Effect of Sex Differences on the Association Between Stroke Risk and Left Atrial Anatomy or Mechanics in Patients With Atrial Fibrillation

Impact of left ventricular diastolic function and direct oral anticoagulant use for predicting embolic events in patients with heart failure and atrial fibrillation

Background

Patients with atrial fibrillation (AF) and heart failure (HF) have high stroke risk owing to left atrial dysfunction. However, anticoagulation is a concern in patients with high bleeding risk. We aimed to identify independent predictors of stroke in HF patients with AF.

Methods

We retrospectively examined 320 patients (mean age 79 ± 12 years, 163 women) hospitalized with acute HF complicated by AF between January 2014 and December 2018. Patients were followed from admission until ischemic stroke or systemic embolism (SSE) onset or death or were censored at the last contact date or September 2023.

Results

SSE occurred in 40 patients (median follow-up of 528 days). Multivariate Cox regression analysis identified age (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.00-1.07, p = .034), direct oral anticoagulant (DOAC) use (HR 0.26, 95% CI 0.11-0.60, p = .002), and early diastolic peak flow velocity to early diastolic peak annular velocity (E/e'; HR 1.05, 95% CI 1.02-1.08, p < .001) to be independent predictors of SSE, whereas left atrial reservoir strain was not. After determining an appropriate E/e' cutoff by receiver-operating characteristic curve analysis and adjusting the multivariate Cox model, E/e' ≥17.5 (HR 3.30, 95% CI 1.56-6.83, p = .001) independently predicted SSE. The results were consistent with no interaction in the subanalysis except for gender.

Conclusion

Elderly patients not on DOACs with elevated E/e' may be at higher risk of stroke, suggesting that DOACs should be the first choice for patients with elevated E/e' and aggressive additional prophylaxis and careful follow-up are needed.

Left Atrial Strain in Multisystem Inflammatory Syndrome in Children and Associations with Systemic Inflammation and Cardiac Injury

Multisystem inflammatory syndrome in children (MIS-C) commonly involves cardiac injury with both systolic and diastolic dysfunction. Left atrial strain (LAS) detects subclinical diastolic dysfunction in adults but is infrequently used in children. We evaluated LAS in MIS-C and the associations with systemic inflammation and cardiac injury. In this retrospective cohort study, LAS parameters [reservoir (LAS-r), conduit (LAS-cd), and contractile (LAS-ct)] obtained from admission echocardiograms of MIS-C patients were compared to healthy controls and between MIS-C patients with and without cardiac injury (BNP > 500 pg/ml or troponin-I > 0.04 ng/ml). Correlation and logistic regression analyses were performed to assess LAS associations with admission inflammatory and cardiac biomarkers. Reliability testing was performed. We identified 118 patients with MIS-C and 20 healthy controls. Median LAS parameters were reduced in MIS-C patients compared to controls (LAS-r: 31.8 vs. 43.1%, p < 0.001; LAS-cd: - 28.8 vs. - 34.5%, p = 0.006; LAS-ct: - 5.2 vs. - 9.3%, p < 0.001) and reduced in MIS-C patients with cardiac injury (n = 59) compared to no injury (n = 59) (LAS-r: 29.6 vs. 35.8%, p = 0.001; LAS-cd: - 26.5 vs. - 30.4%, p = 0.036; LAS-ct: - 4.6 vs. - 9.3%, p = 0.008). A discrete LAS-ct peak was absent in 65 (55%) MIS-C patients but present in all controls (p < 0.001). Procalcitonin correlated strongly with averaged E/e' (r = 0.55, p = 0.001). Moderate correlations were found for ESR and LAS-ct (r = - 0.41, p = 0.007) as well as BNP and LAS-r (r = - 0.39, p < 0.001) and LAS-ct (r = 0.31, p = 0.023). Troponin-I had only weak correlations. Intra-rater reliability was good for all LAS parameters, and inter-rater reliability was good to excellent for LAS-r, and fair for LAS-cd and LAS-ct. LAS analysis, particularly the absence of a LAS-ct peak, was reproducible and may be superior to conventional echocardiographic parameters for detecting diastolic dysfunction in MIS-C. No strain parameters on admission were independently associated with cardiac injury.

Left atrial phasic function: physiology, clinical assessment and prognostic value

Left atrial (LA) phasic function provides significant insights into the pathophysiology of cardiovascular disease. LA function is described in three phases: reservoir (atrial filling, during systole), conduit (passive emptying, during early diastole) and contractile (active emptying, during late diastole). LA phasic function can be evaluated by different imaging modalities, and a variety of techniques including volumetric analysis, deformation (strain) and Doppler methods. LA phasic function (particularly LA reservoir strain) is more sensitive and provides earlier detection of LA dysfunction than alterations in LA volume. LA function parameters have also demonstrated significant diagnostic and prognostic value, particularly in heart failure, atrial fibrillation and stroke. However, there remain barriers to implementation of phasic function parameters in clinical practice and guidelines. This review outlines the physiology of LA phasic function, methods of assessment, and its diagnostic and prognostic utility in varying pathologies.

Left atrial strain in multisystem inflammatory syndrome in children (MIS-C) and associations with systemic inflammation and cardiac injury

Background

Multisystem inflammatory syndrome in children (MIS-C) commonly involves cardiac injury with both systolic and diastolic dysfunction. Left atrial strain (LAS) detects subclinical diastolic dysfunction in adults but is infrequently used in children. We evaluated LAS in MIS-C and the associations with systemic inflammation and cardiac injury.

Methods

In this retrospective cohort study, conventional parameters and LAS (reservoir [LAS-r], conduit [LAS-cd], and contractile [LAS-ct]) obtained from admission echocardiograms of MIS-C patients were compared to healthy controls and between MIS-C patients with and without cardiac injury (BNP >500 pg/ml or troponin-I >0.04 ng/ml). Correlation and logistic regression analyses were performed to assess LAS associations with admission inflammatory and cardiac biomarkers. Reliability testing was performed.

Results

Median LAS components were reduced in MIS-C patients (n=118) compared to controls (n=20) (LAS-r: 31.8 vs. 43.1%, p<0.001; LAS-cd: -28.8 vs. -34.5%, p=0.006; LAS-ct: -5.2 vs. -9.3%, p<0.001) and reduced in MIS-C patients with cardiac injury (n=59) compared to no injury (n=59) (LAS-r: 29.6 vs. 35.8%, p=0.001; LAS-cd: -26.5 vs. -30.4%, p=0.036; LAS-ct: -4.6 vs. -9.3%, p=0.008). An LAS-ct peak was absent in 65 (55%) MIS-C patients but present in all controls (p<0.001). Procalcitonin had strong correlation with averaged E/e' (r=0.55, p=0.001); ESR had moderate correlation with LAS-ct (r=-0.41, p=0.007); BNP had moderate correlation with LAS-r (r=-0.39, p<0.001) and LAS-ct (r=0.31, p=0.023), and troponin-I had only weak correlations. No strain indices were independently associated with cardiac injury on regression analysis. Intra-rater reliability was good for all LAS components; and inter-rater reliability was good to excellent for LAS-r, and fair for LAS-cd and LAS-ct.

Conclusions

LAS analysis, particularly the absence of a LAS-ct peak, was reproducible and may be superior to conventional echocardiographic parameters for detecting diastolic dysfunction in MIS-C. No strain parameters on admission were independently associated with cardiac injury.

Effects of Age, Metabolic and Socioeconomic Factors on Cardiovascular Risk among Saudi Women: A Subgroup Analysis from the Heart Health Promotion Study

Background: Cardiovascular disease (CVD) remains the leading cause of death in women. Along with the effect of age on the risk of CVD, the reproductive profile of women can influence cardiac health among women. Objectives: The objective of this study is to investigate the influence of age and reproductive stages on the development and progression of cardiovascular disease risks in Saudi women. Methods: For this study, we included 1907 Saudi women from the Heart Health Promotion Study. The study cohort was divided into five age groups (less than 40 years, 40-45 years, 46-50 years, 51-55 years, and ≥56 years). The cohort stratification was meant to correspond to the social and hormonal changes in women's life, including reproductive, perimenopausal, menopausal, and postmenopausal age groups. The groups were compared with respect to the prevalence of metabolic, socioeconomic, and cardiac risks, and the age group of less than 40 years was considered as the reference group. The World Health Organization stepwise approach to chronic disease risk factor Surveillance-Instrument v2.1 was used in this study to collect the anthropometric and biochemical measurements and the Framingham Coronary Heart Risk Score was used to calculate the cardiovascular risk (CVR). Logistic regression analysis was conducted to assess the independent effect of age on CVD risks after adjustment of sociodemographic factors. Results: Metabolic and CVR increased progressively with the increase in age. There was a sharp increase in obesity, hypertension, diabetes, and metabolic syndrome, from the age group <40 years to 41-45 years and then again between the age groups of 46-50 and ≥56 years. A similar noticeable increase in metabolic risk factors (high cholesterol, high triglyceride, high Low-Density Lipoprotein) was observed between the age group <40 years and 41-45 years, but with a steady increase with the increase in age between the other age groups. The high and intermediate Framingham Coronary Heart Risk Scores showed a progressive increase in prevalence with the increase in age, where the proportion doubled from 9.4% at the age group 46-50 years, to 22% at the age group 51-55 years. It doubled again at the age group ≥56 years to 53%-these sharp inflections in the risk of CVD correspond to the women's reproductive lives. Conclusions: In Saudi women, CVR increases with the increase of age. The influence of pregnancy and menopause is apparent in the prevalence of increased risks for cardiovascular and metabolic diseases.

Prevalence of Postoperative Atrial Fibrillation and Impact to Nursing Practice—A Cross Sectional Study

Background: Atrial fibrillation is the most common clinically significant cardiac arrhythmia, and it might lead to heart failure, which prolongs the duration of hospitalization and consequently increases the cost of treatment. Thus, diagnosing and treating atrial fibrillation should be the first line of defense against further complications. This study aimed to determine the incidence rate of postoperative atrial fibrillation and correlation with cardiac surgery on heart valves. A specific aim was to determine the relationship between the prevalence of atrial fibrillation and socio-demographic features. Methods: The study has a prospective cross-sectional design. The questionnaire was anonymous, requesting socio-demographic information as inclusion criteria, and the data were analyzed using descriptive statistics methods. Results: The sample was 201 patients. χ2 test and t-test were performed where we found that the frequency of atrial fibrillation was higher in the groups that have had valve surgery compared to other cardiac surgeries (χ2 = 7.695, ss = 2, p = 0.021). Atrial fibrillation increased with the age of the patients, but the prevalence of atrial fibrillation was not correlated with body weight. Conclusion: The results of this this study show that atrial fibrillation was higher in the participants who had valve surgery compared to other cardiac surgeries. There was also an increase in atrial fibrillation in the older participants. The results of this study can help to improve nursing practice and the quality of care for cardiac surgery patients with regard to daily activities, or planning nursing care due to the patient’s condition.

Sex and Gender Bias as a Mechanistic Determinant of Cardiovascular Disease Outcomes

Defined as a prejudice either for or against something, biases at the provider, patient, and societal level all contribute to differences in cardiovascular disease recognition and treatment, resulting in outcome disparities between sexes and genders. Provider bias in the under-recognition of female-predominant cardiovascular disease and risks might result in underscreened and undertreated patients. Furthermore, therapies for female-predominant phenotypes including nonobstructive coronary artery disease and heart failure with preserved ejection fraction are less well researched, contributing to undertreated female patients. Conversely, women are less likely to seek urgent medical attention, potentially related to societal bias to put others first, which contributes to diagnostic delays. Furthermore, women are less likely to have discussions around risk factors for coronary artery disease compared with men, partially because they are less likely to consider themselves at risk for heart disease. Provider bias in interpreting a greater number of presenting symptoms, some of which have been labelled as "atypical," can lead to mislabelling presentations as noncardiovascular. Furthermore, providers might avoid discussions around certain therapies including thrombolysis for stroke, and cardiac resynchronization therapy in heart failure, because it is incorrectly assumed that women are not interested in pursuing options deemed more invasive. To mitigate bias, organizations should aim to increase the visibility and involvement of women in research, health promotion, and clinical and leadership endeavours. More research needs to be done to identify effective interventions to mitigate sex and gender bias and the resultant cardiovascular outcome discrepancies.

Sex Differences in Atrial Fibrillation Risk: The VITAL Rhythm Study

Importance

Women have a lower incidence of atrial fibrillation (AF) compared with men in several studies, but it is unclear whether this sex difference is independent of sex differences in prevalent cardiovascular disease (CVD), body size, and other risk factors.

Objective

To examine sex differences in AF incidence and whether AF risk factors differ by sex in a contemporary cohort of men and women without prevalent CVD.

Design, Setting, and Participants

This was a prospective cohort analysis within the Vitamin D and Omega-3 Trial (VITAL) Rhythm Study, a randomized trial that examined the effect of vitamin D and ω-3 fatty acid supplementation on incident AF among men 50 years or older and women 55 years or older without a prior history of prevalent AF, CVD, or cancer at baseline. Data were analyzed from September 29, 2020, to June 29, 2021.

Exposures

Sex, height, weight, body mass index (BMI), body surface area (BSA), and other AF risk factors at study enrollment.

Main Outcomes and Measures

Incident AF confirmed by medical record review.

Results

A total of 25 119 individuals (mean [SD] age, 67.0 [7.1] years; 12 757 women [51%]) were included in this study. Over a median (IQR) follow-up of 5.3 (5.1-5.7) years, 900 confirmed incident AF events occurred among 12 362 men (495 events, 4.0%) and 12 757 women (405 events, 3.2%). After adjustment for age and treatment assignment, women were at lower risk for incident AF than men (hazard ratio [HR], 0.68; 95% CI, 0.59-0.77; P < .001). The inverse association between female sex and AF persisted after adjustment for race and ethnicity, smoking, alcohol intake, hypertension, diabetes (type 1, type 2, gestational), thyroid disease, exercise, and BMI (HR, 0.73; 95% CI, 0.63-0.85; P <.001). However, female sex was positively associated with AF when height (HR, 1.39; 95% CI, 1.14-1.72; P = .001), height and weight (HR 1.49, 95% CI, 1.21-1.82; P <.001), or BSA (HR, 1.25; 95% CI, 1.06-1.49; P = .009) were substituted for BMI in the multivariate model. In stratified models, risk factor associations with incident AF were similar for women and men.

Conclusions and Relevance

In this cohort study, findings suggest that after controlling for height and/or body size, women without CVD at baseline were at higher risk for AF than men, suggesting that sex differences in body size account for much of the protective association between female sex and AF. These data underscore the importance of AF prevention in women.

Sex-linked genetic mechanisms and atrial fibrillation risk

Atrial fibrillation (AF) is a cardiac condition characterised by an irregular heartbeat, atrial pathology and an elevated downstream risk of thrombosis and heart failure, as well as neurological sequelae including stroke and dementia. The prevalence and presentation of, risk factors for, and therapeutic responses to, AF differ by sex, and this sex bias may be partially explained in terms of genetics. Here, we consider four sex-linked genetic mechanisms that may influence sex-biased phenotypes related to AF and provide examples of each: X-linked gene dosage, X-linked genomic imprinting, sex-biased autosomal gene expression, and male-limited Y-linked gene expression. We highlight novel candidate risk genes and pathways that warrant further investigation in clinical and preclinical studies. Understanding the biological basis of sex differences in AF should allow better prediction of disease risk, identification of novel risk/protective factors, and the development of more effective sex-tailored interventions.

The roles of global longitudinal strain imaging in contemporary clinical cardiology

Myocardial deformation imaging is now readily available during routine echocardiography and plays an important role in the advanced care of cardiovascular diseases. Its clinical value in detecting subtle myocardial dysfunction, by helping diagnose disease and allowing prediction of disease progression and earlier pharmacological intervention, has been demonstrated. Strain imaging has been the most studied and clinically used technique in the field of cardio-oncology. A relative percent reduction in left ventricular (LV) global longitudinal strain > 15% from baseline is considered a marker of early subclinical LV dysfunction and may have the potential to guide early initiation of cardioprotective therapy. The role of strain imaging is expanding to other fields, such as cardiac amyloidosis, other cardiomyopathies, valvular heart diseases, pulmonary hypertension, and heart failure with preserved ejection fraction. It is also used for the evaluation of the right ventricle and atria. This review aims to provide a current understanding of the roles of strain imaging in the evaluation and management of patients with cardiovascular diseases in clinical practice.

Echocardiography in the diagnostic evaluation and phenotyping of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) represents one of the greatest unmet needs in modern cardiology given its diagnostic difficulty and limited therapeutic options. Echocardiography provides valuable information on cardiac structure, function, and hemodynamics and plays a central role in the evaluation of HFpEF. Echocardiography is crucial in identifying HFpEF among patients with dyspnea, especially when overt congestion is absent. The combination of echocardiographic indices of diastolic function, clinical characteristics, and natriuretic peptide tests has been proposed in the diagnostic evaluation of patients with suspected HFpEF. Echocardiography also provides valuable insight into the pathophysiology and underlying phenotypes of HFpEF. Exercise stress echocardiography can also detect abnormalities that develop only during exercise. This may enhance the diagnosis of HFpEF by demonstrating elevation in the left ventricular filling pressure and may have potential for better pathophysiological characterization. This review focuses on the role of echocardiography in the diagnostic evaluation and phenotyping of HFpEF. We also discuss the potential role of exercise stress echocardiography for the diagnosis and disease phenotyping of HFpEF.

Predictive value of echocardiographic left atrial size for incident stoke and stroke cause mortality: a population-based study

OBJECTIVES

To investigate the associations between echocardiographic left atrial (LA) size and incident stoke and stroke cause mortality among a rural population in China.

DESIGN

A prospective study.

SETTING AND PARTICIPANTS

Based on the Northeast China Rural Cardiovascular Health Study, we selected a total of 10 041 participants aged ≥35 years who agreed to have transthoracic echocardiography at baseline and were successfully followed up for incident stoke and stroke cause mortality.

PRIMARY OUTCOME MEASURE

The outcomes were stroke and stroke cause death according to medical records and death certificates during the follow-up period.

RESULTS

LA enlargement (LAE) group had a higher prevalence of cardiovascular disease than normal LA diameter (LAD) group. After excluding individuals who had a prior stroke, subjects with LAE showed higher incident rates of stroke and its mortality in the overall and specific stratified analyses (all p<0.05). Kaplan-Meier analysis revealed that LAE could predict stroke incidence and stroke-free survival, but the association was no longer observed after the adjustment for potential confounding factors. Cox regression analysis reported that per 1 SD increment in LAD and LAD/body surface area (BSA) was associated with an increased incidence of stroke (LAD: HR=1.20, 95% CI 1.08 to 1.33, p<0.001; LAD/BSA: HR=1.22, 95% CI 1.11 to 1.35, p<0.001) and stroke cause mortality (LAD: HR=1.27, 95% CI 1.08 to 1.50, p<0.01; LAD/BSA: HR=1.41, 95% CI 1.20 to 1.65, p<0.001) in the total population, and similar trends were found in both genders (all p<0.05). LAD or LAD/BSA was related to ischaemic and haemorrhagic stroke incidence, and the risk of ischaemic and haemorrhagic stroke mortality (all p<0.05). The dose-response curves further suggested linear associations between LAD, LAD/BSA and the incidence of stroke and subsequent mortality in the general population (all p<0.05).

CONCLUSIONS

Our population-based study implied that LA size, especially LAD and LAD/BSA, might be useful echocardiographic biomarkers that had the potential to predict incident stroke and stroke cause mortality.

Evaluation of left atrial remodeling by 2D-speckle-tracking echocardiography versus by high-density voltage mapping in patients with atrial fibrillation

BACKGROUND

Strain imaging during left atrial (LA) reservoir phase (LASr) is used as a surrogate for LA structural remodeling and fibrosis. Atrial fibrillation (AF) patients with >5% low-voltage zones (LVZs) obtained by 3D-electro-anatomical-mapping have higher recurrence rate post-ablation. We investigated the relationship between LA remodeling using two-dimensional-speckle-tracking echocardiography (2D-STE) and high-density voltage mapping in AF patients.

METHODS

A prospective study of 42 consecutive patients undergoing AF ablation. 2D-echo, 2D-STE, and high-density contact LA bipolar voltage maps were constructed before ablation. LVZs were determined with different bipolar amplitudes and their ratio per patient's LA area were investigated for correlation with LASr. We compared 2D-LASr results in patients with LVZs ≥ 5% (LVZs group) versus those with LVZ < 5% (non-LVZs group).

RESULTS

Compared with non-LVZs group (n = 15), LVZs group (n = 27) included significantly older patients, more women, more persistent AF, higher CHA₂ DS₂ -VASc score, higher E/A ratio and higher LA volume index (p < .05). LVZs group had lower %LASr values (12.4 ± 5.9% vs. 21.1 ± 6.3, respectively; p<.001). LVZs% in different amplitudes (<0.1 mV, <0.2 mV, and <0.5 mV) were negatively correlated with %LASr (r = -.63, r = -.68, and r = -.72, respectively; p< .001). Atrial strain thresholds for LVZs ≥ 5% in amplitudes <0.1 mV, <0.2 mV, and <0.5 mV were associated with %LASr 12.98, 16.16 and 19.55, respectively; p< .05). In a multivariate analysis, %LASr was the only independent indicator of LVZs (OR, 0.8; 95% CI, 0.6-0.9; p= .04).

CONCLUSIONS

LVZs ≥ 5% has a negative association with atrial %LASr. Thus, a simple 2D-STE measurement of %LASr can be used as a noninvasive method to evaluate significant LA remodeling and fibrosis in AF patients.

Sex Influence on Heart Failure Prognosis

Heart failure (HF) affects 1-2% of the population in developed countries and ~50% of patients living with it are women. Compared to men, women are more likely to be older and suffer hypertension, valvular heart disease, and non-ischemic cardiomyopathy. Since the number of women included in prospective HF studies has been low, much information regarding HF in women has been inferred from clinical trials observations in men and data obtained from registries. Several relevant sex-related differences in HF patients have been described, including biological mechanisms, age, etiology, precipitating factors, comorbidities, left ventricular ejection fraction, treatment effects, and prognosis. Women have greater clinical severity of HF, with more symptoms and worse functional class. However, females with HF have better prognosis compared to males. This survival advantage is particularly impressive given that women are less likely to receive guideline-proven therapies for HF than men. The reasons for this better prognosis are unknown but prior pregnancies may play a role. In this review article we aim to describe sex-related differences in HF and how these differences might explain why women with HF can expect to survive longer than men.

Global Left Atrial Longitudinal Strain Using 3-Beat Method Improves Risk Prediction of Stroke Over Conventional Echocardiography in Atrial Fibrillation

Background:

Atrial fibrillation (AF) is associated with a risk of ischemic stroke, and functional myocardial imaging has offered novel insights on its pathophysiology and prognosis, but its use in AF-related stroke remains limited. We aimed to evaluate the feasibility of left atrial (LA) deformations and its prognostic values of ischemic stroke in a large-scale AF population.

Methods:

Peak atrial longitudinal strain (LA strain), left ventricular strain (global longitudinal strain), LA strain rate (LA SR) at reservoir (LA longitudinal systolic strain rate), and early diastolic conduit (LA longitudinal early diastolic strain rate) phases were analyzed using 2-dimensional speckle tracking echocardiography. Consecutive 3-beat averaged values of strain and SR were used. The clinical end point was ischemic stroke.

Results:

Among 1457 AF participants, the mean LA strain, LA longitudinal systolic strain rate, and LA longitudinal early diastolic strain rate values were 12.9±4.8%, 0.80±0.28 s − 1 , and −1.17±0.46 s − 1 , respectively. There were strong positive linear relationships of 3-beat average with index-beat analysis (R=0.94, 0.94, and 0.94 for LA strain, LA longitudinal systolic strain rate, and LA longitudinal early diastolic strain rate, respectively; all P <0.001). Multivariate Cox regression models incorporating conventional echocardiography parameters demonstrated LA strain and SRs to be independent prognosticators of ischemic stroke during a median follow-up of 37.6 months. Utilization of LA strain further provided incremental value over CHA 2 DS 2 -VASc scoring ( C statistics, 0.78–0.81; P =0.006) for ischemic stroke. Overall, the prognostic performances of LA deformations were attenuated after adding global longitudinal strains in models.

Conclusions:

LA deformations by the 3-beat method are feasible and reproducible during AF. LA strain provided additional prognostic implication over clinical information and conventional echocardiographic measures for ischemic stroke in the AF population but not incremental to global longitudinal strains.

Sex Differences in Disease Profiles, Management, and Outcomes Among People with Atrial Fibrillation After Ischemic Stroke: Aggregated and Individual Participant Data Meta-Analyses

Objectives: To examine sex differences in disease profiles, management, and survival at 1 and 5 years after ischemic stroke (IS) among people with atrial fibrillation (AF).

Methods: We performed a systematic literature search of reports of AF at IS onset according to sex. We undertook an individual participant data meta-analysis (IPDMA) of nine population-based stroke incidence studies conducted in Australasia, Europe, and South America (1993–2014). Poisson regression was used to estimate women:men mortality rate ratios (MRRs). Study-specific MRRs were combined using random effects meta-analysis.

Results: In our meta-analysis based on aggregated data from 101 studies, the pooled AF prevalence was 23% (95% confidence interval [CI]: 22%–25%) in women and 17% (15%–18%) in men. Our IPDMA is of 1,862 IS-AF cases, with women (79.2 ± 9.1, years) being older than men (76.5 ± 9.5, years). Crude pooled mortality rate was greater for women than for men (1-year MRR 1.24; 1.01–1.51; 5-year 1.12; 1.03–1.22). However, the sex difference was greatly attenuated after accounting for age, prestroke function, and stroke severity (1-year 1.09; 0.97–1.22; 5-year 0.98; 0.84–1.16). Women were less likely to have anticoagulant prescription at discharge (odds ratio [OR] 0.94; 95% CI: 0.89–0.98) than men when pooling IPDMA and aggregated data.

Conclusions: AF was more prevalent after IS among women than among men. Among IS-AF cases, women were less likely to receive anticoagulant agents at discharge; however, greater mortality rate in women was mostly attributable to prestroke factors. Further information needs to be collected in population-based studies to understand the reasons for lower treatment of AF in women.

Left Atrial Phasic Function in Patients with Hypertension and Recurrent Atrial Fibrillation: Gender Differences of the Relationship with Diastolic Dysfunction and Central Aortic Pressure

Aim. To evaluate gender-related differences of left atrial (LA) phasic function and structural remodeling in conjunction with the parameters of left ventricular (LV) diastolic dysfunction and central aortic pressure in patients with hypertension and recurrent atrial fibrillation (AF).

Material and methods. The comparative study included 30 men and 37 women with non-valvular AF, hypertension and LV hypertrophy. Conventional echocardiographic measures were extended with LA measures, including its volume in three phases, LAemptying fraction (LAEF), passive and active ejection fraction. The parameters of central aortic pressure were estimated by applanation tonometry method.

Results. No difference was observed between LA and LV structural parameters in men and women. However, in women LAEF (39 [28;50] vs 50 [42;55]%; p=0.02) and E/E’(9.7 [7.8;12] vs 7.1 [5.6;8.6]; p=0.001) were worse than in men. Active LA ejection fraction was higher in women (31 [21;42] vs 24 [19;31]%; p=0.04), whereas passive one – in men (12 [10;14] vs 33 [23;38]%; p<0.001), respectively. Men and women had comparable heart rate (HR), central and peripheral systolic and diastolic pressure, pulse wave velocity (PWV), but women had higher augmentation index (AI) values [33 [28;39] vs 23 [21;28]%; p<0.001], even adjusted by HR (AI 75) (34 [27;39] vs 26 [20;29]%; p<0.001). Only in men PWV weakly correlated with AI 75 (r=0.44; p=0.02 versus r=-0.11; p=0.51, respectively for men and women; intergroup differences: z=2.26; p=0.012). In a multivariate regression analysis in men LAEF was significantly associated with height, weight, E’, E/E’ and glomerular filtration rate (GFR), whereas in women – with E’ and AI 75.

Conclusion. Patients of different genders with recurrent AF and hypertension have comparable LA structuralremodeling. However, women characterized by a more pronounced decrease in LAEF and impaired LV diastolic function than men. In women as distinct from men LV filling is predominantly due to LA systole. In a multivariate regression analysis in men LAEF was significantly associated with height, weight, E’, E/E’ and GFR, whereas in women – with E’ and AI 75. 

Sex Differences in Cardiovascular Pathophysiology: Why Women Are Overrepresented in Heart Failure With Preserved Ejection Fraction

Consistent epidemiological data demonstrate that patients with heart failure with preserved ejection fraction (HFpEF) are more likely to be women than men. Exploring mechanisms behind this sex difference in heart failure epidemiology may enrich the understanding of underlying HFpEF pathophysiology and phenotypes, with the ultimate goal of identifying therapeutic approaches for the broader HFpEF population. In this review we evaluate the influence of sex on the key domains of cardiac structure and function, the systemic and pulmonary circulation, as well as extracardiac factors and comorbidities that may explain the predisposition of women to HFpEF. We highlight the potential role of factors exclusive to or more prevalent in women such as pregnancy, preeclampsia, and iron deficiency. Finally, we discuss existing controversies and gaps in knowledge, as well as the clinical importance of known sex differences in the context of the potential need for sex-specific diagnostic criteria, improved risk stratification models, and targeted therapies.

Sex and Heart Failure with Preserved Ejection Fraction: From Pathophysiology to Clinical Studies

Heart failure with preserved ejection fraction (HFpEF) represents the most frequent form of heart failure in women, with almost two-fold higher prevalence than in men. Studies have revealed sex-specific HFpEF pathophysiology, and suggested the possibility of a sex-specific therapeutic approach in these patients. Some cardiovascular risk factors, such as arterial hypertension, obesity, diabetes mellitus, coronary artery disease, atrial fibrillation, and race, show specific features that might be responsible for the development of HFpEF in women. These risk factors are related to specific cardiovascular changes—left ventricular diastolic dysfunction and hypertrophy, ventricular–vascular coupling, and impaired functional capacity—that are related to specific cardiac phenotype and HFpEF development. However, there is no agreement regarding outcomes in women with HFpEF. For HFpEF, most studies have found higher hospitalization rates for women than for men. Mortality rates are usually not different. Pharmacological treatment in HFpEF is challenging, along with many unresolved issues and questions raised. Available data on medical therapy in patients with HFpEF show no difference in outcomes between the sexes. Further investigations are necessary to better understand the pathophysiology and mechanisms of HFpEF, as well as to improve and eventually develop sex-specific therapy for HFpEF.

Sex differences in left ventricular afterload and diastolic function are independent from the aortic size

Background

Women have a greater risk of heart failure with preserved ejection fraction (HFPEF) than men do, yet the basis for this disparity remains unclear. Greater arterial stiffness and afterload causes left ventricular (LV) diastolic dysfunction, a central mechanism of HFPEF. Because of smaller body habitus, previous reports have used body surface area as a surrogate of the size of the aorta. We performed a comprehensive hemodynamic evaluation of elderly patients with preserved EF and evaluated sex differences in the associations between LV function and afterload, before and after adjusting for the aortic sizes.

Methods and results

Four hundred and forty-three patients (mean age: 73 years, 169 women) who underwent clinically indicated echocardiography and computed tomography (CT) were identified. Linear regression analyses were performed to assess the independent contributions of sex to and its interaction with LV function before and after adjusting for CT-derived aortic length and volume. Although blood pressures were similar between the sexes, women had greater arterial elastance, lower arterial compliance, and greater LV ejection fraction (all p<0.001). Sex differences were detected in the associations between LV afterload and relaxation (mitral e′) as well as in the left atrial (LA) emptying fraction, but not in LA size. These differences remained significant after adjusting for the aortic length and volume. Sensitivity analyses in an age-matched subgroup (n = 324; 162 of each sex) confirmed the robustness of these sex disparities in LV diastolic function and afterload.

Conclusion

Women had worse LV relaxation than men did against the same degree of afterload, before and even after adjusting for the aortic sizes.

Left atrial function: evaluation by strain analysis

The left atrium has an important role in modulating left ventricular filling and is an important biomarker of cardiovascular disease and adverse cardiovascular outcomes. While previously left atrial (LA) size was utilised, the role of LA function as a biomarker is increasingly being evaluated, both independently and also in combination with LA size. Strain analysis has been utilised for evaluation of LA function and can be measured throughout the cardiac cycle, thereby enabling the evaluation of LA reservoir, conduit and contractile function. Strain evaluates myocardial deformation while strain rate examines the rate of change in strain. This review will focus on the various types of strain analysis for evaluation of LA function, alterations in LA strain in physiological and pathologic states that alter LA function and finally evaluate its utility as a prognostic marker.

Differences in Cardiovascular Aging in Men and Women

Cardiovascular diseases increase dramatically with age in both men and women. While it is clear that advanced age allows more time for individuals to be exposed to risk factors in general, there is strong evidence that age itself is a major independent risk factor for cardiovascular disease. Indeed, there are distinct age-dependent cellular, structural, and functional changes in both the heart and blood vessels, even in individuals with no clinical evidence of cardiovascular disease. Studies in older humans and in animal models of aging indicate that this age-related remodeling is maladaptive. An emerging view is that the heart and blood vessels accumulate cellular and subcellular deficits with age and these deficits increase susceptibility to disease in older individuals. Aspects of this age-dependent remodeling of the heart and blood vessels differ between the sexes. There is also new evidence that these maladaptive changes are more prominent in older animals and humans with a high degree of frailty. These observations may help explain why men and women are susceptible to different cardiovascular diseases as they age and why frail older adults are most often affected by these diseases.

Gender Differences in the Trends of Hospitalizations for Acute Stroke Among Patients With Atrial Fibrillation in the United States: 2005 to 2014

Female gender was included in stroke prediction algorithms in an attempt to improve anticoagulation rates in women with atrial fibrillation (AF). It is unclear if these efforts reduced stroke burden in women with AF. To bridge this literature gap, using the Nationwide Inpatient Sample, we assessed gender differences in the trends of hospitalizations for stroke among patients with AF in the United States in 2005 to 2014. International classification of diseases, 9th revision, clinical modification codes were used to abstract AF and stroke diagnoses. From 2005 to 2014, 18,413,291 hospitalizations of women with AF and 18,035,866 hospitalizations of men with AF were reported. Of these, 740,635 hospitalizations in women and 595,730 hospitalizations in men had stroke as the primary diagnosis. Age-adjusted stroke hospitalizations increased in women (443 per million in 2005 to 495 per million in 2014) as well as in men (351 per million in 2005 to 453 per million in 2014) (p trend < 0.001). Further, anticoagulation rates increased in women (11.5% in 2005 to 24.0% in 2014) as well as in men (11.7% in 2005 to 24.9% in 2014). Stroke hospitalizations involving anticoagulated patients with AF decreased in women (411 per million in 2005 to 347 per million in 2014) as well as in men (402 per million in 2005 to 311 per million in 2014) (p trend < 0.001). In conclusion, although we noted an increasing trend of stroke hospitalizations in both genders, it is reassuring to note that stroke hospitalizations involving anticoagulated patients with AF is decreasing in both genders and in particular among women.

Sex-related differences in the risk factors for in-hospital mortality and outcomes of ischemic stroke patients in rural areas of Taiwan

Background and purpose

Sex-related differences in the clinical presentation and outcomes of stroke patients are issues that have attracted increased interest from the scientific community. The present study aimed to investigate sex-related differences in the risk factors for in-hospital mortality and outcome in ischemic stroke patients.

Methods

A total of 4278 acute ischemic stroke patients admitted to a stroke unit between January 1, 2007 and December 31, 2014 were included in the study. We considered demographic characteristics, clinical characteristics, co-morbidities, and complications, among others, as factors that may affect clinical presentation and in-hospital mortality. Good and poor outcomes were defined as modified Ranking Score (mRS)≦2 and mRS>2. Neurological deterioration (ND) was defined as an increase of National Institutes of Health Stroke Score (NIHSS) ≥ 4 points. Hemorrhagic transformation (HT) was defined as signs of hemorrhage in cranial CT or MRI scans. Transtentorial herniation was defined by brain edema, as seen in cranial CT or MRI scans, associated with the onset of acute unilateral or bilateral papillary dilation, loss of reactivity to light, and decline of ≥ 2 points in the Glasgow coma scale score.

Results

Of 4278 ischemic stroke patients (women 1757, 41.1%), 269 (6.3%) received thrombolytic therapy. The in hospital mortality rate was 3.35% (139/4278) [4.45% (80/1757) for women and 2.34% (59/2521) for men, p < 0.01]. At discharge, 41.2% (1761/4278) of the patients showed good outcomes [35.4% (622/1757) for women and 45.2% (1139/2521) for men]. Six months after stroke, 56.1% (1813/3231) showed good outcomes [47.4% (629/1328) for women and 62.2% (1184/1903) for men, p < 0.01]. Atrial fibrillation (AF), diabetes mellitus, stroke history, and old age were factors contributing to poor outcomes in men and women. Hypertension was associated with poor outcomes in women but not in men in comparison with patients without hypertension. Stroke severity and increased intracranial pressure were associated with increased in-hospital mortality in men and women. AF was associated with increased in-hospital mortality in women but not in men compared with patients without AF.

Conclusion

The in-hospital mortality rate was not significantly different between women and men. Functional outcomes at discharge and six months after stroke were poorer in women than in men. Hypertension is an independent factor causing poorer outcomes in women than in men. AF is an independent factor affecting sex differences in hospital mortality in women.

Trends in the rates of hospitalizations for acute stroke among patients over 90 years of age with atrial fibrillation in the United States: from 2005 to 2014

BACKGROUND

Acute stroke (AS) rates in patients over 90 years of age (very elderly) with atrial fibrillation (AF) in the United States (US) are not known. We assessed trends in hospitalizations for AS among very elderly with AF in the US from 2005 to 2014.

METHODS

We used the nationwide inpatient sample (NIS) from the USA; 2005-2014. AF and AS diagnoses were abstracted using international classification of diseases, 9th Revision, clinical modification (ICD-9-CM) codes.

RESULTS

From 2005 to 2014, 3,606,073 hospitalizations of very elderly with AF were reported. Of these, 188,948 hospitalizations (141,822 hospitalizations in women and 47,126 hospitalizations in men) had AS as the primary diagnosis. Age adjusted AS hospitalizations increased in the total cohort (3217/million in 2005 to 3871/million in 2014), in women (3540/million in 2005 to 4487/million in 2014) and in men (2490/million in 2005 to 3173/million in 2014) (P < 0.001). Anticoagulation rates increased in women (8% in 2005 to 19.9% in 2014) and in men (8.9% in 2005 to 21.6% in 2014). AS rates, though numerically lower than the total cohort, showed an increasing trend in anticoagulated patients as well (all anticoagulated patients: 212/million in 2005 to 513/million in 2014; anticoagulated women: 224/million in 2005 to 529/million in 2014, anticoagulated men: 184/million in 2005 to 518/million in 2014).

CONCLUSIONS

There is an increasing trend in AS hospitalizations among nonagenarians with AF in the US despite improving utilization of anticoagulants in this patient population. The etiologies driving this alarming trend are unclear and require further study.

[The frequency of cerebrovascular disorders in patients with different forms of atrial fibrillation]

AIM

To study the frequency of blood circulation disorders (BCD) in patients with different forms of atrial fibrillation (AF) and its relationship with AF duration and treatment with anticoagulants.

MATERIAL AND METHODS

Medical records and medical history of 1626 patients with non-valvural AF were analyzed in Moscow from 2009 to 2015.

RESULTS

Patients with persistent AF were older and had a higher risk of thromboembolic and hemorrhagic complications. In the group of patients with paroxysmal and persistent AF, percentage of patients with BCD (including recurrent ones) was decreased by 13.1 and 28.9% compared to the patients with persistent form. There was no correlation between AF duration and BCD frequency. The frequency of using anticoagulants was 10.8% in outpatients and 42.8% in inpatients. Patients with persistent AF received anticoagulants less frequently than patients with less persistent forms.

CONCLUSION

Persistent AF is associated with the higher risk of BCD. The prevention of BCD in patients with persistent AF was insufficient compared to that in patients with less persistent forms.

Atrial Fibrillation and Ventricular Arrhythmias: Sex Differences in Electrophysiology, Epidemiology, Clinical Presentation, and Clinical Outcomes

Sex-specific differences in the epidemiology, pathophysiology, clinical presentation, clinical treatment, and clinical outcomes of atrial fibrillation (AF), sustained ventricular arrhythmias, and sudden cardiac death are recognized. Sex hormones cause differences in cardiac electrophysiological parameters between men and women that may affect the risk for arrhythmias. The incidence and prevalence of AF is lower in women than in men. However, because women live longer and AF prevalence increases with age, the absolute number of women with AF exceeds that of men. Women with AF are more symptomatic, present with more atypical symptoms, and report worse quality of life in comparison with men. Female sex is an independent risk factor for death or stroke attributable to AF. Oral anticoagulation therapy for stroke prevention has similar efficacy for men and women, but older women treated with warfarin have a higher residual risk of stroke in comparison with men. Women with AF are less likely to receive rhythm control antiarrhythmic drug therapy, electric cardioversion, or catheter ablation in comparison with men. The incidence and prevalence of sustained ventricular arrhythmias and sudden cardiac death are lower in women than in men. Women receiving implantable cardioverter defibrillators for primary prevention of sudden cardiac death are less likely to experience sustained ventricular arrhythmias in comparison with men. In contrast, women receiving a cardiac resynchronization therapy implantable cardioverter defibrillator for the treatment of heart failure are more likely to benefit than men. Women are less likely to be referred for implantable cardioverter defibrillator therapy despite current guideline recommendations. Women are more likely to experience a significant complication related to implantable cardioverter defibrillator implantation in comparison with men. Whether sex differences in treatment decisions reflect patient preferences or treatment biases requires further study.