Gender-specific predictors of early mortality after coronary artery bypass graft surgery

Risk factors for anxiety in patients with epilepsy: A meta-analysis

BACKGROUND

Epilepsy is a very common neurological disease, and it is important to focus on both controlling seizures and alleviating the psychological problems associated with this disease.Anxiety is an important risk factor for epilepsy and seriously affects the quality of life of patients with epilepsy (PWE). However, several risk factors for anxiety in PWE are relatively controversial and understudied. This meta-analysis was performed to identify potential risk factors for anxiety in PWE with the aim of reducing the incidence of anxiety and improving the quality of life among the individuals.

METHOD

The PubMed, Embase and Cochrane Library databases were systematically searched up to July 2023 to find eligible original English studies. All the search results were reviewed based on our inclusion and exclusion criteria. We calculated the combined odds ratios (ORs), standard mean differences (SMDs) and their corresponding 95% confidence intervals (CIs) to evaluate the effect of the included risk factors on anxiety in PWE.

RESULTS

Twenty-four studies involving 5,403 PWE were ultimately included. The pooled results of our meta-analysis showed that female sex (OR = 1.67; 95 % CI: 1.30,2.15; p < 0.001), unmarried/divorced/widowed (OR = 0.83; 95 % CI: 0.72,0.96; p = 0.011), low socioeconomic status (OR = 0.47; 95 % CI: 0.33,0.67; p < 0.001), education levels below high school (OR = 1.74; 95 % CI: 1.36,2.23; p < 0.001), a history of trauma (OR = 2.53; 95 % CI: 1.69,3.78; p < 0.001), monotherapy (OR = 0.49; 95 % CI: 0.39,0.62; p < 0.001), AED-induced psychiatric side effects (OR = 2.45; 95 % CI: 1.20,4.98); p = 0.014), depression (OR = 5.45 95 % CI: 2.49,11.94; p < 0.001), a history of suicide (OR = 3.56; 95 % CI: 1.72,7.38; p = 0.001), and illness-related shame (OR = 2.76; 95 % CI: 2.17,3.52; p < 0.001) were risk factors for anxiety.

CONCLUSION

This meta-analysis showed that female, unmarried, low socioeconomic status, education level below senior high school, a history of trauma, monotherapy, AED-induced psychiatric side effects, depression, a history of suicide, and shame were risk factors for anxiety in PWE. However, further research is needed to determine the effect of other potential risk factors on anxiety in PWE. In addition, most of the studies included in this meta-analysis were not uniform in scale, and the risk factors were not comprehensive; therefore, larger prospective studies in different countries are needed to further investigate these risk factors.

Comparison of Effects of Liuzijue Exercise and Conventional Respiratory Training on Patients after Cardiac Surgery: A Randomized Controlled Trial

OBJECTIVE

To evaluate the feasibility and safety of Liuzijue exercise (LE) for the clinical effect in patients after cardiac surgery.

METHODS

Totally 120 patients who underwent cardiac surgery and were admitted to the Cardiothoracic Intensive Care Unit of Nanjing Drum Tower Hospital between July and Oclober, 2022 were allocated to the LE group, the conventional respiratory training (CRT) group, and the control group by a random number table at a ratio of 1:1:1; 40 patients in each group. All patients received routine treatment and cardiac rehabilitation. LE group and CRT group respectively performed LE and CRT once a day for 30 min for 7 days. Control group did not receive specialized respiratory training. The forced vital capacity, forced expiratory volume in 1 s, peak inspiratory flow rate, peak expiratory flow rate, maximum inspiratory pressure, maximum expiratory pressure, modified Barthel index (MBI), and Hamilton Rating Scale for Anxiety (HAM-A) were evaluated before, after 3 and 7 days of intervention. In addition, the postoperative length of hospital stay (LOS) and the adverse events that occurred during the intervention period were compared.

RESULTS

A total of 107 patients completed the study, 120 patients were included in the analysis. After 3 days of intervention, the pulmonary function, respiratory muscle strength, MBI and HAM-A of all 3 groups improved compared with that before the intervention (P<0.05 or P<0.01). Compared with the control group, pulmonary function and respiratory muscle strength were significantly improved in the CRT and LE groups (P<0.05 or P<0.01). MBI and HAM-A were significantly improved in the LE group compared with the control and CRT groups (P<0.05 or P<0.01). On the 7th day after intervention, the difference was still statistically significant (P<0.01), and was significantly different from that on the 3rd day (P<0.05 or P<0.01). In addition, on the 7th day of intervention, the pulmonary function and respiratory muscle strength in the LE group were significantly improved compared with those in the CRT group (P<0.01). MBI and HAM-A were significantly improved in the CRT group compared with the control group (P<0.01). There were no significant differences in postoperative LOS among the 3 groups (P>0.05). No training-related adverse events occurred during the intervention period.

CONCLUSIONS

LE is safe and feasible for improving pulmonary function, respiratory muscle strength, the ability to complete activities of daily living and for relieving anxiety of patients after cardiac surgery (Registration No. ChiCTR2200062964).

Gender medicine: effects of sex and gender on cardiovascular disease manifestation and outcomes

Despite a growing body of evidence, the distinct contributions of biological sex and the sociocultural dimension of gender to the manifestations and outcomes of ischaemic heart disease and heart failure remain unknown. The intertwining of sex-based differences in genetic and hormonal mechanisms with the complex dimension of gender and its different components and determinants that result in different disease phenotypes in women and men needs to be elucidated. The relative contribution of purely biological factors, such as genes and hormones, to cardiovascular phenotypes and outcomes is not yet fully understood. Increasing awareness of the effects of gender has led to efforts to measure gender in retrospective and prospective clinical studies and the development of gender scores. However, the synergistic or opposing effects of sex and gender on cardiovascular traits and on ischaemic heart disease and heart failure mechanisms have not yet been systematically described. Furthermore, specific considerations of sex-related and gender-related factors in gender dysphoria or in heart-brain interactions and their association with cardiovascular disease are still lacking. In this Review, we summarize contemporary evidence on the distinct effects of sex and gender as well as of their interactions on cardiovascular disease and how they favourably or unfavourably influence the pathogenesis, clinical manifestations and treatment responses in patients with ischaemic heart disease or heart failure.

Gender Differences in Coronary Artery Disease, Clinical Characteristics, and Angiographic Features in the Jazan Region, Saudi Arabia

BACKGROUND

Cardiovascular disease is a major cause of death worldwide. In Saudi Arabia and the gulf area, coronary artery disease (CAD) is considered a serious problem with high mortality. Previous studies identified multiple risk factors, that include hypertension, diabetes, dyslipidemia, obesity, smoking, and low physical activity, which might be related to lifestyle changes over the last few decades. Limited data about gender differences in clinical and angiographic characteristics among CAD patients in the Jazan region are available. The aim of this study is to assess potential gender differences in CAD and its clinical characteristics and angiographic features in the Jazan region.

METHODS

This retrospective chart review collected data between January 2020 and March 2021 from the follow-ups of 498 patients (100 females and 398 males) aged over 18 years at the Prince Mohammed bin Nasser Hospital in the Jazan region of Saudi Arabia. The data were collected after all patients admitted to the hospital were reviewed, and cardiac catheterization was performed.

RESULTS

Of the 498 patients with CAD, 100 (20.1%) were female and 398 (79.9%) were male. The mean age of female patients (59.44 years) was significantly higher than that of male patients (55.1 years; P=0.0002). In addition, risk factors differed significantly between genders (P=0.0210). Moreover, vessels differed significantly between genders (P=0.0002). Coronary angiogram findings showed significant correlations between gender and percutaneous coronary intervention (PCI; P=0.0001) and MEDICAL (P=0.0010). Diagnosis findings showed significant gender differences in STEMI (P<0.0010) and unstable angina (P<0.0010).

CONCLUSIONS

CAD severity did not differ by gender, but coronary angiogram findings showed significant relationships between gender, PCI, and MEDICAL treatment with CAD.

Gender differences, inequalities and biases in the management of Acute Coronary Syndrome

OBJECTIVE

The approach to Acute Coronary Syndrome from a gender perspective is relatively recent. Research is extensive at epidemiological and clinical levels. However, available evidence, besides neglecting the social dimensions of the disease, has made women invisible. The objective of this review was to analyze the inequalities and gender biases in Acute Coronary Syndrome, from the beginning of the disease process to the final resolution.

METHODS

An exhaustive review of the literature of the entire health care process, from risk factors to rehabilitation and recovery, was carried out. The search for articles on gender, gender inequalities, or gender bias was conducted in indexed journals of social and health sciences. Also, a specific search was performed for each stage of the process, such as risk factors, prehospital phase, diagnosis, treatment, and rehabilitation.

RESULTS

Results showed the presence of gender biases throughout the entire health care process in Acute Coronary Syndrome. It is shown gender inequalities in the access to medical care, including a poor recognition among women themselves as well as among health professionals; longer prehospital delays; inadequate diagnoses and treatments; or less assistance to cardiac rehabilitation programmes. These biases occurred at the different levels of the health services involved. Finally, this review included recommendations proposed or arising from the revised papers.

CONCLUSIONS

Reducing gender biases in Acute Coronary Syndrome implies developing strategies to raise awareness among women, improve training of professionals serving at the different levels of health services, reduce delays, develop health management measures, and promote a research agenda.

Impact of sex on outcomes after cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Despite advances in cardiac surgery, observational studies suggest that females have poorer post-operative outcomes than males. This study is the first to review sex related outcomes following both coronary artery bypass graft (CABG) and valve surgery with or without combined CABG.

METHODS

We identified 30 primary research articles reporting either short-term mortality (in-hospital/30 day), long-term mortality, and post-operative stroke, sternal wound infection and myocardial infarction (MI) in both sexes following CABG and valve surgery with or without combined CABG. Reported adjusted odds/hazard ratio were pooled using an inverse variance model.

RESULTS

Females undergoing CABG and combined valve and CABG surgery were at higher risk of short-term mortality (odds ratio (OR) 1.40; 95% confidence interval (CI) 1.32-1.49; I² = 79%) and post-operative stroke (OR 1.2; CI 1.07-1.34; I² = 90%) when compared to males. However, for isolated AVR, there was no difference found (OR 1.19; 95% CI 0.74-1.89). There was no increased risk in long-term mortality (OR 1.04; 95% CI: 0.93-1.16; I² = 82%), post-operative MI (OR 1.22; 95%CI: 0.89-1.67; I² = 60%) or deep sternal wound infection (OR 0.92; 95%CI: 0.65-1.03, I² = 87%). No evidence of publication bias or small study effect was found.

CONCLUSION

Females are at a greater risk of short-term mortality and post-operative stroke than males following CABG and valve surgery combined with CABG. However, there is no difference for Isolated AVR. Long-term mortality is equivalent in both sexes. PROSPERO Registration: CRD42021244603.

Assessment of factors affecting short-term pulmonary functions following cardiac surgery: A prospective observational study

BACKGROUND

Pulmonary complications after cardiac surgery are very common and lead to an increased incidence of post-operative morbidity and mortality. Several factors, either modifiable or non-modifiable, may contribute to the associated unfavorable consequences related to pulmonary function. This study was aimed to investigate the degree of alteration and factors influencing pulmonary function (forced expiratory volume in one second (FEV₁) and forced vital capacity), on third, fifth, and seventh post-operative days following cardiac surgery.

METHODS

This study was executed in 71 patients who underwent on-pump cardiac surgery. Pulmonary function was assessed before surgery and on the third, fifth, and seventh post-operative days. Data including surgical details, information about risk factors, and assessment of pulmonary function were obtained.

RESULTS

The FEV₁ and forced vital capacity were significantly impaired on post-operative days 3, 5, and 7 compared to pre-operative values. The reduction in FEV₁ was 41%, 29%, and 16% and in forced vital capacity was 42%, 29%, and 19% consecutively on post-operative days 3, 5, and 7. Multivariate analysis was done to detect the factors influencing post-operative FEV₁ and forced vital capacity.

DISCUSSION

This study observed a significant impairment in FEV₁ and forced vital capacity, which did not completely recover by the seventh post-operative day. Different factors affecting post-operative FEV₁ and forced vital capacity were pre-operative FEV₁, age ≥60, less body surface area, lower pre-operative chest expansion at the axillary level, and having more duration of cardiopulmonary bypass during surgery. Presence of these factors enhances the chance of developing post-operative pulmonary complications.

Sex differences in anxiety in patients with epilepsy: Status and risk factors analysis

OBJECTIVES

Evidence has indicated that there may be sex differences in the prevalence of and risk factors for anxiety in patients with epilepsy (PWE). The prevalence and risk factors for anxiety in male and female PWE in Northeast China were investigated.

METHODS

A consecutive cohort of patients with epilepsy (PWE) from the First Hospital of Jilin University was recruited. Anxiety symptoms were assessed using the 7-item Generalized Anxiety Disorder-7 questionnaire (GAD-7; Chinese version). Multivariate logistic regression analyses were used to confirm independent risk factors for anxiety in male and female patients.

RESULTS

Anxiety was prevalent in 28.2% (n = 162) of the total sample of patients, in 23.2% (n = 79) of males, and in 35.5% (n = 83) of females. Younger age (P = 0.033), higher seizure frequency over the last year (P = 0.003), and higher C-NDDI-E scores (P = 0.001) were risk factors for anxiety in males with epilepsy. Only higher C-NDDI-E scores (P = 0.001) had an independent effect on the risk of anxiety in females with epilepsy.

CONCLUSION

Anxiety is a common psychiatric comorbidity among PWE. There were sex differences in the prevalence and risk factors for anxiety in patients.

Psychosocial and medical predictors of 14-year mortality and morbidity in male and female coronary artery bypass graft recipients: a prospective observational study

BACKGROUND

Psychosocial factors may influence mortality and morbidity after coronary bypass surgery (CABG), but it is unclear when, post-surgery, they best predict the outcome, if they interact, or whether results differ for men and women.

METHODS

This prospective, observational study assessed depression symptoms, social support, marital status, household responsibility, functional impairment, mortality and need for further coronary procedures over 14 years of follow-up. Data were collected in-hospital post-CABG and at home 1-year later. Mortality and subsequent cardiac procedure data were extracted from a Cardiac Registry.

RESULTS

Of 296 baseline participants, 78% (43% were women) completed data at 1-year post-CABG. Long-term survival was shorter with 1-year depression and lower household responsibility but that was not true for the measures taken at baseline [HR for depression = 1.27; 95% CI 1.02-1.59 v. 0.99 (0.78-1.25), and HR = 0.71; 95% CI 0.52-0.97 v. 0.97 (0.80-1.16)] for household responsibility. An interaction between depression symptoms and social support at year 1 [χ2 (11) = 111.05, p < 0.001] revealed a greater hazard of mortality d with increased depression only at mean (HR = 1.67; 95% CI 1.21-2.26) and high social support (HR = 2.23; 95% CI 1.46-3.40). Depression also accounted for increased event recurrence. There were no significant interactions of sex with medical long-term outcomes.

CONCLUSIONS

In a sex-balanced sample, depression and household responsibility measured at 1-year post-CABG were associated with significant variance in unadjusted and adjusted predictor models of long-term mortality whereas the same indices determined right after the procedure were not significant predictors.

Sex differences in marital status of people with epilepsy in Northeast China: An observational study

PURPOSE

Our aims were to determine (1) whether the marriage rate was different between the sexes and (2) whether the influencing factors of marital status varied by sexes.

METHODS

A cross-sectional study was performed among 475 people with epilepsy (PWE) in Northeast China. The demographic information and clinical data were gathered and recorded. Sex differences in the marriage rate of PWE and the related influencing factors were analyzed. Multivariate logistic regression analyses were used to investigate the independent factors influencing marital status in men and women, respectively.

RESULTS

Among 475 participants, 219 (79.6%) men with epilepsy (MWE) were married, and 140 (70%) women with epilepsy (WWE) were married. In MWE, age, educational level, age at seizure onset, and disease duration were significantly different between the married men and the single men. In WWE, age, educational level, occupation and age at seizure onset showed significant differences between the married women and the single women. In the multiple logistic regression model, age and age at first seizure onset had an independent effect on the marital status in men with epilepsy. Multiple logistic regression analysis also revealed that age and age at first seizure onset were independent factors that influenced marital status in WWE.

CONCLUSION

Men with epilepsy were more likely to marry than WWE. Age and the age of seizure onset independently affected the marital status of men and women.

Does affordability matter? Examining the trends and patterns in health care expenditure in India

BACKGROUND

Absence of better financing mechanism results in higher out of pocket expenditure and catastrophe, which leads to impoverishment and poverty especially among low- and middle-income countries like India. This paper examines the major characteristics associated with the higher out of pocket expenditure and provides an insight from Andersen's behavioural model that how predisposing, enabling and need factors influence the level and pattern of out of pocket expenditure in India.

METHODS

Data has been extracted from three rounds of nationally representative consumer expenditure surveys, i.e. 1993-1994, 2004-2005 and 2011-2012 conducted by the Government of India. States were categorized based on regional classification, and adult equivalent scale was used to adjust the household size. Multiple Generalized-Linear-Regression-Model was employed to explore the relative effect of various socio-economic covariates on the level of out of pocket expenditure.

RESULTS

The gap has widened between advantaged and disadvantaged segment of the population along with noticeable regional disparities among Indian states. Generalized-Linear-Regression-Model indicates that the most influential predisposing and enabling factor determining the level of out of pocket expenditure were age composition, religion, social-group, household type, residence, economic status, sources of cooking and lighting arrangements among the households.

CONCLUSIONS

Present study suggests the need for strengthening the affordability mechanism of the households to cope with the excessive burden of health care payments. Furthermore, special consideration is required to accommodate the needs of the elderly, rural, backward states and impoverishment segment of population to reduce the unjust burden of out of pocket expenditure in India.

[Anxiety disorders in epilepsy]

This review is devoted to the place of anxiety disorders in the spectrum of psychiatric comorbidity in patients with epilepsy. The authors present general characteristics of anxiety manifestations and current views on the classification and qualification of anxiety disorders in such patients. Recent data show the relationship of anxiety with different forms of epilepsy, demographic and gender characteristics, localization of epileptic focus. The problem of bidirectional relationship of anxiety and epilepsy as well as the temporal relationship between anxiety and epileptic states are considered.

Gender and intraoperative blood transfusion: analysis of 54,122 non-reoperative coronary revascularization procedures

Background:

Previous studies have shown that women undergoing isolated coronary artery bypass graft (CABG) surgery have an increased risk for postoperative morbidity and mortality when compared to men. Additionally, recent evidence suggests that blood transfusions are independently associated with an increased risk of adverse outcome.

Methods:

We evaluated gender differences in the risk of intraoperative red blood cell (RBC) transfusion during CABG surgery. Consecutive, non-reoperative CABG procedures performed across 196 institutions between April 2012 and May 2015 were retrospectively reviewed. Gender differences for intraoperative transfusion were evaluated with a multi-variable binary logistic regression model, adjusting for age, blood volume (Nadler formula to normalize for height and weight), body mass index, procedure acuity, net extracorporeal circuit prime volume, use of autologous priming, first hematocrit (Hct) in the operating room (OR), nadir Hct on cardiopulmonary bypass (CPB), volume added on CPB, ultrafiltration volume, urine output on CPB and procedure duration.

Results:

Among 54,122 patients (25.3% female), 21.6% (n = 11,701) received a RBC transfusion. Compared to men, female patients were older (66 years vs. 64 years, p<0.001), had lower blood volumes (4.3L vs. 5.6L, p<0.001) and a lower preoperative Hct (32.9% vs. 37.2%, p<0.001). Transfusion rates were three-fold higher in women versus men (45.1% vs. 13.7%, p<0.001). After adjustment for independent predictors of intraoperative transfusion, women remained at increased risk versus men (OR = 1.30, 95%CI = 1.19−1.43).

Conclusions:

Women have an increased risk of intraoperative RBC transfusion versus men. After adjusting for height and weight, much of this risk is due to gender differences in preoperative Hct and blood volume; however, a residual significant risk remained after adjustment. Perfusion strategies aimed at gender differences may minimize unnecessary transfusions. Future study on the impact of gender on transfusion practice in cardiac surgery is warranted.

Sex Difference in Patients With Ischemic Heart Failure Undergoing Surgical Revascularization: Results From the STICH Trial (Surgical Treatment for Ischemic Heart Failure)

BACKGROUND

Female sex is conventionally considered a risk factor for coronary artery bypass grafting (CABG) and has been included as a poor prognostic factor in multiple cardiac operative risk evaluation scores. We aimed to investigate the association of sex and the long-term benefit of CABG in patients with ischemic left ventricular dysfunction enrolled in the prospective STICH trial (Surgical Treatment for Ischemic Heart Failure Study).

METHODS

The STICH trial randomized 1212 patients (148 [12%] women and 1064 [88%] men) with coronary artery disease and left ventricular ejection fraction ≤35% to CABG+medical therapy (MED) versus MED alone. Long-term (10-year) outcomes with each treatment were compared according to sex.

RESULTS

At baseline, women were older (63.4 versus 59.3 years; P=0.016) with higher body mass index (27.9 versus 26.7 kg/m2; P=0.001). Women had more coronary artery disease risk factors (diabetes mellitus, 55.4% versus 37.2%; hypertension, 70.9% versus 58.6%; hyperlipidemia, 70.3% versus 58.9%) except for smoking (13.5% versus 21.8%) and had lower rates of prior CABG (0% versus 3.4%; all P<0.05) than men. Moreover, women had higher New York Heart Association class (class III/IV, 66.2% versus 57.0%), lower 6-minute walk capacity (300 versus 350 m), and lower Kansas City Cardiomyopathy Questionnaire overall summary scores (51 versus 63; all P<0.05). Over 10 years of follow-up, all-cause mortality (49.0% versus 65.8%; adjusted hazard ratio, 0.67; 95% confidence interval, 0.52-0.86; P=0.002) and cardiovascular mortality (34.3% versus 52.3%; adjusted hazard ratio, 0.65; 95% confidence interval, 0.48-0.89; P=0.006) were significantly lower in women compared with men. With randomization to CABG+MED versus MED treatment, there was no significant interaction between sex and treatment group in all-cause mortality, cardiovascular mortality, or the composite of all-cause mortality or cardiovascular hospitalization (all P>0.05). In addition, surgical deaths were not statistically different (1.5% versus 5.1%; P=0.187) between sexes among patients randomized to CABG per protocol as initial treatment.

CONCLUSIONS

Sex is not associated with the effect of CABG+MED versus MED on all-cause mortality, cardiovascular mortality, the composite of death or cardiovascular hospitalization, or surgical deaths in patients with ischemic left ventricular dysfunction. Thus, sex should not influence treatment decisions about CABG in these patients.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Unsettled Issues and Future Directions for Research on Cardiovascular Diseases in Women

Biological sex (being female or male) significantly influences the course of disease. This simple fact must be considered in all cardiovascular diagnosis and therapy. However, major gaps in knowledge about and awareness of cardiovascular disease in women still impede the implementation of sex-specific strategies. Among the gaps are a lack of understanding of the pathophysiology of women-biased coronary artery disease syndromes (spasms, dissections, Takotsubo syndrome), sex differences in cardiomyopathies and heart failure, a higher prevalence of cardiomyopathies with sarcomeric mutations in men, a higher prevalence of heart failure with preserved ejection fraction in women, and sex-specific disease mechanisms, as well as sex differences in sudden cardiac arrest and long QT syndrome. Basic research strategies must do more to include female-specific aspects of disease such as the genetic imbalance of 2 versus one X chromosome and the effects of sex hormones. Drug therapy in women also needs more attention. Furthermore, pregnancy-associated cardiovascular disease must be considered a potential risk factor in women, including pregnancy-related coronary artery dissection, preeclampsia, and peripartum cardiomyopathy. Finally, the sociocultural dimension of gender should be included in research efforts. The organization of gender medicine must be established as a cross-sectional discipline but also as a centered structure with its own research resources, methods, and questions.

Survival Predictors in Liver Transplantation: Time-Varying Effect of Red Blood Cell Transfusion

BACKGROUND

Many attempts have been undertaken to better predict outcome after liver transplantation. The aim of this study was to identify the pre- and intraoperative variables that may influence the survival after liver transplantation, at a single institution.

METHODS

Anesthetic records from 543 consecutive patients who underwent liver transplantation from June 2006 to June 2014 were reviewed in this retrospective study. Patients undergoing retransplantation were excluded from the analysis, as were patients with familial amyloid polyneuropathy. Preoperative variables studied were age, sex, Model for End-Stage Liver Disease score, primary diagnosis, cold ischemia time, preoperative international normalized ratio, serum albumin, and and hemoglobin levels. Intraoperative variables included were norepinephrine consumption, blood loss, red blood cell transfusion, and surgical time. Variables significant in the univariate analysis with a P value of <.2 were included in a multivariate Cox regression model.

RESULTS

Only red blood cell transfusion (hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.04-1.29) and female sex (HR, 1.71; 95% CI, 1.10-2.65) were identified as significant independent predictors for survival after liver transplantation. Because of proportionality assumption violation, the multivariate Cox regression model was subsequently upgraded by adding a time-varying interaction between red blood cell transfusion and time since liver transplantation. As a result, we found that at 3 months after liver transplantation, the rate of dying increased 14% (95% CI, 2%-26%) for each unit transfused, and at 6 months it increased 12% (95% CI, 0.3%-24%).

CONCLUSIONS

Red blood cell transfusion ceased to influence survival from 1 year onward.

Gender based differences in drug eluting stent implantation - data from the German ALKK registry suggest underuse of DES in elderly women

BACKGROUND

Observational studies suggest there are gender based differences in the treatment of coronary artery disease, with women receiving evidence based therapy less frequently than suggested by current guidelines. The aim of our study was to evaluate gender based differences in the use of DES.

METHODS

We analysed prospectively collected data from 100704 stent implantations in the PCI registry of the ALKK between 2005 and 2009.

RESULTS

The usage of DES increased from 16.0 to 43.9%. Although women had smaller vessel sizes, they received DES less often compared to men (28.2 vs. 31.3%), with an adjusted odds ratio of 0.93 (95% confidence interval 0.89-0.97) at the age of 75, and an adjusted odds ratio of 0.89 (95% confidence interval 0.84-0.94) at the age of 80.

CONCLUSION

Despite having smaller vessels than men, women were treated less often with DES. These findings apply to women above the age of 75 years. These findings support previous reports, that elderly women with coronary artery disease are treated differently to men.

Sex Differences in the Epidemiology of New-Onset In-Hospital Post-Coronary Artery Bypass Graft Surgery Atrial Fibrillation: A Large Multicenter Study

BACKGROUND

New-onset atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG) is associated with increased morbidity and poorer long-term survival. Although many studies show differences in outcome in women versus men after CABG, little is known about the sex-specific incidence and characteristics of post-CABG AF.

METHODS AND RESULTS

Overall, 11 236 consecutive patients without preoperative AF underwent isolated CABG from 2002 to 2010 at 4 US academic medical centers and 1 high-volume specialty cardiac hospital. Data routinely collected for the Society of Thoracic Surgeons database were augmented with details on new-onset post-CABG AF events detected via continuous in-hospital ECG/telemetry monitoring. Unadjusted incidence of post-CABG AF was 29.5% (3312/11 236) overall, 30.2% (2485/8214) in men, and 27.4% (827/3022) in women. After adjustment for Society of Thoracic Surgeons-recognized risk factors, women had significantly lower risk for post-CABG AF (odds ratio [95% confidence interval]=0.75 [0.64-0.89]), shorter first, longest, and total duration of AF episodes (mean difference [95% confidence interval]=-2.7 [-4.7 to -0.8] hours; -4.1 [-6.9 to -1.2] hours; -2.4 [-2.5 to -2.3] hours, respectively). At 48 hours, AF-free probabilities were 77% for women and 72% for men (P<0.001). Number of episodes (P=0.18), operative mortality (P=0.048), stroke (P=0.126), and discharge in AF (P=0.234) did not differ significantly by sex.

CONCLUSIONS

These novel data on sex-specific characteristics of new-onset AF after isolated CABG show that women had lower adjusted risk for post-CABG AF and experienced shorter episodes. Investigation of sex-specific impacts on outcomes is needed to identify optimal strategies for prevention and management to ensure all patients achieve the best possible outcomes.

Transcatheter Aortic Valve Replacement Versus Surgery in Women at High Risk for Surgical Aortic Valve Replacement (from the CoreValve US High Risk Pivotal Trial)

The objective of this study was to compare outcomes in women after surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) using a self-expanding prosthesis in patients with severe aortic stenosis who were at high risk for SAVR. Although registries and meta-analyses have suggested that TAVR is of considerable benefit in women, perhaps even more so than in men, a rigorous evaluation of TAVR with a self-expanding valve versus SAVR in women from a randomized trial has not been performed. Patients with severe aortic stenosis were randomized 1:1 to either TAVR or SAVR. Outcomes at 1 year are reported. Treatment was attempted in a total of 353 women (183 TAVR and 170 SAVR). Baseline characteristics and predicted risk of the 2 groups were comparable, although the frequency of diabetes mellitus was lower in patients undergoing TAVR (33.3% vs 45.3%; p = 0.02). TAVR-treated patients experienced a statistically significant 1-year survival advantage compared with SAVR patients (12.7% vs 21.8%; p = 0.03). The composite all-cause mortality or major stroke rate also favored TAVR (14.9% vs 24.2%; p = 0.04). Quality of life, as measured by the Kansas City Cardiomyopathy Questionnaire summary score, for both the TAVR and SAVR groups increased significantly from baseline to 1 year. In conclusion, female TAVR patients had lower 1-year mortality and lower 1-year all-cause mortality or major stroke compared with women undergoing SAVR, with both cohorts experiencing improved quality of life. Further studies specifically in women are warranted to validate these findings.

Pulmonary function and health-related quality of life 1-year follow up after cardiac surgery

Background

Pulmonary function is severely reduced in the early period after cardiac surgery, and impairments have been described up to 4–6 months after surgery. Evaluation of pulmonary function in a longer perspective is lacking. In this prospective study pulmonary function and health-related quality of life were investigated 1 year after cardiac surgery.

Methods

Pulmonary function measurements, health-related quality of life (SF-36), dyspnoea, subjective breathing and coughing ability and pain were evaluated before and 1 year after surgery in 150 patients undergoing coronary artery bypass grafting, valve surgery or combined surgery.

Results

One year after surgery the forced vital capacity and forced expiratory volume in 1 s were significantly decreased (by 4–5 %) compared to preoperative values (p < 0.05). Saturation of peripheral oxygen was unchanged 1 year postoperatively compared to baseline. A significantly improved health-related quality of life was found 1 year after surgery, with improvements in all eight aspects of SF-36 (p < 0.001). Sternotomy-related pain was low 1 year postoperatively at rest (median 0 [min-max; 0–7]), while taking a deep breath (0 [0–4]) and while coughing (0 [0–8]). A more pronounced decrease in pulmonary function was associated with dyspnoea limitations and impaired subjective breathing and coughing ability.

Conclusions

One year after cardiac surgery static and dynamic lung function measurements were slightly decreased, while health-related quality of life was improved in comparison to preoperative values. Measured levels of pain were low and saturation of peripheral oxygen was same as preoperatively.

Applying the Gender Lens to Risk Factors and Outcome after Adult Cardiac Surgery

Background

Applying the gender lens to risk factors and outcome after adult cardiac surgery is of major clinical interest, as the inclusion of sex and gender in research design and analysis may guarantee more comprehensive cardiovascular science and may consecutively result in a more effective surgical treatment as well as cost savings in cardiac surgery.

Methods

We have reviewed classical cardiovascular risk factors (diabetes, arterial hypertension, hyperlipidemia, smoking) according to a gender-based approach. Furthermore, we have examined comorbidities such as depression, renal insufficiency, and hormonal influences in regard to gender. Gender-sensitive economic aspects have been evaluated, surgical outcome has been analyzed, and cardiovascular research has been considered from a gender perspective.

Results

The influence of typical risk factors and outcome after cardiac surgery has been evaluated from a gender perspective, and the gender-specific distribution of these risk factors is reported on. The named comorbidities are listed. Economic aspects demonstrated a gender gap. Outcome after coronary and valvular surgeries as well as after heart transplantation are displayed in this regard. Results after postoperative use of intra-aortic balloon pump are shown. Gender-related aspects of clinical and biomedical cardiosurgical research are reported.

Conclusions

Female gender has become an independent risk factor of survival after the majority of cardiosurgical procedures. Severely impaired left ventricular ejection fraction independently predicts survival in men, whereas age does in females.

Gender differences in depression, but not in anxiety in people with epilepsy

PURPOSE

Anxiety and depression are frequent comorbidities in people with epilepsy (PWE), but possible gender differences are often neglected. The aim of the present study was to analyze if men and women with epilepsy differ with regard to anxiety and depressive symptoms and to identify possible predictors.

METHODS

Adult consecutive PWE (N=302; 53% women) completed self-report questionnaires, including the depression module of the Patient Health Questionnaire (PHQ-9), the anxiety module of the Hospital Anxiety and Depression Scale (HADS-A) and the subscales "medication effects" and "seizure worry" of the Patient-weighted Quality of Life in Epilepsy Inventory-31-P (QOLIE-31-P).

RESULTS

There was no gender difference in extent of anxiety (p=.532), which was mainly due to higher anxiety levels in men compared to the general population. The gender difference in depressive symptoms was significant (p=.009), with female patients being more affected. The most important predictors for anxiety and depressive symptoms were detrimental effects of medication (QOL medication effects) and of seizure worry (QOL seizure worry). Moreover, these predictors were more closely associated with anxiety and depressive symptoms in men.

CONCLUSION

Future intervention studies could show whether providing more information about the illness and medication effects may improve anxiety and depression. Our results suggest that such interventions should be tailored to the different needs of men and women.

Cardiovascular Update

This article provides an update of the current status of cardiovascular disease (CVD) in the United States, including a brief review of the underlying pathophysiology and epidemiology. This article presents a discussion of the latest American Heart Association guidelines that introduce the concept of promoting ideal cardiovascular health, defined by seven identified metrics. Specific CVD risk factors and utilization of the 10-year CVD event prediction calculator are discussed. In addition, current management recommendations of health-related conditions that increase risk for CVD, such as hypertension and hypercholesterolemia, are provided. Finally, a discussion of detailed evidence-based lifestyle recommendations to promote cardiovascular health and reduce CVD risks concludes the update.

Gender differences in therapeutic recommendation after diagnostic coronary angiography: insights from the Coronary Angiography and PCI Registry of the German Society of Cardiology

BACKGROUND

There is information suggesting differences and underuse of invasive coronary diagnostic and therapeutic procedures in women compared to men.

METHODS

Data from consecutive patients (pts) which were enrolled in the Coronary Angiography and PCI Registry of the German Society of Cardiology were analyzed. We compared gender-related differences in diagnosis and therapeutic recommendation of pts undergoing coronary angiography (XA) for stable coronary artery disease (CAD), non-ST elevation acute coronary syndromes (NSTE-ACS) and ST elevation myocardial infarction (STEMI).

RESULTS

From 2004 until the end of 2009, data of 1,060,542 invasive procedures in 1,014,996 pts were prospectively registered. One-third (34.6%) of them were female. Women less often had significant CAD, irrespective of the indication for XA. In pts with relevant CAD, percutaneous coronary interventions (PCI) were recommended in 87.1% of women versus 89.1% of men with STEMI [age-adjusted OR (aOR) 0.98, 95% CI 0.93-1.04], in 67.1 vs. 66.8% in NSTE-ACS (aOR 1.10, 1.07-1.12), and in 50.3 vs 49.4% in stable CAD (aOR 1.07, 1.05-1.09).

CONCLUSIONS

In pts with significant CAD, there was no difference in recommendation for PCI between the genders in stable CAD, whereas in STEMI and NSTE-ACS women were treated even more often with PCI. There were only minor differences in referral for CABG between women and men. Hence, our data provide strong evidence against a gender bias in use of invasive therapeutic procedures once the diagnosis of significant CAD has been confirmed.

Gender differences in patients with cardiogenic shock complicating myocardial infarction: a substudy of the IABP-SHOCK II-trial

BACKGROUND

Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) is associated with high mortality. Previous studies regarding gender-specific differences in CS are conflicting and there are insufficient data for the presence of gender-associated differences in the contemporary percutaneous coronary intervention era. Aim of this study was therefore to investigate gender-specific differences in a large cohort of AMI patients with CS undergoing contemporary treatment.

METHODS

In the randomized Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial, 600 patients with CS complicating AMI undergoing early revascularization were assigned to therapy with or without intra-aortic balloon pump. We compared sex-specific differences in these patients with regard to baseline and procedural characteristics as well as short- and long-term clinical outcome.

RESULTS

Of 600 patients 187 (31%) were female. Women were significantly older than men and had a significantly lower systolic and diastolic blood pressure at presentation (p < 0.05 for all). Diabetes mellitus and hypertension were more frequent in women, whereas smoking was more frequent in men (p < 0.05 for all). Women showed a higher mortality within the first day after randomization (p = 0.004). However, after multivariable adjustment this numerical difference was no longer statistically significant. No gender-related differences in clinical outcome were observed after 1, 6 and 12 months of follow-up.

CONCLUSION

In this large-scale multicenter study in patients with CS complicating AMI, women had a worse-risk profile in comparison to men. No significant gender-related differences in treatment as well as short- and long-term outcome were observed.

Influence of gender on clinical outcomes following transcatheter aortic valve implantation from the UK transcatheter aortic valve implantation registry and the National Institute for Cardiovascular Outcomes Research

Gender differences exist in outcomes after percutaneous coronary intervention and coronary artery bypass graft surgery but have yet to be fully explored after transcatheter aortic valve implantation. We aimed to investigate gender differences after transcatheter aortic valve implantation in the UK National Institute for Cardiovascular Outcomes Research registry. A retrospective analysis was performed of Medtronic CoreValve and Edwards SAPIEN implantation in 1,627 patients (756 women) from January 2007 to December 2010. Men had more risk factors: poor left ventricular systolic function (11.9% vs 5.5%, p <0.001), 3-vessel disease (19.4% vs 9.2%, p <0.001), previous myocardial infarction (29.5% vs 13.0%, p <0.001), peripheral vascular disease (32.4% vs 23.3%, p <0.001), and higher logistic EuroSCORE (21.8 ± 14.2% vs 21.0 ± 13.4%, p = 0.046). Thirty-day mortality was 6.3% (confidence interval 4.3% to 7.9%) in women and 7.4% (5.6% to 9.2%) in men and at 1 year, 21.9% (18.7% to 25.1%) and 22.4% (19.4% to 25.4%), respectively. There was no mortality difference: p = 0.331 by log-rank test; hazard ratio for women 0.91 (0.75 to 1.10). Procedural success (96.6% in women vs 96.4% in men, p = 0.889) and 30-day cerebrovascular event rates (3.8% vs 3.7%, p = 0.962) did not differ. Women had more major vascular complications (7.5% vs 4.2%, p = 0.004) and less moderate or severe postprocedural aortic regurgitation (7.5% vs 12.5%, p = 0.001). In conclusion, despite a higher risk profile in men, there was no gender-related mortality difference; however, women had more major vascular complications and less postprocedural moderate or severe aortic regurgitation.

Early postoperative results for females undergoing isolated coronary artery bypass surgery: comparison of the pre- and postmenopausal periods

PURPOSE

In this retrospective study, we investigated the demographic data and evaluated our early postoperative results of premenopausal and postmenopausal females who underwent coronary artery bypass graft surgery (CABG).

METHODS

A total of 730 female patients who underwent CABG between April 2004 and January 2012 were included in the study. Patients were divided into two groups based on whether they were pre- (group 1) or postmenopausal (group 2). The groups were compared in terms of the demographic and peri-operative parameters.

RESULTS

Smoking and the preoperative hematocrit levels were higher in group 1, whereas the incidence of hypertension and obesity and the European system for cardiac operative risk evaluation values were higher in group 2 (p values <0.01; <0.01; <0.01; 0.004 and <0.01 respectively). The utilization of a left internal mammary artery graft and the postoperative drainage volumes were higher in group 1; however, the number of grafts per patient, cardiopulmonary bypass duration, number of patients who needed inotropic support, blood transfusion volumes, the duration of ventilatory support and the hospital stay were higher in group 2 (p values 0.038; 0.040; 0.026; 0.032; 0.014; 0.001; <0.01 and <0.01, respectively).

CONCLUSIONS

Although the mortality rates were not significantly different, postmenopausal patients require more intensive postoperative care in comparison to premenopausal patients following CABG.

Detection of gender differences in incomplete revascularization after coronary artery bypass surgery varies with classification technique

Background. Incomplete revascularization negatively affects survival after coronary artery bypass surgery (CABG). Since gender and classification technique might impact outcome and reporting, we investigated their effect on revascularization patterns and mortality. Methods. A cohort of bypass patients (N = 1545, 23% women) was enrolled prospectively. The degree of revascularization was determined as mathematical difference between affected vessels upon diagnosis and number of grafts or the surgeon's rating on the case file. Results. Although men displayed more triple-vessel disease, they obtained complete revascularization more frequently than women (85% versus 77%, P < 0.001). The two calculation methods identified analogous percentages of incompletely revascularized patients, yet there was only a 50% overlap between the two groups. Mathematically, more women, older patients, and patients with NYHA class III/IV appeared incompletely revascularized, while the surgeons identified more patients undergoing technically challenging procedures. Regardless of the definition, incompleteness was a significant risk factor for mortality in both genders (mathematical calculation: HR 2.62, 95% CI 1.76–3.89, P < 0.001; surgeon: HR 2.04, 95% CI 1.35–3.89, P = 0.001). Conclusions. Given the differences in identification patterns, we advise that the mathematical calculation be performed after-procedure in all patients regardless of the surgeons' rating to uncover additional subjects at increased risk.