Sex Differences in Mortality After Myocardial Infarction: The Role of Post Pci Flow and its Relation to Time Delay to Reperfusion

Introduction: Little is known regarding gender differences in coronary flow and 30 day mortality after primary PCI in STEMI, despite blood flow is a major determinant of patients\u2019 prognosis. Hypothesis: We sought to investigate the impact of gender on TIMI flow grades, and related 30 day mortality after primary PCI for STEMI. Methods: Two thousand seven hundred twenty six patients (1999 men) with STEMI derived from the ISACSTC registry (NCT01218776) were included in the analysis. Pre PCI TIMI flow grades were categorized as high (2-3) or low (1-2). PCI success was defined as <25% residual insegment stenosis. Low post PCI TIMI flow grade was defined as 642. Multivariate logistic regression model was adjusted for important baseline and clinical covariates. The endpoint was 30 day mortality. Results: Women presented at an older age than men and were more likely to have diabetes and hypertension, but less likely to have a history of smoking. Median time from symptom onset to treatment was longer for women (316.5 vs 285 min\u37e p=0.01). However, there were no differences between the sexes in median door to balloon time (45 vs 44 min p=0.42). Baseline TIMI flow grades were lower in women as compared with men (TIMI flow 2/3: 23.4% vs 28.9%, P=0.006). Women and men had similar angiographic PCI success (94.5% vs 96.1%, P=0.09). Nevertheless after the procedure men had higher rates of TIMI flow grade 3 compared with women (93.3% vs 89.3%, P= 0.001). Thirty day mortality was greater in women than men (6.5% vs 3.6%, P=0.001). Multivariate analysis linked time from symptom onset to treatment >2 hours, with post PCI TIMI flow grade 642 (OR 1.69, CI 1.112.57). The most significant variables associated with mortality were: age (OR 1.53, CI 1.261.87), diabetes (OR 1.65, CI 1.062.54), and post PCI TIMI flow grade 642 (OR 7.92, CI 5.0812.33). Analysis showed that patient sex not to be an independent predictor of mortality (OR 1.10, CI 0.711.70). Conclusions: Time delay to reperfusion and low post PCI TIMI flow grade are significantly related to higher 30 day mortality in STEMI. Women have more delay to hospital presentation and less complete restoration of epicardial blood flow in culprit vessels after PCI

Primary angioplasty vs. early fibrinolysis: the role of reperfusion delay

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Sex difference in the impact of delay to reperfusion on coronary blood flow and outcomes in ST-segment elevation myocardial infarction

Background: Delay from symptom onset to reperfusion by primary percutaneous coronary intervention (PCI) is longer in women and has been linked to increased mortality and worse clinical outcome. The mechanism underlying this association is still unclear. Purpose: We sought to investigate the impact of delay from symptom onset to hospital presentation on sex difference in TIMI flow grades and 30-day mortality after primary PCI for STEMI. Methods: The current study evaluated 2596 patients with STEMI who underwent primary PCI within 12 hours from symptom onset and had a stent implantation between 2010 and 2016 in the ISACS-TC registry (ClinicalTrials.gov, NCT01218776). Main outcomes measures were adjusted 30-day mortality rates and suboptimal post-PCI TIMI (Thrombolysis In Myocardial Infarction) flow (grades 642) estimated using inverse probability of treatment weighted (IPTW) models. Time from symptom onset to hospital presentation was classified as <2 hours, <6 hours, and <12 hours Results: Early reperfusion (<2 hours) was not associated with significant sex differences in the rates of mortality and final flow post-PCI TIMI flow (grades 642). Sex differences in outcomes differed if analyzing patients with 652-hour delay. Mortality rates were 4.0% for women versus 2.1% for men with an OR of 1.94 (95% CI: 1.09 to 3.47) in patients with <6 hours delay, and 4.6% for women versus 2.3% for men with an OR of 2.02 (95% CI: 1.24 to 3.27) in patients with <12 hours delay. The odds of TIMI 642 in women versus men were 1.40 (95% CI: 0.85 to 2.31) in patients with <6 hours delay, and 1.49 (95% CI: 0.99 to 2.24) in patients with <12 hours delay. Conclusions: Longer delays to reperfusion are associated with sex differences in the rates of 30-day mortality and worse outcome in women. Women are more vulnerable to prolonged untreated ischemia. This effect appears not to be mediated by less successful reperfusion

Machine Learning Techniques for Risk Stratification of Non-ST-Elevation Acute Coronary Syndrome: The Role of Diabetes and Age

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Atypical presentation and comorbidities mutually influence management of ACS patients

Background: Limited data are available on the association between comorbidities and acute myocardial ischemia with atypical presentation. Purpose: The aim of this study was to investigate the impact of comorbidities on the management and outcomes of ACS patients with atypical presentation (i.e. ACS without chest pain). Methods: Between 2010 and 2016, 11458 ACS patients were admitted at 57 hospitals included in the network of the ISACS-TC registry (ClinicalTrials.gov, NCT01218776). There were 1394 (12.2%) patients with unstable angina, 2855 (24.9%) with NSTEMI, and 7203 (62.9%) with STEMI. Results: 995 (8.7%) ACS patients have atypical presentation at the initial evaluation, and the 40.2% of the overall study population have comorbidities (diabetes mellitus, heart failure, CKD, COPD, stroke, PAD, GERD or active cancer). Patients with comorbidities were not equally distributed: 38.7% were with typical presentation and 55.2% without typical presentation, (p<0.001). In-hospital mortality rate was much higher in patients with atypical presentation than in patients with the typical one (15.5% vs 6.3%, p<0.001). As well, mortality rate was lower for ACS patients with no-comorbidities than for ACS patients with comorbidities (5.1% versus 10.1%, p<0.001). Stratifying the population by the presence/absence of comorbiditis and the presence/absence typical presentation, we found a decreasing trend in use of evidence base treatment (aspirin, beta-blocker, statin and reperfusion) and invasive procedure. Compare to patients with typical presentation and no-comorbidities (OR: 1, referent), patients with typical presentation and comorbidities (OR: 0.70), as well as those with atypical presentation and no-comorbidities (OR: 0.23), and those with atypical presentation and comorbidities (OR: 0.18) had a significant (p<0.001) lower probability to undergo in-hospital cardiac catheterization. On the opposite, there was an increasing trend (p<0.001) over subgroups in the risk of death (OR:1 referent, typical ACS presentation and no-comorbid; OR:2.00 typical ACS presentation and comordidities; OR: 2.52 atypical ACS presentation and no-comorbid; OR: 4.83 atypical ACS presentation and comordidities). Conclusions: The presence of comorbidities and atypical ACS presentation dramatically influence the process of care. Patients with atypical presentation and comorbidities are those who receive the lowest treatment and those who have the highest risk of in-hospital death

High rates of 30-day mortality in younger women presenting with STEMI: the ISACS Study

Introduction: Previous works have shown that women hospitalized with STEMI have higher short-term mortality rates than men. However, it is unclear if these differences persist among patients undergoing contemporary primary PCI. Purpose: We sought to investigate whether the risk of 30-day mortality after STEMI is higher in women than men and, if so, to assess the role of age, medications and primary PCI in this excess of risk. Methods: From January 2010 to January 2016, a total of 8834 patients have been hospitalized and received medical treatment for STEMI in 41 hospitals, referring data to the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) registry (NCT01218776). Logistic regression model was adjusted to covariates significantly different between groups in univariate analysis. The endpoint was 30-day mortality after STEMI. Results: There were 2657 women and 6177 men. Women were older than man, with a higher prevalence of risk factors and comorbidities. Fewer women than men presented within 2 hours from symptom onset (p<0.001). They presented more (p<0.001) Killip class 652 than men A significantly (p<0.001) lower proportion of women was treated with acute medications, secondary prevention therapies and primary PCI. Thirty day mortality was significantly higher for women than for men (11.6% versus 5.9%, p<0.001). The gap in sex-specific mortality narrowed if restricting the analysis to men and women undergoing primary PCI (7.1% versus 3.3%, p<0.001). A significant interaction was found between sex and age. Women under 60 had higher early mortality risk than men of the same group (OR: 1.78, 95% CI: 1.04\u20133.05, p=0.03) after adjusting for age, comorbidities and treatment variables. Women aged 60\u201374 had the same risk of men (OR: 1.38, 95% CI: 0.95\u20131.99 p=0.08). The same results applied to women aged over 75 (OR: 1.06, 95% CI: 0.74\u20131.52, p=0.71). Conclusions: Younger age is associated with higher short term mortality rate in women with STEMI even after adjustment for medications, primary PCI and other coexisting comorbidities. This difference was no longer observed in older wome

P4652Myocardial infarction: process of care measures in eastern Europe: insights for complementary metrics

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