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      Cardiovascular Risk and Statin Therapy Considerations in Women


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          Despite major progress in the prevention and treatment of cardiovascular diseases, women remain an underdiagnosed and insufficiently treated group, with higher hospitalization and death rates compared to men. Obesity, more frequently encountered in women, raises the risk of metabolic syndrome and cardiovascular diseases as women age. There are some differences based on sex regarding the screening, diagnosis, and treatment of dyslipidemia, as it has been observed that women are less frequently prescribed statins and, when they are, they receive lower doses, even after myocardial infarction or coronary revascularization. Real-life data show that, compared to men, women are at higher risk of non-adherence to statin treatment and are more predisposed to discontinue treatment because of side effects. Statin metabolism has some particularities in women, due to a lower glomerular filtration rate, higher body fat percentage, and overall faster statin metabolism. In women of fertile age, before initiating statin treatment, contraception methods should be discussed because statins may have teratogenic effects. Older women have a higher likelihood of polypharmacy, with greater potential for drug interactions when prescribing a statin.

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          Diabetes and cardiovascular disease. The Framingham study.

          Based on 20 years of surveillance of the Framingham cohort relating subsequent cardiovascular events to prior evidence of diabetes, a twofold to threefold increased risk of clinical atherosclerotic disease was reported. The relative impact was greatest for intermittent claudication (IC) and congestive heart failure (CHF) and least for coronary heart disease (CHD), which was, nevertheless, on an absolute scale the chief sequela. The relative impact was substantially greater for women than for men. For each of the cardiovascular diseases (CVD), morbidity and mortality were higher for diabetic women than for nondiabetic men. After adjustment for other associated risk factors, the relative impact of diabetes on CHD, IC, or stroke incidence was the same for women as for men; for CVD death and CHF, it was greater for women. Cardiovascular mortality was actually about as great for diabetic women as for diabetic men.
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            Tobacco Product Use and Cessation Indicators Among Adults — United States, 2018

            Cigarette smoking is the leading cause of preventable disease and death in the United States ( 1 ). The prevalence of adult cigarette smoking has declined in recent years to 14.0% in 2017 ( 2 ). However, an array of new tobacco products, including e-cigarettes, has entered the U.S. market ( 3 ). To assess recent national estimates of tobacco product use among U.S. adults aged ≥18 years, CDC, the Food and Drug Administration (FDA), and the National Cancer Institute analyzed data from the 2018 National Health Interview Survey (NHIS). In 2018, an estimated 49.1 million U.S. adults (19.7%) reported currently using any tobacco product, including cigarettes (13.7%), cigars (3.9%), e-cigarettes (3.2%), smokeless tobacco (2.4%), and pipes* (1.0%). Most tobacco product users (83.8%) reported using combustible products (cigarettes, cigars, or pipes), and 18.8% reported using two or more tobacco products. The prevalence of any current tobacco product use was higher in males; adults aged ≤65 years; non-Hispanic American Indian/Alaska Natives; those with a General Educational Development certificate (GED); those with an annual household income 30% that are not presented. ††† Hispanic persons could be of any race. All other racial/ethnic groups were non-Hispanic. §§§ Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. ¶¶¶ Based on income variables from the family file (n = 8,310 missing valid income data). Imputed income files were not used in this analysis. **** Private coverage: includes adults who have any comprehensive private insurance plan (including health maintenance organizations and preferred provider organizations). Medicaid: for adults aged 30%; neither daily use nor nondaily use is presented. The figure is a bar chart showing the prevalence of daily and nondaily use of selected tobacco products among adults aged ≥18 years who currently use each tobacco product, in the United States, during 2018. The prevalence of any current tobacco product use was higher among males (25.8%) than among females (14.1%) and among persons aged 25–44 years (23.8%), 45–64 years (21.3%), and 18–24 years (17.1%) than among those aged ≥65 years (11.9%) (Table). Current tobacco product use was also higher among non-Hispanic American Indian/Alaska Native adults (32.3%), non-Hispanic multiracial adults (25.4%), non-Hispanic whites (21.9%), non-Hispanic blacks (19.3%), and Hispanic adults (13.8%) than among non-Hispanic Asian adults (10.0%), as well as among those who lived in the Midwest (23.6%) or the South U.S. Census regions (21.4%) than among those who lived in the West (15.3%) or the Northeast (17.5%). The prevalence of current tobacco product use was also higher among persons who had a GED (41.4%) than among those with other levels of education and among those who were divorced, separated, or widowed (22.6%) or single, never married, or not living with a partner (21.1%) than among those married or living with a partner (18.4%). Current tobacco product use was higher among persons with an annual household income 1 day during the past 12 months because they were trying to quit smoking and former smokers who quit during the past year. † Percentage of former cigarette smokers who quit smoking for ≥6 months during the past year, among current smokers who smoked for ≥2 years and former smokers who quit during the past year. § Percentage of persons who ever smoked (≥100 cigarettes during lifetime) who have quit smoking. The figure is a line chart showing the prevalence of past-year quit attempts and recent cessation and quit ratio among cigarette smokers aged ≥18 years, in the United States, during 2009–2018. Discussion The approximate two thirds decline in adult cigarette smoking prevalence that has occurred since 1965 represents a major public health success ( 1 ). In 2018, 13.7% of U.S. adults aged ≥18 years currently smoked cigarettes, the lowest prevalence recorded since 1965. However, no significant change in cigarette smoking prevalence occurred during 2017–2018. Most cigarette smokers and smokeless tobacco users reported daily use, whereas most e-cigarette and cigar users reported nondaily use. Even nondaily use of cigarettes has been linked to increased mortality risk ( 6 ). Quitting smoking at any age is beneficial for health ( 1 , 4 ). During 2009–2018, significant linear increases occurred in quit attempts, recent successful cessation, and quit ratio. Population-based tobacco control interventions, including high-impact tobacco education campaigns like CDC’s Tips From Former Smokers (https://www.cdc.gov/tobacco/campaign/tips/index.html) campaign and FDA’s Every Try Counts campaign (https://www.fda.gov/tobacco-products/every-try-counts-campaign), combined with barrier-free access to evidence-based cessation treatments, can both motivate persons who use tobacco products to try to quit and help them succeed in quitting. The prevalence of adult e-cigarette use increased from 2.8% in 2017 to 3.2% in 2018 but was much lower than the 20.8% ( 7 ) of U.S. high school students reporting past 30-day e-cigarette use in 2018. The prevalence of e-cigarette use among persons aged 18–24 years is higher than that among other adult age groups, and e-cigarette use in this age group increased from 5.2% in 2017 ( 2 ) to 7.6% in 2018. During 2014–2017 there had been a downward trajectory of adult e-cigarette use ( 2 , 8 ), but during 2017–2018 a significant increase in adult e-cigarette use was detected for the first time. This increase might be related to the emergence of new types of e-cigarettes, especially “pod-mod” devices, which frequently use nicotine salts as opposed to the free-base nicotine used in other e-cigarettes and tobacco products. Sales of JUUL, a pod-mod device, increased by approximately 600% from 2016 to 2017, making it the dominant e-cigarette product in the United States by the end of 2017 ( 9 ). Further research is needed to monitor patterns of e-cigarette use and the relationship between use of e-cigarettes and other tobacco products (e.g., cigarette smoking). The findings in this report are subject to at least three limitations. First, responses were self-reported and were not validated by biochemical testing. However, self-reported smoking status correlates highly with serum cotinine levels ( 10 ). Second, because NHIS is limited to the noninstitutionalized U.S. civilian population, the results are not generalizable to institutionalized populations and persons in the military. Finally, the NHIS Sample Adult response rate of 53.1% might have resulted in nonresponse bias. Coordinated efforts at the local, state, and national levels are needed to continue progress toward reducing tobacco-related disease and death in the United States. Proven strategies include implementation of tobacco price increases, comprehensive smoke-free policies, high-impact antitobacco media campaigns, barrier-free cessation coverage, and comprehensive state tobacco control programs, combined with regulation of the manufacturing, marketing, and distribution of all tobacco products ( 1 , 4 ). Summary What is already known about this topic? Cigarette smoking is the leading cause of preventable disease and death in the United States. Adult cigarette smoking prevalence has declined; however, new tobacco products, including e-cigarettes, have entered the U.S. market. What is added by this report? In 2018, approximately 20% of U.S. adults currently used any tobacco product; cigarette smoking reached an all-time low (13.7%). During 2009–2018, significant increases in three cigarette cessation indicators occurred. During 2017–2018, e-cigarette and smokeless tobacco product use prevalence increased. What are the implications for public health practice? Continued surveillance is critical to informing tobacco control efforts at the national, state, and local levels. Coordinated efforts and regulation of all tobacco products are needed to reduce tobacco-related disease and death in the United States.
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              Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength?

              Diabetes mellitus is a chronic condition that occurs when the body cannot produce enough or effectively use of insulin. Compared with individuals without diabetes, patients with type 2 diabetes mellitus have a considerably higher risk of cardiovascular morbidity and mortality, and are disproportionately affected by cardiovascular disease. Most of this excess risk is it associated with an augmented prevalence of well-known risk factors such as hypertension, dyslipidaemia and obesity in these patients. However the improved cardiovascular disease in type 2 diabetes mellitus patients can not be attributed solely to the higher prevalence of traditional risk factors. Therefore other non-traditional risk factors may be important in people with type 2 diabetes mellitus. Cardiovascular disease is increased in type 2 diabetes mellitus subjects due to a complex combination of various traditional and non-traditional risk factors that have an important role to play in the beginning and the evolution of atherosclerosis over its long natural history from endothelial function to clinical events. Many of these risk factors could be common history for both diabetes mellitus and cardiovascular disease, reinforcing the postulate that both disorders come independently from "common soil". The objective of this review is to highlight the weight of traditional and non-traditional risk factors for cardiovascular disease in the setting of type 2 diabetes mellitus and discuss their position in the pathogenesis of the excess cardiovascular disease mortality and morbidity in these patients.

                Author and article information

                Diagnostics (Basel)
                Diagnostics (Basel)
                16 July 2020
                July 2020
                : 10
                : 7
                : 483
                [1 ]Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; gheorghe_gina2000@ 123456yahoo.com (G.G.); drmadalina@ 123456gmail.com (M.I.)
                [2 ]Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; peter.toth@ 123456cghmc.com
                [3 ]Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania
                [4 ]Chitkara College of Pharmacy, Chitkara University, Punjab 140401, India; tapanbehl31@ 123456gmail.com
                [5 ]Gastroenterology Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
                [6 ]Department 2, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; ancastoian@ 123456yahoo.com
                [7 ]Department 3, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; ovi78doc@ 123456yahoo.com
                [8 ]Department of Surgery, “Ion Cantacuzino” Clinical Hospital, 030167 Bucharest, Romania; nicolae_bacalbasa@ 123456yahoo.ro
                [9 ]Department 13, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
                [10 ]Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; rusmariusr@ 123456yahoo.com
                [11 ]Internal Medicine Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
                Author notes
                [* ]Correspondence: sbungau@ 123456uoradea.ro (S.B.); drcameliadiaconu@ 123456gmail.com (C.C.D.); Tel.: + 40-726-776-588 (S.B.); + 40-726-377-300 (C.C.D.)

                These authors contributed equally to this work.

                Author information
                © 2020 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                : 08 June 2020
                : 12 July 2020

                cardiovascular risk factors,dyslipidemia,myopathy,statin,women


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