Search

The prevalence of cardiovascular disease (CVD) in pregnancy, both diagnosed and previously unknown, is rising, and CVD is a leading cause of maternal morbidity and mortality. Historically, women of child-bearing potential have been underrepresented in research, leading to lasting knowledge gaps in the cardiovascular care of pregnant and lactating women. Despite these limitations, clinicians should be familiar with the safety of frequently used diagnostic and therapeutic interventions to adequately care for this at-risk population. This review, the fourth of a 5-part series, provides evidence-based recommendations regarding the use of common cardiovascular diagnostic tests and medications in pregnant and lactating women.

Purpose of Review Heart centers for women (HCW) were developed due to the rising cardiovascular morbidity and mortality in women in the United States in the early 1990s. Our review encompasses the epidemiology, risk factors, diagnostic strategies, treatments, and the role of HCW in managing women with ischemic heart disease (IHD). Recent Findings HCW use a multidisciplinary team to manage women with IHD. Due to the paucity of randomized controlled trials investigating various manifestations of IHD, some treatments are not evidence-based such as those for coronary microvascular dysfunction and spontaneous coronary artery dissection. Sex-specific risk factors have been identified and multimodality cardiac imaging is improving in diagnosing IHD in women. Treatments are being studied to help improve symptoms and outcomes in women with IHD. Summary There has been progress in the care of women with IHD. HCW can be instrumental in treating women with IHD, doing research, and being a source of research study participants.

Takotsubo Cardiomyopathy (TC) is an uncommon, transient, reversible cardiomyopathy, with a classic pattern of wall-motion abnormalities, usually seen in women after an emotional stressor. Despite its increased recognition, there remain gaps in the exact mechanisms, predisposing factors, and predictors of recovery; this is particularly true for males where the condition occurs far less frequently than in females. TC typically resolves within weeks, and the prognosis is favorable compared to acute coronary syndromes. Nonetheless, about 1% of cases may be complicated by left ventricular (LV) thrombus and embolism. Herein we describe an atypical case of a man with no obvious trigger, who developed TC with left ventricular thrombus and multiple embolic complications, but subsequently showed complete and full resolution. Multimodality imaging including echocardiography, cardiac CT and cardiac MRI was instrumental in this diagnostic dilemma, as well as useful in guiding treatment options and informing prognosis.

Background: To investigate sex differences in coronavirus disease 2019 (COVID-19) outcomes in a large Illinois-based cohort. Methods: A multicenter retrospective cohort study compared males versus females with COVID-19 infections from March 1, 2020, to June 21, 2020, in the Rush University System. We analyzed sex differences in rates of hospitalization, intensive care unit (ICU) admission, vasopressor use, endotracheal intubation, and death in this cohort. A multivariable model correcting for age and sum of comorbidities was used to explore associations between sex and COVID-19-related outcomes. Results: There were 8108 positive COVID-19 patients-4300 (53.0%) females and 3808 (47.0%) males. Males had higher rates of hospitalization (19% vs. 13%; p < 0.001), ICU transfer (8% vs. 4%; p < 0.001), vasopressor support (4% vs. 2%; p < 0.001), and endotracheal intubation (5% vs. 2%; p < 0.001). Of those who died, 92 were males and 64 were females (2% vs. 1%; p = 0.003). A multivariable model correcting for age and sum of comorbidities showed a significant association between male sex and mortality in the total cohort (odds ratio, 1.96; 95% confidence interval, 1.34-2.90; p = 0.001). Conclusion: Male sex was independently associated with death, hospitalization, ICU admissions, and need for vasopressors or endotracheal intubation, after correction for important covariates.

Introduction: The novel coronavirus disease 2019 (COVID-19) pandemic has affected millions of people worldwide. Higher COVID-19 mortality in men compared to women seen in many countries is not yet explained. We analyzed sex differences in COVID-19 outcomes in a large Illinois-based cohort. Methods: This is a multicenter retrospective cohort study of confirmed COVID-19 infections from March 1–June 3, 2020 in Rush University System. We compared men and women with COVID-19 infection for the rates of hospitalization, intensive care unit (ICU) admission, vasopressor use, endotracheal intubation, and death. A multivariable model correcting for age, race, and sum of comorbidities (obesity, hypertension, diabetes, coronary artery disease, heart failure, end-stage renal disease, asthma, chronic obstructive pulmonary disease, active smoking) was used to determine independent association with outcomes. Results: Of the 8,086 patients who tested positive, 4,267 (53%) were females, while 3,819 (47%) were males. Males had a higher rate of hospitalization (19% vs. 14%; p Conclusions: There were more women who tested positive for COVID-19 disease. Male sex was independently associated with higher rates of death, hospitalization, ICU admissions, need for vasopressors or endotracheal intubation, after correction for important covariates. The interplay of biological and and behavioral factors is likely responsible for the worse outcomes observed in men with COVID-19 infection. Further investigations into the pathophysiology of sex differences in COVID-19 outcomes responses are needed.

Coronary artery disease (CAD) is a major cause of morbidity and mortality globally and poses a threat to both men and women across their lifespans. There is accumulating evidence to support that CAD may present differently in women and men, ranging from the clinical presentation, diagnosis, and management of the disease to underlying differences in the biological and pathophysiological mechanisms. This has called for an expansion of our conventional tools used in the diagnosis and management of obstructive CAD. Understanding these key sex differences will potentially help tailor our diagnostic and treatment strategies and provide equitable and optimal care to both men and women. Numerous studies have consistently shown that women with CAD tend to be older, have a higher burden of co-morbidities, and experience worse outcomes compared to their male counterparts. Women tend to wait longer to seek medical care for cardiovascular symptoms and when they do, they are usually referred late in the disease process and treated less aggressively. Women are significantly underrepresented in most cardiovascular clinical trials, thereby creating an important limitation in the evidence base used for treating cardiovascular disease in women. In this review, we sought to describe the sex-based considerations in evaluation and management of obstructive CAD, underscore the mechanisms behind these considerations, and help develop a more personalized approach according to current paradigms.

Microvascular disease, or small-vessel disease, is a multisystem disorder with a common pathophysiological basis that differentially affects various organs in some patients. The prevalence of small-vessel disease in the heart has been found to be higher in women compared with men. Additionally, other diseases prominently affecting women, including heart failure with preserved ejection fraction, Takotsubo cardiomyopathy, cerebral small-vessel disease, preeclampsia, pulmonary arterial hypertension (PAH), endothelial dysfunction in diabetes, diabetic cardiomyopathy, rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis, may have a common etiologic linkage related to microvascular disease. To the best of our knowledge this is the first article to investigate this potential linkage. We sought to identify various diseases with a shared pathophysiology involving microvascular/endothelial dysfunction that primarily affect women, and their potential implications for disease management. Advanced imaging technologies, such as magnetic resonance imaging and positron-emission tomography, enable the detection and increased understanding of microvascular dysfunction in various diseases. Therapies that improve endothelial function, such as those used in PAH, may also be associated with benefits across the full spectrum of microvascular dysfunction. A shared pathology across multiple organ systems highlights the need for a collaborative, multidisciplinary approach among medical subspecialty practitioners who care for women with small-vessel disease. Such an approach may lead to accelerated research in diseases that affect women and their quality of life.

Cardiovascular disease is now the leading cause of pregnancy-related deaths in the United States. Increasing maternal mortality in the United States underscores the importance of proper cardiovascular management. Significant physiological changes during pregnancy affect the heart's ability to respond to pathological processes such as hypertension and heart failure. These physiological changes further affect the pharmacokinetic and pharmacodynamic properties of cardiac medications. During pregnancy, these changes can significantly alter medication efficacy and metabolism. This article systematically reviews the literature on safety, efficacy, pharmacokinetics, and pharmacodynamics of cardiovascular drugs used for hypertension and heart failure during pregnancy and lactation. The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend transitioning pregnant patients to methyldopa, nifedipine, or labetalol. Heart failure medications, including beta-blockers, furosemide, and digoxin, are relatively safe and can be used effectively. Medications that block the renin angiotensin-aldosterone system have been shown to be beneficial in the general population; however, they are teratogenic and, therefore, contraindicated in pregnancy. Cardiovascular medications can also enter breast milk and, therefore, care must be taken when selecting drugs during the lactation period. A summary of the safety of drugs during pregnancy and lactation from an online resource, LactMed by the National Library of Medicine's TOXNET database, is included. High-risk pregnant patients with cardiovascular disease require a multispecialty team of doctors, including health care providers from obstetrics and gynecology, maternal fetal medicine, internal medicine, cardiovascular disease specialists, and specialized pharmacology expertise.

Heart Centers for Women (HCW) developed as a response to the need for improved outcomes for women with cardiovascular disease (CVD). From 1984 until 2012, more women died of CVD every single year in comparison with men. Initially, there was limited awareness and sex-specific research regarding mortality or outcomes in women. HCW played an active role in addressing these disparities, provided focused care for women, and contributed to improvements in these gaps. In 2014 and 2015, death from CVD in women had declined below the level of death from CVD in comparison with men. Even though awareness of CVD in women has increased among the public and healthcare providers and both sex- and gender-specific research is currently required in all research trials, not all women have benefitted equally in mortality reduction. New strategies for HCW need to be developed to address these disparities and expand the current HCW model. The HCW care team needs to direct academic curricula on sex- and gender-specific research and care; expand to include other healthcare professionals and other subspecialties; provide new care models; address diversity; and include more male providers.

Background: Increased detection of heart disease in women has been advocated nationally in recent years. The atherosclerotic cardiovascular disease (ASCVD) risk score was validated as determinant of the 10-year risk for first occurrence of nonfatal myocardial infarction, coronary heart disease death, or fatal or nonfatal stroke in 2013. While measurement of blood pressure, glucose, and lipid levels are common in screening, the utility of non-traditional methods such as electrocardiogram (ECG) and transthoracic echocardiography (TTE) remains unknown. We examined the association of ECG and TTE abnormalities with ASCVD risk score among asymptomatic women from a community-based event. Methods: Data were gathered from 355 women (mean age 53±13 years, 24.2% African American, 59.7% Caucasian, 6.2% Hispanic, 9.9% Others) from a voluntary cardiovascular community screening event sponsored by the 2BigHearts Foundation and Rush University Medical Center in February 2007 and May 2008. Demographics, lipid panel, blood pressure, self- reported medication lists, co-morbidities, screening TTE, and ECG were obtained. The 10-year ASCVD risk score was ascertained for the cohort (283 persons, 79.7%). Chi-square testing was used to determine association of ECG and/or TTE abnormalities with ASCVD risk score. Results: The average ASCVD risk score for the entire cohort was 5.49%, with a range from 0.1-49.2. The mean ASCVD risk score was elevated in patients with either ECG or TTE abnormalities compared to those with normal findings (ECG: 7.59±9.46 vs. 4.62±5.39, p Conclusion: Detection of ECG and/or TTE abnormalities are associated with elevated ASCVD risk scores in this cohort of asymptomatic women and could potentially identify patients at higher risk for cardiovascular events, and facilitate aggressive risk factor modification. Further studies are needed to confirm ECG and TTE as viable additional screening tools to traditional risk screening.

Evolving knowledge of sex-specific presentations, improved recognition of conventional and novel risk factors, and expanded understanding of the sex-specific pathophysiology of ischemic heart disease have resulted in improved clinical outcomes in women. Yet, ischemic heart disease continues to be the leading cause of morbidity and mortality in women in the United States. The important publication by the Institute of Medicine titled “Women’s Health Research—Progress, Pitfalls, and Promise,” highlights the persistent disparities in cardiovascular disease burden among subgroups of women, particularly women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment. These important health disparities reflect underrepresentation of women in research, with the resultant unfavorable impact on diagnosis, prevention, and treatment strategies in women at risk for cardiovascular disease. Causes of disparities are multifactorial and related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. Lack of awareness in both the public and medical community, as well as existing knowledge gap regarding sex-specific differences in presentation, risk factors, pathophysiology, and response to treatment for ischemic heart disease, further contribute to outcome disparities. There is a critical need for implementation of sex- and gender-specific strategies to improve cardiovascular outcomes. This review is tailored to meet the needs of a busy clinician and summarizes the contemporary trends, characterizes current sex-specific outcome disparities, delineates challenges, and proposes transformative solutions for improvement of the full spectrum of ischemic heart disease clinical care and research in women.

Background A multidisciplinary team at a major academic medical center established an Acutely Decompensated Heart Failure Clinical Pathway (ADHFCP) program to reduce inpatient readmission rates among patients with heart failure which, among several interventions, included an immediate consultation from a cardiologist familiar with an ADHFCP patient when the patient presented at the Emergency Department (ED). This study analyzed how that program impacted utilization of services in the ED and its subsequent effect on rates of admission from the ED and on disposition times. Methods ADHFCP inpatient visits were retrospectively risk stratified and matched with non-program inpatient visits to create a control group. A Cox survival model analyzed the ADHFCP's impact on patients' likelihood to visit the ED. Multivariable ANOVA evaluated the impact of the program on the patients' likelihood of being admitted when presenting at the ED. The ADHFCP's impact on bed-to-disposition time in the ED was evaluated by Wilcoxon's rank-sum test, as were doses of diuretics administered in the ED. Results The survival analysis showed no impact of the ADHFCP on patients' likelihood of visiting the ED, but ADHFCP patients presenting to the ED were 13.1 (95% CI: 3.6–22.6) percentage points less likely to be admitted. There was no difference in bed-to-disposition times, but ADHFCP patients received diuretics more frequently and at higher doses. Conclusions Improved communication between cardiologists and ED physicians through the establishment of an explicit pathway to coordinate the care of heart failure patients may decrease that population's likelihood of admission without increasing ED disposition times.

Patients with both ASD and partial anomalous pulmonary venous connection (PAPVC) are at increased risk for developing right to left shunting due to excess right heart volume overload. Treatment options are guided by degree and reversibility of shunt. A 29 year old female with no significant medical

Background— United States and European cardiovascular society guidelines recommend physicians counsel patients about resuming sexual activity after acute myocardial infarction (AMI), but little is known about patients’ experience with counseling about sexual activity after AMI. Methods and Results— The prospective, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, conducted at 127 hospitals in the United States and Spain, was designed, in part, to evaluate gender differences in baseline sexual activity, function, and patient experience with physician counseling about sexual activity after an AMI. This study used baseline and 1-month data collected from the 2:1 sample of women (N=2349) and men (N=1152) ages 18 to 55 years with AMI. Median age was 48 years. Among those who reported discussing sexual activity with a physician in the month after AMI (12% of women, 19% of men), 68% were given restrictions: limit sex (35%), take a more passive role (26%), and/or keep the heart rate down (23%). In risk-adjusted analyses, factors associated with not discussing sexual activity with a physician included female gender (relative risk, 1.07; 95% confidence interval, 1.03–1.11), age (relative risk, 1.05 per 10 years; 95% confidence interval, 1.02–1.08), and sexual inactivity at baseline (relative risk, 1.11; 95% confidence interval, 1.08–1.15). Among patients who received counseling, women in Spain were significantly more likely to be given restrictions than U.S. women (relative risk; 1.36, 95% confidence interval, 1.11–1.66). Conclusions— Very few patients reported counseling for sexual activity after AMI. Those who did were commonly given restrictions not supported by evidence or guidelines. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00597922.

Background Re-hospitalization after discharge for acute decompensated heart failure is a common problem. Low-socioeconomic urban patients suffer high rates of re-hospitalization and often over-utilize the emergency department (ED) for their care. We hypothesized that early consultation with a cardiologist in the ED can reduce re-hospitalization and health care costs for low-socioeconomic urban patients with acute decompensated heart failure. Methods There were 392 patients treated at our center for acute decompensated heart failure who received standardized education and follow-up. Patients who returned to the ED received early consultation with a cardiologist; 392 patients who received usual care served as controls. Thirty- and 90-day re-hospitalization, ED re-visits, heart failure symptoms, mortality, and health care costs were recorded. Results Despite guideline-based education and follow-up, the rate of ED re-visits was not different between the groups. However, the rate of re-hospitalization was significantly lower in patients receiving the intervention compared with controls (odds ratio 0.592), driven by a reduction in the risk of readmission from the ED (0.56 vs 0.79, respectively). Patients receiving the intervention accumulated 14% fewer re-hospitalized days than controls and 57% lower 30-day total health care cost. Despite the reduction in health care resource consumption, mortality was unchanged. After accounting for the total cost of intervention delivery, the health care cost savings was substantially greater than the cost of intervention delivery. Conclusion Early consultation with a cardiologist in the ED as an adjunct to guideline-based follow-up is associated with reduced re-hospitalization and health care cost for low-socioeconomic urban patients with acute decompensated heart failure.