Short and long-term mortality in women and men undergoing primary angioplasty: A comprehensive meta-analysis

Sex Differences and Clinical Outcomes in Patients With Myocardial Infarction With Nonobstructive Coronary Arteries: A Meta-Analysis

BACKGROUND

Although myocardial infarction with nonobstructive coronary arteries (MINOCA) is more common in women, it is unknown whether sex is a risk factor for adverse outcomes in patients with MINOCA. We aimed to investigate the relationship between sex differences and outcomes of patients with MINOCA.

METHODS AND RESULTS

A systematic literature search was performed in PubMed, Embase, and Cochrane databases from their inception until August 2023 for relevant studies. End points were pooled using the Hartung-Knapp-Sidik-Jonkman random-effects model as odds ratio (OR) with 95% CIs. Nine studies, involving 30 281 patients with MINOCA (comprising 18 079 women and 12 202 men), were included in the study. Women were older and had a higher prevalence of hypertension, diabetes, and stroke compared with men. The median duration of follow-up was 3.5 years, with an interquartile range of 2.2 to 4.2 years. Pooled analysis revealed no statistically significant difference in the risk of all-cause mortality (OR, 1.03 [95% CI, 0.87-1.22]), major adverse cardiovascular events (OR, 1.18 [95% CI, 0.89-1.58]), heart failure (OR, 1.32 [95% CI, 0.57-3.03]), stroke (OR, 1.13 [95% CI, 0.56-2.26]), and myocardial infarction (OR, 1.04 [95% CI, 0.29-3.76]) between the 2 groups. Regarding short-term outcomes, women had a significantly higher risk of in-hospital major adverse cardiovascular events compared with men (OR, 1.33 [95% CI, 1.16-1.53]) whereas there was no significant difference in the risk of in-hospital mortality (OR, 0.90 [95% CI, 0.64-1.28]) between the 2 patient groups.

CONCLUSIONS

Despite the differences in demographics and comorbidity profiles, there was no significant difference in the long-term outcomes for patients with MINOCA between sexes. However, it is noteworthy that women experienced a higher risk of in-hospital major adverse cardiovascular events compared with men.

Long term all-cause mortality after myocardial infarction with non-obstructed vs obstructed coronary artery disease: a meta-analysis of adjusted data

BACKGROUND

The difference in the long-term outcomes of myocardial infarction in patients with non-obstructed coronary arteries (MINOCA) and patients with myocardial infarction with obstructed coronary artery disease (MI-CAD) is not clear. The current study aimed to pool adjusted data to compare long-term outcomes of MINOCA vs MI-CAD.

METHODS

Electronic literature search of PubMed, Embase, CENTRAL, and Google Scholar databases was done for publications up to 18th June 2023. Only studies reporting multivariable-adjusted data with > 1 year of follow-up were included.

RESULTS

Sixteen studies met the inclusion criteria. Our meta-analysis revealed no statistically significant difference in the risk of all-cause mortality between MINOCA and MI-CAD patients (HR: 0.90 95% CI 0.68, 1.19 I2 = 94% p = 0.48). Analysis of the limited data showed a reduced combined risk of all-cause mortality and MI (HR: 0.54 95% CI 0.39, 0.76 I2 = 72% p = 0.003) and major adverse cardiac events (MACE) (HR: 0.66 95% CI 0.51, 0.84 I2 = 51% p = 0.0009) in patients with MINOCA vs MI-CAD, and no difference in the risk of cardiovascular mortality (HR: 0.81 95% CI 0.54, 1.22 I2 = 0% p = 0.31) and readmission between the two groups (HR: 0.85 95% CI 0.61, 1.19 I2 = 90% p = 0.35).

CONCLUSION

A pooled analysis of adjusted outcomes from the available studies indicated that MINOCA and MI-CAD patients have similar long-term all-cause mortality risk. Our conclusions on the risk of cardiovascular mortality, MACE and readmission rates need to be taken with caution due to a lack of adequate studies. Further research is needed to strengthen the evidence on this important subject.

LDL-cholesterol target levels achievement in high-risk patients: An (un)expected gender bias

BACKGROUND AND AIMS

Lowering low-density lipoprotein cholesterol (LDL-C) is the cornerstone of cardiovascular disease prevention. Collection of epidemiological data is crucial for monitoring healthcare appropriateness. This analysis aimed to evaluate the proportion of high-risk patients who achieved guidelines recommended LDL-C goal, and explore the predictors of therapeutic failure, with a focus on the role of gender.

METHODS AND RESULTS

Health administrative and laboratory data from seven Local Health Districts in Tuscany were collected for residents aged ≥45 years with a history of major adverse cardiac or cerebrovascular event (MACCE) and/or type 2 diabetes mellitus (T2DM) from January 1, 2019, to January 1, 2021. The study aimed to assess the number of patients with optimal levels of LDL-C (<55 mg/dl for patients with MACCE and <70 mg/dl for patients with T2DM without MACCE). A cohort of 174 200 individuals (55% males) was analyzed and it was found that 11.6% of them achieved the target LDL-C levels. Female gender was identified as an independent predictor of LDL-C target underattainment in patients with MACCE with or without T2DM, after adjusting for age, cardiovascular risk factors, comorbidities, and district area (adjusted-IRR 0.58 ± 0.01; p < 0.001). This result was consistent in subjects without lipid-lowering therapies (adjusted-IRR 0.56 ± 0.01; p < 0.001).

CONCLUSION

In an unselected cohort of high-risk individuals, females have a significantly lower probability of reaching LDL-C recommended targets. These results emphasize the need for action to implement education for clinicians and patients and to establish clinical care pathways for high-risk patients, with a special focus on women.

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

Sex Disparities in Prehospital Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest in South Korea

OBJECTIVE

Sex disparities have been reported in the prehospital and in-hospital care among patients with out-of-hospital cardiac arrest (OHCA). The aim of this study was to investigate the association between sex and prehospital advanced cardiac life support (ACLS) interventions provided by emergency medical services (EMS).

METHODS

This was a cross-sectional observational study using a nationwide OHCA registry in South Korea. The study included adult OHCAs with presumed cardiac etiology from January 2016 to December 2019. The main exposure was the sex of the victim, and the primary outcomes were prehospital ACLS interventions, including advanced airway management (AAM), intravenous access (IV), and epinephrine (EPI) administration. Multivariable logistic regression analysis accounted for age group, health insurance, comorbidities, place of arrest, urbanization level, witness status, bystander CPR and initial rhythm was performed to calculate adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs).

RESULTS

Among 71,154 eligible patients, females with OHCA received less prehospital ACLS interventions than males: risk difference, (95% CIs) -2.76 (-3.41;-2.11) for AAM, -6.03 (-6.79;-5.27) for IV, and -3.81 (-4.37;-3.25) for EPI. In multivariable logistic regression analysis, female sex was significantly associated with a lower probability of prehospital ACLS provision: AOR, (95% CIs) 0.87 (0.84-0.91) for AAM, 0.85 (0.82-0.88) for IV, and 0.81 (0.77-0.84) for EPI.

CONCLUSION

Compared to male patients, female patients were less likely to receive prehospital ACLS. This offers opportunities for EMS systems to reduce disparities and to improve compliance with OHCA resuscitation guidelines and outcomes through quality improvement and educational interventions.

Gender Differences in Treatment Delays, Management and Mortality among Patients with Acute Coronary Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

We aimed to provide a comprehensive overview of existing gender differences in acute coronary syndrome (ACS), with respect to treatment delays, invasive management of ACS, and short and long-term mortality in patients with ACS.

METHODS

We defined 37 observational studies (OSs) and 21 randomized trials (RCTs) that best corresponded to our interests. OSs and RCTs were analyzed separately.

RESULTS

Women with ACS more often experienced delays in treatment compared to men (OR 1.43; 95% CI, 1.12-1.82) in RCTs. Female patients were less often treated invasively: RCTs (OR 0.87; 95% CI, 0.83-0.9), OSs: (OR 0.66; 95% CI, 0.63-0.68). Women had higher crude in-hospital mortality (OR 1.56; 95% CI, 1.53-1.59) and 30-day mortality (OR 1.71; 95% CI, 1.22-2.4) in OSs and (OR 2.74; 95% CI, 2.48-3.02) in RCTs. After adjustment for multiple covariates, gender difference was attenuated: in-hospital mortality (OR 1.19; 95% CI, 1.17-1.2), 30-day mortality (OR 1.18; 95% CI, 1.12-1.24) in OSs. Unadjusted long-term mortality in women was higher than in men (OR 1.41; 95% CI, 1.31-1.52) in RCTs and (OR 1.4; 95% CI, 1.3-1.5) in OSs.

CONCLUSION

Women with ACS experience a delay in time to treatment more often than men. They are also less likely to be treated invasively. Females have shown worse crude short-and long-term all-cause mortality compared to males. However, after adjustment for multiple covariates, a less significant gender difference has been observed. Considering the difference between crude and adjusted mortality, we deem it reasonable to conduct further investigations on gender-related influence of particular risk factors on the outcomes of ACS.

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.

Contemporary sex differences in mortality among patients with ST-segment elevation myocardial infarction: a systematic review and meta-analysis

OBJECTIVES

To assess the effect of sex differences on short-term and long-term mortality among patients with ST-segment elevation myocardial infarction (STEMI).

DESIGN

Systematic review and meta-analysis of contemporary available evidence.

SETTING

PubMed, Embase and Cochrane Library were searched for relevant studies reporting sex-specific outcomes among patients with STEMI published between 1 January 2010 and 1 August 2020. Risk ratios (RRs) and 95% CIs were measured using DerSimonian and Laird random-effects model. Sensitivity analyses were performed and publication bias was also checked. All statistical analyses were performed using STATA V.15.0.

PARTICIPANTS

Studies providing data about short-term or long-term mortality stratified by sex in patients with STEMI were included. Only study conducted in last 10 years were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause death at short-term (in-hospital or 30 days) and long-term (at least 12 months) follow-up.

RESULTS

A total of 15 studies involving 128 585 patients (31 706 (24.7%) female and 96 879 (75.3%) male) were included. In the unadjusted analyses, female were at a higher risk of short-term mortality (RR, 1.73; 95% CI 1.53 to 1.96, p<0.001, I²=77%) but not long-term mortality (RR, 1.23; 95% CI 0.89 to 1.69, p=0.206, I²=77.5%). When adjusted effect estimates from individual studies were used in meta-analysis, the association between female and higher risk of short-term mortality remained significant (RR, 1.24; 95% CI 1.11 to 1.38, p<0.001, I²=39.6%). And adjusted long-term mortality was also similar between female and male (RR, 1.11; 95% CI 0.42 to 1.80, p=0.670, I²=74.5%).

CONCLUSIONS

An increased short-term but not long-term mortality was found in female with STEMI. After adjustment for baseline cardiovascular risk factors and clinical profiles, short-term mortality remains higher in female with STEMI compared with male, indicating the need for further improvements in management in female patients.

Metabolic syndrome and myocardial infarction in women

Metabolic syndrome (MetS) represents a cluster of metabolic disorders that arise from insulin resistance (IR) and adipose tissue dysfunction. As a consequence, there is an increased risk for type 2 diabetes mellitus and atherosclerotic cardiovascular disease (CVD). MetS is associated with a 2-fold increase in cardiovascular outcomes. Earlier population analyses showed a lower prevalence of MetS in women (23.9%) in comparison to men (27.8%), while later analyses suggested significantly reduced difference due to an increase in prevalence in women aged between 20 and 39. However, the prevalence of MetS in specific populations of women, such as in women with polycystic ovary syndrome, ranges from 16% to almost 50% in some geographic regions. Abdominal fat accumulation and IR syndrome are recognized as the most important factors in the pathogenesis of MetS. After menopause, a decline in insulin sensitivity corresponds to an increase in fat mass, circulating fatty acids, low-density lipoproteins, and triglycerides. Prevalence of MetS in acute coronary syndrome (ACS) is significantly more present in women (55.9%-66.3%) than in men (40.2%-47.3%) in different cohorts. Younger women with ACS had a higher mortality rate than younger men. Acute myocardial infarction (AMI) remains a leading cause of death in aging women. Women with AMI have significantly higher rates of prior congestive heart failure, hypertension history, and diabetes. The role of androgens in CVD pathogenesis in women has not yet been clarified. The current review aims to give an insight into the role of MetS components and inflammation for the development of atherosclerosis, CVD, and AMI in women.

Impact of regionalizing ST-elevation myocardial infarction care on sex differences in reperfusion times and clinical outcomes

BACKGROUND

Women with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention historically experience worse in-hospital outcomes compared to men.

HYPOTHESIS

Implementation of a regional STEMI system will reduce care gaps in reperfusion times and in-hospital outcomes between women and men.

METHODS

1928 patients (413 women, 21.4%) presented with an acute STEMI between June 2007 and March 2016. The population was divided into an early cohort (n = 728 patients, 2007-May 2011), and a late cohort (n = 1200 patients, June 2011-2016). The primary endpoints evaluated were reperfusion times and in-hospital outcomes.

RESULTS

Compared to men, women experienced significant delays in first medical contact (FMC) to arrival at the emergency room (26.0 vs. 22.0 min, p < 0.001) and FMC-to-device (109 vs. 101 min p = 0.001). Women had higher incidences of post-PCI heart failure and death compared to men (p < 0.05). Following multivariable adjustment, no mortality difference was observed for women versus men (adjusted OR; 0.82; 95% confidence interval [CI], 0.51-1.34; p = 0.433) or for early versus late cohorts (adjusted OR; 1.04; 95% CI, 0.68-1.60; p = 0.856).

CONCLUSION

Following STEMI regionalization, women continued to experience significantly longer reperfusion times, although there was no difference in adjusted mortality. These results highlight the ongoing disparity of STEMI care between women and men, and suggest that regionalization alone is insufficient to close sex-based care gaps.

Sex-disparities in risk factors and atherosclerosis cardiovascular disease in diabetic patients

Objective: The current study was to evaluate risk factors and atherosclerotic cardiovascular disease (ASCVD) among diabetic patients by sex.Methods: Patients with type 2 diabetes mellitus were enrolled, and baseline characteristics and prevalent ASCVD (including coronary heart disease [CHD], ischemic stroke [IS], and peripheral vascular disease [PVD]) were collected and compared by sex.Results: Females accounted for 48.5% (n = 284) of the current study. Compared to males, females had a longer duration of diabetes mellitus (9.1 ± 4.0 vs 8.0 ± 3.7 years), and were more likely to be obese (38% vs 34.4%), have hypertension (49.3% vs 45.7%) and have a lower estimated glomerular filtration rate (75.0 ± 20.6 vs 77.4 ± 19.2 ml/min/1.73 m²). Females were less likely to smoke (2.8% vs 31.1%), and receive anti-platelets (53.5% vs 56%), angiotensin converting enzyme inhibitor/angiotensin receptor blocker (31.7% vs 35.1%), and metformin (81.7% vs 85.4%). Females had a higher prevalence of CHD (9.9% vs 8.6%) and composite ASCVD (21.8% vs 18.9%). After adjustment for potential covariates, female sex remained independently associated with composite ASCVD (odds ratio [OR]: 1.21 and 95% confidence interval [CI]: 1.05-1.57) and CHD (OR: 1.13 and 95% CI: 1.01-1.38).Conclusion: Among diabetic people, compared to males, females had a higher comorbid burden but received less optimal treatment, which might partly explain their higher prevalence of composite ASCVD and CHD.

Sex Differences in the Incidence and Outcomes of Acute Myocardial Infarction in Spain, 2016-2018: A Matched-Pair Analysis

(1) Background: Our aim was to analyze the incidence, procedures, and in-hospital outcomes of myocardial infarction (MI) in Spain (2016-2018) according to sex. (2) Methods: We estimated the incidence of an ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) according to sex using the Spanish National Hospital Discharge Database. A matched-pair analysis was used. (3) Results: MI was coded in 156,826 patients aged ≥18 years (111,842 men and 44,984 women). Men showed higher incidence rates (205.0 vs. 77.8 per 100,000; p < 0.001; IRR = 2.81(95%CI:2.78-2.84)). After matching, the use of coronary artery by-pass grafting (CABG) (1.0% vs. 0.7%; p < 0.001) and percutaneous coronary intervention (PCI) (57.8% vs. 52.3%; p < 0.001) was higher among men with an STEMI, whereas the in-hospital mortality (IHM) remained higher among women (11.2% vs. 10.1%; p < 0.001). Likewise, CABG (1.9% vs. 3.3%; p < 0.001) and PCI (33.8% vs. 41.9%; p < 0.001) were less often used among women with an NSTEMI, but no sex-related differences were found in IHM. After adjusting for confounders, IHM was more than twofold higher for both men and women with an STEMI than those with an NSTEMI. Women with an STEMI had a 21% higher mortality risk than men (OR = 1.21(95%CI:1.13-1.29). (4) Conclusion: Men had higher incidence rates of MI than women. Women underwent invasive procedures less often and had a higher IHM when admitted for an STEMI.

Predictors of Microvascular Reperfusion After Myocardial Infarction

Purpose of Review

In acute ST-segment elevation myocardial infarction (STEMI), successful restoration of blood flow in the infarct-related coronary artery may not secure effective myocardial reperfusion. The mortality and morbidity associated with acute MI remain significant. Microvascular obstruction (MVO) represents failed microvascular reperfusion. MVO is under-recognized, independently associated with adverse cardiac prognosis and represents an unmet therapeutic need.

Recent Findings

Multiple factors including clinical presentation, patient characteristics, biochemical markers, and imaging parameters are associated with MVO after MI.

Summary

Impaired microvascular reperfusion is common following percutaneous coronary intervention (PCI). New knowledge about disease mechanisms underpins precision medicine with individualized risk assessment, investigation, and stratified therapy. To date, there are no evidence-based therapies to prevent or treat MVO post-MI. Identifying novel therapy for MVO is the next frontier.

Sex Differences in Ischemic and Bleeding Outcomes in Patients With Non-ST-Segment-Elevation Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: Insights From the TAO Trial

BACKGROUND

Previous studies have observed poorer outcomes in females with myocardial infarction, but older age and lower use of percutaneous coronary intervention in females are factors that potentially explain the worse outcome. This study sought to determine if female sex is an independent factor of ischemic and bleeding outcomes in non-ST-segment-elevation acute coronary syndrome treated with a systematic invasive approach.

METHODS

The TAO trial (Treatment of Acute Coronary Syndrome With Otamixaban) randomized patients with non-ST-segment-elevation acute coronary syndrome treated invasively to heparin plus eptifibatide versus otamixaban. In this post hoc analysis, the primary ischemic end point (all-cause death, myocardial infarction within 180 days) and the primary safety end point (Thrombolysis in Myocardial Infarction major or minor bleeding within 30 days) were analyzed according to sex.

RESULTS

Of 13 229 randomized patients, 3980 (30.1%) were females and 9249 (69.9%) were males. Females were older (64.8±11.0 versus 60.7±11.1 years), had more comorbidities, received less peri-procedural antithrombotic therapy, and underwent less frequently revascularization. Overall, females experienced a higher risk of ischemic (10.2% versus 9.1%; odds ratio [OR], 1.15 [1.01-1.30]) and bleeding events (4.2% versus 3.4%; OR, 1.23 [1.02-1.49]) than males. After multivariate analysis, the risk of ischemic outcomes (OR, 1.04 [0.90-1.19]), death (OR, 1.00 [0.75-1.23]), or bleeding (OR, 1.05 [0.85-1.28]), were similar between females and males. Only, noncoronary artery bypass graft related Thrombolysis in Myocardial Infarction major bleeding were increased in females (OR, 1.69 [1.11-2.56]).

CONCLUSIONS

In patients with non-ST-segment-elevation acute coronary syndrome with systematic invasive management, ischemic outcomes, bleeding events, and mortality were higher in females. After multivariate analyses, female sex was not an independent predictor of ischemic and bleeding events although noncoronary artery bypass graft related Thrombolysis in Myocardial Infarction major bleeding was higher in females. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01076764.

Evaluation of sex differences in patients with ST-elevated myocardial infarction: an observational cohort study in Amsterdam and surrounding region

Introduction

Women with ST-elevation myocardial infarction (STEMI) present with different symptoms compared to men. This can result in delays in diagnosis and in the timely treatment of women. The aim of this study is to examine these differences, including the short- and long-term mortality in women and men.

Methods

This quality registry study included all patients with STEMI who received primary percutaneous coronary intervention in 2015 or 2016 in Amsterdam and the surrounding region.

Results

Three PCI centres and the Emergency Medical Service in Amsterdam participated. In total, 558 men (71%) and 229 women (29%) were included. Women were on average 7 years older than men (68 vs 61 years, p < 0.001), and suffered more often from hypertension (46% vs 34%, p = 0.002) and monovascular disease (69% vs 57%, p = 0.002). A higher percentage of men were current smokers (41% vs 49%, p = 0.043). Patient delay, system delay and overall ischaemic times were similar in both women and men (medians: 51, 94 and 157 min, respectively). Initiation of treatment was achieved within 90 min after STEMI diagnosis in 85% of patients (87% in women, 85% in men). Thirty-day and 1‑year mortality adjusted hazard ratio for women versus men was 1.60 (95% CI 0.9–3.0) and 1.24 (95% CI 0.8–2.0), respectively.

Discussion

Recognition of cardiac complaints remains challenging for patients. In the Amsterdam region, time delays and mortality were not significantly different between men and women presenting with STEMI. These results are in contrast to findings in similar registries. This suggests that implementation of current knowledge and national campaigns are effective in increasing awareness of the signs and symptoms suggestive of myocardial infarction.

Sex-Based Differences in Characteristics and In-Hospital Outcomes among Patients With Diagnosed Acute Myocarditis

Data are scarce regarding sex differences among patients with acute myocarditis (AM). Our aim was to define the sex differences in clinical characteristics as well as in-hospital outcomes in a cohort of consecutive patients hospitalized due to AM. We analyzed data of 322 consecutive patients from January 2005 to December 2017 who were hospitalized with the diagnosis of AM. Eighty-four percent (N = 272) of the patients were males. When compared to females, male patients were younger (36 ± 14 vs 45 ± 17 years, p <0.001), more likely to present with ST segment elevation (75% vs 44%. p <0.001) as well as PR depression upon ECG, and have higher admission troponin levels (7.6 ± 11 vs 2.3 ± 4 µg/L, p <0.001). Moreover, males were more likely to have late gadolinium enhancement upon cardiac magnetic resonance. While male patients were more likely to have ventricular arrhythmias during hospitalization (7% vs 0%, p = 0.05), there were no differences in the incidence of in-hospital mortality or the need for escalation therapy during hospitalization between both groups. There were no episodes of mortality upon all patients among a follow-up of 1 year. In conclusion, male patients, which constitute the majority of patients admitted with AM were younger, more likely to present with ST elevation, had higher troponin levels at admission, and had a higher rate of ventricular arrhythmias compared to females. There were no differences in post-discharge mortality rates between males and females.

Sex-Specific Treatment Effects After Primary Percutaneous Intervention: A Study on Coronary Blood Flow and Delay to Hospital Presentation

Background We hypothesized that female sex is a treatment effect modifier of blood flow and related 30-day mortality after primary percutaneous coronary intervention ( PCI ) for ST -segment-elevation myocardial infarction and that the magnitude of the effect on outcomes differs depending on delay to hospital presentation. Methods and Results We identified 2596 patients enrolled in the ISACS - TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry from 2010 to 2016. Primary outcome was the occurrence of 30-day mortality. Key secondary outcome was the rate of suboptimal post- PCI Thrombolysis in Myocardial Infarction ( TIMI ; flow grade 0-2). Multivariate logistic regression and inverse probability of treatment weighted models were adjusted for baseline clinical covariates. We characterized patient outcomes associated with a delay from symptom onset to hospital presentation of ≤120 minutes. In multivariable regression models, female sex was associated with postprocedural TIMI flow grade 0 to 2 (odds ratio [ OR ], 1.68; 95% CI , 1.15-2.44) and higher mortality ( OR, 1.72; 95% CI , 1.02-2.90). Using inverse probability of treatment weighting, 30-day mortality was higher in women compared with men (4.8% versus 2.5%; OR , 2.00; 95% CI , 1.27-3.15). Likewise, we found a significant sex difference in post- PCI TIMI flow grade 0 to 2 (8.8% versus 5.0%; OR , 1.83; 95% CI , 1.31-2.56). The sex gap in mortality was no longer significant for patients having hospital presentation of ≤120 minutes ( OR , 1.28; 95% CI , 0.35-4.69). Sex difference in post- PCI TIMI flow grade was consistent regardless of time to hospital presentation. Conclusions Delay to hospital presentation and suboptimal post- PCI TIMI flow grade are variables independently associated with excess mortality in women, suggesting complementary mechanisms of reduced survival. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01218776.

Age-Related Sex Differences in Clinical Presentation, Management, and Outcomes in ST-Segment-Elevation Myocardial Infarction: Pooled Analysis of 15 532 Patients From 7 Arabian Gulf Registries

Background No studies from the Arabian Gulf region have taken age into account when examining sex differences in ST-segment-elevation myocardial infarction (STEMI) presentation and outcomes. We examined the relationship between sex differences and presenting characteristics, revascularization procedures, and in-hospital mortality after accounting for age in patients hospitalized with STEMI in the Arabian Gulf region from 2005 to 2017. Methods and Results This study was a pooled analysis of 31 620 patients with a diagnosis of acute coronary syndrome enrolled in 7 Arabian Gulf registries. Of these, 15 532 patients aged ≥18 years were hospitalized with a primary diagnosis of STEMI. A multiple variable regression model was used to assess sex differences in revascularization, in-hospital mortality, and 1-year mortality. Odds ratios and 95% CIs were calculated. Women were, on average, 8.5 years older than men (mean age: 61.7 versus 53.2 years; absolute standard mean difference: 68.9%). The age-stratified analysis showed that younger women (aged <65 years) with STEMI were more likely to seek acute medical care and were less likely to receive thrombolytic therapies or primary percutaneous coronary intervention and guideline-recommended pharmacotherapy than men. Women had higher crude in-hospital mortality than men, driven mainly by younger age (46-55 years, odds ratio: 2.60 [95% CI, 1.80-3.7]; P<0.001; 56-65 years, odds ratio: 2.32 [95% CI, 1.75-3.08]; P<0.001; and 66-75 years, odds ratio: 1.79 [95% CI, 1.33-2.41]; P<0.001). Younger women had higher adjusted in-hospital and 1-year mortality rates than younger men (P<0.001). Conclusions Younger women (aged ≤65 years) with STEMI were less likely to receive guideline-recommended pharmacotherapy and revascularization than younger men during hospitalization and had higher in-hospital and 1-year mortality rates.

Coronary artery disease and acute coronary syndrome in women

There are important dissimilarities in clinical presentation, aggregation of comorbidities, cardiovascular risk factors and the quality of delivery of medical care among men and women with acute coronary syndrome (ACS). Compared with men, despite the well-known older age and more pronounced frailty, women with ACS present later from symptom onset and are at high bleeding risk after invasive procedures. In addition, autoimmune/inflammatory disease, fibromuscular dysplasia, polycystic ovary, early menopause and history of pre-eclampsia are risk factors preceding ACS among younger women. They more often experience myocardial infarction in the absence of obstructive coronary arteries (MINOCA), which makes diagnosis and treatment of ACS among women more challenging compared with men. Women and men do both benefit from guideline-recommended treatment, although, compared with men, women with ACS have a higher adjusted risk of early death, which equalises between both sexes within the first year. Young women with ACS suffer frequently of depression and present often with MINOCA. Compared with young men, they (young women) have a higher risk of death. Therefore, focusing on young patients with ACS, understanding the particular physiopathology of MINOCA and developing programmes targeting comorbidities and depression-related behavioural risk factors are urgently needed.

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.

Sex-Related Differences in In-Hospital Mortality in Japanese ST-Elevation Acute Myocardial Infarction Patients Presenting to Hospital in the 24 Hours After Symptom Onset - Results From K-ACTIVE

Background: Despite the drastic advances in clinical care for patients with acute ST-elevation myocardial infarction (STEMI), female STEMI patients have higher in-hospital mortality rates than male patients. This study assessed the influence of sex on in-hospital mortality in STEMI patients in Kanagawa Prefecture, Japan.

Methods and Results: From October 2015 to June 2018, 2,491 consecutive STEMI patients (23.9% female) who presented to hospital in the 24 h after symptom onset were analyzed. The female patients were 9 years older and less frequently had diabetes, smoking and prior MI than male patients. Pre-hospital managements, including prehospital 12-lead electrocardiography, and symptom-to-door time were similar between the sexes. A door-to-device time ≤90 min was achieved in 61.3% of female cases and in 65.0% of male cases (P=0.13). Reperfusion therapy was provided to 94.6% of female and 97.6% of male patients (P<0.001). In-hospital mortality rate was not significantly different between female and male patients (6.6% vs. 7.8%, P=0.37). On multivariate logistic regression analysis, female sex itself was not associated with in-hospital mortality (OR, 1.52; 95% CI: 0.67–3.47, P=0.32).

Conclusions: There was no sex discrepancy in the in-hospital mortality of STEMI patients in this study. Guideline-based treatment, such as advanced pre-hospital management and a high use of reperfusion therapy might have attenuated the sex-related differences in the in-hospital mortality.

Sex differences in the treatment and outcomes of patients hospitalized with ST-elevation myocardial infarction

OBJECTIVES

To compare mortality for women and men hospitalized with ST-elevation myocardial infarction (STEMI) by age and revascularization status.

BACKGROUND

There is little information on the mortality of men and women not undergoing revascularization, and the impact of age on relative male-female mortality needs to be revisited.

METHODS AND RESULTS

An observational database of 23,809 patients with STEMI presenting at nonfederal New York State hospitals between 2013 and 2015 was used to compare risk-adjusted inhospital/30-day mortality for women and men and to explore the impact of age on those differences. Women had significantly higher mortality than men overall (adjusted odds ratio [AOR] = 1.15, 95% CI [1.04, 1.28]), and among patients aged 65 and older. Women had lower revascularization rates in general (AOR = 0.64 [0.59, 0.69]) and for all age groups. Among revascularized STEMI patients, women overall (AOR = 1.30 [1.10, 1.53]) and over 65 had higher mortality than men. Among patients not revascularized, women between the ages of 45 and 64 had lower mortality (AOR = 0.68 [0.48, 0.97]).

CONCLUSIONS

Women with STEMI, and especially older women, had higher inhospital/30-day mortality rates than their male counterparts. Women had higher mortality among revascularized patients, but not among patients who were not revascularized.

Up to 15-Year Survival of Men and Women after Percutaneous Coronary Intervention Paid by the Brazilian Public Healthcare System in the State of Rio de Janeiro, 1999-2010

Background

Percutaneous coronary intervention (PCI) is the most frequently used invasive therapy for ischemic heart disease (IHD). Studies able to provide information about PCI's effectiveness should be conducted in a population of real-world patients.

Objectives

To assess the survival rate of IHD patients treated with PCI in the state of Rio de Janeiro (RJ).

Methods

Administrative (1999-2010) and death (1999-2014) databases of dwellers aged ≥ 20 years old in the state of RJ submitted to one single PCI paid by the Brazilian public healthcare system (SUS) between 1999 and 2010 were linked. Patients were grouped as follows: 20-49 years old, 50-69 years old and ≥ 70 years old, and PCI in primary PCI, with stent and without stent placement (bare metal stent). Survival probabilities in 30 days, one year and 15 years were estimated by using the Kaplan-Meier method. Cox hazards regression models were used to compare risks among sex, age groups and types of PCI. Test results with a p-value < 0.05 were deemed statistically significant.

Results

Data of 19,263 patients (61 ± 11 years old, 63.6% men) were analyzed. Survival rates of men vs. women in 30 days, one year and 15 years were: 97.3% (97.0-97.6%) vs. 97.1% (96.6-97.4%), 93.6% (93.2-94.1%) vs. 93.4% (92.8-94.0%), and 55.7% (54.0-57.4%) vs. 58.1% (55.8-60.3%), respectively. The oldest age group was associated with lower survival rates in all periods. PCI with stent placement had higher survival rates than those without stent placement during a two-year follow-up. After that, both procedures had similar survival rates (HR 0.91, 95% CI 0.82-1.00).

Conclusions

In a population of real-world patients, women had a higher survival rate than men within 15 years after PCI. Moreover, using a bare-metal stent failed to improve survival rates after a two-year follow-up compared to simple balloon angioplasty.

Gender-Related Particularities in Acute Myocardial Infarction – a Study on a Patient Cohort from North East Romania

Introduction: Cardiovascular disease is the leading cause of death among women irrespective of race or ethnicity, and about half of these deaths are caused by coronary artery disease. Several studies have reported that cardiovascular diseases manifest themself with a delay of about 7–10 years in women and that they have higher in-hospital mortality. It has not yet been established whether female gender itself, through biological and sociocultural differences, represents a risk factor for early in-hospital mortality in ST-segment elevation acute myocardial infarction (STEMI). The aim of our study was to identify the angiographic particularities in women with STEMI from North East Romania.

Material and Methods: For one year, 207 (31.7%) women and 445 (68.3%) men diagnosed with acute myocardial infarction were hospitalized in the Cardiology Clinic of the “Prof. Dr. George I. M. Georgescu” Institute of Cardiovascular Diseases in Iași, Romania.

Results: The highest incidence of symptom onset was between 6:00 a.m. and 12:00 a.m., this morning polarization being more obvious in women. Within the first two hours of admission to the hospital, coronary angiography was performed in 78.1% of men and only 67.3% of women, the difference being statistically significant (p <0.05). We found that a large number of women had multivascular coronary disease (47.9% vs. 42.3%). At the same time, we found that left main disease and multivascular disease were more frequent in women than in men (3.8% vs. 0.7%, p = 0.001 for left main plus two-vessel disease, and 19.4% vs. 14.8%, p = 0.0005 for three-vessel disease).

Conclusions: In women, coronary events began more frequently in the morning, with atypical symptoms; also, fewer women presented to the hospital within the first 12 hours after the onset of the acute event. Compared to men, women from North East Romania present a higher incidence of multivascular atherosclerotic coronary lessions, indicating a higher severity of STEMI in the female population from this geographical area.

Gender difference in clinical outcomes of the patients with coronary artery disease after percutaneous coronary intervention: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Previous researches have reported the controversial results regarding the gender difference in clinical outcomes of patients with coronary artery disease after percutaneous coronary intervention. Hence, this systematic review and meta-analysis was designed to investigate whether gender difference existed in patients with coronary artery disease after percutaneous coronary intervention.

METHODS

PubMed, Embase, and the Cochrane Library database were searched up to February 10, 2018. Studies comparing the gender-specific effect on clinical outcomes of patients with coronary artery disease after percutaneous coronary intervention were identified, to analyze mortality, major adverse cardiovascular events (MACE) and revascularization. Statistical software RevMan was utilized in this meta-analysis.

RESULTS

A total of 49 studies, involving 1,032,828 patients (774,115 males and 258,713 females) reporting gender-specific outcomes, were included in this study. The in-hospital mortality, 30-day mortality, 1-year mortality, and at least 2-years mortality in male patients with coronary artery disease after percutaneous coronary intervention were significantly lower than those of females (odds ratio [OR] 0.58 95% confidence interval [CI] 0.52-0.63, P < .001; OR 0.64, 95% CI 0.61-0.66, P = .04; OR 0.67, 95% CI 0.60-0.75, P < .001 and OR 0.71, 95% CI 0.63-0.79, P = .005, respectively). The MACE was significantly decreased in male subjects after initial percutaneous coronary intervention compared with females in <1-year or at least 1-year (OR 0.67, 95% CI 0.56-0.80, P < .001 and OR 0.84, 95% CI 0.76-0.93, P < .001). The male patients after percutaneous coronary intervention harbored higher rate of revascularization compared with females for at least 1-year (OR 1.17, 95% CI 1.00-1.36, P < .001), while the rate of revascularization in male patients for < 1-year was lower than that of females (OR 0.93, 95% CI 0.69-1.26, P < .001).

CONCLUSIONS

The systematic review and meta-analysis suggests that the prognosis of male patients with coronary artery disease after percutaneous coronary intervention is better than that of females, except for long-term revascularization.

Gender is Not a Predictor of Mortality or Major Adverse Cardiovascular Events in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes

BACKGROUND

Historically, studies of percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) have reported worse outcomes for women. We sought to determine if contemporary PCI techniques eliminate gender differences in PCI outcomes.

METHODS

This was a retrospective study of 4,776 consecutive patients who underwent PCI for acute coronary syndromes between January 2008 and July 2015. Primary outcomes studied were major adverse cardiovascular events (MACE) and death at 1year.

RESULTS

Percutaneous coronary intervention success was similar in men and women (97.8% v 97.7%, p=0.76). There was no significant gender difference in the number of vessels attempted (1.14 vs 1.12, p=0.25), mean number of lesions treated (1.34 vs 1.32, p=0.21) or the mean number of stents used (1.32 vs 1.30, p=0.31). There was equivalent use of drug eluting stents (38.2% vs 38.3%, p=0.94). Women with ST-elevation myocardial infarction STEMI had longer median symptom-to-door time (111 vs 90 mins, p=0.0411) but there was no gender difference in door-to-balloon time or symptom-to-balloon time. There was no significant difference in percentages of women and men <75years treated with prasugrel or ticagrelor (11.1% vs 13.4%, p=0.092). Unadjusted 1-year mortality was 6.4% for women and 4% for men (p=0.0012), but on multivariate analysis, female sex was not a predictor of death. There was no significant gender difference in the overall incidence of unadjusted 1-year MACE (11.6% vs 10.8%, p=0.434).

CONCLUSIONS

When contemporary PCI techniques are applied equally to men and women with ACS there is no gender difference in mortality or MACE at 1year.

Impact of gender on short-term and long-term all-cause mortality in patients with non-ST-segment elevation acute coronary syndromes: a meta-analysis

A meta-analysis to determine the impact of gender on mortality in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS): PubMed, EMBASE, and Cochrane Library, was systematically searched. Two investigators independently reviewed retrieved articles and assessed eligibility. Unadjusted mortality rates or adjusted effect estimates regarding gender-specific short-term and long-term all-cause mortality were identified. A total of 30 studies involving 358,827 patients with NSTE-ACS (129, 632 women and 229,195 men) were identified. In the unadjusted analysis, women had significantly higher risk of short-term all-cause mortality (RR 1.37; 95% CI 1.26-1.49; P < 0.00001) and long-term all-cause mortality (RR 1.18; 95% CI 1.07-1.31; P = 0.001) compared with men. However, when a meta-analysis was performed using adjusted effect estimates, the association between women and higher risk of short-term mortality (RR 0.99; 95% CI 0.91-1.07; P = 0.74) and long-term all-cause mortality (RR 0.84; 95% CI 0.68-1.03; P = 0.09) was markedly attenuated. Adjusted short-term and long-term all-cause mortality appeared similar in women and men. In conclusion, women with NSTE-ACS have higher short-term and long-term mortality compared with men. However, gender differences do not differ following adjustment for baseline cardiovascular risk factors and clinical differences.

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.

Comparison of Outcomes in Men Versus Women After Percutaneous Coronary Intervention for Chronic Total Occlusion

Conflicting evidence exists on gender differences in outcomes after coronary stenting, and gender-based data in patients with chronic total occlusions (CTO) who underwent percutaneous coronary intervention (PCI) are scarce. Consecutive patients who underwent CTO PCI from January 2005 to December 2013 were included in the analysis and stratified according to gender. The primary outcome measure was all-cause mortality. Median follow-up was 2.6 years (interquartile range 1.1 to 3.1). Of 2002 patients, 332 (17%) were women. Procedural success was achieved in 82% and 83% of women and men (p = 0.31). All-cause mortality was 15% and 11% in women and men (log-rank p = 0.17) with an adjusted hazard ratio of 0.85 (95% confidence interval [CI] 0.61 to 1.17, p = 0.31). All-cause mortality was significantly reduced in patients with procedural success, both in women (12% vs 32%, adjusted hazard ratio 0.44, 95% CI 0.24 to 0.79, p = 0.006) and men (9% vs 21%, adjusted hazard ratio 0.64, 95% CI 0.47 to 0.88, p = 0.006), with similar mortality benefits associated with successful revascularization in both groups (interaction p = 0.35). In conclusion, recanalization of coronary arterial CTO is equally successful in both women and men.

Comparison of Outcomes of Women Versus Men With Non-ST-elevation Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention (from the Japanese Nationwide Registry)

Previous studies have reported that women have worse outcomes than men after percutaneous coronary intervention (PCI), especially in patients with ST-elevation myocardial infarction. However, gender-related differences in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) have not been thoroughly investigated. In the Japanese nationwide registry, a total of 43,239 patients with NSTE-ACS from 861 hospitals underwent PCI in 2014. Overall, 11,326 patients (26.2%) were women. The women were older (75.0 ± 10.3 vs 68.7 ± 11.4 years, p <0.001) and had a higher prevalence of hypertension (p <0.001), hyperlipidemia (p = 0.003), and heart failure (p <0.001) compared with men. For inpatient outcomes, women had a higher rate of overall complications (3.3% vs 2.4%, p <0.001) and bleeding complications that required blood transfusion (0.6% vs 0.2%, p <0.001). On multivariate analysis, female gender was an independent predictor of overall (odds ratio [OR] 1.20, 95% CI 1.04 to 1.38; p = 0.011) and bleeding complications (OR 1.94, 95% CI 1.35 to 2.79; p <0.001) after adjustment but was not associated with in-hospital mortality (OR 1.05, 95% CI 0.79 to 1.40; p = 0.747). In conclusion, in patients with NSTE-ACS who underwent PCI, women were at greater risk than men for in-hospital complications, especially in bleeding complications.

Transcatheter Aortic Valve Replacement in Women Versus Men (from the US CoreValve Trials)

Treatment for severe symptomatic aortic stenosis has changed significantly in recent years due to advances in transcatheter aortic valve replacement (TAVR). Recent studies with the CoreValve prosthesis have demonstrated superior results compared with surgical aortic valve replacement in patients at increased risk for surgery, but there are limited data on gender-related differences in patient characteristics and outcomes with this device. We compared baseline characteristics and clinical outcomes in women and men undergoing TAVR with the CoreValve prosthesis. A total of 3,687 patients (1,708 women and 1,979 men) were included. At baseline, women tended to be slightly older and to have increased frailty, but they had fewer cardiac co-morbidities, higher left ventricular systolic function, less coronary artery disease, and fewer previous strokes. All-cause mortality was 5.9% for women and 5.8% for men at 30 days (p = 0.87) and 24.1% and 21.3%, respectively, at 1 year (p = 0.08). The incidence of stroke was 5.7% in women and 4.0% in men at 30 days (p = 0.02) and 9.3% and 7.7%, respectively, at 1 year (p = 0.05). Women had a higher incidence of bleeding, including more life-threatening bleeds, and a greater incidence of major vascular complications than men at 30 days. Device success was achieved in 86.9% of women and 86.1% of men (p = 0.50). In conclusion, although there were significant baseline differences and procedure-related complications between women and men undergoing TAVR with the CoreValve prosthesis, this analysis found no significant difference in 30-day or 1-year mortality.

Sex-Based Disparities in Incidence, Treatment, and Outcomes of Cardiac Arrest in the United States, 2003-2012

BACKGROUND

Recent studies have shown improving survival after cardiac arrest. However, data regarding sex-based disparities in treatment and outcomes after cardiac arrest are limited.

METHODS AND RESULTS

We performed a retrospective analysis of all patients suffering cardiac arrest between 2003 and 2012 using the Nationwide Inpatient Sample database. Annual rates of cardiac arrest, rates of utilization of coronary angiography/percutaneous coronary interventions/targeted temperature management, and sex-based outcomes after cardiac arrest were examined. Among a total of 1 436 052 discharge records analyzed for cardiac arrest patients, 45.4% (n=651 745) were females. Women were less likely to present with ventricular tachycardia/ventricular fibrillation arrests compared with men throughout the study period. The annual rates of cardiac arrests have increased from 2003 to 2012 by 14.0% (Ptrend<0.001) and ventricular tachycardia/ventricular fibrillation arrests have increased by 25.9% (Ptrend<0.001). Women were less likely to undergo coronary angiography, percutaneous coronary interventions, or targeted temperature management in both ventricular tachycardia/ventricular fibrillation and pulseless electrical activity/asystole arrests. Over a 10-year study period, there was a significant decrease in in-hospital mortality in women (from 69.1% to 60.9%, Ptrend<0.001) and men (from 67.2% to 58.6%, Ptrend<0.001) after cardiac arrest. In-hospital mortality was significantly higher in women compared with men (64.0% versus 61.4%; adjusted odds ratio 1.02, P<0.001), particularly in the ventricular tachycardia/ventricular fibrillation arrest cohort (49.4% versus 45.6%; adjusted odds ratio 1.11, P<0.001).

CONCLUSIONS

Women presenting with cardiac arrests are less likely to undergo therapeutic procedures, including coronary angiography, percutaneous coronary interventions, and targeted temperature management. Despite trends in improving survival after cardiac arrest over 10 years, women continue to have higher in-hospital mortality when compared with men.

Gender Related Survival Differences in ST-Elevation Myocardial Infarction Patients Treated with Primary PCI

BACKGROUND

Data about gender as an independent risk factor for death in ST-elevation myocardial infarction (STEMI) patients is still contrasting. Aim was to assess how gender influences in-hospital and long-term all-cause mortality in STEMI patients with primary percutaneous coronary intervention (PCI) in our region.

METHODS

We analysed data from 2069 STEMI patients undergoing primary PCI in our institution from January 2009-December 2014, of whom 28.9% were women. In-hospital and long-term mortality were observed in women and men. The effect of gender on in-hospital mortality was assessed by binary logistic regression modelling and by Cox regression analysis for long-term mortality.

RESULTS

Women were older (68.3±61.8 vs 61.8±12.0 years; p<0.0001), with a higher prevalence of diabetes (13.7% vs 9.9%; p=0.013) and tend to be more frequently admitted in cardiogenic shock (8.4% vs 6.3%; p =0.085). They were less frequently treated with bivalirudin (15.9% vs 20.3%; p=0.022). In-hospital mortality was higher among women (14.2% vs 7.8%; p<0.0001). After adjustment, age (adjusted OR: 1.05; 95% CI: 1.03 to 1.08; p < 0.001) and cardiogenic shock at admission (adjusted OR: 24.56; 95% CI: 11.98 to 50.35; p < 0.001), but not sex (adjusted OR: 1.47; 95% CI: 0.80 to 2.71) were identified as prognostic factors of in-hospital mortality. During the median follow-up of 27 months (25th, 75th percentile: 9, 48) the mortality rate (23.6% vs 15.1%; p<0.0001) was significantly higher in women. The multivariate adjusted Cox regression model identified age (HR 1.05; 95% CI 1.04-1.07; p<0.0001), cardiogenic shock at admission (HR 6.09; 95% CI 3.78-9.81; p<0.0001), hypertension (HR 1.49; 95% CI 1.02-2.18; p<0.046), but not sex (HR 1.04; 95% CI 0.74-1.47) as independent prognostic factors of follow-up mortality.

CONCLUSION

Older age and worse clinical presentation rather than gender may explain the higher mortality rate in women with STEMI undergoing primary PCI.