The Role Sex Factors Play in the Diagnosis and Treatment of Myocardial Diseases

1. The Role Sex Factors Play in the Diagnosis and Treatment of Myocardial Diseases An Integrative Review by: Nicole Atkins, RN

2. Abstract • Myocardial disease is a never ending cascade of difficult diagnoses followed by well researched treatments. Gender plays an important role in the manner in which such diseases are managed. The issue lies with the reliably of multiple research studies given the lack of equality in gender representation. Sex related differences in myocardial research is becoming increasingly important. The goal is to determine the efficacy of the most common treatment of myocardial diseases dependent upon gender.

3. Introduction to research • 2001 was the year in which the Institute of Medicine released an initial report regarding the significance of sex differences with regards to health. (Fairweather, Cooper & Blauwet, 2013) • There have been multiple research studies since, conducting and evaluating the efficacy of treatment with regards to myocardial diseases including cardiomyopathy, heart failure and arrhythmias. • Multiple gender studies have concluded that men and woman are prone to different health diagnoses based on genetics, hormones and lifestyle. • Sex has a major impact on the remodeling of the heart’s tissue, (Piro et. al, 2010) • Differences between men and woman are noted to be related to sex hormones, for example, estrogen. (Piro et.al., 2010) • Vascular function and LV mass index (that is greater in males) can be attributed to such cardiac differences as well. (Piro et.al., 2010)

4. Introduction to Research • According to the article entitled “Gender- Related Differences in the Clinical Presentation and Outcome of Hypertrophic Cardiomyopathy,” gender has proved very significant with regards to characterizing and managing multiple cardiovascular conditions. (2005) • As of 2013, sudden cardiac death was the considered one of the top causes of death in the western world, 30,000 in the United States alone. (van derHeijden et al., 2013) • With this information in mind, utilizing the appropriate treatment for each sex is essential.

5. Method Utilized • Integrative literature review • CINAHL and MEDLINE PLUS were the databases accessed • 10 research articles were obtained and analyzed • Dr. James O’Brien and Dr. Lance Sullenberger were consulted for components of the research

6. Results • In the EuroHeart Failure Survey II, women only made up 39% of the study, with an overall mean age of 68 years old. (Nieminen et al., 2008) • Women were found to more frequently diagnosed with congestive heart failure, hypertension or valve disease, while men more common ly had cardiomyopathy and coronary artery disease and were found to more often be habitual smokers. (Nieminen et al., 2008) Fairweather’s et al., was in agreement with this, stating that men were found to have “an increased incidence and severity of most cardiovascular diseases, including atherosclerosis, myocardial infarction, dilated cardiomyopathy.” (2013) • This information correlated closely with facts stating that “gender-specific differences” as well as social, endocrine or genetic factors all influence diagnosis and plan of care, women comprised 41% of the study.. (Olivotto et al., 2005)

7. Results • An article entitled “Sex-Related Differences in Myocardial Remodeling” determined that sex has a “profound impact on myocardial remodeling , which is defined as the molecular and cellular events after an injury to the myocardium,” furthermore, it seemed as though remodeling seemed to favor women as a gender, which was attributed to sex hormones. (2010) • In EP, more men were found to undergo implantable cardioverter defibrillator implantation, though women made up only 27% of the study.. ( Daugherty et al, 2009) Moreover, lower arrhythmic mortality among women was discovered, though this particular study was the only with an even amount of men and women participants . (Bhavnani, 2013) • An evaluation of only one study found that gender was not an important risk factor with regards to mortality or arrhythmic events, though women only made up 37.1% of the study. (Chen, et al., 2007)

8. In conclusion… • The female gender is significantly underrepresented in the cardiac research and treatment community. It is difficult to determine to efficacy of many given treatments given the lack of female participation. However, the information that was available favored women in multiple categories including the efficacy of ICD’s and cardiac resynchronization therapy. • As gender studies continue to grow, there will be more reliable information specifically related to the female gender and their cardiac make up. “A heightened understanding of sex differences is critical for improving diagnostic strategies and clinical management that will lead to optimal care for both women and men with these potentially devastating cardiovascular diseases.” (Fairweather, et al., 2013) Implementation of this study would require encouragement and education provided to females regarding study participation and its benefits.

9. References Bauce, B., Frigo, G., Marcus, F.L., Marcus, F.I., Basso, C., Rampazzo, A., Maddalena, F., Corrado, D., Winnicki, M., Daliento, L., Rigato, I., Steriotis, A., Mazzotti, E., Thiene, G., Nava, A. (2008). Comparison of clinical fdatures of arrhythmogenic right ventricular cardiomyopathy in men versus women. The American Journal of Cardiology, 1252-1256 Bhavnani, S., Pavuluri, V., Coleman, C. I., Guertin, D., Yarlagadda, R. K., Clyne, C. A., & Kluger, J. (2013). The gender-paradox among patients with implantable cardioverter-defibrillators. Pacing Clinic Electrophysiology, 96(7), 878-884. Chen, H. A., Hsia, H. H., Vagelos, R., Fowler, M., Wang, P., & Al-Ahmad, A. (2007). The effect of gender on mortality or appropriate shock in patients with nonischemiccardiomyopathy who have implantable cardioverter-defibrillators. PACE, 30, 390-394. Daugherty, S. L., Person, P. N., Wang, Y., Curtis, J., Heidenreich, P., Lindenfeld, J., Vidaillet, H. J., & Masoudi, F. A. (2009). Use of im0plantable cardioverter defibrillators for primary prevention in the community: Do women and men equally meet trial enrollment criteria?. American Heart Journal, 158(2), 224-229. Fairweather, D., Cooper, L. T., & Blauwet, L. A. (2013). Sex and gender differences in myocarditis and dilated cardiomyopathy. Current Problems in Cardiology, 7-36.

10. References Leyva, F., Foley, P. W. X., Chalil, S., Irwin, N., & Smith, R. E. A. (2011). Female gender is associated with a better outcome after cardiac resynchronization therapy. PACE, 34, 82. Nieminen, M. S., Hajola, V., Hochadel, M., Drexler, H., Komajda, M., Brutsaert, D., Dickenstein, K., & Ponikowski, P. Tavazzi, L., Follath, F., Lopex-Sendon, J.L.(2008). Gender related differences in patients presenting with acute heart failure. results from euroheart failure survery ii. The European Journal of Heart Failure, 10, 140-148. Olivotto, I., Maron, M. S., Adabag, A. S., Casey, S. A., Vargiu, D., Link, M. S., Udelson, J. E., & Cecchi, F., Maron, Barry J. (2005). Gender-related differences in the clinical presentation and outcome of hypertrophic cardiomyopathy. Journal of the American College of Cardiology, 46(3), 480-487. Piro, M., Della Bona, R., Abbate, A., Biasucci, L., & Crea, F. (2010). Sex-related differences in myocardial remodeling. Journal of the American College of Cardiology, 55(11), 1057-1065. van derHeijden, A. C., Thijssen, J., Jan Willem Borleffs, C., van Rees, J.B., Hoke, U., van derVelde, E. T., van Erven, L., & Schalij, M.J. (2013)/ Gender-specific differences in clinical outcome of primary prevention implantable cardioverter defibrillator recipients. Heart, 99(17), 1244-1249.