Electronic Journal Club 2009

This journal club is a part of the education component of Women's Heart Health at Stanford and serves to keep all of us informed and up to date on sex differences in cardiovascular disease.

The key feature of the articles is that they will address sex differences related to cardiovascular disease, but they can come from any discipline (ie, mental health, genetics, ob/gyn, heart failure, nutrition, etc.) Sex-specific articles will also be considered.

December 2009
Angina Symptoms Are Associated With Mortaltiy in Older Women With Ischemic Heart Disease
Berecki-Gisolf et al. Circulation 2009;120:2330-2336

Psychotropic Medication Use and Risk of Adverse Cardiovascular Events in Women with Suspected Coronary Artery Disease: Outcomes from the Women’s Ischemia Syndrome Evaluation (WISE) Study. Heart 2009;95:1901-1906

Age and Gender Effects on the Extent of Myocardial Involvement in Acute Myocarditis: A Cardiovascular Magnetic Resonance Study. Heart 2009;95:1925-1930

I've included two additional articles this month. The first demonstrates that women have a unique increase in their lipids at the time of menopause. The second shows sex differences in attainment of NIH RO1 awards.

November 2009
Women Have a Lower Prevalence of Structural Heart Disease as a Precursor to Sudden Cardiac Arrest: The Ore-SUDS (Oregon Sudden Unexpected Death Study)
Chugh et al. J Am Coll Cardiol 2009;54:2006-11

There were were two additional articles of interest this month. The first demonstrated that age and sex can help with selecting patients who would derive the greatest diagnostic benefit from CTA in the setting of acute chest pain. The second showed that clopidogrel is as safe and effective in women as it is men.

October 2009
Significantly Improved Vascular Complications Among Women Undergoing Percutaneous Coronary Intervention: A Report From the Northern New England Percutaneous Coronary Intervention Registry
Ahmed et al. Circ Cardiovasc Intervent 2009;2:423-429

Gender Differences in Survival in Patients with Severe Left Ventricular Dysfunction Despite Similar Extent of Myocardial Scar Measured on Cardiac Magnetic Resonance. Eur J Heart Fail 2009;11:937-944

Two other articles are included this month. The first shows that age-adjusted mortality from ST-elevation myocardial infraction has significantly decreased over the past 16 years, but there remains a persistently higher mortality rate in women. The second concludes that women in middle eastern countries present with more risk factors and have poorer outcomes with ST-elevation MI, similar to women in America, Europe, and Asia, making these disparities global rather than regional.

September 2009
Use of implantable cardioverter defibrillators for primary prevention in the community: Do women and men equally meet trial enrollment criteria?
Daugherty et al. Am Heart J 2009;158:224-9

This month’s article investigates why women may be less likely to undergo ICD implantation for the primary prevention of sudden cardiac death than men. It uses a large registry to evaluate sex differences in meeting enrollment criteria of either the MADIT-II or SCD-HeFT trials. The hypothesis was that women would be more likely to meet criteria, suggesting a relative permissiveness (overutilization) of ICDs in men.

There were several other articles this month. The first was also about ICDs, reporting that ICD therapy for the primary prevention of sudden cardiac death in women does not reduce all-cause mortality. The second found that variations in retinal vessel caliber (both wider venules and narrower arterioles, which may reflect coronary microvascular damage) are associated with an increased risk for incident CHD in women but not men. The third looked at sex and race, showing that physical activity is associated with increases in HDL among black and white women and men, while decreases in triglycerides occur among white participants, and decreases in LDL are seen in women, particularly black women. Finally, the fourth article is a letter to the editor about sex differences and seasonal variations in lipids.

August 2009
Aspirin Resistance in Healthy Drug-Naïve Men Versus Women (from the Heredity and Phenotype Intervention Heart Study)
Shen et al. Am J Cardiol 2009; 104:606-612

This month's article is about sex differences in pharmacology, specifically platelet function and aspirin. It provokes some interesting thoughts about why aspirin is effective for the primary prevention of stroke, but not heart disease, in women under the age of 65, while it is effective for the primary prevention of heart disease, but not stroke, in similarly aged men.

As often occurs, there were several other articles of interest in August. The first shows that while there are sex-based differences in 30-day mortality among patients with ACS, most of these differences are explained by clinical differences at baseline and severity of angiographic disease. The second demonstrates that women with diabetes have worse cardiovascular risk profiles than men with diabetes, and this is particularly true of African American and Hispanic women. Perhaps this helps explain why diabetes appears to confer a worse prognosis in women compared with men. The third investigates the outcomes of women and men who are newly diagnosed with angina in the primary care setting, finding that men are more likely to undergo revascularization, have an acute myocardial infarction, and die from ischemic heart disease. Finally, there is a great review of heart failure in women.

July 2009
Impact of Sex on 3-Year Outcome After Percutaneous Coronary Intervention Using Bare-Metal and Drug-Eluting Stents in Previously Untreated Coronary Artery Disease
Onuma et al. J Am Coll Cardiol Intv 2009;2:603-10

Gender Differences in Sympathetic Neural Activation Following Uncomplicated Acute Myocardial Infarction. Eur Heart J 2009;30:1764-1770

This month's article confirms that women undergoing PCI basically do as well as men, and both sexes have equally benefitted from drug-eluting stents. An exception that remains is women presenting with acute myocardial infarction, who do not fare as well. In addition, we know that bleeding and vascular complications are higher in women than men, and that younger women may have worse outcomes than younger men. Neither of these latter two points were evaluated in the current study.

I have included several other articles that were published in the first of this month's American Journal of Cardiology. The first describes different electophysiolgic characteristics of focal atrial tachycardia (FAT) between women and men. The second evaluates age- and sex-related differences in quality of care and outcomes of patients hospitalized with heart failure, showing perhaps an improvement in medical care and clinical outcomes in women compared with previous reports. The third shows a steady deline in the age-adjusted incidence of acute ST-elevation myocardial infarction in the United States from 1997 to 2004 to 1/2 of that which it was in the previous 8 years. This decline was similar for women and men, with the ratio of STEMI in women to men remaining 1/2 throughout the study period.

June 2009
The Joint Contribution of Sex, Age and Type of Myocardial Infarction on Hospital Mortality Following Acute Myocardial Infarction
Champney et al. Heart 2009;95:895-899

This month's article is yet another attempt to determine the interaction of sex, age, and myocardial infarction. It analyzes data from the National Registry of Myocardial Infarction (NRMI). It is fairly consistent with previous data showing an excess risk of hospital mortality among younger women (age <70 years) presenting with STEMI compared with similarly aged men, and also demonstrates a survival benefit among older women (age >70 years) presenting with NSTEMI compared with similarly presenting men of the same age.

May 2009
Impact of Gender and Antithrombin Strategy on Early and Late Clinical Outcomes in Patients with Non-ST-Elevation Acute Coronary Syndromes (from the ACUITY Trial)
Lansky et al. Am J Cardiol 2009;103:1196-1203

This month's article again addresses sex differences in bleeding complications in the cath lab. Last month was about using a different access site (radial instead of femoral artery), while this month considers using a different antithrombotic regimen, specifically bivalirudin instead of heparin plus a glycoprotein IIb/IIIa inhibitor. What would be interesting is a trial pitting bivalirudin and a femoral approach against heparin + IIb/IIIa and a radial approach.

I have included some other articles that were published in May. The first investigates sex differences in coronary atherosclerotic plaque, demonstrating that differences decrease with increasing age. The other two articles are publications from the WISE study, one showing worse outcomes in women with symptoms of angina, but normal appearing coronary arteries compared to normal controls, and the other suggesting that somatic, but not cognitive/affective depressive symptoms are associated with an increased risk of cardiovascular events in women with suspected myocardial ischemia.

April 2009
Impact of female gender and transradial coronary stenting with maximal antiplatelet therapy on bleeding and ischemic outcomes
Tizón-Marcos et al. Am Heart J 2009;157:740-5

Effect of Hormone Replacement Therapy on Vasomotor Function of the Coronary Microcirculation in Post-Menopausal Women with Medically Treated Cardiovascular Risk Factors. Eur Heart J 2009;30:978-986

This month's article we are reviewing an article that evaluated sex differences in transradial PCI. We started transradial catheterization at Stanford almost a year ago because of the benefit in lowering bleeding and vascular complications in women.

I have attached several other articles that were published in April. The first examines trends in mortality among women and men with diabetes, and has different findings that the NHANES data that we reviewed in August 2007. The second looks at the impact of smoking on premature myocardial infarction in women compared with men. The third shows that women, particularly older women, are less likely to receive guideline-indicated heart failure therapies, although the fourth finds improved outcomes in women with heart failure compared to men, regardless of race.

March 2009
Gender Differences in Procedure-Related Adverse Events in Patients Receiving Implantable Cardioverter-Defibrillator Therapy
Peterson et al. Circulation 2009;119:1078-1084

Influence of Gender of Physicians and Patients on Guideline-Recommended Treatment of Chronic Heart Failure in a Cross-Sectional Study. Eur J Heart Fail 2009;11:299-303

Survival Trends in Men and Women with Heart Failure of Ischaemic and Non-Ischaemic Origin: Data for the Period 1987–2003 from the Swedish Hospital Discharge Registry. Eur Heart J 2009;30:671-678

This month's article was discussed by Dr. Hadas Shiran at the cardiovascular medicine fellow's monthly journal club. The faculty commentator was contributing author Dr. Paul Heidenreich. The article concludes that women have higher rates of in-hospital adverse events with ICD implantation, reflecting what we've seen with PCI and CABG. Notably, with the knowledge of higher complication rates in women with PCI and CABG, those rates have decreased. Hopefully, over time, the same will occur with ICD implantation.

I am attaching two other articles noted in March. The first demonstrates that stress echocardiography is similarly prognostic in women and men with known and suspected coronary artery disease. The second finds an association of depression and fatal CHD, as well as an association between antidepressant use and sudden cardiac death, in women without baseline CHD.

February 2009
Gender Differences in Stroke Incidence and Poststroke Disability in the Framingham Heart Study
Petrea et al. Stroke 2009;40:00-00 (electronically published ahead of print)

Gender Differences and Risk of Ventricular Tachycardia or Ventricular Fibrillation. Heart Rhythm 2009;6:180-186

February brings American Heart Month and National Wear Red Day (part of the AHA's Go Red for Women campaign to raise awareness of heart disease in women), so we increasingly think of February as Women's Heart Health Month. As is typical, special publications focusing on women and cardiovascular disease appear in February, and this year is no exception. A special Go Red for Women issue of Stroke and an Antithrombotic Research in Women issue of Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB) have both been released ahead of print. The Stroke issue will officially be published in April, while the ATVB issue will be published in March.

There are many articles in these two journals that are worth reviewing on your own. I decided to focus on stroke in women, and am featuring a Framingham study that investigated sex differences in stroke incidence, severity, and post-stroke disability. There is also an article showing preliminary data on carotid endarterectomy versus stenting in women compared with men that is interesting. At the same time, there are important sex differences in the prevalence and presentation of arterial and venous thrombosis. Likewise, sex hormones alter procoagulant protein expression and the function of blood and vascular cells, and women and men do not accrue equal benefit from antithrombotic therapy. The ATVB publication also has an article reviewing the status of women in cardiovascular clinical trials.

January 2009
Impact of Depression on Sex Differences in Outcome after Myocardial Infarction
Parashar et al. Circ Cardiovasc Qual Outcomes 2009;2:33-40

This month's article adds more information to the complex interplay of depression and cardiovascular disease. Women have higher rates of depression than men, both in the general population and after a myocardial infarction. Depression is associated with worse outcomes in both women and men, but may contribute to the excess rates of rehospitalization and angina seen in women post-MI compared with men.

I have included three other articles, also published in Circulation's Cardiovascular Quality and Outcomes journal this month. The first shows that, compared with similar men, women with cardiac complaints have a 50% greater odds of being delayed in the EMS setting. The second demonstrates that, compared with usual care, a group-based psychosocial intervention program for women following an acute cardiac event results in a significant reduction in all-cause mortality independent of other prognostic factors. The third, using the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) continues to show that women with an acute coronary syndrome undergoing percutaneous coronary intervention have higher rates of in-hospital complications and receive less evidence-based medical therapy than men.

Finally, this Friday, February 6 is National Wear Red Day. This event is part of the American Heart Association's Go Red for Women Campaign designed to raise awareness of heart disease in women. To show support of clinical, research, and educational efforts in women and heart disease, Stanford Hospitals and Clinics will be "going red" on Friday by encouraging everyone to wear red.

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