The Development of a Chest-Pain Protocol for Women Presenting to the Emergency Department.

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.

Les maladies cardiovasculaires (MCV) sont la principale cause de décès chez les femmes dans le monde et de décès prématuré chez les femmes au Canada. Malgré les progrès réalisés dans le domaine des soins cardiovasculaires au cours des 15 à 20 dernières années, les taux de syndrome coronarien aigu (SCA) et de mortalité due aux MCV continuent d'augmenter chez les femmes au Canada. La douleur thoracique est un symptôme fréquent qui pousse les hommes et les femmes à se rendre aux urgences. Toutefois, les femmes atteintes d'un SCA présentent de moins bons résultats cliniques que les hommes, en raison d'erreurs de diagnostic ou d'une absence de diagnostic causant des retards dans les soins prodigués et une sous-utilisation des traitements médicaux préconisés dans les lignes directrices. Les taux de mortalité liée aux MCV sont les plus élevés chez les femmes autochtones et les femmes racialisées ainsi que chez celles qui présentent un nombre particulièrement élevé de déterminants sociaux de la santé défavorables. Les MCV continuent d'être sous-estimées, sous-diagnostiquées et sous-traitées chez les femmes et ne sont pas suffisamment étudiées dans cette population. De plus, la méconnaissance par les professionnels de la santé des symptômes, des tableaux cliniques et des facteurs de risque de MCV selon le sexe et le genre entraînent des disparités dans les résultats cliniques. Pour combler ces lacunes dans les connaissances en matière de reconnaissance et de prise en charge des symptômes de douleur thoracique chez les femmes, l'Alliance canadienne de la santé cardiaque des femmes a réalisé une évaluation des besoins et un examen des facteurs de risque de MCV et de la physiopathologie du SCA en tenant compte des particularités liées au sexe et au genre, et a ensuite élaboré un protocole unique d'évaluation de la douleur thoracique faisant appel à une méthodologie algorithmique par programmation dynamique modifiée. Nous présentons le protocole algorithmique qui en est issu. Ce résultat se veut un algorithme de référence rapide pouvant être diffusé dans les services d'urgences et les autres services de soins de courte durée. Les prochaines étapes de notre travail seront d'évaluer la mise en œuvre du protocole et son incidence sur les issues cardiovasculaires chez les femmes.

Sex, Gender, and Women's Heart Health: How Women's Heart Programs Address the Knowledge Gap.

This article aims to bridge existing knowledge gaps that impact clinical cardiovascular care and outcomes for women in Canada. The authors discuss various aspects of women's heart health, emphasizing the efficacy of multidisciplinary care in promoting women's well-being. The article also identifies the impact of national women's heart health campaigns and the value of peer support in improving outcomes. The article addresses the particular risks that women face, such as pregnancy-related complications and hormone replacement therapy, all of which are associated with cardiovascular events, and highlights the differences in ischemic symptoms between men and women. Despite improvements in acute event outcomes, challenges persist in accessing timely ambulatory care, particularly for women. Canada has responded to these challenges by introducing Women Heart Programs, which offer tailored programs, support groups, and specialized testing. However, these programs remain few in number and are found only in urban settings. Overall, this review identifies sex and gender factors related to women's heart health, underscoring the importance of specialized programs and multidisciplinary care in improving women's cardiovascular health.

Cet article vise à répondre aux incertitudes actuelles qui se répercutent sur les soins cardiovasculaires et les issues cliniques chez les femmes au Canada. Les auteurs abordent différents aspects de la santé cardiaque des femmes, mettant l'accent sur l'efficacité des soins multidisciplinaires pour améliorer le bien-être des femmes. L'article présente également l'effet des campagnes nationales sur la santé cardiaque des femmes et l'importance de l'entraide entre collègues pour améliorer les résultats. L'article traite des risques particuliers touchant les femmes, comme les complications liées à la grossesse et l'hormonothérapie substitutive, qui sont toutes associées à des événements cardiovasculaires, et il souligne les différences entre les hommes et les femmes pour ce qui est des symptômes ischémiques. Bien que des améliorations aient été observées quant à l'issue des événements aigus, des difficultés persistent sur le plan de l'accès rapide à des soins ambulatoires, surtout pour les femmes. Le Canada a répondu à ces difficultés en créant des programmes pour la santé cardiaque des femmes, qui offrent des services adaptés, des groupes de soutien et des analyses spécialisées. Cependant, ils sont encore peu nombreux et accessibles seulement en milieu urbain. Dans l'ensemble, cette analyse définit les facteurs liés au sexe et au genre qui interviennent dans la santé cardiaque des femmes, soulignant l'importance de mettre en place des programmes spécialisés et des soins multidisciplinaires pour améliorer la santé cardiovasculaire des femmes.

The Importance of Nontraditional and Sex-Specific Risk Factors in Young Women With Vasomotor Nonobstructive vs Obstructive Coronary Syndromes.

Background: Heart disease is the leading cause of premature death for women in Canada. Ischemic heart disease is categorized as myocardial infarction (MI) with no obstructive coronary artery disease (MINOCA), ischemia with no obstructive coronary arteries (INOCA), and atherosclerotic obstructive coronary artery disease (CAD) with MI (MI-CAD) or without MI (non-MI-CAD). This study aims to study the prevalence of traditional and nontraditional ischemic heart disease risk factors and their relationships with (M)INOCA, compared to MI-CAD and non-MI-CAD in young women. Methods: This study investigated women who presented with premature (at age ≤ 55 years) vasomotor entities of (M)INOCA or obstructive CAD confirmed by coronary angiography, who are currently enrolled in either the Leslie Diamond Women's Heart Health Clinic Registry (WHC) or the Study to Avoid Cardiovascular Events in British Columbia (SAVEBC). Univariable and multivariable regression models were applied to investigate associations of risk factors with odds of (M)INOCA, MI-CAD, and non-MI-CAD. Results: A total of 254 women enrolled between 2015 and 2022 were analyzed, as follows: 77 with INOCA and 37 with MINOCA from the registry, and 66 with non-MI-CAD and 74 with MI-CAD from the study. Regression analyses demonstrated that migraines and preeclampsia or gestational hypertension were the most significant risk factors, with a higher likelihood of being associated with premature (M)INOCA, relative to obstructive CAD. Conversely, the presence of diabetes and a current or previous smoking history had the highest likelihood of being associated with premature CAD. Conclusions: The risk factor profiles of patients with premature (M)INOCA, compared to obstructive CAD, have significant differences.

Contexte: Au Canada, la cardiopathie est la principale cause de décès prématuré chez les femmes. La cardiopathie ischémique est catégorisée comme suit : infarctus du myocarde (IM) en l'absence de coronaropathie obstructive (MINOCA), ischémie sans obstruction des artères coronaires (INOCA) et athérosclérose coronaire obstructive accompagnée d'un IM ou sans IM. La présente étude vise à examiner la prévalence des facteurs de risque classiques et non classiques de cardiopathie ischémique et leurs liens avec le (M)INOCA, comparativement à l'athérosclérose coronaire obstructive accompagnée d'un IM ou sans IM chez les femmes jeunes. Méthodologie: Cette étude portait sur des femmes qui avaient prématurément (55 ans ou moins) souffert d'un (M)INOCA ou d'une coronaropathie obstructive confirmés par coronarographie et qui étaient inscrites au registre de la Leslie Diamond Women's Heart Health Clinic (WHC) ou qui participaient à l'étude visant à éviter les événements cardiovasculaires en Colombie-Britannique (Study toAvoid CardiovascularEvents inBC; SAVEBC). Des modèles de régression univariés et multivariés ont été utilisés pour explorer les associations entre les facteurs de risque et les probabilités de (M)INOCA, ainsi que d'athérosclérose coronaire obstructive accompagnée ou non d'un IM. Résultats: Au total, 254 femmes inscrites de 2015 à 2022 ont été recensées, soit 77 présentant une INOCA et 37, un MINOCA selon le registre WHC, et 66 présentant une athérosclérose coronaire obstructive sans IM et 74, une athérosclérose coronaire obstructive accompagnée d'un IM selon l'étude SAVEBC. Les analyses de régression ont démontré que les migraines et la prééclampsie ou l'hypertension gestationnelle étaient les facteurs de risque les plus importants associés à une probabilité la plus élevée de (M)INOCA comparativement à une coronaropathie obstructive. En revanche, la présence d'un diabète et d'un tabagisme actuel ou passé était associée à la probabilité la plus élevée de coronaropathie prématurée. Conclusions: Il existe d'importantes différences pour ce qui est des profils de facteurs de risque des patientes ayant prématurément souffert d'un (M)INOCA en comparaison d'une coronaropathie obstructive.

Improving Wellbeing After Acute Coronary Syndrome.

Cardiovascular disease is the leading cause of death globally, primarily due to ischemic heart disease and subsequent acute coronary syndrome (ACS). ACS not only impacts physical function, but also psychological wellbeing. Patients who experience acute cardiovascular events are at elevated risk for experiencing symptoms of anxiety and depression. Further, increased levels of depression and anxiety following ACS is associated with amplified morbidity and mortality. Secondary prevention focusing on psychological well-being must be prioritized in this population to improve quality of life and cardiovascular health. The purpose of the present review is to summarize the literature on secondary prevention following ACS via interventions aimed at reducing depression and anxiety. Due to the heterogeneity of programs identified, a large, randomized control trial comparing their efficacy is vital to improving outcomes in this population.

Lipid-lowering therapy for primary prevention of premature atherosclerotic coronary artery disease: Eligibility, utilization, target achievement, and predictors of initiation.

OBJECTIVES: Despite advances in screening and prevention, rates of premature coronary artery disease (CAD) have been stagnant. The goals of this study were to investigate the barriers to early risk detection and preventive treatment in patients with premature CAD. In particular, we: 1) assessed the performance of the latest versions of major international guidelines in detection of risk of premature CAD and eligibility for preventive treatment; and, 2) investigated real-life utilization of primary prevention with lipid-lowering therapies in these patients. METHODS: We included patients in the Study to Avoid cardioVascular Events in British Columbia (SAVE BC), an observational study of patients with premature (males â€‹≤ â€‹50 years, females â€‹≤ â€‹55 years) angiographically confirmed CAD. Eligibility for primary prevention and treatment received were assessed retrospectively based on information recorded prior to or at the index presentation with CAD. RESULTS: Of 417 patients (28.1% females) who met the criteria, 94.3% had at least one major cardiovascular risk factor. In the retrospective risk assessment, 41.7%, 61.4%, and 34.3% (p â€‹< â€‹0.001) of patients met criteria for initiation of statin therapy, and an additional 13.9%, 8.4%, and 46.8% may be considered for treatment using the American College of Cardiology/American Heart Association, Canadian Cardiovascular Society, and European Society of Cardiology guidelines, respectively. Only 17.1% of patients received statins and 11.0% achieved guideline-recommended lipid goals before presentation. Diabetes and elevated plasma lipid levels were positively associated with treatment initiation, while smoking was associated with non-treatment. CONCLUSIONS: The current versions of major guidelines fail to recognize many patients who develop premature CAD as being at risk. The vast majority of these patients, including patients who have guideline-directed indications, do not receive lipid-lowering therapy before presenting with CAD. Our findings highlight the need for more effective screening and prevention strategies for premature CAD.

Genetic Influences on the Amount of Cell Death in the Neural Tube of BXD Mice Exposed to Acute Ethanol at Midgestation.

BACKGROUND: Fetal alcohol spectrum disorders (FASD) have a strong genetic component although the genes that underlie this are only beginning to be elucidated. In the present study, one of the most common phenotypes of FASD, cell death within the early developing neural tube, was examined across a genetic reference population in a reverse genetics paradigm with the goal of identifying genetic loci that could influence ethanol (EtOH)-induced apoptosis in the early developing neural tube. METHODS: BXD recombinant inbred mice as well as the parental strains were used to evaluate genetic differences in EtOH-induced cell death after exposure on embryonic day 9.5. Dams were given either 5.8 g/kg EtOH or isocaloric maltose-dextrin in 2 doses via intragastric gavage. Embryos were collected 7 hours after the initial exposure and cell death evaluated via TUNEL staining in the brainstem and forebrain. Genetic loci were evaluated using quantitative trait locus (QTL) analysis at GeneNetwork.org. RESULTS: Significant strain differences were observed in the levels of EtOH-induced cell death that were due to genetic effects and not confounding variables such as differences in developmental maturity or cell death kinetics. Comparisons between the 2 regions of the developing neural tube showed little genetic correlation with the QTL maps exhibiting no overlap. Significant QTLs were found on murine mid-chromosome 4 and mid-chromosome 14 only in the brainstem. Within these chromosomal loci, a number of interesting candidate genes were identified that could mediate this differential sensitivity including Nfia (nuclear factor I/A) and Otx2 (orthodenticle homeobox 2). CONCLUSIONS: These studies demonstrate that the levels of EtOH-induced cell death occur in strain- and region-dependent manners. Novel QTLs on mouse Chr4 and Chr14 were identified that modulate the differential sensitivity to EtOH-induced apoptosis in the embryonic brainstem. The genes underlying these QTLs could identify novel molecular pathways that are critical in this phenotype.