Blomkalns, A. L. 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. 45, 832-837
We hypothesized that significant disparities in gender exist in the management of patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS).
Gender-related differences in the diagnosis and treatment of ACS have important healthcare implications. No large-scale examination of these disparities has been completed since the publication of the revised American College of Cardiology/American Heart Association guidelines for management of patients with NSTE ACS.
Using data 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, we examined differences of gender in treatment and outcomes among patients with NSTE ACS.
Women (41% of 35,875 patients) were older (median age 73 vs. 65 years) and more often had diabetes and hypertension. Women were less likely to receive acute heparin, angiotensin-converting enzyme inhibitors, and glycoprotein IIb/IIIa inhibitors and less commonly received aspirin, angiotensin-converting enzyme inhibitors, and statins at discharge. The use of cardiac catheterization and revascularization was higher in men, but among patients with significant coronary disease, percutaneous revascularization was performed in a similar proportion of women and men. Women were at higher risk for unadjusted in-hospital death (5.6% vs. 4.3%), reinfarction (4.0% vs. 3.5%), heart failure (12.1% vs. 8.8%), stroke (1.1% vs. 0.8%), and red blood cell transfusion (17.2% vs. 13.2%), but after adjustment, only transfusion was higher in women.
Despite presenting with higher risk characteristics and having higher in-hospital risk, women with NSTE ACS are treated less aggressively than men.
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"In our population, females with diabetes and with acute coronary syndrome (ACS) underwent PTCA and CABG less frequently than males as in the general population . The biological difference between sexes for coronary disease, obstructive in males and microvascular in females, is one of the reasons for the less invasive diagnostic assessment in patients with ACS and consequently fewer revascularization procedures in females than their male counterparts  . "
[Show abstract][Hide abstract] ABSTRACT: Background:
The impact of diabetes on cardiovascular disease in both sexes is known, but the specifics have not been fully clarified. We investigated whether sex-related differences exist in terms of management and hospitalization in patients with newly diagnosed diabetes.
We examined the rates of hospitalization for cardiovascular causes, mortality, treatments and management of patients with diabetes compared to subjects without, from administrative database. Interaction between sex and diabetes on clinical outcomes were calculated using a Cox regression model. Pharmacological treatments and recommended examinations by sex were calculated using logistic regression.
From 2002 to 2006, 158,426 patients with diabetes and 314,115 subjects without were identified and followed up for a mean of 33 months (± 17.5). Diabetes confers a higher risk for all clinical outcomes. Females with diabetes have a risk profile for hospitalization for coronary heart disease comparable to males without (4.6% and 5.3%). Interaction between sex and diabetes shows that females with diabetes had an added 19% higher risk of total death (95% CI 1.13-1.24). No differences were observed in hospitalizations, although females with diabetes were less likely to undergo revascularization after myocardial infarction. Females received cardiovascular prevention drugs less frequently than males and had a slight tendency to get fewer examinations.
Diabetes is linked to a higher increase of mortality in females relative to males. This might reflect sex differences in the use of revascularization procedures or therapeutic regimens. Closer attention and implementation of standard care for females are necessary from the onset of diabetes.
Full-text · Article · Mar 2014 · European Journal of Internal Medicine
"Underestimation of risk among women presenting with ACS by the treating physician may be an important reason. Indeed, gender-related discrepancy in treatment strategies has been observed in several trials and registries –. "
[Show abstract][Hide abstract] ABSTRACT: Coronary artery disease (CAD) is the leading cause of mortality worldwide. The present study evaluated the impact of gender in patients hospitalized with acute coronary syndromes (ACS) over a 20-year period in Qatar.
Data were collected retrospectively from the registry of the department of cardiology for all patients admitted with ACS during the study period (1991-2010) and were analyzed according to gender.
Among 16,736 patients who were admitted with ACS, 14262 (85%) were men and 2474 (15%) were women. Cardiovascular risk factors were more prevalent among women in comparison to men. On admission, women presented mainly with non-ST-elevation ACS and were more likely to be undertreated with β-blockers (BB), antiplatelet agents and reperfusion therapy in comparison to men. However, from 1999 through 2010, the use of aspirin, angiotensin-converting enzyme inhibitors and BB increased from 66% to 79%, 27% to 41% and 17% to 49%, respectively in women. In the same period, relative risk reduction for mortality was 64% in women and 51% in men. Across the 20-year period, the mortality rate decreased from 27% to 7% among the Middle Eastern Arab women. Multivariate logistic regression analysis showed that female gender was independent predictor of in-hospital mortality (odd ratio 1.51, 95% CI 1.27-1.79).
Women presenting with ACS are high-risk population and their in-hospital mortality remains higher for all age groups in comparison to men. Although, substantial improvement in the hospital outcome has been observed, guidelines adherence and improvement in the hospital care have not yet been optimized.
"Gender differences play an important role in the pathophysiology of AMI. Although coronary plaque rupture with acute thrombosis formation is common pathophysiology for men and women, women are usually older than men and associated with a low incidence of AMI, but with a higher mortality          . It has been proposed that gender differences on symptoms, awareness, prehospital delay, treatment responses, and complications may contribute to the different outcome. "
[Show abstract][Hide abstract] ABSTRACT: It is not clear whether gender is associated with different hospitalization cost and lengths for acute myocardial infarction (AMI). We identified patients hospitalized for primary diagnosis of AMI with (STEMI) or without (NSTEMI) ST elevation from 1999 to 2008 through a national database containing 1,000,000 subjects. As compared to that in 1999~2000, total (0.35‰ versus 0.06‰, P < 0.001) and male (0.59‰ versus 0.07‰, P < 0.001) STEMI hospitalization percentages were decreased in 2007~2008, but female STEMI hospitalization percentages were not different from 1999 to 2008. However, NSTEMI hospitalization percentages were similar over the 10-year period. The hospitalization age for AMI, STEMI, and NSTEMI was increased over the 10-year period by 14, 9, and 7 years in male, and by 18, 18, and 21 years in female. The female and male hospitalization cost and lengths were similar in the period. As compared to nonmedical center, the hospitalization cost for STEMI in medical center was higher in male patients, but not in female patients, and the hospitalization cost for NSTEMI was higher in both male and female gender. We found significant differences between male and female, medical center and non-medical center, or STEMI and NSTEMI on medical care over the 10-year period.
Full-text · Article · Sep 2012 · The Scientific World Journal