Sex differences in evaluation and outcome of unstable angina

Gender Differences in Patients With Stable Chest Pain

This study sought to investigate gender differences in clinical presentation, presence, and extent of coronary artery disease (CAD), and all-cause mortality in patients with stable chest pain who underwent coronary computed tomography angiography (CCTA). Patients who visited the fast-track outpatient clinic of the Erasmus Medical Center and underwent CCTA were analyzed. Clinical characteristics of chest pain, CAD on CCTA, coronary artery calcium scores, and survival were collected retrospectively and compared between men and women. Logistic regression was used to identify independent risk factors for the presence of CAD and Cox regression for all-cause mortality. In 1,835 included patients, 966 (52.6%) were female. Men and women were similar in age (55 vs 56 years). Compared with men, women had a lower frequency of typical pain (22.8% vs 31.1%, p <0.001), lower prevalence of significant CAD (22.2% vs 38.1%, p <0.001), and lower coronary artery calcium scores (p <0.001). CAD was more prevalent in men than in women with typical pain (67.4% vs 35.9%, p <0.001) and also with nontypical pain (24.9% vs 18.1%, p = 0.002). After adjustment for baseline characteristic, male sex was associated with all-cause mortality (adjusted hazard ratio 1.87, 95% confidence interval 1.25 to 2.80, p = 0.002). The additional risk of mortality because of CAD was similar between men and women. Stratifying by typical and nontypical pain, women again had a better prognosis. Our study identifies gender-related differences in characteristics, CCTA-findings, and outcomes for women compared with men presenting for CCTA with chest pain. Women have less CAD and a better prognosis than men, the clinical implications of which require further study.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

STRUCTURE

Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

STRUCTURE

Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

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).

Not typical angina and mortality in women with obstructive coronary artery disease: Results from the Women's Ischemic Syndrome Evaluation study (WISE)

BACKGROUND

Women frequently present with symptoms not typical of angina (NTA) making ischemic heart disease recognition, diagnosis and treatment challenging. We compared mortality in women with obstructive coronary artery disease (CAD) with NTA vs typical angina (TA).

METHODS

We studied 326 Women's Ischemia Syndrome Evaluation (WISE) participants undergoing coronary angiography for suspected myocardial ischemia with core-lab measured obstructive CAD. TA was defined as sub-sternal chest pain precipitated by physical exertion or emotional stress and relieved with rest or nitroglycerin; NTA did not meet criteria for TA. The women were followed for non-fatal events and death for a median of 5.9 and 9.6 years respectively. Multivariate cox proportional hazards regression determined relations to events.

RESULTS

Overall, 115 (35%) of the women had TA. Baseline demographics, risk factors or additional symptom characteristics were similar between the two angina groups. Non-fatal events did not differ between groups. Women with NTA had a higher mortality compared to TA women (36% vs 26%, respectively, p = 0.047). Despite adjustment for additional major risk variables, NTA was an independent predictor of mortality compared to TA with a hazard ratio of 1.73 (95% Confidence interval: 1.04, 2.89).

CONCLUSIONS

Among women with suspected ischemia undergoing coronary angiography with obstructive CAD, NTA was more common than TA, and predicted a higher longer-term mortality. Further investigation is needed to confirm these results, and investigate potential explanations for the higher mortality observed in women with NTA women, including lower recognition or action in the setting of obstructive CAD.

Quantifying Sex Differences in Cardiovascular Care Among Patients Evaluated for Suspected Ischemic Heart Disease

Background: Cardiovascular care sex differences are controversial. We examined sex differences in management and clinical outcomes among patients undergoing noninvasive testing for ischemic heart disease (IHD). Methods: In a rural integrated healthcare system, we identified adults age 40-79 without diagnosed IHD who underwent initial evaluation with a cardiac stress test with imaging or coronary computed tomographic angiography (CTA), 2013-2014. We assessed sex differences in statin/aspirin therapy, revascularization, and adverse cardiovascular events. The 2013 American College of Cardiology/American Heart Association statin guidelines and U.S. Preventive Services Task Force aspirin guidelines were applied. Results: Among 2213 patients evaluated for IHD, median age was 57 years, 48.8% were women, and 9% had a positive stress test/CTA. Women were more likely to be missing lipid values than men (p < 0.001). Mean ASCVD risk score at baseline was 7.2% in women versus 12.4% in men (p < 0.001). There was no significant sex difference in statin therapy at baseline or 60-day follow-up. Women were less likely than men to be taking aspirin at baseline (adj. diff. = -8.5%; 95% CI, -4.2 to -12.9) and follow-up (adj. diff. = -7.7%; 95% CI, -3.3 to -12.1). There were no sex differences in revascularization after accounting for obstructive CAD or adverse cardiovascular outcomes during median follow-up of 33 months. Conclusion: In this contemporary cohort of patients with suspected IHD, women were less likely to receive lipid testing and aspirin therapy, but not statin therapy. Women did not experience worse outcomes. Sex differences in statin therapy reported by others may be due to inadequate accounting for baseline risk.

Stable ischemic heart disease in women: current perspectives

Cardiovascular disease is the leading cause of death in women accounting for 1 in every 4 female deaths. Pathophysiology of ischemic heart disease in women includes epicardial coronary artery, endothelial dysfunction, coronary vasospasm, plaque erosion and spontaneous coronary artery dissection. Angina is the most common presentation of stable ischemic heart disease (SIHD) in women. Risk factors for SIHD include traditional risks such as older age, obesity (body mass index [BMI] >25 kg/m²), smoking, hypertension, dyslipidemia, cerebrovascular and peripheral vascular disease, sedentary lifestyle, family history of premature coronary artery disease, metabolic syndrome and diabetes mellitus, and nontraditional risk factors, such as gestational diabetes, insulin resistance/polycystic ovarian disease, pregnancy-induced hypertension, pre-eclampsia, eclampsia, menopause, mental stress and autoimmune diseases. Diagnostic testing can be used effectively to risk stratify women. Guidelines-directed medical therapy including aspirin, statins, beta-blocker therapy, calcium channel blockers and ranolazine should be instituted for symptom and ischemia management. Despite robust evidence regarding the adverse outcomes seen in women with ischemic heart disease, knowledge gaps exist in several areas. Future research needs to be directed toward a greater understanding of the role of nontraditional risk factors for SIHD in women, gaining deeper insights into the sex differences in therapeutic effects and formulating a sex-specific algorithm for the management of SIHD in women.

Utility of Imaging in Risk Stratification of Chest Pain in Women

OPINION STATEMENT

Recent decades have seen a growing recognition that the understanding of sex differences in cardiovascular disease (CVD) is vital to optimal diagnosis and management, particularly of women (Mosca et al. Circulation 124:2145-54, 2011). There is simultaneously an increasing appreciation of the multifactorial nature of ischemic heart disease (IHD) in many patients, in whom disease may extend beyond the epicardial coronaries. While obstructive coronary artery disease (CAD) remains underdiagnosed in women and still represents a major burden of disease, women also present with nonobstructive CAD more commonly than men (Patel et al. N Engl J Med 362:886-95, 2010). Indeed, microvascular dysfunction, coronary artery vasospasm, and coronary dissections contribute to a larger proportion of IHD in women than men (Bairey Merz et al. J Am Coll Cardiol 47:S21-9, 2006). Here, we review the symptom presentation of women with IHD and the noninvasive modalities used to risk stratify women with suspected IHD.

Impact of gender difference in hospital outcomes following percutaneous coronary intervention. Results of the Belgian Working Group on Interventional Cardiology (BWGIC) registry

AIMS

To determine whether there are gender-based differences in in-hospital outcomes among patients undergoing percutaneous coronary intervention (PCI).

METHODS AND RESULTS

We studied a large cohort using clinical data from a registry of 130,985 PCI procedures in Belgium, from January 2006 to February 2011. Compared to males, females were significantly older (70.3 vs. 64.8 years), and were more frequently diabetic or hypertensive. Men smoked more and more frequently had previous myocardial infarction (MI), previous PCI or previous coronary artery bypass graft (CABG) surgery. Coronary artery disease (CAD) was less severe in women, and PCI to the left anterior descending artery was more common in female patients. Unadjusted in-hospital mortality rates were higher in females versus males (2.5% for women and 1.6% for men, p<0.0001). After multivariable analysis, female gender remained an independent predictor of mortality (odds ratio 1.35, 95% CI: 1.22-1.49, p<0.0001).

CONCLUSIONS

Gender-based differences in hospital mortality rates after PCI were observed in this large registry. Female sex remained an independent predictor of mortality after multivariable adjustment.

Sex Differences in Demographics, Risk Factors, Presentation, and Noninvasive Testing in Stable Outpatients With Suspected Coronary Artery Disease: Insights From the PROMISE Trial

OBJECTIVES

The aim of this study was to determine whether presentation, risk assessment, testing choices, and results differ by sex in stable symptomatic outpatients with suspected coronary artery disease (CAD).

BACKGROUND

Although established CAD presentations differ by sex, little is known about stable, suspected CAD.

METHODS

The characteristics of 10,003 men and women in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial were compared using chi-square and Wilcoxon rank-sum tests. Sex differences in test selection and predictors of test positivity were examined using logistic regression.

RESULTS

Women were older (62.4 years of age vs. 59.0 years of age) and were more likely to be hypertensive (66.6% vs. 63.2%), dyslipidemic (68.9% vs. 66.3%), and to have a family history of premature CAD (34.6% vs. 29.3) (all p values <0.005). Women were less likely to smoke (45.6% vs. 57.0%; p < 0.001), although their prevalence of diabetes was similar to that in men (21.8% vs. 21.0%; p = 0.30). Chest pain was the primary symptom in 73.2% of women versus 72.3% of men (p = 0.30), and was characterized as “crushing/pressure/squeezing/tightness” in 52.5% of women versus 46.2% of men (p < 0.001). Compared with men, all risk scores characterized women as being at lower risk, and providers were more likely to characterize women as having a low (<30%) pre-test probability of CAD (40.7% vs. 34.1%; p < 0.001). Compared with men, women were more often referred to imaging tests (adjusted odds ratio: 1.21; 95% confidence interval: 1.01 to 1.44) than nonimaging tests. Women were less likely to have a positive test (9.7% vs. 15.1%; p < 0.001). Although univariate predictors of test positivity were similar, in multivariable models, age, body mass index, and Framingham risk score were predictive of a positive test in women, whereas Framingham and Diamond and Forrester risk scores were predictive in men.

CONCLUSIONS

Patient sex influences the entire diagnostic pathway for possible CAD, from baseline risk factors and presentation to noninvasive test outcomes. These differences highlight the need for sex-specific approaches for the evaluation of CAD.

Computed Tomographic Perfusion Improves Diagnostic Power of Coronary Computed Tomographic Angiography in Women

Background—

Coronary computed tomographic angiography (CTA) and myocardial perfusion imaging (CTP) is a validated approach for detection and exclusion of flow-limiting coronary artery disease (CAD), but little data are available on gender-specific performance of these modalities. In this study, we aimed to evaluate the diagnostic accuracy of combined coronary CTA and CTP in detecting flow-limiting CAD in women compared with men.

Methods and Results—

Three hundred and eighty-one patients who underwent both CTA-CTP and single-photon emission computed tomography myocardial perfusion imaging preceding invasive coronary angiography as part of the CORE320 multicenter study (Coronary Artery Evaluation Using 320-row Multidetector Computed Tomography Angiography and Myocardial Perfusion) were included in this ancillary study. All 4 image modalities were analyzed in blinded, independent core laboratories. Prevalence of flow-limiting CAD defined by invasive coronary angiography equal to 50% or greater with an associated single-photon emission computed tomography myocardial perfusion imaging defect was 45% (114/252) and 23% (30/129) in males and females, respectively. Patient-based diagnostic accuracy defined by the area under the receiver operating curve for detecting flow-limiting CAD by CTA alone in females was 0.83 (0.75–0.89) and for CTA-CTP was 0.92 (0.86–0.97; P =0.003) compared with men where the area under the receiver operating curve for detecting flow-limiting CAD by CTA alone was 0.82 (0.77–0.87) and for CTA-CTP was 0.84 (0.80–0.89; P =0.29).

Conclusions—

The combination of CTA-CTP was performed similarly in men and women for identifying flow-limiting coronary stenosis; however, in women, CTP had incremental value over CTA alone, which was not the case in men.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00934037.

Role of risk stratification and genetics in sudden cardiac death

Sudden cardiac death (SCD) is a major public health issue due to its increasing incidence in the general population and the difficulty in identifying high-risk individuals. Nearly 300 000 - 350 000 patients in the United States and 4-5 million patients in the world die annually from SCD. Coronary artery disease and advanced heart failure are the main etiology for SCD. Ischemia of any cause precipitates lethal arrhythmias, and ventricular tachycardia and ventricular fibrillation are the most common lethal arrhythmias precipitating SCD. Pulseless electrical activity, bradyarrhythmia, and electromechanical dissociation also result in SCD. Most SCDs occur outside of the hospital setting, so it is difficult to estimate the public burden, which results in overestimating the incidence of SCD. The insufficiency and limited predictive value of various indicators and criteria for SCD result in the increasing incidence. As a result, there is a need to develop better risk stratification criteria and find modifiable variables to decrease the incidence. Primary and secondary prevention and treatment of SCD need further research. This critical review is focused on the etiology, risk factors, prognostic factors, and importance of risk stratification of SCD.

The Impact of Unstable Angina Guidelines in the Triage of Emergency Department Patients with Possible Acute Coronary Syndrome

Objective. The primary aim of this study is to determine whether implementing the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline improves emergency physician's decision making in patients with symptoms of possible acute coronary syndrome (ACS), including those for whom the diagnosis of unstable angina is uncertain. Methods. The authors conducted a prospective guideline implementation trial with pre-post design in the emergency departments of 1 university hospital and 1 university-affiliated community teaching hospital from January 2000 to May 2001. They enrolled 1140 adults who presented with chest pain or other symptoms of possible ACS. The intervention included the following: 1) physician training in use of the AHCPR risk groups, 2) algorithm for risk stratification, and 3) group feedback. To determine how accurately physicians interpreted the guideline algorithm, the authors compared their risk ratings with actual guideline risk groups. Results. No significant difference in physician triage decisions was observed between baseline and intervention periods. Analysis of physician's risk ratings during the intervention period revealed low overall concordance with actual guideline risk groups (kappa = 0.31); however, physician's risk ratings showed superior discrimination in identifying patients with confirmed ACS (receiver operating characteristic [ROC] area .81 v. .74, P = 0.008). Strict adherence to guideline recommendations would have resulted in hospitalizing 9% more non-ACS patients without lowering the rate of missed ACS. Conclusion. Implementation of the AHCPR guideline did not improve triage decisions in emergency department patients with possible ACS. Assessing physician triage solely based on concordance with the AHCPR guideline may not accurately reflect the quality of patient care.

Epidemiology of coronary heart disease and acute coronary syndrome

The aim of this review is to summarize the incidence, prevalence, trend in mortality, and general prognosis of coronary heart disease (CHD) and a related condition, acute coronary syndrome (ACS). Although CHD mortality has gradually declined over the last decades in western countries, this condition still causes about one-third of all deaths in people older than 35 years. This evidence, along with the fact that mortality from CHD is expected to continue increasing in developing countries, illustrates the need for implementing effective primary prevention approaches worldwide and identifying risk groups and areas for possible improvement.

Interpreting angina: symptoms along a gender continuum

BACKGROUND

'Typical' angina is often used to describe symptoms common among men, while 'atypical' angina is used to describe symptoms common among women, despite a higher prevalence of angina among women. This discrepancy is a source of controversy in cardiac care among women.

OBJECTIVES

To redefine angina by (1) qualitatively comparing angina symptoms and experiences in women and men and (2) to propose a more meaningful construct of angina that integrates a more gender-centred approach.

METHODS

Patients were recruited between July and December 2010 from a tertiary cardiac care centre and interviewed immediately prior to their first angiogram. Symptoms were explored through in-depth semi-structured interviews, transcribed verbatim and analysed concurrently using a modified grounded theory approach. Angiographically significant disease was assessed at ≥70% stenosis of a major epicardial vessel.

RESULTS

Among 31 total patients, 13 men and 14 women had angiograpically significant CAD. Patients describe angina symptoms according to 6 symptomatic subthemes that array along a 'gender continuum'. Gender-specific symptoms are anchored at each end of the continuum. At the centre of the continuum, are a remarkably large number of symptoms commonly expressed by both men and women.

CONCLUSIONS

The 'gender continuum' offers new insights into angina experiences of angiography candidates. Notably, there is more overlap of shared experiences between men and women than conventionally thought. The gender continuum can help researchers and clinicians contextualise patient symptom reports, avoiding the conventional 'typical' versus 'atypical' distinction that can misrepresent gendered angina experiences.

Age- and Gender-related Disparities in Primary Percutaneous Coronary Interventions for Acute ST-segment elevation Myocardial Infarction

Background

Previous analyses reported age- and gender-related differences in the provision of cardiac care. The objective of the study was to compare circadian disparities in the delivery of primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) according to the patient’s age and gender.

Methods

We investigated patients included into the Acute Myocardial Infarction in Switzerland (AMIS) registry presenting to one of 11 centers in Switzerland providing primary PCI around the clock, and stratified patients according to gender and age.

Findings

A total of 4723 patients presented with AMI between 2005 and 2010; 1319 (28%) were women and 2172 (54%) were ≥65 years of age. More than 90% of patients <65 years of age underwent primary PCI without differences between gender. Elderly patients and particularly women were at increased risk of being withheld primary PCI (males adj. HR 4.91, 95% CI 3.93–6.13; females adj. HR 9.31, 95% CI 7.37–11.75) as compared to males <65 years of age. An increased risk of a delay in door-to-balloon time >90 minutes was found in elderly males (adj HR 1.66 (95% CI 1.40–1.95), p<0.001) and females (adj HR 1.57 (95% CI 1.27–1.93), p<0.001), as well as in females <65 years (adj HR 1.47 (95% CI 1.13–1.91), p = 0.004) as compared to males <65 years of age, with significant differences in circadian patterns during on- and off-duty hours.

Conclusions

In a cohort of patients with AMI in Switzerland, we observed discrimination of elderly patients and females in the circadian provision of primary PCI.

The diagnostic value of clinical symptoms in women and men presenting with chest pain at the emergency department, a prospective cohort study

Background

Previous studies suggested that diagnosing coronary artery disease (CAD) is more difficult in women than in men. Studies investigating the predictive value of clinical signs and symptoms and compare its combined diagnostic value between women and men are lacking.

Methodology

Data from a large multicenter prospective study was used. Patients admitted to the emergency department (ED) with chest pain but without ST-elevation were eligible. The endpoint was proven CAD, defined as a significant stenosis at angiography or the diagnosis of a non-ST-elevation myocardial infarction or cardiovascular death within six weeks after presentation at the ED. Twelve clinical symptoms and seven cardiovascular risk factors were collected. Potential predictors of CAD with a p-value <0.15 in the univariable analysis were included in a multivariable model. The diagnostic value of clinical symptoms and cardiovascular risk factors was quantified in women and men separately and areas under the curve (AUC) were compared between sexes.

Results

A total of 2433 patients were included. We excluded 102 patients (4%) with either an incomplete follow up or ST-elevation. Of the remaining 2331 patients 43% (1003) were women. CAD was present in 111 (11%) women and 278 (21%) men. In women 11 out of 12 and in men 10 out of 12 clinical symptoms were univariably associated with CAD. The AUC of symptoms alone was 0.74 (95%CI: 0.69-0.79) in women and 0.71 (95%CI: 0.68-0.75) in men and increased to respectively 0.79 (95%CI: 0.74-0.83) in women versus 0.75 (95%CI: 0.72-0.78) in men after adding cardiovascular risk factors. The AUCs of women and men were not significantly different (p-value symptoms alone: 0.45, after adding cardiovascular risk factors: 0.11).

Conclusion

The diagnostic value of clinical symptoms and cardiovascular risk factors for the diagnosis of CAD in chest pain patients presenting on the ED was high in women and men. No significant differences were found between sexes.

Sex differences and attitudes toward living donor kidney transplantation among urban black patients on hemodialysis

BACKGROUND AND OBJECTIVES

Living donor kidney transplantation, the treatment of choice for ESRD, is underused by women and blacks. To better understand sex differences in the context of potential barriers to living donor kidney transplantation, the Dialysis Patient Transplant Questionnaire was administered in two urban, predominantly black hemodialysis units.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Dialysis Patient Transplant Questionnaire was designed to study barriers to kidney transplantation from previously validated questions. Between July of 2008 and January of 2009, the Dialysis Patient Transplant Questionnaire was administered to 116 patients on hemodialysis, including potentially eligible and ineligible living donor kidney transplantation candidates. Of 101 patients who self-identified as black or African American, 50 (49.5%) patients had the questionnaire entirely administered by the researcher or assistant, 25 (24.8%) patients required some assistance, and 26 (25.7%) patients completed the Dialysis Patient Transplant Questionnaire entirely by themselves. Multiple logistic regression methods were used to determine if the observed bivariate associations and differences persisted when controlled for potential confounders.

RESULTS

Women were less likely to want living donor kidney transplantation compared with men (58.5% versus 87.5%, P=0.003), despite being nearly two times as likely as men to receive unsolicited offers for kidney transplant (73.2% versus 43.2%, P=0.02). They were also less likely to have been evaluated for a kidney transplant (28.3% versus 52.2%, P=0.01). The multiple logistic regression analysis showed that sex was a statistically significant predictor of wanting living donor kidney transplantation (women versus men odds ratio, 0.13; 95% confidence interval, 0.04 to 0.46), controlling for various factors known to influence transplant decisions. A sensitivity analysis indicated that mode of administration did not bias these results.

CONCLUSIONS

In contrast to previous studies, the study found that black women were less likely to want living donor kidney transplantation compared with black men. Black women were also less likely to be evaluated for a kidney transplant, although they were more likely to receive an unsolicited living donor kidney transplantation offer.

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.

Does patient gender impact resident physicians' approach to the cardiac exam?

BACKGROUND

Physical examination remains an important part of the initial evaluation of patients presenting with chest pain but little is known about the effect of patient gender on physician performance of the cardiovascular exam.

OBJECTIVE

To determine if resident physicians are less likely to perform five key components of the cardiovascular exam on female versus male standardized patients (SPs) presenting with acute chest pain.

DESIGN

Videotape review of SP encounters during Objective Structured Clinical Examinations (OSCEs) administered by the Emory University Internal Medicine Residency Program in 2006 and 2007. Encounters were reviewed to assess residents' performance of five cardiac exam skills: auscultation of the aortic, pulmonic, tricuspid, and mitral valve areas and palpation for the apical impulse.

PARTICIPANTS

One hundred forty-nine incoming residents.

MAIN MEASURES

Residents' performance for each skill was classified as correct, incorrect, or unknown.

KEY RESULTS

One hundred ten of 149 (74 %) of encounters were available for review. Residents were less likely to correctly perform each of the five skills on female versus male SPs. This difference was statistically significant for auscultation of the tricuspid (p = 0.004, RR = 0.62, 95 % CI 0.46-0.83) and mitral (p = 0.007, RR = 0.58, 95 % CI = 0.41-0.83) valve regions and palpation for the apical impulse (p < 0.001, RR = 0.27, 95 % CI = 0.16-0.47). Male residents were less likely than female residents to correctly perform each maneuver on female versus male SPs. The interaction of SP gender and resident gender was statistically significant for auscultation of the mitral valve region (p = 0.006) and palpation for the apical impulse (p = 0.01).

CONCLUSIONS

We observed significant differences in the performance of key elements of the cardiac exam for female versus male SPs presenting with chest pain. This observation represents a previously unidentified but potentially important source of gender bias in the evaluation of patients presenting with cardiovascular complaints.

Elevated PLA2G7 gene promoter methylation as a gender-specific marker of aging increases the risk of coronary heart disease in females

PLA2G7 gene product is a secreted enzyme whose activity is associated with coronary heart disease (CHD). The goal of our study is to investigate the contribution of PLA2G7 promoter DNA methylation to the risk of CHD. Using the bisulphite pyrosequencing technology, PLA2G7 methylation was measured among 36 CHD cases and 36 well-matched controls. Our results indicated that there was a significant association between PLA2G7 methylation and CHD (adjusted P = 0.025). Significant gender-specific correlation was observed between age and PLA2G7 methylation (males: adjusted r = −0.365, adjusted P = 0.037; females: adjusted r = 0.373, adjusted P = 0.035). A breakdown analysis by gender showed that PLA2G7 methylation was significantly associated with CHD in females (adjusted P = 0.003) but not in males. A further two-way ANOVA analysis showed there was a significant interaction between gender and status of CHD for PLA2G7 methylation (gender*CHD: P = 6.04E−7). Moreover, PLA2G7 methylation is associated with the levels of total cholesterols (TC, r = 0.462, P = 0.009), triglyceride (TG, r = 0.414, P = 0.02) and Apolipoprotein B (ApoB, r = 0.396, P = 0.028) in females but not in males (adjusted P>0.4). Receiver operating characteristic (ROC) curves showed that PLA2G7 methylation could predict the risk of CHD in females (area under curve (AUC) = 0.912, P = 2.40E−5). Our results suggest that PLA2G7 methylation changes with aging in a gender-specific pattern. The correlation between PLA2G7 methylation and CHD risk in females is independent of other parameters including age, smoking, diabetes and hypertension. PLA2G7 methylation might exert its effects on the risk of CHD by regulating the levels of TC, TG, and ApoB in females. The gender disparities in the PLA2G7 methylation may play a role in the molecular mechanisms underlying the pathophysiology of CHD.

Sex differences in the management and outcomes of Ontario patients with cardiogenic shock complicating acute myocardial infarction

BACKGROUND

Sex differences in the management of acute myocardial infarction (AMI) patients with cardiogenic shock (CS) have not been well studied.

METHODS

We examined mortality and revascularization rates of 9750 patients with CS between 1992 and 2008 in the Ontario Myocardial Infarction Database. Men and women were compared in the entire cohort and in subgroups divided by age (aged < 75 years vs aged ≥ 75 years) and revascularization availability at presenting hospital. Logistic regression was used to determine the adjusted effect of sex on mortality and to determine predictors of revascularization.

RESULTS

The incidence of CS was higher in women (3.7% of female vs 2.7% of male AMI patients; P < 0.001). Women with CS were older than men (mean age: 75.5 vs 71.1 years; P < 0.001) and less likely to present to revascularization-capable sites (16% vs 19.2%; P < 0.001). Unadjusted 1-year mortality rates were higher in women (80.3% vs 75.4%; P < 0.001). Women were less likely to be revascularized (12.6% vs 17.6%; P < 0.001) and less likely to be transferred when they presented to nonrevascularization sites (11.3% vs 14.2%; P < 0.001). The strongest predictor of revascularization was presentation to a revascularization-capable site (odds ratio, 17.69; P < 0.001). After regression adjustment, there were no significant differences in mortality or revascularization between the sexes.

CONCLUSION

Women with CS are older than men with CS and are less likely to present to revascularization-capable sites. This accounts for the lower unadjusted revascularization rates among women compared with men. However, there are no significant sex-based differences in adjusted mortality rates.

Are there symptom differences in patients with coronary artery disease presenting to the ED ultimately diagnosed with or without ACS?

OBJECTIVES

Symptoms are compared among patients with coronary artery disease (CAD) admitted to the emergency department with or without acute coronary syndrome (ACS). Sex and age are also assessed.

METHODS

A secondary analysis from the PROMOTION (Patient Response tO Myocardial Infarction fOllowing a Teaching Intervention Offered by Nurses) trial, an multicenter randomized controlled trial, was conducted.

RESULTS

Of 3522 patients with CAD, at 2 years, 565 (16%) presented to the emergency department, 234 (41%) with non-ACS and 331 (59%) with ACS. Shortness of breath (33% vs 25%, P = .028) or dizziness (11% vs 3%, P = .001) were more common in non-ACS. Chest pain (65% vs 77%, P = .002) or arm pain (9% vs 21%, P = .001) were more common in ACS. In men without ACS, dizziness was more common (11% vs 2%; P = .001). Men with ACS were more likely to have chest pain (78% vs 64%; P = .003); both men and women with ACS more often had arm pain (men, 19% vs 10% [P = .019]; women, 26% vs 13% [P = .023]). In multivariate analysis, patients with shortness of breath (odds ratio [OR], 0.617 [confidence interval [CI], 0.410-0.929]; P = .021) or dizziness (OR, .0311 [CI, 0.136-0.708]; P = .005) were more likely to have non-ACS. Patients with prior percutaneous coronary intervention (OR, 1.592 [CI, 1.087-2.332]; P = .017), chest pain (OR, 1.579 [CI, 1.051-2.375]; P = .028), or arm pain (OR, 1.751 [CI, 1.013-3.025]; P <.042) were more likely to have ACS.

CONCLUSIONS

In patients with CAD, shortness of breath and dizziness are more common in non-ACS, whereas prior percutaneous coronary intervention and chest or arm pain are important factors to include during ACS triage.

Percutaneous Valve Therapy: Choosing the Appropriate Patients and Outcomes

Surgical aortic valve replacement (SAVR) is the current gold standard for the treatment of severe symptomatic aortic stenosis (AS), but transcatheter aortic valve implantation (TAVI) currently represents a viable alternative to conventional SAVR for patients with AS at high risk of operative mortality. On multivariate analysis it has been shown that female gender is independently associated with better recovery of the left ventricular systolic function after TAVI and that left ventricular hypertrophy reverses more frequently in female patients after SAVR. During follow-up, however, women remain significantly more symptomatic compared with men, mainly because they present with more advanced valve disease at a significantly older age.

National gender-specific trends in myocardial infarction hospitalization rates among patients aged 35 to 64 years

In recent years, the prevalence of myocardial infarction (MI) has increased among women and decreased among men aged 35 to 54 years. To determine the extent to which changes in incidence account for recent variations in prevalence, we assessed the temporal trends in gender-specific hospitalization rates for MI. Using the Nationwide Inpatient Sample, we identified patients aged 35 to 64 years admitted to United States hospitals with a primary discharge diagnosis of MI from 1997 to 2006 (n = 2,824,615). The age-standardized MI hospitalization rates per 100,000 subjects were assessed for men and women aged 35 to 44, 45 to 54, and 55 to 64 years. The MI hospitalization rates per 100,000 subjects decreased by 26% from 168 to 126 for men and by 18% from 56 to 46 for women (both p <0.001). The reductions in the MI hospitalization rates were greatest among men aged 45 to 54, men aged 55 to 64, and women aged 55 to 64 years (standardized rates of change -3%, -4%, and -3% annually, p <0.001). The MI hospitalization rates decreased slightly for women aged 45 to 54 years and men aged 35 to 44 years (standardized rate of change -2% annually, p <0.001) and increased for women aged 35 to 44 years (standardized rate of change 2% annually, p = 0.008). In conclusion, from 1997 to 2006, men and women aged 35 to 64 years experienced an overall decrease in MI hospitalization rates; the reductions were more pronounced in men than in women. The slight increase in MI hospitalizations among women aged 35 to 44 years might have played a small role in the previously noted increases in MI prevalence among middle-age women.

Gender disparity and the appropriateness of myocardial perfusion imaging

BACKGROUND

Appropriate use criteria (AUC) were developed to guide the use of myocardial perfusion imaging (MPI). While MPI use has grown exponentially, women remain under tested. Given this bias in testing, we sought to determine if gender disparity exists in tests categorized by appropriateness and the role of referral bias.

METHODS

The AUC were applied to 314 consecutive MPI. Analysis of variance and chi-squared tests were used for analysis. Gender disparity was assessed using correlation matrices comparing baseline to gender reversed data.

RESULTS

Of the 314 studies, 263 were appropriate, 34 inappropriate, and 17 uncertain. Women had 68% of inappropriate studies, and 82% of uncertain studies (P < .01). Cardiologists ordered more appropriate studies than primary care physicians (PCPs) in women (86% vs 71%, P = .04). Among studies ordered by cardiologists and PCPs, a higher percentage of studies were appropriate in men vs women (96% vs 86%, P = 0.05 and 88% vs 71% P = .003), respectively. Gender reversal demonstrates disparity in the AUC tool with 46 (15%) not correlating (P < .00001).

CONCLUSIONS

Comparing patient gender and ordering physician, the majority of inappropriate and uncertain studies were ordered in women by PCPs, indicating a continuing need for education among PCPs, particularly as the AUC apply to women.

A depressed post-menopausal woman

BACKGROUND

Post-menopausal women are at significant risk for coronary artery disease, have increased rates of depression compared to their male counterparts, and often present atypically with coronary insufficiency. The symptoms of depression and coronary ischemia overlap greatly. Complaints like fatigue, body aches, and sleep disturbance reported by a depressed elderly woman may be cardiac related and need to be investigated seriously without physician bias.

OBJECTIVES

To ensure that clinicians are cautious when evaluating older women with a history of depression who are presenting with atypical complaints.

CASE REPORT

A 61-year-old woman with history of depression presented to the Emergency Department with multiple complaints atypical for acute coronary syndrome. She had an immediate electrocardiogram and troponin-T Biosite point-of-care test (Biosite Incorporated, San Diego, CA) performed, which were positive for cardiac ischemia and myocardial infarction. The patient underwent immediate cardiac catheterization, which revealed occlusion of the mid left circumflex. After aspiration of thrombus and balloon dilatation of the site, a bare metal stent was deployed, restoring excellent flow. The patient did well medically but her depression worsened after the procedure and continues despite psychiatric intervention.

CONCLUSION

For years there have been gender differences in medical treatment of coronary artery disease, and often women's complaints are not investigated aggressively. Post-menopausal women are at great risk for cardiac ischemia and depression, and their symptoms, which are often atypical, may not be diagnosed as anginal equivalents. In addition, depression is an independent risk factor for cardiovascular disease and, if it occurs after myocardial infarction, may lead to poor quality of life and increased morbidity and mortality. Patients who have had a coronary event must be thoroughly evaluated for signs of depression and receive the necessary treatment.

Gender bias revisited: new insights on the differential management of chest pain

Background

Chest pain is a common complaint and reason for consultation in primary care. Few data exist from a primary care setting whether male patients are treated differently than female patients. We examined whether there are gender differences in general physicians' (GPs) initial assessment and subsequent management of patients with chest pain, and how these differences can be explained

Methods

We conducted a prospective study with 1212 consecutive chest pain patients. The study was conducted in 74 primary care offices in Germany from October 2005 to July 2006. After a follow up period of 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient and decided about the etiology of chest pain at the time of patient recruitment (delayed type-reference standard). We adjusted gender differences of six process indicators for different models.

Results

GPs tended to assume that CHD is the cause of chest pain more often in male patients and referred more men for an exercise test (women 4.1%, men 7.3%, p = 0.02) and to the hospital (women 2.9%, men 6.6%, p < 0.01). These differences remained when adjusting for age and cardiac risk factors but ceased to exist after adjusting for the typicality of chest pain.

Conclusions

While observed gender differences can not be explained by differences in age, CHD prevalence, and underlying risk factors, the less typical symptom presentation in women might be an underlying factor. However this does not seem to result in suboptimal management in women but rather in overuse of services for men. We consider our conclusions rather hypothesis generating and larger studies will be necessary to prove our proposed model.

Effect of gender on treatment and outcomes in severe aortic stenosis

The aim of this study was to evaluate the effect of gender on operative rates and outcomes in men and women with severe aortic stenosis. An institutional echocardiographic database was used to identify all adult patients with severe aortic stenosis from 2004 through 2005. Only patients with class I indication for aortic valve replacement (AVR) during the period of follow-up were included in the study. Three hundred sixty-two patients were identified with severe aortic stenosis and class I indication for AVR (52% women). Overall operative rate for the cohort was 72%. In patients who underwent AVR, Kaplan-Meier survival rates were the same for men and women. Sixty-four percent of women versus 81% of men underwent AVR (p <0.001). After adjusting for multiple covariates, women had a 2.1-fold lower odds of undergoing AVR compared to men (p = 0.02). After matching for age and Society of Thoracic Surgery risk score, women underwent AVR at a 19% lower relative rate compared to men (p = 0.03); when stratified by gender, there was no difference in reasons for not undergoing AVR. In conclusion, despite similar outcomes after surgery, women with severe aortic stenosis are less likely than men to undergo AVR.

Ischemic heart disease in women: a review for primary care physicians

Ischemic heart disease (IHD) is the leading cause of death among women in the Western world, and its prevalence is growing. The pathophysiology of heart disease in women differs from that in men. Women with chest pain and abnormal stress tests are less likely than men to have critical stenosis of coronary arteries, a phenomenon attributed to endothelial dysfunction. Hypertension, intimal injury, and cholesterol are among the various factors that contribute to endothelial dysfunction. The presenting symptoms of IHD also differ in women. Women are more likely to describe neck and throat pain and to characterize the pain as intense, sharp, or burning. A history of coronary or other vascular disease, diabetes, or chronic kidney disease places patients at high risk for IHD. Risk factor modification can be tailored based on each patient's risk. Hormone replacement therapy, antioxidants, folic acid, and aspirin in healthy women under 65 years of age have recently been shown to be ineffective in the prevention of IHD.

Interactions among gender, age, hypertension and C-reactive protein in coronary vasospasm

BACKGROUND

Coronary vasospasm (CVsp) has been reported to be an inflammatory disease, reflected by elevated high-sensitivity C-reactive protein (hs-CRP). We investigated the interactions among gender, age, hypertension and hs-CRP in patients with CVsp.

MATERIALS AND METHODS

We retrospectively examined 722 Taiwanese patients with or without CVsp during an 8-year period. None of the patients had obstructive coronary artery disease. Serum hs-CRP levels were examined in a subset of 375 patients to evaluate the interactions of hs-CRP with gender, age, smoking and hypertension in the development of CVsp.

RESULTS

In women, only the highest hs-CRP tertile (> 3 mg L⁻¹) was independently associated with CVsp. In men, age > 58 years and the highest hs-CRP tertile were independently associated with CVsp. In women, elevated risk was only demonstrated in patients ≤ 58 years of age with hs-CRP levels in the highest tertile. In men, a positively monotonic trend was demonstrated between hs-CRP levels and CVsp in those > 58 years of age. The odds ratios of CVsp in both women and men with hs-CRP in the highest tertile reduced from 6·01 to 1·48 and 6·35-2·69 respectively, if they had hypertension.

CONCLUSION

The relationship between hs-CRP and CVsp differed between men and women. Our findings that there is a non-threshold model in men and a threshold model in women provide evidence that more smokers in men (life-style) and age (induction time) contribute to the natural history of CVsp development. The negative effect of hypertension on CVsp suggests that the pathogenesis of CVsp differs from that of coronary atherosclerosis.

Referrals in acute coronary events for CARdiac catheterization: The RACE CAR trial

BACKGROUND

Women with acute coronary syndromes have lower rates of cardiac catheterization (CC) than men.

OBJECTIVE

To determine whether sex⁄gender, age, risk level and patient preference influence physician decision making to refer patients for CC.

METHODS

Twelve clinical scenarios controlling for sex⁄gender, age (55 or 75 years of age), Thrombolysis in Myocardial Infarction risk score (low, moderate or high) and patient preference for CC (agreeable or refused⁄no preference expressed) were designed. Scenarios were administered to specialists across Canada using a web-based computerized survey instrument. Questions were standardized using a five-point Likert scale ranging from 1 (very unlikely to benefit from CC) to 5 (very likely to benefit from CC). Outcomes were assessed using a two-tailed mixed linear regression model.

RESULTS

Of 237 scenarios, physicians rated men as more likely to benefit from CC than women (mean [± SE] 4.44±0.07 versus 4.25±0.07, P=0.03), adjusted for age, risk and patient preference. Low-risk men were perceived to benefit more than low-risk women (4.20±0.13 versus 3.54±0.14, P<0.01), and low-risk younger patients were perceived to benefit more than low-risk older patients (4.52±0.17 versus 3.22±0.16, P<0.01). Regardless of risk, patients who agreed to CC were perceived as more likely to benefit from CC than patients who were disagreeable or made no comment at all (5.0±0.23, 3.67±0.21, 2.95±0.14, respectively, P<0.01).

CONCLUSION

Canadian specialists' decisions to refer patients for CC appear to be influenced by sex⁄gender, age and patient preference in clinical scenarios in which cardiac risk is held constant. Future investigation of possible age and sex⁄gender biases as proxies for risk is warranted.

Although women are less likely to be admitted to coronary care units, they are treated equally to men and have better outcome. A prospective cohort study in patients with non ST-elevation acute coronary syndromes

BACKGROUND

The aim of this study was to assess gender differences in admission level of care, management and outcome in patients with non ST-elevation acute coronary syndromes (NSTE-ACS), initially admitted to either coronary care units (CCU) or general wards.

METHOD

Patients admitted to CCUs were routinely registered in the RIKS-HIA registry. In addition, patients admitted to general wards with suspected ACS were also identified and registered. Multivariable regression analysis was used to adjust for baseline differences between the genders.

RESULTS

We included 570 consecutive patients with a discharge diagnosis of NSTE-ACS. Women were less likely to be admitted to coronary care units (56% versus 69%, P=0.002), even after adjustment (odds ratio (OR), 0.65; 95% confidence interval (CI): 0.43-0.98). After adjustment for differences in baseline characteristics, women were treated similarly to men. We found no significant differences in crude short-, or long-term mortality between the genders. However, adjustment for background characteristics revealed lower one-year mortality in women (OR: 0.58; 95% CI: 0.34-0.99).

CONCLUSION

In this study on patients with NSTE-ACS, women were less likely to be admitted to coronary care units. However, the overall treatment was as intensive for women as for men. Moreover, after adjustment, one-year mortality was lower in women.

Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006

OBJECTIVES

This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain.

METHODS

A nationally representative ED data sample for all adults (>or=18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997-2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics.

RESULTS

Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51 to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered.

CONCLUSIONS

Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect "downstream" clinical care and help eliminate observed disparities in cardiac outcomes.

Identifying women with severe angiographic coronary disease

OBJECTIVES

To determine sex/gender differences in the distribution of risk factors according to age and identify factors associated with the presence of severe coronary artery disease (CAD).

DESIGN

We analysed 23,771 consecutive patients referred for coronary angiography from 2000 to 2006.

SUBJECTS

Patients did not have previously diagnosed CAD and were referred for first diagnostic angiography.

OUTCOME MEASURES

Patients were classified according to angiographic disease severity. Severe CAD was defined as left main stenosis > or = 50%, three-vessel disease with > or = 70% stenosis or two-vessel disease including proximal left anterior descending stenosis of > or = 70%. Univariate and multivariate logistic regression was used to assess the association between risk factors and angina symptoms with severe CAD.

RESULTS

Women were less likely to have severe CAD (22.3% vs. 36.5%) compared with men. Women were also significantly older (69.8 +/- 10.6 vs. 66.3 +/- 10.7 years), had higher rates of diabetes (35.0% vs. 26.6%), hypertension (74.8% vs. 63.3%) and Canadian Cardiovascular Society (CCS) class IV angina symptoms (56.7% vs. 47.8%). Men were more likely to be smokers (56.9% vs. 37.9%). Factors independently associated with severe CAD included age (OR = 1.05; 95% CI 1.05-1.05, P < 0.01), male sex (OR = 2.43; CI 2.26-2.62, P < 0.01), diabetes (OR = 2.00; CI 1.86-2.18, P < 0.01), hyperlipidaemia (OR = 1.50; CI 1.39-1.61, P < 0.01), smoking (OR = 1.10; CI 1.03-1.18, P = 0.06) and CCS class IV symptoms (OR = 1.43; CI 1.34-1.53, P < 0.01). CCS Class IV angina was a stronger predictor of severe CAD amongst women compared with men (women OR = 1.82; CI 1.61-2.04 vs. men OR = 1.28; CI 1.18-1.39, P < 0.01).

CONCLUSIONS

Women referred for first diagnostic angiography have lower rates of severe CAD compared with men across all ages. Whilst conventional risk factors, age, sex, diabetes, smoking and hyperlipidaemia are primary determinants of CAD amongst women and men, CCS Class IV angina is more likely to be associated with severe CAD in women than men.

Sex differences in mortality following acute coronary syndromes

CONTEXT

Conflicting information exists about whether sex differences modulate short-term mortality following acute coronary syndromes (ACS).

OBJECTIVES

To investigate the relationship between sex and 30-day mortality in ACS, and to determine whether this relationship was modified by clinical syndrome or coronary anatomy using a large database across the spectrum of ACS and adjusting for potentially confounding clinical covariates.

DESIGN, SETTING, AND PARTICIPANTS

A convenience sample of patients pooled from 11 independent, international, randomized ACS clinical trials between 1993 and 2006 whose databases are maintained at the Duke Clinical Research Institute, Durham, North Carolina. Of 136 247 patients, 38 048 (28%) were women; 102 004 (26% women) with ST-segment elevation myocardial infarction (STEMI), 14 466 (29% women) with non-STEMI (NSTEMI), and 19 777 (40% women) with unstable angina.

MAIN OUTCOME MEASURE

Thirty-day mortality following ACS.

RESULTS

Thirty-day mortality was 9.6% in women and 5.3% in men (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.83-2.00). After multivariable adjustment, mortality was not significantly different between women and men (adjusted OR, 1.06; 95% CI, 0.99-1.15). A significant sex by type of ACS interaction was demonstrated (P < .001). In STEMI, 30-day mortality was higher among women (adjusted OR, 1.15; 95% CI, 1.06-1.24), whereas in NSTEMI (adjusted OR, 0.77; 95% CI, 0.63-0.95) and unstable angina, mortality was lower among women (adjusted OR, 0.55; 95% CI, 0.43-0.70). In a cohort of 35 128 patients with angiographic data, women more often had nonobstructive (15% vs 8%) and less often had 2-vessel (25% vs 28%) and 3-vessel (23% vs 26%) coronary disease, regardless of ACS type. After additional adjustment for angiographic disease severity, 30-day mortality among women was not significantly different than men, regardless of ACS type. The relationship between sex and 30-day mortality was similar across the levels of angiographic disease severity (P for interaction = .70).

CONCLUSIONS

Sex-based differences existed in 30-day mortality among patients with ACS and vary depending on clinical presentation. However, these differences appear to be largely explained by clinical differences at presentation and severity of angiographically documented disease.

Risk-taking attitudes and their association with process and outcomes of cardiac care: a cohort study

BACKGROUND

Prior research reveals that processes and outcomes of cardiac care differ across sociodemographic strata. One potential contributing factor to such differences is the personality traits of individuals within these strata. We examined the association between risk-taking attitudes and cardiac patients' clinical and demographic characteristics, the likelihood of undergoing invasive cardiac procedures and survival.

METHODS

We studied a large inception cohort of patients who underwent cardiac catheterization between July 1998 and December 2001. Detailed clinical and demographic data were collected at time of cardiac catheterization and through a mailed survey one year post-catheterization. The survey included three general risk attitude items from the Jackson Personality Inventory. Patients' (n = 6294) attitudes toward risk were categorized as risk-prone versus non-risk-prone and were assessed for associations with baseline clinical and demographic characteristics, treatment received (i.e., medical therapy, coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI)), and survival (to December 2005).

RESULTS

2827 patients (45%) were categorized as risk-prone. Having risk-prone attitudes was associated with younger age (p < .001), male sex (p < .001), current smoking (p < .001) and higher household income (p < .001). Risk-prone patients were more likely to have CABG surgery in unadjusted (Odds Ratio [OR] = 1.21; 95% CI 1.08-1.36) and adjusted (OR = 1.18; 95% CI 1.02-1.36) models, but were no more likely to have PCI or any revascularization. Having risk-prone attitudes was associated with better survival in an unadjusted survival analysis (Hazard Ratio [HR] = 0.78 (95% CI 0.66-0.93), but not in a risk-adjusted analysis (HR = 0.92, 95% CI 0.77-1.10).

CONCLUSION

These exploratory findings suggest that patient attitudes toward risk taking may contribute to some of the documented differences in use of invasive cardiac procedures. An awareness of these associations could help healthcare providers as they counsel patients regarding cardiac care decisions.

Sex, gender, and pain: a review of recent clinical and experimental findings

Sex-related influences on pain and analgesia have become a topic of tremendous scientific and clinical interest, especially in the last 10 to 15 years. Members of our research group published reviews of this literature more than a decade ago, and the intervening time period has witnessed robust growth in research regarding sex, gender, and pain. Therefore, it seems timely to revisit this literature. Abundant evidence from recent epidemiologic studies clearly demonstrates that women are at substantially greater risk for many clinical pain conditions, and there is some suggestion that postoperative and procedural pain may be more severe among women than men. Consistent with our previous reviews, current human findings regarding sex differences in experimental pain indicate greater pain sensitivity among females compared with males for most pain modalities, including more recently implemented clinically relevant pain models such as temporal summation of pain and intramuscular injection of algesic substances. The evidence regarding sex differences in laboratory measures of endogenous pain modulation is mixed, as are findings from studies using functional brain imaging to ascertain sex differences in pain-related cerebral activation. Also inconsistent are findings regarding sex differences in responses to pharmacologic and non-pharmacologic pain treatments. The article concludes with a discussion of potential biopsychosocial mechanisms that may underlie sex differences in pain, and considerations for future research are discussed.

PERSPECTIVE

This article reviews the recent literature regarding sex, gender, and pain. The growing body of evidence that has accumulated in the past 10 to 15 years continues to indicate substantial sex differences in clinical and experimental pain responses, and some evidence suggests that pain treatment responses may differ for women versus men.