Observations of the treatment of women in the United States with myocardial infarction: a report from the National Registry of Myocardial Infarction-I

The impact of admission modes on the treatment outcome and in-hospital mortality rate of STEMI patients undergoing PPCI

The current research on ST elevation myocardial infarction (STEMI) patients has been mostly limited to Door-to-Balloon (D-to-B) time. This study aimed to compare the effects of different hospital admission modes to on the time metrics of patients undergoing primary percutaneous coronary intervention (PPCI). It also examined the effects of these modes on in-hospital mortality and other influencing factors. The goal was to prompt healthcare facilities at all levels, including chest hospitals, the Centers for Disease Control and Prevention (CDC), and communities to take measures to enhance the treatment outcomes for patients with STEMI. A total of 1053 cases of STEMI patients admitted to Tianjin Chest Hospital from December 2016 to December 2023 and successfully underwent PPCI were selected for this study. They were divided into three groups based on the admission modes: the ambulances group (363 cases), the self-presentation group (305 cases), and the transferred group (385 cases). Multivariate logistic regression was used to explore the impact of different modes of hospital admission on the standard-reaching rate of key treatment time metrics. The results showed that the S-to-FMC time of transferred patients (OR = 0.434, 95% CI 0.316-0.596, P < 0.001) and self-presentation patients (OR = 0.489, 95% CI 0.363-0.659, P < 0.001) were more likely to exceed the standard than that of ambulance patients; The cath lab pre-activation time of self-presented patients was also less likely to meet the standard than that of ambulance patients (OR = 0.695, 95% CI 0.499-0.967, P = 0.031); D-to-W time of self-presentation patients was less likely to reach the standard than that of ambulance patients (OR = 0.323, 95% CI 0.234-0.446, P < 0.001);However, the FMC-to-ECG time of self-presentation patients was more likely to reach the standard than that of ambulance patients (OR = 2.601, 95% CI 1.326-5.100, P = 0.005). The Cox proportional hazards model analysis revealed that for ambulance patients, the time spent at each key treatment time point is shorter, leading to lower in-hospital mortality rate (HR0.512, 95% CI 0.302-0.868, P = 0.013) compared to patients admitted by other means. We found that direct arrival of STEMI patients to the PCI hospital via ambulance at the onset of the disease significantly reduces the S-to-FMC time, FMC-to-ECG time, D-to-W time, and catheterization room activation time compared to patients who self-present. This admission mode enhances the likelihood of meeting the benchmark standards for each time metric, consequently enhancing patient outcomes.

The spectrum of post-myocardial infarction care: From acute ischemia to heart failure

Heart failure (HF) is the leading cause of mortality in patients with acute myocardial infarction (AMI), with incidence ranging from 14% to 36% in patients admitted due to AMI. HF post-MI develops due to complex inter-play between macrovascular obstruction, microvascular dysfunction, myocardial stunning and remodeling, inflammation, and neuro-hormonal activation. Cardiogenic shock is an extreme presentation of HF post-MI and is associated with a high mortality. Early revascularization is the only therapy shown to improve survival in patients with cardiogenic shock. Treatment of HF post-MI requires prompt recognition and timely introduction of guideline-directed therapies to improve mortality and morbidity. This article aims to provide an up-to-date review on the incidence and pathogenesis of HF post-MI, current strategies to prevent and treat onset of HF post-MI, promising therapeutic strategies, and knowledge gaps in the field.

Sex-Related Differences and Factors Associated with Peri-Procedural and 1 Year Mortality in Chronic Limb-Threatening Ischemia Patients from the CLIMATE Italian Registry

BACKGROUND

Identifying sex-related differences/variables associated with 30 day/1 year mortality in patients with chronic limb-threatening ischemia (CLTI).

METHODS

Multicenter/retrospective/observational study. A database was sent to all the Italian vascular surgeries to collect all the patients operated on for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot are not included.

FOLLOW-UP

One year. Data on demographics/comorbidities, treatments/outcomes, and 30 day/1 year mortality were investigated.

RESULTS

Information on 2399 cases (69.8% men) from 36/143 (25.2%) centers. Median (IQR) age: 73 (66-80) and 79 (71-85) years for men/women, respectively (p < 0.0001). Women were more likely to be over 75 (63.2% vs. 40.1%, p = 0.0001). More men smokers (73.7% vs. 42.2%, p < 0.0001), are on hemodialysis (10.1% vs. 6.7%, p = 0.006), affected by diabetes (61.9% vs. 52.8%, p < 0.0001), dyslipidemia (69.3% vs. 61.3%, p < 0.0001), hypertension (91.8% vs. 88.5%, p = 0.011), coronaropathy (43.9% vs. 29.4%, p < 0.0001), bronchopneumopathy (37.1% vs. 25.6%, p < 0.0001), underwent more open/hybrid surgeries (37.9% vs. 28.8%, p < 0.0001), and minor amputations (22% vs. 13.7%, p < 0.0001). More women underwent endovascular revascularizations (61.6% vs. 55.2%, p = 0.004), major amputations (9.6% vs. 6.9%, p = 0.024), and obtained limb-salvage if with limited gangrene (50.8% vs. 44.9%, p = 0.017). Age > 75 (HR = 3.63, p = 0.003) is associated with 30 day mortality. Age > 75 (HR = 2.14, p < 0.0001), nephropathy (HR = 1.54, p < 0.0001), coronaropathy (HR = 1.26, p = 0.036), and infection/necrosis of the foot (dry, HR = 1.42, p = 0.040; wet, HR = 2.04, p < 0.0001) are associated with 1 year mortality. No sex-linked difference in mortality statistics.

CONCLUSION

Women exhibit fewer comorbidities but are struck by CLTI when over 75, a factor associated with short- and mid-term mortality, explaining why mortality does not statistically differ between the sexes.

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

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

Risk factors for premature coronary artery disease (PCAD) in adults: a systematic review protocol

PCAD possesses a public health challenge resulting in years of productive life lost and an escalating burden on health systems. Objective of this review is to compare modifiable and non-modifiable risk factors for PCAD compared to those without PCAD. This review will include all comparative observational studies conducted in adults aged >18 years with confirmed diagnosis of PCAD (on angiography) compared to those without PCAD. Databases to be searched include; PubMed, CINAHL, Embase, Web of Science, and grey literature (Google Scholar). All identified studies will be screened for title and abstract and full-text against the inclusion criteria on Covidence software. Data relevant to exposures and outcomes will be extracted from all included studies. All studies selected for data extraction will be critically appraised for methodological quality. Meta-analysis using random-effects model will be performed using Review Manager 5.3. Effect sizes for categorical risk factors will be expressed as odds ratios with 95% confidence intervals. For risk factors measured in continuous form, mean difference (if units are consistent) otherwise standardized mean difference (if units are different across studies) will be reported. Heterogeneity between studies will be assessed using I 2 test statistics. GRADE will be used to assess the certainty of the findings. Systematic review registration number:PROSPERO Registration # CRD42020173216.

An Asian Perspective on Gender Differences in In-Hospital and Long-Term Outcome of Cardiac Mortality and Ischemic Stroke after Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

OBJECTIVES

Gender differences historically exist in cardiovascular disease, with women experiencing higher rates of major adverse cardiovascular events. We investigated these trends in a contemporary Asian cohort, examining the impact of gender differences on cardiac mortality and ischemic stroke after primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI).

MATERIALS AND METHODS

We analysed 3971 consecutive patients who underwent primary PCI for STEMI retrospectively. The primary outcome was cardiac mortality and ischemic stroke in-hospital, at one year and on longer-term follow up (median follow up 3.62 years, interquartile range 1.03-6.03 years).

RESULTS

There were 580 (14.6%) female patients and 3391 (85.4%) male patients. Female patients were older and had higher prevalence of hypertension, diabetes, previous strokes, and chronic kidney disease. Cardiac mortality was higher in female patients during in-hospital (15.5% vs. 6.2%), 1-year (17.4% vs. 7.0%) and longer term follow up (19.9% vs. 8.1%, log-rank test: p < 0.001). Similarly, females had higher incidence of ischemic stroke at in-hospital (2.6% vs. 1.0%), 1-year (3.6% vs. 1.4%) and in the longer-term (6.7% vs. 3.1%) as well (log-rank test: p < 0.001). Female gender remained an independent predictor of in-hospital cardiac mortality (HR 1.395, 95%CI 1.061-1.833, p=0.017) and on longer-term follow-up (HR 1.932 95%CI 1.212-3.080, p=0.006) even after adjusting for confounders.

CONCLUSIONS

Females were at higher risk of in-hospital and long-term cardiac mortality and ischemic stroke after PPCI for STEMI. Future studies are warranted to investigate the role of aggressive management of cardiovascular risk factors and follow-up to improve outcomes in the females with STEMI.

Body Mass Index and In-Hospital Management and Outcomes of Acute Myocardial Infarction

Background and Objectives: Contemporary data on the prevalence, management and outcomes of acute myocardial infarction (AMI) in relation to body mass index (BMI) are limited. Materials and Methods: Using the National Inpatient Sample from 2008 through 2017, we identified adult AMI hospitalizations and categorized them into underweight (BMI < 19.9 kg/m²), normal BMI and overweight/obese (BMI > 24.9 kg/m²) groups. We evaluated in-hospital mortality, utilization of cardiac procedures and resource utilization among these groups. Results: Among 6,089,979 admissions for AMI, 38,070 (0.6%) were underweight, 5,094,721 (83.7%) had normal BMI, and 957,188 (15.7%) were overweight or obese. Over the study period, an increase in the prevalence of AMI was observed in underweight and overweight/obese admissions. Underweight AMI admissions were, on average, older, with higher comorbidity, whereas overweight/obese admissions were younger and had lower comorbidity. In comparison to the normal BMI and overweight/obese categories, significantly lower use of coronary angiography (62.3% vs. 74.6% vs. 37.9%) and PCI (40.8% vs. 47.7% vs. 19.6%) was observed in underweight admissions (all p < 0.001). The underweight category was associated with significantly higher in-hospital mortality (10.0% vs. 5.5%; OR 1.23 (95% CI 1.18–1.27), p < 0.001), whereas being overweight/obese was associated with significantly lower in-hospital mortality compared to normal BMI admissions (3.1% vs. 5.5%; OR 0.73 (95% CI 0.72–0.74), p < 0.001). Underweight AMI admissions had longer lengths of in-hospital stay with frequent discharges to skilled nursing facilities, while overweight/obese admissions had higher hospitalization costs. Conclusions: In-hospital management and outcomes of AMI vary by BMI. Underweight status was associated with worse outcomes, whereas the obesity paradox was apparent, with better outcomes for overweight/obese admissions.

Hospital Admissions Due to Ischemic Heart Diseases and Prescriptions of Cardiovascular Diseases Medications in England and Wales in the Past Two Decades

Objectives: The aim of this study was to explore the trend of ischemic heart disease (IHD) admission and the prescriptions of IHD medications in England and Wales. Methods: A secular trends study was conducted during the period of 1999 to 2019. We extracted hospital admission data for patients from all age groups from the Hospital Episode Statistics database in England and the Patient Episode Database for Wales. Prescriptions of IHD medications were extracted from the Prescription Cost Analysis database from 2004 to 2019. The chi-squared test was used to assess the difference between the admission rates and the difference between IHD medication prescription rates. The trends in IHD-related hospital admission and IHD-related medication prescription were assessed using a Poisson model. The correlation between hospital admissions for IHD and its IHD medication-related prescriptions was assessed using the Pearson correlation coefficient. Results: Our study detected a significant increase in the rate of cardiovascular disease (CVD) medication prescriptions in England and Wales, representing a rise in the CVD medications prescription rate of 41.8% (from 539,334.95 (95% CI = 539,286.30–539,383.59) in 2004 to 764,584.55 (95% CI = 764,545.55–764,623.56) in 2019 prescriptions per 100,000 persons), with a mean increase of 2.8% per year during the past 15 years. This increase was connected with a reduction in the IHD hospital admission rate by 15.4% (from 838.50 (95% CI = 836.05–840.94) in 2004 to 709.78 (95% CI = 707.65–711.92) in 2019 per 100,000 persons, trend test, p < 0.01), with a mean decrease of 1.02% per year during the past 15 years and by 5% (from 747.43 (95% CI = 745.09–749.77) in 1999 to 709.78 (95% CI = 707.65–711.92) in 2019 per 100,000 persons, trend test, p < 0.01) with a mean decrease of 0.25% per year during the past two decades in England and Wales. Conclusion: The rate of hospitalisation due to IHD has decreased in England and Wales during the past two decades. Hospitalisation due to IHD was strongly and negatively correlated with the increase in the rates of dispensing of IHD-related medications. Other factors contributing to this decline could be the increase in controlling IHD risk factors during the past few years. Future studies exploring other risk factors that are associated with IHD hospitalisation are warranted.

Estrogen Deprivation and Myocardial Infarction: Role of Aerobic Exercise Training, Inflammation and Metabolomics

In general, postmenopausal women present higher mortality, and worse prognosis after myocardial infarction (MI) compared to men, due to estrogen deficiency. After MI, cardiovascular alterations occur such as the autonomic imbalance and the pro-inflammatory cytokines increase. In this sense, therapies that aim to minimize deleterious effects caused by myocardial ischemia are important. Aerobic training has been proposed as a promising intervention in the prevention of cardiovascular diseases. On the other hand, some studies have attempted to identify potential biomarkers for cardiovascular diseases or specifically for MI. For this purpose, metabolomics has been used as a tool in the discovery of cardiovascular biomarkers. Therefore, the objective of this work is to discuss the changes involved in ovariectomy, myocardial infarction, and aerobic training, with emphasis on inflammation and metabolism.

Heart failure after myocardial infarction: incidence and predictors

Aims

The aim of the present paper was to provide an up‐to‐date view on epidemiology and risk factors of heart failure (HF) development after myocardial infarction.

Methods and results

Based on literature review, several clinical risk factors and biochemical, genetic, and imaging biomarkers were identified to predict the risk of HF development after myocardial infarction.

Conclusions

Heart failure is still a frequent complication of myocardial infarction. Timely identification of subjects at risk for HF development using a multimodality approach, and early initiation of guideline‐directed HF therapy in these patients, can decrease the HF burden.

Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay

STUDY OBJECTIVE

Our objective is to describe the rates of diagnostic reclassification between conventional cardiac troponin I (cTnI) and high-sensitivity cardiac troponin T (hs-cTnT) and between combined and sex-specific hs-cTnT thresholds in adult emergency department (ED) patients in the United States.

METHODS

We conducted a prospective, single-center, before-and-after, observational study of ED patients aged 18 years or older undergoing single or serial cardiac troponin testing in the ED for any reason before and after hs-cTnT implementation. Conventional cTnI and hs-cTnT results were obtained from a laboratory quality assurance database. Combined and sex-specific thresholds were the published 99th percentile upper reference limits for each assay. Cases underwent physician adjudication using the Fourth Universal Definition of Myocardial Infarction. Diagnostic reclassification occurred when a patient received a diagnosis of myocardial infarction or myocardial injury with one assay but not the other assay. Our primary outcome was diagnostic reclassification between the conventional cTnI and hs-cTnT assays. Diagnostic reclassification probabilities were assessed with sample proportions and 95% confidence intervals for binomial data.

RESULTS

We studied 1,016 patients (506 men [50%]; median age 60 years [25th, 75th percentiles 49, 71]). Between the conventional cTnI and hs-cTnT assays, 6 patients (0.6%; 95% confidence interval 0.2% to 1.3%) underwent diagnostic reclassification regarding myocardial infarction (5/6 reclassified as no myocardial infarction) and 166 patients (16%; 95% confidence interval 14% to 19%) underwent diagnostic reclassification regarding myocardial injury (154/166 reclassified as having myocardial injury) by hs-cTnT.

CONCLUSION

Compared with conventional cTnI, the hs-cTnT assay resulted in no clinically relevant change in myocardial infarction diagnoses but substantially more myocardial injury diagnoses.

Sex differences in acute coronary syndrome: insights from an observation study in low socio-economic cohort from India

Aim: To study sex-related differences in acute coronary syndrome (ACS) presentation, management and in-hospital outcomes. Materials & methods: We studied 621 ACS patients (150 women, 471 men) of low socio-economic status from South India from February 2015 to January 2016. Multivariable logistic regression methods were used to assess sex differences in the in-hospital outcomes. Adjudicated major adverse cardiovascular events (MACE) included in-hospital cardiac arrest, cardiogenic shock, heart failure, re-infarction, stroke, major bleeding and mortality. Results & conclusion: Mean age in women was 60.97 ± 11.23 years versus 54.5 ± 10.87 years in men (p < 0.001). Women had higher prevalence of hypertension and diabetes and presented with more non-ST elevation ACS. There were no differences in the use of antiplatelets, statins and other pharmacotherapy except for the higher use of nitrates in women. There were no differences in MACE rates between women and men (15.3 vs 9.6%; adjusted odds ratio: 1.43; CI: 0.76-2.69).

Not typical angina and mortality in women with obstructive coronary artery disease: Results from the Women's Ischemic Syndrome Evaluation study (WISE)

BACKGROUND

Women frequently present with symptoms not typical of angina (NTA) making ischemic heart disease recognition, diagnosis and treatment challenging. We compared mortality in women with obstructive coronary artery disease (CAD) with NTA vs typical angina (TA).

METHODS

We studied 326 Women's Ischemia Syndrome Evaluation (WISE) participants undergoing coronary angiography for suspected myocardial ischemia with core-lab measured obstructive CAD. TA was defined as sub-sternal chest pain precipitated by physical exertion or emotional stress and relieved with rest or nitroglycerin; NTA did not meet criteria for TA. The women were followed for non-fatal events and death for a median of 5.9 and 9.6 years respectively. Multivariate cox proportional hazards regression determined relations to events.

RESULTS

Overall, 115 (35%) of the women had TA. Baseline demographics, risk factors or additional symptom characteristics were similar between the two angina groups. Non-fatal events did not differ between groups. Women with NTA had a higher mortality compared to TA women (36% vs 26%, respectively, p = 0.047). Despite adjustment for additional major risk variables, NTA was an independent predictor of mortality compared to TA with a hazard ratio of 1.73 (95% Confidence interval: 1.04, 2.89).

CONCLUSIONS

Among women with suspected ischemia undergoing coronary angiography with obstructive CAD, NTA was more common than TA, and predicted a higher longer-term mortality. Further investigation is needed to confirm these results, and investigate potential explanations for the higher mortality observed in women with NTA women, including lower recognition or action in the setting of obstructive CAD.

Sex Differences in Acute Myocardial Infarction Hospital Management and Outcomes: Update From Facilities With Comparable Standards of Quality Care

Supplemental digital content is available in the text.

Background:

Acute myocardial infarction (AMI) sex disparities in management and outcomes have long been attributed to multiple factors, although questions regarding their relevance have not been fully addressed.

Objective:

The aim of this study was to identify current factors associated with sex-related AMI management and outcomes disparities in hospitals with comparable quality care standards.

Methods:

This is a cross-sectional study of 299 women and 540 men with AMI discharged in 2013 from 3 southern California hospitals with tertiary cardiac care. Outcomes (adjusted by demographic/clinical variables using multiple logistic regression) included mortality (in-hospital, 30 days), 30-day readmissions, invasive/revascularization procedures, and quality medication performance measures (aspirin, statins/antilipids, β-blockers, angiotensin-converting enzyme inhibitors, <90-minute door-balloon time).

Results:

Performance was similar to the top 10% National Inpatient Quality AMI Measures. Women had similar mortality, 30-day readmission rates, and performance on medication quality measures compared with men; readmissions were higher in patients with County Services/Medicaid or no medical insurance regardless of sex. Women had similar cardiac catheterization and ST-segment elevation myocardial infarction percutaneous coronary intervention rates but significantly less percutaneous coronary intervention for non–ST-segment elevation myocardial infarction (39.1% vs 52.1%, P = .008) and coronary artery bypass graft (6.7% vs 14.1%, P < .001) than men.

Conclusions:

Women with AMI had similar early mortality, 30-day readmissions and quality performance measures compared with men across hospitals with current quality care standards. Type of medical insurance influenced readmission rates for both sexes. Sex disparities in coronary revascularization procedures were likely determined by differences in AMI type and coronary disease vascular expression.

The impact of early comprehensive geriatric screening on the readmission rate in an acute geriatric ward: a quasi-experimental study

Background

Unplanned readmission is an important healthcare quality issue. We studied the effect of a comprehensive geriatric screen (CGS) in the early admission course followed by a comprehensive geriatric assessment on readmission rates in elderly patients.

Methods

This quasi-experimental study with a historical comparison group was conducted in the geriatric ward of a referral centre in northern Taiwan. Older adults (aged > = 65 y/o) admitted from June 2013 to December 2013 were recruited for the geriatric screen group (N = 377). Patients admitted to the same ward from July 2011 to June 2012 were selected for the historical group (N = 380). The CGS was administered within the first 48 h after admission and was followed by a comprehensive geriatric assessment (CGA). Confounding risk factors included age, gender, Charlson comorbidity index, Barthel index score and medical utilization (length of stay and number of admissions), which were controlled using logistic regression models. We also developed a scoring system to identify the group that would potentially benefit the most from the early CGS.

Results

The 30-day readmission rate was significantly lower in the early CGS group than in the historical comparison group (11.4% vs 16.9%, p = 0.03). After adjusting for confounding variables, the hazard ratio of the early CGS group was 0.64 (95% CI 0.43–0.95). After scoring the potential benefit to the patients in the early CGS group, the log rank test showed a significant difference (p = 0.001 in the high-potential group and p = 0.98 in the low-potential group).

Conclusion

An early CGS followed by a CGA may significantly reduce the 30-day readmission rate of elderly patients.

Lymphatic Function and Dysfunction in the Context of Sex Differences

Endothelial cells are the building blocks of the blood vascular system and exhibit well-characterized sexually dimorphic phenotypes with regard to chromosomal and hormonal sex, imparting innate genetic and physiological differences between male and female vascular systems and cardiovascular disease. However, even though females are predominantly affected by disorders of lymphatic vascular function, we lack a comprehensive understanding of the effects of sex and sex hormones on lymphatic growth, function, and dysfunction. Here, we attempt to comprehensively evaluate the current understanding of sex as a biological variable influencing lymphatic biology. We first focus on elucidating innate and fundamental differences between the sexes in lymphatic function and development. Next, we delve into lymphatic disease and explore the potential underpinnings toward bias prevalence in the female population. Lastly, we incorporate more broadly the role of the lymphatic system in sex-biased diseases such as cancer, cardiovascular disease, reproductive disorders, and autoimmune diseases to explore whether and how sex differences may influence lymphatic function in the context of these pathologies.

When the Female Heart Stops: Sex and Gender Differences in Out-of-Hospital Cardiac Arrest Epidemiology and Resuscitation

Sex- and gender-based differences are emerging as clinically significant in the epidemiology and resuscitation of patients with out-of-hospital cardiac arrest (OHCA). Female patients tend to be older, experience arrest in private locations, and have fewer initial shockable rhythms (ventricular fibrillation/ventricular tachycardia). Despite standardized algorithms for the management of OHCA, women are less likely to receive evidence-based interventions, including advanced cardiac life support medications, percutaneous coronary intervention, and targeted temperature management. While some data suggest a protective mechanism of estrogen in the heart, brain, and kidney, its role is incompletely understood. Female patients experience higher mortality from OHCA, prompting the need for sex-specific research.

Medication Administration Delays in Non-ST Elevation Myocardial Infarction: Analysis of 1002 Patients Admitted to an Academic Medical Center

Our goal was to assess adherence to American College of Cardiology/American Heart Association guideline-based medical therapy in patients admitted with type I non-ST elevation myocardial infarction (NSTEMI) and to determine factors associated with medication administration delay. We performed a retrospective analysis using data from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry. Baseline patient demographics, 12-lead electrocardiogram (ECG) findings, laboratory values, medications administered and the time they were administered, and in-hospital clinical outcomes were collected. Global Registry of Acute Coronary Events risk scores were calculated for all patients. We included 1002 patients admitted from the emergency department with a type I NSTEMI. A total of 802 (80%) patients received appropriate initial therapy consisting of therapeutic anticoagulation with heparin and dual antiplatelet therapy. Of the 200 (20%) patients who did not receive therapy, documentation in the chart regarding possible contraindications for administration of the medications was missing in up to half. Female sex, older age, a normal initial ECG, and prolonged time spent in the emergency department were predictors of significant delay in receiving guideline-based medications, while an elevated initial troponin was a predictor of faster medication administration. Global Registry of Acute Coronary Events risk scores had no association with the timing of medication administration. In conclusion, 20% of NSTEMI patients did not receive American College of Cardiology/American Heart Association guideline-based medical therapy. Delay in medication administration was significant for women, older individuals, and patients who did not have ischemic findings on the initial ECG.

Sex differences in the contemporary management of HIV patients admitted for acute myocardial infarction

BACKGROUND

Studies have reported sex differences in the management of patients with acute myocardial infarction (AMI) in the general population. This observational study is designed to evaluate whether sex differences exist in the contemporary management of human immunodeficiency virus (HIV) patients admitted for diagnosis of AMI.

HYPOTHESIS

There is no difference in management of HIV patients with AMI.

METHODS

Using the National Inpatient Sample database, we identified patients with a primary diagnosis of AMI and a secondary diagnosis of HIV. We described baseline characteristics and outcomes using NIS documentation. Our primary areas of interest were revascularization and mortality.

RESULTS

Among 2 977 387 patients presenting from 2010 to 2014 with a primary diagnosis of AMI, 10907 (0.4%) had HIV (mean age, 54.1 ± 9.3 years; n = 2043 [18.9%] female). Females were younger, more likely to be black, and more likely to have hypertension, diabetes, obesity, and anemia. Although neither males nor females were more likely to undergo coronary angiography in multivariate analysis, revascularization was performed less frequently in females than in males (45.4% vs 62.7%; P < 0.01), driven primarily by lower incidence of PCI. In a multivariate model, females were less likely to undergo revascularization (OR: 0.59, 95% CI: 0.45-0.78, P < 0.01), a finding driven solely by PCI (OR: 0.64, 95% CI: 0.49-0.83, P < 0.01). All-cause mortality was similar in both groups.

CONCLUSIONS

AMI was more common in males than females with HIV. Females with HIV were more likely to be younger and black and less likely to be revascularized by PCI.

Infarct size, left ventricular function, and prognosis in women compared to men after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: results from an individual patient-level pooled analysis of 10 randomized trials

Aim

Studies have reported less favourable outcomes in women compared with men after primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI). Whether sex-specific differences in the magnitude or prognostic impact of infarct size or post-infarction cardiac function explain this finding is unknown.

Methods and results

We pooled patient-level data from 10 randomized primary PCI trials in which infarct size was measured within 1 month (median 4 days) by either cardiac magnetic resonance imaging or technetium-99m sestamibi single-photon emission computed tomography. We assessed the association between sex, infarct size, and left ventricular ejection fraction (LVEF) and the composite rate of death or heart failure (HF) hospitalization within 1 year. Of 2632 patients with STEMI undergoing primary PCI, 587 (22.3%) were women. Women were older than men and had a longer delay between symptom onset and reperfusion. Infarct size did not significantly differ between women and men, and women had higher LVEF. Nonetheless, women had a higher 1-year rate of death or HF hospitalization compared to men, and while infarct size was a strong independent predictor of 1-year death or HF hospitalization (P < 0.0001), no interaction was present between sex and infarct size or LVEF on the risk of death or HF hospitalization.

Conclusions

In this large-scale, individual patient-level pooled analysis of patients with STEMI undergoing primary PCI, women had a higher 1-year rate of death or HF hospitalization compared to men, a finding not explained by sex-specific differences in the magnitude or prognostic impact of infarct size or by differences in post-infarction cardiac function.

Impact of gender on short-term and long-term all-cause mortality in patients with non-ST-segment elevation acute coronary syndromes: a meta-analysis

A meta-analysis to determine the impact of gender on mortality in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS): PubMed, EMBASE, and Cochrane Library, was systematically searched. Two investigators independently reviewed retrieved articles and assessed eligibility. Unadjusted mortality rates or adjusted effect estimates regarding gender-specific short-term and long-term all-cause mortality were identified. A total of 30 studies involving 358,827 patients with NSTE-ACS (129, 632 women and 229,195 men) were identified. In the unadjusted analysis, women had significantly higher risk of short-term all-cause mortality (RR 1.37; 95% CI 1.26-1.49; P < 0.00001) and long-term all-cause mortality (RR 1.18; 95% CI 1.07-1.31; P = 0.001) compared with men. However, when a meta-analysis was performed using adjusted effect estimates, the association between women and higher risk of short-term mortality (RR 0.99; 95% CI 0.91-1.07; P = 0.74) and long-term all-cause mortality (RR 0.84; 95% CI 0.68-1.03; P = 0.09) was markedly attenuated. Adjusted short-term and long-term all-cause mortality appeared similar in women and men. In conclusion, women with NSTE-ACS have higher short-term and long-term mortality compared with men. However, gender differences do not differ following adjustment for baseline cardiovascular risk factors and clinical differences.

Ventricular free wall Rupture after Myocardial Infarction

Patients with their first myocardial infarction (MI), who present to the emergency department many hours after the onset of chest pain, who appear to be improving but suddenly develop new chest pain and unexpected hypotension (with or without signs of cardiac tamponade), should be suspected of having ventricular free wall rupture (VFWR). The mainstay of treatment is surgery. These patients may be managed with the administration of fluids, cautious use of inotropes and echocardiographic scanning, which should be performed on an emergent basis, while being prepared to be moved to the emergency surgical suite. However, at no cost should surgery be delayed. This paper reviews the current literature of VFWR after MI, a condition which remains difficult to diagnose, in many aspects, to this day. The review examines the historical background, incidence, postulated risk factors, clinical presentation, investigations and management.

Sex as a Biological Variable in Emergency Medicine Research and Clinical Practice: A Brief Narrative Review

The National Institutes of Health recently highlighted the significant role of sex as a biological variable (SABV) in research design, outcome and reproducibility, mandating that this variable be accounted for in all its funded research studies. This move has resulted in a rapidly increasing body of literature on SABV with important implications for changing the clinical practice of emergency medicine (EM). Translation of this new knowledge to the bedside requires an understanding of how sex-based research will ultimately impact patient care. We use three case-based scenarios in acute myocardial infarction, acute ischemic stroke and important considerations in pharmacologic therapy administration to highlight available data on SABV in evidence-based research to provide the EM community with an important foundation for future integration of patient sex in the delivery of emergency care as gaps in research are filled.

Mechanistic Pathways of Sex Differences in Cardiovascular Disease

Major differences between men and women exist in epidemiology, manifestation, pathophysiology, treatment, and outcome of cardiovascular diseases (CVD), such as coronary artery disease, pressure overload, hypertension, cardiomyopathy, and heart failure. Corresponding sex differences have been studied in a number of animal models, and mechanistic investigations have been undertaken to analyze the observed sex differences. We summarize the biological mechanisms of sex differences in CVD focusing on three main areas, i.e., genetic mechanisms, epigenetic mechanisms, as well as sex hormones and their receptors. We discuss relevant subtypes of sex hormone receptors, as well as genomic and nongenomic, activational and organizational effects of sex hormones. We describe the interaction of sex hormones with intracellular signaling relevant for cardiovascular cells and the cardiovascular system. Sex, sex hormones, and their receptors may affect a number of cellular processes by their synergistic action on multiple targets. We discuss in detail sex differences in organelle function and in biological processes. We conclude that there is a need for a more detailed understanding of sex differences and their underlying mechanisms, which holds the potential to design new drugs that target sex-specific cardiovascular mechanisms and affect phenotypes. The comparison of both sexes may lead to the identification of protective or maladaptive mechanisms in one sex that could serve as a novel therapeutic target in one sex or in both.

Gender differences in cardiovascular prophylaxis: Focus on antiplatelet treatment

Cardiovascular disease (CVD) represents the leading cause of death worldwide, and equally affects both sexes although women develop disease at an older age than men. A number of clinical evidence has identified the female sex as an independent factor for poor prognosis, with the rate of mortality and disability following an acute cardiovascular (CV) event being higher in women than men. It has been argued that the different level of platelet reactivity between sexes may account for a different responsiveness to anti-platelet therapy, with consequent important implications on clinical outcomes. However, conclusive evidence supporting the concept of a gender-dependent effectiveness of platelet inhibitors are lacking. On the contrary, sex-related dissimilarities have been evidenced in cardiovascular patients in terms of age of presentation, comorbidities such as obesity, diabetes and renal disease, and a different pharmacological approach to and effectiveness in controlling classical cardiovascular risk factors such as hypertension, glucose profile and lipid dysmetabolism. All these factors could place women at an increased level of cardiovascular risk compared to men, and may concur to an enhanced pro-thrombogenic profile. The purpose of this manuscript is to provide an overview of gender-related differences in cardiovascular treatment, in order to highlight the need to improve the pharmacological prophylaxis adopted in women through a more accurate evaluation of the overall cardiovascular risk profile with consequent establishment of a more effective and targeted anti-thrombotic strategy which is not limited to the use of anti-platelet agents.

Controversies in the Treatment of Women with ST-Segment Elevation Myocardial Infarction

Coronary artery disease is the leading cause of death in women. Women with ST-segment elevation myocardial infarctions continue to have worse outcomes compared with men despite advancements in therapies. Furthermore, these differences are particularly pronounced among young men and women with myocardial infarctions. Differences in the pathophysiology of coronary artery plaque development, disease presentation, and recognition likely contribute to these outcome disparities. Despite having worse outcomes compared with men, women clearly benefit from aggressive treatment and the latest therapies. This article reviews the treatment options for ST-segment elevation myocardial infarctions and the outcomes of women after treatment with reperfusion therapies.

Women and Ischemic Heart Disease: Recognition, Diagnosis and Management

Cardiovascular disease is one of the most frequent causes of death in both males and females throughout the world. However, women exhibit a greater symptom burden, more functional disability, and a higher prevalence of nonobstructive coronary artery disease (CAD) compared to men when evaluated for signs and symptoms of myocardial ischemia. This paradoxical sex difference appears to be linked to a sex-specific pathophysiology of myocardial ischemia including coronary microvascular dysfunction, a component of the 'Yentl Syndrome'. Accordingly, the term ischemic heart disease (IHD) is more appropriate for a discussion specific to women rather than CAD or coronary heart disease. Following the National Heart, Lung, and Blood Institute Heart Truth/American Heart Association, Women's Ischemia Syndrome Evaluation and guideline campaigns, the cardiovascular mortality in women has been decreased, although significant gender gaps in clinical outcomes still exist. Women less likely undergo testing, yet guidelines indicate that symptomatic women at intermediate to high IHD risk should have further test (e.g. exercise treadmill test or stress imaging) for myocardial ischemia and prognosis. Further, women have suboptimal use of evidence-based guideline therapies compared with men with and without obstructive CAD. Anti-anginal and anti-atherosclerotic strategies are effective for symptom and ischemia management in women with evidence of ischemia and nonobstructive CAD, although more female-specific study is needed. IHD guidelines are not "cardiac catheterization" based but related to evidence of "myocardial ischemia and angina". A simplified approach to IHD management with ABCs (aspirin, angiotensin-converting enzyme inhibitors/angiotensin-renin blockers, beta blockers, cholesterol management and statin) should be used and can help to increases adherence to guidelines.

Sex differences in in-hospital mortality following a first acute myocardial infarction: symptomatology, delayed presentation, and hospital setting

BACKGROUND

Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated.

METHODS

Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated.

RESULTS

Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or ICU, while for females this age-adjusted attributable risk was 4.1 %.

CONCLUSIONS

Our study stresses the need to reappraise decision making in patient selection for admission to specialised care units, whilst raising awareness of possible sex-related bias in management of patients diagnosed with an AMI.

Long-Term Evaluation of Biotronik Linox and Linox(smart) Implantable Cardioverter Defibrillator Leads

INTRODUCTION

Expert consensus holds that post-market, systematic surveillance of ICD leads is essential to ensure confirmation of adequate lead performance. GALAXY (NCT00836589) and CELESTIAL (NCT00810264) are ongoing multicenter, prospective, non-randomized registries conducted to confirm the long-term safety and reliability of Biotronik leads.

METHODS AND RESULTS

ICD and CRT-D patients are followed for Linox and Linox(smart) ICD lead performance and safety for 5 years post-implant. All procedural and system-related adverse events (AEs) were assessed at each follow-up, along with lead electrical parameters. An independent CEC of EPs adjudicated AEs to determine AE category and lead relatedness. The analysis used categories of lead observations per ISO 5841-2 (Third edition). A total of 3,933 leads were implanted in 3,840 patients (73.0% male, mean age 67.0 ± 12.2 years) at 146 US centers. The estimated cumulative survival probability was 96.3% at 5 years after implant for Linox leads and 96.6% at 4 years after implant for Linox(smart) leads. A comparison of the Linox and Linox(smart) survival functions did not find evidence of a difference (P = 0.2155). The most common AEs were oversensing (23, 0.58%), conductor fracture (14, 0.36%), failure to capture (13, 0.33%), lead dislodgement (12, 0.31%), insulation breach (10, 0.25%), and abnormal pacing impedance (8, 0.20%).

CONCLUSIONS

Linox and Linox(smart) ICD leads are safe, reliable and infrequently associated with lead-related AEs. Additionally, estimated cumulative survival probability is clinically acceptable and well within industry standards. Ongoing data collection will confirm the longer-term safety and performance of the Linox family of ICD leads.

Trends in Gender Differences in Cardiac Care and Outcome After Acute Myocardial Infarction in Western Sweden: A Report From the Swedish Web System for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART)

BACKGROUND

Cardiovascular disease is the most common cause of death for both genders. Debates are ongoing as to whether gender-specific differences in clinical course, diagnosis, and management of acute myocardial infarction (MI) exist.

METHODS AND RESULTS

We compared all men and women who were treated for acute MI at cardiac care units in Västra Götaland, Sweden, between January 1995 and October 2014 by obtaining data from the prospective SWEDEHEART (Swedish Web-System for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) registry. We performed unadjusted and adjusted Cox proportional hazards and logistic regression analyses on complete case data and on imputed data sets. Overall, 48 118 patients (35.4% women) were diagnosed with acute MI. Women as a group had better age-adjusted prognosis than men, but this survival benefit was absent for younger women (aged <60 years) and for women with ST-segment elevation MI. Compared with men, younger women and women with ST-segment elevation MI were more likely to develop prehospital cardiogenic shock (adjusted odds ratio 1.67, 95% CI 1.30 to 2.16, P<0.001 and adjusted odds ratio 1.31, 95% CI 1.16 to 1.48, P<0.001) and were less likely to be prescribed evidence-based treatment at discharge (P<0.001 for β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, statins, and P2Y12 antagonists). Differences in treatment between the genders did not decrease over the study period (P>0.1 for all treatments).

CONCLUSIONS

Women on average have better adjusted prognosis than men after acute MI; however, younger women and women with ST-segment elevation MI have disproportionately poor prognosis and are less likely to be prescribed evidence-based treatment.

Gender disparities in stress test utilization in chest pain unit patients based upon the ordering physician's gender

OBJECTIVE

Physicians' gender may impact test utilization in the diagnosis of acute cardiovascular disease. We sought to determine if physician gender affected stress test utilization by patient gender in a low-risk chest pain observation unit.

METHODS

This was a retrospective consecutive cohort study of patients admitted to a chest pain unit in a large volume academic urban emergency department (ED). Inclusion criteria were age>18, American Heart Association low-to-intermediate risk, electrocardiogram nondiagnostic for acute coronary syndrome, and negative initial troponin I. Exclusion criteria were age>75 with a history of coronary artery disease, active comorbid medical problems, or inability to obtain stress testing in the ED for any reason. T-tests were used for univariate comparisons and logistic regression was used to estimate odds ratios (ORs) for receiving testing based on physician gender, controlling for race, insurance, and Thrombolysis In Myocardial Infarction (TIMI) score.

RESULTS

Three thousand eight hundred and seventy-three index visits were enrolled during a 2.5-year period. Mean age was 53±20, 55% (95% CI, 53-56%) were female. There was no difference in overall stress utilization based upon physician gender (P=0.28). However, after controlling for other variables, male physicians had significantly lower odds of stress testing female patients (ORM, 0.82; 95% CI, 0.68-0.99), whereas no difference was found in female physicians (ORF, 0.80; 95% CI, 0.57-1.14).

CONCLUSIONS

Male physicians appear less likely to utilize stress testing in female patients even after controlling for objective clinical variables, including TIMI score. Although adverse outcomes are uncommon in this patient cohort, further investigation into provider-specific practice patterns based on patient gender is necessary.

Sex differences in reperfusion in young patients with ST-segment-elevation myocardial infarction: results from the VIRGO study

BACKGROUND

Sex disparities in reperfusion therapy for patients with acute ST-segment-elevation myocardial infarction have been documented. However, little is known about whether these patterns exist in the comparison of young women with men.

METHODS AND RESULTS

We examined sex differences in rates, types of reperfusion therapy, and proportion of patients exceeding American Heart Association reperfusion time guidelines for ST-segment-elevation myocardial infarction in a prospective observational cohort study (2008-2012) of 1465 patients 18 to 55 years of age, as part of the US Variations in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study at 103 hospitals enrolling in a 2:1 ratio of women to men. Of the 1238 patients eligible for reperfusion, women were more likely to be untreated than men (9% versus 4%, P=0.002). There was no difference in reperfusion strategy for the 695 women and 458 men treated. Women were more likely to exceed in-hospital and transfer time guidelines for percutaneous coronary intervention than men (41% versus 29%; odds ratio, 1.65; 95% confidence interval, 1.27-2.16), more so when transferred (67% versus 44%; odds ratio, 2.63; 95% confidence interval, 1.17-4.07); and more likely to exceed door-to-needle times (67% versus 37%; odds ratio, 2.62; 95% confidence interval, 1.23-2.18). After adjustment for sociodemographic, clinical, and organizational factors, sex remained an important factor in exceeding reperfusion guidelines (odds ratio, 1.72; 95% confidence interval, 1.28-2.33).

CONCLUSIONS

Young women with ST-segment-elevation myocardial infarction are less likely to receive reperfusion therapy and more likely to have reperfusion delays than similarly aged men. Sex disparities are more pronounced among patients transferred to percutaneous coronary intervention institutions or who received fibrinolytic therapy.

Sex differences in predictors of longitudinal changes in carotid artery stiffness: the Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

To identify sex differences in predictors of longitudinal changes in carotid arterial stiffness in a multiethnic cohort.

APPROACH AND RESULTS

Carotid artery distensibility coefficient (DC) and Young's elastic modulus (YEM) were measured in 2650 Multi-Ethnic Study of Atherosclerosis participants (45-84 years old and free of cardiovascular disease) at baseline and after a mean of 9.4 years. Predictors of changes in DC and YEM for each sex were evaluated using multivariable linear regression models. The 1236 men (46.6%) were 60.0 (SD, 9.3) years: 40% were white, 22% black, 16% Chinese, and 22% Hispanic. The 1414 (53.4%) women were 59.8 (9.4) years old with a similar race distribution. Despite similar rates of change in DC and YEM, predictors of changes in distensibility markers differed by sex. In men, Chinese (P=0.002) and black (P=0.003) race/ethnicity, systolic blood pressure (P=0.012), and diabetes mellitus (P=0.05) were associated with more rapidly decreasing DC (accelerated stiffening). Starting antihypertensive medication was associated with improved DC (P=0.03); stopping antihypertensives was associated with more rapid stiffening (increased YEM, P=0.05). In women, higher education was associated with slower stiffening (DC, P=0.041; YEM, P<0.001) as was use of lipid-lowering medication (P=0.03), whereas baseline use of antihypertensive medications (YEM, P=0.01) and systolic blood pressure (DC, P=0.02; P=0.04) predicted increasing stiffening in women.

CONCLUSIONS

Longitudinal changes in carotid artery stiffness are associated with systolic blood pressure and antihypertensive therapy in both sexes; however, race/ethnicity (in men) and level of education (in women) may have different contributions between the sexes.

Gender, TIMI risk score and in-hospital mortality in STEMI patients undergoing primary PCI: results from the Belgian STEMI registry

AIMS

The relationship between the predictive performance of the TIMI risk score for STEMI and gender has not been evaluated in the setting of primary PCI (pPCI). Here, we compared in-hospital mortality and predictive performance of the TIMI risk score between Belgian women and men undergoing pPCI.

METHODS AND RESULTS

In-hospital mortality was analysed in 8,073 (1,920 [23.8%] female and 6,153 [76.2%] male patients) consecutive pPCI-treated STEMI patients, included in the prospective, observational Belgian STEMI registry (January 2007 to February 2011). A multivariable logistic regression model, including TIMI risk score variables and gender, evaluated differences in in-hospital mortality between men and women. The predictive performance of the TIMI risk score according to gender was evaluated in terms of discrimination and calibration. Mortality rates for TIMI scores in women and men were compared. Female patients were older, had more comorbidities and longer ischaemic times. Crude in-hospital mortality was 10.1% in women vs. 4.9% in men (OR 2.2; 95% CI: 1.82-2.66, p<0.001). When adjusting for TIMI risk score variables, mortality remained higher in women (OR 1.47, 95% CI: 1.15-1.87, p=0.002). The TIMI risk score provided a good predictive discrimination and calibration in women as well as in men (c-statistic=0.84 [95% CI: 0.809-0.866], goodness-of-fit p=0.53 and c-statistic=0.89 [95% CI: 0.873-0.907], goodness-of-fit p=0.13, respectively), but mortality prediction for TIMI scores was better in men (p=0.02 for TIMI score x gender interaction).

CONCLUSIONS

In the Belgian STEMI registry, pPCI-treated women had a higher in-hospital mortality rate even after correcting for TIMI risk score variables. The TIMI risk score was effective in predicting in-hospital mortality but performed slightly better in men. The database was registered with clinicaltrials.gov (NCT00727623).

The prevalence of cardiovascular disease risk factors and the Framingham Risk Score in patients undergoing percutaneous intervention over the last 17 years by gender: time-trend analysis from the Mayo Clinic PCI Registry

Objectives:

This study aims to investigate trends of cardiovascular disease (CVD) risk factor profiles over 17 years in percutaneous coronary intervention (PCI) patients at the Mayo Clinic.

Methods:

We performed a time-trend analysis within the Mayo Clinic PCI Registry from 1994 to 2010. Results were the incidence and prevalence of CVD risk factors as estimate by the Framingham risk score.

Results:

Between 1994 and 2010, 25 519 patients underwent a PCI. During the time assessed, the mean age at PCI became older, but the gender distribution did not change. A significant trend towards higher body mass index and more prevalent hypercholesterolemia, hypertension, and diabetes was found over time. The prevalence of current smokers remained unchanged. The prevalence of ever-smokers decreased among males, but increased among females. However, overall CVD risk according to the Framingham risk score (FRS) and 10-year CVD risk significantly decreased. The use of most of medications elevated from 1994 to 2010, except for β-blockers and angiotensin converting enzyme inhibitors decreased after 2007 and 2006 in both baseline and discharge, respectively.

Conclusions:

Most of the major risk factors improved and the FRS and 10-year CVD risk declined in this population of PCI patients. However, obesity, history of hypercholesterolemia, hypertension, diabetes, and medication use increased substantially. Improvements to blood pressure and lipid profile management because of medication use may have influenced the positive trends.

Comparison of left ventricular function following first ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention in men versus women

Previous data reported worse outcomes in female patients after acute ST elevation myocardial infarction (STEMI), related at least in part to less aggressive and nonparallel treatment. We investigated the presence of gender differences in left ventricular (LV) systolic and diastolic function in patients presenting with first STEMI, treated with primary percutaneous coronary intervention (PCI). Study population included 187 consecutive patients (81% men) presenting with STEMI and treated by primary PCI and guideline-based medications. Their mean age was 58 ± 10 years. All patients underwent a comprehensive echocardiographic evaluation within 3 days of admission. Female patients were older (62 ± 11 vs 59 ± 10 years, p = 0.006), with more co-morbidities and longer symptom duration (490 ± 436 vs 365 ± 437 minutes, p = 0.013). Echocardiography demonstrated that female patients had significantly lower LV systolic function (47 ± 8% vs 45 ± 8%, p = 0.03), lower septal and lateral e' velocities, higher average E/e' ratio (all p <0.001), elevated systolic pulmonary artery pressure (p = 0.03), and worse diastolic dysfunction (p = 0.007). No significant changes were present in left atrial volumes. In a logistic multivariate analysis model, female gender emerged as an independent predictor of septal e' <8 cm/s (odds ratio 10.11, 95% confidence interval 1.23 to 82.32, p = 0.002) and E/average e' ratio >15 (odds ratio 6.47, 95% confidence interval 1.63 to 25.61, p = 0.008). In conclusion, female patients undergoing primary PCI for first STEMI demonstrated worse systolic and diastolic LV function, despite receiving similar treatment as male patients.