Acute coronary syndromes in women: is treatment different? Should it be?

Disparities in Cardiovascular Care and Outcomes for Women From Racial/Ethnic Minority Backgrounds

Purpose of review

Racial, ethnic, and gender disparities in cardiovascular care are well-documented. This review aims to highlight the disparities and impact on a group particularly vulnerable to disparities, women from racial/ethnic minority backgrounds.

Recent findings

Women from racial/ethnic minority backgrounds remain underrepresented in major cardiovascular trials, limiting the generalizability of cardiovascular research to this population. Certain cardiovascular risk factors are more prevalent in women from racial/ethnic minority backgrounds, including traditional risk factors such as hypertension, obesity, and diabetes. Female-specific risk factors including gestational diabetes and preeclampsia as well as non-traditional psychosocial risk factors like depressive and anxiety disorders, increased child care, and familial and home care responsibility have been shown to increase risk for cardiovascular disease events in women more so than in men, and disproportionately affect women from racial/ethnic minority backgrounds. Despite this, minimal interventions to address differential risk have been proposed. Furthermore, disparities in treatment and outcomes that disadvantage minority women persist. The limited improvement in outcomes over time, especially among non-Hispanic Black women, is an area that requires further research and active interventions.

Summary

Understanding the lack of representation in cardiovascular trials, differential cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds highlights opportunities for improving cardiovascular care among this particularly vulnerable population.

Sex Difference in Risk Factors, GRACE Scores, and Management among Post-Acute Coronary Syndrome Patients in Sri Lanka

Objective

To assess sex-based differences in the prevalence of risk factor, their management, and differences in the prognosis among acute coronary syndrome (ACS) in Sri Lanka.

Methods

Patients diagnosed with ACS were recruited from hospitals throughout the island. The Joint European Societies guidelines were used to assess recommended targets for coronary heart disease risk factors, and the GRACE score was used to assess the post-ACS prognosis. Age-adjusted regression was performed to calculate odds ratios for men versus women in risk factor control.

Results

A total of 2116 patients, of whom 1242 (58.7%) were men, were included. Significant proportion of women were nonsmokers; OR = 0.11 (95% CI 0.09 to 0.13). The prevalence of hypertension (p < 0.001), diabetes (p < 0.001), and dyslipidemia (p=0.004) was higher in women. The LDL-C target was achieved in a significantly higher percentage of women (12.6%); OR = 0.33 (95% CI 0.10 to 1.05). When stratified by age, no significant differences were observed in achieving the risk factor targets or management strategies used except for fasting blood sugar (p < 0.05) where more men achieved control target in both age categories. Majority of the ACS patients had either high or intermediate risk for one-year mortality as per the GRACE score. In-hospital and 1-year mean mortality risk was significantly higher among men of less than 65 years of age (p < 0.05).

Conclusions

Smoking is significantly lower among Sri Lankan women diagnosed with ACS. However, hypertension, diabetes, and dyslipidemia were more prevalent among them. There was no difference in primary and secondary preventive strategies and management in both sexes but could be further improved in both groups.

Gender-based difference in early mortality among patients with ST-segment elevation myocardial infarction: insights from Kermanshah STEMI Registry

Introduction: This study aimed to evaluate the in-hospital mortality of patients with ST-segment elevation myocardial infarction (STEMI), according to gender and other likely risk factors.

Methods: This study reports on data relating to 1,484 consecutive patients with STEMI registered from June 2016 to May 2018 in the Western Iran STEMI Registry. Data were collected using a standardized case report developed by the European Observational Registry Program (EORP). The relationship between in-hospital mortality and potential predicting variables was assessed multivariable logistic regression. Differences between groups in mortality rates were compared using chi-square tests and independent t-tests.

Results: Out of the 1484 patients, 311(21%) were female. Women were different from men in terms of age (65.8 vs. 59), prevalence of hypertension (HTN) (63.7% vs. 35.4%), diabetes mellitus (DM) (37.7% vs. 16.2%), hypercholesterolemia (36.7% vs. 18.5%) and the history of previous congestive heart failure (CHF) (6.6% vs. 3.0%). Smoking was more prevalent among men (55.9% vs. 13.2%). Although the in-hospital mortality rate was higher in women (11.6% vs. 5.5%), after adjusting for other risk factors, female sex was not an independent predictor for in-hospital mortality. Multivariable analysis identified that age and higher Killip class (≥II) were significantly associated with in-hospital mortality rate.

Conclusion: In-hospital mortality after STEMI in women was higher than men. However, the role of sex as an independent predictor of mortality disappeared in regression analysis. The gender based difference in in-hospital mortality after STEMI may be related to the poorer cardiovascular disease (CVD) risk factor profile of the women.

Gender Disparities in Preoperative Resource Use for Wrist Arthroscopy

BACKGROUND

Although national efforts to minimize gender biases exist, gender differences in surgery persist. This study aims to investigate gender differences in preoperative resource use of patients undergoing wrist arthroscopy for nontraumatic wrist pain.

METHODS

Patients who underwent a wrist arthroscopy for nontraumatic pain from 2009 to 2015 were selected from the Truven MarketScan databases. Demographic and preoperative resource use data were recorded. Multivariable regression models were performed to examine the relationship between gender and preoperative resource use and to investigate the cost of these services.

RESULTS

A total of 8792 patients, 3805 men and 4987 women, met our inclusion criteria. Women were less likely to use imaging modalities preoperatively (OR, 0.08; 95 percent CI, 0.07 to 1.00; p = 0.02). However, women used more occupational therapy (OR, 1.2; 95 percent CI, 1.1 to 1.3; p = 0.002), nonnarcotic analgesia (OR, 1.2; 95 percent CI, 1.1 to 1.3; p = 0.001), and narcotic analgesia (OR, 1.6; 95 percent CI, 1.5 to 1.8; p < 0.001). Preoperative costs during the 12 months before surgery were similar between genders ($1308 versus $1367, respectively; p = 0.07). However, women accrued more costs from occupational therapy ($130 versus $93; p = 0.003), and nonnarcotic ($65 versus $46; p < 0.001) and narcotic medications ($568 versus $197; p < 0.001).

CONCLUSIONS

Significant gender differences exist in the preoperative care for patients undergoing wrist arthroscopy. Men use more imaging, implying more intense preoperative investigation for wrist pain, whereas women use more conservative measures, highlighting possible implicit provider biases in preoperative management and potential gender differences in disease presentation.

Gender-based differences in the management and prognosis of acute coronary syndrome in Korea

PURPOSE

Gender-based differences exist in the characteristics, management, and prognosis of acute coronary syndrome (ACS). However, their impact on prognosis remains unclear. We aimed to identify factors causing these differences in Koreans.

MATERIALS AND METHODS

We examined 6,636 ACS patients (66.2% males) visiting 72 Korean hospitals between April-2007 and December-2008. Gender-based differences in clinical demographics, therapy, and outcomes were analyzed over 6 months.

RESULTS

Women were older than men [mean (standard deviation, SD) age, 67.6 (9.8) vs. 60.6 (11.2) years; p<0.001]; had higher rates of hypertension, diabetes mellitus, and lack of exercise (p<0.001 for all); and lower rates of obesity, familial history of cardiovascular disease (CVD), and smoking (p<0.05 for all). Atypical symptoms were more common in women (20.5% vs. 15.1% in men, p<0.001), whereas myocardial infarction with ST-segment elevation was less common (17.1% vs. 27.8%, p<0.001). Mean (SD) time lapse from symptom onset to arrival at hospital was longer in women [11.44 (18.19) vs. 8.26 (14.89) hours in men, p<0.001], as was the duration of hospitalization [7.58 (7.61) vs. 7.04 (7.72) days, p=0.007]. Fewer women underwent revascularization procedures, including thrombolytic therapy, balloon angioplasty, stent implantation, and coronary artery bypass grafting (79.4% vs. 83.3% men, p<0.001). No significant differences were observed in CVD-related death, recurrent ACS, stroke, refractory angina, or rehospitalization for angina.

CONCLUSION

Female ACS patients were older than male subjects and had more atypical presentation. They arrived at the hospital later than men and had longer hospital stays, but less often required revascularization therapy. However, no gender-based differences were noted in ACS-related mortality and morbidity.

Gender differences in the treatment of non-ST-segment elevation myocardial infarction

BACKGROUND

Women are at greater risk for worse outcomes associated with acute coronary syndrome (ACS) than are men. One explanation may be that they tend to be treated less aggressively than men even when more aggressive treatment is warranted. The purpose of this analysis was to assess this issue.

METHODS

We used the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation (CRUSADE) Quality Improvement Initiative registry, an observational data collection that began in November 2001, with retrospective data collection from January 2001 to December 2006. A total of 32,888 subjects met the inclusion/exclusion criteria for our study, based on strong biochemical evidence of myocardial infarction and acute onset of typical cardiac chest pain. We stratified subjects into 16 cells for coronary intervention, based on 4 age groups and 4 cardiac catheterization findings (insignificant, 1-vessel disease, 2-vessel disease, 3-vessel disease). We also stratified subjects into 20 cells for medical treatment, based on 4 age groups and 5 medical treatments. In each cell we compared the rate of coronary intervention (coronary artery bypass grafting or percutaneous coronary intervention) or medical treatment (glycoprotein IIb/IIIa inhibitors, aspirin, clopidogrel, beta-blocker, and statins) for men vs women.

RESULTS

Men demonstrated significantly higher rates (P < 0.05) of coronary intervention in 7 of the 16 cells and 9 of the 20 medical treatment cells, compared to no cells in which women had statistically higher rates than men.

CONCLUSION

These findings suggest that men are more likely than women to receive coronary intervention and to be medically treated when presenting with evidence of non-ST-segment myocardial infarction, controlled for age, cardiac catheterization findings, and biochemical evidence of myocardial infarction.

Gender differences in the surgical management and early clinical outcome of coronary artery disease: Single centre experience

OBJECTIVE

To investigate the gender disparity in the distribution of patient-related risk factors and their effect on the surgical management and clinical outcome of coronary artery disease in Saudi population.

MATERIALS AND METHODS

We carried out a retrospective analysis of prospectively collected data of 971 patients undergoing isolated coronary artery bypass grafting (CABG) at our institution between January 2005 and December 2008. Seven hundred and eighty seven patients (81%) were males and 184 patients (19%) were females. We analyzed gender-based difference in clinical presentation and patient-related pre-operative risk factors and studied their impact on surgical management and clinical outcome.

RESULTS

The mean age was 59.5 years in males and 63.4 years in females (p = <0.0001). Associated co-morbidities were higher in females. Prevalence of diabetes mellitus was 61.2% in males and 78.8% in females (p-value = <0.0001); hypertension 61.9% in males and 79.9% in females (p-value <0.0001); hyperlipidemia 66.7% in males and 77.7% in females (p-value 0.0035); morbid obesity 24.7% in males and 45.1% in females (p-value <0.0001); and Hypothyroidism 2.5% in males and 13.6% in females (p-value <0.0001). Smoking was the only risk factor with higher prevalence in males compared to females (44.2% v/s 2.2%; p-value <0.0001). The mean logistic euroSCORE was 3.94 in males and 5.51 in females (p < 0.0003). On-pump and off-pump CABG was carried out in equal numbers in two groups. Females required urgent surgery and less than 3 grafts more frequently while males underwent elective surgery and more than 3 grafts in greater numbers. No significant difference was present between the two gender groups in aortic occlusion times and bypass times. Univariant analysis revealed females gender as an independent risk factor for higher in-hospital mortality (1.1% versus 4.9% p = 0.0026) and higher incidence of post-operative complications like surgical wound infection, need for prolonged ventilation, low cardiac output state and multi-organ failure (p-values 0.01 or less).

CONCLUSION

Female gender is an independent predictor of adverse outcome after isolated CABG due to significantly higher co-morbidities and acute presentation and independent of their peri-operative management. Therefore, major socioeconomic education and preventive measures are needed to reduce the burden of major co-morbidities in females and to seek early cardiac advice and care.

Gender differences in correlates of troponin assay in diagnosis of myocardial infarction

Cardiac troponins are the most sensitive and specific biomarker for myocardial infarction (MI) diagnosis. If there is a gender bias in MI diagnosis, it could be reduced by more consistently applying objective diagnostic criteria to improve women's outcomes. This study set out to assess the accuracy and correlates of the cardiac troponin I (cTnI) assay in the diagnosis of non-ST-segment elevation MI, to determine how the assay accuracy and correlates vary by gender, and to explore the interaction between factors that may influence cTnI accuracy and affect gender differences in diagnosis. The data were obtained from the CHECKMATE study. It included 924 patients with possible myocardial ischemia excluding subjects with ST-segment elevation. The Dade-Behring Stratus CS STAT near-patient instrument (Dade Behring, Inc, Newark, Del) was used to measure cTnI. We assessed baseline troponin accuracy using a standard MI definition. There were 125 subjects with a definite MI diagnosis. Baseline troponin was 44% sensitive and 97% specific in predicting MI, with no significant gender differences. In contrast, other positive cardiac markers, namely rising or falling creatine-kinase MB fraction and positive electrocardiogram, occurred more frequently in men. Sensitivity (SE) of baseline troponin was higher in subjects where baseline troponin was obtained longer than 2 hours after the chest pain onset. The study did not observe a significant difference in the assay SE or specificity by gender. This observation, plus the fact that other positive cardiac markers occurred more frequently in men, suggest the troponin test may help to improve the diagnosis of MI in women.

Women tolerate drug therapy for coronary artery disease as well as men do, but are treated less frequently with aspirin, beta-blockers, or statins

BACKGROUND

Women have worse morbidity, mortality, and health-related quality-of-life outcomes associated with coronary artery disease (CAD) compared with men. This may be related to underutilization of drug therapies, such as aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or statins. No studies have sought to describe the relationship of gender with adverse reactions to drug therapy (ADRs) for CAD in clinical practice.

OBJECTIVE

The aim of this study was to determine the prevalence of ADRs associated with common CAD drug therapies in women and men in clinical practice.

METHODS

In a cohort of consecutive outpatients with CAD, detailed chart abstraction was performed to determine the use of aspirin, beta-blocker, ACE inhibitor, and statin therapy, as well as the ADRs reported for these treatments. Baseline clinical characteristics were also determined to identify the independent association of gender with use of standard drug treatments for CAD.

RESULTS

Consecutive patients with CAD (153 men, 151 women) were included in the study. Women and men were observed to have a similar prevalence of cardiac risk factors and comorbidities, except that men had significantly higher prevalence of atrial fibrillation (30 [19.6%] men vs 15 [9.9%] women; P = 0.03) and significantly lower mean (SD) high-density lipoprotein cholesterol concentrations (45 [16] mg/dL for men vs 55 [19] mg/dL for women; P < 0.001). No significant differences were observed between the sexes in the prevalence of ADRs; however, significantly fewer women than men were treated with statins (118 [78.1%] vs 139 [90.8%], respectively; P = 0.003). After adjusting for clinical characteristics, women were also found to be less likely than men to receive aspirin (odds ratio [OR] = 0.164; 95% CI, 0.083-0.322; P = 0.001) and beta-blockers (OR = 0.184; 95% CI, 0.096-0.351; P = 0.001).

CONCLUSIONS

Women and men experienced a similar prevalence of ADRs in the treatment of CAD; however, women were significantly less likely to be treated with aspirin, beta-blockers, and statins than were their male counterparts. To optimize care for women with CAD, further study is needed to identify the cause of this gender disparity in therapeutic drug use.

Exploring the use of feminist philosophy within nursing research to enhance post-positivist methodologies in the study of cardiovascular health

Nursing has historically relied heavily on scientific knowledge. It is not surprising that the cardiovascular health literature has been highly influenced by the post-positivist philosophy. The nursing discipline, as well as the cardiovascular nursing specialty, continues to benefit from research grounded within this philosophical tradition. At the same time, there are limitations associated with post-positivism. Therefore, it is beneficial for researchers and clinicians to examine the potential contributions various philosophical traditions can have for their research and practice. This paper is an exploration of the compatibilities of feminist and post-positivist philosophies in the study of cardiovascular nursing research. The ensuing discussion entails an examination of my clinical and research interests, the grounding of my research within the post-positivist perspective and the significant contribution feminist philosophy can make to my research.

Diferencias de género en el tratamiento de revascularización precoz del infarto agudo de miocardio

BACKGROUND AND OBJECTIVE

Clinical variability in myocardial infarction (MI) regarding age, comorbidities and atypical symptoms could determine gender differences in inhospital care. This study analyzes the magnitude and determinants of differences between men and women in early reperfusion therapy in people hospitalized after MI.

PATIENTS AND METHOD

2,836 patients who arrived to hospital with MI were studied (IBERICA-Basque Country study). The relative risk (RR) of receiving early reperfusion for men versus women, adjusted by age, clinical characteristics, risk factors, and pre-hospital delay was estimated. The effect decomposition methodology and the log binomial regression were applied.

RESULTS

29% of patients were women with a median age of 77 years. The RR of revascularization in men compared to women was different according to age. When factors such as hypertension diabetes, Killip III-IV at admission and atypical symptoms were taken into account, statistically significant differences between sexes were not detected at 45 years old (RR=0.91; 95% CI=0.77-1.07). However, for 64 years old and over, the RR of reperfusion was 1.24 (95% CI=1.05-1.47). Both the differences by sex and the sex-age interaction were no longer statistically significant after adjusting by pre-hospital delay.

CONCLUSIONS

The delay to receive medical care in elderly women is responsible of gender differences in early reperfusion. It is necessary to analyze the reasons for treatment-seeking delay.

Does diabetes mellitus explain the higher hospital mortality of women with acute myocardial infarction? Results from the Berlin Myocardial Infarction Registry

BACKGROUND

Women with acute myocardial infarction (AMI) exhibit greater hospital mortality than do men. In general, diabetes mellitus is one of the major factors influencing the outcome of patients with AMI. The aim of this study was to analyze the interaction between diabetes and gender, specifically with regard to the higher hospital mortality of female AMI patients aged < or = 75 years.

METHODS

We prospectively collected data from 3,715 patients aged < or = 75 (2,794 men, 921 women) with acute myocardial infarction who were treated in 25 hospitals in Berlin, Germany, from 1999 to 2002. In a multivariate analysis, we specifically studied the interaction between the factors diabetes mellitus and gender in their effects on hospital mortality.

RESULTS

After adjustment in multivariate analysis, the interaction between gender and diabetes was statistically significant, and the estimated odds ratios were as follows: female diabetic patients compared with male diabetic patients, odds ratio (OR) = 2.28 (95% confidence interval [CI] 1.42-3.68); female diabetic patients compared with male nondiabetic patients, OR = 2.90 (95% CI 1.90-4.42); and female diabetic patients compared with female nondiabetic patients, OR = 2.92 (95% CI 1.75-4.87). There was no statistically significant difference between the risk of dying for female nondiabetic patients or for male diabetic patients when compared with male nondiabetic patients.

CONCLUSIONS

In AMI patients aged < or = 75 years, female gender alone is not an independent predictor of hospital mortality. Detailed, multivariate analysis reveals that specifically diabetic women demonstrate higher hospital mortality than do men. Special attention should be provided to these female diabetic patients.

Gender differences of revascularization in patients with acute myocardial infarction

Women are less likely to undergo revascularization after acute myocardial infarction (AMI). We assessed whether this was due to patterns of hospital admission or less frequent revascularization even when resources are available. Using New York City hospital discharge records from 1995 to 2002, we determined revascularization rates for patients who were hospitalized for AMI. Rates of admission to hospitals capable of revascularizing and revascularization use were assessed by gender. Odds ratios of admission and procedure use were determined after adjusting for sociodemographic and clinical characteristics and accounting for availability of revascularization in neighborhoods of residence. Of 93,978 patients with AMI (43.7% women), 27% were revascularized (32% and 20% for men and women, respectively, p <0.001). Moreover, women were less likely than men to be admitted to hospitals capable of revascularization (45% vs 52%, p <0.001) and to undergo revascularization (54% vs 60%, p <0.001) when admitted to capable hospitals. These differences were similar for residents of neighborhoods with or without revascularization services. Odds ratios for men versus women were 1.22 (95% confidence interval 1.18 to 1.26) for admission to revascularizing hospitals and 1.28 (95% confidence interval 1.22 to 1.34) for using revascularization among patients in revascularization hospitals. The in-hospital mortality advantage of men over women persisted after revascularization (9.6% vs 14.5%). In conclusion, less revascularization after AMI among women was associated with less frequent admission to hospitals capable of revascularization and less frequent revascularization even when admitted to performing hospitals. However, improving revascularization among women does not eliminate the gender disparity of in-hospital death after AMI.

Ischemic and bleeding outcomes in women treated with bivalirudin during percutaneous coronary intervention: a subgroup analysis of the Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE)-2 trial

BACKGROUND

Outcomes in women undergoing percutaneous coronary intervention (PCI) in the contemporary era are poorly defined. The REPLACE-2 trial demonstrated that bivalirudin with provisional glycoprotein IIb/IIIa (GpIIb-IIIa) blockade is noninferior to heparin with planned GpIIb-IIIa blockade during PCI, with regard to ischemic and bleeding end points.

OBJECTIVES

The aim of this study was to define sex-based clinical ischemic and bleeding outcomes from the REPLACE-2 trial.

METHODS

A retrospective sex-based subgroup analysis of the REPLACE-2 trial comparing clinical ischemic and inhospital bleeding end points was conducted.

RESULTS

Compared with men in REPLACE-2, women were older, had more diabetes, congestive heart failure and hypertension, and less prior revascularization and myocardial infarction. Female sex was a univariate predictor of death and bleeding complications. Among women treated with either bivalirudin or heparin, there was no significant difference in the individual or composite ischemic end points of death, myocardial infarction, or urgent revascularization at 30 days or 6 months. Protocol-defined major bleeding, minor bleeding, and access site bleeding were less frequent with bivalirudin compared with heparin. Multivariable modeling found no significant interactions between sexes, with the composite ischemic end point, major bleeding, or 1-year mortality.

CONCLUSIONS

Women remain at higher risk for poorer outcomes with contemporary PCI, likely because of comorbidities. Bivalirudin with provisional GpIIb-IIIa confers similar protection against ischemic end points compared with heparin and planned GpIIb-IIIa blockade and significantly reduces the inherent bleeding risk of women undergoing contemporary PCI.