Objective: To assess whether sex differences exist in the angiographic severity, management and outcomes of acute coronary syndromes (ACS).
Methods: The study comprised 7638 women and 19 117 men with ACS who underwent coronary angiography and were included in GRACE (Global Registry of Acute Coronary Events) from 1999–2006. Normal vessels/mild disease was defined as <50% stenosis in all epicardial vessels; advanced disease was defined as one vessel with 50% stenosis.
Results: Women were older than men and had higher rates of cardiovascular risk factors. Men and women presented equally with chest pain; however, jaw pain and nausea were more frequent among women. Women were more likely to have normal/mild disease (12% vs 6%, p<0.001) and less likely to have left-main and three-vessel disease (27% vs 32%, p<0.001) or undergo percutaneous coronary intervention (65% vs 68%, p<0.001). Women and men with normal and mild disease were treated less aggressively than those with advanced disease. Women with advanced disease had a higher risk of death (4% vs 3%, p<0.01). After adjustment for age and extent of disease, women were more likely to have adverse outcomes (death, myocardial infarction, stroke and rehospitalisation) at six months compared to men (odds ratio 1.24, 95% confidence interval 1.14 to 1.34); however, sex differences in mortality were no longer statistically significant.
Conclusions: Women with ACS were more likely to have cardiovascular disease risk factors and atypical symptoms such as nausea compared with men, but were more likely to have normal/mild angiographic coronary artery disease. Further study regarding sex differences related to disease severity is warranted.
Coronary heart disease (CHD) is a leading cause of death for women worldwide.1 Each year more women than men die from cardiovascular disease, most from myocardial infarction and sudden death.2 Owing to improvements in cardiac care, more women are living with CHD than ever before.3 In patients with an acute coronary syndrome (ACS), understanding possible sex differences related to symptom presentation, management and outcomes will assist in advancing current management of ACS in women.
Several studies have reported differences in the clinical presentation and baseline comorbidities of men and women with ACS.4–7 Women are typically older and more likely to have hypertension, diabetes and metabolic syndrome but are less likely to smoke tobacco than men.8–10 Women with ACS are less likely than men to undergo cardiac catheterisation and subsequent revascularisation procedures9 11 12 or to receive glycoprotein IIb/IIIa inhibitors while in hospital or to be discharged on evidenced-based cardiac therapies.5 9 10 13 14 Women with ACS have worse in-hospital and long-term prognoses than men in some,15–18 but not all studies.9 10 Many of these studies were completed over a decade earlier; in the meantime treatment strategies for patients with ACS have evolved. Furthermore, data from previous studies are often from randomised trials or specialised populations such as women referred for angiography. Data on a diverse, multiethnic population of real-world patients admitted for ACS, which includes large numbers of women, are scarce. The Global Registry of Acute Coronary Events (GRACE) is a unique dataset with extensive information on ACS presentation characteristics, angiographic data, management and outcomes, which includes large numbers of both men and women patients admitted for ACS.
Using data from GRACE, a large, multinational, observational study, we investigated whether women presenting with ACS have different symptoms, severity of obstructive angiographic coronary artery disease (CAD) and six-month outcomes compared to men. In addition, we examined the use of medical and interventional therapies in women and men to determine if differences in interventional therapy were the result of pathophysiological disparities in disease.
Full details of the GRACE methods have been published.19–21 GRACE is designed to reflect an unbiased population of patients with ACS, irrespective of geographic region. A total of 113 hospitals located in 14 countries (Argentina, Australia, Austria, Belgium, Brazil, Canada, France, Germany, Italy, New Zealand, Poland, Spain, the United Kingdom and the United States) have contributed data to this observational study. Patients from 93 hospitals were included in this analysis.
Adult patients (18 years old) admitted with a presumptive diagnosis of ACS at participating hospitals were potentially eligible for this study. Eligibility criteria were a clinical history of ACS accompanied by at least one of the following: electrocardiographic changes consistent with ACS, serial increases in biochemical markers of cardiac necrosis (creatine kinase isoenzyme, creatine phosphokinase or troponin) and documented coronary artery disease. Patients with non-cardiovascular causes for ACS, such as trauma, surgery or aortic aneurism, were excluded. Patients were followed up at approximately six months by telephone, clinic visits or through calls to their primary care physician to ascertain the occurrence of several long-term outcomes. Where required, study investigators received approval from their local hospital ethics committee or institutional review board.
作者:admin@医学,生命科学 2011-03-09 17:11