Sex Disparities in Post-Acute Myocardial Infarction Pharmacologic Treatment Initiation and Adherence: Problem for Young Women

BACKGROUND

The prevalence of the use of secondary prevention cardiovascular medications is lower among women than men, but it is unclear if this is a result of lower treatment initiation among women or lower treatment adherence. We aimed to map the treatment pathway for survivors of acute myocardial infarction (AMI) by sex and age.

METHODS AND RESULTS

This retrospective population-based cohort study used linked administrative data sets in British Columbia (2004-2011), which include health care, prescription drugs, sociodemographic, and mortality information. The study cohort included all individuals admitted to hospital for AMI in 2007-2009 and survived for 1 year after hospital discharge. Patients were evaluated for whether they initiated and then subsequently filled prescriptions angiotensin-converting enzyme inhibitors, β-blockers, and statins. More than two thirds of AMI survivors initiated treatment on all appropriate medications, given their contraindications, within 2 months of discharge. Younger men were significantly more likely than younger women to initiate appropriate treatment (adjusted odds ratio, 1.38; 95% confidence interval, 1.10-1.75). By the end of 1 year after discharge, only one third of all AMI survivors filled all appropriate prescriptions for at least 80% of the year. There was no significant difference in adherence to medication therapy between women and men.

CONCLUSIONS

The majority of AMI survivors either discontinue treatment or do not refill their prescriptions consistently. Women <55 years are significantly less likely to be on optimal therapy by the end of 1 year after discharge, which is driven by a sex disparity in treatment initiation and not treatment adherence.

Spontaneous Coronary Artery Dissection Misdiagnosed as Takotsubo Cardiomyopathy: A Case Series

Spontaneous coronary artery dissection (SCAD) and Takotsubo cardiomyopathy (TTC) can both cause myocardial infarction with subsequent normalization of wall motion abnormality. Angiograms of patients with TTC at Vancouver General Hospital were reviewed for SCAD. Clinical and investigational characteristics were recorded. Nine women with nonatherosclerotic SCAD were misdiagnosed as having TTC. Their average age was 55 years. Five patients had hypertension and 4 had emotional or physical stress. Fibromuscular dysplasia was present in 4 women. Wall motion abnormalities corresponded to dissected artery location and subsequently resolved. SCAD should be included in the differential diagnosis of patients suspected of having TTC and coronary angiograms scrutinized for subtle SCAD.

Effect of gender after transcatheter aortic valve implantation: a meta-analysis

BACKGROUND

The effect of gender on patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) remains to be defined.

METHODS

MEDLINE, Cochrane Library, and Scopus databases were searched for articles describing sex differences in baseline characteristics, procedures, and outcomes. All-cause death at follow-up of at least 1 year was the primary end point, and the independent effect of female gender was evaluated with pooled analysis using a random-effect model and with meta-regression.

RESULTS

Six studies with 6,645 patients were included, half of them being women presenting with lower European System for Cardiac Operative Risk Evaluation (EuroSCORE) compared with men. At 30 days, more frequent major vascular complications and major and life-threatening bleeding occurred in women, with lower rates of moderate to severe aortic regurgitation, whereas 30-day mortality was similar. After a median follow-up of 365 days (range, 365 to 730 days) all-cause mortality was 24.0% in women and 34.0% in men. A pooled analysis of the multivariable approach found female gender was significantly related to a lower risk of death (odds ratio, 0.82; 95% CI, confidence interval, 0.73 to 0.93; I(2) = 0%). A meta-regression analysis showed age, ejection fraction, previous cardiovascular accident, renal insufficiency, and access site did not influence these data.

CONCLUSIONS

Female patients undergoing TAVI present with a lower burden of comorbidities. The counterbalance between higher rates of vascular complications but lower of valve regurgitation may explain the reduced risk for women after TAVI, independently from baseline features and access site.

Outcomes and transfer patterns for first Non-ST-elevation myocardial infarction (NSTEMI): comparisons between community and tertiary care hospitals

BACKGROUND

Transfer patterns, procedure rates, and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI) presenting to Canadian community hospitals are not well understood.

METHODS

We documented all patients admitted to British Columbia (BC) hospitals with a primary diagnosis of NSTEMI between 2007 and 2008. Patients were divided by admitting hospital type into tertiary care hospitals, nonremote community hospitals, and remote community hospitals. The aims were to compare transfer rates and time to transfer to a tertiary hospital as well as procedure rates and outcomes at index admission, at 30 days, and at 1 year.

RESULTS

The mean transfer rates to a tertiary hospital were 72.6% for nonremote and 57.1% for remote community hospitals (P < 0.001). Times to and rates of cardiac procedures differed significantly among these 3 hospital types. Admission to a nonremote or remote community hospital was associated with similar 1-year mortality compared with admission to a tertiary care hospital (nonremote hospitals, adjusted odds ratio [OR], 0.87; P = 0.26; remote hospitals, adjusted OR, 1.19; P = 0.33). At 1 year, admission to a nonremote community hospital was associated with a lower composite outcome of death or readmission for acute myocardial infarction (AMI) (adjusted OR, 0.80; P = 0.04).

CONCLUSIONS

One-year mortality rates were not different between patients with NSTEMI admitted to BC community and tertiary care hospitals; however, the rate of readmission for AMI/death was significantly less in patients admitted to nonremote community hospitals. This should prompt the evaluation of key outcomes in NSTEMI in other community hospital settings.

Health-related quality of life in premature acute coronary syndrome: does patient sex or gender really matter?

Background

Limited data exist as to the relative contribution of sex and gender on health‐related quality of life (HRQL) among patients with acute coronary syndrome (ACS). This study aims to evaluate the effect of sex and gender‐related variables on long‐term HRQL among young adults with ACS.

Methods and Results

GENESIS‐PRAXY (GENdEr and Sex determInantS of cardiovascular disease: from bench to beyond‐Premature Acute Coronary SYndrome) is a multicenter, prospective cohort study (January 2009 to August 2013) of adults aged 18 to 55 years, hospitalized with ACS. HRQL was measured at baseline, 1, 6, and 12 months using the Short Form‐12 and Seattle Angina Questionnaire (SAQ) among 1213 patients. Median age was 49 years. Women reported worse HRQL than men over time post‐ACS, both in terms of physical and mental functioning. Gender‐related factors were more likely to be predictors of HRQL than sex. Femininity score, social support, and housework responsibility were the most common gender‐related predictors of HRQL at 12 months. We observed an interaction between female sex and social support (β=0.44 [95% confidence interval, 0.01, 0.88]; P=0.047) for the physical limitation subscale of the SAQ.

Conclusions

Young women with ACS report significantly poorer HRQL than young men. Gender appears to be more important than sex in predicting long‐term HRQL post‐ACS. Specific gender‐related factors, such as social support, may be amenable to interventions and could improve the HRQL of patients with premature ACS.

Sex-specific factors in microvascular angina

In women presenting for evaluation of suspected ischemic symptoms, a diagnosis of normal coronary arteries is 5 times more common than it is in men. These women are often labelled as having cardiac syndrome X, and a subset of them have microvascular angina caused by microvascular coronary dysfunction (MCD). MCD is not benign and is associated with an annual 2.5% cardiac event rate. Noninvasive testing for MCD remains insensitive, although newer imaging modalities, such as adenosine cardiac magnetic resonance imaging, appear promising. The gold standard for diagnosis of MCD is coronary reactivity testing, an invasive technique that is not available in many countries. With regard to treatment, large-scale trials are lacking. Although research is ongoing, the current platform of therapy consists of antiangina, antiplatelet, and endothelium-modifying agents (primarily angiotensin-converting enzyme inhibitors and statins).

Sex-related differences in access to care among patients with premature acute coronary syndrome

BACKGROUND

Access to care may be implicated in disparities between men and women in death after acute coronary syndrome, especially among younger adults. We aimed to assess sex-related differences in access to care among patients with premature acute coronary syndrome and to identify clinical and gender-related determinants of access to care.

METHODS

We studied 1123 patients (18-55 yr) admitted to hospital for acute coronary syndrome and enrolled in the GENESIS-PRAXY cohort study. Outcome measures were door-to-electrocardiography, door-to-needle and door-to-balloon times, as well as proportions of patients undergoing cardiac catheterization, reperfusion or nonprimary percutaneous coronary intervention. We performed univariable and multivariable logistic regression analyses to identify clinical and gender-related determinants of timely procedures and use of invasive procedures.

RESULTS

Women were less likely than men to receive care within benchmark times for electrocardiography (≤ 10 min: 29% v. 38%, p = 0.02) or fibrinolysis (≤ 30 min: 32% v. 57%, p = 0.01). Women with ST-segment elevation myocardial infarction (MI) were less likely than men to undergo reperfusion therapy (primary percutaneous coronary intervention or fibrinolysis) (83% v. 91%, p = 0.01), and women with non-ST-segment elevation MI or unstable angina were less likely to undergo nonprimary percutaneous coronary intervention (48% v. 66%, p < 0.001). Clinical determinants of poorer access to care included anxiety, increased number of risk factors and absence of chest pain. Gender-related determinants included feminine traits of personality and responsibility for housework.

INTERPRETATION

Among younger adults with acute coronary syndrome, women and men had different access to care. Moreover, fewer than half of men and women with ST-segment elevation MI received timely primary coronary intervention. Our results also highlight that men and women with no chest pain and those with anxiety, several traditional risk factors and feminine personality traits were at particularly increased risk of poorer access to care.

Do younger women fare worse? Sex differences in acute myocardial infarction hospitalization and early mortality rates over ten years

BACKGROUND

Recent research has identified younger women as an "at-risk" population with rising prevalence of cardiac risk factors and excess mortality risk following acute myocardial infarction (AMI). However, population-based data on trends in AMI hospitalization and early mortality post AMI among younger adults is scarce. We, therefore, aimed to provide a 10-year, descriptive analysis of these trends in a Canadian setting.

METHODS AND RESULTS

We assessed trends and sex differences in AMI hospitalization and 30-day mortality rates using negative binomial and logistic regression, respectively. From 2000 to 2009, there were 70,628 AMI hospitalizations in adults aged ≥20 years, in British Columbia, Canada, with 17.1% of cohort being younger adults ≤55 years. Overall, age-standardized AMI rates (per 100,000 population) declined similarly in men (295.8 to 247.7) and women (152.1 to 128.8) [sex-year interaction p=0.81]. However, these trends differed according to age (age-sex-year interaction p=0.02) with increased rates observed only in younger women (+1.7% per year; p=0.04). The 30-day mortality rates declined similarly for women (19.4% to 13.9%) and men (13.0% to 9.3%) (sex-year interaction p=0.33). Yet, younger women continued to have excess mortality risk, compared with younger men, even in the most recent period [odds ratio: (2008-09)=1.61 (95% onfidence interval: 1.25, 2.08)].

CONCLUSION

While the overall AMI hospitalization and 30-day mortality rates significantly declined in women and men, hospitalization rates in women ≤55 years increased and their excess risk of 30-day mortality persisted. These findings highlight the need to intensify strategies to reduce the incidence of AMI and improve outcomes after AMI in younger women.

Sex differences in clinical outcomes in patients with stable angina and no obstructive coronary artery disease

BACKGROUND

We comparatively evaluated clinical outcomes in men and women presenting with stable angina with no coronary artery disease (CAD), nonobstructive CAD, and obstructive CAD on coronary angiography.

METHODS

We studied all patients ≥20 years with stable angina, undergoing coronary angiography in British Columbia, Canada, from July 1999 to December 2002 (n = 13,695) with maximum follow-up to 3 years. No CAD, nonobstructive CAD, and obstructive CAD were defined as 0%, 1% to 49%, and ≥50% luminal narrowing in any epicardial coronary artery, respectively. Freedom from major adverse cardiac events (MACEs), which included the combined end points of all-cause mortality, nonfatal acute myocardial infarction, nonfatal stroke, and heart failure admissions, was estimated using the Kaplan-Meier method. Hazard ratios (HRs) and 95% CIs for MACE were estimated up to 3 years postcatheterization and compared between sex and CAD groups.

RESULTS

Within the first year, women with nonobstructive CAD had a higher risk of MACE than men with nonobstructive CAD (adjusted HR 2.43, 95% CI 1.08-5.49). Furthermore, women with nonobstructive CAD had a 2.55-fold higher risk of MACE than women with no CAD (95% CI 1.33-4.88). In contrast, men with nonobstructive CAD had a similar risk as men with no CAD (adjusted HR 0.61, 95% CI 0.26-1.45). The differences in MACE according to extent of CAD were not evident in the longer term.

CONCLUSIONS

Women with stable angina and nonobstructive CAD are 3 times more likely to experience a cardiac event within the first year of cardiac catheterization than men. A prospective trial to examine the impact of medical therapy on MACE in patients with nonobstructive CAD is warranted.

5-year outcome after transcatheter aortic valve implantation

OBJECTIVES

The purpose of this study was to investigate the 5-year outcome following transcatheter aortic valve implantation (TAVI).

BACKGROUND

Little is known about long-term outcomes following TAVI.

METHODS

The 5-year outcomes following successful TAVI with a balloon-expandable valve were evaluated in 88 patients. Patients who died within 30 days after TAVI were excluded.

RESULTS

Mean aortic valve gradient decreased from 46 ± 18 mm Hg to 10 ± 4.5 mm Hg after TAVI and 11.8 ± 5.7 mm Hg at 5 years (p for post-TAVI trend = 0.06). Mean aortic valve area increased from 0.62 ± 0.17 cm(2) to 1.67 ± 0.41 cm(2) after TAVI and 1.40 ± 0.25 cm(2) at 5 years (p for post-TAVI trend <0.01). At 5 years, 3 patients (3.4%) had moderate prosthetic valve dysfunction (moderate transvalvular regurgitation in 1, moderate stenosis in 1, and moderate mixed disease in 1). Survival rates at 1 to 5 years were 83%, 74%, 53%, 42%, and 35%, respectively. Median survival time after TAVI was 3.4 years (95% confidence interval [CI]: 2.6 to 4.3), and the risk of death was significantly increased in patients with chronic obstructive pulmonary disease (adjusted hazard ratio [HR]: 2.17; 95% CI: 1.28 to 3.70) and at least moderate paravalvular regurgitation (adjusted HR: 2.98; 95% CI: 1.44 to 6.17).

CONCLUSIONS

Our study demonstrated favorable long-term outcomes after TAVI. Signs of moderate prosthetic valve failure were observed in 3.4% of patients. No patients developed severe prosthetic regurgitation or stenosis. Comorbidities, notably chronic lung disease and at least moderate paravalvular regurgitation, were associated with reduced long-term survival.

Rhythm versus rate control therapy and subsequent stroke or transient ischemic attack in patients with atrial fibrillation

BACKGROUND

Stroke is a debilitating condition with an increased risk in patients with atrial fibrillation. Although data from clinical trials suggest that both rate and rhythm control are acceptable approaches with comparable rates of mortality in the short term, it is unclear whether stroke rates differ between patients who filled prescriptions for rhythm or rate control therapy.

METHODS AND RESULTS

We conducted a population-based observational study of Quebec patients ≥65 years with a diagnosis of atrial fibrillation during the period 1999 to 2007 with the use of linked administrative data from hospital discharge and prescription drug claims databases. We compared rates of stroke or transient ischemic attack (TIA) among patients using rhythm (class Ia, Ic, and III antiarrhythmics), versus rate control (β-blockers, calcium channel blockers, and digoxin) treatment strategies (either current or new users). The cohort consisted of 16 325 patients who filled a prescription for rhythm control therapy (with or without rate control therapy) and 41 193 patients who filled a prescription for rate control therapy, with a mean follow-up of 2.8 years (maximum 8.2 years). A lower proportion of patients on rhythm control therapy than on rate control therapy had a CHADS(2) (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and previous stroke or TIA) score of ≥2 (58.1% versus 67.0%, P<0.001). Treatment with any antithrombotic drug was comparable in the 2 groups (76.8% in rhythm control versus 77.8% in rate control group). Crude stroke/TIA incidence rate was lower in patients treated with rhythm control in comparison with rate control therapy (1.74 versus 2.49, per 100 person-years, P<0.001). This association was more marked in patients in the moderate- and high-risk groups for stroke according to the CHADS(2) risk score. In multivariable Cox regression analysis, rhythm control therapy was associated with a lower risk of stroke/TIA in comparison with rate control therapy (adjusted hazard ratio, 0.80; 95% confidence interval, 0.74, 0.87). The lower stroke/TIA rate was confirmed in a propensity score-matched cohort.

CONCLUSIONS

In comparison with rate control therapy, the use of rhythm control therapy was associated with lower rates of stroke/TIA among patients with atrial fibrillation, in particular, among those with moderate and high risk of stroke.

Elevation in cardiovascular disease risk in South Asians is mediated by differences in visceral adipose tissue

South Asians have a higher risk for cardiovascular disease (CVD) that remains largely unexplained. We hypothesized that the increased CVD risk in South Asians compared to Europeans is mediated through higher levels of visceral adipose tissue (VAT) in South Asians compared to total body fat and subcutaneous abdominal adipose tissue (SAT). South Asians (207) and Europeans (201) underwent assessment for demographics, body fat, and risk factors. Linear regression models were created by sex for each risk factor to explore mediation effects of total body fat, SAT, and VAT adjusted for age, income, smoking, and BMI (menopausal status for women). Mediation was based on changes in the ethnicity β coefficient due to additional adjustment for our adipose variable of interest and the Sobel test for mediation. South Asians had worse lipid, glucose, insulin, and C-reactive protein (CRP) levels than Europeans after adjusting for confounders. Most of these differences remained even after further adjustment by either total body fat or SAT. In contrast, VAT attenuated the ethnic differences in risk factors by 16%-52%. After adjusting for VAT, there were no longer ethnic differences in total cholesterol (TC), LDL-C, TC/HDL-C, glucose, and diastolic blood pressure (BP) in men, and in HDL-C, triglycerides (TG), TC/HDL-C, and homeostasis model (HOMA) in women, and VAT was a significant mediator for these risk factors. Higher levels of risk factors for CVD in South Asians are predominantly because of the unique phenotype of South Asians having greater VAT than Europeans even at the same BMI.

Sex differences in stroke risk among older patients with recently diagnosed atrial fibrillation

CONTEXT

Stroke is a serious complication associated with atrial fibrillation (AF). Women with AF are at higher risk of stroke compared with men. Reasons for this higher stroke risk in women remain unclear, although some studies suggest that undertreatment with warfarin may be a cause.

OBJECTIVE

To compare utilization patterns of warfarin and the risk of subsequent stroke between older men and women with AF at the population level.

DESIGN, SETTING, AND PATIENTS

Population-based cohort study of patients 65 years or older admitted to the hospital with recently diagnosed AF in the province of Quebec, Canada, 1998-2007, using administrative data with linkage between hospital discharge, physicians, and prescription drug claims databases.

MAIN OUTCOME MEASURES

Risk of stroke.

RESULTS

The cohort comprised 39,398 men (47.2%) and 44,115 women (52.8%). At admission, women were older and had a higher CHADS(2) (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack) score than men (1.99 [SD, 1.10] vs 1.74 [SD, 1.13], P < .001). At 30 days postdischarge, 58.2% of men and 60.6% of women had filled a warfarin prescription. In adjusted analysis, women appeared to fill more warfarin prescriptions compared with men (odds ratio, 1.07 [95% CI, 1.04-1.11]; P < .001). Adherence to warfarin treatment was good in both sexes. Crude stroke incidence was 2.02 per 100 person-years (95% CI, 1.95-2.10) in women vs 1.61 per 100 person-years (95% CI, 1.54-1.69) in men (P < .001). The sex difference was mainly driven by the population of patients 75 years or older. In multivariable Cox regression analysis, women had a higher risk of stroke than men (adjusted hazard ratio, 1.14 [95% CI, 1.07-1.22]; P < .001), even after adjusting for baseline comorbid conditions, individual components of the CHADS(2) score, and warfarin treatment.

CONCLUSION

Among older patients admitted with recently diagnosed AF, the risk of stroke was greater in women than in men, regardless of warfarin use.

Transcatheter aortic valve replacement: outcomes of patients with moderate or severe mitral regurgitation

OBJECTIVES

The aim of this study was to evaluate the impact of mitral regurgitation (MR) on outcomes after transcatheter aortic valve replacement (TAVR) and the impact of TAVR on MR.

BACKGROUND

Little is known of the influence of MR on outcomes after TAVR.

METHODS

The outcomes of patients with mild or less (n = 319), moderate (n = 89), and severe (n = 43) MR were evaluated after TAVR at 2 Canadian centers.

RESULTS

Patients with moderate or severe MR had a higher mortality rate than those with mild or less MR during the 30 days after TAVR (adjusted hazard ratio: 2.10; 95% confidence interval: 1.12 to 3.94; p = 0.02). However, the mortality rates after 30 days were similar (adjusted hazard ratio: 0.82; 95% confidence interval: 0.50 to 1.34; p = 0.42). One year after TAVR, moderate MR had improved in 58%, remained moderate in 17%, and worsened to severe in 1%, and 24% of patients had died. Severe MR had improved in 49% and remained severe in 16%, and 35% of patients had died. Multivariate predictors of improved MR at 1 year (vs. unchanged MR, worse MR, or death) were a mean transaortic gradient ≥ 40 mm Hg, functional (as opposed to structural) MR, the absence of pulmonary hypertension, and the absence of atrial fibrillation.

CONCLUSIONS

Moderate or severe MR in patients undergoing TAVR is associated with a higher early, but not late, mortality rate. At 1-year follow-up, MR was improved in 55% of patients with moderate or severe MR at baseline. Improvement was more likely in patients with high transaortic gradients, with functional MR, without pulmonary hypertension and without atrial fibrillation.

Amiodarone-induced thyroid dysfunction: brand-name versus generic formulations

BACKGROUND

Amiodarone is associated with dysfunction of the thyroid. Concerns have arisen regarding the potential for adverse effects with generic formulations of amiodarone. We evaluated and compared the risk of thyroid dysfunction between patients using brand-name versus generic formulations of amiodarone and identified risk factors for thyroid dysfunction.

METHODS

We conducted a retrospective cohort study of patients with atrial fibrillation aged 66 years and older. We used administrative databases that linked information on demographics and clinical characteristics, claims for prescription drugs and discharges from hospital. We estimated thyroid dysfunction using person-year incidence.

RESULTS

Of the 60,220 patients in the cohort, 2804 (4.7%) used the brand-name formulation of amiodarone and 6278 (10.4%) used the generic formulation. Baseline characteristics between these two groups were comparable. The median maintenance dose of amiodarone was 200 mg/d for both groups. The total incidence rate for thyroid dysfunction was 14.1 per 100 person-years for both formulations. The mean time to clinical dysfunction of the thyroid was 4.32 years for the brand-name formulation and 4.09 years for the generic formulation. In a multivariate analysis, there was no significant difference in the incidence rates of thyroid dysfunction between the generic and brand formulations (hazard ratio 0.97, 95% confidence interval 0.87-1.08). Factors associated with an increased risk of thyroid dysfunction were being a woman, increasing age and having chronic obstructive pulmonary disease.

INTERPRETATION

In this population-based study, we saw no difference between brand-name and generic formulations of amiodarone in terms of incidence of thyroid dysfunction.