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

Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction: Evidence from the VIRGO Study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients)

BACKGROUND

Some studies report that women are less likely to present with chest pain for acute myocardial infarction (AMI). Information on symptom presentation, perception of symptoms, and care-seeking behaviors is limited for young patients with AMI.

METHODS

We interviewed 2009 women and 976 men aged 18 to 55 years hospitalized for AMI at 103 US hospitals participating in the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients). Structured patient interviews during the index AMI hospitalization were used to collect information on symptom presentation, perception of symptoms, and care-seeking behaviors. We compared patient characteristics and presentation information by sex. Multivariable hierarchical logistic regression was used to evaluate the association between sex and symptom presentation.

RESULTS

The majority of women (87.0%) and men (89.5%) presented with chest pain (defined as pain, pressure, tightness, or discomfort). Women were more likely to present with ≥3 associated symptoms than men (eg, epigastric symptoms, palpitations, and pain or discomfort in the jaw, neck, arms, or between the shoulder blades; 61.9% for women versus 54.8% for men, P<0.001). In adjusted analyses, women with an ST-segment-elevation AMI were more likely than men to present without chest pain (odds ratio, 1.51; 95% confidence interval, 1.03-2.22). In comparison with men, women were more likely to perceive symptoms as stress/anxiety (20.9% versus 11.8%, P<0.001) but less likely to attribute symptoms to muscle pain (15.4% versus 21.2%, P=0.029). Approximately 29.5% of women and 22.1% of men sought medical care for similar symptoms before their hospitalization (P<0.001); however, 53% of women reported that their provider did not think these symptoms were heart-related in comparison with 37% of men (P<0.001).

CONCLUSIONS

The presentation of AMI symptoms was similar for young women and men, with chest pain as the predominant symptom for both sexes. Women presented with a greater number of additional non-chest pain symptoms regardless of the presence of chest pain, and both women and their healthcare providers were less likely to attribute their prodromal symptoms to heart disease in comparison with men.

Cardiovascular Disease and the Female Disadvantage

Age-standardised rates of cardiovascular disease (CVD) are substantially higher in men than women. This explains why CVD has traditionally been seen as a "man's problem". However, CVD is the leading cause of death in women, worldwide, and is one of the most common causes of disability-adjusted life-years lost. In general, this is under-recognised and, in several ways, women are disadvantaged in terms of CVD. Both in primary and secondary prevention, there is evidence that women are undertreated, compared to men. Women often experience heart disease in a different way compared to men, and lack of recognition of this has been shown to have adverse consequences. Female patients of male cardiac physicians have been found to have worse outcomes than their male counterparts, with no such gender differential for female cardiologists. Clinical trials in CVD primarily recruit male patients, yet, it is well recognised that some drugs act differently in women and men. Diabetes and smoking, and perhaps other risk factors, confer a greater proportional excess cardiovascular risk to women than to men, whilst adverse pregnancies and factors concerned with the female reproductive cycle give women added vulnerability to CVD. However, women's health research is skewed towards mother and child health, an area where, arguably, the greatest public health gains have already been made, and breast cancer. Hence there is a need to redefine what is meant by "women's health" to encompass the whole lifecycle, with a stronger emphasis on CVD and other non-communicable diseases. Sex-specific analyses of research data should be the norm, whenever feasible.

Factors Affecting Early Mortality and 1-Year Outcomes in Young Women With ST-Segment-Elevation Myocardial Infarction Aged Less Than or Equal to 45 Years

Given that up to 2% of patients with myocardial infarction (MI) are young women, the purpose of this study was to evaluate factors affecting outcomes in young women with ST-segment-elevation myocardial infarction (STEMI) aged less than or equal to 45 years. We evaluated 796 women with STEMI aged less than or equal to 45 years between 2007 and 2014, and mortality was 4.0%. Death occurred more often in women with prehospital sudden cardiac arrest, and severe symptoms of heart failure; less commonly, the women were subjected to percutaneous coronary intervention (PCI), with a higher rate of incomplete revascularization. Beta blockers (BB) and angiotensin converting enzyme inhibitors were frequently used in the survivor group. The independent predictor of 30-day mortality was as follows: inability to undergo PCI (odds ratio [OR] 4.6, 95% confidence interval [CI] 1.45-14.76, P = 0.009), sudden cardiac arrest (OR 4.5, 95% CI 1.5-18.3, P = 0.04). An increase in systolic blood pressure for every 5 mm Hg was associated with lower mortality, OR 0.90, 95% CI 0.76-0.97 in patients without cardiogenic shock (CS) and OR 0.69, 95% CI 0.61-0.78, P < 0.0001 in the group with CS. Predictors for 1-year mortality were the inability to undergo PCI (hazard ratio [HR] 84, 95% CI 1.6-43.1, P = 0.01) and CS (HR 6.97, 95% CI 1.39-34.7, P = 0.01). An increase of 5% in left ventricular ejection fraction reduced the mortality rate for 60% (HR 0.40, 95% CI 0.26-0.63, P < 0.0001) and an increase in systolic blood pressure for every 5 mm Hg reduced mortality for 34% (HR 0.66, 95% CI 0.52-0.84, P = 0.02). Both short- and long-term outcomes in young women aged less than or equal to 45 years with STEMI are good. The strongest predictor for both 30-day and 1-year mortality was the inability to undergo PCI. Suboptimal use of beta blockers and angiotensin converting enzyme inhibitors affect the outcomes in young women. Hypotension in the acute phase of MI increased mortality in young women, independent of coexisting CS.

Stress Management and Resilience Intervention in a Women's Heart Clinic: A Pilot Study

Background: In general, women report higher stress levels than men. High baseline anxiety, depression, and stress levels are associated with greater risk of cardiovascular diseases. Current evidence for efficacy of stress management interventions for women is limited. This study aimed at assessing the effect of a stress management and resiliency training (SMART) program for decreasing stress, anxiety, and depressive symptoms. Methods: Fifty moderately or severely stressed Women's Heart/Preventive Cardiology Clinic patients consented to the SMART intervention delivered online (n = 36) or in-person (n = 9). Primary outcome measures were the observed changes between baseline and at 12 weeks for the following psychometric tools: General Anxiety Disorder-7 (GAD-7), Patient Health Questionnaires (PHQ-9), Perceived Stress Scale (PSS), and Brief Resiliency Scale (BRS). Results: Forty-five patients completed the study. We observed significant improvements in PSS and GAD-7, but not in PHQ-9 or BRS, after the SMART intervention. When assessing outcomes among those with depressive symptoms at baseline (PHQ-9 > 15), we observed significant changes in PSS, GAD-7, and PHQ-9. No differences between online and in-person program delivery methods were found (all p-values >0.05). Conclusions: Training exposure using the SMART program to decrease stress and anxiety in women seeking preventive cardiology services was feasible and similarly effective, whether delivered online or in a single in-person session. Impacts on depression and resilience likely require a more intensive approach. In the future, larger randomized clinical trials with additional training and longer follow-up are warranted.

Childhood maltreatment and biomarkers for cardiometabolic disease in mid-adulthood in a prospective British birth cohort: associations and potential explanations

OBJECTIVES

Research on associations between childhood maltreatment and adult cardiometabolic disease risk is sparse. We aimed to investigate associations between different forms of child maltreatment and mid-adult cardiometabolic markers and whether potential intermediaries could account for the associations observed.

SETTING

1958 British birth cohort.

PARTICIPANTS

Approximately 9000 cohort members with data on cardiometabolic markers.

OUTCOMES

Adult (45y) cardiometabolic markers (blood pressure, lipids and glycated haemoglobin [HbA1c]).

RESULTS

Seventeen per cent of participants were identified as neglected; 6.1%, 1.6% and 10.0% were identified as experiencing physical, sexual and psychological abuse, respectively. Childhood neglect and physical abuse were associated with high body mass index (BMI) and large waist circumference when adjusting for early-life covariates. For neglect, the adjusted odds ratio (AOR) was 1.16 (95% CI: 1.02 to 1.32) and 1.15 (1.02 to 1.30) for general and central obesity, respectively, and for physical abuse, the respective AOR was 1.36 (1.13 to 1.64) and 1.38 (1.16 to 1.65). Neglect was also associated with raised triglycerides by 3.9 (0.3 to 7.5)% and HbA1c by 1.2 (0.4 to 2.0)%, and among females, lower high-density lipoprotein cholesterol (HDL-c) by 0.05 (0.01 to 0.08)mmol/L after adjustment. For physical abuse, the AOR was 1.25 (1.00 to 1.56) for high low-density lipoprotein cholesterol, HbA1c was raised by 2.5 (0.7 to 4.3)% (in males) and HDL-c was lower by 0.06 (0.01 to 0.12)mmol/L (in females). Associations for sexual abuse were similar to those for physical abuse but 95% CIs were wide. For psychological abuse, the AOR for elevated triglycerides was 1.21 (1.02 to 1.44) and HDL-c was lower by 0.04 (0.01 to 0.07)mmol/L. Maltreatments were not associated with raised blood pressure. In analyses of potential intermediary factors, several associations attenuated after adjustment for adult lifestyles (mainly smoking and alcohol consumption rather than physical activity) and child-to-adult BMI.

CONCLUSIONS

Childhood maltreatments, particularly neglect and physical abuse, were associated with greater adiposity and poorer lipid and HbA1c profiles decades later in adulthood. Associations were modest but independent of early-life factors linked to these outcomes. Findings implicate adult lifestyles as an important intermediary between child maltreatment and outcomes.

Clarifying the Concept of Depression in Women With Coronary Heart Disease

The concept of depression in women with coronary heart disease has been poorly defined for several reasons: numerous widely variable instruments that operationalize the concept, divergent proposed instrument cutoff scores, and continued lack of female participants and data analysis by gender in coronary heart disease research. In the forty articles from 1990 to 2018 evaluating depression in women with coronary heart disease, the concept is defined by specific somatic and cognitive symptoms, preceded by particular physiological and psychosocial vulnerabilities, and leads to poorer outcomes. Concept clarification is necessary for accurate diagnosis of depression, leading to more timely and appropriate interventions for women.

Impact of Normal Weight Central Obesity on Clinical Outcomes in Male Patients With Premature Acute Coronary Syndrome

There is a lack of studies that evaluate the association between normal weight central obesity and subsequent outcomes in patients with premature acute coronary syndrome (ACS). We evaluated 338 consecutive male patients (aged ≤ 55 years) with premature ACS. The primary outcomes were all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). We compared the hazard ratios (HRs) in patients with and without normal weight central obesity using multivariable Cox proportional hazard models. All-cause mortality (16.8%) of patients with normal weight central obesity was much higher than those (7.1%) without normal weight central obesity (P = .008). The incidence of MACCE in patients with and without normal weight central obesity were 40.7 and 23.6% (P = .001), respectively. After multivariable adjustment, the risks of all-cause mortality and MACCE were significantly higher in patients with normal weight central obesity than those without normal weight central obesity (adjusted HR: 1.83; 95% confidence interval [CI]: 1.04-3.31; P = .004 and adjusted HR: 1.62; 95% CI: 1.18-2.27; P = .017, respectively). In conclusion, the risks of all-cause mortality and MACCE were significantly higher in male patients with premature ACS with normal weight central obesity than in those without normal weight central obesity.

Sex-Specific Physiology and Cardiovascular Disease

Sex differences in cardiovascular diseases can be classified as those which are specific to one sex and those that differ in incidence, prevalence, etiology, symptomatology, response to treatment, morbidity, and mortality in one sex compared to the other. All sex differences in cardiovascular conditions have their basis in the combined expression of genetic and hormonal differences between women and men. This chapter addresses how understanding basic mechanisms of hormone responses, imaging diagnostics, and integration of genomics and proteomics has advanced diagnosis and improved outcomes for cardiovascular conditions, apart from those related to pregnancy that are more prevalent in women. These conditions include obstructive coronary artery disease, coronary microvascular dysfunction, spontaneous coronary artery dissection, diseases of the cardiac muscle including heart failure and takotsubo cardiomyopathy, and conditions related to neurovascular dysregulation including hot flashes and night sweats associated with menopause and effects of exogenous hormones on vascular function. Improvement in technologies allowing for noninvasive assessment of neuronally mediated vascular reactivity will further improve our understanding of the basic etiology of the neurovascular disorders. Consideration of sex, hormonal status, and pregnancy history in diagnosis and treatment protocols will improve prevention and outcomes of cardiovascular disease in women as they age.

Association of Light Physical Activity Measured by Accelerometry and Incidence of Coronary Heart Disease and Cardiovascular Disease in Older Women

IMPORTANCE

To our knowledge, no studies have examined light physical activity (PA) measured by accelerometry and heart disease in older women.

OBJECTIVE

To investigate whether higher levels of light PA were associated with reduced risks of coronary heart disease (CHD) or cardiovascular disease (CVD) in older women.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of older women from baseline (March 2012 to April 2014) through February 28, 2017, for up to 4.91 years. The setting was community-dwelling participants from the Women's Health Initiative. Participants were ambulatory women with no history of myocardial infarction or stroke.

EXPOSURES

Data from accelerometers worn for a requested 7 days were used to measure light PA.

MAIN OUTCOMES AND MEASURES

Cox proportional hazards regression models estimated hazard ratios (HRs) and 95% CIs for physician-adjudicated CHD and CVD events across light PA quartiles adjusting for possible confounders. Light PA was also analyzed as a continuous variable with and without adjustment for moderate to vigorous PA (MVPA).

RESULTS

Among 5861 women (mean [SD] age, 78.5 [6.7] years), 143 CHD events and 570 CVD events were observed. The HRs for CHD in the highest vs lowest quartiles of light PA were 0.42 (95% CI, 0.25-0.70; P for trend <.001) adjusted for age and race/ethnicity and 0.58 (95% CI, 0.34-0.99; P for trend = .004) after additional adjustment for education, current smoking, alcohol consumption, physical functioning, comorbidity, and self-rated health. Corresponding HRs for CVD in the highest vs lowest quartiles of light PA were 0.63 (95% CI, 0.49-0.81; P for trend <.001) and 0.78 (95% CI, 0.60-1.00; P for trend = .004). The HRs for a 1-hour/day increment in light PA after additional adjustment for MVPA were 0.86 (95% CI, 0.73-1.00; P for trend = .05) for CHD and 0.92 (95% CI, 0.85-0.99; P for trend = .03) for CVD.

CONCLUSIONS AND RELEVANCE

The present findings support the conclusion that all movement counts for the prevention of CHD and CVD in older women. Large, pragmatic randomized trials are needed to test whether increasing light PA among older women reduces cardiovascular risk.

Gender-Related Differences in Antiplatelet Therapy and Impact on 1-Year Clinical Outcome in Patients Presenting With ACS: The START ANTIPLATELET Registry

We investigated whether gender influences antiplatelet treatment in patients with acute coronary syndrome (ACS). The primary end point was major adverse cardiac and cerebrovascular events (MACCEs), a composite of death, myocardial infarction (MI), stroke, or target vessel revascularization. The coprimary end point was net adverse cardiac and cerebrovascular events (NACEs), based on MACCE plus major bleeding. From January 2014 to December 2016, 840 consecutive patients with ACS who completed 1-year follow-up were enrolled, 625 (74%) males and 215 (26%) females. Percutaneous coronary interventions (PCI) and drug-eluting stents (DES) were more often used in males (PCI: 532 [87%] vs 168 [80%], P = .02 and DES 474 [76%] vs 143 [66%], P = .01). Males were more often treated with dual antiplatelet therapy (DAPT; 94% vs 88%, P = .01). In DAPT, ticagrelor was the most prevalent strategy, regardless of gender (47% vs 49%, P = .68); clopidogrel was preferred in women (42% vs 33%, P = .04); and prasugrel was preferred in men (11% vs 17%, P = .04). At multivariate analysis, MACCE and NACE were similar between genders. Therefore, although P2Y12 inhibitor choice in DAPT might be influenced by gender, a DAPT choice, tailored by balancing the ischemic/bleeding risk, has a similar clinical outcome irrespective of gender.

Eliminating the Sex and Gender Gap and Transforming the Cardiovascular Health of All Women

Critical to eliminating the sex and gender gap in cardiovascular health is addressing known differences in disease burden, disparities in treatment and clinical outcomes, and the scientific importance of sex as a biological variable that influences resilience, pathophysiology, and ultimately the health of women. Furthermore, key disparities exist at the intersection of sex/gender and race/ethnicity where women of color are disproportionately affected by higher burden of disease and poorer outcomes in several cardiovascular conditions. Through efforts to galvanize strategic partnerships, The NHLBI Strategic Vision sets forth research priorities across all of its objectives relevant to the cardiovascular health of women; it encourages strategic partnerships in both establishing and implementing research priorities. The Vision promotes a promise of precision medicine that embraces sex as its highest order, leverages an integrated approach to data science, explores sex influences on molecular underpinnings of disease, and advances sex-specific and race-sex interaction analyses toward the elimination of gaps in the cardiovascular care and health of all women.

The estimate of average age at the onset of acute myocardial infarction in Iran: A systematic review and meta-analysis study

BACKGROUND

Research indicates that the age of onset of first acute myocardial infarction (AMI) is an essential element in the life expectancy that has been decreasing in developing countries. There are various studies performed in Iran reporting a range of ages at time of AMI. Thus, this meta-analysis study is designed to determine the mean age at first AMI in the Iranian population.

METHODS

All studies that met the inclusion and exclusion criteria were reviewed using standard keywords in the databases from 2000 to 2016. Two raters verified a total of 658 articles. Sixteen studies met the inclusion criteria of this study for meta-analysis. Cochran test and I-squared (I2) were used for samples’ homogeneity. Pooled estimates of mean were calculated using the random effects inverse-variance model.

RESULTS

The mean age of AMI varied between 55.9 to 62.9 years among the primary studies. The pooled mean age of first AMI with a 95% confidence interval (CI) for the total sample, men, and women were 59 (58.9, 60.4), 58.7 (58.3, 59.2), and 64.2 (63.5, 64.8), respectively.

CONCLUSION

Our meta-analysis shows that the mean age of first onset of AMI in Iranian people is slightly lower than that reported elsewhere; and it is lower for men than for women.

Reperfusion and Time to Presentation in Women: Too Little Too Late

See Editorial by Cenko et al.

Population-wide analysis of differences in disease progression patterns in men and women

Sex-stratified medicine is a fundamentally important, yet understudied, facet of modern medical care. A data-driven model for how to systematically analyze population-wide, longitudinal differences in hospital admissions between men and women is needed. Here, we demonstrate a systematic analysis of all diseases and disease co-occurrences in the complete Danish population using the ICD-10 and Global Burden of Disease terminologies. Incidence rates of single diagnoses are different for men and women in most cases. The age at first diagnosis is typically lower for men, compared to women. Men and women share many disease co-occurrences. However, many sex-associated incongruities not linked directly to anatomical or genomic differences are also found. Analysis of multi-step trajectories uncover differences in longitudinal patterns, for example concerning injuries and substance abuse, cancer, and osteoporosis. The results point towards the need for an increased focus on sex-stratified medicine to elucidate the origins of the socio-economic and ethological differences.

The Quality of Symptoms in Women and Men Presenting to the Emergency Department With Suspected Acute Coronary Syndrome

INTRODUCTION

More than 5.5 million patients present to emergency departments in the United States annually for potential acute coronary syndrome (ACS); however, diagnosing ACS remains a challenge in emergency departments. Our aim was to describe the quality of symptoms (chest discomfort/description of pain, location/radiation, and overall symptom distress) reported by women and men ruled-in and ruled-out for ACS in emergency departments.

METHODS

The sample consisted of 1,064 patients presenting to emergency departments with symptoms that triggered cardiac workups. Trained research staff obtained data using the ACS Patient Information Questionnaire upon patient presentation to emergency departments.

RESULTS

The sample (n = 1,064) included 474 (44.55%) patients ruled-in and 590 (55.45%) patients ruled-out for ACS. Symptom distress was significantly higher in patients ruled-in versus ruled-out for ACS (7.3 ± 2.6 vs. 6.8 ± 2.5; P = 0.002) and was a significant predictor for an ACS diagnosis in men (odds ratio [OR], 1.10; confidence interval [CI], 1.03-1.17; P = 0.003). Women also reported more chest pressure (51.75% vs. 44.65; P = 0.02) compared with men, and chest pressure was a significant predictor for a diagnosis of ACS (OR, 1.61; CI, 1.03-2.53; P = 0.02).

DISCUSSION

Higher levels of symptom distress may help ED personnel in making a decision to evaluate a patient for ACS, and the presence of chest pressure may aid in making a differential diagnosis of ACS.

Association between coronary dominance and acute inferior myocardial infarction: a matched, case-control study

Background

Previous studies have found a connection between left coronary artery dominance and worse prognoses in patient with acute coronary syndrome, which remains a predominant cause of morbidity and mortality globally. The aim of this study was to investigate whether coronary dominance is associated with the incidence of acute inferior myocardial infarction (MI).

Methods

Between January 2011 and November 2014, 265 patients with acute inferior MI and 530 age-matched and sex-matched controls were recruited for a case-control study in the Second Affiliated Hospital of Xi’an Jiaotong University in Xi’an, China. All participants underwent coronary angiography. The exclusion criteria included history of coronary artery bypass graft surgery, chronic or systemic diseases (including hepatic failure, kidney failure, hypothyroidism and Grave’s disease), ventricular fibrillation, and known allergy to iodinated contrast agent. Patients with left- or co-dominant anatomies were placed into the LD group and those with right-dominant anatomy were included in the RD group. The association of acute inferior MI and coronary dominant anatomy were assessed using multivariable conditional logistic regression, and to estimate the odds ratio (OR) and 95% confidence interval (95%CI).

Results

Distributions of right dominance were significantly different between the acute inferior MI group and control group (94.0% vs. 87.9%, P = 0.018). Univariable conditional logistic regression revealed that right dominance may be a risk factor for the incident acute inferior MI (OR: 2.137; 95% CI: 1.210–3.776; P = 0.009). After adjusting for baseline systolic blood pressure, heart rate, smoking status, diabetes mellitus, hypertension, hyperlipidaemia, and family history of coronary artery disease, results of multivariate conditional logistic regression showed that right dominance was associated with the incidence of acute inferior MI (OR: 2.396; 95% CI: 1.328–4.321; P = 0.004).

Conclusions

Right coronary dominance may play a disadvantageous role in the incidence of acute inferior MI. However, further studies are needed to verify our findings, especially with regard to the underlying mechanisms.

Age-Specific Sex-Based Differences in Anemia in Patients with Myocardial Infarction

Background: Data are lacking concerning possible age-specific sex-based differences in anemia in myocardial infarction (MI) patients and its association with the outcome. The aim was to assess whether these differences in anemia (on admission and at discharge) in MI patients who underwent percutaneous coronary intervention (PCI) are associated with the outcome. Methods: Data from 5579 MI patients (31.0% women) undergoing PCI at our institution were analyzed. Men and women in different age groups were compared regarding anemia and its association with the 30-day and long-term all-cause mortality. Data were analyzed using descriptive statistics. Results: Women suffered anemia more than men (37.5% vs. 26.8%; p < 0.0001). The prevalence of anemia increased rapidly with age in men but not in women. A J-shaped relationship between age and anemia was found in women. The lower the age, the greater the difference in the prevalence of anemia between the sexes. The difference in the prevalence of anemia at discharge was even more pronounced. Anemia on admission (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.10-1.76; p = 0.005) and at discharge (OR = 2.61; 95% CI = 1.98-3.44; p < 0.0001) predicted a higher 30-day mortality. Women had a better adjusted long-term prognosis (hazard ratio [HR] = 0.78; 95% CI = 0.69-0.87; p < 0.0001) for the total population. Anemia on admission (HR = 1.43; 95% CI = 1.29-1.60; p < 0.0001) and at discharge (HR = 1.96; 95% CI = 1.23-2.21; p < 0.0001) predicted a higher long-term mortality. Conclusion: Younger women with MI suffer anemia more frequently than their male peers. Anemia was associated with a worse outcome. Age-specific sex-based differences in anemia help to explain the increased sex-related mortality in MI patients undergoing PCI.

A biomarker of collagen type I degradation is associated with cardiovascular events and mortality in patients with atherosclerosis

OBJECTIVE

Atherosclerosis is characterized by accumulation of lipids, cells and extracellular matrix (ECM) proteins in the arterial wall. Collagen type I (COL1), a component of the arterial ECM, is cleaved by matrix metalloproteinases (MMPs) and known to be remodelled in atherosclerosis. We explored whether the MMP-mediated COL1 biomarker, C1M, was associated with cardiovascular events, cardiovascular mortality and all-cause mortality in a large prospective cohort of patients with known atherosclerosis.

METHODS

Serum from 787 patients who underwent a carotid endarterectomy was included. Circulating levels of C1M were measured in serum. A total of 473 patients were followed for 6 years after surgery. Associations between C1M and incidence of cardiovascular events, cardiovascular mortality and all-cause mortality were assessed by Kaplan-Meier curves and Cox regression analysis.

RESULTS

A total of 101 (21.4%) patients suffered from nonfatal cardiovascular events during the follow-up period, and 64 (13.5%) patients died. Of these, 39 (60.9%) died from cardiovascular diseases. Patients with C1M levels above the median were significantly associated with cardiovascular events, cardiovascular mortality and all-cause mortality (P < 0.001, P = 0.004 and P < 0.001, respectively). C1M was included in the final model for prediction of cardiovascular events (HR 2.15, 95% CI 1.40-3.32, P = 0.001), cardiovascular mortality (HR 2.20, 95% CI 1.07-4.51, P = 0.031) and all-cause mortality (HR 2.98 95% CI 1.67-5.33, P = < 0.001).

CONCLUSIONS

In patients with atherosclerotic carotid lesions, high levels of C1M predicted cardiovascular events, cardiovascular mortality and all-cause mortality. These findings emphasize the importance of remodelling mechanisms in atherosclerosis that are now becoming more and more explored.

Clinical Presentation, Quality of Care, Risk Factors and Outcomes in Women with Acute ST-Elevation Myocardial Infarction (STEMI): An Observational Report from Six Middle Eastern Countries

BACKGROUND

Most of the available literature on ST-Elevated myocardial infarction (STEMI) in women was conducted in the developed world and data from Middle-East countries was limited.

AIMS

To examine the clinical presentation, patient management, quality of care, risk factors and inhospital outcomes of women with acute STEMI compared with men using data from a large STEMI registry from the Middle East.

METHODS

Data were derived from the third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps), a prospective, multinational study of adults with acute STEMI from 36 hospitals in 6 Middle-Eastern countries. The study included 2928 patients; 296 women (10.1%) and 2632 men (89.9%). Clinical presentations, management and in-hospital outcomes were compared between the 2 groups.

RESULTS

Women were 10 years older and more likely to have diabetes mellitus, hypertension, and hyperlipidemia compared with men who were more likely to be smokers (all p<0.001). Women had longer median symptom-onset to emergency department (ED) arrival times (230 vs. 170 min, p<0.001) and ED to diagnostic ECG (8 vs. 6 min., p<0.001). When primary percutaneous coronary intervention (PPCI) was performed, women had longer door-to-balloon time (DBT) (86 vs. 73 min., p=0.009). When thrombolytic therapy was not administered, women were less likely to receive PPCI (69.7 vs. 76.7%, p=0.036). The mean duration of hospital stay was longer in women (6.03 ± 22.51 vs. 3.41 ± 19.45 days, p=0.032) and the crude in-hospital mortality rate was higher in women (10.4 vs. 5.2%, p<0.001). However, after adjustments, multivariate analysis revealed a statistically non-significant trend of higher inhospital mortality among women than men (6.4 vs. 4.6%), (p=0.145).

CONCLUSION

Our study demonstrates that women in our region have almost double the mortality from STEMI compared with men. Although this can partially be explained by older age and higher risk profiles in women, however, correction of identified gaps in quality of care should be attempted to reduce the high morbidity and mortality of STEMI in our women.

Gender differences in the clinical features and outcomes of patients with coronary artery disease

INTRODUCTION

Women have been at a higher risk for adverse cardiac events following percutaneous coronary intervention (PCI), compared with men. Areas covered: In this review, authors discuss the gender differences that can affect the clinical outcomes after PCI and the important points that can be improved on. Expert commentary: Various factors, such as old age and higher prevalence of comorbidities, have been considered to account for the worse clinical outcomes of PCI in women than in men. In addition, men and women have different presentations of angina or acute coronary syndrome (ACS); atypical symptoms are more frequent in women. This variation of the clinical presentation in women likely contributes to the misdiagnosis or delayed recognition of ischemia, which may explain the worse clinical outcomes. In addition, compared with men, women are less likely to be referred for revascularization for coronary artery disease (CAD) and receive less of these guideline-recommended therapies. Recently, sex differences in cardiovascular events have decreased, especially among stable CAD patients, but sex differences in the clinical outcomes of ACS remain. Further evolution of treatment is expected to narrow these sex differences among patients with CAD and improve the clinical outcomes of both men and women.

Lack of Significant Coronary History and ECG Misinterpretation Are the Strongest Predictors of Undertriage in Prehospital Chest Pain

INTRODUCTION

Appropriate prehospital (PH) triage of patients with chest pain can significantly improve outcomes in acute myocardial infarction (MI). We sought to explore how PH providers triage chest pain as high versus low risk and to evaluate the accuracy and predictors of their triage decision.

METHODS

This was a prospective, observational cohort study that enrolled consecutive patients with chest pain transported by emergency medical services (EMS) to 3 tertiary care hospitals in the US. EMS triage decision (high risk versus low-risk) was defined based on the transmission of PH electrocardiogram (ECG) to a command center for medical consultation with or without catheter laboratory activation. Two independent reviewers examined in-hospital medical records to adjudicate the presence of acute MI and to audit the findings on the presenting ECG.

RESULTS

We enrolled 2,065 patients (aged 56 ± 17, 53% male) of whom 768 (37%) were triaged as high risk. Those triaged as high risk were older, were more likely to be men or have significant cardiac history, and had a higher rate of acute MI events (14.2% versus 3.5%). The sensitivity and specificity for triaging MI events as high risk were 70% and 97%, respectively. A total of 46/155 (30%) MI events were misclassified as low risk. No previous coronary revascularization and ECG misinterpretation were strong independent predictors of such undertriage.

CONCLUSIONS

PH providers have moderate sensitivity in triaging high-risk patients; 1 in 3 MI events are undertriaged. Emergency nurses need to pay special attention to patients with benign past histories during transition of care and should always reinterpret ECGs for subtle ischemic changes.

Evolution of ST-Elevation Acute Myocardial Infarction Prevalence by Gender Assessed Age Pyramid Analysis-The Piramyd Study

Introduction: Recent studies reported a decrease in the incidence of acute myocardial infarction. This favorable evolution does not extend to young women. The interaction between gender, risk factors and myocardial infarction incidence remains controversial. Objective: To compare the evolution of the age pyramid of patients with ST-elevation myocardial infarction (STEMI) according to gender. Methods: Data from patients with STEMI managed in pre-hospital settings prospectively collected in the greater Paris area. Evolution of patient demographics and risk factors was investigated. Results: 28,249 patients with STEMI were included in the registry between 2002 and 2014, 21,883 (77%) males and 6366 (23%) females. The sex ratio did not significantly vary over the study period (p = 0.4). Median patient age was 60.1 years (51.1–73.0) and was significantly different between males and females, respectively 57.9 (50.0–68.3) vs. 72.9 years (58.3–82.2) (p = 0.0004). The median age of males significantly (p = 0.0044) increased from 57.6 (50.1–70.0) in 2002 to 58.1 years (50.5–67.8) in 2014. The median age of females significantly (p = 0.0006) decreased from 73.7 (57.9–81.8) to 69.6 years (57.0–82.4). The median gap between the age of men and women significantly (p = 0.0002) decreased, from 16.1 to 11.5 years. Prevalence of risk factors was unchanged or decreased except for hypertension which significantly increased in males. The rate of STEMI without reported risk factors increased in both males and females. Conclusion: The age of STEMI onset significantly decreased in females, whereas it significantly increased in males. The prevalence of risk factors decreased in males, whereas no significant variation was found in females.

Comparison of long-term mortality in patients with acute myocardial infarction associated with or without sepsis

OBJECTIVES

Although the association between systemic infection and cardiovascular events has been identified, uncertainty remains regarding the incidence and prognosis of sepsis in acute myocardial infarction (AMI). The purpose of this research was to assess the impact of sepsis on survival after first AMI.

METHODS

This was a nationwide cohort study involving the analysis of data from the Taiwan National Health Insurance Research Database for the period 2000-2012, for patients with a primary diagnosis of first AMI. Among the 186112 prospective patients, sepsis was diagnosed in 13065 (7.0%). The propensity score matching technique was used to match 13065 controls to the patients with sepsis and AMI with similar baseline characteristics. Cox proportional hazards regression models, including sepsis, percutaneous coronary intervention (PCI), and comorbidities, were performed to further evaluate the different influences on the mortality risk in patients hospitalized for first AMI.

RESULTS

Overall, the 12-year survival rate was lower in AMI patients with sepsis than in those without sepsis (log rank p-value <0.001); this was also shown in the different age and sex groups. The AMI patients with sepsis had a longer length of hospital stay than those without sepsis (32.5days vs. 11.74 days, p<0.001). In the Cox proportional hazards regression analysis, sepsis was an independent risk factor for mortality in patients after AMI (hazard ratio 1.78; 95% confidence interval 1.72-1.83). Interventional management with PCI or coronary artery bypass grafting improved survival in both the sepsis and non-sepsis patients after first AMI.

CONCLUSIONS

In conclusion, sepsis significantly increased the mortality risk of patients after first AMI. PCI may improve the long-term survival of patients in comparison to those managed conservatively.

Non-ST elevation acute coronary syndrome in women and the elderly: recent updates and stones still left unturned

Despite the growing awareness of adverse events with acute coronary syndrome and vigilance to refine pharmacological and interventional therapies, the understanding of how these events present in and affect women and the elderly remains limited. Pathophysiological differences in these subgroups and under-representation in large trials create a medical gap in sex- and age-related outcomes and in our knowledge of how best to detect, diagnose, and treat acute coronary syndrome. This review provides a general overview of recent advances in non-ST elevation myocardial infarction management in women and the elderly and elucidates areas where further exploration is needed.

Sex-Specific Considerations in Guidelines Generation and Application

New knowledge about male-female differences in pathophysiology, diagnosis, and treatment is shifting the practice of medicine from a one-size-fits all approach to a more individualized process that considers sex-specific interventions at the point of care. In this article, we review how clinical practice guideline committees can incorporate a structured framework to determine whether sex-specific assessments of the quality of the evidence or the particular recommendations should be made. The process can be operationalized by societies who author clinical practice guidelines by developing formal policies to approach biological sex in a systematic way, and by ensuring that writing committees include an individual who will champion the formal appraisal of the literature for associations between sex and the outcomes of interest. Ongoing challenges are discussed, and solutions are provided for how to disaggregate the evidence, how to assess bias, how to improve search strategies, and what to do when the data are insufficient to make sex-specific recommendations. Application of sex-specific recommendations will involve routinely asking whether the presentation, diagnostic workup, or management might change for each patient if they were the opposite sex.

Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management

Spontaneous coronary artery dissection is an increasingly recognised cause of acute coronary syndromes, especially in young and middle-age women. Recognising its particularities and differences with atherosclerotic disease is central for appropriately identifying and approaching these patients. The authors review the current state of knowledge on spontaneous coronary artery dissection and provide practical recommendations for the diagnosis and management of this condition, both in the acute and convalescence phases.

Sex differences in calcified plaque and long-term cardiovascular mortality: observations from the CAC Consortium

Aims

Pathologic evidence supports unique sex-specific mechanisms as precursors for acute cardiovascular (CV) events. Current evidence on long-term CV risk among women when compared with men based on measures of coronary artery calcium (CAC) remains incomplete.

Methods and results

A total of 63 215 asymptomatic women and men were enrolled in the multicentre, CAC Consortium with median follow-up of 12.6 years. Pooled cohort equation (PCE) risk scores and risk factor data were collected with the Agatston score and other CAC measures (number of lesions and vessels, lesion size, volume, and plaque density). Cox proportional hazard models were employed to estimate CV mortality (n = 919). Sex interactions were calculated. Women and men had average PCE risk scores of 5.8% and 9.1% (P < 0.001). Within CAC subgroups, women had fewer calcified lesions (P < 0.0001) and vessels (P = 0.017), greater lesion size (P < 0.0001), and higher plaque density (P = 0.013) when compared with men. For women and men without CAC, long-term CV mortality was similar (P = 0.67), whereas detectable CAC was associated with 1.3-higher hazard for CV death among women when compared with men (P < 0001). Cardiovascular mortality was higher among women with more extensive, numerous, or larger CAC lesions. The relative hazard for cardiovascular disease (CVD) mortality for women and men was 8.2 vs. 5.1 for multivessel CAC, 8.6 vs. 5.9 for ≥5 CAC lesions, and 8.5 vs. 4.4 for a lesion size ≥15 mm3, respectively. Additional explorations revealed that women with larger sized and more numerous CAC lesions had 2.2-fold higher CVD mortality (P < 0.0001) as compared to men. Moreover, CAC density was not predictive of CV mortality in women (P = 0.51) but was for men (P < 0.001), when controlling for CAC volume and cardiac risk factors.

Conclusion

Our overall findings support that measures beyond the Agatston score provide important clues to sex differences in atherosclerotic plaque and may further refine risk detection and focus preventive strategies of care.

Gender Differences in the Rate of 30-Day Readmissions after Percutaneous Coronary Intervention for Acute Coronary Syndrome

BACKGROUND

It has been reported that women have higher 30-day readmission rates than men after acute coronary syndrome (ACS). However, readmission after percutaneous coronary intervention (PCI) for ACS is a distinct subset of patients in whom gender differences have not been adequately studied.

METHODS

Hawaii statewide hospitalization data from 2010 to 2015 were assessed to compare gender differences in 30-day readmission rates among patients hospitalized with ACS who underwent PCI during the index hospitalization. Readmission diagnoses were categorized using an aggregated version of the Centers for Medicare and Medicaid Services Condition Categories. Multivariable logistic regression was applied to evaluate the effect of gender on the 30-day readmission rate.

RESULTS

A total of 5,354 patients (29.4% women) who were hospitalized with a diagnosis of ACS and underwent PCI were studied. Overall, women were older, with more identified as Native Hawaiian, and had a higher prevalence of cardiovascular risk factors compared with men. The 30-day readmission rate was 13.9% in women and 9.6% in men (p < .0001). In the multivariable model, female gender (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.09-1.60), Medicaid (OR, 1.48; 95% CI, 1.07-2.06), Medicare (1.72; 95% CI, 1.35-2.19), heart failure (1.88; 95% CI, 1.53-2.33), atrial fibrillation (OR, 1.54; 95% CI-1.21-1.95), substance use (OR, 1.88; 95% CI, 1.27-2.77), history of gastrointestinal bleeding (OR, 2.43; 95% CI, 1.29-4.58), and chronic kidney disease (OR, 1.78; 95% CI, 1.42-2.22) were independent predictors of 30-day readmissions. Readmission rates were highest during days 1 through 6 (peak, day 3) after discharge. The top three cardiac causes of readmissions were heart failure, recurrent angina, and recurrent ACS.

CONCLUSIONS

Female gender is an independent predictor of 30-day readmission after ACS that requires PCI. Our finding suggests women are at a higher risk of post-ACS cardiac events such as heart failure and recurrent ACS, and further gender-specific intervention is needed to reduce 30-day readmission rate in women after ACS.

Development and validation of Women Acute Myocardial Infarction in-Hospital Mortality Score (WAMI Score)

BACKGROUND

A variety of risk models have been developed to predict acute myocardial infarction (AMI) in-hospital mortality risk. As a distinct, higher-risk population, women with AMI have different risk profiles from their men counterparts. Published researches have indicated that the interaction between variables in these models for in-hospital mortality and gender are significant. Due to the interaction and gender differences, the predicting value of these risk models for women could be controversial.

METHODS

Databases from the China Patient-centered Evaluative Assessment of Cardiac Events (China PEACE) Retrospective AMI Study were utilized for model derivation (n=16,100, women were 4896) and databases from the China PEACE Prospective AMI Study for model validation (n=6207, women were 2090). A multivariable backward stepwise logistic regression was used to examine correlates of in-hospital mortality, and the variables were subsequently weighted and integrated into a scoring system.

RESULTS

We constructed a novel risk-predicting tool to estimate the baseline risk of in-hospital mortality among women with AMI. The risk score includes 8 variables [age, systolic blood pressure, heart rate, initial glomerular filtration rate (GFR), serum glucose, Killip class, cardiac arrest, ventricular tachycardia/ventricular fibrillation (VT/VF)]. The prognostic discriminatory capacity of the Women Acute Myocardial Infarction in-Hospital Mortality (WAMI) risk score was excellent (c statistic 0.84, 95% confidence interval [CI]: 0.83 to 0.86, p<0.001). External validation of the model showed better prognostic capacity (c statistic 0.87, 95% CI: 0.84 to 0.90, p<0.001) than the GRACE risk score (0.77, 95% CI 0.72-0.82, p<0.001) and TIMI risk score (0.72, 95% CI 0.68-0.77, p<0.001).

CONCLUSIONS

The WAMI Score is a simple robust tool for predicting the in-hospital mortality risk of women with AMI.

TRIAL REGISTRATION

"China PEACE-Retrospective AMI Study", NCT01624883, retrospectively registered: April 2012. Date of enrolment of the first participant to the trial: June 17, 2012. "China PEACE-Prospective AMI Study", NCT01624909, prospectively registered: December 2012. Date of enrolment of the first participant to the trial: June 17, 2012.

Anger and Coronary Artery Disease in Women Submitted to Coronary Angiography: A 48-Month Follow-Up

Background

Anger control was significantly lower in patients with coronary artery disease (CAD), regardless of traditionally known risk factors, occurrence of prior events or other anger aspects in a previous study of our research group.

Objective

To assess the association between anger and CAD, its clinical course and predictors of low anger control in women submitted to coronary angiography.

Methods

This is a cohort prospective study. Anger was assessed by use of Spielberger’s State-Trait Anger Expression Inventory (STAXI). Women were consecutively scheduled to undergo coronary angiography, considering CAD definition as ≥ 50% stenosis of one epicardial coronary artery.

Results

During the study, 255 women were included, being divided into two groups according to their anger control average (26.99). Those with anger control below average were younger and had a family history of CAD. Patients were followed up for 48 months to verify the occurrence of major cardiovascular events.

Conclusion

Women with CAD undergoing coronary angiography had lower anger control, which was associated with age and CAD family history. On clinical follow-up, event-free survival did not significantly differ between patients with anger control above or below average.

Acute Myocardial Infarction During Pregnancy and the Puerperium in the United States

OBJECTIVE

To analyze trends in the incidence, in-hospital management, and outcomes of acute myocardial infarction (AMI) complicating pregnancy and the puerperium in the United States.

PATIENTS AND METHODS

Women 18 years or older hospitalized during pregnancy and the puerperium were identified from the National Inpatient Sample database from January 1, 2002, to December 31, 2014. International Classification of Diseases, Ninth Revision diagnosis and procedure codes were used to identify AMI during pregnancy-related admissions.

RESULTS

Overall, 55,402,290 pregnancy-related hospitalizations were identified. A total of 4471 cases of AMI (8.1 [95% CI, 7.5-8.6] cases per 100,000 hospitalizations) occurred, with 922 AMI cases (20.6%) identified in the antepartum period, 1061 (23.7%) during labor and delivery, and 2390 (53.5%) in the postpartum period. ST-segment elevation myocardial infarction occurred in 1895 cases (42.4%), and non-ST-segment elevation myocardial infarction occurred in 2576 cases (57.6%). Among patients with pregnancy-related AMI, 2373 (53.1%) underwent invasive management and 1120 (25.1%) underwent coronary revascularization. In-hospital mortality was significantly higher in patients with AMI than in those without AMI during pregnancy (adjusted odds ratio, 39.9; 95% CI, 23.3-68.4; P<.001). The rate of AMI during pregnancy and the puerperium increased over time (adjusted odds ratio, 1.25 [for 2014 vs 2002]; 95% CI, 1.02-1.52).

CONCLUSION

In patients hospitalized during pregnancy and the puerperium, AMI occurred in 1 of every 12,400 hospitalizations and rates of AMI increased over time. Maternal mortality rates were high. Additional research on the prevention and optimal management of AMI during pregnancy is necessary.

Sex differences in health outcomes at one year following acute myocardial infarction: A report from the China Patient-Centered Evaluative Assessment of Cardiac Events prospective acute myocardial infarction study

BACKGROUND

We examined sex differences in long-term health outcomes following acute myocardial infarction in China, including mortality, major adverse cardiac events and health status (symptoms, functioning, quality of life).

METHODS

A total of 3415 acute myocardial infarction patients (23.2% women) aged ⩾18 years were enrolled across 10 geographic regions in China (2012-2014) in the China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE) study. Clinical data was abstracted from medical records. Generic (Euro-Quality of Life Scale) and disease-specific (Seattle Angina Questionnaire) health status was obtained through interviews at baseline and one year.

RESULTS

At one year, women with acute myocardial infarction had a higher risk of death from all causes ( p<0.001), but had similar rates of major adverse cardiac events ( p=0.2). Women had lower mean generic (Euro-Quality of Life Scale utility index score: 0.90±0.13 vs 0.94±0.11) and disease specific health scores indicating poorer functioning (Seattle Angina Questionnaire summary score: 75.3±11.4 vs 78.4±9.7) and higher rates of daily/weekly angina (Seattle Angina Questionnaire angina frequency score ⩽60 vs >60: 9.1% vs 4.7%; all p<0.001). In multivariable analysis, there was a significant association between female sex and mortality (β=0.45, standard error=0.21, p=0.03) but not for major adverse cardiac events (β=-0.02, standard error=0.14, p=0.89). The association between female sex and worse generic health status persisted (β=-0.02, standard error=0.01, p=0.003), but was no longer significant between sexes for disease-specific health status (β=-0.82, standard error=0.58, p=0.154) or daily/weekly angina (odds ratio=1.39; 95% confidence interval 0.88-2.21).

CONCLUSION

Women in China have higher crude rates of all-cause/cardiovascular death versus men, as well as worse generic/disease specific health status at one-year post-acute myocardial infarction. The association between female sex and worse generic health status persisted following adjustment.

What's the Risk? Older Women Report Fewer Symptoms for Suspected Acute Coronary Syndrome than Younger Women

The purpose of the study was to determine whether older (≥65 years) and younger (<65 years) women presenting to the emergency department (ED) with symptoms suggestive of acute coronary syndrome (ACS) varied on risk factors, comorbid conditions, functional status, and symptoms that have implications for emergent cardiac care. Women admitted to five EDs were enrolled. The ACS Symptom Checklist was used to measure symptoms. Comorbid conditions and functional status were measured with the Charlson Comorbidity Index and Duke Activity Status Index. Logistic regression models were used to evaluate symptom differences in older and younger women adjusting for ACS diagnosis, functional status, body mass index (BMI), and comorbid conditions. Analyses were stratified by age, and interaction of symptom by age was tested. Four hundred women were enrolled. Mean age was 61.3 years (range 21–98). Older women (n = 163) were more likely to have hypertension, hypercholesterolemia, never smoked, lower BMI, more comorbid conditions, and lower functional status. Younger women (n = 237) were more likely to be members of minority groups, be college-educated, and have a non-ACS discharge diagnosis. Younger women had higher odds of experiencing chest discomfort, chest pain, chest pressure, shortness of breath, nausea, sweating, and palpitations. Lack of chest symptoms and shortness of breath (key symptoms triggering a decision to seek emergency care) may cause older women to delay seeking treatment, placing them at risk for poorer outcomes. Younger African American women may require more comprehensive risk reduction strategies and symptom management.

Prognostic Differences between Men and Women with Acute Coronary Syndrome. Data from a Brazilian Registry

Background

Gender-related differences have been reported in patients with acute coronary syndrome. The description of this comparative finding in a Brazilian registry has not yet been documented.

Objective

To compare male vs. female patients regarding the baseline characteristics, coronary findings, treatment and in-hospital and long-term prognosis.

Methods

This is a retrospective, multicenter and observational study that included 3,745 patients (2,437 males and 1,308 females) between May 2010 and May 2015. The primary in-hospital outcome was all-cause mortality. The secondary outcome consisted of combined events (cardiogenic shock, reinfarction, death, stroke and bleeding). The comparison between groups was performed using the chi-square and the t test, considering p < 0.05 as significant. In the long term, mortality and combined events were assessed using the Kaplan-Meier method, with a mean follow-up of 8.79 months.

Results

The mean age was 60.3 years for males and 64.6 for females (p < 0.0001). The most prevalent risk factor was systemic arterial hypertension in 72.9% of the women and 67.8% of the men (p = 0.001). Percutaneous coronary intervention was carried out in 44.9% of the males and 35.4% of the females (p < 0.0001), and coronary artery bypass grafting (CABG) was performed in 17% of the males and 11.8% of females (p < 0.0001), with a higher prevalence of three-vessel coronary artery disease in males (27.3% vs. 16.2%, p < 0.0001). Approximately 79.9% of the female patients received a diagnosis of acute coronary syndrome without ST-segment elevation, while in the male patients, this diagnosis was attained in 71.5% (p < 0.0001). No significant differences were observed between the groups in the short and long term, regarding both mortality and the combined events.

Conclusion

Several gender-related differences were observed in patients with acute coronary syndrome regarding the demographic characteristics, coronary artery disease pattern and implemented treatment. However, the prognostic evolution was similar between the groups.