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Preeclampsia, gestational diabetes, or pregnancy-induced hypertension identify a woman at risk for cardiovascular disease. This information should be incorporated into the routine cardiovascular risk assessment for women, as a basis for appropriate risk factor screening, counseling, and preventive interventions. There is need for development and validation of a clinometric tool to assess cardiovascular risk and guide management.

The Eastern Mediterranean region (EMR) comprises 22 countries or territories spanning from Morocco in the west to Pakistan in the east, and contains a population of almost 600 million people. Like many other developing regions, the burden of disease in the EMR has shifted in the past 30 years from primarily communicable diseases to noncommunicable diseases such as cardiovascular disease (CVD). Cardiovascular mortality in the EMR, mostly attributable to ischaemic heart disease, is expected to increase more dramatically in the next decade than in any other region except Africa. The most prominent CVD risk factors in this region include tobacco consumption, physical inactivity, depression, obesity, hypertension, and diabetes mellitus. Many individuals living in the EMR are unaware of their risk factor status, and even if treated, these risk factors are often poorly controlled. Furthermore, infrequent use of emergency medical services, delays in access to care, and lack of access to cardiac catheterization affects the timely diagnosis of CVD. Treatment of CVD is also suboptimal in this region, consisting primarily of thrombolysis, with insufficient provision of timely revascularization. In this Review, we summarize what is known about CVD burden, risk factors, and treatment strategies for individuals living in the EMR. This information will hopefully aid decision-makers when devising strategies on how to improve CVD prevention and management in this region.

In this multicenter, placebo-controlled, randomized trial of postmenopausal women at high risk for a coronary event, raloxifene had no significant effect on the risk of primary coronary events, reduced the risk of invasive breast cancer and vertebral fractures, and increased the risk of fatal stroke and venous thromboembolism. A decision whether to use raloxifene for the prevention of breast cancer or vertebral fractures should be individualized, weighing benefits against potential risks. In postmenopausal women at high risk for a coronary event, raloxifene had no significant effect on the risk of primary coronary events, reduced the risk of invasive breast cancer and vertebral fractures, and increased the risk of fatal stroke and venous thromboembolism. Raloxifene is a nonsteroidal selective estrogen-receptor modulator (SERM) that binds to the estrogen receptor, leading to estrogen-agonist effects in some tissues and estrogen-antagonist effects in others. 1 Raloxifene therapy has been associated with improvement in the levels of serum lipoprotein cholesterol, 2 , 3 fibrinogen, 3 and homocysteine. 4 The favorable effect of raloxifene on markers of cardiovascular risk, coupled with evidence from observational studies that treatment with estrogen was associated with a reduced risk of coronary heart disease (CHD) in postmenopausal women, 5 , 6 led to the design of the Raloxifene Use for The Heart (RUTH) trial to determine the effect of raloxifene on clinical . . .

Abstract Context Studies of the possible cardiovascular risk of testosterone treatment are inconclusive. Objective To determine the effect of testosterone treatment on cardiovascular biomarkers in older men with low testosterone. Design Double-blind, placebo-controlled trial. Setting Twelve academic medical centers in the United States. Participants In all, 788 men ≥65 years old with an average of two serum testosterone levels <275 ng/dL who were enrolled in The Testosterone Trials. Intervention Testosterone gel, the dose adjusted to maintain the testosterone level in the normal range for young men, or placebo gel for 12 months. Main Outcome Measures Serum markers of cardiovascular risk, including lipids and markers of glucose metabolism, fibrinolysis, inflammation, and myocardial damage. Results Compared with placebo, testosterone treatment significantly decreased total cholesterol (adjusted mean difference, −6.1 mg/dL; P < 0.001), high-density lipoprotein cholesterol (adjusted mean difference, −2.0 mg/dL; P < 0.001), and low-density lipoprotein cholesterol (adjusted mean difference, −2.3 mg/dL; P = 0.051) from baseline to month 12. Testosterone also slightly but significantly decreased fasting insulin (adjusted mean difference, −1.7 µIU/mL; P = 0.02) and homeostatic model assessment‒insulin resistance (adjusted mean difference, −0.6; P = 0.03). Testosterone did not change triglycerides, d-dimer, C-reactive protein, interleukin 6, troponin, glucose, or hemoglobin A1c levels more than placebo. Conclusions and Relevance Testosterone treatment of 1 year in older men with low testosterone was associated with small reductions in cholesterol and insulin but not with other glucose markers, markers of inflammation or fibrinolysis, or troponin. The clinical importance of these findings is unclear and requires a larger trial of clinical outcomes. Compared with placebo, testosterone treatment of older men with low testosterone was associated with small reductions in total, HDL, and LDL cholesterol and in insulin and HOMA-IR but not glucose.

Vascular aging leads to arterial hypertension, which is the leading cause of cardiovascular mortality and morbidity in older adults. Blood pressure reduction is effective in reducing the cardiovascular risk and is safe in ambulatory older adults. It is important to note that blood pressure control in this group of patients is challenging because of comorbidities, polypharmacy, and frailty. Choice of pharmacotherapy is not simple and should be individualized.

Purpose of ReviewHypertensive disorders of pregnancy affect about 5–10% of pregnancies impacting maternal, fetal, and neonatal outcomes. We review the recent studies in this field and discuss the pathophysiology, diagnosis, and management of hypertension during pregnancy, as well as the short- and long-term consequences on the cardiovascular health of women.Recent FindingsAlthough the American College of Cardiology/American Heart Association revised their guidelines for hypertension in the general population in 2017, hypertension during pregnancy continues to be defined as a systolic blood pressure (SBP) ≥ 140 mmHg and/or a diastolic blood pressure (DBP) ≥ 90 mmHg, measured on two separate occasions. The addition of stage 1 hypertension will increase the prevalence of hypertension during pregnancy, identifying more women at risk of preeclampsia; however, more research is needed before changing the BP goal because a lower target BP has a risk of poor placental perfusion. Women with chronic hypertension have a higher incidence of superimposed preeclampsia, cesarean section, preterm delivery before 37 weeks’ gestation, birth weight less than 2500 g, neonatal unit admission, and perinatal death. They also have a higher risk of developing cardiovascular disease later in life. The guidelines recommend low-dose aspirin for women with moderate and high risk of preeclampsia. While treating pregnant women with hypertension, the effectiveness of the antihypertensive agent must be balanced with risks to the fetus.SummaryHypertensive disorders of pregnancy should be appropriately and promptly recognized and treated during pregnancy. They should further be co-managed by the obstetrician and cardiologist to decrease the long-term negative impact on the cardiovascular health of women.

The clinical evidence for treatment of acute coronary syndrome (ACS) in the elderly is less robust than in patients younger than 75 years. The elderly have the highest incidence of cardiovascular disease and frequently present with ACS. This number can be expected to increase over time because society is aging. Older adults often sustain unfavorable outcomes from ACS because of atypical presentation and delay in recognition. In addition, elderly patients commonly do not receive optimal guideline-directed ACS treatment. Owing to their high baseline risk of ischemic complications, the elderly also fare worse even with optimal ACS treatment as they frequently have more complex coronary disease, more comorbidities, less cardiovascular reserve, and a higher risk of treatment complications. They are also subjected to a broader range of pharmacologic treatment. Treatment complications can be mitigated to some extent by meticulous dose adjustment of antithrombotic and adjunctive therapies. While careful transitions of care and appropriate utilization of post-discharge secondary preventive measures are important in ACS patients of all ages, the elderly are more vulnerable to system errors and thus deserve special attention from the clinician.

Several plasma non-lipid biomarkers have been shown to predict major cardiovascular events (MCVEs) in population studies. Our objective was to investigate the relationship between lipid and non-lipid biomarkers levels achieved during statin therapy and the incidence of MCVEs in patients with stable coronary heart disease (CHD). We conducted a substudy of the TNT (Treating to New Targets) study, which was a randomized trial that compared the efficacy of high (80 mg) versus low (10 mg) dose atorvastatin for the secondary prevention of CHD. Fasting plasma levels of standard lipids and of 18 non-lipid biomarkers were obtained after an 8-week run-in period on atorvastatin 10 mg in 157 patients who experienced MCVEs during the 4.9 years of study follow-up and in 1349 controls. MCVE was defined as CHD death, nonfatal, non-procedure-related myocardial infarction, resuscitated cardiac arrest, and fatal or nonfatal stroke. After adjusting for age, sex and treatment arm, plasma levels of high-density lipoprotein (HDL) cholesterol, triglycerides, high-sensitivity C-reactive protein (hsCRP), insulin, neopterin, N-terminal pro-brain natriuretic peptide (BNP), lipoprotein(a) [Lp(a)], and the soluble receptor for advanced glycation end products (sRAGE) were predictive of recurrent MCVEs (P ≤ 0.02 for each doubling of plasma concentration). However, no significant association was observed between the risk of recurrent MCVEs and plasma levels of low-density lipoprotein cholesterol, adiponectin, cystatin C, lipoprotein-associated phospholipase A2, monocyte chemotactic protein-1, matrix metalloproteinase-9, myeloperoxidase, osteopontin, soluble CD40 ligand, soluble intercellular adhesion molecule-1, or soluble vascular cell adhesion molecule-1. After further adjustment for diabetes, hypertension, smoking, and BMI, the relationship between hsCRP, insulin and MCVE were no longer significant, while the relationship between Lp(a), neopterin, NT-proBNP and sRAGE and MCVE remained statistically significant. In conclusion, in patients with CHD treated with atorvastatin, plasma levels of Lp(a), neopterin, NT-proBNP, and sRAGE are associated with the risk of recurrent MCVEs. ClinicalTrials.gov NCT00327691.

The aim of this study was to evaluate the effect of atorvastatin on lipid lowering, cardiovascular (CV) events, and adverse events in women compared with men in 6 clinical trials. In the Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) trial (atorvastatin 80 mg vs simvastatin 20 to 40 mg), the Treating to New Targets (TNT) trial (atorvastatin 80 vs 10 mg), the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial (atorvastatin 80 mg vs placebo), and the Collaborative Atorvastatin Diabetes Study (CARDS), the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), and the Atorvastatin Study for Prevention of Coronary Heart Disease Endpoints in Non-Insulin-Dependent Diabetes Mellitus (ASPEN) (atorvastatin 10 mg vs placebo), lipid changes on treatment were compared between genders with studies grouped by dose. The association of on-study low-density lipoprotein (LDL) cholesterol and CV events by gender was evaluated in the combined studies and the impact of gender on adverse events in each study separately. Major CV events occurred in 3,083 of 30,000 men (10.3%) and 823 of 9,173 women (9.0%). Changes in lipids were similar in women and men. Major CV events were associated with gender-specific quintiles of on-treatment LDL cholesterol for women and men. In women, LDL cholesterol was a significant predictor of stroke, but not in men. Discontinuation rates due to adverse events were higher in women in 4 of 6 trials, but in only 1 trial was a significant treatment-gender interaction seen. Myalgia rates were slightly higher in women in both statin and placebo groups. In conclusion, the response of women to atorvastatin was similar to that of men, with slightly more discontinuations due to adverse events. Higher on-treatment LDL cholesterol was significantly associated with more CV events in both genders, but the association was stronger for stroke in women and for coronary heart disease death in men.

The guidelines (Figure 1) graphically explore the spectrum of clinical presentations such that the patient may initially have had chest pain, but at presentation either has minimal or no symptoms; to the patient with increasing chest pain or other symptoms; to the patient with persistent chest pain or symptoms; to the patient with cardiogenic shock or acute heart failure; and finally, the patient who presents with a cardiac arrest. Very high-risk features include hemodynamic instability or cardiogenic shock; recurrent or ongoing chest pain, refractory to medical management; acute heart failure presumed secondary to ongoing myocardial ischemia; life-threatening arrhythmias or cardiac arrest after presentation; mechanical complications [5]; or recurrent dynamic electrocardiographic changes suggestive of ischemia. Analysis of these components may improve the delivery of care for patients with STEMI and will involve patient education for prompt presentation, the EMS system efficiency, the emergency room contact in the hospital, and transfer to the cardiac catheterization laboratory, ideally in under 90 min [10]. The attainment and maintenance of treatment targets include a systolic blood pressure of less than 130 mmHg and a diastolic blood pressure under 80 mmHg as tolerated, LDL-C below 55 mg/dL, and a HgbA1c less than 7% [26, 27].