Sex differences in time trends in acute coronary syndrome management and in 12-month lethality: Data from the French MONICA registries

Gender Differences in Clinical Practice Regarding Coronary Heart Disease: A Systematic Review

Background/Objectives: A systematic review was performed with the aim of analysing potential sex differences in the overall treatment of coronary heart disease (CHD). Methods: Studies published between January 2011 and November 2023 that conducted a sex-based analysis of the provision of any type of therapeutic measure to treat CHD were included. A search was performed of the Web of Science database in November 2023, resulting in 9070 articles. Study quality was examined using the Newcastle-Ottawa scale. A worksheet was produced to extract data pertaining to the title, year of publication, sample, context, study design, dependent variables, time-frame, treatment type, and outcomes reported by each article. This systematic review followed PRISMA guidelines, and the research protocol was submitted to PROSPERO (CRD42022330238). Results: A total of 80 articles presenting data representing 560.070,624 individual datapoints were selected to comprise the final sample. The main findings revealed that the majority of studies highlighted inequalities that disadvantaged females in all analysed treatment categories (pharmacological treatment, invasive interventions, rehabilitation programmes, and other treatment types). Conclusions: Despite the abundance of evidence on the need to improve healthcare provision to females with CHD, few studies examined the reasons or mechanisms underlying the inequalities identified.

Epidemiology of ischaemic heart disease in France

BACKGROUND

Cardiovascular disease is the leading cause of death worldwide. Ischaemic heart disease (IHD), including acute coronary syndromes (ACS) with or without ST-segment elevation and chronic coronary syndromes, is one of the main causes.

AIM

To describe the epidemiology of IHD in France in 2022.

METHODS

Adults hospitalized due to IHD in 2022 were identified in the French National Health Data System. The characteristics, hospital management and one-year outcomes of patients were described. The IHD prevalence among people alive on 01.01.23 was estimated by combining previous hospitalizations and people in receipt of 100% coverage for a registered long-term disease. IHD-related mortality was estimated from death certificates.

RESULTS

In 2022, 242,227 adults were hospitalized for IHD in France (452/100,000 person-years); 2.98 million prevalent cases of IHD (5.6% of the adult population) and 31,391 IHD-related deaths (4.8% of all deaths) were recorded. The average age at hospitalization for IHD was 69.3years and 29.0% of patients were women. Exposure to cardiovascular risk factors was high. The average length of hospitalization was 4.9 days, 55.9% had undergone a percutaneous coronary intervention and 4.5% a coronary artery bypass graft. The in-hospital death rate was 3.6%. Six months after the index hospitalization, 22.0% of patients had been admitted to a rehabilitation service (42.9% for STE-ACS). In the year following the index hospitalization, 84.5% of patients had received antiplatelet drugs, 82.6% a statin, 68.8% a beta-blocker and 67.7% a renin-angiotensin-aldosterone system treatment. One year after index hospitalization, the rate of rehospitalization for IHD was 29.9% and the rate of all-cause death was 9.3%.

CONCLUSIONS

The burden of IHD remains high in France. These results suggest that primary prevention of IHD should be maintained and improved, as well as secondary prevention, to improve the prognosis and quality of life of the 3 million patients with coronary disease.

Two-year prognosis and cardiovascular disease prevention after acute coronary syndrome: the role of cardiac rehabilitation-a French nationwide study

AIMS

To evaluate the impact of cardiac rehabilitation (CR) on optimization of secondary prevention treatments for acute coronary syndrome (ACS), medication persistence, medical follow-up, rehospitalization, and all-cause mortality.

METHODS AND RESULTS

The National Health Insurance database was used to identify all patients hospitalized for ACS in France in 2019 and those among them who received CR. Patients' characteristics and outcomes were described and compared between CR and non-CR patients. Poisson regression models were used to identify the impact of CR after adjusting for confounders. A Cox model was fitted to identify the variables related to mortality after adjustment for medication persistence and cardiologic follow-up. In 2019, 22% of 134 846 patients hospitalized for ACS in France received CR within 6 months of their discharge. After 1 year, only 60% of patients who did not receive CR were still taking BASI (combination of beta-blockers, antiplatelet agents, statins, and renin-angiotensin-aldosterone system inhibitors) drugs. This rate and the medical follow-up rate were higher in patients who received CR. Two years after the ACS event, patients who received CR had better medical follow-up and lower mortality risk, after adjusting for cofounding variables [adjusted hazard ratio all-cause mortality = 0.65 (0.61-0.69)]. After adjustment for the dispensing of cardiovascular drugs and cardiologic follow-up, the independent effect of CR was not as strong but remained significant [hazard ratio = 0.90 (95% confidence interval: 0.84-0.95)].

CONCLUSION

Patients who received CR after hospitalization for ACS had a better prognosis. Optimization of efficient secondary prevention strategies, improved medication persistence, and enhanced cardiologic follow-up seemed to play a major role.

Identifying Patient Subpopulations with Significant Race-Sex Differences in Emergency Department Disposition Decisions

Background/objectives

The race-sex differences in emergency department (ED) disposition decisions have been reported widely. Our objective is to identify demographic and clinical subgroups for which this difference is most pronounced, which will facilitate future targeted research on potential disparities and interventions.

Methods

We performed a retrospective analysis of 93 987 White and African-American adults assigned an Emergency Severity Index of 3 at 3 large EDs from January 2019 to February 2020. Using random forests, we identified the Elixhauser comorbidity score, age, and insurance status as important variables to divide data into subpopulations. Logistic regression models were then fitted to test race-sex differences within each subpopulation while controlling for other patient characteristics and ED conditions.

Results

In each subpopulation, African-American women were less likely to be admitted than White men with odds ratios as low as 0.304 (95% confidence interval (CI): [0.229, 0.404]). African-American men had smaller admission odds compared to White men in subpopulations of 41+ years of age or with very low/high Elixhauser scores, odds ratios being as low as 0.652 (CI: [0.590, 0.747]). White women were less likely to be admitted than White men in subpopulations of 18 to 40 or 41 to 64 years of age, with low Elixhauser scores, or with Self-Pay or Medicaid insurance status with odds ratios as low as 0.574 (CI: [0.421, 0.784]).

Conclusions

While differences in likelihood of admission were lessened by younger age for African-American men, and by older age, higher Elixhauser score, and Medicare or Commercial insurance for White women, they persisted in all subgroups for African-American women. In general, patients of age 64 years or younger, with low comorbidity scores, or with Medicaid or no insurance appeared most prone to potential disparities in admissions.

Temporal trends in admission for cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021: Persistent sex, age and social disparities

BACKGROUND

Cardiac rehabilitation after an acute coronary syndrome is recommended to decrease patient morbidity and mortality and to improve quality of life.

AIMS

To describe time trends in the rates of patients undergoing cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021, and to identify possible disparities.

METHODS

All patients hospitalized for acute coronary syndrome in France between January 2009 and June 2021 were identified from the national health insurance database. Cardiac rehabilitation attendance was identified within 6 months of acute coronary syndrome hospital discharge. Age-standardized cardiac rehabilitation rates were computed and stratified for sex and acute coronary syndrome subtypes (ST-segment elevation and non-ST-segment elevation). Patient characteristics and outcomes were described and compared. Factors independently associated with cardiac rehabilitation attendance were identified.

RESULTS

In 2019, among 134,846 patients with an acute coronary syndrome, 22.3% underwent cardiac rehabilitation within 6 months of acute coronary syndrome hospital discharge. The mean age of patients receiving cardiac rehabilitation was 62 years. The median delay between acute coronary syndrome hospitalization and cardiac rehabilitation was 32 days, with about 60% receiving outpatient cardiac rehabilitation. Factors significantly associated with higher cardiac rehabilitation rates were male sex, younger age (35-64 years), least socially disadvantaged group, ST-segment elevation, percutaneous coronary intervention and coronary artery bypass graft. Between 2009 and 2019, cardiac rehabilitation rates increased by 40% from 15.9% to 22.3%. Despite greater upward trends in women, their cardiac rehabilitation rate was significantly lower than that for men (14.8% vs. 25.8%). In 2020, cardiac rehabilitation attendance dropped because of the coronavirus disease 2019 pandemic.

CONCLUSIONS

Despite the health benefits of cardiac rehabilitation, current cardiac rehabilitation attendance after acute coronary syndrome remains insufficient in France, particularly among the elderly, women and socially disadvantaged people.

Nationwide time trends in patients hospitalized for acute coronary syndrome: a worrying generational and social effect among women

AIMS

To estimate the time trends in the annual incidence of patients hospitalized for acute coronary syndrome (ACS) in France from 2009 to 2021 and to analyse the current sex and social differences in ACS, management, and prognosis.

METHODS AND RESULTS

All patients hospitalized for ACS in France were selected from the comprehensive National Health Insurance database. Age-standardized rates were computed overall and according to age group (over or under 65 years), sex, proxy of socioeconomic status, and ACS subtype [ST-segment elevation (STSE) and non-ST-segment elevation]. Patient characteristics and outcomes were described for patients hospitalized in 2019. Differences in management (coronarography, revascularization), and prognosis were analysed by sex, adjusting for cofonders. In 2019, 143,670 patients were hospitalized for ACS, including 53,227 STSE-ACS (mean age = 68.8 years; 32% women). Higher standardized incidence rates among the most socially deprived people were observed. Women were less likely to receive coronarography and revascularization but had a higher excess in-hospital mortality. In 2019, the age-standardized rate for hospitalized ACS patients reached 210 per 100 000 person-year. Between 2009 and 2019, these rates decreased by 11.4% (men: -11.2%; women: -14.0%). Differences in trends of age-standardized incidence rate have been observed according to sex, age, and social status. Middle aged women (45-64 years) showing more unfavourable trends than in other age classes or in men. In addition, among women the temporal trends were more unfavourable as social deprivation increased.

CONCLUSION

Despite encouraging overall trends in patients hospitalized for ACS rates, the increasing trends observed among middle-aged women, especially socially deprived women, is worrying. Targeted cardiovascular prevention and close surveillance of this population should be encouraged.

Prevalence and determinants of return to work after various coronary events: meta-analysis of prospective studies

Return to work (RTW) after a coronary event remains a major concern. This systematic review and meta-analysis of prospective studies published between January 1988 and August 2020, aim to evaluate the prevalence of RTW after a coronary event (myocardial infarction, acute coronary syndrome, angina pectoris) and to assess the determinants of RTW (such as follow-up duration, date of recruitment, country, gender, occupational factors, etc.). PRISMA and MOOSE guidelines were followed. Study quality was assessed using the Newcastle–Ottawa Scale. Random-effects models were carried out to determine pooled prevalence estimates and 95% confident interval. A total of 43 prospective studies (34,964 patients) were investigated. RTW overall random effects pooled prevalence was estimated at 81.1% [95% CI 75.8–85.8]. Country, year of implementation or gender did not significantly modify the prevalence estimates. Lower level of education and degraded left ventricular ejection fraction decreased RTW prevalence estimates (respectively, 76.1% vs 85.6% and 65.3% vs 77.8%). RTW prevalence estimates were higher for white-collars (81.2% vs 65.0% for blue-collars) and people with low physical workload (78.3% vs 64.1% for elevated physical workload).Occupational physical constraints seem to have a negative role in RTW while psycho-logical factors at work are insufficiently investigated. A better understanding of the real-life working conditions influencing RTW would be useful to maintain coronary patients in the labor market.