Cardiovascular risk in menopausal women and our evolving understanding of menopausal hormone therapy: risks, benefits, and current guidelines for use

The role of estrogen in Alzheimer's disease pathogenesis and therapeutic potential in women

Estrogens are pivotal regulators of brain function throughout the lifespan, exerting profound effects from early embryonic development to aging. Extensive experimental evidence underscores the multifaceted protective roles of estrogens on neurons and neurotransmitter systems, particularly in the context of Alzheimer's disease (AD) pathogenesis. Studies have consistently revealed a greater risk of AD development in women compared to men, with postmenopausal women exhibiting heightened susceptibility. This connection between sex factors and long-term estrogen deprivation highlights the significance of estrogen signaling in AD progression. Estrogen's influence extends to key processes implicated in AD, including amyloid precursor protein (APP) processing and neuronal health maintenance mediated by brain-derived neurotrophic factor (BDNF). Reduced BDNF expression, often observed in AD, underscores estrogen's role in preserving neuronal integrity. Notably, hormone replacement therapy (HRT) has emerged as a sex-specific and time-dependent strategy for primary cardiovascular disease (CVD) prevention, offering an excellent risk profile against aging-related disorders like AD. Evidence suggests that HRT may mitigate AD onset and progression in postmenopausal women, further emphasizing the importance of estrogen signaling in AD pathophysiology. This review comprehensively examines the physiological and pathological changes associated with estrogen in AD, elucidating the therapeutic potential of estrogen-based interventions such as HRT. By synthesizing current knowledge, it aims to provide insights into the intricate interplay between estrogen signaling and AD pathogenesis, thereby informing future research directions and therapeutic strategies for this debilitating neurodegenerative disorder.

Menopausal age does not affect ventricular structure and function: a Mendelian randomization study

OBJECTIVES

Observational studies have suggested an association between age at natural menopause (ANM) and ventricular structure and function. Nevertheless, the causal relationship remains unclear. This study aimed to evaluate the causal effects of ANM on ventricular structure and function by Mendelian randomization (MR) analysis.

METHODS

Genome-wide association summary statistics for ANM and 16 ventricular structures and functions were obtained. The inverse variance weighted (IVW) method was the primary MR approach for assessing causal associations. In addition, three additional MR methods (MR-Egger, weighted median and weighted mode) were performed to complement the IVW method. Furthermore, various sensitivity tests were conducted to evaluate the reliability of the MR results.

RESULTS

The IVW method identified no causal association between ANM and all 16 ventricular structures or functions (p > 0.05). Three additional MR methods yielded parallel results to the IVW approach (p > 0.05). Various sensitivity tests revealed stability of the MR results, indicating no heterogeneity or horizontal pleiotropy.

CONCLUSION

The present MR study indicated that ANM would not causally affect ventricular structure or function. Therefore, the correlation between ANM and ventricular characteristics in previous observational studies might be attributed to shared upstream cardiovascular risk factors or unidentified genetic mutations that simultaneously affect both ANM and ventricular structure and function.

Coronary risk factor profiles according to different age categories in premature coronary artery disease patients who have undergone percutaneous coronary intervention

Many studies have investigated the coronary risk factors (CRFs) among premature coronary artery disease (PCAD) patients. However, reports on the proportion and CRFs of PCAD according to different age cut-offs for PCAD is globally under-reported. This study aimed to determine the proportion of PCAD patients and analyse the significant CRFs according to different age cut-offs among percutaneous coronary intervention (PCI)-treated patients. Patients who underwent PCI between 2007 and 2018 in two cardiology centres were included (n = 29,241) and were grouped into four age cut-off groups that defines PCAD: (A) Males/females: < 45, (B) Males: < 50; Females: < 55, (C) Males: < 55; Females: < 60 and (D) Males: < 55; Females: < 65 years old. The average proportion of PCAD was 28%; 9.2% for group (A), 21.5% for group (B), 38.6% and 41.9% for group (C) and (D), respectively. The top three CRFs of PCAD were LDL-c level, TC level and hypertension (HTN). Malay ethnicity, smoking, obesity, family history of PCAD, TC level and history of MI were the independent predictors of PCAD across all age groups. The proportion of PCAD in Malaysia is higher compared to other studies. The most significant risk factors of PCAD are LDL-c, TC levels and HTN. Early prevention, detection and management of the modifiable risk factors are highly warranted to prevent PCAD.

Unique features of dyslipidemia in women across a lifetime and a tailored approach to management

Purpose of Review

Cardiovascular disease is a leading cause of death worldwide. Dyslipidemia is a critical modifiable risk factor for the prevention of cardiovascular disease. Dyslipidemia affects a large population of women and is especially pervasive within racial/ethnic minorities.

Recent Findings

Dyslipidemia in pregnancy leads to worse outcomes for patients and creates increased cardiovascular risk for women at an older age. However, women remain underscreened and undertreated compared to men. Females also comprise a small portion of clinical trial participants for lipid lowering agents with increased disease prevalence compared to trial representation. However, recent lipid trials have shown different efficacies of therapies such as ezetimibe, inclisiran, and bempedoic acid with a greater relative benefit for women.

Summary

Pathophysiology of dyslipidemia varies between men and women and across a woman's lifetime. While increased lipid levels or lipid imbalances are more common in postmenopausal women over age 50, conditions such as PCOS and FH produce higher cardiovascular risk for young women.Best practices for management of women with dyslipidemia include early screening with lifestyle intervention and pharmacotherapy with statin and non-statin agents to achieve guideline directed LDL-C thresholds.

The contribution of metabolic risk factors to cardiovascular mortality in Golestan cohort study: Population attributable fraction estimation

Background

Cardiovascular diseases (CVDs) are the leading causes of global mortality and disability. Several studies demonstrated that metabolic risk factors increase cardiovascular mortality. The aim of this study is to examine CVDs deaths and population attributable fractions (PAFs) of their metabolic risk factors in Iran.

Methods

This is a study on 8621 participants aged 45-75 years and older, recruited in the repeated measurement phase of the Golestan cohort study (GCS) in northeast of Iran. The Cox proportional hazards model was used to determine the adjusted hazard ratios (HRs). PAFs were calculated to enumerate CVDs mortality avoidable in the population if metabolic risk factors were eliminated.

Results

The mortality of CVDs was attributable to metabolic factors, including high waist circumference (PAF, 28 %, [95 % CI: 16%-38 %]), high fasting blood sugar (FBS) (20 %, [15%-24 %]), overweight and obesity (19 %, [8%-28 %]), high blood pressure (16 %, [11%-21 %]), high low-density lipoprotein cholesterol (LDL-C) (8 %, [1%-15 %]), and high triglyceride (TG) (7 %, [3%-11 %]). Collectively, these metabolic risk factors accounted for 50 % of CVDs deaths. Females (67 %, [50%-78 %]) had a higher joint PAF of metabolic risk factors compared to males (43 %, [27%-55 %]).

Conclusions

The pattern of CVDs mortality attributable to metabolic risk factors in this study is not the same as similar studies in other parts of the world and previous studies in Iran. It is imperative that CVDs risk factors be specifically evaluated and addressed in various populations due to variety in geographical and temporal patterns in contribution of metabolic risk factors to CVD mortality.

Italian Association of Hospital Cardiologists Position Paper 'Gender discrepancy: time to implement gender-based clinical management'

It has been well assessed that women have been widely under-represented in cardiovascular clinical trials. Moreover, a significant discrepancy in pharmacological and interventional strategies has been reported. Therefore, poor outcomes and more significant mortality have been shown in many diseases. Pharmacokinetic and pharmacodynamic differences in drug metabolism have also been described so that effectiveness could be different according to sex. However, awareness about the gender gap remains too scarce. Consequently, gender-specific guidelines are lacking, and the need for a sex-specific approach has become more evident in the last few years. This paper aims to evaluate different therapeutic approaches to managing the most common women's diseases.

The effect of tibolone treatment on apolipoproteins and lipoprotein (a) concentrations in postmenopausal women: A meta-analysis of randomized controlled trials

OBJECTIVE

Tibolone is a synthetic steroid with estrogenic, androgenic and progestogenic properties that is used as hormone replacement therapy (HRT) in postmenopausal women. Treatment with tibolone has been demonstrated to lead to changes of the lipid profile, including alterations in lipoprotein (a) and apolipoprotein levels. Hence, we conducted the present meta-analysis of randomized controlled trials (RCTs) to assess the effect of tibolone treatment on apolipoproteins and lipoprotein (a) values in postmenopausal women.

METHODS

Several databases (Cochrane Library, PubMed/Medline, Scopus, and Google Scholar) were searched for English-language manuscripts published up to September 2023 that scrutinized the effects of tibolone administration on apolipoprotein A-I (ApoA-I), apolipoprotein A-II (ApoA-II), apolipoprotein B (ApoB), and lipoprotein (a) in postmenopausal women. The results were reported as the weighted mean difference (WMD) with a 95% confidence interval (CI), generated using a random-effects model.

RESULTS

Finally, 12 publications with 13 RCT arms were included in the current meta-analysis. The overall results from the random-effects model demonstrated a notable reduction in ApoA-I (n = 9 RCT arms, WMD: -34.96 mg/dL, 95 % CI: -42.44, -27.48, P < 0.001) and lipoprotein (a) (n = 12 RCT arms, WMD: -7.49 mg/dl, 95 % CI: -12.17, -2.81, P = 0.002) after tibolone administration in postmenopausal women. However, treatment with tibolone did not impact ApoA- II (n = 4 RCT arms, WMD: 1.32 mg/dL, 95 % CI: -4.39, 7.05, P = 0.64) and ApoB (n = 9 RCT arms, WMD: -2.68 mg/dL, 95 % CI: -20.98, 15.61, P = 0.77) values. In the subgroup analyses, we noticed a notable decrease in lipoprotein (a) levels when tibolone was prescribed to females aged < 60 years (WMD: -10.78 mg/dl) and when it was prescribed for ≤ 6 months (WMD: -15.69 mg/dl).

CONCLUSION

The present meta-analysis of RCTs highlighted that treatment with tibolone reduces lipoprotein (a) and apolipoprotein A-I levels in postmenopausal women. As the decrease in serum lipids' concentrations is associated with a decrease in the risk of cardiovascular disease (CVD), treatment with tibolone could be a suitable therapy for postmenopausal women with elevated CVD risk.

Improving Cardiovascular Risk in Postmenopausal Women with an (-)-Epicatechin-Based Nutraceutical: A Randomly Assigned, Double-Blind vs. Placebo, Proof-of-Concept Trial

BACKGROUND

Age-adjusted rates of cardiovascular disease (CVD) are higher in men than in women. CVD risk-factor outcomes are underrecognized, underestimated, and undertreated in women because the clinical expressions in women differ from those of men. There are no universally accepted recommendations on what to do in women when the values of fasting glucose, blood pressure, and lipids are only slightly altered or at borderline values. We reported the positive effects on CVD risk markers using cacao by-products, showing that alternative approaches can be used to prevent cardiovascular disease in women. The objective was to evaluate the changes in lipoprotein subfractions induced by three months of treatment with an epicatechin-enriched cacao supplement.

METHODS

A double-blind, placebo-controlled proof-of-concept study was developed to evaluate the effects of 3 months of treatment with an (-)-epicatechin-enriched cacao supplement on lipoprotein subfractions.

RESULTS

The usual screening workshop for postmenopausal women could be insufficient and misleading. Assessing the effect of a (-)-epicatechin-enriched cacao supplement employing a lipoprotein subfractionation profile analysis suggests a decrease in cardiovascular risk.

CONCLUSIONS

A simple, low-cost, safe (-)-epicatechin-enriched cacao supplement product can improve the cardiovascular risk in postmenopausal women.

Menopause Predisposes Women to Increased Risk of Cardiovascular Disease

(1) Background: Menopause is an important event in women's lives, possibly contributing to the development of CVD, which is associated with changes in the cardiovascular risk profile, markers of metabolic health, and subclinical atherosclerosis. The aim of this study was to assess the association of menopause with CVD risk factors and subclinical markers of cardiometabolic disease. (2) Methods: The study involved 235 women from the general population at different stages of menopause. The methods used in this study were: diagnostic survey, anthropometric measurement (WC, height, BMI, WHtR), blood pressure measurement, biochemical analysis of venous blood (lipid profile, glucose, insulin, HbA1c), and CVD risk assessment (ASCVD Risk Calculator, POL-SCORE, SCORE-2). (3) Results: The vast majority of respondents had low cardiovascular risk, irrespective of the scale used for measuring the risk of CVD. The age at menopause was not an independent risk factor for CVD. In Model 1, the age at menopause and the time since menopause were found to be factors that increased CVD risk (OR = 1.186 and 1.267, respectively). In Models 2 and 3, the severity of menopausal symptoms was not a risk factor for CVD. Models 3 and 4 demonstrated that women with metabolic syndrome (MetS) were at a significantly higher risk of CVD. In model 5, the odds ratio of CVD with MetS as a standalone factor was 13.812. (4) Conclusions: Menopause predisposes women to an increased risk and MetS to a significantly higher risk of CVD.

Gender Differences in Subclinical Coronary Atherosclerosis in the Asian Population With a Coronary Artery Calcium Score of Zero

There is little evidence on whether gender difference influences the incidence of subclinical coronary atherosclerosis in Asian populations with a 0 score. In this study, we investigated the influence of age and gender on the extent of subclinical coronary atherosclerotic burden within a healthy Asian population with a 0 coronary artery calcium (CAC) score. A total of 934 participants (320 women and 614 men) from Taiwan's Han Chinese population with an initial CAC score of 0 were included in this study. They underwent 2 consecutive cardiac computed tomography scans over a clinical follow-up period of 4.35 ± 2.37 years. Clinical information and laboratory measurements were collected for analysis. Compared with the female group, the male group demonstrated significantly higher rates of subclinical CAC progression (27.4% vs 13.8%, p <0.001). Across the age group deciles (≤40, 41 to 50, 51 to 60, ≥61 years), the male group had a higher prevalence of subclinical CAC progression than the female group. For the subclinical CAC progression, the logistic regression model demonstrated that age, gender (male gender), cholesterol level, and follow-up period were statistically significant parameters. In conclusion, these findings support that a gender difference impacts the long-term natural course of subclinical coronary calcification conversion in women compared with men, suggesting that the gender-based effect on coronary CAC conversion plays an important role in subclinical coronary atherosclerosis risk stratification in personalized preventive medicine.

Role of estrogen in the regulation of central and peripheral energy homeostasis: from a menopausal perspective

Estrogen plays a prominent role in regulating and coordinating energy homeostasis throughout the growth, development, reproduction, and aging of women. Estrogen receptors (ERs) are widely expressed in the brain and nearly all tissues of the body. Within the brain, central estrogen via ER regulates appetite and energy expenditure and maintains cell glucose metabolism, including glucose transport, aerobic glycolysis, and mitochondrial function. In the whole body, estrogen has shown beneficial effects on weight control, fat distribution, glucose and insulin resistance, and adipokine secretion. As demonstrated by multiple in vitro and in vivo studies, menopause-related decline of circulating estrogen may induce the disturbance of metabolic signals and a significant decrease in bioenergetics, which could trigger an increased incidence of late-onset Alzheimer's disease, type 2 diabetes mellitus, hypertension, and cardiovascular diseases in postmenopausal women. In this article, we have systematically reviewed the role of estrogen and ERs in body composition and lipid/glucose profile variation occurring with menopause, which may provide a better insight into the efficacy of hormone therapy in maintaining energy metabolic homeostasis and hold a clue for development of novel therapeutic approaches for target tissue diseases.

The Impact of Menopause on Cardiovascular Aging: A Comprehensive Review of Androgen Influences

Menopause represents a critical life stage in women, characterized by hormonal changes that significantly impact cardiovascular health. While the decline in estrogen levels has long been recognized as a major contributor to cardiovascular aging in menopausal women, the role of androgens, particularly testosterone, has gained increasing attention in recent years. This comprehensive review aims to provide a thorough understanding of the impact of menopause on cardiovascular aging, with a specific focus on the influences of androgens. A literature search was conducted to gather relevant studies and clinical evidence exploring the relationship between menopause, androgens, and cardiovascular health. The review integrates findings from various studies to present a holistic view of the topic. The review outlines the changes in hormone levels during menopause and discusses the cardiovascular risk factors associated with this transition. Furthermore, it explores the impact of menopause on cardiovascular structure and function, elucidating the underlying mechanisms that contribute to cardiovascular aging. Androgens' significance in maintaining cardiovascular homeostasis is discussed, followed by exploring the effects of androgen decline during menopause on lipid profiles, insulin sensitivity, vascular function, and other cardiovascular parameters. The review delves into the mechanisms of androgen action on the cardiovascular system, emphasizing the role of androgen receptors and the intricate interplay between androgens, estrogens, and other hormones. Clinical evidence supporting the effects of androgens on cardiovascular aging is presented, including studies investigating the association between androgen levels and cardiovascular outcomes. Additionally, the impact of androgen replacement therapy (ART) on cardiovascular risk markers and events in menopausal women is examined, along with controversies and conflicting findings surrounding the use of androgen therapy in cardiovascular aging. This structured review provides a comprehensive understanding of the impact of menopause on cardiovascular aging, with a specific focus on the role of androgens. By highlighting the significance of androgens in cardiovascular health during menopause, this review aims to create an initial impression and interest among readers, inviting potential citations in the future. The findings underscore the need for further research and offer insights into managing cardiovascular aging in menopausal women, including lifestyle interventions, pharmacological approaches, and the potential role of personalized medicine and precision therapies.

Association between weekend catch-up sleep and hyperuricemia with insufficient sleep in postmenopausal Korean women: a nationwide cross-sectional study

OBJECTIVE

Hyperuricemia is associated with metabolic and cardiovascular diseases and mortality. Efforts to lower the risk of hyperuricemia in various ways are needed as the prevalence of these diseases increases in postmenopausal women. Studies have shown that one of these methods is associated with adequate sleep duration, which is related to a low risk of hyperuricemia. Considering that it is difficult for people to get enough sleep in modern society, this study hypothesized that weekend catch-up sleep could be an alternative. To our knowledge, no past study has investigated the relation between weekend catch-up sleep and hyperuricemia in postmenopausal women. Hence, the aim of this research was to estimate the relation between weekend catch-up sleep and hyperuricemia with insufficient sleep in postmenopausal women during weekday or workday.

METHODS

This study included 1,877 participants extracted from the Korea National Health and Nutrition Examination Survey VII. The study population was divided into weekend catch-up sleep and non-weekend catch-up sleep groups. Odds ratios with 95% confidence intervals were derived using multiple logistic regression analysis.

RESULTS

Weekend catch-up sleep had a significantly lower prevalence of hyperuricemia after adjusting for confounders (odds ratio, 0.758 [95% confidence interval, 0.576-0.997]). In a subgroup analysis, weekend catch-up sleep of 1 to 2 hours was significantly correlated with a lower prevalence of hyperuricemia after adjusting for confounders (odds ratio: 0.522 [95% confidence interval, 0.323-0.845]).

CONCLUSIONS

Weekend catch-up sleep had a decreased prevalence of hyperuricemia in postmenopausal women with sleep deprivation.

Relationship Between the Single Nucleotide Polymorphism rs11558471 in the SLC30A8/ZnT8 Gene and Cardiometabolic Markers in Postmenopausal Women

Postmenopausal women have more risk factors for metabolic syndrome, and genetic alterations in SLC30A8 (zinc transporter 8 [ZnT8]) are directly related to these factors. Our aim was to assess the relationship of the single nucleotide polymorphism (SNP) rs11558471 in the SLC30A8/ZnT8 gene with cardiometabolic markers in postmenopausal women. This cross-sectional study included 53 postmenopausal women divided into two groups according to the SNP genotype (AG + GG [n = 25] and AA [n = 28]). Anthropometric, dietary, and biochemical (glycemic, lipidic, hepatic, renal, and hormonal markers) variables were evaluated and compared between groups. No differences in glycemic, hepatic, renal, and hormonal markers were found between groups. However, the group with the polymorphic allele (AG + GG) had a better lipid profile than non-carriers (total cholesterol, p = 0.041; low-density lipoprotein cholesterol [LDL-c], p = 0.035; non-high-density lipoprotein cholesterol [non-HDL-c], p = 0.043). Logistic regression showed that the group with polymorphic allele had lower chances of increasing levels of LDL-c (odds ratio [OR] = 0.225, p = 0.012) and non-HDL-c (OR = 0.316, p = 0.045). After adjusting for age, body mass index, physical activity, and use of diabetes and dyslipidemia drugs, only LDL-c remained associated (OR = 0.218; p = 0.017). The variant allele of SNP rs11558471 in the SLC30A8 gene was associated with better LDL-c levels, which helps reduce the risks for cardiovascular diseases in postmenopausal women.

Gender Differences and Cardiometabolic Risk: The Importance of the Risk Factors

Metabolic syndrome (Mets) is a clinical condition characterized by a cluster of major risk factors for cardiovascular disease (CVD) and type 2 diabetes: proatherogenic dyslipidemia, elevated blood pressure, dysglycemia, and abdominal obesity. Each risk factor has an independent effect, but, when aggregated, they become synergistic, doubling the risk of developing cardiovascular diseases and causing a 1.5-fold increase in all-cause mortality. We will highlight gender differences in the epidemiology, etiology, pathophysiology, and clinical expression of the aforementioned Mets components. Moreover, we will discuss gender differences in new biochemical markers of metabolic syndrome and cardiovascular risk.

Cardio-Metabolic Health and HRT in Menopause: Novel Insights in Mitochondrial Biogenesis and RAAS

Recent evidence shows the cardiometabolic effects of estrogen administration in postmenopausal women. Women have a cardiometabolic advantage during their reproductive years, which is lost at menopause due to declining estradiol (E2). E2, also known as 17-beta-estradiol, has diverse effects in its target tissues, including the cardiovascular (CV) system, through genomic and non-genomic signaling. Metabolic changes characteristic of menopause include a worsening lipid profile, changes in body fat distribution, epicardial and pericardial fat deposition, increased susceptibility to weight gain, and increased blood pressure, resulting in an increased risk of accelerated cardiovascular disease (CVD) development. E2 mediates its cardioprotective actions by increasing mitochondrial biogenesis, angiogenesis, and vasodilation, decreasing reactive oxygen species (ROS) and oxidative stress, and modulating the renin-angiotensin-aldosterone system (RAAS). In this review, we assess whether it is prudent to develop an approach to managing postmenopausal women based on modifying the patient's CV risk that includes human-identical hormone replacement therapy (HRT), modulation of RAAS, and stimulating mitochondrial biogenesis. Further research is needed to assess the safety and benefit of HRT to reduce cardiometabolic risk.

Pharmacological clearance of senescent cells improves cardiac remodeling and function after myocardial infarction in female aged mice

Cardiovascular diseases (CVD) are predominantly an aging disease. Important sex-specific differences exist and the mechanism(s) by which this sex-by-age interaction influences CVD development and progression remains elusive. Accordingly, it is still unknown whether cell senescence, a main feature of cardiac male aging, is a significant feature also of the female aged mouse heart and whether senolytics, senescence-clearing compounds, promote myocardial repair and regeneration after myocardial infarction (MI) in aged female mice. To this aim, the combination of two senolytics, dasatinib and quercetin (D+Q) or just their vehicle was administered to 22-24 months old C57BL/6 female mice after MI. D+Q improved global left ventricle function and myocardial performance after MI whereby female cardiac aging is characterized by accumulation of cardiac senescent cells that are further increased by MI. Despite their terminal differentiation nature, also cardiomyocytes acquire a senescent phenotype with age in females. D+Q removed senescent cardiac non-myocyte and myocyte cells ameliorating cardiac remodeling and regeneration. Senolytics removed aged dysfunctional cardiac stem/progenitor cells (CSCs), relieving healthy CSCs with normal proliferative and cardiomyogenic differentiation potential. In conclusions, cardiac senescent cells accumulate in the aged female hearts. Removing senescent cells is a key therapeutic target for efficient repair of the aged female heart.

Additive damage in the thromboxane related vasoconstriction and bradykinin relaxation of intramural coronary resistance arterioles in a rodent model of andropausal hypertension

Hypertension and andropause both accelerate age–related vascular deterioration. We aimed to evaluate the effects of angiotensin-II induced hypertension and deficiency of testosterone combined regarding the resistance coronaries found intramurally.

Four male groups were formed from the animals: control group (Co, n = 10); the group that underwenr orchidectomy (ORC, n = 13), those that received an infusion of angiotensin-II (AII, n = 10) and a grous that received AII infusion and were also surgically orchidectomized (AII + ORC, n = 8). AII and AII + ORC animals were infused with infusing angiotensin-II (100 ng/min/kg) using osmotic minipumps. Orchidectomy was perfomed in the ORC and the AII + ORC groupsto establish deficiency regarding testosterone. Following four weeks of treatment, pressure-arteriography was performed in vitro, and the tone induced by administration of thromboxane-agonist (U46619) and bradykinin during analysis of the intramural coronaries (well-known to be resistance arterioles) was studied.

U46619-induced vasoconstriction poved to be significantly decreased in the ORC and AII + ORC groups when compared with Co and AII animals. In ORC and AII + ORC groups, the bradykinin-induced relaxation was also significantly reduced to a greater extent compared to Co and AII rats. Following orchidectomy, the vasocontraction and vasodilatation capacity of blood vessels is reduced. The effect of testosterone deficiency on constrictor tone and relaxation remains pronounced even in AII hypertension: testosterone deficiency further narrows adaptation range in the double noxa (AII + ORC) group. Our studies suggest that vascular changes caused by high blood pressure and testosterone deficiency together may significantly increase age-related cardiovascular risk.

Gender Differences in Coronary Artery Disease, Clinical Characteristics, and Angiographic Features in the Jazan Region, Saudi Arabia

BACKGROUND

Cardiovascular disease is a major cause of death worldwide. In Saudi Arabia and the gulf area, coronary artery disease (CAD) is considered a serious problem with high mortality. Previous studies identified multiple risk factors, that include hypertension, diabetes, dyslipidemia, obesity, smoking, and low physical activity, which might be related to lifestyle changes over the last few decades. Limited data about gender differences in clinical and angiographic characteristics among CAD patients in the Jazan region are available. The aim of this study is to assess potential gender differences in CAD and its clinical characteristics and angiographic features in the Jazan region.

METHODS

This retrospective chart review collected data between January 2020 and March 2021 from the follow-ups of 498 patients (100 females and 398 males) aged over 18 years at the Prince Mohammed bin Nasser Hospital in the Jazan region of Saudi Arabia. The data were collected after all patients admitted to the hospital were reviewed, and cardiac catheterization was performed.

RESULTS

Of the 498 patients with CAD, 100 (20.1%) were female and 398 (79.9%) were male. The mean age of female patients (59.44 years) was significantly higher than that of male patients (55.1 years; P=0.0002). In addition, risk factors differed significantly between genders (P=0.0210). Moreover, vessels differed significantly between genders (P=0.0002). Coronary angiogram findings showed significant correlations between gender and percutaneous coronary intervention (PCI; P=0.0001) and MEDICAL (P=0.0010). Diagnosis findings showed significant gender differences in STEMI (P<0.0010) and unstable angina (P<0.0010).

CONCLUSIONS

CAD severity did not differ by gender, but coronary angiogram findings showed significant relationships between gender, PCI, and MEDICAL treatment with CAD.

Traditional and Emerging Sex-Specific Risk Factors for Cardiovascular Disease in Women

Cardiovascular disease (CVD) remains a major health threat in women. While traditional CVD risk factors such as hypertension, hyperlipidemia, diabetes, and smoking have been recognized for over 50 years, optimal control of these risk factors remains a major challenge. Unique sex-specific risk factors such as adverse pregnancy outcomes, premature menopause and low estrogen states, and chronic autoimmune inflammatory disorders also contribute to increased CVD risk in women. In addition, psychological risk factors such as stress, depression, and social determinants of health may have a disproportionately adverse impact in women. An improved understanding of traditional and emerging sex-specific CVD risk factors and management of modifiable factors is critical for clinicians who provide care for women. Early recognition and treatment of risk factors may alter the trajectory of adverse CVD events. A multi-disciplinary approach with team-based care involving multiple specialists and improved, targeted educational efforts are needed to reduce CVD risk factors and its adverse consequences in women.

It Takes a Village: Expanding Women's Cardiovascular Care to Include the Community as well as Cardiovascular and Primary Care Teams

Purpose of Review

Our aim is to highlight some of the current issues that prevent women from getting sex-specific and gender-specific cardiovascular care and provide recommendations for new approaches and delivery models to improve cardiovascular care for all women.

Recent Findings

Cardiovascular disease remains the number one cause of death for women in the US. Many women remain unaware of cardiovascular risk factors and many healthcare providers who care for women are also poorly informed and feel ill prepared to assess women for cardiovascular risk. Women’s Heart Centers have tried to bridge the gaps in women’s care between primary care and cardiology. Many of the impediments to care in the current models are lack of comprehensive care and socioeconomic societal limitations.

Summary

New models of care and delivery are essential to change cardiovascular outcomes for all women, especially women at high risk.

Update on hormone therapy for the management of postmenopausal women

Hormone therapy (HT) has been used in postmenopausal women for decades in clinical practice. With further analysis and newer studies, the benefits and risks of HT have been repeatedly verified and discussed. HT is recommended for the treatment of vasomotor symptoms (VMS), genitourinary syndrome of menopause (GSM) and the prevention of osteoporosis. However, the precise association between HT and the risks of cardiovascular diseases, venous thromboembolism, neurodegenerative diseases, breast cancer, and endometrial cancer remains controversial. Therefore, determining how to take advantage of and control the risks of HT by adjusting the initiation time, regimen, and duration is crucial. Recent studies have indicated that HT is not related to the risk of all-cause, cardiovascular, or breast cancer mortality although it might increase the incidence of some chronic diseases. For symptomatic postmenopausal women under the age of 60 without contraindications, early initiation of HT is safe and probably has a mortality benefit over the long term. Initiating HT close to menopause at the lowest effective dose is more likely to have maximal benefits and the lowest risks. Transdermal and vaginal HT may have a lower risk, but recent evidence suggests additional clinical benefits of oral HT formulations in relieving VMS and preventing osteoporosis. The pooled cohort risk equation for atherosclerotic cardiovascular disease (ASCVD) and the free app named Menopro can be used to perform individual risk assessments. In addition, Chinese herbal medicines have benefits in alleviating hot flashes, depression, and menopausal symptoms, although further data are needed to strongly support their efficacy. Acupuncture and electroacupuncture have definite efficacy in the treatment of postmenopausal symptoms with few adverse effects, so they are a reasonable option as an alternative therapy for high-risk women. This review discusses the history of, guidelines on, and strategies for HT in order to make suggestions based on the most up-to-date evidence for the management of postmenopausal women.

Cardiovascular Disease in Women Update: Ischemia, Diagnostic Testing, and Menopause Hormone Therapy

OBJECTIVE

This update will address 3 areas specifically that are essential to improving cardiovascular outcomes for women.

METHODS

The current literature has been reviewed and three important areas of cardiovascular care in women are highlighted. First is that even though women and men share many traditional risk factors for ischemic heart disease, several of these risk factors affect women disproportionately when it comes to CVD risk and events. There are also unique sex-specific risk factors for women and risk factors that are more common in women than in men. Adverse outcomes of pregnancy and hypertensive disorders of pregnancy are associated with an increased long-term risk of CVD and events. At menopause, cardiovascular risks increase, and lipids become unfavorable. Second is that diagnostic testing for ischemic heart disease presents different specificities and sensitivities between men and women and testing should be determined according to what is best and safest for women. Third is that currently, menopause hormone therapy is approved by the U.S. Food and Drug Administration for the treatment of vasomotor and genitourinary symptoms, prevention of osteoporosis, and estrogen replacement in the setting of surgical menopause, hypogonadism, or premature ovarian insufficiency. It is not recommended for the primary or secondary prevention of CVD and not recommended for women with high atherosclerotic CVD risk.

RESULTS

Cardiovascular disease (CVD) remains the most common cause of death in women in the United States despite tremendous improvements in cardiovascular care for men and women. The prevention of CVD in women with early detection and implementation of preventive therapies before atherosclerotic CVD develops is critical to improving outcomes for women.

Arterial hypertension in women: Menopause as a risk window

OBJECTIVES

Cardiovascular diseases (CVD) exert a heavy toll on health of women, mainly due to hypertension said to cluster around the period of transition to menopause. This makes this period a good window to target for prevention and control. We therefore sought to determine if this period really heralds arterial hypertension and CVD in women in our environment.

STUDY DESIGN

We secondarily analysed our population data on CVD risk factors in free living rural residents.

MAIN OUTCOME VARIABLES

The data considered were blood pressure, anthropometric and biochemical variables in women stratified based on menstruation status.

RESULTS

There were 488 females, with 218 still menstruating. They were younger (p = .000), had lower systolic and diastolic blood pressures (p = .000), lower anthropometric indices attaining significance only with waist circumference (p = .001) and lower total cholesterol (p = .001). Controlling for age, statistically significant differences remained for systolic and diastolic blood pressures, body mass index, waist and hip circumferences, and total cholesterol.

CONCLUSION

The menopause transition comes with a worse CVD profile. Blood pressure rises and so are the anthropometric variables and some biochemical parameters that fuel CVD. This could be ascribed to age which is higher with those post-menopausal. Controlling for age in this cohort still showed that transiting from pre- to post-menopause still came with CVD burden. Clinicians should take the opportunity presented by menopause transition to screen for CVD risk factors and initiate either preventive or control measures to mitigate morbi-mortality consequences.

Toll-Like Receptors Represent an Important Link for Sex Differences in Cardiovascular Aging and Diseases

Human life span expectancy has increased, and aging affects the organism in several ways, leading, for example, to an increased risk of cardiovascular diseases. Age-adjusted prevalence of the cardiovascular diseases is higher in males than females. Aging also affects the gonadal sex hormones and the sex differences observed in cardiovascular diseases may be therefore impacted. Hormonal changes associated with aging may also affect the immune system and the immune response is sexually different. The immune system plays a role in the pathogenesis of cardiovascular diseases. In this context, toll-like receptors (TLRs) are a family of pattern recognition receptors of the immune system whose activation induces the synthesis of pro-inflammatory molecules. They are expressed throughout the cardiovascular system and their activation has been widely described in cardiovascular diseases. Some recent evidence demonstrates that there are sex differences associated with TLR responses and that these receptors may be affected by sex hormones and their receptors, suggesting that TLRs may contribute to the sex differences observed in cardiovascular diseases. Recent evidence also shows that sex differences of TLRs in cardiovascular system persists with aging, which may represent a new paradigm about the mechanisms that contribute to the sex differences in cardiovascular aging. Therefore, in this mini review we describe the latest findings regarding the sex differences of TLRs and associated signaling in cardiovascular diseases during aging.