Systematic review and meta-analyses investigating whether risk stratification explains lower rates of coronary angiography among women with Non-ST-Segment Elevation Acute Coronary Syndrome

BACKGROUND: Guidelines recommend that all non-ST-segment elevation acute coronary syndrome (NSTEACS) patients with high-risk features receive a coronary angiogram. We hypothesised that the widely reported gender disparity in the use of angiography might be the result of women more frequently being stratified into the lower-risk category.

OBJECTIVES: The aim of the study was to review studies reporting risk stratification of NSTEACS patients by gender, compare risk profiles, and assess impact on use of coronary angiography.

METHODS: PubMed, Scopus, and EMBASE databases were searched on June 17, 2014, using MeSH terms/subheadings and/or key words with no further limits. The search revealed 1230 articles, of which 25 met our objective.

RESULTS: Among the 28 risk-stratified populations described in the 25 articles, women were more likely to be stratified as high-risk in 13 studies; men were more likely to be stratified as high-risk in 3 studies. After meta-analyses, women had a 23% higher odds of being stratified as high-risk than did men (P = .001). Lower-risk patients were more likely to receive an angiogram in 15 study populations.

CONCLUSIONS: Contrary to our hypothesis, this review showed that women with NSTEACS are more likely than men to be considered high-risk when stratified using a range of risk assessment methods. Lower rates of angiography in women form part of a broader treatment-risk paradox, which may involve gender bias in the selection of patients for invasive therapy.

Neuromuscular performance and bone structural characteristics in young healthy men and women

Muscle mass and strength have been shown to be important factors in bone strength. Low muscular force predisposes to falling especially among elderly. Regular exercise helps to prevent falls and resulting bone fractures. Better understanding of muscle function and its importance on bone properties may thus add information to fracture prevention. Therefore the purpose of this study was to examine the relationship between bone strength and muscular force production. Twenty-young men [24 (2) years] and 20 [24 (3) years] women served as subjects. Bone compressive (BSId) and bending strength indices (50 Imax) were measured with peripheral quantitative computed tomography (pQCT) at tibial mid-shaft and at distal tibia. Ankle plantarflexor muscle volume (MV) was estimated from muscle thickness measured with ultrasonography. Neuromuscular performance was evaluated from the measurements of maximal ground reaction force (GRF) in bilateral jumping and of eccentric maximal voluntary ankle plantarflexor torque (MVC). Specific tension (ST) of the plantarflexors was calculated by dividing the MVC with the muscle volume. Activation level (AL) was measured with superimposed twitch method. Distal tibia BSId and tibial mid-shaft 50 Imax correlated positively with GRF, MVC and MV in men (r = 0.45–0.67, P\0.05). Tibial mid-shaft 50 Imax and neuromuscular performance variables were correlated in women (r = 0.46–0.59, P\0.05), whereas no correlation was seen in distal tibia. In the regression analysis, MV and ST could explain 64% of the variance in tibial mid-shaft bone strength and 41% of the variation in distal tibia bone strength. The study emphasizes that tibial strength is related to maximal neuromuscular performance. In addition, tibial mid-shaft seems to be more dependent on the neuromuscular performance, than distal tibia. In young adults, the association between bone adaptation and neuromuscular performance seems to be moderate and also site and loading specific.

Gender difference in treatment and mortality of patients with ST-segment elevation myocardial infarction admitted to Victorian public hospitals: A retrospective database study.

BACKGROUND: Death from acute coronary syndrome (ACS) is avoidable with early reperfusion therapy, however, evidence suggests inequity in women's ACS treatment within a number of international healthcare systems, when compared to men's. Research indicates mortality rates are higher in some age groups of women when compared to men for the sub-group of ACS known as ST-segment elevation myocardial infarction (STEMI). OBJECTIVE: To determine whether patient sex was associated with patterns of reperfusion treatment variation or increased inhospital mortality in patients with STEMI. METHODS: We undertook retrospective analyses on a government database for patients admitted to Victorian public hospitals with STEMI. Patients were categorised into two age groups: 18-64 and 65-84 years (inclusive), to determine whether patient sex and these age groups influenced treatment from 2005 to 2008 and mortality from 2005 to 2010. RESULTS: Both younger and older women received less frequent angioplasty with stent and more often received no reperfusion treatment than men in corresponding younger and older age groups (p=0.006 and p<0.001, respectively). Overall, women in both age groups were more likely to die inhospital than men from equivalent age groups with STEMI (p<0.001, both groups). CONCLUSIONS: Proportionately, both younger and older women received less interventional reperfusion therapy for STEMI than their male cohorts, and died more often during admission than men. Further research needs to be undertaken to verify the findings and causes, and guide future research to ensure application of evidence to treatment in patients with STEMI.

Impact of comorbidities and gender on the use of coronary interventions in patients with high-risk non-ST-segment elevation acute coronary syndrome

OBJECTIVES: To determine the impact of gender and comorbidity on use of coronary interventions in patients diagnosed with high-risk non-ST-segment acute coronary syndrome (NSTEACS). BACKGROUND: Guidelines recommend the use of coronary angiography for all patients diagnosed with NSTEACS with high-risk features, except in the presence of severe comorbidities. However, little is understood about the relationship between gender, comorbidity, and the use of coronary interventions. METHODS: Retrospective analyses of the Victorian Admitted Episodes Data Set (VAED) including all patients diagnosed with NSTEACS with high-risk features on their first admission for ACS between June 2007 and July 2009. Hierarchical logistic regression models and correspondence analyses were used to understand the relationship between gender, comorbidities, and the use of coronary interventions. RESULTS: Out of 16,771 NSTEACS patients with high-risk features, 6,338 (38%) were female. Females were older than males (aged ≥75: 62% vs 39%, p < 0.001) and more likely to have multiple comorbidities (≥2: 66% vs 59%, p < 0.001). After adjusting for potential confounders, females were more likely to receive no coronary intervention than males with a similar number of comorbid conditions (no comorbidities: OR 1.62, 95% CI 1.28-2.05; 1 comorbidity: OR 1.67, 95% CI 1.44-1.93; 2 comorbidities: OR 1.93, 95% CI 1.66-2.23; ≥3 comorbidities: OR 1.42, 95% CI 1.27-1.60). CONCLUSIONS: Lower rates of coronary intervention in females persisted after adjusting for number of comorbidities which suggests that gender may bias decisions regarding referral for coronary intervention in high-risk NSTEACS independent of other factors.