Women face unique risks for high blood pressure and stroke

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Women have a lot on their plates, and sometimes important self-care can take a back seat to work, family and other obligations. In fact, nearly 50% of adult women have high blood pressure, and nearly three-quarters of those with high blood pressure don’t have it under control. Uncontrolled high blood pressure can significantly increase a woman’s risk for a stroke, but a few important steps can help reduce that risk and give women (and their loved ones) one less thing to worry about.

“High blood pressure is a leading cause of stroke and we know that one in five women will have a stroke and stroke kills more women than breast cancer,” according to Dr. Monik Jiménez, a volunteer with the American Heart Association / American Stroke Association and associate epidemiologist at Brigham and Women’s Hospital and assistant professor of Medicine at Harvard Medical School and Harvard T.H. Chan School of Public Health.

“While high blood pressure isn’t directly linked to gender, different health issues throughout a woman’s life, such as birth control, pregnancy, and menopause, can increase the risk of developing high blood pressure, which can increase the risk of stroke if left uncontrolled,” according to Jiménez.

Doctors and researchers have found a link between birth control pills and an increase in blood pressure among some women. They say that it is more likely to occur in women who are already overweight, have kidney disease or have a family history of high blood pressure. A combination of birth control pills and smoking can be very dangerous to women and is not recommended.

A woman’s health during pregnancy can be a preview of her health in the future. Women who had high blood pressure during pregnancy are at an increased risk for developing high blood pressure and having a stroke later in life.

The physical changes associated with menopause also increase a woman’s risk of developing high blood pressure.

Of note, women of Black and Hispanic ethnicity may develop high blood pressure at a younger age and have a higher average blood pressure than other racial groups, according to the Centers for Disease Control and Prevention.

Fortunately, 80% of strokes may be prevented and lowering high blood pressures reduces stroke risk. Women can measure their blood pressure at home regularly and let their doctors know if it’s normally above 120/80. In addition, lifestyle adjustments such as getting enough exercise, eating healthfully, maintaining a healthy weight, and not smoking can go a long way to reduce women’s disease risk from high blood pressure.

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Cardiologists warn about the risks of vaping

"Look before you leap:" Cardiologists warn about the risks of vaping

Electronic cigarette (EC) use, or vaping, has both gained incredible popularity and generated tremendous controversy, but although they may be less harmful than tobacco cigarettes (TCs), they have major potential risks that may be underestimated by health authorities, the public, and medical professionals. Two cardiovascular specialists review the latest scientific studies on the cardiovascular effects of cigarette smoking versus ECs in the Canadian Journal of Cardiology. They conclude that young non-smokers should be discouraged from vaping, flavors targeted towards adolescents should be banned, and laws and regulations restricting their availability to our youth should be passed and strictly enforced.

Arash Nayeri, MD, and Holly Middlekauff, MD, of the David Geffen School of Medicine at UCLA, Department of Medicine, Division of Cardiology, Los Angeles, CA, USA, have written this review to provide physicians with an objective, rather than emotional, assessment of the available scientific data about ECs so that these physicians can help their patients make informed and thoughtful decisions.

TCs are lethal, killing up to half the people who use them. They are a leading cause of preventable cardiovascular morbidity and mortality around the globe, projected to account for an estimated eight million deaths annually worldwide by 2030, most of which resulting from cardiovascular disease.

ECs have gained popularity since 2007, both among long-term TC smokers and youth who have never smoked tobacco. There is evidence that ECs are less harmful than TCs, and the absence of a number of known toxic byproducts of TCs has helped cultivate the perception that ECs are healthy (or at least benign).

A recent review of more than 50 scientific studies involving over 12,000 participants concluded that ECs are more effective for smoking cessation than certified nicotine replacement therapy (NRT) like patches or gum and were also more effective than behavioral support alone, thereby providing a potential alternative to lethal cigarettes for adult smokers addicted to nicotine. However, there is growing concern that some of their constituents, including nicotine, and their thermal degradation byproducts, may have adverse effects.

“EC vaping by our youth has become so popular that it is approaching a public health crisis,” explain the authors. “Fast on its heels is the recent rapid rise in vaping marijuana. In fact, more youth use marijuana, including vaping it, than currently smoke cigarettes. We have got to get this under control, and the first step in doing so is to know the facts.”

Dr. Nayeri and Dr. Middlekauff evaluate:

  • Evolution in devices and nicotine delivery of ECs
  • Cardiovascular effects of nicotine
  • Non-nicotine constituents and byproducts and biomarkers of cardiovascular risk
  • Effects of ECs on hemodynamics, arrhythmogenicity, oxidative stress and Inflammation, thrombogenesis, and vascular health
  • ECs as effective tools to reduce tobacco smoking
  • Public health implications of tobacco smoking versus vaping
  • Emergence of pod-like devices
  • EVALI (EC, or vaping, product use associated lung injury)

It has been calculated that 1.6 to 6.6 million American lives could be saved over 10 years by switching from TCs to ECs. However, the authors point out that the long-term risks of ECs are still unknown and recommend use for the shortest effective time. They also note that fourth generation devices, “pods,” can deliver similar amounts of nicotine as combustible cigarettes by employing “nicotine salts.” Each pod may contain a nicotine load equivalent to a pack of cigarettes, and thus may pose a greater risk of addiction to non-smokers than earlier generation devices. On the other hand, these pod-like devices replicate the nicotine delivery of combustible cigarettes, and thus may have more appeal to smokers addicted to nicotine who want to quit tobacco cigarettes.

The authors point out that smoking one to three cigarettes a day has almost the same cardiovascular risk as smoking one to three packs per day, so using ECs to cut down on smoking (rather than eliminate it) is not an effective strategy. Therefore, they recommend that TC smokers who want to quit and who have failed certified, conventional therapies may consider ECs, but should use them to replace TCs completely.

“Only with great caution and after exhausting all other smoking cessation strategies should we consider recommending that our TC smoking patients switch to ECs,” comments Dr. Nayeri. “Switching to unregulated ECs, with all their promise as smoking cessation devices, may lead to unforeseen, potentially fatal consequences. As currently marketed without quality control, ECs are no panacea,” caution the authors.

Since ECs are not harmless, non-smokers, especially adolescents and young adults, should not use them, say the authors. “The direct marketing to young never smokers and the development of thousands of dessert and candy flavored liquids have unconscionably attracted millions of children to try them,” notes Dr. Middlekauff. To discourage young non-smokers from vaping, the authors propose that flavors should be banned, public health anti-vaping campaigns should be supported, and laws and regulations restricting their availability to young people should be passed and strictly enforced. They also strongly recommend that people should stay away from bootlegged or black-market nicotine- or marijuana-based EC products.

“Look before you leap,” writes Andrew L. Pipe, CM, MD, Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada, in an accompanying editorial.

Dr. Pipe points out that despite limited evidence to support the use of electronic nicotine delivery systems (ENDS) for smoking cessation in recent clinical studies, evidence of successful cessation in “real world” settings is not apparent. “Nonetheless, the use of ENDS containing known quantities of nicotine and limited flavoring might facilitate their use for smoking cessation, however, in the absence of appropriate product regulation such clinical use is unlikely in the near future.”

Commenting on the policy vacuum in Canada that allowed the virtually unregulated entry of ENDS into Canada in contrast to the situation in other jurisdictions, Dr. Pipe notes the government’s lack of consideration of their attractiveness to youth and limited regulation of their content, marketing and merchandising, contributing factors to widespread use and abuse of ENDS in Canada. Outcries from parents, educators, clinicians, and health organizations like the Heart and Stroke Foundation of Canada are now resulting in regulatory proposals.

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Germany halts AstraZeneca jabs over reported clot risks: ministry

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Credit: Pixabay/CC0 Public Domain

Germany on Monday halted the use of AstraZeneca’s coronavirus vaccine after reported blood clotting incidents in Europe, saying that a closer look was necessary.

“After new reports of thromboses of the cerebral veins in connection with the vaccination in Germany and Europe, the PEI considers further investigations to be necessary,” the health ministry said, referring to a recommendation by the country’s vaccine authority, the Paul Ehrlich Institute.

“The European Medicines Agency EMA will decide whether and how the new findings will affect the approval of the vaccine,” it added.

Several European countries, including Ireland and the Netherlands, have suspended usage of the shots, which were jointly developed with the University of Oxford.

German Health Minister Jens Spahn said seven cases of cerebral vein thrombosis had been reported, and that while this is a “very low risk” compared to the 1.6 million jabs already given in the country, it would be above average if confirmed to be linked to the vaccine.

“The decision today is a purely precautionary measure,” said Spahn, adding that he hoped EU medicines regulator EMA would deliver guidance within the week after examining the cases.

Both the British-Swedish company and Oxford have said there was no link between their vaccine and blood clotting.

AstraZeneca had said at the weekend that the 15 incidences of deep vein thrombosis (DVT) and 22 events of pulmonary embolism reported among those given the vaccine was “much lower than would be expected to occur naturally in a general population”.

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Not recommending the AstraZeneca vaccine for the elderly risks the lives of the most vulnerable

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Regulators in Europe are at odds over whether the Oxford/AstraZeneca vaccine should be given to the elderly. In the UK, the vaccine has been approved for use in adults aged 18 and up, but France, Germany, Sweden and Austria say the vaccine should be prioritized for those under the age of 65. Poland only recommends it for those younger than 60. Italy goes one step further and only recommends it for those 55 and younger.

It is only ethical to approve a vaccine if it is safe and effective. Crucially, the reluctance to approve the AstraZeneca vaccine in the elderly is grounded only in concerns about its efficacy.

The concern is not that there is data showing the vaccine to be ineffective in the elderly, it’s that there is not enough evidence to show that it is effective in this age group. The challenge is in how we manage the degree of uncertainty in the efficacy of the vaccine, given the available evidence.

So how much data is there? The interim results from the AstraZeneca vaccine study pooled data from over 11,000 participants who received two doses of either the AstraZeneca vaccine or a placebo. A further report shows that only 660 participants were aged over 65, and there were only two cases of COVID in this group. Because of the low numbers, the authors of the study conclude that the efficacy of the vaccine in the elderly could not be determined. In comparison, the published Pfizer vaccine study included nearly 38,000 participants; around 16,000 of them were aged over 55.

There is also data about the extent to which the AstraZeneca vaccine generates an immune response. A study analyzed whether the vaccine provoked an immune response in 560 participants, including 400 participants over the age of 55. Early phase human trials found that the vaccine elicited a similar immune response across all age groups after the second dose. Although this isn’t proof that the vaccine prevents symptomatic disease, it suggests that the vaccine has an important effect in the elderly.

An ethical rather than scientific disagreement

The disagreement about whether to recommend the vaccine for the elderly concerns an ethical rather than a scientific question, namely, what standard of evidence do we need to establish the efficacy of a vaccine before approving it for use in a pandemic?

The more evidence available, the greater the certainty that regulators can have that a vaccine works, and about which distribution strategies will maximize its public health benefit. But gathering evidence takes time. The higher the standard, the greater the delay before people can access the intervention. In the pandemic, this trade-off is particularly acute. Time here is lives.

Consider the following rough calculations based on publicly available statistics. According to data from the Office for National Statistics, from November 28 2020 to January 1 2021, there were 14,633 COVID-related deaths in the UK. Only 1,351 of those deaths were in the 20-64 age group; 13,280 were in people over 65.

Imagine that the UK had been able to fully vaccinate all of those between the ages of 20-64 before November 28 2020 with a vaccine that was 95% effective. Assume that preventing infection with coronavirus would have been enough to avoid all of the above deaths. On this assumption, the vaccine could have been expected to prevent 1,283 of the deaths that occurred in the 20-64 age band.

Suppose now that we could also have vaccinated all of those over the age of 65 with this vaccine, but that there was limited data about how effective it would be in the elderly. Here is the crucial point: for it to save a same number of lives (1,283) in those over 65, the vaccine would need to be just shy of 10% effective, given the far higher mortality in the elderly.

This is generously assuming that the vaccine is very effective below the age of 65. If the vaccine was 70% effective in the 20-64 age band, then it would need to be only 7.1% effective in the elderly to be expected to save an equivalent number of lives (946 in this case).

Here’s another example. A recent study suggests the average risk of death for 60- to 64-year-olds infected with coronavirus is 0.46%. For a person aged 80 or older, the risk is 8.3%. Again, assume generously that a vaccine is 95% effective in 60- to 64-year-olds. That means for every 1,000 people vaccinated in this group who would have become infected, the vaccine would save 4.3 lives. How effective would a vaccine need to be in those aged 80 and older to still save the same number of lives? 5.2%.

We are not suggesting that the effectiveness of the AstraZeneca vaccine in the elderly is this low, nor that regulators should approve a vaccine as ineffective as this imaginary one. The World Health Organization has stipulated a minimum efficacy of 50% for COVID-19 vaccines. But these examples show how important it is to consider the limitations of efficacy (or its evidence) with the actual mortality risk faced by people in the absence of a vaccine.

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Why COVID-19 poses greater risks for men than women

While it’s not exactly clear why, the finding itself is certain: Men are suffering worse fates than women when it comes to COVID-19, regardless of geography or age. A variety of data from outbreaks across the world has established this fact, and experts like Johns Hopkins biologist Sabra Klein are trying to understand more.

Last month, Klein contributed to a viewpoint in the Journal of Critical Investigations calling for broader study of how biological sex differences between men and women affect outcomes with COVID-19—which she and colleagues believe should be a significant consideration for developing effective treatments and vaccines.

Earlier this week, Klein joined fellow Johns Hopkins University researchers in for a webinar exploring sex and gender dimensions of coronavirus. That talk was hosted by two research units Klein co-chairs, the Center for Women’s Health, Sex, and Gender and a specialized center under the National Institutes of Health that studies sex and age differences in influenza immunity.

The Hub reached out to Klein for more insights on what the scientific community knows so far about the different outcomes between men and women who contract COVID-19.

What is the evidence showing different outcomes for men and women who contract COVID-19?

Around the world, on every continent, we’re observing that men are significantly more likely to be hospitalized with severe COVID-19, and men are also significantly more likely to die from COVID-19. Some studies are showing the risks are twofold for men. Women are contracting the virus at same rates as men, but they are more likely to recover.

Because these findings are cutting across social and cultural boundaries, that strongly suggests the biological difference between males and females is contributing. That likely doesn’t tell the full story, however—social and lifestyle factors may certainly be influencing the trends, but we need to understand more.

What might be the possible explanations for the discrepancy?

I am hypothesizing that because women typically have a more rapid and robust immune response to viruses than men, this may be one factor contributing to female-biased protection against SARS-CoV-2, the virus that causes COVID-19. There are data from early outbreaks in Wuhan, China, for example, that show women clear the virus more quickly than men.

A sex difference in immune responses that control and clear SARS-CoV-2 suggests there there’s a difference between sexes affecting immunity. We have data for other viruses illustrating that sex differences in immunity are caused by genetic as well as hormonal differences between women and men. For example, in females, hormones such as estrogen and progesterone may be protective against the virus, and it’s possible testosterone does the opposite for men.

Scientists are also looking into the role of the ACE-2 receptor, which is found on the cells lining the lung and airways and is used by the SARS-CoV-2 virus to enter cells. From what we know about this receptor, from other conditions such as hypertension and kidney disease, ACE-2 expression is greater in males than in females. We also know from work in the kidneys that estrogen downregulates the expression of ACE-2,which could be a plausible biological explanation for reduced severity of the virus in women.

How is the factor of age overlapping with all of this?

It turns out the male bias severity is happening across a diverse range of ages. A very large JAMA study on cases in New York City, for example, looked at ages 30 through 90, and found that males were significantly more likely to be hospitalized or die regardless of age. Another study in The Lancet examining ages 20 upwards in European countries also shows this trend across ages. What we’re seeing in ages 60 years and older is that this is where we find the most severe outcomes of death.

You said that social and cultural factors may also be playing a role.

My colleague Rosemary Morgan, in international health, is studying this; she specializes in gender-associated factors that impact health and disease, including COVID-19. We know that biological differences are only part of the story of what make men and women different. It also has to do with our behavior and even the social and cultural norms that define our roles and responsibilities. For example, females may be more likely to be frontline workers, which could create more risks for exposure. In terms of lifestyle, men tend to be more likely to be smokers, which is a risk factor, and they’re less likely to seek out medical care when there’s a problem. And with COVID-19, if men are less likely to engage in behaviors like mask-wearing and hand-washing, that may increase risks.

There are also underlying conditions such as hypertension, heart disease, and diabetes, which men are statistically more likely to have and some of which can be attributed to lifestyle factors, that also amplify risks with COVID-19.

What are the implications of all of this for treatment and vaccines?

As my colleagues and I wrote in the Journal of Critical Investigations, we need to be ensuring a large prism of men and women take part in the numerous clinical trials for vaccines and we need to be able compare outcome data between men and women. Formulating vaccines should take into account the differences.

Vaccines are just one arm of how we’re addressing protections from COVID-19, however. Another is therapeutics. We have data from the past showing more adverse reactions for women than men with antiviral drugs, and it’s important to be aware of that. We don’t want the reaction to the drug to be worse than the condition it’s trying to treat.

What are you researching right now related to this issue?

I’m one of the partners working with Hopkins immunologist Arturo Casadevall on the promising treatment of convalescent plasma, which uses antibodies of recovered COVID-19 patients to boost immunity in others. Personally, that’s giving me lots of fabulous serological data to use to characterize differences between men and women in antibody responses to SARS-CoV-2.

My colleague Sean Leng at the School of Medicine and I have also won a grant to study differences in immune responses to the virus in older adults, the people who are most at risks of severe outcomes.

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