Acute myocardial infarction in women: contribution of treatment variables to adverse outcome

ST-Elevation Myocardial Infarction as a First Event

BACKGROUND

Survival after ST-elevation myocardial infarction (STEMI) as a first event in Germany was analyzed.

METHODS

Adults with a first-event STEMI were included for analysis on the basis of insurance data from a German health insurance provider (AOK; approximately 26 million members; median follow-up 48.5 months). The primary endpoints were 30-day mortality, reinfarction or death, major adverse cardiovascular and cerebro - vascular events (MACCE), long-term survival for more than 90 days, and overall survival (OS).

RESULTS

STEMI occurred in 17 444 patients (32.8% women). The women were older than the men (median age 74 versus 60 years) and suffered more frequently from cardiovascular comorbidities such as diabetes mellitus, chronic renal disease, and arterial hypertension. Women underwent endovascular or surgical treatment less frequently, but sustained complications (cardiogenic shock, resuscitation) more frequently. After adjustment of the data, women were at higher risk of 30-day mortality (odds ratio [OR] 1.17, 95% confidence interval [95% CI] [1.07; 1.28]), reinfarction or death (hazard ratio [HR] 1.09, 95% CI [1.04; 1.16]), MACCE (HR 1.09, 95% CI [1.04; 1.15]), and poorer OS (HR 1.10, 95% CI [1.04; 1.17]). This effect was especially pronounced in women aged ≤ 60 years. No differences between the sexes were seen among patients who survived for 90 days after the infarction.

CONCLUSION

In Germany, women ≤ 60 years display a higher 30-day mortality after first-event STEMI, which affects their overall survival. Younger women should receive intensified medical attention after STEMI, especially in the early phase.

Aspirin for cardiovascular disease prevention among adults in the United States: Trends, prevalence, and participant characteristics associated with use

OBJECTIVE

: Aspirin has been widely utilized over several decades for atherosclerotic cardiovascular disease (ASCVD) prevention among adults in the United States. We examined trends in aspirin use among adults aged ≥40 years from 1998 to 2019 and assessed factors associated with its use for primary and secondary ASCVD prevention.

METHODS

: Using 1998-2019 Behavioral Risk Factor Surveillance System data, we obtained weighted prevalence of aspirin use among adults aged ≥40 years for each year and examined trends in use over this period. Using multivariable logistic regression and utilizing data from 54,388 respondents aged ≥40 years in the 2019 data, we assessed factors associated with aspirin use for secondary prevention and for primary prevention stratified by the number of traditional ASCVD risk factors reported (hypertension, diabetes mellitus, high cholesterol, overweight/obesity, and cigarette smoking).

RESULTS

: Aspirin use prevalence increased from 29.0%(95%CI, 27.9%-30.2%) in 1998 to 37.5%(36.9%-38.0%) in 2009. However, use has slightly declined over the last decade: 35.6%(34.6%-36.6%) in 2011 to 33.5%(32.5%-34.6%) in 2019. In 2019, among respondents without cardiovascular disease (CVD), 27.5%(26.4%-28.6%) reported primary prevention aspirin use while 69.7%(67.0%-72.2%) of respondents with CVD reported secondary prevention aspirin use. Of concern, 45.6%(43.5%-47.7%) of adults aged ≥70 years without CVD reported primary prevention aspirin use. Additionally, among individuals without any self-reported traditional ASCVD risk factor, males (adjusted odds ratio(aOR):1.60, 95%CI:1.12-2.27), persons aged ≥70 years (aOR:3.22, 95%CI:2.27-4.55), and individuals with healthcare coverage (aOR:2.28, 95%CI:1.17-4.44) had higher odds of primary prevention aspirin use compared to females, persons aged 40-69 years, and individuals without healthcare coverage, respectively. Females were less likely than males to report secondary prevention aspirin use (aOR:0.64, 95%CI:0.50-0.82).

CONCLUSION

: Aspirin use has slightly declined over the last decade. A significant proportion of adults aged ≥70 years reported primary prevention aspirin use in 2019. Since current guidelines do not recommend primary prevention aspirin use among adults aged ≥70 years, such use should be discouraged.

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

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

Anticoagulant and antiplatelet combined therapy in patients 75 years and over with atrial fibrillation: a prospective observational study assessing adherence to clinical guidelines

Objective

According to current guidelines on atrial fibrillation (AF), the addition of an antiplatelet therapy to an anticoagulant for a stable vascular disease does not decrease the ischaemic hazard but increases the risk of bleeding. The aim of the study was to assess compliance of practices with existing clinical guidelines concerning the use of anticoagulant-antiplatelet combined therapy in patients 75 years and over with AF.

Methods

This prospective observational study was carried out at the University Hospital of Strasbourg (France) between August 2016 and January 2017 with data collection on 1 day of every month. To be included, the patient had to be 75 years and over with AF and treated with anticoagulant-antiplatelet therapy. The population included all the patients admitted at the hospital excluding those from the Gynaecology-Obstetrics and Paediatrics departments. With regard to clinical ongoing guidelines (French, European, American and Canadian), the patients were sorted into three groups. Group 1: combined therapy in compliance with recommendations; Group 2: combined therapy debatable as to benefit-risk ratio; and Group 3: combined therapy not compliant with recommendations.

Result

Ninety-three out of 3307 patients 75 years and over received anticoagulant-antiplatelet combined therapy prior to their hospital admission. Thirty-two patients (34.4% - Group 1) had experienced an acute event and/or revascularisation within the past year. Twenty-four patients (25.8% - Group 2) had not experienced recent revascularisation and had stable coronary disease but were suffering from peripheral artery disease. Group 3 consisted of 37 patients (39.8%), none of which had experienced recent revascularisation or had unstable coronary disease. For all groups, the main dual therapy was acetylsalicylic acid + fluindione (59.1%).

Conclusion

In our study, 37 antiplatelet (39.8%) treatments could have been stopped. These results should spur prescribers into regular reassessment of combination antithrombotic therapy since it contributes to polypharmacy and increases the risk of adverse events.

Clinical Presentation, Risk Factor, and Outcomes of Acute Coronary Syndrome in Women at an Urban Referral Center in Dakar, Senegal

BACKGROUND

Cardiovascular disease is on the rise in Sub-Saharan countries. Recently, consistent studies have reported sex differences in the epidemiology of acute coronary syndrome (ACS). Although, data on the incidence of ACS in Sub-Saharan countries are not rare, few focused closely on women.

OBJECTIVES

The purpose of this study was to examine risk factors, clinical presentations, and management strategies in women with ACS.

METHODS

This was a retrospective study conducted at the Cardiology Department of Principal Hospital of Dakar over a period of 60 months (January 1, 2010, to December 31, 2014), in Dakar, Senegal. Medical records of female subjects admitted for ACS on the basis of anginal pain at rest, suggestive electrocardiographic changes, and elevated troponin I levels were included. We collected and analyzed the epidemiological, clinical, paraclinical, and evolutionary data of the patients.

RESULTS

Hospital prevalence of ACS in women was 2.32%, meaning 38.1% of patients were admitted for ACS during the same period. The mean age of patients was 68.8 ± 9.5 years; 52% of them were aged between 60 and 69 years. The risk factors in our patients were dominated by hypertension found (63.3%) and diabetes (54.1%). Active smoking was found in 6 patients (6.1%). One-half of patients had more than 1 risk factor. Chest pain was present in 94 patients (95.9%). The average time delay before medical care was administered was 53.9 ± 18 h. Thirty patients showed signs of left ventricular failure (Killip classes I and II). Electrocardiography revealed ACS with persistent ST-segment elevation in 53 patients (54.1%) and non-ST-segment elevation ACS in 45 patients (45.9%). Mean troponin I level was 1.68 ± 2.3 ng/ml. Doppler echocardiography revealed impaired segmental kinetics in more than one-half of patients. The mean ventricular ejection fraction was 43.8 ± 10.1%. Thrombolysis was performed in 10 patients, accounting for 10.2% of patients with ST-segment elevation. The evolution during hospitalization after a mean hospital stay of 9.5 ± 3.7 days was favorable in 66 patients (67.3%). Six deaths (6.1%) were recorded. Complications was dominated by pulmonary edema.

CONCLUSIONS

Our study confirms that ACS is not a "man's only" disease in Sub-Saharan countries. The major concern is that there appeared to be continuing evidence of suboptimal treatment and intervention in women with ACS in current practice.

Variation in outcome of hospitalised patients with out-of-hospital cardiac arrest from acute coronary syndrome: a cohort study

Background

Each year, approximately 30,000 people have an out-of-hospital cardiac arrest (OHCA) that is treated by UK ambulance services. Across all cases of OHCA, survival to hospital discharge is less than 10%. Acute coronary syndrome (ACS) is a common cause of OHCA.

Objectives

To explore factors that influence survival in patients who initially survive an OHCA attributable to ACS.

Data source

Data collected by the Myocardial Ischaemia National Audit Project (MINAP) between 2003 and 2015.

Participants

Adult patients who had a first OHCA attributable to ACS and who were successfully resuscitated and admitted to hospital.

Main outcome measures

Hospital mortality, neurological outcome at hospital discharge, and time to all-cause mortality.

Methods

We undertook a cohort study using data from the MINAP registry. MINAP is a national audit that collects data on patients admitted to English, Welsh and Northern Irish hospitals with myocardial ischaemia. From the data set, we identified patients who had an OHCA. We used imputation to address data missingness across the data set. We analysed data using multilevel logistic regression to identify modifiable and non-modifiable factors that affect outcome.

Results

Between 2003 and 2015, 1,127,140 patient cases were included in the MINAP data set. Of these, 17,604 OHCA cases met the study inclusion criteria. Overall hospital survival was 71.3%. Across hospitals with at least 60 cases, hospital survival ranged from 34% to 89% (median 71.4%, interquartile range 60.7–76.9%). Modelling, which adjusted for patient and treatment characteristics, could account for only 36.1% of this variability. For the primary outcome, the key modifiable factors associated with reduced mortality were reperfusion treatment [primary percutaneous coronary intervention (pPCI) or thrombolysis] and admission under a cardiologist. Admission to a high-volume cardiac arrest hospital did not influence survival. Sensitivity analyses showed that reperfusion was associated with reduced mortality among patients with a ST elevation myocardial infarction (STEMI), but there was no evidence of a reduction in mortality in patients who did not present with a STEMI.

Limitations

This was an observational study, such that unmeasured confounders may have influenced study findings. Differences in case identification processes at hospitals may contribute to an ascertainment bias.

Conclusions

In OHCA patients who have had a cardiac arrest attributable to ACS, there is evidence of variability in survival between hospitals, which cannot be fully explained by variables captured in the MINAP data set. Our findings provide some support for the current practice of transferring resuscitated patients with a STEMI to a hospital that can deliver pPCI. In contrast, it may be reasonable to transfer patients without a STEMI to the nearest appropriate hospital.

Future work

There is a need for clinical trials to examine the clinical effectiveness and cost-effectiveness of invasive reperfusion strategies in resuscitated OHCA patients of cardiac cause who have not had a STEMI.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Cardiac diastolic function after recovery from pre-eclampsia

BACKGROUND

Pre-eclampsia is associated with significant changes to the cardiovascular system during pregnancy. Eccentric and concentric remodelling of the left ventricle occurs, resulting in impaired contractility and diastolic dysfunction. It is unclear whether these structural and functional changes resolve completely after delivery.

AIMS

The objective of the study was to determine cardiac diastolic function at delivery and one year post-partum in women with severe pre-eclampsia, and to determine possible future cardiovascular risk.

METHODS

This was a descriptive study performed at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria, South Africa. Ninety-six women with severe preeclampsia and 45 normotensive women with uncomplicated pregnancies were recruited during the delivery admission. Seventy-four (77.1%) women in the pre-eclamptic group were classified as a maternal near miss. Transthoracic Doppler echocardiography was performed at delivery and one year post-partum.

RESULTS

At one year post-partum, women with pre-eclampsia had a higher diastolic blood pressure (p = 0.001) and body mass index (p = 0.02) than women in the normotensive control group. Women with early onset pre-eclampsia requiring delivery prior to 34 weeks' gestation had an increased risk of diastolic dysfunction at one year post-partum (RR 3.41, 95% CI: 1.11-10.5, p = 0.04) and this was irrespective of whether the patient had chronic hypertension or not.

CONCLUSION

Women who develop early-onset pre-eclampsia requiring delivery before 34 weeks are at a significant risk of developing cardiac diastolic dysfunction one year after delivery compared to normotensive women with a history of a low-risk pregnancy.

Sex differences in the management of acute coronary syndromes in Italy: data from the MANTRA registry

AIMS

Several studies have shown sex differences in acute coronary syndromes (ACS), but their understanding is far from complete. Thus, the study aims to evaluate sex differences in management and outcomes of unselected patients with ACS.

METHODS AND RESULTS

From 22 April 2009 to 29 December 2010, 6394 consecutive patients with ACS (44.7% ST-elevation myocardial infarction) were prospectively enrolled and followed for 6 months. Women (N = 1894, 29.6%) were older, had more comorbidities, and worse clinical presentation than men. Fewer women underwent reperfusion [68.0% women vs. 84.1% men, P < 0.0001, adjusted odds ratio (OR): 0.53, 95% confidence interval (CI): 0.43-0.66] in ST-elevation myocardial infarction, and coronary angiography during hospitalization (72.2% women vs. 81.1% men, P < 0.0001, adjusted OR: 0.70, 95% CI: 0.57-0.85) in no-ST-elevation ACS. Women had worse outcomes than men during hospitalization, and at 6-month follow-up. At multivariable analysis, female sex was significantly associated with a higher risk of in-hospital Thrombolysis in Myocardial Infarction major bleedings (OR: 1.80, 95% CI: 1.09-2.96, P = 0.02), but not of 6-month death.

CONCLUSION

Women with ACS in clinical practice present a clustering of high-risk features that may contribute to their worse outcomes as compared with men, although female sex is not an independent predictor of death at 6-month follow-up.

Progesterone Protects Against Bisphenol A-Induced Arrhythmias in Female Rat Cardiac Myocytes via Rapid Signaling

Bisphenol A (BPA) is an estrogenic endocrine-disrupting chemical (EDC) that has a range of potential adverse health effects. Previously we showed that acute exposure to BPA promoted arrhythmias in female rat hearts through estrogen receptor rapid signaling. Progesterone (P4) and estrogen have antagonistic or complementary actions in a number of tissues and systems. In the current study, we examined the influence and possible protective effect of P4 on the rapid cardiac actions of BPA in female rat cardiac myocytes. Preincubation with physiological concentration (1 nM) of P4 abolished BPA-induced triggered activities in female cardiac myocytes. Further, P4 abrogated BPA-induced alterations in Ca2+ handling, including elevated sarcoplasmic reticulum Ca2+ leak and Ca2+ load. Key to the inhibitory effect of P4 is its blockade of BPA-induced increase in the phosphorylation of phospholamban. At myocyte and protein levels, these inhibitory actions of P4 were blocked by pretreatment with the nuclear P4 receptor (nPR) antagonist RU486. Analysis using membrane-impermeable bovine serum albumin-conjugated P4 suggested that the actions of P4 were mediated by membrane-initiated signaling. Inhibitory G (Gi) protein and phophoinositide-3 kinase (PI3K), but not tyrosine protein kinase activation, were involved in the observed effects of P4. In conclusion, P4 exerts an acute protective effect against BPA-induced arrhythmogenesis in female cardiac myocytes through nPR and the Gi/PI3K signaling pathway. Our findings highlight the importance of considering the impact of EDCs in the context of native hormonals and may provide potential therapeutic strategies for protection against the cardiac toxicities associated with BPA exposure.

Effective Factors in Door-to-Needle Time for Streptokinase Administration in Patients With Acute Myocardial Infarction Admitted to the Emergency Department

Background:

Cardiovascular incidents are a common cause of death around the world. Acute myocardial infarction (AMI) poses high risks for the patient due to plaque rupture or erosion along with a superimposed non-occlusive thrombus; therefore, timely treatment with antithrombotic agents plays a key role in reducing an AMI mortality rate.

Objectives:

The present study aimed to assess the time interval between the admission of AMI-suspected patients and treatment initiation.

Patients and Methods:

This cross-sectional study was conducted on 110 patients admitted to the emergency department of Imam Hussein hospital in Tehran, Iran. Data were collected using checklists, completed by the patients’ next of kin or the emergency staff. To analyze the data, student t- test and analysis of variance were used.

Results:

In this study, 31 female and 79 male subjects were included, respectively. The mean time to receive the first dose of streptokinase was 66.39 minutes (73.74 minutes for females and 63.5 minutes for male patients), varying from 49.92 minutes in the morning to 69.78 minutes in the afternoon and 72.68 minutes during night shifts.

Conclusions:

The door-to-needle (DTN) time, in a standard setting, is recommended to be less than 30 minutes. According to the results of this study, the DTN time is comparatively two times longer in females and afternoon and night shifts. Different variables including emergency staff, physicians, patients’ characteristics, and environmental/physical factors induced this difference.

Symptom-to-door times in patients presenting with ST elevation myocardial infarction--do ethnic or gender differences exist?

BACKGROUND

Studies have shown higher in-hospital mortality for female patients and ethnic minorities admitted to hospital with acute ST elevation myocardial infarction (STEMI). Pre-hospital delay is thought to be associated with increased in-hospital mortality.

AIM

To assess the impact of gender and ethnicity on symptom-to-door time (STDT) in patients presenting with STEMI.

DESIGN

Retrospective survey of consecutive patients receiving primary percutaneous coronary intervention between January 2008 and January 2013. A multivariate model was used to adjust for confounders.

MAIN OUTCOME MEASURE

Influence of gender and ethnicity on STDT.

RESULTS

We analysed 1020 patients (75% male, 263 South Asians, 38 Afro Caribbeans and 719 White Europeans.) There was a trend towards longer unadjusted median STDT in women compared with men (132 min vs. 113 min P = 0.07) which disappeared after correction for age and ethnicity (P = 0.15). There was no gender difference in hospital mortality after correction for age (odds ratio 0.69, 95% confidence interval 0.40-1.18, P = 0.17). On linear regression analysis South Asians showed a trend towards longer STDT than other ethnic groups (P = 0.08) however after adjustment for diabetes there was no association between South Asian ethnicity and hospital mortality.

CONCLUSIONS

Neither female gender nor ethnicity were shown to be associated with significant pre-hospital delay.

Excess mortality in women compared to men after PCI in STEMI: an analysis of 11,931 patients during 2000-2009

BACKGROUND

Ambiguity exists whether gender affects outcome in patients undergoing percutaneous coronary intervention (PCI).

METHODS

To evaluate the relationship between gender and outcome in a large cohort of PCI patients, 11,931 consecutive patients who underwent PCI for various indications during 2000-2009 were studied using survival analyses and Cox regression models.

RESULTS

Most patients (n=8588; 72%) were men. Women were older and more often had a history of hypertension and diabetes mellitus. Men smoked more frequently, had a more extensive cardiovascular history (previous MI, PCI and CABG), a higher prevalence of renal impairment and multi-vessel disease. In STEMI patients, women had higher 31-day mortality rates than men (11.6% vs. 6.5%, respectively, p<0.001). This difference remained after adjustment for confounders (aHR at 30-days 1.54 and 95% CI 1.22-1.96). Likewise, higher mortality was observed at 1-year (15.1% vs. 9.3%) and 4-year follow-up (21.6% vs. 15.0%, aHR 1.30 and 95% CI 1.10-1.53). There were no differences in mortality between women and men in NSTE-ACS (aHR at 4-years 1.05 and 95% CI 0.85-1.28) or stable angina (HR at 4-years 0.85 and 95% CI 0.68-1.08).

CONCLUSION

Women undergoing PCI for STEMI had higher mortality than men. The excess mortality in women appeared in the first month after PCI and could only partially be explained by a difference in baseline characteristics. No gender differences in outcome in patients undergoing PCI for NSTE-ACS and stable angina were observed.

Outcomes of patients with prior coronary artery bypass graft who present with acute coronary syndrome

Generally, patients with prior coronary artery bypass graft (CABG) are often under-represented in acute coronary syndrome (ACS) clinical trials. Nevertheless, there is growing global attention concerning their short- and long-term prognosis. Some reports suggest prior CABG as an independent risk factor for increased mortality, while others report an equal or a more favorable prognosis despite their adverse baseline clinical characteristics. The reasons for this 'risk-mortality paradox' need to be further evaluated. More recent reports showed a significant reduction in in-hospital morbidity and mortality over a 20-year period of follow up that may be attributed to the improvement in surgical CABG techniques and increased use of evidence-based therapies over the past two decades. In the current review we discuss the available literature regarding outcomes of prior CABG patients who are presenting with ACS.

Racial/Ethnic and gender gaps in the use of and adherence to evidence-based preventive therapies among elderly Medicare Part D beneficiaries after acute myocardial infarction

BACKGROUND

It is unclear whether gender and racial/ethnic gaps in the use of and patient adherence to β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins after acute myocardial infarction have persisted after establishment of the Medicare Part D prescription program.

METHODS AND RESULTS

This retrospective cohort study used 2007 to 2009 Medicare service claims among Medicare beneficiaries ≥65 years of age who were alive 30 days after an index acute myocardial infarction hospitalization in 2008. Multivariable logistic regression models examined racial/ethnic (white, black, Hispanic, Asian, and other) and gender differences in the use of these therapies in the 30 days after discharge and patient adherence at 12 months after discharge, adjusting for patient baseline sociodemographic and clinical characteristics. Of 85 017 individuals, 55%, 76%, and 61% used angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, and statins, respectively, within 30 days after discharge. No marked differences in use were found by race/ethnicity, but women were less likely to use angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and β-blockers compared with men. However, at 12 months after discharge, compared with white men, black and Hispanic women had the lowest likelihood (≈30%-36% lower; P<0.05) of being adherent, followed by white, Asian, and other women and black and Hispanic men (≈9%-27% lower; P<0.05). No significant difference was shown between Asian/other men and white men.

CONCLUSIONS

Although minorities were initially no less likely to use the therapies after acute myocardial infarction discharge compared with white patients, black and Hispanic patients had significantly lower adherence over 12 months. Strategies to address gender and racial/ethnic gaps in the elderly are needed.

Sex preferences in cardiovascular testing: the contribution of the patient-physician discussion

OBJECTIVES

Prior studies suggest that a decreased cardiac catheterization rate for women with acute coronary syndrome (ACS) is partially attributed to gender differences in patient preferences for testing. The hypothesis was that these preferences are influenced by physician recommendations for cardiovascular testing.

METHODS

This was a cohort study of patients who presented to an emergency department (ED) with chest pain. At the time of ED disposition, patients were surveyed to assess whether or not the doctor discussed the possibility of coronary artery disease (CAD), the physician's recommendations for diagnostic testing, and the patient's preferences for further testing. The survey was repeated at the time of discharge from the hospital if the patient was admitted and again at 30 days for all patients. The main outcome was patient-reported physician recommendation for testing, and the secondary outcome was patient preference for cardiovascular testing.

RESULTS

There were 206 patients enrolled (118 women, 88 men). Women were less likely than men to receive cardiac catheterization as inpatients (9.8% vs. 20.0%, p = 0.04). In the ED, women were less likely to be recommended for stress testing (8.5% vs. 19.3%, p = 0.02) or cardiac catheterization (4.2% vs. 13.6%, p = 0.02) or to see a cardiologist (8.5% vs. 22.7%, p < 0.01). As inpatients, women were more likely to be told that no further testing was needed (70.5% vs. 50.0%, p = 0.03). While there was higher incidence of prior CAD and myocardial infarction among the men in the study, analysis after removal of these patients did not alter results. Physicians were less likely to counsel women about diagnostic testing options in the ED (10.1% vs. 22.7%, p = 0.03), as inpatients (11.5% vs. 40.0%, p < 0.01), and as outpatients (26.1% vs. 48.6%, p = 0.04). No patients in the study refused their doctors' recommendations. Women were less likely to prefer catheterization in the ED (5.1% vs. 15.9%, p = 0.01) and were more likely to prefer no further testing as inpatients (60.7% vs. 40.0%, p = 0.02).

CONCLUSIONS

Women who presented to the ED with symptoms concerning for ACS reported lower rates of physician recommendation for cardiovascular testing, as well as lower rates of counseling regarding cardiac etiologies of their chest pain. These findings suggest sex differences in preference for cardiovascular testing may be partially explained by the discussions between women and their doctors.

Sex disparities in pre-hospital and hospital treatment of ST-segment elevation myocardial infarction

OBJECTIVE

To determine whether sex disparities exist in pre-hospital and hospital time to treatment in patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Evidence suggests that women experience poorer quality of care for STEMI.

METHODS

A retrospective cohort study was conducted on 177 consecutive patients with STEMI who received primary percutaneous coronary intervention at a rural, tertiary medical center between January 2006 and October 2009. A subgroup analysis was conducted to evaluate time to treatment during a period of no-focused process improvement compared with a time period of focused, non–sex-specific process improvement; the post period included implementation of the STEMI process upgrade (STEP-UP) quality-improvement (QI) program.

RESULTS

Median first-emergency-medical-services-contact-to-balloon (E2B) angioplasty time was significantly longer for women compared with men. A Cox proportional hazards model revealed that men had a significantly shorter E2B time than women. After adjustment for differences between sex groups at presentation, the effect of sex on E2B was no longer statistically significant. A similar effect was observed in door-to-balloon (D2B) angioplasty time. The subgroup analysis revealed that from baseline, both men and women experienced improvement in E2B time after implementation of the STEP-UP QI program. Men and women also experienced improvement in D2B time after implementation of the STEP-UP QI program.

CONCLUSIONS

Women with STEMI experienced significantly longer E2B and D2B times compared with men with STEMI, although these differences did not persist after adjustment for differences between sex groups at presentation. In addition to standard STEMI-care QI practices, sex-specific processes and interventions at the systems level may be needed to improve time to treatment for women with STEMI.

Cardiovascular disease in women

Gender-specific data focused on cardiovascular disease (CVD) are becoming increasingly available. This is of great importance, given that CVD has become the number 1 killer of women, and unlike for men, mortality rates do not seem to be declining. Many factors are cited as the causes of sex-based differences, including delays in recognizing symptoms, underutilization of diagnostic tests and treatments, as well as anatomic, physiological, and genetic factors. Evidence of fundamental biological differences in vascular function and the underlying pathologic processes is only beginning to elucidated, motivated by growing evidence of differences in clinical presentations and outcomes between men and women. The good news is that we are starting to see improvements in outcomes for women, such as after coronary revascularization; decrease in complication rates with the advent of new techniques, such as radial access for cardiac catheterizations; as well as increased participation of women in clinical trials. The underlying mechanisms of ischemic heart disease remain to be elucidated, and will help guide therapy and ultimately may explain the higher prevalence of : subendocardial myocardial infarctions, spontaneous arterial dissections, plaque erosion, increased vasospastic disorders, such as coronary microvascular disease, and pulmonary hypertension in women compared with men. We have made great progress in understanding gender-related differences in CVDs, but much remains to be done to optimize the prevention of CVD for both men and women.

Low-dose bisphenol A and estrogen increase ventricular arrhythmias following ischemia-reperfusion in female rat hearts

Bisphenol A (BPA) is an environmental estrogenic endocrine disruptor that may have adverse health impacts on a range of tissue/systems. In previous studies, we reported that BPA rapidly promoted arrhythmias in female rodent hearts through alteration of myocyte calcium handling. In the present study we investigated the acute effects of BPA on ventricular arrhythmias and infarction following ischemia-reperfusion in rat hearts. Rat hearts were subjected to 20 min of global ischemia followed by reperfusion. In female, but not male hearts, acute exposure to 1 nM BPA, either alone or combined with 1 nM 17β-estradiol (E2), during reperfusion resulted in a marked increase in the duration of sustained ventricular arrhythmias. BPA plus E2 increased the duration ventricular fibrillation, and the duration of VF as a fraction of total duration of sustained ventricular arrhythmia. The pro-arrhythmic effects of estrogens were abolished by MPP combined with PHTPP, suggesting the involvements of both ERα and ERβ signaling. In contrast to their pro-arrhythmic effects, BPA and E2 reduced infarction size, agreeing with previously described protective effect of estrogen against cardiac infarction. In conclusion, rapid exposure to low dose BPA, particularly when combined with E2, exacerbates ventricular arrhythmia following IR injury in female rat hearts.

Gender-based differences in long-term outcome after ST-elevation myocardial infarction in patients treated with percutaneous coronary intervention

BACKGROUND

In the era of fibrinolysis, women suffered from higher early and late mortality rates than men after acute ST-elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention (PCI) has been determined to be the most effective therapy strategy in STEMI. It is not clear if female gender is an independent predictor of a worse long-term prognosis among patients who were systematically treated with PCI. We, therefore, examined the effect of PCI on long-term outcome between women and men.

METHODS

Between 1999 and 2001, 500 consecutive patients at the Wuppertal Heart Centre were treated with PCI after acute STEMI. A long-term follow-up (up to 7 years) was achieved in 97% of the patients.

RESULTS

In comparison to men, women were 7 years older (65 +/- 12 vs. 58 +/- 11) and had significantly more diabetes mellitus. The time between onset of symptoms and intervention tended to be longer in women than men. There was no difference in 30-day mortality (8.9% vs. 6.6%), cardiac late mortality (3.6% vs. 3.2%), and long-term cardiac overall mortality up to 7 years (12.1% vs. 9.6%). Stepwise regression analysis did not identify female gender as an independent predictor of late mortality. The quality of life was comparable.

CONCLUSIONS

There was no gender-related difference in the long-term outcome if patients were sytematically treated with PCI in STEMI. PCI in STEMI has a long-lasting positive effect in women and should, therefore, be considered the treatment of choice for women with acute myocardial infarction.

Age and gender differences in quality of care and outcomes for patients with ST-segment elevation myocardial infarction

BACKGROUND

Young patients (aged≤45 years) presenting with ST-segment elevation myocardial infarction present unique challenges. The quality of care and in-hospital outcomes may differ from their older counterparts.

METHODS

A total of 31,544 patients presenting with ST-segment elevation myocardial infarction and enrolled in the American Heart Association's Get With the Guidelines Coronary Artery Disease registry were analyzed. The cohort was divided into those aged 45 years or less and those aged more than 45 years.

RESULTS

Young patients accounted for 10.3% of all ST-segment elevation myocardial infarction cases. Compared with older patients, younger patients were less likely to have traditional cardiovascular risk factors and had similar or better quality/performance measures with lower in-hospital mortality (unadjusted rate 1.6 vs 6.5%, P<.0001; adjusted odds ratio [OR], 0.37; 95% confidence interval [CI], 0.29-0.46). Time trend analysis (2002-2008) suggested an increase over time in the "all or none" composite performance measure in both the younger and older patients (68%-97% and 69%-96%, respectively). However, there was significantly lower quality of care and worse outcomes in women (vs men) and in the very young (≤35 vs 36-45 years). Significant interaction was seen between age and gender for in-hospital death, such that the gender difference was greater in the younger cohort. Similar interaction was seen for door-to-thrombolytic time such that the gender delay was greater in the younger cohort (women:men ratio of means=1.73, 95% CI, 1.21-2.45 [younger] vs 1.08, 95% CI, 1.00-1.18 [older]; P(interaction)=.0031).

CONCLUSION

Young patients aged 45 years or less presenting with ST-segment elevation myocardial infarction overall had similar quality of care and in-hospital outcomes as older counterparts. However, quality of care was significantly lower and mortality was higher in young women (vs young men) and the very young (≤35 vs 36-45 years).

Interventions for ST Elevation Myocardial Infarction in Women

The management of ST-segment elevation myocardial infarction (STEMI) has significantly advanced from supportive care to reperfusion therapies with thrombolytics and percutaneous coronary revascularization techniques. These advances have improved the outcomes of patients with STEMI. Although cardiovascular disease is the leading cause of death in both men and women, the minority of patients in trials studying the impact of these therapies on outcomes are women. Multiple studies have shown that men and women do not have equivalent outcomes after STEMI. This article reviews the treatment options for STEMI and the outcomes of women after treatment with reperfusion therapies.

Cardiogenic Shock in Women

Cardiogenic shock (CS) describes the physiologic state in which reduced cardiac output and resultant tissue hypoxia occur in the presence of adequate intravascular volume. Among patients hospitalized with myocardial infarction (MI), CS is the foremost cause of death. Women are more susceptible to CS than men in the setting of ST segment increase MI. Introduction of early revascularization strategies and mechanical ventricular support have seen a decrease in short-term mortality from CS. However, the prognosis following CS remains poor. This article examines the prevalence, causes, pathophysiology, and therapeutic options for CS among women.

Does prior coronary artery bypass surgery alter the gender gap in patients presenting with acute coronary syndrome? A 20-year retrospective cohort study

OBJECTIVES

Previous studies demonstrated women presenting with acute coronary syndrome (ACS) have poor outcomes when compared with men 'the gender gap phenomenon'. The impact of prior coronary artery bypass graft (CABG) on women presenting with ACS is unknown. We hypothesised that the gender gap is altered in ACS patients with prior CABG. The aim of this study was to evaluate patients presenting with ACS according to their gender and history of prior CABG.

DESIGN

Retrospective, observational (cohort) study.

SETTING

Data were collected from hospital-based registry of patients hospitalised with ACS in Doha, Qatar, from 1991 through 2010. The data were analysed according to their gender and history of prior CABG.

PARTICIPANTS

A total of 16 750 consecutive patients with ACS were studied. In total, 693 (4.3%) patients had prior CABG; among them 125 (18%) patients were women.

PRIMARY AND SECONDARY OUTCOME MEASURES

Comparisons of clinical characteristics, inhospital treatment, and outcomes, including inhospital mortality and stroke were made.

RESULTS

Women with or without prior CABG were older, less likely to be smokers, but more likely to have diabetes mellitus (DM), hypertension and renal impairment than men (p=0.001). Women were less likely to receive reperfusion and early invasive therapies. When compared with men, women without prior CABG carried higher inhospital mortality (11% vs 4.9%; p=0.001) and stroke rates (0.9% vs 0.3%; p=0.001). Female gender was independent predictor of poor outcome. Among prior CABG patients, despite the fact that women had worse baseline characteristics and were less likely to receive evidence-based therapy, there were no significant differences in mortality or stroke rates between the two groups.

CONCLUSIONS

Consistent with the world literature, women presenting with ACS and without prior CABG had higher death rates compared with men. Patients with prior CABG had comparable death rates regardless of the gender status.

Bisphenol A and 17β-estradiol promote arrhythmia in the female heart via alteration of calcium handling

Background

There is wide-spread human exposure to bisphenol A (BPA), a ubiquitous estrogenic endocrine disruptor that has been implicated as having potentially harmful effects on human heart health. Higher urine BPA concentrations have been shown to be associated with cardiovascular diseases in humans. However, neither the nature nor the mechanism(s) of BPA action on the heart are understood.

Methodology/Principal Findings

The rapid (<7 min) effects of BPA and 17β-estradiol (E2) in the heart and ventricular myocytes from rodents were investigated in the present study. In isolated ventricular myocytes from young adult females, but not males, physiological concentrations of BPA or E2 (10⁻⁹ M) rapidly induced arrhythmogenic triggered activities. The effects of BPA were particularly pronounced when combined with estradiol. Under conditions of catecholamine stimulation, E2 and BPA promoted ventricular arrhythmias in female, but not male, hearts. The cellular mechanism of the female-specific pro-arrhythmic effects of BPA and E2 were investigated. Exposure to E2 and/or BPA rapidly altered myocyte Ca²⁺ handling; in particular, estrogens markedly increased sarcoplasmic reticulum (SR) Ca²⁺ leak, and increased SR Ca²⁺ load. Ryanodine (10⁻⁷ M) inhibition of SR Ca²⁺ leak suppressed estrogen-induced triggered activities. The rapid response of female myocytes to estrogens was abolished in an estrogen receptor (ER) β knockout mouse model.

Conclusions/Significance

Physiologically-relevant concentrations of BPA and E2 promote arrhythmias in a female-specific manner in rat hearts; the pro-arrhythmic actions of estrogens are mediated by ERβ-signaling through alterations of myocyte Ca²⁺ handling, particularly increases in SR Ca²⁺ leak. Our study provides the first experimental evidence suggesting that exposure to estrogenic endocrine disrupting chemicals and the unique sensitivity of female hearts to estrogens may play a role in arrhythmogenesis in the female heart.

No gender differences in prognosis and preventive treatment in patients with AMI without significant stenoses

OBJECTIVE

To investigate possible gender differences in patients with acute myocardial infarction (AMI) and without significant stenoses on coronary angiography (CAG) regarding prognosis and use of secondary preventive medication.

DESIGN

Nationwide register-based cohort study.

PATIENTS

By compiling data from Danish registries, we identified 20,800 patients hospitalized with AMI during 2005-2007. We included the 834 women and 761 men without significant stenoses on CAG who were discharged and alive after 60 days.

MAIN OUTCOME MEASURES

All-cause mortality, recurrent AMI, and redeeming a prescription for a lipid-lowering drug, beta-blocker, clopidogrel, or aspirin within 60 days of discharge.

RESULTS

During follow-up, 97 women and 60 men died, resulting in a crude female/male hazard ratio (HR) of 1.51 (95% CI 1.09-2.08). After adjustment for age, time-period, and comorbidity, the gender difference was attenuated (HR 1.22, 95% CI 0.86-1.72). AMI recurrence was experienced by 28 women and 29 men with a female/male HR 0.88 (95% CI 0.52-1.48). After multivariable adjustment results were similar (HR 0.84, 95% CI 0.50-1.43). More women than men redeemed a prescription for lipid-lowering drugs with no differences in other medication. In the adjusted models lipid-lowering drugs, beta-blockers, clopidogrel, and aspirin were all redeemed equally with odds ratio (OR) 1.25 (95% CI 0.99-1.59), OR 1.10 (95% CI 0.88-1.37), OR 1.09 (95% CI 0.88-1.34), and OR 1.13 (95% CI 0.90-1.42), respectively.

CONCLUSION

Our study shows that in a population of patients with a first admission for AMI and no significant stenoses on CAG, women share the same prospects as men regarding long-term prognosis and the extent of secondary preventive medical treatment.

Routine early invasive strategy and in-hospital mortality in women with non-ST-elevation myocardial infarction: results from the Berlin Myocardial Infarction Registry (BMIR)

BACKGROUND

It is under discussion whether female patients with non-ST-elevation myocardial infarction (NSTEMI) benefit from routine invasive treatment strategy. We accordingly applied our data from the Berlin Myocardial Infarction Registry (BMIR) to analyze the association between early percutaneous coronary intervention (PCI) and hospital mortality in NSTEMI patients.

METHODS

Data prospectively collected in the BMIR between 2004 and 2008 from 2808 patients (m=1820/w=988) directly admitted to hospitals with 24-h PCI facilities were included in the analysis. After adjustment for confounding variables, we compared in-hospital mortality for patients of both sexes with vs. without early PCI.

RESULTS

Women with NSTEMI were, on average, 7years older than men and demonstrated significantly more comorbidities. A GPIIb/IIIa antagonist was applied in women less often than in men (31.4% vs. 38.4%, p=0.001), and an early PCI was also performed less often in women than in men (64.0% vs. 76.2%, p<0.001). In-hospital mortality was higher in women than in men (5.4% vs. 3.6%, p=0.027). In female patients with NSTEMI, after adjustment for differences in patients' characteristics, hospital mortality did not differ between those treated with early PCI and those managed conservatively (OR: 1.24, 95% CI 0.53-2.91). In contrast, hospital mortality in male patients was lower in those treated with an early PCI (OR: 0.41, 95% CI 0.21-0.78).

CONCLUSION

In our clinical registry, early PCI in female patients with NSTEMI was not associated with lower hospital mortality. Further randomized-controlled trials are needed to better understand which women may benefit from early invasive therapy, and under which conditions such benefits are possible.

Sex bias in cardiovascular testing: the contribution of patient preference

STUDY OBJECTIVE

Women with potential acute coronary syndromes are less likely to receive cardiac catheterization or revascularization than men. We hypothesize that this may be due to different diagnostic test preferences of female and male patients.

METHODS

We conducted a cohort study at 4 emergency departments enrolling patients who presented with symptoms of potential acute coronary syndromes. After hearing the potential benefits and harms of each test, subjects completed a 21-item survey assessing their preference for noninvasive testing versus cardiac catheterization. Based on hypothetical test results, similar questions about medical versus interventional management were asked. Subjects were also queried about likelihood of following physician recommendation for each test or intervention. Actual 30-day testing and interventions were recorded. The main outcome was patient preference about each procedure and the likelihood of patient saying they would accept the physician recommendation.

RESULTS

One thousand eighty patients enrolled; 652 (60%) were admitted to the hospital. With regard to diagnostic test preference, both women and men preferred stress test to catheterization (women 58% versus men 52%; difference 6% [95% confidence interval {CI} -0.06% to 12%]), and the proportion of women and men who would accept the physician recommendation for stress tests was similar (85% for both); however, the stated acceptance rate for cardiac catheterization was lower for women (65% versus 75%; difference -10% [95% CI -15% to -4%]). Women were 6% less likely (67% versus 73%; 95% CI for difference 12% to 0.5%) to accept percutaneous coronary intervention over medical therapy and 7% less likely (61% versus 68%; 95% CI for difference -13% to 1%) to desire coronary artery bypass grafting over medical therapy. The survey results are consistent with the patients' clinical course. During the initial hospitalization, women were less likely to receive diagnostic testing of any type (38% versus 45%; difference -7%; 95% CI for the difference -13% to -1.5%) and cardiac catheterization (10% versus 17%; difference -7% [95% CI -11% to -2%]). Revascularization was infrequent in both groups (4% versus 6%; difference -2% [95% CI -5% to 0.6%]).

CONCLUSION

Although women and men had similar preferences about cardiac diagnostic tests and treatment options, women were less likely than men to say they would accept the physician recommendation for any intervention. Patient preference may partially explain the disparity in cardiovascular testing between women and men.

The Impact of Gender on the Outcomes of Invasive versus Conservative Management of Patients with Non-ST-Segment Elevation Myocardial Infarction

Introduction: Studies have suggested that women who present with non-ST-segment elevation myocardial infarction (NSTEMI) may differ in their clinical response to early invasive strategy compared to male patients. We examined the impact of gender difference in NSTEMI patients on outcomes following invasive versus conservative treatment. Materials and Methods: Patients enrolled in our national myocardial infarction (MI) registry between January 2000 and September 2005 with diagnosis of NSTEMI were retrospectively analysed. The study endpoint was the occurrence of major adverse cardiac events (MACE) in the patients at 1 year. Results: A total of 1353 patients (62.2% male) with NSTEMI were studied. The mean age of men was 62 ± 14 versus 72 ± 12 years in women in the cohort (P <0.001). The prevalence of hypertension and diabetes mellitus were significantly higher in women. Men were more likely to undergo revascularisation than women (OR, 2.97; 95% CI, 2.18-3.89, P <0.001). Among those who were revascularised, there was no gender difference in survival or recurrent MI rates during hospitalisation and at 1 year. Compared to medical therapy, percutaneous coronary intervention (PCI) was associated with a significant reduction in MACE in both women (OR, 0.44; 95% CI, 0.20-0.95) and men (OR, 0.40; 95% CI, 4.79-12.75). The most important predictor of MACE for females was diabetes mellitus (HR, 1.98; 95% CI, 1.17-3.33). Conclusions: There is a gender-based difference in the rate of revascularisation among patients with NSTEMI. Women benefit from an invasive approach as much as men, despite their advanced age, with similar rates of mortality and recurrent MI at 1-year follow-up. Key words: Acute coronary syndrome, Major adverse cardiac events, Management strategies, Women

Cardiac diastolic dysfunction and metabolic syndrome in young women after placental syndrome

OBJECTIVE

To estimate whether women with a recent history of a placental syndrome and concomitant metabolic syndrome have reduced cardiac diastolic function.

METHODS

In this cohort study, women with a history of a placental syndrome were included. We assessed body mass index, blood pressure, fasting serum lipids, glucose and insulin levels, and 24-hour urinary protein and albumin output after an interval of at least 6 months postpartum. Cardiac diastolic function was assessed by echocardiography.

RESULTS

Metabolic syndrome was found in 22% of the women evaluated. Diastolic dysfunction was seen in 24% of the women with the metabolic syndrome compared with 6.3% in those without (odds ratio 4.77, 95% confidence interval 2.18-10.41; adjusted odds ratio 6.09, 95% confidence interval 2.64-14.04). Univariable analysis showed that all the constituents of the metabolic syndrome related to diastolic dysfunction.

CONCLUSION

In women with a history of placental syndrome complicating pregnancy, the presence of metabolic syndrome increases the risk of cardiac diastolic dysfunction fourfold.

LEVEL OF EVIDENCE

II.

A method for improving arrival-to-electrocardiogram time in emergency department chest pain patients and the effect on door-to-balloon time for ST-segment elevation myocardial infarction

OBJECTIVES

The objectives were to determine if an emergency department (ED) could improve the adherence to a door-to-electrocardiogram (ECG) time goal of 10 minutes or less for patients who presented to an ED with chest pain and the effect of this adherence on door-to-balloon (DTB) time for ST-segment elevation myocardial infarction (STEMI) cardiac catheterization (cath) alert patients.

METHODS

This was a planned 1-month before-and-after interventional study design for implementing a new process for obtaining ECGs in patients presenting to the study ED with chest pain. Prior to the change, patients were registered and triaged before an ECG was obtained. The new procedure required registration clerks to identify those with chest pain and directly overhead page or call a designated ECG technician. This technician had other ED duties, but prioritized performing ECGs and delivering them to attending physicians. A full registration process occurred after the clinical staff performed their initial assessment. The primary outcome was the total percentage of patients with chest pain who received an ECG within 10 minutes of ED arrival. The secondary outcome was DTB time for patients with STEMI who were emergently cath alerted. Data were analyzed using mean differences, 95% confidence intervals (CIs), and relative risk (RR) regression to adjust for possible confounders.

RESULTS

A total of 719 patients were studied: 313 before and 405 after the intervention. The mean (+/-standard deviation [SD]) age was 50 (+/-16) years, 54% were women, 57% were African American, and 36% were white. Patients walked in 89% of the time; 11% arrived by ambulance. Thirty-nine percent were triaged as emergent and 61% as nonemergent. Patients presented during daytime 68% of the time, and 32% presented during the night. Before the intervention, 16% received an ECG at 10 minutes or less. After the intervention, 64% met the time requirement, for a mean difference of 47.3% (95% CI = 40.8% to 53.3%, p < 0.0001). Results were not affected by age, sex, race, mode of arrival, triage classification, or time of arrival. For patients with STEMI cath alerts, four were seen before and seven after the intervention. No patients before the intervention had ECG time within 10 minutes, and one of four had DTB time of <90 minutes. After the intervention, all seven patients had ECG time within 10 minutes; the three arriving during weekday hours when the cath team was on site had DTB times of <90 minutes, but the four arriving at night and on weekends when the cath team was off site had DTB times of >90 minutes.

CONCLUSIONS

The overall percentage of patients with a door-to-ECG time within 10 minutes improved without increasing staffing. An ECG was performed within 10 minutes of arrival for all patients who were STEMI cath alerted, but DTB time under 90 minutes was achieved only when the cath team was on site.

Interventions for cardiovascular disease in women

Cardiovascular disease represents the main health problem for women as it is the leading cause of death and morbidity. In recent years, technological advances and experience gained by surgeons and cardiologists has resulted in a significant improvement of percutaneous coronary procedures, which has been demonstrated to be safe and effective for both men and women. However, gender disparities in the management of coronary artery disease, specifically in the rate of use of these interventional procedures, as well as in the incidence of cardiovascular events have been reported. Treatment inequalities may also impact on outcomes. Possible reasons for treatment bias include a patient's preferences, a physician's decisions, biological and pathophysiological gender differences and inadequate evidence-based medicine among women.

Cardiovascular disease in older women: a challenge in diagnosis and treatment

Cardiovascular disease is the leading cause of death in women and more heart disease is present in elderly women than men. Risk factors for heart disease affect men and women differently, with a greater impact of diabetes, hyperlipidemia and smoking in women. Diagnosis of heart disease can be more challenging in women, especially when elderly, as symptoms may be vague. Understanding the appropriate use of diagnostic testing and appropriate treatment is essential, given the high burden of disease in elderly women. This article will discuss the current guidelines for diagnosis and therapy of heart disease in women and will discuss the appropriate role of prevention strategies.

Gender differences in patient perceptions of involvement in myocardial infarction care

BACKGROUND

Gender differences in the clinical presentation, treatment and outcomes of myocardial infarction (MI) have been demonstrated. However, few studies have examined gender differences in patients' perceptions of involvement in MI care, and whether differing levels of involvement might be associated with gender differences in treatment and outcome.

AIM

To examine possible gender differences in MI patients' perceptions of their involvement during hospitalization.

METHODS

Questionnaire study conducted in 2005-2006 among MI patients under the age of 75 at eleven hospitals. Patient ratings of their involvement during hospitalization were analyzed for age-stratified gender differences.

RESULTS

Younger (<70 years of age) female MI patients placed significantly more value on shared decision-making than younger (<70) men. More than one third of patients would have liked to be more involved in their care during hospitalization and discharge planning, with women significantly more dissatisfied than men. Significantly fewer younger female patients discussed secondary preventive lifestyle changes with cardiology staff prior to hospital discharge.

CONCLUSION

Significant age-specific gender differences exist in MI patient ratings of, and satisfaction with, involvement during hospitalization. Further study is needed regarding the possible role of involvement in the recognized gender differences in the treatment and outcomes of MI.

Sex differences in medical care and early death after acute myocardial infarction

BACKGROUND

Women receive less evidence-based medical care than men and have higher rates of death after acute myocardial infarction (AMI). It is unclear whether efforts undertaken to improve AMI care have mitigated these sex disparities in the current era.

METHODS AND RESULTS

Using the Get With the Guidelines-Coronary Artery Disease database, we examined sex differences in care processes and in-hospital death among 78 254 patients with AMI in 420 US hospitals from 2001 to 2006. Women were older, had more comorbidities, less often presented with ST-elevation myocardial infarction (STEMI), and had higher unadjusted in-hospital death (8.2% versus 5.7%; P<0.0001) than men. After multivariable adjustment, sex differences in in-hospital mortality rates were no longer observed in the overall AMI cohort (adjusted odds ratio [OR]=1.04; 95% CI, 0.99 to 1.10) but persisted among STEMI patients (10.2% versus 5.5%; P<0.0001; adjusted OR=1.12; 95% CI, 1.02 to 1.23). Compared with men, women were less likely to receive early aspirin treatment (adjusted OR=0.86; 95% CI, 0.81 to 0.90), early beta-blocker treatment (adjusted OR=0.90; 95% CI, 0.86 to 0.93), reperfusion therapy (adjusted OR=0.75; 95% CI, 0.70 to 0.80), or timely reperfusion (door-to-needle time </=30 minutes: adjusted OR=0.78; 95% CI, 0.65 to 0.92; door-to-balloon time </=90 minutes: adjusted OR=0.87; 95% CI, 0.79 to 0.95). Women also experienced lower use of cardiac catheterization and revascularization procedures after AMI.

CONCLUSIONS

Overall, no sex differences in in-hospital mortality rates after AMI were observed after multivariable adjustment. However, women with STEMI had higher adjusted mortality rates than men. The underuse of evidence-based treatments and delayed reperfusion among women represent potential opportunities for reducing sex disparities in care and outcome after AMI.

Reduction in sex-based mortality difference with implementation of new cardiology guidelines

BACKGROUND

Mortality from acute coronary syndrome has historically been higher in women as compared with men. We hypothesized that adoption of a more sensitive definition for the diagnosis of acute myocardial infarction and managing patients according to the 2000 European Society of Cardiology and American College of Cardiology guidelines would reduce this difference.

METHODS

A retrospective cohort study was conducted of all acute coronary syndrome admissions to 7 regional tertiary hospitals in Israel during 1999-2004. The primary end point was all-cause 1-year mortality. Differences in risk between men and women were assessed using Cox proportional hazards regression.

RESULTS

The number of patients admitted with acute coronary syndrome was 20,206 and 15,583 before and after adoption of the guidelines, respectively. An invasive strategy during the index hospitalization was more frequent in men in both the pre- (47.6% vs 33.6, P <.001) and post- (55.7% vs 40.9%, P <.001) transition periods. Secondary prevention was intensified in the post-transition period in both sexes. Multivariate analysis adjusting for differences in baseline clinical characteristics between men and women and invasive strategy demonstrated that female sex was associated with increased 1-year mortality during the pretransition period (hazard ratio 1.34, 95% confidence interval, 1.24-1.45), but was not a significant factor in the post-transition period (hazard ratio 1.04, 95% confidence interval, 0.94-1.14).

CONCLUSIONS

The transition to the 2000 European Society of Cardiology and American College of Cardiology guidelines was associated with a reduction in the sex-based mortality difference in patients with acute coronary syndrome despite the fact that an early invasive strategy and secondary prevention continued to be underutilized in female patients in both periods.

Women tolerate drug therapy for coronary artery disease as well as men do, but are treated less frequently with aspirin, beta-blockers, or statins

BACKGROUND

Women have worse morbidity, mortality, and health-related quality-of-life outcomes associated with coronary artery disease (CAD) compared with men. This may be related to underutilization of drug therapies, such as aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or statins. No studies have sought to describe the relationship of gender with adverse reactions to drug therapy (ADRs) for CAD in clinical practice.

OBJECTIVE

The aim of this study was to determine the prevalence of ADRs associated with common CAD drug therapies in women and men in clinical practice.

METHODS

In a cohort of consecutive outpatients with CAD, detailed chart abstraction was performed to determine the use of aspirin, beta-blocker, ACE inhibitor, and statin therapy, as well as the ADRs reported for these treatments. Baseline clinical characteristics were also determined to identify the independent association of gender with use of standard drug treatments for CAD.

RESULTS

Consecutive patients with CAD (153 men, 151 women) were included in the study. Women and men were observed to have a similar prevalence of cardiac risk factors and comorbidities, except that men had significantly higher prevalence of atrial fibrillation (30 [19.6%] men vs 15 [9.9%] women; P = 0.03) and significantly lower mean (SD) high-density lipoprotein cholesterol concentrations (45 [16] mg/dL for men vs 55 [19] mg/dL for women; P < 0.001). No significant differences were observed between the sexes in the prevalence of ADRs; however, significantly fewer women than men were treated with statins (118 [78.1%] vs 139 [90.8%], respectively; P = 0.003). After adjusting for clinical characteristics, women were also found to be less likely than men to receive aspirin (odds ratio [OR] = 0.164; 95% CI, 0.083-0.322; P = 0.001) and beta-blockers (OR = 0.184; 95% CI, 0.096-0.351; P = 0.001).

CONCLUSIONS

Women and men experienced a similar prevalence of ADRs in the treatment of CAD; however, women were significantly less likely to be treated with aspirin, beta-blockers, and statins than were their male counterparts. To optimize care for women with CAD, further study is needed to identify the cause of this gender disparity in therapeutic drug use.

Response to Signs and Symptoms of Acute Coronary Syndrome: Differences Between Lebanese Men and Women

Background Signs and symptoms of acute coronary syndromes differ between men and women, but whether men and women respond differently to these indications is not well understood. Such responses influence health outcomes because success of treatment depends on how quickly healthcare is sought.

Objective To explore differences between Lebanese men and women in cognitive, emotional, and behavioral responses to signs and symptoms of acute coronary syndromes.

Methods A convenience sample of 149 men and 63 women with unstable angina or acute myocardial infarction were interviewed within 72 hours of admission to coronary care in a tertiary center by using the Response to Symptoms Questionnaire. Demographic and clinical data were obtained from medical records.

Results Women were older, less educated, and more often widowed than men. More women had hypertension but more men were current smokers. Women had shoulder pain, dyspnea, nausea and vomiting, and palpitations more often than men did. Women’s signs and symptoms were rated more severe by the women than men’s were by the men. Women were less likely to know signs and symptoms of myocardial infarction than were men and delayed coming to the hospital longer than men did. Delay correlated with the characteristics of the signs and symptoms and not realizing their importance in men and with dyspnea and taking the “wait and see” approach in women.

Conclusion Factors related to promptness in seeking care for acute coronary syndromes differ between Lebanese men and women.

Sex and racial differences in outcomes and guideline-based management of troponin-only-positive acute myocardial infarction in older persons

Multiple studies have shown sex and racial differences in the management and outcomes of ischemic heart disease, but whether these sex and racial disparities persist in patients with troponin-only-positive acute myocardial infarction (AMI) is unknown. The authors evaluated a nationwide sample of eligible Medicare beneficiaries, 65 years or older, who were hospitalized (N=71,120) with a primary discharge diagnosis of AMI. Analysis was restricted to patients with troponin-only-positive AMI (n=5897) and was substratified into 4 groups: white men, white women, nonwhite men, and nonwhite women. The authors found that the traditional sex and racial disparities in the evidence-based medication prescriptions for ischemic heart diseases resolved in this cohort of older patients. Similarly, in settings of equal care, sex and race seem to have no impact on the outcomes for older patients with troponin-only-positive AM.