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Objective: To determine whether contemporary sex-specific cardiovascular disease (CVD) risk prediction equations underestimate CVD risk in people with severe mental illness from the cohort in which the equations were derived. Methods: We identified people with severe mental illness using information on prior specialist mental health treatment. This group were identified from the PREDICT study, a prospective cohort study of 495,388 primary care patients aged 30 to 74 years without prior CVD that was recently used to derive new CVD risk prediction equations. CVD risk was calculated in participants with and without severe mental illness using the new equations and the predicted CVD risk was compared with observed risk in the two participant groups using survival methods. Results: 28,734 people with a history of recent contact with specialist mental health services, including those without a diagnosis of a psychotic disorder, were identified in the PREDICT cohort. They had a higher observed rate of CVD events compared to those without such a history. The PREDICT equations underestimated the risk for this group, with a mean observed:predicted risk ratio of 1.29 in men and 1.64 in women. In contrast the PREDICT algorithm performed well for those without mental illness. Conclusions: Clinicians using CVD risk assessment tools that do not include severe mental illness as a predictor could by underestimating CVD risk by about one-third in men and two-thirds in women in this patient group. All CVD risk prediction equations should be updated to include mental illness indicators. [ABSTRACT FROM AUTHOR]

Background: Outcomes among atrial fibrillation (AF) patients may differ according to race/ethnicity and sex due to differences in biology, the prevalence of cardiovascular risk factors, and the use and effectiveness of AF treatments. We aimed to characterize patterns of cardiovascular risk across subgroups of AF patients by sex and race/ethnicity, since doing so may provide opportunities to identify interventions. We also evaluated whether these patterns changed over time. Methods: We utilized administrative claims data from the Optum Clinformatics® Datamart database from 2009 to 2015. Patients with AF with ≥6 months of enrollment prior to the first non-valvular AF diagnosis were included in the analysis. Final analysis utilized Cox proportional hazard models to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for cardiovascular outcomes stratified by sex and race/ethnicity. An additional analysis stratified outcomes by calendar year of AF diagnosis to evaluate changes in outcomes over time. Results: In a cohort of 380,636 AF patients, women had a higher risk of ischemic stroke [HR (95% CI): 1.25 (1.19, 1.31)] and lower risk of heart failure and myocardial infarction [HR (95% CI): 0.91 (0.88, 0.94) and 0.81 (0.77, 0.86), respectively)] compared to men. Black patients had elevated risk across all endpoints compared to whites, while Hispanics and Asian Americans showed no significant differences in any outcome compared to white patients. These sex and race/ethnic differences did not change over time. Conclusions: We found sex and race/ethnic differences in risk of cardiovascular outcomes among AF patients, without evidence of improvement over time. [ABSTRACT FROM AUTHOR]

Background: Preeclampsia has been suggested to increase the risk of end-stage kidney disease (ESKD); however, most studies were unable to adjust for potential confounders including pre-existing comorbidities such as renal disease and cardiovascular disease (CVD). We aimed to examine the association between preeclampsia and the risk of ESKD in healthy women, while taking into account pre-existing comorbidity and potential confounders.Methods and Findings: Using data from the Swedish Medical Birth Register (MBR), women who had singleton live births in Sweden between 1982 and 2012, including those who had preeclampsia, were identified. Women with a diagnosis of chronic kidney disease (CKD), CVD, hypertension, or diabetes prior to the first pregnancy were excluded. The outcome was a diagnosis of ESKD, identified from the Swedish Renal Registry (SRR) from January 1, 1991, onwards along with the specified cause of renal disease. We conducted Cox proportional hazards regression analysis to examine the association between preeclampsia and ESKD adjusting for several potential confounders: maternal age, body mass index (BMI), education, native country, and smoking. This analysis accounts for differential follow-up among women because women had different lengths of follow-up time. We performed subgroup analyses according to preterm preeclampsia, small for gestational age (SGA), and women who had 2 pregnancies with preeclampsia in both. The cohort consisted of 1,366,441 healthy women who had 2,665,320 singleton live births in Sweden between 1982 and 2012. At the first pregnancy, women's mean (SD) age and BMI were 27.8 (5.13) and 23.4 (4.03), respectively, 15.2% were smokers, and 80.7% were native Swedish. The overall median (interquartile range [IQR]) follow-up was 7.4 years (3.2-17.4) and 16.4 years (10.3-22.0) among women with ESKD diagnosis. During the study period, 67,273 (4.9%) women having 74,648 (2.8% of all pregnancies) singleton live births had preeclampsia, and 410 women developed ESKD with an incidence rate of 1.85 per 100,000 person-years. There was an association between preeclampsia and ESKD in the unadjusted analysis (hazard ratio [HR] = 4.99, 95% confidence interval [CI] 3.93-6.33; p < 0.001), which remained in the extensively adjusted (HR = 4.96, 95% CI 3.89-6.32, p < 0.001) models. Women who had preterm preeclampsia (adjusted HR = 9.19; 95% CI 5.16-15.61, p < 0.001) and women who had preeclampsia in 2 pregnancies (adjusted HR = 7.13, 95% CI 3.12-16.31, p < 0.001) had the highest risk of ESKD compared with women with no preeclampsia. Considering this was an observational cohort study, and although we accounted for several potential confounders, residual confounding cannot be ruled out.Conclusions: The present findings suggest that women with preeclampsia and no major comorbidities before their first pregnancy are at a 5-fold increased risk of ESKD compared with parous women with no preeclampsia; however, the absolute risk of ESKD among women with preeclampsia remains small. Preeclampsia should be considered as an important risk factor for subsequent ESKD. Whether screening and/or preventive strategies will reduce the risk of ESKD in women with adverse pregnancy outcomes is worthy of further investigation. [ABSTRACT FROM AUTHOR]

Background: The exposure to extreme ambient temperatures has been reported to increase mortality, although less is known about its impact on morbidity. The analysis of temporal changes in temperature-health associations has also focused on mortality with no studies on hospitalizations worldwide. Studies on temporal variations can provide insights on changes in susceptibility or on effectiveness of public health interventions. We aimed to analyse the effects of temperature on cause-specific hospital admissions in Spain and assess temporal changes using two periods, the second one characterized by the introduction of a heat health prevention plan. Methods: Daily counts of non-scheduled hospital admissions for cardiovascular, cerebrovascular and respiratory diseases and daily maximum temperature were obtained for each Spanish province for the period 1997–2013. The relationship between temperature and hospitalizations was estimated using distributed lag non-linear models. We compared the risk of hospitalization due to temperatures (cold, heat and extreme heat) in two periods (1997–2002 and 2004–2013). Results: Cold temperatures were associated with increased risk of cardiovascular, cerebrovascular and respiratory hospital admissions. Hot temperatures were only associated with higher hospital admissions for respiratory causes while hospitalizations for cardiovascular and cerebrovascular diseases did not increase with heat. There was a small reduction in heat-related respiratory admissions in period 2. Whereas cold-related hospitalizations for cardiovascular and cerebrovascular diseases increased in period 2, a significant reduction for respiratory hospitalizations was reported. Conclusions: Our results suggested that heat had an adverse impact on hospital admissions for respiratory diseases, while cold increased the risk of the three studied cause-specific hospitalizations. Public health interventions should also focus on morbidity effects of temperature. [ABSTRACT FROM AUTHOR]

Background: There is a high prevalence of cardiovascular disease across diverse groups in the U.S. population, and increasing research has identified stigma as a potential barrier to cardiovascular disease prevention and treatment. This systematic review examines evidence linking discrimination and cardiovascular health among socially stigmatized groups. Study Design: Six databases were systematically reviewed from inception through February 2018 for studies with adult subjects, focusing on cardiovascular health indicators among social groups stigmatized because of their gender, race/ethnicity, age, body weight/obesity, or sexual orientation. The Newcastle-Ottawa Scale was used to evaluate the methodological quality and risk of bias for nonrandomized studies, and the Cochrane Collaboration 7-item domain for randomized controlled and experimental trials. Results: The search identified 84 eligible studies published between 1984 and 2017. Studies retrieved were categorized according to demonstrated links between stigma and cardiovascular disease risk factors including blood pressure (n = 45), heart rate variability (n = 6), blood/saliva cardiovascular biomarkers (n = 18), as well as other indicators of cardiovascular health (n = 15). Based on the findings from included studies, 86% concluded that there was a significant relationship among stigma or discrimination and cardiovascular health indicators among socially stigmatized groups. However, there were varying degrees of evidence supporting these relationships, depending on the type of discrimination and cardiovascular health indicator. The current evidence implies an association between perceived discrimination and cardiovascular health. However, a majority of these studies are cross-sectional (73%) and focus on racial discrimination (79%), while using a wide variety of measurements to assess social discrimination and cardiovascular health. Conclusions: Future research should include longitudinal and randomized controlled trial designs, with larger and more diverse samples of individuals with stigmatized identities, using consistent measurement approaches to assess social discrimination and its relationship with cardiovascular health. [ABSTRACT FROM AUTHOR]

Background: Currently, cardiovascular disease (CVD) is widely acknowledged to be the first leading cause of fatality in the world with 31% of all deaths worldwide and is predicted to remain as such in 2030. Furthermore, CVD is also a major cause of morbidity in adults worldwide. Among these diseases, the coronary artery disease (CAD) is the most common cause, accounting for over 40% of CVD deaths. Despite a decline in mortality rates, the consequences of more effective preventive and management programs, the burden of CAD remains significant. Indeed, the rise in the prevalence of modifiable risk factors due to changes in lifestyle and health behaviors has further increased the burden of this epidemic. Our objective was to evaluate the hospital burden of CAD via MI trends and Percutaneous Coronary Intervention (PCI) in the French Prospective Payment System (PPS). Methods: MI/PCI were identified in the national PPS database from 2009 to 2014 for patients aged 20 to 99, living in metropolitan France. We examined hospitalisation, readmission and mortality trends using standardised rates. Results: Over the six-year period, we identified 678,021 patients, representing 900,121 stays of which, 215,224 had a MI and a PCI. Admission trends increased by nearly 25%. Acute MI cases increased every year, with an alarming increase in women, and more specifically in young women. Men were 3 times more hospitalised than women, who were older. A North-South divide was noted. Twenty seven percent of patients experienced readmission within 1 month. Trajectories of care were significantly different by sex and age. Overall in-hospital death was 3.3%, decreasing by 15% during the period. The highest adjusted mortality rates were observed for inpatients aged <40 or >80. Conclusion: We outlined the public health burden of this condition and the importance of improving the trajectories of care as an aid for better care. [ABSTRACT FROM AUTHOR]

Homozygosity for the p.C282Y substitution in the HFE protein encoded by the hemochromatosis gene on chromosome 6p (HFE) is a common genetic trait that increases susceptibility to iron overload. McLaren et al. used bivariate mixture modeling to analyze the joint population distribution of transferrin saturation (TS) and serum ferritin concentration (SF) measured for participants in the Hemochromatosis and Iron Overload Screening (HEIRS) Study. They identified four components (C1, C2, C3, and C4) with successively increasing means for TS and SF. They demonstrated that bivariate mixture modeling in TS and SF reflect the genetic locus of HFE and may isolate p.C282Y homozygotes from the general population. In the current study we used data from the another large cohort, the Australian HealthIron study of genetic and environmental modifiers of hereditary hemochromatosis, to validate the component analysis approach, to examine stability of component proportions over time and to determine if TS and SF values from an individual move between components at baseline and follow-up. Because sampling fractions from each p.C282Y / p.H63D genotype stratum are not equal, we used frequency weights based on the inverse of the probability of selection for invitation to participate. In the weighted female analytic cohorts, C4 captured most of C282Y homozygotes, and C2 was the largest component. We identified four components from the weighted male analytic cohort and C4 captured most of p.C282Y homozygotes. The bivariate mixture modeling approach suggested that the model is transferable from one white population to another, although estimated means within components may differ. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF), an important cause of thromboembolic events, is often silent and intermittent, thus presenting a diagnostic challenge. The aim of this study was to assess whether the plasma level of N-terminal pro-brain natriuretic peptide (NT-proBNP) is related to the presence of AF and thereby might be used to facilitate screening programs for AF in primary care. Methods: This was a cross sectional screening study. A population of 70–74-year-old individuals registered at a single primary care center in Stockholm were invited to AF screening. Intermittent ECG recording, 30 seconds twice a day using a hand-held device over 2 weeks, was offered to participants without previously known AF. Of the 324 participating persons, 34 patients had already known AF and 16 new cases of AF were detected by screening. Plasma NT-proBNP was measured in patients with previously known AF, newly detected AF, and 53 control participants without AF. Findings: The median NT-proBNP was 697 ng/L in patients with previously known AF, 335 ng/L in new cases of AF, and 146 ng/L in patients without AF. After adjustment for several clinical variables and morbidities, the differences of median NT-proBNP levels were statistically significant between cases of previously known AF and new cases of AF as well as between new cases of AF and those without AF. The area under receiver operating characteristic curve of detection of new AF was 0.68 (95% CI 0.56 to 0.79) yielding a cut-off point of 124 ng/L with 75% sensitivity, 45% specificity, and 86% negative predictive value. Conclusions: The NT-proBNP plasma levels among patients with known AF are higher than those with newly detected AF, and the latter have higher levels than those without AF. Therefore NT-proBNP might be a useful screening marker for the detection of AF and its persistence. [ABSTRACT FROM AUTHOR]

This study explores whether there is a short-term relationship between intragenerational social mobility and mortality while individuals are working and whether it is widespread across different causes of death. Net of accumulated advantages and disadvantages, social mobility may influence mortality through health selection or changes in well-being. Men and women working in 1996 up to age 65 are observed annually until 2012 in Swedish register data. Time-varying covariates and origin and destination status are controlled for in discrete time event-history analyses. Results show that when men were upwardly mobile, mortality was lower due to cancer, CVD, IHD, and suicide. Upward mobility was only associated with lower odds of suicide for women. When downwardly mobile, cancer mortality was higher for both men and women and smoking-related cancer mortality was higher for men. Social mobility was not linked to deaths related to accidents and poisoning or alcohol-related mortality. The results may support a relationship between social mobility and mortality characterized by health selection: Only in the case of a chronic illness (cancer) was downward mobility associated with higher mortality. The widespread relationship between upward mobility and lower mortality for men may also indicate positive health selection into attaining a higher class and that individuals with poor health may be less likely to search for better positions or receive promotions. [ABSTRACT FROM AUTHOR]

Background: Breast arterial calcification (BAC) may be a predictor of cardiovascular events and is highly prevalent in persons with end-stage kidney disease. However, few studies to date have examined the association between mild-to-moderate kidney function and proteinuria with BAC. Methods: We prospectively enrolled women with no prior cardiovascular disease aged 60 to 79 years undergoing mammography screening at Kaiser Permanente Northern California between 10/24/2012 and 2/13/2015. Urine albumin-to-creatinine ratio (uACR), along with specific laboratory, demographic, and medical data, were measured at the baseline visit. Baseline estimated glomerular filtration rate (eGFR), medication history, and other comorbidities were identified from self-report and/or electronic medical records. BAC presence and gradation (mass) was measured by digital quantification of full-field mammograms. Results: Among 3,507 participants, 24.5% were aged ≥70 years, 63.5% were white, 7.5% had eGFR <60 ml/min/1.73m2, with 85.7% having uACR ≥30 mg/g and 3.3% having uACR ≥300 mg/g. The prevalence of any measured BAC (>0 mg) was 27.9%. Neither uACR ≥30 mg/g nor uACR ≥300 were significantly associated with BAC in crude or multivariable analyses. Reduced eGFR was associated with BAC in univariate analyses (odds ratio 1.53, 95% CI: 1.18–2.00), but the association was no longer significant after adjustment for potential confounders. Results were similar in various sensitivity analyses that used different BAC thresholds or analytic approaches. Conclusions: Among women without cardiovascular disease undergoing mammography screening, reduced eGFR and albuminuria were not significantly associated with BAC. [ABSTRACT FROM AUTHOR]

Aim: To provide a comprehensive overview of cardiovascular disease (CVD) risk prediction models for women and models that include female-specific predictors. Methods: We performed a systematic review of CVD risk prediction models for women in the general population by updating a previous review. We searched Medline and Embase up to July 2017 and included studies in which; (a) a new model was developed, (b) an existing model was validated, or (c) a predictor was added to an existing model. Results: A total of 285 prediction models for women have been developed, of these 160 (56%) were female-specific models, in which a separate model was developed solely in women and 125 (44%) were sex-predictor models. Out of the 160 female-specific models, 2 (1.3%) included one or more female-specific predictors (mostly reproductive risk factors). A total of 591 validations of sex-predictor or female-specific models were identified in 206 papers. Of these, 333 (56%) validations concerned nine models (five versions of Framingham, SCORE, Pooled Cohort Equations and QRISK). The median and pooled C statistics were comparable for sex-predictor and female-specific models. In 260 articles the added value of new predictors to an existing model was described, however in only 3 of these female-specific predictors (reproductive risk factors) were added. Conclusions: There is an abundance of models for women in the general population. Female-specific and sex-predictor models have similar predictors and performance. Female-specific predictors are rarely included. Further research is needed to assess the added value of female-specific predictors to CVD models for women and provide physicians with a well-performing prediction model for women. [ABSTRACT FROM AUTHOR]

Objective: To examine the possibility of diagnosing the double burden of malnutrition using estimated deviation values in low- and lower-middle-income countries. Methods: A modified version of the Japanese Diagnostic Tool was used. Data on 194 countries were analyzed, including data from the United Nations International Children’s Fund, World Health Organization and World Bank. After conducting a Box–Cox transformation, deviation values were calculated. The degree to which the values deviated relative to a deviation cutoff value of 50 was assessed. Focusing on countries with low- and middle-income economic levels, we examined the utility of this tool to show characteristic nutritional problems in each country. Results: The deviation values had normal, distorted, bimodal, or trimodal distributions. In the lower-middle-income countries, almost all countries had values ranging from 40 to 60 for education and water environments (urban and rural), and the differences were minimal. However, different causes of noncommunicable disease-related deaths were considered, and the primary cause appeared to be related to lifestyle factors, particularly alcohol consumption and tobacco smoking. In comparison, the deviation values related to death among low-income countries also appeared to be related to differences in education and sanitation in urban and rural areas. Conclusion: The study results can help to determine the status of nutritional inequalities and plan country-specific strategies to reduce the double burden of malnutrition. [ABSTRACT FROM AUTHOR]

Background: Health literacy (HL), defined as the ability to access, understand, appraise and apply health information, offers a promising approach to reduce the development of cardiovascular diseases (CVD) and to improve the management of CVD in populations. Design: We used data from nationwide cross-sectional German Health Update (GEDA2014/2015-EHIS) survey. 13,577 adults ≥ 40 years completed a comprehensive standardized paper or online questionnaire including the short form of the European Health Literacy Survey Questionnaire (HLS-EU-Q16). Methods: We compared participants with and without CVD with regard to their HL. We also analyzed the association between HL level and health care outcomes among individuals with CVD, i.e. frequency of general practitioner or specialist consultations, hospitalization and treatment delay. Results: The percentage of “problematic” or “inadequate” HL, defined as “not sufficient” HL, was significantly higher in individuals with CVD compared to without CVD (men 41.8% vs. 33.6%, women 46.7% vs. 33.4%). Having CVD was independently associated with “not sufficient” HL after adjusting for age, education, income, health consciousness and social support (adjusted OR: men 1.36, women 1.64). Among participants with CVD, individuals with “inadequate” HL were more likely to have more than 6 general practitioner consultations (49.3% vs. 28.7%), hospitalization (46.6% vs. 36.0%) in the last 12 months and to experience delay in getting health care because of long waiting lists for an appointment (30.7% vs. 18.5%) compared to participants with “sufficient” HL. Conclusion: “Problematic” or “inadequate” HL is independently associated with CVD and health care use. This is a challenge and an opportunity for both CVD prevention and treatment. [ABSTRACT FROM AUTHOR]

Background: We previously reported in a cross-sectional analysis an adverse relationship between weight cycling and HDL-cholesterol but not angiographic obstructive coronary artery disease (CAD) among women undergoing coronary angiography for suspected ischemia in the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation (WISE). We now examine the relationship between weight cycling and prospective adverse cardiovascular outcome in this group. Methods: 795 women enrolled between 1996–2001 in the WISE undergoing coronary angiography for evaluation of suspected ischemia and followed for a median of 6.0 years (interquartile range = 3.4 years). Adverse outcome was defined as a composite of all-cause death, cardiovascular mortality, non-fatal myocardial infarction, non-fatal stroke, and hospitalization for heart failure. Weight cycling was defined as the intentional loss of at least 10 lbs. (4.5 kgs.) at least three times during the women’s lifetime. Results: Women (n = 224) who reported a history of weight cycling were younger; more often white and better educated compared those without this history. At baseline, women with a weight cycling history had lower HDL-C values, higher body mass index, larger waist circumferences and higher values for fasting blood sugar, but no difference in obstructive CAD prevalence or severity. There was an inverse relationship between weight cycling and adverse composite cardiovascular outcome, whereby fewer of women with a history of weight cycling experienced an adverse outcome as compared to non-cyclers (21% vs 29%, respectively, p = 0.03). Conclusions: Despite an adverse association with HDL-cholesterol in women undergoing coronary angiography for suspected ischemia, weight cycling was associated with a lower adverse outcome rate in women with suspected ischemia. [ABSTRACT FROM AUTHOR]

Previous studies on the association between number of children and carotid intima-media thickness (cIMT) were limited to Western populations. Pregnancy in women is associated with physiologic changes that may influence the risk of cardiovascular disease. Comparing the association between number of children and cIMT in men and women can provide insights on whether the association may be due to pregnancy. We investigated the association between number of children and cIMT among 718 female (mean age 37.5 years) and 417 male participants (mean age 41.3 years), randomly selected from the Health Effect of Arsenic Longitudinal Study (HEALS), a population-based cohort study in Bangladesh. Multivariate linear regression was used to assess the association and to control for education attainment, history of diabetes, age, smoking, betel use, BMI, systolic blood pressure, and diastolic blood pressure. The average number of children was 4.43 for women and 3.74 for men. There were no nulliparous women. We observed a positive association between number of children and cIMT in women. Mean cIMT increased by 4.5 μm (95% CI, 0.8–8.1) per increment of one birth (P = 0.02). Compared to women with two children, cIMT in women with 4 children and ≥5 children was 23.6μm (95%CI, 2.6–44.7; P = 0.03) and 25.1 μm (95%CI, 3.5–46.6; P = 0.02) greater, respectively. The association was not modified by BMI, SBP, betel use or age. Data in men showed no evidence of association (P = 0.4). The finding suggests a role of high parity in atherosclerosis in women of a low-income, high parity population. [ABSTRACT FROM AUTHOR]

Background: The influence of geographic origin on the risk of severe illness and death on cART has not been explored in European countries. Method: We studied antiretroviral-naïve heterosexual HIV-1-infected individuals enrolled in the FHDH-ANRS CO4 cohort in France who started cART between 2006 and 2011. Individuals originating from France (French natives), sub-Saharan Africa (SSA) and non-French West-Indies (NFW) were studied until 2012. Crude and adjusted rate ratios (aRR) of severe morbid events/deaths (AIDS-related and non-AIDS-related) were calculated using Poisson regression models stratified by sex, comparing each group of migrants to French natives. Results: Among 2334 eligible men, 1379 (59.1%) originated from France, 838 (35.9%) from SSA and 117 (5.0%) from NFW. SSA male migrants had a higher aRR for non-AIDS infections, particularly bacterial infections (aRR 1.56 (95% CI 1.07–2.29), p = 0.0477), than French natives. Among 2596 eligible women, 1347 (51.9%) originated from France, 1131 (43.6%) from SSA, and 118 (4.5%) from NFW. SSA and NFW female migrants had a higher aRR for non-AIDS infections, particularly non-bacterial infections (respectively, 2.04 (1.18–3.53) and 7.87 (2.54–24.4), p = 0.0010), than French natives. We observed no other significant differences related to geographic origin as concerns the aRRs for AIDS-related infections or malignancies, or for other non-AIDS events/deaths such as cardiovascular disease, neurological/psychiatric disorders, non-AIDS malignancies and iatrogenic disorders, in either gender. Conclusion: Heterosexual migrants from SSA or NFW living in France have a higher risk of non-AIDS-defining infections than their French native counterparts. Special efforts are needed to prevent infectious diseases among HIV-infected migrants. [ABSTRACT FROM AUTHOR]

Objective: To assess the relationship between coronary heart disease (CHD) and menopausal symptoms in middle-aged women in Taiwan. Patients and methods: The present study identified 14,340 symptomatic menopausal women without a history of CHD from the Taiwan National Health Insurance Research Database from January 1, 2000, to December 31, 2013. A total of 14,340 age- and Charlson-comorbidity-index-score-matched asymptomatic women were used as controls. Possible comorbidity-attributable risks of CHD were surveyed to assess whether the symptomatic menopausal cohort had a higher incidence of CHD. Results: The incidence of CHD was higher in the symptomatic menopausal cohort than in the control cohort (17.18 vs. 12.05 per 1000 person-years). After adjustment in multivariate Cox analysis, the risk of CHD was significantly higher in the symptomatic menopausal cohort (adjusted hazard ratio = 1.344, 95% confidence interval [CI] = 1.262–1.43, P < 0.001) than in the control cohort. In the symptomatic menopausal cohort, the risk of CHD was significantly higher in all subgroups, except for the hormone therapy (HT) subgroup. Patients undergoing HT had a nonsignificantly higher risk of CHD, regardless of the presence or absence of menopausal symptoms. Conclusion: This large-scale longitudinal retrospective cohort study revealed that menopausal symptoms are an independent risk factor for CHD. Moreover, our findings indicate that HT has a nonsignificant effect on the risk of CHD. [ABSTRACT FROM AUTHOR]

Background: The high prevalence of metabolic syndrome (MetS) and cardiovascular diseases (CVD) is observed among Kazakhs in Xinjiang. Because MetS may significantly predict the occurrence of CVD, the inclusion of CVD-related indicators in metabolic network may improve the predictive ability for a CVD-risk model for Kazakhs in Xinjiang. Methods: The study included 2,644 subjects who were followed for 5 years or longer. CVD cases were identified via medical records of the local hospitals from April 2016 to August 2017. Factor analysis was performed in 706 subjects (267 men and 439 women) with MetS to extract CVD-related potential factors from 18 biomarkers tested in a routine health check-up, served as a synthetic predictor (SP). We evaluated the predictive ability of the CVD-risk model using age and SP, logistic regression discrimination for internal validation (n = 384; men = 164, women = 220) and external validation (n = 219; men = 89, women = 130), calculated the probability of CVD for each participant, and receiver operating characteristic curves. Results: According to the diagnostic criteria of JIS, the prevalence of MetS in Kazakh was 30.9%. Seven potential factors with a similar pattern were obtained from men and women and comprised the CVD predictors. When predicting CVD in the internal validation, the area under the curve (AUC) were 0.857 (95%CI 0.807–0.898) for men and 0.852 (95%CI 0.809–0.889) for women, respectively. In the external validation, the AUC to predict CVD were 0.914 (95%CI 0.832–0.963) for men and 0.848 (95%CI 0.774–0.905) for women. It is suggested that SP might serve as a useful tool in identifying CVD with in Kazakhs, especially for Kazakhs men. Conclusions: Among 7 potential factors were extracted from 18 biomarkrs in Kazakhs with MetS, and SP may be used for CVD risk assessment. [ABSTRACT FROM AUTHOR]

Background: Sexual dimorphism in cardiac sympathetic outflow has recently gained attention in the context of Takotsubo cardiomyopathy. Previous studies suggest that there are sex- and age-dependent differences in peripheral autonomic control, however, data on cardiac-specific sympathetic activation in aged women and men are lacking. Methods and results: Regional quantitative analysis of cardiac fluorine-18 (18F)- Dihydroxyphenylalanine (DOPA) uptake was retrospectively performed in 133 patients (69 females, mean age 52.4±17.7 years) referred for assessment of neuroendocrine tumours (NET) by Positron-Emission-Tomography. Cardiac 18F-DOPA uptake was significantly higher in women as compared to men (1.33±0.21 vs. 1.18±0.24, p<0.001). This sex-difference was most pronounced in the apical region of the left ventricle (LV, 1.30±0.24 in women vs. 1.13±0.25 in men, p<0.001) and in individuals >55 years of age (1.39±0.25 in women vs. 1.09±0.24 in men, p<0.001). Women showed a prominent increase in myocardial 18F-DOPA uptake with age with the strongest increase seen in the LV apical region (r = 0.34, p = 0.004). Accordingly, sex and age were selected as significant predictors of LV apical 18F-DOPA uptake in a stepwise linear regression model. No age-dependent changes of cardiac 18F-DOPA uptake were observed in men or in the right ventricular region. Conclusion: Our study suggests that aging is related to sex-specific changes in regional cardiac sympathetic activity. Future studies will have to assess whether the increase in LV apical 18F-DOPA uptake with age in women is of pathogenic relevance for the higher susceptibility of postmenopausal women to conditions associated with increased sympathetic activity. [ABSTRACT FROM AUTHOR]

Background: Empirical evidence has shown that cardiac rehabilitation programs are effective in reducing morbidity and mortality, improving quality of life in patients with cardiovascular disease. Despite the benefits, women have a high cardiac rehabilitation dropout rate. Our aim was to explore women’s perceptions about the reasons they faced for dropout from these programs. Methods: Semi-structured interviews were conducted with women (n = 10) after dropping out from three different cardiac rehabilitation centers in Spain. In addition, a focus group and a semi-structured interview with cardiovascular professionals were conducted. From a grounded theory perspective, thematic analysis was used to derive themes from interview transcripts. Results: The women were between 41 and 70 years. We identified five general themes that illustrated reasons for cardiac rehabilitation dropout: intrapersonal reasons (self-reported health, self-reported mental health, health beliefs); interpersonal reasons (family caregiver role, work conflicts); logistical reasons (transport, distance); cardiac rehabilitation program characteristics (perception of the objective of cardiac rehabilitation, exercise component, inconvenient timing, cardiac rehabilitation equipment); and health system reasons (financial assistance for transport, long waiting list). The cardiovascular professionals found barriers to cardiac rehabilitation completion similar to those found by the women. Conclusions: In order to prevent cardiac rehabilitation dropout in women, modular and flexible programs are needed. In addition, the inclusion of primary care centers or community resources could improve cardiac rehabilitation completion in women. Psychological assessment and counseling during cardiac rehabilitation should be included as an essential part of the programs and recommended for those women with depressive symptoms. Finally, improved financial assistance for transport from the health system is essential. [ABSTRACT FROM AUTHOR]

In a Policy Forum, Cecilia Sorensen and colleagues discuss the implications of climate change for women's health. [ABSTRACT FROM AUTHOR]

Background: Traditional strategies for primary cardiovascular prevention have been insufficient in reducing the high rates of coronary ischemic events in women, probably because these women are often stratified into low-risk groups. However, cardiovascular diseases continue to be the main cause of morbidity and mortality in women worldwide. We hypothesized that carotid atherosclerosis (CA) is common in middle-aged women. Methods: We prospectively evaluated asymptomatic peri- and post-menopausal women with no cardiovascular diseases or the use of hormone therapy from two gynecologic clinics. All the patients underwent full clinical and laboratory evaluation and underwent a B-mode ultrasound for carotid evaluations. The presence of CA was defined as the presence of plaque and/or carotid intima-media thickness (CIMT)>1.00 mm. We performed logistic regression to evaluate independent predictors of CA. Results: We studied 823 women (age: 54.4±5.4 years; body mass index-BMI: 28.5±4.9 kg/m2; diabetes:10%; hypertension: 58%). The prevalence of CA was 12.7% for the entire population and 11% for the low-risk sub-group as defined by a Framingham risk score <5%. In the multivariate model, age: odds ratio (OR) = 1.54, 95% confidence interval (CI) = 1.25–1.89,p<0.001; current smoker status: OR = 2.69, 95% CI = 1.48–4.91, p = 0.001; total cholesterol: OR = 1.13, 95% CI = 1.03–1.24, p = 0.008; and systolic blood pressure: OR = 1.01, 95% CI = 1.00–1.02, p = 0.030 remained independently associated with CA. Conclusion: Subclinical CA is common among asymptomatic middle-aged women, and traditional risk factors are independently associated with CA. These findings are particularly relevant for improving cardiovascular health in women. [ABSTRACT FROM AUTHOR]

Background: During the last decade, the incidence and mortality rates of ST-elevation myocardial infarction (STEMI) has been steadily increasing in young women but not in men. Environmental variables that contribute to cardiovascular events in women remain ill-defined. Methods and results: A total of 2199 consecutive patients presenting with acute ST-elevation myocardial infarction (STEMI, 25.8% women, mean age 62.6±12.4 years) were admitted at the Montreal Heart Institute between June 2010 and December 2014. Snow fall exceeding 2cm/day was identified as a positive predictor for STEMI admission rates in the overall population (RR 1.28, 95% CI 1.07–1.48, p = 0.005), with a significant effect being seen in men (RR 1.30, 95% CI 1.06–1.53, p = 0.01) but not in women (p = NS). An age-specific analysis revealed a significant increase in hospital admission rates for STEMI in younger women ≤55 years, (n = 104) during days with higher outside temperature (p = 0.004 vs men ≤55 years) and longer daylight hours (p = 0.0009 vs men ≤55 years). Accordingly, summer season, increased outside temperature and sunshine hours were identified as strong positive predictors for STEMI occurrence in women ≤55 years (RR 1.66, 95% CI 1.1–2.5, p = 0.012, RR 1.70, 95% CI 1.2–2.5, p = 0.007, and RR 1.67, 95% CI 1.2–2.5, p = 0.011, respectively), while an opposite trend was observed in men ≤55 years (RR for outside temperature 0.8, 95% CI 0.73–0.95, p = 0.01). Conclusion: The impact of environmental variables on STEMI is age- and sex-dependent. Higher temperature may play an important role in triggering such acute events in young women. [ABSTRACT FROM AUTHOR]

Background: The prevalence of diabetes, heart disease, and stroke multimorbidity (co-occurrence of two or three of these conditions) has increased rapidly. Little is known about how the three conditions progress from one to another sequentially through the life course. We aimed to delineate this progression in middle-aged women and to determine the roles of common risk factors in the accumulation of diabetes, heart disease, and stroke multimorbidity.Methods and Findings: We used data from 13,714 women aged 45-50 years without a history of any of the three conditions. They were participants in the Australian Longitudinal Study on Women's Health (ALSWH), enrolled in 1996, and surveyed approximately every 3 years to 2016. We characterized the longitudinal progression of the three conditions and multimorbidity. We estimated the accumulation of multimorbidity over 20 years of follow-up and investigated their association with both baseline and time-varying predictors (sociodemographic factors, lifestyle factors, and other chronic conditions). Over 20 years, 2,511 (18.3%) of the women progressed to at least one condition, of whom 1,420 (56.6%) had diabetes, 1,277 (50.9%) had heart disease, and 308 (12.3%) had stroke; 423 (16.8%) had two or three of these conditions. Over a 3-year period, the age-adjusted odds of two or more conditions was approximately twice that of developing one new condition compared to women who did not develop any new conditions. For example, the odds for developing one new condition between Surveys 7 and 8 were 2.29 (95% confidence interval [CI], 1.93-2.72), whereas the odds for developing two or more conditions was 6.51 (95% CI, 3.95-10.75). The onset of stroke was more strongly associated with the progression to the other conditions (i.e., 23.4% [95% CI, 16.3%-32.2%] of women after first onset of stroke progressed to other conditions, whereas the percentages for diabetes and heart disease were 9.9% [95% CI, 7.9%-12.4%] and 11.4% [95% CI, 9.1%-14.4%], respectively). Being separated, divorced, or widowed; being born outside Australia; having difficulty managing on their available income; being overweight or obese; having hypertension; being physically inactive; being a current smoker; and having prior chronic conditions (i.e., mental disorders, asthma, cancer, osteoporosis, and arthritis) were significantly associated with increased odds of accumulation of diabetes, heart disease, and stroke multimorbidity. The main limitations of this study were the use of self-reported data and the low number of events.Conclusions: Stroke was associated with increased risk of progression to diabetes or heart disease. Social inequality, obesity, hypertension, physical inactivity, smoking, or having other chronic conditions were also significantly associated with increased odds of accumulating multimorbidity. Our findings highlight the importance of awareness of the role of diabetes, heart disease, and stroke multimorbidity among middle-aged women for clinicians and health-promotion agencies. [ABSTRACT FROM AUTHOR]

Background: Gestational diabetes mellitus (GDM) is associated with developing type 2 diabetes, but very few studies have examined its effect on developing cardiovascular disease.Methods and Findings: We conducted a retrospective cohort study utilizing a large primary care database in the United Kingdom. From 1 February 1990 to 15 May 2016, 9,118 women diagnosed with GDM were identified and randomly matched with 37,281 control women by age and timing of pregnancy (up to 3 months). Adjusted incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated for cardiovascular risk factors and cardiovascular disease. Women with GDM were more likely to develop type 2 diabetes (IRR = 21.96; 95% CI 18.31-26.34) and hypertension (IRR = 1.85; 95% CI 1.59-2.16) after adjusting for age, Townsend (deprivation) quintile, body mass index, and smoking. For ischemic heart disease (IHD), the IRR was 2.78 (95% CI 1.37-5.66), and for cerebrovascular disease 0.95 (95% CI 0.51-1.77; p-value = 0.87), after adjusting for the above covariates and lipid-lowering medication and hypertension at baseline. Follow-up screening for type 2 diabetes and cardiovascular risk factors was poor. Limitations include potential selective documentation of severe GDM for women in primary care, higher surveillance for outcomes in women diagnosed with GDM than control women, and a short median follow-up postpartum period, with a small number of outcomes for IHD and cerebrovascular disease.Conclusions: Women diagnosed with GDM were at very high risk of developing type 2 diabetes and had a significantly increased incidence of hypertension and IHD. Identifying this group of women in general practice and targeting cardiovascular risk factors could improve long-term outcomes. [ABSTRACT FROM AUTHOR]

Aims: To estimate the 10-year risk of fatal cardiovascular disease (CVD) in the 40 to 69 year old general population in Germany stratified by sex and to analyze differences between socio-economic status (SES), region and community size in individuals without CVD. The analysis is based on the newly recalibrated SCORE Deutschland risk charts and considered other comorbidities for the classification of the high CVD risk group according to the guidelines of the European Society of Cardiology. Methods and results: In 3,498 participants (40–69 years) from the German Health Examination Survey for Adults 2008–2011 (DEGS1) without a history of CVD (myocardial infarction, coronary heart disease, heart failure, stroke) we estimated the proportion with a low (SCORE <1%), moderate (SCORE 1-<5%) and high 10-year CVD mortality risk (SCORE ≥5% or diabetes, renal insufficiency, SBP/DPB ≥180/110 mmHg or cholesterol >8 mmol/l). The prevalence of low, moderate and high risk was 42.8%, 38.5% and 18.8% in men and 73.7%, 18.1% and 8.2% in women. The prevalence of high risk was significantly lower in women with a high compared to a low SES (3.3% vs. 11.2%) and in communities with ≥100.000 inhabitants compared to <20.000 inhabitants (5.4% vs.10.9%). There were no significant associations between predicted CVD mortality risk and SES or community size in men and regions in men and women. Among the high risk group, 58.2% of men and 9.8% of women had SCORE ≥5%, leaving the majority of women (60.1%) classified as high risks due to diabetes and SCORE <5%. Conclusion: Our results suggest the persistence of socioeconomic disparities in predicted cardiovascular mortality in women and support the need of large-scale prevention efforts beyond individual lifestyle modification or treatment. Furthermore, the importance of additional comorbidities for the high risk group classification is highlighted. [ABSTRACT FROM AUTHOR]

This study was designed to develop a risk assessment chart for the clinical management and prevention of the risk of cardiovascular disease (CVD) in Iranian population, which is vital for developing national prevention programs. The Isfahan Cohort Study (ICS) is a population-based prospective study of 6504 Iranian adults ≥35 years old, followed-up for ten years, from 2001 to 2010. Behavioral and cardiometabolic risk factors were examined every five years, while biennial follow-ups for the occurrence of the events was performed by phone calls or by verbal autopsy. Among these participants, 5432 (2784 women, 51.3%) were CVD free at baseline examination and had at least one follow-up. Cox proportional hazard regression was used to predict the risk of ischemic CVD events, including sudden cardiac death due to unstable angina, myocardial infarction, and stroke. The model fit statistics such as area under the receiver-operating characteristic (AUROC), calibration chi-square and the overall bias were used to assess the model performance. We also tested the Framingham model for comparison. Seven hundred and five CVD events occurred during 49452.8 person-years of follow-up. The event probabilities were calculated and presented color-coded on each gender-specific PARS chart. The AUROC and Harrell’s C indices were 0.74 (95% CI, 0.72–0.76) and 0.73, respectively. In the calibration, the Nam-D’Agostino χ2 was 10.82 (p = 0.29). The overall bias of the proposed model was 95.60%. PARS model was also internally validated using cross-validation. The Android app and the Web-based risk assessment tool were also developed as to have an impact on public health. In comparison, the refitted and recalibrated Framingham models, estimated the CVD incidence with the overall bias of 149.60% and 128.23% for men, and 222.70% and 176.07% for women, respectively. In conclusion, the PARS risk assessment chart is a simple, accurate, and well-calibrated tool for predicting a 10-year risk of CVD occurrence in Iranian population and can be used in an attempt to develop national guidelines for the CVD management. [ABSTRACT FROM AUTHOR]

Background: There is growing evidence that breastfeeding has short- and long-term cardiovascular health benefits for mothers. The objectives of this systematic review were to examine the association between breastfeeding and maternal cardiovascular risk factors and outcomes that have not previously been synthesized systematically, including metabolic syndrome, hypertension and cardiovascular disease. Methods and findings: This systematic review meets PRISMA guidelines. The MEDLINE, EMBASE and CINAHL databases were systematically searched for relevant publications of any study design from the earliest publication date to March 2016. The reference lists from selected articles were reviewed, and forward and backward referencing were conducted. The methodological quality of reviewed articles was appraised using validated checklists. Twenty-one studies meeting the inclusion criteria examined the association between self-reported breastfeeding and one or more of the following outcomes: metabolic syndrome/metabolic risk factors (n = 10), inflammatory markers/adipokines (n = 2), hypertension (n = 7), subclinical cardiovascular disease (n = 2), prevalence/incidence of cardiovascular disease (n = 3) and cardiovascular disease mortality (n = 2). Overall, 19 studies (10 cross-sectional/retrospective, 9 prospective) reported significant protective effects of breastfeeding, nine studies (3 cross-sectional/retrospective, 5 prospective, 1 cluster randomized controlled trial) reported non-significant findings and none reported detrimental effects of breastfeeding. In most studies reporting significant associations, breastfeeding remained associated with both short- and long-term maternal cardiovascular health risk factors/outcomes, even after covariate adjustment. Findings from several studies suggested that the effects of breastfeeding may diminish with age and a dose-response association between breastfeeding and several metabolic risk factors. However, further longitudinal studies, including studies that measure exclusive breastfeeding, are needed to confirm these findings. Conclusions: The evidence from this review suggests that breastfeeding is associated with cardiovascular health benefits. However, results should be interpreted with caution as the evidence gathered for each individual outcome was limited by the small number of observational studies. Additional prospective studies are needed. PROSPERO registration number: CRD42016047766. [ABSTRACT FROM AUTHOR]

Background: Premenopausal women have fewer cardiovascular disease (CVD) events than postmenopausal women and age-matched men, but the reasons are not fully understood. Coronary endothelial function (CEF), a barometer of coronary vascular health, promises important insights into age and sex differences in atherosclerotic CVD risk, but has not been well characterized in healthy individuals because of the invasive nature of conventional CEF measurements. Recently developed magnetic resonance imaging (MRI) methods were used to quantify CEF (coronary area and flow changes in response to isometric handgrip exercise (IHE), an endothelial-dependent stressor) to test the hypothesis that healthy women have CEF compared to men particularly at a younger age. Methods: The study participants were 50 healthy women and men with no history of coronary artery disease (CAD) or traditional CV risk factors and Agatston coronary calcium score (on prior CT) <10 for those ≥ 50 years. Coronary cross-sectional area (CSA) measurements and flow-velocity encoded images (CBF) were obtained at baseline and during continuous IHE using 3T breath-hold cine MRI-IHE. CEF (%change in CSA and CBF with IHE) comparisons were made according to age and sex, and all women ≥50 years were post-menopausal. Results: In the overall population, there were no differences in CEF between men and women. However, when stratified by age and sex the mean changes in CSA and CBF during IHE were higher in younger premenopausal women than older postmenopausal women (%CSA: 15.2±10.6% vs. 7.0±6.8%, p = 0.03 and %CBF: 59.0±37.0% vs. 30.5±24.5% p = 0.02). CBF change was also nearly two-fold better in premenopausal women than age-matched men (59.0±37.0% vs. 33.6±12.3%, p = 0.03). Conclusions: Premenopausal women have nearly two-fold better mean CEF compared to postmenopausal women. CEF, measured by CBF change is also better in premenopausal women than age-matched men but there are no sex differences in CEF after menopause. Fundamental age and sex differences in CEF exist and may contribute to differences in the development and clinical manifestations of atherosclerotic CVD, and guide future trials targeting sex-specific mechanisms of atherogenesis. [ABSTRACT FROM AUTHOR]

Background: Body fat distribution is, next to overall obesity, an important risk factor for cardiometabolic outcomes in the general population. In particular, visceral adipose tissue (VAT) is strongly associated with cardiometabolic risk factors. Since it is unclear whether body fat distribution is also important in men and women with obesity we investigated the associations between measures of body fat distribution and cardiometabolic risk factors in men and women with obesity. Methods: In this cross-sectional analysis of obese men and women (BMI≥30 kg/m2) included in the Netherlands Epidemiology of Obesity Study, waist:hip ratio(WHR), waist circumference, and MRI-based abdominal subcutaneous adipose tissue (aSAT) and VAT were determined. Associations between measures of body fat distribution and presence of ≥1 risk factor, such as hypertension or hypertriglyceridemia, were examined using logistic regression analyses; stratified by sex and adjusted for age, ethnicity, education, tobacco smoking, alcohol consumption, physical activity and depending on the association additionally for total body fat or VAT. Results: We included 2,983 obese individuals (57% women) with a mean age of 56 and standard deviation (SD) of 6 and mean BMI of 34.0 kg/m2 (4.0), after exclusion of individuals with missing values of cardiometabolic risk factors (n = 33). 241 individuals were obese without other cardiometabolic risk factors. In obese women, all measures of body fat distribution except aSAT (OR per SD:0.76, 95%CI: 0.53, 1.10) were associated with having ≥1 cardiometabolic risk factor, of which VAT most strongly associated (5.77; 3.02, 11.01). In obese men, associations of body fat distribution and the presence of cardiometabolic risk factors were attenuated. (e.g. VAT:1.42; 0.84, 2.41). Conclusions: In obese women, but less so in men, measures of body fat distribution, of which VAT most strongly, are associated with cardiometabolic risk factors. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among older postmenopausal women. The impact of postmenopausal breast cancer on CVD for older women is uncertain. We hypothesized that older postmenopausal women with breast cancer would be at a higher risk of CVD than similar aged women without breast cancer and that CVD would be a major contributor to the subsequent morbidity and mortality. Methods: In a prospective Women’s Health Initiative study, incident CVD events and total and cause-specific death rates were compared between postmenopausal women with (n = 4,340) and without (n = 97,576) incident invasive breast cancer over 10 years post-diagnosis, stratified by 3 age groups (50–59, 60–69, and 70–79). Results: Postmenopausal women, regardless of breast cancer diagnosis, had similar and high levels of CVD risk factors (e.g., smoking and hypertension) at baseline prior to breast cancer, which were strong predictors of CVD and total mortality over time. CVD affected mostly women age 70–79 with localized breast cancer (79% of breast cancer cases in 70–79 age group): only 17% died from breast cancer and CVD was the leading cause of death (22%) over the average 10 years follow up. Compared to age-matched women without breast cancer, women age 70–79 at diagnosis of localized breast cancer had a similar multivariate-adjusted hazard ratio (HR) of 1.01 (95% confidence interval [CI]: 0.76–1.33) for coronary heart disease, a lower risk of composite CVD (HR = 0.84, 95% CI: 0.70–1.00), and a higher risk of total mortality (HR = 1.20, 95% CI: 1.04–1.39). Conclusion: CVD was a major contributor to mortality in women with localized breast cancer at age 70–79. Further studies are needed to evaluate both screening and treatment of localized breast cancer tailored to the specific health issues of older women. [ABSTRACT FROM AUTHOR]

Background/Objectives: The relationship between body mass index (BMI) and mortality remains controversial. Furthermore, the association between BMI and cardiovascular events (CVE) is not conclusive and may differ by ethnicity. We aimed to estimate the associations between the BMI and mortality or cardiovascular disease in a general Korean population. Subjects/Methods: This study was based on a sample cohort database released by the Korean National Health Insurance Service. We analyzed a total of 415,796 adults older than 30 years of age who had undergone a national health examination at least once from 2002 to 2012. Hazard ratios for death and cardiovascular events were calculated using Cox proportional hazards models. Results: For both men and women, BMI and overall mortality showed a U-shaped association, with the lowest mortality rate among those with a BMI of 25–27.4 kg/m2. Compared with them, subjects with a BMI ≥ 30kg/m2, men with a BMI < 25 kg/m2, and women with a BMI < 22.5 kg/m2 showed significantly higher overall mortality. Additionally, men with a BMI < 22.5 kg/m2 and women with a BMI < 20 kg/m2 displayed an increased risk of cardiovascular mortality. Unlike the mortality trend, the CVD events trend showed a linearly positive association. The risk of a CVE was the lowest in men with a BMI ranging from 20 to 22.4 kg/m2 and in women with a BMI < 20 kg/m2. Conclusions: The BMI showed a U-shaped association with overall mortality, where slightly obese subjects showed the lowest rate of mortality. The CVE exhibited a linear association with the BMI, where the lowest risk was observed for normal weight subjects in a general Korean population. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the association between spouse weekly working hours (SWWH) and the estimated 10-years risk of cardiovascular disease (CVD). Methods: This cross-sectional study was based on the data obtained from the Korean National Health and Nutrition Examination Survey 2007–2012. Data of 16,917 participants (8,330 husbands, 8,587 wives) were used for this analysis. The participants’ clinical data were collected to estimate the 10-years risk of CVD, as well as weekly working hours. Multiple logistic regression was conducted to investigate the association between SWWH and the estimated 10-years risk of CVD. We also performed a stratified analysis according to each participant’s and their spouse’s employment status. Results: Compared to those whose spouses worked 30 hours per week, estimated 10-years risk of CVD was significantly higher as SWWH increase among those whose spouses worked >30 hours per week. After adjusting for covariates, the odds ratio for high CVD risk was found to increase as SWWH increased, up to 2.52 among husbands and 2.43 among wives. We also found that the association between SWWH and the estimated 10-years risk of CVD varied according to the employment status. Analysis of each component included in the CVD appraisal model showed that SWWH had close relationship with diabetes in men, and smoking habits in women. Conclusions: Spouse’s long working hours are associated with individual’s risk of CVD in future, especially among husbands. [ABSTRACT FROM AUTHOR]

Background: Women with signs and symptoms of ischemia, no obstructive coronary artery disease (CAD) and preserved left ventricular ejection fraction (EF) often have diastolic dysfunction and experience elevated rates of major adverse cardiac events (MACE), including heart failure (HF) hospitalization with preserved ejection fraction (HFpEF). We evaluated the predictive value of inflammatory biomarkers for long-term HF hospitalization and all-cause mortality in these women. Methods: We performed a cross-sectional analysis to investigate the relationships between inflammatory biomarkers [serum interleukin-6 (IL-6), C-reactive protein (hs-CRP) and serum amyloid A (SAA)] and median of 6 years follow-up for all-cause mortality and HF hospitalization among women with signs and symptoms of ischemia, non-obstructive CAD and preserved EF. Multivariable Cox regression analysis tested associations between biomarker levels and adverse outcomes. Results: Among 390 women, mean age 56 ± 11 years, median follow up of 6 years, we observed that there is continuous association between IL-6 level and HF hospitalization (adjusted hazard ratio [AHR] 2.5 [1.2–5.0], p = 0.02). In addition, we found significant association between IL-6, SAA levels and all-cause mortality AHR (1.8 [1.1–3.0], p = 0.01) (1.5 [1.0–2.1], p = 0.04), respectively. Conclusion: In women with signs and symptoms of ischemia, non-obstructive CAD and preserved EF, elevated IL-6 predicted HF hospitalization and all-cause mortality, while SAA level was only associated with all-cause mortality. These results suggest that inflammation plays a role in the pathogenesis of development of HFpEF, as well all-cause mortality. [ABSTRACT FROM AUTHOR]

Background: While body mass index (BMI) is the most widely used anthropometric measure, its association with all-cause mortality is generally J-shaped or U-shaped. A body shape index (ABSI) is a recently formulated anthropometric measure that shows linear relationship to all-cause mortality, especially in Caucasian cohorts. We aimed to address the relationship between ABSI and all-cause mortality in Asians and to assess the influence of sex difference and of chronic kidney disease (CKD) on this relationship. Methods: This was a longitudinal cohort study assessing the association of ABSI, BMI, waist circumference (WC), and waist-to-height ratio (WHtR) with all-cause mortality in a Japanese nationwide Specific Health Checkup database. The study enrolled 160,625 participants followed-up between 2008 and 2012. We calculated the all-cause mortality risk associated with a 1-standard deviation increase (+1SD) in ABSI, BMI, WC, or WHtR in cohorts stratified by sex and the presence of CKD. Results: During the 4-year follow up, 1.3% of participants died. In men, ABSI (+1SD) significantly increased the risk for all-cause mortality after adjusting for other known risk factors including CKD; hazard ratio (HR) and 95% confidence intervals (CI) of non-CKD cohort, 1.30 (1.18 to 1.43), p<0.01; HR and 95%CI of CKD cohort, 1.16 (1.01 to 1.34), p = 0.04. In women, ABSI (+1SD) did not show significant association with all-cause mortality, especially in the CKD cohort; HR and 95% CI of non-CKD cohort, 1.07 (0.99 to 1.17), p = 0.09; HR and 95%CI of CKD cohort, 0.98 (0.84 to 1.14), p = 0.78. Conversely, BMI (+1SD) was associated with significantly lower risk in men, although minimal association was found in women. WC and WHtR showed little association with all-cause mortality. On stratification per ABSI quartiles, mortality risk increased linearly and significantly with ABSI in men, but not in women with CKD. Both BMI and WC showed significant but U-shaped association with mortality in the non-CKD cohort and in men with CKD. WHtR also showed significant U-shaped association with mortality in men. Conclusions: In the Japanese population, ABSI showed significant and linear correlation with mortality risk in men but not in women, especially in the presence of CKD. [ABSTRACT FROM AUTHOR]

Patients with rheumatoid arthritis are at increased risk for cardiovascular disease. The prerequisites for reducing the risk of cardiovascular disease are adequate levels of knowledge and being aware of the risk. In this study, the levels of knowledge about cardiovascular disease among patients with rheumatoid arthritis and the perception were evaluated in relation to their actual 10-year risk of cardiovascular disease. This cross-sectional study of 200 patients with rheumatoid arthritis was conducted in a university-affiliated hospital in South Korea. The patients’ actual risk of cardiovascular disease was estimated using the Framingham Risk Score. The most common risk factor was physical inactivity, with 77% of the patients not engaging in regular exercise. The patients lacked knowledge about the effects of physical inactivity and anti-inflammatory medication on the development of cardiovascular disease. Misperceptions about the risk of cardiovascular disease were common, i.e., 19.5% of the patients underestimated their risk and 41% overestimated. Hypertension, diabetes, obesity, and smoking were the most prevalent among the patients who underestimated their risk, and these same patients had the lowest level of knowledge about cardiovascular disease. This study demonstrated the rheumatoid arthritis patients’ lack of knowledge about the effects of physical inactivity and anti-inflammatory medications on the development of cardiovascular disease, and their misperception of cardiovascular risk was common. As a preventive measure, educational programs about cardiovascular disease should be tailored specifically for patients with rheumatoid arthritis, and behavioral interventions, including routine exercise, should be made available at the time of diagnosis. [ABSTRACT FROM AUTHOR]

Background: Advances in cardiac surgery and congenital cardiology have led to an increasing number of women with congenital heart disease (CHD) reaching childbearing age. In general, cardiologists recommend vaginal delivery for women with CHD to avoid complications from Caesarean section as many women with CHD tolerate vaginal delivery well. Methods and Results: This is a single-center study comparing mode of delivery, pregnancy outcome, indications for Caesarean section and induction of labor between women with and without CHD. A historical cohort study was conducted including 116 patients with CHD. An individual threefold matching with 348 women without CHD was carried out. Caesarean section was performed in 46.6% of pregnancies with CHD (33.6% without CHD, P = 0.012). Primary Caesarean section increases with severity of CHD (P = 0.036), 33.3% of women with CHD had primary planned Caesarean section due to cardiac reasons. Induction of labor was performed in 45.7% of attempted vaginal deliveries in women with CHD (27.9% without CHD, P = 0.001). Lower mean birth weight (P = 0.004) and Small for Gestational Age (SGA) (P < 0.001) were more common in women with CHD. One CHD patient suffered from postpartum hemorrhage. Conclusions: Concerns about maternal deterioration resulting in higher rates of induction of labor seem unjustified in most cases. Along with a possible reduction of Caesarean section on maternal request, a reduction of planned vaginal delivery may be expedient in reducing the rate of Caesarean section in women with CHD. [ABSTRACT FROM AUTHOR]

Importance: Vasomotor symptoms (hot flushes and night sweats) and other symptoms, including depression, anxiety and panic attacks, are commonly experienced by menopausal women and have been associated with an unfavourable cardiovascular risk profile. Objective: To investigate whether presence of menopausal symptoms is associated with the development of cardiovascular disease (CVD). Methods: Five electronic databases (Medline, EMBASE and Web of Science) were search until February 17th, 2015 to identify relevant studies. Observational cohort studies or randomised intervention studies were eligible for inclusion if they followed participants prospectively (at least 1 year of follow-up), and reported relevant estimates on the association of any vasomotor symptoms, or other menopausal symptoms, with risk of CVD, coronary heart disease (CHD), or stroke in perimenopausal, menopausal, or postmenopausal women. Data were extracted by two independent reviewers using a pre-designed data collection form. Separate pooled relative risks (RRs) for age and non-established cardiovascular risk factors (e.g., education, ethnicity) adjusted data and for established cardiovascular risk factors and potential mediators-adjusted data (e.g., smoking, body mass index, and hypertension) were calculated. Results: Out of 9,987 initially identified references, ten studies were selected, including 213,976 women with a total of 10,037 cardiovascular disease outcomes. The age and non-established cardiovascular risk factors adjusted RRs) [95% confidence intervals] for development of CHD, Stroke and CVD comparing women with and without any menopausal symptoms were 1.34 [1.13–1.58], 1.30 [0.99–1.70], 1.48 [1.21–1.80] respectively, and the corresponding RRs adjusted for cardiovascular risk factors and potential mediators were 1.18 [1.03–1.35], 1.08 [0.89–1.32], 1.29 [0.98–1.71]. However, these analyses were limited by potential unmeasured confounding and the small number of studies on this topic. Conclusion: Presence of vasomotor symptoms and other menopausal symptoms are generally associated with an increased risk of cardiovascular disease, which is mainly explained by cardiovascular risk factors. [ABSTRACT FROM AUTHOR]

Introduction: The incidence of cardiovascular diseases (CVD) is increased in rheumatoid arthritis (RA) patients. It remains unclear whether the load of RA increases cardiovascular (CV) risk especially in female and in younger RA patients. In the present study we aim to analyse the influence of age and gender on CV risk in RA relative to the general population, using meta-analysis of direct comparative studies. Method: Systematic literature search was performed in MEDLINE for studies reporting on occurrence of CV events in RA as compared to the general population, stratified for gender and/or age. Quality was appraised using the Newcastle-Ottawa scale. Meta-analysis was performed on rate ratios using inverse variance methods. Results: There were 1372 records screened and 13 studies included. RA females and males have a similar higher risk (95%CI) to develop stroke with RR 1.35 (1.30–1.40) and RR 1.31 (1.21–1.43); coronary artery disease with RR 1.65 (1.54–1.76) versus RR 1.55 ((1.41–1.69) in men; cardiovascular disease with RR 1.56 (1.49–1.62) versus 1.50 (1.41–1.60). The highest incidence of CV events was observed in the youngest patients, RR 2.59 (1.77–3.79), whereas older patients had the lowest relative risk when compared to the general population, RR 1.27 (1.16–1.38). Conclusion: The relative risk of RA patients for CVD is age dependent, but does not depend on gender: the relative risk on CVD appears to be equally raised for males and females, while relatively young RA patients (<50 years) have the highest, and older patients the lowest relative risk. [ABSTRACT FROM AUTHOR]

Background: Patients with renal impairment are at risk of not only end-stage kidney disease but also cardiovascular disease (CVD). The current definition of CKD stage G3a is eGFR 45–59 ml/min/1.73 m2 and of G3b is 30–44 ml/min/1.73 m2, and subjects in the CKD 3a category are considered to be at lower risk of mortality than are those in CKD 3b. Methods: We evaluated the outcome of 97,043 people (33,131 men and 63,912 women) living in Ibaraki Prefecture who underwent annual community-based health checkups beginning in 1993 at age 40–80 years and who were followed for a mean of 17.1 years. Results: The number of all-causes deaths was 20,534 (10,375 men and 10,159 women), of which 5,995 (2,695 men and 3,300 women) were deaths due to CVD. Multivariable-adjusted hazard ratio for CVD death in the eGFR 45–49 ml/min/1.73 m2 category was significantly increased (1.82; 95% confidential interval, 1.23–2.69) in non-elderly men, whereas all-cause mortality and CVD mortality in elderly men with eGFR 45–49 ml/min/1.73m2 were non significant. In contrast, both in non-elderly women and in elderly women with eGFR 45–49 ml/min/1.73 m2 showed small, but significant, increases in the risks of all-cause mortality and CVD. Conclusions: We demonstrated proportionate increases in mortality with decreasing eGFR in a Japanese CKD population. Like patients in the CKD G3b subgroup, non-elderly men and women with an eGFR of 45–49 ml/min/1.73 m2 (i.e. a part of CKD G3a) are at considerable risk of CVD mortality. Age dependent and eGFR dependent finer risk recognition were required for CVD prevention in clinical practice with regard to CKD patients. [ABSTRACT FROM AUTHOR]

Background: Women are less likely to be prescribed statins than men. Existing reports explain only a fraction of this difference. We conducted a study to identify factors that account for sex differences in statin therapy among patients with coronary artery disease (CAD). Methods and Results: We retrospectively studied 24,338 patients with CAD who were followed for at least a year between 2000 and 2011 at two academic medical centers. Women (9,006 / 37% of study patients) were less likely to either have initiated statin therapy (81.9% women vs. 87.7% men) or to have persistent statin therapy at the end of follow-up (67.0% women vs. 71.4% men). Women were older (72.9 vs. 68.4 years), less likely to have ever smoked (49.8% vs. 65.6%), less likely to have been evaluated by a cardiologist (57.5% vs. 64.5%) and more likely to have reported an adverse reaction to a statin (27.1% vs. 21.7%) (p < 0.0001 for all). In multivariable analysis, patients with history of smoking (OR 1.094; p 0.017), younger age (OR 1.013 / year), cardiologist evaluation (OR 1.337) and no reported adverse reactions to statins (OR 1.410) were more likely (p < 0.0001 for all) to have persistent statin therapy. Together, these four factors accounted for 90.4% of the sex disparity in persistent statin therapy. Conclusions: Several specific factors appear to underlie divergent statin therapy in women vs. men. Identifying such drivers may facilitate programmatic interventions and stimulate further research to overcome sex differences in applying proven interventions for cardiovascular risk reduction. [ABSTRACT FROM AUTHOR]

Background: Depression and depressive symptoms are risk factors for hypertension (HTN) and cardiovascular disease (CVD). Hispanic women have higher rates of depressive symptoms compared to other racial/ethnic groups yet few studies have investigated its association with incident prehypertension and hypertension among postmenopausal Hispanic women. This study aims to assess if an association exists between baseline depression and incident hypertension at 3 years follow-up among postmenopausal Hispanic women. Methods: Prospective cohort study, Women’s Health Initiative (WHI), included 4,680 Hispanic women who participated in the observational and clinical trial studies at baseline and at third-year follow-up. Baseline current depressive symptoms and past depression history were measured as well as important correlates of depression—social support, optimism, life events and caregiving. Multinomial logistic regression was used to estimate prevalent and incident prehypertension and hypertension in relation to depressive symptoms. Results: Prevalence of current baseline depression ranged from 26% to 28% by hypertension category and education moderated these rates. In age-adjusted models, women with depression were more likely to be hypertensive (OR = 1.25; 95% CI 1.04–1.51), although results were attenuated when adjusting for covariates. Depression at baseline in normotensive Hispanic women was associated with incident hypertension at year 3 follow-up (OR = 1.74; 95% CI 1.10–2.74) after adjustment for insurance and behavioral factors. However, further adjustment for clinical covariates attenuated the association. Analyses of psychosocial variables correlated with depression but did not alter findings. Low rates of antidepressant medication usage were also reported. Conclusions: In the largest longitudinal study to date of older Hispanic women which included physiologic, behavioral and psychosocial moderators of depression, there was no association between baseline depressive symptoms and prevalent nor incident pre-hypertension and hypertension. We found low rates of antidepressant medication usage among Hispanic women suggesting a possible point for clinical intervention. Trial Registration: Clinicaltrials.gov [ABSTRACT FROM AUTHOR]

Introduction: Smoking is considered the single most important preventable cause of morbidity and mortality worldwide, contributing to increased incidence and severity of disabling conditions. The aim of this study was to assess the contribution of chronic conditions to the disability burden across smoking categories in middle-aged adults in Belgium. Methods: Data from 10,224 individuals aged 40 to 60 years who participated in the 1997, 2001, 2004, or 2008 Health Interview Surveys in Belgium were used. Smoking status was defined as never, former (cessation ≥2 years), former (cessation <2 years), occasional light (<20 cigarettes/day), daily light, and daily heavy (≥20 cigarettes/day). To attribute disability to chronic conditions, binomial additive hazards models were fitted separately for each smoking category adjusted for gender, except for former (cessation <2 years) and occasional light smokers due to the small sample size. Results: An increasing trend in the disability prevalence was observed across smoking categories in men (never = 4.8%, former (cessation ≥2 years) = 5.8%, daily light = 7.8%, daily heavy = 10.7%) and women (never = 7.6%, former (cessation ≥2 years) = 8.0%, daily light = 10.2%, daily heavy = 12.0%). Musculoskeletal conditions showed a substantial contribution to the disability burden in men and women across all smoking categories. Other important contributors were depression and cardiovascular diseases in never smokers; depression, chronic respiratory diseases, and diabetes in former smokers (cessation ≥2 years); chronic respiratory diseases, cancer, and cardiovascular diseases in daily light smokers; cardiovascular diseases and chronic respiratory diseases in men and depression and diabetes in women daily heavy smokers. Conclusions: Beyond the well-known effect of smoking on mortality, our findings showed an increasing trend of the disability prevalence and different contributors to the disability burden across smoking categories. This information can be useful from a public health perspective to define strategies to reduce disability in Belgium. [ABSTRACT FROM AUTHOR]

Background: Ischemic heart disease (IHD) mortality has been on the decline in the United States for decades. However, declines in IHD mortality have been slower in certain groups, including young women and black individuals. Hypothesis: Trends in IHD vary by age, sex, and race in New York City (NYC). Young female minorities are a vulnerable group that may warrant renewed efforts to reduce IHD. Methods: IHD mortality trends were assessed in NYC 1980–2008. NYC Vital Statistics data were obtained for analysis. Age-specific IHD mortality rates and confidence bounds were estimated. Trends in IHD mortality were compared by age and race/ethnicity using linear regression of log-transformed mortality rates. Rates and trends in IHD mortality rates were compared between subgroups defined by age, sex and race/ethnicity. Results: The decline in IHD mortality rates slowed in 1999 among individuals aged 35–54 years but not ≥55. IHD mortality rates were higher among young men than women age 35–54, but annual declines in IHD mortality were slower for women. Black women age 35–54 had higher IHD mortality rates and slower declines in IHD mortality than women of other race/ethnicity groups. IHD mortality trends were similar in black and white men age 35–54. Conclusions: The decline in IHD mortality rates has slowed in recent years among younger, but not older, individuals in NYC. There was an association between sex and race/ethnicity on IHD mortality rates and trends. Young black women may benefit from targeted medical and public health interventions to reduce IHD mortality. [ABSTRACT FROM AUTHOR]

Objective: Urbanization is an important determinant of cardiovascular disease (CVD) risk. To determine location-based differences in CVD risk factors in India we performed studies among women in rural, urban-poor and urban middle-class locations. Methods: Population-based cross-sectional studies in rural, urban-poor, and urban-middle class women (35–70y) were performed at multiple sites. We evaluated 6853 women (rural 2616, 5 sites; urban-poor 2008, 4 sites; urban middle-class 2229, 11 sites) for socioeconomic, lifestyle, anthropometric and biochemical risk factors. Descriptive statistics are reported. Results: Mean levels of body mass index (BMI), waist circumference, waist-hip ratio (WHR), systolic BP, fasting glucose and cholesterol in rural, urban-poor and urban-middle class women showed significantly increasing trends (ANOVAtrend, p <0.001). Age-adjusted prevalence of diabetes and risk factors among rural, urban-poor and urban-middle class women, respectively was, diabetes (2.2, 9.3, 17.7%), overweight BMI ≥25 kg/m2 (22.5, 45.6, 57.4%), waist >80 cm (28.3, 63.4, 61.9%), waist >90 cm (8.4, 31.4, 38.2%), waist hip ratio (WHR) >0.8 (60.4, 90.7, 88.5), WHR>0.9 (13.0, 44.3, 56.1%), hypertension (31.6, 48.2, 59.0%) and hypercholesterolemia (13.5, 27.7, 37.4%) (Mantel Haenszel X2 ptrend <0.01). Inverse trend was observed for tobacco use (41.6, 19.6, 9.4%). There was significant association of hypertension, hypercholesterolemia and diabetes with overweight and obesity (adjusted R2 0.89–0.99). Conclusions: There are significant location based differences in cardiometabolic risk factors in India. The urban-middle class women have the highest risk compared to urban-poor and rural. [ABSTRACT FROM AUTHOR]

Background: The physiological demands of pregnancy on the maternal cardiovascular system can catapult women into a metabolic syndrome that predisposes to atherosclerosis in later life. We sought to identify the nature of the epigenomic changes associated with the increased cardiovascular disease (CVD) risk in adult women following pre-eclampsia. Findings: We assessed the genome wide epigenetic profile by methyl-C sequencing of monozygotic parous twin sister pairs discordant for a severe variant of pre-eclampsia. In the adult twin sisters at risk for CVD as a consequence of a complicated pregnancy, a set of 12 differentially methylated regions with at least 50% difference in methylation percentage and the same directional change was found to be shared between the affected twin sisters and significantly different compared to their unaffected monozygous sisters. Conclusion: The current epigenetic marker set will permit targeted analysis of differentially methylated regions potentially related to CVD risk in large cohorts of adult women following complicated pregnancies. [ABSTRACT FROM AUTHOR]

Background: It is well known that hepatic hemodynamics is an important physiologic mechanism in the regulation of cardiac output (CO). It has been reported that maternal cardiac output relates to neonatal weight at birth. Aims: In this study, we assessed the correlation between maternal hepatic vein Doppler flow parameters, cardiac output and neonatal birth weight. Methods: Healthy women with uncomplicated second or third trimester pregnancy attending the outpatient antenatal clinic of Ziekenhuis Oost-Limburg in Genk (Belgium), had a standardized combined electrocardiogram-Doppler ultrasound with Impedance Cardiography, for measurement of Hepatic Vein Impedance Index (HVI  =  [maximum velocity – minimum velocity]/maximum velocity), venous pulse transit time (VPTT  =  time interval between corresponding ECG and Doppler wave characteristics) and cardiac output (heart rate x stroke volume). After delivery, a population-specific birth weight chart, established from a cohort of 27000 neonates born in the index hospital, was used to define customized birth weight percentiles (BW%). Correlations between HVI, VPTT, CO and BW% were calculated using Spearman's ρ, linear regression analysis and R2 goodness of fit in SPSS 22.0. Results: A total of 73 women were included. There was a negative correlation between HVI and VPTT (ρ = −0.719, p<0.001). Both HVI and VPTT correlated with CO (ρ = −0.403, p<0.001 and ρ = 0.332, p<0.004 resp.) and with BW% (ρ = −0.341, p<0.003 and ρ = 0.296, p<0.011 resp.) Conclusion: Our data illustrate that the known contribution of hepatic hemodynamics in the regulation of cardiac output is also true for women with uncomplicated pregnancies. Our study is the first to illustrate a potential link between maternal hepatic hemodynamics and neonatal birth weight. Whether this link is purely associative or whether hepatic vascular physiology has a direct impact on fetal growth is to be evaluated in more extensive clinical and experimental research. [ABSTRACT FROM AUTHOR]