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Sex-specific differences in risk factors for in-hospital mortality and complications in patients with acute coronary syndromes

An observational cohort study

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Summary

Background

The goal of this observational cohort study was to examine gender-specific differences in the incidence of acute coronary syndrome (ACS), in-hospital complications and mortality.

Methods

A cohort of 1550 patients with the primary diagnosis of ACS were enrolled in the study over a period of 4 years. The in-hospital mortality and complications were analyzed as the main outcome measures.

Results

Women were significantly older compared to men (71 ± 11 years vs. 64 ± 12 years, p < 0.001) and had higher in-hospital mortality and complications due to this age difference. The prevalence of smoking was lower while hypertension and history of angina pectoris was more frequent in women, independent of age. Percutaneous transluminal coronary angioplasty (PTCA) with or without stenting as well as coronary catheterization significantly reduced in-hospital mortality and complications while thrombolytic therapy was associated with a 3.3 times increased mortality odds ratio (OR, p = 0.01). Other significant predictors of in-hospital mortality were in-hospital complications (OR 25, p < 0.001) and ST segment elevation myocardial infarction (STEMI, OR 4.5, p < 0.001).

Conclusions

Women differed from men in terms of ACS clinical characteristics, treatment, invasive procedures and survival outcome and some of these effects were age-related. The future emphasis should be based on the prevention of modifiable risk factors and identification of subgroups of female patients that could benefit from more aggressive therapeutic strategies.

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References

  1. Rosamond WD, Chambless LE, Folsom AR, Cooper LS, Conwill DE, Clegg L, et al. Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994. N Engl J Med. 1998;339(13):861–7. doi:10.1056/nejm199809243391301.

    Article  CAS  PubMed  Google Scholar 

  2. Bhatnagar P, Wickramasinghe K, Williams J, Rayner M, Townsend N. The epidemiology of cardiovascular disease in the UK 2014. Heart. 2015;101(15):1182–9. doi:10.1136/heartjnl-2015-307516.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Anand SS, Xie CC, Mehta S, Franzosi MG, Joyner C, Chrolavicius S, et al. Differences in the management and prognosis of women and men who suffer from acute coronary syndromes. J Am Coll Cardiol. 2005;46(10):1845–51. doi:10.1016/j.jacc.2005.05.091.

    Article  PubMed  Google Scholar 

  4. Yahagi K, Davis HR, Arbustini E, Virmani R. Sex differences in coronary artery disease: pathological observations. Atherosclerosis. 2015;239(1):260–7. doi:10.1016/j.atherosclerosis.2015.01.017.

    Article  CAS  PubMed  Google Scholar 

  5. Rosengren A, Wallentin L, Gitt AK, Behar S, Battler A, Hasdai D. Sex, age, and clinical presentation of acute coronary syndromes. Eur Heart J. 2004;25(8):663–70. doi:10.1016/j.ehj.2004.02.023.

    Article  PubMed  Google Scholar 

  6. Pearson TA, Blair SN, Daniels SR, Eckel RH, Fair JM, Fortmann SP, et al. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. American heart association science advisory and coordinating committee. Circulation. 2002;106(3):388–91.

    Article  PubMed  Google Scholar 

  7. Steingart RM, Packer M, Hamm P, Coglianese ME, Gersh B, Geltman EM, Survival and Ventricular Enlargement Investigators, et al. Sex differences in the management of coronary artery disease. N Engl J Med. 1991;325(4):226–30. doi:10.1056/nejm199107253250402.

    Article  CAS  PubMed  Google Scholar 

  8. Ghadri JR, Sarcon A, Jaguszewski M, Diekmann J, Bataiosu RD, Hellermann J, et al. Gender disparities in acute coronary syndrome: a closing gap in the short-term outcome. J Cardiovasc Med. 2015;16(5):355–62. doi:10.2459/jcm.0000000000000248.

    Article  Google Scholar 

  9. Pagidipati NJ, Peterson ED. Acute coronary syndromes in women and men. Nat Rev Cardiol. 2016;13(8):471–80. doi:10.1038/nrcardio.2016.89.

    Article  PubMed  Google Scholar 

  10. Dittrich H, Gilpin E, Nicod P, Cali G, Henning H, Ross J Jr. Acute myocardial infarction in women: influence of gender on mortality and prognostic variables. Am J Cardiol. 1988;62(1):1–7.

    Article  CAS  PubMed  Google Scholar 

  11. Moscucci M, Fox KA, Cannon CP, Klein W, Lopez-Sendon J, Montalescot G, et al. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE). Eur Heart J. 2003;24(20):1815–23.

    Article  CAS  PubMed  Google Scholar 

  12. Radovanovic D, Erne P, Urban P, Bertel O, Rickli H, Gaspoz JM. Gender differences in management and outcomes in patients with acute coronary syndromes: results on 20,290 patients from the AMIS Plus Registry. Heart. 2007;93(11):1369–75. doi:10.1136/hrt.2006.106781.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Haynes SG, Feinleib M. Women, work and coronary heart disease: prospective findings from the Framingham heart study. Am J Public Health. 1980;70(2):133–41.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012;307(8):813–22. doi:10.1001/jama.2012.199.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Davis M, Diamond J, Montgomery D, Krishnan S, Eagle K, Jackson E. Acute coronary syndrome in young women under 55 years of age: clinical characteristics, treatment, and outcomes. Clin Res Cardiol. 2015;104(8):648–55. doi:10.1007/s00392-015-0827-2.

    Article  CAS  PubMed  Google Scholar 

  16. Chandrasekhar J, Baber U, Sartori S, Faggioni M, Aquino M, Kini A, et al. Sex-related differences in outcomes among men and women under 55 years of age with acute coronary syndrome undergoing percutaneous coronary intervention: Results from the PROMETHEUS Study. Catheter Cardiovasc Interv. 2016. doi:10.1002/ccd.26606.

    Google Scholar 

  17. Clemmensen P, Roe MT, Hochman JS, Cyr DD, Neely ML, McGuire DK, et al. Long-term outcomes for women versus men with unstable angina/non-ST-segment elevation myocardial infarction managed medically without revascularization: insights from the TaRgeted platelet Inhibition to cLarify the Optimal strateGy to medicallY manage Acute Coronary Syndromes trial. Am Heart J. 2015;170(4):695–705.e5. doi:10.1016/j.ahj.2015.06.011.

    Article  PubMed  Google Scholar 

  18. Sytkowski PA, D’Agostino RB, Belanger A, Kannel WB. Sex and time trends in cardiovascular disease incidence and mortality: the Framingham Heart Study, 1950–1989. Am J Epidemiol. 1996;143(4):338–50.

    Article  CAS  PubMed  Google Scholar 

  19. Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM, National Registry of Myocardial Infarction 2 Participants. Sex-based differences in early mortality after myocardial infarction. N Engl J Med. 1999;341(4):217–25. doi:10.1056/nejm199907223410401.

    Article  CAS  PubMed  Google Scholar 

  20. Vaina S, Milkas A, Crysohoou C, Stefanadis C. Coronary artery disease in women: from the yentl syndrome to contemporary treatment. World J Cardiol. 2015;7(1):10–8. doi:10.4330/wjc.v7.i1.10.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Stock EO, Redberg R. Cardiovascular disease in women. Curr Probl Cardiol. 2012;37(11):450–526. doi:10.1016/j.cpcardiol.2012.07.001.

    Article  PubMed  Google Scholar 

  22. World Health Organization. International statistical classification of diseases and related health problems: World Health Organization. Geneva: World Health Organization; 2004.

  23. Cabrerizo-Garcia JL, Perez-Calvo JI, Zalba-Etayo B. Influence of gender on prognosis of acute coronary syndromes. Rev Port Cardiol. 2015;34(1):43–50. doi:10.1016/j.repc.2014.07.008.

    PubMed  Google Scholar 

  24. El-Menyar A, Ahmed E, Albinali H, Al-Thani H, Gehani A, Singh R, et al. Mortality trends in women and men presenting with acute coronary syndrome: insights from a 20-year registry. PLOS ONE. 2013;8(7):e70066. doi:10.1371/journal.pone.0070066.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Shehab A, Yasin J, Hashim MJ, Al-Dabbagh B, Mahmeed WA, Bustani N, et al. Gender differences in acute coronary syndrome in Arab Emirati women-implications for clinical management. Angiology. 2013;64(1):9–14. doi:10.1177/0003319712443891.

    Article  PubMed  Google Scholar 

  26. Hochman JS, Tamis JE, Thompson TD, Weaver WD, White HD, Van de Werf F, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. New Engl J Med. 1999;341(4):226–32. doi:10.1056/NEJM199907223410402.

    Article  CAS  PubMed  Google Scholar 

  27. Kim M, Chu A, Khan Y, Malik S. Predicting and preventing vascular complications following percutaneous coronary intervention in women. Expert Rev Cardiovasc Ther. 2015;13(2):163–72. doi:10.1586/14779072.2015.995635.

    Article  CAS  PubMed  Google Scholar 

  28. Lu HT, Nordin R, Wan Ahmad WA, Lee CY, Zambahari R, Ismail O, et al. Sex differences in acute coronary syndrome in a multiethnic asian population: results of the malaysian national cardiovascular disease database-acute coronary syndrome (NCVD-ACS) registry. Glob Heart. 2014;9(4):381–90. doi:10.1016/j.gheart.2014.06.001.

    Article  PubMed  Google Scholar 

  29. Nguyen JT, Berger AK, Duval S, Luepker RV. Gender disparity in cardiac procedures and medication use for acute myocardial infarction. Am Heart J. 2008;155(5):862–8. doi:10.1016/j.ahj.2007.11.036.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Blomkalns AL, Chen AY, Hochman JS, Peterson ED, Trynosky K, Diercks DB, et al. Gender disparities in the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: large-scale observations from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative. J Am Coll Cardiol. 2005;45(6):832–7. doi:10.1016/j.jacc.2004.11.055.

    Article  PubMed  Google Scholar 

  31. D’Onofrio G, Safdar B, Lichtman JH, Strait KM, Dreyer RP, Geda M, et al. Sex differences in reperfusion in young patients with ST-segment-elevation myocardial infarction: results from the VIRGO study. Circulation. 2015;131(15):1324–32. doi:10.1161/circulationaha.114.012293.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Choi K, Shofer FS, Mills AM. Sex differences in ST-elevation myocardial infarction activation for patients presenting to the ED. Am J Emerg Med. 2016. doi:10.1016/j.ajem.2016.06.082.

    Google Scholar 

  33. McSweeney JC, Cody M, O’Sullivan P, Elberson K, Moser DK, Garvin BJ. Women’s early warning symptoms of acute myocardial infarction. Circulation. 2003;108(21):2619–23. doi:10.1161/01.cir.0000097116.29625.7c.

    Article  PubMed  Google Scholar 

  34. Izadnegahdar M, Norris C, Kaul P, Pilote L, Humphries KH. Basis for sex-dependent outcomes in acute coronary syndrome. Can J Cardiol. 2014;30(7):713–20. doi:10.1016/j.cjca.

    Article  PubMed  Google Scholar 

  35. Hvelplund A, Galatius S, Madsen M, Rasmussen JN, Rasmussen S, Madsen JK, et al. Women with acute coronary syndrome are less invasively examined and subsequently less treated than men. Eur Heart J. 2010;31(6):684–90. doi:10.1093/eurheartj/ehp493.

    Article  PubMed  Google Scholar 

  36. Ayanian JZ. Increased mortality among middle-aged women after myocardial infarction: searching for mechanisms and solutions. Ann Intern Med. 2001;134(3):239–41.

    Article  CAS  PubMed  Google Scholar 

  37. Graham MM, Westerhout CM, Kaul P, Norris CM, Armstrong PW. Sex differences in patients seeking medical attention for prodromal symptoms before an acute coronary event. Am Heart J. 2008;156(6):1210–6.e1. doi:10.1016/j.ahj.2008.07.016.

    Article  PubMed  Google Scholar 

  38. O’Donoghue M, Boden WE, Braunwald E, Cannon CP, Clayton TC, de Winter RJ, et al. Early invasive vs conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction: a meta-analysis. JAMA. 2008;300(1):71–80. doi:10.1001/jama.300.1.71.

    Article  PubMed  Google Scholar 

  39. Daniels LB, Maisel AS. Cardiovascular biomarkers and sex: the case for women. Nat Rev Cardiol. 2015. doi:10.1038/nrcardio.2015.105.

    PubMed  Google Scholar 

  40. Bhatt P, Parikh P, Patel A, Parikh R, Patel A, Mehta JL, et al. Unique aspects of coronary artery disease in indian women. Cardiovasc Drugs Ther. 2015;29(4):369–76. doi:10.1007/s10557-015-6594-5.

    Article  PubMed  Google Scholar 

  41. Gonzalez-Pacheco H, Vargas-Barron J, Vallejo M, Pina-Reyna Y, Altamirano-Castillo A, Sanchez-Tapia P, et al. Prevalence of conventional risk factors and lipid profiles in patients with acute coronary syndrome and significant coronary disease. Ther Clin Risk Manag. 2014; 815–23. doi:10.2147/tcrm.s67945.

    PubMed  PubMed Central  Google Scholar 

  42. Wenger NK. Heightened cardiovascular risk in diabetic women: can the tide be turned? Ann Intern Med. 2007;147(3):208–10.

    Article  PubMed  Google Scholar 

  43. Hochman JS, Tamis JE, Thompson TD, Weaver WD, White HD, Van de Werf F, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIb investigators. N Engl J Med. 1999;341(4):226–32. doi:10.1056/nejm199907223410402.

    Article  CAS  PubMed  Google Scholar 

  44. Vogel B, Farhan S, Hahne S, Kozanli I, Kalla K, Freynhofer MK, et al. Sex-related differences in baseline characteristics, management and outcome in patients with acute coronary syndrome without ST-segment elevation. Eur Heart J Acute Cardiovasc Care. 2015. doi:10.1177/2048872615585514.

    Google Scholar 

  45. Bucholz EM, Butala NM, Rathore SS, Dreyer RP, Lansky AJ, Krumholz HM. Sex differences in long-term mortality after myocardial infarction: a systematic review. Circulation. 2014;130(9):757–67. doi:10.1161/circulationaha.114.009480.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Bucholz EM, Normand SL, Wang Y, Ma S, Lin H, Krumholz HM. Life expectancy and years of potential life lost after acute myocardial infarction by sex and race: a cohort-based study of medicare beneficiaries. J Am Coll Cardiol. 2015;66(6):645–55. doi:10.1016/j.jacc.2015.06.022.

    Article  PubMed  Google Scholar 

  47. Hasdai D, Behar S, Wallentin L, Danchin N, Gitt AK, Boersma E, et al. A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin; the Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). Eur Heart J. 2002;23(15):1190–201.

    Article  CAS  PubMed  Google Scholar 

  48. Steg PG, James SK, Atar D, Badano LP, Blomstrom-Lundqvist C, Borger MA, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33(20):2569–619. doi:10.1093/eurheartj/ehs215.

    Article  CAS  PubMed  Google Scholar 

  49. Widimsky P, Bilkova D, Penicka M, Novak M, Lanikova M, Porizka V, et al. Long-term outcomes of patients with acute myocardial infarction presenting to hospitals without catheterization laboratory and randomized to immediate thrombolysis or interhospital transport for primary percutaneous coronary intervention. Five years’ fol. Eur Heart J. 2007. doi:10.1093/eurheartj/ehl535.

    Google Scholar 

  50. Grimes DA, Schulz KF. False alarms and pseudo-epidemics: the limitations of observational epidemiology. Obstet Gynecol. 2012;120(4):920–7. doi:10.1097/AOG.0b013e31826af61a.

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors would wish to thank Mario Malički, MD, PhD (Department of Research in Biomedicine and Health, University of Split School of Medicine) for advice about scientific methodology and statistical analysis.

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Authors and Affiliations

  1. Department of Internal Medicine, Division of Cardiology, University of Split Clinical Hospital Center, Spinčićeva 1, 21000, Split, Croatia

    Katarina Novak MD, PhD

  2. Department of Family Medicine, University of Split School of Medicine (USSM), Šoltanska 2, 21000, Split, Croatia

    Davorka Vrdoljak MD, PhD

  3. Faculty of Kinesiology, University of Split, Teslina 6, 21000, Split, Croatia

    Igor Jelaska PhD

  4. Department of Pathophysiology, University of Split School of Medicine (USSM), Soltanska 2, 21000, Split, Croatia

    Josip Anđelo Borovac B.Sc.

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  1. Katarina Novak MD, PhD
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Correspondence to Josip Anđelo Borovac B.Sc..

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Conflict of interest

K. Novak, D. Vrdoljak, I. Jelaska, and J.A. Borovac declare that they have no competing interests.

Ethical standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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Novak, K., Vrdoljak, D., Jelaska, I. et al. Sex-specific differences in risk factors for in-hospital mortality and complications in patients with acute coronary syndromes. Wien Klin Wochenschr 129, 233–242 (2017). https://doi.org/10.1007/s00508-016-1105-7

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  • DOI: https://doi.org/10.1007/s00508-016-1105-7

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