Gender gap in acute coronary heart disease: Myth or reality?

AIM: To investigate potential gender differences in the prevalence of cardiovascular risk factors, cardiovascular disease (CVD) management, and prognosis in acute coronary syndrome (ACS). METHODS: A systematic literature search was performed through Medline using pre-specified key words . An additional search was performed, focusing specifically on randomized controlled clinical trials in relation to therapeutic intervention and prognosis. In total, 92 relevant articles were found. RESULTS: Women with CVD tended to have more hypertension and diabetes at the time of presentation, whereas men were more likely to smoke. Coronary angiography and revascularization by percutaneous coronary intervention were performed more often in men. Women were at a greater risk of short-term mortality and complications after revascularization. Interestingly, women under 40 years presenting with ACS were athighest risk of cardiovascular death compared with men of the same age, irrespective of risk factors. This disadvantage disappeared in older age. The long-term mortality risk of ACS was similar in men and women, and even in favor of women. CONCLUSION: Mortality rates are higher among young women with ACS, but this difference tends to disappear with age, and long-term prognosis is even better among older women.     

Does initial and delayed heart rate predict mortality in patients with acute coronary syndromes?

BACKGROUND: Lower admission heart rate (HR) is known to predict favorable outcome in ST-elevation acute myocardial infarction. However, there are limited short-term and no long-term data available regarding the prediction value of the initial HR in patients with the full spectrum of acute coronary syndromes (ACS). In addition, it is unknown whether the HR obtained later during hospitalization for ACS (i.e., Day 2 or 3) remains prognostically valuable. HYPOTHESIS: The aim of this study was to investigate the utility of the initial and delayed HR in predicting outcome in patients with ACS. METHODS: We examined mortality at 30 days and 10 months in 10,267 patients with ACS enrolled in the oral glycoprotein IIb/IIIa inhibition with Orofiban in Patients with Unstable coronary Syndromes-Thrombolysis In Myocardial Infarction (OPUS-TIMI) 16 trial. Patients were stratified by HR and day from onset of ACS into the following groups: (1) HR < 60 beats/min, (2) HR 60-80 beats/min, (3) HR 80-100 beats/min, (4) HR > 100 beats/min; and HR obtained on (1) Day 1, (2) Day 2, and (3) Day 3. RESULTS: By univariate analysis, mortality at 30 days and at 10 months increased progressively with higher HR strata (1.4 vs. 1.6 vs. 2.3 vs. 5.6%, p < 0.001, and 2.6 vs. 4.2 vs. 6.5 vs. 11.8%, p < 0.001, respectively). Elevated HR remained associated with mortality irrespective of time from onset of ACS. CONCLUSIONS: Higher initial and delayed HR is highly predictive of higher short- and long-term mortality in patients with ACS. This is a simple marker that could be easily used in risk assessment.     

Hyperglycaemia in acute coronary syndromes: risk-marker or therapeutic target?

Patients with acute coronary syndrome (ACS) often have raised blood glucose concentrations when admitted to hospital; a marker for poorer prognosis. Interventions to rapidly normalise blood glucose inconsistently are applied and with uncertain utility. Here we review the association of hyperglycaemia with outcome, present evidence that this hyperglycaemia reflects more than a pre-existing diabetic state and discuss mechanisms by which glucose may adversely affect the course of acute myocardial infarction (AMI). Finally, we seek evidence that intensive insulin treatment improves outcome.     

What seals the inflammation in acute coronary syndromes?

Inflammation plays a key role in the development of acute coronary syndromes and its consequences. Coronary stenting provides improved mortality and morbidity in appropriate cases by several routes. However the beneficial effects of the coronary stenting on inflammation remain controversial as the coronary stenting might lead to--systemically detected--local inflammatory reaction.     

Matrix metalloproteinases in acute coronary syndromes: a new therapeutic target?

Although matrix metalloproteinase (MMP) expression is found to be elevated after acute coronary syndrome (ACS), the slow elevation of MMP levels and the lack of clinical outcome data do not currently make MMPs useful biomarkers for therapeutic decision making or risk stratification in ACS. They do, however, remain an active area of investigation as a therapeutic target.     

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

Background

Coronary heart disease is a major problem in both men and women, but several studies have shown sex differences in symptoms of acute coronary syndromes (ACS). Some findings, however, have been disparate and inadequate, and thus a comprehensive overview of this literature would be of value.

Method

Fifteen studies that identified symptoms of ACS for both women and men were examined through a review of the literature from 1989 to 2002. Terms used for the search included “myocardial infarction,” “symptoms,” “gender differences,” and “acute coronary syndromes.”

Results

Although chest pain was the most common symptom in both men and women, several differences were also noted. In all types of ACS, women had significantly more back and jaw pain, nausea and/or vomiting, dyspnea, indigestion, and palpitations. In a number of studies, which solely sampled patients with acute myocardial infarction, women demonstrated more back, jaw, and neck pain and nausea and/or vomiting, dyspnea, palpitations, indigestion, dizziness, fatigue, loss of appetite, and syncope. Men reported more chest pain and diaphoresis in the myocardial infarction sample. The designs and methodologies of the studies varied considerably.

Conclusion

In addition to the typical symptom of chest pain in ACS, women experience other atypical symptoms more frequently than men. Thus, there may be sex differences in the symptoms of ACS, differences that have a bearing not only on clinical practice, but also on the interpretation of available clinical studies and the design of future investigations.     

Differences in plaque composition and distribution in stable coronary artery disease versus acute coronary syndromes; non‐invasive evaluation with multi‐slice computed tomography

Background: Plaque composition rather than degree of luminal narrowing may be predictive of acute coronary syndromes (ACS). The purpose of the study was to compare plaque composition and distribution with multi‐slice computed tomography (MSCT) between patients presenting with either stable coronary artery disease (CAD) or ACS. Methods: MSCT was performed in 22 and 24 patients presenting with ACS or stable CAD, respectively. Coronary lesions were classified as calcified, non‐calcified or mixed while signal intensity (SI) was measured. Results: In patients with stable CAD, the majority of lesions were calcified (89%). In patients with ACS, less calcifications were observed with a greater proportion of non‐calcified (18%) or mixed (36%) lesions (P<0.001). Accordingly, mean SI of plaques was significantly less in ACS (320±201?HU versus 620±256?HU in stable CAD, P<0.001). Dividing lesions in the ACS group according to culprit versus non‐culprit vessel location resulted in no significant difference in average SI between these two groups while still lower as compared to stable CAD (P<0.001). Conclusions: In patients with ACS, significantly less calcifications were present as compared to stable CAD. Moreover, even in non‐culprit vessels, multiple non‐calcified plaques were detected, indicating diffuse rather than focal atherosclerosis in ACS.