Integration of Women's Cardiovascular Health Content Into Healthcare Provider Education: Results of a Rapid Review and National Survey.

Despite its importance, formal education in healthcare training programs on sex- and gender-specific cardiovascular disease (CVD) risk factors, symptoms, treatment, and outcomes is lacking. We completed rapid reviews of the academic and grey literature to describe the current state of women-specific CVD education in medical, nursing, and other healthcare education programs. Second, we analyzed results from a Canada-wide survey of healthcare professional education programs to identify gaps in curricula related to sex- and gender-specific training in CVD. Our academic review yielded only 15 peer-reviewed publications, and our online search only 20 healthcare education programs, that note that they specifically address women, or sex and gender, and CVD in their curricula. Across both searches, the majority of training and education programs were from the USA, varied greatly in length, delivery mode, and content covered, and lacked consistency in evaluation. Of surveys sent to 213 Canadian universities and other entry-to-practice programs, 80 complete responses (37.6%) were received. A total of 47 respondents (59%) reported that their programs included women-specific CVD content. Among those programs without content specific to CVD in women, 69.0% stated that its inclusion would add "quite a bit" or "a great deal" of value to the program. This study highlights the emerging focus on and substantial gaps in women-specific CVD training and education across healthcare education programs. All medical, nursing, and healthcare training programs are implored to incorporate sex- and gender-based CVD content into their regular curricula as part of a consolidated effort to minimize gaps in cardiovascular care.

Malgré la prévalence des maladies cardiovasculaires (CV), les programmes d'enseignement en santé accordent peu d'attention aux facteurs de risque, aux symptômes, aux traitements et aux issues selon le sexe ou le genre. Premièrement, nous avons fait une revue rapide de la littérature universitaire et la littérature grise pour faire état de la formation sur les maladies CV spécifiques aux femmes dans les programmes d'enseignement en médecine, en soins infirmiers et autres domaines de la santé. Deuxièmement, nous avons analysé les résultats d'une enquête menée à l'échelle du Canada sur des programmes de formation professionnelle pour cerner les lacunes dans les programmes au chapitre de la formation sur les maladies CV en fonction du sexe et du genre. Notre analyse de la littérature universitaire a permis de relever seulement 15 publications révisées par des pairs à ce sujet, et notre recherche en ligne a mis au jour seulement 20 programmes d'enseignement qui comportent un volet portant spécifiquement sur les femmes, ou bien le sexe et le genre, et les maladies CV. Ces deux enquêtes ont révélé que la majorité des programmes de formation et d'enseignement étaient aux États-Unis et qu'ils présentaient une grande diversité sur le plan de la durée, du mode d'enseignement et du contenu abordé. De plus, les méthodes d'évaluation n'étaient pas uniformes. Parmi les sondages envoyés à 213 universités et programmes d'admission à la pratique au Canada, 80 réponses complètes (37,6 %) ont été reçues. Quarante-sept des établissements qui ont répondu (59 %) ont signalé que leurs programmes comprenaient du contenu portant sur les maladies CV spécifiques aux femmes. Parmi les établissements dont les programmes ne comportaient aucun contenu spécifique aux femmes, 69,0 % ont indiqué qu'une telle inclusion ajouterait « beaucoup ¼ ou « énormément ¼ de valeur au programme. Cette étude met en lumière l'attention nouvelle accordée à la formation et à l'enseignement sur les maladies CV spécifiques aux femmes ainsi que les lacunes substantielles observées à cet égard dans les programmes d'enseignement en santé. Les programmes de formation en médecine, en soins infirmiers et en santé sont vivement invités à intégrer du contenu spécifique au sexe et au genre pour ce qui est des maladies CV dans un effort concerté visant à réduire les lacunes dans les soins cardiovasculaires.

Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease.

Patients with widespread atherosclerosis such as peripheral artery disease (PAD) have a high risk of cardiovascular and limb symptoms and complications, which affects their quality of life and longevity. Over the past 2 decades there have been substantial advances in diagnostics, pharmacotherapy, and interventions including endovascular and open surgical to aid in the management of PAD patients. To summarize the evidence regarding approaches to diagnosis, risk stratification, medical and intervention treatments for patients with PAD, guided by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, evidence was synthesized, and assessed for quality, and recommendations provided-categorized as weak or strong for each prespecified research question. Fifty-six recommendations were made, with 27% (15/56) graded as strong recommendations with high-quality evidence, 14% (8/56) were designated as strong recommendations with moderate-quality evidence, and 20% (11/56) were strong recommendations with low quality of evidence. Conversely 39% (22/56) were classified as weak recommendations. For PAD patients, strong recommendations on the basis of high-quality evidence, include smoking cessation interventions, structured exercise programs for claudication, lipid-modifying therapy, antithrombotic therapy with a single antiplatelet agent or dual pathway inhibition with low-dose rivaroxaban and aspirin; treatment of hypertension with an angiotensin converting enzyme or angiotensin receptor blocker; and for those with diabetes, a sodium-glucose cotransporter 2 inhibitor should be considered. Furthermore, autogenous grafts are more effective than prosthetic grafts for surgical bypasses for claudication or chronic limb-threatening ischemia involving the popliteal or distal arteries. Other recommendations indicated that new endovascular techniques and hybrid procedures be considered in patients with favourable anatomy and patient factors, and finally, the evidence for perioperative risk stratification for PAD patients who undergo surgery remains weak.

Incorporating a Women's Cardiovascular Health Curriculum Into Medical Education.

Despite cardiovascular disease (CVD) being the leading cause of death of women globally, research on CVD over the past several decades has focused primarily on men. CVD research has led to progress in diagnosis and treatment, medical education, and public awareness; however, few of these advances have applied specifically to women's cardiovascular health. There is a paucity of sex- and gender-specific educational material regarding CVD in clinical training programs for physicians. The irregularity in integrated curricula across medical schools in Canada may be a factor in persistent disparities in clinical care and outcomes experienced by women, compared with men. In response to this gap, the Training and Education Working Group of the Canadian Women's Heart Health Alliance undertook the planning, development, and dissemination of a Canadian Women's Heart Health Education Course. The development of the course was guided by a 6-step approach for curriculum development for medical education, which included conducting a needs assessment, determining and prioritizing content, setting goals and objectives, selecting educational strategies, implementation, and evaluation.

Bien que les maladies cardiovasculaires (MCV) soient la principale cause de décès chez les femmes dans le monde, la recherche sur les MCV au cours des dernières décennies a été centrée principalement sur les hommes. La recherche sur les MCV a permis de faire des progrès en matière de diagnostic et de traitement, de formation médicale et de sensibilisation du public; toutefois, peu de ces progrès touchaient spécifiquement la santé cardiovasculaire des femmes. Les programmes de formation clinique des médecins ne comportent que peu de matériel éducatif sur les MCV propre à chaque sexe et à chaque genre. Il est possible que l'irrégularité des programmes de formation intégrés des écoles de médecine au Canada contribue aux disparités persistantes dans les soins prodigués aux femmes et les résultats cliniques obtenus chez celles-ci, comparativement aux hommes. Pour combler cette lacune, le Groupe de travail sur la formation et l'éducation de l'Alliance canadienne de santé cardiaque pour les femmes a entrepris la planification, la préparation et la diffusion de l'Initiative nationale de sensibilisation à la santé cardiaque des femmes. La conception de l'Initiative a été guidée par une approche en six volets axée sur l'élaboration d'un programme de formation médicale, qui comprenait une évaluation des besoins, la détermination et la hiérarchisation du contenu, la formulation des buts et des objectifs, la sélection des stratégies de formation, ainsi que la mise en œuvre et les modalités d'évaluation.

Hypertension in menopausal women: the effect and role of estrogen.

States of estrogen imbalance or deprivation are associated with higher risks of hypertension and cardiovascular disease in women; however, the effects of estrogen on hypertension are multifactorial, complex, and not completely understood. Although controversial, hormone therapy may improve cardiovascular outcomes when initiated by recently menopausal women. Improved screening for hypertension, especially in specific groups of younger women at higher risk, is recommended. Further study is needed to determine whether sex-specific differences exist in therapeutic response to pharmacologic management of hypertension.

Coronary artery microvascular dysfunction: Role of sex and arterial load.

BACKGROUND: The prognosis of cardiovascular disease is worse in women than men, and coronary microvascular dysfunction explains the excess cardiovascular risk in women. In addition, age-related increases in pulsatile arterial load are greater in women than men; and lower arterial compliance has been shown to independently predict cardiovascular events. However, whether arterial load differentially affects the coronary microvasculature in men and women remains unknown. We hypothesized that lower arterial compliance would be associated with coronary artery microvascular dysfunction in women. METHODS AND RESULTS: 285 subjects (60% women, age: 61.2 ±â€¯11.0 yrs) undergoing cardiac 82Rb positron-emission tomography between 2010 and 2013, with ejection fraction ≥50%, no heart failure, dyspnea, coronary artery disease or regional perfusion defects were included. Left ventricular microvascular function was assessed by myocardial flow reserve (MFR). Pulsatile arterial load was estimated by indexed arterial compliance [ACi: (stroke volume/pulse pressure)/BSA]. Multivariable linear regression evaluated associations of arterial compliance with myocardial flow reserve after adjustment for confounders. ACi was lower in women than men [0.39 ±â€¯0.15 vs. 0.52 ±â€¯0.28 (mL/mm Hg)/m2, P < 0.0001]. We found that the effect of ACi on MFR differs by sex: lower ACi was associated with lower MFR in women (ß ±â€¯SE: 0.20 ±â€¯0.07, P = 0.004) but not in men (0.03 ±â€¯0.11, P = 0.75). CONCLUSIONS: Lower ACi was associated with altered coronary microvascular function in women, but not in men. Our findings highlight low arterial compliance as a potential link between hypertension, coronary microvascular dysfunction and adverse cardiovascular events in women.

Women and Peripheral Arterial Disease: A Review of Sex Differences in Epidemiology, Clinical Manifestations, and Outcomes.

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in women. Peripheral arterial disease (PAD), a manifestation of CVD and a marker for other adverse CVD outcomes such as ischemic heart disease and stroke, remains underrecognized and undertreated in women. Contrary to the previous belief that PAD is mainly a disease of white men, contemporary data suggest equal, if not higher, prevalence rates in nonwhite women. Women often present with asymptomatic or atypical disease and seek medical attention with more advanced disease. Cardiovascular morbidity and mortality rates, as well as procedural mortality rates, remain elevated in women compared with men. There are sex-specific markers and comorbidities with a higher female prevalence that are associated with PAD. Greater focus on PAD in cardiovascular trials, equivalent enrollment of women in large trials, and focused prevention strategies may help reduce the economic burden and adverse outcomes associated with PAD in women.

Ethnic Differences in Visceral Adiposity Measured in Early Pregnancy.

OBJECTIVE: To determine if visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) depth in early pregnancy differs by maternal ethnicity. METHODS: We prospectively evaluated 482 women without pre-pregnancy diabetes. All underwent sonographic measurement of VAT and SAT depth at 11 to 14 weeks' gestation. RESULTS: SAT did not differ between groups, but VAT did. Compared with Canadian-born women (3.9 cm, 95% CI 3.7-4.1), mean VAT depth was higher among Latin American (4.6 cm, 95% CI 4.1-5.2), Sub-Saharan African (5.0 cm, 95% CI 4.0-6.1), and Caribbean (6.0 cm, 95% CI 4.8-7.3) women. Adjusting for age, parity, and 1/height2, the relative risks of having a VAT depth >80th percentile were 1.69 (95% CI 1.05-2.73) for Latin American, 2.24 (95% CI 1.28-3.93) for Sub-Saharan African, and 3.34 (95% CI 1.91-5.84) for Caribbean women, relative to Canadian-born women. Women from these world regions also had a greater percentage of preterm births and emergency CSs. CONCLUSION: VAT differs appreciably among certain ethnic groups, which may reflect their predisposition to adverse pregnancy outcomes.

Reduced Myocardial Flow in Heart Failure Patients With Preserved Ejection Fraction.

BACKGROUND: There remains limited insight into the pathophysiology and therapeutic advances directed at improving prognosis for patients with heart failure with preserved ejection fraction (HFpEF). Recent studies have suggested a role for coronary microvascular dysfunction in HFpEF. Rb-82 cardiac positron emission tomography imaging is a noninvasive, quantitative approach to measuring myocardial flow reserve (MFR), a surrogate marker for coronary vascular health. The aim of this study was to determine whether abnormalities exist in MFR in patients with HFpEF without epicardial coronary artery disease. METHODS AND RESULTS: A total of 376 patients with ejection fraction ≥50%, no known history of obstructive coronary artery disease, and a confirmed diagnosis of heart failure (n=78) were compared with patients with no evidence of heart failure (n=298), further stratified into those with (n=186) and without (n=112) hypertension. Global and regional left ventricular MFR was calculated as stress/rest myocardial blood flow using Rb-82 positron emission tomography. Patients with HFpEF were more likely to be older, female, and have comorbid hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, anemia, and renal dysfunction. HFpEF was associated with a significant reduction in global MFR (2.16±0.69 in HFpEF versus 2.54±0.80 in hypertensive controls; P<0.02 and 2.89±0.70 in normotensive controls; P<0.001). A diagnosis of HFpEF was associated with 2.62 times greater unadjusted odds of having low global MFR (defined as <2.0) and remained a significant predictor of reduced global MFR after adjusting for comorbidities. CONCLUSIONS: HFpEF, in the absence of known history for obstructive epicardial coronary artery disease, is associated with reduced MFR independent of other risk factors.

Increased urinary angiotensin-converting enzyme 2 in renal transplant patients with diabetes.

Angiotensin-converting enzyme 2 (ACE2) is expressed in the kidney and may be a renoprotective enzyme, since it converts angiotensin (Ang) II to Ang-(1-7). ACE2 has been detected in urine from patients with chronic kidney disease. We measured urinary ACE2 activity and protein levels in renal transplant patients (age 54 yrs, 65% male, 38% diabetes, n = 100) and healthy controls (age 45 yrs, 26% male, n = 50), and determined factors associated with elevated urinary ACE2 in the patients. Urine from transplant subjects was also assayed for ACE mRNA and protein. No subjects were taking inhibitors of the renin-angiotensin system. Urinary ACE2 levels were significantly higher in transplant patients compared to controls (p = 0.003 for ACE2 activity, and p≤0.001 for ACE2 protein by ELISA or western analysis). Transplant patients with diabetes mellitus had significantly increased urinary ACE2 activity and protein levels compared to non-diabetics (p<0.001), while ACE2 mRNA levels did not differ. Urinary ACE activity and protein were significantly increased in diabetic transplant subjects, while ACE mRNA levels did not differ from non-diabetic subjects. After adjusting for confounding variables, diabetes was significantly associated with urinary ACE2 activity (p = 0.003) and protein levels (p<0.001), while female gender was associated with urinary mRNA levels for both ACE2 and ACE. These data indicate that urinary ACE2 is increased in renal transplant recipients with diabetes, possibly due to increased shedding from tubular cells. Urinary ACE2 could be a marker of renal renin-angiotensin system activation in these patients.