Sex-Related Differences in Heart Failure After ST-Segment Elevation Myocardial Infarction

Evaluation of a nomogram model for predicting in-hospital mortality risk in patients with acute ST-elevation myocardial infarction and acute heart failure post-PCI

OBJECTIVES

This study aims to identify the risk factors contributing to in-hospital mortality in patients with acute ST-elevation myocardial infarction (STEMI) who develop acute heart failure (AHF) post-percutaneous coronary intervention (PCI). Based on these factors, we constructed a nomogram to effectively identify high-risk patients.

METHODS

In the study, a collective of 280 individuals experiencing an acute STEMI who then developed AHF following PCI were evaluated. These subjects were split into groups for training and validation purposes. Utilizing lasso regression in conjunction with logistic regression analysis, researchers sought to pinpoint factors predictive of mortality and to create a corresponding nomogram for forecasting purposes. To evaluate the model's accuracy and usefulness in clinical settings, metrics such as the concordance index (C-index), calibration curves, and decision curve analysis (DCA) were employed.

RESULTS

Key risk factors identified included blood lactate, D-dimer levels, gender, left ventricular ejection fraction (LVEF), and Killip class IV. The nomogram demonstrated high accuracy (C-index: training set 0.838, validation set 0.853) and good fit (Hosmer-Lemeshow test: χ2 = 0.545, p = 0.762), confirming its clinical utility.

CONCLUSION

The developed clinical prediction model is effective in accurately forecasting mortality among patients with acute STEMI who develop AHF after PCI.

β-blockades and the risk of atrial fibrillation in patients with cardiovascular diseases

Background

β-blockers have been widely used in patients with extensive cardiovascular disease (CVD) and have provided benefits. However, they are more likely to cause symptomatic bradycardia, hypotension, or glucose metabolism disorders, which may lead to an increased risk of atrial fibrillation (AF), but evidence is lacking.

Aims

This study was to analyze the association between the use of β-blockers and the risk of developing AF.

Methods

This nationwide, prospective cohort study utilized data from the 2013-2020 National Health and Nutrition Examination Survey (NHANES). The patients were stratified into a β-blocker treatment group (n = 2585) and a non-β-blocker treatment group (n = 8525). Univariate and multivariate logistic regression analyses were performed to identify the relationship between β-blockades and the risk of AF. Propensity matching analysis was used to balance patient baseline characteristics and to control for confounders.

Results

A total of 11,110 subjects were included in this study (mean [SD] age, 59.89 [15.07] years; 5657 [49.7%] males). A total of 111/2585 subjects developed AF in the β-blocker treatment group, and 75/8525 developed AF in the non-β-blocker treatment group (incidence rate, 4.2% vs. 0.8%). Compared with the non-β-blocker group, the β-blocker group had an increased risk of incident AF (aOR, 2.339; 95% CI, 1.614-3.410). Some sensitivity analyses also revealed consistent findings of increased AF risk associated with β-blocker treatment.

Conclusion

The findings from this study suggest that β-blocker treatment is associated with an increased risk of incident AF and may help physicians select a modest medication for patients while also assessing the risk of AF.

The COVID-19 impact on STEMI disparities

ST-segment elevation myocardial infarction (STEMI) is a significant source of morbidity and mortality. Despite guideline-driven management and increased awareness of social determinants of health, there are persistent disparities in diagnosis, management, and outcomes. The coronavirus disease 2019 (COVID-19) pandemic has greatly affected emergency department visitation, conditions and throughput. The aim of this study was to find any potential health disparities in patients who presented with STEMI during the COVID-19 pandemic by reviewing STEMI care data from April to September 2019 (pre-pandemic) and April to September 2020 (during the pandemic) for our hospital system. Patients with STEMI within 12 h of presentation were included in this study, and subdivided by age, gender, and race/ethnicity. We compared the turnaround times between emergency department arrival to intervention (electrocardiogram or catheterization) within the patient subgroups to find any notable differences. No statistically significant changes in turnaround times during either study period were found based on age, gender, or race/ethnicity for the STEMI interventions despite shifts in emergency department resources during the pandemic. This study helped assess the status quo in STEMI intervention for our health system and serves as a baseline for us to monitor gaps in care or areas of improvement. As healthcare systems institute new measures to promote equitable care, such as improving the accuracy of demographic data capture, establishing a baseline is an essential first step in evaluating the impact of these measures.

Sex Differences in the Associations of Traditional Risk Factors and Incident Heart Failure Hospitalization: A Prospective Cohort Study of 102 278 Chinese General Adults

BACKGROUND

Evidence regarding sex differences in the associations of traditional risk factors with incident heart failure (HF) hospitalization among Chinese general adults is insufficient. This study aimed to evaluate the potential sex differences in the associations of traditional risk factors with HF among Chinese general adults.

METHODS AND RESULTS

Data were from a subcohort of the China PEACE (Patient-Centered Evaluative Assessment of Cardiac Events) Million Persons Project. The traditional risk factors were collected at baseline, and the study outcome was HF-related hospitalization identified from the Inpatients Registry. A total of 102 278 participants (mean age, 54.3 years; 39.5% men) without prevalent HF were recruited. A total of 1588 cases of HF-related hospitalization were captured after a median follow-up of 3.52 years. The incidence rates were significantly higher in men (2.1%) than in women (1.2%). However, the observed lower risk of HF in women was significantly attenuated or even vanished when several traditional risk factors were poorly controlled (P for sex-by-risk factors <0.05). The selected 11 risk factors collectively explained 62.5% (95% CI, 55.1-68.8) of population attributable fraction for HF in women, which is much higher than in men (population attributable fraction, 39.6% [95% CI, 28.5-48.9]).

CONCLUSIONS

Although women had a lower incidence rate of hospitalization for HF than men in this study, the risk for HF increased more remarkably in women than in men when several traditional risk factors were poorly controlled. This study suggests that intensive preventative strategies are immediately needed in China.

Closing the sex gap in cardiovascular mortality by achieving both horizontal and vertical equity

Addressing sex differences and disparities in coronary heart disease (CHD) involves achieving both horizontal and vertical equity in healthcare. Horizontal equity in the context of CHD means that both men and women with comparable health statuses should have equal access to diagnosis, treatment, and management of CHD. To achieve this, it is crucial to promote awareness among the general public about the signs and symptoms of CHD in both sexes, so that both women and men may seek timely medical attention. Women often face inequity in the treatment of cardiovascular disease. Current guidelines do not differ based on sex, but their applications based on gender do differ. Vertical equity means tailoring healthcare to allow equitable care for all. Steps towards achieving this include developing treatment protocols and guidelines that consider the unique aspects of CHD in women. It also requires implementing guidelines equally, when there is not sex difference rather than inequities in application of guideline directed care.

Age and gender mediated the association between anemia and 30-day outcomes in patients with ST-segment elevated myocardial infarction

Background

The higher prevalence of anemia in females and elderly may be attributed to its association with worsened outcomes in ST-elevation myocardial infarction (STEMI) patients. We aimed to evaluate the precise effects of age and gender on the association between anemia and 30-day outcomes.

Method

We identified 4350 STEMI patients and divided into anemia and non-anemia. Effects were analyzed as categories using Cox proportional-hazards regression and as continuous using restricted cubic splines. Propensity score matching (PSM) and mediation analysis were applied to identify intermediate effects.

Results

Anemic patients were older, more likely to be female, and experienced doubled all-cause death (7.3 % versus 15.0 %), main adverse cardiovascular and cerebrovascular events (MACCE, 11.1 % versus 20.2 %), heart failure (HF, 5.1 % versus 8.6 %), and bleeding events (2.7 % versus 5.4 %). After adjustment, the association between anemia and all-cause death (Hazard ratio (HR) 1.15, 95 % confidence interval (95 %CI) 0.93-1.14), MACCE (HR 1.14, 95 %CI 0.95-1.36) and HF (HR 1.19, 95 %CI 0.92-1.55) were insignificant, the effects persisted nullified across age classes (P-interaction > 0.05) and PSM (P > 0.05). Ulteriorly, age mediated 77.6 %, 66.2 %, 48.0 %, gender mediated 38.1 %, 15.0 %, 3.2 %, age and gender together mediated 99.8 % 72.9 %, 48.1 % of the relationship. Anemia was independently associated with bleeding events (HR 2.02, 95 %CI 1.42-2.88), the effects consisted significant regardless of PSM (P < 0.05), age, and gender classes (P-interaction > 0.05), and no mediating role of age and gender were observed.

Conclusions

In STEMI patients, age and gender largely mediated the relationship between anemia and all-cause death, MACCE, and HF, anemia was independently associated with bleeding complications.

Effects of triglyceride glucose (TyG) and TyG-body mass index on sex-based differences in the early-onset heart failure of ST-elevation myocardial infarction

BACKGROUND AND AIM

Heart failure (HF) is an important complication of ST-elevation myocardial infarction (STEMI), including early- and late-onset HF. This study aimed to investigate the association between insulin resistance (IR)-related parameters triglyceride glucose (TyG) and TyG-body mass index (TyG-BMI) index and early-onset HF in STEMI between sexes.

METHODS AND RESULTS

This cross-sectional study included patients with STEMI who underwent primary percutaneous coronary intervention (PCI) between January 2016 and September 2022. Patients were divided into tertiles according to TyG/TyG-BMI index levels in males and females. The presence of early-onset HF was compared between tertiles in both sexes. Moreover, patients were stratified according to the tertiles of TyG/Tyg-BMI index. Differences in early-onset HF of STEMI were compared between males and females in each tertile group. 1118 patients were included in this study, 20.3% of whom were females. The incidence rate of early-onset HF was significantly higher in females than in males (29% vs. 14.8%). TyG-BMI index was negatively correlated with early-onset HF. In both females and males, there was no difference in the occurrence of early-onset HF between the highest and lowest TyG/TyG-BMI index groups. Sex disparity was observed in females who had a significantly higher prevalence of early-onset HF than males in each TyG/TyG-BMI index tertile group; however, after adjustment, the differences disappeared.

CONCLUSIONS

For patients with STEMI who undergo primary PCI, the incidence of early-onset HF is higher in females than in males. The TyG/TyG-BMI index do not contribute to the difference in early-onset HF between sexes.

Sex Differences in Cardiac and Clinical Phenotypes and Their Relation to Outcomes in Patients with Heart Failure

Biological sex is one of the major factors characterizing the heart failure (HF) patient phenotype. Understanding sex-related differences in HF is crucial to implement personalized care for HF patients with various phenotypes. There are sex differences in left ventricular (LV) remodeling patterns in the HF setting, namely, more likely concentric remodeling and diastolic dysfunction in women and eccentric remodeling and systolic dysfunction in men. Recently supra-normal EF (snLVEF) has been recognized as a risk of worse outcome. This pathology might be more relevant in female patients. The possible mechanism may be through coronary microvascular dysfunction and sympathetic nerve overactivation from the findings of previous studies. Further, estrogen deficit might play a significant role in this pathophysiology. The sex difference in body composition may also be related to the difference in LV remodeling and outcome. Lower implementation in guideline-directed medical therapy (GDMT) in female HFrEF patients might also be one of the factors related to sex differences in relation to outcomes. In this review, we will discuss the sex differences in cardiac and clinical phenotypes and their relation to outcomes in HF patients and further discuss how to provide appropriate treatment strategies for female patients.

Response to interleukin-1 blockade with anakinra in women and men with ST-segment elevation myocardial infarction

BACKGROUND

Interleukin-1 blockade with anakinra reduces high-sensitivity C-reactive protein (hsCRP) levels and prevents heart failure (HF) events after ST-segment myocardial infarction (STEMI). Sex-based differences in STEMI patients have been reported, but no data are available regarding response to anakinra.

METHODS

We analyzed the systemic inflammation and composite end-point of new-onset HF or death in women and men with STEMI treated with anakinra from three different Virginia Commonwealth University Anakinra Response Trial (VCUART) randomized clinical trials.

RESULTS

We analyzed 139 patients, 29 (21%) were women while 110 (79%) were men. Baseline hsCRP was higher in women compared to men (8.9 [5.2-13.5] vs. 4.2 [2.1-7.7] mg/L, P<0.001). Eighty-four patients were treated with anakinra (22 [75%] women and 62 [56%] men). The area under the curve of hsCRP (hsCRP-AUC) after 14 days was numerically lower in patients receiving anakinra versus placebo both in men (86 [37-130] vs. 223 [119-374] mg day/L) and in women (73 [46-313] vs. 242 [102-988] mg day/L) (P<0.001 for multiple groups, P for interaction 0.22). The incidence of the composite endpoint was also numerically lower in the anakinra group compared to placebo, both in men (4 [6.4%] vs. 14 [29.1%]) and in women (3 [13.6%] vs. 2 [28.5%]) (P=0.019 for multiple groups, P for interaction 0.44). There were no statistically significant differences between women and men in hsCRP-AUC and death or HF events when comparing separately the anakinra and placebo groups (all P>0.05).

CONCLUSIONS

Women were underrepresented in the VCUART trials, they appeared to have higher hsCRP levels at time of presentation, yet to benefit similar to men by treatment with anakinra in STEMI.

Sex Differences in Pharmacotherapy and Long-Term Outcomes in Patients With Ischaemic Heart Disease and Comorbid Left Ventricular Dysfunction

BACKGROUND

Left ventricular (LV) dysfunction and ischaemic heart disease (IHD) are common among women. However, women tend to present later and are less likely to receive guideline-directed medical therapy (GDMT) compared with men.

METHODS

We analysed prospectively collected data (2005-2018) from a multicentre registry on GDMT 30 days after percutaneous coronary intervention in 13,015 patients with LV ejection fraction <50%. Guideline-directed medical therapy was defined as beta blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker±mineralocorticoid receptor antagonist. Long-term mortality was determined by linkage with the Australian National Death Index.

RESULTS

Women represented 20% (2,634) of the total cohort. Mean age was 65±12 years. Women were on average >5 years, with higher body mass index and higher rates of hypertension, diabetes, renal dysfunction, prior stroke, and rheumatoid arthritis. Guideline-directed medical therapy was similar between sexes (73% vs 72%; p=0.58), although women were less likely to be on an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (80% vs 82%; p=0.02). Women were less likely to be on statin therapy (p<0.001) or a second antiplatelet agent (p=0.007). Women had higher unadjusted long-term mortality (25% vs 19%; p<0.001); however, there were no differences in long-term mortality between sexes on adjusted analysis (hazard ratio 0.99; 95% confidence interval 0.87-1.14; p=0.94).

CONCLUSIONS

Rates of GDMT for LV dysfunction were high and similar between sexes; however, women were less likely to be on appropriate IHD secondary prevention. The increased unadjusted long-term mortality in women was attenuated in adjusted analysis, which highlights the need for optimisation of baseline risk to improve long-term outcomes of women with IHD and comorbid LV dysfunction.

The prediction model of the short-term outcome in elderly heart failure patients

This study was designed to investigate the effect of the comprehensive geriatric assessment on the short-term prognosis of the elderly heart failure patients (EHFP), analyze the relevant risk factors, and construct an effective risk prediction model. According to the selection and exclusion criteria, 617 patients were filtered from 800 patients from the cadre ward database of the first Hospital of Jilin University. The EHFP were randomly divided into the model group (432 cases) and the validation group (185 cases). A retrospective study on the general clinical data of patients in the model group was conducted to analyze the risk factors associated with the short-term outcomes of EHFP. Based on the risk factors, the risk prediction model was established and validated through the validation group. In the model group, the following independent risk factors were identified for the short-term outcomes in EHFP in the light of univariate logistic and cox regression analysis: female (β = 0.989, OR = 1.277, 95% CI: 1.090-1.847, P = 0.024), age (65-75 years, β = 0.654, OR = 2.320, 95% CI: 1.135-3.136, P = 0.012; 75-85 years, β = 1.123, OR = 3.159, 95% CI: 1.532-5.189, P = 0.001; age > 85 years old, β = 1.513, OR = 4.895, 95% CI: 1.866-979, P = 0.001), frailty (β = 1.015, OR = 2.761, 95% CI: 1.097-6.945, P = 0.031), malnutrition (β = 1.271, OR = 3.560, 95% CI: 1.122-11.325, P = 0.002), and EF≦40% (β = 1.250, OR = 3.498, 95% CI: 1.898-6.447, P = 0.001). The simple risk prediction score was set up in line with the five risk factors, including range (1-7), the area under ROC curve (0.771, 95% CI: 0.723-0.819), and H-L test (P = 0.393), so patients were divided into the low-risk group (1-3) and the high-risk group (4-8). As a result, the number of EHFP in the high-risk group was significantly much more than that in the low-risk group (70.1% versus 29.9%, P < 0.001). Besides, the area under ROC curve (0.758, 95% CI: 0.682-0.835) and H-L test (P = 0.669) of the validation group indicated that this model could be a promising prediction model for the short-term outcomes of EHFP. Female, age, frailty, malnutrition, and EF ≦ 40% are independent risk factors for short-term outcomes of EHFP. The risk prediction model based on the five risk factors provided compelling clinic predictive value for the short-term prognosis of EHFP.

Mechanism of heart failure after myocardial infarction

Despite the widespread use of early revascularization and drugs to regulate the neuroendocrine system, the impact of such measures on alleviating the development of heart failure (HF) after myocardial infarction (MI) remains limited. Therefore, it is important to discuss the development of new therapeutic strategies to prevent or reverse HF after MI. This requires a better understanding of the potential mechanisms involved. HF after MI is the result of complex pathophysiological processes, with adverse ventricular remodeling playing a major role. Adverse ventricular remodeling refers to the heart's adaptation in terms of changes in ventricular size, shape, and function under the influence of various regulatory factors, including the mechanical, neurohormonal, and cardiac inflammatory immune environments; ischemia/reperfusion injury; energy metabolism; and genetic correlation factors. Additionally, unique right ventricular dysfunction can occur secondary to ischemic shock in the surviving myocardium. HF after MI may also be influenced by other factors. This review summarizes the main pathophysiological mechanisms of HF after MI and highlights sex-related differences in the prognosis of patients with acute MI. These findings provide new insights for guiding the development of targeted treatments to delay the progression of HF after MI and offering incremental benefits to existing therapies.

Sex Differences in Clinical Characteristics and Outcomes After Myocardial Infarction With Low Ejection Fraction: Insights From PARADISE-MI

Background Studies demonstrated sex differences in outcomes following acute myocardial infarction, with women more likely to develop heart failure (HF). Sacubitril/valsartan has been shown to reduce cardiovascular death and HF hospitalizations in patients with HF with reduced ejection fraction. Methods and Results A total of 5661 patients (1363 women [24%]) with acute myocardial infarction complicated by reduced left ventricular ejection fraction (≤40%), pulmonary congestion, or both and ≥1 of 8 risk-augmenting factors were randomized to receive sacubitril/valsartan or ramipril. The primary outcome was cardiovascular death or incident HF. Baseline characteristics, clinical outcomes, and safety events were compared according to sex, a prespecified subgroup. Female participants were older and had more comorbidities. After multivariable adjustment, women and men were at similar risks for cardiovascular death or all-cause death. Women were more likely to have first HF hospitalization (hazard ratio [HR], 1.34 [95% CI, 1.05-1.70]; P=0.02) and total HF hospitalizations (HR, 1.39 [95% CI, 1.05-1.84]; P=0.02). Sex did not significantly modify the treatment effect of sacubitril/valsartan compared with ramipril on the primary outcome (P for interaction=0.11). Conclusions In contemporary patients who presented with reduced left ventricular ejection fraction, pulmonary congestion, or both, following acute myocardial infarction, women had a higher incidence of HF during follow-up. Sex did not modify the treatment effect of sacubitril/valsartan relative to ramipril. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02924727.

Sex Differences in Heart Failure Following Acute Coronary Syndromes

Background

There have been conflicting reports regarding outcomes in women presenting with an acute coronary syndrome (ACS).

Objectives

The objective of the study was to examine sex-specific differences in 30-day mortality in patients with ACS and acute heart failure (HF) at the time of presentation.

Methods

This was a retrospective study of patients included in the International Survey of Acute Coronary Syndromes-ARCHIVES (ISACS-ARCHIVES; NCT04008173). Acute HF was defined as Killip classes ≥2. Participants were stratified according to ACS presentation: ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS). Differences in 30-day mortality and acute HF presentation at admission between sexes were examined using inverse propensity weighting based on the propensity score. Estimates were compared by test of interaction on the log scale.

Results

A total of 87,812 patients were included, of whom 30,922 (35.2%) were women. Mortality was higher in women compared with men in those presenting with STEMI (risk ratio [RR]: 1.65; 95% CI: 1.56-1.73) and NSTE-ACS (RR: 1.18; 95% CI: 1.09-1.28; P interaction <0.001). Acute HF was more common in women when compared to men with STEMI (RR: 1.24; 95% CI: 1.20-1.29) but not in those with NSTE-ACS (RR: 1.02; 95% CI: 0.97-1.08) (P interaction <0.001). The presence of acute HF increased the risk of mortality for both sexes (odds ratio: 6.60; 95% CI: 6.25-6.98).

Conclusions

In patients presenting with ACS, mortality is higher in women. The presence of acute HF at hospital presentation increases the risk of mortality in both sexes. Women with STEMI are more likely to present with acute HF and this may, in part, explain sex differences in mortality. These findings may be helpful to improve sex-specific personalized risk stratification.

Sex-based analysis of treatment responses in animal models of sepsis: a preclinical systematic review protocol

BACKGROUND

The importance of investigating sex- and gender-dependent differences has been recently emphasized by major funding agencies. Notably, the influence of biological sex on clinical outcomes in sepsis is unclear, and observational studies suffer from the effect of confounding factors. The controlled experimental environment afforded by preclinical studies allows for clarification and mechanistic evaluation of sex-dependent differences. We propose a systematic review to assess the impact of biological sex on baseline responses to disease induction as well as treatment responses in animal models of sepsis. Given the lack of guidance surrounding sex-based analyses in preclinical systematic reviews, careful consideration of various factors is needed to understand how best to conduct analyses and communicate findings.

METHODS

MEDLINE and Embase will be searched (2011-present) to identify preclinical studies of sepsis in which any intervention was administered and sex-stratified data reported. The primary outcome will be mortality. Secondary outcomes will include organ dysfunction, bacterial load, and IL-6 levels. Study selection will be conducted independently and in duplicate by two reviewers. Data extraction will be conducted by one reviewer and audited by a second independent reviewer. Data extracted from included studies will be pooled, and meta-analysis will be conducted using random effects modeling. Primary analyses will be stratified by animal age and will assess the impact of sex at the following time points: pre-intervention, in response to treatment, and post-intervention. Risk of bias will be assessed using the SYRCLE's risk-of-bias tool. Illustrative examples of potential methods to analyze sex-based differences are provided in this protocol.

DISCUSSION

Our systematic review will summarize the current state of knowledge on sex-dependent differences in sepsis. This will identify current knowledge gaps that future studies can address. Finally, this review will provide a framework for sex-based analysis in future preclinical systematic reviews.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022367726.

Sex Differences in Acute Heart Failure Management: Is There a Gap in Treatment Quality?

PURPOSE OF REVIEW

Differences between men and women in demographics and clinical phenotype of heart failure have previously been described, as well as disparities in management and outcomes. This review summarizes the latest evidence concerning sex-related differences in acute heart failure and its most severe form, cardiogenic shock.

RECENT FINDINGS

Data from the last 5 years reaffirm the previous observations, with women with acute heart failure being older, more often having preserved ejection fraction and less frequently having an ischemic cause of the acute decompensation. Despite women still receive less invasive procedures and a less optimized medical treatment, the most recent studies find similar outcomes regardless of sex. These disparities persist in the context of cardiogenic shock, where women receive less mechanical circulatory support devices even if they present with more severe forms. This review reveals a different clinical picture of women with acute heart failure and cardiogenic shock compared to men, which translates into disparities in management. More female representation in studies would be needed in order to better understand the physiopathological basis of these differences and minimize inequalities in treatment and outcomes.

Gender Differences in Heart Failure Hospitalization Post-Myocardial Infarction

Objectives:

Patients with post-myocardial infarction (MI) are more likely to die later from heart failure (HF), arrhythmic events, or reinfarction. According to recent studies, mortality rates were noticeably higher in women, than in men. This has been linked to variations in age, comorbidities, symptom presentation, and pathophysiology of the underlying coronary artery disease. There is little information on how these typical gender disparities affect post- MI survival. Studies on individuals with coronary artery disease have primarily focused on men, with women typically being left out of most series. Despite the relatively high prevalence of ischemic heart disease in women, there is a lack of information regarding the clinical course of the condition, its management, and clinical outcomes in this particular population due to the underrepresentation of women in the medical literature in this field. The gender disparities in post-MI patients who present with HF will be briefly discussed in this article.

Materials and Methods:

A total of 50 patients that presented with HF and had a previous history of MI were included in this study after taking consent. After taking history and detailed physical examination, investigations that were sent were reviewed and the subjects followed up in the hospital stay to look for outcomes. The data are compiled and subjected to statistical analysis.

Results:

It is observed that among the 50 subjects, 32% of them had recurrent HF (13 of the 30 females and three of the 20 males). p = 0.04 is statistically significant. Among the study subjects, the hospital outcomes observed showed that, out of 50 subjects, 47 subjects recovered and the other three died in hospital stay. All the three deaths are women. p = 0.15 is not statistically significant.

Conclusion:

This study concludes that women are more likely than males to require hospitalization for recurrent HF following a MI. This study also demonstrates that, despite the higher risk of recurrent HF, women do not have a higher mortality risk than males.

Sex Differences in Acute Coronary Syndromes: A Global Perspective

Despite increasing evidence and improvements in the care of acute coronary syndromes (ACS), sex disparities in presentation, comorbidities, access to care and invasive therapies remain, even in the most developed countries. Much of the currently available data are derived from more developed regions of the world, particularly Europe and the Americas. In contrast, in more resource-constrained settings, especially in Sub-Saharan Africa and some parts of Asia, more data are needed to identify the prevalence of sex disparities in ACS, as well as factors responsible for these disparities, particularly cultural, socioeconomic, educational and psychosocial. This review summarizes the available evidence of sex differences in ACS, including risk factors, pathophysiology and biases in care from a global perspective, with a focus on each of the six different World Health Organization (WHO) regions of the world. Regional trends and disparities, gaps in evidence and solutions to mitigate these disparities are also discussed.

Acute Decompensated Heart Failure in the Setting of Acute Coronary Syndrome

Acute coronary syndrome (ACS) is frequently complicated by evidence of heart failure (HF). Those at highest risk for acute decompensated HF in the setting of ACS (ACS-HF) are older, female, and have preexisting heart disease, type 2 diabetes mellitus, hypertension, and/or kidney disease. The presence of ACS-HF is strongly associated with higher mortality and more frequent readmissions, especially for HF. Low implementation of guideline-directed medical therapy has further complicated the clinical care of this high-risk population. Improved utilization of current therapies, coupled with further investigation of strategies to manage ACS-HF, is desperately needed to improve outcomes in this vulnerable population, and the results of currently ongoing or recently concluded ACS-HF studies in this population are of great interest. In this review, we explore the pathophysiology, epidemiology, risk factors, and outcomes for patients with ACS-HF, and describe both existing evidence for management of this challenging condition and areas requiring further research.

Sex-Related Outcomes of Medical, Percutaneous, and Surgical Interventions for Coronary Artery Disease: JACC Focus Seminar 3/7

Biological and sociocultural differences between men and women are complex and likely account for most of the variations in the epidemiology and treatment outcomes of coronary artery disease (CAD) between the 2 sexes. Worse outcomes in women have been described following both conservative and invasive treatments of CAD. For example, increased levels of residual platelet reactivity during treatment with antiplatelet drugs, higher rates of adverse cardiovascular outcomes following percutaneous coronary revascularization, and higher operative and long-term mortality after coronary bypass surgery have been reported in women compared with in men. Despite the growing recognition of sex-specific determinants of outcomes, representation of women in clinical studies remains low and sex-specific management strategies are generally not provided in guidelines. This review summarizes the current evidence on sex-related differences in patients with CAD, focusing on the differential outcomes following medical therapy, percutaneous coronary interventions, and coronary artery bypass surgery.

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

BACKGROUND AND HYPOTHESIS

Two cohorts face high mortality after ST-elevation myocardial infarction (STEMI): females and patients with in-hospital STEMI. The aim of this study was to evaluate sex differences in ischemic times and outcomes of in-hospital STEMI patients.

METHODS

Consecutive STEMI patients treated with percutaneous coronary intervention (PCI) were prospectively recruited from 30 hospitals into the Victorian Cardiac Outcomes Registry (2013-2018). Sex discrepancies within in-hospital STEMIs were compared with out-of-hospital STEMIs. The primary endpoint was 12-month all-cause mortality. Secondary endpoints included symptom-to-device (STD) time and 30-day major adverse cardiovascular events (MACE). To investigate the relationship between sex and 12-month mortality for in-hospital versus out-of-hospital STEMIs, an interaction analysis was included in the multivariable models.

RESULTS

A total of 7493 STEMI patients underwent PCI of which 494 (6.6%) occurred in-hospital. In-hospital versus out-of-hospital STEMIs comprised 31.9% and 19.9% females, respectively. Female in-hospital STEMIs were older (69.5 vs. 65.9 years, p = .003) with longer adjusted geometric mean STD times (104.6 vs. 94.3 min, p < .001) than men. Female versus male in-hospital STEMIs had no difference in 12-month mortality (27.1% vs. 20.3%, p = .92) and MACE (22.8% vs. 19.3%, p = .87). Female sex was not independently associated with 12-month mortality for in-hospital STEMIs which was consistent across the STEMI cohort (OR: 1.26, 95% CI: 0.94-1.70, p = .13).

CONCLUSIONS

In-hospital STEMIs are more frequent in females relative to out-of-hospital STEMIs. Despite already being under medical care, females with in-hospital STEMIs experienced a 10-min mean excess in STD time compared with males, after adjustment for confounders. Adjusted 12-month mortality and MACE were similar to males.

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

OBJECTIVES

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

DESIGN

Systematic review and meta-analysis of contemporary available evidence.

SETTING

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

PARTICIPANTS

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

PRIMARY AND SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of diabetes mellitus interactions with cardiovascular risk factors on post-myocardial infarction heart failure hospitalizations

OBJECTIVE

There is a paucity of information regarding how cardiovascular risk factors (RF) modulate the impact of diabetes mellitus (DM) on the heart failure hospitalization (HFH) risk following an acute myocardial infarction (AMI).

METHODS

Adult survivors of an AMI were retrospectively identified from the 2014 US Nationwide Readmissions Database. The impact of DM on the risk for a 6-month HFH was studied in subgroups of RFs using multivariable logistic regression to adjust for baseline risk differences. Individual interactions of DM with RFs were tested.

RESULTS

Of 237,549 AMI survivors, 37.2% patients had DM. Primary outcome occurred in 12,934 patients (5.4%), at a 106% higher rate in DM patients (7.9% vs 4.0%, p < 0.001), which was attenuated to a 45% higher adjusted risk. Higher HFH risk in DM patients was consistent across subgroups and significant interactions were present between DM and other RFs. The increased HFH risk with DM was more pronounced in patients without certain HF RFs compared with those with these RFs [age < 65: OR for DM 1.84 (1.58-2.13) vs age ≥ 65: OR 1.34 (1.24-1.45); HF absent during index AMI: OR for DM 1.87 (1.66-2.10) vs HF present: OR 1.24 (1.14-1.34); atrial fibrillation absent: OR for DM 1.57 (1.46-1.68) vs present: OR 1.19 (1.06-1.33); P_interaction < 0.001 for all]. Similar results were noted for hypertension and chronic kidney disease.

CONCLUSIONS

AMI survivors with DM had a higher risk of 6-month HFHs. The impact of DM on the increased HFH risk was more pronounced in patients without certain RFs suggesting that more aggressive preventive strategies related to DM and HF are needed in these subgroups to prevent or delay the onset of HFHs.

Statins for primary prevention among elderly men and women

AIMS

We undertook a propensity match-weighted cohort study to investigate whether statin treatment recommendations for statins translate into improved cardiovascular (CV) outcomes in the current routine clinical care of the elderly.

METHODS AND RESULTS

We included in our analysis (ISACS Archives -NCT04008173) a total of 5,619 Caucasian patients with no known prior history of CV disease who presented to hospital with a first manifestation of CV disease with age of 65 years or older. The risk of ST segment elevation myocardial infarction (STEMI) was much lower in statin users than in nonusers in both patients aged 65 to 75 years (14.7% absolute risk reduction; relative risk [RR]: 0.55, 95% CI 0.45 to 0.66) and those aged 76 years and older (13.3% absolute risk reduction; RR: 0.58, 95% CI 0.46 to 0.72). Estimates were similar in patients with and without history of hypercholesterolemia (interaction test; p value= 0.2408). Proportional reductions in STEMI diminished with female sex in the old (p for interaction = 0.002), but not in the very old age (p for interaction = 0.26). We also observed a remarkable reduction in the risk of 30- day mortality from STEMI with statin therapy in both age groups (10.2% absolute risk reduction; RR: 0.39; 95%CI 0.23-0.68 for patients aged 76 or over and 3.8% absolute risk reduction; RR 0.37; 95%CI 0.17-0.82 for patients aged 65 to 75 years old; interaction test, p value = 0.4570).

CONCLUSIONS

Preventive statin therapy in the elderly reduces the risk of STEMI with benefits in mortality from STEMI, irrespective of the presence of a history of hypercholesterolemia. This effect persists after the age of 76 years. Benefits are less pronounced in women. Randomized clinical trials may contribute to more definitively determine the role of statin therapy in the elderly.

TRANSLATIONAL PERSPECTIVE

In this register-based cohort study with match propensity-based design of patients without known prior history of CV disease, we compared statin users versus nonusers in two age groups: 65 to 75 years and 76 years and older. Statin use was associated with a 13% absolute reduction in the risk of ST segment elevation myocardial infarction (STEMI) in patients 76 years and older irrespective of the presence of a history of hypercholesterolemia. Statin use was also significantly related to a 10.2% reduction in 30-day mortality from STEMI. Estimates were similar in patients aged 65 to 75 years. Benefits were less pronounced in women. This study demonstrates that preventive statin therapy is broadly effective at reducing the risk of major cardiovascular events and mortality in the elderly. Results may inform future research and current guidelines.

Risk Factors and Outcomes of Heart Failure Following First-Episode of Acute Myocardial Infarction-A Case Series Study of 161,384 Cases

Background: Heart failure (HF) is one of the important complications of acute myocardial infarction (AMI), but the epidemiology, associated risks and outcomes have not been well investigated in the era of broad use of fluoroscopy-guided angiographic intervention. Methods: We analysed 161,384 subjects who had experienced the first episode of AMI during 1 January 2000 and 31 December 2012 using the Taiwan National Health Insurance Research Database. Results: During the index AMI hospitalization, 23.6% of cases developed HF. Female, ≥65 years-old, non-ST-segment elevation type of MI, diabetes mellitus (DM), peripheral vascular occlusion disease (PAOD), chronic obstructive pulmonary disease (COPD), atrial fibrillation, and ventricular tachycardia/fibrillation (VT/VF) were associated with higher risks of developing HF. HF cases had inferior survival outcomes compared to non-HF cases in both the short and long term. Among those HF patients, ≥65 years, DM, PAOD, and VT/VF were associated with worse outcomes. On the contrary, coronary reperfusion intervention and treat-to-target pharmacologic treatment were associated with favourable survival outcomes. Conclusions: HF remains common in the modern age and poses negative impacts in survival of AMI patients. It highlights that prudent prevention and early treatment of HF during AMI hospitalization is an important medical issue.

The Association of Thyroid Hormones with Cardiogenic Shock and Prognosis in Patients with ST Segment Elevation Myocardial Infarction (STEMI) Treated with Primary PCI

BACKGROUND

Cardiogenic shock (CS) is the leading cause of the death in patients with ST elevation myocardial infarction (STEMI). Thyroid dysfunction is related to prognosis of patients with myocardial infarction. Hence, the aim of this study is to explore the relationship between thyroid hormones (free triiodothyronine [FT3] and free thyroxine [FT4]) and CS.

METHOD

A total of 1270 patients with STEMI treated with percutaneous coronary intervention (PCI) were consecutively enrolled in our study. Patients were classified into two groups according to with or without CS during hospitalization. Stepwise multivariate logistic analysis was conducted to investigate the association of thyroid hormones and CS. Restricted cubic spline method was employed to further explore relationship between CS and thyroid hormones.

RESULTS

Patients who developed CS (n=103) had lower FT3 and higher FT4 on admission. The stepwise logistic analysis showed both FT3 (P=0.038) and FT4 (P=0.024) were independently related to CS. Restricted cubic splines indicated that lower FT3 (<2.25 pg/ml) or higher FT4 (>1.25 ng/dl) was correlated with higher prevalence of CS. Over 2.5 years' follow-up, patients (n=294) with low FT3 (<2.85 pg/ml) and high FT4 (>=0.88 ng/dl) had the highest all-cause mortality (18.2%), whereas patients (n=293) with high FT3 and low FT4 had the lowest all-cause mortality (3.8%) (P for trend <0.0001).

CONCLUSIONS

Both FT3 and FT4 are independently associated with in-hospital CS development in patients with STEMI treated with PCI. Patients with lower range of FT3 and upper range of FT4 had the worst outcomes in a long-term follow-up.

Gender-Related Difference in D-Dimer Level Predicts In-Hospital Heart Failure after Primary PCI for ST-Segment Elevation Myocardial Infarction

Aims

The prognostic value of plasma D-dimer in patients with coronary artery disease (CAD) remains controversial. The study is aimed at investigating the relationship between plasma D-dimer levels and in-hospital heart failure (HF) in ST-segment elevation myocardial infarction (STEMI) patients who underwent primary percutaneous coronary intervention (pPCI).

Methods

STEMI patients who underwent pPCI were enrolled in this study. Venous blood samples were collected from patients on admission before pPCI procedure. The study endpoint was the occurrence of in-hospital HF. The participants were divided into two groups according to plasma D-dimer levels and further compared baseline D-dimer levels between male and female. Logistic regression and receiver operating characteristic (ROC) curves were performed to evaluate the relationship of D-dimer and in-hospital HF.

Results

A total of 778 patients were recruited in the study, of which 539 (69.3%) patients had normal D-dimer levels (≤0.5 mg/L) while 239 (30.7%) had increased D-dimer levels (>0.5 mg/L). The female patients have higher D-dimer levels and higher incident rate of in-hospital HF than that in male patients (p < 0.001). The multivariate logistic regression model revealed that D-dimer was an independent predictor for in-hospital HF in overall population (adjusted odds ratio [OR]: 1.197, 95% CI: 1.003-1.429, and p = 0.046) and female patients (adjusted OR: 1.429, 95% CI: 1.083-1.885, and p = 0.012).

Conclusion

Increased plasma D-dimer levels were an independent risk factor for incidence of in-hospital HF in STEMI patients who underwent pPCI, especially in female patients, which provides guidance for clinicians in identifying patients at high risk of developing HF and lowering their risk.

Randomized comparison of early supplemental oxygen versus ambient air in patients with confirmed myocardial infarction: Sex-related outcomes from DETO2X-AMI

BACKGROUND

The purpose of this study is to investigate the impact of oxygen therapy on cardiovascular outcomes in relation to sex in patients with confirmed myocardial infarction (MI).

METHODS

The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction trial randomized 6,629 patients to oxygen at 6 L/min for 6-12 hours or ambient air. In the present subgroup analysis including 5,010 patients (1,388 women and 3,622 men) with confirmed MI, we report the effect of supplemental oxygen on the composite of all-cause death, rehospitalization with MI, or heart failure at long-term follow-up, stratified according to sex.

RESULTS

Event rate for the composite endpoint was 18.1% in women allocated to oxygen, compared to 21.4% in women allocated to ambient air (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.65-1.05). In men, the incidence was 13.6% in patients allocated to oxygen compared to 13.3% in patients allocated to ambient air (HR 1.03, 95% CI 0.86-1.23). No significant interaction in relation to sex was found (P= .16). Irrespective of allocated treatment, the composite endpoint occurred more often in women compared to men (19.7 vs 13.4%, HR 1.51; 95% CI, 1.30-1.75). After adjustment for age alone, there was no difference between the sexes (HR 1.06, 95% CI 0.91-1.24), which remained consistent after multivariate adjustment.

CONCLUSION

Oxygen therapy in normoxemic MI patients did not significantly affect all-cause mortality or rehospitalization for MI or heart failure in women or men. The observed worse outcome in women was explained by differences in baseline characteristics, especially age.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Associations of Lipoprotein(a) With Coronary Atherosclerotic Burden and All-Cause Mortality in Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

Background: The coronary atherosclerotic burden in patients with ST-segment elevation myocardial infarction (STEMI) has been identified as the main predictor of prognosis. However, the association of lipoprotein(a) [Lp(a)], a well-established proatherogenic factor, with atherosclerotic burden in patients with STEMI is unclear.

Methods: In total, 1,359 patients who underwent percutaneous coronary intervention (PCI) for STEMI were included in analyses. Three prespecified models with adjustment for demographic parameters and risk factors were evaluated. Generalized additive models and restricted cubic spline analyses were used to assess the relationships of Lp(a) with Gensini scores and the no-reflow phenomenon. Kaplan–Meier curves were generated to explore the predictive value of Lp(a) for long-term all-cause mortality. Furthermore, mRNA expression levels of LPA in different groups were compared using the GEO database.

Results: Patients in the highest tertile according to Lp(a) levels had an increased incidence of heart failure during hospitalization. Furthermore, patients with high levels of Lp(a) (>19.1 mg/dL) had sharply increased risks for a higher Gensini score (P_{for trend} = 0.03) and no-reflow (P_{for trend} = 0.002) after adjustment for demographic parameters and risk factors. During a median follow-up of 930 days, 132 deaths (9.95%) were registered. Patients with high levels of Lp(a) (>19.1 mg/dL) had the worst long-term prognosis (P_{for trend} < 0.0001). In a subgroup analysis, patients with higher Lp(a) still had the highest all-cause mortality. Additionally, the mRNA expression levels of LPA in patients with STEMI with lower cardiac function were higher than those in other groups (P = 0.003). A higher coronary atherosclerotic burden was correlated with higher LPA expression (P = 0.01).

Conclusion: This study provides the first evidence that Lp(a) (at both the protein and mRNA levels) is independently associated with coronary atherosclerotic lesions and prognosis in patients with STEMI treated with PCI.

Clinical Trial Registration:http://www.chictr.org.cn/index.aspx, identifier: ChiCTR1900028516.

The Effects of Biological Sex on Sepsis Treatments in Animal Models: A Systematic Review and a Narrative Elaboration on Sex- and Gender-Dependent Differences in Sepsis

Preclinical studies provide an opportunity to evaluate the relationship between sex and sepsis, and investigate underlying mechanisms in a controlled experimental environment. The objective of our systematic review was to assess the impact of biological sex on treatment response to fluid and antibiotic therapy in animal models of sepsis. Furthermore, we provide a narrative elaboration of sex-dependent differences in preclinical models of sepsis.

DATA SOURCES

MEDLINE and Embase were searched from inception to March 16, 2020.

STUDY SELECTION

All studies reporting sex-stratified data comparing antibiotics and/or fluid resuscitation with a placebo or no treatment arm in an in vivo model of sepsis were included.

DATA EXTRACTION

Outcomes of interest were mortality (primary) and organ dysfunction (secondary). Risk of bias was assessed. Study selection and data extraction were conducted independently and in duplicate.

DATA SYNTHESIS

The systematic search returned 2,649 unique studies, and two met inclusion criteria. Both studies used cecal ligation and puncture models with imipenem/cilastatin antibiotics. No eligible studies investigated fluids. In one study, antibiotic therapy significantly reduced mortality in male, but not female, animals. The other study reported no sex differences in organ dysfunction. Both studies were deemed to be at a high overall risk of bias.

CONCLUSIONS

There is a remarkable and concerning paucity of data investigating sex-dependent differences in fluid and antibiotic therapy for the treatment of sepsis in animal models. This may reflect poor awareness of the importance of investigating sex-dependent differences. Our discussion therefore expands on general concepts of sex and gender in biomedical research and sex-dependent differences in key areas of sepsis research such as the cardiovascular system, immunometabolism, the microbiome, and epigenetics. Finally, we discuss current clinical knowledge, the potential for reverse translation, and directions for future studies.

REGISTRATION

PROSPERO CRD42020192738.

Sex differences in long-term cardiovascular outcomes among patients with acute myocardial infarction: A population-based retrospective cohort study

BACKGROUND

Whether a sex difference exists in long-term cardiovascular (CV) outcomes after acute myocardial infarction (AMI) is worth exploration. This study is sought to investigate the relationships among sex, age, and the long-term prognosis after AMI.

METHODS

This population-based retrospective cohort study used Taiwan's National Health Insurance Research Database to investigate the sex differences in in-hospital and long-term CV outcomes in patients with AMI. We enrolled patients who were first diagnosed with AMI from January 1, 2000 to December 31, 2013. The outcomes of interest included all-cause mortality, CV death, non-fatal stroke, non-fatal heart failure, and AMI recurrence during hospitalization and 5-year follow up. The CV outcomes were also analyzed by age stratification.

RESULTS

Overall, 201 921 patients with AMI were analyzed; 68.72% were men and 31.28% were women, with mean ages of 65.34 ± 14.12 and 73.05 ± 12.22 years, respectively. Major adverse cardiac events during hospitalization and up to 5 years were consistently greater in women than in men. Multivariable regression analysis revealed no sex difference existed in long-term all-cause and CV mortality. Men of all age groups consistently showed higher risk of both short- and long-term recurrence of AMI. Nonetheless, the female sex still independently predicted increased risk of non-fatal stroke and heart failure from hospitalization until 3-year follow up.

CONCLUSION

Women with AMI had poorer short-term and long-term outcomes. The sex differences in long-term all-cause and CV death disappear after multivariate analysis. Nonetheless, female AMI patients independently predicted higher risk of stroke and heart failure from hospitalization until a 3-year follow-up. To better understand the pathophysiology of female patients with AMI and develop more effective management, more studies in this field are necessary in the future.

Female gender is associated with a worse prognosis amongst patients hospitalised for de-novo acute heart failure

BACKGROUND

Recent evidence showed that new-onset (de-novo) acute heart failure (AHF) is a distinct type of AHF. However, the prognostic implication of gender on these patients remains unclear.

AIMS

We aimed to investigate the impact of gender on both short and long-term mortality outcomes after hospitalisation for de-novo AHF.

METHODS

We analysed the data of 721 patients with de-novo AHF, who were enrolled in the HF survey in Israel between March and April 2003 and were followed until December 2014.

RESULTS

Fifty-four percent (N = 387) of the patients were men. In comparison to women, men patients were more likely to be younger, smokers, and with ischemic HF aetiology. At 30 days, mortality rates were higher in women (12% vs 7%, P = .013). Survival analysis showed that at 1 and 10 years the all-cause mortality rates were significantly higher in women (28% vs 17%, and 78% vs 67%, 1 and 10 years, P < .001, respectively). Consistently, multivariable analysis showed that women had an independently 82% and 24% higher mortality risk at 1 and 10 years, respectively, (1-year hazard ratio = 1.82; 95% confidence interval = 1.07 to 3.11, P = .03; 10-year hazard ratio = 1.24; 95% confidence interval = 1.03 to 1.48, P = .02).

CONCLUSIONS

Amongst patients with de-novo AHF, women had higher mortality rates compared with men. The observed gender-related differences in de-novo AHF patients highlight the need for further and deeper research in this field.

Randomized Trial of Interleukin-6 Receptor Inhibition in Patients With Acute ST-Segment Elevation Myocardial Infarction

BACKGROUND

Prompt myocardial revascularization with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, as much as 50% of the loss of viable myocardium may be attributed to the reperfusion injury and the associated inflammatory response.

OBJECTIVES

This study sought to evaluate the effect of the interleukin-6 receptor inhibitor tocilizumab on myocardial salvage in acute STEMI.

METHODS

The ASSAIL-MI trial was a randomized, double-blind, placebo-controlled trial conducted at 3 high-volume PCI centers in Norway. Patients admitted with STEMI within 6 h of symptom onset were eligible. Consenting patients were randomized in a 1:1 fashion to promptly receive a single infusion of 280 mg tocilizumab or placebo. The primary endpoint was the myocardial salvage index as measured by magnetic resonance imaging after 3 to 7 days.

RESULTS

We randomized 101 patients to tocilizumab and 98 patients to placebo. The myocardial salvage index was larger in the tocilizumab group than in the placebo group (adjusted between-group difference 5.6 [95% confidence interval: 0.2 to 11.3] percentage points, p = 0.04). Microvascular obstruction was less extensive in the tocilizumab arm, but there was no significant difference in the final infarct size between the tocilizumab arm and the placebo arm (7.2% vs. 9.1% of myocardial volume, p = 0.08). Adverse events were evenly distributed across the treatment groups.

CONCLUSIONS

Tocilizumab increased myocardial salvage in patients with acute STEMI. (ASSessing the effect of Anti-IL-6 treatment in Myocardial Infarction [ASSAIL-MI]; NCT03004703).

Sex differences in patients with cardiogenic shock

Aims

Differences between female and male patients in clinical presentation, causes and treatment of cardiogenic shock (CS) are poorly understood. We aimed to investigate sex differences in presentation with and treatment of CS.

Methods and results

We analysed data of 978 patients presenting with CS to a tertiary care hospital between October 2009 and October 2017. Multivariable adjusted logistic/Cox regression models were fitted to investigate the association between sex and clinical presentation, use of treatments and 30 day mortality.

Median age was 70 years (interquartile range 58–79 years), and 295 (30.2%) patients were female. After adjustment for multiple relevant confounders, female patients were more likely to be older [odds ratio (OR) 1.21, 95% confidence interval (CI) 1.02–1.42, P = 0.027], but other relevant presentation characteristics did not differ between both sexes. Despite the similar presentation, female patients were less likely to be treated with percutaneous left ventricular assist devices (OR 0.78, 95% CI 0.64–0.94, P = 0.010), but more likely to be treated with catecholamines (OR 1.21, 95% CI 1.02–1.44, P = 0.033) or vasopressors (OR 1.26, 95% CI 1.05–1.50, P = 0.012). A 30 day mortality risk in female patients was as high as in male patients (hazard ratio 1.08, 95% CI 1.00–1.18, P = 0.091).

Conclusions

In this large, contemporary cohort, clinical presentation was comparable in female and male patients, and both sexes were associated with a comparably high mortality risk. Nevertheless, female patients received different treatment for CS and were most importantly less likely to be treated with percutaneous left ventricular assist devices.

Heart disease in women: a narrative review

Cardiovascular disease is the worldwide leading cause of death in women. Biological differences between the sexes, a result of genetic, epigenetic and sex hormone-mediated factors, are complex and incompletely understood. These differences are compounded by socio-cultural factors and together account for the variation in the prevalence, presentation and natural history of cardiovascular disease between men and women. Although there is growing recognition of sex-specific determinants of outcomes, women remain under-represented in clinical trials, and sex-disaggregated diagnostic and management strategies are not currently recommended in clinical guidelines. Women remain more likely to experience delays in diagnosis, to be treated less aggressively and to have worse outcomes. As a consequence, cardiovascular disease in women remains understudied, underdiagnosed and undertreated. This review will focus on female-specific characteristics of cardiovascular disease and how these may impact on anaesthetic and peri-operative risk assessment and care. We highlight significant differences between the sexes in the natural history of cardiovascular disease, including those disease entities that are more common in women, such as sudden coronary artery dissection or microvascular dysfunction. Given the rapidly rising incidence of maternal cardiovascular disease and associated complications, special consideration is given to the risk assessment and management of these conditions during pregnancy. Increased awareness of these issues has the potential to improve the effectiveness of the multidisciplinary heart team and ultimately improve the care provided to women.

Comparison of clinical outcomes and left ventricular remodeling after ST-elevation myocardial infarction between patients with and without diabetes mellitus

Left ventricular remodeling (LVR) after ST-elevation myocardial infarction (STEMI) is generally thought to be an adaptive but compromising phenomenon particularly in patients with diabetes mellitus (DM). However, whether the extent of LVR is associated with poor prognostic outcome with or without DM after STEMI in the modern era of reperfusion therapy has not been elucidated. This was a single-center retrospective observational study. Altogether, 243 patients who were diagnosed as having STEMI between January 2016 and March 2019, and examined with echocardiography at baseline (at the time of index admission) and mid-term (from 6 to 11 months after index admission) follow-up were included and divided into the DM (n = 98) and non-DM groups (n = 145). The primary outcome was major adverse cardiovascular events (MACEs) defined as the composite of all-cause death, heart failure (HF) hospitalization, and non-fatal myocardial infarction. The median follow-up duration was 621 days (interquartile range: 304–963 days). The DM group was significantly increased the rate of MACEs (P = 0.020) and HF hospitalization (P = 0.037) compared with the non-DM group, despite of less LVR. Multivariate Cox regression analyses revealed that the patients with DM after STEMI were significantly associated with MACEs (Hazard ratio [HR] 2.79, 95% confidence interval [CI] 1.20–6.47, P = 0.017) and HF hospitalization (HR 3.62, 95% CI 1.19–11.02, P = 0.023) after controlling known clinical risk factors. LVR were also significantly associated with MACEs (HR 2.44, 95% CI 1.03–5.78, P = 0.044) and HF hospitalization (HR 3.76, 95% CI 1.15–12.32, P = 0.029). The patients with both DM and LVR had worse clinical outcomes including MACEs and HF hospitalization, suggesting that it is particularly critical to minimize LVR after STEMI in patients with DM.

Sex differences in heart failure hospitalisation risk following acute myocardial infarction

OBJECTIVE

We evaluated the sex differences in 6-month heart failure (HF) hospitalisation risk in acute myocardial infarction (AMI) survivors.

METHODS

For this retrospective cohort analysis, adult survivors of an AMI between January and June 2014 were identified from the US Nationwide Readmissions Database. The primary outcome was a HF hospitalisation within 6 months. Secondary outcomes were fatal HF hospitalisation and the composite of index in-hospital HF or 6-month HF hospitalisation.

RESULTS

Of 237 549 AMI survivors, females (37.9%) were older (70±14 years vs 65±13 years; p<0.001), had a higher prevalence of cardiac comorbidities and a lower revascularisation rate compared with males. The primary outcome occurred in 12 934 patients (5.4%), at a 49% higher rate in females (6.8% vs 4.6% in males, p<0.001), which was attenuated to a 19% higher risk after multivariable adjustment. Findings were consistent across subgroups of age, AMI type and major risk factors. In the propensity-matched time-to-event analysis, female sex was associated with a 13% higher risk for 6-month HF readmission (6.4% vs 5.8% in males; HR 1.13, 95% CI 1.05 to 1.21, p<0.001), and the increased risk was evident early on after the AMI. Fatal HF rate was similar between groups (4.7% vs 4.6%, p=0.936), but females had a higher rate of the composite HF outcome (36.2% vs 27.5%, p<0.001).

CONCLUSION

In a large all-comers AMI survivors' cohort, females had a higher HF hospitalisation risk that persisted after adjustment for baseline risk differences. This was consistent across several clinically relevant subgroups and was evident early on after the AMI.

Sex-related differences in long-term mortality and heart failure in a contemporary cohort of patients with NSTEACS. The cardiochus-HSUJ registry

INTRODUCTION AND OBJECTIVES

There is insufficient data regarding sex-related prognostic differences in patients with a non-ST elevation acute coronary syndrome (NSTEACS). We performed a sex-specific analysis of cardiovascular outcomes after NSTEACS using a large contemporary cohort of patients from two tertiary hospitals.

METHODS

This work is a retrospective analysis from a prospective registry, that included 5,686 consecutive NSTEACS patients from two Spanish University hospitals between the years 2005 and 2017. We performed a propensity score matching to obtain a well-balanced subset of individuals with the same clinical characteristics, resulting in 3,120 patients. Cox regression models performed survival analyses once the proportional risk test was verified.

RESULTS

Among the study participants, 1,572 patients (27.6%) were women. The mean follow-up was 60.0 months (standard deviation of 32 months). Women had a higher risk of cardiovascular mortality compared with men (OR (Odds ratio) 1.27, CI (confidence interval) 95% 1.08-1.49), heart failure (HF) hospitalization (OR 1.39, CI 95% 1.18-1.63) and risk of all-cause mortality (OR 1.10, CI 95% 1.08-1.49). After a propensity score matching, female gender was associated with a significant reduction in the risk of total mortality (OR 0.77, CI 95% 0.65-0.90) with a similar risk of cardiovascular mortality (OR 0.86, CI 0.71-1.03) and HF hospitalization (OR 0.92, CI 95% 0.68-1.23). After baseline adjustment, the risk of all-cause mortality and cardiovascular mortality was lower in women, whereas the risk of HF remained similar among sexes.

CONCLUSIONS

In a contemporary cohort of patients with NSTEACS, women are at similar risk of developing early and late HF admissions, and have better survival compared with men, with a lower risk of all-cause mortality and cardiovascular mortality. The implementation of NSTEACS guideline recommendations in women, including early revascularization, seems to be accompanied by improved early and long-term prognosis.

Prognostic value of natriuretic peptides and restrictive filling pattern before surgical ventricular restoration

OBJECTIVE

Both increased natriuretic peptide levels and restrictive filling pattern (RFP) are important risk predictors in patients with heart failure. The aim of this study was to examine the role of the combined use of natriuretic peptide and RFP for the prognostic stratification of patients with ischemic cardiomyopathy undergoing surgical ventricular restoration in the Biomarker Plus study.

METHODS

A total of 186 patients (aged 64 ± 10 years) underwent echocardiographic study and N-terminal pro-B-type natriuretic peptide assay at baseline (before surgical ventricular restoration). Patients were divided into 4 groups depending on baseline diastolic filling pattern (RFP/no RFP) and N-terminal pro-B-type natriuretic peptide level (less than or greater than or equal to the upper tertile value of 2003 ŋg/L). RFP was defined as E/A ratio ≥2. All-cause death or heart failure hospitalizations within 36-month follow-up were analyzed.

RESULTS

Despite similar ejection fraction, volumes, and mass, the 4 groups presented distinct clinical and structural pattern of presurgical ventricular restoration ventricular remodeling and significantly different clinical outcome after surgical unloading. During follow-up, 67 patients died or were hospitalized for heart failure (36%). High N-terminal pro-B-type natriuretic peptide levels and RFP, considered individually, were significantly associated with outcome (P < .0001). The combination of both was associated with the highest adjusted hazard of adverse events (hazard ratio, 3.63; 95% CI, 1.73-7.6; P < .0001).

CONCLUSIONS

The simultaneous use of 2 markers, 1 biological and 1 echocardiographic, may allow better prognostic stratification and characterization of the distinct structural and clinical phenotypes in a population of patients with ischemic cardiomyopathy undergoing surgical ventricular restoration. This approach could be useful in the decision-making process to guide treatment choices in patients with ischemic cardiomyopathy.

The Predictive Value of Fragmented QRS for Cardiovascular Events in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

Objective: Fragmented QRS (fQRS) have been reported as a predictor of major adverse cardiac events (MACE) and mortality in several studies on cardiovascular disease. However, most studies have yielded discrepant results. This study aimed to explore the correlation between fQRS and cardiovascular events in patients with acute myocardial infarction (AMI) during their hospital stay and follow-up period, and the predictive value of fQRS in the prognosis of AMI. Methods: We searched for relevant studies in four databases, Medline, Embase, PubMed, and the Cochrane Library from January 2010 to March 2020. Our initial search yielded 585 articles. Of these, we screened 19 studies, and finally included a total of 6,914 patients in this analysis, comparing death events or MACE in AMI patients with or without fQRS. Results: Fragmented QRS was significantly associated with a higher risk of in-hospital mortality (OR, 3.97; 95% CI, 2.45-6.44; p < 0.00001), long-term mortality (OR, 2.93; 95% CI, 1.76-4.88; p < 0.0001), in-hospital MACE (OR, 2.48; 95% CI, 1.62-3.80; p < 0.0001), and long-term MACE (OR, 3.81; 95% CI, 2.21-6.57; p < 0.00001). In particular, it demonstrated a higher predictive value for in-hospital cardiovascular mortality and long-term all-cause mortality in AMI patients and in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI). Moreover, fQRS was also associated with an increased risk of ventricular arrhythmias (OR, 2.76; 95% CI, 1.72-4.43; p < 0.0001) and heart failure (OR, 1.65; 95% CI, 1.02-2.66; p = 0.04). Fragmented QRS was negatively associated with left ventricular ejection function (LVEF) (MD, -5.47; CI, [-7.03, -3.91]; p < 0.00001) and positively associated with a high incidence of coronary artery triple vessel lesions (OR, 2.14; 95% CI, 1.31-3.51; p = 0.002) in AMI patients. Conclusion: Fragmented QRS is significantly associated with in-hospital and long-term mortality and MACE in patients with AMI, as well as ventricular arrhythmias and heart failure. Furthermore, it may be a marker of mortality and MACE risk. Moreover, fQRS also indicates a reduced LVEF and a high incidence of coronary artery triple vessel lesions in AMI patients. Meta-analysis Registration: https://www.crd.york.ac.uk/prospero; ID: CRD42020171668.

Aspirin for primary prevention of ST segment elevation myocardial infarction in persons with diabetes and multiple risk factors

BACKGROUND

Controversy exists as to whether low-dose aspirin use may give benefit in primary prevention of cardiovascular (CV) events. We hypothesized that the benefits of aspirin are underevaluated.

METHODS

We investigated 12,123 Caucasian patients presenting to hospital with acute coronary syndromes as first manifestation of CV disease from 2010 to 2019 in the ISACS-TC multicenter registry (ClinicalTrials.gov, NCT01218776). Individual risk of ST segment elevation myocardial infarction (STEMI) and its association with 30-day mortality was quantified using inverse probability of treatment weighting models matching for concomitant medications. Estimates were compared by test of interaction on the log scale.

FINDINGS

The risk of STEMI was lower in the aspirin users (absolute reduction: 6·8%; OR: 0·73; 95%CI: 0·65-0·82) regardless of sex (p for interaction=0·1962) or age (p for interaction=0·1209). Benefits of aspirin were seen in patients with hypertension, hypercholesterolemia, and in smokers. In contrast, aspirin failed to demonstrate a significant risk reduction in STEMI among diabetic patients (OR:1·10;95%CI:0·89-1·35) with a significant interaction (p: <0·0001) when compared with controls (OR:0·64,95%CI:0·56-0·73). Stratification of diabetes in risk categories revealed benefits (p interaction=0·0864) only in patients with concomitant hypertension and hypercholesterolemia (OR:0·87, 95% CI:0·65-1·15), but not in smokers. STEMI was strongly related to 30-day mortality (OR:1·93; 95%CI:1·59-2·35).

INTERPRETATION

Low-dose aspirin reduces the risk of STEMI as initial manifestation of CV disease with potential benefit in mortality. Patients with diabetes derive substantial benefit from aspirin only in the presence of multiple risk factors. In the era of precision medicine, a more tailored strategy is required.

FUNDING

None.

Sex Differences in Modifiable Risk Factors and Severity of Coronary Artery Disease

Background

It is still unknown whether traditional risk factors may have a sex‐specific impact on coronary artery disease (CAD) burden.

Methods and Results

We identified 14 793 patients who underwent coronary angiography for acute coronary syndromes in the ISACS‐TC (International Survey of Acute Coronary Syndromes in Transitional Countries; Clini​calTr​ials.gov, NCT01218776) registry from 2010 to 2019. The main outcome measure was the association between traditional risk factors and severity of CAD and its relationship with 30‐day mortality. Relative risk (RR) ratios and 95% CIs were calculated from the ratio of the absolute risks of women versus men using inverse probability of weighting. Estimates were compared by test of interaction on the log scale. Severity of CAD was categorized as obstructive (≥50% stenosis) versus nonobstructive CAD. The RR ratio for obstructive CAD in women versus men among people without diabetes mellitus was 0.49 (95% CI, 0.41–0.60) and among those with diabetes mellitus was 0.89 (95% CI, 0.62–1.29), with an interaction by diabetes mellitus status of P =0.002. Exposure to smoking shifted the RR ratios from 0.50 (95% CI, 0.41–0.61) in nonsmokers to 0.75 (95% CI, 0.54–1.03) in current smokers, with an interaction by smoking status of P=0.018. There were no significant sex‐related interactions with hypercholesterolemia and hypertension. Women with obstructive CAD had higher 30‐day mortality rates than men (RR, 1.75; 95% CI, 1.48–2.07). No sex differences in mortality were observed in patients with nonobstructive CAD.

Conclusions

Obstructive CAD in women signifies a higher risk for mortality compared with men. Current smoking and diabetes mellitus disproportionally increase the risk of obstructive CAD in women. Achieving the goal of improving cardiovascular health in women still requires intensive efforts toward further implementation of lifestyle and treatment interventions.

Registration

URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT01218776.

Gender Differences in Residual Risk Factors for Major Adverse Cardiovascular Events Following ACS and How to Bridge the Gap

PURPOSE OF REVIEW

The review aims to describe the differences between men and women in those factors that can influence a worse prognosis in women after an acute cardiovascular event.

RECENT FINDINGS

Women adequately treated with current evidence-based medications for acute myocardial infarction and for conventional cardiovascular risk factors, such as hypertension, diabetes, smoking, and dyslipidemia, still have an extra risk of death compared with men. Additional factors that increase the risk of poor prognosis for the index event have been identified. The residual risk can be due to factors affecting the prognosis of the women from outside (they are external to the patient's body) and also to factors that, on the contrary, belong to the female body (female being/female sex). The review will give an update on those residual risk factors, including young age, vulnerability for de novo heart failure, time from symptom onset to treatment, heath care delivered during the weekend, and depression, which generally negatively influence the outcome of women with an acute myocardial infarction.

Sex Disparities in Myocardial Infarction: Biology or Bias?

Women have generally worse outcomes after myocardial infarction (MI) compared to men. The reasons for these disparities are multifactorial. At the beginning is the notion-widespread in the community and health care providers-that women are at low risk for MI. This can impact on primary prevention of cardiovascular disease in women, with lower use of preventative therapies and lifestyle counselling. It can also lead to delays in presentation in the event of an acute MI, both at the patient and health care provider level. This is of particular concern in the case of ST elevation MI (STEMI), where "time is muscle". Even after first medical contact, women with acute MI experience delays to diagnosis with less timely reperfusion and percutaneous coronary intervention (PCI). Compared to men, women are less likely to undergo invasive diagnostic testing or PCI. After being diagnosed with a STEMI, women receive less guideline-directed medical therapy and potent antiplatelets than men. The consequences of these discrepancies are significant-with higher mortality, major cardiovascular events and bleeding after MI in women compared to men. We review the sex disparities in pathophysiology, risk factors, presentation, diagnosis, treatment, and outcomes for acute MI, to answer the question: are they due to biology or bias, or both?