Age-dependent differences in diabetes and acute hyperglycemia between men and women with ST-elevation myocardial infarction: a cohort study

Myocardial Infarction Signs and Symptoms: Females vs. Males

Cardiovascular disease is the number one killer of females in the United States today, and myocardial infarction (MI) plays a role in many of these deaths. Females also present with more "atypical" symptoms than males and appear to have differences in pathophysiology underlying their MIs. Despite both differences in symptomology and pathophysiology being present in females versus males, a possible link between the two has not been studied extensively. In this systematic review, we analyzed studies examining differences in symptoms and pathophysiology of MI in females and males and evaluated possible links between the two. A search was performed for sex differences in MI in the databases PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Complete, Biomedical Reference Collection: Comprehensive, Jisc Library Hub Discover, and Web of Science. Seventy-four articles were ultimately included in this systematic review. Typical symptoms for both ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) such as chest, arm, or jaw pain were more common in both sexes, but females presented on average with more atypical symptoms such as nausea, vomiting, and shortness of breath. Females with MI also presented with more prodromal symptoms such as fatigue in days leading up to MI, had longer delays in presentation to the hospital after symptom onset, and were older with more comorbidities than males. Males on the other hand were more likely to have a silent or unrecognized MI, which concurs with their overall higher rate of MI. As they age, females have a decrease in antioxidative metabolites and worsened cardiac autonomic function than male. In addition, at all ages, females have less atherosclerotic burden than mles, have higher rates of MI not related to plaque rupture or erosion, and have increased microvasculature resistance when they have an MI. It has been proposed that this physiological difference is etiologic for the male-female difference in symptoms, but this has not been studied directly and is a promising area of future research. It is also possible that differences in pain tolerance between males and females may play a role in differing symptom recognition, but this has only been studied one time where females with higher pain thresholds were more likely to have unrecognized MI. Again, this is a promising area for future study for the early detection of MI. Finally, differences in symptoms for patients with different atherosclerotic burden and for patients with MI due to a cause other than plaque rupture or erosion has not been studied and are both promising avenues to improve detection and patient care in the future.

Prognostic Value of Systemic Immune-Inflammation Index and NT-proBNP in Patients with Acute ST-Elevation Myocardial Infarction

Objective

Our aim was to assess systemic immune-inflammation index (SII) and NT-proBNP value either in singly or in combination to predict acute ST-elevation myocardial infarction (STEMI) patient prognosis.

Methods

Analyzed retrospectively the clinical features and laboratory data of STEMI confirmed patients in our hospital from January to December 2020. The levels of SII and NT-proBNP were detected. The Kaplan-Meier approach and Spearman's rank correlation coefficient were used to construct the overall major adverse cardiac event (MACE) curve. Multivariate Cox regression analysis was applied to detect MACE predictors. In addition, the Delong test and receiver operating characteristic (ROC) curve analyzed each factor performance on its own and composite multivariate index to predict MACEs.

Results

The MACE group showed statistically significant differences in SII, NT- proBNP in comparison to the non-MACE group (P=0.003, P <0.001). Based on Kaplan-Meier analysis, SII and NT-proBNP showed positive correlation with MACE (log-rank P < 0.001). SII and NT-proBNP were independent predicting factors for long-term MACEs in multivariate Cox regression analysis (P <0.001, HR: 2.952, 95% CI 1.565-5.566; P <0.001, HR: 2.112, 95% CI 1.662-2.683). SII and NT-proBNP exhibited a positive correlation (R = 0.187, P < 0.001) in correlation analysis. According to the ROC statistical analysis, the combination exhibited 78.0% sensitivity and 88.0% specificity in the prediction of MACE. According to the results of the AUC and Delong test, the combined SII and NT-proBNP performed better as a prognostic index than each of the individual factor indexes separately (Z = 2.622, P = 0.009; Z = 3.173, P < 0.001).

Conclusion

SII and NT-proBNP were independent indicators of clinical prognosis in acute STEMI patients, and they correlated positively. These factors could be combined to improve clinical prognosis.

Admission glucose level and short-term mortality in older patients with acute myocardial infarction: results from the KORA Myocardial Infarction Registry

STUDY OBJECTIVES

To investigate the association between admission blood glucose levels and 28-day mortality as well as in-hospital complications in older patients with incident acute myocardial infarction (AMI) undergoing modern treatment.

METHODS

From a German population-based regional MI registry, 5530 patients (2016 women), aged 65-84 years, hospitalised with an incident AMI between 1 January 2009 and 31 December 2016 were included in the study. Multivariable logistic regression models were used to assess the associations between admission blood glucose and 28-day mortality as well as in-hospital complications after AMI. Analyses stratified according to age, diabetes and type of infarction (ST-elevation MI (STEMI)/non-STEMI) were conducted.

RESULTS

The adjusted ORs for the association between admission blood glucose and 28-day mortality in young-old (65-74 years) and old (75-84 years) patients with AMI were 1.40 (95% CI: 1.21 to 1.62) and 1.21 (95% CI: 0.98 to 1.50) per 1 SD increase in admission blood glucose, respectively. Furthermore, higher admission blood glucose was related to case fatality irrespective of the diabetes status and type of infarction only in the under-75 group. For the patients aged 75-84 years, it was only true for those without diabetes and STEMI. Admission blood glucose was also associated with major cardiac complications in both age groups.

CONCLUSION

Admission blood glucose was significantly associated with 28-day case fatality in patients with AMI aged 65-74 years but not 75-84 years; furthermore, in both age groups there was an increased risk of major complications. It seems that admission glucose may play a rather minor role in terms of case fatality in higher aged patients with AMI.

Clinical Presentation, Quality of Care, Risk Factors and Outcomes in Women with Acute ST-Elevation Myocardial Infarction (STEMI): An Observational Report from Six Middle Eastern Countries

BACKGROUND

Most of the available literature on ST-Elevated myocardial infarction (STEMI) in women was conducted in the developed world and data from Middle-East countries was limited.

AIMS

To examine the clinical presentation, patient management, quality of care, risk factors and inhospital outcomes of women with acute STEMI compared with men using data from a large STEMI registry from the Middle East.

METHODS

Data were derived from the third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps), a prospective, multinational study of adults with acute STEMI from 36 hospitals in 6 Middle-Eastern countries. The study included 2928 patients; 296 women (10.1%) and 2632 men (89.9%). Clinical presentations, management and in-hospital outcomes were compared between the 2 groups.

RESULTS

Women were 10 years older and more likely to have diabetes mellitus, hypertension, and hyperlipidemia compared with men who were more likely to be smokers (all p<0.001). Women had longer median symptom-onset to emergency department (ED) arrival times (230 vs. 170 min, p<0.001) and ED to diagnostic ECG (8 vs. 6 min., p<0.001). When primary percutaneous coronary intervention (PPCI) was performed, women had longer door-to-balloon time (DBT) (86 vs. 73 min., p=0.009). When thrombolytic therapy was not administered, women were less likely to receive PPCI (69.7 vs. 76.7%, p=0.036). The mean duration of hospital stay was longer in women (6.03 ± 22.51 vs. 3.41 ± 19.45 days, p=0.032) and the crude in-hospital mortality rate was higher in women (10.4 vs. 5.2%, p<0.001). However, after adjustments, multivariate analysis revealed a statistically non-significant trend of higher inhospital mortality among women than men (6.4 vs. 4.6%), (p=0.145).

CONCLUSION

Our study demonstrates that women in our region have almost double the mortality from STEMI compared with men. Although this can partially be explained by older age and higher risk profiles in women, however, correction of identified gaps in quality of care should be attempted to reduce the high morbidity and mortality of STEMI in our women.

Admission plasma glucose levels within the normal to mildly impaired range and the outcome of patients with acute coronary syndrome

BACKGROUND

Elevated admission plasma glucose levels >140 mg/dl are associated with adverse clinical outcomes in both diabetic and non-diabetic patients admitted with acute coronary syndrome (ACS). We aimed to evaluate the association between admission plasma glucose levels <140 mg/dl and the outcome of non-diabetic patients admitted with acute coronary syndrome.

METHODS

The study population consisted of patients with acute coronary syndrome included in the Acute Coronary Syndrome Israeli Survey during 2000-2013. Diabetic patients were excluded. The primary endpoint was all-cause mortality at one year.

RESULTS

The 452 0 patients had a mean age of 61.7±13.5 years and were stratified into four quartiles according to admission plasma glucose (60-94, 95-105, 106-119, 120-140 mg/dl). Patients with higher admission plasma glucose were older and included a higher percentage of smokers. In addition, the higher the glucose so also did they have a poorer risk factor profile including a higher body mass index, total and low-density lipoprotein cholesterol and triglyceride levels, and lower high-density lipoprotein cholesterol levels. During the first year 5.2% of patients died. A comparison of one-year mortality according to admission plasma glucose quartiles demonstrated a significant and progressive increase in mortality risk as admission plasma glucose rose (3.5%, 4.1%, 6.1%, 6.4%, respectively, p=0.001). However, this association lost its clinical significance following a multivariate analysis ( p=0.08).

CONCLUSIONS

High admission plasma glucose levels within the normal to mildly impaired range are associated with increased one-year mortality in non-diabetic acute coronary syndrome patients. However, the higher glucose level is probably not the cause for the adverse outcome but rather a marker for high risk. Our findings support the definition of 140 mg/dl as the cutoff for clinically acceptable admission glucose levels in patients with acute coronary syndrome.

Proposal of a New Approach to Study and Categorize Stress Hyperglycemia in Acute Myocardial Infarction

BACKGROUND

Stress hyperglycemia (SH) is a valid prognosticator of in-hospital complications and mortality in the intensive care unit, and is universally available, simple, and cost-effective. Even small refinements of SH can improve the risk stratification of patients with one of the most important diseases today-acute myocardial infarction (AMI).

OBJECTIVE

The aim of the review was to analyze whether SH nomenclature and methodology have been consistent in the medical literature in order to identify possible methodological faults and to suggest possible solutions.

DISCUSSION

SH nomenclature and glycemic targets have been relatively uniform in recent years, but there has been a pronounced variability in the methodology. Recent meta-analysis showed that AMI patients with new hyperglycemia had a 3.6-fold increased risk of mortality during hospitalization in comparison to those who were normoglycemic. Four SH methodological mistakes were identified. First, using one cutoff value for SH instead of two different values (one for patients with diabetes mellitus [DM] and one for patients without DM). Second, analyzing, for example, either tertiles or quintiles without dividing AMI patients into subgroups according to their DM status. Third, studying only two subgroups (with SH and without SH), without determining the presence of DM, when DM is not analyzed. Fourth, failure to measure glycated hemoglobin.

CONCLUSIONS

The same admission blood glucose (BG) is a marker of different mortality risks in diabetic compared to nondiabetic AMI patients. For example, when admission BG is 108-126 mg/dL (6-7 mmol/L), then the risk of in-hospital mortality is higher in DM patients; however, with an admission BG of 162-180 mg/dL (9-10 mmol/L), the risk is lower in diabetic patients. We can improve the clinical utility of the admission BG in AMI if we analyze four groups of patients (those with and without previously diagnosed DM, and above and below the admission glycemia cutoff values for in-hospital mortality). Those cutoffs should be calculated separately for diabetic and nondiabetic AMI patients.

Impact of Admission Glucose on Non-Diabetic Patients with ST-Segment Elevation Myocardial Infarction Treated with Percutaneous Coronary Intervention: A Meta-Analysis

BACKGROUND

Impaired admission glucose (AG) is thought to significantly increase the risk of both early and late death with ST-segment elevation myocardial infarction (STEMI), especially for non-diabetic patients. However, several earlier studies contradict these relationships. Through our meta-analysis, we aimed to evaluate such a relation between impaired AG, the risk of death and STEMI.

METHODS

We accessed PubMed, EMBASE, Web of Science, and the Cochrane Library and systematically searched their databases to identify all related prospective cohort studies. The relative risks (RRs) with their 95% confidence interval (CI) were pooled quantitatively.

RESULTS

The pooled, unadjusted relative risks of early outcome events indicated that patients who had glucose concentrations ≥ the range of 6.1-11.1 mmol/L, had a 4.38-fold (95% CI, 3.23-5.94) higher early mortality. For late outcome events, the pooled unadjusted RR indicated patients who had glucose concentrations ≥ the range 7.8-11.1 mmol/L, and had a 2.69-fold (95% CI, 2.16-3.34) higher late mortality based on full participants, whereas patients had a 1.65-fold (95% CI, 1.33-2.04) higher late mortality based on based on in-hospital or 30-day survivors.

CONCLUSIONS

In conclusion, the present meta-analysis demonstrated that impaired admission glucose may be an effective prognostic marker for significantly increased risk of early death. Regarding the long-term outcomes based on full population or early survival, high admission glucose also has a distinct but poorer prognostic impact on long-term mortality than early mortality.

KEY WORDS

Admission glucose • Meta-analysis • Myocardial infarction • Non-diabetic.

Admission glucose and risk of early death in non-diabetic patients with ST-segment elevation myocardial infarction: a meta-analysis

Background

Impaired admission glucose (AG) is considered to significantly increase risk on both early and late death of the patients with ST-segment elevation myocardial infarction (STEMI), especially for non-diabetic patients; however, some reports contradict the relationship. We therefore conducted a meta-analysis to clarify this issue.

Material/Methods

PubMed, EMBASE, Web of Science, and Cochrane Library databases were systematically searched to identify all related prospective cohort studies. The relative risks (RR) with their 95% confidence interval (CI) were pooled quantitatively.

Results

The pooled RR of early outcome events indicated patients with glucose concentrations ≥6.1–11.1 mmol/L had a 4.38-fold (95% CI, 3.23–5.94) higher early mortality. The pooled RR of late outcome events indicated that the patients with glucose concentrations ≥7.8–11.1 mmol/L had a 1.65-fold (95% CI, 1.33–2.04) higher late mortality based on in-hospital or 30-day survivors.

Conclusions

High AG may be a helpful prognostic marker of significantly increased risk on early death in non-diabetic patients with STEMI, and has an explicit but prognostic adverse impact on long-term mortality but not early mortality in these patients.