Gender-Related Differences in Heart Failure After STEMI
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersBACKGROUND
ST-segment elevation myocardial infarction (STEMI) complicated by symptoms of acute de novo heart failure is associated with excess mortality. Whether development of heart failure and its outcomes differ by sex is unknown.
OBJECTIVES
This study sought to examine the relationships among sex, acute heart failure, and related outcomes after STEMI in patients with no prior history of heart failure recorded at baseline.
METHODS
Patients were recruited from a network of hospitals in the ISACS-TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry (NCT01218776). Main outcome measures were incidence of Killip class ≥II at hospital presentation and risk-adjusted 30-day mortality rates were estimated using inverse probability of weighting and logistic regression models.
RESULTS
This study included 10,443 patients (3,112 women). After covariate adjustment and matching for age, cardiovascular risk factors, comorbidities, disease severity, and delay to hospital presentation, the incidence of de novo heart failure at hospital presentation was significantly higher for women than for men (25.1% vs. 20.0%, odds ratio [OR]: 1.34; 95% confidence interval [CI]: 1.21 to 1.48). Women with de novo heart failure had higher 30-day mortality than did their male counterparts (25.1% vs. 20.6%; OR: 1.29; 95% CI: 1.05 to 1.58). The sex-related difference in mortality rates was still apparent in patients with de novo heart failure undergoing reperfusion therapy after hospital presentation (21.3% vs. 15.7%; OR: 1.45; 95% CI: 1.07 to 1.96).
CONCLUSIONS
Women are at higher risk to develop de novo heart failure after STEMI and women with de novo heart failure have worse survival than do their male counterparts. Therefore, de novo heart failure is a key feature to explain mortality gap after STEMI among women and men.
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Additional Info
Sex-Related Differences in Heart Failure After ST-Segment Elevation Myocardial Infarction
J Am Coll Cardiol 2019 Nov 12;74(19)2379-2389, E Cenko, M van der Schaar, J Yoon, O Manfrini, Z Vasiljevic, M Vavlukis, S Kedev, D Miličić, L Badimon, R BugiardiniFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Sex-Related Differences in Heart Failure After STEMI
It is well-known that sex-specific differences exist in the presentation, pathophysiologic mechanisms, and outcomes in patients with acute myocardial infarction (AMI).1 It has also been recognized that women with myocardial infarction have a doubled mortality rate compared with men, especially those younger than 50 years of age, with recent narrowing of the gender gap. Nonetheless, women have an excess of recurrent myocardial infarction and the subsequent development of heart failure. Women with AMI are less likely to receive appropriate medications both at presentation and at hospital discharge, including ACE inhibitors, beta blockers, and statins. That women are more likely to develop heart failure symptoms in the setting of AMI may be related to higher rates of underlying hypertension, diabetes, or to a longer delay in presentation to the hospital. Given the significant survival benefit of early revascularization in acute coronary syndromes, women with MI-associated heart failure should undergo angiography.1 Cenko and colleagues, using data from the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) registry, address sex-related differences in heart failure after ST-segment elevation myocardial infarction (STEMI). However, more remains to be learned.
In a study using the Get With The Guidelines database,2 women with STEMI had an increased mortality rate, 10.2%, compared with 5.5% for men. Of note is that this mortality was predominantly in the initial 24 hours and was associated with less use of early aspirin and beta blockers, less reperfusion therapy, and less timely reperfusion therapy. This did not represent a decision by clinicians to withhold therapy from women, but rather reflected the late recognition of STEMI in women, such that life-saving therapies were not administered. This information offers opportunities to lessen disparities in care and in outcomes.
Women were preferentially represented in the VIRGO study, which was designed to examine young patients with STEMI. Women in VIRGO were less likely to receive reperfusion therapy and to meet reperfusion guidelines than their male peers.3,4 Female sex remained a significant determinant of delay in reperfusion even after adjustment by serially added models.
Reforming disparities in clinical, organizational, and educational challenges thus offer opportunities for improving outcomes for women.5 However, in the current manuscript, the incidence of de novo heart failure at hospital presentation for STEMI was significantly higher for women than for men, 25.1% versus 20.0%, and women also had a higher 30-day mortality rate than their male counterparts. The authors posit that de novo heart failure is the key explanatory feature for the mortality gap after STEMI between women and men. The exclusion of patients presenting with cardiogenic shock may have disproportionately excluded women from the analysis. The missing data that are of importance for clinical relevance relate to the anatomic correlations of STEMI; can we assume that most of the STEMI patients had lesions amenable to PCI intervention?
Important will be information for women who had either nonobstructive coronary disease or solely microvascular disease, in that the sex differences may be explained by complicating microvascular disease and/or microvascular disease as a sole contributor to STEMI. The echocardiographic data, albeit incomplete, are not provided. These variables may provide information as to whether there is predominant heart failure with a preserved ejection fraction despite the STEMI, or whether the heart failure is predominantly systolic in etiology. That women have more hypertension and more longstanding hypertension with adverse effects on left ventricular remodeling may be an important contributor to the heart failure, even in the setting of STEMI. Since women received more ACE/ARB inhibitors and beta blockers prior to STEMI, this may reflect greater severity of hypertension and/or more longstanding hypertension as a contributor to left ventricular hypertrophy and diastolic dysfunction prior to the STEMI and accentuation of the de novo heart failure presentation with STEMI.
References