Prevalence of traditional cardiac risk factors and secondary prevention among patients hospitalized for acute myocardial infarction (AMI): variation by age, sex, and race

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).

Association of Sociodemographic Characteristics With 1-Year Hospital Readmission Among Adults Aged 18 to 55 Years With Acute Myocardial Infarction

Importance

Among younger adults, the association between Black race and postdischarge readmission after hospitalization for acute myocardial infarction (AMI) is insufficiently described.

Objectives

To examine whether racial differences exist in all-cause 1-year hospital readmission among younger adults hospitalized for AMI and whether that difference retains significance after adjustment for cardiac factors and social determinants of health (SDOHs).

Design, Setting, and Participants

The VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study was an observational cohort study of younger adults (aged 18-55 years) hospitalized for AMI with a 2:1 female-to-male ratio across 103 US hospitals from January 1, 2008, to December 31, 2012. Data analysis was performed from August 1 to December 31, 2021.

Main Outcomes and Measures

The primary outcome was all-cause readmission, defined as any hospital or observation stay greater than 24 hours within 1 year of discharge, identified through medical record abstraction and clinician adjudication. Logistic regression with sequential adjustment evaluated racial differences and potential moderation by sex and SDOHs. The Blinder-Oaxaca decomposition quantified how much of any racial difference was explained and not explained by covariates.

Results

This study included 2822 participants (median [IQR] age, 48 [44-52] years; 1910 [67.7%] female; 2289 [81.1%] White and 533 [18.9%] Black; 868 [30.8%] readmitted). Black individuals had a higher rate of readmission than White individuals (210 [39.4%] vs 658 [28.8%], P < .001), particularly Black women (179 of 425 [42.1%]). After adjustment for sociodemographic characteristics, cardiac factors, and SDOHs, the odds of readmission were 34% higher among Black individuals (odds ratio [OR], 1.34; 95% CI, 1.06-1.68). The association between Black race and 1-year readmission was positively moderated by unemployment (OR, 1.68; 95% CI, 1.09- 2.59; P for interaction = .02) and fewer number of working hours per week (OR, 1.01; 95% CI, 1.00-1.02; P for interaction = .01) but not by sex. Decomposition indicates that 79% of the racial difference in risk of readmission went unexplained by the included covariates.

Conclusions and Relevance

In this multicenter study of younger adults hospitalized for AMI, Black individuals were more often readmitted in the year following discharge than White individuals. Although interventions to address SDOHs and employment may help decrease racial differences in 1-year readmission, more study is needed on the 79% of the racial difference not explained by the included covariates.

Clinical Characteristics and Prognosis of Patients With No Standard Modifiable Risk Factors in Acute Myocardial Infarction

BACKGROUND

Recently, the impact of the lack of standard modifiable risk factors, including hypertension, diabetes, dyslipidaemia, and current smoking, has been investigated in ST-segment elevation myocardial infarction (MI). The present study aimed to evaluate clinical characteristics and prognosis of the patients with no standard risk factors in acute MI.

METHODS

This bi-centre registry included 1,093 patients with acute MI undergoing percutaneous coronary intervention. The participants were divided into two groups: patients having at least one of the four standard risk factors and those having none of the risk factors. The study endpoints included major adverse cardiovascular events (MACE) (death, recurrent MI, and stroke) and major bleeding events during hospitalisation. Any MACE and major bleeding events after discharge were also evaluated as an exploratory analysis.

RESULTS

Of 1,093 patients, 64 (5.9%) had none of the four standard risk factors. The patients with no standard risk factors were likely to present with Killip class IV and cardiac arrest. The rate of in-hospital MACE was higher in patients with no risk factors than in their counterparts (25.0% vs 9.9%; p<0.001), whereas the incidence of in-hospital major bleeding was not significantly different between the two groups (9.4% vs 6.7%; p=0.44). Active cancer and autoimmune/inflammatory diseases were often found in patients with no standard risk factors. After discharge, no significant differences were observed in the risks of MACE and major bleeding events between the two groups.

CONCLUSIONS

No standard modifiable risk factors were not uncommon and were associated with poor short-term outcomes in patients with acute MI.

Younger Age Impacts Perceptions of Care Received in the Emergency Department Among Women with Spontaneous Coronary Artery Dissection

Background: Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic etiology of acute coronary syndrome (ACS) that primarily affects younger women with few traditional cardiovascular disease risk factors. The primary objective of this study was to evaluate how younger age impacts the perception of care women receive in the emergency department (ED) at the time of their first or only SCAD. Methods: SCAD survivors were recruited using SCAD Alliance social media platforms to complete a one-time online survey regarding their experiences of seeking treatment for SCAD in the ED and their post-SCAD recovery. A total of 409 participants consented to participate in the parent study and data collected from the 367 participants who reported female gender were further analyzed. Results: Fewer participants <50 years old than would be expected under the null hypothesis (i.e., 65.5% observed vs. 71.2% expected, p = 0.009) reported perceived serious treatment by ED staff, more participants <50 years than would be expected under the null hypothesis (i.e., 12.0% observed vs. 9.3% expected, p = 0.049) reported perceived dismissive treatment by ED staff, and more participants <50 years than would be expected under the null hypothesis (i.e., 13.3% observed vs. 10.8% expected, p = 0.02) reported discharge from the ED without a diagnosis. Conclusions: Results of this study highlight the different experiences of younger SCAD survivors' engaging with providers in the ED. Further research regarding strategies for increasing ED providers' clinical interrogation of SCAD when treating and evaluating younger female patients presenting with ACS symptoms is indicated.

Usage of Digital Health Tools and Perception of mHealth Intervention for Physical Activity and Sleep in Black Women

Black women of reproductive age are disproportionately affected by chronic health conditions and related disease risk factors such as physical inactivity and obesity. Health promotion studies need to focus on this population since optimizing preconception health will lead to improvement of both birth outcomes and the woman’s long-term health. mHealth interventions that utilize wearable sensors to provide personalized and timely feedback can be used to promote physical activity (PA). This study aimed to examine Black women’s wearable sensor usage and their perceptions about future mHealth interventions that target PA and sleep. Our analysis included 497 Black women (aged 18–47 years) who completed a cross-sectional online survey. Ninety-two percent of participants did not meet the recommended level of PA, and 32.3% reported poor sleep quality. More participants indicated interest in a remote PA program (77%) than an in-person one (73%). More than half of participants indicated interest in receiving personalized feedback messages based on wearable trackers about PA (58.1%) and sleep (63.5%). This perceived acceptability of remote intervention and wearable-based feedback messages did not differ by socioeconomic status. Remotely delivered mHealth interventions that utilize wearables can be a viable behavioral change strategy to promote PA and sleep quality in Black women.

Prevalence, Clinical Characteristics, and Risk Among Patients with Ischemic Heart Disease in the Young Jordanian Population

PURPOSE

This study aims to evaluate the prevalence of ischemic heart disease (IHD) among the young population in Jordan. We examined the risk factors that might be involved in disease incidence. Clinical characteristics, patients' living standards, and various other risk factors were considered to conduct the study.

METHODS

A retrospective study was conducted at King Abdullah University Hospital. Data were collected from patients who visited this hospital between January 2013 and December 2017. Only young Jordanian adults of age <50 years were included in this study. The data of 358 patients were purposively collected and analyzed (as per the determined inclusion criteria), where information related to their baseline characteristics, clinical characteristics, and related biochemical assays was reviewed.

RESULTS

This study showed a high prevalence of IHD among young males in Jordan. It also revealed that increased age, smoking, hypertension, unfavorable lipid profile, and obesity were the major possible risk factors for the occurrence of disease. These patients were initially diagnosed with either unstable angina or acute myocardial infarction. Initial WBCs count, particularly monocytes differential, was high in about one-third of patients, besides cardiac biomarkers.

CONCLUSION

The high incidence of IHD was noticed among young individuals. We suggest that more efforts should be instigated for reducing the high prevalence of IHD by adopting a healthy lifestyle, preventive attitude, and nutritious food intake.

Lipid-lowering therapy for primary prevention of premature atherosclerotic coronary artery disease: Eligibility, utilization, target achievement, and predictors of initiation

OBJECTIVES

Despite advances in screening and prevention, rates of premature coronary artery disease (CAD) have been stagnant. The goals of this study were to investigate the barriers to early risk detection and preventive treatment in patients with premature CAD. In particular, we: 1) assessed the performance of the latest versions of major international guidelines in detection of risk of premature CAD and eligibility for preventive treatment; and, 2) investigated real-life utilization of primary prevention with lipid-lowering therapies in these patients.

METHODS

We included patients in the Study to Avoid cardioVascular Events in British Columbia (SAVE BC), an observational study of patients with premature (males ​≤ ​50 years, females ​≤ ​55 years) angiographically confirmed CAD. Eligibility for primary prevention and treatment received were assessed retrospectively based on information recorded prior to or at the index presentation with CAD.

RESULTS

Of 417 patients (28.1% females) who met the criteria, 94.3% had at least one major cardiovascular risk factor. In the retrospective risk assessment, 41.7%, 61.4%, and 34.3% (p ​< ​0.001) of patients met criteria for initiation of statin therapy, and an additional 13.9%, 8.4%, and 46.8% may be considered for treatment using the American College of Cardiology/American Heart Association, Canadian Cardiovascular Society, and European Society of Cardiology guidelines, respectively. Only 17.1% of patients received statins and 11.0% achieved guideline-recommended lipid goals before presentation. Diabetes and elevated plasma lipid levels were positively associated with treatment initiation, while smoking was associated with non-treatment.

CONCLUSIONS

The current versions of major guidelines fail to recognize many patients who develop premature CAD as being at risk. The vast majority of these patients, including patients who have guideline-directed indications, do not receive lipid-lowering therapy before presenting with CAD. Our findings highlight the need for more effective screening and prevention strategies for premature CAD.

Clinical characteristics and outcomes in acute myocardial infarction patients with versus without any cardiovascular risk factors

BACKGROUND/AIMS

Although cardiovascular (CV) risk factors are well established, some patients experience acute myocardial infarction (AMI) even without any risk factors.

METHODS

We analyzed total 11,390 patients (63.6 ± 12.6 years old, 8,401 males) with AMI enrolled in Korea Acute Myocardial Infarction Registry-National Institute of Health from November, 2011 to December, 2015. Patients were divided into two groups according to the presence of any CV risk factors (group I, without risk factors, n = 1,420 [12.5%]; group II, with risk factors, n = 9,970 [87.5%]). In-hospital outcomes were defined as in-hospital mortality and complications. One-year clinical outcomes were defined as the composite of major adverse cardiac events (MACE).

RESULTS

Group I was older (67.3 ± 11.6 years old vs. 63.0 ± 12.7 years old, p < 0.001) and had higher prevalence of female gender (36.2% vs. 24.8%, p < 0.001) than the group II. Group I experienced less previous history of angina pectoris (7.0% vs. 9.4%, p = 0.003) and the previous history of cerebrovascular accidents (3.4% vs. 6.9%, p < 0.001). In-hospital mortality (2.6% vs. 3.0%, p = 0.450) and complications (20.6% vs. 20.0%, p = 0.647) were no differences between the groups. And 1 year clinical outcomes (5.7% vs. 5.1%, p = 0.337) were no differences between the groups. In multivariate logistic regression analysis, serum creatinine level (hazard ratio, 1.35; 95% confidence interval, 1.05 to 1.75; p = 0.021) were independent predictors of 1 year MACE in patients without any CV risk factors.

CONCLUSION

Elderly female patients were prone to develop AMI even without any modifiable CV risk factors. We suggest that more intensive care is needed in AMI patients without any CV risk factors who have high serum creatinine levels.

Sex Differences in Ischemic Heart Disease: Advances, Obstacles, and Next Steps

Evolving knowledge of sex-specific presentations, improved recognition of conventional and novel risk factors, and expanded understanding of the sex-specific pathophysiology of ischemic heart disease have resulted in improved clinical outcomes in women. Yet, ischemic heart disease continues to be the leading cause of morbidity and mortality in women in the United States. The important publication by the Institute of Medicine titled "Women's Health Research-Progress, Pitfalls, and Promise," highlights the persistent disparities in cardiovascular disease burden among subgroups of women, particularly women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment. These important health disparities reflect underrepresentation of women in research, with the resultant unfavorable impact on diagnosis, prevention, and treatment strategies in women at risk for cardiovascular disease. Causes of disparities are multifactorial and related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. Lack of awareness in both the public and medical community, as well as existing knowledge gap regarding sex-specific differences in presentation, risk factors, pathophysiology, and response to treatment for ischemic heart disease, further contribute to outcome disparities. There is a critical need for implementation of sex- and gender-specific strategies to improve cardiovascular outcomes. This review is tailored to meet the needs of a busy clinician and summarizes the contemporary trends, characterizes current sex-specific outcome disparities, delineates challenges, and proposes transformative solutions for improvement of the full spectrum of ischemic heart disease clinical care and research in women.

Premature Atherosclerotic Cardiovascular Disease: Trends in Incidence, Risk Factors, and Sex-Related Differences, 2000 to 2016

Background The incidence of atherosclerotic cardiovascular disease has declined in the past 2 decades. However, these benefits may not extend to young patients. The objective of this work was to assess temporal trends in the incidence, risk profiles, sex-related differences, and outcomes in a contemporary population of young patients presenting with coronary artery disease ( CAD ) in British Columbia, Canada. Methods and Results We used a provincial cardiac registry to identify young patients (men aged <50 years, women aged <55 years), with a first presentation of CAD between 2000 and 2016, who had either ≥50% stenosis of ≥1 coronary arteries on angiography or underwent coronary revascularization. A total of 12 519 patients (30% women) met our inclusion criteria. The incidence of CAD remained stable and was higher for men than women (46-53 versus 18-23 per 100 000). Of patients, 92% had at least one traditional cardiovascular risk factor and 67% had multiple risk factors. The prevalence of diabetes mellitus, obesity, and hypertension increased during the study period and was higher for women. Women had fewer emergent procedures and revascularizations. Mortality rates decreased by 31% between 2000 and 2007, then were stable for the remaining 9 years. Mortality was significantly higher for women aged <45 years compared with men. Conclusions The incidence of premature CAD has not declined, and the prevalence of 3 major cardiovascular risk factors increased between 2000 and 2016. The risk burden and mortality rates were worse for women. These data have important implications for the design of strategies to prevent CAD in young adults.

Measuring Emergency Care Survival: The Implications of Risk Adjusting for Race and Poverty

OBJECTIVES

We determined the impact of including race, ethnicity, and poverty in risk adjustment models for emergency care-sensitive conditions mortality that could be used for hospital pay-for-performance initiatives. We hypothesized that adjusting for race, ethnicity, and poverty would bolster rankings for hospitals that cared for a disproportionate share of nonwhite, Hispanic, or poor patients.

METHODS

We performed a cross-sectional analysis of patients admitted from the emergency department to 157 hospitals in Pennsylvania with trauma, sepsis, stroke, cardiac arrest, and ST-elevation myocardial infarction. We used multivariable logistic regression models to predict in-hospital mortality. We determined the predictive accuracy of adding patient race and ethnicity (dichotomized as non-Hispanic white vs. all other Hispanic or nonwhite patients) and poverty (uninsured, on Medicaid, or lowest income quartile zip code vs. all others) to other patient-level covariates. We then ranked each hospital on observed-to-expected mortality, with and without race, ethnicity, and poverty in the model, and examined characteristics of hospitals with large changes between models.

RESULTS

The overall mortality rate among 170,750 inpatients was 6.9%. Mortality was significantly higher for nonwhite and Hispanic patients (adjusted odds ratio [aOR] = 1.27, 95% confidence interval [CI] = 1.19-1.36) and poor patients (aOR = 1.21, 95% CI = 1.12-1.31). Adding race, ethnicity, and poverty to the risk adjustment model resulted in a small increase in C-statistic (0.8260 to 0.8265, p = 0.002). No hospitals moved into or out of the highest-performing decile when adjustment for race, ethnicity, and poverty was added, but the three hospitals that moved out of the lowest-performing decile, relative to other hospitals, had significantly more nonwhite and Hispanic patients (68% vs. 11%, p < 0.001) and poor patients (56% vs. 10%, p < 0.001).

CONCLUSIONS

Sociodemographic risk adjustment of emergency care-sensitive mortality improves apparent performance of some hospitals treating a large number of nonwhite, Hispanic, or poor patients. This may help these hospitals avoid financial penalties in pay-for-performance programs.

Trends in tobacco use among US adults with chronic health conditions: National Survey on Drug Use and Health 2005-2013

INTRODUCTION

Chronic conditions are among the most common and costly of all health problems. Addressing tobacco use among adults with chronic conditions is a public health priority due to high prevalence as well as greater potential harm from continued use.

METHODS

Data were drawn from 9years (2005-2013) of the U.S. National Survey on Drug Use and Health. Adult (≥18years) tobacco use included any past 30-day use of cigarettes, cigars, pipes, or smokeless tobacco. Chronic conditions examined included anxiety, asthma, coronary heart disease, depression, diabetes, hepatitis, HIV, hypertension, lung cancer, stroke, and substance abuse. Controlling for sociodemographics, trends in product use for most conditions and a composite of any condition among those with chronic conditions were compared to respondents with no condition in weighted logistic regression analyses.

RESULTS

Cigarette smoking declined significantly over time among adults with no chronic condition. Adults with one or more chronic condition showed no comparable decrease, with cigarette smoking remaining especially high among those reporting anxiety, depression, and substance abuse. Cigar and pipe use remained stable and more prevalent among those with any chronic condition, with the exception of pipe use declining among those with heart disease. Smokeless tobacco use increased over time, with higher prevalence among those with asthma, mental health, and substance abuse conditions.

CONCLUSIONS

These findings have tobacco control and regulatory implications for addressing higher tobacco use among adults with chronic conditions. Provider advice and cessation resources targeting tobacco use among those with chronic conditions are recommended.

Cardiovascular Risk in Midlife African American Women Participating in a Lifestyle Physical Activity Program

BACKGROUND

Cardiovascular disease (CVD) is the largest contributor to disparate morbidity and mortality in African American women.

OBJECTIVE

The aims of this article are to describe in a cohort of sedentary, urban community-based midlife African American women eligible for a physical activity program their (1) CVD risk factors and (2) awareness, treatment, and control of hypertension and hypercholesterolemia.

METHODS

Cross-sectional baseline findings on 297 women were examined at baseline of a controlled physical activity clinical trial. Cardiovascular disease risks included hypertension, hypercholesterolemia, smoking, diabetes, and obesity. Among women with hypertension and hypercholesterolemia, rates of awareness, treatment, and control were calculated.

RESULTS

Our sample had significantly more hypertension and obesity than reported in other national samples of African American women. The women mirrored national samples of African American women: fewer than 60% had adequate control of hypertension. Versus national samples of African Americans (men/women combined), our study groups both showed significantly lower low-density-lipoprotein cholesterol level: treatment, 33% versus 63.8%, and control, 24.8% versus 45.3%.

CONCLUSIONS

Because national samples are more heterogeneous, our sample provides important information about CVD risks in inactive, urban community-dwelling, midlife African American women. Given the opportunity, many such women at elevated risk for CVD are willing to participate in a physical activity intervention. They must be identified and offered pharmacological and lifestyle interventions.

Racial and Ethnic Differences in Acute Coronary Syndrome and Myocardial Infarction Within the United States: From Demographics to Outcomes

In the United States, different races, ethnicities, and their subgroups experience disparities regarding acute coronary syndrome (ACS) and myocardial infarction (MI). This review highlights these differences across 4 stages that comprise the ACS/MI narrative: (1) patient demographics, (2) patient comorbidities and health risks, (3) treatments and their delays, and (4) outcomes. Overall, black and Hispanic ACS/MI patients are more likely to present with comorbidities, experience longer delays before treatment, and suffer worse outcomes when compared with non-Hispanic white patients. More specifically, across the studies analyzed, black and Hispanic ACS/MI patients were consistently more likely to be younger or female, or to have hypertension or diabetes, than non-Hispanic white patients. ACS/MI disparities also exist among Asian populations, and these are briefly outlined. However, black, Hispanic, and non-Hispanic white ACS/MI patients were the 3 most-studied racial and ethnic groups, indicating that additional studies of other minority groups, such as Native Americans, Asian populations, and black and Hispanic subgroups, are needed for their utility in reducing disparities. Despite notable improvement in ACS/MI treatment quality measures over recent decades, disparities persist. Causes are complex and extend beyond the healthcare system to culture and patients' personal characteristics; sophisticated solutions will be required. Continued research has the potential to further reduce or eliminate disparities in the comorbidities, delays, and treatments surrounding ACS and MI, extending healthy lifespans of many underserved and minority populations, while reducing healthcare costs.

Sex Differences in Cardiac Risk Factors, Perceived Risk, and Health Care Provider Discussion of Risk and Risk Modification Among Young Patients With Acute Myocardial Infarction: The VIRGO Study

BACKGROUND

Differences between sexes in cardiac risk factors, perceptions of cardiac risk, and health care provider discussions about risk among young patients with acute myocardial infarction (AMI) are not well studied.

OBJECTIVES

This study compared cardiac risk factor prevalence, risk perceptions, and health care provider feedback on heart disease and risk modification between young women and men hospitalized with AMI.

METHODS

We studied 3,501 AMI patients age 18 to 55 years enrolled in the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study in U.S. and Spanish hospitals between August 2008 and January 2012, comparing the prevalence of 5 cardiac risk factors by sex. Modified Poisson regression was used to assess sex differences in self-perceived heart disease risk and self-reported provider discussions of risk and modification.

RESULTS

Nearly all patients (98%) had ≥1 risk factor, and 64% had ≥3. Only 53% of patients considered themselves at risk for heart disease, and even fewer reported being told they were at risk (46%) or that their health care provider had discussed heart disease and risk modification (49%). Women were less likely than men to be told they were at risk (relative risk: 0.89; 95% confidence interval: 0.84 to 0.96) or to have a provider discuss risk modification (relative risk: 0.84; 95% confidence interval: 0.79 to 0.89). There was no difference between women and men for self-perceived risk.

CONCLUSIONS

Despite having significant cardiac risk factors, only one-half of young AMI patients believed they were at risk for heart disease before their event. Even fewer discussed their risks or risk modification with their health care providers; this issue was more pronounced among women.

Population-level differences in revascularization treatment and outcomes among various United States subpopulations

Despite recent general improvements in health care, significant disparities persist in the cardiovascular care of women and racial/ethnic minorities. This is true even when income, education level, and site of care are taken into consideration. Possible explanations for these disparities include socioeconomic considerations, elements of discrimination and racism that affect socioeconomic status, and access to adequate medical care. Coronary revascularization has become the accepted and recommended treatment for myocardial infarction (MI) today and is one of the most common major medical interventions in the United States, with more than 1 million procedures each year. This review discusses recent data on disparities in co-morbidities and presentation symptoms, care and access to medical resources, and outcomes in revascularization as treatment for acute coronary syndrome, looking especially at women and minority populations in the United States. The data show that revascularization is used less in both female and minority patients. We summarize recent data on disparities in co-morbidities and presentation symptoms related to MI; access to care, medical resources, and treatments; and outcomes in women, blacks, and Hispanics. The picture is complicated among the last group by the many Hispanic/Latino subgroups in the United States. Some differences in outcomes are partially explained by presentation symptoms and co-morbidities and external conditions such as local hospital capacity. Of particular note is the striking differential in both presentation co-morbidities and mortality rates seen in women, compared to men, especially in women ≤ 55 years of age. Surveillance data on other groups in the United States such as American Indians/Alaska Natives and the many Asian subpopulations show disparities in risk factors and co-morbidities, but revascularization as treatment for MI in these populations has not been adequately studied. Significant research is required to understand the extent of disparities in treatment in these subpopulations.

Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

Smoking and cardiac rehabilitation participation: Associations with referral, attendance and adherence

OBJECTIVE

Continued smoking after a cardiac event greatly increases mortality risk. Smoking cessation and participation in cardiac rehabilitation (CR) are effective in reducing morbidity and mortality. However, these two behaviors may interact; those who smoke may be less likely to access or complete CR. This review explores the association between smoking status and CR referral, attendance, and adherence.

METHODS

A systematic literature search was conducted examining associations between smoking status and CR referral, attendance and completion in peer-reviewed studies published through July 1st, 2014. For inclusion, studies had to report data on outpatient CR referral, attendance or completion rates and smoking status had to be considered as a variable associated with these outcomes.

RESULTS

Fifty-six studies met inclusion criteria. In summary, a history of smoking was associated with an increased likelihood of referral to CR. However, smoking status also predicted not attending CR and was a strong predictor of CR dropout.

CONCLUSION

Continued smoking after a cardiac event predicts lack of attendance in, and completion of CR. The issue of smoking following a coronary event deserves renewed attention.

Decomposing Black-White Disparities in Heart Disease Mortality in the United States, 1973-2010: An Age-Period-Cohort Analysis

Against the backdrop of late 20th century declines in heart disease mortality in the United States, race-specific rates diverged because of slower declines among blacks compared with whites. To characterize the temporal dynamics of emerging black-white racial disparities in heart disease mortality, we decomposed race-sex-specific trends in an age-period-cohort (APC) analysis of US mortality data for all diseases of the heart among adults aged ≥35 years from 1973 to 2010. The black-white gap was largest among adults aged 35-59 years (rate ratios ranged from 1.2 to 2.7 for men and from 2.3 to 4.0 for women) and widened with successive birth cohorts, particularly for men. APC model estimates suggested strong independent trends across generations ("cohort effects") but only modest period changes. Among men, cohort-specific black-white racial differences emerged in the 1920-1960 birth cohorts. The apparent strength of the cohort trends raises questions about life-course inequalities in the social and health environments experienced by blacks and whites which could have affected their biomedical and behavioral risk factors for heart disease. The APC results suggest that the genesis of racial disparities is neither static nor restricted to a single time scale such as age or period, and they support the importance of equity in life-course exposures for reducing racial disparities in heart disease.

A composite measure of gender and its association with risk factors in patients with premature acute coronary syndrome

OBJECTIVE

To create a gender index by using principal component analyses (PCA) and logistic regression, and to determine the association between gender, sex, and cardiovascular risk factors among patients with premature acute coronary syndrome (ACS).

METHODS

GENESIS-PRAXY is a cohort study including ACS patients aged 55 years or below, and with ACS recruited between 2009 and 2013 from 26 centres across Canada, the United States, and Switzerland. A sample of 1075 patients was used for this study. Psychosocial variables assumed to differ between sexes (i.e., gender related) were included in PCA. Variables identified on retained components were included in logistic regressions where coefficient estimates of variables associated with sex were used to calculate a gender score. Cardiovascular risk factors were assessed using self-report and chart review data.

RESULTS

After the inclusion of 26 psychosocial variables in PCA, we identified 17 variables within retained components; 7 of which were associated with sex in logistic regression. The gender distribution revealed that half of women had a more androgyne or masculine gender score, and 16% of men exhibited a more feminine gender score. In univariable analyses, feminine gender scores and female sex were associated with hypertension, diabetes, family history of cardiovascular disease (only gender), and depressive/anxious symptoms. In multivariable models including both gender score and sex, feminine gender score but not female sex was associated with the presence of risk factors.

CONCLUSIONS

Sex and gender are distinct constructs, and the derived gender index offers a current and pragmatic option to measure gender within ACS populations. Our results further suggest that traditional sex differences in cardiovascular disease risk factors may be partly explained by patient's gender-related characteristics.

Symptom recognition and healthcare experiences of young women with acute myocardial infarction

BACKGROUND

Prompt recognition of acute myocardial infarction symptoms and timely care-seeking behavior are critical to optimize acute medical therapies. Relatively little is known about the symptom presentation and care-seeking experiences of women aged ≤55 years with acute myocardial infarction, a group shown to have increased mortality risk as compared with similarly aged men. Understanding symptom recognition and experiences engaging the healthcare system may provide opportunities to reduce delays and improve acute care for this population.

METHODS AND RESULTS

We conducted a qualitative study using in-depth interviews with 30 women (aged 30-55 years) hospitalized with acute myocardial infarction to explore their experiences with prodromal symptoms and their decision-making process to seek medical care. Five themes characterized their experiences: (1) prodromal symptoms varied substantially in both nature and duration; (2) they inaccurately assessed personal risk of heart disease and commonly attributed symptoms to noncardiac causes; (3) competing and conflicting priorities influenced decisions about seeking acute care; (4) the healthcare system was not consistently responsive to them, resulting in delays in workup and diagnosis; and (5) they did not routinely access primary care, including preventive care for heart disease.

CONCLUSIONS

Participants did not accurately assess their cardiovascular risk, reported poor preventive health behaviors, and delayed seeking care for symptoms, suggesting that differences in both prevention and acute care may be contributing to young women's elevated acute myocardial infarction mortality relative to men. Identifying factors that promote better cardiovascular knowledge, improved preventive health care, and prompt care-seeking behaviors represent important target for this population.

Transforming Cardiovascular Disease Prevention in Women: Time for the Pygmalion Construct to End

The transformation of cardiovascular disease prevention for women must address that a number of nontraditional atherosclerotic cardiovascular disease risk factors are unique to or predominant in women. As well, many traditional atherosclerotic cardiovascular disease risk factors impart differential risks for women and for men. Gender-specific risk assessment and management have the potential to improve atherosclerotic cardiovascular disease outcomes in women.

Trends in acute myocardial infarction in young patients and differences by sex and race, 2001 to 2010

BACKGROUND

Various national campaigns launched in recent years have focused on young women with acute myocardial infarctions (AMIs). Contemporary longitudinal data about sex differences in clinical characteristics, hospitalization rates, length of stay (LOS), and mortality have not been examined.

OBJECTIVES

This study sought to determine sex differences in clinical characteristics, hospitalization rates, LOS, and in-hospital mortality by age group and race among young patients with AMIs using a large national dataset of U.S. hospital discharges.

METHODS

Using the National Inpatient Sample, clinical characteristics, AMI hospitalization rates, LOS, and in-hospital mortality were compared for patients with AMI across ages 30 to 54 years, dividing them into 5-year subgroups from 2001 to 2010, using survey data analysis techniques.

RESULTS

A total of 230,684 hospitalizations were identified with principal discharge diagnoses of AMI in 30- to 54-year-old patients from Nationwide Inpatient Sample data, representing an estimated 1,129,949 hospitalizations in the United States from 2001 to 2010. No statistically significant declines in AMI hospitalization rates were observed in the age groups <55 years or stratified by sex. Prevalence of comorbidities was higher in women and increased among both sexes through the study period. Women had longer LOS and higher in-hospital mortality than men across all age groups. However, observed in-hospital mortality declined significantly for women from 2001 to 2010 (from 3.3% to 2.3%, relative change 30.5%; p for trend < 0.0001) but not for men (from 2% to 1.8%, relative change 8.6%; p for trend = 0.60).

CONCLUSIONS

AMI hospitalization rates for young people have not declined over the past decade. Young women with AMIs have more comorbidity, longer LOS, and higher in-hospital mortality than young men, although their mortality rates are decreasing.

Disparities in patients presenting to the emergency department with potential acute coronary syndrome: it matters if you are Black or White

OBJECTIVES

To explore disparities between non-Hispanic Blacks and non-Hispanic Whites presenting to the emergency department (ED) with potential acute coronary syndrome (ACS).

BACKGROUND

Individuals with fewer resources have worse health outcomes and these individuals are disproportionately those of color.

METHODS

This prospective study enrolled 663 patients in four EDs. Clinical presentation, treatment, and patient-reported outcome variables were measured at baseline, 1, and 6 months.

RESULTS

Blacks with confirmed ACS were younger; had lower income; less education; more risk factors; more symptoms, and longer prehospital delay at presentation compared to Whites. Blacks experiencing palpitations, unusual fatigue, and chest pain were more than 3 times as likely as Whites to have ACS confirmed. Blacks with ACS had more clinic visits and more symptoms 1 month following discharge.

CONCLUSIONS

Significant racial disparities remain in clinical presentation and outcomes for Blacks compared to Whites presenting to the ED with symptoms suggestive of ACS.

Coronary artery disease in women: an unsolved dilemma

Cardiovascular disease (CVD) is the leading cause of death in women, as well as an important cause of disability, although many women and their physicians underestimate the risk. The pathogenesis, presentation and diagnosis of CVDs are different in women than men, which make the women prone to under-treatment for these diseases. More gender-based research regarding the management of coronary artery disease (CAD) in women needs to be done. Exercise, hypertension treatment, smoking cessation and aspirin therapy are effective measures for the primary prevention of CAD in women. The roles of hormone replacement therapy in primary prevention are not well established. Hormone replacement therapy has not been effective in lowering the risk of recurrent myocardial infarction. Cardiologists and family physicians should emphasize the use of proven treatments, with particular attention given to underserved populations.