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Saeed H, Abdullah MBBS, Naeem I, Zafar A, Ahmad B, Islam TU, Rizvi SS, Kumari N, Kirmani SGA, Mansoor F, Hassan A, Raja A, Daoud M, Goyal A. Demographic trends and disparities in mortality related to coexisting heart failure and diabetes mellitus among older adults in the United States between 1999 and 2020: A retrospective population-based cohort study from the CDC WONDER database. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 23:200326. [PMID: 39282605 PMCID: PMC11395761 DOI: 10.1016/j.ijcrp.2024.200326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 08/03/2024] [Accepted: 08/22/2024] [Indexed: 09/19/2024]
Abstract
Background Heart Failure (HF) and Diabetes Mellitus (DM) often coexist, and each condition independently increases the likelihood of developing the other. While there has been concern regarding the increasing burden of disease for both conditions individually over the last decade, a comprehensive examination of mortality trends and demographic and regional disparities needs to be thoroughly explored in the United States (US). Methods This study analyzed death certificates from the CDC WONDER database, focusing on mortality caused by the co-occurrence of HF and DM in adults aged 75 and older from 1999 to 2020. Age-adjusted mortality rates (AAMRs) and annual percent changes (APCs) were computed and categorized by year, gender, race, census region, state, and metropolitan status. Results A total of 663,016 deaths were reported in patients with coexisting HF and DM. Overall, AAMR increased from 154.1 to 186.1 per 100,000 population between 1999 and 2020, with a notable significant increase from 2018 to 2020 (APC: 11.30). Older men had consistently higher AAMRs than older women (185 vs. 135.4). Furthermore, we found that AAMRs were highest among non-Hispanic (NH) American Indian or Alaskan natives and lowest in NH Asian or Pacific Islanders (214.4 vs. 104.1). Similarly, AAMRs were highest in the Midwestern region and among those dwelling in non-metropolitan areas. Conclusions Mortality from HF and DM has risen significantly in recent years, especially among older men, NH American Indian or Alaska Natives, and those in non-metropolitan areas. Urgent policies need to be developed to address these disparities and promote equitable healthcare access.
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Affiliation(s)
- Humza Saeed
- Rawalpindi Medical University, Rawalpindi, Punjab, Pakistan
| | | | - Irum Naeem
- King Edward Medical University, Lahore, Punjab, Pakistan
| | - Amna Zafar
- King Edward Medical University, Lahore, Punjab, Pakistan
| | - Bilal Ahmad
- DG Khan Medical College, Dera Ghazi Khan, Punjab, Pakistan
| | - Taimur Ul Islam
- Shifa college of medicine, Shifa Tameer e Millat University, Islamabad, Pakistan
| | - Syed Saaid Rizvi
- Sindh Medical College, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Nikita Kumari
- Sindh Medical College, Jinnah Sindh Medical University, Karachi, Pakistan
| | | | | | | | - Adarsh Raja
- Department of Internal Medicine, Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
| | | | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
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Shi Y, Ma J, Li S, Liu C, Liu Y, Chen J, Liu N, Liu S, Huang H. Sex difference in human diseases: mechanistic insights and clinical implications. Signal Transduct Target Ther 2024; 9:238. [PMID: 39256355 PMCID: PMC11387494 DOI: 10.1038/s41392-024-01929-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 06/26/2024] [Accepted: 07/23/2024] [Indexed: 09/12/2024] Open
Abstract
Sex characteristics exhibit significant disparities in various human diseases, including prevalent cardiovascular diseases, cancers, metabolic disorders, autoimmune diseases, and neurodegenerative diseases. Risk profiles and pathological manifestations of these diseases exhibit notable variations between sexes. The underlying reasons for these sex disparities encompass multifactorial elements, such as physiology, genetics, and environment. Recent studies have shown that human body systems demonstrate sex-specific gene expression during critical developmental stages and gene editing processes. These genes, differentially expressed based on different sex, may be regulated by androgen or estrogen-responsive elements, thereby influencing the incidence and presentation of cardiovascular, oncological, metabolic, immune, and neurological diseases across sexes. However, despite the existence of sex differences in patients with human diseases, treatment guidelines predominantly rely on male data due to the underrepresentation of women in clinical trials. At present, there exists a substantial knowledge gap concerning sex-specific mechanisms and clinical treatments for diverse diseases. Therefore, this review aims to elucidate the advances of sex differences on human diseases by examining epidemiological factors, pathogenesis, and innovative progress of clinical treatments in accordance with the distinctive risk characteristics of each disease and provide a new theoretical and practical basis for further optimizing individualized treatment and improving patient prognosis.
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Affiliation(s)
- Yuncong Shi
- Department of Cardiology, the Eighth Affiliated Hospital, Joint Laboratory of Guangdong-Hong Kong-Macao Universities for Nutritional Metabolism and Precise Prevention and Control of Major Chronic Diseases, Sun Yat-sen University, Shenzhen, China
| | - Jianshuai Ma
- Department of Cardiology, the Eighth Affiliated Hospital, Joint Laboratory of Guangdong-Hong Kong-Macao Universities for Nutritional Metabolism and Precise Prevention and Control of Major Chronic Diseases, Sun Yat-sen University, Shenzhen, China
| | - Sijin Li
- Department of Cardiology, the Eighth Affiliated Hospital, Joint Laboratory of Guangdong-Hong Kong-Macao Universities for Nutritional Metabolism and Precise Prevention and Control of Major Chronic Diseases, Sun Yat-sen University, Shenzhen, China
| | - Chao Liu
- Department of Cardiology, the Eighth Affiliated Hospital, Joint Laboratory of Guangdong-Hong Kong-Macao Universities for Nutritional Metabolism and Precise Prevention and Control of Major Chronic Diseases, Sun Yat-sen University, Shenzhen, China
| | - Yuning Liu
- Department of Cardiology, the Eighth Affiliated Hospital, Joint Laboratory of Guangdong-Hong Kong-Macao Universities for Nutritional Metabolism and Precise Prevention and Control of Major Chronic Diseases, Sun Yat-sen University, Shenzhen, China
| | - Jie Chen
- Department of Radiotherapy, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ningning Liu
- Department of Cardiology, Guangzhou Institute of Cardiovascular Disease, Guangdong Key Laboratory of Vascular Diseases, the Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Shiming Liu
- Department of Cardiology, Guangzhou Institute of Cardiovascular Disease, Guangdong Key Laboratory of Vascular Diseases, the Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China.
| | - Hui Huang
- Department of Cardiology, the Eighth Affiliated Hospital, Joint Laboratory of Guangdong-Hong Kong-Macao Universities for Nutritional Metabolism and Precise Prevention and Control of Major Chronic Diseases, Sun Yat-sen University, Shenzhen, China.
- Department of Cardiology, Guangzhou Institute of Cardiovascular Disease, Guangdong Key Laboratory of Vascular Diseases, the Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China.
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Colombo D, Mercurio V, Klersy C, Temporelli P, Rossi A, Carluccio E, La Rovere MT, Dini FLL, Nappi R, Acquaro M, Greco A, Turco A, Schirinzi S, Scelsi L, Ghio S. The influence of sex on heart failure mortality. J Cardiovasc Med (Hagerstown) 2024; 25:693-699. [PMID: 39083064 DOI: 10.2459/jcm.0000000000001656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
AIMS Little research has investigated how sex may affect the prognosis of patients with chronic heart failure (HF). The present study was aimed at exploring sex-specific differences in prognosis in a cohort of patients with chronic HF, categorized according to severity of left ventricular dysfunction (HFrEF, HFmrEF and HFpEF), right ventricular (RV) dysfunction and ischemic (IHD) or nonischemic (no-IHD) etiology. METHODS This retrospective analysis included 1640 HF patients of whom 24% were females, 759 patients had IHD, 1110 patients had HFrEF, 147 patients had HFmrEF and 383 patients had HFpEF. The median follow-up period was 63 months (25th-75th 27-93). RESULTS In the no-IHD group, no statistically significant sex differences emerged regarding survival, regardless of age and severity of cardiac dysfunction. In contrast, in the IHD group, females had a significantly lower event rate than males in the age group between 65 and 79 years [hazard ratio (HR) 0.39; 95% confidence interval (CI): 0.86-0.18; P < 0.01]; in addition, a lower event rate was observed in females compared with males among patients with HFrEF (HR 0.47; 95% CI: 0.88-0.25; P < 0.01), among patients without RV dysfunction (HR 0.58; 95% CI: 1.02-0.33; P = 0.048) and among patients without diabetes (HR 0.44; 95% CI: 0.84-0.23; P < 0.01). CONCLUSION In nonischemic patients there was no difference between males and females in terms of survival whereas in patients with ischemic etiology survival was better in females among elderly patients, in HFrEF patients, in the absence of RV dysfunction and in the absence of diabetes.
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Affiliation(s)
- Davide Colombo
- Division of Cardiology - Fondazione IRCCS Policlinico S Matteo, Pavia
| | - Valentina Mercurio
- Department of Translational Medical Sciences, 'Federico II' University, Naples
| | - Catherine Klersy
- Biostatistics and Clinical Trial Center - Fondazione IRCCS Policlinico S Matteo
| | - Pierluigi Temporelli
- Istituti Clinici Scientifici Maugeri, IRCCS, Department of Cardiology, Istituto Scientifico di Veruno, Novara
| | | | - Erberto Carluccio
- Cardiology and Cardiovascular Pathophysiology, S. Maria della Misericordia Hospital, University of Perugia, Perugia
| | - Maria Teresa La Rovere
- Istituti Clinici Scientifici Maugeri, IRCCS, Department of Cardiology, Istituto Scientifico di Montescano, Pavia
| | | | - Rossella Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy. Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Pavia, Italy
| | - Mauro Acquaro
- Division of Cardiology - Fondazione IRCCS Policlinico S Matteo, Pavia
| | - Alessandra Greco
- Division of Cardiology - Fondazione IRCCS Policlinico S Matteo, Pavia
| | - Annalisa Turco
- Division of Cardiology - Fondazione IRCCS Policlinico S Matteo, Pavia
| | - Sandra Schirinzi
- Division of Cardiology - Fondazione IRCCS Policlinico S Matteo, Pavia
| | - Laura Scelsi
- Division of Cardiology - Fondazione IRCCS Policlinico S Matteo, Pavia
| | - Stefano Ghio
- Division of Cardiology - Fondazione IRCCS Policlinico S Matteo, Pavia
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Lee Y, Yoon M, Choi DJ, Park JJ. Differential Effect of Sex on Mortality According to Age in Heart Failure. J Am Heart Assoc 2024; 13:e034419. [PMID: 39056343 DOI: 10.1161/jaha.124.034419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/10/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Heart failure exhibits sex-based differences in prevalence, clinical characteristics, and outcomes. However, these differences may have an interaction with age. This study investigates these disparities in Asian patients with acute heart failure according to age. METHODS AND RESULTS We pooled data from the KorHF (Korea Heart Failure) and the KorAHF (Korean Acute Heart Failure) registries including 3200 patients between 2005 and 2009 and 5625 patients between 2011 and 2014, respectively, hospitalized for acute heart failure in Korea. Patients were categorized by their age into 2 groups: those with age ≥70 years and those with age <70 years. The primary endpoint was in-hospital and postdischarge outcomes according to sex, stratified by age. Of 8825 patients, 45.7% had an age <70 years, and 54.3% had an age ≥70 years. Women were older on average in both groups. Differences in baseline characteristics were more apparent in the older group, with women having a higher prevalence of hypertension and valvular heart disease, whereas more men had chronic kidney disease, previous myocardial infarction, chronic obstructive pulmonary disease, and strokes. Both in-hospital and postdischarge mortalities showed differences only in the older group, with men dying more (5.08% versus 7.41%, P<0.001; 17.95% versus 22.20%, P<0.001 respectively). This pattern persisted to adjusted analyses, which revealed that men have a 54% (odds ratio, 1.54 [95% CI, 1.17-2.04]) and 30% (hazard ratio, 1.30 [95% CI, 1.13-1.51]) increased in-hospital and 1-year mortality, respectively, compared with women. CONCLUSIONS In patients hospitalized with acute heart failure, male sex is an independent predictor of mortality in older patients but not younger patients.
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Affiliation(s)
- Yoonpyo Lee
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital Seoul National University College of Medicine Seongnam Republic of Korea
- School of Medicine Monash University Melbourne Australia
| | - Minjae Yoon
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital Seoul National University College of Medicine Seongnam Republic of Korea
| | - Dong-Ju Choi
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital Seoul National University College of Medicine Seongnam Republic of Korea
| | - Jin Joo Park
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital Seoul National University College of Medicine Seongnam Republic of Korea
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Abubakar M, Saleem A, Hajjaj M, Faiz H, Pragya A, Jamil R, Salim SS, Lateef IK, Singla D, Ramar R, Damara I, Shahid L. Sex-specific differences in risk factors, comorbidities, diagnostic challenges, optimal management, and prognostic outcomes of heart failure with preserved ejection fraction: A comprehensive literature review. Heart Fail Rev 2024; 29:235-256. [PMID: 37996694 DOI: 10.1007/s10741-023-10369-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 11/25/2023]
Abstract
Due to hormonal variations, heart failure with preserved ejection fraction (HFpEF) remains prevalent in women and affects almost half of the heart failure (HF) patients. Given the yearly death rate of 10-30% and the unavailability of medications targeting HFpEF, the need arises for a better understanding of the fundamental mechanisms of this syndrome. This comprehensive review explores sex-specific differences in traditional risk factors; female-specific factors that may impact HFpEF development and response to therapy, including variations in hormone levels that may occur pre- and post-menopausal or during pregnancy; and disparities in comorbidities, clinical presentation, and diagnostic challenges. Lastly, the review addresses prognostic outcomes, noting that women with HFpEF have a poor quality of life but a higher survival rate. It also discusses novel biomarkers and precision medicine, emphasizing their potential to improve early detection and personalized treatment.
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Affiliation(s)
- Muhammad Abubakar
- Department of Internal Medicine, Ameer-Ud-Din Medical College, Lahore General Hospital, 6 Birdwood Road, Jinnah Town, Lahore, Punjab, 54000, Pakistan.
| | - Ayesha Saleem
- Department of Internal Medicine, Jinnah Hospital, Lahore, Punjab, Pakistan
| | - Mohsin Hajjaj
- Department of Internal Medicine, Jinnah Hospital, Lahore, Punjab, Pakistan
| | - Haseeb Faiz
- Department of Internal Medicine, Jinnah Hospital, Lahore, Punjab, Pakistan
| | - Aastha Pragya
- Department of Internal Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Rosheen Jamil
- Department of Internal Medicine, Mayo Hospital, Lahore, Punjab, Pakistan
| | - Siffat Saima Salim
- Department of Surgery, Holy Family Red Crescent Medical College Hospital, Dhaka, Bangladesh
| | | | - Deepak Singla
- Department of Internal Medicine, Government Medical College, Patiala, Punjab, India
| | - Rajasekar Ramar
- Department of Internal Medicine, Rajah Muthiah Medical College, Chidambaram, Tamil Nadu, India
| | - Ivan Damara
- Department of Internal Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Laraib Shahid
- Department of Dermatology, Lahore General Hospital, Lahore, Punjab, Pakistan
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Mansur AP, Pereira-Barretto AC, Del Carlo CH, Ianni BM, Avakian SD, Gonçalinho GHF, Nakagawa NK, César LAM, Bocchi EA. Sex Differences in Prognosis of Heart Failure Due to Chronic Chagas Cardiomyopathy. JACC. HEART FAILURE 2023; 11:1284-1286. [PMID: 37178080 DOI: 10.1016/j.jchf.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 05/15/2023]
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Mansur ADP, Pereira-Barretto AC, del Carlo CH, Avakian SD, Nakagawa NK, Cesar LAM, Bocchi EA. Sex Differences in Prognosis of Heart Failure Due to Ischemic and Nonischemic Cardiomyopathy. J Clin Med 2023; 12:5323. [PMID: 37629365 PMCID: PMC10456101 DOI: 10.3390/jcm12165323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/27/2023] [Accepted: 08/02/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Limited research has explored sex-specific differences in death predictors of HF patients with ischemic (iCMP) and nonischemic (niCMP) cardiomyopathy. This study assessed sex differences in niCMP and iCMP prognosis. METHODS We studied 7487 patients with HF between February 2017 and September 2020. Clinical features and echocardiographic findings were collected. We used Kaplan-Meier, Cox proportional hazard models, and chi-square scores of Cox regression to determine death predictors in women and men. RESULTS The mean age was 64.3 ± 14.2 years, with 4417 (59%) males. Women with iCMP and niCMP exhibited a significantly higher mean age, higher mean left ventricular ejection fraction, and smaller left ventricular diastolic diameter than men. Over 2.26 years of follow-up, 325 (14.7%) women and 420 (15.7%) men, and 211 women (24.5%) and 519 men (29.8%) with niCMP (p = NS) and iCMP (p = 0.004), respectively, died. The cumulative incidence of death was higher in men with iCMP (log-rank p < 0.0001) but similar with niCMP. Cox regression showed chronic kidney disease, diabetes, stroke, atrial fibrillation, age, and myocardial infarction as the main predictors of death for iCMP in women and men. CONCLUSIONS Women exhibited a better prognosis than men with iCMP, but similar for niCMP. Nevertheless, sex was not an independent predictor of death for both CMP.
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Affiliation(s)
- Antonio de Padua Mansur
- Serviço de Prevencao, Cardiopatia na Mulher e Reabilitação Cardiovascular, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
| | - Antonio Carlos Pereira-Barretto
- Serviço de Prevencao, Cardiopatia na Mulher e Reabilitação Cardiovascular, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
| | - Carlos Henrique del Carlo
- Hospital Dia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
| | - Solange Desirée Avakian
- Unidade Clinica de Valvopatias, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
| | - Naomi Kondo Nakagawa
- Departamento de Fisioterapia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 01246-903, SP, Brazil;
| | - Luiz Antonio Machado Cesar
- Unidade Clinica de Coronariopatias Crônicas, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
| | - Edimar Alcides Bocchi
- Unidade Clinica de Insuficiencia Cardiaca, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil;
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Gonçalinho GHF, Kuwabara KL, Faria NFDO, Goes MFDS, Roggerio A, Avakian SD, Strunz CMC, Mansur ADP. Sirtuin 1 and Vascular Function in Healthy Women and Men: A Randomized Clinical Trial Comparing the Effects of Energy Restriction and Resveratrol. Nutrients 2023; 15:2949. [PMID: 37447275 DOI: 10.3390/nu15132949] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Background: Sirtuin 1 (SIRT1) has been associated with longevity and protection against cardiometabolic diseases, but little is known about how it influences human vascular function. Therefore, this study evaluated the effects of SIRT1 activation by resveratrol and energy restriction on vascular reactivity in adults. Methods: A randomized trial allocated 48 healthy adults (24 women and 24 men), aged 55 to 65 years, to resveratrol supplementation or energy restriction for 30 days. Blood lipids, glucose, insulin, C-reactive protein, noradrenaline, SIRT1 (circulating and gene expression), and flow-mediated vasodilation (FMD) and nitrate-mediated vasodilation (NMD) were measured. Results: Both interventions increased circulating SIRT1 (p < 0.001). Pre- and post-tests changes of plasma noradrenaline were significant for both groups (resveratrol: p = 0.037; energy restriction: p = 0.008). Baseline circulating SIRT1 was inversely correlated with noradrenaline (r = -0.508; p < 0.01), and post-treatment circulating SIRT1 was correlated with NMD (r = 0.433; p < 0.01). Circulating SIRT1 was a predictor of FMD in men (p = 0.045), but not in women. SIRT1 was an independent predictor of NMD (p = 0.026) only in the energy restriction group. Conclusions: Energy restriction and resveratrol increased circulating SIRT1 and reduced sympathetic activity similarly in healthy adults. SIRT1 was independently associated with NMD only in the energy restriction group.
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Affiliation(s)
- Gustavo Henrique Ferreira Gonçalinho
- Faculdade de Medicina, Universidade de São Paulo, São Paulo 05508-060, Brazil
- Serviço de Prevenção, Cardiopatia da Mulher e Reabilitação Cardiovascular, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo 05403-900, Brazil
| | - Karen Lika Kuwabara
- Faculdade de Medicina, Universidade de São Paulo, São Paulo 05508-060, Brazil
- Serviço de Prevenção, Cardiopatia da Mulher e Reabilitação Cardiovascular, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo 05403-900, Brazil
| | - Nathalia Ferreira de Oliveira Faria
- Faculdade de Medicina, Universidade de São Paulo, São Paulo 05508-060, Brazil
- Serviço de Prevenção, Cardiopatia da Mulher e Reabilitação Cardiovascular, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo 05403-900, Brazil
| | - Marisa Fernandes da Silva Goes
- Pesquisa Clínica, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo 05403-900, Brazil
| | - Alessandra Roggerio
- Laboratório de Análises Clínicas, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo 05403-900, Brazil
| | - Solange Desirée Avakian
- Unidade Clínica de Cardiopatias Valvares, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo 05403-900, Brazil
| | - Célia Maria Cassaro Strunz
- Laboratório de Análises Clínicas, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo 05403-900, Brazil
| | - Antonio de Padua Mansur
- Faculdade de Medicina, Universidade de São Paulo, São Paulo 05508-060, Brazil
- Serviço de Prevenção, Cardiopatia da Mulher e Reabilitação Cardiovascular, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo 05403-900, Brazil
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