Sex differences in acute myocardial infarction: Is it only the age?

Loss of Snord116 protects cardiomyocyte kinetics during ischemic stress

Loss of Snord116, a non-coding RNA, causes Prader Willi Syndrome (PWS), a complex disorder with circadian, metabolic, neurologic, and cardiovascular phenotypes. The Snord116 paternal knockout (Snord116p-) mouse, a model of PWS, demonstrated differential methylation of thousands of genes involved in regulation of metabolism, epigenetics, and ion homeostasis. To determine if Snord116 expression influences the cardiomyocyte response to acute ischemia, we developed a model of ischemia and reperfusion using living myocardial slices and monitored cardiomyocyte function in slices derived from Snord116p- mice and wildtype littermates (WT LM) of both sexes. We found that Snord116 loss reduced ischemia-induced systolic prolongation and delayed diastolic elongation in slices from both males and females. Furthermore, when compared with slices from males, slices from females experienced a greater increase in end-diastolic force after ischemia. We conclude that female myocardium responds more dramatically and quickly to ischemic injury in this model and that loss of Snord116 is cardioprotective; this allows for a more complete myocardial recovery following reperfusion.

Emerging opportunities to target inflammation: myocardial infarction and type 2 diabetes

After myocardial infarction (MI), patients with type 2 diabetes have an increased rate of adverse outcomes, compared to patients without. Diabetes confers a 1.5-2-fold increase in early mortality and, importantly, this discrepancy has been consistent over recent decades, despite advances in treatment and overall survival. Certain assumptions have emerged to explain this increased risk, such as differences in infarct size or coronary artery disease severity. Here, we re-evaluate that evidence and show how contemporary analyses using state-of-the-art characterization tools suggest that the received wisdom tells an incomplete story. Simultaneously, epidemiological and mechanistic biological data suggest additional factors relating to processes of diabetes-related inflammation might play a prominent role. Inflammatory processes after MI mediate injury and repair and are thus a potential therapeutic target. Recent studies have shown how diabetes affects immune cell numbers and drives changes in the bone marrow, leading to pro-inflammatory gene expression and functional suppression of healing and repair. Here, we review and re-evaluate the evidence around adverse prognosis in patients with diabetes after MI, with emphasis on how targeting processes of inflammation presents unexplored, yet valuable opportunities to improve cardiovascular outcomes in this vulnerable patient group.

Predictive value of Killip classification in MINOCA patients

BACKGROUND

Killip classification is a practical clinical tool for risk stratification in patients with acute myocardial infarction (AMI). However, its prognostic role in myocardial infarction with non-obstructive coronary artery (MINOCA) is still poorly explored. Our purpose was to evaluate the prognostic role of high Killip class in the specific setting of MINOCA and compare the results with a cohort of patients with obstructive coronary arteries myocardial infarction (MIOCA).

METHODS

This study included 2455 AMI patients of whom 255 were MINOCA. We compared the Killip classes of MINOCA with those of MIOCA and evaluated the prognostic impact of a high Killip class, defined if greater than I, on both populations' outcome. Short-term outcomes included in-hospital death, re-AMI and arrhythmias. Long-term outcomes were all-cause mortality, re-AMI, stroke, heart failure (HF) hospitalization and the composite endpoint of MACE.

RESULTS

Killip class >1 occurred in 25 (9.8%) MINOCA patients compared to 327 (14.9%) MIOCA cases. In MINOCA subjects, a high Killip class was associated with a greater in-hospital mortality (p = 0.002) and, at long term follow-up, with a three-fold increased mortality (p = 0.001) and a four-fold risk of HF hospitalization (p = 0.003). Among MINOCA, a high Killip class was identified as a strong independent predictor of MACE occurrence [HR 2.66, 95% CI (1.25-5.64), p = 0.01] together with older age and worse kidney function while in MIOCA population also left ventricular ejection fraction and troponin value predicted MACE.

CONCLUSIONS

Killip classification confirmed its prognostic impact on short- and long-term outcomes also in a selected MINOCA population, which still craves for a baseline risk stratification.

Prognostic Implications of High-Degree Atrio-Ventricular Block in Patients with Acute Myocardial Infarction in the Contemporary Era

BACKGROUND

High-degree atrioventricular block (HAVB) is a known complication of ST-segment elevation myocardial infarction (STEMI). We aimed to determine the prevalence and prognostic impact of HAVB in a contemporary cohort of STEMI.

METHODS

Data were collected from the DIAMANTE registry that included STEMI patients admitted to our cardiac intensive care unit treated with urgent reperfusion. We studied the clinical characteristics and evolution in patients with and without HAVB at admission.

RESULTS

From 1109 consecutive patients, HAVB was documented in 95 (8.6%). The right coronary artery was the culprit vessel in 84 patients with HAVB (88.4%). The independent predictors of HAVB were: male sex (OR 1.9, 95% CI 1.2-2.9), age (OR 1.03, 95% CI 1.01-1.05), involvement of right coronary artery (OR 12.4, 95% CI 7.6-20.2), and creatinine value (OR 1.5, 95% CI 1.1-2.0). A transient percutaneous pacemaker was used in 37 patients with HAVB (38.9%). Patients with HAVB had higher mortality that patients without HAVB (15.8% vs. 4.1%, p < 0.001); however, in multivariate analysis, HAVB was not an independent predictor of in-hospital mortality.

CONCLUSIONS

HAVB was seen in 9% of STEMI patients and was particularly frequent in elderly males with renal failure. Patients with HAVB had a poor prognosis during hospitalization, but HAVB was not an independent predictor of in-hospital mortality.

Sex Differences in Outcome and Prescribing Practice in ST-elevation MI Patients with Multivessel Disease and Incomplete Revascularisation

Objective: To investigate the extent to which multivessel disease, incomplete revascularisation and prescribing differences contribute to sex-based outcome disparities in patients with ST-elevation MI (STEMI) and establish whether differences in cardiac death and MI (CDMI) rates persist at long-term follow-up. Methods and results: This observational study evaluates sex-based outcome differences (median follow-up 3.6 years; IQR [2.4–5.4]) in a consecutive cohort of patients (n=2,083) presenting with STEMI undergoing percutaneous coronary intervention). Of the studied patients 20.3% (423/2,083) were women and 38.3% (810/2,083) had multivessel disease (MVD). Incomplete revascularisation was common. The median residual SYNTAX score (rSS) was 5.0 (IQR [0–9]) in women and 5.0 (IQR [1–11]) in men (p=0.369), and in patients with MVD it was 9 (IQR [6–17]) in women and 10 (IQR [6–15]) in men (p=0.838). The primary endpoint CDMI occurred in 20.3% of women (86/423) and in 13.2% of men (219/1,660) (p=0.028). Differences persisted following multivariable risk adjustment: female sex was independently associated with CDMI (aHR 1.33; IQR [1.02–1.74]). Women with MVD had CDMI more often than all other groups (p<0.001 for all). Significant sex-based prescribing differences were evident: women were less likely to receive guideline-recommended potent P2Y12 inhibitors than men (31% versus 43%; p=0.012), and differences were particularly evident in patients with MVD (25% in women versus 45% in men, p=0.011). Conclusion: Sex-based differences in STEMI patient outcome persist at long-term follow-up. Poor outcomes were disproportionately found in women with MVD and those with rSS>8. Observed differences in P2Y12 prescribing practices may contribute to poor outcomes for women with MVD and incomplete revascularisation.

Gender Differences in Heart Failure Hospitalization Post-Myocardial Infarction

Objectives:

Patients with post-myocardial infarction (MI) are more likely to die later from heart failure (HF), arrhythmic events, or reinfarction. According to recent studies, mortality rates were noticeably higher in women, than in men. This has been linked to variations in age, comorbidities, symptom presentation, and pathophysiology of the underlying coronary artery disease. There is little information on how these typical gender disparities affect post- MI survival. Studies on individuals with coronary artery disease have primarily focused on men, with women typically being left out of most series. Despite the relatively high prevalence of ischemic heart disease in women, there is a lack of information regarding the clinical course of the condition, its management, and clinical outcomes in this particular population due to the underrepresentation of women in the medical literature in this field. The gender disparities in post-MI patients who present with HF will be briefly discussed in this article.

Materials and Methods:

A total of 50 patients that presented with HF and had a previous history of MI were included in this study after taking consent. After taking history and detailed physical examination, investigations that were sent were reviewed and the subjects followed up in the hospital stay to look for outcomes. The data are compiled and subjected to statistical analysis.

Results:

It is observed that among the 50 subjects, 32% of them had recurrent HF (13 of the 30 females and three of the 20 males). p = 0.04 is statistically significant. Among the study subjects, the hospital outcomes observed showed that, out of 50 subjects, 47 subjects recovered and the other three died in hospital stay. All the three deaths are women. p = 0.15 is not statistically significant.

Conclusion:

This study concludes that women are more likely than males to require hospitalization for recurrent HF following a MI. This study also demonstrates that, despite the higher risk of recurrent HF, women do not have a higher mortality risk than males.

Sex-specific behavioral, neurobiological, and cardiovascular responses to chronic social stress in mice

Psychosocial stress promotes and links mood and cardiovascular disorders in a sex-specific manner. However, findings in animal models are equivocal, in some cases opposing human dimorphisms. We examined central nervous system (CNS), behavioral, endocrine, cardiac, and hepatic outcomes in male or female C57Bl/6 mice subjected to chronic social stress (56 days of social isolation, with intermittent social confrontation encounters twice daily throughout the final 20 days). Females exhibited distinct physiological and behavioral changes, including relative weight loss, and increases in coronary resistance, hepatic inflammation, and thigmotaxic behavior in the open field. Males evidence reductions in coronary resistance and cardiac ischemic tolerance, with increased circulating and hippocampal monoamine levels and emerging anhedonia. Shared CNS gene responses include reduced hippocampal Maoa and increased Htr1b expression, while unique responses include repression of hypothalamic Ntrk1 and upregulation of cortical Nrf2 and Htr1b in females; and repression of hippocampal Drd1 and hypothalamic Gabra1 and Oprm in males. Declining cardiac stress resistance in males was associated with repression of cardiac leptin levels and metabolic, mitochondrial biogenesis, and anti-inflammatory gene expression. These integrated data reveal distinct biological responses to social stress in males and females, and collectively evidence greater biological disruption or allostatic load in females (consistent with propensities to stress-related mood and cardiovascular disorders in humans). Distinct stress biology, and molecular to organ responses, emphasize the importance of sex-specific mechanisms and potential approaches to stress-dependent disease.

Pharmacological treatment after acute coronary syndrome: Baseline clinical characteristics and gender differences in a population-based cohort study

OBJECTIVE

To describe baseline socio-demographic and clinical characteristics and drugs prescribed for secondary prevention after a first episode of ACS and to assess differences between men and women.

SETTING

PHC in Catalonia.

DATA SOURCE

SIDIAP (Information System for Research in Primary Care).

PARTICIPANTS

Patients who suffered an ACS during 2009-2016 and followed-up in PHC centres of the Catalan Health Institute in Catalonia.

INTERVENTIONS

Not applicable.

MAIN MEASURES

Socio-demographic and clinical characteristics at baseline: sex, age, socioeconomic index, toxic habits, comorbidities, study drugs (prescribed for cardiovascular secondary prevention: antiplatelets, betablockers, statins, drugs acting on the renin-angiotensin system) and comedications.

RESULTS

8071 patients included, 71.3% of them were men and 80.2% had an acute myocardial infarction. Their mean age was 65.3 and women were older than men. The most frequent comorbidities were hypertension, dyslipidaemia and diabetes and they were more common in women. Antiplatelets (91.3%) and statins (85.7%) were the study drugs most prescribed. The uses of all comedications were significantly higher in women, except for nitrates. The combination of four study groups was initially prescribed in 47.7% of patients and combination of beta-blockers, statins and antiplatelets was prescribed in 18.4%. More men than women received all recommended pharmacological groups.

CONCLUSION

Women were older, had more comorbidities and received more comedications. Most patients were treated with a combination of four or three study drugs for secondary prevention. Men initiated more drug treatments for secondary prevention and dual antiplatelet therapy than women.

EUPAS REGISTER

EUPAS19017.

Sex differences in heart failure hospitalisation risk following acute myocardial infarction

OBJECTIVE

We evaluated the sex differences in 6-month heart failure (HF) hospitalisation risk in acute myocardial infarction (AMI) survivors.

METHODS

For this retrospective cohort analysis, adult survivors of an AMI between January and June 2014 were identified from the US Nationwide Readmissions Database. The primary outcome was a HF hospitalisation within 6 months. Secondary outcomes were fatal HF hospitalisation and the composite of index in-hospital HF or 6-month HF hospitalisation.

RESULTS

Of 237 549 AMI survivors, females (37.9%) were older (70±14 years vs 65±13 years; p<0.001), had a higher prevalence of cardiac comorbidities and a lower revascularisation rate compared with males. The primary outcome occurred in 12 934 patients (5.4%), at a 49% higher rate in females (6.8% vs 4.6% in males, p<0.001), which was attenuated to a 19% higher risk after multivariable adjustment. Findings were consistent across subgroups of age, AMI type and major risk factors. In the propensity-matched time-to-event analysis, female sex was associated with a 13% higher risk for 6-month HF readmission (6.4% vs 5.8% in males; HR 1.13, 95% CI 1.05 to 1.21, p<0.001), and the increased risk was evident early on after the AMI. Fatal HF rate was similar between groups (4.7% vs 4.6%, p=0.936), but females had a higher rate of the composite HF outcome (36.2% vs 27.5%, p<0.001).

CONCLUSION

In a large all-comers AMI survivors' cohort, females had a higher HF hospitalisation risk that persisted after adjustment for baseline risk differences. This was consistent across several clinically relevant subgroups and was evident early on after the AMI.

Premature STEMI in Men and Women: Current Clinical Features and Improvements in Management and Prognosis

Background: Coronary artery disease (CAD) is the most frequent cause of ST-segment elevation myocardial infarction (STEMI). Etiopathogenic and prognostic characteristics in young patients may differ from older patients and young women may present worse outcomes than men. We aimed to evaluate the clinical characteristics and prognosis of men and women with premature STEMI.

METHODS

A total 1404 consecutive patients were referred to our institution for emergency cardiac catheterization due to STEMI suspicion (1 January 2014-31 December 2018). Patients with confirmed premature (<55 years old in men and <60 in women) STEMI (366 patients, 83% men and 17% women) were included (359 atherothrombotic and 7 spontaneous coronary artery dissection (SCAD)).

RESULTS

Premature STEMI patients had a high prevalence of classical cardiovascular risk factors. Mean follow-up was 4.1 years (±1.75 SD). Mortality rates, re-hospitalization, and hospital stay showed no significant differences between sexes. More than 10% of women with premature STEMI suffered SCAD. There were no significant differences between sexes, neither among cholesterol levels nor in hypolipemiant therapy. The global survival rates were similar to that expected in the general population of the same sex and age in our region with a significantly higher excess of mortality at 6 years among men compared with the general population.

CONCLUSION

Our results showed a high incidence of cardiovascular risk factors, a high prevalence of SCAD among young women, and a generally good prognosis after standardized treatment. During follow-up, 23% suffered a major cardiovascular event (MACE), without significant differences between sexes and observed survival at 1, 3, and 6 years of follow-up was 96.57% (95% CI 94.04-98.04), 95.64% (95% CI 92.87-97.35), and 94.5% (95% CI 91.12-97.66). An extra effort to prevent/delay STEMI should be invested focusing on smoking avoidance and optimal hypolipemiant treatment both in primary and secondary prevention.

Influence of left ventricular systolic function on the long-term benefit of beta-blockers after ST-segment elevation myocardial infarction

INTRODUCTION

Beta-blockers are recommended after ST-elevation myocardial infarction (STEMI), but their benefit in patients with preserved left ventricular ejection fraction (LVEF) is unclear.

METHODS

Consecutive patients discharged in sinus rhythm after STEMI between January 2010 and April 2015 were followed until December 2017. Percutaneous coronary intervention (PCI) was performed in 969 (99.7%, including 112 with rescue PCI) and three (0.3%) received only thrombolytic therapy without rescue PCI.

RESULTS

Of these 972 patients, mean age 62.6±13.5 years, 212 (21.8%) were women and 835 (85.9%) were prescribed beta-blockers at discharge. Patients who did not receive beta-blockers had more comorbidities than those who did, including chronic obstructive pulmonary disease (14.6% vs. 4.2%), anemia (8.0% vs. 3.7%), and cancer (7.3% vs. 2.8%), and more frequently had inferior STEMI (75.9% vs. 56.0%) and high-grade atrioventricular block (13.1% vs. 5.3%) (all p<0.01). After a mean follow-up of 49.6±24.9 months, beta-blocker treatment at discharge was independently associated with lower mortality (HR 0.61, 95% confidence interval [CI] 0.38-0.96, p=0.03). This effect was present in 192 patients with LVEF ≤40% (HR 0.57, 95% 95% CI 0.34-0.97, p=0.04) but was not clear in 643 patients with LVEF >40% (HR 0.67, 95% 95% CI 0.25-1.76, p=0.42).

CONCLUSION

In the LVEF >40% group, the results raise reasonable doubts about the real benefit of systematic use of beta-blockers as treatment for these patients. These findings reinforce the need for large randomized clinical trials within this group of patients.

Short and Midterm Outcomes in Patients With Acute Myocardial Infarction: Results of the Nationwide TURKMI Registry

This recent Turkish Myocardial Infarction registry reported that guidelines are largely implemented in patients with acute myocardial infarction (MI) in Turkey. We aimed to obtain up-to-date information for short- and midterm outcomes of acute MI. Fifty centers were selected using probability sampling, and all consecutive patients with acute MI admitted to these centers (between November 1 and 16, 2018) were enrolled. Among 1930 (mean age 62 ± 13 years, 26% female) patients, 1195 (62%) had non-ST segment elevation myocardial infarction (NSTEMI) and 735 (38%) had ST segment elevation myocardial infarction (STEMI). Percutaneous coronary intervention (PCI) was performed in 94.4% of patients with STEMI and 60.2% of those with NSTEMI. Periprocedural mortality occurred in 4 (0.3%) patients. In-hospital mortality was significantly higher in STEMI than in patients with NSTEMI (5.4% vs 2.9%, respectively; P = .006). However, the risk became slightly higher in the NSTEMI group at 1 year. Women with STEMI had a significantly higher in-hospital mortality compared with men (11.2% vs 3.8%; P < .001); this persisted at follow-up. In conclusion, PCI is performed in Turkey with a low risk of complications in patients with acute MI. Compared with a previous registry, in-hospital mortality decreased by 50% within 20 years; however, the risk remains too high for women with STEMI.

Prediction Factors of 6-Month Poor Prognosis in Acute Myocardial Infarction Patients

Background: Acute myocardial infarction (AMI) is among the leading causes of death worldwide. Patients with AMI may have the risk of developing recurrent cardiovascular events leading to rehospitalization or even death. The present study aimed to investigate the prediction factors of poor prognosis (mortality and/or readmission) after AMI during a 6-month follow-up.

Methods: A total of 206 consecutive patients hospitalized for the first visit with AMI were enrolled. Data collection included demographic characteristics, medical history, clinical information, laboratory results, and oral medications within 24 h of admission. At 1, 3, and 6 months after discharge, AMI patients were followed up to assess the occurrence of composite endpoint events including in-hospital and out-of-hospital death and/or readmission due to recurrent myocardial infarction (MI) or exacerbated symptoms of heart failure following MI.

Results: After 6-month follow-up, a total of 197 AMI patients were available and divided in two groups according to good prognosis (n = 144) and poor prognosis (n = 53). Our data identified serum myoglobin ≥651 ng/mL, serum creatinine ≥96 μM, Killip classification 2–4, and female gender as independent predictors of 6-month mortality and/or readmission after AMI. Moreover, we demonstrated that Killip classification 2–4 combined with either myoglobin (AUC_{Killip class 2−4+myoglobin} = 0.784, sensitivity = 69.8%, specificity = 79.9%) or creatinine (AUC_{Killip class 2−4+creatinine} = 0.805, sensitivity = 75.5%, specificity = 77.1%) could further enhance the predictive capacity of poor 6-month prognosis among AMI patients.

Conclusions: Patients with AMI ranked in the higher Killip class need to be evaluated and monitored with attention. Multibiomarker approach using Killip classification 2–4 and myoglobin or creatinine may be an effective way for 6-month prognosis prediction in AMI patients.

Comparison of Late Cardiac Death and Myocardial Infarction Rates in Women Vs Men With ST-Elevation Myocardial Infarction

Women and patients with incomplete revascularization (IR) have a worse prognosis after ST elevation myocardial infarction (STEMI). However, the extent to which IR affects outcomes for women with STEMI compared with men is not well characterized. Thus, we examined late outcomes of 589 consecutive STEMI patients who received percutaneous coronary intervention and assessed SYNTAX scores (SS), both at baseline and after all procedures (residual SS). A residual SS >8 defined IR. The primary end point was cardiac death or myocardial infarction (MI), with median follow-up of 3.6 years [interquartile range [IQR] 2.6 to 4.7]. Women (n = 123) had lower baseline SSs 15.0 [IQR 9 to 20], than men (n = 466), 16.0 [IQR 9 to 20; p = 0.02. After all planned procedures, the residual SS was 5.0 [IQR 0 to 9] in women and 5.0 (IQR 1 to 11] in men, p = 0.37. Cardiac death or MI occurred in (97/589) patients (16%), 24% (30/123) in women and 14% (67/466) in men (hazard ratio [HR] 1.75; 95% confidence intervals [CI] 1.14 to 2.69; p = 0.01). In patients with residual SYNTAX score (rSS) >8 cardiac death or MI occurred in 43% (15/35) of women and 23% 36/158 men (HR 2.14; 95% CI 1.17 to 3.91; p = 0.01). In patients with rSS = 0 to 8 cardiac death or MI occurred in 17% (15/88) of women and 10% of men (31/308) (HR 1.68; 95% CI 0.91 to 3.12; p = 0.10; interaction p value 0.58). Multivariate analysis found women were 1.77 times more likely than men to experience cardiac death or MI (95% CI 1.13 to 2.77; p = 0.01). In conclusion, we found despite a lower burden of disease at presentation and no difference in rates of IR between men and women, outcome differences were substantial. Women with rSS >8 were twice as likely as men with the same rSS to experience cardiac death or MI post-STEMI. Differences remained significant postrisk adjustment.

Age-Related Sex Differences in Clinical Presentation, Management, and Outcomes in ST-Segment-Elevation Myocardial Infarction: Pooled Analysis of 15 532 Patients From 7 Arabian Gulf Registries

Background No studies from the Arabian Gulf region have taken age into account when examining sex differences in ST-segment-elevation myocardial infarction (STEMI) presentation and outcomes. We examined the relationship between sex differences and presenting characteristics, revascularization procedures, and in-hospital mortality after accounting for age in patients hospitalized with STEMI in the Arabian Gulf region from 2005 to 2017. Methods and Results This study was a pooled analysis of 31 620 patients with a diagnosis of acute coronary syndrome enrolled in 7 Arabian Gulf registries. Of these, 15 532 patients aged ≥18 years were hospitalized with a primary diagnosis of STEMI. A multiple variable regression model was used to assess sex differences in revascularization, in-hospital mortality, and 1-year mortality. Odds ratios and 95% CIs were calculated. Women were, on average, 8.5 years older than men (mean age: 61.7 versus 53.2 years; absolute standard mean difference: 68.9%). The age-stratified analysis showed that younger women (aged <65 years) with STEMI were more likely to seek acute medical care and were less likely to receive thrombolytic therapies or primary percutaneous coronary intervention and guideline-recommended pharmacotherapy than men. Women had higher crude in-hospital mortality than men, driven mainly by younger age (46-55 years, odds ratio: 2.60 [95% CI, 1.80-3.7]; P<0.001; 56-65 years, odds ratio: 2.32 [95% CI, 1.75-3.08]; P<0.001; and 66-75 years, odds ratio: 1.79 [95% CI, 1.33-2.41]; P<0.001). Younger women had higher adjusted in-hospital and 1-year mortality rates than younger men (P<0.001). Conclusions Younger women (aged ≤65 years) with STEMI were less likely to receive guideline-recommended pharmacotherapy and revascularization than younger men during hospitalization and had higher in-hospital and 1-year mortality rates.

Gender-Specific Predictive Markers of Poor Prognosis for Patients with Acute Myocardial Infarction During a 6-Month Follow-up

Mounting evidence indicates the impact of gender difference on the assessment, treatment, and outcome of patients with acute myocardial infarction (AMI). However, gender-specific prognostic markers of AMI are still lacking. The present study aimed to investigate gender-specific markers of poor prognosis (all-cause mortality or readmission) in a cohort of AMI patients followed up for 6 months. Compared with males (n = 157), females (n = 40) were older and more frequent with previous medical history of hypertension and diabetes mellitus. During the 6-month follow-up, BUN ≥ 7.73 mM, myoglobin ≥ 705.8 ng/mL, and Killip classification 2-4 were identified as the independent predictors of poor prognosis for male AMI patients, while D-dimer ≥ 0.43 mg/L as an independent predictor of poor prognosis in female AMI patients. In conclusion, our data suggest that prognostic markers for AMI patients may differ according to genders. Gender-specific prognostic markers may be useful to guide the risk stratification, clinical therapy, and medications for AMI patients.

Correlation of the ORBIT Score With 30-Day Mortality in Patients With ST-Segment Elevation Myocardial Infarction

A new scoring system Outcomes Registry for Better Informed Treatment (ORBIT) score is used to assess the bleeding risk in anticoagulated patients with atrial fibrillation (AF). Our aim is to investigate the possible correlations of the ORBIT score with 30-day mortality in patients with ST-segment elevation myocardial infarction (STEMI). A total of 639 patients with STEMI were enrolled in this study. The ORBIT, HAS-BLED, and TIMI scores were recorded during admission. After 30 days' follow-up, 639 patients were divided into 2 groups: the survival group and the nonsurvival group. Different clinical parameters were compared. The predictive values of the ORBIT, HAS-BLED, and TIMI scores for 30-day mortality were assessed from receiver operating characteristic (ROC) analyses. The univariate and multivariate Cox proportional hazards analyses were applied to evaluate the relationships between variables and 30-day mortality. Sixty-seven deaths occurred after a 30-day follow-up. The ORBIT, HAS-BLED, and TIMI scores in the death group were higher than those in the survival group (P < .05). The areas under the ROC curve for the ORBIT, HAS-BLED, and TIMI scores to predict the occurrence of 30-day mortality were 0.811 (95% CI: 0.779-0.841, P < .0001), 0.717 (95% CI: 0.680-0.752, P < .0001), and 0.844 (95% CI: 0.813-0.871, P < .0001), respectively. In multivariate Cox proportional hazards modeling, the high ORBIT score was positively associated with 30-day mortality (hazard ratio: 1.309, 95% CI: 1.101-1.556, P = .013) after adjustment. A graded relation is found in the elevated ORBIT score and 30-day mortality in patients with STEMI. Thus, the ORBIT score can be an independent predictor of 30-day mortality in patients with STEMI.

The importance of return to work: How to achieve optimal reintegration in ACS patients

The vocational reintegration of patients after an acute coronary syndrome is a crucial step towards complete convalescence from the social as well as the individual point of view. Return to work rates are determined by medical parameters such as left ventricular function, residual ischaemia and heart rhythm stability, as well as by occupational requirement profile such as blue or white collar work, night shifts and the ability to commute (which is, in part, determined by physical fitness). Psychosocial factors including depression, self-perceived health situation and pre-existing cognitive impairment determine the reintegration rate to a significant extent. Patients at risk of poor vocational outcomes should be identified in the early period of rehabilitation to avoid a reintegration failure and to prevent socio-professional exclusion with adverse psychological and financial consequences. A comprehensive healthcare pathway of acute coronary syndrome patients is initiated by cardiac rehabilitation, which includes specific algorithms and assessment tools for risk stratification and occupational restitution. As the first in its kind, this review addresses determinants and legal aspects of reintegration of patients experiencing an acute coronary syndrome, and offers practical advice on reintegration strategies particularly for vulnerable patients. It presents different approaches and scientific findings in the European countries and serves as a recommendation for action.

Gender differences in the decrease of in-hospital mortality in patients with acute myocardial infarction during the last 20 years in Switzerland

Objective

To assess temporal trends of in-hospital mortality in patients with acute myocardial infarction (AMI) enrolled in the Swiss nationwide registry (AMIS Plus) over the last 20 years with regard to gender, age and in-hospital treatment.

Methods

All patients with AMI from 1997 to 2016 were stratified according to ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI), and gender using logistic regression analyses.

Results

Among 51 725 patients, 30 398 (59%) had STEMI and 21 327 (41%) had NSTEMI; 73% were men (63.9±12.8 years) and 27% were women (71.7±12.5 years). Over 20 years, crude in-hospital STEMI mortality decreased from 9.8% to 5.5% in men and from 18.3% to 6.9% in women. In patients with NSTEMI, it decreased from 7.1% to 2.1% in men and from 11.0% to 3.6% in women. After adjustment for age, mortality decreased per additional admission year by 3% in men with STEMI (OR 0.97, 95% CI 0.96 to 0.98, P<0.001), by 5% in women with STEMI (OR 0.95, 95% CI 0.93 to 0.96, P<0.001), by 6% in men with NSTEMI (OR 0.94, 95% CI 0.93 to 0.96, P<0.001) and by 5% in women with NSTEMI (OR 0.95, 95% CI 0.93 to 0.97, P<0.001). In patients <60 years, a decrease in mortality was seen in women with STEMI (OR 0.94, 95% CI 0.90 to 0.99, P=0.025) and NSTEMI (OR 0.87, 95% CI 0.80 to 0.94, P<0.001) but not in men with STEMI (OR 1.01, 95% CI 0.98 to 1.04, P=0.46) and NSTEMI (OR 0.98, 95% CI 0.94 to 1.03, P=0.41). The mortality decrease in patients with AMI was closely associated with the increase in reperfusion therapy.

Conclusion

From 1997 to 2016, in-hospital mortality of patients with AMI in Switzerland has halved and was more pronounced in women, particularly in the age category <60 years.

Trial registration number

NCT01305785; Results.

Prognostic Impact of Age and Hemoglobin in Acute ST-Segment Elevation Myocardial Infarction Treated With Reperfusion Therapy

Advanced age and low hemoglobin levels have been associated with a poor prognosis in ST-segment elevation myocardial infarction (STEMI). We studied 1,111 patients with STEMI who received reperfusion treatment (1,032 [92.9%] primary angioplasty and 79 [7.1%] fibrinolysis without rescue percutaneous coronary intervention). Mean age was 64.1 ± 14.0 years, and 23.2% were women. Patients in the last age quartile (>76 years) were more frequently women, presented more risk factors (except smoking), received thrombolysis less frequently, had less complete revascularization, and presented more complications and higher mortality. Hemoglobin level at admission was associated with age and ranged from 14.8 ± 1.5 g/dl in the first quartile to 13.2 ± 1.8 g/dl in the last, p <0.001. Multivariate analysis identified age as a predictor of in-hospital and long-term mortality (odds ratio 1.04, 95% confidence interval [CI] 1.00 to 1.07, hazard ratio 1.06, 95% CI 1.04 to 1.08). Hemoglobin levels were associated with better survival (odds ratio 0.8, 95% CI 0.6 to 0.9, hazard ratio 0.85, 95% CI 0.78 to 0.92). The other predictors of inhospital mortality were Killip class, chronic kidney disease, left ventricular ejection fraction, significant pericardial effusion, and ventricular arrhythmias. The association of hemoglobin with hospital mortality was seen in men and in women ≥65 years. In men ≥65 years, this association was also present in those with hemoglobin levels in the normal range. In conclusion, in patients with STEMI, hemoglobin is an independent predictor of inhospital and long-term mortality, especially in those aged ≥65 years. This association is also present in men ≥65 years with normal hemoglobin levels.