Women – ABC CARDIOL

IJCS

Editorial

Difference in Treatment Response Between Men and Women with Acute Myocardial Infarction with ST-segment Elevation Even When Following Well-established Protocols

João Manoel Theotonio dos Santos

The study “Comparison of Clinical and Epidemiological Profiles Between Men and Women with ST-Elevation Myocardial Infarction in Salvador from 2021 to 2023” provides an important contribution by demonstrating that, even in a setting supported by a well-structured ST-elevation myocardial infarction (STEMI) protocol, relevant differences in clinical profiles between men and women persist. Although treatment strategies were homogeneous between sexes—a noteworthy finding in a country where healthcare inequities are often the rule—the observation that women present later, are older at the time of the event, and more frequently receive potent antiplatelet agents reinforces the need to understand acute coronary syndrome in women according to their specific pathophysiological and clinical characteristics.¹

In recent years, increasing evidence has challenged the concept that myocardial infarction in women is simply “the same infarction, occurring later.” Contemporary data indicate that mechanisms such as coronary microvascular dysfunction, plaque erosion, and spontaneous coronary artery dissection are more prevalent among women, demanding greater diagnostic precision and tailored therapeutic strategies.^2,3 In parallel, atypical symptom presentation and lower perceived cardiovascular risk contribute to delays in seeking care—a phenomenon consistently observed worldwide, including in high-income countries.⁴

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Original Article

Body Adiposity and Endothelial Dysfunction Assessed By Laser Speckle Contrast Imaging in Obese and Overweight Individuals With Suboptimal Vitamin D Status: Sex Differences

Adriana de Castro Carvalho Faria et al. Michelle Rabello Cunha Caroline Lyra Moreira Samanta Souza Mattos … Clara Castro Carvalho Oliveira Faria Leticia Castro Carvalho Oliveira Faria Wille Oigman Mario Fritsch Neves

Abstract

Background:

Low Vitamin D levels are prevalent in obesity and have been linked to adverse cardiovascular and metabolic outcomes.

Objective:

This cross-sectional study aimed to assess anthropometric indices, vascular, autonomic function in obese and overweight individuals with suboptimal vitamin D status.

Methods:

Participants of both sexes, 40-69 years, Body Mass Index (BMI) 25-40 kg/m², were divided into two groups above and under the median vitamin D level (22,6 ng/ml), named Suboptimal (SUB-D) and Lower (LOW-D) vitamin D, respectively. Vascular function was assessed using central hemodynamic parameters (Mobil-O-Graph®), endothelial function (microvascular reactivity; Laser Speckle Contrast Image system), and heart rate variability (Polar® monitor). The groups were compared using an unpaired Student’s t-test, and p-values < 0,05 were considered statistically significant.

Results:

The groups (n = 90) had similar ages and blood pressures. The LOW-D group had a higher body fat percentage (%BF; 29 ± 4 vs. 33 ± 3, p = 0.020) and glycated Hb (5.4 ± 0.4 vs. 5.8 ± 0.4, p = 0.029) in males. Females had higher Visceral Adiposity Index (VAI; 2.33 ± 0.86 vs. 3.32 ± 1.86, p = 0.008) and Lipid Accumulation Products (LAP; 39 ± 23 vs. 63 ± 40, p = 0.005). The LOW-D group showed a lower percentage increase in the area under the curve in post-occlusive reactive hyperemia (%AUC-PORH) (70 ± 30 vs. 55 ± 32%, p = 0.034). Females showed inverse correlation of vitamin D levels and VAI and LAP, and a positive correlation with %AUC-PORH.

Conclusions:

In obese and overweight individuals, lower vitamin D content was associated with higher levels of body adiposity in males. Furthermore, impaired metabolic functions and endothelial dysfunction were related to lower vitamin D levels in females, as in the central illustration.

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Original Article

Comparison of Clinical and Epidemiological Profiles Between Men and Women with ST-Elevation Myocardial Infarction in Salvador from 2021 to 2023

Heloisa Gonzaga Menezes de Moraes et al. Mariela Gomes Botelho Carneiro Marianna Deway Andrade Dracoulakis

Abstract

Background:

ST-segment elevation myocardial infarction (STEMI) remains one of the leading causes of morbidity and mortality worldwide. Although studies indicate sex disparities in risk factors, symptomatology, and outcomes, there is a lack of local research validating these differences.

Objectives:

To compare the clinical and epidemiological profiles, treatment times, and in-hospital outcomes of men and women diagnosed with STEMI at a private hospital in Salvador, Brazil from 2021 to 2023.

Methods:

This retrospective observational study analyzed 75 patients, of whom 30.7% were women. Variables assessed included age, cardiovascular risk factors, symptom-to-door time, door-to-ECG time, door-to-reperfusion time, pharmacological therapy, and in-hospital outcomes.

Results:

Women presented STEMI at a significantly older age compared to men (median age: 73.0 versus 62.5 years; p = 0.002). There were no statistically significant differences in treatment times (symptom-to-door, door-to-ECG, and door-to-reperfusion) between sexes. Women were more frequently treated with high-potency antiplatelet agents (prasugrel and ticagrelor) than men (p = 0.047 and p = 0.012, respectively). No differences in complications or mortality rates were observed between the groups.

Conclusions:

Despite being older and using more potent antiplatelet therapy, women did not experience significant differences in treatment times or complications. The limited sample size may have affected the ability to detect more significant differences, underscoring the need for larger studies.

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IJCS

Viewpoint

Disparities in Women's Cardiovascular Health in Brazil

Larissa Franco de Andrade et al. Paolo Blanco Villela Jose Lucas Peres Bichara Luiz Antonio Viegas de Miranda Bastos Glaucia Maria Moraes de Oliveira

Cardiovascular diseases (CVD) are the leading cause of death in women worldwide, responsible for 30.4% of female deaths in 2021, according to the Global Burden Disease (GBD) study. In Brazil, between 1990 and 2020, CVD was the leading cause of death in the female population, represented mainly by ischemic heart disease (IHD) and stroke. In 2021, during the coronavirus pandemic period, COVID-19 was the major cause of death among Brazilian women, reaching 21.9% of total deaths, and the percentage of deaths attributed to IHD and CVD was 8.5% and 7.8%, respectively (). Additionally, from 1990 to 2021, proportional mortality from CVD was higher in females compared to males, with a similar percentage of deaths from IHD between the sexes and a higher percentage of deaths from stroke in women.

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Review Article

Cardiac Amyloidosis in Women: An Underappreciated Diagnosis

Larissa Neto Espíndola et al. Gláucia Maria Moraes de Oliveira Cláudia Maria Vilas Freire Marildes Luiza de Castro Maria Cristina Costa de Almeida

Abstract

Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy that affects the heart mostly in two forms: immunoglobulin light chain amyloidosis (AL-CM) and transthyretin amyloidosis.

Transthyretin amyloid cardiomyopathy (ATTR-CM) predominantly affects the elderly population, mainly men (about 70-80%), and usually manifests with symptoms of heart failure (HF).

Despite technological advances in medicine, CA is still an underdiagnosed condition, especially in women, partly due to the known male predominance and high level of suspicion required for diagnosis. It is important to remember that amyloidosis is a systemic disease with a heterogeneous and non-specific presentation. It’s worth paying attention to the patient’s medical history and red flags in clinical and diagnostic tests (electrocardiogram [ECG], echocardiogram [ECHO], cardiac magnetic resonance [CMR]).

Accurate and timely diagnosis is crucial for appropriate management and prognosis.

So far, the under-representation of women in clinical trials may have also limited the evidence on sex-specific diagnosis, and outcomes.

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Editorial

How Can We Expand Knowledge to Improve Women's Cardiovascular Health in Latin America?

Maria Alayde Mendonça Rivera et al. Carolina María Artucio Glaucia Maria Moraes de Oliveira

Latin America (LA) is characterized by enormous cultural diversity due to its multiplicity of languages (Spanish, Portuguese, French, English, Dutch, and countless indigenous languages), ethnicities (white, black, indigenous), beliefs, climates, religions, and customs. This variability is observed between countries and within each country in the region, making them unique, even though they share a geographic area and numerous historical facts. There is evidence that the epidemiological and nutritional transition has been more heterogeneous in LA than in other areas of the world, which contributes to a significant variability between countries and their subregions not only in the prevalence of different cardiovascular (CV) risk factors (RFs), but in CV mortality as well. Currently, 51% of the 659 744 000 inhabitants (UN, 2022) are women in LA and the Caribbean.

According to the Global Burden of Diseases (GBD) 2021, the leading causes of death in Latin American women in 2021 were related to the COVID-19 pandemic, which reduced life expectancy in the region by approximately three years, more markedly in LA and the Caribbean (). Regarding noncommunicable diseases (NCD), peculiarities in the death rates per 100 000 inhabitants in LA and the Caribbean, and in Southern LA were observed in 2021. CV disease, followed by neoplasms, is responsible for the highest death rates per 100 000 inhabitants in the Caribbean, Tropical LA, and Southern LA, where this ranking is inverse in Chile. Diabetes and kidney diseases, followed by CVD, account for the highest death rates per 100 000 inhabitants in Central LA. In contrast, neoplasms, followed by mental illnesses, predominate in Andean LA.

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IJCS

Review Article

Cardiovascular Disease in Latin American Women Gaps and opportunities

Karen Alexandra Dueñas-Criado et al. Angela Herrara Peña Maria Juliana Rodriguez-González Astrid Fajardo

Abstract

Cardiovascular disease (CVD) remains the leading cause of death in women. This review will address the known disparities in cardiovascular care concerning diagnosing and treating of heart disease in Latin American (LA) women. Gender-specific differences regarding the incidence, treatment, and outcomes of common cardiovascular pathology are increasingly recognized. Today, we identify that women have cardiovascular risk factors (CRFs), specifying the traditional, emerging, unique, or sex-specific determinants and the social and biological determinants that play a leading role in the prevention of CVD. The purpose of this article is to review the literature on cardiovascular disease in LA women, focusing on ischemic heart disease (IHD), valve disease (VD), heart failure, and cardiac rehabilitation (CR), where disparities continue to affect outcomes. Understanding the unique cardiovascular risk profile and barriers to optimal treatment outcomes in women is imperative to eliminate the current disparities in CVD.

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Review Article

Cardiovascular Disease in Women With Breast Cancer: A Contemporary Review

Adriana Puente Barragán et al. Patricia Nuriulú Escobar Alejandra Madrid Miller Luis Antonio Moreno Ruiz

Abstract

Breast cancer (BC) is the most common malignant neoplasia in women and is responsible for one in six deaths from cancer in the female population. Five years after diagnosis, BC survival rates currently exceed 80%. Cardiovascular disease (CVD) is a frequent cause of morbidity and mortality in BC, mainly in patients receiving cardiotoxic drugs (anthracyclines, immunotherapy) and radiotherapy (RT).

CVD and BC have common risk factors (RF), which are related to aging, traditional and cardiometabolic RFs (obesity, dyslipidemia, consumption of alcoholic beverages), and others associated with sex and reproductive women’s age, such as early menarche, late menopause, nulliparity, use of oral contraceptives, as well as hormone replacement therapy in postmenopause.

Risk stratification and the promotion of an ideal state of cardiovascular (CV) health are fundamental in preventing CVD in survivors. Therapeutic management and follow-up of patients with BC require a multidisciplinary team to reduce complications and mortality of CV origin.

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Review Article

One Size Does Not Fit All: The Need to Rethink the Metabolic Syndrome in Women

Maria Cristina Costa de Almeida et al. Marildes Luiza Castro Larissa Espíndola Neto Luciana Nicolau Aranha … Thaís Salim Gláucia Maria Moraes de Oliveira

Abstract

Metabolic syndrome (MetS) is increasing at epidemic proportions worldwide. MetS and its components are frequent among Brazilian women (41.8%). Women are affected by changes in adipose tissue distribution, lipid profile, insulin resistance (IR), and vascular remodeling during their lives. These changes result from the lack of estrogen after menopause. There have been various attempts to propose a uniform origin for the clustering of the MetS components, including genetics, IR, obesity, lifestyle, sleep disturbances, inflammation, fetal and neonatal programming, and disturbed circadian rhythm of the body functions. The proinflammatory and prothrombotic state in MetS is well-defined. Socioeconomic and lifestyle-related factors are also essential triggers of MetS, which is associated with a higher risk for coronary artery diseases (CAD) and stroke in women. Population measures in health and community medicine, such as continuing education on the importance of lifestyle change to reduce cardiovascular risks from early childhood, are fundamental strategies. Statins reduce high-sensitivity C-reactive protein blood levels and treat high cholesterol. According to the patient, hypoglycemic agents, such as dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1(GLP-1a), and sodium-glucose transport protein 2 (SGLT2) inhibitors, in addition to metformin, have their indication due to their beneficial cardiometabolic and vascular effects. Angiotensin-converting enzyme inhibitor (ACEI) and angiotensin-receptor blocker (ARB) should be the first choice to treat hypertension in postmenopausal womem. The recognition of the different gender- and age-specific risk factors, allowing for specific and targeted interventions, is fundamental, especially for women.

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Editorial

Beyond Sex-Based Differences: Exploring the Complexities of Aortic Stenosis in Women

Pâmela Cavalcante et al. Flavio Tarasoutchi

Sex is an important biological variable in the pathophysiology of cardiovascular disease.^, In fact, it could determine great differences in manifestation, treatment, and outcomes of several heart disorders. At the level of the aortic valve, there are sex-specific factors related to the pathogenesis of aortic stenosis (AS) that influence hemodynamics changes resulting from pressure overload response, and they should be considered in the management of patients. Despite the fact that sex-based differences in AS exist, they are often not fully recognized and understood, leading to unequal treatment outcomes between males and females.^,

This issue of the International Journal of Cardiovascular Sciences presents a comprehensive review of the growing evidence on sex disparities, from the pathogenesis to the treatment of severe degenerative AS, focusing on women.

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Original Article

Analysis of the Influence of Abdominal Obesity on Systemic Arterial Hypertension and on the Lipid Profile on Cardiometabolic Risk Stratification in Adult Women

Iury Matheus Lima Cavalcanti et al. Cristian Rodrigues do Nascimento Pedro Pereira Tenório Tiago Ferreira da Silva Araújo

Abstract

Background:

Obesity is a public health problem and has been associated with the development of metabolic disorders that have a strong relationship with the onset of cardiovascular diseases (CVD).

Objective:

The objective was to analyze the influence of abdominal obesity (AO) on systemic arterial hypertension (SAH) and on the lipid profile in cardiovascular risk stratification in adult women.

Methods:

Altogether, 91 women participated in the research. Lifestyle information was collected, in addition to the analysis of clinical measures of cardiovascular risk and biochemical parameters. Unpaired Student’s t-test, logistic regression, and Pearson’s correlation were performed for data analysis, with a value of p <0.05 considered significant.

Results:

The prevalence of AO was 62.6%. Logistic regression showed that AO increased the chance of developing SAH by 2.9-fold. The same behavior was observed in the TG/HDL-c lipid ratio (3.93 ± 0.3 vs. 2.16 ± 0.2), representing an 82% increase in obese women. The present study also demonstrated that the best anthropometric parameter to analyze cardiovascular risk in the studied population was the waist/height ratio (AUC = 0.707).

Conclusions:

It can therefore be concluded that AO plays a significant role in the development of SAH and changes in lipid values that predict increased cardiovascular risk, configuring a strong influence factor for CVD.

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Original Article

Effects of Physical Exercise on Lipid and Inflammatory Profile of Women Using Combined Oral Contraceptive: A Cross-Over Study

Vinícius Afonso Gomes et al. Marvyn de Santana do Sacramento Lucas Mendes Santa Cecilia Daniela Santos de Jesus … Juliane Santos Barbosa Fernanda Oliveira Baptista de Almeida Elaine Carvalho de Oliveira Jefferson Petto

Abstract

Background:

The use of combined oral contraceptives (COC) is a risk factor for atherosclerotic disease, and physical exercise can minimize this condition.

Objective:

To verify if high intensity interval training (HIIT) promotes changes in the lipid and inflammatory profile of women using COC.

Methods:

Sequential crossover study with women aged 20-30 years, classified as irregularly active by the international physical activity questionnaire (IPAQ), when using COC. A physical-clinical assessment was performed with anthropometric measurements, VO_2max, and analysis of lipid and inflammatory profile. Participants were divided into 2 groups: the initial intervention group (GII), which began practicing HIIT for 2 months, and the posterior intervention group (GIP), which remained inactive for the same period. The GII and GIP would then alternate their conditions. The collected data was divided into: Initial moment (IM), post-exercise moment (PEM) and post-inactivity (PIM). The statistical analyses were performed using the Statistical Package for the Social Sciences, adopting a significance level of p <0.05 .

Results:

Twelve women were evaluated. After crossing the GII and GIP data, there was a difference in the C-reactive protein values between the IM of 4 (1.6-6.3 mg/dL) vs. PEM 2 (1.5-5 mg/dL); as well as between the PEM vs. the PIM= 4 (1.5-5.8 mg/dL), with a p -value = 0.04 in the comparisons. There was no change between the “moments” of the lipid profile, although it was possible to notice a reduction in resting HR and an increase in indirect VO_2max.

Conclusion:

The HIIT program was able to reduce the inflammatory profile, but it did not alter the lipid profile of irregularly active women using COC.

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Editorial

Science Gender Gap: Are We in theRight Path?

Gláucia Maria Moraes de Oliveira et al. Marge Tenorio Alessandra de Sá Earp Siqueira

Women are entering the medical and scientific community in growing numbers, reaching and even surpassing their male counterparts in medical schools. However, a settled imbalance between men and women is still a reality in the international cardiology community despite these recent advances. The female presence in Brazilian medical schools was barely noticed until the 1960s; in the following years, there was a gradual increase in the number of women in the medical field, mainly in the first decade of the 21st century (59 % in 2020). In a 2020 demographic analysis of the Brazilian Federal Council of Medicine , men still predominated, accounting for 53.4% of all doctors in the country. Nevertheless, in the age-range below 30-years-old, women are the majority, accounting for 58.5%; the percentage of female doctors is inversely proportional to the increase in the age group, with only 21% of women in the age group above 70 years old.

In the USA, women represent less than 15% of the cardiology workforce and less than 5% of interventional cardiologists, while in Europe, women account for only one-third of cardiologists, and 18% of women are interventionists. Currently, Brazil has nearly 500 thousand doctors, 17,802 thousand cardiologists, of which 31.1% are females, and mostly concentrated in the southeast region. In 2018, only 215 (8.6%) of a total of 2,062 cardiovascular surgeons and 7.5% of 970 interventional cardiologists were women. The Brazilian Society of Cardiology had two female presidents; and the Cardiovascular Surgery Society, the Interventional Cardiology, and the Federation of Portuguese Language Cardiology Societies had one female president. Also, in the last five years, only one fifth of the speakers in the annual congress of the Brazilian Cardiology Society were women.

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Editorial

Challenges in Telemedicine: Even When the Road is Hard, Never Give up

Erito Marques de Souza Filho et al. Alexandra Monteiro

“Even when the road is hard, never give up” – Tupac Shakur and The Outlawz

The above quote is from the hit song “Baby Don’t Cry” immortalized by Tupac and The Outlawz. The song is about a young woman who faces challenges and receives encouragement to persevere and not give up. In a similar way, telemedicine faces several challenges on an arduous path. In this way, imbued with a tenacious spirit, its users have had remarkable experiences. In the current issue of the International Journal of Cardiovascular Sciences, Esmerio and colleagues presented a successful application of a telecardiology service. They emphasized that the work contributed to reducing the distance between patients and specialized professionals, and they highlighted a high level of satisfaction for both patients and health Professionals. Experiences like this represent the relevant role of telemedicine in providing quality health services and generating value. However, these tools still face important challenges that need to be overcome.

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Review Article

Depression and Cardiovascular Disease in Women

Maria Alayde Mendonça Rivera et al. Ivan Romero Rivera Walkiria Avila Celi Marques-Santos … Francisco Assis Costa Carlos Romério Ferro Jose Maria Gonçalves Fernandes

Abstract

The prevalence of depression varies from 1 to 17% in different geographic regions, and its incidence is 70% higher in women than men. Today, depression affects more than 300 million people worldwide, affecting twice as many women from adolescence to adulthood. In addition to this earlier onset, depression in women tends to be more severe. Cardiovascular disease and depression are chronic diseases that have a major impact on cardiovascular and all-cause morbidity and mortality, with evidence of a two-way relationship between them, in which depression is a predictor of cardiovascular disease and vice versa. In females, the degree of illness and prognosis are more severe when both diseases are present, than when diagnosed alone. In patients with acute or chronic cardiovascular disease, especially women, a systematic screening for depression should be considered as a preventive strategy of cardiovascular events, aiming to reduce the risk of future events. There are still no clinical studies designed to assess the impact of antidepressant treatment on cardiovascular outcomes in women.

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Editorial

Women and Cardiac Disease: A Special Issue

Roxana Mehran et al. Birgit Vogel

Cardiovascular disease is the leading cause of death in women worldwide. Despite improvements in awareness on heart disease in women through various campaigns and initiatives, cardiovascular risk in women still tends to be underestimated by health care professionals and women themselves. With respect to the latter, a study from the United States has even shown a decline in awareness regarding the fact that heart disease is the leading cause of death among women over recent years. Especially young women are affected by low awareness about cardiovascular risk as confirmed by the data from the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, which also found that women are less likely than men to have a discussion about their cardiovascular risk and potential risk modification with their health care provider. Health care providers’ preparedness to assess women’s cardiovascular risk appears to be suboptimal, and according to survey data the majority of primary care physicians and cardiologists do not comprehensively implement cardiovascular disease prevention guidelines in women. Accurate and timely diagnosis of various cardiovascular diseases, especially ischemic heart disease, are less frequent in women compared with men. In addition, women with established cardiovascular disease have repeatedly been documented to be less likely to receive guideline-recommended therapies.^, Sex-related differences in disease presentation and comorbidities may contribute to these disparities, and uncertainties persist with respect to diagnosis and treatment of certain disease states that disproportionally affect women (e.g. ischemia with non-obstructive coronary arteries [INOCA], myocardial infarction in the absence of obstructive coronary artery disease [MINOCA], spontaneous coronary artery dissection [SCAD], and takotsubo syndrome).

One of the major issues is the lack of robust study data on cardiovascular disease in women. Women remain underrepresented in the majority of cardiovascular clinical trials, and sex-specific study data reporting is often absent, which results in uncertainty about the safety and efficacy of many cardiovascular therapies. In addition, it leads to knowledge gaps in the sex-specific pathophysiological mechanisms and the natural history of cardiovascular disease in women.

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Original Article

Vegetarian Diets and Cardiovascular Risk in Women

Bianca Oliveira et al. Luciana Nicolau Aranha Priscila dos Santos Gomes Olivares Tamira Guilherme Rocha Negrão … Glorimar Rosa Gláucia Maria Moraes de Oliveira

Abstract

Introduction:

Vegetarian diets have favorable effects on cardiovascular risk, provided that they do not contain ultra-processed foods (UPF).

Objective:

To compare the metabolic profile, cardiovascular risk, body composition, and food consumption in vegan (VEG), lacto-ovo vegetarian (LOV), and omnivorous (OMNI) women. To verify the association between UPF consumption and cardiovascular risk.

Methods:

Cross-sectional study with 119 VEG (n = 43), LOV (n = 38), and OMNI (n = 38) women. Anthropometric and biochemical parameters and the Framingham risk score were assessed. Food consumption was assessed by means of a 3-day food register, and intake of macronutrients, micronutrients, and UPF was estimated. The correlation between UPF consumption and cardiovascular risk was assessed using Spearman’s coefficient, with a significance level of 5%.

Results:

The groups showed low cardiovascular risk, without significant difference between them. The VEG and LOV groups had lower body mass index, neck circumference, body shape index, and systolic blood pressure (p < 0.05) than the OMNI group; greater consumption of carbohydrates, sugars, dietary fibers, micronutrients, beta-carotene, and carotenoids; and lower consumption of total fat, saturated fatty acids, and cholesterol (p < 0.05). Consumption of UPF was lower in the LOV group (5.7 [0.0– 19.8]) than in the OMNI group (14.9 [5.1 – 22.3]; p < 0.05). UPF consumption was associated with SBP (ρ = 0.439; p = 0.007) and blood sugar (ρ = 0.422; p = 0.010) in the VEG group, and in the LOV group it was inversely associated with LDL-c (ρ = −0.456; p = 0.010).

Conclusion:

Vegetarian women showed better body composition and dietary quality than OMNI women. It is important to take consumption of UPF in vegetarians into consideration, in order to improve cardiovascular risk in women.

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Editorial

Are Women the Fragile Sex? Or are They the Singular Sex?

Celi Marques-Santos et al. Gláucia Maria Moraes de Oliveira

Women need specific intervention and information about their particularities, especially regarding CV risk factors, as well as the biological, pathophysiological, and social differences between the sexes. The majority of large clinical trials that address current cardiovascular diseases (CVD) were not conducted with enough women to generate robust evidence. CVD in women remains poorly studied, poorly recognized, underdiagnosed, and undertreated, generating worse outcomes. It is necessary to change this reality so that women are approached according to their singularities in order to reduce the burden of CVD by 2030.

Among the CV risk factors in Brazilian women, arterial hypertension, dietary risks, obesity, increased serum cholesterol, and fasting glucose stand out. Sex-related CV risk factors, which affect CVD throughout life, play a crucial role in women. Menopause, especially in women 40 years, promotes changes in body composition, with an increase in fat mass and a greater probability of metabolic syndrome.^, Hypertensive diseases of pregnancy, such as pre-eclampsia, gestational diabetes, and premature birth, increase CVD in adulthood. The use of contraceptive hormones associated with arterial hypertension increases the risk of myocardial infarction (MI) by 12 times. Polycystic ovary syndrome and autoimmune diseases contribute to increased cardiovascular risk.

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Original Article

Early Use of Handgrip Exercise Associated with Dobutamine Stress Echocardiography in Women

Isabela de Andrade Lindner et al. Patricia Sens de Oliveira Caroline de Oliveira Fischer Bacca Josie Budag Matsuda … Franciani Rodrigues da Rocha Jeancarlo Visentainer Luiz Eduardo Bacca

Abstract

Background

Coronary artery disease (CAD) is an important cause of morbidity and mortality in women and requires early diagnosis for defining the appropriate treatment.

Objective

To identify the positive predictive value (PPV) and safety of the early use of handgrip exercise in pharmacological stress echocardiography using dobutamine (early-ECHO) in women.

Methods

Positive ischemic early-ECHO records from 111 women were evaluated from January 2012 to March 2018. Subsequently, the hospital medical records were verified to locate patients who underwent conventional coronary angiography (CCA), and we analyzed the medical conduct adopted for these patients. Statistical analyses were performed using SPSS employing one-way analysis of variance (ANOVA), Fisher’s exact test, or Pearson’s chi-square test. The level of statistical significance was set at p < 0.05 for all analyses.

Results

Four patients (4.4%) presented serious complications during the examination. Out of 90 patients who underwent CCA, 71 (78.9%) had CAD. Among these 71 patients, 58 (81.7%) had severe lesions and 13 (18.3%) presented moderate CAD. Moreover, CCA did not demonstrate relevant coronary lesions in 19 of the 90 patients (21.1%). Among patients with severe CAD, 16 (27.6%) underwent myocardial revascularization surgery; 34 (58.6%) underwent percutaneous coronary angioplasty; and 08 (13.7%) had their clinical treatments intensified. The PPV for early-ECHO was 78.9%.

Conclusions

Early-ECHO showed a high PPV for diagnosing myocardial ischemia in women. It presented a low complication rate and provided rapid disease identification, allowing the early treatment of injuries and potentially preventing CAD complications.

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Original Article

Exercise Testing, Family History, and Subclinical Atherosclerosis Markers for Cardiovascular Risk Reclassification in Middle-Aged Women

Ricardo Quental Coutinho et al. Ulisses Ramos Montarroyos Isly Maria Lucena de Barros Maria José Bezerra Guimarães … Ana Paula Dornelas Leão Laura Olinda Bregieiro Fernandes Costa Ana Kelley de Lima Medeiros Maria de Fátima Monteiro Moacir de Novaes Lima Ferreira William Azem Chalela Rodrigo Pinto Pedrosa

Abstract

Background

Cardiovascular diseases are the main cause of death in women and the accuracy of currently available risk scores is questionable.

Objective

To reclassify the risk estimated by the Framingham Risk Score (FRS) in asymptomatic middle-aged women by incorporating family history, exercise testing variables, and subclinical atherosclerosis markers.

Methods

This cross-sectional study included 509 women (age range, 46-65 years) without cardiovascular symptoms. Those at low or intermediate risk by the FRS were reclassified to a higher level considering premature family history of acute myocardial infarction and/or sudden death; four variables from exercise testing; and two variables related to subclinical atherosclerosis markers. The homogeneity of these variables according to the FRS was verified by Pearson chi-square test (p<0.05).

Results

According to the FRS, 80.2%, 6.2%, and 13.6% of the women were classified as low (10%) risks, respectively. The intermediate-risk stratum showed the highest increase (from 6.2% to 33.3%) with addition of family history; followed by addition of chronotropic index <80% (to 24.2%); functional capacity 0 (20.6%); decreased one-minute heart rate recovery ≤12 bpm (15.2%); carotid intima-media thickness >1 mm and/or carotid plaque (13.8%) and ST-segment depression (9.0%). The high-risk stratum increased to 14.4% with the addition of reduced heart rate recovery and to 17.1% with the coronary calcium score.

Conclusion

Incorporation of premature family history of cardiovascular events, exercise testing abnormal parameters, and subclinical atherosclerosis markers into the FRS led to risk reclassification in 3.0-29.7% of asymptomatic middle-aged women, mainly by an increase from low to intermediate risk.

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Original Article

Clinical Characteristics and Therapeutic Adherence of Women in a Referral Outpatient Clinic for Severe Hypertension

Pedro Henrique Barletta et al. Eduardo Faria Soares de Magalhães Vitor Fernandes de Almeida Júlia Lasserre Moreira … Murilo Jorge da Silva Cristiano Macedo Roque Aras

Abstract

Background

Cardiovascular disease is the main cause of death worldwide. There is a lack of studies addressing this issue in women and its risk factors, such as hypertension.

Objective

To evaluate the clinical and therapeutic profile of women with hypertension and to determine which factors are related to treatment adherence and blood pressure control.

Methods

Cross-sectional study of 181 hypertensive women treated at an outpatient referral clinic. Data were obtained from medical records, face-to-face interviews, and physical examination, using a standardized form. Statistical analysis was performed with prevalence ratio, chi-square and Student’s t test. Significance was accepted at p<0.05.

Results

Most patients were mixed-race or black (91.7%) and the mean age was 66.09 years. Only 44.2% of patients had controlled blood pressure. The prevalence of stroke was 14.9%, whereas the prevalence of coronary artery disease was 19.3%. The mean number of oral antihypertensive drugs prescribed to each individual was 3.41. A history of stroke was more often found in patients with uncontrolled blood pressure (p=0.013) and in those using three or more antihypertensives (p=0.023). Eighty patients (44.2%) had high treatment adherence. Depression was more frequently reported by patients with poorer adherence to treatment (p=0.026).

Conclusion

Women with hypertension presented a high prevalence of cardiovascular risk factors and cardiovascular events, including a significantly higher prevalence of stroke in those with uncontrolled hypertension. Self-reported depression may help identify patients at risk of nonadherence to treatment.

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Original Article

Women Undergoing Mitral Valve Replacement: A Retrospective Analysis

Júlia Lasserre Moreira et al. Pedro Henrique Andrade Araújo Salvatore Barletta José Augusto Baucia

Abstract

Background

Although cardiovascular disease is the leading cause of death in women, few data exist on risk factors and treatment of these diseases in women. This leads to a delay in the institution of appropriate therapies and worse outcomes in this population.

Objective

We aimed to identify predictors of morbidity and mortality in women undergoing isolated mitral valve replacement.

Methods

This was a retrospective cohort study with 104 women who underwent isolated mitral valve replacement at a referral hospital for treatment of cardiovascular diseases, performed from January 2011 to December 2016. Data were obtained from medical records. Statistical analysis was performed to calculate odds ratio, unpaired Student’s t-test, and binary logistic regression. P values <0.05 were considered statistically significant.

Results

Mean age of patients was 43.73 (±13.85) years. Most patients had a diagnosis of rheumatic disease prior to surgery (76%; N=79). Mortality rate was 4.9% (N = 5). There was a statistically higher risk of death among patients with reduced ejection fraction (EF) (<50%) (OR = 14.833, 95% CI 2.183 – 100.778, P=0.001) and older age (P = 0.009). There was an inverse association between a previous diagnosis of rheumatic disease and death (OR = 0.064, 95% CI 0.007 – 0.606, P=0.002). Logistic regression showed reduced EF at preoperative evaluation as a predictor of death and a diagnosis of rheumatic disease as a protective factor.

Conclusion

Older age and reduced EF were associated with postoperative mortality. Reduced EF was a predictor of death, and rheumatic disease was associated with better surgical outcomes.

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IJCS

Original Article

Cardiovascular Risk Profile of a Young Adult Women Population Assisted in Primary Care

Tomás de Souza Mello et al. Mariana Stutz Klen Rafael Bellotti Azevedo Fernanda Costa Barradas … Luiza Araújo Nogueira Natália Rossilho Moyses Ushijima Rafael Barbosa da Silva Bica Elizabeth Silaid Muxfeldt

Abstract

Background

Although cardiovascular disease is a major cause of death among women, cardiovascular risk assessment in young women is frequently postponed due to a number of factors.

Objectives

To assess cardiovascular risk of young adult women living in one of Rio de Janeiro’s Family Health Strategy geographical units in the city’s central area.

Materials and Methods

populational, cross-sectional study with adults between 20 and 50 years old. Sociodemographic characteristics such as educational level and employment status were recorded. Anthropometric measurements, traditional cardiovascular risk factors, gynecological and gestational history, and selected laboratory exams were assessed. The bivariate analysis compared the baseline characteristics of the population between genders and the prevalence of cardiovascular risk factors in women according to educational level and occupation status, using non-paired Student’s t-test for normal continuous variables, Mann-Whitney test for asymmetrical continuous variables, and chi-square test for categorical variables. A significance level of 5% (p < 0.05) was adopted.

Results

A total of 710 individuals were enrolled. In women, who comprised 59.7% of our sample, central obesity and a sedentary lifestyle were more prevalent, whereas smoking and hypertension were less observed. However, women with lower educational status had a higher prevalence of smoking and hypertension. In hypertensive women, factors such as early menopause, higher prevalence of hypertensive disorders of pregnancy and higher number of pregnancies were noticed.

Conclusion

An adverse cardiovascular risk profile in our population of young women was particularly influenced by central obesity, sedentary lifestyle, hypertensive disorders of pregnancy and lower educational status.

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IJCS

Editorial

Chagas Disease – Past and Future

Aurea Lúcia Alves de Azevedo Grippa de Souza et al. Claudio Tinoco Mesquita

After 111 years of its discovery, Chagas disease remains a major public health challenge in Brazil and in other Latin American countries, reason why it continues to be a relevant topic in discussion panels worldwide. The disease was first described in 1909 by Carlos Justiniano Ribeiro das Chagas after his observations during an expedition to eradicate malaria in the rural areas of the state of Minas Gerais, in the city of Lassance. Carlos Chagas’ magnificent life journey makes him a unique figure in the history of medicine, as he alone described all the stages of a new infectious disease: pathological findings, means of transmission (Triatoma infestans), etiology, clinical manifestations, and epidemiology. For this reason, he was one of the few Brazilians to be nominated for a Nobel Prize, which, unfortunately, he did not win. This issue of the International Journal of Cardiovascular Sciences (IJCS) focuses on Chagas disease and its repercussions on the cardiovascular system.

Carlos Chagas graduated in 1904 in Rio de Janeiro and began his professional life in the city of Niterói as a physician of the Public Hygiene Committee at Santa Isabel Maritime Hospital, after declining Oswaldo Cruz’s invitation to work at Manguinhos. The Maritime Hospital, a beautiful architectural complex () built during the 19th century from an old farm, was considered a reference for the treatment of infectious diseases until the end of the 4th decade of the 20th century. Sailors, immigrants and local residents with bubonic plague, yellow fever or tuberculosis were treated at the institution. In this hospital, the Italian physician Camillo Terni, from the Serum Therapy Institute of Messina, conducted pioneering studies on a plague vaccine (). After working for 1 year at the Maritime Hospital, Chagas left to Manguinhos, where he began his journey to eradicate yellow fever and malaria, which led him to discover the disease caused by the insect known as barbeiro (kissing bug).

[…]

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