Newly Appreciated Pathophysiology of Ischemic Heart Disease in Women Mandates Changes in Perioperative Management: A Core Review

Sex and gender differences in anesthesia: Relevant also for perioperative safety?

Sex (a biological determination) and gender (a social construct) are not interchangeable terms and both impact perioperative management and patient safety. Sex and gender differences in clinical phenotypes of chronic illnesses and risk factors for perioperative morbidity and mortality are relevant for preoperative evaluation and optimization. Sex-related differences in physiology, as well as in pharmacokinetics and pharmacodynamics of anesthetic drugs may influence the anesthesia plan, the management of pain, postoperative recovery, adverse effects, patient satisfaction, and outcomes. Further studies are needed to characterize outcome differences between men and women in non-cardiac, cardiac, and transplantation surgery in order to individualize perioperative management and improve patient safety. Transgender patients represent a vulnerable population who need special perioperative care. Gender balance increases team performance and may improve perioperative outcomes.

Advances in Cardiac Biomarkers of Acute Coronary Syndrome

Acute coronary syndrome (ACS) encompasses a pathophysiological spectrum of cardiovascular diseases, all of which have significant morbidity and mortality. ACS was once considered an acute condition; however, new treatment strategies and improvements in biomarker assays have led to ACS being an acute and chronic disease. Cardiac troponin is the preferred biomarker for the diagnosis of myocardial infarction, and there is considerable interest and efforts toward development and implementation of high-sensitivity cardiac troponin (hs-cTn) assays worldwide. Analytical and clinical performance characteristics of hs-cTn assays as well as testing limitations are important for laboratorians and clinicians to understand in order to utilize testing appropriately. Furthermore, expanding the clinical utility of hs-cTn into other cohorts such as asymptomatic community dwelling populations, heart failure, and chronic kidney disease populations supports novel opportunities for improved short- and long-term prognosis.

Do we need to consider age and gender for accurate diagnosis of myocardial infarction?

According to the universal definition, a diagnosis of acute myocardial infarction (AMI) can be made in the presence of a kinetic change of cardiac troponin (cTn) with at least one value above the 99th percentile of a healthy population together with clinical signs of myocardial ischemia. Thus, differences in 99th percentile cut-off values may have important diagnostic and therapeutic consequences for the correct AMI diagnosis. Following the introduction of high-sensitivity (hs) cTn assays with the ability to detect cTn in virtually every healthy individual, almost all available hs Tn assays suggest to use solitary 99th percentile cut-offs. However, several findings have questioned the use of a solitary cut-off for AMI diagnosis, as apparent age- and gender-dependent differences were found concerning the 99th percentile cut-off value. Moreover, there is an increasing number of studies which suggest a relevant diagnostic and prognostic benefit, when age- or gender-specific cut-offs values are used in comparison to general cut-offs. In contrast, other studies observed only a small impact on diagnostic reclassification and risk stratification. Given these ambiguous findings, there is currently no clear evidence for the use of age- and/or gender-dependent 99th percentiles. This review gives an overview of the rationale for gender- and age-dependent differences in cTn biomarker findings and discusses the implementation of these findings into clinical practice.

Identifying and managing chest pain in women

Heart disease continues to be the leading cause of death in women in the United States. Sex disparities remain despite research highlighting the unique aspects of managing women with ischemic heart disease. Increased mortality in women may be related to the critical differences in the clinical presentation of ischemic heart disease between the sexes. Sex-related differences in the pathophysiology of ischemic heart disease also influence diagnostic testing and management. This article reviews the differences in diagnosis and management between men and women with ischemic heart disease.

Coronary spasm in neurosurgical patients and role of trigeminocardiac reflex

Background. Coronary artery spasm (CAS) is a rarely reported complication in neurosurgical patients and its main causative mechanism was attributed to vagal mediated responses. However, these may be the unusual manifestations of trigeminal cardiac reflex (TCR) which is a well established brain stem reflex observed in various neurosurgical patients. Methods and Results. In this review, we have searched for the case reports/papers related to intraoperative coronary spasm in neurosurgical patients and described the role of TCR in this regard. TCR is a possible mechanism in producing CAS in most of the cases in which stimulation occurred at or near the vicinity of trigeminal nerve. It is likely that TCR mediated coronary spasm may be a physiological mechanism and not related to actual myocardial insult apparent by cardiac enzymes or echocardiography studies in most of the cases. Some common risk factors may also exist related to occurrence of CAS as well as TCR. Conclusions. In conclusion, neurosurgical procedures occurring at the vicinity of trigeminal nerve may produce CAS even in previously healthy patients and may produce catastrophic consequences. There is a need for future reports and experimental studies on the interaction of TCR and pathophysiological mechanisms related to CAS.

Sex differences in young patients with acute myocardial infarction

AIMS

To identify sex differences in risk factors, presenting symptoms and outcomes of young patients with acute myocardial infarction.

METHODS

We adopted a comprehensive approach and performed two parallel studies: (1) using provincial administrative databases from Quebec, Canada from 2000 to 2007, we identified baseline characteristics and post-acute myocardial infarction survival of patients aged < 50 years (n = 10,619); (2) to overcome the lack of clinical data in the administrative databases, a medical chart review was performed on 215 patients < 50 years of age with an acute myocardial infarction between April 2000 and August 2006 from our institution.

RESULTS

Administrative cohort: fewer women than men sought medical attention for retrosternal chest pain 1-month pre-acute myocardial infarction (P = 0.035). Diabetes and hypertension were more prevalent in women, and patients equally received interventional procedures post-infarction. Diabetes significantly reduced post-infarction survival in men and women [HR = 2.02 (95% CI 1.21-3.36) and HR = 2.25 (95% CI 1.06-4.80), respectively]. However, young women had greater post-infarction mortality in-hospital and up to 1 year after discharge (4.23% vs. 2.21%, respectively; P = 0.005). Medical chart review: diabetes and hypertension were more prevalent in women, while men were more obese. There were no significant sex differences in typical presenting symptoms, or in interventional procedures post-infarction.

CONCLUSIONS

Young men and women with acute myocardial infarctions equally presented with retrosternal chest pain, although fewer women sought medical attention for retrosternal chest pain before admission. Diabetes and hypertension were more prevalent in young women, and mortality was higher in young female patients. Our results highlight the continued need for diabetes prevention and control in young patients, especially women.

[Gender aspects in anesthesia : modified approach in research and treatment?]

Gender differences can have a relevant influence on the perioperative outcome as male and female patients are affected differently by adverse events, e.g. side effects of drugs. Furthermore, differences relating to specific drug effects, comorbidities and outcome after anesthesia or intensive care have been demonstrated. There seems to be a gender bias in diagnosis and therapy. While the knowledge regarding this field is still growing certain aspects have already been integrated into clinical practice: prevention of postoperative nausea and vomiting (PONV), target controlled infusion (TCI) model and male only policy with production of blood products. There is a need to study the influence of gender, age and race in order to optimize treatment towards a more individualized therapy. This article highlights already identified differences and discusses potential underlying mechanisms.

Cardiovascular disease in women: implications for improving health outcomes

OBJECTIVE

To collate data on women and cardiovascular disease in Australia and globally to inform public health campaigns and health care interventions.

DESIGN

Literature review.

RESULTS

Women with acute coronary syndromes show consistently poorer outcomes than men, independent of comorbidity and management, despite less anatomical obstruction of coronary arteries and relatively preserved left ventricular function. Higher mortality and complication rates are best documented amongst younger women and those with ST-segment-elevation myocardial infarction. Sex differences in atherogenesis and cardiovascular adaptation have been hypothesised, but not proven. Atrial fibrillation carries a relatively greater risk of stroke in women than in men, and anticoagulation therapy is associated with higher risk of bleeding complications. The degree of risk conferred by single cardiovascular risk factors and combinations of risk factors may differ between the sexes, and marked postmenopausal changes are seen in some risk factors. Sociocultural factors, delays in seeking care and differences in self-management behaviours may contribute to poorer outcomes in women. Differences in clinical management for women, including higher rates of misdiagnosis and less aggressive treatment, have been reported, but there is a lack of evidence to determine their effects on outcomes, especially in angina. Although enrolment of women in randomised clinical trials has increased since the 1970s, women remain underrepresented in cardiovascular clinical trials.

CONCLUSIONS

Improvement in the prevention and management of CVD in women will require a deeper understanding of women's needs by the community, health care professionals, researchers and government.

Gender-specific differences in biomarkers responses to acute coronary syndromes and revascularization procedures

A growing body of gender-related research in coronary artery disease is beginning to gradually elucidate differences between women and men. In patients presenting with acute coronary syndromes (ACS), these sex differences include varying risk factor profiles, accuracy of diagnostic testing, clinical presentations, treatment practices and outcomes. There is also a differential expression of cardiac biomarkers by sex, which remains unexplained. This paper reviews all the available information on the effect of gender on cardiac biomarkers by search of MEDLINE using the terms gender differences, biomarkers, ACS and revascularization procedures. A better understanding of the sex disparities in biomarkers along with all other clinical information is essential to optimal management and patient care in the future.

Gender-related differences in presentation, treatment and long-term outcome in patients with first-diagnosed atrial fibrillation and structurally normal heart: the Belgrade atrial fibrillation study

BACKGROUND

Several studies have investigated gender-related differences in atrial fibrillation (AF), but limited data are available in relation to gender-related differences in presentation, treatment and long-term outcomes of patients with first-diagnosed AF and structurally normal heart.

OBJECTIVE

To compare gender-related clinical characteristics, presentation, treatment and long-term outcomes in a cohort of patients with first-diagnosed non-valvular AF and a structurally normal heart, following a 10-year follow-up.

METHODS

Observational cohort study of patients with AF between 1992 and 2007.

RESULTS

Of 862 patients (mean age 52.2±12.1 years), 315 (36.5%) were female. Paroxysmal AF and hypertension were significantly more prevalent in females, while persistent AF was more common amongst males (all p<0.001). Female patients were more symptomatic (p=0.002). After a mean follow-up of 10.1±6.1 years, more male patients developed tachycardiomyopathy (6.0% vs. 1.9%, p=0.02). In multivariate analysis, male gender remained significantly associated with tachycardiomyopathy (HR 3.1, 95% CI: 1.3-7.4, p=0.012). The rate of transition to permanent AF, thromboembolism, hemorrhage, all-cause mortality, cardiovascular and sudden death did not significantly differ between male and female patients.

CONCLUSIONS

Gender differences are evident in AF. Male patients were less asymptomatic or more frequently developed persistent AF. Male patients were also at higher risk of tachycardiomyopathy, suggesting that these patients require more attention to rate control during follow-up.

The battle of the sexes: women win out in gastrointestinal surgery

BACKGROUND

Women have been shown to have worse outcomes compared with men after cardiac surgery, but fare better after traumatic injury. No study considers the impact of gender on outcomes after major gastrointestinal surgery. We hypothesize that the physiologic insults of a major abdominal operation are similar to an injury model; therefore, women will have improved outcomes.

MATERIAL AND METHODS

We performed a retrospective review of the NIS database from 1998 to 2007. Patients undergoing major gastrointestinal surgery were identified by ICD-9 procedure codes: esophageal (42.4), gastric (43.5-43.9), small intestine (45.6), large intestine (45.7-45.8 and 17.3), rectal (48.4-48.6), hepatic (50.2-50.3), biliary (51.3 and 51.6), and pancreatic (52.5-52.7). Exclusion criteria included age over 60 y and under 18 y, multiple operations, and a sexual developmental disorder (25.52, 75.27, and 25.9). The primary outcome measure was in-hospital death.

RESULTS

A total of 307,124 patients were identified, of whom 50.3% were women. Overall, there were 6574 (2.14%) deaths; 2.45% of men and 1.84% of women died (P < 0.001). In multivariate analysis, women were 21.1% less likely to die than men (OR = 0.789, 95% CI = 0.74-0.84). When subset analysis was performed, women had improved mortality in the following types of surgery: gastric (OR = 0.751, 95% CI = 0.60-0.94), small intestine (OR = 0.704, 95% CI = 0.63-0.79), large intestine (OR = 0.845, 95% CI = 0.77--0.93), hepatic (OR = 0.562, 95% CI = 0.41-0.77), and pancreatic (OR = 0.658, 95% CI = 0.49-0.89, see Fig. 1).

CONCLUSIONS

Our study demonstrates that women may have improved outcomes after some types of major gastrointestinal surgery; however, the mechanism by which this occurs is unclear. Future studies are needed to further evaluate this interesting phenomenon.

Preoperative stress testing in high-risk vascular surgery and its association with gender

BACKGROUND

Despite significant improvement in anesthetic and surgical techniques, the incidence of perioperative myocardial infarction (PMI) and all-cause mortality from any cardiac event during high-risk vascular surgery (abdominal aortic or infrainguinal revascularization procedures) remains high. In addition, there are significant health care costs associated with the management of PMI.

OBJECTIVES

The aim of this analysis was to investigate the utility of routine preoperative myocardial stress testing prior to high-risk vascular surgery and the interventions performed based on the results of the testing. The outcome after surgery, based on sex of the patients, was also examined.

METHODS

A retrospective analysis was performed on consecutive adult patients who had a positive dipyridamole-thallium stress test prior to high-risk vascular surgery in a university hospital (tertiary care center) between July 2001 and August 2004. The patients' preoperative demographic characteristics, perioperative record, and postoperative course in the hospital were analyzed. Combined major adverse outcome was defined as any incidence of MI, congestive heart failure, arrhythmias, renal failure, or death.

RESULTS

Of a total of 503 patients, 160 had a positive stress test prior to high-risk vascular surgery (111 men, 49 women; mean [SD] age, 68 [11] and 70 [12] years, respectively). Men with a positive stress test who had either coronary intervention or perioperative β-blockade prior to surgery had a significant decrease in the incidence of combined major adverse outcomes (P = 0.02). Conversely, women did not have a significant improvement in outcome with either of the preoperative strategies. Using logistic regression, only age and conservative management in men were found to be predictors of adverse outcomes.

CONCLUSIONS

In this small retrospective study, men with positive stress tests had fewer adverse events with either preoperative coronary revascularization or perioperative administration of β-adrenergic blocking drugs, compared with men who received no intervention. There were no significant differences in adverse outcomes between women with positive stress tests who received either treatment compared with those who did not receive any treatment.

Multicenter analytical evaluation of a high-sensitivity troponin T assay

BACKGROUND

High-sensitivity cardiac troponin assays are being introduced clinically for earlier diagnosis of acute myocardial infarction (AMI). We evaluated the analytical performance of a high-sensitivity cardiac troponin T assay (hscTnT, Roche Diagnostics) in a multicenter, international trial.

METHODS

Three US and 5 European sites evaluated hscTnT on the Modular® Analytics E170, cobas® 6000, Elecsys 2010, and cobas® e 411. Precision, accuracy, reportable range, an inter-laboratory comparison trial, and the 99th percentile of a reference population were assessed.

RESULTS

Total imprecision (CVs) were 4.6-36.8% between 3.4 and 10.3 ng/L hscTnT. Assay linearity was up to 10,000 ng/L and the limit of blank and detection were 3 and 5 ng/L, respectively. The 99th percentile reference limit was 14.2 ng/L (n=533). No significant differences between specimen types, assay incubation time, or reagent lots existed. A substantial positive bias (76%) exists between the 4th generation and hscTnT assays at the low end of the measuring range (<50 ng/L). hscTnT serum pool concentrations were within 2SD limits of the mean of means in the comparison trial, indicating comparable results across multiple platforms and laboratories.

CONCLUSION

The Roche hscTnT assay conforms to guideline precision requirements and will likely identify additional patients with myocardial injury suspicious for AMI.

Clinical cardioprotection and the value of conditioning responses

Adjunctive cardioprotective strategies for ameliorating the reversible and irreversible injuries with ischemia-reperfusion (I/R) are highly desirable. However, after decades of research, the promise of clinical cardioprotection from I/R injury remains poorly realized. This may arise from the challenges of trialing and effectively translating experimental findings from laboratory models to patients. One can additionally consider whether features of the more heavily focused upon candidates could limit or preclude therapeutic utility and thus whether we might shift attention to alternate strategies. The phenomena of preconditioning and postconditioning have proven fertile in identification of experimental means of cardioprotection and are the most intensely interrogated responses in the field. However, there is evidence these processes, which share common molecular signaling elements and end effectors, may be poor choices for clinical exploitation. This includes evidence of age dependence, limiting efficacy in target aged or senescent hearts; refractoriness to conditioning stimuli in diseased myocardium; interference from a variety of relevant pharmaceuticals; inadvertent induction of these responses by prior ischemia or commonly used drugs, precluding further benefit; and sex dependence of protective signaling. This review focuses on these features, raising questions about current research strategies, and the suitability of these widely studied phenomena as rational candidates for clinical translation.