Female-Specific Considerations in Aortic Health and Disease.

The aorta plays a central role in the modulation of blood flow to supply end organs and to optimize the workload of the left ventricle. The constant interaction of the arterial wall with protective and deleterious circulating factors, and the cumulative exposure to ventriculoarterial pulsatile load, with its associated intimal-medial changes, are important players in the complex process of vascular aging. Vascular aging is also modulated by biomolecular processes such as oxidative stress, genomic instability, and cellular senescence. Concomitantly with well-established cardiometabolic and sex-specific risk factors and environmental stressors, arterial stiffness is associated with cardiovascular disease, which remains the leading cause of morbidity and mortality in women worldwide. Sexual dimorphisms in aortic health and disease are increasingly recognized and explain-at least in part-some of the observable sex differences in cardiovascular disease, which will be explored in this review. Specifically, we will discuss how biological sex affects arterial health and vascular aging and the implications this has for development of certain cardiovascular diseases uniquely or predominantly affecting women. We will then expand on sex differences in thoracic and abdominal aortic aneurysms, with special considerations for aortopathies in pregnancy.

L'aorte joue un rôle central dans la modulation du débit sanguin pour irriguer les organes cibles et optimiser la charge de travail du ventricule gauche. L'interaction constante entre la paroi artérielle et des facteurs protecteurs et délétères présents dans la circulation, ainsi que l'exposition cumulative à la charge pulsatile ventriculo-artérielle accompagnée des variations de l'épaisseur intima-média, sont des facteurs importants dans le processus complexe du vieillissement vasculaire. Le vieillissement vasculaire est également modulé par des processus biomoléculaires comme le stress oxydatif, l'instabilité génomique et la sénescence cellulaire. Conjointement avec les facteurs de risque cardiométaboliques et spécifiques au sexe bien établis et les sources de stress environnementales, la rigidité artérielle est associée aux maladies cardiovasculaires, qui demeurent la première cause de morbidité et de mortalité chez les femmes à l'échelle mondiale. Les dimorphismes sexuels en ce qui concerne la santé et les maladies de l'aorte sont de plus en plus reconnus et expliquent, du moins en partie, certaines des différences observables liées au sexe dans les maladies cardiovasculaires, ce qui a fait l'objet de cette analyse. Plus précisément, nous verrons le rôle que joue le sexe biologique dans la santé artérielle et le vieillissement vasculaire, et ce que cela implique dans l'évolution de certaines maladies cardiovasculaires qui touchent surtout ou uniquement les femmes. Nous élargirons ensuite l'étude des différences sexuelles aux anévrismes de l'aorte thoracique et abdominale, en accordant une attention particulière aux maladies de l'aorte pendant la grossesse.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations.

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.

Dans ce chapitre final de l'ATLAS sur l'épidémiologie, le diagnostic et la prise en charge de la maladie cardiovasculaire chez les femmes de l'Alliance canadienne de santé cardiaque pour les femmes, nous présentons les points saillants de l'ATLAS au sujet de l'état actuel des soins cardiovasculaires offerts aux femmes, ainsi que des défis et des occasions dans ce domaine. Nous concluons par 12 recommandations concrètes sur les prochaines étapes à entreprendre pour donner suite aux progrès déjà réalisés afin de combler les lacunes dans les connaissances, en s'attaquant aux disparités qui subsistent dans les soins cardiovasculaires prodigués aux femmes, dans le but d'améliorer les résultats de santé des femmes au Canada.

Sex Differences in Systemic and Coronary Arterial Hemodynamics in Heart Failure With Preserved Ejection Fraction.

Heart failure (HF) with preserved ejection fraction (HFpEF) predominantly affects females. Systemic and coronary arterial abnormalities are present in HFpEF and may contribute to HFpEF in females. We performed a cross-sectional study of 32 participants with HFpEF and 26 controls. Arterial hemodynamics were noninvasively assessed by combining arterial tonometry with echocardiography. Coronary microvascular function was assessed by rubidium-82 positron emission tomography as the myocardial flow reserve. Coronary vascular resistance (CVR) at rest and vasodilator stress were calculated using positron emission tomography. CVR reserve was calculated as stress - rest CVR. Multivariable linear regression assessed the associations of female sex with arterial hemodynamics in participants with and without HF, and the association of HF with arterial hemodynamics within each sex stratum. Demographics and left ventricular systolic and diastolic function were similar between males and females. Among those with HFpEF, females had a higher steady and pulsatile arterial load and more impaired (less negative) CVR reserve than males. Conversely, in controls, females had similar hemodynamics to males. We then divided the sample based on sex. Femaleswith HFpEF had a higher pulsatile arterial load and higher stress CVR than control females. Among males, arterial hemodynamics were similar, regardless of HFpEF status. The measures of early pulsatile arterial load were independently associated with higher E/e' and lower myocardial flow reserve in females only. In conclusion, despite similar left ventricular function between sexes, older females with HFpEF are characterized by additional systemic and coronary arterial hemodynamic abnormalities compared with males with HFpEF and similarly aged females without HFpEF.

Imaging for Cardiovascular Complications of COVID-19: Cardiac Manifestations in Context.

After the first confirmed case in 2019, COVID-19 rapidly spread worldwide and overwhelmed the medical community. In the intervening time, we have learned about COVID-19's clinical manifestations and have developed effective therapies and preventative vaccines. Severe COVID-19 infection is associated with many cardiovascular disorders in the acute phase, and patients recovered from illness can also manifest long-term sequelae, including long COVID syndrome. Furthermore, severe acute respiratory syndrome-related coronavirus-2 messenger RNA (mRNA) vaccination can trigger rare cases of myopericarditis. We have gained significant knowledge of the acute and long-term cardiovascular complications of COVID-19- and mRNA vaccine-associated myocarditis through clinical and investigative studies using cardiac imaging. In this review, we describe how cardiovascular imaging can be used to understand the cardiovascular complications and cardiac injury associated with acute COVID-19 infection, review the imaging findings in patients recovered from illness, and discuss the role and limitations of cardiac imaging in COVID-19 mRNA vaccine-associated myocarditis.

Profound Elevation in LDL Cholesterol Level Following a Ketogenic Diet: A Case Series.

The ketogenic diet (KD) is currently popular for the achievement of weight loss and improvement in glycemic variables. The diet allows consumption of foods high in fat and protein, with strict limitation of carbohydrates. We present a case series of substantial increases in total cholesterol and low-density lipoprotein cholesterol following the initiation of a KD, with improvements in cholesterol levels once the KD was stopped. Novel teaching points include the need for lipid monitoring in patients who choose to follow a KD and for raising awareness of the extreme lipid response that can occur in some patients, particularly lean individuals.

À l'heure actuelle, le régime cétogène (RC) est populaire pour obtenir une perte de poids et améliorer les variables de la glycémie. Le régime repose sur la consommation d'aliments riches en matières grasses et en protéines, et une stricte limitation des aliments riches en glucides. Nous présentons une série de cas dont le cholestérol total et le cholestérol à lipoprotéines de faible densité avaient augmenté de façon substantielle après l'adoption du RC, et dont les concentrations de cholestérol s'étaient améliorées après l'arrêt du RC. Parmi les nouveaux points à retenir figurent la nécessité d'effectuer le bilan lipidique chez les patients qui choisissent de suivre un RC et la conscientisation à la réponse lipidique extrême que l'on peut observer chez certains patients, particulièrement chez les personnes minces.

Intensity of Guideline-Directed Medical Therapy for Coronary Heart Disease and Ischemic Heart Failure Outcomes.

PURPOSE: The impact of guideline-directed medical therapy for coronary heart disease in those hospitalized with acute heart failure is unknown. METHODS: We studied guideline-directed medical therapies for coronary disease: angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta-adrenoreceptor antagonists, antiplatelet agents or anticoagulants, and statins. Using inverse probability of treatment weighting the propensity score, we examined associations of guideline-directed medical therapy intensity (categorized as low [0-1], high [2-3], or very high [4] number of drugs) with mortality in 1873 patients with angina, troponin elevation, or prior myocardial infarction. RESULTS: At discharge, 0-1, 2-3, and 4 medications were prescribed in 467 (25%), 705 (38%), and 701 (37%) patients, respectively. Relative to those prescribed 0-1 drugs (reference), all-cause mortality was lower with 2-3 (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.28-0.84, P = 0.009) or all 4 drug classes (HR 0.56, 95% CI 0.33-0.96, P = 0.034) over 181-365 days, with similar reductions present from 0-180 days. In those with heart failure with preserved ejection fraction, mortality trended lower with 2-3 drug classes (HR 0.43, 95% CI 0.18-1.02, P = 0.054) and was significantly reduced with 4 drugs (HR 0.32, 95%CI 0.12-0.84, P = 0.021) during 0-180 day follow-up. In heart failure with reduced ejection fraction, all-cause mortality was reduced during both 0-180 and 181-365 days when discharged on 2-3 (HR 0.30 for 181-365 days, 95%CI 0.14-0.64, P = 0.002) or all 4 drug classes (HR 0.43, 95%CI 0.19-0.95, P = 0.038). CONCLUSIONS: Increasing guideline-directed medical therapy intensity for coronary heart disease resulted in lower mortality in patients with acute ischemic heart failure with both preserved and reduced ejection fractions.

Role of ethnicity in treating uterine fibroids with ulipristal acetate.

OBJECTIVE: To study differences in treatment effect between black and white premenopausal women prescribed ulipristal acetate (UPA) for symptomatic uterine fibroids. DESIGN: Prospective observational cohort study. SETTING: Gynecology clinics. PATIENT(S): Premenopausal women aged 18-55 years, at least one symptomatic uterine fibroid, UPA-naïve, and no contraindications for UPA treatment. INTERVENTION(S): One 3-month course of UPA at 5 mg daily. MAIN OUTCOME MEASURE(S): Patients' ethnicity self-identification adapted from Statistics Canada National Household Survey. Change in fibroid symptoms according to Uterine Fibroid Symptoms Quality of Life Questionnaire symptom severity and health-related quality of life score. Bleeding symptoms and amenorrhea rates according to Aberdeen Bleeding Score. RESULT(S): A total of 148 patients enrolled (45 black, 59 white, 44 other ethnicity). Black patients were younger (40.3 y vs. 44.5 y) with larger uteri (523 mL vs. 351 mL) than white counterparts. Baseline symptom severity was similar between groups. After 3 months of UPA treatment, both groups experienced similar improvements in symptom severity. White women had 52% greater improvement in bleeding score (-40.3 vs. -26.5) and were more likely to be amenorrheic at the end of treatment (66% vs. 41%). Both groups experienced adverse events at similar frequencies. Black women were more dissatisfied with UPA compared with white women (27.3% vs. 8%). CONCLUSION(S): Black women had greater fibroid burden at baseline. Both ethnicities had similar improvement in fibroid symptomatology following UPA treatment, but white women experienced higher amenorrhea rates. Black women were more dissatisfied with UPA treatment, which may be related to the lower amenorrhea rates.