A gender perspective on short- and long term mortality in ST-elevation myocardial infarction--a report from the SWEDEHEART register

Ensemble machine learning for predicting in-hospital mortality in Asian women with ST-elevation myocardial infarction (STEMI)

The accurate prediction of in-hospital mortality in Asian women after ST-Elevation Myocardial Infarction (STEMI) remains a crucial issue in medical research. Existing models frequently neglect this demographic's particular attributes, resulting in poor treatment outcomes. This study aims to improve the prediction of in-hospital mortality in multi-ethnic Asian women with STEMI by employing both base and ensemble machine learning (ML) models. We centred on the development of demographic-specific models using data from the Malaysian National Cardiovascular Disease Database spanning 2006 to 2016. Through a careful iterative feature selection approach that included feature importance and sequential backward elimination, significant variables such as systolic blood pressure, Killip class, fasting blood glucose, beta-blockers, angiotensin-converting enzyme inhibitors (ACE), and oral hypoglycemic medications were identified. The findings of our study revealed that ML models with selected features outperformed the conventional Thrombolysis in Myocardial Infarction (TIMI) Risk score, with area under the curve (AUC) ranging from 0.60 to 0.93 versus TIMI's AUC of 0.81. Remarkably, our best-performing ensemble ML model was surpassed by the base ML model, support vector machine (SVM) Linear with SVM selected features (AUC: 0.93, CI: 0.89-0.98 versus AUC: 0.91, CI: 0.87-0.96). Furthermore, the women-specific model outperformed a non-gender-specific STEMI model (AUC: 0.92, CI: 0.87-0.97). Our findings demonstrate the value of women-specific ML models over standard approaches, emphasizing the importance of continued testing and validation to improve clinical care for women with STEMI.

Contemporary Outcomes of Acute Coronary Syndromes in Indigenous Compared With Non-Indigenous Patients: A Northern Saskatchewan Perspective

BACKGROUND

In patients presenting with an acute coronary syndrome (ACS), the impact of efforts to bridge historical care gaps between Indigenous and non-Indigenous patients remains limited.

METHODS

For consecutive ACS presentations (ST-segment elevation myocardial infarction [STEMI] and non-ST-segment elevation myocardial infarction [NSTEMI]/unstable angina [UA], respectively) at the Royal University Hospital, Saskatoon, we compared self-identified Indigenous and non-Indigenous patients' demographics, treatments, and all-cause mortality (in-hospital and within 3 years). We used propensity score inverse probability weighting to mitigate confounding and Cox regression models to estimate the adjusted hazard ratio (aHR) for all-cause mortality.

RESULTS

Of 3946 ACS patients, 37.2% (n = 1468) were STEMI, of whom 11.3% (n = 166) were Indigenous. Of the NSTEMI/UA (n = 2478), 12.6% (n = 311), were Indigenous. Overall, Indigenous compared with non-Indigenous patients were likely to be younger, female, have higher risk burden, and live more remotely; Indigenous STEMI patients triaged to primary percutaneous coronary intervention had longer times from first medical contact to device, and Indigenous NSTEMI/UA patients more likely to present with heart failure, cardiac arrest, and cardiogenic shock. No significant differences were noted for in-hospital mortality (STEMI 8.4% vs 5.7% [P = 0.16], NSTEMI/UA 1.9% vs 1.6% [P = 0.68]), although in follow-up, Indigenous STEMI patients were associated with a higher all-cause mortality risk (aHR 1.98, 95% CI 1.19-3.31; P = 0.009) with no between-group differences evident for NSTEMI/UA (aHR 1.03, 95% CI 0.63 1.69; P = 0.91).

CONCLUSIONS

Indigenous compared with non-Indigenous patients presenting with an ACS had higher cardiovascular risk profiles and consequent residual mortality risk. Improving primary care and intensifying secondary risk reduction, particularly for Indigenous patients, will substantially modify ACS outcomes in Saskatchewan.

Sex differences in secondary preventive follow-up after coronary heart events

BACKGROUND AND AIMS

Some studies point to sex differences in cardiovascular preventive practices. The aim of this study was to investigate differences in achievement of secondary preventive targets and long-term outcome in men and women after a coronary heart event.

METHODS

This study was a subanalysis from a randomized controlled trial of hospital-based versus primary care-based secondary preventive follow-up at Sorlandet Hospital, Norway, 2007-2022 and included both groups. The main outcome was achievement of treatment targets two years after the index event. Event-free survival was calculated based on the composite of mortality, coronary intervention, stroke, or myocardial infarction during follow-up. Participants were followed-up for up to 10 years after the index event through out-patient consultations.

RESULTS

In total, 337 women and 1203 men were eligible for the study. Due to loss of follow-up during the first two years after the index coronary event 106 (7%) participants were excluded from further analysis (53% withdrawal of consent, 12% death, and 35% other causes) leaving 307 (21%) women and 1127 (79%) men. After two years of follow-up we found no differences between women and men in achievement of blood pressure targets (61% vs. 59%; p = 0.57), LDL-cholesterol goals (64% vs. 69%; p = 0.15), HbA1c-goal in patients with diabetes (49% vs. 45%; p = 0.57), non-smoking (79% vs. 81%; p = 0.34), healthy diets (14% vs. 13%, p = 0.89), physical activity (55% vs. 58%; p = 0.38), use of acetylsalicylic acid (93% vs. 94%; p = 0.39), and use of lipid lowering therapy (92% vs. 94%; p = 0.15). After a median follow-up time of 5.0 [SD 3.2] years there were no differences between women and men regarding composite endpoint (89 [30.0%] vs. 345 [30.6]; p = 0.58), and composite endpoint-free survival did not differ between women and men (hospital-based follow-up HR for women versus men, 0.87, 95% CI 0.62-1.23; p = 0.44 and primary care service HR for women versus men 0.95, 95% CI 0.69-1.31; p = 0.78).

CONCLUSIONS

The study show no sex differences in achievement of secondary preventive targets or composite endpoint after coronary heart events. However, many women and men did not achieve treatment goals, and further improvement in secondary prevention is needed.

TRIAL REGISTRATION

The study is registered in ClinicalTrials.gov (NCT00679237).

Sex differences in the relationship between body mass index and outcome in myocardial infarction

BACKGROUND

The data on sex-related differences regarding the body mass index (BMI) in patients with myocardial infarction (MI) are rare and inconclusive. We aimed to assess sex differences in the relationship between BMI and 30-day mortality in men and women with MI.

METHODS

A single-center retrospective study of 6453 patients with MI who underwent PCI was performed. Patients were divided into five BMI categories and these were compared. The relationship between BMI and 30-day mortality was assessed in men and women.

RESULTS

An L-shaped relationship between BMI and mortality was observed in men (p=0.003) with the highest mortality rate (9.4%) in normal weight patients and the lowest in patients with obesity grade I (5.3%). In women, similar mortality was found in all BMI categories (p=0.42). After adjustment for potential confounders, the negative association between BMI category and 30-day mortality was found in men, but not in women (p=0.033 and p=0.13, respectively). Overweight men had a 33% lower risk of death within 30 days compared to normal weight patients (OR 0.67,95%CI 0.46-0.96;p=0.03). Other BMI categories in men had a similar mortality risk to the normal weight category.

CONCLUSIONS

Our results suggest that the relationship between BMI and outcome in patients with MI is different in men and women. We found an L-shaped relationship between BMI and 30-day mortality in men, but no relationship was observed in women. The obesity paradox was not found in women. Sex itself could not explain this differential relationship, and the underlying cause is likely multifactorial.

Between-Sex Differences in Risk Factors for Cardiovascular Disease among Patients with Myocardial Infarction-A Systematic Review

Between-sex differences in the presentation, risk factors, management, and outcomes of acute myocardial infarction (MI) are well documented. However, as such differences are highly sensitive to cultural and social changes, there is a need to continuously re-evaluate the evidence. The present contemporary systematic review assesses the baseline characteristics of men and women presenting to secondary, tertiary, and quaternary centres with acute myocardial infarction (MI). Over 1.4 million participants from 18 studies, including primary prospective, cross sectional and retrospective observational studies, as well as secondary analysis of registry data are included in the study. The study showed that women were more likely than men to have a previous diagnosis of diabetes, hypertension, cerebrovascular disease, and heart failure. They also had lower odds of presenting with previous ischaemic heart disease and angina, dyslipidaemia, or a smoking history. Further work is necessary to understand the reasons for these differences, and the role that gender-specific risk factors may have in this context. Moreover, how these between-gender differences are implicated in management and outcomes also requires further work.

Predictive value of CHA2 DS2 -VASc score for in-hospital prognosis of patients with acute ST-segment elevation myocardial infarction undergoing primary PCI

BACKGROUND

This study aimed to explore the predictive value of CHA2 DS2 -VASc score for in-hospital major adverse cardiac events (MACEs) in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary artery intervention.

METHODS

A total of 746 STEMI patients were divided into four groups according to CHA2 DS2 -VASc score (1, 2-3, 4-5, >5). The predictive ability of the CHA2 DS2 -VASc score for in-hospital MACE was made. Subgroup analysis was made between gender differences.

RESULTS

In a multivariate logistic regression analysis model including creatinine, total cholesterol, and left ventricular ejection fraction, CHA2 DS2 -VASc score was an independent predictor of MACE as a continuous variable (adjusted odds ratio: 1.43, 95% confidence interval [CI]: 1.27-1.62, p < .001). As a category variable, using the lowest CHA2 DS2 -VASc score of 1 as a reference, CHA2 DS2 -VASc score 2-3, 4-5, >5 groups for predicting MACE was 4.62 (95% CI: 1.94-11.00, p = .001), 7.74 (95% CI: 3.18-18.89, p < .001), and 11.71 (95% CI: 4.14-33.15, p < .001). The CHA2 DS2 -VASc score was also an independent risk factor for MACE in the male group, either as a continuous variable or category variable. However, CHA2 DS2 -VASc score was not a predictor of MACE in the female group. The area under the curve value of the CHA2 DS2 -VASc score for predicting MACE was 0.661 in total patients (74.1% sensitivity and 50.4% specificity [p < .001]), 0.714 in the male group (69.4% sensitivity and 63.1% specificity [p < .001]), but there was no statistical significance in the female group.

CONCLUSIONS

CHA2 DS2 -VASc score could be considered as a potential predictor of in-hospital MACE with STEMI, especially in males.

Sex differences in 123I-mIBG scintigraphy imaging techniques in patients with heart failure

BACKGROUND

123I-mIBG-scintigraphy could be a useful stratifying tool for patients with heart failure (HF). The purpose of this retrospective study is to evaluate whether there are differences between men and women with HF in terms of the prediction of cardiac arrhythmic events (AE).

RESEARCH AND METHODS

A total of 306 patients, before implantable-cardioverter-defibrillator (ICD) implantation, were evaluated. They underwent 123I-mIBG-scintigraphy and an evaluation of the results was performed after 85 months of follow-up. Early and late planar and SPECT cardiac images were acquired. Heart-to-mediastinum ratio (HM) for planar images and the sum of the segmental scores (SS) for SPECT were calculated.

RESULTS

In the general population, age, early SS (ESS), late SS (LSS), and ejection fraction (EF) were statistically significant for the prediction of AE at Cox regression, while early and late HM (eHM,lHM) were not significative for the prediction of AE. Population was divided into females and males and univariate analysis was conducted separately for the two cohorts: no significant variables for prediction of AE were found in females. For males, ESS, LSS, EF, and late HM were statistically significant predictors of AE. The overall survival was similar in males and females, but the risk of AE is lower in males than in females.

CONCLUSIONS

123I-mIBG represents a more effective tool for the prediction of AE in male patients than in women.

Differential impact of anemia in relation to sex in patients with myocardial infarction

Background

Data on the possible sex-specific effects of anemia on clinical outcome in patients with myocardial infarction are extremely sparse, conflicting, and inconclusive. We investigated the possible sex-specific effects of anemia on outcome in patients with myocardial infarction (MI) who underwent percutaneous coronary intervention (PCI).

Methods

Data from 8,318 patients, who were divided into four groups: men and women with and without anemia on admission, were analyzed. The association between anemia and sex and 30-day and long-term mortality was assessed. The median follow-up time was 7 years (25th, 75th percentile: 4, 11).

Results

Non-anemic men had the lowest 30-day and long-term observed mortality (4.3, 18.7%), followed by non-anemic women (7.0, 25.3%; p < 0.0001, p < 0.0001). Anemic men and women had similar mortality rates (12.8, 46.2%) and (13.4, 45.6%; p = 0.70, p = 0.80), respectively. The anemia/sex groups were independently associated with 30-day and long-term mortality (p = 0.033 and p < 0.0001, respectively). Compared to non-anemic men, non-anemic and anemic women had a similar risk of death at 30 days, but anemic men had a 50% higher risk of death (OR 1.12; 95% CI 0.83-1.52; p = 0.45, OR 1.30; 95% CI 0.94-1.79; p = 0.11, OR 1.50; 95% CI 1.13-1.98; p = 0.004, respectively). In the long term, anemic men had a 46% higher, non-anemic women 15% lower, and anemic women a similar long-term mortality risk to non-anemic men (HR 1.46; 95% CI 1.31-1.63; p < 0.0001, HR 0.85; 95% CI 0.76-0.96; p = 0.011, and HR 1.06; 95% CI 0.93-1.21; p = 0.37, respectively).

Conclusion

Our result suggests that the influence of anemia in patients with MI is different in men and women, with anemia seemingly much more harmful in male than in female patients with MI.

Assessment of distance to primary percutaneous coronary intervention centres in ST-segment elevation myocardial infarction: Overcoming inequalities with process mining tools

Objectives

In ST-segment elevation myocardial infarction (STEMI), time delay between symptom onset and treatment is critical to improve outcome. The expected transport delay between patient location and percutaneous coronary intervention (PCI) centre is paramount for choosing the adequate reperfusion therapy. The "Centro" region of Portugal has heterogeneity in PCI assess due to geographical reasons. We aimed to explore time delays between regions using process mining tools.

Methods

Retrospective observational analysis of patients with STEMI from the Portuguese Registry of Acute Coronary Syndromes. We collected information on geographical area of symptom onset, reperfusion option, and in-hospital mortality. We built a national and a regional patient's flow models by using a process mining methodology based on parallel activity-based log inference algorithm.

Results

Totally, 8956 patients (75% male, 48% from 51 to 70 years) were included in the national model. Most patients (73%) had primary PCI, with the median time between admission and treatment <120 minutes in every region; "Centro" had the longest delay. In the regional model corresponding to the "Centro" region of Portugal divided by districts, only 61% had primary PCI, with "Guarda" (05:04) and "Castelo Branco" (06:50) showing longer delays between diagnosis and reperfusion than "Coimbra" (01:19). For both models, in-hospital mortality was higher for those without reperfusion therapy compared to PCI and fibrinolysis.

Conclusion

Process mining tools help to understand referencing networks visually, easily highlighting its inefficiencies and potential needs for improvement. A new PCI centre in the "Centro" region is critical to offer timely first-line treatment to their population.

Risk factors, clinical features, and outcomes of premature acute myocardial infarction

AIMS

To investigate the risk factors, clinical features, and prognostic factors of patients with premature acute myocardial infarction (AMI).

MATERIALS AND METHODS

A retrospective cohort study of patients with AMI included in data from the West China Hospital of Sichuan University from 2011 to 2019 was divided into premature AMI (aged < 55 years in men and < 65 years in women) and non-premature AMI. Patients' demographics, laboratory tests, Electrocardiography (ECG), cardiac ultrasound, and coronary angiography reports were collected. All-cause death after incident premature MI was enumerated as the primary endpoint.

RESULTS

Among all 8,942 AMI cases, 2,513 were premature AMI (79.8% men). Compared to the non-premature AMI group, risk factors such as smoking, dyslipidemia, overweight, obesity, and a family history of coronary heart disease (CHD) were more prevalent in the premature AMI group. The cumulative survival rate of patients in the premature AMI group was significantly better than the non-premature AMI group during a mean follow-up of 4.6 years (HR = 0.27, 95% CI 0.22-0.32, p < 0.001). Low left ventricular ejection fraction (LVEF) (Adjusted HR 3.00, 95% CI 1.85-4.88, P < 0.001), peak N-terminal pro-B-type natriuretic peptide (NT-proBNP) level (Adjusted HR 1.34, 95% CI 1.18-1.52, P < 0.001) and the occurrence of in-hospital major adverse cardiovascular and cerebrovascular events (MACCEs) (Adjusted HR 2.36, 95% CI 1.45-3.85, P = 0.001) were predictors of poor prognosis in premature AMI patients.

CONCLUSION

AMI in young patients is associated with unhealthy lifestyles such as smoking, dyslipidemia, and obesity. Low LVEF, elevated NT-proBNP peak level, and the occurrence of in-hospital MACCEs were predictors of poor prognosis in premature AMI patients.

Relation of Gender to the Occurrence of AKI in STEMI Patients

Patients undergoing percutaneous coronary interventions (PCIs) are prone to a wide range of complications; one complication that is constantly correlated with a worse prognosis is acute kidney injury (AKI). Gender as an independent risk factor for said complications has raised some interest; however, studies have shown conflicting results so far. We aimed to investigate the possible relation of gender to the occurrence of AKI in STEMI patients undergoing PCI. This retrospective observational study cohort included 2967 consecutive patients admitted with STEMI between the years 2008 and 2019. Their renal outcomes were assessed according to KDIGO criteria (AKI serum creatinine ≥ 0.3 mg/dL from baseline within 48 h from admission), and in-hospital complications and mortality were reviewed. Our main results show that female patients were older (69 vs. 60, p < 0.001) and had higher rates of diabetes (29.2% vs. 23%, p < 0.001), hypertension (62.9% vs. 41.3%, p < 0.001), and chronic kidney disease (26.7% vs. 19.3%, p < 0.001). Females also had a higher rate of AKI (12.7% vs. 7.8%, p < 0.001), and among patients with AKI, severe AKI was also more prevalent in females (26.1% vs. 14.5%, p = 0.03). However, in multivariate analyses, after adjusting for the baseline characteristics above, the female gender was a non-significant predictor for AKI (adjusted OR 1.01, 95% CI 0.73−1.4, p = 0.94) or severe AKI (adjusted OR 1.65, 95% CI 0.80−1.65, p = 0.18). In conclusion, while females had higher rates of AKI and severe AKI, gender was not independently associated with AKI after adjusting for other confounding variables. Other comorbidities that are more prevalent in females can account for the difference in AKI between genders.

Sex-related differences in the management and outcomes of patients hospitalized with ST-elevation myocardial infarction: a comparison within four European myocardial infarction registries

Aims

Data on how differences in risk factors, treatments, and outcomes differ between sexes in European countries are scarce. We aimed to study sex-related differences regarding baseline characteristics, in-hospital managements, and mortality of ST-elevation myocardial infarction (STEMI) patients in different European countries.

Methods and results

Patients over the age of 18 with STEMI who were treated in hospitals in 2014–17 and registered in one of the national myocardial infarction registers in Estonia (n = 5817), Hungary (n = 30 787), Norway (n = 33 054), and Sweden (n = 49 533) were included. Cardiovascular risk factors, hospital treatment, and recommendation of discharge medications were obtained from the infarction registries. The primary outcome was mortality, in-hospital, after 30 days and after 1 year. Logistic and cox regression models were used to study the associations of sex and outcomes in the respective countries. Women were older than men (70–78 and 62–68 years, respectively) and received coronary angiography, percutaneous coronary intervention, left ventricular ejection fraction assessment, and evidence-based drugs to a lesser extent than men, in all countries. The crude mortality in-hospital rates (10.9–15.9 and 6.5–8.9%, respectively) at 30 days (13.0–19.9 and 8.2–10.9%, respectively) and at 1 year (20.3–28.1 and 12.4–17.2%, respectively) after hospitalization were higher in women than in men. In all countries, the sex-specific differences in mortality were attenuated in the adjusted analysis for 1-year mortality.

Conclusion

Despite improved awareness of the sex-specific inequalities on managing patients with acute myocardial infarction in Europe, country-level data from this study show that women still receive less guideline-recommended management.

Treatment gaps, 1-year readmission and mortality following myocardial infarction by diabetes status, sex and socioeconomic disadvantage

AIMS

We evaluated variation in treatment for, and outcomes following, myocardial infarction (MI) by diabetes status, sex and socioeconomic disadvantage.

METHODS

We included all people aged ≥30 years who were discharged alive from hospital following MI between 1 July 2012 and 30 June 2017 in Victoria, Australia (n=43 272). We assessed receipt of inpatient procedures and discharge dispensing of cardioprotective medications for each admission, as well as 1-year all-cause, cardiovascular, and MI readmission rates and 1-year all-cause mortality.

RESULTS

Risk of all-cause (HR: 1.22 (1.19-1.26)), cardiovascular (1.29 (1.25-1.34)), MI (1.52 (1.43-1.62)) and heart failure readmission (1.62 (1.50-1.75)) and mortality (1.18 (1.11-1.26)) were higher in people with diabetes. Males and people in more disadvantaged areas were at increased risk of readmission and mortality following MI. People with diabetes (vs without) were more likely to receive coronary artery bypass grafting (CABG) but less likely to receive percutaneous coronary intervention (PCI) during, or within 30 days of, their index admission. Females were less likely to receive either (eg, 87% of males with a STEMI received PCI or CABG vs 70% of females), and people in more disadvantaged areas were less likely to receive PCI. People with diabetes, males and people in more disadvantaged areas were more likely to be dispensed cardioprotective medications at or within 90 days of discharge.

CONCLUSIONS

Following an MI, people with diabetes and males had poorer outcomes but received more intensive cardiovascular treatments. However, socioeconomic disadvantage was associated with both less intensive inpatient treatment and poorer outcomes.

Sex Differences in Cardiovascular Outcomes of Older Adults After Myocardial Infarction

Background Evidence on the impact of sex on prognoses after myocardial infarction (MI) among older adults is limited. We evaluated sex differences in long-term cardiovascular outcomes after MI in older adults. Methods and Results All patients with MI ≥70 years admitted to 20 Finnish hospitals during a 10-year period and discharged alive were studied retrospectively using a combination of national registries (n=31 578, 51% men, mean age 79). The primary outcome was combined major adverse cardiovascular event within 10-year follow-up. Sex differences in baseline features were equalized using inverse probability weighting adjustment. Women were older, with different comorbidity profiles and rarer ST-segment-elevation MI and revascularization, compared with men. Adenosine diphosphate inhibitors, anticoagulation, statins, and high-dose statins were more frequently used by men, and renin-angiotensin-aldosterone inhibitors and beta blockers by women. After balancing these differences by inverse probability weighting, the cumulative 10-year incidence of major adverse cardiovascular events was 67.7% in men, 62.0% in women (hazard ratio [HR], 1.17; CI, 1.13-1.21; P<0.0001). New MI (37.0% in men, 33.1% in women; HR, 1.16; P<0.0001), ischemic stroke (21.1% versus 19.5%; HR, 1.10; P=0.004), and cardiovascular death (56.0% versus 51.1%; HR, 1.18; P<0.0001) were more frequent in men during long-term follow-up after MI. Sex differences in major adverse cardiovascular events were similar in subgroups of revascularized and non-revascularized patients, and in patients 70 to 79 and ≥80 years. Conclusions Older men had higher long-term risk of major adverse cardiovascular events after MI, compared with older women with similar baseline features and evidence-based medications. Our results highlight the importance of accounting for confounding factors when studying sex differences in cardiovascular outcomes.

Risk of in-hospital life-threatening ventricular arrhythmia or death after ST-elevation myocardial infarction vs. the Takotsubo syndrome

AIMS

The risk of life-threatening ventricular arrhythmias (LTVA) has been reported to be lower in Takotsubo syndrome (TS) compared with ST-elevation myocardial infarction (STEMI). However, the extent to which these differences relate to the fact that most patients with TS are women (who have a lower risk of LTVA) and a relatively larger proportion of patients with STEMI are men is incompletely understood. We aimed to investigate the risk of LTVA or death in sex-matched and age-matched patients with TS, anterior STEMI, and non-anterior STEMI.

METHODS AND RESULTS

We systematically reviewed the charts of all patients with TS who were treated at Sahlgrenska University Hospital (Gothenburg, Sweden) between 2008 and 2019. A total of 155 patients with confirmed TS (according to the European Society of Cardiology diagnostic criteria for TS) were sex-matched and age-matched 1:1:1 to patients with anterior and non-anterior STEMI. Baseline characteristics and in-hospital outcomes were recorded directly from the patient charts for all patients, and all admission electrocardiographs were analysed. The primary outcome was the composite of death or LTVA [defined as sustained ventricular tachycardia (>30 s) or ventricular fibrillation] within 72 h. The risk of LTVA or death within 72 h after admission was considerably lower in TS (2.6%) vs. anterior STEMI (14%; P = 0.002) and non-anterior STEMI (9.0%; P = 0.02), despite similar or greater risks of acute heart failure, and similar risks of cardiogenic shock. Compared with STEMI, TS was associated with a lower risk of sustained and non-sustained ventricular tachycardia and ventricular fibrillation.

CONCLUSIONS

In a predominantly female age-matched and sex-matched cohort of patients with TS, anterior STEMI, and non-anterior STEMI, the adjusted risk of in-hospital LTVA or death was considerably lower in TS compared with STEMI, despite similar or greater risk of acute heart failure and similar risk of cardiogenic shock.

Effect of Gender on the Outcomes of ST-Elevation Myocardial Infarction at a Tertiary Care Hospital in Riyadh, Saudi Arabia

Objective

This study aimed to evaluate the impact of gender on the outcomes among ST elevation myocardial infarction patients at King Abdulaziz Medical City in Riyadh, Saudi Arabia.

Methods

This retrospective study analyzed the data of 900 patients (770 males and 130 females) admitted between January 2016 and December 2018 diagnosed with ST-elevation myocardial infarction (STEMI). We recorded the baseline characteristics, comorbidities, treatment, complications, and mortality for all patients, and compared these data between female and male patients.

Results

The baseline characteristics: BMI and age were higher in females and were statistically significant (p = 0.0001). We found a higher incidence of heart failure in females than in males which was statistically significant (p = 0.0010). In addition, the mortality rate was higher in female than in male patients, although this difference was not statistically significant (p = 0.3850).

Conclusion

In conclusion, despite the advances in the technology and the use of novel reperfusion therapies females were associated with poorer outcomes after adjustment of the baseline characteristics and risk factors. In other words, heart failure, mitral regurgitation, and arrhythmias were higher in females with significant p values.

The sex difference in 6-month MACEs and its explaining variables in acute myocardial infarction survivors: Data from CPACS-3 study

BACKGROUND

We aimed to assess sex difference in developing major adverse cardiovascular events (MACEs) after discharge and factors associated with the gender disparity among AMI survivors.

METHODS

We selected the patients hospitalized with either NSTEMI or STEMI from 101 Chinese centers in the CPACS 3 study. We compared sex differences in MACEs and mortality in 6 months after discharge using a Cox proportional hazards model, following sequential adjustment for covariates.

RESULTS

8958 patients with AMI were included and 30.3% were women. Overall, the crude rate of MACEs at 6 month for women were significantly higher than men (6.5% vs 4.5%; hazard ratio (HR) =1.47; 95% CI, 1.21-1.77). Women also had significantly higher total mortality compared to men (4.4% vs 2.7%; HR = 1.65; 95% CI, 1.30-2.09). Among possible explanatory factors, patients' cardiovascular risk profile might explain 53%, age 38%, low level of education and socioeconomic status 32%. Interestingly, medications at discharge did not contribute to the sex disparity in 6-month risk of MACEs. These factors could explain a similar proportion of the gender disparity in total death. All together, these factors could explain all the disparity in the risk of both MACEs (HR = 1.05,95% CI, 0.85-1.31) and total death (HR = 1.00,95% CI,0.76-1.30).

CONCLUSIONS

The gender disparity in MACEs and total death among AMI patients continues at 6 months after discharged surviving. Multiple factors could explain the higher risk for women, including poorer cardiovascular risk factor profile, older age and lower socioeconomic status.

TRIAL REGISTRATION

CPACS-3 was registered on www.clinicaltrails.gov, and the registration number is NCT01398228.

Sex-Specific Outcomes in Patients with Acute Coronary Syndrome

Sex differences in patients with acute coronary syndrome (ACS) are a matter of debate. We investigated sex-specific differences in the incidence, outcomes, and related interventions in patients diagnosed with ACS in Germany over the past decade. All ACS cases from 2005 to 2015 were collected. Procedures and inhospital mortality were assessed by sex. Age-adjusted incidence rates were calculated. In total, 1,366,045 females and 2,431,501 males presenting with ACS were recorded. Females were older than males (73.1 vs. 66.4 years of age), had a longer mean hospital stay (7.7 vs. 6.9 days), and less frequently underwent coronary angiographies (55% vs. 66%) and coronary interventions (35% vs. 47%). The age-adjusted incidence rate of ACS was lower in females than in males, and decreased in both sexes from 2005 to 2015. The age-adjusted inhospital mortality rate was substantially higher in females than in males, but decreased in both sexes over time (in females, from 87 to 71 cases per 1000 person years; in males, from 57 to 51 cases per 1000 person years). In conclusion, we reported sex differences in the incidence, treatment, and outcomes of ACS patients in Germany within the past decade. Women had a substantially higher mortality rate and lower rate of coronary interventions.

Clinical Presentation, Quality of Care, Risk Factors and Outcomes in Women with Acute ST-Elevation Myocardial Infarction (STEMI): An Observational Report from Six Middle Eastern Countries

BACKGROUND

Most of the available literature on ST-Elevated myocardial infarction (STEMI) in women was conducted in the developed world and data from Middle-East countries was limited.

AIMS

To examine the clinical presentation, patient management, quality of care, risk factors and inhospital outcomes of women with acute STEMI compared with men using data from a large STEMI registry from the Middle East.

METHODS

Data were derived from the third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps), a prospective, multinational study of adults with acute STEMI from 36 hospitals in 6 Middle-Eastern countries. The study included 2928 patients; 296 women (10.1%) and 2632 men (89.9%). Clinical presentations, management and in-hospital outcomes were compared between the 2 groups.

RESULTS

Women were 10 years older and more likely to have diabetes mellitus, hypertension, and hyperlipidemia compared with men who were more likely to be smokers (all p<0.001). Women had longer median symptom-onset to emergency department (ED) arrival times (230 vs. 170 min, p<0.001) and ED to diagnostic ECG (8 vs. 6 min., p<0.001). When primary percutaneous coronary intervention (PPCI) was performed, women had longer door-to-balloon time (DBT) (86 vs. 73 min., p=0.009). When thrombolytic therapy was not administered, women were less likely to receive PPCI (69.7 vs. 76.7%, p=0.036). The mean duration of hospital stay was longer in women (6.03 ± 22.51 vs. 3.41 ± 19.45 days, p=0.032) and the crude in-hospital mortality rate was higher in women (10.4 vs. 5.2%, p<0.001). However, after adjustments, multivariate analysis revealed a statistically non-significant trend of higher inhospital mortality among women than men (6.4 vs. 4.6%), (p=0.145).

CONCLUSION

Our study demonstrates that women in our region have almost double the mortality from STEMI compared with men. Although this can partially be explained by older age and higher risk profiles in women, however, correction of identified gaps in quality of care should be attempted to reduce the high morbidity and mortality of STEMI in our women.

Observed and Expected Survival in Men and Women After Suffering a STEMI

INTRODUCTION

Mortality caused by ST elevation myocardial infarction (STEMI) has declined because of greater use of primary percutaneous coronary intervention (PCI). It is unknown if patients >75 have similar survival as peers. We aim to know it stratifying by sex and assessing how the sex may impact the survival.

METHODS

We retrospectively selected all patients >75 who suffered a STEMI treated with primary PCI at our institution. We compared their survival with that of the reference population (general population matched by age, sex, and geographical region). A Cox-regression analysis controlling for clinical factors was performed to know if sex was a risk factor.

RESULTS

Total of 450 patients were studied. Survival at 1, 3, and 5 years of follow-up for patients who survived the first 30 days was 91.22% (CI95% 87.80-93.72), 79.71% (CI95% 74.58-83.92), and 68.02% (CI95% 60.66-74.3), whereas in the reference population it was 93.11%, 79.10%, and 65.01%, respectively. Sex was not a risk factor, Hazard Ratio = 1.02 (CI95% 0.67-1.53; p = 0.92).

CONCLUSIONS

Life expectancy of patients suffering a STEMI is nowadays intimately linked to survival in the first 30 days. After one year, the risk of death for both men and women seems similar to that of the general population.

Sex-Specific Management in Patients With Acute Myocardial Infarction and Cardiogenic Shock: A Substudy of the CULPRIT-SHOCK Trial

BACKGROUND

Women are more likely to suffer and die from cardiogenic shock (CS) as the most severe complication of acute myocardial infarction. Data concerning optimal management for women with CS are scarce. Aim of this study was to better define characteristics of women experiencing CS and to the influence of sex on different treatment strategies.

METHODS

In the CULPRIT-SHOCK trial (The Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock), patients with CS complicating acute myocardial infarction and multivessel coronary artery disease were randomly assigned to one of the following revascularization strategies: either percutaneous coronary intervention of the culprit-lesion-only or immediate multivessel percutaneous coronary intervention. Primary end point was composite of death from any cause or severe renal failure leading to renal replacement therapy within 30 days. We investigated sex-specific differences in general and according to the revascularization strategies.

RESULTS

Among all 686 randomized patients included in the analysis, 24% were women. Women were older and had more often diabetes mellitus and renal insufficiency, whereas they had less often history of previous acute myocardial infarction and smoking. After 30 days, the primary clinical end point was not significantly different between groups (56% women versus 49% men; odds ratio, 1.29 [95% CI, 0.91-1.84]; P=0.15). There was no interaction between sex and coronary revascularization strategy regarding mortality and renal failure (P_interaction=0.11). The primary end point occurred in 56% of women treated by the culprit-lesion-only strategy versus 42% men, whereas 55% of women and 55% of men in the multivessel percutaneous coronary intervention group.

CONCLUSIONS

Although women presented with a different risk profile, mortality and renal replacement were similar to men. Sex did not influence mortality and renal failure according to the different coronary revascularization strategies. Based on these data, women and men presenting with CS complicating acute myocardial infarction and multivessel coronary artery disease should not be treated differently. However, further randomized trials powered to address potential sex-specific differences in CS are still necessary. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01927549.

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.

Efficacy and Safety of High Potent P2Y12 Inhibitors Prasugrel and Ticagrelor in Patients With Coronary Heart Disease Treated With Dual Antiplatelet Therapy: A Sex-Specific Systematic Review and Meta-Analysis

Background

Sex differences in efficacy and safety of dual antiplatelet therapy remain uncertain because of the underrepresentation of women in cardiovascular trials. The aim of this study was to perform a sex‐specific analysis of the pooled efficacy and safety data of clinical trials comparing a high potent P2Y₁₂ inhibitor+aspirin with clopidogrel+aspirin in patients with acute coronary syndrome.

Methods and Results

A systematic literature search was performed. Randomized clinical trials that compared patients following percutaneous coronary intervention/acute coronary syndrome who were taking high potent P2Y₁₂ inhibitors+aspirin versus clopidogrel+aspirin were selected. Random effects estimates were calculated and relative risks with 95% CIs on efficacy and safety end points were determined per sex. We included 6 randomized clinical trials comparing prasugrel/ticagrelor versus clopidogrel in 43 990 patients (13 030 women), with a median follow‐up time of 1.06 years. Women and men had similar relative risk (RR) reduction for major cardiovascular events (women: RR, 0.89 [95% CI, 0.80–1.00; men: RR, 0.84 [95% CI, 0.79–0.91) (P for interaction=0.39). Regarding safety, women and men had similar risk of major bleeding by high‐potency dual antiplatelet therapy (RR, 1.18 [95% CI, 0.98–1.41] versus RR, 1.03 [95% CI, 0.93–1.14]) (P for interaction=0.20).

Conclusions

The small and statistically insignificant difference in efficacy and safety estimates of high‐potency dual antiplatelet therapy between women and men following percutaneous coronary intervention/acute coronary syndrome do not justify differential dual antiplatelet therapy treatment for both sexes.

Few with ST-segment elevation myocardial infarction are diagnosed within 10 minutes from first medical contact, and women have longer delay times than men

Background

Previous reports have questioned the feasibility and gender equality of obtaining a prehospital ECG within 10 minutes of ambulance arrival for patients with ST-segment elevation myocardial infarction (STEMI). The main objective of this study was to investigate the proportion of STEMI patients with a prehospital ECG within 10 minutes of ambulance arrival. The secondary objective was to study the gender differences in delay times in prehospital STEMI care.

Methods

This study was a retrospective study based on 539 patients with STEMI at the investigating hospital. Ambulance and medical charts, as well as the national quality registry “SWEDEHEART”, were reviewed for each patient for demographics and time information.

Results

A prehospital ECG was obtained within 10 minutes of ambulance arrival for 99 (29%) of the men and 19 (14%) of the women, p = 0.001. Women had a 2 minutes longer delay between ambulance arrival and prehospital ECG (95% CI 0–4 min, p = 0.018) than men. Women also had a significantly longer patient delay. None of the other time intervals differed among men and women.

Conclusions

Only for a minority of patients is a prehospital ECG taken within the recommended ten minutes from ambulance arrival. Women have longer patient delay times, as well as delay times to the acquisition of a prehospital ECG than men. Improvements of prehospital ECG acquisition and adjustments of the guidelines are warranted.

ST-elevation myocardial infarction in a real world population - An observational retrospective study with a sex perspective

BACKGROUND

Mortality after myocardial infarction is higher in women than in men. Data on the association between sex and mortality are conflicting and inconclusive. We evaluated whether there is a sex difference in survival and if sex is associated with the outcome in patients with ST-elevation myocardial infarction (STEMI).

METHODS

We analyzed 3671 STEMI patients. Long-term and 30-day mortality in men and women were compared.

RESULTS

Unadjusted mortality at day 30 was higher in women [221 (8.7%) men died compared to 147 (13.1%) women; p < 0.0001]. After multivariate adjustments, this became insignificant (OR 1.65; 95% CI; 0.81 to 1.40). The long-term, unadjusted mortality was also higher in women [674 (26.3%) men died compared to 382 (34%) women; p < 0.0001]. After multivariable adjustments, female sex (adjusted HR 0.81; 95% CI 0.71 to 0.93; p = 0.002), bleeding (adjusted HR 1.79; 95% CI 1.52 to 2.10; p < 0.0001), renal dysfunction adjusted HR (1.60; 95% CI 1.40 to 1.84; p < 0.0001), hyperlipidemia (adjusted HR 1.61; 95% CI 1.40 to 1.85; p < 0.0001), arterial hypertension (adjusted HR 1.17; 95% CI 1.03 to 1.33; p = 0.015), diabetes (adjusted HR 1.55; 95% CI 1.35 to 1.78; p < 0.0001), age (adjusted HR 1.05; 95% CI 1.04 to 1.06; p < 0.0001), anemia on admission (adjusted HR 1.38; 95% CI 1.23 to 1.58; p < 0.0001), and heart failure (adjusted HR 2.40; 95% CI 2.09 to 2.75; p < 0.0001) predicted long-term mortality.

CONCLUSION

Female sex was associated with a lower risk of dying in the long term. However, risk factors, age, and comorbidities associated with female patients affected the worse outcome.

Gender but not diabetes, hypertension or smoking affects infarct evolution in ST-elevation myocardial infarction patients - data from the CHILL-MI, MITOCARE and SOCCER trials

BACKGROUND

Infarct evolution rate and response to acute reperfusion therapy may differ between patients, which is important to consider for accurate management and treatment of patients with ST-elevation myocardial infarction (STEMI). The aim of this study was therefore to investigate the association of infarct size and myocardial salvage with gender, smoking status, presence of diabetes or history of hypertension in a cohort of STEMI-patients.

METHODS

Patients (n = 301) with first-time STEMI from the three recent multi-center trials (CHILL-MI, MITOCARE and SOCCER) underwent cardiac magnetic resonance (CMR) imaging to determine myocardium at risk (MaR) and infarct size (IS). Myocardial salvage index (MSI) was calculated as MSI = 1-IS/MaR. Pain to balloon time, culprit vessel, trial treatments, age, TIMI grade flow and collateral flow by Rentrop grading were included as explanatory variables in the statistical model.

RESULTS

Women (n = 66) had significantly smaller MaR (mean difference: 5.0 ± 1.5% of left ventricle (LV), p < 0.01), smaller IS (mean difference: 5.1 ± 1.4% of LV, p = 0.03), and larger MSI (mean difference: 9.6 ± 2.8% of LV, p < 0.01) compared to men (n = 238). These differences remained significant when adjusting for other explanatory variables. There were no significant effects on MaR, IS or MSI for diabetes, hypertension or smoking.

CONCLUSIONS

Female gender is associated with higher myocardial salvage and smaller infarct size suggesting a pathophysiological difference in infarct evolution between men and women.

Usage of PCI and long-term cardiovascular risk in post-myocardial infarction patients: a nationwide registry cohort study from Finland

BACKGROUND

Despite currently available treatments, the burden of myocardial infarction (MI) morbidity and mortality remains prominent. The aim of this was to investigate the risk of developing subsequent cardiovascular events in MI patients.

METHODS

This was an observational, retrospective cohort database linkage study using patient level data from Finland. Cox proportional hazards models were used to assess the association of risk between the preselected covariates and incidence of specific outcomes. The primary endpoints were new MI, stroke, cardiovascular mortality and overall mortality.

RESULTS

Finnish adult MI patients alive 7 days after discharge in 2009-2012 were included. The study cohort consisted of 32,909 MI patients, of whom 25,875 (79%) survived 12 months without subsequent MI or stroke. ST-elevation MI (STEMI) was associated with lower risk of subsequent MI and overall mortality compared to non-STEMI patients. Percutaneous coronary intervention (PCI) was used two times more often in STEMI patients, but patients with prior stroke were more than two times less likely to have PCI. Dementia/Alzheimer's disease decreased the use of PCI as much as age over 85 years. Female sex was an independent factor for not undergoing PCI (OR 0.75, P < 0.001 compared to men) but was nevertheless associated with lower risk of new MI and mortality (HR 0.8-0.9, P < 0.001 for all). Increased age was associated with increased event risk and PCI with decreased event risk.

CONCLUSIONS

Risk of cardiovascular events and mortality after MI increases steeply with age. Although at higher risk, aging patients and those with cardiovascular comorbidities are less likely to receive PCI after MI. Female sex is associated with better survival after MI regardless of less intensive treatment in women.

[Association of Strategy of Direct Stenting of Infarct-Related Artery with Reduction of Mortality in Woman with ST-Elevation Myocardial Infarction]

Aim of this study was to evaluate the impact of direct stenting (DS) strategy on the results of treatment of female patients with STelevation myocardial infarction (STEMI) undergoing percutaneous coronary interventions (PCIs).

MATERIALS AND METHODS

Among 1297 patients with STEMI admitted to the coronary care unit and subjected to PCIs from 2006 to 2015 there were 330 women (25.4 %). Data from 161 women (48.8 %) who underwent DS were compared with those from 169 women who underwent indirect stenting (IS). Among patients of IS group in 148 (87.6 %) stenting was performed after predilation, in 7 (4.1 %) after manual thrombus aspiration, and in 14 (8.3 %) after combination of predilation and thrombus aspiration.

RESULTS

The rate of angiographic success was higher in the DS group (97.5 vs. 87.6 %, р&lt;0.001). Rates of deaths (4.3 vs. 11.8 %; p=0.013), major adverse cardiac events (MACE)(4.3 vs. 13 %; p=0.005), and no-reflow (1.9 % vs. 11.2 %; p=0.013) were significantly lower in the DS group. There were no differences in rates of recurrent myocardial infarction and access site complications. Following propensity score matching, each group contained 78 patients. Rates of MACE (2.6 vs. 14.1 %; p=0.009) and deaths (2.6 vs. 12.8 %; p=0.016) remained significantly lower in the DS group. After multivariate adjustment, DS strategy was independently associated with lower mortality (odds ratio [OR] 0.29; 95 % confidence interval [CI] 0.09-0.97; p=0.04) and MACE (OR=0.28; 95 %CI 0.09-0.087; p=0.03).

CONCLUSION

DS strategy in STEMI female patients turned out to be safe and effective technique.

Age-Specific Sex-Based Differences in Anemia in Patients with Myocardial Infarction

Background: Data are lacking concerning possible age-specific sex-based differences in anemia in myocardial infarction (MI) patients and its association with the outcome. The aim was to assess whether these differences in anemia (on admission and at discharge) in MI patients who underwent percutaneous coronary intervention (PCI) are associated with the outcome. Methods: Data from 5579 MI patients (31.0% women) undergoing PCI at our institution were analyzed. Men and women in different age groups were compared regarding anemia and its association with the 30-day and long-term all-cause mortality. Data were analyzed using descriptive statistics. Results: Women suffered anemia more than men (37.5% vs. 26.8%; p < 0.0001). The prevalence of anemia increased rapidly with age in men but not in women. A J-shaped relationship between age and anemia was found in women. The lower the age, the greater the difference in the prevalence of anemia between the sexes. The difference in the prevalence of anemia at discharge was even more pronounced. Anemia on admission (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.10-1.76; p = 0.005) and at discharge (OR = 2.61; 95% CI = 1.98-3.44; p < 0.0001) predicted a higher 30-day mortality. Women had a better adjusted long-term prognosis (hazard ratio [HR] = 0.78; 95% CI = 0.69-0.87; p < 0.0001) for the total population. Anemia on admission (HR = 1.43; 95% CI = 1.29-1.60; p < 0.0001) and at discharge (HR = 1.96; 95% CI = 1.23-2.21; p < 0.0001) predicted a higher long-term mortality. Conclusion: Younger women with MI suffer anemia more frequently than their male peers. Anemia was associated with a worse outcome. Age-specific sex-based differences in anemia help to explain the increased sex-related mortality in MI patients undergoing PCI.

Gender differences in patient and system delay for primary percutaneous coronary intervention: current trends in a Swiss ST-segment elevation myocardial infarction population

Background:

Women with ST-segment elevation myocardial infarction (STEMI) experience greater delays for percutaneous coronary intervention-facilitated reperfusion than men. Whether women and men benefit equally from current strategies to reduce ischaemic time and whether there are gender differences in factors determining delays is unclear.

Methods:

Patient delay (symptom onset to first medical contact) and system delay (first medical contact to percutaneous coronary intervention-facilitated reperfusion) were compared between women ( n=967) and men ( n=3393) in a Swiss STEMI treatment network. Trends from 2000 to 2016 were analysed, with additional comparisons between three time periods (2000–2005, 2006–2011 and 2012–2016). Factors predicting delays and hospital mortality were determined by multivariate regression modelling.

Results:

Female gender was independently associated with greater patient delay ( P=0.02 vs. men), accounting for a 12% greater total ischaemic time among women in 2012–2016 (median 215 vs. 192 minutes, P<0.001 vs. men). From 2000–2005 to 2012–2016, median system delay was reduced by 18 and 25 minutes in women and men, respectively ( P<0.0001 for trend, P=n.s. for gender difference). Total occlusion of the culprit artery, stent thrombosis, a Killip class of 3 or greater, and presentation during off-hours predicted delays in men, but not in women. A Killip class of 3 or greater and age, but not gender or delays, were independently associated with hospital mortality.

Conclusions:

STEMI-related ischaemic time in women remains greater than in men due to persistently greater patient delays. In contrast to men, clinical signs of ongoing chest discomfort do not predict delays in women, suggesting that female STEMI patients are less likely to attribute symptoms to a condition requiring urgent treatment.

Sex-Related Differences in Short- and Long-Term Outcome among Young and Middle-Aged Patients for ST-Segment Elevation Myocardial Infarction Underwent Percutaneous Coronary Intervention

Background:

Females with ST-segment elevation myocardial infarction (STEMI) have higher in-hospital and short-term mortality rates compared with males in China, suggesting that a sex disparity exists. The age of onset of STEMI is ahead of time and tends to be younger. However, there are relatively little data on the significance of sex on prognosis for long-term outcomes for adult patients with STEMI after percutaneous coronary intervention (PCI) in China. This study sought to analyze the sex differences in 30-day, 1-year, and long-term net adverse clinical events (NACEs) in Chinese adult patients with STEMI after PCI.

Methods:

This study retrospectively analyzed 1920 consecutive STEMI patients (age ≤60 years) treated with PCI from January 01, 2006, to December 31, 2012. A propensity score analysis between males and females was performed to adjust for differences in baseline characteristics and comorbidities. The primary endpoint was the incidence of 3-year NACE. Survival curves were constructed with Kaplan-Meier estimates and compared by log-rank tests between the two groups. Multivariate analysis was performed using a Cox proportional hazards model for 3-year NACE.

Results:

Compared with males, females had higher risk profiles associated with old age, longer prehospital delay at the onset of STEMI, hypertension, diabetes mellitus, and chronic kidney disease, and a higher Killip class (≥3), with more multivessel diseases (P < 0.05). The female group had a higher levels of low-density lipoprotein (2.72 [2.27, 3.29] vs. 2.53 [2.12, 3.00], P < 0.001), high-density lipoprotein (1.43 [1.23, 1.71] vs. 1.36 [1.11, 1.63], P = 0.003), total cholesterol (4.98 ± 1.10 vs. 4.70 ± 1.15, t = −3.508, P < 0.001), and estimated glomerular filtration rate (103.12 ± 22.22 vs. 87.55 ± 18.03, t = −11.834, P < 0.001) than the male group. In the propensity-matched analysis, being female was associated with a higher risk for 3-year NACE and major adverse cardiac or cerebral events compared with males. In the multivariate model, female gender (hazard ratio [HR]: 2.557, 95% confidence interval [CI]: 1.415–4.620, P = 0.002), hypertension (HR: 2.017, 95% CI: 1.138–3.576, P = 0.016), and family history of coronary heart disease (HR: 2.256, 95% CI: 1.115–4.566, P = 0.024) were independent risk factors for NACE. The number of stents (HR: 0.625, 95% CI: 0.437–0.894, P = 0.010) was independent protective factors of NACE.

Conclusions:

Females with STEMI undergoing PCI have a significantly higher risk for 3-year NACE compared with males in this population. Sex differences appear to be a risk factor and present diagnostic challenges for clinicians.

A review of sex-specific benefits and risks of antithrombotic therapy in acute coronary syndrome

Over the past decade, more men than women have shown improved outcomes from antithrombotic therapies after acute coronary syndrome (ACS), which raises the question of whether there are sex-specific differences in treatment patterns and response to therapy. Differences in presenting clinical characteristics, pathophysiologic profile, and disparities in treatment may contribute to this outcomes discrepancy. Analyses of large trials and registry data suggest that male and female ACS patients experience similar benefits from antithrombotic therapy without significant difference in treatment utilization rates, yet women are consistently at higher risk of bleeding than men. Bleeding may result in antithrombotic treatment disruption, which increases the risk of long-term thrombotic events. Additionally, female ACS patients are more likely to receive suboptimal medication dosing and have lower rates of long-term medication adherence. These differences have significant clinical implications for women, indicating the need for strategies that will optimize initial treatment and long-term management attuned to these recognized sex-specific gaps.

Bleeding complications after myocardial infarction in a real world population - An observational retrospective study with a sex perspective

INTRODUCTION

The aim of the current study was to assess bleeding events, including severity, localisation and prognostic impact, in a real world population of men and women with myocardial infarction (MI).

METHODS AND RESULTS

In total 850 consecutive patients were included during 2010 and followed for one year. Bleeding complications were identified by searching of each patients' medical records and characterised according to the TIMI criteria. For this analysis, only the first event was calculated. The total incidence of bleeding events was 24.4% (81 women and 126 men, p = ns). The incidence of all in-hospital bleeding events was 13.2%, with no sex difference. Women had significantly more minor non-surgery related bleeding events than men (5% vs 2.2%, p = 0.02). During follow-up, 13.5% had a bleeding, with more non-surgery related bleeding events among women, 14.7% vs 9.7% (p = 0.03). The most common bleeding localisation was the gastrointestinal tract, more in women than men (12.1% vs 7.6%, p = 0.03). Women had also more access site bleeding complications (4% vs 1.7%, p = 0.04), while men had more surgery related bleeding complications (6.4% vs 0.9%, p ≤0.001). Increased mortality was found only in men with non-surgery related bleeding events (p = 0.008).

CONCLUSIONS

Almost one in four patients experienced a bleeding complication through 12 months follow-up after a myocardial infarction. Women experienced more non-surgery related minor/minimal bleeding complications than men, predominantly GI bleeding events and access site bleeding events, with no apparent impact on outcome. In contrast men with non-surgery related bleeding complications had higher mortality. Improved bleeding prevention strategies are warranted for both men and women.

Gender disparities in first medical contact and delay in ST-elevation myocardial infarction: a prospective multicentre Swedish survey study

OBJECTIVES

Compare gender disparities in ST-elevation myocardial infarction (STEMI) regarding first medical contact (FMC) and prehospital delay times and explore factors associated with prehospital delay in men and women separately.

DESIGN

Cross-sectional study based on medical records and a validated questionnaire. Eligible patients were enrolled within 24 hours after admittance to hospital.

SETTING

Patients were included from November 2012 to January 2014 from five Swedish hospitals with catheterisation facilities 24/7.

PARTICIPANTS

340 men and 109 women aged between 31 and 95 years completed the survey.

MAIN OUTCOME MEASURES

FMC were divided into five possible contacts: primary healthcare centre by phone or directly, national advisory nurse by phone, emergency medical services (EMS) and emergency room directly. Two parts of prehospital delay times were studied: time from symptom onset to FMC and time from symptom onset to diagnostic ECG.

RESULTS

Women more often called an advisory nurse as FMC (28% vs 18%, p=0.02). They had a longer delay until FMC, 90 (IQR 39-221) vs 66 (28-161) min, p=0.04 and until ECG, 146 (68-316) vs 103 (61-221) min, p=0.03. Men went to hospital because of believing they were stricken by an MI to a higher extent than women did (25% vs 15%, p=0.04) and were more often recommended to call EMS by bystanders (38% vs 22%, p<0.01). Hesitating about going to hospital and experiencing pain in the stomach/back/shoulders were factors associated with longer delays in women. Believing the symptoms would disappear or interpreting them as nothing serious were corresponding factors in men. In both genders bystanders acting by contacting EMS explained shorter prehospital delays.

CONCLUSIONS

In STEMI, women differed from men in FMC and they had longer delays. This was partly due to atypical symptoms and a longer decision time. Bystanders acted more promptly when men than when women fell ill. Public knowledge of MI symptoms, and how to act properly, still seems insufficient.

Sex Differences in Outcomes After STEMI: Effect Modification by Treatment Strategy and Age

IMPORTANCE

Previous works have shown that women hospitalized with ST-segment elevation myocardial infarction (STEMI) have higher short-term mortality rates than men. However, it is unclear if these differences persist among patients undergoing contemporary primary percutaneous coronary intervention (PCI).

OBJECTIVE

To investigate whether the risk of 30-day mortality after STEMI is higher in women than men and, if so, to assess the role of age, medications, and primary PCI in this excess of risk.

DESIGN, SETTING, AND PARTICIPANTS

From January 2010 to January 2016, a total of 8834 patients were hospitalized and received medical treatment for STEMI in 41 hospitals referring data to the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) registry (NCT01218776).

EXPOSURES

Demographics, baseline characteristics, clinical profile, and pharmacological treatment within 24 hours and primary PCI.

MAIN OUTCOMES AND MEASURES

Adjusted 30-day mortality rates estimated using inverse probability of treatment weighted (IPTW) logistic regression models.

RESULTS

There were 2657 women with a mean (SD) age of 66.1 (11.6) years and 6177 men with a mean (SD) age of 59.9 (11.7) years included in the study. Thirty-day mortality was significantly higher for women than for men (11.6% vs 6.0%, P < .001). The gap in sex-specific mortality narrowed if restricting the analysis to men and women undergoing primary PCI (7.1% vs 3.3%, P < .001). After multivariable adjustment for comorbidities and treatment covariates, women under 60 had higher early mortality risk than men of the same age category (OR, 1.88; 95% CI, 1.04-3.26; P = .02). The risk in the subgroups aged 60 to 74 years and over 75 years was not significantly different between sexes (OR, 1.28; 95% CI, 0.88-1.88; P = .19 and OR, 1.17; 95% CI, 0.80-1.73; P = .40; respectively). After IPTW adjustment for baseline clinical covariates, the relationship among sex, age category, and 30-day mortality was similar (OR, 1.56 [95% CI, 1.05-2.3]; OR, 1.49 [95% CI, 1.15-1.92]; and OR, 1.21 [95% CI, 0.93-1.57]; respectively).

CONCLUSIONS AND RELEVANCE

Younger age was associated with higher 30-day mortality rates in women with STEMI even after adjustment for medications, primary PCI, and other coexisting comorbidities. This difference declines after age 60 and is no longer observed in oldest women.

Characteristics and Prognosis in Women and Men With Type 1 Diabetes Undergoing Coronary Angiography: A Nationwide Registry Report

OBJECTIVE

To describe sex aspects on extent of coronary artery disease (CAD) and prognosis in a contemporary population with type 1 diabetes.

RESEARCH DESIGN AND METHODS

All patients undergoing coronary angiography, 2001-2013, included in the Swedish Coronary Angiography and Angioplasty Registry and the Swedish National Diabetes Register as type 1 diabetes were followed for mortality until 31 December 2013. The coronary angiogram was classified into normal, one-vessel disease, two-vessel disease, three-vessel disease, and left main stem disease.

RESULTS

In all, 2,776 patients (42% women) with mean age 58 years (SD 11) were followed for 7.2 years (SD 2.2). Diabetes duration was longer in women (37 ± 14 vs. 34 ± 14 years in men; P < 0.001), who also had more retinopathy (68% vs. 65%; P = 0.050), whereas microalbuminuria was less common (41% vs. 51%; P < 0.001). Indications for coronary angiography did not substantially differ in women and men. The extent of CAD was somewhat less severe in women (normal angiogram 23.5% vs. 19.1%, three-vessel and left main stem disease 34.5% vs. 40.4%; P = 0.002), whereas mortality did not differ (adjusted hazard ratio 1.03 [95% CI 0.88-1.20]; P = 0.754). The standard mortality ratio for women the first year was 7.49 (5.73-9.62) and for men was 4.58 (3.60-5.74).

CONCLUSIONS

In patients with type 1 diabetes admitted for coronary angiography, the extent of CAD was almost similar in women and men, and total long-term mortality did not differ. Type 1 diabetes was associated with higher mortality risk in women than in men when compared with the general population. These data support that type 1 diabetes attenuates the cardiovascular risk difference seen in men and women in the general population.

Gender differences in symptom presentation of ST-elevation myocardial infarction - An observational multicenter survey study

BACKGROUND

Symptom presentation has been sparsely studied from a gender perspective restricting the inclusion to ST elevation myocardial infarction (STEMI) patients. Correct symptom recognition is vital in order to promptly seek care in STEMI where fast reperfusion therapy is of utmost importance. Female gender has been found associated with atypical presentation in studies on mixed MI populations but it is unclear whether this is valid also in STEMI.

OBJECTIVES

We assessed whether there are gender differences in symptoms and interpretation of these in STEMI, and if this is attributable to sociodemographic and clinical factors.

METHODS

SymTime was a multicenter observational study including a validated questionnaire and data from medical records. Eligible STEMI patients (n = 532) were enrolled within 24 h after admittance at five Swedish hospitals.

RESULTS

Women were older, more often single and had lower educational level. Chest pain was less prevalent in women (74 vs 93%, p < 0.001), whereas shoulder (33 vs 15%, p < 0.001), throat/neck (34 vs 18%, p < 0.001), back pain (29 versus 12%, p < 0.001) and nausea (49 vs 29%, p < 0.001) were more prevalent. Women less often interpreted their symptoms as of cardiac origin (60 vs 69%, p = 0.04). Female gender was the strongest independent predictor of non-chest pain presentation, odds ratio 5.29, 95% confidence interval 2.85-9.80.

CONCLUSIONS

A striking gender difference in STEMI symptoms was found. As women significantly misinterpreted their symptoms more often, it is vital when informing about MI to the society or to high risk individuals, to highlight also other symptoms than just chest pain.

Sex Differences in Treatments, Relative Survival, and Excess Mortality Following Acute Myocardial Infarction: National Cohort Study Using the SWEDEHEART Registry

BACKGROUND

This study assessed sex differences in treatments, all-cause mortality, relative survival, and excess mortality following acute myocardial infarction.

METHODS AND RESULTS

A population-based cohort of all hospitals providing acute myocardial infarction care in Sweden (SWEDEHEART [Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies]) from 2003 to 2013 was included in the analysis. Excess mortality rate ratios (EMRRs), adjusted for clinical characteristics and guideline-indicated treatments after matching by age, sex, and year to background mortality data, were estimated. Although there were no sex differences in all-cause mortality adjusted for age, year of hospitalization, and comorbidities for ST-segment-elevation myocardial infarction (STEMI) and non-STEMI at 1 year (mortality rate ratio: 1.01 [95% confidence interval (CI), 0.96-1.05] and 0.97 [95% CI, 0.95-0.99], respectively) and 5 years (mortality rate ratio: 1.03 [95% CI, 0.99-1.07] and 0.97 [95% CI, 0.95-0.99], respectively), excess mortality was higher among women compared with men for STEMI and non-STEMI at 1 year (EMRR: 1.89 [95% CI, 1.66-2.16] and 1.20 [95% CI, 1.16-1.24], respectively) and 5 years (EMRR: 1.60 [95% CI, 1.48-1.72] and 1.26 [95% CI, 1.21-1.32], respectively). After further adjustment for the use of guideline-indicated treatments, excess mortality among women with non-STEMI was not significant at 1 year (EMRR: 1.01 [95% CI, 0.97-1.04]) and slightly higher at 5 years (EMRR: 1.07 [95% CI, 1.02-1.12]). For STEMI, adjustment for treatments attenuated the excess mortality for women at 1 year (EMRR: 1.43 [95% CI, 1.26-1.62]) and 5 years (EMRR: 1.31 [95% CI, 1.19-1.43]).

CONCLUSIONS

Women with acute myocardial infarction did not have statistically different all-cause mortality, but had higher excess mortality compared with men that was attenuated after adjustment for the use of guideline-indicated treatments. This suggests that improved adherence to guideline recommendations for the treatment of acute myocardial infarction may reduce premature cardiovascular death among women.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02952417.

Association between gender and short-term outcome in patients with ST elevation myocardial infraction participating in the international, prospective, randomised Administration of Ticagrelor in the catheterisation Laboratory or in the Ambulance for New ST elevation myocardial Infarction to open the Coronary artery (ATLANTIC) trial: a prespecified analysis

OBJECTIVES

To evaluate gender differences in outcomes in patents with ST-segment elevation myocardial infarction (STEMI) planned for primary percutaneous coronary intervention (PPCI).

SETTINGS

A prespecified gender analysis of the multicentre, randomised, double-blind Administration of Ticagrelor in the catheterisation Laboratory or in the Ambulance for New ST elevation myocardial Infarction to open the Coronary artery.

PARTICIPANTS

Between September 2011 and October 2013, 1862 patients with STEMI and symptom duration <6 hours were included.

INTERVENTIONS

Patients were assigned to prehospital versus in-hospital administration of 180 mg ticagrelor.

OUTCOMES

The main objective was to study the association between gender and primary and secondary outcomes of the main study with a focus on the clinical efficacy and safety outcomes.

PRIMARY OUTCOME

the proportion of patients who did not have 70% resolution of ST-segment elevation and did not meet the criteria for Thrombolysis In Myocardial Infarction (TIMI) flow 3 at initial angiography. Secondary outcome: the composite of death, MI, stent thrombosis, stroke or urgent revascularisation and major or minor bleeding at 30 days.

RESULTS

Women were older, had higher TIMI risk score, longer prehospital delays and better TIMI flow in the infarct-related artery. Women had a threefold higher risk for all-cause mortality compared with men (5.7% vs 1.9%, HR 3.13, 95% CI 1.78 to 5.51). After adjustment, the difference was attenuated but remained statistically significant (HR 2.08, 95% CI 1.03 to 4.20). The incidence of major bleeding events was twofold to threefold higher in women compared with men. In the multivariable model, female gender was not an independent predictor of bleeding (Platelet Inhibition and Patient Outcomes major HR 1.45, 95% CI 0.73 to 2.86, TIMI major HR 1.28, 95% CI 0.47 to 3.48, Bleeding Academic Research Consortium type 3-5 HR 1.45, 95% CI 0.72 to 2.91). There was no interaction between gender and efficacy or safety of randomised treatment.

CONCLUSION

In patients with STEMI planned for PPCI and treated with modern antiplatelet therapy, female gender was an independent predictor of short-term mortality. In contrast, the higher incidence of bleeding complications in women could mainly be explained by older age and clustering of comorbidities.

CLINICAL TRIAL REGISTRATION

NCT01347580;Post-results.

Sex differences in survival after myocardial infarction in Sweden, 1987-2010

Objective

In this nationwide study, we investigated age-specific and sex-specific trends in sex differences in survival after acute myocardial infarction (AMI), including deaths from coronary heart disease (CHD) that occurred outside hospital.

Methods

Observational study in Sweden of 28-day and 1-year mortality among 658 110 persons (35.7% women) aged 35–84 years with a first-time CHD event 1987–2010 with data retrieved from the national Swedish death and hospital registries.

Results

Age-adjusted 28-day case fatality decreased from 23.5% to 8.5% over the period (p<0.05). In hospitalised cases, short-term survival in women aged 35–54 years compared with men of the same age was poorer, not changing appreciably over time (HRs for women relative to men 1.63 (95% CI 1.28 to 2.08) at age 35–54 years and 1.28 (95% CI 1.12 to 1.46) at age 55–64 years in 2005–2010), but after adjustment for comorbidities, differences between men and women were no longer significant (HR 1.25 (95% CI 0.97 to 1.61) and 1.05 (95% CI 0.91 to 1.20)). When CHD deaths outside hospital were included, women had better prognosis regardless of age and period. In patients surviving the first 28 days, age-adjusted 1-year case fatality decreased from 15.3% to 7.7% (p<0.05) for both men and women. After adjustment for comorbidities, no significant sex differences persisted below the age of 75 years in the last period. Female 28-day survivors 75–84 years old had a consistently better prognosis than older men.

Conclusions

The worse short-term outcomes in women <55 years of age hospitalised with AMI did not persist after adjustment for comorbidities. When CHD deaths outside hospital were included, women had consistently better short-term prognosis. In 28-day survivors, women did not fare worse than men when differences in comorbidities were considered.

Gender differences in all-cause, cardiovascular and cancer mortality during long-term follow-up after acute myocardial infarction; a prospective cohort study

BACKGROUND

Gender differences in short-term mortality in acute myocardial infarction (AMI) have been studied extensively, whereas gender differences in long-term mortality and cause of death largely remain unknown. The aim of this study was to assess the long-term risk of all-cause, cardiovascular and cancer death after AMI in women compared to men.

METHODS

Consecutive AMI patients were enrolled in a prospective registry between 2005 and 2011. Date and cause of death were obtained by linkage with the Norwegian Cause of Death Registry, with censoring date 31 December 2012. AMI patients with ST-segment elevation (STEMI, n = 5159) and without (NSTEMI, n = 4899) were analysed separately.

RESULTS

The 5-years all-cause mortality rates in STEMI were 29% in women vs. 17% in men, and 42% vs. 29% in NSTEMI, respectively. After adjustment for age and other confounders, women with STEMI had similar (HR 1.13 [95% CI: 0.98-1.32]) and women with NSTEMI lower (HR 0.82 [95% CI: 0.73-0.92]) risk of long-term all-cause mortality compared to men. Competing-risks analysis showed no significant gender differences in age-adjusted risk of cardiovascular death nor of cancer death. In both genders, the annual risk of cardiovascular death was low after 1 year, but exceeded annual risk of cancer death throughout follow-up.

CONCLUSION

During long-term follow-up, women with STEMI had similar and women with NSTEMI lower adjusted risk of all-cause mortality compared to men. Age-adjusted risk of death due to cardiovascular disease was similar in both genders and higher than risk of death due to cancer throughout the follow-up period.

Impact of Sex and Contact-to-Device Time on Clinical Outcomes in Acute ST-Segment Elevation Myocardial Infarction-Findings From the National Cardiovascular Data Registry

Background

Emergent myocardial reperfusion via primary percutaneous coronary intervention is optimal care for patients presenting with ST‐segment elevation myocardial infarction (STEMI). Delays in such interventions are associated with increases in mortality. With the shift in focus to contact‐to‐device (C2D) time as a new perfusion metric, this study was designed to examine how sex affects C2D time and mortality in STEMI patients.

Methods and Results

Clinical data on male and female STEMI patients were extracted and analyzed from the National Cardiovascular Data Registry from July 1, 2008 to December 31, 2014. A total of 102 515 patients were included in the final analytic cohort. The median C2D time in female patients with STEMI was delayed when compared to male patients (80 [65–97] versus 75 [61–90] minutes; P<0.001). The unadjusted mortality was higher in female patients when compared to male patients with STEMI (4.1% versus 2.0%; P<0.001). For every 5‐minute increase in C2D time, the adjusted odds ratio for mortality was 1.04 (95% CI, 1.03–1.06) for female patients with STEMI and 1.07 (95% CI, 1.06–1.09) for male patients (P for sex by C2D interaction=0.003).

Conclusions

To date, this is the largest analysis of STEMI patients that measures the impact of the new recommended C2D reperfusion metric on in‐hospital mortality. Female STEMI patients have longer C2D times and increased mortality. The disparity can be improved and survival can increase in this high‐risk patient cohort by decreasing systems issues that cause increased reperfusion times in female STEMI patients.