Racial, Ethnic, and Sex Disparities in Patients With STEMI and Cardiogenic Shock

A 10-year review of presentation, management and outcomes of STEMI in a high-volume regional tertiary Australian centre

OBJECTIVE

To assess the trends and impact of changes in management of ST Elevation Myocardial Infarction (STEMI) from 2010 to 2019.

DESIGN

Retrospective analysis of data from STEMI hospitalisations including demographic, comorbidity, angiographic and outcome data.

SETTING/PARTICIPANTS

High-volume non-surgical regional Australian tertiary referral centre.

MAIN OUTCOME MEASUREMENTS

Index & 12-month mortality (all-cause & cardiovascular), door-to-balloon time, target-vessel failure, target-vessel revascularisation & procedure-related bleeding.

RESULTS

From 2010 to 2019, 1299 patients presented with STEMI. The cardiovascular risk factor profile did not significantly change over the 10-year study period, p = 0.23. There was a significant trend toward culprit vessel percutaneous coronary intervention with stenting, rather than balloon angioplasty followed by surgical revascularisation, p = 0.029. The mean door-to-balloon time was 88 +/- 5.7 min and demonstrated a statistically significant improvement across the decade, p = 0.035. Radial access became the preferred angiographic approach (2010 92% femoral, 2019 91% radial). Drug-eluting stents (DES) replaced bare metal stent use. There was a statistically significant reduction in 12-month cardiovascular mortality across the decade (p = 0.042). However index hospitalisation (cardiovascular and all-cause) and 12-month all-cause mortality did not reduce. Young patients and women are important sub-groups of STEMI presentations with different risk factor profile.

CONCLUSIONS

Advances in management of STEMI such as radial access, use of DES and a significant reduction in door-to-balloon time across the decade resulted in a reduction of 12-month cardiovascular mortality over the decade however there was no significant reduction in 12-month all-cause mortality, or index hospitalisation cardiovascular or index hospitalisation all-cause mortality. Further research is needed to ensure non-mortality outcomes, such as heart failure hospitalisation and quality of life, also demonstrate temporal improvement with STEMI management advances. Earlier cardiovascular risk assessment should be considered in smokers than is currently recommended in Australian guidelines (≥45yo for most individuals).

Sex differences in the presentation and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock: a critical review of contemporary data and a look towards future directions

PURPOSE OF REVIEW

Cardiogenic shock (CS) is a devasting complicating of acute myocardial infarction (AMI), associated with significant mortality. Prior studies have reported sex differences in the presentation, management and outcomes of patients with AMI and CS. These differences are likely due to a variety of factors influencing therapeutic decision-making and impacting survival. This review highlights the more contemporary studies exploring differences in women and men with AMI-CS, providing a critical perspective towards understanding the factors that might lead to these differences and outlining potential opportunities to reduce disparities in treatment and improve survival for women with AMI-CS.

RECENT FINDINGS

Recent reports demonstrate that women with AMI-CS are older than men and have more cardiovascular comorbidities. When examining an unselected population of patients with AMI-CS, women receive less aggressive treatment compared to men and have poorer outcomes. However, when examining a selected population of patients with AMI-CS treated with mechanical circulatory support (MCS) and/or admitted to centers that implement CS protocols to manage AMI-CS, these sex-based differences in outcomes are largely mitigated.

SUMMARY

Standardizing protocols for the diagnosis and treatment of patients with AMI-CS, with an emphasis on early revascularization and appropriate invasive therapies, can improve outcomes in women and narrow the gender gap.

Sex and Racial Disparities in Proportionate Mortality of Premature Myocardial Infarction in the United States: 1999 to 2020

BACKGROUND

The incidence of premature myocardial infarction (PMI) in women (<65 years and men <55 years) is increasing. We investigated proportionate mortality trends in PMI stratified by sex, race, and ethnicity.

METHODS AND RESULTS

CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) was queried to identify PMI deaths within the United States between 1999 and 2020, and trends in proportionate mortality of PMI were calculated using the Joinpoint regression analysis. We identified 3 017 826 acute myocardial infarction deaths, with 373 317 PMI deaths corresponding to proportionate mortality of 12.5% (men 12%, women 14%). On trend analysis, proportionate mortality of PMI increased from 10.5% in 1999 to 13.2% in 2020 (average annual percent change of 1.0 [0.8-1.2, P <0.01]) with a significant increase in women from 10% in 1999 to 17% in 2020 (average annual percent change of 2.4 [1.8-3.0, P <0.01]) and no significant change in men, 11% in 1999 to 10% in 2020 (average annual percent change of -0.2 [-0.7 to 0.3, P=0.4]). There was a significant increase in proportionate mortality in both Black and White populations, with no difference among American Indian/Alaska Native, Asian/Pacific Islander, or Hispanic people. American Indian/Alaska Natives had the highest PMI mortality with no significant change over time.

CONCLUSIONS

Over the last 2 decades, there has been a significant increase in the proportionate mortality of PMI in women and the Black population, with persistently high PMI in American Indian/Alaska Natives, despite an overall downtrend in acute myocardial infarction-related mortality. Further research to determine the underlying cause of these differences in PMI mortality is required to improve the outcomes after acute myocardial infarction in these populations.

Sex differences in treatments and outcomes of patients with cardiogenic shock: a systematic review and epidemiological meta-analysis

BACKGROUND

Women are at higher risk of mortality from many acute cardiovascular conditions, but studies have demonstrated differing findings regarding the mortality of cardiogenic shock in women and men. To examine differences in 30-day mortality and mechanical circulatory support use by sex in patients with cardiogenic shock.

MAIN BODY

Cochrane Central, PubMed, MEDLINE and EMBASE were searched in April 2024. Studies were included if they were randomised controlled trials or observational studies, included adult patients with cardiogenic shock, and reported at least one of the following outcomes by sex: raw mortality, adjusted mortality (odds ratio) or use of mechanical circulatory support. Out of 4448 studies identified, 81 met inclusion criteria, pooling a total of 656,754 women and 1,018,036 men. In the unadjusted analysis for female sex and combined in-hospital and 30-day mortality, women had higher odds of mortality (Odds Ratio (OR) 1.35, 95% confidence interval (CI) 1.26-1.44, p < 0.001). Pooled unadjusted mortality was 35.9% in men and 40.8% in women (p < 0.001). When only studies reporting adjusted ORs were included, combined in-hospital/30-day mortality remained higher in women (OR 1.10, 95% CI 1.06-1.15, p < 0.001). These effects remained consistent across subgroups of acute myocardial infarction- and heart failure- related cardiogenic shock. Overall, women were less likely to receive mechanical support than men (OR = 0.67, 95% CI 0.57-0.79, p < 0.001); specifically, they were less likely to be treated with intra-aortic balloon pump (OR = 0.79, 95% CI 0.71-0.89, p < 0.001) or extracorporeal membrane oxygenation (OR = 0.84, 95% 0.71-0.99, p = 0.045). No significant difference was seen with use of percutaneous ventricular assist devices (OR = 0.82, 95% CI 0.51-1.33, p = 0.42).

CONCLUSION

Even when adjusted for confounders, mortality for cardiogenic shock in women is approximately 10% higher than men. This effect is seen in both acute myocardial infarction and heart failure cardiogenic shock. Women with cardiogenic shock are less likely to be treated with mechanical circulatory support than men. Clinicians should make immediate efforts to ensure the prompt diagnosis and aggressive treatment of cardiogenic shock in women.

Untwisting healthcare access disparities: A comprehensive analysis of demographic, socio-economic and racial disparities impacting patient outcomes in myocardial infarction patients

INTRODUCTION

Myocardial infarction (MI) is one of the most life-threatening pathologies characterized by sudden cardiac death and is among the leading causes of mortality in the developed world.

AIMS

This study investigates the demographic, socio-economic, and healthcare access disparities in the US among patients with myocardial infarction (MI).

METHODOLOGY

This was a retrospective original research study conducted using the BRFSS (Behavioural risk factor surveillance system) database of CDC (Centers for disease control and prevention).Data was extracted from the BRFSS on 3rd January 2024 to identify patients with MI in the year 2021 and multivariate models were used to assess the relationship between factors such as age, gender, income levels, and education in patients with myocardial infarction.

RESULTS

Individuals in the age group of 65 years or older constituted the highest percentage of MI cases at 66.33 % (OR, 16.66; 95 % CI, 10.27-27.02; p-value <0.0001).Males showed a higher prevalence of MI, accounting for 61.19 % of cases, and females demonstrated lower susceptibility (OR, 0.46; 95 % CI, 0.43-0.50; p-value <0.0001).High school graduates (Grade 12 or GED) exhibited the highest incidence at 32.08 % (OR, 1.44; 95 % CI, 0.81-2.56; p-value 0.2084). Retirees accounted for the highest incidence at 56.06 %, with significantly increased odds compared to those employed for wages (OR, 1.93; 95 % CI, 1.71-2.19; p-value <0.0001).The analysis of income levels indicated the highest MI incidence in the $25,000 <= Income < $35,000 group (17.31 % of cases).

CONCLUSIONS

Additional research is necessary to further disentangle the interaction between MI and factors such as age, gender, education level, race, employment status, and income level, and as the findings of this study suggest, retired individuals and individuals from lower-income groups indicate a disparity in access to timely treatment regarding MI. Thus, the determination of such discrepancies needs to be addressed regarding how such factors affect access to timely healthcare, especially in matters of widely prevalent diseases such as MI.

Disparity in the Under-Utilization of Novel P2Y12 Inhibitors in ST-Elevation Myocardial Infarction Following Percutaneous Coronary Intervention

Background

The most recent guidelines (European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA)) all favor prasugrel/ticagrelor over clopidogrel in the setting of acute coronary syndrome (ACS). We therefore sought to investigate which P2Y12 inhibitors were being prescribed in our community hospital setting upon discharge among patients undergoing percutaneous coronary intervention (PCI) in the setting of ST-elevation myocardial infarction (STEMI).

Methods

We identified patients presenting to two Metro Detroit Michigan hospitals with STEMI between January 1, 2018, to December 31, 2021 using the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) PCI registry. The primary outcome was the choice of P2Y12 inhibitor prescribed on day of discharge following hospitalization for STEMI, and baseline characteristics were compared including race, sex and type of insurance.

Results

A total of 366 patients presented to these two Metro Detroit hospitals from January 1, 2018, to December 31, 2021. Female and non-White patients were more likely to be discharged on clopidogrel than ticagrelor or prasugrel (odds ratio (OR): 1.56, confidence interval (CI): 0.99 - 2.45, and OR: 1.43, CI: 0.91 - 2.25, respectively), however, did not reach statistical significance. Patients without private insurance presenting with STEMI were more likely to be discharged on clopidogrel (OR: 1.83, CI: 1.22 - 2.74), which did reach statistical significance in our cohort.

Conclusions

In this retrospective single-center study evaluating BMC2 registry, we demonstrate a clinically significant disparity in prescribing patterns based on insurance, with trends for disparity based on gender and ethnicity.

Understanding the spectrum of cardiovascular risk in women - A primer for prevention

Cardiovascular disease (CVD) is the leading cause of death in women worldwide and the lifetime risk of CVD in women is similar to men. However, the pathophysiology of CVD varies between women and men necessitating a sex-specific understanding of cardiovascular (CV) risk. A belief that women have a lower CVD risk than men, and an underrepresentation in clinical research for many years has led to a paucity of evidence in the prevention and management of CVD in women. Many recent efforts have tried to bridge the gap. As a result, we now know that traditional risk factors impact CVD risk differently in women when compared with men. There are also numerous sex-specific and pregnancy related risk factors that modify the risk and can predict the future development of CVD in women. This is important as risk calculators, in general, tend to misclassify risk in young women with nontraditional CVD risk factors. To address this, guidelines have introduced the concept of risk enhancers that can suggest a higher risk. The use of coronary artery calcium score can further accurately delineate risk in these women, leading to an appropriate matching of therapy to underlying risk. This review discusses implementation strategies that are essential to mitigate disparities in CVD outcomes and optimizing CVD risk in women.

Sex-related differences in patients presenting with heart failure-related cardiogenic shock

BACKGROUND

Heart failure-related cardiogenic shock (HF-CS) accounts for a significant proportion of all CS cases. Nevertheless, there is a lack of evidence on sex-related differences in HF-CS, especially regarding use of treatment and mortality risk in women vs. men. This study aimed to investigate potential differences in clinical presentation, use of treatments, and mortality between women and men with HF-CS.

METHODS

In this international observational study, patients with HF-CS (without acute myocardial infarction) from 16 tertiary-care centers in five countries were enrolled between 2010 and 2021. Logistic and Cox regression models were used to assess differences in clinical presentation, use of treatments, and 30-day mortality in women vs. men with HF-CS.

RESULTS

N = 1030 patients with HF-CS were analyzed, of whom 290 (28.2%) were women. Compared to men, women were more likely to be older, less likely to have a known history of heart failure or cardiovascular risk factors, and lower rates of highly depressed left ventricular ejection fraction and renal dysfunction. Nevertheless, CS severity as well as use of treatments were comparable, and female sex was not independently associated with 30-day mortality (53.0% vs. 50.8%; adjusted HR 0.94, 95% CI 0.75-1.19).

CONCLUSIONS

In this large HF-CS registry, sex disparities in risk factors and clinical presentation were observed. Despite these differences, the use of treatments was comparable, and both sexes exhibited similarly high mortality rates. Further research is necessary to evaluate if sex-tailored treatment, accounting for the differences in cardiovascular risk factors and clinical presentation, might improve outcomes in HF-CS.

Sex differences in the outcomes after transcatheter aortic valve replacement with newer generation devices: A meta-analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a reasonable therapeutic approach among patients with symptomatic severe aortic stenosis irrespective of surgical risk. Data regarding sex-specific differences in the outcomes with newer generation valves are limited.

METHODS

Electronic databases were searched for studies assessing sex differences in the outcomes of patients undergoing TAVR with newer generation valves (SAPIEN 3 or Evolut). Random effects model was constructed for summary estimates.

RESULTS

Four observational studies with 4522 patients (44.8% women) were included in the meta-analysis. Women were older and had a lower prevalence of coronary artery disease and mean EuroScore. Women had a higher incidence of short-term mortality (up to 30 days) (risk ratio [RR]: 1.60, 95% confidence interval [CI]: 1.14-2.25), but no difference in 1-year mortality (RR: 0.92, 95% CI: 0.72-1.17). There was no significant difference in the incidence of major bleeding (RR: 1.16, 95% CI: 0.86-1.57), permanent pacemaker (PPM) (RR: 0.80, 95% CI: 0.62-1.04), or disabling stroke (RR: 1.16, 95% CI: 0.54-2.45).

CONCLUSION

In this meta-analysis, we found that women undergoing TAVR with newer-generation devices were older but had a lower prevalence of comorbidities. Women had a higher incidence of short-term mortality but no difference in the 1-year mortality, bleeding, PPM, or stroke compared with men. Future studies are required to confirm these findings.

Cardiogenic shock-sex-specific risk factors and outcome differences

Cardiogenic shock (CS) remains a high-mortality condition despite technological and therapeutic advances. One key to potentially improving CS prognosis is understanding patient heterogeneity and which patients may benefit most from different treatment options, a key element of which is sex differences. While cardiovascular diseases (CVDs) have historically been considered a male-dominant condition, the field is increasingly aware that females are also a substantial portion of the patient population. While estrogen has been implicated in protective roles against CVD and tissue hypoxia, its role in CS remains unclear. Clinically, female CS patients tend to be older, have more severe comorbidities and are more likely to have non-acute myocardial infarction etiologies with preserved ejection fractions. Female CS patients are more likely to receive pharmacotherapy while less likely to receive mechanical circulatory support. There is increased short-term mortality in females, although long-term mortality is similar between the sexes. More sex-specific and age-stratified research needs to be done to fully understand the relevant pathophysiological differences in CS, to better recognize and manage CS patients and reduce its mortality.

Untwisting healthcare access disparities: A comprehensive analysis of demographic, socio-economic and racial disparities impacting patient outcomes in myocardial infarction patients

INTRODUCTION

Myocardial infarction (MI) is one of the most life-threatening pathologies characterized by sudden cardiac death and is among the leading causes of mortality in the developed world.

AIMS

This study investigates the demographic, socio-economic, and healthcare access disparities in the US among patients with myocardial infarction (MI).

METHODOLOGY

This was a retrospective original research study conducted using the BRFSS (Behavioural risk factor surveillance system) database of CDC (Centers for disease control and prevention).Data was extracted from the BRFSS on 3rd January 2024 to identify patients with MI in the year 2021 and multivariate models were used to assess the relationship between factors such as age, gender, income levels, and education in patients with myocardial infarction.

RESULTS

Individuals in the age group of 65 years or older constituted the highest percentage of MI cases at 66.33% (OR, 16.66; 95% CI, 10.27-27.02; p-value <0.0001).Males showed a higher prevalence of MI, accounting for 61.19% of cases, and females demonstrated lower susceptibility (OR, 0.46; 95% CI, 0.43-0.50; p-value <0.0001).High school graduates (Grade 12 or GED) exhibited the highest incidence at 32.08% (OR, 1.44; 95% CI, 0.81-2.56; p-value 0.2084). Retirees accounted for the highest incidence at 56.06%, with significantly increased odds compared to those employed for wages (OR, 1.93; 95% CI, 1.71-2.19; p-value <0.0001).The analysis of income levels indicated the highest MI incidence in the $25,000 <= Income < $35,000 group (17.31% of cases).

CONCLUSIONS

Additional research is necessary to further disentangle the interaction between MI and factors such as age, gender, education level, race, employment status, and income level, and as the findings of this study suggest, retired individuals and individuals from lower-income groups indicate a disparity in access to timely treatment regarding MI. Thus, the determination of such discrepancies needs to be addressed regarding how such factors affect access to timely healthcare, especially in matters of widely prevalent diseases such as MI.

Impella Versus Intra-Aortic Balloon Pump in Patients With Cardiogenic Shock Treated With Venoarterial Extracorporeal Membrane Oxygenation: An Observational Study

BACKGROUND

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for patients with cardiogenic shock. Although Impella or intra-aortic balloon pump (IABP) is frequently used for left ventricular unloading (LVU) during VA-ECMO treatment, there are limited data on comparative outcomes. We compared outcomes of Impella and IABP for LVU during VA-ECMO.

METHODS AND RESULTS

Using the Nationwide Readmissions Database between 2016 and 2020, we analyzed outcomes in 3 groups of patients with cardiogenic shock requiring VA-ECMO based on LVU strategies: extracorporeal membrane oxygenation (ECMO) only, ECMO with IABP, and ECMO with Impella. Of 15 980 patients on VA-ECMO, IABP and Impella were used in 19.4% and 16.4%, respectively. The proportion of patients receiving Impella significantly increased from 2016 to 2020 (6.5% versus 25.8%; P-trend<0.001). In-hospital mortality was higher with ECMO with Impella (54.8%) compared with ECMO only (50.4%) and ECMO with IABP (48.4%). After adjustment, ECMO with IABP versus ECMO only was associated with lower in-hospital mortality (adjusted odds ratio [aOR], 0.83; P=0.02). ECMO with Impella versus ECMO only had similar in-hospital mortality (aOR, 1.09; P=0.695) but was associated with more bleeding (aOR, 1.21; P=0.007) and more acute kidney injury requiring hemodialysis (aOR, 1.42; P<0.001). ECMO with Impella versus ECMO with IABP was associated with greater risk of acute kidney injury requiring hemodialysis (aOR, 1.49; P=0.002), higher in-hospital mortality (aOR, 1.32; P=0.001), and higher 40-day mortality (hazard ratio, 1.25; P<0.001).

CONCLUSIONS

In patients with cardiogenic shock on VA-ECMO, LVU with Impella, particularly with 2.5/CP, was not associated with improved survival at 40 days but was associated with increased adverse events compared with IABP. More data are needed to assess Impella platform-specific comparative outcomes of LVU.

Cardiogenic shock in a young woman with SCAD: The importance of early access to VA-ECMO in the community

Spontaneous coronary artery dissection (SCAD) is a common cause of myocardial infarction in young and middle-aged women. Patients with SCAD present rarely with hemodynamic collapse and cardiogenic shock, requiring immediate resuscitation and mechanical circulatory support. Percutaneous mechanical circulatory support may serve as a bridge to recovery, decision or heart transplantation. We present a case of a young woman with SCAD of the left main coronary artery, presenting with ST-elevation myocardial infarction, cardiac arrest and cardiogenic shock. She was stabilized emergently with Impella and early escalation with extracorporeal membrane oxygenation (ECPELLA) at a non-surgical community hospital. Despite revascularization with percutaneous coronary intervention (PCI), her left ventricular recovery was poor, and ultimately required cardiac transplantation on day 5 of her presentation.

Sex Differences in Coronary Inflammation and Atherosclerosis Phenotypes in Response to Imaging Marker of Stress-Related Neural Activity

BACKGROUND

Sex-specific differences in coronary phenotypes in response to stress have not been elucidated. This study investigated the sex-specific differences in the coronary computed tomography angiography-assessed coronary response to mental stress.

METHODS

This retrospective study included patients with coronary artery disease and without cancer who underwent resting 18F-fluorodexoyglucose positron emission tomography/computed tomography and coronary computed tomography angiography within 3 months. 18F-flourodeoxyglucose resting amygdalar uptake, an imaging biomarker of stress-related neural activity, coronary inflammation (fat attenuation index), and high-risk plaque characteristics were assessed by coronary computed tomography angiography. Their correlation and prognostic values were assessed according to sex.

RESULTS

A total of 364 participants (27.7% women and 72.3% men) were enrolled. Among those with heightened stress-related neural activity, women were more likely to have a higher fat attenuation index (43.0% versus 24.0%; P=0.004), while men had a higher frequency of high-risk plaques (53.7% versus 39.3%; P=0.036). High amygdalar 18F-flourodeoxyglucose uptake (B-coefficient [SE], 3.62 [0.21]; P<0.001) was selected as the strongest predictor of fat attenuation index in a fully adjusted linear regression model in women, and the first-order interaction term consisting of sex and stress-related neural activity was significant (P<0.001). Those with enhanced imaging biomarkers of stress-related neural activity showed increased risk of major adverse cardiovascular event both in women (24.5% versus 5.1%; adjusted hazard ratio, 3.62 [95% CI, 1.14-17.14]; P=0.039) and men (17.2% versus 6.9%; adjusted hazard ratio, 2.72 [95% CI, 1.10-6.69]; P=0.030).

CONCLUSIONS

Imaging-assessed stress-related neural activity carried prognostic values irrespective of sex; however, a sex-specific mechanism linking psychological stress to coronary plaque phenotypes existed in the current hypothesis-generating study.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05545618.

Association of socioeconomic status in the incidence, quality-of-care metrics, and outcomes for patients with cardiogenic shock in a pre-hospital setting

AIMS

The relationship between lower socioeconomic status (SES) and poor cardiovascular outcomes is well described; however, there exists a paucity of data exploring this association in cardiogenic shock (CS). This study aimed to investigate whether any disparities exist between SES and the incidence, quality of care or outcomes of CS patients attended by emergency medical services (EMS).

METHODS AND RESULTS

This population-based cohort study included consecutive patients transported by EMS with CS between 1 January 2015 and 30 June 2019 in Victoria, Australia. Data were collected from individually linked ambulance, hospital, and mortality datasets. Patients were stratified into SES quintiles using national census data produced by the Australian Bureau of Statistics.A total of 2628 patients were attended by EMS for CS. The age-standardized incidence of CS amongst all patients was 11.8 [95% confidence interval (95% CI), 11.4-12.3] per 100 000 person-years, with a stepwise increase from the highest to lowest SES quintile (lowest quintile 17.0 vs. highest quintile 9.7 per 100 000 person-years, P-trend < 0.001). Patients in lower SES quintiles were less likely to attend metropolitan hospitals and more likely to be received by inner regional and remote centres without revascularization capabilities. A greater proportion of the lower SES groups presented with CS due to non-ST elevation myocardial infarction (NSTEMI) or unstable angina pectoris (UAP), and overall were less likely to undergo coronary angiography. Multivariable analysis demonstrated an increased 30-day all-cause mortality rate in the lowest three SES quintiles when compared with the highest quintile.

CONCLUSION

This population-based study demonstrated discrepancies between SES status in the incidence, care metrics, and mortality rates of patients presenting to EMS with CS. These findings outline the challenges in equitable healthcare delivery within this cohort.

Cardiogenic Shock: Pathogenesis, Classification, and Management

Cardiogenic shock (CS) is a life-threatening circulatory failure syndrome which can progress rapidly to irreversible multiorgan failure through self-perpetuating pathophysiological processes. Recent developments in CS classification have highlighted its etiologic, mechanistic, and hemodynamic heterogeneity. Optimal CS management depends on early recognition, rapid reversal of the underlying cause, and prompt initiation of hemodynamic support.

Prognostic effect of sex according to shock severity in patients with acute myocardial infarction complicated by cardiogenic shock

BACKGROUND

Sex disparities in cardiogenic shock (CS) treatment are controversial, and the prognostic implications of sex remain unclear in CS caused by acute myocardial infarction (AMI).

OBJECTIVES

This study aimed to evaluate the prognostic effect of sex according to the severity of CS in patients undergoing percutaneous coronary intervention (PCI) for AMI complicated by CS.

METHODS

We assessed 695 patients from 12 tertiary centers in South Korea who underwent PCI for AMI complicated by CS, and analyzed outcomes by sex (female [n = 184] vs. male [n = 511]). We compared a 12-month patient-oriented composite endpoint (POCE, defined as a composite of all-cause mortality, myocardial infarction, re-hospitalization due to heart failure, and repeat revascularization) between the sexes, respective of SCAI shock stage C&D or E. Propensity score-matched analysis was performed to reduce bias.

RESULTS

We found that the female group was older and had higher vasoactive-inotropic and IABP-SHOCK II scores than the male group, with findings consistent across SCAI shock stages. During the 12-month follow-up period, multivariate analysis revealed no significant differences in POCE (HR 1.01, 95% CI 0.67-1.53, p = 0.963 for SCAI stage C&D, HR 1.24, 95% CI 0.84-1.84, p = 0.286 for SCAI stage E) between females and males. After propensity score matching, the incidence of POCE (HR 1.47, 95% CI 0.79-2.72, p = 0.220 for SCAI stage C&D, HR 0.88, 95% CI 0.49-1.57, p = 0.665 for SCAI stage E) was similar between sexes.

CONCLUSIONS

Sex does not appear to influence the risk of 12-month POCE in patients treated with PCI for CS caused by AMI, irrespective of shock severity.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT02985008. RESCUE (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock), NCT02985008, Registered December 5, 2016 - retrospectively and prospectively.

IRB INFORMATION

This study was approved by the institutional review board of Samsung Medical Center (Reference number: 2016-03-130).

Impact of Acute Myocardial Infarction Type on Prognosis in Female Patients With Cardiogenic Shock

There are limited data about mid-term prognosis according to acute myocardial infarction (AMI) type in female patients with AMI complicated by cardiogenic shock (CS). In this study, we evaluated the impact of AMI type on prognosis in female patients who underwent percutaneous coronary intervention (PCI) for AMI complicated by CS. A total of 184 female patients who underwent PCI for AMI complicated by CS were enrolled from 12 centers in the Republic of Korea. Patients were divided into 2 groups according to AMI type: the ST-segment elevation myocardial infarction (n = 114) and the non-ST-segment elevation myocardial infarction (n = 70) group. Primary outcome was a major adverse cardiac event (MACE) (defined as a composite of cardiac death, myocardial infarction, or repeat revascularization). Propensity-score matching analysis was performed to reduce selection bias and potential confounding factors. During 12-month follow-up, a total of 73 MACEs occurred (ST-segment elevation myocardial infarction group, 47 [41.2%] vs non-ST-segment elevation myocardial infarction group, 26 [37.1%], p = 0.643). Multivariate analysis revealed no significant difference in the incidence of MACE at 12 months between the 2 groups (adjusted hazard ratio 1.16, 95% confidence interval 0.70 to 2.37, p = 0.646). After propensity-score matching, the incidence of MACE at 12 months remained similar between the 2 groups (hazard ratio 1.31, 95% confidence interval 0.69 to 2.52, p = 0.413). The similarity in MACEs between the 2 groups was consistent across a variety of subgroups. In conclusion, after adjusting for baseline differences, AMI clinical type did not appear to increase the risk of MACEs at 12 months in female patients who underwent emergency PCI for AMI complicated by CS.

Percutaneous Coronary Interventions in Women

PURPOSEOF REVIEW

Cardiovascular disease is the leading cause of morbidity and mortality among women globally. Numerous studies show ongoing disparities in diagnosis, management, and outcomes of ischemic heart disease in women compared to men. We aim to review the factors contributing to sex-based differential outcomes of percutaneous coronary interventions in women.

RECENT FINDINGS

Hormonal influence on coronary arteries and progression of atherosclerosis in women results in distinct coronary plaque characteristics and unique pathological process such as spontaneous coronary artery dissection and myocardial infarction with non-obstructive coronary arteries. During the presentation of acute coronary syndromes, women are older and have higher burden of comorbidities, with higher short- and long-term mortality. Awareness of differences in vascular biology and unique risk factors for cardiovascular disease in women is essential for sustained improvement in cardiovascular mortality. Better representation of women in trials is crucial to address the gaps in knowledge and allow for individualized treatment approaches in women.

Sex differences in the management of atherosclerotic cardiovascular disease

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

Racial disparities in women with ST elevation myocardial infarction: A National Inpatient Sample review of baseline characteristics, co-morbidities, and outcomes in women with STEMI

BACKGROUND

A third of the patients admitted with Acute coronary syndrome (ACS) have ST-elevation myocardial infarction (STEMI). Previous studies showed that females with STEMI have higher mortality than men.

HYPOTHESIS

There exist significant disparities in outcomes among women of different races presenting with STEMI.

METHODS

National inpatient sample (NIS) data was obtained from January 2016 to December 2018 for the hospitalization of female patients with STEMI. We compared outcomes, using an extensive multivariate regression analysis amongst women from different races. Our primary outcome was in-hospital mortality. Secondary outcomes were revascularization use, procedure complications, and healthcare utilization.

RESULTS

Of 202 223 female patients with STEMI; 11.3% were African American, 7.4% Hispanic, 2.4% Asian, and 4.3% another race. In-hospital mortality was higher in non-Caucasian groups. African American (adjusted odds ratio [aOR] 1.2; 95% confidence interval [CI]: 1.07-1.30; p < .01) and another race (aOR 1.37; 95% CI: 1.15-1.63; p < .01) had higher odds of mortality when compared with white women. African American (aOR 0.69; 95% CI: 0.62-0.72; p < .01), Hispanics (aOR 0.81; 95% CI: 0.74-0.88; p < .01), and Asian (aOR 0.79; 95% CI: 0.69-0.90; p < .01) had lower odds of percutaneous intervention (PCI) when compared with whites. African Americans had fewer odds of Coronary Artery Bypass Graft (CABG) and use of Mechanical Circulatory Support (MCS) during the index admission. Non-Caucasians had more comorbidities, complications, and healthcare utilization costs.

CONCLUSION

There are significant racial disparities in clinical outcomes and revascularization in female patients with STEMI. African American women have a higher likelihood of mortality among the different races. Females from minority groups are also less likely to undergo PCI.

Factors associated with complications in ST-elevation myocardial infarction: a single-center experience

BACKGROUND

ST-elevation myocardial infarction (STEMI) is a major public health problem. This study aimed to determine the prevalence and identify the determinants of STEMI-related complications in the Cardiology Intensive Care Unit of the Sud Francilien Hospital Center (SFHC).

METHODS

We retrospectively analyzed the data of 315 patients with STEMI aged ≥ 18 years. Logistic regression was used to identify factors independently associated with the occurrence of complications.

RESULTS

Overall, 315 patients aged 61.7 ± 13.4 years, of whom 261 were men, had STEMI during the study period. The hospital frequency of STEMI was 12.7%. Arrhythmias and acute heart failure were the main complications. Age ≥ 75 years (adjusted odds ratio [aOR], 5.18; 95% confidence interval [CI], 3.92-8.75), hypertension (aOR, 3.38; 95% CI, 1.68-5.82), and cigarette smoking (aOR, 3.52; 95% CI, 1.69-7.33) were independent determinants of acute heart failure. Meanwhile, diabetes mellitus (aOR, 1.74; 95% CI, 1.09-3.37), history of atrial fibrillation (aOR, 2.79; 95% CI, 1.66-4.76), history of stroke or transient ischemic attack (aOR, 1.99; 95% CI, 1.31-2.89), and low high-density lipoprotein-cholesterol (HDL-C) levels (aOR, 3.70; 95% CI, 1.08-6.64) were independent determinants of arrhythmias.

CONCLUSION

STEMI is a frequent condition at SFHC and is often complicated by acute heart failure and arrhythmias. Patients aged ≥ 75 years, those with hypertension or diabetes mellitus, smokers, those with a history of atrial fibrillation or stroke, and those with low HDL-C levels require careful monitoring for the early diagnosis and management of these complications.

Characteristics of Premature Myocardial Infarction Among Women With Prior Adverse Pregnancy Outcomes

BACKGROUND

Adverse pregnancy outcomes (APOs), hypertensive disorders of pregnancy, gestational diabetes mellitus, and preterm birth are associated with ischemic heart disease in later life.

OBJECTIVES

The authors aimed to study the features of premature myocardial infarction (MI) among women with and without prior APOs.

METHODS

We performed a retrospective analysis of women with premature MI (<65 years of age) referred for left heart catheterization matched with a database of abstracted pregnancy data. We compared MI characteristics and epicardial coronary anatomy between women with and without APOs during their index pregnancy and evaluated time from delivery to MI.

RESULTS

Of 391 women with premature MI and associated coronary angiography (age: 49 ± 8 years), 154 (39%) had a prior APO (hypertensive disorders of pregnancy n = 78, preeclampsia n = 35, gestational diabetes mellitus n = 28, and preterm birth n = 48). Women with APO history had a higher prevalence of diabetes (33% vs 16% without APO; P = 0.001) and presented earlier with MI following delivery (19.6 [IQR: 14.3-23.5] years vs those without APO 21.5 [IQR: 17.0-25.4] years; P = 0.012), driven by preeclampsia (17.1 [IQR: 12.7-22.4] years, P = 0.010). Women with and without APOs had similar MI features including rates of ST-segment elevation MI, obstructive and multi-vessel coronary artery disease, percutaneous coronary intervention, and shock.

CONCLUSIONS

Among women with premature MIs, 39% had a history of an APO. Women with APO history presented sooner after pregnancy but had similar MI characteristics vs those without APOs. Pregnancy history may identify women who warrant early, aggressive cardiovascular disease prevention.

Impact of Gender, Race, and Insurance Status on Inhospital Management and Outcomes in Patients With COVID-19 and ST-Elevation Myocardial Infarction (a Nationwide Analysis)

There is a paucity of data exploring the impact of gender, race, and insurance status on invasive management and inhospital mortality in patients with COVID-19 with ST-elevation myocardial infarction (STEMI) in the United States. The National Inpatient Sample database for the year 2020 was queried to identify all adult hospitalizations with STEMI and concurrent COVID-19. A total of 5,990 patients with COVID-19 with STEMI were identified. Women had 31% lower odds of invasive management and 32% lower odds of coronary revascularization than men. Black patients had lower odds of invasive management (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.43 to 0.85, p = 0.004) than White patients. Black and Asian patients had lower odds of percutaneous coronary intervention (Black: OR 0.55, 95% CI 0.38 to 0.80, p = 0.002; Asian: OR 0.39, 95% CI 0.18 to 0.85, p = 0.018) than White patients. Uninsured patients had higher odds of getting percutaneous coronary intervention (OR 1.78, 95% CI 1.05 to 2.98, p = 0.031) and lower odds of inhospital mortality (OR 0.41, 95% CI 0.19 to 0.89, p = 0.023) than privately insured patients. Patients with out-of-hospital STEMI had 19 times higher odds of invasive management and 80% lower odds of inhospital mortality than inhospital STEMI. In conclusion, we note important gender and racial disparities in invasive management of patients with COVID-19 with STEMI. Surprisingly, uninsured patients had higher revascularization rates and lower mortality than privately insured patients.

US Initiative to Eliminate Racial and Ethnic Disparities in Health: The Impact on the Outcomes of ST-Segment-Elevation Myocardial Infarction in New Jersey

Background In 1998, President Clinton launched a federal initiative to eliminate racial and ethnic health disparities. The impact on the outcomes of ST-segment-elevation myocardial infarction has not been well studied. Methods and Results ST-segment-elevation myocardial infarction outcomes from 1994 to 2015 were studied in 7942 Black, 27 665 Hispanic, and 88 727 White patients with first admission of ST-segment-elevation myocardial infarction using the Myocardial Infarction Data Acquisition System. Logistic regressions were used to assess mortality adjusting for demographics, comorbidities, and interventional procedures. There was an overall rise from 1994 to 2015 in the use of percutaneous coronary interventions in all 3 groups. Before 1998, White patients received more percutaneous coronary interventions compared with Black and Hispanic patients (P<0.05). After 1998, the disparity in use of percutaneous coronary interventions in Black and Hispanic patients was greatly reduced compared with White patients, and the difference reversed in favor of Hispanic patients after 2005 (P<0.05). There was an overall downward trend of in-hospital mortality without evidence of disparity among Black, Hispanic, and White patients. A linear regression model was used with a change point in 1998. Before 1998, the slope of 1-year all-cause and cardiovascular mortality was not statistically significant. After 1998, the mortality showed negative slopes for all 3 groups, however, with lower overall crude mortality for Hispanic patients compared with Black and White patients (P<0.0001). Conclusions The initiative launched in 1998 may have contributed to a reduction in percutaneous coronary intervention usage disparity in patients with ST-segment-elevation myocardial infarction. Short- and long-term mortality decreased in all 3 groups, but more in the Hispanic population.

Clinical and epidemiological profile of ST-segment elevation myocardial infarction patients in a megacity of west of Iran

Background and Aims

Low- and middle-income nations account for at least three-quarters of cardiovascular disease deaths worldwide. This study aimed to obtain real knowledge about ST segment elevation myocardial infarction (STEMI) patients and provide the context for developing a principles for care quality improvement.

Method

This cross-sectional study was conducted from July 2018 through December 2019. The study sample consisted of1169 eligible patients based on inclusion criteria. The data were collected using the standard EROP and three specialized, trained questionnaires. The collected data were checked by the quality control officer and analyzed using Stata Version 14.

Results

Patient baseline characteristics showed that body mass index, low-density lipoprotein, high-density lipoprotein, total cholesterol, and triglyceride levels were higher in women. Also, females recorded a considerable history of diabetes mellitus, hypertension, and hypercholesterolemia compared to men. The results also showed that most men were smokers (46.80%). Aspirin (94.27%), statins (91.48%), and clopidogrel (90.68%) were the common medications used at hospital discharge for patients.

Conclusion

The present study suggests that identifying and managing modifiable risk factors can improve cardiovascular disease outcomes. Also, considering the early identification of STEMI patients with new therapies can effectively decrease the rate of cardiovascular disease and its attributed health outcomes.

Locking the Revolving Door: Racial Disparities in Cardiovascular Disease

Racial disparities in cardiovascular disease are unjust, systematic, and preventable. Social determinants are a primary cause of health disparities, and these include factors such as structural and overt racism. Despite a number of efforts implemented over the past several decades, disparities in cardiovascular disease care and outcomes persist, pervading more the outpatient rather than the inpatient setting, thus putting racial and ethnic minority groups at risk for hospital readmissions. In this article, we discuss differences in care and outcomes of racial and ethnic minority groups in both of these settings through a review of registries. Furthermore, we explore potential factors that connote a revolving door phenomenon for those whose adverse outpatient environment puts them at risk for hospital readmissions. Additionally, we review promising strategies, as well as actionable items at the policy, clinical, and educational levels aimed at locking this revolving door.

Racial Disparity Among the Clinical Outcomes Post-Myocardial Infarction Patients: A Systematic Review and Meta-analysis

The clinical outcomes post-Myocardial Infarction (MI) between Black and White patients have not been well studied, with limited literature available. We conducted a meta-analysis to estimate the clinical outcomes between Black and White patients post-MI.We systematically searched the PubMed, Embase, and Scopus databases from inception until September 26, 2022. A total of 6 studies with 220,984 patients have been included in the analysis. The mean age of patients with White and Black race was 68.46 and 65.14 years, respectively. The most common comorbidity among White and Black patients was hypertension (53% vs 87.73%). Our analysis showed that the likelihood of all-cause mortality (OR, 0.71[95%CI: 0.56-0.91]), P=0.01] and stroke (OR, 0.74[95%CI: 0.67-0.81]), P<0.001] were significantly lower in white patients compared with black patients. However, Black patients had fewer utilization of CABG (OR, 1.38[95%CI: 1.19-1.62], P<0.001]) and PCI (OR, 1.31[95%CI: 1.101-1.68]), P=0.04] compared with White patients, while 30-day mortality was comparable between both the groups. To our knowledge, this is the first meta-analysis with the largest sample size thus far, highlighting that Black patients are at increased risk for all-cause mortality and stroke but have lower utilization of revascularization among MI patients than White patients.

Does sex affect the risk of 30-day all-cause mortality in cardiogenic shock?

BACKGROUND

Mortality rates following CS have stagnated on an unacceptably high level. Limited data regarding the prognostic value of sex in patients suffering from CS is available. Therefore, this study aims to investigate the prognostic value of sex in patients with cardiogenic shock (CS).

METHODS

Consecutive patients with CS of any cause were included from 2019 to 2021. Prognosis of females was compared to males regarding 30-day all-cause mortality. Further risk stratification was performed according to the presence or absence of CS related to acute myocardial infarction (AMI). Kaplan-Meier and multivariable Cox proportional regression analyses were used for statistics.

RESULTS

From a total of 273 CS patients (AMI-CS: 49%; non-AMI-CS: 51%), 60% were males and 40% females. The risk of 30-day all-cause mortality did not differ among males and females (56% vs. 56%; log rank p = 0.775; HR = 1.046; 95% CI 0.756-1.447; p = 0.785). Even after multivariable adjustment, sex was not associated with prognosis in CS patients (HR = 1.057; 95% CI 0.713-1.564; p = 0.784). Comparable risks of short-term mortality in both sexes were observed irrespective of the presence of AMI-related CS (64.0% vs. 64.6%; log rank p = 0.642; HR = 1.103; 95% CI 0.710-1.713; p = 0.664) and non-AMI-related CS (46.2% vs. 49.2%; log rank p = 0.696; HR = 1.099; 95% CI 0.677-1.783; p = 0.704).

CONCLUSION

Sex was not associated with the risk of 30-day all-cause mortality in CS patients irrespective of CS etiology. (clinicaltrials.gov identifier: NCT05575856).

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.

Mechanical Circulatory Support in Patients With COVID-19 Presenting With Myocardial Infarction

ST-segment elevation myocardial infarction (STEMI) complicating COVID-19 is associated with an increased risk of cardiogenic shock and mortality. However, little is known about the frequency of use and clinical impact of mechanical circulatory support (MCS) in these patients. We sought to define patterns of MCS utilization, patient characteristics, and outcomes in patients with COVID-19 with STEMI. The NACMI (North American COVID-19 Myocardial Infarction) is an ongoing prospective, observational registry of patients with COVID-19 positive (COVID-19+) with STEMI with a contemporary control group of persons under investigation who subsequently tested negative for COVID-19 (COVID-19-). We compared the baseline characteristics and in-hospital outcomes of COVID-19+ and patients with COVID-19- according to the use of MCS. The primary outcome was a composite of in-hospital mortality, stroke, recurrent MI, and repeat unplanned revascularization. A total of 1,379 patients (586 COVID-19+ and 793 COVID-19-) enrolled in the NACMI registry between January 2020 and November 2021 were included in this analysis; overall, MCS use was 12.3% (12.1% [n = 71] COVID-19+/MCS positive [MCS+] vs 12.4% [n = 98] COVID-19-/MCS+). Baseline characteristics were similar between the 2 groups. The use of percutaneous coronary intervention was similar between the groups (84% vs 78%; p = 0.404). Intra-aortic balloon pump was the most frequently used MCS device in both groups (53% in COVID-19+/MCS+ and 75% in COVID-19-/MCS+). The primary outcome was significantly higher in COVID-19+/MCS+ patients (60% vs 30%; p = 0.001) because of very high in-hospital mortality (59% vs 28%; p = 0.001). In conclusion, patients with COVID-19+ with STEMI requiring MCS have very high in-hospital mortality, likely related to the significantly higher pulmonary involvement compared with patients with COVID-19- with STEMI requiring MCS.

Trends and outcomes of cardiogenic shock in Asian populations compared with non-Asian populations in the US: NIS Analysis (2002-2019)

BACKGROUND

Current understanding of outcomes of cardiogenic shock (CS) in Asian populations is limited. We aim to study the clinical outcomes of CS in Asian population compared with non-Asians in the US.

METHODS

The National Inpatient Sample (NIS) database was queried between 2002-2019 to identify hospitalizations with CS. Race was classified as Asians and non-Asians. The adjusted odds ratios (aOR) for in-hospital outcomes were calculated using multivariate logistic regression analysis.

RESULTS

Results Of 1,573,285 CS hospitalizations, 48,398 (3%) were Asians and 1,524,887 (97%) were non-Asians between 2002-2019. Adjusted odds of in-hospital mortality (aOR 1.03, 95% CI 1.01-1.05), and use of intra-aortic balloon pump (IABP) (aOR 1.15, 95% CI 1.12-1.17) were significantly higher among Asians compared with non-Asians. The in-hospital mean cost of hospitalization was higher in Asian population ($63,787±$80,261) with CS compared with non-Asians ($56,207±$76,120, p < 0.001). The use of Impella (aOR 0.90, 95% CI 0.86-0.95) and left ventricular assist devices (LVAD) (aOR 0.71, 95% CI 0.65-0.77) were lower with no difference in the use of extracorporeal membrane oxygenation (ECMO) compared with non-Asians.

CONCLUSION

Asian populations with CS have higher in-hospital mortality, increased requirement of IABP and higher mean cost of hospitalization compared with non-Asians.

Effect of ticagrelor and prasugrel on remote myocardial inflammation in patients with acute myocardial infarction with ST-elevation: a CMR T1 and T2 mapping study

PURPOSE

Acute myocardial ischaemia triggers a non-specific inflammatory response of remote myocardium through the increase of plasma concentrations of acute-phase proteins, which causes myocardial oedema. As ticagrelor has been shown to significantly decrease circulating levels of several pro-inflammatory cytokines in patients after acute myocardial infarction with ST-elevation (STEMI), we sought to investigate a potential suppressive effect of ticagrelor over prasugrel on cardiac magnetic resonance (CMR) T1 and T2 values in remote myocardium.

METHODS

Ninety STEMI patients were prospectively included and randomised to receive either ticagrelor or prasugrel maintenance treatment after successful primary percutaneous coronary intervention. Patients underwent CMR after 2-7 days. The protocol included long and short axis cine imaging, T1 mapping, T2 mapping and late gadolinium enhancement imaging.

RESULTS

After excluding 30 patients due to either missing images or insufficient quality of the T1 or T2 maps, 60 patients were included in our analysis. Of those, 29 patients were randomised to the ticagrelor group and 31 patients to the prasugrel group. In the remote myocardium, T1 values did not differ between groups (931.3 [919.4-950.4] ms for ticagrelor vs. 932.6 [915.5-949.2] ms for prasugrel (p = 0.94)), nor did the T2 values (53.8 ± 4.6 ms for ticagrelor vs. 53.7 ± 4.7 ms for prasugrel (p = 0.86)). Also, in the infarcted myocardium, T1 and T2 values did not differ between groups.

CONCLUSION

In revascularised STEMI patients, ticagrelor maintenance therapy did not show superiority over prasugrel in preventing early remote myocardial inflammation as assessed by CMR T1 and T2 mapping.

Socioeconomic Factors and their Impact on Access and Use of Coronary and Structural Interventions

In the past few decades, the accelerated improvement in technology has allowed the development of new and effective coronary and structural heart disease interventions. There has been inequitable patient access to these advanced therapies and significant disparities have affected patients from low socioeconomic positions. In the US, these disparities mostly affect women, black and hispanic communities who are overrepresented in low socioeconomic. Other adverse social determinants of health influenced by structural racism have also contributed to these disparities. In this article, we review the literature on disparities in access and use of coronary and structural interventions; delineate the possible reasons underlying these disparities; and highlight potential solutions at the government, healthcare system, community and individual levels.

Sex-Related Differences in Thrombus Burden in STEMI Patients Undergoing Primary Percutaneous Coronary Intervention

BACKGROUND

Women have a worse prognosis after ST-segment elevation myocardial infarction (STEMI) than men. The prognostic role of thrombus burden (TB) in influencing the sex-related differences in clinical outcomes after STEMI has not been clearly investigated.

OBJECTIVES

The aim of this study was to assess the sex-related differences in TB and its clinical implications in patients with STEMI.

METHODS

Individual patient data from the 3 major randomized clinical trials of manual thrombus aspiration were analyzed, encompassing a total of 19,047 patients with STEMI, of whom 13,885 (76.1%) were men and 4,371 (23.9%) were women. The primary outcome of interest was 1-year cardiovascular (CV) death. The secondary outcomes of interest were recurrent myocardial infarction, heart failure, all-cause mortality, stroke, stent thrombosis (ST), and target vessel revascularization at 1 year.

RESULTS

Patients with high TB (HTB) had worse 1-year outcomes compared with those presenting with low TB (adjusted HR for CV death: 1.52; 95% CI: 1.10-2.12; P = 0.01). In unadjusted analyses, female sex was associated with an increased risk for 1-year CV death regardless of TB. After adjustment, the risk for 1-year CV death was higher only in women with HTB (HR: 1.23; 95% CI: 1.18-1.28; P < 0.001), who also had an increased risk for all-cause death and ST than men.

CONCLUSIONS

In patients with STEMI, angiographic evidence of HTB negatively affected prognosis. Among patients with HTB, women had an excess risk for ST, CV, and all-cause mortality than men. Further investigations are warranted to better understand the pathophysiological mechanisms leading to excess mortality in women with STEMI and HTB.

Utilization trends and outcomes of catheter-directed thrombolysis for pulmonary embolism in the US by race/ethnicity

Contemporary data on catheter-directed thrombolysis (CDT) utilization trends and associated hospital outcomes in pulmonary embolism (PE) n the US is limited. Using the nationwide inpatient sample database, we identified patients hospitalized for acute PE treated with CDT from January 1, 2008, to December 31, 2018. Cochrane-Armitage test was used to evaluate the temporal trends in utilization, hospital mortality, and major bleeding rates. Multivariate logistic regression was used to compare differences in the outcomes across race/ethnicity, 4444 patients (unweighted hospitalizations) underwent CDT during the study period. The mean age ± standard deviation of the population was 58 ± 16 years and the majority were males (54%). 3269 (73.6%) patients were non-Hispanic White (NHW), 802 (18.0%) patients were non-Hispanic Black (NHB), and 373 (8.4%) patients were of 'other' races/ethnicities. There was a more than tenfold increase in CDT use in 2018 compared to 2008. The total mortality and bleeding rates were approximately 7 and 10% respectively. Hospital mortality rates trended down across all races/ethnicities during the study period. A similar downward trend in bleeding rates was noted in NHB only (28.6% vs 10.7%, p = 0.04). In-hospital mortality and major bleeding odds were comparable across all races/ethnicities were comparable. NHB patients and other races were more likely to require blood transfusion and incur higher hospitalization costs compared with NHW patients. CDT use increased significantly in the US during the study period with a corresponding downward trend in in-hospital mortality across all races, and bleeding rates in NHB.

Mortality in ST-segment elevation myocardial infarction patients without standard modifiable risk factors: A race disaggregated analysis

Background

Individuals who present with STEMI without the standard cardiovascular risk factors (SMuRFs) of diabetes, hypercholesterolemia, hypertension, and smoking, coined SMuRF-less are not uncommon. Little is known about their outcomes as a cohort and how they differ by race.

Methods & Results

We identified 431,615 admissions with STEMI in the National Inpatient Sample (NIS) database 2015–2018, including patients with ≥ 1 SMuRF (n = 369,870) and those who were SMuRF-less (n = 234,745). SMuRF-less patients presented at a similar age (median age 63y vs 63y), were less likely to be female (33.6 % vs 34.6 %) and were almost twice as likely to present as a cardiac arrest (13.7 % vs 7.0 %), than those with ≥ 1 SMuRFs. SMuRF-less patients were less frequently in receipt of ICA (71.3 % vs 83.8 %) and PCI (58.0 % vs 72.2 %) compared to those with ≥ 1 SMuRF. Our race disaggregated analysis showed ethnic minority SMuRF-less patients were less likely than White patients to receive ICA and PCI, which was most apparent in Black patients with reduced odds of ICA (OR: 0.47, 95 % CI: 0.43–0.52) and PCI (OR: 0.46, 95 % CI: 0.52–0.50). Similarly, in ethnic minority subgroups within the SMuRF-less cohort, mortality and MACCE were significantly higher than in White patients. This was most profound in Black patients with in-hospital mortality (OR: 1.90, 95 % CI: 1.72–2.09) and MACCE (OR: 1.63, 95 % CI: 1.49–1.78) compared to White patients.

Conclusion

Ethnic Minority SMuRF-less patients were less likely than White SMuRF-less patients to receive ICA and PCI and had worse mortality outcomes.

Sex Differences in Management and Outcomes Among Patients With High-Risk Pulmonary Embolism: A Nationwide Analysis

OBJECTIVE

To examine the sex differences in management and outcomes among patients with high-risk acute pulmonary embolism (PE).

PATIENTS AND METHODS

The Nationwide Readmissions Database was used to identify hospitalizations with high-risk PE from January 1, 2016, to December 31, 2018. Differences in use of advanced therapies, in-hospital mortality, and bleeding events were compared between men and women.

RESULTS

A total of 125,901 weighted hospitalizations with high-risk PE were identified during the study period; 46.3% were women (n=58,253). Women were older and had a higher prevalence of several comorbidities and risk factors of PE such as morbid obesity, diabetes mellitus, chronic pulmonary disease, heart failure, and metastatic cancer. Systemic thrombolysis and catheter-directed interventions were more commonly used among women; however, mechanical circulatory support was less frequently used. In-hospital mortality was higher among women in the unadjusted analysis (30.7% vs 27.8%, P<.001) and after propensity score matching (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.08 to 1.25; P<.001), whereas the rates of intracranial hemorrhage and non-intracranial hemorrhage were not different. On multivariate regression analysis, female sex (OR, 1.18; 95% CI, 1.15 to 1.21; P<.001) was independently associated with increased odds of in-hospital mortality.

CONCLUSION

In this contemporary observational cohort of patients admitted with high-risk PE, women had higher rates of in-hospital mortality despite receiving advanced therapies more frequently, whereas the rate of major bleeding events was not different from men. Efforts are needed to minimize the excess mortality observed among women.

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.

Gender Differences in the Outcomes of Cardiogenic Shock Requiring Percutaneous Mechanical Circulatory Support

There is evidence for the lower use of percutaneous mechanical circulatory support (pMCS) in women. We aimed to determine (1) whether gender differences exist regarding in-hospital mortality, hospital course, and procedures; (2) whether socio-demographic and treatment-related factors were associated with these differences. Using the National Inpatient Sample, we collected the International Classification of Diseases, Ninth Revision, Clinical Modification codes for cardiogenic shock (CS) because of acute myocardial infarction AMI or acutely decompensated advanced heart failure and included intra-aortic balloon pump, Impella or Tandem Heart percutaneous ventricular assist devices (pVADs), extracorporeal membrane oxygenation. Demographics, co-morbidities, in-hospital course and procedures were recorded, and the Charlson Co-morbidity Index was calculated. Multivariable hierarchical logistic regression analysis and additional sensitivity analyses were performed. We identified 376,116 cases of CS because of acute myocardial infarction or acutely decompensated advanced heart failure, of which 113,305 required pMCS. Women were more likely to be older, non-White, insured by Medicare, and have a higher burden of co-morbidities and higher Charlson Co-morbidity Index. pMCS devices were inserted in 35,516 women (24.9%) and 77,789 men (33.3%). Women were less likely to receive pVAD or pulmonary artery (PA) catheters. Blood transfusions and acute respiratory failure were more common in women than men. Women had 15% higher in-hospital mortality and in a multivariate analysis, women, older age, having no insurance, diabetes mellitus, chronic kidney disease, cerebrovascular disease, peripheral arterial disease, longer time to pMCS insertion, receiving PA catheter, pVAD or extracorporeal membrane oxygenation and having cardiac arrest were associated with higher in-hospital mortality. In conclusion, women requiring pMCS support had a higher co-morbidity load, in-hospital mortality, acute respiratory failure, blood transfusions, and lower PA catheter use. Studies addressing early gender-specific interventions in CS are needed to reduce these differences.

Racial and Ethnic Disparities in the Trends and Outcomes of Cardiogenic Shock Complicating Peripartum Cardiomyopathy

IMPORTANCE

Cardiogenic shock (CS) is a recognized complication of peripartum cardiomyopathy (PPCM) associated with poor prognosis. Although racial and ethnic disparities have been described in the occurrence and outcomes of PPCM, it is unclear if these disparities persist among patients with PPCM and CS.

OBJECTIVES

To evaluate the temporal trends in CS incidence among hospitalized patients with PPCM stratified by race and ethnicity and to investigate the racial and ethnic differences in hospital mortality, mechanical circulatory support (MCS) use, and heart transplantation (HT).

DESIGN, SETTING, AND PARTICIPANTS

This multicenter retrospective cohort study included hospitalized patients with PPCM complicated by CS in the US from 2005 to 2019 identified from the National Inpatient Sample (NIS). Data analysis was conducted in November 2021.

EXPOSURE

PPCM complicated by CS.

MAIN OUTCOMES AND MEASURES

The main outcome was incidence of CS in PPCM stratified by race and ethnicity. The secondary outcome was racial and ethnic differences in hospital mortality, MCS use, and HT.

RESULTS

Of 55 804 hospitalized patients with PPCM, 1945 patients had CS, including 947 Black patients, 236 Hispanic patients, and 702 White patients, translating to an incidence rate of 35 CS events per 1000 patients with PPCM. The mean (SD) age was 31 (9) years. Black and Hispanic patients had higher CS incidence rates (39 events per 1000 patients with PPCM) compared with White patients (33 events per 1000 patients with PPCM). CS incidence rates significantly increased across all races and ethnicities over the study period. Overall, the odds of developing CS were higher in Black patients (aOR, 1.17 [95% CI, 1.15-1.57]; P < .001) and Hispanic patients (aOR, 1.37 [95% CI, 1.17-1.59]; P < 001) compared with White patients during the study period. Compared with White patients, the odds of in-hospital mortality were higher in Black (adjusted odds ratio [aOR], 1.67 [95% CI, 1.21-2.32]; P = .002) and Hispanic (aOR, 2.20 [95% CI, 1.45-3.33]; P < .001) patients. Hispanic patients were more likely to receive any type of MCS device (aOR, 2.23 [95% CI, 1.60-3.09]; P < .001), intraaortic balloon pump (aOR, 1.65 [95% CI, 1.11-2.44]; P < .001), and ventricular assisted device (aOR, 4.45 [95% CI, 2.45-8.08]; P < .001), compared with White patients. Black patients were more likely to receive VAD (aOR, 2.69 [95% CI, 1.63-4.42]; P < .001) compared with White patients. Black and Hispanic patients were significantly less likely to receive HT compared with White patients (Black patients: aOR, 0.51 [95% CI, 0.33-0.78]; P = .02; Hispanic patients: aOR, 0.15 [95% CI, 0.06-0.42]; P < .001).

CONCLUSIONS AND RELEVANCE

These findings highlight significant racial disparities in mortality and HT among hospitalized patients with PPCM complicated by CS in the US. More research to identify factors of racial and ethnic disparities is needed to guide interventions to improve outcomes of patients with PPCM.

Interaction Between Race, Ethnicity, Severe Mental Illness, and Cardiovascular Disease

Severe mental illnesses, such as schizophrenia or bipolar disorder, affect ≈1% of the population who, as a group, experience significant disadvantage in terms of physical health and reduced life expectancy. In this review, we explore the interaction between race, ethnicity, severe mental illness, and cardiovascular disease, with a focus on cardiovascular care pathways. Finally, we discuss strategies to investigate and address disparities in cardiovascular care for patients with severe mental illness.

Age stratified sex-related differences in incidence, management, and outcomes of cardiogenic shock

BACKGROUND

There is a lack of data on age-stratified sex differences in the incidence, treatment, and outcomes of cardiogenic shock (CS). We sought to study these differences from a contemporary database.

METHODS

Patients admitted with CS (2004-2018) were identified from the United States National Inpatient Sample. We compared CS (acute myocardial infarction-related cardiogenic shock [AMI-CS] and non-acute myocardial infarction-related cardiogenic shock [Non-AMI-CS]) incidence, management, and outcomes in males and females, stratified into four age groups (20-44, 45-64, 65-84, and ≥85 years of age). Propensity score matching (PSM) was used for adjustment.

RESULTS

A total of 1,506,281 weighted hospitalizations for CS were included (AMI-CS, 39%; Non-AMI-CS, 61%). Across all age groups, females had a lower incidence of CS compared with males. After PSM and among the AMI-CS cohort, higher mortality among females compared with males was observed in the age groups 45-64 (28.5% vs. 26.3%) and 65-84 years (39.3% vs. 37.9%) (p < 0.01, for all). Among the Non-AMI-CS cohort, higher mortality among females compared with males was observed in the age groups 20-44 (33.5% vs. 30.5%), 45-64 (35.1% vs. 31.9%), and 65-84 years (41.7% vs. 40.3%) (p < 0.01, for all). Similar age-dependent differences in the management of CS were also observed between females and males.

CONCLUSIONS

Females have a lower incidence of CS regardless of age. Significant disparities in the management and outcomes of CS were observed based on sex. However, these disparities varied by age and etiology of CS (AMI-CS vs. Non-AMI-CS) with pronounced disparity among females in the age range of 45-84 years.

Outcomes, Temporal Trends, and Resource Utilization in Ischemic versus Nonischemic Cardiogenic Shock

Cardiogenic shock (CS) is associated with significant morbidity and mortality. Differentiating the etiologic factors driving CS has epidemiological significance and aids in optimization of therapeutic strategies, prognostication, and resource utilization. The aim herein is to investigate the epidemiology and clinical outcomes of CS in those with ischemic and nonischemic CS etiologies. Using International Classification of Diseases codes, we queried the national inpatient sample for CS hospitalization from 2007 to 2018 and divided the study sample into cohorts of ischemic (I-CS) and nonischemic cardiogenic shock (NI-CS). We then compared the primary outcome of in-hospital mortality between these 2 cohorts. Two groups of secondary outcomes (clinical and procedural) were also assessed between the 2 cohorts. CS was present in 557,860 hospitalizations; 84% of these were I-CS and 15.8% NI-CS. Patients with I-CS were older, more commonly males, with more risk factors for coronary artery disease (P < 0.05). NI-CS had higher prevalence of preexisting systolic heart failure and atrial fibrillation. The in-hospital mortality was significantly higher in patients with I-CS (32.2% vs. 29.5%, adjusted odds ratio 1.10, P < 0.001). Frequencies of acute ischemic stroke, mechanical ventilation, ventricular arrhythmias, and vascular complications were higher in I-CS versus NI-CS, while acute kidney injury and acute liver failure were more common in NI-CS (P < 0.05). The use of mechanical circulatory support devices was higher in the I-CS group. In conclusion, patients with I-CS comprise the vast majority of CS and are associated with higher mortality and higher resource utilization. Conversely, patients with NI-CS appear to have higher survival but with a higher prevalence of end-organ dysfunction.