The Women's Health Initiative Randomized Trials and Clinical Practice: A Review

Importance

Approximately 55 million people in the US and approximately 1.1 billion people worldwide are postmenopausal women. To inform clinical practice about the health effects of menopausal hormone therapy, calcium plus vitamin D supplementation, and a low-fat dietary pattern, the Women's Health Initiative (WHI) enrolled 161 808 postmenopausal US women (N = 68 132 in the clinical trials) aged 50 to 79 years at baseline from 1993 to 1998, and followed them up for up to 20 years.

Observations

The WHI clinical trial results do not support hormone therapy with oral conjugated equine estrogens plus medroxyprogesterone acetate for postmenopausal women or conjugated equine estrogens alone for those with prior hysterectomy to prevent cardiovascular disease, dementia, or other chronic diseases. However, hormone therapy is effective for treating moderate to severe vasomotor and other menopausal symptoms. These benefits of hormone therapy in early menopause, combined with lower rates of adverse effects of hormone therapy in early compared with later menopause, support initiation of hormone therapy before age 60 years for women without contraindications to hormone therapy who have bothersome menopausal symptoms. The WHI results do not support routinely recommending calcium plus vitamin D supplementation for fracture prevention in all postmenopausal women. However, calcium and vitamin D are appropriate for women who do not meet national guidelines for recommended intakes of these nutrients through diet. A low-fat dietary pattern with increased fruit, vegetable, and grain consumption did not prevent the primary outcomes of breast or colorectal cancer but was associated with lower rates of the secondary outcome of breast cancer mortality during long-term follow-up.

Conclusions and Relevance

For postmenopausal women, the WHI randomized clinical trials do not support menopausal hormone therapy to prevent cardiovascular disease or other chronic diseases. Menopausal hormone therapy is appropriate to treat bothersome vasomotor symptoms among women in early menopause, without contraindications, who are interested in taking hormone therapy. The WHI evidence does not support routine supplementation with calcium plus vitamin D for menopausal women to prevent fractures or a low-fat diet with increased fruits, vegetables, and grains to prevent breast or colorectal cancer. A potential role of a low-fat dietary pattern in reducing breast cancer mortality, a secondary outcome, warrants further study.

Heart Failure Risk Among African-American Women With an ICAM1 Missense Variant

BACKGROUND

A common genetic variant of ICAM1 among African-American individuals (rs5491; p.K56M) is associated with heart failure (HF) hospitalization, but whether this risk is specific to heart failure with preserved ejection fraction (HFpEF) remains unclear. Older women are at high risk for HFpEF, and the relationship between rs5491 and HFpEF across the age spectrum is unknown.

OBJECTIVES

This study assessed risk of HF and its subtypes conferred by ICAM1 p.K56M (rs5491).

METHODS

Associations of rs5491 with risk of HF and its subtypes were estimated among African American individuals in WHI (Women's Health Initiative). The study evaluated whether the association between rs5491 and HF hospitalizations was modified by baseline age. Subsequently, African-American women in WHI and MESA (Multi-Ethnic Study of Atherosclerosis) were pooled and analyses were repeated.

RESULTS

Among 8,401 women in WHI, the minor allele frequency of rs5491 was 20.7%, and 731 HF hospitalizations occurred over 19.2 years. The rs5491 variant was not associated with HF or its subtypes across WHI. Interaction analyses suggested that age as a continuous variable modified the association of rs5491 with HFpEF hospitalization (interaction P = 0.04). Upon categorizing women into age decades, rs5491 conferred increased risk of HFpEF among women ≥70 years (HR per additional rs5491 allele: 1.82 [95% CI: 1.25-2.65]; P = 0.002) but was not associated with HFpEF risk among women <70 years. Pooling African-American women in WHI (n = 8,401) and MESA (n = 856) demonstrated that the effect modification by age on the association of rs5491 with HFpEF became more significant (interaction P = 0.009), with consistent HFpEF risk effect estimates among women ≥70 years.

CONCLUSIONS

ICAM1 p.K56M (rs5491) is associated with HFpEF among African-American women ≥70 years.

The relationship between optimism, MCI, and dementia among postmenopausal women

OBJECTIVES

The relationship between optimism and cognitive functioning is not fully understood. We examined the association of optimism with risk of mild cognitive impairment (MCI) and dementia in the Women's Health Initiative Memory Study (WHIMS).

METHODS

Optimism was measured by the Life Orientation Test-Revised (LOT-R) total score, and optimism and pessimism subscales. A panel of experts adjudicated cognitive endpoints based on annual cognitive assessments. We used cox proportional hazard regression models to examine the association of LOT-R total score and optimism and pessimism sub-scores with MCI/dementia. We also examined the relationship between vascular disease, LOT-R total score, optimism and pessimism, and cognition.

RESULTS

Mean age was 70.5 (SD = 3.9) years. The sample (N = 7249) was 87% white, and 29.8% of participants had < 12 years of education. Total LOT-R score (HR = 0.96, 95% CI: 0.94, 0.98, p < 0.001) was associated with lower risk of combined MCI or dementia. More pessimism (HR = 1.08, 95% CI: 1.05, 1.11, p < 0.0001) was associated with higher risk of MCI or dementia after adjustment for ethnicity, education, vascular disease, and depression. No significant relationships emerged from the optimism subscale.

CONCLUSION

These data suggest that less pessimism, but not more optimism, was associated with a lower risk of MCI and dementia.

Contributions of the Women's Health Initiative to Cardiovascular Research: JACC State-of-the-Art Review

The WHI (Women's Health Initiative) enrolled 161,808 racially and ethnically diverse postmenopausal women, ages 50-79 years, from 1993 to 1998 at 40 clinical centers across the United States. In its clinical trial component, WHI evaluated 3 randomized interventions (menopausal hormone therapy; diet modification; and calcium/vitamin D supplementation) for the primary prevention of major chronic diseases, including cardiovascular disease, in older women. In the WHI observational study, numerous clinical, behavioral, and social factors have been evaluated as predictors of incident chronic disease and mortality. Although the original interventions have been completed, the WHI data and biomarker resources continue to be leveraged and expanded through ancillary studies to yield novel insights regarding cardiovascular disease prevention and healthy aging in women.

Adverse Pregnancy Outcomes and Incident Heart Failure in the Women's Health Initiative

IMPORTANCE

Some prior evidence suggests that adverse pregnancy outcomes (APOs) may be associated with heart failure (HF). Identifying unique factors associated with the risk of HF and studying HF subtypes are important next steps.

OBJECTIVE

To investigate the association of APOs with incident HF overall and stratified by HF subtype (preserved vs reduced ejection fraction) among postmenopausal women in the Women's Health Initiative (WHI).

DESIGN, SETTING, AND PARTICIPANTS

In 2017, an APO history survey was administered in the WHI study, a large multiethnic cohort of postmenopausal women. The associations of 5 APOs (gestational diabetes, hypertensive disorders of pregnancy [HDP], low birth weight, high birth weight, and preterm delivery) with incident adjudicated HF were analyzed. In this cohort study, the association of each APO with HF was assessed using logistic regression models and with HF subtypes using multinomial regression, adjusting for age, sociodemographic characteristics, smoking, randomization status, reproductive history, and other APOs. Data analysis was performed from January 2020 to September 2021.

EXPOSURES

APOs (gestational diabetes, HDP, low birth weight, high birth weight, and preterm delivery).

MAIN OUTCOMES AND MEASURES

All confirmed cases of women hospitalized with HF and HF subtype were adjudicated by trained physicians using standardized methods.

RESULTS

Of 10 292 women (median [IQR] age, 60 [55-64] years), 3185 (31.0%) reported 1 or more APO and 336 (3.3%) had a diagnosis of HF. Women with a history of any APO had a higher prevalence of hypertension, diabetes, coronary heart disease, or smoking. Of the APOs studied, only HDP was significantly associated with HF with a fully adjusted odds ratio (OR) of 1.75 (95% CI, 1.22-2.50), and with HF with preserved ejection fraction in fully adjusted models (OR, 2.06; 95% CI, 1.29-3.27). In mediation analyses, hypertension explained 24% (95% CI, 12%-73%), coronary heart disease 23% (95% CI, 11%-68%), and body mass index 20% (95% CI, 10%-64%) of the association between HDP and HF.

CONCLUSIONS AND RELEVANCE

In this large cohort of postmenopausal women, HDP was independently associated with incident HF, particularly HF with preserved ejection fraction, and this association was mediated by subsequent hypertension, coronary heart disease, and obesity. These findings suggest that monitoring and modifying these factors early in women presenting with HDP may be associated with reduced long-term risk of HF.

Electrocardiographic findings in peripartum cardiomyopathy

Background

There is limited data on electrocardiographic (ECG) abnormalities and their prognostic significance in women with peripartum cardiomyopathy (PPCM). We sought to characterize ECG findings in PPCM and explore the association of ECG findings with myocardial recovery and clinical outcomes.

Hypothesis

We hypothesized that ECG indicators of myocardial remodeling would portend worse systolic function and outcomes.

Methods

Standard 12‐lead ECGs were obtained at enrollment in the Investigations of Pregnancy‐Associated Cardiomyopathy study and analyzed for 88 women. Left ventricular ejection fraction (LVEF) was measured by echocardiography at baseline, 6 months, and 12 months. Women were followed for clinical events (death, mechanical circulatory support, and/or cardiac transplantation) until 1 year.

Results

Half of women had an “abnormal” ECG, defined as atrial abnormality, ventricular hypertrophy, ST‐segment deviation, and/or bundle branch block. Women with left atrial abnormality (LAA) had lower LVEF at 6 months (44% vs 52%, P = 0.02) and 12 months (46% vs 54%, P = 0.03). LAA also predicted decreased event‐free survival at 1 year (76% vs 97%, P = 0.008). Neither left ventricular hypertrophy by ECG nor T‐wave abnormalities predicted outcomes. A normal ECG was associated with recovery in LVEF to ≥50% (84% vs 49%, P = 0.001) and event‐free survival at 1 year (100% vs 85%, P = 0.01).

Conclusions

ECG abnormalities are common in women with PPCM, but a normal ECG does not rule out the presence of PPCM. LAA predicted lower likelihood of myocardial recovery and event‐free survival, and a normal ECG predicted favorable event‐free survival.

Cardiovascular Risk Factors: Does Sex Matter?

Coronary heart disease (CHD) is the leading cause of death for women worldwide, most of which is believed to be preventable. Numerous risk factors for CHD are well described, and understanding these risk factors is the first step to reducing the burden of CHD. There are clear differences in risk factors between women and men. The incidence of myocardial infarction is much lower among women under the age of 50 years compared with men, but after menopause, the incidence in women dramatically increases to approach that of men. For this reason, estrogen is postulated to be cardioprotective but results of recent randomized clinical trials challenge this hypothesis. The significance of cardiovascular risk factors appears to vary between women and men, the reasons for which remain elusive but could include the interaction of these risk factors with hormones. Confounding this observation is that most early studies of cardiovascular risk factors enrolled primarily men. This review will focus solely on the differences in cardiovascular risk factors in women and men including the current role of hormone therapy in CHD prevention, sex differences in established CHD risk factors and emerging risk factors for CHD in women.

Incidence and Prognosis of Atrial Fibrillation in Patients With Sepsis

Background

Although the mortality rate among patients with sepsis is declining, the incidence of both sepsis and sepsis-related deaths is increasing, likely due to its presence in a growing elderly population. As atrial fibrillation is more common in the elderly, we hypothesize that its presence will be associated with greater mortality among patients with sepsis.

Methods

The Medical Intensive Care Unit (MICU) database of a large tertiary care medical center was queried for sepsis-related codes and atrial fibrillation.

Results

Atrial fibrillation was associated with older age and a higher mortality in this series of patients with sepsis.

Conclusions

Whether atrial fibrillation is a marker of disease severity or contributes to mortality is uncertain. Further studies are necessary to determine optimal management.

Prognostic significance of nonsustained ventricular tachycardia during dobutamine stress echocardiography

Nonsustained ventricular tachycardia (NSVT) is a well-recognized side effect during dobutamine stress echocardiography (DSE). This study sought to evaluate the prognostic implications of NSVT during DSE on 1,266 consecutive dobutamine stress echocardiograms performed over 1 year. NSVT, defined as > or =3 consecutive ventricular premature beats, occurred in 65 of 1,266 patients (5.1%). There was no absolute increased risk in all-cause mortality between the NSVT and no NSVT groups (22% vs 17%, p = 0.15) during the 3-year follow-up. Survival curves generated by the Kaplan-Meier method also demonstrated no increased risk in mortality between the NSVT and no NSVT groups (p = 0.43). When only studies with negative results for inducible ischemia were taken into account, survival curves showed no significant difference in all-cause mortality (p = 0.26). Studies with negative results for inducible ischemia were also stratified according to the ejection fraction (EF). Patients without inducible ischemia and mildly reduced to normal EFs (>0.45) did not have significant differences in survival between the NSVT and no NSVT groups over the 3-year follow-up (p = 0.86). However, patients without inducible ischemia and moderately reduced EFs (0.35 to 0.45) who had NSVT during DSE had significantly reduced survival over the follow-up (p = 0.01).

The perceived validity of eyewitness identification testimony: a test of the five Biggers criteria

The U.S. Supreme Court has outlined five criteria on which evaluations of eyewitness identifications should be based (certainty, view, attention, description, and time; Neil v. Biggers, 1972). We postulated that certainty plays a qualitatively different role from the four other Biggers criteria in evaluations of eyewitness identification testimony. Specifically, we hypothesized that participants would ignore reports on other criteria when certainty was high (the certainty-trumps hypothesis), but not when certainty was low. Participants (N = 386) read a fictitious trial transcript in which three of the five Biggers criteria were manipulated (certainty, view, and attention, or certainty, description, and time) and completed a questionnaire. The certainty-trumps hypothesis was not supported. Instead, the Biggers criteria combined only as main effects, not interactions, supporting a summative hypothesis. Surprisingly, collateral effects indicated that manipulations of one criterion (e.g., certainty) affected perceptions of other criteria (e.g., attention and view) and vice versa. Implications of the results are discussed.

From the lab to the police station. A successful application of eyewitness research

The U.S. Department of Justice released the first national guide for collecting and preserving eyewitness evidence in October 1999. Scientific psychology played a large role in making a case for these procedural guidelines as well as in setting a scientific foundation for the guidelines, and eyewitness researchers directly participated in writing them. The authors describe how eyewitness researchers shaped understanding of eyewitness evidence issues over a long period of time through research and theory on system variables. Additional pressure for guidelines was applied by psychologists through expert testimony that focused on deficiencies in the procedures used to collect the eyewitness evidence. DNA exoneration cases were particularly important in leading U.S. Attorney General Janet Reno to notice the eyewitness literature in psychology and to order the National Institute of Justice to coordinate the development of national guidelines. The authors describe their experience as members of the working group, which included prosecutors, defense lawyers, and law enforcement officers from across the country.

A technique for performing transesophageal echocardiography in patients with Zenker's diverticulum

A patient with a large Zenker's diverticulum and narrow, angulated passageway successfully underwent transesophageal echocardiography using a pediatric endoscope, short esophageal overtube, and a pediatric transesophageal echocardiographic probe.

From the lab to the police station. A successful application of eyewitness research

The U.S. Department of Justice released the first national guide for collecting and preserving eyewitness evidence in October 1999. Scientific psychology played a large role in making a case for these procedural guidelines as well as in setting a scientific foundation for the guidelines, and eyewitness researchers directly participated in writing them. The authors describe how eyewitness researchers shaped understanding of eyewitness evidence issues over a long period of time through research and theory on system variables. Additional pressure for guidelines was applied by psychologists through expert testimony that focused on deficiencies in the procedures used to collect the eyewitness evidence. DNA exoneration cases were particularly important in leading U.S. Attorney General Janet Reno to notice the eyewitness literature in psychology and to order the National Institute of Justice to coordinate the development of national guidelines. The authors describe their experience as members of the working group, which included prosecutors, defense lawyers, and law enforcement officers from across the country.

Trait aggressiveness and hockey penalties: predicting hot tempers on the ice

Previous studies examining the validity of measures of trait aggressiveness either have been retrospective studies or have used laboratory aggression as the criterion behavior. Can a measure of trait aggressiveness predict nonlaboratory physical aggression? The Physical Aggression subscale of the Aggression Questionnaire was completed by 91 high school hockey players prior to the start of the season. At the end of the season, these trait aggressiveness scores were regressed on minutes in the penalty box for aggressive penalties (e.g., fighting, slashing, tripping) and minutes in the penalty box for nonaggressive penalties (e.g., delay of game, illegal equipment, too many players). As expected, preseason trait aggressiveness scores predicted aggressive penalty minutes (r = .33) but not nonaggressive penalty minutes (r = .04).

Congenital heart disease in infants with Down's syndrome

Medical records of 118 newborn infants with Down's syndrome were reviewed to document the types of congenital heart disease (CHD) in those having echocardiography. Of 102 infants having echocardiography, 49 (48%) had heart defects; 47 of these had trisomy 21 and 2 had unbalanced translocation karyotypes. Of the 53 (52%) who did not have heart defects, all had trisomy except 1 with a mosaic karyotype and 1 with a translocation karyotype. The most common heart malformation was an atrioventricular canal, followed in frequency by ventricular septal defect, atrial septal defect, patent ductus arteriosus, and tetralogy of Fallot. Benefits of echocardiography in such infants are early detection of CHD, with aggressive management to prevent future complications, and reassurance to parents if the infant does not have CHD.