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Cardiovascular disease – more attention required for women
Cardiovascular disease (CVD) is by far the leading cause of death in industrial countries. However, there are significant differences by continent/region, and even more so in terms of gender. There have also been some major recent changes in the evolution of CVD, compared to another major source of mortality – cancer. Once again here, there are some female-specific factors of interest.
The US and Europe
For Europe as a whole, latest figures from the World Health Organization (WHO) show CVD accounting for 45percent of deaths, approximately the same level as the US, where the figure is 44percent.
Cancer is the second largest cause of death in both the US and Europe. However, a significant margin separates its mortality impact from CVD.
There are also differences between the US and Europe in the relative impact of CVD versus cancer. In the former, cancer accounts for 32percent of deaths (or almost three-fourths of that from CVD). In Europe, the share of cancer is less than half CVD deaths. The WHO data cover 52 countries in Europe, including all members of the European Union (EU).
A man’s illness ?
Traditionally, heart disease was thought of as a man’s’ illness, although approximately the same number of women and men died each year of heart disease in the US and the EU.
Indeed, gender issues in CVD deaths are significant, both in the US and Europe. Although a higher number of males die in the US from CVD as compared to females, the share of CVD as a cause of death is only slightly higher in American women (44.3percent vs. 43.4percent).
In Europe, the gap is far more dramatic, with CVD accounting for 51percent of deaths among women and 42percent among men.
Cancer replaces CVD as leading cause of death in northern/western Europe
There are nevertheless considerable divergences across European countries in CVD mortality as well as in recent changes in death rates due to CVD.
In ten advanced EU countries, more men now die from cancer than CVD. These countries are Belgium, Denmark, France, Italy, Luxembourg, the Netherlands, Portugal, Slovenia, Spain, and the UK. The case is the same for an EU non-member, Norway. Conversely, the highest numbers of deaths from CVD tend to be seen in Eastern European countries.
In much of Europe, however, latest WHO data show more than double the number of deaths from CVD compared with cancer, in women. 15 countries in this group report CVD causing more than four times the number of deaths in women as cancer, compared to only 6 for men.
Meanwhile, death rates from CVD have declined in all countries over the past ten years. However, in some countries, women have seen a relatively lower fall than men in age standardized mortality rates, over the period. These include Luxembourg (50percent for men vs. 42percent for women), the Netherlands (39percent vs. 32percent) and Sweden (31percent vs. 26percent), and to some extent Ireland, Italy and Switzerland.
Raising awareness
One immediate priority for health professionals and policy makers is to raise awareness about CVD and women. Currently, Red Day’, Go Red for Women’ and Women at Heart’ campaigns by professional societies and patient groups in the US and Europe have sought to boost awareness further, and do this faster.
The reasons for this are evident. In the US, just over half of women surveyed recognize heart disease as their Number 1 killer, according to a 12-year follow-up study published in 2010 in Circulation: Cardiovascular Quality Outcomes’.
Nevertheless, the situation had improved significantly compared to the baseline year of 1997 when only 30 percent identified heart disease as the leading killer of women, with 35 percent believing that cancer took this role.
The situation is worse in parts of Europe. In Ireland, for example, a recent Irish Heart Foundation report showed that less than one in 5 Irish women knew CVD as being the leading cause of female mortality.
CVD protection in younger women
The reasons for believing CVD was a man’s’ disease (as mentioned above) were not simply hearsay. Women are protected by their hormones against CVD during their child-bearing years. However, this protection is lost as soon as they enter menopause. The net result is that women tend to get CVD at an age about 10 years more than men.
To complicate matters, CVD symptoms in women are sometimes different from those in men. This adds to under-recognition of heart disease in women. For example, heart attack symptoms in women such as chest pain can be less profound than in men. Women may only feel an uncomfortable pressure in the chest centre which occurs sporadically or lasts a few minutes, or experience pain in one or both arms, their neck, back or stomach, along with shortness of breath and accompanied by a cold sweat, nausea, vertigo and weakness. Moreover, it has also been established that women have a higher prevalence of silent ischemia and of unrecognized myocardial infarction than men.
As a result, both women and physicians need to be trained to recognize female-specific symptoms.
HRT and CVD risks
One of the beliefs which has endured for several decades is that the estrogen drop during menopausal transition induces increased post-menopausal CVD risk in women, probably through harmful changes in CVD risk factors. One of the findings supporting this conclusion was that women who reached menopause before the age of 40 had a two-year lower life expectancy than women with a normal or late menopause.
Indeed, circulating estrogens do have a regulating effect on several metabolic factors, such as lipids, inflammatory markers, and the coagulation system.
This was the reason for the popularity of Hormone Replacement Therapy (HRT), or exogenous estrogens. Until recently, HRT was recommended for use in post-menopausal women to limit CVD risk. The hypothesis was supported by several observational studies, but could not be conclusively proved in large randomized trials. Instead, HRT was shown to increase CVD event rate in older (>60 years) post-menopausal women. As a result, clinicians now recommend a careful evaluation of the risk/benefit of HRT replacement for preventing CVD, and the use of HRT has declined.
Concurrent risk factors for women
Other, concurrent risk factors include hypertension, hypercholesterolemia, hypertriglyceridemia and metabolic syndrome. These increase in women over the age of 45, or a few years before menopause.
For example, systolic blood pressure rises steeply in older women compared with men. Hypertension is associated strongly with a higher prevalence of left ventricular hypertrophy and diastolic heart failure (HF). Studies have shown that even borderline hypertension (less than 14/9 cm Hg) causes more cardiovascular complications in females than in men.
At younger age, the prevalence of hypercholesterolemia is lower in women than men, but at over 65 years age, mean LDL-cholesterol levels are higher in women. Hypertriglyceridemia and low HDL-C levels are far more important risk factors for CVD in women than for men, as discussed below.
Type 2 Diabetes
Nevertheless, of the biggest areas of concern is Type 2 diabetes mellitus, which poses a much higher greater risk for cardiovascular complications in women than in men.
One meta-analysis of 37 prospective cohort studies published in the British Medical Journal’ in December 2006 found mortality risk to be 50percent higher in women with diabetes compared with men. In addition, it has been shown that Type 2 diabetes is a potent, independent risk factor for heart failure in women. However, this cannot be fully explained by coexisting cardiovascular risk factors or previous myocardial infarctions.
Lifestyle factors
Lifestyle changes also play a role. Obesity, for example, is a major CVD risk factor. It is more prevalent in men under the age of 45, but has begun to increase with advancing age in women, reducing the gap with time, and often reversing it in older women. This was one of the findings of a report called European Heart Health Strategy: Red Alert on Women’s Hearts’, published in 2009 by the EuroHeart Project, funded by the EU Commission and conducted jointly by the European Heart Network (EHN) and the European Society of Cardiology (ESC).
Women and clinical trials
The case of HRT, where findings from large randomized trials reversed those of observational studies, has brought another priority to the forefront, namely to increase the presence of women in CVD clinical trials.
The EU-funded EuroHeart project (see above) found women to be under-represented in many trials, even where important gender differences are present within most areas of heart disease. The proportion of women enrolled was 27-41percent, even though the female prevalence of clinical conditions under study in the general population was similar for both men and women.
The case in the US is similar, in spite of a legal requirement that research funded by tax receipts must include women and minority groups. One study found that trials by the National Heart Lung and Blood Institute, attached to the National Institutes of Health (NIH), enrolled 38percent women for the years 1965-1998. This fell further to 27percent in 1997-2006. Furthermore, only 13 of 19 studies analysed gender differences.
Apart from the traditional belief that CVD was a man’s’ disease, some experts believe that cost may also have been a consideration in under-recruitment of women, whose hormonal fluctuations tend to complicate pharmacokinetic and pharmacodynamic analysis.
Nevertheless, given the growing burden of CVD in middle-aged women relative to men, it is evident that greater gender-specific cardiovascular research is required to adapt existing guidelines for better cardiovascular health in women.
Pregnancy as stress test for future CVD
There is intriguing evidence that pregnancy might be a useful stress-test’ for future CVD risk. Hypertensive disorders in pregnancy have been shown to be predictors for CVD events in later life. Impaired glucose tolerance and gestational diabetes in pregnancy are also female-specific risk factors for the development of diabetes and metabolic syndrome in young women.
One of the conditions under close scrutiny is pre-eclampsia, which is characterized by high blood pressure and large amounts of protein in the urine. Although the etiology of pre-eclampsia has yet to be established with certainty, the hyperlipidemia of normal pregnancy (elevated total cholesterol and triglycerides) becomes more extreme in women developing the condition. The sharp growth in triglycerides leads to increased production of LDL (up to 3-4 times more than in a normal’ pregnancy), along with reduced HDL-C. Together, this contributes to endothelial dysfunction.
One ongoing trial at Brigham and Women’s Hospital in Massachusetts seeks to demonstrate an association between pre-eclampsia during pregnancy and altered blood vessel function and abnormal hormone levels in later life. The trial, known as Preeclampsia: A Marker for Future Cardiovascular Risk in Women’ commenced in 2012. Its results are expected to be published in the near future.
Mortara Instrument, Inc. Announces Expansion of ECG Warehouse Contract Award with the U.S. FDA
Mortara has been awarded a multi-year contract for ongoing maintenance and support of the FDA ECG Warehouse including continuous ECG studies analyzed by VERITASTM.
Mortara collaborated with the FDA to develop the ECG Warehouse which was initially deployed in 2005. The ECG Warehouse acts as a repository for annotated electrocardiograph (‘ECG’) studies provided to the FDA in support of new drug applications. With the ECG Warehouse, the FDA uses Mortara’s VERITAS ECG algorithms and viewing technologies to review ECG data submitted as part of new drug applications.
Since inception of the ECG Warehouse, more than 9 million resting ECGs have been analyzed with Mortara’s VERITAS algorithms, making this one of the largest cloud-based clinical data repositories in the world. The ECG Warehouse has subsequently been expanded to also include continuous 12-lead recordings, which now number nearly 800 in total. The warehouse tools include web-based upload, navigation of continuous data, arrhythmia identification and waveform morphology comparison.
Under this expanded ECG Warehouse contract, Mortara will continue to support Sponsor and ECG Central Laboratory upload of ECG studies, provide support to FDA personnel and provide on-going basic development enhancements to the ECG Warehouse including advances in the VERITAS ECG algorithms.
‘Mortara is pleased to continue its longstanding relationship with the FDA in providing the ECG Warehouse solution,’ said Dr. Justin Mortara, CEO of Mortara. ‘This award is testimony to our leadership role in ECG acquisition and algorithm technologies. We are honored to be chosen by the FDA and to play our part in the cardiac safety evaluation of new drugs.’
About Mortara
For over 30 years, Mortara Instrument, Inc. has served as a leading designer, developer, and manufacturer of diagnostic cardiology and, most recently, patient monitoring technologies. Mortara is focused on delivering world-class medical devices, as evidenced by its innovative portfolio of solutions designed to serve throughout the continuum of clinical care. The company’s comprehensive range of products spans modalities including resting ECG, cardiac stress exercise, Holter monitoring, cardiac and pulmonary rehabilitation, and ambulatory blood pressure and multi-parameter patient monitoring. Mortara’s global headquarters is located in Milwaukee, Wisconsin with direct operations in Australia, Germany, Italy, the Netherlands, and the United Kingdom. While Mortara distributes its products and technologies globally, it remains dedicated to manufacturing in the United States in order to consistently deliver the quality products for which it is known.
Mortara’s approach to innovation has a global reach that impacts both mature and emerging healthcare systems. To learn more about Mortara and its expanding product portfolio, including the Burdick and Quinton brands, visit www.mortara.com.
Why the chronic shortage of anesthesiologists?
We are all aware that there is a dearth of physicians both in primary healthcare and several hospital specialities in the West, an escalating problem that is particularly acute in the case of anesthesiologists. In some European countries this situation is at least partially the result of poor planning and under-investment in medical education, coupled with aggressive attempts to recruit medical professionals overseas, but there are other factors involved that must be addressed before we can hope to consider approaches that could alleviate the problem.
A major contributing factor is that today’s anesthesiologists are not only active in the operating theatre: their expertise is required during patient evaluation prior to surgery, and in critical care and pain management post-surgery. And not only has medical research augmented the number of surgical procedures that are now possible, but Europe’s increasing numbers of senior citizens, who are the most likely to suffer from non-communicable and chronic diseases, are the main beneficiaries of these innovative approaches. Inevitably this results in the demand for anesthesiologists exceeding the supply.
Another factor is that the generation of predominantly male anesthesiologists who focussed on their careers and were prepared to work in the evenings, at night and during weekends and holidays, severely limiting the time they could spend with their families, are retiring and being replaced by younger specialists who are legally entitled to work fewer hours per week and are also aware that social changes in recent decades, allowing both genders to enjoy satisfactory careers, require them to contribute practically (as well as financially) at home.
There is also a shortage of surgeons in Europe but this problem is not so acute as with anesthesiologists. Sadly this may well be because of the greater prestige enjoyed by practitioners of the former specialization, a situation which should surely be an anachronism. It is to be hoped that the primary goal of all medical professionals is to help their patients but until all specialisms are equally valued and respected for their essential contribution to patient care, some will continue to attract fewer recruits than others. There could even be a long-term solution to the problem if physicians themselves, including anesthesiologists, would value and respect non-medical healthcare professionals as they deserve. Surely the ever evolving technologies available in critical care settings and the relevant training offered could allow specialized anesthesia nurses to be trusted to administer anesthesia for certain procedures and patients, as well as sedation and pain relief, without requiring direct supervision from on high?
Hands up for HIV prevention!
This was the theme for the 29th World AIDS Day on December 1st. Substantial progress has been made in developing and disseminating effective antiretroviral therapy (ART) for people diagnosed with HIV/AIDS. Indeed for the around 19 million people globally currently taking ART, the disease can be considered a chronic condition, albeit one that requires careful and continuous monitoring.
Huge strides have also been made in reducing transmission of infection. Concerted efforts by national programmes and development partners have promoted safe sex and condom use (though not without some controversy and pontification about the value of celibacy) with studies showing that this reduces HIV transmission by 85percent. Medical male circumcision, which reduces the risk of heterosexual men becoming infected by an estimated 60percent, is also becoming acceptable in high risk countries where performance of this operation is not the cultural norm. The efficacy of pre-exposure prophylaxis (PrEP) for subjects at a high risk of becoming infected with HIV, such as those with infected sexual partners, has been demonstrated and is advocated in many countries. Vertical transmission, formerly accounting for up to 45percent of babies acquiring the infection from their HIV positive mother, can now be prevented by prescribing ART to both mother and child during pregnancy, labour, delivery and breastfeeding. And programmes have been set up both to educate people who inject recreational drugs about the risks of HIV infection and to provide sterile injecting equipment to reduce the risk.
However an enormous obstacle blocking the goal to end the AIDS epidemic by 2030 is that according to the WHO an estimated 14 million people (around 40percent of all people with HIV) are unaware that they are infected with the virus. Not only are they not receiving ART, they are also unwittingly infecting others. Highly accurate rapid diagnostic tests or enzyme immunoassays are available, but many people are either geographically distant from such testing services or are too diffident to access them. So it is wonderful news that, according to WHO, twenty-three countries have so far approved policies for HIV self-testing, and many others are aiming to follow suit. Studies have shown that with such testing, performed in the privacy of one’s home with results available after 20 minutes, the number of people tested doubles. While there is great need to distribute kits to the most high risk areas, how many of us currently living in lower risk countries are celibate until we meet our life partner who has also been celibate prior to meeting us?