51
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Vrancic JM, Navia DO, Espinoza JC, Piccinini F, Camporrotondo M, Benzadon M, Dorsa A. Is sex a risk factor for death in patients with bilateral internal thoracic artery grafts? J Thorac Cardiovasc Surg 2019; 158:1345-1353.e1. [DOI: 10.1016/j.jtcvs.2019.01.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 12/23/2018] [Accepted: 01/03/2019] [Indexed: 12/17/2022]
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52
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Haberer K, Silversides CK. Congenital Heart Disease and Women's Health Across the Life Span: Focus on Reproductive Issues. Can J Cardiol 2019; 35:1652-1663. [PMID: 31813502 DOI: 10.1016/j.cjca.2019.10.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 01/11/2023] Open
Abstract
From adolescence to older age, women with congenital heart disease (CHD) face unique challenges. In this review we explore the ways in which CHD affects women's sexual and reproductive health and, in turn, how their sexual and reproductive history affects the course of their CHD. In adolescence, special attention must be paid to menstrual irregularities and concerns of developing sexuality and self-image. Discussions about sexuality and reproduction are an important part of transition planning and must be done with an awareness of the adolescent's developing understanding and maturity. Pregnancy imposes a hemodynamic load on the heart which may lead to cardiac, obstetric, and fetal/neonatal complications in women with CHD. Prepregnancy counselling must include an assessment of maternal and fetal risk according to several well developed models. Counselling should also include discussions about fertility and alternatives to pregnancy when appropriate. Recommendations for contraception must be made according to the patient's cardiac lesion. In caring for women with CHD during pregnancy, a multidisciplinary cardio-obstetrics team is recommended to optimize care. More research is needed into the long-term impact of pregnancy on the prognosis of patients with CHD. As women with CHD increasingly survive into old age, more attention will need to be directed toward the treatment of menopause and acquired heart disease in this population.
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Affiliation(s)
- Kim Haberer
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada
| | - Candice K Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada.
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53
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ter Woorst JF, van Straten AH, Houterman S, Soliman-Hamad MA. Sex Difference in Coronary Artery Bypass Grafting: Preoperative Profile and Early Outcome. J Cardiothorac Vasc Anesth 2019; 33:2679-2684. [DOI: 10.1053/j.jvca.2019.02.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/21/2019] [Accepted: 02/21/2019] [Indexed: 01/05/2023]
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Abstract
Background Prior research has shown higher mortality in women with severe coronary artery disease compared with men, particularly in younger patients. It is unknown if this could be attributable to an adverse risk factor profile. Methods and Results In a population‐based cohort study, we included all adults ≤50 years of age (932 women and 4514 men) who underwent coronary artery bypass grafting from 1995 to 2013 from the SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) register. Following inverse probability of treatment weighting, we investigated differences between women and men. Women had a higher prevalence of cardiovascular risk factors compared with men. There was no difference in early mortality between women and men (unadjusted: 1.3% versus 0.9%; hazard ratio, 1.42; 95% CI, 0.75–2.70; weighted sample: 1.1% versus 1.0%; hazard ratio, 1.10; 95% CI, 0.52–2.30). During a median follow‐up time of 11.8 years, in the unweighted population, the risk of death was greater in women compared with men (hazard ratio, 1.34; 95% CI, 1.13–1.58). However, in the weighted sample, the risk of death was not significantly different in women compared with men (hazard ratio, 1.02; 95% CI, 0.83–1.26). Conclusions Women ≤50 years of age had a higher unadjusted risk of death after coronary artery bypass grafting compared with men, but this was explained by a clustering of cardiovascular risk factors. Female sex per se was not associated with increased mortality or major adverse cardiovascular events. Early mortality was not increased in women compared with men, even though younger women in our study had an increased burden of risk factors known to affect early risk. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02276950.
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Affiliation(s)
- Magnus Dalén
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden.,Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - Susanne Nielsen
- Department of Molecular and Clinical Medicine Gothenburg University Gothenburg Sweden
| | - Torbjörn Ivert
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden.,Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - Martin J Holzmann
- Functional Area of Emergency Medicine Karolinska University Hospital Stockholm Sweden.,Department of Medicine Karolinska Institutet Stockholm Sweden
| | - Ulrik Sartipy
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden.,Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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55
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Allabadi H, Probst-Hensch N, Alkaiyat A, Haj-Yahia S, Schindler C, Kwiatkowski M, Zemp E. Mediators of gender effects on depression among cardiovascular disease patients in Palestine. BMC Psychiatry 2019; 19:284. [PMID: 31510958 PMCID: PMC6739957 DOI: 10.1186/s12888-019-2267-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 08/29/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Among patients suffering from coronary heart disease (CHD) and comorbid depression, women experience a higher burden compared to men. Little is known on the characteristics that differentiate men and women with both diseases and whether these factors mediate gender effects on depression. This study assessed whether women are more likely to suffer from depression and which characteristics mediate gender effects on depression among a cardiac population in Palestine, specifically addressing the role of post-traumatic stress disorder (PTSD). METHODS Using a cross-sectional design, patients consecutively admitted with a CHD to one of the four main hospitals in Nablus, Palestine, were interviewed using a structured questionnaire with validated instruments. Data was also obtained from hospital medical records. Patients were assessed for depression using the Cardiac Depression Scale (CDS). Bivariate analysis was conducted to compare characteristics of women and men with and without depressive symptoms. Mediators (direct and indirect effects) of the association between gender and depression were evaluated using a structural equation model (SEM). RESULTS Women were more likely to suffer from severe depression than men (28.7% vs. 18.8%). Female gender was positively associated with higher PTSD symptoms, comorbidities, somatic symptoms and income, and with lower resilience, self-esteem, quality of life, education, prevalence of smoking and physical activity. Structural equation modeling revealed negative indirect effects of gender on depression (CDS score) through resilience, self-esteem and physical activity, whereas positive indirect effects of gender on depression were observed through PTSD, comorbidities, somatic symptoms and smoking. There was no direct effect of gender on depression. CONCLUSION This study found a higher prevalence of severe depression in female patients with cardiac disease compared to male cardiac patients. Our findings provide novel information on mediating factors of the association between gender and depression among cardiac patients, in particular PTSD. The results emphasize the need for further research on potential mediating factors that could account for gender differences in depression and the need to provide support programs for female patients with comorbid CHD and depression to improve their psycho-social well-being.
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Affiliation(s)
- Hala Allabadi
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box, 4002, Basel, Switzerland. .,University of Basel, Petersplatz 1, 4001, Basel, Switzerland. .,Faculty of Medicine and Health Sciences, An-Najah National University, Rafidia Street, P.O. Box 7, Nablus, Palestine.
| | - Nicole Probst-Hensch
- 0000 0004 0587 0574grid.416786.aDepartment of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box, 4002, Basel, Switzerland ,0000 0004 1937 0642grid.6612.3University of Basel, Petersplatz 1, 4001 Basel, Switzerland
| | - Abdulsalam Alkaiyat
- 0000 0004 0587 0574grid.416786.aDepartment of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box, 4002, Basel, Switzerland ,0000 0004 1937 0642grid.6612.3University of Basel, Petersplatz 1, 4001 Basel, Switzerland ,0000 0004 0631 5695grid.11942.3fFaculty of Medicine and Health Sciences, An-Najah National University, Rafidia Street, P.O. Box 7, Nablus, Palestine
| | - Saleem Haj-Yahia
- 0000 0004 0631 5695grid.11942.3fAn-Najah National University Hospital, Asira Street, Nablus, Palestine ,0000 0004 1936 7603grid.5337.2School of Clinical Sciences, University of Bristol, 69 St Michael’s Hill, Bristol, BS2 8DZ UK ,0000 0001 2193 314Xgrid.8756.cInstitute of Cardiovascular and Medical Sciences, Glasgow University, 126 University Place, Glasgow, G12 8TA UK
| | - Christian Schindler
- 0000 0004 0587 0574grid.416786.aDepartment of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box, 4002, Basel, Switzerland ,0000 0004 1937 0642grid.6612.3University of Basel, Petersplatz 1, 4001 Basel, Switzerland
| | - Marek Kwiatkowski
- 0000 0004 0587 0574grid.416786.aDepartment of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box, 4002, Basel, Switzerland ,0000 0004 1937 0642grid.6612.3University of Basel, Petersplatz 1, 4001 Basel, Switzerland
| | - Elisabeth Zemp
- 0000 0004 0587 0574grid.416786.aDepartment of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box, 4002, Basel, Switzerland ,0000 0004 1937 0642grid.6612.3University of Basel, Petersplatz 1, 4001 Basel, Switzerland
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Nuru A, Weltzien JAH, Sandvik L, Tønnessen T, Bjørnstad JL. Short- and long-term survival after isolated coronary artery bypass grafting, the impact of gender and age. SCAND CARDIOVASC J 2019; 53:342-347. [PMID: 31321989 DOI: 10.1080/14017431.2019.1646430] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives. Assess the short- and long-term survival for patients who underwent isolated coronary artery bypass grafting (CABG) and evaluate the impact of gender and age. Furthermore to assess the long-term survival in the CABG group compared to the general population. Design. This study included 4044 consecutive patients who underwent isolated CABG at Oslo University Hospital, Ullevål, in Oslo, Norway in the time period from 01 January 2003 to 31 December 2015. Patient data was collected retrospectively from the quality register at the department. Information on survival status was obtained from the Norwegian National Registry. Life expectancy data for the general population was gained from Statistics Norway. Results. Female patients were significantly older than male patients at the time of surgery (mean age 67.0 and 63.9 years, respectively, p < .001), and had significantly lower 30-day survival (mortality was 1.4% and 0.6%, respectively, p = .017). Male gender was independently associated with lower long-term survival (p = .0037) in a multivariate analysis. Male patients aged less than 60 years also showed significantly lower long-term survival (SMR = 1.84, 95% CI = 1.49-2.25) compared to the age-matched general population. Among patients older than 60 years, survival was similar to survival in the age-matched general population. Conclusions. Survival was excellent for patients undergoing surgery. Despite increased age and operative mortality, female patients had better adjusted long-time survival than male patients. There was lower long-term survival among male patients aged less than 60 compared to the general population. Our findings may help clinicians in selecting appropriate patients for surgery.
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Affiliation(s)
- A Nuru
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - J A H Weltzien
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - L Sandvik
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - T Tønnessen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - J L Bjørnstad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
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Abstract
Heart disease is the leading cause of death among women in the industrialized world. However, women after myocardial infarctions (MIs) are less likely to receive preventive medications or revascularization and as many as 47% experience heart failure, stroke or die within 5 years. Premenopausal women with MIs frequently have coronary plaque erosions or dissections. Women under 50 years with angina and nonobstructive epicardial coronary artery disease often have coronary microvascular dysfunction (CMD) with reductions in coronary flow reserve that may require nontraditional therapies. In women with coronary artery disease treated with stents, the 3-year incidence of recurrent MI or death is 9.2%. Coronary bypass surgery operative mortality averages 4.6% for women compared with 2.4% in men. Addition of internal mammary artery and radial artery coronary grafts in women does not increase operative survival but improves 5-year outcome to greater than 80%.
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58
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Gofus J, Vobornik M, Sorm Z, Dergel M, Karalko M, Harrer J, Pojar M. Female sex as a risk factor in minimally invasive direct coronary artery bypass grafting. SCAND CARDIOVASC J 2019; 53:141-147. [DOI: 10.1080/14017431.2019.1612088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Jan Gofus
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Martin Vobornik
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Zdenek Sorm
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Martin Dergel
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Mikita Karalko
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Jan Harrer
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Marek Pojar
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
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Garatti A, Parolari A, Canziani A, Mossuto E, Daprati A, Abu Farah A, Brugnetti D, Ranucci M, Menicanti L. Is female sex an independent risk factor for early mortality in isolated coronary artery bypass graft? A propensity-matched analysis. J Cardiovasc Med (Hagerstown) 2019; 19:497-502. [PMID: 29917004 DOI: 10.2459/jcm.0000000000000659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Despite several studies reporting a higher mortality rate for women undergoing isolated coronary artery bypass graft (CABG) surgery, this issue has not been completely clarified. The aim of the current study was to determine if sex differences in CABG surgery affect adjusted operative results and operative mortality. METHODS Between January 2005 and December 2012, 3756 consecutive patients (3009 men and 747 women) underwent isolated CABG at our institution. Women presented with older age, smaller BSA and higher rate of preoperative comorbidities. The propensity score methodology was used to obtain risk-adjusted outcome comparisons between the two groups. RESULTS The distribution of preoperative variables among matched pairs (553 patients in both groups) was, on average, equal. Propensity-matched women received a similar number of distal anastomoses (P = 0.56), had similar rate of left internal thoracic artery (LITA) graft (P = 0.73) and comparable extracorporeal circulation (P = 0.61) and aortic cross-clamp (P = 0.39) time as men. Postoperative complications were comparable in the two study groups with the exception of postoperative transfusion rate which was significantly higher in women (P = 0.01). However, operative mortality (3.8 vs. 2.7%; P = 0.20), perioperative acute myocardial infarction (P = 0.50) and stroke (P = 0.75) were not significantly different between the two groups. Interestingly, after adjustment for the other baseline characteristics, female patients with diabetes (P = 0.03), preoperative renal dysfunction (P = 0.07) and obesity (P = 0.07) exhibited a greater operative mortality rate compared with men with the same comorbidities. CONCLUSION After adjustment for preoperative variables, female sex seems not to be an independent risk factor for early mortality in isolated CABG surgery. However, renal impairment, diabetes and obesity seem to play an important role in the operative risk profile of women undergoing isolated CABG.
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Affiliation(s)
- Andrea Garatti
- Department of Cardiac Surgery, I.R.C.C.S. Policlinico San Donato, Milan, Italy
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60
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Vignoli A, Tenori L, Giusti B, Takis PG, Valente S, Carrabba N, Balzi D, Barchielli A, Marchionni N, Gensini GF, Marcucci R, Luchinat C, Gori AM. NMR-based metabolomics identifies patients at high risk of death within two years after acute myocardial infarction in the AMI-Florence II cohort. BMC Med 2019; 17:3. [PMID: 30616610 PMCID: PMC6323789 DOI: 10.1186/s12916-018-1240-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 12/14/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Risk stratification and management of acute myocardial infarction patients continue to be challenging despite considerable efforts made in the last decades by many clinicians and researchers. The aim of this study was to investigate the metabolomic fingerprint of acute myocardial infarction using nuclear magnetic resonance spectroscopy on patient serum samples and to evaluate the possible role of metabolomics in the prognostic stratification of acute myocardial infarction patients. METHODS In total, 978 acute myocardial infarction patients were enrolled in this study; of these, 146 died and 832 survived during 2 years of follow-up after the acute myocardial infarction. Serum samples were analyzed via high-resolution 1H-nuclear magnetic resonance spectroscopy and the spectra were used to characterize the metabolic fingerprint of patients. Multivariate statistics were used to create a prognostic model for the prediction of death within 2 years after the cardiovascular event. RESULTS In the training set, metabolomics showed significant differential clustering of the two outcomes cohorts. A prognostic risk model predicted death with 76.9% sensitivity, 79.5% specificity, and 78.2% accuracy, and an area under the receiver operating characteristics curve of 0.859. These results were reproduced in the validation set, obtaining 72.6% sensitivity, 72.6% specificity, and 72.6% accuracy. Cox models were used to compare the known prognostic factors (for example, Global Registry of Acute Coronary Events score, age, sex, Killip class) with the metabolomic random forest risk score. In the univariate analysis, many prognostic factors were statistically associated with the outcomes; among them, the random forest score calculated from the nuclear magnetic resonance data showed a statistically relevant hazard ratio of 6.45 (p = 2.16×10-16). Moreover, in the multivariate regression only age, dyslipidemia, previous cerebrovascular disease, Killip class, and random forest score remained statistically significant, demonstrating their independence from the other variables. CONCLUSIONS For the first time, metabolomic profiling technologies were used to discriminate between patients with different outcomes after an acute myocardial infarction. These technologies seem to be a valid and accurate addition to standard stratification based on clinical and biohumoral parameters.
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Affiliation(s)
- Alessia Vignoli
- Magnetic Resonance Center (CERM), University of Florence, Sesto Fiorentino, Italy.,Consorzio Interuniversitario Risonanze Magnetiche di Metallo Proteine - C.I.R.M.M.P, Sesto Fiorentino, Italy
| | - Leonardo Tenori
- Magnetic Resonance Center (CERM), University of Florence, Sesto Fiorentino, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy. .,Careggi Hospital, Florence, Italy.
| | | | | | | | | | | | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Careggi Hospital, Florence, Italy
| | | | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Careggi Hospital, Florence, Italy
| | - Claudio Luchinat
- Magnetic Resonance Center (CERM), University of Florence, Sesto Fiorentino, Italy.,Consorzio Interuniversitario Risonanze Magnetiche di Metallo Proteine - C.I.R.M.M.P, Sesto Fiorentino, Italy.,Department of Chemistry, University of Florence, Sesto Fiorentino, Italy
| | - Anna Maria Gori
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Careggi Hospital, Florence, Italy
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Warraich HJ, Califf RM. Differences in Health Outcomes between Men and Women: Biological, Behavioral, and Societal Factors. Clin Chem 2019; 65:19-23. [DOI: 10.1373/clinchem.2018.287334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 06/26/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Haider J Warraich
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Robert M Califf
- Duke Forge, Duke University School of Medicine, Durham, NC
- Department of Medicine, Stanford University, Stanford, CA
- Verily Life Sciences (Alphabet), South San Francisco, CA
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Pabbidi MR, Kuppusamy M, Didion SP, Sanapureddy P, Reed JT, Sontakke SP. Sex differences in the vascular function and related mechanisms: role of 17β-estradiol. Am J Physiol Heart Circ Physiol 2018; 315:H1499-H1518. [DOI: 10.1152/ajpheart.00194.2018] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The incidence of cardiovascular disease (CVD) is lower in premenopausal women but increases with age and menopause compared with similarly aged men. Based on the prevalence of CVD in postmenopausal women, sex hormone-dependent mechanisms have been postulated to be the primary factors responsible for the protection from CVD in premenopausal women. Recent Women’s Health Initiative studies, Cochrane Review studies, the Early Versus Late Intervention Trial with Estradiol Study, and the Kronos Early Estrogen Prevention Study have suggested that beneficial effects of hormone replacement therapy (HRT) are seen in women of <60 yr of age and if initiated within <10 yr of menopause. In contrast, the beneficial effects of HRT are not seen in women of >60 yr of age and if commenced after 10 yr of menopause. The higher incidence of CVD and the failure of HRT in postmenopausal aged women could be partly associated with fundamental differences in the vascular structure and function between men and women and in between pre- and postmenopausal women, respectively. In this regard, previous studies from human and animal studies have identified several sex differences in vascular function and associated mechanisms. The female sex hormone 17β-estradiol regulates the majority of these mechanisms. In this review, we summarize the sex differences in vascular structure, myogenic properties, endothelium-dependent and -independent mechanisms, and the role of 17β-estradiol in the regulation of vascular function.
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Affiliation(s)
- Mallikarjuna R. Pabbidi
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Maniselvan Kuppusamy
- Division of Endocrinology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Sean P. Didion
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Padmaja Sanapureddy
- Department of Primary Care and Medicine, G. V. (Sonny) Montgomery Veterans Affairs Medical Center, Jackson, Mississippi
| | - Joey T. Reed
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Sumit P. Sontakke
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi
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63
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Galati A, Piccoli M, Tourkmani N, Sgorbini L, Rossetti A, Cugusi L, Bellotto F, Mercuro G, Abreu A, D’Ascenzi F. Cardiac rehabilitation in women. J Cardiovasc Med (Hagerstown) 2018; 19:689-697. [DOI: 10.2459/jcm.0000000000000730] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Stammers AH, Tesdahl EA, Mongero LB, Stasko A. Gender and intraoperative blood transfusion: analysis of 54,122 non-reoperative coronary revascularization procedures. Perfusion 2018; 34:236-245. [DOI: 10.1177/0267659118808728] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Previous studies have shown that women undergoing isolated coronary artery bypass graft (CABG) surgery have an increased risk for postoperative morbidity and mortality when compared to men. Additionally, recent evidence suggests that blood transfusions are independently associated with an increased risk of adverse outcome. Methods: We evaluated gender differences in the risk of intraoperative red blood cell (RBC) transfusion during CABG surgery. Consecutive, non-reoperative CABG procedures performed across 196 institutions between April 2012 and May 2015 were retrospectively reviewed. Gender differences for intraoperative transfusion were evaluated with a multi-variable binary logistic regression model, adjusting for age, blood volume (Nadler formula to normalize for height and weight), body mass index, procedure acuity, net extracorporeal circuit prime volume, use of autologous priming, first hematocrit (Hct) in the operating room (OR), nadir Hct on cardiopulmonary bypass (CPB), volume added on CPB, ultrafiltration volume, urine output on CPB and procedure duration. Results: Among 54,122 patients (25.3% female), 21.6% (n = 11,701) received a RBC transfusion. Compared to men, female patients were older (66 years vs. 64 years, p<0.001), had lower blood volumes (4.3L vs. 5.6L, p<0.001) and a lower preoperative Hct (32.9% vs. 37.2%, p<0.001). Transfusion rates were three-fold higher in women versus men (45.1% vs. 13.7%, p<0.001). After adjustment for independent predictors of intraoperative transfusion, women remained at increased risk versus men (OR = 1.30, 95%CI = 1.19−1.43). Conclusions: Women have an increased risk of intraoperative RBC transfusion versus men. After adjusting for height and weight, much of this risk is due to gender differences in preoperative Hct and blood volume; however, a residual significant risk remained after adjustment. Perfusion strategies aimed at gender differences may minimize unnecessary transfusions. Future study on the impact of gender on transfusion practice in cardiac surgery is warranted.
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65
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Does Robotic Beating Heart Connector Totally Endoscopic Coronary Artery Bypass Bridge the Gender Gap in Coronary Bypass Surgery? INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:35-39. [PMID: 29462052 DOI: 10.1097/imi.0000000000000465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Previous studies have shown that women carry a higher risk of morbidity and mortality after coronary artery bypass surgery. We investigated gender differences in risk factors and outcomes in our patients undergoing robotic beating heart connector totally endoscopic coronary artery bypass. METHODS From July 2013 to April 2017, patients undergoing connector totally endoscopic coronary artery bypass were reviewed. We compared the outcomes of men versus women. RESULTS A total of 192 men and 71 women underwent connector totally endoscopic coronary artery bypass. The mean ± SD age was 65.4 ± 10.6 years. The Society of Thoracic Surgeons score was higher in women than men (median = 1.46 vs 0.73, P = 0.001), and women had a higher rate of peripheral vascular disease (22.5% vs 9.9%, P = 0.007). Intraoperative data in women and men were similar except for the rate of multi-vessel connector totally endoscopic coronary artery bypass and the rate of bilateral internal mammary artery use, which were both lower in women (49.3% vs 64.6%, P = 0.024, and 42.3% vs 56.8%, P = 0.036, respectively). The mean ± SD length of hospital stay (women vs men: 3.99 ± 4.00 vs 3.39 ± 2.42, P = 0.324) was comparable. The 30-day mortality in women and men was 0% (0/71) and 2.1% (4/192), respectively (P = 0.577). The morbidity and mortality of single- or multi-vessel connector totally endoscopic coronary artery bypass were similar between men and women. CONCLUSIONS We conclude that the morbidity and mortality in women after robotic beating heart connector totally endoscopic coronary artery bypass in our center were similar to those seen in men.
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Mokhles MM, Soloukey Tbalvandany S, Siregar S, Versteegh MIM, Noyez L, van Putte B, Vonk ABA, Roos-Hesselink JW, Bogers AJJC, Takkenberg JJM. Male-female differences in aortic valve and combined aortic valve/coronary surgery: a national cohort study in the Netherlands. Open Heart 2018; 5:e000868. [PMID: 30228910 PMCID: PMC6135410 DOI: 10.1136/openhrt-2018-000868] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/05/2018] [Accepted: 07/24/2018] [Indexed: 11/05/2022] Open
Abstract
Objective The outcome of female patients after adult cardiac surgery has been reported to be less favourable compared with the outcome of male patients. This study compares men with women with respect to patient and procedural characteristics and early mortality in a contemporary national cohort of patients who underwent aortic valve (AV) and combined aortic valve/coronary (CABG/AV) surgery. Methods All patients who underwent AV (n=8717, 56% male) or a combined CABG/AV surgery (n=5867, 67% male) in the Netherlands between January 2007 and December 2011 were included. Results In both groups, women were generally older than men (p<0.001) and presented with higher logistic EuroSCORES. In isolated AV surgery, men and women had comparable in-hospital mortality (OR 1.20, 95% CI 0.90 to 1.61; p=0.220). In concomitant CABG/AV surgery, in-hospital mortality was higher in women compared with men (OR 2.00, 95% CI 1.44 to 2.79; p<0.001). The area under the curve for logistic EuroSCORE 1 was systematically higher for men versus women in isolated AV surgery 0.82 (95% CI 0.78 to 0.86) vs 0.75 (95% CI 0.69 to 0.80) and in concomitant CABG/AV surgery 0.78 (95% CI 0.73 to 0.82) vs 0.69 (95% CI 0.63 to 0.74). Finally, (the weight of) risk factors associated with in-hospital mortality differed between men and women. Conclusions There are substantial male-female differences in patient presentation and procedural aspects in isolated AV and concomitant CABG/AV surgery in the Netherlands. Further studies are necessary to explore the mechanisms underlying the observed differences. In addition, the observation that standard risk scores perform worse in women warrants exploration of male-female specific risk models for patients undergoing cardiac surgery.Brief title:
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Affiliation(s)
- M Mostafa Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Sabrina Siregar
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Michel I M Versteegh
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Luc Noyez
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart van Putte
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Alexander B A Vonk
- Department of Cardiothoracic Surgery, Free University Medical Center, Amsterdam, The Netherlands
| | - Jolien W Roos-Hesselink
- Department of Congenital Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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67
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Lamin V, Jaghoori A, Jakobczak R, Stafford I, Heresztyn T, Worthington M, Edwards J, Viana F, Stuklis R, Wilson DP, Beltrame JF. Mechanisms Responsible for Serotonin Vascular Reactivity Sex Differences in the Internal Mammary Artery. J Am Heart Assoc 2018; 7:JAHA.117.007126. [PMID: 29987120 PMCID: PMC6064825 DOI: 10.1161/jaha.117.007126] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The increased adverse cardiac events in women undergoing coronary artery bypass grafting are multifactorial and may include clinical, psychosocial, and biological factors. Potential contributing biological factors could include vascular hyperreactivity of the internal mammary artery (IMA) to endogenous vasoconstrictors in women, resulting in a predilection to myocardial ischemia. This study evaluated sex differences in serotonin and thromboxane A2 dependent vasoconstriction in human isolated IMA, with the mechanistic role of (1) the endothelium, (2) nitric oxide (NO), (3) prostaglandins, and (4) receptor activity investigated for any observed sex difference. Methods and Results Viable isolated human IMA segments were obtained from 116 patients (44 women [mean age, 66.8±12.2 years] and 72 men [mean age, 66.6±10.4 years]) undergoing coronary artery bypass grafting. Cumulative concentration‐response curves for serotonin and thromboxane A2 mimetic, U46619, were determined and revealed an increased sensitivity to serotonin but not U46619 in women. This sex difference to serotonin was further assessed by the following: (1) endothelial denudation, (2) endothelial NO synthase inhibition and NO quantification using electron paramagnetic resonance, (3) cyclooxygenase inhibition and prostaglandin metabolite quantification using mass spectrometry, and (4) quantification of receptor activity status. The female hyperreactivity to serotonin was (1) abolished by endothelial denudation; (2) unaffected by NO synthase inhibition, with no difference in electron paramagnetic resonance–assessed NO levels; (3) abolished by cyclooxygenase inhibition (quantification of prostaglandins in IMA revealed a trend towards reduced 6‐keto prostaglandin F1α in female IMA; P=0.08); and (4) unrelated to receptor activity. Conclusions These data indicate that female IMAs are hyperreactive to serotonin but not U46619, with the former attributable to an endothelium‐dependent cyclooxygenase pathway.
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Affiliation(s)
- Victor Lamin
- Discipline of Medicine, Adelaide Medical School, University of Adelaide, South Australia, Australia.,Cardiology Unit, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Amenah Jaghoori
- Discipline of Medicine, Adelaide Medical School, University of Adelaide, South Australia, Australia.,Cardiology Unit, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Rachel Jakobczak
- Discipline of Medicine, Adelaide Medical School, University of Adelaide, South Australia, Australia.,Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Irene Stafford
- Cardiology Unit, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Tamila Heresztyn
- Cardiology Unit, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Michael Worthington
- D'Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - James Edwards
- D'Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Fabiano Viana
- D'Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Robert Stuklis
- D'Arcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - David P Wilson
- Discipline of Medicine, Adelaide Medical School, University of Adelaide, South Australia, Australia.,Cardiology Unit, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - John F Beltrame
- Discipline of Medicine, Adelaide Medical School, University of Adelaide, South Australia, Australia .,Cardiology Unit, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Central Adelaide Local Health Network, Adelaide, South Australia, Australia
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68
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Kim WJ, Jeong MH, Kang DG, Lee SU, Cho SK, Ahn Y, Kim YJ, Kim CJ, Cho MC. Clinical Outcomes of Elderly Patients with Non ST-Segment Elevation Myocardial Infarction Undergoing Coronary Artery Bypass Surgery. Chonnam Med J 2018; 54:41-47. [PMID: 29399565 PMCID: PMC5794478 DOI: 10.4068/cmj.2018.54.1.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/01/2018] [Accepted: 01/15/2018] [Indexed: 12/02/2022] Open
Abstract
The aim of this study is to investigate the clinical outcomes of the elderly patients with Non ST-segment elevation myocardial infarction (NSTEMI) undergoing coronary artery bypass surgery (CABG) compared to non-elderly patients. Patients with NSTEMI and undergoing CABG (n=451) who were registered in the Korea Acute Myocardial Infarction Registry between December 2003 and August 2012 were divided into two groups.; the non-elderly group (<75 years, n=327) and the elderly group (≥75 years, n=124). In-hospital mortality was higher in the elderly group (4.9% vs. 11.3%, p=0.015), but cardiac death, myocardial infarction, and major adverse cardiovascular events (MACE) including cardiac death, myocardial infarction, percutaneous revascularization, and redo-CABG after a one-year follow up were not different between the two groups. Predictors of in-hospital mortality in patients with NSTEMI undergoing CABG were left ventricular (LV) dysfunction (ejection fraction ≤40%) [hazard ratio (HR): 2.76, 95% confidence interval (CI): 1.16–6.57, p=0.022] and age (HR: 1.05, 95% CI: 1.01–1.10, p=0.047). So elderly NSTEMI patients should be considered for CABG if appropriate, but careful consideration for surgery is required, especially if the patients have severe LV systolic dysfunction.
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Affiliation(s)
- Woo Jin Kim
- Department of Cardiology, Kwangju Christian Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Dong Goo Kang
- Department of Cardiology, Kwangju Christian Hospital, Gwangju, Korea
| | - Seung Uk Lee
- Department of Cardiology, Kwangju Christian Hospital, Gwangju, Korea
| | - Sang Ki Cho
- Department of Cardiology, Kwangju Christian Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Young Jo Kim
- Department of Cardiology, Yeungnam University Hospital, Daegu, Korea
| | - Chong Jin Kim
- Department of Cardiology, Kyung Hee University Hospital, Seoul, Korea
| | - Myeong Chan Cho
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Korea
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69
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Jabagi H, Tran DT, Hessian R, Glineur D, Rubens FD. Impact of Gender on Arterial Revascularization Strategies for Coronary Artery Bypass Grafting. Ann Thorac Surg 2018; 105:62-68. [DOI: 10.1016/j.athoracsur.2017.06.054] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 05/24/2017] [Accepted: 06/21/2017] [Indexed: 02/03/2023]
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70
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Kitahara H, McCrorey M, Patel B, Nisivaco S, Balkhy HH. Does Robotic Beating Heart Connector Totally Endoscopic Coronary Artery Bypass Bridge the Gender Gap in Coronary Bypass Surgery? INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018. [DOI: 10.1177/155698451801300106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Hiroto Kitahara
- Department of Surgery, University of Chicago Medicine, Chicago, IL USA
| | | | - Brooke Patel
- Department of Surgery, University of Chicago Medicine, Chicago, IL USA
| | - Sarah Nisivaco
- Department of Surgery, University of Chicago Medicine, Chicago, IL USA
| | - Husam H. Balkhy
- Department of Surgery, University of Chicago Medicine, Chicago, IL USA
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71
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Arri SS, Patterson T, Williams RP, Moschonas K, Young CP, Redwood SR. Myocardial revascularisation in high-risk subjects. Heart 2017; 104:166-179. [PMID: 29180542 DOI: 10.1136/heartjnl-2016-310487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Satpal S Arri
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Tiffany Patterson
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rupert P Williams
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Christopher P Young
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon R Redwood
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Rieß FC, Behrendt CA, Amin W, Heller S, Hansen L, Winkel S, Stripling J, Rieß HC. Complete arterial revascularization using bilateral internal mammary artery in T-graft technique for multivessel coronary artery disease in on- or off-pump approach: does gender lose its historical impact on clinical outcome? Eur J Cardiothorac Surg 2017; 52:917-923. [DOI: 10.1093/ejcts/ezx287] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 07/16/2017] [Indexed: 11/13/2022] Open
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73
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Leclercq F. [Cardiovascular disease in women in 2017]. REVUE DE L'INFIRMIÈRE 2017; 66:16-19. [PMID: 28865690 DOI: 10.1016/j.revinf.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
From an anatomical, physiological and clinical point of view, cardiovascular diseases in women are specific. Long considered as being less exposed to these risks, women are nevertheless victims of coronary disease, which remains, in developed countries, the leading cause of death in women. The situation is all the more concerning given that the number of young women presenting risk factors is constantly rising. Encouraging female patients to become players in their health care with regard to this pathology is especially important given that effective treatments exist which can improve the prognosis.
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Affiliation(s)
- Florence Leclercq
- Département de cardiologie, CHU de Montpellier, 371 avenue du Doyen Gaston-Giraud, 34090 Montpellier, France.
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Faerber G, Zacher M, Reents W, Boergermann J, Kappert U, Boening A, Diegeler A, Doenst T. Female sex is not a risk factor for post procedural mortality in coronary bypass surgery in the elderly: A secondary analysis of the GOPCABE trial. PLoS One 2017; 12:e0184038. [PMID: 28854266 PMCID: PMC5576733 DOI: 10.1371/journal.pone.0184038] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/23/2017] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE Female sex is considered a significant risk in cardiac surgery and is included in the majority of scores for risk assessment. However, the evidence is controversial and older women undergoing cardiac surgery have not specifically been investigated. We assessed the influence of female sex on surgical risk (30-day mortality) in a secondary analysis of the GOPCABE trial (German Off-Pump Coronary Artery Bypass grafting in the Elderly (GOPCABE) trial, comparing on- to off-pump) and also evaluated its impact on risk prediction from commonly used risk scores. METHODS We performed logistic regression analyses on the GOPCABE trial population, where patients were randomized to either on- or off-pump CABG. The study was performed in 12 cardiac surgery centers in Germany and analyzed 2394 patients having undergone CABG at age ≥75 years (1187 on-pump, 1207 off-pump). Of the 2394 patients, 755 (32%) were women. The logistic EuroSCORE and the German KCH score were calculated as expected (E) mortality and values were compared to observed (O) 30-day mortality (O/E ratio). RESULTS There was no difference in mortality or major cardiovascular adverse events after 30 days between men and women for both on- and off-pump CABG (men: on- vs. off-pump OR = 0.90, 95%-CI: [0.63;1.27]; women: on- vs. off-pump OR = 1.07, 95%-CI: [0.62;1.87]). Therefore, groups were combined for further analyses. Both men and women had considerable and similar comorbidities. Expected mortality was significantly higher for women than for men (logistic EuroSCORE: 8.88±6.71% vs. 7.99±6.69%, p = 0.003; KCH score: 4.42±3.97% vs. 3.57±3.65%, p = 0.001). However, observed mortality rates (O) tended to be even lower in women (2.1% vs. 3.0%). The O/E ratio was closer to 1 in men than in women (0.84 vs. 0.47). Excluding female sex from the risk models increased O/E ratio to 0.69. CONCLUSIONS Female sex is not a risk factor in coronary bypass surgery in the GOPCABE population. The result is the same for on- and off-pump surgery. Since female sex is a component of most risk scores, the findings may identify a potential inaccuracy in current surgical risk assessment, specifically for elderly women. TRIAL REGISTRATION Clinicaltrials.gov GOPCABE trial No. NCT00719667.
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Affiliation(s)
- Gloria Faerber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Michael Zacher
- Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Wilko Reents
- Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Jochen Boergermann
- Clinic for Heart, Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Utz Kappert
- Department of Cardiac Surgery, Cardiovascular Institute, University of Dresden, Dresden, Germany
| | - Andreas Boening
- Department of Cardiovascular Surgery, University of Gießen, Gießen, Germany
| | - Anno Diegeler
- Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
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Unique Presentations and Etiologies of Myocardial Infarction in Women. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:66. [DOI: 10.1007/s11936-017-0571-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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76
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Tsuji M, Kawasaki T, Matsuda T, Arai T, Gojo S, Takeuchi JK. Sexual dimorphisms of mRNA and miRNA in human/murine heart disease. PLoS One 2017; 12:e0177988. [PMID: 28704447 PMCID: PMC5509429 DOI: 10.1371/journal.pone.0177988] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 05/05/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Sexual dimorphisms are well recognized in various cardiac diseases such as ischemic cardiomyopathy (ICM), hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM). Thorough understanding of the underlying genetic programs is crucial to optimize treatment strategies specified for each gender. By performing meta-analysis and microarray analysis, we sought to comprehensively characterize the sexual dimorphisms in the healthy and diseased heart at the level of both mRNA and miRNA transcriptome. RESULTS Existing mRNA microarray data of both mouse and human heart were integrated, identifying dozens/ hundreds of sexually dimorphic genes in healthy heart, ICM, HCM, and DCM. These sexually dimorphic genes overrepresented gene ontologies (GOs) important for cardiac homeostasis. Further, microarray of miRNA, isolated from mouse sham left ventricle (LV) (n = 6 & n = 5 for male & female) and chronic MI LV (n = 19 & n = 19) and from human normal LV (n = 6 & n = 6) and ICM LV (n = 4 & n = 5), was conducted. This revealed that 13 mouse miRNAs are sexually dimorphic in MI and 6 in normal heart. In human, 3 miRNAs were sexually dimorphic in ICM and 15 in normal heart. These data revealed miRNA-mRNA networks that operate in a sexually-biased fashion. CONCLUSIONS mRNA and miRNA transcriptome of normal and disease heart show significant sex differences, which might impact the cardiac homeostasis. Together this study provides the first comprehensive picture of the genome-wide program underlying the heart sexual dimorphisms, laying the foundation for gender specific treatment strategies.
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Affiliation(s)
- Masato Tsuji
- Division of Bio-informational Pharmacology, Medical Research Institute, Tokyo Medical Dental University, Tokyo, Japan
- Department of Biological Sciences, Graduate School of Science, The University of Tokyo, Tokyo, Japan
- * E-mail: (MT); (JKT)
| | - Takanori Kawasaki
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takeru Matsuda
- Department of Mathematical Informatics, Graduate School of Information Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Tomio Arai
- Department of Pathology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Satoshi Gojo
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Jun K. Takeuchi
- Division of Bio-informational Pharmacology, Medical Research Institute, Tokyo Medical Dental University, Tokyo, Japan
- Department of Biological Sciences, Graduate School of Science, The University of Tokyo, Tokyo, Japan
- * E-mail: (MT); (JKT)
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Wang J, Yu W, Zhao D, Liu N, Yu Y. In-Hospital and Long-Term Mortality in 35,173 Chinese Patients Undergoing Coronary Artery Bypass Grafting in Beijing: Impact of Sex, Age, Myocardial Infarction, and Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2017; 31:26-31. [DOI: 10.1053/j.jvca.2016.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Indexed: 11/11/2022]
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78
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Epps KC, Holper EM, Selzer F, Vlachos HA, Gualano SK, Abbott JD, Jacobs AK, Marroquin OC, Naidu SS, Groeneveld PW, Wilensky RL. Sex Differences in Outcomes Following Percutaneous Coronary Intervention According to Age. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2016; 9:S16-25. [PMID: 26908855 DOI: 10.1161/circoutcomes.115.002482] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Women <50 years of age with coronary artery disease may represent a group at higher risk for recurrent ischemic events after percutaneous coronary intervention (PCI); however, no long-term, multicenter outcomes assessment exists in this population. METHODS AND RESULTS Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated the association of sex and age on cardiovascular-related outcomes in 10,963 patients (3797 women, 394 <50 years) undergoing PCI and followed for 5 years. Death, myocardial infarction, coronary artery bypass graft surgery, and repeat PCI were primary outcomes comprising major adverse cardiovascular events. Although procedural success rates were similar by sex, the cumulative rate of major adverse cardiovascular events at 1 year was higher in young women (27.8 versus 19.9%; P=0.003), driven largely by higher rates of repeat revascularizations for target vessel or target lesion failure (coronary artery bypass graft surgery: 8.9% versus 3.9%, P<0.001, adjusted hazard ratio 2.4, 95% confidence interval 1.5-4.0; PCI: 19.0% versus 13.0%, P=0.005, adjusted hazard ratio 1.6, 95% confidence interval 1.2-2.2). At 5 years, young women remained at higher risk for repeat procedures (coronary artery bypass graft surgery: 10.7% versus 6.8%, P=0.04, adjusted hazard ratio 1.71, 95% confidence interval 1.01-2.88; repeat PCI [target vessel]: 19.7% versus 11.8%, P=0.002, adjusted hazard ratio 1.8, 95% confidence interval 1.24-2.82). Compared with older women, younger women remained at increased risk of major adverse cardiovascular events, whereas all outcome rates were similar in older women and men. CONCLUSIONS Young women, despite having less severe angiographic coronary artery disease, have an increased risk of target vessel and target lesion failure. The causes of this difference deserve further investigation. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00005677.
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Affiliation(s)
- Kelly C Epps
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Elizabeth M Holper
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Faith Selzer
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Helen A Vlachos
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Sarah K Gualano
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - J Dawn Abbott
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Alice K Jacobs
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Oscar C Marroquin
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Srihari S Naidu
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Peter W Groeneveld
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
| | - Robert L Wilensky
- From the Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, and Cardiovascular Institute, University of Pennsylvania, Philadelphia (K.C.E., R.L.W.); Department of Medicine, Division of Cardiology, Medical City Hospital, Dallas, TX (E.M.H.); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA (F.S., H.A.V.); Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (S.K.G.); Department of Medicine, Rhode Island Hospital, Cardiovascular Institute, Providence, RI (J.D.A.); Department of Medicine, Section of Cardiology, Boston University Medical Center, MA (A.K.J.); Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA (O.C.M.); Department of Medicine, Division of Cardiology, Winthrop University Hospital, Mineola, NY (S.S.N.); and Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine and the Leonard Davis Institute for Health Economics, University of Pennsylvania, Michael J. Crescenz VA Medical Center, Philadelphia (P.W.G.)
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Ghannem M, Ghannem L, Lamouchi S, Justin KD, Meimoun P, Ghannem L. [Cardiac rehabilitation in women]. Ann Cardiol Angeiol (Paris) 2016; 65:462-467. [PMID: 27817849 DOI: 10.1016/j.ancard.2016.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Coronary artery disease (CAD) occurs later in life in women when compared to men (10 years later). The FAST-MI study has shown that the profile of women with CAD has changed in the past 15 years, they are younger, more obese, and usually smokers. Whatever the age at which CAD occurs in women, the prognosis tends to be worse than in men, despite a higher frequency of acute coronary syndrome (ACS) with angiographically normal coronary arteries in women. In women without significant lesion at coronary angiography, the WISE study has shown abnormalities of the coronary vasomotricy. Despite its beneficial effect on morbidity and mortality, cardiac rehabilitation is underused particularly in women. Indeed, several factors do not encourage a woman to follow a cardiac rehabilitation program, even after an ACS. These factors may be cultural, domestic, familial, orthopedic, or even the fear of exercising. Therefore, physicians have to be particularly convincing in women, in order to have them participating in rehabilitation programs. Physical capacity is lower in women when compared to men. However, the weaker the physical capacity, the better the benefit of cardiac rehabilitation. Physical endurance training continuously or in interval, associated to muscle strengthening can improve the physical capacity in women. Vascular risk factors correction is also an important step for the management of women with CAD. Therapeutic education and several available workshops help women to better understand their disease and to improve their self-management when they return home. Anxiety, depression, and sexual dysfunction frequently deteriorate the quality of life of our patients. Therefore, psychological management is also essential in our departments.
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Affiliation(s)
- M Ghannem
- Centre hospitalier de Gonesse, service de cardiologie, 2, boulevard du 19-Mars-1962, 95500 Gonesse, France; Centre hospitalier intercommunal de Compiègne, 60200 Compiègne, France.
| | - L Ghannem
- Centre hospitalier de Gonesse, service de cardiologie, 2, boulevard du 19-Mars-1962, 95500 Gonesse, France
| | - S Lamouchi
- Service de cardiologie, hôpital de Médenine, Médenine, Tunisie
| | - K D Justin
- Service de médecine, institut de cardiologie d'Abidjan, Abidjan, Sénégal
| | - P Meimoun
- Centre hospitalier intercommunal de Compiègne, 60200 Compiègne, France
| | - L Ghannem
- Centre hospitalier de Gonesse, service de cardiologie, 2, boulevard du 19-Mars-1962, 95500 Gonesse, France
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80
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Lakhter V, Alkhouli M, Zack CJ, Zhao H, Cohen HA, O'Neill BP, O'Murchu B, Bove AA, Bashir R. Sex Differences in Fractional Flow Reserve-Guided Revascularization: A Nationwide Analysis. J Womens Health (Larchmt) 2016; 26:109-115. [PMID: 27754754 DOI: 10.1089/jwh.2016.5806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Women with coronary artery disease are less likely to be revascularized than men based on angiography alone. Recent studies have shown that female patients have higher fractional flow reserve (FFR) values for a given severity of coronary stenosis. However, gender differences in coronary revascularization rates following FFR assessment are unknown. METHODS The nationwide inpatient sample database was used to identify all patients who underwent FFR in the United States between January 2009 and December 2010. We used propensity score matching to compare revascularization rates and in-hospital outcomes among men and women undergoing FFR measurements. RESULTS Among 3712 patients who underwent FFR during the study period, 1235 matched pairs of men and women were identified. The overall revascularization rates were lower in women than men (40.1% vs. 52.8%, p < 0.01). Women were less likely to undergo either percutaneous (35.2% vs. 45.6%, p < 0.01) or surgical revascularization following FFR than men (5.2% vs. 7.4%, p = 0.03). Women had a nonsignificant trend toward higher in-hospital mortality (0.8% vs. 0.5%, p = 0.32) and significantly higher rates of access site hematoma formation (2.7% vs. 0.8%, p < 0.01) compared to men. CONCLUSION In conclusion, this large nationwide study reveals that coronary revascularization rates are significantly lower in women than in men even after functional assessment with FFR.
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Affiliation(s)
- Vladimir Lakhter
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
| | - Mohamad Alkhouli
- 2 Division of Cardiology, WVU Heart & Vascular Institute, West Virginia University , Morgantown, West Virginia
| | - Chad J Zack
- 3 Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic , Rochester, Minnesota
| | - Huaqing Zhao
- 4 Department of Clinical Sciences, Temple University School of Medicine , Philadelphia, Pennsylvania
| | - Howard A Cohen
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
| | - Brian P O'Neill
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
| | - Brian O'Murchu
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
| | - Alfred A Bove
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
| | - Riyaz Bashir
- 1 Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital , Philadelphia, Pennsylvania
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81
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Dorbala S, Shaw LJ. Changing the trajectory of ischemic heart disease in women: Role of imaging. J Nucl Cardiol 2016; 23:973-975. [PMID: 27457523 DOI: 10.1007/s12350-016-0604-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
Abstract
Mortality from coronary artery disease in women declined from nearly 500,000 deaths in 2000 to 398,096 deaths in 2013. Despite these significant gains, cardiovascular disease mortality in women remains unacceptably high. Much additional progress in awareness, evaluation, and management of cardiovascular diseases is needed. Progress in cardiovascular imaging, over the past four decades, has substantially improved the evaluation and management of ischemic heart disease. Ischemic heart disease is now diagnosed early and with greater accuracy, leading to improved risk assessment and timely therapies. The next gains in ischemic heart disease mortality in women will probably be due to application of these imaging advances in a personalized fashion. Thoughtful leaders provide their viewpoints on the use of imaging in the evaluation and management of ischemic heart disease in women.
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Affiliation(s)
- Sharmila Dorbala
- Noninvasive Cardiovascular Imaging Program, Departments of Radiology and Medicine (Cardiology), Harvard Medical School, Brigham and Women's Hospital, 70 Francis Street, Shapiro 5th Floor, Room 128, Boston, MA, 02115, USA.
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, 70 Francis Street, Shapiro 5th Floor, Room 128, Boston, MA, 02115, USA.
| | - Leslee J Shaw
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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82
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McIlvennan CK, Lindenfeld J, Kao DP. Sex differences and in-hospital outcomes in patients undergoing mechanical circulatory support implantation. J Heart Lung Transplant 2016; 36:82-90. [PMID: 27773454 DOI: 10.1016/j.healun.2016.08.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 07/19/2016] [Accepted: 08/17/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Mechanical circulatory support (MCS) is a widely available management strategy. No studies have described sex differences in both extracorporeal and durable MCS. We analyzed sex-related differences of in-hospital outcomes for extracorporeal and durable MCS using administrative hospital data. METHODS In total, 134.5 million hospital records between 1994 and 2012 were screened for placement of MCS using procedure codes of the International Classification of Diseases-9, Clinical Modification. Major adverse events (MAEs) were defined as death, major bleeding, stroke, device infection or mechanical complication. Participation in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry was determined on an annual basis using quarterly reports of the INTERMACS. Associations between characteristics and outcomes were determined using multivariable logistic regression. RESULTS Sex was reported in 3,523 of 4,337 patients undergoing MCS placement from 45 INTERMACS sites (n = 1,383) and 246 non-INTERMACS sites (n = 2,954). Twenty-two percent were female. Baseline characteristics were significantly different with women being slightly younger (33.5% vs 27.4% age <50 years, p < 0.001; mean 55.7 ± 17.3 vs 56.1 ± 14.6 years) with fewer comorbidities. Women had higher rates of in-hospital mortality (52.3% vs 40.8%, p < 0.001) and MAEs (64.8% vs 52.5%, p < 0.001). Women had an 89% higher likelihood of MAEs when corrected for multivariate predictors (p < 0.001). In-hospital mortality decreased over time for both men and women (10% relative risk reduction/year, p < 0.001), but mortality in women was higher than in men throughout the study period. CONCLUSION There are significant sex differences in characteristics and outcomes of patients receiving MCS. Women had higher in-hospital mortality and were at increased risk of MAEs, which could not be explained by age or comorbid conditions. Further research on the causes of these disproportionate outcomes is needed.
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Affiliation(s)
- Colleen K McIlvennan
- Division of Cardiology, School of Medicine, University of Colorado, Aurora, Colorado, USA.
| | - JoAnn Lindenfeld
- Division of Cardiology, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - David P Kao
- Division of Cardiology, School of Medicine, University of Colorado, Aurora, Colorado, USA
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83
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Fox AA, Nussmeier NA. Does Gender Influence the Likelihood or Types of Complications Following Cardiac Surgery? Semin Cardiothorac Vasc Anesth 2016; 8:283-95. [PMID: 15583790 DOI: 10.1177/108925320400800403] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Over 410,000 cardiac surgeries are performed in American women each year. Women having coronary artery bypass graft (CABG) and valve surgery do so at an older age and with more cardiovascular risk factors than men. Women's smaller body size may also increase risk by increasing the technical difficulty of surgical procedures. Female CABG patients appear to have higher perioperative mortality and cardiac morbidity, although studies of neurologic outcomes in female CABG patients have produced equivocal findings. Women undergoing CABG tend to consume more hospital resources than men do in terms of blood transfusion, mechanical ventilation, and length of intensive care unit and overall hospital stay. With regard to valve surgery, women appear to have worse outcomes than men if the surgery is combined with a CABG operation. Women and men undergoing isolated aortic valve surgery have similar mortality, but little is known about gender differences in mitral and tricuspid valve surgery outcomes. Women who require heart transplantation tend to have idiopathic cardiomyopathy rather than the ischemic cardiomyopathy that is more common in male heart transplant candidates. Although female heart transplant recipients seem to have a stronger immunologic response after transplantation, which manifests in more frequent acute rejection episodes, it is not clear whether this increases women's mortality risk. Men appear to have a greater incidence of posttransplant vasculopathy than women. Further research is needed to identify risk factors for perioperative morbidity and mortality in women undergoing cardiac surgery and to develop medical interventions to mitigate these risks.
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Affiliation(s)
- Amanda A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
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84
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Xuereb R, Magri CJ, Xuereb S, Xuereb M, Mangion MZ, Xuereb RG. Female gender and cardiovascular disease. Br J Hosp Med (Lond) 2016; 77:454-9. [DOI: 10.12968/hmed.2016.77.8.454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Rachel Xuereb
- Third year medical student at the University of Malta, Malta
| | - Caroline J Magri
- Resident Specialist in the Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Msida MSD 2090, Malta, and Visiting Lecturer, University of Malta, Malta
| | - Sara Xuereb
- Foundation Year 2 Doctor in the Department of Medicine, Mater Dei Hospital, Malta
| | - Mariosa Xuereb
- Consultant Cardiologist in the Department of Cardiology, Mater Dei Hospital, and Visiting Senior Lecturer, University of Malta, Malta
| | | | - Robert G Xuereb
- Chairman and Consultant Cardiologist in the Department of Cardiology, Mater Dei Hospital, and Visiting Senior Lecturer, University of Malta, Malta
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Swaminathan RV, Feldman DN, Pashun RA, Patil RK, Shah T, Geleris JD, Wong SC, Girardi LN, Gaudino M, Minutello RM, Singh HS, Bergman G, Kim LK. Gender Differences in In-Hospital Outcomes After Coronary Artery Bypass Grafting. Am J Cardiol 2016; 118:362-8. [PMID: 27269585 DOI: 10.1016/j.amjcard.2016.05.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 05/04/2016] [Accepted: 05/04/2016] [Indexed: 12/21/2022]
Abstract
Women historically have a greater risk of operative mortality than men after coronary artery bypass grafting (CABG). There is paucity of contemporary data in gender outcomes of surgical revascularization and understanding modifiable factors that contribute to gender differences are critical for quality improvement and practice change. We, therefore, sought to examine whether the gender gap in CABG outcomes is closing in the contemporary era by conducting a retrospective analysis from the Nationwide Inpatient Sample database from 2003 to 2012. We included all patients who underwent isolated CABG surgery (n = 2,272,998; female n = 623,423 [27.4%]; male n = 1,649,575 [72.6%]). The annual rate of CABG surgeries decreased by 53.7% in men and 57.8% in women over the 10-year study period. Although internal mammary artery use in women was less frequent than in men in 2003 (77.4% vs 81.9%, p <0.001), a significant uptrend closed this gap by 2012 (86.2% vs 87.0%, ptrend 0.003). Overall, unadjusted in-hospital mortality was greater in women (3.2% vs 1.8%, p <0.001). Female gender remained an independent predictor of mortality after multivariate adjustment (odds ratio 1.40, 95% CI 1.36 to 1.43, p <0.001) across all age groups. However, in-hospital mortality decreased at a faster rate in women (3.8% to 2.7%, RR -29.1%, ptrend 0.002) than in men (2.2% to 1.6%, RR -25.7%, ptrend <0.001) from 2003 to 2012. In conclusion, CABG rates in the United States are decreasing over time, yet in-hospital mortality continues to improve. Women have worse in-hospital outcomes than men; however, the gender gap is slowly closing.
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Affiliation(s)
- Rajesh V Swaminathan
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York.
| | - Dmitriy N Feldman
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Raymond A Pashun
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Rupa K Patil
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Tara Shah
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Joshua D Geleris
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Shing-Chiu Wong
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York; Department of Cardiovascular Sciences, Catholic University, Rome, Italy
| | - Robert M Minutello
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Harsimran S Singh
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Geoffrey Bergman
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Luke K Kim
- Greenberg Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
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Mokhles MM, Siregar S, Versteegh MIM, Noyez L, van Putte B, Vonk ABA, Roos-Hesselink JW, Bogers AJJC, Takkenberg JJM. Male-female differences and survival in patients undergoing isolated mitral valve surgery: a nationwide cohort study in the Netherlands. Eur J Cardiothorac Surg 2016; 50:482-7. [PMID: 27174553 DOI: 10.1093/ejcts/ezw151] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/08/2016] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES The objective of this study was to compare male-female differences with respect to baseline characteristics and short-term outcome in a contemporary nationwide cohort of patients who underwent isolated mitral valve (MV) surgery. METHODS All patients [N = 3411; 58% males (N = 1977)] who underwent isolated MV surgery (replacement: N = 1048, 31%; reconstruction: N = 2364, 69%) in the Netherlands between January 2007 and December 2011 were included in this study. Differences in patient and procedural characteristics and in-hospital outcome were compared between male and female patients. RESULTS Female patients were generally older (mean age, 64 vs 61 years, P < 0.001), presented more often with pulmonary hypertension (P = 0.03) and had higher logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) I (P < 0.001). Male patients presented more often with prior coronary artery bypass graft surgery (P < 0.001) and active endocarditis (P = 0.002). Female patients underwent MV replacement more often (P < 0.001) and, in case of replacement, received stented bioprostheses more often (P < 0.001). In-hospital mortality rates after MV replacement were 7% (n = 33) and 7% (n = 40) in male and female patients, respectively (OR 1.08, 95% CI 0.67-1.75; P = 0.75). In-hospital mortality rates after MV reconstruction were 1.4% (n = 21) and 1.3% (n = 11) in male and female patients, respectively (OR 0.88, 95% CI 0.42-1.84; P = 0.74). CONCLUSIONS There are substantial male-female differences in patient presentation and procedural aspects in isolated MV surgery in the Netherlands. Female patients are older, have more severe disease at the time of surgery and undergo valve repair less often. Future studies are needed to identify potentially modifiable patient factors to improve the outcome of female patients with MV disease.
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Affiliation(s)
- Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Sabrina Siregar
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Michel I M Versteegh
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Luc Noyez
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Bart van Putte
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Alexander B A Vonk
- Department of Cardiothoracic Surgery, Free University Medical Center, Amsterdam, Netherlands
| | - Jolien W Roos-Hesselink
- Department of Congenital Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
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87
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Filardo G, Hamman BL, Pollock BD, da Graca B, Sass DM, Phan TK, Edgerton J, Prince SL, Ring WS. Excess short-term mortality in women after isolated coronary artery bypass graft surgery. Open Heart 2016; 3:e000386. [PMID: 27042323 PMCID: PMC4809184 DOI: 10.1136/openhrt-2015-000386] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/21/2016] [Accepted: 02/14/2016] [Indexed: 01/28/2023] Open
Abstract
Objective Female sex is considered a risk factor for adverse outcomes following isolated coronary artery bypass graft (CABG) surgery. We assessed the association between sex and short-term mortality following isolated CABG, and estimated the ‘excess’ deaths occurring in women. Methods Short-term mortality was investigated in 13 327 consecutive isolated CABG patients in North Texas between January 2008 and December 2012. The association between sex and CABG short-term mortality, and the excess deaths among women were assessed via a propensity-adjusted (by Society of Thoracic Surgeons-recognised risk factors) generalised estimating equations model approach. Results Short-term mortality was significantly higher in women than men (adjusted OR=1.39; 95% CI 1.04 to 1.86; p=0.027). This significantly greater risk translates into 35 ‘excess’ deaths among women included in this study (>10% of the total 343 deaths in the study cohort) and into 392 ‘excess’ deaths among the ∼40 000 women undergoing isolated CABG in the USA each year. Conclusions The higher risk associated with female sex lead to 35 ‘excess’ deaths in women in this study cohort (over 10% of the total deaths) and to 392 ‘excess’ deaths among women undergoing isolated CABG in the USA each year. Further research is needed to assess the causal mechanisms underlying this sex-related difference. Results of such work could inform the development and implementation of sex-specific treatment and management strategies to reduce women's mortality following CABG. Based on our results, if such work brought women's short-term mortality into line with men's, total short-term mortality could be reduced by up to 10%.
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Affiliation(s)
- Giovanni Filardo
- Department of Epidemiology , Office of the Chief Quality Officer, Baylor Scott & White Health , Dallas, Texas , USA
| | - Baron L Hamman
- Department of Cardiothoracic Surgery , Baylor Heart and Vascular Institute, Baylor University Medical Center , Dallas, Texas , USA
| | - Benjamin D Pollock
- Department of Epidemiology , Office of the Chief Quality Officer, Baylor Scott & White Health , Dallas, Texas , USA
| | - Briget da Graca
- Department of Epidemiology , Office of the Chief Quality Officer, Baylor Scott & White Health , Dallas, Texas , USA
| | - Danielle M Sass
- Department of Epidemiology , Office of the Chief Quality Officer, Baylor Scott & White Health , Dallas, Texas , USA
| | - Teresa K Phan
- Department of Epidemiology , Office of the Chief Quality Officer, Baylor Scott & White Health , Dallas, Texas , USA
| | | | - Syma L Prince
- Cardiopulmonary Research Science & Technology Institute , Dallas, Texas , USA
| | - W Steves Ring
- Department of Cardiothoracic Surgery , UT Southwestern Medical Center , Dallas, Texas , USA
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88
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Figueiredo Neto JAD, Barroso LC, Nunes JKVRS, Nina VJDS. Sex Differences in Mortality After CABG Surgery. Braz J Cardiovasc Surg 2016; 30:610-4. [PMID: 26934399 PMCID: PMC4762551 DOI: 10.5935/1678-9741.20150073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 10/12/2015] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Numerous studies have shown that women undergoing coronary artery bypass
graft surgery present higher mortality rate during hospitalization, and
often complications when compared to men. OBJECTIVE To compare the mortality of men and women undergoing coronary artery bypass
graft surgery and identify factors related to differences occasionally
found. METHODS Retrospective cohort study conducted with 215 consecutive patients who
underwent coronary bypass surgery. RESULTS Women had a higher average age. Low body surface and dyslipidemia were more
prevalent in women (1.65 vs. 1.85, P
<0.001: 53% vs. 30%, P =0.001), whereas
history of smoking and previous myocardial infarction were more prevalent in
men (35% vs.14.7%, P =0.001; 20%
vs. 2.7%, P =0.007). Regarding
complications in the postoperative period, there was a higher rate of blood
transfusions in women. The overall mortality rate was 5.6%, however there
was no statistically significant difference in mortality between men and
women. It was observed that among the patients who died, the average body
surface area was lower than that of patients who did not have this
complication. CONCLUSION There was no difference in mortality between the sexes after coronary artery
bypass graft in this service.
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89
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Arif R, Farag M, Gertner V, Szabó G, Weymann A, Veres G, Ruhparwar A, Bekeredjian R, Bruckner T, Karck M, Kallenbach K, Beller CJ. Female Gender and Differences in Outcome after Isolated Coronary Artery Bypass Graft Surgery: Does Age Play a Role? PLoS One 2016; 11:e0145371. [PMID: 26845158 PMCID: PMC4741386 DOI: 10.1371/journal.pone.0145371] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 12/01/2015] [Indexed: 11/21/2022] Open
Abstract
Introduction Female gender is a known risk factor for early and late mortality after coronary artery bypass graft surgery (CABG). Higher age of women at operation may influence outcome, since age per se is also an important risk factor. The purpose of our study was to analyze possible gender differences in outcome after isolated CABG in different age groups to delineate the impact of female gender and age. Methods All patients over 60 years of age undergoing isolated CABG at our department during 2001 and 2011 were included and categorized by age into sexagenarians (2266, 16.6% women), septuagenarians (2332, 25.4% women) and octogenarians (374, 32% women) and assessed by gender for 30-day and 180-day mortality. Results Thirty-day mortality was significantly higher in women only amongst septuagenarians (7.1 vs. 4.7%, p = 0.033). Same differences apply for 180-day mortality (12.3 vs. 8.2%, p = 0.033) and estimated one-year survival (81.6 ± 4.2 vs. 86.9 ± 2.2%, p = 0.001). Predictive factors for 30-day mortality of septuagenarian were logistic EuroSCORE (ES) (p = 0.003), perioperative myocardial infarction (MI) (p<0.001), pneumonia (p<0.001), abnormal LV-function (p<0.04) and use of LIMA graft (p<0.001), but not female gender. However, female gender was found to be an independent predictor for 180-day mortality (HR 1.632, p = 0.001) in addition to ES, use of LIMA graft, perioperative MI, pneumonia and abnormal LV function (HR 1.013, p = 0.004; HR 0.523, p<0.001; HR 2.710, p<0.001; HR 3.238, p<0.001; HR 2.013, p<0.001). Conclusion Women have a higher observed probability of early death after CABG in septuagenarians. However, female gender was not found to be an independent risk factor for 30-day, but for 180-day survival. Therefore, reduction of high impact risk factors such as perioperative MI and enhancement of LIMA use should be future goals. In view of our findings, decision for surgical revascularization should not be based on gender.
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Affiliation(s)
- Rawa Arif
- Department of Cardiac Surgery, Heart Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
- * E-mail:
| | - Mina Farag
- Department of Cardiac Surgery, Heart Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Victor Gertner
- Department of Cardiac Surgery, Heart Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Gabor Szabó
- Department of Cardiac Surgery, Heart Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, Heart Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Gabor Veres
- Department of Cardiac Surgery, Heart Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, Heart Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Raffi Bekeredjian
- Department of Cardiology, Angiology and Pneumology, Heart Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Tom Bruckner
- Institute of Medical Biometry and Informatics, Heart Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heart Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Klaus Kallenbach
- Department of Cardiac Surgery, Heart Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Carsten J. Beller
- Department of Cardiac Surgery, Heart Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
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90
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Prognosis after maternal placental events and revascularization: PAMPER study. Am J Obstet Gynecol 2016; 214:106.e1-106.e14. [PMID: 26283454 DOI: 10.1016/j.ajog.2015.08.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 07/29/2015] [Accepted: 08/10/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Middle-aged women are at higher risk than men of death after coronary artery revascularization. Maternal placental syndromes (gestational hypertension, preeclampsia, placental abruption, and placental infarction) are associated with premature coronary artery disease, but their influence on survival after coronary artery revascularization is unknown. OBJECTIVE The purpose of this study was to determine whether a history of maternal placental syndromes alters the risk of death after coronary artery revascularization in middle-aged women. STUDY DESIGN We completed a population-based retrospective cohort study among all hospitals in Ontario, Canada, where universal health care includes all aspects of antenatal and delivery care as well as all outpatient and inpatient health care, which includes coronary revascularization. We included 1985 middle-aged women who underwent a first percutaneous coronary intervention or coronary artery bypass grafting between 1993 and 2012 and who had ≥1 previous delivery. We excluded those with cardiovascular disease ≤1 year before or coronary revascularization ≤90 days after any delivery. The main study outcome, determined a priori, was all-cause death. Hazard ratios were adjusted for age, socioeconomic status, parity, revascularization type, time since last delivery, hypertension, diabetes mellitus, obesity, dyslipidemia, tobacco or drug dependence, and kidney disease. RESULTS Three hundred sixty-two of 1985 women (18.2%) who underwent coronary artery revascularization had a previous maternal placental syndrome event. The mean age at index coronary revascularization was 45 years; percutaneous coronary intervention comprised approximately 80% of procedures. After a mean follow-up time of approximately 5 years, 41 deaths (2.2 per 100 person-years) occurred in women with previous maternal placental syndromes and 83 deaths (1.1 per 100 person-years) in women without maternal placental syndrome (adjusted hazard ratio, 1.96; 95% confidence interval, 1.29-2.99). Of the maternal placental syndrome subtypes, the risk of death was significant in women with placental abruption (adjusted hazard ratio, 2.79; 95% confidence interval, 1.31-5.96), placental infarction (adjusted hazard ratio, 3.09; 95% confidence interval, 1.23-7.74), and preeclampsia (adjusted hazard ratio, 1.61; 95% confidence interval, 1.00-2.58). Women with maternal placental syndrome in ≥2 pregnancies had the highest adjusted hazard ratio of death (4.31; 95% confidence interval, 1.71-10.89). CONCLUSION In middle-aged women who undergo coronary revascularization, previous maternal placental syndrome doubles the risk of death; recurrent maternal placental syndrome quadruples that risk. Some covariates and secondary measures may not have been well-captured and classified herein, leading to residual confounding.
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91
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Fukui T, Tabata M, Morita S, Takanashi S. Gender differences in patients undergoing surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg 2015; 150:581-7.e1. [DOI: 10.1016/j.jtcvs.2015.06.031] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 05/25/2015] [Accepted: 06/05/2015] [Indexed: 11/27/2022]
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92
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Lee J, Jung Y, Park JY, Lee SH, Ryu DH, Hwang GS. LC/MS-based polar metabolite profiling reveals gender differences in serum from patients with myocardial infarction. J Pharm Biomed Anal 2015; 115:475-86. [PMID: 26299524 DOI: 10.1016/j.jpba.2015.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 08/01/2015] [Accepted: 08/09/2015] [Indexed: 12/30/2022]
Abstract
Myocardial infarction (MI), a leading cause of death worldwide, results from prolonged myocardial ischemia with necrosis of myocytes due to a blood supply obstruction to an area of the heart. Many studies have reported gender-related differences in the clinical features of MI, but the reasons for these differences remain unclear. In this study, we applied ultra-performance liquid chromatography/quadrupole time-of-flight mass spectrometry (UPLC/Q-TOF MS) and various statistical methods-such as multivariate, pathway, and correlation analyses-to identify gender-specific metabolic patterns in polar metabolites in serum from healthy individuals and patients with MI. Patients with diagnosed MI (n=68), and age- and body mass index-matched healthy individuals (n=68), were included in this study. The partial least-squares discriminant analysis (PLS-DA) model was generated from metabolic profiling data, and the score plots showed a significant gender-related difference in patients with MI. Many pathways were associated with amino acids and purines; amino acids, acylcarnitines, and purines differed significantly between male and female patients with MI. This approach could be utilized to observe gender-specific metabolic pattern differences between healthy controls and patients with MI.
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Affiliation(s)
- Jueun Lee
- Integrated Metabolomics Research Group, Western Seoul Center, Korea Basic Science Institute (KBSI), Seoul 120-140,Republic of Korea; Department of Chemistry, Sungkyunkwan University (SKKU), Suwon 440-746, Republic of Korea
| | - Youngae Jung
- Integrated Metabolomics Research Group, Western Seoul Center, Korea Basic Science Institute (KBSI), Seoul 120-140,Republic of Korea
| | - Ju Yeon Park
- Integrated Metabolomics Research Group, Western Seoul Center, Korea Basic Science Institute (KBSI), Seoul 120-140,Republic of Korea
| | - Sang-Hak Lee
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 120-752, Republic of Korea
| | - Do Hyun Ryu
- Department of Chemistry, Sungkyunkwan University (SKKU), Suwon 440-746, Republic of Korea.
| | - Geum-Sook Hwang
- Integrated Metabolomics Research Group, Western Seoul Center, Korea Basic Science Institute (KBSI), Seoul 120-140,Republic of Korea; Department of Life Science, Ewha Womans University, Seoul 120-750, Republic of Korea.
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Comparison of outcomes and presentation in men-versus-women with bicuspid aortic valves undergoing aortic valve replacement. Am J Cardiol 2015; 116:250-5. [PMID: 25983125 DOI: 10.1016/j.amjcard.2015.04.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 04/07/2015] [Accepted: 04/07/2015] [Indexed: 11/22/2022]
Abstract
Gender disparities in short- and long-term outcomes have been documented in cardiac and valvular heart surgery. However, there is a paucity of data regarding these differences in the bicuspid aortic valve (BAV) population. The aim of this study was to examine gender-specific differences in short- and long-term outcomes after surgical aortic valve (AV) replacement in patients with BAV. A retrospective analysis was performed in 628 consecutive patients with BAV who underwent AV surgery from April 2004 to December 2013. To reduce bias when comparing outcomes by gender, propensity score matching obtained on the basis of potential confounders was used. Women with BAV who underwent AV surgery presented with more advanced age (mean 60.7 ± 13.8 vs 56.3 ± 13.6 years, p <0.001) and less aortic regurgitation (29% vs 44%, p <0.001) and had a higher risk for in-hospital mortality (mean Ambler score 3.4 ± 4.4 vs 2.5 ± 4.0, p = 0.015). After propensity score matching, women received more blood products postoperatively (48% vs 34%, p = 0.028) and had more prolonged postoperative lengths of stay (median 5 days [interquartile range 5 to 7] vs 5 days [interquartile range 4 to 6], p = 0.027). Operative, discharge, and 30-day mortality and overall survival were not significantly different. In conclusion, women with BAV who underwent AV surgery were older, presented with less aortic regurgitation, and had increased co-morbidities, lending higher operative risk. Although women received more blood products and had significantly longer lengths of stay, short- and long-term outcomes were similar.
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94
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Morris AA, Cole RT, Laskar SR, Kalogeropoulos A, Vega JD, Smith A, Butler J. Improved Outcomes for Women on the Heart Transplant Wait List in the Modern Era. J Card Fail 2015; 21:555-60. [DOI: 10.1016/j.cardfail.2015.03.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 01/20/2015] [Accepted: 03/09/2015] [Indexed: 10/23/2022]
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95
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Masjedi S, Ferdous Z. Understanding the Role of Sex in Heart Valve and Major Vascular Diseases. Cardiovasc Eng Technol 2015; 6:209-19. [PMID: 26577355 DOI: 10.1007/s13239-015-0226-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 04/17/2015] [Indexed: 12/25/2022]
Abstract
Cardiovascular disease (CVD) is the major cause of mortality in the elderly population. The cost of CVD treatment and surgeries was over $300 billion in the United States alone in 2010, making this disorder a critical healthcare issue. Many studies have suggested sex as a risk factor for heart valve and major vascular diseases, such as aortic valve stenosis, mitral prolapse and regurgitation, atherosclerosis, coronary artery disease, and abdominal aortic aneurysm. Unfortunately, only a handful of studies have illustrated the role of sex in the etiology and progression of these disorders. Moreover, knowledge of biomolecular factors that affect these diseases in men and women is very limited. Numerous clinical studies have revealed obvious differences in the prevalence of these diseases between the sexes. These reports were supported by a few molecular and cellular physiology studies that associated this difference to sex and sex hormones. In particular, male sex has commonly been identified as a risk factor for majority of heart valve and vascular diseases, whereas females have been identified as higher risk for certain disorders as well. In addition, menopause is a critical issue that turns the tables against women and enhances complications in their cardiovascular structure due to hormonal change. In this review, major vascular and heart valve diseases for which sex is associated as a risk factor have been reviewed to highlight the importance of this risk factor in CVDs.
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Affiliation(s)
- Shirin Masjedi
- Mechanical, Aerospace, and Biomedical Engineering, The University of Tennessee, 312 Perkins Hall, Knoxville, TN, 37996, USA
| | - Zannatul Ferdous
- Mechanical, Aerospace, and Biomedical Engineering, The University of Tennessee, 312 Perkins Hall, Knoxville, TN, 37996, USA.
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96
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Lee PH, Park DW. Sex differences in clinical outcomes following coronary revascularization. Interv Cardiol 2015. [DOI: 10.2217/ica.15.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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97
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Pollock B, Hamman BL, Sass DM, da Graca B, Grayburn PA, Filardo G. Effect of gender and race on operative mortality after isolated coronary artery bypass grafting. Am J Cardiol 2015; 115:614-8. [PMID: 25596952 DOI: 10.1016/j.amjcard.2014.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/11/2014] [Accepted: 12/11/2014] [Indexed: 11/18/2022]
Abstract
Studies examining outcomes after coronary artery bypass grafting (CABG) by gender and/or race have shown conflicting results. It remains to be determined if, or how, gender and race are independent risk factors for CABG operative mortality. Using all consecutive patients who underwent isolated CABG at Baylor University Medical Center in Dallas, Texas, from January 2004 to October 2011, the risk-adjusted associations between gender and race, respectively, and operative mortality were estimated using a generalized propensity approach, accounting for recognized Society of Thoracic Surgeons risk factors for mortality. Women were nearly 2 times more likely to die during or within 30 days of the operation than men (odds ratio 1.96, 95% confidence interval 1.44 to 2.66, p <0.0001), while no significant mortality differences were observed among races. In conclusion, these findings suggest that women face a significantly greater risk for operative death that should be taken into account during the treatment decision-making process but that race is not associated with CABG mortality and so should not be among the factors considered.
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Affiliation(s)
- Benjamin Pollock
- Department of Epidemiology, Office of the Chief Quality Officer, Baylor Scott & White Health, Dallas, Texas
| | - Baron L Hamman
- Department of Cardiothoracic Surgery, Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Danielle M Sass
- Department of Epidemiology, Office of the Chief Quality Officer, Baylor Scott & White Health, Dallas, Texas
| | - Briget da Graca
- Department of Epidemiology, Office of the Chief Quality Officer, Baylor Scott & White Health, Dallas, Texas
| | - Paul A Grayburn
- Department of Cardiology, Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Giovanni Filardo
- Department of Epidemiology, Office of the Chief Quality Officer, Baylor Scott & White Health, Dallas, Texas.
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98
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den Ruijter HM, Haitjema S, van der Meer MG, van der Harst P, Rouleau JL, Asselbergs FW, van Gilst WH. Long-term outcome in men and women after CABG; results from the IMAGINE trial. Atherosclerosis 2015; 241:284-8. [PMID: 25731671 DOI: 10.1016/j.atherosclerosis.2015.02.039] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 02/05/2015] [Accepted: 02/18/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study is to determine sex differences in long-term outcome after coronary artery bypass grafting (CABG). METHODS The international randomized controlled IMAGINE study included 2553 consecutive patients with a left ventricular ejection fraction of >40% who underwent isolated CABG. Median follow-up was 32 months (IQR 17-42 months). The composite endpoint comprised of death, myocardial infarction (MI), cerebrovascular event, angina, revascularization and congestive heart failure. Cox regression analysis was used to examine sex differences in outcome post-CABG. RESULTS Of the 2553 patients, 2229 were men and 324 (13%) were women. Women were older and more often reported diabetes and hypertension. Smoking and impaired renal function were more prevalent in men. Women experienced a higher event rate during follow-up (composite endpoint 18% vs 12%; P = 0.007). Cox regression showed an increased risk of the composite endpoint in women after adjustment for age (HR 1.48 (95% CI: 1.11-1.97)) which was non-significant after additional adjustment for other confounders (HR 1.26 (95% CI: 0.92-1.72)). CONCLUSION Women have a worse long-term outcome after CABG than men in univariate analysis. However, after adjusting for potential confounders female sex became a non-significant predictor for prognosis, possibly due to the small sample size of women. Definite answers regarding sex-differences in long-term outcome after CABG should come from future pooling of studies comprising a larger number of women.
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Affiliation(s)
- Hester M den Ruijter
- Experimental Cardiology Laboratory, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Saskia Haitjema
- Experimental Cardiology Laboratory, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Manon G van der Meer
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pim van der Harst
- Experimental Cardiology Laboratory, University Medical Center Groningen, Groningen, The Netherlands; Durrer Center for Cardiogenetic Research, Interuniversity Cardiology Institute Netherlands-Netherlands Heart Institute, Utrecht, The Netherlands
| | - Jean L Rouleau
- Institute of Circulatory and Respiratory Health, Canadian Institutes of Health Research, University of Montreal, Montreal, Canada
| | - Folkert W Asselbergs
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands; Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, United Kingdom; Durrer Center for Cardiogenetic Research, Interuniversity Cardiology Institute Netherlands-Netherlands Heart Institute, Utrecht, The Netherlands
| | - Wiek H van Gilst
- Experimental Cardiology Laboratory, University Medical Center Groningen, Groningen, The Netherlands
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Ferreira RG, Worthington A, Huang CC, Aranki SF, Muehlschlegel JD. Sex differences in the prevalence of diastolic dysfunction in cardiac surgical patients. J Card Surg 2015; 30:238-45. [PMID: 25571945 DOI: 10.1111/jocs.12506] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The mortality from diastolic dysfunction is approximately 9% to 28%. In patients with ischemic heart disease, female sex and advanced age are associated with increases in ventricular diastolic stiffness. Clinical studies have found higher rates of diastolic dysfunction in women, despite higher ejection fractions, than in men post-myocardial infarction. Therefore, we hypothesized that female patients undergoing cardiac surgery have higher degrees of diastolic dysfunction and experience more adverse outcomes, such as prolonged hospitalization. METHODS We prospectively enrolled 153 patients undergoing cardiac surgery. Diastolic function was assessed using early transmitral velocity (E) and early diastolic lateral mitral annular tissue velocity (e'). Left ventricular diastolic dysfunction was defined as binary and a continuous outcome (E/e'). RESULTS Females were more likely than males to present with higher E/e' (11.5 vs. 7.9, p = 0.001) and higher left ventricular diastolic dysfunction (71% vs. 36%, p < 0.001). The addition of sex to the model for left ventricular diastolic dysfunction was significant. The relationship between sex and E/e' ratio showed the biggest difference between males and females in the 56-72-year-old age brackets, where women were much more likely to have a higher E/e' than males. CONCLUSIONS We identified a significantly higher prevalence of diastolic dysfunction among females presenting for elective cardiac surgery compared to males. This finding is more pronounced with age. Additionally, we found that female sex is at higher risk of prolonged ICU and hospital length of stay.
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Affiliation(s)
- Renata G Ferreira
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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Ashurst JV, McGregor AJ, Safdar B, Weaver KR, Quinn SM, Rosenau AM, Goyke TE, Roth KR, Greenberg MR. Emergency Medicine Gender-specific Education. Acad Emerg Med 2014; 21:1453-8. [PMID: 25491708 PMCID: PMC6452861 DOI: 10.1111/acem.12545] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/09/2014] [Accepted: 06/26/2014] [Indexed: 01/07/2023]
Abstract
The 2014 Academic Emergency Medicine consensus conference has taken the first step in identifying gender-specific care as an area of importance to both emergency medicine (EM) and research. To improve patient care, we need to address educational gaps in this area concurrent with research gaps. In this article, the authors highlight the need for sex- and gender-specific education in EM and propose guidelines for medical student, resident, and faculty education. Specific examples of incorporating this content into grand rounds, simulation, bedside teaching, and journal club sessions are reviewed. Future challenges and strategies to fill the gaps in the current education model are also described.
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Affiliation(s)
- John V Ashurst
- Department of Emergency Medicine, Lehigh Valley Hospital/USF Morsani College of Medicine, Allentown, PA
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