Does gender influence the impact of impaired renal function on prognosis after ST-segment elevated myocardial infarction?

Improving translational research in sex-specific effects of comorbidities and risk factors in ischaemic heart disease and cardioprotection: position paper and recommendations of the ESC Working Group on Cellular Biology of the Heart

Ischaemic heart disease (IHD) is a complex disorder and a leading cause of death and morbidity in both men and women. Sex, however, affects several aspects of IHD, including pathophysiology, incidence, clinical presentation, diagnosis as well as treatment and outcome. Several diseases or risk factors frequently associated with IHD can modify cellular signalling cascades, thus affecting ischaemia/reperfusion injury as well as responses to cardioprotective interventions. Importantly, the prevalence and impact of risk factors and several comorbidities differ between males and females, and their effects on IHD development and prognosis might differ according to sex. The cellular and molecular mechanisms underlying these differences are still poorly understood, and their identification might have important translational implications in the prediction or prevention of risk of IHD in men and women. Despite this, most experimental studies on IHD are still undertaken in animal models in the absence of risk factors and comorbidities, and assessment of potential sex-specific differences are largely missing. This ESC WG Position Paper will discuss: (i) the importance of sex as a biological variable in cardiovascular research, (ii) major biological mechanisms underlying sex-related differences relevant to IHD risk factors and comorbidities, (iii) prospects and pitfalls of preclinical models to investigate these associations, and finally (iv) will provide recommendations to guide future research. Although gender differences also affect IHD risk in the clinical setting, they will not be discussed in detail here.

Sex differences in long-term mortality among acute myocardial infarction patients: Results from the ISAR-RISK and ART studies

BACKGROUND

Mortality rates in females who survived acute myocardial infarction (AMI) exceed those in males. Differences between sexes in age, cardiovascular risk factors and revascularization therapy have been proposed as possible reasons.

OBJECTIVE

To select sets of female and male patients comparable in respect of relevant risk factors in order to compare the sex-specific risk in a systematic manner.

METHODS

Data of the ISAR-RISK and ART studies were investigated. Patients were enrolled between 1996 and 2005 and suffered from AMI within 4 weeks prior to enrolment. Patients of each sex were selected with 1:1 equivalent age, previous AMI history, sinus-rhythm presence, hypertension, diabetes mellitus, smoking status, left ventricular ejection fraction (LVEF), and revascularization therapy. Survival times were compared between sex groups in the whole study cohort and in the matched cohort.

RESULTS

Of 3840 consecutive AMI survivors, 994 (25.9%) were females and 2846 (74.1%) were males. Females were older and suffered more frequently from hypertension and diabetes mellitus. In the whole cohort, females showed an increased mortality with a hazard ratio (HR) of 1.54 compared to males (p<0.0001). The matched cohort comprised 802 patients of each sex and revealed a trend towards poorer survival in females (HR for female sex 1.14; p = 0.359). However, significant mortality differences with a higher risk in matched females was observed during the first year after AMI (HR = 1.61; p = 0.045) but not during the subsequent years.

CONCLUSION

Matched sub-groups of post-AMI patients showed a comparable long-term mortality. However, a female excess mortality remained during first year after AMI and cannot be explained by differences in age, cardiovascular risk factors, and modes of acute treatment. Other causal factors, including clinical as well as psychological and social aspects, need to be considered. Female post-AMI patients should be followed more actively particularly during the first year after AMI.

Gender-related differences in long-term outcome among high-risk patients with myocardial infarction treated invasively

INTRODUCTION

Treating acute myocardial infarction (AMI) with percutaneous coronary intervention (PCI) has an impact on improving long-term outcome. However, patients with other comorbidities are challenging, and are considered as a high-risk population.

AIM

To assess gender-related differences in long-term prognosis after AMI among high-risk patients.

MATERIAL AND METHODS

The single-center registry encompassed 4375 AMI patients treated with PCI. The following high-risk groups were selected: age > 70 group (n = 1081), glomerular filtration rate (GFR ) < 60 group (n = 848), diabetes mellitus (DM) group (n = 782), low ejection fraction (EF) group (n = 560) defined as EF < 35%, and incomplete coronary revascularization (ICR) group (n = 2008). Within each group, comparative analysis of long-term mortality with respect to gender and age was performed.

RESULTS

There were no significant differences in long-term mortality with respect to gender among groups with age > 70 (29.0% vs. 30.3%) and GFR < 60 (37.2% vs. 42.3%) (both p = NS respectively for men vs. women). In the DM group (24.8% vs. 30.8%; p = 0.06) and EF < 35% group (36.3% vs. 44.5%; p = 0.07) there was a trend towards significance. The ICR group showed a higher mortality rate with respect to gender (19.7% vs. 27.3%; p < 0.001). Differences in survival assessed by the log-rank test were significant among ICR and EF < 35% groups.

CONCLUSIONS

Female gender is related to higher long-term mortality among high-risk groups, but a statistically significant difference was observed only in patients with ICR and those with EF < 35%. Female gender may be associated with worse prognosis in diabetic patients, but it needs evaluation. However, worse prognosis in women was not independent and was associated mainly with other comorbidities and worse clinical characteristics.