Coronary disease in women

Depressive Symptoms in Women With Coronary Heart Disease: A Systematic Review of the Longitudinal Literature

BACKGROUND

Interpreting studies about women with coronary heart disease and depressive symptoms is challenging: women continue to be underrepresented in research; data are often not presented separately by sex; many studies do not examine depressive symptoms longitudinally, leaving our understanding incomplete; and the use of multiple depressive symptom assessment instruments makes comparisons between studies problematic.

PURPOSE

The authors of this systematic review examined 20 longitudinal descriptive studies on women with coronary heart disease and depressive symptoms, including prevalence of elevated symptoms, changes in symptoms over time, findings in women versus men, and findings based on assessment instruments.

CONCLUSIONS

The prevalence of elevated depressive symptoms in women was 35.75% at baseline (hospitalization). The Beck Depression Inventory II yielded the highest baseline prevalence (40.3%), slightly higher than the Depression Interview and Structured Hamilton Scale (36%). The Hospital Anxiety and Depression Scale and the Kellner questionnaire yielded much lower prevalence (21.45% and 23%, respectively). Higher prevalence was linked to inclusion of somatic symptoms on measurement instruments except in post-coronary bypass surgery patients. Symptoms trended toward improvement, particularly in the first 6 months, although a few studies measured beyond this time. Women demonstrated higher prevalence than men initially (35.75% vs 23.46%, respectively) and over 24 months (22.71% vs 19.82%, respectively).

CLINICAL IMPLICATIONS

Women experienced significantly more depressive symptoms than men initially and over time, although most women's symptoms improved. Measurement varies widely based on instrument and the inclusion/exclusion of somatic symptoms. More longitudinal studies beyond 6 months with prevalence data and analysis by sex/gender are needed.

Epidemiology and Management Cost of Myocardial Infarction in North Punjab, Pakistan

Background:

Coronary heart disease (CHD) is an important cause of morbidity and mortality in Pakistan. The temporal trends in the risk factors for myocardial infarction (MI) and the impact of socioeconomic status on these risk factors remain ambiguous.

Objectives:

The objectives of the present analysis were to investigate the potential association between various risk factors and MI in North Punjab, Pakistan, and to assess the status of the control of the risk factors associated with MI in this population.

Patients and Methods:

The present study included 515 patients admitted to the coronary care units or equivalent cardiology wards of the participating hospitals between 2011 and 2012 in North Punjab, Pakistan. The analysis was focused on identifying the socioeconomic status, lifestyle, family history of MI, and risk factors (i.e. hypertension, diabetes, smoking, and hyperlipidemia). A structured questionnaire was designed to collect data. The lipid profile was recorded from the investigation chart of every patient. For statistical analysis, the Kruskal Wallis, Mann-Whitney U, Wilcoxon, and chi-square tests were used.

Results:

MI was common in the males at the age of 41 - 60 years as compared to the females (P = 0.015). Patients with a positive parental history of CHD experienced MI at a younger age (P = 0.0001) at a body mass index (BMI) ≤ 25 kg/m². Sedentary lifestyle (70%) and smoking (60%) had a male predominance. Hypertension accounted for nearly 37%, hyperlipidemia 26%, and diabetes 19.4% of the rural and urban subjects (P < 0.01). High-density lipoprotein cholesterol decreased (up to 34 mg/dl), while low-density lipoprotein cholesterol and hypertension increased with age. The mean monthly cost of medicines and physicians’ fees per patient was 2381.132 Pakistani Rupees (24.24 USD).

Conclusions:

Higher BMI, positive family history, smoking, hypertension, hyperlipidemia, and diabetes were the strong predictors of MI in North Punjab, Pakistan. Preventive efforts are needed to start early in life and continue throughout the life course.

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.

Relationship between leisure-time physical activity and risk factors for coronary heart disease in middle-aged Finnish women

Risk factors for coronary heart disease (CHD) and levels of leisure-time physical activity (LTPA) were measured in a random sample of 4,059 women aged 25-64 years, residing in four areas of Finland. LTPA indexed as the product of weekly exercise sessions X their usual intensity showed an inverse association with smoking (p = 0.02) and with CHD risk estimate which combines the three main risk factors, smoking, serum cholesterol and blood pressure (p = 0.06), and a positive association with HDL cholesterol (p = 0.002). It was not associated with mean arterial pressure and serum total cholesterol. In a multiple regression analysis LTPA contributed independently, though modestly, to the model for CHD risk estimate. Age and body mass index were the most important independent predictors of both mean arterial pressure and CHD risk estimate. It is concluded that in middle-aged Finnish women, unlike men of the same population, high LTPA is only weakly related to lower CHD risk factor levels.

Acute myocardial infarction and pulmonary tuberculosis in a young female patient: a case report

Introduction

Tuberculous coronaritis is known to be a very rare phenomenon, although Mycobacterium tuberculosis, as some other infectious agents, may also act in the coronary vessels by activating the inflammatory mechanism of atherosclerosis. The association between active pulmonary tuberculosis and acute myocardial infarction has not been reported for around three and a half decades.

Case presentation

We presented here a case of a young, 30 year old, Caucasian woman who presented to Emergency Ward with severe chest pain, ECG and enzyme profile typical for acute myocardial infarction. Chest X-ray displayed high intensity shades in the left lung field, which after additional laboratory tests were shown to be due to active pulmonary tuberculosis.

Conclusion

As the patient did not have any other known coronary artery disease risk factors, we held responsible Mycobacterium tuberculosis for occurrence of acute myocardial infarction in this young female patient. We believe that the presentation of this rare case of myocardial infarction in a patient with active pulmonary tuberculosis should encourage researchers to investigate the potential role of Mycobacterium tuberculosis in pathogenesis of coronary heart disease.

Morbidity and mortality rates in women with heart disease: lessons in gender differences from Korea

Korean health statistics and available research were reviewed, focusing on the gender differences in morbidity and mortality rates of heart disease, and factors affecting health outcomes of heart disease internationally with Korea. The growth rate and aging of population, and the morbidity and mortality rate from heart disease among Koreans were compared to the data provided by the World Health Organization (WHO) and the United Nations (UN). Both morbidity and mortality rates from heart disease were higher among women than among men in Korea. However, most of the knowledge about heart disease was based on research conducted on men, and not much is known about women with heart disease. The lack of information about women with heart disease may contribute to delay in diagnosis and treatment, longer stays in the hospital, increased medical costs and a higher mortality rate among women than among men in Korea.

There is a difference in characteristics and outcome between women and men who suffer out of hospital cardiac arrest

OBJECTIVE

To evaluate whether there is a difference in characteristics and outcome in relation to gender among patients who suffer out of hospital cardiac arrest.

DESIGN

Observational study.

SETTING

The community of Göteborg.

PATIENTS

All patients in the community of Göteborg who suffered out of hospital cardiac arrest between 1980 and 1996, and in whom cardiopulmonary resuscitation (CPR) was initiated.

MAIN OUTCOME MEASURES

Factors at resuscitation and the proportion of patients being hospitalized and discharged from hospital. P values were corrected for age.

RESULTS

The women were older than the men (median of 73 vs. 69 years; P < 0.0001), they received bystander-CPR less frequently (11 vs. 15%; P = 0.003), they were found in ongoing ventricular fibrillation less frequently (28 vs. 44%; P < 0.0001), and their arrests were judged to be of cardiac origin less frequently. In a multivariate analysis considering age, gender, arrest being due to a cardiac etiology, initial arrhythmia and by-stander initiated CPR, female gender appeared as an independent predictor for patients being brought to hospital alive (odds ratio 1.37; P = 0.001) but not for patients being discharged from hospital.

CONCLUSION

Among patients who suffer out of hospital cardiac arrest with attempted CPR women differ from men being older, receive bystander CPR less frequently, have a cardiac etiology less frequently and are found in ventricular fibrillation less frequently. Finally female gender is associated with an increased chance of arriving at hospital alive.

Percutaneous transluminal coronary angioplasty in the elderly: epidemiology, clinical risk factors, and in-hospital outcomes. The Northern New England Cardiovascular Disease Study Group

OBJECTIVES

To explore the relation between older age and clinical presentation, procedural success, and in-hospital outcomes among a large unselected population undergoing percutaneous transluminal coronary angioplasty (PTCA).

BACKGROUND

Although more elderly patients are receiving PTCA, studies of post-PTCA outcomes among the elderly have been limited by small numbers and exclusive selection criteria.

METHODS

Data were collected as a part of a prospective registry of all percutaneous coronary interventions performed in Maine, New Hampshire, and from 1 institution in Massachusetts between October 1989 and December 1993. Comparisons across 4 age groups, (<60, 60 to 69, 70 to 79, and 80 years and above) were performed using chi-square tests, the Mantel-Haenzsel test for trend, and logistic regression.

RESULTS

Twelve thousand one hundred seventy-two hospitalizations for PTCA were performed with 507 of them (4%) in persons at least 80 years old. Octogenarians were more likely to be women, have multivessel disease, high-grade stenoses, and complex lesions but were less likely to have hypercholesterolemia, a history of smoking, or have undergone a previous PTCA. In the elderly, PTCAs were more often performed urgently and for unstable syndromes compared with younger age groups. Advancing age is strongly associated with in-hospital death, and among the oldest old with an increased risk of postprocedural myocardial infarction. Despite differing presentation and procedural priority, angiographic success and subsequent bypass surgery did not vary by age.

CONCLUSIONS

With the increasing age of the population at large as well as that segment at risk for cardiac revascularization, information about age-associated risks of the procedure, especially the substantially higher risk of death in octogenarians, will be critical for both physicians and patients considering PTCA.

Diabetes abolishes the vascular protective effects of estrogen in female rats

Estrogen is known to exert a protective effect against cardiovascular disease. However, women with diabetes have three times the risk as compared with age-matched non-diabetic women. Our previous study on aortic rings of ovariectomized (OVX) female rats treated with 17-beta-estradiol (E2) demonstrated that the beneficial effect of estrogen is related to the basal release of NO from endothelial cells. In the present study, in order to understand why estrogen protection is abolished in diabetes, we tested vascular responses in OVX, streptozotocin-diabetic female rats and their non-diabetic controls receiving or not E2 replacement. Concentration-response curves to norepinephrine (NE) showed attenuation of the contractile response in E2-treated diabetic, with respect to non-diabetic preparations. This response was further impaired in diabetic, E2-deprived rats. The basal release of NO, as evaluated by concentration-related responses to N(G)-methyl-L-arginine acetate in NE-precontracted aortic rings, was found to be impaired in E2-treated diabetic rats, no further effect being induced by E2 deprivation. The endothelium-dependent relaxation produced by carbachol did not change between groups, whereas the relaxation produced by histamine was enhanced by both diabetes and E2 deprivation. However, E2 treatment counteracted the response to histamine only in preparations from non-diabetic animals. Finally, the relaxation induced by sodium nitroprusside, an endothelium-independent relaxant agent, was comparable between groups. These findings suggest that the lack of protective effects of estrogen in diabetes may be mainly ascribed to the failure of estrogen to reverse the impaired basal release of NO and the abnormal relaxation to histamine, which are observed in the aorta of diabetic rats.

Cardiac rehabilitation: gender differences in factors influencing participation

This study investigates gender differences in the barriers and incentives that are most influential in the coronary patient's decision to participate in cardiac rehabilitation programs (CRPs) and suggests strategies to counter these barriers. Patient surveys were administered to consecutive English-speaking attenders and referred nonattenders to a cardiac rehabilitation center at a university healthcare system in Toronto, Canada. A survey questionnaire, constructed from a literature review and advice from key informants, examined potential factors affecting decisions to engage in CRPs. One hundred twenty-nine attenders at a CRP and 61 referred nonattenders completed the questionnaire. Physician recommendation was reported to be the most important factor influencing both women's and men's decisions to participate in CRPs, followed by encouragement from family members. For women who had attended CRP, encouragement from their adult children was significantly more influential than it was for men. Attention to health promotion was also a significantly more powerful motivator for women than it was for men. For CRP nonattenders, concomitant illness, transportation problems, and inconvenient timing of the program were stated to be the three most important barriers to CRP participation in both sexes, although women rated concomitant illness as a significantly more powerful barrier than did men. The decision to participate in CRPs involves several factors, some of which are different or more important for women. As physician recommendations continue to be the single most important factor in motivating both men and women to attend, strengthened and increased physician endorsement will likely encourage higher levels of participation in CRPs. For women, permission should be sought to discuss the advantages of CRPs with adult children who are apparently influential in the decision. As women nonattenders are more concerned than men about the effects of concomitant illnesses, reassurance should be provided about customized programs and exercise targets that consider the needs and limitations of individuals with other health conditions.

Effect of risk factors on the mechanism of acute thrombosis and sudden coronary death in women

BACKGROUND

Traditional risk factors have been linked to atherosclerotic heart disease in women. However, the effect of risk factors and menopausal status on the mechanism of sudden coronary death is unknown.

METHODS AND RESULTS

We examined 51 cases of sudden coronary death and 15 hearts from women who died of trauma. Coronary deaths were divided into four mechanisms of death: ruptured plaque with acute thrombus (n = 8), eroded plaque with acute thrombus (n = 18), stable plaque with healed infarct (n = 18), and stable plaque without infarction (n = 7). Vulnerable plaques prone to rupture were defined as those with a thin, fibrous cap infiltrated by macrophages and were quantitated in coronary deaths and control subjects. Total cholesterol (TC), HDL cholesterol, glycosylated hemoglobin, cigarette smoking, and hypertension were determined in each case. Compared with control subjects, women with plaque ruptures had elevated TC (270 +/- 55 versus 194 +/- 44 mg/dL, P = 0.002), and those with erosions were more likely to be smokers (78% versus 33%, P = 0.01). Women with stable plaque and healed infarct had elevated glycosylated hemoglobin (10.2 +/- 5.0% versus 6.4 +/- 0.4% in control subjects, P = 0.001) and were more likely to be hypertensive (50% versus 15% in control subjects, P = 0.03). By multivariate analysis, cigarette smoking was associated with plaque erosion (P = 0.03, odds ratio [OR] 21), glycoslyated hemoglobin with stable plaque and healed infarct (P = 0.03, OR 41), TC with plaque rupture (P = 0.02, OR 7), and hypertension with stable plaque with healed infarct (P = 0.02, OR 15). Seven of 8 plaque ruptures occurred in women > 50 years of age versus 3 of 18 erosions (P = 0.001). In cases of coronary death, vulnerable plaques were associated with elevated cholesterol (P = 0.002) and age > 50 years (P = 0.002), independent of other risk factors.

CONCLUSIONS

In women, traditional risk factors have distinct effects on the mechanisms of sudden coronary death, which vary by menopausal status. Effective risk factor modification may therefore differ between younger and older women and may be targeting different mechanisms of plaque instability.

Preoperative cardiac evaluation of women for noncardiac surgery

Cardiac risk assessment is a crucial aspect of perioperative evaluation because it is estimated that 1 million people, regardless of gender, will have perioperative cardiac complications at a cost of 20 billion dollars. Unfortunately, establishment of optimal guidelines for selected patient subgroups, particularly women, are lacking. More prospective studies are needed to help evaluate the most cost-effective, yet accurate way to noninvasively assess the presence of coronary artery disease in women.

Sex and diagnostic evaluation of possible coronary artery disease after exercise treadmill testing at one academic teaching center

Controversy exists as to whether a sex bias exists that affects the diagnostic approach to suspected coronary artery disease: previous studies have used coronary angiography, but not other noninvasive testing, as a primary end point. This investigation examined posttest sex differences in diagnostic evaluation after exercise treadmill testing according to a broader end point than just coronary angiography alone. The design was a cohort analytic study with a 90-day follow-up. The study was done at the Cleveland Clinic Foundation, an academic group practice. Patients included consecutive adults (1023 men and 579 women) with chest pain but no documented coronary disease who were referred for symptom-limited exercise treadmill testing without adjunctive imaging; none had undergone prior invasive cardiac procedures. Main outcome measures included (1) performance of any subsequent diagnostic study (invasive or noninvasive) and (2) performance of coronary angiography as the next diagnostic study. During follow-up, 89 (8.7%) men and 48 (8.3%) women underwent a second diagnostic study (odds ratio 0.95; 95% confidence interval 0.66 to 1.37; p > 0.8), whereas 64 (6.3%) men and 21 (3.6%) women went straight to coronary angiography (odds ratio 0.56; 95% confidence interval 0.34 to 0.93; p = 0.02). In multivariable logistic regression analyses, which considered baseline clinical characteristics, the ST-segment response, and other prognostically important exercise responses, women tended to be less likely than men to be referred to any second test (adjusted odds ratio 0.70; 95% confidence interval 0.42 to 1.19; p > 0.1) but were markedly and significantly less likely to be referred straight to coronary angiography (adjusted odds ratio 0.33; 95% confidence interval 0.17 to 0.65). After exercise treadmill testing, women were only slightly less likely than men to be referred for subsequent diagnostic testing; they were, however, much less likely to be referred straight to coronary angiography as opposed to another noninvasive study.

Trends in success rate after percutaneous transluminal coronary angioplasty in men and women with coronary artery disease

Women with coronary artery disease are less likely to undergo percutaneous transluminal coronary angioplasty (PTCA) because of the potential referral bias in favor of men with coronary artery disease in the use of invasive diagnostic procedures and interventions. This difference may represent a sex bias in the delivery of medical care. The apparent sex difference in short-term success of PTCA seen in the early 1980s has not persisted in subsequent studies. The higher in-hospital mortality rate, if any, in women compared with men after PTCA is related more to the severity of their underlying disease rather than sex alone. In addition, women have a better long-term PTCA success rate. PTCA should not be withheld in women who are considered appropriate anatomic candidates for fear of reduced success or increased major complications.

Ethnic differences in mortality of male and female patients surviving acute myocardial infarction: long-term follow-up of 5,700 patients. The Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) Study Group

In migrant countries, ethnic origin may represent a complex of cultural, behavioral and possibly genetic differences. These have been shown to influence acute myocardial infarction (AMI) incidence. How ethnic origin may affect survival after AMI is unknown. Data from 5,692 patients included in the Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) registry were analyzed. Patients were divided into eight different ethnic groups, according to birthplaces from five continents, representing major socio-economic and possibly some genetic variation. Mortality was analyzed after adjustment for baseline characteristics known to predict death from coronary artery disease (CAD) using Jews born in Israel as a reference. The odds ratio for in-hospital mortality was higher in women than in men, but unrelated to ethnic origin. The odds ratio for men ranged between 1.08 (95% confidence interval (CI): 0.67-1.73) for Jews born in Eastern Europe and 1.84 (95% CI: 1.07-3.15) for counterparts born in the Middle East. The odds ratio for women ranged between 0.73 in Jews born in Central Europe (95% CI: 0.35-1.50) and 1.45 (95% CI: 0.76-3.15) for Jewish women born in the Balkan countries. Among 4,686 patients surviving the hospital phase, long-term mortality rates (mean follow-up 7.1 +/- 3.5 years) were 43.3% in men and 57.6% in women. Among 3,586 surviving men, the adjusted risk ratios for 10-year mortality varied between 0.92 (95% CI: 0.72-1.18) for men born in Romania and 1.49 (95% CI: 1.07-2.09) for Israeli born Arabs. The variation among men is within the limits of statistical error. However, among 1,100 surviving women, the risk ratio for 10-year mortality differed significantly, from as low as 1.43 (95% CI: 0.84-2.41) in Jewish women born in Central Europe to as high as 2.83 (95% CI: 1.67-4.79) in counterparts born in the Middle East. The latter observations were consistent with the mortality after 3 years. Thus, ethnic origin of Israelis marginally influenced the in-hospital mortality. The long-term prognosis varied significantly among women from different origins but not among men.

Outcome and profile of women and men presenting with acute coronary syndromes: a report from TIMI IIIB. TIMI Investigators. Thrombolysis in Myocardial Infarction

OBJECTIVES

Women and men enrolled in the Thrombolysis in Myocardial Infarction (TIMI) IIIB trial of unstable angina and non-Q wave myocardial infarction (MI) were evaluated to determine gender differences in characteristics and outcome.

BACKGROUND

Coronary heart disease is the leading cause of death for women and men. However, the characteristics and outcome of women compared with men with unstable angina and non-Q wave MI have not been extensively studied.

METHODS

The characteristics, outcomes and proportion of 497 women and 976 men with unstable angina and non-Q wave MI at the time of enrollment were compared. When these proportions were noted to be significantly different, we compared them with the 7,731-patient TIMI IIIB Registry, which represents the non-trial, screened population with these syndromes at these centers.

RESULTS

For both coronary syndromes, women were older, were less frequently white, had a higher incidence of diabetes and hypertension and were receiving more cardiac medications. The 42-day rate of death and MI in TIMI IIIB was similar for women and men (7.4% vs. 7.5%). Coronary angiography revealed less severe coronary artery disease for women than for men, with absence of critical obstructions in 25% versus 16% and mean ejection fractions 62 +/- 12% versus 57 +/- 13% for women versus men (p < 0.01). Medical management failed in women as often as in men, and rates of cardiac catheterization and percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery were similar for women and men in the conservative strategy arm as well as in the invasive strategy arm. Women in the TIMI IIIB trial had proportionately more unstable angina than did men. The proportion of unstable angina and non-Q wave MI for women was similar in the trial and Registry. However, proportionately more men in the trial had non-Q wave MI than men in the Registry.

CONCLUSIONS

1) Women with each acute coronary syndrome are older than men and have more comorbidity. 2) The outcome with unstable angina and non-Q wave MI is related to severity of illness and not gender. 3) Mortality associated with revascularization for unstable angina and non-Q wave MI was similar for women and men. 4) The proportion of women and men enrolled with each acute coronary syndrome is different. These rates reflect both the prevalence of disease and selection bias owing to trial eligibility criteria and other identified factors.

Gender and referral for coronary angiography after treadmill thallium testing

Considerable controversy exists regarding whether women are less likely than men to be referred to coronary angiography after an abnormal noninvasive test. This prospective cohort study analyzed consecutive subjects (2,351 men and 1,318 women) with no prior history of invasive cardiac procedures who were referred for treadmill thallium testing at the Cleveland Clinic Foundation. The primary end point was performance of coronary angiography within 90 days of treadmill thallium testing. A secondary end point was all-cause mortality during 1.8 years of follow-up. Women were less likely than men to undergo coronary angiography (6% vs 14%, odds ratio [OR] 0.42, 95% confidence interval [Cl] 0.33 to 0.54, p < 0.001), but were also less likely to have an abnormal thallium scan (8% vs 29%, p < 0.001). In logistic regression analyses with adjustment for thallium result and age, women were as likely as men to be referred for coronary angiography (adjusted OR 1.00, 95% Cl 0.75 to 1.34, p > 0.9). Women were less likely to have severe coronary disease on angiography (15% vs 30%, p = 0.006). During 1.8 years of follow-up there were 26 deaths (2%) among women and 84 deaths (4%) among men. After adjusting for age, thallium abnormalities, and clinical characteristics in Cox regression analyses, women had a lower mortality rate than men (relative risk 0.58, 95% Cl 0.36 to 0.94, p = 0.03). Thus, gender-related differences in referral for coronary angiography after treadmill thallium testing can be explained by a higher rate of abnormal tests in men. No evidence of a post-test gender bias was detected, but a pretest bias affecting referral to nuclear testing cannot be excluded. Furthermore, women have a lower prevalence of severe coronary disease and a lower adjusted mortality rate.

Cardiovascular, pulmonary, and cancer rehabilitation. 1. Cardiac rehabilitation

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of cardiac patients and other rehabilitation patients with cardiac diseases. It is part of the chapter on cardiovascular, pulmonary, and cancer rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. New advances covered in this article include the management of patients who have undergone cardiac surgery, including transplantation, and gender differences in evaluation, therapy, and outcome.

Clinical science review: current aspects of thrombolytic therapy in women with acute myocardial infarction

Acute myocardial infarction (AMI) remains the greatest threat to health in our society and is the most common cause of death in the United States and in many other Western industrialized countries. Recent data demonstrate that mortality from MI is continuing to decline. In these days of more aggressive management of acute MI (AMI) there has been a resurgence of interest in advances in thrombolytic therapy. However, observational studies of patients with AMI have shown that women sustaining an AMI have a worse prognosis than men. AMI is the number-one killer of women in the United States; approximately 247,000 of more than 520,000 deaths due to AMI that occur each year are among women, and almost one-third of the women are younger than forty-five years old. While there have been great advances in thrombolytic therapy, these advances have benefited men to a more significant degree than they have benefited women. The purpose of this paper is to critically review the efficacy of thrombolytic therapy in women with AMI with consideration of some of the key components of its effectiveness: mortality, bleeding risk, infarct-artery patency, ventricular function, and cardiac arrhythmia.

Coronary artery disease and colorectal neoplasia

PURPOSE

This study was designed to determine whether patients with coronary artery disease are at elevated risk for colorectal neoplasia.

METHODS

A case-control study was conducted among consecutive patients in three colonoscopy practices in New York City from 1986 to 1988. All study participants completed an interview questionnaire covering demographics, diet, environmental and behavioral exposures, family and personal medical history, and other variables. For the present study, 298 newly diagnosed colorectal adenoma cases and 107 incident cancer cases were compared with 507 colonoscoped controls without colorectal neoplasia or other significant findings on colonoscopy. Data on history of coronary artery disease (angina and/or heart attack) were obtained solely from the study participants' questionnaire responses.

RESULTS

No association was observed between angina, heart attack, or either and colorectal adenomas in males. However, prior coronary artery disease was found to be associated with colorectal cancer in males more than 60 years of age and with colorectal adenomas in females aged 50 years or younger.

CONCLUSION

Men with coronary artery disease may be at elevated risk for subsequent colorectal cancer. Young women with coronary artery disease also may be at elevated risk for colorectal neoplasia.

Sex differences in early mortality after acute myocardial infarction (the Minnesota Heart Survey)

Although numerous studies indicate that women have a higher early mortality from acute myocardial infarction (AMI) than men, reasons for the difference are largely unexplained. We studied the role of sex in the prognosis of 1,600 patients with AMI aged 30 to 74 years in the population-based Minnesota Heart Survey. A 50% random sample was taken of all AMI patients hospitalized in 1980 and 1985 in the Twin Cities of Minnesota (Minneapolis-St. Paul) (1,168 men, 432 women). A multiple logistic regression model was used for predicting early death (within 28 days) and included baseline characteristics: sex, age, chest pain on admission, history of previous AMI, angina pectoris, coronary artery bypass surgery or hypertension, presence of heart failure, cardiac arrhythmias requiring direct-current shock, diabetes mellitus, valvular disease, cardiomyopathy, and levels of serum enzymes and blood urea nitrogen. Age-adjusted early mortality rate was significantly higher in women than men, but only in those aged < 65 years (12.5% of women vs 6.5% of men, p < 0.01) versus those aged > or = 65 years (19.5% vs 21.6%, p > 0.05). Multivariate analysis also showed that among those < 65 years, female sex was a strong and independent predictor of early death (odds ratio 2.0, 95% confidence interval 1.2 to 3.5, p < 0.01). Rates of coronary angiography, coronary artery bypass surgery, percutaneous transluminal coronary angioplasty, and thrombolysis performed during hospital stay were higher in men, but after adjustment for age, congestive heart failure, and diabetes mellitus, a statistically significant difference persisted only in the frequency of coronary angiography (26% in men vs 17% in women, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Independent and incremental prognostic value of exercise thallium single-photon emission computed tomographic imaging in women

BACKGROUND

This study examined the independent and incremental prognostic value of exercise thallium single-photon emission computed tomographic imaging in 212 women who also underwent coronary angiography.

METHODS AND RESULTS

The left ventricular ejection fraction was normal (65% +/- 15%). During a mean follow-up of 40 months, 27 women had events (cardiac death or nonfatal myocardial infarction). Univariate Cox survival analysis showed several variables to be different between patients with events and those without events: age, exercise heart rate, the extent of coronary artery disease, reversible thallium defects, number of segments with reversible abnormality, and size of perfusion abnormality. Multivariate survival analysis showed that a large perfusion abnormality and age were the independent predictors of events. Actuarial life-table analysis showed that women with a large thallium abnormality (> or = 15% of the myocardium) had significantly worse event-free survival rates than had women with no or small abnormalities (Mantel-Cox statistic = 16; p = 0.0001).

CONCLUSIONS

Thus exercise thallium-201 single-photon emission computed tomographic imaging provides independent and incremental prognostic information to clinical, exercise, and coronary angiographic results in women. The presence of a larger thallium abnormality identifies women at high risk of cardiac events.

Effects of sex steroids on women's health: implications for practitioners

Androgen excess in women is manifested typically by clinical features that may include hirsutism, acne, central obesity, male-pattern baldness, upper torso widening, increased waist-to-hip ratio, clitoral hypertrophy, and deepening of the voice. The differential diagnosis includes androgen-producing ovarian and adrenal neoplasms, Cushing's syndrome, polycystic ovary syndrome, and the intake of exogenous androgens. Physicians treating patients for one symptom of androgen excess must be alert for other symptoms and signs. The cosmetic manifestations of androgen excess belie the serious health risks associated with this condition, including cardiovascular disease, intravascular thrombosis, and insulin resistance. Prompt clinical recognition of androgen excess, understanding of the androgen-related biochemical abnormalities underlying the risks associated with this condition, and implementation of risk modification can reduce the incidence of associated morbidity and mortality. An interdisciplinary approach to management is strongly recommended. Risk reduction strategies include correction of dyslipidemias, low-dose aspirin for primary prevention of myocardial infarction, maintenance of ideal weight, smoking cessation, exercise, use of oral contraceptives containing a low-androgenic progestin, and postmenopausal estrogen replacement. Combination oral contraceptives containing low-androgenic progestins are effective not only in reducing signs of androgen excess but also in potentially retarding the progression of long-term sequelae such as cardiovascular disease.

Sexual healing: caring for patients recovering from myocardial infarction

Sexuality is rarely addressed when patients are recovering from myocardial infarction (MI). This article discusses both nurses' and patients' attitudes to sexuality, and examines ways to increase nurses' awareness so that they can offer sexual advice and apply a truly holistic approach when caring for patients following an MI.

Prognosis in myocardial infarction in relation to gender

We studied 921 consecutive patients admitted to a single hospital for acute myocardial infarction during a period of 21 months and related their prognosis to gender. Women (n = 300, 33%) were on average 7 years older (p < 0.001) and more frequently had a previous history of hypertension (p < 0.001) and congestive heart failure (p < 0.001) than did men. They also tended to delay longer in seeking medical treatment and more often presented with only vague symptoms (p < 0.05). The in-hospital mortality for women was 19% versus 12% for men (p < 0.01). Women more often showed signs of congestive heart failure (p < 0.05) despite smaller infarcts as estimated from enzyme levels (p < 0.05). Total mortality during 1 year was 36% in women and 25% in men (p < 0.01). In a multivariate analysis, female gender did not appear as an independent risk factor for death. During 1 year of follow-up no differences in morbidity were observed between the sexes. We conclude that if women fare worse than men after suffering an acute myocardial infarction, the increased mortality is accounted for by older age.

Issues in design, measurement, and analysis for menopause research

Two broad classes of studies relating to menopause are reviewed: descriptive studies (cross-sectional or longitudinal); and comparative studies (observational or experimental). For descriptive studies the issues are: costs of sampling from a general population; measurement of last menstrual period (LMP) in the context of hormone therapy; unbiased symptom reporting in ethnically diverse populations; and in-home vs. clinic-based measurement. Comparative cohort studies of menopause-related therapies are somewhat more vulnerable to selection bias from medical care access than case-control studies with hospital or patient controls. Ideally, in clinical trials, no subjects should have previously used any of the trial therapies to ensure unbiased assessment of side effects and to maximize preservation of masking if a placebo is used. In terms of analysis, information (precision) depends on the proportion in the sample for whom LMP is defined, not the total number in the sample. The role of cigarette smoking as covariate in any analysis is of particular concern as it is the major determinant of the timing of LMP. These design and analysis issues, although identified from research to date, are still new. Some lack wide documentation and are thus not well understood. Others lack clear solutions.

Thrombolytic therapy for women with myocardial infarction: is there a gender gap? Thrombolysis and Angioplasty in Myocardial Infarction Study Group

OBJECTIVES

The goal of this study was to investigate whether female gender portends an adverse prognosis independent of the severity of the underlying disease after acute myocardial infarction treated by thrombolysis. A total of 348 women were compared with 1,271 men enrolled in the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) trials.

BACKGROUND

The reasons for gender differences in the management and prognosis of acute coronary artery syndromes remain poorly defined. The extent to which gender itself explains observed differences in outcome and use of diagnostic procedures remains unclear because confounding factors have not been specified.

METHODS

Patients < 76 years of age presenting within 6 h of onset of ischemic symptoms with electrocardiographic ST segment elevation and without contraindications to thrombolysis, previous infarction in the same distribution or cardiogenic shock were prospectively enrolled in Phases 1 to 3, 5 and 7 of the TAMI trials. All patients received recombinant tissue-type plasminogen activator, urokinase or a combination of both agents. Protocol-mandated cardiac catheterization was performed during the hospital period. Rescue coronary angioplasty was carried out for reperfusion failure at angiography 90 min after initiation of thrombolytic therapy. Coronary artery bypass grafting or coronary angioplasty was performed for clinical indications.

RESULTS

Women were older than men (61.0 +/- 9.7 vs. 55.8 +/- 10.1 years, mean +/- SD) and had a higher incidence of many risk factors for adverse outcome after myocardial infarction. There were no differences in baseline hemodynamic variables or time to thrombolytic treatment. Rates of acute and predischarge infarct-related artery patency and global and regional left ventricular function were similar in the two groups. Rates of in-hospital coronary angioplasty (52.6% and 54.1%) and bypass graft surgery (20.4% and 22.0%) were comparable in women and men, respectively. Women had higher unadjusted rates of mortality (9.2% vs. 5.4%, p = 0.014), reinfarction (6.4% vs. 2.6%, p = 0.005) and hemorrhagic stroke (2.0% vs. 0.55%, p = 0.017) than did men during the hospital period. When adjusted for clinical and angiographic variables, differences in mortality and hemorrhagic stroke did not reach statistical significance, and the risk of reinfarction was only marginally associated with gender.

CONCLUSIONS

In selected patients undergoing thrombolytic therapy and cardiac catheterization for acute myocardial infarction, adjusted mortality rates and utilization of postlysis revascularization are similar in women and men. However, women may be at increased risk for reinfarction.

Nutrition and diseases of women: cardiovascular disorders

Studies of prevention, diagnosis, and intervention for coronary heart disease and hypertension have either been conducted largely in men, or gender differences have not always been fully sought. This has added to a general perception that coronary artery disease is basically a male affliction despite the fact that coronary artery disease is the leading cause of death among women, especially elderly women. Many risk factors among women are similar to men, i.e., high blood pressure (BP), elevated serum cholesterol levels, and cigarette smoking; however, women compared to men have greater incidence of diabetes mellitus, congestive heart failure, and hypertension as they become older. The risk of cardiovascular disorders can be reduced by postmenopausal estrogen replacement, exercising sufficiently, and ceasing smoking. In addition, good nutrition, taking into consideration the proper amount and forms of calories, sodium, potassium, calcium, magnesium, and macronutrients to maintain an ideal lipid profile and BP, is helpful in preventing cardiovascular perturbations.

Contraception and dyslipidemia

The risks of cardiovascular disease associated with dyslipidemia differ in women and men, being more strongly associated with triglyceride/high-density lipoprotein in middle-aged women than in men. Although the incidence of heart disease is lower in women because they live longer, over a lifetime, cardiovascular disease in women is equal to that in men, with the greatest incidence after age 65 years. Major coronary events are rare among reproductive-age women who use oral contraceptives and are related to the concomitant effects of age, smoking, diabetes, hypertension, and obesity. Low estrogen-progestin dose oral contraceptives appear not to promote cardiovascular disease and can be used in women with controlled cholesterol elevations. Alternative contraceptive measures should be considered for patients with severe uncontrolled hypercholesterolemia or a lipid disorder that carries a high risk of coronary heart disease. In these conditions, thrombotic propensity associated with supraphysiologic doses of estrogen in oral contraceptives might accelerate coronary thrombosis should an arteriosclerotic plaque rupture. Treatment of hypercholesterolemia should follow the guidelines of the National Cholesterol Education Program and emphasize hygienic measures. Contraceptive selection in hyperlipidemic patients should reflect a balance between the risks--and their management--of developing cardiovascular disease versus the risks of pregnancy.

Aspirin for the prevention of vascular death in women

OBJECTIVE

To review current information relevant to the use of aspirin for preventing vascular death in women, and to provide recommendations based on this information.

DATA SOURCES

References from pertinent articles are identified throughout the text.

DATA SYNTHESIS

Based on current information, low-dose aspirin is not recommended as primary prevention for cardiovascular death in women; efforts are better focused at promoting risk-factor reduction. Low-dose aspirin is recommended for reducing further cardiovascular morbidity and mortality in women with known cardiovascular disease. Women presenting with unstable angina or myocardial infarction should receive aspirin 325 mg as soon as the diagnosis is confirmed, and this dosage should be continued on a chronic basis. Women who have experienced transient ischemic attacks or ischemic stroke should receive aspirin 1000 mg/d, with a subsequent dosage reduction to 325 mg/d in patients who do not tolerate the higher dose.

CONCLUSIONS

Current recommendations are based on the results of studies that involved few women. Further investigation of antiplatelet agents for primary and secondary prevention of vascular death in women is needed.

Coronary artery disease in women. How it is--and isn't--unique

Various risk factors, such as smoking and diabetes, have an adverse effect on women's inherent biological protection from coronary artery disease (CAD). In women, CAD is most likely to present as angina. Although infarction as the initial event is less common in women than in men, it is more likely to be fatal. The prognosis for women with diabetes and CAD is especially poor. Differences in the therapeutic approach to CAD in men and women do not appear justified. Preventive strategies for women center around cessation of smoking, aspirin therapy, diet modification, and estrogen therapy.

Usefulness of the total cholesterol to high-density lipoprotein cholesterol ratio in predicting angiographic coronary artery disease in women

To investigate the relation between lipids and angiographic coronary artery disease (CAD) in women, fasting lipid profiles were obtained on 108 women undergoing coronary angiography (group I). CAD, defined as greater than or equal to 25% luminal diameter narrowing in a major coronary artery, was present in 57 (53%). Neither serum total cholesterol nor triglyceride levels correlated with the presence of CAD. Mean total/high-density lipoprotein (HDL) cholesterol ratio was higher among women with than without CAD (5.5 +/- 0.3 vs 4.2 +/- 0.2, p less than 0.0001). Multiple regression analyses identified a higher total/HDL cholesterol ratio as the variable most predictive of the presence (p less than 0.001), extent (number of narrowed arteries) (p less than 0.0001), and severity (% maximum stenosis) (p less than 0.001) of CAD. Age and lack of estrogen use were also independently associated with the presence of CAD, age and low-density lipoprotein cholesterol level were additional indicators of extent, and age was the only other discriminator of severity of CAD. In 56 women with total cholesterol less than 200 mg/dl (group II), mean total/HDL cholesterol ratio was higher in women with (n = 24) than without CAD (4.3 +/- 0.2 vs 3.5 +/- 0.2, p = 0.01). Higher total/HDL cholesterol ratio was the variable most predictive of the presence of CAD (p = 0.01), and the lone variable associated with severity (p less than 0.001) after adjustment for other risk factors. Age was independently associated with presence and extent, and hypertension was also independently related to extent.(ABSTRACT TRUNCATED AT 250 WORDS)

In-hospital and 1-year mortality in 1,524 women after myocardial infarction. Comparison with 4,315 men

We determined in-hospital and 1-year prognoses after acute myocardial infarction (MI) in 5,839 consecutive patients derived from 14 of 21 coronary care units in Israel during 1981-1983. Age-adjusted in-hospital mortality was 23.1% in 1,524 women and 15.7% in 4,315 men (p less than 0.0005). One-year age-adjusted mortality rates in patients surviving hospitalization were 11.8% in women and 9.3% in men (p = 0.03). Cumulative age-adjusted 1-year mortality rates were 31.8% in women and 23.1% in men (p less than 0.0005). Relative odds of mortality, covariate-adjusted for major prognostic factors that included age, prior MI, congestive heart failure, and infarct location by electrocardiogram, indicated that female gender was independently and significantly associated with increased mortality both during hospitalization (relative odds, 1.72; 95% confidence interval, 1.45-2.04) and at 1 year after discharge (relative odds, 1.32; 95% confidence interval, 1.05-1.66). In separate multivariate analyses for each gender, a major factor that emerged as a predictor of outcome in women, but not in men, was a reported history of diabetes mellitus, both for in-hospital mortality and for 1-year mortality. However, even in the nondiabetics in this population, female gender was a significant, independent predictor of in-hospital mortality. The findings of the present study substantiate that women fare worse than men after suffering an acute MI, that increased age does not fully account for the increased mortality in women, and that diabetic women are at particularly high risk once MI has occurred.

Obesity, stress, and smoking: their role as cardiovascular risk factors in women

Obesity, defined as an increase of 20% or more above desired weight, has been found to be an independent, albeit weak, risk factor for coronary heart disease in women and may increase the relative risk of other factors such as hypertension, diabetes mellitus, and elevated total serum cholesterol and low-density lipoprotein-cholesterol. Type A personality and stress, on the other hand, appear to be moderate risk factors for coronary heart disease in women as well as in men. Approximately twice as many cardiovascular events occurred in type A women 35 to 64 years old as in type B women of the same age group. As expected, cigarette smoking is a major risk factor, primarily in young women. Women with smoking patterns similar to those of men experience similar rates of cardiovascular morbidity and mortality. In addition, smoking apparently acts synergistically with oral contraceptives and elevated total serum cholesterol to further increase risk.

Effects of gender and race on prognosis after myocardial infarction: adverse prognosis for women, particularly black women

Controversy has arisen concerning whether gender influences the prognosis after myocardial infarction. Although some studies have shown there to be no difference between the sexes, most have indicated a worse prognosis for women, attributing this to differences in baseline characteristics. It has been further suggested that black women have a particularly poor prognosis after infarction. To determine the contribution of gender and race to the course of infarction, 816 patients with confirmed myocardial infarction who were enrolled in the Multicenter Investigation of the Limitation of Infarct Size (MILIS) were analyzed. Of those patients, 226 were women and 590 were men, 142 were black and 674 were white. The cumulative mortality rate at 48 months was 36% for women versus 21% for men (p less than 0.001, mean follow-up 32 months). The cumulative mortality rate by race was 34% for blacks versus 24% for whites (p less than 0.005). Both women and blacks exhibited more baseline characteristics predictive of mortality than did their male or white counterparts. It was possible to account for the greater mortality rate of blacks by identifiable baseline variables; however, even after adjustment, the mortality rate for women remained significantly higher (p less than 0.002). The poorer prognosis for women was influenced by a particularly high mortality rate among black women (48%); the mortality rate for white women was 32%, for black men 23% and for white men 21%. The mortality for black women was significantly greater than that of the other subgroups. Thus, findings in the MILIS population indicate that the prognosis after myocardial infarction is worse for women, particularly black women.

Patterns of coronary heart disease morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population

A population-based survey, using data from the Framingham study, assessed sex-specific patterns of coronary heart disease occurring over a 26-year period of time. Among subjects ages 35 to 84 years, men have about twice the total incidence of morbidity and mortality of women. The sex gap in morbidity tends to diminish during the later years of the age range, mainly because of a surge in growth of female morbidity after age 45 years, while by that age, the growth in the male rate begins to taper off. An approximate 10-year difference between the sexes persists in mortality rates throughout the life span. The relative health advantage that is possessed by women, however, is buffered by a case fatality rate from coronary attacks that exceeds the male rate (32% vs 27%). Coronary disease manifestations differ between the sexes. Myocardial infarction is more likely to be unrecognized in women than in men (34% vs 27%). Angina pectoris in women more frequently is uncomplicated (80%), whereas in men angina tends to evolve out of infarction (66%). Also, sudden death comprises a greater proportion of male deaths than female deaths (50% vs 39%). Because women maintain a lesser probability of the disease than do men at any level of the major cardiovascular risk factors, distinctions in their risk factor profiles do not explain completely the observed disease patterns.