Strategies and methods to study female-specific cardiovascular health and disease: a guide for clinical scientists

Incorporating reproductive system history data into cardiovascular nursing research to advance women's health

The lack of sex-specific variables, such as reproductive system history (RSH), in cardiovascular research studies is a missed opportunity to address the cardiovascular disease (CVD) burden, especially among women who face sex-specific risks of developing CVD. Collecting RSH data from women enrolled in research studies is an important step towards improving women's cardiovascular health. In this paper, we describe two approaches to collecting RSH in CVD research: extracting RSH from the medical record and participant self-report of RSH. We provide specific examples from our own research and address common data management and statistical analysis problems when dealing with RSH data in research.

Sex as a biological variable for cardiovascular physiology

There have been ongoing efforts by federal agencies and scientific communities since the early 1990s to incorporate sex and/or gender in all aspects of cardiovascular research. Scientific journals provide a critical function as change agents to influence transformation by encouraging submissions for topic areas, and by setting standards and expectations for articles submitted to the journal. As part of ongoing efforts to advance sex and gender in cardiovascular physiology research, the American Journal of Physiology-Heart and Circulatory Physiology recently launched a call for papers on Considering Sex as a Biological Variable. This call was an overwhelming success, resulting in 78 articles published in this collection. This review summarizes the major themes of the collection, including Sex as a Biological Variable Within: Endothelial Cell and Vascular Physiology, Cardiovascular Immunity and Inflammation, Metabolism and Mitochondrial Energy, Extracellular Matrix Turnover and Fibrosis, Neurohormonal Signaling, and Cardiovascular Clinical and Epidemiology Assessments. Several articles also focused on establishing rigor and reproducibility of key physiological measurements involved in cardiovascular health and disease, as well as recommendations and considerations for study design. Combined, these articles summarize our current understanding of sex and gender influences on cardiovascular physiology and pathophysiology and provide insight into future directions needed to further expand our knowledge.

Guidelines on the use of sex and gender in cardiovascular research

In cardiovascular research, sex and gender have not typically been considered in research design and reporting until recently. This has resulted in clinical research findings from which not only all women, but also gender-diverse individuals have been excluded. The resulting dearth of data has led to a lack of sex- and gender-specific clinical guidelines and raises serious questions about evidence-based care. Basic research has also excluded considerations of sex. Including sex and/or gender as research variables not only has the potential to improve the health of society overall now, but it also provides a foundation of knowledge on which to build future advances. The goal of this guidelines article is to provide advice on best practices to include sex and gender considerations in study design, as well as data collection, analysis, and interpretation to optimally establish rigor and reproducibility needed to inform clinical decision-making and improve outcomes. In cardiovascular physiology, incorporating sex and gender is a necessary component when optimally designing and executing research plans. The guidelines serve as the first guidance on how to include sex and gender in cardiovascular research. We provide here a beginning path toward achieving this goal and improve the ability of the research community to interpret results through a sex and gender lens to enable comparison across studies and laboratories, resulting in better health for all.

Sexual Dimorphism in Cardiovascular Biomarkers: Clinical and Research Implications

Sex-based differences in cardiovascular disease presentation, diagnosis, and response to therapies are well established, but mechanistic understanding and translation to clinical applications are limited. Blood-based biomarkers have become an important tool for interrogating biologic pathways. Understanding sexual dimorphism in the relationship between biomarkers and cardiovascular disease will enhance our insights into cardiovascular disease pathogenesis in women, with potential to translate to improved individualized care for men and women with or at risk for cardiovascular disease. In this review, we examine how biologic sex associates with differential levels of blood-based biomarkers and influences the effect of biomarkers on disease outcomes. We further summarize key differences in blood-based cardiovascular biomarkers along central biologic pathways, including myocardial stretch/injury, inflammation, adipose tissue metabolism, and fibrosis pathways in men versus women. Finally, we present recommendations for leveraging our current knowledge of sex differences in blood-based biomarkers for future research and clinical innovation.

Association of Sex and Age With Mild Traumatic Brain Injury-Related Symptoms: A TRACK-TBI Study

IMPORTANCE

Knowledge of differences in mild traumatic brain injury (mTBI) recovery by sex and age may inform individualized treatment of these patients.

OBJECTIVE

To identify sex-related differences in symptom recovery from mTBI; secondarily, to explore age differences within women, who demonstrate poorer outcomes after TBI.

DESIGN, SETTING, AND PARTICIPANTS

The prospective cohort study Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) recruited 2000 patients with mTBI from February 26, 2014, to July 3, 2018, and 299 patients with orthopedic trauma (who served as controls) from January 26, 2016, to July 27, 2018. Patients were recruited from 18 level I trauma centers and followed up for 12 months. Data were analyzed from August 19, 2020, to March 3, 2021.

EXPOSURES

Patients with mTBI (defined by a Glasgow Coma Scale score of 13-15) triaged to head computed tomography in 24 hours or less; patients with orthopedic trauma served as controls.

MAIN OUTCOMES AND MEASURES

Measured outcomes included (1) the Rivermead Post Concussion Symptoms Questionnaire (RPQ), a 16-item self-report scale that assesses postconcussion symptom severity over the past 7 days relative to preinjury; (2) the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5), a 20-item test that measures the severity of posttraumatic stress disorder symptoms; (3) the Patient Health Questionnaire-9 (PHQ-9), a 9-item scale that measures depression based on symptom frequency over the past 2 weeks; and (4) the Brief Symptom Inventory-18 (BSI-18), an 18-item scale of psychological distress (split into Depression and Anxiety subscales).

RESULTS

A total of 2000 patients with mTBI (1331 men [67%; mean (SD) age, 41.0 (17.3) years; 1026 White (78%)] and 669 women [33%; mean (SD) age, 43.0 (18.5) years; 505 (76%) White]). After adjustment of multiple comparisons, significant TBI × sex interactions were observed for cognitive symptoms (B = 0.76; 5% false discovery rate-corrected P = .02) and somatic RPQ symptoms (B = 0.80; 5% false discovery rate-corrected P = .02), with worse symptoms in women with mTBI than men, but no sex difference in symptoms in control patients with orthopedic trauma. Within the female patients evaluated, there was a significant TBI × age interaction for somatic RPQ symptoms, which were worse in female patients with mTBI aged 35 to 49 years compared with those aged 17 to 34 years (B = 1.65; P = .02) or older than 50 years (B = 1.66; P = .02).

CONCLUSIONS AND RELEVANCE

This study found that women were more vulnerable than men to persistent mTBI-related cognitive and somatic symptoms, whereas no sex difference in symptom burden was seen after orthopedic injury. Postconcussion symptoms were also worse in women aged 35 to 49 years than in younger and older women, but further investigation is needed to corroborate these findings and to identify the mechanisms involved. Results suggest that individualized clinical management of mTBI should consider sex and age, as some women are especially predisposed to chronic postconcussion symptoms even 12 months after injury.

Menopausal Vasomotor Symptoms and Risk of Incident Cardiovascular Disease Events in SWAN

Background

Cardiovascular disease (CVD) in women has unique features, including associations with reproductive factors that are incompletely understood. Vasomotor symptoms (VMS), the classic menopausal symptom, are linked to CVD risk factors and subclinical CVD. Evidence linking VMS to CVD events is limited. We tested whether frequent and/or persistent VMS were associated with increased risk for fatal and nonfatal CVD events in SWAN (Study of Women’s Health Across the Nation).

Methods and Results

A total of 3083 women, aged 42 to 52 years at baseline, underwent up to 16 in‐person visits over 22 years. Assessments included questionnaires on VMS frequency (0, 1–5, or ≥6 days/2 weeks), physical measures, phlebotomy, and reported CVD events (myocardial infarction, stroke, heart failure, and revascularization). A subset of events was adjudicated via medical record. Death certificates were obtained. Relationships between baseline VMS or persistent VMS over the follow‐up (proportion of visits with frequent VMS) with combined incident nonfatal and fatal CVD were tested in Cox proportional hazards models adjusted for demographics, medication use, and CVD risk factors. Participants experienced 231 CVD events over the follow‐up. Women with frequent baseline VMS had an elevated risk of subsequent CVD events (relative to no VMS; ≥6 days: hazard ratio [HR] [95% CI], 1.51 [1.05–2.17], P=0.03; 1–5 days: HR [95% CI], 1.02 [0.75–1.39], P=0.89, multivariable). Women with frequent VMS that persisted over time also had an increased CVD event risk (>33% versus ≤33% of visits: HR [95% CI], 1.77 [1.33–2.35], P<0.0001, multivariable).

Conclusions

Frequent and persistent VMS were associated with increased risk of later CVD events. VMS may represent a novel female‐specific CVD risk factor.

Structure of communities in semantic networks of biomedical research on disparities in health and sexism

Introducción.

Como una iniciativa para mejorar la calidad de la atención sanitaria, en la investigación biomédica se ha incrementado la tendencia centrada en el estudio de las disparidades en salud y sexismo.

Objetivo.

Caracterizar la evidencia científica sobre la disparidad en salud definida como la brecha existente entre la distribución de la salud y el posible sesgo por sexo en el acceso a los servicios médicos.

Materiales y métodos.

Se hizo una búsqueda simultánea de la literatura científica en la base de datos Medline PubMed de dos descriptores fundamentales: Healthcare disparities y Sexism. Posteriormente, se construyó una red semántica principal y se determinaron algunas subunidades estructurales (comunidades) para el análisis de los patrones de organización de la información. Se utilizó el programa de código abierto Cytoscape para el analisis y la visualización de las redes y el MapEquation, para la detección de comunidades. Asimismo, se desarrolló código ex profeso disponible en un repositorio de acceso público.

Resultados.

El corpus de la red principal mostró que los términos sobre las enfermedades del corazón fueron los descriptores de condiciones médicas más concurrentes. A partir de las subunidades estructurales, se determinaron los patrones de información relacionada con las políticas públicas, los servicios de salud, los factores sociales determinantes y los factores de riesgo, pero con cierta tendencia a mantenerse indirectamente conectados con los nodos relacionados con condiciones médicas.

Conclusiones.

La evidencia científica indica que la disparidad por sexo sí importa para la calidad de la atención de muchas enfermedades, especialmente aquellas relacionadas con el sistema circulatorio. Sin embargo, aún se percibe un distanciamiento entre los factores médicos y los sociales que dan lugar a las posibles disparidades por sexo.

Higher urinary nitrate was associated with lower prevalence of congestive heart failure: results from NHANES

Background

Some studies have reported that nitrate intake from vegetables was inversely associated with many vascular diseases, but few studies have paid attention to the relationship between urinary nitrate and cardiovascular diseases (CVDs). This cross-sectional study aimed to explore the connections between urinary nitrate and prevalence of CVDs.

Methods

The data of this study was collected from National Health and Nutrition Examination Survey (NHANES). Finally, several years’ data of NHANES were merged into 14,894 observations. Logistic regression models were used to examine the associations between urinary nitrate and CVDs by using the “survey” package in R software (version 3.2.3).

Results

In the univariable logistic analysis, significant association was discovered between urinary nitrate and congestive heart failure, coronary heart disease, angina pectoris, myocardial infarction (all P < 0.001). By adjusting related covariates, the multivariable logistic analysis showed that the significant association only existed between urinary nitrate and congestive heart failure (OR = 0.651, 95% CI 0.507–0.838, P < 0.001). Compared to Q1 urinary nitrate level as reference, the risk for prevalent heart failure diminished along with increasing levels of urinary nitrates, (OR of Q2 level = 0.633, 95% CI 0.403–0.994), (OR of Q3 level = 0.425, 95% CI 0.230–0.783), (OR of Q4 level = 0.375, 95% CI 0.210–0.661), respectively. Moreover, urinary nitrate levels were associated with congestive heart failure in a dose-dependent manner in both 20–60 years group, 60+ years group and male, female group (P < 0.001, P = 0.011 and P = 0.009, P = 0.004).

Conclusions

Independent of related covariates, higher urinary nitrate was associated with lower prevalent congestive heart failure.

Depressive Symptoms in Women With Coronary Heart Disease: A Systematic Review of the Longitudinal Literature

BACKGROUND

Interpreting studies about women with coronary heart disease and depressive symptoms is challenging: women continue to be underrepresented in research; data are often not presented separately by sex; many studies do not examine depressive symptoms longitudinally, leaving our understanding incomplete; and the use of multiple depressive symptom assessment instruments makes comparisons between studies problematic.

PURPOSE

The authors of this systematic review examined 20 longitudinal descriptive studies on women with coronary heart disease and depressive symptoms, including prevalence of elevated symptoms, changes in symptoms over time, findings in women versus men, and findings based on assessment instruments.

CONCLUSIONS

The prevalence of elevated depressive symptoms in women was 35.75% at baseline (hospitalization). The Beck Depression Inventory II yielded the highest baseline prevalence (40.3%), slightly higher than the Depression Interview and Structured Hamilton Scale (36%). The Hospital Anxiety and Depression Scale and the Kellner questionnaire yielded much lower prevalence (21.45% and 23%, respectively). Higher prevalence was linked to inclusion of somatic symptoms on measurement instruments except in post-coronary bypass surgery patients. Symptoms trended toward improvement, particularly in the first 6 months, although a few studies measured beyond this time. Women demonstrated higher prevalence than men initially (35.75% vs 23.46%, respectively) and over 24 months (22.71% vs 19.82%, respectively).

CLINICAL IMPLICATIONS

Women experienced significantly more depressive symptoms than men initially and over time, although most women's symptoms improved. Measurement varies widely based on instrument and the inclusion/exclusion of somatic symptoms. More longitudinal studies beyond 6 months with prevalence data and analysis by sex/gender are needed.

Sex Differences in Ischemic Heart Disease: Advances, Obstacles, and Next Steps

Evolving knowledge of sex-specific presentations, improved recognition of conventional and novel risk factors, and expanded understanding of the sex-specific pathophysiology of ischemic heart disease have resulted in improved clinical outcomes in women. Yet, ischemic heart disease continues to be the leading cause of morbidity and mortality in women in the United States. The important publication by the Institute of Medicine titled "Women's Health Research-Progress, Pitfalls, and Promise," highlights the persistent disparities in cardiovascular disease burden among subgroups of women, particularly women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment. These important health disparities reflect underrepresentation of women in research, with the resultant unfavorable impact on diagnosis, prevention, and treatment strategies in women at risk for cardiovascular disease. Causes of disparities are multifactorial and related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. Lack of awareness in both the public and medical community, as well as existing knowledge gap regarding sex-specific differences in presentation, risk factors, pathophysiology, and response to treatment for ischemic heart disease, further contribute to outcome disparities. There is a critical need for implementation of sex- and gender-specific strategies to improve cardiovascular outcomes. This review is tailored to meet the needs of a busy clinician and summarizes the contemporary trends, characterizes current sex-specific outcome disparities, delineates challenges, and proposes transformative solutions for improvement of the full spectrum of ischemic heart disease clinical care and research in women.

Inflammation, depression and cardiovascular disease in women: the role of the immune system across critical reproductive events

Women are at increased risk for developing depression and cardiovascular disease (CVD) across the lifespan and their comorbidity is associated with adverse outcomes that contribute significantly to rates of morbidity and mortality in women worldwide. Immune-system activity has been implicated in the etiology of both depression and CVD, but it is unclear how inflammation contributes to sex differences in this comorbidity. This narrative review provides an updated synthesis of research examining the association of inflammation with depression and CVD, and their comorbidity in women. Recent research provides evidence of pro-inflammatory states and sex differences associated with alterations in the hypothalamic–pituitary–adrenal axis, the renin–angiotensin–aldosterone system and the serotonin/kynurenine pathway, that likely contribute to the development of depression and CVD. Changes to inflammatory cytokines in relation to reproductive periods of hormonal fluctuation (i.e. the menstrual cycle, perinatal period and menopause) are highlighted and provide a greater understanding of the unique vulnerability women experience in developing both depressed mood and adverse cardiovascular events. Inflammatory biomarkers hold substantial promise when combined with a patient’s reproductive and mental health history to aid in the prediction, identification and treatment of the women most at risk for CVD and depression. However, more research is needed to improve our understanding of the mechanisms underlying inflammation in relation to their comorbidity, and how these findings can be translated to improve women’s health.

Influences of Sex and Estrogen in Arterial and Valvular Calcification

Vascular and cardiac valvular calcification was once considered to be a degenerative and end stage product in aging cardiovascular tissues. Over the past two decades, however, a critical mass of data has shown that cardiovascular calcification can be an active and highly regulated process. While the incidence of calcification in the coronary arteries and cardiac valves is higher in men than in age-matched women, a high index of calcification associates with increased morbidity, and mortality in both sexes. Despite the ubiquitous portending of poor outcomes in both sexes, our understanding of mechanisms of calcification under the dramatically different biological contexts of sex and hormonal milieu remains rudimentary. Understanding how the critical context of these variables inform our understanding of mechanisms of calcification-as well as innovative strategies to target it therapeutically-is essential to advancing the fields of both cardiovascular disease and fundamental mechanisms of aging. This review will explore potential sex and sex-steroid differences in the basic biological pathways associated with vascular and cardiac valvular tissue calcification, and potential strategies of pharmacological therapy to reduce or slow these processes.

Sex differences in ischemic heart disease and heart failure biomarkers

Since 1984, each year, more women than men die of ischemic heart disease (IHD) and heart failure (HF), yet more men are diagnosed. Because biomarker assessment is often the first diagnostic employed in such patients, understanding biomarker differences in men vs. women may improve female morbidity and mortality rates.

Some key examples of cardiac biomarker utility based on sex include contemporary use of “unisex” troponin reference intervals under-diagnosing myocardial necrosis in women; greater use of hsCRP in the setting of acute coronary syndrome (ACS) could lead to better stratification in women; and greater use of BNP with sex-specific thresholds in ACS could also lead to more timely risk stratification in women.

Accurate diagnosis, appropriate risk management, and monitoring are key in the prevention and treatment of cardiovascular diseases; however, the assessment tools used must also be useful or at least assessed for utility in both sexes. In other words, going forward, we need to evaluate sex-specific reference intervals or cutoffs for laboratory tests used to assess cardiovascular disease to help close the diagnostic gap between men and women.

Sex and Gender Differences Research Design for Basic, Clinical, and Population Studies: Essentials for Investigators

A sex- and gender-informed perspective increases rigor, promotes discovery, and expands the relevance of biomedical research. In the current era of accountability to present data for males and females, thoughtful and deliberate methodology can improve study design and inference in sex and gender differences research. We address issues of motivation, subject selection, sample size, data collection, analysis, and interpretation, considering implications for basic, clinical, and population research. In particular, we focus on methods to test sex/gender differences as effect modification or interaction, and discuss why some inferences from sex-stratified data should be viewed with caution. Without careful methodology, the pursuit of sex difference research, despite a mandate from funding agencies, will result in a literature of contradiction. However, given the historic lack of attention to sex differences, the absence of evidence for sex differences is not necessarily evidence of the absence of sex differences. Thoughtfully conceived and conducted sex and gender differences research is needed to drive scientific and therapeutic discovery for all sexes and genders.

Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.

Vasomotor symptoms: natural history, physiology, and links with cardiovascular health

Vasomotor symptoms (VMS), or hot flushes and night sweats, are the classic symptom of menopause. Recent years have brought key advances in the knowledge about VMS. VMS last longer than previously thought, on average 7-10 years for frequent or moderate to severe VMS. Although VMS have long been understood to be important to women's quality of life, research has also linked VMS to indicators of cardiovascular disease (CVD) risk, such as an adverse CVD risk factor profile, greater subclinical CVD and, in emerging work, CVD events. Relations between VMS and CVD are not typically accounted for by CVD risk factors. In newer work, VMS-CVD risk relations are demonstrated with state-of-the-art subjective and objective measures of VMS. Some research indicates that VMS-CVD risk relations may be sensitive to the timing or duration of VMS. Thus, research collectively supports relations between VMS and CVD risk independent of known CVD risk factors. Next steps include identifying the mechanisms linking VMS and CVD risk indicators, understanding any timing effects, and clarifying the precise nature of relations between VMS and CVD risk. Clinical implications are discussed.

Assessment of cardiovascular risk and vascular age in overweight/obese adults with primary hypertension: the EXERDIET-HTA study

OBJECTIVE

Hypertension (HTN), obesity and low cardiorespiratory fitness (CRF) are associated with an increased risk for a cardiovascular event. Enrolling overweight/obese individuals with HTN, the current study aimed to estimate cardiovascular risk (CVR) and vascular age (VA) profiles analyzing potential sex differences, determine whether VA is higher than chronological age, and whether CVR is associated with a low level of CRF.

METHODS

Overweight/obese non-Hispanic White participants (n=209; 141 men and 68 women) with primary HTN had their CVR and VA determined using the New Pooled Cohort Risk Equations and The Framingham method, respectively. Considering values of peak oxygen uptake, participants were divided into tertiles for each sex.

RESULTS

The CVR, but not VA (P=0.339), was higher (P<0.001) in men compared with women irrespective of age. Irrespective of sex, VA was higher than chronological age (P<0.001). Age and BMI were higher (P<0.05) in the low CRF group compared with that in other groups. There were no differences in CVR (P=0.907) and VA (P=1.643) when values were separated into CRF groups.

CONCLUSION

Pooled Cohort Equations could underestimate the risk of suffering a cardiovascular event in the following 10 years in overweight/obese non-Hispanic White women with HTN compared with men. The VA appears to be a useful tool in communicating CVR in this population irrespective of sex. The CRF alone may not be enough to moderate the CVR.

Unsettled Issues and Future Directions for Research on Cardiovascular Diseases in Women

Biological sex (being female or male) significantly influences the course of disease. This simple fact must be considered in all cardiovascular diagnosis and therapy. However, major gaps in knowledge about and awareness of cardiovascular disease in women still impede the implementation of sex-specific strategies. Among the gaps are a lack of understanding of the pathophysiology of women-biased coronary artery disease syndromes (spasms, dissections, Takotsubo syndrome), sex differences in cardiomyopathies and heart failure, a higher prevalence of cardiomyopathies with sarcomeric mutations in men, a higher prevalence of heart failure with preserved ejection fraction in women, and sex-specific disease mechanisms, as well as sex differences in sudden cardiac arrest and long QT syndrome. Basic research strategies must do more to include female-specific aspects of disease such as the genetic imbalance of 2 versus one X chromosome and the effects of sex hormones. Drug therapy in women also needs more attention. Furthermore, pregnancy-associated cardiovascular disease must be considered a potential risk factor in women, including pregnancy-related coronary artery dissection, preeclampsia, and peripartum cardiomyopathy. Finally, the sociocultural dimension of gender should be included in research efforts. The organization of gender medicine must be established as a cross-sectional discipline but also as a centered structure with its own research resources, methods, and questions.

Cardiac Adaptations to High-Intensity Aerobic Training in Premenopausal and Recent Postmenopausal Women: The Copenhagen Women Study

BACKGROUND

We examined the role of menopause on cardiac dimensions and function and assessed the efficacy of exercise training before and after menopause.

METHODS AND RESULTS

Two groups of healthy premenopausal (n=36, 49.4±0.3 years) and postmenopausal (n=37, 53.5±0.5 years) women with no history of cardiovascular disease and with a mean age difference between groups of only 4 years were studied. Cardiac dimensions and systolic and diastolic function were determined by transthoracic echocardiography with tissue Doppler imaging and 2-dimensional speckle tracking. Measurements were performed at baseline and after a 12-week period of high-intensity aerobic cycle training. LV internal diastolic diameter and LV mass were similar in the 2 groups at baseline and increased by ≈2% to 8% (P=0.04-0.0007) with training in both groups. Left atrial end-diastolic and end-systolic volumes were similar for both groups and increased by 23% to 36% (P=0.0006-0.0001) with training. Systolic function assessed by mean global strain was similar in both groups at baseline and increased by ≈8% (P=0.0004) with training in the postmenopausal group. LV displacement increased by ≈3% (P=0.04) in the premenopausal women only. Diastolic function assessed by E/A ratio was similar at baseline and increased by ≈7% (P=0.01) in the premenopausal group and 11% (P=0.0001) in the postmenopausal group with training.

CONCLUSIONS

These results suggest that training-induced cardiac adaptations are preserved in the early postmenopausal phase. Furthermore, the hormonal changes associated with the menopausal transition do not appear to affect cardiac dimensions and function.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02135575.

Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease-state-of-the-evidence and clinical recommendations

This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Evidence is substantial that both SPECT and PET MPI effectively risk stratify women with SIHD. The addition of coronary flow reserve (CFR) with PET improves risk detection, including for women with nonobstructive coronary artery disease and coronary microvascular dysfunction. With the advent of PET with computed tomography (CT), multiparametric imaging approaches may enable integration of MPI and CFR with CT visualization of anatomical atherosclerotic plaque to uniquely identify at-risk women. Radiation dose-reduction strategies, including the use of ultra-low-dose protocols involving stress-only imaging, solid-state detector SPECT, and PET, should be uniformly applied whenever possible to all women undergoing MPI. Appropriate candidate selection for stress MPI and for post-MPI indications for guideline-directed medical therapy and/or invasive coronary angiography are discussed in this statement. The critical need for randomized and comparative trial data in female patients is also emphasized.

A Guide for the Design of Pre-clinical Studies on Sex Differences in Metabolism

In animal models, the physiological systems involved in metabolic homeostasis exhibit a sex difference. Investigators often use male rodents because they show metabolic disease better than females. Thus, females are not used precisely because of an acknowledged sex difference that represents an opportunity to understand novel factors reducing metabolic disease more in one sex than the other. The National Institutes of Health (NIH) mandate to consider sex as a biological variable in preclinical research places new demands on investigators and peer reviewers who often lack expertise in model systems and experimental paradigms used in the study of sex differences. This Perspective discusses experimental design and interpretation in studies addressing the mechanisms of sex differences in metabolic homeostasis and disease, using animal models and cells. We also highlight current limitations in research tools and attitudes that threaten to delay progress in studies of sex differences in basic animal research.

Interactive associations of physical activity, adiposity, and oral contraceptive use on C-reactive protein levels in young women

Oral contraceptives (OCs) are the most frequently used type of birth control among young women. OC-users have higher C-reactive protein (CRP) values, an indicator of systemic inflammation, than do non-OC-users. In addition, adiposity (percent fat) is positively associated with CRP, and physical activity (PA) is inversely associated with CRP. The present study determined the interactive associations of PA, percent fat, and OC-use with CRP. Data were collected during 2012-2015 at the University of Georgia. Objective PA was measured via pedometers. Percent fat was measured via dual X-ray absorptiometry. The current OC-use was self-reported. High-sensitivity (hs) CRP was determined using venipuncture. Multivariate linear regression determined the interactive associations of percent fat, OC-use, and PA with hs-CRP. Participants (n = 247; mean age 18.9 ± 1.4 years, 60.7 percent white) accumulated a mean of 10,075.7 ± 3,593.4 steps/day. One-third of participants were categorized as overweight/obese by BMI (mean = 24.5 ± 4.8 kg/m², mean percent fat = 35.2 ± 6.8). The current OC-use was reported by 26.2 percent of the sample (n = 61). A significant three-way interaction (β = 0.01, p = .03) indicated that higher PA was associated with lower hs-CRP in non-OC-users with higher percent fat, but not among OC-users with higher percent fat. These results highlight the need to measure and account for the current OC-use in studies examining the relationship between PA and CRP.

Pathogenesis of depression- and anxiety-like behavior in an animal model of hypertrophic cardiomyopathy

Cardiovascular dysfunction is highly comorbid with mood disorders, such as anxiety and depression. However, the mechanisms linking cardiovascular dysfunction with the core behavioral features of mood disorder remain poorly understood. In this study, we used mice bearing a knock-in sarcomeric mutation, which is exhibited in human hypertrophic cardiomyopathy (HCM), to investigate the influence of HCM over the development of anxiety and depression. We employed behavioral, MRI, and biochemical techniques in young (3-4 mo) and aged adult (7-8 mo) female mice to examine the effects of HCM on the development of anxiety- and depression-like behaviors. We focused on females because in both humans and rodents, they experience a 2-fold increase in mood disorder prevalence vs. males. Our results showed that young and aged HCM mice displayed echocardiographic characteristics of the heart disease condition, yet only aged HCM females displayed anxiety- and depression-like behaviors. Electrocardiographic parameters of sympathetic nervous system activation were increased in aged HCM females vs. controls and correlated with mood disorder-related symptoms. In addition, when compared with controls, aged HCM females exhibited adrenal gland hypertrophy, reduced volume in mood-related brain regions, and reduced hippocampal signaling proteins, such as brain-derived neurotrophic factor and its downstream targets vs. controls. In conclusion, prolonged systemic HCM stress can lead to development of mood disorders, possibly through inducing structural and functional brain changes, and thus, mood disorders in patients with heart disease should not be considered solely a psychologic or situational condition.-Dossat, A. M., Sanchez-Gonzalez, M. A., Koutnik, A. P., Leitner, S., Ruiz, E. L., Griffin, B., Rosenberg, J. T., Grant, S. C., Fincham, F. D., Pinto, J. R. Kabbaj, M. Pathogenesis of depression- and anxiety-like behavior in an animal model of hypertrophic cardiomyopathy.

Gender Differences in Post-Traumatic Stress

Acute stress can trigger cardiovascular events and disease. The earthquake is an "ideal" natural experiment for acute and chronic stress, with impact mainly on the cardiovascular system. On May 20th and 29th, 2012, two earthquakes of magnitude 5.9° to 6.4° on the Richter scale, hit the province of Modena and Reggio Emilia, an area of the north-center of Italy never considered at seismic risk. The purpose of our study was to assess whether there were gender-specific differences in stress-induced incidence of cardiovascular events and age of patients who arrived at the Emergency Departments (ED) of the three main teaching hospitals of the University of Modena and Reggio Emilia. Global access of patients, divided in relation to age, gender, and diagnosis was compared with that one detected in the same departments and in the same interval of time in 2010. The data collected were relative to consecutive cases derived by retrospective chart and acute cardiovascular events were classified according to ICD-9 (International Classification of Diseases, ninth revision). A total of 1,401 accesses were recorded in the year of earthquake versus 530 in 2010 (p ≤ 0.05), with no statistically significant differences in number of cases and mean age in relation to gender, despite the number of women exceeded that of men in 2012 (730 vs. 671); the opposite occurred, in 2010 (328 vs. 202). The gender analysis of 2012 showed a prevalence of acute coronary syndromes (ACSs 177 vs. 73, p ≤ 0.03) in men, whereas women presented more strokes and transient ischemic attacks (TIAs) (90 vs. 94, p ≤ 0.05), atrial fibrillation (120 vs. 49, p ≤ 0.05), deep venous thrombosis and pulmonary embolism (DVT/PE; 64 vs. 9, p ≤ 0.05), panic attacks (124 vs. 26, p ≤ 0.03), aspecific chest pain (122 vs. 18, p ≤ 0.05), TakoTsubo cardiomyopathy (10 vs. 0, p ≤ 0.05), and DVT/PE (61 vs. 3, p ≤ 0.03). The gender analysis of 2010 showed no difference in number of accesses and age, with higher incidence of ACS in men (130 vs. 34, p ≤ 0.05) and aspecific chest pain in women (42 vs. 5, p ≤ 0.05). The analysis between 2012 and the standard period (2010) showed women recurring to ED in larger number with more panic attacks (124 vs. 3, p ≤ 0.01), more atrial fibrillation (120 vs. 40, p ≤ 0.01) and, as a possible consequence, more TIAs and strokes (190 vs. 25, p ≤ 0.005), more TakoTsubo (10 vs. 0, p ≤ 0.05), DVT/PE (61 vs. 3, p ≤ 0.05), and aspecific chest pain (122 vs. 5, p ≤ 0.01). The difference between men's accesses to ED was less striking, but in 2012 men reported more panic attacks (26 vs. none, p ≤ 0.05), more atrial fibrillations, TIAs, and strokes (49 vs. 13, p ≤ 0.05 and 94 vs. 18, p ≤ 0.03). In conclusion, clinical (stress induced) events recorded during and immediately after the 2012 earthquakes were quite different between women and men, although the pathophysiological mechanism was probably the same, consisting acute sympathetic nervous activation, with elevation of blood pressure and heart rate, endothelial dysfunction, platelet and hemostatic activation, increased blood viscosity, and hypercoagulation. Women, in our observation, appeared to be more sensitive and responsive to acute stress, although men also appeared to suffer from stress effects when compared with a standard period, which, nevertheless, reflects in our population the most common epidemiology of gender difference in ED accesses for cardiovascular events.