Dyslipidemia in midlife women: Approach and considerations during the menopausal transition.

Dyslipidemia is an established risk factor for cardiovascular disease (CVD), which remains the leading cause of morbidity and mortality in women globally. The incidence of dyslipidemia increases over a woman's lifespan, with adverse changes around the time of menopause. Menopause, and the years leading up to the final menstrual period, is a time of estrogen fluctuation and ultimately estrogen deficiency, which has been associated with proatherogenic changes in the lipid profile. Independent of aging, menopausal status is associated with elevations in serum total cholesterol, LDL cholesterol, apolipoproteins, and triglycerides, and decreases in HDL cholesterol (HDL-C). Emerging research also suggests that after menopause there is a loss of functional HDL cardioprotective properties. Early initiation of menopausal hormone therapy (MHT) confers a favorable effect on lipid profile, though this does not translate into improved CVD outcomes and therefore guidelines do not indicate it for primary or secondary prevention of CVD. At the time of menopause, special consideration should be given to women with conditions more associated with CVD, including polycystic ovarian syndrome, premature menopause, early menopause, premature ovarian insufficiency, and familial hypercholesterolemia. Statins remain the mainstay of dyslipidemia therapy, though novel lipid-lowering agents are emerging. This review provides an overview of lipid alterations observed during the menopausal transition, summarizes the current evidence on the role of estrogen and progestogen on lipids, identifies special populations of women at especially high risk for lipid dysregulation at menopause, and describes approaches to the screening and treatment of midlife women.

Ambulatory and silent myocardial ischemia in women with coronary microvascular dysfunction: Results from the Cardiac Autonomic Nervous System study (CANS).

BACKGROUND: Up to two-thirds of patients with obstructive coronary artery disease (CAD) have silent ischemia (SI), which predicts an adverse prognosis and can be a treatment target in obstructive CAD. Over 50% of women with ischemia and no obstructive CAD have coronary microvascular dysfunction (CMD), which is associated with adverse cardiovascular outcomes. We aimed to investigate the prevalence of SI in CMD in order to consider it as a potential treatment target. METHODS: 36 women with CMD by coronary reactivity testing and 16 age matched reference subjects underwent 24-h 12-lead ambulatory ECG monitoring (Mortara Instruments) after anti-ischemia medication withdrawal. Ambulatory ECG recordings were reviewed by two-physician consensus masked to subject status for SI measured by evidence of ≥1 minute horizontal or downsloping ST segment depression ≥1.0 mm, measured 80 ms from the J point. RESULTS: Demographics, resting heart rate, and systolic blood pressure were similar between CMD and reference subjects. Thirty-nine percent of CMD women had a total of 26 SI episodes vs. 0 episodes in the reference group (p = 0.002). Among these women 13/14 (93%) had SI, and few episodes (3/26, 12%) were symptomatic. Mean HR at the onset of SI was 96 ±â€¯13 bpm and increased to 117 ±â€¯16 bpm during the ischemic episodes. 87% reported symptoms that were not associated with ST depressions. CONCLUSIONS: Ambulatory ischemia is prevalent in women with CMD, with a majority being SI, while most reported symptoms were not accompanied by ambulatory ischemia. Clinical trials evaluating anti-ischemic medications should be considered in the CMD population.

Cardiovascular implications of gender-affirming hormone treatment in the transgender population.

Transgender men and women represent a growing population in the United States and Europe, with 0.5% of adults and 3% of youth identifying as transgender. Globally, an estimated 0.3-0.5% of the population identify as transgender. Despite the increasing percentage of individuals whose gender identity, gender expression and behavior differ from their assigned sex at birth, health outcomes in transgenders have been understudied. Many transgender people seek treatment with cross-sex hormone therapy starting from a young age and frequently at high doses in order to obtain the secondary sex characteristics of the desired gender. There is a need to understand the potential long-term health consequences of cross-sex hormone therapy, given that cardiovascular disease is the leading disease-specific cause of death in this population. This review discusses the cardiovascular risks of gender-affirming hormone treatments with respect to transgender women and transgender men.

Vascular Aging Is Accelerated in Flight Attendants With Occupational Secondhand Smoke Exposure.

OBJECTIVE: To determine whether early vascular aging may be present in flight attendants with remote in-cabin secondhand smoke (SHS) exposure. METHODS: Twenty-six flight attendants with a history of in-cabin SHS exposure prior to the airline smoking bans were recruited. Pulse wave analysis, peripheral arterial tonometry, and brachial artery reactivity testing evaluated their arterial compliance and endothelial function. RESULTS: Flight attendants with remote in-cabin SHS exposure have normal blood pressure, pulse wave velocity, and reactive hyperemia index, but abnormal pulse pressure, augmentation index, flow-mediated dilation, and hyperemic mean flow ratio. CONCLUSION: These preliminary findings suggest that flight attendants with remote in-cabin SHS exposure have preclinical signs of accelerated vascular aging and raise new questions about the relationship between remote SHS exposure and vascular health.

A clinical prescription for heart health in midlife women.

Cardiovascular disease is the leading cause of death in women throughout the United States and Europe. Despite efforts to raise awareness, the sex-specific risk factors are still poorly recognized in both regions, and many women do not identify cardiovascular disease as a primary threat. During midlife, the incidence of cardiovascular disease increases dramatically, and this unique time gives an opportunity to identify both traditional cardiovascular risk factors as well as emerging risk factors unique to women. This review will focus on the current guidelines for cardiovascular risk assessment in Europe and the United States, traditional and emerging cardiovascular risk factors, and preventive lifestyle recommendations for midlife women.