Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators

Clinical, electrocardiographic, and biochemical data for immediate risk stratification in acute coronary syndromes

The recent evolution in therapeutic options for acute coronary syndromes (ACS) mandates early risk stratification in order to select the appropriate treatment strategy for individual patients. Simple clinical data derived from the patient's medical history and physical examination, a standard twelve-lead electrocardiogram (ECG), and determinations of biochemical markers of myocardial damage can be obtained in the emergency room and serve as a guide for deciding appropriate medical management and optimal use of available resources. Even the most important classification of the ACS is based upon a simple and dichotomous description of the ECG, where the presence of ST-segment elevation mandates an immediate attempt to restore coronary perfusion (either pharmacologically or mechanically), whereas its absence suggests pharmacological stabilization before further evaluation. Across the whole spectrum of ACS, clinical history data (such as older age, previous coronary events, and diabetes) and clinical variables (such as higher heart rate, lower blood pressure, and higher Killip class) are the most powerful prognostic determinants at multivariate analyses derived from large databases. The ECG adds significant and independent prognostic information using the analysis of qualitative (direction of ST-segment shift, associated T-wave inversion, and presence of conduction disturbances) and quantitative (number of leads involved, amount of ST- segment shifts, duration of QRS) characteristics. Biochemical markers of myocardial damage have also been identified as independent predictors of events. In addition, retrospective analyses of clinical trials have suggested that biochemical markers might serve as a guide to select pharmacological therapy. However, how to best combine electrocardiographic and biochemical data for immediate risk stratification remains to be further elucidated.

Does diabetes mellitus explain the higher hospital mortality of women with acute myocardial infarction? Results from the Berlin Myocardial Infarction Registry

BACKGROUND

Women with acute myocardial infarction (AMI) exhibit greater hospital mortality than do men. In general, diabetes mellitus is one of the major factors influencing the outcome of patients with AMI. The aim of this study was to analyze the interaction between diabetes and gender, specifically with regard to the higher hospital mortality of female AMI patients aged < or = 75 years.

METHODS

We prospectively collected data from 3,715 patients aged < or = 75 (2,794 men, 921 women) with acute myocardial infarction who were treated in 25 hospitals in Berlin, Germany, from 1999 to 2002. In a multivariate analysis, we specifically studied the interaction between the factors diabetes mellitus and gender in their effects on hospital mortality.

RESULTS

After adjustment in multivariate analysis, the interaction between gender and diabetes was statistically significant, and the estimated odds ratios were as follows: female diabetic patients compared with male diabetic patients, odds ratio (OR) = 2.28 (95% confidence interval [CI] 1.42-3.68); female diabetic patients compared with male nondiabetic patients, OR = 2.90 (95% CI 1.90-4.42); and female diabetic patients compared with female nondiabetic patients, OR = 2.92 (95% CI 1.75-4.87). There was no statistically significant difference between the risk of dying for female nondiabetic patients or for male diabetic patients when compared with male nondiabetic patients.

CONCLUSIONS

In AMI patients aged < or = 75 years, female gender alone is not an independent predictor of hospital mortality. Detailed, multivariate analysis reveals that specifically diabetic women demonstrate higher hospital mortality than do men. Special attention should be provided to these female diabetic patients.

Women and men with unstable angina and/or non-ST-elevation myocardial infarction

BACKGROUND

In unstable angina and/or non-ST-elevation myocardial infarction (UA/NSTEMI), sex-related differences in outcomes are less well known than in ST-elevation myocardial infarction (STEMI), where women experience worse outcomes than men. Our aim was a prospective comparison between men and women with UA/NSTEMI of baseline characteristics, in-hospital complications, mortality, reinfarctions and combined endpoint of mortality and/or reinfarction during hospital stay, at 30 days and at six months.

METHODS

Initial medical treatment was given to 92 men and 47 women with UA/NSTEMI. Percutaneous coronary interventions (PCI) were performed within the first 48 hours in cases of recurrent chest pain and/or rhythmic and/or hemodynamic instability.

RESULTS

Women were significantly older (66.6 +/- 9.6 vs. 59.7 +/- 10.6, P = 0.0001), less physically active (76.6% vs. 91.3%, P = 0.035), with significantly more frequent arterial hypertension (78.7% vs. 51%, P = 0.0039) and insulin-treated diabetes (17% vs. 5.4%, P = 0.0341), but with less likely prior MI (21.3% vs. 48.9%, P = 0.003), smoking (10.6% vs. 32.6%, P = 0.009) and dyslipidemia with HDL-cholesterol < 1.0 mmol/L (25.5% vs. 46.4%, P = 0.015) than men. Though medical and invasive treatments were similar in both sexes, women were at significantly increased risk of in-hospital pulmonary edema (OR 4.16, 95% CI 1.51 to 11.45) but not at increased risk of adverse in-hospital, 30-day and six-month outcomes in comparison with men.

CONCLUSIONS

Women with UA/NSTEMI, being significantly older and with more comorbidity, were at significantly increased risk of in-hospital heart failure but not at increased risk of in-hospital, 30-day and six-month adverse outcomes when compared with men, despite their similar treatments.

Coronary Artery Disease in Women

There is a large media effort currently available to increase awareness of coronary artery disease in women. Despite this, there is still a misconception among some people, and unfortunately, some healthcare providers, that heart disease is a man's disease. This article will review some of the information about women and coronary artery disease; a short review of the literature, symptoms, diagnostic tests, and treatment pertinent to women; and the action nurses can take to help educate the public, and other healthcare providers, about this deadly threat.

Activation of estrogen receptor-alpha reduces aortic smooth muscle differentiation

Women are at high risk of dying from unrecognized cardiovascular disease. Many differences in cardiovascular disease between men and women appear to be mediated by vascular smooth muscle cells (SMC). Because estrogen reduces the proliferation of SMC, we hypothesized that activation of estrogen receptor-alpha (ERalpha) by agonists or by growth factors altered SMC function. To determine the effect of growth factors, estrogen, and ERalpha expression on SMC differentiation, human aortic SMC were cultured in serum-free conditions for 10 days. SMC from men had lower spontaneous expression of ERalpha and higher levels of the differentiation markers calponin and smooth muscle alpha-actin than SMC from women. When SMC containing low expression of ERalpha were transduced with a lentivirus containing ERalpha, activation of the receptor by ligands or growth factors reduced differentiation markers. Conversely, inhibiting ERalpha expression by small interfering RNA (siRNA) in cells expressing high levels of ERalpha enhanced the expression of differentiation markers. ERalpha expression and activation reduced the phosphorylation of Smad2, a signaling molecule important in differentiation of SMC and initiated cell death through cleavage of caspase-3. We conclude that ERalpha activation switched SMC to a dedifferentiated phenotype and may contribute to plaque instability.

Early invasive versus conservative strategies for unstable angina & non-ST-elevation myocardial infarction in the stent era

BACKGROUND

In patients with unstable angina and non-ST-elevation myocardial infarction (UA/NSTEMI) two strategies are possible: a routine invasive strategy where all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularization; or a conservative strategy where medical therapy alone is used initially with selection of patients for angiography based on clinical symptoms or investigational evidence of persistent myocardial ischemia.

OBJECTIVES

To determine the benefits of an invasive compared to a conservative strategy for treating UA/NSTEMI in the stent era.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (Issue 3 2005), MEDLINE and EMBASE were searched from 1996 to September 2005 with no language restrictions.

SELECTION CRITERIA

Included studies were prospective trials comparing invasive with conservative strategies in UA/NSTEMI.

DATA COLLECTION AND ANALYSIS

We identified 5 studies (7818 participants). Using intention-to-treat analysis with random effects models, summary estimates of relative risk (95% confidence interval [CI]) were determined for primary end-points of all-cause death, fatal and non-fatal myocardial infarction; all-cause death or non-fatal myocardial infarction; and refractory angina. Further analysis of included studies was undertaken based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. Heterogeneity was assessed using chi-square and variance (I(2)) methods.

MAIN RESULTS

In the all-study analysis, mortality during initial hospitalization showed a trend to hazard with an invasive strategy; relative risk 1.59 (95% CI 0.96 to 2.64). Mortality and myocardial infarction assessed at 2-5 years in two trials were significantly decreased by an invasive strategy with relative risk of 0.75 (95% CI 0.62 to 0.92) and 0.75 (95% CI 0.61 to 0.91) respectively. The composite end-point of death or non-fatal myocardial infarction was significantly decreased by an invasive strategy at several time points after initial hospitalization. The incidence of early (<4 months) and intermediate (6-12 months) refractory angina were both significantly decreased by an invasive strategy; relative risk 0.47 (95% CI 0.32 to 0.68) and 0.67 (95% CI 0.55 to 0.83) respectively, as were early and intermediate rehospitalization rates with relative risk 0.60 (95% CI 0.41 to 0.88) and 0.67 (95% CI 0.61 to 0.74) respectively. The invasive strategy was associated with a two-fold increase in the relative risk of peri-procedural myocardial infarction (as variably defined) and a 1.7-fold increase in the relative risk of bleeding.

AUTHORS' CONCLUSIONS

An early invasive strategy is preferable to a conservative strategy in the treatment of UA/NSTEMI.

Gender differences in acute non-ST-segment elevation myocardial infarction

To assess gender-based differences in presentation and outcome after non-ST-elevation myocardial infarction (NSTEMI) in clinical practice, this study examined data from the Acute Coronary Syndrome registry, which enrolled 16,817 patients from 2000 through the end of 2002, 6,358 of them with NSTEMIs (34.1% women). Women with NSTEMIs were 7.5 years older, had a history of myocardial infarction and percutaneous coronary intervention or coronary artery bypass graft less often, and were less likely to have smoked. They more often had a history of systemic hypertension and diabetes mellitus, but this difference was due to their older age. Reperfusion therapy was performed less often in women, which still was significant after adjustment for baseline variables (odds ratio 0.71, 95% confidence interval 0.63 to 0.80). Clopidogrel was given less often in women (43.4% vs 56%). After adjustment for age, gender differences in medical therapy with statins, aspirin, and beta blockers were not significant. Hospital mortality was 1.7 times greater in women. This difference was not significant after adjustment for age (odds ratio 1.07, 95% confidence interval 0.84 to 1.35). Women had greater crude long-term mortality, but after age adjustment, this difference was no longer significant (odds ratio 0.92, 95% confidence interval 0.76 to 1.11). In conclusion, women with NSTEMIs were older than men and thus more often had concomitant diseases but less often had a history of myocardial infarction or coronary artery bypass grafts. They less often received acute percutaneous coronary intervention and less often were treated with clopidogrel. However, there was no difference in age-adjusted mortality in women.

Comparison of results of percutaneous coronary intervention for non-ST-elevation acute myocardial infarction or unstable angina pectoris in men versus women

Previous randomized trials have addressed the impact of gender on outcomes, showing worse results in women assigned to invasive strategies compared with men with non-ST-elevation (NSTE) acute coronary syndrome (ACS). However, there is still a significant amount of controversy on strategies of treatment on the basis of gender. This study evaluated the impact of gender on treatment strategies and outcomes in patients with NSTE ACS in a high-volume, single-site tertiary center. We identified 1,197 consecutive patients with NSTE ACS (381 women, 816 men) who underwent percutaneous coronary intervention during their index hospitalizations. Patients were stratified by gender and baseline clinical and angiographic characteristics, and in-hospital and 9-month clinical outcomes were compared between the 2 groups. There were clear differences in baseline characteristics between men and women with ACS at presentation. Women were, on average, slightly older than men, with more hypertension and morbid obesity, but there were no differences in racial backgrounds or the prevalence of diabetes or dyslipidemia, nor were there treatment disparities in pharmacologic interventions. Women and men with ACS had similar rates of percutaneous coronary intervention on index admission. Women had a greater incidence of bleeding complications requiring blood transfusions. Overall, in-hospital and 9-month event-free survival were equivalent for the 2 genders. In conclusion, in this single-site observational study, patients with NSTE ACS who underwent angiography followed by percutaneous coronary intervention demonstrated no significant gender differences in treatment or in-hospital or 9-month event-free survival. From these results, interventional strategies should not be based on gender.

Sociodemographic, Disease Status, and Illness Perceptions Predictors of Global Self-ratings of Health and Quality of Life Among those with Coronary Heart Disease – One Year Follow-up Study

This one-year follow-up study (n = 130 at baseline, n =2745 at follow-up, aged 45-74 years) examined the relationship of patients' perceptions of coronary heart disease (CHD) and illness-related factors with global health status and global quality of life (QOL) ratings. The independent variables were CHD history (myocardial infarction, revascularisation), CHD severity (use of nitrates, CHD risk factors and co-morbidities) and illness perceptions. In multivariate regression analysis, CHD history and severity explained 13% of variance in global health status and 8% in global QOL ratings at the baseline. Illness perceptions increased the share of explained variance by 18% and 16% respectively. In the follow-up, illness perceptions explained a significant but modest share of variance in change in health status and QOL when baseline health status and QOL and CHD severity were adjusted for more symptoms being attributed to CHD, severe perceived consequences of CHD, as well as a weak belief in the controllability of CHD were related to poor global health status and QOL ratings. In structural path models associations of CHD severity factors were mediated by illness perceptions. The association of disease severity with dependent variables was weaker after controlling for illness perceptions. Cognitive representations of CHD contribute to both global health status and QOL ratings and they also mediate the associations between CHD severity and well-being. No gender differences were found in associations of illness perceptions with health status or QOL ratings.

Coronary revascularisation in women

Coronary heart disease is the leading cause of death in men and women worldwide. It is still considered a disease of men and there has been little recognition of its importance in women. Gender differences exist in acute and chronic ischaemia in terms of clinical manifestations, investigations and treatment. There are clear gender differences in coronary revascularisation with a higher mortality seen in women. At the time a woman presents with coronary artery disease she is older and has more co-morbid factors. Furthermore, women have smaller coronary arteries making them more difficult to revascularise. In recent years there has been a general trend towards improved outcomes in women undergoing both surgical and percutaneous coronary intervention. The increasing use of drug eluting stents and adjunctive medical treatment as well as the use of off-pump bypass surgery needs further evaluation in terms of gender differences. This article reviews the current literature on coronary revascularisation in women.

Differences in in-hospital mortality between men and women with acute myocardial infarction undergoing percutaneous coronary intervention in Japan: Tokai Acute Myocardial Infarction Study (TAMIS)

BACKGROUND

It is a matter of concern that women have higher in-hospital mortality rates than men with percutaneous coronary intervention (PCI); however, it is not yet clear whether significant sex differences exist. This study aimed to determine if there are sex differences in the characteristics and in-hospital mortality among patients with acute myocardial infarction (AMI) undergoing PCI in Japan.

METHODS

We used data from 13 acute care hospitals in the Tokai region (central Japan) included in the sample from the TAMIS, a retrospective study of all patients admitted to these hospitals from 1995 to 1997 with a diagnosis of AMI. We abstracted the baseline and procedural characteristics from detailed chart reviews which included not only physician notes but also nursing notes, and a questionnaire included baseline characteristics, procedural course, and in-hospital mortality. Multivariate analysis was performed, controlling for age and other variables which were found to be significantly different between men and women by chi2 test or Mann-Whitney U test.

RESULTS

In TAMIS, we had a total of 2020 subjects. A total of 303 women and 1033 men undergoing PCI were included in the present study. There were sex differences in age, comorbid conditions, smoking status, activities of daily living, and heart failure on presentation. In univariate analysis, women had a higher in-hospital mortality rate than men; however, this sex difference disappeared after multivariable adjustment.

CONCLUSIONS

Our study demonstrates that women with AMI who undergo PCI do not have a significantly higher in-hospital mortality rate than men in Japan; additional larger-scale studies are needed to confirm these results.

[Predictive value of chest pain score for the diagnosis of acute coronary syndromes]

BACKGROUND AND OBJECTIVE

We analyzed the diagnostic utility of a chest pain score in patients evaluated for chest pain of possible coronary origin.

PATIENTS AND METHOD

We studied 1,068 consecutive patients coming to the emergency room with acute chest pain of possible coronary origin without ST-segment elevation, using a chest pain unit protocol. Chest pain was quantified by validated score (0-20 points). The diagnostic value of the chest pain score was analyzed for the diagnosis of acute myocardial infarction (AMI), unstable angina (UA) and acute coronary syndrome (ACS; AMI or UA).

RESULTS

The diagnosis of ACS was established in 651 patients (61%), AMI in 439 (41%) and UA in 212 (20%). In the multivariate analysis a chest pain score > or = 10 was an independent predictor of ACS (odds ratio [OR] = 2.9; 95% confidence interval [CI] 2.1-4; p = 0.0001), along with an age older than 70 years (OR = 2.6; 95% CI,1.8-3.7; p = 0.0001), male gender (OR = 2; 95% CI, 1.4-2.8; p = 0.0001); insulin-dependent diabetes (OR = 2.3; 95% CI, 1.2-4.6; p = 0.016); previous myocardial infarction (OR = 1.6; 95% CI, 1.1-2.4; p = 0.022), ST depression (OR = 9.3; 95% CI, 5.2-16.7; p = 0.0001) and T wave inversion (OR = 2.5; 95% CI, 1.4-4.3; p = 0.0001). The chest pain score was associated with the diagnosis of both AMI (OR = 1.4; 95% CI, 1.1-1.9; p < 0.02) and UA (OR = 2.8; 95% CI, 1.8-4.2; p < 0.0001).

CONCLUSIONS

The chest pain score allows independent information for the early diagnosis of patients coming to the emergency department with acute chest pain of possible coronary origin.

[Therapeutic attitude after coronariography in elderly patients with ischemic heart disease]

INTRODUCTION

The incidence of ischemic heart disease in the elderly is high. These patients are increasing referred for coronariography.

OBJECTIVES

Identify factors associated with coronary revascularization in elderly patients.

MATERIAL AND METHODS

Retrospective study of 473 patients > or = 75 years who underwent coronariography in relationship with ischemic heart disease. Their clinical-epidemiological characteristics and treatment adopted were analyzed. A multivariate analysis model was used to identify factors associated with revascularization.

RESULTS

Mean age was 77.6 +/- 2.8 years; 70.4% were men. A total of 36% smoked, 53% were hypertensive, 33% diabetics and 30% dislipidemic. Thirty one % had multivessel disease and 11% involvement of left coronary trunk. There was evidence of anterior descending artery in 68%. Medical treatment was done in 48.4%, percutaneous revascularization in 41.5% and surgical in 10.1%. Patients with lesions of the anterior descending artery were revascularized in greater proportion: 67.7% vs 32.3%; p. 0.001. A logistic regression model was used to identify revascularization predictors, obtaining a direct relationship with the involvement of the anterior descending artery (OR: 4.87; 95% CI: 2.98-7.94; (p < 0.001) and inverse on with the previous revascularization (OR: 0.47; 95% CI: 0.26-0.85; p < 0.02), left ventricular dysfunction (OR: 0.58; 95% CI: 0.39-0.88; p = 0.01) and presence of multivessel disease (OR: 0.51; 95% CI: 0.31-0.84; p < 0.01).

CONCLUSIONS

The elderly subjects with ischemic heart disease who underwent coronariography received revascularizing treatment in somewhat more than 50% of the cases. A direct relationship was found between involvement of the anterior descending artery and performance of revascularizing treatment and an inverse on between previous revascularization, left ventricular dysfunction and presence of multivessel disease.

Cardiovascular diseases in women: a statement from the policy conference of the European Society of Cardiology

Cardiovascular diseases (CVD) are the leading cause of mortality both in men and women. In Europe, about 55% of all females' deaths are caused by CVD, especially coronary heart disease and stroke. Unfortunately, however, the risk of heart disease in women is underestimated because of the perception that women are 'protected' against ischaemic heart disease. What is not fully understood is that women during the fertile age have a lower risk of cardiac events, but this protection fades after menopause thus leaving women with untreated risk factors vulnerable to develop myocardial infarction, heart failure, and sudden cardiac death. Furthermore, clinical manifestations of ischaemic heart disease in women may be different from those commonly observed in males and this factor may account for under-recognition of the disease. The European Society of Cardiology has recently initiated an extensive 'Women at heart' program to coordinate research and educational initiatives on CVD in women. A Policy Conference on CVD in Women was one of the first steps in the development of this program. The objective of the conference was to collect the opinion of experts in the field coming from the European Society of Cardiology member countries to: (1) summarize the state-of-the-art from an European perspective; (2) to identify the scientific gaps on CVD in women; and (3) to delineate the strategies for changing the misperception of CVD in women, improving risk stratification, diagnosis, and therapy from a gender perspective and increasing women representation in clinical trials. The Policy Conference has provided the opportunity to review and comment on the current status of knowledge on CVD in women and to prioritize the actions needed to advance this area of knowledge in cardiology. In the preparation of this document we intend to provide the medical community and the stakeholders of this field with an overview of the more critical aspects that have emerged during the discussion. We also propose some immediate actions that should be undertaken with the hope that synergic activities will be implemented at European level with the support of national health care authorities.

Female sex: a protective role in suspected myocardial ischemia

OBJECTIVE

Women are felt to have poor outcomes in coronary artery disease, largely on the basis of secondary observations in acute coronary syndrome trials. We sought to examine the neglected topic of sex differences in workup and outcomes in the general population presenting with chest pain.

METHODS

We examined 439 consecutive patients admitted via the emergency department with ongoing chest pain. Cardiac testing was defined as any cardiac catheterization or stress test. Positive testing was defined as a 70% or greater stenosis in an epicardial coronary artery on catheterization, or a positive stress test result. Follow-up was obtained via telephone contact at 4 months following discharge.

RESULTS

Further cardiac testing was deemed necessary in 68% (164/241) of women and 77% (153/198) of men (P=0.038). Among women undergoing further testing, only 21% (35/164) had positive tests, whereas 41% (62/153) of men had positive tests (P=0.002). At 4 months, women were less likely to have suffered the combined endpoint of subsequent myocardial infarction, revascularization, or death, than men (15 vs. 23%, P=0.027). Events were more likely to occur in patients who had further testing, and especially in those who had positive testing.

CONCLUSIONS

These data suggest that women admitted with chest pain are less likely to have active coronary artery disease, and much less likely to have poor outcomes at 4 months than men. This apparent 'gender protection' effect warrants further study.

Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies

Despite a dramatic decline in mortality over the past three decades, coronary heart disease is the leading cause of death and disability in the U.S. Importantly, recent advances in the field of cardiovascular medicine have not led to significant declines in case fatality rates for women when compared to the dramatic declines realized for men. The current review highlights gender-specific issues in ischemic heart disease presentation, evaluation, and outcomes with a special focus on the results published from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. We will present recent evidence on traditional and novel risk markers (e.g., high sensitivity C-reactive protein) as well as gender-specific differences in symptoms and diagnostic approaches. An overview of currently available diagnostic test evidence (including exercise electrocardiography and stress echocardiography and single-photon emission computed tomographic imaging) in symptomatic women will be presented as well as data using innovative imaging techniques such as magnetic resonance subendocardial perfusion, and spectroscopic imaging will also be discussed.

Women and cardiovascular heart disease: clinical implications from the Women's Ischemia Syndrome Evaluation (WISE) Study. Are we smarter?

Review of the trend in cardiovascular disease mortality for males and females clearly demonstrated that whereas the trend shows a decline in males this decline is not observed in females. Multiple important reports emerged from the initial phases of the Women's Ischemic Syndrome Evaluation (WISE) study that may have significant clinical implications for our approach to cardiovascular disease in women. The data derived from the WISE study certainly provided important information to our understanding of the approach to women with cardiovascular disease. The clinical presentation may be different, and a gender-oriented questionnaire may enhance our diagnosis. In a multivariable model, low hemoglobin was associated with significantly higher risk of adverse outcomes. The risk factor assessment and the risk factor profiles in women that are associated with coronary artery disease may be different. Based on the studies from the WISE study, metabolic syndrome is a leading and a major risk factor in women. Moreover, the data further support the concept that the mechanism of ischemia in women may be localized in the microvascular coronary arteries. Therefore, the diagnoses of coronary microvascular dysfunction or endothelial dysfunction should be considered in women with chest pain who do not have obstructive coronary artery disease. It may be advantageous to add such diagnostic tests when the conventional tests are nondiagnostic. A revised clinical approach to cardiovascular disease in women may be designed and tested based on these findings.

Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease

Coronary heart disease is the leading cause of death and disability in the U.S., but recent advances have not led to declines in case fatality rates for women. The current review highlights gender-specific issues in ischemic heart disease (IHD) presentation, evaluation, and outcomes with a special focus on the results derived from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. In the second part of this review, we will assess new evidence on gender-based differences in vascular wall or metabolic alterations, atherosclerotic plaque deposition, and functional expression on worsening outcomes of women. Additionally, innovative cardiovascular imaging techniques will be discussed. Finally, we identify critical areas of further inquiry needed to advance this new gender-specific IHD understanding into improved outcomes for women.

Noninvasive diagnosis of coronary artery disease in women

Cardiovascular disease is the leading cause of mortality and significant morbidly among women in the United States. The frequent absence of antecedent symptoms, the potential for an initial fatal cardiac event and the limitations of currently available noninvasive diagnostic tests pose challenges to healthcare practitioners as they try to optimally risk stratify patients. Therefore, the purpose of this article is to discuss the accuracy of noninvasive tests for CAD diagnosis in women.

Impact of age and gender on in-hospital and late mortality after acute myocardial infarction: increased early risk in younger women: results from the French nation-wide USIC registries

AIMS

To determine whether sex differences of in-hospital and after-discharge mortality differ according to the age.

METHODS AND RESULTS

Data of 4347 consecutive patients hospitalized within 48 h of the onset of acute myocardial infarction (AMI) were analysed. Patients were classified according to median age (68 years): Group 1 (G1) (308 women, 30-67 years), G2 (1878 men, 30-67 years), G3 (860 women, 68-89 years), and G4 (1301 men, 68-89 years). In both age groups, women were older, had more frequent co-morbidities, lower rate of reperfusion therapy, and received less anti-platelet agents, beta-blockers, and statins than men. The overall 1-year mortality was higher in women (25% vs. 16% in men, P<0.0001). After adjustment, in-hospital mortality was higher only for the women in the younger age group. (G1 vs. G2: OR=2.2, 95%CI=1.3-3.8; G3 vs. G4: OR=1.1, 95%CI=the risk of death, after hospital discharge, was no longer related to gender in any age group.

CONCLUSION

The higher 1-year mortality following AMI in women is explained by the higher risk of death in young women during the first days of hospitalization. Further investigations are crucial to determine the cause in order to improve the chance of survival in younger women.

Age-related differences in the delivery of cardiac management to women versus men with acute myocardial infarction in Japan: Tokai Acute Myocardial Infarction Study: TAMIS

It is of concern that women are more likely to undergo fewer diagnostic tests and receive less treatment for acute myocardial infarction (AMI) than men. However, it is still unclear whether gender differences exist according to age groups. Therefore, we studied the influence of gender on the delivery of cardiac management according to two age groups (< 65, >or= 65) in Japan. Data from the Tokai Acute Myocardial Infarction Study (TAMIS) sample were used. This is a retrospective study of all consecutive patients admitted to the 13 acute care hospitals in the Tokai region of Japan, which includes Aichi and Shizuoka Prefectures, with a diagnosis of AMI from 1995 to 1997. A total of 143 younger women, 822 younger men, 391 older women, and 611 older men were included. Information concerning patient demographics, in-hospital course, comorbid conditions, electrocardiography (ECG), ultrasound-echocardiography (UCG), treadmill test (TMT), coronary angiography (CAG), percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), intra-aortic balloon pump (IABP), mechanical ventilation, and in-hospital or discharge medication (thrombolytics, vasopressors, aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium antagonists, nitrates) were collected. Among the young, after controlling for these baseline variables, women were significantly less likely to undergo PTCA compared to men (OR, 0.54, 95%CI, 0.35-0.82). After controlling for these baseline variables, only lipid-lowering therapy tended to be more frequent in women than in men among the elderly (OR, 2.79, 95%CI, 1.47-2.58). The findings suggest that younger women with AMI are less likely than younger men to undergo PTCA, and that older women with AMI are more likely to receive lipid-lowering therapy.

Clinical course of acute myocardial infarction in the hypertensive patient in Eastern Spain: The PRIMVAC registry

OBJECTIVE

The study's objective was to analyze the acute complications and prognosis of acute myocardial infarction (AMI) in hypertensive patients in Spain.

METHOD

Complications and early mortality were recorded among the patients with AMI admitted to the coronary care units of the 17 hospitals in the Valencia Community (Spain) between 1995 and 2000.

RESULTS

A total of 12.071 patients were registered, of whom 46% were hypertensive (5.550 cases). Atrial fibrillation was more frequent in the hypertensive group, whereas ventricular fibrillation was more common among normotensive patients. We found higher mortality rates in the hypertensive group (14.4% vs 12.4%; P<.001). However, after multivariate adjustment, hypertension was not independently associated with mortality (odds ratio: .95; P=.46), and remained independently associated with a lower risk of primary ventricular fibrillation (odds ratio: .83; P<.05).

CONCLUSION

Hypertensive patients do not present comparatively greater mortality during AMI, although primary ventricular fibrillation is less common in such subjects.

Are we 'WISE'r? Findings from the NHLBI-sponsored Women's Ischemia Syndrome Evaluation study

Recognition of cardiovascular disease as the leading healthcare threat to women continues to shape the prioritization of efforts to more effectively diagnose and treat heart disease in women. At its inception almost 8 years ago, the National Heart, Lung and Blood Institute in the USA sponsored the Women's Ischemia Syndrome Evaluation (WISE) study, aiming to optimize symptom evaluation and diagnostic testing for ischemic heart disease in women and to explore pathophysiologic mechanisms for symptoms and myocardial ischemia in the absence of epicardial coronary artery stenosis. The WISE study has investigated the spectrum of anginal symptoms, diagnostic strategies for micro- and macrovascular coronary disease, and the role of psychosocial variables and reproductive hormones in ischemic heart-disease presentation. One of the pivotal WISE findings sheds light on chest pain in the absence of significant obstructive epicardial luminal coronary stenosis, otherwise known as Cardiac Syndrome X. In the WISE study, using coronary vasomotor testing during angiography, investigators observed prevalent abnormalities in coronary flow reserve, suggestive of microvascular coronary dysfunction in relation to adverse morbidity and mortality among these women. Findings such as these from the WISE study have significantly added to the current management approach to heart disease in women.

Trends in event rate and case fatality of patients hospitalized with myocardial infarction between 1984 and 2001This paper is one of a selection of papers published in this Special Issue, entitled Young Investigator's Forum

Between 1984 and 1993, prevalence and case fatality of hospitalized acute myocardial infarction (AMI) had declined in the population of Halifax County. We aimed to determine whether these trends continued into the 21st century by investigating patient characteristics, treatment methods, and fatality for hospital admissions of residents of Halifax County, aged 25–74, during 1984–1989 (period 1), 1990–1993 (period 2), and 1998–2001 (period 3) and diagnosed as AMI that were extracted from databases for the Halifax County MONICA and ICONS (Improving Cardiovascular Outcomes in Nova Scotia) Studies. Trends in patient characteristics and treatment methods were assessed by χ2 statistics. Their association with 28-day fatality was determined by logistic regression. Event rate declined during 1984–1993 but not into 1998–2001 (p = 0.206). Compared with 1990–1993, fewer AMI patients during 1998–2001 were ≥55 years (73.3% vs. 69.9%), cigarette smokers (49.8% vs. 42.9%), had a history of myocardial infarction (28.9% vs. 24.9%), and had an admission heart rate >100 (34.8% vs. 17.4%). Additionally, more patients had a history of diabetes (22.5% vs. 28.1%). Case fatality declined progressively over the 3 study time periods (16.6%, 13.1%, and 9.4%, respectively). Changes also occurred in prevalence of Killip class 4 status during admission (20.2%, 10.3%, and 13.3%, respectively), use of thrombolysis (9.0%, 30.9, and 32.6%, respectively), and percutaneous coronary intervention (PCI) (4.3%, 11.2%, and 22.4%, respectively) in the different periods. Significant associations were found between case fatality and patient history of diabetes, history of MI, age, elevated admission heart rate, Killip class 4 impairment, thrombolysis, and PCI. The ICONS registry of hospitalized acute myocardial infarctions was used to compare case fatality during 1998–2001 with that reported by the Halifax County MONICA Project for 1984–1993. Whereas the population rate of myocardial infarctions had declined between 1984–1993 but not subsequently, case fatality declined significantly throughout the study period. The continued decline in case fatality is likely explained by changes in patient profile on presentation and medical therapies, including the increased use of thrombolysis and PCI.

Gender differences in coronary artery disease

Coronary artery disease in women is associated with higher morbidity and mortality than in men. The purpose of this article is to summarize recent literature concerning gender-based differences. Specific differences in pathophysiology, traditional and psychosocial risk factors, symptom presentation, treatments, and outcomes between women and men will be reviewed.

Differences in the management and prognosis of women and men who suffer from acute coronary syndromes

OBJECTIVES

The purpose of this research was to determine if sex and gender differences in the management of acute coronary syndromes (ACS) are associated with differences in prognosis after ACS.

BACKGROUND

Previous investigators have reported sex/gender differences in the management of patients with ACS, but the impact of these differences on prognosis is unclear.

METHODS

We analyzed data from the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial, which enrolled 4,836 women and 7,726 men with ACS. Patients were classified into risk strata using the Thrombolysis In Myocardial Infarction (TIMI) score.

RESULTS

Women underwent fewer invasive procedures including angiography, angioplasty, and coronary artery bypass graft (CABG) surgery (47.6% vs. 60.5%; p = 0.0001) compared to men. No significant differences in cardiovascular death, myocardial infarction (MI), or stroke were observed (9.8% vs. 10.9%; p = 0.04), although women were more likely than men to develop refractory ischemia and to be rehospitalized for chest pain during follow-up (16.6% vs. 13.9%; p = 0.0001). These differences were particularly evident among TIMI high-risk women. A significant interaction between TIMI risk and gender for the outcome of refractory angina and rehospitalization for angina was present.

CONCLUSIONS

Compared to men, high-risk women with ACS undergo less coronary angiography, angioplasty, and CABG surgery, and while they do not have higher incidence cardiovascular death, recurrent MI, or stroke, they suffer an increased rate of refractory ischemia and rehospitalization. All high-risk women and men with ACS should receive optimal medical management, and be considered for coronary angiography with possible revascularization if their coronary anatomy warrants it.

Gender differences in symptoms associated with acute myocardial infarction: a review of the research

Recognizing similarities and differences in symptom experiences of acute myocardial infarction (AMI) between men and women has implications for both health care providers and the general public. Rapid accurate diagnosis is necessary to implement timely lifesaving treatment. The purpose of this article is to critically review and evaluate studies that have compared symptoms of AMI between men and women. Research to date has demonstrated that during AMI, women are more likely than men to report shortness of breath, nausea, vomiting, back pain, jaw pain, neck pain, cough, and fatigue, but less likely than men to report chest pain and sweating. However, the findings were inconsistent across studies. These inconsistent findings could be attributable to methodological issues such as collecting data from medical records, small sample sizes, and controversial eligibility criteria for studies. More studies are needed to confirm gender differences in symptom experiences of AMI.

Diabetes mellitus: clinical presentation and outcome in men and women with acute coronary syndromes. Data from the Euro Heart Survey ACS

AIMS

To study clinical presentation, in-hospital course and short-term prognosis in men and women with diabetes mellitus and acute coronary syndromes (ACS).

METHODS

Men (n = 6488, 21.2% with diabetes) and 2809 women (28.7% with diabetes) < or = 80 years old, with a discharge diagnosis of ACS were prospectively enrolled in the Euro Heart Survey of ACS.

RESULTS

Women with diabetes were more likely to present with ST elevation than non-diabetic women, a difference that became more marked after adjustment for differences in smoking, hypertension, obesity, medication and prior disease [adjusted odds ratio (OR) 1.46 (1.20, 1.78)], whereas there was little difference between diabetic and non-diabetic men [adjusted OR 0.99 (0.86, 1.14)]. In addition, women with diabetes were more likely to develop Q-wave myocardial infarction (MI) than non-diabetic women [adjusted OR 1.61 (1.30, 1.99)], while there was no difference between men with and without diabetes [adjusted OR 0.99 (0.85, 1.15)]. There were significant interactions between sex, diabetes and presenting with ST-elevation ACS (P < 0.001), and Q-wave MI (P < 0.001), respectively. Of the women with diabetes, 7.4% died in hospital, compared with 3.6% of non-diabetic women [adjusted OR 2.13 (1.39, 3.26)], whereas corresponding mortality rates in men with and without diabetes were 4.1% and 3.3%, respectively [OR 1.13 (0.76, 1.67)] (P for diabetes-sex interaction 0.021).

CONCLUSION

In women with ACS, diabetes is associated with higher risk of presenting with ST-elevation ACS, developing Q-wave MI, and of in-hospital mortality, whereas in men with ACS diabetes is not significantly associated with increased risk of either. These findings suggest a differential effect of diabetes on the pathophysiology of ACS based on the patient's sex.

Acute Coronary Syndromes: Risk Stratification and Initial Management

For patients who have acute coronary syndromes (ACS), risk stratification is key to initiating appropriate treatment. For ST-segment elevation MI, immediate reperfusion therapy is needed, and thus rapid identification of ST elevation on the ECG is critical. Then, having a standardized protocol for rapid treatment- with either primary percutaneous coronary intervention or thrombolysis - is critical. For unstable angina/non-ST elevation ACS, after first identifying the patients who have a higher likelihood of actually having an ACS (as opposed to noncardiac chest pain) stratification to high versus lower risk is needed to choose appropriate therapies. Thus, it is important for risk stratification to be a central part of all management of patients who have ACS.

Gender-Related Differences in Rhythm Control Treatment in Persistent Atrial Fibrillation

OBJECTIVES

This study sought to compare whether gender affects the outcome of rate versus rhythm control treatment in patients with persistent atrial fibrillation (AF).

BACKGROUND

Large trials have shown that rate control is an acceptable alternative to rhythm control. However, the effects of treatment may differ between male and female patients.

METHODS

In the Rate Control versus Electrical Cardioversion (RACE) study, 522 patients (192 female) were included and randomized to rate or rhythm control. The occurrence of cardiovascular end points and quality of life (QoL) were compared between female and male patients.

RESULTS

At baseline, female patients differed from male patients with regard to age, underlying heart disease, diabetes mellitus, and left ventricular function. Female patients had more AF-related complaints, and QoL was significantly lower. After a mean follow-up of 2.3 +/- 0.6 years, cardiovascular morbidity and mortality was equally distributed between female (21%) and male patients (19%). However, in contrast to male patients, female patients randomized to rhythm control developed more end points (adjusted hazard ratio was 3.1 [95% confidence interval 1.5 to 6.3], p = 0.002), mainly heart failure, thromboembolic complications, and adverse effects of antiarrhythmic drugs, compared with rate control randomized female patients. During follow-up, QoL in female patients remained worse compared with that for male patients. Randomized strategy did not influence QoL in female patients.

CONCLUSIONS

In female patients with persistent AF, a rhythm control approach leads to more cardiovascular morbidity and mortality. Because treatment strategy did not influence QoL in female patients, a rate control approach may be considered in these patients.

Gender-related differences in the clinical presentation and outcome of hypertrophic cardiomyopathy

OBJECTIVES

The goal of this study was to assess gender-related differences in a multicenter population with hypertrophic cardiomyopathy (HCM).

BACKGROUND

Little is known regarding the impact of gender on the heterogeneous clinical profile and clinical course of HCM.

METHODS

We studied 969 consecutive HCM patients from Italy and the U.S. followed over 6.2 +/- 6.1 years.

RESULTS

Male patients had a 3:2 predominance (59%), similar in Italy and the U.S. (p = 0.24). At initial evaluation, female patients were older and more symptomatic than male patients (47 +/- 23 years vs. 38 +/- 18 years; p < 0.001; mean New York Heart Association [NYHA] functional class 1.8 +/- 0.8 vs. 1.4 +/- 0.6; p < 0.001), and more frequently showed left ventricular outflow obstruction (37% vs. 23%; p < 0.001). Moreover, female patients were less often diagnosed fortuitously by routine medical examination (23% vs. 41% in male patients, p < 0.001). Female gender was independently associated with the risk of symptom progression to NYHA functional classes III/IV or death from heart failure or stroke compared with male gender (independent relative hazard 1.5; p < 0.001), particularly patients > or =50 years of age and with resting outflow obstruction (p < 0.005). Hypertrophic cardiomyopathy-related mortality and risk of sudden death were similar in men and women.

CONCLUSIONS

Women with HCM were under-represented, older, and more symptomatic than men, and showed higher risk of progression to advanced heart failure or death, often associated with outflow obstruction. These gender-specific differences suggest that social, endocrine, or genetic factors may affect the diagnosis and clinical course of HCM. A heightened suspicion for HCM in women may allow for timely implementation of treatment strategies, including relief of obstruction and prevention of sudden death or stroke.

Influence of gender on treatment and short-term mortality of patients with acute myocardial infarction in Berlin

AIMS

Previous studies have shown higher hospital mortality rates in women, especially younger women, than in men. In light of the fact that myocardial infarction therapy is rapidly developing, and since gender-specific aspects have been discussed in detail during recent years, it was our goal to re-evaluate factors influencing hospital mortality rate, especially those involving gender-specific differences, in the city of Berlin, Germany.

METHODS

We prospectively collected data from 5133 patients (3330 men and 1803 women) with acute myocardial infarction who were treated in 25 hospitals in Berlin during the years 1999 to 2002.

RESULTS

During hospitalization the overall mortality rate was 18.6% among women and 8.4% among men. Women were older (mean age for men 62 years; women 73 years) and less likely to be married (men 74.6%; women 36.9%) than men. Women generally took longer to arrive at the hospital after infarction than did men (median time: men 2.0 h; women 2.6 h). Women furthermore demonstrated a higher proportion of diabetes (men 22.8%; women 36.5%) and hypertension (men 58.0%; women 69.3%). Reperfusion therapy (men 68.8%; women 49.7%) and administration of beta-blockers (men 76.0%; women 66.0%) took place less often for women than for men. A multivariate analysis revealed the following factors to be independent predictors of hospital mortality: age, gender, diabetes mellitus, hypercholesterolemia, pre-existing heart failure, pre-hospital cardiopulmonary resuscitation, cardiogenic shock and pulmonary congestion on admission, admission to a hospital with >600 beds, ST-elevation in the initial ECG, reperfusion therapy, as well as beta-blocker and ACE inhibitor treatment within 48 h of hospitalization.

CONCLUSION

Even after adjustment in multivariate analysis, women with acute myocardial infarction still demonstrate a higher risk for in-hospital death than men.

Cardiovascular disease in women: Sex differences in presentation, risk factors, and evaluation

Cardiovascular disease (CVD) is the leading cause of mortality in women. Pathophysiology, risk factors, clinical presentation, and outcomes of coronary artery disease (CAD) differ in women, and a better understanding of the sex differences in these factors will potentially lead to a slowing of this epidemic in women. Often forgotten, women have higher complication rates post revascularization and higher in-hospital mortality post myocardial infarction compared with men despite a smaller burden of disease in women. Though overall women share the same risk factors as men in the development of CAD, certain risk factors appear to be particularly ominous, such as the presence of diabetes mellitus, low values of high-density lipoprotein cholesterol, high triglycerides, and psychologic depression. Disease detection in advanced CAD is more accurate with stress echocardiography (ECG) and perfusion single-photon emission computed tomography imaging in women than with stress ECG. Subclincial atherosclerotic disease detection with carotid artery intima media thickness assessment provides an opportunity to target preventive measures in women. This article focuses on some of the sex-specific differences.

Predictors of type and site of first acute myocardial infarction in men and women

BACKGROUND

The importance of pathophysiological mechanisms involved in onset of acute myocardial infarction (AMI) differs with age, gender, and risk profiles. Diversity in the triggering of cardiovascular events has been observed, particularly between men and women. Therefore, we investigated the relationship between age, gender, and risk factors and location of AMI and the presence of Q waves in ECG.

PATIENTS AND METHODS

Data was obtained from a chart review of 2958 patients with first AMI: 770 (26%) patients with non-Q-wave AMI and 2188 (74%) patients with Q-wave AMI. Four clinical groups were formed by predetermined criteria (anterior Q-wave, anterior non-Q-wave, inferior Q-wave, inferior non-Q-wave). A logistic regression was performed to assess independent predictors of AMI type and site.

RESULTS

Key findings were: 1) inferior non-Q-wave AMI was more frequent in young women (P<0.001); 2) inferior Q-wave AMI was more common in young men (P<0.001); 3) anterior non-Q-wave AMI was more common in older men (P<0.001). Multivariate analysis revealed that independent predictors of anterior non-Q-wave AMI were age over 65 (P=0.002), male gender (P=0.04) and hypercholesterolemia (P=0.0003), and that predictors of inferior Q-wave AMI were male gender (P<0.0001), smoking (P=0.04) and diabetes (P=0.049). In the gender-subgroup analyses, age <45 years (P=0.04), hypecholesterolemia (P=0.02) and smoking (P=0.01) were independent predictors of inferior Q-wave AMI whereas age >65 years (P<0.0001) and smoking (P=0.0003) were predictors of anterior non-Q-wave AMI in men. In women, age <45 years (P<0.0001) and smoking (P=0.02) were independent predictors of non-Q-wave AMI and hypercholesterolemia (P=0.02) was a predictor of inferior Q-wave AMI.

CONCLUSION

The link between particular types and the site of AMI and age, gender and risk factors suggest that the importance of pathophysiological mechanisms for onset of AMI differs according to sex and age subgroup.

Exercise treadmill testing using a modified exercise protocol in women with suspected myocardial ischemia: findings from the National Heart, Lung and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE)

BACKGROUND

Exercise testing, a major diagnostic modality in individuals with suspected coronary artery disease (CAD), has in general demonstrated less overall diagnostic accuracy in women compared to men. As part of the WISE, a modified protocol was examined with the intention of improving reliability of exercise testing.

METHODS

Criteria for entry in the WISE study include clinically indicated coronary angiography. Exercise testing was performed using a protocol modified to be more appropriate for women. The study population consisted of 96 women, mean age of 55.8 y (range 34-77), who completed exercise treadmill test (ETT). Most (78%) were postmenopausal; 96% had >or =2 risk factors for CAD.

RESULTS

By core laboratory angiography, 29/96 women had stenosis > or =50% in at least one coronary artery. Of these 29 women, 9 had abnormal ETT, yielding overall sensitivity of 31%. The remaining 20 women had normal (12/29, 41%) or nondiagnostic (8/29, 28%) studies. Among the 67 women with minimal or no coronary stenosis, 35 had no ischemic ST-segment changes during ETT, yielding overall specificity of 52%. Analysis with exclusion of women with nondiagnostic studies yielded sensitivity and specificity of 43% and 66%, respectively. The presence of coronary artery stenosis and inability to perform ETT, but not results of testing, predicted the outcomes of myocardial infarction, heart failure, and death.

CONCLUSIONS

Exercise treadmill test appears to be of limited diagnostic value in women with suspected myocardial ischemia referred for coronary angiography. Sensitivity and specificity remain poor even with modified exercise protocol and core laboratory angiographic analysis. These findings merit consideration in view of current guidelines that recommend exercise testing in women with suspected CAD.

Presenting symptoms, admission electrocardiogram, management, and prognosis in acute coronary syndromes: differences by age

In a nationwide survey conducted in all 26 hospitals in Israel during February and March 2000, data were collected on 2133 consecutive acute coronary syndrome patients. The patients were divided into three age subgroups: <65 years (n=974), 65-74 years (n=500), and > or =75 years (n=639). The frequency of no anginal pain/atypical symptoms on presentation increased with age for all acute coronary syndrome patients (14%, 21%, and 32%, in the three age subgroups, respectively; p for trend <0.0001). The frequency of ST-elevation on admission electrocardiogram decreased with advancing age (59%, 46%, and 42%, in the three age subgroups, respectively; p for trend <0.0001), whereas ST-depression gradually increased (14%, 24%, and 28%, respectively; p for trend <0.0001). In multivariate analysis, variables associated with no anginal pain/atypical symptoms on presentation (in decreasing order) were: history of heart failure, age, lack of past angina, diabetes, and nonsmoking. ST-elevation was inversely associated with no anginal pain/atypical symptoms on admission (odds ratio, 0.48; 95% confidence interval, 0.37-0.63). The use of acute reperfusion therapy significantly declined with advancing age. Seven-day, 30-day, and 1-year mortality increased with advancing age. No anginal pain/atypical symptoms on presentation were associated with an increased early and late mortality in all three age subgroups.

Identification of Women's Coronary Heart Disease and Risk Factors Prior to First Myocardial Infarction

PURPOSE

To understand when women's coronary heart disease (CHD) and CHD risk factors are recognized prior to first myocardial infarction (MI).

METHODS

Medical record review of the 10 years prior to incident MI among women with a confirmed incident MI between January 1, 1996, and December 31, 2001, to determine the timing of CHD diagnosis as well as assessment and treatment for risk factors.

RESULTS

One hundred fifty women had incident MIs during the study period. They made 8732 ambulatory visits and had 457 hospitalizations during the period of review (mean 9.1 years, range 6.2-10 years). Average age at incident MI was 74.7 years (SD 12.6, range 38.9-99.8 years). A CHD diagnosis prior to first MI was present in 52% (n = 78) of the women but was less common in those <70 years (p = 0.001). All but 3 women had one or more modifiable risk factors identified prior to their first MI. Treatment of recognized risk factors varied from 81% (antihypertension medications) to only 28% (drug therapy for abnormal lipid levels). Having a diagnosis of CHD was associated with an increased likelihood of having identified risk factors and receiving drug treatment for identified risk factors.

CONCLUSIONS

Women with undiagnosed CHD (48%) and those with unrecognized or untreated risk factors for CHD, especially younger women, represent missed opportunities for prevention of cardiac events.

Increased cardiac mortality in women compared with men in patients with acute myocardial infarction

OBJECTIVE

It has been reported that women with acute myocardial infarction (AMI) have a higher short-term mortality rate than men, but the reason is not known. The profile in relation to age, gender and risk factors was evaluated to compare AMI and unstable angina pectoris (UAP).

METHODS

Findings from 984 patients including 580 patients with AMI (129 women, 451 men) and 404 patients with UAP (131 women, 273 men) were analyzed by the South Osaka Acute Coronary Syndrome Study Group (SACS). The primary endpoint of the study was in-hospital death. The primary endpoints of interest (cardiac death) were fatal recurrent myocardial infarction, death from congestive heart failure, and sudden death.

RESULTS

Cardiac death during hospitalization within 30 days in AMI was higher in women than in men (12.4% vs 6.7%, p < 0.05). On the other hand, in UAP there was no significant difference between women and men (1.5% vs 0.7%, NS). The incidence of cardiac death in AMI was significantly higher for patients 75 years old and older (19.0%) than for patients less than 55 years old (4.2%), 55-64 years old (3.5%) and 65-74 years old (4.7%) (p < 0.001, respectively).

CONCLUSIONS

Cardiac death was higher for women compared with men in patients with AMI. The worse prognosis for the AMI women patients was likely to be derived from less performance of percutaneous coronary intervention, and a high incidence of severe myocardial infarction. Further research should be focused on the analysis of various clinical backgrounds.

Perimenopausal and Postmenopausal Health

HEALTH ISSUE: The average age of natural menopause in Western societies is estimated to be 51 years; women in Canada can therefore expect to live, on average, a third of their lives in post-menopausal years. During these years women are at increased risk of chronic diseases such as osteoporosis and cardiovascular disease. KEY FINDINGS: Clinical and epidemiological data on women in perimenopause are limited. There are no adequate Canadian data on symptom severity and prevalence among perimenopausal and postmenopausal women. Scientific evidence is lacking to support or refute claims that commonly used botanical products can offer therapeutic relief of menopausal symptoms.Recent data from the Women's Health Initiative suggest that combined estrogen plus therapy increases the risk of stroke, coronary artery disease and breast cancer. Hormone therapy is no longer recommended for the prevention of chronic diseases for asymptomatic women. Stroke is an important issue for perimenopausal and postmenopausal women and sex differences may exist in the progestin treatment of stroke. Osteoporosis affects an estimated one in six women over the age of 50. DATA GAPS AND RECOMMENDATIONS: There is a need to conduct clinical and epidemiological research aimed at better understanding the menopausal transition and defining its clinical phases. Investigations aimed at alternative combinations and doses of hormone therapy and non-pharmaceutical alternatives in light of known risks and benefits are also necessary. Health care practitioners and women need to be educated on the risks and effective treatment related to cardiovascular disease so they can present for treatment more quickly and receive the most effective therapies.

Gender and the treatment of heart disease in older persons in the United States, France, and England: a comparative, population-based view of a clinical phenomenon

BACKGROUND

Gender disparities in the treatment of coronary artery disease (CAD) have been extensively documented in studies from the United States. However, they have been less well studied in other countries and, to our knowledge, have not been investigated at the more disaggregated spatial level of cities.

OBJECTIVE

This study tests the hypothesis that there is a common international pattern of gender disparity in the treatment of CAD in persons aged > or =65 years by analyzing data from the United States, France, and England and from their largest cities-New York City and its outer boroughs, Paris and its First Ring, and Greater London.

METHODS

This was an ecological study based on a retrospective analysis of comparable administrative data from government health databases for the 9 spatial units of analysis: the 3 countries, their 3 largest cities, and the urban cores of these 3 cities. A simple index was used to assess the relationship between treatment rates and a measure of CAD prevalence by gender among age-adjusted cohorts of patients. Differences in rates were examined by univariate analysis using the Student t test for statistical differences in mean values.

RESULTS

Despite differences in health system characteristics, including health insurance coverage, availability of medical resources, and medical culture, we found consistent gender differences in rates of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting across the 9 spatial units. The rate of interventional treatment in women with CAD was less than half that in men. This difference persisted after adjustment for the prevalence of heart disease.

CONCLUSIONS

A consistent pattern of gender disparity in the interventional treatment of CAD was seen across 3 national health systems with known differences in patterns of medical practice. This finding is consistent with the results of clinical studies suggesting that gender disparities in the treatment of CAD are due at least in part to the underdiagnosis of CAD in women.

Spectrum of Acute Coronary Syndromes: History and Clinical Presentation in Relation to Sex and Age

OBJECTIVES

To study sex-based differences in the clinical presentation in relation to age and type of acute coronary syndrome (ACS) in patients under 80 years of age.

METHODS

The study includes 1,744 consecutive patients with the full spectrum of ACS (ST elevation myocardial infarction (MI), non-ST elevation MI, and unstable angina of high- and low-risk types) admitted to the coronary care unit in a university hospital.

RESULTS

The women were older than the men and were as likely to present with ST elevation MI. They had lower rates of prior MI and prior coronary artery bypass surgery than men but similar rates of percutaneous coronary interventions. Further, women were less likely to have a short delay before admission to hospital and they were attended to less rapidly in the emergency department. The prevalence of risk factors, prior cardiovascular disease and ongoing treatment with cardiovascular drugs were strongly associated with less severe type of ACS with no significant sex interaction. Presentation with non-ST elevation MI was significantly associated with older age while the opposite was true for unstable low-risk angina. ECG signs of acute ischemia were not associated with age. Significant interactions between age and sex were observed for the prevalence of treatment with diuretics as well as hypotension at presentation, both more prevalent among women than men below 65 years of age.

CONCLUSIONS

Women are struck by ACS at a higher age than men, are less likely to present early for hospital care, and at younger age women are more likely to present with hypotension. There is a striking difference in risk factors and previous history depending on type of ACS in both sexes.

Outcomes of thrombolytic therapy for acute myocardial infarction in women

Coronary artery disease is the leading cause of mortality in women older than 50 years of age. Thrombolytic therapy substantially reduces mortality in both women and men with ST-elevation acute myocardial infarction. However, the mortality risk reduction is somewhat lower in women, in spite of similar rates of successful coronary reperfusion after thrombolytic therapy in women and men. Hemorrhagic complications including stroke and other major bleeding appear to be more common in women, particularly elderly women. The risk of reinfarction after thrombolytic therapy also is greater in women compared with men. Because of the higher complication rates, women should be monitored closely after thrombolytic therapy. However, this lifesaving treatment should not be withheld or delayed in women when indicated.

Do Emergency Nursesʼ Triage Decisions Predict Differences in Admission or Discharge Diagnoses for Acute Coronary Syndromes?

Coronary heart disease is the number 1 killer of adults in the United States, affecting 1 in 5 men and women. However, women are more likely than men to die after an acute coronary event and are less likely to receive prompt or aggressive treatment. Few studies have examined the role of emergency nurses' triage decisions in these disparities, even though nurses often determine initial patient priority and urgency status for emergency cardiac evaluation and treatment. The purpose of this prospective study was to examine if nurses' initial triage decisions could predict admission or discharge diagnoses for acute coronary syndromes (ACS). A total of 108 nurses' triage decisions made by 13 nurses were examined. There were no differences in nurses' triage decisions based on patient gender, race, or age. By multivariate analysis, chest pain, history of coronary heart disease, history of myocardial infarction, and smoking were predictive of an ACS decision. Overall, accuracy for predicting admission diagnosis was poor. Sensitivity and specificity were 57% and 59%, respectively, with a positive predictive value of 68% and a negative predictive value of 56%. It was similarly poor for predicting discharge diagnosis. Sensitivity and specificity for discharge diagnosis were 55% and 69%, respectively, with a positive predictive value of 17% and a negative predictive value of 93%. Findings indicate limitations in the ability of nurses' triage decisions to predict admission and discharge diagnoses for ACS.

The prevalence of coronary heart disease in Type 2 diabetic patients in Italy: the DAI study

AIMS

Type 2 diabetes is associated with at least a twofold increase in risk of coronary heart disease (CHD). We aimed to estimate the prevalence of CHD in the population of Type 2 diabetics cared for by the Italian network of outpatient diabetic units.

METHODS

The DAI (Diabetes and Informatics study group, Italian Association of Diabetologists, and Italian National Institute of Health) study is a multicentre cohort study of patients with Type 2 diabetes. Patients were classified as having CHD if they had: (i) a history for hospital admission for either an acute myocardial infarction (AMI) or angina; (ii) a positive ECG for prior AMI or angina; (iii) a positive history for coronary artery bypass graft; or (iv) a positive history for percutaneous transluminal coronary angioplasty.

RESULTS

A cohort of 19 468 patients was analysed: 3157 patients had CHD. The majority of events (80%) had occurred after the diagnosis of diabetes and were considered in the CHD prevalence estimate. The prevalence of CHD, adjusted by age and sex, was 9.9%: 11.0% male and 9.0% female. Angina without AMI occurred in 1306 patients; this condition was more frequent in females while a documented AMI was more frequent in males. Therapeutic procedures were performed more frequently in males. A positive association with CHD was found for gender, age at visit, duration of diabetes, hypertension, relatives with CHD, tryglicerides and microvascular complications.

CONCLUSIONS

The prevalence of CHD in this cohort is lower than previously reported; nevertheless, patients attending the diabetic care units may not be fully representative of the general diabetic population in Italy. Revascularization is less frequent in females than in males; microvascular complications and a worse metabolic control are significantly associated with CHD.