Sex differences in long-term mortality among acute myocardial infarction patients: Results from the ISAR-RISK and ART studies

[Benefits of an observatory for myocardial infarction in women under 50 : The WAMIF study]

The WAMIF study was conducted from 2017 to 2019 to include 314 patients in 30 French investigative centers in France. We have systematically collected the clinical, morphological and biological characteristics of cases of myocardial infarction affecting women under 50 years of age and evaluated their short-term (intra-hospital) and mid-term (at 12 months) prognosis. . The main results were: a particularly high incidence of modifiable risk factors affecting 86% of patients with smoking in the first place in 75% of them. The clinical presentation revealed chest pain in more than 90% of cases. The pathophysiological forms of acute coronary syndrome identified the culprit artery in 90% of cases, MI without obstruction (MINOCA) was found in 17.8% of the ST elevation MI (STEMI), spontaneous dissection in 14.6% of STEMI and 16.3% of NSTEMI. Hospital events included 3 strokes, 3 cases of bleeding and no deaths. At 12 months, follow-up showed no cardiovascular deaths. The results of this study allow us to better understand the particularities of cardiovascular diseases in women and thus to develop targeted strategies for prevention and improvement of their management.

Sex as a Biological Variable in Cardiovascular Diseases: JACC Focus Seminar 1/7

Sex and gender influence all aspects of cardiovascular health and disease-including epidemiology, pathophysiology, diagnosis, clinical manifestation, disease progression, and response to treatment-in complex and interrelated ways. Sex-based and gender-based differences have been identified in risk and presentation of cardiovascular diseases (CVDs); however, failure to address sex and gender as key variables in CVD research and reporting and limited understanding of differences have contributed to disparities in risk assessment, prevention, diagnosis, treatment, and outcomes. Improved consideration of both sex and gender in all phases of the biomedical research continuum, along with educational and training curricula focused on the role of sex and gender in CVD, are needed to provide targeted therapies and improve cardiovascular health outcomes for all.

Susceptibility of Women to Cardiovascular Disease and the Prevention Potential of Mind-Body Intervention by Changes in Neural Circuits and Cardiovascular Physiology

Women have been reported to be more vulnerable to the development, prognosis and mortality of cardiovascular diseases, yet the understanding of the underlying mechanisms and strategies to overcome them are still relatively undeveloped. Studies show that women's brains are more sensitive to factors affecting mental health such as depression and stress than men's brains. In women, poor mental health increases the risk of cardiovascular disease, and conversely, cardiovascular disease increases the incidence of mental illness such as depression. In connection with mental health and cardiovascular health, the presence of gender differences in brain activation, cortisol secretion, autonomic nervous system, vascular health and inflammatory response has been observed. This connection suggests that strategies to manage women's mental health can contribute to preventing cardiovascular disease. Mind-body interventions, such as meditation, yoga and qigong are forms of exercise that strive to actively manage both mind and body. They can provide beneficial effects on stress reduction and mental health. They are also seen as structurally and functionally changing the brain, as well as affecting cortisol secretion, blood pressure, heart rate variability, immune reactions and reducing menopausal symptoms, thus positively affecting women's cardiovascular health. In this review, we investigate the link between mental health, brain activation, HPA axis, autonomic nervous system, blood pressure and immune system associated with cardiovascular health in women and discuss the effects of mind-body intervention in modulating these factors.

Chronic Coronary Syndromes in Women: Challenges in Diagnosis and Management

Sex matters in science. This particularly applies to ischemic heart disease, which displays key differences in pathophysiology, presentation, and effectiveness in diagnostic strategies and management between women and men. However, underrepresentation of women in randomized trials has led to an evidence gap in clinical practice. Nevertheless, it has become clear that women present with a higher burden of symptoms and comorbidities, experience worse outcomes, but are less likely to have flow-limiting stenosis in epicardial coronary arteries than men. A major contributor to this paradox is coronary microvascular disease, a heterogeneous disorder with multifactorial etiology that predominantly affects women. There is a significant interplay between coronary microvascular disease, obstructive coronary artery disease, and the cardiovascular risk associated with it, with impaired vasomotor function often preceding the development of advanced atheroma. This novel concept has recently been referred to as chronic coronary syndromes, which better meets the female phenotype of ischemic heart disease, questioning current management recommendations that still largely apply to flow-limiting stenoses in epicardial coronary arteries typically found in men. The goal of this review is to highlight the most recent scientific advances in understanding chronic coronary syndromes in women. It provides practical advice with focus on challenges in diagnosis and management, and discusses perspectives towards the implementation of sex-specific, safer, and more effective therapeutic strategies.

Spatial distribution of physiologic 12-lead QRS complex

The normal physiologic range of QRS complex duration spans between 80 and 125 ms with known differences between females and males which cannot be explained by the anatomical variations of heart sizes. To investigate the reasons for the sex differences as well as for the wide range of normal values, a technology is proposed based on the singular value decomposition and on the separation of different orthogonal components of the QRS complex. This allows classification of the proportions of different components representing the 3-dimensional representation of the electrocardiographic signal as well as classification of components that go beyond the 3-dimensional representation and that correspond to the degree of intricate convolutions of the depolarisation sequence. The technology was applied to 382,019 individual 10-s ECG samples recorded in 639 healthy subjects (311 females and 328 males) aged 33.8 ± 9.4 years. The analyses showed that QRS duration was mainly influenced by the proportions of the first two orthogonal components of the QRS complex. The first component demonstrated statistically significantly larger proportion of the total QRS power (expressed by the absolute area of the complex in all independent ECG leads) in females than in males (64.2 ± 11.6% vs 59.7 ± 11.9%, p < 0.00001—measured at resting heart rate of 60 beats per minute) while the second component demonstrated larger proportion of the QRS power in males compared to females (33.1 ± 11.9% vs 29.6 ± 11.4%, p < 0.001). The analysis also showed that the components attributable to localised depolarisation sequence abnormalities were significantly larger in males compared to females (2.85 ± 1.08% vs 2.42 ± 0.87%, p < 0.00001). In addition to the demonstration of the technology, the study concludes that the detailed convolution of the depolarisation waveform is individual, and that smoother and less intricate depolarisation propagation is the mechanism likely responsible for shorter QRS duration in females.

The Neuro-Inflammatory-Vascular Circuit: Evidence for a Sex-Dependent Interrelation?

Cardiovascular disease (CVD) is the leading cause of death worldwide with mortality rates in women currently exceeding those in men. To date, evidence is widely lacking for unique female determinants of CVD. However, strong associations with psychological stress, obesity or elevated inflammatory biomarkers with adverse cardiovascular outcomes in women have been identified in various studies. Interestingly, amygdalar metabolic activity, a central neural structure involved in emotional stress processing, has proven to be an independent predictor of major adverse cardiovascular events (MACE). Moreover, upregulated amygdalar metabolism was directly linked to myocardial injury in women, but not in men. This newly suggested sex-dependent brain-heart interrelation was further supported by the discovery that bone marrow activity, a surrogate parameter of inflammation, represents a potential bridging link between amygdalar activity and cardiovascular pathology by fueling inflammatory processes that promote atherosclerotic disease. Such malignant cascade of events might account, at least in part, for the excess female mortality seen in women with coronary artery disease and calls for sex-specific research toward pharmacologic or behavioral modulators to improve cardiovascular outcomes, particularly in women. This mini review summarizes recent advances in cardiovascular sex-specific medicine, thereby focusing on the interplay between the limbic system, autonomic regulation and inflammatory biomarkers, which may help to tailor CVD management toward the female cardiovascular phenotype.

Differential impact of a cardiac rehabilitation program in functional parameters according to patient gender

INTRODUCTION

Exercise-based cardiac rehabilitation (EBCR) programs are of paramount importance in the management of acute myocardial infarction (AMI) survivors. Albeit this, female patients tend to be less referred for these programs, while also having a poorer prognosis. We aimed at assessing the impact of a contemporary EBCR program on functional parameters after an AMI, and specifically the impact of gender on its potential benefits.

METHODS

Observational, retrospective cohort study including all patients admitted to a tertiary center due to an AMI who completed a phase II EBCR program after discharge, between November 2012 and April 2017. Functional parameters were assessed by a symptom-limited cardiopulmonary exercise test (CPET). Patients were dichotomized according to gender.

RESULTS

A total of 379 patients were included, 19% of whom were women. After the program, peak oxygen uptake (pVO2) and exercise duration increased significantly (P<0.001). Though female patients presented a lower pVO2 and completed a shorter CPET at both the beginning and end of the study, there were no differences in the magnitude of improvement in these parameters between both groups [pVO2 delta 1.37 ± 3.08 vs 1.31 ± 2.62 mL/kg/min, P=0.876; CPET duration delta 120 (60-167) vs 85 (60-146), P=0.176].

CONCLUSIONS

A contemporary EBCR program was associated with significant improvements in functional parameters, as assessed by CPET. Though female patients had lower levels of pVO2, the benefits of this program were similar among groups. These results highlight the importance of EBCR among this higher risk subset of patients.

[Comorbidity and Gender of Patients at Risk of Hospital Mortality After Emergency Percutaneous Coronary Intervention]

Aim        To study gender aspects of comorbidity in evaluating the risk of in-hospital death for patients with acute coronary syndrome (ACS) after a percutaneous coronary intervention (PCI).Material and methods        The presented results are based on data of two ACS registries, the city of Sochi and RECORD-3. 986 patients were included into this analysis by two additional criteria, age &lt;70 years and PCI. 80% of the sample were men. Analysis of comorbidity severity was performed for all patients and included 9 indexes: type 2 diabetes mellitus, chronic kidney disease, atrial fibrillation, anemia, stroke, arterial hypertension, obesity, and peripheral atherosclerosis. Group 1 (minimum comorbidity) consisted of patients with not more than one disease (n=367); group 2 (moderate comorbidity) consisted of patients with 2 or 3 diseases (n=499), and group 3 (pronounced comorbidity) consisted of patients with 4 or more diseases (n=120). In-hospital mortality was 2.7 % (n=27).Results   Significant data on the effect of comorbidity on the in-hospital prognosis were obtained only for men of the compared groups: 0.6, 1.8, and 8.8 %, respectively (χ2=21.6; р&lt;0.0001). At the same time, among 44 women with minimum comorbidity, there were no cases of in-hospital death, and the presence of moderate (n=110) and pronounced comorbidity (n=40) was associated with a similar death rate (7.3 and 7.5 %, respectively). Noteworthy, in moderate comorbidity, the female gender was associated with a 4-fold increase in the risk of in-hospital death (odd ratio, OR 4.3 at 95 % confidence interval, CI from 1.5 to 12.1; р=0.003). In addition, both in men and women with minimum comorbidity, even a high risk by the GRACE scale (score ≥140) was not associated with increased in-hospital mortality, which was minimal (0 for women and 1 % for men). At the same time, in the patient subgroup with moderate and pronounced comorbidity, a GRACE score ≥140 resulted in a 6-fold increase in the risk of in-hospital death for men (OR 6.0 at 95 % CI from 1.7 to 21.9; р=0.002) and a 16-fold increase for women (OR 16.2 at 95 % CI from 2.0 to 130.4; р=0.0006).Conclusion            This study identified gender-related features in predicting the risk of in-hospital death for ACS patients with comorbidities after PCI, which warrants reconsideration of existing approaches to risk stratification.

Association between resting amygdalar activity and abnormal cardiac function in women and men: a retrospective cohort study

AIMS

Cardiovascular outcomes of women with coronary artery disease (CAD) are perceived as relatively worse when compared to men. Amygdalar metabolic activity has recently been shown to independently predict cardiovascular events in patients without known cardiovascular disease. Given that traditional algorithms for risk prediction perform worse in women than in men, we sought to assess sex-specific associations between amygdalar metabolic activity and cardiac dysfunction with suspected or known CAD.

METHODS AND RESULTS

This retrospective study included 302 patients (mean age 66.8 ± 10.2 years, 29.1% women) selected for evaluation of CAD, malignant, or inflammatory disease. All patients had undergone both, myocardial perfusion imaging by single photon emission computed tomography (MPI-SPECT) and whole-body fluoro-18-deoxyglucose (18F-FDG) positron emission tomography (PET), within 6 months. 18F-FDG resting amygdalar uptake was significantly increased in women with abnormal MPI scans (standardized uptake value 33.4 ± 6.5 vs. 30.4 ± 4.7, P = 0.043), while no such difference was observed in men (P = 0.808). In women, but not in men, a negative association between 18F-FDG resting amygdalar activity and left ventricular ejection fraction (LVEF) was observed (Pearson r = -0.308, P = 0.004). Accordingly, either LVEF [B-coefficient (standard error, SE) = -0.232 (0.109), P = 0.045] or abnormal MPI [B-coefficient (SE) = 8.264 (2.449), P = 0.003] were selected as significant predictors of high amygdalar 18F-FDG uptake in a fully adjusted linear regression model in women, and a first order interaction term consisting of sex and LVEF or sex and abnormal MPI was significant (P = 0.035 and P = 0.001, respectively).

CONCLUSION

Resting amygdalar metabolic activity is associated with abnormal cardiac function and perfusion in women, suggesting a link between emotional stress and cardiovascular disease in women.

Digit ratio (2D:4D) is not related to cardiovascular diseases or their risk factors in menopausal women

OBJECTIVES

Digit ratio (2D:4D) is widely used as a biomarker of prenatal hormonal environment linked to the growing number of adult health and disease-related characteristics. It has been suggested that 2D:4D is a good predictor of cardiovascular diseases (CVD) risk among men, but results in women are still inconclusive. Here we test the relationship between 2D:4D and the incidence of cardiovascular diseases (CVD), and their risk factors in Polish, rural women.

METHODS

The participants were 410 women age 50 and older. Structured questionnaire was used to gather personal and medical data, including the history of CVD diagnosed by a medical doctor. Anthropometric measurements of body height, weight, and finger lengths were performed. Right-hand and left-hand 2D:4D, mean 2D:4D, D_l-r , and BMI were calculated afterward. For a subgroup of participants (n = 329) fasting blood sample was collected (in order to assess the lipid profile and glucose levels) and blood pressure was measured. Age, education level and BMI were included as potential covariates.

RESULTS

No statistically significant association was observed between 2D:4D markers and the incidence of CVD (eg, heart attack, stroke) or CVD risk factors (dyslipidaemia, dysglycaemia or hypertension), when controlled for age, education and BMI.

CONCLUSIONS

The results of our study add to the growing number of studies investigating the sex-difference of the association between 2D:4D and cardiac health. We conclude that from a public health perspective 2D:4D may not be a valuable biomarker of elevated risk of CVDs in women.

Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments

OBJECTIVE

To determine whether sex differences exist in the triage, management and outcomes associated with non-traumatic chest pain presentations in the emergency department (ED).

METHODS

All adults (≥18 years) with non-traumatic chest pain presentations to three EDs in Melbourne, Australia between 2009 and 2013 were retrospectively analysed. Data sources included routinely collected hospital databases. Triage scoring of the urgency of presentation, time to medical examination, cardiac troponin testing, admission to specialised care units, and in-ED and in-hospital mortality were each modelled using the generalised estimating equations approach.

RESULTS

Overall 54 138 patients (48.7% women) presented with chest pain, contributing to 76 216 presentations, of which 26 282 (34.5%) were cardiac. In multivariable analyses, compared with men, women were 18% less likely to be allocated an urgency of 'immediate review' or 'within 10 min review' (OR=0.82, 95% CI 0.79 to 0.85), 16% less likely to be examined within the first hour of arrival to the ED by an emergency physician (0.84, 0.81 to 0.87), 20% less likely to have a troponin test performed (0.80, 0.77 to 0.83), 36% less likely to be admitted to a specialised care unit (0.64, 0.61 to 0.68), and 35% (p=0.039) and 36% (p=0.002) more likely to die in the ED and in the hospital, respectively.

CONCLUSIONS

In the ED, systemic sex bias, to the detriment of women, exists in the early management and treatment of non-traumatic chest pain. Future studies that identify the drivers explaining why women presenting with chest pain are disadvantaged in terms of care, relative to men, are warranted.

Age- and sex-dependent changes in sympathetic activity of the left ventricular apex assessed by 18F-DOPA PET imaging

BACKGROUND

Sexual dimorphism in cardiac sympathetic outflow has recently gained attention in the context of Takotsubo cardiomyopathy. Previous studies suggest that there are sex- and age-dependent differences in peripheral autonomic control, however, data on cardiac-specific sympathetic activation in aged women and men are lacking.

METHODS AND RESULTS

Regional quantitative analysis of cardiac fluorine-18 (18F)- Dihydroxyphenylalanine (DOPA) uptake was retrospectively performed in 133 patients (69 females, mean age 52.4±17.7 years) referred for assessment of neuroendocrine tumours (NET) by Positron-Emission-Tomography. Cardiac 18F-DOPA uptake was significantly higher in women as compared to men (1.33±0.21 vs. 1.18±0.24, p<0.001). This sex-difference was most pronounced in the apical region of the left ventricle (LV, 1.30±0.24 in women vs. 1.13±0.25 in men, p<0.001) and in individuals >55 years of age (1.39±0.25 in women vs. 1.09±0.24 in men, p<0.001). Women showed a prominent increase in myocardial 18F-DOPA uptake with age with the strongest increase seen in the LV apical region (r = 0.34, p = 0.004). Accordingly, sex and age were selected as significant predictors of LV apical 18F-DOPA uptake in a stepwise linear regression model. No age-dependent changes of cardiac 18F-DOPA uptake were observed in men or in the right ventricular region.

CONCLUSION

Our study suggests that aging is related to sex-specific changes in regional cardiac sympathetic activity. Future studies will have to assess whether the increase in LV apical 18F-DOPA uptake with age in women is of pathogenic relevance for the higher susceptibility of postmenopausal women to conditions associated with increased sympathetic activity.

Taking cardiology clinical trials to the next level: A call to action

Physicians previously perceived heart disease to be a man's disease; yet, since 1984, more women have died of ischemic heart disease. Because women who develop obstructive coronary heart disease and heart failure tend to do so 10 years later than men, cardiology clinical trials that use arbitrary age cutoffs or exclusion criteria based on comorbidities and polypharmacy often limit the pool of potential participants to a greater extent for women. Issues related to trial design and insufficient accounting for female-predominant disease patterns have contributed to low rates of enrollment of women in certain domains of cardiology research. Accordingly, women do not benefit from as rich an evidence base for cardiology as men. Here, we review major sex differences in heart disease and discuss areas of cardiology research in which women have been underrepresented. Considering the widespread sex differences in cardiovascular structure and function, it is important to include balanced numbers of women and men in cardiovascular clinical trials. Beyond inclusion, sex-specific reporting is also essential. Moreover, with ongoing developments of clinical-trial methodology, it is imperative to seek innovative ways to learn as much as possible about how interventions behave in women and men. Adaptive trials are specifically identified as promising opportunities to consider sex-based analyses at interim stages, allowing sex-specific flexibility as these trials unfold. Finally, we emphasize the importance of factoring sex as a biological variable into the design, analysis, and reporting of preclinical research, because this research critically informs the design and execution of clinical trials.