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Øhrn AM, Nielsen CS, Schirmer H, Stubhaug A, Wilsgaard T, Lindekleiv H. Pain Tolerance in Persons With Recognized and Unrecognized Myocardial Infarction: A Population-Based, Cross-Sectional Study. J Am Heart Assoc 2016; 5:e003846. [PMID: 28003255 PMCID: PMC5210406 DOI: 10.1161/jaha.116.003846] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 10/26/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Unrecognized myocardial infarction (MI) is a prevalent condition associated with a similar risk of death as recognized MI. It is unknown why some persons experience MI with few or no symptoms; however, one possible explanation is attenuated pain sensitivity. To our knowledge, no previous study has examined the association between pain sensitivity and recognition of MI. METHODS AND RESULTS We conducted a population-based cross-sectional study with 4849 included participants who underwent the cold pressor test (a common experimental pain assay) and ECG. Unrecognized MI was present in 387 (8%) and recognized MI in 227 (4.7%) participants. Participants with unrecognized MI endured the cold pressor test significantly longer than participants with recognized MI (hazard ratio for aborting the cold pressor test, 0.64; CI, 0.47-0.88), adjusted for age and sex. The association was attenuated and borderline significant after multivariable adjustment. The association between unrecognized MI and lower pain sensitivity was stronger in women than in men, and statistically significant in women only, but interaction testing was not statistically significant (P for interaction=0.14). CONCLUSIONS Our findings suggest that persons who experience unrecognized MI have reduced pain sensitivity compared with persons who experience recognized MI. This may partially explain the lack of symptoms associated with unrecognized MI.
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Affiliation(s)
- Andrea Milde Øhrn
- Faculty of Health Sciences, University of Tromsø, Norway
- Norwegian National Advisory Unit on Women's Health, Oslo University Hospital, Oslo, Norway
| | | | - Henrik Schirmer
- Faculty of Health Sciences, University of Tromsø, Norway
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway
| | - Audun Stubhaug
- Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway
| | - Tom Wilsgaard
- Faculty of Health Sciences, University of Tromsø, Norway
| | - Haakon Lindekleiv
- Faculty of Health Sciences, University of Tromsø, Norway
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway
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De Luca L, Marini M, Gonzini L, Boccanelli A, Casella G, Chiarella F, De Servi S, Di Chiara A, Di Pasquale G, Olivari Z, Caretta G, Lenatti L, Gulizia MM, Savonitto S. Contemporary Trends and Age-Specific Sex Differences in Management and Outcome for Patients With ST-Segment Elevation Myocardial Infarction. J Am Heart Assoc 2016; 5:e004202. [PMID: 27881426 PMCID: PMC5210417 DOI: 10.1161/jaha.116.004202] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 10/07/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Age- and sex-specific differences exist in the treatment and outcome of ST-elevation myocardial infarction (STEMI). We sought to describe age- and sex-matched contemporary trends of in-hospital management and outcome of patients with STEMI. METHODS AND RESULTS We analyzed data from 5 Italian nationwide prospective registries, conducted between 2001 and 2014, including consecutive patients with STEMI. All the analyses were age- and sex-matched, considering 4 age classes: <55, 55 to 64, 65 to 74, and ≥75 years. A total of 13 235 patients were classified as having STEMI (72.1% men and 27.9% women). A progressive shift from thrombolysis to primary percutaneous coronary intervention occurred over time, with a concomitant increase in overall reperfusion rates (P for trend <0.0001), which was consistent across sex and age classes. The crude rates of in-hospital death were 3.2% in men and 8.4% in women (P<0.0001), with a significant increase over age classes for both sexes and a significant decrease over time for both sexes (all P for trend <0.01). On multivariable analysis, age (odds ratio 1.09, 95% CI 1.07-1.10, P<0.0001) and female sex (odds ratio 1.44, 95% CI 1.07-1.93, P=0.009) were found to be significantly associated with in-hospital mortality after adjustment for other risk factors, but no significant interaction between these 2 variables was observed (P for interaction=0.61). CONCLUSIONS Despite a nationwide shift from thrombolytic therapy to primary percutaneous coronary intervention for STEMI affecting both sexes and all ages, women continue to experience higher in-hospital mortality than men, irrespective of age.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, San Giovanni Evangelista Hospital, Tivoli (Rome), Italy
| | - Marco Marini
- Department of Cardiovascular Sciences, Ospedali Riuniti, Ancona, Italy
| | | | | | - Gianni Casella
- Department of Cardiology, Maggiore Hospital, Bologna, Italy
| | - Francesco Chiarella
- Division of Cardiology, Azienda Ospedaliera-Universitaria S. Martino, Genova, Italy
| | - Stefano De Servi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Antonio Di Chiara
- Division of Cardiology, Ospedale Sant'Antonio Abate, Tolmezzo, Italy
| | | | - Zoran Olivari
- Department of Cardiology, Ca' Foncello Hospital, Treviso, Italy
| | - Giorgio Caretta
- Division of Cardiology, Sant'Andrea Hospital, ASL 5 Liguria, La Spezia, Italy
| | - Laura Lenatti
- Division of Cardiology, Ospedale A. Manzoni, Lecco, Italy
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Chin EL, Hoggatt M, McGregor AJ, Rojek MK, Templeton K, Casanova R, Klein WS, Miller VM, Jenkins M. Sex and Gender Medical Education Summit: a roadmap for curricular innovation. Biol Sex Differ 2016; 7:52. [PMID: 27790364 PMCID: PMC5073999 DOI: 10.1186/s13293-016-0091-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The Sex and Gender Medical Education Summit: a roadmap for curricular innovation was a collaborative initiative of the American Medical Women's Association, Laura W. Bush Institute for Women's Health, Mayo Clinic, and Society for Women's Health Research (www.sgbmeducationsummit.com). It was held on October 18-19, 2015 to provide a unique venue for collaboration among nationally and internationally renowned experts in developing a roadmap for the incorporation of sex and gender based concepts into medical education curricula. The Summit engaged 148 in-person attendees for the 1 1/2-day program. Pre- and post-Summit surveys assessed the impact of the Summit, and workshop discussions provided a framework for informal consensus building. Sixty-one percent of attendees indicated that the Summit had increased their awareness of the importance of sex and gender specific medicine. Other comments indicate that the Summit had a significant impact for motivating a call to action among attendees and provided resources to initiate change in curricula within their home institutions. These educational efforts will help to ensure a sex and gender basis for delivery of health care in the future.
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Affiliation(s)
- Eliza L. Chin
- American Medical Women‘s Association, University of California San Francisco, San Francisco, CA USA
| | - Marley Hoggatt
- Laura W. Bush Institute for Women‘s Health, Texas Tech University Health Sciences Center, Amarillo, TX USA
| | - Alyson J. McGregor
- Division of Sex and Gender in Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI USA
| | - Mary K. Rojek
- Center for Urban Research and Learning, Loyola University Chicago, Chicago, IL USA
| | - Kimberly Templeton
- American Medical Women‘s Association, Orthopedic Surgery, University of Kansas School of Medicine, Kansas City, KS USA
| | - Robert Casanova
- Obstetrics and Gynecology, Texas Tech University Health Sciences Center, Lubbock, TX USA
| | - Wendy S. Klein
- VCU Institute for Women‘s Health, Virginia Commonwealth University School of Medicine, Richmond, VA USA
| | | | - Marjorie Jenkins
- Laura W. Bush Institute for Women‘s Health, Texas Tech University Health Sciences Center, Amarillo, TX USA
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Wenger NK. Clinical presentation of CAD and myocardial ischemia in women. J Nucl Cardiol 2016; 23:976-985. [PMID: 27510175 DOI: 10.1007/s12350-016-0593-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 03/15/2016] [Indexed: 01/05/2023]
Abstract
Angina is the most frequent initial and subsequent manifestation of ischemic heart disease in women. Women with stable ischemic heart disease have a more diverse symptom presentation than men, with prominent anginal equivalents; symptoms are more often precipitated by emotional or mental stress. Women, especially at younger age, whose acute myocardial infarction presentation is without chest pain have higher mortality rates than men without chest pain.
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Affiliation(s)
- Nanette K Wenger
- Division of Cardiology, Emory University School of Medicine, Emory Heart and Vascular Center, Atlanta, GA, USA.
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Bucholz EM, Strait KM, Dreyer RP, Lindau ST, D'Onofrio G, Geda M, Spatz ES, Beltrame JF, Lichtman JH, Lorenze NP, Bueno H, Krumholz HM. Editor's Choice-Sex differences in young patients with acute myocardial infarction: A VIRGO study analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:610-622. [PMID: 27485141 DOI: 10.1177/2048872616661847] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS Young women with acute myocardial infarction (AMI) have a higher risk of adverse outcomes than men. However, it is unclear how young women with AMI are different from young men across a spectrum of characteristics. We sought to compare young women and men at the time of AMI on six domains of demographic and clinical factors in order to determine whether they have distinct profiles. METHODS AND RESULTS Using data from Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO), a prospective cohort study of women and men aged ⩽55 years hospitalized for AMI ( n = 3501) in the United States and Spain, we evaluated sex differences in demographics, healthcare access, cardiovascular risk and psychosocial factors, symptoms and pre-hospital delay, clinical presentation, and hospital management for AMI. The study sample included 2349 (67%) women and 1152 (33%) men with a mean age of 47 years. Young women with AMI had higher rates of cardiovascular risk factors and comorbidities than men, including diabetes, congestive heart failure, chronic obstructive pulmonary disease, renal failure, and morbid obesity. They also exhibited higher levels of depression and stress, poorer physical and mental health status, and lower quality of life at baseline. Women had more delays in presentation and presented with higher clinical risk scores on average than men; however, men presented with higher levels of cardiac biomarkers and more classic electrocardiogram findings. Women were less likely to undergo revascularization procedures during hospitalization, and women with ST segment elevation myocardial infarction were less likely to receive timely primary reperfusion. CONCLUSIONS Young women with AMI represent a distinct, higher-risk population that is different from young men.
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Affiliation(s)
- Emily M Bucholz
- 1 Yale School of Medicine, New Haven, CT, USA.,2 Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA.,3 Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Kelly M Strait
- 4 Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Rachel P Dreyer
- 4 Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA.,5 Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Stacy T Lindau
- 6 Department of Obstetrics and Gynecology Program in Integrative Sexual Medicine, Department of Medicine - Geriatrics, MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
| | - Gail D'Onofrio
- 7 Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mary Geda
- 8 Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Erica S Spatz
- 4 Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA.,5 Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - John F Beltrame
- 9 Discipline of Medicine, The Queen Elizabeth Hospital, University of Adelaide, Australia
| | - Judith H Lichtman
- 2 Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Nancy P Lorenze
- 4 Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Hector Bueno
- 10 Centro Nacional de Investigaciones Cardiovasculares, Instituto de Investigacion i+12, Cardiology Department, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Spain
| | - Harlan M Krumholz
- 4 Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA.,5 Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,11 Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,12 Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
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57
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Hillinger P, Twerenbold R, Wildi K, Rubini Gimenez M, Jaeger C, Boeddinghaus J, Nestelberger T, Grimm K, Reichlin T, Stallone F, Puelacher C, Sabti Z, Kozhuharov N, Honegger U, Ballarino P, Miro O, Denhaerynck K, Ekrem T, Kohler C, Bingisser R, Osswald S, Mueller C. Gender-specific uncertainties in the diagnosis of acute coronary syndrome. Clin Res Cardiol 2016; 106:28-37. [DOI: 10.1007/s00392-016-1020-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 07/05/2016] [Indexed: 12/12/2022]
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58
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Gencer B, Rodondi N, Auer R, Nanchen D, Räber L, Klingenberg R, Pletscher M, Jüni P, Windecker S, Matter CM, Lüscher TF, Mach F, Perneger TV, Girardin FR. Health utility indexes in patients with acute coronary syndromes. Open Heart 2016; 3:e000419. [PMID: 27252878 PMCID: PMC4885435 DOI: 10.1136/openhrt-2016-000419] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/15/2016] [Accepted: 04/25/2016] [Indexed: 11/14/2022] Open
Abstract
Background Acute coronary syndromes (ACS) have been associated with lower health utilities (HUs) compared with the general population. Given the prognostic improvements after ACS with the implementation of coronary angiography (eg, percutaneous coronary intervention (PCI)), contemporary HU values derived from patient-reported outcomes are needed. Methods We analysed data of 1882 patients with ACS 1 year after coronary angiography in a Swiss prospective cohort. We used the EuroQol five-dimensional questionnaire (EQ-5D) and visual analogue scale (VAS) to derive HU indexes. We estimated the effects of clinical factors on HU using a linear regression model and compared the observed HU with the average values of individuals of the same sex and age in the general population. Results Mean EQ-5D HU 1-year after coronary angiography for ACS was 0.82 (±0.16) and mean VAS was 0.77 (±0.18); 40.9% of participants exhibited the highest utility values. Compared with population controls, the mean EQ-5D HU was similar (expected mean 0.82, p=0.58) in patients with ACS, but the mean VAS was slightly lower (expected mean 0.79, p<0.001). Patients with ACS who are younger than 60 years had lower HU than the general population (<0.001). In patients with ACS, significant differences were found according to the gender, education and employment status, diabetes, obesity, heart failure, recurrent ischaemic or incident bleeding event and participation in cardiac rehabilitation (p<0.01). Conclusions At 1 year, patients with ACS with coronary angiography had HU indexes similar to a control population. Subgroup analyses based on patients' characteristics and further disease-specific instruments could provide better sensitivity for detecting smaller variations in health-related quality of life.
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Affiliation(s)
- Baris Gencer
- Cardiology Division , Geneva University Hospitals, University of Geneva , Geneva , Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Reto Auer
- Department of Community Medicine and Ambulatory Care , University of Lausanne , Lausanne , Switzerland
| | - David Nanchen
- Department of Community Medicine and Ambulatory Care , University of Lausanne , Lausanne , Switzerland
| | - Lorenz Räber
- Department of Cardiology , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Roland Klingenberg
- Department of Cardiology , University Heart Center , Zurich , Switzerland
| | - Mark Pletscher
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences , Winterthur , Switzerland
| | - Peter Jüni
- Institute of Primary Health Care, University of Bern, Bern, Switzerland; Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Stephan Windecker
- Department of Cardiology , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Christian M Matter
- Department of Cardiology , University Heart Center , Zurich , Switzerland
| | - Thomas F Lüscher
- Department of Cardiology , University Heart Center , Zurich , Switzerland
| | - François Mach
- Cardiology Division , Geneva University Hospitals, University of Geneva , Geneva , Switzerland
| | - Thomas V Perneger
- Division of Clinical Epidemiology , University Hospital , Geneva , Switzerland
| | - François R Girardin
- Medical Directorate, University Hospital of Geneva, Geneva, Switzerland; Department of Anaesthesiology, Clinical Pharmacology, and Intensive Care Medicine, University Hospitals of Geneva, Switzerland
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Kreatsoulas C, Crea-Arsenio M, Shannon HS, Velianou JL, Giacomini M. Interpreting angina: symptoms along a gender continuum. Open Heart 2016; 3:e000376. [PMID: 27158523 PMCID: PMC4854148 DOI: 10.1136/openhrt-2015-000376] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 02/08/2016] [Accepted: 02/23/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND 'Typical' angina is often used to describe symptoms common among men, while 'atypical' angina is used to describe symptoms common among women, despite a higher prevalence of angina among women. This discrepancy is a source of controversy in cardiac care among women. OBJECTIVES To redefine angina by (1) qualitatively comparing angina symptoms and experiences in women and men and (2) to propose a more meaningful construct of angina that integrates a more gender-centred approach. METHODS Patients were recruited between July and December 2010 from a tertiary cardiac care centre and interviewed immediately prior to their first angiogram. Symptoms were explored through in-depth semi-structured interviews, transcribed verbatim and analysed concurrently using a modified grounded theory approach. Angiographically significant disease was assessed at ≥70% stenosis of a major epicardial vessel. RESULTS Among 31 total patients, 13 men and 14 women had angiograpically significant CAD. Patients describe angina symptoms according to 6 symptomatic subthemes that array along a 'gender continuum'. Gender-specific symptoms are anchored at each end of the continuum. At the centre of the continuum, are a remarkably large number of symptoms commonly expressed by both men and women. CONCLUSIONS The 'gender continuum' offers new insights into angina experiences of angiography candidates. Notably, there is more overlap of shared experiences between men and women than conventionally thought. The gender continuum can help researchers and clinicians contextualise patient symptom reports, avoiding the conventional 'typical' versus 'atypical' distinction that can misrepresent gendered angina experiences.
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Affiliation(s)
| | - Mary Crea-Arsenio
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Harry S Shannon
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - James L Velianou
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Interventional Cardiology, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Mita Giacomini
- Faculty of Health Sciences, McMaster University, Centre for Health Economics & Policy Analysis, Hamilton, Ontario, Canada
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McSweeney JC, Rosenfeld AG, Abel WM, Braun LT, Burke LE, Daugherty SL, Fletcher GF, Gulati M, Mehta LS, Pettey C, Reckelhoff JF. Preventing and Experiencing Ischemic Heart Disease as a Woman: State of the Science: A Scientific Statement From the American Heart Association. Circulation 2016; 133:1302-31. [PMID: 26927362 PMCID: PMC5154387 DOI: 10.1161/cir.0000000000000381] [Citation(s) in RCA: 176] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Smilowitz NR, Maduro GA, Lobach IV, Chen Y, Reynolds HR. Adverse Trends in Ischemic Heart Disease Mortality among Young New Yorkers, Particularly Young Black Women. PLoS One 2016; 11:e0149015. [PMID: 26882207 PMCID: PMC4755569 DOI: 10.1371/journal.pone.0149015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/25/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Ischemic heart disease (IHD) mortality has been on the decline in the United States for decades. However, declines in IHD mortality have been slower in certain groups, including young women and black individuals. HYPOTHESIS Trends in IHD vary by age, sex, and race in New York City (NYC). Young female minorities are a vulnerable group that may warrant renewed efforts to reduce IHD. METHODS IHD mortality trends were assessed in NYC 1980-2008. NYC Vital Statistics data were obtained for analysis. Age-specific IHD mortality rates and confidence bounds were estimated. Trends in IHD mortality were compared by age and race/ethnicity using linear regression of log-transformed mortality rates. Rates and trends in IHD mortality rates were compared between subgroups defined by age, sex and race/ethnicity. RESULTS The decline in IHD mortality rates slowed in 1999 among individuals aged 35-54 years but not ≥55. IHD mortality rates were higher among young men than women age 35-54, but annual declines in IHD mortality were slower for women. Black women age 35-54 had higher IHD mortality rates and slower declines in IHD mortality than women of other race/ethnicity groups. IHD mortality trends were similar in black and white men age 35-54. CONCLUSIONS The decline in IHD mortality rates has slowed in recent years among younger, but not older, individuals in NYC. There was an association between sex and race/ethnicity on IHD mortality rates and trends. Young black women may benefit from targeted medical and public health interventions to reduce IHD mortality.
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Affiliation(s)
- Nathaniel R. Smilowitz
- Cardiovascular Clinical Research Center, NYU School of Medicine, New York, NY, United States of America
| | - Gil A. Maduro
- New York City Department of Health and Mental Health, New York, NY, United States of America
| | - Iryna V. Lobach
- Department of Biostatistics, NYU School of Medicine, New York, NY, United States of America
| | - Yu Chen
- Department of Population Health, NYU School of Medicine, New York, NY, United States of America
| | - Harmony R. Reynolds
- Cardiovascular Clinical Research Center, NYU School of Medicine, New York, NY, United States of America
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Graham G. Acute Coronary Syndromes in Women: Recent Treatment Trends and Outcomes. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:1-10. [PMID: 26884685 PMCID: PMC4747299 DOI: 10.4137/cmc.s37145] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/28/2015] [Accepted: 01/02/2016] [Indexed: 11/22/2022]
Abstract
In the USA and internationally, women experience farranging differences with respect to acute coronary syndrome (ACS) and myocardial infarction (MI). Women suffer from more comorbidities than men, such as smoking, obesity, hypertension, diabetes, and poor mental health. They some-times exhibit atypical MI presentation symptoms and are overall less likely to present with chest pain. Women are more likely than men to encounter delays between the onset of symptoms and arrival at the hospital or to guideline treatment. The use of various surgical and pharmacological treatments, including revascularization approaches, also differs. Women, on average, have worse outcomes than men following MI, with more complications, higher mortality rates, and poorer recovery. Internationally, outcomes are similar despite various differences in health care and culture in non-US countries. In this review, we detail differences regarding ACS and MI in women, describing their complex correlations and discussing their possible causes. Educational approaches that are tailored to women might help to reduce the incidence of ACS and MI, as well as outcomes following hospitalization. Although outcomes following acute MI have been improving over the years, women may require special consideration in order to see continued improvement.
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Affiliation(s)
- Garth Graham
- Aetna Foundation, Hartford, CT, USA.; University of Connecticut School of Medicine, Farmington, CT, USA
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Graham G, Xiao YYK, Rappoport D, Siddiqi S. Population-level differences in revascularization treatment and outcomes among various United States subpopulations. World J Cardiol 2016; 8:24-40. [PMID: 26839655 PMCID: PMC4728105 DOI: 10.4330/wjc.v8.i1.24] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/29/2015] [Accepted: 11/04/2015] [Indexed: 02/06/2023] Open
Abstract
Despite recent general improvements in health care, significant disparities persist in the cardiovascular care of women and racial/ethnic minorities. This is true even when income, education level, and site of care are taken into consideration. Possible explanations for these disparities include socioeconomic considerations, elements of discrimination and racism that affect socioeconomic status, and access to adequate medical care. Coronary revascularization has become the accepted and recommended treatment for myocardial infarction (MI) today and is one of the most common major medical interventions in the United States, with more than 1 million procedures each year. This review discusses recent data on disparities in co-morbidities and presentation symptoms, care and access to medical resources, and outcomes in revascularization as treatment for acute coronary syndrome, looking especially at women and minority populations in the United States. The data show that revascularization is used less in both female and minority patients. We summarize recent data on disparities in co-morbidities and presentation symptoms related to MI; access to care, medical resources, and treatments; and outcomes in women, blacks, and Hispanics. The picture is complicated among the last group by the many Hispanic/Latino subgroups in the United States. Some differences in outcomes are partially explained by presentation symptoms and co-morbidities and external conditions such as local hospital capacity. Of particular note is the striking differential in both presentation co-morbidities and mortality rates seen in women, compared to men, especially in women ≤ 55 years of age. Surveillance data on other groups in the United States such as American Indians/Alaska Natives and the many Asian subpopulations show disparities in risk factors and co-morbidities, but revascularization as treatment for MI in these populations has not been adequately studied. Significant research is required to understand the extent of disparities in treatment in these subpopulations.
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Marijon E, Uy-Evanado A, Dumas F, Karam N, Reinier K, Teodorescu C, Narayanan K, Gunson K, Jui J, Jouven X, Chugh SS. Warning Symptoms Are Associated With Survival From Sudden Cardiac Arrest. Ann Intern Med 2016; 164:23-9. [PMID: 26720493 PMCID: PMC5624713 DOI: 10.7326/m14-2342] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Survival after sudden cardiac arrest (SCA) remains low, and tools for improved prediction of patients at long-term risk for SCA are lacking. Alternative short-term approaches aimed at preemptive risk stratification and prevention are needed. OBJECTIVE To assess characteristics of symptoms in the 4 weeks before SCA and whether response to these symptoms is associated with better outcomes. DESIGN Ongoing prospective population-based study. SETTING Northwestern United States (2002 to 2012). PATIENTS Residents aged 35 to 65 years with SCA. MEASUREMENT Assessment of symptoms in the 4 weeks preceding SCA and association with survival to hospital discharge. RESULTS Of 839 patients with SCA and comprehensive assessment of symptoms (mean age, 52.6 years [SD, 8]; 75% men), 430 (51%) had warning symptoms (50% of men vs. 53% of women; P = 0.59), mainly chest pain and dyspnea. In most symptomatic patients (93%), symptoms recurred within the 24 hours preceding SCA. Only 81 patients (19%) called emergency medical services (911) to report symptoms before SCA; these persons were more likely to be patients with a history of heart disease (P < 0.001) or continuous chest pain (P < 0.001). Survival when 911 was called in response to symptoms was 32.1% (95% CI, 21.8% to 42.4%) compared with 6.0% (CI, 3.5% to 8.5%) in those who did not call (P < 0.001). LIMITATION Potential for recall and response bias, symptom assessment not available in 24% of patients, and missing data for some patients and SCA characteristics. CONCLUSION Warning symptoms frequently occur before SCA, but most are ignored. Emergent medical care was associated with survival in patients with symptoms, so new approaches are needed for short-term prevention of SCA. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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The relationships between psychological symptoms and cardiovascular symptoms experienced during the menopausal transition: racial/ethnic differences. Menopause 2015; 23:396-402. [PMID: 26645821 DOI: 10.1097/gme.0000000000000545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The purpose of the study was to examine the relationships between psychological and cardiovascular symptoms in a multiethnic group of midlife women while controlling for other influencing factors, and to determine the association of race/ethnicity to the relationships between psychological and cardiovascular symptoms. METHODS This was a secondary analysis of the data among 1,054 midlife women from two Internet surveys. The instruments included the questions on background characteristics, health, and menopause status and the Midlife Women's Symptom Index. The data were analyzed using correlation analyses, chi-squared tests, analysis of variance, and multivariate linear and logistic regression analyses. RESULTS The total numbers and total severity scores of psychological symptoms were significantly related to those of cardiovascular symptoms as a whole and in each racial/ethnic group (P < 0.01). In total participants, both the total numbers and total severity scores of psychological symptoms were significantly associated with increased risk for cardiovascular symptoms after adjusting for race/ethnicity (P < 0.01), and there were no interactions between race/ethnicity and psychological symptoms. The existence of diagnosed cardiovascular diseases was significantly associated with the total numbers of and total severity scores of psychological symptoms only in Asian women. CONCLUSIONS Further studies on the mechanisms through which psychological symptoms are related to cardiovascular symptoms are needed while controlling for race/ethnicity.
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Im EO, Ham OK, Chee E, Chee W. Racial/Ethnic Differences in Cardiovascular Symptoms in Four Major Racial/Ethnic Groups of Midlife Women: A Secondary Analysis. Women Health 2015; 55:525-47. [PMID: 25826460 DOI: 10.1080/03630242.2015.1022813] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ethnic minority midlife women frequently do not recognize cardiovascular symptoms that they experience during the menopausal transition. Racial/ethnic differences in cardiovascular symptoms are postulated as a plausible reason for their lack of knowledge and recognition of the symptoms. The purpose of this study was to explore racial/ethnic differences in midlife women's cardiovascular symptoms and to determine the factors related to these symptoms in each racial/ethnic group. This was a secondary analysis of the data from a larger study among 466 participants, collected from 2006 to 2011. The instruments included questions on background characteristics, health and menopausal status, and the Cardiovascular Symptom Index for Midlife Women. The data were analyzed using inferential statistics, including Poisson regression and logistic regression analyses. Significant racial/ethnic differences were observed in the total numbers and total severity scores of cardiovascular symptoms (p < .01). Non-Hispanic Asians had significantly lower total numbers and total severity scores compared to other racial/ethnic groups (p < .05). The demographic and health factors associated with cardiovascular symptoms were somewhat different in each racial/ethnic group. Further studies are needed about possible reasons for the racial/ethnic differences and the factors associated with cardiovascular symptoms in each racial/ethnic group.
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Affiliation(s)
- Eun-Ok Im
- a School of Nursing , University of Pennsylvania , Philadelphia , Pennsylvania , USA
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D'Onofrio G, Safdar B, Lichtman JH, Strait KM, Dreyer RP, Geda M, Spertus JA, Krumholz HM. Sex differences in reperfusion in young patients with ST-segment-elevation myocardial infarction: results from the VIRGO study. Circulation 2015; 131:1324-32. [PMID: 25792558 DOI: 10.1161/circulationaha.114.012293] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 01/26/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Sex disparities in reperfusion therapy for patients with acute ST-segment-elevation myocardial infarction have been documented. However, little is known about whether these patterns exist in the comparison of young women with men. METHODS AND RESULTS We examined sex differences in rates, types of reperfusion therapy, and proportion of patients exceeding American Heart Association reperfusion time guidelines for ST-segment-elevation myocardial infarction in a prospective observational cohort study (2008-2012) of 1465 patients 18 to 55 years of age, as part of the US Variations in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study at 103 hospitals enrolling in a 2:1 ratio of women to men. Of the 1238 patients eligible for reperfusion, women were more likely to be untreated than men (9% versus 4%, P=0.002). There was no difference in reperfusion strategy for the 695 women and 458 men treated. Women were more likely to exceed in-hospital and transfer time guidelines for percutaneous coronary intervention than men (41% versus 29%; odds ratio, 1.65; 95% confidence interval, 1.27-2.16), more so when transferred (67% versus 44%; odds ratio, 2.63; 95% confidence interval, 1.17-4.07); and more likely to exceed door-to-needle times (67% versus 37%; odds ratio, 2.62; 95% confidence interval, 1.23-2.18). After adjustment for sociodemographic, clinical, and organizational factors, sex remained an important factor in exceeding reperfusion guidelines (odds ratio, 1.72; 95% confidence interval, 1.28-2.33). CONCLUSIONS Young women with ST-segment-elevation myocardial infarction are less likely to receive reperfusion therapy and more likely to have reperfusion delays than similarly aged men. Sex disparities are more pronounced among patients transferred to percutaneous coronary intervention institutions or who received fibrinolytic therapy.
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Affiliation(s)
- Gail D'Onofrio
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.).
| | - Basmah Safdar
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Judith H Lichtman
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Kelly M Strait
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Rachel P Dreyer
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Mary Geda
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - John A Spertus
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
| | - Harlan M Krumholz
- From Department of Emergency Medicine (G.D., B.S.) and Department of Medicine (R.P.D., H.M.K.), Yale University School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT (J.H.L., H.M.K.); The Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M.S., R.P.D., M.G., H.M.K.); Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City (J.A.S.); and Center of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.)
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Lichtman JH, Leifheit-Limson EC, Watanabe E, Allen NB, Garavalia B, Garavalia LS, Spertus JA, Krumholz HM, Curry LA. Symptom recognition and healthcare experiences of young women with acute myocardial infarction. Circ Cardiovasc Qual Outcomes 2015; 8:S31-8. [PMID: 25714826 DOI: 10.1161/circoutcomes.114.001612] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prompt recognition of acute myocardial infarction symptoms and timely care-seeking behavior are critical to optimize acute medical therapies. Relatively little is known about the symptom presentation and care-seeking experiences of women aged ≤55 years with acute myocardial infarction, a group shown to have increased mortality risk as compared with similarly aged men. Understanding symptom recognition and experiences engaging the healthcare system may provide opportunities to reduce delays and improve acute care for this population. METHODS AND RESULTS We conducted a qualitative study using in-depth interviews with 30 women (aged 30-55 years) hospitalized with acute myocardial infarction to explore their experiences with prodromal symptoms and their decision-making process to seek medical care. Five themes characterized their experiences: (1) prodromal symptoms varied substantially in both nature and duration; (2) they inaccurately assessed personal risk of heart disease and commonly attributed symptoms to noncardiac causes; (3) competing and conflicting priorities influenced decisions about seeking acute care; (4) the healthcare system was not consistently responsive to them, resulting in delays in workup and diagnosis; and (5) they did not routinely access primary care, including preventive care for heart disease. CONCLUSIONS Participants did not accurately assess their cardiovascular risk, reported poor preventive health behaviors, and delayed seeking care for symptoms, suggesting that differences in both prevention and acute care may be contributing to young women's elevated acute myocardial infarction mortality relative to men. Identifying factors that promote better cardiovascular knowledge, improved preventive health care, and prompt care-seeking behaviors represent important target for this population.
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Affiliation(s)
- Judith H Lichtman
- From the Department of Chronic Disease Epidemiology (J.H.L., E.C.L.-L., E.W.) and Department of Health Policy and Management (H.M.K., L.A.C.), Yale School of Public Health, New Haven, CT; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (N.B.A.); Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (B.G., J.A.S.); School of Medicine (B.G., J.A.S.) and School of Pharmacy (L.S.G.), University of Missouri-Kansas City; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (H.M.K.) and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine (H.M.K., L.A.C.), Yale School of Medicine, New Haven, CT; and Global Health Leadership Institute, Yale University, New Haven, CT (L.A.C.).
| | - Erica C Leifheit-Limson
- From the Department of Chronic Disease Epidemiology (J.H.L., E.C.L.-L., E.W.) and Department of Health Policy and Management (H.M.K., L.A.C.), Yale School of Public Health, New Haven, CT; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (N.B.A.); Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (B.G., J.A.S.); School of Medicine (B.G., J.A.S.) and School of Pharmacy (L.S.G.), University of Missouri-Kansas City; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (H.M.K.) and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine (H.M.K., L.A.C.), Yale School of Medicine, New Haven, CT; and Global Health Leadership Institute, Yale University, New Haven, CT (L.A.C.)
| | - Emi Watanabe
- From the Department of Chronic Disease Epidemiology (J.H.L., E.C.L.-L., E.W.) and Department of Health Policy and Management (H.M.K., L.A.C.), Yale School of Public Health, New Haven, CT; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (N.B.A.); Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (B.G., J.A.S.); School of Medicine (B.G., J.A.S.) and School of Pharmacy (L.S.G.), University of Missouri-Kansas City; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (H.M.K.) and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine (H.M.K., L.A.C.), Yale School of Medicine, New Haven, CT; and Global Health Leadership Institute, Yale University, New Haven, CT (L.A.C.)
| | - Norrina B Allen
- From the Department of Chronic Disease Epidemiology (J.H.L., E.C.L.-L., E.W.) and Department of Health Policy and Management (H.M.K., L.A.C.), Yale School of Public Health, New Haven, CT; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (N.B.A.); Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (B.G., J.A.S.); School of Medicine (B.G., J.A.S.) and School of Pharmacy (L.S.G.), University of Missouri-Kansas City; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (H.M.K.) and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine (H.M.K., L.A.C.), Yale School of Medicine, New Haven, CT; and Global Health Leadership Institute, Yale University, New Haven, CT (L.A.C.)
| | - Brian Garavalia
- From the Department of Chronic Disease Epidemiology (J.H.L., E.C.L.-L., E.W.) and Department of Health Policy and Management (H.M.K., L.A.C.), Yale School of Public Health, New Haven, CT; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (N.B.A.); Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (B.G., J.A.S.); School of Medicine (B.G., J.A.S.) and School of Pharmacy (L.S.G.), University of Missouri-Kansas City; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (H.M.K.) and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine (H.M.K., L.A.C.), Yale School of Medicine, New Haven, CT; and Global Health Leadership Institute, Yale University, New Haven, CT (L.A.C.)
| | - Linda S Garavalia
- From the Department of Chronic Disease Epidemiology (J.H.L., E.C.L.-L., E.W.) and Department of Health Policy and Management (H.M.K., L.A.C.), Yale School of Public Health, New Haven, CT; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (N.B.A.); Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (B.G., J.A.S.); School of Medicine (B.G., J.A.S.) and School of Pharmacy (L.S.G.), University of Missouri-Kansas City; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (H.M.K.) and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine (H.M.K., L.A.C.), Yale School of Medicine, New Haven, CT; and Global Health Leadership Institute, Yale University, New Haven, CT (L.A.C.)
| | - John A Spertus
- From the Department of Chronic Disease Epidemiology (J.H.L., E.C.L.-L., E.W.) and Department of Health Policy and Management (H.M.K., L.A.C.), Yale School of Public Health, New Haven, CT; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (N.B.A.); Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (B.G., J.A.S.); School of Medicine (B.G., J.A.S.) and School of Pharmacy (L.S.G.), University of Missouri-Kansas City; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (H.M.K.) and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine (H.M.K., L.A.C.), Yale School of Medicine, New Haven, CT; and Global Health Leadership Institute, Yale University, New Haven, CT (L.A.C.)
| | - Harlan M Krumholz
- From the Department of Chronic Disease Epidemiology (J.H.L., E.C.L.-L., E.W.) and Department of Health Policy and Management (H.M.K., L.A.C.), Yale School of Public Health, New Haven, CT; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (N.B.A.); Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (B.G., J.A.S.); School of Medicine (B.G., J.A.S.) and School of Pharmacy (L.S.G.), University of Missouri-Kansas City; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (H.M.K.) and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine (H.M.K., L.A.C.), Yale School of Medicine, New Haven, CT; and Global Health Leadership Institute, Yale University, New Haven, CT (L.A.C.)
| | - Leslie A Curry
- From the Department of Chronic Disease Epidemiology (J.H.L., E.C.L.-L., E.W.) and Department of Health Policy and Management (H.M.K., L.A.C.), Yale School of Public Health, New Haven, CT; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (N.B.A.); Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (B.G., J.A.S.); School of Medicine (B.G., J.A.S.) and School of Pharmacy (L.S.G.), University of Missouri-Kansas City; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.); Section of Cardiovascular Medicine, Department of Internal Medicine (H.M.K.) and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine (H.M.K., L.A.C.), Yale School of Medicine, New Haven, CT; and Global Health Leadership Institute, Yale University, New Haven, CT (L.A.C.)
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van der Meer MG, Backus BE, van der Graaf Y, Cramer MJ, Appelman Y, Doevendans PA, Six AJ, Nathoe HM. The diagnostic value of clinical symptoms in women and men presenting with chest pain at the emergency department, a prospective cohort study. PLoS One 2015; 10:e0116431. [PMID: 25590466 PMCID: PMC4295862 DOI: 10.1371/journal.pone.0116431] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 12/08/2014] [Indexed: 12/31/2022] Open
Abstract
Background Previous studies suggested that diagnosing coronary artery disease (CAD) is more difficult in women than in men. Studies investigating the predictive value of clinical signs and symptoms and compare its combined diagnostic value between women and men are lacking. Methodology Data from a large multicenter prospective study was used. Patients admitted to the emergency department (ED) with chest pain but without ST-elevation were eligible. The endpoint was proven CAD, defined as a significant stenosis at angiography or the diagnosis of a non-ST-elevation myocardial infarction or cardiovascular death within six weeks after presentation at the ED. Twelve clinical symptoms and seven cardiovascular risk factors were collected. Potential predictors of CAD with a p-value <0.15 in the univariable analysis were included in a multivariable model. The diagnostic value of clinical symptoms and cardiovascular risk factors was quantified in women and men separately and areas under the curve (AUC) were compared between sexes. Results A total of 2433 patients were included. We excluded 102 patients (4%) with either an incomplete follow up or ST-elevation. Of the remaining 2331 patients 43% (1003) were women. CAD was present in 111 (11%) women and 278 (21%) men. In women 11 out of 12 and in men 10 out of 12 clinical symptoms were univariably associated with CAD. The AUC of symptoms alone was 0.74 (95%CI: 0.69-0.79) in women and 0.71 (95%CI: 0.68-0.75) in men and increased to respectively 0.79 (95%CI: 0.74-0.83) in women versus 0.75 (95%CI: 0.72-0.78) in men after adding cardiovascular risk factors. The AUCs of women and men were not significantly different (p-value symptoms alone: 0.45, after adding cardiovascular risk factors: 0.11). Conclusion The diagnostic value of clinical symptoms and cardiovascular risk factors for the diagnosis of CAD in chest pain patients presenting on the ED was high in women and men. No significant differences were found between sexes.
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Affiliation(s)
- Manon G. van der Meer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Barbra E. Backus
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Yolanda van der Graaf
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maarten J. Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Yolande Appelman
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pieter A. Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A. Jacob Six
- Department of Cardiology, Zuwe Hofpoort hospital, Woerden, the Netherlands
| | - Hendrik M. Nathoe
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
- * E-mail:
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Khera S, Kolte D, Aronow WS, Palaniswamy C, Subramanian KS, Hashim T, Mujib M, Jain D, Paudel R, Ahmed A, Frishman WH, Bhatt DL, Panza JA, Fonarow GC. Non-ST-elevation myocardial infarction in the United States: contemporary trends in incidence, utilization of the early invasive strategy, and in-hospital outcomes. J Am Heart Assoc 2014; 3:jah3604. [PMID: 25074695 PMCID: PMC4310389 DOI: 10.1161/jaha.114.000995] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background There has been a paradigm shift in the definition of timing of early invasive strategy (EIS) for patients admitted with non‐ST‐elevation myocardial infarction (NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in‐hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in‐hospital outcomes of NSTEMI in the United States. Methods and Results We analyzed the 2002–2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction (AMI) and NSTEMI. Logistic regression was used for overall, age‐, sex‐, and race/ethnicity‐stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI. Of these, 3 981 119 (61.1%) had NSTEMI. The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [OR; per year], 1.055; 95% confidence interval [CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age‐, sex‐, and race/ethnicity‐stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% (Ptrend<0.001) and utilization of EIS at day 0 or 1 increased from 27.8% to 41.4% (Ptrend<0.001). Risk‐adjusted in‐hospital mortality in the overall cohort decreased during the study period (adjusted OR [per year], 0.976; 95% CI, 0.974 to 0.978). Conclusions There have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS. This has been accompanied by temporal decreases in in‐hospital mortality and length of stay.
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Affiliation(s)
- Sahil Khera
- New York Medical College, Valhalla, NY (S.K., D.K., W.S.A., C.P., K.S.S., M.M., D.J., R.P., W.H.F., J.A.P.)
| | - Dhaval Kolte
- New York Medical College, Valhalla, NY (S.K., D.K., W.S.A., C.P., K.S.S., M.M., D.J., R.P., W.H.F., J.A.P.)
| | - Wilbert S Aronow
- New York Medical College, Valhalla, NY (S.K., D.K., W.S.A., C.P., K.S.S., M.M., D.J., R.P., W.H.F., J.A.P.)
| | - Chandrasekar Palaniswamy
- New York Medical College, Valhalla, NY (S.K., D.K., W.S.A., C.P., K.S.S., M.M., D.J., R.P., W.H.F., J.A.P.)
| | - Kathir Selvan Subramanian
- New York Medical College, Valhalla, NY (S.K., D.K., W.S.A., C.P., K.S.S., M.M., D.J., R.P., W.H.F., J.A.P.)
| | - Taimoor Hashim
- University of Alabama at Birmingham, Birmingham, AL (T.H., A.A.)
| | - Marjan Mujib
- New York Medical College, Valhalla, NY (S.K., D.K., W.S.A., C.P., K.S.S., M.M., D.J., R.P., W.H.F., J.A.P.)
| | - Diwakar Jain
- New York Medical College, Valhalla, NY (S.K., D.K., W.S.A., C.P., K.S.S., M.M., D.J., R.P., W.H.F., J.A.P.)
| | - Rajiv Paudel
- New York Medical College, Valhalla, NY (S.K., D.K., W.S.A., C.P., K.S.S., M.M., D.J., R.P., W.H.F., J.A.P.)
| | - Ali Ahmed
- University of Alabama at Birmingham, Birmingham, AL (T.H., A.A.)
| | - William H Frishman
- New York Medical College, Valhalla, NY (S.K., D.K., W.S.A., C.P., K.S.S., M.M., D.J., R.P., W.H.F., J.A.P.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Julio A Panza
- New York Medical College, Valhalla, NY (S.K., D.K., W.S.A., C.P., K.S.S., M.M., D.J., R.P., W.H.F., J.A.P.)
| | - Gregg C Fonarow
- David-Geffen School of Medicine University of California at Los Angeles (UCLA), Los Angeles, CA (G.C.F.)
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71
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DeVon HA, Burke LA, Nelson H, Zerwic JJ, Riley B. Disparities in patients presenting to the emergency department with potential acute coronary syndrome: it matters if you are Black or White. Heart Lung 2014; 43:270-7. [PMID: 24992880 PMCID: PMC4082800 DOI: 10.1016/j.hrtlng.2014.04.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 04/22/2014] [Accepted: 04/23/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To explore disparities between non-Hispanic Blacks and non-Hispanic Whites presenting to the emergency department (ED) with potential acute coronary syndrome (ACS). BACKGROUND Individuals with fewer resources have worse health outcomes and these individuals are disproportionately those of color. METHODS This prospective study enrolled 663 patients in four EDs. Clinical presentation, treatment, and patient-reported outcome variables were measured at baseline, 1, and 6 months. RESULTS Blacks with confirmed ACS were younger; had lower income; less education; more risk factors; more symptoms, and longer prehospital delay at presentation compared to Whites. Blacks experiencing palpitations, unusual fatigue, and chest pain were more than 3 times as likely as Whites to have ACS confirmed. Blacks with ACS had more clinic visits and more symptoms 1 month following discharge. CONCLUSIONS Significant racial disparities remain in clinical presentation and outcomes for Blacks compared to Whites presenting to the ED with symptoms suggestive of ACS.
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Affiliation(s)
- Holli A DeVon
- University of Illinois at Chicago College of Nursing, Chicago, IL, USA.
| | - Larisa A Burke
- University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | | | - Julie J Zerwic
- University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Barth Riley
- University of Illinois at Chicago College of Nursing, Chicago, IL, USA
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72
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Fabreau GE, Leung AA, Southern DA, Knudtson ML, McWilliams JM, Ayanian JZ, Ghali WA. Sex, socioeconomic status, access to cardiac catheterization, and outcomes for acute coronary syndromes in the context of universal healthcare coverage. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2014; 7:540-9. [PMID: 24895450 DOI: 10.1161/circoutcomes.114.001021] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sex and neighborhood socioeconomic status (nSES) may independently affect the care and outcomes of acute coronary syndrome, partly through barriers in timely access to cardiac catheterization. We sought to determine whether sex modifies the association between nSES and the receipt of cardiac catheterization and mortality after an acute coronary syndrome in a universal healthcare system. METHODS AND RESULTS We studied 14 012 patients with acute coronary syndrome admitted to cardiology services between April 18, 2004, and December 31, 2011, in Southern Alberta, Canada. We used multivariable logistic regression to compare the odds of cardiac catheterization within 2 and 30 days of admission and the odds of 30-day and 1-year mortality for men and women by quintile of neighborhood median household income. Significant relationships between nSES and the receipt of cardiac catheterization and mortality after acute coronary syndrome were detected for women but not men. When examined by nSES, each incremental decrease in neighborhood income quintile for women was associated with a 6% lower odds of receiving cardiac catheterization within 30 days (P=0.01) and a 14% higher odds of 30-day mortality (P=0.03). For men, each decrease in neighborhood income quintile was associated with a 2% lower odds of receiving catheterization within 30 days (P=0.10) and a 5% higher odds of 30-day mortality (P=0.36). CONCLUSIONS Associations between nSES and receipt of cardiac catheterization and 30-day mortality were noted for women but not men in a universal healthcare system. Care protocols designed to improve equity of access to care and outcomes are required, especially for low-income women.
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Affiliation(s)
- Gabriel E Fabreau
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.).
| | - Alexander A Leung
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
| | - Danielle A Southern
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
| | - Merrill L Knudtson
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
| | - J Michael McWilliams
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
| | - John Z Ayanian
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
| | - William A Ghali
- From the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.E.F., J.M.M.); Institute for Public Health, Department of Medicine (G.E.F., A.A.L., W.A.G.) and Department of Community Health Sciences (D.A.S., W.A.G.), University of Calgary, Calgary, Alberta, Canada; Department of Health Care Policy, Harvard Medical School, Boston, MA (G.E.F., J.M.M., J.Z.A.); Libin Cardiovascular Institute of Alberta, Department of Medicine, Department of Cardiac Sciences, Calgary, Alberta, Canada (M.L.K.); and Institute for Healthcare Policy and Innovation and Department of Medicine, University of Michigan, Ann Arbor (J.Z.A.)
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73
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Devon HA, Rosenfeld A, Steffen AD, Daya M. Sensitivity, specificity, and sex differences in symptoms reported on the 13-item acute coronary syndrome checklist. J Am Heart Assoc 2014; 3:e000586. [PMID: 24695650 PMCID: PMC4187491 DOI: 10.1161/jaha.113.000586] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Clinical symptoms are part of the risk stratification approaches used in the emergency department (ED) to evaluate patients with suspected acute coronary syndromes (ACS). The objective of this study was to determine the sensitivity, specificity, and predictive value of 13 symptoms for a discharge diagnosis of ACS in women and men. Methods and Results The sample included 736 patients admitted to 4 EDs with symptoms suggestive of ACS. Symptoms were assessed with the 13‐item validated ACS Symptom Checklist. Mixed‐effects logistic regression models were used to estimate sensitivity, specificity, and predictive value of each symptom for a diagnosis of ACS, adjusting for age, obesity, diabetes, and functional status. Patients were predominantly male (63%) and Caucasian (70.5%), with a mean age of 59.7±14.2 years. Chest pressure, chest discomfort, and chest pain demonstrated the highest sensitivity for ACS in both women (66%, 66%, and 67%) and men (63%, 69%, and 72%). Six symptoms were specific for a non‐ACS diagnosis in both women and men. The predictive value of shoulder (odds ratio [OR]=2.53; 95% CI=1.29 to 4.96) and arm pain (OR 2.15; 95% CI=1.10 to 4.20) in women was nearly twice that of men (OR=1.11; 95% CI=0.67 to 1.85 and OR=1.21; 95% CI=0.74 to 1.99). Shortness of breath (OR=0.49; 95% CI=0.30 to 0.79) predicted a non‐ACS diagnosis in men. Conclusions There were more similarities than differences in symptom predictors of ACS for women and men.
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Affiliation(s)
- Holli A Devon
- College of Nursing, University of Illinois at Chicago, Chicago, IL
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74
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Abstract
Contrary to the long-held postulate of steroid-hormone binding globulin action, these protein carriers of steroids are major players in steroid actions in the body. This manuscript will focus on our work with sex hormone binding globulin (SHBG) and corticosteroid binding globulin (CBG) and demonstrate how they are actively involved in the uptake, intracellular transport, and possibly release of steroids from cells. This manuscript will also discuss our own findings that the steroid estradiol is taken up into the cell, as demonstrated by uptake of fluorescence labeled estradiol into Chinese hamster ovary (CHO) cells, and into the cytoplasm where it may have multiple actions that do not seem to involve the cell nucleus. This manuscript will focus mainly on events in two compartments of the cell, the plasma membrane and the cytoplasm.
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Affiliation(s)
| | - Gustav F Jirikowski
- Institute of Anatomy II, University Hospital Jena, Friedrich Schiller University, Jena, Germany
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75
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Akinkuolie AO, Mora S. Are there sex differences in acute coronary syndrome presentation?: a guide through the maze. JAMA Intern Med 2013; 173:1861-2. [PMID: 24042698 PMCID: PMC3830727 DOI: 10.1001/jamainternmed.2013.8075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Akintunde O Akinkuolie
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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