Sex differences in mortality following acute coronary syndromes

Cardiovascular risk assessment in hypertensive patients

OBJECTIVE

to assess cardiovascular risk by means of the traditional Framingham score and the version modified through the incorporation of emerging risk factors, such as family history of acute myocardial infarction, metabolic syndrome and chronic kidney disease.

METHOD

participants were 50 hypertensive patients under outpatient treatment. The clinical data were collected through a semi-structured interview and the laboratory data from patients' histories.

RESULTS

it was verified that the traditional Framingham score was predominantly low (74%), with 14% showing medium risk and 12% high risk. After the inclusion of emerging risk factors, the chance of a coronary event was low in 22% of the cases, medium in 56% and high in 22%.

CONCLUSIONS

the comparison between the traditional Framingham risk score and the modified version demonstrated a significant difference in the cardiovascular risk classification, whose correlation shows discreet agreement between the two scales. Lifestyle elements seem to play a determinant role in the increase in cardiovascular risk levels.

Gender and Age Differences in Short- and Long-Term Outcomes Following Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

BACKGROUND

Studies have reported that women with ST elevation myocardial infarction (STEMI) have worse short- and long-term outcomes than men. It has not yet been confirmed whether these differences reflect differences in age between men and women.

METHODS

We retrospectively enrolled 1035 consecutive STEMI patients treated with primary percutaneous coronary intervention (PCI). Baseline clinical characteristics, coronary anatomy, and outcome were compared between young (< 65 years old) and older patients (≥ 65 years old) of both sexes.

RESULTS

Younger women presented with a lower incidence of typical angina (83% vs. 93%, p = 0.03), single-vessel disease (21% vs. 35%, p = 0.03), and total occlusion of infarct-related artery (65% vs. 83%, p = 0.001) than younger men, with no gender difference noted in the older group. Younger women in the study had a higher incidence of reinfarction, heart failure requiring admission, or mortality (23% vs. 6%, p < 0.001) during follow-up, compared with younger men, with no gender difference in the older group. Using the Kaplan-Meier analysis, younger women had lower rates of event-free survival (p < 0.001 by log-rank test) than younger men, with no gender difference in the older group. In multivariate analysis, age could predict long-term outcome in men (Hazard ratio 4.43, 95% confidence interval: 2.89-6.78, p < 0.001) but not in women.

CONCLUSIONS

In STEMI patients receiving primary PCI, sex-related long-term outcome differences were age-dependent, with younger women likely to have a worse long-term outcome when compared with younger men.

KEY WORDS

Coronary heart disease; Gender; Myocardial infarction.

Do gender differences in primary PCI mortality represent a different adherence to guideline recommended therapy? a multicenter observation

BACKGROUND

It is uncertain whether gender differences in outcome after primary percutaneous coronary intervention (PCI) are only attributable to different baseline characteristics or additional factors.

METHODS

Databases of two German myocardial infarction network registries were combined with a total of 1104 consecutive patients admitted with acute ST-elevation myocardial infarction (STEMI) and treated according to standardized protocols.

RESULTS

Approximately 25% of patients were females. Mean age (69 vs 61 years), incidence of diabetes (28% vs 20%), hypertension (68 vs 58%) and renal insufficiency (26% vs 19%) was significantly higher compared to males. Mean prehospital delay was numerically longer in females (227 vs 209 min) as was in hospital delay (35 vs 30 min). PCI was finally performed in 92% of females and 95% of males with comparable procedural success (95% vs 97%). Use of drug eluting stents (55% vs 68%) and application of GP 2b 3a blockers (75% vs 89%) was significantly less frequent in women. At discharge, prescription of beta blockers and lipid lowering drugs was also significantly lower in females (84% vs 90% and 71% vs 84%). Unadjusted in-hospital mortality was significantly higher in females (10% vs 5%) without attenuation after 12 months. Adjusted mortality however did not differ significantly between genders.

CONCLUSION

Higher unadjusted mortality in females after primary PCI was accompanied by significant differences in baseline characteristics, interventional approach and secondary prophylaxis in spite of the same standard of care. Lower guideline adherence seems to be less gender specific but rather a manifestation of the risk-treatment paradox.

Effects of angiotensin-converting enzyme inhibitors and beta blockers on clinical outcomes in patients with and without coronary artery obstructions at angiography (from a Register-Based Cohort Study on Acute Coronary Syndromes)

We sought to determine the effectiveness of angiotensin-converting enzyme (ACE) inhibition and β-blocker treatment as a function of the degree of coronary artery disease (CAD) obstruction at angiography. The Evaluation of Methods and Management of Acute Coronary Events registry enrolled patients who had been hospitalized for an acute coronary syndrome. There were 1,602 patients who had cardiac catheterization that were used for this analysis. The main outcome measures were evidence-based therapies prescribed at discharge and 6-month incidence of all-cause mortality. The cohort consisted of 1,252 patients with obstructive CAD (>50% luminal diameter obstructed) and 350 patients with nonobstructive CAD. Multivariate logistic regression analysis adjusted for further medications and other clinical factors was performed. Patients with nonobstructive CAD had significantly (p <0.001) higher rates of β-blocker (77.8% vs 63.3%) and lower rates of ACE-inhibitor (57.7% vs 66.4%) prescriptions. In patients with nonobstructive CAD, ACE-inhibitor therapy was clearly associated with a lower 6-month mortality (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.03 to 0.78, p = 0.004). No significant association between β-blocker use and death was found. In patients with obstructive CAD, both β blockers (OR 0.47, 95% CI 0.32 to 0.67, p <0.001) and ACE inhibitors (OR 0.47, 95% CI 0.26 to 0.87, p = 0.01) were significantly associated with a reduced risk of 6-month mortality. In conclusion, ACE-inhibitor therapy seems to be an effective first-line treatment for preventing the occurrence of mortality in patients with nonobstructive CAD.

Characteristics of plaque disruption by intravascular ultrasound in women presenting with myocardial infarction without obstructive coronary artery disease

BACKGROUND

In a prospective study, we previously identified plaque disruption (PD: plaque rupture or ulceration) in 38% of women with myocardial infarction (MI) without angiographically obstructive coronary artery disease (CAD), using intravascular ultrasound (IVUS). Underlying plaque morphology has not been described in these patients and may provide insight into the mechanisms of MI without obstructive CAD.

METHODS

Forty-two women with MI and <50% angiographic stenosis underwent IVUS (n = 114 vessels). Analyses were performed by a blinded core laboratory. Sixteen patients had PD (14 ruptures and 5 ulcerations in 18 vessels). Plaque area, % plaque burden, lumen area stenosis, eccentricity, and remodeling index were calculated for disrupted plaques and largest plaque by area in each vessel.

RESULTS

Disrupted plaques had lower % plaque burden than the largest plaque in the same vessel (31.9% vs 49.8%, P = .005) and were rarely located at the site of largest plaque (1/19). Disrupted plaques were typically fibrous and were not more eccentric or remodeled than the largest plaque in the same vessel.

CONCLUSIONS

Plaque disruption was often identifiable on IVUS in women with MI without obstructive CAD. Plaque disruption in this patient population occurred in fibrous or fibrofatty plaques and, contrary to expectations based on prior studies of plaque vulnerability, did not typically occur in eccentric, outwardly remodeled, or soft plaque in these patients. Plaque disruption rarely occurred at the site of the largest plaque in the vessel. These findings suggest that the pathophysiology of PD in women with MI without angiographically obstructive CAD may be different from MI with obstructive disease and requires further investigation.

Outcomes of patients with prior coronary artery bypass graft who present with acute coronary syndrome

Generally, patients with prior coronary artery bypass graft (CABG) are often under-represented in acute coronary syndrome (ACS) clinical trials. Nevertheless, there is growing global attention concerning their short- and long-term prognosis. Some reports suggest prior CABG as an independent risk factor for increased mortality, while others report an equal or a more favorable prognosis despite their adverse baseline clinical characteristics. The reasons for this 'risk-mortality paradox' need to be further evaluated. More recent reports showed a significant reduction in in-hospital morbidity and mortality over a 20-year period of follow up that may be attributed to the improvement in surgical CABG techniques and increased use of evidence-based therapies over the past two decades. In the current review we discuss the available literature regarding outcomes of prior CABG patients who are presenting with ACS.

Sex differences in early outcomes after lung cancer resection: analysis of the Society of Thoracic Surgeons General Thoracic Database

OBJECTIVES

Women with lung cancer have superior long-term survival outcomes compared with men, independent of stage. The cause of this disparity is unknown. For patients undergoing lung cancer resection, these survival differences could be due, in part, to relatively better perioperative outcomes for women. This study was undertaken to determine differences in perioperative outcomes after lung cancer surgery on the basis of sex.

METHODS

The Society of Thoracic Surgeons' General Thoracic Database was queried for all patients undergoing resection of lung cancer between 2002 and 2010. Postoperative complications were analyzed with respect to sex. Univariable analysis was performed, followed by multivariable modeling to determine significant risk factors for postoperative morbidity and mortality.

RESULTS

A total of 34,188 patients (16,643 men and 17,545 women) were considered. Univariable analysis demonstrated statistically significant differences in postoperative complications favoring women in all categories of postoperative complications. Women also had lower in-hospital and 30-day mortality (odds ratio, 0.56; 95% confidence interval, 0.44-0.71; P < .001). Multivariable analysis demonstrated that several preoperative conditions independently predicted 30-day mortality: male sex, increasing age, lower diffusion capacity, renal insufficiency, preoperative radiation therapy, cancer stage, extent of resection, and thoracotomy as surgical approach. Coronary artery disease was an independent predictor of mortality in women but not in men. Thoracotomy as the surgical approach and preoperative radiation therapy were predictive of mortality for men but not for women. Postoperative prolonged air leak and empyema predicted mortality in men but not in women.

CONCLUSIONS

Women have lower postoperative morbidity and mortality after lung cancer surgery. Some risk factors are sex-specific with regard to mortality. Further study is warranted to determine the cause of these differences and to determine their effect on survival.

Sex-based differences in outcomes after percutaneous coronary intervention for acute myocardial infarction: a report from TRANSLATE-ACS

Background

Data regarding sex‐based outcomes after percutaneous coronary intervention (PCI) for myocardial infarction are mixed. We sought to examine whether sex differences in outcomes exist in contemporary practice.

Methods and Results

We examined acute myocardial infarction patients undergoing PCI between April 2010 and October 2012 at 210 US hospitals participating in the Treatment with Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE‐ACS) observational study. Outcomes included 1‐year risk of major adverse cardiac events and bleeding according to Global Utilization of Strategies To Open Occluded Arteries (GUSTO) and Bleeding Academic Research Consortium (BARC) definitions. Among 6218 patients, 27.5% (n=1712) were female. Compared with men, women were older, had more comorbidities, and had lower functional status. Use of multivessel PCI and drug‐eluting stents was similar between sexes, while women received less prasugrel. Unadjusted cumulative incidence of 1‐year major adverse cardiac events was higher for women than for men (15.7% versus 13.6%, P=0.02), but female sex was no longer associated with higher incidence of major adverse cardiac events after multivariable adjustment (hazard ratio 0.98, 95% CI 0.83 to 1.15). Female sex was associated with higher risks of post‐PCI GUSTO bleeding (9.1% versus 5.7%, P<0.0001) and postdischarge BARC bleeding (39.6% versus 27.9%, P<0.0001). Differences persisted after adjustment (GUSTO: hazard ratio 1.32, 95% CI 1.06 to 1.64; BARC: incidence rate ratio 1.42, 95% CI 1.27 to 1.56).

Conclusions

Female and male myocardial infarction patients undergoing PCI differ regarding demographic, clinical, and treatment profiles. These differences appear to explain the higher observed major adverse cardiac event rate but not higher adjusted bleeding risk for women versus men.

Comparison of clinical outcomes of Chinese men and women after coronary stenting for coronary artery disease: a multi-center retrospective analysis of 4,334 patients

The outcome differences between Chinese male and female patients within one-year follow-up after percutaneous coronary intervention (PCI) with stent remain unclear. The present study was aimed to compare clinical outcomes in such two populations. From May 1999 to December 2009, 4,334 patients with acute myocardial infarction (MI), unstable angina, stable angina, or silent ischemia, who underwent PCI, were registered at our centers. Among these, 3,089 were men and 1,245 were women. We compared these groups with respect to the primary outcomes of MI and secondary outcomes including a composite of major adverse cardiac events (MACE) including cardiac death, MI, target lesion revascularization, target vessel revascularization (TVR), stent thrombosis (ST), definite ST and probable ST at one-year follow-up. Chinese male patients had a higher MACE rate (13% vs. 10.7%, P  =  0.039), mainly led by TVR (9.09% vs. 6.98%, P = 0.024) at one year, which was significantly different than female patients. Chinese male and female patients showed a significant difference on MACEs. However, there was no significant difference with respect to MI between these groups.

Mechanisms of myocardial infarction without obstructive coronary artery disease

Angiography in patients with myocardial infarction (MI) most commonly reveals one or more significantly narrowed coronary arteries, but a substantial minority of patients with spontaneous MI have no obstructive coronary artery disease (CAD) at angiography. This review summarizes evidence for the most commonly hypothesized mechanisms, including plaque disruption, plaque erosion, vasospasm, embolism, and spontaneous coronary dissection. In addition, tako-tsubo syndrome and myocarditis are discussed. The best treatment of MI without obstructive CAD is likely to differ substantially based on the underlying cause. Additional mechanistic research is needed to facilitate the design of research studies aimed at documenting the best treatments for these patients, numbering as many as 225,000 per year in the US.

Association between bleeding and mortality among women and men with high-risk acute coronary syndromes: insights from the Early versus Delayed, Provisional Eptifibatide in Acute Coronary Syndromes (EARLY ACS) trial

BACKGROUND

Female sex is an established risk factor for bleeding, which is an important safety end point in patients presenting with non-ST-segment elevation acute coronary syndromes (NSTE ACS). However, it is unknown whether the association between bleeding and mortality is modulated by sex in this patient population.

METHODS

We examined the interaction between sex and bleeding and 30-day mortality outcomes among 2,975 women and 6,431 men with high-risk NSTE ACS enrolled in the EARLY ACS trial. The Global Utilization of Strategies to Open Occluded Arteries (GUSTO) criteria were used to identify moderate or severe bleeds.

RESULTS

Women were older and had more comorbid disease compared with men. Bleeding rates were higher among women (8.2%) than among men (5.5%; P < .01). However, the association of bleeding and 30-day mortality was stronger among men (odds ratio 5.8, 95% CI 3.9-8.8) than among women (odds ratio 1.5, 95% CI 0.8-2.9; sex * bleeding interaction P < .01). Sex differences in the association of bleeding and mortality persisted in a landmark analysis of 120-hour survivors.

CONCLUSIONS

In a contemporary high-risk NSTE ACS cohort, women had higher bleeding rates than did men. Paradoxically, the association between bleeding and mortality was worse among men than among women.

Presentation, management, and outcomes of ischaemic heart disease in women

Scientific interest in ischaemic heart disease (IHD) in women has grown considerably over the past 2 decades. A substantial amount of the literature on this subject is centred on sex differences in clinical aspects of IHD. Many reports have documented sex-related differences in presentation, risk profiles, and outcomes among patients with IHD, particularly acute myocardial infarction. Such differences have often been attributed to inequalities between men and women in the referral and treatment of IHD, but data are insufficient to support this assessment. The determinants of sex differences in presentation are unclear, and few clues are available as to why young, premenopausal women paradoxically have a greater incidence of adverse outcomes after acute myocardial infarction than men, despite having less-severe coronary artery disease. Although differential treatment on the basis of patient sex continues to be described, the extent to which such inequalities persist and whether they reflect true disparity is unclear. Additionally, much uncertainty surrounds possible sex-related differences in response to cardiovascular therapies, partly because of a persistent lack of female-specific data from cardiovascular clinical trials. In this Review, we assess the evidence for sex-related differences in the clinical presentation, treatment, and outcome of IHD, and identify gaps in the literature that need to be addressed in future research efforts.

Are there gender differences in coronary artery disease? The Malaysian National Cardiovascular Disease Database - Percutaneous Coronary Intervention (NCVD-PCI) Registry

Objectives

To assess whether gender differences exist in the clinical presentation, angiographic severity, management and outcomes in patients with coronary artery disease (CAD).

Methods

The study comprised of 1,961 women and 8,593 men who underwent percutaneous coronary intervention (PCI) and were included in the Malaysian NCVD-PCI Registry from 2007–2009. Significant stenosis was defined as ≥70% stenosis in at least one of the epicardial vessels.

Results

Women were significantly older and had significantly higher rates of diabetes mellitus, hypertension, chronic renal failure, new onset angina and prior history of heart failure whereas smokers and past history of myocardial infarction were higher in men. In the ST-elevation myocardial infarction (STEMI) cohort, more women were in Killip class III-IV, had longer door-to-balloon time (169.5 min. vs 127.3 min, p<0.052) and significantly longer transfer time (300.4 min vs 166.3 min, p<0.039). Overall, women had significantly more left main stem (LMS) disease (1.3% vs 0.6%, p<0.003) and smaller diameter vessels (<3.0 mm: 45.5% vs 34.8%, p<0.001). In-hospital mortality rates for all PCI, STEMI, Non-STEMI (NSTEMI) and unstable angina for women and men were 1.99% vs 0.98%, Odds ratio (OR): 2.06 (95% confidence interval (CI): 1.40 to 3.01), 6.19% vs 2.88%, OR: 2.23 (95% CI: 1.31 to 3.79), 2.90% vs 0.79%, OR: 3.75 (95% CI: 1.58 to 8.90) and 1.79% vs 0.29%, OR: 6.18 (95% CI: 0.56 to 68.83), respectively. Six-month adjusted OR for mortality for all PCI, STEMI and NSTEMI in women were 2.18 (95% CI: 0.97 to 4.90), 2.68 (95% CI: 0.37 to 19.61) and 2.66 (95% CI: 0.73 to 9.69), respectively.

Conclusions

Women who underwent PCI were older with more co-morbidities. In-hospital and six-month mortality for all PCI, STEMI and NSTEMI were higher due largely to significantly more LMS disease, smaller diameter vessels, longer door-to-balloon and transfer time in women.

Mortality trends in women and men presenting with acute coronary syndrome: insights from a 20-year registry

BACKGROUND

Coronary artery disease (CAD) is the leading cause of mortality worldwide. The present study evaluated the impact of gender in patients hospitalized with acute coronary syndromes (ACS) over a 20-year period in Qatar.

METHODS

Data were collected retrospectively from the registry of the department of cardiology for all patients admitted with ACS during the study period (1991-2010) and were analyzed according to gender.

RESULTS

Among 16,736 patients who were admitted with ACS, 14262 (85%) were men and 2474 (15%) were women. Cardiovascular risk factors were more prevalent among women in comparison to men. On admission, women presented mainly with non-ST-elevation ACS and were more likely to be undertreated with β-blockers (BB), antiplatelet agents and reperfusion therapy in comparison to men. However, from 1999 through 2010, the use of aspirin, angiotensin-converting enzyme inhibitors and BB increased from 66% to 79%, 27% to 41% and 17% to 49%, respectively in women. In the same period, relative risk reduction for mortality was 64% in women and 51% in men. Across the 20-year period, the mortality rate decreased from 27% to 7% among the Middle Eastern Arab women. Multivariate logistic regression analysis showed that female gender was independent predictor of in-hospital mortality (odd ratio 1.51, 95% CI 1.27-1.79).

CONCLUSIONS

Women presenting with ACS are high-risk population and their in-hospital mortality remains higher for all age groups in comparison to men. Although, substantial improvement in the hospital outcome has been observed, guidelines adherence and improvement in the hospital care have not yet been optimized.

Survival after hospital discharge for ST-segment elevation and non-ST-segment elevation acute myocardial infarction: a population-based study

Background

Limited recent data are available describing differences in long-term survival, and factors affecting prognosis, after ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI), especially from the more generalizable perspective of a population-based investigation. The objectives of this study were to examine differences in post-discharge prognosis after hospitalization for STEMI and NSTEMI, with a particular focus on factors associated with reduced long-term survival.

Methods

We reviewed the medical records of residents of the Worcester, MA, USA metropolitan area hospitalized at eleven central Massachusetts medical centers for acute myocardial infarction (AMI) during 2001, 2003, 2005, and 2007.

Results

A total of 3762 persons were hospitalized with confirmed AMI; of these, 2539 patients (67.5%) were diagnosed with NSTEMI. The average age of study patients was 70.3 years and 42.9% were women. Patients with NSTEMI experienced higher post-discharge death rates with 3-month, 1-year, and 2-year death rates of 12.6%, 23.5%, and 33.2%, respectively, compared to 6.1%, 11.5%, and 16.4% for patients with STEMI. After multivariable adjustment, patients with NSTEMI were significantly more likely to have died after hospital discharge (adjusted hazards ratio 1.28; 95% confidence interval 1.14–1.44). Several demographic (eg, older age) and clinical (eg, history of stroke) factors were associated with reduced long-term survival in patients with NSTEMI and STEMI.

Conclusions

The results of this study in residents of central Massachusetts suggest that patients with NSTEMI are at higher risk for dying after hospital discharge, and several subgroups are at particularly increased risk.

Cardiac hemodynamics in men versus women during acute ST-segment elevation myocardial infarction

Several biologic and clinical factors contribute to the increased 30-day mortality and re-infarction rate in women with ST-segment elevation myocardial infarction (STEMI). Sex differences in cardiac hemodynamic parameters such as pulmonary capillary wedge pressure (PCWP) have not been examined and might play an important role. The objectives of the present study were to examine whether female sex is an independent determinant of PCWP during acute STEMI and whether an elevated PCWP contributes to all-cause 30-day mortality and re-infarction in women. The clinical, angiographic, and hemodynamic features of 470 consecutive patients with STEMI (n = 135 women) undergoing emergency coronary angiography with right-side heart catheterization were evaluated with respect to sex. Women had an elevated PCWP (20 ± 8 vs 16 ± 7 mm Hg, p <0.001) and reduced mixed venous oxygen saturation (67 ± 11% vs 71 ± 9%, p = 0.004). On multivariate analysis, female sex (β = 4.04, 95% confidence interval [CI] 2.04 to 6.04, p <0.001), hypertension (β = 2.07, 95% CI 0.31 to 3.83, p = 0.021), and creatine kinase-estimated infarct size (β = 0.001, 95% CI 0.001 to 0.002, p ≤0.001) were independent predictors of an elevated PCWP. Female sex exerted a minor independent effect on 30-day mortality and re-infarction (odds ratio 2.36, 95% CI 1.25 to 4.46, p = 0.008). However, once PCWP was entered into the mediation model, sex was no longer significant, suggesting that the effect of sex on the post-STEMI outcomes is potentially mediated through PCWP (odds ratio 1.07, 95% CI 1.02 to 1.12, p = 0.011). In conclusion, during acute STEMI, women have greater left ventricular filling pressures compared with men, independent of age, hypertension, and infarct size. The biologic explanation for this difference requires additional investigation, although it does not appear to contribute to the increased 30-day mortality and re-infarction rate observed in women.

[Acute myocardial infarction in Charleroi: evolution of risk factors and therapeutic practices]

OBJECTIVES

The aim of the study consists in analyzing the evolution of acute coronary risk factors as well as the 28 days case fatality and the therapeutic practices over 12 years of follow-up in Charleroi. The factors influencing the mortality of these patients are also investigated.

METHODS

The Charleroi register of ischaemic cardiopathies is the oldest register of infarctions in the French-speaking community of Belgium. Analyses presented hereafter relate only patients in the 25-69-year age range over time from 1998 to 2009. Some analysis was extended to 25-74-year range. Treatment and risk factors evolutions over time were analysed using Chi(2) tests. Logistic regression was used to identify factors influencing 28 days mortality.

RESULTS

The analysis shows a significant decline in 28 days mortality. A marked increase in the prevalence of hypertension and hypercholesterolemia is highlighted as well as an increase of utilization of percutaneous transluminal coronary angioplasty (PTCA) between 1998 and 2009. The use of ß-blockers and antiplatelet drugs remained fairly stable between 1998 and 2009 with approximately 75% and 90% of the patients treated, respectively. The factors associated with fatality were specifically age of patients, antecedents of diabetes and antecedents of myocardial infarction, hypercholesterolaemia as well as oral antiplatelet drugs, ß-blockers therapies and PTCA.

CONCLUSIONS

The evolution of the therapeutic data on AMI in this register confirms that PTCA becomes the main coronary reperfusion. Angiotensin-converting enzyme inhibitors were without effect on mortality.

Age-dependent differences in diabetes and acute hyperglycemia between men and women with ST-elevation myocardial infarction: a cohort study

BACKGROUND

Both acute hyperglycemia as diabetes results in an impaired prognosis in ST-elevation myocardial infarction (STEMI) patients. It is unknown whether there is a different prevalence of diabetes and acute hyperglycemia in men and women within age-groups.

METHODS

Between 2004 and 2010, 4640 consecutive patients (28% women) with STEMI, were referred for primary PCI. Patients were stratified into two age groups, < 65 years (2447 patients) and ≥65 years (2193 patients). Separate analyses were performed in 3901 patients without diabetes. Diabetes was defined as known diabetes or HbA1c ≥6.5 mmol/l at admission.

RESULTS

The prevalence of diabetes was comparable between women and men in the younger age group (14% vs 12%, p = 0.52), whereas in the older age group diabetes was more prevalent in women (25% vs 17% p < 0.001). In patients without diabetes, admission glucose was comparable between both genders in younger patients (8.1 ± 2.0 mmol/l vs 8.0 ± 2.2 mmol/l p = 0.36), but in older patients admission glucose was higher in women than in men (8.7 ± 2.1 mmol/l vs 8.4 ± 2.1 mmol/l p = 0.028). After multivariable analyses, the occurrence of increased admission glucose was comparable between men and women in the younger age group (OR 1.1, 95%CI 0.9-1.5), but increased in women in the older age group (OR 1.3, 95% CI 1.1-1.7). Both diabetes and hyperglycemia were associated with a higher one-year mortality in both men and women.

CONCLUSIONS

The differences between men and women in hyperglycemia and diabetes in patients with STEMI are age dependent and can only be observed in older patients. This may have implications for medical treatment and should be investigated further.

Heterogeneous properties of intermediate- and low-density lipoprotein subpopulations

OBJECTIVE

Intermediate-density lipoprotein (IDL) and low-density lipoprotein (LDL) consist of heterogeneous particles whose subpopulations may have different atherogenic characteristics. This study investigated the associations between these subpopulations and other lipids, lipoproteins and atherosclerosis-related markers.

DESIGN AND METHODS

A total of 416 subjects (124 males and 292 females, mean age: 50.8 years) were enrolled in this study. Using polyacrylamide gel electrophoresis, serum lipoproteins were separated according to their specific electrophoretic mobility based on particle size. The IDL particles were separated into three midbands (MID-A to C), and the LDL particles were separated into seven subfractions (LDL1 to 7).

RESULTS

MID-B, MID-C, LDL2 and LDL3 to 6 (as a small LDL fraction) were significantly and positively correlated with very LDL (VLDL), while MID-A and LDL1 were significantly and inversely correlated with VLDL. MID-A and LDL1 were significantly and positively correlated with high-density lipoprotein (HDL). The correlation patterns between MID-A or LDL1 and triglycerides, apolipoprotein A-I, glucose, the insulin resistance index, creatinine and the mean LDL particle size had similar trends to those between HDL and these parameters.

CONCLUSIONS

The respective subpopulations of IDL and LDL particles can vary in their ability to predict cardiovascular disease risks. These variations may partially explain why quantitative assessments using LDL-cholesterol concentrations, as typically performed in conventional practice, are not perfect predictors of cardiovascular disease. Further studies are required to determine the clinical relevance of analyzing the IDL and LDL subpopulations.

Higher mortality in women after ST-segment elevation myocardial infarction in very young patients

INTRODUCTION

Data on mortality in young patients with ST-segment elevation myocardial infarction (STEMI) when compared to older people or regarding therapeutic strategies are contradictory. We investigate the prognosis of women under 40 after STEMI in a prospective nationwide acute coronary syndrome registry.

MATERIAL AND METHODS

We analyzed all 527 consecutive men and women (12.3% females) aged from 20 to 40 years (mean 35.7 ±4.5) presenting with STEMI, of all 26035 STEMI patients enrolled.

RESULTS

Differences between genders in the major cardiovascular risk factors, clinical presentation, extent of the disease and time to reperfusion were insignificant. The majority of patients (67%) underwent coronary angiography followed by primary percutaneous coronary intervention (PCI) in 79.9% of them. A 92% reperfusion success rate measured by post-procedural TIMI 3 flow was achieved. There were no significant differences between genders in the administration of modern pharmacotherapy both on admission and after discharge from hospital. In-hospital mortality was very low in both genders, but 12-month mortality was significantly higher in women (10.8% vs. 3.0%; p = 0.003). Killip class 3 or 4 on admission (95% CI 19.6-288.4), age per 5-year increase (95% CI 1.01-3.73) and primary PCI (95% CI 0.1-0.93) affected mortality. In patients who underwent reperfusion there was moderately higher mortality in women than in men (7.1% vs. 1.9%; p = 0.046).

CONCLUSIONS

Despite little difference in the basic clinical characteristics and the management including a wide use of primary PCI, long-term mortality in women under forty after STEMI is significantly higher than in men.

Gender differences in clinical outcomes among diabetic patients hospitalized for cardiovascular disease

BACKGROUND

The risk of incident cardiovascular disease (CVD) has been shown to be greater among diabetic women than men, but gender differences in clinical outcomes among diabetic patients hospitalized with CVD are not established. We aimed to determine if hemoglobin A1c (HbA1c) was associated with 30-day and 1-year CVD rehospitalization and total mortality among diabetic patients hospitalized for CVD, overall and by gender.

METHODS

This was a prospective analysis of diabetic patients hospitalized for CVD, enrolled in an National Heart, Lung and Blood Institute-sponsored observational clinical outcomes study (N = 902, 39% female, 53% racial/ethnic minority, mean age 67 ± 12 years). Laboratory, rehospitalization, and mortality data were determined by hospital-based electronic medical record. Poor glycemic control was defined as HbA1c ≥7%. The association between HbA1c and clinical outcomes was evaluated using logistic regression; gender modification was evaluated by interaction terms and stratified models.

RESULTS

Hemoglobin A1c ≥7% prevalence was 63% (n = 566) and was similar by gender. Hemoglobin A1c ≥7% vs <7% was associated with increased 30-day CVD rehospitalization in univariate (odds ratio [OR] = 1.63, 95% CI 1.05-2.54) and multivariable-adjusted models (OR 1.74, 95% CI 1.06-2.84). There was an interaction between glycemic control and gender for 30-day CVD rehospitalization risk (P = .005). In stratified univariate models, the association was significant among women (OR 4.83, 95% CI 1.84-12.71) but not among men (OR 1.02, 95% CI 0.60-1.71). The multivariate-adjusted risk for HbA1c ≥7% versus <7% among women was 8.50 (95% CI 2.31-31.27) and 1.02 (95% CI 0.57-1.80) for men. A trend toward increased 30-day/1-year mortality risk was observed for HbA1c <6% vs ≥6% for men and women.

CONCLUSIONS

Risk of 30-day CVD rehospitalization was 8.5-fold higher among diabetic women hospitalized for CVD with HbA1c ≥7% vs <7%; no association was observed among men. A trend for increased 30-day/1-year mortality risk with HbA1c <6% deserves further study.

Gender differences in the pathophysiology, clinical presentation, and outcomes of ischemic heart failure

Despite advances in the treatment of acute myocardial infarction (MI), heart failure (HF) remains a frequent acute and long-term outcome of ischemic heart disease (IHD). In response to acute coronary ischemia, women are relatively protected from apoptosis, and experience less adverse cardiac remodeling than men, frequently resulting in preservation of left ventricular size and ejection fraction. Despite these advantages, women are at increased risk for HF- complicating acute MI when compared with men. However, women with HF retain a survival advantage over men with HF, including a decreased risk of sudden death. Sex-specific treatment of HF has been hindered by historical under-representation of women in clinical trials, though recent work has suggested that women may have a differential response to some therapies such as cardiac resynchronization. This review highlights the sex differences in the pathophysiology, clinical presentation and outcomes of ischemic heart failure and discusses key areas worthy of further investigation.

Sex differences in cardiovascular drug-induced adverse reactions causing hospital admissions

AIMS

Cardiovascular disease in women is often underestimated. The effects of cardiovascular drugs differ between the sexes because of pharmacokinetic and pharmacodynamic differences. Adverse drug reactions (ADRs) within these drug classes may have serious consequences, leading to hospital admission. We aimed to study differences between men and women in hospital admissions for ADRs due to cardiovascular drugs.

METHODS

We conducted a nationwide study of all hospital admissions between 2000 and 2005 with data from the Dutch National Medical Register. Relative risks were calculated of hospital admissions due to ADRs to the different cardiovascular drug groups for women compared with men. By an ecological design, risks were adjusted for the total number of Dutch inhabitants and the total number of prescriptions.

RESULTS

In total, 14 207 of the hospital admissions (34% of all ADR-related admissions) were attributed to cardiovascular drugs [7690 in women (54%; 95% confidence interval 53-55%)]. 'Anticoagulants and salicylates' (n= 8988), 'high- and low-ceiling diuretics' (n= 2242) and 'cardiotonic glycosides' (n= 932) were responsible for the majority of the ADR-related hospital admissions. The most pronounced sex differences were seen in users of low-ceiling diuretics (relative risk 4.02; 95% confidence interval 3.12-5.19), cardiotonic glycosides (relative risk 2.38; 95% confidence interval 2.06-2.74), high-ceiling diuretics (relative risk 2.10; 95% confidence interval 1.91-2.32) and coronary vasodilators (relative risk 0.77; 95% confidence interval 0.65-0.91).

CONCLUSIONS

Clear sex differences exist in ADRs requiring hospital admission for different cardiovascular drug groups. Sex differences should be taken into account in the prescription and evaluation of drugs.

Does the clinical spectrum of incident cardiovascular disease differ between men and women?

BACKGROUND

Cardiovascular diseases (CVDs) are the main cause of death and disability in the western world. Women are known to be older at the time of first CVD event, but the main types of CVD events and their relative importance and differences compared with men are not well known. Our aim was to evaluate gender differences in the clinical presentation of incident major adverse cardiovascular events (MACE).

DESIGN

A population-based study with prospective follow-up.

METHODS

We used data from the population-based National FINRISK Surveys from years 1992, 1997, 2002 and 2007. People with prevalent cardiovascular disease were excluded. In total, 27,897 participants (53, 2% women) aged 25-74 years were included in the analyses.

RESULTS

During the 292,316 person-years of follow-up, 2573 MACE were identified. MACE were more frequent in men than women (1318; 95% CI 1252-1388 in men vs. 736; 686-789 in women). Men had four times more fatal coronary heart disease (CHD) events (149; 126-174 vs. 39; 28-53) and three times more non-fatal CHD events (512; 471-555 vs. 164; 141-189) than women. Stroke incidence was higher in men than women (268; 238-301 vs. 169; 145-195). Heart failure (HF) incidence did not differ between genders. The relative proportions of MACE categories differed substantially between genders: HF was the most common type among women (50% vs. 30% in men), whereas the most common type among men was CHD (50% vs. 28% in women).

CONCLUSIONS

Incident MACE were more common in men than women. HF was the dominant type of MACE in women, whereas CHD dominated in men.

Sex differences in presentation and outcome among patients with type 2 diabetes and coronary artery disease treated with contemporary medical therapy with or without prompt revascularization: a report from the BARI 2D Trial (Bypass Angioplasty Revascularization Investigation 2 Diabetes)

OBJECTIVES

This study evaluated differences in outcome among women and men enrolled in the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial.

BACKGROUND

Women and men with coronary artery disease have different clinical presentations and outcomes that might be due to differences in management.

METHODS

We compared baseline variables, study interventions, and outcomes between women and men enrolled in the BARI 2D trial and randomized to aggressive medical therapy alone or aggressive medical therapy with prompt revascularization.

RESULTS

At enrollment, women were more likely than men to have angina (67% vs. 58%, p < 0.01) despite less disease on angiography (Myocardial Jeopardy Index 41 ± 24 vs. 46 ± 24, p < 0.01; number of significant lesions 2.3 ± 1.7 vs. 2.8 ± 1.8, p < 0.01). Over 5 years, no sex differences were observed in BARI 2D study outcomes after adjustment for difference in baseline variables (death/myocardial infarction/cerebrovascular accident: hazard ratio: 1.11, 99% confidence interval [CI]: 0.85 to 1.44). However, women reported more angina than men (adjusted odds ratio: 1.51, 99% CI: 1.21 to 1.89, p < 0.0001) and had lower scores for the Duke Activity Status Index (adjusted beta coefficient: -1.58, 99% CI: -2.84 to -0.32, p < 0.01).

CONCLUSIONS

There were no sex differences in death, myocardial infarction, or cerebrovascular accident among patients enrolled in the BARI 2D trial. However, compared with men, women had more symptoms and less anatomic disease at baseline, with persistence of higher angina rates and lower DASI scores after 5 years of medical therapy with or without prompt revascularization. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes [BARI 2D]; NCT00006305).

Influence of gender on ischemic times and outcomes after ST-elevation myocardial infarction

Previous studies investigating the influence of gender on ST-segment elevation myocardial infarction have reported conflicting results. The aim of this study was to assess the influence of gender on ischemic times and outcomes after ST-segment elevation myocardial infarction in patients treated with primary percutaneous coronary intervention in modern practice. The present multicenter registry included consecutive patients with ST-segment elevation myocardial infarctions treated with primary percutaneous coronary intervention at 3 hospitals. Adjusted mortality rates were calculated using Cox proportional-hazards analyses. In total, 3,483 patients were included, of whom 868 were women (25%). Women were older, had a higher risk factor burden, and more frequently had histories of malignancy. Men more often had cardiac histories and peripheral vascular disease. Ischemic times were longer in women (median 192 minutes [interquartile range 141 to 286] vs 175 minutes [interquartile range 128 to 279] in men, p = 0.002). However, multivariate linear regression showed that this was due to age and co-morbidity. All-cause mortality was higher at 7 days (6.0% in women vs 3.0% in men, p <0.001) and at 1 year (9.9% in women vs 6.6% in men, p = 0.001). After adjustment, female gender predicted 7 day all-cause mortality (hazard ratio 1.61, 95% confidence interval 1.06 to 2.46) and cardiac mortality (hazard ratio 1.58, 95% confidence interval 1.03 to 2.42) but not 1-year mortality. Moreover, gender was an independent effect modifier for cardiogenic shock, leading to substantially worse outcomes in women. In conclusion, ischemic times remain longer in women because of age and co-morbidity. Female gender independently predicted early all-cause and cardiac mortality after primary percutaneous coronary intervention, and a strong interaction between gender and cardiogenic shock was observed.

Is the difference in outcome between men and women treated by primary percutaneous coronary intervention age dependent? Gender difference in STEMI stratified on age

AIM

Poorer outcomes in women with ST-elevation myocardial infarction (STEMI) are often attributed to gender differences in baseline characteristics. However, these may be age dependent. We examined the importance of gender in separate age groups of patients with STEMI undergoing primary percutaneous coronary intervention (PPCI).

METHODS AND RESULTS

Data of 6746 consecutive patients with STEMI admitted for PPCI between 1998 and 2008 in our hospital were evaluated. Age was stratified into two groups, <65 years (young group) and ≥65 years (elderly). Endpoints were enzymic infarct size as well as 30-day and 1 year mortality. We studied a total of 4991 (74.0%) men and 1755 (26.0%) women; 40% of women were <65 years and 60% of men were <65 years of age. In the elderly group (≥65 years), women had more frequently diabetes and hypertension while they smoked less frequently than men. Younger women smoked more often than similarly aged men and had more hypertension. At angiography, single-vessel disease and TIMI 3 flow before PPCI was more present in younger women than men, whereas these differences were not found in the older age group. Patient delay before admission was shorter in men at all ages, while women had lower creatine kinase levels. Younger women had a higher mortality after 30 days (HR 2.1, 95% CI 1.3-3.4) and at 1 year (HR 1.7, 95% CI 1.2-2.6), whereas in the older age group women mortality rates were higher at 30 days (HR 1.5, 95% CI 1.1-2.0) but not at 1 year (HR 1.2, 95% CI 0.9-1.5). After multivariate analysis, 1-year mortality remained significantly higher in women at younger age (HR 1.7, 95% CI 1.1-2.5). Patient delay before admission was shorter in men in both age groups. Creatine kinase levels were in both age groups higher in men.

CONCLUSIONS

Differences in mortality between men and women with STEMI treated with PPCI are age dependent. Although young women have less obstructive coronary artery disease and more often TIMI 3 flow before PCI (suggesting a lower risk), survival was worse compared to similarly aged men. Women had a longer patient delay compared to men, but this was not related to gender-specific mortality.

Two-year clinical outcomes after coronary drug-eluting stent placement in Chinese men and women: a multicenter, prospective registry study

BACKGROUND

Previous studies have reported a discrepancy in baseline characteristics and outcomes after percutaneous coronary intervention between men and women. However, this finding has never been verified in the Chinese population. The present study analyzed two-year clinical outcomes after placement of coronary drug-eluting stents in Chinese men and women.

METHODS

From January 2005 to December 2010, a total of 3804 Chinese patients (2776 men, 1028 women) who underwent drug-eluting stent implantation were studied prospectively. The primary endpoint was the composite major adverse cardiac event (MACE) rate, including myocardial infarction, cardiac death, and target vessel revascularization at two years. Stent thrombosis served as the safety endpoint. Propensity score matching was used to compare the adjusted MACE rate between the two groups.

RESULTS

At two-year follow-up, unadjusted rates of myocardial infarction, non-ST segment elevation myocardial infarction, target vessel revascularization, and MACE were significantly different between men (6.84%, 4.6%, 13.1%, and 21.7%, respectively) and women (3.8% [P = 0.001], 2.0% [P < 0.001] 10.3% [P = 0.025], and 16.3% [P < 0.001], respectively). After propensity score matching, there were no significant differences in composite MACE and individual endpoints at two years between the genders.

CONCLUSION

Despite all the unfavorable risk factor clustering in women and complex coronary disease in men, the two-year clinical outcomes after coronary stent placement were comparable between Chinese women and men.

Cardiovascular disease prevention in women: a rapidly evolving scenario

The past decade has witnessed a long overdue recognition of the importance of CVD in women, accompanied by an increasing awareness of gender differences in risk factors, natural history, preventive strategies, treatment, and prognosis of CVD. Reflecting the disease burden and the specific aspects of CVD in women, the American Heart Association has developed women-specific evidence-based guidelines and consensus documents for CVD prevention. The most recent update of these guidelines, published in 2011, is a milestone in the field and shows the rapidly evolving scenario of CVD prevention in women. We discuss some novel aspects of the 2011 update. The new guidelines change the focus from evidence-based to effectiveness-based, with consideration of both benefits and harms/costs of preventive interventions. The guidelines also introduce "ideal cardiovascular health" as the lowest category of risk, which implies the need of communitywide preventive, educational and policy initiatives to promote healthy lifestyles in the general population. Furthermore, the guidelines emphasize long-term overall CVD risk rather than short-term coronary risk. We also address several barriers and open questions in the evaluation and implementation of these guidelines, including how to increase the small proportion of women with ideal cardiovascular health; how to increase implementation and compliance with the recommendations; how to provide effectiveness-based recommendations for lifetime prevention goals based on short-term trials; how to obtain the best possible evidence in women; how to identify subgroups of women with different cardiovascular risk profiles or who may require tailored preventive strategies; and how to adapt current guidelines to international settings, particularly to low- and middle-income countries.

A gender perspective on short- and long term mortality in ST-elevation myocardial infarction--a report from the SWEDEHEART register

BACKGROUND

Previous studies of patients admitted for ST-elevation myocardial infarction [STEMI] have indicated that women have a higher risk of early mortality than do men. These studies have presented limited information on gender related differences in the short term and almost no information on the long term.

METHODS AND RESULTS

We analysed a prospective, consecutively included STEMI population consisting of 54,146 patients (35% women). This population consists of almost all patients hospitalised in Sweden between January 1, 1995 and December 31, 2006 as recorded in the SWEDEHEART register (formerly RIKS-HIA). Follow-up time ranged from one to 13 years (mean 4.6). Women had a lower probability of being given reperfusion therapy, odds ratio [OR] 0.83 (95% confidence interval [CI] 0.79-0.88). During the time these STEMI patients were in the hospital, 13% of the women and 7% of men died, multivariable adjusted OR 1.21 (95% CI 1.11-1.32). During the follow up period, 46% of the women died as compared with 32% of the men. There was, however, no gender difference in age-adjusted risk of long term mortality (hazard ratio [HR] 0.98, 95% CI 0.95-1.01) whereas the multivariable adjusted risk was lower in women (HR 0.92, 95% CI 0.89-0.96). The long term risk of re-infarction was the same in men and women (HR 0.98, 95% CI 0.93-1.03) whereas men in the youngest group had a higher risk than women in that age group (HR 0.82, 95% CI 0.72-0.94).

CONCLUSION

In STEMI, women had a higher risk of in-hospital mortality but the long-term risk of death was higher in men. More studies are needed in the primary percutaneous coronary intervention (pPCI) era that are designed to determine why women fare worse than men after STEMI during the first phase when they are in hospital.

Sex-related trends in mortality in hospitalized men and women after myocardial infarction between 1985 and 2008: equal benefit for women and men

BACKGROUND

We aimed to study sex-related differences in temporal trends in short- and long-term mortality from 1985 to 2008 in patients hospitalized for acute myocardial infarction.

METHODS AND RESULTS

We included a total of 14 434 consecutive patients admitted to our intensive coronary care unit between 1985 and 2008 for myocardial infarction. A total of 4028 patients (28%) were women. Women were more likely to present with a higher risk profile and were equally likely to receive pharmacological and invasive reperfusion therapy compared with men. Women had a higher unadjusted mortality rate at 30 days (odds ratio, 1.3; 95% confidence interval, 1.1-1.5) and during 20 years (hazard ratio, 1.1; 95% confidence interval, 1.0-1.2) of follow-up. After adjustment for baseline characteristics, 30-day mortality was equal (adjusted odds ratio, 1.0; 95% confidence interval, 0.85-1.2) but the hazard for 20-year mortality was lower (adjusted hazard ratio, 0.77; 95% confidence interval, 0.66-0.90) in women compared to men. For 30-day mortality, there was no significant interaction between sex and age, diagnosis, or diabetes mellitus. Survival improved between 1985 and 2008. Temporal mortality reductions between 1985 and 2008 were at least as high in women as in men with myocardial infarction for both 30-day mortality and long-term mortality hazard.

CONCLUSIONS

The fact that adjusted mortality rates for men and women treated for myocardial infarction in an intensive coronary care unit were similar and declined markedly over a 24-year period suggests that both sexes benefit from the evidence-based therapies that have been developed and implemented during this time period.

Clinical presentation and hospital outcome of patients with ST-elevation myocardial infarction – Hungarian Myocardial Infarction Registry data

Introduction: There are only very few data on gender differences in patients with ST-elevation myocardial infarction. Aim: To compare the clinical data and prognosis of patients with ST-elevation myocardial infarction in the Hungarian Myocardial Infarction Registry database. Patients and methods: Between January 1, 2010 and December 31, 2011 4981 patients (3038 men) were included in the database. Results: Women were significantly older (67.7±13.5 vs. 60.5±12.5 years; p<0.001). Hypertension, diabetes, and stroke were more frequent among women, whereas smoking and previous myocardial infarction were found more often among men. Percutaneous coronary intervention was significantly more frequently performed in men than in women (82.4% vs. 75.3%; p<0.001), and the time between the onset of pain and arrival of patients to the site of percutaneous coronary intervention was longer in women than in men. Hospital mortality was higher among women than men (7.5% vs. 4.4%; p<0.001). Conclusions: At present women have a poorer hospital outcome than men. By increasing the revascularization treatment ratio in women an improvement may be achieved in the prognosis. Orv. Hetil., 2012, 153, 1465–1468.

Women and men with stable coronary artery disease have similar clinical outcomes: insights from the international prospective CLARIFY registry

Aims

Men and women differ in terms of presentation and management in coronary artery disease (CAD). Whether these differences translate into different clinical outcomes in stable CAD is unclear. We analysed data from the international prospective CLARIFY registry to compare cardiovascular clinical outcomes in men and women with stable CAD.

Methods and results

We analysed 1-year outcomes in 30 977 outpatients with stable CAD [23 975 (77.4%) men; 7002 (22.6%) women]. Women were older than men, more likely to have hypertension and diabetes, and less likely to exercise or smoke. They had more frequent angina, but were less likely to have undergone diagnostic non-invasive testing or coronary angiography. Women received less optimized treatment for stable CAD. One-year outcomes were similar for men and women for the composite of cardiovascular death, non-fatal myocardial infarction, or stroke [adjusted rates 1.7 vs. 1.8%, respectively, odds ratio (OR) 0.93, 95% confidence interval (CI) 0.75–1.15]; all-cause death (adjusted 1.5 vs. 1.6%, OR: 0.91, 95% CI: 0.72–1.13); fatal or non-fatal myocardial infarction (adjusted 1.0 vs. 0.9%, OR: 0.81, 95 CI: 0.60–1.08); and cardiovascular death or non-fatal myocardial infarction (adjusted 1.4 vs. 1.4%, OR: 0.89, 95% CI: 0.70–1.12). Fewer women underwent revascularization (2.6 vs. 2.2%, OR: 0.77, 95% CI: 0.64–0.93), although appropriateness was not analysed.

Conclusion

The risk profiles of women and men with stable CAD differ substantially. However, 1-year outcomes were similar. Fewer women underwent revascularization. Further research is needed to better understand gender determinants of outcome and devise strategies to minimize bias in the management and treatment of women.

Relationship of female sex to outcomes after myocardial infarction with persistent total occlusion of the infarct artery: analysis of the Occluded Artery Trial (OAT)

BACKGROUND

Long-term follow-up (up to 9 years) from the OAT allows for the examination of sex differences in outcomes and the effect of percutaneous coronary intervention (PCI) in a relatively homogeneous cohort of myocardial infarction (MI) survivors.

METHODS

The OAT randomized 484 (22%) women and 1717 men to PCI of the occluded infarct-related artery vs medical therapy alone >24 hours post-MI. There was no benefit of PCI on the composite of death, MI, and class IV heart failure. We analyzed outcomes by sex and investigated for sex-based trial selection bias using a concurrent registry.

RESULTS

Women were older and more likely to have left anterior descending infarct-related artery, diabetes and hypertension, history of heart failure, and rales at randomization but were less likely to smoke. The proportion and characteristics of women enrolled in the trial and the registry were similar, including left ventricular ejection fraction and extent of disease. Women had higher rates of the primary composite (hazard ratio [HR] 1.48, P = .0002), death (HR 1.50, P = .001), and heart failure (HR 2.53, P < .0001) but not reinfarction (HR 1.12, P = .57). Female sex was not independently associated with the primary end point or death on multivariate analysis. There was a trend toward independent association of female sex with heart failure (HR 1.66, P = .02).

CONCLUSION

Women in OAT had a higher primary end point event rate than did men, mainly driven by heart failure. Female sex was not independently associated with death or MI in this well-defined cohort with comparable extent of coronary artery disease, similar medical therapy, and equivalent left ventricular ejection fraction by sex.

Smoke-free laws, gender, and reduction in hospitalizations for acute myocardial infarction

OBJECTIVE

We examined gender differences in the incidence of acute myocardial infarction (AMI) after the passage of a smoke-free law in Lexington, Kentucky. The initial legislation had exemptions not covering manufacturing facilities and government buildings, which may have put men at greater risk for AMI.

METHODS

We examined the effect of Lexington's smoke-free public places law on hospitalizations for AMI (i.e., heart attack) among men and women 40 months prior to and 32 months after enactment of the law. We used the statewide administrative database (Comp Data) for all hospital billing records for the four health-care systems in Lexington-Fayette County. Cases were included in the analysis if (1) the patient was $35 years of age; (2) the patient had a primary discharge diagnosis of AMI, with an International Classification of Diseases, Ninth Revision code in the range of 410.00 to 410.99; and (3) the date of service was between January 1, 2001, and December 31, 2006.

RESULTS

Among women, AMI hospitalizations declined 23% after the law took effect. The rate of AMI events among men did not change significantly. There was an overrepresentation of women in the hospitality industry and a disproportionate number of men working in manufacturing facilities and government worksites not mandated by the law.

CONCLUSIONS

We found gender differences in the reduction of AMI hospitalizations following implementation of a smoke-free law that covered only some sectors of the workforce. Enacting smoke-free laws that cover all places of employment and strengthening existing partial laws may extend protection against AMIs to female and male workers.