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

Cardiovascular disease in women: Executive summary of the expert panel statement of women in cardiology of the hellenic cardiological society

The perception that women represent a low-risk population for cardiovascular (CV) disease (CVD) needs to be reconsidered. Starting from risk factors, women are more likely to be susceptible to unhealthy behaviors and risk factors that have different impact on CV morbidity and mortality as compared to men. Despite the large body of evidence as regards the effect of lifestyle factors on the CVD onset, the gender-specific effect of traditional and non-traditional risk factors on the prognosis of patients with already established CVD has not been well investigated and understood. Furthermore, CVD in women is often misdiagnosed, underestimated, and undertreated. Women also experience hormonal changes from adolescence till elder life that affect CV physiology. Unfortunately, in most of the clinical trials women are underrepresented, leading to the limited knowledge of CV and systemic impact effects of several treatment modalities on women's health. Thus, in this consensus, a group of female cardiologists from the Hellenic Society of Cardiology presents the special features of CVD in women: the different needs in primary and secondary prevention, as well as therapeutic strategies that may be implemented in daily clinical practice to eliminate underestimation and undertreatment of CVD in the female population.

Age-Stratified Sex Disparities in Care and Outcomes in Patients With ST-Elevation Myocardial Infarction

BACKGROUND

Women are undertreated and have worse clinical outcomes than men after acute myocardial infarction. It remains uncertain whether the sex disparities in treatments and outcomes persist in the contemporary era and whether they affect all age groups equally.

METHODS

Using the National Inpatient Sample (NIS) registry, we evaluated 1,260,200 hospitalizations for ST-elevation myocardial infarction (STEMI) between 2010 and 2016, of which 32% were for women. The age-stratified sex differences in care measures and mortality were examined. Stepwise multivariable adjustment models, including baseline comorbidities, hospital characteristics, and reperfusion and revascularization therapies, were used to compare measures and outcomes between women and men across different age subgroups.

RESULTS

Overall, women with STEMI were older than men and had more comorbidities. Women were less likely to receive fibrinolytic therapy, percutaneous coronary intervention (PCI), and coronary artery bypass surgery across all age subgroups. Women with STEMI overall experienced higher unadjusted in-hospital mortality (11.1% vs 6.8%; adjusted odds ratio [OR] = 1.039, 95% confidence interval [CI]: 1.003-1.077), which persisted after multivariable adjustments. However, when stratified by age, the difference in mortality became non-significant in most age groups after stepwise multivariable adjustment, except among the youngest patients 19-49 years of age with STEMI (women vs men: 3.9% vs 2.6%; adjusted odds ratio = 1.259, 95% confidence interval: 1.083-1.464).

CONCLUSIONS

Women with STEMI were less likely to receive reperfusion and revascularization therapies and had higher in-hospital mortality and complications compared with men. Younger women with STEMI (19-49 years of age) experienced higher in-hospital mortality that persisted after multivariable adjustment.

Role of the Fatty Acid Binding Proteins in Cardiovascular Diseases: A Systematic Review

Cardiovascular diseases (CVD) remain a global pandemic and leading cause of deaths worldwide. While several guidelines have been developed to control the development of CVDs, its prevalence keeps on increasing until this day. Cardiovascular risk factors, such as reduced exercises and high fat or glucose diets, culminate in the development of the metabolic syndrome and eventually atherosclerosis, which is driven by high blood lipid and cholesterol levels, and by endothelial dysfunction. Late complications of atherosclerosis give rise to serious clinical cardiovascular manifestations such as myocardial infarction and hypertension. Therefore, endothelial functions and the lipid metabolism play critical roles in the pathogenesis of CVDs. Fatty acid-binding proteins are a family of intracellular proteins expressed in many cell types known mainly for their interaction with and trafficking of cellular lipids. The roles of a number of isoforms in this family have been implicated in lipid metabolic homeostasis, but their influence on endothelial function and vascular homeostasis remain largely unknown. This review's purpose is to update fundamentals about the connection between cardiovascular disease, metabolism, endothelial function, and mainly the roles of fatty acid-binding proteins.

Sex differences in clinical phenotype and transitions of care among individuals dying of COVID-19 in Italy

Background

Among the unknowns posed by the coronavirus disease 2019 (COVID-19) outbreak, the role of biological sex to explain disease susceptibility and progression is still a matter of debate, with limited sex-disaggregated data available.

Methods

A retrospective analysis was performed to assess if sex differences exist in the clinical manifestations and transitions of care among hospitalized individuals dying with laboratory-confirmed SARS-CoV-2 infection in Italy (February 27–June 11, 2020). Clinical characteristics and the times from symptoms’ onset to admission, nasopharyngeal swab, and death were compared between sexes. Adjusted multivariate analysis was performed to identify the clinical features associated with male sex.

Results

Of the 32,938 COVID-19-related deaths that occurred in Italy, 3517 hospitalized and deceased individuals with COVID-19 (mean 78 ± 12 years, 33% women) were analyzed. At admission, men had a higher prevalence of ischemic heart disease (adj-OR = 1.76, 95% CI 1.39–2.23), chronic obstructive pulmonary disease (adj-OR = 1.7, 95% CI 1.29–2.27), and chronic kidney disease (adj-OR = 1.48, 95% CI 1.13–1.96), while women were older and more likely to have dementia (adj-OR = 0.73, 95% CI 0.55–0.95) and autoimmune diseases (adj-OR = 0.40, 95% CI 0.25–0.63), yet both sexes had a high level of multimorbidity. The times from symptoms’ onset to admission and nasopharyngeal swab were slightly longer in men despite a typical acute respiratory illness with more frequent fever at the onset. Men received more often experimental therapy (adj-OR = 2.89, 95% CI 1.45–5.74) and experienced more likely acute kidney injury (adj-OR = 1.47, 95% CI 1.13–1.90).

Conclusions

Men and women dying with COVID-19 had different clinical manifestations and transitions of care. Identifying sex-specific features in individuals with COVID-19 and fatal outcome might inform preventive strategies.

Gender differences in heart transplantation: Twenty-five year trends in the nationwide Spanish heart transplant registry

The study of gender differences may lead into improvement in patient care. We have aimed to identify the gender differences in heart transplantation (HT) of adult HT recipients in Spain and their evolution in a study covering the years 1993-2017 in which 6740 HT (20.6% in women) were performed. HT indication rate per million inhabitants was lower in women, remaining basically unchanged during the 25-year study period. HT rate was higher in men, although this decreased over the 25-year study period. Type of heart disease differed in men versus women (p < .001): ischemic heart disease 47.6% versus 22.5%, dilated cardiomyopathy 41.3% versus 34.6%, or other 36% versus 17.8%, respectively. Men were more frequently diabetics (18% vs. 13.1% p < .001), hypertensives (33.1% vs. 24% p < .001), and smokers (21.7% vs. 12.9% p < .001), respectively. Women had more pre-HT malignancies (7.1% vs. 2.8% p < .001), and their clinical status was worse at HT due to renal function and mechanical ventilation. Adjusted survival (p = .198) and most of the mortality-related variables were similar in men and women. Death occurred more frequently in women due to rejection (7.9% vs. 5.1% p < .001) and primary failure (18.2% vs. 12.5% p < .001) and in men due to malignancies (15.1% vs. 6.6% p < .001).

State of the Art in Noninvasive Imaging of Ischemic Heart Disease and Coronary Microvascular Dysfunction in Women: Indications, Performance, and Limitations

PURPOSE OF REVIEW

Establishing a diagnosis of ischemic heart disease (IHD) in women, including assessment for coronary microvascular dysfunction (CMD) when indicated, can be challenging. Access to performance of invasive testing when appropriate may be limited, and noninvasive imaging assessments have evolved. This review will summarize the various noninvasive imaging modalities available for the diagnosis of IHD and CMD in women, outlining indications, performance modalities, advantages, and limitations.

RECENT FINDINGS

While stress echocardiography and single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) are widely available and can detect IHD in women, their ability to specifically identify CMD is limited. Novel developments in cardiac magnetic resonance (CMR) imaging, including spectroscopy, and positron emission tomography (PET) have changed the diagnostic landscape. Coronary computed tomographic angiography (CCTA), while unable to diagnose CMD, is developing an emerging role in the risk stratification of ischemic syndromes. Despite the discovery of increased CMD prevalence in symptomatic women and technological advances in diagnostic imaging, practitioners are limited by user expertise and center availability when choosing a diagnostic imaging modality. Knowledge of this evolving field is imperative as it highlights the need for sex-specific assessment of cardiovascular syndromes.

Comparison of Outcomes of Coronary Revascularization for Acute Myocardial Infarction in Men Versus Women

This study sought to examine the differences in the characteristics and outcomes between men and women who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) in contemporary US practice. The Nationwide Inpatient Sample was used to identify patients who underwent revascularization for AMI between January 1, 2003 and December 31, 2016. The primary outcome was in-hospital mortality. Propensity score matching was utilized to account for differences in baseline characteristics. In total, 3,603,142 patients were included, of whom only 1,180,436 (33%) were women. Compared with men, women were older and had higher prevalence of key co-morbidities including diabetes, hypertension, congestive heart failure, and chronic kidney and lung disease (p <0.001). In the PCI cohort, women were significantly less likely to undergo multivessel PCI, to receive mechanical circulatory support, or to undergo atherectomy. In the CABG group, women were more likely to have concomitant valve surgery. In the propensity-matched cohorts, in-hospital mortality was higher for women than men regardless of revascularization strategy: 7.6% versus 6.6% for PCI in ST-elevation myocardial infarction, 2.0% versus 1.9% for PCI in non-ST-elevation myocardial infarction, and 5.7% versus 4.3% for CABG in any AMI (p <0.001). Women also had higher rates of major complications, longer hospitalizations, higher costs, and were less likely to be discharged home (vs nursing facility). These sex-based differences persisted over the study 14-year period. In conclusion, in a contemporary nationwide analysis of propensity score-matched patients, women who undergo revascularization for AMI have worse in-hospital outcomes than men regardless of revascularization mode.

Focusing Heart Failure Research on Myocardial Fibrosis to Prioritize Translation

Heart failure (HF) has traditionally been defined by symptoms of fluid accumulation and poor perfusion, but it is now recognized that specific HF classifications hold prognostic and therapeutic relevance. Specifically, HF with reduced ejection fraction is characterized by reduced left ventricular systolic pump function and dilation and HF with preserved ejection fraction is characterized primarily by abnormal left ventricular filling (diastolic failure) with relatively preserved left ventricular systolic function. These forms of HF are distributed equally among patients with HF and likely require distinctly different strategies to mitigate the morbidity, mortality, and medical resource utilization of this disease. In particular, HF is a significant medical issue within the US Department of Veterans Affairs (VA) hospital system and constitutes a major translational research priority for the VA. Because a common underpinning of both HF with reduced ejection fraction and HF with preserved ejection fraction seems to be changes in the structure and function of the myocardial extracellular matrix, a conference was convened sponsored by the VA, entitled, "Targeting Myocardial Fibrosis in Heart Failure" to explore the extracellular matrix as a potential therapeutic target and to propose specific research directions. The conference was conceptually framed around the hypothesis that although HF with reduced ejection fraction and HF with preserved ejection fraction clearly have distinct mechanisms, they may share modifiable pathways and biological mediators in common. Inflammation and extracellular matrix were identified as major converging themes. A summary of our discussion on unmet challenges and possible solutions to move the field forward, as well as recommendations for future research opportunities, are provided.

Estrogen-Mediated Gaseous Signaling Molecules in Cardiovascular Disease

Gender difference is well recognized as a key risk factor for cardiovascular disease (CVD). Estrogen, the primary female sex hormone, improves cardiovascular functions through receptor (ERα, ERβ, or G protein-coupled estrogen receptor)-initiated genomic or non-genomic mechanisms. Gaseous signaling molecules, including nitric oxide (NO), hydrogen sulfide (H₂S), and carbon monoxide (CO), are important regulators of cardiovascular function. Recent studies have demonstrated that estrogen regulates the production of these signaling molecules in cardiovascular cells to exert its cardiovascular protective effects. We discuss current understanding of gaseous signaling molecules in cardiovascular disease (CVD), the underlying mechanisms through which estrogen exerts cardiovascular protective effects by regulating these molecules, and how these findings can be translated to improve the health of postmenopausal women.

Sex Disparities in the Management and Outcomes of Cardiogenic Shock Complicating Acute Myocardial Infarction in the Young

BACKGROUND

There are limited data on how sex influences the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in young adults.

METHODS

A retrospective cohort of AMI-CS admissions aged 18 to 55 years, during 2000 to 2017, was identified using the National Inpatient Sample. Use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support and noncardiac interventions was identified. Outcomes of interest included in-hospital mortality, use of cardiac interventions, hospitalization costs, and length of stay.

RESULTS

A total 90 648 AMI-CS admissions ≤55 years of age were included, of which 26% were women. Higher rates of CS were noted in men (2.2% in 2000 to 4.8% in 2017) compared with women (2.6% in 2000 to 4.0% in 2017; P<0.001). Compared with men, women with AMI-CS were more frequently of Black race, from a lower socioeconomic status, with higher comorbidity, and admitted to rural and small hospitals (all P<0.001). Women had lower rates of ST-segment elevation presentation (73.0% versus 78.7%), acute noncardiac organ failure, cardiac arrest (34.3% versus 35.7%), and received less-frequent coronary angiography (78.3% versus 81.4%), early coronary angiography (49.2% versus 54.1%), percutaneous coronary intervention (59.2% versus 64.0%), and mechanical circulatory support (50.3% versus 59.2%; all P<0.001). Female sex was an independent predictor of in-hospital mortality (23.0% versus 21.7%; adjusted odds ratio, 1.11 [95% CI, 1.07-1.16]; P<0.001). Women had lower hospitalization costs ($156 372±$198 452 versus $167 669±$208 577; P<0.001) but comparable lengths of stay compared with men.

CONCLUSIONS

In young AMI-CS admissions, women are treated less aggressively and experience higher in-hospital mortality than men.

Dissection of coronary artery: A clinical overview

Spontaneous coronary artery dissection (SCAD) is a rare but life-threatening disorder. SCAD is gaining importance as an emerging cause of acute coronary syndrome (ACS), especially in otherwise healthy young women. While SCAD and ACS show similarity in presentation, the management of SCAD differs to that of ACS. If not managed properly SCAD can lead to sudden death. This review examines the pathophysiology, clinical presentation, diagnostic algorithms, and the current and future management of SCAD.

Cardiovascular disease in women: insights from magnetic resonance imaging

The presentation and identification of cardiovascular disease in women pose unique diagnostic challenges compared to men, and underrecognized conditions in this patient population may lead to clinical mismanagement.This article reviews the sex differences in cardiovascular disease, explores the diagnostic and prognostic role of cardiovascular magnetic resonance (CMR) in the spectrum of cardiovascular disorders in women, and proposes the added value of CMR compared to other imaging modalities. In addition, this article specifically reviews the role of CMR in cardiovascular diseases occurring more frequently or exclusively in female patients, including Takotsubo cardiomyopathy, connective tissue disorders, primary pulmonary arterial hypertension and peripartum cardiomyopathy. Gaps in knowledge and opportunities for further investigation of sex-specific cardiovascular differences by CMR are also highlighted.

Trends in Recurrent Coronary Heart Disease After Myocardial Infarction Among US Women and Men Between 2008 and 2017

BACKGROUND

Rates for recurrent coronary heart disease (CHD) events have declined in the United States. However, few studies have assessed whether this decline has been similar among women and men.

METHODS

Data were used from 770 408 US women and 700 477 US men <65 years of age with commercial health insurance through MarketScan and ≥66 years of age with government health insurance through Medicare who had a myocardial infarction (MI) hospitalization between 2008 and 2017. Women and men were followed up for recurrent MI, recurrent CHD events (ie, recurrent MI or coronary revascularization), heart failure hospitalization, and all-cause mortality (Medicare only) in the 365 days after MI.

RESULTS

From 2008 to 2017, age-standardized recurrent MI rates per 1000 person-years decreased from 89.2 to 72.3 in women and from 94.2 to 81.3 in men (multivariable-adjusted P interaction by sex <0.001). Recurrent CHD event rates decreased from 166.3 to 133.3 in women and from 198.1 to 176.8 in men (P interaction <0.001). Heart failure hospitalization rates decreased from 177.4 to 158.1 in women and from 162.9 to 156.1 in men (P interaction=0.001). All-cause mortality rates decreased from 403.2 to 389.5 in women and from 436.1 to 417.9 in men (P interaction=0.82). In 2017, the multivariable-adjusted rate ratios comparing women with men were 0.90 (95% CI, 0.86-0.93) for recurrent MI, 0.80 (95% CI, 0.78-0.82) for recurrent CHD events, 0.99 (95% CI, 0.96-1.01) for heart failure hospitalization, and 0.82 (95% CI, 0.80-0.83) for all-cause mortality.

CONCLUSIONS

Rates of recurrent MI, recurrent CHD events, heart failure hospitalization, and mortality in the first year after an MI declined considerably between 2008 and 2017 in both men and women, with proportionally greater reductions for women than men. However, rates remain very high, and rates of recurrent MI, recurrent CHD events, and death continue to be higher among men than women.

Sex-specific differences in children attending the emergency department: prospective observational study

OBJECTIVE

To assess the role of sex in the presentation and management of children attending the emergency department (ED).

DESIGN

The TrIAGE project (TRiage Improvements Across General Emergency departments), a prospective observational study based on curated electronic health record data.

SETTING

Five diverse European hospitals in four countries (Austria, The Netherlands, Portugal, UK).

PARTICIPANTS

All consecutive paediatric ED visits of children under the age of 16 during the study period (8-36 months between 2012 and 2015).

MAIN OUTCOME MEASURES

The association between sex (male of female) and diagnostic tests and disease management in general paediatric ED visits and in subgroups presenting with trauma or musculoskeletal, gastrointestinal and respiratory problems and fever. Results from the different hospitals were pooled in a random effects meta-analysis.

RESULTS

116 172 ED visits were included of which 63 042 (54%) by boys and 53 715 (46%) by girls. Boys accounted for the majority of ED visits in childhood, and girls in adolescence. After adjusting for age, triage urgency and clinical presentation, girls had more laboratory tests compared with boys (pooled OR 1.10, 95% CI 1.05 to 1.15). Additionally, girls had more laboratory tests in ED visits for respiratory problems (pooled OR 1.15, 95% CI 1.04 to 1.26) and more imaging in visits for trauma or musculoskeletal problems (pooled OR 1.10, 95% CI 1.01 to 1.20) and respiratory conditions (pooled OR 1.14, 95% CI 1.05 to 1.24). Girls with respiratory problems were less often treated with inhalation medication (pooled OR 0.76, 95% CI 0.70 to 0.83). There was no difference in hospital admission between the sexes (pooled OR 0.99, 95% CI 0.95 to 1.04).

CONCLUSION

In childhood, boys represent the majority of ED visits and they receive more inhalation medication. Unexpectedly, girls receive more diagnostic tests compared with boys. Further research is needed to investigate whether this is due to pathophysiological differences and differences in disease course, whether girls present signs and symptoms differently, or whether sociocultural factors are responsible.

Cardiogenic shock due to predominantly right ventricular failure complicating acute myocardial infarction

AIMS

The objective was to describe patient characteristics, interventions, and outcome in acute myocardial infarction complicated by cardiogenic shock (AMICS), due to predominantly right ventricular (RV) failure after revascularization, in comparison with patients suffering from left ventricular (LV) failure as these patients remain sparsely characterized.

METHODS AND RESULTS

From 2010 to 2017, consecutive AMICS patients admitted to either of two tertiary heart centres, covering 3.9 million citizens, corresponding to two-thirds of the Danish population, were identified and individually reviewed through patient records. A total of 1716 AMICS patients were identified, of which 1482 underwent acute revascularization and included for analysis. Hereof, 101 (7%) patients developed cardiogenic shock due to predominantly RV failure, while 1381 (93%) had significant LV involvement. Female sex was the only demographic factor associated with RV failure (35% vs. 25%, P = 0.01). Despite having a preserved LV ejection fraction, patients with predominantly RV failure were comparable to patients with LV involvement, in terms of haemodynamic and metabolic profile, here among variables commonly used in the cardiogenic shock definition including blood pressure (82 mmHg vs. 83 mmHg, P = 0.90) and lactate level (5.7 mmol/L vs. 5.4 mmol/L, P = 0.70). Patients with RV AMICS had significantly lower 30-day mortality than LV AMICS, and this result persisted after multivariable adjustment (RV vs. LV; hazard ratio 0.61, 95% confidence interval 0.41-0.92, P = 0.01).

CONCLUSION

In contemporary AMICS patients undergoing revascularization, patients with predominantly RV failure had comparable haemodynamics and metabolic derangement on admission compared to patients with LV failure but was associated with female sex and a significantly lower 30-day mortality.

In silico identification of common and specific signatures in coronary heart diseases

Coronary heart disease (CHD) is on the increase in developing countries, where lifestyle choices such as smoking, bad diet, and no exercise contribute and increase the incidence of high blood pressure and high cholesterol levels to cause CHD. Through utilization of a biomarker-based approach for developing interventions, the aim of the study was to identify differentially expressed genes (DEGs) and their association and impact on various bio-targets. The microarray datasets of both healthy and CHD patients were analyzed to identify the DEGs and their interactions using Gene Ontology, PANTHER, Reactome, and STRING (for the possible associated genes with multiple targets). Our data mining approach suggests that the DEGs were associated with molecular functions, including protein binding (75%) and catalytic activity (56%); biological processes such as cellular process (83%), biological regulation (57%), and metabolic process (44%); and cellular components such as cell (65%) and organelle (58%); as well as other associations including apoptosis, inflammatory, cell development and metabolic pathways. The molecular functions were further analyzed, and protein binding in particular was analyzed using network analysis to determine whether there was a clear association with CHD and disease. The ingenuity pathway analysis revealed pathways related to cell cholesterol biosynthesis, the immune system including cytokinin signaling, in which, the understanding of DEGs is crucial to predict the advancement of preventive strategies. Results of the present study showed that, there is a need to validate the top DEGs to rule out their molecular mechanism in heart failure caused by CHD.

Effect of Resistance Training Intensity on Blood Pressure in Older Women

This study aimed to compare the effects of resistance training performed with low versus moderate loads on systemic resting blood pressure (BP) in older women. A total of 29 women (72.6 ± 5.1 years) were randomized into two groups: low load (LOW, n = 15) and moderate load (MOD, n = 14). An 8-week whole-body resistance training program was carried out 3 days/week (eight exercises, three sets, 10 or 15 repetition maximum). The LOW and MOD groups trained with a relative load of 15 and 10 repetition maximum, respectively. Outcome measures included resting systolic and diastolic BP. After 8 weeks, both groups presented significant changes (p < .05) in systolic BP (LOW = -3.0%; MOD = -4.6%) and mean BP (LOW = -1.9%; MOD = -3.1%). There was no change for diastolic BP in the posttest in both groups. The results suggest that low and moderate loads are equally effective for promoting decreases in resting BP in older women.

Acute coronary syndrome in Behcet's syndrome: A systematic review

Behcet syndrome is a rare vasculitis that affects both arteries and veins. Vasculo-Bechet Syndrome (VBS) is seen predominantly in men. Genetic predisposition and immune dysregulation leading to inflammation, endothelial damage, and impaired fibrinolysis contribute to its pathogenesis. Isolated case reports of Behcet syndrome (BS) with associated acute coronary syndrome (ACS) have been reported in the past. In this study, we present the first systematic review of such cases. A systematic search was conducted using Pubmed, Google Scholar, CINAHL, Cochrane CENTRAL, and Web of Science databases from 1980-2018 to identify case reports of myocardial infarction associated with BS. Cases that fulfilled the criteria for BS were selected for analysis. Demographic data, electrocardiography, echocardiography, angiography findings, and management were analyzed when available. We identified 62 case reports. Most subjects were men with a mean age of 37 years. Twenty-one percent were smokers, but other traditional cardiovascular risk factors were less common. Myocardial infarction was confirmed in half of the cases with findings on electrocardiogram (ECG). Echocardiogram revealed wall motion abnormality in 76% of patients, and angiography showed double-vessel disease in more than half of the cases. Mortality was reported in 1.6% of the cases. This systematic review shows that ACS in BS affects young males with low prevalence of coronary artery disease risk factors. Chest pain is the most common presenting feature and ST-segment elevation myocardial infarction (STEMI) was the most common ECG finding. Immunotherapy may be helpful to prevent future ACS in these patients.

Gender Differences in Residual Risk Factors for Major Adverse Cardiovascular Events Following ACS and How to Bridge the Gap

PURPOSE OF REVIEW

The review aims to describe the differences between men and women in those factors that can influence a worse prognosis in women after an acute cardiovascular event.

RECENT FINDINGS

Women adequately treated with current evidence-based medications for acute myocardial infarction and for conventional cardiovascular risk factors, such as hypertension, diabetes, smoking, and dyslipidemia, still have an extra risk of death compared with men. Additional factors that increase the risk of poor prognosis for the index event have been identified. The residual risk can be due to factors affecting the prognosis of the women from outside (they are external to the patient's body) and also to factors that, on the contrary, belong to the female body (female being/female sex). The review will give an update on those residual risk factors, including young age, vulnerability for de novo heart failure, time from symptom onset to treatment, heath care delivered during the weekend, and depression, which generally negatively influence the outcome of women with an acute myocardial infarction.

Sex and Gender Disparities in the Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Older Adults

OBJECTIVE

To evaluate outcomes by sex in older adults with cardiogenic shock complicating acute myocardial infarction (AMI-CS).

MATERIALS AND METHODS

A retrospective cohort of older (≥75 years) AMI-CS admissions during January 1, 2000, to December 31, 2014, was identified using the National Inpatient Sample. Interhospital transfers were excluded. Use of angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), and noncardiac interventions was identified. The primary outcome was in-hospital mortality stratified by sex, and secondary outcomes included temporal trends of prevalence, in-hospital mortality, use of cardiac and noncardiac interventions, hospitalization costs, and length of stay.

RESULTS

In this 15-year period, there were 134,501 AMI-CS admissions 75 years or older, of whom 51.5% (n=69,220) were women. Women were on average older, were more often Hispanic or nonwhite race, and had lower comorbidity, acute organ failure, and concomitant cardiac arrest. Compared with older men (n=65,281), older women (n=69,220) had lower use of coronary angiography (55.4% [n=35,905] vs 49.2% [n=33,918]), PCI (36.3% [n=23,501] vs 34.4% [n=23,535]), MCS (34.3% [n=22,391] vs 27.2% [n=18,689]), mechanical ventilation, and hemodialysis (all P<.001). Female sex was an independent predictor of higher in-hospital mortality (adjusted odds ratio, 1.05; 95% CI, 1.02-1.08; P<.001) and more frequent discharges to a skilled nursing facility. In subgroup analyses of ethnicity, presence of cardiac arrest, and those receiving PCI and MCS, female sex remained an independent predictor of increased mortality.

CONCLUSION

Female sex is an independent predictor of worse in-hospital outcomes in older adults with AMI-CS in the United States.

Survival and quality of life after early discharge in low-risk pulmonary embolism

Introduction

Early discharge of patients with acute low-risk pulmonary embolism requires validation by prospective trials with clinical and quality-of-life outcomes.

Methods

The multinational Home Treatment of Patients with Low-Risk Pulmonary Embolism with the Oral Factor Xa Inhibitor Rivaroxaban (HoT-PE) single-arm management trial investigated early discharge followed by ambulatory treatment with rivaroxaban. The study was stopped for efficacy after the positive results of the predefined interim analysis at 50% of the planned population. The present analysis includes the entire trial population (576 patients). In addition to 3-month recurrence (primary outcome) and 1-year overall mortality, we analysed self-reported disease-specific (Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire) and generic (five-level five-dimension EuroQoL (EQ-5D-5L) scale) quality of life as well as treatment satisfaction (Anti-Clot Treatment Scale (ACTS)) after pulmonary embolism.

Results

The primary efficacy outcome occurred in three (0.5%, one-sided upper 95% CI 1.3%) patients. The 1-year mortality was 2.4%. The mean±sd PEmb-QoL decreased from 28.9±20.6% at 3 weeks to 19.9±15.4% at 3 months, a mean change (improvement) of −9.1% (p<0.0001). Improvement was consistent across all PEmb-QoL dimensions. The EQ-5D-5L was 0.89±0.12 at 3 weeks after enrolment and improved to 0.91±0.12 at 3 months (p<0.0001). Female sex and cardiopulmonary disease were associated with poorer disease-specific and generic quality of life; older age was associated with faster worsening of generic quality of life. The ACTS burden score improved from 40.5±6.6 points at 3 weeks to 42.5±5.9 points at 3 months (p<0.0001).

Conclusions

Our results further support early discharge and ambulatory oral anticoagulation for selected patients with low-risk pulmonary embolism. Targeted strategies may be necessary to further improve quality of life in specific patient subgroups.

Sex Disparities in Myocardial Infarction: Biology or Bias?

Women have generally worse outcomes after myocardial infarction (MI) compared to men. The reasons for these disparities are multifactorial. At the beginning is the notion-widespread in the community and health care providers-that women are at low risk for MI. This can impact on primary prevention of cardiovascular disease in women, with lower use of preventative therapies and lifestyle counselling. It can also lead to delays in presentation in the event of an acute MI, both at the patient and health care provider level. This is of particular concern in the case of ST elevation MI (STEMI), where "time is muscle". Even after first medical contact, women with acute MI experience delays to diagnosis with less timely reperfusion and percutaneous coronary intervention (PCI). Compared to men, women are less likely to undergo invasive diagnostic testing or PCI. After being diagnosed with a STEMI, women receive less guideline-directed medical therapy and potent antiplatelets than men. The consequences of these discrepancies are significant-with higher mortality, major cardiovascular events and bleeding after MI in women compared to men. We review the sex disparities in pathophysiology, risk factors, presentation, diagnosis, treatment, and outcomes for acute MI, to answer the question: are they due to biology or bias, or both?

Sex differences in memory clinic patients with possible vascular cognitive impairment

INTRODUCTION

We aimed to establish sex differences in vascular brain damage of memory clinic patients with possible vascular cognitive impairment (VCI).

METHODS

A total of 860 memory clinic patients (aged 67.7 ± 8.5; 46% female) with cognitive complaints and vascular brain damage (ie, possible VCI) from the prospective TRACE-VCI (Utrecht-Amsterdam Clinical Features and Prognosis in Vascular Cognitive Impairment) cohort study with 2-year follow-up were included. Age-adjusted female-to-male differences were calculated with general linear models, for demographic variables, vascular risk factors, clinical diagnosis, cognitive performance, and brain magnetic resonance imaging markers.

RESULTS

We found no difference in age nor distribution of clinical diagnoses between females and males. Females performed worse on the MMSE (Mini-Mental State Examination) and CAMCOG (Cognitive and Self-Contained Part of the Cambridge Examination for Mental Disorders of the Elderly). Females had a larger white matter hyperintensity volume, while males more often showed (lacunar) infarcts. There was no difference in microbleed prevalence. Males had smaller normalized total brain and gray matter volumes. During follow-up, occurrence of cognitive decline and institutionalization was comparable, but mortality was higher in males.

DISCUSSION

Our results suggest that susceptibility and underlying etiology of VCI might differ by sex. Males seem to have more large vessel brain damage compared to females that have more small vessel brain damage.

Sex and gender: modifiers of health, disease, and medicine

Clinicians can encounter sex and gender disparities in diagnostic and therapeutic responses. These disparities are noted in epidemiology, pathophysiology, clinical manifestations, disease progression, and response to treatment. This Review discusses the fundamental influences of sex and gender as modifiers of the major causes of death and morbidity. We articulate how the genetic, epigenetic, and hormonal influences of biological sex influence physiology and disease, and how the social constructs of gender affect the behaviour of the community, clinicians, and patients in the health-care system and interact with pathobiology. We aim to guide clinicians and researchers to consider sex and gender in their approach to diagnosis, prevention, and treatment of diseases as a necessary and fundamental step towards precision medicine, which will benefit men's and women's health.

Sex Differences in Compositional Plaque Volume Progression in Patients With Coronary Artery Disease

OBJECTIVES

This study sought to explore sex-based differences in total and compositional plaque volume (PV) progression.

BACKGROUND

It is unclear whether sex has an impact on PV progression in patients with coronary artery disease (CAD).

METHODS

The study analyzed a prospective multinational registry of consecutive patients with suspected CAD who underwent 2 or more clinically indicated coronary computed tomography angiography (CTA) at ≥2-year intervals. Total and compositional PV at baseline and follow-up were quantitatively analyzed and normalized using the analyzed total vessel length. Multivariate linear regression models were constructed.

RESULTS

Of the 1,255 patients included (median coronary CTA interval 3.8 years), 543 were women and 712 were men. Women were older (62 ± 9 years of age vs. 59 ± 9 years of age; p < 0.001) and had higher total cholesterol levels (195 ± 41 mg/dl vs. 187 ± 39 mg/dl; p = 0.002). Prevalence of hypertension, diabetes, and family history of CAD were not different (all p > 0.05). At baseline, men possessed greater total PV (31.3 mm³ [interquartile range (IQR): 0 to 121.8 mm³] vs. 56.7 mm³ [IQR: 6.8 to 152.1 mm³] p = 0.005), and there was an approximately 9-year delay in women in developing total PV than in men. The prevalence of high-risk plaques was greater in men than women (31% vs. 20%; p < 0.001). In multivariate analysis, after adjusting for age, clinical risk factors, medication use, and total PV at baseline, despite similar total PV progression rates, female sex was associated with greater calcified PV progression (β = 2.83; p = 0.004) but slower noncalcified PV progression (β = -3.39; p = 0.008) and less development of high-risk plaques (β = -0.18; p = 0.049) than in men.

CONCLUSIONS

The compositional PV progression differed according to sex, suggesting that comprehensive plaque evaluation may contribute to further refining of risk stratification according to sex. (NCT02803411).

Gender Differences in Patients Admitted to a Certified German Chest Pain Unit: Results from the German Chest Pain Unit Registry

INTRODUCTION

Gender-specific atypical clinical presentation in acute coronary syndrome and sex-specific outcomes in cardiovascular disease in women are well known. The aim of this study is to analyze possible differences between men and women presenting to certified German chest pain units (CPUs).

METHODS

Data from 13,900 patients derived from the German CPU registry were analyzed for gender differences in patient characteristics, cardiovascular disease manifestation, critical time intervals, treatment and prognosis.

RESULTS

A total of 37.8% of patients were female. Typical chest pain occurred more frequently in men, while atypical symptoms occurred more frequently in women. Female gender was associated with longer pre- and in-hospital time delays. Women were more often diagnosed with a nonischemic origin of pain. In a 3-month follow-up, there was no gender-specific difference in combined major adverse coronary and cerebrovascular events.

DISCUSSION/CONCLUSION

This study points out gender-specific differences in prehospital time intervals and a significantly higher percentage of atypical symptoms in suspected myocardial ischemia as well as more noncoronary diagnoses in women. Symptom awareness and a broader diagnostic workup in women are essential.

Trends in Daily Use of Biotin Supplements Among US Adults, 1999-2016

This pharmacoepidemiology study uses NHANES data to characterize the prevalence and trends in use of high-dosage biotin supplementation among US adults between 1999 and 2016.

Effects of Alcohol on the Cardiovascular System in Women

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality for women. This review summarizes the relationship between alcohol consumption and common CVDs in women and highlights potential differences from men. Except for risk of hypertension, no sex-related effects of alcohol consumption on the risk for coronary heart disease and stroke have been reported, and data on the sex-related effects on risk for peripheral arterial disease are limited. For women, alcohol consumption has a J-shaped relationship with hypertension. About 1 to 2 standard drinks per day is associated with lower risk for the development of hypertension, whereas for men, the relationship is relatively linear. In the area of alcoholic cardiomyopathy, the prevalence is greater for men, but women may develop alcoholic cardiomyopathy at a lower lifetime level of alcohol consumption. Overall, data support that 1 to 2 standard drinks per day for women and men is associated with a lower risk of CVD, and higher daily amounts may increase the risk of CVD.

Prevalence of Cardiovascular Diseases Risk Factors among Jordanians

Background and aims

One of the most common causes of death worldwide is cardiovascular diseases (CVDs). This study evaluated the prevalence of CVDs risk factors (RFs) and their constellation electively among the Jordanian population and, assessing the most prevalent RF interplay with the rest of CVDs RFs as well as the impact of age and gender dimorphism on the frequencies of coexistence of multiple CVDs risk factors (RFs) among the Jordanian population.

Methods and results

In this observational multicenter study, a total of 1449 subjects were enrolled. The mean age (±SD) was 44.35 ± 14.46 years; 796 (54.9%) of them were females and 801 (55.28%) of the whole study pool had no family history of premature CVDs. Only 5.9% of the population did not have any of these RFs. The prevalence of CVDs MRFs within-affected subjects was as follows: there were 1081 (74.6%) subjects with overall dyslipidemia, 471 (32.51%) with obesity, 456 (31.47%) were smokers, and at the first diagnostic encounter 541 (37.47%) were with elevated blood pressure and, 310 (21.51%) were with elevated random blood sugar. The coexistence of ≥ two, ≥ three and, ≥ four RFs was observed in 75.7%, 44.4%, and 21.4% of the subjects, respectively. The constellation of multiple RFs was more frequent in men than that in women, where the presence of ≥ two RFs for men was at 86.18% vs. 67.09% for women. Similarly, the appearance of multiple RFs increases with age, starting from the existence of ≥ three, and four RFs respectively. Most notably the clustering of ≥ five RFs in the age group of 45–59 years showed the greatest frequency vs. any other age group.

Conclusions

CVDs risk factors (RFs) and clusters of them are extremely prevalent in the Jordanian population. Overall dyslipidemia is the most prevalent MRF and the most favors clustering with other CVDs RFs. Combined two RFs had the highest proportional frequency between all six RFs clusters. The constellation of at least two, three, and four CVDs RFs presented at almost three-fourth, half, and around one-fourth; respectively, Middle-aged males presented significantly higher rates of ≥ five RFs occurrences than females.

The role of oxidative stress on subclinical atherosclerosis in premature ovarian insufficiency and relationship with carotid intima-media thickness

Objective: We aimed to investigate the relationship between oxidative stress (OS) and subclinical atherosclerosis in patients with premature ovarian insufficiency (POI), by analyzing the dynamic thiol/disulfide homeostasis (TDH) parameters as an OS marker and carotid intima-media thickness (CIMT).Materials and methods: A total of 69 women, 34 with POI and 35 healthy controls were included in this prospective cross-sectional study. TDH parameters (plasma native thiol, total thiol, disulfide, disulfide/native thiol, native thiol/total thiol, and disulfide/total thiol ratios) and CIMT were measured and compared between the two groups.Results: In primary ovarian insufficiency group, native thiol (p=.009) and total thiol (p=.010) levels were significantly decreased, and CIMT values were significantly increased (p= <.001). CIMT values were negatively correlated with native thiol (r=-0.553, p=.001) and total thiol levels (r=-0.565, p=.001); and positively correlated with age (r = 0.457, p=.007), BMI (r = 0.408, p=.017), and total cholesterol (r = 0.605, p<.001) in POI group.Conclusions: Decreased native thiol and total thiol levels demonstrate the defective anti-oxidant mechanism in POI. Negative correlation between native thiol, total thiol levels, and CIMT means the presence of abnormal anti-oxidant mechanisms may play a role in the development of subclinical atherosclerosis in patients with POI. This is a novel report on the mechanism of subclinical atherosclerosis in women with POI, which needs to be supported with further studies evaluating the pathophysiology of OS.

Pregnancy-Associated Myocardial Infarction: Prevalence, Causes, and Interventional Management

Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.

Temporal trends and predictors of time to coronary angiography following non-ST-elevation acute coronary syndrome in the USA

OBJECTIVE

This study aims to investigate the temporal trends in utilization of invasive coronary angiography (CA) at different time points and changing profiles of patients undergoing CA following non-ST-elevation acute coronary syndrome (NSTEACS). We also describe the association between time to CA and in-hospital clinical outcomes.

PATIENTS AND METHODS

We queried the National Inpatient Sample to identify all admissions with a primary diagnosis of NSTEACS from 2004 to 2014. Patients were stratified into early (day 0, 1), intermediate (day 2) and late strategy (day≥3) according to time to CA. Multivariable logistic regression was used to investigate the association between time to CA and in-hospital mortality, major bleeding, stroke and Major Adverse Cardiac and Cerebrovascular Events.

RESULTS

A total of 4 380 827 records were identified with a diagnosis of NSTEACS, out of which 57.5% received CA. The proportion of patients undergoing early CA increased from 65.6 to 72.6%, whereas late CA commensurately declined from 19.6 to 13.5%. Patients receiving early CA were younger (age: 64 vs. 70 years), more likely to be male (63.7 vs. 55.3%) and of Caucasian ethnic background (68.7 vs. 64.7%) compared with late CA group. Similarly, Women, weekend admissions and African Americans remain less likely to receive early CA. In-hospital mortality was lowest in the intermediate group (odds ratio=0.30, 95% confidence interval: 0.28-0.33).

CONCLUSION

Use of early CA has increased in the management of NSTEACS; however, there remain significant disparities in utilization of an early invasive approach in women, African Americans, admission day and older patients in the USA.

Systematic Incorporation of Sex-Specific Information Into Clinical Practice Guidelines for the Management of ST -Segment-Elevation Myocardial Infarction: Feasibility and Outcomes

Background Clinical practice guideline ( CPG ) developers have yet to endorse a consistent and systematic approach for considering sex-specific cardiovascular information in CPG s. This article describes an initiative led by the Canadian Cardiovascular Society to determine the feasibility and outcomes of a structured process for considering sex in a CPG for the management of ST-segment-elevation myocardial infarction. Methods and Results A sex and gender champion was appointed to the guideline development committee. The feasibility of tailoring the CPG to sex was ascertained by recording (1) the male-female distribution of the study population, (2) the adequacy of sex-specific representation in each study using the participation/prevalence ratio, and (3) whether data were disaggregated by sex. The outcome was to determine whether recommendations for CPG s based on an assessment of the evidence should differ by sex. In total, 175 studies were included. The mean percentage of female participants reported in the studies was 24.5% ( SD : 6.6%; minimum: 0%; maximum: 51%). The mean participation/prevalence ratio was 0.62 ( SD : 0.16; minimum: 0.00; maximum: 1.19). Eighteen (10.2%) studies disaggregated the data by sex. Based on the participation/prevalence ratio and the sex-specific analyses presented, only 1 study provided adequate evidence to confidently inform the applicability of the CPG recommendations to male and female patients. Conclusions Implementing a systematic process for critically appraising sex-specific evidence for CPG s was straightforward and feasible. Inadequate enrollment and reporting by sex hindered comprehensive sex-specific assessment of the quality of evidence and strength of recommendations for a CPG on the management of ST-segment-elevation myocardial infarction.

Pre-Term Delivery and Risk of Ischemic Heart Disease in Women

BACKGROUND

Women who deliver pre-term have been reported to have increased future risks of cardiometabolic disorders. However, their long-term risks of ischemic heart disease (IHD) and whether such risks are due to shared familial factors are unclear. A better understanding of these risks may help improve long-term clinical follow-up and interventions to prevent IHD in women.

OBJECTIVES

The purpose of this study was to determine the long-term risks of IHD in women by pregnancy duration.

METHODS

A national cohort study was conducted of all 2,189,190 women with a singleton delivery in Sweden from 1973 to 2015, who were followed up for IHD through the end of 2015. Cox regression was used to compute adjusted hazard ratios (aHRs) for IHD associated with pregnancy duration, and cosibling analyses assessed the influence of shared familial (genetic and/or environmental) factors.

RESULTS

In 47.5 million person-years of follow-up, 49,955 (2.3%) women were diagnosed with IHD. In the 10 years following delivery, the aHR for IHD associated with pre-term delivery (<37 weeks) was 2.47 (95% confidence interval [CI]: 2.16 to 2.82), and further stratified was 4.04 (95% CI: 2.69 to 6.08) for extremely pre-term (22 to 27 weeks), 2.62 (95% CI: 2.09 to 3.29) for very pre-term (28 to 33 weeks), 2.30 (95% CI: 1.97 to 2.70) for late pre-term (34 to 36 weeks), and 1.47 (95% CI: 1.30 to 1.65) for early-term (37 to 38 weeks), compared with full-term (39 to 41 weeks). These risks declined but remained significantly elevated after additional follow-up (pre-term vs. full-term, 10 to 19 years: aHR: 1.86; 95% CI: 1.73 to 1.99; 20 to 29 years: aHR: 1.52; 95% CI: 1.45 to 1.59; 30 to 43 years: aHR: 1.38; 95% CI: 1.32 to 1.45). These findings did not appear attributable to shared genetic or environmental factors within families. Additional pre-term deliveries were associated with further increases in risk.

CONCLUSIONS

In this large national cohort, pre-term delivery was a strong independent risk factor for IHD. This association waned over time but remained substantially elevated up to 40 years later. Pre-term delivery should be recognized as a risk factor for IHD in women across the life course.

2019 John M. Eisenberg Patient Safety and Quality Awards: SPOTting Sepsis to Save Lives: A Nationwide Computer Algorithm for Early Detection of Sepsis: Innovation in Patient Safety and Quality at the National Level (Eisenberg Award)

BACKGROUND

In recognition of the potential of data to drive care and the need for early identification of patients with sepsis, HCA Healthcare developed an automated sepsis detection algorithm-SPOT (Sepsis Prediction and Optimization of Therapy). The algorithm was deployed at scale and served as a mechanism to reduce the time to detection and improve sepsis mortality in 173 hospitals across the United States.

METHODS

The SPOT algorithm was designed as a rules-based detection of defined criteria that would interpret available electronic and basic laboratory data in near real time. Working from an organizational recognition of the need to construct a national clinical data warehouse to allow for the aggregation and analysis of data streams, HCA Healthcare designed and deployed SPOT and delivered the alert from the algorithm to the bedside to initiate existing clinical workflows for patients with sepsis.

RESULTS

SPOT improved the timeliness of sepsis detection by providing alerts when signals of sepsis become available, triggering initiation of sepsis screens. This gave an advantage of about six hours over the legacy practice of sepsis screening at shift change. When deployed alongside existing sepsis improvement initiatives, SPOT was associated with an acceleration of improvement in mortality-particularly in the not-present-on-admission (NPOA) septic shock population, the patients at greatest risk for mortality. This population had seen little improvement with prior initiatives, but mortality improved 3.9 percentage points from 2018 to 2019. When accounting for seasonal variation, there was a decline in mortality rate following the deployment of SPOT, as compared to the year prior, of 9.9% for NPOA severe sepsis and 5.1% for NPOA septic shock.

CONCLUSION

Development of the SPOT algorithm for the detection of sepsis from data available in the electronic health record resulted in more timely recognition, faster initiation of treatment, and improved survival for patients.

A Cardiac Troponin T Biosensor Based on Aptamer Self-assembling on Gold

In this study, a sensitive and accurate aptasensor was designed for early detection of myocardial infarction through the determination of troponin T (TnT). The successful immobilization of a specific aptamer sequence on the surface of gold that had a high affinity toward TnT was accomplished. TnT was electrochemically quantified. The results indicated that the aptasensor detected TnT in a range of 0.05-5 ng mL, and with a detection limit of 0.01 ng/mL. The performance of the aptasensor was investigated by analyzing 99 human serum samples. Both diagnostic specificity and sensitivity of the aptasensor were found to be 95%. The use of the designed aptamer-based biosensor could be an essential achievement in health policy, preventing deaths caused by myocardial infarction, and reducing patients with heart failure. The extensive use of this aptamer-based biosensor can also reduce costs, enhance speed, and improve accuracy in the diagnosis of TnT as an important myocardial infarction biomarker.

Sex-Based Differences in Unrecognized Myocardial Infarction

Background

Myocardial infarction is an important cause of morbidity and mortality in both men and women. Atypical or the absence of symptoms, more prevalent among women, may contribute to unrecognized myocardial infarctions and missed opportunities for preventive therapies. The aim of this research is to investigate sex‐based differences of undiagnosed myocardial infarction in the general population.

Methods and Results

In the Lifelines Cohort Study, all individuals ≥18 years with a normal baseline ECG were followed from baseline visit till first follow‐up visit (≈5 years, n=97 203). Individuals with infarct‐related changes between baseline and follow‐up ECGs were identified. The age‐ and sex‐specific incidence rates were calculated and sex‐specific cardiac symptoms and predictors of unrecognized myocardial infarction were determined. Follow‐up ECG was available after a median of 3.8 (25th and 75th percentile: 3.0–4.6) years. During follow‐up, 198 women experienced myocardial infarction (incidence rate 1.92 per 1000 persons‐years) compared with 365 men (incidence rate 3.30; P<0.001 versus women). In 59 (30%) women, myocardial infarction was unrecognized compared with 60 (16%) men (P<0.001 versus women). Individuals with unrecognized myocardial infarction less often reported specific cardiac symptoms compared with individuals with recognized myocardial infarction. Predictors of unrecognized myocardial infarction were mainly hypertension, smoking, and higher blood glucose level.

Conclusions

A substantial proportion of myocardial infarctions are unrecognized, especially in women. Opportunities for secondary preventive therapies remain underutilized if myocardial infarction is unrecognized.

Sex and Age Differences in Patients With Unstable Angina Pectoris: A Single-Center Retrospective Study

BACKGROUND

Sex and age may affect the pathogenesis of coronary heart disease, such as cardiovascular risk factors, treatment and prognosis, but this information is not well known.

METHODS

This was a single-center retrospective cohort study. Patients with unstable angina pectoris between January 2013 and June 2018 were included and stratified into 4 age groups (<55, 55-64, 65-74 and ≥75 years). The cardiovascular risk factors profile, treatment and in-hospital prognosis differences by sex and age were explored.

RESULTS

This study included 5,908 patients (2,198 women). The women were older than the men (mean age 67 vs. 62 years). Approximately 2 of 3 patients had ≥3 cardiovascular risk factors. Men were more likely to be smokers, and women had a higher level of total cholesterol, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol. Hypertension, diabetes and chronic kidney disease were more frequent in women ≥ 65 years old than in similarly aged men. Men and women less than 65 years of age had more frequent family history of coronary heart disease, higher body mass index, higher fasting plasma glucose, and higher lipid levels, especially for patients <55 years of age. More women tended to receive medical therapy than men (51.6% vs. 42.8%, P < 0.01). The overall incidence of in-hospital major adverse cardiovascular events was higher in men than in women (4.1% vs. 2.6%, P < 0.05), whereas there was no sex difference in the in-hospital cardiac mortality (0.2% vs. 0.2%, P > 0.05).

CONCLUSIONS

Women had higher cholesterol levels, and were less likely to undergo revascularization therapy than similarly aged men, and elderly women had a higher prevalence of hypertension, diabetes, and chronic kidney disease than elderly men. In-hospital major adverse cardiovascular events were lower in women than in men; however, there was no sex difference in the in-hospital cardiac mortality.

Differences in in-hospital mortality after STEMI versus NSTEMI by sex. Eleven-year trend in the Spanish National Health Service

INTRODUCTION AND OBJECTIVES

Conflicting results have been reported on the possible existence of sex differences in mortality after myocardial infarction (MI). There is also a scarcity of data on the impact of sex on outcomes after ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). The aim of this study was to analyze sex difference trends in sex-related differences in mortality for STEMI and NSTEMI.

METHODS

A retrospective analysis of 445 145 episodes of MI (2005-2015) was carried out using information from the Spanish National Health System. The incidence rates were expressed as events per 10 000 person-years. The denominators (age-specific groups) were obtained from the nationwide census. We calculated crude and adjusted (multilevel logistic regression) mortality. Poisson regression analysis was used to study temporal trends for in-hospital mortality.

RESULTS

A total of 69.8% episodes occurred in men. The mean age in men was 66.1±13.3 years, which was significantly younger than in women, 74.9±12.1 (P<.001). A total of 272 407 (61.2%) episodes were STEMI, and 172 738 (38.8%) were NSTEMI. Women accounted for 28.8% of STEMI and 33.9% of NSTEMI episodes (P <.001). The effect of female sex on risk-adjusted models for in-hospital mortality was the opposite in STEMI (OR for women, 1.18; 95%CI, 1.14-1.22; P <.001) and NSTEMI (OR for women, 0.85; 95%CI, 0.81-0.89; P <.001). MI hospitalization rates were higher in men than in women for all age groups [20 vs 7.7 per 10 000 individuals aged 35-94 years (P <.001)], with a trend to diminish in both sexes.

CONCLUSIONS

Women had a slight but significantly increased risk of in-hospital mortality after MI, but the effect of sex depended on MI type, with women exhibiting higher mortality for STEMI and lower mortality for NSTEMI.

Sex Disparities in the Use and Outcomes of Temporary Mechanical Circulatory Support for Acute Myocardial Infarction-Cardiogenic Shock

Background

There are limited sex-specific data on patients receiving temporary mechanical circulatory support (MCS) for acute myocardial infarction-cardiogenic shock (AMI-CS).

Methods

All admissions with AMI-CS with MCS use were identified using the National Inpatient Sample from 2005 to 2016. Outcomes of interest included in-hospital mortality, discharge disposition, use of palliative care and do-not-resuscitate (DNR) status, and receipt of durable left ventricular assist device (LVAD) and cardiac transplantation.

Results

In AMI-CS admissions during this 12-year period, MCS was used more frequently in men-50.4% vs 39.5%; P < 0.001. Of the 173,473 who received MCS (32% women), intra-aortic balloon pumps, percutaneous LVAD, extracorporeal membrane oxygenation, and ≥ 2 MCS devices were used in 92%, 4%, 1%, and 3%, respectively. Women were on average older (69 ± 12 vs 64 ± 13 years), of black race (10% vs 6%), and had more comorbidity (mean Charlson comorbidity index 5.0 ± 2.0 vs 4.5 ± 2.1). Women had higher in-hospital mortality than men (34% vs 29%, adjusted odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.16-1.23; P < 0.001) overall, in intra-aortic balloon pumps users (OR: 1.20 [95% CI: 1.16-1.23]; P < 0.001), and percutaneous LVAD users (OR: 1.75 [95% CI: 1.49-2.06]; P < 0.001), but not in extracorporeal membrane oxygenation or ≥ 2 MCS device users (P > 0.05). Women had higher use of palliative care, DNR status, and discharges to skilled nursing facilities.

Conclusions

There are persistent sex disparities in the outcomes of AMI-CS admissions receiving MCS support. Women have higher in-hospital mortality, palliative care consultation, and use of DNR status.

Investing in the health of girls and women: a best buy for sustainable development

Human rights, theory, evidence, and common sense all suggest that greater investment in women’s health could be among the “best buys” for broader economic development and societal wellbeing, say Michelle Remme and colleagues

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-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome

BACKGROUND

Major disparities between women and men in the diagnosis, management, and outcomes of acute coronary syndrome are well recognized.

OBJECTIVES

The aim of this study was to evaluate the impact of implementing a high-sensitivity cardiac troponin I assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome.

METHODS

Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge, cluster-randomized controlled trial across 10 hospitals. Myocardial injury was defined as high-sensitivity cardiac troponin I concentration >99th centile of 16 ng/l in women and 34 ng/l in men. The primary outcome was recurrent myocardial infarction or cardiovascular death at 1 year.

RESULTS

A total of 48,282 patients (47% women) were included. Use of the high-sensitivity cardiac troponin I assay with sex-specific thresholds increased myocardial injury in women by 42% and in men by 6%. Following implementation, women with myocardial injury remained less likely than men to undergo coronary revascularization (15% vs. 34%) and to receive dual antiplatelet (26% vs. 43%), statin (16% vs. 26%), or other preventive therapies (p < 0.001 for all). The primary outcome occurred in 18% (369 of 2,072) and 17% (488 of 2,919) of women with myocardial injury before and after implementation, respectively (adjusted hazard ratio: 1.11; 95% confidence interval: 0.92 to 1.33), compared with 18% (370 of 2,044) and 15% (513 of 3,325) of men (adjusted hazard ratio: 0.85; 95% confidence interval: 0.71 to 1.01).

CONCLUSIONS

Use of sex-specific thresholds identified 5 times more additional women than men with myocardial injury. Despite this increase, women received approximately one-half the number of treatments for coronary artery disease as men, and outcomes were not improved. (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]; NCT01852123).

Exploring Representation of Diverse Samples in fMRI Studies Conducted in Patients With Cardiac-Related Chronic Illness: A Focused Systematic Review

Introduction/Purpose: Cardiovascular disease (CVD) is the leading cause of death worldwide, and in the United States alone, CVD causes nearly 840,000 deaths annually. Using functional magnetic resonance imaging (fMRI), a tool to assess brain activity, researchers have identified some brain-behavior connections and predicted several self-management behaviors. The purpose of this study was to examine the sample characteristics of individuals with CVD who participated in fMRI studies. Methods: A literature search was conducted in PubMed, CINAHL, and Scopus. No date or language restrictions were applied and research methodology filters were used. In October 2017, 1659 titles and abstracts were identified. Inclusion criteria were: (1) utilized an empirical study design, (2) used fMRI to assess brain activity, and (3) focused on patients with CVD-related chronic illness. Articles were excluded if they: were theory or opinion articles, focused on mental or neuropathic illness, included non-human samples, or were not written in English. After duplicates were removed (230), 1,429 titles and abstracts were reviewed based on inclusion criteria; 1,243 abstracts were then excluded. A total of 186 studies were reviewed in their entirety; after additional review, 142 were further excluded for not meeting the inclusion criteria. Forty-four articles met criteria and were included in the final review. An evidence table was created to capture the demographics of each study sample. Results: Ninety eight percent of the studies did not report the racial or ethnic composition of their sample. Most studies (66%) contained more men than women. Mean age ranged from 38 to 78 years; 77% reported mean age ≥50 years. The most frequently studied CVD was stroke (86%), while hypertension was studied the least (2%). Conclusion: Understanding brain-behavior relationships can help researchers and practitioners tailor interventions to meet specific patient needs. These findings suggest that additional studies are needed that focus on populations historically underrepresented in fMRI research. Researchers should thoughtfully consider diversity and purposefully sample groups by including individuals that are: women, from diverse backgrounds, younger, and diagnosed with a variety of CVD-related illnesses. Identifying and addressing these gaps by studying more representative samples will help healthcare providers reduce disparities and tailor interventions for all CVD populations.