Circulation February 20, 2018 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 Centre and
Duke National University of Singapore. This week’s issue is the
Go Red for Women issue, my favorite discussions of the year
happened during this podcast.


                                               
Today, I am so delighted to have with me, our Editor-in-Chief
himself, Dr. Joe Hill, from UT Southwestern, as well as, of
course, the editor that made this issue possible, Dr. Sharon
Reimold, also from UT Southwestern. Joe, would you like to tell
us a little bit about this year’s Go Red issue? From the birds
eye view.


Dr. Joseph
Hill:                 
Well Carolyn, I share your enthusiasm. This is our second annual
Go Red for Women issue and it is fantastic. It has generated
great interest in the community. We had a number of papers coming
in, unsolicited. Our frame of reference-type content. Original
research articles. State of the art.


                                               
We clearly touched a nerve with this issue. As we will discuss
further, we shine a bright light here on some of the very best
science, focusing on sex-based differences in the biology of
heart disease, the presentation of heart disease, how women
function, and are treated in the academic environment. The ways
in which they are impacted by psychological stress. It's an
absolute bonanza of science, in this issue.


Dr. Carolyn
Lam:              
You took the words out of my mouth. It is a bonanza issue. I
mean, we had seven original articles. Lots of new stuff, but lots
of good, important papers on plain old ischemic heart disease.
What I really liked was that, three of these original papers
focused on myocardial infractions, in the young, and their risk
factors, prevention, and so on. Sharon, shall we go through
those? I mean, there was the one on genetics, lifestyle, and LDL
in young women.


Dr. Sharon Reimold:       
That would be great. That manuscript looked at, sort of, a
distribution of lipids, in women, that would have otherwise
expect to be healthy. They sorted them out by individuals that
had extremely low LDL levels and those that had high LDL levels.
They pointed out that the individuals with high LDL levels. Ended
up having hypercholesterolemia heritable, but they also found
genetic variance of related to those with low LDL levels. I think
this manuscript points out the importance of screening younger
women for lipid disorders and incorporating those data into their
clinical management.


Dr. Carolyn
Lam:              
Absolutely. Then, there was that paper that, again, talked about
young women experiencing myocardial infarction, and the sex
differences in their presentation, and perception. That was super
cool. From the Virgo trial.


Dr. Sharon Reimold:       
There are several other papers, that are published, demonstrating
that women tend to have multiple symptoms when they present with
symptoms of ischemia. That's true for both myocardial infarction,
as well as for other unstable syndromes. They certainly have more
symptoms than men.


                                               
But what was very interesting about this particular paper, is
that when women presented with multiple symptoms, providers were
less likely to think that the symptoms were due to a cardiac
etiology. So even when women are trying to tell their providers
what is going on, sometimes, they're not taken seriously, because
they have multiple symptoms. So I'm hoping that this resonates
with our providers, clinical providers, and we think about this.
Whether we're cardiologist, or emergency room providers, or even
EMTs.


Dr. Carolyn
Lam:              
Exactly. Then, the third original paper in these young women,
kind of scary, mental stress induced myocardial ischemia.


Dr. Sharon Reimold:       
Right. So there's been a lot of interest in the myocardial
infarction without obstructive coronary disease, in the last year
or two. Because a lot of those individuals, even thought, they
don't have typical atherosclerotic pathologies, they don't have
good outcomes. So this article looks at the role that mental
stress plays in inducing ischemia, by EKG, in these individuals.


                                               
I think we still need to understand more about how this
contributes to the biology, and outcomes, in these individuals.
Also, get a better understanding if this is also true in older
women, who have ischemic heart disease.


Dr. Carolyn
Lam:              
Exactly. You know, but speaking of the older women, it's not like
the issue left out the older women this time either. I did think
that the study on the metabolic predictors of incident ischemic
events, in postmenopausal women, was really interesting, as well.
Basically, the authors identified a cluster of novel metabolites,
that were related to oxidative stress, that added to. you know?


                                               
They weren't correlated with the traditional biomarkers. Really
suggesting that there may be a whole area of metabolites, and
other biomarkers, that we may be needing to check, and to
understand better, for risk prediction. At least, in older women.
But, of course, in men as well. Then, finally, there was the data
on sex differences from the STICH trial, on surgical
revascularization. What did you think of that one?


Dr. Sharon Reimold:       
Well, I thought that this was a very important addition to the
cardiology literature. Because we are accustomed to thinking of
women as having poor outcomes, after they have cabbage
revascularization surgery. Certainly, the STICH trial enrolled
patients who were more sick than the average patient, with their
underline LV dysfunction. They found that sex did not influence
the outcomes in this trial.


                                               
So the importance of that, for the medical community, is
obviously we should not consider sex as a barrier to sending
women to surgery, even if they're at high risk, because they can
have equally good outcomes.


Dr. Carolyn
Lam:              
Exactly. Important message. Important paper. Then, moving from
ischemic heart disease. We also had a paper focusing on stroke,
which I thought was a really intriguing one, talking about atrial
fibrillation, and questioning if being a woman is a risk
modifier, or a risk factor. Do you want to elaborate on that one?


Dr. Sharon Reimold:        So
instead of the using the CHA2DS2–VASc algorithm they use the
CHADS2-VA program and then looked to see how well that predicted
risk, and how much the S and C, the gender actually influenced
outcome. I think this is an important issue. I'll say it's for
women, perhaps. because as a woman, you know, without doing
anything, you start out with a risk factor of one. Then, once you
get to a certain age you have a risk factor of two. That's even
for somebody who has no other disease processes.


Dr. Carolyn
Lam:              
Yeah.


Dr. Sharon Reimold:        So
I think it's a little different way to look at how the risk is
modified. They propose that if your CHADS2-VA score is two, or
greater, certainly, your risk goes up if you're also female. They
propose, then, that you would treat those patients more
intensively. It's just a little twist on the CHA2DS2–VASc and
maybe will provide us different ways to refine our knowledge
about outcomes in atrial fibrillation.


Dr. Carolyn
Lam:              
Yeah. I love that paper, too, because it's quite different from
the papers that we had in the first Go Red issue. Isn't it? But
in the first Go Red issue, we had lots of papers on pregnancy.
The current issue certainly has those papers as well.


Dr. Sharon Reimold:       
Yes. There are increasing number of pregnancy related
complications. Both maternal, and offspring, complications that
predict increased cardiac risk, down the line. This issue has a
series of women who had, had preeclampsia during pregnancy, and
found that 17% of their women had a coronary artery calcium score
of greater than 95th percentile. While that doesn't entirely get
you from the biology, in between those two, it at least gives you
an idea of where to start going back, and taking a look at what's
going on.


Dr. Carolyn
Lam:              
What about the one in rheumatic mitral valve disease? Pregnancy
outcomes in women with those?


Dr. Sharon Reimold:        So
rheumatic heart disease and pregnancy outcomes, you know, we
don't see much written about it anymore. because most of the
active disease is in certain areas, in the world. But obviously,
these women can have symptoms related to their mitral stenosis
and/or their regurgitation during their pregnancy, with heart
failure being the most common presenting cardiovascular
complication. While some of that is much more quantitative, than
perhaps, it was in the past, which is useful.


                                               
I think that the take-home message from this particular trial is
that you need to talk to these patients, and screen them, prior
to pregnancy, if possible, to help achieve the best possible
outcome. I think that the risk of heart failure was a little bit
less than 2% during the trial, which is obviously much higher
than the average woman's cardiovascular risk during pregnancy.


Dr. Carolyn
Lam:              
this is still definitely an important issue, in many other parts
of the world. I really appreciate that you invited this
editorial, that gave that global perspective. The editorial, by
Athena Poppas and Katharine French, really beautiful work there.
You know, I have to say that one of my favorite papers, in this
issue, was that in depth paper, regarding gender versus sex, as a
social determinant of cardiovascular risk. I found that so
intriguing, the first time I read it, and just love it.


Dr. Sharon Reimold:       
Social determinants of health is a hot topic, in a lot of
different areas of medicine these days. But they point out some
really interesting things, that I don't think I had thought
about. One is the fact that, when you are a child, you know maybe
10 or 12, that boys are encouraged more to be physically active.
Athletics and other sorts of activities. Whereas many girls,
don't have the opportunity or are not as interested. Perhaps we
set up an abnormal social situation very early in most people's
lives.


Dr. Carolyn
Lam:              
Yeah, that represents cardiovascular risk. I know. That stuck out
to me too.


Dr. Sharon Reimold:       
Obviously, how and where people live, as children, can influence
outcome. That can be influential for both boys and girls. But I
think bringing the idea back to cardiovascular diseases, and
risk, are really long term, lifelong processes, that we can make
changes in, from a preventative standpoint, even in young people.


Dr. Carolyn
Lam:              
Something we don't usually think about and I just love the way it
was presented, so clearly, and I just love it. Now, to an area
that really cuts close to the heart. Pun intended. That is the
bias in research grants, bias in manuscript authorship. Joe you
mentioned that, right from the introduction, I would love your
comments on those papers.


Dr. Joseph
Hill:                 
The reality, that we all are aware of, is, in many countries,
including the United States, 50% of medical students now are
female. But as we move through the ranks, into the different
subspecialties, and up the career ladder of academic cardiology,
we see a thinning of female representation. Arguably, it's been
improving, over the last number of years.


                                               
But the reality is, that there remains a bias against
representation of women, in terms of extra mural grant funding,
authorship on high-profile papers. This article digs into that,
and analyzes those numbers, takes a snapshot of what it looks
like at the present time. In some ways, I believe it's a call to
arms on how we must do a better job of recognizing this and
rectifying it, going forward.


Dr. Carolyn
Lam:              
Sharon, did you have comments to add?


Dr. Sharon Reimold:       
Yeah. I mean, I think, I wholeheartedly agree with Joe about
those sorts of things. I mean, we see the same types of issues in
clinical cardiology as well as in the research components of what
we do. we need to figure out how to do this better, so that we
all can be productive, going forward.


Dr. Carolyn
Lam:              
You know it's just such a beautiful issue. So rich, in so many
ways. Was there anything else you might want to highlight to our
listeners?


Dr. Joseph
Hill:                 
I might add that Sharon and I kicked off the issue with a brief
introduction. Pointing out that the reality is, that one and four
women will die of heart disease. Most women don't know that. Most
healthcare providers don't know that. Many Cardiologist don't
know that.


                                               
When you compare that to the realities of breast cancer, it's 1
in 40. It's 10 times different. Now, that community has done a
fantastic job. The Susan G. Komen program, in the United States.
The pink ribbons, that we see all around the world. That
community has done a fabulous job of getting the message out
about that grievous disorder.


                                               
We have to do better. We have to do better educating ourselves,
educating the lay public, about the realities of heart disease in
women. 1 in 4, around the world. We also have to do a better job
of digging into the science. That's where this issue does an
especially good job.


                                               
That the reality is that heart disease is different in men and
women. It presents differently. It presents at a different age.
The way in which women respond to therapies, can differ from men.
So there's work to be done, in terms of awareness. There's work
to be done, in terms of the underline biology. This is an
especially exciting time in this arena.


Dr. Carolyn
Lam:              
I couldn't agree more. I'd add to it, even sex differences and
the perceptions about own symptoms, and that of women versus men
with chest pain. Then, the whole gender, social element to it.
Oh, just so much to discuss, so much to learn from.


                                               
Well, listeners you heard it right here. I want you to please
send this episode, share it with as many other women as you can
think of. Do help us to spread this message, it's such an
important one.


                                               
Thank you so much, Joe and Sharon, for joining me today. Thank
you, listeners, as well. Tune in again next week.