Sex differences in aortic stenosis: Identification of knowledge gaps for sex-specific personalized medicine

Objectives

This review summarizes sex-based differences in aortic stenosis (AS) and identifies knowledge gaps that should be addressed by future studies.

Background

AS is the most common valvular heart disease in developed countries. Sex-specific differences have not been fully appreciated, as a result of widespread under diagnosis of AS in women.

Summary

Studies including sex-stratified analyses have shown differences in pathophysiology with less calcification and more fibrosis in women's aortic valve. Women have impaired myocardial perfusion reserve and different compensatory response of the left ventricle (LV) to pressure overload, with concentric remodeling and more diffuse fibrosis, in contrast to men with more focal fibrosis and more dilated/eccentrically remodeled LV. There is sex difference in clinical presentation and anatomical characteristics, with women having more paradoxical low-flow/low-gradient AS, under-diagnosis and severity underestimated, with less referral to aortic valve replacement (AVR) compared to men. The response to therapies is also different: women have more adverse events with surgical AVR and greater survival benefit with transcatheter AVR. After AVR, women would have more favorable LV remodeling, but sex-related differences in changes in myocardial reserve flow need future research.

Conclusions

Investigation into these described sex-related differences in AS offers potential utility for improving prevention and treatment of AS in women and men. To better understand sex-based differences in pathophysiology, clinical presentation, and response to therapies, sex-specific critical knowledge gaps should be addressed in future research for sex-specific personalized medicine.

[Infective endocarditis in Argentina: what have we learned in the last 25 years ?]

The epidemiology of infectious endocarditis (IE) has undergone changes due to a series of factors such as aging, comorbidities and medical procedures. The aim of this study was to evaluate the main clinical, epidemiological and etiological changes of the IE in the last 25 years in Argentina. A comparative analysis of three observational prospective registries was performed in which cases of definite and possible IE were consecutively included according to the Duke criteria: two multicentre studies (EIRA-1 [1992-1994] and EIRA-2 [2001-2002]) and one study in a reference cardiology center (CRC [2007-2017]). In the 1065 episodes of EI evaluated, there were no differences regarding sex, and the patients were older in each period (p < 0.001). Intracardiac device-associated IE was more frequent in the last decade: pacemaker (5.4 vs. 23% p < 0.0001) and prosthetic valve IE (8.5% vs. 19.2% vs. 47.5% p < 0.0001). On the other hand, IE associated with intravenous drugs (P < 0.0001) and congenital heart diseases (p = 0.001) was significantly less frequent. The etiology changed substantially: Streptococcus viridans group decreased (30.8% vs. 26.8% vs. 15.9%, p < 0.001) and IE by Staphylococcus spp. predominated over other microorganisms, with a statistically significant increase in IE due to coagulase-negative Staphylococcus. Surgical treatment was more frequently implemented in the last decade and was accompanied by a trend towards lower mortality in the CRC (23.5%, 24.3% vs. 17.2% p = 0.058).

[Infective endocarditis due to non-HACEK gram-negative bacilli in a Level III cardiovascular center in Argentina (1998-2016)]

Non-HACEK Gram-negative bacilli are a rare cause of infective endocarditis. Epidemiological, diagnostic and prognostic aspects of this entity are little known, and there is limited experience. The aim of this study was to analyze the clinical, microbiological and in-hospital outcomes of non-HACEK Gram negative bacilli endocarditis and to compare them with those due to other microorganisms.