Sex After a Heart Attack: 7 Things Cardiologists Want You to Know

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    1 Cardiac Risk Factors See Details

    А.Н. Балдин

    Globally, cardiovascular disease CVD is the number one killer of women; one third of инфаркта deaths are due to ischemic heart disease and stroke WHO The seminal publication from the Institute of Medicine — Exploring the Biological Contributions to Human Health: Does Sex Matter 1 — laid the foundation for the importance of examining sex and gender in order to better understand human health. Incorporating sex and gender into research leads to better science, and better science has the potential to после the diagnosis, treatment and outcomes of стентирования women and men.

    These initiatives have the potential to improve the science that informs care, but more work needs to be done. In this review, we predominantly focus on an examination of sex стентирования, which is evolving into a mature science with a body of knowledge that can inform the prevention, diagnosis and treatment of CVD. When available, the impact of gender is also addressed.

    As research and clinical practice move towards precision medicine, sex and gender differences are a critical component. As an example, sexual dimorphism in drug metabolism impacts both drug effectiveness and adverse drug reactions 45which directly inform the practice of precision medicine.

    Over the years, the Framingham Heart Study identified age, sex, smoking, high blood pressure, high blood cholesterol, and diabetes as major cardiac risk factors. These modifiable risk factors include: smoking, hypertension, abnormal lipids, diabetes, abdominal obesity, high-risk diet, psychosocial factors, lack of physical activity and absence of alcohol use compared to moderate use 7.

    These established cardiac risk factors play an important role in development and progression of CVD in both men and women. Инфаркта, there are important sex differences in some of these factors 89. Секс particular, diabetes and smoking have a stronger association with development of CVD in women than in men, and they are the focus of our review in this section.

    The WHO has estimated that the global prevalence of diabetes has increased continuously over three decades, with million adults affected in In many regions, including Canada and the United States, the prevalence of diabetes is higher among men than in women 7.

    The Framingham стентирования showed the relative risk of CVD in diabetics as compared to non-diabetics was 1. This finding of excess risk in women was consistent for risk of heart failure, intermittent claudication as well as overall CVD 13 Note: Adapted from Kannel et alwith permission. In more recent years, several studies have also shown that the impact of diabetes on development of coronary heart disease CHD is greater in women than после men.

    A meta-analysis by Peters et al. Furthermore, the diabetes-related risk of fatal CHD was higher in women than in men. Huxley et al. Our understanding of the mechanism for the observed excess risk of CVD in women with diabetes as compared to men with diabetes is still evolving. A more adverse cardiac risk profile in women with diabetes, as well as greater worsening of cardiac risk status during transition from normoglycemia to diabetes, may play an important role in the excess risk seen in women compared to men In a meta-analysis comparing diabetics and non-diabetics, the mean differences in systolic blood pressure, total cholesterol, HDL cholesterol, body mass index BMI and waist circumference were greater for women than for men Additionally, it has been reported that women with diabetes are less likely to receive lipid-lowering medication 19despite evidence that statins reduce adverse vascular events Although the observed excess risk of CVD in women with diabetes may be primarily driven by biological factors, gender-related factors also play a role.

    A Canadian national health survey demonstrated an inverse association between SES and obesity, a major risk factor for diabetes, with a stronger association observed in women than in men Gendered-based factors such as lower SES, lower levels of physical activity and higher stress levels due to greater family responsibilities are all interrelated and often more prevalent among women than men 22 — The combination of these unfavorable factors could also contribute to the excess risk of CVD in women with diabetes.

    Smoking is a key cardiac risk factor for development of CVD in both women and men. Based on statistics, the prevalence of smoking is higher in men than in women, both in Canada Similar to diabetes, the risk of development of CHD due to smoking is greater among women than men.

    Note: Adapted from Prescott et al 28with permission. The reason for the differential impact of smoking on development of CVD in women versus men is not fully understood. Some have speculated that после use of oral contraceptives may be a contributing factor as it has been shown that the combination of oral contraceptive use and smoking increases CVD risks 29 It has been suggested that the negative impact of smoking on HDL level, may be greater in women than in men and could contribute to the observed excess CVD risk among секс Furthermore, increased levels of hormones including fasting insulin, free testosterone as секс as neuroendocrine hormones such as arginine vasopressin После have been observed in female smokers, which can potentially lead после higher risk of cardiovascular disease 32 — These findings are based on small studies and as such our current understanding of the секс pronounced negative impact of smoking in females remain largely speculative.

    It has long been observed that acute and chronic emotional stress, and stress-induced physiological perturbations, predict future cardiovascular disease events 35 Not all psychosocial risk factors may affect the two sexes equally.

    Among women, depression, early-life adversities, and posttraumatic stress disorder PTSD are especially prevalent and have shown some of the most robust associations with CVD 38 Unifying features of these factors include a link with severe stress, chronic dysregulation of neuroendocrine stress systems, and an average onset at young age, possibly resulting in protracted perturbations affecting women many years before CVD becomes manifest Depression in women is also on average more severe than in men and has an earlier age of onset.

    Among cardiac patients, depression rates are doubled in females compared with males 42 — Depression is a recognized risk factor for incident MI and cardiac death 45 Among women, depression approximately doubles their cardiovascular risk 47 Even among patients referred for coronary angiography depression has been shown to be more predictive of инфаркта cardiovascular outcomes in young women than in other groups There are insufficient data on whether these sex-related differences in outcome also apply to patients post-MI.

    Overall, however, depression seems to affect post-MI prognosis similarly in women and секс Severe childhood adversities, such as physical and sexual abuse and child инфаркта, are unfortunately common in the population, especially among girls, and are emerging risk factors for CVD 53in addition to being frequent precursors of major depression and PTSD.

    Early life trauma appears to be a stronger predictor of CVD in younger women than it is in similarly aged men 55 General symptoms of anxiety, measured with a variety of scales, have been associated with incident CVD in a number of studies, although individual study results are heterogeneous and effect sizes in general modest In contrast, symptoms of PTSD, a condition previously classified инфаркта anxiety disorders, have been consistently related to increased risk of CVD PTSD affects 9.

    Thus, women exposed to psychological trauma may experience an increased risk of CVD после in the absence of PTSD, although the presence of the disorder likely has an additive effect. Health behaviors инфаркта clearly implicated, such as smoking, poor dietary habits, and physical inactivity. However, lifestyle behaviors do not appear to explain entirely the connection between psychosocial factors and CVD. Alterations in neurobiological stress response pathways, leading to после inflammation, chronic autonomic dysregulation, endothelial dysfunction and hypercoagulability are all plausible mechanisms that have been demonstrated in human and animal studies In addition to the chronic stressors and mental health инфаркта described above, acute stressful events can contribute to CVD morbidity and mortality.

    Sudden, intense emotions can cause ACS and death инфаркта susceptible individuals 63 — However, because these events are unpredictable, it is difficult to study them rigorously. MSIMI occurs in approximately one third to half of patients with CVD and is associated with approximately a doubling of subsequent CVD events and mortality; similar to ischemia induced by conventional stress testing These results were not explained by factors such as severity of disease or traditional CVD risk factors.

    Possible mechanisms for the higher rates of MSIMI in women include abnormal стентирования vasomotion and peripheral vasoconstriction. MSIMI is at least in part caused by coronary microcirculatory dysfunction, due to a failure of small coronary arteries to dilate during stress 69 — As noted in section 4, women have a tendency towards abnormal vasomotion and microvascular dysfunction.

    Thus, it is possible that women exhibit enhanced microvascular dysregulation with mental stress due to their propensity to vasomotor reactivity Stress-induced vasoconstriction could be accentuated in young women given their после baseline levels of inflammation Overall, these studies have uncovered vulnerability for adverse effects of emotional stress on cardiovascular function in women. In addition стентирования the traditional risk factors discussed in section 1. These remain the focus of ongoing study, but will not be reviewed here.

    HDP can be divided into gestational hypertension and preeclampsia, both of which the American Heart Association considers major risk factors for the development of CVD Gestational hypertension после associated with development of hypertension later in life, инфаркта possibly associated with секс of Инфаркта, hyperlipidemia, chronic kidney disease and diabetes mellitus.

    A prospective study of over 15, women showed that women with gestational hypertension in consecutive pregnancies had significantly higher blood секс later in life стентирования women who remained normotensive Women who develop preeclampsia during pregnancy have a twofold or greater risk of developing CVD later in life 79 — This increased risk is strongly supported by two systematic reviews that evaluated the risk of late cardiovascular events in women with and without a history of preeclampsia 79 Prospective cohort studies have also reported similar findings 85 — It is important to consider whether gestational hypertension and preeclampsia are indeed independent risk factors for CVD or if they act predominantly through traditional risk factors.

    It is clear that women with HDP are at increased секс of developing hypertension later in life. Some epidemiologic data suggest that the increased risk of late CVD may be attributed to underlying genetic and other cardiac risk factors that are common to both disorders 7888 — It may also be that HDP induces physiologic and metabolic changes that remain after delivery leading to late CVD 91 — The relative risk was 4.

    Even mild glucose impairment identifies women at increased risk of future development of CVD стентирования Early menarche appears to be associated with an increased risk of future CVD. A стентирования study of 1. There is a definite shift in the post-menopausal state, which is recognized as a CVD risk factor equivalent to male sex Among women aged 45 to 49 at the onset of menopause as compared to those aged 50 or older there was no increased risk of CVD or death.

    Menopause at usual стентирования may not be directly responsible for the increased CVD risk after menopause. После the CVD incidence rises over time following menopause, there is similarly an increase in risk among men with increasing age An important contributing factor is that postmenopausal women who develop CVD have an increased burden of risk factors compared with those who do not.

    It is unclear whether the increased incident risk of CVD when moving from the pre-menopausal to postmenopausal state, is related to changes in in hormone levels specifically a decline in estrogen levels. There are multiple purported biologic mechanisms for the benefits of estrogen including: 1 decreased LDL and increased HDL cholesterol levels; 2 endothelium dependent vasodilation; 3 enhancing the release or bioavailability стентирования nitric oxide from endothelial cells, resulting in increased vasorelaxation and 4 positive hemostatic effects.

    Ischemic heart disease refers to a spectrum of pathological changes or events that results in myocardial ischemia or actual myocardial injury. Furthermore, evidence supports the role of coronary microvascular dysfunction in ACS due to existing endothelial and non-endothelial dysfunction Note: Although Coronary vasospasm, spontaneous coronary artery dissection SCAD and stress-related Takotsubo секс do occur in both males and females, these presentations are much more common among females.

    With respect to thrombus formation, males are more likely to present with ruptured plaque while females are more likely to present with eroded plaques. Adapted from Pagidipati et al To facilitate immediate treatment, such as reperfusion therapies, it is common to designate Секс based on ischemic symptoms, ECG findings and elevated biomarker values.

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