Gender-Related Differences in Hypertrophic Cardiomyopathy: A Systematic Review and Meta-Analysis

Background

Gender-related differences in phenotypic expression and outcomes have been established in many cardiac conditions; however, the impact of gender in hypertrophic cardiomyopathy (HCM) remains unclear. We conducted a systematic review and meta-analysis to assess the differences in clinical outcomes between female and male HCM patients.

Methods

We searched MEDLINE and EMBASE from inception to October 2020. Included were cohort studies that compared outcomes of interest including all-cause mortality, HCM-related mortality, and worsening heart failure (HF) or HF hospitalization between male and female. Data from each study were combined using the random effects model to calculate pooled odds ratio (OR) with 95% confidence interval (CI).

Results

Eleven retrospective cohort studies with a total of 9,427 patients (3,719 females) were included. Female gender was significantly associated with an increased risk of all-cause mortality (pooled OR = 1.63, 95% CI: 1.26-2.10, p ≤ 0.001), HCM-related mortality (pooled OR = 1.47, 95% CI: 1.08-2.01, p = 0.015), and worsening HF or HF hospitalization (pooled OR = 2.05, 95% CI: 1.76-2.39, p ≤ 0.001).

Conclusions

Female gender was associated with a worse prognosis in HCM. These findings suggest the need for improved care in women including early identification of disease and more possible aggressive management. Moreover, gender-based strategy may benefit in HCM patients.

Direct oral anticoagulants vs. vitamin K antagonists for left ventricular thrombus: a systematic review and meta-analysis

BACKGROUND

Current guidelines recommend vitamin K antagonists (VKAs) to reduce the risk of systemic thromboembolic (STE) events in patients with left ventricular (LV) thrombus. Direct oral anticoagulants (DOACs) are an emerging alternative to VKAs; however, data supporting DOAC use in LV thrombus are still lacking. We conducted this systematic review and meta-analysis to compare the efficacy and safety between DOACs and VKAs in this population.

METHODS

We searched MEDLINE, Embase, and the Cochrane Library databases from inception to October 2020 to identify studies that compared clinical outcomes of interest, including stroke or any STE, LV thrombus resolution, and bleeding, between patients who used DOACs and VKAs for LV thrombus. Data from each study were combined using the random-effects model.

RESULTS

Eight cohort studies with a total of 1771 patients (426 in DOAC group, 1345 in VKA group) were included. There were no statistically significant differences between VKA group and DOAC group on rates of STE events (pooled RR = 1.12, 95% confidence interval [CI]: 0.91-1.39, p = .286), LV thrombus resolution (pooled RR = 1.09, 95% CI: 0.94-1.27, p = .242), or bleeding events (pooled RR = 0.94, 95% CI: 0.59-1.51, p = .808).

CONCLUSIONS

Our meta-analysis found no significant differences in rates of STE events, LV thrombus resolution, or bleeding events between the use of DOACs and VKAs in LV thrombus. Further randomised controlled trials are needed to confirm our findingsHighlightsThere is limited evidence comparing the use of direct oral anticoagulants (DOACs) to vitamin K antagonists (VKAs) in left ventricular (LV) thrombus.Our systematic review and meta-analysis showed that DOACs are not inferior to VKAs in the incidence of systemic thromboembolism (STE), the rate of LV thrombus resolution, and the risk of bleeding.Current evidence is based on observational studies only. Further randomised controlled trials are needed to confirm the findings.

Massive bilateral pulmonary embolism in a patient with subsequent occurrence of severe mitral regurgitation due to ruptured chordae tendineae--a case report

This report concerns an apparently healthy woman who presented simultaneously with acute massive bilateral pulmonary embolism and mitral regurgitation, subsequently, a month later, resulting in pulmonary edema secondary to chordae rupture of the mitral valve. The authors believe that massive pulmonary embolism predisposed to chordal rupture in this case. It is suggested that increased awareness of ruptured chordae tendineae as a cause of mitral regurgitation and the prompt use of transesophageal echocardiography will facilitate the early recognition of this potentially fatal, but treatable, cause of mitral regurgitation in patients with pulmonary embolism.

Referral pattern and outcome in men and women undergoing coronary artery bypass surgery--a critical review

Women with coronary artery disease are less likely to undergo coronary artery bypass surgery, and this may represent a potential referral bias in favor of men. A higher in-hospital mortality rate in women compared with men has been reported earlier. Accumulating evidence currently suggests, however, that variables other than gender, such as advanced age, late referral, angina classification, diabetes mellitus, concurrent medical conditions, the number of diseased vessels, the caliber of coronary arteries, and the decreased body surface area in women may have accounted for this difference. In fact, when these variables are taken into account, female gender is no longer a statistically significant predictor of operative mortality. Women appear to have comparable immediate and late survival rates. Recurrent angina, perioperative myocardial infarction, congestive heart failure, incomplete revascularization, and early and late graft reocclusion following surgery are, however, more prevalent in women. Men and women show differences in recovery experiences after discharge following bypass surgery. When coronary bypass surgery is offered to women, the decision should be individualized, based on the patients' perioperative baseline clinical risk factors and coronary anatomy. Coronary artery bypass surgery should not be withheld in women who are considered to be appropriate candidates for fear of a reduced success rate.

Trends in success rate after percutaneous transluminal coronary angioplasty in men and women with coronary artery disease

Women with coronary artery disease are less likely to undergo percutaneous transluminal coronary angioplasty (PTCA) because of the potential referral bias in favor of men with coronary artery disease in the use of invasive diagnostic procedures and interventions. This difference may represent a sex bias in the delivery of medical care. The apparent sex difference in short-term success of PTCA seen in the early 1980s has not persisted in subsequent studies. The higher in-hospital mortality rate, if any, in women compared with men after PTCA is related more to the severity of their underlying disease rather than sex alone. In addition, women have a better long-term PTCA success rate. PTCA should not be withheld in women who are considered appropriate anatomic candidates for fear of reduced success or increased major complications.

Evaluation and management of a supraventricular tachycardia with a standard bradycardia support pacemaker

A standard dual chamber pacemaker with the ability to telemeter intracardiac electrograms and to perform noninvasive electrophysiological studies was implanted in a patient with previously documented complex ventricular arrhythmias treated with amiodarone who later presented with a hypersensitive carotid sinus syndrome and syncope. Subsequently, he developed a supraventricular tachyarrhythmia with an atrial cycle length of 320 ms. Its diagnosis was facilitated by the ability to noninvasively telemeter atrial endocardial electrograms directly from the implanted pacemaker. Its management was aided by utilizing the already implanted bradycardia support pacemaker to stimulate the patient with premature extrastimuli coupled to his intrinsic atrial rhythm (PS1 and S1S2 each 170 ms.) by connecting the pacemaker to an electrophysiological stimulator via the pacemaker programmer. This particular pacemaker was not chosen because of this capability at the time of its original implantation. However, this capability facilitated the patient's evaluation and subsequent management.