Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators

Clinical Characteristics and Outcome of Patients With Myocardial Infarction With Nonobstructive Coronary Arteries in Japan: Insights From the Miyagi Acute Myocardial Infarction Registry Study

BACKGROUND

Clinical characteristics and outcomes of patients with myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) are not fully understood, particularly in Japan.

METHODS AND RESULTS

We enrolled a total of 8881 patients with acute MI from the Miyagi Acute Myocardial Infarction Registry Study (2012-2020), with a median age of 69 years. Among them, 239 patients (2.7%) were diagnosed with MINOCA. Compared with those with MI with obstructive coronary artery disease (MI-CAD), patients with MINOCA were more often women, had a higher incidence of non-ST-segment-elevation MI and a lower prevalence of dyslipidemia. Compared with patients with MI-CAD, patients with MINOCA in all age groups (<59, 60-69, 70-79, >80 years of age) had a higher incidence of non-ST-segment-elevation MI. Additionally, those ≤59 years of age were more often women and had a lower prevalence of diabetes and dyslipidemia. In-hospital mortality increased with age in patients with MI-CAD (3.9% for <59 years of age, 5.6% for 60-69 years of age, 8.3% for 70-79 years of age, and 15.2% for >80 years of age; P<0.01), but not in patients with MINOCA (4.5%, 7.4%, 6.0%, and 9.6%, respectively; P=0.36). Compared with patients with MI-CAD, patients with MINOCA had lower in-hospital mortality for Killip class IV (40.7% versus 20.0%; adjusted odds ratio [OR], 0.31 [95% CI, 0.10-0.94]; P=0.04) and renal dysfunction (20.0% versus 7.1%; adjusted OR, 0.29 [95% CI, 0.09-0.96]; P=0.04).

CONCLUSIONS

Patients with MINOCA exhibit distinct clinical characteristics and outcomes compared with those with MI-CAD, particularly in terms of age, sex, prevalence of comorbidities, and in-hospital mortality. These findings underscore the importance of tailored clinical approaches for patients with MINOCA.

Discovery of plasma proteins and metabolites associated with left ventricular cardiac dysfunction in pan-cancer patients

BACKGROUND

Cancer-therapy related cardiac dysfunction (CTRCD) remains a significant cause of morbidity and mortality in cancer survivors. In this study, we aimed to identify differential plasma proteins and metabolites associated with left ventricular dysfunction (LVD) in cancer patients.

METHODS

We analyzed data from 50 patients referred to the Cleveland Clinic Cardio-Oncology Center for echocardiograph assessment, integrating electronic health records, proteomic, and metabolomic profiles. LVD was defined as an ejection fraction ≤ 55% based on echocardiographic evaluation. Classification-based machine learning models were used to predict LVD using plasma metabolites and proteins as input features.

RESULTS

We identified 13 plasma proteins (P < 0.05) and 14 plasma metabolites (P < 0.05) associated with LVD. Key proteins included markers of inflammation (ST2, TNFRSF14, OPN, and AXL) and chemotaxis (RARRES2, MMP-2, MEPE, and OPN). Notably, sex-specific associations were observed, such as uridine (P = 0.003) in males. Furthermore, metabolomic features significantly associated with LVD included 1-Methyl-4-imidazoleacetic acid (P = 0.015), COL1A1 (P = 0.009), and MMP-2 (P = 0.016), and pointing to metabolic shifts and heightened inflammation in patients with LVD.

CONCLUSION

Our findings suggest that circulating metabolites may non-invasively detect clinical and molecular differences in patients with LVD, providing insights into underlying disease pathways and potential therapeutic targets.

Sex-related differences in the clinical course of aortic root and ascending aortic aneurysms: the DisSEXion Study

BACKGROUND AND AIMS

To explore male-female differences in aneurysm growth and clinical outcomes in a two-centre retrospective Dutch cohort study of adult patients with ascending aortic aneurysm (AscAA).

METHODS

Adult patients in whom imaging of an AscAA (root and/or ascending: ≥40 mm) was performed between 2007 and 2022 were included. Aneurysm growth was analysed using repeated measurements at the sinuses of Valsalva (SoV) and tubular ascending aorta. Male-female differences were explored in presentation, aneurysm characteristics, treatment strategy, survival, and clinical outcomes.

RESULTS

One thousand eight hundred and fifty-eight patients were included (31.6% female). Median age at diagnosis was 65.4 years (interquartile range: 53.4-71.7) for females and 59.0 years (interquartile range: 49.3-68.0) for males (P < .001). At diagnosis, females more often had tubular ascending aortic involvement (75.5% vs. 70.2%; P = .030) while males more often had SoV involvement (42.8% vs. 21.6%; P < .001). Maximum absolute aortic diameter, at any location, at diagnosis did not differ between females (45.0 mm) and males (46.5 mm; P = .388). In females, tubular ascending growth was faster (P < .001), whereas in males, SoV growth was faster (P = .005), corrected for covariates. Unadjusted 10-year survival was 72.5% [95% confidence interval (CI) 67.8%-77.6%] for females and 78.3% (95% CI 75.3%-81.3%) for males (P = .010). Twenty-three type A dissections occurred, with an incidence rate of 8.2/1000 patient-years (95% CI 4.4-14.1) in females and 2.4/1000 patient-years (95% CI 1.2-4.5) in males [incidence rate ratio females/males: 3.4 (95% CI 1.5-8.0; P = .004)].

CONCLUSIONS

In patients having entered a diagnostic programme, involvement of aortic segments and age- and segment-related growth patterns differ between women and men with AscAA, particularly at an older age. Unravelling of these intertwined observations will provide a deeper understanding of AscAA progression and outcome in women and men and can be used as an evidence base for patient-tailored clinical guideline development.

Sex differences in ST-segment elevation myocardial infarction patients treated by primary percutaneous intervention

INTRODUCTION

The impact of sex on coronary artery disease prognosis is debated. It has been postulated that women receive less prompt treatment compared with men, potentially adversely affecting their prognosis by significantly increasing the risk of morbidity and mortality. We aim to investigate the influence of sex on the timing and clinical outcomes of ST-segment elevation myocardial infarction (STEMI) patients using a controlled Swiss registry.

METHODS AND RESULTS

Based on the Fribourg STEMI Fast Track Registry, 1177 patients (288 women, 889 men) with >12 months clinical follow-up were selected. Women had longer first medical contact to reperfusion times (1.31 (1.14-2.00) vs 1.27 (1.09-1.54) hours, p=0.035) but similar total ischaemic times (3.04 (2.15-4.50) vs 2.56 (2.07-4.38) hours, p=0.064). Men had higher rates of diabetes, smoking and dyslipidaemia, while women had higher hypertension and renal insufficiency rates. No significant sex differences in clinical outcomes were observed at 1-year and 5-year follow-ups.

DISCUSSION

The study found sex differences in patient profiles and minor treatment delays for women, which did not significantly affect outcomes. Efforts to improve sex equity in STEMI care are effective, as no significant outcome differences were observed. Disparities are more related to patient characteristics than sex.

CONCLUSION

Despite slight delays and different risk profiles for women with STEMI, clinical outcomes are similar between sexes. Ongoing efforts are needed to ensure sex equity in acute coronary syndrome management.

TRIAL REGISTRATION NUMBER

NCT04185285.

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.

Sex Disparity in the In-Hospital Outcomes of Patients with Kidney Disease Admitted for Myocardial Infarction: Insights from a Large National Database

INTRODUCTION

There is limited evidence as to the effect of sex on the outcomes of patients admitted for ST-elevation myocardial infarction (STEMI) who have a concomitant diagnosis of chronic kidney disease (CKD) and end-stage renal disease (ESRD). We aimed to determine if there are differences in the outcomes between males and females in these patient populations.

METHODS

Data were obtained from the National Inpatient Sample database and patients were selected using the International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and -10) codes. Hospitalizations for patients with CKD who had STEMI from 2012 to 2020 were included. The primary outcome of interest was in-hospital mortality. Secondary outcomes evaluated included ischemic stroke, major bleeding complications, pressor requirement, permanent pacemaker implantation, percutaneous coronary intervention, coronary artery bypass grafting, surgery, pericardiocentesis, mechanical circulatory support, and mechanical ventilation.

RESULTS

A total of 1,283,255 STEMI patients without CKD, 158,715 STEMI patients with CKD, and 22,690 STEMI patients with ESRD were identified and analyzed. Among patients with STEMI and CKD, females demonstrated higher in-hospital mortality compared to male counterparts (16.7% vs. 12.7%, aOR = 1.13, 95% CI: 1.05-1.21, p < 0.01). While there was no sex difference in the in-hospital mortality among STEMI patients with ESRD, female patients in this group were less likely to receive coronary artery bypass grafting and mechanical circulatory support.

CONCLUSION

Increased in-hospital mortality rates were shown for females admitted for STEMI with CKD. Among patients with ESRD who had STEMI, females were less likely to receive coronary artery bypass grafting and mechanical circulatory support. Further research needs to be conducted to better explain this said difference in outcomes.

ST-segment elevation myocardial infarction without culprit lesion-a case report picturing the challenging interplay of epicardial atherosclerosis and coronary artery spasm

Background

Approximately 5-15% of patients with acute coronary syndrome have myocardial infarction with unobstructed coronary arteries (MINOCA). Guidelines recommend invasive assessments to identify underlying causes for MINOCA such as coronary artery spasm (CAS), spontaneous coronary dissection, or microvascular disease as well as non-invasive assessments in search of myocarditis, takotsubo syndrome, or cardiomyopathies.

Case summary

A 54-year-old male patient presented with ST-segment elevation myocardial infarction (STEMI). Upon arrival, ST-segment elevation and symptoms had ceased. Emergency coronary angiography showed diffuse epicardial atherosclerosis with stenoses in the distal left anterior descending coronary artery (LAD) and second diagonal branch (D2); however, no epicardial occlusion was seen. Left ventriculography showed no clear wall motion abnormalities. Based on these findings, intracoronary acetylcholine (ACh) testing in search of CAS was performed. At 200 µg ACh intracoronary ST-segment elevation and chest pain recurred. Angiography showed occlusive epicardial spasm in the LAD and D2. Based on studies where the tendency of epicardial CAS was linked with the presence of epicardial atherosclerosis, the decision was made to perform PCI in the LAD and D2. ACh re-challenge after intracoronary nitroglycerine revealed only very mild symptoms, no demonstrable epicardial CAS, and no ST-segment elevation anymore. Cardiac enzymes reached their peak on day one [creatine kinase max 262 U/L (norm < 190 U/L), maximum of high-sensitivity troponin T 269 pg/mL (n < 14 pg/mL)].

Discussion

There is a broad spectrum of patients with STEMI without culprit lesion regarding the extent of epicardial disease. In cases with an unclear culprit lesion, other causes for the acute presentation such as CAS should be investigated in an ad hoc fashion. The interplay of epicardial atherosclerosis and CAS should receive more attention in future trials.

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.

Gender differences in presentation, management, and outcomes among Egyptian patients with acute coronary syndrome: a single-centre registry

BACKGROUND

Despite a significant rise in cardiovascular disease (CVD)-related mortality in low- and middle-income countries (LMICs), data are scarce regarding the quality of care provided, particularly for women.

METHODS

This is a prospective observational, cross-sectional study. Acute coronary syndrome (ACS) patients presented to the Cardiology Department at Tanta University, Egypt, between September 1, 2023, and December 31, 2023, were enrolled. The study assessed gender disparities by comparing men and women regarding presentation, management, and major adverse cardiovascular events (MACE) occurrence during hospitalization and 30 days after discharge.

RESULTS

A total of 400 ACS patients were included, with 29.5% being women. Women were comparatively older (59 ± 9 years vs. 55 ± 13 years), with a significantly higher prevalence of hypertension (70.3% vs. 47.5%) and diabetes (55% vs. 36.8%). Non-ST-segment elevation myocardial infarction (Non-STEMI) was more common in women (35.29% vs. 21%). Dyspnea was expressed by 34.4% of women (vs. 21.35% of men). Women were hospitalized later (9.29 h vs. 6.74 h). In-hospital outcomes were poorer for women with worse NYHA classes III and IV. Additionally, the odds ratio (OR) for in-hospital cardiac mortality was 0.303 (95% CI 0.103-0.893) for women compared to men. However, a one-month follow-up for MACE post-hospital discharge did not indicate significant gender differences.

CONCLUSIONS

The current study suggests that women with ACS in Egypt exhibit a higher risk profile for CVD compared to men and tend to present later with atypical symptoms. Women additionally experience poorer in-hospital MACE and higher cardiac mortality. Therefore, increasing awareness about ACS syndrome and eliminating obstacles that delay hospital admission are imperative.

A Cross-Sectional Study on the Epidemiology and Risk Factors of Acute Coronary Syndrome in Northern Iraq

INTRODUCTION

There is an upward trend in the key cardiovascular risk factors in Iraq. Accordingly, the current study was initiated to address the changing epidemiology of acute coronary heart disease in Iraq.

METHODS

In this cross-sectional study, a total of 600 patients diagnosed with acute coronary syndrome (ACS) in the period between October 2020 and September 2022, and admitted to the Heart Center at Azadi Teaching Hospital, Duhok, Iraq, were recruited. All patients had detailed histories, clinical examinations, and relevant investigations, with particular scrutiny of the major cardiovascular risk factors at enrollment. Patients were categorized as having ST-segment elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI) following the American Society of Cardiology guidelines.

RESULTS

The patients had a mean age of 56.2 (SD: 10.5) years, with a male-to-female ratio of 2.5:1. The study included 185 (30.8%) patients with NSTEMI and 415 (69.2%) patients with STEMI. The frequency of regular smokers, those with hyperlipidemia, hypertension, and diabetes mellitus were 57.0%, 56.2%, 47%, and 40.7%, respectively. Family history of coronary heart disease and being overweight were encountered in a further 24.8% and 29.8%, respectively. Females were significantly older, with higher frequencies of hypertension, diabetes, hyperlipidemia, and overweight, while they were less likely to be smokers than males. Patients with hypertension, diabetes, and hyperlipidemia were significantly older, while smokers and those with a family history of ischemic heart disease were significantly younger. STEMI patients were significantly younger, more likely to be males, smokers, and overweight, but less likely to be diabetic than NSTEMI patients.

CONCLUSION

Iraqi patients with ACS were eight to 10 years younger than their Western counterparts. Males were more frequently involved and were younger than females. Hyperlipidemia and smoking were the most frequent risk factors, with the former's frequency exceeding reports from neighboring countries and the West. STEMI was more frequent and occurred at younger ages than NSTEMI. The results of the study support the need to institute effective targeted preventive and educational programs to reduce the risk of ACS in this part of the world.

Differences in coronary angiographic findings and outcomes between men and postmenopausal women with stable chest pain

BACKGROUND

Despite the significant increase in cardiovascular events in women after menopause, studies comparing postmenopausal women and men are scarce.

METHODS

We analyzed data from a nationwide, multicenter, prospective registry and enrolled 2412 patients with stable chest pain who underwent elective coronary angiography. Binary coronary artery disease (b-CAD) was defined as the ≥50% stenosis of epicardial coronary arteries, including the left main coronary artery.

RESULTS

Compared with the men, postmenopausal women were older (66.6 ± 8.5 vs. 59.5 ± 11.4 years) and had higher high-density lipoprotein cholesterol levels (49.0 ± 12.8 vs. 43.6 ± 11.6 mg/dl, P  < 0.01). The prevalence of diabetes did not differ significantly ( P  = 0.40), and smoking was more common in men than in postmenopausal women ( P  ≤ 0.01). At enrollment, b-CAD and revascularization were more common in men than in postmenopausal women (50.3% vs. 41.0% and 14.4% vs. 9.7%, respectively; both P  < 0.01). However, multivariate analyses revealed that revascularization [odds ratio (OR): 0.72; 95% confidence interval (CI): 0.49-1.08] was not significantly related to sex and a similar result was found in age propensity-matched population (OR: 0.80; 95% CI: 0.52-1.24). During the follow-up period, the secondary composite cardiovascular outcomes were lower in postmenopausal women than in men (OR: 0.55; 95% CI: 0.31-0.98), also consistent with the result using the age propensity-mated population (OR: 0.33; 95% CI: 0.13-0.85).

CONCLUSION

Postmenopausal women experienced coronary revascularization comparable to those in men at enrollment, despite the average age of postmenopausal women was 7 years older than that of men.Postmenopausal women exhibit better clinical outcomes than those of men if optimal treatment is provided.

Gender disparities in all-cause mortality among individuals with early-onset cardiovascular diseases

BACKGROUND AND OBJECTIVE

Gender disparities in mortality among individuals with early-onset cardiovascular disease (CVD) remain uncertain. This study aimed to investigate gender differences in all-cause mortality and identify influencing factors.

METHODS

Data extracted from the Kailuan Study, a prospective cohort study initiated in 2006, were analyzed. A total of 2,829 participants with early-onset CVD were included. Cox proportional hazard models were used to assess hazard ratios (HR) and 95% confidence intervals (CI) for gender disparities in all-cause mortality, adjusting for various factors.

RESULTS

Males experienced a median follow-up duration of 7.54 years with 276 recorded deaths, and females had a median follow-up of 6.45 years with 105 recorded deaths. Gender disparities in all-cause mortality were observed, with men experiencing a higher all-cause mortality risk compared to women (HR: 1.42, 95% CI: 1.04, 1.92) in the fully adjusted model. Both in men and women with early-onset CVD, elevated hs-CRP levels and an eGFR < 60 mL/min/1.73m2 notably escalated the risk of all-cause mortality. Furthermore, the utilization of antiplatelet agents and successful blood glucose control might mitigate the risk of all-cause mortality. Smoking and eGFR decline modified the association between gender and all-cause death, women were more vulnerable to tobacco consumption and kidney misfunctioning than men (P-interaction = 0.019).

CONCLUSION

The study highlights gender disparities in all-cause mortality among individuals with early-onset CVD, with men experiencing a higher risk of mortality compared to women. Addressing these disparities is important for improving outcomes in this population. Further research is needed to develop sex-specific interventions and strategies to reduce gender-related mortality disparities in early-onset CVD.

Acute Coronary Syndrome in Women: An Update

PURPOSE OF REVIEW

The goal of this manuscript is to provide a concise summary of recent developments in the approach to and treatment of women with acute coronary syndrome (ACS).

RECENT FINDINGS

This review covers terminology updates relating to ACS and myocardial injury and infarction. Updates on disparities in recognition, treatments, and outcomes of women with ACS due to atherosclerotic coronary artery disease are covered. Other causes of ACS, including spontaneous coronary artery dissection and myocardial infarction with non-obstructive coronary artery disease are discussed, given the increased frequency in women compared with men. The review summarizes the latest on the unique circumstance of ACS in women who are pregnant or post-partum, including etiologies, diagnostic approaches, medication safety, and revascularization considerations. Compared with men, women with ACS have unique risk factors, presentations, and pathophysiology. Treatments known to be effective for men with atherosclerosis-related ACS are also effective for women; further work remains on reducing the disparities in diagnosis and treatment. Implementation of multimodality imaging will improve diagnostic accuracy and allow for targeted medical therapy in the setting of myocardial infarction with non-obstructive coronary artery disease.

Predictors of Revascularization in Patients with Unstable Angina

BACKGROUND

The factors that determine the necessity of coronary artery revascularization in patients with unstable angina (UA) have been supported by limited data. Therefore, this study aimed to identify the predictors of revascularization in patients with UA.

METHODS

The study included the recorded data of 3668 patients with UA who underwent cardiac catheterization (age 66 ± 9.2, men 70%); 2615 of them (71%) underwent revascularization (percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), or hybrid revascularization. The remaining 1053 patients (29%) had no significant coronary stenosis and were regarded as controls. Multivariable logistic regression analysis was performed to separate the predictors of revascularization.

RESULTS

It was found that severe angina (OR 2.7, 95%CI 1.9-3.7), male gender (OR 1.4, 95%CI 1.1-1.7), and hyperlipidemia were the predictors of revascularization. It was also noted that intraventricular conduction disorders including left and right bundle branch blocks and a history of previous revascularization and myocardial infarction were associated with lower odds of revascularization.

CONCLUSION

Overall, however, the predictive value of the studied factors proved to be poor and may still point to the multifactorial nature of significant coronary artery stenosis and the need for revascularization in patients with UA.

The Development of a Chest-Pain Protocol for Women Presenting to the Emergency Department

Cardiovascular disease (CVD) is the leading cause of death in women worldwide, and of premature death in women in Canada. Despite improvements in cardiovascular care over the past 15-20 years, acute coronary syndrome (ACS) and CVD mortality continue to increase among women in Canada. Chest pain is a common symptom leading to emergency department visits for both men and women. However, women with ACS experience worse outcomes. compared with those of men, due to misdiagnosis or lack of diagnosis resulting in delayed care and underuse of guideline-directed medical therapies. CVD mortality rates are highest in Indigenous and racialized women and those with a disproportionately high number of adverse social determinants of health. CVD remains underrecognized, underdiagnosed, undertreated, and underresearched in women. Moreover, a lack of awareness of unique symptoms, clinical presentations, and sex-and-gender specific CVD risk factors, by healthcare professionals, leads to outcome disparities. In response to this knowledge gap, in acute recognition and management of chest-pain syndromes in women, the Canadian Women's Heart Health Alliance performed a needs assessment and review of CVD risk factors and ACS pathophysiology, through a sex and gender lens, and then developed a unique chest-pain assessment protocol utilizing modified dynamic programming algorithmic methodology. The resulting algorithmic protocol is presented. The output is intended as a quick reference algorithm that could be posted in emergency departments and other acute-care settings. Next steps include protocol implementation evaluation and impact assessment on CVD outcomes in women.

Preeclampsia's Cardiovascular Aftermath: A Comprehensive Review of Consequences for Mother and Offspring

Preeclampsia (PE), a multisystem hypertensive disorder affecting 2-8% of pregnancies, has emerged as a novel risk factor for cardiovascular disease (CVD) in affected mothers and in their offspring. Between 10 and 15 years following gestation, women with a history of PE have double the risk of CVD, nearly 4 times the risk of hypertension, and increased all-cause mortality. Offspring exposed to PE in utero carry an increased risk of CVD and congenital heart defects. Due to the multifactorial nature of both PE and CVD, a clear dependency has been difficult to establish. The interplay between CVD and PE is an area of active investigation, likely involving placental, genetic, and epigenetic factors resulting in enduring endothelial, vascular, and immune dysfunction. Fetal developmental programming induced by adverse intrauterine environments, epigenetic changes triggered by oxidative stress, and underlying genetic predisposition play pivotal roles in the development of CVD in offspring exposed to PE. Though the literature has discussed the cardiovascular outcomes associated with PE for nearly a decade, patient risk perception and health care provider awareness remain low, representing a substantial missed opportunity for early intervention in this vulnerable population. This review article will discuss the pathophysiology of preeclampsia, its intersection with CVD, and the long-term cardiovascular consequences for affected mothers and their offspring. Our objective is to increase health care provider awareness and garner greater research interest in this important topic.

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.

Sex differences in prevalence and outcomes of the different endotypes of chronic coronary syndrome in symptomatic patients undergoing invasive coronary angiography: Insights from the global ILIAS invasive coronary physiology registry

BACKGROUND AND AIMS

The management of chronic coronary syndrome (CCS) is informed by studies predominantly including men. This study investigated the relationship between patients sex and different endotypes of CCS, including sex-specific clinical outcomes.

METHODS

In patients with CCS undergoing coronary angiography, invasive Fractional Flow Reserve (FFR) and Coronary Flow Reserve (CFR) were measured. Patients were stratified into groups: 1) obstructive coronary artery disease (oCAD) (FFR≤0.80, no revascularization), 2) undergoing revascularization, 3) non-obstructive coronary artery disease with coronary microvascular dysfunction (CMD) (FFR>0.80, CFR≤2.5), and 4) non-obstructive coronary artery disease without CMD (FFR>0.80 and CFR>2.5).

RESULTS

1836 patients (2335 vessels) were included, comprising 1359 (74.0%) men and 477 (26.0%) women. oCAD was present in 14.1% and was significantly less prevalent in women than in men (10.3% vs 15.5%, respectively p < 0.01). Revascularization was present in 30.9% and was similarly prevalent in women and men (28.2% vs. 31.9%, respectively p = 0.13). CMD was present in 24.2% and was significantly more prevalent in women than men (28.6% vs 22.6%, respectively p < 0.01). Normal invasive measurements were found in 564 patients (33.0% women vs 30.0% men, p = 0.23). Male sex was associated with an increased risk of target vessel failure compared to women (HR.1.89, 95% CI 1.12-3.18, p = 0.018), regardless of CCS-endotype.

CONCLUSIONS

Sex differences exist in the prevalence and outcomes of different endotypes of CCS in symptomatic patients undergoing invasive coronary angiography. In particular, oCAD (and subsequent revascularization) were more prevalent in men. Conversely, CMD was more prevalent in women. Overall, men experienced a worse cardiovascular outcome compared to women, independent of any specific CCS endotype.

Sex-related differences in the impact of nutritional status on in-hospital mortality in acute coronary syndrome: A retrospective cohort study

BACKGROUND AND AIMS

In patients with some cardiovascular disease conditions the result of Nutritional Risk Screening 2002 (NRS-2002) and body mass index (BMI) is related to the in-hospital mortality. The aim of this study was to assess the prognostic impact of BMI and NRS 2002 on in-hospital mortality among patients with acute myocardial infarction (AMI) in relation to sex.

METHODS AND RESULTS

The study was based on a retrospective analysis of 945 medical records of AMI patients admitted to the Cardiology Department between 2017 and 2019. Patients with a score NRS2002 ≥ 3 are considered to be nutritionally at risk. The WHO BMI criteria were used. The endpoint was in-hospital mortality. Logistic regression was used to analyse the impact of quantitative variables on dichotomous outcome. Odds ratios (OR) with 95% confidence intervals were reported. Female patients were significantly older than male patients (73.24 ± 11.81 vs 67 ± 11.81). In an unadjusted model, the risk of malnutrition was a significant predictor of the odds of in-hospital mortality only in female patients (OR = 7.51, p = 0.001). In a multivariate model adjusted by all variables, heart failure (HF) (OR = 8.408, p = 0.003) and the risk of malnutrition (OR = 6.555, p = 0.007) were independent predictors of the odds of in-hospital mortality in female patients. The only significant independent predictor of the odds of in-hospital mortality in male patients was HF (OR = 3.789 p = 0.006).

CONCLUSIONS

Only in the case of female patients with AMI, the risk of malnutrition was independently associated with the odds of in-hospital mortality. There was no effect of BMI on in-hospital mortality in both sexes.

Coronary Artery Calcium in Assessment of Atherosclerotic Cardiovascular Disease Risk and its Role in Primary Prevention

Coronary artery calcium (CAC), which is detected using computed tomography scanning, is a well-established indicator of subclinical atherosclerosis. The CAC score is independently associated with atherosclerotic cardiovascular disease (ASCVD) outcomes and provides improved predictive values for estimating the risk of ASCVD beyond traditional risk factors. Thus, CAC is considered to have important implications for reclassification as a decision aid among individuals in the preclinical phase and as the primary prevention of ASCVD. This review is focused on epidemiological evidence on CAC in asymptomatic population-based samples from Western countries and Japan. We also discuss the usability of CAC as a tool for assessing ASCVD risk and its role in the primary prevention of ASCVD. A lack of evidence for the CAC score in ASCVD risk assessment beyond traditional risk factors in populations other than those in Western countries (including Japan) warrants further investigation. Clinical trials are also necessary to demonstrate the usefulness and safety of CAC screening in the primary prevention of ASCVD.

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).

Statin therapy in multimorbid older patients with polypharmacy- a cross-sectional analysis of the Swiss OPERAM trial population

Background

Statin therapy in multimorbid older individuals with polypharmacy is controversial, particularly in primary prevention of cardiovascular disease. Thereby, physicians must weigh potential benefits against potential side effects, drug-drug interactions, and limited life expectancy.

Aim

To assess the prevalence and determinants of potentially inappropriate statin therapy in multimorbid older patients.

Methods

We conducted a cross-sectional analysis of patients aged ≥70 years with multimorbidity and polypharmacy in the Swiss study center of OPERAM, a cluster-randomized trial on pharmacotherapy optimization to reduce drug-related hospital admissions. We assessed potential underuse (no statin but formal indication) and potential overuse (statin but no formal indication, including predicted >60% one-year mortality based on the Walter Score) based on current guidelines for patients in secondary and primary cardiovascular prevention. We assessed the association of potential statin overuse and underuse with six patient characteristics (age, gender, number of diagnoses, number of medications, mental impairment, being housebound) in LASSO-selection analyses.

Results

Of 715 multimorbid older adults (79.7 ± 6.5 years, 39.9% women), 337 (47%) were on statin. Statin therapy was appropriate in 474 (66.3%), underused in 130 (18.2%), and overused in 111 (15.5%) patients. In participants in secondary cardiovascular prevention (n = 437), being female (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.67-4.22) was significantly associated with potential underuse while being housebound (OR 3.53, 95%CI 1.32-9.46) and taking ≥10 medications (OR 1.95,95%CI 1.05-3.67) were associated with potential overuse. In participants in primary cardiovascular prevention (n = 278), 28.1% were potentially under- (9%) or overusing (19%) a statin, with no identified risk factor.

Conclusion

A third of hospitalized multimorbid older patients with polypharmacy potentially (either) overused or underused statin therapy. Among patients in secondary cardiovascular prevention, women were at risk for potential statin underuse. Housebound patients and those taking ≥10 medications were at risk for potential overuse of a statin. Physicians should carefully evaluate the indication for statin prescription in multimorbid older patients with polypharmacy.

Epidemiologic trends and risk factors associated with the decline in mortality from coronary heart disease in the United States, 1990-2019

BACKGROUND

Despite the decline in the rate of coronary heart disease (CHD) mortality, it is unknown how the 3 strong and modifiable risk factors - alcohol, smoking, and obesity -have impacted these trends. We examine changes in CHD mortality rates in the United States and estimate the preventable fraction of CHD deaths by eliminating CHD risk factors.

METHODS

We performed a sequential time-series analysis to examine mortality trends among females and males aged 25 to 84 years in the United States, 1990-2019, with CHD recorded as the underlying cause of death. We also examined mortality rates from chronic ischemic heart disease (IHD), acute myocardial infarction (AMI), and atherosclerotic heart disease (AHD). All underlying causes of CHD deaths were classified based on the International Classification of Disease 9th and 10th revisions. We estimated the preventable fraction of CHD deaths attributable to alcohol, smoking, and high body-mass index (BMI) through the Global Burden of Disease.

RESULTS

Among females (3,452,043 CHD deaths; mean [standard deviation, SD] age 49.3 [15.7] years), the age-standardized CHD mortality rate declined from 210.5 in 1990 to 66.8 per 100,000 in 2019 (annual change -4.04%, 95% CI -4.05, -4.03; incidence rate ratio [IRR] 0.32, 95% CI, 0.41, 0.43). Among males (5,572,629 CHD deaths; mean [SD] age 47.9 [15.1] years), the age-standardized CHD mortality rate declined from 442.4 to 156.7 per 100,000 (annual change -3.74%, 95% CI, -3.75, -3.74; IRR 0.36, 95% CI, 0.35, 0.37). A slowing of the decline in CHD mortality rates among younger cohorts was evident. Correction for unmeasured confounders through a quantitative bias analysis slightly attenuated the decline. Half of all CHD deaths could have been prevented with the elimination of smoking, alcohol, and obesity, including 1,726,022 female and 2,897,767 male CHD deaths between 1990 and 2019.

CONCLUSIONS

The decline in CHD mortality is slowing among younger cohorts. The complex dynamics of risk factors appear to shape mortality rates, underscoring the importance of targeted strategies to reduce modifiable risk factors that contribute to CHD mortality.

Sex and age-specific interactions of coronary atherosclerotic plaque onset and prognosis from coronary computed tomography

AIMS

The totality of atherosclerotic plaque derived from coronary computed tomography angiography (CCTA) emerges as a comprehensive measure to assess the intensity of medical treatment that patients need. This study examines the differences in age onset and prognostic significance of atherosclerotic plaque burden between sexes.

METHODS AND RESULTS

From a large multi-center CCTA registry the Leiden CCTA score was calculated in 24 950 individuals. A total of 11 678 women (58.5 ± 12.4 years) and 13 272 men (55.6 ± 12.5 years) were followed for 3.7 years for major adverse cardiovascular events (MACE) (death or myocardial infarction). The age where the median risk score was above zero was 12 years higher in women vs. men (64-68 years vs. 52-56 years, respectively, P < 0.001). The Leiden CCTA risk score was independently associated with MACE: score 6-20: HR 2.29 (1.69-3.10); score > 20: HR 6.71 (4.36-10.32) in women, and score 6-20: HR 1.64 (1.29-2.08); score > 20: HR 2.38 (1.73-3.29) in men. The risk was significantly higher for women within the highest score group (adjusted P-interaction = 0.003). In pre-menopausal women, the risk score was equally predictive and comparable with men. In post-menopausal women, the prognostic value was higher for women [score 6-20: HR 2.21 (1.57-3.11); score > 20: HR 6.11 (3.84-9.70) in women; score 6-20: HR 1.57 (1.19-2.09); score > 20: HR 2.25 (1.58-3.22) in men], with a significant interaction for the highest risk group (adjusted P-interaction = 0.004).

CONCLUSION

Women developed coronary atherosclerosis approximately 12 years later than men. Post-menopausal women within the highest atherosclerotic burden group were at significantly higher risk for MACE than their male counterparts, which may have implications for the medical treatment intensity.

Sex Differences in Outcomes of ST Elevation Myocardial Infarction Patients Submitted to Primary Percutaneous Coronary Intervention

BACKGROUND

Several studies have shown that women are usually undertreated and have worse outcomes after ST-segment elevation myocardial infarction (STEMI), hence the need to investigate questions related to sex in Brazil to better deal with the problem.

OBJECTIVE

To determine whether female sex is still associated with adverse events in a contemporary cohort of patients with STEMI undergoing primary percutaneous coronary intervention (pPCI).

METHODS

This was a prospective cohort study of STEMI patients submitted to pPCI in a tertiary university hospital between March 2011 and December 2021. Patients were categorized into groups based on their sex at birth. The primary clinical outcome was long-term MACCE. Patients were followed-up for up to five years. All hypothesis tests had a two-sided significance level of 0.05.

RESULTS

Among 1457 patients admitted with STEMI in the study period, 1362 were included and 468 (34.4%) were women. Female patients had a higher prevalence of hypertension (73% vs. 60%, p <0.001), diabetes (32% vs. 25%, p=0.003) and Killip class 3-4 at hospital admission (17% vs. 12%, p=0.01); TIMI risk score was higher among women (4 [2, 6] vs. 3 [2, 5], p<0.001). In-hospital mortality was not different between groups (12.8% vs. 10.5%, p=0.20). In-hospital MACCE (16.0% vs. 12.6%, p=0.085) and long-term MACCE (28.7% vs. 24.4%, p=0.089) were numerically higher in women, with borderline significance. After multivariate analysis, female sex was not associated with MACCE (HR = 1.14; 95% CI 0.86 - 1.51; p = 0.36).

CONCLUSION

In a prospective cohort of STEMI patients submitted to pPCI, female patients were older and had more comorbidities at baseline, but no significant differences were found in terms of long-term adverse outcomes.

Association of cardiovascular health score trajectory and risk of subsequent cardiovascular disease in non-diabetic population: a cohort study

BACKGROUND

Diabetes is an important risk factor for cardiovascular disease (CVD), but in the non-diabetic population, high glucose values within the normal range are also positively associated with CVD risk. There is a lack of concern for people without diabetes and evidence is lacking regarding the association between changes in cardiovascular health score (CVHS) and CVD risk in the non-diabetic population.

METHODS

The current study included 37,970 non-diabetic participants free of CVD events in or before 2010 from the Kailuan Study and calculated CVHS according to the overall status of 7 cardiovascular health metrics between the 2006 and 2010 waves. Latent mixture models were used to explore the subgroups with different development trends included in the context of the Kailuan non-diabetic population and to identify the trajectory of each subgroup. The outcomes of the current study were CVD events, including myocardial infarction and stroke. CVHS trajectory was developed to predict subsequent CVD risk from 2010 to 2020. The Cox proportional hazard model was established to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) of CVD across different trajectory patterns.

RESULTS

Five distinct CVHS trajectory patterns were identified, including low-stable pattern (n = 2835), moderate-increasing pattern (n = 3492), moderate-decreasing pattern (n = 7526), high-stable I pattern (n = 17,135), and high-stable II pattern (n = 6982). Compared with the low-stable pattern, participants with the high-stable II pattern had a lower subsequent risk of CVD (HR = 0.22, 95%CI = 0.18-0.28); In stratification analysis, the lower risk for CVD was observed in females (HR = 0.10, 95%CI = 0.05-0.23, P for interaction < 0.05) and those aged < 60 years (HR = 0.16, 95%CI = 0.11 to 0.22, P for interaction < 0.05).

CONCLUSIONS

CVHS trajectory patterns were associated with an altered CVD risk in the non-diabetic population. When stratified by age and sex, the association was stronger in young adults and females.

Outcomes in Patients With Early Menopause Who Underwent Transcatheter Aortic Valve Implantation

Early menopause is associated with an increased risk of cardiovascular diseases, including aortic stenosis (AS). We sought to investigate the prevalence and impact of early menopause on clinical outcomes in patients who underwent transcatheter aortic valve implantation (TAVI) for severe symptomatic AS. Women's International TAVI is a multinational, prospective, observational registry of women who underwent TAVI for severe symptomatic AS (n = 1,019). Patients were divided into 2 groups based on age of menopause: early menopause (age ≤45 years) and regular menopause (age >45 years). The primary outcome of interest was Valve Academic Research Consortium 2 efficacy end point, a composite of mortality, stroke, myocardial infarction, hospitalization for valve-related symptoms, or heart failure or valve-related dysfunction at 1-year follow-up. Of 732 patients with available data on menopause age, 173 (23.6%) were classified as having early menopause. These patients presented for TAVI at a younger age (81.6 ± 6.9 vs 82.7 ± 5.9, p = 0.05) and had a significantly lower Society of Thoracic Surgeons score (6.6 ± 4.8 vs 8.2 ± 7.1, p = 0.03) than those with regular menopause. However, the total valve calcium volume was smaller among patients with early versus regular menopause (731.8 ± 850.9 mm³ vs 807.6 ± 633.8 mm^3, p = 0.002). Other co-morbidities were similar between the 2 groups. At 1-year follow-up, there were no significant differences in clinical outcomes between patients with early versus regular menopause (hazard ratio 1.00, 95% confidence interval 0.61 to 1.63, p = 1.00). In conclusion, despite presenting for TAVI at a younger age, patients with early menopause had a similar risk of adverse events as patients with regular menopause at 1 year after TAVI.

Sex differences of patients with acute chest pain evaluated through a chest pain unit

BACKGROUND

Although sex disparities between patients with acute myocardial infarction are well known, the data regarding sex differences among symptomatic patients with acute chest pain (ACP) are limited.

METHODS

We retrospectively evaluated the records of 1000 consecutive patients with ACP and hospitalized in a tertiary medical center chest pain unit (CPU). Patients were divided according to sex. The primary outcome was defined as a composite end point of readmission because of chest pain, incidence of acute coronary syndrome, revascularization, and death at 90 days and 1 year.

RESULTS

Overall, 673 men and 327 women were included in the current analysis. There was no difference in regard to sex for patients who underwent noninvasive evaluation, (87.8 vs. 87.3%, P = 0.85, for female vs. male, respectively). Among patients who underwent coronary computed tomography angiography, women were less likely to have significant coronary artery disease (CAD) (4.2 vs. 11.3%, P = 0.005). Similarly, women had fewer significant findings (4.4 vs. 7.6%, P = 0.007) on myocardial perfusion imaging. Consequently, fewer women underwent angiography (8 vs. 14%, P = 0.006) and revascularization (2.8 vs. 7.3%, P = 0.004). During follow-up, sex was not associated with the development of the primary composite outcome [odds ratio (OR) 0.91, 95% confidence interval (CI) 0.39-2.09, P-value = 0.82 and OR 1.16, 95% CI 0.65-2.06, P-value = 0.59 for 90-day and 1-year follow-up, respectively].

CONCLUSION

Evaluation of patients through a CPU enables comparable noninvasive evaluation, appropriate utilization of invasive assessment with similar outcomes during the short and intermediate follow-up period regardless of patients' sex.

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 computed tomography angiography-derived coronary plaque burden in relation to invasive fractional flow reserve

BACKGROUND

Distinct sex-related differences exist in coronary artery plaque burden and distribution. We aimed to explore sex differences in quantitative plaque burden by coronary CT angiography (CCTA) in relation to ischemia by invasive fractional flow reserve (FFR).

METHODS

This post-hoc analysis of the PACIFIC trial included 581 vessels in 203 patients (mean age 58.1 ​± ​8.7 years, 63.5% male) who underwent CCTA and per-vessel invasive FFR. Quantitative assessment of total, calcified, non-calcified, and low-density non-calcified plaque burden were performed using semiautomated software. Significant ischemia was defined as invasive FFR ≤0.8.

RESULTS

The per-vessel frequency of ischemia was higher in men than women (33.5% vs. 7.5%, p ​< ​0.001). Women had a smaller burden of all plaque subtypes (all p ​< ​0.01). There was no sex difference on total, calcified, or non-calcified plaque burdens in vessels with ischemia; only low-density non-calcified plaque burden was significantly lower in women (beta: -0.183, p ​= ​0.035). The burdens of all plaque subtypes were independently associated with ischemia in both men and women (For total plaque burden (5% increase): Men, OR: 1.15, 95%CI: 1.06-1.24, p ​= ​0.001; Women, OR: 1.96, 95%CI: 1.11-3.46, p ​= ​0.02). No significant interaction existed between sex and total plaque burden for predicting ischemia (interaction p ​= ​0.108). The addition of quantitative plaque burdens to stenosis severity and adverse plaque characteristics improved the discrimination of ischemia in both men and women.

CONCLUSIONS

In symptomatic patients with suspected CAD, women have a lower CCTA-derived burden of all plaque subtypes compared to men. Quantitative plaque burden provides independent and incremental predictive value for ischemia, irrespective of sex.

The Gamut of Coronary Artery Disease in Indian Women

Coronary artery disease is the leading cause of death among women. Majority of women suffering from CAD have one or more risk factors for CAD in their parents. Women are at higher risk for cardiac events with respect to traditional risk factors including dyslipidemia, hypertension, diabetes, and smoking. Menopause, pregnancy complications, inflammation, anemia, migraines, and depression are important sex-specific novel risk factors for CVD, and it is important that clinicians should be aware of these risks to design strategies for prevention. Education, self-awareness in women, and timely recognition of CAD in women with lifestyle modifications and timely intervention result in better outcomes.

[Clinical and procedural characteristics of patients with acute coronary syndrome during the COVID-19 pandemic 2020 compared to a control group from 2019]

BACKGROUND

During the COVID-19 pandemic medical treatments including emergencies were often delayed, in part because of fear of an infection with Sars-CoV-2. Even patients with an acute coronary syndrome (ACS) were affected by these circumstances. In the present study we provide a systematic comparison of patients with ACS during the COVID-19 pandemic compared to a control group.

METHODS

This is a retrospective cross-sectional study including all patients admitted with an ACS (STEMI, NSTEMI, unstable angina) undergoing coronary angiography between March 2019 and June 2019 (group A) and between March 2020 and June 2020 (group B). Demographic factors, cardiovascular risk factors and procedural data (extent of coronary disease, clinical diagnose, revascularisation strategy and outcome, use of mechanical support devices, door-to-needle time and in-hospital mortality) were compared.

RESULTS

469 patients were included in the present study (239 patients in group A and 230 in group B, mean age 69 years, 71% male). Compared to group A there were fewer patients with STEMI and unstable angina (p=0,033) but more patients with NSTEMI (p=0,047) in group B. Patients in group B had less often single vessel disease (p=0,001) but in contrast more often triple vessel disease compared to group A (p=0,052).

CONCLUSION

Despite overall comparable numbers of ACS patients those admitted during the COVID-19 pandemic were more frequently diagnosed with NSTEMI and had a larger extent of coronary disease compared to a control group.

The outcome of ST-elevation myocardial infarction by sex: a retrospective cohort study

We aimed to compare in-hospital mortality (IHM) of acute myocardial infarction (AMI) between male and females. We assessed the association of sex with IHM after AMI using simple and multivariate cox regression models. Results were presented as crude and adjusted hazard ratios along with their 95% confidence interval (HR; 95% CI). Multivariable Cox regression analysis revealed females had a higher risk of death than males after ST-elevation MI (STEMI) (adjusted HR [95% CI]: 1.64 [1.15-2.36]; p = 0.007). In subgroup analysis by age group, this significantly increased risk was only observed in 50- to 64-year-old females. There were no significant differences between genders after non-STEMI and unspecified MI. Women aged 50 to 64 years had higher IHM after STEMI than men.

Sex-specific features of optical coherence tomography detected plaque vulnerability related to clinical outcomes: insights from the CLIMA study

PURPOSE

To investigate the different impact of optical coherence tomography (OCT)-derived vulnerable plaque features on future adverse events (AEs) according to the biological sex.

METHODS

The prospective multicenter CLIMA study (ClinicalTrials.gov: NCT02883088) enrolled 1003 patients with OCT plaque analysis of non-treated coronary plaques located in the proximal left anterior descending artery. Sex-specific differences in plaque composition and vulnerable features were described. We investigated the incidence of AEs, including cardiac death, any myocardial infarction and target vessel revascularization at 1-year.

RESULTS

Among 1003 patients, 24.6% were women. Women were older and more frequently affected by chronic kidney disease. Dyslipidemia, prior MI and smoking habit were more common in men. At OCT analysis, women had shorter plaque length (p < 0.001), ticker fibrous cap (p = 0.001), smaller maximum lipid arc (p = 0.019), lower macrophage infiltration (p < 0.001) and intra-plaque layered tissue (p = 0.007). During follow-up, 65 AEs were registered. The presence of a thin fibrous cap and a large macrophage infiltration (> 67°) predicted AEs in both sexes. The presence of macrophages (HR 3.38, p = 0.018) and a small minimum lumen area (HR 4.97, p = 0.002) were associated with AEs in women but not in men, while a large lipid arc (> 180°) was associated with AEs in men (HR 2.56, p = 0.003) but not in women.

CONCLUSION

This subanalysis of the CLIMA study investigated for the first-time sex-specific OCT features of plaque vulnerability associated with AEs. Local inflammation was associated with AEs in women and a large lipid arc was predictive in men. OCT may help develop sex-specific risk stratification strategies.

Measures of Pregnancy Intention: Why Use Them and What Do They Tell Us?

Understanding pregnancy intention is an important public health measure that captures the ability of individuals to access information, resources, and services needed to plan the timing and spacing of pregnancies. Pregnancy intention is a complex construct impacted by social, emotional, financial, cultural, and contextual factors. In this review, we will examine the range of available tools for individuals and populations to evaluate pregnancy intention, the timing of the tools in relation to pregnancy, their interpretation, and use for policy and practice. Traditionally, pregnancy intention was only assessed in population health surveys; however, more sophisticated tools and measures have been developed. These tools can be used at several time points: before pregnancy, during pregnancy, or after the pregnancy has ended. It is important to appreciate the varied contexts globally for women and their partners when assessing pregnancy intention, and the ability of a given tool to capture this when used retrospectively or prospectively. These tools can inform targeted delivery of services for a person or couple before, during, and after pregnancy. This knowledge can inform strategies at an individual, community, and population level as an indicator of access to sexual and reproductive health information and knowledge and uptake of preconception health.

Sex Difference in Coronary Artery Spasm Tested by Intracoronary Acetylcholine Provocation Test in Patients with Nonobstructive Coronary Artery Disease

Introduction

Cardiovascular diseases manifest differently in men and women. The purpose of this study is to compare the sex difference in the characteristics of coronary artery spasm (CAS) in patients with nonobstructive cardiovascular disease (NOCVD) and the clinical outcomes in accordance with sex in CAS patients.

Methods

The study analysed 5,491 patients with NOCVD who underwent an acetylcholine provocation test from November 2004 to May 2014 for evaluation of chest pain. CAS was defined as greater than 70% of luminal narrowing of the artery during the acetylcholine provocation test.

Results

The patients were divided into men (n = 2,506) and women (n = 2,985). Mean follow-up days were 1,218 ± 577 days. To adjust for confounding factors, the propensity score matching (PSM) analysis was performed in all patients and among the CAS patients. After PSM analysis, a total of 1,201 pairs in all patients and a total of 713 pairs in CAS patients were generated. In all patients, women showed significantly less incidence of CAS compared with men (62.3% vs 50.9%, P < 0.01). Myocardial bridge (MB) and moderate stenosis were less prevalent in women, while transient ST elevation and ischemic chest pain during provocation were more frequent in women. In CAS patients, men had a higher incidence of multivessel spasm than women (35.7% vs. 29.7%, P < 0.01). Old age, dyslipidemia, and MB were independent risk factors of CAS in both men and women. In CAS patients, there was no statistical differences for various individual and composite major outcomes up to five years in either men or women. In men with CAS, old age was a risk factor of a 5-year major adverse cardiac event (MACE), and moderate stenosis was a risk factor of both 5-year MACE and 5-year recurrent angina. In women with CAS, mild stenosis was a risk factor of 5-year MACE, while myocardial bridge was a risk factor of 5-year recurrent angina.

Conclusions

In this study, there were sex differences in the angiographic and clinical parameters during the acetylcholine provocation test, incidence of CAS, risk factors of CAS, 5-year MACE, and recurrent angina. Old age, dyslipidemia, and MB were independent risk factors of CAS in both sexes. However, major clinical outcomes up to five years in CAS patients were not different according to sex.

Women Are Less Likely to Survive AMI Presenting With Out-of-Hospital Cardiac Arrest: A Nationwide Study

OBJECTIVE

To assess the impact of patient's sex on outcomes and management of acute myocardial infarction (AMI) patients presenting with out-of-hospital cardiac arrest (OHCA).

PATIENTS AND METHODS

We conducted a population-based retrospective cohort study in AMI patients admitted with OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) registry. We used multivariable logistic regression models to evaluate the role of sex as a predictor of clinical outcomes and treatment strategy.

RESULTS

Of 16,278 patients, women constituted almost one-quarter of the population (n=3710 [22.7%]). Women were older (median age 69 [IQR, 57-79] years vs 63 [IQR, 54-72] years, P<.001), experienced longer call-to-hospital-arrival time (median, 1.2 hours vs 1.1 hours; P=.008), were less likely to present with shockable rhythm (86.8% vs 91.5%, P<.001), and less likely to receive dual antiplatelet therapy (73.8% vs 78.6%, P<.001), beta blockers (64.7% vs 72.3%, P<.001), angiotensin-converting enzyme inhibitors (49.0% vs 55.3%, P<.001), coronary angiography (73.7% vs 83.3%, P<.001), and percutaneous coronary intervention (37.5% vs. 40.7%, p 0.004). After adjusting for patient characteristics and management, women had significantly higher odds of in-hospital death compared with men (odds ratio [OR], 1.3; 95% CI, 1.1 to 1.5) and lower odds of receiving coronary angiography (OR, 0.67; 95% CI, 0.59 to 0.75) and coronary artery bypass graft (OR, 0.28; 95% CI, 0.19 to 0.40).

CONCLUSION

Women were less likely to survive following OHCA secondary to AMI. Hospital protocols that minimize physician bias and improve women-physician communication are needed to close this gap.

The association between CPR quality of In-hospital resuscitation and sex: A hypothesis generating, prospective observational study

Introduction

The relationship between sex and cardiopulmonary resuscitation (CPR) outcomes remains unclear. Particularly, questions remain regarding the potential contribution of unmeasured confounders. We aimed to examine the differences in the quality of chest compression delivered to men and women.

Methods

Prospective study of observational data recorded during consecutive resuscitations occurring in a single tertiary center (Feb-1-2015 to Dec-31-2018) with real-time follow-up to hospital discharge. The studied variables included time in CPR, no-flow-time and fraction, compression rate and depth and release velocity. The primary study endpoint was the unadjusted association between patient sex and the chest compression quality (depth and rate). The secondary endpoint was the association between the various components of chest compression quality, sex, and survival to hospital discharge/neurologically intact survival.

Results

Overall 260 in-hospital resuscitations (57.7% male patients) were included. Among these 100 (38.5%) achieved return of spontaneous circulation (ROSC) and 35 (13.5%) survived to hospital discharge. Female patients were significantly older. Ischemic heart disease and ventricular arrhythmias were more prevalent among males. Compression depth was greater in female vs male patients (54.9 ± 11.3 vs 51.7 ± 10.9 mm; p = 0.024). Other CPR quality-metrics were similar. The rates of ROSC, survival to hospital discharge and neurologically intact survival did not differ between males and females. Univariate analysis revealed no association between sex, quality metrics and outcomes.

Discussion

Women received deeper chest compressions during in-hospital CPR. Our findings require corroboration in larger cohorts but nonetheless underscore the need to maintain high-quality CPR in all patients using real-time feedback devices. Future studies should also include data on ventilation rates and volumes which may contribute to survival outcomes.

Short-term mortality differs between men and women according to the presence of previous cardiovascular disease: Insights from a nationwide STEMI cohort

BACKGROUND

Sex and prior cardiovascular disease (CVD) are known independent prognostic factors following an ST-elevation myocardial infarction (STEMI). We aimed to examine whether the association between sex and 30-day mortality differ according to the presence of previous CVD in STEMI patients.

METHODS

Prospective, observational, multicentre registry of consecutive patients managed in 17 STEMI networks in Spain (83 centres), between April and June 2019. Unadjusted and adjusted logistic regression models assessed the association of 30-day mortality with sex and prior CVD status, as well as their interaction.

RESULTS

Among 4366 patients (mean age 63.7 ± 13.0 years; 78% male), there were 337 (8.1%) deaths within the first 30 days. There was an association between crude 30-day mortality and sex (women 10.4% vs. men 7.4%, p = 0.003), and prior CVD (CVD 13.7% vs non-CVD 6.8%, p < 0.001). After adjustment for potential confounding, neither sex nor prior CVD were apparently associated with mortality. Nevertheless, we found a significant sex-CVD interaction (p-interaction = 0.006), since women were at lower risk than men in the subset of patients with prior CVD (OR = 0.30, 95%CI = 0.12-0.80) but not in those without CVD (OR = 1.17, 95%CI = 0.79-1.74).

CONCLUSIONS

Women as well as patients with prior CVD have an increased crude risk of 30-day mortality. However, sex-related differences in short term mortality are modulated by the interaction with CVD in STEMI patients. Compared to men, women had a similar prognosis in the subset of patients without CVD, whereas they were associated with a lower risk of mortality among those with prior CVD after adjusting for other prognostic factors.

Post-Cardiac Arrest PCI is Underutilized Among Cancer Patients: Machine Learning Augmented Nationally Representative Case-Control Study of 30 Million Hospitalizations

BACKGROUND

Cancer patients are less likely to undergo percutaneous coronary intervention (PCI) after cardiac arrest, although they demonstrate improved mortality benefit from the procedure. We produced the largest nationally representative analysis of mortality of cardiac arrest and PCI for patients with cancer versus non-cancer.

METHODS

Propensity score adjusted multivariable regression for mortality was performed in this case-control study of the United States' largest all-payer hospitalized dataset, the 2016 National Inpatient Sample. Regression models of mortality and PCI weighted by the complex survey design were fully adjusted for age, race, income, cancer metastases, NIS-calculated mortality risk by Diagnosis Related Group (DRG), acute coronary syndrome, and likelihood of undergoing PCI RESULTS: Of the 30,195,722 hospitalized adult patients, 15.43% had cancer, and 0.79% of the whole sample presented with cardiac arrest (of whom 20.57% underwent PCI). In fully adjusted regression analysis among patients with cardiac arrest, PCI significantly reduced mortality (OR 0.15, 95%CI 0.13-0.19; p<0.001) among patients with cancer greater than those without it (OR 0.21, 95%CI 0.20-0.23; p<0.001).

CONCLUSIONS

This nationally representative study suggests that post-cardiac arrest PCI is underutilized among patients with cancer despite its significant mortality reduction for such patients (independent of clinical acuity).

9-1-1 Caller-Described Heart Attack Symptoms

INTRODUCTION

Heart attacks (HAs) present clinically with varying symptoms, which are not always described by patients as chest pain (CP) or chest discomfort (CD). Emergency Medical Dispatchers (EMDs) select the CP/CD dispatch protocol for non-chest pain HA symptoms or classic HA complaint of CP/CD. Nevertheless, it is still unknown how often callers report HA symptoms other than CP/CD.

OBJECTIVES

The objective of this study was to characterize the caller's descriptions of the primary HA symptoms, descriptions of the other HA symptoms, and the use of a case entry (CE) question clarifier.

METHODS

A retrospective descriptive study analyzed randomly selected EMD audios (where CD/CD protocol was used) from five accredited emergency communication centers in the United States. Several Quality Performance Review (QPR) experts reviewed the audios and recorded callers' initial problem descriptions, the use of and responses to the CE question clarifier, including the EMD-assigned final determinant code.

RESULTS

A total of 1,261 audios were reviewed. The clarifier was used only 8.5% of the time. The CP/CD symptoms were mentioned alone or with other problems 87.0% of the time. Overall, CP symptom was mentioned alone 70.8%, HA alone 4.0%, and CD symptom alone 1.4% of the time.

CONCLUSION

9-1-1 callers report potential HA cases using a variety of terms and descriptions-most commonly CP. Other less-common symptoms associated with a HA may be mentioned. Therefore, EMDs must be well-trained to be prepared to probe the caller with a clarifying query to elicit more specific information when "having a heart attack" is the only complaint initially mentioned.

Socioeconomic environment and survival in patients after ST-segment elevation myocardial infarction (STEMI): a longitudinal study for the City of Vienna

OBJECTIVES

This study investigates the relationship between socioeconomic environment (SEE) and survival after ST-segment elevation myocardial infarction (STEMI) separately for women and men in the City of Vienna, Austria.

DESIGN

Hospital-based observational data of STEMI patients are linked with district-level information on SEE and the mortality register, enabling survival analyses with a 19-year follow-up (2000-2018).

SETTING

The analysis is set at the main tertiary care hospital of the City of Vienna. On weekends, it is the only hospital in charge of treating STEMIs and thus provides representative data for the Viennese population.

PARTICIPANTS

The study comprises a total of 1481 patients with STEMI, including women and men aged 24-94 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures are age at STEMI and age at death. We further distinguish between deaths from coronary artery disease (CAD), deaths from acute coronary syndrome (ACS), and other causes of death. SEE is proxied via mean individual gross income from employment in each municipal district.

RESULTS

Results are based on Kaplan-Meier survival probability estimates, Cox proportional hazard regressions and competing risk models, always using age as the time scale. Descriptive findings suggest a socioeconomic gradient in the age at death after STEMI. This finding is, however, not supported by the regression results. Female patients with STEMI have better survival outcomes, but only for deaths related to CAD (HR: 0.668, 95% CIs 0.452 to 0.985) and other causes of deaths (HR: 0.627, 95% CIs 0.444 to 0.884), and not for deaths from the more acute ACS.

CONCLUSIONS

Additional research is necessary to further disentangle the interaction between SEE and age at STEMI, as our findings suggest that individuals from poorer districts have STEMI at younger ages, which indicates vulnerability in regard to health conditions in these neighbourhoods.

Sex-Related Differences in Long-Term Outcomes After Early-Onset Myocardial Infarction

Importance

There is growing awareness of sex-related differences in cardiovascular risk profiles, but less is known about whether these extend to pre-menopausal females experiencing an early-onset myocardial infarction (MI), who may benefit from the protective effects of estrogen exposure.

Methods

A nationwide study involving 125 Italian Coronary Care Units recruited 2,000 patients between 1998 and 2002 hospitalized for a type I myocardial infarction before the age of 45 years (male, n = 1,778 (88.9%). Patients were followed up for a median of 19.9 years (IQR 18.1–22.6). The primary composite endpoint was the occurrence of cardiovascular death, non-fatal myocardial re-infarction or non-fatal stroke, and the secondary endpoint of hospitalization for revascularisation by means of a percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG).

Results

ST-elevation MI was the most frequent presentation among both men and women (85.1 vs. 87.4%, p = ns), but the men had a greater baseline coronary atherosclerotic burden (median Duke Coronary Artery Disease Index: 48 vs. 23; median Syntax score 9 vs. 7; both p < 0.001). The primary composite endpoint occurred less frequently among women (25.7% vs. 37.0%; adjusted hazard ratio: 0.69, 95% CI 0.52–0.91; p = 0.01) despite being less likely to receive treatment with most secondary prevention medications during follow up.

Conclusions

There are significant sex-related differences in baseline risk factors and outcomes among patients with early-onset MI: women present with a lower atherosclerotic disease burden and, although they are less frequently prescribed secondary prevention measures, experience better long-term outcomes.

Trial Registration

4272/98 Ospedale Niguarda, Ca' Granda 03/09/1998.

Gender Differences in Cardiovascular Risk Factors, Clinical Presentation, and Outcome of Patients Admitted with a Hypertensive Crisis at the Buea Regional Hospital, Cameroon

Background. Several recent studies have shown differences in the risk profile and outcome of cardiovascular diseases between men and women, with a dearth of data from African populations. This study aimed to examine gender differences in a group of patients from Cameroon hospitalized with a hypertensive crisis. Methods. We conducted a cross-sectional study from June 2018 until June 2019. The criteria to define a hypertensive crisis (HC) were systolic and/or diastolic blood pressure should be ≥180/110 mmHg. We compared the clinical presentation and outcome of males versus females. Results. Out of the 1536 patients admitted, 95 (6.2%) had an HC. There were 49 (51.6%) men. There was no significant age difference between men and women (52.7 years vs. 49.3 years, $p=0.28$ ). Alcohol consumption ( $p<0.0001$ ), previous stroke ( $p=0.04$ ), and smoking ( $p=0.03$ ) were significantly higher in men compared to women. Men had a higher proportion of psychomotor agitation ( $p=0.05$ ). There was an equal proportion of men and women with hypertensive emergencies. Although acute left ventricular failure was most frequent in women (46.4% vs 42.9%), cerebral infarction (14.3% vs 17.9%), and acute coronary syndrome (0% vs 7.1%) were higher in men, the differences were not statistically significant (all $p>0.05$ ). Case fatality was also higher in men compared to women but the difference was not statistically significant. Conclusions. Men admitted for an HC had a significantly higher cardiovascular risk burden and higher psychomotor agitation. However, there were no significant differences in the types of hypertensive emergencies and outcomes between men and women.

Sex differences in the clinical presentation of acute coronary syndromes

The clinical presentation of acute coronary syndromes (ACS) as ST-elevation ACS (STEACS) or non-ST-elevation ACS (NSTEACS) differs between women and men. The aim of this study was to describe the difference in the clinical presentation of ACS between sexes. A total of 10,019 patients included in the Epi-Cardio Registry were analyzed. A higher proportion of women than men presented with NSTEACS (60.3% vs. 46.7%; p <0.001). The difference between sexes was driven by a higher prevalence of ACS with non-obstructive coronary arteries (20.9% vs. 6.6%) mainly in young women, since ACS without coronary lesions were mostly NSTEACS (77.7% vs. 22.3%). In patients with obstructive coronary heart disease, there were no differences in the clinical presentation between sexes. In conclusion, younger women are more likely than men to present ACS with non-obstructive coronary arteries, whereas no significant difference exists between sexes regarding the prevalence of ACS with obstructive coronary artery disease.

Accuracy Difference of Noninvasive Blood Pressure Measurements by Sex and Height

IMPORTANCE

Women are at higher risk of cardiovascular events than men with similar blood pressure (BP). Whether this discrepancy in risk is associated with the accuracy of brachial cuff BP measurements is unknown.

OBJECTIVES

To examine the difference in brachial cuff BP accuracy in men and women compared with invasively measured aortic BP and to evaluate whether noninvasive central BP estimation varies with sex.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study enrolled 500 participants without severe aortic stenosis or atrial fibrillation from January 1 to December 31, 2019, who were undergoing nonurgent coronary angiography at a tertiary care academic hospital.

EXPOSURES

Simultaneous measurements of invasive aortic BP and noninvasive BP.

MAIN OUTCOMES AND MEASURES

Sex differences in accuracy were determined by calculating the mean difference between the noninvasive measurements (brachial and noninvasive central BP) and the invasive aortic BP (reference). Linear regression and mediation analyses were performed to identify mediators between sex and brachial cuff accuracy.

RESULTS

This study included 500 participants (145 female [29%] and 355 male [71%]; 471 [94%] White; mean [SD] age, 66 [10] years). Baseline characteristics were similar for both sexes apart from body habitus. Despite similar brachial cuff systolic BP (SBP) (mean [SD], 124.5 [17.7] mm Hg in women vs 124.4 [16.4] in men; P = .97), invasive aortic SBP was higher in women (mean [SD], 130.9 [21.7] in women vs 124.7 [20.1] mm Hg in men; P < .001). The brachial cuff was relatively accurate compared with invasive aortic SBP estimation in men (mean [SD] difference, -0.3 [11.7] mm Hg) but not in women (mean [SD] difference, -6.5 [12.1] mm Hg). Noninvasive central SBP (calibrated for mean and diastolic BP) was more accurate in women (mean [SD] difference, 0.6 [15.3] mm Hg) than in men (mean [SD] difference, 8.3 [14.2] mm Hg). This association of sex with accuracy was mostly mediated by height (3.4 mm Hg; 95% CI, 1.1-5.6 mm Hg; 55% mediation).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, women had higher true aortic SBP than men with similar brachial cuff SBP, an association that was mostly mediated by a shorter stature. This difference in BP measurement may lead to unrecognized undertreatment of women and could partly explain why women are at greater risk for cardiovascular diseases for a given brachial cuff BP than men. These findings may justify the need to study sex-specific BP targets or integration of sex-specific parameters in BP estimation algorithms.