Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants

Impact of gender on treatment and outcome of ICU patients

BACKGROUND

Gender modifies immunologic responses caused by severe trauma or critical illness. The aim of this study was to investigate the impact of gender on hospital mortality, length of intensive care unit (ICU) stay, and intensity of care of patients treated in ICUs.

METHODS

Data on 24,341 ICU patients were collected from a national database. We measured severity of illness with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and intensity of care with Therapeutic Intervention Scoring System (TISS) scores. We used logistic regression analysis to test the independent effect of gender on hospital mortality. We compared the lengths of ICU stay and the intensity of care of men and women.

RESULTS

Male gender was associated with increased hospital mortality among postoperative ICU patients [adjusted odds ratio 1.33 (95% confidence interval 1.12-1.58, P = 0.001)] but not among medical patients [adjusted odds ratio 1.02 (95% confidence interval 0.92-1.13, P = 0.74)]. Male gender was associated with an increased risk of death particularly in the oldest age group (75 years or older) and among the patients with relatively low APACHE II scores (<16). Mean length of ICU stay was 3.2 days for men and 2.6 days for women (P < 0.001). Male patients comprised 61.7% of the study population but consumed 66.0% of days in intensive care.

CONCLUSION

Male gender contributes to poor outcome in postoperative ICU patients. Approximately two-thirds of ICU resources are consumed by male patients.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Defining and measuring gender: a social determinant of health whose time has come

This paper contributes to a nascent scholarly discussion of sex and gender as determinants of health. Health is a composite of biological makeup and socioeconomic circumstances. Differences in health and illness patterns of men and women are attributable both to sex, or biology, and to gender, that is, social factors such as powerlessness, access to resources, and constrained roles. Using examples such as the greater life expectancy of women in most of the world, despite their relative social disadvantage, and the disproportionate risk of myocardial infarction amongst men, but death from MI amongst women, the independent and combined associations of sex and gender on health are explored. A model for incorporating gender into epidemiologic analyses is proposed.

The Role of Gender and Other Factors as Predictors of Not Receiving Reperfusion Therapy and of Outcome in ST-Segment Elevation Myocardial Infarction

BACKGROUND

The standard of care for ST-segment elevation myocardial infarction (STEMI) is prompt coronary reperfusion with thrombolysis or percutaneous coronary intervention. Women have higher mortality rates than men following STEMI and fewer women are considered eligible for reperfusion therapy. We analyzed the impact of gender, and other factors, on the outcome and treatment of STEMI in the TETAMI trial and registry.

METHODS

This exploratory analysis included 2741 patients from Treatment with Enoxaparin and Tirofiban in Acute Myocardial Infarction (TETAMI) presenting with STEMI within 24 hours of symptom onset. The primary composite end point was the combined incidence of all-cause death, recurrent myocardial infarction, and recurrent angina, at 30 days. Three multivariate analyses were performed to determine predictors of not receiving reperfusion therapy, the composite end point, or death.

RESULTS

The triple end point occurred in 17.8% of women versus 13.3% of men. Reperfusion therapy was utilized in 38.2% of women versus 47.3% in men. However, age > 75 years, delayed presentation, high systolic blood pressure (> 100) and region (South Africa), were significant, independent predictors of not receiving reperfusion therapy. Significant predictors of the triple end point included not receiving reperfusion therapy, age > 60 years, and higher Killip class. Predictors of death included age > 60 years, low systolic blood pressure, higher Killip class, high heart rate, delayed presentation, and region (South Africa and South America).

CONCLUSION

Female gender was not an independent predictor of outcome or underutilization of reperfusion therapy. Factors more common in female STEMI patients (advanced age and delayed presentation) were associated with not receiving reperfusion therapy and adverse outcome. Increased awareness is needed to reduce delayed presentation after symptom onset, especially among women. Abbreviated abstract. In this analysis of 2741 ST-segment elevation myocardial infarction patients in the TETAMI trial and registry, a trend was observed for women being less likely to receive reperfusion therapy and more likely to have an adverse outcome than men. This was related to factors more common in female patients (advanced age and delayed presentation), and showed that an increased awareness is needed to reduce delayed presentation after symptom onset, especially among women.

Gender differences in the link between depression and cardiovascular disease

Cardiovascular disease is the leading cause of mortality in women costing more than 500,000 lives each year in the United States alone. Major depression in healthy subjects increases cardiovascular mortality in both men and women. The presence of major depression in patients with recent acute myocardial infarction (AMI) or unstable angina more than doubles the risk of cardiac death in both men and women. In the presence of depression, lack of social integration has an additive effect on cardiac events. Depression is more prevalent in women with coronary heart disease (CHD) than in men. Psychologic counseling as well as cognitive behavioral treatment in women post-AMI seems to adversely affect prognosis, whereas it has neutral effects in men. Pharmacologic treatment of depression with serotonin reuptake inhibitors is safe in men and women post-AMI and is particularly effective in patients with recurrent depression. Whether effective treatment of depression lowers cardiac mortality remains to be proven.

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

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

Hypertensive retinopathy: there's more than meets the eye

Hypertension is associated with increased cardiovascular risk, leading to systemic end-organ damage, including retinopathy. However, the recent European Society of Hypertension-European Society of Cardiology and World Health Organization-International Society of Hypertension 2003 guidelines propose new prognostic indications for the classification of hypertensive retinopathy. In particular, grades I and II are no longer included among signs of end-organ damage, and only grades III and IV are retained as associated clinical conditions for the stratification of global cardiovascular risk. This review article will focus on the wider implications of clinical markers of microvascular damage in the retina, with specific reference to hypertension and end-organ damage. Early recognition of retinal changes remains an important step in the risk stratification of hypertensive patients.

Estimating cholesterol treatment rates among individuals with multiple risk factors and without coronary heart disease

This retrospective study examined lipid-lowering therapy treatment rates from 2000 to 2001 using the Ingenix LabRx Database. Patients with multiple risk factors without coronary heart disease were identified based on the presence of >/=2 of the following: men >/=45 years, women >/=55 years, hypertension, high-density lipoprotein cholesterol <40 mg/dl, total cholesterol >/=200 mg/dl, or obesity. Lipid treatment rates were estimated among those needing therapy (defined as low-density lipoprotein cholesterol >/=130 mg/dl or currently receiving lipid-lowering therapy). The overall lipid-lowering therapy treatment rate was 38% and the estimated lipid treatment gap (percent needing treatment who were not receiving it) was 62%.

Estrogen inhibits hyperthermia-induced expression of heat-shock protein 72 and cardioprotection against ischemia/reperfusion injury in female rat heart

There is still controversy as to whether estrogen inhibits or enhances heat-shock protein (HSP72) expression in the heart. To evaluate the gender difference, whole-body hyperthermia (HT, 43 degrees C for 20 min) or normothermia (NT, 37 degrees C for 20 min) was applied to both male and female rats. Twenty-four hours after each thermo-treatment, the heart was isolated for either Western blot analysis or isolated-perfused heart experiments. Induction of HSP72 expression and post-ischemic recovery of left ventricular (LV) function was pronounced in male than in female heart. To evaluate the effect of estrogen, female rats received ovariectomy. One week after the operation, ovariectomized rats were treated with 17beta-estradiol in a single administration of 4, 40, or 400 mug/kg or vehicle (placebo) intraperitoneally (IP), followed by HT or NT at 6 h after the administration. In the placebo-treated ovariectomized female, HT-induced cardiac HSP72 expression was more remarkable with better LV functional recovery than sham-operated gonadally intact female. Treatment with 17beta-estradiol reduced HT-induced cardiac HSP72 overexpression and abolished better LV functional recovery observed in placebo-treated ovariectomized female. Inhibition of HT-induced HSP72 expression was in association with the inhibition of activation of heat-shock factor 1 (HSF1). In cultured rat neonatal cardiomyocytes, prior exposure to H(2)O(2)-induced HSP72 expression and rendered protection against hypoxia/reoxygenation, which was attenuated by the treatment with 17beta-estradiol. The washout of 17beta-estradiol for 48 h recovered the H(2)O(2)-induced HSP72 expression and tolerance against hypoxia/reoxygenation. Our results suggest that the male heart is more sensitive than gonadally intact female heart in terms of response to HT to express HSP72 in association with protection against ischemic insult. This observation may be due to the inhibitory effects of estrogen on HSP72 expression at a transcriptional level.

Management of dyslipidemia in women in the post-hormone therapy era

OBJECTIVE

Cardiovascular disease (CVD) is the leading cause of death for women in the United States and is largely preventable. The American Heart Association has recently released evidence-based guidelines for the prevention of CVD in women; these include gender-specific recommendations for the management of dyslipidemia. This article reviews these recommendations and the evidence supporting them.

DESIGN

This was a qualitative review of a systematic literature search related to lipid guidelines for women and discussion of rationale and evidence for new clinical recommendations.

MAIN RESULTS

Lifestyle modifications are the cornerstone of lipid management. Substantial evidence from randomized clinical trials supports the use of low-density lipoprotein cholesterol-lowering therapy (primarily statins) in all high-risk women and the use of niacin or fibrates when high-density lipoprotein cholesterol is low or non-high-density lipoprotein cholesterol is elevated. Fewer data are available for women at lower or intermediate risk.

CONCLUSIONS

Encouragement of lifestyle modification and appropriate use of lipid-altering therapy will have a substantial impact on reducing the burden of cardiovascular disease in women.

Womenʼs Hearts—Stress Management for Women With Ischemic Heart Disease

PURPOSE

This randomized controlled study aimed to evaluate the effects on psychosocial variables of a 1-year group-based cognitive-behavioral stress management program developed specifically for women with ischemic heart disease.

METHODS

The present explanatory (per protocol) analyses include 80 women who were randomized to a 1-year cognitive-behavioral stress management program and 86 who were randomized to usual care (age = 35-77 years). Data were obtained before randomization and after 1 year, when the intervention group had completed the program.

RESULTS

There were no statistically significant differences between the intervention and usual care groups in the psychosocial endpoints at randomization. Both groups improved in all psychosocial variables during the 1-year study period, but the rate of improvement was significantly greater in the intervention group for self-rated stress behavior (P = .006) and vital exhaustion (P = .03). Although changes were in favor of the treatment group also for depressive mood and quality of life, the rates of improvement between the 2 groups did not reach statistical significance (P = .23 and P = .10, respectively).

CONCLUSION

A 1-year cognitive-behavioral stress management program designed specifically for women improved psychological well-being in some aspects in comparison with usual care.

Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: Consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association

Cardiovascular disease is the leading cause of mortality for women in the United States. Coronary heart disease, which includes coronary atherosclerotic disease, myocardial infarction, acute coronary syndromes, and angina, is the largest subset of this mortality, with >240,000 women dying annually from the disease. Atherosclerotic coronary artery disease (CAD) is the focus of this consensus statement. Research continues to report underrecognition and underdiagnosis of CAD as contributory to high mortality rates in women. Timely and accurate diagnosis can significantly reduce CAD mortality for women; indeed, once the diagnosis is made, it does appear that current treatments are equally effective at reducing risk in both women and men. As such, noninvasive diagnostic and prognostic testing offers the potential to identify women at increased CAD risk as the basis for instituting preventive and therapeutic interventions. Nevertheless, the recent evidence-based practice program report from the Agency for Healthcare Research and Quality noted the paucity of women enrolled in diagnostic research studies. Consequently, much of the evidence supporting contemporary recommendations for noninvasive diagnostic studies in women is extrapolated from studies conducted predominantly in cohorts of middle-aged men. The majority of diagnostic and prognostic evidence in cardiac imaging in women and men has been derived from observational registries and referral populations that are affected by selection and other biases. Thus, a better understanding of the potential impact of sex differences on noninvasive cardiac testing in women may greatly improve clinical decision making. This consensus statement provides a synopsis of available evidence on the role of the exercise ECG and cardiac imaging modalities, both those in common use as well as developing technologies that may add clinical value to the diagnosis and risk assessment of the symptomatic and asymptomatic woman with suspected CAD.

Sex-specific genetic architecture of whole blood serotonin levels

Recently, a quantitative-trait locus (QTL) for whole blood serotonin level was identified in a genomewide linkage and association study in a founder population. Because serotonin level is a sexually dimorphic trait, in the present study, we evaluated the sex-specific genetic architecture of whole blood serotonin level in the same population. Here, we use an extended homozygosity-by-descent linkage method that is suitable for large complex pedigrees. Although both males and females have high broad heritability (H2=0.99), females have a higher additive component (h2=0.63 in females; h2=0.27 in males). Furthermore, the serotonin QTL on 17q that was identified previously in this population, integrin beta 3 (ITGB3), and a novel locus on 2q influence serotonin levels only in males, whereas linkage to a region on chromosome 6q is specific to females. Both sexes contribute to linkage signals on 12q and 16p. There were, overall, more associations meeting criteria for suggestive significance in males than in females, including those of ITGB3 and the serotonin transporter gene (5HTT). This analysis is consistent with heritable sexual dimorphism in whole blood serotonin levels resulting from the effects of a combination of sex-specific and sex-independent loci.

In-hospital management and outcome in women with acute myocardial infarction (data from the AMI-Florence Registry)

Primary percutaneous coronary intervention proved to be superior to thrombolysis in reducing ST-segment elevation acute myocardial infarction (STEAMI) mortality. However, whether such benefit is similar in women and men remains unclear. The aim of the present analysis was to assess the independent effect of female gender on management and on early and 1-year mortality in Florence, Italy, where primary percutaneous coronary intervention is the preferred reperfusion strategy for STEAMI. The study included a cohort of 920 unselected patients with STEAMI (men = 627, women = 293) prospectively enrolled in the AMI-Florence, population-based registry over 12 months. Women were older (76 vs 68 years, p <0.001) and more frequently had Killip class >I heart failure than men. The median delay to hospital admission was marginally longer in women (160 vs 130 minutes, p = 0.09). Coronary reperfusion treatment was performed less often in women (49% vs 58%, p <0.013); primary percutaneous coronary intervention was performed more often in both genders (90% vs 91%) and with similar median door-to-balloon time (50 vs 45 minutes, p = 0.44). Both in-hospital (16% vs 8%, p <0.001) and 1-year mortality (25% vs 18%, p = 0.016) were higher in women. However, after adjusting for age and other baseline characteristics, reperfusion treatment (odds ratio 1.27, 95% confidence interval [CI] 0.78 to 2.08) and 1-year mortality (hazard ratio [HR] 0.91, 95% CI 0.67 to 1.24) were independent of female gender. Compared with conservative therapy, reperfusion treatment was associated with a similar reduction in 1-year mortality in women (HR 0.59, 95% CI 0.34 to 1.02) and men (HR 0.58, 95% CI 0.37 to 0.92). Our data suggest that older age and several age-related factors may largely account for the higher mortality of women after STEAMI. Even in the general population,improvement in prognosis associated with reperfusion treatment is independent of gender.

Sex-related differences in outcome after ST-segment elevation myocardial infarction treated by primary angioplasty: data from the Zwolle Myocardial Infarction study

BACKGROUND

Several studies have found that among patients with ST-elevation myocardial infarction (STEMI) treated by thrombolysis, female sex is associated with a worse outcome. The aim of this study was to investigate sex-related differences in clinical and angiographic findings and in long-term outcome in patients with STEMI treated with primary angioplasty.

METHODS

Our population is represented by 1548 consecutive patients with STEMI treated by primary angioplasty from April 1997 to October 2001. All clinical, angiographic, and follow-up data were prospectively collected.

RESULTS

Among 1548 patients, 353 were women (22.8%). Female sex was associated with more advanced age, higher prevalence of diabetes, hypertension, more advanced Killip class, longer ischemia time, and smaller vessel caliber. No difference was observed in terms of procedural success, postprocedural epicardial flow, myocardial perfusion, ST-segment resolution, and enzymatic infarct size. At 1-year follow-up, female sex was associated with a significantly higher 1-year mortality rate at univariate (9.3% vs 4.9 %, RR [95% CI] = 1.79 [1.14 to 2.8], P = .002) but not at multivariate analysis (RR [95% CI] = 1.41 [0.86 to 2.32], P = NS).

CONCLUSIONS

This study shows that in patients with STEMI treated by primary angioplasty, women are associated with higher mortality rate in comparison with men, mainly because of their high-risk profile and angiographic features. Female sex did not emerge as an independent predictor of death.

Short-term (28 days) prognosis between genders according to the type of coronary event (Q-wave versus non-Q-wave acute myocardial infarction versus unstable angina pectoris)

The type of acute coronary syndrome may account for different prognoses between men and women after myocardial infarction. This study assessed gender differences in 28-day mortality rates for first or recurrent Q-wave and non-Q-wave myocardial infarctions and unstable angina by using data from 5 registries that included 20,836 patients (24.8% women). Mortality rates were higher in women with first Q-wave myocardial infarction but not in the other patients after adjusting for confounding variables.

Acute coronary syndromes in women: is treatment different? Should it be?

The vast majority of acute coronary syndrome (ACS) trials conducted over the past two decades support the view that women have persistently higher mortality and morbidity despite the introduction of new medical therapies and devices. Even after adjustment for older age, higher prevalence of diabetes, hypertension, heart failure, smaller vessel size, and late presentation, some studies still point to a persistent sex disadvantage. Even in contemporary practice, women continue to have longer delays in presentation and treatment. Selection bias in unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) trials allows inclusion of large numbers of women with clinically insignificant coronary disease and may mistakenly shift results toward apparent benefit of a less aggressive approach. This bias causes further difficulty in determining efficacy and safety of new antithrombotic agents such as direct thrombin inhibitors and glycoprotein IIb/IIa inhibitors across the spectrum of ACS. In trials of UA/NSTEMI, use of objective evidence of ischemia such as elevated troponin levels, would greatly assist the determination of efficacy and benefit in women. Enrollment of more women in clinical trials and timely sex-specific analysis would promote a better understanding of the role of female gender in ACS and would facilitate better care of all patients.

Outcome of ST-elevation myocardial infarction treated with thrombolysis in the unselected population is vastly different from samples of eligible patients in a large-scale clinical trial

BACKGROUND

Patients in clinical trials of fibrinolytic agents have been shown to be younger, less often female, and to have lower risk characteristics and a better outcome compared with unselected patients with ST-elevation myocardial infarction. However, a direct comparison of patients treated with fibrinolytic agents and not enrolled versus those enrolled in a trial, including a large number of patients, has not been performed.

METHODS

Prospective data from the Swedish Register of Cardiac Intensive Care on patients admitted with acute myocardial infarction treated with thrombolytic agents in 60 Swedish hospitals were linked to data on trial participants in the ASsessment of Safety and Efficacy of a New Thrombolytic (ASSENT)-2 trial of fibrinolytic agents. Baseline characteristics, treatments, and long-term outcome were evaluated in 729 trial participants (A2), 2048 nonparticipants at trial hospitals (non-A2), and 964 nonparticipants at other hospitals (non-A2-Hosp).

RESULTS

Nontrial patients compared with A2 patients were older and had higher risk characteristics and more early complications, although the treatments were similar. Patients at highest risk of death were the least likely to be enrolled in the trial. The 1-year mortality rate was 8.8% versus 20.3% and 19.0% (P <.001 for both) among A2 compared with non-A2 and non-A2-Hosp patients, respectively. After adjustment for a number of risk factors, the 1-year mortality rate was still twice as high in nontrial compared with A2 patients.

CONCLUSIONS

The adjusted 1-year mortality rate was twice as high in patients treated with fibrinolytic agents and not enrolled in a clinical trial compared with those enrolled. One major reason for the difference in outcome appeared to be the selection of less critically ill patients to the trial.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

'Add women & stir'--the biomedical approach to cardiac research!

In conditions shared by women and men, the biomedical model of disease assumes that illness-symptoms and outcomes are biologically and socially 'neutral'. Consequently, up until a decade ago, white middle-aged men were the model subjects in most funded cardiac trials, with the assumption that whatever the findings, the results would also hold true for women. This 'add women and stir' approach has resulted in imbalances in cardiac care and an image of coronary artery disease, which portrays a middle-aged male as its victim. Moreover, cardiac health care has been designed with the male anatomy and male experience of illness in mind, and health promotional measures have been targeted towards men. Women have received these health promotional messages to protect the hearts of men, and have been less likely to modify their own lifestyles in a cardio-protective manner. However, the biological and social differences that exist between women and men, must surely invalidate such biased biomedical assertions, and signify a need to delve beyond the realm of biomedical reductionism for greater insights and understanding. This review examines how scientific reductionism has failed to explore the impact of coronary artery disease on the lives of women and how the gendered image of this disease has privileged the normative frame.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ischemic heart disease in women and the role of hormone therapy

The prevalence of ischemic heart disease (IHD) has been increasing among the women in developed countries. The well recognized IHD excess in men has often obscured the fact that IHD is the leading cause of death in women. Women have atypical symptoms of IHD that lead to a delay in the diagnosis and an overall poor prognosis. Women have a delay in the onset of IHD due to the beneficial effects of their sex hormones. Postmenopausal women lose this beneficial effect of estrogen and undergo significant changes in their lipid profile, arterial pressure, glucose tolerance, and vascular reactivity that increase their risk for development of IHD. Recently there has been considerable interest in the sex hormones and their role in IHD in women. The general belief that hormone replacement therapy (HRT) has an overall beneficial effect on cardiovascular disease (CVD) in women and hence decreases CVD mortality and morbidity has not been shown in the recent multicenter prospective studies. With the availability of various types of estrogen and progestins, physicians prescribing these agents should take into consideration their varying effects on the cardiovascular system. Risk factor modifications should include diet, weight loss, regular exercise, smoking cessation and adequate control of hypertension (HTN), diabetes (DM) and hyperlipidemia. In the appropriate setting, treatment with proven beneficial agents like aspirin, beta-blockers, angiotensin converting enzyme (ACE) inhibitors and statins will help decrease the burden of IHD in women.

Outcomes of thrombolytic therapy for acute myocardial infarction in women

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

Symptoms in acute coronary syndromes: does sex make a difference?

BACKGROUND

Coronary heart disease is a major problem in both men and women, but several studies have shown sex differences in symptoms of acute coronary syndromes (ACS). Some findings, however, have been disparate and inadequate, and thus a comprehensive overview of this literature would be of value.

METHOD

Fifteen studies that identified symptoms of ACS for both women and men were examined through a review of the literature from 1989 to 2002. Terms used for the search included "myocardial infarction," "symptoms," "gender differences," and "acute coronary syndromes."

RESULTS

Although chest pain was the most common symptom in both men and women, several differences were also noted. In all types of ACS, women had significantly more back and jaw pain, nausea and/or vomiting, dyspnea, indigestion, and palpitations. In a number of studies, which solely sampled patients with acute myocardial infarction, women demonstrated more back, jaw, and neck pain and nausea and/or vomiting, dyspnea, palpitations, indigestion, dizziness, fatigue, loss of appetite, and syncope. Men reported more chest pain and diaphoresis in the myocardial infarction sample. The designs and methodologies of the studies varied considerably.

CONCLUSION

In addition to the typical symptom of chest pain in ACS, women experience other atypical symptoms more frequently than men. Thus, there may be sex differences in the symptoms of ACS, differences that have a bearing not only on clinical practice, but also on the interpretation of available clinical studies and the design of future investigations.

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

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

Relation of age and race with hospital death after acute myocardial infarction

BACKGROUND

Prior studies have suggested that young blacks with acute myocardial infarction (AMI) may have higher hospital mortality rates than whites of similar age. However, the influence of age and race on short-term death has not been explored in detail. We examined the relation of age and race on short-term death in a large AMI population and ascertained the factors that may have contributed to differences in mortality rates.

METHODS

We compared the crude and adjusted hospital mortality rates stratified by age among 40,903 blacks and 501,995 whites with AMI enrolled in the National Registry of Myocardial Infarction-2 in 1482 participating US hospitals from June 1994 through March 1998.

RESULTS

Overall crude mortality was lower among blacks compared with whites (10.9% vs 12.0%, P <.0001). However, blacks had a significantly higher crude mortality rate compared with the whites in the age groups <65 years (<45 years, and 5-year age groups between 45 and 64 years). There was a statistically significant interaction between age and black race on hospital death (P value for interaction <.001). Each 5-year decrement in age from 85 years was associated with 7.2% higher odds of death in blacks compared with whites (95% CI, 5.7% to 7.6%). After adjusting for differences in the baseline, clinical presentation, early treatment, and hospital characteristics, 5-year decrements in age was still associated with increases in the odds for death in blacks compared with whites (5.4%; 95% CI, 3.6% to 7.2%). This interaction between age and black race was present in both sexes but was stronger among men.

CONCLUSIONS

Blacks younger than 65 years had higher hospital mortality rates compared with whites hospitalized for AMI, and decreasing age was associated with progressively higher risk of hospital death for blacks. Differences in the clinical presentation, early treatment, and hospital characteristics could only partly explain this age-race interaction.

Cardiovascular health and economic effects of smoke-free workplaces

PURPOSE

Smoking is the leading controllable risk factor for heart disease. Only about 69% of U.S. indoor workers are currently covered by a smoke-free workplace policy. This analysis projects the cardiovascular health and economic effects of making all U.S. workplaces smoke free after 1 year and at steady state.

METHODS

We estimated the number of U.S. indoor workers not covered by smoke-free workplace policies, and the effects of making all workplaces smoke free on smoking behavior and on the relative risks of acute myocardial infarctions and strokes. One-year and steady-state results were calculated using an exponential decline model. A Monte Carlo simulation was performed for a sensitivity analysis.

RESULTS

The first-year effect of making all workplaces smoke free would produce about 1.3 million new quitters and prevent over 950 million cigarette packs from being smoked annually, worth about 2.3 billion dollars in pretax sales to the tobacco industry. In 1 year, making all workplaces smoke free would prevent about 1500 myocardial infarctions and 350 strokes, and result in nearly $60 [corrected] in savings in direct medical costs. At steady state, 6250 myocardial infarctions and 1270 strokes would be prevented, and $279 million [corrected] would be saved in direct medical costs annually. Reductions in passive smoking would account for 60% of effects among acute myocardial infarctions.

CONCLUSION

Making all U.S. workplaces smoke free would result in considerable health and economic benefits within 1 year. Reductions in passive smoking would account for a majority of these savings. Similar effects would occur with enactment of state or local smoke-free policies.

Ethnic variations in female vulnerability after an acute coronary event

OBJECTIVE

To determine the ethnic variation of short and long term female vulnerability after an acute coronary event in a population of Chinese, Indians, and Malays.

DESIGN

Population based registry.

PATIENTS

Residents of Singapore between the ages of 20-64 years with coronary events. Case identification and classification procedures were modified from the MONICA (monitoring trends and determinants in cardiovascular disease) project.

MAIN OUTCOME MEASURES

Adjusted 28 day case fatality and long term mortality.

RESULTS

From 1991 to 1999, there were 16 320 acute coronary events, including 3497 women. Age adjusted 28 day case fatality was greater in women (51.5% v 38.6%, p < 0.001), with a larger sex difference evident among younger Malay patients. This inequality between the sexes was observed in both the pre-hospitalisation and post-admission periods. Among hospitalised patients, women were older, were less likely to have suffered from a previous Q wave or anterior wall myocardial infarction, and had lower peak creatine kinase concentrations. Case fatality was higher among women, with adjusted hazard ratios of 1.64 (95% confidence interval (CI) 1.43 to 1.88) and 1.50 (95% CI 1.37 to 1.64) for 28 day and mean four year follow up periods. There were significant interactions of sex and age with ethnic group (p = 0.017). The adjusted hazards for mortality among Chinese, Indian, and Malay women versus men were 1.30, 1.71, and 1.96, respectively. The excess mortality among women diminished with age.

CONCLUSION

In this multiethnic population, both pre-hospitalisation and post-admission case fatality rates were substantially higher among women. The sex discrepancy in long term mortality was greatest among Malays and in the younger age groups.

Gender-related differences in acute aortic dissection

BACKGROUND

Few data exist on gender-related differences in clinical presentation, diagnostic findings, management, and outcomes in acute aortic dissection (AAD).

METHODS AND RESULTS

Accordingly, we evaluated 1078 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) to assess differences in clinical features, management, and in-hospital outcomes between men and women. Of the patients enrolled in IRAD (32.1%) with AAD, 346 were women. Although less frequently affected by AAD (32.1% of AAD), women were significantly older and had more often presented later than men (P=0.008); symptoms of coma/altered mental status were more common, whereas pulse deficit was less common. Diagnostic imaging suggestive of rupture, ie, periaortic hematoma, and pleural or pericardial effusion were more commonly observed in women. In-hospital complications of hypotension and tamponade occurred with greater frequency in women, resulting in higher in-hospital mortality compared with men. After adjustment for age and hypertension, women with aortic dissection die more frequently than men (OR, 1.4, P=0.04), predominantly in the 66- to 75-year age group. Moreover, surgical outcome was worse in women than men (P=0.013); type A dissection in women was associated with a higher surgical mortality of 32% versus 22% in men despite similar delay, surgical technique, and hemodynamics.

CONCLUSIONS

Our analysis provides insights into gender-related differences in AAD with regard to clinical characteristics, management, and outcomes; important diagnostic and therapeutic implications may help shed light on aortic dissection in women to improve their outcomes.

Gender and place of death from coronary artery disease in Washington State

Men may be more likely than women to die outside the hospital from coronary artery disease, whereas women may be as likely as men to die inside the hospital. This study used Washington State death records to compare death rates from coronary artery disease inside and outside the hospital for women and men from 1980 to 2001. For in-hospital deaths, the men:women ratio of deaths was 1.6 in 1980 and 2001; for out-of-hospital deaths, the ratio decreased slightly from 2.6 in 1980 to 2.3 in 2001. These findings support the contention that, despite significant decreases in mortality, men continue to have higher rates of death outside and inside the hospital than do women, although there has been a slight decrease in male:female mortality for deaths outside the hospital.

Effect of estrogen replacement treatment on ischemic preconditioning in isolated rat hearts

In the present study, we tested the effects of long-term estrogen replacement treatment on myocardial ischemia-reperfusion injury and on the cardioprotection of ischemic preconditioning in isolated hearts from ovariectomized rats. Ovariectomized rats were treated with 17β-estradiol (30 µg/kg/d, s.c.) for 12 weeks. Isolated rat hearts were perfused in the Langendorff mode. Heart rate, coronary flow, left ventricular pressure and its first derivative (±LVdp/dtmax) were recorded. Fifteen-min global ischemia and 30-min reperfusion caused a significant decrease of cardiac mechanical function, which were not affected by ovariectomy or estrogen replacement treatment. The isolated hearts in all groups could be preconditioned, and the cardioprotection afforded by preconditioning in the sham-operated rats was greater compared with ovariectomized rats with or without estrogen treatment. These results suggest that long-term estrogen replacement treatment exerts no effect on the inhibition of mechanical function after ischemia-reperfusion, and this study also suggests that estrogen does not affect ischemic preconditioning in isolated hearts of ovariectomized rats.Key words: ERT (estrogen replacement treatment), ischemia-reperfusion, ischemic preconditioning, heart, rat.

Comparison of differences in outcome after percutaneous coronary intervention in men versus women <40 years of age

We evaluated the outcomes of 177 consecutive patients (43 women, 134 men) <40 years of age with premature atherosclerosis who underwent percutaneous coronary intervention. Women were younger, had more diabetes mellitus (37% vs 10%; p <0.001), but less hyperlipidemia (58% vs 75%; p <0.001) compared with men. In-hospital vascular complications and 1-year mortality rate or Q-wave myocardial infarction (7.9% vs 0.08%, p <0.01) were higher in women. By multivariable regression analysis, female gender was the only independent predictor of vascular complications (odds ratio, 14.1; 95% confidence intervals, 1.59 to 125, p = 0.01) and of 1-year mortality rate or nonfatal myocardial infarction (odds ratio, 12.5; 95% confidence interval, 1.14 to 111, p = 0.03). Women with premature coronary disease had a distinctive risk factor profile relative to men, with a predominance of diabetes and hypercholesterolemia, and were at higher risk of developing vascular and ischemic complications after percutaneous coronary intervention, warranting aggressive risk factor modification and vigilance in this population.

High Prevalence of Metabolic Syndrome among Young Women with Nonfatal Myocardial Infarction

OBJECTIVE

The aim of this study was to determine if the metabolic syndrome (MetS) or other risk factors might be common among young women with nonfatal myocardial infarction (MI).

METHODS

A matched case-control study using a structured interview and questionnaires, plus analysis of conventional and nonconventional risk factors for MI in serum or plasma was carried out at a teaching hospital. Subjects were 40 women with nonfatal MI at or before age 45 and an equal number of age-matched, ethnicity-matched, and smoking-matched female control subjects.

RESULTS

Cases and control subjects were not significantly different with regard to serum or plasma levels of homocysteine, anticardiolipin antibodies, beta(2)-glycoprotein I, prothrombin, folate, vitamin B(12), high-sensitivity C-reactive protein (CPR), fibrinogen, amyloid A, plasminogen activator inhibitor type 1 (PAI-1), or tissue plasminogen activator (tPA) antigen levels. Compared with matched controls, cases had a higher rate of obesity (37% vs. 12%, p = 0.02), a higher proportion of fasting glucose >/=110 mg/dl (9% vs. 1%, p = 0.01), and higher overall insulin resistance (27% vs. 5%, p = 0.007). Type 2 diabetes tended to be more common in cases (17% vs. 5%, p = 0.10). Cases were also more likely to be hypertensive (35% vs. 12%, p = 0.04) and dyslipidemic (80% vs. 42%, p = <0.001) and to have higher triglyceride levels (110 +/- 13 mg/dl vs. 96 +/- 12, p = 0.02). Overall, after controlling for weight, cases were 4.7 times more likely to have three or more diagnostic criteria of the MetS than matched controls: chi-square = 7.2, OR = 4.7, 95% CI (1.3, 25.3), p = 0.008.

CONCLUSIONS

Although this study may have been underpowered to recognize the contribution of other risk factors, we found that the dominant predictor of nonfatal MI in young women was the MetS. Screening young women with central obesity for other parameters of the MetS may help reduce the risk of MI at an early age.

Sex differences in the expression of haemorheological determinants in individuals with atherothrombotic risk factors and in apparently healthy people

BACKGROUND

Increased red cell aggregation can be detrimental, leading to slow capillary blood flow and tissue hypoxaemia. Sex differences in the degree of erythrocyte adhesiveness/aggregation in the peripheral blood have not been clearly shown.

OBJECTIVES

To determine whether there are sex differences in the expression of erythrocyte adhesiveness/aggregation in the peripheral blood in individuals with atherothrombotic risk factors and in apparently healthy people.

METHODS

From a cohort of 965 participants in the Tel Aviv Medical Centre inflammation survey, 192 pairs of different sex were matched for age, body mass index, hip and waist circumferences, cardiovascular risk factors, and the intake of active cardiovascular drugs.

RESULTS

Women had an enhanced degree of red cell aggregation (p < 0.0005) as well as increased concentrations of inflammation sensitive proteins including fibrinogen and C reactive protein. Women had a lower haemoglobin concentration than men, but this did not affect the degree of erythrocyte adhesiveness/aggregation.

CONCLUSIONS

The significant increase in red blood cell adhesiveness/aggregation in the peripheral blood of women with atherothrombosis could be relevant to the more eventful course that some women experience during and following acute ischaemic disease.

Coronary heart disease: the female heart is vulnerable

During the past decade, an overall theme has emerged, validating the exploration of gender-based differences in coronary heart disease (CHD) as a basis for clinical strategies to improve outcomes for women. Underrepresentation of women in most of CHD and lack of gender-specific reporting in many clinical trials continue to limit the available knowledge and evidence-based medicine needed to devise optimal managements for women with CHD. Control of conventional coronary risk factors provides comparable cardioprotection for men and women. Current evidence fails to show cardiac protection from menopausal hormone therapy. Clinical presentations of coronary heart disease (CHD) and management strategies differ between the sexes. Underutilization of proven beneficial therapies is a contributor to less-favorable outcomes in women. The contemporary increased application of appropriate diagnostic, therapeutic, and interventional managements has favorably altered the prognosis for women, particularly when the data are adjusted for baseline characteristics. Better education of women during office visits, earlier and more aggressive control of coronary risk factors, and a greater index of suspicion regarding chest pain and its appropriate evaluation may help to reverse the trend of late referral and late intervention. Research indicates that behavioral changes on the part of women and reshaping of practice patterns by their health care providers may dramatically reduce the number of women disabled and killed by CHD each year.

Prehospital cardiac arrest and the adverse effect of male gender, but not age, on outcome

OBJECTIVE

To analyze the incidence and outcome of prehospital cardiac arrest as it correlated to gender and age as a secondary end point in an interventional clinical trial.

METHODS

This prospective, randomized, double-blinded clinical intervention trial enrolled 874 prehospital cardiopulmonary arrest patients encountered by prehospital urban, suburban, and rural regional emergency medical service (EMS) areas. This trial evaluated outcome and profiled demographic predictors of cardiac arrest patients refractory to defibrillation with intravenous access who underwent standard advanced cardiac life support (ACLS) intervention and empiric early administration of bicarbonate. Survival was measured to the emergency department (ED), and data analysis used chi-square with Pearson correlation.

RESULTS

The overall survival rate was 14.2%. There was no age correlate to survival, with an average age of 67.4 for both groups. Male patients had a 2.4-fold increased incidence (70.7 vs. 29.3%, p = 0.001) of arrest, which was associated with a 60% increase in mortality (19.6% vs. 11.8, p = 0.004) compared with women. The risk of unfavorable outcome was increased for men (OR 1.826, 95% CI 1.182-2.821; RR 1.097, 95% CI 1.025-1.180) on univariate analysis. There appeared to be no intergroup differences found with other historical variables, such as the presence of myocardial infarction (MI), hypertension (HTN), diabetes mellitus (DM), congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), which were analyzed. However, HTN was found more commonly (2.2 times) in men (69.1 vs. 30.9%) than in women but did not correlate with survival.

CONCLUSIONS

Male gender, but not age, is associated with both an increased incidence and a worsened outcome in prehospital cardiac arrest.

Predictors of neurocardiogenic injury after subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Subarachnoid hemorrhage (SAH) frequently results in myocardial necrosis with release of cardiac enzymes. Historically, this necrosis has been attributed to coronary artery disease, coronary vasospasm, or oxygen supply-demand mismatch. Experimental evidence, however, indicates that excessive release of norepinephrine from the myocardial sympathetic nerves is the most likely cause. We hypothesized that myocardial necrosis after SAH is a neurally mediated process that is dependent on the severity of neurological injury.

METHODS

Consecutive patients admitted with SAH were enrolled prospectively. Predictor variables reflecting demographic (age, sex, body surface area), hemodynamic (heart rate, systolic blood pressure), treatment (phenylephrine dose), and neurological (Hunt-Hess score) factors were recorded. Serial cardiac troponin I measurements and echocardiography were performed on days 1, 3, and 6 after enrollment. Troponin level was treated as a dichotomous outcome variable. We performed univariate and multivariate analyses on the relationships between the predictor variables and troponin level.

RESULTS

The study included 223 patients with an average age of 54 years. Twenty percent of the subjects had troponin I levels >1.0 microg/L (range, 0.3 to 50 microg/L). By multivariate logistic regression, a Hunt-Hess score >2, female sex, larger body surface area and left ventricular mass, lower systolic blood pressure, and higher heart rate and phenylephrine dose were independent predictors of troponin elevation.

CONCLUSIONS

The degree of neurological injury as measured by the Hunt-Hess grade is a strong, independent predictor of myocardial necrosis after SAH. This finding supports the hypothesis that cardiac injury after SAH is a neurally mediated process.

Random output and hospital performance

Many countries are under pressure to reform health care financing and delivery. Hospital care is one part of the health system that is under scrutiny. Private management initiatives are a possible way to increase efficiency in health care delivery. This motivates the interest in developing methodologies to assess hospital performance, recognizing hospitals as a different sort of firm. We present a simple way to describe hospital production: hospital output as a change in the distribution of survival probabilities. This output definition allows us to separate hospital production from patients' characteristics. The notion of "better performance" has a precise meaning: (first-order) stochastic dominance of a distribution of survival probabilities over another distribution. As an illustration, we compare, for an important DRG, private and public management and find that private management performs better, mainly in the range of high-survival probabilities. The measured performance difference cannot be attributed to input prices or to economies of scale and/or scope. It reflects pure technological and organisational differences.