22 research outputs found
The Canadian Women's Heart Health Alliance Atlas on the epidemiology, diagnosis, and management of cardiovascular disease in women - Chapter 5 : sex- and gender-unique manifestations of cardiovascular disease.
This Atlas chapter summarizes sex- and some gender-associated, and unique aspects and manifestations of cardiovascular disease (CVD) in women. CVD is the primary cause of premature death in women in Canada and numerous sex-specific differences related to symptoms and pathophysiology exist. A review of the literature was done to identify sex-specific differences in symptoms, pathophysiology, and unique manifestations of CVD in women. Although women with ischemic heart disease might present with chest pain, the description of symptoms, delay between symptom onset and seeking medical attention, and prodromal symptoms are often different in women, compared with men. Nonatherosclerotic causes of angina and myocardial infarction, such as spontaneous coronary artery dissection are predominantly identified in women. Obstructive and nonobstructive coronary artery disease, aortic aneurysmal disease, and peripheral artery disease have worse outcomes in women compared with men. Sex differences exist in valvular heart disease and cardiomyopathies. Heart failure with preserved ejection fraction is more often diagnosed in women, who experience better survival after a heart failure diagnosis. Stroke might occur across the lifespan in women, who are at higher risk of stroke-related disability and age-specific mortality. Sex- and gender-unique differences exist in symptoms and pathophysiology of CVD in women. These differences must be considered when evaluating CVD manifestations, because they affect management and prognosis of cardiovascular conditions in women.Dans le prĂ©sent chapitre dâAtlas sont rĂ©capitulĂ©s les aspects et les manifestations uniques, associĂ©s au sexe et certains associĂ©s au genre, des maladies cardiovasculaires (MCV) chez les femmes. Les MCV sont la cause principale de dĂ©cĂšs prĂ©maturĂ©s chez les femmes au Canada. De nombreuses diffĂ©rences quant aux symptĂŽmes et Ă la physiopathologie existent entre les sexes. Nous avons rĂ©alisĂ© une revue de la littĂ©rature pour dĂ©terminer les diffĂ©rences entre les sexes dans les symptĂŽmes et la physiopathologie, et les manifestations uniques des MCV chez les femmes. Bien que les femmes atteintes dâune cardiopathie ischĂ©mique puissent Ă©prouver des douleurs thoraciques, la description des symptĂŽmes, le dĂ©lai entre lâapparition des symptĂŽmes et lâobtention de soins mĂ©dicaux, et les symptĂŽmes prodromiques sont souvent diffĂ©rents de ceux des hommes. Les causes de lâangine et de lâinfarctus du myocarde non liĂ©es Ă lâathĂ©rosclĂ©rose telles que la dissection spontanĂ©e de lâartĂšre coronaire sont principalement observĂ©es chez les femmes. La coronaropathie obstructive et non obstructive, lâanĂ©vrisme aortique et la maladie artĂ©rielle pĂ©riphĂ©rique montrent de plus mauvaises issues chez les femmes que chez les hommes. Des diffĂ©rences entre les sexes sont observĂ©es dans la cardiopathie valvulaire et les cardiomyopathies. Le diagnostic dâinsuffisance cardiaque avec fraction dâĂ©jection prĂ©servĂ©e est plus souvent posĂ© chez les femmes qui prĂ©sentent un meilleur taux de survie aprĂšs un diagnostic dâinsuffisance cardiaque. Lâaccident vasculaire cĂ©rĂ©bral (AVC) pourrait survenir tout au long de la vie des femmes, qui sont exposĂ©es Ă un risque plus Ă©levĂ© dâincapacitĂ©s liĂ©es Ă lâAVC et de mortalitĂ© par Ăąge. Il existe des diffĂ©rences uniques entre les sexes et les genres pour ce qui est des symptĂŽmes et de la physiopathologie des MCV chez les femmes. Lors de lâĂ©valuation des manifestations des MCV, il faut tenir compte de ces diffĂ©rences puisquâelles influencent la prise en charge et le pronostic des maladies cardiovasculaires chez les femmes
The Canadian Women's Heart Health Alliance atlas on the epidemiology, diagnosis, and management of cardiovascular disease in women - Chapter 6 : sex- and gender-specific diagnosis and treatment
This chapter summarizes the sex- and gender-specific diagnosis and treatment of acute/unstable presentations and nacute/stable presentations of cardiovascular disease in women. Guidelines, scientific statements, systematic reviews/meta-analyses, and primary research studies related to diagnosis and treatment of coronary artery disease, cerebrovascular disease (stroke), valvular heart disease, and heart failure in women were reviewed. The evidence is summarized as a narrative, and when available, sex- and gender-specific practice and research recommendations are provided. Acute coronary syndrome presentations and emergency department delays are different in women than they are in men. Coronary angiography remains the gold-standard test for diagnosis of obstructive coronary artery disease. Other diagnostic imaging modalities for ischemic heart disease detection (eg, positron emission tomography, echocardiography, single-photon emission computed tomography, cardiovascular magnetic resonance, coronary computed tomography angiography) have been shown to be useful in women, with their selection dependent upon both the goal of the individualized assessment and the testing resources available. Noncontrast computed tomography and computed tomography angiography are used to diagnose stroke in women. Although sex-specific differences appear to exist in the efficacy of standard treatments for diverse presentations of acute coronary syndrome, many cardiovascular drugs and interventions tested in clinical trials were not powered to detect sex-specific differences, and knowledge gaps remain. Similarly, although knowledge is evolving about sex-specific difference in the management of valvular heart disease, and heart failure with both reduced and preserved ejection fraction, current guidelines are lacking in sex-specific recommendations, and more research is needed.Ce chapitre prĂ©sente un rĂ©sumĂ© sur le diagnostic et le traitement des tableaux cliniques aigus/instables et non aigus/stables des maladies cardiovasculaires chez les femmes, et les diffĂ©rences propres Ă chacun des deux sexes. Les lignes directrices, les Ă©noncĂ©s scientifiques, les revues systĂ©matiques/mĂ©ta-analyses et les Ă©tudes de recherche originale sur le diagnostic et le traitement des coronaropathies, des maladies vasculaires cĂ©rĂ©brales (AVC), des valvulopathies cardiaques et de lâinsuffisance cardiaque chez les femmes ont Ă©tĂ© examinĂ©s. Les donnĂ©es probantes sont rĂ©sumĂ©es sous forme narrative et, lorsquâelles sont disponibles, des recommandations en matiĂšre de pratique et de recherche pour chacun des deux sexes sont prĂ©sentĂ©es. Les tableaux cliniques du syndrome coronarien aigu et les dĂ©lais dâattente Ă lâurgence sont diffĂ©rents selon quâune femme ou un homme en est atteint. Lâangiographie coronarienne reste lâexamen de rĂ©fĂ©rence pour le diagnostic des coronaropathies obstructives. Dâautres examens dâimagerie diagnostique (p. ex. la tomographie par Ă©mission de positons, lâĂ©chocardiographie, la tomographie d'Ă©mission Ă photon unique, la rĂ©sonance magnĂ©tique cardiovasculaire, lâangiographie coronarienne par tomodensitomĂ©trie) se sont avĂ©rĂ©s utiles pour la dĂ©tection des cardiopathies ischĂ©miques chez les femmes. Le recours Ă ces modalitĂ©s dĂ©pend de lâobjectif de lâĂ©valuation personnalisĂ©e et des ressources disponibles. La tomodensitomĂ©trie sans agent de contraste et lâangiographie par tomodensitomĂ©trie sont utilisĂ©es pour le diagnostic des AVC chez les femmes. MalgrĂ© les diffĂ©rences entre les sexes quant Ă lâefficacitĂ© des traitements de rĂ©fĂ©rence des divers tableaux cliniques du syndrome coronarien aigu, bon nombre des mĂ©dicaments et des interventions cardiovasculaires qui ont fait lâobjet dâessais cliniques nâavaient pas la puissance statistique nĂ©cessaire pour dĂ©tecter des diffĂ©rences selon les sexes, de sorte que les connaissances restent fragmentaires sur ce sujet. De mĂȘme, malgrĂ© lâĂ©volution des connaissances sur les diffĂ©rences sexuelles quant Ă la prise en charge des valvulopathies cardiaques et de lâinsuffisance cardiaque avec fraction dâĂ©jection rĂ©duite ou prĂ©servĂ©e, on ne trouve pas de recommandations pour chaque sexe dans les lignes directrices actuelles, dâoĂč la pertinence dâĂ©tudes supplĂ©mentaires portant sur cette question
Pregnancy outcome in thoracic aortic disease data from the Registry of Pregnancy and Cardiac disease
Background: Cardiovascular disease is the leading cause of death during pregnancy with thoracic aortic dissection being one of the main causes. Thoracic aortic disease is commonly related to hereditary disorders and congenital heart malformations such as bicuspid aortic valve (BAV). Pregnancy is considered a high risk period in women with underlying aortopathy. Methods: The ESC EORP Registry Of Pregnancy And Cardiac disease (ROPAC) is a prospective global registry that enrolled 5739 women with pre-existing cardiac disease. With this analysis, we aim to study the maternal and fetal outcome of pregnancy in women with thoracic aortic disease. Results: Thoracic aortic disease was reported in 189 women (3.3%). Half of them were patients with Marfan syndrome (MFS), 26% had a BAV, 8% Turner syndrome, 2% vascular Ehlers-Danlos syndrome and 11% had no underlying genetic defect or associated congenital heart defect. Aortic dilatation was reported in 58% of patients and 6% had a history of aortic dissection. Four patients, of whom three were patients with MFS, had an acute aortic dissection (three type A and one type B aortic dissection) without maternal or fetal mortality. No complications occurred in women with a history of aortic dissection. There was no significant difference in median fetal birth weight if treated with a beta-blocker or not (2960 g (2358-3390 g) vs 3270 g (2750-3570 g), p value 0.25). Conclusion: This ancillary analysis provides the largest prospective data review on pregnancy risk for patients with thoracic aortic disease. Overall pregnancy outcomes in women with thoracic aortic disease followed according to current guidelines are good
Bleeding and thrombotic risk in pregnant women with Fontan physiology
Background/objectives Pregnancy may potentiate the inherent hypercoagulability of the Fontan circulation, thereby amplifying adverse events. This study sought to evaluate thrombosis and bleeding risk in pregnant women with a Fontan. Methods We performed a retrospective observational cohort study across 13 international centres and recorded data on thrombotic and bleeding events, antithrombotic therapies and pre-pregnancy thrombotic risk factors. Results We analysed 84 women with Fontan physiology undergoing 108 pregnancies, average gestation 33 +/- 5 weeks. The most common antithrombotic therapy in pregnancy was aspirin (ASA, 47 pregnancies (43.5%)). Heparin (unfractionated (UFH) or low molecular weight (LMWH)) was prescribed in 32 pregnancies (30%) and vitamin K antagonist (VKA) in 10 pregnancies (9%). Three pregnancies were complicated by thrombotic events (2.8%). Thirty-eight pregnancies (35%) were complicated by bleeding, of which 5 (13%) were severe. Most bleeds were obstetric, occurring antepartum (45%) and postpartum (42%). The use of therapeutic heparin (OR 15.6, 95% CI 1.88 to 129, p=0.006), VKA (OR 11.7, 95% CI 1.06 to 130, p=0.032) or any combination of anticoagulation medication (OR 13.0, 95% CI 1.13 to 150, p=0.032) were significantly associated with bleeding events, while ASA (OR 5.41, 95% CI 0.73 to 40.4, p=0.067) and prophylactic heparin were not (OR 4.68, 95% CI 0.488 to 44.9, p=0.096). Conclusions Current antithrombotic strategies appear effective at attenuating thrombotic risk in pregnant women with a Fontan. However, this comes with high (>30%) bleeding risk, of which 13% are life threatening. Achieving haemostatic balance is challenging in pregnant women with a Fontan, necessitating individualised risk-adjusted counselling and therapeutic approaches that are monitored during the course of pregnancy
Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries
Abstract
Background
Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.
Methods
This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and lowâmiddle-income countries.
Results
In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of âsingle-useâ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for lowâmiddle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.
Conclusion
This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both highâ and lowâmiddleâincome countries
Pregnancy risks in women with pre-existing coronary artery disease, or following acute coronary syndrome
Objective The objective of this study was to determine outcomes in pregnant women with pre-existing coronary artery disease (CAD) or following an acute coronary syndrome (ACS) including myocardial infarction (MI). Background The physiological changes of pregnancy can contribute to myocardial ischaemia. The pregnancy risk for women with pre-established CAD or a history of ACS/MI is not well studied. Methods This was a retrospective multicentre study. Adverse maternal cardiac, obstetric and fetal/neonatal events were examined. The primary outcome was a composite endpoint of cardiac arrest, ACS/MI, ventricular arrhythmia or congestive heart failure. The prevalence of new or progressive angina during pregnancy was also examined. Results Fifty pregnancies in 43 women (mean age 35 +/- 5 years) were included. Coronary atherosclerosis (40%) and coronary thrombus (36%) were the most common underlying diagnoses. The primary outcome occurred in 10% (5/50) of pregnancies and included one maternal death secondary to cardiac arrest. Other events included ACS/MI (3/50) and heart failure (1/50). New or progressive angina occurred in 18% of pregnancies. Ischaemic complications of any type (new or progressive angina, ACS/MI, ventricular arrhythmia, cardiac arrest) occurred more commonly in women with coronary atherosclerosis compared with those without (50% vs 10%, p=0.003). A high rate of adverse obstetric (16%) and fetal/neonatal (30%) events was observed. Conclusions Pregnant women with pre-existing CAD or ACS/MI before pregnancy are at increased risk of adverse events during pregnancy. Those with coronary atherosclerosis are at highest risk of adverse maternal cardiac events due to myocardial ischaemia during pregnancy
Pheochromocytoma and Paraganglioma in Cyanotic Congenital Heart Disease
CONTEXT Aberrant cellular oxygen sensing (pseudo-hypoxia) is a leading theory for development of pheochromocytoma (PHEO) and paraganglioma (PGL). OBJECTIVE To test the hypothesis that chronic hypoxia in patients with cyanotic congenital heart disease (CCHD, CHD) increases the risk for PHEO-PGL. DESIGN/SETTING/PARTICIPANTS We investigated the association between CCHD and PHEO-PGL with 2 complementary studies: Study 1) An international consortium was established to identify patients with PHEO-PGL diagnosis confirmed by pathology, or biochemistry and imaging. Study 2) The 2000-2009 Nationwide Inpatient Survey, a nationally representative discharge database, was used to determine population-based cross-sectional PHEO-PGL frequency in hospitalized CCHD patients compared with non-cyanotic CHD and those without CHD using multivariable logistic regression adjusted for age, sex, and genetic PHEO-PGL syndromes. RESULTS Study 1) We identified 20 PHEO-PGL cases, of which 18 had CCHD. Most presented with cardiovascular or psychiatric symptoms. Median cyanosis duration for the CCHD PHEO-PGL cases was 20y (range 1-57y). Cases were young at diagnosis (median 31.5y, range 15-57) and 7/18 had multiple tumors (2 bilateral PHEO; 6 multi-focal or recurrent PGL) while 11 had single tumors (7 PHEO; 4 PGL). PGL were abdominal (13/17) or head/neck (4/17). Cases displayed a noradrenergic biochemical phenotype similar to reported hypoxia-related PHEO-PGL genetic syndromes, but without clinical signs of such syndromes. Study 2) Hospitalized CCHD patients had increased likelihood of PHEO-PGL (adjusted OR=6.0, 95%CI [2.6-13.7], p<0.0001) compared with those without CHD; patients with non-cyanotic CHD had no increased risk (OR=0.9, p=0.48). CONCLUSIONS There is a strong link between CCHD and PHEO-PGL. Whether these rare diseases co-associate due to hypoxic stress, common genetic or developmental factors, or some combination, requires further investigation