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

Disparities in cardiovascular disease outcomes and economic burdens among minorities in southeastern Virginia

BACKGROUND

Cardiovascular diseases are the leading cause of mortality in the United States, presenting significant public health challenges and financial burdens, particularly in Southeastern Virginia, where African American and Hispanic (AA&H) populations are disproportionately affected.

METHODS

This retrospective observational study analyzed data from 30,855 hospital discharges of AA&H patients across Southeastern Virginia from 2016 to 2020, focusing on individuals aged 18 to 85 with cardiovascular diseases. Utilizing the Virginia Health Information database, we examined demographic information, clinical data, and healthcare utilization patterns through hypothesis tests and regression models to explore associations between these variables and the economic impacts of cardiovascular diseases.

RESULTS

Heart failure and shock (47.2% of discharges) and cardiac arrhythmia and conduction disorders (12.3%) were the most prevalent cardiovascular conditions. Female patients incurred significantly higher charges than males across conditions (7.1% higher in heart failure, p < 0.0001; 8.8% higher in chest pain, p < 0.01). Younger patients (< 65 years) faced 8.5% higher charges for cardiac arrhythmia with procedures (p < 0.0001) and 5.2% higher charges for circulatory disorders (p < 0.05). Year of discharge consistently predicted increasing costs (standardized coefficient 0.816 for acute myocardial infarction, p < 0.0001). The presence of fluid and electrolyte disorders was associated with significantly higher charges across conditions (standardized coefficient 0.042 for heart failure, p < 0.0001; 0.051 for acute myocardial infarction, p < 0.0001).

DISCUSSION

The findings highlight the complex interplay between demographic characteristics and healthcare costs among AA&H populations, underscoring the need for targeted interventions. The significant economic impact observed calls for culturally competent healthcare strategies that can mitigate high costs and improve health outcomes. However, the retrospective, administrative nature of the data limits establishing causality, with potential misclassification of some conditions.

CONCLUSION

This study provides crucial insights into cardiovascular disease management's demographic and economic dimensions among AA&H populations in Southeastern Virginia. By identifying key factors contributing to healthcare disparities, the research supports the development of tailored interventions aimed at reducing the burden of cardiovascular diseases, thereby improving overall health equity and reducing economic strains on the healthcare system.

Cardiac arrhythmia following acute myocardial infarction: a retrospective analysis of 27,648 hospitalized patients in a tertiary heart hospital

Arrhythmia frequently complicates acute myocardial infarction (AMI) and contributes to high morbidity and mortality. We aimed to investigate the prevalence, risk factors, and impact of cardiac arrhythmias in AMI patients at a tertiary heart hospital. This retrospective observational study included AMI patients who were admitted between January 1991 and May 2022. Patients' data were analyzed and compared according to the absence or presence of cardiac arrhythmias post-AMI. We hypothesized that arrhythmias are associated with higher mortality following AMI. During the study, 27,648 patients were hospitalized with AMI, of whom 2118 (7.7%) developed arrhythmia. Patients who developed arrhythmia had a higher average age compared to those without arrhythmia (57.2 vs. 54.8 years, p=0.001), and a larger proportion were male compared to female patients (85.2% vs. 14.8%, p=0.001). Atrial fibrillation was observed in 383 patients (18.1%). Ventricular tachycardia was found in 461 (21.8%), and ventricular fibrillation occurred in 526 patients (24.8%). Complete heart block was developed in 286 (13.5%) patients, 1st-degree atrioventricular (AV) block in 36 (1.7%), 2nd-degree AV block in 138 (6.5%), left bundle branch block in 81 (3.8%), and right bundle branch block in 118 (5.6%). The rate of β-blocker use has increased in the arrhythmias group at discharge compared to the on-admission rate (55.7% vs. 32.5%). However, it remained sub-optimal. Arrhythmias were associated with longer hospital stays and five times higher hospital mortality than the non-arrhythmia group. Multivariable logistic regression analysis indicated that arrhythmia was associated with increased mortality risk three times following AMI (adjusted odds ratio 3.01; 95% confidence interval 2.42-3.75, p=0.001). Almost one-tenth of patients hospitalized with AMI in Qatar developed arrhythmia with variable outcomes; however, the in-hospital mortality remained high. Addressing the risk factors and optimizing the prevention and treatment of AMI and arrhythmias is crucial to improving clinical outcomes. This study may underestimate the incidence of arrhythmias post-AMI as it did not report all types.

Sex Differences in Peripheral Vascular Disease: A Scientific Statement From the American Heart Association

Sex differences in the risk factors, diagnosis, treatment, and outcomes of patients with cardiovascular disease have been well described; however, the bulk of the literature has focused on heart disease in women. Data on sex differences in peripheral vascular disease are ill defined, and there is a need to report and understand those sex-related differences to mitigate adverse outcomes related to those disparities. Although peripheral vascular disease is a highly diverse group of disorders affecting the arteries, veins, and lymphatics, this scientific statement focuses on disorders affecting the peripheral arteries to include the aorta and its branch vessels. The purpose of this scientific statement is to report the current status of sex-based differences and disparities in peripheral vascular disease and to provide research priorities to achieve health equity for women with peripheral vascular disease.

Real-world family planning and pregnancy practices in women with homozygous familial hypercholesterolemia

BACKGROUND AND AIMS

Homozygous familial hypercholesterolemia (HoFH) is characterized by extremely high plasma low-density lipoprotein cholesterol (LDL-C) levels and high premature atherosclerotic cardiovascular disease risk. During pregnancy LDL-C levels increase, while limited therapeutic options are available. This international study documented current approaches of healthcare professionals (HCPs) to family planning, pregnancy, and breastfeeding in HoFH.

METHODS

An online HCP survey was distributed among the HoFH International Clinical Collaborators (HICC, NCT04815005). Responses were analyzed according to HCPs' gender, medical specialty, country income status, and world region.

RESULTS

In total, 87 HCPs (39.1 % women) from 48 countries participated (64.4 % practicing in high-income countries). Most HCPs (79.3 %) always discuss family planning with patients with HoFH. Most (72.4 %) recommend contraception, with intrauterine devices (50.8 %) and oral contraceptives (49.2 %) being most commonly recommended. One in three HCPs would advise against pregnancy if ASCVD risks were deemed too high. Except for lipoprotein apheresis and colesevelam, most HCPs would recommend discontinuing LLT during the conception, pregnancy, and breastfeeding periods. However, approximately 30 % advise continuation or reinitiation of statins and/or ezetimibe during pregnancy and breastfeeding despite labelled restrictions on use during pregnancy and breastfeeding. Nearly half (48.3 %) of HCPs would recommend that women with HoFH shorten the breastfeeding period to resume LLT earlier, with HCPs from high-income countries significantly more likely to do so (51.8 % vs. 41.9 %; p = 0.008).

CONCLUSIONS

This study highlights significant variability in the management of HoFH in women of childbearing age, especially concerning LLT use during conception, pregnancy, and breastfeeding. The findings underscore the need for further research to establish global evidence-based guidelines tailored to individual needs, to improve cardiovascular risk management and reproductive health outcomes for women with HoFH worldwide.

Sex Differences in Patients Presenting With ST-Segment Elevation Myocardial Infarction and Nonobstructive Coronary Arteries

BACKGROUND

Sex differences in ST-segment elevation myocardial infarction (STEMI) due to obstructive coronary artery disease (CAD) are well-established, but limited research exists on sex differences in STEMI patients with nonobstructive coronary arteries (MINOCA) and MINOCA mimickers.

METHODS

We analyzed 8560 consecutive STEMI patients, enrolled in the Midwest STEMI Consortium from 2003 to 2020. Patients with non-obstructive CAD were classified into MINOCA (defined as < 50% coronary artery stenosis and confirmed or suspected coronary artery plaque disruption, epicardial coronary spasm, or coronary embolism/thrombosis) and MINOCA mimickers (takotsubo cardiomyopathy, myocarditis, or non-ischemic cardiomyopathy). The primary outcome was 5-year all-cause mortality.

RESULTS

Of the 8560 patients, 409 (4.8%) had non-obstructive CAD, including 120 (1.4%) MINOCA and 289 (3.4%) MINOCA mimickers. Females were more likely to have MINOCA and MINOCA mimickers (49.2% and 56.4%, respectively). There were no significant sex differences in in-hospital or 5-year mortality in MINOCA, but females with MINOCA mimickers had higher unadjusted 5-year mortality (HR 2.90, 95% CI 1.53-5.53). After adjusting for age and comorbidities, the long-term mortality risk was similar between sexes (adjusted HR 1.16, 95% CI: 0.61-2.24). Females with obstructive CAD had higher 5-year mortality in unadjusted models (HR 1.66, 95% CI 1.48, 1.86), but the difference was not significant after adjustment (adjusted HR 1.1, 95% CI: 0.98-1.24).

CONCLUSIONS

Our findings highlight important sex-based differences in the prevalence, treatment, and long-term outcomes of STEMI patients with MINOCA, MINOCA mimickers, and obstructive CAD. Despite clinical disparities, mortality risks were similar across sexes after adjusting for comorbidities.

Influence of estradiol deficiency on the mineralocorticoid receptor response in postmenopausal women: a cross-sectional study

OBJECTIVE

Premenopausal women (PreM) have a cardioprotective advantage over postmenopausal women (PostM) due to estrogen. The interaction of estrogen with the mineralocorticoid receptor (MR) pathway remains unexplored. This study aimed to identify changes in aldosterone, renin and sexual steroid levels and MR surrogate biomarkers in PostM that may explain changes in blood pressure and renal damage.

METHODS

A cross-sectional study was carried out with 47 normotensive and hypertensive Chilean women distributed between PreM and PostM. Clinical, anthropometric and biochemical parameters, including aldosterone, plasma renin activity (PRA) and surrogate markers of MR activity, were assessed.

RESULTS

PostM had greater systolic blood pressure (SBP) (p < 0.001) than PreM. A negative correlation was observed between estradiol and fractional excretion of potassium (FEK) (ρ = -0.29; p = 0.023), adjusted for age and SBP. Compared with hypertensive PreM, hypertensive PostM (PostM-HT) showed reduced PRA (p = 0.045) and greater FEK (p = 0.04). Normotensive PostM (Post-NT) exhibited greater SBP (p = 0.03), neutrophil gelatinase-associated lipocalin (NGAL) levels (p = 0.04) and FEK (p = 0.03) than normotensive PreM.

CONCLUSION

Our results suggest enhanced MR sensitivity not only in PostM-HT, as evidenced by lower PRA and elevated FEK, but also in PostM-NT, who exhibited greater FEK and NGAL levels, surrogate markers of MR activation. These results support a novel role of MR activation and cardiovascular risk in PostM women.

Trends and Disparities in Acute Myocardial Infarction-Related Mortality Among U.S. Adults With Hypertension, 2000-2023

BACKGROUND

Hypertension is a major public health concern and a key risk factor for acute myocardial infarction (AMI), significantly contributing to cardiovascular mortality. Despite advancements in management and treatment, trends in associated mortality remain underexplored.

OBJECTIVE

This study examines U.S. national trends in hypertension- and AMI-associated mortality from 2000 to 2023, focusing on demographics and regions.

METHODS

Age-adjusted mortality rates (AAMRs) per 100,000 for adults aged ≥ 25 with hypertension and AMI were extracted from the CDC WONDER database. Annual percent changes (APCs) and average APCs (AAPCs) with 95% confidence intervals (CIs) were calculated, stratified by year, sex, race/ethnicity, age, urbanization, and Census region.

RESULTS

From 2000 to 2023, 933,024 hypertension- and AMI-related deaths were recorded. Overall, AAMR declined from 19.84 per 100,000 in 2000 to 16.26 in 2023 (AAPC: -0.93%, 95% CI: -1.18% to -0.76%). However, a sharp rise in mortality occurred between 2018 and 2021, coinciding with the COVID-19 pandemic. Stratified analyses revealed persistently higher mortality rates among menmen, non-Hispanic BlackBlack individuals, and residents of the Southern and rural U.S. regions. Younger adults showed an increasing AAMR trend, indicating a growing burden of hypertension and AMI-associated disease.

CONCLUSION

While long-term mortality trends show a decline, recent years have seen a rise, particularly among high-risk groups. Targeted public health interventions addressing hypertension management, cardiovascular risk reduction, and healthcare disparities are essential to mitigate the ongoing burden of hypertension and AMI mortality in the U.S.

Sex-specific outcomes in myocardial infarction: a dual-cohort analysis using clinical and real-world data

BACKGROUND

Sex-related differences in symptoms, treatment, and outcomes in patients presenting with myocardial infarction have been reported but vary largely between studies. We sought to characterize sex differences in presentation and outcomes of patients with acute ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous intervention (PPCI).

METHODS AND RESULTS

We included 1206 STEMI patients from a clinical cohort and 35,123 STEMI patients obtained from the German health insurance claims. Women, despite being older and thus having a worse cardiovascular risk profile, had greater myocardial salvage and smaller infarct size than men in all patients (median with [interquartile ranges (25th-75th percentiles), IQR]; salvage index: 0.58 [IQR: 0.32-0.91] in females vs. 0.47 [IQR: 0.23-0.77] in males, p < 0.0001; infarct size: 7.0% [IQR: 1.0-22.0%] in females vs. 11.0% [IQR: 3.0-23.0%] of the left ventricle in males, p = 0.002). Same results were shown for propensity score matched pairs (n = 242) (salvage index: 0.60 [IQR: 0.33-0.91] in females vs. 0.44 [IQR: 0.23-0.70] in males, p = 0.0002; infarct size: 7.0% [IQR: 1.0-23.0%] vs. 10% [IQR: 3.0-23.0%] of the left ventricle in males, p = 0.042). Furthermore, women showed a lower risk of 5-year mortality, assessed after propensity score matching, in the health insurance cohort (n = 19,404) (HR = 0.92 [95% CI 0.87-0.97], p = 0.002).

CONCLUSIONS

In patients with STEMI, women appear to have better myocardial salvage and smaller infarct size after PPCI and a lower 5-year mortality compared with men, suggesting better ischemic tolerance in female patients.

Sex differences in cardiac dynamics during myocardial ischemia using a single cell approach

Myocardial ischemia, arising from severe blockages in coronary arteries, poses a significant global health risk due to its potential to cause arrhythmia and heart failure, often leading to sudden cardiac death. During acute myocardial ischemia, profound changes occur in cardiac electrophysiology and anatomy, influencing action potential morphology and propagation, which increased susceptibility to arrhythmias. Sex differences play a critical role in myocardial ischemia and arrhythmogenesis. Females exhibit distinct genetic and hormonal influences on ion channel expression and cardiac function, affecting susceptibility to arrhythmias like Torsade de Pointes. Using the O'Hara-Rudy dynamic (ORd) model, this study shows that females are more likely than males to exhibit cardiac alternans (2:2), a periodic variation in action potential duration between consecutive heartbeats, as well as 2:1 arrhythmic behaviors-characterized by inexcitability in the even beats-under ischemic conditions. Additionally, hormones further exacerbate these gender differences. Moreover, females show a higher propensity than males to terminate 2:2 and 2:1 arrhythmic responses during ischemia treatment. This manuscript aims to uncover sex-specific disparities in electrophysiological responses and drug reactions during myocardial ischemia using the optimized ORd model. These findings underscore the importance of considering sex-specific factors in cardiovascular research and clinical practice.

Gender-specific associations between sleep stages and cardiovascular risk factors

STUDY OBJECTIVES

Sleep characteristics are associated with cardiovascular disease (CVD) risk and both sleep and CVD risk vary by gender. Our objective was to examine associations between polysomnographic sleep characteristics and CVD risk after excluding moderate-severe sleep apnea, and whether gender modifies these associations.

METHODS

This was a cross-sectional study with at-home polysomnography in adults in Brazil (n = 1102 participants with apnea-hypopnea index (AHI) <15 events/hour). Primary exposures were N3, REM, wake after sleep onset (WASO), arousal index, and AHI, and outcomes were blood pressure (BP) and lipid levels.

RESULTS

Associations between sleep and BP varied by gender. In women, more N3 was associated with lower systolic BP (-0.40 mmHg per 10 minutes, 95% CI: -0.71, -0.09), lower diastolic BP (-0.29 mmHg per 10 minutes, 95% CI: -0.50, -0.07), and lower odds of hypertension (OR 0.94, 95% CI: 0.89, 0.98). In men, more WASO was associated with higher systolic BP (0.41 mmHg per 10 minutes, 95% CI: 0.08, 0.74) and higher odds of hypertension (OR 1.07, 95% CI: 1.01, 1.14). No interactions by gender were observed for lipids. More WASO was associated with lower total cholesterol (-0.71 per 10 minutes, 95% CI: -1.37, -0.05). Higher AHI was associated with higher total cholesterol (+0.97 per event/hour, 95% CI: 0.24, 1.70) and higher LDL (+0.84 per event/hour, 95% CI: 0.04, 1.64).

CONCLUSIONS

N3 is more strongly associated with BP in women, which is consistent with other studies demonstrating gender differences in BP control and CVD risk and adds a novel risk factor. Longitudinal and interventional studies are required to determine whether changes in N3 result in BP changes.

Sex Differences in Acute Coronary Syndromes: A Scoping Review Across the Care Continuum

Introduction

Optimal diagnosis and management of acute coronary syndrome (ACS) is essential to improve clinical outcomes and prognosis. Sex disparities in ACS care have been reported in the literature, but evidence gaps remain. This review aims to map and to summarize the global evidence on sex differences in the provision of care across the ACS continuum.

Methods

A systematic literature search was conducted in Pubmed, EMBASE, and the World Health Organization Global Index Medicus. The search was restricted to original research articles published between January 1, 2013, and August 30th, 2023, and with a full-text available in English, Spanish, Dutch, or French. The search terms and key words covered five aspects of the ACS care continuum: pre-hospital care, diagnosis, treatment, in-hospital events, and discharge.

Results

Of the 15,033 identified articles, 446 articles (median percentage of women per study: 29%), reporting on 1,483 outcomes, were included. Most studies were conducted in high-income regions (65%). Studies reported on pre-hospital care (8%), diagnosis (9%), treatment (45%), discharge (14%) and events (24%). For 45% of outcomes, results favored men, 5% favored women, and 50% showed mixed results or no sex difference. ACS care aspects with the largest sex differences were pre-hospital care (58% of the outcomes favored men vs 7% favored women) and diagnosis (70% favored men vs 2% favored women).

Conclusion

Studies on sex differences in ACS mainly come from high-income regions. Sex differences in ACS management are widely reported and mainly unfavorable to women, especially in the early phases of pre-hospital care and diagnosis.

Importance of Age and Sex in Carotid Artery Plaque Detection and Cardiovascular Disease Risk

Importance

Carotid artery plaque (CAP) is commonly encountered in clinical practice. Presence of CAP predicts future atherosclerotic cardiovascular disease (ASCVD) events; however, CAP prevalence increases with age, and it is unknown how age and sex affect the association of CAP presence and ASCVD risk.

Objectives

To describe CAP prevalence by age, sex, race, and ethnicity in a multiethnic population and to investigate whether the impact of CAP detection on relative ASCVD risk declines with age and differs by sex.

Design, Setting, and Participants

This cohort study examines participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Adults aged 45 to 84 years who were free of clinical ASCVD at recruitment (2000-2002) were included, and follow-up for ASCVD events was conducted through December 2019. Data analysis was performed from July 2023 to April 2024.

Exposure

Presence of CAP.

Main Outcomes and Measures

The primary outcome was ASCVD events (coronary heart disease events, stroke, and ASCVD death). Prevalence of CAP by age, sex, race, and ethnicity was calculated. Cox proportional hazards models with age interaction terms were used to investigate associations of CAP and incident ASCVD events across sexes.

Results

Among 6814 adults in the MESA cohort, 5689 participants had complete data and were included in this analysis. Among these 5689 participants, mean (SD) age was 62.0 (10.2) years, and 3002 participants (53%) were female. The cohort included 1551 Black participants (27%), 687 Chinese participants (12%), 1276 Hispanic participants (22%), and 2165 White participants (38%). In total, participants experienced 1043 ASCVD events over a median (IQR) period of 17.6 (10.5-18.4) years. Prevalence of CAP differed by age, sex, race, and ethnicity, ranging from 15% in Chinese women younger than 50 years to 95% in non-Hispanic White men aged 80 to 84 years. CAP independently predicted ASCVD events (hazard ratio, 1.38; 95% CI, 1.20-1.58; P < .001). The strength of this association was stronger among younger participants (≤60 years) vs older (>60 years) (P for interaction = .01), especially among women (P for interaction = .005) vs men (P for interaction = .66). CAP detection in younger individuals conferred higher relative ASCVD risk than in older participants, who had higher absolute risk regardless of CAP.

Conclusions and Relevance

CAP becomes very common with increasing age among individuals without clinical ASCVD, and the association of CAP with incident ASCVD events was strongest in younger ages, especially among women. These data can help guide ASCVD risk assessment in younger adults and provide perspective when CAP is detected on clinical imaging studies in older adults.

Sex Differences in Psychosocial Factors and Angina in Patients With Chronic Coronary Disease

BACKGROUND

Women with chronic coronary disease have more frequent angina and worse health status than men, despite having less coronary artery disease (CAD). We examined whether perceived stress and depressive symptoms mediate sex differences in angina, and whether this relationship differs in the setting of obstructive CAD or ischemia with no obstructive coronary artery disease (INOCA).

METHODS

We analyzed the association between sex, stress (Perceived Stress Scale-4) and depressive symptoms (Patient Health Questionnaire-8) on angina-related health status (Seattle Angina Questionnaire [SAQ]) at enrollment in the ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial and CIAO-ISCHEMIA (Changes in Ischemia and Angina Over 1 Year Among ISCHEMIA Trial Screen Failures With No Obstructive CAD on Coronary CT [Computed Tomography] Angiography) ancillary study.

RESULTS

Scores for the SAQ, Perceived Stress Scale-4, and Patient Health Questionnaire-8 were available in 1626 participants (N=1439 CAD and N=187 INOCA). Women had lower (worse) SAQ-7 summary scores than men in both CAD and INOCA cohorts (CAD: median 76 [25th, 75th percentiles 60, 90] versus 83 [70, 96], P<0.001; INOCA: 80 [64,89] versus 85 [75, 93], P=0.012). Higher stress and depressive symptoms were associated with worse angina in both cohorts. Female sex, Perceived Stress Scale-4 score, and Patient Health Questionnaire-8 score were each independently associated with lower SAQ summary score, but CAD versus INOCA cohort was not. There was no interaction between sex and stress (-0.39 [95% CI, -1.01 to 0.23]) or sex and depression (-0.00 [95% CI, -0.53 to 0.53]) on SAQ summary score.

CONCLUSIONS

High stress and depressive symptoms were independently associated with worse angina and poorer health status, without interaction with sex with or without obstructive CAD. Factors other than stress or depression contribute to worse health status in women with obstructive CAD or INOCA.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02347215, NCT01471522.

Body Composition Risk Assessment of All-Cause Mortality in Patients With Coronary Artery Disease Completing Cardiac Rehabilitation

BACKGROUND

Obesity, measured by body mass index, is a risk factor for cardiovascular disease. However, the role of body composition, including body fat percentage and lean body mass (LBM), in cardiovascular outcomes has not been well studied in patients with coronary artery disease (CAD). This study aims to evaluate the association of body composition with cardiovascular outcomes and all-cause mortality in patients with CAD.

METHODS AND RESULTS

Body composition was obtained via bioelectrical impedance analysis from 1291 patients with CAD before starting cardiac rehabilitation. Patients were divided into quintiles by body composition and analyzed in total and after sex stratification. All-cause mortality and a composite of major adverse cardiovascular events, including acute coronary syndrome, coronary revascularization, heart failure hospitalization, and stroke, were primary study outcomes. In the total cohort adjusted analyses, body mass index, body fat percentage, and LBM were not predictors of all-cause mortality or major adverse cardiovascular events. In sex-stratified analyses, among women, the third LBM quintile was associated with decreased risk of all-cause mortality compared with the lowest LBM quintile (adjusted hazard ratio, 0.07 [95% CI, 0.01-0.57]; P=0.01). No other body composition variables were associated with all-cause mortality or major adverse cardiovascular events in either sex.

CONCLUSIONS

In women with CAD, moderate LBM was associated with lower mortality when compared with low LBM, whereas body fat percentage and body mass index were not associated with mortality or major adverse cardiovascular events in either sex. Future research studying the implications of changes in body composition on outcomes in men and women with CAD is warranted.

Early Versus Delayed Invasive Management of Female Patients With Non-ST-Elevation Acute Coronary Syndrome: An Individual Patient Data Meta-Analysis

BACKGROUND

Female patients are at greater risk of adverse events following non-ST-elevation acute coronary syndrome but less frequently receive guideline-recommended coronary angiography and revascularization. Routine invasive management benefits high-risk patients, but evidence informing the optimal timing of angiography specifically in female patients is lacking.

METHODS

Medline, Web of Science, and Scopus were searched up to November 2023. Randomized controlled trials investigating early versus delayed timing of coronary angiography in patients with non-ST-elevation acute coronary syndrome were included. Individual patient data from female patients were extracted. The primary end point was a composite of all-cause mortality or myocardial infarction at 6 months. We performed a 1-stage individual patient data meta-analysis using random-effects Cox models.

RESULTS

Six trials contributed individual patient data from 2257 female patients. Median time to coronary angiography was 5 hours in the early invasive group (n=1141) and 49 hours in the delayed invasive group (n=1116). Overall, there was no significant reduction in the risk of the primary end point in the early invasive group compared with the delayed group (hazard ratio, 0.79 [95% CI, 0.60-1.06]; P=0.12). Early invasive management was associated with a reduction in recurrent ischemia (hazard ratio, 0.60 [95% CI, 0.39-0.94]; P=0.025). In the prespecified subgroup analysis, high-risk female patients with Global Registry of Acute Coronary Events score >140 receiving early invasive management experienced a significantly reduced hazard for all-cause mortality or myocardial infarction at 6 months (hazard ratio, 0.65 [95% CI, 0.45-0.94]; P=0.021; Pinteraction=0.035). Similar benefits were observed for female patients with elevated cardiac biomarkers.

CONCLUSIONS

Early invasive management in female patients with non-ST-elevation acute coronary syndrome, compared with delayed invasive management, was not associated with a significant reduction in the hazard for the primary end point. In prespecified subgroup analysis, high-risk female patients as assessed with Global Registry of Acute Coronary Events score >140 or elevated cardiac biomarkers experienced significant reductions in all-cause mortality or myocardial infarction at 6 months following early invasive management.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42023468604.

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

A systematic review of sex and gender differences in treatment outcome of inflammatory skin diseases: Is it time for new guidelines?

BACKGROUND

Gender- and sex-specific differences in medicine were long-time disregarded. Despite numerous indications of gender- and sex-specific influences on the treatment of dermatological conditions, these have not yet been systematically investigated.

OBJECTIVES

To meet this unmet need, we conducted the present systematic review on the topic of gender and sex differences in the treatement outcome of skin diseases.

METHODS

Embase (via Ovid), PubMed Medline and Web of Science were searched, in between January 2001 and December 2022. English and german randomized controlled trials, prospective and retrospective cohorts and case-control studies that examined differences between men and women in treatment outcomes of skin diseases were included.

RESULTS

Two authors independently screened the reports for eligibility, one extracted all data (the second double-checked) and critically appraised the quality and risk of bias of the studies. Eighty-three reports were included. The largest share of the identified publications focused on gender differences in psoriasis and psoriatic arthritis (n = 49), followed by melanoma (n = 8) and sporadic studies (n < 5) of inflammatory, infectious and autoimmune skin diseases. The main topics in which gender differences could be identified were choice of treatment, time to initiation of treatment, therapy response, adverse events, adherence and treatment satisfaction. For psoriasis, gender differences could be found in all aspects, while for the other skin diseases specific publications on gender differences are still missing.

CONCLUSIONS

This systematic review shows numerous gender differences but also reveals major gaps in gender-specific care in dermatology which should be narrowed in the upcoming years to optimize a patient-centred, individualized, gender-equal healthcare. PROSPERO Registration: CRD42022306626.

Optimism mitigated impacts of pre-operative depression and anxiety on post-operative distress in cardiac patients

Both anxiety and depression are comorbid mortality risks in middle-aged and older patients with heart diseases. Open-heart surgery (OHS), a life-altering procedure, can induce psychological distress that impedes postoperative recovery. Extensive research has shown the health benefit of optimism, an indicator of hope-a Character Strength in positive psychology. It predicts low mortality in cardiovascular disease-the number one killer of all Americans. Few studies, however, have explored whether that optimism mitigates the negative impact of preoperative depression and anxiety on postoperative general psychological distress. This interdisciplinary clinical study evaluated a hypothetical model of these relationships prior to and 1 month following OHS in 311 U.S. patients using a three-wave survey. Structural equation modeling (SEM) was performed to predict post-OHS general psychological distress. Optimism was indicated by two subscales in the Life Orientation Test (LOT). Based on the definition, general psychological distress was indicated by low symptom levels of somatization, depression, and anxiety as measured by the SCL-90 subscales. The final solution demonstrated a good fit. Optimism alleviates the negative effects of preoperative depression and anxiety, as indicators of poor mental health, on postoperative distress. Both older age and female gender were positively and directly associated with higher levels of post-OHS symptoms. The finding supports the beneficial role of optimism in mitigating the damage of poor mental health in the postoperative outcome of cardiac patients. The desirable function of character strength hope suggests that health providers should be attentive to and enhance inner strength for reducing the distress of cardiac patients in the postoperative recovery month.

Survival rate and readmission rate after the first episode of myocardial infarction

The aim is to estimate the overall one-year survival rate and readmission rate after the first myocardial infarction. A cohort study involving 689 patients followed up between August 2016 and March 2022. The Kaplan-Meier estimator and the log-rank test were used. Cox semiparametric model was used to estimate death and readmission risk. The mean age was 60.0 (SD 11.0) years old, 67.9% men and 50.7% with ST-elevation myocardial infarction. The overall survival rate was 96.3%, with median time of death of 41.5 days. The readmission-free survival rate was 83.4%, with median time of readmission of 54 days. Age of 60 years and over increased death risk by 10.01 and the presence of systemic arterial hypertension increased readmission risk by 1.52. The overall survival rate was 96.2% with difference in age groups. The readmission-free survival rate was 83.4%, with difference by the presence of systemic arterial hypertension. As these events are quite prevalent, a better assessment of the effectiveness of the health care provided and the actions that must be taken to reduce the incidence and consequent morbidity and mortality is necessary.

Toxic stress is associated with cardiovascular disease among younger but not older women in the United States: Results from the research goes red registry

Introduction

Psychosocial stress may be an under-recognized risk factor for cardiovascular disease among younger women (ages 35-54 years).

Methods

Data was obtained from the Research Goes Red Registry, initiated in 2019, and included women from the United States. Women self-reported diagnoses of cardiovascular disease and experiences of toxic stress defined as a significant life-defining stressful activity over a prolonged period unaccompanied by sufficient social resources. Logistic regression models were used to estimate odds ratios between toxic stress and cardiovascular disease and differences by age (< 55 versus ≥ 55 years of age) using an interaction term.

Results

The analytic dataset included 1346 women. The mean age of women was 47.8 (SD: 12.6), 71 % were less than 55 years of age, 83 % were Non-Hispanic White, 59 % indicated that they had experienced toxic stress, and 12 % had cardiovascular disease. In final multivariable models, there were significant differences in the association between toxic stress and cardiovascular disease by age group (toxic stress-by-age interaction = 0.0412) such that toxic stress was only significantly associated with an increased odds of cardiovascular disease among women < 55 years of age (OR: 1.79; 95 % CI: 1.03, 3.11) but not older women ≥ 55 years of age (OR: 0.82; 95 % CI: 0.49, 1.39).

Conclusion

Toxic stress was associated with an increased odds of cardiovascular disease among younger, but not older women in this cross-sectional study. Stress may be an under-recognized risk factor for cardiovascular disease, especially among younger women who may benefit from interventions to mitigate and prevent stress.

Underpinnings of Heart Failure With Preserved Ejection Fraction in Women - From Prevention to Improving Function. A Co-publication With the American Journal of Preventive Cardiology and the Journal of Cardiac Failure

Heart failure with preserved ejection fraction (HFpEF) represents a major clinical challenge with rising global prevalence. Women have a nearly double lifetime risk of developing HFpEF compared to heart failure with reduced ejection fraction (HFrEF). In HFpEF, sex differences emerge both in how traditional cardiovascular risk factors (such as hypertension, obesity, and diabetes) affect cardiac function and through distinct pathophysiological mechanisms triggered by sex-specific events like menopause and adverse pregnancy outcomes. These patterns influence not only disease development, but also therapeutic responses, necessitating sex-specific approaches to treatment. This review aims to synthesize existing knowledge regarding HFpEF in women including traditional and sex-specific risk factors, pathophysiology, presentation, and therapies, while outlining important knowledge gaps that warrant further investigation. The impact of HFpEF spans a woman's entire lifespan, requiring prevention and management strategies tailored to different life stages. While understanding of sex-based differences in HFpEF has improved, significant knowledge gaps persist. Through examination of current evidence and challenges, this review highlights promising opportunities for innovative research, therapeutic development, and clinical care approaches that could transform the management of HFpEF in women.

Cardiomyocytes in Hypoxia: Cellular Responses and Implications for Cell-Based Cardiac Regenerative Therapies

Myocardial infarction (MI) is a severe hypoxic event, resulting in the loss of up to one billion cardiomyocytes (CMs). Due to the limited intrinsic regenerative capacity of the heart, cell-based regenerative therapies, which feature the implantation of stem cell-derived cardiomyocytes (SC-CMs) into the infarcted myocardium, are being developed with the goal of restoring lost muscle mass, re-engineering cardiac contractility, and preventing the progression of MI into heart failure (HF). However, such cell-based therapies are challenged by their susceptibility to oxidative stress in the ischemic environment of the infarcted heart. To maximize the therapeutic benefits of cell-based approaches, a better understanding of the heart environment at the cellular, tissue, and organ level throughout MI is imperative. This review provides a comprehensive summary of the cardiac pathophysiology occurring during and after MI, as well as how these changes define the cardiac environment to which cell-based cardiac regenerative therapies are delivered. This understanding is then leveraged to frame how cell culture treatments may be employed to enhance SC-CMs' hypoxia resistance. In this way, we synthesize both the complex experience of SC-CMs upon implantation and the engineering techniques that can be utilized to develop robust SC-CMs for the clinical translation of cell-based cardiac therapies.

Neighborhood disorder and social cohesion: A longitudinal investigation of links with maternal cardiometabolic risk one year postpartum

OBJECTIVE

Neighborhood characteristics can influence cardiometabolic health, including during the perinatal period. However, maternal health research has largely examined the influence of objective neighborhood measures, limiting insights into psychological and social processes. We examined associations of perceived neighborhood disorder and social cohesion with maternal cardiometabolic risk 1 year postpartum and explored potential pathways of psychological distress and physical activity.

METHODS

A predominantly low-income sample of Black, Latina, and White postpartum women (n = 987) were participants in the Community Child Health Network study. Women reported on neighborhood characteristics at 1 month postpartum and on symptoms of depression, anxiety, and posttraumatic stress disorder and physical activity at 6 months postpartum. Biometrics and biological samples were collected at 1 year postpartum, including blood pressure, height, weight, and dried blood spots for cardiometabolic biomarkers (e.g., C-reactive protein, glycosylated hemoglobin). In this pre-registered study, we used structural equation modeling to estimate latent variables for disorder, social cohesion, distress, physical activity, and cardiometabolic risk. We fit a parallel mediation model to test associations between latent neighborhood factors at 1 month postpartum, distress and physical activity at 6 months postpartum, and cardiometabolic risk at 1 year postpartum.

RESULTS

Greater social cohesion, but not disorder, was significantly associated with lower distress and greater physical activity. However, there were no significant associations between disorder or social cohesion with subsequent cardiometabolic risk nor evidence for indirect effects of distress or physical activity.

CONCLUSION

Results suggest that social cohesion may be more pertinent than disorder for health-relevant behavioral mechanisms in postpartum women.

Assessing the Likelihood of Procedural Intubation During Percutaneous Coronary Intervention

BACKGROUND

Preprocedural fasting is widely used before percutaneous coronary intervention (PCI). However, the incidence of procedural intubation during PCI is unknown. This study aims to identify the incidence and predictors for procedural intubation during PCI.

METHODS AND RESULTS

A retrospective cohort study was performed on patients undergoing PCI between 2014 and 2021 within the Victorian Cardiac Outcomes Registry. Patients were classified into urgent, semiurgent, or elective PCI on the basis of recorded PCI indication. Those undergoing semiurgent or elective PCI were presumed to be fasted preprocedurally. The incidence of procedural intubation was reported for each PCI group. Inverse probability treatment weighting was used to determine the association between 30-day death and procedural intubation. Logistic regression was performed to determine clinical, procedural, and lesion characteristics associated with procedural intubation among fasted patients. Among 83 929 patients, the incidence of procedural intubation was 0.5%. Patients undergoing urgent PCI (odds ratio [OR], 19.68 [95% CI, 13.91-27.86]; P<0.01) had the highest risk of procedural intubation. Procedural intubation was associated with increased 30-day death (OR, 4.79 [95% CI, 3.29-6.96]; P<0.01). Among fasted patients, estimated glomerular filtration rate (OR, 0.99 [95% CI, 0.98-0.99]; P<0.01), cardiogenic shock (OR, 96.24 [95% CI, 56.01-165.35]; P<0.01), out-of-hospital cardiac arrest (OR, 3.42 [95% CI, 1.30-8.97]; P=0.01), femoral access (OR, 2.09 [95% CI, 1.38-3.19]; P<0.01), left main disease (OR, 5.77 [95% CI, 3.16-10.54]; P<0.01), type C lesions (OR, 3.86 [95% CI, 1.19-12.56]; P=0.03), and rotational atherectomy (OR, 2.20 [95% CI, 1.03-4.69]; P=0.04) were associated with procedural intubation.

CONCLUSIONS

Despite an association with a worse 30-day mortality rate, the incidence of procedural intubation during PCI was low. Universal preprocedural fasting may be unnecessary and could be targeted at higher-risk groups.

Awareness for the risk of adverse outcomes of female patients after ST-segment elevation acute coronary syndrome

INTRODUCTION

Women increased risk of early mortality following ST-segment elevation myocardial infarction (STEMI) has been attributed to older age, more comorbidities, and less primary revascularization (PCI). Data on long-term outcomes is conflicting, and younger patients' specific evidence is limited.

PURPOSE

Compare gender outcomes following STEMI within a cohort of younger (≤55 years) and older (>55 years) individuals.

METHODS

Retrospective analysis of consecutive patients with STEMI who underwent PCI within 48 h of symptom onset, between 2010 and 2015. Adverse outcomes were defined as 30-day, 1-year and 5-year all-cause mortality, and 5-year MACE. Propensity score matching for age, CV risk factors, and prior CV disease aimed to establish a well-balanced subset of male and female individuals.

RESULTS

Among 882 patients, 26.8 % were females. Women were older and had higher clinical severity. Although clinical and PCI success were similar, over a mean follow-up of 91 months, women demonstrated nearly three times the risk of 30-day mortality (10.4 % vs 3.7 %, HR 2.88; p ≤0.001) and double the risk of 5-year death (31.9 % vs 17.0 %, HR 2.07; p < 0.001) and MACE (39.0 % vs 17.6 %, HR 1.95; p < 0.001). Sex differences in the younger subgroup were seen for 1-year (HR 3.74, p < 0.001), and long-term outcomes: HR 2.20 (p = 0.05) for 5-year mortality; HR 2.10 (p = 0.027) for 5-year MACE. After propensity matching, sex remained an independent predictor of adverse outcomes.

CONCLUSIONS

Females showed more CV events following STEMI, even after adjusting for potential confounders. These findings raise awareness for women risk and the need for strict post-STEMI surveillance.

Exposure to specific polyfluoroalkyl chemicals is associated with cardiovascular disease in US adults: a population-based study

Background

Polyfluoroalkyl chemicals (PFCs) present potential health risks due to their persistence and bioaccumulation. However, there is currently insufficient evidence regarding their impact on cardiovascular disease (CVD). Consequently, it is imperative to investigate the correlation between PFCs and CVD.

Methods

The data was collected from National Health and Nutrition Examination Survey in 2005-2012. Logistic regression models were employed to assess the association between single PFC and CVD. Generalized additive model (GAM) was used for evaluating nonlinear relationships. Subgroup analyses were conducted to explore interaction effects. Bayesian kernel machine regression (BKMR) and weighted quantile sum (WQS) models were used to evaluate the joint effect of PFC exposures on CVD.

Results

In logistic regression, PFDE, MPAH, and PFUA were positively associated with CVD. In the GAM, there was a significant nonlinear relationship between MPAH and CVD. Subgroup analysis revealed the interaction of gender and race in the effects of PFCs and CVD. PFUA was positively correlated with CVD in males but show no significant difference in females. PFDE was positively associated with CVD among non-Hispanic white individual. The results of BKMR indicated that the impact of mixed PFCs on CVD increased initially and then weakened, showing an overall positive trend. The results of WQS suggested that PFDO contributed most to the effect.

Conclusion

Our study showed that serum PFDE, MPAH, and PFUA levels were positively correlated with CVD. PUFA was found to interact with gender and race in relation to CVD. A general positive correlation exists between mixed exposure to PFCs and CVD, with PFDO being the most contributory PFC. Our study provided important evidence for probing the impact of PFCs on CVD and laid a foundation for further mechanism research.

Sex Differences in Procedural Characteristics and Clinical Outcomes Among Patients Undergoing Bifurcation PCI

BACKGROUND AND OBJECTIVES

The risk profiles, procedural characteristics, and clinical outcomes for women undergoing bifurcation percutaneous coronary intervention (PCI) are not well defined compared to those in men.

METHODS

COronary BIfurcation Stenting III (COBIS III) is a multicenter, real-world registry of 2,648 patients with bifurcation lesions treated with second-generation drug-eluting stents. We compared the angiographic and procedural characteristics and clinical outcomes based on sex. The primary outcome was 5-year target lesion failure (TLF), a composite of cardiac death, myocardial infarction, and target lesion revascularization.

RESULTS

Women (n=635, 24%) were older, had hypertension and diabetes more often, and had smaller main vessel and side branch reference diameters than men. The pre- and post-PCI angiographic percentage diameter stenoses of the main vessel and side branch were comparable between women and men. There were no differences in procedural characteristics between the sexes. Women and men had a similar risk of TLF (6.3% vs. 7.1%, p=0.63) as well as its individual components and sex was not an independent predictor of TLF. This finding was consistent in the left main and 2 stenting subgroups.

CONCLUSIONS

In patients undergoing bifurcation PCI, sex was not an independent predictor of adverse outcome.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03068494.

Bibliometric analysis of ST elevation myocardial infarction research from 1933 to 2023: Focus on top 100 most-cited articles

The primary objective of this study was to conduct a bibliometric analysis of the most influential papers on ST-Elevation Myocardial Infarction (STEMI). Using the Scopus database (October 2024), a targeted search was performed to identify relevant publications. Three retrieval options were considered based on the appearance of search terms. Precisely those documents were analyzed where the search terms appeared only in the title, allowing for a focused analysis of the most directly relevant studies. Next, from this search, the top 100 most cited papers, spanning from 1981 to 2018, were selected for detailed examination. Data analysis was conducted using VOSviewer and R Studio to provide insights into publication trends, author productivity, and the thematic focus of STEMI research. Author performance was evaluated through various bibliometric indicators, including total publications (TP), total citations (TC), h-index, g-index, m-index, HG composite, and Q2 index. Key metrics such as mean total citations per article (MeanTCperArt) and mean annual citation rate (MeanTCperYear) were also calculated. Thematic analysis of research topics was conducted using unigrams, bigrams, and trigrams, highlighting primary areas of focus across the most impactful STEMI studies. The results underscore significant trends in STEMI research, with highly cited papers shaping the field's evolution. This bibliometric approach provides valuable insights into research patterns, major contributors, and prevalent themes within STEMI literature.

Sex-Specific Troponin and Creatine Kinase Thresholds After Coronary Bypass Surgery

BACKGROUND

The impact of sex-differences on the release of cardiac biomarkers after coronary artery bypass grafting (CABG) remains unknown. The aim of our study was to (1) investigate the impact of sex-differences in cardiac biomarker release after CABG and (2) determine sex-specific thresholds for high-sensitivity cardiac troponin (hs-cTn) and creatine kinase-myocardial band (CK-MB) associated with 30-day major adverse cardiovascular events (MACE) and mortality.

METHODS

A consecutive cohort of 3687 patients, comprising 643 women (17.4%) and 3044 men (82.6%), undergoing CABG from 2008 to 2021 in 2 tertiary university centers with serial postoperative cTn and CK-MB measurement was analyzed. The composite primary outcome was MACE at 30 days. Secondary end points were 30-day mortality and 5-year mortality and MACE. Sex-specific thresholds for cTn and CK-MB were determined.

RESULTS

Lower levels of cTn were found in women after CABG (69.18 vs 77.57 times the upper reference limit [URL]; P < .001). The optimal threshold value for cTn was calculated at 94.36 times the URL for female patients and 206.07 times the URL for male patients to predict 30-day MACE. Female patients missed by a general threshold had increased risk for MACE or death within 30 days (cTn: MACE: odds ratio [OR], 3.78; 95% CI, 1.03-13.08; P = .035; death: OR, 4.98; 95% CI, 1.20-20.61; P = .027; CK-MB: MACE: OR, 10.04; 95% CI, 2.07-48.75; P < .001; death: OR 13.59; 95% CI, 2.66-69.47; P = .002).

CONCLUSIONS

We provide evidence for sex-specific differences in the outcome and biomarker release after CABG. Sex-specific cutoffs are necessary for the diagnosis of perioperative myocardial injury to improve outcomes of women after CABG.

The Clinical Approach to Angina in Women

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

Sex-specific outcomes in acute myocardial infarction-associated cardiogenic shock treated with and without V-A ECMO: a retrospective German nationwide analysis from 2014 to 2018

Acute myocardial infarction-associated cardiogenic shock (AMICS) remains a condition with high mortality. Some patients require mechanical circulatory support (MCS) as their condition deteriorates. Sex-specific differences in risk factors and outcomes of cardiovascular disease have previously been described but are inconclusive regarding the use of MCS in AMICS. We aimed to investigate these with a focus on long-term outcomes. Health claim data from AOK - Die Gesundheitskasse (local health care funds) for patients hospitalized with AMICS between January 1, 2014, and December 31, 2015, was descriptively analyzed. Then, a Cox proportional hazards model was used to adjust for confounders. We analyzed 10,023 patients, of which 477 (4.8%) were treated with veno-arterial extra-corporeal membrane oxygenation (V-A ECMO). In-hospital mortality was high, but similar between treatments (V-A ECMO 59.1%, no V-A ECMO 56.6%). Women had a higher median age (78.9 years, IQR 13.8 vs. 71.8 years, IQR 17.9; p < 0.001), a different cardiovascular risk profile and in the conservatively treated patients underwent revascularization less often (69.2% vs. 77.1%; p < 0.001) than men did. In a multivariate analysis, female sex was not associated with lower survival (HR 1.03, CI 0.98-1.09; p = 0.233). V-A ECMO, however, was associated with lower survival in both sexes. We observed a low overall survival in follow-up after three years (no V-A ECMO: men 28.9% vs. women 21.7%, V-A ECMO: men 18.2% vs. women 17.0%). In conclusion, women with AMICS presented with a different risk profile, especially a higher age, and underwent guideline-recommended therapies such as revascularization less often than men. Female sex, however, was not associated with lower survival in a multivariate analysis. In-hospital mortality was high, regardless of treatment, and V-A ECMO was associated with lower survival in follow-up.

Mammographic Vascular Microcalcifications as a Surrogate Parameter for Coronary Heart Disease: Correlation to Cardiac Computer Tomography and Proposal of a Classification Score

OBJECTIVE

This study develops a BI-RADS-like scoring system for vascular microcalcifications in mammographies, correlating breast arterial calcification (BAC) in a mammography with coronary artery calcification (CAC), and specifying differences between microcalcifications caused by BAC and microcalcifications potentially associated with malignant disease.

MATERIALS AND METHODS

This retrospective single-center cohort study evaluated 124 consecutive female patients (with a median age of 57 years). The presence of CAC was evaluated based on the Agatston score obtained from non-enhanced coronary computed tomography, and the calcifications detected in the mammography were graded on a four-point Likert scale, with the following criteria: (1) no visible or sporadically scattered microcalcifications, (2) suspicious microcalcification not distinguishable from breast arterial calcification, (3) minor breast artery calcifications, and (4) major breast artery calcifications. Inter-rater agreement was assessed in three readers using the Fleiss' kappa, and the correlation between CAC and BAC was evaluated using the Spearman's rank-order and by the calculation of sensitivity/specificity.

RESULTS

The reliability of the visual classification of BAC was high, with an overall Fleiss' kappa for inter-rater agreement of 0.76 (ranging between 0.62 and 0.89 depending on the score). In 15.1% of patients, a BAC score of two was assigned indicating calcifications indistinguishable regarding vascular or malignant origin. In 17.7% of patients, minor or major breast artery calcifications were found (BAC 3-4). BAC was more prevalent among the patients with CAC (p < 0.001), and the severity of CAC increased with the BAC score; in the group with a BAC score of one, 15% of patients exhibited mild and severe CAC, in those with a BAC of two, this was 31%, in those with BAC of three, this was 38%, and in those with a BAC of four, this was 44%. The sensitivity for detecting CAC, based on the mammographic BAC score, was 30.3% at a specificity of 96.7%.

CONCLUSIONS

The standardized visual grading of BAC in mammographies on a four-point scale is feasible with substantial interobserver agreement, potentially improving the treatment of patients with suspicious microcalcifications and CAC.

Sex-Related Differences in Outcome of Patients Treated With Microaxial Percutaneous Left Ventricular Assist Device for Cardiogenic Shock

BACKGROUND

The use of microaxial percutaneous left ventricular assist devices (pLVADs) in cardiogenic shock (CS) has increased in recent years, despite limited evidence, and data on sex disparities are particularly scarce. This study aimed to compare short-term outcomes between males and females.

METHODS

Data were retrospectively collected from the Dresden Impella Registry, which is a large, prospective, single-centre registry that consecutively enrolled patients who received microaxial pLVAD. Inclusion criteria were CS due to left ventricular failure with serum lactate >4 mM. Patients with pLVAD other than Impella CP were excluded. The primary endpoint was the composite of all-cause mortality at 30 days or requirement of renal replacement therapy (RRT). Secondary endpoints were the components of the primary endpoint alone. Propensity score matched (PSM) analysis was used to adjust for baseline characteristics.

RESULTS

A total of 319 male (69 years; body mass index, 26.7 kg/m2) and 113 female patients (74 years; 27.9 kg/m2) were included in the study. The primary composite endpoint occurred less frequently in female patients in the unmatched analysis (♂ 75.9% [n=239] vs ♀ 64.4% [n=72]; p=0.040) but not in the PSM analysis (♂ 81.1% [n=73] vs ♀ 68.9% [n=42]; p=0.056). However, females less frequently required RRT in both analyses (♂ 48.2% [n=126] vs ♀ 25.9% [n=25]; p=0.001; PSM: ♂ 49.1% [n=36] vs ♀ 23.3% [n=12]; p=0.007). All-cause mortality did not differ between the cohorts.

CONCLUSIONS

This study showed no differences in all-cause mortality at 30 days between male and female patients receiving microaxial pLVAD in CS. Larger studies are required to confirm whether female sex is associated with reduced requirement of RRT in CS treated with microaxial pLVAD.

Evaluation of a nomogram model for predicting in-hospital mortality risk in patients with acute ST-elevation myocardial infarction and acute heart failure post-PCI

OBJECTIVES

This study aims to identify the risk factors contributing to in-hospital mortality in patients with acute ST-elevation myocardial infarction (STEMI) who develop acute heart failure (AHF) post-percutaneous coronary intervention (PCI). Based on these factors, we constructed a nomogram to effectively identify high-risk patients.

METHODS

In the study, a collective of 280 individuals experiencing an acute STEMI who then developed AHF following PCI were evaluated. These subjects were split into groups for training and validation purposes. Utilizing lasso regression in conjunction with logistic regression analysis, researchers sought to pinpoint factors predictive of mortality and to create a corresponding nomogram for forecasting purposes. To evaluate the model's accuracy and usefulness in clinical settings, metrics such as the concordance index (C-index), calibration curves, and decision curve analysis (DCA) were employed.

RESULTS

Key risk factors identified included blood lactate, D-dimer levels, gender, left ventricular ejection fraction (LVEF), and Killip class IV. The nomogram demonstrated high accuracy (C-index: training set 0.838, validation set 0.853) and good fit (Hosmer-Lemeshow test: χ2 = 0.545, p = 0.762), confirming its clinical utility.

CONCLUSION

The developed clinical prediction model is effective in accurately forecasting mortality among patients with acute STEMI who develop AHF after PCI.

Diagnostic delays in familial Mediterranean fever: a Juvenile Inflammatory Rheumatism (JIR) cohort study

Several studies reported that Familial Mediterranean Fever (FMF) diagnosis may be missed or delayed even in countries with a high FMF prevalence. Our aim was to study on a large cohort of European FMF patients the frequency and associated factors of diagnosis delay. Clinical data were extracted from the Juvenile Inflammatory Rheumatism (JIR)-cohort. All FMF patients fulfilled Livneh Criteria and had been sequenced for MEFV exon 10. FMF-diagnostic delay (d-FMF) was defined as the duration between the onset of the symptoms and the diagnosis of more than 10 years. 960 FMF patients were enrolled: delayed diagnosis (d-FMF) was noted in 200 patients (20%). d-FMF patients were significantly older compared to non d-FMF with a median age of 46.4 years old vs. 15.5 (p < 0.0001). Women displayed more d-FMF compared to men (56 vs. 47%, p = 0.03). Clinical presentation during attacks was not statistically significant except for erysipelas-like erythema, which was higher among d-FMF patients (33 vs. 22%, p = 0.0003). The presence of one or two pathogenic MEFV mutation was not different between patients. Compared to other FMF, d-FMF patients displayed significantly more AA amyloidosis (10 vs. 2.6%, p < 0.0001) and received more biotherapy (18 vs. 3.8%, p < 0.0001). Twenty percent of FMF patients had a diagnostic delay >10 years, including more women. The differential diagnosis of abdominal attacks with menstrual pain may be an explanation, and erysipelas-like erythema may not be recognized as FMF by all practitioners.

The impact of breast cancer radiation therapy exposure on the prevalence of breast arterial calcification

OBJECTIVES

Mammographic breast arterial calcification (BAC) is an emerging imaging biomarker of cardiovascular disease (CVD) risk in women. The purpose of this study was to assess if breast radiation therapy (RT) exposure impacts the screening utility of this imaging biomarker.

METHODS

This cross-sectional study included women ages 40-75 years who underwent index screening mammography between January 1, 2011 and December 31, 2012. Chart review was performed to extract data on the breast cancer RT exposure and CVD risk factors. Mammograms were reviewed for the presence of BAC. Multivariate logistic regression was used to examine breast RT exposure and BAC, with adjustment for age, body mass index, smoking status, hypertension, Type 2 diabetes, statin medication use, and antihypertensive medication use.

RESULTS

Of the 1155 women included in this analysis, 222 (19.2%) had mammographic evidence of BAC, 122 (10.6%) had a history of RT exposure, and 39 (32%) women with RT exposure had mammographic BAC. Women with breast RT exposure had higher odds of BAC compared to women without (odds ratio: 2.18, 95% CI: 1.43, 3.28; P-value = .0008). However, this association became non-significant after multivariable adjustment, with the maximally adjusted model demonstrating an odds ratio of 1.52 (95% CI: 0.95, 2.40; P-value = .07).

CONCLUSIONS

Our findings suggest that breast RT exposure does not impact the prevalence of mammographic BAC. Therefore, it does not affect its utility as an imaging biomarker of CVD risk.

ADVANCES IN KNOWLEDGE

This is the first observational study addressing the knowledge gap pertaining to the influence of breast RT exposure on BAC.

Evaluating the diagnostic potential of SOCS3 in copper metabolism for acute myocardial infarction

Acute myocardial infarction (AMI) represents a critical cardiovascular condition necessitating rapid and precise diagnostic strategies. This study investigates the diagnostic implications of genes involved in copper metabolism homeostasis in AMI. We identified genes related to copper metabolism and AMI from Genecards and GEO databases, conducting differential gene analysis via R software. Gene function was annotated through Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses, while the STRING database facilitated key gene identification via topological analysis. The diagnostic value of these genes, particularly cytokine signaling 3 (SOCS3), was assessed using ROC curve analysis. SOCS3 expression was validated using in-vitro and in-vivo models, including cardiomyocyte hypoxia/reoxygenation (H/R) and rat myocardial infarction (MI) model. Further, we examined the effects of SOCS3 knockout on cell proliferation, apoptosis, and myocardial infarction severity. 77 genes were identified, with 73 showing upregulation and 4 downregulation. These genes mainly participated in pathways related to cytokine activation, inflammation regulation, and lipid metabolism. Network analysis highlighted 10 key genes, with SOCS3 exhibiting significant diagnostic potential (AUC > 0.9). Validation experiments confirmed SOCS3 overexpression in disease models, with its knockout leading to decreased apoptosis, reduced infarct size, and improved cardiac function. This study highlights the diagnostic relevance of genes associated with copper metabolism, particularly SOCS3, in AMI. These findings offer novel insights into the molecular mechanisms of AMI, supporting the development of targeted diagnostic and therapeutic strategies.

Effect of patient gender on the decision of ceiling of care: an European study of emergency physicians' treatment decisions in simulated cases

BACKGROUND AND IMPORTANCE

Gender bias in healthcare can significantly influence clinical decision-making, potentially leading to disparities in treatment outcomes. This study addresses the impact of patient gender on the decision-making process for establishing a ceiling of care in emergency medicine, particularly the decision to limit tracheal intubation.

OBJECTIVE

To determine whether patient gender influences emergency physicians' decisions regarding the recommendation for tracheal intubation in critically ill patients.

DESIGN

A European survey-based study was conducted using a standardized clinical scenario to assess physicians' decisions in a controlled setting.

SETTINGS AND PARTICIPANTS

The survey targeted European emergency physicians over a 2-week period in April 2024. A total of 3423 physicians participated, with a median age of 40 years and a distribution of 46% women. Physicians were presented with a clinical vignette of a 75-year-old patient in acute respiratory distress. The vignettes were randomized to vary only by the patient's gender (woman/man) and level of functional status: (1) can grocery shop alone, (2) cannot grocery shop alone but can bathe independently, or (3) cannot perform either task independently.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was the recommendation for intubation, with secondary analyses exploring the influence of patient functional status levels. Multivariable logistic regression was used to adjust for potential confounders, including physician gender, age, experience, and practice setting.

MAIN RESULTS

A total of 3423 physicians responded, mostly from France, Spain, Italy, and the UK (1,532, 494, 247, and 245 respectively). Women patients were less likely to be intubated compared to male patients [67.9% vs. 71.7%; difference 3.81%; 95% confidence interval (CI), 0.7-6.9%]. The likelihood of recommending intubation decreased with lower levels of patient functional status. Women physician gender was also associated with a reduced likelihood of recommending intubation.

CONCLUSION

This study suggests a significant gender-based disparity in emergency care decision-making, with women patients being less likely to receive recommendations for intubation. However, these results should be interpreted with caution due to potential limitations in the representativity of respondents and the uncertain applicability of survey responses to real-life clinical practice.

Incorporating equity, diversity, and inclusion into the epidemiology and biostatistics curriculum: A workshop report and implementation strategies recommendations

There is an obligation among those teaching epidemiology to incorporate principles of equity, diversity, and inclusion (EDI) into the curriculum. While there is a well-established literature related to teaching epidemiology, this literature rarely addresses critical aspects of EDI. To our knowledge, there is no working group or central point of discussion and learning for incorporating EDI into epidemiology teaching in Canada. To address this gap, we convened a workshop entitled "Incorporating EDI into the epidemiology and biostatistics curriculum and classroom." The workshop discussed nine strategies to incorporate EDI in the epidemiology curriculum: positionality (or reflexivity) statements; opportunities for feedback; land acknowledgements; clarifying the purpose of collecting data on race and ethnicity, sex and gender, Indigeneity; acknowledging that race/ethnicity is a social construct, not a biological variable; describing incidence and prevalence of disease; demonstrating explicit bias using directed acyclic graphs (DAGs); critical appraisal of study population diversity; and admission criteria and considerations. Key take-aways from the workshop were the need to be more intentional when determining the validity of evidence, particularly with respect to historical context and the need to recognize that there is no single solution that will address EDI.

The Gut-Heart Axis: Molecular Perspectives and Implications for Myocardial Infarction

Myocardial infarction (MI) remains the leading cause of death globally, imposing a significant burden on healthcare systems and patients. The gut-heart axis, a bidirectional network connecting gut health to cardiovascular outcomes, has recently emerged as a critical factor in MI pathophysiology. Disruptions in this axis, including gut dysbiosis and compromised intestinal barrier integrity, lead to systemic inflammation driven by gut-derived metabolites like lipopolysaccharides (LPSs) and trimethylamine N-oxide (TMAO), both of which exacerbate MI progression. In contrast, metabolites such as short-chain fatty acids (SCFAs) from a balanced microbiota exhibit protective effects against cardiac damage. This review examines the molecular mediators of the gut-heart axis, considering the role of factors like sex-specific hormones, aging, diet, physical activity, and alcohol consumption on gut health and MI outcomes. Additionally, we highlight therapeutic approaches, including dietary interventions, personalized probiotics, and exercise regimens. Addressing the gut-heart axis holds promise for reducing MI risk and improving recovery, positioning it as a novel target in cardiovascular therapy.

Prognostic impact of high-intensity lipid-lowering therapy under-prescription after acute myocardial infarction in women

AIMS

Women are less likely to receive lipid-lowering therapy (LLT) after acute myocardial infarction (AMI). We analysed whether this under-prescription currently persists and has an impact on long-term outcomes.

METHODS AND RESULTS

The FAST-MI programme consists of nationwide registries including all patients admitted for AMI ≤ 48 h from onset over a 1 month period in 2005, 2010, and 2015, with long-term follow-up. This analysis focused on high-intensity LLT (atorvastatin ≥ 40 mg or equivalent, or any combination of statin and ezetimibe) in women and men. Women accounted for 28% (N = 3547) of the 12 659 patients. At discharge, high-intensity LLT was significantly less prescribed in women [54 vs. 68% in men, P < 0.001, adjusted odds ratio (OR) 0.78(95% confidence interval (CI) 0.71-0.87)], a trend that did not improve over time: 2005, 25 vs. 35% (P = 0.14); 2010, 66 vs. 79% (P < 0.001); 2015, 67 vs. 79.5% (P = 0.001). In contrast, female sex was not associated with a lack of other recommended treatments at discharge: beta-blockers [adjusted OR 0.98(95% CI 0.88-1.10), P = 0.78], or renin-angiotensin blockers [adjusted OR 0.94(95% CI 0.85-1.03), P = 0.18]. High-intensity LLT at discharge was significantly associated with improved 5 year survival and infarct- and stroke-free survival in women [adjusted hazard ratios (HR) 0.74(95% CI 0.64-0.86), P < 0.001 and adjusted HR: 0.81(95% CI: 0.74-0.89); P < 0.001, respectively]. Similar results were found using a propensity score-matched analysis [HR for 5 year survival in women with high-intensity LLT: 0.82(95% CI 0.70-0.98), P = 0.03].

CONCLUSION

Women suffer from a bias regarding the prescription of high-intensity LLT after AMI, which did not attenuate between 2005 and 2015, with potential consequences on both survival and risk of cardiovascular events.

Prevalence of Cardiac Arrhythmias in Transgender and Nonbinary Adult Community Health Center Patients

Purpose: Sex differences in cardiac arrhythmias are well established. This study aimed to explore the prevalence of arrhythmias in transgender and nonbinary (TGNB) adults. Methods: This cross-sectional study utilized electronic medical records from a center specializing in TGNB care. Adults aged ≥18 years with ≥2 medical visits between January 1, 2010, and December 31, 2021, were categorized into self-reported gender groups: TGNB (transgender men, transgender women, nonbinary [NB]-assigned male at birth, NB-assigned female at birth), cisgender men, and cisgender women. The primary outcome was any arrhythmia using age- and race-adjusted regression models comparing transgender patients with cisgender men and cisgender women. Prevalence of arrhythmias was explored in transgender people with a gender-affirming hormone therapy (GAHT) prescription. Results: The sample included 49,862 adults, with 7121 (14%) TGNB persons. Median age was 28 years. Prevalence of arrhythmias was low (0.7-1.4% NB persons, 1.4-1.5% transgender persons). After adjustment, transgender women and transgender men had similar odds of any arrhythmia compared with cisgender men (transgender women: adjusted odds ratio [aOR] 0.89, 95% confidence interval [CI] 0.63-1.24, p = 0.52; transgender men: aOR 1.17, 95% CI 0.82-1.62, p = 0.37), but higher odds of any arrhythmia compared with cisgender women (transgender women: aOR 1.65, 95% CI 1.13-2.34, p = 0.01; transgender men: aOR 2.15, 95% CI 1.48-3.04, p < 0.001). Prevalence of arrhythmias appeared similar among transgender adults regardless of GAHT use (transgender men: 1.5% vs 1.9%, transgender women: 1.2% vs 2.1%). Conclusion: Further research examining arrhythmias in TGNB patients and across gender minority subgroups is warranted, including longitudinal studies evaluating the potential impact of GAHT.

Menstrual cycle and the protective effects of remote ischemic preconditioning against endothelial ischemia/reperfusion injury: comparison with postmenopausal women

The aim of this study was to determine whether the capacity of remote ischemic preconditioning (IPC) against endothelial ischemia/reperfusion (I/R) injury changes across the menstrual cycle in premenopausal women and to compare IPC responses to postmenopausal women. Thirty-five women were studied (22 premenopausal/13 postmenopausal). Changes in endothelial function were determined during the early follicular vs. the late follicular phase (after positive urine ovulation test; Study 1), vs. the mid-luteal phase (after positive urine progesterone test; Study 2), and vs. estrogen-deficient postmenopausal women; Study 3). Endothelium-dependent vasodilation was assessed by the forearm blood flow (FBF) to reactive hyperemia with/without I/R injury with remote IPC (3 × 5 min cycles of upper arm ischemia). In the premenopausal women, peak FBF responses during the early follicular phase were blunted 20% (P < 0.0001) with I/R injury (from baseline: 23.4 ± 6.2 to 19.5 ± 4.9 mL/100 mL tissue/min) compared with the late follicular/mid-luteal phases despite IPC. In postmenopausal women, peak FBF was diminished (from: 21.1 ± 5.1 to 17.2 ± 4.4 mL/100 mL tissue/min), and total FBF (area under the curve) was decreased a third (-32%; P < 0.001) with I/R injury. Protection from I/R injury was preserved during the late follicular (from baseline: 21.7 ± 5.3 to 24.8 ± 5.9 mL/100 mL tissue/min; P = 0.109) and mid-luteal phases (from: 25.1 ± 3.9 to 27.2 ± 5.7 mL/100 mL tissue/min; P = 0.267). Reduced estrogen during the early follicular phase and the rise in estrogen associated with ovulation and the mid-luteal phase may contribute to changes in IPC-mediated protection in premenopausal women and shed light on how cardioprotection may change with ovarian hormone deficiency with the menopause transition.NEW & NOTEWORTHY The capacity of remote ischemic preconditioning to protect against vascular endothelial ischemia/reperfusion injury varies widely across the phases of the menstrual cycle in healthy premenopausal women. Robust protection was afforded during the late follicular and mid-luteal phases. In contrast, weakened protection was demonstrated during the early follicular phase, with a level of impairment similar to estrogen-deficient postmenopausal women.

[Patients hospitalized in the ICU for acute coronary syndrome from 2012 to 2021: A single-center retrospective study]

INTRODUCTION

Acute Coronary Syndrome (ACS) are one of the main causes of mortality in France. Patients presenting with ACS are typically hospitalized in a specialized cardiology ward. The main objective of this study was to describe, characterize and evaluate the outcome of patients hospitalized for ACS in a generalist intensive care unit (rather than a cardiac care unit).

METHODS

This was a retrospective study. Our population consisted of ACS patients admitted to an intensive care unit in a hospital center (Centre Hospitalier de Troyes) between 2012 and 2021. All patients admitted for ACS to the intensive care unit and who underwent coronary angiography were included.

RESULTS

In 10 years, 104 patients, or 3.8% of ACS patients who underwent coronary angiography were admitted to intensive care. The majority were admitted after recovered cardiac arrest (72%) and were in cardiogenic shock (68%), accounting for a high in-hospital mortality (45.2%). In-hospital mortality was 45.2%. In multivariate analysis, the GRACE score was associated with in-hospital mortality (OR for each additional point = 1.024, 95% confidence interval 1.006-1.045, p = 0.01). Among the survivors, 88% had good neurological function when leaving the hospital.

DISCUSSION

Mortality of ACS patients in intensive care was close to 50%. However, the neurological prognosis of the surviving patients was good. This population is rarely mentioned in the literature, and deserves to be evaluated by multicenter, prospective registries, with a view to improving management and prognosis.

Is there a difference between women and men in chronic spontaneous urticaria? A systematic review on gender and sex differences in CSU patients

In recent years, there has been a notable surge in interest in gender medicine, with a growing focus on exploring gender and sex differences in skin diseases.Although it is noticeable in clinical practice that more women than men present with chronic spontaneous urticaria (CSU) in the outpatient setting, there is currently no systematic review available which addresses gender differences in CSU. PubMed Medline, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched until July 2023. English and German randomized controlled trials, prospective and retrospective cohorts, and case-control studies that examined gender and sex differences in CSU were included. Two authors independently screened the reports for eligibility. One extracted all data, the second double-checked and critically appraised the quality and risk of bias of the studies. Twenty-six reports were included. The article reviewed differences in epidemiology, diagnostics, clinical characteristics, treatment, and quality of life in female and male patients. The findings provide limited data for the substantial impact of gender and sex in CSU patients and reveal major gaps in gender-specific care in dermatology which should be narrowed in the upcoming years to optimize patient-centered, individualized, gender-equal healthcare.

PROSPERO registration

CRD42023442958.

Sex differences in clinical presentation, treatment response, and side effects of nutritional therapy among patients at nutritional risk: a secondary analysis of the randomized clinical trial EFFORT

BACKGROUND

Considering sex-specific factors has become an increasingly recognized area for research and practice, in the field of clinical nutrition, there is insufficient evidence regarding differences in clinical presentation, treatment response, and side effects of nutritional therapy among female and male patients.

OBJECTIVES

We hypothesized that the clinical presentation, response to nutritional therapy, and side effects from the intervention would differ in the two sexes.

METHODS

This secondary analysis investigated differences among female and male patients at risk for malnutrition regarding initial presentation, clinical outcomes, and treatment response in patients included in the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized controlled trial comparing individualized nutritional support to usual care.

RESULTS

Of 2028 patients included in the trial, 964 were females and 1064 were males. The nutritional history and clinical presentation of female patients was different: they consumed less food and had a greater loss of appetite than the male population. Male patients had higher risk for mortality at 180 d [27% compared with 19%; adjusted hazards ratio (HR): 1.35; 95% CI: 1.12, 1.63] and further adverse clinical outcomes. However, there was no difference in the effect of nutritional support on mortality among female and male patients (HR: 0.76; 95% CI: 0.45, 1.27, compared with HR: 0.81; 95% CI: 0.54, 1.21, respectively; P-interaction = 0.939).

CONCLUSIONS

Results of this multicenter randomized trial suggest that multimorbid female inpatients have a different clinical presentation and are more prone to loss of appetite and reduced daily dietary intake than male inpatients. Importantly, the favorable response to nutritional interventions was similar in both sexes. This trial was registered at clinicaltrials.gov as NCT02517476.

Characterizing chest pain in patients with acute coronary syndrome at Vietnam National Heart Institute: a case-control study

OBJECTIVE

This study aimed to distinguish chest pain characteristics between patients with and without acute coronary syndrome (ACS) at Vietnam National Heart Institute.

METHODS

A case-control study using a structured chest pain assessment questionnaire was performed to examine pain characteristics.

RESULTS

Smoking, a history of heart attack, and a family history of cardiovascular disease were associated with increased ACS-related chest pain risk. Patients without ACS more frequently reported left or central chest pain, mild discomfort, pain triggered by activity, and relief with rest or nitroglycerin. ACS-related chest pain was more often characterized by pain radiating to the back, a sensation of tightness or severe discomfort, gradual intensity increase, occurrence at rest or with minimal exertion, and accompanying sweating. No significant sex differences were found in ACS-related chest pain symptoms.

CONCLUSIONS

Targeted assessment of chest pain features-such as pain radiation, pressure sensation, symptom escalation, duration, activity triggers, and relief factors-could improve public awareness and support the development of educational resources on ACS and non-ACS symptoms.