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1.
Purpose of Review
The goal of this article is to review the disparities that exist for women who present for treatment of ischemic heart disease.Recent Findings
It is well known that women are more likely to present with ischemic heart disease at an advanced age with more comorbidities when compared to male counterparts. Despite correction of risk factors, women experience worse outcomes, even in the absence of obstructive coronary artery disease. A review of the literature highlights the importance of a thoughtful approach to medical therapy and revascularization.Summary
While most recommendations applied to women are derived mostly from male data, further study of sex-specific differences may lead to approaches which can ultimately reduce disparities for the treatment of ischemic heart disease in women.2.
Purpose of Review
Cardiovascular disease remains the leading cause of death among women globally, majority of which are due to ischemic heart disease. Despite the recent advances in the overall management of CVD, there are unique challenges in the diagnosis and management of women as well as poorer outcomes.Recent Findings
Women with ischemic cardiomyopathy experience significant morbidity and mortality. Differences in underlying pathology, delays in presentation, diagnosis, and treatment as well as the under-representation of women in clinical trials contribute to these poor outcomes.Summary
In this review, we discuss the nuances of gender-specific differences in the burden, clinical presentation, and outcomes of ischemic cardiomyopathy in women, in addition to discussion of areas needing further research.3.
Varsha G. Vimalananda Donald R. Miller Timothy P. Hofer Robert G. Holleman Mandi L. Klamerus Eve A. Kerr 《Journal of general internal medicine》2013,28(2):529-535
BACKGROUND
Women with diabetes have higher low-density lipoprotein (LDL) levels than men, resulting in apparent disparities between genders on quality indicators tied to LDL thresholds.OBJECTIVE
To investigate whether gender disparities persist when accounting for clinical action with statins or cardiovascular risk.DESIGN
Retrospective cohort study.PARTICIPANTS
Veterans Health Administration patients (21,780 women and 646,429 men) aged 50–75 with diabetes.MAIN MEASURES
Threshold measure: LDL < 100 mg/dL; clinical action measure: LDL < 100 mg/dL; or LDL ≥ 100 mg/dL and the patient was prescribed a moderate or high-dose statin at the time of the test; or LDL ≥ 100 mg/dL and the patient received other appropriate clinical action within 90 days; adherence: continuous multiple interval measure of gaps in dispensed medication (CMG).KEY RESULTS
Women were much less likely to have LDL < 100 mg/dL than were men (55 % vs. 68 %). This disparity narrowed from 13 % to 6 % for passing the clinical action measure (79 % vs. 85 %). These gender differences persisted among those with ischemic heart disease (IHD). Women had a lower odds of passing the clinical action measure (odds ratio 0.68, 95 % confidence interval 0.66–0.71). Among those with IHD, the gender gap increased with age. Differences in pass rates were explained by women’s higher LDL levels, but not by their slightly worse adherence (3 % higher CMG).CONCLUSIONS
Women and men veterans receive more similar quality of care for lipids in diabetes than previously indicated. Less reassuringly, the remaining gender differences appear to be as common in women at high cardiovascular risk as in those at low risk. Rather than focus on simply improving LDL levels in all women with diabetes, future efforts should ensure that patients with high cardiovascular risk are appropriately treated with statins when clinically indicated, feasible, and concordant with patient preferences.4.
Purpose of Review
Increased awareness of cardiovascular disease in women has prompted studies to investigate gender-related disparities in acute coronary syndromes (ACSs). In this review, we discuss findings from current literature on the clinical presentation, pathophysiology, diagnosis, and management of ACS in women as compared to men.Recent Findings
Emerging data show that cardiovascular disease (CVD) continues to be the leading cause of death in women and the annual mortality rate from CVD remains higher in women compared to men. Recent studies demonstrate sex-specific differences in patients presenting with ACS. Comorbidities, especially diabetes, are more common in young women compared with age-matched men who develop acute myocardial infarction (AMI). Women are more likely to have atypical symptoms and nonobstructive coronary disease on angiography. Women are less likely to receive guideline-based therapies. They have higher rates of peri-procedural complications with PCI and are less likely to be referred to cardiac rehabilitation.Summary
Awareness of differences in the underlying pathophysiology of coronary disease in women compared to men may lead to improved gender-based diagnostic and treatment modalities. However, until more studies are performed, efforts should be directed toward improving delivery of current, gender-neutral guidelines in women just as in men.5.
Aisha James Seth A. Berkowitz Jeffrey M. Ashburner Yuchiao Chang Daniel M. Horn Sandra M. O’Keefe Steven J. Atlas 《Journal of general internal medicine》2018,33(4):463-470
Background
Healthcare systems use population health management programs to improve the quality of cardiovascular disease care. Adding a dedicated population health coordinator (PHC) who identifies and reaches out to patients not meeting cardiovascular care goals to these programs may help reduce disparities in cardiovascular care.Objective
To determine whether a program that used PHCs decreased racial/ethnic disparities in LDL cholesterol and blood pressure (BP) control.Design
Retrospective difference-in-difference analysis.Participants
Twelve thousdand five hundred fifty-five primary care patients with cardiovascular disease (cohort for LDL analysis) and 41,183 with hypertension (cohort for BP analysis).Intervention
From July 1, 2014–December 31, 2014, 18 practices used an information technology (IT) system to identify patients not meeting LDL and BP goals; 8 practices also received a PHC. We examined whether having the PHC plus IT system, compared with having the IT system alone, decreased racial/ethnic disparities, using difference-in-difference analysis of data collected before and after program implementation.Main Measures
Meeting guideline concordant LDL and BP goals.Key Results
At baseline, there were racial/ethnic disparities in meeting LDL (p?=?0.007) and BP (p?=?0.0003) goals. Comparing practices with and without a PHC, and accounting for pre-intervention LDL control, non-Hispanic white patients in PHC practices had improved odds of LDL control (OR 1.20 95% CI 1.09–1.32) compared with those in non-PHC practices. Non-Hispanic black (OR 1.15 95% CI 0.80–1.65) and Hispanic (OR 1.29 95% CI 0.66–2.53) patients saw similar, but non-significant, improvements in LDL control. For BP control, non-Hispanic white patients in PHC practices (versus non-PHC) improved (OR 1.13 95% CI 1.05–1.22). Non-Hispanic black patients (OR 1.17 95% CI 0.94–1.45) saw similar, but non-statistically significant, improvements in BP control, but Hispanic (OR 0.90 95% CI 0.59–1.36) patients did not. Interaction testing confirmed that disparities did not decrease (p?=?0.73 for LDL and p?=?0.69 for BP).Conclusions
The population health management intervention did not decrease disparities. Further efforts should explicitly target improving both healthcare equity and quality.Clinical Trials #: NCT02812303 (ClinicalTrials.gov).6.
BACKGROUND
Educating medical students about health disparities may be one step in diminishing the disparities in health among different populations. According to adult learning theory, learners’ opinions are vital to the development of future curricula.DESIGN
Qualitative research using focus group methodology.OBJECTIVES
Our objectives were to explore the content that learners value in a health disparities curriculum and how they would want such a curriculum to be taught.PARTICIPANTS
Study participants were first year medical students with an interest in health disparities (n?=?17).APPROACH
Semi-structured interviews consisting of 12 predetermined questions, with follow-up and clarifying questions arising from the discussion. Using grounded theory, codes were initially developed by the team of investigators, applied, and validated through an iterative process.MAIN RESULTS
The students perceived negative attitudes towards health disparities education as a potential barrier towards the development of a health disparities curriculum and proposed possible solutions. These solutions centered around the learning environment and skill building to combat health disparities.CONCLUSIONS
While many of the students’ opinions were corroborated in the literature, the most striking differences were their opinions on how to develop good attitudes among the student body. Given the impact of the provider on health disparities, how to develop such attitudes is an important area for further research.7.
Purpose of review
Multiple myeloma treatment regimens consist of proteasome inhibitors (bortezomib, carfilzomib, and ixazomib), immunomodulatory drugs (thalidomide, lenalidomide, and pomalidomide), and steroids. In this paper, we will review the pathophysiology and associated cardiotoxicities of the different multiple myeloma therapeutic modalities and present methods to mitigate the development of cardiovascular complications.Recent findings
Although proteasome inhibitors and immunomodulatory drugs have led to significant improvements in oncologic outcomes, there is increasing evidence of serious cardiovascular side effects which may be exacerbated in the setting of underlying cardiovascular risk factors or disease. Cardiotoxicities include cardiomyopathy and heart failure, accelerated hypertension, arrhythmias, and both arterial and venous thromboembolism.Summary
Given the frequency of cardiovascular risk factors in multiple myeloma patients as well as the cardiotoxicities associated with the different treatment regimens, it is essential to closely monitor these patients. Collaboration between cardiologists and oncologists is necessary to ensure patients receive optimal cancer treatment while minimizing cardiovascular risk.8.
Brian D. Hoit 《Current cardiology reports》2018,20(10):96
Purpose of Review
To review the current status of measuring left atrial functions with echocardiography and the ability of atrial functional analysis to predict cardiovascular outcomes.Recent Findings
An increasing body of data suggests that left atrium (LA) function assessed with echocardiography provides incremental prognostic information in general and referral populations, and in patients with atrial fibrillation, stroke, heart failure, and ischemic and valvular heart disease. In addition to volumetric analysis and spectral and tissue Doppler, deformational (strain and strain rate) imaging has most recently been used to assess LA reservoir, conduit, and booster pump functions and predict cardiovascular events.Summary
Studies of LA function provide new insights into the contribution of LA performance to cardiovascular disease and are promising tools for predicting cardiovascular events in healthy subjects and patients with heart disease. However, robust clinical outcome data from large prospective outcome trials are needed to confirm the incremental predictive ability of these LA functional measures before they are widely accepted.9.
Purpose of Review
The goal of this review is to highlight the potential of induced pluripotent stem cell (iPSC)-based modeling as a tool for studying human cardiovascular diseases. We present some of the current cardiovascular disease models utilizing genome editing and patient-derived iPSCs.Recent Findings
The incorporation of genome-editing and iPSC technologies provides an innovative research platform, providing novel insight into human cardiovascular disease at molecular, cellular, and functional level. In addition, genome editing in diseased iPSC lines holds potential for personalized regenerative therapies.Summary
The study of human cardiovascular disease has been revolutionized by cellular reprogramming and genome editing discoveries. These exceptional technologies provide an opportunity to generate human cell cardiovascular disease models and enable therapeutic strategy development in a dish. We anticipate these technologies to improve our understanding of cardiovascular disease pathophysiology leading to optimal treatment for heart diseases in the future.10.
Purpose of Review
This review aims to summarize and discuss heart failure outcomes for current glucose-lowering agents in patients with type 2 diabetes mellitus.Recent Findings
Current regulations require cardiovascular outcomes trials for new glucose-lowering therapies to establish that there is no unacceptable increase in cardiovascular risk prior to approval. These cardiovascular outcomes trials include glucagon-like peptide 1 receptor agonists, dipeptidyl peptidase-4 inhibitors, and sodium-glucose cotransporter-2 inhibitors. Overall, 87,162 patients have been studied in 10 published cardiovascular outcomes trials. There was no significant increase in major adverse cardiovascular events including cardiovascular mortality, myocardial infarction, and stroke in any of these trials. Heart failure was a component of the secondary endpoint of all of these trials, but only two of these studies show a significant improvement in rates of hospitalization for heart failure.Summary
Expanded regulatory labeling for reduction in cardiovascular mortality (empagliflozin) and reduction in major adverse cardiovascular events (liraglutide) has recently been established. Saxagliptin and to a lesser part alogliptin have been associated with an increased rate of hospitalization for heart failure. Canagliflozin and empagliflozin are the only two medications that have shown a clear benefit in rates of heart failure hospitalization in treatment of patients with type 2 diabetes mellitus.11.
Ciorsti MacIntyre Chinyere Iwuala Ratika Parkash 《Current treatment options in cardiovascular medicine》2018,20(8):63
Purpose of reviews
In this review, the challenges of managing cardiac arrhythmias and syncope in the setting of pregnancy will be discussed.Recent findings
Arrhythmias in pregnancy are increasing, as diagnostic and therapeutic options have advanced and women are older at the time of gestation. Atrial fibrillation has become the most common arrhythmia in pregnancy. Inherited arrhythmia has become a more common entity, with advances in treatments and genetic testing, and require specialized treatments in pregnancy.Summary
The majority of arrhythmias in pregnancy are benign. The potential risk of increased cardiac morbidity and mortality exists for mother and fetus, especially in women with structural heart disease, which is becoming increasingly common. Early evaluation, diagnosis, and appropriate treatment are necessary to achieve optimal outcomes for both mother and fetus.12.
Purpose of the Review
To summarize current advances in the understanding and management of heart failure (HF) in patients with advanced chronic kidney disease (CKD).Recent Findings
Diagnosis of HF and treatment of congestion are crucial in the management of patients with advanced CKD to reduce symptoms, preserve organ function, and improve outcomes. Echocardiography and cardiovascular biomarkers may help to differentiate cardiac from non-cardiac components of overhydration. Renal replacement therapy or ultrafiltration may be required to treat congestion. Furthermore, patients with advanced CKD are frequently undertreated with disease-modifying HF therapies, but the use of beta-blockers and ACEi should be considered under close monitoring of kidney function and serum potassium. The use of the new oral potassium binders may translate into improved outcomes.Summary
The treatment of HF in patients with advanced CKD requires a multi-disciplinary approach. New diagnostic and therapeutic strategies are under evaluation and may contribute to improved outcomes.13.
Purpose of Review
Ethnicity has long been described as a major risk factor for the development of gestational diabetes mellitus (GDM), and it is widely recognised that women from ethnicities other than Europids are at higher risk of developing GDM. There are also described differences between ethnicities in key GDM pregnancy outcomes. This review describes some of the factors that relate to the ethnic disparities in GDM.Recent Findings
The global prevalence of GDM has been steadily increasing and estimated to be 16.2% from the International Diabetes Federation extrapolation. Reported prevalence rates may understate the true prevalence, due to factors of access and attitudes to GDM diagnosis and screening in low resource settings for foreign-born women and indigenous populations. Other factors may relate to genes associated with specific ethnicities, obesity, body composition and gestational weight gain.Summary
Various factors such as access to screening, body composition, genetics and gestational weight gain may result in ethnic disparities in the prevalence and outcomes of GDM.14.
Purpose of Review
Depression, anxiety, and cognitive impairment constitute established risk markers for incident cardiovascular disease (CVD) and are associated with impaired life expectancy and quality of life and high hospitalization rates and healthcare expenditure. This review summarizes current knowledge about mental health disorders in patients with CVD and heart failure (HF).Recent Findings
Emerging evidence suggests various shared pathophysiological mechanisms between psychological comorbidities and CVD (e.g., systemic inflammation and autonomic dysfunction). Bi-directional interactions involving the central nervous and cardiovascular systems may help explain the rising prevalence of comorbid mood disorders with increasing CVD severity and support the concept of alternative pathophysiological mechanisms in the presence of severe somatic illness, making symptoms less responsive or unresponsive to psychotropic pharmacotherapy.Summary
Considering high prevalence and negative impact of psychological comorbidities in CVD and HF, routine care should integrate screening for these conditions. Multidisciplinary treatment approaches with active patient participation in disease management were shown to improve outcomes. However, better understanding of factors mediating the adverse prognostic effects of mood disorders is needed. This might enable more targeted treatment and possibly also facilitate better understanding of the pathophysiological mechanisms driving CVD.15.
Purpose of Review
We review the cardiovascular and renal outcomes and safety of newer anti-diabetic medications in high-risk patients. We examine the outcomes of the IRIS, EMPA-REG OUTCOME, CANVAS, LEADER, SAVOR-TIMI 53, and EXAMINE trials demonstrating the cardiovascular and renal benefits of thiazolidinediones, SGLT2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors.Recent Findings
Diabetes mellitus is a leading risk factor for cardiovascular disease with rising prevalence and disease burden. The microvascular and macrovascular complications of diabetes are well-recognized and include increased risk of cardiovascular disease, myocardial infarction, and stroke. Newer diabetes medications have demonstrated significant cerebrovascular, cardiovascular, renal, and mortality benefits in high risk patients with diabetes. In addition to their glucose-lowering effects, the thiazolidinedione pioglitazone, SGLT2 inhibitors, GLP-1 agonist, and DPP-4 inhibitors have demonstrated significant cerebrovascular, cardiovascular, renal, and mortality effects.Summary
The outcomes and safety data of newer diabetes medications from recent trials demonstrate cardiovascular and mortality effects with significant implications for clinical practice.16.
Purpose of Review
Adult obesity and cardiovascular diseases are closely linked. Yet, the relationship of childhood and adolescent obesities with cardiovascular diseases in adulthood requires additional evidence. The goal of the review is to inspect the relationship between childhood- and adolescent-increased body mass index (BMI) and cardiovascular risk factors, fatal and non-fatal cardiovascular diseases in adulthood.Recent Findings
Cardiovascular diseases in adulthood are linked by most of the studies to childhood and adolescent obesities.Summary
Studies showed that childhood and adolescent obesities increased the incidence of cardiovascular disease risk factors and were linked to higher risk of cardiovascular morbidity and mortality in adulthood. Childhood and adolescent obesities were also associated, likely with a causal relationship, with an increased likelihood for various cardiovascular morbidities including ischemic heart disease, stroke, but also non-ischemic heart disease-related cardiac pathologies.17.
Qurat-ul-ain Jelani Mikhail Petrov Sara C. Martinez Lene Holmvang Khaled Al-Shaibi Mirvat Alasnag 《Current atherosclerosis reports》2018,20(8):40
Purpose of Review
Peripheral arterial disease (PAD) is the third most common manifestation of cardiovascular disease (CVD), following coronary artery disease (CAD) and stroke. PAD remains underdiagnosed and under-treated in women.Recent Findings
Women with PAD experience more atypical symptoms and poorer overall health status. The prevalence of PAD in women increases with age, such that more women than men have PAD after the age of 40 years. There is under-representation of PAD patients in clinical trials in general and women in particular. In this article, we address the lack of women participants in PAD trials. We then present a comprehensive overview of the epidemiology/risk factor profile, clinical features, treatment, and outcomes.Summary
PAD is prevalent in women and its global burden is on the rise despite a decline in global age-standardized death rate from CVD. The importance of this issue has been underlined by the American Heart Association’s (AHA) “Call to Action” scientific statement on PAD in women. Large-scale campaigns are needed to increase awareness among physicians and the general public. Furthermore, effective treatment strategies must be implemented.18.
Oni J. Blackstock Janet P. Tate Kathleen M. Akgün Stephen Crystal Mona Duggal E. Jennifer Edelman Cynthia L. Gibert Kirsha S. Gordon David Rimland Maria C. Rodriguez-Barradas Emily A. Wang David A. Fiellin Amy C. Justice 《Journal of general internal medicine》2013,28(2):577-582
BACKGROUND
Whether sex disparities exist in overall burden of disease among human immunodeficiency virus (HIV)-infected individuals in the Veterans Affairs healthcare system (VA) is unknown.OBJECTIVE
To determine whether sex differences exist in overall burden of disease after 1 year of combined antiretroviral therapy (ART) among HIV-infected individuals in VA.DESIGN
Retrospective cohort study.PARTICIPANTS
Among patients in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC), all ART-naïve HIV-infected Veterans who received VA-based HIV care between 1996 and 2009.MAIN MEASURES
Overall burden of disease was measured using the VACS Index, an index that incorporates HIV (e.g. CD4 cell count) and non-HIV biomarkers (e.g. hemoglobin) and is highly predictive of all-cause mortality. Possible scores range from 0 to 164, although scores typically range from 0 to 50 for 80 % of patients in VACS-VC. A higher score indicates greater burden of disease (each additional five points indicates approximately 20 % increased 5-year mortality risk). ART adherence was measured using pharmacy data.KEY RESULTS
Complete data were available for 227 women and 8,073 men. At ART initiation, compared with men, women were younger and more likely to be Black, less likely to have liver dysfunction, but more likely to have lower hemoglobin levels. Median VACS Index scores changed from ART initiation to 1 year after ART initiation: women’s scores went from 41 to 28 for women (13 point improvement) and men’s from 42 to 27 for men (15 point improvement). In multivariable regression, women had 3.6 point worse scores than men after 1 year on ART (p?=?0.002); this difference decreased to 3.2 points after adjusting for adherence (p?=?0.004).CONCLUSIONS
In VA, compared to men, women experienced less improvement in overall burden of disease after 1 year of HIV treatment. Further study is needed to elucidate the modifiable factors that may explain this disparity.19.
Purpose of the review
To discuss the ethnic and racial disparities observed in patients with autoimmune liver diseases, with special focus on epidemiology, patterns of inheritance, clinical presentation, and outcomes.Recent findings
Black, Hispanics, and Asians with autoimmune hepatitis appear to have more aggressive clinical features, poorer initial response to standard therapy, and higher rates of complications including hepatocellular carcinoma, with worse survival than their White counterparts. African American and Hispanic patients with primary biliary cholangitis have more advanced disease at presentation and Hispanics appear to have lower rates of biochemical response to UDCA compared to non-Hispanics. African American patients with PSC are significantly younger at presentation and appear to have more aggressive liver disease when compared to European Americans.Summary
The clinical presentation and outcomes of autoimmune liver diseases vary by ethnicity and race, with significant disparities reported in recent years. The goal of this review is to make clinicians aware of these differences to facilitate diagnosis and management of autoimmune liver diseases and eventually improve outcomes across various races and ethnicities.20.
