Impact of diagnosis and sex on long-term prognosis in acute coronary syndromes

Seventeen-Year Mortality following the Acute Coronary Syndrome: Gender-Specific Baseline Variables and Impact on Outcome

BACKGROUND

Gender differences in outcome and its predictors in patients with acute coronary syndrome (ACS) continue to be debated.

OBJECTIVES

To assess long-term mortality and explore its association with the baseline variables in women and men.

METHODS

We followed 2,176 consecutive patients (665 women and 1,511 men) with ACS admitted to a single hospital and still alive after 30 days for a median of 16 years 8 months.

RESULTS

At the end of the follow-up, 415 (62.4%) women and 849 (56.2%) men had died (unadjusted hazard ratio [HR] for women/men 1.18 (95% confidence interval [CI], 1.05-1.33, p =0.005). After adjustment for age, the HR was reversed to 0.88 (95% CI, 0.78-1.00, p =0.04). Additional adjustment for potential confounders yielded a HR of 0.86 (95% CI, 0.76-0.98, p = 0.02). Using multivariable Cox regression, previous heart failure, previous or new-onset atrial fibrillation, and psychotropic drugs at discharge were significantly associated with increased long-term mortality in men only. Known hypertension, elevated creatinine, and inhospital Killip class >1/cardiogenic shock were significantly associated with mortality only in women. For late mortality, hypertension and inhospital Killip class >1/cardiogenic shock interacted significantly with gender.

CONCLUSION

For patients with ACS surviving the first 30 days, late mortality was lower in women than in men after adjusting for age. The effects of several baseline characteristics on late outcome differed between women and men. Gender-specific strategies for long-term follow-up of ACS patients should be considered.

A Survey of Coping Strategies With Stress in Patients With Acute Myocardial Infarction and Individuals Without a History of Fixed Myocardial Infarction

Background

This study aimed at investigating the coping strategies with stress in patients with acute myocardial infarction (MI) and individuals without a history of fixed MI and cardiovascular disorders.

Methods

This case-control crossover study was conducted from March 2015 to February 2016 on 220 patients with acute MI (MI patients) as case group and 220 patients without any history of MI and cardiovascular diseases as the control group using availability sampling method. To collect the required data, demographic information questionnaire, Holms-Raheh life stress inventory, perceived stress questionnaire, and coping inventory for stressful situations (CISS) were applied.

Results

On the basis of our findings, 118 patients (53.6%) with MI used emotion-focused coping strategy. Ninety-seven patients (82.2%) with MI who used emotion-focused coping strategy had negative perceived stress. Additionally, 71 patients (60.2%) with MI who had used emotion-focused coping strategy suffered from very high level of stress.

Conclusion

The most MI patients had very high level of stress while most people in control group had high level of stress. Most MI patients that had very high level of stress cope with it in emotion-focused coping strategy and it proves that people with higher levels of stress are more likely to use inefficient coping strategies.

Sex differences in long-term mortality after myocardial infarction: a systematic review

BACKGROUND

Studies of sex differences in long-term mortality after acute myocardial infarction have reported mixed results. A systematic review is needed to characterize what is known about sex differences in long-term outcomes and to define gaps in knowledge.

METHODS AND RESULTS

We searched the Medline database from 1966 to December 2012 to identify all studies that provided sex-based comparisons of mortality after acute myocardial infarction. Only studies with at least 5 years of follow-up were reviewed. Of the 1877 identified abstracts, 52 studies met the inclusion criteria, of which 39 were included in this review. Most studies included fewer than one-third women. There was significant heterogeneity across studies in patient populations, methodology, and risk adjustment, which produced substantial variability in risk estimates. In general, most studies reported higher unadjusted mortality for women compared with men at both 5 and 10 years after acute myocardial infarction; however, many of the differences in mortality became attenuated after adjustment for age. Multivariable models varied between studies; however, most reported a further reduction in sex differences after adjustment for covariates other than age. Few studies examined sex-by-age interactions; however, several studies reported interactions between sex and treatment whereby women have similar mortality risk as men after revascularization.

CONCLUSIONS

Sex differences in long-term mortality after acute myocardial infarction are largely explained by differences in age, comorbidities, and treatment use between women and men. Future research should aim to clarify how these differences in risk factors and presentation contribute to the sex gap in mortality.

Mortality after myocardial infarction: impact of gender and smoking status

We have shown previously that smoking causes a first myocardial infarction (MI) to occur significantly more prematurely in women than in men. The aim of the study was to investigate mortality after MI with special emphasis on the impact of smoking and gender. The study included 2,281 consecutive patients (36.8% women) who died or were discharged from a central hospital with a diagnosis of MI from 1998 to 2005; the median follow-up of survivors was 7 years. Death after MI was adjusted for confounders. Mean age for women was 5.8 years older than for men (76.0 vs. 70.2 years) and women were less likely to have been smokers. In-hospital mortality for the first MI was 8.9% for men and 13.3% for women, and total mortality rates for all indexed MI after 7 years were 47% for men and 61% for women. Using Cox regression analysis, with all indexed MIs included, the after-discharge mortality for women was significantly lower than for men (hazard ratio 0.82; 95% confidence interval 0.70-0.96; P = 0.015). Compared with non-smokers, patients who were smokers on admission had significantly increased seven-year mortality after discharge (hazard ratio 1.30; 95% confidence interval 1.03-1.63; P = 0.002). In conclusion, current smoking at the time of the indexed MI was associated with increased mortality after 7 years follow-up. The smoking effect was independent of gender. Female gender was associated with a moderately lower risk of death during the same follow-up period.

Coronary heart disease in women: less extensive disease and improved long-term survival compared to men

OBJECTIVES

The aim of the study was to compare extent of coronary disease and subsequent long-term survival in women compared to men adjusted for baseline differences in demographics and morbidity.

DESIGN

In the database at Feiring Heart Clinic 18 767 patients had a coronary angiographic examination in the period from March 1999 to December 31, 2006. Their survival status as of May 31, 2007 was ascertained through the Norwegian National Registry. Survival was compared using age stratified analyses and Cox regression adjusting for baseline differences.

RESULTS

Significantly more women than men had no coronary disease (28.7 vs. 10.5%, p <0.001), while three vessel disease was more frequently present in men (38.7 vs. 21.8%, p <0.001), as judged by coronary angiography. Covariate adjusted survival was significantly better in women compared to men with an overall hazard ratio of 1.29 (p <0.001), but with no significant difference in the subgroup with high left ventricular end diastolic pressure.

CONCLUSIONS

At the time of referral to invasive examination women had less extensive coronary artery disease than men as judged by coronary angiography and improved long-term survival when baseline differences were accounted for.

Treatment and outcome in acute myocardial infarction in a community in relation to gender

AIM

To describe treatment and outcome in all patients in a community with acute myocardial infarction (AMI) in relation to gender.

METHODS

All patients discharged from hospital between 2001 and 2002 in Göteborg, Sweden, with a diagnosis of AMI underwent a survey to find possible gender differences. All p-values are age adjusted.

RESULTS

Among 1423 admissions, women comprised 41% and were older than men (mean 79 versus mean 72 years). Women were admitted to a coronary care unit less frequently than men (49% versus 67%; p=0.005). Women underwent coronary angiography less frequently (21% versus 40%; p=0.02). Percutaneous coronary intervention (PCI) was performed in 10% of the women and 18% of the men (p=0.36). Coronary artery bypass grafting (CABG) was performed in 2% of the women and in 9% of the men (p<0.0001). Female gender was associated with a lower risk of reinfarction during first year after hospital discharge (12% versus 16%; p=0.003). The cumulative three-year mortality was 49% in women and 41% in men. However, when adjusting for age, admittance to CCU, coronary angiography and coronary revascularisation, risk of death during 3 years was lower in women than men (odds ratio 0.72; 95% confidence interval 0.60-0.85; p=0.0001).

CONCLUSION

In the community of Göteborg women (mean age 79 years) with AMI are prioritised differently than men (mean age 72 years), prior to admission to a CCU. This results in a less invasive strategy in women, particularly with regard to CABG. When adjusting for difference in age, admittance to CCU and coronary revascularisation female gender was associated with a low risk of death during the subsequent 3 years.