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      Acute Coronary Syndromes in Women: Recent Treatment Trends and Outcomes

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          Abstract

          In the USA and internationally, women experience farranging differences with respect to acute coronary syndrome (ACS) and myocardial infarction (MI). Women suffer from more comorbidities than men, such as smoking, obesity, hypertension, diabetes, and poor mental health. They some-times exhibit atypical MI presentation symptoms and are overall less likely to present with chest pain. Women are more likely than men to encounter delays between the onset of symptoms and arrival at the hospital or to guideline treatment. The use of various surgical and pharmacological treatments, including revascularization approaches, also differs. Women, on average, have worse outcomes than men following MI, with more complications, higher mortality rates, and poorer recovery. Internationally, outcomes are similar despite various differences in health care and culture in non-US countries. In this review, we detail differences regarding ACS and MI in women, describing their complex correlations and discussing their possible causes. Educational approaches that are tailored to women might help to reduce the incidence of ACS and MI, as well as outcomes following hospitalization. Although outcomes following acute MI have been improving over the years, women may require special consideration in order to see continued improvement.

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          Most cited references43

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          Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality.

          Women are generally older than men at hospitalization for myocardial infarction (MI) and also present less frequently with chest pain/discomfort. However, few studies have taken age into account when examining sex differences in clinical presentation and mortality. To examine the relationship between sex and symptom presentation and between sex, symptom presentation, and hospital mortality, before and after accounting for age in patients hospitalized with MI. Observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients (481,581 women and 661,932 men). We examined predictors of MI presentation without chest pain and the relationship between age, sex, and hospital mortality. The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P < .001). There was a significant interaction between age and sex with chest pain at presentation, with a larger sex difference in younger than older patients, which became attenuated with advancing age. Multivariable adjusted age-specific odds ratios (ORs) for lack of chest pain for women (referent, men) were younger than 45 years, 1.30 (95% CI, 1.23-1.36); 45 to 54 years, 1.26 (95% CI, 1.22-1.30); 55 to 64 years, 1.24 (95% CI, 1.21-1.27); 65 to 74 years, 1.13 (95% CI, 1.11-1.15); and 75 years or older, 1.03 (95% CI, 1.02-1.04). Two-way interaction (sex and age) on MI presentation without chest pain was significant (P < .001). The in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age, with adjusted OR for age younger than 45 years, 1.18 (95% CI, 1.00-1.39); 45 to 54 years, 1.13 (95% CI, 1.02-1.26); 55 to 64 years, 1.02 (95% CI, 0.96-1.09); 65 to 74 years, 0.91 (95% CI, 0.88-0.95); and 75 years or older, 0.81 (95% CI, 0.79-0.83). The 3-way interaction (sex, age, and chest pain) on mortality was significant (P < .001). In this registry of patients hospitalized with MI, women were more likely than men to present without chest pain and had higher mortality than men within the same age group, but sex differences in clinical presentation without chest pain and in mortality were attenuated with increasing age.
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            Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002: concealed leveling of mortality rates.

            The objective of our study was to examine age-specific mortality rates from coronary heart disease (CHD), particularly those among younger adults. Trends for obesity, diabetes, blood pressure, and metabolic syndrome among young adults raise concerns about the mortality rates from CHD in this group. We used mortality data from 1980 to 2002 to calculate age-specific mortality rates from CHD for U.S. adults age > or =35 years. Overall, the age-adjusted mortality rate decreased by 52% in men and 49% in women. Among women age 35 to 54 years, the estimated annual percentage change (EAPC) in mortality was -5.4% (95% confidence interval [CI] -5.8 to -4.9) from 1980 until 1989, -1.2% (95% CI -1.6 to -0.8) from 1989 until 2000, and 1.5% (95% CI -3.4 to 6.6) from 2000 until 2002. Among men age 35 to 54 years, the EAPC in mortality was -6.2% (95% CI -6.4 to -5.9) from 1980 until 1989, -2.3% (95% CI -2.6 to -2.1) from 1989 until 2000, and -0.5% (95% CI -3.7 to 2.9) from 2000 until 2002. Among women and men age > or =55 years, the estimated annual percentage decrease in mortality from CHD accelerated in more recent years compared with earlier periods. The mortality rates for CHD among younger adults may serve as a sentinel event. Unfavorable trends in several risk factors for CHD provide a likely explanation for the observed mortality rates.
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              High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study.

              To evaluate the diagnosis of myocardial infarction using a high sensitivity troponin I assay and sex specific diagnostic thresholds in men and women with suspected acute coronary syndrome.
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                Author and article information

                Journal
                Clin Med Insights Cardiol
                Clin Med Insights Cardiol
                Clinical Medicine Insights: Cardiology
                Clinical Medicine Insights. Cardiology
                Libertas Academica
                1179-5468
                2016
                08 February 2016
                : 10
                : 1-10
                Affiliations
                [1 ]Aetna Foundation, Hartford, CT, USA.
                [2 ]University of Connecticut School of Medicine, Farmington, CT, USA.
                Author notes
                Article
                cmc-10-2016-001
                10.4137/CMC.S37145
                4747299
                26884685
                938dc79f-6308-499d-b1bb-bdac8dd04be9
                © 2016 the author(s), publisher and licensee Libertas Academica Ltd.

                This is an open-access article distributed under the terms of the Creative Commons CC-BY-NC 3.0 License.

                History
                : 30 October 2015
                : 28 December 2015
                : 02 January 2016
                Categories
                Review

                Cardiovascular Medicine
                myocardial infarction,acute coronary syndrome,women,comorbidities,disparities,symptoms,diagnosis,treatment,outcomes,international

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