Acute coronary syndromes in women and men

Sex Differences in the Outcomes of Elderly Patients with Acute Coronary Syndrome

Background

The impact of sex on the outcome of patients with acute coronary syndrome (ACS) has been suggested, but little is known about its impact on elderly patients with ACS.

Methods

This study analyzed the impact of sex on in-hospital and 1-year outcomes of elderly (≥75 years of age) patients with ACS hospitalized in our department between January 2013 and December 2017.

Results

A total of 711 patients were included: 273 (38.4%) women and 438 (61.6%) men. Their age ranged from 75 to 94 years, similar between women and men. Women had more comorbidities (hypertension (79.5% vs. 72.8%, p=0.050), diabetes mellitus (35.2% vs. 26.5%, p=0.014), and hyperuricemia (39.9% vs. 32.4%, p=0.042)) and had a higher prevalence of non-ST-segment elevation ACS (NSTE-ACS) (79.5% vs. 71.2%, p=0.014) than men. The prevalence of current smoking (56.5% vs. 5.4%, p < 0.001), creatinine levels (124.4 ± 98.6 vs. 89.9 ± 54.1, p < 0.001), and revascularization rate (39.7% vs. 30.0%, p=0.022) were higher, and troponin TnT and NT-proBNP tended to be higher in men than in women. The in-hospital mortality rate was similar (3.5% vs. 4.4%, p=0.693), but the 1-year mortality rate was lower in women than in men (14.7% vs. 21.7%, p=0.020). The multivariable analysis showed that female sex was a protective factor for 1-year mortality in all patients (OR = 0.565, 95% CI 0.351–0.908, p=0.018) and in patients with STEMI (OR = 0.416, 95% CI 0.184–0.940, p=0.035) after adjustment.

Conclusions

Among the elderly patients with ACS, the 1-year mortality rate was lower in women than in men, which could be associated with comorbidities and ACS type.

Hyperuricemia is a Risk Factor for One-Year Overall Survival in Elderly Female Patients with Acute Coronary Syndrome

Background

Hyperuricemia is a risk factor for cardiovascular diseases, but the impact of hyperuricemia and sex-related disparities is not fully clear in elderly patients with acute coronary syndrome (ACS).

Objective

To investigate the association between hyperuricemia and 1-year all-cause mortality in elderly patients with ACS.

Methods

This retrospective cohort study included 711 consecutive ACS patients aged ≥75 years, hospitalized in our center between January 2013 and December 2017. Serum uric acid (sUA), in-hospital events, and 1-year follow-up were analyzed. Multivariable logistic regression models were used to explore the risk factors for in-hospital events and 1-year all-cause mortality.

Results

sUA levels were higher in males than in females (381.4 ± 110.1 vs. 349.3 ± 119.1 μmol/l, P < 0.001). Prevalence of hypertension (80.5% vs. 72.6%, P < 0.001). Prevalence of hypertension (80.5% vs. 72.6%, P < 0.001). Prevalence of hypertension (80.5% vs. 72.6%, P < 0.001). Prevalence of hypertension (80.5% vs. 72.6%, P < 0.001). Prevalence of hypertension (80.5% vs. 72.6%, P < 0.001). Prevalence of hypertension (80.5% vs. 72.6%, P < 0.001). Prevalence of hypertension (80.5% vs. 72.6%, P < 0.001). Prevalence of hypertension (80.5% vs. 72.6%, P < 0.001). Prevalence of hypertension (80.5% vs. 72.6%,

Conclusions

Hyperuricemia is an independent risk factor for 1-year all-cause mortality in elderly female patients with ACS.

Age-Related Sex Differences in Clinical Presentation, Management, and Outcomes in ST-Segment-Elevation Myocardial Infarction: Pooled Analysis of 15 532 Patients From 7 Arabian Gulf Registries

Background No studies from the Arabian Gulf region have taken age into account when examining sex differences in ST-segment-elevation myocardial infarction (STEMI) presentation and outcomes. We examined the relationship between sex differences and presenting characteristics, revascularization procedures, and in-hospital mortality after accounting for age in patients hospitalized with STEMI in the Arabian Gulf region from 2005 to 2017. Methods and Results This study was a pooled analysis of 31 620 patients with a diagnosis of acute coronary syndrome enrolled in 7 Arabian Gulf registries. Of these, 15 532 patients aged ≥18 years were hospitalized with a primary diagnosis of STEMI. A multiple variable regression model was used to assess sex differences in revascularization, in-hospital mortality, and 1-year mortality. Odds ratios and 95% CIs were calculated. Women were, on average, 8.5 years older than men (mean age: 61.7 versus 53.2 years; absolute standard mean difference: 68.9%). The age-stratified analysis showed that younger women (aged <65 years) with STEMI were more likely to seek acute medical care and were less likely to receive thrombolytic therapies or primary percutaneous coronary intervention and guideline-recommended pharmacotherapy than men. Women had higher crude in-hospital mortality than men, driven mainly by younger age (46-55 years, odds ratio: 2.60 [95% CI, 1.80-3.7]; P<0.001; 56-65 years, odds ratio: 2.32 [95% CI, 1.75-3.08]; P<0.001; and 66-75 years, odds ratio: 1.79 [95% CI, 1.33-2.41]; P<0.001). Younger women had higher adjusted in-hospital and 1-year mortality rates than younger men (P<0.001). Conclusions Younger women (aged ≤65 years) with STEMI were less likely to receive guideline-recommended pharmacotherapy and revascularization than younger men during hospitalization and had higher in-hospital and 1-year mortality rates.

Gender-Specific Predictive Markers of Poor Prognosis for Patients with Acute Myocardial Infarction During a 6-Month Follow-up

Mounting evidence indicates the impact of gender difference on the assessment, treatment, and outcome of patients with acute myocardial infarction (AMI). However, gender-specific prognostic markers of AMI are still lacking. The present study aimed to investigate gender-specific markers of poor prognosis (all-cause mortality or readmission) in a cohort of AMI patients followed up for 6 months. Compared with males (n = 157), females (n = 40) were older and more frequent with previous medical history of hypertension and diabetes mellitus. During the 6-month follow-up, BUN ≥ 7.73 mM, myoglobin ≥ 705.8 ng/mL, and Killip classification 2-4 were identified as the independent predictors of poor prognosis for male AMI patients, while D-dimer ≥ 0.43 mg/L as an independent predictor of poor prognosis in female AMI patients. In conclusion, our data suggest that prognostic markers for AMI patients may differ according to genders. Gender-specific prognostic markers may be useful to guide the risk stratification, clinical therapy, and medications for AMI patients.

In-stent restenosis of drug-eluting stents: clinical presentation and outcomes in a real-world scenario

BACKGROUND

Drug-eluting stents (DES) have substantially reduced the incidence of coronary in-stent restenosis (ISR), but the problem persists. Clinical presentation and outcomes of DES-ISR in a real-world scenario remains underreported.

RESULTS

In this retrospective study, we examined medical records of 191 consecutive patients with DES-ISR (210 ISR lesions) hospitalized between January 2013 and December 2017. ISR clinical presentation was classified as acute coronary syndrome (ACS) or non-ACS. Clinical, angiographic features and 1-year outcomes [composite of death, myocardial infarction (MI) and repeat-target lesion revascularization] for these two groups were compared. The mean age of study population was 61 ± 10 years and 81.2% were males. ACS was the dominant clinical presentation mode occurring in 118 (61.8%) patients. MI was seen in 66 (34.6%) patients. Female gender (odds ratio, 2.71; 95% confidence interval [CI], 1.13-6.52; P = 0.026) and chronic kidney disease (odds ratio, 3.85; 95% CI, 1.05-14.20; P = 0.043) correlated significantly with ACS ISR presentation. A majority [104 (54.5%)] of patients underwent percutaneous coronary intervention (PCI), of whom 72 (69.2%) received a new DES. The rest either underwent CABG (26.2%) or received medical therapy (19.4%). Patients presenting with ACS had a significantly worse clinical outcome at 1-year follow-up (ACS versus non-ACS presentation: hazard ratio [HR], 2.66; 95% CI, 1.09-6.50; P = 0.032).

CONCLUSIONS

DES-ISR presents most commonly as ACS. Female gender and chronic kidney disease seem to be associated with ACS presentation. ACS presentation of ISR is associated with worse 1-year outcomes. Early identification of those with ACS risk and closer follow-up may improve outcomes.

Targeting mitochondria for cardiovascular disorders: therapeutic potential and obstacles

A large body of evidence indicates that mitochondrial dysfunction has a major role in the pathogenesis of multiple cardiovascular disorders. Over the past 2 decades, extraordinary efforts have been focused on the development of agents that specifically target mitochondria for the treatment of cardiovascular disease. Despite such an intensive wave of investigation, no drugs specifically conceived to modulate mitochondrial functions are currently available for the clinical management of cardiovascular disease. In this Review, we discuss the therapeutic potential of targeting mitochondria in patients with cardiovascular disease, examine the obstacles that have restrained the development of mitochondria-targeting agents thus far, and identify strategies that might empower the full clinical potential of this approach.

Microencapsulated Pomegranate Reverts High-Density Lipoprotein (HDL)-Induced Endothelial Dysfunction and Reduces Postprandial Triglyceridemia in Women with Acute Coronary Syndrome

(1) Background: the composition of high-density lipoproteins (HDL) becomes altered during the postprandial state, probably affecting their functionality vis-à-vis the endothelium. Since acute coronary syndrome (ACS) in women is frequently associated with endothelial dysfunction, it is likely that HDL are unable to improve artery vasodilation in these patients. Therefore, we characterized HDL from women with ACS in fasting and postprandial conditions. We also determined whether microencapsulated pomegranate (MiPo) reverts the HDL abnormalities, since previous studies have suggested that this fruit improves HDL functionality. (2) Methods: Eleven women with a history of ACS were supplemented daily with 20 g of MiPo, for 30 days. Plasma samples were obtained during fasting and at different times, after a lipid load test to determine the lipid profile and paraoxonase–1 (PON1) activity. HDL were isolated by sequential ultracentrifugation to determine their size distribution and to assess their effect on endothelial function, by using an in vitro model of rat aorta rings. (3) Results: MiPo improved the lipid profile and increased PON1 activity, as previously reported, with fresh pomegranate juice. After supplementation with MiPo, the incremental area under the curve of triglycerides decreased to half of the initial values. The HDL distribution shifted from large HDL to intermediate and small-size particles during the postprandial period in the basal conditions, whereas such a shift was no longer observed after MiPo supplementation. Consistently, HDL isolated from postprandial plasma samples hindered the vasodilation of aorta rings, and this endothelial dysfunction was reverted after MiPo consumption. (4) Conclusions: MiPo exhibited the same beneficial effects on the lipid profile and PON1 activity as the previously reported fresh pomegranate. In addition, MiPo supplementation reverted the negative effects of HDL on endothelial function generated during the postprandial period in women with ACS.

Variation in cardiovascular disease care: an Australian cohort study on sex differences in receipt of coronary procedures

OBJECTIVES

The aim of this study was to quantify sex differences in diagnostic and revascularisation coronary procedures within 1 year of hospitalisation for acute myocardial infarction (AMI) or angina.

DESIGN

This is a prospective cohort study. Baseline questionnaire (January 2006-April 2009) data from the Sax Institute's 45 and Up Study were linked to hospitalisation and mortality data (to 30 June 2016) in a time-to-event analysis, treating death as a censoring event.

SETTING

This was conducted in New South Wales, Australia.

PARTICIPANTS

The study included participants aged ≥45 years with no history of ischaemic heart disease (IHD) who were admitted to hospital with a primary diagnosis of AMI (n=4580) or a primary diagnosis of angina or chronic IHD with secondary diagnosis of angina (n=4457).

OUTCOME MEASURES

The outcome of this study was coronary angiography and coronary revascularisation with percutaneous coronary intervention or coronary artery bypass graft (PCI/CABG) within 1 year of index admission. Cox regression models compared coronary procedure rates in men and women, adjusting sequentially for age, sociodemographic variables and health characteristics.

RESULTS

Among patients with AMI, 71.6% of men (crude rate 3.45/person-year) and 64.7% of women (2.62/person-year) received angiography; 57.8% of men (1.73/person-year) and 37.4% of women (0.77/person-year) received PCI/CABG. Adjusted HRs for men versus women were 1.00 (0.92-1.08) for angiography and 1.51 (1.38-1.67) for PCI/CABG. In the angina group, 67.3% of men (crude rate 2.36/person-year) and 54.9% of women (1.32/person-year) received angiography; 44.6% of men (0.90/person-year) and 19.5% of women (0.26/person-year) received PCI/CABG. Adjusted HRs were 1.24 (1.14-1.34) and 2.44 (2.16-2.75), respectively.

CONCLUSIONS

Men are more likely than women to receive coronary procedures, particularly revascularisation. This difference is most evident among people with angina, where clinical guidelines are less prescriptive than for AMI.

Sweet dreams: How mini-invasive surgery tackles obstructive sleep apnea

In this issue of the Biomedical Journal we uncover how the discovery of tyrosine phosphorylation thirty years ago led to the recent development of potent cancer drugs. Furthermore we learn about the state of the art of surgery for obstructive sleep apnea and how modern automated hematology could be used to detect various pathologies. Finally we discuss the risk factors for hospital-acquired Clostridium difficile infection and how to minimize ultrasonic motor-induced magnetic resonance imaging artifacts.

Sex differences in characteristics and outcome in acute coronary syndrome patients in the Netherlands

BACKGROUND

Sex differences in acute coronary syndrome (ACS) have been reported, but little is known about the situation in the Netherlands.

METHODS

This registry is a merge of available data on ACS patients in the electronic data capture systems of 11 centres with 24/7 interventional cardiology services. We included patients >18 years undergoing a cardiac catheterisation between 2010-2012. We evaluated sex differences in clinical and procedural characteristics and 1‑year mortality.

RESULTS

A total of 29,265 ACS patients (8,720 women and 20,545 men) were registered. Women were on average 4.5 years older (68.5 vs 63.0 years, p < 0.001) and had a higher prevalence of hypertension (62.7 vs 49.8%, p < 0.001) and insulin-dependent diabetes mellitus (9.6 vs 6.8%, p < 0.001) than men. Women less often presented with ST-elevation myocardial infarction (43.7% vs 47.6%, p < 0.001) and appeared to have less extensive coronary artery disease than men. Women less often underwent coronary angiography by radial access (52.5 vs 55.9%, p < 0.001). One-year mortality was higher in women than in men (7.3% and 5.6%, p < 0.001). More specific, the relationship between sex and mortality was age-dependent and showed higher mortality in women ≤71 years, but lower mortality in older women compared with men (p-interaction <0.001).

CONCLUSION

We found differences in clinical and procedural characteristics and outcome between women and men admitted for ACS, which are in line with other Western countries. The limitations of our registry, based on existing local databases, can be overcome by the use of the prospective Netherlands Heart Registry that is currently in development.

Dietary nitrate consumption and risk of CHD in women from the Nurses' Health Study

The consumption of nitrate-rich vegetables can acutely lower blood pressure and improve mediators shown to optimise vascular health. However, we do not yet understand the impact of long-term habitual dietary nitrate intake and its association with CVD. Therefore, the aim of this investigation was to examine the relationship between habitual dietary nitrate intakes and risk of CHD in women from the Nurses' Health Study. We prospectively followed 62 535 women who were free from diabetes, CVD and cancer at baseline in 1986. Information on diet was updated every 4 years with validated FFQ. The main outcome was CHD defined by the occurrence of non-fatal myocardial infarction or fatal CHD. Cox proportional hazard regression models were used to estimate the relative risks (RR) and 95 % CI. During 26 years of follow-up, 2257 cases of CHD were identified. When comparing the highest quintile of nitrate intake with the lowest quintile, in aged-adjusted analysis there was a protective association for CHD (RR=0·77, 95 % CI 0·68, 0·97; P=0·0002) which dissipated after further adjustment for smoking, physical activity, BMI and race (RR=0·91; 95 % CI 0·80, 1·04; P=0·27). This magnitude of association was further attenuated once we adjusted for the Alternative Healthy Eating Index excluding vegetable and fruit consumption (RR=1·04, 95 % CI 0·91, 1·20; P=0·34). Dietary nitrate intake was not related to the risk of CHD after adjustment for other lifestyle and non-vegetable dietary factors in a large group of US women.

Development and validation of Women Acute Myocardial Infarction in-Hospital Mortality Score (WAMI Score)

BACKGROUND

A variety of risk models have been developed to predict acute myocardial infarction (AMI) in-hospital mortality risk. As a distinct, higher-risk population, women with AMI have different risk profiles from their men counterparts. Published researches have indicated that the interaction between variables in these models for in-hospital mortality and gender are significant. Due to the interaction and gender differences, the predicting value of these risk models for women could be controversial.

METHODS

Databases from the China Patient-centered Evaluative Assessment of Cardiac Events (China PEACE) Retrospective AMI Study were utilized for model derivation (n=16,100, women were 4896) and databases from the China PEACE Prospective AMI Study for model validation (n=6207, women were 2090). A multivariable backward stepwise logistic regression was used to examine correlates of in-hospital mortality, and the variables were subsequently weighted and integrated into a scoring system.

RESULTS

We constructed a novel risk-predicting tool to estimate the baseline risk of in-hospital mortality among women with AMI. The risk score includes 8 variables [age, systolic blood pressure, heart rate, initial glomerular filtration rate (GFR), serum glucose, Killip class, cardiac arrest, ventricular tachycardia/ventricular fibrillation (VT/VF)]. The prognostic discriminatory capacity of the Women Acute Myocardial Infarction in-Hospital Mortality (WAMI) risk score was excellent (c statistic 0.84, 95% confidence interval [CI]: 0.83 to 0.86, p<0.001). External validation of the model showed better prognostic capacity (c statistic 0.87, 95% CI: 0.84 to 0.90, p<0.001) than the GRACE risk score (0.77, 95% CI 0.72-0.82, p<0.001) and TIMI risk score (0.72, 95% CI 0.68-0.77, p<0.001).

CONCLUSIONS

The WAMI Score is a simple robust tool for predicting the in-hospital mortality risk of women with AMI.

TRIAL REGISTRATION

"China PEACE-Retrospective AMI Study", NCT01624883, retrospectively registered: April 2012. Date of enrolment of the first participant to the trial: June 17, 2012. "China PEACE-Prospective AMI Study", NCT01624909, prospectively registered: December 2012. Date of enrolment of the first participant to the trial: June 17, 2012.

Large-scale in silico identification of drugs exerting sex-specific effects in the heart

Background

Major differences exist between men and women in both physiology and pathophysiology. Dissecting the underlying processes and contributing mechanisms of sex differences in health and disease represents a crucial step towards precision medicine. Considering the significant differences between men and women in the response to pharmacotherapies, our aim was to develop an in silico model able to predict sex-specific drug responses in a large-scale.

Methods

For this purpose, we focused on cardiovascular effects because of their high morbidity and mortality. Our model predicted several drugs (including acebutolol and tacrine) with significant differences in the heart between men and women. To validate the sex-specific drug responses identified by our model, acebutolol was selected to lower blood pressure in spontaneous hypertensive rats (SHR), tacrine was used to assess cardiac injury in mice and metformin as control for a non-sex-specific response.

Results

As our model predicted, acebutolol exhibited a stronger decrease in heart rate and blood pressure in female than male SHRs. Tacrine lowered heart rate in male but not in female mice, induced higher plasma cTNI level and increased cardiac superoxide (DHE staining) generation in female than male mice, indicating stronger cardiac toxicity in female than male mice. To validate our model in humans, we employed two Chinese cohorts, which showed that among patients taking a beta-receptor blocker (metoprolol), women reached significantly lower diastolic blood pressure than men.

Conclusions

We conclude that our in silico model could be translated into clinical practice to predict sex-specific drug responses, thereby contributing towards a more appropriate medical care for both men and women.

Electronic supplementary material

The online version of this article (10.1186/s12967-018-1612-6) contains supplementary material, which is available to authorized users.

Etiology of Acute Coronary Syndrome after Noncardiac Surgery

BACKGROUND

The objective of this investigation was to determine the etiology of perioperative acute coronary syndrome with a particular emphasis on thrombosis versus demand ischemia.

METHODS

In this retrospective cohort study, adult patients were identified who underwent coronary angiography for acute coronary syndrome within 30 days of noncardiac surgery at a major tertiary hospital between January 2008 and July 2015. Angiograms were independently reviewed by two interventional cardiologists who were blinded to clinical data and outcomes. Acute coronary syndrome was classified as ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, or unstable angina; myocardial infarctions were adjudicated as type 1 (plaque rupture), type 2 (demand ischemia), or type 4b (stent thrombosis).

RESULTS

Among 215,077 patients screened, 146 patients were identified who developed acute coronary syndrome: 117 were classified as non-ST-elevation myocardial infarction (80.1%); 21 (14.4%) were classified as ST-elevation myocardial infarction, and 8 (5.5%) were classified as unstable angina. After coronary angiography, most events were adjudicated as demand ischemia (type 2 myocardial infarction, n = 106, 72.6%) compared to acute coronary thrombosis (type 1 myocardial infarction, n = 37, 25.3%) and stent thrombosis (type 4B, n = 3, 2.1%). Absent or only mild, nonobstructive coronary artery disease was found in 39 patients (26.7%). In 14 patients (9.6%), acute coronary syndrome was likely due to stress-induced cardiomyopathy. Aggregate 30-day and 1-yr mortality rates were 7 and 14%, respectively.

CONCLUSIONS

The dominant mechanism of perioperative acute coronary syndrome in our cohort was demand ischemia. A subset of patients had no evidence of obstructive coronary artery disease, but findings were consistent with stress-induced cardiomyopathy.

Sex-Specific Versus Overall Clinical Decision Limits for Cardiac Troponin I and T for the Diagnosis of Acute Myocardial Infarction: A Systematic Review

BACKGROUND

The overall clinical decision limits of high-sensitivity cardiac troponin I (hs-cTnI; 26 ng/L) and T (hs-cTnT; 14 ng/L) may contribute to underdiagnosis of acute myocardial infarction in women. We performed a systematic review to investigate sex-specific and overall 99th percentiles of hs-cTnI and hs-cTnT derived from healthy reference populations.

CONTENT

We searched in PubMed and EMBASE for original studies, and by screening reference lists. Reference populations designed to establish 99th percentiles of hs-cTnI (Abbott) and/or hs-cTnT (Roche), published between January 2009 and October 2017, were included. Sex-specific and overall 99th percentile values of hs-cTnI and hs-cTnT were compared with overall clinical decision ranges (hs-cTnI, 23-30 ng/L; hs-cTnT, 13-25 ng/L). Twenty-eight studies were included in the systematic review. Of 16 hs-cTnI and 18 hs-cTnT studies, 14 (87.5%) and 11 (61.1%) studies reported lower female-specific hs-cTn cutoffs than overall clinical decision ranges, respectively. Conversely, male-specific thresholds of both hs-cTnI and hs-cTnT were in line with currently used overall thresholds, particularly hs-cTnT (90% concordance). The variation of estimated overall 99th percentiles was much higher for hs-cTnI than hs-cTnT (29.4% vs 80.0% of hs-cTnI and hs-cTnT studies reported values within the current overall clinical decision range, respectively).

SUMMARY

Our data show substantially lower female-specific upper reference limits of hs-cTnI and hs-cTnT than overall clinical decision limits of 26 ng/L and 14 ng/L, respectively. The statistical approach strongly affects the hs-cTnI threshold. Downward adjustment of hs-cTn thresholds in women may be warranted to reduce underdiagnosis of acute myocardial infarction in women.

Taking cardiology clinical trials to the next level: A call to action

Physicians previously perceived heart disease to be a man's disease; yet, since 1984, more women have died of ischemic heart disease. Because women who develop obstructive coronary heart disease and heart failure tend to do so 10 years later than men, cardiology clinical trials that use arbitrary age cutoffs or exclusion criteria based on comorbidities and polypharmacy often limit the pool of potential participants to a greater extent for women. Issues related to trial design and insufficient accounting for female-predominant disease patterns have contributed to low rates of enrollment of women in certain domains of cardiology research. Accordingly, women do not benefit from as rich an evidence base for cardiology as men. Here, we review major sex differences in heart disease and discuss areas of cardiology research in which women have been underrepresented. Considering the widespread sex differences in cardiovascular structure and function, it is important to include balanced numbers of women and men in cardiovascular clinical trials. Beyond inclusion, sex-specific reporting is also essential. Moreover, with ongoing developments of clinical-trial methodology, it is imperative to seek innovative ways to learn as much as possible about how interventions behave in women and men. Adaptive trials are specifically identified as promising opportunities to consider sex-based analyses at interim stages, allowing sex-specific flexibility as these trials unfold. Finally, we emphasize the importance of factoring sex as a biological variable into the design, analysis, and reporting of preclinical research, because this research critically informs the design and execution of clinical trials.

Exercise Electrocardiogram Neither Predicts Nor Excludes Coronary Artery Disease in Women with Low to Intermediate Risk

AIM

The value of exercise electrocardiogram (ExECG) in symptomatic female patients with low to intermediate risk for significant coronary artery disease (CAD) has been under debate for many years, and nondiagnostic or even erroneous test results are frequently encountered. Cardiac-CT may be more appropriate to exclude CAD in women. This study compares the results of ExECGs with those of cardiac-CTs, performed within a time frame of 1 month in an all-comers female chest pain population.

PATIENTS AND METHODS

Five hundred fifty-one consecutive female patients from a patient registry were included. ExECGs were negative in 324 (59%), positive in 14 (3%), and nondiagnostic in 213 (39%) patients. CAD was revealed by cardiac-CT in 57% of the women with negative ExECG. No signs of CAD were present on cardiac-CT in 64% of the women with a positive ExECG. Cardiac-CT showed presence of CAD in 268/551 (49%) patients, of whom 56/268 (21%) was diagnosed with ≥50% stenosis. The ExECG of the latter group was negative in 26 (46%), inconclusive in 29 (52%), and positive in 1 (2%). Considering ≥50% stenosis at cardiac-CT as the reference, sensitivity, specificity, PPV, and NPV of ExECG for the present population were 3.7%, 95.7%, 7.1%, and 91.7%, respectively. Similar diagnostic performance was calculated when considering ≥70% stenosis at cardiac-CT as the reference.

CONCLUSION

ExECG failed to detect CAD in more than half of this cohort and in almost half of women with >50% stenosis at cardiac-CT. Importantly, no CAD was detected by cardiac-CT in 64% of women with a positive ExECG. ExECG is therefore questionable as a diagnostic strategy in women with low-to-intermediate risk of CAD, although prospective studies are warranted to determine whether replacing ExECG by cardiac-CT provides better prognoses.

Sex-Related Aspects of Biomarkers in Cardiac Disease

Biomarkers play an important role in the clinical management of cardiac care. In particular, cardiac troponins (cTn) and natriuretic peptides are the cornerstones for the diagnosis of acute myocardial infarction (AMI) and for the diagnosis of heart failure (HF), respectively. Current guidelines do not make a distinction between women and men. However, the commonly used "one size fits all" algorithms are topic of debate to improve assessment of prognosis, particularly in women. Due to the high-sensitivity assays (hs-cTn), lower cTn levels (and 99th percentile upper reference limits) were observed in women as compared with men. Sex-specific diagnostic thresholds may improve the diagnosis of AMI in women, though clinical relevance remains controversial and more trials are needed. Also other diagnostic aspects are under investigation, like combined biomarkers approach and rapid measurement strategies. For the natriuretic peptides, previous studies observed higher concentrations in women than in men, especially in premenopausal women who might benefit from the cardioprotective actions. Contrary to hs-cTn, natriuretic peptides are particularly incorporated in the ruling-out algorithms for the diagnosis of HF and not ruling-in. Clinical relevance of sex differences here seems marginal, as clinical research has shown that negative predictive values for ruling-out HF were hardly effected when applying a universal diagnostic threshold that is independent from sex or other risk factors. Apart from the diagnostic issues of AMI in women, we believe that in the future most sex-specific benefits of cardiac biomarkers can be obtained in patient follow-up (guiding therapy) and prognostic applications, fitting modern ideas on preventive and personalized medicine.

Sex-specific differences in risk factors for in-hospital mortality and complications in patients with acute coronary syndromes : An observational cohort study

BACKGROUND

The goal of this observational cohort study was to examine gender-specific differences in the incidence of acute coronary syndrome (ACS), in-hospital complications and mortality.

METHODS

A cohort of 1550 patients with the primary diagnosis of ACS were enrolled in the study over a period of 4 years. The in-hospital mortality and complications were analyzed as the main outcome measures.

RESULTS

Women were significantly older compared to men (71 ± 11 years vs. 64 ± 12 years, p < 0.001) and had higher in-hospital mortality and complications due to this age difference. The prevalence of smoking was lower while hypertension and history of angina pectoris was more frequent in women, independent of age. Percutaneous transluminal coronary angioplasty (PTCA) with or without stenting as well as coronary catheterization significantly reduced in-hospital mortality and complications while thrombolytic therapy was associated with a 3.3 times increased mortality odds ratio (OR, p = 0.01). Other significant predictors of in-hospital mortality were in-hospital complications (OR 25, p < 0.001) and ST segment elevation myocardial infarction (STEMI, OR 4.5, p < 0.001).

CONCLUSIONS

Women differed from men in terms of ACS clinical characteristics, treatment, invasive procedures and survival outcome and some of these effects were age-related. The future emphasis should be based on the prevention of modifiable risk factors and identification of subgroups of female patients that could benefit from more aggressive therapeutic strategies.

Atorvastatin attenuates plaque vulnerability by downregulation of EMMPRIN expression via COX-2/PGE2 pathway

Extracellular matrix metalloproteinase inducer (EMMPRIN) reportedly has a key regulatory role in matrix metalloproteinase (MMP) activities and the progression of atherosclerosis. Statins, which are anti-atherosclerotic pharmacological agents, are widely applied in clinical settings. The aim of the present study was to investigate the pharmaceutical effect of atorvastatin on EMMPRIN expression in atherosclerotic plaques. An atherosclerotic mouse model was established using apoliprotein E-deficient (ApoE^−/−) mice raised on a high-fat diet. Additionally, a low (5 mg/kg/day) or high dosage (10 mg/kg/day) of atorvastatin suspension was administered orally for eight weeks, beginning on week 7 or 11 respectively. The effects of atorvastatin on atherosclerotic plaque formation and EMMPRIN expression were subsequently determined. The THP-1 cell line was used to investigate the effect of atorvastatin on EMMPRIN expression in vitro. The results demonstrated that the high-fat diet led to vulnerable plaques (VPs) and increased EMMPRIN expression in VPs in ApoE^−/− mice. Atorvastatin treatment decreased EMMPRIN expression in the aortas and plaques of ApoE^−/− mice. In vitro, oxidized low-density lipoprotein (ox-LDL) induced the expression of cyclooxygenase-2 (COX-2) and EMMPRIN in THP-1 macrophages, and atorvastatin inhibited ox-LDL-induced expression of PGE2, EMMPRIN and COX-2 in THP-1 macrophages. Therefore, the present data indicated that atorvastatin treatment reduces the vulnerability of atherosclerotic plaques and expression of EMMPRIN, and that the inhibitory effect of atorvastatin on EMMPRIN may occur via the COX-2/PGE2 signaling pathway in macrophages.