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

Factors associated with emergency medical service delays in suspected ST-elevation myocardial infarction in Victoria, Australia: A retrospective study

OBJECTIVE

To assess the effect of patient and system characteristics on emergency medical service (EMS) delays prior to arrival at hospital in suspected ST-elevation myocardial infarction (STEMI).

METHODS

This was a retrospective observational study of 1739 patients who presented with suspected STEMI to the EMS in Melbourne, Australia between October 2011 and January 2014. Our primary outcome measure was call-to-hospital time, defined as the time in minutes from emergency call to hospital arrival. We examined the association of patient and system characteristics on call-to-hospital time using multivariable linear regression.

RESULTS

The mean call-to-hospital time was 60.1 min (standard deviation 20.5) and the median travel distance was 13.0 km (interquartile range 7.2-23.1). In the multivariable model, patient characteristics associated with longer call-to-hospital time were age ≥75 years (2.3 min; 95% confidence interval [CI] 0.6-4.0), female sex (1.9 min; 95% CI 0.3-3.4), pre-existing mental health disorder (4.0 min; 95% CI 1.9-6.1) or musculoskeletal disease (2.7 min; 95% CI 1.0-4.4), absence of chest pain (3.0 min; 95% CI 1.1-4.8), and presentation with clinical complications. System factors associated with call-to-hospital time include lower dispatch priority (12.7 min; 95% CI 9.0-16.5) and non-12-lead electrocardiography (ECG) capable ambulance first on scene (4.5 min; 95% CI 3.1-5.8). Patients who were not initially attended by a 12-lead capable ambulance were less likely to receive a 12-lead ECG within 10 min (18.5% vs 71.0%, P < 0.001).

CONCLUSION

A range of patient and system factors may influence EMS delays in STEMI. However, optimising dispatch prioritisation and widespread availability of prehospital 12-lead ECG could lead to substantial reduction in time to treatment.

Quality Improvement in the Emergency Department: A Project to Reduce Door-to-Electrocardiography Times for Patients Presenting With Chest Pain

INTRODUCTION

The American Heart Association/American College of Cardiology guidelines recommend obtaining electrocardiography for patients who present to the emergency department with chest pain in less than 10 minutes of arrival. Reducing door-to-electrocardiography time is an important step in adhering to the recommended door-to-balloon times (≤ 90 minutes) for patients who present with ST-segment elevation myocardial infarction.

METHODS

Based on lean sigma principles, a protocol was implemented in an adult emergency department that included deferring nurse triage for patients with complaints of chest pain, chest tightness, and chest pressure and providing them with a red heart symbol as an indicator for clinical technicians to prioritize their electrocardiography order. Pre- and postintervention data were collected over a 12-month period.

RESULTS

Before the intervention, the mean door-to-electrocardiography time was 17 minutes for patients with chest pain (n = 893). After the intervention, the mean door-to-electrocardiography time for patients with chest pain significantly decreased to 7 minutes (n = 1,057) (t = 10.47, P ≤ 0.001). Initially, the percentage of compliance with door-to-electrocardiography standard of 10 minutes was 31% and improved to 83% after implementation of the new protocol.

DISCUSSION

Implementation of the optimized door-to-electrocardiography protocol decreased the time for obtaining diagnostics and improved compliance with the American Heart Association/American College of Cardiology guidelines, potentially decreasing door-to-balloon times for patients who presented with ST-segment elevation myocardial infarction.

Health-related risk behaviors among myocardial infarction survivors in the United States: A propensity score matched study

BACKGROUND

According to the American College of Cardiology/the American Heart Association (ACC/AHA) recommendations, health-related risk behaviors for secondary prevention of myocardial infarction (MI) are critical to determine.

OBJECTIVE

This study aimed to compare health-related risk behaviors between MI survivors and propensity-score-matched non-MI controls using nationally representative data.

METHODS

This cross-sectional, matched case-control study used publicly available Behavioral Risk Factor Surveillance System (BRFSS) 2017 data. Older adults with MI were propensity-score-matched to their non-MI controls. The 10 dependent variables included body mass index (BMI), smoking status, heavy alcohol consumption, influenza vaccine, length of time since last routine and cholesterol checkup, alcohol consumption, fruit and vegetable consumption, and physical activity. Chi-square tests and binomial logistic regression were used to examine the health-related risk behaviors differences between MI survivors and propensity-score-matched non-MI controls.

RESULTS

The final study sample consisted of 18,021 MI survivors and 54,063 non-MI controls after propensity score matching. Multivariable logistic regression analysis showed significant differences between MI survivors and matched non-MI controls in terms of cholesterol checkup, smoking status, and alcohol consumption. For example, multivariate analysis of health-related risk behaviors showed MI survivors were more likely to be smokers (AOR = 1.46, 95% CI: 1.28-1.68).

CONCLUSION

Based on this national survey of adults, MI survivors were more likely to be smokers but less likely to consume alcohol compared to their propensity-score-matched controls. Moreover, MI survivors were more likely to have their cholesterol checkup within the past 2 years compared to matched non-MI controls. Although lower alcohol consumption and greater chances of cholesterol checkups are reassuring health-related behaviors, interventions are needed to minimize the chances of smoking in this population.

Association of gender with clinical outcomes of patients with acute ST-segment elevation myocardial infarction presenting with acute heart failure

BACKGROUND

There is limited data evaluating the sex differences in outcomes of patients with ST-segment elevation myocardial infarction presenting with acute heart failure. We compared the outcomes between women and men with ST-segment elevation myocardial infarction presenting with acute heart failure (Killip classification ≥II).

METHOD

All ST-segment elevation myocardial infarction patients presenting to the emergency department of a cardiovascular center in Jakarta, Indonesia, from 1 February 2011 to 30 August 2019 were retrospectively analyzed.

RESULTS

Of 6557 patients recorded, 929 were women, and 276 (4.2%) presented with acute heart failure. Compared with men with acute heart failure (N = 1540), women who presented with acute heart failure were older (63 ± 10 vs. 57 ± 10 years, P < 0.001), had a greater proportion of thrombolysis in myocardial infarction risk score >4 (85% vs. 73%, P < 0.001), received fewer primary angioplasty and in-hospital fibrinolytic therapy (40% vs. 48%, P = 0.004 and 1.1% versus 3.5%, P = 0.03, respectively), and had longer median door-to-device and total ischemia times (96 vs. 83 minutes, P = 0.001, and 516 versus 464 minutes, P = 0.02, respectively). Multivariate analysis showed that women and men with acute heart failure were each associated with increased risk of in-hospital mortality (odds ratio: 4.70; 95% confidence interval: 3.28-6.73 and odds ratio: 4.75; 95% confidence interval: 3.84-5.88, respectively), and this remained relatively unchanged even among patients with acute heart failure who had undergone reperfusion therapy (odds ratio: 5.35; 95% confidence interval: 3.01-9.47 and odds ratio: 5.19; 95% confidence interval: 3.80-7.08, respectively).

CONCLUSION

In our population, women with ST-segment elevation myocardial infarction presenting with acute heart failure had relatively similar risk of early mortality with their male counterpart (≈5-fold), thus should receive evidence-based treatment.

Sex differences in leukocyte profile in ST-elevation myocardial infarction patients

Background: Whether sex differences exist in the inflammatory response after ST-elevation myocardial infarction (STEMI) remains to be elucidated. We studied leukocyte profiles and their prognostic value in men and women presenting with STEMI. Methods: From a total of 552 consecutive STEMI patients, blood samples were collected at hospital admission. Linear regression was used to assess the relationship between leukocyte profiles and enzymatic infarct size. Cox regression was used to assess the association between leukocyte profiles and one-year mortality. Results: Women presented with higher lymphocyte counts (2.3·10⁹ cells/L (IQR 1.6–3.1) vs. 1.8·10⁹ cells/L (IQR 1.4–2.5), p = 3.00 ∙ 10⁻⁴) and percentages (21.1% (IQR 14.4–28.1) vs. 17.1% (IQR 12.3–24.3), p = 0.004). Lymphocyte to monocyte ratio (LMR) was also higher in women (3.25 (IQR 2.56–4.5) vs. 2.68 (IQR 2.08–3.59), p = 7.28 ∙ 10⁻⁷). Higher LMR was associated with lower peak CK-MB (β = −0.27 (95% CI: −0.50, −0.03), p = 0.026), lower peak troponin T (β = −0.45 (95% CI: −0.77, −0.13), p = 0.006) and lower one-year mortality risk (HR 0.35 (95% CI: 0.13, 0.96), p = 0.042). Conclusion: At admission for STEMI, women present with higher lymphocyte count and LMR. Higher LMR is associated with smaller infarct size and decreased one-year mortality risk and could be used as a biomarker to predict outcome.

Sex and gender differences in Alzheimer's disease: current challenges and implications for clinical practice: Position paper of the Dementia and Cognitive Disorders Panel of the European Academy of Neurology

Alzheimer's disease (AD) is characterized by high heterogeneity in disease manifestation, progression and risk factors. High phenotypic variability is currently regarded as one of the largest hurdles in early diagnosis and in the design of clinical trials; there is therefore great interest in identifying factors driving variability that can be used for patient stratification. In addition to genetic and lifestyle factors, the individual's sex and gender are emerging as crucial drivers of phenotypic variability. Evidence exists on sex and gender differences in the rate of cognitive deterioration and brain atrophy, and in the effect of risk factors as well as in the patterns of diagnostic biomarkers. Such evidence might be of high relevance and requires attention in clinical practice and clinical trials. However, sex and gender differences are currently seldom appreciated; importantly, consideration of sex and gender differences is not currently a focus in the design and analysis of clinical trials for AD. The objective of this position paper is (i) to provide an overview of known sex and gender differences that might have implications for clinical practice, (ii) to identify the most important knowledge gaps in the field (with a special regard to clinical trials) and (iii) to provide conclusions for future studies. This scientific statement is endorsed by the European Academy of Neurology.

Acute Myocardial Infarction in a Young Woman: Role of Cardiac Magnetic Resonance Imaging in Establishing the Diagnosis

Evaluation of acute coronary syndromes (ACS) in young women presents a clinical challenge. An unremarkable coronary angiogram may not exclude ACS, as spontaneous lesion revascularization, resolved coronary spams, or spontaneous coronary dissection (SCAD) can often be missed. Cardiac magnetic resonance imaging (CMR) can provide useful information in acute myocardial infarction (MI) by confirming and sizing acute infarction and delineating the etiology when angiography is inconclusive. Here, we report a case of a 39-year-old postpartum woman with a history of hyperlipidemia who presented with a one-day history of atypical angina. On presentation, she was found to have transient ST-segment elevation in high lateral leads and elevated troponin. Coronary angiography revealed a nonobstructive lesion in the first obtuse marginal branch (OM1) distribution. The patient subsequently underwent cardiac magnetic resonance imaging (MRI) for further delineation of etiology, which confirmed acute infarction in the OM1 distribution. Diagnosis of myocardial infarction with no obstructive coronary artery disease (MINOCA) secondary to acute coronary artery dissection type 2 (SCAD-2) was made. The patient was managed conservatively with medical therapy. CMR has emerged as a front-line diagnostic imaging modality in acute MI and can provide invaluable information in the confirmation and sizing of infarction, delineating tissue characteristics, establishing the etiology of infarction, and prognostication.

Not typical angina and mortality in women with obstructive coronary artery disease: Results from the Women's Ischemic Syndrome Evaluation study (WISE)

BACKGROUND

Women frequently present with symptoms not typical of angina (NTA) making ischemic heart disease recognition, diagnosis and treatment challenging. We compared mortality in women with obstructive coronary artery disease (CAD) with NTA vs typical angina (TA).

METHODS

We studied 326 Women's Ischemia Syndrome Evaluation (WISE) participants undergoing coronary angiography for suspected myocardial ischemia with core-lab measured obstructive CAD. TA was defined as sub-sternal chest pain precipitated by physical exertion or emotional stress and relieved with rest or nitroglycerin; NTA did not meet criteria for TA. The women were followed for non-fatal events and death for a median of 5.9 and 9.6 years respectively. Multivariate cox proportional hazards regression determined relations to events.

RESULTS

Overall, 115 (35%) of the women had TA. Baseline demographics, risk factors or additional symptom characteristics were similar between the two angina groups. Non-fatal events did not differ between groups. Women with NTA had a higher mortality compared to TA women (36% vs 26%, respectively, p = 0.047). Despite adjustment for additional major risk variables, NTA was an independent predictor of mortality compared to TA with a hazard ratio of 1.73 (95% Confidence interval: 1.04, 2.89).

CONCLUSIONS

Among women with suspected ischemia undergoing coronary angiography with obstructive CAD, NTA was more common than TA, and predicted a higher longer-term mortality. Further investigation is needed to confirm these results, and investigate potential explanations for the higher mortality observed in women with NTA women, including lower recognition or action in the setting of obstructive CAD.

Risk Factors and Outcomes During a First Acute Myocardial Infarction in Breast Cancer Survivors Compared with Females Without Breast Cancer

PURPOSE

The purpose of this research was to study the differences in epidemiology and outcomes of a first myocardial infarction in breast cancer survivors compared with the general female population in the United States.

METHODS

We retrospectively analyzed the US National Inpatient Sample years 2005-2015 to identify adult women with a first myocardial infarction. In this cohort, breast cancer survivors were identified. Outcomes evaluated were the differences in baseline demographics, comorbidities, and adjusted in-hospital mortality in women with and without breast cancer.

RESULTS

Among 1,644,032 first myocardial infarction cases in adult women, there were 56,842 (3.5%) breast cancer survivors. Compared with women without breast cancer, breast cancer survivors were 6 years older (mean age 77 vs 71 years, P < .001), had significantly higher prevalence of dyslipidemia and hypertension, and lower prevalence of obesity, diabetes mellitus, and smoking. Breast cancer survivors were more likely to have a non-ST segment elevation acute myocardial infarction and less likely to receive mechanical revascularization. In-hospital mortality was lower in breast cancer survivors (7.1%) compared with those without (7.9%, P < .001), findings that persisted after risk adjustment (odds ratio 0.89; 95% CI, 0.82-0.94).

CONCLUSIONS

Breast cancer survivors had a first acute myocardial infarction at an older age and had small but favorable differences in cardiovascular disease risk factors and outcomes compared with women without breast cancer. The favorable impact of health education, preventative medical care, greater motivation for a healthier lifestyle, and participation in cancer survivorship programs on these seemingly paradoxical findings in breast cancer survivors should be further explored.

Clinical Advances in Sex- and Gender-Informed Medicine to Improve the Health of All: A Review

IMPORTANCE

Biological sex and sociocultural gender represent major sources of diversity among patients, and recent research has shown the association of sex and gender with health. A growing body of literature describes widespread associations of sex and gender with cells, organs, and the manner in which individual patients interact with health care systems. Sex- and gender-informed medicine is a young paradigm of clinical practice and medical research founded on this literature that considers the association of sex and gender with each element of the disease process from risk, to presentation, to response to therapy.

OBSERVATIONS

Characteristics that underlie sex and gender involve both endogenous and exogenous factors that change throughout the life course. This review details clinical examples with broad applicability that highlight sex and gender differences in the key domains of genetics, epigenomic modifiers, hormonal milieu, immune function, neurocognitive aging process, vascular health, response to therapeutics, and interaction with health care systems. These domains interact with one another in multidimensional associations, contributing to the diversity of the sex and gender spectra. Novel research has identified differences of clinical relevance with the potential to improve care for all patients.

CONCLUSIONS AND RELEVANCE

Clinicians should consider incorporating sex and gender in their decision-making to practice precision medicine that integrates fundamental components of patient individuality. Recognizing the biological and environmental factors that affect the disease course is imperative to optimizing care for each patient. Research highlights the myriad ways sex and gender play a role in health and disease. However, these clinically relevant insights have yet to be systematically incorporated into care. The framework described in this review serves as a guide to help clinicians consider sex and gender as they practice precision medicine.

Assessing gender identity differences in cardiovascular disease in US adults: an analysis of data from the 2014-2017 BRFSS

The purpose of this study was to assess gender identity differences in CVD risk and CVD conditions among adults in the U.S. Using data from the 2014-2017 BRFSS we compared CVD risk and CVD conditions in gender minorities (transgender men, transgender women and gender nonconforming persons) to both cisgender men and women. The sample consisted of 662,903 participants. Transgender women (AOR 1.34, 95% CI 1.05-1.72) and transgender men (AOR 1.54, 95% CI 1.07-2.24) were more likely to be overweight than cisgender women. Compared to cisgender women, transgender women reported higher rates of diabetes (AOR 1.45, 95% CI 1.05-1.99), angina/coronary heart disease (AOR 1.90, 95% CI 1.34-2.68), stroke (AOR 1.88, 95% CI 1.16-3.03), and myocardial infarction (AOR 2.98, 95% CI 2.14-4.17). Gender nonconforming participants (AOR 2.68, 95% CI 1.14-6.30) reported higher odds of myocardial infarction than cisgender women. Transgender women also had higher rates of reporting any CVD than cisgender men (AOR 1.38, 95% CI 1.01-1.88). There is a need to elucidate the cardiovascular effects of minority stressors and gender affirming therapy in this population. More research focused on CVD prevention and management in gender minorities is recommended.

Sex-Related Differences of the Effect of Lipoproteins and Apolipoproteins on 10-Year Cardiovascular Disease Risk; Insights from the ATTICA Study (2002-2012)

The sex-specific effect of lipid-related biomarkers on 10-year first fatal/non fatal cardiovascular disease (CVD) incidence was evaluated. ATTICA study was conducted during 2001-2012. n = 1514 men and n = 1528 women (>18 years) from greater Athens area, Greece were recruited. Follow-up (2011-2012) was achieved in n = 2020 participants. Baseline lipid profile was measured. Overall CVD event was 15.5% (n = 317) (19.7% in men and 11.7% in women, p < 0.001). High density lipoprotein cholesterol (HDL-C) and triglycerides (TAG) were independently associated with CVD in women; per 10 mg/dL HDL-C increase, hazard ratio (HR) = 0.73, 95% confidence interval (95% CI) (0.53, 1.00); and per 10 mg/dL TAG increase, HR = 1.10, 95% CI (1.00, 1.21). Apolipoprotein A1 (ApoA1) (per 10 mg/dL increase, HR = 0.90, 95% CI (0.81, 0.99)) was inversely associated with CVD in women, while a positive association with apolipoprotein B100 (ApoB100) was observed only in men (per 10 mg/dL increase, HR = 1.10, 95% CI (1.00, 1.21)). Non-HDL-C was associated with CVD in the total sample (HR = 1.10, 95% CI (1.00, 1.21)) and in women (HR = 1.10, 95% CI (1.00, 1.21)); a steep increase in HR was observed for values >185 mg/dL in the total sample and in men, while in women, a raise in CVD risk was observed from lower values (>145 mg/dL). As for non-HDL-C/HDL-C and TC/HDL-C ratios, similar trends were observed. Beyond the common cholesterol-adjusted risk scores, reclassifying total CVD risk according to other lipid markers may contribute to early CVD prevention. Biomarkers such as HDL-C, non-HDL-C, and TAG should be more closely monitored in women.

Understanding a woman's heart: Lessons from 14 177 women with acute coronary syndrome

INTRODUCTION

Coronary artery disease is becoming the leading cause of death in women in Western society. However, the available data shows that women are still underdiagnosed and undertreated with guideline-recommended secondary prevention therapy, leading to a significantly higher rate of in-hospital complications and in-hospital mortality.

OBJECTIVE

The main objective of this work is to assess the approach to acute coronary syndrome (ACS) in Portugal, including form of presentation, in-hospital treatment and in-hospital complications, according to gender and in three different periods.

METHODS

We performed an observational study with retrospective analysis of all patients included between 2002 and 2019 in the Portuguese Registry of Acute Coronary Syndromes (ProACS), a voluntary, observational, prospective, continuous registry of the Portuguese Society of Cardiology and the National Center for Data Collection in Cardiology.

RESULTS

A total of 49 113 patients (34 936 men and 14 177 women) were included. Obesity, hypertension, diabetes (p<0.001 for all) and dyslipidemia (p=0.022) were all more prevalent in women, who were more frequently admitted for non-ST segment elevation ACS (p<0.001), and more frequently presented with atypical symptoms. Women had more time until needle and until reperfusion, which is less accessible to this gender (p<0.001). During hospitalization, women had a significantly higher risk of in-hospital mortality (OR 1.94 [1.78-2.12], p<0.001), major bleeding (OR 1.53 [1.30-1.80], p<0.001), heart failure (OR 1.87 [1.78-1.97], p<0.001), atrial fibrillation (OR 1.55 [1.36-1.77], p<0.001), mechanical complications (OR 2.12 [1.78-2.53], p<0.001), cardiogenic shock (OR 1.71 [1.57-1.87], p<0.001) and stroke (OR 2.15 [1.76-2.62], p<0.001). Women were more likely to have a normal coronary angiogram or coronary lesions with <50% luminal stenosis (p<0.001 for both), and thus a final diagnosis other than ACS. Both during hospitalization and at hospital discharge, women were less likely to receive guideline-recommended secondary prevention therapy.

CONCLUSION

In women admitted for ACS, revascularization strategies are still underused, as is guideline-recommended secondary prevention therapy, which may explain their higher incidence of in-hospital complications and higher unadjusted mortality.

Development and usability testing of HEARTPA♀N: protocol for a mixed methods strategy to develop an integrated smartphone and web-based intervention for women with cardiac pain

INTRODUCTION

More women experience cardiac pain related to coronary artery disease and cardiac procedures compared with men. The overall goal of this programme of research is to develop an integrated smartphone and web-based intervention (HEARTPA♀N) to help women recognise and self-manage cardiac pain.

METHODS AND ANALYSIS

This protocol outlines the mixed methods strategy used for the development of the HEARTPA♀N content/core feature set (phase 2A), usability testing (phase 2B) and evaluation with a pilot randomised controlled trial (RCT) (phase 3). We are using the individual and family self-management theory, mobile device functionality and pervasive information architecture of mHealth interventions, and following a sequential phased approach recommended by the Medical Research Council to develop HEARTPA♀N. The phase 3 pilot RCT will enable us to refine the prototype, inform the methodology and calculate the sample size for a larger multisite RCT (phase 4, future work). Patient partners have been actively involved in setting the HEARTPA♀N research agenda, including defining patient-reported outcome measures for the pilot RCT: pain and health-related quality of life (HRQoL). As such, the guidelines for Inclusion of Patient-Reported Outcomes in Clinical Trial Protocols (SPIRIT-PRO) are used to report the protocol for the pilot RCT (phase 3). Quantitative data (eg, demographic and clinical information) will be summarised using descriptive statistics (phases 2AB and 3) and a content analysis will be used to identify themes (phase 2AB). A process evaluation will be used to assess the feasibility of the implementation of the intervention and a preliminary efficacy evaluation will be undertaken focusing on the outcomes of pain and HRQoL (phase 3).

ETHICS AND DISSEMINATION

Ethics approval was obtained from the University of Toronto (36415; 26 November 2018). We will disseminate knowledge of HEARTPA♀N through publication, conference presentation and national public forums (Café Scientifique), and through fact sheets, tweets and webinars.

TRIAL REGISTRATION NUMBER

NCT03800082.

A Systematic Review on the Use of Wearable Body Sensors for Health Monitoring: A Qualitative Synthesis

The use of wearable body sensors for health monitoring is a quickly growing field with the potential of offering a reliable means for clinical and remote health management. This includes both real-time monitoring and health trend monitoring with the aim to detect/predict health deterioration and also to act as a prevention tool. The aim of this systematic review was to provide a qualitative synthesis of studies using wearable body sensors for health monitoring. The synthesis and analysis have pointed out a number of shortcomings in prior research. Major shortcomings are demonstrated by the majority of the studies adopting an observational research design, too small sample sizes, poorly presented, and/or non-representative participant demographics (i.e., age, gender, patient/healthy). These aspects need to be considered in future research work.

Sex-based pharmacotherapy in acute care setting, a narrative review for emergency providers

INTRODUCTION

Sex-based medicine, which can be defined as the process of understanding the inherent differences in disease pathophysiology and response to medications that exist between the sexes, seems like a necessary step in the movement towards personalized medicine. While there are strict guidelines for weight-based dosage of pediatric medications, similar guidelines do not exist for the treatment of adults, despite prominent biologic differences between the sexes. The lack of individualization is of particular importance in the treatment of adult patients in the emergency department (ED), because it can determine the trajectory of a patient's stay at the hospital.

OBJECTIVES

This review was conducted to better understand the need for and possible benefits of altering drug dosing guidelines for different categories of medications in the ED. PubMed, SCOPUS, and Google Scholar were queried using a combination of the keywords "gender differences," "sex differences," "treatment," and "emergency". Abstracts, unpublished data, and duplicate articles were excluded.

DISCUSSION

In considering some of the most common causes of ED visits, the majority of diseases demonstrate differences in morbidity and mortality between female and male patients, despite similar treatment regimens. These differences can be attributed to variations in drug pharmacodynamics and pharmacokinetics, which may be affected by sex-based biologic variations in body mass index and body composition, and physiologic variations such as hormonal changes, menstruation, pregnancy, and lactation. Regardless of the mechanism of these differences, there is overwhelming evidence that universal drug dosing results in suboptimal outcomes for both male and female patients.

CONCLUSIONS

Female sex is a risk factor for clinically significant adverse drug reactions, which range from cutaneous reactions to major bleeding, and can have long-standing implications on patient outcomes. However, future studies are needed to understand the exact pathophysiology of these sex differences, after controlling for potential confounding factors such as demographic differences and provider bias in treatment.

Sex-Specific Treatment Effects After Primary Percutaneous Intervention: A Study on Coronary Blood Flow and Delay to Hospital Presentation

Background We hypothesized that female sex is a treatment effect modifier of blood flow and related 30-day mortality after primary percutaneous coronary intervention ( PCI ) for ST -segment-elevation myocardial infarction and that the magnitude of the effect on outcomes differs depending on delay to hospital presentation. Methods and Results We identified 2596 patients enrolled in the ISACS - TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry from 2010 to 2016. Primary outcome was the occurrence of 30-day mortality. Key secondary outcome was the rate of suboptimal post- PCI Thrombolysis in Myocardial Infarction ( TIMI ; flow grade 0-2). Multivariate logistic regression and inverse probability of treatment weighted models were adjusted for baseline clinical covariates. We characterized patient outcomes associated with a delay from symptom onset to hospital presentation of ≤120 minutes. In multivariable regression models, female sex was associated with postprocedural TIMI flow grade 0 to 2 (odds ratio [ OR ], 1.68; 95% CI , 1.15-2.44) and higher mortality ( OR, 1.72; 95% CI , 1.02-2.90). Using inverse probability of treatment weighting, 30-day mortality was higher in women compared with men (4.8% versus 2.5%; OR , 2.00; 95% CI , 1.27-3.15). Likewise, we found a significant sex difference in post- PCI TIMI flow grade 0 to 2 (8.8% versus 5.0%; OR , 1.83; 95% CI , 1.31-2.56). The sex gap in mortality was no longer significant for patients having hospital presentation of ≤120 minutes ( OR , 1.28; 95% CI , 0.35-4.69). Sex difference in post- PCI TIMI flow grade was consistent regardless of time to hospital presentation. Conclusions Delay to hospital presentation and suboptimal post- PCI TIMI flow grade are variables independently associated with excess mortality in women, suggesting complementary mechanisms of reduced survival. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01218776.

Sex-Specific Determinants of Coronary Artery Disease and Atherosclerotic Risk Factors: Estrogen and Beyond

The way we view coronary artery disease in women has changed dramatically over the past decades. From an initial perspective that coronary artery disease was a male disorder and that women were protected by estrogens, there has been the gradual appreciation that this is an equal opportunity disease. Postmenopausal women are more likely than men to be hypertensive, dyslipidemic, and have multiple risk factors. Beyond the appreciation of estrogen's global effects on cardiovascular and metabolic function, our further advances in the understanding of sex-specific risks and management will be based on a greater understanding of the diversity of estrogen-mediated receptor pathways, including appreciation of the sometimes divergent effects of estrogen when acting either via the classic estrogen receptor or the more recently appreciated G protein-coupled estrogen receptor. In addition, the importance of sex-specific regulation of cardiometabolic processes beyond the sex hormones, specifically via SRY regulation, is only beginning to be understood. Finally, the author summarizes his recent studies demonstrating sex-specific G protein-coupled estrogen receptor regulation of blood pressure and cholesterol metabolism that may serve as a paradigm for the elucidation of sex-specific determinants of cardiovascular risk and the basis for sex-specific management of those risks.

Psychosocial Correlates of Body Image and Lipodystrophy in Women Aging With HIV

Body image disturbance is increasingly relevant as women living with HIV (WLWH) live longer. We explored body image disturbance and changes in fat distribution (lipodystrophy) in 63 WLWH (mean age = 51 years) and evaluated associations among lipodystrophy, body image, and psychosocial variables. Eighty-one percent of participants reported one or more body parts (of six assessed) demonstrating lipodystrophy, and more than one third reported three or more affected body parts. Increased belt/waist (58%) and increased chest/breast (39%) sizes were most common. More diffuse lipodystrophy was significantly associated with poorer body image (F[2,54] = 11.86, p < .001, partial η = .313) and anxiety (F[2,52] = 3.82, p = .029, partial η = .133) after controlling for age and duration of infection. Lipodystrophy was prevalent in our sample; more diffuse lipodystrophy was associated with anxiety and poor body image. Providers should assess lipodystrophy in older WLWH and provide referrals for mental health services.

Sex Differences in Blood Pressure Trajectories Over the Life Course

Importance

If we assume that women and men exhibit variations of the same fundamental vascular physiology, then conventional analyses of subclinical measures would suggest that women catch up to men by midlife in the extent of potentially important vascular disease. Alternatively, under the assumption that vascular physiology may fundamentally differ between women and men, a sex-specific analysis of existing data could offer new insights and augment our understanding of sex differences in cardiovascular diseases.

Objective

To evaluate whether longitudinal patterns of blood pressure (BP) elevation differ between women and men during the life course when considering baseline BP levels as the reference.

Design, Setting, and Participants

We conducted sex-specific analyses of longitudinal BP measures (144 599 observations) collected for a period of 43 years (1971 to 2014) in 4 community-based US cohort studies. The combined total included 32 833 participants (54% female) spanning ages 5 to 98 years. Data were analyzed between May 4, 2019, and August 5, 2019.

Exposures

Age and serially assessed longitudinal BP measures: systolic BP, diastolic BP, mean arterial pressure (MAP), and pulse pressure (PP).

Main Outcomes and Measures

Sex-specific change in each primary BP measure compared with baseline BP levels, derived from multilevel longitudinal models fitted over the age span, and new-onset cardiovascular disease events.

Results

Of the 32 833 participants, 17 733 were women (54%). Women compared with men exhibited a steeper increase in BP that began as early as in the third decade and continued through the life course (likelihood ratio test χ2 = 531 for systolic BP; χ2 = 123 for diastolic BP; χ2 = 325 for MAP; and χ2 = 572 for PP; P for all <.001). After adjustment for multiple cardiovascular disease risk factors, these between-sex differences in all BP trajectories persisted (likelihood ratio test χ2 = 314 for systolic BP; χ2 = 31 for diastolic BP; χ2 = 129 for MAP; and χ2 = 485 for PP; P for all <.001).

Conclusions and Relevance

In contrast with the notion that important vascular disease processes in women lag behind men by 10 to 20 years, sex-specific analyses indicate that BP measures actually progress more rapidly in women than in men, beginning early in life. This early-onset sexual dimorphism may set the stage for later-life cardiovascular diseases that tend to present differently, not simply later, in women compared with men.

Translation and validation of the cardiac rehabilitation barriers scale in the Czech Republic (CRBS-CZE): Protocol to determine the key barriers in East-Central Europe

BACKGROUND

Cardiovascular diseases are highly prevalent and represent leading causes of morbidity worldwide, including in Central Europe. Cardiac rehabilitation (CR) is an effective method of secondary prevention, but utilization is low. Barriers to CR use in the Czech Republic are not well-characterized, and therefore we propose a protocol to translate and validate the cardiac rehabilitation barriers scale (CRBS).

METHODS

In this multi-method study, we translated and cross-culturally validated the CRBS to Czech (CRBS-CZE) first through the following main steps: professional translation, reconciliation/harmonization, and cross-cultural adaptation, and piloting in 50 cardiac patients. A prospective study will be undertaken to psychometrically-validate the CRBS-CZE, where 300 to 600 cardiac inpatients eligible for phase II/outpatient CR will be recruited. Consenting participants will be informed about the CR program and their sociodemographic, clinical characteristics, and the CRBS-CZE administered. Factor analysis will be performed with oblique rotation, factors will be extracted based on eigenvalues, the examination of the scree plot, and factor loadings. The internal reliability of the total scale and subscales will be assessed with Cronbach alpha. Overall CRBS scores will be compared by patient characteristics such as sex, socioeconomic indicators, risk factor burden, and travel time to investigate content validity. Their CR enrollment, adherence (% of 24 prescribed sessions attended), and completion will be tracked. The second administration of CRBS-CZE will be undertaken in patients at 3 weeks after enrollment. To test criterion validity, t tests and Pearson correlation (for adherence) will be used to determine the association of these utilization indicators with CRBS scores.

RESULTS

The translated version was considered by 2 bilingual CR experts. Some revisions and example additions were made to the items. Upon piloting with patients, some further edits were made. No additional barriers were raised.

DISCUSSION

Through this study, a reliable and valid means of assessing patient's CR barriers will be established. Results will be used to identify ways to help patients overcome barriers to CR utilization.

Sex Differences in Symptom Phenotypes Among Patients With Acute Myocardial Infarction

BACKGROUND

The diagnosis of acute myocardial infarction (AMI) is missed more frequently in young women than men, which may be related to the cognitive psychology of the diagnostic process. Physicians start the diagnostic process by intuitively recognizing familiar symptom phenotypes, but little is known about how symptoms combine in individuals as unique symptom phenotypes. We examined how symptoms of AMI combine as unique symptom phenotypes in individual patients to compare the distribution of symptom phenotypes in women versus men.

METHODS AND RESULTS

The VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) was a multicenter, observational cohort study of 3501 young adults hospitalized with AMI. Data were collected on presenting symptoms with standardized interviews and from medical record abstraction. The number and distribution of unique symptom phenotypes were compared between women and men. Because of the 2:1 female-to-male enrollment ratio, women and men were compared with permutation testing and repeated subsampling. There were 426 interview-symptom phenotypes in women and 280 in men. The observed difference between women and men of 146 phenotypes was significant, even allowing for the greater enrollment of women (permutation P=0.004, median difference 110 under the null hypothesis of no association between sex and phenotype). The repeated subsample analysis also showed significantly more interview-symptom phenotypes in women than men (206.8±7.3 versus 188.6±6.0, P<0.001). Women were more broadly distributed among symptom phenotype subgroups than men (P<0.001). Similar findings were observed in the analysis of symptoms abstracted from the medical record.

CONCLUSIONS

Women exhibited substantially more variation in unique symptom phenotypes than men, regardless of whether the symptoms were derived from structured interviews or abstracted from the medical record. These findings may provide an explanation for the higher missed diagnosis rate in young women with AMI and may have important implications for teaching and improving clinicians' ability to recognize the diagnosis of AMI in women.

Myocardial infarction with non-obstructive coronary arteries as compared with myocardial infarction and obstructive coronary disease: outcomes in a Medicare population

AIMS

The prognosis of patients with MINOCA (myocardial infarction with non-obstructive coronary arteries) is poorly understood. We examined major adverse cardiac events (MACE) defined as all-cause mortality, re-hospitalization for acute myocardial infarction (AMI), heart failure (HF), or stroke 12-months post-AMI in patients with MINOCA versus AMI patients with obstructive coronary artery disease (MICAD).

METHODS AND RESULTS

Multicentre, observational cohort study of patients with AMI (≥65 years) from the National Cardiovascular Data Registry CathPCI Registry (July 2009-December 2013) who underwent coronary angiography with linkage to the Centers for Medicare and Medicaid (CMS) claims data. Patients were classified as MICAD or MINOCA by the presence or absence of an epicardial vessel with ≥50% stenosis. The primary endpoint was MACE at 12 months, and secondary endpoints included the components of MACE over 12 months. Among 286 780 AMI admissions (276 522 unique patients), 16 849 (5.9%) had MINOCA. The 12-month rates of MACE (18.7% vs. 27.6%), mortality (12.3% vs. 16.7%), and re-hospitalization for AMI (1.3% vs. 6.1%) and HF (5.9% vs. 9.3%) were significantly lower for MINOCA vs. MICAD patients (P < 0.001), but was similar between MINOCA and MICAD patients for re-hospitalization for stroke (1.6% vs. 1.4%, P = 0.128). Following risk-adjustment, MINOCA patients had a 43% lower risk of MACE over 12 months (hazard ratio = 0.57, 95% confidence interval 0.55-0.59), in comparison to MICAD patients. This pattern was similar for adjusted risks of the MACE components.

CONCLUSION

This study confirms an unfavourable prognosis in elderly patients with MINOCA undergoing coronary angiography, with one in five patients with MINOCA suffering a major adverse event over 12 months.

Sex Differences in Coronary Artery Calcium and Long-term CV Mortality

PURPOSE OF REVIEW

To summarize differences in plaque depositions, coronary artery calcium (CAC) scoring, and the role of CAC in predicting atherosclerotic cardiovascular disease (ASCVD) mortality in men and women.

RECENT FINDINGS

Women have coronary plaque that is more lipid-rich, dense, and less calcified than their male counterparts. CAC scoring has emerged as a useful tool to quantify ASCVD burden. However, recent evidence favors the use of sex-adjusted CAC cutoffs for women to account for the relatively lower overall CAC burden and therefore risk stratify women appropriately. Several studies have identified CAC distribution patterns in women associated with increased CV mortality, particularly the number of lesions involved, CAC volume, and size. Multiple studies have shown that the pathophysiology and associated risks of ASCVD are different in women when compared with men. CAC scoring is a tool that is widely being used for ASCVD risk stratification. Recent studies have shown that although men have higher CAC burdens, women are more likely to develop plaque erosions with non-calcified plaque that carries a greater risk for cardiovascular events. Providers should be aware of sex-specific CAC patterns carrying increased mortality risk for women, particularly increasing lesion size and number. Given the differences in plaque composition and distribution, revised sex-adjusted CAC scoring is suggested to better risk stratify patients, especially those deemed intermediate risk, and decrease CV mortality.

Advancing Healthcare Reform: The American Heart Association's 2020 Statement of Principles for Adequate, Accessible, and Affordable Health Care: A Presidential Advisory From the American Heart Association

The mission of the American Heart Association is to be a relentless force for a world of longer, healthier lives. The American Heart Association has consistently prioritized the needs and perspective of the patient in taking positions on healthcare reform while recognizing the importance of biomedical research, providers, and healthcare delivery systems in advancing the care of patients and the prevention of disease. The American Heart Association's vision for healthcare reform describes the foundational changes needed for the health system to serve the best interests of patients and to achieve health care and coverage that are adequate, accessible, and affordable for everyone living in the United States. The American Heart Association is committed to advancing the dialogue around healthcare reform and has prepared this updated statement of our principles, placed in the context of the advances in coverage and care that have occurred after the passage of the Affordable Care Act, the rapidly changing landscape of healthcare delivery systems, and our evolving recognition that efforts to prevent cardiovascular disease can have synergistic benefit in preventing other diseases and improving overall well-being. These updated principles focus on expanding access to affordable health care and coverage; enhancing the availability of evidence-based preventive services; eliminating disparities that limit the availability and equitable delivery of health care; strengthening the public health infrastructure to respond to social determinants of health; prioritizing and accelerating investments in biomedical research; and growing a diverse, culturally competent health and healthcare workforce prepared to meet the challenges of delivering high-value health care.

Ageing, sex, and cardioprotection

Translation of cardioprotective interventions aimed at reducing myocardial injury during ischaemia-reperfusion from experimental studies to clinical practice is an important yet unmet need in cardiovascular medicine. One particular challenge facing translation is the existence of demographic and clinical factors that influence the pathophysiology of ischaemia-reperfusion injury of the heart and the effects of treatments aimed at preventing it. Among these factors, age and sex are prominent and have a recognised role in the susceptibility and outcome of ischaemic heart disease. Remarkably, some of the most powerful cardioprotective strategies proven to be effective in young animals become ineffective during ageing. This article reviews the mechanisms and implications of the modulatory effects of ageing and sex on myocardial ischaemia-reperfusion injury and their potential effects on cardioprotective interventions. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.23/issuetoc.

Blood Pressure Variability in Pregnancy: an Opportunity to Develop Improved Prognostic and Risk Assessment Tools

PURPOSE OF REVIEW

This review discusses the mortality and morbidity of hypertensive disorders of pregnancy (HDP) and the current diagnostic thresholds. It then explores measurement of variability in blood pressure (BP) during pregnancy as an opportunity to identify women at high risk of cardiovascular disease (CVD) later in life.

RECENT FINDINGS

HDP is known to be associated with increased risk of long-term CVD. Current CVD prognostic tools do not incorporate a history of HDP given a lack of improved risk discrimination. However, HDP diagnostic criteria are currently based on a binary threshold, and there is some evidence for the use of variability in BP throughout gestation as a marker of CVD risk. HDP increases long-term risk of CVD. Future studies investigating changes in diagnostic criteria, including the use of BP variability, may improve long-term CVD risk prediction and be incorporated into future risk assessment tools.

Coronary artery disease and acute coronary syndrome in women

There are important dissimilarities in clinical presentation, aggregation of comorbidities, cardiovascular risk factors and the quality of delivery of medical care among men and women with acute coronary syndrome (ACS). Compared with men, despite the well-known older age and more pronounced frailty, women with ACS present later from symptom onset and are at high bleeding risk after invasive procedures. In addition, autoimmune/inflammatory disease, fibromuscular dysplasia, polycystic ovary, early menopause and history of pre-eclampsia are risk factors preceding ACS among younger women. They more often experience myocardial infarction in the absence of obstructive coronary arteries (MINOCA), which makes diagnosis and treatment of ACS among women more challenging compared with men. Women and men do both benefit from guideline-recommended treatment, although, compared with men, women with ACS have a higher adjusted risk of early death, which equalises between both sexes within the first year. Young women with ACS suffer frequently of depression and present often with MINOCA. Compared with young men, they (young women) have a higher risk of death. Therefore, focusing on young patients with ACS, understanding the particular physiopathology of MINOCA and developing programmes targeting comorbidities and depression-related behavioural risk factors are urgently needed.

Words Matter: Sex and Gender as Unique Variables in Research

Sex and gender are not equivalent concepts, even though these 2 variables are often used interchangeably by researchers. The precise use of variables is critical to ensure that research and theoretical work is of the highest quality. This article defines sex and gender and the importance of recognizing both of these variables as being unique and then demonstrates the benefit of measuring both of these variables using the cardiovascular disease literature as an exemplar. Additionally, recommendations for scholars regarding the use of sex and gender in the research and theoretical literature are provided.

Cardiovascular Risk Reduction in Rural Women: A Literature Synthesis

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in most countries. Lack of awareness of the impact CVD has on women is a continuing problem. Rural women are at a great risk for CVD and have specific barriers to early recognition and to access to treatment.

OBJECTIVE

The purpose of this systematic review was to identify how the state of the science for rural women and CVD has progressed over the last decade.

METHODS

Searches were conducted using the databases Cochrane, PubMed, and CINAHL with 5 major subject headings. The search resulted in the identification of 571 articles. Specific exclusion criteria resulted in an in-depth review of 15 articles. Two of the authors reviewed each article for scientific merit and interrater reliability.

RESULTS

Most studies were conducted in the United States (67%). Four studies focused on CVD knowledge; one, on physical activity; one, on diet plus other factors; one, on the effect of dried curry leaf powder and cucumber slices on hyperlipidemia; and one each, on waist circumference, exposure to smoke from wood stoves, and social support. Five of the 15 studies focused on more than 1 component, most on diet and physical activity.

CONCLUSIONS

Depth in a body of knowledge on any 1 topic, such as the most efficacious means to decrease CVD risk factors in rural women and increase health promotion activities in the population, is lacking. Another area of concern is the lack of research articles published in cardiovascular journals that include CVD in rural women.

Klinefelter syndrome and testosterone treatment: a national cohort study on thrombosis risk

OBJECTIVES

Klinefelter syndrome (KS), 47,XXY, can be viewed as a disease model for investigating the risk of thrombosis in male hypogonadism and the subsequent risk related to testosterone treatment. We describe rates of thrombotic risk factors, thrombosis and thrombosis mortality in KS and the association with testosterone treatment.

METHODS

National registry-based matched cohort study with follow-up from 1995 to 2016 set in Denmark. For the study, 1155 men with KS were each matched by year and month of birth to 100 men from the background population. First thrombotic events and thrombosis mortality was evaluated by event rates and hazard ratios (HRs) and by applying testosterone treatment as a time-dependent covariate.

RESULTS

The KS cohort had higher incidence of venous thromboembolism relative to the comparison cohort (HR, 3.95; 95% CI, 2.83-5.52). Total thrombotic deaths were increased in KS (HR, 1.76; 95% CI, 1.18-2.62), and all-cause mortality was increased in KS following arterial thrombosis (HR 1.73; 95% CI 1.22-2.47). Only 48.7% of men with KS redeemed prescriptions for testosterone. Untreated men with KS were on average born 12 years before those treated, and the majority of untreated men with KS with available biochemistry were hypogonadal. Testosterone treatment in KS was associated with a non-significant decrease in venous thromboembolism and thrombotic deaths.

CONCLUSION

Thrombosis and thrombotic deaths are increased in KS. Only half of the men with KS ever received testosterone treatment, despite overt hypogonadism in the non-treated. Testosterone treatment in Klinefelter syndrome was insignificantly associated with lower incidence rates of venous thrombosis and thrombotic deaths.

Coronary Embolism and Myocardial Infarction: A Scoping Study

Coronary embolism is a cause of acute myocardial infarction (AMI)in which obstructive foci enter the coronary circulation, block normal blood flow and precipitate ischemia. Precise studies focusing on patient population affected, pathophysiological mechanisms, and treatment strategies are scanty, in spite of a reported prevalence estimated at 2.9%. As the understanding of myocardial infarction without evidence of coronary artery disease continues to grow, an in-depth review of this previously seldomly reported subtype of coronary ischemia was in order. Patients suffering coronary embolism are 15 to 20 years younger than traditional AMI patients with a slight predominance towards male sex, which resembles the gender data of the populations affected by non-traditional myocardial infarction in published reports. While the expected prevalence rate of cardiovascular disease risk factors such as hypertension and hyperlipidemia are present, this population also has a relatively high prevalence of atrial fibrillation and valve pathology, especially endocarditis. Initial presentation is indistinguishable from other causes of myocardial infarction however fever is commonly present, when endocarditis with valvular involvement is the primary cause of the coronary embolism. Mechanical thrombectomy is the mainstay of treatment, followed by percutaneous coronary intervention. Mortality is the highest in patients who do not receive targeted treatment for the coronary embolism, particularly if only antimicrobial agents or anticoagulation without thrombolytic agents are employed. The unique features of coronary embolism highlighted in this historical study justify further examination in contemporary patient populations.

Differential features in composition of coronary thrombus of women with ST-segment elevation myocardial infarction

OBJECTIVES

To characterize sex differences in the composition of coronary thrombus in patients with ST-segment elevation myocardial infarction (STEMI), especially in the young (age ≤ 55 years).

BACKGROUND

Women have smaller coronary vessels than men and their vascular lesions can be influenced by different exposure to circulating estrogens throughout life. These factors could determine a different composition of the coronary thrombus in women with STEMI.

METHODS

A prospective, multicenter study was conducted on patients with STEMI and coronary thrombus was aspirated immediately before percutaneous coronary intervention (PCI) using a suction catheter (ProntoV3® or Export®). Histopathology, immunohistochemistry and ELISA techniques were used for the quantitative determination of fibrin, p-selectin and von Willebrand factor (vWF) within thrombi.

RESULTS

Thrombi were collected from 100 patients (50 men and 50 women; 13 women and 13 men of <55 years). Women presented similar baseline characteristics and pain-to-balloon elapsed time than men. Thrombi from women showed a trend to a lower concentration of fibrin than those from men [median = 1.2 ng/mg (IQR 3.5) vs median = 2.2 ng/mg (IQR 5.9), p = 0.102]. No differences were found between sexes in p-selectin and vWF concentration in thrombi. However, thrombi from young women showed lower levels of p-selectin [median = 2.2 ng/mg (IQR 4.5) vs 6.5 ng/mg (IQR 4.8), p = 0.004], fibrin [median = 1.1 ng/mg; (IQR: 3.4) vs 4.1 ng/mg (IQR 15.6), p = 0.014] and vWF [median = 3.2 ng/mg (IQR 10.6) vs 25.8 ng/mg (IQR 15.0), p = 0.003] than those from young men.

CONCLUSIONS

Thrombi from young women with STEMI showed a lower content of fibrin, p-selectin and vWF than those from men.

"Bridging the Gap" Everything that Could Have Been Avoided If We Had Applied Gender Medicine, Pharmacogenetics and Personalized Medicine in the Gender-Omics and Sex-Omics Era

Gender medicine is the first step of personalized medicine and patient-centred care, an essential development to achieve the standard goal of a holistic approach to patients and diseases. By addressing the interrelation and integration of biological markers (i.e., sex) with indicators of psychological/cultural behaviour (i.e., gender), gender medicine represents the crucial assumption for achieving the personalized health-care required in the third millennium. However, ‘sex’ and ‘gender’ are often misused as synonyms, leading to frequent misunderstandings in those who are not deeply involved in the field. Overall, we have to face the evidence that biological, genetic, epigenetic, psycho-social, cultural, and environmental factors mutually interact in defining sex/gender differences, and at the same time in establishing potential unwanted sex/gender disparities. Prioritizing the role of sex/gender in physiological and pathological processes is crucial in terms of efficient prevention, clinical signs’ identification, prognosis definition, and therapy optimization. In this regard, the omics-approach has become a powerful tool to identify sex/gender-specific disease markers, with potential benefits also in terms of socio-psychological wellbeing for each individual, and cost-effectiveness for National Healthcare systems. “Being a male or being a female” is indeed important from a health point of view and it is no longer possible to avoid “sex and gender lens” when approaching patients. Accordingly, personalized healthcare must be based on evidence from targeted research studies aimed at understanding how sex and gender influence health across the entire life span. The rapid development of genetic tools in the molecular medicine approaches and their impact in healthcare is an example of highly specialized applications that have moved from specialists to primary care providers (e.g., pharmacogenetic and pharmacogenomic applications in routine medical practice). Gender medicine needs to follow the same path and become an established medical approach. To face the genetic, molecular and pharmacological bases of the existing sex/gender gap by means of omics approaches will pave the way to the discovery and identification of novel drug-targets/therapeutic protocols, personalized laboratory tests and diagnostic procedures (sex/gender-omics). In this scenario, the aim of the present review is not to simply resume the state-of-the-art in the field, rather an opportunity to gain insights into gender medicine, spanning from molecular up to social and psychological stances. The description and critical discussion of some key selected multidisciplinary topics considered as paradigmatic of sex/gender differences and sex/gender inequalities will allow to draft and design strategies useful to fill the existing gap and move forward.

Temporal trends in the incidence, treatment patterns, and outcomes of coronary artery disease and peripheral artery disease in the UK, 2006–2015

Aims

Most reports estimating national incidence rates of coronary (CAD) and peripheral arterial disease (PAD) have focused on stable outpatients or acute or elective hospital admissions, but not on the overall burden of disease. In this study, we report the changing trends in the population-level incidence of CAD and PAD, respectively from 2006 to 2015, statin utilization for secondary prevention and survival outcomes using multiple nationally representative data sources from the UK (primary care encounters, hospital admissions, and procedure-level data).

Methods and results

A nationally representative study of linked primary and secondary care electronic health records of 4.6 million individuals from the UK. We calculated crude and standardized annual incidence rates separately for CAD and PAD. Statin use for secondary prevention, trends in annual major vascular event rates, and mortality between 2006 and 2015, were estimated for CAD and PAD, respectively. We identified 160 376 and 70 753 patients with incident CAD and PAD, respectively. The age- and sex-standardized incidence of CAD was similar in 2006 (443 per 100 000 person-years) and 2015 [436 per 100 000 person-years; adjusted incidence rate ratio (IRR) 0.98, 95% confidence interval (CI) 0.96–1.00]. In contrast, there was a 15% decline in the standardized incidence of PAD (236 per 100 000 person-years in 2006 to 202 per 100 000 person-years in 2015; adjusted IRR 0.85, 95% CI 0.82–0.88). The proportion of incident CAD and PAD patients prescribed long-term statins, was only 66% and 55%, respectively and was less common amongst women, patients aged &gt;70 years, with heart failure, chronic lung disease, or depression. Cardiovascular mortality declined by 43% for incident CAD (adjusted IRR 0.57, 95% CI 0.50–0.64) between 2006 and 2015 but did not decline for incident PAD (adjusted IRR 0.84, 95% CI 0.70–1.00).

Conclusion and relevance

In the UK, the standardized incidence of CAD appears stable but mortality rates are falling, whereas the standardized incidence of PAD is falling but mortality rates are not.