Call to Action for Cardiovascular Disease in Women: Epidemiology, Awareness, Access, and Delivery of Equitable Health Care: A Presidential Advisory From the American Heart Association

Disparities in access to endovenous treatment options in chronic lower extremity superficial venous insufficiency: A national 7-year analysis

OBJECTIVE

The goal of this study was to analyze trends in treatment access for chronic superficial venous disease and to identify disparities in care.

METHODS

This retrospective study was exempt from institutional review board approval. The American College of Surgeon National Surgical Quality Improvement Program database was used to identify patients who underwent vein stripping (VS) and endovenous procedures for treatment of chronic superficial venous disease. Endovenous options included radiofrequency ablation (RFA) and laser ablation. Data was available from 2011 to 2018 and demographic information was extracted for each patient identified by Current Procedural Terminology codes. For all racial and ethnic groups, trend lines were plotted, and the relative rate of change was determined within each specified demographic.

RESULTS

There were 21,025 patients included in the analysis. The overall mean age was 54.2 years, and the majority of patients were female (64.8%). In total, 27.9%, 55.2%, and 16.9% patients underwent VS, RFA, and laser ablation, respectively. Patients who received laser ablation were older (P < .001). Hispanic ethnicity was associated with significantly lower odds of receiving endovascular thermal ablation (EVTA) over VS (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.64-0.78; P < .001). American Indian/Alaska Native patients were more likely to receive EVTA over VS (OR, 4.02; 95% CI, 2.48-6.86); similarly, Native Hawaiian/Pacific Islander patients were more likely to receive EVTA over VS, although this difference was not statistically significant (OR, 1.44; 95% CI, 0.93-2.27). On multinomial regression, Hispanic patients were less likely to receive RFA over VS, whereas American Indian/Alaskan Native patients were more likely to receive RFA over VS. In all racial and ethnic groups, the percentage of endovenous procedures increased, whereas vein stripping decreased.

CONCLUSIONS

Based on a hospital-based dataset, demographic indicators, including age, sex, race, and ethnicity, are associated with differences in endovenous treatments for chronic superficial venous insufficiency suggesting disparities in obtaining minimally invasive treatment options among certain patient groups.

Sex Differences in Trends in Stroke Recurrence and Postrecurrence Mortality 2000-2020: Population-Based Brain Attack Surveillance in Corpus Christi Project

OBJECTIVE

This study was undertaken to delineate 21-year sex-specific trends in recurrence and postrecurrence mortality.

METHODS

Between 2000 and 2020, first-ever ischemic stroke (IS) patients, ascertained from the population-based BASIC (Brain Attack Surveillance in Corpus Christi) project in South Texas, were followed for recurrent stroke and all-cause mortality until December 31, 2020. Multivariable regression models with an interaction between calendar year and sex were used to estimate sex-specific trends and sex differences in recurrence and postrecurrence mortality.

RESULTS

Of the 6,057 IS patients (median age = 69 years, 49.8% women), 654 (10.8%) had a recurrence and 399 (47.7%) had postrecurrence mortality during 5 years of follow-up. In 2000, women had 2.5% higher albeit non-statistically significant 5-year risk of recurrence than men in absolute scale. With the trend declining in women by 7.6% (95% confidence interval [CI] = -10.8 to -4.5%) and in men by 3.6% (95% CI = -6.5% to -0.7%), the risk at the end of the study period was 1.5% (95% CI = -0.3% to 3.6%) lower among women than men. For postrecurrence mortality, the risk was 10.2% lower among women in 2000, but the sex difference was 3.3% by the end of the period, which was due to a larger overall increase in the risk among women than men over the entire time period.

INTERPRETATION

The declines in recurrent stroke suggest successful secondary stroke prevention, especially in women. However, the continued high postrecurrence mortality among both sexes at the end of study period emphasizes the need for ongoing interventions to improve prognosis in those who have had recurrent cerebrovascular events. ANN NEUROL 2024.

Sex in cardiovascular disease: Why this biological variable should be considered in in vitro models

Cardiovascular disease (CVD), the world's leading cause of death, exhibits notable epidemiological, clinical, and pathophysiological differences between sexes. Many such differences can be linked back to cardiovascular sexual dimorphism, yet sex-specific in vitro models are still not the norm. A lack of sex reporting and apparent male bias raises the question of whether in vitro CVD models faithfully recapitulate the biology of intended treatment recipients. To ensure equitable treatment for the overlooked female patient population, sex as a biological variable (SABV) inclusion must become commonplace in CVD preclinical research. Here, we discuss the role of sex in CVD and underlying cardiovascular (patho)physiology. We review shortcomings in current SABV practices, describe the relevance of sex, and highlight emerging strategies for SABV inclusion in three major in vitro model types: primary cell, stem cell, and three-dimensional models. Last, we identify key barriers to inclusive design and suggest techniques for overcoming them.

Low income and education are associated with greater ASCVD risk scores among adults in the US

Introduction

Social determinants of health (SDOH) are fundamental causes of poor cardiovascular health, yet cardiovascular disease (CVD) risk assessment tools exclude SDOH. Our objective was to determine whether SDOH are independently associated with CVD risk in US adults.

Methods

Utilizing the National Health and Nutrition Examination Survey (NHANES), we combined years 1999-2018 and included participants aged 40-79 without history of CVD and with information to calculate CVD risk (n = 21,694). Ten-year risk of atherosclerotic CVD (ASCVD) was calculated using the American Heart Association/American College of Cardiology (AHA/ACC) pooled cohort equations. We used linear regression models to estimate the association between SDOH and ASCVD risk, after adjusting for demographic factors. All analyses accounted for the complex survey design.

Results

Mean age was 54.7 years, with 52.7 % female, 73.8 % non-Hispanic White, 9.4 % non-Hispanic Black, and 10.7 % Hispanic. From adjusted models, compared with an income of ≥ $75 K, ASCVD risk was greater by 3.06 (95 % CI: 2.65, 3.47) among those with income < $25 K, by 1.55 (95 % CI: 1.21, 1.89) among those with income $25 K-<$55 K, and by 1.20 (95 % CI: 0.84, 1.56) among those with income $55 K-<$75 K. Compared to college graduates, ASCVD risk was greater by 3.09 (95 % CI: 2.56, 3.62) among those with less than a high school education, by 1.65 (95 % CI: 1.31, 200) among those who were high school graduates, and by 1.41 (95 % CI: 1.11, 1.72) among those with some college education.

Conclusion

We found strong graded associations between lower income and lower educational attainment with greater CVD risk.

Cardiovascular Disease in Hispanic Women: JACC Review Topic of the Week

Cardiovascular disease affects 37% of Hispanic women and is the leading cause of death among Hispanic women in the United States. Hispanic women have a higher burden of cardiovascular risk factors, are disproportionally affected by social determinants of health, and face additional barriers related to immigration, such as discrimination, language proficiency, and acculturation. Despite this, Hispanic women show lower rates of cardiovascular disease and mortality compared with non-Hispanic White women. However, this "Hispanic paradox" is challenged by recent studies that account for the diversity in culture, race, genetic background, country of origin, and social determinants of health within Hispanic subpopulations. This review provides a comprehensive overview of the cardiovascular risk factors in Hispanic women, emphasizing the role of social determinants, and proposes a multipronged approach for equitable care.

Ovarian Insufficiency: Clinical Spectrum and Management Challenges

The term "ovarian insufficiency" describes the decline of ovarian function resulting in fertility loss and the marked decrease of ovarian steroid hormone production. From a clinical standpoint, ovarian insufficiency presents in three different settings. The first is natural menopause at midlife occurring at the average age of 51 years. The second arises after surgical oophorectomy owing to disease or elective cancer prophylaxis. Finally, primary or premature ovarian insufficiency is characterized by menopause occurring before age 40, often of undetermined etiology, but at times linked with genetic mutations, autoimmune syndromes, metabolic conditions, iatrogenic etiologies, and toxic exposures. Each clinical situation presents unique concerns and management challenges. The majority of women with intact ovaries who live to age 51 experience natural menopause, with early menopause <45 years. In the United States, surgical menopause with bilateral oophorectomy occurs in ∼600,000 women per year. The timing and specific clinical indication for oophorectomy alters management. Primary ovarian insufficiency occurs in 1% of women, although recent estimates suggest the prevalence may be increasing. Symptoms of ovarian insufficiency include hot flashes or vasomotor symptoms, mood disorders, sleep disruption, and vaginal/urinary symptoms. Health concerns include bone, cardiovascular, and cognitive health. Management of symptoms and preventive strategies varies depending upon the age, clinical situation, and specific health concerns of each individual. Treatment options for symptom relief include cognitive behavior therapy and hypnosis, nonhormonal prescription therapies, and hormone therapy. Tailoring the therapeutic approach over time in response to age, emerging medical issues, and patient desires constitutes individualized care.

Longitudinal Management of Cardiovascular Risk Factors Among Postpartum Women

Background: Pregnancy-related cardiovascular (CV) conditions, including hypertensive disorders of pregnancy (HDP) and gestational diabetes (GDM), are associated with increased long-term CV risk. Methods: This retrospective cohort study defined the prevalence of HDP and GDM within a large, academic health system in the southeast United States between 2012 and 2015 and described health care utilization and routine CV screening up to 1-year following delivery among those with pregnancy-related CV conditions. Rates of follow-up visits and blood pressure, hemoglobin A1c (HbA1c), and lipid screening in the first postpartum year were compared by provider type and pregnancy-related CV condition. Results: Of the 6027 deliveries included, 20% were complicated by HDP and/or GDM. Rates of pre-pregnancy CV risk factors were high, with a significantly higher proportion of pre-pregnancy obesity among women with HDP than in normal pregnancies. Those with both HDP/GDM had the highest rates of follow-up by 1-year postpartum, yet only half of those with any pregnancy-related CV condition had any follow-up visit after 12 weeks. Although most (70%) of those with HDP had postpartum blood pressure screening, less than one-third of those with GDM had a repeat HbA1c by 12 months. Overall, postpartum lipid screening was rare (<20%). Conclusion: There is a high burden of pregnancy-related CV conditions in a large U.S. academic health system. Although overall rates of follow-up in the early postpartum period were high, gaps in longitudinal follow-up exist. Low rates of CV risk factor follow-up at 1 year indicate a missed opportunity for early CV prevention.

Cardio-rheumatology: the cardiovascular, pharmacological, and surgical risks associated with rheumatological diseases in women

Cardiovascular disease (CVD) remains the number one cause of death worldwide. Women are at increased risk of death from CVD, but the mechanisms for how and why this occurs remain elusive. One subset of women who are exceptionally vulnerable to CVD are those with rheumatic diseases (RDs). Indeed, women account for 80% of all RDs, disorders that encompass a broad range of autoimmune and autoinflammatory diseases that lead to chronic inflammation and pathology. The clear association of increased CVD risk in women with RD is thought to be mediated by a number of factors, including RD pathology itself, pharmacological induction of CVD, and/or as yet unidentified mechanisms. As such, elucidation of the causes and treatments of these pathologies has given rise to a new subspecialty of cardiology: cardio-rheumatology. Here, we review and discuss the CVD risks in patients with RDs, the associated sex disparities in RD and CVD care, as well as the current therapeutic and interventional options available to specifically help women with RDs. We hope this discussion will provide guidance and support to patients, as well as to cardio-rheumatologists, as these groups are the most uniquely positioned to radically improve CVD care in these individuals. Moreover, we are hopeful this discussion may lead to better, more efficacious approaches to treating these disorders in women in the near future.

Incorporating reproductive system history data into cardiovascular nursing research to advance women's health

The lack of sex-specific variables, such as reproductive system history (RSH), in cardiovascular research studies is a missed opportunity to address the cardiovascular disease (CVD) burden, especially among women who face sex-specific risks of developing CVD. Collecting RSH data from women enrolled in research studies is an important step towards improving women's cardiovascular health. In this paper, we describe two approaches to collecting RSH in CVD research: extracting RSH from the medical record and participant self-report of RSH. We provide specific examples from our own research and address common data management and statistical analysis problems when dealing with RSH data in research.

John J, Van Iterson EH, Laffin LJ. Association of pulse pressure with death, myocardial infarction, and stroke among cardiovascular outcome trial participants

Background

Prior evidence demonstrates that pulse pressure (PP), a surrogate marker of arterial stiffness, is an independent risk factor for mortality and major adverse cardiovascular (CV) events.

Objectives

The study aimed to identify the association of PP with death, myocardial infarction, and stroke among participants enrolled in large CV outcome clinical trials and determine if this association was impacted by pre-existing CV disease, or specific CV risk factors.

Methods

A total of 65,382 individuals, ages 19 to 98 years, that were enrolled in one of five CV outcome trials were analyzed. Baseline demographics, history, blood pressures, and medications were collected. Univariate and multivariable analyses were conducted to explore temporal patterns, risks, and adjusted survival rates.

Results

Mean baseline PP was 52 ± 12 mmHg. For every 10 mmHg increase in PP, there was an increased risk of death, stroke, or myocardial infarction (hazard ratio (HR) 1.11, 95 % CI 1.08 to 1.14, p < 0.001). Similarly, a PP ≥ 60 mmHg demonstrated an HR of 1.27 (95 % CI 1.19 to 1.36, p < 0.001) compared with PP < 60 mmHg. A similar association existed for all subgroups analyzed except for participants with a history of stroke where increasing PP did not increase risk (HR 1.02, 95 % CI 0.95 to 1.10, p = 0.53). PP was a better predictor of adverse outcomes when compared to both systolic and diastolic blood pressures using the AIC and C-index.

Conclusions

Among participants enrolled in CV outcome trials, baseline PP is associated with increased risk of death, myocardial infarction, and stroke for those with pre-existing CV disease and risk factors with the exception of a prior history of stroke.

Psychological Health and Ischemic Heart Disease in Women: A Review of Current Evidence and Clinical Considerations across the Healthspan

PURPOSE OF REVIEW

Psychological health encompasses a constellation of negative and positive factors-i.e., psychosocial stress, depression, anxiety, trauma, loneliness and social isolation, anger and hostility, optimism, and a sense of purpose. This narrative review presents current evidence at the intersection of psychological health, risk of ischemic heart disease (IHD), and IHD-related outcomes, with an emphasis on associations in women.

RECENT FINDINGS

For women, relations between psychological health and IHD reflect important sex and gender differences in biological and psychosocial factors. Although efforts devoted to understanding psychological health and IHD risk have varied by psychological factor-scientific evidence is strongest for psychosocial stress and depression, while anxiety, trauma, and positive psychological factors warrant more investigation-less optimal psychological health is consistently associated with an earlier and greater risk of IHD morbidity and mortality in women. Still, many past prospective studies of psychological factors and IHD risk had a limited representation of women, did not include analyses by sex, or failed to account for other influential, sex-specific factors. Thus, there are multiple pathways for further, rigorous investigation into psychological health-IHD associations, mechanisms, and empirically supported psychological interventions to mitigate IHD risk among women. Given the robust evidence linking psychological health with women's risk for IHD, implementing routine, brief, psychological screening is recommended. Significant life events, developmental milestones specific to women, and IHD diagnoses or events could cue further psychological assessment and referral, efforts which will mutually strengthen the evidence for integrated psychological and IHD care and delivery of such care to this vulnerable group.

Measurements of Postmenopausal Serum Estradiol Levels and Cardiovascular Events: A Systematic Review

Background

Cardiovascular disease (CVD) is the leading cause of death among female patients and its likelihood increases following menopause. However, whether estradiol levels are related to CVD remains unknown. We aimed to determine the association between serum estradiol levels and cardiovascular (CV) events in postmenopausal females.

Methods

Electronic databases (MEDLINE, Embase) were searched systematically from inception to October 2022. Studies were eligible for inclusion if they included the following: (i) postmenopausal females; (ii) examination of the association between total serum estradiol levels and CV events (CV mortality, CVD, coronary heart disease, myocardial infarction, stroke, venous thromboembolism, heart failure, and CV hospitalization); (iii) original data (randomized controlled trial, quasi-experimental, cohort, case-control, or cross-sectional study). A narrative synthesis was completed because the data were not amenable to meta-analysis.

Results

Of the 9026 citations retrieved, 8 articles were included, representing a total of 5635 women. The risk-of-bias was fair, and considerable heterogeneity was present. In those not using menopausal hormone therapy, 3 studies demonstrated mixed results between estradiol levels and risk of coronary heart disease, and 1 study showed that higher estradiol levels were associated with an increased risk of myocardial infarction. No significant associations were present between estradiol levels and the remaining events (ie, CV mortality, heart failure, CVD, and stroke).

Conclusions

The association between serum estradiol levels and CV events in postmenopausal females remains unclear. Further studies assessing this association are warranted, given the elevated CVD risk in this population.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 7: Sex, Gender, and the Social Determinants of Health

Women vs men have major differences in terms of risk-factor profiles, social and environmental factors, clinical presentation, diagnosis, and treatment of cardiovascular disease. Women are more likely than men to experience health issues that are complex and multifactorial, often relating to disparities in access to care, risk-factor prevalence, sex-based biological differences, gender-related factors, and sociocultural factors. Furthermore, awareness of the intersectional nature and relationship of sociocultural determinants of health, including sex and gender factors, that influence access to care and health outcomes for women with cardiovascular disease remains elusive. This review summarizes literature that reports on under-recognized sex- and gender-related risk factors that intersect with psychosocial, economic, and cultural factors in the diagnosis, treatment, and outcomes of women's cardiovascular health.

The Importance of Nontraditional and Sex-Specific Risk Factors in Young Women With Vasomotor Nonobstructive vs Obstructive Coronary Syndromes

Background

Heart disease is the leading cause of premature death for women in Canada. Ischemic heart disease is categorized as myocardial infarction (MI) with no obstructive coronary artery disease (MINOCA), ischemia with no obstructive coronary arteries (INOCA), and atherosclerotic obstructive coronary artery disease (CAD) with MI (MI-CAD) or without MI (non-MI-CAD). This study aims to study the prevalence of traditional and nontraditional ischemic heart disease risk factors and their relationships with (M)INOCA, compared to MI-CAD and non-MI-CAD in young women.

Methods

This study investigated women who presented with premature (at age ≤ 55 years) vasomotor entities of (M)INOCA or obstructive CAD confirmed by coronary angiography, who are currently enrolled in either the Leslie Diamond Women's Heart Health Clinic Registry (WHC) or the Study to Avoid Cardiovascular Events in British Columbia (SAVEBC). Univariable and multivariable regression models were applied to investigate associations of risk factors with odds of (M)INOCA, MI-CAD, and non-MI-CAD.

Results

A total of 254 women enrolled between 2015 and 2022 were analyzed, as follows: 77 with INOCA and 37 with MINOCA from the registry, and 66 with non-MI-CAD and 74 with MI-CAD from the study. Regression analyses demonstrated that migraines and preeclampsia or gestational hypertension were the most significant risk factors, with a higher likelihood of being associated with premature (M)INOCA, relative to obstructive CAD. Conversely, the presence of diabetes and a current or previous smoking history had the highest likelihood of being associated with premature CAD.

Conclusions

The risk factor profiles of patients with premature (M)INOCA, compared to obstructive CAD, have significant differences.

Integration of Women's Cardiovascular Health Content Into Healthcare Provider Education: Results of a Rapid Review and National Survey

Despite its importance, formal education in healthcare training programs on sex- and gender-specific cardiovascular disease (CVD) risk factors, symptoms, treatment, and outcomes is lacking. We completed rapid reviews of the academic and grey literature to describe the current state of women-specific CVD education in medical, nursing, and other healthcare education programs. Second, we analyzed results from a Canada-wide survey of healthcare professional education programs to identify gaps in curricula related to sex- and gender-specific training in CVD. Our academic review yielded only 15 peer-reviewed publications, and our online search only 20 healthcare education programs, that note that they specifically address women, or sex and gender, and CVD in their curricula. Across both searches, the majority of training and education programs were from the USA, varied greatly in length, delivery mode, and content covered, and lacked consistency in evaluation. Of surveys sent to 213 Canadian universities and other entry-to-practice programs, 80 complete responses (37.6%) were received. A total of 47 respondents (59%) reported that their programs included women-specific CVD content. Among those programs without content specific to CVD in women, 69.0% stated that its inclusion would add "quite a bit" or "a great deal" of value to the program. This study highlights the emerging focus on and substantial gaps in women-specific CVD training and education across healthcare education programs. All medical, nursing, and healthcare training programs are implored to incorporate sex- and gender-based CVD content into their regular curricula as part of a consolidated effort to minimize gaps in cardiovascular care.

Reproductive milestones across the lifespan and cardiovascular disease risk in women

Cardiovascular disease (CVD) is the leading cause of death for women across the developed and developing world. Beyond traditional cardiovascular risk factors, a number of reproductive milestones have been recognized. The goal of this White Paper, issued by the International Menopause Society in conjunction with World Menopause Day 2023, is to highlight female reproductive milestones in terms of potential cardiovascular risk and to review recommendations for minimizing that risk. The primary milestones discussed relate to menstrual cyclicity, adverse pregnancy outcomes, breast cancer treatments and menopause. Each of these categories has a number of permutations that have been shown in observational studies to be associated with increased cardiovascular risks. In current clinical care, recognition of these reproductive milestones has been encouraged so patients can be informed and motivated to engage in primary prevention of CVD early in their life course rather than retrospectively later in life. Options for specifically targeted care with specialist teams are designed to enhance success with risk identification, screening and possible detection of CVD and, optimally, primary or secondary prevention of CVD. Promoting cardiovascular health of women has far-reaching effects for themselves, their families and their progeny. It is time to make women's cardiovascular health a priority.

Twelve tips for developing healthcare learners' uncertainty tolerance

BACKGROUND

Uncertainty is pervasive throughout healthcare practice. Uncertainty tolerance (i.e. adaptively responding to perceived uncertainty) is considered to benefit practitioner wellbeing, encourage person-centred care, and support judicious healthcare resource utilisation. Accordingly, uncertainty tolerance development is increasingly referenced within training frameworks. Practical approaches to support healthcare learners' uncertainty tolerance development, however, are lacking.

AIMS

Drawing on findings across the literature, and the authors' educational experiences, twelve tips for promoting healthcare learners' uncertainty tolerance were developed.

RESULTS

Tips are divided into 1. Tips for Learners, 2. Tips for Educators and Supervisors, and 3. Tips for Healthcare Education Institutions and Systems. Each tip summarises relevant research findings, alongside applications to educational practice.

CONCLUSIONS

Approaches to developing uncertainty tolerance balance factors supporting learners through uncertain experiences, with introducing challenges for learners to further develop uncertainty tolerance. These tips can reassure healthcare education stakeholders that developing learner uncertainty tolerance, alongside core knowledge, is achievable.

Prioritizing the primary prevention of heart failure: Measuring, modifying and monitoring risk

With the rising incidence of heart failure (HF) and increasing burden of morbidity, mortality, and healthcare expenditures, primary prevention of HF targeting individuals in at-risk HF (Stage A) and pre-HF (Stage B) Stages has become increasingly important with the goal to decrease progression to symptomatic (Stage C) HF. Identification of risk based on traditional risk factors (e.g., cardiovascular health which can be assessed with the American Heart Association's Life's Essential 8 framework), adverse social determinants of health, inherited risk of cardiomyopathies, and identification of risk-enhancing factors, such as patients with viral disease, exposure to cardiotoxic chemotherapy, and history of adverse pregnancy outcomes should be the first step in evaluation for HF risk. Next, use of guideline-endorsed risk prediction tools such as Pooled Cohort Equations to Prevent Heart Failure provide quantification of absolute risk of HF based in traditional risk factors. Risk reduction through counseling on traditional risk factors is a core focus of implementation of prevention and may include the use of novel therapeutics that target specific pathways to reduce risk of HF, such as mineralocorticoid receptor agonists (e.g., fineronone), angiotensin-receptor/neprolysin inhibitors, and sodium glucose co-transporter-2 inhibitors. These interventions may be limited in at-risk populations who experience adverse social determinants and/or individuals who reside in rural areas. Thus, strategies like telemedicine may improve access to preventive care. Gaps in the current knowledge base for risk-based prevention of HF are highlighted to outline future research that may target approaches for risk assessment and risk-based prevention with the use of artificial intelligence, genomics-enhanced strategies, and pragmatic trials to develop a guideline-directed medical therapy approach to reduce risk among individuals with Stage A and Stage B HF.

Chronic Hypertension and the Risk of Readmission for Postpartum Cardiovascular Complications

OBJECTIVE

Preeclampsia is an important risk factor for cardiovascular disease (CVD, including heart disease and stroke) along the life course. However, whether exposure to chronic hypertension in pregnancy, in the absence of preeclampsia, is implicated in CVD risk during the immediate postpartum period remains poorly understood. Our objective was to estimate the risk of readmission for CVD complications within the calendar year after delivery for people with chronic hypertension.

METHODS

The Healthcare Cost and Utilization Project's Nationwide Readmission Database (2010-2018) was used to conduct a retrospective cohort study of patients aged 15-54 years. International Classification of Diseases codes were used to identify patients with chronic hypertension and postpartum readmission for CVD complications within 1 year of delivery. People with CVD diagnosed during pregnancy or delivery admission, multiple births, or preeclampsia or eclampsia were excluded. Excess rates of CVD readmission among patients with and without chronic hypertension were estimated. Associations between chronic hypertension and CVD complications were determined from Cox proportional hazards regression models.

RESULTS

Of 27,395,346 delivery hospitalizations that resulted in singleton births, 2.0% of individuals had chronic hypertension (n=544,639). The CVD hospitalization rate among patients with chronic hypertension and normotensive patients was 645 (n=3,791) per 100,000 delivery hospitalizations and 136 (n=37,664) per 100,000 delivery hospitalizations, respectively (rate difference 508, 95% CI 467-549; adjusted hazard ratio 4.11, 95% CI 3.64-4.66). The risk of CVD readmission, in relation to chronic hypertension, persisted for 1 year after delivery.

CONCLUSION

The heightened CVD risk as early as 1 month postpartum in relation to chronic hypertension underscores the need for close monitoring and timely care after delivery to reduce blood pressure and related complications.

[Russian eligibility criteria prescribing menopausal hormonal hormones therapy for patients with cardiovascular and metabolic diseases. Consensus document of the Russian Cardiological Society, Russian Society of Obstetricians and Gynecologists, Russian Association of Endocrinologists, Eurasian Association of Therapists, Association of Phlebologists of Russia]

Menopausal symptoms can disrupt the life course of women at the peak of their career and family life. Currently, the most effective treatment for these manifestations is menopausal hormone therapy (MHT). The presence of cardiovascular and metabolic diseases in itself does not exclude the possibility of prescribing MHT to relieve menopausal symptoms and improve quality of life. However, often an obstacle to the use of this type of hormonal therapy is the fear of doctors who are afraid of doing more harm to patients than good. Caution is especially important when it comes to women with underlying health conditions. Moreover, it should be recognized that there is a lack of high-quality research regarding the safety of MHT for major chronic non-infectious diseases and common comorbid conditions. The presented consensus document analyzed all currently available data obtained from clinical trials of various designs and created a set of criteria for the acceptability of prescribing MHT to women with concomitant cardiovascular and metabolic diseases. Based on the presented document, doctors of various specialties who advise women in menopause will receive an accessible algorithm that will allow them to avoid potentially dangerous situations and reasonably prescribe MHT in real practice.

[Russian Eligibility Criteria for Prescribing Menopausal Hormone Therapy to Patients With Cardiovascular and Metabolic Diseases. Consensus Document of RSC, RSOG, RAE, EUAT, RAP]

Menopausal symptoms can impair the life of women at the peak of their career and family life. At the present time, the most effective treatment for these manifestations is menopausal hormone therapy (MHT). The presence of cardiovascular and metabolic diseases in itself does not exclude the possibility of prescribing MHT to relieve menopausal symptoms and improve quality of life. However, often an obstacle to the use of this type of hormone therapy is the fear of physicians to do more harm to patients than good. Caution is especially important when it comes to women with concurrent diseases. Moreover, it should be recognized that there is a shortage of high-quality research on the safety of MHT for underlying chronic non-infectious diseases and common comorbidities. The presented consensus analyzed all currently available data from clinical trials of various designs and created a set of criteria for the appropriateness of prescribing MHT to women with concomitant cardiovascular and metabolic diseases. Based on the presented document, physicians of various specialties who advise menopausal women will receive an accessible algorithm that will allow them to avoid potentially dangerous situations and reasonably prescribe MHT in real-life practice.

Sex-Specific Effects of Blood Pressure Lowering Pharmacotherapy for the Prevention of Cardiovascular Disease: An Individual Participant-Level Data Meta-Analysis

BACKGROUND

Whether the relative effects of blood pressure (BP)-lowering treatment on cardiovascular outcomes differ by sex, particularly when BP is not substantially elevated, has been uncertain.

METHODS

We conducted an individual participant-level data meta-analysis of randomized controlled trials of pharmacological BP lowering. We pooled the data and categorized participants by sex, systolic BP categories in 10-mm Hg increments from <120 to ≥170 mm Hg, and age categories spanning from <55 to ≥85 years. We used fixed-effect one-stage individual participant-level data meta-analyses and applied Cox proportional hazard models, stratified by trial, to analyze the data.

RESULTS

We included data from 51 randomized controlled trials involving 358 636 (42% women) participants. Over 4.2 years of median follow-up, a 5-mm Hg reduction in systolic BP decreased the risk of major cardiovascular events both in women and men (hazard ratio [95% CI], 0.92 [0.89-0.95] for women and 0.90 [0.88-0.93] for men; P for interaction, 1). There was no evidence for heterogeneity of relative treatment effects by sex for the major cardiovascular disease, its components, or across the different baseline BP categories (all P for interaction, ≥0.57). The effects in women and men were consistent across age categories and the types of antihypertensive medications (all P for interaction, ≥0.14).

CONCLUSIONS

The effects of BP reduction were similar in women and men across all BP and age categories at randomization and with no evidence to suggest that drug classes had differing effects by sex. This study does not substantiate sex-based differences in BP-lowering treatment.

Improvements in dietary intake, behaviors, and psychosocial measures in a community-randomized cardiovascular disease risk reduction intervention: Strong Hearts, Healthy Communities 2.0

BACKGROUND

Cardiovascular disease (CVD) prevalence has disproportionately risen among midlife and older female adults of rural communities, partly due to poor diet and diet-related behaviors and psychosocial factors that impede healthy eating.

OBJECTIVES

This study aimed to evaluate the impact of Strong Hearts Healthy Communities 2.0 (SHHC-2.0) on secondary diet-related outcomes between intervention and control participants that align with the dietary goal and behavioral aims of the SHHC-2.0, a CVD risk reduction program.

METHODS

A community-randomized controlled trial was conducted in rural, medically underserved communities. Participants were female adults ≥40 y who were classified as obese or both overweight and sedentary. Communities were randomized to SHHC-2.0 intervention (n = 5 communities; n = 87 participants) or control (with delayed intervention) (n = 6 communities; n = 95 participants). SHHC-2.0 consisted of 24 wk of twice-weekly experiential nutrition education and group-based physical activity classes led by local health educators. Changes between baseline and end point (24 wk) in dietary intake (24-h recalls), dietary behaviors (e.g., Rapid Eating Assessment for Participants-Short Version [REAP-S] scores) and diet-related psychosocial measures (e.g., Three Factor Eating questionnaire) between groups were analyzed using linear mixed-effects multilevel models.

RESULTS

At 24 wk, participants from the 5 intervention communities, compared with controls, consumed fewer calories (mean difference [MD]= -211 kcal, 95% CI: -412, -110, P = 0.039), improved overall dietary patterns measured by REAP-S scores (MD: 3.9; 95% CI: 2.26, 5.6; P < 0.001), and improved psychosocial measures (healthy eating attitudes, uncontrolled eating, cognitive restraint, and emotional eating).

CONCLUSIONS

SHHC-2.0 has strong potential to improve diet patterns and diet-related psychosocial wellbeing consistent with improved cardiovascular health. This trial was registered at www.

CLINICALTRIALS

gov as NCT03059472.

High levels of lipoprotein(a) in transgenic mice exacerbate atherosclerosis and promote vulnerable plaque features in a sex-specific manner

BACKGROUND AND AIMS

Despite increased clinical interest in lipoprotein(a) (Lp(a)), many questions remain about the molecular mechanisms by which it contributes to atherosclerotic cardiovascular disease. Existing murine transgenic (Tg) Lp(a) models are limited by low plasma levels of Lp(a) and have not consistently shown a pro-atherosclerotic effect of Lp(a).

METHODS

We generated Tg mice expressing both human apolipoprotein(a) (apo(a)) and human apoB-100, with pathogenic levels of plasma Lp(a) (range 87-250 mg/dL). Female and male Lp(a) Tg mice (Tg(LPA+/0;APOB+/0)) and human apoB-100-only controls (Tg(APOB+/0)) (n = 10-13/group) were fed a high-fat, high-cholesterol diet for 12 weeks, with Ldlr knocked down using an antisense oligonucleotide. FPLC was used to characterize plasma lipoprotein profiles. Plaque area and necrotic core size were quantified and immunohistochemical assessment of lesions using a variety of cellular and protein markers was performed.

RESULTS

Male and female Tg(LPA+/0;APOB+/0) and Tg(APOB+/0) mice exhibited proatherogenic lipoprotein profiles with increased cholesterol-rich VLDL and LDL-sized particles and no difference in plasma total cholesterol between genotypes. Complex lesions developed in the aortic sinus of all mice. Plaque area (+22%), necrotic core size (+25%), and calcified area (+65%) were all significantly increased in female Tg(LPA+/0;APOB+/0) mice compared to female Tg(APOB+/0) mice. Immunohistochemistry of lesions demonstrated that apo(a) deposited in a similar pattern as apoB-100 in Tg(LPA+/0;APOB+/0) mice. Furthermore, female Tg(LPA+/0;APOB+/0) mice exhibited less organized collagen deposition as well as 42% higher staining for oxidized phospholipids (OxPL) compared to female Tg(APOB+/0) mice. Tg(LPA+/0;APOB+/0) mice had dramatically higher levels of plasma OxPL-apo(a) and OxPL-apoB compared to Tg(APOB+/0) mice, and female Tg(LPA+/0;APOB+/0) mice had higher plasma levels of the proinflammatory cytokine MCP-1 (+3.1-fold) compared to female Tg(APOB+/0) mice.

CONCLUSIONS

These data suggest a pro-inflammatory phenotype exhibited by female Tg mice expressing Lp(a) that appears to contribute to the development of more severe lesions with greater vulnerable features.

Clinical determinants of ischemic heart disease in Eastern Europe

Cardiovascular inequalities remain pervasive in the European countries. Disparities in disease burden is apparent among population groups based on sex, ethnicity, economic status or geography. To address this challenge, The Lancet Regional Health - Europe convened experts from a broad range of countries to assess the current state of knowledge of cardiovascular disease inequalities across Europe. This report presents the main challenges in Eastern Europe. There were pronounced variations in cardiovascular disease mortality rates across Eastern European countries with a remarkably high disease burden in the North-Eastern Europe. There were also significant differences in access and delivery to healthcare and unmet healthcare needs. Addressing the cardiovascular determinants of health and reducing health disparities in its many dimensions has long been a priority of the European Parliament's work through resolutions and by financing pilot projects. Yet, despite these efforts, few large-scale studies have been conducted to examine the feasibility of reducing cardiovascular disparities in Eastern Europe. There is an urgent need for improved data, measurements, reporting, and comparisons; and for dedicated, collaborative research. There is also a need for a broader understanding of the typology of actions needed to tackle cardiovascular inequalities and a clear political will.

Detection and quantification of breast arterial calcifications on mammograms: a deep learning approach

OBJECTIVE

Breast arterial calcifications (BAC) are a sex-specific cardiovascular disease biomarker that might improve cardiovascular risk stratification in women. We implemented a deep convolutional neural network for automatic BAC detection and quantification.

METHODS

In this retrospective study, four readers labelled four-view mammograms as BAC positive (BAC+) or BAC negative (BAC-) at image level. Starting from a pretrained VGG16 model, we trained a convolutional neural network to discriminate BAC+ and BAC- mammograms. Accuracy, F1 score, and area under the receiver operating characteristic curve (AUC-ROC) were used to assess the diagnostic performance. Predictions of calcified areas were generated using the generalized gradient-weighted class activation mapping (Grad-CAM++) method, and their correlation with manual measurement of BAC length in a subset of cases was assessed using Spearman ρ.

RESULTS

A total 1493 women (198 BAC+) with a median age of 59 years (interquartile range 52-68) were included and partitioned in a training set of 410 cases (1640 views, 398 BAC+), validation set of 222 cases (888 views, 89 BAC+), and test set of 229 cases (916 views, 94 BAC+). The accuracy, F1 score, and AUC-ROC were 0.94, 0.86, and 0.98 in the training set; 0.96, 0.74, and 0.96 in the validation set; and 0.97, 0.80, and 0.95 in the test set, respectively. In 112 analyzed views, the Grad-CAM++ predictions displayed a strong correlation with BAC measured length (ρ = 0.88, p < 0.001).

CONCLUSION

Our model showed promising performances in BAC detection and in quantification of BAC burden, showing a strong correlation with manual measurements.

CLINICAL RELEVANCE STATEMENT

Integrating our model to clinical practice could improve BAC reporting without increasing clinical workload, facilitating large-scale studies on the impact of BAC as a biomarker of cardiovascular risk, raising awareness on women's cardiovascular health, and leveraging mammographic screening.

KEY POINTS

• We implemented a deep convolutional neural network (CNN) for BAC detection and quantification. • Our CNN had an area under the receiving operator curve of 0.95 for BAC detection in the test set composed of 916 views, 94 of which were BAC+ . • Furthermore, our CNN showed a strong correlation with manual BAC measurements (ρ = 0.88) in a set of 112 views.

Menstrual Cycle Irregularity in Adolescence Is Associated With Cardiometabolic Health in Early Adulthood

Background Menstrual cycle irregularities are associated with cardiovascular and cardiometabolic disease. We tested associations between age at menarche and cycle irregularity in adolescence and cardiometabolic health in early adulthood in a subsample from the Pittsburgh Girls Study. Methods and Results Data from annual interviews were used to assess age at menarche and cycle irregularity (ie, greater or less than every 27-29 days) at age 15 years. At ages 22 to 25 years, cardiometabolic health was measured in a subsample of the Pittsburgh Girls Study (n=352; 68.2% Black), including blood pressure, waist circumference, and fasting serum insulin, glucose, and lipids. T tests were used for continuous data and odds ratios for dichotomous data to compare differences in cardiometabolic health as a function of onset and regularity of menses. Early menarche (ie, before age 11 years; n=52) was associated with waist circumference (P=0.043). Participants reporting irregular cycles (n=50) in adolescence had significantly higher levels of insulin, glucose, and triglycerides, and higher systolic and diastolic blood pressure (P values range from 0.035 to 0.005) and were more likely to have clinical indicators of cardiometabolic predisease in early adulthood compared with women who reported regular cycles (odds ratios ranged from 1.89 to 2.56). Conclusions Increasing rates and earlier onset of cardiovascular and metabolic disease among women, especially among Black women, highlights the need for identifying early and reliable risk indices. Menstrual cycle irregularity may serve this purpose and help elucidate the role of women's reproductive health in protecting and conferring risk for later cardiovascular and cardiometabolic diseases.

Cardiovascular Disease in Women: An Update for Nurses

Cardiovascular disease (CVD) is the leading cause of death in women but is often underrecognized and undertreated. Women are more likely to experience delay in treatment and worse outcomes, even though they experience similar symptoms as men. Women are more likely to experience ischemia related to microvascular dysfunction, which is not readily diagnosed by commonly used diagnostic tests. Nurses are ideally positioned to be patient advocates and use evidence-based guidelines to encourage primary prevention and ensure prompt treatment. This paper provides an update on CVD in women for clinical nurses based on the latest research evidence.

Achieving Equity in Emergency Medicine Quality Measures Requires a Sex and Gender Lens

BACKGROUND

Quality measures within Emergency Medicine (EM) were developed to standardize and improve care. Their development has been limited by lack of consideration of sex- and gender-based differences. Research has suggested that sex and gender can impact clinical care and treatment. Inclusion of sex and gender differences is needed to create EM quality measures that are equitable to all.

OBJECTIVE

The aim of the review is to provide a brief history of EM quality measures and the value of considering sex- and gender-based evidence in their development to ensure equity, using acute myocardial infarction (AMI) as an example.

DISCUSSION

Current quality measures related to AMI, such as time-to-electrocardiogram and door-to-balloon time in percutaneous coronary intervention, may have important and modifiable disparities when stratified by sex. Even when presenting with signs and symptoms of AMI, women experience delayed time to diagnosis and treatment. Few studies have considered interventions to mitigate these differences. However, the data available suggest that sex-based disparities can be minimized by implementation of strategies such as a quality control checklist.

CONCLUSIONS

Quality measures were created to deliver high-quality, evidence-based, and standardized care, but without the inclusion of sex and gender metrics, they may not advance care to an equitable level.

The menopause transition: a critical stage for cardiovascular disease risk acceleration in women

The menopause transition is a critical period for cardiovascular health. During this stage, women experience adverse changes in multiple components that are key for optimal cardiovascular health. Additionally, women struggle to maintain ideal health behaviors, which if adopted collectively, have been shown in observational studies to prevent more than 70% of coronary heart disease cases. Significant efforts should be directed toward increasing awareness among women and healthcare professionals about the menopause transition as a stage of cardiovascular disease risk acceleration that is amenable to reduction with positive lifestyle measures.

Comorbid obstructive sleep apnea is associated with adverse cardiovascular outcomes in female patients with acute coronary syndrome complicating metabolic syndrome

BACKGROUND

Obstructive sleep apnea (OSA) and metabolic syndrome (MetS) are each increasingly common in patients with acute coronary syndrome (ACS). Whether OSA increases cardiovascular consequences in ACS patients with MetS has not been investigated.

HYPOTHESIS

OSA increases cardiovascular risk in ACS patients with MetS. We aimed to examine the association between OSA and cardiovascular consequences in ACS patients with MetS.

METHODS

In this prospective cohort study, we consecutive recruited 2160 ACS patients who underwent portable sleep breathing monitoring. OSA is defined as an apnea-hypopnea index (AHI) ≥ 15 events/h. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), including cardiovascular death, myocardial infarction, stroke, ischemia-driven revascularization, or hospitalization for unstable angina or heart failure.

RESULTS

A total of 1927 patients with ACS were enrolled. Among them, 1486 (77.1%) had MetS and 1014 (52.6%) had OSA. During 2.9 years of follow-up, the cumulative incidence of MACCE was similar between OSA and non-OSA groups in patients with MetS (21.9% vs. 17.9%, adjusted hazard ratio [HR] = 1.29 95% confidence interval [CI]: 0.99-1.67, p = .06) and patients without MetS (24.4% vs. 17.3%, adjusted HR = 1.21 95% CI: 0.73-2.03, p = .46). Patients with MetS and OSA had a significantly higher risk of MACCE than patients with MetS and without OSA in women (27.8% vs. 18.1%, adjusted HR = 1.70, 95% CI: 1.01-3.09, p = .04) but not in men (21.0% vs. 17.9%, adjusted HR = 1.19, 95% CI: 0.91-1.59, p = .21).

CONCLUSIONS

In hospitalized ACS patients with MetS, comorbid OSA was associated with increased risk of cardiovascular consequences among women.

Sex Differences in Vascular Response to Mental Stress and Adverse Cardiovascular Events Among Patients With Ischemic Heart Disease

BACKGROUND

Microvascular measures of vascular dysfunction during acute mental stress may be important determinants of major adverse cardiovascular events (MACE), especially among younger and middle-aged women survivors of an acute myocardial infarction.

METHODS

In the MIMS2 study (Myocardial Infarction and Mental Stress 2), individuals who had been hospitalized for a myocardial infarction in the past 8 months were prospectively followed for 5 years. MACE was defined as a composite index of cardiovascular death and first/recurring events for nonfatal myocardial infarction and hospitalizations for heart failure. Reactive hyperemia index and flow-mediated dilation were used to measure microvascular and endothelial function, respectively, before and 30 minutes after a public-speaking mental stress task. Survival models for recurrent events were used to examine the association between vascular response to stress (difference between poststress and resting values) and MACE. Reactive hyperemia index and flow-mediated dilation were standardized in analyses.

RESULTS

Of 263 patients (the mean age was 51 years; range, 25-61), 48% were women, and 65% were Black. During a median follow-up of 4.3 years, 64 patients had 141 adverse cardiovascular events (first and repeated). Worse microvascular response to stress (for each SD decrease in the reactive hyperemia index) was associated with 50% greater risk of MACE (hazard ratio, 1.50 [95% CI, 1.05-2.13]; P=0.03) among women only (sex interaction: P=0.03). Worse transient endothelial dysfunction in response to stress (for each SD decrease in flow-mediated dilation) was associated with a 35% greater risk of MACE (hazard ratio, 1.35 [95% CI, 1.07-1.71]; P=0.01), and the association was similar in women and men.

CONCLUSIONS

Peripheral microvascular dysfunction with mental stress was associated with adverse events among women but not men. In contrast, endothelial dysfunction was similarly related to MACE among both men and women. These results suggest a female-specific mechanism linking psychological stress to adverse outcomes.

Trends and Outcomes of ST-Segment-Elevation Myocardial Infarction Among Young Women in the United States

Background Although there has been a decrease in the incidence of ST-segment-elevation myocardial infarction (STEMI) in the United States, this trend might be stagnant or increasing in young women. We assessed the trends, characteristics, and outcomes of STEMI in women aged 18 to 55 years. Methods and Results We identified 177 602 women aged 18 to 55 with the primary diagnosis of STEMI from the National Inpatient Sample during years 2008 to 2019. We performed trend analyses to assess hospitalization rates, cardiovascular disease (CVD) risk factor profile, and in-hospital outcomes stratified by three age subgroups (18-34, 35-44, and 45-55 years). We found STEMI hospitalization rates were decreased in the overall study cohort from 52 per 100 000 hospitalizations in 2008 to 36 per 100 000 in 2019. This was driven by decreased proportion of hospitalizations in women aged 45 to 55 years (74.2% to-71.7%; P<0.001). Proportion of STEMI hospitalizationincreased in women aged 18-34 (4.7%-5.5%; P<0.001) and 35-44 years (21.2%-22.7%; P<0.001). The prevalence of traditional and non-traditional female-specific or female-predominant CVD risk factors increased in all age subgroups. The adjusted odds of in-hospital mortality in the overall study cohort and age subgroups were unchanged throughout the study period. Additionally, we observed an increase in the adjusted odds of cardiogenic shock, acute stroke, and acute kidney injury in the overall cohort over the study period. Conclusions STEMI hospitalizations are increasing among women aged <45 years, and in-hospital mortality has not changed over the past 12 years in women aged <55 years. Future studies on the optimization of risk assessment and management of STEMI in young women are urgently needed.

Sex Differences in Temporal Trends and Risk Factors of Aortic Dissection in Taiwan

Background Although sex differences in the epidemiological features of aortic dissection (AD) are known, whether there were sex differences in the associations of comorbidities and risk factors with AD is unclear. We evaluated the temporal trends and risk factors of AD by sex. Methods and Results Using claims data from a universal health insurance program linked to the National Death Registry in Taiwan, we identified 16 368 men and 7052 women with newly diagnosed AD from 2005 to 2018. In the case-control analysis, a matched control group without AD was selected for men and women separately. Conditional logistic regression was used to evaluate risk factors of AD and sex differences. Over the 14 years, the annual incidence of diagnosed AD was 12.69 and 5.34 per 100 000 in men and women, respectively. The 30-day mortality was greater in women than in men (18.1% versus 14.1%; adjusted odds ratio [95% CI], 1.19 [1.10-1.29]), and the sex difference was observed mainly in patients not treated with surgery. The 30-day mortality declined over time in male patients undergoing surgical treatments, but no significantly temporal change was found in other patient groups stratified by sex and surgery. After multivariable adjustments, atrial fibrillation, chronic kidney disease, and coronary artery bypass graft surgery were associated with a greater increase in the odds of AD occurrence in women than in men. Conclusions Greater 30-day mortality and stronger associations of atrial fibrillation, chronic kidney disease, and coronary artery bypass graft surgery with AD in women than in men require further attention.

Assessment of Cardiovascular Risk in Women: Progress so Far and Progress to Come

Cardiovascular disease is the leading cause of death in women worldwide. Nonetheless, there exist several uncertainties in the prediction, diagnosis, and treatment of cardiovascular disease in women. A cornerstone in the prediction of cardiovascular disease is the implementation of risk scores. A variety of pregnancy- and reproductive-factors have been associated with lower or higher risk of cardiovascular disease. Consequently, the question has been raised, whether these female-specific factors also provide added value to cardiovascular risk prediction. In this review, we provide an overview of the existing literature on sex differences in the association of established cardiovascular risk factors with cardiovascular disease and the relation between female-specific factors and cardiovascular risk. Furthermore, we systematically reviewed the literature for studies that assessed the added value of female-specific factors beyond already established cardiovascular risk factors. Adding female-specific factors to models containing established cardiovascular risk factors has led to little or no significant improvement in the prediction of cardiovascular events. However, analyses primarily relied on data from women aged ≥40 years. Future investigations are needed to quantify whether pregnancy-related factors improve cardiovascular risk prediction in young women in order to support adequate treatment of risk factors and enhance prevention of cardiovascular disease in women.

Kenton Award Lecture-Stroke Disparities Research: Learning From the Past, Planning for the Future

Inequities in stroke care and outcomes have been documented both within and among countries based on factors, such as race, geography, and socioeconomic status. Research can help us to identify, understand, and address inequities, and this article offers considerations for scientists working in this area. These include designing research aimed at identifying the underlying causes of inequities, recognizing the importance of the social determinants of health, considering interventions that go beyond the individual patient and provider to include policies and systems, acknowledging the role of structural racism, performing community-engaged participatory research, considering intersecting social identities, learning from cross-national comparisons, maintaining the data sources needed for inequities research, using terminology that advances health equity, and improving diversity across the research enterprise.

Moderate walking speed and survival association across 23-years follow-up in female patients with cardiovascular disease

AIMS

To estimate the association between average walking speed (WS), determined using a moderate 1-km treadmill-walking test (1 k-TWT), and all-cause mortality in female patients with stable cardiovascular disease (CVD).

METHODS

A sample of 431 patients (age 67 [34-88] years), performed a 1 k-TWT and were followed for all-cause mortality for up to 23 years. Variables significantly associated with mortality were determined by Cox proportional hazard models. Based on average WS during the 1k_TWT the sample was subdivided into tertiles, and mortality risk was calculated. Receiver-operating-characteristic curves were constructed to assess the discriminatory accuracy of WS for estimating survival.

RESULTS

During a median follow-up of 10.4 years, a total of 135 deaths from any cause occurred, with an average mortality rate of 4.2%. The strongest predictor of mortality was WS (c-statistic for all-cause mortality 0.801, 95% confidence intervals: 0.51-1.11, p < 0.0001). Survival rate decreased from the fastest to the lowest tertile. Compared to the group with the lowest WS, the hazard ratios (95% confidence intervals) for the second and third tertiles were 0.73 (0.48-1.12) and 0.47 (0.25-0.91), respectively (p for trend <0.0001).

CONCLUSION

Average WS maintained during a moderate treadmill-walk is inversely related to survival in female patients with CVD. The 1 k-TWT is a simple and useful tool for assessing progress and stratifying risk in women undergoing secondary prevention programs.