Gender/Sex as a Social Determinant of Cardiovascular Risk

X-Chromosome-Linked miRNAs Regulate Sex Differences in Cardiac Physiology

BACKGROUND

Males and females exhibit distinct anatomic and functional characteristics of the heart, predisposing them to specific disease states.

METHODS

We identified microRNAs (miRNAs/miR) with sex-differential expression in mouse hearts.

RESULTS

Four conserved miRNAs are present in a single locus on the X-chromosome and are expressed at higher levels in females than males. We show miRNA, miR-871, is responsible for decreased expression of the protein SRL (sarcalumenin) in females. SRL is involved in calcium signaling, and we show it contributes to differences in electrophysiology between males and females. miR-871 overexpression mimics the effects of the cardiac physiology of conditional cardiomyocyte-specific Srl-null mice. Inhibiting miR-871 with an antagomir in females shortened ventricular repolarization. The human orthologue of miR-871, miR-888, coevolved with the SRL 3' untranslated region and regulates human SRL.

CONCLUSIONS

These data highlight the importance of sex-differential miRNA mechanisms in mediating sex-specific functions and their potential relevance to human cardiac diseases.

Global trends in the burden of ischemic heart disease based on the global burden of disease study 2021: the role of metabolic risk factors

BACKGROUND

Ischemic heart disease (IHD) remains a leading cause of mortality and morbidity globally. This study aims to evaluate the trends in IHD burden across different socioeconomic regions using data from the Global Burden of Disease Study 2021 (GBD 2021) and to understand the impact of the metabolic risk factors on these trends.

METHODS

Data from GBD 2021 was analyzed to evaluate the global age-standardized death rates (ASDR) and disability-adjusted life years (ASRDALYs) linked to IHD. Key metabolic risk factors evaluated included high systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDLc), fasting plasma glucose (FPG), and body mass index (BMI). Temporal trends were assessed using estimated annual percentage changes (EAPCs), with further analysis by age, sex and socio-demographic index (SDI).

RESULTS

Resource-abundant regions showed notable reductions in ASDR and ASRDALYs, largely due to effective management of SBP and LDLc, resulting in an EAPC of -3.43 (95% CI: -3.32, -3.53). In contrast, resource-limited regions, particularly among males, experienced stagnation or even increases in IHD burden. The EAPC of ASDR in low-, low-middle-, and middle-SDI regions ranged from - 0.12 (95% CI: -0.04, -0.19) to 0.16 (95% CI: 0.09, 0.23). Among males, the values ranged from 0.22 (95% CI: 0.14, 0.29) to 0.55 (95% CI: 0.47, 0.62). The increase in IHD burden in these regions was primarily driven by rising levels of FPG and BMI. Younger populations (15-49 years) were disproportionately affected, showing increasing exposure to these metabolic risks.

CONCLUSION

Regional disparities in IHD burden persist, primarily driven by metabolic risk factors. Resource-abundant regions have benefitted from effective control of SBP and LDLc, whereas resource-limited regions face growing challenges, especially related to FPG and BMI. The use of secondary data from the GBD 2021 database provides a comprehensive global perspective but may not fully capture local variations in disease burden. Targeted public health strategies and early interventions are essential to reduce the growing IHD burden in these vulnerable populations.

Influence of Sex and Gender on Adherence to Self-care Behaviors for Cardiovascular Disease Risk Management in the Global Context: A Systematic Review

BACKGROUND

Adherence to self-care behaviors can prevent or delay adverse outcomes associated with cardiovascular disease (CVD). Sex and socioculturally constructed gender might impact individuals' ability to adhere to healthy lifestyles.

OBJECTIVE

The aim of this study was to systematically identify, evaluate, and synthesize the literature on the influence of sex and gender on adherence to self-care behaviors for CVD risk management in the global context.

METHODS

We searched the MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, and Global Health Databases for peer-reviewed original articles published between 2013 and 2023. We selected studies that investigated self-care behaviors, self-care maintenance, or self-care management as outcomes and reported sex- and gender-related factors (such as education level, employment status, and marital status). The data were synthesized in a narrative form.

RESULTS

The search identified 3540 studies, 52 of which met the inclusion criteria for full-text review. Global North countries accounted for 55% of all the studies. Self-reported questionnaire scores were used in most of the studies (n = 47). Better self-care was associated with being a woman (n = 17), attaining a higher education level (n = 15), and having higher perceived social support (n = 10). The associations between adherence to self-care behaviors and employment status, socioeconomic status, marital status, and household size were inconsistent.

CONCLUSIONS

Adherence to self-care behaviors for CVD risk management varied widely, based on gender-related factors. Further research is needed to use a consistent measure of self-care adherence behavior and integrate a wider range of gender-related factors.

Physical activity, sedentary behaviour, and cardiovascular disease risk factors in Canadians living with and without cardiovascular disease

BACKGROUND

To describe and compare the proportion of adult Canadians living with and without cardiovascular disease (CVD) meeting the physical activity (PA) and sedentary behaviour (SB) recommendations from the Canadian 24-Hour Movement Guidelines using accelerometer and self-reported measures.

METHODS

Using adult (aged 18-79 years) accelerometer data (Actical worn during waking hours for 7 consecutive days) as well as chronic condition, socio-demographic, recreational screen time, and PA questions from three combined cycles of the Canadian Health Measures Survey, the PA, SB, and CVD risk factors of adults living with and without CVD were compared.

RESULTS

A total of 7,035 Canadian adults who reported living with (n=363) and without (n=6,672) CVD were included. Few adults living with CVD were meeting the PA (29%) and SB (15%) recommendations. CVD status was not significantly associated with the likelihood of meeting the PA or screen time recommendations, but adults living with CVD had a lower likelihood of meeting the sedentary time recommendation when compared to adults without CVD (aOR=0.49, 95% CI: 0.30 - 0.82). Adults, primarily males, living with rather than without CVD engaged in less light and moderate intensity PA.

CONCLUSION

The PA and SB of Canadian adults living with and without CVD are significantly different. Adults living with CVD had a lower likelihood of meeting the sedentary time recommendation, and adults living with CVD, primarily males, engaged in less light and moderate intensity PA. The identification of these movement behaviour targets may assist in allocating resources to sedentary individuals with the greatest need of PA.

Development and rollout of a national plan on cardiovascular health. Spain's cardiovascular health strategy (ESCAV)

INTRODUCTION AND OBJECTIVES

Cardiovascular disease (CVD) remains the leading cause of death in most countries; however, few specific political actions have been implemented to improve cardiovascular health at both national and international levels. We aimed to describe the methodology used for the development and initial rollout of Spain's Cardiovascular Health Strategy of the National Health System (ESCAV, Estrategia en Salud Cardiovascular del Sistema Nacional de Salud).

METHODS

A multidisciplinary team comprising diverse stakeholders developed a national strategy to reduce the burden of CVD in Spain. The team used qualitative methodologies to identify and select priorities and design strategic map models.

RESULTS

The strategy was structured around a matrix with 6 cross-cutting themes (citizen empowerment; health promotion, prevention, and early CVD detection; comprehensive management of acute and chronic CVD; health care coordination; equity; and knowledge management) and 4 longitudinal lines (ischemic heart disease, heart failure, arrhythmias, and valve disease). The framework was further supported by 3 overarching axes: continuity of care, patient safety, and leveraging of information systems. A total of 27 critical points were selected, leading to the definition of 99 strategic objectives (32 general and 67 specific) and 136 actions through iterative reviews and prioritization. Strategic maps were developed for the overall strategy and for each action line, incorporating 61 indicators to facilitate and monitor the development of the strategy.

CONCLUSIONS

ESCAV represents one of the most ambitious initiatives aimed at transforming a nation's cardiovascular health. The methods and steps undertaken in this process could serve as a valuable reference for other countries seeking to establish similar initiatives. Furthermore, it may act as a catalyst to advance efforts toward establishing a European plan for cardiovascular health.

Chronotype and lifestyle in the transition to adulthood: Exploring the role of sleep health and circadian misalignment

OBJECTIVES

The present study aimed at exploring the association between eveningness and lifestyle-related variables, that is, body mass index, alcohol, and cigarette consumption, in adults (18-40years), focusing on the possible moderator effect of age and the role of sleep disturbances and circadian misalignment (social jetlag).

METHODS

A web-based survey was administered to 437 participants, covering demographics, lifestyle-related variables, chronotype, sleep quality, and daytime sleepiness. A subset of 206 participants wore a wrist actigraph for a week, allowing the creation of a sleep health index within the RU-SATED framework. Regression analysis was used to investigate the associations between chronotype and lifestyle-related outcomes, accounting for social jetlag and sleep health; and to explore the lifestyle trajectories over time.

RESULTS

Evening chronotypes showed higher body mass index levels, consumed more alcohol, and smoked more cigarettes than other circadian typologies, in particular after 25 years of age. Poor sleep health and social jetlag significantly contribute to explaining evening types smoking behavior, while not affecting body mass index levels. Social jetlag plays a more important role compared to sleep disturbances and eveningness in predicting more detrimental drinking and smoking behavior.

CONCLUSIONS

Participants who maintain the evening trait past the age of 25years are more prone to adopt an unhealthy lifestyle, especially if experiencing poor sleep health and circadian misalignment. Circadian preferences and sleep health should be considered when planning interventions aimed at promoting healthy lifestyles in adults aged 18-40years. Further investigations should explore the effect of modifications in lifestyle in the prevention of noncommunicable diseases.

Sex-Specific Association Between Genetic Risk of Psychiatric Disorders and Cardiovascular Diseases

BACKGROUND

Though epidemiological studies show increased cardiovascular disease (CVD) risks among individuals with psychiatric disorders, findings on sex differences in comorbidity have been inconsistent.

METHODS

This genetic epidemiology study examined the sex-specific association between the genetic risk of 3 psychiatric disorders (major depression [MD], schizophrenia, and bipolar disorder), estimated using polygenic scores (PGSs), and risks of 3 CVDs (atrial fibrillation [AF], coronary artery disease [CAD], and heart failure [HF]) in 345 169 European-ancestry individuals (UK Biobank), with analyses replicated in an independent BioVU cohort (n=49 057). Mediation analysis was conducted to determine whether traditional CVD risk factors could explain any observed sex difference.

RESULTS

In the UK Biobank, a 1-SD increase in PGSMD was significantly associated with the incident risks of all 3 CVDs in females after multiple testing corrections (hazard ratio [HR]AF-female=1.04 [95% CI, 1.02-1.06]; P=1.5×10-4; HRCAD-female=1.07 [95% CI, 1.04-1.11]; P=2.6×10-6; and HRHF-female=1.09 [95% CI, 1.06-1.13]; P=9.7×10-10), but not in males. These female-specific associations remained even in the absence of any psychiatric disorder diagnosis or psychiatric medication use. Although mediation analysis demonstrated that the association between PGSMD and CVDs in females was partly mediated by baseline body mass index, hypercholesterolemia, hypertension, and smoking, these risk factors did not explain the higher risk compared with males. The association between PGSMD and CAD was consistent between females who were premenopausal and postmenopausal at baseline, while the association with AF and HF was only observed in the baseline postmenopausal cohort. No significant association with CVD risks was observed for the PGS of schizophrenia or bipolar disorder. The female-specific positive association of PGSMD with CAD risk was replicated in BioVU.

CONCLUSIONS

Genetic predisposition to MD confers a greater risk of CVDs in females versus males, even in the absence of any depression diagnosis. This study warrants further investigation into whether genetic predisposition to depression could be useful for improving cardiovascular risk prediction, especially in women.

Gender-specific aspects of socialisation and risk of cardiovascular disease among community-dwelling older adults: a prospective cohort study using machine learning algorithms and a conventional method

BACKGROUND

Gender influences cardiovascular disease (CVD) through norms, social relations, roles and behaviours. This study identified gender-specific aspects of socialisation associated with CVD.

METHODS

A longitudinal study was conducted, involving 9936 (5,231 women and 4705 men) initially healthy, community-dwelling Australians aged 70 years or more from the ASPirin in Reducing Events in the Elderly (ASPREE) study and ASPREE Longitudinal Study of Older Persons, with a median follow-up time of 6.4 years. Variable categorisation, variable selection (using machine learning (ML) models; Elastic Net and extreme gradient boosting) and Cox-regression were employed separately by binary gender to identity socialisation factors (n=25 considered) associated with CVD.

RESULTS

Different socialisation factors were identified using the ML models. In the Cox model, for both genders, being married/partnered was associated with a reduced risk of CVD (men: HR 0.76, 95% CI 0.60 to 0.96; women: HR 0.67, 95% CI 0.58 to 0.95). For men, having 3-8 relatives they felt close to and could call on for help (HR 0.76, 95% CI 0.58 to 0.99; reference <3 relatives), having 3-8 relatives they felt at ease talking with about private matters (HR 0.70, 95% CI 0.55 to 0.90; reference <3 relatives) or playing games such as chess or cards (HR 0.82, 95% CI 0.67 to 1.00) was associated with reduced risk of CVD. For women, living with others (HR 0.71, 95% CI 0.55 to 0.91) or having ≥3 friends they felt at ease talking with about private matters (HR 0.74, 95% CI 0.58 to 0.95; reference <3 friends) was associated with a lower risk of CVD.

CONCLUSIONS

This study demonstrates the need to prioritise gender-specific social factors to improve cardiovascular health in older adults.

Association between vitamin D and cardiovascular health in Chinese children and adolescents: Basing on Life's Essential 8

BACKGROUND AND AIMS

The relationship between vitamin D and cardiovascular health (CVH) in children remains unclear. We aimed to explore the association between vitamin D and CVH metrics using the latest Life's Essential 8 (LE8) among Chinese children and adolescents.

METHODS AND RESULTS

A cross-sectional study containing 2680 participants aged 7-18 years (1340 boys and 1340 girls) was performed in South China in 2013. Vitamin D levels were categorized as follows: ≥20 ng/mL (sufficiency), 12 - < 20 ng/mL (inadequacy), and <12 ng/mL (deficiency). The CVH metrics of LE8 was assessed by overall CVH score, health behavior score, health factor score and high CVH, among which the health behaviors included diet, physical activity, nicotine exposure, and sleep health, as well as the health factors contained body mass index, blood lipids, blood glucose, and blood pressure. Different regression models were used to assess the associations between vitamin D levels and CVH metrics of LE8. Results showed that the prevalence of vitamin D deficiency and inadequacy was 7.5% and 44.4%, respectively. Boys had lower levels in overall CVH score, health behavior score, and health factor score than girls. After adjusting for potential confounds, upward trends in diet score, health behavior score, and high CVH were observed with increasing vitamin D levels.

CONCLUSION

Vitamin D levels were positively associated with high CVH based on LE8, and more attention should be paid on boys due to whose lower levels in CVH metrics.

[Cardiovascular preventive recommendations. PAPPS 2024 thematic updates]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of vascular diseases (VD) are presented. New in this edition are new sections such as obesity, chronic kidney disease and metabolic hepatic steatosis, as well as a 'Don't Do' section in the different pathologies treated. The sections have been updated: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; vascular risk (VR) and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.

Animal models of chronic obstructive pulmonary disease: a systematic review

Objective

Experimental animal models have been used for decades to study the development and progression of chronic obstructive pulmonary disease (COPD). However, there is a lack of methods for constructing animal models of COPD for optimal modelling. This systematic literature review (SLR) aimed to assess the various methods used to establish COPD animal models, highlight their advantages and limitations, and explore more optimized approaches for establishing such models.

Methods

A systematic search was performed in four English databases (PubMed, Embase, Web of Science, and the Cochrane Library) and four Chinese databases (Chinese Biomedical Literature Database, China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang Database). Of the 8,015 retrieved full-text manuscripts, 453 were selected.

Results

Smoking (n = 140), smoking combined with lipopolysaccharide (LPS) (n = 275), smoking combined with protease drip (PPE) (n = 10), smoking combined with bacteria (n = 23), and smoking combined with particulate matter (PM2.5) (n = 5) were the most used methods for establishing animal models of COPD. Rats and mice were the most frequently selected experimental animals, with male animals accounting for 79.47% of the total. A total of 92.49 and 29.14% of the articles reviewed considered lung pathology of experimental animals only and lung pathology and lung function tests, respectively.

Conclusion

Our review suggests that the best way to establish an animal model of COPD is to combine smoking with LPS. Although findings from animal models of COPD cannot be directly extrapolated to human COPD, they could provide useful tools for further investigation into human COPD disease.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023407555, Identifier PROSPERO CRD42023407555.

Sex and 30-day survival following out-of-hospital cardiac arrest in Scotland 2011-2020

BACKGROUND

Differences in 30-day survival between males and females following out-of-hospital cardiac arrest (OHCA) are well documented. Biological sex does not appear to be responsible for this survival gap independently of potential mediating factors. We investigated the role of potential mediating factors in the association between sex and 30-day survival after OHCA in Scotland.

METHODS

A retrospective cohort study of adult non-emergency medical services (EMS)-witnessed OHCA cases was conducted. We included incidents from the whole of Scotland where resuscitation was attempted by the Scottish Ambulance Service (SAS) between April 1, 2011 and March 1, 2020. Logistic regression was used to assess the contribution of age, socioeconomic status, urban-rural location of the incident, initial cardiac rhythm, bystander cardiopulmonary resuscitation (CPR) and location of the arrest (home or away from home).

RESULTS

The cohort consisted of 20,585 OHCA cases (13,130 males and 7,455 females). Median (IQR) age was 69 years (22) for males versus 72 years (23) for females. A higher proportion of males presented with initial shockable rhythm (29.4% versus 12.4%) and received bystander CPR (56.7% versus 53.2%) compared with females. A higher proportion of females experienced OHCA at home (78.8% versus 66.8%). Thirty-day survival after OHCA was higher for males compared with females (8.2% versus 6.2%). Males had higher age-adjusted odds for 30-day survival after OHCA than females (OR, 1.26; (95% CI), 1.12-1.41). Mediation analyses suggested a role for initial cardiac rhythm and location of the arrest (home or away from home).

CONCLUSION

Males had higher age-adjusted 30-day survival after OHCA than females. However, after adjusting for confounding/mediating variables, sex was not associated with 30-day survival after OHCA. Our findings suggest that initial cardiac rhythm and location of the arrest are potential mediators of higher 30-day OHCA survival in males than females. Improving proportions of females who present with initial shockable rhythm may reduce sex differences in survival after OHCA.

Adolescent obesity and short sleep duration as independent risk factors for hypertension: a population-based cohort study

Prevalence of hypertension in adolescents has increased worldwide and is considered a risk factor for hypertension and cardiovascular disease in adulthood. Although obesity and sleep deficiency increase this risk, the combined effects of these factors on hypertension remain unclear. This study aimed to examine the combined effects of obesity and sleep duration on hypertension in adolescents. This study was conducted using data from the 2016 to 2018 Korean National Health and Nutrition Examination Survey, which included a study population of 1272 adolescents. The participants were categorized into four groups based on sleep duration and body mass index (BMI) percentiles: normal sleep and normal body mass group (reference; normal), only short sleep group (short sleep), only overweight/obesity group (overweight/obesity), and short sleep and overweight/obesity group (short sleep and overweight/obesity). Short sleep duration was defined as <8 h of average sleep duration, and overweight/obesity was defined as a BMI ≥ 85th percentile. Hypertension in adolescents was defined as a systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg. The prevalence of hypertension was 9.2% among Korean adolescents. Short sleep duration with overweight/obesity were associated with a significantly increased risk of hypertension (odds ratio = 6.57; 95% confidence interval: 3.27-13.20) in adolescents, and controlling for the potential confounding variables only partially attenuated this relationship (odds ratio = 5.28; 95% confidence interval: 2.28-12.26). This study demonstrated that the coexistence of short sleep duration and obesity was associated with an increased risk of hypertension in Korean adolescents.

Disparities in mortality rates from aortic aneurysm and dissection by country-level income status and sex

Objective

To investigate the impact of national income level and sex on mortality trends from aortic aneurysm and dissection in addition to all aortic disease as a whole.

Methods

Using data from the World Health Organization mortality database, we conducted an analysis of mortality trends from aortic disease between 2000 and 2019, Countries were categorized into middle-income and high-income countries (MICs and HICs) on the basis of income level. Age-standardized and sex-specific age-standardized mortality rates per 100,000 persons, along with male-to-female mortality ratios, were calculated. Trends over the study period were analyzed using joinpoint regression.

Results

Our analysis comprised 29 MICs and 46 HICs, with an average population of 595 million and 1042 million during the observation period. During the observation period, age-standardized mortality rates from aortic disease decreased to 2.21 (2.17-2.25) and 2.28 (2.26-2.30) in MICs and HICs, respectively (average annual percentage change of -0.5% in MICs and -1.8% in HICs, P < .05 for both). However, mortality rates from aortic dissection increased in HICs from 2000 to 2019 (average annual percentage change of 1.3%, P < .001). Mortality from aortic disease, aortic dissection, and aortic aneurysm were male dominant in MICs and HICs but decreasing trends during the observation periods except for aortic dissection in MICs.

Conclusions

We present the contemporary and comprehensive analysis of global socioeconomic status and aortic diseases mortality. Although trends of mortality from aortic diseases are on the decline in both MICs and HICs, there is a striking increase in mortality for aortic dissection, specifically in HICs.

Male Gender Expressivity and Diagnosis and Treatment of Cardiovascular Disease Risks in Men

Importance

Male gender expressivity (MGE), which reflects prevalent sociocultural pressures to convey masculinity, has been associated with health. Yet, little is known about associations of MGE with the diagnosis and treatment of modifiable cardiovascular disease (CVD) risks.

Objective

To investigate associations of MGE with modifiable CVD risk diagnoses and treatment in men.

Design, Setting, and Participants

This population-based cohort study included data from waves I (1994-1995), IV (2008-2009), and V (2016-2018) of the US National Longitudinal Study of Adolescent to Adult Health (Add Health). Participants were male adolescents (age 12-18 years) followed up longitudinally through younger adulthood (age 24-32 years) and adulthood (age 32-42 years). Data were analyzed from January 5, 2023, to August 28, 2024.

Exposure

Male gender expressivity was quantified in adolescence and younger adulthood using an empirically-derived and validated measurement technique that incorporates participants' responses to existing Add Health survey items to capture how similarly participants behave to same-gendered peers.

Main Outcomes and Measures

Outcomes included self-reported diagnoses of CVD risk conditions (hypertension, diabetes, or hyperlipidemia) in adult men with elevated blood pressure, hemoglobin A1c, or non-high-density lipoprotein cholesterol levels, and self-reported treatment with antihypertensive, hypoglycemic, or lipid-lowering medications in adults reporting hypertension, diabetes, or hyperlipidemia. Multivariable regression was used to examine associations of adolescent and younger adult MGE with adult CVD risk diagnoses and treatment, adjusting for sociodemographic covariates.

Results

Among 4230 eligible male participants, most were non-Hispanic White (2711 [64%]) and privately insured (3338 [80%]). Their mean (SD) age was 16.14 (1.81) years in adolescence, 29.02 (1.84) years in younger adulthood, and 38.10 (1.95) years in adulthood. Compared with participants whose younger adult MGE was below average, those with higher younger adult MGE were overall less likely to report hypertension (22% vs 26%; P < .001), diabetes (5% vs 8%; P < .001), and hyperlipidemia (19% vs 24%; P < .001) diagnoses and diabetes treatment (3% vs 5%; P = .02) as adults. In multivariable models, every SD increase in adolescent MGE was associated with lower probabilities of adult hypertension treatment (MGE,-0.11; 95% CI, -0.16 to -0.6) and diabetes diagnoses (MGE, -0.15; 95% CI, -0.27 to -0.03). Higher younger adult MGE was associated with lower probabilities of adult hypertension diagnoses (MGE, -0.04; 95% CI, -0.07 to -0.01), hypertension treatment (MGE, -0.07; 95% CI, -0.13 to -0.01), and diabetes treatment (MGE, -0.10; 95% CI, -0.20 to -0.01). Adolescent and younger adult MGE outcomes were not associated with other adult CVD outcomes.

Conclusions and Relevance

In this cohort study of US males, higher adolescent and younger adult MGE was associated with lower adult hypertension and diabetes diagnoses and treatment. These findings suggest that males with high MGE may bear distinctive risks and correspondingly benefit from tailored public health efforts to prevent downstream CVD.

Twelve-year (2008-2019) trends in socioeconomic inequalities in cardiovascular risk factors in a Swiss representative survey of the general population

Objective

We assessed trends in socioeconomic inequalities in cardiovascular risk factors prevalence among Swiss adults from 2008 to 2019.

Methods

Using data from the Bus Santé study, an annual survey of adults living in Geneva, Switzerland, we calculated the prevalence per period and by demographic and socioeconomic indicators, assessing inequality trends using the relative index of inequality (RII) and the slope index of inequality (SII).

Results

Among 10,739 participants, most CVD risk factors decreased over time, while diabetes, obesity, and smoking prevalence remained steady. In 2017-2019, prevalence of most CVD risk factors was higher in socioeconomically disadvantaged groups. Relative and absolute inequalities decreased over time, but mostly remained, for hypertension [in 2017-2019, education-RII (95 % CI) = 1.27 (1.12-1.46), income-RII = 1.27 (1.10-1.47)], hypercholesterolemia [education-RII = 1.15 (1.00-1.32)], and sedentarity [education-RII = 1.95 (1.52-2.51), income-RII = 1.69 (1.28-2.23)], and appeared to have reversed for hazardous alcohol use [income-RII = 0.75 (0.60-0.93)]. Substantial and persistent relative and absolute inequalities in diabetes prevalence were observed [education-RII = 2.39 (1.75-3.27), income-RII = 3.18 (2.25-4.48), and subsidy-RII = 2.77 (1.89-4.05)]. Inequalities were also marked across all socioeconomic indicators for obesity prevalence [education-RII = 3.32 (2.63-4.19), income-RII = 2.37 (1.85-3.04), subsidy-RII = 1.98 (1.48-2.66)] and for smoking [education-RII = 2.42 (2.06-2.84), income-RII = 2.37 (1.99-2.84), subsidy-RII = 1.91 (1.56-2.35)].

Conclusions

Over 12 years in Geneva, Switzerland, socioeconomic inequalities in hypertension, hypercholesterolemia, hazardous alcohol use, and sedentarity decreased but persist, while substantial inequalities in diabetes, obesity, and smoking remained unchanged.

Sex-Specific Variation in Metabolic Responses to Diet

Suboptimal nutrition is a leading cause of cardiometabolic disease and mortality. Biological sex is a variable that influences individual responses to dietary components and may modulate the impact of diet on metabolic health and disease risk. This review describes findings of studies reporting how biological sex may associate with or affect metabolic outcomes or disease risk in response to varying dietary macronutrient content, Mediterranean diet, Western diet, and medical very low-calorie diet. Although few dietary interventions have been specifically designed to identify sex-diet interactions, future studies improving understanding how sex influences dietary responses could inform precision nutrition interventions for disease prevention and management.

Association of anaesthesia provider sex with perioperative complications: a two-centre retrospective cohort study

BACKGROUND

Previous studies suggested that surgeon sex is associated with differential patient outcomes. Whether this also applies to anaesthesia providers is unclear. We hypothesised that female sex of the primary anaesthesia provider is associated with lower risk of perioperative complications.

METHODS

The first case for all adult patients undergoing anaesthesia care between 2008 and 2022 at two academic healthcare networks in the USA was included in this retrospective cohort study. The primary exposure was the sex of the anaesthesia provider who spent the most time in the operating theatre during the case. The primary outcome was intraoperative complications, defined as hypotension (mean arterial blood pressure <55 mm Hg for ≥5 cumulative minutes) or hypoxaemia (oxygen saturation <90% for >2 consecutive minutes). The co-primary outcome was 30-day adverse postoperative events (including complications, readmission, and mortality). Analyses were adjusted for a priori defined confounders.

RESULTS

Among 364,429 included patients, 57,550 (15.8%) experienced intraoperative complications and 55,168 (15.1%) experienced adverse postoperative events. Care by female compared with male anaesthesia providers was associated with lower risk of intraoperative complications (adjusted odds ratio [aOR] 0.95, 95% confidence interval [CI] 0.94-0.97, P<0.001), which was magnified among non-trainees (aOR 0.84, 95% CI 0.82-0.87, P-for-interaction<0.001). Anaesthesia provider sex was not associated with the composite of adverse postoperative events (aOR 1.00, 95% CI 0.98-1.02, P=0.88).

CONCLUSIONS

Care by a female anaesthesia provider was associated with a lower risk of intraoperative complications, which was magnified among non-trainees. Future studies should investigate underlying mechanisms.

Up-regulation of BRD4 contributes to gestational diabetes mellitus-induced cardiac hypertrophy in offspring by promoting mitochondria dysfunction in sex-independent manner

Gestational diabetes mellitus (GDM) is associated with cardiovascular disease in postnatal life. The current study tested the hypothesis that GDM caused the cardiac hypertrophy in fetal (ED18.5), postnatal day 7 (PD7), postnatal day 21 (PD21) and postnatal day 90 (PD90) offspring by upregulation of BRD4 and mitochondrial dysfunction. Pregnant mice were divided into control and GDM groups. Hearts were isolated from ED18.5, PD7, PD21 and PD90. GDM increased the body weight (BW) and heart weight (HW) in ED18.5 and PD7, but not PD21 and PD90 offspring. However, HW/BW ratio was increased in all ages of GDM offspring compared to control group. Electron microscopy showed disorganized myofibrils, mitochondrial swelling, vacuolization, and cristae disorder in GDM offspring. GDM resulted in myocardial hypertrophy in offspring, which persisted from fetus to adult in a sex-independent manner. Echocardiography analysis revealed that GDM caused diastolic dysfunction, but had no effect on systolic function. Meanwhile, myocardial BRD4 was significantly upregulated in GDM offspring and BRD4 inhibition by JQ1 alleviated GDM-induced myocardial hypertrophy in offspring. Co-immunoprecipitation showed that BRD4 interacted with DRP1 and there was an increase of BRD4 and DRP1 interaction in GDM offspring. Furthermore, GDM caused the accumulation of damaged mitochondria in hearts from all ages of offspring, including mitochondrial fusion fission imbalance (upregulation of DRP1, and downregulation of MFN1, MFN2 and OPA1) and myocardial mitochondrial ROS accumulation, which was reversed by JQ1. These results suggested that the upregulation of BRD4 is involved in GDM-induced myocardial hypertrophy in the offspring through promoting mitochondrial damage in a gender-independent manner.

Evaluating Ischemic Heart Disease in Women: Focus on Angina With Nonobstructive Coronary Arteries (ANOCA)

Ischemic heart disease (IHD) is common in women, and cardiovascular disease is a leading cause of morbidity and mortality. While obstructive coronary artery disease is the most common form of IHD, millions of women suffer from angina with nonobstructive coronary arteries (ANOCA), an umbrella term encompassing multiple nonatherosclerotic disorders of the coronary tree. The underlying pathology leading to ischemia in these syndromes may be challenging to diagnose, leaving many women without a diagnosis despite persistent symptoms that impact quality of life and adversely affect long-term cardiovascular prognosis. In the last decade, there have been significant advances in the recognition and diagnostic evaluation of ANOCA. Despite these advances, the standard approach to evaluating suspected IHD in women continues to focus predominantly on the assessment of atherosclerotic coronary artery disease, leading to missed opportunities to accurately diagnose and treat underlying coronary vasomotor disorders. The goal of this review is to describe advances in diagnostic testing that can be used to evaluate angina in women and present a pragmatic diagnostic algorithm to guide evaluation of ANOCA in symptomatic patients. The proposed approach for the assessment of ANOCA is consistent with prior expert consensus documents and guidelines but is predicated on the medical interview and pretest probability of disease to inform a personalized diagnostic strategy.

Gender inequalities in secondary prevention of cardiovascular disease: a scoping review

BACKGROUND

Despite significant progress in cardiovascular disease (CVD) management, it remains a public health priority and a global challenge. Within the disease process, health care after a cardiovascular event (secondary prevention) is essential to prevent recurrences. Nonetheless, evidence has suggested the existence of gender disparities in CVD management, leaving women in a vulnerable situation. The objective of this study is to identify all available evidence on the existence of gender differences in health care attention after a major adverse cardiovascular event.

METHODS

A scoping review following the structure of PRISMA-ScR was conducted. To define the inclusion criteria, we used Joanna Briggs Institute (JBI) population, concept, context framework for scoping reviews. A systematic search was performed in MEDLINE (PubMed), EMBASE and Cochrane. The methods of this review are registered in the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) (INPLASY202350084).

RESULTS

The initial search retrieved 3,322 studies. 26 articles were identified manually. After the reviewing process, 93 articles were finally included. The main intervention studied was the pharmacological treatment received (n = 61, 66%), distantly followed by guideline-recommended care (n = 26, 28%) and cardiac rehabilitation (CR) referral (n = 16)". Literature described gender differences in care and management of secondary prevention of CVD. Women were less frequently treated with guideline-recommended medications and seem more likely to be non-adherent. When analysing guideline recommendations, women were more likely to make dietary changes, however, men were more likely to increase physical activity. Studies also showed that women had lower rates of risk factor testing and cholesterol goals attainment. Female sex was associated with lower rates of cardiac rehabilitation referral and participation.

CONCLUSIONS

This review allowed us to compile knowledge on the existence of gender inequalities on the secondary prevention of CVD. Additional research is required to delve into various factors influencing therapeutic disparities, referral and non-participation in CR programs, among other aspects, in order to improve existing knowledge about the management and treatment of CVD in men and women. This approach is crucial to ensure the most equitable and effective attention to this issue.

A Systematic Review of Artificial Intelligence Models for Time-to-Event Outcome Applied in Cardiovascular Disease Risk Prediction

Artificial intelligence (AI) based predictive models for early detection of cardiovascular disease (CVD) risk are increasingly being utilised. However, AI based risk prediction models that account for right-censored data have been overlooked. This systematic review (PROSPERO protocol CRD42023492655) includes 33 studies that utilised machine learning (ML) and deep learning (DL) models for survival outcome in CVD prediction. We provided details on the employed ML and DL models, eXplainable AI (XAI) techniques, and type of included variables, with a focus on social determinants of health (SDoH) and gender-stratification. Approximately half of the studies were published in 2023 with the majority from the United States. Random Survival Forest (RSF), Survival Gradient Boosting models, and Penalised Cox models were the most frequently employed ML models. DeepSurv was the most frequently employed DL model. DL models were better at predicting CVD outcomes than ML models. Permutation-based feature importance and Shapley values were the most utilised XAI methods for explaining AI models. Moreover, only one in five studies performed gender-stratification analysis and very few incorporate the wide range of SDoH factors in their prediction model. In conclusion, the evidence indicates that RSF and DeepSurv models are currently the optimal models for predicting CVD outcomes. This study also highlights the better predictive ability of DL survival models, compared to ML models. Future research should ensure the appropriate interpretation of AI models, accounting for SDoH, and gender stratification, as gender plays a significant role in CVD occurrence.

A Scoping Review of Risk Factors of Hypertensive Disorders of Pregnancy in Black Women Living in High-Income Countries: An Intersectional Approach

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are maternity-related increases in blood pressure (eg, gestational hypertension, preeclampsia, and eclampsia). Compared with women of other races in high-income countries, Black women have a comparatively higher risk of an HDP. Intersectionality helps to provide a deeper understanding of the multifactorial identities that affect health outcomes in this high-risk population.

OBJECTIVE

In this review, we sought to explore the literature on HDP risk factors in Black women living in high-income countries and to assess the interaction of these risk factors using the conceptual framework of intersectionality.

METHODS

We conducted this review using the Arksey and O'Malley methodology with enhancements from Levac and colleagues. Published articles in English on HDP risk factors with a sample of not less than 10% of Black women in high-income countries were included. Six databases, theses, and dissertations were searched from January 2000 to July 2021. A thematic analysis was used to summarize the results.

RESULTS

A final total of 36 studies were included from the 15 480 studies retrieved; 4 key themes of HDP risks were identified: (1) biological; (2) individual traditional; (3) race and ethnicity, geographical location, and immigration status; and (4) gender related. These intersectional HDP risk factors intersect to increase the risk of HDP among Black women living in high-income countries.

CONCLUSION

Upstream approaches are recommended to lower the risks of HDP in this population.

Socioeconomic status as a potential mediator of arterial aging in marginalized ethnic and racial groups: current understandings and future directions

Cardiovascular diseases (CVDs) are the leading cause of death in the United States. However, disparities in CVD-related morbidity and mortality exist as marginalized racial and ethnic groups are generally at higher risk for CVDs (Black Americans, Indigenous People, South and Southeast Asians, Native Hawaiians, and Pacific Islanders) and/or development of traditional CVD risk factors (groups above plus Hispanics/Latinos) relative to non-Hispanic Whites (NHW). In this comprehensive review, we outline emerging evidence suggesting these groups experience accelerated arterial dysfunction, including vascular endothelial dysfunction and large elastic artery stiffening, a nontraditional CVD risk factor that may predict risk of CVDs in these groups with advancing age. Adverse exposures to social determinants of health (SDOH), specifically lower socioeconomic status (SES), are exacerbated in most of these groups (except South Asians-higher SES) and may be a potential mediator of accelerated arterial aging. SES negatively influences the ability of marginalized racial and ethnic groups to meet aerobic exercise guidelines, the first-line strategy to improve arterial function, due to increased barriers, such as time and financial constraints, lack of motivation, facility access, and health education, to performing conventional aerobic exercise. Thus, identifying alternative interventions to conventional aerobic exercise that 1) overcome these common barriers and 2) target the biological mechanisms of aging to improve arterial function may be an effective, alternative method to aerobic exercise to ameliorate accelerated arterial aging and reduce CVD risk. Importantly, dedicated efforts are needed to assess these strategies in randomized-controlled clinical trials in these marginalized racial and ethnic groups.

Perceived Access to Healthcare of Indigenous Peoples in Canada With Rheumatoid Arthritis and Their First-Degree Relatives

OBJECTIVE

There are complex and interrelated factors that lead to inequitable healthcare delivery in Canada. Many of the factors that underlie these inequities for Canada's geographically dispersed Indigenous peoples remain underexamined.

METHODS

A cohort of 831 First Nations (FN) individuals from urban and remote communities were recruited into a longitudinal study of rheumatoid arthritis (RA) risk from 2005 to 2017. Data from each participant's initial enrollment visit were assessed using a survey that captured concerns with healthcare access.

RESULTS

We found that remote participants with RA reported poor access compared to remote first-degree relatives (FDRs; P < 0.001); this difference was not observed for urban participants with RA. We observed substantial differences based on sex; female participants perceived access to care to be more difficult than male participants in both urban and remote cohorts (P < 0.001). We also observed that male participants with RA reported poor access to care compared to male FDRs. Importantly, access to care in remote communities appeared to improve over the duration of the study (P = 0.01). In a logistic regression analysis, female sex, remote location, and older age were independent predictors of poor access to care. Predictors of poor access in participants with RA also included female sex, remote location, and older age.

CONCLUSION

FN peoples living in remote communities, particularly those with an established RA diagnosis, report more problems accessing health care. Sex-based inequities exist, with FN female individuals reporting greater difficulties in accessing appropriate health care, regardless of RA diagnosis. Addressing these sex-based inequities should be a high priority for improving healthcare delivery.

Inequalities in cardiovascular disease among elderly Indians: A gender perspective analysis using LASI wave-I (2017-18)

BACKGROUND

While Cardiovascular disease (CVD) affects both men and women, emerging evidence suggests notable gender differentials in disease prevalence. This study aims to explore and analyse the gender differentials in CVD disease prevalence in India.

METHODS

The present study utilizes data from first wave of the nationally representative survey "Longitudinal Ageing Study in India" (LASI, WAVE-I, 2017-18) with the eligible sample size of 31,464 individuals aged 60 years and above. Logistic regression analysis was used to understand risk of CVD by demographic characteristics. Factors contribution to gender differences in CVD prevalence was examined using a non-linear Fairlie decomposition.

RESULTS

The prevalence of CVD was lower in men (31.06%) compared to women (38.85%). Women have a 33% higher likelihood of CVD compared to men (OR: 1.33; 95% CI: 1.25-1.42). Lack of education also confers a lower risk, more pronounced in women with no schooling (OR: 0.81; 95% CI: 0.7-0.94) compared to men (OR: 0.52; 95% CI: 0.47-0.58). Morbidity influences CVD presence more among women than men, with individuals suffering from three or more diseases having markedly increased odds (Men: OR: 3.89; 95% CI: 3.54-4.3, Women: OR: 6.97; 95% CI: 6.48-10.11). Smoking accounted increase in (20.52%) the gender gap while years of schooling dramatically lessened the gender gap (-46.30%).

CONCLUSION

Result show gender differential in CVD prevalence and underlying risk factors, underscoring the need for gender-specific preventive strategies and interventions. Our findings highlight the importance of refined approach to cardiovascular health that considers the complex interplay of biological, social, and environmental determinants.

mHealth Intervention for Elevated Blood Pressure Among College Students: Single-Arm Intervention Study

BACKGROUND

Current evidence reveals a growing pattern of hypertension among young adults, significantly increasing their risk for cardiovascular disease later in life. Young adults, particularly those of college age, often develop risk factors related to lifestyle choices in diet, exercise, and alcohol consumption. Developing useful interventions that can assist with screening and possible behavioral modifications that are suitable and appealing to college-aged young adults could help with early identification and intervention for hypertension. Recent studies indicate mobile health (mHealth) apps are acceptable and effective for communication and message delivery among this population.

OBJECTIVE

The purpose of this study was to examine the feasibility of using a mobile smartphone delivery system that provides tailored messages based on participant self-measured blood pressure (BP) with college-aged young adults.

METHODS

Using a single-arm intervention, pilot study design, the mHealth to Optimize BP Improvement (MOBILE) intervention was implemented with college students aged 18 years to 39 years who had systolic BP >120 mm Hg and diastolic BP ≥80 mm Hg. Participants were required to measure their BP daily for 28 days, submit the readings to the app, and receive preset educational text messages tailored to their BP value and related to encouraging healthy lifestyle modifications. Changes in a participant's BP was evaluated using a mixed regression model, and a postintervention survey evaluated their perspectives on the mHealth intervention.

RESULTS

The participants' (N=9) mean age was 22.64 (SD 4.54) years; 56% (5/9) were overweight, and 11% (1/9) were obese. The average daily participation rate was 86%. Of the 9 participants, 8 completed the survey, and all indicated the intervention was easy to use, found it increased awareness of their individual BP levels, indicated the text messages were helpful, and reported making lifestyle changes based on the study intervention. They also provided suggestions for future implementation of the intervention and program. Overall, no significant changes were noted in BP over the 28 days.

CONCLUSIONS

The mHealth-supported MOBILE intervention for BP monitoring and tailored text messaging was feasible to implement, as our study indicated high rates of participation and acceptability. These encouraging findings support further development and testing in a larger sample over a longer time frame and hold the potential for early identification and intervention among college-aged adults, filling a gap in current research.

Exploring sex variations in the incidence of cardiovascular events: a counterfactual decomposition analysis

BACKGROUND

Some cardiovascular risk factors (CVRFs) that occur differently in men and women can be addressed to reduce the risk of suffering a major adverse cardiovascular event (MACE). Furthermore, the development of MACE is highly influenced by social determinants of health. Counterfactual decomposition analysis is a new methodology that has the potential to be used to disentangle the role of different factors in health inequalities. This study aimed to assess sex differences in the incidence of MACE and to estimate how much of the difference could be attributed to the prevalence of diabetes, hypertension, hypercholesterolaemia and socioeconomic status (SES).

METHODS

Descriptive and counterfactual analyses were conducted in a population of 278 515 people with CVRFs. The contribution of the causal factors was estimated by comparing the observed risk ratio with the causal factor distribution that would have been observed if men had been set to have the same factor distribution as women. The study period was between 2018 and 2021.

RESULTS

The most prevalent CVRF was hypercholesterolaemia, which was similar in both sexes, while diabetes was more prevalent in men. The incidence of MACE was higher in men than in women. The main causal mediating factors that contributed to the sex differences were diabetes and SES, the latter with an offsetting effect.

CONCLUSIONS

This result suggests that to reduce the MACE gap between sexes, diabetes prevention programmes targeting men and more gender-equal salary policies should be implemented.

Patterns of Health-Risk Behaviours and Their Associations With Anxiety and Depression Among Chinese Young Adults by Gender: A Latent Class Analysis

This study investigated gender differences in health-risk behaviour patterns among young adults and assessed the associations of anxiety and depression with these patterns. A cross-sectional survey was conducted with 1740 young Chinese adults aged 18-24 years. Latent class analysis (LCA) and multinomial logistic regression were conducted to identify the clusters of health-risk behaviours and their associations with anxiety and depression. Three common patterns were found for both genders: physical inactivity, substance use, and insufficient fruit intake (5.7% for males [M] and 11.6% for females [F]); a sedentary lifestyle only (48.4% for M and 48.9% for F); and a sedentary lifestyle, substance use, and an unhealthy diet (7.6% for M and 20.0% for F). Additionally, two additional unique patterns were found: physical inactivity and unhealthy diet in males (38.3%) and physical inactivity and insufficient fruit intake in females (19.6%). Sociodemographic variables exert different effects on health-risk behaviour patterns as a function of gender. Lower anxiety levels (odds ratio [OR]: 0.892; 95% confidence interval [CI]: 0.823-0.966) and greater depression levels (OR: 1.074; 95% CI: 1.008-1.143) were associated with a sedentary lifestyle, substance use, and unhealthy diet class only in female young adults compared with a sedentary-only class. These findings underscore the need for the implementation of targeted interventions based on gender differences.

Sex differences in modifiable risk factors for stroke incidence and recurrence: the UCC-SMART study

BACKGROUND AND PURPOSE

Risk factors for stroke differ between women and men in general populations. However, little is known about sex differences in secondary prevention. We investigated if sex interacted with modifiable risk factors for stroke in a large arterial disease cohort.

METHODS

Within the prospective UCC-SMART study, 13,898 patients (35% women) with atherosclerotic disease or high-risk factor profile were followed up to 23 years for stroke incidence or recurrence. Hypertension, smoking, diabetes, overweight, dyslipidemia, high alcohol use, and physical inactivity were studied as risk factors. Association between these factors and ischemic and hemorrhagic stroke incidence or recurrence was studied in women and men using Cox proportional hazard models and Poisson regression models. Women-to-men relative hazard ratios (RHR) and rate differences (RD) were estimated for each risk factor. Left-truncated age was used as timescale.

RESULTS

The age-adjusted stroke incidence rate was lower in women than men (3.9 vs 4.4 per 1000 person-years), as was the age-adjusted stroke recurrence rate (10.0 vs 11.7). Hypertension and smoking were associated with stroke risk in both sexes. HDL cholesterol was associated with lower stroke incidence in women but not in men (RHR 0.49; CI 0.27-0.88; and RD 1.39; CI - 1.31 to 4.10). Overweight was associated with a lower stroke recurrence in women but not in men (RHR 0.42; CI 0.23-0.80; and RD 9.05; CI 2.78-15.32).

CONCLUSIONS

In high-risk population, sex modifies the association of HDL cholesterol on stroke incidence, and the association of overweight on stroke recurrence. Our findings highlight the importance of sex-specific secondary prevention.

Are Socioeconomic Factors Associated With Atrial Fibrillation Sex-Dependent? A Narrative Review

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia, poses a significant public health and economic burden. Although socioeconomic factors such as income and education have been implicated in AF incidence and outcomes, the potential sex-specific associations remained underexplored. This narrative review aimed to fill this gap by synthesizing existing literature on the sex-specific impact of socioeconomic factors on AF incidence, treatment, and outcome. Among these socioeconomic factors, we identified income and education as the most frequently cited determinants. Nevertheless, the magnitude and direction of these sex differences remained inconsistent across studies. The review uncovered that many studies did not include sex in the analysis when assessing the impact of socioeconomic factors on AF. We highlighted that there is a paucity of studies employing sex-stratified reporting and sex interaction analyses, thereby hindering a deeper understanding of these relationships.

Gender Matters: A Multidimensional Approach to Optimizing Cardiovascular Health in Women

Cardiovascular diseases remain a leading cause of mortality among women, yet they are often underestimated and insufficiently addressed. This narrative review delves into the gender disparities in cardiovascular health, underscoring the critical importance of recognizing and addressing the unique challenges women face. The article explores the pathophysiological differences between men and women, highlighting the role of hormonal factors, such as estrogen and menopause, in conferring cardioprotection or increasing risk. It examines the complexities of diagnosis and assessment, including differences in symptom presentation, diagnostic accuracy, and the challenges of interpreting non-invasive testing in women. The review also highlights the need for tailored risk assessment and prevention strategies, incorporating sex-specific conditions and pregnancy-related factors. It emphasizes the importance of lifestyle modifications and interventions, as well as the potential benefits of personalized treatment approaches, considering gender-specific variations in medication responses and cardiac interventions. Furthermore, the article sheds light on the impact of psychosocial and sociocultural factors, such as gender norms, mental health considerations, and access to healthcare, on women's cardiovascular health. It also addresses the significant gaps and challenges in research, including the historical underrepresentation of women in clinical trials and the lack of sex- and gender-sensitive studies. Finally, the review advocates for a multidisciplinary approach, involving patient-centered care, shared decision-making, and collaboration among policymakers, stakeholders, and healthcare systems. This comprehensive strategy aims to enhance awareness, prevention, diagnosis, and treatment of cardiovascular disease in women, ultimately improving health outcomes and reducing the burden of this often overlooked epidemic.

Achieving Equity in EMS Care and Patient Outcomes Through Quality Management Systems: A Position Statement

Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies:make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.

Influence of nonalcoholic fatty liver disease severity on carotid adventitial vasa vasorum

Introduction

Nonalcoholic fatty liver disease (NAFLD) affects a quarter of the world's population and encompasses a spectrum of liver conditions, from non-alcoholic steatohepatitis (NASH) to inflammation and fibrosis. In addition, NAFLD also links to extrahepatic conditions like diabetes or obesity. However, it remains unclear if NAFLD independently correlates with the onset and progression of atherosclerosis.

Material and methods

This cross-sectional study aimed to explore the relationship between NAFLD severity, assessed via liver biopsy, and early atherosclerosis using adventitial vasa vasorum (VV) density. It included 44 patients with obesity (33 with steatosis, 11 with NASH) undergoing bariatric surgery.

Results

Results revealed no significant differences in adventitial VV density between steatosis and NASH groups, neither in the mean values [0.759 ± 0.104 vs. 0.780 ± 0.043, P=0.702] nor left-right sides. Similarly, carotid intima-media thickness (cIMT) did not vary between these groups. Additionally, no linear correlation existed between VV density and cIMT. Only gender showed an association with VV density.

Conclusion

These findings suggest that NASH severity doesn't independently drive early atherosclerosis or affects cIMT. Gender might play a role in early atherosclerotic disease in NAFLD, impacting VV density and cIMT. This highlights the need to consider other risk factors when evaluating cardiovascular risk in NAFLD patients.

Cardiovascular Health Trajectories in Adolescence and Their Association With Sociodemographic and Cardiometabolic Outcomes in Spain

PURPOSE

To determine cardiovascular health (CVH) trajectories and their association with sociodemographic and cardiometabolic outcomes in adolescence.

METHODS

One thousand eighty adolescents attending 24 secondary schools enrolled in the SI! Program for Secondary Schools trial in Spain were assessed at approximately 12, 14, and 16 years of age. CVH was assessed according to American Heart Association criteria based on seven metrics (smoking status, body mass index, physical activity, diet, blood pressure, total cholesterol, and blood glucose), and CVH trajectories were identified by latent class trajectory modeling. Associations between CVH trajectories, sociodemographic characteristics, and cardiometabolic outcomes were analyzed using generalized linear and Poisson models.

RESULTS

Five CVH trajectory groups were identified: poor-stable (27 adolescents [2.5%]), intermediate-substantial rise (79 [7.3%]), intermediate-substantial decline (63 [5.8%]), intermediate-mild decline (403 [37.3%]), and intermediate-mild rise (508 [47.1%]). Boys and adolescents from families with low-average income, low-intermediate educational attainment, and a migrant background more frequently belonged to groups with lower baseline CVH and poor or declining trajectories. The intermediate-substantial decline group had the highest prevalence ratio for overweight/obesity (3.84; 95% confidence interval: 2.86-5.16) and metabolic syndrome (4.93; 95% confidence interval: 1.21-20.04) at age 16, whereas prevalence was lowest in the intermediate-mild rise group.

DISCUSSION

Adolescent CVH trajectories differ according to socioeconomic characteristics and are associated with cardiometabolic outcomes. Primordial prevention interventions should be implemented early in life, taking into account CVH trajectories and with a particular focus on vulnerable populations.

Impact of Gender on Chronic Complications in Participants With Type 2 Diabetes: Evidence From a Cross-Sectional Study

INTRODUCTION

This study aimed to assess and compare the prevalence of diabetes complications between men and women with Type 2 diabetes (T2D), as well as how gender relates to these complications.

METHODS

In this cross-sectional study, complications of diabetes, including coronary artery disease (CAD), retinopathy, neuropathy and diabetic kidney disease (DKD), were evaluated in 1867 participants with T2D. Additionally, baseline characteristics of the individuals, including anthropometric measurements, metabolic parameters and the use of dyslipidaemia drugs and antihyperglycaemic agents, were assessed. Gender differences in complications were examined using the chi-squared test. Multivariate logistic regression was employed to investigate the relationship between gender and T2D complications, with and without adjusting for the characteristics of the studied population.

RESULTS

In the studied population, 62.1% had at least one complication, and complications were 33.5% for DKD, 29.6% for CAD, 22.9% for neuropathy and 19.1% for retinopathy. The prevalence of CAD and neuropathy was higher in men. However, DKD and retinopathy were more prevalent among women. Odds ratios of experiencing any complication, CAD and retinopathy in men compared with women were 1.57 (95% CI: 1.27-2.03), 2.27 (95% CI: 1.72-2.99) and 0.72 (95% CI: 0.52-0.98), respectively, after adjusting for demographic factors, anthropometric measures, metabolic parameters and the consumption of dyslipidaemia drugs and antihyperglycaemic agents.

CONCLUSION

The prevalence of diabetes complications was significantly higher in men with diabetes, highlighting the need for better treatment adherence. CAD was associated with the male gender, whereas retinopathy was associated with the female gender. Men and women with diabetes should be monitored closely for CAD and retinopathy, respectively, regardless of their age, diabetes duration, anthropometric measures, laboratory findings and medications.

Gender Disparities in Cardiovascular Disease and Their Management: A Review

Worldwide, cardiovascular diseases (CVDs) are still the primary cause of death, and there are notable differences between sexes when it comes to symptoms/course and treatment. Due to evolving healthcare technologies, significant progress has been made in understanding CVDs. Hence, it is evident that gender disparities exist in the clinical presentation, prevalence, management, outcomes, and risk factors, including biological, behavioral, and sociocultural factors. This narrative review is designed to provide a generalized idea of gender disparities in CVDs. It aims to provide insights to prove the role of hormonal influences, genetic predispositions, and the difference in physiological outcomes owing to different genders. This review explores subtle distinctions in CVD across genders, including changes in structure, biology, and hormones that affect how illness presents and progresses. Lifestyle variables also influence sociocultural factors and gender disparities in risk profiles. Traditional risk factors, diabetes mellitus (DM), cholesterol levels, and smoking may have different weights and relevance in men and women. Moreover, age and other conventional risk variables have distinct effects on gender. Treatment efficacy may be impacted by the expression of gender-specific factors, emphasizing the necessity for customized strategies. Development of CVDs can be delayed or prevented, and its consequences can be lessened with the early identification and effective management of gender-specific factors. More investigation is necessary to clarify complex interactions between structural, biochemical, and hormonal aspects across genders in order to maximize treatment results and reduce the burden of CVDs.

Testosterone therapy and the risk of cardiovascular disease in older, hypogonadal men

The debate over the cardiovascular (CV) implications of testosterone therapy (TT) have resulted in diverging safety recommendations and clinical guidelines worldwide. This narrative review synthesizes and critically evaluates long-term studies examining the effects of TT within the context of aging, obesity, and endogenous sex hormones on CV disease (CVD) risk to support informed clinical decision-making. Observational studies have variably linked low endogenous testosterone with increased CVD risk, while randomized controlled trials (RCTs) demonstrate that TT yields cardiometabolic benefits without increasing short-term CV risk. The TRAVERSE trial, as the first RCT powered to assess CVD events, did not show increased major adverse cardiac events (MACE) incidence; however, its limitations - specifically the maintenance of testosterone at low-normal levels, a high participant discontinuation rate, and short follow-up - warrant a careful interpretation of its results. Furthermore, findings from the TTrials cardiovascular sub-study, which showed an increase in non-calcified plaque, indicate the need for ongoing research into the long-term CV impact of TT. The decision to initiate TT should consider the current evidence gaps, particularly for older men with known CVD. The CV effects of maintaining physiological testosterone levels through exogenous means remain to be fully explored. Until more definitive evidence is available, clinical practice should prioritize individualized care and informed discussions on the potential CV implications of TT.

Association between movement behavior patterns and cardiovascular risk among Chinese adults aged 40-75: a sex-specific latent class analysis

BACKGROUND

Cardiovascular disease (CVD) is a major global health threat, particularly in China, contributing to over 40% of deaths. While sleep behaviors, sedentary behaviors, and physical activities are recognized as independent lifestyle risk factors for CVD, there remains limited understanding of specific movement behavior patterns and their CVD risks, especially considering sex-specific differences. This study examines movement behavior patterns among Chinese adults (40-75) and their associations with cardiovascular risk, with a focus on sleep, physical activity (PA), and sedentary behavior (SB).

METHODS

Data pertaining to 13,465 male participants and 15,613 female participants, collected from the Chronic Disease and Risk Factor Surveillance Survey in Nanjing from February 2020 to December 2022. The latent class analysis method was employed to identify underlying movement patterns across sexes. Multinomial logistic regression models assessed CVD risk, and the China-PAR model calculated 10-year risk.

RESULTS

Three male and four female movement patterns emerged. Active Movers (17.10% males, 5.93% females) adhered to PA recommendations but had poorer sleep quality. Moderate Achievers (61.42% males, 45.32% females) demonstrated moderate behavior. Sedentary Sleepers (21.48% males, 10.20% females) exhibited minimal PA but good sleep. Female Moderate Physical Activity (MPA) Dominant Movers demonstrated a prevalent adherence to recommended MPA levels. Active movers had the lowest CVD risk. After adjusting for potential confounders, moderate achievers (OR = 1.462, 95% CI 1.212, 1.764) and sedentary sleepers (OR = 1.504, 95% CI 1.211, 1.868) were both identified as being associated with a high-risk of cardiovascular diseases (CVDs) compared to active movers in males, demonstrating a similar trend for intermediate risk. Such associations were not statistically significant among females.

CONCLUSIONS

Our study revealed sex-specific movement patterns associated with CVD risks among middle-aged Chinese adults. We suggest that adopting an active movement behavior pattern, characterized by meeting or exceeding recommended levels of vigorous physical activity (VPA) and reducing sedentary behavior, is beneficial for all middle-aged adults, particularly males. An active lifestyle could help counteract the adverse effects of relatively poor sleep quality on the risk of developing CVD in this population. Integrating sleep, PA, and SB information provides a holistic framework for understanding and mitigating CVD risks.

Sex- and Gender-Based Analysis on Norepinephrine Use in Septic Shock: Why Is It Still a Male World?

Sex and gender are fundamental health determinants and their role as modifiers of treatment response is increasingly recognized. Norepinephrine is a cornerstone of septic shock management and its use is based on the highest level of evidence compared to dopamine. The related 2021 Surviving Sepsis Campaign (SCC) recommendation is presumably applicable to both females and males; however, a sex- and gender-based analysis is lacking, thus not allowing generalizable conclusions. This paper was aimed at exploring whether sex- and gender-disaggregated data are available in the evidence supporting this recommendation. For all the studies underpinning it, four pairs of authors, including a woman and a man, extracted data concerning sex and gender, according to the Sex and Gender Equity in Research guidelines. Nine manuscripts were included with an overall population of 2126 patients, of which 43.2% were females. No sex analysis was performed and gender was never reported. In conclusion, the present manuscript highlighted that the clinical studies underlying the SCC recommendation of NE administration in septic shock have neglected the likely role of sex and gender as modifiers of treatment response, thus missing the opportunity of sex- and gender-specific guidelines.

Factors associated with cardiovascular disease: A comparative study of the UK Asian diaspora and residents of India

INTRODUCTION

The aim of this paper is to investigate what factors are associated to cardiovascular disease and what differences exists between Asians living in the UK (from the English Longitudinal Study of Ageing) and the Asians living in India (from the Longitudinal Ageing Study in India).

METHODS

Logistic regression was used to investigate how demographic and physical performance factors were associated with cardiovascular disease using data from Wave 6 of the English Longitudinal Study of Ageing and Wave 1 of the Longitudinal Study of Ageing in India, with the main variable of interest being country of residence, Asians in England or Asians in India.

RESULTS

A total of 83,997 participants were included in the analyses. In the primary analysis, 73,396 participants from LASI were compared to 171 Asians in ELSA. After adjusting for age, blood pressure, resting heart rate, sex, waist circumference, gait, handgrip strength and standing balance, there was a statistically significant difference for the outcome of CVD between Whites ELSA (reference) and the participants of LASI (odds ratio = 0.77; 95% confidence interval = 0.60 to 0.99). There were no significant differences in CVD between the LASI participants, Asian ELSA, and the Non-White but not Asian ELSA groups.

DISCUSSION

No difference was found between Asians that live in India compared to ethnic minorities living in England, including Asians, after adjusting for confounders, but was found between Whites in ELSA compared to LASI participants. A key limitation was the massive disparity in sample sizes between the ELSA subgroups and LASI. Further work is required where comparable sample sizes and longitudinal analyses allow trends to be identified and to investigate the factors associated with the difference in CVD between two similar ethnicities living in distinct locations.

CONCLUSION

After adjusting for risk factors, there was no difference in CVD between localised Asians and the ethnic minorities in the UK, but there was a difference between the majority ethnicities in the respective countries.

The global burden and risk factors of cardiovascular diseases in adolescent and young adults, 1990-2019

BACKGROUND

To provide details of the burden and the trend of the cardiovascular disease (CVD) and its risk factors in adolescent and young adults.

METHODS

Age-standardized rates (ASRs) of incidence, mortality and Disability-Adjusted Life Years (DALYs) were used to describe the burden of CVD in adolescents and young adults. Estimated Annual Percentage Changes (EAPCs) of ASRs were used to describe the trend from 1990 to 2019. Risk factors were calculated by Population Attributable Fractions (PAFs).

RESULTS

In 2019, the age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR) and age-standardized DALYs rate (ASDR) of CVD were 129.85 per 100 000 (95% Confidence interval (CI): 102.60, 160.31), 15.12 per 100 000 (95% CI: 13.89, 16.48) and 990.64 per 100 000 (95% CI: 911.06, 1076.46). The highest ASRs were seen in low sociodemographic index (SDI) and low-middle SDI regions. The burden was heavier in male and individuals aged 35-39. From 1990 to 2019, 72 (35.29%) countries showed an increasing trend of ASIR and more than 80% countries showed a downward trend in ASMR and ASDR. Rheumatic heart disease had the highest ASIR and Ischemic Heart Disease was the highest in both ASMR and ASDR. The main attributable risk factor for death and DALYs were high systolic blood pressure, high body-mass index and high LDL cholesterol.

CONCLUSIONS

The burden of CVD in adolescent and young adults is a significant global health challenge. It is crucial to take into account the disparities in SDI levels among countries, gender and age characteristics of the population, primary types of CVD, and the attributable risk factors when formulating and implementing prevention strategies.

Sex Differences in the Relationship Between Schizophrenia and the Development of Cardiovascular Disease

BACKGROUND

There are few data on sex differences in the association between schizophrenia and the development of cardiovascular disease (CVD). We sought to clarify the relationship of schizophrenia with the risk of developing CVDs and to explore the potential modification effect of sex differences.

METHODS AND RESULTS

We conducted a retrospective analysis using the JMDC Claims Database between 2005 and 2022. The study population included 4 124 508 individuals aged 18 to 75 years without a history of CVD or renal replacement therapy. The primary end point is defined as a composite end point that includes myocardial infarction, angina pectoris, stroke, heart failure, atrial fibrillation, and pulmonary thromboembolism. During a mean follow-up of 1288±1001 days, we observed 182 158 composite end points. We found a significant relationship of schizophrenia with a greater risk of developing composite CVD events in both men and women, with a stronger association observed in women. The hazard ratio for the composite end point was 1.63 (95% CI, 1.52-1.74) in women and 1.42 (95% CI, 1.33-1.52) in men after multivariable adjustment (P for interaction=0.0049). This sex-specific difference in the association between schizophrenia and incident CVD was consistent for angina pectoris, heart failure, and atrial fibrillation.

CONCLUSIONS

Our analysis using a large-scale epidemiologic cohort demonstrated that the association between schizophrenia and subsequent CVD events was more pronounced in women than in men, suggesting the clinical importance of addressing schizophrenia and tailoring the CVD prevention strategy based on sex-specific factors.

Redefining global cardiac surgery through an intersectionality lens

Although cardiovascular diseases are the leading cause of morbidity and mortality worldwide, six billion people lack access to safe, timely and affordable cardiac surgical care when needed. The burden of cardiovascular disease and disparities in access to care vary widely based on sociodemographic characteristics, including but not limited to geography, sex, gender, race, ethnicity, indigeneity, socioeconomic status and age. To date, the majority of cardiovascular, global health and global surgical research has lacked intersectionality lenses and methodologies to better understand access to care at the intersection of multiple identities and traditions. As such, global (cardiac) surgical definitions and health system interventions have been rooted in reductionism, focusing, at most, on singular sociodemographic characteristics. In this article, we evaluate barriers in global access to cardiac surgery based on existing intersectionality themes and literature. We further examine intersectionality methodologies to study access to cardiovascular care and cardiac surgery and seek to redefine the definition of 'global cardiac surgery' through an intersectionality lens.

Exploring gender disparities in the disease and economic tobacco-attributable burden in Latin America

Introduction

Tobacco use has significant health consequences in Latin America, and while studies have examined the overall impact, the gender-specific effects have not been thoroughly researched. Understanding these differences is crucial for effective tobacco control policies. The objective of this study was to explore the differences in tobacco-attributable disease and economic burden between men and women in Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Mexico, and Peru.

Methods

We used a previously validated economic model to quantify the impact of tobacco-related illnesses, including morbidity, mortality, healthcare costs, productivity losses, informal care expenses, and DALYs, by gender and age. We utilized data from national surveys, records, studies, and expert opinions to populate the model.

Results

In 2020, there were 351,000 smoking-attributable deaths. Men accounted for 69% and women 31%. Ecuador and Mexico had the highest male-to-female death ratio, while Peru and Chile had the smallest disparities. 2.3 million tobacco-related disease events occurred, with 65% in men and 35% in women. Ecuador and Mexico had higher disease rates among men, while Peru had a more balanced ratio. Regarding DALYs, men lost 6.3 million due to tobacco, while women lost 3.3 million, primarily from COPD, cardiovascular disease, and cancer. Brazil and Mexico had the highest DALY losses for both genders. Costa Rica had a lower male-to-female tobacco use prevalence ratio but ranked second in deaths, disease events, and DALYs attributed to tobacco. Colombia had a unique pattern with a male-to-female death ratio of 2.08 but a higher ratio for disease events. The health systems spent $22.8 billion to treat tobacco-attributable diseases, with a male-to-female cost ratio 2.15. Ecuador showed the greatest gender cost difference, while Peru had the lowest. Productivity loss due to tobacco was $16.2 billion, with Ecuador and Mexico exhibiting the highest gender disparities and Peru the lowest. Informal care costs amounted to $10.8 billion, with men incurring higher costs in Ecuador, Costa Rica, and Mexico.

Discussion

Tobacco causes significant health and economic burdens in Latin America, with gender-based differences. There is a need for gender-disaggregated data to improve tobacco control policies.

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

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

Impact of Sex and Gender on Metabolic Syndrome in Adults: A Retrospective Cohort Study From the Canadian Primary Care Sentinel Surveillance Network

OBJECTIVE

Metabolic syndrome (MetS), a cluster of 5 interconnected factors, is the main contributor to cardiovascular disease. Although sex- and gender-related elements have been linked to MetS and its components, this association has not been explored among Canadians with or without MetS. In this study, we aimed to identify sex and gender differences in characteristics of MetS in the Canadian population.

METHODS

This retrospective cohort study used data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) database. The CPCSSN contains de-identified electronic health records of >1.5 million Canadians (2010-2019). Individuals 35 to 75 years of age who had a primary care encounter formed the study sample (N=37,813). Multiple logistic regression models were used to estimate adjusted odds ratios for sex and gender differences among Canadians with and without MetS, which was the primary outcome variable.

RESULTS

The estimated prevalence of MetS was 41.9%. The risk of developing MetS was significantly lower among females compared with males (odds ratio 0.73, 95% confidence interval 0.70 to 0.76). However, the risk was higher in females who used antidepressants (odds ratio 1.53, 95% confidence interval 1.42 to 1.65). An equal distribution of deprivation indexes was observed between males and females with MetS, with risk slightly higher for those with material deprivation. Females were found to be the most socially deprived.

CONCLUSIONS

This study provides important sex- and gender-specific differences in MetS among Canadians. Targeting sex- and gender-specific risk factors could assist in reversing the trend of adverse cardiovascular outcomes associated with MetS.

Knowledge, attitudes, and practices regarding cardiovascular disease prevention among middle school students in China: a cross-sectional study

Background

The prevalence of cardiovascular disease (CVD) is rapidly increasing globally. With a concerning increase among adolescents due to unhealthy habits, obesity, and hypertension, understanding the current status of knowledge, attitudes, and practices (KAP) related to CVD prevention among middle school students is crucial for developing effective school-based health programs to prevent CVD.

Methods

The analytic cross-sectional survey is used in questionnaires to assess KAP related to CVD prevention among middle school students (N = 17,731) from 50 schools across 16 provinces in China in June-July 2023. The pass rate of KAP scores is categorized as good and poor. Independent predictors of good KAP of CVD prevention are ascertained using a binary logistic regression model.

Results

The study surveyed 8,118 (45.78%) junior high school students and 9,613 (54.22%) high school students. The overall mean [standard deviation (SD)] for the knowledge, attitude, and practice scores were 26.88 (8.12), 53.53 (7.22), and 39.80 (5.96), respectively. The knowledge scores had the lowest pass rate at 56.89%. Only 6.83% of the students know "the definition of blood pressure in adolescents." Attitudes toward health were positive, though the attitude regarding "the danger of prolonged sedentary to cardiovascular health" scored lowest at 73.55%. The practice section had a pass rate of 89.30%; 40.27% of students reported that they spend more than an hour a day on screens. Only one-third of the students would go to bed before 12 o'clock. In univariate analysis, junior high school and high school students differed significantly in knowledge and practice (p < 0.001), but attitude did not differ significantly (p = 0.103).

Conclusion

The majority of students lack sufficient knowledge about CVD. It is also found that socioeconomic background, family environment, and educational levels have an impact on cardiovascular health behaviors among students. Strengthening health education involving students, parents, teachers, and communities is essential to promote health knowledge and practices among adolescents.