more_vertThe American College of Cardiology and American Heart Association has modified the definition of hypertension in adults.1 In this definition, blood pressure is divided into four groups, including normal blood pressure, elevated blood pressure, stage 1 hypertension, and stage 2 hypertension. These cutoffs were chosen on the basis of the relationship between systolic blood pressure (SBP) and diastolic blood pressure (DBP) with the incidence of cardiovascular diseases.1
Preference: Cardiology and Cardiac Surgery
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Fewer than five in 100 interventional cardiologists are women
A new study has highlighted a critical gender gap in interventional cardiology, the medical field specialising in treating blocked arteries in heart disease.
There are only 19 female interventional cardiologists in all of Australia and New Zealand – just 4.8 per cent of that workforce, a new study by medical researchers, including a UNSW PhD student, has shown.
In light of the findings, the researchers have called for change to increase much-needed diversity in the field – and to improve clinical care and outcomes for women. With cardiovascular disease the main cause of death for both men and women, the study is relevant to a large number of Australians.
The findings, published in the Journal of the American College of Cardiology, are the result of research performed by Women in Interventional Cardiology of Australian and New Zealand (WiiCAN – pronounced ‘we can’).
On top of the severe gender disparity in interventional cardiology, the data also reveal that only 15 per cent of all cardiologists across the two countries are women, that 73 per cent of public hospitals have no female interventional cardiologists at all, and that three Australian States have none either.
One of the lead authors, interventional cardiologist Dr Sonya Burgess, is working at Nepean Hospital in Sydney. She is also completing a doctorate at UNSW Sydney, studying patients with heart attacks and the importance of complete revascularisation of the coronary arteries for these patients. She says there are many barriers for female trainees.
“I started my cardiology training in 2007 in New Zealand, the country that first gave women the vote, yet also a country that now has had more female prime ministers than female interventional cardiologists,” she said.
“The reasons for this are complex, but can be overcome with positive changes.”
The paper discusses factors contributing to this gap, including the importance of role models, the expectations of training and society, the impact of geography, occupational radiation, cardiology’s workplace culture, unconscious gender bias, and strategies for promoting change.
The authors call for more evidence-based solutions to tackle the problem, including systematic approaches to actively address disparity and achieve more visibility, so trainees see female role models in leadership positions, in faculty at conferences and in training hospitals.
“We need leaders who believe the data is important and who value diversity, to allow us to change from a culture of de-facto exclusion to one of active inclusion,” Dr Burgess said.
“It is now well documented that women with heart disease receive less treatment, fewer appropriate medications, and experience higher mortality compared to men.
“At the same time, several studies have reported better clinical outcomes for patients treated by female cardiologists and physicians, notably including improved survival rates for female heart attack patients when treated by a female doctor.”
To help address some of these issues and create a community of women, Dr Burgess co-founded WiiCAN.
Dr Burgess helped found the social network in 2017, when she met the other two co-founders, Dr Sarah Zaman from Monash Medical Centre and Dr Elizabeth Shaw from Hornsby Ku-ring-gai Hospital, at a conference that brought together Australian and New Zealand interventional cardiologists. Their goal is to give a voice to female cardiology trainees, patients and colleagues, so they would not feel isolated in a male-dominated workforce.
Artery hardening begins before high school: Australian study
Only a minority of Australian 12-year-olds have ideal cardiovascular health, research shows, with arterial stiffening evident before some children start high school.
A team from Melbourne’s Murdoch Children’s Research Institute assessed the cardiovascular health of 1028 Australian children aged 11-12 using the seven risk factors of the American Heart Association’s Cardiovascular Health (ICVH) score: physical activity, weight, diet, blood glucose, cholesterol, blood pressure and smoking status.
Only 7% of the children (76) had a perfect ICVH score, and only 39% (406) achieved ideal levels in six out of the seven metrics. The median score was 5/7.
For the first time, the researchers demonstrated that ICVH scores in children were associated with vascular function.
Each additional point in a child’s ICVH score was associated with slower carotid-femoral pulse wave velocity (0.07m/s reduction in pulse wave velocity) and greater carotid elasticity (0.009% per mm Hg).
This relationship was largely mediated by BMI and blood pressure, according to the study published this month in the International Journal of Cardiology.
Study co-author, Professor David Burgner of the University of Melbourne told doctorportal: “If parents were aware that even before their child starts high school, risk factors such as increased BMI and raised BP were already associated with stiffer arteries – which increases the chance of heart attack and stroke as adults – then you’d hope that would galvanise families to try to reduce their risk factors.”
“Cardiovascular disease risk occurs from childhood onwards and we already see associations between risk factors and preclinical changes in the arteries by mid-childhood,” he said.
A family problem
The researchers also assessed 1,235 parents of the children – in most cases the mothers.
The median ICVH score in the parents was lower than in children (4/7), and the association with vascular function was stronger, the study found.
ICVH scores in adults were also linked with changes in vascular structure. Each additional point in an adult’s ICVH score was associated with a smaller carotid intima-media thickness (-7.3μm per metric unit), a measure of subclinical atherosclerosis.
The study found children whose parent had non-ideal health in any of the seven metrics had substantially higher odds for non-ideal health in that metric, for all metrics except physical activity and serum glucose. Children typically did more exercise than their parents.
Ideal diet was the metric least likely to be attained by both adults and children.
Family-based interventions
Professor Burgner said the study highlighted the need for family-based interventions to reduce cardiovascular risk from early on in life.
“Clearly many of the risk factors are shared within families, so considering the family rather than the individual as the unit for interventions that address modifiable environmental risk factors such as increased physical activity or diet may have more impact than just focusing on the adult or child in isolation,” he said.
Professor Burgner said it was unknown whether the poorer vascular function seen in children with lower ICVH scores in the study was reversible.
“The adverse changes in children are smaller than in adults and only relate to the elasticity of the arteries. This likely reflects a longer cumulative exposure to risk factors the older you get,” he said. “Certainly the consensus is that children are physiologically more ‘plastic’, so changes are likely to be reversible, but it is not well understood.”
The study cohort was drawn from the Longitudinal Study of Australian Children and Child Health Checkpoint. The authors cautioned that it was likely to have under-represented socio-economically disadvantaged families.
Dr Richard Liu, another co-author of the study, said that BP measurement should be routine in children. However in practice it was rare.
“Arguably all children with a raised BMI should be screened but it is important that it be done appropriately – that abnormal readings are repeated at least twice, the cuff is appropriately sized and equipment calibrated, and values are measured against established centiles for age, sex and height,” he said.
[Comment] Where are the women in academic cardiology?
Women are a minority of cardiologists. Despite gender parity among medical students and internal medicine residents in the USA and in Europe, only 21% of cardiology fellows in the USA and 16·8% in the UK are women.1,2 This drop-off has been labelled the “residency to fellowship cliff” by Pamela Douglas, Chair of the American College of Cardiology (ACC) Taskforce on Diversity, and former ACC president.3 These proportions are comparable to US female trainees in thoracic surgery (21%), neurosurgery (17%), and orthopaedic surgery (15%).
Being heart smart could prevent cognitive decline in women
New research has revealed that cardiovascular risk factors, particularly high cholesterol, play a role in the development of cognitive decline, further highlighting the importance of kickstarting healthy heart habits earlier in life.
Professor Cassandra Szoeke, director of the Healthy Ageing Program at the University of Melbourne and lead researcher, said the results showed that strategies to target vascular damage are vital to prevent brain cell loss.
“Neurodegenerative brain disease works insidiously for decades before people are diagnosed with dementia – we need to stop it in its tracks, or ideally before it starts.”
“What you do now affects what you will be decades later.”
What did the study involve?
The Australian study, published in Brain Imaging and Behaviour, included 135 participants from the Women’s Healthy Ageing Project. These women had completed midlife cardiovascular risk measurement in 1992, followed by an MRI scan and cognitive assessment in 2012.
The researchers found that higher midlife Framingham Cardiovascular Risk Profile (FCRP) score was associated with greater White Matter Hyperintensity (WMH) volume two decades later, and was predominantly driven by the impact of HDL cholesterol level.
Structural equation modelling demonstrated that the relationship between midlife FCRP score and late-life executive function was mediated by WMH volume.
“We saw those with low brain volume lost even more volume over the next 10 years,” Professor Szoeke said.
The authors wrote that their results indicated that intervention strategies targeting major cardiovascular risk factors at midlife might be effective in reducing the development of WMH lesions and thus late-life cognitive decline.
Massive exercise changes aren’t needed – but being active every day is key
“We all know we should eat healthily and exercise, but we also know many people who start up a program are not participating 3 months later, and 12 months later even less are still participating,” Professor Szoeke said.
Going into the study, her research team had expected that women who did intense physical activity would have the best cognition down the track.
“We found it was those who did activity every day over the 20 years of follow-up. It could be walking the block or gardening or a mix of Saturday dancing, Sunday walking home, and Monday walking to work – but it is each and every day for 20 years.”
Professor Szoeke said the impact of the research should be a greater recognition that vascular risk is modifiable, If it’s left unchanged, this will lead to brain damage in the form of WMH, low brain volume and poor cognition.
She said modifying this risk doesn’t mean a huge lifestyle change. In fact, the benefit can be obtained from just being more active.
“Move often and eat healthily. Choose what works for you, change it as you need, and do it each and every day.”
Women are disproportionately affected by dementia
Women account for around two-thirds of all dementia cases. Understanding the reasons behind this is an issue close to Professor Szoeke’s heart.
She said while women generally live 3 to 4 years more than men, it is not just an effect of age. The fact that the symptoms, assessment, treatment, management and prevention of heart disease differs between men and women suggested that cardiovascular risk also plays a role.
“Last year, the Australian Hidden Hearts report was released, showing that women have more heart disease, heart failure and stroke than men,” Professor Szoeke said.
“The Health Minister Greg Hunt has announced an update of women’s health policy. There has been $18 million announced for research to fill these gaps in knowledge, particularly highlighting issues not often focused on in traditional women’s health.”
She said the strategic areas for the new update reflect key issues for women, including mental health, dementia, chronic disease and healthy ageing.
“I hope we can quickly see major improvements with investment in these areas.”
[Clinical Picture] External left atrium compression by spinal osteophytes
A previously healthy 76-year-old woman was assessed preoperatively prior to hip arthroplasty. Cardiac examination was notable for a mid-diastolic murmur at the apex—appreciable only in the supine position. She had no signs or symptoms of heart failure. The patient’s N-terminal-pro-B-type natriuretic peptide blood concentration was normal (71 pg/mL). A transthoracic echocardiogram showed preserved biventricular systolic function, unimpaired diastolic relaxation, normal left atrial dimensions free of any intra-atrial septation, and no valvular abnormalities.
[Department of Error] Department of Error
Gupta A, Mackay J, Whitehouse A, et al. Long-term mortality after blood pressure-lowering and lipid-lowering treatment in patients with hypertension in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy study: 16-year follow-up results of a randomised factorial trial. Lancet 2018; 392: 1127–37—In this Article, the fourth sentence of the findings section of the summary has been corrected to read “there was no overall difference in cardiovascular mortality between treatments”. This correction has been made to the online version as of Oct 18, 2018.
[Correspondence] World Restart a Heart initiative: all citizens of the world can save a life
Sudden cardiac arrest is the third leading cause of death in industrialised nations, resulting in more than 700 000 deaths in Europe and the USA annually.1 After cardiac arrest, the brain can survive for 3–5 min, which could be the minimum time that emergency medical services take to arrive. Consequently, the most important way to improve survival is the instigation of early bystander cardiopulmonary resuscitation (CPR).2 Bystander CPR increases survival by two to four times, which is much better than with any other intervention by emergency medical services or hospital staff.
[Comment] Are all drug-eluting stents created equal?
Non-inferiority trials with combined clinical endpoints in allcomer populations were suggested as a compromise between premarket assessments and speed of innovation.1 However, it is important to remain aware of the limitations of the information provided by these trials. In The Lancet, Clemens von Birgelen and colleagues2 report their comparison of two highly regarded drug-eluting stents in clinical use (the Resolute Onyx and the Orsiro stents) in a population of 2488 allcomers. The primary endpoint was target vessel failure, a hierarchical combination of safety endpoints (cardiac death or target vessel myocardial infarction) with an efficacy endpoint (target vessel revascularisation) at 1 year.
More subsidised MRI scans made available
New Medicare-subsidised MRI licences have been granted in an additional 30 locations around Australia.
More than 400,000 Australians will now be able to access lifesaving scans for cancer, stroke, heart and other medical conditions.
The Government has allocated $175 million for the rollout, with the first 10 hospitals to receive the new Medicare support being:
- Mount Druitt Hospital, New South Wales
- Sale Hospital, Victoria
- Royal Darwin Hospital, Northern Territory
- Mount Barker, South Australia
- Pindara Private Hospital, Gold Coast, Queensland
- Northern Beaches Hospital, New South Wales
- Toowoomba Hospital, Queensland
- Monash Children’s Hospital, Clayton Victoria
- St John of God Midland Public and Private Hospital, Western Australia
- Kalgoorlie Health Campus, Western Australia
Health Minister Greg Hunt said each of the sites had been identified as a location of critical patient need. In many cases hospitals already have this technology, ready to provide services from November 1 this year.
“Not only will our new Medicare support ensure patients get the most appropriate treatment and save money, it will also cut down the amount of time patients have to spend travelling to get a scan,” the Minister said.
“Medicare subsidised MRIs will be accessible in these locations from 1 November 2018, subject to the sites meeting the required approvals and administrative requirements.”
A competitive public application process for the location of a further 20 Medicare eligible MRIs has also been opened.
Shadow Health Minister Catherine King welcomed the new licences, but said the Government was only following Labor’s move on the issue.
“After five years of abject failure when it comes to the cost of medical scans, the Liberals have finally decided to follow Labor’s lead and award more Medicare-subsidised MRI licences,” Ms King said.
“When Labor was last in Government, we awarded 238 MRI licences – delivering more affordable scans to hundreds of communities across the country.
“In May this year, we promised a Bill Shorten Labor government would invest an extra $80 million to deliver a further 20 licences in locations of pressing need.”
Mr Hunt pointed out that earlier this year, the Government boosted Medicare support for a new MRI scan for prostate cancer checks helping 26,000 men each year. It also provided a new Medicare listing for 3D breast cancer checks, helping around 240,000 women each year.
“The Liberal National Government has also announced an additional $2 billion investment in diagnostic imaging over the next decade,” he said.
“We are retaining the bulk-billing incentive and indexing targeted diagnostic imaging services including mammography, fluoroscopy, CT scans and interventional procedures.
“By contrast, Labor has only committed $80 million and not made any commitment to the re-indexation of diagnostic imaging rebates.”
An MRI is a commonly used medical scan which gives a detailed view of the soft tissues of the body such as muscles, ligaments, brain tissue, discs and blood vessels, and helps with the diagnosis of (among other things) cancer, cardiac conditions, trauma and sporting injuries.