Brachial Artery Constriction during Brachial Artery Reactivity Testing Predicts Major Adverse Clinical Outcomes in Women with Suspected Myocardial Ischemia: Results from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study

Background:Limited brachial artery (BA) flow-mediated dilation during brachial artery reactivity testing (BART) has been linked to increased cardiovascular risk. We report on the phenomenon of BA constriction (BAC) following hyperemia.Objectives:To determine whether BAC predicts adverse CV outcomes and/or mortality in the women's ischemic Syndrome Evaluation Study (WISE). Further, as a secondary objective we sought to determine the risk factors associated with BAC.Methods:We performed BART on 377 women with chest pain referred for coronary angiography and followed for a median of 9.5 years. Forearm ischemia was induced with 4 minutes occlusion by a cuff placed distal to the BA and inflated to 40mm Hg > systolic pressure. BAC was defined as >4.8% artery constriction following release of the cuff. The main outcome was major adverse events (MACE) including all-cause mortality, non-fatal MI, non-fatal stroke, or hospitalization for heart failure.Results:BA diameter change ranged from -20.6% to +44.9%, and 41 (11%) women experienced BAC. Obstructive CAD and traditional CAD risk factors were not predictive of BAC. Overall, 39% of women with BAC experienced MACE vs. 22% without BAC (p=0.004). In multivariate Cox proportional hazards regression, BAC was a significant independent predictor of MACE (p=0.018) when adjusting for obstructive CAD and traditional risk factors.Conclusions:BAC predicts almost double the risk for major adverse events compared to patients without BAC. This risk was not accounted for by CAD or traditional risk factors. The novel risk marker of BAC requires further investigation in women. © 2013 Sedlak et al

TIMI frame count and adverse events in women with no obstructive coronary disease: A pilot study from the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE)

Background: TIMI frame count (TFC) predicts outcomes in patients with obstructive coronary artery disease (CAD); it remains unclear whether TFC predicts outcomes in patients without obstructive CAD. Methods: TFC was determined in a sample of women with no obstructive CAD enrolled in the Women's Ischemia Syndrome Evaluation (WISE) study. Because TFC is known to be higher in the left anterior descending artery (LAD), TFC determined in the LAD was divided by 1.7 to provide a corrected TFC (cTFC). Results: A total of 298 women, with angiograms suitable for TFC analysis and long-term (6-10 year) follow up data, were included in this sub-study. Their age was 55±11 years, most were white (86%), half had a history of smoking, and half had a history of hypertension. Higher resting cTFC was associated with a higher rate of hospitalization for angina (34% in women with a cTFC >35, 15% in women with a cTFC ≤35, P<0.001). cTFC provided independent prediction of hospitalization for angina after adjusting for many baseline characteristics. In this cohort, resting cTFC was not predictive of major events (myocardial infarction, heart failure, stroke, or all-cause death), cardiovascular events, all-cause mortality, or cardiovascular mortality. Conclusions: In women with signs and symptoms of ischemia but no obstructive CAD, resting cTFC provides independent prediction of hospitalization for angina. Larger studies are required to determine if resting TFC is predictive of major events in patients without obstructive coronary artery disease. © 2014 Petersen et al

Automatic Quantification of Breast Arterial Calcification on Mammographic Images

© 2019, Springer Nature Singapore Pte Ltd. This paper describes the research and development of an automatic computer system that is used to quantify breast arterial calcifications in mammography scans. A few prior studies have attempted to establish a relationship between breast arterial calcification (BAC) and the rate of coronary artery disease (CAD) risk factors. The majority of these studies demonstrated a positive association between BAC and increasing age. Large scale cohort studies and retrospective studies have almost uniformly suggested a strong association between BAC and cardiovascular disease-related morbidity and mortality. This strong association of BAC with cardiovascular pathology suggests that BAC should also be persistently associated with radiographically determined CAD. A method of image processing, segmentation, and quantification used to highlight and recognise calcified blood vessels in the breast is proposed and described in detail. This project aims to introduce a new use for digital Mammography, which is currently solely used for diagnosing breast cancer in female patients. A method of detecting BAC is introduced at no additional cost, having an adequate degree of accuracy, around 82%, which means that this type of system could be used to assist a radiographer in diagnosing BAC by indicating whether the patient has a high or low severity of calcification

Women and Heart Disease: Neglected Directions for Future Research

Before age 65, women have less heart disease than men. For many years, estrogen was the most popular explanation for this female advantage, and observational studies through the 1980s showed a lower risk of heart attacks in postmenopausal women taking “replacement” estrogen. But the Women’s Health Initiative (WHI), the first placebo-controlled trials of hormone therapy with the size and statistical power necessary to study clinical cardiovascular outcomes, did not confirm the hormone-healthy heart hypothesis. Now, at least 5 years later, the most unexpected WHI result may be how resilient the estrogen hypothesis has been. Where, beyond estrogen therapy, should we go from here to explain the striking sex differences in heart disease rates? A broader spectrum of research about the female cardiovascular advantage and its translation is needed

Sex differences in in-hospital mortality following a first acute myocardial infarction: Symptomatology, delayed presentation, and hospital setting

Background: Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated. Methods: Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated.Results: Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or ICU, while for females this age-adjusted attributable risk was 4.1 %. Conclusions: Our study stresses the need to reappraise decision making in patient selection for admission to specialised care units, whilst raising awareness of possible sex-related bias in management of patients diagnosed with an AMI

Awareness, Accuracy, and Predictive Validity of Self-Reported Cholesterol in Women

BACKGROUND: Although current guidelines emphasize the importance of cholesterol knowledge, little is known about accuracy of this knowledge, factors affecting accuracy, and the relationship of self-reported cholesterol with cardiovascular disease (CVD). METHODS: The 39,876 female health professionals with no prior CVD in the Women’s Health Study were asked to provide self-reported and measured levels of total and high-density lipoprotein (HDL) cholesterol. Demographic and cardiovascular risk factors were considered as determinants of awareness and accuracy. Accuracy was evaluated by the difference between reported and measured cholesterol. In addition, we examined the relationship of self-reported cholesterol with incident CVD over 10 years. RESULTS: Compared with women who were unaware of their cholesterol levels, aware women (84%) had higher levels of income, education, and exercise and were more likely to be married, normal in weight, treated for hypertension and hypercholesterolemia, nonsmokers, moderate drinkers, and users of hormone therapy. Women underestimated their total cholesterol by 9.7 mg/dL (95% CI: 9.2–10.2); covariates explained little of this difference (R(2) < .01). Higher levels of self-reported cholesterol were strongly associated with increased risk of CVD, which occurred in 741 women (hazard ratio 1.23/40 mg/dL cholesterol, 95% CI: 1.15–1.33). Women with elevated cholesterol who were unaware of their level had particularly increased risk (HR=1.88, P <. 001) relative to aware women with normal measured cholesterol. CONCLUSION: Women with obesity, smoking, untreated hypertension, or sedentary lifestyle have decreased awareness of their cholesterol levels. Self-reported cholesterol underestimates measured values, but is strongly related to CVD. Lack of awareness of elevated cholesterol is associated with increased risk of CVD

Gender differences in the clinical management of patients with angina pectoris: a cross-sectional survey in primary care

Non peer reviewedPublisher PD

Expert consensus document: A 'diamond' approach to personalized treatment of angina.

In clinical guidelines, drugs for symptomatic angina are classified as being first choice (β-blockers, calcium-channel blockers, short-acting nitrates) or second choice (ivabradine, nicorandil, ranolazine, trimetazidine), with the recommendation to reserve second-choice medications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. No direct comparisons between first-choice and second-choice treatments have demonstrated the superiority of one group of drugs over the other. Meta-analyses show that all antianginal drugs have similar efficacy in reducing symptoms, but provide no evidence for improvement in survival. The newer, second-choice drugs have more evidence-based clinical data that are more contemporary than is available for traditional first-choice drugs. Considering some drugs, but not others, to be first choice is, therefore, difficult. Moreover, double or triple therapy is often needed to control angina. Patients with angina can have several comorbidities, and symptoms can result from various underlying pathophysiologies. Some agents, in addition to having antianginal effects, have properties that could be useful depending on the comorbidities present and the mechanisms of angina, but the guidelines do not provide recommendations on the optimal combinations of drugs. In this Consensus Statement, we propose an individualized approach to angina treatment, which takes into consideration the patient, their comorbidities, and the underlying mechanism of disease