausal women with metabolic syndrome (MetS) have increased cardiovascular morbidity and left ventricular diastolic dysfunction (LVDD). The various protective effects of astragalus membranaceus (AM) have been described in previous studies. Therefore, this study aimed to evaluate the effects of different doses of AM on diastolic function in postmenopausal hypertensive women with MetS.

Methods:

This was a prospective, randomized controlled study. The postmenopausal hypertensive patients with MetS were enrolled from Lanzhou University Second Hospital from March 2014 to April 2015. Patients were divided into three groups: control group (received conventional medical treatment), AM Group 1 (received AM capsules at 5 g/d additionally), and AM Group 2 (received AM capsules at 10 g/d additionally). Echocardiographic and clinical characteristics were evaluated before and 12 months after treatment. Quantitative data were analyzed using unpaired t-test, analysis of variance, and multiple linear regression analysis.

Results:

A total of 154 patients were subjected to final analysis. In the AM Group 2, significant improvements were noted in diastolic function 12 months after treatment than those of the control group, including the early diastolic mitral annular velocity (E’; 0.065 ± 0.007 m/s vs. 0.061 ± 0.008 m/s, P = 0.014), the ratio of the early diastolic mitral peak flow velocity to the late diastolic mitral peak flow velocity (E/A; 0.81 ± 0.05 vs. 0.80 ± 0.06, P = 0.012), the ratio of E’ to the late diastolic mitral annular velocity (E’/A’; 0.56 ± 0.12 vs. 0.51 ± 0.13, P = 0.048), and the ratio of the early diastolic mitral peak flow velocity (E) to E’ (E/E’; 10.70 ± 1.30 vs. 11.37 ± 1.73, P = 0.031). After treatment, E/E’ (10.70 ± 1.30 vs. 11.24 ± 1.56, P = 0.021), deceleration time (DT; 261.49 ± 44.41 ms vs. 268.74 ± 53.87 ms, P = 0.046), and E’/A’ (0.56 ± 0.12 vs. 0.52 ± 0.13, P = 0.019) values improved more significantly than those of AM Group 2 before treatment. Besides, waist circumference was positively correlated with E’ (r = 0.472; P = 0.003) and E’/A’ (r = 0.321; P = 0.047). In addition, the waist-to-hip ratio was a significant predictor of DT (r = 0.276; P = 0.041), E’ (r = −0.590; P < 0.001), E/E’ (r = 0.454; P = 0.004), and E’/A’ (r = −0.377; P = 0.018).

Conclusions:

Conventional medical plus AM therapy improved diastolic function. Moreover, WC and WHR might be risk factors for LVDD.

Chinese Clinical Trial Register:

ChiCTR-TRC-11001747. http://www.chictr.org.cn/showprojen.aspx?proj=7798.

Specialized Care for Women: the Impact of Women's Heart Centers

PURPOSE OF THE REVIEW

Cardiovascular disease (CVD) has been and remains the leading cause of mortality in women in the United States. For decades, more women died every year of CVD compared to men. Heart centers for women (HCW) are developed in response to the need for greater patient and physician awareness of CVD in women and to conduct sex-specific research in women. Today, many HCW provide multispecialty and focused areas of cardiovascular care for women. HCW provide their female patients with expertise over the many stages of a woman's life. And HCW partner with national organizations to advance research and education through specialized and focused care for women. The purpose of this review is to review the historical development of heart centers for women and discuss the types of care they provide for women.

RECENT FINDINGS

Mortality rates from cardiovascular disease in women are finally reaching the levels of men after decades of focus on awareness, prevention, and evidence-based guideline-directed care for women. Heart centers for women have evolved to provide subspecialty and comprehensive care for women that includes education and research. Heart centers for women are partnering with many other disease-based and patient advocacy organizations to provide care for all women at all stages of life. Alarmingly, there has been increasing CVD mortality in both men and women recently.

Lipids and Women's Health: Recent Updates and Implications for Practice

The obstetrician/gynecologist frequently serves as the primary care physician for women. Specialty-specific guidelines vary in screening recommendations for lipid disorders; women's health practitioners often follow recommendations to screen at age 45 in the absence of other risk factors. However, 2013 American College of Cardiology/American Heart Association cholesterol guidelines recommend screening at age 21 to capture those at risk of cardiovascular disease and allow for early intervention with lifestyle and, in the most severe cases, evidence-based statins. We discuss the care of women who primarily benefit from screening: those with familial hypercholesterolemia (FH), those with the metabolic syndrome (MetS) or polycystic ovary syndrome, and those with hypertriglyceridemia. Those with FH have elevated low-density lipoprotein cholesterol from birth and a propensity for premature coronary heart disease. Early recognition of FH can allow risk-reducing interventions, as well as identification of additional affected relatives. Early detection of metabolic variables, such as in the MetS and hypertriglyceridemia, can lead to an enhanced focus on physical activity and heart-healthy diet. Finally, we discuss a practical approach to lipid management and review concerns regarding drug safety. Our objective is to provide a current overview of cardiovascular risk factor optimization that women's health practitioners can use in identifying and/or treating patients at risk for cardiovascular disease and diabetes.

Aging-Induced Biological Changes and Cardiovascular Diseases

Aging is characterized by functional decline in homeostatic regulation and vital cellular events. This process can be linked with the development of cardiovascular diseases (CVDs). In this review, we discussed aging-induced biological alterations that are associated with CVDs through the following aspects: (i) structural, biochemical, and functional modifications; (ii) autonomic nervous system (ANS) dysregulation; (iii) epigenetic alterations; and (iv) atherosclerosis and stroke development. Aging-mediated structural and biochemical modifications coupled with gradual loss of ANS regulation, vascular stiffening, and deposition of collagen and calcium often disrupt cardiovascular system homeostasis. The structural and biochemical adjustments have been consistently implicated in the progressive increase in mechanical burden and functional breakdown of the heart and vessels. In addition, cardiomyocyte loss in this process often reduces adaptive capacity and cardiovascular function. The accumulation of epigenetic changes also plays important roles in the development of CVDs. In summary, the understanding of the aging-mediated changes remains promising towards effective diagnosis, discovery of new drug targets, and development of new therapies for the treatment of CVDs.

Matrix Metalloproteinase Mediated Type I Collagen Degradation is an Independent Predictor of Increased Risk of Acute Myocardial Infarction in Postmenopausal Women

Acute myocardial infarction (AMI) is often underdiagnosed in women. It is therefore of interest to identify biomarkers that indicate increased risk of AMI and thereby help clinicians to have additional focus on the difficult AMI diagnosis. Type I Collagen, a component of the cardiac extracellular matrix, is cleaved by matrix metalloproteinases (MMPs) generating the neo-epitope C1M. We investigated the association between serum-C1M and AMI and evaluated whether C1M is a prognostic marker for outcome following AMI. This study is based on The Prospective Epidemiological Risk Factor (PERF) Study including postmenopausal women. 316 out of 5,450 women developed AMI within the follow-up period (14 years, median). A multivariate Cox analysis assessed association between serum-C1M and AMI, and re-infaction or death subsequent to AMI. The risk of AMI increased by 18% (p = 0.03) when serum-C1M was doubled and women in the highest quartile had a 33% increased risk compared to those in the low quartiles (p = 0.025). Serum-C1M was, however not related to reinfarction or death subsequent to AMI. In this study C1M was be an independent risk factor for AMI. Measuring MMP degraded type I collagen could be useful for prediction of increased risk of AMI if replicated in other cohorts.

Lipid Effects of Icosapent Ethyl in Women with Diabetes Mellitus and Persistent High Triglycerides on Statin Treatment: ANCHOR Trial Subanalysis

Background: High triglycerides (TG) and diabetes mellitus type 2 (DM2) are stronger predictors of cardiovascular disease (CVD) in women than in men, but few randomized, controlled clinical trials have investigated lipid-lowering interventions in women and none have reported results specifically in women with high TG and DM2. Icosapent ethyl (Vascepa) is pure prescription eicosapentaenoic acid (EPA) ethyl ester approved at 4 g/day as an adjunct to diet to reduce TG ≥500 mg/dL.

Methods: The 12-week ANCHOR trial randomized 702 statin-treated patients (73% with DM; 39% women) at increased CVD risk with TG 200–499 mg/dL despite controlled low-density lipoprotein cholesterol (LDL-C; 40–99 mg/dL) to receive icosapent ethyl 2 g/day, 4 g/day, or placebo. This post hoc analysis included 146 women with DM2 (97% white, mean age 62 years) randomized to icosapent ethyl 4 g/day (n = 74) or placebo (n = 72).

Results: Icosapent ethyl significantly reduced TG (−21.5%; p < 0.0001) without increasing LDL-C and lowered other potentially atherogenic lipid/lipoprotein, apolipoprotein, and inflammatory parameters versus placebo. Icosapent ethyl increased EPA levels in plasma (+639%; p < 0.0001; n = 49) and red blood cells (+599%; p < 0.0001; n = 47) versus placebo. Safety and tolerability of icosapent ethyl were generally similar to placebo.

Conclusion: In women with DM2 at high CVD risk with persistently high TG on statins, icosapent ethyl 4 g/day reduced potentially atherogenic parameters with safety and tolerability comparable to placebo. Potential CVD benefits of icosapent ethyl are being tested in ∼8000 men and women at high CVD risk with high TG on statins in the ongoing Reduction of Cardiovascular Events with Icosapent Ethyl - Intervention Trial (REDUCE-IT) cardiovascular (CV) outcome trial.

Knowledge of clinical trials regarding hormone therapy and likelihood of prescribing hormone therapy

OBJECTIVE

The aim of the study was to examine whether physicians who are better informed about large, published hormone therapy (HT) trials (eg, the Women's Health Initiative) are more likely to prescribe HT for menopausal symptoms.

METHODS

US obstetricians/gynecologists and primary care physicians completed a 15- to 20-minute Internet-based survey. Knowledge was assessed via nine true-false statements about HT trials (range: 0-9). Prescribing practices were assessed via six case studies with a seven-point response scale of "extremely unlikely" to "extremely likely" in relation to treatment options (range: 6-42). The primary analysis examined the correlation between HT trial knowledge and likelihood of prescribing HT. Secondary analyses gauged knowledge and prescribing practices based on practice type, sex, and years in practice.

RESULTS

Among 501 physicians who completed the survey (representing 10.7% of those invited; median age: 51.0 y; female: 26.9%; obstetricians/gynecologists: 49.9%; median 19.0 y in practice), HT knowledge (mean [SD] 3.8 [2.3]), and prescribing (mean [SD] 24.5 [5.6]) exhibited a statistically significant, moderate positive correlation (0.30; 95% CI, 0.21-0.37; P < 0.0001). Obstetricians/gynecologists were significantly (P < 0.0001) more knowledgeable and more likely to prescribe HT than primary care physicians. Male physicians were more likely (P < 0.05) to prescribe HT but not more knowledgeable about it than female physicians. Knowledge (but not likelihood of prescribing) significantly increased as a function of years in practice.

CONCLUSIONS

Physicians who are more knowledgeable about large, published HT trials are more likely to prescribe HT for menopausal symptoms.

Association between modified CHA2DS2-VASc Score with Ankle-Brachial index < 0.9

The ankle-brachial index (ABI) is a reliable diagnostic examination for peripheral arterial occlusive disease (PAOD). We previously reported CHADS₂ score was significantly correlated with PAOD. However, the association between CHA₂DS₂-VASc score and ABI < 0.9 is not evaluated in the literature. The aim of the present study was to investigate whether CHA₂DS₂-VASc score has a strong association with PAOD. We enrolled 1482 patients in this study. PAOD was defined as ABI < 0.9 in either leg. Vascular disease in CHA₂DS₂-VASc score was modified as vascular disease except PAOD. Of the 1482 subjects, the prevalence of ABI < 0.9 was 5.6%. Multivariate analysis showed that the increased age, decreased estimated glomerular filtration rate and increased modified CHA₂DS₂-VASc score (OR, 1.764; p < 0.001) were independent associated with ABI < 0.9. In addition, the percentage of ABI < 0.9 in patients with modified CHA₂DS₂-VASc score of 0, 1, and <2 were 0%, 0.9%, and 0.7%, respectively (All < 1%). Our study demonstrated modified CHA₂DS₂-VASc score was significantly associated with ABI < 0.9. Calculation of modified CHA₂DS₂-VASc score might be useful in identifying patients with PAOD and in stratifying the risk of PAOD in non-AF patients.

Prevalence of peripheral artery disease (PAD) and factors associated: An epidemiological analysis from the population-based Screening PRE-diabetes and type 2 DIAbetes (SPREDIA-2) study

AIM

To describe the prevalence of Peripheral Artery Disease (PAD) in a random population sample and to evaluate its relationship with Mediterranean diet and with other potential cardiovascular risk factors such as serum uric acid and pulse pressure in individuals ranged 45 to 74 years.

METHODS

Cross-sectional analysis of 1568 subjects (mean age 6.5 years, 43% males), randomly selected from the population. A fasting blood sample was obtained to determine glucose, lipids, and HbA1C levels. An oral glucose tolerance test was performed in non-diabetic subjects. PAD was evaluated by ankle-brachial index and/or having a prior diagnosis.

RESULTS

PAD prevalence was 3.81% (95% CI, 2.97-4.87) for all participants. In men, PAD prevalence was significantly higher than in women [5.17% (95% CI, 3.74-7.11) vs. 2.78% (95% CI, 1.89-4.07); p = 0.014]. Serum uric acid in the upper quartile was associated with the highest odds ratio (OR) of PAD (for uric acid > 6.1 mg/dl, OR = 4.31; 95% CI, 1.49-12.44). The remaining variables more strongly associated with PAD were: Heart rate >90 bpm (OR = 4.16; 95%CI, 1.62-10.65), pulse pressure in the upper quartile (≥ 54 mmHg) (OR = 3.82; 95%CI, 1.50-9.71), adherence to Mediterranean diet (OR = 2.73; 95% CI, 1.48-5.04), and former smoker status (OR = 2.04; 95%CI, 1.00-4.16).

CONCLUSIONS

Our results show the existence of a low prevalence of peripheral artery disease in a population aged 45-74 years. Serum uric acid, pulse pressure and heart rate >90 bpm were strongly associated with peripheral artery disease. The direct association between Mediterranean diet and peripheral artery disease that we have found should be evaluated through a follow-up study under clinical practice conditions.

Sex-specific impact of aging on the blood pressure response to exercise

An exaggerated blood pressure (BP) response to exercise has been linked to cardiovascular disease, but little is known about the impact of age and sex on this response. Therefore, this study examined the hemodynamic and skeletal muscle metabolic response to dynamic plantar flexion exercise, at 40% of maximum plantar flexion work rate, in 40 physical activity-matched young (23 ± 1 yr, n = 20) and old (73 ± 2 yr, n = 20), equally distributed, male and female subjects. Central hemodynamics and BP (finometer), popliteal artery blood flow (Doppler ultrasound), and skeletal muscle metabolism (³¹P-magnetic resonance spectroscopy) were measured during 5 min of plantar flexion exercise. Popliteal artery blood flow and high-energy phosphate responses to exercise were not affected by age or sex, whereas aging, independent of sex, attenuated stroke volume and cardiac output responses. Systolic BP and mean arterial pressure responses were exaggerated in old women (Δ42 ± 4 and Δ28 ± 3 mmHg, respectively), with all other groups exhibiting similar increases in systolic BP (old men: Δ27 ± 8 mmHg, young men: Δ27 ± 3 mmHg, and young women: Δ22 ± 3 mmHg) and mean arterial pressure (old men: Δ15 ± 4 mmHg, young men: Δ19 ± 2 mmHg, and young women: Δ17 ± 2 mmHg). Interestingly, the exercise-induced change in systemic vascular resistance in old women (∆0.8 ± 1.0 mmHg·l^-1·min^-1) was augmented compared with young women and young and old men (∆-2.8 ± 0.5, ∆-1.6 ± 0.6, and ∆-3.18 ± 1.4 mmHg·l^-1·min^-1, respectively, P < 0.05). Thus, in combination, advancing age and female sex results in an exaggerated BP response to exercise, likely the result of a failure to reduce systemic vascular resistance. NEW & NOTEWORTHY An exaggerated blood pressure response to exercise has been linked to cardiovascular disease; however, little is known about how age and sex impact this response in healthy individuals. During dynamic exercise, older women exhibited an exaggerated blood pressure response driven by an inability to lower systemic vascular resistance.

Non-Atherosclerotic Vascular Disease in Women

OPINION STATEMENT

Takayasu arteritis, fibromuscular dysplasia (FMD), spontaneous arterial dissection, Raynaud's phenomenon, and chilblains are vascular conditions that are associated with an increased predisposition in women and are often underdiagnosed. Takayasu arteritis has an incidence rate of 2.6 cases per million individuals per year in the USA and predominantly affects women of childbearing age. HLA-B5 genetic locus is linked with Takayasu arteritis susceptibility. Methods to determine active disease are limiting; currently utilized clinical and imaging findings and laboratory tests are of limited value for this purpose. Pregnancy poses risks for maternal and fetal complications, and these patients need additional monitoring and care before and after conception. Controlling hypertension and immunosuppression using steroids, biological and non-biological immunosuppressants, are key components of managing patients with this arteritis. FMD commonly affects middle-aged, white females. Its true prevalence is unknown. Renal and cerebrovascular beds are the most frequently involved vascular beds. Its clinical presentation varies from no symptoms to catastrophic events. Controlling vascular risk factors, periodic surveillance, and revascularization when indicated are important factors in FMD management. Spontaneous arterial dissections are less common, but are an important cause of morbidity and mortality in specific populations. Cervicocephalic dissection causes 10-20% of the strokes in young adults, and coronary artery dissection is the culprit in almost one fourth of young women presenting with acute myocardial infarction. Early diagnosis is key to improving prognosis in these patients, as the majority of patients have spontaneous resolution of the dissection with conservative management alone. Increased clinician awareness of the presentation features and angiographic findings are imperative for early diagnosis. Raynaud's phenomenon and chilblains are cold- or stress-induced cutaneous lesions, commonly involving distal extremities. Secondary causes such as connective tissue diseases and malignancies must be thoroughly excluded during evaluation of these conditions. Cold avoidance, systemic and local warming, and oral vasodilator therapy are the mainstays of therapy.

Coronary artery disease in women

BACKGROUND

Despite the importance of CAD for women, there is persistent perception that CAD is a man's disease. Contributing to this notion is the observation of differences in incidence rates according to age; the incidence of CAD in women is lower than men, but rises steadily after fifth decade. The distribution of CAD risk factors varies between men and women across age ranges and failure to consider these differences may have contributed to the belief that women are at lower risk of CAD compared with men. In addition, women are more likely to have symptoms considered atypical compared with men. There is an urgent need to better understand the presentation of cardiac symptoms in women, in order to facilitate diagnosis and treatment, to initiate aggressive risk factor intervention and to improve the quality of life.

METHODS

We studied clinical and angiographic profile of women undergoing coronary angiogram over a period of 6 years at Nanavati Hospital, Mumbai. The objectives were to examine the distribution of risk factor and coronary angiographic patterns of CAD in women.

RESULTS

It was observed that coronary artery disease is most commonly involving females between the age 60 to 80 years. Raised LDL-C was found to be most common risk factor involved in development of coronary artery disease in females. Most common presentation of CAD in women is unstable angina or non-ST segment elevation MI. Most common coronary angiography finding was single vessel disease.

CONCLUSION

Though coronary artery disease is late to present in women it significantly hamper quality of life. The clinical presentation of coronary artery disease in women varies from asymptomatic to severe unstable angina to myocardial infarction. Stress testing and 2D-ECHO helps to some extent for prediction of coronary artery disease but false positive as well as false negative test results are not negligible. Coronary angiography is the conclusive test to determine spectrum and characterization of coronary artery anatomy in women. As this study is based on experience at single center, various biases may be possible. Widespread data collection involving multiple center and multiple operators will be helpful.

Vasomotor symptoms in menopause: a biomarker of cardiovascular disease risk and other chronic diseases?

Menopausal disorders may include shorter-term symptoms, such as hot flushes and night sweats (vasomotor symptoms, VMS) and longer-term chronic conditions such as cardiovascular disease (CVD), osteoporosis, and cognitive impairment. Initially, no clear link between the shorter-term symptoms and longer-term chronic conditions was evident and these disorders seemed to occur independently from each other. However, there is a growing body of evidence demonstrating that VMS may be a biomarker for chronic disease. In this review, the association between VMS and a range of chronic postmenopausal conditions including CVD, osteoporosis, and cognitive decline is discussed. Prevention of CVD in women, as for men, should be started early, and effective management of chronic disease in postmenopausal women has to start with the awareness that VMS during menopause are harbingers of things to come and should be treated accordingly.

Between mind and heart: Sex-based cognitive bias in cardiovascular disease treatment

Given that both men and women experience cardiovascular disease (CVD), a common misconception is that they have similar risk factors and clinical presentation, receive comparable treatment, and have equivalent clinical outcomes; in reality differences are observed between men and women for each of these endpoints. Moreover, these differences occur as a function of both gender and sex. A review of the literature reveals widespread bias in the selection of research subjects based on these factors, in addition to implicit patient and provider biases that impede the access of women to recommended primary and secondary CVD management. In this perspective, we identify strategies to eliminate such biases and improve women's access to CVD treatments to ensure their care is consistent with current guidelines.

Predictors of electrocardiographic abnormalities in type 1 Diabetes: the Wisconsin Epidemiologic Study of Diabetic Retinopathy

PURPOSE

To determine the incidence and determinants of developing abnormalities on the 12-lead electrocardiogram (ECG) in persons with type 1 diabetes.

METHODS

We evaluated the distribution of ECG abnormalities and risk factors for developing new abnormalities in 266 (mean age = 44 years ± 9.0; 50 % female) people with type 1 diabetes from the Wisconsin Epidemiologic Study of Diabetic Retinopathy. This analysis included participants with complete ECG data from study visit 5 (2000-2001) and follow-up ECGs from study visit 7 (2012-2014). ECG abnormalities were classified as major and minor according to Minnesota Code Classification.

RESULTS

At baseline, 94 (35 %) participants had at least one ECG abnormality, including 13 major ECG abnormalities. At follow-up, 117 (44 %) participants developed at least one new ECG abnormality, including 35 new major ECG abnormalities. In a multivariable logistic regression model, older age (per 5-year increase: OR = 1.31, 95 % CI = 1.08, 1.60) was associated with the development of at least one new ECG abnormality, while serum HDL cholesterol (per 10-unit increase: OR = 0.98, 95 % CI = 0.96, 1.00) was protective against developing new ECG abnormalities.

CONCLUSIONS

The development of new ECG abnormalities is common in type 1 diabetes. Older age and HDL cholesterol are independent risk factors for developing new ECG abnormalities. Further research is needed to determine whether routine ECG screening is indicated in people with type 1 diabetes to identify those with underlying subclinical coronary heart disease.

The Impact of Medication Use in a Multicomponent Intervention: Results from the WISEWOMAN Program

Purpose.

To assess the impact of medication use on improvements in coronary heart disease (CHD) risk among WISEWOMAN participants.

Design.

Pre-post analysis.

Setting.

WISEWOMAN projects operating at the local level in 8 states.

Subjects.

WISEWOMAN participants with baseline and one-year follow-up data with at least one abnormal risk factor at baseline (N = 2385; 24% of women with baseline visits).

Intervention.

WISEWOMAN provides low-income uninsured women with CHD risk factor screenings, lifestyle interventions, access to medications, and referral services.

Measures.

One-year changes in blood pressure, cholesterol, and 10-year CHD risk by medication status.

Analysis.

Regression analysis was used to estimate risk factor changes by medication status (newly medicated women, women medicated at baseline, or not medicated women) and quantify the percentage of improvements in risk factors attributed to medication use.

Results.

Participants experienced statistically significant improvements in systolic (12.6 mm Hg) and diastolic (9.7 mm Hg) blood pressure, total (25.7 mg/dl) and HDL (4.9 mg/dl) cholesterol, and 10-year CHD risk (11.6%). Medication use was responsible for 4% to 5% of the reduction in blood pressure, 32% of the reduction in total cholesterol, 3% of the increase in HDL cholesterol, and 31% of the reduction in 10-year CHD risk.

Conclusions.

Some of the improvements in CHD risk factors can be attributed to medication use; however, the majority of improvements are likely driven by a combination of other factors, including screenings, risk factor counseling, and lifestyle interventions.

Role of mineralocorticoid receptor activation in cardiac diastolic dysfunction

The prevalence of cardiac diastolic dysfunction and heart failure with preserved ejection, a major cause of morbidity and mortality in the western world, is increasing due, in part, to increases in obesity and type 2 diabetes. Characteristics of cardiac diastolic dysfunction include increased myocardial stiffness and impaired left ventricular (LV) relaxation that is characterized by prolonged isovolumic LV relaxation and slow LV filling. Obesity, insulin resistance and type 2 diabetes, especially in females promote activation of mineralocorticoid receptor (MR) signaling with resultant increases in oxidative stress, maladaptive immune responses, inflammation, and impairment of coronary blood flow and cardiac interstitial fibrosis. This review highlights findings from the recent surge in cardiac diastolic dysfunction research. To this end it highlights our contemporary understanding of molecular mechanisms of MR regulation by genetic, epigenetic and posttranslational modifications and resultant cardiac diastolic dysfunction associated with insulin resistance, obesity and type 2 diabetes. This review also explores potential preventative and therapeutic strategies directed in the prevention of cardiac diastolic dysfunction and heart failure with preserved ejection. This article is part of a Special Issue entitled: Genetic and epigenetic control of heart failure edited by Dr. Jun Ren & Yingmei Zhang.

Is Heart Disease or Cancer the Leading Cause of Death in United States Women?

PURPOSE

This paper compares the mortality burden of heart disease versus cancer among women by age, race, and ethnicity.

METHODS

U.S. death and population data for the years 2000 through 2013 were used to calculate heart disease and cancer death rates. Detailed analyses focused on age (15-19 years old to ≥100 years old) and race and ethnicity (Whites, Blacks, Hispanics, Asians and Pacific Islanders (A/PIs), and American Indians and Alaska Natives (AI/ANs)).

RESULTS

Among women aged 15 years and older, there were 289,467 heart disease deaths and 276,716 cancer deaths in 2013. The majority of heart disease deaths (51.6%) occurred among women 85 years or older, compared with 18.9% of female cancer deaths. The age-adjusted death rates (per 100,000 population) were 171 (95% confidence interval [CI], 170-171) for heart disease versus 177 (95% CI, 176-178) for cancer. For all racial and ethnic groups, cancer mortality was significantly higher than heart disease mortality among women younger than 80 years of age. For all ages combined, cancer deaths exceeded heart disease deaths among Hispanics, A/PIs, and AI/ANs. Black non-Hispanic women were the only racial/ethnic group who had a higher age-adjusted death rate for heart disease than for cancer: 224 (95% CI, 222-226) versus 207 (95% CI, 205-209).

CONCLUSIONS

Heart disease remains the leading cause of death among all women combined in the United States by a narrow margin. However, cancer predominantly kills middle-aged and young women, whereas heart disease predominantly kills the very old. New research on the overreporting of heart disease on death certificates for elderly women is needed. National summary statistics obscure the fact that cancer is already the overall leading cause of death for Hispanic women, Asian and Pacific Islander women, and American Indian and Alaska Native women.

Changing the trajectory of ischemic heart disease in women: Role of imaging

Mortality from coronary artery disease in women declined from nearly 500,000 deaths in 2000 to 398,096 deaths in 2013. Despite these significant gains, cardiovascular disease mortality in women remains unacceptably high. Much additional progress in awareness, evaluation, and management of cardiovascular diseases is needed. Progress in cardiovascular imaging, over the past four decades, has substantially improved the evaluation and management of ischemic heart disease. Ischemic heart disease is now diagnosed early and with greater accuracy, leading to improved risk assessment and timely therapies. The next gains in ischemic heart disease mortality in women will probably be due to application of these imaging advances in a personalized fashion. Thoughtful leaders provide their viewpoints on the use of imaging in the evaluation and management of ischemic heart disease in women.

Controversies in the Treatment of Women with ST-Segment Elevation Myocardial Infarction

Coronary artery disease is the leading cause of death in women. Women with ST-segment elevation myocardial infarctions continue to have worse outcomes compared with men despite advancements in therapies. Furthermore, these differences are particularly pronounced among young men and women with myocardial infarctions. Differences in the pathophysiology of coronary artery plaque development, disease presentation, and recognition likely contribute to these outcome disparities. Despite having worse outcomes compared with men, women clearly benefit from aggressive treatment and the latest therapies. This article reviews the treatment options for ST-segment elevation myocardial infarctions and the outcomes of women after treatment with reperfusion therapies.

Longitudinal Effects of Social Support on the Health and Functioning of Older Women with Heart Disease

This study examined the effects of: 1) four dimensions of social support, 2) the number of close social ties, and 3) marital status on the physical and psychological health and functioning of 471 women aged 60 years and over with heart disease. Linear mixed models were used to assess the impact of each baseline social relations predictor on health outcomes at four-, 12-, and 18-month follow-up intervals. A second set of models examined the association between change in support variables over time with concomitant change in health outcomes. Results indicated that baseline emotional/informational support, positive social interaction, affectionate support, tangible support, number of close friends and relatives, and marital status all significantly predicted ( p < .05) one or more health outcomes over time. Increases in positive social interaction and emotional support over time were significantly associated with concurrent improvement in all self-reported physical and psychological health outcomes. Interventions that enhance the availability of emotional/informational support and promote social interaction are needed for this population.

Drop-out predictors in cardiac rehabilitation programmes and the impact of sex differences among coronary heart disease patients in an Iranian sample: a cohort study

Objective : To determine whether patients who subsequently drop out of a structured cardiac rehabilitation programme could be prospectively distinguished from those who remain in the programme based upon their initial baseline characteristics.

Design : A cohort study.

Setting : A referral rehabilitation department in a cardiovascular research and training institute.

Subjects : One thousand one hundred and fifteen coronary heart disease patients including patients with ischaemic heart disease, and those undergoing bypass surgery or percutaneous coronary interventions.

Interventions : Demographic characteristics, coronary heart disease risk factors, ejection fraction, functional capacity and laboratory tests were considered at baseline.

Main measures : Patients who completed all 24 sessions of the cardiac rehabilitation programme were compared with drop-out cases who did not.

Results : Four hundred and ninety-nine patients (44.8%) completed the whole cardiac rehabilitation programme. Women (adjusted odds ratio (AOR) 1.817, P < 0.001), older patients (AOR 1.015, P = 0.047), patients with lower risk of coronary heart disease (AOR 1.573, P = 0.008) or lower body mass index (BMI) (AOR 0.945, P = 0.001) and higher waist-to-hip ratio (AOR 12.871, P = 0.009) and those who were non-smokers (AOR 1.779, P = 0.001) were significantly more likely to complete cardiac rehabilitation.

Conclusions : Developing interventions to address special needs of young, obese, smoker male patients who have a lower waist-to-hip ratio and higher clinical risk may be important, especially in attempts to retain this high-risk group in cardiac rehabilitation therapy.

A Review of Cardiovascular Disease and Treatment Differences in Women

Cardiovascular disease (CVD) is a significant health care problem in the United States today. Women comprise an increasing component of the population affected by this disease. Recent reports have suggested that women are not enrolled in adequate numbers in major clinical studies and, furthermore, are less likely to receive treatment as recommended by evidence-based medicine guidelines. Historical differences in the investigation and treatment of cardiovascular disease between women and men are discussed. Reasons for differences in study enrollment of women are proposed. Efforts by the Food and Drug Administration to improve data collection in women are outlined. The influence of major risk factors, including smoking, hyperlipidemia, and hypertension, on development and progression of CVD is addressed. Major trials of CVD and heart failure are examined. An assessment of progress toward a goal of gender treatment equality is made.

Predictors of coronary artery disease in middle-aged Taiwanese women at premenopause, postmenopause and after undergoing hysterectomy

AIMS AND OBJECTIVES

To examine the predictors of coronary artery disease among middle-aged women at various menopausal statuses.

BACKGROUND

Few studies have explored coronary artery disease predictors among middle-aged women at various menopausal statuses, particularly with the inclusion of women who underwent a hysterectomy.

DESIGN

A cross-sectional design was adopted.

METHODS

Two hundred and twenty-five middle-aged women who were waiting for catheterisation examinations because of possible coronary artery disease were selected. These patients were divided into premenopausal (n = 41), postmenopausal (n = 143) and women who had undergone a hysterectomy groups (n = 41). The differences in the risk factors for coronary artery disease between patients with coronary artery disease (catheterisation results showing stenosis of >50% in at least one major coronary artery) and those without coronary artery disease in the three groups were compared.

RESULTS

The participants were aged 56·8 ± 5·9 years. In the premenopausal group, the odds of coronary artery disease among ever or current smokers was 8·46 times the odds of coronary artery disease for the never smokers. In the postmenopausal group, the odds of coronary artery disease among diabetes patients was 2·89 times the odds of coronary artery disease for those without diabetes. Each additional point on the Chinese Beck Depression Inventory-II increased the risk of coronary artery disease by 5%. In the hysterectomy group, each additional increase in 1 mmHg in systolic blood pressure increased the risk of coronary artery disease by 4%.

CONCLUSIONS

Smoking, diabetes, depression and systolic blood pressure are predictors of coronary artery disease in middle-aged women at premenopause, postmenopause and after undergoing hysterectomy respectively.

RELEVANCE TO CLINICAL PRACTICE

These results are beneficial for middle-aged women at various menopausal stages to effectively implement prevention of coronary artery disease. These findings were among women being evaluated for possible coronary artery disease, we suggest the need for further study in lager, longitudinal studies.

The role of life-course socioeconomic and lifestyle factors in the intergenerational transmission of the metabolic syndrome: results from the LifeLines Cohort Study

BACKGROUND

The risk of metabolic syndrome is associated between parents and offspring, but studies are inconsistent on differences by sex of parents and offspring. Our aim is to investigate to what extent metabolic syndrome present in fathers and mothers is associated with risk of metabolic syndrome in sons and daughters. Furthermore, we investigate to what extent these associations are explained by socioeconomic factors and health behaviours.

METHODS

We used data from the LifeLines Cohort Study (N = 7239). Metabolic syndrome was defined according to the NCEP-ATPIII criteria. Logistic regression analyses were performed to investigate associations of metabolic syndrome present in parents with the risk of metabolic syndrome in offspring. Analyses were sequentially adjusted for: age and sex; childhood factors (socioeconomic position and parental smoking); and adult factors (education, income, smoking, physical activity, alcohol intake, and dietary factors).

RESULTS

Multivariate regression analysis adjusted for age and sex showed associations of the metabolic syndrome between father-son: odds ratio (OR) [95% confidence interval (CI)] 2.41 (1.93-3.00), father-daughter: OR (95% CI) 1.80 (1.39-2.33)), mother-son: OR (95% CI) 1.82 (1.44-2.29) and mother-daughter: OR (95% CI) 1.97 (1.52-2.55). Furthermore, each individual factor underlying the metabolic syndrome in parents was associated with metabolic syndrome in offspring, but not for all parent-offspring combinations. None of the parent-offspring associations was attenuated when adjusting for socioeconomic factors and health behaviours.

CONCLUSIONS

High risk of metabolic syndrome is transmitted from fathers and mothers to sons and daughters. Our results suggest that this transmission is irrespective of the socioeconomic position and health behaviours of the offspring.

Validity of two brief physical activity questionnaires with accelerometers among African-American women

AIM

To evaluate the validity of the Stanford Brief Activity Survey (SBAS) and Exercise Vital Sign (EVS) questionnaire against accelerometer-determined time in moderate-to-vigorous physical activity (MVPA) among African-American (AA) women.

BACKGROUND

Limited research has evaluated the validity of brief physical activity (PA) questionnaires among AA women. Since the validity of PA questionnaires may differ among members of varying racial/ethnic groups, research is needed to explore the validity of self-report PA measures among AA women.

METHODS

A total of 30 AA women [M age = 35.5 ± 5.3; M body mass index (BMI) = 31.1 ± 7.8] wore ActiGraph GT3X+ accelerometers (ActiGraph, LLC, Pensacola FL, USA) for seven days and completed both the SBAS and EVS at two different assessment periods (T1 and T2). Criterion validity was calculated using Spearman's rank order correlations between each questionnaire score and accelerometer-measured MVPA. Sensitivity, specificity, and positive and negative predictive values were calculated using accelerometer-measured MVPA as the criterion to determine the ability of each questionnaire to predict whether or not a participant was meeting the 2008 US PA Guidelines.

FINDINGS

Spearman correlation coefficients between questionnaire scores and minutes of accelerometer-measured MVPA were low (EVS, r = 0.27 at T1 and r = 0.26 at T2; SBAS, r = 0.10 at T1 and r = 0.28 at T2) and not statistically significant (P's > 0.05). The EVS had sensitivity, specificity, and negative and positive predictive values of 27, 89, 59, and 68% at T1 and 33, 74, 38, and 70% at T2, respectively. The SBAS had sensitivity, specificity, and negative and positive predictive values were 18, 79, 33, and 62% at T1 and 67, 58, 43, and 79% at T2. While both questionnaires may be useful in identifying AA women who do not meet the 2008 PA Guidelines, using the questionnaires to identify AA women meeting the PA Guidelines should be done with caution.

Estimated incidence and risk factors of sudden unexpected death

OBJECTIVE

In this manuscript, we estimate the incidence and identify risk factors for sudden unexpected death in a socioeconomically and racially diverse population in one county in North Carolina. Estimates of the incidence and risk factors contributing to sudden death vary widely. The Sudden Unexpected Death in North Carolina (SUDDEN) project is a population-based investigation of the incidence and potential causes of sudden death.

METHODS

From 3 March 2013 to 2 March 2014, all out-of-hospital deaths in Wake County, North Carolina, were screened to identify presumed sudden unexpected death among free-living residents between the ages of 18 and 64 years. Death certificate, public and medical records were reviewed and adjudicated to confirm sudden unexpected death cases.

RESULTS

Following adjudication, 190 sudden unexpected deaths including 122 men and 68 women were identified. Estimated incidence was 32.1 per 100 000 person-years overall: 42.7 among men and 22.4 among women. The majority of victims were white, unmarried men over age 55 years, with unwitnessed deaths at home. Hypertension and dyslipidaemia were common in men and women. African-American women dying from sudden unexpected death were over-represented. Women who were under age 55 years with coronary disease accounted for over half of female participants with coronary artery disease.

CONCLUSIONS

The overall estimated incidence of sudden unexpected death may account for approximately 10% of all deaths classified as 'natural'. Women have a lower estimated incidence of sudden unexpected death than men. However, we found no major differences in age or comorbidities between men and women. African-Americans and young women with coronary disease are at risk for sudden unexpected death.

Primary Prevention of Atherosclerotic Cardiovascular Disease in Women

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality among women. Despite improvements in cardiovascular disease prevention efforts, there remain gaps in cardiovascular disease awareness among women, as well as age and racial disparities in ASCVD outcomes for women. Disparity also exists in the impact the traditional risk factors confer on ASCVD risk between women and men, with smoking and diabetes both resulting in stronger relative risks in women compared to men. Additionally there are risk factors that are unique to women (such as pregnancy-related factors) or that disproportionally affect women (such as auto-immune disease) where preventive efforts should be targeted. Risk assessment and management must also be sex-specific to effectively reduce cardiovascular disease and improve outcomes among women. Evidence supports the use of statin therapy for primary prevention in women at higher ASCVD risk. However, some pause should be given to prescribing aspirin therapy in women without known ASCVD, with most evidence supporting the use of aspirin for women≥65 years not at increased risk for bleeding. This review article will summarize (1) traditional and non-traditional assessments of ASCVD risk and (2) lifestyle and pharmacologic therapies for the primary prevention of ASCVD in women.

The effect of cardiac rehabilitation on quality of life in patients with acute coronary syndrome

BACKGROUND

Acute coronary syndrome is one of the major cardiovascular diseases that leads to a significant amount of morbidity. The purpose of the present study was to investigate the effect of cardiac rehabilitation on quality of life in patients with acute coronary syndrome.

MATERIALS AND METHODS

This was a clinical trial study conducted on 50 patients with acute coronary syndrome admitted to the coronary care units of Shohada Hospital in Isfahan in 2013-2014. The participants were randomly assigned to control (n = 25) and study (n = 25) groups. The study group received cardiac rehabilitation in phase 1 and 2. Phase 1 was conducted in a hospital in Isfahan province that had no cardiac rehabilitation center but had minimal cardiac rehabilitation equipments. Phase 2 was conducted at home by follow-up through telephone and referring the patients to the hospital. The control group received usual cardiac rehabilitation. The data were collected via a demographic questionnaire and SF-36 quality of life questionnre before and 1 month after intervention by the researcher. Data were analyzed by independent samples t-test.

RESULTS

In the study group, the mean scores in all domains of quality of life increased significantly after intervention (P < 0.05). In the control group, the mean scores of quality of life were not significantly different before and after intervention (P < 0.05). A significant difference was found between the study and control groups in all domains of quality of life except for general health and social function (P < 0.05) in favor of the study group.

CONCLUSIONS

The results of this study showed that cardiac rehabilitation program could lead to improving the quality of life in the patients with acute coronary syndrome.

Endothelial Mineralocorticoid Receptor Deletion Prevents Diet-Induced Cardiac Diastolic Dysfunction in Females

Overnutrition and insulin resistance are especially prominent risk factors for the development of cardiac diastolic dysfunction in females. We recently reported that consumption of a Western diet (WD) containing excess fat (46%), sucrose (17.5%), and high fructose corn syrup (17.5%) for 16 weeks resulted in cardiac diastolic dysfunction and aortic stiffening in young female mice and that these abnormalities were prevented by mineralocorticoid receptor blockade. Herein, we extend those studies by testing whether WD-induced diastolic dysfunction and factors contributing to diastolic impairment, such as cardiac fibrosis, hypertrophy, inflammation, and impaired insulin signaling, are modulated by excess endothelial cell mineralocorticoid receptor signaling. Four-week-old female endothelial cell mineralocorticoid receptor knockout and wild-type mice were fed mouse chow or WD for 4 months. WD feeding resulted in prolonged relaxation time, impaired diastolic septal wall motion, and increased left ventricular filling pressure indicative of diastolic dysfunction. This occurred in concert with myocardial interstitial fibrosis and cardiomyocyte hypertrophy that were associated with enhanced profibrotic (transforming growth factor β1/Smad) and progrowth (S6 kinase-1) signaling, as well as myocardial oxidative stress and a proinflammatory immune response. WD also induced cardiomyocyte stiffening, assessed ex vivo using atomic force microscopy. Conversely, endothelial cell mineralocorticoid receptor deficiency prevented WD-induced diastolic dysfunction, profibrotic, and progrowth signaling, in conjunction with reductions in macrophage proinflammatory polarization and improvements in insulin metabolic signaling. Therefore, our findings indicate that increased endothelial cell mineralocorticoid receptor signaling associated with consumption of a WD plays a key role in the activation of cardiac profibrotic, inflammatory, and growth pathways that lead to diastolic dysfunction in female mice.