Age- and gender-related ventricular-vascular stiffening: a community-based study

Ventricular-arterial coupling: changes with ageing and implications across cardiovascular conditions

PURPOSE

Ventricular-arterial coupling (VAC) is a crucial concept in cardiovascular physiology, representing the dynamic interaction between the left ventricle and the arterial system. This comprehensive literature review explores the changes in VAC with ageing and various cardiovascular diseases (CVDs).

MATERIALS AND METHODS

This literature review covers studies on changes in VAC with age and common CVDs, such as arterial hypertension, atrial fibrillation (AF) and heart failure with preserved and reduced ejection fraction and aortic stenosis (AS). The review discusses traditional measures of VAC, including arterial elastance (Ea) and ventricular elastance (Ees), as well as emerging parameters, such as global longitudinal strain (GLS) and pulse wave velocity (PWV). The review introduces the PWV/GLS ratio as a novel method for assessing VAC.

RESULTS

With ageing, both Ea and Ees increase, while the Ea/Ees ratio remains relatively stable, reflecting balanced arterial and ventricular adaptations. Novel measures, such as PWV/GLS ratio, show greater impairment in older adults and provide a comprehensive evaluation of VAC.

CONCLUSIONS

Ageing disrupts VAC through arterial stiffening and reduced heart function, often exacerbated by CVDs. Novel metrics like PWV/GLS may improve VAC assessment, helping clinicians manage age-related cardiovascular issues by identifying risks earlier and guiding treatment to support efficient heart-artery interaction.

Sex-Specific Patterns in Blood Pressure and Vascular Parameters: The MUJER-EVA Project

Recent evidence suggests that sex-related differences in cardiovascular health extend beyond traditional risk factors, affecting vascular structure and function. This study aimed to examine sex differences in vascular parameters, including central and peripheral blood pressure, pulse wave velocity (PWv), augmentation index at 75 bpm (AIx75), cardiac output, stroke volume, and peripheral vascular resistance, using harmonized data from three population-based cohorts (EVasCu, VascuNET, and ExIC-FEp) as part of the MUJER-EVA project. A total of 669 adult participants were included in this pooled cross-sectional analysis. Sex-stratified comparisons were conducted using multiple linear regression models adjusted for anthropometric, sociodemographic, and clinical covariates. The results showed that men had significantly higher values for central and peripheral blood pressure (p < 0.001), PWv (p = 0.003), cardiac output (p < 0.001), and stroke volume (p < 0.001), whereas women presented higher values of AIx75 (p < 0.001) and peripheral vascular resistance (p = 0.002). These differences remained statistically significant after full adjustment for potential confounders. These findings highlight the need to consider sex as a key biological variable in cardiovascular research and clinical decision-making. Incorporating sex-specific reference values and personalized treatment strategies could improve vascular health assessment and the effectiveness of cardiovascular disease prevention.

The Particularities of Arterial Hypertension in Female Sex: From Pathophysiology to Therapeutic Management

Arterial hypertension is the most important modifiable cardiovascular risk factor and a major cause of cardiovascular mortality worldwide. In daily clinical practice, the hypertensive patient is often treated in a uniform way, thus ignoring the significant effects of sex on several aspects of hypertension, including its prevalence, pathophysiology, response to antihypertensive treatment, and outcomes. Along with the immune response and several cardiometabolic risk factors that frequently coexist, the substantial hormonal changes during a woman's life cycle are among the main pathophysiological mechanisms driving hypertension in women. Concurrently, women exhibit increased cardiovascular risk at lower blood pressure (BP) levels compared to age-matched men and present certain disparities in the incidence of cardiovascular events and subsequent hypertension-related cardiovascular prognosis. In addition, women respond differently to antihypertensive treatment, experience more drug-related side effects, and exhibit lower rates of BP control compared to men. Currently, international guidelines propose the same targets and the same therapeutic algorithms for the treatment of hypertension in both sexes without taking into account the sex differences that exist. In this review, we aim to describe certain particularities of arterial hypertension in the female sex, moving from pathophysiological aspects to clinical and therapeutical management.

Association of Impaired Relaxation Mitral Inflow Pattern (Grade 1 Diastolic Function) With Long-Term Noncardiovascular and Cardiovascular Mortality

BACKGROUND

Abnormalities of left ventricular diastolic function are established independent predictors of heart failure and mortality. The aim of this study was to determine whether the association of diastolic function with all-cause mortality is driven by cardiovascular or noncardiovascular death and if impaired relaxation mitral inflow filling pattern is a risk marker.

METHODS

Diastolic function was graded by the Mayo Clinic algorithm using the well-characterized prospective Olmsted County Heart Function Study. Those with reduced left ventricular ejection fraction, moderate or greater valve disease, clinical diagnosis of heart failure, or indeterminate diastolic function were excluded. Notably, all patients with an impaired relaxation pattern (E/A ratio < 0.8) were classified as abnormal (grade 1) regardless of ejection fraction and clinical or other echocardiographic abnormalities. Individuals were followed for a median of 19.7 years (interquartile range, 18.9-20.6 years) for mortality outcomes.

RESULTS

In a community cohort of 1,005 subjects 63 years (interquartile range, 57-71 years) of age, grade 1 diastolic function was common (26%) and associated with all-cause mortality (hazard ratio [HR], 4.05; 95% CI, 3.22-5.09; P < .0001). This association persisted in a subgroup of those with impaired myocardial relaxation and no other clinical or echocardiographic abnormalities (HR, 2.71; 95% CI, 1.89-3.88; P < .0001). The association of diastolic function with noncardiovascular death was not significant after adjustment for age, sex, and comorbidities, though there was an association with grade 1 diastolic function and risk for death of dementia (age- and sex-adjusted HR, 2.30; 95% CI, 1.54-3.45; P < .001). The association of diastolic function and cardiovascular mortality persisted in multivariable model, including for grade 1 diastolic function (HR, 2.43; 95% CI, 1.16-5.05; P = .02).

CONCLUSIONS

Impaired relaxation mitral inflow pattern (grade 1) is common in older adults in the community and found to be associated with cause-specific death, highlighting this simple echocardiographic finding as a potential biomarker of cardiovascular and cognitive risk and not necessarily a benign finding that is normal with age.

Age- and sex-based normal reference ranges of the cardiac time intervals: the Copenhagen City Heart Study

BACKGROUND

Color tissue Doppler imaging (TDI) M-mode can be used to measure the cardiac time intervals including the isovolumic contraction time (IVCT), the left ventricular ejection time (LVET), the isovolumic relaxation time (IVRT), and the combination of all the cardiac time intervals in the myocardial performance index (MPI) defined as [(IVCT + IVRT)/LVET]. The aim of this study was to establish normal age- and sex-based reference ranges for the cardiac time intervals.

METHODS AND RESULTS

A total of 1969 participants free of cardiovascular diseases and risk factors from the general population with limited age range underwent an echocardiographic examination including TDI. The median age was 46 years (25th-75th percentile: 33-58 years), and 61.5% were females. In the entire study population, the IVCT was observed to be 40 ± 10 ms [95% prediction interval (PI) 20-59 ms], the LVET 292 ± 23 ms (95% PI 248-336 ms), the IVRT 96 ± 19 ms (95% PI 59-134 ms) and MPI 0.47 ± 0.09 (95% PI 0.29-0.65). All the cardiac time intervals differed significantly between females and males. With increasing age, the IVCT increased in females, but not in males. The LVET did not change with age in both sexes, while the IVRT increased in both sexes with increasing age. Furthermore, we developed regression equations relating the heart rate to the cardiac time intervals and age- and sex-based normal reference ranges corrected for heart rate.

CONCLUSION

In this study, we established normal age- and sex-based reference ranges for the cardiac time intervals. These normal reference ranges differed significantly with sex.

Insights Into the Role of Obesity in Heart Failure With Preserved Ejection Fraction Pathophysiology and Management

Heart failure (HF) is a significant global health issue, categorized by left ventricular ejection fraction, being either reduced (HFrEF < 0.40) or preserved (HFpEF > 0.50), or in the middle of this range. Although the overall incidence of HF remains stable, HFpEF cases are increasing, representing about 50% of all HF cases. Outcomes for HFpEF are similar to those for HFrEF, leading to substantial health-care resource use. Despite extensive research over the past 2 decades, the prognosis and mortality rates for HFpEF remain high. A key feature of HFpEF is exercise intolerance, characterized by severe exertional dyspnea and fatigue, which significantly impacts quality of life. The underlying mechanisms of exercise intolerance are not fully understood due to the complex pathophysiology and multisystem involvement. Obesity is a common comorbidity in HFpEF, especially in North America, leading to worsening symptoms, hemodynamics, and mortality rates. Increased adiposity leads to inflammation, hypertension, dyslipidemia, and insulin resistance, and impairing cardiac, vascular, pulmonary, and skeletal muscle function. Therefore, managing obesity is crucial in treating HFpEF. In this review we explore the pathophysiologic mechanisms of HFpEF, emphasizing obesity's role, and we discuss current management strategies while identifying areas needing further research.

The role of estrogen in the sex difference for the risk factors of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is a major subtype of heart failure, primarily characterized by a normal or mildly reduced left ventricular ejection fraction along with left ventricular diastolic dysfunction. Recent studies have shown that the prevalence of HFpEF is higher in women than that in men, particularly in postmenopausal women. Concurrently, it has been observed that the incidence of risk factors contributing to HFpEF (such as obesity, hypertension, diabetes, and atrial fibrillation) also notably increases post-menopause, affecting the incidence of HFpEF. This review aimed to examine the relationship between estrogen and risk factors associated with HFpEF, clarifying the underlying mechanisms through which estrogen affects these risk factors from epidemiological and pathophysiological perspectives. This review also provides a comprehensive understanding of the association between estrogen and the risk factors for HFpEF, thus helping explore potential targets for HFpEF treatment.

Association Between Mediterranean Diet and Other Healthy Habits and Sociodemographic Variables with the Values of Vascular and Heart Age in Spanish Workers

Introduction: The assessment of cardiovascular risk has traditionally relied on validated scales designed to estimate the likelihood of experiencing a cardiovascular event within a specific timeframe. In recent years, novel methodologies have emerged, offering a more objective evaluation of this risk through indicators such as vascular age (VA) and heart age (HA). Objective: This study aimed to investigate the relationship between sociodemographic factors, lifestyle behaviors, and their impact on VA and HA. Materials and Methods: A dual study design, encompassing both cross-sectional and longitudinal retrospective approaches, was conducted among a cohort of employees. The variables assessed included sociodemographic characteristics (age, sex, and socioeconomic status) and health-related habits (smoking, physical activity, adherence to the Mediterranean diet, and alcohol consumption). Results: The findings revealed that all analyzed variables were significantly associated with elevated VA and HA values. Among these, age demonstrated the strongest association, with odds ratios (OR) of 114.91 (95% CI: 100.45-131.43) for high HA and 34.48 (95% CI: 31.41-37.56) for high VA. Conclusions: The profile of individuals most at risk for elevated VA and HA encompasses males of advanced age, characterized by low socioeconomic status, a sedentary lifestyle, poor adherence to the Mediterranean diet, and regular alcohol consumption.

Sex-dependent Pathophysiology and Therapeutic Considerations in Right Heart Disease

Right ventricular (RV) adaptation to the increased afterload in the setting of pulmonary hypertension (PH) and other cardiac and pulmonary vascular conditions is a major determinant of survival. Although the RV remains understudied and less well understood than the left ventricle, recent advances have been made in understanding the function and biology of the RV in health and in disease, particularly in PH. RV adaptation in PH exhibits significant sexual dimorphisms in pathophysiology, adaptation, and outcomes. Despite a higher incidence of PH, women consistently demonstrate better RV adaptation and survival rates in the setting of increased RV afterload compared with men. Sexual dimorphisms extend to therapy responsiveness, with women benefiting more from certain pulmonary vasodilators and exhibiting superior RV recovery. In this review we discuss the current literature on sexual dimorphisms in RV structure, function, and molecular pathways in health and disease, as well as in RV-specific clinical manifestations, treatments, and outcomes in PH. Sex steroid-mediated effects as well as emerging studies on sex steroid-independent effects are reviewed. In general, sex steroids such as 17β-estradiol and dehydroepiandrosterone exert RV-protective effects. In contrast, testosterone negatively impacts RV structure and function. Emerging evidence highlights the influence of nonhormonal genetic determinants, such as BMPR1A and DMRT2 loci, which are associated with better RV function in women. A better understanding of the interplay between sex hormones, genetic factors, and RV biology is crucial for advancing and developing RV-directed therapies for patients of either sex.

Sex-specific molecular drivers of cardiac fibrosis in aging hearts

The aging population, defined as individuals 65 years or older, is rapidly increasing, with age as the most significant and independent risk factor for cardiovascular diseases (CVD). Older women show greater susceptibility to cardiac remodeling and dysfunction compared to men. Despite this, the specific molecular drivers of sex differences in cardiac aging remain poorly understood. In this study, cardiac fibrosis and gene expression profiles were investigated in left atrial appendage samples obtained from 24 consecutive patients undergoing cardiac surgery. Using Masson's trichrome staining, we found that cardiac fibrosis significantly increased with age in females (p = 0.02) but not in males (p = 0.27). A subsequent medium-throughput gene expression analysis targeting approximately 800 cardiovascular genes revealed no differences in overall cardiac gene expression between sexes based on principal component analyses (PCA). However, pathway-specific analyses identified the thrombosis and hemostasis pathway as prominently dysregulated in females. Specifically, older females showed significant upregulation of PTPN1, PTPN11, and RAPGEF4, genes implicated in cardiac remodeling and metabolic health, compared to younger females, while males exhibited no significant changes across the age range. Correlation analyses confirmed significant positive associations between PTPN1, PTPN11, and RAPGEF4 expression and age in females but not in males. These findings suggest that aging in females is associated with cardiac fibrosis, which is likely driven by the sex-specific upregulation of key genes within the thrombosis and hemostasis pathway.

Comprehensive Assessment of Biventricular and Biatrial Myocardial Strain Parameters at 4 Years Postpartum in a Cohort of Women with Previous Gestational Diabetes Mellitus

Background/Objectives: No previous study has provided a comprehensive evaluation of all biventricular and biatrial myocardial strain parameters in women with previous gestational diabetes mellitus (pGDM). Accordingly, we aimed at investigating the structural and myocardial deformation properties of all cardiac chambers in a cohort of pGDM women at 4 years postpartum. Methods: A consecutive cohort of pGDM women was compared to a control group of healthy women with previous uncomplicated pregnancy, matched by age, ethnicity and gestational week, at 4 years postpartum. Both groups of women underwent transthoracic echocardiography (TTE) implemented with speckle-tracking echocardiography (STE) and subsequent carotid ultrasonography. The primary endpoint was subclinical myocardial dysfunction, defined as left-ventricular (LV) global longitudinal strain (GLS) < 20%, whereas the secondary endpoint was early carotid atherosclerosis, defined as common carotid artery (CCA) intima-media thickness (IMT) ≥ 0.7 mm. Results: A total of 32 pGDM women (39.1 ± 6.5 yrs) and 30 matched healthy controls (40.8 ± 5.0 yrs) were analyzed. Despite normal and similar systolic function on conventional TTE, all biventricular and biatrial strain parameters were significantly lower in pGDM women than controls. Mean follow-up period was 4.0 ± 1.9 yrs. During follow-up, 62.5% of pGDM women developed subclinical myocardial dysfunction, and 78.1% of them were diagnosed with early carotid atherosclerosis. Third-trimester BMI (OR 1.88, 95% CI 1.19-2.98) and third-trimester glycosylated hemoglobin (HbA1C) (OR 2.34, 95% CI 1.08-5.04) were independently associated with the primary endpoint. Third-trimester BMI and HbA1C also independently predicted the secondary endpoint. Third-trimester BMI > 27 kg/m2 and HbA1C > 33 mmol/mol showed the best sensitivity and specificity for predicting both endpoints. Conclusions: Women with a previous history of GDM complicated by overweight/obesity and uncontrolled diabetes have a significantly increased risk of subclinical myocardial dysfunction and early carotid atherosclerosis at 4 years postpartum.

Echocardiographic Assessment of Cardiac Structure and Function of Centenarians: A Systematic Review

Background: During the last two decades, a limited number of studies have provided echocardiographic details regarding the cardiac structure and function of individuals aged ≥100 years. These studies analyzed limited sample sizes of centenarians using different methodologies. The present systematic review was primarily designed to summarize the main findings of these studies and to examine the overall influence of extremely advanced age on cardiac structure and function. Methods: All echocardiographic studies that evaluated the cardiac structure and function in individuals aged ≥100 years, selected from the PubMed, Embase, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) databases, were included. There was no limitation on the time period. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: A total of eight studies with 1340 centenarians [median age 101.4 years (IQR 101-103 years)] met the eligibility criteria and were analyzed. The centenarians were predominantly females [76.3% (IQR 60-85%)] with a small body surface area, long history of hypertension and slightly impaired renal functional reserve. The centenarian population showed a reduced burden of cardiovascular disease but an increased comorbidity burden, as assessed using the Charlson [median value 3.7 (IQR 1.8-5.5)] and Katz [median value 2.1 (IQR 1.1-3.1)] indexes. The echocardiographic findings comprised left ventricular (LV) concentric remodeling, with first-degree diastolic dysfunction [median E/A ratio 0.8 (IQR 0.7-0.9)], a moderate increase in LV filling pressure [median E/e' ratio 16.8 (IQR 16.2-17)], normal LV systolic function [median left ventricular ejection fraction (LVEF) 60.9% (IQR 55-84%)] and mild-to-moderate pulmonary hypertension [median systolic pulmonary artery pressure 42.1 mmHg (IQR 37-54 mmHg)]. The pooled prevalence of LV systolic dysfunction (LVEF < 50%) was 15.8%. Moderate-to-severe valvular heart diseases were detected in less than one-third of the centenarians. Compared with the outpatient and in-home cohorts, hospitalized centenarians were less commonly females and were more likely to be affected by significant LV hypertrophy with a supra-normal LVEF, higher degrees of valvulopathies and impaired pulmonary hemodynamics. Conclusions: The evidence currently suggests that centenarians have typical LV concentric remodeling with increased myocardial stiffness and diastolic dysfunction, which predispose them to heart failure with a preserved ejection fraction (HFpEF). Cardioprotective treatment should be considered for personalized implementation and uptitration in this special population.

Prevalence and Long-Term Prognostic Significance of Advanced Diastolic Dysfunction Among Hospitalized Patients Referred for Echocardiography

Background/Objectives: Left ventricular diastolic dysfunction (LVDD) is associated with unfavorable outcomes, and though it is recognized as an important clinical diagnosis, specific quantification and effective management continue to challenge clinicians, representing an unmet need in modern cardiology. Advanced LVDD diagnosis is likely to have a prognostic role among hospitalized patients. The aim of this study was to describe the prevalence and predictors of advanced LVDD among hospitalized patients and its long-term (5-year) prognostic significance on all-cause mortality. Methods: This was a retrospective observational study of consecutive, non-selected hospitalized patients referred for echocardiography at a tertiary care medical center from October 2013 to February 2024. Diastolic function was classified into normal/LVDD grade I vs. advanced LVDD (grades II and III). Results: A total of 5926 participants were included in the analysis, of whom 3229 (54%) were men, with a mean age of 66 ± 2 years. These included 4779 (81%) patients with normal/LVDD grade I and 1147 (19%) with advanced LVDD. Compared to patients with normal/LVDD grade I, those with advanced LVDD were older, were more likely to be men, and had a higher burden of hypertension, diabetes mellitus, congestive heart failure, atrial fibrillation/flutter and renal failure, abnormal laboratory findings, worse echocardiogram parameters, and longer hospital stay. Multivariate analysis revealed that advanced LVDD was independently associated with increasing age, the male sex, significant aortic stenosis, hypertension, and atrial fibrillation. Patients with advanced LVDD vs. normal/LVDD grade I had higher 5-year all-cause mortality rates (plog-rank < 0.001). Multivariate Cox proportional hazards regression model revealed that advanced LVDD was associated with a 24% increase in the 5-year mortality rate (HR = 1.236, 95% CI of 1.008-1.517, p = 0.042). Conclusions: Among hospitalized patients referred for echocardiography, the prevalence of advanced LVDD was 19%, and it was independently associated with age, the male sex and the presence of multiple comorbidities. Moreover, advanced LVDD was identified as an independent predictor of long-term all-cause mortality. Advanced LVDD should be proactively diagnosed among admitted patients at risk for early therapy tailoring.

Correlations Between Endothelial Function and Right Ventricular Performance in Primary Hypertension

Background

This study aims to elucidate the correlation between endothelial function and both cardiac structure and function in patients newly diagnosed with primary (essential) grade 1 hypertension.

Methods

We retrospectively reviewed clinical and echocardiographic data from 109 patients attending a cardiology outpatient clinic from January to December 2022. All subjects underwent comprehensive laboratory tests including lipid profile, glucose, electrolytes, and high-sensitivity C-reactive protein, alongside echocardiography to assess cardiac function. A subset of 34 patients underwent flow-mediated dilation (FMD) testing to evaluate endothelial function, and the results categorized them into normal (FMD ≥ 6%) and reduced (FMD < 6%) endothelial function groups.

Results

The study found no significant differences in baseline demographic or clinical parameters between groups. Age was negatively correlated with FMD values, indicating decreased endothelial function with advancing age. The normal endothelial function group demonstrated better diastolic and systolic parameters and lower right ventricular Tei indices compared to the reduced function group. Additionally, there was a significant negative correlation between the right ventricular Tei index and FMD values.

Conclusions

Endothelial function is associated with right ventricular performance in patients with primary (essential) grade 1 systemic hypertension. Improved endothelial function is associated with better overall cardiac performance. Further studies with age-matched controls are necessary to confirm these findings and determine the independent effects of hypertension on cardiac function.

Risk factors of male and female Alzheimer's disease patients with neuropsychiatric symptoms

BACKGROUND

This study investigates risk factors in the population of Alzheimer disease (AD) patients with NPS (ADNPS).

METHOD

Baseline risk factors associated with male and female ADNPS were examined using data from a regional AD care center. Univariate analysis was used to determine factors in male and female patients, while logistic regression models were developed to generate odds ratios (OR) to predict risk factors that are associated with male or female ADNPS.

RESULTS

In the adjusted analysis, dyslipidemia (OR = 0.630, 95 % CI, 0.431-0.992, P = 0.017), thyroid dysfunction (OR = 0.549, 95 % CI, 0.377-0.798, P = 0.002), and cerebral infarction (OR = 0.684, 95 % CI, 0.472-0.991, P = 0.0085) were associated with male ADNPS patients, whereas chronic heart failure (OR = 1.408, 95 % CI, 0.953-2.079, P = 0.0085) was associated with female ADNPS patients.

CONCLUSIONS

Our results reveal that female ADNPS patients were associated with heart failure, whereas male patients were associated with dyslipidemia and cerebral infarction.

Assessment of left ventricular function in subjects with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is the world's third leading cause of death, posing a significant public health challenge. Heart failure is an important milestone in the natural history of this disease's ever-decreasing course. Cor pulmonale alone is sometimes insufficient to explain the scenario, as many heart failures are refractory even after standard treatment. A possible explanation is the involvement of the left ventricle (LV). However, there is currently no consensus on a therapeutic approach to LV dysfunction in COPD. Some previous studies were conducted on COPD patients regardless of the presence or absence of other factors influencing LV function. This study attempted to rule out all known confounding factors/comorbidities that influence LV function. We discovered that LV diastolic dysfunction was common in subjects at all stages of COPD. We believe that all COPD patients, regardless of stage, should have screening echocardiography.

Identifying sex similarities and differences in structure and function of the sinoatrial node in the mouse heart

Background

The sinoatrial node (SN) generates the heart rate (HR). Its spontaneous activity is regulated by a complex interplay between the modulation by the autonomic nervous system (ANS) and intrinsic factors including ion channels in SN cells. However, the systemic and intrinsic regulatory mechanisms are still poorly understood. This study aimed to elucidate the sex-specific differences in heart morphology and SN function, particularly focusing on basal HR, expression and function of hyperpolarization-activated HCN4 and HCN1 channels and mRNA abundance of ion channels and mRNA abundance of ion channels contributing to diastolic depolarization (DD) and spontaneous action potentials (APs).

Methods

Body weight, heart weight and tibia length of 2- to 3-month-old male and female mice were measured. Conscious in-vivo HR of male and female mice was recorded via electrocardiography (ECG). Unconscious ex-vivo HR, stroke volume (SV) and ejection fraction (EF) were recorded via echocardiography. Ex-vivo HR was measured via Langendorff apparatus. Volume of atria, ventricles and whole hearts were measured from the ex-vivo hearts by microcomputed tomography (micro-CT). Immunohistochemistry targeting HCN4 and HCN1 was conducted in the SN and RA tissues from both male and female hearts. The funny current (I f) of SN cells in 1 nM and following wash-on of 1 μM isoproterenol (ISO) were recorded via whole cell patch clamp. The APs of SN tissue were recorded via sharp microelectrode and optical mapping of membrane voltage. The relative abundance of mRNAs was measured in male and female mice by qPCR.

Results

Heart weight to tibia length ratio and heart volume of females were significantly smaller than males. Unconscious in-vivo HR in male mice was higher than that in females. Conscious in-vivo HR, ex-vivo HR, SV, and EF showed no notable difference between male and female mice. Immunohistochemistry revealed HCN4, HCN1, and the sum of HCN4 and HCN1, expression in the SN was notably elevated compared with the RA in both male and females, but there was no sex difference in these channels expression. There were also no significant sex differences in the V 0.5 of I f in SN cells in the presence of 1 nM ISO, however wash-on 1 μM ISO in the same cells induced a significantly increased shift of V 0.5 to more positive voltages in males than in females. The expression of mRNA coding for adrenergic receptor beta-1 (Adrb1) and cholinergic receptors muscarinic 2 (chrm2) in male mice was higher compared with that in female mice. Early diastolic depolarization (EDD) rate in APs from peripheral SN (pSN) from male mice were higher than these in female mice. Mice of both sexes showed equivalent frequency of SN APs and spatial localization of the leading site in control, and similar significant response to ISO 100 nM superfusion.

Conclusion

Males display faster in-vivo HR, but not ex-vivo HR, than females associated with increased expression of Adrb1 in male versus female. This suggests a possible difference in the β-adrenergic modulation in males and females, possibly related to the greater ISO response of I f observed in cells from males. The role of hormonal influences or differential expression of other ion channels may explain these sex-specific variations in HR dynamics. Further investigations are necessary to pinpoint the precise molecular substrates responsible for these differences.

Risk factors for raised left ventricular filling pressure by cardiovascular magnetic resonance: Prognostic insights

BACKGROUND

Cardiovascular magnetic resonance (CMR) imaging shows promise in estimating pulmonary capillary wedge pressure (PCWP) non-invasively. At the population level, the prognostic role of CMR-modelled PCWP remains unknown. Furthermore, the relationship between CMR-modelled PCWP and established risk factors for cardiovascular disease has not been well characterized.

OBJECTIVE

The main aim of this study was to investigate the prognostic value of CMR-modelled PCWP at the population level.

METHODS

Employing data from the imaging substudy of the UK Biobank, a very large prospective population-based cohort study, CMR-modelled PCWP was calculated using a model incorporating left atrial volume, left ventricular mass and sex. Logistic regression explored the relationships between typical cardiovascular risk factors and raised CMR-modelled PCWP (≥15 mmHg). Cox regression was used to examine the impact of typical risk factors and CMR-modelled PCWP on heart failure (HF) and major adverse cardiovascular events (MACE).

RESULTS

Data from 39 163 participants were included in the study. Median age of all participants was 64 years (inter-quartile range: 58 to 70), and 47% were males. Clinical characteristics independently associated with raised CMR-modelled PCWP included hypertension [odds ratio (OR) 1.57, 95% confidence interval (CI) 1.44-1.70, P < 0.001], body mass index (BMI) [OR 1.57, 95% CI 1.52-1.62, per standard deviation (SD) increment, P < 0.001], male sex (OR 1.37, 95% CI 1.26-1.47, P < 0.001), age (OR 1.33, 95% CI 1.27-1.41, per decade increment, P < 0.001) and regular alcohol consumption (OR 1.10, 95% CI 1.02-1.19, P = 0.012). After adjusting for potential confounders, CMR-modelled PCWP was independently associated with incident HF [hazard ratio (HR) 2.91, 95% CI 2.07-4.07, P < 0.001] and MACE (HR 1.48, 95% CI 1.16-1.89, P = 0.002).

CONCLUSIONS

Raised CMR-modelled PCWP is an independent risk factor for incident HF and MACE. CMR-modelled PCWP should be incorporated into routine CMR reports to guide HF diagnosis and further management.

ALPK2 prevents cardiac diastolic dysfunction in heart failure with preserved ejection fraction

Protein phosphorylation, controlled by protein kinases, is central to regulating various pathophysiological processes, including cardiac systolic function. The dysregulation of protein kinase activity plays a significant role in the pathogenesis of cardiac systolic dysfunction. While cardiac contraction mechanisms are well documented, the mechanisms underlying cardiac diastole remain elusive. This gap persists owing to the historical focus on systolic dysfunction in heart failure research. Recently, heart failure with preserved ejection fraction (HFpEF), an age-related disease characterized by cardiac diastolic dysfunction, has emerged as a major public health concern. However, its underlying mechanism remains unclear. In this study, we investigated cardiac protein kinases by analyzing the gene expression of 518 protein kinases in human tissues. We identified alpha-kinase 2 (ALPK2) as a novel cardiac-specific atypical kinase and generated tamoxifen-inducible, cardiomyocyte-specific Alpk2-knockout mice and Alpk2-overexpressing mice. Alpk2 deficiency did not affect cardiac systolic dysfunction in the myocardial infarction model or the pressure-overload-induced heart failure model. Notably, cardiomyocyte-specific Alpk2 deficiency exacerbated cardiac diastolic dysfunction induced by aging and in the HFpEF model. Conversely, Alpk2 overexpression increased the phosphorylation of tropomyosin 1, a major regulator that binds myosin to actin, and mitigated cardiac stiffness in HFpEF. This study provides novel evidence that ALPK2 represents a potential therapeutic target for cardiac diastolic dysfunction in HFpEF and age-related cardiac impairments.

Sex-Specific Left Ventricular and Aorta Size Cut-Off Values for Hemodynamically Significant Chronic Aortic Regurgitation - Implications for Treatment in Asian Populations

BACKGROUND

There are no sex-specific guidelines for chronic aortic regurgitation (AR). This retrospective study examined sex-specific differences and propose treatment criteria from an Asian AR cohort.

METHODS AND RESULTS

Consecutive 1,305 patients with moderate-severe AR or greater at 3 tertiary centers in Taiwan and Japan (2008-2022) were identified. Study endpoints were aortic valve surgery (AVS), all-cause death (ACD), and cardiovascular death (CVD). The median follow up was 3.9 years (interquartile range 1.3-7.1 years). Compared with men (n=968), women (n=337) were older, had more advanced symptoms, more comorbidities, larger indexed aorta size (iAortamax) and indexed left ventricular (LV) end-systolic dimension (LVESDi; P<0.001 for all). Symptomatic status was poorly correlated with the degree of LV remodeling in women (P≥0.18). Women received fewer AVS (P≤0.001) and men had better overall 10-year survival (P<0.01). Ten-year post-AVS survival (P=0.9) and the progression of LV remodeling were similar between sexes (P≥0.16). Multivariable determinants of ACD and CVD were age, advanced symptoms, iAortamax, LV ejection fraction (LVEF), LVESDi, LV end-systolic volume index (LVESVi), and Taiwanese ethnicity (all P<0.05), but not female sex (P≥0.05). AVS was associated with better survival (P<0.01). Adjusted LVEF, LVESDi, LVESVi, and iAortamaxcut-off values for ACD were 53%, 24.8 mm/m2, 44 mL/m2, and 25.5 mm/m2, respectively, in women and 52%, 23.4 mm/m2, 52 mL/m2, and 23.2 mm/m2, respectively, in men.

CONCLUSIONS

Early detection and intervention using sex-specific cut-off values may improve survival in women with AR.

The Role of Vascular Aging in the Development of Hypertension

Vascular stiffness is an age-related pathophysiological process that represents a significant risk of cardiovascular morbidity and mortality in the older adult.

Arterial stiffness measured by pulse wave velocity correlated with cognitive decline in hypertensive individuals: a systematic review

BACKGROUND

Arterial stiffness is a degenerative modification in the arterial wall that significantly affects normal aging. Arterial hypertension is a major risk factor for cerebrovascular impairment. Pulse wave velocity (PWV) is an established gold standard for measuring arterial stiffness. Studies demonstrated that individuals with elevated blood pressure (BP) and PWV are more likely to experience worse cognitive decline compared to those with either condition alone. The aim of this review is to explore the clinical importance of arterial stiffness for cognitive function in older adults with hypertension.

METHODS

The systematic review was reported following the PRISMA 2020 guidelines and Cochrane protocol and was registered in NIHR PROSPERO. PubMed, Embase, Web of Science, CINAHL, and Cochrane databases were searched for relevant publications up to December 2022. Articles were filtered by age and type of study and only those including a sample size of at least 500 individuals were selected. Screening of abstracts and full-text review of selected articles were carried out through Covidence.

RESULTS

The full-text review included a total of 434 articles. Twenty-eight prospective studies have met the inclusion criteria. Selected studies used PWV as the main measurement of stiffness: 24 used carotid-femoral, 2 used brachial-ankle, 1 used aortic PWV, and 11 compared different measures. Studies demonstrated a strong association between increased BP and PWV with brain damage and cognitive deterioration among older adults. One study did not find an interaction with hypertension, while another study found that PWV but not BP was associated with cognitive decline. Few studies showed that the association between stiffness and cognitive outcomes was not significant after adjustment for BP. Several authors suggested that cognitive decline induced by stiff vasculature and hypertension benefited from antihypertensive therapy.

CONCLUSION

The results of this review demonstrated that arterial hypertension is an important factor linking arterial stiffness to cognitive health in older individuals. BP plays a crucial role in brain integrity, whereas PWV was shown to be a strong measure associated with cognitive decline. Together, they can lead to disabling cognitive outcomes. Early screening of stiffness, BP control, and compliance with treatment are essential for cerebrovascular disease prevention.

TRIAL REGISTRATION

NIHR PROSPERO registry ID: CRD42022379887 .

Sex-specific cardiovascular remodeling leads to a divergent sex-dependent development of heart failure in aged hypertensive rats

INTRODUCTION

The prevalence of heart failure with preserved ejection fraction (HFpEF) is continuously rising and predominantly affects older women often hypertensive and/or obese or diabetic. Indeed, there is evidence on sex differences in the development of HF. Hence, we studied cardiovascular performance dependent on sex and age as well as pathomechanisms on a cellular and molecular level.

METHODS

We studied 15-week- and 1-year-old female and male hypertensive transgenic rats carrying the mouse Ren-2 renin gene (TG) and compared them to wild-type (WT) controls at the same age. We tracked blood pressure and cardiac function via echocardiography. After sacrificing the 1-year survivors we studied vascular smooth muscle and endothelial function. Isolated single skinned cardiomyocytes were used to determine passive stiffness and Ca2+-dependent force. In addition, Western blots were applied to analyse the phosphorylation status of sarcomeric regulatory proteins, titin and of protein kinases AMPK, PKG, CaMKII as well as their expression. Protein kinase activity assays were used to measure activities of CaMKII, PKG and angiotensin-converting enzyme (ACE).

RESULTS

TG male rats showed significantly higher mortality at 1 year than females or WT male rats. Left ventricular (LV) ejection fraction was specifically reduced in male, but not in female TG rats, while LV diastolic dysfunction was evident in both TG sexes, but LV hypertrophy, increased LV ACE activity, and reduced AMPK activity as evident from AMPK hypophosphorylation were specific to male rats. Sex differences were also observed in vascular and cardiomyocyte function showing different response to acetylcholine and Ca2+-sensitivity of force production, respectively cardiomyocyte functional changes were associated with altered phosphorylation states of cardiac myosin binding protein C and cardiac troponin I phosphorylation in TG males only. Cardiomyocyte passive stiffness was increased in TG animals. On a molecular level titin phosphorylation pattern was altered, though alterations were sex-specific. Thus, also the reduction of PKG expression and activity was more pronounced in TG females. However, cardiomyocyte passive stiffness was restored by PKG and CaMKII treatments in both TG sexes.

CONCLUSION

Here we demonstrated divergent sex-specific cardiovascular adaptation to the over-activation of the renin-angiotensin system in the rat. Higher mortality of male TG rats in contrast to female TG rats was observed as well as reduced LV systolic function, whereas females mainly developed HFpEF. Though both sexes developed increased myocardial stiffness to which an impaired titin function contributes to a sex-specific molecular mechanism. The functional derangements of titin are due to a sex-specific divergent regulation of PKG and CaMKII systems.

Impact of sex on clinical and laboratory parameters in patients with heart failure: insights from the Colombian Heart Failure Registry (RECOLFACA)

INTRODUCTION

Heart failure (HF) is one of the leading causes of morbidity and mortality worldwide. This study aimed to assess the impact of sex on sociodemographic, clinical, and laboratory parameters in patients with HF who were included in the Colombian Heart Failure Registry (RECOLFACA).

METHODS

This was a cross-sectional analytical research. All 2528 patients included in RECOLFACA were analysed. The Mann-Whitney U test was used to compare median values as well as first and third quartiles (Q1-Q3). The age-related trend of NT-proBNP levels for both men and women groups was statistically evaluated.

RESULTS

The study included 2528 patients with HF (1072 women and 1456 men). The echocardiographic evidence showed that men presented reduced left ventricular ejection fraction (LVEF) (79.63 vs. 69.75%, respectively; p < 0.001) more often than women, which had a significantly higher proportion of preserved LVEF (20.46 vs.11.24%, respectively; p < 0.001). Women displayed a higher value of systolic blood pressure (p < 0.001) and heart rate (p = 0.014) compared to men. Haemoglobin, creatinine, and sodium levels were significantly higher in men. Men had a considerably lower glomerular filtration rate value, with the median reaching a G3a value for chronic renal failure. According to age, the levels of NT-proBNP in each sex increased equivalently with age.

CONCLUSION

Sex differences presented in this study are comparable to those discovered in other nations. However, certain variations show that these sex differences may differ by geographical area, which should encourage further investigations to describe them.

Cardiac Molecular Analysis Reveals Aging-Associated Metabolic Alterations Promoting Glycosaminoglycans Accumulation via Hexosamine Biosynthetic Pathway

Age is a prominent risk factor for cardiometabolic disease, often leading to heart structural and functional changes. However, precise molecular mechanisms underlying cardiac remodeling and dysfunction exclusively resulting from physiological aging remain elusive. Previous research demonstrated age-related functional alterations in baboons, analogous to humans. The goal of this study is to identify early cardiac molecular alterations preceding functional adaptations, shedding light on the regulation of age-associated changes. Unbiased transcriptomics of left ventricle samples are performed from female baboons aged 7.5-22.1 years (human equivalent ≈30-88 years). Weighted-gene correlation network and pathway enrichment analyses are performed, with histological validation. Modules of transcripts negatively correlated with age implicated declined metabolism-oxidative phosphorylation, tricarboxylic acid cycle, glycolysis, and fatty-acid β-oxidation. Transcripts positively correlated with age suggested a metabolic shift toward glucose-dependent anabolic pathways, including hexosamine biosynthetic pathway (HBP). This shift is associated with increased glycosaminoglycan synthesis, modification, precursor synthesis via HBP, and extracellular matrix accumulation, verified histologically. Upregulated extracellular matrix-induced signaling coincided with glycosaminoglycan accumulation, followed by cardiac hypertrophy-related pathways. Overall, these findings revealed a transcriptional shift in metabolism favoring glycosaminoglycan accumulation through HBP before cardiac hypertrophy. Unveiling this metabolic shift provides potential targets for age-related cardiac diseases, offering novel insights into early age-related mechanisms.

Long-term impact of air pollution on heart failure readmission in unstable angina patients

Cardiovascular disease remains the leading cause of death worldwide, with air pollution's impact on cardiovascular health being closely monitored. However, the specific effects of air pollution on the risk of hospital readmission for heart failure (HF) in patients with unstable angina (UA) have not been fully explored. We conducted a retrospective study involving 12,857 consecutive patients diagnosed with acute coronary syndrome (ACS) between January 2015 and March 2023. After rigorous screening, we included 8,737 patients with UA in the analysis. Furthermore, we used a Cox proportional hazards regression model to examine the relationship between air quality indicators and hospital readmission for HF in patients with UA. Additionally, a decision tree model identified air quality indicators levels that had the most significant impact on readmission for HF risk. After adjusting for confounding factors, we found that elevated levels of PM10 [hazard ratio (HR) = 1.003, 95% confidence interval (CI): 1.000-1.005, p = 0.04453] and CO (HR = 1.013, 95% CI: 1.005-1.021, p = 0.00216) were associated with an increased risk of hospital readmission for HF in UA patients. Specifically, patients exposed to PM10 levels above 112.5 µ g/m3 had a 1.61-fold higher risk of readmission for HF in UA patients. (HR = 1.609, 95% CI: 1.190-2.176, p = 0.00201), and those exposed to CO levels above 37.5 mg/m3 had a 2.70-fold higher risk of readmission for HF in UA patients. (HR = 2.681, 95% CI: 1.731-4.152, p < 0.00001). Higher concentrations of PM10 and CO significantly increased the risk of HF (HF) readmission in patients with UA after discharge, particularly when PM10 levels exceeded 112.5 ug/m3 and CO levels surpassed 37.5 ug/m3. Besides, female patients with UA, with fewer underlying diseases, were more susceptible to the adverse effects of PM10 and CO.

Effects of sacubitril-valsartan on aging-related cardiac dysfunction

Heart failure (HF) remains a huge medical burden worldwide, with aging representing a major risk factor. Here, we report the effects of sacubitril/valsartan, an approved drug for HF with reduced EF, in an experimental model of aging-related HF with preserved ejection fraction (HFpEF). Eighteen-month-old female Fisher 344 rats were treated for 12 weeks with sacubitril/valsartan (60 mg/kg/day) or with valsartan (30 mg/kg/day). Three-month-old rats were used as control. No differential action of sacubitril/valsartan versus valsartan alone, either positive or negative, was observed. The positive effects of both sacubitril/valsartan and valsartan on cardiac hypertrophy was evidenced by a significant reduction of wall thickness and myocyte cross-sectional area. Contrarily, myocardial fibrosis in aging heart was not reduced by any treatment. Doppler echocardiography and left ventricular catheterization evidenced diastolic dysfunction in untreated and treated old rats. In aging rats, both classical and non-classical renin-angiotensin-aldosterone system (RAAS) were modulated. In particular, with respect to untreated animals, both sacubitril/valsartan and valsartan showed a partial restoration of cardioprotective non-classical RAAS. In conclusion, this study evidenced the favorable effects, by both treatments, on age-related cardiac hypertrophy. The attenuation of cardiomyocyte size and hypertrophic response may be linked to a shift towards cardioprotective RAAS signaling. However, diastolic dysfunction and cardiac fibrosis persisted despite of treatment and were accompanied by myocardial inflammation, endothelial activation, and oxidative stress.

Computational investigation of the role of ventricular remodelling in HFpEF: The key to phenotype dissection

Recent clinical studies have reported that heart failure with preserved ejection fraction (HFpEF) can be divided into two phenotypes based on the range of ejection fraction (EF), namely HFpEF with higher EF and HFpEF with lower EF. These phenotypes exhibit distinct left ventricle (LV) remodelling patterns and dynamics. However, the influence of LV remodelling on various LV functional indices and the underlying mechanics for these two phenotypes are not well understood. To address these issues, this study employs a coupled finite element analysis (FEA) framework to analyse the impact of various ventricular remodelling patterns, specifically concentric remodelling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH), with and without LV wall thickening on LV functional indices. Further, the geometries with a moderate level of remodelling from each pattern are subjected to fibre stiffening and contractile impairment to examine their effect in replicating the different features of HFpEF. The results show that with severe CR, LV could exhibit the characteristics of HFpEF with higher EF, as observed in recent clinical studies. Controlled fibre stiffening can simultaneously increase the end-diastolic pressure (EDP) and reduce the peak longitudinal strain (ell) without significant reduction in EF, facilitating the moderate CR geometries to fit into this phenotype. Similarly, fibre stiffening can assist the CH and 'EH with wall thickening' cases to replicate HFpEF with lower EF. These findings suggest that potential treatment for these two phenotypes should target the bio-origins of their distinct ventricular remodelling patterns and the extent of myocardial stiffening.

Single-cell analysis of chromatin and expression reveals age- and sex-associated alterations in the human heart

Sex differences and age-related changes in the human heart at the tissue, cell, and molecular level have been well-documented and many may be relevant for cardiovascular disease. However, how molecular programs within individual cell types vary across individuals by age and sex remains poorly characterized. To better understand this variation, we performed single-nucleus combinatorial indexing (sci) ATAC- and RNA-Seq in human heart samples from nine donors. We identify hundreds of differentially expressed genes by age and sex and find epigenetic signatures of variation in ATAC-Seq data in this discovery cohort. We then scale up our single-cell RNA-Seq analysis by combining our data with five recently published single nucleus RNA-Seq datasets of healthy adult hearts. We find variation such as metabolic alterations by sex and immune changes by age in differential expression tests, as well as alterations in abundance of cardiomyocytes by sex and neurons with age. In addition, we compare our adult-derived ATAC-Seq profiles to analogous fetal cell types to identify putative developmental-stage-specific regulatory factors. Finally, we train predictive models of cell-type-specific RNA expression levels utilizing ATAC-Seq profiles to link distal regulatory sequences to promoters, quantifying the predictive value of a simple TF-to-expression regulatory grammar and identifying cell-type-specific TFs. Our analysis represents the largest single-cell analysis of cardiac variation by age and sex to date and provides a resource for further study of healthy cardiac variation and transcriptional regulation at single-cell resolution.

HFpEF and sex: understanding the role of sex differences

Heart failure is a complex clinical syndrome with many etiological factors and complex pathophysiology affecting millions worldwide. Males and females can have distinct clinical presentation and prognosis, and there is an emerging understanding of the factors that highlight the similarities and differences to synthesize and present available data for sex-specific differences in heart failure with preserved ejection fraction (HFpEF). While the majority of data demonstrate more similarities than differences between females and males in terms of heart failure, there are key differences. Data showed that females have a higher risk of developing HFpEF, but a lower risk of mortality and hospitalization. This can be conditioned by different profiles of comorbidities, postmenopausal changes in sex hormone levels, higher levels of inflammation and chronic microvascular dysfunction in females. These factors, combined with different left ventricular dimensions and function, which are more pronounced with age, lead to a higher prevalence of LV diastolic dysfunction at rest and exercise. As a result, females have lower exercise capacity and quality of life when compared to males. Females also have different activities of systems responsible for drug transformation, leading to different efficacy of drugs as well as higher risk of adverse drug reactions. These data prove the necessity for creating sex-specific risk stratification scales and treatment plans.

Guidelines for mechanistic modeling and analysis in cardiovascular research

Computational, or in silico, models are an effective, noninvasive tool for investigating cardiovascular function. These models can be used in the analysis of experimental and clinical data to identify possible mechanisms of (ab)normal cardiovascular physiology. Recent advances in computing power and data management have led to innovative and complex modeling frameworks that simulate cardiovascular function across multiple scales. While commonly used in multiple disciplines, there is a lack of concise guidelines for the implementation of computer models in cardiovascular research. In line with recent calls for more reproducible research, it is imperative that scientists adhere to credible practices when developing and applying computational models to their research. The goal of this manuscript is to provide a consensus document that identifies best practices for in silico computational modeling in cardiovascular research. These guidelines provide the necessary methods for mechanistic model development, model analysis, and formal model calibration using fundamentals from statistics. We outline rigorous practices for computational, mechanistic modeling in cardiovascular research and discuss its synergistic value to experimental and clinical data.

Exploring Sirtuins: New Frontiers in Managing Heart Failure with Preserved Ejection Fraction

With increasing research, the sirtuin (SIRT) protein family has become increasingly understood. Studies have demonstrated that SIRTs can aid in metabolism and affect various physiological processes, such as atherosclerosis, heart failure (HF), hypertension, type 2 diabetes, and other related disorders. Although the pathogenesis of HF with preserved ejection fraction (HFpEF) has not yet been clarified, SIRTs have a role in its development. Therefore, SIRTs may offer a fresh approach to the diagnosis, treatment, and prevention of HFpEF as a novel therapeutic intervention target.

The impact of female sex hormones on cardiovascular disease: from mechanisms to hormone therapy

Cardiovascular disease remains the leading cause of mortality in women, yet it has not raised the awareness from the public. The pathogenesis of cardiovascular disease differs significantly between females and males concerning the effect of sex hormones. Estrogen and progestogen impact cardiovascular system through genomic and non-genomic effects. Before menopause, cardiovascular protective effects of estrogens have been well described. Progestogens were often used in combination with estrogens in hormone therapy. Fluctuations in sex hormone levels, particularly estrogen deficiency, were considered the specific risk factor in women's cardiovascular disease. However, considerable heterogeneity in the impact of hormone therapy was observed in clinical trials. The heterogeneity is likely closely associated with factors such as the initial time, administration route, dosage, and formulation of hormone therapy. This review will delve into the pathogenesis and hormone therapy, summarizing the effect of female sex hormones on hypertension, pre-eclampsia, coronary heart disease, heart failure with preserved ejection fraction, and cardiovascular risk factors specific to women.

Lean body mass and the cardiorespiratory phenotype: An ethnic-specific relationship in Hans Chinese women and men

BACKGROUND

Lean body mass (LBM) and the functional capacity of cardiovascular (CV) and respiratory systems constitute a female-specific relationship in European-American individuals. Whether this recent finding be extrapolated to the world's largest ethnic group, that is, Hans Chinese (HC, a population characterized by low LBM), is unknown.

METHODS

Healthy HC adults (n = 144, 50% ♀) closely matched by sex, age and physical activity were included. Total and regional (leg, arm and trunk) LBM and body composition were measured via dual-energy X-ray absorptiometry. Cardiac structure, stiffness, central/peripheral haemodynamics and peak O2 consumption (VO2peak) were assessed via transthoracic echocardiography and pulmonary gas analyses at rest and during exercise up to peak effort. Regression analyses determined the sex-specific relationship of LBM with cardiac and aerobic phenotypes.

RESULTS

Total and regional LBM were lower and body fat percentage higher in women compared with men (P < 0.001). In both sexes, total LBM positively associated with left ventricular (LV) mass and peak volumes (r ≥ 0.33, P ≤ 0.005) and negatively with LV end-systolic and central arterial stiffness (r ≥ -0.34, P ≤ 0.004). Total LBM strongly associated with VO2peak (r ≥ 0.60, P < 0.001) and peak cardiac output (r ≥ 0.40, P < 0.001) in women and men. Among regional LBM, leg LBM prominently associated with the arterio-venous O2 difference at peak exercise in both sexes (r ≥ 0.43, P < 0.001). Adjustment by adiposity or CV risk factors did not modify the results.

CONCLUSIONS

LBM independently determines internal cardiac dimensions, ventricular mass, distensibility and the capacity to deliver and consume O2 in HC adults irrespective of sex.

One size does not fit all: Perioperative management of patients with heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is recognized as an important risk factor for perioperative complications. However, anesthesia management of HFpEF patients remains a considerable challenge without clear guidance. HFpEF is heterogeneous in its pathophysiological processes, diverse clinical presentations, adverse remodeling of cardiovascular and other organs, and clinical outcomes. It is difficult to manage the disease with one fixed approach because of this. This review phenotypes HFpEF patients by combining their clinical features and anesthesia care issues. Five phenotypes of HFpEF patients are identified: A, O, P, C, and Y. The clinical features, anesthesia implications, and anesthesia management for each phenotype are highlighted and discussed. Such an approach to HFpEF patients in the operating room could deliver safe, high-quality perioperative care.

Effects of short-term moderate intensity exercise on the serum metabolome in older adults: a pilot randomized controlled trial

BACKGROUND

We previously reported changes in the serum metabolome associated with impaired myocardial relaxation in an asymptomatic older community cohort. In this prospective parallel-group randomized control pilot trial, we subjected community adults without cardiovascular disease to exercise intervention and evaluated the effects on serum metabolomics.

METHODS

Between February 2019 to November 2019, thirty (83% females) middle-aged adults (53 ± 4 years) were randomized with sex stratification to either twelve weeks of moderate-intensity exercise training (Intervention) (n = 15) or Control (n = 15). The Intervention group underwent once-weekly aerobic and strength training sessions for 60 min each in a dedicated cardiac exercise laboratory for twelve weeks (ClinicalTrials.gov: NCT03617653). Serial measurements were taken pre- and post-intervention, including serum sampling for metabolomic analyses.

RESULTS

Twenty-nine adults completed the study (Intervention n = 14; Control n = 15). Long-chain acylcarnitine C20:2-OH/C18:2-DC was reduced in the Intervention group by a magnitude of 0.714 but increased in the Control group by a magnitude of 1.742 (mean difference -1.028 age-adjusted p = 0.004). Among Controls, alanine correlated with left ventricular mass index (r = 0.529, age-adjusted p = 0.018) while aspartate correlated with Lateral e' (r = -764, age-adjusted p = 0.016). C20:3 correlated with E/e' ratio fold-change in the Intervention group (r = -0.653, age-adjusted p = 0.004). Among Controls, C20:2/C18:2 (r = 0.795, age-adjusted p = 0.005) and C20:2-OH/C18:2-DC fold-change (r = 0.742, age-adjusted p = 0.030) correlated with change in E/A ratio.

CONCLUSIONS

Corresponding relationships between serum metabolites and cardiac function in response to exercise intervention provided pilot observations. Future investigations into cellular fuel oxidation or central carbon metabolism pathways that jointly impact the heart and related metabolic systems may be critical in preventive trials.

Determinants and effects of microvascular obstruction on serial change in left ventricular diastolic function after reperfused acute myocardial infarction

Background

Although left ventricular (LV) diastolic dysfunction is more related to functional capacity after acute myocardial infarction (AMI), the determinants of LV diastolic functional change after reperfused AMI remain unknown. This study aimed to investigate the effects of microvascular obstruction (MVO) on mid-term changes in LV diastolic function after reperfused AMI.

Methods

In a cohort of 72 AMI patients who underwent successful revascularization, echocardiography and cardiovascular magnetic resonance imaging were repeated at 9-month intervals. The late gadolinium enhancement (LGE) amount, segmental extracellular volume fraction, global LV, and left atrial (LA) phasic functions, along with mitral inflow and tissue Doppler measurements, were repeated.

Results

Among the included patients, 31 (43%) patients had MVO. During the 9-month interval, LV ejection fraction (EF) and LV global longitudinal strain (GLS) were significantly improved in accordance with a decrease in LGE amount (from 18.2 to 10.3 g, p < 0.001) and LV mass. The deceleration time (DT) of early mitral inflow (188.6 ms-226.3 ms, p < 0.001) and LV elastance index (Ed; 0.133 1/ml-0.127 1/ml, p = 0.049) were significantly improved, but not in conventional diastolic functional indexes. Their improvements occurred in both groups; however, the degree was less prominent in patients with MVO. The degree of decrease in LGE amount and increase in LVEF was significantly correlated with improvement in LV-Ed or LA phasic function, but not with conventional diastolic functional indexes.

Conclusions

In patients with reperfused AMI, DT of early mitral inflow, phasic LA function, and LV-Ed were more sensitive diastolic functional indexes. The degree of their improvement was less prominent in patients with MVO.

Age- and sex-specific physiological cardiac remodeling: the search for the Fountain of Youth

Graphical Abstract

Figure: Concepts of cardiac aging. Abbreviations: E/e’, transmitral early velocity to early diastolic mitral annular velocity; EF, ejection fraction; LV, left ventricular; LVEDD, left ventricular end-diastolic diameter; M/V left, ventricular mass to volume ratio.

Early menopause is associated with abnormal diastolic function and poor clinical outcomes in women with suspected angina

Early identification of women at high risk for cardiovascular diseases (CVD), with subsequent monitoring, will allow for improved clinical outcomes and generally better quality of life. This study aimed to identify the associations between early menopause, abnormal diastolic function, and clinical outcomes. This retrospective study included 795 menopausal women from is a nationwide, multicenter, registry of patients with suspected angina visiting outpatient clinic. The patients into two groups: early and normal menopause (menopausal age ≤ 45 and > 45 years, respectively). If participants met > 50% of the diastolic function criteria, they were classified as having normal diastolic function. Multivariable-adjusted Cox models were used to test associations between menopausal age and clinical outcomes including the incidence of major adverse cardiovascular events (MACE), over a median follow-up period of 771 days. Early menopause was associated with increased waist circumference (p = 0.001), diabetes prevalence (p = 0.003), obstructive coronary artery disease (p = 0.005), abnormal diastolic function (p = 0.003) and greater incidences of MACE, acute coronary syndrome, and hospitalization for heart failure. In patients with abnormal diastolic function, early menopause increased MACE risk significantly, with no significant difference in normal diastolic function. These findings highlight early menopause and abnormal diastolic function as being potential risk markers in women for midlife CVD events.

Cardiomyopathies in Women

Heart failure affects over 2.6 million people in the United States. While women have better overall survival rates, they also suffer from higher morbidity as shown by higher rates of hospitalization and worse quality of life. Several anatomical differences in women's hearts affect both systolic and diastolic cardiac physiology. Despite these findings, women are significantly underrepresented in clinical trials, necessitating extrapolation of data from males. Because women have sex-specific etiologies of heart failure and unique manifestations in genetic-related cardiomyopathies, meaningful sex-related differences affect heart failure outcomes as well as access to and outcomes in advanced heart failure therapies in women. This review explores these gender-specific differences and potential solutions to balance care between women and men.

Gender-specific genetic and epigenetic signatures in cardiovascular disease

Cardiac sex differences represent a pertinent focus in pursuit of the long-awaited goal of personalized medicine. Despite evident disparities in the onset and progression of cardiac pathology between sexes, historical oversight has led to the neglect of gender-specific considerations in the treatment of patients. This oversight is attributed to a predominant focus on male samples and a lack of sex-based segregation in patient studies. Recognizing these sex differences is not only relevant to the treatment of cisgender individuals; it also holds paramount importance in addressing the healthcare needs of transgender patients, a demographic that is increasingly prominent in contemporary society. In response to these challenges, various agencies, including the National Institutes of Health, have actively directed their efforts toward advancing our comprehension of this phenomenon. Epigenetics has proven to play a crucial role in understanding sex differences in both healthy and disease states within the heart. This review presents a comprehensive overview of the physiological distinctions between males and females during the development of various cardiac pathologies, specifically focusing on unraveling the genetic and epigenetic mechanisms at play. Current findings related to distinct sex-chromosome compositions, the emergence of gender-biased genetic variations, and variations in hormonal profiles between sexes are highlighted. Additionally, the roles of DNA methylation, histone marks, and chromatin structure in mediating pathological sex differences are explored. To inspire further investigation into this crucial subject, we have conducted global analyses of various epigenetic features, leveraging data previously generated by the ENCODE project.

Sex-specific structural and functional cardiac remodeling during healthy aging assessed by cardiovascular magnetic resonance

BACKGROUND

Aging as a major non-modifiable cardiac risk factor challenges future cardiovascular medicine and economic demands, which requires further assessments addressing physiological age-associated cardiac changes.

OBJECTIVES

Using cardiovascular magnetic resonance (CMR), this study aims to characterize sex-specific ventricular adaptations during healthy aging.

METHODS

The population included healthy volunteers who underwent CMR at 1.5 or 3 Tesla scanners applying cine-imaging with a short-axis coverage of the left (LV) and right (RV) ventricle. The cohort was divided by sex (female and male) and age (subgroups in years): 1 (19-29), 2 (30-39), 3 (40-49), and 4 (≥50). Cardiac adaptations were quantitatively assessed by CMR indices.

RESULTS

After the exclusion of missing or poor-quality CMR datasets or diagnosed disease, 140 of 203 volunteers were part of the final analysis. Women generally had smaller ventricular dimensions and LV mass, but higher biventricular systolic function. There was a significant age-associated decrease in ventricular dimensions as well as a significant increase in LV mass-to-volume ratio (LV-MVR, concentricity) in both sexes (LV-MVR in g/ml: age group 1 vs. 4: females 0.50 vs. 0.57, p=0.016, males 0.56 vs. 0.67, p=0.024). LV stroke volume index decreased significantly with age in both sexes, but stronger for men than for women (in ml/m2: age group 1 vs. 4: females 51.76 vs. 41.94, p<0.001, males 55.31 vs. 40.78, p<0.001). Ventricular proportions (RV-to-LV-volume ratio) were constant between the age groups in both sexes.

CONCLUSIONS

In both sexes, healthy aging was associated with an increase in concentricity and a decline in ventricular dimensions. Furthermore, relevant age-related sex differences in systolic LV performance were observed.

Considering impact of age and sex on cardiac cytoskeletal components

The cardiac cytoskeletal components are integral to cardiomyocyte function and are responsible for contraction, sustaining cell structure, and providing scaffolding to direct signaling. Cytoskeletal components have been implicated in cardiac pathology; however, less attention has been paid to age-related modifications of cardiac cytoskeletal components and how these contribute to dysfunction with increased age. Moreover, significant sex differences in cardiac aging have been identified, but we still lack a complete understanding to the mechanisms behind these differences. This review summarizes what is known about how key cardiomyocyte cytoskeletal components are modified because of age, as well as reported sex-specific differences. Thorough consideration of both age and sex as integral players in cytoskeletal function may reveal potential avenues for more personalized therapeutics.

Effect of age and gender on ventricular-arterial coupling estimated using a non-invasive technique

BACKGROUND

Left ventricular-arterial coupling is assessed as the ratio of left ventricular end-systolic elastance (Ees) to arterial elastance (Ea). Previous studies have introduced non-invasive estimations of Ees/Ea. It requires only four variables, namely pre-ejection period, ejection time, end-systolic pressure and diastolic pressure. The aims of the present study were to clarify the reference values of Ees/Ea estimated using the noninvasive technique, and to investigate the effects of age and gender on Ees/Ea in healthy subjects.

METHODS

This retrospective study utilized data from healthy, 30-79-year-old subjects. We recorded electrocardiogram, phonocardiogram, and brachial arterial pulse waves simultaneously using the vascular screening system, and used the observed variables to calculate Ees/Ea. We separated subjects into five groups according to their age and compared Ees/Ea among the different age groups.

RESULTS

The study included 2114 males and 2292 females. Ees/Ea ranged from 1.87 to 2.04 in males, and 1.98 to 2.32 in females. We observed no age-related differences in Ees/Ea in males (p = 0.10), and significant differences in females (p < 0.001). Ees/Ea in males was not different compared to those in females in 60-69-year-old group (p = 0.92). Whereas Ees/Ea was higher in females compared to those in males in the other age groups. The differences between medians of Ees/Ea in males and those in females were 0.45 (p < 0.001), 0.24 (p < 0.001), 0.13 (p = 0.01), and 0.13 (p = 0.03) in 30-39, 40-49, 50-59, and 70-79-year-old age groups, respectively.

CONCLUSIONS

We clarified the reference values of Ees/Ea in healthy subjects. The effect of age on Ees/Ea is different in males and females, although Ees/Ea is maintained within a relatively narrow range in all subjects.

Ratio of transmitral early filling velocity to diastolic strain rate and prognosis in type-1 diabetes

BACKGROUND

Impaired diastolic function is a hallmark of diabetic cardiomyopathy and a common feature in type 1 diabetes mellitus (T1DM). The ratio of transmitral early filling velocity to early diastolic strain rate (E/e'sr) has in recent studies proved to have strong prognostic value. This study aimed to investigate the prognostic value of E/e'sr compared to E/e' in T1DM without known heart disease.

METHODS

In this prospective cohort of T1DM patients, echocardiography was performed including two-dimensional speckle tracking. Follow-up was performed using nationwide registries. Outcomes were all-cause mortality and major cardiovascular events (MACE).

RESULTS

In total 1079 patients (age: 49.6 ± 14.5 years, 52.5% male, duration of diabetes 25.8 ± 14.6 years) were included in the study. During follow-up (median 6.3 years, IQR:5.7-6.9) 13.2% experienced MACE and 5.8% died. Following multivariable adjustment, both E/e'sr and E/e' was significantly associated with both MACE (E/e'sr: HR 1.16 CI95%:[1.05-1.29], p = 0.005, per 10 cm increase) vs. (E/e': HR 1.09 CI95%:[1.03-1.15], p = 0.001, per 1 unit increase) and all-cause mortality (E/e'sr: HR 1.20 [1.03-1.40], p = 0.016) vs. (E/e': HR: 1.11 [1.02-1.20], p = 0.016). Sex modified the association between E/e'sr and MACE (p for interaction = 0.008) such that E/e'sr after multivariable adjustment only remained significantly associated with MACE in females (HR: 1.41 [1.19-1.67], p < 0.001) but not in males (HR: 1.06 [0.93-1.20], p = 0.42). In females, E/e'sr provided incremental information beyond the Steno T1 Risk Engine (Harrell's C-statistic: 0.78 (0.72-0.83) vs. 0.81 (0.75-0.86), p = 0.007).

CONCLUSION

In patients with T1DM, both E/e'sr and E/e' provides independent prognostic information regarding prognosis. E/e'sr seems to have stronger prognostic value in females with T1DM.

Echocardiography Assessment of Left Ventricular Function in Extremely Preterm Infants, Born at Less Than 28 Weeks' Gestation, With Bronchopulmonary Dysplasia and Systemic Hypertension

BACKGROUND

The survival of smaller and more immature premature infants has been associated with lifelong cardiorespiratory comorbidities. Infants with bronchopulmonary dysplasia (BPD) undergo routine screening echocardiography to evaluate for development of chronic pulmonary hypertension, a late manifestation of pulmonary vascular disease.

METHODS

Our aim was to evaluate left ventricular (LV) performance in infants with BPD and pulmonary vascular disease who developed systemic hypertension. We hypothesized that infants with hypertension were more likely to have impaired LV performance. We present a single-center cross-sectional study of premature infants born at less than 28 0/7 weeks' gestational age with a clinical diagnosis of BPD. Infants were categorized by the systolic arterial pressure (SAP) at time of echocardiography as hypertensive (SAP ≥90 mm Hg) or normotensive (SAP <90 mm Hg). Sixty-four patients were included.

RESULTS

Infants with hypertension showed altered LV diastolic function with prolonged tissue Doppler imaging-derived isovolumic relaxation time (54.2 ± 5.1 vs 42.9 ± 8.2, P < .001), lower E:A, and higher E:e'. Indices of left heart volume/pressure loading (left atrium:aorta and LV end-diastolic volume [6.1 ± 2 vs 4.2 ± 1.2, P < .001]) were also higher in the hypertensive group. Finally, infants in the hypertensive group had higher pulmonary vascular resistance index (4.42 ± 1.1 vs 3.69 ± 0.8, P = .004).

CONCLUSIONS

We conclude that extremely preterm infants with BPD who develop systemic hypertension are at risk of abnormal LV diastolic dysfunction. Increased pulmonary vascular resistance index in the hypertensive group may relate to pulmonary venous hypertension secondary to LV dysfunction. This is an important consideration in this cohort when selecting the physiologically most appropriate treatment.

Iron Deficiency: A Silent Threat in Patients With Heart Failure With Reduced Ejection Fraction

Background Iron deficiency is a prevalent and clinically significant comorbidity in patients with heart failure with reduced ejection fraction (HFrEF). Despite its high prevalence, its impact on clinical outcomes, mortality, and various physiological parameters remains a subject of ongoing investigation. The findings of this study are anticipated to contribute valuable insights into the management and prognosis of patients with HFrEF, potentially informing future interventions and improving patient outcomes. This study aimed to assess the clinical profile of iron deficiency and its implications on morbidity and mortality in patients with HFrEF. Methodology A prospective cohort study was conducted at King Edward Memorial Hospital, India, involving 371 patients with HFrEF. Participants underwent comprehensive clinical and laboratory assessments, evaluating iron deficiency with signs, symptoms, comorbidities, dyspnea, elevated jugular venous pressure (JVP), past medical history, and various hematological and biochemical parameters. Results Overall, 50% of HFrEF participants were iron deficient (n = 185), of whom 80% (n = 148) had anemia against 43% (n = 81) anemics in iron repletes (n = 186). Of the 185 iron-deficient patients, 44 (11.86%) had absolute iron deficiency and 141 (38%) had functional iron deficiency. Iron deficiency significantly correlated with increased mortality in HFrEF patients (χ2 (1, N = 371) = 3.88, p = 0.048). A large positive correlation was observed between absolute iron deficiency and dyspnea severity (r2 = 0.949, p = 0.026). Statistically significant differences were found in hemoglobin (anemia), serum iron, serum ferritin, total iron-binding capacity, and transferrin saturation between iron-deficient and iron-replete patients (p < 0.05). However, no statistically significant difference in left ventricular ejection fraction between iron-deficient and replete patients was noted. Conclusions Iron deficiency emerges as more than a mere comorbidity in heart failure, becoming a prognostic factor with multifaceted outcomes. Its impact extends beyond cardiovascular consequences, encompassing adverse manifestations such as anemia, ascites, edema, dyspnea, elevated JVP, and a heightened risk of mortality. This intricate interplay positions iron deficiency as a critical determinant, significantly influencing the clinical trajectory and outcomes for patients with HFrEF.

The Influence of Anthropometrics on Cardiac Mechanics in Healthy Women With Opposite Obesity Phenotypes (Android vs Gynoid)

BACKGROUND

The possible influence exerted by mechanical factors and/or compressive phenomena on myocardial strain parameters in healthy individuals with opposite obesity phenotypes (android vs gynoid) has never been previously investigated. Accordingly, we aimed at evaluating the relationship between anthropometrics, such as the waist-to-hip ratio (WHR), modified Haller index (MHI, the ratio of chest transverse diameter over the distance between sternum and spine), and epicardial adipose tissue (EAT), and left ventricular (LV)-global longitudinal strain (GLS), in healthy women with opposite obesity phenotypes (android vs gynoid).

METHODS

Forty healthy women with obesity (body mass index (BMI) ≥30 Kg/m2) and WHR ≥0.85 ("android group") (52.5±13.2 yrs), 40 age- and BMI-matched healthy women with obesityand WHR <0.78 ("gynoid group") (49.8±13.4 yrs) and 40 age-matched healthy women without obesity (BMI <30 Kg/m2) (controls) (50.3±12.5 yrs) were retrospectively analyzed. All women underwent transthoracic echocardiography implemented with echocardiographic strain analysis of all cardiac chambers. Correlation between LV-GLS and anthropometrics (WHR, MHI, and EAT) was assessed in both groups of obese women. Age, WHR, homeostasis model assessment for insulin resistance (HOMA-IR), and left ventricular mass index (LVMi) were included in the logistic regression analysis performed for evaluating the independent predictors of reduced LV-GLS magnitude (less negative than -20%) in women with android obesity.

RESULTS

Compared to the other groups of women, those with android obesity were found with significantly greater LVMi, higher LV filling pressures, and lower biventricular and biatrial deformation indices. A strong inverse correlation between LV-GLS and all anthropometrics (WHR, MHI, and EAT) was demonstrated in both groups of women with obesity. Univariate logistic regression analysis revealed that WHR (OR 1.58, 95%CI 1.22-2.03, p<0.001) and LVMi (OR 1.09, 95%CI 1.02-1.16, p=0.006) were independently correlated with LV-GLS impairment in women with android obesity. On multivariate logistic regression analysis, the WHR maintained a statistically significant association with the above-mentioned outcome (OR 1.68, 95%CI 1.14-2.48, p=0.009). Receiver operating characteristic (ROC) curve analysis showed that a WHR value ≥1.01 had 93% sensitivity and 100% specificity for detecting LV-GLS impairment in women with android obesity (AUC=0.98; 95%CI 0.96-1.00).

CONCLUSIONS

Anthropometrics may strongly influence cardiac mechanics in healthy women with obesity. The WHR is associated with reduced LV-GLS magnitude in healthy women with android obesity, independent of age, glycometabolic status, and LV size.

Sex-specific differences in risk factors, comorbidities, diagnostic challenges, optimal management, and prognostic outcomes of heart failure with preserved ejection fraction: A comprehensive literature review

Due to hormonal variations, heart failure with preserved ejection fraction (HFpEF) remains prevalent in women and affects almost half of the heart failure (HF) patients. Given the yearly death rate of 10-30% and the unavailability of medications targeting HFpEF, the need arises for a better understanding of the fundamental mechanisms of this syndrome. This comprehensive review explores sex-specific differences in traditional risk factors; female-specific factors that may impact HFpEF development and response to therapy, including variations in hormone levels that may occur pre- and post-menopausal or during pregnancy; and disparities in comorbidities, clinical presentation, and diagnostic challenges. Lastly, the review addresses prognostic outcomes, noting that women with HFpEF have a poor quality of life but a higher survival rate. It also discusses novel biomarkers and precision medicine, emphasizing their potential to improve early detection and personalized treatment.

Effects of aging and endurance exercise training on cardiorespiratory fitness and cardiac structure and function in healthy midlife and older women

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in women in developed societies. Unfavorable structural and functional adaptations within the heart and central blood vessels with sedentary aging in women can act as the substrate for the development of debilitating CVD conditions such as heart failure with preserved ejection fraction (HFpEF). The large decline in cardiorespiratory fitness, as indicated by maximal or peak oxygen uptake (V̇o2max and V̇o2peak, respectively), that occurs in women as they age significantly affects their health and chronic disease status, as well as the risk of cardiovascular and all-cause mortality. Midlife and older women who have performed structured endurance exercise training for several years or decades of their adult lives exhibit a V̇o2max and cardiac and vascular structure and function that are on par or even superior to much younger sedentary women. Therefore, regular endurance exercise training appears to be an effective preventative strategy for mitigating the adverse physiological cardiovascular adaptations associated with sedentary aging in women. Herein, we narratively describe the aging and short- and long-term endurance exercise training adaptations in V̇o2max, cardiac structure, and left ventricular systolic and diastolic function at rest and exercise in midlife and older women. The role of circulating estrogens on cardiac structure and function is described for consideration in the timing of exercise interventions to maximize beneficial adaptations. Current research gaps and potential areas for future investigation to advance our understanding in this critical knowledge area are highlighted.