Gender-based approach to cardiovascular monitoring

Federica Moscucci

Dipartimento di Scienze Cliniche, Internistiche,

Anestesiologiche e Cardiovascolari

«Sapienza», Università di Roma

Cardiovascular disease in Europe 2016: epidemiological update

Townsend N Eur Heart J 2016

Proportion of all deaths due to major causes in Europe

Men

Women

CVD in 2012

17.3 million deaths/year worldwide

>23.6 million by 2030

Yahagi et al: Atherosclerosis 2015

Large prevalence of CVD in women is

associated with

coronary atherosclerosis

Traditionally, the enrollment of women in clinical trials has been minimal,

resulting in a lack of gender-specific analysis of clinical trial data and,

therefore, the absence of concrete risk factor assessment among women

Anum Saeed 2017

Under-representation of old women in RCTs.

• Elderly has frequently impaired renal function and politherapies and high comorbidity degree.

• Women suffering from CVD are often older than men, with less impaired ventricular function, more impaired diastolic function and many anatomical differencies.

Int J Cardiol. 2017 Apr 1;232:216-221.

We are using guidelines derived from studies that enrolled

men, with different ethiologies and younger than CV

diseases affected old women.

Prevention: difficult?

Anum Saeed 2017

Muka T et al, Maturitas. 2016 Apr

Erβ receptor on endothelium

Muka T et al, Maturitas. 2016 Apr

Possible Erβ receptor actions in cardiomyocytes

Microvascular Coronary Disease

Endothelial Dysfunction

Framingham Heart Study, N=2,883

Benjamin EJ et al., Circulation 2004

• Women have better endothelial

function than men

• Advantage declines with age

Xing, D. et al. Arterioscler Thromb Vasc Biol 2009;29:289-295

Gulati M, Journal of the American Heart Association. 2019;8:e012873

1) Public awareness and

education of women

2) Education of healthcare

providers

3) Protocol‐driven STEMI

care

4) Use of artificial intelligence

in STEMI management

5) Increased research on sex

disparities in STEMI and

ongoing reporting of

STEMI care by sex

Ischemic Heart Disease

Heart Failure

Crousillat D Curr Treat Opt Cardio Med 2018

Traditional vs Emerg(ED) CV risk factors in women

Garcia M Circ Res 2016

<37 weeks’ gestation

(5% to 12.7% of deliveries worldwide)

Main mechanisms : inflammation,

infection, vascular diseases.

Conclusions and Relevance

Women who had an infant with

PTB-SGA may be at higher

future risk of premature cardiac

disease or death.

Hypertensive

Pregnancy

Disorders

Gestational hypertension New onset hypertension (>140/90 mm Hg) after 20 weeks’ gestation

in a woman who was originally normotensive

Chronic hypertension Hypertension developed before 20 weeks of gestation

Preeclampsia New onset hypertension (>140/90 mm Hg) after 20 weeks’ gestation

and proteinuria (0.3 g/24 hours) and end-organ renal dysfunction

CVD risk persists into later life

Preeclampsia

Can J Cardiol. 2019 Jul 11. pii: S0828-282X(19)30464-7.

Annual visits to a primary care physician to check BP and

metabolic factors are recommended.

Pre-eclampsia, particularly early preterm

preeclampsia, was strongly associated with

several chronic renal disorders later in life.

More research is needed to determine which women are most

likely to develop kidney disease after pre-eclampsia, what

mechanisms underlie the association, and what clinical follow-up

and interventions (and in what timeframe post-pregnancy) would

be most appropriate and effective.

Gestational Diabetes

Persistence of Weight Gain After Pregnancy

Weight at 1 year postpartum is a stronger predictor of the

likelihood of being overweight 15 years later than the weight

gained during the pregnancy itself Kew S et Al. Cardiometabolic implications of postpartum weight changes in the first year

after delivery. Diabetes Care. 2014

Daly B, PlosOne 2018

Poola-Kella S et al Rev Recent Clin Trials. 2018

• Looking for specific risk factors

• Planning ante-natal care

• Organize peri-partum and intra partum assistance (glucose monitoring, basal insuline administration during labour, etc)

POST PARTUM CARE

Clinical Medicine 2019 Vol 19, No 5: 399–402

Menopause

Age at menopause

50.2 - 50.9 yrs in Italy

Dratva J, Menopause, December 2008

The age at menopause is, in itself, a fundamental item to be acquired,

in order to plan the right timing for prevention and possible

treatments

physicians learn to acquire the main anamnestic data concerning the female hormonal life, starting from

menarche, through pregnancy, up to the hormonal therapies that accompany and follow menopause

Multidimensional women’s assessemnt

Climateric symptoms are important as:

• CV risk factors;

• early diagnosis;

• Appropriate therapy and specific prevention program!

Visita del Medico- 1665-Jan Steen

Autoimmune

Diseases

Cardiovascular risk scoring systems

underestimate the burden of

cardiovascular risk in patients with

rheumatoid arthritis and systemic lupus

erythematosus or systemic sclerosis

Pts with rheumatoid arthritis have

increased

cardiovascular risk

Predisposition to ASCVD

(increase in the carotid intima-media

thickness)

JAHA 2019

There has been a tremendous improvement in the survival

rates of breast cancer

Breast Cancer Treatments

This improvement in outcome has been associated with chemotherapy dose-dependent acute,

subacute, and late cardiotoxicity

Breast cancer patients treated with chemotherapy may be at risk for either or

both Type I (anthracycline-like agents) and Type II (Trastuzumablike agents)

cardiotoxicity

M Garcia, S. L. Mulvagh, C. Noel Bairey Merz, J. E. Buring, JAnn E. Manson Circ Research 2016

Cardiotoxicity was comparable across the 3

groups for the entire study cohort. However,

for women receiving combination

anthracycline-trastuzumab chemotherapy, the

incidence of cardiac dysfunction was lower

in the lisinopril group (37%) and in the

carvedilol group (31%) than in the placebo

group (47%). Lisinopril and carvedilol were

also associated with longer cardiotoxicity-

free survival compared with placebo.

Randomized Trial of Lisinopril Versus Carvedilol to Prevent

Trastuzumab Cardiotoxicity in Patients With Breast Cancer Maya Guglin, Jeffrey Krischer, Roy Tamura, Angelina Fink, Lauren Bello-Matricaria, Worta McCaskill-Stevens and Pamela

N. Munster

Journal of the American College of Cardiology Volume 73, Issue 22, June 2019

All women who received

lisinopril or carvedilol had fewer

interruptions in their

trastuzumab therapy than those

who received placebo.

Rates of major coronary events increased linearly with the mean

dose to the heart by 7.4% per gray

The radiation categories were less than 2, 2 to 4, 5 to 9, and 10 Gy or more, the

overall averages of the mean doses to the heart of women in these categories were 1.4,

3.4, 6.5, and 15.8 Gy, respectively.

Cancer Treatment – breast cancer treatmen

Radiotherapy

Cumulative Risks of Death from Ischemic Heart Disease and of at Least One Acute Coronary Event

Women who underwent radiotherapy for breast cancer (1958 – 2001)

963 women with major coronary events and 1205 controls included

Exposure of the heart to ionizing radiation during radiotherapy for breast cancer

increases the subsequent rate of ischemic heart disease

The increase is proportional to the mean dose to the heart,

begins within a few years after exposure, and continues for at

least 20 yrs

A Role For

Pre existing Risk Factors

Sarah C. Darby et Al N engl j med march 14, 2013

J Cancer Res Ther. 2017 Apr-Jun;13

Polycystic ovary syndrome (PCOS):

not just a fertility matter

(a) CV risk scores should be updated, taking into account these data and

(b) meticulous CV screening should be recommended to patients with PCOS, in order to

recognize and counteract their multiple CV risk factors as early as possible.

It is now well established that PCOS, as a major CV risk factor,

precedes the development of heart disease during the early stages of life

Diabetes Metab Syndr. 2018 Jan 27.

J Cardiovasc Med (Hagerstown). 2018 Dec

Vasomotor Symptoms impacts

Unfavorable CVD risk profile

Osteoporosis

Cognitive decline

Who deserves our attention?

Inclusion of these data in an appropriate risk assessment

No CV risk score has implemented the scientific results of sex-

based CV medicine

Oral contracectives (OCPs) and

postmenopausal Hormone Therapy (HT)

OCPs: thromboembolic risk

evaluation

Loss of estrogens periodicity

increased inflammation

Consider:

- Patient hormonal status;

- Possible OCPs therapy in past ad its impact;

- Possible HT after menopause and its impact.

21 years old Female

(BMI = 24.3 kg/m2)

73 years old

Female

(BMI = 24.5

kg/m2)

Overweight and Sarcopenia

Wittmann K, Clin Int Aging 2016

According to data from a 2011 National Health Interview Survey (NHIS)

in adults, inactivity was higher among women than men (33.2% versus

29.9%, age-adjusted) and increased with age (from 26.1% to 52.4%).

Risk Factors in Women

Physical Inactivity

Schiller JS LJ et Al: Summary Health Statistics for US Adults: National Health Interview Survey, 2010

Physical inactivity

The prevalence of inactivity and

sedentary behaviors is higher among

women than men.

Overwhelming evidence indicates

that regular physical activity is one of

the most powerful health-promoting

practices that clinicians can

recommend for patients.

Women should be advised to

accumulate at least 150 min/wk of

moderate exercise, 75 min/wk of

vigorous exercise, or an equivalent

combination.

SEX-BASED DIFFERENCES

Garcia M Cardiovascular Disease in Women:

Clinical Perspectives 2017

Biased Discrimination

Setting: The 2014 to 2016 Behavioral Risk Factor Surveillance

System.

Participants: A total of. 395 154 participants

Prevention of cardiovascular risk factors in women: The lifestyle paradox and stereotypes we need to defeat.

Sciomer S, Moscucci F, Maffei S, Gallina S, Mattioli AV

Eur J Prev Cardiol. 2018 Oct [Epub ahead of print]

income level

Lack of awareness education

culture

social role

CV risk increased

STARTING WITH A COMPLETE AND METICOLOUS ANAMNESIS.

TAKE HOME MESSAGE

Multidimensional approach in anamnesis.

Target anamnesis, target prevention, target therapy, target follow up.

Filippo Palizzi, Fanciulla sulla roccia a Sorrento, 1871

olio su tela, cm 55x80