Annabelle S. Volgman

Women With Atrial Fibrillation: Greater Risk, Less Attention

BACKGROUND In 1995, atrial fibrillation (AF) was estimated to affect 2.2 million people in the United States. After the age of 75 years (the median age for onset of AF), approximately 60% of people with AF are women. Women have a significantly higher risk of AF-related stroke than do men and are more likely to live with stroke-related disability and a significantly lower quality of life. OBJECTIVE This article provides an overview of the contributing factors and clinical presentation of AF in women and offers a rational, safe, effective, and gender-specific approach to therapy for women with AF. METHODS Search engines, including PubMed and Google Scholar, were used to review the English-language literature addressing AF gender differences for the years 1989-2009. The search term atrial fibrillation was combined with multiple other terms, as well as with female, gender, sex, or women. Full-length manuscripts were reviewed. Original studies obtained were searched for additional relevant manuscripts using the cited references. RESULTS Studies have shown that women are more likely than men to experience symptomatic attacks, a higher frequency of recurrences, and significantly higher heart rates during AF. Hormonal fluctuations during the menstrual cycle that affect QT intervals are an important consideration when selecting antiarrhythmic drugs for premenopausal women. Women are treated with statins less frequently than are men, possibly contributing to an increased incidence of AF in women. Women may have a higher incidence of AF because of the association with obesity. Some evidence suggests that women have a significantly higher risk of bleeding from anticoagulation. Reluctance among physicians and patients to use warfarin may be especially problematic in elderly women, who benefit most from it. Outcomes after catheter ablation for AF are similar between the sexes, yet women are referred later and less frequently. CONCLUSIONS We favor emphasizing therapies to prevent AF and ensure safe arrhythmia management (ie, rate control and appropriate anticoagulation) once AF has been diagnosed. Gender differences should be kept in mind for women with AF to reduce risks and improve quality of life.

Cardiac rhythm disturbances among children with idiopathic congenital central hypoventilation syndrome

The objective of this study was to determine whether subjects with congenital central hypoventilation syndrome (CCHS) had an increased frequency of cardiac arrhythmias and decreased heart rate variability when compared to subjects without a known deficit in control of breathing, and that these abnormalities would be exaggerated by anesthesia. Continuous ambulatory Holter recordings were obtained in patients with CCHS and compared to two otherwise healthy control groups without a deficit in control of breathing: one with an intact airway (n = 11) and a second group with a tracheostomy (n = 6). Holter recordings were obtained before, during (under general anesthesia), and after bronchoscopy. Fourteen children with CCHS (age: 9.3 ± 4.4 years mean ± S.D.) were studied, and 7 underwent bronchoscopy. Seventeen control children were studied (age 6.6 ± 3.6 years): 11 without a tracheostomy, and 6 with a tracheostomy who also underwent bronchoscopy.

Women tolerate drug therapy for coronary artery disease as well as men do, but are treated less frequently with aspirin, β-blockers, or statins

BACKGROUND Women have worse morbidity, mortality, and health-related quality-of-life outcomes associated with coronary artery disease (CAD) compared with men. This may be related to underutilization of drug therapies, such as aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or statins. No studies have sought to describe the relationship of gender with adverse reactions to drug therapy (ADRs) for CAD in clinical practice. OBJECTIVE The aim of this study was to determine the prevalence of ADRs associated with common CAD drug therapies in women and men in clinical practice. METHODS In a cohort of consecutive outpatients with CAD, detailed chart abstraction was performed to determine the use of aspirin, beta-blocker, ACE inhibitor, and statin therapy, as well as the ADRs reported for these treatments. Baseline clinical characteristics were also determined to identify the independent association of gender with use of standard drug treatments for CAD. RESULTS Consecutive patients with CAD (153 men, 151 women) were included in the study. Women and men were observed to have a similar prevalence of cardiac risk factors and comorbidities, except that men had significantly higher prevalence of atrial fibrillation (30 [19.6%] men vs 15 [9.9%] women; P = 0.03) and significantly lower mean (SD) high-density lipoprotein cholesterol concentrations (45 [16] mg/dL for men vs 55 [19] mg/dL for women; P < 0.001). No significant differences were observed between the sexes in the prevalence of ADRs; however, significantly fewer women than men were treated with statins (118 [78.1%] vs 139 [90.8%], respectively; P = 0.003). After adjusting for clinical characteristics, women were also found to be less likely than men to receive aspirin (odds ratio [OR] = 0.164; 95% CI, 0.083-0.322; P = 0.001) and beta-blockers (OR = 0.184; 95% CI, 0.096-0.351; P = 0.001). CONCLUSIONS Women and men experienced a similar prevalence of ADRs in the treatment of CAD; however, women were significantly less likely to be treated with aspirin, beta-blockers, and statins than were their male counterparts. To optimize care for women with CAD, further study is needed to identify the cause of this gender disparity in therapeutic drug use.

Beneficial Effects of Dextro‐Amphetamine in the Treatment of Vasodepressor Syncope

Three patients with history of documented hypolension, near syncope, or syncope before or after the administration of isoproterenol during head‐up tilt table are reported. Severe bradycardia was also noted in one patient. All three patients responded to the administration of 2.5 mg of oral dextro‐amphetamine 45 minutes prior to a repeat head‐up tilt table study. The potent central and peripheral adrenergic agonist pharmacological properties of this drug permitted the prevention of severe vasodepressor syncope in these patients.

Cardiovascular Disease and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association

Cardiovascular disease (CVD) remains the leading cause of mortality in women, yet many people perceive breast cancer to be the number one threat to women’s health. CVD and breast cancer have several overlapping risk factors, such as obesity and smoking. Additionally, current breast cancer treatments can have a negative impact on cardiovascular health (eg, left ventricular dysfunction, accelerated CVD), and for women with pre-existing CVD, this might influence cancer treatment decisions by both the patient and the provider. Improvements in early detection and treatment of breast cancer have led to an increasing number of breast cancer survivors who are at risk of long-term cardiac complications from cancer treatments. For older women, CVD poses a greater mortality threat than breast cancer itself. This is the first scientific statement from the American Heart Association on CVD and breast cancer. This document will provide a comprehensive overview of the prevalence of these diseases, shared risk factors, the cardiotoxic effects of therapy, and the prevention and treatment of CVD in breast cancer patients.

Study of Warfarin patients Investigating attitudes toward Therapy Change (SWITCH Survey)

Although the oral anticoagulant warfarin has undoubtedly saved lives and reduced the number of strokes in patients with atrial fibrillation, it is a cumbersome medication to manage and take. Novel oral anticoagulants, such as dabigatran, offer therapeutic anticoagulation without requisite blood testing or dietary restrictions. We conducted a survey of the attitudes of patients enrolled in a warfarin clinic toward switching to a novel anticoagulant. From September to December 2010, a written survey was offered to 180 patients in the Warfarin Clinic of the Rush University Medical Center and 155 patients filled out the survey (86% response rate). Inclusion criteria included being 18 years of age or older, on warfarin for 2 months. Fifty-eight percent of patients were willing to switch anticoagulants. Women were significantly less willing to switch from warfarin than men (31 of 71, 44% vs. 54 of 78, 69%; P = 0.003). Patients older than 70 years were significantly more willing to switch anticoagulants than those younger than 70 years (48 of 68, 71% vs. 38 of 75, 51%; P = 0.017). There are significant differences across age and gender in the initial willingness of patients to accept novel anticoagulants. These differences may have important implications in the prevention and treatment of thromboembolic events.

Effectiveness, efficiency, duration, and costs of recruiting for an African American women's lifestyle physical activity program

In a 48-week lifestyle physical activity controlled trial in African American women, we analyzed recruitment effectiveness, efficiency, duration, and costs. Social networking was the most effective approach for inviting women to the trial. Of the 609 who responded to invitations, 514 completed telephone screening; of these, 409 (80%) were found eligible. The health assessment screening was completed by 337 women; of these, 297 (88%) were found eligible. The mean number of days from completion of the telephone and health assessment screenings to beginning the intervention was 23.01, and the mean cost was

In Anterior Myocardial Infarction, Frequency Domain is Better than Time Domain Analysis of the Signal-Averaged ECG for Identifying Patients at Risk for Sustained Ventricular Tachycardia

74.57 per person. Results suggest that provision of health assessment screening by study staff as part of recruitment is effective for minimizing attrition and also might be cost-effective.

Randomized Clinical Trial of the Women’s Lifestyle Physical Activity Program for African-American Women 24- and 48-Week Outcomes

Low amplitude signals at the end of the QRS in patients with prior myocardial infarction (MI) are related to fragmentation of the electrical impulse in ventricular myocardium and are known to correlate with an increased risk of sustained ventricular tachycardia (VT). We hypothesized that in patients with anterior MI (AMI), earlier activation of the damaged anterior wall would cause an earlier fragmentation of the signal‐averaged EGG (SAECG) signal, making conventional time domain analysis of late potentials difficult. We performed SAECG in 213 patients (62 with AMI and 58 with inferior MI [IMI]). Fifty‐seven had prior sustained VT; 23 with AMI and 24 with IMI. We examined the standard time domain SAECG parameters including the duration of the filtered QRS (40–250 Hz), the duration of the late QRS < 40 μV, and the root mean square amplitude of the last 40 msec of the QRS. We also examined the power law scaling (PLS) in the frequency domain. Receiver operating characteristic curve analysis of a discriminant function demonstrated significant differences for PLS as compared to time domain indices. An important finding was the significance of MI locus in the time domain indices. PLS did not exhibit this dependence. These data suggest that the usual indices are insufficient for identifying AMI patients at risk of VT. PLS, on the other hand, is valuable regardless of MI location.

Burden of stroke in women.

Purpose: To compare the effects of a physical activity (PA) intervention of group meetings versus group meetings supplemented by personal calls or automated calls on the adoption and maintenance of PA and on weight stability among African-American women. Design: Randomized clinical trial with three conditions randomly assigned across six sites. Setting: Health settings in predominately African-American communities. Subjects: There were 288 women, aged 40 to 65, without major signs/symptoms of pulmonary/cardiovascular disease. Intervention: Six group meetings delivered over 48 weeks with either 11 personal motivational calls, 11 automated motivational messages, or no calls between meetings. Measures: Measures included PA (questionnaires, accelerometer, aerobic fitness), weight, and body composition at baseline, 24 weeks, and 48 weeks. Analysis: Analysis of variance and mixed models. Results: Retention was 90% at 48 weeks. Adherence to PA increased significantly (p < .001) for questionnaire (d = .56, 128 min/wk), accelerometer (d = .37, 830 steps/d), and aerobic fitness (d = .41, 7 steps/2 min) at 24 weeks and was maintained at 48 weeks (p < .001), with no differences across conditions. Weight and body composition showed no significant changes over the course of the study. Conclusion: Group meetings are a powerful intervention for increasing PA and preventing weight gain and may not need to be supplemented with telephone calls, which add costs and complexity.