Does hormonal status influence the clinical presentation of acute coronary syndromes in women?

Fatigue and acute coronary syndrome: a systematic review of contributing factors

Fatigue is a symptom of ACS, but it remains unclear who is at risk and what factors contribute to fatigue. The purpose of the systematic review was to identify factors that influence fatigue in patients with ACS. The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature published from 1981 to 2017 was reviewed, and of 983 articles screened, 36 met inclusion criteria. Variables contributing to fatigue fell into 3 categories: demographic characteristics, clinical characteristics, and other factors. More fatigue was found in women than men, and significant differences in fatigue were identified by race. Additionally, sleep deprivation, depression, and anxiety were associated with higher levels of fatigue. The findings highlight the importance of demographic, clinical, and other factors' impact on fatigue in ACS patients. Fatigue is an important symptom in ACS and healthcare providers must recognize how patient variables affect symptom expression.

Gender, race and the presentation of acute coronary syndrome and serious cardiopulmonary diagnoses in ED patients with chest pain

OBJECTIVE

To assess the relationship between reported chest pain symptoms and a diagnosis of acute coronary syndrome (ACS) and serious cardiopulmonary diagnoses (SCPD) in black males, white males, black females and white females.

METHODS

This was a secondary analysis of a prospective cohort study of 4162 ED patients with chest pain enrolled between 1999 and 2008. We used logistic regression, adjusting for age and cardiovascular comorbidities to test the association between 24 chest pain symptoms and 30-day ACS for the primary outcome and SCPD as the secondary outcome.

RESULT

In black males, diaphoresis was associated with ACS (OR 1.47; 95% CI 1.02 to 2.13), while in white males, left arm radiation, pressure/tightness and substernal pain were associated with ACS (OR 1.73, 95% CI 1.16 to 2.59; OR 1.65, 95% CI 1.16 to 2.59; OR 1.51, 95% CI 1.07 to 2.11, respectively). In black females, diaphoresis, palpitations and left arm radiation were associated with ACS (OR 1.66, 95% CI 1.17 to 2.35; 1.66, 95% CI 1.13 to 2.45; 1.44, 95% CI 1.02 to 2.03, respectively) while pleuritic pain, and left anterior chest pain lowered ACS risk (OR 0.69, 95% CI 0.5 to 0.96; 0.54, 95% CI 0.35 to 0.84). No symptoms predicted ACS or SCPD in white females. Fewer but similar symptoms predicted SCPD in white males and black females. No symptoms predicted SCPD in black males.

CONCLUSION

Chest pain symptoms are important predictors of ACS and SCPD in certain combinations of race and gender but less so in others. These differences might explain difficulties using symptoms to identify patients at higher or lower risk of ACS and SCPD in practice.

Spinal cord processing of cardiac nociception: are there sex differences between male and proestrous female rats?

Sex differences in the characteristics of cardiac pain have been reported from clinical studies. For example, women experience chest pain less frequently than men. Women describe their chest pain as sharp and stabbing, while men have chest pain that is felt as a pressure or heaviness. Pain is also referred to the back more often in women than men. The mechanisms underlying sex differences in cardiac pain are unknown. One possible mechanism for the observed differences could be related to plasma estradiol. This study investigated the actions of estradiol on the activity of T(3) spinal neurons that process cardiosomatic information in male and female rats. Extracellular potentials of T(3) spinal neurons were recorded in response to mechanical somatic stimulation and noxious chemical cardiac stimulation in pentobarbital-anesthetized male and proestrous female rats. Fifty one percent and fifty percent of neurons responded to intrapericardial algogenic chemicals (0.2 ml) in male and female rats, respectively. Somatic fields were located by applying brush, pressure, and pinch to the upper body. Of those neurons receiving cardiac input, 54% in female and 55% in male rats also received somatic input. In both male and female rats, 81% of neurons responding to somatic stimuli had somatic fields located on the side of the upper body, while 19% of neurons had somatic fields located on the chest. These results indicate there are no significant differences in the responses of T(3) spinal neurons to cardiosomatic stimulation between male and proestrous female rats, despite differences in estradiol levels.

Interleukin-8 gene polymorphism is associated with acute coronary syndrome in the Chinese Han population

BACKGROUND

Acute coronary syndrome (ACS) is one of the most common forms of heart disease. Recent studies have shown that interleukin (IL)-8 plays a key role in the development of atherosclerotic plaques, but the relationship between the common genetic variants of IL-8 and ACS has not been extensively studied.

METHODS

This case-control study in the Chinese Han population included 675 patients with ACS and 636 age- and sex-matched controls. We investigated IL-8 polymorphisms and their association with susceptibility to ACS. The investigation was replicated in the second study comprising 360 cases and 360 control subjects. The plasma concentration of IL-8 was measured by enzyme-linked immunosorbent assay.

RESULTS

IL-8 -251 A/T polymorphism was associated with increased susceptibility to ACS (P=0.004; odds ratio=1.30; 95% confidence interval: 1.12-1.53). The second study yielded similar results. An increased IL-8 level was found in the plasma of acute myocardial infarction patients, suggesting that IL-8 -251 A/T may affect the expression of IL-8.

CONCLUSION

IL-8 -251 A/T polymorphism is associated with ACS risk in the Chinese Han population and the A allele of IL-8 -251 A/T may be an independent predictive factor for ACS.

Gender differences on chest pain perception associated with acute myocardial infarction in Chinese patients: a questionnaire survey

AIMS

To investigate gender differences in chest pain perception among Chinese patients with acute myocardial infarction.

BACKGROUND

Thrombolytic therapy is beneficial to outcomes of acute myocardial infarction if administered within 12 hours from the onset of chest pain. However, cardiac symptom interpretation may impact time of presentation to hospital. Differences in cardiac symptom reports by gender partly explain misdiagnoses and delays in treatment, particularly among women. Whether, such trends apply to Chinese patients with myocardial infarction is unknown.

DESIGN

A descriptive prospective study.

METHODS

Using questionnaires, data on demographic variables, the number of patients reporting chest pain and other chest sensations at the onset of acute myocardial infarction and chest pain intensity, description, location and radiation across the chest were collected.

RESULTS

A total of 128 participants equally divided by gender were recruited. Chest pain was more prevalent among men than women (84.37% vs. 67.19%, p < 0.05). Although no statistical significance was found, Chinese men had higher mean chest pain intensity scores (7.54 SD 2.35 vs. 7.51 SD 2.25) and reported less atypical chest pain (0.00% vs. 9.3%) compared with women. Men had more upper right sided chest pain (40.74% vs. 20.93%, p = 0.038) whereas women experienced increased neck pain and pain to the upper central chest, middle central chest, upper central back, middle central back and middle right back regions.

CONCLUSIONS

Discreet gender differences in chest pain perceptions exist between Chinese men and women, with the latter group, who may be considered as a high-risk group for missed and delayed diagnosis from myocardial infarction, reporting more atypical presentations.

RELEVANCE TO CLINICAL PRACTICE

Irrespective of culture, women with myocardial infarction tend to present with atypical chest pain symptoms and therefore they should be aggressively investigated.

Cardiovascular risk in women with non-specific chest pain (from the Women's Health Initiative Hormone Trials)

Women discharged with diagnoses of nonspecific chest pain (NSCP) may be at increased risk for subsequent coronary artery disease (CAD) events. The influence of hormone therapy on NSCP is unknown. The Women's Health Initiative (WHI) enrolled postmenopausal women aged 50 to 79 years. The duration of follow-up was 7.1 years in the WHI Estrogen-Alone trial (E-Alone) and 5.6 years in the WHI Estrogen Plus Progestin trial (E+P). After excluding women with previous cardiovascular disease, 9,427 women in E-Alone and 15,105 women in E+P were included in this analysis. NSCP, defined as having a primary hospital discharge diagnosis of NSCP by International Classification of Diseases, Ninth Revision, code, was reported in 322 women in E-Alone and 249 in E+P. Risks for subsequent CAD events were estimated using intent-to-treat Cox proportional-hazards models stratified by clinic and adjusted for age and other risk factors. In the fully adjusted models of the combined trials, women with NSCP had a twofold greater risk for subsequent nonfatal CAD events, including nonfatal myocardial infarction (2.3% vs 1.7%, hazard ratio [HR] 2.10, 95% confidence interval [CI] 1.11 to 3.98), revascularization (3.5% vs 2.6%, HR 1.99, 95% CI 1.20 to 3.30), and hospitalized angina (3.7% vs 2.3%, HR 2.39, 95% CI 1.46 to 3.92). Hormone therapy did not appear to have a significant effect on either the incidence of NSCP hospitalizations (E-Alone: HR 1.04, 95% CI 0.81 to 1.32; E+P: HR 0.78, 95% CI 0.59 to 1.02) or the risk for a subsequent CAD event. In conclusion, a hospitalization for NSCP doubles the risk for a subsequent CAD event in postmenopausal women over the next 5 to 7 years and identifies them as candidates for aggressive risk factor treatment.

Sex differences in prodromal symptoms of patients with acute coronary syndrome: a pilot study

Increasing evidence suggests that there are sex/gender differences in the presentation and prodromal symptoms of acute coronary syndrome (ACS). The purpose of this pilot study was to identify sex differences in the prodromal symptoms of ACS using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS). Telephone surveys using the MAPMISS were conducted between 4 and 6 months after the ACS event. Seventy-six patients (24 women) participated in the study. The women generally reported higher prodromal scores. Moreover, scores demonstrated differences in prodromal symptoms based on menopausal status. The premenopausal and perimenopausal women reported a greater number and higher frequency of symptoms compared with the men and menopausal women. The results of this study suggest that both men and women report nontraditional prodromal symptoms of ACS. In addition, there appears to be a difference in the frequency and number of symptoms reported based on menopausal status.

A comprehensive view of sex-specific issues related to cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of mortality in women. In fact, CVD is responsible for a third of all deaths of women worldwide and half of all deaths of women over 50 years of age in developing countries. The prevalence of CVD risk factor precursors is increasing in children. Retrospective analyses suggest that there are some clinically relevant differences between women and men in terms of prevalence, presentation, management and outcomes of the disease, but little is known about why CVD affects women and men differently. For instance, women with diabetes have a significantly higher CVD mortality rate than men with diabetes. Similarly, women with atrial fibrillation are at greater risk of stroke than men with atrial fibrillation. Historically, women have been underrepresented in clinical trials. The lack of good trial evidence concerning sex-specific outcomes has led to assumptions about CVD treatment in women, which in turn may have resulted in inadequate diagnoses and suboptimal management, greatly affecting outcomes. This knowledge gap may also explain why cardiovascular health in women is not improving as fast as that of men. Over the last decades, mortality rates in men have steadily declined, while those in women remained stable. It is also becoming increasingly evident that gender differences in cultural, behavioural, psychosocial and socioeconomic status are responsible, to various degrees, for the observed differences between women and men. However, the interaction between sex-and gender-related factors and CVD outcomes in women remains largely unknown.

The ACE-DD genotype is associated with endothelial dysfunction in postmenopausal women

OBJECTIVE

To evaluate the effects of the angiotensin-converting enzyme (ACE) insertion/deletion (I/D), the angiotensinogen M235T and the angiotensin II type 1 receptor A1166C polymorphisms, and hormone therapy used on endothelial function in postmenopausal women without manifestation of coronary artery disease.

DESIGN

Sixty-four postmenopausal women (42 hormone therapy users and 22 hormone therapy nonusers) without clinical manifestation of coronary artery disease were evaluated using external vascular ultrasonography to measure endothelium-dependent (hyperemic response, flow-mediated dilatation) and -independent (nitroglycerin) dilatation. Genotypes were determined by polymerase chain reaction amplification.

RESULTS

Women with the ACE-DD genotype displayed a lower flow-mediated dilatation compared to those with the ACE-II genotype (8.4% +/- 3.9% vs 12.6% +/- 5.4%, P = 0.04). Endothelial function was not associated with the angiotensinogen M235T and anglotensin II type 1 receptor A1166C polymorphisms. ACE polymorphism seems to modulate endothelial function among postmenopausal women without hormone therapy (8.2% +/- 5.1% vs 18.4% +/- 5.9% for the DD and the II genotype, respectively, P = 0.02). However, in hormone therapy users, flow-mediated dilatation was similar according to the ACE genotypes.

CONCLUSIONS

Our findings suggest that ACE-I/D polymorphism is related to endothelial dysfunction in postmenopausal women. Furthermore, a potential interaction between estrogen users and ACE polymorphism on endothelial function may be present.

ACE-DD genotype is associated with the occurrence of acute coronary syndrome in postmenopausal women

The insertion/deletion (I/D) polymorphism of the angiotensin converting enzyme (ACE), the A1166C polymorphism in the angiotensin type 1 receptor (AT1R), and the M235T polymorphism of the angiotensinogen gene are associated with cardiovascular disease mostly in men. Few data are available on the effects of these genetic variations in postmenopausal women according to hormone replacement therapy (HRT) use. In this case-control study, we determine the frequency of mutant alleles in the ACE I/D, M235T and A1166C polymorphisms in postmenopausal Caucasian women with and without a diagnosis of acute coronary syndrome (ACS). Data from 198 women with ACS (63+/-10 years) and 149 controls (62+/-7 years) showed that ACE-DD genotype was more prevalent in women with ACS compared to controls (30% vs. 19%, P<0.05). There was no difference in genotype distributions for either the M235T or the A1166C polymorphisms between groups. The difference in ACE genotype distribution between ACS women and controls was driven by current HRT users with 30% of ACS and 15% of controls carrying the ACE-DD genotype (P<0.05). The oligenic combination of ACE-DD and M235T-TT genotypes was higher in ACS compared to controls. Among carriers of M235T-TT, 7% of ACS and 1% of controls also had the ACE-DD genotype, P<0.05. Thus, the ACE-DD genotype may be associated with ACS in postmenopausal women, particularly in HRT users.