Differences between men and women in the management of unstable angina pectoris (The GUARANTEE Registry). The GUARANTEE Investigators

Sex-Based Differences in Clinical Outcomes of Acute Coronary Syndrome Among Patients With Mediastinal Radiation Exposure: Insights From The National Inpatient Sample (2009-2020)

There is a paucity of data about the sex differences in acute coronary syndrome (ACS) outcomes in patients with prior mediastinal radiation. The National Inpatient Sample database from years 2009 to 2020 were queried for ACS hospitalizations of patients with prior mediastinal radiation. The primary outcome was MACCE (major cardiovascular events), and secondary outcomes included other clinical outcomes. A total of 23,385 hospitalizations for ACS with prior mediastinal radiation exposure ([15,904 (68.01%) females, and 7481 (31.99%) males]) were included in analysis. Males were slightly younger than females (median, age (70 [62-78] vs 72 [64-80]). Female patients with ACS had a higher burden of hypertension (80.82% vs 73.55%), diabetes mellitus (33% vs 28.35%), hyperlipidemia (66.09% vs 62.2%), obesity (17.02% vs 8.6%) however, males had a higher burden of peripheral vascular disease (18.29% vs 12.51%), congestive heart failure (41.8% vs 39.35%) and smoking (70.33% vs 46.92%). After propensity matching, primary outcome MACCE was higher in males (20.85% vs 13.29%, aOR: 1.80 95% CI (1.65-1.96), P < 0.0001) along with cardiogenic shock (8.74% vs 2.42%, aOR: 1.77 95% CI (1.55-2.02), P < 0.0001) and mechanical circulatory support use (aOR: 1.48 95% CI [1.29 -1.71], P < 0.0001). We observed no differences in the length of hospital stay, however total hospitalization cost was higher in males. This nationwide analysis showed significant disparities in outcomes among male and female ACS patients with prior mediastinal radiation history, with increasing trend in hospitalization for ACS among males and females but decreasing mortality among females.

Aspirin for cardiovascular disease prevention among adults in the United States: Trends, prevalence, and participant characteristics associated with use

OBJECTIVE

: Aspirin has been widely utilized over several decades for atherosclerotic cardiovascular disease (ASCVD) prevention among adults in the United States. We examined trends in aspirin use among adults aged ≥40 years from 1998 to 2019 and assessed factors associated with its use for primary and secondary ASCVD prevention.

METHODS

: Using 1998-2019 Behavioral Risk Factor Surveillance System data, we obtained weighted prevalence of aspirin use among adults aged ≥40 years for each year and examined trends in use over this period. Using multivariable logistic regression and utilizing data from 54,388 respondents aged ≥40 years in the 2019 data, we assessed factors associated with aspirin use for secondary prevention and for primary prevention stratified by the number of traditional ASCVD risk factors reported (hypertension, diabetes mellitus, high cholesterol, overweight/obesity, and cigarette smoking).

RESULTS

: Aspirin use prevalence increased from 29.0%(95%CI, 27.9%-30.2%) in 1998 to 37.5%(36.9%-38.0%) in 2009. However, use has slightly declined over the last decade: 35.6%(34.6%-36.6%) in 2011 to 33.5%(32.5%-34.6%) in 2019. In 2019, among respondents without cardiovascular disease (CVD), 27.5%(26.4%-28.6%) reported primary prevention aspirin use while 69.7%(67.0%-72.2%) of respondents with CVD reported secondary prevention aspirin use. Of concern, 45.6%(43.5%-47.7%) of adults aged ≥70 years without CVD reported primary prevention aspirin use. Additionally, among individuals without any self-reported traditional ASCVD risk factor, males (adjusted odds ratio(aOR):1.60, 95%CI:1.12-2.27), persons aged ≥70 years (aOR:3.22, 95%CI:2.27-4.55), and individuals with healthcare coverage (aOR:2.28, 95%CI:1.17-4.44) had higher odds of primary prevention aspirin use compared to females, persons aged 40-69 years, and individuals without healthcare coverage, respectively. Females were less likely than males to report secondary prevention aspirin use (aOR:0.64, 95%CI:0.50-0.82).

CONCLUSION

: Aspirin use has slightly declined over the last decade. A significant proportion of adults aged ≥70 years reported primary prevention aspirin use in 2019. Since current guidelines do not recommend primary prevention aspirin use among adults aged ≥70 years, such use should be discouraged.

Sex differences in acute coronary syndrome: insights from an observation study in low socio-economic cohort from India

Aim: To study sex-related differences in acute coronary syndrome (ACS) presentation, management and in-hospital outcomes. Materials & methods: We studied 621 ACS patients (150 women, 471 men) of low socio-economic status from South India from February 2015 to January 2016. Multivariable logistic regression methods were used to assess sex differences in the in-hospital outcomes. Adjudicated major adverse cardiovascular events (MACE) included in-hospital cardiac arrest, cardiogenic shock, heart failure, re-infarction, stroke, major bleeding and mortality. Results & conclusion: Mean age in women was 60.97 ± 11.23 years versus 54.5 ± 10.87 years in men (p < 0.001). Women had higher prevalence of hypertension and diabetes and presented with more non-ST elevation ACS. There were no differences in the use of antiplatelets, statins and other pharmacotherapy except for the higher use of nitrates in women. There were no differences in MACE rates between women and men (15.3 vs 9.6%; adjusted odds ratio: 1.43; CI: 0.76-2.69).

Gender differences in clinical features and complications of infective endocarditis: 11-year experience of a single institute in Egypt

BACKGROUND

No data exists about the gender differences among patients with infective endocarditis (IE) in Egypt. The objective was to study possible gender differences in clinical profiles and outcomes of patients in the IE registry of a tertiary care center over 11 years.

RESULTS

The IE registry included 398 patients with a median age of 30 years (interquartile range, 15 years); 61.1% were males. Males were significantly older than females. Malignancy and recent culprit procedures were more common in females while chronic liver disease and intravenous drug abuse (IVDU) were more in males. IE on top of structurally normal hearts was significantly more in males (25.6% vs 13.6%, p = 0.005) while rheumatic valvular disease was more common in females (46.3% vs 29.9%, p = 0.001). There was no difference in the duration of illness before presentation to our institution. The overall complication rate was high but significantly higher in females. However, there were no significant differences in the major complications: mortality, fulminant sepsis, renal failure requiring dialysis, heart failure class III-IV, or major cerebrovascular emboli.

CONCLUSION

In this registry, IE occurred predominantly in males. Females were significantly younger at presentation. History of recent culprit procedures was more common in females while IVDU was more common in males who had a higher incidence of IE on structurally normal hearts. The overall complication rate was higher in women. IE management and its outcomes were similar in both genders.

Incidence and Predictors of Obstructive Coronary Artery Disease and the Role of Cardiac Troponin Assays in Patients with Unstable Angina

In a time when cardiac troponin assays are widely used to detect myocardial injury, data remain scarce concerning the incidence and predictors of substantial obstructive coronary artery disease that causes unstable angina. This retrospective single-center study included consecutive patients hospitalized for unstable angina from January 2015 through January 2016. Patients with troponin I levels above the upper reference limit and those who did not undergo angiography were excluded. Multivariate logistic regression analysis was used to identify predictors of obstructive coronary artery disease that warranted revascularization and of major adverse cardiac events up to 6 months after discharge from the hospital. Of the 114 patients who met the inclusion criteria, 46 (40%) had obstructive coronary artery disease. In the univariate analysis, male sex, white race, history of coronary artery disease, prior revascularization, hyperlipidemia, chronic kidney disease, aspirin use, long-acting nitrate use, and Thrombolysis in Myocardial Infarction score ≥3 were associated with obstructive coronary artery disease. History of coronary artery disease, prior revascularization, hyperlipidemia, and long-acting nitrate use were associated with major adverse cardiac events. Male sex was an independent predictor of obstructive coronary artery disease (adjusted odds ratio=4.82; 95% CI, 1.79-13; P=0.002) in the multivariate analysis. Our results showed that coronary artery disease warranting revascularization is present in a considerable proportion of patients who have unstable angina. The association that we found between male sex and obstructive coronary artery disease suggests that the risk stratification of patients presenting with unstable angina may need to be refined to improve outcomes.

Gender-Specific Differences in All-Cause Mortality Between Incomplete and Complete Revascularization in Patients With ST-Elevation Myocardial Infarction and Multi-Vessel Coronary Artery Disease

The best revascularization strategy (complete vs incomplete revascularization) in patients with ST-elevation myocardial infarction (STEMI) is still debated. The interaction between gender and revascularization strategy in patients with STEMI on all-cause mortality is uncertain. The aim of the present study was to evaluate gender-specific difference in all-cause mortality between incomplete and complete revascularization in patients with STEMI and multi-vessel coronary artery disease. The study population consisted of 375 men and 115 women with a first STEMI and multi-vessel coronary artery disease without cardiogenic shock at admission or left main stenosis. The 30-day and 5-year all-cause mortality was examined in patients categorized according to gender and revascularization strategy (incomplete and complete revascularization). Within the first 30 days, men and women with incomplete revascularization were associated with higher mortality rates compared with men with complete revascularization. However, the gender-strategy interaction variable was not independently associated with 30-day mortality after STEMI when corrected for baseline characteristics and angiographic features. Within the survivors of the first 30 days, men with incomplete revascularization (compared with men with complete revascularization) were independently associated with all-cause mortality during 5 years of follow-up (hazard ratios 3.07, 95% confidence interval 1.24;7.61, p = 0.016). In contrast, women with incomplete revascularization were not independently associated with 5-year all-cause mortality (hazard ratios 0.60, 95% confidence interval 0.14;2.51, p = 0.48). In conclusion, no gender-strategy differences occurred in all-cause mortality within 30 days after STEMI. However, in the survivors of the first 30 days, incomplete revascularization in men was independently associated with all-cause mortality during 5-year follow-up, but this was not the case in women.

Gender Differences in Outcomes and Predictors of All-Cause Mortality After Percutaneous Coronary Intervention (Data from United Kingdom and Sweden)

To determine gender differences and predictors of all-cause mortality (30 days and 1 year) after percutaneous coronary intervention (PCI) in patients with stable angina pectoris and acute coronary syndrome (non-ST-elevation myocardial infarction/unstable angina pectoris and ST-elevation myocardial infarction) in the British Cardiovascular Intervention Society (BCIS) and Swedish Coronary Angiography and Angioplasty Registry (SCAAR) data sets, an analysis of prospectively collected data from 2007 to 2011 was performed. In total, 458,261 patients (BCIS: n = 368,492 [25.9% women]; Sweden: n = 89,769 [27.2% women]) who underwent PCI were included in this analysis. Using multiple regression analysis, in the BCIS registry, female gender was an independent predictor of all-cause mortality at 30 days (odds ratio [OR] 1.15, 95% CI 1.10 to 1.22, p <0.0001) and at 1 year (OR 1.08, 95% CI 1.04 to 1.12, p <0.0001) after PCI for all patients. Likewise, in the SCAAR registry, female gender was an independent predictor of all-cause mortality at 30 days (OR 1.15, 95% CI 1.05 to 1.26, p = 0.002) and 1 year (OR 1.09, 95% CI 1.03 to 1.17, p = 0.006) after PCI for all patients. In both data sets, there was no statistically significant interaction between age and gender for all-cause mortality at 30 days (BCIS, p = 0.59; SCAAR, p = 0.40) and at 1 year (BCIS, p = 0.11; SCAAR, p = 0.83). In conclusion, despite advances in care, women compared with men continue to experience higher all-cause mortality after PCI for coronary artery disease. The patient's age at the time of PCI remains a strong predictive factor of mortality in this population. Strategies and further research are warranted to better address the management of coronary artery disease in women with possibly earlier diagnosis and more tailored treatments.

Gender differences in outcomes in patients with acute coronary syndrome in the current era: A review

Coronary heart disease is the most common cause of death worldwide. In the United Kingdom in 2010, over 80,000 deaths were attributed to coronary heart disease, and one in 10 female deaths were due to coronary heart disease. Acute coronary syndrome, a subset of coronary heart disease, was responsible for 175,000 inpatient admissions in the United Kingdom in 2012. While men have traditionally been considered to be at higher risk of acute coronary syndrome, various studies have demonstrated that women often suffer from poorer outcomes following an adverse cardiovascular event. This gap is gradually narrowing with the introduction of advanced interventional strategies and pharmacotherapy. However, a better understanding of these differences is of crucial importance for the improvement of the pharmacological and interventional management of acute coronary syndrome and for the development of possible new gender-specific diagnostic and therapeutic options. The goals of this review are to evaluate gender differences in outcomes in patients with acute coronary syndrome in the current era and identify potential mechanisms behind these differences in outcomes following percutaneous coronary intervention.

Association between gender, process of care measures, and outcomes in ACS in India: results from the detection and management of coronary heart disease (DEMAT) registry

Background

Studies from high-income countries have shown that women receive less aggressive diagnostics and treatment than men in acute coronary syndromes (ACS), though their short-term mortality does not appear to differ from men. Data on gender differences in ACS presentation, management, and outcomes are sparse in India.

Methods and Results

The Detection and Management of Coronary Heart Disease (DEMAT) Registry collected data from 1,565 suspected ACS patients (334 women; 1,231 men) from ten tertiary care centers throughout India between 2007–2008. We evaluated gender differences in presentation, in-hospital and discharge management, and 30-day death and major adverse cardiovascular event (MACE; death, re-hospitalization, and cardiac arrest) rates. Women were less likely to present with STEMI than men (38% vs. 55%, p<0.001). Overall inpatient diagnostics and treatment patterns were similar between men and women after adjustment for potential confounders. Optimal discharge management with aspirin, clopidogrel, beta-blockers, and statin therapy was lower for women than men, (58% vs. 65%, p = 0.03), but these differences were attenuated after adjustment (OR = 0.86 (0.62, 1.19)). Neither the outcome of 30-day mortality (OR = 1.40 (0.62, 3.16)) nor MACE (OR = 1.00 (0.67, 1.48)) differed significantly between men and women after adjustment.

Conclusions

ACS in-hospital management, discharge management, and 30-day outcomes did not significantly differ between genders in the DEMAT registry, though consistently higher treatment rates and lower event rates in men compared to women were seen. These findings underscore the importance of further investigation of gender differences in cardiovascular care in India.

Racial disparities in left main stenting: insights from a real world inner city population

BACKGROUND

Left main coronary artery (LMCA) disease is associated with significant cardiovascular mortality. The data on patient characteristics' predicting outcomes after LMCA revascularization is sparse.

METHODS

A retrospective study of 227 patients with LMCA disease documented on coronary angiography from March 2000 to December 2008. Data included demographic variables, co-morbidities, cardiac function, and medications. Race was self-identified. The study outcome was a composite end-point including myocardial infarction (MI) and all-cause mortality. Cox proportional hazard analysis was performed to study the effect of various patient attributes including race and gender on the composite end-point.

RESULTS

Baseline characteristics were specifically compared between individuals who had the study outcome versus those who did not. Mean age was higher in the group with study outcomes when compared to the group without any outcomes (64.3 ± 11.8 years versus 59.2 ± 13.6 years; p = 0.013). After the final multivariate regression analysis, only African American (AA) race and age were found to be independent predictors of adverse cardiac outcome at the end of the first year (race-hazard ratio (HR) 3.82, 95% confidence interval (CI) 1.38-10.62, p = 0.010; age-HR 1.08, 95% CI 1.04-1.13, p < 0.001) and at the end of the study (race-HR 2.71, 95% CI 1.44-5.10, p = 0.002; age-HR 1.03, 95% CI 1.01-1.08, p = 0.017).

CONCLUSION

In our study of patients with unprotected LMCA disease, AA race, and age were significantly predictive of poor prognosis following revascularization, while gender had no predictive value in prognosticating cardiovascular mortality.

The association of angina pectoris with heart disease mortality among men and women by diabetes status: the Rancho Bernardo Study

OBJECTIVE

To study the sex-specific association of angina pectoris with mortality in community-dwelling older adults with and without diabetes.

METHODS

Baseline prevalence of angina was evaluated in 822 men and 1184 postmenopausal women aged 50-89 years at the 1984-1987 Rancho Bernardo Study clinic visit, when an oral glucose tolerance test (OGTT) and the Rose angina questionnaire were administered. All-cause and coronary heart disease (CHD) mortality were assessed after an average follow-up period of 13.2 years. Sex-specific Cox proportional hazard models were used to examine the independent association of angina with mortality by glucose tolerance category.

RESULTS

At baseline, average age was 71 years for both sexes; 61 men (7.4%) and 142 women (12.0%) had angina. Overall, 129 men (15.9%) and 130 women (11.0%) had type 2 diabetes; 228 men (27.7%) and 357 women (30.2%) had impaired glucose tolerance (IGT). During follow-up, 485 men (59%) and 557 women (47%) died, of whom 103 men (21.2%) and 104 women (18.7%) had fatal CHD. Women with diabetes and angina had a 3-4-fold greater risk of dying from CHD than women with diabetes but without angina, independent of covariates. Women with angina and IGT had twice the risk of CHD mortality compared with women with IGT but without angina. A smaller increased risk of fatal CHD in men was not statistically significant.

CONCLUSIONS

Angina was associated with an increased risk of dying from CHD among women, especially among those who also had IGT or diabetes.

Pre- and early in-hospital procedures in patients with acute coronary syndromes: first results of the "German chest pain unit registry"

BACKGROUND

In an attempt to improve the treatment of patients with acute coronary syndromes (ACS), a network of certified chest pain units (CPUs) has been recently established in Germany.

METHODS

Data from patients admitted between December 2008 and September 2011 for ACS in 40 certified CPUs participating in the registry were prospectively collected.

RESULTS

A total of 5,457 patients was admitted for ACS; 798 patients (14.6 %) were diagnosed with an ST-elevation myocardial infarction (STEMI), 2,244 (41.1 %) with a non-ST-elevation myocardial infarction (NSTEMI), and 2,415 (44.3 %) with unstable angina. The mean time to first medical contact was 2:08 h for STEMI patients. A pre-hospital ECG was available in 23.8 % of all ACS patients. Importantly, evidence of ST-segment elevation was present in 79.7 % of the STEMI patients already in this pre-hospital ECG. As many as 76.6 % of the patients, independently of their symptoms and final diagnosis, received an ECG within 10 min of reaching the CPU. 98.2 % of STEMI patients underwent invasive diagnostics, with an in-hospital delay as little as 31 (11-75) min.

CONCLUSION

The establishment of a nation-wide network of certified CPUs optimizes the medical treatment of patients with ACS while providing an ideal infrastructure to evaluate and improve, both on a nation-wide and a single center scale, the adherence to guidelines. The median delay between symptom onset and first medical contact remains high. Although performed relatively rarely, a pre-hospital ECG facilitates earlier diagnosis of a STEMI in a large majority of patients. The introduction of CPUs minimizes in-hospital delays and exploits the benefit of invasive diagnostics and treatment.

Possible participation of endothelial cell apoptosis of coronary microvessels in the genesis of Takotsubo cardiomyopathy

BACKGROUND

Takotsubo cardiomyopathy (TCM) is characterized by systolic ballooning of the left ventricular apex. It is triggered by emotional or physical stress, but the exact mechanism through which stress leads to TCM is not known.

HYPOTHESIS

Coronary microvessel apoptosis is the missing link between stress and TCM.

METHODS

In 8 female patients with TCM, plasma catecholamines, Thrombolysis in Myocardial Infarction (TIMI) coronary flow grade and myocardial perfusion grade, and apoptosis of the coronary microvessels in the biopsied myocardial specimen by terminal deoxynucleotidyl transferase-mediated nick end-labeling (TUNEL) were examined.

RESULTS

Plasma epinephrine and norepinephrine were increased to 663 +/- 445 and 875 +/- 812 pg/mL (mean +/- SD), respectively. Acetylcholine-induced delayed myocardial perfusion through the ballooning apical segment without flow disturbance in the epicardial coronary arteries (indicating microvessel spasm) and focal myocardial necrosis were observed in all subjects. Apical ballooning disappeared and myocardial perfusion delay was not inducible 1 month later. The number of vessels having apoptotic endothelial cells/10 vessels in arterioles, venules, and capillaries at initial biopsy and repeat biopsy 1 month later were 8.3 +/- 1.4 vs 0.4 +/- 1.1, P < 0.0001; 6.8 +/- 1.8 vs 0.3 +/- 0.7, P < 0.0001; and 7.9 +/- 1.0 vs 0.5 +/- 0.9, P < 0.0001, respectively.

CONCLUSIONS

Left ventricular apical ballooning in TCM was considered to be caused by coronary microvessel spasm due to catecholamine-induced endothelial cell apoptosis and myocardial stunning after release of microvessel spasm. Endothelial cell apoptosis of coronary microvessel is therefore considered to be the missing link between stress and TCM.

Fluffy luminal surface of the non-stenotic culprit coronary artery in patients with acute coronary syndrome: an angioscopic study

BACKGROUND

Approximately 15% of acute coronary syndrome (ACS) cases have no significant coronary stenosis. Mechanisms underlying the attacks are, however, unknown.

METHODS AND RESULTS

The clinical study had 254 patients with ACS; 38 patients (31 females and 7 males; aged 51.0 ± 8.0 years) had no significant coronary stenosis on angiography. They underwent a dye-staining angioscopy of the suspected culprit coronary artery using Evans blue, which selectively stains fibrin and damaged endothelial cells. A fluffy coronary luminal surface was observed in the suspected culprit artery in all 38 patients. The fluffy luminal surface was stained blue with Evans blue. In animal experiments involving 5 beagles, 10% hydrogen peroxide solution was injected into the iliac arteries to damage endothelial cells, which was then followed by blood reperfusion, and then the artery was examined by intravascular microscopy and histology. In the beagles, the arterial segment, where the thrombus had been formed, exhibited a fluffy luminal surface after a washout of the thrombus, and the surface was stained blue. Histologically, the fluffy surfaces were composed of damaged endothelial cells attached by multiple fibrin threads and platelets.

CONCLUSIONS

It was considered that the coronary segment exhibiting a fluffy luminal surface was the culprit lesion and that the fluffy surface was caused by residual thrombi after dispersion of an occlusive thrombus, which had formed on the damaged endothelial cells.

Gender differences in the treatment of non-ST-segment elevation myocardial infarction

BACKGROUND

Women are at greater risk for worse outcomes associated with acute coronary syndrome (ACS) than are men. One explanation may be that they tend to be treated less aggressively than men even when more aggressive treatment is warranted. The purpose of this analysis was to assess this issue.

METHODS

We used the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation (CRUSADE) Quality Improvement Initiative registry, an observational data collection that began in November 2001, with retrospective data collection from January 2001 to December 2006. A total of 32,888 subjects met the inclusion/exclusion criteria for our study, based on strong biochemical evidence of myocardial infarction and acute onset of typical cardiac chest pain. We stratified subjects into 16 cells for coronary intervention, based on 4 age groups and 4 cardiac catheterization findings (insignificant, 1-vessel disease, 2-vessel disease, 3-vessel disease). We also stratified subjects into 20 cells for medical treatment, based on 4 age groups and 5 medical treatments. In each cell we compared the rate of coronary intervention (coronary artery bypass grafting or percutaneous coronary intervention) or medical treatment (glycoprotein IIb/IIIa inhibitors, aspirin, clopidogrel, beta-blocker, and statins) for men vs women.

RESULTS

Men demonstrated significantly higher rates (P < 0.05) of coronary intervention in 7 of the 16 cells and 9 of the 20 medical treatment cells, compared to no cells in which women had statistically higher rates than men.

CONCLUSION

These findings suggest that men are more likely than women to receive coronary intervention and to be medically treated when presenting with evidence of non-ST-segment myocardial infarction, controlled for age, cardiac catheterization findings, and biochemical evidence of myocardial infarction.

Sex differences in native-valve infective endocarditis in a single tertiary-care hospital

The aim of this study was to assess whether the clinical characteristics, management, and outcomes of infective endocarditis differ in women and men through a prospective observational cohort study at a single tertiary care teaching hospital. From January 2000 to December 2008, 271 new cases of infective endocarditis were diagnosed (183 in men, 88 in women) according to modified Duke criteria, and patients were followed for 1 year. Women were older than men (mean age 63 +/- 16 vs 58 +/- 18 years, p = 0.006); more women were taking immunosuppressants (14% vs 3%, p = 0.006) and had mitral valve involvement (52% vs 36%, p = 0.02). However, more men had human immunodeficiency virus infection than women. There were no gender differences in Charlson index, regurgitation severity, culprit pathogens, or major complications. When surgery was indicated, women were less likely to undergo the procedure (26% vs 47%, relative risk [RR] 0.4, 95% confidence interval [CI] 0.2 to 0.7), p = 0.001). Mortality tended to be higher in women in the hospital (32% vs 23%, RR 1.58, 95% CI 1 to 2.5, p = 0.05) and at 1 year (38% vs 26%, RR 1.7, 95% CI 1.0 to 2.9, p = 0.04). Surgical treatment was a protective factor against death in the hospital (RR 0.18, 95% CI 0.04 to 0.77, p = 0.02) and at 1 year (RR 0.12, 95% CI 0.03 to 0.48, p = 0.03) after adjustment for age, gender, Charlson index, infection by Staphylococcus aureus, severity at presentation, heart failure, acute renal failure, stroke, and the ejection fraction. In conclusion, women with infective endocarditis were slightly older than men but showed similar co-morbidities. Women underwent surgery less frequently and consequently had worse prognosis than men.

Percutaneous revascularization in women with coronary artery disease: we've come so far, yet have so far to go

Coronary artery disease (CAD) has traditionally been thought of as a disease that predominantly affects men. Women, however, are more likely than men to die from a myocardial infarction (MI). In this article, the data on access to cardiovascular care, treatment of stable and unstable coronary disease, and outcomes in women undergoing percutaneous coronary intervention (PCI) will be reviewed. Despite increased awareness of heart disease in women, and improved outcomes after PCI, women with MI have more mortality and delays to treatment than men. Women with CAD have symptoms that differ from men with CAD. Improved understanding of the symptoms of CAD in women by patients and health care providers may improve treatment and outcomes in women with CAD.

Acute coronary syndrome emergency treatment strategies: a rationale and road map for critical pathway implementation

Clinical guidelines have been established to improve the effectiveness of treatment of patients seeking treatment for acute coronary syndromes and to address the variability in physician approaches to these risks. In patients with established coronary heart disease, clinical trials have consistently demonstrated reduction in morbidity and mortality with secondary prevention therapies. Both ends of this spectrum of therapy can be underused in patients receiving conventional care. Because implementation of evidence-based guideline recommendations into clinical care is limited, presented here is a rationale and process that have been successful in guideline implementation for patients with acute coronary syndromes.

Gender differences in correlates of troponin assay in diagnosis of myocardial infarction

Cardiac troponins are the most sensitive and specific biomarker for myocardial infarction (MI) diagnosis. If there is a gender bias in MI diagnosis, it could be reduced by more consistently applying objective diagnostic criteria to improve women's outcomes. This study set out to assess the accuracy and correlates of the cardiac troponin I (cTnI) assay in the diagnosis of non-ST-segment elevation MI, to determine how the assay accuracy and correlates vary by gender, and to explore the interaction between factors that may influence cTnI accuracy and affect gender differences in diagnosis. The data were obtained from the CHECKMATE study. It included 924 patients with possible myocardial ischemia excluding subjects with ST-segment elevation. The Dade-Behring Stratus CS STAT near-patient instrument (Dade Behring, Inc, Newark, Del) was used to measure cTnI. We assessed baseline troponin accuracy using a standard MI definition. There were 125 subjects with a definite MI diagnosis. Baseline troponin was 44% sensitive and 97% specific in predicting MI, with no significant gender differences. In contrast, other positive cardiac markers, namely rising or falling creatine-kinase MB fraction and positive electrocardiogram, occurred more frequently in men. Sensitivity (SE) of baseline troponin was higher in subjects where baseline troponin was obtained longer than 2 hours after the chest pain onset. The study did not observe a significant difference in the assay SE or specificity by gender. This observation, plus the fact that other positive cardiac markers occurred more frequently in men, suggest the troponin test may help to improve the diagnosis of MI in women.

Gender-related differences in the management of non-ST-elevation acute coronary syndrome patients

OBJECTIVES

To compare management and outcome of female and male non-ST-elevation acute coronary syndrome (ACS) patients.

DESIGN

FINACS Studies are prospective registries of non-ST-elevation ACS patients conducted in 2001, 2003, and 2005 in nine hospitals.

RESULTS

The studies enrolled 1,399 patients from which 39% were women. During hospitalisation women were treated less often than men with aspirin (odds ratio [OR]) for women 0.60, 95% confidence interval [CI] 0.41 to 0.88, p=0.03). Women underwent less often in-hospital coronary angiography than men (adjusted OR 0.71, 95% CI 0.55 to 0.93, p=0.01). Also in the subgroup of younger (<75 years) high-risk patients, female sex was independent predictor for not performing in-hospital angiography (OR 0.64, 95% CI 0.42 to 0.97, p=0.04). Age-adjusted mortality at 6 months was similar between men and women.

CONCLUSIONS

Compared to men women received less often aspirin. Women were referred less often to in-hospital coronary angiography. Under-use of in-hospital angiography was evident also in patients with high-risk features when guidelines recommend early invasive treatment.

Cardiovascular disease in older women: a challenge in diagnosis and treatment

Cardiovascular disease is the leading cause of death in women and more heart disease is present in elderly women than men. Risk factors for heart disease affect men and women differently, with a greater impact of diabetes, hyperlipidemia and smoking in women. Diagnosis of heart disease can be more challenging in women, especially when elderly, as symptoms may be vague. Understanding the appropriate use of diagnostic testing and appropriate treatment is essential, given the high burden of disease in elderly women. This article will discuss the current guidelines for diagnosis and therapy of heart disease in women and will discuss the appropriate role of prevention strategies.

The Role of Aspirin in Cardiovascular Disease Prevention in Women

Cardiovascular disease is the nation's number one killer of women. Through its actions on platelet inhibition, aspirin is an effective agent for primary and secondary cardiovascular disease prevention and for use with cardiac interventions. However, the evidence for aspirin's effectiveness in women differs by age and indication compared to men. As primary prevention, low dose aspirin is recommended for women over age 65 to reduce the risk of myocardial infarction and stroke while younger women at high risk for stroke may benefit from aspirin. Aspirin has benefits in other selected patient groups, including diabetics and patients presenting with ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction acute coronary syndrome (NSTEMI/ACS), peripheral arterial disease, stroke, coronary artery bypass graft (CABG), and percutaneous coronary intervention (PCI). Alternative platelet therapy using dipyridamole or clopidogrel, alone or with aspirin, provides some improved efficacy for reduction in recurrent events for NSTEMI, ASC and PCI, although bleeding risks may be greater. However, dual antiplatelet therapy is not currently recommended for primary prevention in even high risk subjects. Despite the evidence base and guidelines, the use of aspirin in women remains suboptimal and warrants improved provider and patient awareness.

Women tolerate drug therapy for coronary artery disease as well as men do, but are treated less frequently with aspirin, beta-blockers, or statins

BACKGROUND

Women have worse morbidity, mortality, and health-related quality-of-life outcomes associated with coronary artery disease (CAD) compared with men. This may be related to underutilization of drug therapies, such as aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or statins. No studies have sought to describe the relationship of gender with adverse reactions to drug therapy (ADRs) for CAD in clinical practice.

OBJECTIVE

The aim of this study was to determine the prevalence of ADRs associated with common CAD drug therapies in women and men in clinical practice.

METHODS

In a cohort of consecutive outpatients with CAD, detailed chart abstraction was performed to determine the use of aspirin, beta-blocker, ACE inhibitor, and statin therapy, as well as the ADRs reported for these treatments. Baseline clinical characteristics were also determined to identify the independent association of gender with use of standard drug treatments for CAD.

RESULTS

Consecutive patients with CAD (153 men, 151 women) were included in the study. Women and men were observed to have a similar prevalence of cardiac risk factors and comorbidities, except that men had significantly higher prevalence of atrial fibrillation (30 [19.6%] men vs 15 [9.9%] women; P = 0.03) and significantly lower mean (SD) high-density lipoprotein cholesterol concentrations (45 [16] mg/dL for men vs 55 [19] mg/dL for women; P < 0.001). No significant differences were observed between the sexes in the prevalence of ADRs; however, significantly fewer women than men were treated with statins (118 [78.1%] vs 139 [90.8%], respectively; P = 0.003). After adjusting for clinical characteristics, women were also found to be less likely than men to receive aspirin (odds ratio [OR] = 0.164; 95% CI, 0.083-0.322; P = 0.001) and beta-blockers (OR = 0.184; 95% CI, 0.096-0.351; P = 0.001).

CONCLUSIONS

Women and men experienced a similar prevalence of ADRs in the treatment of CAD; however, women were significantly less likely to be treated with aspirin, beta-blockers, and statins than were their male counterparts. To optimize care for women with CAD, further study is needed to identify the cause of this gender disparity in therapeutic drug use.

Clinical quality in non-ST-elevation acute coronary syndromes

We have entered a new era of medicine in which both the interest of scientific rigor and pressure from health care purchasers demand increased adoption of empirically based standards of care. Certain therapeutic areas have seen rapid transformation from a model in which care is based on a clinician's intuition to one based on therapies and standards backed by substantial clinical evidence. The condition of non-ST-elevation acute coronary syndromes, a leading cause of death in industrialized nations, provides an excellent example of this transformation and a potential model for other areas of disease treatment. This article discusses the cycle of quality (the conceptual basis for quality improvement in non-ST-elevation acute coronary syndromes), the approach taken by the American College of Cardiology and the American Heart Association in developing their clinical practice guidelines, the use of performance indicators in clinical practice, and the ever-increasing evidence that adherence to practice guidelines and attention to performance measures result in improved patient outcomes.

[Mean length of stay and prognosis in unstable angina. Results from the ARIAM database]

BACKGROUND AND OBJECTIVE

The objective of this project is to investigate the factors predicting mortality and mean length of stay in patients diagnosed with unstable angina (UA) during admission to the Intensive Care Unit or Critical Care Unit (ICU/CCU).

PATIENTS AND METHOD

A retrospective cohort study including all the UA patients listed in the Spanish ARIAM register. The study period comprised from June, 1996 to December, 2003. The follow-up period is limited to the stay in the ICU/CCU. One univariate analysis was performed between deceased and live patients; and another between prolonged and non-prolonged stay patients. Three multivariate analyses were also performed; one to evaluate the factors related to mortality, another to evaluate the variables associated to percutaneous coronary intervention (PCI) and another to evaluate the factors associated to the prolonged mean stay in ICU/CCU.

RESULTS

14,096 patients with UA were included in the study. The UA mortality rate during ICU/CCU admission was 1.1%. Mortality was associated to Killip classification, age, the need for CPR, development of cardiogenic shock, development of arrhythmia (such as VF, sinus tachycardia or high-degree atrioventricular block) and diabetes; whereas patients who smoke were associated to a lower mortality rate. PCI was only performed in 1,226 patients (8.9%), increasing over the years. The PCI-predicting variables were: age, being referred from another hospital, smoking, presenting prior acute myocardial infarction (AMI), complications consisting of cardiogenic shock or high-degree atrioventricular block and being treated with oral beta blockers. The mean length of stay in ICU/CCU was 3.15 (18.65) days (median, 2 days), depending on age, a coronariography having previously been performed, the Killip classification, having required coronariography and PCI or echocardiography or mechanical ventilation, and presenting complications such as angina that is difficult to control, arrhythmia, right ventricular failure or death.

CONCLUSIONS

The factors are associated to mortality were; greater age, diabetes, Killip classification, arrhythmia, cardiogenic shock and the need for CPR, whereas smoking is associated to a lower mortality rate. The patients on whom PCI was performed represent a less severe population. Management has changed over the years, with an increase in PCI. A prolonged mean length of stay is associated to the appearance of arrhythmia, right or left heart failure, angina that is difficult to control, age and PCI.

Gender differences in infective endocarditis: pre- and co-morbid conditions lead to different management and outcomes in female patients

The impact of gender on the presenting characteristics, management, and outcomes in infective endocarditis (IE) has not been adequately studied. The goal of our study was to better understand differences in management and outcome of IE between genders. Data were obtained prospectively from 439 patients in the Duke Endocarditis Database from 1996 to 2004. Baseline characteristics of patients were examined using univariable analysis. Variables associated with gender, in-hospital surgery and long-term mortality in patients with IE were considered for multivariable analysis. Hemodialysis, diabetes mellitus, and immunosuppression were more frequent in female patients with IE. Intracardiac abscesses and new conduction abnormalities were more common in male patients. The following factors were predictive of short-term mortality through univariable analysis: female gender, age, diabetes mellitus, septic pulmonary infarcts, intracranial hemorrhage, infection with Staphylococcus aureus, and persistently positive blood cultures. Female gender was not associated with mortality in an adjusted analysis of short-term outcome. Age, diabetes mellitus, renal failure requiring hemodialysis, cancer, pulmonary edema, systemic embolization, persistently positive blood cultures, and chronic indwelling central catheters but not female gender were associated with long-term mortality using univariable and an adjusted analysis. In both analyses, surgery was associated with improved mortality. Female gender, a history of diabetes mellitus, hemodialysis, and immunosuppression therapy were predictive of a medical management without the use of surgery, although in the adjusted analysis there was no association between surgery and gender. In conclusion, differences between genders in treatment and outcomes frequently reported in patients with IE most likely result from pre- and co-existing conditions such as diabetes mellitus, renal failure requiring hemodialysis, and chronic immunosuppression.

Gender differences in aspirin use among adults with coronary heart disease in the United States

BACKGROUND

Aspirin reduces mortality for men and women with coronary heart disease (CHD). Previous research suggests women with acute coronary syndromes receive less aggressive care, including less frequent early administration of aspirin. The presence of gender differences in aspirin use for secondary prevention is less clear.

OBJECTIVE

To determine if a gender difference exists in the use of aspirin for secondary prevention among individuals with CHD.

DESIGN

We analyzed data from the nationally representative 2000-2002 Medical Expenditure Panel Surveys to determine the prevalence of regular aspirin use among men and women with CHD.

PARTICIPANTS

Participants, 1,869, 40 years and older who reported CHD or prior myocardial infarction.

RESULTS

Women were less likely than men to use aspirin regularly (62.4% vs 75.6%, p < .001) even after adjusting for demographic, socioeconomic and clinical characteristics (adjusted OR = 0.62, 95% CI, 0.48-0.79). This difference narrowed but remained significant when the analysis was limited to those without self-reported contraindications to aspirin (79.8% vs 86.4%, P = .002, adjusted OR = 0.68, 95% CI, 0.48-0.97). Women were more likely than men to report contraindications (20.5% vs 12.5%, P < .001). Differences in aspirin use were greater between women and men with private health insurance (61.8% vs 79.0%, P < .001, adjusted OR = 0.48, 95% CI, 0.35-0.67) than among those with public coverage (62.5% vs 70.7%, P = .04, adjusted OR = 0.74, 95% CI, 0.50-1.11) (P < .001 for gender-insurance interaction).

CONCLUSION

We found a gender difference in aspirin use among patients with CHD not fully explained by differences in patient characteristics or reported contraindications. These findings suggest a need for improved secondary prevention of cardiovascular events for women with CHD.

Gender differences in management and outcome in non-ST-elevation acute coronary syndrome

OBJECTIVE

To study gender differences in management and outcome in patients with non-ST-elevation acute coronary syndrome.

DESIGN, SETTING AND PATIENTS

Cohort study of 53 781 consecutive patients (37% women) from the Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA), with a diagnosis of either unstable angina pectoris or non-ST-elevation myocardial infarction. All patients were admitted to intensive coronary care units in Sweden, between 1998 and 2002, and followed for 1 year.

MAIN OUTCOME MEASURES

Treatment intensity and in-hospital, 30-day and 1-year mortality.

RESULTS

Women were older (73 vs 69 years, p<0.001) and more likely to have a history of hypertension and diabetes, but less likely to have a history of myocardial infarction or revascularisation. After adjustment, there were no major differences in acute pharmacological treatment or prophylactic medication at discharge. Revascularisation was, however, even after adjustment, performed more often in men (OR 1.15; 95% CI, 1.09 to 1.21). After adjustment, there was no significant difference in in-hospital (OR 1.03; 95% CI, 0.94 to 1.13) or 30-days (OR 1.07; 95% CI, 0.99 to 1.15) mortality, but at 1 year being male was associated with higher mortality (OR 1.12; 95% CI, 1.06 to 1.19).

CONCLUSION

Although women are somewhat less intensively treated, especially regarding invasive procedures, after adjustment for differences in background characteristics, they have better long-term outcomes than men.

Comparison of results of percutaneous coronary intervention for non-ST-elevation acute myocardial infarction or unstable angina pectoris in men versus women

Previous randomized trials have addressed the impact of gender on outcomes, showing worse results in women assigned to invasive strategies compared with men with non-ST-elevation (NSTE) acute coronary syndrome (ACS). However, there is still a significant amount of controversy on strategies of treatment on the basis of gender. This study evaluated the impact of gender on treatment strategies and outcomes in patients with NSTE ACS in a high-volume, single-site tertiary center. We identified 1,197 consecutive patients with NSTE ACS (381 women, 816 men) who underwent percutaneous coronary intervention during their index hospitalizations. Patients were stratified by gender and baseline clinical and angiographic characteristics, and in-hospital and 9-month clinical outcomes were compared between the 2 groups. There were clear differences in baseline characteristics between men and women with ACS at presentation. Women were, on average, slightly older than men, with more hypertension and morbid obesity, but there were no differences in racial backgrounds or the prevalence of diabetes or dyslipidemia, nor were there treatment disparities in pharmacologic interventions. Women and men with ACS had similar rates of percutaneous coronary intervention on index admission. Women had a greater incidence of bleeding complications requiring blood transfusions. Overall, in-hospital and 9-month event-free survival were equivalent for the 2 genders. In conclusion, in this single-site observational study, patients with NSTE ACS who underwent angiography followed by percutaneous coronary intervention demonstrated no significant gender differences in treatment or in-hospital or 9-month event-free survival. From these results, interventional strategies should not be based on gender.

Gender differences in management and outcome of patients with acute myocardial infarction

BACKGROUND

The study objectives were to assess any gender differences in the application of diagnostic and therapeutic procedures and their impact on outcome in patients with acute myocardial infarction (AMI).

METHODS

Prospective cohort study of patients in the PRIAMHO II registry. 58 randomly selected public hospitals in Spain included 6209 patients with AMI admitted to Coronary/Critical Care Unit from May 15 to December 15 2000 with 1-year follow-up. Data were gathered on use of coronary angiography and reperfusion procedures, on a combined outcome variable (including death, reinfarction, postinfarction angina, and stroke during hospital stay), and on 28-day and 1-year mortality rates.

RESULTS

4641 (74.75%) of the patients were male and 1568 (25.5%) female. No gender differences in coronary angiography or reperfusion therapy use were found. However, female sex alongside age, use of reperfusion therapy, diabetes mellitus, previous revascularization, previous AMI, and higher Killip class were predictors of the combined outcome variable, with an adjusted OR of 1.21 (CI 95% 1.02-1.42).

CONCLUSIONS

No association was observed between the gender of patients with AMI and the application of diagnostic or therapeutic procedures. Nevertheless, female sex behaved as an independent adverse short-term prognostic factor.

Coronary revascularization for non-ST elevation acute coronary syndrome: state of the art

Immediate as well as early revascularization may be beneficial in patients with acute coronary syndromes (ACS) without ST elevation, but has traditionally employed as an 'ischemia-guided' strategy. A number of randomized trials (including more than 10 000 patients) and observational studies have compared routine invasive versus selective invasive treatment in patients with an acute coronary syndrome without ST elevation. Most randomized trials are limited by a high cross-over rate, whereas observational studies are limited by selection bias. Data from registries have demonstrated benefits with an invasive approach. The results from randomized trials are less clear regarding mortality reduction, although long-term survival after hospital discharge may be better after the invasive approach. In the randomized trials, there was a decreased risk of death or myocardial infarction after the invasive approach (odds ratio = 0.88, 95% confidence interval = 0.76-1.0). Despite the optimal timing of angiography and subsequent revascularization, if appropriate, angiography and revascularization should be considered in every patient admitted with an ACS without ST elevation, particularly in patients with high-risk characteristics, such as ST segment depression > 0.1 mV, accelerated angina in the prior 2 months, nitrate use in the prior week before admission and elevated troponin.

Moving from Evidence to Practice in the Care of Patients Who Have Acute Coronary Syndrome

Both acute management and secondary prevention for patients presenting with the spectrum of ACS have evolved greatly during the last decade, as evidenced by the multitude of clinical trials and the development of CPGs. The goal of the next decade is to ensure the accurate, equal,and timely application of these therapies and management strategies in clinical practice. In the emergency department, initiation of guideline-based management is especially challenging given the dynamic process of risk stratification that must take place to ensure properly directed care. It is clear, however, that application of such therapies leads to improved outcomes. Lessons learned from previous and ongoing quality improvement initiatives will provide the tools needed to ensure that widespread adoption of guideline-based therapy is complete.

Are we appropriately triaging patients with unstable angina?

BACKGROUND

It is uncertain how aggressively patients should be monitored and admitted to the hospital for chest pain syndromes and if the monitoring itself affects patient care, process, or outcomes. We assessed the appropriateness of care based on retrospective analysis of admission bed assignment (nonmonitored vs monitored) and Thrombolysis in Myocardial Infarction (TIMI) risk score in patients from the Global Unstable Angina Registry and Treatment Evaluation (GUARANTEE) Registry.

METHODS

Baseline characteristics, process of care, and outcomes were compared among 2939 patients admitted to 1 of 35 hospitals in the United States. Patients were stratified into low (0-2), intermediate (3 or 4), and high (5-7) risk based on TIMI risk score.

RESULTS

Among the patients, 92 (3%) were admitted to the cardiac care unit (CCU), 1602 (56%) were admitted to the telemetry unit, and 1163 (41%) were admitted to an unmonitored bed. Paradoxically, high-risk patients comprised only 1% of those in the CCU, 5% of those in telemetry, and 10% of those in nonmonitored units. Conversely, low-risk patients were 64% of those in the CCU, 53% of those in telemetry, and 42% of those in unmonitored beds. Procedures were done more often on patients admitted to nonmonitored units than those on telemetry or in the CCU irrespective of TIMI risk score.

CONCLUSIONS

This registry suggests that triage of patients does not routinely follow the risk-based approach suggested in the American College of Cardiology and American Heart Association guidelines and could therefore potentially lead to inefficiencies in care. Better implementation of risk stratification for acute coronary syndrome evaluation and management is necessary.