Gender differences in presentation, management, and in-hospital outcomes for patients with AMI in a lower-middle income country: evidence from Egypt

Sex, Racial, and Ethnic Disparities in Acute Coronary Syndrome: Novel Risk Factors and Recommendations for Earlier Diagnosis to Improve Outcomes

In this review, sex, racial, and ethnic differences in acute coronary syndromes on a global scale are summarized. The relationship between disparities in presentation and management of acute coronary syndromes and effect on worse clinical outcomes in acute coronary syndromes are discussed. The effect of demographic, geographic, racial, and ethnic factors on acute coronary syndrome care disparities are reviewed. Differences in risk factors including systemic inflammatory disorders and pregnancy-related factors and the pathophysiology underlying them are discussed. Finally, breast arterial calcification and coronary calcium scoring are discussed as methods to detect subclinical atherosclerosis and start early treatment in an attempt to prevent clinical disease.

Gender Differences in Heart Failure Hospitalization Post-Myocardial Infarction

Objectives:

Patients with post-myocardial infarction (MI) are more likely to die later from heart failure (HF), arrhythmic events, or reinfarction. According to recent studies, mortality rates were noticeably higher in women, than in men. This has been linked to variations in age, comorbidities, symptom presentation, and pathophysiology of the underlying coronary artery disease. There is little information on how these typical gender disparities affect post- MI survival. Studies on individuals with coronary artery disease have primarily focused on men, with women typically being left out of most series. Despite the relatively high prevalence of ischemic heart disease in women, there is a lack of information regarding the clinical course of the condition, its management, and clinical outcomes in this particular population due to the underrepresentation of women in the medical literature in this field. The gender disparities in post-MI patients who present with HF will be briefly discussed in this article.

Materials and Methods:

A total of 50 patients that presented with HF and had a previous history of MI were included in this study after taking consent. After taking history and detailed physical examination, investigations that were sent were reviewed and the subjects followed up in the hospital stay to look for outcomes. The data are compiled and subjected to statistical analysis.

Results:

It is observed that among the 50 subjects, 32% of them had recurrent HF (13 of the 30 females and three of the 20 males). p = 0.04 is statistically significant. Among the study subjects, the hospital outcomes observed showed that, out of 50 subjects, 47 subjects recovered and the other three died in hospital stay. All the three deaths are women. p = 0.15 is not statistically significant.

Conclusion:

This study concludes that women are more likely than males to require hospitalization for recurrent HF following a MI. This study also demonstrates that, despite the higher risk of recurrent HF, women do not have a higher mortality risk than males.

Symptoms of Infarction in Women: Is There a Real Difference Compared to Men? A Systematic Review of the Literature with Meta-Analysis

(1) Context: The management of acute coronary syndrome (ACS) is based on a rapid diagnosis. The aim of this study was to focus on the ACS symptoms differences according to gender, in order to contribute to the improvement of knowledge regarding the clinical presentation in women. (2) Methods: We searched for relevant literature in two electronic databases, and analyzed the symptom presentation for patients with suspected ACS. Fifteen prospective studies were included, with a total sample size of 10,730. (3) Results: During a suspected ACS, women present more dyspnea, arm pain, nausea and vomiting, fatigue, palpitations and pain at the shoulder than men, with RR (95%CI) of 1.13 [1.10; 1.17], 1.30 [1.05; 1.59], 1,40 [1.26; 1.56], 1.08 [1.01; 1.16], 1.67 [1.49; 1.86], 1.78 [1.02; 3.13], respectively. They are older by (95%CI) 4.15 [2.28; 6.03] years compared to men. The results are consistent in the analysis of the ACS confirmed subgroup. (4) Conclusions: We have shown that there is a gender-based symptomatic difference and a female presentation for ACS. The “typical” or “atypical” semiology of ACS symptoms should no longer be used.

Atypical Manifestations of Women Presenting with Myocardial Infarction at Tertiary Health Care Center: An Analytical Study

Introduction:

Typical chest pain symptoms are the cause that requires individuals to seek out medical care in Acute coronary syndrome(ACS). Evidence suggests, symptoms labelled as 'atypical 'is more common in women with ACS. The present study focuses on the need for the implementation of a gender specific approach in the current scenario by identifying gender based differences that exist in clinical presentations of the patients with ACS. Early identification of women's prodromal and acute symptoms of Myocardial Infarction is an important step in provision of appropriate treatment modality. Present study focus on need for implementation of gender-specific approach in current scenario by identifying gender based differences that exist in risk factors, clinical manifestations in patients presenting with MI.

Methodology:

Cross- sectional analytical study was conducted among 240 Participants (120 males and 120 females). Both men and women diagnosed with MI, who survived, stabilized after admission was included in the study. Consecutive sampling technique was used to select the participants. Data was collected on risk factors profile, clinical manifestations by administering structured questionnaire.

Results:

Risk factors such as history of diabetes, history of dyslipidemia was found to be homogenous among both men and women. 60% of men were ever smokers. Hypertension and known IHD was noted to be significant in women (p<0.002, p <0.001) but men presented with higher BMI (p<0.030). Females increasingly presented with atypical presentations when compared to males (p<0.005). Women commonly had squeezing and tightness type of pain and men reported tightness, burning, pricking type of pain (p<0.003). The majority of the women reported the onset of pain occurrence between 6am to 12 pm(p<0.004), whereas men significantly reported the onset of pain between 12 am -6 am(p<0.001).

Conclusion:

Gender based differences in risk factors and clinical presentation in men and women with myocardial infarction had been a focus in researches that emphasized need for focused assessment for women as they increasingly presents with atypical symptoms. The current study also supports the need of a gender specific approach to avoid delay in diagnosis and care of them.

Gender divides in the clinical profiles of patients with acute myocardial infarction at a tertiary care center in South India

BACKGROUND:

Early identification of myocardial infarction (MI) is a determinant in the provision of appropriate treatment modalities. The focus of the present study is on the identification of gender-based differences in risk factors, clinical manifestations, and coronary angiography findings in patients presenting with MI.

MATERIALS AND METHODS:

A cross-sectional study was conducted among patients admitted with MI at a tertiary care center in South India during March 2016 to June 2017. Selected 120 male and 120 female consecutive patients admitted with acute MI, who had survived and been stabilized. Data was collected using a pre-tested structure data sheet. Appropriate parametric and nonparametric tests were used to analyze the data.

RESULTS:

Participants were homogenous as regards age (P < 0.107); majority of men and women were from the rural areas. About 32.5% of the men interpreted the pain as due to a cardiac problem or indigestion, whereas 60.8% of the women thought it was fatigue/muscle pain. The self-interpretation or perception of pain in both genders was statistically significant (P < 0.001). Compared to the men, the females increasingly presented with atypical symptoms (P = 0.005). Regarding ST-elevated MI, male preponderance was noted (P = 0.004)). Considering the anatomical location of MI, the presentation of Inferior Wall Myocardial Infarction (IWMI) was predominant in females compared to men (P = 0.003). The majority of men had increased presentation of single-vessel disease compared to women (P = 0.02), whereas normal coronaries and double-vessel disease were found statistically significantly higher in females (P = 0.03 and P = 0.008, respectively).

CONCLUSION:

Public education is needed on the atypical presentations which are common with women than in men. The public should, therefore, be informed of those symptoms and how to recognize them so that they may seek medical care promptly.

Sex disparities in the presentation, management and outcomes of patients with acute coronary syndrome: insights from the ACS QUIK trial

Aims

Our aim was to explore sex differences and inequalities in terms of medical management and cardiovascular disease (CVD) outcomes in a low/middle-income country (LMIC), where reports are scarce.

Methods

We examined sex differences in presentation, management and clinical outcomes in 21 374 patients presenting with acute coronary syndrome (ACS) in Kerala, India enrolled in the Acute Coronary Syndrome Quality Improvement in Kerala trial. The main outcomes were the rates of in-hospital and 30-day major adverse cardiovascular events (MACEs) defined as composite of death, reinfarction, stroke and major bleeding. We fitted log Poisson multivariate random effects models to obtain the relative risks comparing women with men, and adjusted for clustering by centre and for age, CVD risk factors and cardiac presentation.

Results

A total of 5191 (24.3%) patients were women. Compared with men, women presenting with ACS were older (65±12 vs 58±12 years; p<0.001), more likely to have hypertension and diabetes. They also had longer symptom onset to hospital presentation time (median, 300 vs 238 min; p<0.001) and were less likely to receive primary percutaneous coronary intervention for ST-elevation myocardial infarction (45.9% vs 49.8% of men, p<0.001). After adjustment, women were more likely to experience in-hospital (adjusted relative risk (RR)=1.53; 95% CI 1.32 to 1.77; p<0.001) and 30-day MACE (adjusted RR=1.39; 95% CI 1.23 to 1.57, p<0.001).

Conclusion

Women presenting with ACS in Kerala, India had greater burden of CVD risk factors, including hypertension and diabetes mellitus, longer delays in presentation, and were less likely to receive guideline-directed management. Women also had worse in-hospital and 30-day outcomes. Further efforts are needed to understand and reduce cardiovascular care disparities between men and women in LMICs.

Sex Difference in Risk Factors, GRACE Scores, and Management among Post-Acute Coronary Syndrome Patients in Sri Lanka

Objective

To assess sex-based differences in the prevalence of risk factor, their management, and differences in the prognosis among acute coronary syndrome (ACS) in Sri Lanka.

Methods

Patients diagnosed with ACS were recruited from hospitals throughout the island. The Joint European Societies guidelines were used to assess recommended targets for coronary heart disease risk factors, and the GRACE score was used to assess the post-ACS prognosis. Age-adjusted regression was performed to calculate odds ratios for men versus women in risk factor control.

Results

A total of 2116 patients, of whom 1242 (58.7%) were men, were included. Significant proportion of women were nonsmokers; OR = 0.11 (95% CI 0.09 to 0.13). The prevalence of hypertension (p < 0.001), diabetes (p < 0.001), and dyslipidemia (p=0.004) was higher in women. The LDL-C target was achieved in a significantly higher percentage of women (12.6%); OR = 0.33 (95% CI 0.10 to 1.05). When stratified by age, no significant differences were observed in achieving the risk factor targets or management strategies used except for fasting blood sugar (p < 0.05) where more men achieved control target in both age categories. Majority of the ACS patients had either high or intermediate risk for one-year mortality as per the GRACE score. In-hospital and 1-year mean mortality risk was significantly higher among men of less than 65 years of age (p < 0.05).

Conclusions

Smoking is significantly lower among Sri Lankan women diagnosed with ACS. However, hypertension, diabetes, and dyslipidemia were more prevalent among them. There was no difference in primary and secondary preventive strategies and management in both sexes but could be further improved in both groups.

Sex differences in acute coronary syndrome: insights from an observation study in low socio-economic cohort from India

Aim: To study sex-related differences in acute coronary syndrome (ACS) presentation, management and in-hospital outcomes. Materials & methods: We studied 621 ACS patients (150 women, 471 men) of low socio-economic status from South India from February 2015 to January 2016. Multivariable logistic regression methods were used to assess sex differences in the in-hospital outcomes. Adjudicated major adverse cardiovascular events (MACE) included in-hospital cardiac arrest, cardiogenic shock, heart failure, re-infarction, stroke, major bleeding and mortality. Results & conclusion: Mean age in women was 60.97 ± 11.23 years versus 54.5 ± 10.87 years in men (p < 0.001). Women had higher prevalence of hypertension and diabetes and presented with more non-ST elevation ACS. There were no differences in the use of antiplatelets, statins and other pharmacotherapy except for the higher use of nitrates in women. There were no differences in MACE rates between women and men (15.3 vs 9.6%; adjusted odds ratio: 1.43; CI: 0.76-2.69).

Gender differences in the management of acute coronary syndrome patients: One year results from HPIAR (HP-India ACS Registry)

INTRODUCTION

Data from high-income countries suggest that women receive less intensive diagnostic and therapeutic management than men for acute coronary syndrome (ACS). There is a paucity of such data in the Indian population, which is 69% rural and prior studies focused mostly on urban populations. The objective of the present study was to identify the gender based differences in ACS management, if any, in a predominantly rural population.

METHODS

Data from 35 hospitals across Himachal Pradesh covering >90% of state population were collected for one year (July 2015-June 2016). A total of 2118 ACS subjects met inclusion criteria and baseline characteristics, in-hospital treatments and mortality rates were analyzed.

RESULTS

Women constituted less than one-third of ACS population. Women were older compared to men and were more likely to present with NSTEMI/UA. Misinterpretation of initial symptoms and late presentation were also common in women. Fewer women received optimal guideline based treatment and PCI (0.9% vs 4.2%, p<0.01). Compare to men, women more often had Killip class >1 (27.3% vs 20.4%, p<0.01) and higher in-hospital mortality (8.5% vs 5.6%, p=0.009). On multivariate analysis the association between female gender and mortality was attenuated (adjusted odds ratio [OR]=1.36 [0.77-2.38]).

CONCLUSION

The present study from India, is the first of its kind to evaluate the gender based differences among ACS patients, in a predominantly rural population. Our analysis demonstrates a significant gender based difference between symptom awareness and delay in presentation, management and in-hospital outcome. Further studies are warranted across other parts of country to investigate this gender disparity.

Gender Based Differences in Risk Factor Profile and Coronary Angiography of Patients Presenting with Acute Myocardial Infarction in North Indian Population

INTRODUCTION

Coronary Artery Disease (CAD) among women presents atypically with atypical chest pain, neck pain, nausea, fatigue and dyspnoea. Co-existing co-morbidities such as Diabetes Mellitus (DM) and hypertension along with difference in risk factor prevalence makes it necessary to have a gender specific approach.

AIM

To study gender specific differences in diagnosing and treating Acute Myocardial Infarction (AMI) in North Indian population.

MATERIALS AND METHODS

Fifty consecutive men and women presenting with AMI were studied. A detailed history including symptoms, history of DM, hypertension, smoking and dyslipidaemia was obtained. ECG, evaluation of cardiac enzymes (CPK-MB, Troponin I), RBS, lipid profile, two dimensional transthoracic echocardiography and coronary angiography were performed. The data was statistically analysed.

RESULTS

Among 100 patients (50 males and females each), we found a later age at presentation (62 y vs 56.5 y) and higher prevalence of diabetes (52% vs 24%, p=0.004) and hypertension (46% vs 28%) among females but more dyslipidaemia (34% vs 26%), smoking (44% vs 0%, p=0.0) and higher BMI (25.58 vs 23.74, p=0.019) among males. More females presented with atypical symptoms (16% vs 6%) and were detected to have insignificant CAD (14% vs 2%) than males.

CONCLUSION

North Indian women with presentation at a later age, with atypical symptoms, more incidences of risk factors such as diabetes and hypertension along with lesser dyslipidaemia and BMI than males need a higher index of suspicion while evaluating them for CAD. Misdiagnosis is more likely because of atypical presentation. A milder disease on angiography and a lower incidence of multiple vessel disease is a common finding. We recommend more and larger Indian studies to acquire more data so that this growing prevalence of CAD in women can be curbed.

Sex Differences in Stroke Incidence, Prevalence, Mortality and Disability-Adjusted Life Years: Results from the Global Burden of Disease Study 2013

BACKGROUND

Accurate information on stroke burden in men and women are important for evidence-based healthcare planning and resource allocation. Previously, limited research suggested that the absolute number of deaths from stroke in women was greater than in men, but the incidence and mortality rates were greater in men. However, sex differences in various metrics of stroke burden on a global scale have not been a subject of comprehensive and comparable assessment for most regions of the world, nor have sex differences in stroke burden been examined for trends over time.

METHODS

Stroke incidence, prevalence, mortality, disability-adjusted life years (DALYs) and healthy years lost due to disability were estimated as part of the Global Burden of Disease (GBD) 2013 Study. Data inputs included all available information on stroke incidence, prevalence and death and case fatality rates. Analysis was performed separately by sex and 5-year age categories for 188 countries. Statistical models were employed to produce globally comprehensive results over time. All rates were age-standardized to a global population and 95% uncertainty intervals (UIs) were computed.

FINDINGS

In 2013, global ischemic stroke (IS) and hemorrhagic stroke (HS) incidence (per 100,000) in men (IS 132.77 (95% UI 125.34-142.77); HS 64.89 (95% UI 59.82-68.85)) exceeded those of women (IS 98.85 (95% UI 92.11-106.62); HS 45.48 (95% UI 42.43-48.53)). IS incidence rates were lower in 2013 compared with 1990 rates for both sexes (1990 male IS incidence 147.40 (95% UI 137.87-157.66); 1990 female IS incidence 113.31 (95% UI 103.52-123.40)), but the only significant change in IS incidence was among women. Changes in global HS incidence were not statistically significant for males (1990 = 65.31 (95% UI 61.63-69.0), 2013 = 64.89 (95% UI 59.82-68.85)), but was significant for females (1990 = 64.892 (95% UI 59.82-68.85), 2013 = 45.48 (95% UI 42.427-48.53)). The number of DALYs related to IS rose from 1990 (male = 16.62 (95% UI 13.27-19.62), female = 17.53 (95% UI 14.08-20.33)) to 2013 (male = 25.22 (95% UI 20.57-29.13), female = 22.21 (95% UI 17.71-25.50)). The number of DALYs associated with HS also rose steadily and was higher than DALYs for IS at each time point (male 1990 = 29.91 (95% UI 25.66-34.54), male 2013 = 37.27 (95% UI 32.29-45.12); female 1990 = 26.05 (95% UI 21.70-30.90), female 2013 = 28.18 (95% UI 23.68-33.80)).

INTERPRETATION

Globally, men continue to have a higher incidence of IS than women while significant sex differences in the incidence of HS were not observed. The total health loss due to stroke as measured by DALYs was similar for men and women for both stroke subtypes in 2013, with HS higher than IS. Both IS and HS DALYs show an increasing trend for both men and women since 1990, which is statistically significant only for IS among men. Ongoing monitoring of sex differences in the burden of stroke will be needed to determine if disease rates among men and women continue to diverge. Sex disparities related to stroke will have important clinical and policy implications that can guide funding and resource allocation for national, regional and global health programs.

Sex Differences in the Presentation, Diagnosis, and Management of Acute Coronary Syndromes: Findings From the Kerala-India ACS Registry

BACKGROUND

Previous literature from high-income countries has repeatedly shown sex differences in the presentation, diagnosis, and management of acute coronary syndromes (ACS), with women having atypical presentations and undergoing less aggressive diagnostic and therapeutic measures. However, much less data exist evaluating sex differences in ACS in India.

OBJECTIVES

This study sought to evaluate sex differences in the diagnosis, management, and treatment of patients with ACS in Kerala, India.

METHODS

The Kerala ACS Registry collected data from 25,748 consecutive ACS admissions (19,923 men and 5,825 women) from 125 hospitals in the Indian state of Kerala from 2007 to 2009. This study evaluated the association between sex differences in presentation, in-hospital management, and discharge care with in-hospital mortality and in-hospital major adverse cardiovascular events (defined as death, reinfarction, stroke, heart failure, or cardiogenic shock).

RESULTS

Women with ACS were older than men with ACS (64 vs. 59, p < 0.001) and were more likely to have a history of previous myocardial infarction (16% vs. 14%, p < 0.001). Inpatient diagnostics and management and discharge care were similar between sexes. No significant differences between men and women in the outcome of death (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 0.80 to 1.38) or in the composite outcome of death, reinfarction, stroke, heart failure, or cardiogenic shock (OR: 0.99, 95% CI: 0.79 to 1.25) were seen after adjustment for possible confounding factors.

CONCLUSIONS

In Kerala, even though women with ACS were older and more likely to have previous myocardial infarction, there were no significant differences in in-hospital and discharge management, in-hospital mortality, or major adverse cardiovascular events between sexes. Whether these results apply to other parts of India or acute presentations of other chronic diseases in low- and middle-income countries warrants further study.

Ischaemic Heart Disease at the University Hospital of the West Indies: Trends in Hospital Admissions and Inpatient Mortality Rates 2005-2010

OBJECTIVES

This study aimed to estimate hospital admission rates and inpatient mortality rates for ischaemic heart disease (IHD) and its subtypes at the University Hospital of the West Indies (UHWI) for the years 2005─2010, and to identify factors associated with inpatient mortality.

METHODS

Data from electronic discharge summaries for patients diagnosed with acute myocardial infarction (A-MI), unstable angina (UA) or other IHD were obtained from the Patient Information Management Systems database of the Medical Records Department of the UHWI. Data were entered into an electronic database and analysed using Stata 10.1. Random effects logistic regression was used to identify factors associated with inpatient mortality.

RESULTS

Analysis included 3794 admissions (2821 persons: 1415 males, 1406 females; mean age 63.9 ± 13.5 years). Overall admission rates for IHD were 12.1% (95% CI 11.7, 12.5) for medical admissions and 4.02% (95% CI 3.89, 4.15) for non-paediatric admissions. Admission rates were higher among males compared to females. There was a statistically significant trend for an overall increase in the rates for IHD admissions over the study period. Inpatient mortality rate was 18.9% for A-MI, 1.6% for UA and 7.8% for other IHD. In multivariable models, adjusted for age and gender, A-MI was associated with higher mortality compared to other IHD (OR 3.38, p < 0.001).

CONCLUSIONS

Ischaemic heart disease admission rate is increasing at the UHWI and accounts for approximately one of every eight medical admissions. Inpatient mortality for acute myocardial infarction is approximately 19%. Further studies are required to determine the factors associated with inpatient mortality and to inform strategies for improving outcomes.

Prevalence of comorbidities and their impact on hospital management and short-term outcomes in Vietnamese patients hospitalized with a first acute myocardial infarction

Background

Cardiovascular disease is one of the leading causes of morbidity and mortality in Vietnam. We conducted a pilot study of Hanoi residents hospitalized with a first acute myocardial infarction (AMI) at the Vietnam National Heart Institute in Hanoi for purposes of describing the prevalence of cardiovascular (CVD) and non-CVD comorbidities and their impact on hospital management, in-hospital clinical complications, and short-term mortality in these patients.

Methods

The study population consisted of 302 Hanoi residents hospitalized with a first AMI at the largest tertiary care medical center in Hanoi in 2010.

Results

The average age of study patients was 66 years and one third were women. The proportions of patients with none, any 1, and ≥ 2 CVD comorbidities were 34%, 42%, and 24%, respectively. Among the CVD comorbidities, hypertension was the most commonly reported (59%). There were decreasing trends in the proportion of patients who were treated with effective cardiac medications and coronary interventions as the number of CVD comorbidities increased. Patients with multiple CVD comorbidities tended to develop acute clinical complications and die at higher rates during hospitalization compared with patients with no CVD comorbidities (Odds Ratio: 1.40; 95% Confidence Interval: 0.40–4.84).

Conclusions

Our data suggest that patients with multiple cardiac comorbidities tended to experience high in-hospital death rates in the setting of AMI. Full-scale surveillance of Hanoi residents hospitalized with AMI at all Hanoi hospitals is needed to confirm these findings. Effective strategies to manage Vietnamese patients hospitalized with AMI who have multiple comorbidities are warranted to improve their short-term prognosis.

Sex differences in clinical characteristics, hospital management practices, and in-hospital outcomes in patients hospitalized in a Vietnamese hospital with a first acute myocardial infarction

Background

Cardiovascular disease is one of the leading causes of morbidity and mortality in Vietnam. We conducted a pilot study of Hanoi residents hospitalized with acute myocardial infarction (AMI) at the Vietnam National Heart Institute in Hanoi. The objectives of this observational study were to examine sex differences in clinical characteristics, hospital management, in-hospital clinical complications, and mortality in patients hospitalized with an initial AMI.

Methods

The study population consisted of 302 Hanoi residents hospitalized with a first AMI at the largest tertiary care medical center in Hanoi in 2010.

Results

The average age of study patients was 66 years and one third were women. Women were older (70 vs. 64 years) and were more likely than men to have had hyperlipidemia previously diagnosed (10% vs. 2%). During hospitalization, women were less likely to have undergone percutaneous coronary intervention (PCI) compared with men (57% vs. 74%), and women were more likely to have developed heart failure compared with men (19% vs. 10%). Women experienced higher in-hospital case-fatality rates (CFRs) than men (13% vs. 4%) and these differences were attenuated after adjustment for age and history of hyperlipidemia (OR: 2.64; 95% CI: 1.01, 6.89), and receipt of PCI during hospitalization (OR: 2.09; 95% CI: 0.77, 5.09).

Conclusions

Our pilot data suggest that among patients hospitalized with a first AMI in Hanoi, women experienced higher in-hospital CFRs than men. Full-scale surveillance of all Hanoi residents hospitalized with AMI at all Hanoi medical centers is needed to confirm these findings. More targeted and timely educational and treatment approaches for women appear warranted.

Sex differentiation with regard to coronary artery disease

Coronary artery disease was considered a male disease for many years. However, nowadays, coronary artery disease constitutes the leading cause of death in women, although there are a lot of gender-related differences regarding the presentation of acute myocardial infarction, its diagnosis, its treatment, short- and long-term mortality rates, and post-acute myocardial infarction complications. Generally, women have smaller and stiffer hearts and cardiac vessels, suffering a greater extent of atherosclerosis and endothelial and smooth muscle dysfunction. They are usually older than men and they have more comorbidities such as hypertension, renal impairment, and diabetes mellitus. Moreover, female coronary artery disease, the diagnosis of which is more complicated due to more false negative results of some diagnostic methods in women, is more often presented with atypical symptoms and women's symptoms of typical or atypical angina are more severe. Furthermore, women delay significantly more in seeking care and they are more frequently undertreated. Finally, women are associated with generally poorer in-hospital and long-term prognosis having almost two-fold higher early mortality and they are more prone to complications such as bleeding complications, shock, and heart failure, as well as to post-myocardial infarction depression and poorer physical function and mental health. In this review, we discuss these sex-related differences according to current literature.

Association between gender, process of care measures, and outcomes in ACS in India: results from the detection and management of coronary heart disease (DEMAT) registry

Background

Studies from high-income countries have shown that women receive less aggressive diagnostics and treatment than men in acute coronary syndromes (ACS), though their short-term mortality does not appear to differ from men. Data on gender differences in ACS presentation, management, and outcomes are sparse in India.

Methods and Results

The Detection and Management of Coronary Heart Disease (DEMAT) Registry collected data from 1,565 suspected ACS patients (334 women; 1,231 men) from ten tertiary care centers throughout India between 2007–2008. We evaluated gender differences in presentation, in-hospital and discharge management, and 30-day death and major adverse cardiovascular event (MACE; death, re-hospitalization, and cardiac arrest) rates. Women were less likely to present with STEMI than men (38% vs. 55%, p<0.001). Overall inpatient diagnostics and treatment patterns were similar between men and women after adjustment for potential confounders. Optimal discharge management with aspirin, clopidogrel, beta-blockers, and statin therapy was lower for women than men, (58% vs. 65%, p = 0.03), but these differences were attenuated after adjustment (OR = 0.86 (0.62, 1.19)). Neither the outcome of 30-day mortality (OR = 1.40 (0.62, 3.16)) nor MACE (OR = 1.00 (0.67, 1.48)) differed significantly between men and women after adjustment.

Conclusions

ACS in-hospital management, discharge management, and 30-day outcomes did not significantly differ between genders in the DEMAT registry, though consistently higher treatment rates and lower event rates in men compared to women were seen. These findings underscore the importance of further investigation of gender differences in cardiovascular care in India.