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

lncRNA-ZFAS1 induces mitochondria-mediated apoptosis by causing cytosolic Ca2+ overload in myocardial infarction mice model

Previously, we have identified ZFAS1 as a potential new long non-coding RNA (lncRNA) biomarker of acute myocardial infarction (MI) and as a sarcoplasmic reticulum Ca²⁺-ATPase 2a (SERCA2a) inhibitor, causing intracellular Ca²⁺ overload and contractile dysfunction in a mouse model of MI. In the current study, we aimed to evaluate the effects of ZFAS1 on the apoptosis of cardiomyocytes in the MI mouse model. Knockdown of endogenous ZFAS1 by virus-mediated silencing shRNA or siZFAS1 partially abrogated the ischemia-induced apoptosis of cardiomyocytes. Overexpression of ZFAS1 in normal cardiomyocytes reduced the cell viability, similar to that observed in hypoxia-treated cardiomyocytes. Moreover, ZFAS1 cardiac-specific knock-in mice showed impaired cardiac function, adversely altered Ca²⁺ homeostasis, repressed expression and activities of SERCA2a, and increased apoptosis. At the subcellular level, ZFAS1 induced mitochondrial swelling and showed a pronounced decrease in mitochondrial membrane potential. At the molecular level, ZFAS1 activated the mitochondria apoptosis pathway, which could be nearly abolished by a calcium chelator. The effects of ZFAS1 were readily reversible upon knockdown of this lncRNA. Notably, ZFAS1-FD (only functional domain) mimicked the effects of full-length ZFAS1 in regulation of cardiomyocyte apoptosis. In conclusion, our study shows that ZFAS1, an endogenous SERCA2a inhibitor, induces mitochondria-mediated apoptosis via cytosolic Ca²⁺ overload. Therefore, anti-ZFAS1 might be considered a new therapeutic strategy for protecting cardiomyocytes from MI-induced apoptosis.

Communicating acute coronary syndrome risk to women in primary care: A scoping review of the literature

OBJECTIVES

Delay from symptom onset to hospital arrival drives poor outcomes in acute coronary syndrome (ACS), particularly for women. Primary care clinicians can discuss ACS with high-risk women, potentially reducing delay. We conducted a scoping review to assess what is known about ACS risk communication to women in primary care.

METHODS

We used Arksey and O'Malley's framework. The PubMed, CINAHL, PsycINFO, and Embase databases were searched for relevant articles from inception through September, 2018. No restrictions on study methodology were applied. At least two reviewers assessed each article. Articles addressing risk communication, coronary heart disease, and ACS, related to primary care settings, and including women were retained.

RESULTS

Eleven articles met inclusion criteria. Cardiovascular disease (CVD) risk communication is common in primary care; however, ACS symptoms are rarely discussed. Structured risk calculators are used to frame discussions. Communication styles include patient-centered discussions, paternalistic orders, and "scare tactics;" no single style is more effective. Analysis of gender differences in risk communication is extremely limited.

CONCLUSION

There is scant evidence that primary care clinicians communicate effectively about ACS risk, symptoms, and appropriate symptom response.

PRACTICE IMPLICATIONS

Interventions are needed to improve communication about ACS to at-risk women in the primary care setting.

Sex Differences in Acute Myocardial Infarction Hospital Management and Outcomes: Update From Facilities With Comparable Standards of Quality Care

Supplemental digital content is available in the text.

Background:

Acute myocardial infarction (AMI) sex disparities in management and outcomes have long been attributed to multiple factors, although questions regarding their relevance have not been fully addressed.

Objective:

The aim of this study was to identify current factors associated with sex-related AMI management and outcomes disparities in hospitals with comparable quality care standards.

Methods:

This is a cross-sectional study of 299 women and 540 men with AMI discharged in 2013 from 3 southern California hospitals with tertiary cardiac care. Outcomes (adjusted by demographic/clinical variables using multiple logistic regression) included mortality (in-hospital, 30 days), 30-day readmissions, invasive/revascularization procedures, and quality medication performance measures (aspirin, statins/antilipids, β-blockers, angiotensin-converting enzyme inhibitors, <90-minute door-balloon time).

Results:

Performance was similar to the top 10% National Inpatient Quality AMI Measures. Women had similar mortality, 30-day readmission rates, and performance on medication quality measures compared with men; readmissions were higher in patients with County Services/Medicaid or no medical insurance regardless of sex. Women had similar cardiac catheterization and ST-segment elevation myocardial infarction percutaneous coronary intervention rates but significantly less percutaneous coronary intervention for non–ST-segment elevation myocardial infarction (39.1% vs 52.1%, P = .008) and coronary artery bypass graft (6.7% vs 14.1%, P < .001) than men.

Conclusions:

Women with AMI had similar early mortality, 30-day readmissions and quality performance measures compared with men across hospitals with current quality care standards. Type of medical insurance influenced readmission rates for both sexes. Sex disparities in coronary revascularization procedures were likely determined by differences in AMI type and coronary disease vascular expression.

Association of RS708272 (CETP Gene Variant) with Lipid Profile Parameters and the Risk of Myocardial Infarction in the White Population of Western Siberia

: The TaqI B (rs708272) single-nucleotide variant, i.e., the +279 G/A substitution in intron 1 of the CETP gene, is actively investigated as a risk factor of lipid metabolism disorders. The aim of this study was to analyze the association of rs708272 with lipid parameters and the risk of myocardial infarction in the population of Western Siberia (Russia). The study population was selected from a sample surveyed within the framework of the Health, Alcohol and Psychosocial Factors In Eastern Europe (HAPIEE) study (9360 participants, >90% white, aged 45-69 years, males: 50%). In total, 3132 randomly selected patients were included. Plasma lipid levels were determined by standard enzymatic assays. Rs708272 was analyzed by RT-PCR via TaqMan single-nucleotide polymorphism (SNP) Genotyping Assays (Thermo Fisher Scientific, USA). The frequencies of rs708272 genotypes AA (homozygote), AG (heterozygote), and GG were 0.21, 0.49, and 0.30, respectively, in this population. Allele A frequency was 0.46. We found an association of allele G with low levels of high-density lipoprotein cholesterol and a high index of atherogenicity in this population (p < 0.001 and p < 0.001, respectively). Allele G was significantly associated with the risk of myocardial infarction among the male participants (odds ratio 1.96, 95% confidence interval 1.208-3.178, p = 0.008) and in the study population (odds ratio 1.465, 95% confidence interval 1.028-2.087, p = 0.036). Thus, rs708272 is associated with myocardial infarction in the white population of Western Siberia (Russia).

Effectiveness of the short-term use of Cimicifuga racemosa in the endothelial function of postmenopausal women: a double-blind, randomized, controlled trial

Objective: This study aimed to assess the effects of daily use of Cimicifuga racemosa on endothelial function through flow-mediated dilation of the brachial artery, when used for 28 days by healthy postmenopausal women.Methods: The double-blind, randomized, placebo-controlled study included two groups of postmenopausal women (n = 31 each). The subjects were clinically assessed and flow-mediated dilation of the brachial artery was measured before and after 28 days of treatment. Patients received dry extract corresponding to 160 mg C. racemosa (extract with 4 mg of triterpene glycosides) or placebo.Results: Mean age, time since menopause, and body mass index in the two groups were similar. The measurements of flow-mediated dilation of the brachial artery, pre and post treatment, respectively, showed a significant increase in patients who used C. racemosa (p = 0.006), unlike patients who used placebo, who did not present changes in the outcome of flow-mediated dilation of the brachial artery after 28 days of use (p ≥ 0.05). When comparing the number of women in both groups who showed an increase in flow-mediated dilation, a significant difference was found in the measurements of the treated group after the use of the medication (p = 0.018).Conclusions: Daily use of 160 mg C. racemosa extract by postmenopausal women for 28 days beneficially influences endothelial function by promoting elasticity of the brachial artery.

Spontaneous Coronary Artery Dissection (SCAD): FEMALE SURVIVORS' EXPERIENCES OF STRESS AND SUPPORT

PURPOSE

Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic type of acute myocardial infarction that primarily affects young, healthy women without typical risk factors for heart disease. Few investigations have examined psychosocial variables in this population and none have looked at patient perceptions of the experience and stresses associated with having a SCAD event or the resources currently available to SCAD survivors. This investigation describes survivors' subjective experiences of SCAD. Participants also provided information about types and helpfulness of resources available to them post-SCAD, including cardiac rehabilitation.

METHODS

Participants were recruited online and completed a one-time questionnaire.

RESULTS

Participants (n = 409) completed a questionnaire concerning their experiences with their SCAD event in the 1 y and 2 wk prior to the SCAD event. Their responses reflected moderate to high perceptions of stress. Participants experienced the SCAD event as highly stressful and frightening and their heart health presents as a moderate-severe source of current, post-diagnosis stress. Spontaneous coronary artery dissection-based informational support was frequently rated as inadequate, whereas other supportive resources varied in their helpfulness and accessibility. Participants reported positive experiences in cardiac rehabilitation and strong interest in SCAD-specific, professionally led, online patient education and support groups.

CONCLUSIONS

This study is the largest to date investigation of SCAD survivors and their experiences in this understudied and perhaps underrecognized condition. Opportunities for researchers and providers to develop, tailor, and disseminate SCAD-specific interventions are discussed.

Physiologically assessed hot flashes and endothelial function among midlife women

OBJECTIVE

Hot flashes are experienced by most midlife women. Emerging data indicate that they may be associated with endothelial dysfunction. No studies have tested whether hot flashes are associated with endothelial function using physiologic measures of hot flashes. We tested whether physiologically assessed hot flashes were associated with poorer endothelial function. We also considered whether age modified associations.

METHODS

Two hundred seventy-two nonsmoking women reporting either daily hot flashes or no hot flashes, aged 40 to 60 years, and free of clinical cardiovascular disease, underwent ambulatory physiologic hot flash and diary hot flash monitoring; a blood draw; and ultrasound measurement of brachial artery flow-mediated dilation to assess endothelial function. Associations between hot flashes and flow-mediated dilation were tested in linear regression models controlling for lumen diameter, demographics, cardiovascular disease risk factors, and estradiol.

RESULTS

In multivariable models incorporating cardiovascular disease risk factors, significant interactions by age (P < 0.05) indicated that among the younger tertile of women in the sample (age 40-53 years), the presence of hot flashes (beta [standard error] = -2.07 [0.79], P = 0.01), and more frequent physiologic hot flashes (for each hot flash: beta [standard error] = -0.10 [0.05], P = 0.03, multivariable) were associated with lower flow-mediated dilation. Associations were not accounted for by estradiol. Associations were not observed among the older women (age 54-60 years) or for self-reported hot flash frequency, severity, or bother. Among the younger women, hot flashes explained more variance in flow-mediated dilation than standard cardiovascular disease risk factors or estradiol.

CONCLUSIONS

Among younger midlife women, frequent hot flashes were associated with poorer endothelial function and may provide information about women's vascular status beyond cardiovascular disease risk factors and estradiol.

The ratio of total cholesterol to high density lipoprotein cholesterol and myocardial infarction in Women's health in the Lund area (WHILA): a 17-year follow-up cohort study

Background

Identifying variables predictive of acute myocardial infarction (AMI) in women is important. The use of the ratio of total cholesterol-to-high density lipoprotein cholesterol (TC/HDL-C) is often overlooked. The aim was to study TC/HDL-C in relation to later AMI, in a large sample of women, adjusted for age, educational status, smoking, waist-hip ratio, blood pressure, and neighbourhood socioeconomic status. The hypothesis was that increasing TC/HDL-C is associated with an increased risk of later AMI.

Methods

From December 1995 to February 2000, 6147 women aged 50–59 years from the Womens’ Health in Lund area (WHILA) study in southern Sweden underwent a physical examination, laboratory tests and filled in a questionnaire. The women were followed through national registers for incidence of AMI during a mean follow up of 17 years.

Results

An increasing TC/HDL-C showed a strong relationship with AMI, with the lowest hazard ratio (HR = 1) in women with a ratio of ≤3.5. The HR for AMI was 1.14 (95% CI: 0.73–1.78) for those with a ratio between 3.5 and 4.0; in those with a ratio between 4.0 and 5.0 the HR for AMI was 1.46 (95% CI: 1.00–2.13) and in those with a ratio > 5.0 the HR was 1.89 (95% CI 1.26–2.82), after adjusting for potential confounding factors.

Conclusions

TC/HDL-C ratio is a powerful predictor of AMI in middle-aged women. The results indicate that this variable should be used in clinical practice and is important for early identification of individuals at risk of AMI.

Predicting acute coronary syndrome in males and females with chest pain who call an emergency medical communication centre

Background

Chest pain is a frequent reason for calls in emergency medical communication centre (EMCC). Detecting a coronary origin by phone is a challenge. This is especially so as the presentations differ according to gender. We aimed to establish and validate a sex-based model to predict a coronary origin of chest pain in patients calling an EMCC.

Methods

This prospective cohort study enrolled patients at 18 years of age or older who called the EMCC because of non-traumatic chest pain. The main outcome was the diagnosis of acute coronary syndrome (ACS) determined by expert evaluation of patient files.

Results

During 18 months, 3727 patients were enrolled: 2097 (56%) men and 1630 (44%) women. ACS was diagnosed in 508 (24%) men and 139 (9%) women. For men, independent factors associated with an ACS diagnosis were age, tobacco use, severe and permanent pain; retrosternal, breathing non-related and radiating pain; and additional symptoms. The area under the receiver operating characteristic curve (AUC) was 0.76 (95% confidence interval [CI] 0.73–0.79) for predicting ACS. The accuracy of the male model to predict ACS was validated in a validation dataset (Hosmer-Lemeshow test: p = 0.554); the AUC was 0.77 (95%CI 0.73–0.80). For women, independent factors associated with an ACS diagnosis were age ≥ 60 years, personal history of coronary artery disease, and breathing non-related and radiating pain. The AUC was 0.79 (95%CI 0.75–0.83). The accuracy of the female model to predict ACS was not validated in the validation dataset (Hosmer-Lemeshow test: p = 0.035); the AUC was 0.67 (95%CI 0.60–0.74).

Conclusions

Predictors of an ACS diagnosis in patients calling an EMCC for chest pain differ between men and women. We developed an accurate predictive model for men, but for women, the accuracy was poor.

Trial registration

This study is registered with ClinicalTrials.gov (NCT02042209).

Association of APOL1 With Heart Failure With Preserved Ejection Fraction in Postmenopausal African American Women

Importance

APOL1 genotypes are associated with kidney diseases in African American individuals and may influence cardiovascular disease and mortality risk, but findings have been inconsistent.

Objective

To discern whether high-risk APOL1 genotypes are associated with cardiovascular disease and stroke in postmenopausal African American women, who are at high risk for these outcomes.

Design, Setting, and Participants

The Women's Health Initiative is a prospective cohort that enrolled 161 838 postmenopausal women into clinical trials and an observational study between 1993 and 1998. This study includes 11 137 African American women participants who had a clinical event from enrollment to June 2014. Data analyses were completed from January 2017 to August 2017.

Exposures

The variants of APOL1 were genotyped or imputed from whole-exome sequencing.

Main Outcomes and Measures

Incident coronary heart disease, stroke and heart failure subtypes, and overall and cause-specific mortality were adjudicated from hospital records and death certificates. Estimated incidence rates were determined for each outcome and hazard ratios (HR) and 95% CIs for the associations of APOL1 groups with outcomes.

Results

The mean (SD) age of participants was 61.7 (7.1) years. Carriers of high-risk APOL1 variants (n = 1370; 12.3%) had higher prevalence of hypertension, use of cholesterol-lowering medications, and reduced estimated glomerular filtration rate (eGFR). After a mean (SD) of 11.0 (3.6) years, carriers of high-risk APOL1 variants had a higher incidence rate of hospitalized heart failure with preserved ejection fraction (HFpEF) than low-risk carriers did but showed no differences for other outcomes. In adjusted models, there was a significant 58% increased hazard of hospitalized HFpEF (HR, 1.58 [95% CI, 1.03-2.41]) among carriers of high-risk APOL1 variants compared with carriers of low-risk APOL1 variants. The association with HFpEF was attenuated (HR = 1.50 [95% CI, 0.98-2.30]) and no longer significant when adjusting for baseline eGFR.

Conclusions and Relevance

Status as a carrier of a high-risk APOL1 genotype was associated with HFpEF hospitalization among postmenopausal women, which is partly accounted for by baseline kidney function. These findings do not support an association of high-risk APOL1 genotypes with coronary heart disease, stroke, or mortality in postmenopausal African American women.

Lymphatic Function and Dysfunction in the Context of Sex Differences

Endothelial cells are the building blocks of the blood vascular system and exhibit well-characterized sexually dimorphic phenotypes with regard to chromosomal and hormonal sex, imparting innate genetic and physiological differences between male and female vascular systems and cardiovascular disease. However, even though females are predominantly affected by disorders of lymphatic vascular function, we lack a comprehensive understanding of the effects of sex and sex hormones on lymphatic growth, function, and dysfunction. Here, we attempt to comprehensively evaluate the current understanding of sex as a biological variable influencing lymphatic biology. We first focus on elucidating innate and fundamental differences between the sexes in lymphatic function and development. Next, we delve into lymphatic disease and explore the potential underpinnings toward bias prevalence in the female population. Lastly, we incorporate more broadly the role of the lymphatic system in sex-biased diseases such as cancer, cardiovascular disease, reproductive disorders, and autoimmune diseases to explore whether and how sex differences may influence lymphatic function in the context of these pathologies.

Heart disease prevention in women: The NP's role

More women die from heart disease than any other illness. This article focuses on risk factors and their prevalence in women along with strategies for preventing this disease. Armed with this information, the NP can play a major role in preventing cardiovascular deaths in women.

Prodromal Myocardial Infarction Fatigue: A Concept Analysis

Patients' care-seeking behaviors are often based on the symptoms they experience. Prodromal myocardial infarction symptoms are those symptoms that occur prior to a myocardial infarction, and fatigue is common. However, the concept of prodromal myocardial infarction fatigue has not been explored from a multidimensional perspective using a concept analysis approach. The purpose of this concept analysis was to analyze this concept, using Walker and Avant's (2011) concept analysis methodology. A comprehensive literature search revealed 41 records for analysis. The structure and function of this concept was examined, and an operational definition of prodromal myocardial infarction fatigue was developed.

The Gender Perspective Within the OFRECE Study: Differences in Health Care Among Patients Consulting for Chest Pain and/or Palpitations

INTRODUCTION AND OBJECTIVES

To analyze differences between sexes in the clinical management of patients presenting with symptoms of chest pain and/or palpitations within a population-based study.

METHODS

The OFRECE study included a random sample of 8400 individuals from the Spanish population aged 40 years and older; 1132 (13.5%) had previously consulted for chest pain and 1267 (15.1%) had consulted for palpitations and were included in the present study. We calculated both the crude and adjusted odds ratios (OR) of undergoing certain tests and the results of consultations by sex. Adjustment was performed by classic cardiovascular risk factors, a personal history of cardiovascular disease, and a diagnosis of stable angina or atrial fibrillation confirmed in the OFRECE study in each case.

RESULTS

No differences were observed in history of consultation for chest pain between women and men (13% vs 14.1%; P=.159) but differences were found in palpitations (19% vs 10.4%, respectively; P <.001). Women who had previously consulted for chest pain underwent fewer echocardiograms (32.5% vs 45.3%, respectively; P <.001), were less frequently referred to a cardiologist (49.1% vs 60.1%; P <.001), were less often admitted to hospital (20.1% vs 39.4%; P <.001), and less frequently received a confirmed diagnosis (60.9 vs 71, 9; P <.001). After full adjustment, all differences decreased and become nonsignificant echocardiograms: adjusted OR, 0.81; 95%CI, 0.60-1.09; referral to a cardiologist: adjusted OR, 0.86; 95%CI, 0.63-1.16; hospital admission: adjusted OR, 0.76; 95%CI, 0.54-1.09). For palpitations, crude differences were smaller and all became nonsignificant after adjustment.

CONCLUSIONS

This study does not confirm the existence of sex-related bias in the management of chest pain and palpitations. However, such bias cannot be completely ruled out in diagnoses confirmed within the OFRECE study, which might limit its ability to detect sex-related differences in health care.

Somewhere over the sex differences rainbow of myocardial infarction remodeling: hormones, chromosomes, inflammasome, oh my

Introduction: Cardiovascular disease is a major cause of death in both men and women. While women are protected until the onset of menopause, after menopause women have increased risk of adverse cardiovascular disease events. Animal models of myocardial infarction recapitulate many of the sex differences observed in humans, and proteomics evaluations offer mechanistic insights to explain sex differences.Areas covered: In this review, we will discuss how proteomics has helped us understand the hormonal, chromosomal, and immune mechanisms behind sex differences in response to ischemic injury and the development of heart failure.Expert opinion: There are a number of ways in which proteomics has and will continue to facilitate our understanding of sex differences in cardiac remodeling after myocardial infarction.

Presenting Symptoms in Men and Women Diagnosed With Myocardial Infarction Using Sex-Specific Criteria

Background Sex-specific criteria are recommended for the diagnosis of myocardial infarction, but the impact of these on presenting characteristics is unknown. Methods and Results We evaluated patient-reported symptoms in 1941 patients (39% women) with suspected acute coronary syndrome attending the emergency department in a substudy of a prospective trial. Standardized criteria defined typical and atypical presentations based on pain nature, location, radiation, and additional symptoms. Diagnosis of myocardial infarction was adjudicated using a high-sensitivity cardiac troponin I assay with sex-specific thresholds (>16 ng/L women, >34 ng/L men). Patients identified who were missed by the contemporary assay with a uniform threshold (≥50 ng/L) were reclassified by this approach. Type 1 myocardial infarction was diagnosed in 16% (184/1185) of men and 12% (90/756) of women, with 9 (5%) men and 27 (30%) women reclassified using high-sensitivity cardiac troponin I and sex-specific thresholds. Chest pain was the presenting symptom in 91% (1081/1185) of men and 92% (698/756) of women. Typical symptoms were more common in women than in men with myocardial infarction (77% [69/90] versus 59% [109/184]; P=0.007), and differences were similar in those reclassified (74% [20/27] versus 44% [4/9]; P=0.22). The presence of ≥3 typical features was associated with a positive likelihood ratio for the diagnosis of myocardial infarction in women (positive likelihood ratio, 1.18; 95% CI, 1.03-1.31) but not in men (positive likelihood ratio 1.09; 95% CI, 0.96-1.24). Conclusions Typical symptoms are more common and have greater predictive value in women than in men with myocardial infarction whether or not they are diagnosed using sex-specific criteria. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier NCT01852123.

Longitudinal associations between self-reported experiences of discrimination and depressive symptoms in young women and men post- myocardial infarction

Objectives

Research suggests that following a myocardial infarction (MI), women under the age of 60 have more elevated depressive symptoms and adverse outcomes than similarly aged men. Identifying risk factors that contribute to gender differences in depressive symptoms among this group may be critical to the development of psychosocial interventions. Experiences of discrimination may be an important correlate of depressive symptoms in this group; however, studies of this relationship have largely been cross-sectional and focused on healthy populations. This study examines longitudinal associations among gender, discrimination, and depressive symptoms in a young post-MI cohort.

Methods

Participants were 313 adults from the Myocardial Infarction and Mental Stress Ischemia Study 2 of young (≤60 yrs) post-MI patients. At baseline and 6 month follow-up, depressive symptoms were measured with the Beck Depression Inventory-II and discrimination was assessed with the 10-item version Everyday Discrimination scale. Linear regression models were used to assess the longitudinal association between reports of discrimination and depressive symptoms adjusted for sociodemographic characteristics, psychosocial factors and health status indicators and tested for gender differences.

Results

The mean age was 51.2, 49.6% were women, and 69.5% were African-American. Although the discrimination-by-gender interaction was marginally significant (p=.09) in the fully adjusted model, findings suggest that the association between changes in reports of discrimination and depressive symptoms over time may be more pronounced for women (β=.61, standard error=.15, p<.001) than men (β=.27, standard error=.13, p=.033).

Conclusion

Our findings suggest that discrimination is a risk factor for depressive symptoms in young post-MI populations over time.

Sex differences in crude mortality rates and predictive value of intensive care unit-based scores when applied to the cardiac intensive care unit

BACKGROUND

Limited data exists regarding sex differences in outcome and predictive accuracy of intensive care unit-based scoring systems when applied to cardiac intensive care unit patients.

METHODS

We reviewed medical records of patients admitted to cardiac intensive care unit from 1 January 2011-31 December 2016. Sex differences in mortality rates and the performance of intensive care unit-based scoring systems in predicting in-hospital mortality were analyzed. Calibration was assessed by the Hosmer-Lemeshow test and locally weighted scatterplot smoothing curves. Discrimination was assessed using the c statistic and receiver-operating characteristic curve.

RESULTS

Among 6963 patients, 2713 (39%) were women. Overall in-hospital and cardiac intensive care unit mortality rates were similar in women and men (9.1% vs 9.4%, p=0.67 and 5.9% vs 6%, p=0.88, respectively) and in age and major diagnosis subgroups. Of the scoring systems, Acute Physiology and Chronic Health Evaluation III and Sequential Organ Failure Assessment had poor calibration (Hosmer-Lemeshow p value <0.001), while Simplified Acute Physiology Score II performed better (Hosmer-Lemeshow p value 0.09), in both women and men. All scores had good discrimination (C statistics >0.8). In the subgroups of acute myocardial infarction and heart failure patients, all scores had good calibration (Hosmer-Lemeshow p>0.001) and discrimination (C statistic >0.8) while in diagnosis subgroups with highest mortality, the calibration varied among scores and by sex, and discrimination was poor.

CONCLUSIONS

No sex differences in mortality were seen in cardiac intensive care unit patients. The mortality predictive value of intensive care unit-based scores is limited in both sexes and variable among different subgroups of diagnoses.

ST-elevation myocardial infarction in a real world population - An observational retrospective study with a sex perspective

BACKGROUND

Mortality after myocardial infarction is higher in women than in men. Data on the association between sex and mortality are conflicting and inconclusive. We evaluated whether there is a sex difference in survival and if sex is associated with the outcome in patients with ST-elevation myocardial infarction (STEMI).

METHODS

We analyzed 3671 STEMI patients. Long-term and 30-day mortality in men and women were compared.

RESULTS

Unadjusted mortality at day 30 was higher in women [221 (8.7%) men died compared to 147 (13.1%) women; p < 0.0001]. After multivariate adjustments, this became insignificant (OR 1.65; 95% CI; 0.81 to 1.40). The long-term, unadjusted mortality was also higher in women [674 (26.3%) men died compared to 382 (34%) women; p < 0.0001]. After multivariable adjustments, female sex (adjusted HR 0.81; 95% CI 0.71 to 0.93; p = 0.002), bleeding (adjusted HR 1.79; 95% CI 1.52 to 2.10; p < 0.0001), renal dysfunction adjusted HR (1.60; 95% CI 1.40 to 1.84; p < 0.0001), hyperlipidemia (adjusted HR 1.61; 95% CI 1.40 to 1.85; p < 0.0001), arterial hypertension (adjusted HR 1.17; 95% CI 1.03 to 1.33; p = 0.015), diabetes (adjusted HR 1.55; 95% CI 1.35 to 1.78; p < 0.0001), age (adjusted HR 1.05; 95% CI 1.04 to 1.06; p < 0.0001), anemia on admission (adjusted HR 1.38; 95% CI 1.23 to 1.58; p < 0.0001), and heart failure (adjusted HR 2.40; 95% CI 2.09 to 2.75; p < 0.0001) predicted long-term mortality.

CONCLUSION

Female sex was associated with a lower risk of dying in the long term. However, risk factors, age, and comorbidities associated with female patients affected the worse outcome.

Seventeen-Year Mortality following the Acute Coronary Syndrome: Gender-Specific Baseline Variables and Impact on Outcome

BACKGROUND

Gender differences in outcome and its predictors in patients with acute coronary syndrome (ACS) continue to be debated.

OBJECTIVES

To assess long-term mortality and explore its association with the baseline variables in women and men.

METHODS

We followed 2,176 consecutive patients (665 women and 1,511 men) with ACS admitted to a single hospital and still alive after 30 days for a median of 16 years 8 months.

RESULTS

At the end of the follow-up, 415 (62.4%) women and 849 (56.2%) men had died (unadjusted hazard ratio [HR] for women/men 1.18 (95% confidence interval [CI], 1.05-1.33, p =0.005). After adjustment for age, the HR was reversed to 0.88 (95% CI, 0.78-1.00, p =0.04). Additional adjustment for potential confounders yielded a HR of 0.86 (95% CI, 0.76-0.98, p = 0.02). Using multivariable Cox regression, previous heart failure, previous or new-onset atrial fibrillation, and psychotropic drugs at discharge were significantly associated with increased long-term mortality in men only. Known hypertension, elevated creatinine, and inhospital Killip class >1/cardiogenic shock were significantly associated with mortality only in women. For late mortality, hypertension and inhospital Killip class >1/cardiogenic shock interacted significantly with gender.

CONCLUSION

For patients with ACS surviving the first 30 days, late mortality was lower in women than in men after adjusting for age. The effects of several baseline characteristics on late outcome differed between women and men. Gender-specific strategies for long-term follow-up of ACS patients should be considered.

Sex Differences in Ischemic Heart Disease: Advances, Obstacles, and Next Steps

Evolving knowledge of sex-specific presentations, improved recognition of conventional and novel risk factors, and expanded understanding of the sex-specific pathophysiology of ischemic heart disease have resulted in improved clinical outcomes in women. Yet, ischemic heart disease continues to be the leading cause of morbidity and mortality in women in the United States. The important publication by the Institute of Medicine titled "Women's Health Research-Progress, Pitfalls, and Promise," highlights the persistent disparities in cardiovascular disease burden among subgroups of women, particularly women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment. These important health disparities reflect underrepresentation of women in research, with the resultant unfavorable impact on diagnosis, prevention, and treatment strategies in women at risk for cardiovascular disease. Causes of disparities are multifactorial and related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. Lack of awareness in both the public and medical community, as well as existing knowledge gap regarding sex-specific differences in presentation, risk factors, pathophysiology, and response to treatment for ischemic heart disease, further contribute to outcome disparities. There is a critical need for implementation of sex- and gender-specific strategies to improve cardiovascular outcomes. This review is tailored to meet the needs of a busy clinician and summarizes the contemporary trends, characterizes current sex-specific outcome disparities, delineates challenges, and proposes transformative solutions for improvement of the full spectrum of ischemic heart disease clinical care and research in women.

Addressing the Gap in Physician Preparedness To Assess Cardiovascular Risk in Women: a Comprehensive Approach to Cardiovascular Risk Assessment in Women

PURPOSE OF REVIEW

Increased recognition of risk factors and improved knowledge of sex-specific presentations has led to improved clinical outcomes for women with cardiovascular disease (CVD) compared to two decades ago. Yet, CVD remains the leading cause of death for women in the USA. Women have unique risk factors for CVD that continue to go under-recognized by their physicians.

RECENT FINDINGS

In a nationwide survey of primary care physicians (PCPs) and cardiologists, only 22% of PCPs and 42% of cardiologists reported being extremely well prepared to assess CVD risk in women. A presidential advisory from the American Heart Association (AHA) and American College of Obstetrics and Gynecologist (ACOG) recommends that cardiologists and obstetricians and gynecologists (Ob/Gyns) collaborate to promote CVD risk identification and reduction throughout a woman's lifetime. We suggest a comprehensive approach to identify unique and traditional risk factors for CVD in women, address the gap in physician knowledge, and improve cardiovascular care for women.

Variation in cardiovascular disease care: an Australian cohort study on sex differences in receipt of coronary procedures

OBJECTIVES

The aim of this study was to quantify sex differences in diagnostic and revascularisation coronary procedures within 1 year of hospitalisation for acute myocardial infarction (AMI) or angina.

DESIGN

This is a prospective cohort study. Baseline questionnaire (January 2006-April 2009) data from the Sax Institute's 45 and Up Study were linked to hospitalisation and mortality data (to 30 June 2016) in a time-to-event analysis, treating death as a censoring event.

SETTING

This was conducted in New South Wales, Australia.

PARTICIPANTS

The study included participants aged ≥45 years with no history of ischaemic heart disease (IHD) who were admitted to hospital with a primary diagnosis of AMI (n=4580) or a primary diagnosis of angina or chronic IHD with secondary diagnosis of angina (n=4457).

OUTCOME MEASURES

The outcome of this study was coronary angiography and coronary revascularisation with percutaneous coronary intervention or coronary artery bypass graft (PCI/CABG) within 1 year of index admission. Cox regression models compared coronary procedure rates in men and women, adjusting sequentially for age, sociodemographic variables and health characteristics.

RESULTS

Among patients with AMI, 71.6% of men (crude rate 3.45/person-year) and 64.7% of women (2.62/person-year) received angiography; 57.8% of men (1.73/person-year) and 37.4% of women (0.77/person-year) received PCI/CABG. Adjusted HRs for men versus women were 1.00 (0.92-1.08) for angiography and 1.51 (1.38-1.67) for PCI/CABG. In the angina group, 67.3% of men (crude rate 2.36/person-year) and 54.9% of women (1.32/person-year) received angiography; 44.6% of men (0.90/person-year) and 19.5% of women (0.26/person-year) received PCI/CABG. Adjusted HRs were 1.24 (1.14-1.34) and 2.44 (2.16-2.75), respectively.

CONCLUSIONS

Men are more likely than women to receive coronary procedures, particularly revascularisation. This difference is most evident among people with angina, where clinical guidelines are less prescriptive than for AMI.

Contemporary differences between men and women with acute coronary syndromes: CIAM multicenter registry

AIM

Differences exist in the diagnosis and treatment of acute coronary syndrome (ACS) between men and women. However, recent advancements in the management of ACSs might have attenuated this sex gap. We evaluated the status of ACS management in a multicenter registry in 10 tertiary Spanish hospitals.

METHODS

We enrolled 1056 patients in our study, including only those with type 1 myocardial infarctions or unstable angina presumably not related to a secondary cause in an 'all-comers' design.

RESULTS

The women enrolled (29%) were older than men (71.0 ± 12.8 vs. 64.0 ± 12.3, P = 0.001), with a higher prevalence of hypertension (71.0 vs. 56.5%, P < 0.001), insulin-treated diabetes (13.7 vs. 7.9%, P = 0.003), dyslipidemia (62.2 vs. 55.3%, P = 0.038), and chronic kidney disease (16.9 vs. 9.1%, P = 0.001). Women presented more frequently with back or arm pain radiation (57.3 vs. 49.7%, P = 0.025), palpitations (5.9 vs. 2.0%, P = 0.001), or dyspnea (33.0 vs. 19.4%, P = 0.001). ACS without significant coronary stenosis was more prevalent in women (16.8 vs. 8.1%, P = 0.001). There were no differences in percutaneous revascularization rates, but drug-eluting stents were less frequently employed in women (75.4 vs. 67.8%, P = 0.024); women were less often referred to a cardiac rehabilitation program (19.9 vs. 33.9%, P = 0.001). There were no significant differences in in-hospital complications such as thrombosis or bleeding.

CONCLUSION

ACS presenting with atypical symptoms and without significant coronary artery stenosis is more frequent in women. Selection of either an invasive procedure or conservative management is not influenced by sex. Cardiac rehabilitation referral on discharge is underused, especially in women.

Persistent cardiac dysfunction on echocardiography in African American women with severe preeclampsia

BACKGROUND

Cardiovascular disease (CVD) and preeclampsia both disproportionally affect African American women. Evidence continues to grow linking a history of preeclampsia to future CVD. Therefore, we sought to determine whether abnormalities in cardiac function, as determined by echocardiography, could be identified at the time of preeclampsia diagnosis in African American women, and if they persist into the early postpartum period.

STUDY DESIGN

This prospective blinded longitudinal cohort study was performed from April 2015 to May 2017. We identified African American women diagnosed with preterm (<37 weeks) preeclampsia with severe features and compared them to control normotensive pregnant women matched on race, gestational age, maternal age, and body mass index. We obtained transthoracic echocardiograms on cases and controls at time of diagnosis and again 4-12 weeks postpartum. We quantified the systolic function with longitudinal strain, ventricular-arterial coupling parameters and diastolic function.

RESULTS

There were 29 matched (case-control) pairs of African American women for a total of 58 women. At time of preeclampsia diagnosis, there was more abnormal cardiac function as evidenced by worse cardiac systolic function (longitudinal strain), increased chamber stiffness (end systolic elastance), and worse diastolic function (E/e') in preeclampsia cases compared to controls. These findings persisted 4-12 weeks postpartum. There were additional notable abnormalities in E/A, and Ea (arterial load) postpartum, indicative of potentially worse diastolic function and increased arterial stiffness in the postpartum period.

CONCLUSIONS

Among African American women, we found notable cardiac function differences between women with severe preeclampsia and healthy pregnant controls that persist postpartum.

Appropriateness of Cardiac Troponin Testing: Insights from the Use of TROPonin In Acute coronary syndromes (UTROPIA) Study

OBJECTIVE

Our objective was to examine the appropriateness of cardiac troponin (cTn) testing among patients with cTn increases.

METHODS

This is a planned secondary analysis of the Use of TROPonin In Acute coronary syndromes (UTROPIA, NCT02060760) observational cohort study. Appropriateness of cTn testing was adjudicated for emergency department patients with cTn increases >99^th percentile and analyzed using both contemporary and high-sensitivity (hs) cTnI assays according to sub-specialty, diagnoses, and symptoms.

RESULTS

Appropriateness was determined from 1272 and 1078 adjudication forms completed for 497 and 422 patients with contemporary and hs-cTnI increases, respectively. Appropriateness of cTnI testing across adjudication forms was 71.5% and 72.0% for cTnI and hs-cTnI, respectively. Compared with emergency physicians, cardiologists were less likely to classify cTnI orders as appropriate (cTnI: 79% vs 56%, P < .0001; hs-cTnI: 82% vs 51%, P < .0001). For contemporary cTnI, appropriateness of 95%, 70%, and 39% was observed among adjudication forms completed by cardiologists for type 1 myocardial infarction, type 2 myocardial infarction, and myocardial injury, respectively; compared with 90%, 86%, and 71%, respectively, among emergency physicians. Similar findings were observed using hs-cTnI. Discordance in appropriateness adjudication forms occurred most frequently in cases of myocardial injury (62% both assays) or type 2 myocardial infarction (cTnI 31%; hs-cTnI 23%).

CONCLUSIONS

Marked differences exist in the perception of what constitutes appropriate clinical use of cTn testing between cardiologists and emergency physicians, with emergency physicians more likely to see testing as appropriate across a range of clinical scenarios. Discordance derives most often from cases classified as myocardial injury or type 2 myocardial infarction.

Age at Menarche and Risk of Cardiovascular Disease Outcomes: Findings From the National Heart Lung and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation

Background Previous studies have reported an association between the timing of menarche and cardiovascular disease ( CVD ). However, emerging studies have not examined the timing of menarche in relation to role of estrogen over a lifetime and major adverse cardiac events ( MACE ). Methods and Results A total of 648 women without surgical menopause undergoing coronary angiography for suspected ischemia in the WISE (Women's Ischemia Syndrome Evaluation) study were evaluated at baseline and followed for 6 years (median) to assess major adverse CVD outcomes. MACE was defined as the first occurrence of all-cause death, nonfatal myocardial infarction, nonfatal stroke, or heart failure hospitalization. Age at menarche was self-reported and categorized (≤10, 11, 12, 13, 14, ≥15 years) with age 12 as reference. Total estrogen time and supra-total estrogen time were calculated. Cox regression analysis was performed adjusting for CVD risk factors. Baseline age was 57.9 ± 12 years (mean ± SD ), body mass index was 29.5 ± 6.5 kg/m2, total estrogen time was 32.2 ± 8.9 years, and supra-total estrogen time was 41.4 ± 8.8 years. MACE occurred in 172 (27%), and its adjusted regression model was J-shaped. Compared with women with menarche at age 12 years, the adjusted MACE hazard ratio for menarche at ≤10 years was 4.53 (95% CI 2.13-9.63); and at ≥15 years risk for MACE was 2.58 (95% CI , 1.28-5.21). Conclusions History of early or late menarche was associated with a higher risk for adverse CVD outcomes. These findings highlight age at menarche as a potential screening tool for women at risk of adverse CVD events. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT00000554.

Association of serum androgens and coronary artery calcium scores in women

OBJECTIVE

To determine the association between serum androgens measured by high-resolution liquid chromatography-mass spectrometry and coronary artery calcium (CAC) scores.

DESIGN

Cross-sectional study.

SETTING

Academic institution.

PATIENT(S)

A total of 239 women, aged 40-75 years, with CAC testing and complete cardiovascular disease risk evaluation. Total T, DHEA, and androstenedione were measured using high-resolution liquid chromatography-mass spectrometry, whereas E₂ and sex hormone-binding globulin were measured using commercial assays.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Independent associations between CAC scores and sex steroids.

RESULT(S)

Overall, 164 subjects had a CAC score < 10, 48 had a CAC score between 10 and 100, and 27 had a score > 100. There were no differences in sex hormone levels between women with CAC scores > 10 vs. CAC scores ≤ 10. In multivariable models adjusting for age, body mass index, and low-density lipoprotein cholesterol, a higher T/E₂ ratio was associated with an elevated CAC score, with an unadjusted odds ratio associated with 1-SD change in log-transformed T/E₂ of 1.38 (95% confidence interval 1.01-1.89) and adjusted OR 1.02 (95% confidence interval 1.002-1.04). Total T, DHEA, androstenedione, sex hormone-binding globulin, and E₂ levels were not associated with increased CAC.

CONCLUSION(S)

In the general population, there are mixed reports regarding the relationship between serum androgens and risk factors for cardiovascular disease, and limited information on the relationship between androgens and subclinical atherosclerosis. Our study shows that increased androgens relative to estrogens may have a weak but independent association with subclinical atherosclerosis, as measured by CAC scores.

Psychological Distress Among Female Cardiac Patients Presenting to a Women's Heart Health Clinic

Female cardiac patients are at greater risk for mental health disorders than their male counterparts, and these mental health disorders have been associated with increased cardiac morbidity and mortality. However, few studies have closely examined the mental health disorders found among the female cardiac population. The primary aim of this study was to examine the prevalence of psychological distress in a sample of female cardiac outpatients at an academic medical center. A secondary aim was to determine whether different demographic variables, cardiac risk factors, or cardiac diagnoses were associated with different levels of emotional distress. A survey, including demographic information, medical status, and standardized symptom measures was completed by 117 female patients scheduled for medical visits at an outpatient women's heart health clinic over a 4-month period. Using standardized self-report questionnaires, 38% scored in the moderate-to-severe range for at least 1 mental disorder and 50% endorsed current insomnia. Symptoms of clinical depression (20%) and anxiety (42)% were endorsed at higher rates than predominantly male or mixed comparison samples. Although there was no apparent relation between the severity of cardiac problems and the degree of psychological distress, women with diagnoses of hyperlipidemia, prediabetes, and diabetes reported greater psychological distress than those without these problems. Women with lower income also reported more psychological distress. In conclusion, our findings suggest an unmet need for integrated mental health services for female cardiac patients.

Sex Differences in 1-Year Rehospitalization for Heart Failure and Myocardial Infarction After Primary Percutaneous Coronary Intervention

It is unclear whether universal access to primary percutaneous coronary intervention (pPCI) may reduce sex differences in 1-year rehospitalization for heart failure (HF) and myocardial infarction (MI) after ST-elevation myocardial infarction (STEMI). We studied 7,597 consecutive STEMI patients (13.8% women, n = 1,045) who underwent pPCI from January 2007 to December 2013. Cox regression models adjusted for competing risk from death were used to assess sex differences in rehospitalization for HF and MI within 1 year from discharge. Compared with men, women were older (median age 67.6 vs 56.0 years, p < 0.001) with higher prevalence of co-morbidities and multivessel disease. Women had longer median door-to-balloon time (76 vs 66 minutes, p < 0.001) and were less likely to receive drug-eluting stents (19.5% vs 24.1%, p = 0.001). Of the medications prescribed at discharge, fewer women received aspirin (95.8% vs 97.6%, p = 0.002) and P2Y₁₂ antagonists (97.6% vs 98.5%, p = 0.039), but there were no significant sex differences in other discharge medications. After adjusting for differences in baseline characteristics and treatment, sex differences in risk of rehospitalization for HF attenuated (hazard ratio [HR] 1.05, 95% confidence interval [CI] 0.79 to 1.40), but persisted for MI (HR 1.68, 95% CI 1.22 to 2.33), with greater disparity in patients aged ≥60 years (HR 1.83, 95% CI 1.18 to 2.85) than those aged <60 years (HR 1.45, 95% CI 0.84 to 2.50). In conclusion, in a setting of universal access to pPCI, the adjusted risk of 1-year rehospitalization for HF was similar in both sexes, but women had significantly higher adjusted risk of 1-year rehospitalization for MI, especially older women.

Recognition and treatment of ischemic heart diseases in women

Heart disease is the leading cause of death among women in the industrialized world. However, women after myocardial infarctions (MIs) are less likely to receive preventive medications or revascularization and as many as 47% experience heart failure, stroke or die within 5 years. Premenopausal women with MIs frequently have coronary plaque erosions or dissections. Women under 50 years with angina and nonobstructive epicardial coronary artery disease often have coronary microvascular dysfunction (CMD) with reductions in coronary flow reserve that may require nontraditional therapies. In women with coronary artery disease treated with stents, the 3-year incidence of recurrent MI or death is 9.2%. Coronary bypass surgery operative mortality averages 4.6% for women compared with 2.4% in men. Addition of internal mammary artery and radial artery coronary grafts in women does not increase operative survival but improves 5-year outcome to greater than 80%.

Treatment-Seeking Delay Among Hispanic and Non-Hispanic Women with Acute Myocardial Infarction

Purpose: Women and minorities with acute myocardial infarction (AMI) often fail to recognize prodromal symptoms leading to delays in care. The objective of this study was to conduct a mixed method assessment of the impact of ethnicity on symptom description, recognition, and treatment-seeking behavior in Hispanic and non-Hispanic women before hospitalization for AMI.

Methods: We explored differences in symptomatology, treatment-seeking behavior, and delay patterns among a convenience sample of 43 women diagnosed with AMI (17 Hispanic women, 26 non-Hispanic women) in seven rural and urban Colorado hospitals. We performed in-depth interviews to establish patterns (typologies) of treatment-seeking behaviors. Chart abstraction provided delay times as a function of ethnicity.

Results: Most (28/43) women reported prodromal symptoms in the weeks before their index AMI. Overall, fewer Hispanic women presented within 24 h of symptom onset (3/18, 17% vs. 15/18, 83%, p<0.01). A typology of treatment-seeking behavior emerged: women who (1) recognized symptoms and promptly sought care; (2) did not recognize symptoms, yet promptly sought care; (3) recognized symptoms and promptly sought care, but providers misconstrued symptoms as noncardiac; and (4) misinterpreted symptoms due to an underlying chronic disease.

Conclusion: Women and primary care providers often underappreciate prodromal AMI symptoms. Hispanic women are more likely to misinterpret ischemic symptoms and delay care, suggesting a need for tailored patient and provider education.

In-situ optical assessment of rat epicardial kinematic parameters reveals frequency-dependent mechanic heterogeneity related to gender

BACKGROUND

Gender-related cardiac mechanics following the electrical activity has been investigated from basic to clinical research, but results are still controversial. The aim of this work is to study the gender related cardiac mechanics and to focus on its heart rate dependency.

METHODS

We employed 12 Sprague Dawley rats (5 males and 7 females) of the same age and, through a novel high resolution artificial vision contactless approach, we evaluated in-situ cardiac kinematic. The hearts were paced on the right atria appendage via cathodal stimuli at rising frequency.

RESULTS

Kinematic data obtained at rising pacing rates are different between male and female rat hearts: male tended to maintain the same level of cardiac force, energy and contractility, while female responded with an increment of such parameters at increasing heart rate. Female hearts preserved their pattern of contraction and epicardial torsion (vorticity) at rising pacing rates compared to male. Furthermore, we observed a difference in the mechanical restitution: systolic time vs. diastolic time, as an index of cardiac performance, reached higher value in male compared to female hearts.

CONCLUSION

Our innovative technology was capable to evaluate in-situ rat epicardial kinematic at high stimulation frequency, revealing that male preserved kinematic parameters but varying the pattern of contraction/relaxation. On the contrary, female preserved the pattern of contraction/relaxation increasing kinematic parameters.

Temperature variability and hospitalization for ischaemic heart disease in Brazil: A nationwide case-crossover study during 2000-2015

BACKGROUND

Previous studies have suggested a potential relationship between temperature variability (TV) and ischaemic heart disease (IHD) but the nature and strength differ between studies. We quantify the association between TV and risk of hospitalization for IHD across Brazilian regions and examine how the relationship varies across important population subgroups.

METHODS

Data on hospitalization for IHD and meteorological parameters were collected from 1814 cities during 2000-2015. TV was defined as the standard deviation of daily minimum and maximum temperatures during exposure days. City-specific estimates were quantified using a time-stratified case-crossover approach, and then pooled at the national level using a random-effect meta-analysis. Stratified analyses were performed by region, sex and three age-groups.

RESULTS

There were 2,864,904 IHD hospitalizations during 2000-2015. The estimate of TV effect was strongest on 0-1 days' exposure: odds ratio was 1.019 [95% confidence interval (CI): 1.013-1.025] per 5 °C increase in TV. The relationship was stronger in men [1.025 (95%CI: 1.017-1.033)] than in women [1.011 (95%CI: 1.002-1.019)] and in successively older age groups [1.034 (95%CI: 1.018-1.050)]. Regional differences existed, with the association only apparent in the most ageing parts of Brazil.

CONCLUSIONS

Exposure to TV is associated with increased risk of hospitalization for IHD, particularly in men and in older age groups. Our findings add to the growing evidence regarding the potential impact of climatic factors on important health outcomes.

Apolipoprotein profiling as a personalized approach to the diagnosis and treatment of dyslipidaemia

An elevated low-density lipoprotein cholesterol concentration is a classical risk factor for cardiovascular disease. This has led to pharmacotherapy in patients with atherosclerotic heart disease or high heart disease risk with statins to reduce serum low-density lipoprotein cholesterol. Even in patients in whom the target levels of low-density lipoprotein cholesterol are reached, there remains a significant residual cardiovascular risk; this is due, in part, to a focus on low-density lipoprotein cholesterol alone and neglect of other important aspects of lipoprotein metabolism. A more refined lipoprotein analysis will provide additional information on the accumulation of very low-density lipoproteins, intermediate density lipoproteins, chylomicrons, chylomicron-remnants and Lp(a) concentrations. Instead of measuring the cholesterol and triglyceride content of the lipoproteins, measurement of their apolipoproteins (apos) is more informative. Apos are either specific for a particular lipoprotein or for a group of lipoproteins. In particular measurement of apos in atherogenic particles is more biologically meaningful than the measurement of the cholesterol concentration contained in these particles. Applying apo profiling will not only improve characterization of the lipoprotein abnormality, but will also improve definition of therapeutic targets. Apo profiling aligns with the concept of precision medicine by which an individual patient is not treated as 'average' patient by the average (dose of) therapy. This concept of precision medicine fits the unmet clinical need for stratified cardiovascular medicine. The requirements for clinical application of proteomics, including apo profiling, can now be met using robust mass spectrometry technology which offers desirable analytical performance and standardization.

Sex-based associations with microvascular injury and outcomes after ST-segment elevation myocardial infarction

Objectives

We aimed to assess for sex differences in invasive parameters of acute microvascular reperfusion injury and infarct characteristics on cardiac MRI after ST-segment elevation myocardial infarction (STEMI).

Methods

Patients with STEMI undergoing emergency percutaneous coronary intervention (PCI) were prospectively enrolled. Index of microcirculatory resistance (IMR) and coronary flow reserve (CFR) were measured in the culprit artery post-PCI. Contrast-enhanced MRI was used to assess infarct characteristics, microvascular obstruction and myocardial haemorrhage, 2 days and 6 months post-STEMI. Prespecified outcomes were as follows: (i) all-cause death/first heart failure hospitalisation and (ii) cardiac death/non-fatal myocardial infarction/urgent coronary revascularisation (major adverse cardiovascular event, MACE) during 5- year median follow-up.

Results

In 324 patients with STEMI (87 women, mean age: 61 ± 12.19 years; 237 men, mean age: 59 ± 11.17 years), women had anterior STEMI less often, fewer prescriptions of beta-blockers at discharge and higher baseline N-terminal pro-B-type natriuretic peptide levels (all p < 0.05). Following emergency PCI, fewer women than men had Thrombolysis in Myocardial Infarction (TIMI) myocardial perfusion grades ≤ 1 (20% vs 32%, p = 0.027) and women had lower corrected TIMI frame counts (12.94 vs 17.65, p = 0.003). However, IMR, CFR, microvascular obstruction, myocardial haemorrhage, infarct size, myocardial salvage index, left ventricular remodelling and ejection fraction did not differ significantly between sexes. Female sex was not associated with MACE or all-cause death/first heart failure hospitalisation.

Conclusion

There were no sex differences in microvascular pathology in patients with acute STEMI. Women had less anterior infarcts than men, and beta-blocker therapy at discharge was prescribed less often in women.

Trial registration number

NCT02072850.

No time to delay reperfusion: A cross-sectional study of primary percutaneous coronary intervention times

AIMS AND OBJECTIVES

To establish and report cross-sectional data of reperfusion times for emergency primary percutaneous coronary interventions (PPCI) and to examine factors associated with times to reperfusion.

BACKGROUND

Rapid coronary reperfusion can salvage myocardial tissue, preserve left ventricular function and reduce mortality. PPCI is the gold standard of management. Researchers have reported on international median reperfusion times, but this is the first Irish study to do so.

METHODS

This observational, prospective, cross-sectional study included patients diagnosed with ST-segment elevation myocardial infarction (STEMI) and admitted for emergency PPCI. Descriptive and inferential statistics were used. The study was ethically approved. We adopted the STROBE guidelines.

RESULTS

All patients (N = 133) who met the inclusion criteria were included initially. Of these, 105 (79%) were diagnosed with STEMI and received emergency PPCI. The majority of STEMIs were diagnosed by paramedics and most (67%) were reperfused within 120 min, with a median time of 96 min. The results suggested that younger patients achieved timelier PPCI and source of referral was also significant in that more of those transferred directly to the coronary catheterisation laboratory achieved reperfusion within 120 min, compared with those who presented to the emergency department.

CONCLUSION

A timely reperfusion service is achieved for the majority. Attention is needed in respect of the ageing and those admitted directly to the emergency departments with STEMI.

RELEVANCE TO CLINICAL PRACTICE

Further international research is recommended to compare current reperfusion times against guidelines and to identify areas for improvement. Clinicians should be mindful of the importance of rapid reperfusion and the implications of its delay for patients with STEMI. Those presenting to emergency departments with chest pain should be prioritised.