Twelve-year follow-up of American women's awareness of cardiovascular disease risk and barriers to heart health

Sex Disparities in the Management of Acute Coronary Syndromes: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

BACKGROUND

Previous work has demonstrated disparities in the management of cardiovascular disease among men and women. We sought to evaluate these disparities and their associations with clinical outcomes among patients admitted with acute coronary syndromes to the Veterans Affairs Healthcare System.

METHODS AND RESULTS

We identified all patients that were discharged with acute coronary syndromes within the Veterans Affairs Healthcare System from October 1, 2015 to September 30, 2022. Medical and procedural management of patients was subsequently assessed, stratified by sex. In doing so, we identified 76 454 unique admissions (2327 women, 3.04%), which after propensity matching created an analytic cohort composed of 6765 men (74.5%) and 2295 women (25.3%). Women admitted with acute coronary syndromes were younger with fewer cardiovascular comorbidities and a lower prevalence of preexisting prescriptions for cardiovascular medications. Women also had less coronary anatomic complexity compared with men (5 versus 8, standardized mean difference [SMD]=0.40), as calculated by the Veterans Affairs SYNTAX score. After discharge, women were significantly less likely to receive cardiology follow-up at 30 days (hazard ratio [HR], 0.858 [95% CI, 0.794-0.928]) or 1 year (HR, 0.891 [95% CI, 0.842-0.943]), or receive prescriptions for guideline-indicated cardiovascular medications. Despite this, 1-year mortality rates were lower for women compared with men (HR, 0.841 [95% CI, 0.747-0.948]).

CONCLUSIONS

Women are less likely to receive appropriate cardiovascular follow-up and medication prescriptions after hospitalization for acute coronary syndromes. Despite these differences, the clinical outcomes for women remain comparable. These data suggest an opportunity to improve the posthospitalization management of cardiovascular disease regardless of sex.

Outcomes by sex in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial

BACKGROUND

In the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial, among participants with stable coronary artery disease, the risk of cardiac events was similar between an invasive (INV) strategy of angiography and coronary revascularisation and a conservative (CON) strategy of initial medical therapy alone. Outcomes according to participant sex were not reported.

AIMS

We aimed to analyse the outcomes of ISCHEMIA by participant sex.

METHODS

We evaluated 1) the association between participant sex and the likelihood of undergoing revascularisation for participants randomised to the INV arm; 2) the risk of the ISCHEMIA primary composite outcome (cardiovascular death, any myocardial infarction [MI] or rehospitalisation for unstable angina, heart failure or resuscitated cardiac arrest) by participant sex; and 3) the contribution of the individual primary outcome components to the composite outcome by participant sex.

RESULTS

Of 5,179 randomised participants, 1,168 (22.6%) were women. Female sex was independently associated with a lower likelihood of revascularisation when assigned to the INV arm (adjusted odds ratio 0.75, 95% confidence interval [CI]: 0.57-0.99; p=0.04). The INV versus CON effect on the primary composite outcome was similar between sexes (women: hazard ratio [HR] 0.96, 95% CI: 0.70-1.33; men: HR 0.90, 95% CI: 0.76-1.07; pinteraction=0.71). The contribution of the individual components to the composite outcome was similar between sexes except for procedural MI, which was significantly lower in women (9/151 [5.9%]) than men (67/519 [12.9%]; p=0.01).

CONCLUSIONS

In ISCHEMIA, women assigned to the INV arm were less likely to undergo revascularisation than men. The effect of an INV versus CON strategy was consistent by sex, but women had a significantly lower contribution of procedural MI to the primary outcome.

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.

Sex Differences in Delirium after Coronary Artery Bypass Graft Surgery and Perioperative Neuropsychiatric Conditions: A Secondary Analysis of a Cohort Study

BACKGROUND

Biological sex influences the risk of depression and cognitive impairment, but its role in relation to postoperative delirium is unclear. This analysis investigates sex differences in delirium risk after coronary artery bypass graft (CABG) surgery and sex-related differences in relation to affective and cognitive symptoms.

METHODS

This is a secondary analysis of the Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study, a single-site, observational study of a CABG surgery cohort (n = 149). Preoperative characteristics are stratified by sex, and baseline variables that differ by sex are evaluated to understand whether sex modifies their relationships with delirium. We also evaluate sex differences in one-month depression and cognition.

RESULTS

Female sex is associated with several delirium risk factors, including higher risk of preoperative depression and middle cerebral artery (MCA) stenosis. MCA stenosis was statistically associated with delirium only among women (OR 15.6, 95% CI 1.5, 164.4); mild cognitive impairment (MCI) was associated with delirium only in men (OR 4.6, 95% CI 1.2, 17.9). Other sex-based differences failed to reach statistical significance. Depression remained commoner among women 1 month post-CABG.

CONCLUSIONS

Women in this CABG cohort were more likely to have depression at baseline and 1 month postoperatively, as well as MCA stenosis and postoperative delirium. Sex might modify the relationship between post-CABG delirium and its risk factors including MCA stenosis and MCI. Cerebrovascular disease deserves study as a potential explanation linking female sex and a range of poor outcomes among women with coronary heart disease.

Inequalities in the management of diabetic kidney disease in UK primary care: A cross-sectional analysis of a large primary care database

AIMS

To determine differences in the management of diabetic kidney disease (DKD) relevant to patient sex, ethnicity and socio-economic group in UK primary care.

METHODS

A cross-sectional analysis as of January 1, 2019 was undertaken using the IQVIA Medical Research Data dataset, to determine the proportion of people with DKD managed in accordance with national guidelines, stratified by demographics. Robust Poisson regression models were used to calculate adjusted risk ratios (aRR) adjusting for age, sex, ethnicity and social deprivation.

RESULTS

Of the 2.3 million participants, 161,278 had type 1 or 2 diabetes, of which 32,905 had DKD. Of people with DKD, 60% had albumin creatinine ratio (ACR) measured, 64% achieved blood pressure (BP, <140/90 mmHg) target, 58% achieved glycosylated haemoglobin (HbA1c, <58 mmol/mol) target, 68% prescribed renin-angiotensin-aldosterone system (RAAS) inhibitor in the previous year. Compared to men, women were less likely to have creatinine: aRR 0.99 (95% CI 0.98-0.99), ACR: aRR 0.94 (0.92-0.96), BP: aRR 0.98 (0.97-0.99), HbA1c : aRR 0.99 (0.98-0.99) and serum cholesterol: aRR 0.97 (0.96-0.98) measured; achieve BP: aRR 0.95 (0.94-0.98) or total cholesterol (<5 mmol/L) targets: aRR 0.86 (0.84-0.87); or be prescribed RAAS inhibitors: aRR 0.92 (0.90-0.94) or statins: aRR 0.94 (0.92-0.95). Compared to the least deprived areas, people from the most deprived areas were less likely to have BP measurements: aRR 0.98 (0.96-0.99); achieve BP: aRR 0.91 (0.8-0.95) or HbA1c : aRR 0.88 (0.85-0.92) targets, or be prescribed RAAS inhibitors: aRR 0.91 (0.87-0.95). Compared to people of white ethnicity; those of black ethnicity were less likely to be prescribed statins aRR 0.91 (0.85-0.97).

CONCLUSIONS

There are unmet needs and inequalities in the management of DKD in the UK. Addressing these could reduce the increasing human and societal cost of managing DKD.

Critical Lessons in Tailoring Interventions: Listening to WISEWOMAN Participants

PURPOSE

To explore perspectives of participants in the WISEWOMAN program in Pennsylvania (PA-WISE) on challenges and facilitators of reducing cardiovascular disease risk as low-income and un-/under-insured middle-aged women.

APPROACH

Researchers conducted this 2 year qualitative data collection as one component of a broader, 5 year PA-WISE process and outcome evaluation.

SETTING

Women from across Pennsylvania, primarily from rural communities.

PARTICIPANTS

Interviewees were low-income, un-/under-insured women aged 40-64 years who had recently participated in PA-WISE-facilitated health coaching and lifestyle programs (HC/LSPs).

METHODS – DATA COLLECTION AND ANALYSIS

Researchers conducted individual telephone interviews with 38 women from four discrete samples of PA-WISE participants at 4 time points. Three researchers used grounded theory, and an iterative process of line-by-line coding, data display, and reanalysis to identify emerging themes, sub-themes, and their relationships.

RESULTS

Participants shared the important benefits of specific PA-WISE program traits. However, participants described significant financial constraints, difficult schedules, caregiving responsibilities, and insufficient social support as persistent challenges in their lives, making lifestyle changes in general, and program participation specifically, difficult.

CONCLUSION

The challenges that low-income and un-/under-insured women identified amplify the importance of having interventions that offer flexibility, options, and tailoring of supports and resources. The timeless challenges articulated by participants in this study completed just before the COVID-19 pandemic, remain relevant to be addressed through the pandemic and beyond.

Gender disparities in the mediating role of symptom knowledge level in reducing acute coronary syndrome (ACS) decision delay: Findings from a community-based study in China

BACKGROUND

Implementing training programs to educate patients on the prodromal symptoms of acute coronary syndrome (ACS) may assist patients in accurately recognizing these symptoms, and ultimately decrease their time delay in seeking emergency medical services (EMS). However, the effectiveness of this approach remains uncertain, particularly among the Chinese population.

METHODS

A cross-sectional study was conducted within 22 communities in Beijing, China between 2015 and 2018, with a total of 1099 participants recruited. The study utilized a standardized questionnaire to evaluate the presence of intentional decision delay in turning to EMS under a hypothetical chest pain, the participants' knowledge of ACS prodromal symptoms, and whether they had ever received any training programs aimed at increasing their symptom knowledge. Mediation analysis was performed with regression models and bootstrapping methods, and gender difference was further analyzed through moderated mediation analysis.

RESULTS

A total of 1099 participants (58.2% female, median [IQR] age 34 [20]) were included in the study. The results of the mediation analysis indicated that training programs were associated with a decrease risk in decision delay, with increased knowledge playing a mediating role (mediation effect/total effect = 36.59%, P < 0.0001). Gender modified this mediation effect, with it being observed only in the male group. Specifically, training programs were not found to significantly decrease decision delay among females (P > 0.05), even though they did improve women's knowledge of ACS prodromal symptoms (β = 0.57, P = 0.012).

CONCLUSION

The results suggested a relationship between prior training programs and reduced decision delay, with increased knowledge of prodromal symptoms of ACS serving as a mediator. However, the effect was only observed in male participants and not in female participants. This highlights the notion that mere transfer of knowledge regarding ACS prodromal symptoms may not be sufficient to mitigate decision delay in the female population. Further research is needed to corroborate these results and to gain deeper insights into the gender-specific barriers encountered in this study.

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

Racial and Ethnic Differences in Awareness and Prevalence of Unidentified Cardiovascular Risk Factors Among Health System Employees

PURPOSE

To evaluate awareness about cardiovascular (CVD) risk among a racially and ethnically diverse cohort of health system employees.

DESIGN

Cross-sectional study.

SETTING

Voluntary survey of health system employees during an annual CVD awareness and screening event.

SUBJECTS

759 health system employees.

MEASURES

We performed initial CVD screening measurements (blood pressure, body mass index) and collected patient-reported answers to questions about their own CVD risk factors (hypertension, high cholesterol, diabetes, overweight, smoking, physical inactivity and family history of CVD) and whether or not they believed that CVD is preventable. Subjects were offered in-depth follow-up CVD screening (lipid panel, hs-CRP, hemoglobin A1c), if interested.

ANALYSIS

Continuous measures were compared across sex and racial/ethnic subsets using a t test and analysis of variance technique. Univariable and multivariable logistic regression models were used to estimate the employee's willingness to undergo further comprehensive screening.

RESULTS

African American, Hispanic, and Asian employees were younger than white employees (P < .0001). More than one-quarter of African Americans reported a history of hypertension, a higher rate than for other subgroups (P = .001). The rate of self-reported diabetes was highest in African American and Asian employees (P = .001). African Americans had a 54% reduced odds of electing to pursue follow-up CVD screening (odds ratio: .46, 95% confidence interval = .24-.91, P = .025).

CONCLUSION

Presence of CVD risk factors and knowledge of their importance differ among racial and ethnic groups of health system employees in our cohort as does interest in pursuing follow-up screening once risk factors are identified. Development of evidence-based customization strategies by racial and ethnic group may improve understanding of and interest in CVD risk factors and advance prevention. The data from this study will inform future research and strategies for employee health promotion.

Risk Factors for Premature Coronary Heart Disease in Women Compared to Men: Systematic Review and Meta-Analysis

Background: We aimed to systematically examine literature on the prevalence of known modifiable and nonmodifiable risk factors for premature coronary heart disease (PCHD) in women compared with men. Materials and Methods: PubMed, CINAHL, Embase, and Web of Science databases were searched. Review protocol is registered in PROSPERO (CRD42020173216). Quality was assessed using the National Heart, Lung, and Blood Institute tool. Review Manager 5.3 was used for meta-analysis. Effect sizes were expressed as odds ratio (OR) and mean differences/standardized mean differences (SMD) with 95% confidence intervals (CIs) for categorical and continuous variables. Results: In this PCHD cohort (age <65 years), the mean age of presentation in women was 3 years older than men. Women had higher total cholesterol (SMD 0.11; 95% CI 0.00 to 0.23) and higher high-density lipoprotein cholesterol (SMD 0.49; 95% CI 0.29 to 0.69). Women were more likely to have hypertension (OR 1.51, 95% CI 1.42 to 1.60), diabetes mellitus (OR 1.78, 95% CI 1.55 to 2.04), obesity (OR 1.33, 95% CI 1.24 to 1.42), metabolic syndrome (OR 3.73, 95% CI 1.60 to 8.69), stroke (OR 1.63, 95% CI 1.51 to 1.77), peripheral vascular disorder (OR 1.67, 95% CI 1.43 to 1.96), and depression (OR 2.29, 95% CI 1.96 to 2.67). Women were less likely to be smokers (OR 0.60, 95% CI 0.55 to 0.66), have reported alcohol intake (OR 0.36, 95% CI 0.33 to 0.40), and reported use of illicit drug (OR 0.32, 95% CI 0.16 to 0.62). Conclusions: Risk factor profile in PCHD has a clear sex difference that supports early, aggressive, holistic, but sex-specific, approach to prevention.

Perceived Cardiovascular Disease Risk Following Preeclampsia: A Cross-Sectional Study

Preeclampsia has been linked to an increased risk of cardiovascular disease (CVD), and the preeclamptic women were unaware of this link. Therefore, this study aims to assess women's knowledge and perception of future CVD after preeclampsia. This study used a cross-sectional descriptive design. Two hundred and forty-six women with a preeclampsia history were recruited from the Al Salam MCH Center and Suez Canal University Hospital. Data were collected during March 2022 using a socio-demographic questionnaire, an Adapted Coronary Heart disease knowledge tool for preeclamptic women, and The Perception of Risk of Heart Disease Scale (PRHDS). Most women (96%) were unaware of the relationship between CVD and preeclampsia. The women had a low CVD knowledge level (10.26 ± 6.08) as well as a low perception of cardiovascular disease risk (37.15 ± 7.22). There was a significant positive correlation between CVD knowledge and CVD risk perception (r = 0.434, p = 0.000). This study found that preeclampsia survivors underestimated their CVD risk. Based on these findings, preeclamptic women should receive health education sessions on CVD risk and prevention from their nurses and obstetricians. The hospital pre-discharge plan must contain these sessions in written and electronic formats to help women remember and follow CVD risk reduction measures.

Predictors of program interest in a digital health pilot study for heart health

Digital health programs can play a key role in supporting lifestyle changes to prevent and reduce cardiovascular disease (CVD) risk. A key concern for new programs is understanding who is interested in participating. Thus, the primary objective of this study was to utilize electronic health records (EHR) to predict interest in a digital health app called Lark Heart Health. Because prior studies indicate that males are less likely to utilize prevention-focused digital health programs, secondary analyses assessed sex differences in recruitment and enrollment. Data were drawn from an ongoing pilot study of the Heart Health program, which provides digital health behavior coaching and surveys for CVD prevention. EHR data were used to predict whether potential program participants who received a study recruitment email showed interest in the program by "clicking through" on the email to learn more. Primary objective analyses used backward elimination regression and eXtreme Gradient Boost modeling. Recruitment emails were sent to 8,649 patients with available EHR data; 1,092 showed interest (i.e., clicked through) and 345 chose to participate in the study. EHR variables that predicted higher odds of showing interest were higher body mass index (BMI), fewer elevated lab values, lower HbA1c, non-smoking status, and identifying as White. Secondary objective analyses showed that, males and females showed similar program interest and were equally represented throughout recruitment and enrollment. In summary, BMI, elevated lab values, HbA1c, smoking status, and race emerged as key predictors of program interest; conversely, sex, age, CVD history, history of chronic health issues, and medication use did not predict program interest. We also found no sex differences in the recruitment and enrollment process for this program. These insights can aid in refining digital health tools to best serve those interested, as well as highlight groups who may benefit from behavioral intervention tools promoted by additional recruitment efforts tailored to their interest.

Racial Disparities in Cardiovascular Risk and Cardiovascular Care in Women

PURPOSE OF REVIEW

Research on sex and gender aspects cardiovascular disease has contributed to a reduction in cardiovascular mortality in women. However, cardiovascular disease remains the leading cause of death of women in the United States. Disparities in cardiovascular risk and outcomes among women overall persist and are amplified for women of certain ethnic and racial subgroups. We review the evidence of racial and ethnic differences in cardiovascular risk and care among women and describe a path forward to achieve equitable cardiovascular care for women of racial and ethnic minority groups.

RECENT FINDINGS

There is a disproportionate effect on cardiovascular outcomes in women and certain racial and ethnic groups in part due to disparities in triage, diagnosis, treatment, which lead to amplification of inequalities in women of minority racial and ethnic background. Data suggest gender and racial bias, underappreciation of nontraditional risk factors, underrepresentation of women in clinical trials and undertreatment of disease contributes to persistent differences in cardiovascular disease outcomes in women of color. Understanding the myriad of factors that contribute to increased cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds is imperative to improving cardiovascular care for this patient population.

Hypertension in pregnancy as an early sex-specific risk factor for cardiovascular diseases: evidence and awareness

Despite being a physiological condition, human pregnancy is known to cause numerous complications that can endanger the life of the mother and the fetus alike. While the majority of complications are mostly limited within the peripartum period, more and more information is available about persistently higher short- and long-term cardiovascular risk after a pregnancy complicated by a hypertensive disorder. There is evidence that women after gestational hypertension or preeclampsia are more likely to develop arterial hypertension, coronary atherosclerosis, myocardial infarction, stroke, peripheral artery disease, and even diabetes mellitus and venous thromboembolism years after the target pregnancy. This has urged some authors to view hypertensive disorders of pregnancy as a "stress test" for the maternal organism that unmasks latent endothelial dysfunction. An explanation is sought in the presence of common risk factors and underlying pathological pathways with cardiovascular diseases, although a certain etiological mechanism for the development of hypertensive disorders in pregnancy has not been established yet. More attention is needed towards the follow-up of women after a hypertensive pregnancy as it could be an opportunity for early prevention of cardiovascular diseases.

Sex-Based Differences in Outcomes Following Peripheral Artery Revascularization: Insights From VOYAGER PAD

Background

Despite high female prevalence of peripheral artery disease (PAD), little is known about sex‐based outcomes after lower extremity revascularization (LER) for symptomatic PAD. The effects of rivaroxaban according to sex following LER have not been fully reported.

Methods and Results

In VOYAGER PAD (Vascular Outcomes Study of ASA [acetylsalicylic acid] Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for Peripheral Artery Disease), low‐dose rivaroxaban versus placebo on a background of aspirin reduced the composite primary efficacy outcome of cardiovascular and limb events in patients with PAD undergoing LER. Unplanned index limb revascularization was prespecified and prospectively ascertained. The primary safety outcome was Thrombolysis in Myocardial Infarction major bleeding. Analyses of outcomes and treatment effects by sex were performed using Cox proportional hazards models. Among 6564 randomly assigned patients followed for a median of 28 months, 1704 (26.0%) were women. Among patients administered placebo, women were at similar risk for the primary efficacy outcome (hazard ratio [HR], 0.90; [95% CI, 0.74–1.09]; P=0.29) as men, while female sex was associated with a trend toward higher risk of unplanned index limb revascularization (HR, 1.18; [95% CI, 1.00–1.40]; P=0.0499). Irrespective of sex, effects of rivaroxaban were consistent for the primary efficacy outcome (P‐interaction=0.22), unplanned index limb revascularization (P‐interaction=0.64), and bleeding (P‐interaction=0.61). Women were more likely than men to discontinue study treatment (HR, 1.13; [95% CI, 1.03–1.25]; P=0.0099).

Conclusions

Among >1700 women with PAD undergoing LER, women and men were at similar risk for the primary outcome, but a trend for greater risk of unplanned index limb revascularization among women was observed. Effects of rivaroxaban were consistent by sex, though women more often discontinued treatment. Better understanding of sex‐based outcomes and treatment adherence following LER is needed.

Registration

URL: http://clinicaltrials.gov; Unique identifier: NCT02504216.

Review of Lipid-Lowering Therapy in Women from Reproductive to Postmenopausal Years

Although cardiovascular disease is the leading cause of death in women, cardiovascular risk factors remain underrecognized and undertreated. Hyperlipidemia is one of the leading modifiable risk factors for CVD. Statins are the mainstay of lipid lowering therapy (LLT), with additional agents such as ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors as additive or alternative therapies. Clinical trials have demonstrated that these LLTs are equally efficacious in lipid lowering and cardiovascular risk reduction in women as they are in men. Although the data on statin teratogenicity is evolving, in times of pregnancy or attempted pregnancy, most lipid-lowering agents are generally avoided due to lack of high-quality safety data. This leads to limited treatment options in pregnant women with hyperlipidemia or cardiovascular disease. During the perimenopausal period, the mainstay of lipid management remains consistent with guidelines across all ages. Hormone replacement therapy for cardiovascular risk reduction is not recommended. Future research is warranted to target sex-based disparities in LLT initiation and persistence across the life course.

Addressing the Helper's and Victim's Gender Is Crucial in Schoolchildren Resuscitation Training-A Prospective, Educative Interventional Trial

Background: A victim’s gender is a known factor that influences the willingness of adult bystanders to perform cardiopulmonary resuscitation (CPR) if an out-of-hospital cardiac arrest (OHCA) occurs. This study aims to identify whether gender characteristics of OHCA victims are also relevant to schoolchildren, who are the key target group of CPR trainings worldwide. Methods: A prospective, educative intervention study was performed in schoolchildren (5th−7th grade). Schoolchildren’s willingness to perform CPR was assessed by means of questionnaires before (t0) and after (t1) standardized CPR training. Participants were asked how determined they were to perform CPR in male and female OHCA victims on a 5-point Likert scale (not being determined to being very determined). A data analysis was performed according to the gender characteristics of schoolchildren. Results: Overall, 342 schoolchildren aged 10−15 years were included, and 166 male (MG) and 176 female (FG) schoolchildren served as a comparison group. Before (t0) and after (t1) the intervention, females showed a significantly higher general willingness to perform CPR than males (t0: 97.1% vs. 89.0%; p < 0.003 and t1: 95.7% vs. 98.9%; p = 0.038). The general willingness to perform CPR after training had a stronger increase in males (8.0% vs. 2.3%; p = 0.017). In the case that the OHCA victim was female, male schoolchildren were less willing to perform CPR than females at baseline (MG: n = 101;60.8% vs. FG: n = 147;84.5%; p < 0.001) and after training (MG: n = 97;58.4% vs. FG: n = 138;79.3%; p < 0.001). At t1, CPR willingness for female victims was improved in males (MG: n = 36;21.7% vs. FG: n = 19;10.9%; p = 0.006). Conclusions: The gender characteristics of OHCA victims, as well as schoolchildren themselves, have a relevant impact on the willingness to perform CPR. Training concepts should effectively motivate male schoolchildren to reduce preexisting inhibitions, especially towards female OHCA patients. Trial registration: This study was registered at the German Clinical Trials Register (Registration number: DRKS00017707) on 2 August 2019.

Sex-Related Outcomes of Medical, Percutaneous, and Surgical Interventions for Coronary Artery Disease: JACC Focus Seminar 3/7

Biological and sociocultural differences between men and women are complex and likely account for most of the variations in the epidemiology and treatment outcomes of coronary artery disease (CAD) between the 2 sexes. Worse outcomes in women have been described following both conservative and invasive treatments of CAD. For example, increased levels of residual platelet reactivity during treatment with antiplatelet drugs, higher rates of adverse cardiovascular outcomes following percutaneous coronary revascularization, and higher operative and long-term mortality after coronary bypass surgery have been reported in women compared with in men. Despite the growing recognition of sex-specific determinants of outcomes, representation of women in clinical studies remains low and sex-specific management strategies are generally not provided in guidelines. This review summarizes the current evidence on sex-related differences in patients with CAD, focusing on the differential outcomes following medical therapy, percutaneous coronary interventions, and coronary artery bypass surgery.

Cardiovascular Risk Perception and Knowledge among Italian Women: Lessons from IGENDA Protocol

A multicenter, cross-sectional observational study (Italian GENder Differences in Awareness of Cardiovascular risk, IGENDA study) was carried out to evaluate the perception and knowledge of cardiovascular risk among Italian women. An anonymous questionnaire was completed by 4454 women (44.3 ± 14.1 years). The 70% of respondents correctly identified cardiovascular disease (CVD) as the leading cause of death. More than half of respondents quoted cancer as the greatest current and future health problem of women of same age. Sixty percent of interviewed women considered CVD as an almost exclusively male condition. Although respondents showed a good knowledge of the major cardiovascular risk factors, the presence of cardiovascular risk factors was not associated with higher odds of identifying CVD as the biggest cause of death. Less than 10% of respondents perceived themselves as being at high CVD risk, and the increased CVD risk perception was associated with ageing, higher frequency of cardiovascular risk factors and disease, and a poorer self-rated health status. The findings of this study highlight the low perception of cardiovascular risk in Italian women and suggest an urgent need to enhance knowledge and perception of CVD risk in women as a real health problem and not just as a as a life-threatening threat.

Early Detection of Cardiovascular Risk Factors and Definition of Psychosocial Profile in Women Through a Systematic Approach: The Monzino Women Heart Center's Experience

Introduction

Cardiovascular (CV) disease is the leading mortality cause among women, yet an alarming misrepresentation of women in CV studies and a low awareness of the impact of CV among women still persist to date. The Monzino Women Heart Center has been established as a clinical and research program dedicated to primary prevention of CV disease in women.

Methods

Patients aged between 35 and 60 years and with no history of CV disease underwent a comprehensive evaluation including a cardiologic outpatient visit with electrocardiogram, individual CV risk calculation, first-level cardiovascular examinations and a psychological assessment.

Results

A total of 635 women, with a mean age of 52.2 ± 6.4 participated to the project on a voluntary basis during the period January 2017–August 2021. Included patients had a high level of education (40.4% with a graduate or postgraduate university degree), the majority of them, in a stable couple and with children, were actively working. More than half of the patients performed physical activity on a regular basis. Prevalence of traditional CV risk factors were family history (70.2%), hypertension (46%), hypercholesterolemia (22%) and diabetes (14%). Early or premature menopause was reported by 17.7% of the patients, gestational hypertension and diabetes by 4.96 and 1.7%, respectively. Symptoms of depression were reported by 27%; nearly 36% of the participants rated high score of state anxiety and 41% of trait anxiety. Nearly 69% of the participants showed moderate-to-high perceived stress. The mean value of perceived general self-efficacy was moderate (mean = 28.78, SD = 4.69).

Conclusion

A CV prevention program dedicated to women can help identifying a considerable number of patients with risk factors for whom early interventions can help reducing the risk of developing CV disease. Psychological assessment might unmask depression or anxiety disorders, which might have a potential long-terme detrimental effect on CV health.

Cardiovascular Risk Factor Profiles, Emergency Department Visits, and Hospitalizations for Women and Men with a History of Stroke or Transient Ischemic Attack: A Cross-Sectional Study

Background: The relationship between cardiovascular disease risk factors (CVD-RFs) and health care utilization may differ by sex. We determined whether having more CVD-RFs was associated with all-cause emergency department (ED) visits and all-cause hospitalizations for women and men with prior stroke/transient ischemic attack (TIA). Materials and Methods: In this cross-sectional study, we used nationally representative Medical Expenditure Panel Survey (2012-2015) data for persons aged ≥18 years with a prior stroke/TIA. CVD-RF summary scores include six self-reported factors (hypertension, diabetes, high cholesterol, physical inactivity, smoking, and obesity). Sex-specific covariate-adjusted logistic regression models assessed associations between CVD-RF scores and having one or more all-cause ED visits and one or more all-cause hospitalizations. Results: The weighted sample represents 9.1 million individuals (mean age 66.6 years; 54.3% women). Prevalence of low (0-1 risk factors), intermediate (2-3), and high (4-6) CVD-RF scores was 19.4%, 60.5%, and 20.1% for women and 14.6%, 60.2%, and 25.2% for men, respectively. Women having intermediate and high scores had a 1.58-fold (95% confidence interval [CI], 1.14-2.18) and 2.21-fold (95% CI, 1.50-3.25) increased odds of ED visits compared with women with low scores. Women with high CVD-RF scores had a 2.18-fold (95% CI, 1.42-3.34) increased odds of hospitalizations, but there was no association for women with intermediate CVD-RF profiles. There was no association between CVD-RF scores and either outcome for men. Conclusions: Women, but not men, with high and intermediate CVD-RF profiles had increased odds of all-cause ED visits; women with high CVD-RF profiles had increased odds of all-cause hospitalizations. The burden of CVD-RFs may be a sex-specific predictor of higher health care utilization in women with a history of stroke/TIA.

Physical Activity and Cancer Status Among Middle-Aged and Older Chinese: A Population-Based, Cross-Sectional Study

Background

The relative contributions of demographic and lifestyle behaviors to the association between physical activity (PA) and cancer are poorly understood. This study assesses the relationship between PA level and cancer status considering the full activity spectrum within a large and representative Chinese population.

Methods

Data were derived from the Chinese Health and Retirement Longitudinal Study (using four-stage stratified probability-proportional-to-size sampling), including 416 cancer survivors and 14,574 individuals without cancer from 28 provinces in China. Cancer status and sites were self-reported, and PA, other health behaviors (e.g., smoking, drinking) and comorbidities (e.g., hypertension, diabetes) were assessed by a questionnaire. The total PA score was calculated using metabolic equivalent (MET) multipliers. Multivariable logistic regression was used to estimate differences in PA levels between cancer survivors and those without a cancer diagnosis, adjusting for age, sex, and other potential confounding factors.

Results

Cancer survivors (416, 2.8%) were more likely to be women than men (65.4 vs. 34.6%). They were older (age ≥65 years, 43.8 vs. 38.9%) and more likely to be overweight (18.3 vs. 13.3%), be depressed (49.5 vs. 37.6%), have quit smoking (17.8 vs. 14.4%), drink less (17.5 vs. 26.6%), sleep less (65.9 vs. 56.8%) and have more chronic comorbidities (≥2 comorbidities, 26.0 vs. 19.2%) than those without cancer. There was a significant associations between cancer status and participation in vigorous-intensity activity for at least 10 min every week, when compared with the inactivity [odds ratio (OR) = 0.56, 95% CI = 0.39–0.80], while no differences were observed in the moderate and light activity groups. Individuals who spent more than half an hour performing moderate or vigorous intensity activity every day were significantly less likely to report a cancer diagnosis than inactive individuals (moderate OR = 0.64, 95% CI = 0.48–0.86; vigorous OR = 0.50, 95% CI = 0.37–0.68). Participants who spent more than 2 h performing light, moderate or vigorous intensity activity reported fewer cancer cases than their inactive counterparts. In addition, there was an inverse dose-response relationship between the total PA score and cancer status (P_–trend < 0.001).

Conclusion

Associations between PA and cancer status were independent of demographics, lifestyle confounders, and comorbidities. Cancer survivors are less physically active than those without cancer.

Gender differences, inequalities and biases in the management of Acute Coronary Syndrome

OBJECTIVE

The approach to Acute Coronary Syndrome from a gender perspective is relatively recent. Research is extensive at epidemiological and clinical levels. However, available evidence, besides neglecting the social dimensions of the disease, has made women invisible. The objective of this review was to analyze the inequalities and gender biases in Acute Coronary Syndrome, from the beginning of the disease process to the final resolution.

METHODS

An exhaustive review of the literature of the entire health care process, from risk factors to rehabilitation and recovery, was carried out. The search for articles on gender, gender inequalities, or gender bias was conducted in indexed journals of social and health sciences. Also, a specific search was performed for each stage of the process, such as risk factors, prehospital phase, diagnosis, treatment, and rehabilitation.

RESULTS

Results showed the presence of gender biases throughout the entire health care process in Acute Coronary Syndrome. It is shown gender inequalities in the access to medical care, including a poor recognition among women themselves as well as among health professionals; longer prehospital delays; inadequate diagnoses and treatments; or less assistance to cardiac rehabilitation programmes. These biases occurred at the different levels of the health services involved. Finally, this review included recommendations proposed or arising from the revised papers.

CONCLUSIONS

Reducing gender biases in Acute Coronary Syndrome implies developing strategies to raise awareness among women, improve training of professionals serving at the different levels of health services, reduce delays, develop health management measures, and promote a research agenda.

Post-9/11 veterans' heart disease knowledge, self-perceived risk, and prevention beliefs and behaviors

OBJECTIVE

Veterans, including the growing number of women veterans, have a greater risk of heart disease than nonveterans, and the incidence of heart disease is increasing among the most recent veterans who participated in post-9/11 military conflicts. Investigating heart disease-related knowledge, self-perceived risk, and prevention beliefs and behavior among these veterans, and identifying potential differences in knowledge, risk, beliefs and behavior between men and women, may guide prevention strategies.

METHOD

Cross-sectional data from a nationwide survey of 1,141 (53% women) post-9/11 veterans were used to examine heart disease awareness and information-seeking, perceived risk and importance of heart disease risk factors, beliefs about traditional (e.g., weight, blood pressure) and nontraditional (e.g., stress, sleep) factors, and engagement in prevention behaviors. Differences between men and women were also tested, using t-tests, chi-square, and Fisher's exact tests.

RESULTS

Only one-third reported they felt very informed or sought information about heart disease, or that their providers had discussed heart disease with them. Although veterans generally believe that addressing traditional and nontraditional factors can reduce their risk of heart disease, far fewer endorsed the value of mental health treatment in prevention. Overall, women were slightly more knowledgeable about heart disease risk, and of behaviors that can lower this risk, but for both men and women, this knowledge did not translate to engaging in equivalent prevention behaviors.

CONCLUSIONS

Post-9/11 veterans, and potentially their providers, may each benefit from improved education regarding their risk of heart disease. Veterans may also require better, more personalized approaches to prevention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Knowledge and cardiovascular disease risk perception from the perspectives of prisoners and staff in a Scottish prison: a qualitative study

PURPOSE

Prisoners have an increased risk of cardiovascular disease (CVD) compared to the general population. Knowledge and risk perception of CVD can influence engagement in preventative behaviours that lower an individual's CVD risk. This paper aims to explore prisoners' knowledge of CVD, and prisoners and staff's perceptions of prisoners' CVD risk.

DESIGN/METHODOLOGY/APPROACH

This was a qualitative study in which semi-structured interviews were conducted with 16 prisoners and 11 prison and National Health Services staff in a Scottish prison. Data were analysed thematically using the framework method.

FINDINGS

Most prisoners had limited knowledge of CVD as they could not describe it or could only identify one or two risk factors or cardiovascular events. Both prisoners and staff viewed prisoners' CVD risk as either pertaining to one individual, or pertaining to the general prisoner population. Unhealthy behaviours that were believed to increase CVD risk were linked to three perceived consequences of imprisonment: mental health problems, boredom and powerlessness.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first study to explore the CVD knowledge of prisoners, and perceptions of CVD risk from the perspectives of prisoners and prison staff. Findings from this study indicate that CVD education needs to be a priority for prisoners, addressing knowledge of CVD, its risk and risk perceptions. Additionally, the findings indicate that individual and socio-environmental factors linked to prisoners' CVD risk need to be targeted to reduce this risk. Future research should focus on socio-environmental interventions that can lead to reducing the CVD risk of prisoners.

Challenges in Optimizing Lipid Management in Women

While there are physiologic differences in lipid metabolism in men and women, pharmacologic therapy is very effective in both with similar management strategies recommended in the current guidelines for the management of dyslipidemia. Despite similar guidelines for treatment, studies have shown that women have worse control of dyslipidemia than their male counterparts. This may stem from multiple contributing factors including underestimation of cardiovascular disease risk in women, decreased prescription and utilization of lipid-lowering therapies, decreased medication adherence, and higher risk of statin intolerance, all of which may contribute to lower attainment of lipid targets. Furthermore, heart disease is the leading cause of mortality in women, with heart disease noted an average of 7-10 years later than in men. This has historically led to the misperception that women are protected from heart disease and can be treated less aggressively. In fact, traditional risk factors for atherosclerotic cardiovascular disease often impact risk in women to a greater extent than they do in men. Unique risk factors such as pregnancy-related disorders also contribute to the level of risk and therefore warrant consideration in risk stratification. This review summarizes the efficacy of contemporary lipid-lowering therapies in women versus men and discusses the challenges that arise with lipid management in women along with potential ways to tackle these obstacles.

Sex Difference in Long-Term Survival After Coronary Artery Bypass Grafting Is Age-Dependent

OBJECTIVES

Women undergoing coronary artery bypass grafting (CABG) demonstrate higher rates of postoperative morbidity and mortality than men. The aim of this study was to compare the patient profile and long-term outcomes of men and women undergoing isolated CABG.

DESIGN

A retrospective patient record study and propensity score-matched analysis.

SETTING

This single-center study was performed at Catharina Hospital in Eindhoven, The Netherlands.

PARTICIPANTS

The study comprised 17,483 patients, of whom 13,564 (77.6%) were men and 3,919 (22.4%) were women.

INTERVENTIONS

Coronary artery bypass grafting was performed between January 1998 and December 2015.

MEASUREMENTS AND MAIN RESULTS

The mean follow-up period was 8.8 ± 5.0 years. Women were older than men (67.7 ± 9.4 years v 63.9 ± 9.6 years, p < 0.001) and had lower preoperative hemoglobin levels. Early mortality (30-day) (2.8% v 1.9%; p < 0.001) and one-year mortality (5.2% v 3.8%; p < 0.001) rates were significantly higher in women than in men. Women demonstrated worse long-term survival than men only in the population younger than 70 years. After propensity score matching, female sex was not identified as an independent risk factor for long-term survival.

CONCLUSIONS

In the patient population, propensity score-matched analysis showed that female sex was not an independent risk factor for long-term survival after CABG. Poorer survival in women after CABG only was observed in patients <70 years of age.

Baseline Characteristics from the Women Veterans Cohort Study: Gender Differences and Similarities in Health and Healthcare Utilization

Introduction: With the unprecedented expansion of women's roles in the U.S. military during recent (post-9/11) conflicts in Iraq and Afghanistan, the number of women seeking healthcare through the Veterans Health Administration (VHA) has increased substantially. Women Veterans often present as medically complex due to multiple medical, mental health, and psychosocial comorbidities, and consequently may be underserved. Thus, we conducted the nationwide Women Veterans Cohort Study (WVCS) to examine post-9/11 Veterans' unique healthcare needs and to identify potential disparities in health outcomes and care. Methods: We present baseline data from a comprehensive questionnaire battery that was administered from 2016 to 2019 to a national sample of post-9/11 men and women Veterans who enrolled in Veterans Affairs care (WVCS2). Data were analyzed for descriptives and to compare characteristics by gender, including demographics; health risk factors and symptoms of cardiovascular disease, chronic pain, and mental health; healthcare utilization, access, and insurance. Results: WVCS2 included 1,141 Veterans (51% women). Women were younger, more diverse, and with higher educational attainment than men. Women also endorsed lower traditional cardiovascular risk factors and comorbidities (e.g., weight, hypertension) and greater nontraditional cardiovascular risk factors (e.g., trauma, psychological symptoms). More women reported single-site pain (e.g., neck, stomach, pelvic) and multisite pain, but did not differ from men in posttraumatic stress disorder (PTSD) symptoms or treatment for PTSD. Women seek care at VHA medical centers more frequently, often combined with outside health services, but do not significantly differ from men in their insurance coverage. Conclusion: Overall, this investigation indicates substantial variation in risk factors, health outcomes, and healthcare utilization among post-9/11 men and women Veterans. Further research is needed to determine best practices for managing women Veterans in the VHA healthcare system.

Postpartum counseling in women with hypertensive disorders of pregnancy

BACKGROUND

Hypertensive disorders of pregnancy are associated with increased cardiovascular disease risk across the lifespan. The American College of Obstetricians and Gynecologists and the American Heart Association emphasize the postpartum period as an important opportunity to identify and intervene women at high risk of future cardiovascular disease.

OBJECTIVE

This study aimed to determine the proportion of women with documented counseling on risks and transitions of care after hypertensive disorders of pregnancy at the postpartum visit.

STUDY DESIGN

This was a retrospective longitudinal descriptive study of women with hypertensive disorders of pregnancy who were enrolled in a text-based blood pressure program from September 2018 to February 2019. We abstracted counseling in the discharge summary and postpartum note from the electronic medical record. The primary outcome was counseling at the postpartum visit defined as documentation of (1) follow-up with primary care or cardiology, (2) risk of cardiovascular disease, or (3) recommendation for aspirin in a future pregnancy. We assessed demographic and clinical factors that may influence counseling through multivariable logistic regression. We also compared the proportion of women counseled on hypertensive disorders of pregnancy vs contraception and glucose tolerance tests at the postpartum visit.

RESULTS

Of 320 eligible women, most women had gestational hypertension or preeclampsia without severe features (64%). Postpartum visits were scheduled in our hospital system for 284 women, of whom 253 attended (89%). Documented counseling occurred for 62 women (25%). Counseling on follow-up with primary care or cardiology, cardiovascular disease risk, and aspirin in future pregnancies was documented for 51 (20%), 15 (6%), and 1 (0.4%), respectively. Only 1 woman had documented counseling on all 3 components. In multivariable analysis, black race remained an independent factor that increased the likelihood of counseling on hypertensive disorders of pregnancy (adjusted odds ratio, 2.77; 95% confidence interval, 1.32-5.83). Women were significantly less likely to be counseled on hypertensive disorders of pregnancy than on contraceptives (99%, P<.001) or glucose tolerance testing after gestational diabetes mellitus (79%, P<.001).

CONCLUSION

Postpartum counseling on hypertensive disorders of pregnancy merits urgent improvement efforts among obstetrical care providers.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Coronary Heart Disease and Depression or Anxiety: A Bibliometric Analysis

This study aimed to conduct a bibliometric analysis of published studies on the association between coronary heart disease (CHD) and depression or anxiety. The study also aimed to identify leading authors, institutions, and countries to determine research hotspots and obtain some hints from the speculated future frontiers. Publications about CHD and depression or anxiety between 2004 and 2020 were collected from the Web of Science Core Collection (WOSCC) database. Bibliographic information, such as authorship, country, citation frequency, and interactive visualization, was generated using VOSviewer1.6.16 and CiteSpace5.6.R5. In total, 8,073 articles were identified in the WOSCC database. The United States (2,953 publications), Duke University and Harvard University (214 publications), Psychosomatic Medicine (297 publications), and Denollet Johan. (99 publications) were the most productive country, institutions, journal, and author, respectively. The three hotspots of the research were “The relationship between depression and CHD,” “depression and myocardial infarction,” and “The characteristic of women suffering depression after MI.” The four future research frontiers are predicted to be “treating depression in CHD patients with multimorbidity,” “psychometric properties of instruments for assessing depression and anxiety in CHD patients,” “depression or anxiety in post-PCI patients,” and “other mental diseases in CHD patients.” Bibliometric analysis of the association between CHD and depressive disorders might identify new directions for future research.

Prodromal symptoms as unfamiliar feelings: Experiences of Iranian myocardial infarction patients

BACKGROUND

Patients affected by myocardial infarction (MI) report prodromal symptoms before heart attack. Deep understanding of these symptoms can increase the likelihood of early recognition and treatment of coronary heart disease (CHD). The purpose of this study was to describe the prodromal symptoms of MI experienced by Iranian adults.

METHODS

In this qualitative conventional content analysis, data was collected through an in-depth semi-structured interview with 14 men and women (aged 40-82 years). The patients were interviewed at the hospital 2 or 3 days after hospitalization due to MI. MAXQDA software was used for data analysis.

RESULTS

Data analysis led to the emergence of the 4 categories of 'Misperception of the symptoms', 'Reactions to the symptoms', 'Heart disease knowledge deficit', and 'Ideas and beliefs about heart disease'. The participants had not recognized the prodromal symptoms of MI and they attributed their symptoms to non-cardiac causes. They did not consider themselves at risk of heart disease, so they did not seek health services.

CONCLUSION

The participants were unaware of their prodromal symptoms. Clinicians should be attentive that men and women at risk of MI may experience a range of unfamiliar and vague prodromal symptoms, so they must give greater attention to their narratives. A greater understanding of the prodromal symptoms experienced may lead to a more truthful and timely interpretation of their symptoms and earlier detection by physicians.

Ten-Year Differences in Women's Awareness Related to Coronary Heart Disease: Results of the 2019 American Heart Association National Survey: A Special Report From the American Heart Association

BACKGROUND

High awareness that cardiovascular disease is the leading cause of death (LCOD) among women is critical to prevention. This study evaluated longitudinal trends in this awareness among women.

METHODS AND RESULTS

Online surveys of US women (≥25 years of age) were conducted in January 2009 and January 2019. Data were weighted to the US population distribution of sociodemographic characteristics. Multivariable logistic regression was used to evaluate knowledge of the LCOD. In 2009, awareness of heart disease as the LCOD was 65%, decreasing to 44% in 2019. In 2019, awareness was greater with older age and increasing education and lower among non-White women and women with hypertension. The 10-year awareness decline was observed in all races/ethnicities and ages except women ≥65 years of age. The greatest declines were among Hispanic women (odds ratio of awareness comparing 2019 to 2009, 0.14 [95% CI, 0.07-0.28]), non-Hispanic Black women (odds ratio, 0.31 [95% CI, 0.19-0.49]), and 25- to 34-year-olds (odds ratio, 0.19 [95% CI, 0.10-0.34]). In 2019, women were more likely than in 2009 to incorrectly identify breast cancer as the LCOD (odds ratio, 2.59 [95% CI, 1.86-3.67]), an association that was greater in younger women. Awareness of heart attack symptoms also declined.

CONCLUSIONS

Awareness that heart disease is the LCOD among women declined from 2009 to 2019, particularly among Hispanic and non-Hispanic Black women and in younger women (in whom primordial/primary prevention may be most effective). An urgent redoubling of efforts by organizations interested in women's health is required to reverse these trends.

The Importance of Gender to Understand Sex Differences in Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. There is robust evidence of heterogeneity in underlying mechanism, manifestation, prognosis, and response to treatment of CVD between male and female patients. Gender, which refers to the socially constructed roles, behaviours, expressions, and identities of individuals, is an important determinant of CV health, and its consideration might help in attaining a broader understanding of the observed sex differences in CVD. Established risk factors such as hypertension, dyslipidemia, diabetes mellitus, obesity, and smoking are well known to contribute to CVD. However, despite the differences in CVD risk between male and female, most studies looking into the magnitude of effect of each risk factor have traditionally focused on male subjects. While biological sex influences disease pathophysiology, the psycho-socio-cultural construct of gender can further interact with this effect. Behavioural, psychosocial, personal, cultural, and societal factors can create, repress, or strengthen underlying biological CV health differences. Although mechanisms of action are largely unclear, it is suggested that gender-related factors can further exacerbate the detrimental effect of established risk factors of CVD. In this narrative review, we explore the current literature investigating the role of gender in CV risk and its impact on established risk factors as a fundamental step toward precision medicine.

Sex Differences in the Age of Diagnosis for Cardiovascular Disease and Its Risk Factors Among US Adults: Trends From 2008 to 2017, the Medical Expenditure Panel Survey

Background Sex differences in the trends for control of cardiovascular disease (CVD) risk factors have been described, but temporal trends in the age at which CVD and its risk factors are diagnosed and sex-specific differences in these trends are unknown. Methods and Results We used the Medical Expenditure Panel Survey 2008 to 2017, a nationally representative sample of the US population. Individuals ≥18 years, with a diagnosis of hypercholesterolemia, hypertension, coronary heart disease, or stroke, and who reported the age when these conditions were diagnosed, were included. We included 100 709 participants (50.2% women), representing 91.9 million US adults with above conditions. For coronary heart disease and hypercholesterolemia, mean age at diagnosis was 1.06 and 0.92 years older for women, compared with men, respectively (both P<0.001). For stroke, mean age at diagnosis for women was 1.20 years younger than men (P<0.001). The mean age at diagnosis of CVD risk factors became younger over time, with steeper declines among women (annual decrease, hypercholesterolemia [women, 0.31 years; men 0.24 years] and hypertension [women, 0.23 years; men, 0.20 years]; P<0.001). Coronary heart disease was not statistically significant. For stroke, while age at diagnosis decreased by 0.19 years annually for women (P=0.03), it increased by 0.22 years for men (P=0.02). Conclusions The trend in decreasing age at diagnosis for CVD and its risk factors in the United States appears to be more pronounced among women. While earlier identification of CVD risk factors may provide opportunity to initiate preventive treatment, younger age at diagnosis of CVD highlights the need for the prevention of CVD earlier in life, and sex-specific interventions may be needed.

Women discontinue antihypertensive drug therapy more than men. Evidence from an Italian population-based study

OBJECTIVE

Several factors affect adherence to antihypertensive drug treatment, but whether these factors include a sex difference is unclear. Aim of the study was to compare persistence with antihypertensive drug therapy between men and women in a large cohort of patients.

METHODS

The 60 526 residents of the Italian Lombardy Region aged 40-80 years newly treated with antihypertensive drugs during 2010 were identified and followed for 1 year after the first prescription. Discontinuation of treatment was defined as lack of prescription renewal for at least 90 days. Log-binomial regression models were fitted to estimate the risk ratio of treatment discontinuation in relation to sex. Other than for the whole population, analyses were stratified according to age, comorbidity status and the initial antihypertensive treatment strategy.

RESULTS

Thirty-seven percent of the patients discontinued the drug treatment during follow-up. Compared with women, men had a 10% lower risk of discontinuation of drug treatment (95% confidence interval: 8-12). Persistence on antihypertensive treatment was better in men than in women, this being the case in both younger (40-64 years) and older patients (65-80 years), in patients starting treatment with any major antihypertensive drug and in patients who had a low comorbidity status. There was no evidence that men and women had a different risk of treatment discontinuation when their comorbidity status was worse, or initial antihypertensive treatment was based on drug combinations.

CONCLUSION

Our data show that in a real-life setting, men are more persistent to antihypertensive drug therapy than women.

Women have lower chances than men to be resuscitated and survive out-of-hospital cardiac arrest

Aims

Previous studies on sex differences in out-of-hospital cardiac arrest (OHCA) had limited scope and yielded conflicting results. We aimed to provide a comprehensive overall view on sex differences in care utilization, and outcome of OHCA.

Methods and results

We performed a population-based cohort-study, analysing all emergency medical service (EMS) treated resuscitation attempts in one province of the Netherlands (2006–2012). We calculated odds ratios (ORs) for the association of sex and chance of a resuscitation attempt by EMS, shockable initial rhythm (SIR), and in-hospital treatment using logistic regression analysis. Additionally, we provided an overview of sex differences in overall survival and survival at successive stages of care, in the entire study population and in patients with SIR. We identified 5717 EMS-treated OHCAs (28.0% female). Women with OHCA were less likely than men to receive a resuscitation attempt by a bystander (67.9% vs. 72.7%; P < 0.001), even when OHCA was witnessed (69.2% vs. 73.9%; P < 0.001). Women who were resuscitated had lower odds than men for overall survival to hospital discharge [OR 0.57; 95% confidence interval (CI) 0.48–0.67; 12.5% vs. 20.1%; P < 0.001], survival from OHCA to hospital admission (OR 0.88; 95% CI 0.78–0.99; 33.6% vs. 36.6%; P = 0.033), and survival from hospital admission to discharge (OR 0.49, 95% CI 0.40–0.60; 33.1% vs. 51.7%). This was explained by a lower rate of SIR in women (33.7% vs. 52.7%; P < 0.001). After adjustment for resuscitation parameters, female sex remained independently associated with lower SIR rate.

Conclusion

In case of OHCA, women are less often resuscitated by bystanders than men. When resuscitation is attempted, women have lower survival rates at each successive stage of care. These sex gaps are likely explained by lower rate of SIR in women, which can only partly be explained by resuscitation characteristics.

Sex differences in prevalence, treatment and control of cardiovascular risk factors in England

OBJECTIVE

To investigate sex differences in prevalence, treatment and control of major cardiovascular risk factors in England.

METHODS

Data from the Health Survey for England 2012-2017 on non-institutionalised English adults (aged ≥16 years) were used to investigate sex differences in prevalence, treatment and control of major cardiovascular risk factors: body mass index, smoking, systolic blood pressure and hypertension, diabetes, and cholesterol and dyslipidaemia. Physical activity and diet were not assessed in this study.

RESULTS

Overall, 49 415 adults (51% women) were included. Sex differences persisted in prevalence of cardiovascular risk factors, with smoking, hypertension, overweight and dyslipidaemia remaining more common in men than in women in 2017. The proportion of individuals with neither hypertension, dyslipidaemia, diabetes nor smoking increased from 32% to 36% in women and from 28% to 29% in men between 2012 and 2017. Treatment and control of hypertension and diabetes improved over time and were comparable in both sexes in 2017 (66% and 51% for treatment and control of hypertension and 73% and 20% for treatment and control of diabetes). However, women were less likely than men to have treated and controlled dyslipidaemia (21% vs 28% for treatment and 15% vs 24% for control, for women versus men in 2017).

CONCLUSIONS

Important sex differences persist in cardiovascular risk factors in England, with an overall higher number of risk factors in men than in women. A combination of public health policy and individually tailored interventions is required to further reduce the burden of cardiovascular disease in England.

Aspirin Use and Awareness for Cardiovascular Disease Prevention Among Hispanics: Prevalence and Associations with Health Behavior Beliefs

Cardiovascular disease (CVD) persists as the leading cause of death and disability in many Americans including Hispanics. Primary prevention for CVD may be achieved through regular aspirin use in high risk individuals. This study examined regular aspirin use and specific attitudes and social norms toward CVD and aspirin use within an urban Hispanic population in Minnesota. A sample of primary prevention Hispanics aged 45-79 years were surveyed about CVD history and risk factors, aspirin use, demographic characteristics, and health beliefs and social norms in relation to CVD and aspirin. Relative risk estimation using Poisson regression with robust error variance was used to examine associations with aspirin use. In this sample of 152 Hispanics (55% women), the mean age was 53 years, 70% had a regular healthcare provider, and 22% used aspirin. Aspirin discussions with a regular healthcare provider were strongly associated with aspirin use (adjusted risk ratio 3.02, 95% CI 1.20-7.60). There was a positive association between health beliefs and social norms that affirm preventive behaviors and aspirin use (adjusted linear risk ratio 1.23, 95% CI 1.04-1.45) while uncertainty about the role of aspirin for individual use and in the community was negatively associated with aspirin use (adjusted linear risk ratio 0.85, 95% CI 0.70-1.03). This growing population may benefit from health education about CVD risk and the role of aspirin in prevention.

Feasibility and Utility of a Cardiovascular Risk Screening Tool in Women Undergoing Routine Gynecology Evaluation

Background

The goals of this multicenter survey were to examine the prevalence and patient awareness of cardiovascular risk factors, and the association between history of adverse pregnancy outcomes (APO—including gestational hypertension, gestational diabetes, and preeclampsia) and prevalence of cardiovascular risks among women presenting to outpatient obstetrics/gynecology (OB/GYN) clinics.

Materials and Methods

We surveyed 2,946 female patients attending 16 outpatient OB/GYN clinics across the United States between January 2010 and January 2012. Main outcome measures were self-reported cardiovascular risk factors and symptoms such as angina and dyspnea.

Results

Mean age of the patients was 51 ± 13.6 years. Cardiovascular risks and symptoms were highly prevalent (86.0% and 40.1%, respectively). Many patients did not know if they had common risk factors such as hypertension, hypercholesterolemia, or diabetes (18.4%, 32.0%, and 17.9%, respectively). Women with a history of APO were slightly more likely to be aware of common risk factors, including abnormal blood pressure (17% vs. 18.6%), high cholesterol (31.7% vs. 32%), and obesity/elevated body mass index (43.9% vs. 49.7%). Compared with patients with no history of APO, patients with APO (n = 380, 12.9%) were more likely to have risk factors (89.5% vs. 83.9%, p = 0.002) and symptoms (45.5% vs. 39.3%, p = 0.02).

Conclusions

Awareness of cardiovascular risk factors and symptoms among all women surveyed in this study was poor, although awareness for some risk factors was relatively higher among patients with APO. This study demonstrates the feasibility of cardiovascular assessment in OB/GYN clinics using a simple questionnaire and its potential role for early recognition and timely intervention.

Sex Differences in Cardiovascular Medication Prescription in Primary Care: A Systematic Review and Meta-Analysis

Background

Sex differences in the management of cardiovascular disease have been reported in secondary care. We conducted a systematic review with meta‐analysis of systematically investigated sex differences in cardiovascular medication prescription among patients at high risk or with established cardiovascular disease in primary care.

Methods and Results

PubMed and Embase were searched between 2000 and 2019 for observational studies reporting on the sex‐specific prevalence of aspirin, statins, and antihypertensive medication prescription, including beta blockers, calcium channel blockers, angiotensin‐converting enzyme inhibitors, and diuretics, in primary care. Random effects meta‐analysis was used to obtain pooled women‐to‐men prevalence ratios for each cardiovascular medication prescription. Metaregression models assessed the impact of age and year on the findings. A total of 43 studies were included, involving 2 264 600 participants (28% women) worldwide. Participants’ mean age ranged from 51 to 76 years. The pooled prevalence of cardiovascular medication prescription for women was 41% for aspirin, 60% for statins, and 68% for any antihypertensive medications. Corresponding rates for men were 56%, 63%, and 69% respectively. The pooled women‐to‐men prevalence ratios were 0.81 (95% CI, 0.72–0.92) for aspirin, 0.90 (95% CI, 0.85–0.95) for statins, and 1.01 (95% CI, 0.95–1.08) for any antihypertensive medications. Women were less likely to be prescribed angiotensin‐converting enzyme inhibitors (0.85; 95% CI, 0.81–0.89) but more likely with diuretics (1.27; 95% CI, 1.17–1.37). Mean age, mean age difference between the sexes, and year of study had no significant impact on findings.

Conclusions

Sex differences in the prescription of cardiovascular medication exist among patients at high risk or with established cardiovascular disease in primary care, with a lower prevalence of aspirin, statins, and angiotensin‐converting enzyme inhibitors prescription in women and a lower prevalence of diuretics prescription in men.

Using 4-vinylcyclohexene diepoxide as a model of menopause for cardiovascular disease

There is a sharp rise in cardiovascular disease (CVD) risk and progression with the onset of menopause. The 4-vinylcyclohexene diepoxide (VCD) model of menopause recapitulates the natural, physiological transition through perimenopause to menopause. We hypothesized that menopausal female mice were more susceptible to CVD than pre- or perimenopausal females. Female mice were treated with VCD or vehicle for 20 consecutive days. Premenopausal, perimenopausal, and menopausal mice were administered angiotensin II (ANG II) or subjected to ischemia-reperfusion (I/R). Menopausal females were more susceptible to pathological ANG II-induced cardiac remodeling and cardiac injury from a myocardial infarction (MI), while perimenopausal, like premenopausal, females remained protected. Specifically, ANG II significantly elevated diastolic (130.9 ± 6.0 vs. 114.7 ± 6.2 mmHg) and systolic (156.9 ± 4.8 vs. 141.7 ± 5.0 mmHg) blood pressure and normalized cardiac mass (15.9 ± 1.0 vs. 7.7 ± 1.5%) to a greater extent in menopausal females compared with controls, whereas perimenopausal females demonstrated a similar elevation of diastolic (93.7 ± 2.9 vs. 100.5 ± 4.1 mmHg) and systolic (155.9 ± 7.3 vs. 152.3 ± 6.5 mmHg) blood pressure and normalized cardiac mass (8.3 ± 2.1 vs. 7.5 ± 1.4%) compared with controls. Similarly, menopausal females demonstrated a threefold increase in fibrosis measured by Picrosirus red staining. Finally, hearts of menopausal females (41 ± 5%) showed larger infarct sizes following I/R injury than perimenopausal (18.0 ± 5.6%) and premenopausal (16.2 ± 3.3, 20.1 ± 4.8%) groups. Using the VCD model of menopause, we provide evidence that menopausal females were more susceptible to pathological cardiac remodeling. We suggest that the VCD model of menopause may be critical to better elucidate cellular and molecular mechanisms underlying the transition to CVD susceptibility in menopausal women.NEW & NOTEWORTHY Before menopause, women are protected against cardiovascular disease (CVD) compared with age-matched men; this protection is gradually lost after menopause. We present the first evidence that demonstrates menopausal females are more susceptible to pathological cardiac remodeling while perimenopausal and cycling females are not. The VCD model permits appropriate examination of how increased susceptibility to the pathological process of cardiac remodeling accelerates from pre- to perimenopause to menopause.

Barriers to cardiovascular disease preventive behaviors among OEF/OIF/OND women and men veterans

OBJECTIVE

OEF/OIF/OND Veterans have an elevated risk for developing cardiovascular disease (CVD), but research suggests that engagement in CVD preventive behaviors is low even among at-risk individuals. It is critical to understand barriers to prevention engagement among Veterans to inform the development of tailored interventions addressing barriers and reducing CVD incidence.

METHOD

The Women Veterans Cohort Study survey of OEF/OIF/OND Veterans (586 women and 555 men) assessed patient, interpersonal, and systems level barriers to CVD risk prevention. Prevalence of barriers was determined, and chi-squares were conducted to examine sex differences. Multivariate logistic regressions were conducted to determine if sex differences remained when adjusting for demographic factors (age, marital status, education, employment status).

RESULTS

Despite a low response rate (11.5%), endorsement of barriers was high for both women and men, with most (56.8%) not perceiving themselves to be at CVD risk. More men preferred making no lifestyle change (40.9% vs. 29.1%). More women endorsed lack of confidence (42.4% vs. 36.1%), stress (36.9% vs. 27.8%) and depression (36.9% vs. 27.8%), and inadequate social support (26% vs. 20.9%), along with the belief that their clinician does not perceive them as at risk (57.8% vs. 32%) and has not explained CVD preventive behaviors (19% vs. 12.3%). Multivariate analyses reduced statistical significance of sex differences.

CONCLUSIONS

Given the low response rate, testing of efforts-for example, implementation science methods-to assess CVD risk reduction barriers in this population are needed, a task for which the Veterans Health Administration is well suited. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Gender differences among ischemic heart disease patients enrolled in a cardiac rehabilitation program

BACKGROUND

Cardiac rehabilitation programs reduce cardiovascular events and mortality in ischemic heart disease patients. The aim of this study was to assess gender differences among ischemic heart disease patients enrolled in a cardiac rehabilitation program regarding adherence to the program, as well as, changes in clinical, laboratory, and echocardiographic parameters.

RESULTS

A prospective study that included 30 men and 30 women with stable ischemic heart disease who had been totally revascularized by percutaneous coronary intervention. Patients were enrolled in a 12-week cardiac rehabilitation program. Assessment of demographics, anthropometric measurements, risk factors, and functional capacity was performed. Lipid profile, glycated hemoglobin, and left ventricular ejection fraction were assessed. Assessments were performed at baseline and after completion of the program. Time to enrollment in the program was prolonged for women 39.17 ± 40.49 vs. 19.77 ± 10.26 days (p = 0.014). At baseline, more women were diabetic (p = 0.004), hypertensive (p = 0.02), had a larger waist circumference (p = 0.022), a higher BMI (p = 0.011), and higher HbA1c (p = 0.033). More men were active smokers (p < 0.001). After completion of the program, it was found that men attended 19.1 ± 4.77 (79.6%) sessions compared to 15.7 ± 5.72 (65.4%) sessions for women (p = 0.015). Women had more reduction in diastolic BP - 10.93 ± 8.94 vs. - 5.47 ± 12.57 mmHg (p = 0.058). The magnitude of reduction in resting heart rate was significant in men (p = 0.018) but not in women (p = 0.376). The magnitude of reduction in serum total cholesterol and triglycerides was more in men (p = 0.018 and p = 0.014). Women showed more reduction in HbA1c (p = 0.052).

CONCLUSION

Men are more adherent to cardiac rehabilitation programs. Recruitment of women is significantly delayed. Women have a higher cardiovascular risk burden in the form of prevalence of diabetes, hypertension, and obesity. Completion of a cardiac rehabilitation program causes a reduction in BMI, waist circumference, blood pressure measurements, total cholesterol, triglycerides, LDL-C, HDL-C, HbA1c, and LVEDD with an increase in LVEF in both genders. Men show more reduction in resting HR, total cholesterol, and triglyceride levels while women show more reduction in diastolic BP and HBA1c.

Survival Differences in Women and Men After Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy

Importance

Recent data indicate that women with hypertrophic cardiomyopathy (HCM) are older and more symptomatic at presentation and have worse clinical outcomes than men. However, to our knowledge, there are no large studies of the association of patient sex with outcomes after surgical myectomy.

Objective

To analyze preoperative characteristics and overall survival of women and men undergoing septal myectomy for obstructive HCM.

Design, Setting, and Participants

This retrospective, single-center study included the clinical data of adult patients who underwent septal myectomy from January 1961 through April 2016. Data analysis occurred from December 2017 to December 2018.

Exposures

Septal myectomy.

Main Outcomes and Measures

Survival.

Results

A total of 2506 adults were included; 1379 patients (55.0%) were men. At the time of surgery, women were older, with median (IQR) age of 59.5 (46.6-68.2) years vs 52.9 (42.9-62.7) years in men (P < .001). Women were more likely to have New York Heart Association class III or IV status at presentation (women, 1023 [90.8%]; men, 1169 [84.8%]; P < .001) and more severe obstructive physiology, as reflected in higher resting left ventricular outflow tract gradients (women, 67.0 [36.0-97.0] mm Hg; men, 50.0 [23.0-81.0] mm Hg; P < .001). Women also had a greater likelihood of having moderate or severe mitral regurgitation (606 [55.2%]) than men (581 [43.1%]; P < .001) and higher right ventricular systolic pressure (women, 36.0 [30.0-46.0] mm Hg; men, 33.0 [28.0-39.0] mm Hg; P < .001). The unadjusted overall survival was lower in women, corresponding to a median 3.9-year shorter survival than men (median [IQR] survival time: women, 18.2 [12.1-27.2] years; men, 22.1 [15.1-32.5] years; P < .001). In a multivariable Cox regression analysis, however, the association between sex and mortality was attenuated and not significant after controlling for other baseline variables (hazard ratio, 0.98 [95% CI, 0.76-1.26]; P = .86). Among the covariates in the model, older age at surgery (adjusted hazard ratio [aHR], 3.09 [95% CI, 2.12-4.52]; P < .001), higher body mass index (aHR, 1.22 [95% CI, 0.90-1.66]; P < .001), greater NYHA class (aHR, 2.31 [95% CI, 1.03-5.15]; P = .04), and presence of diabetes prior to surgery (aHR, 1.57 [95% CI, 1.10-2.24]; P = .01) were each independently associated with increased mortality. Operations performed later in the study period (2013 vs 2004) were associated with decreased mortality (aHR, 0.82 [95% CI, 0.55-1.22]; P = .001).

Conclusions and Relevance

In this large cohort of surgical patients with obstructive HCM, we observed significant differences at clinical presentation between women and men, in that women were older and more symptomatic. However, after adjustment for important baseline prognostic factors, there was no survival difference after septal myectomy by sex. Improved care of women with obstructive HCM should focus on early identification of disease and prompt surgical referral of appropriate patients who do not respond to medical treatment.