Trends in acute myocardial infarction in young patients and differences by sex and race, 2001 to 2010

Incidence of Atherosclerotic Cardiovascular Disease in Young Adults at Low Short-Term But High Long-Term Risk

BACKGROUND

Young adults may have high long-term atherosclerotic cardiovascular disease (ASCVD) risk despite low short-term risk.

OBJECTIVES

In this study, we sought to compare the performance of short-term and long-term ASCVD risk prediction tools in young adults and evaluate ASCVD incidence associated with predicted short-term and long-term risk.

METHODS

We included adults aged 18 to 39 years, from 2008 to 2009 in a U.S. integrated health care system, and followed them through 2019. We calculated 10-year and 30-year ASCVD predicted risk and assessed ASCVD incidence.

RESULTS

Among 414,260 young adults, 813 had an incident ASCVD event during a median of 4 years (maximum 11 years). Compared with 10-year predicted risk, 30-year predicted risk improved reclassification (net reclassification index: 16%) despite having similar discrimination (Harrell's C: 0.749 vs 0.726). Overall, 1.0% and 2.2% of young adults were categorized as having elevated 10-year (≥7.5%) and elevated 30-year (≥20%) predicted risk, respectively, and 1.6% as having low 10-year (<7.5%) but elevated 30-year predicted risk. The ASCVD incidence rate per 1,000 person-years was 2.60 (95% CI: 1.92-3.52) for those with elevated 10-year predicted risk, 1.87 (95% CI: 1.42-2.46) for those with low 10-year but elevated 30-year predicted risk, and 0.32 (95% CI: 0.30-0.35) for those with low 10-year and 30-year predicted risk. The age- and sex-adjusted incidence rate ratio was 3.04 (95% CI: 2.25-4.10) comparing those with low 10-year but elevated 30-year predicted risk and those with low 10-year and 30-year predicted risk.

CONCLUSIONS

Long-term ASCVD risk prediction tools further discriminate a subgroup of young adults with elevated observed risk despite low estimated short-term risk.

The Effect of Biological Sex on Arterial Stiffness and Renin-Angiotensin-Aldosterone System Activity in Response to Cyclooxygenase-2 (COX-2) Inhibition

Background

Cardiovascular disease is the leading cause of death globally. Cyclooxygenase (COX)-derived prostaglandins play an important role in cardiovascular health regulation. Animal studies suggest a greater vascular dependence on prostaglandins in female subjects, but whether this extends to humans is unknown. We aimed to assess the effect of COX-2 inhibition on blood pressure and arterial stiffness, validated markers of cardiovascular risk, in human adults.

Methods

Healthy premenopausal females and males were studied in high-salt balance before and after 14 days of daily oral celecoxib, 200 mg ingestion, on 2 identical study days. Blood pressure (BP) and pulse-wave velocity (PWV) were measured at baseline and in response to an Angiotensin II (AngII) challenge, a validated marker of renin-angiotensin-aldosterone system activity.

Results

Thirteen females (age [mean ± standard deviation], 38 ± 13 years) and 11 males (age, 34 ± 9 years) were studied. Pre-COX-2 inhibition, resting measures of systolic (S)BP (P = 0.2) and diastolic (D)BP (P = 0.1) were similar between sexes. Post-COX-2 inhibition, resting SBP (P < 0.001) and DBP (P = 0.02) were significantly lower in females than in males. COX-2 inhibition was not associated with changes in arterial parameters by sex (change in DBP: P = 0.54; change in PWV: P = 0.55; females vs males). COX-2 inhibition was associated with increased SBP (P = 0.039 vs pre-COX-2 inhibition), but no change in DBP (P = 0.16) or PWV (P = 0.52) response to AngII challenge in females. Measures did not differ in response to AngII pre- vs post-COX-2 inhibition in males (SBP: P = 0.88; DBP: P = 0.93; PWV: P = 0.97).

Conclusions

The effects of COX-2 inhibition on arterial function may differ by sex, but further studies are needed. Given the association between nonsteroidal anti-inflammatory drugs (NSAIDs) and cardiovascular risk, increased attention regarding sex-specific pathophysiology is warranted.

Prognostic value of short-term trajectories of left ventricular ejection fraction in patients with first myocardial infarction and percutaneous coronary intervention

Aim. To assess periprocedural dynamics of left ventricular ejection fraction (LVEF) in patients with first acute myocardial infarction (AMI) and percutaneous coronary intervention (PCI) without heart failure (HF) in the medical history, as well as its prognostic value in the development of cardiovascular complications in the postinfarction period.

Materials and methods. A prospective, single-center observational study included 131 patients with first AMI without HF in the past medical history and successful PCI. LVEF was assessed before PCI at admission and before discharge. In patients with reduced baseline LVEF of less than 50%, the criteria for its periprocedural improvement were chosen: 1) LVEF ≥ 50%; 2) ΔLVEF of more than 5%, but EF < 50%. The endpoints were hospitalization for the development of HF and death from cardiovascular disease in combination with the development of HF. The average follow-up period was 2.5 years.

Results. At admission, LVEF was < 50% in 74 (56.5%) patients. At discharge, according to the criteria for LVEF improvement, the proportion of patients in this group was 40.5 and 14.9%, respectively. In 44.6% of cases, no increase in LVEF was noted. The predictors of the absence of periprocedural dynamics in LFEF included impaired regional contractility index > 1.94, left ventricular end-systolic volume > 57 ml, left ventricular end-diastolic diameter > 5.1 cm, pulmonary artery systolic pressure >27 mm Hg, NT-proBNP > 530 pg / ml, and E / A ratio > 1.06. During the follow-up period, 28 (21.4%) patients were hospitalized for the development of HF, 33 (25.2%) patients had a combined endpoint. The absence of periprocedural improvement in left ventricular contractility was independently associated with higher odds of hospitalization for HF (relative risk (RR) 3.5; 95% confidence interval (CI) 1.63–7.55; p = 0.001) and the combined endpoint (RR 2.6; 95% CI 1.28–5.48; p = 0.009) in the postinfarction period.

Conclusion. In patients with first AMI and left ventricular systolic dysfunction, periprocedural evaluation of LVEF is reasonable to stratify the risk of adverse cardiovascular outcomes.

The framing of time-dependent machine learning models improves risk estimation among young individuals with acute coronary syndromes

Acute coronary syndrome (ACS) is a common cause of death in individuals older than 55 years. Although younger individuals are less frequently seen with ACS, this clinical event has increasing incidence trends, shows high recurrence rates and triggers considerable economic burden. Young individuals with ACS (yACS) are usually underrepresented and show idiosyncratic epidemiologic features compared to older subjects. These differences may justify why available risk prediction models usually penalize yACS with higher false positive rates compared to older subjects. We hypothesized that exploring temporal framing structures such as prediction time, observation windows and subgroup-specific prediction, could improve time-dependent prediction metrics. Among individuals who have experienced ACS (n_{global_cohort} = 6341 and n_yACS = 2242), the predictive accuracy for adverse clinical events was optimized by using specific rules for yACS and splitting short-term and long-term prediction windows, leading to the detection of 80% of events, compared to 69% by using a rule designed for the global cohort.

Temporal trends in mortality and provision of intensive care in younger women and men with acute myocardial infarction or stroke

BACKGROUND

Timely management of acute myocardial infarction (AMI) and acute stroke has undergone impressive progress during the last decade. However, it is currently unknown whether both sexes have profited equally from improved strategies. We sought to analyze sex-specific temporal trends in intensive care unit (ICU) admission and mortality in younger patients presenting with AMI or stroke in Switzerland.

METHODS

Retrospective analysis of temporal trends in 16,954 younger patients aged 18 to ≤ 52 years with AMI or acute stroke admitted to Swiss ICUs between 01/2008 and 12/2019.

RESULTS

Over a period of 12 years, ICU admissions for AMI decreased more in women than in men (- 6.4% in women versus - 4.5% in men, p < 0.001), while ICU mortality for AMI significantly increased in women (OR 1.2 [1.10-1.30], p = 0.032), but remained unchanged in men (OR 0.99 [0.94-1.03], p = 0.71). In stroke patients, ICU admission rates increased between 3.6 and 4.1% per year in both sexes, while ICU mortality tended to decrease only in women (OR 0.91 [0.85-0.95, p = 0.057], but remained essentially unaltered in men (OR 0.99 [0.94-1.03], p = 0.75). Interventions aimed at restoring tissue perfusion were more often performed in men with AMI, while no sex difference was noted in neurovascular interventions.

CONCLUSION

Sex and gender disparities in disease management and outcomes persist in the era of modern interventional neurology and cardiology with opposite trends observed in younger stroke and AMI patients admitted to intensive care. Although our study has several limitations, our data suggest that management and selection criteria for ICU admission, particularly in younger women with AMI, should be carefully reassessed.

Trends and outcomes of cardiogenic shock in Asian populations compared with non-Asian populations in the US: NIS Analysis (2002-2019)

BACKGROUND

Current understanding of outcomes of cardiogenic shock (CS) in Asian populations is limited. We aim to study the clinical outcomes of CS in Asian population compared with non-Asians in the US.

METHODS

The National Inpatient Sample (NIS) database was queried between 2002-2019 to identify hospitalizations with CS. Race was classified as Asians and non-Asians. The adjusted odds ratios (aOR) for in-hospital outcomes were calculated using multivariate logistic regression analysis.

RESULTS

Results Of 1,573,285 CS hospitalizations, 48,398 (3%) were Asians and 1,524,887 (97%) were non-Asians between 2002-2019. Adjusted odds of in-hospital mortality (aOR 1.03, 95% CI 1.01-1.05), and use of intra-aortic balloon pump (IABP) (aOR 1.15, 95% CI 1.12-1.17) were significantly higher among Asians compared with non-Asians. The in-hospital mean cost of hospitalization was higher in Asian population ($63,787±$80,261) with CS compared with non-Asians ($56,207±$76,120, p < 0.001). The use of Impella (aOR 0.90, 95% CI 0.86-0.95) and left ventricular assist devices (LVAD) (aOR 0.71, 95% CI 0.65-0.77) were lower with no difference in the use of extracorporeal membrane oxygenation (ECMO) compared with non-Asians.

CONCLUSION

Asian populations with CS have higher in-hospital mortality, increased requirement of IABP and higher mean cost of hospitalization compared with non-Asians.

The sex-dependent response to psychosocial stress and ischaemic heart disease

Stress is an important risk factor for modern chronic diseases, with distinct influences in males and females. The sex specificity of the mammalian stress response contributes to the sex-dependent development and impacts of coronary artery disease (CAD). Compared to men, women appear to have greater susceptibility to chronic forms of psychosocial stress, extending beyond an increased incidence of mood disorders to include a 2- to 4-fold higher risk of stress-dependent myocardial infarction in women, and up to 10-fold higher risk of Takotsubo syndrome-a stress-dependent coronary-myocardial disorder most prevalent in post-menopausal women. Sex differences arise at all levels of the stress response: from initial perception of stress to behavioural, cognitive, and affective responses and longer-term disease outcomes. These fundamental differences involve interactions between chromosomal and gonadal determinants, (mal)adaptive epigenetic modulation across the lifespan (particularly in early life), and the extrinsic influences of socio-cultural, economic, and environmental factors. Pre-clinical investigations of biological mechanisms support distinct early life programming and a heightened corticolimbic-noradrenaline-neuroinflammatory reactivity in females vs. males, among implicated determinants of the chronic stress response. Unravelling the intrinsic molecular, cellular and systems biological basis of these differences, and their interactions with external lifestyle/socio-cultural determinants, can guide preventative and therapeutic strategies to better target coronary heart disease in a tailored sex-specific manner.

Sex and Gender Bias as a Mechanistic Determinant of Cardiovascular Disease Outcomes

Defined as a prejudice either for or against something, biases at the provider, patient, and societal level all contribute to differences in cardiovascular disease recognition and treatment, resulting in outcome disparities between sexes and genders. Provider bias in the under-recognition of female-predominant cardiovascular disease and risks might result in underscreened and undertreated patients. Furthermore, therapies for female-predominant phenotypes including nonobstructive coronary artery disease and heart failure with preserved ejection fraction are less well researched, contributing to undertreated female patients. Conversely, women are less likely to seek urgent medical attention, potentially related to societal bias to put others first, which contributes to diagnostic delays. Furthermore, women are less likely to have discussions around risk factors for coronary artery disease compared with men, partially because they are less likely to consider themselves at risk for heart disease. Provider bias in interpreting a greater number of presenting symptoms, some of which have been labelled as "atypical," can lead to mislabelling presentations as noncardiovascular. Furthermore, providers might avoid discussions around certain therapies including thrombolysis for stroke, and cardiac resynchronization therapy in heart failure, because it is incorrectly assumed that women are not interested in pursuing options deemed more invasive. To mitigate bias, organizations should aim to increase the visibility and involvement of women in research, health promotion, and clinical and leadership endeavours. More research needs to be done to identify effective interventions to mitigate sex and gender bias and the resultant cardiovascular outcome discrepancies.

Gut-microbiome-based predictive model for ST-elevation myocardial infarction in young male patients

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) in young male patients accounts for a significant proportion of total heart attack events. Therefore, clinical awareness and screening for acute myocardial infarction (AMI) in asymptomatic patients at a young age is required. The gut microbiome is potentially involved in the pathogenesis of STEMI. The aim of the current study is to develop an early risk prediction model based on the gut microbiome and clinical parameters for this population.

METHODS

A total of 81 young males (age < 44 years) were enrolled in this study. Forty-one young males with STEMI were included in the case group, and the control group included 40 young non-coronary artery disease (CAD) males. To identify the differences in gut microbiome markers between these two groups, 16S rRNA-based gut microbiome sequencing was performed using the Illumina MiSeq platform. Further, a nomogram and corresponding web page were constructed. The diagnostic efficacy and practicability of the model were analyzed using K-fold cross-validation, calibration curves, and decision curve analysis (DCA).

RESULTS

Compared to the control group, a significant decrease in tendency regarding α and β diversity was observed in patients in the case group and identified as a significantly altered gut microbiome represented by Streptococcus and Prevotella. Regarding clinical parameters, compared to the control group, the patients in the case group had a higher body mass index (BMI), systolic blood pressure (SBP), triglyceride (TG), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) and low blood urea nitrogen (BUN). Additionally, BMI and SBP were significantly (p<0.05) positively correlated with Streptococcus and [Ruminococcus]. Further, BMI and SBP were significantly (p<0.05) negatively correlated with Prevotella and Megasphaera. A significant negative correlation was only observed between Prevotella and AST (p < 0.05). Finally, an early predictive nomogram and corresponding web page were constructed based on the gut microbiome and clinical parameters with an area under the receiver-operating characteristic (ROC) curve (AUC) of 0.877 and a C-index of 0.911. For the internal validation, the stratified K-fold cross-validation (K = 3) was as follows: AUC value of 0.934. The calibration curves of the model showed good consistency between the actual and predicted probabilities. The DCA results showed that the model had a high net clinical benefit for use in the clinical setting.

CONCLUSION

In this study, we combined the gut microbiome and common clinical parameters to construct a prediction model. Our analysis shows that the constructed model is a non-invasive tool with potential clinical application in predicting STEMI in the young males.

Risk factors, clinical features, and outcomes of premature acute myocardial infarction

AIMS

To investigate the risk factors, clinical features, and prognostic factors of patients with premature acute myocardial infarction (AMI).

MATERIALS AND METHODS

A retrospective cohort study of patients with AMI included in data from the West China Hospital of Sichuan University from 2011 to 2019 was divided into premature AMI (aged < 55 years in men and < 65 years in women) and non-premature AMI. Patients' demographics, laboratory tests, Electrocardiography (ECG), cardiac ultrasound, and coronary angiography reports were collected. All-cause death after incident premature MI was enumerated as the primary endpoint.

RESULTS

Among all 8,942 AMI cases, 2,513 were premature AMI (79.8% men). Compared to the non-premature AMI group, risk factors such as smoking, dyslipidemia, overweight, obesity, and a family history of coronary heart disease (CHD) were more prevalent in the premature AMI group. The cumulative survival rate of patients in the premature AMI group was significantly better than the non-premature AMI group during a mean follow-up of 4.6 years (HR = 0.27, 95% CI 0.22-0.32, p < 0.001). Low left ventricular ejection fraction (LVEF) (Adjusted HR 3.00, 95% CI 1.85-4.88, P < 0.001), peak N-terminal pro-B-type natriuretic peptide (NT-proBNP) level (Adjusted HR 1.34, 95% CI 1.18-1.52, P < 0.001) and the occurrence of in-hospital major adverse cardiovascular and cerebrovascular events (MACCEs) (Adjusted HR 2.36, 95% CI 1.45-3.85, P = 0.001) were predictors of poor prognosis in premature AMI patients.

CONCLUSION

AMI in young patients is associated with unhealthy lifestyles such as smoking, dyslipidemia, and obesity. Low LVEF, elevated NT-proBNP peak level, and the occurrence of in-hospital MACCEs were predictors of poor prognosis in premature AMI patients.

Sex-specific behavioral, neurobiological, and cardiovascular responses to chronic social stress in mice

Psychosocial stress promotes and links mood and cardiovascular disorders in a sex-specific manner. However, findings in animal models are equivocal, in some cases opposing human dimorphisms. We examined central nervous system (CNS), behavioral, endocrine, cardiac, and hepatic outcomes in male or female C57Bl/6 mice subjected to chronic social stress (56 days of social isolation, with intermittent social confrontation encounters twice daily throughout the final 20 days). Females exhibited distinct physiological and behavioral changes, including relative weight loss, and increases in coronary resistance, hepatic inflammation, and thigmotaxic behavior in the open field. Males evidence reductions in coronary resistance and cardiac ischemic tolerance, with increased circulating and hippocampal monoamine levels and emerging anhedonia. Shared CNS gene responses include reduced hippocampal Maoa and increased Htr1b expression, while unique responses include repression of hypothalamic Ntrk1 and upregulation of cortical Nrf2 and Htr1b in females; and repression of hippocampal Drd1 and hypothalamic Gabra1 and Oprm in males. Declining cardiac stress resistance in males was associated with repression of cardiac leptin levels and metabolic, mitochondrial biogenesis, and anti-inflammatory gene expression. These integrated data reveal distinct biological responses to social stress in males and females, and collectively evidence greater biological disruption or allostatic load in females (consistent with propensities to stress-related mood and cardiovascular disorders in humans). Distinct stress biology, and molecular to organ responses, emphasize the importance of sex-specific mechanisms and potential approaches to stress-dependent disease.

Temporal Trends in Incidence of Premature Cardiovascular Disease Over the Past 7 Decades: The Framingham Heart Study

Background Premature onset of cardiovascular disease (CVD) imposes a significant societal burden and challenges prevention efforts. Methods and Results Trends in the incidence of premature CVD (before age 55, 60, or 65 years, separate analysis for each threshold) were evaluated in 14 464 Framingham Heart Study participants over 7 decades of observation (1950-2019). The change in the incidence of premature CVD (per decade) in men and women was assessed using overdispersed Poisson regression (accounting for cohort effects), adjusting for age at entry and age at onset of premature CVD within each decade. CVD was defined as a composite of fatal or nonfatal coronary heart disease, stroke or transient ischemic attack, peripheral vascular disease, and heart failure. There were 2223 first CVD events (832 in women) before age 65 years during 282 481 person-years of observations (154 587 in women) between 1950 and 2019. The age-adjusted CVD incidence before age 65 years decreased from 14.8 per 1000 person-years (1950-1959) to 4.69 per 1000 person-years (2010-2019) in men and from 7.23 per 1000 person-years (1950-1959) to 1.73 per 1000 person-years (2010-2019) in women. In adjusted analyses, the incidence of premature CVD decreased per decade in men (18.4% [95% CI, 12.0%-24.0%], for onset before age 55 years; 19.5% [95% CI, 12.0%-27.0%], for onset before age 60 years; 21.3% [95% CI, 16.0%-27.0%], for onset before age 65 years) and women (15.1% [95% CI, 7.0%-22.0%], for onset before age 55 years; 14.0% [95% CI, 6.0%-22.0%], for onset before age 60 years; 18.2% [95% CI, 12.0%-24.0%], for onset before age 65 years). The decline in premature CVD was accompanied by a reduction in smoking and increased use of lipid-lowering treatments across the decades. Incidence of premature coronary heart disease decreased, whereas the contribution of stroke to premature CVD burden increased over time. Conclusions The incidence of premature CVD has decreased among White adults in the Framingham cohort over the past 70 years; the residual burden of premature stroke warrants further study. Additional studies of trends in premature CVD in more racially and geographically diverse populations are warranted to elucidate the generalizability of these findings.

Ischemic Heart Disease in Young Women: JACC Review Topic of the Week

The Cardiovascular Disease in Women Committee of the American College of Cardiology convened a working group to develop a consensus regarding the continuing rise of mortality rates in young women aged 35 to 54 years. Heart disease mortality rates in young women continue to increase. Young women have increased mortality secondary to ischemic heart disease (IHD) compared with comparably aged men and similar mortality to that observed among older women. The authors reviewed the published evidence, including observational and mechanistic/translational data, and identified knowledge gaps pertaining to young women. This paper provides clinicians with pragmatic, evidence-based management strategies for young women at risk for IHD. Next-step research opportunities are outlined. This report presents highlights of the working group review and a summary of suggested research directions to advance the IHD field in the next decade.

Sex Disparity in Characteristics, Management, and In-Hospital Outcomes of Patients with ST-Segment Elevated Myocardial Infarction: Insights from Henan STEMI Registry

Background

Women hospitalized with ST-elevation myocardial infarction (STEMI) experience higher risk of early mortality than men. We aimed to investigate the potential impact of risk factors, clinical characteristics, and management among gender-related risk differences.

Method

We analyzed 5063 STEMI patients prospectively enrolled from 66 hospitals during 2016-2018 and compared sex differences in mortality, death, or treatment withdrawal and main adverse cardiovascular and cerebrovascular events (MACCE) using the generalized linear mixed model, following sequential adjustment for covariates.

Results

Women were older and had a higher prevalence of hypertension (53.3% vs. 41.1%, P < 0.001) and diabetes (24.5% vs. 15.2%, P < 0.001). Eligible women were less likely to receive reperfusion therapy (56.1% vs. 62.4%, P < 0.001); the onset to first medical contact (FMC) (255 vs. 190 minutes, P < 0.001), onset to fibrinolysis (218 vs. 185 minutes, P < 0.001), and onset to percutaneous coronary intervention (PCI) (307 vs. 243 minutes, P < 0.001) were significantly delayed in women. The incidence of in-hospital death (6.8% vs. 3.0%, P < 0.001), death or treatment withdrawal (14.5% vs. 5.6%, P < 0.001), and MACCE (18.5% vs. 9.4%, P < 0.001) were notably higher. The gender disparities persist in death (OR: 1.61, 95% CI: 1.12-2.33), death or treatment withdrawal (OR: 1.68, 95% CI: 1.26-2.24), and MACCE (OR: 1.37, 95% CI: 1.08-1.74) after adjustment for covariates. Among possible explanatory factors, age (-58.46%, -59.04%, -62.20%) and cardiovascular risk factors (-40.77%, -39.36%, -41.73%) accounted for most of the gender-associated risk differences.

Conclusions

Women experienced worse in-hospital outcomes, and age and cardiovascular risk factors were major factors influencing sex-related differences. The sex disparity stressed the awareness and importance of quality improvement efforts against female patients in clinical practice.

Sex-specific evaluation and redevelopment of the GRACE score in non-ST-segment elevation acute coronary syndromes in populations from the UK and Switzerland: a multinational analysis with external cohort validation

BACKGROUND

The Global Registry of Acute Coronary Events (GRACE) 2.0 score was developed and validated in predominantly male patient populations. We aimed to assess its sex-specific performance in non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and to develop an improved score (GRACE 3.0) that accounts for sex differences in disease characteristics.

METHODS

We evaluated the GRACE 2.0 score in 420 781 consecutive patients with NSTE-ACS in contemporary nationwide cohorts from the UK and Switzerland. Machine learning models to predict in-hospital mortality were informed by the GRACE variables and developed in sex-disaggregated data from 386 591 patients from England, Wales, and Northern Ireland (split into a training cohort of 309 083 [80·0%] patients and a validation cohort of 77 508 [20·0%] patients). External validation of the GRACE 3.0 score was done in 20 727 patients from Switzerland.

FINDINGS

Between Jan 1, 2005, and Aug 27, 2020, 400 054 patients with NSTE-ACS in the UK and 20 727 patients with NSTE-ACS in Switzerland were included in the study. Discrimination of in-hospital death by the GRACE 2.0 score was good in male patients (area under the receiver operating characteristic curve [AUC] 0·86, 95% CI 0·86-0·86) and notably lower in female patients (0·82, 95% CI 0·81-0·82; p<0·0001). The GRACE 2.0 score underestimated in-hospital mortality risk in female patients, favouring their incorrect stratification to the low-to-intermediate risk group, for which the score does not indicate early invasive treatment. Accounting for sex differences, GRACE 3.0 showed superior discrimination and good calibration with an AUC of 0·91 (95% CI 0·89-0·92) in male patients and 0·87 (95% CI 0·84-0·89) in female patients in an external cohort validation. GRACE 3·0 led to a clinically relevant reclassification of female patients to the high-risk group.

INTERPRETATION

The GRACE 2.0 score has limited discriminatory performance and underestimates in-hospital mortality in female patients with NSTE-ACS. The GRACE 3.0 score performs better in men and women and reduces sex inequalities in risk stratification.

FUNDING

Swiss National Science Foundation, Swiss Heart Foundation, Lindenhof Foundation, Foundation for Cardiovascular Research, and Theodor-Ida-Herzog-Egli Foundation.

Premature coronary artery disease, risk factors, clinical presentation, angiography and interventions: Hospital based registry

BACKGROUND & AIMS

Premature coronary artery disease (CAD) is endemic in India. We performed a study to identify risk factors, clinical presentation, angiographic findings and interventions in premature CAD.

METHODS

Successive patients who underwent percutaneous intervention (PCI) were enrolled from January 2018 to June 2021. Premature CAD was defined as women 45-59 y and men 40-54 y and very premature as women <45 y and men <40 y. Descriptive statistics are presented. Univariate odds ratio (OR) and 95% confidence intervals (95%CI) were calculated to identify differences in various groups.

RESULTS

4672 patients (women 936, men 3736) were enrolled. Premature CAD was in 1238 (26.5%; women 31.9%; men 25.1%) and very premature in 212 (4.5%; women 6.5%, men 4.0%). In premature and very premature vs non-premature CAD, OR (95%CI) for high cholesterol ≥200 mg/dl [women 1.52(1.03-2.25) and 1.59(0.79-3.20); men 1.73(1.38-2.17) and 1.92(1.22-3.03)], non-HDL cholesterol ≥130 mg/dl [women 1.84(1.35-2.52) and 1.32(0.72-2.42); men 1.69(1.43-1.90) and 1.67(1.17-2.34)], LDL cholesterol [men 1.10(0.95-1.25) and 1.04(0.77-1.41)], and tobacco [women 1.40(0.84-2.35) and 2.14(0.95-4.82); men 1.63(1.34-1.98) and 1.27(0.81-1.97)] were higher while hypertension, diabetes and chronic kidney disease were more in non-premature(p < 0.05). Presentation as STEMI was marginally more in women with premature [1.13(0.85-1.51)] and very premature [1.29(0.75-2.22)] CAD and was significantly higher in men [1.35(1.16-1.56) and 1.79(1.29-2.49)]. Location and extent of CAD were not different.

CONCLUSIONS

In India, a third of CAD patients presenting for coronary intervention have premature disease. Important risk factors are high total and non-HDL cholesterol and tobacco (men) with greater presentation as STEMI. Extent and type of CAD are similar to non-premature CAD indicating severe disease.

Acute myocardial infarction in young adults with chronic kidney disease

OBJECTIVE

The goal of this study was to evaluate the prevalence of chronic kidney disease (CKD) in young patients with acute myocardial infarction (AMI) and to report their characteristics and clinical outcomes.

BACKGROUND

Underlying renal dysfunction is a risk factor for poor cardiovascular outcomes in older patients. The implication of CKD in young patients with AMI is not well studied.

METHODS

This is a retrospective population-based cohort study of patients aged 18-50 who presented with AMI between 2006 and 2016. Medical records were reviewed to confirm diagnosis and to identify treatment and long-term outcomes. Cox regression models were used to evaluate the association of CKD with mortality.

RESULTS

Among 1753 young patients with type 1 AMI (median age 45 years, 85.3% male), CKD was present in 112 (6.8%) patients. A higher proportion of CKD patients had concomitant hypertension, hyperlipidemia, diabetes, and obesity. Use of statin and P2Y12 inhibitors post-AMI was lower in CKD patients. Over a median follow-up of 7.2 years, CKD was associated with higher all-cause mortality [hazard ratio (HR), 9.3; 95% CI, 6.3-13.8]. This association persisted after adjusting for demographics, comorbidities, and treatment (adjusted HR, 3.6; 95% CI, 2.2-6.0).

CONCLUSION

Presence of CKD was associated with 3.6-fold higher mortality over a median follow-up of 7.2 years. A lower proportion of CKD patients were treated with statin therapy and P2Y12 inhibitors. These findings highlight the need for intensive risk factor modification and optimal use of guideline-directed medical therapies in this high-risk population.

Triglyceride-glucose index in the prediction of adverse cardiovascular events in patients with premature coronary artery disease: a retrospective cohort study

Background

Premature coronary artery disease (PCAD) has become more common in recent years and is often associated with poor outcomes. Triglyceride-glucose (TyG) index is a simple and reliable surrogate for insulin resistance (IR) and is an independent predictor of cardiovascular prognosis. However, the prognostic value of the TyG index in patients with PCAD remains uncertain. Thus, this study aimed to investigate the prognostic value and predictive performance of the TyG index in patients with PCAD.

Methods

A total of 526 young subjects (male < 45 years, female < 55 years) with angiographically proven CAD from January 2013 to December 2018 were included consecutively in this study. Their clinical and laboratory parameters were collected, and the TyG index was calculated as \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\mathrm{Ln}[\mathrm{fasting triglyceride }(\mathrm{TG}) (\mathrm{mg}/\mathrm{dL})\times \mathrm{fasting plasma glucose }(\mathrm{FPG}) (\mathrm{mg}/\mathrm{dL})/2]$$\end{document}Ln[fastingtriglyceride(TG)(mg/dL)×fastingplasmaglucose(FPG)(mg/dL)/2]. The follow-up time after discharge was 40–112 months (median, 68 months; interquartile range, 49‒83 months). The primary endpoint was the occurrence of the major adverse cardiovascular events (MACE), defined as the composite of all-cause death, non-fatal myocardial infarction (MI), coronary artery revascularization, and non-fatal stroke.

Results

The TyG index was significantly associated with traditional cardiovascular risk factors and the Gensini score (GS). Kaplan–Meier survival (MACE-free) curves by tertiles of the TyG index showed statistically significant differences (log-rank test, p = 0.001). In the fully adjusted Cox regression model, the Hazard ratio (95% CI) of MACE was 2.17 (1.15–4.06) in tertile 3 and 1.45 (1.11–1.91) for per SD increase in the TyG index. Time-dependent ROC analyses of the TyG for prediction of MACE showed the area under the curves (AUC) reached 0.631 at 3 years, 0.643 at 6 years, and 0.710 at 9 years. Furthermore, adding TyG index to existing risk prediction model could improve outcome prediction [C-statistic increased from 0.715 to 0.719, p = 0.007; continuous net reclassification improvement (NRI) = 0.101, p = 0.362; integrated discrimination improvement (IDI) = 0.011, p = 0.017].

Conclusion

The TyG index is an independent predictor of MACE in patients with PCAD, suggesting that the TyG index has important clinical implications for risk stratification and early intervention of PCAD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01576-8.

MiR-146a Contributes to Thromboinflammation and Recurrence in Young Patients with Acute Myocardial Infarction

Studies on older patients have established notable conceptual changes in the etiopathogenesis of acute coronary syndrome (ACS), but little is known about this disease in young patients (<45 years). Of special interest is thromboinflammation, key at onset, evolution and therapy of cardiovascular pathology. Therefore, we explored whether ACS at an early age is a thromboinflammatory disease by analyzing NETs and rs2431697 of miR-146a (a miRNA considered as a brake of TLR/NF-kB pathway), elements previously related to higher rates of recurrence in atrial fibrillation and sepsis. We included 359 ACS patients (<45 years) and classified them for specific analysis into G1 (collected during the hospitalization of the first event), G2 and G3 (retrospectively collected from patients with or without ACS recurrence, respectively). cfDNA and citH3−DNA were quantified, and rs2431697 was genotyped. Analysis in the overall cohort showed a moderate but significant correlation between cfDNA and citH3−DNA and Killip−Kimball score. In addition, patients with citH3−DNA > Q4 more frequently had a history of previous stroke (6.1% vs. 1.6%). In turn, rs2431697 did not confer increased risk for the onset of ACS, but T carriers had significantly higher levels of NET markers. By groups, we found that cfDNA levels were similarly higher in all patients, but citH3−DNA was especially higher in G1, suggesting that in plasma, this marker may be attenuated over time. Finally, patients from G2 with the worst markers (cfDNA and citH3−DNA > Q2 and T allele) had a two-fold increased risk of a new ischemic event at 2-year follow-up. In conclusion, our data confirm that ACS is younger onset with thromboinflammatory disease. In addition, these data consolidate rs2431697 as a silent proinflammatory factor predisposing to NETosis, and to a higher rate of adverse events in different cardiovascular diseases.

Clinical Presentation and In-Hospital Outcomes of Acute Myocardial Infarction in Young Patients: Japanese Nationwide Registry

Background

Acute myocardial infarction (AMI) in young patients is a concerning issue because of its adverse health and social impacts. Nevertheless, risk factors and prognosis of AMI in young patients are yet to be characterized.

Objectives

This study aimed to characterize AMI in young patients who underwent primary percutaneous coronary intervention (PCI) using large-scale nationwide all-comer registry data in Japan, the Japanese Percutaneous Coronary Intervention (J-PCI).

Methods

This retrospective cohort study evaluated the J-PCI registry data of patients with AMI aged 20 to 79 years who underwent primary PCI between January 2014 and December 2018. Data on risk factor profiles, clinical features, post-procedural complications, and in-hospital outcomes were reviewed.

Results

Among 213,297 patients with AMI who underwent primary PCI, 23,985 (11.2%) were young (ages 20 to 49 years). Compared with the older group (ages 50 to 79 years; n = 189,312), the younger group included a higher number of men, smokers, patients with dyslipidemia, and patients with single-vessel disease, and a lower number of patients with hypertension and diabetes. Despite favorable clinical profiles, younger age was associated with a higher rate of presentation with cardiopulmonary arrest (CPA). Further, concomitant CPA was strongly associated with in-hospital mortality in young patients (odds ratio: 14.2; 95% CI: 9.2 - 21.9).

Conclusions

Younger patients with AMI presented a higher risk of CPA, which was strongly associated with in-hospital mortality. The results of this study highlight the importance of primary AMI prevention strategies in young individuals.

Sex-related differences in the management and outcomes of patients hospitalized with ST-elevation myocardial infarction: a comparison within four European myocardial infarction registries

Aims

Data on how differences in risk factors, treatments, and outcomes differ between sexes in European countries are scarce. We aimed to study sex-related differences regarding baseline characteristics, in-hospital managements, and mortality of ST-elevation myocardial infarction (STEMI) patients in different European countries.

Methods and results

Patients over the age of 18 with STEMI who were treated in hospitals in 2014–17 and registered in one of the national myocardial infarction registers in Estonia (n = 5817), Hungary (n = 30 787), Norway (n = 33 054), and Sweden (n = 49 533) were included. Cardiovascular risk factors, hospital treatment, and recommendation of discharge medications were obtained from the infarction registries. The primary outcome was mortality, in-hospital, after 30 days and after 1 year. Logistic and cox regression models were used to study the associations of sex and outcomes in the respective countries. Women were older than men (70–78 and 62–68 years, respectively) and received coronary angiography, percutaneous coronary intervention, left ventricular ejection fraction assessment, and evidence-based drugs to a lesser extent than men, in all countries. The crude mortality in-hospital rates (10.9–15.9 and 6.5–8.9%, respectively) at 30 days (13.0–19.9 and 8.2–10.9%, respectively) and at 1 year (20.3–28.1 and 12.4–17.2%, respectively) after hospitalization were higher in women than in men. In all countries, the sex-specific differences in mortality were attenuated in the adjusted analysis for 1-year mortality.

Conclusion

Despite improved awareness of the sex-specific inequalities on managing patients with acute myocardial infarction in Europe, country-level data from this study show that women still receive less guideline-recommended management.

Causes, Angiographic Characteristics, and Management of Premature Myocardial Infarction: JACC State-of-the-Art Review

Among patients presenting with acute myocardial infarction (AMI), the proportion of young individuals has increased in recent years. Although coronary atherosclerosis is less extensive in young patients with AMI, with higher prevalence of single-vessel disease and rare left main involvement, the long-term prognosis is not benign. Young patients with AMI with obstructive coronary artery disease have similar risk factors as older patients except for higher prevalence of smoking, lipid disorders, and family history of premature coronary artery disease, and lower prevalence of diabetes mellitus and hypertension. Smoking cessation is by far the most effective secondary preventive measure. Myocardial infarction with nonobstructive coronary arteries is a relatively common clinical entity (10%-20%) among young patients with AMI, with intravascular and cardiac magnetic resonance imaging being key for diagnosis and potentially treatment. Spontaneous coronary artery dissection is a frequent pathogenetic mechanism of AMI among young women, requiring a high degree of suspicion, especially in the peripartum period.

Readmission in Patients With ST-Elevation Myocardial Infarction in 4 Age Groups (<45, >45 to <60, 60 to <75, and >75)

The incidence of ST-elevation myocardial infarction (STEMI) among younger adults is increasing due to an increased prevalence of cardiometabolic risk factors. Readmissions after STEMI in young patients could lead to substantial health care costs and a significant burden on health care resources. Although STEMI readmissions are well studied in elderly patients, limited data are available regarding readmissions after STEMI in young patients and the etiologies remain poorly understood. Because younger patients with STEMI have different sociodemographic profiles th;an older patients with STEMI, one would postulate that the risk factors for readmissions in young patients would differ from that reported in the older patients with STEMI. We performed a contemporary nationwide study using the 2016 and 2017 Nationwide Readmissions Database to identify patterns of readmissions after STEMI in the young adult population. Our analysis of the Nationwide Readmissions Database revealed a total of 243,747 hospitalizations for STEMI between 2016 and 2017. Readmission rates demonstrated a steady increase from discharge, increasing to 7.8% at 30 days and 10.3% at 60 days before relatively plateauing at 12.1% at 90 days. Cardiovascular etiologies were the most common cause of readmission (53.6%). After multivariable analysis, development of cardiogenic shock (adjusted odds ratio 1.48, 95% confidence interval 1.11 to 1.97; p = 0.008) and acute renal failure (adjusted odds ratio 1.46, 95% confidence interval 1.14 to 1.87; p = 0.003) during the index admission were associated with significantly higher rates of readmission. In conclusion, close monitoring in young patients who presented with STEMI and concomitant with cardiogenic shock or acute renal failure, and possibly, aggressive therapy during index admission may be needed. However, this population may be heterogeneous and further research is needed.

Impact of risk factors related to metabolic syndrome on acute myocardial infarction in younger patients

Despite diagnostic and therapeutic advancements in cardiovascular medicine, myocardial infarction (MI) remains a major cause of adverse outcomes in younger MI patients, i.e., those who are aged 55 years or younger. Traditional cardiovascular risk factors have not often been emphasized in the management of younger MI patients. However, plaque rupture or erosion, which is deeply related to cardiovascular risk factors, remains the most common etiology of MI even in younger patients. The global increase in the prevalence of obesity underscores the clinical importance of metabolic syndrome (MetS), i.e., obesity-associated cardiovascular risk factors, dyslipidemia, diabetes mellitus and particularly hypertension, in younger people. The concept of "lifetime risk" of cardiovascular disease reinforces the need for prevention or treatment of MetS. This review focuses on the risk factors related to MetS and an overall understanding of recent profiles of younger MI patients. We hope that this review will aid in the primary prevention of MetS-related risk factors and the prevention of cardiovascular disease, particularly MI, in younger patients.

Demographic and State-Level Trends in Mortality Due to Ischemic Heart Disease in the United States from 1999 to 2019

Although there have been advances in ischemic heart disease (IHD) care, variation in IHD-related mortality trends across the United States has not been well described. We used the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research database to evaluate variation in IHD-related mortality for demographic groups in the United States between 1999 and 2019. Age-adjusted mortality rates (AAMRs) were stratified by gender, race, Hispanic ethnicity, and US state. Crude mortality rates were evaluated using 10-year age groups. IHD-related AAMRs decreased from 195 to 88 per 100,000 nationally, with slower a decrease from 2010 to 2019 (average annual percent change [AAPC] -2.6% [95% confidence interval -2.9% to -2.2%]) compared with 2002 to 2010 (AAPC -5.3% [95% confidence interval -5.6% to -4.9%]). All groups had decreases in AAMRs, although Black populations persistently had the highest AAMR, and women had greater relative decreases than men. AAPC was -3.7% for White men, -4.7% for White women, -3.9% for Black men, -4.9% for Black women, -4.1% for Hispanic men, and -5.1% for Hispanic women. Populations ≥65 years had greater relative mortality decreases than populations <65 years. The median AAMR (2019) and AAPC (1999 to 2019) across states was 86 (range 58 to 134) and -3.8% (range -1.7% to -4.8%), respectively. In conclusion, declines in IHD-related mortality have slowed in the United States, with a significant geographic variation. Black populations persistently had the highest AAMRs, and decreases were relatively greater for women and populations ≥65 years. The impact of demographics and geography on IHD should be further explored and addressed as part of public health measures.

Sex and Race Differences in the Evaluation and Treatment of Young Adults Presenting to the Emergency Department With Chest Pain

Background Acute myocardial infarctions are increasingly common among young adults. We investigated sex and racial differences in the evaluation of chest pain (CP) among young adults presenting to the emergency department. Methods and Results Emergency department visits for adults aged 18 to 55 years presenting with CP were identified in the National Hospital Ambulatory Medical Care Survey 2014 to 2018, which uses stratified sampling to produce national estimates. We evaluated associations between sex, race, and CP management before and after multivariable adjustment. We identified 4152 records representing 29 730 145 visits for CP among young adults. Women were less likely than men to be triaged as emergent (19.1% versus 23.3%, respectively, P<0.001), to undergo electrocardiography (74.2% versus 78.8%, respectively, P=0.024), or to be admitted to the hospital or observation unit (12.4% versus 17.9%, respectively, P<0.001), but ordering of cardiac biomarkers was similar. After multivariable adjustment, men were seen more quickly (hazard ratio [HR], 1.15 [95% CI, 1.05-1.26]) and were more likely to be admitted (adjusted odds ratio, 1.40 [95% CI, 1.08-1.81]; P=0.011). People of color waited longer for physician evaluation (HR, 0.82 [95% CI, 0.73-0.93]; P<0.001) than White adults after multivariable adjustment, but there were no racial differences in hospital admission, triage level, electrocardiography, or cardiac biomarker testing. Acute myocardial infarction was diagnosed in 1.4% of adults in the emergency department and 6.5% of admitted adults. Conclusions Women and people of color with CP waited longer to be seen by physicians, independent of clinical features. Women were independently less likely to be admitted when presenting with CP. These differences could impact downstream treatment and outcomes.

Sex-Specific Risk Factors Associated With First Acute Myocardial Infarction in Young Adults

IMPORTANCE

An increasing proportion of people in the US hospitalized for acute myocardial infarction (AMI) are younger than 55 years, with the largest increase in young women. Effective prevention requires an understanding of risk factors associated with risk of AMI in young women compared with men.

OBJECTIVES

To assess the sex-specific associations of demographic, clinical, and psychosocial risk factors with first AMI among adults younger than 55 years, overall, and by AMI subtype.

DESIGN, SETTING, AND PARTICIPANTS

This study used a case-control design with 2264 patients with AMI, aged 18 to 55 years, from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study and 2264 population-based controls matched for age, sex, and race and ethnicity from the National Health and Nutrition Examination Survey from 2008 to 2012. Data were analyzed from April 2020 to November 2021.

EXPOSURES

A wide range of demographic, clinical, and psychosocial risk factors.

MAIN OUTCOMES AND MEASURES

Odds ratios (ORs) and population attributable fractions (PAF) for first AMI associated with demographic, clinical, and psychosocial risk factors.

RESULTS

Of the 4528 case patients and matched controls, 3122 (68.9%) were women, and the median (IQR) age was 48 (44-52) years. Seven risk factors (diabetes [OR, 3.59 (95% CI, 2.72-4.74) in women vs 1.76 (1.19-2.60) in men], depression [OR, 3.09 (95% CI, 2.37-4.04) in women vs 1.77 (1.15-2.73) in men], hypertension [OR, 2.87 (95% CI, 2.31-3.57) in women vs 2.19 (1.65-2.90) in men], current smoking [OR, 3.28 (95% CI, 2.65-4.07) in women vs 3.28 (2.65-4.07) in men], family history of premature myocardial infarction [OR, 1.48 (95% CI, 1.17-1.88) in women vs 2.42 (1.71-3.41) in men], low household income [OR, 1.79 (95% CI, 1.28-2.50) in women vs 1.35 (0.82-2.23) in men], hypercholesterolemia [OR, 1.02 (95% CI, 0.81-1.29) in women vs 2.16 (1.49-3.15) in men]) collectively accounted for the majority of the total risk of AMI in women (83.9%) and men (85.1%). There were significant sex differences in risk factor associations: hypertension, depression, diabetes, current smoking, and family history of diabetes had stronger associations with AMI in young women, whereas hypercholesterolemia had a stronger association in young men. Risk factor profiles varied by AMI subtype, and traditional cardiovascular risk factors had higher prevalence and stronger ORs for type 1 AMI compared with other AMI subtypes.

CONCLUSIONS AND RELEVANCE

In this case-control study, 7 risk factors, many potentially modifiable, accounted for 85% of the risk of first AMI in young women and men. Significant differences in risk factor profiles and risk factor associations existed by sex and by AMI subtype. These findings suggest the need for sex-specific strategies in risk factor modification and prevention of AMI in young adults. Further research is needed to improve risk assessment of AMI subtypes.

Cardiac computed tomography-derived coronary artery volume to myocardial mass

In the absence of disease impacting the coronary arteries or myocardium, there exists a linear relationship between vessel volume and myocardial mass to ensure balanced distribution of blood supply. This balance may be disturbed in diseases of either the coronary artery tree, the myocardium, or both. However, in contemporary evaluation the coronary artery anatomy and myocardium are assessed separately. Recently the coronary lumen volume to myocardial mass ratio (V/M), measured noninvasively using coronary computed tomography angiography (CTCA), has emerged as an integrated measure of myocardial blood supply and demand in vivo. This has the potential to yield new insights into diseases where this balance is altered, thus impacting clinical diagnoses and management. In this review, we outline the scientific methodology underpinning CTCA-derived measurement of V/M. We describe recent studies describing alterations in V/M across a range of cardiovascular conditions, including coronary artery disease, cardiomyopathies and coronary microvascular dysfunction. Lastly, we highlight areas of unmet research need and future directions, where V/M may further enhance our understanding of the pathophysiology of cardiovascular disease.

Cardiovascular Risk Screening among Women Veterans: Identifying Provider and Patient Barriers and Facilitators to Develop a Clinical Toolkit

INTRODUCTION

Cardiovascular (CV) disease is the leading cause of death among women in the United States, making CV risk screening and management a women's health priority. Objectives were to elicit barriers and facilitators to CV risk identification and reduction among women veterans, and iteratively cocreate clinical tools to identify CV risk factors and promote goal-setting for lifestyle changes.

METHODS

We conducted three exploratory focus groups with 21 Veterans Health Administration primary care team members and piloted patient CV screeners with brief interviews with 19 patients from two Veterans Health Administration women's clinics to inform toolkit development. We then conducted two focus groups and one interview for feedback from a total of 12 staff on the proposed toolkit components. Transcripts were summarized, and a matrix analysis was used to synthesize qualitative findings.

RESULTS

Provider-identified barriers included difficulties disseminating CV information in clinic, limited patient knowledge, and lack of organized resources for provider communication and available referrals. Women's complex health needs were notable challenges to CV risk reduction. Facilitators included having a single place to track patient CV risks (e.g., an electronic template note), a patient screening worksheet, and aids to complete referrals. Patient-identified barriers included difficulties balancing health, finances, and physical and mental health concerns. Facilitators included resources for accountability and gender-specific information about CV risks and complications. Providers requested easy, accessible tools in the electronic record with gender-specific CV data and resources linked. Patients requested lifestyle change supports, including trustworthy sources vetted by providers.

CONCLUSIONS

Iteratively eliciting end-users' perspectives is critical to developing user-friendly, clinically relevant tools. CV risk reduction among women veterans will require multilevel tools and resources that meet providers' and women's needs.

Sex Differences and Temporal Trends in Revascularization and Outcomes of ST-Elevation Myocardial Infarction in Older Adults in the United States

BACKGROUND

Previous studies have suggested that in-hospital mortality is higher in younger women with ST-segment elevation myocardial infarction (STEMI) than in men. However, more coronary artery disease diagnoses occurred in patients older than 60 years.

AIM OF THE STUDY

This study sought to investigate the temporal trends and sex differences in revascularization and in-hospital outcomes in older STEMI patients.

METHODS

National Inpatient Sample databases from 2005-2014 were utilized to identify all STEMI patients with age greater than 60 years old. We studied the temporal trends and sex differences in revascularization therapies and in-hospital mortality.

RESULTS

From 2005-2014, there were 192,204 older adults diagnosed with STEMI. Older women with STEMI were less likely to receive reperfusion (percutaneous coronary intervention (PCI) adjusted OR: 0.90; 95% CI: 0.87-0.92) compared to older men. Also, the adjusted odds ratio comparing the likelihood of receiving PCI between women and men decreased by an annual average of 0.9% (p = 0.028). Older women had higher in-hospital mortality than men (adjusted OR: 1.12; 95% CI: 1.08 to 1.17). There was no significant change of adjusted in-hospital mortality in both genders (all p >0.05).

CONCLUSIONS

Older women were less likely to receive revascularization for STEMI, and this gap was increasing during the study period. Older women had higher in-hospital mortality as compared with older men, but there was no significant temporal change for both genders. These findings present an opportunity to bridge the gender-gap in providing care to older patients with STEMI.

Incidence trends and long-term outcomes of myocardial infarction in young adults: Does gender matter?

AIMS

Data about long-term clinical outcomes of young patients experiencing an acute myocardial infarction (MI) and about the potential impact of gender on juvenile MI incidence and prognosis are scant.

METHODS AND RESULTS

Hospital Discharge Register records of Piedmont region (Italy) from 2007 to 2018 were interrogated to identify incident juvenile MI cases and MI recurrences. Patients were considered young if the first MI occurred before or at 47 years of age (5th percentile). Incidence of first juvenile MI event and overall survival were the primary outcomes. Gender differences and survival rate after an MI recurrence were secondary outcomes. Out of 114.816 hospitalizations due to MI, 4482 (3.9%) occurred in people aged ≤47. Average incidence rate of juvenile MI over the study period was 24.5 (23.8-25.2) per 100.000 person-years, with a decline among men and a stable trend among women through the years. The risk of in hospital death was higher for women (1.9% vs. 0.9%, p = 0.02), while the survival rate at 10 years after the first MI was 94.8%, without gender differences (HR 1.05: 0.69-1.60). MI recurrence occurred in 348 (7.8%) and was less common in women (HR 0.72: 0.52-0.99). After multivariate adjustment, MI recurrence was associated with a significantly higher risk of death at follow-up as compared with a single MI episode (HR 3.05: 1.9-4.80, all CI 95%).

CONCLUSION

Among young patients with MI, women had a higher in-hospital mortality compared to men, but long-term prognosis after hospital discharge did not differ. MI recurrences were associated with increased mortality at follow up.

Nuclear Cardiology in Women and Underrepresented Minority Populations

PURPOSE OF REVIEW

To outline sex-specific features of coronary artery disease (CAD) that should be considered in the assessment of women, including those from ethnic minority populations with suspected stable ischemic heart disease (IHD). Second, to determine the latest nuclear imaging tools available to assess microvascular CAD.

RECENT FINDINGS

Latest studies indicate that women are more likely to have ischemia with no obstructive coronary arteries (INOCA) and paradoxically have worse outcomes. Therefore, the evaluation of women with suspected IHD should include assessing microvascular and epicardial coronary circulation. The prevalence of CAD is increasing in younger women due to the increased cardiovascular disease (CVD) risk burden. CAD is often underrecognized in these patients. There is increasing recognition that INOCA is not benign and should be accurately diagnosed and managed. Nuclear imaging assesses the full spectrum of CAD from microvascular CAD to multivessel obstructive epicardial CAD. Further research on myocardial blood flow (MBF) assessment with PET MPI is needed.

Acute coronary syndromes in young patients: Phenotypes, causes and clinical outcomes following percutaneous coronary interventions

BACKGROUND

The prevalence of acute coronary syndromes (ACS) among young individuals is increasing, but the phenotypic characteristics, causes and clinical outcomes in this group have not been well described.

METHODS

Between 2009 and 2017, 8712 ACS patients underwent percutaneous coronary intervention (PCI) and were prospectively enrolled. We defined a young patient as female <50 years and male <45 years. The causes of ACS were defined by an adjudication committee. The primary endpoint was the patient-oriented composite endpoint (POCE) of all-cause mortality, myocardial infarction or any revascularization at 12 months.

RESULTS

Among 8712 ACS patients, 472 (5.4%) patients were young (26% female). The main cause of ACS in young patients was atherosclerosis (86.5%), followed by coronary artery embolism (9%), and spontaneous coronary artery dissection (SCAD) (4.5%). POCE occurred less frequently in young compared to old patients (8.5% vs. 16.7%, hazard ratio 0.48 (95% confidence interval 0.35-0.66), p < 0.001). The rates of the individual components of the POCE were lower in young including all-cause mortality (3.2% versus 9.5%, 0.32 (0.19-0.54), p < 0.001), myocardial infarction (1.9% versus 3.7%, 0.49 (0.25-0.95), p = 0.035) and any revascularization (5.1% versus 7.4%, 0.65 (0.43-0.97), p = 0.037). Young patients with SCAD had a higher rate of death as compared to those with atherosclerosis, mainly attributed to cardiac deaths.

CONCLUSIONS

One out of 20 ACS patients undergoing PCI was young and the principal cause was atherosclerosis. Young carry a lower risk for future events compared to older ACS patients. The underlying cause leading to ACS should be considered in appropriate risk stratification of young patients.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov. NCT02241291.

Health Care Professional's Knowledge of Pregnancy Complications and Women's Cardiovascular Health: An International Study Utilizing Social Media

Background: Despite guidelines recommending the evaluation of adverse pregnancy outcomes (APOs) as a part of the atherosclerotic cardiovascular disease (ASCVD) risk assessment in women, there is limited awareness of this issue in health care professionals. We sought to evaluate the extent of this gap in knowledge. Methods: An online study using a standardized questionnaire was advertised through newsletters and websites of professional organizations. After a low response rate, the link to the survey was announced on Twitter and via personal email invitations. Differences between groups of respondents were evaluated with z-tests of proportion. Results: Out of 446 complete responses, there were 315 cardiologists and 112 obstetricians and gynecologists (OBGyns). There was an >90% awareness of association of adverse maternal outcomes with gestational hypertension and gestational diabetes with ASCVD, but only <60% awareness of association of adverse maternal outcomes with preterm birth. There were significant differences in ASCVD risk assessment and awareness of the association of APOs with adverse outcomes between cardiologists and OBGyns, and between female and male cardiologists. A greater proportion of female cardiologists thought that the guidelines recommended annual follow-up for high-risk women. Conversely, a greater proportion of male cardiologists were unsure of the frequency of follow-up of such women in the relevant guidelines. A higher proportion of U.K. respondents thought that women with high-risk pregnancies should never be screened for cardiovascular disease postpartum compared with U.S. respondents. Conclusions: In a self-selected group of health care professionals interested in women's cardiovascular health, there remains a large gap in knowledge and awareness of the association of APOs with ASCVD risk, in particular, a lack of awareness of the association of ASCVD risk with preterm delivery. Specific target groups for improving knowledge regarding these sex-specific risk enhancers include male cardiologists and health care professionals practicing in the United Kingdom.

Impact of Metabolic Syndrome and Its Components on Clinical Severity and Long-Term Prognosis in Patients With Premature Myocardial Infarction

BACKGROUND

The effects of metabolic syndrome (MS) on premature myocardial infarction (PMI) are not clear to date. This study aimed to investigate the impact of MS and its components on clinical severity and long-term prognosis in patients with PMI.

METHODS

We enrolled 772 patients aged ≤45 years old who were diagnosed with acute myocardial infarction (AMI) at our hospital consecutively between 2015 and 2020. The patients were divided into an MS group and non-MS group. The parameters of clinical severity were compared using regression analysis. Patients were followed for median of 42 months for major adverse cardiovascular events (MACE).

RESULTS

Hyperglycemia was associated with multi-vessel disease [odds ratio(OR)=1.700, 95% confidence interval (CI)=1.172-2.464, P=0.005] and Syntax score ≥33 (OR=2.736, 95% CI=1.241-6.032, P=0.013). Increased MACE were observed in the MS group(17.9% vs 10.3%, P=0.004).The Kaplan-Meier curve also showed significant differences (P< 0.001). MS was an independent risk factor for MACE. Of each component of MS, BMI ≥28 kg/m² (hazard ratio [HR]=2.022, 95% CI =1.213-3.369, P=0.007] and hyperglycemia (HR=2.904, 95% CI=1.847-4.567, P<0.001) were independent risk factors for MACE.

CONCLUSIONS

In patients with PMI, 1) hyperglycemia usually indicates more severe lesions; 2) MS as a whole was an independent risk factor for MACE; 3) BMI ≥28.0 kg/m² and hyperglycemia were associated with MACE.

Sex disparities in in-hospital outcomes of left ventricular aneurysm complicating acute myocardial infarction: A United States nationwide analysis

Background

Previous studies have reported sex-specific differences in the presentation, mechanisms, and outcomes of acute myocardial infarction (AMI). We assessed differences between women and men in the incidence and in-hospital outcomes of left ventricular (LV) aneurysm complicating AMI.

Methods

Hospitalizations for AMI with LV aneurysm were identified retrospectively in the National Inpatient Sample (NIS) from 2001 to 2017. Incidence and trends in in-hospital mortality, complications, length of stay and costs were analyzed in women and men.

Results

A total of 16,334 AMI hospitalizations with concomitant LV aneurysm were identified including 6994 (42.8%) women and 9340 (57.2%) men. Among these hospitalizations, women had a higher incidence of LV aneurysm compared to men (0.16% vs. 0.14%; p < 0.001). Unadjusted in-hospital mortality was higher in women than men (12.7% vs. 7.2%; p < 0.001). After adjusting for demographic and baseline characteristics and excluding inter-hospital transfers, women with AMI complicated by LV aneurysm had 49% greater odds of in-hospital mortality than men (OR 1.49, 95% confidence interval 1.06-2.10, p = 0.02). Women with LV aneurysm were less likely than men to undergo percutaneous coronary intervention (28.5% vs. 35.4%; p < 0.001), bypass surgery (15.8% vs. 25.1%; p < 0.001), coronary atherectomy (0.8% vs. 1.9%; p = 0.009) and LV aneurysm surgery (7.8% vs. 11.1%; p = 0.001).

Conclusions

In this large population-based cohort study, women had a slightly higher incidence but dramatically higher in-hospital mortality associated with LV aneurysm complicating AMI compared to men. Further research is necessary to validate strategies to ensure that women receive guideline-directed therapy for AMI and LV aneurysm to address the sex disparity in mortality.

Trends in Premature Mortality From Acute Myocardial Infarction in the United States, 1999 to 2019

Background

Evaluating premature (<65 years of age) mortality because of acute myocardial infarction (AMI) by demographic and regional characteristics may inform public health interventions.

Methods and Results

We used the Centers for Disease Control and Prevention’s WONDER (Wide‐Ranging Online Data for Epidemiologic Research) death certificate database to examine premature (<65 years of age) age‐adjusted AMI mortality rates per 100 000 and average annual percentage change from 1999 to 2019. Overall, the age‐adjusted AMI mortality rate was 13.4 (95% CI, 13.3–13.5). Middle‐aged adults, men, non‐Hispanic Black adults, and rural counties had higher mortality than young adults, women, NH White adults, and urban counties, respectively. Between 1999 and 2019, the age‐adjusted AMI mortality rate decreased at an average annual percentage change of −3.4 per year (95% CI, −3.6 to −3.3), with the average annual percentage change showing higher decline in age‐adjusted AMI mortality rates among large (−4.2 per year [95% CI, −4.4 to −4.0]), and medium/small metros (−3.3 per year [95% CI, −3.5 to −3.1]) than rural counties (−2.4 per year [95% CI, −2.8 to −1.9]). Age‐adjusted AMI mortality rates >90th percentile were distributed in the Southern states, and those with mortality <10th percentile were clustered in the Western and Northeastern states. After an initial decline between 1999 and 2011 (−4.3 per year [95% CI, −4.6 to −4.1]), the average annual percentage change showed deceleration in mortality since 2011 (−2.1 per year [95% CI, −2.4 to −1.8]). These trends were consistent across both sexes, all ethnicities and races, and urban/rural counties.

Conclusions

During the past 20 years, decline in premature AMI mortality has slowed down in the United States since 2011, with considerable heterogeneity across demographic groups, states, and urbanicity. Systemic efforts are mandated to address cardiovascular health disparities and outcomes among nonelderly adults.

Kidney Disease as Risk of In-Hospital Mortality in Patients With Acute Coronary Syndrome

Background

An acute coronary syndrome (ACS) event can be linked to several risk factors, including kidney disease. Currently, it is unknown if kidney disease is associated with the in-hospital mortality of patients admitted with ACS, regardless of the main confounders. In this study, we aimed to determine if kidney disease predicts in-hospital mortality among ACS patients.

Methodology

This is a retrospective cohort study that included patients who were admitted to the cardiology center with ACS. The patients were analyzed for their clinical characteristics, previous diseases, risk factors, and blood samples for laboratory analysis. Continuous variables were analyzed using Student’s t-test, and categorical variables using the chi-square test. A p-value of <0.05 was considered statistically significant.

Results

Of the 340 patients who were included in the study, 59 had ST-elevation myocardial infarction. The mean age of the patients was 62.17 years, 59.41% were male, 67.9% were Caucasian, 26% had diabetes, and 20% had a history of coronary artery disease. Age, systolic blood pressure, and a history of myocardial infarction and chronic kidney disease were linked with a higher mortality rate. In the multivariate analysis, only kidney disease was shown to be an independent marker of mortality.

Conclusions

Among individuals admitted with ACS, kidney disease at hospital admission is associated with increased chances of in-hospital mortality, regardless of other major and minor cardiovascular comorbidities and inflammation at baseline.

Acute Myocardial Infarction in Young Men Under 50 Years of Age: Clinical Characteristics, Treatment, and Long-Term Prognosis

Aim

The prevalence of acute myocardial infarction (AMI) is increasing in young adults, especially in men. This study aims to compare the characteristics and explore the association between age and clinical outcomes in male adults who first experienced AMI.

Methods

A total of 2737 male patients with AMI were divided into three groups by age: <50, 50–65, and ≥65 years. Clinical characteristics and long-term results (all-cause and cardiac deaths, nonfatal MI, revascularization, nonfatal stroke, cardiac rehospitalization) were identified across different age subgroups. The association between age and the outcomes was assessed by Cox proportional hazard models.

Results

This population was followed up for a median of 36.7 months. Patients <50 years had a lower prevalence of diabetes (19.4%) and previous stroke (1.8%), while they were more often to be smokers (77.1%), obese (26%), dyslipidemia (74.7%), and with the single-vessel disease (16.2%). The risk of cardiovascular and all-cause death in patients ≥65 years was higher than patients <50 years, which was noticed through competing risk regression analysis after adjusting for confounding factors (adjusted HR 3.24; 95% CI 2.26–4.22, p=0.020 for cardiovascular death, adjusted HR 4.17; 95% CI 1.91–9.10, p<0.001 for all-cause death).

Conclusion

In conclusion, although men who suffered from first AMI under the age of 50 had lower mortality, they had a higher burden of modifiable traditional risk factors. The management of modifiable lifestyles should be addressed to all young AMI patients.

Job burnout is associated with slow improvement of quality of life in the employees after a first episode of acute coronary syndrome: A hospital-based longitudinal study in China

OBJECTIVE

This study investigated the association between job burnout and quality of life (QoL) after acute coronary syndrome (ACS) in a Chinese sample.

METHODS

This was a one-year longitudinal study. Participants included patients with a first episode of ACS who were still employed. The Copenhagen Burnout Inventory (CBI) assessed job burnout before discharge, and QoL was assessed using the Medical Outcome Study 8-Items Short Form Health Survey (SF-8) and the Seattle Angina Questionnaire (SAQ) before discharge (baseline), at one month, six months and 12 months after discharge. Generalized estimating equations determined the association between job burnout and longitudinal changes of QoL.

RESULTS

All participants were assigned to either a "low job burnout" group (n = 70) or a "high job burnout" group (n = 50), based on the upper quartile of job burnout scores. Longitudinally over 1-year follow-up period, the scores of the SF-8 and SAQ among patients with a high level of burnout were lower than those in the low job burnout group. Job burnout was significantly associated with lower physical and mental health (SF-8), as well as greater physical limitation and lower treatment satisfaction (SAQ) over time.

CONCLUSION

Job burnout at baseline predicted slow improvement of QoL after ACS in a Chinese working sample.

Heterogenicity of diabetes as a risk factor for all-cause mortality after acute myocardial infarction: Age and sex impact

AIM

Type 2 diabetes mellitus (T2DM) is a risk factor for mortality after acute myocardial infarction (AMI). We studied the impact of T2DM related to sex and age on post-AMI long-term mortality.

METHODS

A retrospective study included post-AMI patients. Data were obtained from electronic medical records. We defined the study groups by T2DM, stratified by age-sex.

OUTCOME

up-to-10 years post-discharge all-cause mortality.

RESULTS

16,168 patients were analyzed, 40.3% had T2DM. Ten-year mortality rates were 50.3% with T2DM vs. 33.1% without T2DM, adjHR = 1.622 (p < 0.001). Females (adjHR = 1.085, p = 0.052) and increased age (adjHR = 1.056 for one-year increase, p < 0.001) were associated with a higher risk of mortality (borderline statistical significance for sex). The relationship between T2DM and mortality was stronger in females than in males at < 50 and 60-69 years (p-for-interaction 0.025 and 0.009 respectively), but not for other age groups.

CONCLUSIONS

The study implies heterogeneity in the impact of T2DM on mortality of post-AMI patients, being greater among young patients, particularly females, and no significant impact in octogenarians. That implies that young women with T2DM should have advanced measures for early detection of coronary artery disease and tight control of cardiovascular risk factors to lower the propensity to develop AMI.

Trends of Sex Differences in Clinical Outcomes After Myocardial Infarction in the United States

BACKGROUND

Female patients have been shown to experience worse clinical outcomes after acute myocardial infarction (AMI) compared with male patients. However, it is unclear what trend these differences followed over time.

METHODS

Data from patients hospitalized with AMI between 2004 and 2015 in the National Inpatient Sample were retrospectively analyzed, stratified according to sex. Multivariable logistic regression analyses were performed to examine the adjusted odds ratios (aORs) of invasive management and in-hospital outcomes according to sex. The Mantel-Haenszel extension of the χ2 test was performed to examine the trend of management and in-hospital outcomes over the study period.

RESULTS

Of 7,026,432 AMI hospitalizations, 39.7% (n = 2,789,494) were women. Overall, women were older (median: 77 vs 70 years), with a higher prevalence of risk factors such as diabetes, hypertension, and depression. Women were less likely to receive coronary angiography (aOR, 0.92; 95% confidence interval [CI], 0.91-0.93) and percutaneous coronary intervention (aOR, 0.82; 95% CI, 0.81-0.83) compared with men. Odds of all-cause mortality were higher in women (aOR, 1.03; 95% CI, 1.02-1.04; P < 0.001) and these rates have not narrowed over time (2004 vs 2015: aOR, 1.07 [95% CI, 1.04-1.09] vs 1.11 [95% CI, 1.07-1.15), with similar observations recorded for major adverse cardiovascular and cerebrovascular events.

CONCLUSIONS

In this temporal analysis of AMI hospitalizations over 12 years, we showed lower receipt of invasive therapies and higher mortality rates in women, with no change in temporal trends. There needs to be a systematic and consistent effort toward exploring these disparities to identify strategies to mitigate them.

Not All Heart Attacks are Created Equal: Thinking Differently About Acute Myocardial Infarction in the Young

Cardiovascular disease, particularly myocardial infarction, remains a major cause of morbidity and mortality among young individuals. Although myocardial infarctions have declined significantly in the general population, this decline has not been uniformly observed in younger cohorts. Young adults often have different risk factors, including a higher burden of tobacco use and substance abuse, and they are less likely to be treated with preventive therapies since they are often categorized as having low risk. This review examines the existing literature on myocardial infarction in young patients, with a focus on risk factors, therapeutic challenges, and opportunities for prevention.

Association of the triglyceride-glucose index and major adverse cardiac and cerebrovascular events in female patients undergoing percutaneous coronary intervention with drug-eluting stents: A retrospective study

AIMS

We aimed to examine the association between the Triglyceride-glucose (TyG) index and clinical outcome of percutaneous coronary intervention (PCI) patients with drug-eluting stents (DESs).

METHODS

From July 2009 to August 2011, 2533 patients who underwent at least one PCI with DESs were enrolled to determine the relationship between the TyG index and MACCEs with a 29.8-month follow-up. In addition, the Logistic regression proportional hazard model was applied to assess the prognostic value of the TyG index.

RESULTS

The MACCEs was associated with, history of heart failure (p = 0.049), third degree AVB (p = 0.008) and stroke (p = 0.033), SBP (p < 0.001), DBP (p = 0.001), number of diseased vessels, location of target lesions, characteristics of lesion, number of treated vessels, number of stents, length of stents (p = 0.003) and stent diameter (p < 0.001). The multivariate Logistic regression analysis revealed that the TyG index was an independent prognostic factor for MACCEs in female patients (OR = 1.68, 95 %CI = 1.12-2.54, p = 0.013) but not in male (OR = 0.95, 95 %CI = 0.74-1.21, p = 0.657).

CONCLUSION

The TyG index was independently associated with MACCEs in female patients undergoing PCI with DESs, but not in men.

Distribution, management and outcomes of AMI according to principal diagnosis priority during inpatient admission

BACKGROUND

In recent years, there has been a growing interest in outcomes of patients with acute myocardial infarction (AMI) using large administrative datasets. The present study was designed to compare the characteristics, management strategies and acute outcomes between patients with primary and secondary AMI diagnoses in a national cohort of patients.

METHODS

All hospitalisations of adults (≥18 years) with a discharge diagnosis of AMI in the US National Inpatient Sample from January 2004 to September 2015 were included, stratified by primary or secondary AMI. The International Classification of Diseases, ninth revision and Clinical Classification Software codes were used to identify patient comorbidities, procedures and clinical outcomes.

RESULTS

A total of 10 864 598 weighted AMI hospitalisations were analysed, of which 7 186 261 (66.1%) were primary AMIs and 3 678 337 (33.9%) were secondary AMI. Patients with primary AMI diagnoses were younger (median 68 vs 74 years, P < .001) and less likely to be female (39.6% vs 48.5%, P < .001). Secondary AMI was associated with lower odds of receipt of coronary angiography (aOR 0.19; 95%CI 0.18-0.19) and percutaneous coronary intervention (0.24; 0.23-0.24). Secondary AMI was associated with increased odds of MACCE (1.73; 1.73-1.74), mortality (1.71; 1.70-1.72), major bleeding (1.64; 1.62-1.65), cardiac complications (1.69; 1.65-1.73) and stroke (1.68; 1.67-1.70) (P < .001 for all).

CONCLUSIONS

Secondary AMI diagnoses account for one-third of AMI admissions. Patients with secondary AMI are older, less likely to receive invasive care and have worse outcomes than patients with a primary diagnosis code of AMI. Future studies should consider both primary and secondary AMI diagnoses codes in order to accurately inform clinical decision-making and health planning.