Women in cardiology leadership of randomized clinical trials and participation of women in late-breaking clinical trials: has the COVID-19 pandemic changed a thing or not exactly?

Introduction

Despite considerable developments made in the representation of women in cardiology (WIC) recently, there still remain substantial disparities in the representation of women participants in clinical trials, as well as women physicians and scientists in clinical trial leadership. Under-representation of women in Randomized Clinical Trials (RCTs) remains the bane of the modern medicine, impeding the development of sex-specific guidelines in cardiovascular diseases. Female leadership in clinical trials has been shown to enhance the inclusion of women as trial participants. Furthermore, while the COVID-19 pandemic has impacted women in academia, there is no data thus far reporting the impact of the pandemic in terms of presenters and leadership of late-breaking clinical trials (LBCT) in cardiology during this period.

Purpose

We aimed to determine inclusion of WIC in LBCTs leadership and their correlation to inclusion of women in reported RCTs.

Methods

In our comprehensive analysis, we included all LBCTs presented at major international cardiovascular meetings reported over the period of January 2020 to February 2022. Data were derived from the original presentation at the meeting and/or simultaneous/ subsequent publication of manuscript. Sex of the presenter (woman or man), was assessed by either original videos of the presentation at the meeting, or based on pronoun use in the biographies derived from institutional profiles. The presence or absence of reporting of sex distribution of study participants were also recorded from original presentation at the meeting and/or published manuscript. Proportion of women included in each trial was sourced from either original publication or calculated from any similar data shown during the presentations.

Results

A total of 400 of RCTs from 19 meetings were included with a total of 400 presenters/principal investigators recorded – 32 (8%) women and 368 (92%) men. There were no significant differences between 2020 and 2021 [15 (7.2%) women in 2021 vs. 17 (19.3%) in 2020 (P=0.446)]. Proportions of women included in RCTs with WIC (37.3%) vs. non-WIC (38.7%) presenters were comparable (p=0.559), while 45% of RCTs didn't report sex distribution of participants. Except for 2 meetings (CRT 2020 and 2022), all others were virtual.

Conclusion

WIC representation as RCTs presenters was significantly low, despite the opportunity of virtual attendance afforded during the COVID-19 pandemic. Modest inclusion of women irrespective of sex of RCT leadership emphasizes multi-level problems that require more actionable solutions: i.e. implicit bias training started as early as medical school, continuing education on necessity for diversity, equity and inclusion, patient and public involvement, and comprehensive guidance on trial design, such that future RCT participants reflect the populations intended to treat.

Funding Acknowledgement

Type of funding sources: None.

Beneficial effects of aggressive low-density lipoprotein cholesterol lowering in women with stable coronary heart disease in the Treating to New Targets (TNT) study

OBJECTIVE

To examine by secondary analysis of the Treating to New Targets (TNT) study whether the benefits of intensive versus standard levels of lipid lowering are equally applicable to women.

METHODS

A total of 10 001 patients (1902 women) with stable coronary heart disease (CHD) were randomised to double-blind treatment with atorvastatin 10 or 80 mg/day for a median follow-up of 4.9 years.

RESULTS

In women and men, intensive treatment with atorvastatin 80 mg significantly reduced the rate of major cardiovascular events compared with atorvastatin 10 mg. Among women, the relative and absolute reductions were 27% and 2.7%, respectively (hazard ratio (HR) = 0.73, 95% confidence interval (CI) 0.54 to 1.00, p = 0.049). In men, the corresponding rate reductions were 21% and 2.2% (HR = 0.79, 95% CI 0.69 to 0.91, p = 0.001). The number needed to treat value (to prevent one cardiovascular event over 4.9 years compared with patients treated with atorvastatin 10 mg) for atorvastatin 80 mg was 29 for women and 30 for men. Rates of death of non-cardiovascular origin in the atorvastatin 80 mg and atorvastatin 10 mg were 3.6% and 1.6%, respectively (p = 0.004) among women, and 2.8% and 3.1% (p = 0.47) among men.

CONCLUSION

Intensive lipid-lowering treatment with atorvastatin 80 mg produced significant reductions in relative risk for major cardiovascular events compared with atorvastatin 10 mg in both women and men with stable CHD.

Coronary heart disease in women: update 2008

Coronary heart disease (CHD) remains the leading cause of mortality for US women, responsible for almost 250,000 deaths annually. Preventive heart-health behavioral changes by women and aggressive coronary risk reduction can decrease the number of women disabled and killed by CHD. Angina is the predominant initial and subsequent presentation of CHD in women; categorization of chest pain and risk stratification of women assume pivotal roles. A robust evidence-based algorithm can guide cardiovascular imaging techniques to evaluate women with suspected myocardial ischemia to detect those with worsened survival. Restricted functional capacity (<5 METs) is a consistent marker of worsened prognosis. Younger women have substantially higher mortality rates than men following myocardial infarction and coronary bypass surgery. Although these women have more comorbidity and risk factors, other issues including biological differences, treatment differences, and psychosocial factors require management strategies tailored to the unique needs of women.

Coronary heart disease in women: battle is won, but the war remains

According to the most recent report of the US National Heart, Lung, and Blood Institute, mortality from coronary heart disease has declined in women from one in three to one in four. Due to massive campaigning efforts in educating the medical community and the general public, coronary heart disease has become increasingly recognized as a woman's disease. Indeed, it is the number one killer in women, exceeding cancer and infectious diseases. Numerous observational studies, clinical trials, and reports have indicated that there are gender-specific differences in the presentation, diagnosis, treatment, and outcomes of coronary heart disease. One common theme, not only in United States, but world-wide is the underutilization of known and validated medical and interventional therapies in women compared to men. Even though previously conducted large, randomized controlled trials had limited numbers of women, recent large scale cardiac trials in women have enabled the development of evidence-based guidelines for coronary heart disease diagnosis and management in women. Importantly, menopausal hormone therapy and antioxidant vitamin therapy do not protect post-menopausal women from coronary heart disease. Aggressive life-style and pharmacologic management of known coronary risk factors in women should be a top priority to improve coronary heart disease morbidity and mortality. Research data continue to emerge to fill the gaps of how gender affects atherosclerosis; in the meantime, continued patient and physician education to increase awareness of coronary heart disease may help to eliminate some of the gender-based disparities in the delivery of coronary care to women.

Cardiovascular disease in the elderly

Cardiovascular disease is the major cause of death and disability in the elderly. Atherosclerotic coronary heart disease is the most prevalent problem, followed by hypertensive cardiovascular disease. Calcific aortic stenosis is the most common haemodynamically important valvular lesion; surgical correction significantly improves the prognosis. Pulmonary embolism occurs frequently, related to immobilization and co-morbidity. Congestive heart failure is both under-diagnosed and over-diagnosed. Complete heart block and sick sinus syndrome increase with age; appropriate pacemaker therapy can improve the length and quality of life. Clinical evaluation of elderly patients is often hampered by multiple co-existing disease involving other organ systems, problems in reporting symptoms, and associated functional and structural changes of ageing that may mimic or mask cardiovascular disease. Presentations of cardiac illness often differ from those in a younger population. Most of the available data on therapy and prognosis do not apply to contemporary practice, so that clinical decisions are often extrapolated from information acquired in younger patients. Elderly patients are at high risk of complications of most diagnostic and therapeutic procedures, more related to co-morbidity than to age; they have more frequent and serious adverse drug reactions, due both to co-morbidity and to multiple medications. Age as such should not constitute a barrier to cardiac care; in the USA at least one-third of all cardiovascular procedures are performed in elderly patients. The goals of therapy are improvement in function and postponement of debilitating illness, enabling an extended active independent lifestyle.

Women in cardiology: the US experience

"You are not required to complete the work, but neither are you at liberty to abstain from it.."-Rabbi Tarfon, Pirke Avot 2:16.

Managing ambulatory anticoagulation

This overview of the management of ambulatory oral anticoagulant therapy addresses the importance of patient education and highlights tested educational techniques; describes issues of documentation of the patient encounter in the medical record; and reviews drug dosage adjustments, the management of patients with high International Normalized Ratio (INR) values, and the recommended changes of oral anticoagulation for patients who undergo invasive procedures.

Renal insufficiency and cardiovascular events in postmenopausal women with coronary heart disease

OBJECTIVES

This study sought to determine the independent association of renal insufficiency with cardiovascular risk among women with known coronary heart disease (CHD).

BACKGROUND

Although patients with end-stage renal disease and proteinuria are at high risk for cardiovascular events, little is known about the cardiovascular risk associated with moderate renal insufficiency.

METHODS

The Heart and Estrogen/progestin Replacement Study (HERS) was a clinical trial among 2,763 women with coronary disease who were randomized to conjugated estrogen plus progestins or identical placebo and followed for a mean of 4.1 years. Women were categorized as having normal renal function (creatinine < 1.2 mg/dl; n = 2,012), mild renal insufficiency (1.2 mg/dl to 1.4 mg/dl; n = 567) and moderate renal insufficiency (>1.4 mg/dl; n = 182). We examined the independent association of renal function with incident cardiovascular events including CHD death, nonfatal myocardial infarction, hospitalization for unstable angina, stroke and transient ischemic attacks.

RESULTS

Compared with women with normal renal function, those with mild and moderate renal insufficiency were older, more likely to be black, have a history of hypertension and diabetes and have higher serum levels of triglycerides and lipoprotein(a). After multivariate adjustment, both mild (relative hazards [RH] = 1.24; 95% confidence interval [CI]: 1.0 to 1.5) and moderate renal insufficiency (RH = 1.57; 95% CI: 1.2 to 2.1) were independently associated with increased risk for cardiovascular events compared with women with normal renal function.

CONCLUSIONS

Renal insufficiency is an independent risk factor for cardiovascular events in postmenopausal women with known coronary artery disease. Renal function may add helpful information to CHD risk stratification.

Design and methods of the Raloxifene Use for The Heart (RUTH) study

Raloxifene is a selective estrogen receptor modulator that lowers total and low-density lipoprotein (LDL) cholesterol, reduces the risk of vertebral fracture, and is associated with a reduced incidence of invasive breast cancer in postmenopausal women with osteoporosis. The Raloxifene Use for The Heart (RUTH) trial is designed to determine whether raloxifene 60 mg/day compared with placebo: (1) lowers the risk of the coronary events (coronary death, nonfatal myocardial infarction [MI], or hospitalized acute coronary syndromes other than MI); and (2) reduces the risk of invasive breast cancer in women at risk for a major coronary event. RUTH is a double-blind, placebo-controlled, randomized clinical trial of 10,101 postmenopausal women aged > or =55 years from 26 countries. Women are eligible for randomization if they are postmenopausal and have documented coronary heart disease (CHD), peripheral arterial disease, or multiple risk factors for CHD. Use of estrogen within the previous 6 months is an exclusion factor. The study will be terminated after a minimum of 1,670 participants experience a primary coronary end point. Secondary end points include cardiovascular death, myocardial revascularization, noncoronary arterial revascularization, stroke, all-cause hospitalization, all-cause mortality, all breast cancers, clinical fractures, and venous thromboembolic events, in addition to the individual components of the composite primary coronary end point. RUTH will provide important information about the risk-benefit ratio of raloxifene in preventing acute coronary events and invasive breast cancer, as well as information about the natural history of CHD in women at risk of major coronary events.

Mutations in the genes regulating methylene tetrahydrofolate reductase (MTHFR C-->T677) and cystathione beta-synthase (CBS G-->A919, CBS T-->c833) are not associated with myocardial infarction in African Americans

Moderate hyperhomocysteinemia is a putative risk factor for cardiovascular disease. Molecular studies have demonstrated increased plasma homocysteine levels in the presence of DNA mutations in either the methylenetetrahydrofolate reductase (MTHFR) enzyme found in the remethylation pathway or the enzyme cystathione beta-synthase (CBS) of the transsulfuration pathway. To determine whether the mutation C-->T677 in the MTHFR gene or the T-->C833/844ins68 and G-->A919 mutations in the CBS gene are associated with myocardial infarction (MI) in African Americans, DNA was analyzed from samples obtained from a case-control study conducted at a large, inner-city hospital. One-hundred ten African American subjects with a diagnosis of MI and 185 race- and age-matched controls were recruited. Our results demonstrated that 15% of the MI cases were heterozygous for the C-->T677 (MTHFR) mutation, while 1.8% were homozygous. When compared to the controls in which 15% were heterozygous and 2.1% were homozygous, no significant association with MI was observed. In addition, 34% of the cases were heterozygous for the T-->C833 (CBS) mutation while 6% were homozygous. This is compared to 32% and 5% of the controls having the heterozygous and homozygous genotype, respectively. No significant association was observed for the T-->C833 (CBS) mutation among the cases and controls. Although this mutation has no significant association with MI, the prevalence of the heterozygous state was higher than what has been reported for whites (12%). No mutations for G-->A919 (CBS) were detected in the cases or controls. The racial differences of the CBS T-->C833 polymorphism suggest that further investigation into the other areas of the CBS gene is needed.

Adherence to screening guidelines for breast and cervical cancer in postmenopausal women with coronary heart disease: an ancillary study of volunteers for hers

Postmenopausal women with coronary heart disease (CHD) who volunteered for the Heart and Estrogen/Progestin Replacement Study (HERS) randomized clinical trial had high rates of gynecological abnormalities. We examined compliance with gynecological cancer screening and factors affecting this behavior. Women who met inclusion criteria for HERS and were seen for screening by the study gynecologist were considered eligible for this study. Data were abstracted from study records, and additional information was obtained by telephone questionnaire. Adherence to mammography, breast examination, pelvic examination, and Pap smear recommendations was assessed. Provider behavior and its effect on compliance were assessed. Compliance rates were 59.1% for monthly breast self-examination (BSE), 67.2% for yearly mammography, 73% for yearly Pap smear and pelvic examination, and 75.7% for provider breast examination. Over 50% of patients had most of their screening tests done within the last year. Provider behavior was significantly related to patient screening compliance for mammography, breast examination, Pap smear, and pelvic examination. Provider gender was not significantly related to adherence. There were no significant differences in compliance rates based on the type of most recent coronary event. Compliance rates did not differ significantly between patients with and without gynecological abnormalities, except for mammography (78.3% versus 48.3%, p = 0.02). The majority of patients were compliant with gynecological screening. Among patients with gynecological abnormalities, mammography compliance was significantly lower. Provider behavior was an important factor in influencing women to obtain preventive screening. There were no significant differences in compliance based on provider gender or type of coronary event preceding HERS enrollment.

Coronary heart disease in African Americans

African Americans have the highest overall mortality rate from coronary heart disease (CHD) of any ethnic group in the United States, particularly out-of-hospital deaths, and especially at younger ages. Although all of the reasons for the excess CHD mortality among African Americans have not been elucidated, it is clear that there is a high prevalence of certain coronary risk factors, delay in the recognition and treatment of high-risk individuals, and limited access to cardiovascular care. The clinical spectrum of acute and chronic CHD in African Americans is similar to that in whites. However, African Americans have a higher risk of sudden cardiac death and present more often with unstable angina and non-Q-wave myocardial infarction than whites. African Americans have less obstructive coronary artery disease on angiography, but may have a similar or greater total burden of coronary atherosclerosis. Ethnic differences in the clinical manifestations of CHD may be explained largely by the inherent heterogeneity of the coronary syndromes, and the disproportionately high prevalence and severity of hypertension and type 2 diabetes in African Americans. Identification of high-risk individuals for vigorous risk factor modification-especially control of hypertension, regression of left ventricular hypertrophy, control of diabetes, treatment of dyslipidemia, and smoking cessation--is key for successful risk reduction.

Venous thrombosis in relation to fibrinogen and factor VII genes among African-Americans

We evaluated the relation between venous thrombosis and plasma fibrinogen levels, the HaeIII and BcI polymorphisms of the beta fibrinogen gene, and the MspI polymorphisms of the factor VII gene in a case-control study of African-Americans. The study included 91 venous thrombosis cases and 185 control subjects obtained from a hospital in Atlanta, Georgia. High plasma fibrinogen was associated with increased risk of venous thrombosis, but the finding was not statistically significant. There was little association between the HaeIII polymorphisms and the BclI polymorphisms and the risk of venous thrombosis. The prevalence of the M2/M2 genotype of the factor VII gene was higher among cases than controls, but the difference was not statistically significant. The prevalence of the HaeIII H2 allele and the BclI B2 allele of the beta fibrinogen gene, both of which have been associated with slightly higher levels of plasma fibrinogen in most studies, is considerably lower among African-Americans in this study than it is among Whites in the United States and among Northern Europeans. The study is limited by its small size. However, despite this limitation, it supports the belief that increased plasma fibrinogen levels are associated with increased venous thrombosis risk. The study also indicated that the HaeIII and the BclI polymorphisms of the beta fibrinogen gene and the MspI polymorphisms of the factor VII gene are not strong determinants of venous thrombosis.

The role of the t-PA I/D and PAI-1 4G/5G polymorphisms in African-American adults with a diagnosis of myocardial infarction or venous thromboembolism

To determine whether or not the PAI-1 4G/5G and t-PA I/D polymorphisms in African-Americans were linked to cardiovascular disease, the association of these polymorphisms to disease expression was analyzed in a recently completed case-control study of myocardial infarction or venous thromboembolism among African-Americans. All African-Americans patients with a history of venous thromboembolism attending an anticoagulant clinic, and patients with a history of a MI attending a cardiology clinic at a large local urban public hospital were eligible for inclusion as cases in the study. In this study it was observed that there was a statistically significant association between the D allele of the t-PA I/D polymorphism and venous thromboembolism and a nonsignificant association between the D allele and myocardial infarction among African-Americans. t-PA antigen levels were statistically significantly higher among both myocardial infarction and venous thromboembolism cases compared with control subjects. The genotypes were unrelated to t-PA plasma levels. There was no association between either myocardial infarction or venous thromboembolism and the 4G/5G PAI-1 genotype. It was also found that genotype frequencies for both PAI-1 4G/5G and t-PA I/D polymorphisms in African-American adults were different from those reported for both U.S. Causcians and Europeans.

Postmenopausal hormone therapy increases risk for venous thromboembolic disease. The Heart and Estrogen/progestin Replacement Study

BACKGROUND

Oral contraceptive use increases risk for venous thromboembolism, but data on the effect of postmenopausal hormone therapy are limited.

OBJECTIVE

To determine the effect of therapy with estrogen plus progestin on risk for venous thromboembolic events in postmenopausal women.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

20 clinical centers in the United States.

PARTICIPANTS

2763 postmenopausal women younger than 80 years of age (mean age, 67 years) who had coronary heart disease but no previous venous thromboembolism and had not had a hysterectomy.

INTERVENTION

Conjugated equine estrogens, 0.625 mg, plus medroxyprogesterone acetate, 2.5 mg, in one tablet (n = 1380) or placebo that was identical in appearance (n = 1383).

MEASUREMENTS

Documented deep venous thrombosis or pulmonary embolism.

RESULTS

During an average of 4.1 years of follow-up, 34 women in the hormone therapy group and 13 in the placebo group experienced venous thromboembolic events (relative hazard, 2.7 [95% CI, 1.4 to 5.0] [P = 0.003]; excess risk, 3.9 per 1000 woman-years [CI, 1.4 to 6.4 per 1000 woman-years]; number needed to treat for harm, 256 [CI, 157 to 692]). In multivariate analysis, the risk for venous thromboembolism was increased among women who had lower-extremity fractures (relative hazard, 18.1 [CI, 5.4 to 60.4]) or cancer (relative hazard, 3.9 [CI, 1.6 to 9.4]) and for 90 days after inpatient surgery (relative hazard, 4.9 [CI, 2.4 to 9.8]) or nonsurgical hospitalization (relative hazard, 5.7 [CI, 3.0 to 10.8]). Risk was decreased with aspirin (relative hazard, 0.5 [CI, 0.2 to 0.8]) or statin use (relative hazard, 0.5 [CI, 0.2 to 0.9]).

CONCLUSIONS

Postmenopausal therapy with estrogen plus progestin increases risk for venous thromboembolism in women with coronary heart disease. This risk should be considered when the risks and benefits of therapy are being weighed.

Postmenopausal hormone therapy increases risk for venous thromboembolic disease. The Heart and Estrogen/progestin Replacement Study

BACKGROUND

Oral contraceptive use increases risk for venous thromboembolism, but data on the effect of postmenopausal hormone therapy are limited.

OBJECTIVE

To determine the effect of therapy with estrogen plus progestin on risk for venous thromboembolic events in postmenopausal women.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

20 clinical centers in the United States.

PARTICIPANTS

2763 postmenopausal women younger than 80 years of age (mean age, 67 years) who had coronary heart disease but no previous venous thromboembolism and had not had a hysterectomy.

INTERVENTION

Conjugated equine estrogens, 0.625 mg, plus medroxyprogesterone acetate, 2.5 mg, in one tablet (n = 1380) or placebo that was identical in appearance (n = 1383).

MEASUREMENTS

Documented deep venous thrombosis or pulmonary embolism.

RESULTS

During an average of 4.1 years of follow-up, 34 women in the hormone therapy group and 13 in the placebo group experienced venous thromboembolic events (relative hazard, 2.7 [95% CI, 1.4 to 5.0] [P = 0.003]; excess risk, 3.9 per 1000 woman-years [CI, 1.4 to 6.4 per 1000 woman-years]; number needed to treat for harm, 256 [CI, 157 to 692]). In multivariate analysis, the risk for venous thromboembolism was increased among women who had lower-extremity fractures (relative hazard, 18.1 [CI, 5.4 to 60.4]) or cancer (relative hazard, 3.9 [CI, 1.6 to 9.4]) and for 90 days after inpatient surgery (relative hazard, 4.9 [CI, 2.4 to 9.8]) or nonsurgical hospitalization (relative hazard, 5.7 [CI, 3.0 to 10.8]). Risk was decreased with aspirin (relative hazard, 0.5 [CI, 0.2 to 0.8]) or statin use (relative hazard, 0.5 [CI, 0.2 to 0.9]).

CONCLUSIONS

Postmenopausal therapy with estrogen plus progestin increases risk for venous thromboembolism in women with coronary heart disease. This risk should be considered when the risks and benefits of therapy are being weighed.

Lipid management and control of other coronary risk factors in the postmenopausal woman

This review identifies coronary heart disease (CHD) as the leading cause of mortality among postmenopausal women and highlights the well-documented problem of underrecognition and undertreatment of women who are at risk for or who already have CHD. This undertreatment encompasses both preventive care (i.e., drug treatment for lipid management) and more invasive treatments (e.g., revascularization procedures). Preventive interventions to reduce dyslipidemia and control other coronary risk factors can lessen CHD mortality and morbidity in the postmenopausal woman.

The relationship between polymorphisms in the endothelial cell nitric oxide synthase gene and the platelet GPIIIa gene with myocardial infarction and venous thromboembolism in African Americans

STUDY OBJECTIVES

To determine whether the polymorphic dinucleotide repeats found in intron 4 of the endothelial cell nitric oxide synthase (ecNOS) gene and the platelet GPIIIa PLA(1)/A(2) polymorphism are associated with myocardial infarction (MI) and venous thromboembolism (VTE) in African Americans. Because these two genes may interact physiologically, the third objective was to determine if there was a relationship between the polymorphisms with respect to MI and VTE.

DESIGN

A hospital-based case-control study. After informed consent was obtained, blood used for DNA extraction was drawn from the subjects.

SETTING

The study was conducted in the Anticoagulant Clinic and the Cardiology Clinic at Grady Memorial Hospital in Atlanta Georgia.

PATIENTS

Subjects were recruited from African-American patients with a reported history of MI (n = 110) or VTE (n = 91). Control subjects (n = 185) without a history of cardiovascular or venous disease were recruited from an outpatient clinic.

MEASUREMENTS AND RESULTS

The 393 ecNOS allele was more common among MI cases (36%; p = 0.01) and VTE cases (35%; p = 0.04) than among control subjects (26%). There was no association between the GPIIIa genotypes and either MI or VTE. However, among the MI subjects, there was a strong association between the ecNOS 393/393 genotype and the Pl(A2) allele. It was also found that the frequency of the 393 allele was higher in African-American persons (0.26) compared with what has been reported for Australian Caucasians (0. 14) and Japanese (0.10).

CONCLUSIONS

The 393 allele but not the Pl(A2) allele was significantly associated with both MI and VTE in African Americans. Homozygosity for the 393 allele was significantly associated to the diagnosis of MI prior to the age of 45. The combination of the 393 allele and a Pl(A2) allele was also highly associated with MI. The frequency of the 393 allele was significantly higher in African Americans than what has been reported for other populations. This study furthers not only extends the association of the 393 allele to VTE but has demonstrated an interaction with the Pl(A2) allele with respect to MI.

Postmenopausal hormone use for cardioprotection: what we know and what we must learn

Coronary heart disease is a highly prevalent and lethal illness for women, particularly in their menopausal years, a fact that fostered interest in hormone use for cardioprotection. Despite the compelling evidence of cardiovascular benefit of estrogen therapy and estrogen and progestin therapy in observational studies of postmenopausal women, and multiple biologically plausible mechanisms for estrogen benefit, precise clinical outcome information from prospective randomized controlled trials is lacking. The only such trial reported, the Heart and Estrogen/Progestin Replacement Study, not only failed to demonstrate cardioprotection, but showed an early adverse outcome in women with documented coronary heart disease who received daily conjugated equine estrogen and medroxy-progesterone acetate. Several large randomized clinical trials of hormone and selective estrogen receptor moderator therapy for primary and secondary prevention are currently underway.

Women, myocardial infarction, and coronary revascularization: concordant and discordant clinical trial and registry data

Contemporary data define the persisting less favorable outcome for women than men after myocardial infarction. An important contributor is likely lesser application of beneficial therapies. Current outcomes of percutaneous transluminal coronary angioplasty for women have improved, despite its use in older and sicker women, and are comparable with or better than those for men. Although most reports of coronary artery bypass graft surgery continue to document a doubled mortality for women compared with men, recent clinical trial data suggest that elective surgery with improved surgical and perioperative management may constitute determining factors for favorable outcomes.

Prevalence of the prothrombin 20210 G-to-A variant in blacks: infants, patients with venous thrombosis, patients with myocardial infarction, and control subjects

A genetic variation in the prothrombin gene is located in the 3-untranslated region at position 20210 where a G-->A transition occurs. The prevalence of the mutation is 1% to 2% in white populations, and the mutation is associated with an increased risk of venous thrombosis and myocardial infarction. We report the prevalence of the A allele in blacks at birth; in black control subjects with no history of heart attack, stroke, or blood clots; in black patients with venous thrombosis; and in black patients with myocardial infarction. Among 318 infants, the prevalence of the A allele was 0.2% (1 heterozygote), with an exact, one-sided upper 95% confidence limit of 0.7%. Among 185 control subjects the variant was absent, yielding an exact, one-sided upper 95% confidence limit of 0.8% for the A allele. The heterozygous genotype was found in 2 of 91 subjects with deep vein thrombosis and in none of 123 subjects with myocardial infarction. The very low prevalence of the A allele indicates that the prothrombin variant is not a major cause of venous thrombosis or myocardial infarction in blacks.

Lipid metabolism, physical activity, and postmenopausal hormone therapy

The current concept of coronary risk reduction for the general population involves matching the intensity of the intervention to the intensity of the risk. In an evidence-based model, two components must be addressed: the strength of evidence of the risk of each attribute and the efficacy of specific interventions, both lifestyle modifications and pharmacotherapy. This format guides national recommendations for the control of lipid abnormalities and for physical activity for the general population. In the absence of randomized trial data for postmenopausal hormone therapy, presentation of relative benefits and risks should be offered with individualization of advice based on the characteristics of the specific patient. Patients with chronic renal disease have a high prevalence of coronary risk factors and are at high risk for coronary heart disease. Goals for coronary risk factor intervention must be developed for patients with specific subsets of chronic renal disease.

Addressing coronary heart disease risk in women

Contrary to popular perceptions, coronary heart disease (CHD) is a serious and widespread problem in US women. Public education, preventive interventions, and better data on CHD risk and prevention in women are needed.

Hormone and nonhormone therapy for the maintenance of postmenopausal health: the need for randomized controlled trials of estrogen and raloxifene

Multiple health benefits have been postulated for the long-term use of hormone therapy in postmenopausal women, most notably for prevention of osteoporotic fractures and coronary heart disease, as well as several risks, including cancer of the breast and uterus and venous thromboembolism. Cardiovascular disease is the most common cause of death among postmenopausal women. If real, the reduction in risk of coronary heart disease by hormone use suggested by observational studies would likely outweigh the risks. The decision to initiate and maintain hormone therapy is complicated by uncertainties about estrogen's true benefits and risks. Raloxifene, a selective estrogen receptor modulator (SERM), appears to have many of the benefits of estrogen without the cancer risks. It is not known if SERMs can provide significant cardiovascular protection. This article reviews the relation of use of postmenopausal hormones and raloxifene to women's health and addresses the need for large randomized trials to quantify the effect of both postmenopausal estrogen and raloxifene on cardiovascular health.

Secondary prevention of coronary heart disease

Despite the significant reduction in cardiovascular mortality during the past three decades, atherosclerotic coronary heart disease (CHD) remains the leading cause of death and disability in the United States. Randomized clinical trials in patients with CHD have provided convincing evidence that risk factor modification is beneficial in decreasing all-cause mortality and cardiovascular morbidity and mortality. Multifactorial coronary risk reduction provides the most substantial benefit. Coronary risk reduction is associated with a decrease in cardiovascular-related hospital admissions, a reduced need for myocardial revascularization procedures, and an improved quality of life for the patients so treated. Control of coronary risk factors is an integral component of the optimal care of the patient with CHD.

Comparison of the Heart and Estrogen/Progestin Replacement Study (HERS) cohort with women with coronary disease from the National Health and Nutrition Examination Survey III (NHANES III)

BACKGROUND

The Heart and Estrogen/Progestin Replacement Study (HERS) is the first large clinical trial designed to test the efficacy of postmenopausal estrogen/progestin therapy for secondary prevention of coronary heart disease (CHD). To examine the representativeness of the HERS cohort to the general population of postmenopausal women with CHD, we compared the baseline cardiovascular risk factor data from HERS with similar data from women presumed to have CHD from the National Health and Nutrition Examination Survey (NHANES) III.

METHODS

Age, race, and cardiovascular disease risk factors were compared in the 2763 postmenopausal women younger than 80 years old, with a uterus, and with documented CHD in HERS versus 145 similarly aged women with clinical or electrocardiographic evidence of CHD from phase I of NHANES III.

RESULTS

There were fewer current smokers in HERS (13%) than in the NHANES cohort (21.7%, p = 0.05). Similarly, a history of hypertension was less prevalent in HERS (58.6%) than in the NHANES cohort (69.3%, p = 0.03). Women with fasting triglyceride levels >3.39 mmol/L or fasting glucose levels >16.6 mmol/L were excluded from HERS, resulting in fewer diabetics (22.9% vs 29.5%, p = 0.26) and lower serum triglyceride levels (1.88 mmol/L vs 2.25 mmol/L, p = 0.19) in HERS versus the NHANES cohort. Systolic and diastolic blood pressure, body mass index, physical activity, and total LDL and HDL cholesterol were not significantly different between the two groups.

CONCLUSIONS

The HERS cohort had fewer CHD risk factors than women with myocardial infarction or angina in NHANES III, although comparison is hindered by differences in selection criteria. The many women with diabetes and hypertriglyceridemia in the NHANES cohort emphasizes the importance of testing strategies for secondary prevention of CHD in this high-risk subgroup.

An update on coronary heart disease in women

Coronary heart disease is the leading cause of mortality for adult women in the United States, accounting for the death of nearly 250,000 women each year. Once coronary disease becomes clinically evident, it causes prominent morbidity and disability in women, particularly among older women. Women are more likely to die from an episode of myocardial infarction than are men, and first-year mortality following myocardial infarction is comparably greater for women. Similarly, women do not fare as well as men following myocardial revascularization procedures, having a greater mortality from coronary artery bypass graft surgery, less graft patency, less symptomatic relief, and more reoperation within the initial postoperative 5 years. Despite initial favorable outcomes from percutaneous transluminal coronary angioplasty, women have less long-term symptomatic relief and decreased long-term survival, the latter, however, predominantly related to their older age. The increased case fatality rates and greater morbidity of women following both myocardial infarction and myocardial revascularization procedures underscore the need for preventive interventions for women across their life span. Dramatic strides have been made in recent years, based on the recognition of the importance of coronary heart disease as a health problem for women. There is an increased emphasis on coronary preventive strategies, improvement in the prompt evaluation of chest pain syndromes, and increase in the performance of myocardial revascularization when appropriate; research is also under way to assess risk interventions unique to women.

Postmenopausal hormone therapy. Is it useful for coronary prevention?

Contemporary interest in postmenopausal hormone therapy as a coronary preventive intervention in women derives from the increased prevalence of coronary disease in the postmenopausal years, the importance of estrogen status as a determinant of coronary risk for women, the less favorable outcomes of coronary events for women than for men, the biologically plausible mechanisms of estrogen benefit, and encouraging epidemiologic data suggesting that estrogen use may favorably affect coronary risk. Observational studies describe the greatest reduction in mortality risk with estrogen use in women at high risk for coronary disease or with documented coronary heart disease, with greater benefit currently accruing for those with angiographically severe rather than angiographically mild disease. Noncoronary risks of estrogen use warrant consideration; these include endometrial hyperplasia, breast cancer, and venous thromboembolism. Noncoronary benefits include a decrease in osteoporosis and osteoporotic fractures and in vasomotor symptoms of estrogen deficiency. Because about one of two U.S. women die from cardiovascular disease (heart disease and stroke), emphasis is warranted on available data, which suggest that the group of women likely to experience the greatest cardioprotection from hormone therapy are those with defined coronary disease or those at high risk for occurrence; the group of women least likely to benefit are those at increased risk for breast cancer.

Relation of three genetic traits to venous thrombosis in an African-American population

A mutation in the Factor V gene (Factor V Leiden), a variant in the 5,10-methylenetetrahydrofolate reductase gene (MTHFR), and an insertion/deletion polymorphism of the angiotensin I-converting enzyme gene (ACE) may be related to abnormal blood clotting. The authors examined the associations between these genetic traits and venous thrombosis among African Americans. This study comprised 93 patients with venous thrombosis and 185 control subjects attending clinics at an urban, public hospital in Atlanta, Georgia, in 1995-1996. Subjects' DNA was extracted from blood and assayed for these genetic traits. Odds ratios were obtained from logistic regression and used as a measure of association between each genetic trait and venous thrombosis. Factor V Leiden was unrelated to venous thrombosis, but the mutation ws too rare among our African-American subjects to evaluate adequately its relation to venous thrombosis. The homozygous and heterozygous genotypes for the V allele of the MTHFR gene were unrelated to venous thrombosis (odds ratio = 0.9, 95% confidence interval 0.5-1.8). Subjects with the deletion/deletion ACE polymorphism experienced a moderate increase in venous thrombosis risk compared with persons with the other genotypes (odds ratio = 1.5, 95% confidence interval 0.9-2.6). However, women with this ACE genotype experienced no increased risk (odds ratio = 0.9, 95% confidence interval 0.5-1.9), whereas men with this genotype had nearly three times the risk (odds ratio = 2.8, 95% confidence interval 1.2-6.2; p value for interaction = 0.06). These data indicate that the prevalence of Factor V Leiden and the V allele of the MTHFR gene is low among African Americans. The D allele of the ACE gene is equally prevalent among African Americans and whites and may be related to venous thrombosis among African-American men.

Personal use of postmenopausal hormone replacement therapy by women physicians in the United States

BACKGROUND

Women physicians' use of postmenopausal hormone replacement therapy (HRT) is unknown.

OBJECTIVE

To study use of HRT by women physicians in the United States.

DESIGN

Stratified random-sample mail survey.

SETTING

United States Participants: 1466 postmenopausal women U.S. physicians in the Women Physicians' health study.

MEASUREMENTS

Self-reported personal use of HRT and information on demographic, professional, and behavioral characteristics and medical history.

RESULTS

Overall, 47.4% of participants currently use HRT; the prevalence of use is 59.8% in women 40 to 49 years of age, 49.4% in women 50 to 59 years of age, and 36.4% in women 60 to 70 years of age (P < 0.001). In an adjusted logistic regression model, current users were significantly more likely to be gynecologists, to be younger, to be white, to be sexually active, to be previous users of oral contraceptives, to live in Pacific or Mountain states, to have had a hysterectomy, and to have no personal or family history of breast cancer.

CONCLUSIONS

Women physicians have a higher rate of HRT use than that reported in cross-sectional U.S. surveys. This may presage greater use of HRT for U.S. women in the future.