Gender difference in clinical outcomes of the patients with coronary artery disease after percutaneous coronary intervention: A systematic review and meta-analysis

Sex-Based Outcomes of Dual-Antiplatelet Therapy After Percutaneous Coronary Intervention: A Pairwise and Network Meta-Analysis

BACKGROUND

Although dual antiplatelet therapy (DAPT) improves the outcomes of patients undergoing percutaneous coronary intervention (PCI), sex-specific differences in efficacy and safety of DAPT remain unresolved. We compared sex differences for DAPT outcomes and DAPT durations (1-3 months [short-term], 6 months [mid-term], and >12 months [extended] vs. 12 months).

METHODS

We searched databases through 31 December 2023 for trials reporting DAPT after PCI. The endpoints were major adverse cardiovascular and cerebrovascular events (MACCE), net adverse clinical and cerebrovascular events (NACCE), and any bleeding. Extracted data were pooled in a frequentist network and pairwise, random-effects meta-analysis.

RESULTS

Twenty-two trials (99,591 participants, 25.2% female) were included. Female sex was significantly associated with a higher 1-year MACCE risk (hazard ratio 1.14 [95% confidence interval 1.02-1.28]) and bleeding (1.13 [1.00-1.28]), but not NACCE (1.12 [0.96-1.31]). In sub-analyses, the association between female sex and MACCE was related to use of clopidogrel as the second antiplatelet agent (1.11 [1.03-1.20]), whereas higher bleeding events were related to newer P2Y12 inhibitors (P2Y12i) (1.58 [1.01-2.46]). For DAPT duration, short-term DAPT followed by P2Y12i monotherapy was non-inferior for MACCE in females and males (0.95 [95% CI 0.83-1.10; and 0.96 [0.80-1.16]) but tended to be superior in males for NACCE versus 12-month DAPT (0.96 [0.91-1.01]); mid-term DAPT tended to be associated with a lower bleeding risk in males (0.43 [0.17-1.09]).

CONCLUSIONS

Female sex is associated with higher MACCE and bleeding when newer P2Y12i agents are used. Short-term DAPT followed by P2Y12i monotherapy is safe and effective in both sexes undergoing PCI.

CLINICAL TRIALS REGISTRATION

PROSPERO ID: CRD42021278663.

Achieving Equity in EMS Care and Patient Outcomes Through Quality Management Systems: A Position Statement

Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies:make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.

In-hospital and 1-year outcomes of patients without modifiable risk factors presenting with acute coronary syndrome undergoing PCI: a Sex-stratified analysis

Aim

A considerable proportion of patients admitted with acute coronary syndrome (ACS) have no standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, dyslipidemia, and cigarette smoking). The outcomes of this population following percutaneous coronary intervention (PCI) are debated. Further, sex differences within this population have yet to be established.

Methods

This retrospective cohort study included 7,847 patients with ACS who underwent PCI. The study outcomes were in-hospital mortality, all-cause mortality, and major adverse cardio-cerebrovascular events (MACCE). The association between the absence of SMuRFs (SMuRF-less status) and outcomes among all the patients and each sex was assessed using logistic and Cox proportional hazard regressions.

Results

Approximately 11% of the study population had none of the SMuRFs. During 12.13 [11.99-12.36] months of follow-up, in-hospital mortality (adjusted-odds ratio (OR):1.51, 95%confidence interval (CI): 0.91-2.65, P:0.108), all-cause mortality [adjusted-hazard ratio (HR): 1.01, 95%CI: 0.88-1.46, P: 0.731], and MACCE (adjusted-HR: 0.93, 95%CI:0.81-1.12, P: 0.412) did not differ between patients with and without SMuRFs. Sex-stratified analyses recapitulated similar outcomes between SMuRF+ and SMuRF-less men. In contrast, SMuRF-less women had significantly higher in-hospital (adjusted-OR: 3.28, 95%CI: 1.92-6.21, P < 0.001) and all-cause mortality (adjusted-HR:1.41, 95%CI: 1.02-3.21, P: 0.008) than SMuRF+ women.

Conclusions

Almost one in 10 patients with ACS who underwent PCI had no SMuRFs. The absence of SMuRFs did not confer any benefit in terms of in-hospital mortality, one-year mortality, and MACCE. Even worse, SMuRF-less women paradoxically had an excessive risk of in-hospital and one-year mortality.

Factors associated with health-related quality of life in patients undergoing percutaneous coronary intervention: Thai PCI registry

Background

Percutaneous coronary intervention (PCI) has been shown to improve health-related quality of life (HRQoL) in patients with coronary artery disease (CAD). The objectives of this study were to assess the changes in HRQoL and factors influencing these changes in CAD patients after undergoing PCI.

Methods

Data from a nationwide PCI registry across 39 hospitals in Thailand were collected in 2018-2019, including baseline characteristics, comorbid diseases, angiographic CAD severity, procedural details, and type of health insurance. HRQoL, as measured by utility scores, was determined in all patients using the Thai version of EQ-5D-5l at admission, discharge, and 6 and 12 months after discharge. The effects of time after PCI procedure and various factors on mean utility scores were assessed using a mixed-effect linear regression model.

Results

A total of 19,701 patients were included in the analysis; they had a mean age of 64.2 ± 11.7 years and were predominantly (69.1%) male. Following PCI, the mean utility scores increased from 66.6 ± 19.6 at admission to 81.9 ± 13.8 at discharge, and remained stable at 6 and 12 months (86.1 ± 12.3 and 88.0 ± 11.7, respectively). After adjusting for potential confounding variables, several factors were found to be independently associated with improved HRQoL, including angiographic success, male gender, overweight status, dyslipidemia, and radial access. Six other factors were associated with less improved HRQoLs, including cardiogenic shock/IABP support, old age, CKD, clinical presentation (STEMI and NSTEMI), prior cerebrovascular disease, and heart failure. There were no associations of CAD severity and procedural details with HRQoL. No differences were found related to type of health insurance, except that patients who were uninsured or self-pay tended to have less improvement in HRQoL.

Conclusion

HRQoL improved significantly after PCI in these subjects, as observed through 1 year of follow-up. Identifying the factors influencing these improvements may assist clinicians in tailoring patient interventions to optimise quality of life after PCI.

Sex Differences in Coronary Artery Disease: Insights From the KoRean wOmen'S chest pain rEgistry (KoROSE)

Interest in sex differences in coronary artery disease (CAD) has been steadily increasing. Concurrently, most of the data on these differences have primarily been Western-oriented. The KoRean wOmen'S chest pain rEgistry (KoROSE), started in 2011, has since published numerous research findings. This review aims to summarize the reported differences between men and women in CAD, integrating data from KoROSE. Cardiovascular risk in postmenopausal women escalates dramatically due to the decrease in estrogen levels, which normally offer cardiovascular protective effects. Lower estrogen levels can lead to abdominal obesity, insulin resistance, increased blood pressure, and endothelial dysfunction in older women. Upon analyzing patients with CAD, women are typically older and exhibit more cardiovascular risk factors than men. Diagnosing CAD in women tends to be delayed due to their symptoms being more atypical than men's. While in-hospital outcome was similar between sexes, bleeding complications after percutaneous coronary intervention occur more frequently in women. The differences in long-term prognosis for CAD patients between men and women are still a subject of ongoing debate. Pregnancy and reproductive factors also play a significant role as risk factors for cardiovascular disease in women. A notable sex disparity exists, with women found to use fewer cardiovascular protective drugs and undergo fewer interventional or surgical procedures than men. Additionally, women participate less frequently than men in clinical research. Through concerted efforts to increase awareness of sex differences and mitigate sex disparity, personalized treatment can be provided. This approach can ultimately improve patient prognosis.

The Influence of Sex, Age, and Race on Coronary Artery Disease: A Narrative Review

Cardiovascular disease has remained one of the leading causes of mortality in the world. The basic pathophysiology of coronary artery disease (CAD) is a reduction of the blood flow in coronary vessels, leading to restricted blood flow to the heart muscle. Both modifiable and non-modifiable risk factors contribute to its multifactorial etiology. The clinical presentation ranges from asymptomatic to typical symptoms like chest pain, shortness of breath, and left arm or jaw pain. The purpose of this review is to investigate and analyze the variation of CAD depending on the biological sex, age, race, or ethnicity and how it might differ in the studied population while comparing the symptoms and prognosis of CAD. For this research, PubMed's database was used. A total of 926 articles were selected using pre-determined inclusion and exclusion criteria, with 74 articles eligible to be included in the narrative review. Studies were selected from the general population of patients with CAD, regardless of their severity, stage of diagnosis, and treatment plan. The scale for the assessment of non-systematic review articles (SANRA) was used to assess the quality of the study. As humans age, the incidence of CAD increases, and people over 75 are more likely to have multiple-vessel CAD. It has been observed that South Asians have the highest rate of CAD at 24%, while the White population has the lowest at 8%. The prevalence of CAD also depends on race, with the White population having the lowest rate at 3.2%, followed by Hispanics at 5%, Black women at 5.2%, and Black men at 5.7%. Younger Black women tend to have more chest pain. Men with CAD commonly experience chest pain, and women are more likely to present with atypical symptoms. Modifiable risk factors such as smoking and alcoholism are more commonly observed in young men than in young women. Coronary artery disease in the elderly, female, minority, and Black patients is associated with a higher mortality rate. Acknowledging the prevalence of certain risk factors, signs, results, and responses to treatment in certain socio-demographic groups, as well as the provision and accessibility of diagnosis and treatment, would lead to a better outcome for all individuals. The impact of this shift can range from an earlier diagnosis of CAD to a faster and more customized treatment plan tailored to each patient's individual requirements.

Interleukin-36 is vasculoprotective in both sexes despite sex-specific changes in the coronary microcirculation response to IR injury

Aims

Risks and outcomes of myocardial infarction (MI) are different between men and women and some studies have demonstrated that the latter have a higher risk of mortality. Whilst there are many reasons for this, it may also partially be linked to stronger innate and adaptive immune responses mounted by females compared to males. However, little is known about how sex impacts the coronary microvessels, the site where inflammatory processes take place, after an MI. Intravital and laser speckle microscopy was used to image coronary microvessels and ventricular perfusion in vivo in response to myocardial ischaemia-reperfusion (IR) injury in male and female mice. Interleukin-36 (IL-36) is the latest addition to the IL-1 superfamily of pro-inflammatory cytokines and has recently been shown to mediate inflammation in a number of non-cardiovascular diseases. Its role in mediating potential sex-related microcirculatiory pertubations in the heart are unknown. Therefore, the vasculoprotective efficacy of an IL-36 receptor antagonist (IL-36Ra) was also investigated.

Methods and results

Immunostaining and flow cytometry demonstrated higher expression of IL-36 and its receptor in female hearts, an observation confirmed in human samples. Intravital imaging of the anaesthetised mouse beating heart identified significantly greater neutrophil recruitment in female hearts, but a greater burden of thrombotic disease in male hearts. Male mice had reduced functional capillary density and were unable to restore perfusion to baseline values as effectively as females. However, female mice had significantly larger infarcts. Interestingly, IL-36Ra decreased inflammation, improved perfusion, and reduced infarct size in both sexes despite increasing platelet presence in male hearts. Mechanistically, this was explained by IL-36Ra attenuating endothelial oxidative damage and VCAM-1 expression. Importantly, IL-36Ra administration during ischaemia was critical for vasculoprotection to be realised.

Conclusion

This novel study identified notable sex-related differences in the coronary microcirculatory response to myocardial IR injury which may explain why some studies have noted poorer outcomes in women after MI. Whilst contemporary MI treatment focuses on anti-platelet strategies, the heightened presence of neutrophils in female IR injured coronary microvessels necessitates the development of an effective anti-inflammatory approach for treating female patients. We also emphasise the importance of early intervention during the ischaemic period in order to maximise therapeutic effectiveness.

Women are Not at Higher Risk for Reintervention or Major Amputation after Lower Extremity Atherectomy for Peripheral Artery Disease

BACKGROUND

Our objective was to compare short-term and long-term differences in reintervention-free and major amputation-free survival between female and male patients undergoing lower extremity atherectomy for peripheral artery disease.

METHODS

We analyzed lower extremity atherectomy procedures performed on 294 patients between January 2014 and September 2019. Reintervention was defined as either open bypass or endovascular procedure to the same region following the index operation. Kaplan-Meier (KM) survival analysis was performed to compare reintervention-free and major amputation-free survival between sexes. Multivariate logistic regression analyses were performed to determine the adjusted odds of reintervention and major amputation based on sex. We conducted subgroup analyses by anatomic region (femoropopliteal vs. tibial), indication (claudication vs. chronic limb-threatening ischemia (CLTI)), and balloon type (drug-coated balloon (DCB) versus plain balloon angioplasty (POBA)) across sexes.

RESULTS

Of the 294 patients, 125 (42.5%) were female. Compared to men, women receiving atherectomy were more likely to be Black (28.0% vs. 16.6%; P = 0.018), a nonsmoker (44.8% vs. 21.3%; P < 0.001), and present with CLTI (55.2% vs. 43.2%; P = 0.042). There were no differences in atherectomy region, lesion type, or balloon type between sexes. KM analysis showed similar 4-year reintervention-free survival (68.8% vs. 75.1%; P = 0.88) and major amputation-free survival (97.6% vs. 97.6%; P = 0.41) between sexes. Women and men had similar reintervention-free survival when grouped by femoropopliteal (67.9% vs. 70.8%; P = 0.69) or tibial (76.2% vs. 83.9%; P = 0.68) atherectomy region. Indication (claudication versus CLTI) did not affect reintervention-free survival in either women (64.5% vs. 69.6%; P = 0.28) or men (68.5% vs. 76.7%; P = 0.84). KM curves for DCB versus POBA were also similar between sexes and showed an early benefit in reintervention rate favoring DCB, which dissipated in both women (65.4% vs. 72.7%; P = 0.61) and men (75.5% vs. 78.4%; P = 0.18) by 3 years.

CONCLUSIONS

Compared to men, women demonstrate commensurate benefit from atherectomy for lower extremity revascularization. There were no differences seen in long-term reintervention or major amputation between sexes.

Between-Sex Differences in Risk Factors for Cardiovascular Disease among Patients with Myocardial Infarction-A Systematic Review

Between-sex differences in the presentation, risk factors, management, and outcomes of acute myocardial infarction (MI) are well documented. However, as such differences are highly sensitive to cultural and social changes, there is a need to continuously re-evaluate the evidence. The present contemporary systematic review assesses the baseline characteristics of men and women presenting to secondary, tertiary, and quaternary centres with acute myocardial infarction (MI). Over 1.4 million participants from 18 studies, including primary prospective, cross sectional and retrospective observational studies, as well as secondary analysis of registry data are included in the study. The study showed that women were more likely than men to have a previous diagnosis of diabetes, hypertension, cerebrovascular disease, and heart failure. They also had lower odds of presenting with previous ischaemic heart disease and angina, dyslipidaemia, or a smoking history. Further work is necessary to understand the reasons for these differences, and the role that gender-specific risk factors may have in this context. Moreover, how these between-gender differences are implicated in management and outcomes also requires further work.

Sex difference in the association of the triglyceride glucose index with obstructive coronary artery disease

Insulin resistance (IR) is associated with cardiovascular disease in non-diabetic patients. The triglyceride-glucose (TyG) index, incorporating serum glucose and insulin concentrations, is a surrogate insulin resistance marker. We investigated its association with obstructive coronary artery disease (CAD) and sex differences therein. Patients with stable angina pectoris requiring invasive coronary angiography between January 2010 and December 2018 were enrolled. They were divided into two groups according to TyG index. Two interventional cardiologists diagnosed obstructive CAD by angiography review. Demographic characteristics and clinical outcomes were compared between groups. Relative to lower index, patients with higher (≥ 8.60) TyG index had higher BMIs and more prevalent hypertension, diabetes, and elevated lipid profiles [total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides (TG), fasting plasma glucose (FPG)]. Higher TyG index increased women's obstructive CAD risk after multivariate adjustment (adjusted odds ratio (aOR) 2.15, 95% confidence interval (95% CI) 1.08-4.26, p = 0.02) in non-diabetic populations compared with men. No sex difference was found for diabetic patients. Higher TyG index significantly increased the obstructive CAD risk, overall and for non-diabetic women. Larger-scale studies are needed to confirm our findings.

ST-Segment Elevation Myocardial Infarction Differences between Genders - A Single Center Retrospective Analysis

BACKGROUND

Although outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary interventions (PCI) have improved, women show higher mortality.

OBJECTIVES

To assess gender differences in presentation, management and in-hospital mortality, at 30-days, 6-months and 1-year after STEMI.

METHODS

We retrospectively collected data from 809 consecutive patients treated with primary PCI and compared the females versus males at the local intervention cardiology database. The level of significance used was p<0.05.

RESULTS

Women were older than man (69,1±14,6 vs. 58,5±12,7 years; p<.001) with higher prevalence of age over 75 years (36.7% vs. 11.7%; p<.001), diabetes (30,6% vs. 18,5%; p=.001), hypertension (60.5% vs. 45.9%; p=.001), chronic kidney disease (3.4% vs. 0.6%; p=.010) and acute ischemic stroke (6.8% vs. 3.0%; p=.021). At presentation, women had more atypical symptoms, less chest pain (p=.014) and were more frequently in cardiogenic shock (p=.011)). Women had longer time until reperfusion (p=.001) and were less likely to receive optimal medical therapy (p<0.05). In-hospital mortality (p=.001), at 30-days (p<.001), 6-months (p<.001) and 1-year (16.4% vs. p<.001) was higher in women. The multivariate analysis identified age over 75 years (HR=4.25; 95% CI[1.67-10.77];p=.002), Killip class II (HR=8.80; 95% CI[2.72-28.41];p<.001), III (HR=5.88; 95% CI [0.99-34.80]; p=.051) and IV (HR=9.60; 95% CI[1.86-48.59];p=.007), Acute Kidney Injury (HR=2.47; 95% CI[1.00-6.13];p=.051) and days of hospitalization (HR=1.04; 95% CI[1.01-1.08];p=.030) but not female gender (HR=0.83; 95% CI[0.33-2.10];p=.690) as independent prognostic factors of mortality.

CONCLUSIONS

Compared to men, women with STEMI undergoing primary PCI have higher mortality rates. Women admitted for STEMI have a worse risk profile, are treated with a higher reperfusion time related with system delays and are less likely to receive the recommended therapy. Female gender was not an independent prognostic factor for mortality in the studied population.

Trends in outcomes of women with myocardial infarction undergoing primary angioplasty-Analysis of randomized trials

Background

Sex- and gender-associated differences determine the disease response to treatment.

Aim

The study aimed to explore the hypothesis that progress in the management of STE-myocardial infarction (STEMI) overcomes the worse outcome in women.

Methods and results

We performed an analysis of three randomized trials enrolling patients treated with primary PCI more than 10 years apart. PRAGUE-1,-2 validated the preference of transport for primary PCI over on-site fibrinolysis. PRAGUE-18 enrollment was ongoing at the time of the functional network of 24/7PCI centers, and the intervention was supported by intensive antiplatelets. The proportion of patients with an initial Killip ≥ 3 was substantially higher in the more recent study (0.6 vs. 6.7%, p = 0.004). Median time from symptom onset to the door of the PCI center shortened from 3.8 to 3.0 h, p < 0.001. The proportion of women having total ischemic time ≤3 h was higher in the PRAGUE-18 (OR [95% C.I.] 2.65 [2.03-3.47]). However, the percentage of patients with time-to-reperfusion >6 h was still significant (22.3 vs. 27.2% in PRAGUE-18). There was an increase in probability for an initial TIMI flow >0 in the later study (1.49 [1.0-2.23]), and also for an optimal procedural result (4.24 [2.12-8.49], p < 0.001). The risk of 30-day mortality decreased by 61% (0.39 [0.17-0.91], p = 0.029).

Conclusion

The prognosis of women with MI treated with primary PCI improved substantially with 24/7 regional availability of mechanical reperfusion, performance-enhancing technical progress, and intensive adjuvant antithrombotic therapy. A major modifiable hindrance to achieving this benefit in a broad population of women is the timely diagnosis by health professional services.

Establishment of a Predictive Model for Poor Prognosis of Incomplete Revascularization in Patients with Coronary Heart Disease and Multivessel Disease

OBJECTIVE

To establish a predictive model for poor prognosis after incomplete revascularization (ICR) in patients with multivessel coronary artery disease (MVD).

METHODS

Clinical data of 757 patients with MVD and ICR after percutaneous coronary intervention (PCI) in the Affiliated Hospital of Chengde Medical University from January 2020 to August 2021 were retrospectively collected. The least absolute shrinkage and selection operator regression method was used to screen variables, and multivariate logistic regression was used to establish a predictive model. An independent cohort was used to validate the model. The C-statistic was used to verify and evaluate the discriminative ability of the model; the calibration curve was drawn, and the decision curve analysis (DCA) was performed to evaluate the calibration degree, the clinical net benefit, and the practicability of the model.

RESULTS

The predictive factors included female, age, unconjugated bilirubin, uric acid, low-density lipoprotein, hyperglycemia, total occlusion, and severe tortuosity lesion on coronary angiography. The C-statistic of the training and validation sets were 0.628 and 0.745, respectively. The statistical value of the Hosmer-Lemeshow test for the calibration curve of the training and validation sets were 5.27(P = 0.873) and 6.27 (P = 0.792), respectively. DCA showed that the model was clinically applicable when the predicted probability value of major adverse cardiovascular events(MACEs) ranged from 0.07 to 0.68.

CONCLUSIONS

We established a predictive model for poor prognosis after ICR in patients with MVD. The predictive and calibration ability and the clinical net benefit of the predictive model were good, indicating that it can be used as an effective tool for the early prediction of poor prognosis after ICR in patients with MVD.

Serum brain-derived neurotrophic factor in coronary heart disease: Correlation with the T helper (Th)1/Th2 ratio, Th17/regulatory T (Treg) ratio, and major adverse cardiovascular events

BACKGROUND

Brain-derived neurotrophic factor (BDNF) exerts protective roles against dyslipidemia, atherosclerosis, and inflammation in cardiovascular diseases; meanwhile, it retards CD4⁺ T cell differentiation into T helper (Th)1 and Th17 cells. Hence, this study aimed to investigate the linkage of serum BDNF with Th1/Th2 ratio, Th17/regulatory T (Treg) ratio, and major adverse cardiovascular events (MACE) risk in the coronary heart disease (CHD) patients.

METHODS

This prospective study detected serum BDNF in 210 CHD patients, 50 disease controls (DCs), and 50 healthy controls (HCs) using an enzyme-linked immunosorbent assay. For CHD patients only, the proportion of Th1, Th2, Th17, and Treg cells in blood CD4⁺ T cells was calculated by flow cytometry.

RESULTS

The BDNF varied among CHD patients, DC, and HC (p < 0.001). Specifically, BDNF was declined in CHD patients compared with DCs (p < 0.001) and HCs (p < 0.001). In CHD patients, BDNF was negatively related to Th1 cells (p = 0.031), Th1/Th2 ratio (p = 0.026), Th17 cells (p = 0.001), and Th17/Treg ratio (p = 0.002). Concerning the prognosis, BDNF was reduced in patients with MACE occurrence compared to patients without MACE occurrence (p = 0.006). Furthermore, BDNF showed a trend (lacked statistical significance) to relate to longer MACE-free survival (p = 0.059). Besides, BDNF was related to the absence of obesity (p = 0.019), decreased total cholesterol (p = 0.043), low-density lipoprotein cholesterol (p = 0.019), C-reactive protein (p = 0.012), and Gensini score (p = 0.005).

CONCLUSION

Serum BDNF negatively correlates with Th1/Th2 ratio, Th17/Treg ratio, and estimates lower MACE risk in CHD patients.

Sex differences in pressure and flow waveform physiology across the life course

Cardiovascular disease (CVD) has long been deemed a disease of old men. However, in 2019 CVD accounted for 35% of all deaths in women and, therefore, remains the leading cause of death in both men and women. There is increasing evidence to show that risk factors, pathophysiology and health outcomes related to CVD differ in women compared with men, yet CVD in women remains understudied, underdiagnosed and undertreated. Differences exist between the sexes in relation to the structure of the heart and vasculature, which translate into differences in blood pressure and flow waveform physiology. These physiological differences between women and men may represent an important explanatory factor contributing to the sex disparity in CVD presentation and outcomes but remain understudied. In this review we aim to describe sex differences in arterial pressure and flow waveform physiology and explore how they may contribute to differences in CVD in women compared to men. Given that unfavourable alterations in the cardiovascular structure and function can start as early as in utero, we report sex differences in waveform physiology across the entire life course.

Narrowing disparities in PCI outcomes in women; From risk assessment, to referral pathways and outcomes

This review evaluates published data regarding outcomes for women with ACS undergoing PCI. Data is discussed from a patient centred perspective and timeline, beginning with sex-based differences in perception of risk, time to presentation, time to treatment, access to angiography, access to angioplasty, the impact of incomplete revascularization, prescribing practices, under-representation of women in randomized controlled trials and in cardiology physician workforces. The objective of the review is to identify factors contributing to outcome disparities for women with ACS, and to discuss potential solutions to close this outcome gap.

Dual Antiplatelet Therapy After Drug-Eluting Stents Implantation in East Asians: A Network Meta-Analysis of Randomized Controlled Trials

ABSTRACT

Dual antiplatelet therapy (DAPT) is essential to prevent the risk of ischemia events, but it is difficult to avoid concurrent bleeding events. East Asians are associated with a higher tendency of bleeding than Caucasians, which may affect the DAPT duration. Therefore, this network meta-analysis to explore optimum DAPT duration for East Asians. The related randomized controlled trials that compared the different DAPT duration in East Asian patients were included by searching PubMed, EMBASE, and Cochrane Library database. The outcomes included myocardial infarction, stent thrombosis, all-cause death, stroke, and major bleeding. In addition, net adverse cardiac and cardiovascular events was defined as a composite outcome in this study. We calculated the odds ratio (OR) and 95% confidence intervals for end point events by the fixed effects model in the Bayesian's network frame. We included a total of 12 randomized controlled trials with 30,640 patients. Compared with 12-month DAPT, 1- to 3-month DAPT is effective in myocardial infarction (OR 0.72, 0.46-1.08), stents thrombosis (OR 1.27, 0.59-2.84), all-cause death (OR 0.91, 0.65-1.28), and stroke (OR 0.89, 0.57-1.39). The 1- to 3-month DAPT was associated with a lower risk of major bleeding compared with 12-month DAPT (OR 0.55, 0.4-0.76), 6-month DAPT (OR 0.54, 0.31-0.94), and >12-month DAPT (OR 0.43, 0.28-0.65). In addition, more than 12 months of DAPT did not reduce the incidence of myocardial infarction (OR 0.75, 0.51-1.11) and increased the risk of major bleeding (OR 1.28, 0.88-1.87) compared with 12-month DAPT. The 1- to 3-month DAPT was more secure and effective than the other 3 DAPT strategies. Although East Asians have a higher risk of bleeding, more than 12 months of DAPT does not increase this incidence of major bleeding.

Sex and Gender Equity in Prehospital Electrocardiogram Acquisition

INTRODUCTION

Research in cardiac care has identified significant gender-based differences across many outcomes. Women with heart disease are less likely both to be diagnosed and to receive standard care. Gender-based disparities in the prehospital setting are under-researched, but they were found to exist within rates of 12-lead electrocardiogram (ECG) acquisition within one urban Emergency Medical Services (EMS) agency.

STUDY OBJECTIVE

This study evaluates the quality improvement (QI) initiative that was implemented in that agency to raise overall rates of 12-lead ECG acquisition and reduce the gap in acquisition rates between men and women.

METHODS

This QI project included two interventions: revised indications for 12-lead acquisition, and training that highlighted sex- and gender-based differences relevant to patient care. To evaluate this project, a retrospective database review identified all patient contacts that potentially involved cardiac assessment over 18 months. The primary outcome was the rate of 12-lead acquisition among patients with qualifying complaints. This was assessed by mean rates of acquisition in before and after periods, as well as segmented regression in an interrupted time series. Secondary outcomes included differences in rates of 12-lead acquisition, both overall and in individual complaint categories, each compared between men/women and before/after the interventions.

RESULTS

Among patients with qualifying complaints, the mean rate of 12-lead acquisition in the lead-in period was 22.5% (95% CI, 21.8% - 23.2%) with no discernible trend. The protocol change and training were each associated with a significant absolute level increase in the acquisition rate: 2.09% (95% CI, 0.21% - 4.0%; P = .03) and 3.2% (95% CI, 1.18% - 5.22%; P = .003), respectively. When compared by gender and time period, women received fewer 12-leads than men overall, and more 12-leads were acquired after the interventions than before. There were also significant interactions between gender and period, both overall (2.8%; 95% CI, 1.9% - 3.6%; P < .0001) and in all complaint categories except falls and heart problems.

CONCLUSION

This QI project resulted in an increase in 12-leads acquired. Pre-existing gaps in rates of acquisition between men and women were reduced but did not disappear. On-going research is examining the reasons behind these differences from the perspective of prehospital providers.

Achievement of European Society of Cardiology/European Atherosclerosis Society lipid targets in very high-risk patients: Influence of depression and sex

AIMS

To explore differences in the use of lipid lowering therapy and/or achievement of lipid guideline targets in patients with and without prior depression and influence of sex in very high-risk coronary patients.

METHODS & FINDINGS

A retrospective observational cohort study was conducted using individual-level linked electronic health record data in patients who underwent percutaneous coronary intervention (2012-2017) in Wales. The cohort comprised of 13,781 patients (27.4% female), with 26.1% having prior depression. Lipid levels were recorded in 10,050 patients of whom 25% had depression. History of depression was independently associated with not having lipids checked (OR 0.79 95%CI 0.72-0.87 p<0.001). Patients with prior depression were less likely to achieve targets for low density lipoprotein cholesterol (LDL-C <1.8mmol/l), non-high density lipoprotein cholesterol (non-HDL-C <2.6mmol/l) and triglycerides (<2.3mmol/l) than patients without depression (OR 0.86 95%CI 0.78-0.96 p = 0.007, OR 0.80 95%CI 0.69-0.92 p = 0.003 & OR 0.69 95CI% 0.61-0.79 p<0.001 respectively). Females were less likely to achieve targets for LDL-C and non-HDL-C than males (OR 0.55 95%CI 0.50-0.61 p<0.001 & OR 0.63 95%CI 0.55-0.73 p<0.001). There was an additive effect of depression and sex; females with depression were not only least likely to be tested (OR 0.74 95%CI 0.65-0.84 p<0.001) but also (where levels were known) less likely to achieve LDL-C (OR 0.47 95%CI 0.41-0.55 p<0.001) and non-HDL-C targets (OR 0.50 95%CI 0.41-0.60 p<0.001). It was not possible to look at the influence of medication adherence on achievement of lipid targets due to limitations of the use of anonymised routinely-held clinical care data.

CONCLUSION

Patients with prior depression were less likely to have their lipids monitored and achieve guideline targets within 1-year. Females with depression are the least likely to be tested and achieve lipid targets, suggesting not only a greater risk of future events, but also an opportunity to improve care.

Update on Management of Cardiovascular Diseases in Women

Cardiovascular diseases (CVD) have a lower prevalence in women than men; although, a higher mortality rate and a poorer prognosis are more common in women. However, there is a misperception of CVD female risk since women have commonly been considered more protected so that the real threat is vastly underestimated. Consequently, female patients are more likely to be treated less aggressively, and a lower rate of diagnostic and interventional procedures is performed in women than in men. In addition, there are substantial sex differences in CVD, so different strategies are needed. This review aims to evaluate the main gender-specific approaches in CVD.

Gender-related differences in clinical outcomes after either single or double left main bifurcation stenting

We sought to examine the impact of gender differences in clinical outcomes at 3 years also comparing the role of double versus single stenting approach for the treatment of coronary unprotected LM bifurcation lesions. We retrospectively analyzed both the procedural and medical data of patients referred to our hub center for complex LM bifurcation disease, treated using Crossover provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT) techniques between January 1st, 2008 and May 1st 2018. The main outcome of the study was to evaluate the association between gender and target lesion failure (TLF) based on the different stenting technique used. Five hundred and sixty-seven patients (251 females, mean age 70.0 ± 10 years, mean Syntax score 31.6 ± 6.3) were evaluated. Crossover, T or TAP, culotte and NIT techniques were performed in 171 (30.1%), 61 (10.7%), 98 (17.2%) and 237 (41.8%) patients, respectively with no differences in baseline and peri-procedural items among gender. At a mean follow-up of 37.1 ± 10.8 months (range 22.1-39.3 moths), the overall TLF rate, cardiovascular mortality and stent thrombosis were 12.1%, 3.1% and 1.0%, respectively. Female gender was associated with an increased rate of major bleeding when treated with double stent strategy (p = 0.02). No gender difference in TLF was noted among gender, independently from the stenting approach used. Among patients with ULM bifurcation disease undergoing PCI, TLF rates were not different between genders at 3-year follow-up either using a single or double stent technique.

Safety profile of bivalirudin in Chinese female patients undergoing percutaneous coronary intervention: a multi-center study

Background

The present study aimed to comprehensively investigate the occurrence and risk factors of adverse events (AEs) or adverse drug reactions (ADRs) (especially for thrombocytopenia and bleeding) in Chinese female patients receiving bivalirudin during percutaneous coronary intervention (PCI).

Methods

A total of 918 female patients from 27 Chinese medical centers took bivalirudin as anticoagulant for PCI were enrolled in this prospective, multi-center, intensive monitoring study. Safety data (AEs, ADRs, thrombocytopenia and bleeding) were collected from admission to 72 h post bivalirudin administration; then, patients were followed up at the 30^th day with the safety data collected as well.

Results

One hundred and twenty (13.1%) patients occurred AEs, among which 7 (0.8%) cases experienced severe AEs, and 2 (0.2%) cases died. Besides, 40 (4.4%) patients occurred bivalirudin-related ADRs, in which 3 (0.3%) cases experienced severe ADRs, but 0 (0.0%) cases died. It was of note that 27 (2.9%) and 13 (1.4%) patients experienced thrombocytopenia and bleeding, respectively. Subsequent multivariate analyses observed that: clinical presentation of spontaneous coronary artery dissection (SCAD) (odds ratio (OR) = 3.191, P = 0.004), CRUSADE high risk (OR = 2.075, P = 0.031), multiple culprit vessel (OR = 2.328, P = 0.019) independently correlated with higher risk of bivalirudin-related ADRs; clinical presentation of SCAD (OR = 4.388, P = 0.002) and multiple culprit vessel (OR = 2.974, P = 0.010) independently linked with raised thrombocytopenia risk; history of diabetes mellitus (OR = 5.227, P = 0.007) and CRUSADE high risk (OR = 4.475, P = 0.016) were independent factor related to elevated bleeding risk.

Conclusion

Bivalirudin is well tolerated with low ADRs, thrombocytopenia and bleeding incidences in Chinese female patients undergoing PCI.

Relationship between Hemoglobin Concentration at Admission with the Incidence of No-Reflow Phenomenon and In-Hospital Mortality in Acute Myocardial Infarction with Elevation of ST Segments in Patients who underwent Primary Percutaneous Coronary Intervention

Anemia in acute ST-segment elevation myocardial infarction (STEMI) is associated with a pro-coagulant state, contributing to the incidence of no-reflow phenomenon and increased mortality following primary percutaneous coronary intervention (PPCI). However, clinical data remain contradictory. The objective of our study was to evaluate the association of admission hemoglobin (Hb) concentration and in-hospital mortality of STEMI patients' post-PPCI, as well as final thrombolysis in myocardial infarction (TIMI) flow. A cross-sectional study was performed from the database of Jakarta Acute Coronary Syndrome Registry, consisting of 3,071 STEMI patients who underwent PPCI between January 2014 and December 2019. No-reflow phenomenon was defined as final TIMI flow <3 of the infarct-related artery. Outcome measures were the occurrence of no-reflow and in-hospital mortality. Anemia criteria were based on the World Health Organization. Anemia was found in 550 patients (17.9%). Patients with anemia were older (60 ± 10 years, p < 0.001), predominantly women (20.7 vs. 11.2%, p < 0.001), TIMI risk score >4 (45.8 vs. 30.4%, p < 0.00), and Killip classification >1 (25.8 vs. 20.8%, p < 0.009). Anemia at admission was not associated with no-reflow phenomenon (odds ratio [OR] = 0.889; 95% confidence interval [CI] = 0.654–1.209, p = 0.455). Multivariate regression models showed that anemia was not associated with in-hospital mortality (OR = 0.963; 95% CI = 0.635–1.459, p = 0.857) and with no-reflow phenomenon (OR = 0.939; 95% CI = 0.361–2.437, p = 0.896). Anemia upon admission was not related to the no-reflow phenomena or in-hospital mortality in STEMI patients undergoing PPCI.

Gender-Associated Outcomes Following Percutaneous Coronary Intervention With a Third-Generation, Ultrathin-Strut Drug-Eluting Stent: A Real-World, Single-Center Experience

Introduction

In recent years, the new third-generation ultrathin bioresorbable-polymer sirolimus-eluting stent (BP-SES), characterized by some of the thinnest struts among commercially available devices (60–80 μm) and an amorphous silicon carbide coating, has been introduced for the treatment of coronary artery disease (CAD). The present study aimed to assess different clinical outcomes and safety of this drug-eluting stent in male and female patients in a real-world setting.

Methods

The present study is a retrospective analysis including all patients treated with BP-SES between January 2017 and December 2019 at a single high-volume center. Follow-up data, including stress test results and clinical setting, were collected during outpatient visits or by telephone contact. Patients symptomatic for angina or with a positive stress test were addressed to CT scan/coronary angiogram. The main study outcome was target lesion failure (TLF), defined as a composite of cardiovascular death, target vessel myocardial infarction, or target lesion revascularization.

Results

Overall, 66 (15.9%) female and 349 (84.1%) male patients were included; women were older (median age 70 vs. 66, P = 0.003) and with a lower body mass index (BMI) (25.0 vs. 26.1, P = 0.010) compared to men, with no other relevant differences in baseline characteristics. Indication for percutaneous coronary intervention (PCI) was acute coronary syndrome in 86 (20.7%) of the cases, with no significant differences between male and female patients. A total of 558 lesions were treated with BP-SES stents, 90 in women and 468 in men (1.36 vs. 1.34 lesions per patient, P = 0.83); cumulative stent length (33.6 vs. 38.4 mm, P = 0.078), and mean stent diameter (2.92 vs. 3.0 mm, P = 0.39) did not differ in women compared to men. Technical and clinical successes were achieved in all patients. Stent thrombosis (ST) occurred in 2 (0.5%) patients, both men. TLF occurred in 10 (2.9%) men and 2 (3.0%) women after a median follow-up of 402 days, without significant differences at log-rank analysis (2.34 events per 100 patient-years in men, 2.53 in women; P = 0.80).

Conclusion

Ultrathin struts BP-SES showed to be a safe and effective option for the treatment of CAD in both women and men, with a very low ST rate and favorable long-term outcomes.

Geschlechtsspezifische Unterschiede bei koronarer Herzerkrankung

Die koronare Herzerkrankung ist die häufigste Herzerkrankung bei Frauen und Männern. Geschlechtsspezifische Unterschiede in der Symptomatik, der Prognose und der Behandlung bei Patienten mit koronarer Herzerkrankung wurden bereits in zahlreichen Studien untersucht. Frauen sind älter, besitzen mehr Komorbiditäten, beklagen eher atypische Symptome, suchen später ärztliche Hilfe auf und werden weniger leitliniengerecht behandelt. In dem Artikel sollen geschlechtsspezifische Unterschiede bei Patienten mit akutem und chronischem Koronarsyndrom zusammengefasst werden.

Role of Gender on the Outcomes of ST-Elevation Myocardial Infarction Patients Following Primary Coronary Angioplasty

Background There are considerable differences in the prevalence of coronary artery disease (CAD) and its cardiovascular risk factors between men and women. Due to the significance of gender as a factor that potentially affects cardiovascular disorders and patient outcomes, the present study aimed to assess the baseline characteristics and outcomes of CAD patients in terms of gender distribution. Methods All consecutive patients diagnosed with ST-elevation myocardial infarction (MI) who had undergone primary percutaneous coronary intervention (PCI) in the previous two years in a comprehensive cardiology center were included. Data were retrospectively collected from the hospital record files. Color Doppler echocardiography, valvular involvement, and the type of coronary vessel involvement were also evaluated. Results In total, 557 consecutive patients (437 men and 120 women) were included with a mean age of 59.37 ± 26.23 years and 64.07 ± 11.60 years for men and women, respectively (p = 0.004). The prevalence of mitral regurgitation (MR) and tricuspid regurgitation (TR) was significantly higher among women than men. Conclusion Female patients who suffered from CAD and underwent PCI were older than men. Also, ischemic mitral regurgitation (MR) and tricuspid regurgitation (TR) were more prevalent among women, while smoking was more prevalent among men.

Review of the differences in outcomes between males and females after revascularization

PURPOSE OF REVIEW

This review aims to compare outcomes of males and females undergoing coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), off-pump CABG (OPCAB), minimally invasive direct CABG (MIDCAB), and robotic total endoscopic CABG (TECAB).

RECENT FINDINGS

Females demonstrated increased rates of morbidity and mortality post PCI and CABG. In studies that performed risk adjustments, these differences were reduced. Although inferior outcomes were observed for females in some measures, generally outcomes between males and females were comparable post OPCAB, MIDCAB, and TECAB.

SUMMARY

Previous literature has demonstrated that females undergoing coronary revascularization experience inferior postoperative outcomes when compared to their male counterparts. The discrepancies between males and females narrow, but do not disappear when preoperative risks are accounted for and when considering minimally invasive approaches such as MIDCAB, OPCAB, and TECAB. Minimally invasive cardiac surgery has demonstrated numerous benefits with reduced morbidity, mortality, and shorter recovery times. In patients with increased comorbidities, minimally invasive approaches confer a greater advantage. As females often fall within this category, it is paramount that the diagnosis and referral process be optimized to account for preoperative differences to provide the most beneficial approach if the disparity between the sexes is to be addressed.

Comparison of Long-Term Outcomes in Men versus Women Undergoing Percutaneous Coronary Intervention

There has been a significant decrease in mortality associated with coronary artery disease (CAD) in recent decades, although at discordant rates between men and women. Using a well-established multicenter registry, we sought to examine the impact of gender on long-term mortality stratified by indication for percutaneous coronary intervention (PCI). Data from 54,440 consecutive patients (12,805, 23.5% women) undergoing PCI from the Victorian Cardiac Outcomes Registry (2013 to 2018) were analyzed. We aimed to compare gender-related differences of patients undergoing PCI for stable angina pectoris (SAP), non-ST-elevation acute coronary syndrome (NSTEACS) and ST-elevation myocardial infarction (STEMI). The primary outcome was long-term all-cause mortality. Female patients were older across all indications (SAP: 67 vs 71 years, NSTEACS: 64 vs 69 years, STEMI 61 vs 67 years; p value for all <0.001), with age-adjusted higher rates of diabetes mellitus (p value for all <0.02) and renal impairment (p value for all <0.001), and were more likely to have femoral artery access for intervention (p value for all <0.001). Unadjusted in-hospital and 30-day mortality rates were comparable between men and women across all indications. Compared to men, women had a higher rate of unadjusted long-term mortality (9.0% vs 7.37%; p <0.001). However, after adjusting for variables significant on univariate analysis, female gender was independently associated with improved long-term survival (HR 0.76, 95% CI 0.66 to 0.87; p <0.001). In conclusion, contrary to previous studies, despite being older with a differing clinical profile and interventional approach, women undergoing PCI have a long-term survival advantage.

Managing Ischemic Heart Disease in Women: Role of a Women's Heart Center

PURPOSE OF REVIEW

Heart centers for women (HCW) were developed due to the rising cardiovascular morbidity and mortality in women in the United States in the early 1990s. Our review encompasses the epidemiology, risk factors, diagnostic strategies, treatments, and the role of HCW in managing women with ischemic heart disease (IHD).

RECENT FINDINGS

HCW use a multidisciplinary team to manage women with IHD. Due to the paucity of randomized controlled trials investigating various manifestations of IHD, some treatments are not evidence-based such as those for coronary microvascular dysfunction and spontaneous coronary artery dissection. Sex-specific risk factors have been identified and multimodality cardiac imaging is improving in diagnosing IHD in women. Treatments are being studied to help improve symptoms and outcomes in women with IHD. There has been progress in the care of women with IHD. HCW can be instrumental in treating women with IHD, doing research, and being a source of research study participants.

Differences in the reaction of hyperlipidemia on different endothelial progenitor cells based on sex

The sex of a patient can affect the outcomes of several cardiovascular diseases, and men generally tend to experience earlier episodes of cardiovascular diseases compared with women. The progression of atherosclerosis during hyperlipidemia can be induced by reactive oxygen species (ROS) and oxidized-low-density lipoprotein (ox-LDL). By contrast, bone marrow (BM)-derived endothelial progenitor cells (EPCs) have been reported to serve a protective role against atherosclerosis. The aim of the present was to compare the effects of sex under conditions of hyperlipidemia on different populations of EPCs, and to identify the potential underlying mechanisms. EPC numbers and ROS levels in the blood and BM were measured using fluorescence activated cell sorting in male and female LDL receptor knock-out C57BL/6 mice maintained on a high-fat diet for 6 months, and in male and female wild type C57BL/6 mice following ox-LDL injection for 3 days. Female hyperlipidemic mice exhibited lower levels of plasma lipids, atherosclerotic plaque formation, intracellular EPC ROS formation and inflammatory cytokine levels. Furthermore, BM CD34⁺/ fetal liver kinase-1 (Flk-1⁺), CD34⁺/CD133⁺ and stem cell antigen-1⁺/Flk-1⁺, as well as all circulating EPCs, were maintained at higher levels in female hyperlipidemic mice. In addition, similar changes with regards to BM CD34⁺/Flk-1⁺, CD34⁺/CD133⁺, c-Kit⁺/CD31⁺ and circulating CD34⁺/Flk1⁺ and CD34⁺/CD133⁺ EPCs were observed in female mice following ox-LDL treatment. These sustained higher levels of BM and circulating EPCs in female mice with hyperlipidemia may be associated with reduced levels of ox-LDL as a result of reduced intracellular ROS formation in EPCs and decreased inflammatory cytokine production.

Outcomes following the percutaneous coronary intervention in contemporary Vietnamese practice: Insight from a single centre prospective cohort

BACKGROUND

Evidence regarding the outcomes of percutaneous coronary intervention (PCI) in low-and-middle incomes countries remains limited.

OBJECTIVES

To report the outcomes post PCI at discharge, 30 days and 12 months in Vietnam and identify the key factors associated with adverse outcomes at 12 months.

METHODS

We used data from a single centre prospective cohort in Vietnam. Data regarding demographics, clinical presentation, procedural information, and outcomes of patients were collected and analysed. Primary outcomes were mortality and major adverse cardiac and cerebrovascular events.

RESULTS

In total, 926 patients were included. Poor outcomes were relatively low in those undergoing PCI. Predictors of mortality and major adverse cardiac and cerebrovascular events at 12 months post-PCI included being older than 75, being male, having acute myocardial infarction, left ventricular ejection fraction ≤ 40%, prior cerebral vascular disease and having an unsuccessful PCI.

CONCLUSIONS

Adverse outcomes of patients undergoing PCI in Vietnam are relatively low in comparison with those reported in other countries across the Asia Pacific region. Identification of factors associated with poor outcomes is beneficial for improving the quality of cardiac care and developing the prediction model of outcomes post-PCI in Vietnam.

Impact of type II diabetes and gender on major clinical events after percutaneous coronary intervention

AIMS

Incidence of type 2 diabetes is markedly rising worldwide. Some studies suggest that the occurrence of major adverse cardiac events (MACE) after PCI is different in men and women, but data are conflicting.

METHODS

We studied patients with stable coronary artery disease (CAD) who underwent PCI between years 2000 and 2017. Patients with primary PCI were excluded. Drug-eluting stent (DES) and dual antiplatelet therapy were administered in all patients. We followed these patients for a mean of 68 months. MACE as a composite of coronary revascularization, myocardial infarction or cardiovascular death was sought in three time windows.

RESULTS

We studied 1799 patients, 29.6% of whom with diabetes. Women were 52%. In multivariate analyses, there were no significant differences in the risk of MACE between diabetic and non-diabetic patients, as well as between men and women, neither in different time windows, nor in the whole duration of follow-up. The components of MACE did not show any significant differences between diabetic and non-diabetic patients, as well as between the genders.

CONCLUSION

In our patients with stable CAD who received a modern therapeutic management after PCI, neither type 2 diabetes nor gender were associated with an excess risk of MACE.

Establishment and validation of a risk model for prediction of in-hospital mortality in patients with acute ST-elevation myocardial infarction after primary PCI

Background

Currently, how to accurately determine the patient prognosis after a percutaneous coronary intervention (PCI) remains unclear and may vary among populations, hospitals, and datasets. The aim of this study was to establish a prediction model of in-hospital mortality risk after primary PCI in patients with acute ST-elevated myocardial infarction (STEMI).

Methods

This was a multicenter, observational study of patients with acute STEMI who underwent primary PCI. The outcome was in-hospital mortality. The least absolute shrinkage and selection operator (LASSO) method was used to select the features that were the most significantly associated with the outcome. A regression model was built using the selected variables to select the significant predictors of mortality. Receiver operating characteristic (ROC) curve and decision curve analysis (DCA) were used to evaluate the performance of the nomogram.

Results

Totally, 1169 and 316 patients were enrolled in the training and validation sets, respectively. Fourteen predictors were identified by the LASSO analysis: sex, Killip classification, left main coronary artery disease (LMCAD), grading of thrombus, TIMI classification, slow flow, application of IABP, administration of β-blocker, ACEI/ARB, symptom-to-door time (SDT), symptom-to-balloon time (SBT), syntax score, left ventricular ejection fraction (LVEF), and CK-MB peak. The mortality risk prediction nomogram achieved good discrimination for in-hospital mortality (training set: C-statistic = 0.987; model calibration: P = 0.722; validation set: C-statistic = 0.984, model calibration: P = 0.669). Area under the curve (AUC) values for the training and validation sets are 0.987 (95% CI: 0.981–0.994, P = 0.003) and 0.990 (95% CI: 0.987–0.998, P = 0.007), respectively. DCA shows that the nomogram can achieve good net benefit.

Conclusions

A novel nomogram was developed and is a simple and accurate tool for predicting the risk of in-hospital mortality in patients with acute STEMI who underwent primary PCI.

[Comorbidity and Gender of Patients at Risk of Hospital Mortality After Emergency Percutaneous Coronary Intervention]

Aim        To study gender aspects of comorbidity in evaluating the risk of in-hospital death for patients with acute coronary syndrome (ACS) after a percutaneous coronary intervention (PCI).Material and methods        The presented results are based on data of two ACS registries, the city of Sochi and RECORD-3. 986 patients were included into this analysis by two additional criteria, age &lt;70 years and PCI. 80% of the sample were men. Analysis of comorbidity severity was performed for all patients and included 9 indexes: type 2 diabetes mellitus, chronic kidney disease, atrial fibrillation, anemia, stroke, arterial hypertension, obesity, and peripheral atherosclerosis. Group 1 (minimum comorbidity) consisted of patients with not more than one disease (n=367); group 2 (moderate comorbidity) consisted of patients with 2 or 3 diseases (n=499), and group 3 (pronounced comorbidity) consisted of patients with 4 or more diseases (n=120). In-hospital mortality was 2.7 % (n=27).Results   Significant data on the effect of comorbidity on the in-hospital prognosis were obtained only for men of the compared groups: 0.6, 1.8, and 8.8 %, respectively (χ2=21.6; р&lt;0.0001). At the same time, among 44 women with minimum comorbidity, there were no cases of in-hospital death, and the presence of moderate (n=110) and pronounced comorbidity (n=40) was associated with a similar death rate (7.3 and 7.5 %, respectively). Noteworthy, in moderate comorbidity, the female gender was associated with a 4-fold increase in the risk of in-hospital death (odd ratio, OR 4.3 at 95 % confidence interval, CI from 1.5 to 12.1; р=0.003). In addition, both in men and women with minimum comorbidity, even a high risk by the GRACE scale (score ≥140) was not associated with increased in-hospital mortality, which was minimal (0 for women and 1 % for men). At the same time, in the patient subgroup with moderate and pronounced comorbidity, a GRACE score ≥140 resulted in a 6-fold increase in the risk of in-hospital death for men (OR 6.0 at 95 % CI from 1.7 to 21.9; р=0.002) and a 16-fold increase for women (OR 16.2 at 95 % CI from 2.0 to 130.4; р=0.0006).Conclusion            This study identified gender-related features in predicting the risk of in-hospital death for ACS patients with comorbidities after PCI, which warrants reconsideration of existing approaches to risk stratification.

Sex-related impacts on clinical outcomes after percutaneous coronary intervention

The aim of this study is to investigate sex-related impacts on clinical outcomes after percutaneous coronary intervention (PCI). We analyzed 90,305 patients (29.0% of women) with the first episode of coronary artery disease who underwent PCI from the Korean National Health Insurance claims database between July 2013 and June 2017. Women were significantly older than men (71.5 ± 10.5 vs. 61.8 ± 11.7 years, p < 0.001). The study population had a median follow-up of 2.2 years (interquartile range, 1.2–3.3). In the propensity-score matched angina population (15,104 pairs), the in-hospital mortality of women was not different from men (odds ratio, 0.87; 95% confidence interval: 0.71–1.08, p = 0.202). However, the post-discharge mortality of women was significantly lower (hazard ratio, 0.74; 95% confidence interval: 0.69–0.80, p < 0.001) than that of men. In the propensity-score matched acute myocardial infarction (AMI) population (8,775 pairs), the in-hospital mortality of women was significantly higher than that of men (odds ratio, 1.19; 95% confidence interval: 1.05–1.34, p = 0.006). Meanwhile, there was no difference in mortality after discharge (hazard ratio, 0.98; 95% confidence interval: 0.91–1.06, p = 0.605). The post-discharge mortality of women was not higher than men under the contemporary PCI treatment. Altered sex-related impacts on clinical outcomes might be attributed to improved medical and procedural strategies.

Estimated glomerular filtration rate as one of the main predictors of in-hospital mortality in Egyptian patients with ST elevation myocardial infarction: a two-year retrospective study

Background

Renal dysfunction is one of the major causes of in-hospital mortality in STEMI patients. In this study, we evaluated the combined predictive value of eGFR by CKD-EPI equation and shock index for in-hospital mortality and other adverse clinical outcomes in Egyptian patients with STEMI.

Results

A total of 450 STEMI patients were divided into 2 groups according to their eGFR with a cutoff value of 60 ml/min/1.73 m² and compared as regards mortality, major bleeding, reinfarction, development of heart failure, stroke, and atrial fibrillation during the period of admission. Univariate analysis was performed to define significant factors that affected mortality; then, significant factors were subjected to a multivariate logistic regression.

Patients with eGFR < 60 ml/min/1.73 m² had higher rates of mortality (P  < 0.0005) and atrial fibrillation (P  =  .006) during the hospital admission. A multivariate logistic regression model showed the predictors of mortality were factors SI (OR = 28.56, 95% CI 8–101.97, P < 0.0001), cardiac troponin (OR = 2.89, 95% CI 1.08–7.77, P = 0.03), age (OR = 1.07, 95% CI 1.02–1.2, P = 0.002), and eGFR (OR = 0.98, 95% CI 0.96–0.99, P = 0.04).

Conclusions

Estimated GFR < 60 ml/min/1.73 m² in STEMI patients is associated with higher rate of mortality. Estimated GFR, age, shock index, and cardiac troponin were the most significant predictors of mortality in STEMI patients

Continuity of care and its associations with self-reported health, clinical characteristics and follow-up services after percutaneous coronary intervention

AIMS

Complexity of care in patients with coronary artery disease is increasing, due to ageing, improved treatment, and more specialised care. Patients receive care from various healthcare providers in many settings. Still, few studies have evaluated continuity of care across primary and secondary care levels for patients after percutaneous coronary intervention (PCI). This study aimed to determine multifaceted aspects of continuity of care and associations with socio-demographic characteristics, self-reported health, clinical characteristics and follow-up services for patients after PCI.

METHODS

This multi-centre prospective cohort study collected data at baseline and two-month follow-up from medical records, national registries and patient self-reports. Univariable and hierarchical regressions were performed using the Heart Continuity of Care Questionnaire total score as the dependent variable.

RESULTS

In total, 1695 patients were included at baseline, and 1318 (78%) completed the two-month follow-up. Patients stated not being adequately informed about lifestyle changes, medication and follow-up care. Those experiencing poorer health status after PCI scored significantly worse on continuity of care. Patients with ST-segment elevation myocardial infarction scored significantly better on informational and management continuity than those with other cardiac diagnoses. The regression analyses showed significantly better continuity (P ≤ 0.034) in patients who were male, received written information from hospital, were transferred to another hospital before discharge, received follow-up from their general practitioner or had sufficient consultation time after discharge from hospital.

CONCLUSION

Risk factors for sub-optimal continuity were identified. These factors are important to patients, healthcare providers and policy makers. Action should be taken to educate patients, reconcile discharge plans and organise post-discharge services. Designing pathways with an interdisciplinary approach and shared responsibility between healthcare settings is recommended.

Differential Impact of Cigarette Smoking on Prognosis in Women and Men Undergoing Percutaneous Coronary Intervention

We sought to compare the effects of smoking on clinical outcomes in women and men with coronary artery disease undergoing percutaneous coronary intervention (PCI). We prospectively followed up 10 369 patients undergoing elective PCI. All patients were stratified according to smoking status and sex. The impacts of smoking on long-term major adverse cardiovascular events (MACEs, the composite of all-cause death, myocardial infarction, or target vessel revascularization) were assessed. Among 7773 men and 2596 women undergoing PCI, the prevalence of cigarette smoking was 66.7% (n = 5185) and 11.0% (n = 286; P < .001). During the 3 years of follow-up (median: 20.6 months), smoking increased MACE in both men and women (men 10.8% vs 8.1%, P < .001; women 23.2% vs 6.4%; P < .001). After adjusting for baseline characteristics, smoking had a greater effect on MACE in women (hazard ratio [HR]: 3.68, 95% confidence interval [CI]: 1.86-7.28; P < .001) compared with men (HR: 1.35, 95% CI: 1.03-1.77; P = .005, interaction P = .026). There was a lower prevalence of smoking in women compared to men among patients undergoing PCI. However, smoking confers a higher excess risk for MACE among women compared with men.

Outcomes After Percutaneous Coronary Intervention in Women: Are There Differences When Compared with Men?

Despite advances in the diagnosis and treatment of coronary artery disease, there remains evidence of a disparity in the outcomes for women when compared with men. This article provides a review of the evidence for this discrepancy and discusses some of the potential contributing factors.