Gender based differences in patients with acute coronary syndrome: findings from Chinese Registry of Acute Coronary Events (CRACE):

Gender differences in presentation, management, and outcomes among Egyptian patients with acute coronary syndrome: a single-centre registry

BACKGROUND

Despite a significant rise in cardiovascular disease (CVD)-related mortality in low- and middle-income countries (LMICs), data are scarce regarding the quality of care provided, particularly for women.

METHODS

This is a prospective observational, cross-sectional study. Acute coronary syndrome (ACS) patients presented to the Cardiology Department at Tanta University, Egypt, between September 1, 2023, and December 31, 2023, were enrolled. The study assessed gender disparities by comparing men and women regarding presentation, management, and major adverse cardiovascular events (MACE) occurrence during hospitalization and 30 days after discharge.

RESULTS

A total of 400 ACS patients were included, with 29.5% being women. Women were comparatively older (59 ± 9 years vs. 55 ± 13 years), with a significantly higher prevalence of hypertension (70.3% vs. 47.5%) and diabetes (55% vs. 36.8%). Non-ST-segment elevation myocardial infarction (Non-STEMI) was more common in women (35.29% vs. 21%). Dyspnea was expressed by 34.4% of women (vs. 21.35% of men). Women were hospitalized later (9.29 h vs. 6.74 h). In-hospital outcomes were poorer for women with worse NYHA classes III and IV. Additionally, the odds ratio (OR) for in-hospital cardiac mortality was 0.303 (95% CI 0.103-0.893) for women compared to men. However, a one-month follow-up for MACE post-hospital discharge did not indicate significant gender differences.

CONCLUSIONS

The current study suggests that women with ACS in Egypt exhibit a higher risk profile for CVD compared to men and tend to present later with atypical symptoms. Women additionally experience poorer in-hospital MACE and higher cardiac mortality. Therefore, increasing awareness about ACS syndrome and eliminating obstacles that delay hospital admission are imperative.

Combined effect of inflammation and malnutrition for long-term prognosis in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a cohort study

BACKGROUND

Inflammation is a key driver of atherosclerotic diseases and is often accompanied by disease-related malnutrition. However, the long-term burden of dysregulated inflammation with superimposed undernutrition in patients with acute coronary syndrome (ACS) remains unclear. This study sought to investigate the double burden and interplay of inflammation and malnutrition in patients with ACS undergoing percutaneous Coronary Intervention (PCI).

METHODS

We retrospectively included 1,743 ACS patients undergoing PCI from June 2016 through November 2017 and grouped them according to their baseline nutritional and inflammatory status. Malnutrition was determined using the nutritional risk index (NRI) with a score lower than 100 and a high-inflamed condition defined as hs-CRP over 2 mg/L. The primary outcome was major adverse cardiovascular events (MACEs), compositing of cardiac mortality, non-fatal myocardial infarction, non-fatal stroke, and unplanned revascularization. Long-term outcomes were examined using the Kaplan-Meier method and compared with the log-rank test. Multivariable Cox proportional hazards regression analysis was applied to adjust for confounding. The reclassification index (NRI)/integrated discrimination index (IDI) statistics estimated the incremental prognostic impact of NRI and hs-CRP in addition to the Global Registry of Acute Coronary Events (GRACE) risk score.

RESULTS

During a median follow-up of 30 months (ranges 30-36 months), 351 (20.1%) MACEs occurred. Compared with the nourished and uninflamed group, the malnourished and high-inflamed group displayed a significantly increased risk of MACEs with an adjusted hazard ratio of 2.446 (95% CI: 1.464-4.089; P < 0.001). The prognostic implications of NRI were influenced by patients' baseline inflammatory status, as it was only associated with MACEs among those high-inflamed (P for interaction = 0.005). Incorporating NRI and hs-CRP into the GRACE risk score significantly improved its predictive ability for MACEs (NRI: 0.210, P < 0.001; integrated discrimination index; IDI: 0.010, P < 0.001) and cardiac death (NRI: 0.666, P < 0.001; IDI: 0.023, P = 0.002).

CONCLUSIONS

Among patients with ACS undergoing PCI, the double burden of inflammation and malnutrition signifies poorer outcomes. Their prognostic implications may be amplified by each other and jointly improve the GRACE risk score's risk prediction performance.

Sex, Racial, and Ethnic Disparities in Acute Coronary Syndrome: Novel Risk Factors and Recommendations for Earlier Diagnosis to Improve Outcomes

In this review, sex, racial, and ethnic differences in acute coronary syndromes on a global scale are summarized. The relationship between disparities in presentation and management of acute coronary syndromes and effect on worse clinical outcomes in acute coronary syndromes are discussed. The effect of demographic, geographic, racial, and ethnic factors on acute coronary syndrome care disparities are reviewed. Differences in risk factors including systemic inflammatory disorders and pregnancy-related factors and the pathophysiology underlying them are discussed. Finally, breast arterial calcification and coronary calcium scoring are discussed as methods to detect subclinical atherosclerosis and start early treatment in an attempt to prevent clinical disease.

Gender-based differences in primary percutaneous coronary intervention in patients with myocardial infarction from a developing country: A retrospective cohort study

Introduction

Limited data exists about gender's impact on differences in risk factors and outcomes in our setting. Therefore, we sought to ascertain sex-related differences in patients with AMI in our setting.

Material and methods

This retrospective study analyzed data from 247 myocardial infarction patients hospitalized in a tertiary care hospital, between March and October 2020. After hospital admission, all patients underwent ECG, myocardial enzymes, troponin and other biochemical tests followed by primary PCI.

Results

Patients were divided in two groups male (n = 153, mean age 55.2 ± 11.0 years) and female (n = 94, mean age 58.4 ± 12.7 years). The prevalence of smoking was higher in males than females (22.8% vs. 3.1%, p < 0.01) and so was history of three-vessel disease (3VD; 18.9% vs. 7.4%, p = 0.013). History of myocardial infarction was lower in females than males (13.8% vs. 24.8%, p = 0.03) however the age did not vary significantly between the two groups (p = 0.21). Serum creatinine (sCr) levels (1.0 ± 0.77 μmol/L vs. 1.2 ± 0.73 μmol/L, p = 0.28) and body mass index (28.4 ± 5.3 vs 27.4 ± 4.8, p = 0.45) were lower in females as compared to males, however not statistically significant. The incidence of major adverse events, severe arrhythmia and in-hospital outcomes showed no significant difference (p > 0.05) between the two groups. Post-op TIMI score and average length of hospital stay were not statistically different either (3.29 ± 2.9 vs. 2.6 ± 1.7, p = 0.726).

Conclusion

Our study shows that females have a comparable age of onset of major cardiovascular events as that of males. Post-PCI clinical outcomes and in-hospital stay had no significant differences between the two groups.

What is already known on this topic:•

Limited data exists about gender's impact on differences in risk factors and outcomes STEMI in developing countries like Pakistan.

•

Previous analyses on gender disparities have revealed higher mortality in females compared to males when hospitalized for STEMI.

What this study adds:

•

The incidence of major adverse events during in-hospital stay showed no significant difference among gender.

•

The prevalence of smoking and 3VD in males was higher than in females. Despite of differences in co-morbidities between the groups, clinical outcomes remained consistent.

Regional Differences in the Ratio of Observed and Expected In-hospital Mortality for Acute Coronary Syndrome Patients in China: The Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project Analysis

Previous studies reported regional variations in in-hospital acute coronary syndrome (ACS) mortality, but the reasons for that were not clearly defined. We explored whether differences in patient characteristics could explain regional variation. The Improving Care for Cardiovascular Disease in China (CCC)-ACS project is an ongoing national registry and quality improvement project, involving 150 tertiary hospitals from 30 provinces across China. We applied a prediction model that included patient-specific variables to calculate the expected in-hospital mortality. For each province, we reported the observed, expected in-hospital mortality and the risk-adjusted ratio which is based on the observed divided by the expected mortality. From 2014 to 2018, 79 585 ACS patients were enrolled. The average in-hospital mortality was 1.8%. There was a wide variation in the in-hospital mortality among different provinces (0.2-3.9%). Patient characteristics explained part of this variation because of differences in the expected in-hospital mortality (0.7-2.8%). There was a substantial variation in the risk-adjusted ratio among provinces (0.2-3.5), which suggests that the variations in the mortality cannot be completely explained by the differences in patient characteristics. In conclusion, we observed a wide regional variation in mortality for ACS, part of which could be explained by the difference in patient characteristics.

Sex Differences in Characteristics and Outcomes among Low-Risk Non-ST-Elevation Acute Coronary Syndrome Patients during Long Term Follow-Up

Previous heterogenous studies show conflicting data about sex-based outcomes of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients. This study evaluated 300 NSTE-ACS patients undergoing a coronary angiography between September 2012 and May 2015 that were managed with all-treatment strategies. The sample was stratified by sex and analyzed for the baseline characteristics and outcomes. The main outcome included major adverse cardiovascular and cerebrovascular events (MACCE), which were a composite of cardiac death, nonfatal myocardial infarction, ischemic stroke or urgent coronary revascularization. The female patients were older (median of 69.0 vs. 63.0 years, p = 0.008) and had lower values of BMI (median of 26.3 vs. 28.2 kg/m², p < 0.001) and eGFR (76.44 ± 22.43 vs. 94.04 ± 27.91 mL/min, p < 0.001). There was no significant difference in the treatment strategies, angiographic characteristics and discharge therapy between the groups (p > 0.05). The female patients had significantly higher unadjusted rates of ischemic stroke (4.2% vs. 0.5%, p = 0.023), cardiac mortality (11.3%, vs. 3.9%, p = 0.022) and MACCE (33.8%, vs. 19.5%, p = 0.014); female sex was a significant predictor of MACCE in the univariate analysis (HR 1.86, 95%CI 1.12–3.09, p = 0.014); and the cumulative incidence of MACCE was higher in female patients (p = 0.014). After the adjustment, the predictive effect of female sex became non-significant (HR 1.60, 95%CI 0.94–2.73, p = 0.083), while there was no difference in the cumulative incidence of MACCE among the propensity score matched cohort (p = 0.177). Female NSTE-ACS patients have worse long-term outcomes compared to their male counterparts. However, the differences disappear after adjustment and propensity score matching. Continuing efforts and health measures are required to alleviate any sex-based differences in the NSTE-ACS population.

Sex disparities in the presentation, management and outcomes of patients with acute coronary syndrome: insights from the ACS QUIK trial

Aims

Our aim was to explore sex differences and inequalities in terms of medical management and cardiovascular disease (CVD) outcomes in a low/middle-income country (LMIC), where reports are scarce.

Methods

We examined sex differences in presentation, management and clinical outcomes in 21 374 patients presenting with acute coronary syndrome (ACS) in Kerala, India enrolled in the Acute Coronary Syndrome Quality Improvement in Kerala trial. The main outcomes were the rates of in-hospital and 30-day major adverse cardiovascular events (MACEs) defined as composite of death, reinfarction, stroke and major bleeding. We fitted log Poisson multivariate random effects models to obtain the relative risks comparing women with men, and adjusted for clustering by centre and for age, CVD risk factors and cardiac presentation.

Results

A total of 5191 (24.3%) patients were women. Compared with men, women presenting with ACS were older (65±12 vs 58±12 years; p<0.001), more likely to have hypertension and diabetes. They also had longer symptom onset to hospital presentation time (median, 300 vs 238 min; p<0.001) and were less likely to receive primary percutaneous coronary intervention for ST-elevation myocardial infarction (45.9% vs 49.8% of men, p<0.001). After adjustment, women were more likely to experience in-hospital (adjusted relative risk (RR)=1.53; 95% CI 1.32 to 1.77; p<0.001) and 30-day MACE (adjusted RR=1.39; 95% CI 1.23 to 1.57, p<0.001).

Conclusion

Women presenting with ACS in Kerala, India had greater burden of CVD risk factors, including hypertension and diabetes mellitus, longer delays in presentation, and were less likely to receive guideline-directed management. Women also had worse in-hospital and 30-day outcomes. Further efforts are needed to understand and reduce cardiovascular care disparities between men and women in LMICs.

The Influence of Sex on Cardiac Physiology and Cardiovascular Diseases

Cardiovascular disease (CVD) is the leading cause of death world-wide. Most of treatment strategies were based on studies conducted on male patients. Studies have shown that significant differences exist between the two sexes in the development of CVD. There are certain differences between men and women in the structure and physiological functions of the heart such as left ventricular mass index, resting heart rate, and contractile function. Accordingly, the pathological features of the heart such as the extend of hypertrophy, fibrosis, and remodeling are also different. In addition, different genders also affect clinical symptoms, responses to treatment and prognosis in the development of CVD. Therefore, it is important to take these differences into consideration when design treatment options for men and women.

Genetic and Nongenetic Implications of Racial Variation in Response to Antiplatelet Therapy

Race has been identified as an independent risk factor for poor prognosis and an independent predictor of survival in coronary artery disease. Race-related dissimilarities have been identified in cardiovascular patients in terms of age of presentation, co-morbidities, socioeconomic status, and treatment approach as well as genetically driven race-related disparities in responsiveness to medications. Antiplatelet therapy represents a fundamental component of therapy in cardiovascular patients, especially in patients presenting with acute coronary syndromes. It has been argued that the different level of platelet reactivity and varying response to antiplatelet therapy among races may account in part for worse outcomes in certain populations. The purpose of this review is to describe genotypic and phenotypic race-related differences in platelet reactivity and responsiveness to cardiovascular treatment, focusing on antiplatelet therapy to highlight the need establish a more effective and targeted antithrombotic strategy.

Gender Variations in In-Hospital Mortality in Patients Hospitalized With Dizziness: A Retrospective Study

Women with cardiac diseases generally have a higher mortality than men. Suggested reasons include delay in reporting to hospital, less aggressive management, and higher cardiovascular risk profiles in women. We assessed gender differences in patients hospitalized with dizziness. We retrospectively reviewed the database of patients hospitalized with acute cardiac disease in Qatar from 1991 to the end of 2010. Patients hospitalized with dizziness were analyzed; 1611 (3.8%; 95% confidence interval [CI]: 3.6%-4%) of the total N = 42 144 patients were hospitalized with dizziness during the 20 years: 410 (25.5%) females and 1201 (74.5%) males. Mean age (female 55 [16] and male 53 [16] years) was comparable ( P = .06). Women had more hypertension, diabetes mellitus, palpitation, and arrhythmia compared with men. In-hospital mortality was 3.8% (women 5.6% vs men 3.2%, P = .03). After adjusting for potential confounders, female gender remained an independent factor for increased in-hospital mortality (adjusted odds ratio: 2.2, 95% CI: 1.21-4, P = .01). In this 20-year data set from a Middle Eastern country, female gender was an independent factor associated with increased in-hospital mortality in patients hospitalized with dizziness after adjusting for confounders. Further research is warranted to confirm this novel gender difference.

Treatment and outcomes of acute coronary syndromes in women: An analysis of a multicenter quality improvement Chinese study

BACKGROUND

Variations in care and outcomes by sex in patients with acute coronary syndrome (ACS) have been reported worldwide. The aims of this study are to describe ACS management according to sex in China and the effects of a quality improvement program in Chinese male and female ACS patients.

METHODS AND RESULTS

Clinical Pathways for Acute Coronary Syndromes - Phase 2 (CPACS-2) was a cluster randomized trial to test whether a clinical pathways-based intervention would improve ACS management in China. The study enrolled 15,141 hospitalized patients [4631 (30.6%) were women] from 75 hospitals throughout China between October 2007 and August 2010. The intervention included clinical pathway implementation and performance measurement using standardized indicators with 6 monthly audit-feedback cycles. Eight key performance indicators reflecting in hospital management of ACS were measured. After adjustment for differences in patient characteristics and comorbidities at presentation, women were significantly less likely to undergo coronary angiography when indicated (RR 0.88 [0.85 to 0.92], P<0.001), less likely to receive guideline recommended medical therapies at discharge (RR 0.94 [0.91 to 0.98], P=0.003) and more likely to be hospitalized for shorter (mean difference -0.42 [-0.73 to -0.12] days, P=0.007). However, in-hospital clinical outcomes did not differ by sex. There was no evidence of heterogeneity in the relative effects of the quality improvement initiative by sex.

CONCLUSIONS

Sex disparities were apparent in some key quality of care indicators for patients with suspected with ACS presenting to hospitals in China. The beneficial effect of the quality improvement program was consistent in women and men.

CLINICAL TRIAL REGISTRATION

http://www.anzctr.org.au/default.aspx. Unique identifier: ACTRN12609000491268.

Effect of multiple clinical factors on recurrent angina after percutaneous coronary intervention: A retrospective study from 398 ST-segment elevation myocardial infarction patients

Recurrent angina (RA) has an important influence on health status of patients after percutaneous coronary intervention (PCI). This study aimed to retrospectively investigate the effect of multiple clinical factors on both short-term and long-term development of RA.A total of 398 ST-segment elevation myocardial infarction (STEMI) patients were studied for up to 12 months. The primary clinical outcome, RA, was assessed at 1-month and 12-month. In multivariate analyses, the effect of clinical factors, including baseline demographics, medical history, infarction-related arteries, procedural characteristics of PCI, and the use of medicines, was investigated in patients with and without RA.The Logistic regression analysis showed that the patients with treatment through radial approach PCI (odds ratio [OR]: 0.42, 95% confidence interval [CI]: 0.18-0.96, P < 0.05) were less likely to have RA during 1-month assessment. During 12 months after PCI, male patients (OR: 0.53, 95% CI: 0.29-0.96, P < 0.05), and/or those treated with radial approach PCI (OR: 0.45, 95% CI: 0.21-0.97, P < 0.05) were less likely to have RA, whereas the patients with infarction related artery (IRA) in left anterior descending (LAD) (OR: 2.41, 95% CI: 1.20-4.84, P < 0.01) were more likely to have RA at follow-up. The Cox regression analysis further revealed that the patients with infarction of the LAD artery (hazard ratio [HR]: 2.08, 95% CI: 1.10-3.92, P < 0.05), but not with treatment through radial artery during PCI (HR: 0.42, 95% CI: 0.18-0.96, P < 0.05) had higher potential of development of RA during 12 months after PCI.We studied the effects of multiple clinical factors on the development of RA after PCI. Our findings suggest that patients with infarction of the LAD artery, and/or treatment not through radial artery during PCI were associated with higher risk of RA and may require close follow-up.

Sex Differences in Clinical Profiles and Quality of Care Among Patients With ST-Segment Elevation Myocardial Infarction From 2001 to 2011: Insights From the China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE)-Retrospective Study

BACKGROUND

China is experiencing a marked increase in ST-segment elevation myocardial infarction hospitalizations, with 30% occurring among women and higher risk of in-hospital death in relatively younger age groups (<70). Yet, little is known about sex differences in ST-segment elevation myocardial infarction presentation and management.

METHODS AND RESULTS

In a nationally representative sample of patients with ST-segment elevation myocardial infarction admitted to 162 Chinese hospitals in 2001, 2006, and 2011, we examined sex differences in hospitalization rates, clinical profiles, and quality of care. Among 11 986 patients, the proportion of women was unchanged between 2001 and 2011. The estimated national rates of hospital admission per 100 000 people increased from 4.6 in 2001 to 18.0 in 2011 among men (3.9-fold increase) and from 1.9 to 8.0 among women (4.2-fold increase) (Ptrend<0.0001). The median age of women increased from 68 years in 2001 to 72 years in 2011 (Ptrend<0.001); however, there was no age change in men (63 years in 2011) (Ptrend=0.48). After accounting for age, women had a higher frequency of comorbidities. Although there were significant sex differences in the time interval of >12 hours between symptom onset and admission time in 2001, since 2006 delays in presentation were comparable between women and men. Fewer women without contraindications received evidence-based therapies than men, including reperfusion (57.5% versus 44.2%), early aspirin (88.8% versus 85.9%), and clopidogrel (56.9% versus 52.5%, P<0.001 for all) and the differences were largely unchanged over time.

CONCLUSIONS

Women experienced a higher increase in hospitalization rates for ST-segment elevation myocardial infarction in China between 2001 and 2011 and were less likely to receive evidence-based therapies, especially reperfusion. In addition to efforts to improve quality of care generally, understanding the reasons for this sex disparity and addressing these differences in care should be a priority.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01624883.

Sex Differences in the Presentation, Diagnosis, and Management of Acute Coronary Syndromes: Findings From the Kerala-India ACS Registry

BACKGROUND

Previous literature from high-income countries has repeatedly shown sex differences in the presentation, diagnosis, and management of acute coronary syndromes (ACS), with women having atypical presentations and undergoing less aggressive diagnostic and therapeutic measures. However, much less data exist evaluating sex differences in ACS in India.

OBJECTIVES

This study sought to evaluate sex differences in the diagnosis, management, and treatment of patients with ACS in Kerala, India.

METHODS

The Kerala ACS Registry collected data from 25,748 consecutive ACS admissions (19,923 men and 5,825 women) from 125 hospitals in the Indian state of Kerala from 2007 to 2009. This study evaluated the association between sex differences in presentation, in-hospital management, and discharge care with in-hospital mortality and in-hospital major adverse cardiovascular events (defined as death, reinfarction, stroke, heart failure, or cardiogenic shock).

RESULTS

Women with ACS were older than men with ACS (64 vs. 59, p < 0.001) and were more likely to have a history of previous myocardial infarction (16% vs. 14%, p < 0.001). Inpatient diagnostics and management and discharge care were similar between sexes. No significant differences between men and women in the outcome of death (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 0.80 to 1.38) or in the composite outcome of death, reinfarction, stroke, heart failure, or cardiogenic shock (OR: 0.99, 95% CI: 0.79 to 1.25) were seen after adjustment for possible confounding factors.

CONCLUSIONS

In Kerala, even though women with ACS were older and more likely to have previous myocardial infarction, there were no significant differences in in-hospital and discharge management, in-hospital mortality, or major adverse cardiovascular events between sexes. Whether these results apply to other parts of India or acute presentations of other chronic diseases in low- and middle-income countries warrants further study.

Prevalence of comorbidities and their impact on hospital management and short-term outcomes in Vietnamese patients hospitalized with a first acute myocardial infarction

Background

Cardiovascular disease is one of the leading causes of morbidity and mortality in Vietnam. We conducted a pilot study of Hanoi residents hospitalized with a first acute myocardial infarction (AMI) at the Vietnam National Heart Institute in Hanoi for purposes of describing the prevalence of cardiovascular (CVD) and non-CVD comorbidities and their impact on hospital management, in-hospital clinical complications, and short-term mortality in these patients.

Methods

The study population consisted of 302 Hanoi residents hospitalized with a first AMI at the largest tertiary care medical center in Hanoi in 2010.

Results

The average age of study patients was 66 years and one third were women. The proportions of patients with none, any 1, and ≥ 2 CVD comorbidities were 34%, 42%, and 24%, respectively. Among the CVD comorbidities, hypertension was the most commonly reported (59%). There were decreasing trends in the proportion of patients who were treated with effective cardiac medications and coronary interventions as the number of CVD comorbidities increased. Patients with multiple CVD comorbidities tended to develop acute clinical complications and die at higher rates during hospitalization compared with patients with no CVD comorbidities (Odds Ratio: 1.40; 95% Confidence Interval: 0.40–4.84).

Conclusions

Our data suggest that patients with multiple cardiac comorbidities tended to experience high in-hospital death rates in the setting of AMI. Full-scale surveillance of Hanoi residents hospitalized with AMI at all Hanoi hospitals is needed to confirm these findings. Effective strategies to manage Vietnamese patients hospitalized with AMI who have multiple comorbidities are warranted to improve their short-term prognosis.

Global perspective on acute coronary syndrome: a burden on the young and poor

Ischemic heart disease (IHD) is the greatest single cause of mortality and loss of disability-adjusted life years worldwide, and a substantial portion of this burden falls on low- and middle-income countries (LMICs). Deaths from IHD and acute coronary syndrome (ACS) occur, on average, at younger ages in LMICs than in high-income countries, often at economically productive ages, and likewise frequently affect the poor within LMICs. Although data about ACS in LMICs are limited, there is a growing literature in this area and the research gaps are being steadily filled. In high-income countries, decades of investigation into the risk factors for ACS and development of behavioral programs, medications, interventional procedures, and guidelines have provided us with the tools to prevent and treat events. Although similar tools can be, and in fact have been, implemented in many LMICs, challenges remain in the development and implementation of cardiovascular health promotion activities across the entire life course, as well as in access to treatment for ACS and IHD. Intersectoral policy initiatives and global coordination are critical elements of ACS and IHD control strategies. Addressing the hurdles and scaling successful health promotion, clinical and policy efforts in LMICs are necessary to adequately address the global burden of ACS and IHD.

Sex differences in clinical characteristics, hospital management practices, and in-hospital outcomes in patients hospitalized in a Vietnamese hospital with a first acute myocardial infarction

Background

Cardiovascular disease is one of the leading causes of morbidity and mortality in Vietnam. We conducted a pilot study of Hanoi residents hospitalized with acute myocardial infarction (AMI) at the Vietnam National Heart Institute in Hanoi. The objectives of this observational study were to examine sex differences in clinical characteristics, hospital management, in-hospital clinical complications, and mortality in patients hospitalized with an initial AMI.

Methods

The study population consisted of 302 Hanoi residents hospitalized with a first AMI at the largest tertiary care medical center in Hanoi in 2010.

Results

The average age of study patients was 66 years and one third were women. Women were older (70 vs. 64 years) and were more likely than men to have had hyperlipidemia previously diagnosed (10% vs. 2%). During hospitalization, women were less likely to have undergone percutaneous coronary intervention (PCI) compared with men (57% vs. 74%), and women were more likely to have developed heart failure compared with men (19% vs. 10%). Women experienced higher in-hospital case-fatality rates (CFRs) than men (13% vs. 4%) and these differences were attenuated after adjustment for age and history of hyperlipidemia (OR: 2.64; 95% CI: 1.01, 6.89), and receipt of PCI during hospitalization (OR: 2.09; 95% CI: 0.77, 5.09).

Conclusions

Our pilot data suggest that among patients hospitalized with a first AMI in Hanoi, women experienced higher in-hospital CFRs than men. Full-scale surveillance of all Hanoi residents hospitalized with AMI at all Hanoi medical centers is needed to confirm these findings. More targeted and timely educational and treatment approaches for women appear warranted.

Cost-effectiveness of optimal use of acute myocardial infarction treatments and impact on coronary heart disease mortality in China

BACKGROUND

The cost-effectiveness of the optimal use of hospital-based acute myocardial infarction (AMI) treatments and their potential impact on coronary heart disease (CHD) mortality in China is not well known.

METHODS AND RESULTS

The effectiveness and costs of optimal use of hospital-based AMI treatments were estimated by the CHD Policy Model-China, a Markov-style computer simulation model. Changes in simulated AMI, CHD mortality, quality-adjusted life years, and total healthcare costs were the outcomes. The incremental cost-effectiveness ratio was used to assess projected cost-effectiveness. Optimal use of 4 oral drugs (aspirin, β-blockers, statins, and angiotensin-converting enzyme inhibitors) in all eligible patients with AMI or unfractionated heparin in non-ST-segment-elevation myocardial infarction was a highly cost-effective strategy (incremental cost-effectiveness ratios approximately US $3100 or less). Optimal use of reperfusion therapies in eligible patients with ST-segment-elevation myocardial infarction was moderately cost effective (incremental cost-effectiveness ratio ≤$10,700). Optimal use of clopidogrel for all eligible patients with AMI or primary percutaneous coronary intervention among high-risk patients with non-ST-segment-elevation myocardial infarction in tertiary hospitals alone was less cost effective. Use of all the selected hospital-based AMI treatment strategies together would be cost-effective and reduce the total CHD mortality rate in China by ≈9.6%.

CONCLUSIONS

Optimal use of most standard hospital-based AMI treatment strategies, especially combined strategies, would be cost effective in China. However, because so many AMI deaths occur outside of the hospital in China, the overall impact on preventing CHD deaths was projected to be modest.

Sex differences in the treatment and outcome of patients with acute coronary syndrome after percutaneous coronary intervention: a population-based study

BACKGROUND

This study was performed to assess the influence of sex on drug therapy and long-term outcomes in acute coronary syndrome (ACS) patients who underwent percutaneous coronary intervention (PCI).

METHODS

This is a retrospective cohort study of ACS patients who underwent PCI [women (n=8,884) and men (n=23,937)] between January 1, 2006, and December 31, 2007, with at least a 1-year follow-up, based on the National Health Insurance Research Database in Taiwan. Propensity score was used to identify a 1:1 matched cohort (n=17,768) for multivariable adjustment. The influence of sex on drug therapy and outcomes was examined by multivariate logistic regression and multivariable Cox proportional hazards regression.

RESULTS

Female patients had an 18% and 12% lower likelihood of receiving aspirin (adjusted odds ratio [OR(adj)]=0.82, 95% confidence interval [CI]=0.77-0.88) and clopidogrel (OR(adj)=0.88, 95% CI=0.81-0.95), respectively, than male patients but had a 17% and 22% higher likelihood of receiving beta-blockers (OR(adj)=1.17, 95% CI=1.10-1.24) and statins (OR(adj)=1.22, 95% CI=1.14-1.29), respectively, than male patients in the matched cohort. The adjusted hazard ratio (HR(adj)) of rehospitalization for revascularization in women was 0.84 (95% CI=0.79-0.90) compared with men after at least a 1-year follow-up in the matched cohort.

CONCLUSIONS

Female patients with ACS who underwent PCI were less likely to receive aspirin and clopidogrel but were more likely to receive beta-blockers and statins than male patients. Male sex was associated with a higher risk of rehospitalization for revascularization than female sex.

Association between gender, process of care measures, and outcomes in ACS in India: results from the detection and management of coronary heart disease (DEMAT) registry

Background

Studies from high-income countries have shown that women receive less aggressive diagnostics and treatment than men in acute coronary syndromes (ACS), though their short-term mortality does not appear to differ from men. Data on gender differences in ACS presentation, management, and outcomes are sparse in India.

Methods and Results

The Detection and Management of Coronary Heart Disease (DEMAT) Registry collected data from 1,565 suspected ACS patients (334 women; 1,231 men) from ten tertiary care centers throughout India between 2007–2008. We evaluated gender differences in presentation, in-hospital and discharge management, and 30-day death and major adverse cardiovascular event (MACE; death, re-hospitalization, and cardiac arrest) rates. Women were less likely to present with STEMI than men (38% vs. 55%, p<0.001). Overall inpatient diagnostics and treatment patterns were similar between men and women after adjustment for potential confounders. Optimal discharge management with aspirin, clopidogrel, beta-blockers, and statin therapy was lower for women than men, (58% vs. 65%, p = 0.03), but these differences were attenuated after adjustment (OR = 0.86 (0.62, 1.19)). Neither the outcome of 30-day mortality (OR = 1.40 (0.62, 3.16)) nor MACE (OR = 1.00 (0.67, 1.48)) differed significantly between men and women after adjustment.

Conclusions

ACS in-hospital management, discharge management, and 30-day outcomes did not significantly differ between genders in the DEMAT registry, though consistently higher treatment rates and lower event rates in men compared to women were seen. These findings underscore the importance of further investigation of gender differences in cardiovascular care in India.

Automated heart-type fatty acid-binding protein assay for the early diagnosis of acute myocardial infarction

We compared an automated quantitative heart-type fatty acid-binding protein (H-FABP) assay with other cardiac-marker assays to examine its usefulness as an early diagnostic marker of acute myocardial infarction (AMI). Serum samples for cardiac troponin T (cTnT), creatine kinase-MB isozyme (CK-MB), myoglobin, and H-FABP were obtained from 64 patients with AMI and 53 patients with other conditions (control group). H-FABP was measured by using 2 immunoassays, the H-FABP enzyme-linked immunosorbent assay (ELISA; Biocheck, Foster City, CA) and the H-FABP latex turbidimetric immunoassay (LTIA; HBI, Anyang, Korea). Sensitivities of assays for cTnT, CK-MB, myoglobin, H-FABP (by ELISA), H-FABP (by LTIA), and electrocardiogram (ECG) for the diagnosis of AMI at hospital admission were 39.1%, 59.4%, 64.1%, 68.7%, 70.3%, and 54.7%, respectively. Specificities of cTnT, CK-MB, myoglobin, H-FABP (by ELISA), H-FABP (by LTIA), and ECG were 98.1%, 71.7%, 81.1%, 77.4%, 90.6%, and 92.5%, respectively. The automated H-FABP (by LTIA) is superior to cTnT, CK-MB, myoglobin, and H-FABP (by ELISA) tests for the diagnosis of AMI in patients admitted within 4 hours from the onset of chest pain.

Therapy for ST-segment elevation myocardial infarction patients who present late or are ineligible for reperfusion therapy

Despite the wide contemporary availability of pharmacological and mechanical means of reperfusion, a very significant proportion of ST-segment elevation myocardial infarction (STEMI) patients are still not offered any reperfusion therapy, and some of them are considered "ineligible for reperfusion." Spontaneous reperfusion and contraindications to the use of fibrinolytics and/or mechanical reperfusion methods account only for a small part of these clinical situations. The boundary between "timely" and "late" presentation in STEMI, the appropriateness of percutaneous intervention in patients presenting late after onset of symptoms, and the impact of sex and age on the eligibility and/or choice of reperfusion therapy continue to be challenged by the most recent published data. In the current invasive-driven reperfusion era, if scientific evidence and clinical guidelines are applied diligently, the vast majority of eligible STEMI patients should receive reperfusion therapy. Pharmacological nonlytic therapy of patients with STEMI, regardless of the choice of reperfusion strategy or the absence of it, is clearly defined by the current practice guidelines. Available data suggest that for patients who do not receive any form of reperfusion, anticoagulation therapy with low molecular weight heparin provides a clear additional mortality benefit versus placebo. Fondaparinux as compared with usual care (unfractionated heparin infusion or placebo) significantly reduces the composite of death or myocardial reinfarction without increasing severe bleeding or number of strokes. In the treatment of late-presenting patients with STEMI (beyond the first 12 h after onset of symptoms), clinical evaluation and risk stratification represent the crucial elements helping in decision making between therapeutic interventions.

Effects of systolic and diastolic blood pressures on incident coronary heart disease and all-cause death in Chinese women with Type 2 diabetes: the Hong Kong Diabetes Registry

BACKGROUND

Elevated blood pressure (BP) is an important risk factor for the development of coronary heart disease (CHD), although the threshold above which the risk increases has not been clearly defined. The aim of the present study was to examine the full-range association between BP and CHD.

METHODS

A prospective cohort of 3861 Chinese women with Type 2 diabetes mellitus (T2DM) was followed for a median of 5.61 years. Restricted cubic spline analysis was used to examine the relationship between BP and CHD.

RESULTS

Subjects who developed CHD were older, more likely to be smokers, had a significantly longer duration of diabetes, higher systolic BP (SBP), glycated hemoglobin, albuminuria, low-density lipoprotein-cholesterol, and triglycerides, and lower estimated glomerular filtration rate and high-density lipoprotein-cholesterol. Mortality was higher in those who developed CHD compared with those who did not, with all-cause death in 30.2% and 7.8% of patients, respectively. Over 21,641 and 22 049 person-years follow up, 4.4% of patients (n = 169) developed CHD and 8.8% (n = 340) died, respectively. The relative risk of SBP for CHD was constant up to 120 mmHg, after which it started to rise: from 130 mmHg, each 10-mmHg increase in SBP was associated with a 1.13-fold increased risk of CHD.

CONCLUSIONS

We identified 130 mmHg as the threshold of SBP for increased risk of CHD in Chinese female patients with T2DM. It appears that 67-77 mmHg is the optimal range for diastolic BP, within which the risk of CHD is lowest.

Impact of an audit program and other factors on door-to-balloon times in acute ST-elevation myocardial infarction patients destined for primary coronary intervention

OBJECTIVES

This before-after study investigated the association between an audit program and door-to-balloon times in patients with acute ST-elevation myocardial infarction (STEMI) and explored other factors associated with the door-to-balloon time.

METHODS

An audit program that collected time data for essential time intervals in acute STEMI was developed with data feedback to both the Department of Emergency Medicine and the Department of Cardiology. The door-to-balloon times for 76 consecutive acute STEMI patients were collected from February 16, 2007, through October 31, 2007, after the implementation of the audit program, as the intervention group. The control group was defined by 104 consecutive acute STEMI patients presenting from April 1, 2006, through February 15, 2007, before the audit was applied. A multivariate linear regression model was used for analysis of factors associated with the door-to-balloon time.

RESULTS

The geometric mean 95% CI of the door-to-balloon time decreased from 164.9 (150.3, 180.9) minutes to 141.9 (127.4, 158.2) minutes (p = 0.039) in the intervention phase. The median door-to-balloon time was 147.5 minutes in the control group and 136.0 minutes in the intervention group (p = 0.09). In the multivariate regression model, the audit program was associated with a shortening of the door-to-balloon time by 35.5 minutes (160.4 minutes vs. 195.9 minutes, p = 0.004); female gender was associated with a mean delay of 58.4 minutes (208.9 minutes vs. 150.5 minutes; p = 0.001); posterolateral wall infarction was associated with a mean delay of 70.5 minutes compared to anterior wall infarction (215.4 minutes vs. 144.9 minutes; p = 0.037) and a mean delay of 69.5 minutes compared to inferior wall infarction (215.4 minutes vs. 145.9 minutes; p = 0.044). The use of a glycoprotein IIb/IIIa inhibitor was associated with a 46.1 minutes mean shortening of door-to-balloon time (155.7 minutes vs. 201.8 minutes; p < 0.001).

CONCLUSIONS

The implementation of an audit program was associated with a significant reduction in door-to-balloon times among patients with acute STEMI. In addition, female patients, posterolateral wall infarction territory, and nonuse of glycoprotein IIb/IIIa inhibitor were associated with longer door-to-balloon times.