Gender Disparities in Presentation, Management, and Outcomes of Acute Myocardial Infarction.

PURPOSE OF REVIEW: This review provides updates in gender disparities in the symptom profile, risk factors, quality and timeliness of guideline-based medical care, and clinical outcomes, including mortality, bleeding, and vascular complications, in patients with acute myocardial infarction (AMI). RECENT FINDINGS: While AMI continues to be a leading cause of mortality in both men and women, significant gender differences exist in presentation, management, and outcomes. Women with AMI are older, suffer atypical symptoms, and more often present with HF and cardiogenic shock. Delays in medical care and hence longer ischemic times exist in women, partly due to decreased awareness and lack of symptom recognition. Women continue to be less likely to receive guideline-based pharmacological therapies and revascularization than men with AMI. While women suffer from significantly higher risk-adjusted rates of bleeding, vascular complications, and short-term mortality, the risk-adjusted rates of long-term mortality remain similar between men and women. Further investigations and efforts are needed to aggressively modify risk factors, reduce delays in care, and address the higher rates of adverse events seen in women with AMI. Significant sex disparities are prevalent in presentation, management, and outcomes of adults with AMI. Further investigations and efforts are needed to aggressively modify risk factors, reduce delays in care, and address the higher rates of adverse events seen in women with AMI.

Does ischemic burden on stress testing influence patient survival in subjects with known severe multi-vessel CAD?

BACKGROUND: Ischemic burden observed during stress testing has been postulated to predict prognosis irrespective of anatomic atherosclerotic burden observed on angiography. However, it is not known if the stress test result influences the long-term prognosis of subjects with diffuse coronary artery disease. We sought to determine the prognostic importance of stress test false negativity amongst patients with severe multi-vessel coronary artery disease (CAD) undergoing stress testing in the previous decade. METHODS: We selected subjects from the dates of 1/1/2000 to 12/31/2005 who underwent a nuclear stress test (MPI) or stress echocardiogram (SE) within six months of a coronary angiogram demonstrating severe, multi-vessel CAD. We excluded those with a prior MI, PCI, CABG, resting wall motion abnormality, or perfusion defect at rest. Determination of patient death during the followup period was performed using the U.S. social security index. RESULTS: 139 subjects (MPI 81, SE 58) were studied; stress tests were positive for ischemia in 80%. Rates of death were similar at 1 year (MPI 9%, SE 5%, p-value 0.44), 5 years (MPI 20%, SE 14%, p-value 0.36) and 10 years (MPI 30%, SE 26%, p-value 0.63). Using multivariate analysis, mortality at each time period was not affected by stress test positivity. CONCLUSION: Amongst subjects with diffuse and severe atherosclerosis with preserved ventricular function, ischemic burden on stress testing did not influence short or long-term survival.

Outcomes in patients with various forms of aortic stenosis including those with low-flow low-gradient normal and low ejection fraction.

Low-flow low-gradient aortic stenosis with normal ejection fraction (LFLGNEF AS) is a newly characterized poorly understood entity within the AS spectrum. Whether LFLGNEF AS has a worse prognosis than typical AS remains controversial. We retrospectively identified 4,546 individual patients with any type of AS on echocardiogram from 2003 through 2013 and categorized them into 5 cohorts: (1) mild AS, (2) moderate AS, (3) severe AS, (4) LFLGNEF AS (ejection fraction≥55%), and (5) low-flow low-gradient low ejection fraction AS (LFLGLEF AS; ejection fraction<55%). Survival analysis was used to compare outcomes of LFLGNEF AS with those of the other cohorts. AS was classified as mild in 591 patients, moderate in 2,358, severe in 500, LFLGNEF in 776, and LFLGLEF in 318. The study group had a mean age of 80.5 years, 61% were women, and the patients were followed for 2.26±1.16 years. Among subjects managed without valve replacement, total mortality for the LFLGNEF AS group was lower compared with that in both the severe AS and the LFLGLEF AS groups (p=0.007 and p<0.001, respectively). The prognosis for LFLGNEF AS was worse, however, compared with those with mild and moderate AS (p<0.001, both). In conclusion, no survival differences were found among AS types among those who received valve replacement. The survival rate in LFLGNEF is better than that in severe AS or LFLGLEF but is worse than that in mild or moderate AS. Valve replacement seems reasonable to pursue in select patients.