Socioeconomic Disparities in Women's Cardiovascular Health in the United States and Canada.

Cardiovascular disease has been the leading cause of death in the United States and Canada for decades. Although it affects millions of people across a multitude of backgrounds, notable disparities in cardiovascular health are observed among women and become more apparent when accounting for race and socioeconomic status. Although intrinsic sex-specific physiologic differences predispose women to poorer outcomes, social determinants of health (SDOH) and biases at both the individual provider and the larger health care system levels play an equal, if not greater, role. This review examines socioeconomic disparities in women compared with men regarding cardiovascular risk factors, treatments, and outcomes. Although various at-risk subpopulations exist, we highlight the impact of SDOH in specific populations, including patients with disabilities, transgender persons, and South Asian and Indigenous populations. These groups are underrepresented in studies and experience poorer health outcomes owing to structural barriers to care. These findings emphasise the significance of understanding the interplay of different socioeconomic factors and how their stacking can negatively affect women's cardiovascular health. To address these disparities, we propose a multipronged approach to augment culturally sensitive and patient-centred care. This includes increased cardiovascular workforce diversity, inclusion of underrepresented populations into analyses of cardiovascular metrics, and greater utilisation of technology and telemedicine to improve access to health care. Achieving this goal will necessitate active participation from patients, health care administrators, physicians, and policy makers, and is imperative in closing the cardiovascular health gap for women over the coming decades.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 8: Knowledge Gaps and Status of Existing Research Programs in Canada.

Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women.

En dépit des avancées importantes de la recherche médicale et des efforts en santé publique, il reste des lacunes dans les connaissances sur la santé cardiaque des femmes sur les plans de l'épidémiologie, du tableau clinique, de la prise en charge, des résultats, de l'éducation, de la recherche et des publications. Du point de vue historique, la cardiopathie a d'abord été perçue comme une maladie qui touchait les hommes et les individus de sexe masculin. De ce fait, la compréhension des risques particuliers et des symptômes qu'éprouvent les femmes est limitée. Ces lacunes dans les connaissances posent particulièrement problème puisqu'à l'échelle mondiale la cardiopathie est la cause principale de décès chez les femmes. Jusqu'à récemment, la recherche en cardiologie, notamment la recherche préclinique et clinique, ne portait pas sur le sexe et le genre. Le recrutement souvent limité aux participants masculins et aux individus dont l'identité de genre correspond au sexe masculin et l'absence d'analyses de données en fonction du sexe ou du genre ont eu pour conséquence un manque de données sur la façon dont les traitements et les interventions nuisent aux patientes féminines et aux individus dont l'identité de genre correspond au sexe féminin, et ce, de façon différente. Cette absence de données a mené à un traitement sous-optimal et à des limites de notre compréhension des mécanismes sous-jacents de la cardiopathie chez les femmes, et est directement reliée à nos connaissances limitées, et à nos lacunes en formation professionnelle et en éducation du public. Le fait que les femmes ne connaissent souvent pas leurs facteurs de risque de maladies du cœur ou les symptômes qu'elles peuvent éprouver entraîne des retards de diagnostic et de traitements. De plus, le fait que les prestataires de soins de santé ne reçoivent pas la formation adéquate pour poser le diagnostic et traiter la cardiopathie chez les femmes les mène à poser un mauvais diagnostic ou à ne pas traiter suffisamment. Pour pallier ces lacunes de connaissances, il faut une approche à plusieurs volets, qui porte notamment sur l'éducation et les changements dans les politiques, et qui repose sur la recherche fondée sur des données probantes. Dans ce chapitre, nous passons en revue l'état actuel de la recherche existante sur les maladies cardiovasculaires au Canada, plus particulièrement chez les femmes.

Women's Heart Health and the Menopausal Transition: Two Faces of the Same Coin.

The impact of the presence or absence of sex hormones on women's health is woefully underresearched. Fundamentally, women's bodies are now understood to spend considerable time under widely fluctuating hormonal influences, including puberty, pregnancy, peripartum, and menopause, and a woman's vessels are therefore preset for functional and physiological alterations based on levels of sex hormones. However, our understanding of the influences of sex hormones on the regulation of a multitude of biological and physiological processes has not translated into the development and/or collection or analyses of data on therapeutic treatments and/or outcomes in the context of women's disease management.

Les effets sur la santé des femmes associés à la présence ou à l'absence d'hormones sexuelles ont fait l'objet de trop peu d'études. On sait essentiellement que les taux d'hormones fluctuent considérablement tout au long des étapes de la vie des femmes, qu'il s'agisse de la puberté, de la grossesse, de la période périnatale et de la ménopause, et que leurs vaisseaux sont en fait préréglés pour permettre diverses modifications fonctionnelles et physiologiques en fonction du taux d'hormones sexuelles. Cependant, notre compréhension de l'influence des hormones sexuelles sur la régulation d'une multitude de processus biologiques et physiologiques ne s'est pas traduite par la collecte et/ou l'analyse de données sur les traitements ou les résultats thérapeutiques dans le contexte de la prise en charge de diverses maladies chez les femmes.

The Women@Heart NS Pilot Project: Rationale and Design of a Community-Based Peer Support Program for Women Living With Heart Disease in Nova Scotia.

Cardiac rehabilitation is associated with lower mortality and improved psychosocial outcomes. However, disparities exist in referral and access to cardiac rehabilitation for Nova Scotian women, a situation exacerbated by the COVID-19 pandemic. Women@Heart (W@H) is a 4-month community-based peer support program developed and validated by the University of Ottawa Heart Institute, for women living with heart disease. The program aims to empower women with coping strategies, provide a supportive learning environment, and establish volunteer advocacy groups. The primary objective of this study is to evaluate the implementation feasibility of the W@H program for women living in Nova Scotia. The primary outcome is the implementation feasibility of W@H in Nova Scotia, measured through participant attendance and program completion rates. Peer leaders will record participant attendance. The psychosocial impact of W@H will be assessed using psychometric tools that measure the following: social support, adaptive coping, stress, symptoms of anxiety and depression, and health-related and disease-specific quality of life. Data will be collected using a pre- and post-program questionnaire administered to participants. The pilot program is expected to commence in the first quarter of 2024. One peer leader with lived experience of heart disease, who has previously completed the W@H program as a participant, has been trained. Participants have been identified through healthcare provider referral, self-referral, brochures, and peer-networking. Each cohort will consist of 5-10 participants. The W@H pilot project will assess the implementation feasibility and the impact of community-based peer support on the well-being of Nova Scotian women living with heart disease.

La réadaptation cardiaque est associée à une mortalité plus faible et à des bienfaits psychosociaux. Cependant, il existe des disparités en ce qui a trait à l'orientation et à l'accès à la réadaptation cardiaque pour les femmes de la Nouvelle-Écosse, une situation exacerbée par la pandémie de COVID-19. Femmes@Cœur est un programme de soutien collectif par les pairs, créé et validé par l'Institut de cardiologie de l'Université d'Ottawa, à l'intention des femmes atteintes d'une maladies du cœur. Le programme vise à autonomiser les femmes en leur proposant des stratégies d'adaptation, à leur fournir un environnement propice à l'apprentissage et à former des groupes de bénévoles pour la défense de leurs intérêts. La présente étude a pour principal objectif d'évaluer la faisabilité de la mise en œuvre du programme Femmes@Cœur pour les femmes de la Nouvelle-Écosse. Le critère d'évaluation principal de l'étude est la faisabilité de la mise en œuvre du programme Femmes@Cœur en Nouvelle-Écosse, déterminée par la mesure des taux de participation et d'achèvement du programme. Des responsables parmi les pairs consigneront la présence des participantes. Les répercussions psychosociales du programme Femmes@Cœur seront évaluées à l'aide d'outils psychométriques mesurant une gamme de paramètres : soutien social, stratégies d'adaptation, niveau de stress, symptômes d'anxiété et de dépression, et qualité de vie liée à la santé et à la maladie en question. Les données seront recueillies au moyen de questionnaires administrés aux participantes avant et après le programme, et le projet pilote devrait être lancé le premier trimestre de 2024. Une responsable parmi les pairs, elle-même atteinte d'une maladie du cœur et ayant déjà pris part au programme Femmes@Cœur en tant que participante, a été formée à cet effet. Les participantes ont été trouvées de diverses façons : orientation par un professionnel de la santé, inscription spontanée, brochures et réseautage entre pairs. Chaque cohorte sera par ailleurs composée de 5 à 10 participantes. Enfin, le projet pilote Femmes@Cœur évaluera la faisabilité de la mise en œuvre et les répercussions du soutien collectif entre pairs sur le bien-être des femmes de la Nouvelle-Écosse atteintes de maladies cardiaques.

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.

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.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 7: Sex, Gender, and the Social Determinants of Health.

Women vs men have major differences in terms of risk-factor profiles, social and environmental factors, clinical presentation, diagnosis, and treatment of cardiovascular disease. Women are more likely than men to experience health issues that are complex and multifactorial, often relating to disparities in access to care, risk-factor prevalence, sex-based biological differences, gender-related factors, and sociocultural factors. Furthermore, awareness of the intersectional nature and relationship of sociocultural determinants of health, including sex and gender factors, that influence access to care and health outcomes for women with cardiovascular disease remains elusive. This review summarizes literature that reports on under-recognized sex- and gender-related risk factors that intersect with psychosocial, economic, and cultural factors in the diagnosis, treatment, and outcomes of women's cardiovascular health.

Les profils de facteurs de risque, les facteurs sociaux et environnementaux, le tableau clinique, le diagnostic et le traitement des maladies cardiovasculaires montrent des différences importantes entre les femmes et les hommes. Il est plus probable que les femmes expérimentent des problèmes de santé complexes et multifactoriels, qui sont souvent en relation avec les disparités dans l'accès aux soins, la prévalence des facteurs de risque, les différences biologiques entre les sexes, les facteurs liés au genre et les facteurs socioculturels. De plus, la sensibilisation à la nature et à la relation intersectionnelles des déterminants socioculturels de santé, notamment les facteurs liés au sexe et au genre, qui influencent l'accès aux soins et les résultats cliniques des femmes atteintes d'une maladie cardiovasculaire demeure insaisissable. La présente revue résume la littérature qui porte sur les facteurs de risque liés au sexe et au genre peu reconnus qui se recoupent aux facteurs psychosociaux, économiques et culturels dans le diagnostic, le traitement et les résultats cliniques en lien avec la santé cardiovasculaire des femmes.

Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology.

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

Spontaneous Coronary Artery Dissection Across the Health Care Pathway: A National, Multicenter, Patient-Informed Investigation.

BACKGROUND: Clinical practice guidelines for the management and convalescence of patients with spontaneous coronary artery dissection (SCAD) have yet to be developed. The targeted content, delivery, and outcomes of interventions that benefit this population remain unclear. Patient-informed data are required to substantiate observational research and provide evidence to inform and standardize clinical activities. METHODS AND RESULTS: Patients diagnosed with SCAD (N=89; 86.5% women; mean age, 53.2 years) were purposively selected from 5 large tertiary care hospitals. Patients completed sociodemographic and medical questionnaires and participated in an interview using a patient-piloted semistructured interview guide. Interviews were transcribed and subjected to framework analysis using inductive and then deductive coding techniques. Approximately 1500 standard transcribed pages of interview data were collected. Emotional distress was the most commonly cited precipitating factor (56%), with an emphasis on anxiety symptoms. The awareness and detection of SCAD as a cardiac event was low among patients (35%) and perceived to be moderate among health care providers (55%). Health care providers' communication of the prognosis and self-management of SCAD were perceived to be poor (79%). Postevent psychological disorders among patients were evident (30%), and 73% feared recurrence. Short- and longer-term follow-up that was tailored to patients' needs was desired (72%). Secondary prevention programming was recommended, but there were low completion rates of conventional cardiac rehabilitation (48%), and current programming was deemed inadequate. CONCLUSIONS: This early-stage, pretrial research has important implications for the acute and long-term management of patients with SCAD. Additional work is required to validate the hypotheses generated from this patient-oriented research.

Performance of the ACC/AHA Pooled Cohort Cardiovascular Risk Equations in Clinical Practice.

BACKGROUND: The performance of the American College of Cardiology/American Heart Association pooled cohort equation (PCE) for atherosclerotic cardiovascular disease (ASCVD) in real-world clinical practice has not been evaluated extensively. OBJECTIVES: The goal of this study was to test the performance of PCE to predict ASCVD risk in the community, and determine if including individuals with values outside the PCE range (ie, age, blood pressure, cholesterol) or statin therapy initiation over follow-up would significantly affect PCE predictive capabilities. METHODS: The PCE was validated in a community-based cohort of consecutive patients who sought primary care in Olmsted County, Minnesota, between 1997 and 2000, followed-up through 2016. Inclusion criteria were similar to those of PCE derivation. Patient information was ascertained by using the record linkage system of the Rochester Epidemiology Project. ASCVD events (nonfatal and fatal myocardial infarction and ischemic stroke) were validated in duplicate. Calculated and observed ASCVD risk and c-statistics were compared across predefined groups. RESULTS: This study included 30,042 adults, with a mean age of 48.5 ± 12.2 years; 46% were male. Median follow-up was 16.5 years, truncated at 10 years for this analysis. Mean ASCVD risk was 5.6% ± 8.73%. There were 1,555 ASCVD events (5.2%). The PCE revealed good performance overall (c-statistic 0.78) and in sex and race subgroups; it was highest among non-White female subjects (c-statistic 0.81) and lowest in White male subjects (c-statistic 0.77). Out-of-range values and initiation of statin medication did not affect model performance. CONCLUSIONS: The PCE performed well in a community cohort representing real-world clinical practice. Values outside PCE ranges and initiation of statin medication did not affect performance. These results have implications for the applicability of current strategies for the prevention of ASCVD.

Women in cardiovascular imaging: a call for action to address ongoing challenges.

AIMS: The EACVI Scientific Initiatives Committee and the EACVI women's taskforce conducted a global survey to evaluate the barriers faced by women in cardiovascular imaging (WICVi). METHODS AND RESULTS: In a prospective international survey, we assessed the barriers faced at work by WICVi. Three hundred fourteen participants from 53 countries responded. The majority were married (77%) and had children (68%), but most reported no flexibility in their work schedule during their pregnancy or after their maternity leave. More than half of the women reported experiencing unconscious bias (68%), verbal harassment (59%), conscious bias (51%), anxiety (70%), lack of motivation (60%), imposter syndrome (54%), and burnout (61%) at work. Furthermore, one in five respondents had experienced sexual harassment, although this was rarely reported formally. The majority reported availability of mentorship (73%), which was mostly rated as 'good' or 'very good'. While more than two-thirds of respondents (69%) now reported being well trained and qualified to take on leadership roles in their departments, only one-third had been afforded that opportunity. Despite the issues highlighted by this survey, >80% of the participating WICVi would still choose cardiovascular imaging if they could restart their career. CONCLUSION: The survey has highlighted important issues faced by WICVi. While progress has been made in areas such as mentorship and training, other issues including bullying, bias, and sexual harassment are still widely prevalent requiring urgent action by the global cardiovascular imaging community to collectively address and resolve these challenges.

Ultrasound Enhancing Agents with Transthoracic Echocardiography for Maximal Wall Thickness in Hypertrophic Cardiomyopathy.

Objectives: To determine whether ultrasound enhancing agent (UEA) changes maximal wall thickness (WT) in hypertrophic cardiomyopathy (HCM), and if it improves correlation with magnetic resonance imaging (MRI). Patients and Methods: A total of 107 patients with HCM were prospectively enrolled at a single tertiary referral center between July 10, 2014, and August 31, 2017, and underwent transthoracic echocardiography (TTE) with and without UEA and MRI. Maximal WT measurements were compared, and variability among the 3 modalities was evaluated using a simple linear regression analysis and paired t tests and Bland-Altman plots. Interobserver variability for each technique was assessed. Results: Most (63%) of cardiac imagers found UEA helpful in determining maximal WT by TTE, with 49% reporting change in WT. Of 52 patients where UEA changed WT measurement, 32 (62%) reported an increase and 20 (38%) reported a decrease in WT. The UEA did not alter the median discrepancy in WT between MRI and TTE. However, where UEA increased reported WT, the difference between MRI and TTE improved in 79% of cases (P=.001) from 2.0-0.5mm. In those with scar on MRI, UEA improved agreement of WT between TTE and MRI compared with that of TTE without UEA (79% vs 39%; P=.011). Interclass correlation coefficient for WT for TTE without UEA, with UEA, and MRI was 0.84; (95% CI, 0.61-0.92), 0.88; (95%CI, 0.82-0.92), and 0.97; (95%CI, 0.96-0.98), respectively. Conclusion: Although use of UEA did not eliminate differences in WT discrepancy between modalities, the addition of UEA to TTE aided in WT determination and improved correlation with MRI in those with greater WT and in all patients with myocardial scars.

A Survey of Female-Specific Cardiovascular Protocols in Emergency Departments in Canada.

Background: Cardiovascular diseases (CVD) remain the leading cause of death for women. However, systematic inequalities exist in how women experience clinical cardiovascular (CV) policies, programs, and initiatives. Methods: In collaboration with the Heart and Stroke Foundation of Canada, a question regarding female-specific CV protocols in an emergency department (ED), or an inpatient or ambulatory care area of a healthcare site was sent via e-mail to 450 healthcare sites in Canada. Contacts at these sites were established through the larger initiative-the Heart Failure Resources and Services Inventory-conducted by the foundation. Results: Responses were received from 282 healthcare sites, with 3 sites confirming the use of a component of a female-specific CV protocol in the ED. Three sites noted using sex-specific troponin levels in the diagnosis of acute coronary syndromes; 2 of the sites are participants in the hs-cTn-Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women (CODE MI) trial. One site reported the integration of a female-specific CV protocol component into routine use. Conclusions: We have identified an absence of female-specific CVD protocols in EDs that may be associated with the identified poorer outcomes in women impacted by CVD. Female-specific CV protocols may serve to increase equity and ensure that women with CV concerns have access to the appropriate care in a timely manner, thereby helping to mitigate some of the current adverse effects experienced by women who present to Canadian EDs with CV symptoms.

Contexte: Les maladies cardiovasculaires (MCV) demeurent la principale cause de décès chez les femmes. Toutefois, il existe des inégalités systématiques à l'égard des femmes dans les politiques, les programmes et les initiatives cliniques cardiovasculaires (CV). Méthodologie: En collaboration avec la Fondation des maladies du cœur et de l'AVC du Canada, une question relative à l'utilisation de protocoles de prise en charge des manifestations cardiovasculaires spécifiques aux femmes dans les services d'urgence ou les services de soins pour patients hospitalisés et ambulatoires a été envoyée par courriel à 450 établissements de santé au Canada. Les contacts ont été établis dans ces centres dans le cadre d'une initiative de plus grande envergure, l'inventaire des ressources et des services en matière d'insuffisance cardiaque, menée par la Fondation. Résultats: Des réponses ont été reçues de 282 établissements de santé; dont trois ont confirmé l'utilisation d'une composante spécifique aux femmes dans leurs protocoles de prise en charge des manifestations CV dans leur service des urgences. Trois centres ont déclaré utiliser un taux de troponine adapté au sexe pour le diagnostic du syndrome coronarien aigu; or, deux de ces centres participent à l'essai CODE MI (hs-cTn­Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women), qui porte sur l'optimisation du diagnostic de l'infarctus du myocarde aigu ou des atteintes myocardiques chez les femmes. Un seul centre a signalé l'intégration d'une composante spécifique aux femmes dans son protocole CV en pratique courante. Conclusions: Nous avons constaté que l'absence de protocoles spécifiques aux femmes en matière de prise en charge des manifestations CV dans les services d'urgences pourrait être associée aux moins bons résultats observés chez les femmes atteintes de MCV. Des protocoles spécifiques aux femmes en matière de prise en charge des manifestations CV pourraient contribuer à accroître l'équité et à faire en sorte que les femmes souffrant de problèmes CV aient accès aux soins appropriés en temps opportun. Une telle initiative contribuerait à atténuer certains des effets indésirables dont sont victimes les femmes qui se présentent aux urgences des établissements de soins canadiens avec des symptômes CV.

Effects of oral semaglutide on cardiovascular outcomes in individuals with type 2 diabetes and established atherosclerotic cardiovascular disease and/or chronic kidney disease: Design and baseline characteristics of SOUL, a randomized trial.

AIM: To describe the design of the SOUL trial (Semaglutide cardiOvascular oUtcomes triaL) and the baseline clinical data of its participants. MATERIALS AND METHODS: In SOUL, the effects of oral semaglutide, the first oral glucagon-like peptide-1 receptor agonist, on the risk of cardiovascular (CV) events in individuals with type 2 diabetes and established atherosclerotic CV disease (ASCVD) and/or chronic kidney disease (CKD) will be assessed. SOUL is a randomized, double-blind, parallel-group, placebo-controlled CV outcomes trial comparing oral semaglutide (14 mg once daily) with placebo, both in addition to standard of care, in individuals aged ≥50 years with type 2 diabetes and evidence of ASCVD (coronary artery disease [CAD], cerebrovascular disease, symptomatic peripheral arterial disease [PAD]) and/or CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2 ). The primary outcome is time from randomization to first occurrence of a major adverse CV event (MACE; a composite of CV death, nonfatal myocardial infarction or nonfatal stroke). This event-driven trial will continue until 1225 first adjudication-confirmed MACEs have occurred. Enrolment has been completed. RESULTS: Overall, 9650 participants were enrolled between June 17, 2019 and March 24, 2021 (men 71.1%, White ethnicity 68.9%, mean age 66.1 years, diabetes duration 15.4 years, body mass index 31.1 kg/m2 , glycated haemoglobin 63.5 mmol/mol [8.0%]). The most frequently used antihyperglycaemic medications at baseline were metformin (75.7%), insulin and insulin analogues (50.5%), sulphonylureas (29.1%), sodium-glucose cotransporter-2 inhibitors (26.7%) and dipeptidyl peptidase-4 inhibitors (23.0%). At randomization, 70.7% of participants had CAD, 42.3% had CKD, 21.1% had cerebrovascular disease and 15.7% had symptomatic PAD (categories not mutually exclusive). Prevalent heart failure was reported in 23.0% of participants. CONCLUSION: SOUL will provide evidence regarding the CV effects of oral semaglutide in individuals with type 2 diabetes and established ASCVD and/or CKD.

Female Risk Factors for Post-Infarction Depression and Anxiety: Trial Design.

INTRODUCTION: Female patients are at elevated risk for adverse mental health outcomes following hospital admission for ischemic heart disease. These psychosocial characteristics are correlated with unacceptably higher rates of cardiovascular (CV) morbidity and mortality. Guidelines to address mental health following acute coronary syndrome (ACS) can only be developed with the aid of studies elucidating which subgroups of female patients are at the highest risk. METHODS/DESIGN: The Female Risk factors for post-Infarction Depression and Anxiety (FRIDA) Study is a prospective multicenter questionnaire-based study of female participants admitted to hospital with ACS. Data are collected within 72 h of admission as well as at 3 and 6 months. At baseline, participants complete a sociodemographic questionnaire, social support survey, and Hospital Depression and Anxiety Scale (HADS). Follow-up will consist of a demographic questionnaire, HADS, changes to health status, and quality of life indicators. Statistical analysis will include descriptive and inferential methods to observe baseline distributions and significance between groups. DISCUSSION/CONCLUSION: Our primary outcome is to determine if specific CV and sociodemographic factors correlate with increased depression and anxiety scores (HADS-D >7; HADS-A >7) at baseline. Our secondary aim is to determine if increased HADS scores at baseline and follow-up correlate with 3 and 6-month health and quality of life outcomes. A total of 2,000 patients will be enrolled across seven study sites. The aim of the FRIDA Study is to understand which groups of female patients have the highest rates of depression and anxiety following ACS to better inform care.

Training of Non-expert Users Using Remotely Delivered, Point-of-Care Tele-Ultrasound: A Proof-of-Concept Study in 2 Canadian Communities.

ABSTRACT: Many physicians, particularly those practicing in remote regions, lack training opportunities to develop point-of-care ultrasound (POCUS) skills. This pretest-posttest study quantified the skill improvement of learners after participating in a virtual training program that used real-time, remotely delivered point-of-care tele-ultrasound (tele-POCUS) for teaching and learner feedback provision. Ten physicians practicing in an urban tertiary (Kingston, Ontario, Canada, n = 6) or remote care center (Moose Factory, Ontario, Canada, n = 4) completed a 3-week educational program that consisted of e-learning module review, independent image acquisition practice, and expert-guided tele-POCUS consultations. Pretraining and posttraining assessments were performed to evaluate skill enhancement in image acquisition, image quality, and image interpretation for cardiac and lung/pleura POCUS using a 5-point Likert scale. A total of 76 tele-POCUS consultations were performed during the study period. Significant improvements in image quality were noted following remotely delivered mentorship and guidance (all P < 0.01). In cardiac POCUS, pretraining and posttraining comparisons noted significant improvements in image acquisition (means, 2.69-4.33; P < 0.02), quality (means, 2.40-4.03; P < 0.01), and interpretation (means, 2.50-4.40; P < 0.02). In lung/pleura POCUS, significant improvements in image acquisition (means, 3.00-4.43; P < 0.01), quality (means, 3.23-4.37; P < 0.01), and interpretation (means, 3.00-4.40; P < 0.01) were demonstrated. Introductory ultrasound can be taught to novice users using a virtual, live-streamed training format with tele-POCUS while demonstrating significant enhancement in imaging skills.