Curriculum in cardiology

Symptoms in acute coronary syndromes: does sex make a difference?☆

Although gender difference in long-term outcomes after acute myocardial infarction have been shown previously, impact of age on gender difference is still controversial. This study focused on the association between age and gender difference in long-term outcome. We analyzed data from 3,283 consecutive patients who were included in a prospective, nationwide, multicenter registry (Japan Registry of Acute Myocardial Infarction Diagnosed by Universal Definition) from 2012 to 2014. The primary end point was the major adverse cardiovascular event (MACE), which was defined as a composite of death, myocardial infarction, stroke, heart failure, and revascularization for unstable angina during 3 years. Patients were divided into 4 strata according to age: those with age <65 years (group 1: n = 1161), 65 to 74 years (group 2: n = 954), 75 to 84 years (group 3: n = 866) and 84< years (group 4: n = 302). Although the crude incidence of 3-year MACE was significantly higher in women than men (36.4% vs. 28.5%, p <0.001), there was not significant gender difference in each group (group 1, 19.6% vs 19.0%, p = 0.74; group 2, 33.1% vs 28.3%, p = 0.25; group 3, 38.9% vs 39.6%, p = 0.54; and group 4, 54.0% vs 56.8%, p = 0.24). In conclusion, although women had higher crude incidence of 3-year MACE than men, there was no gender difference in each group.

The cornerstones in the assessment of emergency department (ED) patients with suspected acute coronary syndrome (ACS) are patient history and physical examination, electrocardiogram, and cardiac troponins. Although there are several prior studies on this subject, they have in some cases produced inconsistent results.

The aim of this study was to evaluate the diagnostic and prognostic accuracy of elements of patient history and the physical examination in ED chest pain patients for predicting major adverse cardiac events (MACE) within 30 days. Methods: This was a prospective observational study that included 1167 ED patients with nontraumatic chest pain. We collected clinical data during the initial ED assessment of the patients. Our primary outcome was 30-day MACE.

Pain radiating to both arms increased the probability of 30-day MACE (positive likelihood ratio [LR+] 2.7), whereas episodic chest pain lasting seconds (LR+ 0.0) and >24 h (LR+ 0.1) markedly decreased the risk. In the physical examination, pulmonary rales (LR+ 3.0) increased the risk of 30-day MACE, while pain reproduced by palpation (LR+ 0.3) decreased the risk. Among cardiac risk factors, a history of diabetes (LR+ 3.0) and peripheral arterial disease (LR+ 2.7) were the most predictive factors.

No clinical findings reliably ruled in 30-day MACE, whereas episodic chest pain lasting seconds and pain lasting more than 24 h markedly decreased the risk of 30-day MACE. Consequently, these two findings can be adjuncts in ruling out 30-day MACE.

Prognosis of low-risk women presenting to the emergency department (ED) with chest pain has not been clarified. We assessed early and long-term outcomes of such patients and determined the need for predischarge testing.

Retrospective assessment of consecutive low-risk women presenting to the ED with chest pain evaluated in a chest pain unit (CPU). Criteria of low risk: age ≤51 years; no history of cardiovascular disease, diabetes, or smoking; negative initial electrocardiogram (ECG); and cardiac troponin. Predischarge testing (treadmill or stress imaging) was performed at the discretion of the CPU attending physician.

The study group comprised 214 consecutive women. Predischarge testing was performed in 142 patients (66%, age 43.9 years) and 72 patients (34%, age 43.1 years) had no predischarge testing. Predischarge testing comprised exercise treadmill (n = 102, 72%) or stress imaging (n = 40, 28%). Length of stay with no predischarge testing was 4.1 hours, compared with 8.6 hours with predischarge testing (P = .04). There were no cardiovascular events in the index presentation; during a 5-year interval (100% follow-up), there were 2 cardiovascular events (fatal heart failure, 1 patient; fatal stroke, 1 patient [total, 2/214, 0.93%]).

Low-risk women presenting to the ED with chest pain have an excellent short- and long-term prognosis. A majority of patients did not receive predischarge testing, and their length of stay was reduced by >50% compared with those with predischarge testing. These findings suggest that such patients may not require predischarge testing for disposition from a CPU, which can reduce length of stay, decrease cost, and improve resource utilization.

The aim of this study was to investigate gender related differences in the management and risk factor control of patients with coronary heart disease (CHD), taking into account their age and educational level.

Analyses are based on the EUROASPIRE IV (EUROpean Action on Secondary and Primary Prevention through Intervention to Reduce Events) survey. Males and females between 18 and 80 years of age, hospitalized for a first or recurrent coronary event were included in the study.

Data were available for 7998 patients of which 75.6% were males. Overall, females had a worse risk factor profile compared to males and were more likely to have 3 or more risk factors (29.5% vs. 34.9%; p < 0.001) across all age groups. A significant gender by education interaction (p < 0.05) and gender by age interaction effect (p < 0.05) was found. Furthermore, males were more likely to have a LDL-cholesterol on target (OR = 1.50[1.28–1.76]), a HbA1c on target (OR = 1.33[1.07–1.64]), to be non-obese (OR = 1.45[1.30–1.62]) and perform adequate physical activity (OR = 1.71[1.46–2.00]). In contrast males were less likely to be non-smokers (OR = 0.71[0.60–0.83]). Furthermore, males were less likely to have made a dietary change (OR = 0.78[0.64–0.95]) or a smoking cessation attempt (OR = 0.70[0.50–0.96]) and more likely to have received smoking cessation advice if they were smokers (OR = 1.52[1.10–2.09]).

Whereas gender differences in CHD treatment are limited, substantial differences were found regarding target achievement. The largest gender difference was seen in less educated and elderly patients. The gender gap declined with decreasing age and higher education.