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Odin B, Thevenon E, Miganeh-Hadi S, Lesaine E, Galinski M. Influence of sex on the dispatch decision for patients subsequently diagnosed with ST-elevation myocardial infarction. Eur J Emerg Med 2024; 31:365-367. [PMID: 39206878 DOI: 10.1097/mej.0000000000001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Affiliation(s)
| | | | | | - Emilie Lesaine
- INSERM, U1219, CHU de Bordeaux
- INSERM, BPH, U1219, Univ. Bordeaux
| | - Michel Galinski
- Emergency Department SAMU 33, CHU de Bordeaux
- INSERM U1219, Bordeaux Population Health, ISPED, AHeaD Team, University of Bordeaux, Bordeaux, Nouvelle-Aquitaine, France
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Nanyoshi M, Hayashi T, Sugimoto R, Nishisaki H, Kenzaka T. Type I Kounis syndrome in a young woman without chest pain: a case report. BMC Cardiovasc Disord 2024; 24:467. [PMID: 39218904 PMCID: PMC11367997 DOI: 10.1186/s12872-024-04141-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Kounis syndrome is defined as the concurrence of acute coronary syndromes in the setting of allergic or anaphylactic reactions. It primarily affects men aged 40-70 years and is often associated with chest pain. This syndrome is often unrecognized and undiagnosed in clinical practice due to a low level of awareness. Herein, we present a case of type I Kounis syndrome in a young woman without chest pain. CASE PRESENTATION A 28-year-old Japanese woman with a history of atopic dermatitis received a glycyrrhizin, glutathione, and neurotropin preparation (a preparation of inflamed skin extract from rabbits inoculated with vaccinia virus) at a dermatology clinic to treat pruritus caused by atopic dermatitis. Immediately after the administration, the patient developed abdominal pain and generalized body wheals. The patient was diagnosed with anaphylaxis and was transported to our hospital. She had no chest pain on arrival at our hospital; however, a 12-lead electrocardiogram showed ST elevation in leads I, aVL, V2, and V3, and an echocardiogram showed decreased wall motion in the anterior and lateral walls of the left ventricle. Sublingual nitroglycerin administration improved ST-segment elevation and left ventricular wall motion abnormalities. The patient underwent emergency coronary angiography, which revealed no significant stenosis, and was diagnosed with type I Kounis syndrome. CONCLUSION Kounis syndrome without chest pain is rare in young women. Since it can be fatal in cases with severe allergic symptoms such as anaphylaxis, the possibility of concurrent acute coronary syndrome should be considered when treating systemic allergic reactions, regardless of age, sex, or the presence or absence of chest symptoms.
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Affiliation(s)
- Miki Nanyoshi
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, 2002-7, Iso, Hikami-cho, Tamba, 669-3495, Japan
| | - Tomohiro Hayashi
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, 2002-7, Iso, Hikami-cho, Tamba, 669-3495, Japan.
- Division of Community Medicine and Career Development, Kobe University Graduate School of Medicine, 2-1-5, Arata-cho, Hyogo-ku, Kobe, 652-0032, Japan.
| | - Ryu Sugimoto
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, 2002-7, Iso, Hikami-cho, Tamba, 669-3495, Japan
| | - Hogara Nishisaki
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, 2002-7, Iso, Hikami-cho, Tamba, 669-3495, Japan
| | - Tsuneaki Kenzaka
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, 2002-7, Iso, Hikami-cho, Tamba, 669-3495, Japan
- Division of Community Medicine and Career Development, Kobe University Graduate School of Medicine, 2-1-5, Arata-cho, Hyogo-ku, Kobe, 652-0032, Japan
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Farcas AM, Crowe RP, Kennel J, Little N, Haamid A, Camacho MA, Pleasant T, Owusu-Ansah S, Joiner AP, Tripp R, Kimbrell J, Grover JM, Ashford S, Burton B, Uribe J, Innes JC, Page DI, Taigman M, Dorsett M. Achieving Equity in EMS Care and Patient Outcomes Through Quality Management Systems: A Position Statement. PREHOSP EMERG CARE 2024; 28:871-881. [PMID: 38727731 DOI: 10.1080/10903127.2024.2352582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies:make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.
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Affiliation(s)
- Andra M Farcas
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Jamie Kennel
- Oregon Health & Science University and Oregon Institute of Technology, Portland, Oregon
| | | | - Ameera Haamid
- Section of Emergency Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Mario Andres Camacho
- Department of Emergency Medicine, Denver Health Medical Center, School of Medicine, University of Colorado, Denver, Colorado
| | | | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anjni P Joiner
- Department of Emergency Medicine, School of Medicine, Duke University, Durham, North Carolina
| | - Rickquel Tripp
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joshua Kimbrell
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Jamaica, New York
| | - Joseph M Grover
- UNC Department of Emergency Medicine, Chapel Hill, North Carolina
| | | | - Brooke Burton
- Unified Fire Authority in Salt Lake County, Salt Lake City, Utah
| | - Jeffrey Uribe
- Department of Emergency Medicine, Medstar Health, Columbia, Maryland
| | - Johanna C Innes
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - David I Page
- Center for Prehospital Care, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | | | - Maia Dorsett
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
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4
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Ma Z, Antoine MK, Vefali H, Manda Y, Salen P, Shoemaker M, Stoltzfus J, Puleo P. Non-chest pain symptoms and likelihood of coronary occlusion in emergency department patients with ST segment elevation undergoing emergent coronary angiography. Coron Artery Dis 2024:00019501-990000000-00235. [PMID: 38804200 DOI: 10.1097/mca.0000000000001391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
OBJECTIVES Patients presenting with suspected ST segment elevation myocardial infarction frequently have symptoms in addition to chest pain, including dyspnea, nausea or vomiting, diaphoresis, and lightheadedness or syncope. These symptoms are often regarded as supporting the diagnosis of infarction. We sought to determine the prevalence of the non-chest pain symptoms among patients who were confirmed as having a critically diseased coronary vessel as opposed to those with no angiographic culprit lesion. METHODS Data from 1393 consecutive patients with ST segment elevation who underwent emergent coronary angiography were analyzed. Records were reviewed in detail for symptoms, ECG findings, prior history, angiographic findings, and in-hospital outcomes. RESULTS Dyspnea was present in 50.8% of patients, nausea or vomiting in 36.5%, diaphoresis in 51.2%, and lightheadedness/syncope in 16.8%. On angiography, 1239 (88.9%) patients had a culprit lesion and 154 (11.1%) were found not to have a culprit. Only diaphoresis had a higher prevalence among the patients with, as compared with those without a culprit, with an odds ratio of 2.64 (P < 0.001). The highest occurrence of diaphoresis was among patients with a totally occluded artery, with an intermediate frequency among patients with a subtotal stenosis, and the lowest prevalence among those with no culprit. These findings were consistent regardless of ECG infarct location, affected vessel, patient age, or sex. Among the subset of patients who presented without chest discomfort, none of the symptoms were associated with the presence of a culprit. CONCLUSION The presence of diaphoresis, but not dyspnea, nausea, or lightheadedness is associated with an increased likelihood that patients presenting with ST elevation will prove to have a culprit lesion. In patients who present with ST elevation but without chest discomfort, these symptoms should not be regarded as 'chest pain equivalents'. Further objective data among patients with angiographic confirmation of culprit lesion status is warranted.
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Affiliation(s)
- Zhiyuan Ma
- Section of Cardiology, St. Luke's University Hospital, Bethlehem, Pennsylvania
| | - Marc Kervin Antoine
- Section of Cardiology, University of Maryland Capital Region Medical Center, Largo, Maryland
| | - Huseng Vefali
- Section of Cardiology, St David's Medical Center, Austin
| | - Yugandhar Manda
- Section of Cardiology, The Heart Institute of East Texas, Lufkin, Texas
| | | | - Melinda Shoemaker
- Section of Cardiology, St. Luke's University Hospital, Bethlehem, Pennsylvania
| | - Jill Stoltzfus
- Biostatistics, St. Luke's University Hospital, Bethlehem, Pennsylvania, USA
| | - Peter Puleo
- Section of Cardiology, St. Luke's University Hospital, Bethlehem, Pennsylvania
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Kunow A, Freyer Martins Pereira J, Chenot JF. Extravertebral low back pain: a scoping review. BMC Musculoskelet Disord 2024; 25:363. [PMID: 38714994 PMCID: PMC11075250 DOI: 10.1186/s12891-024-07435-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 04/11/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered. METHODS A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included. RESULTS The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes. DISCUSSION Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient. CONCLUSION The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.
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Affiliation(s)
- Anna Kunow
- Department of General Practice, University Medicine Greifswald, 17475, Fleischmannstraße, Greifswald, Germany.
| | | | - Jean-François Chenot
- Department of General Practice, University Medicine Greifswald, 17475, Fleischmannstraße, Greifswald, Germany
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Theofilis P, Vlachakis PK, Mantzouranis E, Sakalidis A, Chrysohoou C, Leontsinis I, Lazaros G, Dimitriadis K, Drakopoulou M, Vordoni A, Oikonomou E, Tsioufis K, Tousoulis D. Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics. Angiology 2023:33197231218331. [PMID: 37995282 DOI: 10.1177/00033197231218331] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
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.
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Affiliation(s)
- Panagiotis Theofilis
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panayotis K Vlachakis
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Emmanouil Mantzouranis
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Sakalidis
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christina Chrysohoou
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Leontsinis
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Lazaros
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Kyriakos Dimitriadis
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Drakopoulou
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Aikaterini Vordoni
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, "Sotiria" Chest Disease Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Tousoulis
- 1st Department of Cardiology, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Stepney D, Attarian HP, Knutson KL. Association between severity of obstructive sleep apnea and its common symptoms varies by race, ethnicity, and sex. J Clin Sleep Med 2023; 19:1727-1733. [PMID: 37786380 PMCID: PMC10545998 DOI: 10.5664/jcsm.10660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 10/04/2023]
Abstract
STUDY OBJECTIVES The US Preventive Services Task Force recently released guidelines suggesting little evidence of benefit to screening asymptomatic adults for obstructive sleep apnea (OSA). Our goal was to provide important context to this statement. Specifically, we examined associations between common OSA symptoms, excessive daytime sleepiness and snoring, and OSA severity for different racial/ethnic and sex groups. METHODS Analyses were performed on 2 samples. One combined 2 observational studies that included full polysomnography, the Epworth Sleepiness Scale (ESS), and questions about snoring (mean [standard deviation] age 39 [15.2] years). The second sample was the Multi-Ethnic Study of Atherosclerosis study of older adults (mean [standard deviation] age 69 [9.1] years), which also included polysomnography, ESS and a question about snoring. Apnea-hypopnea index represented OSA severity. For each racial/ethnic-sex group we estimated correlations between apnea-hypopnea index and ESS and the sensitivity and specificity of excessive daytime sleepiness (ESS >10) or frequent snoring to predict moderate-to-severe OSA (apnea-hypopnea index >15 events/h). RESULTS A weak significant correlation between OSA severity and ESS was found only in White men in the first sample and Black men in the second sample. Screening tool characteristics for ESS and snoring were poor except for moderate specificity in some racial/ethnic-sex groups. CONCLUSIONS Excessive daytime sleepiness and snoring are commonly used to identify symptomatic patients. Our results suggest that the accuracy of these symptoms to identify OSA varies by race/ethnicity and sex. Therefore, focus on common symptoms as an OSA screen could systematically leave out certain patient populations who would benefit from treatment. CITATION Stepney D, Attarian HP, Knutson KL. Association between severity of obstructive sleep apnea and its common symptoms varies by race, ethnicity, and sex. J Clin Sleep Med. 2023;19(10):1727-1733.
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Affiliation(s)
- David Stepney
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hrayr P. Attarian
- Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kristen L. Knutson
- Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Taha YK, Dungan JR, Weaver MT, Xu K, Handberg EM, Pepine CJ, Bairey Merz CN. Symptom Presentation among Women with Suspected Ischemia and No Obstructive Coronary Artery Disease (INOCA). J Clin Med 2023; 12:5836. [PMID: 37762777 PMCID: PMC10531826 DOI: 10.3390/jcm12185836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/23/2023] [Accepted: 09/02/2023] [Indexed: 09/29/2023] Open
Abstract
Identifying ischemic heart disease (IHD) in women based on symptoms is challenging. Women are more likely to endorse non-cardiac symptoms. More than 50% of women with suspected ischemia have no obstructive coronary disease (and thus, INOCA) and impaired outcomes during follow-up. We aimed to identify symptoms having predictive capacity for INOCA in women with clinical evidence of coronary ischemia. We included 916 women from the original WISE cohort (NCT00000554) who had coronary angiography performed for suspected ischemia and completed a 65-item WISE symptom questionnaire. Sixty-two percent (n = 567) had suspected INOCA. Logistic regression models using a best subsets approach were examined to identify the best predictive model for INOCA based on Score χ2 and AICc. A 10-variable, best-fit model accurately predicted INOCA (AUC 0.72, 95% CI 0.68, 0.75). The model indicated that age ≤ 55 years, left side chest pain, chest discomfort, neck pain, and palpitations had independent, positive relationship (OR > 1) to INOCA (p < 0.001 to 0.008). An inverse relationship (OR < 1) was observed for impending doom, and pain in the jaw, left or bilateral arm, and right hand, interpreted as INOCA associated with the absence of these symptoms (p ≤ 0.001 to 0.023). Our best-fit model accurately predicted INOCA based on age and symptom presentation ~72% of the time. While the heterogeneity of symptom presentation limits the utility of this unvalidated 10-variable model, it has promise for consideration of symptom inclusion in future INOCA prediction risk modeling for women with evidence of symptomatic ischemia.
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Affiliation(s)
- Yasmeen K. Taha
- College of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32610, USA; (Y.K.T.); (E.M.H.); (C.J.P.)
| | - Jennifer R. Dungan
- College of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32610, USA; (Y.K.T.); (E.M.H.); (C.J.P.)
- College of Nursing, University of Florida, 1225 Center Drive, Gainesville, FL 32610, USA;
| | - Michael T. Weaver
- College of Nursing, University of Florida, 1225 Center Drive, Gainesville, FL 32610, USA;
| | - Ke Xu
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL 32611, USA;
| | - Eileen M. Handberg
- College of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32610, USA; (Y.K.T.); (E.M.H.); (C.J.P.)
| | - Carl J. Pepine
- College of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32610, USA; (Y.K.T.); (E.M.H.); (C.J.P.)
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
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Sohail H, Umer MR, Afzal MW, Ullah A, Salahuddin SA, Malik J, Ashraf W. Sociodemographic determinants of gender disparity in primary percutaneous coronary intervention in Pakistan. Expert Rev Cardiovasc Ther 2023; 21:895-899. [PMID: 37921689 DOI: 10.1080/14779072.2023.2277356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVES This study aims to contribute to the body of literature on gender disparities after acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PPCI). METHODS We identified all adult patients who had AMI between January 2017, and December 2022 and were in follow-up at our institute. We collected data on PPCI, revascularization strategy, sociodemographic characteristics, and in-hospital complications in the years following the procedure. RESULTS A total of 5,872 patients who underwent PCI for AMI were included in the study, out of which 2,058 (35%) were women and 3,814 (65%) were men. Regarding the timing of PCI, female patients had a significantly longer median door-to-balloon time compared to male patients (136 minutes vs 108 minutes, P-value = 0.006). Female patients had a significantly higher rate of in-hospital mortality compared to male patients (5.5% vs 1.2%, P-value = 0.011). Multivariate logistic regression analysis showed that female gender, older age, and lower household income were independent predictors of longer door-to-balloon time. CONCLUSION This study highlights gender disparities in PPCI in Pakistan, with female patients facing longer door-to-balloon times and higher in-hospital mortality rates. The findings suggest the need for targeted interventions to improve the access and quality of care for female patients with AMI.
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Affiliation(s)
- Hasan Sohail
- Department of Cardiology, Sialkot Medical Complex, Sialkot, Pakistan
| | | | | | - Asif Ullah
- Department of Cardiology, KMU Institute of Medical Sciences, Kohat, Pakistan
| | | | - Jahanzeb Malik
- Department of Cardiovascular Research, Cardiovascular Analytics Group, Islamabad, Pakistan
| | - Waheed Ashraf
- Department of Cardiology, Abbas Institute of Medical Sciences, Muzaffrabad, Pakistan
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Jang SJ, Kim LK, Sobti NK, Yeo I, Cheung JW, Feldman DN, Amin NP, Narotsky DL, Goyal P, McCullough SA, Krishnan U, Zarich S, Wong SC, Kim SM. Mortality of patients with ST-segment-elevation myocardial infarction without standard modifiable risk factors among patients without known coronary artery disease: Age-stratified and sex-related analysis from nationwide readmissions database 2010-2014. Am J Prev Cardiol 2023; 14:100474. [PMID: 36923367 PMCID: PMC10009437 DOI: 10.1016/j.ajpc.2023.100474] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/06/2023] [Accepted: 02/12/2023] [Indexed: 03/06/2023] Open
Abstract
Objective The proportion of ST-segment elevation myocardial infarction (STEMI) patients without standard modifiable risk factors (SMuRFs: hypertension, diabetes, hypercholesterolemia and smoking) has increased over time. The absence of SMuRFs is known to be associated with worse outcomes, but its association with age and sex is uncertain. We sought to evaluate the association between age and sex with the outcomes of post-STEMI patients without SMuRFs among patients without preexisting coronary artery disease. Methods Patients who underwent primary PCI for STEMI were identified from the Nationwide Readmission Database of the United States. Clinical characteristics, in-hospital, and 30-day outcomes in patients with or without SMuRFs were compared in men versus women and stratified into five age groups. Results Between January 2010 and November 2014, of 474,234 patients who underwent primary PCI for STEMI, 52,242 (11.0%) patients did not have SMuRFs. Patients without SMuRFs had higher in-hospital mortality rates than those with SMuRFs. Among those without SMuRFs, the in-hospital mortality rate was significantly higher in women than men (10.6% vs 7.3%, p<0.001), particularly in older age groups. The absence of SMuRFs was associated with higher 30-day readmission-related mortality rates (0.5% vs 0.3% with SMuRFs, p<0.001). Among patients without SMuRFs, women had a higher 30-day readmission-related mortality rates than men (0.6% vs 0.4%, p<0.001). After multivariable adjustment, the increased rates of in-hospital (odds ratio 1.89 (95% CI 1.72 to 2.07) and 30-day readmission-related mortality (hazard ratio 1.30 (95% CI 1.01 to 1.67)) in patients without SMuRFs remained significant. Conclusions STEMI patients without SMuRFs have a significantly higher risk of in-hospital and 30-day mortality than those with SMuRFs. Women and older patients without SMuRFs experienced significantly higher in-hospital and 30-day readmission-related mortality.
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Affiliation(s)
- Sun-Joo Jang
- Department of Medicine, Yale New Haven Health/Bridgeport Hospital, 267 Grant St, Bridgeport, CT 06610, United States
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
| | - Luke K. Kim
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
| | - Navjot Kaur Sobti
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
| | - Ilhwan Yeo
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
| | - Jim W. Cheung
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
| | - Dmitriy N. Feldman
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
| | - Nivee P. Amin
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
- Weill Cornell Medicine Women's Heart Program, Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
| | - David L. Narotsky
- Division of Cardiology, Yale New Haven Health/Bridgeport Hospital, Bridgeport, CT, United States
| | - Parag Goyal
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, United States
| | - S. Andrew McCullough
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
| | - Udhay Krishnan
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
| | - Stuart Zarich
- Division of Cardiology, Yale New Haven Health/Bridgeport Hospital, Bridgeport, CT, United States
| | - S. Chiu Wong
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
| | - Samuel M. Kim
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Department of Medicine, Division of Cardiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, United States
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Wilmes N, van Luik EM, Vaes EWP, Vesseur MAM, Laven SAJS, Mohseni-Alsalhi Z, Meijs DAM, Dikovec CJR, de Haas S, Spaanderman MEA, Ghossein-Doha C. Exploring Sex Differences of Beta-Blockers in the Treatment of Hypertension: A Systematic Review and Meta-Analysis. Biomedicines 2023; 11:biomedicines11051494. [PMID: 37239165 DOI: 10.3390/biomedicines11051494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
AIMS In the prevention of cardiovascular morbidity and mortality, early recognition and adequate treatment of hypertension are of leading importance. However, the efficacy of antihypertensives may be depending on sex disparities. Our objective was to evaluate and quantify the sex-diverse effects of beta-blockers (BB) on hypertension and cardiac function. We focussed on comparing hypertensive female versus male individuals. METHODS AND RESULTS A systematic search was performed for studies on BBs from inception to May 2020. A total of 66 studies were included that contained baseline and follow up measurements on blood pressure (BP), heart rate (HR), and cardiac function. Data also had to be stratified for sex. Mean differences were calculated using a random-effects model. In females as compared to males, BB treatment decreased systolic BP 11.1 mmHg (95% CI, -14.5; -7.8) vs. 11.1 mmHg (95% CI, -14.0; -8.2), diastolic BP 8.0 mmHg (95% CI, -10.6; -5.3) vs. 8.0 mmHg (95% CI, -10.1; -6.0), and HR 10.8 beats per minute (bpm) (95% CI, -17.4; -4.2) vs. 9.8 bpm (95% CI, -11.1; -8.4)), respectively, in both sexes' absolute and relative changes comparably. Left ventricular ejection fraction increased only in males (3.7% (95% CI, 0.6; 6.9)). Changes in left ventricular mass and cardiac output (CO) were only reported in males and changed -20.6 g (95% CI, -56.3; 15.1) and -0.1 L (95% CI, -0.5; 0.2), respectively. CONCLUSIONS BBs comparably lowered BP and HR in both sexes. The lack of change in CO in males suggests that the reduction in BP is primarily due to a decrease in vascular resistance. Furthermore, females were underrepresented compared to males. We recommend that future research should include more females and sex-stratified data when researching the treatment effects of antihypertensives.
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Affiliation(s)
- Nick Wilmes
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, School for Cardiovascular Diseases, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Eveline M van Luik
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
| | - Esmée W P Vaes
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
| | - Maud A M Vesseur
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
| | - Sophie A J S Laven
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
| | - Zenab Mohseni-Alsalhi
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- GROW-School for Oncology and Developmental Biology, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Daniek A M Meijs
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, School for Cardiovascular Diseases, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Cédric J R Dikovec
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
| | - Sander de Haas
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- GROW-School for Oncology and Developmental Biology, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Marc E A Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- GROW-School for Oncology and Developmental Biology, Maastricht University, 6229 ER Maastricht, The Netherlands
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Chahinda Ghossein-Doha
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, School for Cardiovascular Diseases, Maastricht University, 6229 ER Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
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12
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Symptoms of Acute Myocardial Infarction as Described in Calls to Tele-Nurses and in Questionnaires: A Mixed-Methods Study. J Cardiovasc Nurs 2023; 38:150-157. [PMID: 36156094 PMCID: PMC9924961 DOI: 10.1097/jcn.0000000000000873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patient-reported symptoms of acute myocardial infarction (MI) may be affected by recall bias depending on when and where symptoms are assessed. AIM The aim of this study was to gain an understanding of patients' symptom description in more detail before and within 24 hours after a confirmed MI diagnosis. METHODS A convergent parallel mixed-methods design was used to examine symptoms described in calls between the tele-nurse and the patient compared with symptoms selected by the patient from a questionnaire less than 24 hours after hospital admission. Quantitative and qualitative data were analyzed separately and then merged into a final interpretation. RESULTS Thirty patients (median age, 67.5 years; 20 men) were included. Chest pain was the most commonly reported symptom in questionnaires (24/30). Likewise, in 19 of 30 calls, chest pain was the first complaint mentioned, usually described together with the symptom onset. Expressions used to describe symptom quality were pain, pressure, discomfort, ache, cramp, tension, and soreness. Associated symptoms commonly described were pain or numbness in the arms, cold sweat, dyspnea, weakness, and nausea. Bodily sensations, such as feeling unwell or weak, were also described. Fear and tiredness were described in calls significantly less often than reported in questionnaires ( P = .01 and P = .02), whereas "other" symptoms were more often mentioned in calls compared with answers given in the questionnaire ( P = .02). Some symptoms expressed in the calls were not listed in the questionnaire, which expands the understanding of acute MI symptoms. The results showed no major inconsistencies between datasets. CONCLUSION Patients' MI symptom descriptions in tele-calls and those reported in questionnaires after diagnosis are comparable and convergent.
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Quesada O, Van Hon L, Yildiz M, Madan M, Sanina C, Davidson L, Htun WW, Saw J, Garcia S, Dehghani P, Stanberry L, Bortnick A, Henry TD, Grines CL, Benziger C. Sex Differences in Clinical Characteristics, Management Strategies, and Outcomes of STEMI With COVID-19: NACMI Registry. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100360. [PMID: 35812987 PMCID: PMC9117757 DOI: 10.1016/j.jscai.2022.100360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 12/11/2022]
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Mehta PK, Wei J, Shufelt C, Quesada O, Shaw L, Bairey Merz CN. Gender-Related Differences in Chest Pain Syndromes in the Frontiers in CV Medicine Special Issue: Sex & Gender in CV Medicine. Front Cardiovasc Med 2021; 8:744788. [PMID: 34869650 PMCID: PMC8635525 DOI: 10.3389/fcvm.2021.744788] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/13/2021] [Indexed: 12/30/2022] Open
Abstract
Coronary artery disease (CAD) is the leading cause of morbidity and mortality among both women and men, yet women continue to have delays in diagnosis and treatment. The lack of recognition of sex-specific biological and socio-cultural gender-related differences in chest pain presentation of CAD may, in part, explain these disparities. Sex and gender differences in pain mechanisms including psychological susceptibility, the autonomic nervous system (ANS) reactivity, and visceral innervation likely contribute to chest pain differences. CAD risk scores and typical/atypical angina characterization no longer appear relevant and should not be used in women and men. Women more often have ischemia with no obstructive CAD (INOCA) and myocardial infarction, contributing to diagnostic and therapeutic equipoise. Existing knowledge demonstrates that chest pain often does not relate to obstructive CAD, suggesting a more thoughtful approach to percutaneous coronary intervention (PCI) and medical therapy for chest pain in stable obstructive CAD. Emerging knowledge regarding the central and ANS and visceral pain processing in patients with and without angina offers explanatory mechanisms for chest pain and should be investigated with interdisciplinary teams of cardiologists, neuroscientists, bio-behavioral experts, and pain specialists. Improved understanding of sex and gender differences in chest pain, including biological pathways as well as sociocultural contributions, is needed to improve clinical care in both women and men.
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Affiliation(s)
- Puja K Mehta
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute and Emory Women's Heart Center, Emory University School of Medicine, Atlanta, GA, United States
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Odayme Quesada
- Women's Heart Center, The Christ Hospital Heart Institute, Cincinnati, OH, United States
| | - Leslee Shaw
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
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Sielski J, Kaziród-Wolski K, Jurys K, Wałek P, Siudak Z. 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. J Clin Med 2021; 10:5716. [PMID: 34884418 PMCID: PMC8658305 DOI: 10.3390/jcm10235716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Janusz Sielski
- Collegium Medicum, Jan Kochanowski University in Kielce, Żeromskiego 5 St., 25-600 Kielce, Poland; (J.S.); (K.K.-W.); (Z.S.)
| | - Karol Kaziród-Wolski
- Collegium Medicum, Jan Kochanowski University in Kielce, Żeromskiego 5 St., 25-600 Kielce, Poland; (J.S.); (K.K.-W.); (Z.S.)
| | - Karolina Jurys
- Hospital Emergency Department, Provincial Hospital, 25-736 Kielce, Poland;
| | - Paweł Wałek
- Collegium Medicum, Jan Kochanowski University in Kielce, Żeromskiego 5 St., 25-600 Kielce, Poland; (J.S.); (K.K.-W.); (Z.S.)
| | - Zbigniew Siudak
- Collegium Medicum, Jan Kochanowski University in Kielce, Żeromskiego 5 St., 25-600 Kielce, Poland; (J.S.); (K.K.-W.); (Z.S.)
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16
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Analysis of the hospitalization time impact on hospital mortality from acute myocardial infarction. EUREKA: HEALTH SCIENCES 2021. [DOI: 10.21303/2504-5679.2021.001813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Diseases of the circulatory system and their most severe form – acute myocardial infarction (AMI) – is one of the most important problems of modern medicine due to the steady increase in morbidity, negative impact on quality of life, early disability of patients. 19.5 % of patients die from AMI, 50 % among which die 90-120 minutes after the first symptoms of the disease.
The aim of the research was to analyse the impact of hospitalization on the mortality of patients with AMI and predict the risk of death in case of untimely hospitalization of this category of patients.
Materials and methods. We have conducted a retrospective analysis of 876 medical records of patients diagnosed with AMI who were treated in the cardiology department of Kharkiv Regional Clinical Hospital in 2019. During the study, we have used retrospective, logical, medical and statistical methods. Odds ratios and a 95 % confidence interval were also calculated.
Results and discussion. The research revealed the impact of hospitalization on the organization of medical care and hospital mortality of patients with AMI. It was found that the largest share of patients with AMI, both among the dead and those who left the hospital, were hospitalized in the period from 2 to 12 hours from the onset of the disease (49.6 % and 52.33 %, respectively), as well as in period after 24 hours – 28.00 % and 21.70 %, respectively. The largest share of patients with AMI, regardless of the time of hospitalization were persons older than 60 years. The results of the analysis showed that in the period up to 2 h from the onset of the disease, the share of hospitalized patients with more severe heart muscle damage (presence of Q wave) was 91.35 % against 8.65 % of patients with AMI without ST segment elevation. It should be noted that in almost 50 % of cases, patients with AMI without ST segment elevation were hospitalized after 24 h from the onset of the disease. At the same time, the largest share of deaths in this group of patients was observed in the hospital stay from 12 to 24 hours. According to the results of the research, risk factors for fatal outcome in AMI were identified, in particular male gender, the presence of an established ECG diagnosis of NSTEMI, conducting SKA in patients with AMI. It was also found that timely hospitalization of patients within the therapeutic window reduces the chances of hospital mortality by 52 %.
Conclusions. The obtained data indicate a strong relationship between the time of hospitalization and the organization of medical care and hospital mortality of patients with AMI. It is reliably established that timely hospitalization of patients within the therapeutic window reduces the chances of hospital mortality by 52 %: HS is 0.483 (95 % CI 0.238 – 0.981), p=0.175.
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Bessonov IS, Kuznetsov VA, Gorbatenko EA, Dyakova AO, Sapozhnikov SS. Influence of Total Ischemic Time on Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction. ACTA ACUST UNITED AC 2021; 61:40-46. [PMID: 33734047 DOI: 10.18087/cardio.2021.2.n1314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/11/2020] [Accepted: 11/24/2020] [Indexed: 11/18/2022]
Abstract
Aim To evaluate the effect of the total time of myocardial ischemia on results of the treatment of patients with ST segment elevation acute myocardial infarction (STEMI) who underwent percutaneous coronary interventions (PCI).Material and methods This study used data from a hospital register for PCI in STEMI from 2006 through 2017. 1649 patients were included. Group 1 consisted of 604 (36.6 %) patients with a total time of myocardial ischemia not exceeding 1880 min; group 2 included 531 (32.2 %) patients with a duration of myocardial ischemia from 180 to 360 min; and group 3 included 514 (31.2 %) patients with a duration of myocardial ischemia longer than 360 min.Results Mortality was lower in group 1 (2.3 %) than in groups 2 and 3 (6.2 and 7.2 %, respectively; p1-2=0.001; p1-3<0.001; p2-3=0.520). The incidence of major cardiac complications ("adverse cardiac events", MACE) was lower in group 1 (4.1 %) than in groups 2 and 3 (7.3 and 9.5 %, respectively, p1-2=0.020; p1-3<0.001; p2-3=0.200). The incidence of no-reflow phenomenon was higher in group 3 (9.7 %) than in groups 2 and 3 (4.5 and 5.3 %, respectively (p1-2=0.539; p1-3=0.001; p2-3=0.005). The major factors associated with the increased total time of myocardial ischemia >180 min were age (odd ratio, OR, 1.01 at 95 % confidence interval, CI, 1.0 to 1.02; р=0.044), female gender (OR, 1.64 at 95 % CI 1.26 to 2.13; р<0.001), chronic kidney disease (OR 1.82 at 95 % CI 1.21 to 2.74; р=0.004). Performing prehospital thrombolysis was associated with a decrease in the total time of myocardial ischemia (OR 0.4 at 95 % CI 0.31 to 0.51; р<0.001). A strong direct correlation was observed between the total time of myocardial ischemia and the time from the onset of pain syndrome to hospitalization (r=0.759; р<0.001).Conclusion The total time of myocardial ischemia >180 min was associated with increased mortality and development of MACE. The total time of myocardial ischemia > 360 min was associated with increased incidence of the no-reflow phenomenon. The major predictors for the time of myocardial ischemia >180 min included age, female gender, and chronic kidney disease. The use of pharmacoinvasive strategy was associated with an increased number of patients with a total duration of myocardial ischemia <180 min. The contribution of the time of prehospital delay to the total time of myocardial ischemia was greater than the contribution of the "door-to-balloon" time. The time of prehospital delay showed a strong direct correlation with the total time of myocardial ischemia.
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Affiliation(s)
- I S Bessonov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk
| | - V A Kuznetsov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk
| | - E A Gorbatenko
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk
| | - A O Dyakova
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk
| | - S S Sapozhnikov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk
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Barradas-Pires A, Boyalla V, Dimopoulos K. Gender, an additional cardiovascular risk factor? Int J Cardiol 2021; 331:270-272. [PMID: 33607191 DOI: 10.1016/j.ijcard.2021.02.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/04/2021] [Accepted: 02/11/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Ana Barradas-Pires
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, United Kingdom; Autonomous University of Barcelona, Barcelona, Spain.
| | - Vennela Boyalla
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, United Kingdom; National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, United Kingdom; National Heart & Lung Institute, Imperial College London, United Kingdom
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Steitieh DA, Lu DY, Kalil RK, Kim LK, Sharma G, Yeo I, Feldman DN, Cheung JW, Mecklai A, Paul TK, Ascunce RR, Amin NP. Sex-based differences in revascularization and 30-day readmission after ST-segment-elevation myocardial infarction in the United States. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 31:41-47. [PMID: 33358184 DOI: 10.1016/j.carrev.2020.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/13/2020] [Accepted: 12/14/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death for women in the United States. Revascularization is considered the standard of care for treatment of ST-segment elevation myocardial infarction (STEMI) and is known to reduce readmission. However there is a paucity of data that examines the sex-dependent impact of revascularization on readmission. We aimed to investigate sex differences in revascularization rates, 30-day readmission rates, and primary cause of readmissions following STEMIs. METHODS STEMI hospitalizations were selected in the Nationwide Readmissions Database from 2010 to 2014. Revascularization rates, 30-day readmission rates, and primary cause of readmission were examined. Interaction between sex and revascularization was assessed. Multivariable regression analysis was performed to identify predictors of 30-day readmission and revascularization for both sexes. RESULTS 219,944 women and 489,605 men were admitted with STEMIs. Women were more likely to be older, and have more comorbidities. Women were less likely to undergo revascularization by percutaneous coronary intervention (adjusted odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.66-0.70) or coronary artery bypass graft surgery (adjusted OR 0.40; CI 0.39-0.44). Women had higher 30-day readmission rates (15.7% vs. 10.8%, p < 0.001; OR 1.20, CI 1.17-1.23), and revascularization in women was not associated with a decreased likelihood of 30-day readmission. The primary cardiac cause of readmission in women was heart failure. CONCLUSION Compared to men, women with STEMIs had lower rates of revascularization and higher rates of 30-day readmission. When revascularized, women were still more likely to be readmitted as compared to non-revascularized women.
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Affiliation(s)
- Diala A Steitieh
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor, New York, NY 10021, United States of America.
| | - Daniel Y Lu
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor, New York, NY 10021, United States of America
| | - Ramsey K Kalil
- Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 525 East 68th Street, Box 130, New York, NY 10065, United States of America
| | - Luke K Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor, New York, NY 10021, United States of America; Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor - Cardiology, New York, NY 10021, United States of America
| | - Garima Sharma
- Ciccarone Center for Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, 601 N. Caroline Street, 7th Floor, Baltimore, MD 21287, United States of America
| | - Ilhwan Yeo
- Division of Cardiology, New York Presbyterian Queens Hospital, 56-45 Main Street, Flushing, NY 11355, United States of America
| | - Dmitriy N Feldman
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor, New York, NY 10021, United States of America; Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor - Cardiology, New York, NY 10021, United States of America
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor, New York, NY 10021, United States of America; Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor - Cardiology, New York, NY 10021, United States of America
| | - Alicia Mecklai
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor, New York, NY 10021, United States of America; Weill Cornell Women's Heart Program, Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8th Floor - Cardiology, New York, NY 10021, United States of America
| | - Tracy K Paul
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor, New York, NY 10021, United States of America; Weill Cornell Women's Heart Program, Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8th Floor - Cardiology, New York, NY 10021, United States of America
| | - Rebecca R Ascunce
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor, New York, NY 10021, United States of America; Weill Cornell Women's Heart Program, Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8th Floor - Cardiology, New York, NY 10021, United States of America
| | - Nivee P Amin
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor, New York, NY 10021, United States of America; Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8(th) Floor - Cardiology, New York, NY 10021, United States of America; Weill Cornell Women's Heart Program, Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, 1305 York Ave, 8th Floor - Cardiology, New York, NY 10021, United States of America
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Tizón-Marcos H, Vaquerizo B, Marrugat J, Ariza A, Carrillo X, Muñoz JF, Cárdenas M, García-Picart J, Rojas SG, Tomás-Querol C, Massotti M, Lidón RM, Jiménez J, Martí-Almor J, Farré N, Pérez-Fernández S, Curós A, Mauri Ferré J. Complicaciones y mortalidad a 30 días y al año en pacientes con primer IAMCEST tratados en la red Codi IAM en 2010-2016: análisis del efecto del género. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2020.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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21
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Tizón-Marcos H, Vaquerizo B, Marrugat J, Ariza A, Carrillo X, Muñoz JF, Cárdenas M, García-Picart J, Rojas SG, Tomás-Querol C, Massotti M, Lidón RM, Jiménez J, Martí-Almor J, Farré N, Pérez-Fernández S, Curós A, Mauri Ferré J. 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. ACTA ACUST UNITED AC 2020; 74:674-681. [PMID: 32660910 DOI: 10.1016/j.rec.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/19/2020] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Helena Tizón-Marcos
- Servicio de Cardiología, Hospital del Mar, Grupo de Investigación Biomédica en Enfermedades del Corazón, Instituto Hospital del Mar de Investigaciones Médica (IMIM), Barcelona, Spain; Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain.
| | - Beatriz Vaquerizo
- Servicio de Cardiología, Hospital del Mar, Grupo de Investigación Biomédica en Enfermedades del Corazón, Instituto Hospital del Mar de Investigaciones Médica (IMIM), Barcelona, Spain; Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Jaume Marrugat
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Grupo de Trabajo en Epidemiología y Genética Cardiovascular, Instituto Hospital del Mar de Investigaciones Médica (IMIM), Barcelona, Spain
| | - Albert Ariza
- Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Carrillo
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Juan-Francisco Muñoz
- Servicio de Cardiología, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Mérida Cárdenas
- Servicio de Cardiología, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Joan García-Picart
- Servicio de Cardiología, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | | | - Carlos Tomás-Querol
- Servicio de Cardiología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Mònica Massotti
- Servicio de Cardiología, Hospital Clínic i Provincial, Barcelona, Spain
| | - Rosa-Maria Lidón
- Servicio de Cardiología, Hospital Universitari de la Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Josep Jiménez
- Departament de Salut, Generalitat de Catalunya, Barcelona, Spain
| | - Julio Martí-Almor
- Servicio de Cardiología, Hospital del Mar, Grupo de Investigación Biomédica en Enfermedades del Corazón, Instituto Hospital del Mar de Investigaciones Médica (IMIM), Barcelona, Spain; Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Núria Farré
- Servicio de Cardiología, Hospital del Mar, Grupo de Investigación Biomédica en Enfermedades del Corazón, Instituto Hospital del Mar de Investigaciones Médica (IMIM), Barcelona, Spain; Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Sílvia Pérez-Fernández
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Grupo de Trabajo en Epidemiología y Genética Cardiovascular, Instituto Hospital del Mar de Investigaciones Médica (IMIM), Barcelona, Spain
| | - Antoni Curós
- Departament de Salut, Generalitat de Catalunya, Barcelona, Spain
| | - Josepa Mauri Ferré
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Departament de Salut, Generalitat de Catalunya, Barcelona, Spain
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22
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Evaluation of sex differences in patients with ST-elevated myocardial infarction: an observational cohort study in Amsterdam and surrounding region. Neth Heart J 2020; 28:595-603. [PMID: 32529555 PMCID: PMC7596126 DOI: 10.1007/s12471-020-01435-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
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.
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23
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Bautz B, Schneider JI. High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update). Emerg Med Clin North Am 2020; 38:453-498. [PMID: 32336336 DOI: 10.1016/j.emc.2020.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.
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Affiliation(s)
- Benjamin Bautz
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Jeffrey I Schneider
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA; Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA.
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24
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van Oosterhout REM, de Boer AR, Maas AHEM, Rutten FH, Bots ML, Peters SAE. Sex Differences in Symptom Presentation in Acute Coronary Syndromes: A Systematic Review and Meta-analysis. J Am Heart Assoc 2020; 9:e014733. [PMID: 32363989 PMCID: PMC7428564 DOI: 10.1161/jaha.119.014733] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 01/13/2020] [Indexed: 12/24/2022]
Abstract
Background Timely recognition of patients with acute coronary syndromes (ACS) is important for successful treatment. Previous research has suggested that women with ACS present with different symptoms compared with men. This review assessed the extent of sex differences in symptom presentation in patients with confirmed ACS. Methods and Results A systematic literature search was conducted in PubMed, Embase, and Cochrane up to June 2019. Two reviewers independently screened title-abstracts and full-texts according to predefined inclusion and exclusion criteria. Methodological quality was assessed using the Newcastle-Ottawa Scale. Pooled odds ratios (OR) with 95% CI of a symptom being present were calculated using aggregated and cumulative meta-analyses as well as sex-specific pooled prevalences for each symptom. Twenty-seven studies were included. Compared with men, women with ACS had higher odds of presenting with pain between the shoulder blades (OR 2.15; 95% CI, 1.95-2.37), nausea or vomiting (OR 1.64; 95% CI, 1.48-1.82) and shortness of breath (OR 1.34; 95% CI, 1.21-1.48). Women had lower odds of presenting with chest pain (OR 0.70; 95% CI, 0.63-0.78) and diaphoresis (OR 0.84; 95% CI, 0.76-0.94). Both sexes presented most often with chest pain (pooled prevalences, men 79%; 95% CI, 72-85, pooled prevalences, women 74%; 95% CI, 72-85). Other symptoms also showed substantial overlap in prevalence. The presence of sex differences has been established since the early 2000s. Newer studies did not materially change cumulative findings. Conclusions Women with ACS do have different symptoms at presentation than men with ACS, but there is also considerable overlap. Since these differences have been shown for years, symptoms should no longer be labeled as "atypical" or "typical."
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Affiliation(s)
- Roos E. M. van Oosterhout
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Annemarijn R. de Boer
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- Dutch Heart FoundationThe Haguethe Netherlands
| | - Angela H. E. M. Maas
- Department of CardiologyRadboud University Medical CenterNijmegenthe Netherlands
| | - Frans H. Rutten
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Sanne A. E. Peters
- Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
- The George Institute for Global HealthUniversity of OxfordUnited Kingdom
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25
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Feng L, Li M, Xie W, Zhang A, Lei L, Li X, Gao R, Wu Y. Prehospital and in-hospital delays to care and associated factors in patients with STEMI: an observational study in 101 non-PCI hospitals in China. BMJ Open 2019; 9:e031918. [PMID: 31712344 PMCID: PMC6858215 DOI: 10.1136/bmjopen-2019-031918] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 09/23/2019] [Accepted: 10/18/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES To describe the prehospital and in-hospital delays to care and factors associated with the delays among patients with ST-segment elevation myocardial infarction (STEMI) in non-percutaneous coronary intervention (PCI) hospitals in China. DESIGN, SETTING AND PARTICIPANTS We analysed data from a large registry-based quality of care improvement trial conducted from 2011 to 2014 among 101 non-PCI hospitals in China. A total of 7312 patients with STEMI were included. Prehospital delay was defined as time from symptom onset to hospital arrival >120 min, first ECG delay as time from arrival to first ECG >10 min, thrombolytic therapy delay as time from first ECG to thrombolytic therapy >10 min and in-hospital delay as time from arrival to thrombolytic therapy >30 min. Logistic regressions with generalised estimating equations were preformed to identify the factors associated with each delay. RESULTS The rates of prehospital delay, first ECG delay, thrombolytic therapy delay and in-hospital delay were 67.1%, 31.4%, 85.8% and 67.8%, respectively. Patients who were female, older than 65 years old, illiterate, farmers, onset during late night and forenoon, had heart rate ≥100 beats/m at admission were more likely and patients who had history of myocardial infarction, hypertension or SBP <90 mm Hg at admission were less likely to have prehospital delay. First ECG delay was more likely to take place in patients arriving on regular hours. Thrombolytic therapy delay rate was lower in patients who had prehospital delay or first ECG delay but higher in those with heart rate ≥100 beats/m at admission. In-hospital delay rate was lower in patients with a history of dyslipidaemia and those who arrived during regular hours. CONCLUSION Chinese patients with STEMI in low medical resource areas suffered severe prehospital and in-hospital delays to care. Future efforts should be made to improve the prehospital delay among vulnerable populations with low socioeconomic status. TRIAL REGISTRATION NUMBER NCT01398228; Post-results.
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Affiliation(s)
- Lin Feng
- Clinical Research Institute, Peking University First Hospital, Beijing, China
- Peking University Clinical Research Institute, Beijing, China
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Min Li
- Clinical Epidemiology and EBM Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing, China
| | - Wuxiang Xie
- Peking University Clinical Research Institute, Beijing, China
| | - Aihua Zhang
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Licheng Lei
- The Department of Cardiology, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Xian Li
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - R Gao
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Beijing, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Beijing, China
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
- Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
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26
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Ferry AV, Anand A, Strachan FE, Mooney L, Stewart SD, Marshall L, Chapman AR, Lee KK, Jones S, Orme K, Shah ASV, Mills NL. Presenting Symptoms in Men and Women Diagnosed With Myocardial Infarction Using Sex-Specific Criteria. J Am Heart Assoc 2019; 8:e012307. [PMID: 31431112 PMCID: PMC6755854 DOI: 10.1161/jaha.119.012307] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/24/2019] [Indexed: 12/12/2022]
Abstract
Background Sex-specific criteria are recommended for the diagnosis of myocardial infarction, but the impact of these on presenting characteristics is unknown. Methods and Results We evaluated patient-reported symptoms in 1941 patients (39% women) with suspected acute coronary syndrome attending the emergency department in a substudy of a prospective trial. Standardized criteria defined typical and atypical presentations based on pain nature, location, radiation, and additional symptoms. Diagnosis of myocardial infarction was adjudicated using a high-sensitivity cardiac troponin I assay with sex-specific thresholds (>16 ng/L women, >34 ng/L men). Patients identified who were missed by the contemporary assay with a uniform threshold (≥50 ng/L) were reclassified by this approach. Type 1 myocardial infarction was diagnosed in 16% (184/1185) of men and 12% (90/756) of women, with 9 (5%) men and 27 (30%) women reclassified using high-sensitivity cardiac troponin I and sex-specific thresholds. Chest pain was the presenting symptom in 91% (1081/1185) of men and 92% (698/756) of women. Typical symptoms were more common in women than in men with myocardial infarction (77% [69/90] versus 59% [109/184]; P=0.007), and differences were similar in those reclassified (74% [20/27] versus 44% [4/9]; P=0.22). The presence of ≥3 typical features was associated with a positive likelihood ratio for the diagnosis of myocardial infarction in women (positive likelihood ratio, 1.18; 95% CI, 1.03-1.31) but not in men (positive likelihood ratio 1.09; 95% CI, 0.96-1.24). Conclusions Typical symptoms are more common and have greater predictive value in women than in men with myocardial infarction whether or not they are diagnosed using sex-specific criteria. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier NCT01852123.
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Affiliation(s)
- Amy V. Ferry
- BHF Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
| | - Atul Anand
- BHF Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
| | - Fiona E. Strachan
- BHF Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
| | | | - Stacey D. Stewart
- BHF Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
| | - Lucy Marshall
- BHF Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
| | - Andrew R. Chapman
- BHF Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
| | - Simon Jones
- BHF Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
| | - Katherine Orme
- BHF Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
| | - Anoop S. V. Shah
- BHF Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
- Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghUnited Kingdom
| | - Nicholas L. Mills
- BHF Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
- Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghUnited Kingdom
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27
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Bessonov IS, Kuznetsov VA, Ziryanov IP, Sapozhnikov SS. [Association of Strategy of Direct Stenting of Infarct-Related Artery with Reduction of Mortality in Woman with ST-Elevation Myocardial Infarction]. ACTA ACUST UNITED AC 2019; 59:5-11. [PMID: 31002033 DOI: 10.18087/cardio.2019.4.10246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 04/16/2019] [Indexed: 11/18/2022]
Abstract
Aim of this study was to evaluate the impact of direct stenting (DS) strategy on the results of treatment of female patients with STelevation myocardial infarction (STEMI) undergoing percutaneous coronary interventions (PCIs). MATERIALS AND METHODS Among 1297 patients with STEMI admitted to the coronary care unit and subjected to PCIs from 2006 to 2015 there were 330 women (25.4 %). Data from 161 women (48.8 %) who underwent DS were compared with those from 169 women who underwent indirect stenting (IS). Among patients of IS group in 148 (87.6 %) stenting was performed after predilation, in 7 (4.1 %) after manual thrombus aspiration, and in 14 (8.3 %) after combination of predilation and thrombus aspiration. RESULTS The rate of angiographic success was higher in the DS group (97.5 vs. 87.6 %, р<0.001). Rates of deaths (4.3 vs. 11.8 %; p=0.013), major adverse cardiac events (MACE)(4.3 vs. 13 %; p=0.005), and no-reflow (1.9 % vs. 11.2 %; p=0.013) were significantly lower in the DS group. There were no differences in rates of recurrent myocardial infarction and access site complications. Following propensity score matching, each group contained 78 patients. Rates of MACE (2.6 vs. 14.1 %; p=0.009) and deaths (2.6 vs. 12.8 %; p=0.016) remained significantly lower in the DS group. After multivariate adjustment, DS strategy was independently associated with lower mortality (odds ratio [OR] 0.29; 95 % confidence interval [CI] 0.09-0.97; p=0.04) and MACE (OR=0.28; 95 %CI 0.09-0.087; p=0.03). CONCLUSION DS strategy in STEMI female patients turned out to be safe and effective technique.
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Affiliation(s)
- I S Bessonov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences
| | - V A Kuznetsov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences
| | - I P Ziryanov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences
| | - S S Sapozhnikov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences
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28
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Hollinger A, Gayat E, Féliot E, Paugam-Burtz C, Fournier MC, Duranteau J, Lefrant JY, Leone M, Jaber S, Mebazaa A, Arrigo M. Gender and survival of critically ill patients: results from the FROG-ICU study. Ann Intensive Care 2019; 9:43. [PMID: 30927096 PMCID: PMC6441070 DOI: 10.1186/s13613-019-0514-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/06/2019] [Indexed: 02/06/2023] Open
Abstract
Purpose Few studies analyzed gender-related outcome differences of critically ill patients and found inconsistent results. This study aimed to test the independent association of gender and long-term survival of ICU patients.
Materials and methods FROG-ICU was a prospective, observational, multi-center cohort designed to investigate the long-term mortality of critically ill adult patients. The primary endpoint of this study was 1-year mortality after ICU admission of women compared to men. Results The study included 2087 patients, 726 women and 1361 men. Women and men had similar baseline characteristics, clinical presentation, and disease severity. No significant difference in 1-year mortality was found between women and men (34.9% vs. 37.9%, P = 0.18). After multivariable adjustment, no difference in the hazard of death was observed [HR 0.99 (95% CI 0.77–1.28)]. Similar 1-year survival between women and men was found in a propensity score-matched patient cohort of 506 patients [HR 0.79 (95% CI 0.54–1.14)].
Conclusion Women constituted one-third of the population of critically ill patients and were unexpectedly similar to men regarding demographic characteristics, clinical presentation, and disease severity and had similar risk of death at 1 year after ICU admission. Trial registration ClinicalTrials.gov NCT01367093; registered on June 6, 2011. Electronic supplementary material The online version of this article (10.1186/s13613-019-0514-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexa Hollinger
- Department of Anesthesiology, Critical Care and Burn Unit, Hôpitaux Universitaires Saint Louis - Lariboisière, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot - Paris 7, Sorbonne Paris Cité, UMR-S 942, INSERM, Paris, France.,Intensive Care Unit, Assistance Publique - Hopitaux de Paris, University Hospital Ambroise Paré, 26930, Boulogne-Billancourt, France.,Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Etienne Gayat
- Department of Anesthesiology, Critical Care and Burn Unit, Hôpitaux Universitaires Saint Louis - Lariboisière, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot - Paris 7, Sorbonne Paris Cité, UMR-S 942, INSERM, Paris, France.,Intensive Care Unit, Assistance Publique - Hopitaux de Paris, University Hospital Ambroise Paré, 26930, Boulogne-Billancourt, France
| | - Elodie Féliot
- Department of Anesthesiology, Critical Care and Burn Unit, Hôpitaux Universitaires Saint Louis - Lariboisière, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot - Paris 7, Sorbonne Paris Cité, UMR-S 942, INSERM, Paris, France.,Intensive Care Unit, Assistance Publique - Hopitaux de Paris, University Hospital Ambroise Paré, 26930, Boulogne-Billancourt, France
| | - Catherine Paugam-Burtz
- Anesthesiology and Perioperative Care Medicine Department, APHP Hopital Beaujon and University, Paris 7, France
| | - Marie-Céline Fournier
- Department of Anesthesiology, Critical Care and Burn Unit, Hôpitaux Universitaires Saint Louis - Lariboisière, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot - Paris 7, Sorbonne Paris Cité, UMR-S 942, INSERM, Paris, France.,Intensive Care Unit, Assistance Publique - Hopitaux de Paris, University Hospital Ambroise Paré, 26930, Boulogne-Billancourt, France
| | - Jacques Duranteau
- Département d'Anesthésie-Réanimation, UMR 942, Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Jean-Yves Lefrant
- Service des Réanimations, CHU Nîmes, Place du Pr Robert Debré, 30029, Nîmes Cedex, France
| | - Marc Leone
- Department of Anaesthesiology and Critical Care Medicine, AP-HM, Hôpital Nord, Marseille, France
| | - Samir Jaber
- Department of Anesthesiology and Intensive Care (DAR B), Saint Eloi University Hospital, Montpellier, France.,PhyMedExp, INSERM U-1046, CNRS, Montpellier University, Montpellier, France
| | - Alexandre Mebazaa
- Department of Anesthesiology, Critical Care and Burn Unit, Hôpitaux Universitaires Saint Louis - Lariboisière, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot - Paris 7, Sorbonne Paris Cité, UMR-S 942, INSERM, Paris, France. .,Intensive Care Unit, Assistance Publique - Hopitaux de Paris, University Hospital Ambroise Paré, 26930, Boulogne-Billancourt, France. .,Department of Anesthesiology and Intensive Care, Saint Louis - Lariboisière University Hospitals, 2 rue Ambroise Paré, 75010, Paris, France.
| | - Mattia Arrigo
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
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Lim SC, Rahman A, Yaacob NM. Pre-Hospital Factors Influencing Time of Arrival at Emergency Departments for Patients with Acute ST-Elevation Myocardial Infarction. Malays J Med Sci 2019; 26:87-98. [PMID: 30914896 PMCID: PMC6419865 DOI: 10.21315/mjms2019.26.1.8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/26/2018] [Indexed: 11/21/2022] Open
Abstract
Background Pre-hospital delay is currently a major factor limiting early reperfusion among ST-elevation myocardial infarction (STEMI) patients worldwide. This study aims to determine pre-hospital factors affecting symptom-to-door time among STEMI patients in Malaysia. Methods This cross-sectional study included 222 STEMI patients admitted to two tertiary hospitals in Malaysia. By determining symptom-to-door time, the study population was categorised into two definitive treatment seeking groups: early (≤ 3 h) and delayed (> 3 h). Data was collected focusing on socio-demographical data, risk factors and comorbidities, clinical presentation, situational factors and action taken by patients. Results The mean age of our patients was 58.0 (SD = 11.9) years old, and the population consisted of 186 (83.8%) males and 36 (16.2%) females. Our study found that the median symptom-to-door time was 130.5 (IQR 240) min, with 64% of subjects arriving early and 36% arriving late. Pre-hospital delays were found to be significant among females (adj OR = 2.42; 95% CI: 1.02, 5.76; P = 0.046), patients with recurrence of similar clinical presentations (adj OR = 2.74; 95% CI: 1.37, 5.46; P = 0.004), patients experiencing atypical symptoms (adj OR = 2.64; 95% CI: 1.11, 6.31; P = 0.029) and patients who chose to have their first medical contact (FMC) for their symptoms with a general practitioner (adj OR = 2.80; 95% CI: 1.20, 6.56; P = 0.018). However, patients with hyperlipidaemia (adj OR = 0.46; 95% CI: 0.23, 0.93; P = 0.030), self-perceived cardiac symptoms (adj OR = 0.36; 95% CI: 0.17, 0.73; P = 0.005) and symptoms that began in public places (adj OR = 0.21; 95% CI: 0.06, 0.69; P = 0.010) tended to seek treatment earlier. Conclusion The symptom-to-door time among the Malaysian population is shorter in comparison to other developing countries. Nevertheless, identified, modifiable pre-hospital factors can be addressed to further shorten symptom-to-door time among STEMI patients.
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Affiliation(s)
- See Choo Lim
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan
| | - Andey Rahman
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan
| | - Najib Majdi Yaacob
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan
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Evolution of ST-Elevation Acute Myocardial Infarction Prevalence by Gender Assessed Age Pyramid Analysis-The Piramyd Study. J Clin Med 2018; 7:jcm7120509. [PMID: 30513879 PMCID: PMC6306837 DOI: 10.3390/jcm7120509] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/12/2018] [Accepted: 11/23/2018] [Indexed: 12/30/2022] Open
Abstract
Introduction: Recent studies reported a decrease in the incidence of acute myocardial infarction. This favorable evolution does not extend to young women. The interaction between gender, risk factors and myocardial infarction incidence remains controversial. Objective: To compare the evolution of the age pyramid of patients with ST-elevation myocardial infarction (STEMI) according to gender. Methods: Data from patients with STEMI managed in pre-hospital settings prospectively collected in the greater Paris area. Evolution of patient demographics and risk factors was investigated. Results: 28,249 patients with STEMI were included in the registry between 2002 and 2014, 21,883 (77%) males and 6366 (23%) females. The sex ratio did not significantly vary over the study period (p = 0.4). Median patient age was 60.1 years (51.1–73.0) and was significantly different between males and females, respectively 57.9 (50.0–68.3) vs. 72.9 years (58.3–82.2) (p = 0.0004). The median age of males significantly (p = 0.0044) increased from 57.6 (50.1–70.0) in 2002 to 58.1 years (50.5–67.8) in 2014. The median age of females significantly (p = 0.0006) decreased from 73.7 (57.9–81.8) to 69.6 years (57.0–82.4). The median gap between the age of men and women significantly (p = 0.0002) decreased, from 16.1 to 11.5 years. Prevalence of risk factors was unchanged or decreased except for hypertension which significantly increased in males. The rate of STEMI without reported risk factors increased in both males and females. Conclusion: The age of STEMI onset significantly decreased in females, whereas it significantly increased in males. The prevalence of risk factors decreased in males, whereas no significant variation was found in females.
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Meyer MR, Bernheim AM, Kurz DJ, O’Sullivan CJ, Tüller D, Zbinden R, Rosemann T, Eberli FR. Gender differences in patient and system delay for primary percutaneous coronary intervention: current trends in a Swiss ST-segment elevation myocardial infarction population. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:283-290. [DOI: 10.1177/2048872618810410] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Women with ST-segment elevation myocardial infarction (STEMI) experience greater delays for percutaneous coronary intervention-facilitated reperfusion than men. Whether women and men benefit equally from current strategies to reduce ischaemic time and whether there are gender differences in factors determining delays is unclear. Methods: Patient delay (symptom onset to first medical contact) and system delay (first medical contact to percutaneous coronary intervention-facilitated reperfusion) were compared between women ( n=967) and men ( n=3393) in a Swiss STEMI treatment network. Trends from 2000 to 2016 were analysed, with additional comparisons between three time periods (2000–2005, 2006–2011 and 2012–2016). Factors predicting delays and hospital mortality were determined by multivariate regression modelling. Results: Female gender was independently associated with greater patient delay ( P=0.02 vs. men), accounting for a 12% greater total ischaemic time among women in 2012–2016 (median 215 vs. 192 minutes, P<0.001 vs. men). From 2000–2005 to 2012–2016, median system delay was reduced by 18 and 25 minutes in women and men, respectively ( P<0.0001 for trend, P=n.s. for gender difference). Total occlusion of the culprit artery, stent thrombosis, a Killip class of 3 or greater, and presentation during off-hours predicted delays in men, but not in women. A Killip class of 3 or greater and age, but not gender or delays, were independently associated with hospital mortality. Conclusions: STEMI-related ischaemic time in women remains greater than in men due to persistently greater patient delays. In contrast to men, clinical signs of ongoing chest discomfort do not predict delays in women, suggesting that female STEMI patients are less likely to attribute symptoms to a condition requiring urgent treatment.
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Affiliation(s)
- Matthias R Meyer
- Division of Cardiology, Triemli Hospital, Zurich, Switzerland
- Institute of Primary Care, University of Zurich, Switzerland
| | | | - David J Kurz
- Division of Cardiology, Triemli Hospital, Zurich, Switzerland
| | | | - David Tüller
- Division of Cardiology, Triemli Hospital, Zurich, Switzerland
| | - Rainer Zbinden
- Division of Cardiology, Triemli Hospital, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Switzerland
| | - Franz R Eberli
- Division of Cardiology, Triemli Hospital, Zurich, Switzerland
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