Lack of effects of transdermal estradiol on diastolic function: a randomized placebo-controlled double-blind short-term trial

Associations between menopause, cardiac remodeling, and diastolic function: the CARDIA study

OBJECTIVES

Heart failure with preserved ejection fraction (HFpEF) affects more women than men. Menopause may influence HFpEF development in women. We assessed cross-sectional and longitudinal associations between menopause and echocardiographic measures of left ventricular (LV) function and cardiac remodeling.

METHODS

We studied 1,723 women with available echo data from at least two of: year 5 (Y5) (1990-1991), Y25 (2010-2011), or Y30 (2015-2016) in the Coronary Artery Risk Development in Young Adults study. Cardiac structure and function were measured using 2D and Doppler echocardiography. Cross-sectional associations between menopausal status and repeated echo measures at Y25 and Y30 were analyzed using linear mixed models. Two-segmented models were used to compare longitudinal changes in echocardiographic measures in the premenopausal period to changes in the postmenopausal period.

RESULTS

Mean ± SD age (years) at enrollment was 27 ± 3 in those with menopause by Y25, 25 ± 3 in those with menopause between Y25 and Y30, and 21 ± 3 in those premenopausal at Y30. There were no significant differences in race, body mass index, systolic blood pressure, or diabetes between the groups. Postmenopausal women had higher early diastolic mitral inflow (E) to annular (e') velocity ratio than premenopausal after adjusting for demographics and risk factors (P < 0.05). Menopause was associated with relative increases in the rates of change in LV mass and left atrial volume, even after adjustment. Change in E/e' ratio was similar before and after menopause.

CONCLUSIONS

Menopause is associated cross-sectionally with worse diastolic function and longitudinally with adverse LV and left atrial remodeling. This may contribute to the increased HFpEF risk in postmenopausal women.

Effects of hormone replacement therapy on left ventricular diastolic function in postmenopausal women: a systematic review and meta-analysis

BACKGROUND

Postmenopausal women tend to experience significant changes in left ventricular diastolic function (LVDF). However, there are conflicting reports about LVDF between postmenopausal women on hormone replacement therapy (HRT) and those not on HRT. This meta-analysis is to evaluate the effects of HRT on LVDF in postmenopausal women.

METHODS

We conducted a systemic review of randomized controlled trials published up to December 31 2019 using Embase, Pubmed, and the Cochrane library database.

RESULTS

Eight studies involving 668 postmenopausal women were identified. Our analysis indicated that the ratio of the peak velocity during early filing to late filling from atrial contraction improvement in HRT group was better than that in placebo group (MD 0.20, 95%CI 0.12 to 0.28). There was a significant reduction in deceleration time and left ventricular mass index in HRT group compared with placebo group (MD -21.01, 95%CI -40.11 to -1.91 vs MD -8.26, 95%CI -14.10 to -2.42). No significant difference was observed in left ventricular end systole diameter (MD 0.80, 95%CI -0.72 to 2.31), left ventricular end diastole diameter (MD -0.07, 95%CI -1.25 to 1.10), left atrial size (MD -0.33, 95%CI -1.34 to 0.68)and the isovolumic relaxation time (MD -12.08, 95%CI -27.65 to 3.5).

CONCLUSIONS

Our meta-analysis illustrated that postmenopausal women seem to obtain more beneficial effects from HRT on LVDF, though future studies are required to elucidate the specific mechanisms for this phenomenon.

Postmenopausal hypertension

Cardiovascular disease is the leading cause of morbidity and mortality in postmenopausal women. Hypertension is a major risk factor for cardiovascular disease. The mechanisms responsible for postmenopausal hypertension have not been completely elucidated. However, various mechanisms have been implicated to play a role. For example, there is evidence that changes in estrogen/androgen ratios favoring increases in androgens, activation of the renin-angiotensin and endothelin systems, activation of the sympathetic nervous system, metabolic syndrome and obesity, inflammation, increased vasoconstrictor eicosanoids, and anxiety and depression may be important in the pathogenesis of postmenopausal hypertension. There is also evidence that hypertension is less well controlled in aging women than in aging men, but the reasons for this gender difference is not clear. Postmenopausal hypertension is likely multifactorial. Future studies will be necessary to determine the contribution of these systems listed above in mediating postmenopausal hypertension and to design treatment strategies that encompass these mechanisms to improve the quality of life of postmenopausal women as they age.

Menopause does not affect blood pressure and risk profile, and menopausal women do not become similar to men

OBJECTIVE

Menopause is considered to be a cardiovascular risk factor, but this belief is based on opinions rather than on evidence. Confounding effects of age are often neglected.

DESIGN

Population-based study with further subanalysis of case-to-case age-matched cohorts of men and fertile and menopausal women.

SETTING

Epidemiology in primary, public, institutional frame.

PARTICIPANTS

Nine thousand three hundred and sixty-four men and women aged 18-70 years representative of Italian general population followed-up for 18.8 +/- 7.7 years.

MAIN OUTCOME MEASURES

Blood pressure (BP), prevalence and incidence of hypertension, serum total, high-density lipoprotein and low-density lipoprotein cholesterol, glucose tolerance, body adiposity, vascular reactivity, target organ damage, overall and cardiovascular mortality and morbidity, by gender and by menopausal status.

RESULTS

Cross-sectional: crude BP, pressor response to cold, orthostatic BP decrease, BMI, skinfold thickness, fasting and postload blood glucose and insulin, serum lipids, left ventricular mass, serum creatinine, microalbuminuria and augmetantion index were higher in menopausal than in fertile women, and comparable in menopausal women and men, a difference that was no longer present when adjusting for age or considering age-matched cohorts. Longitudinal: BP increase during follow-up, cardiovascular mortality and morbidity were greater in menopausal than in fertile women, and comparable in menopausal women and men, a difference no longer present in age-matched cohorts. Menopausal status was rejected from multivariate Cox analysis also including age.

CONCLUSION

The cardiovascular effects usually attributed to menopause seem to be a mere consequence of the older age of menopausal women.

Gender disparities in hypertension among different ethnic groups in Amsterdam, The Netherlands: the SUNSET study

BACKGROUND

Studies have consistently shown a lower prevalence of hypertension in women than in men. Obesity is an important risk factor for hypertension, and the rate of obesity is particularly high among ethnic minority women. It is therefore questionable whether the lower prevalence of hypertension in women is also true among specific ethnic minority groups in Europe. Hence, we sought to determine whether gender disparity in hypertension is consistent across different ethnic groups, and if not so, whether differences in body sizes (body mass index (BMI) and waist circumferences) explain demonstrated gender disparities in hypertension among different ethnic groups in Amsterdam, the Netherlands.

METHODS

The SUNSET study was a random sample of 1,432 people aged 35-60 years (508 White-Dutch, 591 African-Surinamese, and 333 Hindustani-Surinamese).

RESULTS

Age-adjusted hypertension rate was significantly lower in White-Dutch women than in White-Dutch men as expected--the odds ratio (95% confidence interval) was 0.35 (0.23-0.54). This difference hardly changed after adjustment for body sizes and other factors. However, among the ethnic minority groups, age-adjusted hypertension rate did not differ significantly between women and men in both African-Surinamese 0.74 (0.51-1.08) and Hindustani-Surinamese 0.80 (0.49-1.29). It was only after further adjustment for body sizes that African-Surinamese women were significantly less likely than African-Surinamese men to have hypertension 0.54 (0.36-0.81). The same pattern applied to the Hindustani-Surinamese, although less pronounced 0.59 (0.34-1.02).

CONCLUSION

Gender differences in hypertension are not consistent across ethnic groups. The lack of differences in ethnic minority groups is related to lifestyle factors particularly overweight and obesity.

Novel mechanisms responsible for postmenopausal hypertension

Blood pressure increases in many women after menopause. Hypertension is one of the major risk factors for cardiovascular disease. However, the mechanisms responsible for the postmenopausal increase in blood pressure are yet to be elucidated. Various humoral systems have been proposed to play a role in postmenopausal hypertension, such as changes in estrogen/androgen ratios, increases in endothelin and oxidative stress, and activation of the renin-angiotensin system (RAS). In addition, obesity, type II diabetes, and activation of the sympathetic nervous system are common in postmenopausal women and may also play important roles. However, progress in elucidating the mechanisms responsible for postmenopausal hypertension has been hampered by the lack of a suitable animal model. The aging female spontaneously hypertensive rat (SHR) exhibits many of the characteristics found in postmenopausal women. In this review, some of the possible mechanisms that could play a role in postmenopausal hypertension are discussed, as well as the characteristics of the aged female SHR as a model to study.

Systemic hypertension in postmenopausal women: a clinical approach

Gender-specific differences in the incidence of cardiovascular disease have long been known, and estrogens have been considered to be responsible for this dissimilarity. Recently, the steep increase in cardiovascular risk in the no longer fertile woman has become evident. The postmenopausal metabolic syndrome is very frequent, with obesity, insulin resistance, and hyperinsulinemia, which convey increased sodium reabsorption, stimulation of the sympathetic nervous system, and smooth muscle growth. The clinical corollary of these overall changes is hypertension. Gender differences in components of the renin-angiotensin system have been shown to exist, and may play a central role in blood pressure control. In normotensive populations, plasma renin activity is significantly higher in men than in women, and is higher in postmenopausal versus premenopausal women. Two angiotensin-converting enzyme inhibitors, ramipril and moexipril, have undergone trials aimed specifically at older people with cardiovascular risk and with postmenopausal hypertension, and could be the first therapeutic choice. However, a comprehensive treatment should include nonpharmacologic measures with strong emphasis on weight normalization and regular physical activity, prevention of osteoporosis, as well as decisions on the use of estrogen replacement therapy and treatment of the menopausal metabolic syndrome. Finally, education of both patients and physicians on the nature and prognosis of untreated hypertension is crucial.

The acute effects of sublingual estradiol on left ventricular diastolic function in normotensive and hypertensive postmenopausal women

AIM

limited information is available on estrogen influences on diastole. We aimed to investigate the acute effects of a single dose of sublingual 17beta-estradiol on left ventricular diastolic function in postmenopausal women.

METHODS

the study included 28 women aged 55.6 +/- 6 (15 normotensive and 13 hypertensive), who underwent Doppler echocardiography and estradiol plasma levels determination before and 60 min after sublingual administration of 4 mg of 17beta-estradiol.

RESULTS

there were no modifications in heart rate. Both systolic and diastolic blood pressure dropped significantly in the hypertensives and remained unchanged in normotensives. Estradiol levels were 1790 +/- 869 pg/ml in the normotensives and 2664 +/- 1490 in the hypertensives (P < 0.05). Peak early velocity, in the population as a whole, increased from 84 +/- 18 to 91 +/- 18 cm/s and the early-to-atrial velocity ratio from 1.1 +/- 0.4 to 1.4 +/- 0.6 (P < 0.0001 for both). Both acceleration and deceleration rates increased significantly (P < 0.0001). These changes were shared by all the patients. In addition, the hypertensive patients, who presented a baseline pattern characterized mainly by a grossly increased peak atrial velocity with reduction in the early-to-atrial velocity ratio, demonstrated a decrease in peak atrial velocity from 92 +/- 12 to 78 +/- 10 cm/s (P < 0.0001), associated with significant reductions in deceleration time (P < 0.0001) and pressure half time (P < 0.005). Therefore, the typical picture of impaired ventricular relaxation was favorably changed after estradiol administration.

CONCLUSIONS

the sublingual administration of estradiol induces acute modifications in left ventricular diastolic function in postmenopausal women, with improvement in the age-related left ventricular relaxation pattern, and that these beneficial changes are more pronounced in hypertensive that in normotensive women.