Showing papers by "C. Noel Bairey Merz published in 2022"

Heart-brain interactions in cardiac and brain diseases: why sex matters.

Abstract: Cardiovascular disease and brain disorders, such as depression and cognitive dysfunction, are highly prevalent conditions and are among the leading causes limiting patient's quality of life. A growing body of evidence has shown an intimate crosstalk between the heart and the brain, resulting from a complex network of several physiological and neurohumoral circuits. From a pathophysiological perspective, both organs share common risk factors, such as hypertension, diabetes, smoking or dyslipidaemia, and are similarly affected by systemic inflammation, atherosclerosis, and dysfunction of the neuroendocrine system. In addition, there is an increasing awareness that physiological interactions between the two organs play important roles in potentiating disease and that sex- and gender-related differences modify those interactions between the heart and the brain over the entire lifespan. The present review summarizes contemporary evidence of the effect of sex on heart-brain interactions and how these influence pathogenesis, clinical manifestation, and treatment responses of specific heart and brain diseases.

Microvascular dysfunction as a systemic disease: A review of the evidence.

Abstract:

Abstract

Microvascular dysfunction describes a varied set of conditions that includes vessel destruction, abnormal vasoreactivity, in situ thrombosis, and fibrosis, which ultimately results in tissue damage and progressive organ failure. Microvascular dysfunction has a wide array of clinical presentations, ranging from ischemic heart disease to renal failure, stroke, blindness, pulmonary arterial hypertension, and dementia. An intriguing unifying hypothesis suggests that microvascular dysfunction of specific organs is an expression of a systemic illness that worsens with age and is accelerated by vascular risk factors. Studying relationships across a spectrum of microvascular diseases affecting the brain, retina, kidney, lung, and heart may uncover shared pathologic mechanisms that could inform novel treatment strategies. We review the evidence that supports the notion that microvascular dysfunction represents a global pathologic process. Our focus is on studies reporting concomitant microvascular dysfunction of the heart with that of the brain, kidney, retina, and lung.

Association of N-Terminal Pro-Brain Natriuretic Peptide Concentration in Early Pregnancy With Development of Hypertensive Disorders of Pregnancy and Future Hypertension.

Abstract: Importance Hypertensive disorders of pregnancy are associated with future cardiovascular disease, perhaps because of subclinical cardiac dysfunction before pregnancy leading to impaired adaptation to pregnancy. Natriuretic peptides are promising biomarkers for detecting subclinical cardiac dysfunction outside of pregnancy. Objective To investigate whether higher concentrations of N-terminal pro-brain natriuretic peptide (NT-proBNP) in early pregnancy would be associated with hypertensive disorders of pregnancy and hypertension 2 to 7 years post partum. Design, Setting, and Participants This cohort study used data from the The Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be Heart Health Study, a prospective multicenter observational study. A total of 4103 nulliparous women with complete data and no prepregnancy hypertension or diabetes who were treated at 8 clinical sites were included. Women were followed up with for 2 to 7 years after pregnancy. Data were collected from October 2010 to October 2017, and data were analyzed from August 2020 to November 2021. Exposures NT-proBNP concentration, measured using an electrochemiluminescence immunoassay from a first-trimester blood sample. Main Outcomes and Measures Hypertensive disorders of pregnancy and incident hypertension (systolic blood pressure of 130 mm Hg or diastolic blood pressure of 80 mm Hg or use of antihypertensive agents) at follow-up visit. Results A total of 4103 women met inclusion criteria; the mean (SD) age was 27.0 (5.6) years. Among these women, 909 (22.2%) had an adverse pregnancy outcome, and 817 (19.9%) had hypertension at the follow-up visit. Higher NT-proBNP concentrations were associated with a lower risk of hypertensive disorders of pregnancy (adjusted odds ratio per doubling, 0.81; 95% CI, 0.73-0.91), which persisted after adjustment for age, self-reported race and ethnicity, early-pregnancy body mass index, smoking, and aspirin use. Similarly, higher NT-proBNP concentration in early pregnancy was also associated with a lower risk of incident hypertension 2 to 7 years after delivery (adjusted odds ratio per doubling, 0.84; 95% CI, 0.77-0.93), an association that persisted after controlling for confounders, including hypertensive disorders of pregnancy. Conclusions and Relevance In this cohort study, higher NT-proBNP concentrations in early pregnancy were associated with a lower risk of hypertensive disorders of pregnancy and hypertension 2 to 7 years post partum. These findings suggest that normal early-pregnancy cardiovascular physiology, as assessed by NT-proBNP concentration, may provide biologic insights into both pregnancy outcome and cardiovascular disease risk.

Coronary Arterial Function and Disease in Women With No Obstructive Coronary Arteries

Abstract: Ischemic heart disease (IHD) is the leading cause of mortality in women. While traditional cardiovascular risk factors play an important role in the development of IHD in women, women may experience sex-specific IHD risk factors and pathophysiology, and thus female-specific risk stratification is needed for IHD prevention, diagnosis, and treatment. Emerging data from the past 2 decades have significantly improved the understanding of IHD in women, including mechanisms of ischemia with no obstructive coronary arteries and myocardial infarction with no obstructive coronary arteries. Despite this progress, sex differences in IHD outcomes persist, particularly in young women. This review highlights the contemporary understanding of coronary arterial function and disease in women with no obstructive coronary arteries, including coronary anatomy and physiology, mechanisms of ischemia with no obstructive coronary arteries and myocardial infarction with no obstructive coronary arteries, noninvasive and invasive diagnostic strategies, and management of IHD.

Body weight and physical fitness in women with ischaemic heart disease: does physical fitness contribute to our understanding of the obesity paradox in women?

Abstract: Aims Body mass index (BMI) defined obesity is paradoxically associated with lower all-cause mortality in patients with known cardiovascular disease. This study aims to determine the role of physical fitness in the obesity paradox in women with ischaemic heart disease (IHD). Methods and Results Women undergoing invasive coronary angiography with signs/symptoms of IHD in the Women’s Ischemia Syndrome Evaluation (WISE) prospective cohort (enrolled 1997–2001) were analysed. This study investigated the longer-term risk of major adverse cardiovascular events (MACE) and all-cause mortality associated with BMI and physical fitness measured by Duke Activity Status Index (DASI). Overweight was defined as BMl ≥25 to 30 kg/m2, obese as BMI ≥30 kg/m2, unfit as DASI scores <25, equivalent to ≤7 metabolic equivalents. Among 899 women, 18.6% were normal BMI-fit, 11.4% overweight-fit, 10.4% obese-fit, 15.3% normal BMI-unfit, 23.8% overweight-unfit, and 30.4% obese-unfit. In adjusted models compared to normal BMI-fit, normal BMI-unfit women had higher MACE risk [hazard ratio (HR) 1.65, 95% confidence interval (CI) 1.17–2.32; P = 0.004]; whereas obese-fit and overweight-fit women had lower risk of mortality (HR 0.60, 95% CI 0.40–0.89; P = 0.012 and HR 0.62, 95% CI 0.41–0.92; P = 0.018, respectively). Conclusion To address the paradox of body weight and outcomes in women, we report for the first time that among women with signs/symptoms of IHD overweight-fit and obese-fit were at lower risk of long-term all-cause mortality; whereas normal BMI-unfit were at higher risk of MACE. Physical fitness may contribute to the obesity paradox in women, warranting future studies to better understand associations between body weight, body composition, and physical fitness to improve cardiovascular outcomes in women.

Autologous CD34+ Stem Cell Therapy Increases Coronary Flow Reserve and Reduces Angina in Patients With Coronary Microvascular Dysfunction

Abstract: Background: Coronary microvascular dysfunction results in angina and adverse outcomes in patients with evidence of ischemia and nonobstructive coronary artery disease; however, no specific therapy exists. CD34+ cell therapy increases microvasculature in preclinical models and improves symptoms, exercise tolerance, and mortality in refractory angina patients with obstructive coronary artery disease. The objective of this research was to evaluate the safety, tolerability, and efficacy of intracoronary CD34+ cell therapy in patients with coronary microvascular dysfunction. Methods: We conducted a 2-center, 20-participant trial of autologous CD34+ cell therapy (protocol CLBS16-P01; NCT03508609) in patients with ischemia and nonobstructive coronary artery disease with persistent angina and coronary flow reserve ≤2.5. Efficacy measures included coronary flow reserve, angina frequency, Canadian Cardiovascular Society angina class, Seattle Angina Questionnaire, SF-36, and modified Bruce exercise treadmill test obtained at baseline and 6 months after treatment. Autologous CD34+ cells (CLBS16) were mobilized by administration of granulocyte-colony stimulating factor 5µg/kg/day for 5 days and collected by leukapheresis. Participants received a single intracoronary left anterior descending infusion of isolated CD34+ cells in medium that enhances cell function. Results: Coronary flow reserve improved from 2.08±0.32 at baseline to 2.68±0.79 at 6 months after treatment (P<0.005). Angina frequency decreased (P<0.004), Canadian Cardiovascular Society class improved (P<0.001), and quality of life improved as assessed by the Seattle Angina Questionnaire (P≤0.03, all scales) and SF-36 (P≤0.04, all scales). There were no cell-related serious adverse events. Conclusions: In this pilot clinical trial of microvascular angina, patients with ischemia and nonobstructive coronary artery disease receiving intracoronary infusion of CD34+ cell therapy had higher coronary flow reserve, less severe angina, and better quality of life at 6 months. The current study supports a potential therapeutic role for CD34+ cells in patients with microvascular angina. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03508609.

Association of a Mediterranean Diet Pattern With Adverse Pregnancy Outcomes Among US Women

Abstract: Key Points Question Among geographically, racially, and ethnically diverse nulliparous US women, is concordance to a Mediterranean diet around the time of conception associated with risk of developing any adverse pregnancy outcome (APO) and individual APOs? Findings In this cohort study of 7798 women, greater concordance to a Mediterranean diet pattern was significantly associated with 21% lower risk of developing any APO, with evidence of a dose-response association. There were no differences by race, ethnicity, and prepregnancy body mass index, but associations were stronger among older women. Meaning This study suggests that the Mediterranean diet pattern is inversely associated with APOs; intervention studies are needed to assess whether promoting a Mediterranean-style diet around the time of conception and throughout pregnancy can prevent APOs.

Coronary Microvascular Dysfunction in Patients With Systemic Lupus Erythematosus and Chest Pain

Abstract: Chest pain is a common symptom in patients with systemic lupus erythematosus, an autoimmune disease that is associated with increased cardiovascular morbidity and mortality. While chest pain mechanisms can be multifactorial and often attributed to non-coronary or non-cardiac cardiac etiologies, emerging evidence suggests that ischemia with no obstructive coronary arteries (INOCA) is a prevalent condition in patients with chest pain and no obstructive coronary artery disease. Coronary microvascular dysfunction is reported in approximately half of SLE patients with suspected INOCA. In this mini review, we highlight the cardiovascular risk assessment, mechanisms of INOCA, and diagnostic approach for patients with SLE and suspected CMD.

Sex‐Specific Temporal Trends in Hypertensive Crisis Hospitalizations in the United States

Abstract: Background Despite recent improvements in hypertension control overall, the extent to which these trends apply to the most extreme forms of elevated blood pressure—hypertensive crises requiring hospitalization—in both women and men at risk remains unknown. Methods and Results Using data from the National Inpatient Sample, we estimated sex‐pooled and sex‐specific temporal trends in hypertensive crisis hospitalization and case fatality rates over serial time periods: years 2002 to 2006, 2007 to 2011, and 2012 to 2014. Over the entire study period (years 2002–2014), there were an estimated 918 392±9331 hypertensive crisis hospitalizations and 4377±157 in‐hospital deaths. Hypertensive crisis represented 0.23%±0.002% of all hospitalizations during the entire study period: 0.24%±0.002% for men and 0.22%±0.002% for women. In multivariable analyses adjusting for age, race or ethnicity, and cardiovascular conditions, the odds of experiencing a hospitalization primarily for hypertensive crisis increased annually for both men (odds ratio [OR], 1.083 per year; 95% CI, 1.08–1.09) and women (OR, 1.07 per year, 95% CI, 1.07–1.08) with a higher rate of increase observed in men compared with women (P<0.001). The multivariable‐adjusted odds of death during hypertensive crisis hospitalization decreased annually and similarly for men (OR, 0.89 per year; 95% CI, 0.86–0.92) and for women (0.92 per year; 95% CI, 0.90–0.94). Conclusions Hypertensive crisis hospitalizations have steadily increased, slightly more among men than women, along with an observed increase in the burden of cardiovascular conditions. These trends, observed despite contemporaneous improvements in hypertension prevention and control nationwide, warrant further investigations to identify contributing factors that could be amenable to targeted interventions.

Early identification and treatment of women's cardiovascular risk factors prevents cardiovascular disease, saves lives, and protects future generations: Policy recommendations and take action plan utilizing policy levers

Abstract: Cardiovascular diseases (CVD) including heart attacks, strokes, heart failure, and uncontrolled hypertension are leading causes of death among women of all ages. Despite efforts to increase awareness about CVD among women, over the past decade there has been stagnation in the reduction of CVD in women, and CVD among younger women and women of color has in fact increased. We recommend taking action using policy levers to address CVD in women including: (1) Promoting periodic screening for risk factors including blood pressure, lipids/cholesterol, diabetes for all women starting at 18–21 years, with calculated atherosclerotic CVD (ASCVD) risk score use among women 40 years or older. (2) Considering coronary artery calcium (CAC) screening for those with intermediate risk per current guidelines. (3) Enhancing Obstetrics and Gynecology and primary care physician education on reproductive age CVD risk markers, and that follow‐up is needed, including extended postpartum follow‐up. (4) Offering Health Coaching/motivational Interviewing to support behavior change. (5) Funding demonstration projects using different care models. (6) Creating a Stop High Blood Pressure consult line (for providers and patients) and providing other support resources with actions consumers can take, modeled after the California tobacco quit line. And (7) Requiring inclusion of adverse pregnancy outcomes in all Electronic Health Records, with reminder systems to follow‐up on hypertension post‐partum.

Disparities in Geographic Access to Cardiac Rehabilitation in Los Angeles County

Abstract: Background Exercise‐based cardiac rehabilitation (CR) is known to reduce morbidity and mortality for patients with cardiac conditions. Sociodemographic disparities in accessing CR persist and could be related to the distance between where patients live and where CR facilities are located. Our objective is to determine the association between sociodemographic characteristics and geographic proximity to CR facilities. Methods and Results We identified actively operating CR facilities across Los Angeles County and used multivariable Poisson regression to examine the association between sociodemographic characteristics of residential proximity to the nearest CR facility. We also calculated the proportion of residents per area lacking geographic proximity to CR facilities across sociodemographic characteristics, from which we calculated prevalence ratios. We found that racial and ethnic minorities, compared with non‐Hispanic White individuals, more frequently live ≥5 miles from a CR facility. The greatest geographic disparity was seen for non‐Hispanic Black individuals, with a 2.73 (95% CI, 2.66–2.79) prevalence ratio of living at least 5 miles from a CR facility. Notably, the municipal region with the largest proportion of census tracts comprising mostly non‐White residents (those identifying as Hispanic or a race other than White), with median annual household income <$60 000, contained no CR facilities despite ranking among the county's highest in population density. Conclusions Racial, ethnic, and socioeconomic characteristics are significantly associated with lack of geographic proximity to a CR facility. Interventions targeting geographic as well as nongeographic factors may be needed to reduce disparities in access to exercise‐based CR programs. Such interventions could increase the potential of CR to benefit patients at high risk for developing adverse cardiovascular outcomes.

Reduced myocardial perfusion is common among subjects with ischemia and no obstructive coronary artery disease and heart failure with preserved ejection fraction: a report from the WISE-CVD continuation study

Abstract: Aim: Women with evidence of ischemia and no obstructive coronary artery disease (INOCA) have an increased risk of major adverse cardiac events, including heart failure with preserved ejection fraction (HFpEF). To investigate potential links between INOCA and HFpEF, we examined pathophysiological findings present in both INOCA and HFpEF. Methods: We performed adenosine stress cardiac magnetic resonance imaging (CMRI) in 56 participants, including 35 women with suspected INOCA, 13 women with HFpEF, and 8 reference control women. Myocardial perfusion imaging was performed at rest and with vasodilator stress with intravenous adenosine. Myocardial perfusion reserve index was quantified as the ratio of the upslope of increase in myocardial contrast at stress vs. rest. All CMRI measures were quantified using CVI42 software (Circle Cardiovascular Imaging Inc). Statistical analysis was performed using linear regression models, Fisher’s exact tests, ANOVA, or Kruskal-Wallis tests. Results: Age (P = 0.007), Body surface area (0.05) were higher in the HFpEF group. Left ventricular ejection fraction (P = 0.02) was lower among the INOCA and HFpEF groups than reference controls after age adjustment. In addition, there was a graded reduction in myocardial perfusion reserve index in HFpEF vs. INOCA vs. reference controls (1.5 ± 0.3, 1.8 ± 0.3, 1.9 ± 0.3, P = 0.02), which was attenuated with age-adjustment. Conclusion: Reduced myocardial perfusion reserve appears to be a common pathophysiologic feature in INOCA and HFpEF patients.

Coronary morphological features in women with non-ST-segment elevation MINOCA and MI-CAD as assessed by optical coherence tomography

Abstract: Abstract Aims We aimed to use optical coherence tomography (OCT) to identify differences in atherosclerotic culprit lesion morphology in women with myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) compared with MI with obstructive coronary artery disease (MI-CAD). Methods and results Women with an OCT-determined atherosclerotic aetiology of non-ST segment elevation (NSTE)-MINOCA (angiographic diameter stenosis <50%) who were enrolled in the multicentre Women’s Heart Attack Research Program (HARP) study were compared with a consecutive series of women with NSTE-MI-CAD who underwent OCT prior to coronary intervention at a single institution. Atherosclerotic pathologies identified by OCT included plaque rupture, plaque erosion, intraplaque haemorrhage (IPH, a region of low signal intensity with minimum attenuation adjacent to a lipidic plaque without fibrous cap disruption), layered plaque (superficial layer with clear demarcation from the underlying plaque indicating early thrombus healing), or eruptive calcified nodule. We analysed 58 women with NSTE-MINOCA and 52 women with NSTE-MI-CAD. Optical coherence tomography features of underlying vulnerable plaque (thin-cap fibroatheroma) were less common in MINOCA (3 vs. 35%) than in MI-CAD. Intraplaque haemorrhage (47 vs. 2%) and layered plaque (31 vs. 12%) were more common in MINOCA than MI-CAD, whereas plaque rupture (14 vs. 67%), plaque erosion (8 vs. 14%), and calcified nodule (0 vs. 6%) were less common in MINOCA. The angle of ruptured cavity was smaller and thrombus burden was lower in MINOCA. Conclusion The prevalence of atherothrombotic culprit lesion subtype varied substantially between MINOCA and MI-CAD. A majority of culprit lesions in MINOCA had the appearance of IPH or layered plaque. Clinical Trial Registration Information Clinical Trial Name: Heart Attack Research Program- Imaging Study (HARP); ClinicalTrial.gov Identifier: NCT02905357; URL: https://clinicaltrials.gov/ct2/show/NCT02905357

Sleep Disordered Breathing in Pregnancy and Post-Delivery: Associations with Cardiometabolic Health.

Abstract: RATIONALE Knowledge gaps exist regarding health implications of sleep disordered breathing (SDB) identified in pregnancy and/or post-delivery. OBJECTIVE To determine whether SDB in pregnancy and/or post-delivery is associated with hypertension (HTN) and metabolic syndrome (MS). METHODS The nuMoM2b Heart Health Study (n=4,508) followed participants initially recruited during their first pregnancy. Participants returned for a visit 2-7 years after pregnancy. This study examined a subgroup who underwent SDB assessments during their first pregnancy (n=1,964) and a repeat SDB assessment post-delivery (n=1,222). Two SDB definitions were considered: apnea-hypopnea index (AHI) ≥5; oxygen desaturation index (ODI) ≥5. Associations between SDB and incident HTN and MS were evaluated with adjusted risk ratios (aRR). RESULTS The aRR for MS given an AHI ≥5 during pregnancy was 1.44 (95% CI 1.08, 1.93), but no association with HTN was found. ODI ≥5 in pregnancy was associated with both an increased risk for HTN (aRR 2.02, 95% CI 1.30, 3.14) and MS (aRR 1.53, 95% CI 1.19, 1.97). Participants with an AHI ≥5 in pregnancy that persisted post-delivery were at higher risk for both HTN (aRR 3.77, 95% CI 1.84, 7.73) and MS (aRR 2.46, 95% 1.59, 3.76). Similar associations were observed for persistent post-delivery ODI ≥5. CONCLUSIONS An AHI ≥5 in pregnancy was associated with an increased risk of MS. An ODI ≥5 in pregnancy was significantly associated with both HTN and MS. Participants with persistent elevations in AHI and ODI both during pregnancy and at 2-7 post-delivery were at the highest risk for HTN and MS.

Heart and brain interactions: is small vessel disease a link?

Abstract: Central Figure Legend: Heart and brain microvascular disorders. Left panel and top: these microvascular disorders occur mostly in women and involve inflammation and oxidative stress. Central panel: coronary microvascular disfunction (CMD). Mostly middle-aged women, causes myocardial ischaemia, recurrent angina, shortness of breath, frequent emergency department visits, hospitalizations, and reduced quality of life (QOL). Key functional changes: reduced coronary endothelial dependent vasodilation (EDVD), enhanced vasoconstriction, spasm, limited coronary flow reserve (CFR). Prevalent in hypertension, cardiomyopathies, diabetes, hypercholesterolaemia, metabolic syndrome, chronic kidney disease, and sedentary lifestyles (not shown). Cardiac imaging features: reduced TIMI (thrombolysis in myocardial infarction) flow grade, ‘slow flow’ on invasive coronary angiography; reduced coronary blood flow (Doppler velocity) or cardiac magnetic resonance imaging (cMRI) as myocardial perfusion reserve index (MPRI) to adenosine, also small scar by late gadolinium (LGE). Is reversible. Right panel: cerebral small vessel disease (CSVD). Mostly older women, closely correlated with age; prevalence increases from ∼5% at age 50 to nearly 100% by age 90. Causes gait and balance disorders, increased risk of falls, stroke, decreased QOL, and contributes to cognitive decline or directly disrupts motor pathways. Brain imaging features: magnetic resonance imaging (MRI) as white matter hyperintensities (WMH), cerebral microbleeds (CMB), lacunar infarctions (LI), enlarged perivascular spaces (EPVS), and brain atrophy. Functional MRI and transcranial Doppler. Different CSVD imaging features have different characteristics. The brain parenchymal lesions can be either ischaemic or haemorrhagic. Various aetiological classifications have been proposed [e.g. atherosclerosis, cerebral amyloid angiopathy, inherited or genetic (CADASIL, CARASIL, Fabry’s disease, COL4A1 mutations etc.), inflammatory and immune-mediated, venous collagenosis, other (post radiation angiopathy, non-amyloid microvessel degeneration in Alzheimer’s disease)]. Not reversible at present.

Ultra-high sensitivity cardiac troponin-I concentration and left ventricular structure and function in women with ischemia and no obstructive coronary artery disease

Abstract: Women are disproportionally impacted by ischemia and no obstructive coronary artery disease (INOCA), and such women are at increased risk of developing heart failure with preserved ejection fraction (HFpEF), however the mechanisms linking these conditions remain poorly understood. The aim of this study was to determine whether ultra-high sensitivity cardiac troponin I (u-hscTnI), an indicator of cardiomyocyte injury, is associated with abnormalities in myocardial perfusion and left ventricular (LV) structure and function in women with INOCA.327 women with INOCA enrolled in the Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction (WISE-CVD) study underwent vasodilator stress cardiac magnetic resonance imaging (CMRI) and u-hscTnI measurements (Simoa HD-1 Analyzer, Quanterix Corporation). Multivariable linear regression was used to evaluate associations between u-hscTnI concentrations and myocardial perfusion (MPRI), LV mass index and feature-tracking derived strain measures of LV function.u-hscTnI concentrations were quantifiable in 100% of the cohort and ranged from 0.004 to 79.6 pg/mL. In adjusted models, u-hscTnI was associated with LV mass index (+2.03; 95% CI 1.17, 2.89; p < 0.01) and early diastolic radial strain rate (SR) (+0.13; 95% CI 0.01, 0.25; p = 0.03), early diastolic circumferential SR (-0.04; 95% CI -0.08, 0.002; p = 0.06) and early diastolic longitudinal SR (-0.03; 95% CI -0.07, 0.002; p = 0.06). u-hscTnI was not associated with MPRI (p = 0.39) in adjusted models.Together, these findings support cardiomyocyte injury as a putative pathway towards adverse LV remodeling and dysfunction; however, further research is needed to define the specific mechanism(s) driving myocellular injury in INOCA.

Premature menopause and cardiovascular disease: can we blame estrogen?

Abstract: Journal Article Premature menopause and cardiovascular disease: can we blame estrogen? Get access Tina Torbati, Tina Torbati Barbra Streisand Women’s Heart Center, Cedars-Sinai Smidt Heart Institute, 127 S. San Vicente Blvd, Suite A3206, 90048, Los Angeles, CA Search for other works by this author on: Oxford Academic PubMed Google Scholar Chrisandra Shufelt, Chrisandra Shufelt Barbra Streisand Women’s Heart Center, Cedars-Sinai Smidt Heart Institute, 127 S. San Vicente Blvd, Suite A3206, 90048, Los Angeles, CA https://orcid.org/0000-0001-6886-9210 Search for other works by this author on: Oxford Academic PubMed Google Scholar Janet Wei, Janet Wei Barbra Streisand Women’s Heart Center, Cedars-Sinai Smidt Heart Institute, 127 S. San Vicente Blvd, Suite A3206, 90048, Los Angeles, CA Search for other works by this author on: Oxford Academic PubMed Google Scholar C Noel Bairey Merz C Noel Bairey Merz Barbra Streisand Women’s Heart Center, Cedars-Sinai Smidt Heart Institute, 127 S. San Vicente Blvd, Suite A3206, 90048, Los Angeles, CA Corresponding author. Tel: 310-423-9680, Fax: 310-423-9681, Email: Noel.BaireyMerz@cshs.org https://orcid.org/0000-0002-9933-5155 Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal, Volume 43, Issue 40, 21 October 2022, Pages 4158–4160, https://doi.org/10.1093/eurheartj/ehac321 Published: 20 July 2022

Depression Symptom Patterns as Predictors of Metabolic Syndrome and Cardiac Events in Symptomatic Women with Suspected Myocardial Ischemia: The Women’s Ischemia Syndrome Evaluation (WISE and WISE-CVD) Projects

Abstract: Background: Ischemic heart disease (IHD) risk in women includes biomedical, behavioral, and psychosocial contributors. The purpose of this study was to build upon previous research suggesting that in women, somatic symptoms (SS) of depression may be important to the development of IHD risk factors and major adverse cardiovascular events (MACE). Based on previous findings, we hypothesized that: (1) SS would be associated with robust biomedical predictors of heart disease and functional capacity, while cognitive symptoms (CS) of depression would not, and (2) SS would independently predict adverse health outcomes while CS would not. Methods: We examined the relationships between symptoms of depression (SS/CS), metabolic syndrome (MetS), inflammatory markers (IM), coronary artery disease (CAD) severity, and functional capacity in two independent cohorts of women with suspected IHD. In the Women's Ischemia Syndrome Evaluation (WISE), we also examined these variables as predictors of all-cause mortality (ACM) + MACE over a median 9.3-year follow-up. The WISE sample included 641 women with suspected ischemia with or without obstructive CAD. The WISE-Coronary Vascular Dysfunction (WISE-CVD) sample consisted of 359 women with suspected ischemia and no obstructive CAD. All study measures were collected uniformly at baseline. Depressive symptoms were measured via the Beck Depression Inventory. MetS was assessed according to Adult Treatment Panel III (ATP-III) criteria. Results: In both studies, SS was associated with MetS (Cohen's d = 0.18, 0.26, P < 0.05, respectively), while CS was not. Within WISE, using Cox Proportional Hazard Regression, SS (Hazard ratio [HR] = 1.08, 95% confidence interval [CI] = 1.01–1.15; HR = 1.07, 95% CI = 1.00–1.13) and MetS (HR = 1.89, 95% CI = 1.16–3.08; HR = 1.74, 95% CI=1.07–2.84) were independent predictors of ACM + MACE after controlling for demographics, IM, and CAD severity, while CS was not. Conclusions: In two independent samples of women undergoing coronary angiography due to suspected ischemia, SS but not CS of depression were associated with MetS, and both SS and MetS independently predicted ACM and MACE. These results add to previous studies suggesting that SS of depression may warrant specific attention in women with elevated cardiovascular disease (CVD) risk. Future research evaluating the biobehavioral basis of the relationship between depression, MetS, and CVD is needed.

The Impact of Living with INOCA

Abstract: There is limited literature available on the impact of myocardial ischemia but no obstructive coronary arteries (INOCA) on patients' lives. We sought to determine how INOCA impacts the physical, social, and mental health of persons with this diagnosis. A survey was made available to all members of the patient support group from INOCA International over a 3-month time period. Fitness was estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed prior to the onset of INOCA symptoms, and after the diagnosis of INOCA. The formula to estimate fitness in metabolic equivalents (METs) = 0.43 × DASI + 9.6 / 3.5 A total of 297 patients with INOCA responded to the survey; 91.2% were women. The most common diagnosis was coronary microvascular dysfunction (64.3%) and coronary artery spasm (50.5%) (Table 1). 34.4% reported living with symptoms for ≥3 years before their diagnosis of INOCA was made. 77.8% who had been told their symptoms were not cardiac. The symptoms the respondents experienced were numerous, but 92.9% reported symptoms of chest pain, pressure, or discomfort. Fitness levels prior to the onset of INOCA symptoms were significantly higher compared to after diagnosed with INOCA (8.6±1.8 METs vs 5.6±1.8 METs; P<0.0001). Most respondents reported an adverse impact on their home life (80.5%), social life (80.1%), mental health (70.4%), outlook on life (69.7%), sex life (55.9%), and their partner/spouse relationship (53.9%). Work life was also affected once living with INOCA: approximately three-quarters had reduced their work hours or stopping work completely, 47.5% retired early, and 38.4% applied for disability. While living with INOCA, for each 1-MET decrease in fitness, there was a loss of 3.0±0.6 days/months of physical health, 1.8±0.6 days/month of mental health, and 2.9±0.7 days/months of inability to perform recreational activities (p<0.0001) (Figure 1). Living with INOCA has significant impact on physical, mental and social health. Significant physical fitness declines are seen in those living with INOCA and are lower in those experiencing any adverse impact of living with INOCA. Additionally, the impact of INOCA on the ability to work has important economic consequences to both the patient and society. Increased recognition of the impact of INOCA on these aspects of health need to be recognized and further work is needed to better diagnosis and treat the symptoms of INOCA to improve the quality of life, cardiovascular outcomes, and overall health of this frequently encountered cardiovascular disorder. Type of funding sources: None.