Gender differences in short- and long-term mortality in the Vienna STEMI registry

Sex differences in the management and outcome of acute coronary syndrome-Still an issue of equal treatment?

Significant sex-specific differences were described in the presentation, management and outcome of acute coronary syndrom (ACS) patients. Female ACS patients more often presented with noncardiac symptoms, which lead to significant time delays between symptom onset and treatment. Furthermore, multiple studies from various countries described that women with ACS were less likely to receive the medical or reperfusion therapy recommended by the respective guidelines, resulting in higher in-hospital mortality rates.The treating physicians and the patients need to be more aware of the described differences to ensure the best possible medical care for ACS patients, irrespective of sex.

STEMI in women. Life expectancy recovery after primary percutaneous coronary intervention

INTRODUCTION AND OBJECTIVES

Despite medical advances, mortality after ST-elevation myocardial infarction (STEMI) remains high. Women are often underrepresented in trials and registries, limiting knowledge of their management and prognosis. It is unknown whether life expectancy in women of all ages treated with primary percutaneous coronary intervention (PPCI) is similar to that in a reference population free of the disease. The main objective of this study was to determine whether life expectancy in women undergoing PPCI and surviving the main event returns to a similar level to that in the general population of the same age and region.

METHODS

We included all patients diagnosed with STEMI from January 2014 to October 2021. We matched women to a reference population of the same age and region from the National Institute of Statistics to determine observed survival, expected survival, and excess mortality (EM) using the Ederer II method. We repeated the analysis in women aged ≤ 65 and> 65 years.

RESULTS

A total of 2194 patients were recruited, of whom 528 were women (23.9%). In women surviving the first 30 days, EM at 1, 5 and 7 years was 1.6% (95%CI, 0.3-4), 4.7% (95%CI, 0.3-10.1), and 7.2% (95%CI, 0.5-15.1), respectively.

CONCLUSIONS

EM was reduced in women with STEMI who were treated with PPCI and who survived the main event. However, life expectancy remained lower than that in a reference population of the same age and region.

Sex differences in the management of atherosclerotic cardiovascular disease

Disparities between women and men persist in the diagnosis, treatment, and prognosis of atherosclerotic cardiovascular disease (ASCVD). Despite growing attention to sex-based differences in cardiovascular care, there are continued disparities in short- and long-term outcomes. Such disparities highlight the need to identify pathophysiologic differences in treatment patterns for stable ischemic heart disease, non-ST elevation myocardial infarction (NSTE-ACS), ST-elevation myocardial infarction (STEMI), and myocardial infarction with non-obstructive coronary arteries (MINOCA). The role of age as an effect modifier should also be considered given that young women diagnosed with ACS continue to experience increased rates of in-hospital mortality and major adverse cardiovascular events. Both patient-directed and systems-based approaches remain integral to improve outcomes in cardiovascular care. While inadequate representation of women in clinical trials remains a barrier to the implementation of evidence-based therapies, a growing body of data has established the efficacy and safety of medications in women across acute coronary syndromes. This review seeks to feature existing data on the differential treatment guidelines, care implementation, and cardiovascular outcomes between women and men, highlighting next directions for clinical investigation.

Implementation of the ESC STEMI guidelines in female and elderly patients over a 20-year period in a large German registry

AIMS

We investigated the implementation of new guidelines in ST-segment elevation myocardial infarction (STEMI) patients in a large real-world patient population in the metropolitan area of Berlin (Germany) over a 20-year period.

METHODS

From January 2000 to December 2019, a total of 25 792 patients were admitted with STEMI to one of the 34 member hospitals of the Berlin-Brandenburg Myocardial Infarction Registry (B2HIR) and were stratified for sex and age < 75 and ≥ 75 years.

RESULTS

The median age of women was 72 years (IQR 61-81) compared to 61 years in men (IQR 51-71). PCI treatment as a standard of care was implemented in men earlier than in women across all age groups. It took two years from the 2017 class IA ESC STEMI guideline recommendation to prefer the radial access route rather than femoral until > 60% of patients were treated accordingly. In 2019, less than 60% of elderly women were treated via a radial access. While the majority of patients < 75 years already received ticagrelor or prasugrel as antiplatelet agent in the year of the class IA ESC STEMI guideline recommendation in 2012, men ≥ 75 years lagged two years and women ≥ 75 three years behind. Amongst the elderly, in-hospital mortality was 22.6% (737) for women and 17.3% (523) for men (p < 0.001). In patients < 75 years fatal outcome was less likely with 7.2% (305) in women and 5.8% (833) in men (p < 0.001). After adjustment for confounding variables, female sex was an independent predictor of in-hospital mortality in patients ≥ 75 years (OR 1.37, 95% CI 1.12-1.68, p = 0.002), but not in patients < 75 years (p = 0.076).

CONCLUSION

In-hospital mortality differs considerably by age and sex and remains highest in elderly patients and in particular in elderly females. In these patient groups, guideline recommended therapies were implemented with a significant delay.

BUN/albumin ratio predicts short-term mortality better than SYNTAX score in ST-elevation myocardial infarction patients

OBJECTIVE

The aim of the study is to compare the prognostic power of the BUN/albumin ratio (BAR) calculated on admission to the emergency department and the SYNergy between Percutaneous Coronary Intervention with TAXus (SYNTAX) score calculated after coronary angiography (CAG) in predicting 30-day mortality in patients with ST-segment elevation myocardial infarction (STEMI).

METHOD AND MATERIAL

The study was conducted prospectively between March 2021 and March 2022 in the emergency department of a tertiary hospital. Patients over the age of 18 who underwent CAG with a diagnosis of STEMI were included in the study. Demographic charecteristics, comorbidities, laboratory parameters of the patients at the time of admission and SYNTAX (SX) score were recorded in the data form.

RESULTS

A total of 1147 patients (77% male) diagnosed with STEMI were included in the study. When the receiver-operating characteristic analysis for SX score and laboratory parameters' power to predict mortality was examined, it was found that the AUC value of the BAR level (AUC: 0.736; 95% confidence interval: 0.670-0.802, P  < 0.001) was the highest. If the threshold value of the serum BAR level, which was determined to predict mortality, was taken as 4, the sensitivity was found to be 76.7% and the specificity was 56.9%. With multivariate logistic analysis, it was determined that the risk of mortality increased by 1.25 for each unit increase in the BAR value in STEMI patients ( P  < 0.001).

CONCLUSION

According to the study data, the BAR may guide the clinician in the early period as a practical and valuable predictor of 30-day mortality in patients diagnosed with STEMI.

Evaluation of Intermountain Risk Score for Short- and Long-Term Mortality in ST Elevation Myocardial Infarction Patients

The aim of this study was to examine the Intermountain Risk Score (IMRS) for short- and long-term mortality in ST elevation myocardial infarction (STEMI) patients and compare it with the well-known risk scores, such as the Thrombolysis in Myocardial Infarction (TIMI) and the Global Registry of Acute Coronary Events (GRACE). In this retrospective and cross-sectional study, 1057 consecutive patients with STEMI were evaluated. The end-points of the study were short- and long-term mortality. The overall mortality rate was 16% (n = 170 patients). The IMRS was significantly higher in STEMI patients who did not survive compared with those who survived. According to multivariable COX proportional regression analysis, the IMRS was independently related to both short- (HR: 1.482, 95% CI: 1.325-1.675, p < .001) and long-term mortality (HR: 1.915, 95% CI: 1.711-2.180, p < .001). The comparison of receiver operating characteristic curves revealed that the IMRS had non-inferior predictive capability for short- and long-term mortality than the TIMI and GRACE risk scores. To the best of our knowledge, this is the first study to show that the IMRS can predict short- and long-term prognosis of patients with STEMI. Further, the IMRS' predictive value for overall mortality was non-inferior compared with TIMI and GRACE scores.

Women with Acute Myocardial Infarction: Clinical Characteristics, Treatment, and In-Hospital Outcomes from a Latin American Country

Background

Women are underrepresented in acute myocardial infarction (AMI) studies. Furthermore, there is scarce information regarding women with AMI in Latin America.

Aims

To describe the presentation, clinical characteristics, risk factor burden, evidence-based care, and in-hospital outcome in a population of women with AMI admitted to a coronary care unit (CCU) in Mexico.

Methods

Retrospective cohort study including patients with AMI admitted from January 2006 to December 2021 in a CCU. We identified patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). We described demographic characteristics, clinical variables, treatment, and in-hospital outcomes according to gender. Cox regression analysis was used to identify predictors of mortality.

Results

Our study included 12,069 patients with AMI, of whom 7,599 had STEMI and 4,470 had NSTEMI. Women represented 19.6% of the population. Women had higher rates of hypertension, diabetes, stroke, and atrial fibrillation than men. For STEMI, women were less likely to receive reperfusion therapy (fibrinolysis; 23.7 vs. 28.5%, p < 0.001 and primary percutaneous coronary intervention (PCI); 31.2 vs. 35.1%, p = 0.001) and had more major adverse events than men: heart failure (4.2 vs. 2.5%, p = 0.002), pulmonary edema (3.4% vs. 1.7%, p < 0.001), major bleeding (2.1% vs. 1%, p = 0.002), stroke (1.3% vs. 0.6%, p = 0.008), and mortality (15.1% vs. 8.1%, p < 0.001). For NSTEMI, women were less likely to undergo coronary angiography or PCI and had more major bleeding and mortality. Multivariate Cox regression analysis revealed that females had an increase in mortality in STEMI and NSTEMI (HR 1.21, CI 1.01-1.47, p = 0.05 and HR 1.39, CI 1.06-1.81, p = 0.01).

Conclusion

Real-world evidence from a hospital in a Latin American low- to middle-income country (LMIC) showed that women with AMI had more comorbidities, received less reperfusion treatment or invasive strategies, and had worse outcomes. In STEMI and NSTEMI, female gender represented an independent predictor of in-hospital mortality.

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.

Pharmaco-invasive Strategy in Myocardial Infarction: Descriptive Analysis, Presentation of Ischemic Symptoms and Mortality Predictors

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) is defined by symptoms accompanied by typical electrocardiogram changes. However, the characterization of ischemic symptoms is unclear, especially in subgroups such as women and the elderly.

OBJECTIVES

To analyze the typification of ischemic symptoms, temporal metrics and observe the occurrence of in-hospital outcomes, in the analysis of predictive scores, in patients with STEMI, in a drug-invasive strategy.

METHODS

Study involving 2,290 patients. Types of predefined clinical presentations: typical pain, atypical pain, dyspnea, syncope. We measured the time between the onset of symptoms and demand for care and the interval between arrival at the medical unit and thrombolysis. Odds-ratios (OR; CI-95%) were estimated in a regression model. ROC curves were constructed for mortality predictors. The adopted significance level (alpha) was 5%.

RESULTS

Women had a high prevalence of atypical symptoms; longer time between the onset of symptoms and seeking care; delay between arrival at the emergency room and fibrinolysis. Hospital mortality was 5.6%. Risk prediction by Killip-Kimball classification: AUC: [0.77 (0.73-0.81)] in class ≥II. Subgroups studied [OR (CI-95%)]: women [2.06 (1.42-2.99); p=0.01]; chronic renal failure [3.39 (2.13-5.42); p<0.001]; elderly [2.09 (1.37-3.19) p<0.001]; diabetics [1.55 (1.04-2.29); p=0.02]; obese 1.56 [(1.01-2.40); p=0.04]: previous stroke [2.01 (1.02-3.96); p=0.04] correlated with higher mortality rates.

CONCLUSION

Despite higher mortality rates in some subgroups, significant disparity persists in women, with delays in symptom recognition and prompt thrombolysis. We highlight the applicability of the Killip-Kimball score in prediction, regardless of the clinical presentation.

Sex Disparity in Characteristics, Management, and In-Hospital Outcomes of Patients with ST-Segment Elevated Myocardial Infarction: Insights from Henan STEMI Registry

Background

Women hospitalized with ST-elevation myocardial infarction (STEMI) experience higher risk of early mortality than men. We aimed to investigate the potential impact of risk factors, clinical characteristics, and management among gender-related risk differences.

Method

We analyzed 5063 STEMI patients prospectively enrolled from 66 hospitals during 2016-2018 and compared sex differences in mortality, death, or treatment withdrawal and main adverse cardiovascular and cerebrovascular events (MACCE) using the generalized linear mixed model, following sequential adjustment for covariates.

Results

Women were older and had a higher prevalence of hypertension (53.3% vs. 41.1%, P < 0.001) and diabetes (24.5% vs. 15.2%, P < 0.001). Eligible women were less likely to receive reperfusion therapy (56.1% vs. 62.4%, P < 0.001); the onset to first medical contact (FMC) (255 vs. 190 minutes, P < 0.001), onset to fibrinolysis (218 vs. 185 minutes, P < 0.001), and onset to percutaneous coronary intervention (PCI) (307 vs. 243 minutes, P < 0.001) were significantly delayed in women. The incidence of in-hospital death (6.8% vs. 3.0%, P < 0.001), death or treatment withdrawal (14.5% vs. 5.6%, P < 0.001), and MACCE (18.5% vs. 9.4%, P < 0.001) were notably higher. The gender disparities persist in death (OR: 1.61, 95% CI: 1.12-2.33), death or treatment withdrawal (OR: 1.68, 95% CI: 1.26-2.24), and MACCE (OR: 1.37, 95% CI: 1.08-1.74) after adjustment for covariates. Among possible explanatory factors, age (-58.46%, -59.04%, -62.20%) and cardiovascular risk factors (-40.77%, -39.36%, -41.73%) accounted for most of the gender-associated risk differences.

Conclusions

Women experienced worse in-hospital outcomes, and age and cardiovascular risk factors were major factors influencing sex-related differences. The sex disparity stressed the awareness and importance of quality improvement efforts against female patients in clinical practice.

Age and Sex Differences and Temporal Trends in the Use of Invasive and Noninvasive Procedures in Patients Hospitalized With Acute Myocardial Infarction

Background

Few studies have examined age and sex differences in the receipt of cardiac diagnostic and interventional procedures in patients hospitalized with acute myocardial infarction and trends in these possible differences during recent years.

Methods and Results

Data from patients hospitalized with a first acute myocardial infarction at the major medical centers in the Worcester, Massachusetts, metropolitan area were utilized for this study. Logistic regression analysis was used to examine age (<55, 55–64, 65–74, and ≥75 years) and sex differences in the receipt of echocardiography, exercise stress testing, coronary angiography, percutaneous coronary interventions, and coronary artery bypass graft surgery, and trends in the use of those procedures during patients' acute hospitalization, between 2005 and 2018, while adjusting for important confounding factors. The study population consisted of 1681 men and 1154 women with an initial acute myocardial infarction who were hospitalized on an approximate biennial basis between 2005 and 2018. A smaller proportion of women underwent cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery, while there were no sex differences in the receipt of echocardiography and exercise stress testing. Patients aged ≥75 years were less likely to undergo cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery, but were more likely to receive echocardiography compared with younger patients. Between 2005 and 2018, the use of echocardiography and coronary artery bypass graft surgery nonsignificantly increased among all age groups and both sexes, while the use of cardiac catheterization and percutaneous coronary intervention increased nonsignificantly faster in women and older patients.

Conclusions

We observed a continued lower receipt of invasive cardiac procedures in women and patients aged ≥75 years with acute myocardial infarction, but age and sex gaps associated with these procedures have narrowed during recent years.

The Effect of Periprocedural Clinical Factors Related to the Course of STEMI in Men and Women Based on the National Registry of Invasive Cardiology Procedures (ORPKI) between 2014 and 2019

BACKGROUND

There are several sex-related differences in the course, management, and outcomes of ST-elevation myocardial infarction (STEMI). This study aimed to identify the risk factors that may affect the odds of procedure-related death in patients with STEMI.

METHODS

The observational cohort study group consisted of 118,601 participants recruited from the National Registry of Invasive Cardiology Procedures (ORPKI).

RESULTS

Procedure-related death occurred in 802 (1.0%) men and in 663 (1.7%) women. The odds of procedure-related death among women were significantly higher than among men (OR, 1.76; 95% CI, 1.59-1.95; p < 0.001). The probability of procedure-related mortality was highest in both men and women with cardiac arrest in the cath lab, critical stenosis of the left main coronary artery, and direct transfer to the cath lab. The factors that reduced the probability of procedure-related mortality in both men and women were thrombolysis in myocardial infarction (TIMI) flow grade and the use of P2Y12 inhibitors in the peri-infarct period. Psoriasis was associated with increased odds of procedure-related death among men, whereas cigarette smoking reduced the odds among women.

CONCLUSIONS

Procedure-related deaths occurred more frequently in women than men with STEMI. Additional scrutiny needs to be undertaken to identify factors influencing survival regarding gender differences.

Sex and Medium-term Outcomes of ST-Segment Elevation Myocardial Infarction in Kerala, India: A Propensity Score–Matched Analysis

Background

Sex-based differences have been found in outcomes following ST-segment myocardial infarction (STEMI). Studies assessing sex-based differences in STEMI among Indian patients have reported conflicting results.

Methods

A prospective multicenter registry of consecutive patients with STEMI who presented to percutaneous coronary intervention (PCI)–capable hospitals in the Indian state of Kerala between June 2013 and March 2017 was used to assess 1-year outcomes. The primary endpoint was a composite of major adverse cardiac events (MACE), including death, stroke, nonfatal myocardial infarction, and rehospitalization for heart failure. Outcomes of 2 sex-based propensity score–matched groups were compared.

Results

We included 3194 patients (19.4% women). Women presenting with STEMI were older, had more traditional cardiovascular risk factors, and were more likely to be classified as living in poverty. After propensity-score matching, women experienced greater incidence of MACE (20.9% vs 14.3%, P < 0.01), primarily driven by increased 1-year mortality (14.3% vs 8.6%, P < 0.01). Women were more likely to experience prehospital delays, compared with men. Although reperfusion rates were similar between the groups, men were more likely than women to undergo reperfusion within the first 12 hours of chest pain onset. Among patients undergoing primary PCI, women were more likely to have delayed PCI than were men (80.2% vs 72.9%, P = 0.03). Procedural characteristics were similar between groups.

Conclusions

Women in this cohort experienced higher incidence of MACE at 1 year, compared to men, primarily owing to increased mortality. Timeliness of reperfusion appears to be the primary factor impacting differences in outcomes between the 2 groups and may represent an attractive target for quality-improvement initiatives.

The effect of sex on door-to-balloon time in patients presenting with ST-elevation myocardial infarction and referred for primary percutaneous coronary intervention: A systematic review

Timely reperfusion using primary percutaneous coronary intervention (pPCI) is the cornerstone of acute ST-elevation myocardial infarction (STEMI) management. We conducted a systematic review to examine the effect of sex on door-to-balloon (D2B) time and symptom-to-balloon (S2B) time. We observed longer D2B times and S2B times in female patients presenting with STEMI and referred for pPCI when compared to male patients. Future work is required to try and elucidate and mitigate sex-based front-line treatment delays for female STEMI patients.

Prediction of 11-year incidence of psychophysically dependent status or death among community-dwelling younger elderlies: from an age-specified community-based cohort study (the NISSIN project)

Background

Predicting adverse health events and implementing preventative measures are a necessary challenge. It is important for healthcare planners and policymakers to allocate the limited resource to high-risk persons. Prediction is also important for older individuals, their family members, and clinicians to prepare mentally and financially. The aim of this study is to develop a prediction model for within 11-year dependent status requiring long-term nursing care or death in older adults for each sex.

Methods

We carried out age-specified cohort study of community dwellers in Nisshin City, Japan. The older adults aged 64 years who underwent medical check-up between 1996 and 2000 were included in the study. The primary outcome was the incidence of the psychophysically dependent status or death or by the end of the year of age 75 years. Univariable logistic regression analyses were performed to assess the associations between candidate predictors and the outcome. Using the variables with p-values less than 0.1, multivariable logistic regression analyses were then performed with backward stepwise elimination to determine the final predictors for the model.

Results

Of the 1525 female participants at baseline, 105 had an incidence of the study outcome. The final prediction model consisted of 15 variables, and the c-statistics for predicting the outcome was 0.763 (95% confidence interval [CI] 0.714–0.813). Of the 1548 male participants at baseline, 211 had incidence of the study outcome. The final prediction model consisted of 16 variables, and the c-statistics for predicting the outcome was 0.735 (95% CI 0.699–0.771).

Conclusions

We developed a prediction model for older adults to forecast 11-year incidence of dependent status requiring nursing care or death in each sex. The predictability was fair, but we could not evaluate the external validity of this model. It could be of some help for healthcare planners, policy makers, clinicians, older individuals, and their family members to weigh the priority of support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12199-021-00968-8.

Premature STEMI in Men and Women: Current Clinical Features and Improvements in Management and Prognosis

Background: Coronary artery disease (CAD) is the most frequent cause of ST-segment elevation myocardial infarction (STEMI). Etiopathogenic and prognostic characteristics in young patients may differ from older patients and young women may present worse outcomes than men. We aimed to evaluate the clinical characteristics and prognosis of men and women with premature STEMI.

METHODS

A total 1404 consecutive patients were referred to our institution for emergency cardiac catheterization due to STEMI suspicion (1 January 2014-31 December 2018). Patients with confirmed premature (<55 years old in men and <60 in women) STEMI (366 patients, 83% men and 17% women) were included (359 atherothrombotic and 7 spontaneous coronary artery dissection (SCAD)).

RESULTS

Premature STEMI patients had a high prevalence of classical cardiovascular risk factors. Mean follow-up was 4.1 years (±1.75 SD). Mortality rates, re-hospitalization, and hospital stay showed no significant differences between sexes. More than 10% of women with premature STEMI suffered SCAD. There were no significant differences between sexes, neither among cholesterol levels nor in hypolipemiant therapy. The global survival rates were similar to that expected in the general population of the same sex and age in our region with a significantly higher excess of mortality at 6 years among men compared with the general population.

CONCLUSION

Our results showed a high incidence of cardiovascular risk factors, a high prevalence of SCAD among young women, and a generally good prognosis after standardized treatment. During follow-up, 23% suffered a major cardiovascular event (MACE), without significant differences between sexes and observed survival at 1, 3, and 6 years of follow-up was 96.57% (95% CI 94.04-98.04), 95.64% (95% CI 92.87-97.35), and 94.5% (95% CI 91.12-97.66). An extra effort to prevent/delay STEMI should be invested focusing on smoking avoidance and optimal hypolipemiant treatment both in primary and secondary prevention.

Age-Stratified Sex-Related Differences in the Incidence, Management, and Outcomes of Acute Myocardial Infarction

OBJECTIVE

To assess the impact of female sex on the incidence, management, and outcomes of myocardial infarction (MI) in different age groups.

METHODS

Patients admitted with ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI), between January 1, 2003, and December 31, 2015, were identified in the National Inpatient Sample. We compared STEMI and NSTEMI rates, management patterns, and in-hospital morbidity and mortality in men and women stratified into 4 age groups (<45, 45 to 64, 65 to 84, and ≥85 years of age).

RESULTS

A total of 6,720,639 weighted hospitalizations for MI (79.8% NSTEMI, and 20.2% STEMI) were included. The incidence rate of hospitalizations for MI was lower in women than men across all age groups. Women were less likely than men to undergo coronary angiography, revascularization, or to use circulatory-support devices. These differences were consistent across all age groups. Adjusted odds of death for women (vs men) varied by age: odds ratio (95% confidence interval) 1.08 (0.97 to 1.20), 1.05 (1.02 to 1.08), 0.92 (0.91 to 0.94), and 0.86 (0.85 to 0.88) for NSTEMI, and 1.15 (1.04 to 1.27), 1.22 (1.18 to 1.26), 1.09 (1.06 to 1.11), and 0.97 (0.94 to 0.99), for STEMI, in age groups (<45, 45 to 64, 65 to 84, and ≥85), respectively. The magnitude of differences in complications between men and women was higher in younger and middle-age patients.

CONCLUSION

Compared with men, women have lower incidence of MI and less likelihood of undergoing invasive treatment regardless of age. However, post-MI outcomes are age specific. The negative impact of female sex on most outcomes was most pronounced in young and middle-aged women.

Short and Midterm Outcomes in Patients With Acute Myocardial Infarction: Results of the Nationwide TURKMI Registry

This recent Turkish Myocardial Infarction registry reported that guidelines are largely implemented in patients with acute myocardial infarction (MI) in Turkey. We aimed to obtain up-to-date information for short- and midterm outcomes of acute MI. Fifty centers were selected using probability sampling, and all consecutive patients with acute MI admitted to these centers (between November 1 and 16, 2018) were enrolled. Among 1930 (mean age 62 ± 13 years, 26% female) patients, 1195 (62%) had non-ST segment elevation myocardial infarction (NSTEMI) and 735 (38%) had ST segment elevation myocardial infarction (STEMI). Percutaneous coronary intervention (PCI) was performed in 94.4% of patients with STEMI and 60.2% of those with NSTEMI. Periprocedural mortality occurred in 4 (0.3%) patients. In-hospital mortality was significantly higher in STEMI than in patients with NSTEMI (5.4% vs 2.9%, respectively; P = .006). However, the risk became slightly higher in the NSTEMI group at 1 year. Women with STEMI had a significantly higher in-hospital mortality compared with men (11.2% vs 3.8%; P < .001); this persisted at follow-up. In conclusion, PCI is performed in Turkey with a low risk of complications in patients with acute MI. Compared with a previous registry, in-hospital mortality decreased by 50% within 20 years; however, the risk remains too high for women with STEMI.

Comparison of Outcomes of Coronary Revascularization for Acute Myocardial Infarction in Men Versus Women

This study sought to examine the differences in the characteristics and outcomes between men and women who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) in contemporary US practice. The Nationwide Inpatient Sample was used to identify patients who underwent revascularization for AMI between January 1, 2003 and December 31, 2016. The primary outcome was in-hospital mortality. Propensity score matching was utilized to account for differences in baseline characteristics. In total, 3,603,142 patients were included, of whom only 1,180,436 (33%) were women. Compared with men, women were older and had higher prevalence of key co-morbidities including diabetes, hypertension, congestive heart failure, and chronic kidney and lung disease (p <0.001). In the PCI cohort, women were significantly less likely to undergo multivessel PCI, to receive mechanical circulatory support, or to undergo atherectomy. In the CABG group, women were more likely to have concomitant valve surgery. In the propensity-matched cohorts, in-hospital mortality was higher for women than men regardless of revascularization strategy: 7.6% versus 6.6% for PCI in ST-elevation myocardial infarction, 2.0% versus 1.9% for PCI in non-ST-elevation myocardial infarction, and 5.7% versus 4.3% for CABG in any AMI (p <0.001). Women also had higher rates of major complications, longer hospitalizations, higher costs, and were less likely to be discharged home (vs nursing facility). These sex-based differences persisted over the study 14-year period. In conclusion, in a contemporary nationwide analysis of propensity score-matched patients, women who undergo revascularization for AMI have worse in-hospital outcomes than men regardless of revascularization mode.

Differences in 30-day complications and 1-year mortality by sex in patients with a first STEMI managed by the Codi IAM network between 2010 and 2016

INTRODUCTION AND OBJECTIVES

ST-segment elevation myocardial infarction (STEMI) emergency care networks aim to increase reperfusion rates and reduce ischemic times. The influence of sex on prognosis is still being debated. Our objective was to analyze prognosis according to sex after a first STEMI.

METHODS

This multicenter cohort study enrolled first STEMI patients from 2010 to 2016 to determine the influence of sex after adjustment for revascularization delays, age, and comorbidities. End points were 30-day mortality, the 30-day composite of mortality, ventricular fibrillation, pulmonary edema, or cardiogenic shock, and 1-year all-cause mortality.

RESULTS

From 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74-124] in 2016, both P=.001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P=.001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95).

CONCLUSIONS

Compared with men, women with a first STEMI had similar 30-day mortality and complication rates but significantly lower 1-year mortality after adjustment for age and severity.

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.

Early and late case fatality after hospitalization for acute coronary syndrome in France, 2010-2015

BACKGROUND

Case-fatality data for acute coronary syndromes (ACS) are scarce in unselected French patients.

AIMS

To analyse early and late case-fatality rates in patients with ACS in France, case fatality determinants and time trends between 2010 and 2015.

METHODS

For each year from 2010 to 2015, all patients hospitalized for ACS in France and aged>18 years were selected. Multivariable Cox models were used to assess determinants of case fatality at 3 days, 4-30 days and 31-365 days after hospital admission.

RESULTS

In 2015, cumulative 3-day, 30-day and 1-year case-fatality rates were, respectively, 2.0%, 5.1% and 11.1% for all patients with ACS, and 3.9%, 8.5% and 13.8% for those with ST-segment elevation myocardial infarction (STEMI). Admission through the emergency department was associated with a higher risk of death, particularly at 3 days. Female sex was associated with higher case-fatality rates at 3 days, but with lower case-fatality rates at 31-365 days. Social deprivation was associated with higher case-fatality rates for all periods for all patients with ACS. A significant decrease was found between 2010 and 2015 in case-fatality rates at 31-365 days, particularly for patients with STEMI; this time trend was no longer significant after additional adjustment for hospital management.

CONCLUSIONS

Case fatality up to 1 year after hospitalization for ACS was non-negligible, highlighting the need to ensure better follow-up after the acute stage, particularly in the most deprived patients. As hospital admission through the emergency department still occurs frequently, health policy should promote a national campaign to increase the awareness and preparedness of the general population regarding ACS. Finally, our results suggest that women need specific attention early after the index event.

Premature Atherosclerotic Cardiovascular Disease: Trends in Incidence, Risk Factors, and Sex-Related Differences, 2000 to 2016

Background The incidence of atherosclerotic cardiovascular disease has declined in the past 2 decades. However, these benefits may not extend to young patients. The objective of this work was to assess temporal trends in the incidence, risk profiles, sex-related differences, and outcomes in a contemporary population of young patients presenting with coronary artery disease ( CAD ) in British Columbia, Canada. Methods and Results We used a provincial cardiac registry to identify young patients (men aged <50 years, women aged <55 years), with a first presentation of CAD between 2000 and 2016, who had either ≥50% stenosis of ≥1 coronary arteries on angiography or underwent coronary revascularization. A total of 12 519 patients (30% women) met our inclusion criteria. The incidence of CAD remained stable and was higher for men than women (46-53 versus 18-23 per 100 000). Of patients, 92% had at least one traditional cardiovascular risk factor and 67% had multiple risk factors. The prevalence of diabetes mellitus, obesity, and hypertension increased during the study period and was higher for women. Women had fewer emergent procedures and revascularizations. Mortality rates decreased by 31% between 2000 and 2007, then were stable for the remaining 9 years. Mortality was significantly higher for women aged <45 years compared with men. Conclusions The incidence of premature CAD has not declined, and the prevalence of 3 major cardiovascular risk factors increased between 2000 and 2016. The risk burden and mortality rates were worse for women. These data have important implications for the design of strategies to prevent CAD in young adults.

Contemporary differences between men and women with acute coronary syndromes: CIAM multicenter registry

AIM

Differences exist in the diagnosis and treatment of acute coronary syndrome (ACS) between men and women. However, recent advancements in the management of ACSs might have attenuated this sex gap. We evaluated the status of ACS management in a multicenter registry in 10 tertiary Spanish hospitals.

METHODS

We enrolled 1056 patients in our study, including only those with type 1 myocardial infarctions or unstable angina presumably not related to a secondary cause in an 'all-comers' design.

RESULTS

The women enrolled (29%) were older than men (71.0 ± 12.8 vs. 64.0 ± 12.3, P = 0.001), with a higher prevalence of hypertension (71.0 vs. 56.5%, P < 0.001), insulin-treated diabetes (13.7 vs. 7.9%, P = 0.003), dyslipidemia (62.2 vs. 55.3%, P = 0.038), and chronic kidney disease (16.9 vs. 9.1%, P = 0.001). Women presented more frequently with back or arm pain radiation (57.3 vs. 49.7%, P = 0.025), palpitations (5.9 vs. 2.0%, P = 0.001), or dyspnea (33.0 vs. 19.4%, P = 0.001). ACS without significant coronary stenosis was more prevalent in women (16.8 vs. 8.1%, P = 0.001). There were no differences in percutaneous revascularization rates, but drug-eluting stents were less frequently employed in women (75.4 vs. 67.8%, P = 0.024); women were less often referred to a cardiac rehabilitation program (19.9 vs. 33.9%, P = 0.001). There were no significant differences in in-hospital complications such as thrombosis or bleeding.

CONCLUSION

ACS presenting with atypical symptoms and without significant coronary artery stenosis is more frequent in women. Selection of either an invasive procedure or conservative management is not influenced by sex. Cardiac rehabilitation referral on discharge is underused, especially in women.

ST-segment elevation myocardial infarction

ST-segment elevation myocardial infarction (STEMI) is the most acute manifestation of coronary artery disease and is associated with great morbidity and mortality. A complete thrombotic occlusion developing from an atherosclerotic plaque in an epicardial coronary vessel is the cause of STEMI in the majority of cases. Early diagnosis and immediate reperfusion are the most effective ways to limit myocardial ischaemia and infarct size and thereby reduce the risk of post-STEMI complications and heart failure. Primary percutaneous coronary intervention (PCI) has become the preferred reperfusion strategy in patients with STEMI; if PCI cannot be performed within 120 minutes of STEMI diagnosis, fibrinolysis therapy should be administered to dissolve the occluding thrombus. The initiation of networks to provide around-the-clock cardiac catheterization availability and the generation of standard operating procedures within hospital systems have helped to reduce the time to reperfusion therapy. Together with new advances in antithrombotic therapy and preventive measures, these developments have resulted in a decrease in mortality from STEMI. However, a substantial amount of patients still experience recurrent cardiovascular events after STEMI. New insights have been gained regarding the pathophysiology of STEMI and feed into the development of new treatment strategies.

Women were noninferior to men in cardiovascular outcomes among patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention from Taiwan acute coronary syndrome full-spectrum registry

This study was conducted to compare the survival rate and the influencing factors between women and men following ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).A national-wide Acute Coronary Syndrome Full Spectrum Registry conducted by the Taiwan Society of Cardiology was used for data collection between October 2008 and January 2010. Details of 1621 patients with STEMI treated with primary PCI, including 1350 (83%) men and 271 (17%) women, were collected. Composite outcomes included all-cause death, myocardial reinfarction, and an ischemic stroke. Demographic data, comorbidities, clinical presentations, details of treatment received, and outcomes were recorded at 3-month intervals for 1 year.No significant difference was observed between men and women in the composite endpoints after STEMI during their hospital stay (5.5% vs 2.5%, P = .07). However, women showed significantly higher in-hospital and 1-year mortality rates than those of men (4.1% vs 1.8%, P = .008; 11.0% vs 4.1%, P = .000, respectively). Compared with men, women presented with higher age (mean age 68.9 vs 58.9 years, P = .001), less body weight (58.7 vs 70.9 kg, P < .001), more number of risk factors, delayed diagnosis, and more number of inadequate medical treatments. After adjusting for age and cardiovascular risk factors, the difference in mortality ceased to exist between men and women.Although female patients with STEMI-treated primary PCI had higher in-hospital and 1-year mortality rates than those of males in Taiwan, there was no gender difference after adjusting for age and cardiovascular risk factors.