A meta-analysis of sex-related differences in outcomes after primary percutaneous intervention for ST-segment elevation myocardial infarction

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

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.

ST-Segment Elevation Myocardial Infarction: Sex Differences in Incidence, Etiology, Treatment, and Outcomes

PURPOSE

Although there have been marked improvements in the standard of care for treatment of ST-elevation myocardial infarction, women, especially younger women, continue to have significantly worse outcomes than men.

RECENT FINDINGS

This review highlights the current sex differences in presentation, etiology, treatment, and outcomes among these patients in order to make providers aware of the heterogeneous entities that cause ST-elevation myocardial infarction particularly in women and of disparities in treatment that lead to poorer outcomes in women. Furthermore, it emphasizes evidence-based strategies including standardized protocols for early revascularization, mechanical circulatory support, and access methodology that can reduce sex-based disparities in treatments and outcomes.

Meta-Analysis of Gender Disparities in In-hospital Care and Outcomes in Patients with ST-Segment Elevation Myocardial Infarction

Gender disparities in ST-segment elevation myocardial infarction (STEMI) outcomes continue to be reported worldwide; however, the magnitude of this gap remains unknown. To evaluate gender-based discrepancies in clinical outcomes and identify the primary driving factors a global meta-analysis was performed. Studies were selected if they included all comers with STEMI, reported gender specific patient characteristics, treatments, and outcomes, according to the registered PROSPERO protocol: CRD42020161469. A total of 56 studies (705,098 patients, 31% females) were included. Females were older, had more comorbidities and received less antiplatelet therapy and primary percutaneous coronary intervention (PCI). Females experienced significantly longer delays to first medical contact (mean difference 42.5 min) and door-to-balloon time (mean difference 4.9 min). In-hospital, females had increased rates of mortality (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.84 to 1.99, p <0.00001), repeat myocardial infarction (MI) (OR 1.25, 95% CI 1.00 to 1.56, p=0.05), stroke (OR 1.67, 95% CI 1.27 to 2.20, p <0.001), and major bleeding (OR 1.82, 95% CI 1.56 to 2.12, p <0.00001) compared with males. Older age at presentation was the primary driver of excess mortality in females, although other factors including lower rates of primary PCI and aspirin usage, and longer door-to-balloon times contributed. In contrast, excess rates of repeat MI and stroke in females appeared to be driven, at least in part, by lower use of primary PCI and P2Y12 inhibitors, respectively. In conclusion, despite improvements in STEMI care, women continue to have in-hospital rates of mortality, repeat MI, stroke, and major bleeding up to 2-fold higher than men. Gender disparities in in-hospital outcomes can largely be explained by age differences at presentation but comorbidities, delays to care and suboptimal treatment experienced by women may contribute to the gender gap.

Age-Stratified Sex-Related Differences in the Incidence, Management, and Outcomes of Acute Myocardial Infarction

OBJECTIVE

To assess the impact of female sex on the incidence, management, and outcomes of myocardial infarction (MI) in different age groups.

METHODS

Patients admitted with ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI), between January 1, 2003, and December 31, 2015, were identified in the National Inpatient Sample. We compared STEMI and NSTEMI rates, management patterns, and in-hospital morbidity and mortality in men and women stratified into 4 age groups (<45, 45 to 64, 65 to 84, and ≥85 years of age).

RESULTS

A total of 6,720,639 weighted hospitalizations for MI (79.8% NSTEMI, and 20.2% STEMI) were included. The incidence rate of hospitalizations for MI was lower in women than men across all age groups. Women were less likely than men to undergo coronary angiography, revascularization, or to use circulatory-support devices. These differences were consistent across all age groups. Adjusted odds of death for women (vs men) varied by age: odds ratio (95% confidence interval) 1.08 (0.97 to 1.20), 1.05 (1.02 to 1.08), 0.92 (0.91 to 0.94), and 0.86 (0.85 to 0.88) for NSTEMI, and 1.15 (1.04 to 1.27), 1.22 (1.18 to 1.26), 1.09 (1.06 to 1.11), and 0.97 (0.94 to 0.99), for STEMI, in age groups (<45, 45 to 64, 65 to 84, and ≥85), respectively. The magnitude of differences in complications between men and women was higher in younger and middle-age patients.

CONCLUSION

Compared with men, women have lower incidence of MI and less likelihood of undergoing invasive treatment regardless of age. However, post-MI outcomes are age specific. The negative impact of female sex on most outcomes was most pronounced in young and middle-aged women.

Female sex impact on culprit plaque at optical coherence tomography analysis in the setting of acute coronary syndrome in OCT-FORMIDABLE registry

Aim: To evaluate sex difference in culprit plaque features at optical coherence tomography (OCT) and major adverse cardiovascular events at follow-up. Patients and methods: We analyse data from the OCT-FORMIDABLE (OCT-Features Of moRphology, coMposItion anD instABility of culprit and pLaquE in acute coronary syndrome [ACS] patients) registry. A total of 285 patients (20%, 58 females) were included. Results: Females with ST segment elevation myocardial infarction showed a longer ruptured area of the plaque (8.6 ± 7.6 vs 4.6 ± 5.4; p = 0.003) and a major necrotic core macrophage infiltration (43 vs 17%; p = 0.017). Females with non-ST segment elevation-ACS had less lipidic plaques (62 vs 80%; p = 0.04). No between-group sex differences in major adverse cardiovascular events emerged at follow-up (5 vs 9%; p = 0.88 in ST segment elevation myocardial infarction group and 19 vs 15%; p = 0.6 in non-ST segment elevation-ACS group). At multivariate analysis, female sex was not a major risk of plaque rupture (hazard ratio [HR]: 1.59, CI: 0.44–5.67; p = 0.48). Conclusion: Female sex seems to have no significant impact.

ClincalTrial. gov registration number: NCT02486861.

Sex-Related Differences in In-Hospital Mortality in Japanese ST-Elevation Acute Myocardial Infarction Patients Presenting to Hospital in the 24 Hours After Symptom Onset - Results From K-ACTIVE

Background: Despite the drastic advances in clinical care for patients with acute ST-elevation myocardial infarction (STEMI), female STEMI patients have higher in-hospital mortality rates than male patients. This study assessed the influence of sex on in-hospital mortality in STEMI patients in Kanagawa Prefecture, Japan.

Methods and Results: From October 2015 to June 2018, 2,491 consecutive STEMI patients (23.9% female) who presented to hospital in the 24 h after symptom onset were analyzed. The female patients were 9 years older and less frequently had diabetes, smoking and prior MI than male patients. Pre-hospital managements, including prehospital 12-lead electrocardiography, and symptom-to-door time were similar between the sexes. A door-to-device time ≤90 min was achieved in 61.3% of female cases and in 65.0% of male cases (P=0.13). Reperfusion therapy was provided to 94.6% of female and 97.6% of male patients (P<0.001). In-hospital mortality rate was not significantly different between female and male patients (6.6% vs. 7.8%, P=0.37). On multivariate logistic regression analysis, female sex itself was not associated with in-hospital mortality (OR, 1.52; 95% CI: 0.67–3.47, P=0.32).

Conclusions: There was no sex discrepancy in the in-hospital mortality of STEMI patients in this study. Guideline-based treatment, such as advanced pre-hospital management and a high use of reperfusion therapy might have attenuated the sex-related differences in the in-hospital mortality.

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

BACKGROUND AND OBJECTIVES

Previous researches have reported the controversial results regarding the gender difference in clinical outcomes of patients with coronary artery disease after percutaneous coronary intervention. Hence, this systematic review and meta-analysis was designed to investigate whether gender difference existed in patients with coronary artery disease after percutaneous coronary intervention.

METHODS

PubMed, Embase, and the Cochrane Library database were searched up to February 10, 2018. Studies comparing the gender-specific effect on clinical outcomes of patients with coronary artery disease after percutaneous coronary intervention were identified, to analyze mortality, major adverse cardiovascular events (MACE) and revascularization. Statistical software RevMan was utilized in this meta-analysis.

RESULTS

A total of 49 studies, involving 1,032,828 patients (774,115 males and 258,713 females) reporting gender-specific outcomes, were included in this study. The in-hospital mortality, 30-day mortality, 1-year mortality, and at least 2-years mortality in male patients with coronary artery disease after percutaneous coronary intervention were significantly lower than those of females (odds ratio [OR] 0.58 95% confidence interval [CI] 0.52-0.63, P < .001; OR 0.64, 95% CI 0.61-0.66, P = .04; OR 0.67, 95% CI 0.60-0.75, P < .001 and OR 0.71, 95% CI 0.63-0.79, P = .005, respectively). The MACE was significantly decreased in male subjects after initial percutaneous coronary intervention compared with females in <1-year or at least 1-year (OR 0.67, 95% CI 0.56-0.80, P < .001 and OR 0.84, 95% CI 0.76-0.93, P < .001). The male patients after percutaneous coronary intervention harbored higher rate of revascularization compared with females for at least 1-year (OR 1.17, 95% CI 1.00-1.36, P < .001), while the rate of revascularization in male patients for < 1-year was lower than that of females (OR 0.93, 95% CI 0.69-1.26, P < .001).

CONCLUSIONS

The systematic review and meta-analysis suggests that the prognosis of male patients with coronary artery disease after percutaneous coronary intervention is better than that of females, except for long-term revascularization.

Are women with type 2 diabetes mellitus more susceptible to cardiovascular complications following coronary angioplasty?: a meta-analysis

Background

Scientific reports have shown Type 2 Diabetes Mellitus (T2DM) to be independently associated with adverse outcomes following Percutaneous Coronary Intervention (PCI). However, gender difference has also often been a controversial issue following PCI. Till date, very few meta-analyses have systematically compared the adverse cardiovascular outcomes in male versus female patients with T2DM following PCI. Therefore, we aimed to carry out this analysis in order to find out an answer to this interesting question.

Methods

Electronic databases were searched for English language publications reporting adverse cardiovascular outcomes in male versus female patients with diabetes mellitus respectively following coronary angioplasty. The RevMan 5.3 software was used to analyze selected adverse cardiovascular events whereby Odds Ratios (OR) and 95% Confidence Intervals (CI) were the statistical parameters.

Results

A total number of 19,304 patients with T2DM (12,986 male patients versus 6318 female patients) were included in this analysis. At baseline, female patients were older (68.7 versus 62.9 years), with a higher percentage of hypertension (75.6% versus 66.5%) and dyslipidemia (53.3% versus 50.0%) whereas majority of the male patients were smokers (46.3% versus 14.9%). Results of this analysis showed short and long-term mortality to be significantly higher in female patients with T2DM (OR: 1.71, 95% CI: 1.46–2.00; P = 0.00001), and (OR: 1.20, 95% CI: 1.07–1.35; P = 0.002) respectively. In addition, women were also more at risk for short and long-term major adverse cardiac events (MACEs) with OR: 1.49, 95% CI: 1.07–2.07; P = 0.02 and OR: 1.15, 95% CI: 1.04–1.28; P = 0.009 respectively. Subgroup analysis showed this significant result to have mainly been observed in patients with acute myocardial infarction compared to those with stable coronary artery disease.

Conclusions

Following PCI, women with T2DM were indeed more susceptible to short and long-term cardiovascular complications compared to male patients with the same chronic disease. Even though this result was more applicable to patients with acute myocardial infarction, the fact that women were older with higher co-morbidities at baseline compared to men, should also not be ignored.

Research of Medical Expenditure among Inpatients with Unstable Angina Pectoris in a Single Center

Background:

With the rising incidence as well as the medical expenditure among patients with unstable angina pectoris, the research aimed to investigate the inpatient medical expenditure through the combination of diagnosis-related groups (DRGs) among patients with unstable angina pectoris in a Grade A tertiary hospital to conduct the referential standards of medical costs for the diagnosis.

Methods:

Single-factor analysis and multiple linear stepwise regression method were used to investigate 3933 cases between 2014 and 2016 in Beijing Hospital (China) whose main diagnosis was defined as unstable angina pectoris to determine the main factors influencing the inpatient medical expenditure, and decision tree method was adopted to establish the model of DRGs grouping combinations.

Results:

The major influential factors of inpatient medical expenditure included age, operative method, therapeutic effects as well as comorbidity and complications (CCs) of the disease, and the 3933 cases were divided into ten DRGs by four factors: age, CCs, therapeutic effects, and the type of surgery with corresponding inpatient medical expenditure standards setup. Data of nonparametric test on medical costs among different groups were all significant (P < 0.001, by Kruskal-Wallis test), with R² = 0.53 and coefficient of variation (CV) = 0.524.

Conclusions:

The classification of DRGs by adopting the type of surgery as the main branch node to develop cost control standards in inpatient treatment of unstable angina pectoris is conducive in standardizing the diagnosis and treatment behaviors of the hospital and reducing economic burdens among patients.

Long-term Outcomes of Primary Percutaneous Coronary Intervention with Second-generation Drug-eluting Stents in ST-elevation Myocardial Infarction Patients Caused by Very Late Stent Thrombosis

Background:

The ST-segment elevation myocardial infarction (STEMI) patients due to stent thrombosis (ST) remain a therapeutic challenge for a clinician. Till date, very few researches have been conducted regarding the safety and effectiveness of primary percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) for STEMI caused by very late ST (VLST). This retrospective study evaluated the safety, efficacy, and outcomes of primary PCI with second-generation DES for STEMI due to VLST compared with primary PCI for STEMI due to de novo lesion.

Methods:

Between January 2007 and December 2013, STEMI patients with primary PCI in Fuwai Hospital had only second-generation DES implanted for de novo lesion (558 patients) and VLST (50 patients) were included in this retrospective study. The primary end points included cardiac death and reinfarction. The secondary end points included cardiac death, reinfarction, and target lesion revascularization. Continuous variables were expressed as mean (standard deviation) or median (interquartile range) and compared by Student's t-test or Mann-Whitney U-test as appropriate. Categorical variables were expressed as counts and percentages, and comparison of these variables was performed with Chi-square or Fisher's exact test. A two-tailed value of P < 0.05 was considered statistically significant for all comparisons. Statistical analyses were performed by SAS software (version 9.4, SAS Institute Inc., Cary, USA) for Windows.

Results:

In-hospital primary end point and the secondary end point were no significant differences between two groups (P = 1.000 and P = 1.000, respectively). No significant differences between two groups were observed according to the long-term primary end point and the secondary end point. Kaplan-Meier survival curves showed no significant difference between the two groups in the primary end point and the secondary end point at 2 years (P = 0.340 and P = 0.243, respectively). According to Cox analysis, female, intra-aortic balloon pump support, and postprocedural thrombolysis in myocardial infarction flow 3 were found to be independent predictors for long-term follow-up.

Conclusion:

Primary PCI with second-generation DES is a reasonable choice for STEMI patients caused by VLST.

Impact of Sex and Contact-to-Device Time on Clinical Outcomes in Acute ST-Segment Elevation Myocardial Infarction-Findings From the National Cardiovascular Data Registry

Background

Emergent myocardial reperfusion via primary percutaneous coronary intervention is optimal care for patients presenting with ST‐segment elevation myocardial infarction (STEMI). Delays in such interventions are associated with increases in mortality. With the shift in focus to contact‐to‐device (C2D) time as a new perfusion metric, this study was designed to examine how sex affects C2D time and mortality in STEMI patients.

Methods and Results

Clinical data on male and female STEMI patients were extracted and analyzed from the National Cardiovascular Data Registry from July 1, 2008 to December 31, 2014. A total of 102 515 patients were included in the final analytic cohort. The median C2D time in female patients with STEMI was delayed when compared to male patients (80 [65–97] versus 75 [61–90] minutes; P<0.001). The unadjusted mortality was higher in female patients when compared to male patients with STEMI (4.1% versus 2.0%; P<0.001). For every 5‐minute increase in C2D time, the adjusted odds ratio for mortality was 1.04 (95% CI, 1.03–1.06) for female patients with STEMI and 1.07 (95% CI, 1.06–1.09) for male patients (P for sex by C2D interaction=0.003).

Conclusions

To date, this is the largest analysis of STEMI patients that measures the impact of the new recommended C2D reperfusion metric on in‐hospital mortality. Female STEMI patients have longer C2D times and increased mortality. The disparity can be improved and survival can increase in this high‐risk patient cohort by decreasing systems issues that cause increased reperfusion times in female STEMI patients.