Cardiovascular risk assessment in women: which women are suited for menopausal hormone therapy?

Individual risk assessment for atherosclerotic cardiovascular disease is important for safe menopausal hormone prescription. Besides the traditional risk factors, female-specific risk variables related to pregnancy and gynecologic conditions importantly contribute to a more tailored risk assessment in women at middle age. Of these, prior pre-eclampsia/HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome and early spontaneous menopause (<40 years) seem to be the strongest adverse risk variables. Concomitant inflammatory disorders should also be taken into account. Adding a coronary artery calcium score with a computed tomography scan to risk assessment has a high predictive value for future cardiovascular events. This should be considered to discriminate between low-risk and high-risk women when uncertainty exists. In women at intermediate risk, menopausal hormone therapy can be easily combined with preventive medication if cardiovascular risk factors are present. In women at higher risk who have severe disabling vasomotor symptoms, a lower dosage of hormone therapy can be considered in good collaboration between the gynecologist and the cardiologist/vascular specialist.

Design and rationale of the NetherLands registry of invasive Coronary vasomotor Function Testing (NL-CFT)

BACKGROUND

Angina without angiographic evidence of obstructive coronary artery disease (ANOCA) is a highly prevalent condition with insufficient pathophysiological knowledge and lack of evidence-based medical therapies. This affects ANOCA patients prognosis, their healthcare utilization and quality of life. In current guidelines, performing a coronary function test (CFT) is recommended to identify a specific vasomotor dysfunction endotype. The NetherLands registry of invasive Coronary vasomotor Function testing (NL-CFT) has been designed to collect data on ANOCA patients undergoing CFT in the Netherlands.

METHODS

The NL-CFT is a web-based, prospective, observational registry including all consecutive ANOCA patients undergoing clinically indicated CFT in participating centers throughout the Netherlands. Data on medical history, procedural data and (patient reported) outcomes are gathered. The implementation of a common CFT protocol in all participating hospitals promotes an equal diagnostic strategy and ensures representation of the entire ANOCA population. A CFT is performed after ruling out obstructive coronary artery disease. It comprises of both acetylcholine vasoreactivity testing as well as bolus thermodilution assessment of microvascular function. Optionally, continuous thermodilution or Doppler flow measurements can be performed. Participating centers can perform research using own data, or pooled data will be made available upon specific request via a secure digital research environment, after approval of a steering committee.

CONCLUSION

NL-CFT will be an important registry by enabling both observational and registry based (randomized) clinical trials in ANOCA patients undergoing CFT.

Absolute flow and resistance have a lower variability in repeated testing as compared to CFR and IMR: an EDIT-CMD substudy

Background

Invasive coronary function testing (CFT), including both acetylcholine (ACH) spasm provocation testing and assessment of coronary flow and resistance, is recommended to assess coronary vasomotor dysfunction (CVDys) in patients with angina and non-obstructive coronary artery disease (ANOCA).

Objectives

To determine repeat testing reliability of invasive measurements of CVDys.

Methods

In the EDIT-CMD trial, 73 patients underwent both baseline and follow-up CFT after six weeks. Repeat testing reliability for CVDys assessment, including coronary flow reserve (CFR), index of microvascular resistance (IMR), absolute flow (Q) and microvascular resistance (R) was assessed by 1.) comparing continuous values between baseline and follow-up measurement, including difference and correlation between the two measurements 2.) classification agreement (CCA) for the presence of CMD according to cut-offs, which was also assessed for ACH spasm provocation test and 3.) Bland-Altman plots. Fisher-Z scores were used to compare correlations.

Results

Mean CFR was 3.1±1.5 at baseline and 4.1±1.5 at follow-up (P=0.03), with no significant correlation (ρ=0.285, P=0.10). Mean IMR was 27±12 at baseline and 27±19 at follow-up (P=0.94), with a trend to a significant correlation (ρ=0.312, P=0.07). The CCA between the baseline and follow-up was 74% for CFR and 57% for IMR.

Mean Q was 183±72 at baseline and 192±78 at follow-up (P=0.49), with a significant correlation (ρ=0.579, P&lt;0.001). Mean R was 527±233 at baseline and 506±228 at follow-up (P=0.67), with a significant correlation (ρ=0.51, p=0.03). The CCA between R at baseline and 6 weeks follow-up was 72% and for Q this was 82%.

The correlation coefficient (ρ) of Q was significantly better than the ρ of CFR (P=0.006). The ρ of R and IMR did not differ.

For the ACH spasm provocation test we found a CCA of 79% between both measurements.

Conclusion

This is the first study to assess re-test reliability of the invasive CFT. Measurements of Q and R show higher agreement and correlation than their surrogates CFR and IMR in assessing microvascular function. ACH provocation spasm test also demonstrated good re-test reliability.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott

Home blood pressure monitoring detects unrevealed hypertension in women with a history of preeclampsia: results of the BP-PRESELF study

Background/Introduction

The risk of cardiovascular disease more than doubles after hypertensive disorders of pregnancy. As early onset chronic hypertension contributes to cardiovascular risk, implementation of screening strategies, using home blood pressure monitoring (HBPM), may help to improve long-term cardiovascular health.

Purpose

We evaluated whether HBPM among women with a history of preeclampsia/HELLP syndrome is feasible for early detection and management of hypertension.

Methods

The Blood Pressure after PREeclampsia by SELF monitoring (BP-PRESELF) is a multicenter randomized controlled trial. We recruited 198 women with a mean age of 45 years, approximately 12 years after the index pregnancy. Participants were randomized to intervention group with HBPM for the duration of one year or the control group with 'usual care' (Figure 1). The primary outcome was feasibility of HBPM during 1 year of follow-up, defined as protocol adherence, protocol persistence and patient acceptance. Secondary outcomes were blood pressure levels and prevalence of hypertension.

Results

The baseline characteristics did not show statistically significant differences between groups, except for years since index pregnancy. Especially blood pressure levels were very similar at time of inclusion.

Protocol adherence decreased during the first 6 months, after which it stabilized (Figure 2A). Protocol persistence remained high throughout follow-up (Figure 2B). During the study period, 33 women (34%) in the intervention group were diagnosed with hypertension versus only 10 women (11%) in the control group. At 1-year follow-up, mean systolic blood pressure (SD) was 120.4 (11.6) mm Hg in the intervention group versus 126.1 (14.3) mm Hg in the control group, P=0.003. Mean diastolic blood pressure (SD) values were 77.2 (8.0) mm Hg versus 81.7 (9.4) mm Hg, P&lt;0.001, respectively. Adjusted systolic and diastolic differences (95% confidence interval) were −6.81 (−10.17, −3.45) and −4.93 (−7.26, −2.61) mm Hg, with 80% less hypertension at 1-year follow-up in the intervention group.

Conclusion(s)

HBPM appears to be feasible for follow-up of blood pressure in women after preeclampsia/HELLP syndrome, while it detected hypertension and reduced blood pressure levels after intervention in one-third of women in this group.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): INTERREG-V-A program Germany-The Netherlands “Zorg Verbindt”, co-financed by the European Union (EU), Ministry for Economy, Innovation, Digitalization and Energy of the Federal State of Nordrhein-Westfalen (Germany), and the Province of Gelderland (The Netherlands). CONSORT flowchartProtocol adherence (A) and persistence (B)

Cardiometabolic health in premature ovarian insufficiency

Premature ovarian insufficiency (POI) is an increasing public health problem with a prevalence now approaching 4%. POI results in adverse effects on the skeleton and central nervous system as well as disturbances of metabolic and cardiological factors that predispose to a major increased risk of cardiovascular disease (CVD). This article reviews the effects of the premature loss of ovarian function on lipids and lipoproteins, glucose and insulin metabolism, body composition, hemostasis and blood pressure, together with effects on the development of metabolic syndrome and diabetes mellitus. The article examines the effects of POI on vascular endothelial function and inflammation that result in arterial disease, and reviews the effects of hormone replacement therapy (HRT) on these various metabolic processes and on cardiovascular outcomes. It is essential that women with POI receive hormonal treatment to help prevent the development of CVD, and that this treatment is continued at least until the normal age of menopause. It appears that HRT has a more favorable effect than the combined oral contraceptive, but larger clinical trials are needed to establish the optimal treatment. Other therapeutic measures may need to be added to correct existing metabolic abnormalities and, in particular, attention to lifestyle factors such as diet and exercise must be encouraged.

Diagnostic approach in patients with angina and no obstructive coronary artery disease: emphasising the role of the coronary function test

BACKGROUND

Many patients with angina do not have obstructive coronary artery disease (CAD), also referred to as "Ischaemia with No Obstructive Coronary Arteries" (INOCA). Coronary vascular dysfunction is the underlying cause of this ischaemic heart disease in as much as 59-89% of these patients, including the endotypes of coronary microvascular dysfunction and epicardial coronary vasospasm. Currently, a coronary function test (CFT) is the only comprehensive diagnostic modality to evaluate all endotypes of coronary vascular dysfunction in patients with INOCA.

OBJECTIVE

In this paper we discuss the relevance of performing a CFT, provide considerations for patient selection, and present an overview of the procedure and its safety.

METHODS

We reviewed the latest published data, guidelines and consensus documents, combined with a discussion of novel original data, to present this point of view.

RESULTS

The use of a CFT could lead to a more accurate and timely diagnosis of vascular dysfunction, identifies patients at risk for cardiovascular events, and enables stratified treatment which improves symptoms and quality of life. Current guidelines recommend considering a CFT in patients with INOCA and persistent symptoms. The safety of the procedure is comparable to that of a regular coronary angiography with physiological measurements. Non-invasive alternatives have limited diagnostic accuracy for the identification of coronary vascular dysfunction in patients with INOCA, and a regular coronary angiography and/or coronary computed tomography scan cannot establish the diagnosis.

CONCLUSIONS

A complete CFT, including acetylcholine and adenosine tests, should be considered in patients with INOCA.

Ischaemia with no obstructive coronary arteries

Ischaemia with no obstructive coronary arteries (INOCA) is a common ischaemic heart disease with a female preponderance, mostly due to underlying coronary vascular dysfunction comprising coronary microvascular dysfunction and/or epicardial coronary vasospasm. Since standard ischaemia detection tests and coronary angiograms are not suitable to diagnose coronary vascular dysfunction, INOCA is often overlooked in current cardiology practice. Future research, including large outcome trials, is much awaited. Yet, adequate diagnosis is possible and treatment options are available and vital to reduce symptoms and most probably improve cardiovascular prognosis. This review intends to give a brief overview of the clinical presentation, underlying pathophysiology, and the diagnostic and treatment options in patients with suspected INOCA.

Psychological and clinical characteristics of female patients with spontaneous coronary artery dissection

Aims

Spontaneous coronary artery dissection (SCAD) is increasingly recognised as a cause of myocardial infarction, but psychological characteristics of patients with SCAD have not yet been extensively investigated. We assessed the prevalence of a broad range of psychological and clinical factors, and their inter-relationships in patients with a history of SCAD. Furthermore, we investigated whether specific clusters of patients with SCAD can be identified.

Methods

Participants were recruited between March and May 2019 from a Dutch SCAD database and completed online questionnaires. Clinical information was verified by review of medical records. Participants were predominantly female (172/183; 94%). Analyses focused on the 172 female patients (mean age 52.0 ± 7.5 years, 37% postmenopausal).

Results

The most common comorbidities of SCAD were migraine (52%), fibromuscular dysplasia (FMD; 29%), chronic pain (29%), and tinnitus (28%). Six women (3%) had pregnancy-associated SCAD. Traditional cardiovascular risk factors were rare (<10%), except for hypertension (31%). Psychological assessment indicated high levels of perceived stress (PSS-10 ≥14; 50%), fatigue (FAS-10 ≥22; 56%), and a frequent history of burnout (25%). The prevalence of depression (9%) and anxiety (12%) was relatively low. Three clusters were identified: (A) FMD and chronic non-ischaemic conditions (tinnitus, chronic pain, and irritable bowel syndrome); (B) migraine; and (C) none of these conditions.

Conclusion

This study shows that perceived stress and fatigue are common in patients with SCAD, in addition to prevalent comorbid FMD, migraine, tinnitus, and non-ischaemic pain conditions. These factors may add to developing tailored rehabilitation programmes for patients with SCAD.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01437-7) contains supplementary material, which is available to authorized users.

4117Cardiac surveillance during breast cancer treatment; a snapshot of current practice

Background

Breast cancer (BC) is the most common type of cancer in women. Over the past decades survival rates increased up to 90% at 5 years and 83% at 10 years. The various BC treatments, such as radiotherapy, chemotherapy and immunotherapy increase cardiotoxicity risk, leading to premature ischemic heart disease and heart failure amongst survivors. Both affect women's daily routine and quality of life. Reducing this adverse risk, by early recognition and (preventive) treatment, is therefore important. Despite, screening for cardiotoxicity is currently insufficiently standardized in daily practice.

A fundamental step in identifying areas of improvement is providing an overview of current practice.

Purpose

This study aims to describe current cardiac surveillance for women with BC during and after cancer treatment, using routinely collected hospital data in the Netherlands.

Methods

An observational study has been performed on Dutch hospital data from 2012 up to 2015, provided by Statistics Netherlands. Information about cardiology and oncology diagnoses, diagnostic procedures, treatments and preventive measures were available. Newly diagnosed female patients with codes malignant neoplasm of the breast (ICD-10, C50.0-C50.9) in 2013 and without any comorbidities since 1–1-2012 were included in the analyses. In follow-up data up to 31–12 2015, we mapped all types of care the patients received for BC and cardiology related indications.

Results

We included 16040 newly diagnosed BC patients in 2013, with a mean age of 65.9 (sd 12.9). A total of 5084 (31.7%) received chemotherapy, 1385 (8.6%) immunotherapy and 7870 (49.1%) radiotherapy. Amongst all included patients, 4376 (27.3%) received any type of cardiac care. Cardiology specific laboratory tests (e.g. Troponin) were performed in 96 (0.6%). Imaging procedures, such as echocardiography and MUGA occurred in 1853 (11.5%) and 1544 (9.6%) patients, respectively.

Of the 5084 patients receiving chemotherapy 1862 (36.6%) received any type of imaging or cardiac care, of the 1385 patients receiving immunotherapy 689 (49.7%), and of the 7870 patients receiving radiotherapy 2401 (31.7%).

Conclusions

This study shows that only a quarter of Dutch women treated for BC receive cardiac surveillance. Diagnostic procedures or laboratory tests to detect cardiotoxicity are not structurally performed in women receiving cardiotoxic cancer treatments (e.g. chemo- and radiotherapy). A more structural approach and individual risk assessment is needed to provide more tailored cardiac care during BC treatment.

Similar pro-NT and pro-RLX2 levels after preeclampsia and after uncomplicated pregnancy

OBJECTIVE

Women are at increased risk of developing cardiovascular disease (CVD) after preeclampsia. Proneurotensin 1-117 (pro-NT) and prorelaxin 2 connecting peptide (pro-RLX2) have recently emerged as potential biomarkers for CVD risk in women. We assessed pro-NT and pro-RLX2 levels in women with and without a history of preeclampsia.

STUDY DESIGN

339 women with a history of early-onset preeclampsia and 327 women with an uncomplicated pregnancy underwent cardiovascular screening 10 years after delivery (the Preeclampsia Risk EValuation in FEMales (PREVFEM) cohort).

MAIN OUTCOME MEASURES

Pro-NT, a stable fragment of the neurotensin precursor, was assessed in the whole cohort. Pro-RLX2, the stable connecting peptide of the relaxin 2 prohormone, was assessed in a subset of this cohort, consisting of 27 women with a history of preeclampsia and 23 healthy controls. Associations between biomarker levels and traditional CVD risk factors in the preeclampsia and control group were assessed by Pearson's correlation coefficient.

RESULTS

We found no differences in pro-NT and pro-RLX2 levels between the preeclampsia and control group. Pro-NT levels were associated with higher HbA1c levels (r=0.113, p-value 0.045) and with BMI (r=0.124, p-value 0.027), but only in the control group. Pro-RLX2 was related to current smoking and triglyceride levels in women with a history of preeclampsia and related to LDL-cholesterol in women with an uncomplicated pregnancy.

CONCLUSIONS

Pro-NT and pro-RLX2 levels were comparable in women 10 years after preeclampsia and women with an uncomplicated pregnancy. The role of pro-NT and pro-RLX2 in CVD development after preeclampsia should be further investigated.

Long-term cardiovascular health in adult cancer survivors

The number of cancer survivors has tremendously increased over the past decades as a result of aging of the population and improvements in early cancer detection and treatment. Ongoing successes in cancer treatment are expected to result in a further increase in the number of long-term survivors. However, cancer treatment can have detrimental cardiovascular side-effects that impact morbidity and mortality, reducing quality of life in cancer survivors. The spectrum of radiotherapy- and chemotherapy-induced cardiovascular disease is broad, varying from subclinical valvular dysfunction to overt congestive heart failure, and such effects may not be apparent for more than twenty years after the initial cancer treatment. Awareness of these long-term side-effects is of crucial value in the management of these patients, in order to reduce the impact of cardiovascular morbidity and mortality. This review provides a comprehensive overview of the long-term cardiovascular complications of cancer treatments (radiotherapy and chemotherapy) in adult cancer survivors.

Diagnosis of takotsubo cardiomyopathy is increasing over time in patients presenting as ST-elevation myocardial infarction

Background

Takotsubo cardiomyopathy often presents with the clinical signs of ST-elevation myocardial infarction (STEMI). The increase in scientific publications addressing this relatively rare condition may result in higher awareness and diagnosis of takotsubo cardiomyopathy.

Aim

To assess the observed prevalence per year of takotsubo cardiomyopathy in a large registry of patients with STEMI, during a 12-year inclusion period.

Method

All patients presenting with STEMI at a large regional cardiology clinic were entered into a database (n = 8,413, mean age 63 ± 13 years). Takotsubo cardiomyopathy was diagnosed in 42 patients (0.5 %). Years of evaluation were defined as ‘early years’ (January 2002 to December 2007; n = 4350) and ‘later years’ (January 2008 to December 2013). Multivariable analyses were performed to adjust for differences in demographical and clinical variables.

Results

In later years, the age of STEMI patients was slightly higher (64 ± 13 vs. 63 ± 13 years, p < 0.001), with more patients with clinical symptoms of shock (10 vs. 7 %, p < 0.001) or a history of percutaneous coronary intervention or hypertension (10 vs. 8 %, p = 0.001 and 37 vs. 34 %, p < 0.001). Smoking and a positive family history were less often observed during later years (39 vs. 46 %, p < 0.001 and 37 vs. 42 % p < 0.001). Patients with takotsubo cardiomyopathy were more often female (81 vs. 27 %, p = 0.001). Takotsubo cardiomyopathy was more often diagnosed in the later period (0.7 vs. 0.3 %, OR 2.4, 95 % CI 1.2–4.6, p = 0.009). The higher prevalence of takotsubo cardiomyopathy in recent years remained significant after adjustment for differences in patient characteristics (OR 2.1, 95 % CI 1.1–4.3).

Conclusion

Takotsubo cardiomyopathy is currently more often diagnosed in patients with STEMI compared with in earlier years. This is probably due to the increased scientific and clinical awareness among doctors, but the prevalence is still low.

Does diastolic dysfunction precede systolic dysfunction in trastuzumab-induced cardiotoxicity? Assessment with multigated radionuclide angiography (MUGA)

BACKGROUND

Trastuzumab is successfully used for the treatment of HER2-positive breast cancer. Because of its association with cardiotoxicity, LVEF is monitored by MUGA, though this is a relatively late measure of cardiac function. Diastolic dysfunction (DD) is believed to be an early predictor of cardiac impairment. We evaluate the merit of MUGA-derived diastolic function parameters in the early detection of trastuzumab-induced cardiotoxicity (TIC).

METHODS AND RESULTS

77 trastuzumab-treated patients with normal baseline systolic and diastolic function were retrospectively selected (n = 77). All serial MUGA examinations were re-analyzed for systolic and diastolic function parameters. 36 patients (47%) developed SD and 45 patients (58%) DD during treatment. Both systolic and diastolic parameters significantly decreased. Of the patients with SD, 24 (67%) also developed DD. DD developed prior to systolic impairment in 54% of cases, in 42% vice versa, while time to occurrence did not differ significantly (P = .52). This also applied to the subgroup of advanced stage breast cancer patients (P = .1).

CONCLUSIONS

Trastzumab-induced SD and DD can be detected by MUGA. An impairment of MUGA-derived diastolic parameters does not occur prior to SD and therefore cannot be used as earlier predictors of TIC.

['Red yeast rice' as a cholesterol-lowering substance?Caution is warranted]

- In various non-medical publications, red yeast rice (red fermented rice, RYR) is recommended as a cholesterol-lowering substance. This supplement contains a naturally occurring statin, namely monacolin K.- Patients who wish to use RYR should be advised to only take products from reputable pharmaceutical companies. Pharmacists can provide advice on this.- Users of RYR should be alerted to the potential drug interactions and serious risks associated with its use during pregnancy.- RYR appears to be better tolerated than statins. This difference in tolerance can be traced back to the applied dosages. On average, the daily RYR dosage contains less statin than the standard dosage for statins.- The Netherlands Food and Consumer Product Safety Authority should urgently test the RYR supplements available in the Netherlands to gain more insight into the quality of said products.- Mandatory registration of RYR as an herbal medicine appears necessary to guarantee the quality of, and monacolin levels in, the products and to reduce health risks.

Yearly hypertension screening in women with a history of pre-eclampsia: a cost-effectiveness analysis

Background

Women with a history of preeclampsia are at increased risk for future hypertension and cardiovascular disease (CVD); until now it is not clear whether preventive measures are needed.

Methods

A decision-analytic Markov model was constructed to evaluate healthcare costs and effects of screening and treatment (100 % compliance) for hypertension post preeclampsia based on the available literature. Cardiovascular events and CVD mortality were defined as health states. Outcomes were measured in absolute costs, events, life-years and quality-adjusted life-years (QALYs). Sensitivity and threshold analyses were performed to address uncertainty.

Results

Over a 20-year time horizon, events occurred in 7.2 % of the population after screening, and in 8.5 % of the population without screening. QALYs increased from 16.37 (no screening strategy) to 16.40 (screening strategy), an increment of 0.03 (95 % CI 0.01;0.05) QALYs. Total expected costs were € 8016 in the screening strategy, and € 9087 in the none screening strategy (expected saving of € 1071 (95 % CI − 3146;-87) per person).

Conclusion

Annual hypertension screening and treatment in women with a history of preeclampsia may save costs, for at least a similar quality of life and survival due to prevented CVD compared with standard care.

Electronic supplementary material

The online version of this article (doi:10.1007/s12471-015-0760-z) contains supplementary material, which is available to authorized users.

Serum AMH levels in women with a history of preeclampsia suggest a role for vascular factors in ovarian aging

CONTEXT

The association between early menopause and vascular disease as a possible causative factor has recently received attention. Preeclampsia (PE) is associated with future cardiovascular risk factors, and this premature vascular aging potentially modifies the ovarian aging process.

OBJECTIVE

The purpose of this study was to assess whether women with a history of PE have lower anti-Müllerian hormone (AMH) levels than women with normotensive pregnancies.

DESIGN

This was a retrospective cohort study.

SETTING

The study was conducted in a tertiary referral center.

PATIENTS

Clinical data and blood samples of participants in the Preeclampsia Risk EValuation in FEMales study were used (336 women with a history of PE and 329 women after a normotensive pregnancy).

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURES

The relative decrease in AMH levels was assessed after a median follow-up of 10.5 years.

RESULTS

The mean AMH level was 2.00 ± 1.87 μg/L in the PE group compared with 2.26 ± 2.56 μg/L in the reference group. Linear regression analysis with censoring for undetectable AMH levels, adjusted for age, smoking, and hormonal contraceptive use, showed a relative reduction in AMH levels of 20.9% at any age (fold change 0.79, 95% confidence interval, 0.67-0.94).

CONCLUSIONS

We demonstrate that women with a history of PE have significantly lower AMH levels than women with normotensive pregnancies. Calculations based on a reference population indicate advancement of reproductive age of approximately 1.5 years. Because PE is considered a manifestation of impaired vascular health, these results support the hypothesis that compromised vascular health could act as a causative mechanism in early ovarian aging.

Sex-Based Differences in Cardiac Arrhythmias, ICD Utilisation and Cardiac Resynchronisation Therapy

Many important differences in the presentation and clinical course of cardiac arrhythmias are present between men and women that should be accounted for in clinical practice. In this paper, we review published data on gender differences in cardiac excitable properties, supraventricular tachycardias, ventricular tachycardias, sudden cardiac death, and the utilisation of implantable defibrillators and cardiac resynchronisation therapy. Women have a higher heart rate at rest, and a longer QT interval than men. They further have a narrower QRS complex and lower QRS voltages on the 12-lead ECG with more often non-specific repolarisation abnormalities at rest. Supraventricular tachycardias, such as AV nodal reentrant tachycardia, are twice as frequent in women compared with men. Atrial fibrillation, however, has a 1.5-fold higher prevalence in men. The triggers for idiopathic right ventricular outflow tract tachycardia (VT) initiation are gender specific, i.e. hormonal changes play an important role in the occurrence of these VTs in women. There are clear-cut gender differences in acquired and congenital LQTS. Brugada syndrome affects men more commonly and severely than women. Sudden cardiac death is less prevalent in women at all ages and occurs 10 years later in women than in men. This may be related to the later onset of clinically manifest coronary heart disease in women. Among patients who receive ICDs and CRT devices, women appear to be under-represented, while they may benefit even more from these novel therapies.

Cardiovascular risk in women after metabolic complications in pregnancy

Hypertensive pregnancy disorders complicate 10% of all pregnancies. In this article we discuss the spectrum of hypertensive conditions that may occur during pregnancy. Recent studies have consistently shown that hypertensive disorders in pregnancy implicate a two-fold higher risk for the development of hypertension and cardiovascular disease later in life. To optimise preventive management of cardiovascular disease in women with previous complicated pregnancies, we therefore recommend monitoring of hypertension and other cardiac risk factors at an early stage in life. Furthermore, the obstetric history should be routinely incorporated in cardiovascular risk assessment in women who seek medical attention for hypertension and/or cardiac symptoms. (Neth Heart J 2007;15:415-7.).

Progression of calcifications in breast arteries in women at high risk for coronary heart disease events

OBJECTIVE

To study changes in breast artery calcifications (BAC) over time and its relation with coronary heart disease (CHD) risk factors.

METHODS

Breast arterial calcifications were studied at baseline and after five years follow-up in 453 women participating in the Raloxifene Use for The Heart (RUTH) study. All mammograms were scored by two observers. With logistic regression analysis the independent effect of risk factors on the progression of BAC was evaluated.

RESULTS

BAC was present in 94 of 453 (21%) women at baseline and in 116 of 453 (26%) women after 5.0±1.04 years. Progression of BAC was seen in 44 of 453 (10%) women. In 22 participants (5%) BAC was not present at baseline, while in 22 participants (5%) the severity of BAC merely changed from grade 1 to grade 2 calcification. Age was significantly associated with progression of BAC (OR 1.09, 95% CI 1.03 to 1.14). Multivariate regression analysis with adjustment for age and the duration of follow-up showed no association between CHD risk factors and the progression of BAC. Lipid-lowering drugs protected for progression (adjusted OR 0.5, 95% CI 0.22 to 0.98). The strongest determinant in the progression of BAC was BAC at baseline (adjusted OR 4.2, 95% CI 2.10 to 8.27).

CONCLUSION

Progression of BAC is not associated with CHD risk factors, but with increasing age and BAC at baseline. Lipid-lowering drugs protect against progression of BAC.

Hormone replacement therapy and heart disease: the remains of the oestrogen hypothesis

BACKGROUND

While observational data for postmenopausal women using hormone replacement therapy (HRT) have shown a protective effect against cardiovascular disease, prospective, randomised trials have demonstrated a harmful effect on the vascular system.

DESIGN AND RESULTS

The effects of HRT on lipids, haemostatic parameters, inflammation, and the vascular wall are described. Reasons for the different results of observational and experimental studies of HRT are postulated. The timing of hormonal supplementation seems crucial. Used chronically, HRT has no harmful effects; however, first-time use of HRT after a recent cardiovascular event results in an early increase in adverse cardiovascular events. In most observational studies, women started HRT for postmenopausal symptoms, whereas in experimental studies women started HRT 10 to 20 years or longer after the menopause.

CONCLUSION

HRT has more effect in maintaining vascular health than in alleviating endothelial dysfunction. HRT is not beneficial but harmful in women at risk of a cardiovascular event. The interval between the menopause and starting HRT plays a crucial role in the effectiveness of HRT on the vascular system.

[Postmenopausal hormone-replacement therapy discredited, except in healthy women shortly after menopause]

Results from the Women's Health Initiative randomized trial in 16,608 healthy postmenopausal women have revealed more risks than benefits in terms of invasive breast cancer and cardiovascular disease rates in patients treated for more than 5 years with a combination of conjugated oestrogens and progestin compared with placebo. Hormone-replacement therapy (HRT) is more effective in healthy women (maintaining vascular health) than in older women with atherosclerosis (restoring endothelial dysfunction). The initiation of HRT in patients at risk of a cardiovascular event results in an increased rate of cardiovascular complications and has not been proven beneficial in the long term. The point at which HRT is started after menopause plays a crucial role in the effectiveness of hormones on the vascular system: it is uncertain whether HRT initiated shortly after menopause can delay clinical signs of atherosclerotic disease.