Sex differences in coronary artery lesions and in‐hospital outcomes for patients with ST‐segment elevation myocardial infarction under the age of 45

Spontaneous coronary artery dissection in women in the generative period: clinical characteristics, treatment, and outcome-a systematic review and meta-analysis

Introduction

Spontaneous coronary artery dissection (SCAD) is a non-traumatic and non-iatrogenic separation of the coronary arterial wall.

Materials and methods

This systematic review and meta-analysis is reported following the PRISMA guidelines and is registered in the PROSPERO database. A literature search was focused on female patients in generative period (16-55 of age) with acute coronary syndrome (ACS) caused by SCAD, and comparison from that database NP-SCAD (spontaneous coronary artery dissection in non pregnant women) and P-SCAD (spontaneous coronary artery dissection in pregnant women).

Results

14 studies with 2,145 females in the generative period with ACS caused by SCAD were analyzed. The median age was 41 years (33.4-52.3 years). The most common risk factor was previous smoking history in 24.9% cases. The most common clinical presentation of ACS was STEMI in 47.4%. Conservative treatment was reported in 41.1%. PCI was performed in 32.7%, and 3.8% of patients had CABG surgery. LAD was the most frequently affected (50.5%). The prevalence of composite clinical outcomes including mortality, non-fatal MI and recurrent SCAD was 3.3% (95% CI: 1.4-5.1), 37.7% (95% CI: 1.9-73.4) and 15.2% (95% CI: 9.1-21.3) of patients. P-SCAD compared to NP-SCAD patients more frequently had STEMI (OR = 3.16; 95% CI: 2.30-4.34; I2 = 64%); with the left main and LAD more frequently affected [(OR = 14.34; 95% CI: 7.71-26.67; I2 = 54%) and (OR = 1.57; 95% CI: 1.06-2.32; I2 = 23%)]; P-SCAD patients more frequently underwent CABG surgery (OR = 6.29; 95% CI: 4.08-9.70; I2 = 0%). NP-SCAD compared to P-SCAD patients were more frequently treated conservatevly (OR = 0.61; 95% CI: 0.37-0.98; I2 = 0%). In P-SCAD compared to NP-SCAD mortality rates (OR = 1.13; 95% CI: 0.06-21.16; I2 = not applicable) and reccurence of coronary artery dissection (OR = 2.54; 95% CI: 0.97-6.61; I2 = 0%) were not more prevalent.

Conclusion

The results of this meta-analysis indicated that patients with P-SCAD more frequently had STEMI, and events more frequently involved left main and LAD compared to NP-SCAD patients. Women with NP-SCAD were significantly more often treated conservatively compared to P-SCAD patients. P-SCAD compared to NP-SCAD patients did not have significantly higher mortality rates or recurrent coronary dissection.

Spontaneous coronary artery dissection: an overview

The prevalence of spontaneous coronary artery dissection (SCAD) has increased over the last decades in young adults presenting with acute coronary syndrome. Although the diagnostic tools, including intracoronary imaging, have permitted a more accurate diagnosis of SCAD, the prognosis and overall outcomes remain dismal. Furthermore, the disproportionate sex distribution affecting more women and the underdiagnosis in many parts of the world render this pathology a persistent clinical challenge, particularly since the management remains largely supportive with a limited and controversial role for percutaneous or surgical interventions. The purpose of this review is to summarize the available literature on SCAD and to provide insights into the gaps in knowledge and areas requiring further investigation.

Pathophysiology of spontaneous coronary artery dissection: hematoma, not thrombus

Spontaneous coronary artery dissection (SCAD) accounts for 1.7%-4% of all acute coronary syndrome presentations, particularly among young women with an emerging awareness of its importance. The demarcation of acute SCAD from coronary atherothrombosis and the proper therapeutic approach still represents a major clinical challenge. Certain arteriopathies and triggers are related to SCAD, with high variability in their prevalence, and often, the cause remains unknown. The objective of this review is to provide contemporary knowledge of the pathophysiology of SCAD and possible therapeutic solutions.

Risk Factors for Premature Coronary Heart Disease in Women Compared to Men: Systematic Review and Meta-Analysis

Background: We aimed to systematically examine literature on the prevalence of known modifiable and nonmodifiable risk factors for premature coronary heart disease (PCHD) in women compared with men. Materials and Methods: PubMed, CINAHL, Embase, and Web of Science databases were searched. Review protocol is registered in PROSPERO (CRD42020173216). Quality was assessed using the National Heart, Lung, and Blood Institute tool. Review Manager 5.3 was used for meta-analysis. Effect sizes were expressed as odds ratio (OR) and mean differences/standardized mean differences (SMD) with 95% confidence intervals (CIs) for categorical and continuous variables. Results: In this PCHD cohort (age <65 years), the mean age of presentation in women was 3 years older than men. Women had higher total cholesterol (SMD 0.11; 95% CI 0.00 to 0.23) and higher high-density lipoprotein cholesterol (SMD 0.49; 95% CI 0.29 to 0.69). Women were more likely to have hypertension (OR 1.51, 95% CI 1.42 to 1.60), diabetes mellitus (OR 1.78, 95% CI 1.55 to 2.04), obesity (OR 1.33, 95% CI 1.24 to 1.42), metabolic syndrome (OR 3.73, 95% CI 1.60 to 8.69), stroke (OR 1.63, 95% CI 1.51 to 1.77), peripheral vascular disorder (OR 1.67, 95% CI 1.43 to 1.96), and depression (OR 2.29, 95% CI 1.96 to 2.67). Women were less likely to be smokers (OR 0.60, 95% CI 0.55 to 0.66), have reported alcohol intake (OR 0.36, 95% CI 0.33 to 0.40), and reported use of illicit drug (OR 0.32, 95% CI 0.16 to 0.62). Conclusions: Risk factor profile in PCHD has a clear sex difference that supports early, aggressive, holistic, but sex-specific, approach to prevention.

Risk factors profile of young and older patients with myocardial infarction

Myocardial infarction (MI) among young adults (<45 years) represents a considerable proportion of the total heart attack incidents. The underlying pathophysiologic characteristics, atherosclerotic plaque features, and risk factors profile differ between young and older patients with MI. This review article discusses the main differences between the younger and elderly MI patients as well as the different pathogenic mechanisms underlying the development of MI in the younger. Young patients with MI often have eccentric atherosclerotic plaques with inflammatory features but fewer lesions, and are more likely to be smokers, obese, and have poor lifestyle, such as inactivity and alcohol intake. Compared to older MI patients, younger are more likely to be men, have familial-combined hyperlipidaemia and increased levels of lipoprotein-a. In addition, MI in younger patients may be related to use of cannabis, cocaine use, and androgenic anabolic steroids. Genomic differences especially in the pathways of coagulation and lipid metabolism have also been identified between young and older patients with MI. Better understanding of the risk factors and the anatomic and pathophysiologic processes in young adults can improve MI prevention and treatment strategies in this patient group. Awareness could help identify young subjects at increased risk and guide primary prevention strategies. Additional studies focusing on gene pathways related to lipid metabolism, inflammation, and coagulation are needed.

Spontaneous Coronary Artery Dissection: A Rare Event?

Spontaneous coronary artery dissection is an infrequent cause of acute coronary syndrome with comparable clinical features. Previously considered a rare disease, recent scientific interest has revealed spontaneous coronary artery dissection as an important differential diagnosis of acute coronary syndrome, especially in young women, during pregnancy or postpartum, and in patients with fibromuscular dysplasia or other arteriopathies. However, there remain many uncertainties regarding pathophysiology, risk factors, acute treatment, and optimal long-term management. The aim of this review is to summarize current scientific evidence on epidemiology, management, and outcomes.

[Infarto agudo de miocardio: revisión sobre factores de riesgo, etiología, hallazgos angiográficos y desenlaces en pacientes jóvenes]

La enfermedad cardiovascular persiste como primera causa mundial de muerte en los adultos. La población de adultos jóvenes ha cursado con cambios en el estilo de vida con el paso de las décadas, favoreciendo la aparición de ateroesclerosis en etapas más tempranas y como consecuencia la aparición de eventos cardiovasculares de manera más prematura. Se ha identificado que dentro de los factores de riesgo más comunes, la mayoría de ellos son potencialmente modificables. En comparación con adultos mayores, se ha identificado con mayor prevalencia la presencia de etiologías no ateroescleróticas de infarto de miocardio, como la disección coronaria espontánea, alteraciones anatómicas, embolia y espasmo coronarios. Los hallazgos angiográficos y desenlaces son diferentes de acuerdo con el grupo de edad y el sexo. Por dicho motivo realizamos una búsqueda en PubMed de los estudios y registros publicados para el estudio del infarto agudo de miocardio en paciente jóvenes. Con dicha información realizamos la presente revisión con el objetivo de una mejor comprensión de los hallazgos comunes en este grupo y realizar su comparación con grupos de mayor edad.

Premature STEMI in Men and Women: Current Clinical Features and Improvements in Management and Prognosis

Background: Coronary artery disease (CAD) is the most frequent cause of ST-segment elevation myocardial infarction (STEMI). Etiopathogenic and prognostic characteristics in young patients may differ from older patients and young women may present worse outcomes than men. We aimed to evaluate the clinical characteristics and prognosis of men and women with premature STEMI.

METHODS

A total 1404 consecutive patients were referred to our institution for emergency cardiac catheterization due to STEMI suspicion (1 January 2014-31 December 2018). Patients with confirmed premature (<55 years old in men and <60 in women) STEMI (366 patients, 83% men and 17% women) were included (359 atherothrombotic and 7 spontaneous coronary artery dissection (SCAD)).

RESULTS

Premature STEMI patients had a high prevalence of classical cardiovascular risk factors. Mean follow-up was 4.1 years (±1.75 SD). Mortality rates, re-hospitalization, and hospital stay showed no significant differences between sexes. More than 10% of women with premature STEMI suffered SCAD. There were no significant differences between sexes, neither among cholesterol levels nor in hypolipemiant therapy. The global survival rates were similar to that expected in the general population of the same sex and age in our region with a significantly higher excess of mortality at 6 years among men compared with the general population.

CONCLUSION

Our results showed a high incidence of cardiovascular risk factors, a high prevalence of SCAD among young women, and a generally good prognosis after standardized treatment. During follow-up, 23% suffered a major cardiovascular event (MACE), without significant differences between sexes and observed survival at 1, 3, and 6 years of follow-up was 96.57% (95% CI 94.04-98.04), 95.64% (95% CI 92.87-97.35), and 94.5% (95% CI 91.12-97.66). An extra effort to prevent/delay STEMI should be invested focusing on smoking avoidance and optimal hypolipemiant treatment both in primary and secondary prevention.

Recurrent spontaneous coronary artery dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is a cause of non-atherosclerotic acute coronary syndrome and sudden cardiac death that predominantly impacts young and middle-aged women. In addition to the challenges of acute SCAD including arrhythmias, heart failure, and recurrent chest pain, de novo recurrent SCAD occurs in 5-29% of patients. Recurrent SCAD presents both a psychological burden and a significant cardiac risk to patients. Research regarding SCAD recurrence risk has been growing and can guide providers and patients alike.Areas covered: This review provides up-to-date information about many aspects of SCAD with a focus on SCAD recurrence. PubMed articles were reviewed through October 2020, with particular focus on clinical studies and original research. The resulting literature was scrutinized for information on SCAD recurrence. SCAD-associated conditions, genetic data, clinical characteristics, medications, and aspects of post-SCAD care are summarized.Expert Opinion: SCAD recurrence poses a concerning risk for patients with SCAD. Conditions such as hypertension and severe coronary tortuosity may be associated with recurrence. More research is needed to further elucidate risk factors for recurrence and clarify interventions, such as beta blocker therapy, that may reduce recurrence risk.

Gender differences in clinical characteristics and in-hospital and one-year outcomes of young patients with ST-segment elevation myocardial infarction under the age of 40

Introduction: Although the incidence of acute ST-segment elevation myocardial infarction (STEMI) in the elderly population has decreased in recent years, this is not the case for young people. At the same time, no reduction in hospitalization rate after STEMI was shown in young people. Clinical characteristics, risk factors, angiographic findings, in-hospital and one-year outcomes of patients under the age of 40 and their gender differences were investigated. Methods: This study has been performed retrospectively in two centers. Between January 2015 and April 2019, 212 patients aged 18-40 years with STEMI and who underwent reperfusion therapy were included. The gender differences were compared. Results: The median age of (male 176; 83.0% and female 36; 17.0%) patients included in the study was 36 (33-38) for men and 36 (34-38) for women. Chest pain was the most common complaint for both genders (96.0% vs. 94.4%; P = 0.651). While men presented more often with Killip class 1,women presented more often with Killip class 2. The anterior myocardial infarction (MI) was the most common MI type and it was higher in women than in man (P = 0.027). At one year of follow-up, the prevalence of all-cause hospitalization was 24%, MI 3.8%, coronary angiography 15.1%, cardiovascular death 1.4%, and all-cause death 0.47%, there was no gender difference. Conclusion: Anterior MI was the most common type of MI and it was more common in women than in men. Left anterior descending artery was the most common involved coronary artery. The most common risk factor is smoking. In terms of in-hospital outcome, left ventricular ejection fraction was significantly lower in women. There was no significant difference in one-year outcomes between both genders.