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Managing cardiovascular disease often requires the ability to identify the many pieces contributing to the disease and its outcomes much like a jigsaw puzzle that only reveals a picture when the pieces are properly placed together.
Like any good detective, cardiologists continually study the patterns of presentation and admissions to hospitals for cardiovascular events in an attempt to decipher a code that could lead to preventing those admissions. A recent article published in the Journal of the American Heart Association sought to describe what men and women are presenting to the emergency department with, when they come for cardiovascular care.
As might be expected, the authors found striking differences in how and for what reasons men and women present to the hospital with cardiovascular complaints. For instance, women more commonly present with essential hypertension (16% of admissions), followed by hypertensive heart or kidney disease (14.1%), and finally atrial fibrillation/flutter (10.2%).1 Men most often presented with hypertensive heart or kidney disease (14.7%), followed by essential hypertension (10.8%), and then myocardial infarction (10.7%).1 We see in these data that men are at higher risk of presenting with conditions that affect the heart while women were more likely to have conditions that affect the blood vessels of the brain.1
Looking at risk allows us to target areas for intervention prior to presenting with cardiovascular events. It appears that women are at lower risk overall for admission with a cardiovascular event but also had an elevated risk for dying from the specific diseases they present with, most notably stroke.1 Mamas Mamas, BMBCh, DPhil, the lead author of this study points out that sex differences and cardiovascular risk have long been known, however, this large sample of patients provides a more a more detailed understanding of sex disparities in hospitalization and the cumulative risk for death.1
While sex disparities are important, we are seeing an increasing number of new factors that have unknown contributions to the burden of disease our patients realize. For instance, we know that the earth is in a warming phase and more and more extreme weather events are occurring and with greater frequency than previously reported. Kidney disease and cardiovascular disease have long been associated with each other. Now, in light of changing weather patterns, researchers have become interested in the impact of increasing temperatures on emergency department visits.
Yanji Qu, MD, PhD, and Wangjian Zhang, MD, PhD, recently published an article in the American Journal of Kidney Diseases examining the link between emergency visits and extreme ambient heat in New York. Extreme heat was defined as a daily temperature exceeding the 90th percentile for that month.2 They found that extreme heat exposure was significantly associated with increased risk for emergency visits for acute kidney injury, kidney stones, and urinary infections.2 While not specifically looking at cardiovascular disease this is one of the first investigations looking at environmental heat and hospital visits.
It is convenient to simply think of heat stroke or dehydration as consequences of rising summer temperatures, especially in urban settings. However, heat is associated with many health problems from respiratory distress to increased coronary oxygen demand. More study must be done beyond the renal literature to identify those at risk for poor outcomes related to climate change. Increasing awareness is an important first step. At risk patients can be targeted for community outreach and efforts to provide cooler home environments. Telemedicine has become a regular part of practice since COVID-19 and could be employed to prevent exposure to the elements in the future.
In the 2 studies reviewed here, we see several patient characteristics that appear unrelated. The truth is that sex, environment, cardiovascular disease, and kidney health, are likely related on many levels. It is our job as clinicians and researchers to put the puzzle pieces together so that the picture becomes clear enough to make a difference in our patients lives.