Not All HDL Cholesterol is Good – Size Matters

MedicalResearch.com Interview with:

Samar R. El Khoudary, PhD, MPH, BPharm, FAHA Associate Professor, Epidemiology PITT Public Health Epidemiology Data Center University of Pittsburgh Pittsburgh, PA 15260 

Dr. El Khoudary

Samar R. El Khoudary, Ph.D., M.P.H. BPharm, FAHA
Associate Professor
Department of Epidemiology
University of Pittsburgh Graduate School of Public Health

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The background for this study is based on the current measurements used to determine cardiovascular disease risk in postmenopausal women. Higher levels of HDL “good cholesterol” as measured by the widely available clinical test, HDL-Cholesterol, may not always be indicative of a lower risk of cardiovascular disease in postmenopausal women.

HDL is a family of particles found in the blood that vary in sizes, cholesterol contents and function. HDL particles can become dysfunctional under certain conditions such as chronic inflammation. HDL has traditionally been measured as the total cholesterol carried by the HDL particles, known as HDL cholesterol. HDL cholesterol, however, does not necessarily reflect the overall concentration, the uneven distribution, or the content and function of HDL particles.

We looked at 1,138 women aged 45 through 84 enrolled across the U.S. in the Multi-Ethnic Study of Atherosclerosis (MESA), a medical research study sponsored by the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH). MESA began in 1999 and is still following participants today. We assessed two specific measurements of HDL: the number and size of the HDL particles and total cholesterol carried by HDL particles. Our study also looked at how age when women transitioned into post menopause, and the amount of time since transitioning, may impact the expected cardio-protective associations of HDL measures.

Our study points out that the traditional measure of the good cholesterol, HDL cholesterol, fails to portray an accurate depiction of heart disease risk for postmenopausal women. We reported a harmful association between higher HDL cholesterol and atherosclerosis risk that was most evident in women with older age at menopause and who were greater than, or equal to, 10 years into post menopause. In contrast to HDL cholesterol, a higher concentration of total HDL particles was associated with lower risk of atherosclerosis. Additionally, having a high number of small HDL particles was found beneficial for postmenopausal women. These findings persist irrespective of age and how long it has been since women became postmenopausal.

On the other hand, large HDL particles are linked to an increased risk of cardiovascular disease close to menopause. Women are subject to a variety of physiological changes in their sex hormones, lipids, body fat deposition and vascular health as they transition through menopause. We are hypothesizing that the decrease of estrogen, a cardio-protective sex hormone, along with other metabolic changes, can trigger chronic inflammation over time, which may alter the quality of HDL particles. Future studies should test this hypothesis.

The study findings indicate that measuring size and number of HDL particles can better reflect the well-known cardio-protective features of the good cholesterol in postmenopausal women. Continue reading

Heart Attacks Less Common in Women, But More Likely To Be Fatal

MedicalResearch.com Interview with:
Dr. Edina Cenko  MD, PhD first author  and
Dr. Raffaele Bugiardini M.D. FESC, FAHA,
Professor of Cardiovascular Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy

MedicalResearch.com: What is the background for this study?

Response: Recent studies have identified younger women as “at-higher risk of mortality” after acute myocardial infarction. However, There are few studies looking at sex differences in mortality of patients with ST-Elevation Myocardial Infarction (STEMI). None of these studies have adjusted outcomes for treatment and delay to primary PCI, which may largely contribute to variations in clinical decision making and sex differences in outcomes. We used a large data set with fully risk and medications-adjusted models to investigate whether the risk of 30-day mortality after STEMI is higher in women than men and, if so, to assess the role of age in this excess of risk.

MedicalResearch.com: What are the main findings? 

Response: The different twist to this manuscript is to demonstrate that even when women have the same aggressive interventional and medical therapy as men, they die more than men and much more if women are younger , less than 60 years

MedicalResearch.com: What should readers take away from your report?

Response: Younger women are less likely to have a STEMI, but when they do so they show an excess of 30-day death than men, even in primary PCI treated patients. One strategy does not fit all in terms of women and men and mortality after STEMI. We need a more personalized approach to cardiovascular care. Behind sex disparities, sex is a biological variable in myocardial infarction. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: The study supports the new NIH initiative requiring researchers to factor sex into the design, analysis, and reporting of studies. Severe adverse effects in women were not recognized by clinical trials as there was not a sufficient sample of women. Studying (balancing or randomizing) both sexes may inform appropriate medical care for women.  

MedicalResearch.com: Is there anything else you would like to add? 

Response: The current study is the first investigation which demonstrates that differences between younger men and younger women in STEMI mortality rates are unrelated to disparities in treatment. This holds true even in patients undergoing primary PCI. However, more studies are needed. Findings from men could not necessarily be applied to women. It is central considering the effects of sex as a biological variable at all stages and in any type of research on ischemic heart disease.

Any disclosures? Nothing to disclose 

Citations:

Cenko E, Yoon J, Kedev S, et al. Sex Differences in Outcomes After STEMIEffect Modification by Treatment Strategy and Age. JAMA Intern Med. Published online April 09, 2018. doi:10.1001/jamainternmed.2018.0514 

 

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Cardiovascular Disease Not a Top Concern For Women or Their Physicians

MedicalResearch.com Interview with:

C. Noel Bairey Merz, MD, FACC  Director, Barbra Streisand Women's Heart Center Director, Linda Joy Pollin Women's Heart Health Program Director, Erika Glazer Family Foundation Women's Heart Disease Initiative Director, Preventive Cardiac Center  Professor of Medicine  Cedars-Sinai Medical Center

Dr. Merz

C. Noel Bairey Merz, MD, FACC 
Director, Barbra Streisand Women’s Heart Center
Director, Linda Joy Pollin Women’s Heart Health Program
Director, Erika Glazer Family Foundation Women’s Heart Disease Initiative
Director, Preventive Cardiac Center
Professor of Medicine
Cedars-Sinai Medical Center

MedicalResearch.com: What is the background for this study?

Response: Cardiovascular disease (CVD) is the number 1 killer of women in the U.S.A., yet few younger women personalize awareness. CVD campaigns focus little attention on physicians and their role assessing risk.

MedicalResearch.com: What are the main findings?

Response: Overall, 45% of women were unaware that CVD is the #1 killer of women, only 11% knew a woman who has died from it.  Overall, 45% of women reported it is common to cancel or postpone a physician appointment until losing weight. Cardiovascular disease was a top concern for only 39% of PCPs, after weight and breast health. A minority of physicians (22% of PCPs and 42% of cardiologists) felt well prepared to assess women’s CVD risk, and infrequently use guidelines.

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Paracardial Fat Linked To Postmenopausal Coronary Artery Calcification

MedicalResearch.com Interview with:

Samar R. El Khoudary, Ph.D., M.P.H. Assistant professor Department of Epidemiology University of Pittsburgh Graduate School of Public Health

Dr. El Khoudary,

Samar R. El Khoudary, Ph.D., M.P.H.
Assistant professor
Department of Epidemiology
University of Pittsburgh Graduate School of Public Health

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Our study revealed a previously unknown, menopause-specific indicator of heart disease risk. For the first time, we’ve pinpointed the type of heart fat, linked it to a risk factor for heart disease and shown that menopausal status and estrogen levels are critical modifying factors of its associated risk in women.

My team evaluated clinical data, including blood samples and heart CT scans, on 478 women from Pittsburgh and Chicago enrolled in the Study of Women’s Health Across the Nation (SWAN). The women were in varying stages of menopause, averaged 51 years old and were not on hormone replacement therapy.

In a previous study, we showed that a greater volume of paracardial fat, but not epicardial fat, after menopause is associated with a decline in the sex hormone estradiol—the most potent estrogen—in women. The higher volume of epicardial fat was tied to other risk factors, such as obesity.

In the new study, we built on those findings to discover that not only is a greater paracardial fat volume specific to menopause, but—in postmenopausal women and women with lower levels of estradiol—it’s also associated with a greater risk of coronary artery calcification, an early sign of heart disease that is measured with a heart CT scan.

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STEMI Outcomes Improve For Both Genders, But More So For Men

MedicalResearch.com Interview with:
Dr. Stefano Savonitto 

Director, Division of Cardiology
Manzoni Hospital

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Over the last 15 years, there has been a shift from fibrinolytic therapy for STEMI to primary angioplasty, which required a re-organization of the whole STEMI treatment network. Besides the higher reperfusion efficiency of primary angioplasty, as compared to lytic therapy, it has been a global upgrade of the STEMI care system that has reduced the rate of no reperfusion.

Elderly patients and women (who are, on average, also older than men) had theoretically the most to gain from this shift, but little data were available to assess this benefit.

In the present paper, we have shown that “lack of reperfusion” was reduced dramatically across all age groups and in both sexes, with a progressive and uniform increase in primary angioplasty, and a significant reduction in mortality. Almost as expected, elderly women were the category with the most relevant mortality benefit.

Nevertheless, after adjustment for age and other confounders, women continue to experience a higher mortality as compared to men. In the discussion of the paper, we propose some hypotheses for this persistently higher mortality in women.

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Women Undergoing Stent Surgery for Total Coronary Occlusions Tend To Be Older and Have More Complications

MedicalResearch.com Interview with:
Dr James Spratt Bsc, MD, FRCP, FESC, FACC

Spire Edinburgh Hospitals and Spire Murrayfield Edinburgh
Spire Shawfair Park Hospital

MedicalResearch.com: What is the background for this study?

Response: Gender differences exist between male and female patients following routine PCI but data regarding these differences in Chronic Total Occlusions (CTO) Percutaneous Coronary Intervention (PCI) is limited. We maintain a dedicated national (United Kingdom) prospective CTO database contributed to by dedicated CTO PCI operators (lifetime CTO PCI >300). We retrospectively analysed this database from 2011-2015 to compare outcomes and characteristics of male versus female patients undergoing CTO PCI. We attempted to limit the bias of this observational study by propensity matched analysis.

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Regardless of Ethnicity, Women Have Worse Outcomes From Acute Coronary Syndromes

MedicalResearch.com Interview with:

Karin H Humphries, MBA, DSc | Scientific Director BC Centre for Improved Cardiovascular Health UBC-HSF Professor in Women's Cardiovascular Health Vancouver, BC

Karin Humphries

Karin H Humphries, MBA, DSc | Scientific Director
BC Centre for Improved Cardiovascular Health
UBC-HSF Professor in Women’s Cardiovascular Health
Vancouver, BC

Medical Research: What is the background for this study?

Response: Prior studies have shown that among patients with obstructive coronary artery disease (CAD), women have higher short- and long-term mortality rates as compared to men. Furthermore, a few studies have highlighted the existence of ethnic differences in the incidence of acute myocardial infarction (AMI) and outcomes following an AMI event. However, the joint contribution of sex and ethnicity on outcomes of patients with obstructive  coronary artery disease remains unknown.

Our primary objective was to extend these findings by examining the joint impact of sex and ethnicity on long-term adverse outcomes of all patients with angiographic evidence of obstructive CAD presenting with myocardial ischemia.

Our study included a population-based cohort of patients ≥ 20 years of age who underwent coronary angiography for acute coronary syndromes (ACS) or stable angina in British Columbia, Canada with angiographic evidence of ≥ 50% stenosis in any epicardial artery.

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Symptoms of Anxiety and Heart Disease May Overlap in Women

MedicalResearch.com Interview with:

Dr. Kim Lavoie

Dr.Kim Lavoie

Dr. Kim Lavoie, Ph.D.
CIHR New Investigator, FRQS Chercheur-Boursier Co-Director,
Montreal Behavioural Medicine Centre
Professor, Dept. of Psychology University of Quebec at Montreal Director, Chronic Disease Research Division, Hôpital du Sacré-Coeur de Montreal Adjunct Professor, Faculty of Medicine, University of Montreal
Associate Researcher, Montreal Heart Institute
Chair, Health Psychology and Behavioral Medicine Section
Canadian Psychological Association
 

Medical Research: What is the background for this study?

Dr. Lavoie: We were interested in looking at whether rates of ischemia in men and women were different as a function of whether or not you had pre-existing heart disease (we would expect those with existing heart disease to have more ischemia because it’s a major marker of disease) or a comorbid anxiety or mood disorder (we expected anx/mood disorders would be associated with higher rates of ischemia because they reflect clinical levels of chronic stress, which has been linked to higher rates of ischemia in previous studies).

Medical Research: What are the main findings?

Dr. Lavoie: Overall, we found that men have higher rates of ischemia than women, and that anxiety or mood disorders overall aren’t associated with higher or lower risk of ischemia (in those with or without previously diagnosed heart disease).

HOWEVER, what we did find that was interesting and perhaps new, was that if you looked within women, those without previously diagnosed heart disease AND anxiety disorders (which including things like panic disorder and generalized anxiety – panickers and worriers) had higher rates of ischemia compared to those without anxiety disorders. This suggests higher rates of ischemia among women without heart disease, which seems counter-intuitive because you would expect those WITH disease to have more ischemia. The fact that anxiety disorders were present in those without previously diagnosed heart disease – and they were the ones with more ischemia, suggests that these women likely HAD heart disease that just hadn’t been diagnosed up yet, and that the reason might have been because of their anxiety disorder, which can mask many symptoms of heart disease because many of them overlap (e.g., fatigue, decreased energy, heart palpitations, sweating, chest discomfort, hyperventilation, and fear/worry). This could lead physicians to misinterpret symptoms of real heart disease as those of anxiety – but this only appears to be the case in women according to our study, suggesting a possible sex/gender bias here.

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Multiple Pregnancies May Raise Metabolic Syndrome Risk in Latina Women

MedicalResearch.com Interview with:

Catherine J. Vladutiu, PhD, MPH Research Assistant Professor, Department of Obstetrics & Gynecology Adjunct Assistant Professor, Department of Epidemiology Chapel Hill, NC

Dr. Catherine Vladutiu

Catherine J. Vladutiu, PhD, MPH
Research Assistant Professor, Department of Obstetrics & Gynecology
Adjunct Assistant Professor, Department of Epidemiology
Chapel Hill, NC

Medical Research: What is the background for this study?

Dr. Vladutiu: During pregnancy, women experience physiological changes and are at risk of pregnancy-related complications, some of which are associated with a higher risk of cardiovascular health outcomes in later life.  Physiologic adaptations occurring across successive pregnancies may be associated with an even higher risk of adverse cardiovascular outcomes. Previous studies have found an association between higher parity (i.e., number of live births) and the metabolic syndrome (MetS). However, no studies have examined this association in a Hispanic/Latina population. Hispanic women have a higher prevalence of the MetS than non-Hispanic women.  Latinos are also the fastest growing minority population in the U.S. and Hispanic/Latina women report higher fertility and birth rates than their non-Hispanic counterparts.

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Young Women With CAD Need Repeat Procedures More Often Than Men

MedicalResearch.com Interview with:

Dr. Robert L. Wilensky MD Director, Interventional Cardiology Research Director, Interventional Cardiology Training Program Professor of Medicine Hospital of the University of Pennsylvania

Dr. Robert Wilensky

Dr. Robert L. Wilensky MD
Director, Interventional Cardiology Research
Director, Interventional Cardiology Training Program
Professor of Medicine Hospital of the University of Pennsylvania

Medical Research: What is the background for this study?

Dr. Wilensky: We wanted to evaluate whether young women, under the age of 50 years, had an increased risk for recurrent ischemic events after percutaneous coronary intervention (PCI) compared to young men or older women.

Medical Research: What are the main findings?

 Dr. Wilensky: Despite having less severe coronary artery disease,  had an increased risk of repeated events, generally need for repeat PCI in either the exact location of the original procedure or within the artery that underwent the procedure. This despite the finding that young women were treated with the same medications as young men.

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Many Patients With Heart Failure Report Impairment of Daily Activities

dr-shannon-dunlayMedicalResearch.com Interview with:
Shannon M. Dunlay, M.D. M.S.
Advanced Heart Failure and Cardiac Transplantation
Assistant Professor of Medicine and Health Care Policy and Research
Mayo Clinic Rochester
MedicalResearch: What is the background for this study?

Dr. Dunlay: Loss of mobility and independence can complicate the care of patients with chronic conditions such as heart failure, and can degrade their quality of life.  However, we have a very poor understanding of the burden of disability in patients with heart failure and how it impacts outcomes.  What are the main findings?  In this study, patients with heart failure were asked whether they had difficulty performing activities of daily living (ADLs)—these include normal activities that most people do in daily life such as eating, bathing, dressing, and walking.  Most patients with heart failure reported having difficulty with at least one ADL at the beginning of the study, and over 1/3 had moderate or severe difficulty with activities of daily living.  Patients who were older, female and had other chronic conditions such as diabetes, dementia and obesity had more difficulty with activities of daily living.  Patients that reported more difficulty with ADLs (worse mobility) were more likely to die and be hospitalized over time.  Some patients had a decline in function over time, and this was also predictive of worse outcomes.

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Research Aims To Understand Heart Failure In Women

Dawn Pedrotty, MD, PhD Cardiovascular Medicine Fellowship University of PennsylvaniaMedicalResearch.com Interview with:
Dawn Pedrotty, MD, PhD

Cardiovascular Medicine Fellowship
University of Pennsylvania

MedicalResearch: What is the background for this review? What are the main findings?

Dr. Pedrotty: Heart failure (HF) is the most common cause for hospitalization among patients 65 years and older, affecting approximately 6 million Americans; at 40 years of age, American males and females have a one in five lifetime risk of developing heart failure. There are two distinct heart failure phenotypes: a syndrome with normal or near-normal left ventricular ejection fraction (LVEF) referred to as HF with preserved ejection fraction (HFpEF), and the phenotype associated with poor cardiac contractility or heart failure with reduced ejection fraction (HFrEF). Risk factors associated with HFpEF include female gender, especially women with diabetes, higher body mass index, smoking, hypertension, concentric left ventricular hypertrophy (LVH), and atrial fibrillation (AF). There has been a growing interest in the development of criteria for specific subsets of HFpEF, a syndromal disease where multiple cardiac and vascular abnormalities exist. One approach is to implement phenomapping, identifying phenotypically distinct HFpEF categories and developing a classification system to group together pathophysiologically similar individuals who may respond in a more homogeneous, predictable way to intervention. Another option would be to focus on a known physiologic differences which might shed light on pathologic mechanisms e.g. gender and the influences of obesity and atrial fibrillation.
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Women With Atrial Fibrillation At Greater Risk Of Stroke Than Men

Gregory YH Lip MD, FRCP (London, Edinburgh, Glasgow), DFM, FACC, FESC Professor of Cardiovascular Medicine, University of Birmingham, UK; Adjunct Professor of Cardiovascular Sciences, Thrombosis Research Unit, Aalborg University, Denmark; Visiting Professor of Haemostasis Thrombosis & Vascular Sciences, Aston University, Birmingham, UK; Visiting Professor of Cardiology, University of Belgrade, Serbia Centre for Cardiovascular Sciences City Hospital Birmingham  England UKMedicalResearch.com Interview with:
Gregory YH Lip MD, FRCP (London, Edinburgh, Glasgow), DFM, FACC, FESC
Professor of Cardiovascular Medicine,
Adjunct Professor of Cardiovascular Sciences,
Thrombosis Research Unit, Aalborg University, Denmark;
Aston Centre for Cardiovascular Sciences City Hospital Birmingham
England UK

Medical Research: What is the background for this study? What are the main findings?

Prof. Lip: Women with atrial fibrillation are at higher risk of stroke than men with atrial fibrillation.

The reasons for this elevated risk remain unclear.

The results from our worldwide study suggest that women are treated no differently to men in terms of anticoagulant therapy for stroke prevention.

Thromboprophylaxis was, however, suboptimal in substantial proportions of men and women, with underuse in those at moderate-to-high risk of stroke and overuse in those at low risk.

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Young Women With Heart Attack May Have Confusing Symptoms

Judith Lichtman, PhD, MPH Associate Professor (with tenure) Chair, Department of Chronic Disease Epidemiology Yale School of Public Health New Haven, CT 06520-803MedicalResearch.com Interview with:
Judith Lichtman, PhD, MPH
Associate Professor (with tenure)
Chair, Department of Chronic Disease Epidemiology
Yale School of Public Health
New Haven, CT 06520-803

Medical Research: What is the background for this study? What are the main findings?

Dr. Lichtman: Heart disease in younger women (18-55 years of age) is relatively rare, and represents less than 5% of all heart disease in women; however, young women who present with a heart attack are twice as likely to die in the hospital as compared with a similarly aged man, and this excess mortality risk continues beyond the index event. Delays in seeking prompt care has been suggested as one potential cause for the excess mortality in young women. We were interested in learning about the recognition of symptoms, perceived risk of heart disease, decision-making process to seek medical care, and interactions with the healthcare system among young women who recently had a heart attack. We found that even though the majority of young women presented with chest pain, they also experienced many other symptoms such as fatigue, nausea, muscle pain, and weakness. They commonly attributed symptoms to non-cardiac conditions because they felt they did not experience the “Hollywood Heart Attack” that is commonly portrayed in the media. Interestingly, despite reporting a strong family history of cardiac disease, and having multiple risk factors, many of the women we spoke with did not perceive they were at risk for heart disease, and many were not working with their physicians to manage their risk factors. They were also concerned about being seen as a hypochondriac if they reported their symptoms. Finally, women reported that the healthcare system was not consistently responsive when they reported their symptoms.

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Women With Heart Failure Less Likely To Be Referred For Specialty Care

Jennifer L. Cook, MD FAHA Assistant Professor of Medicine | Heart Failure and Transplantation Medical Director Left Ventricular Assist Device Program Medical University of South Carolina Charleston, SC 29425MedicalResearch.com Interview with:
Jennifer L. Cook, MD FAHA
Assistant Professor of Medicine | Heart Failure and Transplantation
Medical Director Left Ventricular Assist Device Program
Medical University of South Carolina
Charleston, SC 29425

Medical Research: What is the background for this study? What are the main findings?

Dr. Cook: Although the incidence of heart failure is similar in men and women, women are more likely to die from it.  Despite this fact a common misperception persists that men are at greater risk.  Although advanced therapies such as mechanical support are as effective in women as in men, women are less likely to receive mechanical support.  In clinical trials investigating mechanical support as a bridge to transplant less than 30% of patients were women.  In trials investigating mechanical support for patients ineligible for heart transplant even fewer were women, less than 20%.  .

Medical Research: What should clinicians and patients take away from your report?

Dr. Cook: It has been shown that women with heart failure are more likely to remain under the care of a primary physician instead of being referred for specialized cardiovascular care.  The explanation for this pattern is not understood.  It is important to raise awareness and emphasize the high risk of heart failure mortality among women.

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Women Veterans Undergoing Cardiac Catheterization Highlight Link Between Stress and CAD

Claire Duvernoy, MD Chief, Cardiology Section VA Ann Arbor Healthcare System Professor of Medicine University of Michigan Health System Ann Arbor, MI MedicalResearch.com Interview with:
Claire Duvernoy, MD

Chief, Cardiology Section
VA Ann Arbor Healthcare System
Professor of Medicine
University of Michigan Health System Ann Arbor, MI

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Duvernoy: We wanted to look at the indications and outcomes for women veterans undergoing cardiac catheterization procedures as compared with men veterans, given that we know that there are significant gender differences in the non-veteran population between women and men undergoing cardiac catheterization.
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