gender-based approach to cardiovascular monitoring · 2020-01-07 · gender-based approach to...
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Gender-based approach to cardiovascular monitoring
Federica Moscucci
Dipartimento di Scienze Cliniche, Internistiche,
Anestesiologiche e Cardiovascolari
«Sapienza», Università di Roma
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Cardiovascular disease in Europe 2016: epidemiological update
Townsend N Eur Heart J 2016
Proportion of all deaths due to major causes in Europe
Men
Women
CVD in 2012
17.3 million deaths/year worldwide
>23.6 million by 2030
Yahagi et al: Atherosclerosis 2015
Large prevalence of CVD in women is
associated with
coronary atherosclerosis
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Traditionally, the enrollment of women in clinical trials has been minimal,
resulting in a lack of gender-specific analysis of clinical trial data and,
therefore, the absence of concrete risk factor assessment among women
Anum Saeed 2017
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Under-representation of old women in RCTs.
• Elderly has frequently impaired renal function and politherapies and high comorbidity degree.
• Women suffering from CVD are often older than men, with less impaired ventricular function, more impaired diastolic function and many anatomical differencies.
Int J Cardiol. 2017 Apr 1;232:216-221.
We are using guidelines derived from studies that enrolled
men, with different ethiologies and younger than CV
diseases affected old women.
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Prevention: difficult?
Anum Saeed 2017
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Muka T et al, Maturitas. 2016 Apr
Erβ receptor on endothelium
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Muka T et al, Maturitas. 2016 Apr
Possible Erβ receptor actions in cardiomyocytes
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Microvascular Coronary Disease
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Endothelial Dysfunction
Framingham Heart Study, N=2,883
Benjamin EJ et al., Circulation 2004
• Women have better endothelial
function than men
• Advantage declines with age
Xing, D. et al. Arterioscler Thromb Vasc Biol 2009;29:289-295
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Gulati M, Journal of the American Heart Association. 2019;8:e012873
1) Public awareness and
education of women
2) Education of healthcare
providers
3) Protocol‐driven STEMI
care
4) Use of artificial intelligence
in STEMI management
5) Increased research on sex
disparities in STEMI and
ongoing reporting of
STEMI care by sex
Ischemic Heart Disease
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Heart Failure
Crousillat D Curr Treat Opt Cardio Med 2018
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Traditional vs Emerg(ED) CV risk factors in women
Garcia M Circ Res 2016
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<37 weeks’ gestation
(5% to 12.7% of deliveries worldwide)
Main mechanisms : inflammation,
infection, vascular diseases.
Conclusions and Relevance
Women who had an infant with
PTB-SGA may be at higher
future risk of premature cardiac
disease or death.
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Hypertensive
Pregnancy
Disorders
Gestational hypertension New onset hypertension (>140/90 mm Hg) after 20 weeks’ gestation
in a woman who was originally normotensive
Chronic hypertension Hypertension developed before 20 weeks of gestation
Preeclampsia New onset hypertension (>140/90 mm Hg) after 20 weeks’ gestation
and proteinuria (0.3 g/24 hours) and end-organ renal dysfunction
CVD risk persists into later life
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Preeclampsia
Can J Cardiol. 2019 Jul 11. pii: S0828-282X(19)30464-7.
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Annual visits to a primary care physician to check BP and
metabolic factors are recommended.
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Pre-eclampsia, particularly early preterm
preeclampsia, was strongly associated with
several chronic renal disorders later in life.
More research is needed to determine which women are most
likely to develop kidney disease after pre-eclampsia, what
mechanisms underlie the association, and what clinical follow-up
and interventions (and in what timeframe post-pregnancy) would
be most appropriate and effective.
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Gestational Diabetes
Persistence of Weight Gain After Pregnancy
Weight at 1 year postpartum is a stronger predictor of the
likelihood of being overweight 15 years later than the weight
gained during the pregnancy itself Kew S et Al. Cardiometabolic implications of postpartum weight changes in the first year
after delivery. Diabetes Care. 2014
Daly B, PlosOne 2018
Poola-Kella S et al Rev Recent Clin Trials. 2018
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• Looking for specific risk factors
• Planning ante-natal care
• Organize peri-partum and intra partum assistance (glucose monitoring, basal insuline administration during labour, etc)
POST PARTUM CARE
Clinical Medicine 2019 Vol 19, No 5: 399–402
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Menopause
Age at menopause
50.2 - 50.9 yrs in Italy
Dratva J, Menopause, December 2008
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The age at menopause is, in itself, a fundamental item to be acquired,
in order to plan the right timing for prevention and possible
treatments
physicians learn to acquire the main anamnestic data concerning the female hormonal life, starting from
menarche, through pregnancy, up to the hormonal therapies that accompany and follow menopause
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Multidimensional women’s assessemnt
Climateric symptoms are important as:
• CV risk factors;
• early diagnosis;
• Appropriate therapy and specific prevention program!
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Visita del Medico- 1665-Jan Steen
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Autoimmune
Diseases
Cardiovascular risk scoring systems
underestimate the burden of
cardiovascular risk in patients with
rheumatoid arthritis and systemic lupus
erythematosus or systemic sclerosis
Pts with rheumatoid arthritis have
increased
cardiovascular risk
Predisposition to ASCVD
(increase in the carotid intima-media
thickness)
JAHA 2019
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There has been a tremendous improvement in the survival
rates of breast cancer
Breast Cancer Treatments
This improvement in outcome has been associated with chemotherapy dose-dependent acute,
subacute, and late cardiotoxicity
Breast cancer patients treated with chemotherapy may be at risk for either or
both Type I (anthracycline-like agents) and Type II (Trastuzumablike agents)
cardiotoxicity
M Garcia, S. L. Mulvagh, C. Noel Bairey Merz, J. E. Buring, JAnn E. Manson Circ Research 2016
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Cardiotoxicity was comparable across the 3
groups for the entire study cohort. However,
for women receiving combination
anthracycline-trastuzumab chemotherapy, the
incidence of cardiac dysfunction was lower
in the lisinopril group (37%) and in the
carvedilol group (31%) than in the placebo
group (47%). Lisinopril and carvedilol were
also associated with longer cardiotoxicity-
free survival compared with placebo.
Randomized Trial of Lisinopril Versus Carvedilol to Prevent
Trastuzumab Cardiotoxicity in Patients With Breast Cancer Maya Guglin, Jeffrey Krischer, Roy Tamura, Angelina Fink, Lauren Bello-Matricaria, Worta McCaskill-Stevens and Pamela
N. Munster
Journal of the American College of Cardiology Volume 73, Issue 22, June 2019
All women who received
lisinopril or carvedilol had fewer
interruptions in their
trastuzumab therapy than those
who received placebo.
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Rates of major coronary events increased linearly with the mean
dose to the heart by 7.4% per gray
The radiation categories were less than 2, 2 to 4, 5 to 9, and 10 Gy or more, the
overall averages of the mean doses to the heart of women in these categories were 1.4,
3.4, 6.5, and 15.8 Gy, respectively.
Cancer Treatment – breast cancer treatmen
Radiotherapy
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Cumulative Risks of Death from Ischemic Heart Disease and of at Least One Acute Coronary Event
Women who underwent radiotherapy for breast cancer (1958 – 2001)
963 women with major coronary events and 1205 controls included
Exposure of the heart to ionizing radiation during radiotherapy for breast cancer
increases the subsequent rate of ischemic heart disease
The increase is proportional to the mean dose to the heart,
begins within a few years after exposure, and continues for at
least 20 yrs
A Role For
Pre existing Risk Factors
Sarah C. Darby et Al N engl j med march 14, 2013
J Cancer Res Ther. 2017 Apr-Jun;13
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Polycystic ovary syndrome (PCOS):
not just a fertility matter
(a) CV risk scores should be updated, taking into account these data and
(b) meticulous CV screening should be recommended to patients with PCOS, in order to
recognize and counteract their multiple CV risk factors as early as possible.
It is now well established that PCOS, as a major CV risk factor,
precedes the development of heart disease during the early stages of life
Diabetes Metab Syndr. 2018 Jan 27.
J Cardiovasc Med (Hagerstown). 2018 Dec
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Vasomotor Symptoms impacts
Unfavorable CVD risk profile
Osteoporosis
Cognitive decline
Who deserves our attention?
Inclusion of these data in an appropriate risk assessment
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No CV risk score has implemented the scientific results of sex-
based CV medicine
Oral contracectives (OCPs) and
postmenopausal Hormone Therapy (HT)
OCPs: thromboembolic risk
evaluation
Loss of estrogens periodicity
increased inflammation
Consider:
- Patient hormonal status;
- Possible OCPs therapy in past ad its impact;
- Possible HT after menopause and its impact.
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21 years old Female
(BMI = 24.3 kg/m2)
73 years old
Female
(BMI = 24.5
kg/m2)
Overweight and Sarcopenia
Wittmann K, Clin Int Aging 2016
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According to data from a 2011 National Health Interview Survey (NHIS)
in adults, inactivity was higher among women than men (33.2% versus
29.9%, age-adjusted) and increased with age (from 26.1% to 52.4%).
Risk Factors in Women
Physical Inactivity
Schiller JS LJ et Al: Summary Health Statistics for US Adults: National Health Interview Survey, 2010
Physical inactivity
The prevalence of inactivity and
sedentary behaviors is higher among
women than men.
Overwhelming evidence indicates
that regular physical activity is one of
the most powerful health-promoting
practices that clinicians can
recommend for patients.
Women should be advised to
accumulate at least 150 min/wk of
moderate exercise, 75 min/wk of
vigorous exercise, or an equivalent
combination.
SEX-BASED DIFFERENCES
Garcia M Cardiovascular Disease in Women:
Clinical Perspectives 2017
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Biased Discrimination
Setting: The 2014 to 2016 Behavioral Risk Factor Surveillance
System.
Participants: A total of. 395 154 participants
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Prevention of cardiovascular risk factors in women: The lifestyle paradox and stereotypes we need to defeat.
Sciomer S, Moscucci F, Maffei S, Gallina S, Mattioli AV
Eur J Prev Cardiol. 2018 Oct [Epub ahead of print]
income level
Lack of awareness education
culture
social role
CV risk increased
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STARTING WITH A COMPLETE AND METICOLOUS ANAMNESIS.
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TAKE HOME MESSAGE
Multidimensional approach in anamnesis.
Target anamnesis, target prevention, target therapy, target follow up.
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Filippo Palizzi, Fanciulla sulla roccia a Sorrento, 1871
olio su tela, cm 55x80