Dawn C. Scantlebury

Why are women more likely than men to develop heart failure with preserved ejection fraction

Purpose of review Women are approximately two times more likely than men to develop heart failure in the setting of preserved left ventricular ejection fraction [i.e. heart failure with preserved left ventricular ejection fraction (HFpEF)], but the reasons for this disparity are unknown. Recent findings HFpEF is caused by changes in ventricular–vascular properties that are associated with aging and hypertensive cardiac remodeling. These changes lead to diastolic and systolic dysfunction and impaired reserve capacity. Many of the cardiovascular alterations seen in HFpEF are also noted to greater extent in women compared with men. Women demonstrate more concentric left ventricular remodeling and less ventricular dilatation in response to arterial hypertension. Ventricular and arterial stiffness increases with age in both sexes, but the increase is more dramatic in women. Recently, age–sex interactions have also been observed in the manner in which left ventricular function changes across the lifespan, wherein systolic and diastolic function and functional reserve become more compromised in women as compared with men in the postmenopausal years, despite similar or enhanced function in women during youth. Summary The prevalence of HFpEF is increasing and women outnumber men by a 2 : 1 ratio. Recent data have identified striking parallels between structure–function alterations observed in HFpEF and sex differences in cardiovascular function across the adult lifespan. These data suggest that sex-specific maladaptations to hypertensive aging in women may underlie greater risk of HFpEF.

Hypertension in Pregnancy Is a Risk Factor for Microalbuminuria Later in Life

The authors aimed to compare renal function by estimated glomerular filtration rate and albuminuria in 3 groups of women: nulliparous women, women with a history of normotensive pregnancies, and women with a history of at least one hypertensive pregnancy. Women who participated in the second Family Blood Pressure Program Study visit (2000–2004) and had serum creatinine and urine albumin measurements (n=3015) were categorized as having had no pregnancy lasting >6 months (n=341), having had only normotensive pregnancies (n=2199), or having had at least 1 pregnancy with hypertension (n=475) based on a standardized questionnaire. Women who reported having had at least one pregnancy with hypertension were significantly more likely to be hypertensive (75.6% vs 59.4%, P<.001), diabetic (34.2% vs 27.3%, P≤.001), and have higher body mass index (32.8 vs 30.5, P<.001) than those who reported normotensive pregnancies. There was a significantly greater risk of microalbuminuria (urine albumin‐creatinine ratio >25 mg/g) in those who reported at least one pregnancy with hypertension (odds ratio, 1.37; confidence interval, 1.02–1.85; P=.04) than in those with normotensive pregnancies, after adjusting for risk factors for chronic kidney and cardiovascular disease. Hypertension in pregnancy is associated with an increased risk of future microalbuminuria.

How Does Preeclampsia Predispose to Future Cardiovascular Disease

Over the last few decades, there has been increasing emphasis on cardiovascular disease in women and study of female-specific cardiovascular risk factors. Hypertension in pregnancy, and specifically preeclampsia, has been identified as one such risk factor. In this review, we explore the epidemiological evidence for preeclampsia as a risk factor for cardiovascular disease. We propose reasons for this association, giving evidence for potential pathways linking preeclampsia with future cardiovascular disease.

Limitations of Doppler Echocardiography in the Evaluation of Serial Stenoses

A 71-year-old man with a history of coronary artery disease with multiple previous interventions, atrial fibrillation, and moderate aortic stenosis presented with progressive angina. Physical examination revealed decreased peripheral pulses and a 2 to 3/6 mid- to-late peaking systolic ejection murmur at the upper right sternal border, unchanged with squat-to-stand maneuver. Coronary angiography ruled out significant obstructive coronary disease. Echocardiography revealed a septal thickness of 19 mm (Figure 1A). Doppler interrogation of the left ventricular (LV) outflow tract revealed a late peaking systolic velocity of 4.2 m/s (Figure 1B) and an early peaking systolic velocity of 3.8 m/s with a mean gradient of 40 mm Hg (Figure 1C), with 2 discrete levels of color aliasing noted on 2-dimensional (2D) Doppler color imaging (Movies I and II in the online-only Data Supplement). Because of patient reluctance to undergo surgery based on noninvasive evaluation, hemodynamic catheterization was performed to characterize the degree of obstruction accurately at each level. Figure 1. Hemodynamic assessment of tandem stenoses. A , Transthoracic echocardiography via a parasternal window revealed thickening of the intraventricular septum, measuring 19 mm. B , Doppler interrogation of the left ventricular outflow tract revealed a late peaking systolic velocity of 4.2 m/s. C , In addition, Doppler interrogation of the left ventricular outflow tract demonstrated a distinct early peaking …

Hemodynamic evaluation of severe tricuspid regurgitation

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] An 83-year-old woman with rheumatic heart disease presented with 1 year of progressive right heart failure following pacemaker implantation. Transthoracic echocardiography demonstrated severe tricuspid regurgitation (TR) with

Left ventricular hypertrophy after hypertensive pregnancy disorders

Objective Cardiac changes of hypertensive pregnancy include left ventricular hypertrophy (LVH) and diastolic dysfunction. These are thought to regress postpartum. We hypothesised that women with a history of hypertensive pregnancy would have altered LV geometry and function when compared with women with only normotensive pregnancies. Methods In this cohort study, we analysed echocardiograms of 2637 women who participated in the Family Blood Pressure Program. We compared LV mass and function in women with hypertensive pregnancies with those with normotensive pregnancies. Results Women were evaluated at a mean age of 56 years: 427 (16%) had at least one hypertensive pregnancy; 2210 (84%) had normotensive pregnancies. Compared with women with normotensive pregnancies, women with hypertensive pregnancy had a greater risk of LVH (OR: 1.42; 95% CI 1.01 to 1.99, p=0.05), after adjusting for age, race, research network of the Family Blood Pressure Program, education, parity, BMI, hypertension and diabetes. When duration of hypertension was taken into account, this relationship was no longer significant (OR: 1.19; CI 0.08 to 1.78, p=0.38). Women with hypertensive pregnancies also had greater left atrial size and lower mitral E/A ratio after adjusting for demographic variables. The prevalence of systolic dysfunction was similar between the groups. Conclusions A history of hypertensive pregnancy is associated with LVH after adjusting for risk factors; this might be explained by longer duration of hypertension. This finding supports current guidelines recommending surveillance of women following a hypertensive pregnancy, and sets the stage for longitudinal echocardiographic studies to further elucidate progression of LV geometry and function after pregnancy. Clinical trial registrations GENOA- NCT00005269; HyperGEN- NCT00005267; Sapphire- NCT00005270; GenNet- NCT00005268.

Stress-coping skills and neuroticism in apical ballooning syndrome (Takotsubo/stress cardiomyopathy)

Introduction Apical ballooning syndrome (ABS) is typically associated with an antecedent stressful situation. Affected patients have been reported to have higher frequencies of premorbid affective disorders. We hypothesised that patients with ABS would have elevated levels of neuroticism (tendency to experience negative affect) and greater vulnerability to stress. Methods In this cross-sectional study, all active participants in the Mayo Clinic ABS prospective follow-up registry were invited to complete the third edition of the NEO Personality Inventory (NEO-PI-3). The NEO-PI-3 is the universally accepted measure of the ‘Five-Factor Model’ of personality. Inventory responses were scored using the NEO-PI-3 computer program and the data were compared with US normative sample used in standardisation of the inventory. Significance was set at 0.0014 to account for multiple comparisons. Results Of 106 registry participants approached, 53 completed the inventory. There was no difference in age, gender, time from ABS diagnosis, type of antecedent stressor (emotional, physical or none) or severity of initial illness between the responders and non-responders. Responders had mean Neuroticism T-scores of 48.0±10.6 (95% CI 45.1 to 50.9); p=0.18, when compared with the normal mean of 50. There was also no significant difference in the facet scale of Vulnerability: 46.9±8.4 (44.6 to 49.2), p=0.038, at α=0.0014. Conclusions Contrary to our hypothesis, patients with ABS do not manifest higher levels of neuroticism and do not have greater vulnerability to stress than the general population. These findings have implications for the clinicians’ perception of, and approach to, patients with ABS.

Percutaneous device closure of a pseudoaneurysm arising from the junction of the innominate artery and the aorta

References 1. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. J Am Coll Cardiol. 2010;55:27-129. 2. Roberts WC, Vowels TJ, Ko JM, Filardo G, Hebeler RF Jr, Henry AC, et al. Comparison of the structure of the aortic valve and ascending aorta in adults

Response to Letter Regarding Article, “Limitations of Doppler Echocardiography in the Evaluation of Serial Stenoses”

We appreciate the insightful comments by Drs Jenni and Martin regarding our recent publication.1 We agree with them that the determination of serial gradients using conventional Doppler data is problematic. The derivation used for Figure 3 results in the generation of negative gradients, which are nonphysiological, supporting the conclusions that we and Drs Jenni and Martin have presented. Drs Jenni and Martin correctly pointed out that the velocity V2 in …

Doubly obstructive hypertrophic cardiomyopathy.

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 40-year-old woman with hypertrophic cardiomyopathy presented with New York Heart Association functional class III dyspnea and angina despite optimal medical therapy. Left heart catheterization with a high-fidelity,