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

Predictors of major adverse cardiac and cerebrovascular events after percutaneous coronary intervention in older adults: a systematic review and meta-analysis

AIM

We systematically reviewed and meta-analyzed the predictors of major adverse cardiac and cerebrovascular events (MACE/MACCE) in older adults who underwent PCI.

METHODS

Three databases, PubMed, Embase, and Scopus, were searched for observational studies considering the out-of-hospital MACE/MACCE in adults ≥ 60 years old with coronary artery disease (acute or chronic) who underwent PCI. Studies were eligible if they had determined at least two statistically significant predictors of MACE/MACCE by multivariable analysis. We used the QUIPS tool to evaluate the risk of bias in the studies. Random-effects meta-analysis was utilized to pool the hazard ratios (HRs) of the most reported predictors.

RESULTS

A total of 34 studies were included in the review. Older age (HR = 1.04, 95% Confidence Interval (CI): 1.03-1.06, P-value < 0.001), diabetes (HR = 1.36, 95% CI: 1.22-1.53, P < 0.001), history of myocardial infarction (MI) (HR = 1.88, 95% CI: 1.37-2.57, P < 0.001), ST-elevation MI (STEMI) at presentation (HR = 1.72, 95% CI: 1.37-2.18, P < 0.001), reduced left ventricular ejection fraction (LVEF) (HR = 2.01, 95% CI: 1.52-2.65, P < 0.001), successful PCI (HR = 0.35, 95% CI: 0.27-0.47, P < 0.001), eGFR (HR = 0.99, 95% CI: 0.97-1.00; P-value = 0.04) and left main coronary artery (LMCA) disease (HR = 2.07, 95% CI: 1.52-2.84, P < 0.001) were identified as predictors of MACE.

CONCLUSION

We identified older age, diabetes, history of MI, STEMI presentation, lower LVEF, and LMCA disease increased the risk of MACE/MACCE after PCI in older adults. Meanwhile, higher eGFR and successful PCI predicted lower adverse events risk. Future studies should focus on a more robust methodology and a precise definition of MACE.

REGISTRATION

PROSPERO (CRD42023480332).

Sex differences in outcomes after acute coronary syndrome vary with age: a New Zealand national study

AIMS

This study investigated age-specific sex differences in short- and long-term clinical outcomes following hospitalization for a first-time acute coronary syndrome (ACS) in New Zealand (NZ).

METHODS AND RESULTS

Using linked national health datasets, people admitted to hospital for a first-time ACS between January 2010 and December 2016 were included. Analyses were stratified by sex and 10-year age groups. Logistic and Cox regression were used to assess in-hospital death and from discharge the primary outcome of time to first cardiovascular (CV) readmission or death and other secondary outcomes at 30 days and 2 years. Among 63 245 people (mean age 69 years, 40% women), women were older than men at the time of the ACS admission (mean age 73 vs. 66 years), with a higher comorbidity burden. Overall compared with men, women experienced higher rates of unadjusted in-hospital death (10% vs. 7%), 30-day (16% vs. 12%) and 2-year (44% vs. 34%) death, or CV readmission (all P < 0.001). Age group-specific analyses showed sex differences in outcomes varied with age, with younger women (<65 years) at higher risk than men and older women (≥85 years) at lower risk than men: unadjusted hazard ratio of 2-year death or CV readmission for women aged 18-44 years = 1.51 [95% confidence interval (CI) 1.21-1.84] and aged ≥85 years = 0.88 (95% CI 0.83-0.93). The increased risk for younger women was no longer significant after multivariable adjustment whereas the increased risk for older men remained.

CONCLUSION

Men and women admitted with first-time ACS have differing age and comorbidity profiles, resulting in contrasting age-specific sex differences in the risk of adverse outcomes between the youngest and oldest age groups.

A cross-sectional study determining prevalence and factors associated with ST-segment elevation myocardial infarction and non-ST segment elevation myocardial infarction in Iran: results from fasa registry on acute myocardial infarction (FaRMI)

BACKGROUND

Acute myocardial infarction is still a leading cause of death worldwide, accounting for roughly three million deaths yearly. This study aimed to investigate the prevalence and factors associated with ST-Segment Elevation Myocardial Infarction and Non-ST Segment Elevation Myocardial Infarction in Iran.

METHODS

This cross-sectional study was conducted using the databases of the Fasa Registry on Acute Myocardial Infarction (FaRMI) and the Fasa Adult Cohort Study (FACS). chi-squared and one-way ANOVA tests were utilized to calculate the unadjusted associations between the study variables. A multivariate multinomial logistic regression model was also employed to determine the adjusted association of each independent variable with the risk of ST-elevation myocardial infarction (STEMI).

RESULTS

The prevalence of STEMI and non-STEMI was 31.60% and 11.80%, respectively. Multinomial logistic regression showed that older age, anemia, high WBC, and high creatinine levels were associated with higher odds of STEMI and non-STEMI compared to healthy individuals. In addition, based on the analysis being a woman(OR = 0.63,95%CI:0.51-0.78), anemia(OR = 0.67,95%CI:0.54-0.63)and hypertension (OR = 0.80,95%CI:0.65-0.97)decreased the likelihood of STEMI occurrence compared to non-STEMI, while high WBC(OR = 1.19,95%CI:1.15-1.23)increased the odds.

CONCLUSION

In this study, significant predictors of MI risk included age, gender, anemia, lipid profile, inflammation, and renal function. Subsequent investigations ought to prioritize the comprehensive understanding of the underlying mechanisms that drive these connections and assess the effectiveness of specific interventions aimed at diminishing the occurrence of MI and improving patient outcomes.

Sex differences in trends and outcomes of acute myocardial infarction with mechanical complications in the United States

BACKGROUND

Mechanical complications (MC) are rare but significant sequelae of acute myocardial infarction (AMI). Current data on sex differences in AMI with MC is limited.

METHODS

We queried the National Inpatient Sample database to identify adult patients with the primary diagnosis of AMI and MC. The main outcome of interest was sex difference in-hospital mortality. Secondary outcomes were sex differences in the incidence of acute kidney injury (AKI), major bleeding, use of inotropes, permanent pacemaker implantation (PPMI), performance of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), surgery (VSD repair and MV surgery), pericardiocentesis, use of mechanical circulatory support (MCS), ischemic stroke, and mechanical ventilation.

RESULTS

Among AMI-MC cohort, in-hospital mortality was higher among females compared to males (41.24% vs 28.13%: aOR 1.39. 95% CI 1.079-1.798; p = 0.01). Among those who had VSD, females also had higher in-hospital mortality compared to males (56.7% vs 43.1%: aOR 1.74, 95% CI 1.12-2.69; p = 0.01). Females were less likely to receive CABG compared to males (12.03% vs 20%: aOR 0.49 95% CI 0.345-0.690; p < 0.001).

CONCLUSION

Despite the decreasing trend in AMI admission, females had higher risk of MC and associated mortality. Significant sex disparities still exist in AMI treatment.

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

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

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.

Revascularization strategies for multivessel coronary artery disease based on sex and age

OBJECTIVES

This study describes coronary revascularization strategies used by sex and age in the USA.

METHODS

A sex-stratified cohort study from the National Inpatient Sample from the Agency for Healthcare Research and Quality (USA) including patients admitted for coronary revascularization with primary or secondary diagnoses of chronic coronary syndrome or non-ST elevation myocardial infarction who underwent ≥3-vessel coronary artery bypass grafting or percutaneous coronary intervention from January 2019 to December 2020. The primary outcome was the use rate of coronary artery bypass grafting or multivessel percutaneous coronary intervention. Prespecified subgroups included age and non-ST elevation myocardial infarction.

RESULTS

Among 121 150 patients (21.7% women), there were no sex differences in age (women: 66.6 [66.5-66.7], men: 67.6 [67.5-67.7], standardized mean difference: 0.1) or non-ST elevation myocardial infarction incidence (women: 37.4%, men: 45.7%, standardized mean difference: 0.17). The majority of women (74.2%) and men (84.9%) underwent bypass grafting, which was unaffected by age, race or non-ST elevation myocardial infarction. Women were less likely to undergo bypass grafting than percutaneous intervention (adjusted odds ratio 0.49, 95% confidence interval 0.44-0.54; P < 0.001) and a disparity most pronounced in patients >80 years old (adjusted odds ratio 0.31, 95% confidence interval 0.22-0.45; P < 0.001).

CONCLUSIONS

Most patients with multivessel coronary artery disease needing revascularization undergo bypass grafting, irrespective of sex, age or clinical presentation. The sex disparity in the use of bypass grafting is mostly seen among patients >80 years old.

Cardiovascular Disease Risk Factors and Outcomes of Acute Myocardial Infarction in Young Adults: Evidence From 2 Nationwide Cohorts in the United States a Decade Apart

The purpose of this study was to evaluate 2 national in-patient cohorts of young adults (18-44 years) hospitalized with acute myocardial infarction (AMI) a decade apart to highlight its prevalence, associated comorbidities, and in-hospital outcomes. We identified hospitalizations for AMI in young adults in 2007 and 2017 using the weighted data from the National Inpatient Sample. We compared admission rates, sociodemographic characteristics, in-hospital morbidity, complications, mortality, rate of coronary interventions, and healthcare utilization between the 2 cohorts. We found that the admission rate of AMI increased among young adults in 2017 vs 2007. The overall admission rate was higher in males, although with a decline (77.1% vs 66.1%), whereas it rose from 28.9% to 33.9% in females. Hypertension (47.8% vs 60.7%), smoking (49.7% vs 55.8%), obesity (14.8% vs 26.8%), and diabetes mellitus (22.0% vs 25.6%) increased in the 2017 cohort. Post-AMI complications: cardiogenic shock (aOR = 1.16 [1.06-1.27]) and fatal arrhythmias heightened with comparable all-cause mortality (aOR = 1.01 [0.93-1.10], P = 0.749). Reperfusion interventions, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) decreased in the 2017 cohort (PCI; aOR = 0.95 [0.91-0.98], CABG; aOR = 0.66 [0.61-0.71], P < 0.001). Our study highlights the rise in AMI hospitalizations, plateauing of mortality, sex-based and racial disparities, the surge in post-MI complications, and a reassuring decline in the requirement of reperfusion interventions in young AMI patients over the decade.

Disparities in the management of non-ST-segment elevation myocardial infarction in the United States

Guidelines recommend managing patients aged ≥75 with non-ST-segment elevation myocardial infarction (NSTEMI) similar to younger patients. We analyze disparities in NSTEMI management and compare those ≥80 years to those <80 years. This is a matched case-control study using the 2016 National Inpatient Sample data of adults with NSTEMI receiving percutaneous coronary intervention with drug-eluting stent (PCI-DES) - one artery or no intervention. We included the statistically significant variables in univariate analysis in exploratory multivariate logistic regression models. Total sample included 156,328 patients, out of which 43,265 were ≥ 80 years, and 113,048 were < 80 years. Patients ≥80 years were more likely to not have an intervention (73.3%) when compared to those <80 (44.1%), P < 0.0005. Regardless of age, PCI-DES-one artery improved survival compared to no intervention (Age < 80: OR 0.230, 95% CI 0.189-0.279, and ≥ 80: OR 0.265, 95% CI 0.195-0.361, P < 0.0005). Women (OR 0.785, 95% CI 0.766-0.804, P < 0.0005) and non-white race (OR 0.832, 95% CI 0.809-0.855, P < 0.0005) were less likely to receive an intervention. Non-Medicare/Medicaid insurance was associated with 40% lower likelihood of dying in <80 age group (OR 0.596, 95% CI 0.491-0.724, P < 0.0005), and 16% higher chance of intervention overall (OR 1.160, 95% CI 1.125-1.197, P < 0.0005). Patients aged ≥80 with NSTEMI were 29% less likely to receive an intervention compared to patients aged <80, even though patients >80 derived similar mortality benefits from the intervention. There were gender, payor, and race-based disparities in NSTEMI management in 2016.

Gender disparities in prevalence by diagnostic criteria, treatment and mortality of newly diagnosed acute myocardial infarction in Korean adults

Acute myocardial infarction (AMI) is highly prevalent and remains the leading cause of mortality. Particularly in women, under-recognition and management of AMI have been raised. The aim of this study was to investigate the long-term trends of prevalence, treatment methodologies, and mortality of AMI by gender. The subjects of this study were patients hospitalized for AMI according to the Korean National Health Insurance Claims Database from 2002 to 2018. Total 633,097 AMI patients were hospitalized, 40% women. The incidence of AMI has been increasing since 2011, with a lower incidence in women. Overall, 53.1% of patients underwent CAG, with a lower tendency in women than in men (39.8% vs. 62.3%). Furthermore, fewer women underwent PCI than men (77.5% vs. 85.8% in 2018, p < 0.0001). Of the 336,463 AMI patients undergoing CAG, women were undertreated with a lower prescription rate of beta-blockers or statins at discharge. When adjusted for age, women showed higher 7-day mortality but lower 1-year mortality relative to men. According to the Korean National Health Insurance Claims Database, women with AMI have been under-recognized, underdiagnosed, and undertreated in terms of revascularization or medical therapy for years suggesting that efforts to close the gender gap are necessary.

Trends and Outcomes of ST-Segment-Elevation Myocardial Infarction Among Young Women in the United States

Background Although there has been a decrease in the incidence of ST-segment-elevation myocardial infarction (STEMI) in the United States, this trend might be stagnant or increasing in young women. We assessed the trends, characteristics, and outcomes of STEMI in women aged 18 to 55 years. Methods and Results We identified 177 602 women aged 18 to 55 with the primary diagnosis of STEMI from the National Inpatient Sample during years 2008 to 2019. We performed trend analyses to assess hospitalization rates, cardiovascular disease (CVD) risk factor profile, and in-hospital outcomes stratified by three age subgroups (18-34, 35-44, and 45-55 years). We found STEMI hospitalization rates were decreased in the overall study cohort from 52 per 100 000 hospitalizations in 2008 to 36 per 100 000 in 2019. This was driven by decreased proportion of hospitalizations in women aged 45 to 55 years (74.2% to-71.7%; P<0.001). Proportion of STEMI hospitalizationincreased in women aged 18-34 (4.7%-5.5%; P<0.001) and 35-44 years (21.2%-22.7%; P<0.001). The prevalence of traditional and non-traditional female-specific or female-predominant CVD risk factors increased in all age subgroups. The adjusted odds of in-hospital mortality in the overall study cohort and age subgroups were unchanged throughout the study period. Additionally, we observed an increase in the adjusted odds of cardiogenic shock, acute stroke, and acute kidney injury in the overall cohort over the study period. Conclusions STEMI hospitalizations are increasing among women aged <45 years, and in-hospital mortality has not changed over the past 12 years in women aged <55 years. Future studies on the optimization of risk assessment and management of STEMI in young women are urgently needed.

Sex-based Differences in Percutaneous Coronary Intervention Outcomes in Patients With Ischemic Heart Disease

In high-income countries, ischaemic heart disease is the leading cause of death in women and men, accounting for more than 20% of deaths in both sexes. However, women are less likely to receive guideline-recommended percutaneous coronary intervention (PCI) than men. Women undergoing PCI have poorer unadjusted outcomes because they are older and have greater comorbidity than men, but uncertainty remains whether sex affects outcome after these differences in clinical characteristics are considered. In this paper, we review recent published evidence comparing outcomes between men and women undergoing PCI. We focus on the sex differences in PCI outcomes in different scenarios: acute coronary syndromes, stable angina and complex lesions, including the approach of left main coronary artery. We also review how gender is considered in recent guidelines and offer a common clinical scenario to illustrate the contemporary management strategies an interventional cardiologist should consider when performing PCI on a female patient.

Association between insomnia and the incidence of myocardial infarction: A systematic review and meta-analysis

BACKGROUND

Insomnia has been closely associated with cardiovascular disease (CVD) including myocardial infarction (MI). Our study aims to assess the eligibility of insomnia as a potential risk factor for MI.

METHODS

PubMed, Scopus, and Web of Science were searched using terms; such as "Insomnia" and "MI." Only observational controlled studies with data on the incidence of MI among insomniacs were included. Revman software version 5.4 was used for the analysis.

RESULTS

Our pooled analysis showed a significant association between insomnia and the incidence of MI compared with noninsomniacs (relative risk [RR] = 1.69, 95% confidence interval [CI] = 1.41-2.02, p < .00001). Per sleep duration, we detected the highest association between ≤5 h of sleep, and MI incidence compared to 7-8 h of sleep (RR = 1.56, 95% CI = 1.41-1.73). Disorders of initiating and maintaining sleep were associated with increased MI incidence (RR = 1.13, 95% CI = 1.04-1.23, p = .003). However, subgroup analysis of nonrestorative sleep and daytime dysfunction showed an insignificant association with MI among both groups (RR = 1.06, 95% CI = 0.91-1.23, p = .46). Analysis of age, follow-up duration, sex, and comorbidities showed a significant association in insomniacs.

CONCLUSION

Insomnia and ≤5 h of sleep are highly associated with increased incidence of MI; an association comparable to that of other MI risk factors and as such, it should be considered as a risk factor for MI and to be incorporated into MI prevention guidelines.

Reproducing extracellular matrix adverse remodelling of non-ST myocardial infarction in a large animal model

The rising incidence of non-ST-segment elevation myocardial infarction (NSTEMI) and associated long-term high mortality constitutes an urgent clinical issue. Unfortunately, the study of possible interventions to treat this pathology lacks a reproducible pre-clinical model. Indeed, currently adopted small and large animal models of MI mimic only full-thickness, ST-segment-elevation (STEMI) infarcts, and hence cater only for an investigation into therapeutics and interventions directed at this subset of MI. Thus, we develop an ovine model of NSTEMI by ligating the myocardial muscle at precise intervals parallel to the left anterior descending coronary artery. Upon histological and functional investigation to validate the proposed model and comparison with STEMI full ligation model, RNA-seq and proteomics show the distinctive features of post-NSTEMI tissue remodelling. Transcriptome and proteome-derived pathway analyses at acute (7 days) and late (28 days) post-NSTEMI pinpoint specific alterations in cardiac post-ischaemic extracellular matrix. Together with the rise of well-known markers of inflammation and fibrosis, NSTEMI ischaemic regions show distinctive patterns of complex galactosylated and sialylated N-glycans in cellular membranes and extracellular matrix. Identifying such changes in molecular moieties accessible to infusible and intra-myocardial injectable drugs sheds light on developing targeted pharmacological solutions to contrast adverse fibrotic remodelling.

The outcome of ST-elevation myocardial infarction by sex: a retrospective cohort study

We aimed to compare in-hospital mortality (IHM) of acute myocardial infarction (AMI) between male and females. We assessed the association of sex with IHM after AMI using simple and multivariate cox regression models. Results were presented as crude and adjusted hazard ratios along with their 95% confidence interval (HR; 95% CI). Multivariable Cox regression analysis revealed females had a higher risk of death than males after ST-elevation MI (STEMI) (adjusted HR [95% CI]: 1.64 [1.15-2.36]; p = 0.007). In subgroup analysis by age group, this significantly increased risk was only observed in 50- to 64-year-old females. There were no significant differences between genders after non-STEMI and unspecified MI. Women aged 50 to 64 years had higher IHM after STEMI than men.

Clinical Outcomes in Younger Women Hospitalized With an Acute Myocardial Infarction: A Contemporary Population-Level Analysis

BACKGROUND

For younger women with acute myocardial infarction (AMI), little is known regarding their contemporary care pathways and clinical outcomes.

METHODS

We studied AMI patients aged 18-55 years, hospitalized from April 1, 2009, to March 31, 2019, in Ontario, Canada. We compared trends in comorbidities, angiographic findings, and revascularisation rates in men and women. The primary outcome was 1-year all-cause mortality or readmission for unstable angina, AMI, heart failure, or stroke. Inverse probability of treatment weighting was used to account for differences in baseline clinical characteristics between men and women.

RESULTS

Among the 38,071 AMI patients included, 8,077 (21.2%) were women. Over the study period, women had increasing rates of diabetes (24.8% to 34.9%; P_trend < 0.001), and declining rates of smoking (53.2% to 41.7%; P_trend < 0.005). Although most patients received coronary angiography (96%), coronary revascularisation was less frequent among women than men (percutaneous coronary intervention: 61.9% vs 78.8% [P < 0.001]; surgery: 4.1% vs 6.0% [P < 0.001]). Women had more normal coronary anatomy (5.8% vs 1.7%; P < 0.001) and nonobstructive disease (22.8% vs 9.3%; P < 0.001) than men. Compared with men, the primary composite end point was significantly increased among women (10.0% vs 7.9%, adjusted HR 1.11; P = 0.02) and related to increased readmission rates for cardiovascular events. All-cause readmission was significantly increased among women (25.8% vs 21.1%, adjusted HR 1.34; P < 0.0001).

CONCLUSIONS

Coronary angiography is performed almost universally in younger women with AMI; however, coronary revascularisation is less frequent, perhaps reflecting less obstructive disease. Although mortality rates after AMI were similar between sexes, cardiovascular readmission rates and all-cause readmissions were significantly increased among women.

Sex differences in time trends in acute coronary syndrome management and in 12-month lethality: Data from the French MONICA registries

BACKGROUND

Sex differences in clinical presentation, patient care and fatal outcomes after an acute coronary syndrome (ACS) have been reported. However, recent improvements in the care and treatment of ACSs have not been assessed with regard to possible sex differences.

AIM

To assess sex differences in trends between 2006 and 2016 in the characteristics of ACSs, their management, and the associated mortality.

METHODS

We assessed all men and women (aged 35-74) covered by the MONICA registries in north, east and south-west France and having been hospitalized for an incident (first) ACS during a 12-month period in 2006 or a 6-month period in 2016. We analyzed the patients' clinical, biochemical, electrocardiographic and care-related data, and their vital status 28 days and 12 months after the ACS.

RESULTS

In 2006, women were older (<0.0001) and had more atypical symptoms than men (p < 0.01). These differences were no longer statistically significant in 2016. Medical care improved in both men and women. However, revascularization treatment, prescriptions of platelet aggregation inhibitors, statins, and functional rehabilitation were still more frequently provided to men than to women (p < 0.01) in 2016, independently of confounders. The 28-day or 12-month case fatality was not different between men and women in both 2006 and 2016.

CONCLUSIONS

The results of the present study evidenced an improvement over time in the management of ACS. However, although there were no longer sex differences in the patients' age and clinical presentation, women with ACS were still less likely than men to receive revascularization and pharmacological treatments in 2016.

Risk factors profile of young and older patients with myocardial infarction

Myocardial infarction (MI) among young adults (<45 years) represents a considerable proportion of the total heart attack incidents. The underlying pathophysiologic characteristics, atherosclerotic plaque features, and risk factors profile differ between young and older patients with MI. This review article discusses the main differences between the younger and elderly MI patients as well as the different pathogenic mechanisms underlying the development of MI in the younger. Young patients with MI often have eccentric atherosclerotic plaques with inflammatory features but fewer lesions, and are more likely to be smokers, obese, and have poor lifestyle, such as inactivity and alcohol intake. Compared to older MI patients, younger are more likely to be men, have familial-combined hyperlipidaemia and increased levels of lipoprotein-a. In addition, MI in younger patients may be related to use of cannabis, cocaine use, and androgenic anabolic steroids. Genomic differences especially in the pathways of coagulation and lipid metabolism have also been identified between young and older patients with MI. Better understanding of the risk factors and the anatomic and pathophysiologic processes in young adults can improve MI prevention and treatment strategies in this patient group. Awareness could help identify young subjects at increased risk and guide primary prevention strategies. Additional studies focusing on gene pathways related to lipid metabolism, inflammation, and coagulation are needed.

Sex-Specific Differences in Clinical Outcomes After Percutaneous Coronary Intervention: Insights from the TAILOR-PCI Trial

Background TAILOR-PCI (Tailored Antiplatelet Initiation to Lessen Outcomes due to decreased Clopidogrel Response After Percutaneous Coronary Intervention) studied genotype-guided selection of antiplatelet therapy after percutaneous coronary intervention versus conventional therapy with clopidogrel. The presence of CYP2C19 loss-of-function alleles in patients treated with clopidogrel may be associated with increased risk for ischemic events. We report a prespecified sex-specific analysis of genotyping and associated cardiovascular outcomes from this study. Methods and Results Associations between sex and major adverse cardiac events (MACE: cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia) and Bleeding Academic Research Consortium (BARC) bleeding at 12 months were analyzed using Cox proportional-hazards models. Among 5276 randomized patients, loss-of-function carriers were observed in ≈36% of both sexes, and >80% of carriers were heterozygotes. At 12 months, after adjustment for baseline differences, risks of MACE (HR , 1.28 [0.97 to 1.68]; P=0.088) and BARC bleeding (hazard ratio [HR], 1.36 [0.91 to 2.05]; P=0.14) were comparable among women and men. There were no significant interactions between sex and treatment strategy for MACE interaction P value (P_int=0.59) or BARC bleeding (P_int=0.47) nor for sex and genotype (MACE P_int=0.15, and BARC bleeding P_int=0.60). Conclusions CYP2C19 loss-of-function alleles were present in ≈1 in 3 women and men. Women had similar adjusted risks of MACE and bleeding as men following percutaneous coronary intervention. Genotype-guided therapy did not significantly reduce the risk of MACE or bleeding relative to conventional therapy for both sexes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01742117.

Real-world management and outcomes of 7 million patients with acute coronary syndrome according to clinical research trial enrolment status: a propensity matched analysis

AIMS

We aimed to determine whether clinical outcomes and invasive care of acute coronary syndrome (ACS) patients participating in trials differed from those of non-participants, particularly including those who were trial eligible.

METHODS AND RESULTS

We included all hospitalizations with a principal diagnosis of ACS in the US National Inpatient Sample between January 2004 and September 2015, stratified by trial enrolment and eligibility using the International Classification of Diseases, ninth revision. We conducted propensity score matching to investigate the following outcomes: all-cause mortality; major bleeding; stroke; composite of mortality, stroke, and cardiac complications [major adverse cardiovascular and cerebrovascular events (MACCEs)]; coronary angiography (CA); and percutaneous coronary intervention (PCI). A total of 7 091 179 weighted ACS hospitalizations were analysed, including 19 684 (0.3%) trial participants and 7 071 495 non-participants (3 485 514 of whom were trial eligible). Trial participants were more likely to receive CA [Δ% 28.73%, 95% confidence interval (CI) 27.22-30.24, P < 0.001] and PCI (Δ% 27.13%, 95% CI 24.86-29.41, P < 0.001), with decreased mortality (Δ% -3.51%, 95% CI -4.72 to -2.31, P < 0.001), MACCEs (Δ% -3.04%, 95% CI -4.55 to -1.53, P < 0.001), and bleeding (Δ% -0.89%, 95% CI -1.59 to -0.19, P = 0.013) compared with non-participants. After accounting for eligibility, trial participants were more likely to undergo CA (Δ% 22.78%, 95% CI 21.58-23.99, P < 0.001) and PCI (Δ% 23.95%, 95% CI 21.77-26.13, P < 0.001), and had no difference in mortality (Δ% -0.21%, 95% CI -0.65 to 0.24, P = 0.362).

CONCLUSION

Among ACS patients, trial enrolment was associated with significantly greater invasive care and lower mortality than among matched non-participants. Trial participants were more likely to be invasively managed even when compared with eligible non-participants, even though there was no difference in mortality.

Sex Differences in Characteristics, Treatments, and Outcomes Among Patients Hospitalized for Non-ST-Segment-Elevation Myocardial Infarction in China: 2006 to 2015

BACKGROUND

Sex differences in clinical characteristics and in-hospital outcomes among patients with non-ST-segment-elevation myocardial infarction have been described in Western countries, but whether these differences exist in China is unknown.

METHODS

We used a 2-stage random sampling design to create a nationally representative sample of patients admitted to 151 Chinese hospitals for non-ST-segment-elevation myocardial infarction in 2006, 2011, and 2015 and examined sex differences in clinical profiles, treatments, and in-hospital outcomes over this time. Multivariable logistic regression models adjusting for age or other potentially confounding clinical covariates were used to estimate these sex-specific differences.

RESULTS

Among 4611 patients, the proportion of women (39.8%) was unchanged between 2006 and 2015. Women were older with higher rates of hypertension, diabetes, and dyslipidemia. Among patients without contraindications, women were less likely to receive treatments than men, with significant differences for aspirin in 2015 (90.3% versus 93.9%) and for invasive strategy in 2011 (28.7% versus 45.7%) and 2015 (34.0% versus 48.4%). After adjusting for age, such differences in aspirin and invasive strategy in 2015 were not significant, but the difference in invasive strategy in 2011 persisted. The sex gaps in the use of invasive strategy did not narrow. From 2006 to 2015, a significant decrease in in-hospital mortality was observed in men (from 16.9% to 8.7%), but not in women (from 11.8% to 12.0%), with significant interaction between sex and study year (P=0.023). After adjustment, in-hospital mortality in women was significantly lower than men in 2006, but not in 2011 or 2015.

CONCLUSIONS

Sex differences in cardiovascular risk factors and invasive strategy after non-ST-segment-elevation myocardial infarction were observed between 2011 and 2015 in China. Although sex gaps in in-hospital mortality were largely explained by age differences, efforts to narrow sex-related disparities in quality of care should remain a focus.

REGISTRATION

URL: http://www.

CLINICALTRIALS

gov; Unique identifier: NCT01624883.

Prognostic Outcomes in Acute Myocardial Infarction Patients Without Standard Modifiable Risk Factors: A Multiethnic Study of 8,680 Asian Patients

Background

An increasing proportion of patients with acute myocardial infarction (AMI) are presenting without standard modifiable risk factors (SMuRFs) of hypertension, hypercholesterolemia, diabetes, and smoking, but with an unexpectedly increased mortality. This study examined the SMuRF-less patients presenting with AMI in a multiethnic Asian population.

Methods

We recruited patients presenting with AMI from 2011 to 2021 and compared the prevalence, clinical characteristics, and outcomes of SMuRF-less and SMuRF patients. Multivariable analysis was used to compare the outcomes of 30-day cardiovascular mortality, all-cause mortality, readmission, cardiogenic shock, stroke, and heart failure. Kaplan-Meier curves were constructed for 30-day cardiovascular mortality, with stratification by ethnicity, gender and AMI type, and 10-year all-cause mortality.

Results

Standard modifiable risk factor-less patients, who made up 8.6% of 8,680 patients, were significantly younger with fewer comorbidities that include stroke and chronic kidney disease, but higher rates of ventricular arrhythmias and inotropic or invasive ventilation requirement. Multivariable analysis showed higher rates of cardiovascular mortality (HR 1.48, 95% CI: 1.09-1.86, p = 0.048), cardiogenic shock (RR: 1.31, 95% CI: 1.09-1.52, p = 0.015), and stroke (RR: 2.51, 95% CI: 1.67-3.34, p = 0.030) among SMuRF-less patients. A 30-day cardiovascular mortality was raised in the SMuRF-less group, with similar trends in men, patients with ST-segment elevation myocardial infarction (STEMI), and the three Asian ethnicities. All-cause mortality remains increased in the SMuRF-less group for up to 5 years.

Conclusion

There is a significant proportion of patients with AMI without standard risk factors in Asia, who have worse short-term mortality. This calls for greater focus on the management of this unexpectedly high-risk subgroup of patients.

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.

ST-Segment Elevation Myocardial Infarction: Sex Differences in Incidence, Etiology, Treatment, and Outcomes

PURPOSE

Although there have been marked improvements in the standard of care for treatment of ST-elevation myocardial infarction, women, especially younger women, continue to have significantly worse outcomes than men.

RECENT FINDINGS

This review highlights the current sex differences in presentation, etiology, treatment, and outcomes among these patients in order to make providers aware of the heterogeneous entities that cause ST-elevation myocardial infarction particularly in women and of disparities in treatment that lead to poorer outcomes in women. Furthermore, it emphasizes evidence-based strategies including standardized protocols for early revascularization, mechanical circulatory support, and access methodology that can reduce sex-based disparities in treatments and outcomes.

Systematic Review of Sex Differences in Ischemic Strokes Among Young Adults: Are Young Women Disproportionately at Risk?

BACKGROUND AND PURPOSE

Recent evidence suggests that young women (18-45 years) may be at higher risk of ischemic strokes than men of the same age. The goal of this systematic review is to reconcile and synthesize existing evidence of sex differences among young adults with ischemic strokes.

METHODS

We searched PubMed from January 2008 to July 2021 for relevant articles and reviews and consulted their references. We included original studies that (1) were population based and (2) reported stroke incidence by sex or sex-specific incidence rate ratios of young adults ≤45 years. We excluded studies that (1) omitted measurements of error for incidence rates or incidence rate ratios, (2) omitted age adjustment, and (3) were not in English. Statistical synthesis was performed to estimate sex difference by age group (≤35, 35-45, and ≤45) and stroke type.

RESULTS

We found 19 studies that reported on sex-specific stroke incidence among young adults, including 3 that reported on overlapping data. Nine studies did not find a statistically significant sex difference among young adults ≤45 years. Three studies found higher rates of ischemic stroke among men among young adults ≥30 to 35 years. Four studies found more women with ischemic strokes among young adults ≤35 years. Overall, in young adults ≤35 years, the estimated effect size favored more ischemic strokes in women (incidence rate ratio, 1.44 [1.18-1.76], I²=82%) and a nonsignificant sex difference in young adults 35 to 45 years (incidence rate ratio, 1.08 [0.85-1.38], I²=95%).

CONCLUSIONS

Overall, there were 44% more women ≤35 years with ischemic strokes than men. This gap narrows in young adults, 35 to 45 years, and there is conflicting evidence whether more men or women have ischemic strokes in the 35 to 45 age group.

Treatment Effect of Percutaneous Coronary Intervention in Dialysis Patients With ST-Elevation Myocardial Infarction

RATIONALE & OBJECTIVE

Patients receiving maintenance dialysis have higher mortality following primary percutaneous coronary intervention (pPCI) than patients not receiving dialysis. Whether pPCI confers a similar benefit to patients receiving dialysis remains unknown. We compared the effect of pPCI on in-hospital outcomes among patients hospitalized for STEMI and receiving maintenance dialysis to the effect among patients hospitalized for STEMI but not receiving dialysis.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

We used the National-Inpatient-Sample (2016-2018) and included all adult hospitalizations with a primary diagnosis of STEMI.

PREDICTORS

Primary exposure was PCI. Confounders included dialysis status, demographics, insurance, household income, comorbidities, and the elective nature of the admission.

OUTCOMES

In-hospital mortality, stroke, AKI, new dialysis requirements, vascular complications, gastrointestinal bleeding, blood transfusion, mechanical ventilation, palliative care, and discharge destination.

ANALYTICAL APPROACH

The average treatment effect [ATE] of pPCI was estimated using propensity score matching within ESRD and non-ESRD groups independently to explore if the effect is modified by ESRD status. Additionally, the average marginal effect [AME] was calculated accounting for the clustering within hospitals.

RESULTS

4,220 (1.07%) out of 413,500 hospitalizations were for patients receiving dialysis. The dialysis cohort was older (65.2±12.2 vs. 63.4±13.1, p<0.001), had more females (42.4% vs. 30.6%, p<0.001) and more comorbidities, but fewer White patients (41.1% vs. 71.7%, p<0.001). Patients receiving dialysis underwent less angiography (73.1% vs. 85.4%, p<0.001) or pPCI (57.5% vs. 79.8%, p<0.001). pPCI was associated with lower mortality in patients receiving dialysis (15.7% vs. 27.1%, p<0.001) as well as in those who were not (5.0% vs. 17.4%, p<0.001). The ATE on mortality did not differ significantly between patients receiving dialysis (-8.6% [-15.6%, -1.6%], p=0.02) and those who were not (-8.2% [-8.8%, -7.5%], p<0.001 (p-interaction=0.9). The AME method showed similar results (-9.4% [-14.8%, -4.0%], p<0.001) among patients receiving dialysis and those who were not (-7.9% [-8.5%, -7.4%], p<0.001) (p-interaction=0.59). Both the ATE and AME were comparable for other in-hospital outcomes in both groups.

LIMITATIONS

Administrative data, lack of pharmacotherapy and long-term outcome data, and residual confounding.

CONCLUSION

Compared with conservative management, pPCI for STEMI was associated with comparable reductions in short-term mortality among patients irrespective of their receipt of maintenance dialysis.

Prognosis Impact of Diabetes in Elderly Women and Men with Non-ST Elevation Acute Coronary Syndrome

Few studies have addressed to date the interaction between sex and diabetes mellitus (DM) in the prognosis of elderly patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). Our aim was to address the role of DM in the prognosis of non-selected elderly patients with NSTEACS according to sex. A retrospective analysis from 11 Spanish NSTEACS registries was conducted, including patients aged ≥70 years. The primary end point was one-year all-cause mortality. A total of 7211 patients were included, 2,770 (38.4%) were women, and 39.9% had DM. Compared with the men, the women were older (79.95 ± 5.75 vs. 78.45 ± 5.43 years, p < 0.001) and more often had a history of hypertension (77% vs. 83.1%, p < 0.01). Anemia and chronic kidney disease were both more common in women. On the other hand, they less frequently had a prior history of arteriosclerotic cardiovascular disease or comorbidities such as peripheral artery disease and chronic pulmonary disease. Women showed a worse clinical profile on admission, though an invasive approach and in-hospital revascularization were both more often performed in men (p < 0.001). At a one-year follow-up, 1090 patients (15%) had died, without a difference between sexes. Male sex was an independent predictor of mortality (HR = 1.15, 95% CI 1.01 to 1.32, p = 0.035), and there was a significant interaction between sex and DM (p = 0.002). DM was strongly associated with mortality in women (HR: 1.45, 95% CI = 1.18–1.78; p < 0.001), but not in men (HR: 0.98, 95% CI = 0.84–1.14; p = 0.787). In conclusion, DM is associated with mortality in older women with NSTEACS, but not in men.

Treatment Effect of Percutaneous Coronary Intervention in Men Versus Women With ST-Segment-Elevation Myocardial Infarction

Background Women are less likely to receive primary percutaneous coronary intervention (pPCI) than men. A potential reason is risk aversion because of the worse outcomes with pPCI among women. However, whether pPCI is associated with a comparable mortality benefit in men and women remains unknown. Methods and Results We selected patients admitted with a principal diagnosis of ST-segment-elevation myocardial infarction in the National Inpatient Sample (2016-2018). We used propensity-score matching to calculate average treatment effects of pPCI for in-hospital mortality, major complications, length of stay, and cost. As a sensitivity analysis, we used logit models followed by a marginal command to calculate the average marginal effect. We included 413 500 weighted hospitalizations (30.7% women, 69.3% men). Women had more comorbidities except smoking and prior sternotomy. Compared with men, women were less likely to undergo angiography (81.0% versus 87.0%; adjusted odds ratio [OR], 0.77; 95% CI, 0.74-0.81; P<0.001) or pPCI (74.0% versus 82.0%; adjusted OR, 0.76; 95% CI, 0.73-0.79; P<0.001). There were no significant differences in average treatment effects of pPCI on mortality between men (-8.4% [-9.3% to -7.6%], P<0.001), and women (-9.5% [-10.8% to -8.3%], P<0.001) (P interaction=0.16). This persisted in age-stratified analyses (≥85, 65-84, 45-64, <45 years) and sensitivity analysis, excluding emergent admissions. The average treatment effects of pPCI on major complications were comparable except for acute stroke, leaving against medical advice, and palliative encounter. There were no differences in the average treatment effects of pPCI on length of stay, but the proportional increase in cost with pPCI was higher in women. Conclusions pPCI results in a comparable reduction in in-hospital mortality in men and women. Nonetheless, risk-adjusted rates of pPCI remain lower in women in contemporary US practice.

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

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