Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Evaluation of a nomogram model for predicting in-hospital mortality risk in patients with acute ST-elevation myocardial infarction and acute heart failure post-PCI

OBJECTIVES

This study aims to identify the risk factors contributing to in-hospital mortality in patients with acute ST-elevation myocardial infarction (STEMI) who develop acute heart failure (AHF) post-percutaneous coronary intervention (PCI). Based on these factors, we constructed a nomogram to effectively identify high-risk patients.

METHODS

In the study, a collective of 280 individuals experiencing an acute STEMI who then developed AHF following PCI were evaluated. These subjects were split into groups for training and validation purposes. Utilizing lasso regression in conjunction with logistic regression analysis, researchers sought to pinpoint factors predictive of mortality and to create a corresponding nomogram for forecasting purposes. To evaluate the model's accuracy and usefulness in clinical settings, metrics such as the concordance index (C-index), calibration curves, and decision curve analysis (DCA) were employed.

RESULTS

Key risk factors identified included blood lactate, D-dimer levels, gender, left ventricular ejection fraction (LVEF), and Killip class IV. The nomogram demonstrated high accuracy (C-index: training set 0.838, validation set 0.853) and good fit (Hosmer-Lemeshow test: χ2 = 0.545, p = 0.762), confirming its clinical utility.

CONCLUSION

The developed clinical prediction model is effective in accurately forecasting mortality among patients with acute STEMI who develop AHF after PCI.

Reproductive factors and risk of cardiovascular outcomes in women with ST-elevation myocardial infarction

BACKGROUND

There are many sex-specific factors affecting myocardial infarction (MI) outcomes in males and females. This study aimed to evaluate the relationship between reproductive factors and cardiovascular outcomes in women after ST-elevation MI.

METHOD

This retrospective cohort study was initiated in 2016-2017 at Chamran Hospital, Isfahan, Iran. One hundred eighty women with a diagnosis of ST-elevation MI were followed up for 3 years, and any occurrence of cardiovascular events (CVs) was recorded. All information regarding reproductive factors was recorded via questionnaire. This information was compared between women with cardiovascular events and women without adverse events using a sample t test, chi-square test, and multiple backward logistic regression analysis. SPSS version 24 was used to conduct all analyses.

RESULT

Sixty-four women with a mean age of 65.81 ± 13.14 years experienced CV events, and 116 women with a mean age of 65.51 ± 10.88 years did not experience CV events. A history of ischemic heart disease and diabetes mellitus were more prevalent in women with CV events (P = 0.024 and P = 0.019). After adjusting for ischemic heart disease and diabetes mellitus, oral contraceptive pill (OCP) usage was more prevalent in women with CV events than in women without CV events (60.9% vs. 40.4%, P = 0.008). There was a greater chance of CV events in women with OCP usage (OR = 3.546, P = 0.038) and a lower chance of CV events in women with greater age at menarche (OR = 0.630, P = 0.009) and longer breastfeeding duration (OR = 0.798, P = 0.041) according to multiple backward logistic regression models.

CONCLUSION

Based on this study, OCP consumption is a risk factor, while older age at menarche and longer duration of breastfeeding are protective factors for cardiovascular outcomes in women after STEMI.

The influence of socio-demographic and clinical factors on sick leave and return to work after open-heart surgery: a nationwide registry-based cohort study

AIMS

To estimate sick leave (SL) duration after first-time elective open-heart surgery and identify factors contributing to increased SL.

METHODS AND RESULTS

A retrospective nationwide cohort study combined data from the Norwegian Register for Cardiac Surgery and SL data from the Norwegian Labour and Welfare Administrations. All able-bodied adults who underwent first-time elective open-heart surgery in Norway between 2012 and 2021 were followed until 1 year after surgery. The impact of socio-demographic and clinical factors on SL after surgery was analysed using logistic regression and odds ratios. Of 5456 patients, 1643 (30.1%), 1798 (33.0%), 971 (17.8%), 1035 (18.9%), and 9 (0.2%) had SL of <3, 3-6, 6-9, and 9-12 months, and 1 year, respectively. SL >6 months was associated with female gender, primary education only, and average annual income. Post-operative stroke, post-operative renal failure, New York Heart Association Functional Classification system (NYHA) score >3, earlier myocardial infarction, and diabetes mellitus increased the odds of SL >6 months.

CONCLUSION

This study demonstrates that socio-demographic and clinical factors impact SL after first-time elective open-heart surgery. Patients who experience a stroke or develop renal failure after surgery have the highest odds of SL >6 months. Females and patients with low education levels, earlier myocardial infarction, or NYHA scores III-IV have a two-fold chance of SL >6 months. The findings allow for future investigations of pre- and post-surgery interventions that can most effectively reduce SL and aid return to work.

Challenging assumptions about the demographics of eosinophilic gastrointestinal diseases: A systematic review

Background

The demographic characteristics of patients with eosinophilic gastrointestinal diseases (EGIDs) are poorly understood. Population-based assessments of EGID demographics may indicate health disparities in diagnosis.

Objectives

We aimed to characterize the demographic distribution of EGIDs and evaluate the potential for bias in reporting patient characteristics.

Methods

We conducted a systematic review, extracting data on age, sex, gender, race, ethnicity, body mass index, insurance, and urban/rural residence on EGID patients and the source population. Differences in proportions were assessed by chi-square tests. Demographic reporting was compared to recent guidelines.

Results

Among 50 studies that met inclusion/exclusion criteria, 12 reported ≥1 demographic feature in both EGID and source populations. Except for age and sex or gender, demographics were rarely described (race = 4, ethnicity = 1, insurance = 1) or were not described (body mass index, urban/rural residence). A higher proportion of male subjects was observed for EoE or esophageal eosinophilia relative to the source population, but no difference in gender or sex distribution was observed for other EGIDs. "Sex" and "gender" were used interchangeably, and frequently only the male proportion was reported. Reporting of race and ethnicity was inconsistent with guidelines.

Conclusion

Current data support a male predominance for EoE only. Evidence was insufficient to support enrichment of EGIDs in any particular racial, ethnic, or other demographic group. Population-based studies presenting demographics on both cases and source populations are needed. Implementation of guidelines for more inclusive reporting of demographic characteristics is crucial to prevent disparities in timely diagnosis and management of patients with EGIDs.

Female-specific risk variables: From innocent bystanders to key players in cardiovascular risk prediction

There is an increasing interest among professionals in cardiovascular medicine in women-specific risk variables related to gynecologic conditions over the life span. Although adverse lifestyle factors, hypertension, dyslipidemia and insulin resistance are recognized as the most important risk factors in older women, there is still uncertainty over how to account for other risk variables. For instance, migraine from puberty onwards, chronic inflammatory conditions and mental stress affect cardiovascular risk in women. As prevention should start as early in life as possible, appropriate risk estimation in women at middle age is crucial. In case of doubt, a coronary artery calcium score with a computed tomography scan at a radiology department can be helpful to discriminate between low and high risk for an individual. This may also pave the way for safe menopausal hormone therapy if needed. In this paper we summarize the current status of women-specific and other relevant risk variables from the perspective of the cardiologist.

A systematic review of sex and gender differences in treatment outcome of inflammatory skin diseases: Is it time for new guidelines?

Gender- and sex-specific differences in medicine were long-time disregarded. Despite numerous indications of gender- and sex-specific influences on the treatment of dermatological conditions, these have not yet been systematically investigated. To meet this unmet need, we conducted the present systematic review on the topic of gender and sex differences in the treatement outcome of skin diseases. Embase (via Ovid), PubMed Medline and Web of Science were searched, in between January 2001 and December 2022. English and german randomized controlled trials, prospective and retrospective cohorts and case-control studies that examined differences between men and women in treatment outcomes of skin diseases were included. Two authors independently screened the reports for eligibility, one extracted all data (the second double-checked) and critically appraised the quality and risk of bias of the studies. Eighty-three reports were included. The largest share of the identified publications focused on gender differences in psoriasis and psoriatic arthritis (n = 49), followed by melanoma (n = 8) and sporadic studies (n < 5) of inflammatory, infectious and autoimmune skin diseases. The main topics in which gender differences could be identified were choice of treatment, time to initiation of treatment, therapy response, adverse events, adherence and treatment satisfaction. For psoriasis, gender differences could be found in all aspects, while for the other skin diseases specific publications on gender differences are still missing. This systematic review shows numerous gender differences but also reveals major gaps in gender-specific care in dermatology which should be narrowed in the upcoming years to optimize a patient-centred, individualized, gender-equal healthcare. PROSPERO Registration: CRD42022306626.

Impact of Sex Differences on Clinical Outcomes in Patients Following Primary Revascularization for Acute Myocardial Infarction - Insights From the Japanese Nationwide Registry

BACKGROUND

Women with acute myocardial infarction (AMI) often present a worse risk profile and experience a higher rate of in-hospital mortality than men. However, sex differences in post-discharge prognoses remain inadequately investigated. We examined the impact of sex on 1-year post-discharge outcomes in patients with AMI undergoing percutaneous coronary intervention.

METHODS AND RESULTS

We extracted patient-level data for the period January 2017-December 2018 from the J-PCI OUTCOME Registry, endorsed by the Japanese Association of Cardiovascular Intervention and Therapeutics. One-year all-cause and cardiovascular mortality and major adverse cardiovascular events were compared between men and women. In all, 29,856 AMI patients were studied, with 6,996 (23.4%) being women. Women were significantly older and had a higher prevalence of comorbidities than men. Crude all-cause mortality was significantly higher among women than men (7.5% vs. 5.4% [P<0.001] for ST-elevation myocardial infarction [STEMI]; 7.0% vs. 5.2% [P=0.006] for non-STEMI). These sex-related differences in post-discharge outcomes were attenuated after stratification by age. Multivariate analysis demonstrated an increase in all-cause mortality in both sexes with increasing age and advanced-stage chronic kidney disease (CKD).

CONCLUSIONS

Within this nationwide cohort, women had worse clinical outcomes following AMI than men. However, these sex-related differences in outcomes diminished after adjusting for age. In addition, CKD was significantly associated with all-cause mortality in both sexes.

Body Mass Index and Hypertension as Mediators of the Association Between Age at Menarche and Subclinical Atherosclerosis: A Sex-Specific Mendelian Randomization Analysis

BACKGROUND

Early age at menarche (AAM) has been associated with a higher risk of carotid artery intima-media thickness (cIMT), an indicator of subclinical vascular disease, albeit the mechanisms underlying this association remain elusive. A better understanding of the relationship between AAM, modifiable cardiometabolic risk factors, and subclinical atherosclerosis may contribute to improved primary prevention and cardiovascular disease treatment. We aimed to investigate the putative causal role of AAM on cIMT, and to identify and quantify the potentially mediatory effects of cardiometabolic risk factors underlying this relationship.

METHODS AND RESULTS

We conducted linkage disequilibrium score regression analyses between our exposure of interest, AAM, our outcome of interest, cIMT and potential mediators of the AAM-cIMT association to gauge cross-trait genetic overlap. We considered as mediators the modifiable anthropometric risk factors body mass index (BMI), systolic blood pressure (SBP), lipid traits (total cholesterol, triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol), and glycemic traits (fasting glucose). We then leveraged the paradigm of Mendelian randomization to infer causality between AAM and cIMT, and to identify whether cardiometabolic risk factors served as potential mediators of this effect. Our analyses showed that genetically predicted AAM was inversely associated with cIMT, BMI, SBP, and triglycerides, and positively associated with high-density lipoprotein, low-density lipoprotein, and total cholesterol. We showed that the effect of genetically predicted AAM on cIMT may be partially mediated through BMI (20.1% [95% CI, 1.4% to 38.9%]) and SBP (13.5% [95% CI, 0.5%-26.6%]). Our cluster-specific Mendelian randomization revealed heterogeneous causal effect estimates of age at menarche on BMI and SBP.

CONCLUSIONS

We highlight supporting evidence for a potential causal association between earlier AAM and cIMT, and almost one third of the effect of AAM on cIMT may be mediated by BMI and SBP. Early intervention aimed at lowering BMI and hypertension may be beneficial in reducing the risk of developing subclinical atherosclerosis due to earlier age at menarche.

Inequalities in cardiovascular disease among elderly Indians: A gender perspective analysis using LASI wave-I (2017-18)

BACKGROUND

While Cardiovascular disease (CVD) affects both men and women, emerging evidence suggests notable gender differentials in disease prevalence. This study aims to explore and analyse the gender differentials in CVD disease prevalence in India.

METHODS

The present study utilizes data from first wave of the nationally representative survey "Longitudinal Ageing Study in India" (LASI, WAVE-I, 2017-18) with the eligible sample size of 31,464 individuals aged 60 years and above. Logistic regression analysis was used to understand risk of CVD by demographic characteristics. Factors contribution to gender differences in CVD prevalence was examined using a non-linear Fairlie decomposition.

RESULTS

The prevalence of CVD was lower in men (31.06%) compared to women (38.85%). Women have a 33% higher likelihood of CVD compared to men (OR: 1.33; 95% CI: 1.25-1.42). Lack of education also confers a lower risk, more pronounced in women with no schooling (OR: 0.81; 95% CI: 0.7-0.94) compared to men (OR: 0.52; 95% CI: 0.47-0.58). Morbidity influences CVD presence more among women than men, with individuals suffering from three or more diseases having markedly increased odds (Men: OR: 3.89; 95% CI: 3.54-4.3, Women: OR: 6.97; 95% CI: 6.48-10.11). Smoking accounted increase in (20.52%) the gender gap while years of schooling dramatically lessened the gender gap (-46.30%).

CONCLUSION

Result show gender differential in CVD prevalence and underlying risk factors, underscoring the need for gender-specific preventive strategies and interventions. Our findings highlight the importance of refined approach to cardiovascular health that considers the complex interplay of biological, social, and environmental determinants.

The impact of female sex hormones on cardiovascular disease: from mechanisms to hormone therapy

Cardiovascular disease remains the leading cause of mortality in women, yet it has not raised the awareness from the public. The pathogenesis of cardiovascular disease differs significantly between females and males concerning the effect of sex hormones. Estrogen and progestogen impact cardiovascular system through genomic and non-genomic effects. Before menopause, cardiovascular protective effects of estrogens have been well described. Progestogens were often used in combination with estrogens in hormone therapy. Fluctuations in sex hormone levels, particularly estrogen deficiency, were considered the specific risk factor in women's cardiovascular disease. However, considerable heterogeneity in the impact of hormone therapy was observed in clinical trials. The heterogeneity is likely closely associated with factors such as the initial time, administration route, dosage, and formulation of hormone therapy. This review will delve into the pathogenesis and hormone therapy, summarizing the effect of female sex hormones on hypertension, pre-eclampsia, coronary heart disease, heart failure with preserved ejection fraction, and cardiovascular risk factors specific to women.

Addressing the Global Burden of Cardiovascular Disease in Women: JACC State-of-the-Art Review

Cardiovascular diseases (CVDs) are responsible for approximately 35% of all deaths in women. In 2019, the global age-standardized CVD prevalence and mortality of women were 6,403 per 100,000 and 204 per 100,000, respectively. Although the age- and population-adjusted prevalence has decreased globally, opposite trends are evident in regions of socioeconomic deprivation. Cardiovascular health and outcomes are influenced by regional socioeconomic, environmental, and community factors, in addition to health care system and individual factors. Cardiovascular care in women is commonly plagued by delayed diagnoses, undertreatment, and knowledge gaps, particularly in women-specific or women-predominant conditions. In this paper, we describe the global epidemiology of CVD and highlight multilevel determinants of cardiometabolic health. We review knowledge and health care gaps that serve as barriers to improving CVD outcomes in women. Finally, we present national, community, health care system, and research strategies to comprehensively address cardiometabolic risk and improve outcomes in women.

The Interplay between Mechanoregulation and ROS in Heart Physiology, Disease, and Regeneration

Cardiovascular diseases are currently the most common cause of death in developed countries. Due to lifestyle and environmental factors, this problem is only expected to increase in the future. Reactive oxygen species (ROS) are a key player in the onset of cardiovascular diseases but also have important functions in healthy cardiac tissue. Here, the interplay between ROS generation and cardiac mechanical forces is shown, and the state of the art and a perspective on future directions are discussed. To this end, an overview of what is currently known regarding ROS and mechanosignaling at a subcellular level is first given. There the role of ROS in mechanosignaling as well as the interplay between both factors in specific organelles is emphasized. The consequences at a larger scale across the population of heart cells are then discussed. Subsequently, the roles of ROS in embryogenesis, pathogenesis, and aging are further discussed, exemplifying some aspects of mechanoregulation. Finally, different models that are currently in use are discussed to study the topics above.

Sex and Racial Disparities in Proportionate Mortality of Premature Myocardial Infarction in the United States: 1999 to 2020

BACKGROUND

The incidence of premature myocardial infarction (PMI) in women (<65 years and men <55 years) is increasing. We investigated proportionate mortality trends in PMI stratified by sex, race, and ethnicity.

METHODS AND RESULTS

CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) was queried to identify PMI deaths within the United States between 1999 and 2020, and trends in proportionate mortality of PMI were calculated using the Joinpoint regression analysis. We identified 3 017 826 acute myocardial infarction deaths, with 373 317 PMI deaths corresponding to proportionate mortality of 12.5% (men 12%, women 14%). On trend analysis, proportionate mortality of PMI increased from 10.5% in 1999 to 13.2% in 2020 (average annual percent change of 1.0 [0.8-1.2, P <0.01]) with a significant increase in women from 10% in 1999 to 17% in 2020 (average annual percent change of 2.4 [1.8-3.0, P <0.01]) and no significant change in men, 11% in 1999 to 10% in 2020 (average annual percent change of -0.2 [-0.7 to 0.3, P=0.4]). There was a significant increase in proportionate mortality in both Black and White populations, with no difference among American Indian/Alaska Native, Asian/Pacific Islander, or Hispanic people. American Indian/Alaska Natives had the highest PMI mortality with no significant change over time.

CONCLUSIONS

Over the last 2 decades, there has been a significant increase in the proportionate mortality of PMI in women and the Black population, with persistently high PMI in American Indian/Alaska Natives, despite an overall downtrend in acute myocardial infarction-related mortality. Further research to determine the underlying cause of these differences in PMI mortality is required to improve the outcomes after acute myocardial infarction in these populations.

Precision in Action: The Role of Clustered Regularly Interspaced Short Palindromic Repeats/Cas in Gene Therapies

Clustered Regularly Interspaced Short Palindromic Repeat (CRISPR)-associated enzyme-CAS holds great promise for treating many uncured human diseases and illnesses by precisely correcting harmful point mutations and disrupting disease-causing genes. The recent Food and Drug Association (FDA) approval of the first CRISPR-based gene therapy for sickle cell anemia marks the beginning of a new era in gene editing. However, delivering CRISPR specifically into diseased cells in vivo is a significant challenge and an area of intense research. The identification of new CRISPR/Cas variants, particularly ultra-compact CAS systems with robust gene editing activities, paves the way for the low-capacity delivery vectors to be used in gene therapies. CRISPR/Cas technology has evolved beyond editing DNA to cover a wide spectrum of functionalities, including RNA targeting, disease diagnosis, transcriptional/epigenetic regulation, chromatin imaging, high-throughput screening, and new disease modeling. CRISPR/Cas can be used to engineer B-cells to produce potent antibodies for more effective vaccines and enhance CAR T-cells for the more precise and efficient targeting of tumor cells. However, CRISPR/Cas technology has challenges, including off-target effects, toxicity, immune responses, and inadequate tissue-specific delivery. Overcoming these challenges necessitates the development of a more effective and specific CRISPR/Cas delivery system. This entails strategically utilizing specific gRNAs in conjunction with robust CRISPR/Cas variants to mitigate off-target effects. This review seeks to delve into the intricacies of the CRISPR/Cas mechanism, explore progress in gene therapies, evaluate gene delivery systems, highlight limitations, outline necessary precautions, and scrutinize the ethical considerations associated with its application.

Sex-based utilization of guideline recommended statin therapy and cardiovascular disease outcomes: Data from a multisite healthcare network primary prevention cohort

Background

In the US, women have similar cardiovascular death rates as men. However, less is known about sex differences in statin use for primary prevention and associated atherosclerotic cardiovascular disease (ASCVD) outcomes.

Methods

Statin prescriptions using electronic health records were examined in patients without ASCVD (myocardial infarction (MI), revascularization or ischemic stroke) between 2013 and 2019. Guideline-directed statin intensity (GDSI) at index (at least moderate intensity, defined per pooled-cohort equation) and follow-up visits were compared between sexes across ASCVD risk groups, defined by the pooled-cohort equation. Cox regression hazard ratios were calculated for statin use and outcomes (myocardial infarction, stroke/transient ischemic attack (TIA), and all-cause mortality) stratified by sex. Interaction terms (statin and sex) were applied.

Results

Among 282,298 patients, (mean age ∼ 50 years) 17.1 % women and 19.5 % men were prescribed any statin at index visit. Time to GDSI was similar between sexes, but the proportion of high-risk women on GDSI at follow-up were lower compared to high-risk men (2-years: 27.7 vs 32.0 %, and 5-years: 47.2 vs 55.2 %, p < 0.05). When compared to GDSI, no statin use was associated with higher risk of MI and ischemic stroke/TIA among both sexes. High-risk women on GDSI had a lower risk of mortality (HR=1.39 [1.22-1.59]) vs. men (HR=1.67 [1.50-1.86]) of similar risk (p value interaction=0.004).

Conclusion

In a large contemporary healthcare system, there was underutilization of statins across both sexes in primary prevention. High-risk women were less likely to remain on GDSI compared to high-risk men. GDSI significantly improved the survival in both sexes regardless of ASCVD risk group. Future strategies to ensure continued use of GDSI, specifically among women, should be explored.

Proteomic Analysis and Sex-Specific Changes in Chronically Ischemic Swine Myocardium Treated with Sodium-Glucose Cotransporter-2 Inhibitor Canagliflozin

BACKGROUND

Although sodium-glucose cotransporter-2 inhibitors have been shown to improve cardiovascular outcomes in general, little is presently known about any sex-specific changes that may result from this therapy. We sought to investigate and quantify potential sex-specific changes seen with the sodium-glucose cotransporter-2 inhibitor canagliflozin (CAN) in a swine model of chronic myocardial ischemia.

STUDY DESIGN

Eighteen Yorkshire swine underwent left thoracotomy with placement of an ameroid constrictor. Two weeks postop, swine were assigned to receive either control (F = 5 and M = 5) or CAN 300 mg daily (F = 4 and M = 4). After 5 weeks of therapy, swine underwent myocardial functional measurements, and myocardial tissue was sent for proteomic analysis.

RESULTS

Functional measurements showed increased cardiac output, stroke volume, ejection fraction, and ischemic myocardial flow at rest in male swine treated with CAN compared with control male swine (all p < 0.05). The female swine treated with CAN had no change in cardiac function as compared with control female swine. Proteomic analysis demonstrated 6 upregulated and 97 downregulated proteins in the CAN female group compared with the control female group. Pathway analysis showed decreases in proteins in the tricarboxylic acidic cycle. The CAN male group had 639 upregulated and 172 downregulated proteins compared with control male group. Pathway analysis showed increases in pathways related to cellular metabolism and decreases in pathways relevant to the development of cardiomyopathy and to oxidative phosphorylation.

CONCLUSIONS

Male swine treated with CAN had significant improvements in cardiac function that were not observed in female swine treated with CAN. Moreover, CAN treatment in male swine was associated with significantly more changes in protein expression than in female swine treated with CAN. The increased proteomic changes seen in the CAN male group likely contributed to the more robust changes in cardiac function seen in male swine treated with CAN.

Sex differences in the management of patients with suspected acute coronary syndrome in China

Few studies have assessed sex differences in the management of suspected acute coronary syndrome (ACS). We aimed to compare the evaluation, treatment, and outcomes between males and females with suspected ACS in the emergency department. Data were obtained from a prospective registry of acute chest pain involving 21 emergency departments in Shandong Province, China. The primary endpoint was 30-day major adverse cardiac events (MACEs). Overlap propensity score weighting was used to address potential confounding. A total of 8046 patients were analysed (42.8% female). Overlap-weighted analysis showed no significant association of female sex with 30-day MACEs (odds ratio, 0.91; 95% CI 0.75 to 1.11; P = 0.363). Secondary analyses found that women were less likely to be identified as high risk at first presentation (odds ratio, 0.86; 95% CI 0.78 to 0.94; P < 0.001). In the emergency department, women were less likely to undergo antiplatelet therapy (odds ratio, 0.87; 95% CI 0.79 to 0.96; P = 0.004) or coronary angiography (odds ratio, 0.78; 95% CI, 0.69 to 0.88; P < 0.001). Women had a longer length of stay in the emergency department and were less likely to be admitted to a ward at disposition. These sex differences existed only in the non-ST-elevation subgroup and were independent of risk stratification. Women with non-ST-elevation chest pain in China received suboptimal treatment in the emergency department. However, their clinical outcomes were not significantly different from those of men. Further studies are needed to determine the causes and impacts of these sex differences.

Process quality, diagnosis quality, and patient satisfaction of primary care in Rural Western China: A study using standardized patients

OBJECTIVES

Patient satisfaction is an essential indicator of the doctor-patient relationship. This study aimed to investigate the relationship between primary care quality and patient satisfaction for non-communicable diseases (NCDs) in rural western China.

METHODS

The study utilized the standardized patients (SPs) approach to present typical symptoms of unstable angina and diabetes to rural healthcare providers. After the consultations, the SPs completed a satisfaction survey. Ordinary least squares and quantile regression were used to examine the association between quality of primary care and patient satisfaction.

RESULTS

We examined 178 anonymous SPs visits. The results showed that higher process quality for angina SPs was correlated with stronger satisfaction for provider ability at a low quantile of ability satisfaction. For diabetes SPs, higher process quality increased overall satisfaction at a low quantile of overall satisfaction, whereas a correct diagnosis significantly contributed to communication satisfaction at a high quantile of communication satisfaction.

CONCLUSIONS

The study found positive associations between process and diagnosis quality and SPs satisfaction. Notably, the influence of process quality was most significant among patients with lower satisfaction levels.

PRACTICE IMPLICATIONS

Provider's process quality could be a key area of improving the satisfaction levels, especially for patients with lower levels of satisfaction.

AMPA receptor inhibition alleviates inflammatory response and myocardial apoptosis after myocardial infarction by inhibiting TLR4/NF-κB signaling pathway

Myocardial infarction leads to myocardial inflammation and apoptosis, which are crucial factors leading to heart failure and cardiovascular dysfunction, eventually resulting in death. While the inhibition of AMPA receptors mitigates inflammation and tissue apoptosis, the effectiveness of this inhibition in the pathophysiological processes of myocardial infarction remains unclear. This study investigated the role of AMPA receptor inhibition in myocardial infarction and elucidated the underlying mechanisms. This study established a myocardial infarction model by ligating the left anterior descending branch of the coronary artery in Sprague-Dawley rats. The findings suggested that injecting the AMPA receptor antagonist NBQX into myocardial infarction rats effectively alleviated cardiac inflammation, myocardial necrosis, and apoptosis and improved their cardiac contractile function. Conversely, injecting the AMPA receptor agonist CX546 into infarcted rats exacerbated the symptoms and tissue damage, as reflected by histopathology. This agonist also stimulated the TLR4/NF-κB pathway, further deteriorating cardiac function. Furthermore, the investigations revealed that AMPA receptor inhibition hindered the nuclear translocation of P65, blocking its downstream signaling pathway and attenuating tissue inflammation. In summary, this study affirmed the potential of AMPA receptor inhibition in countering inflammation and tissue apoptosis after myocardial infarction, making it a promising therapeutic target for mitigating myocardial infarction.

Ensemble machine learning for predicting in-hospital mortality in Asian women with ST-elevation myocardial infarction (STEMI)

The accurate prediction of in-hospital mortality in Asian women after ST-Elevation Myocardial Infarction (STEMI) remains a crucial issue in medical research. Existing models frequently neglect this demographic's particular attributes, resulting in poor treatment outcomes. This study aims to improve the prediction of in-hospital mortality in multi-ethnic Asian women with STEMI by employing both base and ensemble machine learning (ML) models. We centred on the development of demographic-specific models using data from the Malaysian National Cardiovascular Disease Database spanning 2006 to 2016. Through a careful iterative feature selection approach that included feature importance and sequential backward elimination, significant variables such as systolic blood pressure, Killip class, fasting blood glucose, beta-blockers, angiotensin-converting enzyme inhibitors (ACE), and oral hypoglycemic medications were identified. The findings of our study revealed that ML models with selected features outperformed the conventional Thrombolysis in Myocardial Infarction (TIMI) Risk score, with area under the curve (AUC) ranging from 0.60 to 0.93 versus TIMI's AUC of 0.81. Remarkably, our best-performing ensemble ML model was surpassed by the base ML model, support vector machine (SVM) Linear with SVM selected features (AUC: 0.93, CI: 0.89-0.98 versus AUC: 0.91, CI: 0.87-0.96). Furthermore, the women-specific model outperformed a non-gender-specific STEMI model (AUC: 0.92, CI: 0.87-0.97). Our findings demonstrate the value of women-specific ML models over standard approaches, emphasizing the importance of continued testing and validation to improve clinical care for women with STEMI.

Maturation of Human iPSC-Derived Cardiac Microfiber with Electrical Stimulation Device

Here an electrical stimulation system is described for maturing microfiber-shaped cardiac tissue (cardiac microfibers, CMFs). The system enables stable culturing of CMFs with electrical stimulation by placing the tissue between electrodes. The electrical stimulation device provides an electric field covering whole CMFs within the stimulation area and can control the beating of the cardiac microfibers. In addition, CMFs under electrical stimulation with different frequencies are examined to evaluate the maturation levels by their sarcomere lengths, electrophysiological characteristics, and gene expression. Sarcomere elongation (14% increase compared to control) is observed at day 10, and a significant upregulation of electrodynamic properties such as gap junction protein alpha 1 (GJA1) and potassium inwardly rectifying channel subfamily J member 2 (KCNJ2) (maximum fourfold increase compared to control) is observed at day 30. These results suggest that electrically stimulated cultures can accelerate the maturation of microfiber-shaped cardiac tissues compared to those without electrical stimulation. This model will contribute to the pathological research of unexplained cardiac diseases and pharmacologic testing by stably constructing matured CMFs.

Alzheimer's disease as a women's health challenge: a call for action on integrative precision medicine approaches

Alzheimer's Disease (AD) is marked by pronounced sex differences in pathophysiology and progression. However, the field has yet to fully recognize AD as a women's health issue, delaying the development of targeted preventative strategies and treatments. This perspective explores the elements impacting AD in women, identifying sex specificity in risk factors, highlighting new diagnostic approaches with electronic health records, and reviewing key molecular studies to underscore the need for integrative precision medicine approaches. Established AD risk factors such as advancing age, the apolipoprotein E4 allele, and poorer cardiovascular health affect women differently. We also shed light on sociocultural risk factors, focusing on the gender disparities that may play a role in AD development. From a biological perspective, sex differences in AD are apparent in biomarkers and transcriptomics, further emphasizing the need for targeted diagnostics and treatments. The convergence of novel multiomics data and cutting-edge computational tools provides a unique opportunity to study the molecular underpinnings behind sex dimorphism in AD. Thus, precision medicine emerges as a promising framework for understanding AD pathogenesis through the integration of genetics, sex, environment, and lifestyle. By characterizing AD as a women's health challenge, we can catalyze a transformative shift in AD research and care, marked by improved diagnostic accuracy, targeted interventions, and ultimately, enhanced clinical outcomes.

Gender Differences in the Short and Long-Term Outcomes Following Rotational Atherectomy: A Meta-Analysis

Rotational atherectomy (RA) is used to address complex calcified coronary lesions but data regarding the association between gender and outcomes of patients who underwent RA remain uncertain. We aimed to investigate the short- and long-term outcomes of patients who underwent RA based on gender. A systematic literature search was performed in PubMed, Embase, and Cochrane databases from its inception until August 2023 for relevant studies. Endpoints were pooled using the DerSimonian and Laird random-effects model as odd ratios (OR) with 95% confidence intervals (CIs). A total of 7 studies with 8,490 patients (2,565 women and 5,925 men) who underwent RA were included in the study. In terms of periprocedural outcomes, women had a higher risk of in-hospital mortality (OR 2.00, 95% CI 1.08 to 3.68, p = 0.03), coronary dissection (OR 1.80, 95% CI 1.05 to 3.10, p = 0.03), coronary perforation (OR 1.96, 95% CI 1.19 to 3.23, p = 0.01), and stroke (OR 4.22, 95% CI 1.06 to 16.82, p = 0.04) than men. There were no significant differences between women and men in terms of major adverse cardiovascular events (OR 1.43, 95% CI 0.69 to 2.94, p = 0.33), myocardial infarction (OR 1.35, 95% CI 0.87 to 2.08, p = 0.18), bleeding (OR 1.71, 95% CI 0.88 to 3.30, p = 0.11), and cardiac tamponade (OR 2.30, 95% CI 0.45 to 11.68, p = 0.32). Over a follow-up period of 3 years, the results of meta-analysis showed that women had a higher risk of all-cause mortality (OR 1.45, 95% CI 1.19 to 1.77, p <0.001), long-term major adverse cardiovascular events (OR 1.38, 95% CI 1.10 to 1.74, p = 0.01), and long-term stroke (OR 3.41, 95% CI 1.63 to 7.17, p <0.001). The risk of long-term myocardial infarction was found to be similar between both genders (OR 1.45, 95% CI 0.95 to 2.22, p = 0.09). In conclusion, female gender is associated with adverse periprocedural and long-term outcome after RA. Women consistently demonstrated higher risk of in-hospital mortality, coronary dissection, coronary perforation, and stroke in the periprocedural period. Long-term follow-up further highlighted a heightened risk for women in terms of all-cause mortality and stroke.

Women Acute Myocardial Infarction-Identifying and Understanding the Gender Gap (WAMy-GAP): A Study Protocol

Barriers to accessing care and misinterpretations of ischemic heart disease symptoms due to lack of awareness contribute to women's delay in seeking care. Women may delay seeking treatment for up to 3 h or even up to 5 days. They often perceive themselves to be at low risk of cardiovascular disease (CVD) and prioritize family responsibilities or household chores. The causes of this delay are multifactorial and influence the decision-making process, particularly in the pre-hospital phase. The objective of this study protocol is to evaluate prodromal symptoms and identify risk behaviors in women with acute myocardial infarction (AMI). This is a protocol for a multicenter study that will be conducted using the mixed-method methodology using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) to evaluate symptoms and semi-structured interviews to investigate behaviors. This study protocol is intended to fill an important knowledge gap on premonitory and acute symptoms of AMI in women in Italy, as well as to understand the causes and mechanisms underlying delays in accessing healthcare services during an acute event such as AMI. The investigation of this issue will facilitate the removal of gender-related inequalities in the diagnosis and treatment of acute myocardial infarction while also fostering dialogue on the barriers to behavior change.

DANSPOT: A Multicenter Stepped-Wedge Cluster-Randomized Trial of the Reclassification of Acute Myocardial Infarction: Rationale and Study Design

BACKGROUND

Cardiac troponins are the preferred biomarkers for the diagnosis of acute myocardial infarction. Although sex-specific 99th percentile thresholds of troponins are recommended in international guidelines, the clinical effect of their use is poorly investigated. The DANSPOT Study (The Danish Study of Sex- and Population-Specific 99th percentile upper reference limits of Troponin) aims to evaluate the clinical effect of a prospective implementation of population- and sex-specific diagnostic thresholds of troponins into clinical practice.

METHODS

This study is a nationwide, multicenter, stepped-wedge cluster-randomized trial of the implementation of population- and sex-specific thresholds of troponins in 22 of 23 clinical centers in Denmark. We established sex-specific thresholds for 5 different troponin assays based on troponin levels in a healthy Danish reference population. Centers will sequentially cross over from current uniform manufacturer-derived thresholds to the new population- and sex-specific thresholds. The primary cohort is defined as patients with symptoms suggestive of acute coronary syndrome having at least 1 troponin measurement performed within 24 hours of arrival with a peak troponin value between the current uniform threshold and the new sex-specific female and male thresholds. The study will compare the occurrence of the primary outcome, defined as a composite of nonfatal myocardial infarction, unplanned revascularization, and all-cause mortality within 1 year, separately for men and women before and after the implementation of the new sex-specific thresholds.

CONCLUSIONS

The DANSPOT Study is expected to show the clinical effects on diagnostics, treatment, and clinical outcomes in patients with myocardial infarction of implementing sex-specific diagnostic thresholds for troponin based on a national Danish reference population.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05336435.

Protective effect of esculentoside A against myocardial infarction via targeting C-X-C motif chemokine receptor 2

Myocardial infarction (MI) is the primary cause of cardiac mortality. Esculentoside A (EsA), a triterpenoid saponin, has anti-inflammatory and antioxidant activities. However, its effect on MI remains unknown. In this study, the protective effect and mechanisms of EsA against MI were investigated. EsA significantly alleviated hypoxia-induced HL-1 cell injury, including increasing cell viability, inhibiting reactive oxygen species (ROS) production, mitochondrial membrane potential (MMP) and lactate dehydrogenase (LDH) leakage. In mouse MI model by left coronary artery (LAD) ligating, EsA obviously restored serum levels of creatine kinase isoenzymes (CK-MB), cardiac troponin I (cTnI), superoxide dismutase (SOD) and malondialdehyde (MDA). In addition, the cardioprotective effect of EsA was further confirmed by infarct size, electrocardiogram and echocardiography. Mechanistically, the targeted binding relationship between EsA and C-X-C motif chemokine receptor 2 (CXCR2) was predicted by molecular docking and dynamics, and validated by small molecule pull-down and surface plasmon resonance tests. EsA inhibited CXCR2 level both in vitro and in vivo, correspondingly alleviated oxidative stress by suppressing NOX1 and NOX2 and relieved inflammation through inhibiting p65 and p-p65. It demonstrated that EsA could play a cardioprotective role by targeting CXCR2. However, the effect of EsA against MI was abolished in combination with CXCR2 overexpression both in vitro and in vivo. This study revealed that EsA showed excellent cardioprotective activities by targeting CXCR2 to alleviate oxidative stress and inflammation in MI. EsA may function as a novel CXCR2 inhibitor and a potent candidate for the prevention and intervention of MI in the future.

Ischemic Heart Disease in Women

This review synthesizes the current understanding of ischemic heart disease in women, briefly discussing differences in risk factors, presentation, and treatment. We have underscored the unique clinical phenotype of IHD in women with a higher prevalence of ischemia with non-obstructive coronary arteries. Further research is needed to elucidate the complexities of ischemic heart disease in women, understand the discordance between ischemic burden and clinical symptoms, and optimize treatment strategies.

RBM15 Protects From Myocardial Infarction by Stabilizing NAE1

RNA-binding proteins play multiple roles in several biological processes. However, the roles of RBM15-an important RNA-binding protein and a significant regulator of RNA methylation-in cardiovascular diseases remain elusive. This study aimed to investigate the biological function of RBM15 and its fundamental mechanisms in myocardial infarction (MI). Methylated RNA immunoprecipitation sequencing was used to explore the N6-methyladenosine (m6A) difference between MI and normal tissues. Our findings showed the elevated level of m6A in MI, and its transcription profile in both MI and normal tissues. RBM15 was the main regulator and its overexpression attenuated apoptosis in cardiomyocytes and improved cardiac function in mice after MI. Then, we used one target NEDD8 activating enzyme E1 subunit and its inhibitor (MLN4924) to investigate the impact of RBM15 targets on cardiomyocytes. Finally, the enhanced m6A methylation in the presence of RBM15 overexpression led to the increased expression and stability of NEDD8 activating enzyme E1 subunit. Our findings suggest that the enhanced m6A level is a protective mechanism in MI, and RBM15 is significantly upregulated in MI and promotes cardiac function. This study showed that RBM15 affected MI by stabilizing its target on the cell apoptosis function, which might provide a new insight into MI therapy.

Closing the sex gap in cardiovascular mortality by achieving both horizontal and vertical equity

Addressing sex differences and disparities in coronary heart disease (CHD) involves achieving both horizontal and vertical equity in healthcare. Horizontal equity in the context of CHD means that both men and women with comparable health statuses should have equal access to diagnosis, treatment, and management of CHD. To achieve this, it is crucial to promote awareness among the general public about the signs and symptoms of CHD in both sexes, so that both women and men may seek timely medical attention. Women often face inequity in the treatment of cardiovascular disease. Current guidelines do not differ based on sex, but their applications based on gender do differ. Vertical equity means tailoring healthcare to allow equitable care for all. Steps towards achieving this include developing treatment protocols and guidelines that consider the unique aspects of CHD in women. It also requires implementing guidelines equally, when there is not sex difference rather than inequities in application of guideline directed care.

Acute Coronary Syndrome in Women: An Update

PURPOSE OF REVIEW

The goal of this manuscript is to provide a concise summary of recent developments in the approach to and treatment of women with acute coronary syndrome (ACS).

RECENT FINDINGS

This review covers terminology updates relating to ACS and myocardial injury and infarction. Updates on disparities in recognition, treatments, and outcomes of women with ACS due to atherosclerotic coronary artery disease are covered. Other causes of ACS, including spontaneous coronary artery dissection and myocardial infarction with non-obstructive coronary artery disease are discussed, given the increased frequency in women compared with men. The review summarizes the latest on the unique circumstance of ACS in women who are pregnant or post-partum, including etiologies, diagnostic approaches, medication safety, and revascularization considerations. Compared with men, women with ACS have unique risk factors, presentations, and pathophysiology. Treatments known to be effective for men with atherosclerosis-related ACS are also effective for women; further work remains on reducing the disparities in diagnosis and treatment. Implementation of multimodality imaging will improve diagnostic accuracy and allow for targeted medical therapy in the setting of myocardial infarction with non-obstructive coronary artery disease.

Sex-related differences in outcome of thoracic aortic surgery

BACKGROUND

Sex-related dissimilarities' influence on outcomes following thoracic aortic surgery is poorly understood. Our aim is to examine sex-related disparities in patients undergoing thoracic aortic aneurysm (TAA).

METHODS

A total of 455 cases undergoing thoracic aortic aneurysm (TAA) surgery were consecutively enrolled between December 2009 and December 2015 in a Chinese hospital. Primary outcomes, including overall mortality and related risk factors, were evaluated. Cox regression is utilized to recognize the independent risk factor of these consequences.

RESULTS

Females, compared to males, had greater indexed aortic diameters and higher aortic transvalvular pressure differences. For the location of aortic aneurysms, females had a higher rate of aortic arch involvement, while males had a higher rate of root involvement. Females underwent less frequent complex proximal aortic operations compared with males (29.5% versus 46.9%; p < 0.001). Women and men both had a lower rate of aortic transvalvular pressure difference and LV volume index 7 days after thoracic aortic surgery. The overall mortality for the women's groups (11%) was suggestively greater compared to 4.9% for the men's groups (p = 0.026). Renal failure and aortic arch involvement were the main risk factors associated with males' survival, while maximum indexed aortic diameter and cross-clamp time were the risk factors associated with females' survival.

CONCLUSIONS

The outcome after TAA surgery was less favorable in women with significantly increased overall mortality. It highlights the need to focus on implementing personalized surgery strategies and gender-specific guidelines in treating female patients following TAA surgery.

Incorporating equity, diversity, and inclusion into the epidemiology and biostatistics curriculum: A workshop report and implementation strategies recommendations

There is an obligation among those teaching epidemiology to incorporate principles of equity, diversity, and inclusion (EDI) into the curriculum. While there is a well-established literature related to teaching epidemiology, this literature rarely addresses critical aspects of EDI. To our knowledge, there is no working group or central point of discussion and learning for incorporating EDI into epidemiology teaching in Canada. To address this gap, we convened a workshop entitled "Incorporating EDI into the epidemiology and biostatistics curriculum and classroom." The workshop discussed nine strategies to incorporate EDI in the epidemiology curriculum: positionality (or reflexivity) statements; opportunities for feedback; land acknowledgements; clarifying the purpose of collecting data on race and ethnicity, sex and gender, Indigeneity; acknowledging that race/ethnicity is a social construct, not a biological variable; describing incidence and prevalence of disease; demonstrating explicit bias using directed acyclic graphs (DAGs); critical appraisal of study population diversity; and admission criteria and considerations. Key take-aways from the workshop were the need to be more intentional when determining the validity of evidence, particularly with respect to historical context and the need to recognize that there is no single solution that will address EDI.

Representation of Women and Women's Health in Australian Medical School Course Outlines, Curriculum Requirements, and Selected Core Clinical Textbooks

Background

Historically, medical research has, outside of reproductive health, neglected the health needs of women. Medical studies have previously excluded female participants, meaning research data have been collected from males and generalized to females. Knowledge gained from research is translated to clinical education and patient care, and female exclusion may result in gaps in the medical school curricula and textbooks.

Materials and Methods

This study involved a desktop review of the Australian Medical Council Standards for assessment and accreditation of primary medical programs, the online publicly available Australian medical school course outlines, and finally, an analysis of the recommended textbooks.

Results

There is no fixed or explicit requirement to include women's health in Australian medical school curricula. Medical school course outlines do not adequately include women's health; similarly, clinical medicine textbooks do not account for sex and gender differences.

Conclusion

Important sex and gender differences in medicine are not reflected adequately in the medical school course outlines, curricula, or clinical textbooks. This may have significant consequences on women's health.

A Near Miss in the Emergency Department: Atypical Presentation of Acute Coronary Syndrome

Acute coronary syndrome is an umbrella term encompassing three types of coronary artery disease that affect millions worldwide annually. Despite the availability of diagnostic tests (blood analysis, imaging, electrocardiogram, and screening tools), the diagnosis of myocardial infarction (MI) is still sometimes missed. According to the Centers for Disease Control and Prevention, the reported prevalence of heart disease is higher among males than females, with adults over the age of 75 having the highest prevalence. Typical "heart attack" features include chest pain that feels like pressure or squeezing, pain or discomfort in one or both arms that can radiate to the neck or jaw, shortness of breath, diaphoresis, nausea, vomiting, and lightheadedness. However, there are three subgroups where the typical warning signs do not always present: the elderly, individuals with diabetes, and females. The following is an atypical case presentation of unstable angina and non-ST-elevation MI.

Sex Differences in Diagnosis, Treatment, and Cardiovascular Outcomes in Homozygous Familial Hypercholesterolemia

Importance

Homozygous familial hypercholesterolemia (HoFH) is a rare genetic condition characterized by extremely increased low-density lipoprotein (LDL) cholesterol levels and premature atherosclerotic cardiovascular disease (ASCVD). Heterozygous familial hypercholesterolemia (HeFH) is more common than HoFH, and women with HeFH are diagnosed later and undertreated compared to men; it is unknown whether these sex differences also apply to HoFH.

Objective

To investigate sex differences in age at diagnosis, risk factors, lipid-lowering treatment, and ASCVD morbidity and mortality in patients with HoFH.

Design, Setting, and Participants

Sex-specific analyses for this retrospective cohort study were performed using data from the HoFH International Clinical Collaborators (HICC) registry, the largest global dataset of patients with HoFH, spanning 88 institutions across 38 countries. Patients with HoFH who were alive during or after 2010 were eligible for inclusion. Data entry occurred between February 2016 and December 2020. Data were analyzed from June 2022 to June 2023.

Main Outcomes and Measures

Comparison between women and men with HoFH regarding age at diagnosis, presence of risk factors, lipid-lowering treatment, prevalence, and onset and incidence of ASCVD morbidity (myocardial infarction [MI], aortic stenosis, and combined ASCVD outcomes) and mortality.

Results

Data from 389 women and 362 men with HoFH from 38 countries were included. Women and men had similar age at diagnosis (median [IQR], 13 [6-26] years vs 11 [5-27] years, respectively), untreated LDL cholesterol levels (mean [SD], 579 [203] vs 596 [186] mg/dL, respectively), and cardiovascular risk factor prevalence, except smoking (38 of 266 women [14.3%] vs 59 of 217 men [27.2%], respectively). Prevalence of MI was lower in women (31 of 389 [8.0%]) than men (59 of 362 [16.3%]), but age at first MI was similar (mean [SD], 39 [13] years in women vs 38 [13] years in men). Treated LDL cholesterol levels and lipid-lowering therapy were similar in both sexes, in particular statins (248 of 276 women [89.9%] vs 235 of 258 men [91.1%]) and lipoprotein apheresis (115 of 317 women [36.3%] vs 118 of 304 men [38.8%]). Sixteen years after HoFH diagnosis, women had statistically significant lower cumulative incidence of MI (5.0% in women vs 13.7% in men; subdistribution hazard ratio [SHR], 0.37; 95% CI, 0.21-0.66) and nonsignificantly lower all-cause mortality (3.0% in women vs 4.1% in men; HR, 0.76; 95% CI, 0.40-1.45) and cardiovascular mortality (2.6% in women vs 4.1% in men; SHR, 0.87; 95% CI, 0.44-1.75).

Conclusions and Relevance

In this cohort study of individuals with known HoFH, MI was higher in men compared with women yet age at diagnosis and at first ASCVD event were similar. These findings suggest that early diagnosis and treatment are important in attenuating the excessive cardiovascular risk in both sexes.

Sex- and gender-related disparities in chest pain syndromes: the feminine mystique of chest pain

Chest pain syndromes encompass a wide range of different clinical conditions, being coronary artery disease one of the most important and feared aetiology. Sex and gender disparities have been reported in pathophysiology, clinical presentations, diagnostic work-up and outcomes of patients admitted for chest pain. Biological differences in sexual hormones and neurological pain procession pathways have been proposed as contributors to disparities between men and women; however, gender-related disparities in socio-economic and psychological status have emerged as additional factors involved in these conditions. A better understanding of gender- and sex-related disparities will lead to improved clinical care and management of chest pain syndromes in both men and women. In this comprehensive review, we describe the existing knowledge regarding sex and gender-based differences in management and outcomes of chest pain syndromes in order to stimulate and promote the development of a more sex- and gender-oriented approach to these conditions.

Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

Sex Differences in Outcomes of Acute Myocardial Injury After Stroke

BACKGROUND

Sex differences in presentation, treatment, and prognosis of cardiovascular disorders are well recognized. Although an association between acute myocardial injury and mortality after ischemic stroke has been demonstrated, it is unclear whether prevalence and outcome of poststroke acute myocardial injury differ between women and men.

METHODS AND RESULTS

We prospectively screened consecutive patients with acute ischemic stroke and serial high-sensitivity cardiac troponin T measurements admitted to our center. Acute myocardial injury was defined as at least 1 high-sensitivity cardiac troponin T value above the upper reference limit (14 ng/L) with a rise/fall of >20%. Rates of acute myocardial injury were also calculated using sex-specific high-sensitivity cardiac troponin T cutoffs (women upper reference limit, 9 ng/L; men upper reference limit, 16 ng/L). Logistic regression analyses were performed to evaluate the association between acute myocardial injury and outcomes. Of 1067 patients included, 494 were women (46%). Women were older, had a higher rate of known atrial fibrillation, were more likely to be functionally dependent before admission, had higher stroke severity, and more often had cardioembolic strokes (all P values <0.05). The crude prevalence of acute myocardial injury differed by sex (29% women versus 23% men, P=0.024). Statistically significant associations between acute myocardial injury and outcomes were observed in women (7-day in-hospital mortality: adjusted odds ratio [aOR], 3.2 [95% CI, 1.07-9.3]; in-hospital mortality: aOR, 3.3 [95% CI, 1.4-7.6]; modified Rankin Scale score at discharge: aOR, 1.6 [95% CI, 1.1-2.4]) but not in men. The implementation of sex-specific cutoffs did not increase the prognostic value of acute myocardial injury for unfavorable outcomes.

CONCLUSIONS

The prevalence of acute myocardial injury after ischemic stroke and its association with mortality and greater disability might be sex-dependent.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03892226.

Management of cardiac emergencies in women: a clinical consensus statement of the Association for Acute CardioVascular Care (ACVC), the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the Heart Failure Association (HFA), and the European Heart Rhythm Association (EHRA) of the ESC, and the ESC Working Group on Cardiovascular Pharmacotherapy

Cardiac emergencies in women, such as acute coronary syndromes, acute heart failure, and cardiac arrest, are associated with a high risk of adverse outcomes and mortality. Although women historically have been significantly underrepresented in clinical studies of these diseases, the guideline-recommended treatment for these emergencies is generally the same for both sexes. Still, women are less likely to receive evidence-based treatment compared to men. Furthermore, specific diseases affecting predominantly or exclusively women, such as spontaneous coronary dissection, myocardial infarction with non-obstructive coronary arteries, takotsubo cardiomyopathy, and peripartum cardiomyopathy, require specialized attention in terms of both diagnosis and management. In this clinical consensus statement, we summarize current knowledge on therapeutic management of these emergencies in women. Key statements and specific quality indicators are suggested to achieve equal and specific care for both sexes. Finally, we discuss several gaps in evidence and encourage further studies designed and powered with adequate attention for sex-specific analysis.

Sex Disparities in the Management, Outcomes, and Transfer of Patients Hospitalized for Cardiogenic Shock

Background

Previous studies have shown that women have worse outcomes for cardiogenic shock (CS) than men. Patients who receive care in CS "hubs" have also been shown to have improved outcomes when compared to those treated at "spokes." This study aimed to examine the presence of sex disparities in the outcomes of CS in relation to hospital type.

Methods

Hospitalizations of adults with a diagnosis of CS were identified using data from the 2016-2019 Nationwide Readmissions Database. CS "hubs" were defined as any centers receiving at least 1 interhospital transfer with CS, while those without such transfers were classified as "spokes." Data were combined across years and multivariable logistic regression modeling was used to evaluate the association of sex with in-hospital mortality, invasive procedures, and transfer to hubs.

Results

There were a total of 618,411 CS hospitalizations (62.2% men) with CS related to acute myocardial infarction comprising 15.3 to 17.3% of women hospitalizations and 17.8 to 20.3% of men hospitalizations. In-hospital mortality was lower at hubs (34.5% for direct admissions, 31.6% for transfers) than at spokes (40.3%, all P < .01). Women underwent fewer invasive procedures (right heart catheterization, percutaneous coronary intervention, mechanical circulatory support) and had higher mortality than men. Female sex was independently associated with decreased transfers to hubs (odds ratio, 0.93; 95% CI, 0.89-0.96) and increased mortality (odds ratio, 1.09; 95% CI, 1.05-1.12).

Conclusions

Women with CS were less likely to be treated at a hub or transferred to a hub, had higher in-hospital mortality, and had a lower likelihood of receiving CS-related procedures than men. Further research is needed to understand sex-specific gaps in CS outcomes.

Sex differences in the presentation, treatment and outcomes of patients with homozygous familial hypercholesterolemia

BACKGROUND

Homozygous familial hypercholesterolemia (HoFH) is a rare, autosomal semi-dominant lipid metabolism disorder characterized by extremely high low-density lipoprotein cholesterol (LDL-C) levels and premature cardiovascular disease. The objective of this study was to investigate sex-differences in the treatment and outcomes of patients with HoFH.

METHODS

We examined clinical characteristics, lipid-lowering therapy (LLT), and cardiovascular events using descriptive statistics of patients in the Canadian HoFH registry. Major adverse cardiovascular events (MACE) were defined as the composite of cardiovascular death, non-fatal myocardial infarction, and stroke. Sex differences between continuous and categorical variables were analyzed using Mann-Whitney U test and Fisher's Exact test, respectively.

RESULTS

This study included 48 patients (27 (56%) female). The median age at diagnosis in females was 14.0 (interquartile range (IQR) 9.0-30.0) and in males was 8.0 (IQR 2.0-23.0) (p = 0.07). Baseline clinical characteristics were comparable between both sexes. The median baseline LDL-C was 12.7 mmol/L (10.0-18.3) in females and 15.3 (10.5-20.0) in males (p = 0.51). Follow up LDL-C levels were 7.6 mmol/L (IQR 4.8-11.0) in females and 6.3 (IQR 4.6-7.5) in males (p = 0.1). Most patients were taking 3 or more LLTs, with comparable proportions in both sexes (p = 0.26). Apheresis was similar in both sexes, 14 (51.8%) vs. 10 (47.6%) (p = 0.2). Over a mean of 10 years of follow-up, MACE occurred in 3 females (11.1%) and 4 males (19.1%) (p = 0.2).

CONCLUSION

Lipid levels and treatment were similar between sexes. MACE occurred in similar proportions between sexes, indicating that HoFH offsets the inherently lower cardiovascular risk in pre-menopausal females. Further investigation into sex-differences in HoFH in larger sample sizes is warranted.

Social determinants of health and its impact on cardiovascular disease in underserved populations: A critical review

In the United States, a patient succumbs to cardiovascular disease (CVD) every 33 seconds and costs the healthcare system close to $240 billion dollars annually. Social determinants of health (SDOH) are key factors responsible in structuring the well-being of individuals and communities. It significantly influences health outcomes and is reliant on several factors such as economic stability, education, healthcare access, community composition, and governmental policies. This review explores the impact of SDOH on the escalating global burden of CVD and identifies potential modifiable risk factors that contribute to acute coronary syndrome (ACS) among underserved communities. In addition, it also addresses the necessity for interventions to narrow healthcare related disparities ensuring improvement in CVD outcomes in this subgroup of population.

Effects of triglyceride glucose (TyG) and TyG-body mass index on sex-based differences in the early-onset heart failure of ST-elevation myocardial infarction

BACKGROUND AND AIM

Heart failure (HF) is an important complication of ST-elevation myocardial infarction (STEMI), including early- and late-onset HF. This study aimed to investigate the association between insulin resistance (IR)-related parameters triglyceride glucose (TyG) and TyG-body mass index (TyG-BMI) index and early-onset HF in STEMI between sexes.

METHODS AND RESULTS

This cross-sectional study included patients with STEMI who underwent primary percutaneous coronary intervention (PCI) between January 2016 and September 2022. Patients were divided into tertiles according to TyG/TyG-BMI index levels in males and females. The presence of early-onset HF was compared between tertiles in both sexes. Moreover, patients were stratified according to the tertiles of TyG/Tyg-BMI index. Differences in early-onset HF of STEMI were compared between males and females in each tertile group. 1118 patients were included in this study, 20.3% of whom were females. The incidence rate of early-onset HF was significantly higher in females than in males (29% vs. 14.8%). TyG-BMI index was negatively correlated with early-onset HF. In both females and males, there was no difference in the occurrence of early-onset HF between the highest and lowest TyG/TyG-BMI index groups. Sex disparity was observed in females who had a significantly higher prevalence of early-onset HF than males in each TyG/TyG-BMI index tertile group; however, after adjustment, the differences disappeared.

CONCLUSIONS

For patients with STEMI who undergo primary PCI, the incidence of early-onset HF is higher in females than in males. The TyG/TyG-BMI index do not contribute to the difference in early-onset HF between sexes.

Complications and Outcomes in 39,864 Patients Receiving Standard Care Plus Mechanical Circulatory Support or Standard Care Alone for Infarct-Associated Cardiogenic Shock

BACKGROUND

Temporary mechanical circulatory support devices (tMCS) are increasingly being used in patients with infarct-associated cardiogenic shock (AMICS). Evidence on patient selection, complications and long-term outcomes is lacking. We aim to investigate differences in clinical characteristics, complications and outcomes between patients receiving no tMCS or either intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (V-A ECMO) or Impella® for AMICS, with a particular focus on long-term outcomes.

METHODS

Using health claim data from AOK-Die Gesundheitskasse (local health care funds), we retrospectively analysed complications and outcomes of all insured patients with AMICS between 1 January 2010 and 31 December 2017.

RESULTS

A total of 39,864 patients were included (IABP 5451; Impella 776; V-A ECMO 833; no tMCS 32,804). In-hospital complications, including renal failure requiring dialysis (50.3% V-A ECMO vs. 30.5% Impella vs. 29.2 IABP vs. 12.1% no tMCS), major bleeding (38.1% vs. 20.9% vs. 18.0% vs. 9.3%) and sepsis (22.5% vs. 15.9% vs. 13.9% vs. 9.3%) were more common in V-A ECMO patients. In a multivariate analysis, the use of both V-A ECMO (HR 1.57, p < 0.001) and Impella (HR 1.25, p < 0.001) were independently associated with long-term mortality, whereas use of IABP was not (HR 0.89, p < 0.001). Kaplan-Meier estimates showed better survival for patients on IABP compared with Impella, V-A ECMO and no-tMCS. Short- and long-term mortality was high across all groups.

CONCLUSIONS

Our data show noticeably more in-hospital complications in patients on tMCS and higher mortality with V-A ECMO and Impella. The use of both devices is an independent risk factor for mortality, whereas the use of IABP is associated with a survival benefit.

Update on sex specific risk factors in cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of death worldwide and accounts for roughly 1 in 5 deaths in the United States. Women in particular face significant disparities in their cardiovascular care when compared to men, both in the diagnosis and treatment of CVD. Sex differences exist in the prevalence and effect of cardiovascular risk factors. For example, women with history of traditional cardiovascular risk factors including hypertension, tobacco use, and diabetes carry a higher risk of major cardiovascular events and mortality when compared to men. These discrepancies in terms of the relative risk of CVD when traditional risk factors are present appear to explain some, but not all, of the observed differences among men and women. Sex-specific cardiovascular disease research-from identification, risk stratification, and treatment-has received increasing recognition in recent years, highlighting the current underestimated association between CVD and a woman's obstetric and reproductive history. In this comprehensive review, sex-specific risk factors unique to women including adverse pregnancy outcomes (APO), such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus, preterm delivery, and newborn size for gestational age, as well as premature menarche, menopause and vasomotor symptoms, polycystic ovarian syndrome (PCOS), and infertility will be discussed in full detail and their association with CVD risk. Additional entities including spontaneous coronary artery dissection (SCAD), coronary microvascular disease (CMD), systemic autoimmune disorders, and mental and behavioral health will also be discussed in terms of their prevalence among women and their association with CVD. In this comprehensive review, we will also provide clinicians with a guide to address current knowledge gaps including implementation of a sex-specific patient questionnaire to allow for appropriate risk assessment, stratification, and prevention of CVD in women.

Sex shapes gut-microbiota-brain communication and disease

Research into the microbiota-gut-brain axis (MGBA) has entered a golden age, raising the hope that therapeutics acting on it may offer breakthroughs in the treatment of many illnesses. However, most of this work overlooks a fundamental, yet understudied, biological variable: sex. Sex differences exist at every level of the MGBA. Sex steroids shape the structure of the gut microbiota, and these microbes in turn regulate levels of bioactive sex steroids. These hormones and microbes act on gut sensory enteroendocrine cells, which modulate downstream activity in the enteric nervous system, vagus nerve, and brain. We examine recent advances in this field, and discuss the scientific and moral imperative to include females in biomedical research, using autism spectrum disorder (ASD) as an example.

The Development of a Chest-Pain Protocol for Women Presenting to the Emergency Department

Cardiovascular disease (CVD) is the leading cause of death in women worldwide, and of premature death in women in Canada. Despite improvements in cardiovascular care over the past 15-20 years, acute coronary syndrome (ACS) and CVD mortality continue to increase among women in Canada. Chest pain is a common symptom leading to emergency department visits for both men and women. However, women with ACS experience worse outcomes. compared with those of men, due to misdiagnosis or lack of diagnosis resulting in delayed care and underuse of guideline-directed medical therapies. CVD mortality rates are highest in Indigenous and racialized women and those with a disproportionately high number of adverse social determinants of health. CVD remains underrecognized, underdiagnosed, undertreated, and underresearched in women. Moreover, a lack of awareness of unique symptoms, clinical presentations, and sex-and-gender specific CVD risk factors, by healthcare professionals, leads to outcome disparities. In response to this knowledge gap, in acute recognition and management of chest-pain syndromes in women, the Canadian Women's Heart Health Alliance performed a needs assessment and review of CVD risk factors and ACS pathophysiology, through a sex and gender lens, and then developed a unique chest-pain assessment protocol utilizing modified dynamic programming algorithmic methodology. The resulting algorithmic protocol is presented. The output is intended as a quick reference algorithm that could be posted in emergency departments and other acute-care settings. Next steps include protocol implementation evaluation and impact assessment on CVD outcomes in women.

At the Heart of Resilience: Empowering Women's Agency in Navigating Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of death among women globally, emphasizing the need for a healthcare approach that empowers women through agency. This review focuses on the critical role of women's agency in navigating CVD, integrating insights from various fields, including medicine, education, psychology, and sociology. The review highlights the shift toward patient-centred care, a framework in which women are recognized as key decision-makers, a crucial change given the historical underemphasis on women's health issues in medical practice. The diagnosis of CVD in women often involves emotional and psychological challenges. Unexpected diagnoses significantly disrupt perceived well-being, and prolonged diagnostic processes lead to professional skepticism and neglect of symptoms, resulting in delayed or inaccurate diagnoses and strained healthcare relationships. Effective management of CVD necessitates continuous self-management and a holistic approach to care, particularly for those with trauma who are at increased risk of cardiac incidents. Empowerment for women with CVD involves promoting self-confidence, autonomy, and active patient participation in healthcare. Implementing comprehensive care models is crucial for improving chronic CVD management, highlighting the need for healthcare systems that prioritize patient agency and empowerment. From the perspective of a woman with lived experience, this article examines the impact of CVD on women's agency throughout the diagnostic journey. By highlighting women's agency rather than particular behavioural changes, this review offers a comprehensive analysis that can shape policy, stimulate new research, and foster a more equitable, efficient, and empathetic healthcare system for women with CVD.

Antithrombotic Management and Outcomes of Anterior ST-Elevation Myocardial Infarction With New-Onset Wall Motion Abnormalities in Men and Women

Background

In patients with anterior ST-elevation myocardial infarction (STEMI) and new-onset antero-apical wall motion abnormalities (WMAs), whether the rate of prophylaxis against left ventricular thrombus and outcomes differ between men and women is unknown.

Methods

A multicentre retrospective cohort study of patients with STEMI and new-onset antero-apical WMAs treated with primary percutaneous coronary intervention was conducted. Patients with an established indication of oral anticoagulation (OAC) were excluded. The rates of triple therapy (double antiplatelet therapy + OAC) at discharge were compared for women vs men. The rates of net adverse clinical events, a composite of mortality, myocardial infarction, stroke or transient ischemic attack, systemic thromboembolism or Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding at 6 months were compared across sex using a multivariate logistic regression model.

Results

A total of 1664 patients were included in the primary analysis, of whom 402 (24.2%) were women and 1262 (75.8%) were men. A total of 138 women (34.3%) and 489 men (38.7%) received a triple therapy prescription at discharge (P = 0.11). At 6 months, 33 women (8.2%) and 96 men (7.6%) experienced a net adverse clinical event (adjusted odds ratio 0.82; 95% confidence interval 0.49-1.37). No difference occurred in the risk of bleeding events and ischemic events between men and women, when these were analyzed separately.

Conclusions

The rates of OAC prescription for left ventricular thrombus prophylaxis and clinical outcomes at 6 months were similar in women and men following anterior STEMI with new-onset antero-apical WMAs.