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Schmitt A, Schupp T, Rusnak J, Ruka M, Egner-Walter S, Mashayekhi K, Tajti P, Ayoub M, Behnes M, Akin I, Weidner K. Does sex affect the risk of 30-day all-cause mortality in cardiogenic shock? Int J Cardiol 2023; 381:105-111. [PMID: 37004944 DOI: 10.1016/j.ijcard.2023.03.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Mortality rates following CS have stagnated on an unacceptably high level. Limited data regarding the prognostic value of sex in patients suffering from CS is available. Therefore, this study aims to investigate the prognostic value of sex in patients with cardiogenic shock (CS). METHODS Consecutive patients with CS of any cause were included from 2019 to 2021. Prognosis of females was compared to males regarding 30-day all-cause mortality. Further risk stratification was performed according to the presence or absence of CS related to acute myocardial infarction (AMI). Kaplan-Meier and multivariable Cox proportional regression analyses were used for statistics. RESULTS From a total of 273 CS patients (AMI-CS: 49%; non-AMI-CS: 51%), 60% were males and 40% females. The risk of 30-day all-cause mortality did not differ among males and females (56% vs. 56%; log rank p = 0.775; HR = 1.046; 95% CI 0.756-1.447; p = 0.785). Even after multivariable adjustment, sex was not associated with prognosis in CS patients (HR = 1.057; 95% CI 0.713-1.564; p = 0.784). Comparable risks of short-term mortality in both sexes were observed irrespective of the presence of AMI-related CS (64.0% vs. 64.6%; log rank p = 0.642; HR = 1.103; 95% CI 0.710-1.713; p = 0.664) and non-AMI-related CS (46.2% vs. 49.2%; log rank p = 0.696; HR = 1.099; 95% CI 0.677-1.783; p = 0.704). CONCLUSION Sex was not associated with the risk of 30-day all-cause mortality in CS patients irrespective of CS etiology. (clinicaltrials.gov identifier: NCT05575856).
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Affiliation(s)
- Alexander Schmitt
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, Lahr, Germany
| | - Péter Tajti
- Gottsegen György National Cardiovascular Center, Hungary
| | - Mohammed Ayoub
- Division of Cardiology and Angiology, Heart Center University of Bochum, Bad Oeynhausen, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany.
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
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Crilly J, Huang Y, Krahe M, Wilhelms D, Ekelund U, Hörlin E, Hayes J, Keijzers G. Research priority setting in emergency care: A scoping review. J Am Coll Emerg Physicians Open 2022; 3:e12852. [PMCID: PMC9742830 DOI: 10.1002/emp2.12852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 09/13/2022] [Accepted: 10/26/2022] [Indexed: 12/14/2022] Open
Abstract
Objective Priority areas for emergency care research are emerging and becoming ever more important. The objectives of this scoping review were to (1) provide a comprehensive overview of published emergency care priority‐setting studies by collating and comparing priority‐setting methodology and (2) describe the resulting research priorities identified. Methods The Joanna Briggs Institute methodological framework was used. Inclusion criteria were peer‐review articles available in English, published between January 1, 2008 and March 31, 2019 and used 2 or more search terms. Five databases (Scopus, AustHealth, EMBASE, CINAHL, and Ovid MEDLINE) were searched. REporting guideline for PRIority SEtting of health research (REPRISE) criteria were used to assess the quality of evidence of included articles. Results Forty‐five studies were included. Fourteen themes for emergency care research were considered within 3 overarching research domains: emergency populations (pediatrics, geriatrics), emergency care workforce and processes (nursing, shared decision making, general workforce, and process), and emergency care clinical areas (imaging, falls, pain management, trauma care, substance misuse, infectious diseases, mental health, cardiology, general clinical care). Variation in the reporting of research priority areas was evident. Priority areas to drive the global agenda for emergency care research are limited given the country and professional group‐specific context of existing studies. Conclusion This comprehensive summary of generated research priorities across emergency care provides insight into current and future research agendas. With the nature of emergency care being inherently broad, future priorities may warrant population (eg, children, geriatrics) or subspecialty (eg, trauma, toxicology, mental health) focus and be derived using a rigorous framework and patient engagement.
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Affiliation(s)
- Julia Crilly
- Department of Emergency MedicineGold Coast Hospital and Health ServiceQueenslandGold CoastAustralia,School of Nursing and MidwiferyGriffith UniversityGold CoastQueenslandAustralia,Menzies Health Institute QueenslandGriffith UniversityGold CoastQueenslandAustralia
| | - Ya‐Ling Huang
- Department of Emergency MedicineGold Coast Hospital and Health ServiceQueenslandGold CoastAustralia,School of Nursing and MidwiferyGriffith UniversityGold CoastQueenslandAustralia,Faculty of Health (Nursing)Southern Cross UniversityQueenslandGold CoastAustralia
| | - Michelle Krahe
- Office of the Pro Vice Chancellor (Indigenous)Griffith UniversityMeadowbrookQueenslandAustralia
| | - Daniel Wilhelms
- Department of Emergency MedicineLocal Health Care ServicesCentral ÖstergötlandLinköpingSweden,Department of Biomedical and Clinical SciencesLinköping UniversitySweden
| | - Ulf Ekelund
- Department of Clinical SciencesFaculty of MedicineLund UniversityLundSweden
| | - Erika Hörlin
- Department of Emergency MedicineLocal Health Care ServicesCentral ÖstergötlandLinköpingSweden,Department of Biomedical and Clinical SciencesLinköping UniversitySweden
| | - Jessica Hayes
- Department of Emergency MedicineGold Coast Hospital and Health ServiceQueenslandGold CoastAustralia,School of Nursing and MidwiferyGriffith UniversityGold CoastQueenslandAustralia
| | - Gerben Keijzers
- Department of Emergency MedicineGold Coast Hospital and Health ServiceQueenslandGold CoastAustralia,Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia,School of MedicineGriffith UniversityGold CoastQueenslandAustralia
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Truesdell AG, Ofosu-Somuah A, Ibrahim NE. In Search of Cardiogenic Shock Equity, Equality, and Justice…. JACC Cardiovasc Interv 2022; 15:653-655. [PMID: 35331457 DOI: 10.1016/j.jcin.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander G Truesdell
- Virginia Heart, Falls Church, Virginia, USA; Inova Heart and Vascular Institute, Falls Church, Virginia, USA.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 319] [Impact Index Per Article: 106.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 152] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Gaeta M, Nowroozpoor A, Dziura J, D'Onofrio G, Sinusas AJ, Safdar B. Use of peripheral arterial tonometry in detection of abnormal coronary flow reserve. Microvasc Res 2021; 138:104223. [PMID: 34256085 DOI: 10.1016/j.mvr.2021.104223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/05/2021] [Accepted: 07/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND We assessed the utility of EndoPAT, a device that measures reactive hyperemia index (RHI) as a clinical screening tool for identifying low coronary flow reserve (CFR). Distinguishing normal from low CFR aids assessment for coronary microvascular dysfunction (CMD) or large vessel coronary artery disease (CAD). METHODS From June 2014-May 2019, in a convenience sample, we measured RHI in adults undergoing clinically indicated cardiac Rubidium-82 positron emission tomography/computed tomography (PET/CT) at a single center. Exclusion criteria were inability to consent, lack of English proficiency, and physical limitation. We defined low RHI as <1.67 and low CFR as <2.5. Distribution of RHI was skewed so we used its natural logarithm (LnRHI) to calculate Pearson correlation and area under the curve (AUC). RESULTS Of 265 patients with PET/CT, we enrolled 131, and 100 had adequate data. Patients had a mean age of 61 years (SD = 12), 46% were female, 29% non-white. Thirty-six patients had low RHI, and 60 had depressed CFR. LnRHI did not distinguish patients with low from normal CFR (AUC = 0.53; 95% Cl, 0.41-0.64) and did not correlate with CFR (r = -0.021, p = 0.83). Low RHI did not distinguish patients with traditional CAD risk factors, presence of calcification, or perfusion defect (p > 0.05). Conversely, mean augmentation index, a measure of arterial stiffness, was higher with low RHI (p = 0.005) but not CFR (p = 0.625). RHI was lower in patients we identified as CMD (low CFR, no perfusion defect and calcium score of 0) (1.88 versus 2.21, p = 0.35) although we were underpowered (n = 12) to meet statistical significance. CONCLUSIONS Peripheral RHI is insufficient as a clinical screening tool for low CFR as measured by cardiac PET/CT. Differences in vascular pathology assessed by each method may explain this finding.
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Affiliation(s)
- Marina Gaeta
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Armin Nowroozpoor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - James Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Albert J Sinusas
- Department of Medicine (Section of Cardiology), Yale School of Medicine, New Haven, CT, United States of America
| | - Basmah Safdar
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America.
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Gender Disparities in Cardiac Catheterization Rates Among Emergency Department Patients With Chest Pain. Crit Pathw Cardiol 2021; 20:67-70. [PMID: 33116062 DOI: 10.1097/hpc.0000000000000247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Previous studies have noted differences in rates of cardiac testing based on gender of patients. We evaluated cardiac catheterization rates for men and women presenting to the emergency department (ED) with chest pain, particularly among patients without a history of myocardial infarction (MI) or recent positive stress test. METHODS We performed a prospective evaluation of patients presenting to an urban, academic medical center for assessment of chest pain. We recorded baseline information, testing, and outcomes related to ED, observation unit, and inpatient stay. Primary outcomes included gender differences in cardiac catheterization and stenting rates among patients without an MI or positive stress test. RESULTS Over the 5.5 year study period, 2242 ED patients with chest pain participated in the study (45% male). Men and women had similar rates of cardiac stress testing (16.7% vs. 15.2%, P = 0.317) as well as similar rates of positive cardiac stress testing (2.9% vs. 1.9%, P = 0.116). Men were more likely to undergo cardiac catheterization (10.4% vs. 4.9%, P < 0.001). Men who had neither MI nor positive stress test were more likely than women to undergo cardiac catheterization: 5.8% versus 3.3%, P = 0.010. Similarly, men in this group were more likely to experience stent placement: 2.1% versus 0.7%, P = 0.003. CONCLUSIONS Similar to previous studies, we noted disparities in cardiac testing by gender. Men were more likely to go to cardiac catheterization without an MI or a positive stress test. This disparity in a more aggressive strategy of cardiac catheterization in men may result in higher stenting rates in this group.
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Sella YO, Manistamara H, Apriliawan S, Lukitasari M, Rohman MS. Characteristic differences of chest pain in male and female patients with acute coronary syndrome: A pilot study. J Public Health Res 2021; 10. [PMID: 33855424 PMCID: PMC8129765 DOI: 10.4081/jphr.2021.2242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/07/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The typical sign or main symptom in acute coronary syndrome (ACS) patients is chest pain, which is an initial benchmark or early sign for diagnosis. Certain factors, such as gender differences, the presence of diabetes mellitus or other clinical conditions, may make the patient not realize they have ACS. Therefore, this study aims to identify the characteristics of chest pain symptoms in male and female patients with ACS. Design and Methods: This is a non-experimental quantitative study, namely analytical observation using a cross-sectional approach within 4 months (January-April 2019). Furthermore, the samples were 53 ACS patients (28 male and 25 female). Results: The chest pain characteristics that have a significant relationship with gender differences in ACS patients are shown based on the aspects of location, pain duration and quality. Male patients are more likely to feel pain at the left or middle chest, the duration is between <20 to >20 min with moderate pain quality, which tends to become severe, while females are more likely to feel pain at the chest which radiates to the neck and chin, the duration is usually >20 min, with mild to moderate pain quality. Conclusions: The result showed a significant difference in chest pain characteristics in male and female patients with ACS. Regarding location, duration and quality of chest pain, male ACS patients mostly have more typical symptoms, while females’ symptoms are atypical. Significance for public health There are various characteristics of chest pain differences between male and female patients with Acute Coronary Syndrome. The findings of this study showed that it is important to provide optimal nursing care and also educate patients and families about the signs, or symptoms that often occur, especially atypical symptoms. This will reduce the tendency to delay in seeking treatment, which will affect prehospital delay time.
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Affiliation(s)
| | | | - Sony Apriliawan
- Department of Nursing, Faculty of Medicine, Universitas Brawijaya, Malang.
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Jarman AF, Mumma BE, Singh KS, Nowadly CD, Maughan BC. Crucial considerations: Sex differences in the epidemiology, diagnosis, treatment, and outcomes of acute pulmonary embolism in non-pregnant adult patients. J Am Coll Emerg Physicians Open 2021; 2:e12378. [PMID: 33532761 PMCID: PMC7839235 DOI: 10.1002/emp2.12378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/30/2020] [Accepted: 01/06/2021] [Indexed: 12/12/2022] Open
Abstract
Acute pulmonary embolism (PE) affects over 600,000 Americans per year and is a common diagnostic consideration among emergency department patients. Although there are well-documented differences in the diagnosis, treatment, and outcomes of cardiovascular conditions, such as ischemic heart disease and stroke, the influence of sex and gender on PE remains poorly understood. The overall age-adjusted incidence of PE is similar in women and men, but women have higher relative rates of PE during early and mid-adulthood (ages 20-40 years); whereas, men have higher rates of PE after age 60 years. Women are tested for PE at far higher rates than men, yet women who undergo computed tomography pulmonary angiography are ultimately diagnosed with PE 35%-55% less often than men. Among those diagnosed with PE, women are more likely to have severe clinical features, such as hypotension and signs of right ventricular dysfunction. When controlled for PE severity, women are less likely to receive reperfusion therapies, such as thrombolysis. Finally, women have more bleeding complications for all types of anticoagulation. Further investigation of possible sex-specific diagnostic and treatment algorithms is necessary in order to more accurately detect and treat acute PE in non-pregnant adults.
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Affiliation(s)
- Angela F. Jarman
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Bryn E. Mumma
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Kajol S. Singh
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Craig D. Nowadly
- Department of Emergency Medicine, Davis School of MedicineUniversity of California, DavisSacramentoCaliforniaUSA
| | - Brandon C. Maughan
- Department of Emergency MedicineOregon Health and Science UniversityPortlandOregonUSA
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Lei H, Hu J, Liu L, Xu D. Sex differences in survival after out-of-hospital cardiac arrest: a meta-analysis. Crit Care 2020; 24:613. [PMID: 33076963 PMCID: PMC7570116 DOI: 10.1186/s13054-020-03331-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 10/06/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a leading cause of sudden cardiac death worldwide. Researchers have found significant pathophysiological differences between females and males and clinically significant sex differences related to medical services. However, conflicting results exist and there is no uniform agreement regarding sex differences in survival and prognosis after OHCA. Therefore, we investigated the relationship between the prognosis of OHCA and sex factors. METHODS We comprehensively searched the PubMed, Embase, and Cochrane databases and obtained a total of 1042 articles, from which 33 studies were selected for inclusion. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a random-effects model. RESULTS The meta-analysis included 1,268,664 patients. Compared with males, females were older (69.7 years vs. 65.4 years, p < 0.05) and more frequently suffered OHCA without witnesses (58.39% vs 62.70%, p < 0.05). Females were less likely to receive in-hospital interventions than males. There was no significant difference between females and males in the survival from OHCA to hospital admission (OR 0.99, 95% CI 0.89-1.1). However, females had lower chances for survival from hospital admission to discharge (OR 0.59, 95% CI 0.48-0.73), overall survival to hospital discharge (OR 0.73, 95% CI 0.62-0.86), and favorable neurological outcomes (OR 0.62, 95% CI 0.47-0.83) compared with males. CONCLUSIONS Our results indicate that the overall discharge survival rate of females is lower than that of males, and females face a poor prognosis of the nervous system. This is likely related to the pathophysiological characteristics of females, more conservative treatment measures compared with males, and different post-resuscitation care. However, these findings should be interpreted with caution due to the presence of several confounding factors.
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Affiliation(s)
- Hao Lei
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, 410011 Hunan China
| | - Jiahui Hu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, 410011 Hunan China
| | - Leiling Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, 410011 Hunan China
| | - Danyan Xu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, 410011 Hunan China
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He S, Qu L, He X, Zhang D, Xie N. Comparative evaluation of 15-minute rapid diagnosis of ischemic heart disease by high-sensitivity quantification of cardiac biomarkers. Exp Ther Med 2020; 20:1702-1708. [PMID: 32742399 PMCID: PMC7388240 DOI: 10.3892/etm.2020.8853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 04/17/2020] [Indexed: 12/05/2022] Open
Abstract
A rapid clinical diagnosis may efficiently improve the survival rate and prognosis of patients with ischemic heart disease (IHD). Therefore, a one-step, rapid and inexpensive analysis for the quick diagnosis of IHD was investigated in the present study. Consecutive patients who were subjected to myoglobin, cardiac troponin I and creatine kinase-MB isoenzyme assessment at the Emergency Department of Shenzhen Second People's Hospital (Shenzhen, China) between December 2017 and March 2018 prior to treatment were screened. Clinically applicable disposable strips were employed for quantification of the cardiac biomarkers. The analytical performance of the strips was evaluated by receiver operating characteristic (ROC) curves and compared with the traditional chemiluminescence immunoassay (CLIA) method. The data of 391 participants were collected. At the baseline, 57 patients were diagnosed with IHD and 334 patients were diagnosed with other diseases. The area under the ROC curve (AUC) of the CLIA model was 0.787 (95% CI, 0.709-0.865) with a specificity of 76.7% and a sensitivity of 71.9%. At the optimal cutoff value of -1.867, the negative and the positive predictive value were 94.1 and 34.5%, respectively. The AUC of the disposable strip model was 0.792 (95% CI, 0.729-0.855). At the cutoff value of -1.820 or below, the negative predictive value was 94.9%, the positive predictive value was 28.9%, the specificity was 66.8% and the sensitivity was 79.0%. The P-value of the ROCs was 0.858, indicating no statistically significant difference between the two assay methods. The cost of the disposable strip was 50% of that of the CLIA method and it took only 25% of the time that was required for the quantification of the three cardiac markers by CLIA. In conclusion, the disposable strip provides a platform for point-of-care testing and may be an easy, rapid, reliable and cost-saving method for the diagnosis of IHD.
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Affiliation(s)
- Shengnan He
- Institute of Translational Medicine, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong 518035, P.R. China
| | - Long Qu
- Institute of Translational Medicine, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong 518035, P.R. China
| | - Xi He
- Institute of Translational Medicine, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong 518035, P.R. China
| | - Dan Zhang
- Institute of Translational Medicine, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong 518035, P.R. China
| | - Ni Xie
- Institute of Translational Medicine, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong 518035, P.R. China
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Fodeh SJ, Li T, Jarad H, Safdar B. Classification of Patients with Coronary Microvascular Dysfunction. IEEE/ACM TRANSACTIONS ON COMPUTATIONAL BIOLOGY AND BIOINFORMATICS 2020; 17:704-711. [PMID: 31056516 DOI: 10.1109/tcbb.2019.2914442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
While coronary microvascular dysfunction (CMD) is a major cause of ischemia, it is very challenging to diagnose due to lack of CMD-specific screening measures. CMD has been identified as one of the five priority areas of investigation in a 2014 National Research Consensus Conference on Gender-Specific Research in Emergency Care. In this study, we utilized methods from machine learning that leverage structured and unstructured narratives in clinical notes to detect patients with CMD. We have shown that structured data are not sufficient to detect CMD and integrating unstructured data in the computational model boosts the performance significantly.
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14
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Jarman AF, Mumma BE, Perman SM, Kotini-Shah P, McGregor AJ. When the Female Heart Stops: Sex and Gender Differences in Out-of-Hospital Cardiac Arrest Epidemiology and Resuscitation. Clin Ther 2019; 41:1013-1019. [PMID: 31053294 DOI: 10.1016/j.clinthera.2019.03.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/21/2019] [Accepted: 03/27/2019] [Indexed: 11/16/2022]
Abstract
Sex- and gender-based differences are emerging as clinically significant in the epidemiology and resuscitation of patients with out-of-hospital cardiac arrest (OHCA). Female patients tend to be older, experience arrest in private locations, and have fewer initial shockable rhythms (ventricular fibrillation/ventricular tachycardia). Despite standardized algorithms for the management of OHCA, women are less likely to receive evidence-based interventions, including advanced cardiac life support medications, percutaneous coronary intervention, and targeted temperature management. While some data suggest a protective mechanism of estrogen in the heart, brain, and kidney, its role is incompletely understood. Female patients experience higher mortality from OHCA, prompting the need for sex-specific research.
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Affiliation(s)
- Angela F Jarman
- Department of Emergency Medicine, University of California-Davis, Sacramento, CA, USA.
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California-Davis, Sacramento, CA, USA
| | - Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Alyson J McGregor
- Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, RI, USA
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15
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Safdar B, Guo X, Johnson C, D'Onofrio G, Dziura J, Sinusas AJ, Testani J, Rao V, Desir G. Elevated renalase levels in patients with acute coronary microvascular dysfunction - A possible biomarker for ischemia. Int J Cardiol 2019; 279:155-161. [PMID: 30630613 PMCID: PMC6482834 DOI: 10.1016/j.ijcard.2018.12.061] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 12/21/2018] [Indexed: 12/20/2022]
Abstract
AIMS We explored the relationship between inflammation, renalase an anti-inflammatory protein, and acute chest pain with coronary microvascular dysfunction (CMD). METHODS AND RESULTS We used cardiac Rb-82 PET/CT imaging to diagnose coronary artery disease (CAD/CALC) (defect or coronary calcification) and CMD (depressed coronary flow reserve without CAD) in patients with chest pain in an emergency department (ED). Blood samples were collected pre-imaging within 24 h of ED presentation and were analyzed for renalase and inflammatory markers including C-reactive protein, interleukins, interferon gamma, tumor necrosis factor, vascular endothelial growth factor, and metalloproteinases. Exclusions were age ≤30 years, myocardial infarction, hemodynamic instability, hypertensive crisis, heart failure or dialysis. Between 6/2014 and 11/2015, 80 patients undergoing PET/CT provided blood and were categorized as normal (18%), CAD/CALC (27%) and CMD (55%). Median renalase values were highest in patients with CMD (5503 ng/ml; IQR 3070) compared to patients with normal flows (4266 ng/ml; IQR 1503; p = 0.02) or CAD/CALC (4069 ng/ml IQR 1850; p = 0.004). CMD patients had similar median values for inflammatory markers as normal patients (p > 0.05). Renalase remained an independent predictor of CMD (OR 1.34; 95% CI = 1.1-1.7, per 1000 ng/ml) after adjustment for smoking, family history, obesity and Framingham risk score. In a model for CMD diagnosis with Framingham risk score, typical angina history and CRP, renalase improved discrimination from C-statistic = 0.60 (95% CI 0.47, 0.73) to 0.70 (95% CI, 0.59-0.82). CONCLUSION We found elevated renalase in response to ischemia from acute CMD. Its role as a biomarker needs validation in larger trials.
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Affiliation(s)
- Basmah Safdar
- Department of Emergency Medicine, New Haven, CT, United States of America.
| | - Xiaojia Guo
- Department of Internal Medicine (Section of Nephrology), New Haven, CT, United States of America
| | - Caitlin Johnson
- Department of Emergency Medicine, New Haven, CT, United States of America
| | - Gail D'Onofrio
- Department of Emergency Medicine, New Haven, CT, United States of America
| | - James Dziura
- Yale Center for Analytical Sciences, New Haven, CT, United States of America
| | - Albert J Sinusas
- Department of Internal Medicine (Section of Cardiology), New Haven, CT, United States of America
| | - Jeffrey Testani
- Department of Internal Medicine (Section of Cardiology), New Haven, CT, United States of America
| | - Veena Rao
- Department of Internal Medicine (Section of Nephrology), New Haven, CT, United States of America; Department of Internal Medicine (Section of Cardiology), New Haven, CT, United States of America
| | - Gary Desir
- Department of Internal Medicine (Section of Nephrology), New Haven, CT, United States of America
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16
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Araújo C, Laszczyńska O, Viana M, Melão F, Henriques A, Borges A, Severo M, Maciel MJ, Moreira I, Azevedo A. Sex differences in presenting symptoms of acute coronary syndrome: the EPIHeart cohort study. BMJ Open 2018; 8:e018798. [PMID: 29476027 PMCID: PMC5855399 DOI: 10.1136/bmjopen-2017-018798] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 12/22/2017] [Accepted: 01/02/2018] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Prompt diagnosis of acute coronary syndrome (ACS) remains a challenge, with presenting symptoms affecting the diagnosis algorithm and, consequently, management and outcomes. This study aimed to identify sex differences in presenting symptoms of ACS. DESIGN Data were collected within a prospective cohort study (EPIHeart). SETTING Patients with confirmed diagnosis of type 1 (primary spontaneous) ACS who were consecutively admitted to the Cardiology Department of two tertiary hospitals in Portugal between August 2013 and December 2014. PARTICIPANTS Presenting symptoms of 873 patients (227 women) were obtained through a face-to-face interview. OUTCOME MEASURES Typical pain was defined according to the definition of cardiology societies. Clusters of symptoms other than pain were identified by latent class analysis. Logistic regression was used to quantify differences in presentation of ACS symptoms by sex. RESULTS Chest pain was reported by 82% of patients, with no differences in frequency or location between sexes. Women were more likely to feel pain with an intensity higher than 8/10 and this association was stronger for patients aged under 65 years (interaction P=0.028). Referred pain was also more likely in women, particularly pain referred to typical and atypical locations simultaneously. The multiple symptoms cluster, which was characterised by a high probability of presenting with all symptoms, was almost fourfold more prevalent in women (3.92, 95% CI 2.21 to 6.98). Presentation with this cluster was associated with a higher 30-day mortality rate adjusted for the GRACE V.2.0 risk score (4.9% vs 0.9% for the two other clusters, P<0.001). CONCLUSIONS While there are no significant differences in the frequency or location of pain between sexes, women are more likely to feel pain of higher intensity and to present with referred pain and symptoms other than pain. Knowledge of these ACS presentation profiles is important for health policy decisions and clinical practice.
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Affiliation(s)
- Carla Araújo
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Serviço de Cardiologia, Centro Hospitalar de Trás-os-Montes e Alto Douro, EPE, Hospital de São Pedro, Vila Real, Portugal
| | - Olga Laszczyńska
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Marta Viana
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Filipa Melão
- Serviço de Cardiologia, Centro Hospitalar São João, EPE, Porto, Portugal
| | - Ana Henriques
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Andreia Borges
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Milton Severo
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Maria Júlia Maciel
- Serviço de Cardiologia, Centro Hospitalar São João, EPE, Porto, Portugal
| | - Ilídio Moreira
- Serviço de Cardiologia, Centro Hospitalar de Trás-os-Montes e Alto Douro, EPE, Hospital de São Pedro, Vila Real, Portugal
| | - Ana Azevedo
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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17
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McGregor AJ, Beauchamp GA, Wira CR, Perman SM, Safdar B. Sex as a Biological Variable in Emergency Medicine Research and Clinical Practice: A Brief Narrative Review. West J Emerg Med 2017; 18:1079-1090. [PMID: 29085541 PMCID: PMC5654878 DOI: 10.5811/westjem.2017.8.34997] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/18/2017] [Accepted: 08/21/2017] [Indexed: 12/16/2022] Open
Abstract
The National Institutes of Health recently highlighted the significant role of sex as a biological variable (SABV) in research design, outcome and reproducibility, mandating that this variable be accounted for in all its funded research studies. This move has resulted in a rapidly increasing body of literature on SABV with important implications for changing the clinical practice of emergency medicine (EM). Translation of this new knowledge to the bedside requires an understanding of how sex-based research will ultimately impact patient care. We use three case-based scenarios in acute myocardial infarction, acute ischemic stroke and important considerations in pharmacologic therapy administration to highlight available data on SABV in evidence-based research to provide the EM community with an important foundation for future integration of patient sex in the delivery of emergency care as gaps in research are filled.
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Affiliation(s)
- Alyson J McGregor
- Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Division of Sex and Gender in Emergency Medicine, Providence, Rhode Island
| | - Gillian A Beauchamp
- Oregon Health & Science University, Department of Emergency Medicine, Portland, Oregon
| | - Charles R Wira
- Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Sarah M Perman
- University of Colorado, School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Basmah Safdar
- Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
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18
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Volpe M, Uglietti A, Castagna A, Mussini C, Marchetti G, Bellagamba R, Bini T, Mancusi D, Termini R. Cardiovascular disease in women with HIV-1 infection. Int J Cardiol 2017; 241:50-56. [PMID: 28285796 DOI: 10.1016/j.ijcard.2017.02.117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 01/30/2017] [Accepted: 02/24/2017] [Indexed: 12/14/2022]
Abstract
Cardiovascular disease is a leading cause of death in women, nevertheless it is often underestimated in female patients without overt risk factors. The chronic infection by Human Immunodeficiency Virus (HIV) is clearly associated, along with the use of certain antiretroviral drugs and traditional risk factors, with an increased risk of cardiovascular diseases. The aim of this manuscript is to review the epidemiology, risk factors, pathogenesis, diagnostic approach, primary and secondary prevention strategies of cardiovascular disease in HIV-negative and HIV-positive female subjects. The ultimate goal is to promote knowledge and development of specific and appropriate clinical interventions and guidelines in this group of high-risk patients, mostly in view of the expected growth of ageing females with HIV.
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Affiliation(s)
- Massimo Volpe
- Cardiology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189, University of Rome Sapienza, Italy; IRCCS Neuromed, IS, Italy.
| | | | | | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Marchetti
- Department of Health Sciences, Clinic of Infectious Diseases, University of Milan, ASST Santi Paolo and Carlo, Milan, Italy
| | | | - Teresa Bini
- Department of Health Sciences, Clinic of Infectious Diseases, University of Milan, ASST Santi Paolo and Carlo, Milan, Italy
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19
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Musey PI, Kline JA. Do Gender and Race Make a Difference in Acute Coronary Syndrome Pretest Probabilities in the Emergency Department? Acad Emerg Med 2017; 24:142-151. [PMID: 27862670 DOI: 10.1111/acem.13131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 10/07/2016] [Accepted: 10/26/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The objective was to test for significant differences in subjective and objective pretest probabilities for acute coronary syndrome (ACS) in a large cohort of chest pain patients stratified by race or gender. Secondarily we wanted to test for any differences in rates of ACS, rates of 90-day returns, cost, and chest radiation exposure after these stratifications. METHODS This is a secondary analysis of a prospective outcomes study of ED patients with chest pain and shortness of breath. We performed two separate analyses. The data set was divided by gender for analysis 1 while the analysis 2 stratification was made by race (nonwhite vs. white). For each analysis, groups were compared on several variables: provider visual analog scales (VAS) for likelihood of ACS, PREtest Consult ACS probabilities, rates of ACS, total radiation exposure to the chest, total costs at 30 days, and 90-day recidivism (ED, overnight observations, and inpatient admissions). RESULTS A total of 844 patients were studied. Gender information was present on all 844 subjects, while complete race/ethnicity information was available on 783 (93%) subjects. For the first analysis, female patients made up 57% (478/844) of the population and their mean provider VAS scores for ACS were significantly lower (p = 0.000) at 14% (95% confidence interval [CI] = 13% to 16%) than that of males at 22% (95% CI = 19% to 24%). This was consistent with the objective pretest ACS probabilities subsequently calculated via the validated online tool, PREtest Consult, which were also significantly lower (p = 0.000) at 2.7% (95% CI = 2.4% to 3.1%) for females versus 6.6% (95% CI = 5.9% to 7.3%) for males. However, comparing females to males, there was no significant difference in diagnosis of ACS (3.6% vs. 1.6%), mean chest radiation doses (5.0 mSv vs. 4.9 mSv), total costs at 30 days ($3,451.24 vs. $3,847.68), or return to the ED within 90 days (26% each). For analysis 2 by race, nonwhite patients also comprised 57% (444/783) of individuals. Similar to the gender analysis, mean provider VAS scores for ACS were found to be significantly lower (p = 0.000) at 15% (95% CI = 13% to 16%) for nonwhite versus 20% (95% CI = 18% to 23%) for white subjects. Concordantly, objective pretest ACS probabilities were also significantly lower (p = 0.000) at 3.4% (95% CI = 2.9% to 3.9%) for nonwhite versus 5.3% (95% CI = 4.7% to 5.9%) for white subjects. There were no significant differences in outcomes in nonwhite versus white subjects when compared on diagnosis of ACS (3.2% vs 2.4%), mean chest radiation dose (4.6 mSv vs. 5.0 mSv), cost ($3,156.02 vs. $2,885.18), or 90-day ED returns (28% vs. 23%). CONCLUSIONS Despite consistently estimating the risk for ACS to be lower for both females and minorities concordantly with calculated objective pretest assessments, there does not appear to have been any significant decrease in subsequent evaluation of these perceived lower-risk groups when radiation exposure and costs are taken into account. Further studies on the impact of pretest assessments on gender and racial disparities in ED chest pain evaluation are needed.
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Affiliation(s)
- Paul I. Musey
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
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20
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Safdar B, D'Onofrio G, Dziura J, Russell RR, Johnson C, Sinusas AJ. Ranolazine and Microvascular Angina by PET in the Emergency Department: Results From a Pilot Randomized Controlled Trial. Clin Ther 2017; 39:55-63. [PMID: 28081848 DOI: 10.1016/j.clinthera.2016.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/02/2016] [Accepted: 12/02/2016] [Indexed: 01/09/2023]
Abstract
PURPOSE Coronary microvascular dysfunction (CMD) is a common but underdiagnosed cause of chest pain. Literature is scant regarding effective treatments. We explored the effect of ranolazine on coronary flow reserve (CFR) among symptomatic patients with CMD. METHODS This pilot double-blinded randomized controlled trial included emergency department patients with chest pain and CMD admitted to an observation unit between June 2014 and November 2015. Participants were assessed by cardiac Rb-82 positron emission tomography and computed tomography imaging at baseline and 30 days. CMD was defined as CFR <2 corrected for rate pressure product or <2.5 uncorrected, with no evidence of obstructive or nonobstructive coronary artery disease or calcification. Patients with infarction, hypertensive urgency, heart failure, or prescribed QTc-prolonging drugs were excluded. Participants were assigned to ranolazine or placebo in a 2:1 ratio. Primary outcome was change in CFR at 30 days. FINDINGS We enrolled 31 patients (71% female, mean [SD] age 50 [6] years) with CMD (mean [SD] corrected CFR 1.6 [0.3]). Ranolazine improved CFR at 30 days by 17% (P = 0.005) compared with 0% with placebo (P = 0.67). However, there was no significant difference in the primary outcome as measured by mean change in CFR (0.27 ranolazine compared with 0.06 placebo; 95% CI, -0.08 to 0.62). IMPLICATIONS The emergency department offers a unique venue to diagnose CMD with acute symptoms. In an exploratory randomized controlled trial of symptomatic patients with CMD and no coronary artery disease, promising results were seem with ranolazine and CFR improving at 30 days. Large robust clinical trials are needed to verify improvement of CMD in a sex-specific model. ClinicalTrials.gov identifier NCT02052011.
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Affiliation(s)
- Basmah Safdar
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - James Dziura
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut; Yale Center for Analytical Sciences, New Haven, Connecticut
| | - Raymond R Russell
- Department of Internal Medicine, Section of Cardiovascular Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Caitlin Johnson
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Albert J Sinusas
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
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21
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Michelsen MM, Mygind ND, Frestad D, Prescott E. Women with Stable Angina Pectoris and No Obstructive Coronary Artery Disease: Closer to a Diagnosis. Eur Cardiol 2017; 12:14-19. [PMID: 30416544 DOI: 10.15420/ecr.2016:33:2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
A large proportion of women with chest pain have no obstructive coronary artery disease. Recent studies have demonstrated that these women continue to have symptoms and are at increased risk of cardiovascular morbidity and mortality. Coronary microvascular dysfunction (CMD) leads to an impairment of blood flow regulation to the myocardium and possible transient ischaemia. CMD is a disease entity with several pathophysiologic aspects and diagnostic modalities continue to be developed. However, due to the complexity of the disease, it remains elusive whether CMD is the explanation for the symptoms and the poor prognosis in women with angina and no obstructive coronary artery disease.
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Affiliation(s)
- Marie Mide Michelsen
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen Copenhagen, Denmark
| | - Naja Dam Mygind
- Department of Cardiology, Rigshospitalet, University of Copenhagen Copenhagen, Denmark
| | - Daria Frestad
- Department of Cardiology, Hvidovre Hospital, University of Copenhagen Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen Copenhagen, Denmark
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22
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Women and Chest Pain: Recognizing the Different Faces of Angina in the Emergency Department. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2016; 89:227-38. [PMID: 27354848 PMCID: PMC4918863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Emergency departments (ED) in the United States see over eight million cases of chest pain annually. While a cardinal symptom of acute coronary syndrome (ACS), multiple emergent and non-emergent causes can attribute to chest pain. This case-based perspective describes the different sex-specific causes of angina seen in ED patients. Once coronary artery disease (CAD) is ruled out with standard protocols, microvascular dysfunction is perhaps the most prevalent but under-diagnosed cause of non-CAD related angina in ED patients. Additional causes include coronary artery spasm, coronary artery dissection, coronary artery endothelial dysfunction and myocardial bridging. Non-CAD related angina is associated with persistent chest pain causing poor function, quality of life, and recidivism. Clinicians should consider additional diagnostics to routinely screen for non-CAD related causes of angina in patients with recurrent chest pain. Future work is needed to better define the epidemiological, clinical, biological, and genetic correlates of microvascular dysfunction in these patients.
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23
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Dean J, Cruz SD, Mehta PK, Merz CNB. Coronary microvascular dysfunction: sex-specific risk, diagnosis, and therapy. Nat Rev Cardiol 2015; 12:406-14. [PMID: 26011377 DOI: 10.1038/nrcardio.2015.72] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cardiovascular disease is the leading cause of death worldwide. In the presence of signs and symptoms of myocardial ischaemia, women are more likely than men to have no obstructive coronary artery disease (CAD). Women have a greater burden of symptoms than men, and are often falsely reassured despite the presence of ischaemic heart disease because of a lack of obstructive CAD. Coronary microvascular dysfunction should be considered as an aetiology for ischaemic heart disease with signs and symptoms of myocardial ischaemia, but no obstructive CAD. Coronary microvascular dysfunction is defined as impaired coronary flow reserve owing to functional and/or structural abnormalities of the microcirculation, and is associated with an adverse cardiovascular prognosis. Therapeutic lifestyle changes as well as antiatherosclerotic and antianginal medications might be beneficial, but clinical outcome trials are needed to guide treatment. In this Review, we discuss the prevalence, presentation, diagnosis, and treatment of coronary microvascular dysfunction, with a particular emphasis on ischaemic heart disease in women.
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Affiliation(s)
- Jenna Dean
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Sherwin Dela Cruz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Puja K Mehta
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
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24
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Ashurst JV, Cherney AR, Evans EM, Kennedy Hall M, Hess EP, Kline JA, Mitchell AM, Mills AM, Weigner MB, Moore CL. Research priorities for the influence of gender on diagnostic imaging choices in the emergency department setting. Acad Emerg Med 2014; 21:1431-7. [PMID: 25420885 DOI: 10.1111/acem.12537] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 09/05/2014] [Accepted: 09/09/2014] [Indexed: 12/14/2022]
Abstract
Diagnostic imaging is a cornerstone of patient evaluation in the acute care setting, but little effort has been devoted to understanding the appropriate influence of sex and gender on imaging choices. This article provides background on this issue and a description of the working group and consensus findings reached during the diagnostic imaging breakout session at the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes." Our goal was to determine research priorities for how sex and gender may (or should) affect imaging choices in the acute care setting. Prior to the conference, the working group identified five areas for discussion regarding the research agenda in sex- and gender-based imaging using literature review and expert consensus. The nominal group technique was used to identify areas for discussion for common presenting complaints to the emergency department where ionizing radiation is often used for diagnosis: suspected pulmonary embolism, suspected kidney stone, lower abdominal pain with a concern for appendicitis, and chest pain concerning for coronary artery disease. The role of sex- and gender-based shared decision-making in diagnostic imaging decisions is also raised.
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Affiliation(s)
- John V. Ashurst
- Department of Emergency Medicine; Lehigh Valley Hospital/USF Morsani College of Medicine; Allentown PA
| | - Alan R. Cherney
- Department of Emergency Medicine; Lehigh Valley Hospital/USF Morsani College of Medicine; Allentown PA
| | - Elizabeth M. Evans
- Department of Emergency Medicine; Lehigh Valley Hospital/USF Morsani College of Medicine; Allentown PA
| | - Michael Kennedy Hall
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Erik P. Hess
- Department of Emergency Medicine; Mayo Clinic; Rochester MN
| | - Jeffrey A. Kline
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - Alice M. Mitchell
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - Angela M. Mills
- Department of Emergency Medicine; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA
| | - Michael B. Weigner
- Department of Emergency Medicine; Lehigh Valley Hospital/USF Morsani College of Medicine; Allentown PA
| | - Christopher L. Moore
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
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Safdar B, Greenberg MR. Applying the gender lens to emergency care: from bench to bedside. Acad Emerg Med 2014; 21:1325-8. [PMID: 25413233 DOI: 10.1111/acem.12521] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 06/17/2014] [Accepted: 06/18/2014] [Indexed: 11/30/2022]
Abstract
This article outlines the history, need, and evolution of gender medicine in emergency care research. Clinical examples are used where sex and gender play a role in diagnosis, management, or prognosis of patients in the emergency department (ED). The ED serves as an ideal setting to advance sex- and gender-specific research as the primary access point for health care for much of the U.S. population, with more than 136 million annual visits. Gender medicine provides the biologic and social framework to provide high-quality, safe, equitable, and cost-effective sex- and gender-specific care in the ED. With a 24-hour hospital presence, and with access to high-acuity patients, emergency physicians are well positioned to lead sex- and gender-specific clinical studies for time-sensitive conditions and also to serve as vital partners in interdisciplinary research projects. The ED also provides the primary access point for less life-threatening conditions such as substance abuse, mental health, and pain management (both acute and chronic). Because one-fifth of the U.S. population is without health insurance, and many more lack a regular provider or rapid access to their providers, the ED is often the only point of contact for advancing gender medicine in this population.
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Affiliation(s)
- Basmah Safdar
- Department of Emergency Medicine; Yale School of Medicine; New Haven CT
| | - Marna R. Greenberg
- Lehigh Valley Health Network/USF Morsani College of Medicine; Allentown PA
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McGregor AJ, Frank Peacock W, Marie Chang A, Safdar B, Diercks D. Sex- and gender-specific research priorities for the emergency management of heart failure and acute arrhythmia: proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup. Acad Emerg Med 2014; 21:1361-9. [PMID: 25422074 DOI: 10.1111/acem.12526] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 08/11/2014] [Accepted: 08/29/2014] [Indexed: 12/27/2022]
Abstract
The emergency department (ED) is the point of first contact for patients with acute heart failure and arrhythmias, with 1 million annual ED visits in the United States. Although the total numbers of men and women living with heart failure are similar, female patients are underrepresented in clinical studies, with current knowledge predominantly based on data from male patients. This has led to an underappreciation of the sex-specific differences in clinical characteristics and pathophysiology-based management of heart failure. Similar disparities have been found in management of acute arrhythmias, especially atrial arrhythmias that lead to an increased risk of stroke in women. Additionally, peripartum and postpartum cardiomyopathy represent a diagnostic and treatment dilemma. This article is the result of a breakout session in the cardiovascular and resuscitation work group of the 2014 Academic Emergency Medicine consensus conference "Gender-Specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes." A nominal group technique was used to identify and prioritize themes and research questions using electronic mail, monthly conference calls, in-person meetings, and Web-based surveys between June 2013 and May 2014. Consensus was achieved through three rounds of nomination followed by the meeting on May 13, 2014, and resulted in seven priority themes that are essential to the common complex clinical syndrome of heart failure for both men and women and include the areas of pathophysiology; presentation and symptomatology; and diagnostic strategies using biomarkers, treatment, and mortality, with special consideration to arrhythmia management and pregnancy.
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Affiliation(s)
- Alyson J. McGregor
- Department of Emergency Medicine; Warren Alpert Medical School of Brown University; Providence RI
| | - W. Frank Peacock
- Department of Emergency Medicine; Baylor College of Medicine; Portland OR
| | - Anna Marie Chang
- Section of Emergency Medicine; Oregon Health and Science University; Portland OR
| | - Basmah Safdar
- Department of Emergency Medicine; Yale University; New Haven CT
| | - Deborah Diercks
- Department of Emergency Medicine; UC Davis Medical Center; Davis CA
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Wigginton JG, Perman SM, Barr GC, McGregor AJ, Miller AC, Napoli AF, Safdar B, Weaver KR, Deutsch S, Kayea T, Becker L, Becker L. Sex- and gender-specific research priorities in cardiovascular resuscitation: proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Resuscitation Research Workgroup. Acad Emerg Med 2014; 21:1343-9. [PMID: 25491706 DOI: 10.1111/acem.12541] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 09/12/2014] [Accepted: 09/13/2014] [Indexed: 12/21/2022]
Abstract
Significant sex and gender differences in both physiology and psychology are readily acknowledged between men and women; however, data are lacking regarding differences in their responses to injury and treatment and in their ultimate recovery and survival. These variations remain particularly poorly defined within the field of cardiovascular resuscitation. A better understanding of the interaction between these important factors may soon allow us to dramatically improve outcomes in disease processes that currently carry a dismal prognosis, such as sudden cardiac arrest. As part of the 2014 Academic Emergency Medicine consensus conference "Gender-Specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes," our group sought to identify key research questions and knowledge gaps pertaining to both sex and gender in cardiac resuscitation that could be answered in the near future to inform our understanding of these important issues. We combined a monthly teleconference meeting of interdisciplinary stakeholders from largely academic institutions with a focused interest in cardiovascular outcomes research, an extensive review of the existing literature, and an open breakout session discussion on the recommendations at the consensus conference to establish a prioritization of the knowledge gaps and relevant research questions in this area. We identified six priority research areas: 1) out-of-hospital cardiac arrest epidemiology and outcome, 2) customized resuscitation drugs, 3) treatment role for sex steroids, 4) targeted temperature management and hypothermia, 5) withdrawal of care after cardiac arrest, and 6) cardiopulmonary resuscitation training and implementation. We believe that exploring these key topics and identifying relevant questions may directly lead to improved understanding of sex- and gender-specific issues seen in cardiac resuscitation and ultimately improved patient outcomes.
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Affiliation(s)
- Jane G. Wigginton
- Department of Surgery; Division of Emergency Medicine; University of Texas Southwestern Medical Center; Dallas TX
| | - Sarah M. Perman
- Department of Emergency Medicine; University of Colorado School of Medicine; Denver CO
| | - Gavin C. Barr
- University of South Florida; Lehigh Valley Health Network; Allentown PA
| | - Alyson J. McGregor
- Department of Emergency Medicine at Warren Alpert Medical School of Brown University; Providence RI
| | - Andrew C. Miller
- University of South Florida; Lehigh Valley Health Network; Allentown PA
| | - Anthony F. Napoli
- Department of Emergency Medicine at Warren Alpert Medical School of Brown University; Providence RI
| | - Basmah Safdar
- Department of Emergency Medicine; Yale University; New Haven CT
| | - Kevin R. Weaver
- University of South Florida; Lehigh Valley Health Network; Allentown PA
| | | | - Tami Kayea
- Dallas Fire-Rescue Department; Dallas TX
| | - Lance Becker
- Department of Emergency Medicine; University of Pennsylvania; Philadelphia PA
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