Ethnic variations in female vulnerability after an acute coronary event

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

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

Gender-associated dimensional differences among normal to non-flow limiting coronary artery dimensions

Aim and objectives

To study gender-specific differences in coronary artery diameters among subjects with normal to non-flow limiting disease (NFLD) coronary arteries (up to 0 - 20% of stenosis) and to assess the possible association of body-mass index (BMI) with coronary dimensions, among the west coastal population of Karnataka and Kerala.

Materials and Methods

A prospective cohort study was conducted for a period of one year. Two thousand angiograms samples were collected and assessed from two study centers (one from each state), after obtaining the ethical clearance. Patients with past history of myocardial infarction and those with recanalized normal looking coronary arteries and those who had diabetes for more than five years were excluded. Ten segments of coronary arteries- left main coronary artery, ostial and proximal segments of left anterior descending artery and its first diagonal branch, ostial and proximal segments of left circumflex coronary artery and its obtuse marginal branch, ramus intermedius and the ostial and proximal segments of the right coronary artery- were included in diameter measurement. BMI values of the patients were calculated.

Results

Out of 2000 patients included in the study, 454 (22.7%; mean age 53.4 ± 14.2 years) had normal to NFLD coronaries of which 253 (55.7%) were males and 201 (44.3%) were females. As compared to women, men had larger diameters of coronary arteries for eight segments, except the obtuse marginal branch and the proximal right coronary artery. A weak, yet statistically significant, negative correlation existed between BMI and coronary artery diameters in total cohort, indicating that an increase in BMI was associated with a decrease in artery diameters. No such association was seen when men and women were assessed separately.

Conclusions

The present study indicates that men have higher caliber for coronary arteries compared to women. The study also indicates that when BMI increases there is a relative decrease in the coronary artery diameter.

Association between in-hospital guideline adherence and postdischarge major adverse outcomes of patients with acute coronary syndrome in Vietnam: a prospective cohort study

OBJECTIVE

We aimed to determine the association between physician adherence to prescribing guideline-recommended medications during hospitalisation and 6-month major adverse outcomes of patients with acute coronary syndrome in Vietnam.

DESIGN

Prospective cohort study.

SETTING

The study was carried out in two public hospitals in Vietnam between January and October 2015. Patients were followed for 6 months after discharge.

PARTICIPANTS

Patients who survived during hospitalisation with a discharge diagnosis of acute coronary syndrome and who were eligible for receiving at least one of the four guideline-recommended medications.

EXPOSURES

Guideline adherence was defined as prescribing all guideline-recommended medications at both hospital admission and discharge for eligible patients. Medications were antiplatelet agents, beta-blockers, ACE inhibitors or angiotensin II receptor blockers and statins.

MAIN OUTCOME MEASURE

Six-month major adverse outcomes were defined as all-cause mortality or hospital readmission due to cardiovascular causes occurring during 6 months after discharge. Cox regression models were used to estimate the association between guideline adherence and 6-month major adverse outcomes.

RESULTS

Overall, 512 patients were included. Of those, there were 242 patients (47.3%) in the guideline adherence group and 270 patients (52.3%) in the non-adherence group. The rate of 6-month major adverse outcomes was 30.5%. A 29% reduction in major adverse outcomes at 6 months after discharge was found for patients of the guideline adherence group compared with the non-adherence group (adjusted HR, 0.71; 95% CI, 0.51 to 0.98; p=0.039). Covariates significantly associated with the major adverse outcomes were percutaneous coronary intervention, prior heart failure and renal insufficiency.

CONCLUSIONS

In-hospital guideline adherence was associated with a significant decrease in major adverse outcomes up to 6 months after discharge. It supports the need for improving adherence to guidelines in hospital practice in low-income and middle-income countries like Vietnam.

Influence of Ethnicity, Age, and Time on Sex Disparities in Long-Term Cause-Specific Mortality After Acute Myocardial Infarction

Background

We examined the influence of sex, ethnicity, and time on competing cardiovascular and noncardiovascular causes of death following acute myocardial infarction in a multiethnic Asian cohort.

Methods and Results

For 12 years, we followed a prospective nationwide cohort of 15 151 patients (aged 22–101 years, median age 63 years; 72.3% male; 66.7% Chinese, 19.8% Malay, 13.5% Indian) who were hospitalized for acute myocardial infarction between 2000 and 2005. There were 6463 deaths (4534 cardiovascular, 1929 noncardiovascular). Compared with men, women had a higher risk of cardiovascular death (age‐adjusted hazard ratio [HR] 1.3, 95% CI 1.2–1.4) but a similar risk of noncardiovascular death (HR 0.9, 95% CI 0.8–1.0). Sex differences in cardiovascular death varied by ethnicity, age, and time. Compared with Chinese women, Malay women had the greatest increased hazard of cardiovascular death (HR 1.4, 95% CI 1.2–1.6) and a marked imbalance in death due to heart failure or cardiomyopathy (HR 3.4 [95% CI 1.9–6.0] versus HR 1.5 [95% CI 0.6–3.6] for Indian women). Compared with same‐age Malay men, Malay women aged 22 to 49 years had a 2.5‐fold (95% CI 1.6–3.8) increased hazard of cardiovascular death. Sex disparities in cardiovascular death tapered over time, least among Chinese patients and most among Indian patients; the HR comparing cardiovascular death of Indian women and men decreased from 1.9 (95% CI 1.5–2.4) at 30 days to 0.9 (95% CI 0.5–1.6) at 10 years.

Conclusion

Age, ethnicity, and time strongly influence the association between sex and specific cardiovascular causes of mortality, suggesting that health care policy to reduce sex disparities in acute myocardial infarction outcomes must consider the complex interplay of these 3 major modifying factors.

Impact of gender on clinical outcomes after mTOR-inhibitor drug-eluting stent implantation in patients with first manifestation of ischaemic heart disease

BACKGROUND

Women have a worse outcome than men after percutaneous coronary intervention (PCI). However, in the drug-eluting stent (DES) era, limited data are available about the impact of gender-related differences on clinical outcome. Furthermore, many series have also included patients previously treated by coronary-artery bypass grafts or PCI, which may bias the evaluation of DES-related clinical events at follow up. We aimed to assess the impact of gender on clinical outcomes in a consecutive series of patients at first manifestation of coronary artery disease (CAD) undergoing PCI with mTOR-inhibitor DES.

METHODS AND RESULTS

A total of 138 consecutive patients (age 64 ± 13 years, female gender 29%) undergoing successful mTOR-inhibitor DES implantation [sirolimus-eluting stent (SES); zotarolimus-eluting stent (ZES); and everolimus-eluting stent (EES)] for the treatment of stable chronic angina or an acute coronary syndrome, as their first clinical manifestation of CAD, were prospectively enrolled between February 2008 and May 2009. Major adverse cardiac events (MACE), defined as a combination of cardiac death, myocardial infarction (MI), and clinically driven target lesion revascularization (TVR) at 12-month follow up, constituted the endpoint of the study. Fifty-one (37%) patients received SES; 46 (33%) patients received ZES; and 41 (30%) patients received EES. At follow up, 21 (15%) patients experienced a MACE. Three (2%) patients had cardiac death, five (4%) had MI, while 13 (9%) patients underwent clinically driven TVR. MACE occurred more frequently in females than males [10 (25%) vs. 11 (11%), p = 0.05]. At Cox regression analysis, the only independent predictors of MACE were female gender and implantation of more than one stent [hazard ratio (HR) 3.70, 95% confidence interval (CI) 1.46-9.36, p = 0.006; HR 1.26, 95% CI 0.99-2.74, p = 0.01, respectively].

CONCLUSIONS

In conclusion, our finding suggests that women may have a worse outcome as compared with men after mTOR-inhibitor DES implantation.

Gender differences in acute myocardial infarction, twenty-five years registration

BACKGROUND/OBJECTIVES

The French-speaking Community of Belgium has set up a register of ischaemic cardiopathies (1983-2007). The aim consists in analyzing the evolution of fatal and non-fatal acute coronary events rates as well as the 28 days case fatality on a 25-year period and examine sex differences in lethality.

METHODS

This register assures a standardized procedure according to the MONICA criteria. For each period, we present attack rates and trends analysis. Hospital lethality takes again in-patients and community lethality is calculated starting from all the cases.

RESULTS

The total attack rate is rather stable between 1983 and 2007 for women (from 12 to 19 per 10,000 residents). For men, there is a distinct decline of the total attack rate since 1991 till 1993 (63 to 43 per 10,000 residents). We systematically observe a reduction in risk between men and women according to the age. For each 5-year period, this risk decreases significantly with age and this difference is strongest during the periods 1993-1997 and 1998-2002. The analysis shows also a significant decline in lethality between the 1983-1987 and 1993-1997 periods. Among women, lethality is systematically higher than in men in spite of the presence or the absence of antecedents of myocardial infarction.

CONCLUSIONS

Favourable evolutions in the attack rates of acute coronary events in the study population appear clearly on the 25-year period of observation. The whole lethality rates decreased during the first 15 years of the register; after that, it stabilized.

Women tolerate drug therapy for coronary artery disease as well as men do, but are treated less frequently with aspirin, beta-blockers, or statins

BACKGROUND

Women have worse morbidity, mortality, and health-related quality-of-life outcomes associated with coronary artery disease (CAD) compared with men. This may be related to underutilization of drug therapies, such as aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or statins. No studies have sought to describe the relationship of gender with adverse reactions to drug therapy (ADRs) for CAD in clinical practice.

OBJECTIVE

The aim of this study was to determine the prevalence of ADRs associated with common CAD drug therapies in women and men in clinical practice.

METHODS

In a cohort of consecutive outpatients with CAD, detailed chart abstraction was performed to determine the use of aspirin, beta-blocker, ACE inhibitor, and statin therapy, as well as the ADRs reported for these treatments. Baseline clinical characteristics were also determined to identify the independent association of gender with use of standard drug treatments for CAD.

RESULTS

Consecutive patients with CAD (153 men, 151 women) were included in the study. Women and men were observed to have a similar prevalence of cardiac risk factors and comorbidities, except that men had significantly higher prevalence of atrial fibrillation (30 [19.6%] men vs 15 [9.9%] women; P = 0.03) and significantly lower mean (SD) high-density lipoprotein cholesterol concentrations (45 [16] mg/dL for men vs 55 [19] mg/dL for women; P < 0.001). No significant differences were observed between the sexes in the prevalence of ADRs; however, significantly fewer women than men were treated with statins (118 [78.1%] vs 139 [90.8%], respectively; P = 0.003). After adjusting for clinical characteristics, women were also found to be less likely than men to receive aspirin (odds ratio [OR] = 0.164; 95% CI, 0.083-0.322; P = 0.001) and beta-blockers (OR = 0.184; 95% CI, 0.096-0.351; P = 0.001).

CONCLUSIONS

Women and men experienced a similar prevalence of ADRs in the treatment of CAD; however, women were significantly less likely to be treated with aspirin, beta-blockers, and statins than were their male counterparts. To optimize care for women with CAD, further study is needed to identify the cause of this gender disparity in therapeutic drug use.

Circadian analysis of myocardial infarction incidence in an Argentine and Uruguayan population

Background

The occurrence of variations in the spectrum of cardiovascular disease between different regions of the world and ethnic groups have been the subject of great interest. This study report the 24-h variation of myocardial infarction (MI) occurrence in patients recruited from CCU located in Argentina and Uruguay.

Methods

A cohort of 1063 patients admitted to the CCU within 24 h of the onset of symptoms of an acute MI was examined. MI incidence along the day was computed in 1 h-intervals.

Results

A minimal MI incidence between 03:00 and 07:00 h and the occurrence of a first maximum between 08:00 and 12:00 h and a second maximum between 15:00 and 22:00 h were verified. The best fit curve was a 24 h cosinor (acrophase ~ 19:00 h, accounting for 63 % of variance) together with a symmetrical gaussian bell (maximum at ~ 10:00 h, accounting for 37 % of variance). A similar picture was observed for MI frequencies among different excluding subgroups (older or younger than 70 years; with or without previous symptoms; diabetics or non diabetics; Q wave- or non-Q wave-type MI; anterior or inferior MI location). Proportion between cosinor and gaussian probabilities was maintained among most subgroups except for older patients who had more MI at the afternoon and patients with previous symptoms who were equally distributed among the morning and afternoon maxima.

Conclusion

The results support the existence of two maxima (at morning and afternoon hours) in MI incidence in the Argentine and Uruguayan population.

Premature coronary artery disease in Indians and its associated risk factors

Of particular concern to India is not only the high burden of cardiovascular diseases (CVDs), but also the effects of these diseases on the productive workforce aged 35-65 years. Heart diseases are rising in Asian Indians 5-10 years earlier than in other populations around the world. The mean age for first presentation of acute myocardial infarction in Indians is 53 years. Coronary artery disease (CAD) that manifests at a younger age can have devastating consequences for an individual, the family, and society. Prevention of these deaths in young people is a nation's moral responsibility. A strategy involving prevention of CVDs long before their onset will be more cost-effective than providing interventions at a stage when the disease is well established. We review the rising trends in CAD with particular emphasis on prevalence of premature CAD and the associated risk factors in young Indian CAD patients. Action strategies to reduce the risk are suggested.

Ethnic variations in acute coronary syndromes

Although it is very likely that ethnic variations in the incidence and, possibly, clinical outcome of acute coronary artery disease events exist, the causes for such differences are many and difficult to address fully, given the complex interplay of contributing factors.