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

Long-term all-cause mortality of metabolic-dysfunction associated steatotic liver disease based on body weight phenotypes following acute myocardial infarction: A retrospective cohort study

OBJECTIVE

Metabolic dysfunction-associated steatotic liver disease (MASLD) and obesity increases risk of cardiovascular disease. This cohort study examines the prognostic value of MASLD, across body weight categories, in a secondary preventative acute myocardial infarction (AMI) cohort.

METHODS

Patients with AMI were stratified into four phenotypes-obesity MASLD, non-obesity MASLD, obesity non-MASLD, non-obesity non-MASLD. The primary outcome was all-cause mortality. Cox regression analysis was performed to investigate determinants of long-term all-cause mortality.

RESULTS

Of 5702 patients, majority were in the non-obesity non-MASLD group (66.7%), followed by obesity MASLD (16.1%), non-obesity MASLD (11.2%) and non-obesity MASLD (6.0%). Across the four phenotypes, obesity MASLD had the highest cardiometabolic burden, followed by non-obesity MASLD. Non-obesity MASLD had the highest risk of heart failure (p = 0.034), cardiogenic shock (p < 0.001), and all-cause long-term mortality (p = 0.019). The non-obesity MASLD (HR 1.400, 95%CI 1.077-1.820, p = 0.012) and obesity MASLD phenotypes (HR 1.222, 95%CI 1.005-1.485, p = 0.044) were independently associated with long-term all-cause mortality.

CONCLUSIONS

Obesity and non-obesity MASLD phenotypes were predictors of all-cause mortality following AMI, with an even larger magnitude of mortality risk in the non-obesity MASLD group. The recognition of MASLD and its body weight phenotypes will be beneficial in the prognostication following AMI.

Sex-related differences in the prognostic utility of inflammatory and thrombotic cardiovascular risk markers in patients with chest pain of suspected coronary origin

Background

α1-antichymotrypsin (SERPINA3), high sensitivity C-reactive protein (hsCRP) and pentraxin 3 (PTX3) are acute phase proteins triggered by inflammation, whereas D-dimer, fibrin monomer and α2-antiplasmin are thrombo-fibrinolytic markers. Sex differences in relation to cardiovascular disease were investigated.

Methods

A total of 871 consecutive patients (61.0 % males; females: 77.3 years, males 69.1 years) were included. Of these, 380 were diagnosed with an acute myocardial infarction (MI). Stepwise Cox regression models, applying normalized continuous loge/SD values, were fitted for the biomarkers with all-cause mortality, MI and stroke, respectively, and a composite endpoint within 7 years as the dependent variables.

Results

Except for α2-antiplasmin, all biomarkers were significantly associated with all-cause mortality and the combined endpoint in the univariate analysis. None of the inflammatory biomarkers predicted all-cause mortality in females after multivariable adjustment but were significant predictors in males (SERPINA3: HR 1.34 (95 %CI 1.16-1.56), p < 0.0001. hsCRP: HR 1.19 (95 %CI 1.02-1.38), p = 0.027. PTX3: HR 1.22 [95 %CI 1.04-1.44], p = 0.018. The p-value for interaction suggests a sex difference in the prognostic weighting of SERPINA3 (p = 0.015). None of the thrombo-fibrinolytic biomarkers predicted all-cause mortality in males after adjustment, but D-dimer and fibrin monomer were significant predictors of all-cause mortality in females (HR 1.51 [1.29-1.78], p < 0.0001, and HR 1.28 [1.08-1.53] p = 0.005, respectively). A trend towards interaction for D-dimer (p = 0.07) may suggest a sex difference in its prognostic weighting.

Conclusion

SERPINA3, hsCRP and PTX3 predicted long-term all-cause mortality in males but not in females. The opposite relationship was observed for D-dimer and fibrin monomer.

Sex differences in in-hospital outcomes and readmission rates after percutaneous coronary intervention

Background

Previous studies have reported worse outcomes in women following percutaneous coronary intervention (PCI), but contemporary studies examining sex differences in in-hospital outcomes and 90-day readmission risk are lacking. Therefore, we sought to compare 90-day readmission rates and in-hospital adverse outcomes after PCI.

Methods

We used the United States National Readmissions Database to stratify all inpatient PCIs from 2017 to 2018 by sex. We then performed propensity score matching of the two groups based on demographics, medical history, hospital characteristics, clinical presentation, socioeconomic status, and procedures. The primary outcome of interest was 90-day readmission to the hospital. Secondary outcomes included 30-day readmission, in-hospital mortality, and additional in-hospital outcomes. We performed Cox proportional-hazards modeling to compare the hazard of readmission between women and men and logistic regression to calculate odds ratios for the secondary outcomes of interest.

Results

After propensity score matching, 206,556 women and 205,134 men were included. At index hospitalization, women experienced higher odds of in-hospital mortality, hypovolemic shock, and need of blood transfusion, while men experienced higher odds of cardiac arrest, intracranial hemorrhage, and acute kidney injury. Women had a higher hazard of 30-day readmission (hazard ratio 1.16, 95% confidence interval 1.14-1.18, P < 0.01) and 90-day readmission (hazard ratio 1.14, 95% confidence interval 1.12-1.15), with the greatest difference seen among younger women <45 years of age. Findings were similar after stratification into different age groups and clinical presentations.

Conclusion

Substantial sex differences in outcomes after PCI persist, with variable sex differences in in-hospital complications, and women at higher risk of 30- and 90-day readmission to the hospital. Given the clinical and reimbursement implications of readmissions to patients and health systems, urgent efforts are needed to close these gaps.

Bridging Care Gaps for Older Women Undergoing Percutaneous Coronary Intervention

This paper reviews the distinct clinical, pathophysiological, and therapeutic challenges faced by older women undergoing percutaneous coronary intervention (PCI). Older women present with a greater comorbidity burden, smaller coronary vessels, and post-menopausal hormonal changes, which increase procedural complexity and adverse cardiovascular outcomes. Despite these challenges, older women are less likely to receive evidence-based therapies, resulting in higher risks of major adverse cardiovascular events (MACE) and bleeding. The paper further discusses the limitations of current risk stratification tools and outlines strategies for improving outcomes through tailored procedural techniques and patient-centered care approaches in this underrepresented population.

The Clinical Approach to Angina in Women

Women presenting with angina are more likely to have cardiac chest pain accompanied more frequently by associated symptoms like abdominal pain and lightheadedness. The evaluation of women with suspected coronary disease can be complex because many have microvascular dysfunction, coronary vasospasm, and altered coagulation that require specific testing protocols beyond the conventional stress testing and a coronary angiogram. Therefore, terms such as angina, ischemia, and myocardial infarction with no obstructive coronary disease have been introduced in recent years. More studies are required to elaborate guidelines on the diagnosis and management of these entities.

Long-term gender disparities in new-onset heart failure after acute coronary syndrome

AIMS

A paucity of studies addressed sex-related differences in clinical outcomes in the long term following acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). In these patients, it remains uncertain whether heart failure (HF) might exert a differential impact on the prognosis in the long term.

METHODS

We queried a large-scale database of ACS patients undergoing PCI. The primary endpoint was new-onset HF. Secondary endpoints included mortality, myocardial infarction, re-PCI and ischaemic stroke. Propensity score matching was generated to balance group characteristics. A total of 3334 patients after propensity score matching were analysed. Follow-up was assessed at the 5 year term.

RESULTS

At 5 year follow-up, HF risk increased significantly in males versus females {17.9% vs. 14.8%, hazard ratio [HR] [95% confidence interval (CI)] = 1.22 [1.03-1.44], P = 0.02}. At 5 year follow-up, mortality was significantly higher in the male cohort as compared with the female cohort [HR (95% CI) = 1.23 (1.02-1.47), P = 0.02]. On landmark analysis, differences in mortality emerged after the first year and were maintained thereafter. Ischaemic outcomes were comparable between cohorts.

CONCLUSIONS

Following ACS, males experienced a greater long-term risk of developing new-onset HF as compared with females. This difference remained consistent across all prespecified subgroups. Mortality was significantly higher in males. No differences were observed in ischaemic outcomes. New-onset HF emerges as a primary contributor to long-term gender disparities after ACS and a strong predictor of mortality in men with HF.

Endometriosis and long-term cardiovascular risk: a nationwide Danish study

BACKGROUND AND AIMS

Endometriosis, a systemic gynaecological disease affecting 10% of women in reproductive age, shares pathophysiological characteristics with cardiovascular disease. However, data on the relationship between endometriosis and cardiovascular outcomes are scarce, prompting this study to address the knowledge gap.

METHODS

Using Danish nationwide registries, women diagnosed with endometriosis (1977-2021) were identified and matched with controls in a 1:4 ratio based on year of birth. The primary outcome was a composite of acute myocardial infarction and ischaemic stroke. The secondary outcomes were arrhythmias, heart failure, and mortality.

RESULTS

In total, 60 508 women with endometriosis and 242 032 matched controls were included (median age 37.3 years). Women with endometriosis were more comorbid and used more medications than controls. The incidence rates of the composite outcomes were 3.2 [95% confidence interval (CI) 3.2-3.3] and 2.7 (95% CI 2.7-2.8) per 1000 person-years among women with and without endometriosis, respectively. Women with endometriosis had a significantly higher associated rate of the composite outcome compared with controls [unadjusted hazard ratio (HR) 1.18 (95% CI 1.14-1.23), adjusted HR 1.15 (95% CI 1.11-1.20)]. Likewise, women with endometriosis were also at significantly increased associated risk of arrhythmias [unadjusted HR 1.24 (95% CI 1.20-1.28) and adjusted HR 1.21 (95% CI 1.17-1.25)] and heart failure [unadjusted HR 1.16 (95% CI 1.09-1.22) and adjusted HR 1.11 (95% CI 1.05-1.18)] but at decreased risk of mortality [unadjusted HR 0.95 (95% CI 0.92-0.97) and adjusted HR 0.93 (95% CI 0.91-0.96)].

CONCLUSIONS

Women with endometriosis have a higher associated long-term risk of cardiovascular outcomes compared with controls. Despite subtle absolute risk differences, the high prevalence of endometriosis underscores the importance of these findings.

Incidental Breast Arterial Calcifications and Assessment of Coronary Artery Disease Risk: A Review and Recommendation

Coronary artery disease (CAD) continues to be the leading cause of morbidity and mortality in women, contributing to about 20%, or nearly 400,000, of female deaths annually in the United States. Despite their significant burden from CAD, women have been traditionally underrepresented in trials, and therefore, there is still much to be studied regarding the sex-based variations that have been reported regarding the pathophysiology, clinical presentation, efficacy of diagnostic workup, and response to therapy in CAD. Previous studies have reported that breast arterial calcifications, commonly found incidentally on screening mammography, may be associated with risk of CAD; however, there are currently no specific guidelines concerning reporting and quantification practices, as well as further workup recommendations for patients who are found to have vascular calcifications. Thus, the question remains whether breast arterial calcifications can serve as a sex-specific marker for CAD, and whether there is enough evidence to support the use of mammography as a screening tool for CAD in women. In this review, we will summarize the current understanding of cardiovascular disease in women, the existing literature regarding breast arterial calcifications and current reporting practices, and the association of vascular calcifications with CAD risk; based on the collected evidence, we will make a recommendation whether screening mammography and breast arterial calcifications should be used to assess CAD risk, and if so, what additional workup, if any, we recommend in women found to have breast arterial calcifications on imaging.

Analysis of risk factors in angiographically proven coronary artery disease in rural and urban Indian population. Prospective observational multicentre study: Kashmir Heart Survey

Background

The global burden of cardiovascular diseases is increasing rapidly, and changing trends in epidemiological risk factors are identified among diverse Indian population. There has been a significant increase in heart attack deaths over the past 3 years after the COVID-19 pandemic. Are we missing a link? There is an urgent need for studies to confirm any epidemiological shift in coronary artery disease (CAD) risk factors.

Aims and Objectives

To analyse the risk factors in patients with established CAD in rural and urban Indian Kashmiri populations in the post-COVID period.

Material and Methods

A prospective observational study of all patients with angiographically proven CAD who have undergone revascularisation or have a clinical suspicion of CAD on the basis of symptoms or positive stress test and later proven to have CAD on coronary angiograms, coming from rural and urban areas of Jammu and Kashmir were enrolled for the study and screened for various modifiable and non-modifiable CAD risk factors. Data was compiled and analysed to know the pattern of various CAD risk factors in our population.

Results

The study included total 600 patients (rural and urban 300 each), mean age was 59.13 ± 11.62 years. Male patients were 65.50% with a mean age of 57.53 ± 14.17 years and female patients were 34.50% with a mean age of 62.16 ± 10.02 years. In rural subgroup of 300 patients mean age was 60.99 ± 16.86 years and in the urban population we found a mean age of 57.26 ± 16.21 years. The most common risk factor was smoking in 76% rural and 67% urban. Diabetes (39% rural, 43% urban), dyslipidaemia (47.33%, 48.66% urban), hypertension (61% rural, 66% urban), obesity (23% rural, 29.33% urban) and physical inactivity (33.66% rural, 37.33% urban.

Conclusion

CAD manifests earlier in males and urban populations. Smoking is the most common risk factor for CAD in the Kashmiri Indian population and is more common in the rural population. Coronary artery disease risk factors, such as physical inactivity, diabetes, smoking, hypertension, obesity and dyslipidaemia, are more common in the urban population. Preventive strategies should focus on modifying the risk factors to decrease the prevalence of CAD in communities.

Characteristics of Young Women Presenting With Acute Myocardial Infarction: The Prospective, Multicenter, Observational Young Women Presenting Acute Myocardial Infarction in France Study

BACKGROUND

The percentage of women <50 years of age hospitalized with myocardial infarction is increasing. We describe the clinical, morphological, and biological characteristics, as well as the clinical outcomes of this population.

METHODS AND RESULTS

This prospective, observational study included consecutive women <50 years of age admitted for myocardial infarction at 30 centers in France (May 2017-June 2019). The primary outcome was the composite of net adverse clinical events: all-cause death, cardiovascular death, recurrent myocardial infarction, stent thrombosis, any stroke, or major bleeding occurring during hospitalization with a 12-month follow up. Three hundred fourteen women were included. The mean age was 43.0 (±5.7) years, 60.8% presented with ST-segment-elevation myocardial infarction, 75.5% were current smokers, 31.2% had a history of complicated pregnancy, and 55.1% reported recent emotional stress. Most (91.6%) women presented with typical chest pain. Of patients on an estrogen-containing contraceptive, 86.0% had at least 1 contraindication. Of patients with ST-segment-elevation myocardial infarction, 17.8% had myocardial infarction with nonobstructive coronary arteries and 14.6% had spontaneous coronary artery dissection, whereas 29.3% presented with multivessel vessel disease. During hospitalization, 11 net adverse clinical events occurred in 9 (2.8%) women, but no deaths or stent thromboses occurred. By 12 months, 14 net adverse clinical events occurred in 10 (3.2%) women; 2 (0.6%) died (from progressive cancer) and 25 (7.9%) had an ischemia-driven repeat percutaneous coronary intervention.

CONCLUSIONS

Most young women with myocardial infarction reported typical chest pain and had modifiable cardiovascular risk factors. History of adverse pregnancy outcomes and prescription of combined oral contraceptive despite a contraindication were prevalent, emphasizing the need for comprehensive cardiological and gynecological evaluation and follow-up.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03073447.

Race, Ethnicity, and Gender Disparities in Acute Myocardial Infarction

Cardiovascular disease continues to be the leading cause of morbidity and mortality in the United States. Despite advancements in medical care, there remain persistent racial, ethnic, and gender disparity in the diagnosis, treatment, and prognosis of individuals with cardiovascular disease. In this review we seek to discuss differences in pathophysiology, clinical course, and risk profiles in the management and outcomes of acute myocardial infarction and related high-risk states. We also seek to highlight the demographic and psychosocial inequities that cause disparities in acute cardiovascular care.

The High-Sensitivity HEART Pathway Safely Reduces Hospitalizations Regardless of Sex or Race in a Multisite Prospective US Cohort

BACKGROUND

The high-sensitivity HEART pathway (hs-HP) risk stratifies emergency department (ED) patients with chest pain. It is unknown if its safety and effectiveness vary by sex or race.

METHODS

We conducted a subgroup analysis of the hs-HP implementation study, a pre-post interrupted time series at five US EDs. The pre-implementation period (January 2019 to April 2020) utilized the traditional HEART pathway with contemporary troponin (Siemens) and the post-implementation period (November 2020 to February 2022) used the hs-HP using hs-cTnI (Beckman Coulter). Patients were risk-stratified using the hs-HP to rule-out, observation, and rule-in groups. Safety and effectiveness outcomes were 30-day all-cause mortality or myocardial infarction (MI) and 30-day hospitalization.

RESULTS

Twenty-six thousand and one hundred twenty-six patients were accrued (12 317 pre- and 13 809 post-implementation), of which 35.3% were non-White and 52.7% were female. Among 9703 patients with complete hs-HP assessments, 48.6% of White and 55.4% of non-White patients were ruled-out (p < 0.001). Additionally, 47.3% of males and 54.4% of females were ruled-out (p < 0.001). Among rule-out patients, 0.3% of White versus 0.3% of non-White patients (p = 0.98) and 0.3% of females versus males 0.3% (p = 0.90) experienced 30-day death or MI. Post-implementation, 30-day hospitalization decreased 17.2% among White patients (aOR 0.49, 95% CI: 0.45-0.52), 14.1% among non-White patients (aOR 0.53, 95% CI: 0.48-0.59), 15.6% among females (aOR 0.50, 95% CI: 0.46-0.54), and 16.6% among males (aOR 0.51, 95% CI: 0.47-0.56). The interactions for 30-day hospitalization between hs-HP implementation and race (p = 0.10) and sex (p = 0.69) were not significant.

CONCLUSIONS

The hs-HP safely decreases 30-day hospitalizations regardless of sex or race. However, it classifies more non-White patients and women to the rule-out group.

Impact of sex differences on the feasibility and safety of distal radial access for coronary procedures: a multicenter prospective observational study

BACKGROUND

Conventional transradial access in women is associated with a lower success rate and a higher incidence of spasm compared to men. To date, the effect of sex on the performance of distal radial access (DRA) has not been fully elucidated. The aim of this study was to assess the impact of sex on catheterization success and other performance parameters of DRA procedures.

METHODS

This is a prospective three-center observational study. From August 2020 to September 2022, data from all consecutive patients who underwent DRA for coronary procedures were collected.

RESULTS

A total of 868 procedures were registered and stratified into two groups according to sex: women (n = 258) and men (n = 610). Female patients had less favorable baseline characteristics than male patients in terms of absent or weak pulse (29% vs. 17%; P  < 0.001), distal radial diameter (2.2 ± 0.3 vs. 2.4 ± 0.4 mm; P  < 0.001) and proximal radial diameter (2.5 ± 0.7 vs. 2.7 ± 0.7 mm; P  = 0.001). No differences in success rates were found in women compared to men (94.2% vs. 96.6%; P  = 0.135), with a higher presence of arterial spasm in women (5.8% vs. 3.0%; P  = 0.044). The preprocedural ultrasound evaluation was the only predictor of DRA success [odds ratio = 20.0 (4.739-83.333); P  < 0.001].

CONCLUSION

In patients undergoing coronary procedures, the success rate of DRA was high regardless of sex, with a higher incidence of arterial spasm in women.

Sex differences in the presentation and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock: a critical review of contemporary data and a look towards future directions

PURPOSE OF REVIEW

Cardiogenic shock (CS) is a devasting complicating of acute myocardial infarction (AMI), associated with significant mortality. Prior studies have reported sex differences in the presentation, management and outcomes of patients with AMI and CS. These differences are likely due to a variety of factors influencing therapeutic decision-making and impacting survival. This review highlights the more contemporary studies exploring differences in women and men with AMI-CS, providing a critical perspective towards understanding the factors that might lead to these differences and outlining potential opportunities to reduce disparities in treatment and improve survival for women with AMI-CS.

RECENT FINDINGS

Recent reports demonstrate that women with AMI-CS are older than men and have more cardiovascular comorbidities. When examining an unselected population of patients with AMI-CS, women receive less aggressive treatment compared to men and have poorer outcomes. However, when examining a selected population of patients with AMI-CS treated with mechanical circulatory support (MCS) and/or admitted to centers that implement CS protocols to manage AMI-CS, these sex-based differences in outcomes are largely mitigated.

SUMMARY

Standardizing protocols for the diagnosis and treatment of patients with AMI-CS, with an emphasis on early revascularization and appropriate invasive therapies, can improve outcomes in women and narrow the gender gap.

Hearts apart: sex differences in cardiac remodeling in health and disease

Biological sex is an important modifier of physiology and influences pathobiology in many diseases. While heart disease is the number one cause of death worldwide in both men and women, sex differences exist at the organ and cellular scales, affecting clinical presentation, diagnosis, and treatment. In this Review, we highlight baseline sex differences in cardiac structure, function, and cellular signaling and discuss the contribution of sex hormones and chromosomes to these characteristics. The heart is a remarkably plastic organ and rapidly responds to physiological and pathological cues by modifying form and function. The nature and extent of cardiac remodeling in response to these stimuli are often dependent on biological sex. We discuss organ- and molecular-level sex differences in adaptive physiological remodeling and pathological cardiac remodeling from pressure and volume overload, ischemia, and genetic heart disease. Finally, we offer a perspective on key future directions for research into cardiac sex differences.

Gender, racial and ethnic disparities in acute coronary syndromes with coronary in-stent restenosis

Background

Coronary in-stent restenosis (ISR) is a major clinical challenge of contemporary percutaneous revascularization and portends adverse cardiovascular outcomes.

Objectives

We aimed to evaluate gender, race, and ethnicity related outcomes in acute coronary syndromes (ACS) with ISR.

Methods

Primary hospitalizations for ACS and ISR in the National Inpatient Sample database from 2016 to 2019 were included. Patients were stratified by gender, race, and ethnicity. The primary end points were all cause in-hospital mortality and coronary revascularization defined as composite of percutaneous coronary intervention (PCI), balloon angioplasty and/or coronary artery bypass grafting (CABG).

Results

During the study period, a nationally weighted total of 97,680 patients with ACS and ISR were included. There was substantial variation in comorbidities, with greatest burden among Black and Hispanic women. All-cause in-hospital mortality was 2.4 % in the study cohort, but significantly higher in women (2.1 % vs. 2.1 %; aOR: 1.282, 95 % CI: 1.174-1.4; p < 0.001) and revascularization rates were significantly lower in women (77 % vs 80.2 %; aOR: 0.891, 95 % CI: 0.862-0.921; p < 0.001). Compared to White men, all women except Hispanic women, had significantly higher likelihood of in-hospital mortality, while White women, Black men and women, and Hispanic men had lower odds of revascularization.

Conclusions

There are significant gender, racial, and ethnic related differences in revascularization practices and clinical outcomes in patients with ACS and ISR with an adverse impact on women, racial and ethnic minorities in the U.S.

Impact of Guideline-Directed Drug Therapy after ST-Elevation Myocardial Infarction on Outcome in Young Patients-Age and Sex-Specific Factors

Background: Specifically young women are at risk for a poor outcome after ST-elevation myocardial infarction (STEMI). We aimed to investigate sex- and age-specific differences in outcome and associate these results with adherence to a guideline-directed optimal medical therapy (OMT). Methods: Administrative insurance data (≈26 million insured) were screened for patients aged 18-60 years with STEMI. Patient demographics, details on in-hospital treatment, adherence to OMT and its effect on mortality were assessed. Adherence to OMT was analyzed using multistate models and an association of those with death was fitted using multivariable Cox regression models with time-dependent co-variables. Results: Overall, 59,401 patients (19.3% women), median age 52 (interquartile range 48, 56) presented with STEMI. Female sex was associated with a poor outcome early after STEMI (90-day mortality: odds ratio 1.22, 95% confidence interval (CI) 1.12-1.32, p < 0.001). Overall survival was reduced in women compared to same-aged men. The ten-year survival rate was 19.7% (18.1-21.2%) versus 19.6% (18.9-20.4%) in men (p < 0.001). Although long-term drug adherence was low, its intake was associated with a better outcome. Specifically younger women showed a markedly lower mortality when on OMT (hazard ratio (HR) 0.22 (95% CI 0.19-0.26) versus HR 0.31 (95% CI 0.28-0.33) in men, pint < 0.001). Conclusions: Specifically young women were at risk for a poor outcome in the early phase after STEMI. Although long-term adherence to OMT was low, it was generally associated with a lower mortality, specifically in women. Our findings emphasize on early and long-term preventive measures in all patients after STEMI.

Sex and Racial Disparities in Proportionate Mortality of Premature Myocardial Infarction in the United States: 1999 to 2020

BACKGROUND

The incidence of premature myocardial infarction (PMI) in women (<65 years and men <55 years) is increasing. We investigated proportionate mortality trends in PMI stratified by sex, race, and ethnicity.

METHODS AND RESULTS

CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) was queried to identify PMI deaths within the United States between 1999 and 2020, and trends in proportionate mortality of PMI were calculated using the Joinpoint regression analysis. We identified 3 017 826 acute myocardial infarction deaths, with 373 317 PMI deaths corresponding to proportionate mortality of 12.5% (men 12%, women 14%). On trend analysis, proportionate mortality of PMI increased from 10.5% in 1999 to 13.2% in 2020 (average annual percent change of 1.0 [0.8-1.2, P <0.01]) with a significant increase in women from 10% in 1999 to 17% in 2020 (average annual percent change of 2.4 [1.8-3.0, P <0.01]) and no significant change in men, 11% in 1999 to 10% in 2020 (average annual percent change of -0.2 [-0.7 to 0.3, P=0.4]). There was a significant increase in proportionate mortality in both Black and White populations, with no difference among American Indian/Alaska Native, Asian/Pacific Islander, or Hispanic people. American Indian/Alaska Natives had the highest PMI mortality with no significant change over time.

CONCLUSIONS

Over the last 2 decades, there has been a significant increase in the proportionate mortality of PMI in women and the Black population, with persistently high PMI in American Indian/Alaska Natives, despite an overall downtrend in acute myocardial infarction-related mortality. Further research to determine the underlying cause of these differences in PMI mortality is required to improve the outcomes after acute myocardial infarction in these populations.

The COVID-19 impact on STEMI disparities

ST-segment elevation myocardial infarction (STEMI) is a significant source of morbidity and mortality. Despite guideline-driven management and increased awareness of social determinants of health, there are persistent disparities in diagnosis, management, and outcomes. The coronavirus disease 2019 (COVID-19) pandemic has greatly affected emergency department visitation, conditions and throughput. The aim of this study was to find any potential health disparities in patients who presented with STEMI during the COVID-19 pandemic by reviewing STEMI care data from April to September 2019 (pre-pandemic) and April to September 2020 (during the pandemic) for our hospital system. Patients with STEMI within 12 h of presentation were included in this study, and subdivided by age, gender, and race/ethnicity. We compared the turnaround times between emergency department arrival to intervention (electrocardiogram or catheterization) within the patient subgroups to find any notable differences. No statistically significant changes in turnaround times during either study period were found based on age, gender, or race/ethnicity for the STEMI interventions despite shifts in emergency department resources during the pandemic. This study helped assess the status quo in STEMI intervention for our health system and serves as a baseline for us to monitor gaps in care or areas of improvement. As healthcare systems institute new measures to promote equitable care, such as improving the accuracy of demographic data capture, establishing a baseline is an essential first step in evaluating the impact of these measures.

Closing the sex gap in cardiovascular mortality by achieving both horizontal and vertical equity

Addressing sex differences and disparities in coronary heart disease (CHD) involves achieving both horizontal and vertical equity in healthcare. Horizontal equity in the context of CHD means that both men and women with comparable health statuses should have equal access to diagnosis, treatment, and management of CHD. To achieve this, it is crucial to promote awareness among the general public about the signs and symptoms of CHD in both sexes, so that both women and men may seek timely medical attention. Women often face inequity in the treatment of cardiovascular disease. Current guidelines do not differ based on sex, but their applications based on gender do differ. Vertical equity means tailoring healthcare to allow equitable care for all. Steps towards achieving this include developing treatment protocols and guidelines that consider the unique aspects of CHD in women. It also requires implementing guidelines equally, when there is not sex difference rather than inequities in application of guideline directed care.

Infertility treatment is associated with increased risk of postpartum hospitalization due to heart disease

BACKGROUND

Cardiovascular disease is a major cause of maternal mortality, but the extent to which infertility treatment is implicated in heart disease remains unclear.

OBJECTIVE

To evaluate the association between infertility treatment and postpartum heart disease.

METHODS

We designed a retrospective cohort study of patients who delivered in the United States between 2010 and 2018. The primary outcome was hospitalization within 12-month post-delivery due to heart disease (including ischemic heart disease, atherosclerotic heart disease, cardiomyopathy, hypertensive disease, heart failure, and cardiac dysrhythmias). We estimated the rate difference (RD) of hospitalizations among patients who conceived with infertility treatment and those who conceived spontaneously. Associations were expressed as hazard ratios (HRs) and 95% confidence intervals (CIs), derived from Cox proportional hazards regression after adjustment for potential confounders.

RESULTS

Infertility treatment was recorded in 0.9% (n = 287,813) of 31,339,991 deliveries. Rates of heart disease hospitalizations with infertility treatment and with spontaneous conception were 550 and 355 per 100,000, respectively (RD 195, 95% CI: 143-247; adjusted HR 1.99, 95% CI: 1.80-2.20). The most important increase in risk was observed for hypertensive disease (adjusted HR 2.16, 95% CI: 1.92-2.42). This increased risk was apparent as early as 30-day post-delivery (HR 1.61, 95% CI: 1.39-1.86), with progressively increasing risk up to a year.

CONCLUSIONS

Although the absolute risk of postpartum heart disease hospitalization is low, infertility treatment is associated with an increased risk, especially for hypertensive disease. These findings highlight the importance of timely postpartum follow-ups in patients who received infertility treatment.

Impact of COVID-19 Pandemic on Sex and Racial Disparities in Chest Pain Presentation and Management Through the Emergency Department

Background

Sex and racial disparities in the presentation and management of chest pain persist, however, the impact of coronavirus disease 2019 (COVID-19) on these disparities have not been studied. We sought to determine whether the COVID-19 pandemic contributed to pre-existing sex and racial disparities in the presentation, management, and outcomes of patients presenting to the emergency department (ED) with chest pain.

Methods

We conducted an observational cohort study with retrospective data collection of patients between January 1, 2016, and May 1, 2022. This was a single study conducted at a quaternary academic medical center of all patients who presented to the ED with a complaint of chest pain or chest pain equivalent symptoms. Patient were further segregated into different groups based on sex (male, female), race, ethnicity (Asian, Black, Hispanic, White, and other), and age (18 - 40, 41 - 65, > 65). We compared diagnostic evaluations, treatment decisions, and outcomes during prespecified time points before, during, and after the COVID-19 pandemic.

Results

This study included 95,764 chest pain encounters. Total chest pain presentations to the ED fell about 38% during the early pandemic months. Females presented significantly less than males during initial COVID-19 (48% vs. 52%, P < 0.001) and Asian females were least likely to present. There was an increase in the total number of troponins and echocardiograms ordered during peak COVID-19 across both sexes, but females were still less likely to have these tests ordered across all timepoints. The number of coronary angiograms did not increase during peak COVID-19, and females were less likely to undergo coronary angiogram during all timepoints. Finally, females with chest pain were less likely to be diagnosed with acute myocardial infarction (AMI) during all timepoints, while in-hospital deaths were similar between males and females during all timepoints.

Conclusions

During COVID-19, females, especially Asian females, were less likely to present to the ED for chest pain. Non-White patients were less likely to present to the ED compared to White patients prior to and during the pandemic. Disparities in management and outcomes of chest pain encounters remained similar to pre-COVID-19, with females receiving less cardiac workup and AMI diagnoses than males, but in-hospital mortality remaining similar between groups and timepoints.

The Importance of Nontraditional and Sex-Specific Risk Factors in Young Women With Vasomotor Nonobstructive vs Obstructive Coronary Syndromes

Background

Heart disease is the leading cause of premature death for women in Canada. Ischemic heart disease is categorized as myocardial infarction (MI) with no obstructive coronary artery disease (MINOCA), ischemia with no obstructive coronary arteries (INOCA), and atherosclerotic obstructive coronary artery disease (CAD) with MI (MI-CAD) or without MI (non-MI-CAD). This study aims to study the prevalence of traditional and nontraditional ischemic heart disease risk factors and their relationships with (M)INOCA, compared to MI-CAD and non-MI-CAD in young women.

Methods

This study investigated women who presented with premature (at age ≤ 55 years) vasomotor entities of (M)INOCA or obstructive CAD confirmed by coronary angiography, who are currently enrolled in either the Leslie Diamond Women's Heart Health Clinic Registry (WHC) or the Study to Avoid Cardiovascular Events in British Columbia (SAVEBC). Univariable and multivariable regression models were applied to investigate associations of risk factors with odds of (M)INOCA, MI-CAD, and non-MI-CAD.

Results

A total of 254 women enrolled between 2015 and 2022 were analyzed, as follows: 77 with INOCA and 37 with MINOCA from the registry, and 66 with non-MI-CAD and 74 with MI-CAD from the study. Regression analyses demonstrated that migraines and preeclampsia or gestational hypertension were the most significant risk factors, with a higher likelihood of being associated with premature (M)INOCA, relative to obstructive CAD. Conversely, the presence of diabetes and a current or previous smoking history had the highest likelihood of being associated with premature CAD.

Conclusions

The risk factor profiles of patients with premature (M)INOCA, compared to obstructive CAD, have significant differences.

Heterogeneity of platelets and their responses

There has been increasing recognition of heterogeneity in blood platelets and their responses, particularly in recent years, where next-generation technologies and advanced bioinformatic tools that interrogate "big data" have enabled large-scale studies of RNA and protein expression across a growing list of disease states. However, pioneering platelet biologists and clinicians were already hypothesizing upon and investigating heterogeneity in platelet (and megakaryocyte) activity and platelet metabolism and aggregation over half a century ago. Building on their foundational hypotheses, in particular Professor Marian A. Packham's pioneering work and a State of the Art lecture in her memoriam at the 2023 International Society on Thrombosis and Haemostasis Congress by Anandi Krishnan, this review outlines the key features that contribute to the heterogeneity of platelets between and within individuals. Starting with important epidemiologic factors, we move stepwise through successively smaller scales down to heterogeneity revealed by single-cell technologies in health and disease. We hope that this overview will urge future scientific and clinical studies to recognize and account for heterogeneity of platelets and aim to apply methods that capture that heterogeneity. Finally, we summarize other exciting new data presented on this topic at the 2023 International Society on Thrombosis and Haemostasis Congress.

Sex-related differences in non-ischemic myocardial injury in the emergency department: A real-world perspective

BACKGROUND

Myocardial injury is associated with adverse outcomes. No data are reported about sex differences in incidence and factors associated with myocardial injury in an emergency department (ED) setting from a real-world perspective. We aimed to assess whether sex plays a major role in the diagnosis of myocardial injury in the ED.

METHODS

In this subanalysis of a retrospective study, patients presenting at the ED with at least one high-sensitivity cardiac troponin T (hs-cTnT) value and without acute coronary syndromes diagnosis were compared.

RESULTS

31,383 patients were admitted to the ED, 4660 had one hs-cTnT value, and 3937 were enrolled: 1943 females (49.4%) and 1994 males (50.6%). The diagnosis of myocardial injury was higher among men (36.8% vs. 32.9%, p < 0.01). Male sex was independently associated with myocardial injury. An older age, an elevated NT-proB-type Natriuretic Peptide and a lower estimated glomerular filtrate rate were independently associated with myocardial injury in both sexes.

CONCLUSIONS

In the ED, from a real-world perspective, myocardial injury occurred more frequently in males, and it was associated with older age and the presence of cardiac, lung, and kidney disease but not higher hs-cTnT values.

Unraveling the Role of Sex in Endothelial Cell Dysfunction: Evidence From Lineage Tracing Mice and Cultured Cells

BACKGROUND

Biological sex differences play a vital role in cardiovascular diseases, including atherosclerosis. The endothelium is a critical contributor to cardiovascular pathologies since endothelial cells (ECs) regulate vascular tone, redox balance, and inflammatory reactions. Although EC activation and dysfunction play an essential role in the early and late stages of atherosclerosis development, little is known about sex-dependent differences in EC.

METHODS

We used human and mouse aortic EC as well as EC-lineage tracing (Cdh5-CreERT2 Rosa-YFP [yellow fluorescence protein]) atherosclerotic Apoe-/- mice to investigate the biological sexual dimorphism of the EC functions in vitro and in vivo. Bioinformatics analyses were performed on male and female mouse aortic EC and human lung and aortic EC.

RESULTS

In vitro, female human and mouse aortic ECs showed more apoptosis and higher cellular reactive oxygen species levels than male EC. In addition, female mouse aortic EC had lower mitochondrial membrane potential (ΔΨm), lower TFAM (mitochondrial transcription factor A) levels, and decreased angiogenic potential (tube formation, cell viability, and proliferation) compared with male mouse aortic EC. In vivo, female mice had significantly higher lipid accumulation within the aortas, impaired glucose tolerance, and lower endothelial-mediated vasorelaxation than males. Using the EC-lineage tracing approach, we found that female lesions had significantly lower rates of intraplaque neovascularization and endothelial-to-mesenchymal transition within advanced atherosclerotic lesions but higher incidents of missing EC lumen coverage and higher levels of oxidative products and apoptosis. RNA-seq analyses revealed that both mouse and human female EC had higher expression of genes associated with inflammation and apoptosis and lower expression of genes related to angiogenesis and oxidative phosphorylation than male EC.

CONCLUSIONS

Our study delineates critical sex-specific differences in EC relevant to proinflammatory, pro-oxidant, and angiogenic characteristics, which are entirely consistent with a vulnerable phenotype in females. Our results provide a biological basis for sex-specific proatherosclerotic mechanisms.

Trend, regional variation and socioeconomic inequality in cardiovascular disease among the elderly population in China: evidence from a nationwide longitudinal study during 2011-2018

INTRODUCTION

Cardiovascular disease (CVD) continues to pose a significant burden among the elderly population in China. There is a knowledge gap in the temporal trends, regional variations and socioeconomic inequalities among this vulnerable population.

METHODS

This study conducted cross-sectional and cohort analyses based on four survey waves of the China Health and Retirement Longitudinal Study among adults aged ≥60 years spanning 2011-2018 across 28 provinces. Cross-sectional analyses examined temporal trends, regional variations and socioeconomic inequalities in CVD prevalence. Cohort analyses identified individuals without CVD in 2011 and followed them up until 2018 to calculate CVD incidence. Generalised estimating equations (GEE) were employed to identify associated factors.

RESULTS

A total of 5451, 7258, 8820 and 11 393 participants were eligible for cross-sectional analyses, and 4392 and 5396 participants were included in cohort analyses of CVD and comorbid CVD. In 2018, the age-adjusted and sex-adjusted prevalence of CVD and comorbid CVD was 31.21% (95% CI 27.25% to 35.17%) and 3.83% (95% CI 2.85% to 4.81%), respectively. Trend analyses revealed a significant increase in the adjusted prevalence from 2011 to 2018 (p for trend <0.001). There were substantial provincial variations in the adjusted prevalence of CVD and comorbid CVD. Higher socioeconomic status (SES) participants exhibited higher prevalence, and the concentration curves and concentration indices suggested persistent but narrowing inequalities in CVD and comorbid CVD across survey waves. Cohort analyses from 2011 to 2018 yielded overall CVD and comorbid CVD incidence densities of 17.96 and 2.65 per 1000 person-years, respectively. GEE results indicated increased CVD risks among older individuals, women, higher SES participants and northern residents.

CONCLUSION

More efforts should be taken to optimise strategies for high-quality CVD prevention and management in China's elderly population. Future interventions and policies should address age-specific and gender-specific, geographical, and socioeconomic disparities to ensure equitable access and outcomes for all.

[Benefits of an observatory for myocardial infarction in women under 50 : The WAMIF study]

The WAMIF study was conducted from 2017 to 2019 to include 314 patients in 30 French investigative centers in France. We have systematically collected the clinical, morphological and biological characteristics of cases of myocardial infarction affecting women under 50 years of age and evaluated their short-term (intra-hospital) and mid-term (at 12 months) prognosis. . The main results were: a particularly high incidence of modifiable risk factors affecting 86% of patients with smoking in the first place in 75% of them. The clinical presentation revealed chest pain in more than 90% of cases. The pathophysiological forms of acute coronary syndrome identified the culprit artery in 90% of cases, MI without obstruction (MINOCA) was found in 17.8% of the ST elevation MI (STEMI), spontaneous dissection in 14.6% of STEMI and 16.3% of NSTEMI. Hospital events included 3 strokes, 3 cases of bleeding and no deaths. At 12 months, follow-up showed no cardiovascular deaths. The results of this study allow us to better understand the particularities of cardiovascular diseases in women and thus to develop targeted strategies for prevention and improvement of their management.

Chest Pain in Women: Gender- and Sex-based Differences in the Presentation and Diagnosis of Heart Disease

Ischemic heart disease is a major cause of morbidity and mortality in the US, affecting both men and women significantly. The presentation of chest pain is largely similar in female and male patients, but additional non-chest pain symptoms can confound timely diagnosis in women. Management, diagnostic evaluation, and clinical outcomes for patients admitted with chest pain differ significantly between men and women, and understanding of these discrepancies is limited. The objective of this review is to familiarize readers with gender- and sex-specific differences in the presentation, diagnosis, and management of chest pain.

Associations Between Albuminuria and Mortality Among US Adults by Demographic and Comorbidity Factors

Background Albuminuria is a known marker of mortality risk. Whether the association between albuminuria and mortality differs by demographic and comorbidity factors remains unclear. Therefore, we sought to determine whether albuminuria is differentially associated with mortality. Methods and Results This study included 49 640 participants from the National Health and Nutrition Examination Survey (1999-2018). All-cause mortality through 2019 was linked from the National Death Index. Multivariable-adjusted Poisson regression models were used to determine whether levels of urine albumin-to-creatinine ratio (ACR) were associated with mortality. Models were adjusted for demographic, socioeconomic, behavioral, and clinical factors. Mean age in the population was 46 years, with 51.3% female, and 30.3% with an ACR ≥10 mg/g. Over a median follow-up of 9.5 years, 6813 deaths occurred. Compared with ACR <10, ACR ≥300 was associated with increased risk of mortality by 132% overall (95% CI, 2.01-2.68), 124% among men (95% CI, 1.84-2.73), 158% among women (95% CI, 2.14-3.11), 130% among non-Hispanic White adults (95% CI: 1.89-2.79), 135% among non-Hispanic Black adults (95% CI, 1.82-3.04), and 114% among Hispanic adults (95% CI, 1.55-2.94). Compared with ACR <10, ACR ≥300 was associated with increased risk of mortality by 148% among individuals with neither hypertension nor hypercholesterolemia (95% CI, 1.69-3.64), 128% among individuals with hypertension alone (95% CI, 1.86-2.79), and 166% among individuals with both hypertension and hypercholesterolemia (95% CI, 2.18-3.26). Conclusions We found strong associations between albuminuria and mortality risk, even at mildly increased levels of albuminuria. Associations persisted across categories of sex, race or ethnicity, and comorbid conditions, with subtle differences.

Long-Term Clinical Impact of Patients with Multi-Vessel Non-Obstructive Coronary Artery Disease

BACKGROUND

Non-obstructive coronary artery disease (CAD) is a disease commonly diagnosed in patients undergoing coronary angiography. However, little is known regarding the long-term clinical impact of multi-vessel non-obstructive CAD. Therefore, the object of this study was to investigate the long-term clinical impact of multi-vessel non-obstructive CAD.

METHOD

A total of 2083 patients without revascularization history and obstructive CAD were enrolled between January 2010 and December 2015. They were classified into four groups according to number of vessels involved in non-obstructive CAD (25% ≤ luminal stenosis < 70%): zero, one, two, or three diseased vessels (DVs). We monitored the patients for 5 years. The primary outcome was major cardiovascular and cerebrovascular events (MACCEs), defined as a composite of cardiac death, stroke, and myocardial infarction (MI).

RESULT

The occurrence of MACCEs increased as the number of non-obstructive DVs increased, and was especially high in patients with three DVs. After adjustment, patients with three DVs still showed significantly poorer clinical outcomes of MACCEs, stroke, and MI compared those with zero DVs.

CONCLUSION

Multi-vessel non-obstructive CAD, especially in patients with non-obstructive three DVs, is strongly associated with poor long-term clinical outcomes. This finding suggests that more intensive treatment may be required in this subset of patients.

Gender differences in vascular aging and in coronary artery disease pathophysiology

Women have a clinical advantage over men in relation to atherosclerotic cardiovascular disease (CVD) (morbidity and mortality). This advantage disappears once women become older, and in their seventh decade, the risk to develop CVD equals men at that age. There have been several theories about this gender difference that were related to hormones, and the different morphology and physiology that characterize the cardiovascular system in women. In this review, the different mechanisms will be reviewed and discussed.

Sex- and age-related differences in outcomes of patients with acute myocardial infarction: MINOCA vs. MIOCA

AIMS

The aim of the study is to evaluate the impact of sex on acute myocardial infarction (AMI) patients' clinical presentation and outcomes, comparing those with non-obstructive and obstructive coronary arteries (MINOCA vs. MIOCA).

METHODS AND RESULTS

We enrolled 2455 patients with AMI undergoing coronary angiography from January 2017 to September 2021. Patients were divided according to the type of AMI and sex: male (n = 1593) and female (n = 607) in MIOCA and male (n = 87) and female (n = 168) in MINOCA. Each cohort was further stratified based on age (≤/> 70 years). The primary endpoint (MAE) was a composite of all-cause death, recurrent AMI, and hospitalization for heart failure (HF) at follow-up. Secondary outcomes included all-cause and cardiovascular death, recurrent AMI, HF re-hospitalization, and stroke. MINOCA patients were more likely to be females compared with MIOCA ones (P < 0.001). The median follow-up was 28 (15-41) months. The unadjusted incidence of MAE was significantly higher in females compared with males, both in MINOCA [45 (26.8%) vs. 12 (13.8%); P = 0.018] and MIOCA cohorts [203 (33.4%) vs. 428 (26.9%); P = 0.002]. Age was an independent predictor of MAE in both cohorts. Among MINOCA patients, females ≤70 years old had a higher incidence of MAE [18 (23.7%) vs. 4 (5.9%); P = 0.003] compared with male peers, mainly driven by a higher rate of re-hospitalization for HF (P = 0.045) and recurrence of AMI (P = 0.006). Only in this sub-group of MINOCA patients, female sex was an independent predictor of MAE (hazard ratio = 3.09; 95% confidence interval: 1.02-9.59; P = 0.040). MINOCA females ≤70 years old had worse outcomes than MIOCA female peers.

CONCLUSION

MINOCA females ≤70 years old had a significantly higher incidence of MAE, compared with males and MIOCA female peers, likely due to the different pathophysiology of the ischaemic event.

TRIAL REGISTRATION

Data were part of the ongoing observational study 'AMIPE: Acute Myocardial Infarction, Prognostic and Therapeutic Evaluation' (ClinicalTrials.gov Identifier: NCT03883711).

Gender Disparities in Presentation, Management, and Outcomes of Acute Pulmonary Embolism

Pulmonary embolism (PE) is the third most common cause of cardiovascular death; however, gender disparities in PE remain understudied. All PE cases at a single institution between January 2013 and June 2019 were retrospectively reviewed. The clinical presentation, treatment modalities, and outcomes were compared between men and women using univariate and multivariate analyses adjusting for differences in baseline characteristics. A total of 1,345 patients were diagnosed with acute PE, of whom 56.3% were women (n = 757). Women had a significantly higher mean body mass index (29.4 vs 28.4) and a higher frequency of hypertension (53% vs 46%) and hormone use (6.6% vs 0%; all p <0.02). Men had a higher frequency of smoking (45% vs 33%, p <0.0001). Women had significantly lower PE severity index classifications (p = 0.0009). The rates of intensive care unit admission, vasopressor requirements, extracorporeal membrane oxygenation cannulation, and mechanical ventilation were similar between the genders. There was no significant difference in the treatment modality used between the genders. Although the risk factors and PE severity index class differed between the genders, there was no significant difference in resource utilization or treatment modality. Gender was also not a significant predictor of in-hospital mortality, moderate or severe bleeding, increased length of stay, or readmission in the study population.

Kidney Injury after Cardiac Surgery: Prevention-Associated Cost Reduction

INTRODUCTION

Cardiac surgery may induce acute kidney injury and the need for renal replacement therapy. It is also associated with higher hospital costs, morbidity and mortality. The aims of this study were to investigate predictors of cardiac surgery associated acute kidney injury in our population and to determine the burden of acute kidney injury in elective cardiac surgery, evaluating the potential cost effectiveness of preventing it through the application of the Kidney Disease: Improving Global Outcomes bundle of care to high-risk patient groups identified by the [TIMP-2]x[IGFBP7] used as a screening test.

MATERIAL AND METHODS

In a University Hospital single-center retrospective cohort study we analyzed a consecutive sample of adults who underwent elective cardiac surgery between January and March 2015. A total of 276 patients were admitted during the study period. Data from all patients was analyzed until hospital discharge or the patient's death. The economic analysis was performed from the hospital costs' perspective.

RESULTS

Cardiac surgery associated acute kidney injury occurred in 86 patients (31%). After adjustment, higher preoperative serum creatinine (mg/L, ORadj = 1.09; 95% CI: 1.01 - 1.17), lower preoperative hemoglobin (g/dL, ORadj = 0.79; 95% CI: 0.67 - 0.94), chronic systemic hypertension (ORadj = 5.00; 95% CI: 1.67 - 15.02), an increase in cardiopulmonary bypass time (min, ORadj = 1.01; 95% CI: 1.00 - 1.01) and perioperative use of sodium nitroprusside (ORadj = 6.33; 95% CI: 1.80 - 22.28) remained significantly associated with cardiac surgery related acute kidney injury. The expected cumulative surplus cost for the hospital linked with cardiac surgery associated acute kidney injury (86 patients) was €120 695.84. Based on a median absolute risk reduction of 16.6%, by dosing kidney damage biomarkers in every patient and using preventive measures in high-risk patients, we would expect a break-even point upon screening 78 patients, which would translate, in our patient cohort, into an overall cost benefit of €7145.

CONCLUSION

Preoperative hemoglobin, serum creatinine, systemic hypertension, cardiopulmonary bypass time and perioperative use of sodium nitroprusside were independent predictors of cardiac surgery associated acute kidney injury. Our cost-effectiveness modelling suggests that the use of kidney structural damage biomarkers combined with an early prevention strategy could be associated with potential cost savings.

Explainable SHAP-XGBoost models for in-hospital mortality after myocardial infarction

Background

A lack of explainability in published machine learning (ML) models limits clinicians' understanding of how predictions are made, in turn undermining uptake of the models into clinical practice.

Objective

The purpose of this study was to develop explainable ML models to predict in-hospital mortality in patients hospitalized for myocardial infarction (MI).

Methods

Adult patients hospitalized for an MI were identified in the National Inpatient Sample between January 1, 2012, and September 30, 2015. The resulting cohort comprised 457,096 patients described by 64 predictor variables relating to demographic/comorbidity characteristics and in-hospital complications. The gradient boosting algorithm eXtreme Gradient Boosting (XGBoost) was used to develop explainable models for in-hospital mortality prediction in the overall cohort and patient subgroups based on MI type and/or sex.

Results

The resulting models exhibited an area under the receiver operating characteristic curve (AUC) ranging from 0.876 to 0.942, specificity 82% to 87%, and sensitivity 75% to 87%. All models exhibited high negative predictive value ≥0.974. The SHapley Additive exPlanation (SHAP) framework was applied to explain the models. The top predictor variables of increasing and decreasing mortality were age and undergoing percutaneous coronary intervention, respectively. Other notable findings included a decreased mortality risk associated with certain patient subpopulations with hyperlipidemia and a comparatively greater risk of death among women below age 55 years.

Conclusion

The literature lacks explainable ML models predicting in-hospital mortality after an MI. In a national registry, explainable ML models performed best in ruling out in-hospital death post-MI, and their explanation illustrated their potential for guiding hypothesis generation and future study design.

A bibliometric analysis of acute myocardial infarction in women from 2000 to 2022

Background

Plenty of publications had been written in the last several decades on acute myocardial infarction (AMI) in women. However, there are few bibliometric analyses in such field. In order to solve this problem, we attempted to examine the knowledge structure and development of research about AMI in women based on analysis of related publications.

Method

The Web of Science Core Collection was used to extract all publications regarding AMI in women, ranging from January 2000 to August 2022. Bibliometric analysis was performed using VOSviewer, Cite Space, and an online bibliometric analysis platform.

Results

A total of 14,853 publications related to AMI in women were identified from 2000 to 2022. Over the past 20 years, the United States had published the most articles in international research and participated in international cooperation the most frequently. The primary research institutions were Harvard University and University of Toronto. Circulation was the most cited journal and had an incontrovertible academic impact. 67,848 authors were identified, among which Harlan M Krumholz had the most significant number of articles and Thygesen K was co-cited most often. And the most common keywords included risk factors, disease, prognosis, mortality, criteria and algorithm.

Conclusion

The research hotspots and trends of AMI in women were identified and explored using bibliometric and visual methods. Researches about AMI in women are flourishing. Criteria and algorithms might be the focus of research in the near future, which deserved great attentions.

Impacts of gender and lifestyle on the association between depressive symptoms and cardiovascular disease risk in the UK Biobank

We investigated the effects of gender and lifestyle on the association between frequency of depressive symptoms and CVD risk. The UK Biobank is a national prospective cohort study that recruited 502,505 participants aged 40-69 years between 2006 and 2010. Participants without CVD were classified as having low, moderate, high, or very high frequency of depressive symptoms according to the number of days they felt depressed in a 2-week period. UKBB data include self-reported questionnaires covering lifestyle behaviors such as smoking, physical activity, eating habits, and sleep duration. The primary outcomes included incident CVD including coronary artery disease, ischemic stroke, hemorrhagic stroke, peripheral artery disease, atrial fibrillation/flutter, and heart failure. Cox proportional hazard models were used to evaluate the effects of gender and lifestyle on the association of frequency of depressive symptoms and CVD risk. During a median follow-up of 8.9 years, 27,394 (6.3%) developed CVD. The frequency of depressive symptoms increased the risk of CVD according to low, moderate, high, and very high frequency of depressive symptoms (P for trend < 0.001). The adjusted CVD risk was 1.38-fold higher for participants with very high frequency of depressive symptoms compared to those with low frequency of depressive symptoms (HR 1.38, 95% CI 1.24-1.53, P < 0.001). The correlation between frequency of depressive symptoms and CVD risk was more remarkable in females than in males. In participants with high or very high frequency of depressive symptoms, the individual lifestyle factors of no current smoking, non-obesity, non-abdominal obesity, regular physical activity, and appropriate sleep respectively was associated with lower CVD risk by 46% (HR 0.54, 95% CI 0.48-0.60, P < 0.001), 36% (HR 0.64, 95% CI 0.58-0.70, P < 0.001), 31% (HR 0.69, 95% CI 0.62-0.76, P < 0.001), 25% (HR 0.75, 95% CI 0.68-0.83, P < 0.001), and 22% (HR 0.78, 95% CI 0.71-0.86, P < 0.001). In this large prospective cohort study, a higher frequency of depressive symptoms at baseline was significantly associated with increased risk of CVD in the middle-aged population, and this relationship was prominent in women. In the middle-aged population with depressive symptoms, engaging in a healthier lifestyle could prevent CVD risk.

Pharmacoepidemiologic study of association between apparent treatment resistant hypertension, cardiovascular disease and interaction effect by sex and age

BACKGROUND

A limited number of studies have been conducted to test the magnitudes of the association between apparent treatment resistant hypertension (aTRH) and risk of cardiovascular disease (CVD).

AIM

To investigate the association between aTRH and risk of CVD and examine whether sex and age modify this association.

METHODS

We applied an observational analysis study design using data from the United States Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). ALLHAT recruited participants (n = 25516) from 625 primary care settings throughout the United States, Canada, Puerto Rico, and United States Virgin Islands, aged 55 and older with hypertension and at least one additional risk factor for heart disease. aTRH was assessed from the year 2 visit. CVD event was defined as one of the following from the year 2 follow-up visit: Fatal or non-fatal myocardial infarction, coronary revascularization, angina, stroke, heart failure, or peripheral artery disease. Cox proportional hazards regression was used to examine the effect of aTRH on CVD risk. Potential modifications of sex and age on this association were examined on the multiplicative scale by interaction term and additive scale by joint effects and relative excess risk for interaction.

RESULTS

Of the total study participants (n = 25516), 5030 experienced a CVD event during a mean of 4.7 years follow-up. aTRH was associated with a 30% increase in risk of CVD compared to non-aTRH [hazards ratio (HR) = 1.3, 95%CI: 1.19-1.42]. Sex and age modified this relationship on both multiplicative and additive scales independently. Stratified by sex, aTRH was associated with a 64% increase in risk of CVD (HR = 1.64, 95%CI: 1.43–1.88) in women, and a 13% increase in risk of CVD (HR = 1.13, 95%CI: 1.01–1.27) in men. Stratified by age, aTRH had a stronger impact on the risk of CVD in participants aged < 65 (HR = 1.53, 95%CI: 1.32–1.77) than it did in those aged ≥ 65 (HR = 1.18, 95%CI: 1.05–1.32). Significant two-way interactions of sex and aTRH, and age and aTRH on risk of CVD were observed (P < 0.05). The observed joint effect of aTRH and ages ≥ 65 years (HR = 1.85, 95%CI: 1.22–2.48) in males was less than what was expected for both additive and multiplicative models (HR = 4.10, 95%CI: 3.63–4.57 and 4.88, 95%CI: 3.66–6.31), although three-way interaction of sex, age, and aTRH on the risk of CVD and coronary heart disease did not reach a statistical significance (P > 0.05).

CONCLUSION

aTRH was significantly associated with an increased risk of CVD and this association was modified by both sex and age. Further studies are warranted to test these mechanisms.

Sex Differences in Heart Failure Following Acute Coronary Syndromes

Background

There have been conflicting reports regarding outcomes in women presenting with an acute coronary syndrome (ACS).

Objectives

The objective of the study was to examine sex-specific differences in 30-day mortality in patients with ACS and acute heart failure (HF) at the time of presentation.

Methods

This was a retrospective study of patients included in the International Survey of Acute Coronary Syndromes-ARCHIVES (ISACS-ARCHIVES; NCT04008173). Acute HF was defined as Killip classes ≥2. Participants were stratified according to ACS presentation: ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS). Differences in 30-day mortality and acute HF presentation at admission between sexes were examined using inverse propensity weighting based on the propensity score. Estimates were compared by test of interaction on the log scale.

Results

A total of 87,812 patients were included, of whom 30,922 (35.2%) were women. Mortality was higher in women compared with men in those presenting with STEMI (risk ratio [RR]: 1.65; 95% CI: 1.56-1.73) and NSTE-ACS (RR: 1.18; 95% CI: 1.09-1.28; P interaction <0.001). Acute HF was more common in women when compared to men with STEMI (RR: 1.24; 95% CI: 1.20-1.29) but not in those with NSTE-ACS (RR: 1.02; 95% CI: 0.97-1.08) (P interaction <0.001). The presence of acute HF increased the risk of mortality for both sexes (odds ratio: 6.60; 95% CI: 6.25-6.98).

Conclusions

In patients presenting with ACS, mortality is higher in women. The presence of acute HF at hospital presentation increases the risk of mortality in both sexes. Women with STEMI are more likely to present with acute HF and this may, in part, explain sex differences in mortality. These findings may be helpful to improve sex-specific personalized risk stratification.

An Evaluation of Sex-Based Differences in Surrogate Consent for Older Adults Undergoing Surgical Intervention

INTRODUCTION

Differences between female and male patients have been identified in many facets of medicine. We sought to understand whether differences in frequency of surrogate consent for operation exist between older female and male patients.

MATERIALS AND METHODS

A descriptive study was designed using data from the hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. Patients age 65 y and older who underwent operation between 2014 and 2018 were included.

RESULTS

Of 51,618 patients identified, 3405 (6.6%) had surrogate consent for surgery. Overall, 7.7% of females had surrogate consent compared to 5.3% of males (P < 0.001). Stratified analysis based on age categories showed no difference in surrogate consent between female and male patients aged 65-74 yy (2.3% versus 2.6%, P = 0.16), but higher rates of surrogate consent in females than males among patients aged 75-84 y old (7.3% versus 5.6%, P < 0.001) and age ≥85 y (29.7% versus 20.8%, P < 0.001). A similar relationship was seen between sex and preoperative cognitive status. There was no difference in preoperative cognitive impairment in female and male patients age 65-74 y (4.4% versus 4.6%, P = 0.58), but higher rates of preoperative cognitive impairment were seen in females than males for those age 75-84 (9.5% versus 7.4%, P < 0.001) and aged ≥85 y (29.4% versus 21.3%, P < 0.001). Matching for age and cognitive impairment, there was no significant difference between rate of surrogate consent in males and females.

CONCLUSIONS

Female patients are more likely than males to undergo surgery with surrogate consent. This difference is not based on patient sex alone - females undergoing operation are older than their male counterparts and more likely to be cognitively impaired.

Effect of Gender on Postoperative Outcome and Duration of Ventilation After Coronary Artery Bypass Grafting (CABG)

INTRODUCTION

The study assessed coronary artery bypass grafting (CABG) postoperative outcomes and associated factors in Saudi male and female patients. This was a retrospective cohort of patients who underwent CABG at the King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, from January 2015 to December 2022.  Results: We included 392 patients, of whom 63 (16.1%) were female. Female undergoing CABG were significantly older (p=0.0001), had a significantly higher incidence of diabetes (p=0.0001), obesity (p=0.001), hypertension (p=0.001), and congestive heart failure (p=0.005), with a smaller body surface area (BSA) (p=0.0001) than male. Though renal dysfunction, previous cerebrovascular accident/transient ischemic attack (CVA/TIA), and myocardial infarction (MI), incidences were similar in both genders. Females were at significantly higher risk of mortality (p=0.0001), longer hospital stay (p=0.0001), and prolonged ventilation (p=0.0001). Preoperative renal dysfunction was the only statistically significant predictor of postoperative complications (p=0.0001). Female gender and preoperative renal dysfunction, were significant independent predictors of postoperative mortality and prolonged ventilation (p=0.005).

CONCLUSION

This study's findings indicated that females have worse CABG outcomes and a higher risk of morbidities and complications. Uniquely our study showed a higher incidence of prolonged ventilation in females postoperatively.

Higher burden of cardiometabolic and socioeconomic risk factors in women with type 2 diabetes: an analysis of the Glycemic Reduction Approaches in Diabetes (GRADE) baseline cohort

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a powerful risk factor for cardiovascular disease (CVD), conferring a greater relative risk in women than men. We sought to examine sex differences in cardiometabolic risk factors and management in the contemporary cohort represented by the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE).

RESEARCH DESIGN AND METHODS

GRADE enrolled 5047 participants (1837 women, 3210 men) with T2DM on metformin monotherapy at baseline. The current report is a cross-sectional analysis of baseline data collected July 2013 to August 2017.

RESULTS

Compared with men, women had a higher mean body mass index (BMI), greater prevalence of severe obesity (BMI≥40 kg/m2), higher mean LDL cholesterol, greater prevalence of low HDL cholesterol, and were less likely to receive statin treatment and achieve target LDL, with a generally greater prevalence of these risk factors in younger women. Women with hypertension were equally likely to achieve blood pressure targets as men; however, women were less likely to receive ACE inhibitors or angiotensin receptor blockers. Women were more likely to be divorced, separated or widowed, and had fewer years of education and lower incomes.

CONCLUSIONS

This contemporary cohort demonstrates that women with T2DM continue to have a greater burden of cardiometabolic and socioeconomic risk factors than men, particularly younger women. Attention to these persisting disparities is needed to reduce the burden of CVD in women.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT01794143).

Sex differences in myocardial injury after non-cardiac surgery and postoperative mortality

BACKGROUND

Myocardial injury after non-cardiac surgery (MINS) has recently been accepted as a predictor of mortality. However, sex differences in the incidence of MINS and survival thereafter are not fully understood. This study aimed to compare the incidence of MINS and mortality among male and female patients.

METHODS

This single-center study was conducted using the database of a large tertiary referral hospital. Consecutive patients with cardiac troponin (cTn) detected within 30 days after non-cardiac surgery performed between January 2010 and June 2019 were grouped according to sex. The incidence of MINS and mortality of patients with MINS were compared between men and women.

RESULTS

Of the 33,311 patients, 18,546 (55.7%) were men and 14,765 (44.3%) were women. In a multivariable analysis, women showed a significantly lower incidence of MINS than did men (17.9% vs. 14.2%; odds ratio, 0.76; 95% confidence interval [CI], 0.71-0.81; P < 0.001). In patients with MINS, the propensity-score-matched analysis showed that 30-day mortality did not differ according to sex, but mortality in females was significantly lower than that in males during the overall follow-up (33.0% vs. 25.7%; hazard ratio, 0.75; 95% CI, 0.66-0.84; P < 0.001).

CONCLUSION

The incidence of MINS was lower in women than in men. In patients with MINS, female sex may be associated with a survival benefit. Further studies are needed to confirm these findings.

Sex-Specific Reproductive Factors Augment Cardiovascular Disease Risk in Women: A Mendelian Randomization Study

Background Observational studies suggest that reproductive factors are associated with cardiovascular disease, but these are liable to influence by residual confounding. This study explores the causal relevance of reproductive factors on cardiovascular disease in women using Mendelian randomization. Methods and Results Uncorrelated (r2<0.001), genome-wide significant (P<5×10-8) single-nucleotide polymorphisms were extracted from sex-specific genome-wide association studies of age at first birth, number of live births, age at menarche, and age at menopause. Inverse-variance weighted Mendelian randomization was used for primary analyses on outcomes of atrial fibrillation, coronary artery disease, heart failure, ischemic stroke, and stroke. Earlier genetically predicted age at first birth increased risk of coronary artery disease (odds ratio [OR] per year, 1.49 [95% CI, 1.28-1.74], P=3.72×10-7) heart failure (OR, 1.27 [95% CI, 1.06-1.53], P=0.009), and stroke (OR, 1.25 [95% CI, 1.00-1.56], P=0.048), with partial mediation through body mass index, type 2 diabetes, blood pressure, and cholesterol traits. Higher genetically predicted number of live births increased risk of atrial fibrillation (OR for <2, versus 2, versus >2 live births, 2.91 [95% CI, 1.16-7.29], P=0.023), heart failure (OR, 1.90 [95% CI, 1.28-2.82], P=0.001), ischemic stroke (OR, 1.86 [95% CI, 1.03-3.37], P=0.039), and stroke (OR, 2.07 [95% CI, 1.22-3.52], P=0.007). Earlier genetically predicted age at menarche increased risk of coronary artery disease (OR per year, 1.10 [95% CI, 1.06-1.14], P=1.68×10-6) and heart failure (OR, 1.12 [95% CI, 1.07-1.17], P=5.06×10-7); both associations were at least partly mediated by body mass index. Conclusions These results support a causal role of a number of reproductive factors on cardiovascular disease in women and identify multiple modifiable mediators amenable to clinical intervention.

Sex Differences in Delayed Hospitalization in Patients with Non-ST-Segment Elevation Myocardial Infarction Undergoing New-Generation Drug-Eluting Stent Implantation

We compared the effects of sex differences in delayed hospitalization (symptom-to-door time [SDT], ≥24 h) on major clinical outcomes in patients with non-ST-segment elevation myocardial infarction after new-generation drug-eluting stent implantation. A total of 4593 patients were classified into groups with (n = 1276) and without delayed hospitalization (SDT < 24 h, n = 3317). Thereafter, these two groups were subdivided into male and female groups. The primary clinical outcomes were major adverse cardiac and cerebrovascular events (MACCE), defined as all-cause death, recurrent myocardial infarction, repeat coronary revascularization, and stroke. The secondary clinical outcome was stent thrombosis. After multivariable- and propensity score-adjusted analyses, in-hospital mortalities were similar between the male and female groups in both the SDT < 24 h and SDT ≥ 24 h groups. However, during a 3-year follow-up period, in the SDT < 24 h group, all-cause death (p = 0.013 and p = 0.005, respectively) and cardiac death (CD, p = 0.015 and p = 0.008, respectively) rates were significantly higher in the female group than those in the male group. This may be related to the lower all-cause death and CD rates (p = 0.022 and p = 0.012, respectively) in the SDT < 24 h group than in the SDT ≥ 24 h group among male patients. Other outcomes were similar between the male and female groups and between the SDT < 24 h and SDT ≥ 24 h groups. In this prospective cohort study, female patients showed higher 3-year mortality, especially in the SDT < 24 h, compared to male patients.

Gender-related differences in the coagulofibrinolytic responses and long-term outcomes in patients with isolated traumatic brain injury: A 2-center retrospective study

Coagulation function differs by gender, with women being characterized as more hypercoagulable. Even in the early stages of trauma, women have been shown to be hypercoagulable. Several studies have also examined the relationship between gender and the prognosis of trauma patients, but no certain conclusions have been reached. Patients with isolated traumatic brain injury (iTBI) are known to have coagulopathy, but no previous studies have examined the gender differences in detail. This is a retrospective analysis of a prospective registry conducted at 2 centers. The study included adult patients with iTBI enrolled from April 2018 to March 2021. Coagulofibrinolytic markers were measured in each patient at 1 hour, 24 hours, 3 days, and 7 days after injury, and neurological outcomes were assessed with the Glasgow Outcome Scale Extended at 6 months. Subgroup analysis was also performed by categorizing patients into groups according to neurological prognosis or age at 50 years. Males (n = 31) and females (n = 21) were included in the analysis. In males, there was a significant difference in the levels of activated partial thromboplastin time (P = .007), fibrin/fibrinogen degradation products (P = .025), D-dimer (P = .034), α2-plasmin inhibitor (P = .030), plasmin-α2-plasmin inhibitor complex (P = .004) at 1 hour after injury between favorable and unfavorable long-term neurological outcome groups, while in females there was no significant difference in these markers between 2 groups. In the age group under 50 years, there were significant gender differences in fibrinogen (day 3: P = .018), fibrin/fibrinogen degradation products (1 hour: P = .037, day 3: P = .009, day 7: P = .037), D-dimer (day 3: P = .005, day 7: P = .010), plasminogen (day 3: P = .032, day 7: P = .032), and plasmin-α2-plasmin inhibitor complex (day 3: P = .001, day 7: P = .001), and these differences were not evident in the age group over 50 years. There were differences in coagulofibrinolytic markers depending on gender in patients with iTBI. In male patients, aggravation of coagulofibrinolytic markers immediately after traumatic brain injury may be associated with poor neurologic outcome 6 months after injury.