Primary Prevention In Women Research Articles

Asociación entre la razón triglicéridos/colesterol HDL y ateromatosis carotídea en mujeres posmenopáusicas de mediana edad

Background and objectiveThe triglyceride/HDL cholesterol ratio, as a surrogate marker of insulin resistance, may be associated to presence of subclinical carotid atherosclerosis in postmenopausal women. The aim of this study was to explore this association. Patients and methodsWomen (last menstrual period≥2 years) in primary prevention up to 65 years of age were recruited. Association between the triglyceride/HDL cholesterol (HDL-C) ratio and presence of carotid plaque, assessed by ultrasonography, was analyzed. ROC analysis was performed, determining the precision of this ratio to detect carotid plaque. ResultsA total of 332 women (age 57±5 years) were recruited. Triglyceride/HDL-C ratio was 2.35±1.6. Prevalence of carotid plaque was 29%. Women with carotid plaque had higher triglyceride/HDL-C ratios (3.33±1.96 vs. 2.1±1.2, P<.001) than women with no carotid plaque. A positive relationship was seen between quintiles of this ratio and prevalence of carotid plaque (p<.001). Regardless of other risk factors, women with higher triglyceride/HDL-C ratios were more likely to have carotid plaque (odds ratio 1.47, 95% confidence interval 1.20-1.79, P<.001). The area under the curve of the triglyceride/HDL-C ratio to detect carotid plaque was .71 (95% confidence interval .65 to .76), and the optimal cut-off point was 2.04. ConclusionsIn postmenopausal women in primary prevention, insulin resistance, estimated from the triglyceride/HDL-C ratio, was independently associated to a greater probability of carotid plaque. A value of such ratio greater than 2 may be used for assessing cardiovascular risk in this particular group of women.

Prevalence of chemopreventive agent use among hospitalized women at high risk for breast cancer.

e13050Background: Preventing breast cancer would be highly valued by all women. Recent attention about risk stratification for breast cancer in women stems from opportunities for risk reduction using chemopreventive agents like tamoxifen and raloxifen. Effectiveness of primary prevention for women at highest risk for breast cancer has resulted in strategies for implementing chemoprevention guidelines. The purpose of the current study was to characterize the current utilization of chemoprevention agents among hospitalized women who are at higher risk for breast cancer. Methods: A cross sectional bedside survey of 250 women aged 50-75 years hospitalized to a general medicine service was conducted. Reproductive history, family history for breast cancer, chemopreventive agents use, and medical comorbidities data was collected for all patients. Chi square and t-tests were utilized to analyze population characteristics. Results: Mean age for the study population was 61.5 years (SD 7.5), and mean 5-year Gail ris...

Primary Prevention of Atherosclerotic Cardiovascular Disease in Women.

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality among women. Despite improvements in cardiovascular disease prevention efforts, there remain gaps in cardiovascular disease awareness among women, as well as age and racial disparities in ASCVD outcomes for women. Disparity also exists in the impact the traditional risk factors confer on ASCVD risk between women and men, with smoking and diabetes both resulting in stronger relative risks in women compared to men. Additionally there are risk factors that are unique to women (such as pregnancy-related factors) or that disproportionally affect women (such as auto-immune disease) where preventive efforts should be targeted. Risk assessment and management must also be sex-specific to effectively reduce cardiovascular disease and improve outcomes among women. Evidence supports the use of statin therapy for primary prevention in women at higher ASCVD risk. However, some pause should be given to prescribing aspirin therapy in women without known ASCVD, with most evidence supporting the use of aspirin for women≥65 years not at increased risk for bleeding. This review article will summarize (1) traditional and non-traditional assessments of ASCVD risk and (2) lifestyle and pharmacologic therapies for the primary prevention of ASCVD in women.

All else being equal, men and women are still not the same: using risk models to understand gender disparities in care.

Despite growing awareness of the burden of cardiovascular disease (CVD) in women over the past 2 decades, reports of disparities in the delivery of health care for these diseases have persisted over time.1 Under-treatment of women as compared with men has been described for primary prevention, stable coronary artery disease (CAD) and suspected or diagnosed acute coronary syndromes in both observational studies and controlled experiments.2–6 However, because men and women are nonidentical in many ways that might be relevant for treatment decisions, a critical question for policy makers and clinicians is whether these gender-based variations in treatment correspond to lower quality care. A demonstration of clinical inequity (unequal treatment despite equal clinical need) rather than strict inequality (unequal treatment regardless of need or condition) has been proposed as a framework to identify inappropriate variations in healthcare utilization.7 Following this model, it is important to consider whether observed gender differences correspond to inequities or may reflect appropriate variations explained by differences in treatment indications and contraindications or patient preferences.7 In a well-known study published over a decade ago, investigators devised a clever experiment to address just this question of identifying inappropriate healthcare variations.8 Using actors posing as patients with chest pain, primary care physicians were less likely to refer women for cardiac catheterization than men. Because these patients were carefully designed to be identical in age, cardiac risk factors, and symptoms, followed a script standardizing patient communication, and only differed by gender (and race), it seemed obvious that biased decision-making must account for treatment differences. In this commentary, we illustrate why analyses that attempt to control for all known cardiac risk factors that affect treatment decisions might still yield misleading findings about the presence, magnitude, and causes of gender disparities. This residual bias occurs …

Individualised prediction of alternate-day aspirin treatment effects on the combined risk of cancer, cardiovascular disease and gastrointestinal bleeding in healthy women

BackgroundThe value of aspirin in primary prevention of cancer and cardiovascular disease (CVD) remains unclear. The aim of this study was to identify women who benefit from alternate-day aspirin with...

Women and Cardiovascular Disease: Gender-Based Issues Regarding Detection and Primary Prevention

Society has come a long way over the past several decades from the old fashion belief that cardiovascular disease (CVD) is a man’s disease. Throughout the years, gender-based studies have provided compelling evidence to uncover several unique features in disease presentation, pathology and primary prevention in women. Studies reviewing differences among men and women have placed specific emphasis on cardiovascular risk factors, symptoms and vascular pathology as potential etiologies for the higher cardiovascular mortality and disability among women. In addition, although weight loss and exercise have been shown to promote cardiovascular health in men, more recently findings have presented data to support the importance of these interventions among women. Although tremendous strides have been made throughout the years in the gender-based cardiovascular research, more questions than answers remain and additional research efforts are still needed to better understand the disease process in women. The objectives of this review are two-fold: First, to present a comparative analysis focusing on evidence-based similarities and differences among males and females in cardiovascular disease presentation, detection and clinical pathology; Second, to offer insights highlighting recent findings regarding primary prevention and treatment protocols in women. Based on our current knowledge, continued efforts geared toward optimal diagnostic testing and screening protocols for primary disease detection and risk factor modification programs are recommended. This would include further investigations of the potential role that genetics and/or environment play/plays in the natural progression of the disease process. Additionally, comprehensive lifestyle interventions aimed at reducing cardiovascular disability and mortality in women is also recommended.

Statins and Primary Prevention of Cardiovascular Disease in Women

Objectives. A systematic review of randomized clinical trials and meta-analyses evaluating the efficacy, tolerability, and safety of statins in preventing cardiovascular disease (CVD) in women without cardiovascular disease. Background. Several meta-analyses have been performed evaluating statins in CVD primary prevention trials involving women. This review is an update incorporating the results of recent CVD primary prevention trials in women and the recent concerns of statins and new-onset diabetes. Method. PubMed database was searched for primary prevention trials and meta-analyses. The key terms “statins, cardiovascular disease, primary prevention in women” were used. Search was limited to all English publications published up to October 2012. Results. Statin use led to a trend towards reduction in cardiovascular mortality and morbidity in women. No significant increased risk in adverse events was observed. The slight increased incidence of diabetes is outweighed by the greater cardiovascular benefit derived from statin use. Conclusions. The data support the use of statins for primary prevention of CVD in women at higher risk of CVD. The lack of statistical significance in prior randomized controlled trials and meta-analyses is attributable to the lower numbers of women enrolled in these trials and the lower CVD risk of women in the trials resulting in the inadequate powering of these studies. Higher risk women who may benefit from CVD primary prevention with statins may be identified using validated tools such as the Reynolds scoring system, the 2011 American Heart Association risk algorithm for women, and the forthcoming National Heart, Lung, and Blood Institute risk equations.

Problems and possible solutions for therapy with statins.

Despite issues about the value of statins, benefit for high cardiovascular (CV) risk outweighs problems. However, the practitioner must be aware of concerns, be prepared to respond, and justify statin usage. Symptoms of statin-related myopathy are of more concern than stated by pharmaceutical companies. Occurrence of myopathy symptoms, estimated to be up to 10.4%, can decrease statin adherence of high CV risk patients. Dosage modification, or use of pitavastatin, may help the problematic patient. There are concerns that there may be little benefit of statins for primary prevention in women. However, evidence appears to support statin use in women at high CV risk, both in primary and secondary prevention. Abandoning low-density lipoprotein cholesterol (LDL-C) as a valid target is unwarranted; there is much evidence to support "lower is better." The practitioner must be aware of the complicated processes causing atherosclerosis and when to incorporate new approaches to disease management. Tailoring therapy for CV risk, when indicated, may contribute further to LDL-C reduction. Liver inflammation can occur with statins but is of minimal concern; frequently, statins alleviate the problem. Unless liver transaminases are over three times normal, a statin should be prescribed, if indicated. The net effect of statins on cognition appears to be zero-no harm, no benefit. Despite reports of improved cognition, statins should not be prescribed for this. With diabetes mellitus (DM), statins can increase incidence, but the CV benefit far outweighs any risk. Therefore, statins should be prescribed in DM to reduce CV risk. Statins are a major medical contribution when used appropriately.

In Reply: Sex, statins, and diabetes (December 2012)

Readers comment on emergency contraception (November 2012), adrenal masses (December 2012), and the use of statins for primary prevention in women (December 2012).

In Reply: Emergency contraception (November 2012)

Readers comment on emergency contraception (November 2012), adrenal masses (December 2012), and the use of statins for primary prevention in women (December 2012).

Emergency contraception (November 2012)

Readers comment on emergency contraception (November 2012), adrenal masses (December 2012), and the use of statins for primary prevention in women (December 2012).

Sex, statins, and diabetes (December 2012)

Readers comment on emergency contraception (November 2012), adrenal masses (December 2012), and the use of statins for primary prevention in women (December 2012).

Bilateral adrenal masses (December 2012)

Readers comment on emergency contraception (November 2012), adrenal masses (December 2012), and the use of statins for primary prevention in women (December 2012).

Effects of FDA Safety Warnings May Vary

of risk,” said Grundy, who is also director of the Center for Human Nutrition at the University of Texas Southwestern Medical Center in Dallas. “But a lot of physicians do not do that assessment. They just treat the cholesterol level, and that is inappropriate.” Mosca agreed that statin therapy may be appropriate for certain women in primary prevention, provided they can be identified. “If I have a woman who is a high-risk primary prevention case— maybeshehasageneticfamilyhistoryand multiple risk factorsdespitemaximizing lifestyle changes—I might view her differentlythanawomanwithrelatively low risk who is overweight and has not adopted lifestyle modification,” she said. For Mosca, the ambiguity surrounding statin therapy for primary prevention in women highlights the need for long-term rigorous clinical trials that capture data from patients in realworld settings. “We need to have gender-specific breakouts of trial results not only to show efficacy, but also to detect long-term side effects and adverse events,” Mosca said. “I’m concerned about diabetes and other side effects in women we see in our office setting who might not be as healthy as participants in clinical trials—so there may be a different risk profile and we cannot detect that.” And while there is an ongoing debate into the benefits of statin therapy for primary prevention, experts remind women already taking a statin to not stop using the medication; and if they have questions as to the risks and benefits, to discuss that with their physicians.

Aspirin

> Among the many useful discoveries which this age has made, there are very few which better deserve the attention of the public that what I am going to lay before your Lordship. > > —Reverend Edward Stone –Chipping-Norton, Oxfordshire –April 25, 1763 These prophetic words, written by Reverend Edward Stone in a 1763 letter to George Parker, the second Earl of Macclesfield, describe the results of the first clinical trial recorded in medical history.1 Stone's report on the rediscovery of the medicinal value of willow bark among subjects suffering from malarial symptoms is considered a significant milestone in the development of aspirin. Although society now takes many of its beneficial effects for granted, aspirin did not suddenly appear for medicinal use after Reverend Stone's discovery. Instead, its tumultuous journey was fueled by individual scientific curiosity, accidental discoveries, and intense business rivalry.1 No other drug is used by a greater number of people worldwide than aspirin, the benefits of which span centuries, beginning with the very first uses of willow bark by Egyptian physicians (Figure 1). Aspirin single-handedly transformed a coal-dye company into a pharmaceutical giant and has emerged as a cornerstone in the present-day therapies available for treating cardiovascular disease (CVD), pain, and inflammation. This article discusses the sentinel historical aspects of the discovery and clinical cardiovascular developments of aspirin, as well as its contemporary use in today's medical arena. Figure 1. Timeline of historical events in the development of aspirin. ### Historical Developments of Salicylates On January 20, 1862, Edwin Smith made one of the most historically important purchases of his life. Well-regarded among his peers for his keen scholarship and intricate knowledge of Egyptology, Smith purchased, for £12, 2 worn papyrus scrolls in a local Luxor street market1 that later turned out to be a formative medical textbook unlocking ancient Egyptian's practice of medicine. Although authorless, the Ebers Papyrus is 110 pages …

Estrogen Implants: Embodiments of Deeper Problems in the Marketing of Drugs

Estrogen Implants: Embodiments of Deeper Problems in the Marketing of Drugs

Statins for the Primary Prevention of Cardiovascular Events in Women With Elevated High-Sensitivity C-Reactive Protein or Dyslipidemia

Background— Statin therapy in women without cardiovascular disease (CVD) is controversial, given the insufficient evidence of benefit. We analyzed sex-specific outcomes in the Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) and synthesized the results with prior trials. Methods and Results— JUPITER participants included 6801 women ≥60 years of age and 11 001 men ≥50 years of age with high-sensitivity C-reactive protein ≥2 mg/L and low-density lipoprotein cholesterol &lt;130 mg/dL randomized to rosuvastatin versus placebo. Meta-analysis studies were randomized placebo-controlled statin trials with predominantly or exclusively primary prevention in women and sex-specific outcomes (20 147 women; &gt;276 CVD events; mean age, 63 to 69 years). Absolute CVD rates (per 100 person-years) in JUPITER women for rosuvastatin and placebo (0.57 and 1.04, respectively) were lower than for men (0.88 and 1.54, respectively), with similar relative risk reduction in women (hazard ratio, 0.54; 95% confidence interval, 0.37 to 0.80; P =0.002) and men (hazard ratio, 0.58; 95% confidence interval, 0.45 to 0.73; P &lt;0.001). In women, there was significant reduction in revascularization/unstable angina and nonsignificant reductions in other components of the primary end point. Meta-analysis of 13 154 women (240 CVD events; 216 total deaths) from exclusively primary prevention trials found a significant reduction in primary CVD events with statins by a third (relative risk, 0.63; 95% confidence interval, 0.49 to 0.82; P &lt;0.001; P for heterogeneity=0.56) with a smaller nonsignificant effect on total mortality (relative risk, 0.78; 95% confidence interval, 0.53 to 1.15; P =0.21; P for heterogeneity=0.20). Similar results were obtained for trials that were predominantly but not exclusively primary prevention. Conclusion— JUPITER demonstrated that in primary prevention rosuvastatin reduced CVD events in women with a relative risk reduction similar to that in men, a finding supported by meta-analysis of primary prevention statin trials. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00239681.

Abstract 4128: Evaluating Sex Differences in Population-Based Utilization of Implantable Cardioverter Defibrillators (ICDs): The Role of Cardiac Conditions and Non-Cardiac Comorbidities

BACKGROUND: Although sex differences exist in the use of ICDs, reasons for the disparities are poorly understood. We determined if age, comorbid conditions, or ICD indication explained the sex differences. METHODS: We examined all patients in Ontario, Canada, with cardiac arrest (CA, 1998 –2007), myocardial infarction (MI, 2002–2007), or heart failure (HF, 2005–2007), using the Canadian Institute for Health Information Database. MI and HF cohorts excluded those with prior CA, and included patients post-MADIT-2 and SCD-HeFT trials. Patients were followed until ICD implant using Cox regression, with hazard ratio (HR) &gt;1.0 indicating greater likelihood of ICD implant in men. RESULTS: Among 9246 patients eligible for ICD implantation after CA, 237 (2.6%) women and 725 (7.8%) men received ICDs. In 105,516 primary prevention MI patients, 172 (0.2%) women and 836 (0.8%) men received ICDs. Among 61,160 primary prevention HF patients, 221 (0.4%) women and 852 (1.4%) men received ICDs. The rate of ICD implant was significantly higher in men across indications adjusting for age, prior arrhythmia, and comorbidities (Figure ). Post-CA, the HR for secondary prevention ICD was 1.92 (95%CI, 1.66 –2.23). Men were more likely to undergo ICD implant than women for primary prevention, with HRs 3.00 (95%CI, 2.53–3.55) post-MI and 3.01 (95%CI, 2.59 –3.50) in HF patients. Although death after primary prevention ICD did not differ by sex, mortality risk was higher in men after CA (HR 1.42; 95%CI, 1.03–1.95). CONCLUSIONS: Differences in ICD use for all indications were not explained by age or comorbidities. Despite increased use, men had reduced post-implant survival after cardiac arrest.

Impact of gender in primary prevention of coronary heart disease with statin therapy: A meta-analysis

Background Evidence of lipid-lowering from clinical trials that included women is adequate to support their use in secondary prevention in women with known coronary disease. However the role of statin therapy in primary prevention is still controversial, in particular for female gender. The aim of our study is to perform a meta-analysis comparing by gender the cardiovascular outcomes related to statin therapy in primary prevention. Methods We performed a meta-analysis including 8 randomized controlled trials (19,052 and 30,194 men, mean follow-up 3.9 years) that assessed the cardiovascular outcomes related to statin therapy, including studies that provided sex-specific results. MEDLINE and the Cochrane Database, were searched for articles published in English and other languages up to March 2008. Results Statins do not appear to have a beneficial effect on total mortality for both men and women in primary prevention over the 2.8- to 5.3 year study period (men: 95% Confidence Interval (CI) 0.83–1.04; comparison p = 0.22; women: 0.96; CI 0.81–1.13; p = 0.61). Statin therapy reduced the risk of coronary heart disease (CHD) events in men (0.59; CI 0.48–0.74; p = 0.0001), however in women this risk reduction was weakly significant (0.89 CI 0.79–1.00; p = 0.05) and disappeared when in sensitivity analysis, trials not entirely of primary prevention were excluded (HPS, PROSPER) (0.95 CI 0.78–1.16; comparison p = 0.562). Conclusions Our study showed that statin therapy reduced the risk of CHD events in men without prior cardiovascular disease, but not in women. Statins did not reduce the risk of total mortality both in men and women.

Neurohormonal biomarkers and UKPDS stroke risk in type 2 diabetic women on primary cardiovascular prevention

Summary Aims An unfavourable upregulation of neurohormonal profile is present in type 2 diabetes (T2DM). Little is known regarding neurohormonal profile and cardiovascular (CV) risk in diabetic women in primary prevention. Methods We therefore explored gender-associated disparities in neurohormonal profile and modeled cardiovascular risk in this population ( n = 231) and modeled its 10-year risk of lethal and non-lethal coronary heart disease (CHD) and stroke using the UKPDS Risk Engine, a diabetes-specific risk calculator. Results There were significant differences between female and male patients ( n = 311) with respect to all measured neurohormones, which were higher in women by a mean 27% for N-terminal pro-atrial natriuretic peptide, 8% for Big endothelin-1 (Big ET-1), 25% for brain natriuretic peptide and 24% for urotensin II. While risk estimates for women were significantly lower than those in males with respect to non-fatal and fatal CHD, fatal CHD, non-fatal and fatal stroke, they were nevertheless worryingly high for females, reaching 68%, 72%, and 76% of the corresponding risks in males. Female patients with T2DM in primary prevention with a high prevalence of hypertension and metabolic syndrome (MetS) exhibit a significant sexual dimorphism in circulating neurohormones. Conclusions We conclude that these incremental differences may intervene in raising the true CV risk observed in female subjects with diabetes or insulin resistance, or in accruing the predicted risk computed by models such as the UKPDS Risk Engine.