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OBJECTIVE: To assess the feasibility and diagnostic accuracy of real-time myocardial contrast echocardiography (MCE)-derived absolute myocardial blood flow for detection of myocardial perfusion abnormalities compared with simultaneous technetium 99 m sestamibi single-photon emission computed tomography (SPECT). DESIGN: Prospective study. SETTING: Tertiary-care medical institution. PATIENTS: 79 patients with known or suspected coronary artery disease. INTERVENTIONS: Simultaneous SPECT and real-time MCE during adenosine stress. MAIN OUTCOME MEASURES: Absolute myocardial blood flow (MBF, ml/min/g), microbubble velocity (beta, min(-1)), and reserve values. Endpoints included sensitivity, specificity, positive likelihood ratio (LR+) or negative likelihood ratio (LR-) and area under the curve (AUC) of the receiver operating characteristic curve. RESULTS: Reserve measurements were feasible in 975 of 1343 segments (73%); of these, 130 segments (13%) were abnormal by SPECT. MCE perfusion parameters clearly distinguished abnormal from normal segments for beta reserve (1.13 (0.99) vs 2.22 (1.36), p<0.001) and MBF reserve (1.80 (2.29) vs 3.69 (2.79), p<0.001). The beta reserve cut-off of 1.60 provided the following: AUC, 0.787; sensitivity, 82%; specificity, 66%; LR+, 2.40; and LR-, 0.28. The MBF reserve cut-off of 1.90 provided the following: AUC, 0.779; sensitivity, 73%; specificity, 72%; LR+, 2.69; and LR-, 0.37. MBF reserve had an AUC of 0.773 for the left anterior descending coronary artery, 0.885 for the left circumflex coronary artery and 0.739 for the right coronary artery. CONCLUSIONS: Real-time MCE-derived absolute MBF, beta, and reserve values are feasible and accurate for detecting myocardial perfusion abnormalities as defined by SPECT. [ABSTRACT FROM AUTHOR]

Harmonic and fundamental imaging techniques were directly compared in 20 patients undergoing intravenous contrast echocardiography for enhancement of left ventricular endocardial border definition. Harmonic imaging demonstrated significantly enhanced left ventricular endocardial border detection and improved the duration and intensity of a contrast effect despite a reduced dosing requirement. [ABSTRACT FROM AUTHOR]

Objective: To describe two cases of Takotsubo like myocardial contractile pattern during exercise stress test secondary to hypertensive response.Background: Treadmill exercise testing is known to cause sympathetic stimulation, leading to increased levels of catecholamine, resulting in alteration in vascular tone. Hypertensive response during exercise testing can cause abnormal consequences, resulting in false positive results.Cases: We present the cases of two patients experiencing apical and basal akinesis during exercise stress echocardiography, in whom normal wall motion response was observed on subsequent pharmacologic stress testing. The first patient developed transient left ventricular (LV) apical akinesis during exercise stress echocardiography. Due to high suspicion that this abnormality might be secondary to hypertensive response, pharmacologic stress testing was performed after three days, which was completely normal and showed no such wall motion abnormality. Qualitative assessment of myocardial perfusion using contrast was also performed, which showed good myocardial blood flow, indicating low probability for significant obstructive coronary artery disease. The second patient developed LV basal akinesis as a result of hypertensive response during exercise testing. Coronary angiogram was not performed in either patient due to low suspicion for coronary artery disease, and subsequently negative stress studies.Results: Transient stress induced cardiomyopathy can develop secondary to hypertensive response during exercise stress testing.Conclusion: These cases provide supporting evidence to the hyper-sympathetic theory of left ventricular ballooning syndrome. [ABSTRACT FROM AUTHOR]

Point-of-care ultrasound (POCUS) involves the acquisition, interpretation, and immediate clinical integration of ultrasonographic imaging performed by a treating clinician. The current state of cardiac POCUS terminology is heterogeneous and ambiguous, in part because it evolved through siloed specialty practices. In particular, the medical literature and colloquial medical conversation contain a wide variety of terms that equate to cardiac POCUS. While diverse terminology aided in the development and dissemination of cardiac POCUS throughout multiple specialties, it also contributes to confusion and raises patient safety concerns. This statement is the product of a diverse and inclusive Writing Group from multiple specialties, including medical linguistics, that employed an iterative process to contextualize and standardize a nomenclature for cardiac POCUS. We sought to establish a deliberate vocabulary that is sufficiently unrelated to any specialty, ultrasound equipment, or clinical setting to enhance consistency throughout the academic literature and patient care settings. This statement (1) reviews the evolution of cardiac POCUS-related terms; (2) outlines specific recommendations, distinguishing between intrinsic and practical differences in terminology; (3) addresses the implications of these recommendations for current practice; and (4) discusses the implications for novel technologies and future research., (Copyright © 2024. Published by Elsevier Inc.)

Myocardial infarction with no obstructive coronary artery disease (MINOCA) represents 6%-15% of all acute coronary syndromes, and women are disproportionately represented. MINOCA is an encompassing preliminary diagnosis, and emerging evidence supports a more expansive comprehensive diagnostic and therapeutic clinical approach. The current clinical practice update summarizes the latest evidence regarding the epidemiology, clinical presentation, and diagnostic evaluation of MINOCA. A cascaded approach to diagnostic workup is outlined for clinicians, for noninvasive and invasive diagnostic pathways, depending on clinical setting and local availability of diagnostic modalities. Evidence concerning the nonpharmacological and pharmacological treatment of MINOCA are presented and summarized according to underlying cause of MINOCA, with practical tips on the basis of expert opinion, outlining a real-life, evidence-based, comprehensive approach to management of this challenging condition., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Cardiovascular disease (CVD) is the leading cause of death in women worldwide, and of premature death in women in Canada. Despite improvements in cardiovascular care over the past 15-20 years, acute coronary syndrome (ACS) and CVD mortality continue to increase among women in Canada. Chest pain is a common symptom leading to emergency department visits for both men and women. However, women with ACS experience worse outcomes. compared with those of men, due to misdiagnosis or lack of diagnosis resulting in delayed care and underuse of guideline-directed medical therapies. CVD mortality rates are highest in Indigenous and racialized women and those with a disproportionately high number of adverse social determinants of health. CVD remains underrecognized, underdiagnosed, undertreated, and underresearched in women. Moreover, a lack of awareness of unique symptoms, clinical presentations, and sex-and-gender specific CVD risk factors, by healthcare professionals, leads to outcome disparities. In response to this knowledge gap, in acute recognition and management of chest-pain syndromes in women, the Canadian Women's Heart Health Alliance performed a needs assessment and review of CVD risk factors and ACS pathophysiology, through a sex and gender lens, and then developed a unique chest-pain assessment protocol utilizing modified dynamic programming algorithmic methodology. The resulting algorithmic protocol is presented. The output is intended as a quick reference algorithm that could be posted in emergency departments and other acute-care settings. Next steps include protocol implementation evaluation and impact assessment on CVD outcomes in women., (© 2023 The Authors.)

This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada., (© 2023 The Authors.)

Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women., (© 2023 The Authors.)

Aims: The EACVI Scientific Initiatives Committee and the EACVI women's taskforce conducted a global survey to evaluate the barriers faced by women in cardiovascular imaging (WICVi)., Methods and Results: In a prospective international survey, we assessed the barriers faced at work by WICVi. Three hundred fourteen participants from 53 countries responded. The majority were married (77%) and had children (68%), but most reported no flexibility in their work schedule during their pregnancy or after their maternity leave. More than half of the women reported experiencing unconscious bias (68%), verbal harassment (59%), conscious bias (51%), anxiety (70%), lack of motivation (60%), imposter syndrome (54%), and burnout (61%) at work. Furthermore, one in five respondents had experienced sexual harassment, although this was rarely reported formally. The majority reported availability of mentorship (73%), which was mostly rated as 'good' or 'very good'. While more than two-thirds of respondents (69%) now reported being well trained and qualified to take on leadership roles in their departments, only one-third had been afforded that opportunity. Despite the issues highlighted by this survey, >80% of the participating WICVi would still choose cardiovascular imaging if they could restart their career., Conclusion: The survey has highlighted important issues faced by WICVi. While progress has been made in areas such as mentorship and training, other issues including bullying, bias, and sexual harassment are still widely prevalent requiring urgent action by the global cardiovascular imaging community to collectively address and resolve these challenges., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The performance of the American College of Cardiology/American Heart Association pooled cohort equation (PCE) for atherosclerotic cardiovascular disease (ASCVD) in real-world clinical practice has not been evaluated extensively., Objectives: The goal of this study was to test the performance of PCE to predict ASCVD risk in the community, and determine if including individuals with values outside the PCE range (ie, age, blood pressure, cholesterol) or statin therapy initiation over follow-up would significantly affect PCE predictive capabilities., Methods: The PCE was validated in a community-based cohort of consecutive patients who sought primary care in Olmsted County, Minnesota, between 1997 and 2000, followed-up through 2016. Inclusion criteria were similar to those of PCE derivation. Patient information was ascertained by using the record linkage system of the Rochester Epidemiology Project. ASCVD events (nonfatal and fatal myocardial infarction and ischemic stroke) were validated in duplicate. Calculated and observed ASCVD risk and c-statistics were compared across predefined groups., Results: This study included 30,042 adults, with a mean age of 48.5 ± 12.2 years; 46% were male. Median follow-up was 16.5 years, truncated at 10 years for this analysis. Mean ASCVD risk was 5.6% ± 8.73%. There were 1,555 ASCVD events (5.2%). The PCE revealed good performance overall (c-statistic 0.78) and in sex and race subgroups; it was highest among non-White female subjects (c-statistic 0.81) and lowest in White male subjects (c-statistic 0.77). Out-of-range values and initiation of statin medication did not affect model performance., Conclusions: The PCE performed well in a community cohort representing real-world clinical practice. Values outside PCE ranges and initiation of statin medication did not affect performance. These results have implications for the applicability of current strategies for the prevention of ASCVD., Competing Interests: Funding Support and Author Disclosures This study used the resources of the Rochester Epidemiology Project (REP) medical records linkage system, which is supported by the National Institute on Aging (AG 058738), by the Mayo Clinic Research Committee, and by fees paid annually by REP users. Dr Somers is supported by the Mayo Foundation Alice Sheets Marriott Professorship. The content of this paper is solely the responsibility of the authors and does not represent the views of the funding sources. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The impact of the presence or absence of sex hormones on women's health is woefully underresearched. Fundamentally, women's bodies are now understood to spend considerable time under widely fluctuating hormonal influences, including puberty, pregnancy, peripartum, and menopause, and a woman's vessels are therefore preset for functional and physiological alterations based on levels of sex hormones. However, our understanding of the influences of sex hormones on the regulation of a multitude of biological and physiological processes has not translated into the development and/or collection or analyses of data on therapeutic treatments and/or outcomes in the context of women's disease management., (© 2023 The Authors.)

Cardiac rehabilitation is associated with lower mortality and improved psychosocial outcomes. However, disparities exist in referral and access to cardiac rehabilitation for Nova Scotian women, a situation exacerbated by the COVID-19 pandemic. Women@Heart (W@H) is a 4-month community-based peer support program developed and validated by the University of Ottawa Heart Institute, for women living with heart disease. The program aims to empower women with coping strategies, provide a supportive learning environment, and establish volunteer advocacy groups. The primary objective of this study is to evaluate the implementation feasibility of the W@H program for women living in Nova Scotia. The primary outcome is the implementation feasibility of W@H in Nova Scotia, measured through participant attendance and program completion rates. Peer leaders will record participant attendance. The psychosocial impact of W@H will be assessed using psychometric tools that measure the following: social support, adaptive coping, stress, symptoms of anxiety and depression, and health-related and disease-specific quality of life. Data will be collected using a pre- and post-program questionnaire administered to participants. The pilot program is expected to commence in the first quarter of 2024. One peer leader with lived experience of heart disease, who has previously completed the W@H program as a participant, has been trained. Participants have been identified through healthcare provider referral, self-referral, brochures, and peer-networking. Each cohort will consist of 5-10 participants. The W@H pilot project will assess the implementation feasibility and the impact of community-based peer support on the well-being of Nova Scotian women living with heart disease., (© 2023 The Authors.)

Abstract: Many physicians, particularly those practicing in remote regions, lack training opportunities to develop point-of-care ultrasound (POCUS) skills. This pretest-posttest study quantified the skill improvement of learners after participating in a virtual training program that used real-time, remotely delivered point-of-care tele-ultrasound (tele-POCUS) for teaching and learner feedback provision. Ten physicians practicing in an urban tertiary (Kingston, Ontario, Canada, n = 6) or remote care center (Moose Factory, Ontario, Canada, n = 4) completed a 3-week educational program that consisted of e-learning module review, independent image acquisition practice, and expert-guided tele-POCUS consultations. Pretraining and posttraining assessments were performed to evaluate skill enhancement in image acquisition, image quality, and image interpretation for cardiac and lung/pleura POCUS using a 5-point Likert scale. A total of 76 tele-POCUS consultations were performed during the study period. Significant improvements in image quality were noted following remotely delivered mentorship and guidance (all P < 0.01). In cardiac POCUS, pretraining and posttraining comparisons noted significant improvements in image acquisition (means, 2.69-4.33; P < 0.02), quality (means, 2.40-4.03; P < 0.01), and interpretation (means, 2.50-4.40; P < 0.02). In lung/pleura POCUS, significant improvements in image acquisition (means, 3.00-4.43; P < 0.01), quality (means, 3.23-4.37; P < 0.01), and interpretation (means, 3.00-4.40; P < 0.01) were demonstrated. Introductory ultrasound can be taught to novice users using a virtual, live-streamed training format with tele-POCUS while demonstrating significant enhancement in imaging skills., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Women vs men have major differences in terms of risk-factor profiles, social and environmental factors, clinical presentation, diagnosis, and treatment of cardiovascular disease. Women are more likely than men to experience health issues that are complex and multifactorial, often relating to disparities in access to care, risk-factor prevalence, sex-based biological differences, gender-related factors, and sociocultural factors. Furthermore, awareness of the intersectional nature and relationship of sociocultural determinants of health, including sex and gender factors, that influence access to care and health outcomes for women with cardiovascular disease remains elusive. This review summarizes literature that reports on under-recognized sex- and gender-related risk factors that intersect with psychosocial, economic, and cultural factors in the diagnosis, treatment, and outcomes of women's cardiovascular health., (© 2023 The Authors.)

Objectives: To determine whether ultrasound enhancing agent (UEA) changes maximal wall thickness (WT) in hypertrophic cardiomyopathy (HCM), and if it improves correlation with magnetic resonance imaging (MRI)., Patients and Methods: A total of 107 patients with HCM were prospectively enrolled at a single tertiary referral center between July 10, 2014, and August 31, 2017, and underwent transthoracic echocardiography (TTE) with and without UEA and MRI. Maximal WT measurements were compared, and variability among the 3 modalities was evaluated using a simple linear regression analysis and paired t tests and Bland-Altman plots. Interobserver variability for each technique was assessed., Results: Most (63%) of cardiac imagers found UEA helpful in determining maximal WT by TTE, with 49% reporting change in WT. Of 52 patients where UEA changed WT measurement, 32 (62%) reported an increase and 20 (38%) reported a decrease in WT. The UEA did not alter the median discrepancy in WT between MRI and TTE. However, where UEA increased reported WT, the difference between MRI and TTE improved in 79% of cases ( P =.001) from 2.0-0.5mm. In those with scar on MRI, UEA improved agreement of WT between TTE and MRI compared with that of TTE without UEA (79% vs 39%; P =.011). Interclass correlation coefficient for WT for TTE without UEA, with UEA, and MRI was 0.84; (95% CI, 0.61-0.92), 0.88; (95%CI, 0.82-0.92), and 0.97; (95%CI, 0.96-0.98), respectively., Conclusion: Although use of UEA did not eliminate differences in WT discrepancy between modalities, the addition of UEA to TTE aided in WT determination and improved correlation with MRI in those with greater WT and in all patients with myocardial scars., Competing Interests: The authors have no conflicts of interest to disclose., (© 2023 The Authors.)

Aim: To describe the design of the SOUL trial (Semaglutide cardiOvascular oUtcomes triaL) and the baseline clinical data of its participants., Materials and Methods: In SOUL, the effects of oral semaglutide, the first oral glucagon-like peptide-1 receptor agonist, on the risk of cardiovascular (CV) events in individuals with type 2 diabetes and established atherosclerotic CV disease (ASCVD) and/or chronic kidney disease (CKD) will be assessed. SOUL is a randomized, double-blind, parallel-group, placebo-controlled CV outcomes trial comparing oral semaglutide (14 mg once daily) with placebo, both in addition to standard of care, in individuals aged ≥50 years with type 2 diabetes and evidence of ASCVD (coronary artery disease [CAD], cerebrovascular disease, symptomatic peripheral arterial disease [PAD]) and/or CKD (estimated glomerular filtration rate <60 mL/min/1.73 m 2 ). The primary outcome is time from randomization to first occurrence of a major adverse CV event (MACE; a composite of CV death, nonfatal myocardial infarction or nonfatal stroke). This event-driven trial will continue until 1225 first adjudication-confirmed MACEs have occurred. Enrolment has been completed., Results: Overall, 9650 participants were enrolled between June 17, 2019 and March 24, 2021 (men 71.1%, White ethnicity 68.9%, mean age 66.1 years, diabetes duration 15.4 years, body mass index 31.1 kg/m 2 , glycated haemoglobin 63.5 mmol/mol [8.0%]). The most frequently used antihyperglycaemic medications at baseline were metformin (75.7%), insulin and insulin analogues (50.5%), sulphonylureas (29.1%), sodium-glucose cotransporter-2 inhibitors (26.7%) and dipeptidyl peptidase-4 inhibitors (23.0%). At randomization, 70.7% of participants had CAD, 42.3% had CKD, 21.1% had cerebrovascular disease and 15.7% had symptomatic PAD (categories not mutually exclusive). Prevalent heart failure was reported in 23.0% of participants., Conclusion: SOUL will provide evidence regarding the CV effects of oral semaglutide in individuals with type 2 diabetes and established ASCVD and/or CKD., (© 2023 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Introduction: Female patients are at elevated risk for adverse mental health outcomes following hospital admission for ischemic heart disease. These psychosocial characteristics are correlated with unacceptably higher rates of cardiovascular (CV) morbidity and mortality. Guidelines to address mental health following acute coronary syndrome (ACS) can only be developed with the aid of studies elucidating which subgroups of female patients are at the highest risk., Methods/design: The Female Risk factors for post-Infarction Depression and Anxiety (FRIDA) Study is a prospective multicenter questionnaire-based study of female participants admitted to hospital with ACS. Data are collected within 72 h of admission as well as at 3 and 6 months. At baseline, participants complete a sociodemographic questionnaire, social support survey, and Hospital Depression and Anxiety Scale (HADS). Follow-up will consist of a demographic questionnaire, HADS, changes to health status, and quality of life indicators. Statistical analysis will include descriptive and inferential methods to observe baseline distributions and significance between groups., Discussion/conclusion: Our primary outcome is to determine if specific CV and sociodemographic factors correlate with increased depression and anxiety scores (HADS-D >7; HADS-A >7) at baseline. Our secondary aim is to determine if increased HADS scores at baseline and follow-up correlate with 3 and 6-month health and quality of life outcomes. A total of 2,000 patients will be enrolled across seven study sites. The aim of the FRIDA Study is to understand which groups of female patients have the highest rates of depression and anxiety following ACS to better inform care., (© 2022 S. Karger AG, Basel.)

Background: Cardiovascular diseases (CVD) remain the leading cause of death for women. However, systematic inequalities exist in how women experience clinical cardiovascular (CV) policies, programs, and initiatives., Methods: In collaboration with the Heart and Stroke Foundation of Canada, a question regarding female-specific CV protocols in an emergency department (ED), or an inpatient or ambulatory care area of a healthcare site was sent via e-mail to 450 healthcare sites in Canada. Contacts at these sites were established through the larger initiative-the Heart Failure Resources and Services Inventory-conducted by the foundation., Results: Responses were received from 282 healthcare sites, with 3 sites confirming the use of a component of a female-specific CV protocol in the ED. Three sites noted using sex-specific troponin levels in the diagnosis of acute coronary syndromes; 2 of the sites are participants in the hs- c Tn- O ptimizing the D iagnosis of Acut e M yocardial I nfarction/Injury in Women (CODE MI) trial. One site reported the integration of a female-specific CV protocol component into routine use., Conclusions: We have identified an absence of female-specific CVD protocols in EDs that may be associated with the identified poorer outcomes in women impacted by CVD. Female-specific CV protocols may serve to increase equity and ensure that women with CV concerns have access to the appropriate care in a timely manner, thereby helping to mitigate some of the current adverse effects experienced by women who present to Canadian EDs with CV symptoms., (© 2022 The Authors.)

Background: Females are historically underenrolled in heart failure (HF) randomized controlled trials (RCTs) relative to disease prevalence. Sex differences in trial flow, including withdrawals and losses to follow up, may further limit the generalizability of results., Objectives: This study aimed to assess the frequency of sex-specific reporting of trial flow, treatment efficacy, and adverse events in HF RCTs., Methods: We systematically searched MEDLINE, Embase, and CINAHL for HF RCTs published between 2000 and 2020 in journals with an impact factor ≥10. We assessed whether trial flow, treatment effect, and adverse events were disaggregated by sex. We used multivariable regression to assess associations between trial characteristics and sex subgroup analysis. We analyzed temporal trends in sex-specific reporting., Results: We included 224 RCTs with 228,801 total participants (28.2% female). No RCT reported sex-disaggregated screening, consent, or withdrawal rates; and 2 (0.9%) reported sex-disaggregated losses to follow-up. Seventy-five RCTs (33.4%) presented sex subgroup analysis, and 63 (28.3%) reported sex-treatment interaction. No RCT reported sex-specific adverse events. Large trial size (odds ratio: 13.16, 95% CI: 5.67-30.52; P  < 0.001) and device/procedure interventions (odds ratio: 5.13, 95% CI: 1.55-16.95; P  < 0.007) were independently associated with sex subgroup analysis. Over the study period, there was an increase in sex subgroup analysis ( P  < 0.001) and testing for sex-treatment interaction ( P  < 0.001)., Conclusions: HF RCTs rarely reported sex differences in trial flow or adverse events and uncommonly performed sex subgroup analysis. Improved sex-disaggregated reporting could highlight the causes and extent of sex differences in trial participation and facilitate appropriate inferences about treatment effect., Competing Interests: This work is funded by the 10.13039/501100000024Canadian Institutes of Health Research (principal investigator: Dr Van Spall). Dr Van Spall has received research funding from the 10.13039/501100000024Canadian Institutes of Health Research and 10.13039/100004411Heart and Stroke Foundation of Canada. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2022 The Authors.)

Childhood and adolescent cancer survivors are disproportionately more likely to develop cardiovascular diseases from the late effects of cardiotoxic therapies (e.g., anthracycline-based chemotherapy and chest-directed radiotherapy). Currently, dexrazoxane is the only approved drug for preventing cancer treatment-related cardiac damage. While animal models highlight the beneficial effects of exercise cancer treatment-related cardiac dysfunction, few clinical studies have been conducted. Thus, the objective of this scoping review was to explore the designs and impact of exercise-based interventions for managing cancer treatment-related cardiac dysfunction in childhood and adolescent cancer survivors. Reviewers used Joanna Briggs Institute's methodology to identify relevant literature. Then, 4616 studies were screened, and three reviewers extracted relevant data from six reports. Reviewers found that exercise interventions to prevent cancer treatment-related cardiac dysfunction in childhood and adolescent cancer survivors vary regarding frequency, intensity, time, and type of exercise intervention. Further, the review suggests that exercise promotes positive effects on managing cancer treatment-related cardiac dysfunction across numerous indices of heart health. However, the few clinical studies employing exercise interventions for childhood and adolescent cancer survivors highlight the necessity for more research in this area.

The present CEUS Cardiac Exam Protocols represent the first effort to promulgate a standard set of protocols for optimal administration of ultrasound enhancing agents (UEAs) in echocardiography, based on more than two decades of experience in the use of UEAs for cardiac imaging. The protocols reflect current clinical CEUS practice in many modern echocardiography laboratories throughout the world. Specific attention is given to preparation and dosing of three UEAs that have been approved by the United States Food and Drug Administration (FDA) and additional regulatory bodies in Europe, the Americas and Asia-Pacific. Consistent with professional society guidelines (J Am Soc Echocardiogr 31:241-274, 2018; J Am Soc Echocardiogr 27:797-810, 2014; Eur Heart J Cardiovasc Imaging 18:1205, 2017), these protocols cover unapproved "off-label" uses of UEAs-including stress echocardiography and myocardial perfusion imaging-in addition to approved uses. Accordingly, these protocols may differ from information provided in product labels, which are generally based on studies performed prior to product approval and may not always reflect state of the art clinical practice or guidelines., (© 2022. The Author(s).)

Cardiovascular disease is the leading global cause of mortality, with ischemic heart disease causing the majority of cardiovascular deaths. Despite this, diagnostic delay commonly occurs in women experiencing acute myocardial infarction (AMI) who have a higher associated in-hospital mortality. Several studies have demonstrated that women are significantly more likely than men to experience depression and anxiety following AMI which is linked with increased morbidity, rehospitalization, and mortality, as well as decreased quality of life. Thus, it is imperative that future work aims to understand the factors that put women at higher risk for depression and anxiety following AMI, informing prevention and intervention. This narrative review will summarize the current literature on the association between AMI and mental health in women, including the impact on morbidity, mortality, and quality of life., (Crown Copyright © 2021. Published by Elsevier Inc. All rights reserved.)

This chapter summarizes the sex- and gender-specific diagnosis and treatment of acute/unstable presentations and nacute/stable presentations of cardiovascular disease in women. Guidelines, scientific statements, systematic reviews/meta-analyses, and primary research studies related to diagnosis and treatment of coronary artery disease, cerebrovascular disease (stroke), valvular heart disease, and heart failure in women were reviewed. The evidence is summarized as a narrative, and when available, sex- and gender-specific practice and research recommendations are provided. Acute coronary syndrome presentations and emergency department delays are different in women than they are in men. Coronary angiography remains the gold-standard test for diagnosis of obstructive coronary artery disease. Other diagnostic imaging modalities for ischemic heart disease detection (eg, positron emission tomography, echocardiography, single-photon emission computed tomography, cardiovascular magnetic resonance, coronary computed tomography angiography) have been shown to be useful in women, with their selection dependent upon both the goal of the individualized assessment and the testing resources available. Noncontrast computed tomography and computed tomography angiography are used to diagnose stroke in women. Although sex-specific differences appear to exist in the efficacy of standard treatments for diverse presentations of acute coronary syndrome, many cardiovascular drugs and interventions tested in clinical trials were not powered to detect sex-specific differences, and knowledge gaps remain. Similarly, although knowledge is evolving about sex-specific difference in the management of valvular heart disease, and heart failure with both reduced and preserved ejection fraction, current guidelines are lacking in sex-specific recommendations, and more research is needed., (© 2022 The Authors.)

Cardiovascular disease remains the leading cause of death in women. Given accumulating evidence on sex- and gender-based differences in cardiovascular disease development and outcomes, the need for more effective approaches to screening for risk factors and phenotypes in women is ever urgent. Public health surveillance and health care delivery systems now continuously generate massive amounts of data that could be leveraged to enable both screening of cardiovascular risk and implementation of tailored preventive interventions across a woman's life span. However, health care providers, clinical guidelines committees, and health policy experts are not yet sufficiently equipped to optimize the collection of data on women, use or interpret these data, or develop approaches to targeting interventions. Therefore, we provide a broad overview of the key opportunities for cardiovascular screening in women while highlighting the potential applications of artificial intelligence along with digital technologies and tools.

Although cardiovascular disease (CVD) is the leading cause of mortality in women globally, cardiovascular care for women remains suboptimal, with poorer outcomes than for men. During the past two decades, there has been an incremental increase in research and publications on CVD in women, addressing sex-specific risk factors, symptoms, pathophysiology, treatment, prevention and identification of inequities in care. Nonetheless, once women have manifested CVD, they continue to have increasingly worse outcomes than men. An approach to addressing these global disparities has been the worldwide establishment of specialised centres providing cardiovascular care for women. These women's heart centres (WHCs) allow a comprehensive approach to the cardiovascular care of women across the lifespan. The purpose of this article is to define the need for and role of these specialised centres by outlining sex-specific gaps in CVD care, and to provide guidance on components within WHCs that may be considered when establishing such programmes., Competing Interests: Disclosure: MG is a Guest Editor of the Women and Heart Disease special collection for European Cardiology Review. All other authors have no conflicts of interest to declare., (Copyright © 2021, Radcliffe Cardiology.)

This Atlas chapter summarizes sex- and some gender-associated, and unique aspects and manifestations of cardiovascular disease (CVD) in women. CVD is the primary cause of premature death in women in Canada and numerous sex-specific differences related to symptoms and pathophysiology exist. A review of the literature was done to identify sex-specific differences in symptoms, pathophysiology, and unique manifestations of CVD in women. Although women with ischemic heart disease might present with chest pain, the description of symptoms, delay between symptom onset and seeking medical attention, and prodromal symptoms are often different in women, compared with men. Nonatherosclerotic causes of angina and myocardial infarction, such as spontaneous coronary artery dissection are predominantly identified in women. Obstructive and nonobstructive coronary artery disease, aortic aneurysmal disease, and peripheral artery disease have worse outcomes in women compared with men. Sex differences exist in valvular heart disease and cardiomyopathies. Heart failure with preserved ejection fraction is more often diagnosed in women, who experience better survival after a heart failure diagnosis. Stroke might occur across the lifespan in women, who are at higher risk of stroke-related disability and age-specific mortality. Sex- and gender-unique differences exist in symptoms and pathophysiology of CVD in women. These differences must be considered when evaluating CVD manifestations, because they affect management and prognosis of cardiovascular conditions in women., (© 2021 The Authors.)

Women have unique sex- and gender-related risk factors for cardiovascular disease (CVD) that can present or evolve over their lifespan. Pregnancy-associated conditions, polycystic ovarian syndrome, and menopause can increase a woman's risk of CVD. Women are at greater risk for autoimmune rheumatic disorders, which play a role in the predisposition and pathogenesis of CVD. The influence of traditional CVD risk factors (eg, smoking, hypertension, diabetes, obesity, physical inactivity, depression, anxiety, and family history) is greater in women than men. Finally, there are sex differences in the response to treatments for CVD risk and comorbid disease processes. In this Atlas chapter we review sex- and gender-unique CVD risk factors that can occur across a woman's lifespan, with the aim to reduce knowledge gaps and guide the development of optimal strategies for awareness and treatment., (© 2021 The Authors.)