Circulation February 19, 2019 Issue

Dr Carolyn Lam: Welcome to Circulation on the Run, your weekly
podcast summary and backstage pass to the journal and it's
editors. I'm Dr Carolyn Lam, associate editor from the National
Heart Center and Duke National University of Singapore. And I am
so privileged to be joined by Senior Associate Editors whom I
respect and admire so much. And they are Dr Biykem Bozkurt from
Baylor College of Medicine and Dr Sana Al-Khatib from Duke
University. And we have three woman discussing the Go Red for
Women issue. Yes!


                               
The current issue is the third Go Red for Women issue and boy, is
it a bonanza issue. It tackles a wide spectrum of topics relating
to cardiovascular disease in women, including prevention, risk
stratification, myocardial infarction, pregnancy, heart failure,
cardiac arrest, sudden cardiac death, and in so many wonderful
formats; from original papers to systematic reviews,
state-of-the-art papers, in-depth reviews, a research letter, and
even frame of reference papers.


                               
So, let’s get digging into this issue, shall we? And Biykem, we
could start with you because I'd like to start with three
original papers that really set the scene. The first discussed
temporal changes and the very contemporary data from 2001 to
2016, describing cardiovascular risk factors and their treatment.
And then the second focuses on young females with acute
myocardial infarction. And the third on older women. Could you
take us through these papers Biykem?


Dr Biykem
Bozkurt:         Lets
first start looking at the sex differences through the Anne
Haines Survey which enrolled more than 35000 patients. And they
examined the trend all the way back from 2000 to 2016. Now the
good news is the improvement in hypertension diabetes
hyperlipidemia in woman were similar to men. So that's the good
news. But BMI increased more in women than in men and overall,
the ability to control blood pressure and diabetes hyperlipidemia
appear to be a little bit better for women than in men.


                               
But the concerning trend becomes apparent when we look at another
paper that examined the twenty-year trend in young adults. Now,
the first message is, and this is important for both genders, the
proportion of the hospitalizations that are attributable to young
patients, and young patients are defined as ages between 35 and
54 in this study, and this study was from Erik, increased from
1995 to 2014. So young patients appear to be having more in life
compared to before, compared to 1990s and the 2000s. And that was
actually partly due to the increasing prevalence of
comorbidities, such as hypertension diabetes among young
patients.


                               
Now, interestingly among young patients, young women presenting
with [inaudible] had a lower likelihood of receiving guideline
directed therapy which, of course, sound familiar to our audience
because we have the disparities of lower treatments and lower
access to care in women with MI presentation compared to men. And
unfortunately, again this will sound like the former news, the
pre-hospital mortality was quite high in young women and has
declined less in young women, compared to men.


                               
So, the Erik study highlights the disparity for young women
compared to young men. And then we have to recognize that most
young patients in my hospitalization attributed to young patients
is increasing. So this is probably a population that we need to
be aware of. Regarding the older patients, there is a publication
from the Opach Study looking at the sedentary behavior and
cardiovascular disease in older women. And they looked at more
than 5500 patients aged between 63 and all the way up until 97.
And they looked at sedentary time and they looked at the duration
of sedentary time all the way over eleven hours in some of the
patients. And of course the higher the sedentary time was, the
worse the cardiovascular disease risk was amongst the older
women. So now we are recognizing that among older women, the
post-menopausal or elderly women, the risk of cardiovascular
disease rises with sedentary lifestyle.


                               
And I think these three papers highlight the overall trend that
we tend to see, maybe, better emphasis for comorbidity control.
But at the same time we are now starting to recognize that in
younger patients, especially in younger women the risk of MI is
on the rise. And in older women, activity and remaining active
and not having too much sedentary time are important to prevent
cardiovascular disease.


Dr Carolyn Lam: Oh, Biykem, thank you for framing that so
beautifully. So some good news, some bad news, and certainly some
things we should be looking out for. You know, in another patient
group that we always need to touch on when we talk about the Go
Red for Women issue is pregnant women, or post-pregnancy. Could
you comment, perhaps, on the systematic review that we have?


Dr Biykem Bozkurt: This is a very comprehensive, systematic
review looking at the cardiovascular disease morbidity and
mortality in women with a history of pregnancy complications. And
they provide detailed systematic review and method analysis. It's
becoming more apparent that the spectrum of cardiovascular
disease ranges all the way from preeclampsia to arrythmia to
pericardial myopathy. And we're recognizing this continuum both
in the peripartum period, at the same time as the future risk. So
those with preeclampsia and premature birth and delivery are
associated with lifetime risk of cardiovascular disease. So, I
think this paper is providing the right overview and a very
comprehensive meta-analysis recognizing that pregnancy led to
complications and morbidity and mortality in women.


Dr Carolyn Lam: Indeed. And it does just add so nicely to this
issue, you know? Letting us know that we should watch out for the
young women. We should watch out for the sedentary older women.
And we should watch out for women with a history of pregnancy
complications. But let’s switch tracks now. Sana, there was an
amazing autopsy paper, actually, relating to sudden death in
women. And as well as another original paper focusing on out of
hospital cardiac arrest that is really very interesting. Would
you like to tell us about those two?


Dr Sana Al-Khatib: Oh absolutely. I would love to. As someone who
has devoted her life to the study of sudden cardiac death and you
know, identifying factors, prevention. I really like that the
paper looking at the risk of cardiac death in women and men. This
study, Carolyn, was conducting in Finland, and the aim of the
study was to determine autopsy findings and causes of death among
women in a large population of sudden cardiac death.


                               
They also were able to classify some EKG characteristics in men
and women cardiac death victims. That really added helpful
information. To do that, they systematically collected clinical
and autopsy data from sudden cardiac death victims in Northern
Finland between 1998 and 2017. So they actually had data on close
to 5870 SCD victims. The findings were very interesting because
they found that victims were significantly older than that. You
know, so when they provided the median age it was 70 years for
women versus 63 for men. So that was a significant difference
there. And when they looked at the most frequently identified
cause of death, they found that it was ischemic heart disease in
both factions. Seventy two percent in women verses seventy six
percent among men. And what was really striking about this was
that the seventy two percent presence among women was higher than
what had been reported in other theories.


                               
They also reported that women were more likely to have lung
ischemic cause of sudden cardiac death than men. It commented on
the fact that primary myocardiac fibrosis was more likely to be
found in woman victims rather than in men. And then they were
able to identify some EKG factors stating that, in general, women
were more likely to have a prior normal EKG than men. But that it
increased the marker for sudden cardiac death with the presence
of MDH with the polarization changes that were more commonly seen
in women.


                               
So, I thought that the findings were really interesting. They
sure to be advance the field.


Dr Carolyn Lam: I couldn't agree more. Sex differences in sudden
cardiac death. I don't think many people could tell you they knew
much about it at all before this paper. And what about at a
hospital cardiac arrest?


Dr Sana Al-Khatib: So, the other paper, which was really
interesting, was a study that really looked at the public
perception on why women receive less bystander CPR than men in
out of hospital cardiac arrest. And this was an observation that
was made a long time ago, Carolyn. So what's interesting for
these investigators to be able to shed some light on this
observation. What they did was they conducted a national survey
of members of the public. And they were able to get 548 people to
respond. Not a very high response rate, but pretty good for
getting qualitative research studies. About fifty percent of the
responders were women, so it was important to note that. And
there was a good geographic distribution of the people; this was
done in the U.S. And after they corrected their data, and they
analyzed their data, the major thing emerged in terms of why the
public perceived that women received less bystander CPR. The
findings were really interesting.


                               
The first finding was that people were concerned about being
accused of sexual assault if they were to do CPR on the woman,
which was interesting. Some actually were concerned that women
were too weak or too frail. If they were to ever do CPR, might
they cause any bone fractures, any injuries to the woman because
they're more fragile, so to speak, than men. And their last theme
was misperceptions about women in medical distress. What that
meant was they felt that, well, you know, are women actually
victims of sudden cardiac death? Yes, definitely, women can have
sudden cardiac arrest and some people said, "Well, sometimes
women can be overly dramatic and so maybe those presentations
were not real presentations of sudden cardiac arrest," which I
thought was really interesting.


                               
I felt these were really interesting insights into why women
don't receive CPR as much as men, and hopefully future
interventions can be targeting these misconceptions or these
concerns that the public has about doing CPR on women.


Dr Carolyn Lam: Isn't that so intriguing. The misconception that
women are either too shy, too frail, or too dramatic. Oh my
goodness. Anyway, that was all the original papers, which were
fantastic. But I have to admit that one of the things that I love
most about the Go Red for Women issues is that it talks about
women in cardiology. And Biykem, you've always been such a huge
mentor to me. And what I love about this issue is that there are
a few papers, aren't there, that actually focus on the importance
of this mentorship. Could you tell us about that?


Dr Biykem Bozkurt: It's a very important concept that I think is
underlying a few papers in our issue. The first one is women in
cardiology and perhaps the lack of increase in the representation
of women in cardiology. Even though women make up about half of
our medical graduates, among practicing cardiologists women
comprise less than about twelve to fifteen percent of the
population. That perhaps disparity hasn't changed in the last two
decades. We tend to sometimes compare our profession to the
surgical field, and I think gender inequality appears to be a
little bit similar to general surgery and orthopedic.


                               
But the paper by Ziman underlines the following: Even though our
gender inequality is similar to the surgical field, to look at
the temporal trends there has been a significant rise in female
representation in general surgery. And actually, among medical
trainees, about one third of the medical trainees, not fifty
percent like us, one third of the medical trainees are in
surgical fields after they go to medical school. But the female
representation has been steadily increasing in the surgical
fields; about three-fold out of cardiology. Whereas female
representation cardiology has the main slot, so the surgical
fields are doing a better job in either welcoming, supporting,
and mentoring their female trainees than the cardiology field.


                               
This is an important concept for us to recognize, and usually the
disparity reasons are perceived to be gender and lifestyle and/or
personal preferences. That doesn't appear to be the case. Perhaps
the better role models and better mentorship could eliminate this
disparity and this is underlined in the Olmein Mein paper by
Ziman.


                               
Another paper by Sharon Hunt also underlines this concept. She
portrays the woman needed in cardiac transplantation from a
historical and personal perspective, and underlines the
following: We tend to have a large number of woman leaders in
advance heart failure and cardiac transplantation. And part of
this may be attributed to the fact that women have been part of
the fabric, part of the readership, part of the group that has
developed the field and has been practicing. And thus, there has
not been a nation or incorporation of the women in the field. And
thus, since they've been involved in the practice from the
beginning, they have been seen as a natural partner. Even though
cardiac transplantation is quite demanding, requires bedside
presence, and hours which are usually used as a reason for women
not to go into certain fields, such as interventional. In
transplant, we don't seem to have that much disparity for women.
Women tend to select this field on one of the reasons in Sharon
Hunt's piece is identified as being part of the team from the
beginning, and having good role models and mentors.


                               
And finally, there is a research letter that identifies if the
corresponding author is a female author. There is a large
representation of co-authors. This is a very interesting finding
by Ouyang stating that even though the female to male senior
authorship rates have not been different over the years, if the
senior author or the corresponding author is a female there tends
to be a higher number of co-authors. This may suggest that female
corresponding authors are able to mentor or include their
partners or team members. Or vice versa, female co-authors may
feel more invited and incorporated as a team. So, this paper also
underlines that women in leadership positions connected to
cardiology may serve as positive role models to recruit and
retain talented junior female investigators.


Dr Carolyn Lam: Ah, indeed, indeed, indeed. So many topics that
come close to my own heart. But Sana, among the numerous other
papers here, we have two state of the art papers, two in-depth
reviews, there are three frame of reference papers. Which one, or
ones, stood out to you?


Dr San Al-Khatib: One important paper, Carolyn, you certainly
mentioned is an online paper that was titled "Why are Young Black
Women as High Risk for Cardiovascular Disease". I personally like
this paper a lot because it highlights such an important issue
that has great impact on public health. And sometimes the
population of young black women may go unrecognized in terms of
their risk of cardiovascular disease and what have you. So really
the On My Mind paper tackles what are these things that are
driving the worsening cardiovascular disease trends in this
patient population. And what can we do about it? And they talk
about how the awareness of heart disease and the leading cause of
death among these women is actually more among black patients.
And so, they talk about the need to really implement multi-level
strategies to try to address this, raise awareness, identify
disparities in care. They even also call for really investing in
black women scientists.


                               
And so, this was such a really good paper and I'm sure that the
readers will enjoy it as much as I have.


Dr Carolyn Lam: Oh, thank you so much for that, Sana. That
really, really makes for such a rich issue with such a lot of
different papers. We're running out of time, so we don't even
have the opportunity to really discuss, but I want to mention
these so that the listeners will look out for them. Beyond the
papers we've already discussed, we have state-of-the-art papers
on cardiovascular care in women veterans and the management of
cardiovascular disease in women with breast cancer. We even have
two in-depth reviews. One on sex differences in advance heart
failure therapies and a second on the role of breast arterial
calcification in cardiovascular risk stratification in women. And
finally, there's a research letter on the size of thoracic aortic
aneurysms in women. So many papers, such a beautiful, beautiful
issue. I just want to thank you both Sana and Biykem for leading
this beautiful Go Red for Women issue.


                               
Thank you, listeners, for joining us today. You've been listening
to Circulation on the Run. Don't forget to tune in again next
week.


                               
This program is copyright American Heart Association 2019.