Prospective randomized study of the effect of "add-back" hormone replacement on vascular function during treatment with gonadotropin-releasing hormone agonists

The sex-dependent response to psychosocial stress and ischaemic heart disease

Stress is an important risk factor for modern chronic diseases, with distinct influences in males and females. The sex specificity of the mammalian stress response contributes to the sex-dependent development and impacts of coronary artery disease (CAD). Compared to men, women appear to have greater susceptibility to chronic forms of psychosocial stress, extending beyond an increased incidence of mood disorders to include a 2- to 4-fold higher risk of stress-dependent myocardial infarction in women, and up to 10-fold higher risk of Takotsubo syndrome-a stress-dependent coronary-myocardial disorder most prevalent in post-menopausal women. Sex differences arise at all levels of the stress response: from initial perception of stress to behavioural, cognitive, and affective responses and longer-term disease outcomes. These fundamental differences involve interactions between chromosomal and gonadal determinants, (mal)adaptive epigenetic modulation across the lifespan (particularly in early life), and the extrinsic influences of socio-cultural, economic, and environmental factors. Pre-clinical investigations of biological mechanisms support distinct early life programming and a heightened corticolimbic-noradrenaline-neuroinflammatory reactivity in females vs. males, among implicated determinants of the chronic stress response. Unravelling the intrinsic molecular, cellular and systems biological basis of these differences, and their interactions with external lifestyle/socio-cultural determinants, can guide preventative and therapeutic strategies to better target coronary heart disease in a tailored sex-specific manner.

Aging, sex and NLRP3 inflammasome in cardiac ischaemic disease

Experimentally, many strong cardioprotective treatments have been identified in different animal models of acute ischaemia/reperfusion injury (IRI) and coronary artery disease (CAD). However, the translation of these cardioprotective therapies for the benefit of the patients into the clinical scenario has been very disappointing. The reasons for this lack are certainly multiple. Indeed, many confounding factors we must deal in clinical reality, such as aging, sex and inflammatory processes are neglected in many experiments. Due to the pivotal role of aging, sex and inflammation in determining cardiac ischaemic disease, in this review, we take into account age as a modifier of tolerance to IRI in the two sexes, dissecting aging and myocardial reperfusion injury mechanisms and the sex differences in tolerance to IRI. Then we focus on the role of the gut microbiota and the NLRP3 inflammasome in myocardial IRI and on the possibility to consider NLRP3 inflammasome as a potential target in the treatment of CAD in relationship with age and sex. Finally, we consider the cardioprotective mechanisms and cardioprotective treatments during aging in the two sexes.

Endometriosis and cardiovascular disease

Endometriosis is a chronic gynaecological disease affecting 1 in 10 reproductive-age women. It is defined as the presence of endometrium-like tissue outside the uterus. Beyond this placid anatomical definition, endometriosis is a complex, hormonal, inflammatory, and systemic condition that poses significant familial, psychological, and economic burden. The interaction between the cardiovascular system and endometriosis has become a field of interest as the underlying mutual mechanisms become better understood. On the basis of accumulating fundamental and clinical evidence, it is likely that there exists a close relationship between endometriosis and the cardiovascular system. Therefore, investigating the endometriosis-cardiovascular interaction is highly clinically significant. In this review, we highlight our current understanding of the pathophysiology of endometriosis with systemic hormonal, pro-inflammatory, pro-angiogenic, immunologic, and genetic processes beyond the peritoneal microenvironment. Additionally, we provide current clinical evidence about how endometriosis interacts with cardiovascular risk factors and cardiovascular disease (CVD). To date, only small associations between endometriosis and CVD have been reported in observational studies, inherently limited by the potential influence of unmeasured confounding. Cardiovascular disease in women with endometriosis remains understudied, under-recognized, and underdiagnosed. More detailed study of the cardiovascular-endometriosis interaction is needed to fully understand its clinical relevance, underlying pathophysiology, possible means of early diagnosis and prevention.

Sex Differences in Cardiovascular Aging and Heart Failure

PURPOSE OF THE REVIEW

This review summarizes sex-related changes in the heart and vasculature that occur with aging, both in the presence and absence of cardiovascular disease (CVD).

RECENT FINDINGS

In the presence of CVD risk factors and/or overt CVD, sex-specific changes in the number of cardiomyocytes, extent of the myocardial extracellular matrix, and myocellular hypertrophy promote unique patterns of LV remodeling in men and women. In addition, age- and sex-specific vascular stiffening is also well established, driven by changes in endothelial dysfunction, elastin-collagen content, microvascular dysfunction, and neurohormonal signaling. Together, these changes in LV chamber geometry and morphology, coupled with heightened vascular stiffness, appear to drive both age-related increases in systolic function and declines in diastolic function, particularly in postmenopausal women. Accordingly, estrogen has been implicated as a key mediator, given its direct vasodilating properties, association with nitric oxide excretion, and involvement in myocellular Ca2+ handling, mitochondrial energy production, and oxidative stress. The culmination of the abovementioned sex-specific cardiac and vascular changes across the lifespan provides important insight into heart failure development, particularly of the preserved ejection fraction variety, while offering promise for future preventive strategies and therapeutic approaches.

Asymptomatic atherosclerosis in egyptian rheumatoid arthritis patients and its relation to disease activity

Aim. To detect the frequency of subclinical atherosclerosis in rheumatoid arthritis patients without clinically evident atherosclerosis and to correlate its presence with the disease activity. Patients and Methods. Our study includes 112 RA patients (group 1) and 40 healthy controls (group 11). All patients and controls were subjected to full history taking, clinical examination, and laboratory investigations. Carotid intima media wall thickness (IMT) and carotid plaques were measured in both groups by B-mode ultrasonography; also color duplex Doppler ultrasound of the brachial artery was done to detect endothelial function. Results. There is atherosclerosis in 31.3% of asymptomatic RA patients compared with only 5% in controls (P = 0.003(**)). A significant difference was detected in patients with and without atherosclerosis regarding duration of the disease (P = 0.0001(***)) and patient's age (P = 0.01(*)). There is highly statistical significant correlation between atherosclerosis and disease activity index. Conclusion. The frequency of subclinical atherosclerosis was high in long-term active RA patients.

Effect of Hormone Therapy on Exercise Capacity in Early Postmenopausal Women

OBJECTIVE

To compare the exercise capacity of postmenopausal women with matched premenopausal controls, as well as postmenopausal women before and after 3 months of hormone therapy (HT).

METHODS

This study examined the response to strenuous isotonic exercise in 30 women with recently developed menopause (age, mean+/-standard deviation, 50.6+/-1.1 years) without cardiovascular risk factors or diseases. Thirty premenopausal subjects, matched one-to-one for age and biophysical characteristics, were the control group. Postmenopausal women underwent examination before (T(0)) and 3 months after (T(1)) HT (oral 0.625 mg conjugated estrogen and 2.5 mg medroxyprogesterone acetate/day) with high-resolution ultrasound determination of peripheral flow-mediated vasodilation and an integrative cardiopulmonary test.

RESULTS

Postmenopausal women showed an impairment of flow-mediated vasodilation (P<.001) in the radial artery and a worsening of physical performance, primarily exemplified by lower maximal workload (P<.01) and peak oxygen consumption (Vo(2)max, P<.001) compared with premenopausal women. After 3 months on HT, ergometabolic parameters and vasodilation reserve were at a level comparable to premenopausal women. Flow-mediated vasodilation measurements after 3 months on HT significantly correlated with those of peak oxygen consumption (r=0.77, P<.001) and the ratio between the increase in oxygen consumption and that in work rate (DeltaVo(2)/DeltaWR) (r=0.73, P<.001).

CONCLUSION

The peripheral circulation is the limiting system in postmenopausal women experiencing exercise intolerance, and there are benefits in introducing HT.

Serum vascular endothelial growth factor as a possible indicator of arterial reactivity in postmenopausal women

OBJECTIVE

To determine whether serum vascular endothelial growth factor (VEGF) concentration is correlated with arterial reactivity in postmenopausal women.

METHODS

An observational study was conducted on 24 postmenopausal women who did not receive any hormone therapy in the 6 months preceding the study and had no pre-existing cardiovascular diseases or cardiovascular risk factors. Serum samples were obtained from all participants and analyzed for VEGF concentrations. Arterial reactivity was assessed by the measurement of endothelium-dependent dilatation and endothelium-independent dilatation of the brachial artery, using color duplex Doppler ultrasound.

RESULTS

The study population was aged 50.8 years on average, with about 2 years of menopause. Serum VEGF concentration in postmenopausal women was significantly correlated with both endothelium-dependent dilatation (r = -0.66, p < 0.01) and endothelium-independent dilatation (r = -0.65, p < 0.01) of the brachial artery.

CONCLUSIONS

Serum VEGF level may be a potential indicator of arterial reactivity in postmenopausal women.

Ischemic heart disease in women and the role of hormone therapy

The prevalence of ischemic heart disease (IHD) has been increasing among the women in developed countries. The well recognized IHD excess in men has often obscured the fact that IHD is the leading cause of death in women. Women have atypical symptoms of IHD that lead to a delay in the diagnosis and an overall poor prognosis. Women have a delay in the onset of IHD due to the beneficial effects of their sex hormones. Postmenopausal women lose this beneficial effect of estrogen and undergo significant changes in their lipid profile, arterial pressure, glucose tolerance, and vascular reactivity that increase their risk for development of IHD. Recently there has been considerable interest in the sex hormones and their role in IHD in women. The general belief that hormone replacement therapy (HRT) has an overall beneficial effect on cardiovascular disease (CVD) in women and hence decreases CVD mortality and morbidity has not been shown in the recent multicenter prospective studies. With the availability of various types of estrogen and progestins, physicians prescribing these agents should take into consideration their varying effects on the cardiovascular system. Risk factor modifications should include diet, weight loss, regular exercise, smoking cessation and adequate control of hypertension (HTN), diabetes (DM) and hyperlipidemia. In the appropriate setting, treatment with proven beneficial agents like aspirin, beta-blockers, angiotensin converting enzyme (ACE) inhibitors and statins will help decrease the burden of IHD in women.

Relative contribution of estrogen withdrawal and gonadotropins increase secondary to ovariectomy on prostaglandin generation in mesenteric microvessels

Recent studies have established that ovariectomy impairs endothelial function, partially by increasing vasoconstrictor prostaglandins generation. Because ovariectomy causes concomitant lack of estrogen and increase of gonadotropins (ie, LH and FSH), in this study we explored the relative role of estrogen and LH/FSH in modulating vasoconstrictor prostaglandins generation in mesenteric arteriolar bed of SHR. Endothelium-dependent relaxation to acetylcholine (ACh) and bradykinin (Bk) was markedly reduced in ovariectomized (OVX) compared with SHR in physiological estrus (OE). Estrogen replacement (OVX + E), but not the decrease in LH/FSH levels with leuprolide (OVX + Leu), corrected the altered vasorelaxation response in OVX. Treatment of mesenteries with diclofenac, prostaglandin-H synthase (PGHS) inhibitor, significantly enhanced the relaxing response in arteries from OVX and OVX + Leu, but not those from OE, indicating that a PGHS-derived vasoconstrictor has modified the endothelium-dependent response during estrogen but not LH/FSH deprivation. Confirming these data, in response to exogenous arachidonic acid, whereas arteries from OVX and OVX + Leu exhibited a marked and similar vasoconstrictor response, the arteries from OE and OVX + E rats exhibited a slight vasodilation. We also demonstrated by RT-PCR that ovariectomy significantly increased PGHS-2 but not PGHS-1 mRNA expression in comparison to OE. The PGHS-2 overexpression in OVX was corrected by estrogen replacement, but not by the reduction of LH/FSH levels. Altogether these data strongly support a role for hypoestrogenism rather than LH/FSH enhancement, associated with the removal of ovaries, in the increase of vasoconstrictor prostaglandins, possibly by a mechanism involving PGHS-2 overexpression.

Clinical cardiovascular studies of hormone replacement therapy

Coronary artery disease (CAD) is the number 1 cause of death and disability in the Western world. The incidence of CAD increases with age, although, on average, women present with symptomatic CAD about 10 years later than men. The belief that hormone replacement therapy (HRT) may reduce the incidence of CAD is based on its favorable effects on (1) vasoreactivity, (2) progression of atherosclerosis, (3) lipids and lipoproteins, (4) hemostasis, and (5) impaired glucose tolerance. However, unopposed estrogen may be related to an increased risk of endometrial cancer. The belief that HRT has an overall beneficial effect on cardiovascular disease comes from the results of prospective cohort studies. The Heart and Estrogen/progestin Replacement Study (HERS), however, showed no beneficial effect of HRT on cardiovascular morbidity and mortality. Uncertainty exists about the duration and optimal type of HRT regimen to use, because different estrogens and progestins have yielded different results. Results of ongoing trials addressing similar questions will be published in future years. The Women's Hormone Intervention Secondary Prevention (WHISP) pilot study, using a different HRT regimen from that used in HERS, will assess the effect of HRT on lipid and hemostatic risk markers of heart disease, and it may provide the rationale for a large trial evaluating the effect of HRT on morbidity and mortality.

A comparison of brachial artery reactivity measured by external and intravascular ultrasound

External ultrasound (US), EXUS, is widely used to measure brachial artery (BA) diameter changes in the assessment of vascular function; however, it has not been compared with other imaging modalities. We simultaneously measured BA diameter responses to hyperaemic flow and nitrate using EXUS and intravascular ultrasound (US), IVUS, in 10 patients. Mean diameters measured across all time periods correlated closely (r = 0.67, p < 0.001). Percent diameter change to hyperaemia and nitrate also correlated well (r = 0.67, p < 0.01). IVUS cross-sectional area (CSA) was significantly different from that calculated from EXUS using pir(2) (23.95 +/- 4.89 vs. 20.35 +/- 4.51 mm(2), respectively, p < 0.001). Orthogonal diameters measured by IVUS were significantly different (5.45 +/- 0.85 vs. 5.17 +/- 0.79 mm, respectively, p < 0.005). In conclusion, EXUS and IVUS BA diameter measurements correlated well; however, discrepancies in absolute measurements were revealed. The cross-section of the BA is oval; therefore, deriving CSA by pir(2) is inaccurate.

The effect of continuous combined hormone replacement therapy on arterial reactivity in postmenopausal women with established angina pectoris

Most epidemiological studies have suggested that the administration of estrogen reduces cardiovascular risk in healthy postmenopausal women. More recently, however, in the large Heart Estrogen/progestin Replacement Study (HERS), it was unexpectedly found that in women with established cardiovascular disease, there was overall no difference in cardiovascular events between those treated with combined oestrogen/progestin hormone replacement therapy and those on placebo. The aim of this study was to examine the effect of combined hormone replacement therapy on arterial reactivity in women with existing angina pectoris. Seventy-four postmenopausal women with angina pectoris were recruited into a 16 week double-blind, placebo-controlled study of treatment with 2 mg of estradiol combined with 1 mg of norethisterone acetate daily. The median endothelium-dependent change in arterial relaxation increased from 5.00 to 7.69% in the treatment group and decreased from 5.57 to 3.64% in the controls. The median endothelium-independent change in arterial relaxation increased from 6.49 to 7.27% in the treatment group and decreased from 4.39 to 2.07% in the controls. The changes in arterial relaxation between the treatment and control groups were not statistically significant. The administration of estrogen/progestin did not significantly improve either endothelium-dependent or -independent arterial relaxation in postmenopausal women with established cardiovascular disease. We have previously shown that estrogen/progestin treatment improves endothelium dependent relaxation in healthy women. The results of our study provide one possible explanation for the clinical findings of the HERS study. In women with established cardiovascular disease, arterial relaxation does not increase significantly in response to treatment with combined hormone replacement therapy.

Preserved forearm endothelial responses with acute exposure to progesterone: A randomized cross-over trial of 17-beta estradiol, progesterone, and 17-beta estradiol with progesterone in healthy menopausal women

Regularly menstruating women are relatively protected from cardiovascular disease. Epidemiological and endothelial function studies attribute this protection to estradiol (E(2)), but both progesterone (P) and E(2) are normally present. A range of vascular effects of added progestins have been described, from neutral to detrimental, but the effects of P per se on endothelial function in humans have not been reported. We therefore investigated the acute effects of E(2), P, and E(2) combined with P, on endothelium-dependent and -independent forearm blood flow responses. Using venous occlusion plethysmography, forearm blood flow (FBF) was measured during acute brachial artery infusions, achieving physiologic levels of 17-beta-E(2), P, and 17-beta-E(2) with P in healthy menopausal women with no cardiovascular disease risk factors. Vehicle or hormones were infused, in random order, on 4 days, 1 week apart. Flow responses were measured during coinfusions of hormone with the endothelium-dependent vasodilator acetylcholine and the endothelium-independent vasodilator sodium nitroprusside. Twenty-seven healthy menopausal women were studied, and all had normal baseline endothelial responses. Small ( approximately 15%), statistically nonsignificant increases in endothelium-dependent flow responses were seen after all acute hormone treatments. No impairment in response was seen with P alone or in combination with 17-beta-E(2). In healthy menopausal women without cardiovascular disease risk factors and without baseline defects in endothelial function, acute exposure to physiologic levels of 17-beta-E(2), P, and 17-beta-E(2) with P produced equivalent endothelium-dependent responses. These data suggest that P does not have detrimental vascular effects in humans.