2. Occurrence
๏ต Although there has been a reduction in the death rate from CHD since 1980, it
accounted for 22 % of all-cause mortality in women in 2013.
๏ต Between the ages of 45 and 64, 1 in 9 women develop symptoms of some form
of cardiovascular disease.
๏ต After age 65, the ratio climbs to 1 in 3 women, according to the National Center
for Health Statistics
๏ต Women with CHD are generally about 10 years older than men at the time of
presentation and carry a greater burden of risk factors. They have less income
also.
3. Occurrence
๏ต INOCA is more prevalent in females (65%vs 32%). MINOCA is twice more
common.
๏ต Women account for 90% of all Takotsubo Cardiomyopathy.
๏ต Incidence of ACS in pregnancy is 6.2 per 100000.
๏ต Risk of MI in pregnancy increases 3 to 4 fold. Mostly within 3rd trimester and 6
weeks postpartum.
๏ต SCAD is also more common in females. More than 90% cases.
5. Difference in symptoms
๏ต The classic syndrome of MI (eg, substernal or left-sided chest pain with radiation
to neck or jaw) is the most common form of presentation for women.
๏ต During an MI, women are more likely than men to present without chest pain.
๏ต The prevalence of unrecognized MI was shown to be higher in women than men
(30 versus 16 percent).
๏ต National Registry of MI : women were more likely to present with MI without
chest pain. (42% vs 31%), particularly younger had highest mortality rate.
6. Difference in symptoms
๏ต Delay in care : VIRGO study showed the delay in seeking care. Some other
studies showed delay in reperfusion.
๏ต VIRGO study showed younger female with AMI (18-55) had worse CVD specific
health ( angina, stroke, CHF) and lower physical function than male with AMI
in the same age group.
๏ต Young women experience more associated symptoms.
๏ต More anxiety and depression before ACS onset.
๏ต Hs-Troponin T is important for diagnosis in women.
7. Difference in pathophysiology
๏ต Plaque erosion is most frequent cause of ACS in women compared to Plaque
rupture in men.
๏ต Women have increased PCWP than men during STEMI. This increased LV filling
pressure is independent of age, HTN, infarct size; S/O gender dependent.
๏ต Females have less complex coronary artery disease and relatively smaller
coronary arteries.
8. Difference in pathophysiology
๏ต In a study of female with chest pain and nonobstructive CAD, who underwent
adenosine CMR, subendocardial ischaemia was frequently present.
๏ต Even in normal coronaries, female had abnormalities on late gadolinium
enhancement consistent with ischaemia.
๏ต In a study of 150 patients of ACS in pregnancy it was found:
9. Role of autoimmune disease
๏ต Framingham offspring study : Women with SLE and between 34 to 44
years of age have 50 fold more likely to have AMI than the same age-
group without SLE.
๏ต SLE with myocardial perfusion defect was independently associated
with increased risk of CAD.
๏ต Women with lupus, serial carotid ultrasound demonstrated that 28%
have progressive atherosclerosis over 34 months follow up period.
10. Difference in management
๏ต SWEDEHEART (2003-2013): Excess mortality in women of STEMI & NSTEMI due
to underused GDMT.
๏ต In-hospital mortality is higher in AMI with obstructive CAD : ACTION-GWTG
registry.
๏ต Nationwide Inpatient Sample 2010-2016: less reperfusion and
revascularization ; hence more mortality.
๏ต Women do worse with incomplete revascularization after STEMI.
๏ต Increased bleeding risk with GP 2b/3a inhibitors.
11. Difference in fibrinolysis
๏ต Women were less likely to receive fibrinolysis, even if eligible, and were likely to
experience a greater delay.
๏ต Although definitive data are not available, it appears that fibrinolysis reduces
mortality in AMI by the same proportion in both sexes.
๏ต Women receiving fibrinolysis have a higher rate of mortality and morbidity.
๏ต Women have a modestly increased risk of bleeding, including hemorrhagic
stroke, after fibrinolysis.
๏ต Fibrinolysis in menstruation; should not automatically be excluded: data are
limited. Among 12 menstruating women in GUSTO-I, there was no significant
increase in severe bleeding compared with non-menstruating women. A
significant increase in moderate bleeding was found that was offset by the
benefits of fibrinolytic therapy.
12. Difference in intervention
๏ต In a study of 91,088 AMI hospitalizations for STEMI and NSTEMI, women were
older than men for both diagnoses and were less likely to be treated with PCI
or CABG.
๏ต Females with NSTEMI were less likely to have PCI similar proportion of cath
study.
๏ต Increased post PCI mortality and bleeding in women.
๏ต Mortality after PCI : women have higher short term risk but equal long term
risk.
๏ต Observational studies and subset analyses of randomized trials suggest that
women with STEMI (similar to men) have better outcomes with primary PCI
than fibrinolysis.
13. Difference in intervention
๏ต A meta-analysis of contemporary trials suggested that while an early invasive
strategy had a survival benefit in men, there was no such benefit in women.
๏ต However, when the subgroup of women with elevated troponin levels was
examined, a clear benefit in six-month outcomes emerged.
๏ต A subsequent meta-analysis of 8 trials, with over 3000 women and over 7000
men, found that an early invasive strategy had a similar benefit in high-risk
(biomarker-positive) women as it did in men, but that benefit could not be
shown for lower-risk (biomarker-negative) women.
14. Difference in intervention
๏ต CADILLAC trial: Post-primary PCI: at 1 year, women had significantly higher
rates of mortality (7.6 versus 3.0 percent in men), target vessel revascularization
(16.7 versus 12.1 percent), and MACE (23.9 versus 15.3 percent).
๏ต These differences were largely due to a higher prevalence of clinical risk factors
in women (older age and more frequent diabetes, hypertension, and renal
insufficiency) and smaller body size.
๏ต After adjustment, female sex was not an independent risk factor for mortality in
the CADILLAC trial.
15. Difference in complications
๏ต Free wall rupture and rupture of IVS are more common in females.
๏ต Post MI NOAF was significantly a/w increased risk of ischemic stroke after
discharge, specially among women.
๏ต Women with CHD more frequently have or develop symptomatic HF than men;
may be due to more diastolic dysfunction.
๏ต Women had a lower SCD rate than men at all ages and at any level of
multivariate risks. (Half than men).
๏ต Women having acute MI complicated by cardiogenic shock may have a higher
in-hospital mortality than men.
16. Management of MI in pregnancy
๏ต Principles are same as General population.
๏ต A high coordination between emergency, obstetrics and cardiovascular
teams are needed.
๏ต Fibrinolytic therapy is relatively contraindicated.
๏ต ACEI, ARB and statins are not indicated.
๏ต Heparin, aspirin, beta-blockers and nitrates are mainstay of
treatment.
17. CABG in women
๏ต In BARI trial 27% were women.
๏ต Crude mortality rate was similar.
๏ต Again women were older and having more HF, DM and
HTN.
18. Difference in outcome
๏ต In a pooled analysis of 10 PCI RCTs (n= 2632,22% women), women were older
and had greater delays in reperfusion, but had better early post- MI LVEF &
similar infarct size to men. Women still had higher adjusted 1- year rates of
death or HF hospitalizations (HR 2.13, 95% CI 1.34 to 3.38), which were not
explained by LVEF or infarct size.
๏ต WISE study : symptomatic women with documented ischemia and
nonobstructive CAD had a 10- year all- cause mortality and cardiac mortality
of 17% and 11%, respectively. In those women with normal coronary arteries
but documented ischemia, the 10- year all- cause mortality and cardiac
mortality was 10% and 6%, respectively.
19. Difference in outcome
๏ต Women have more both in-hospital complications & readmissions
following PCI.
๏ต Women have greater risk of one-year rehospitalization for ACS
following MI.
๏ต Thyroid dysfunction is a/w worse outcome and higher risk of
reinfarction in patients with ACS. Women have higher incidence of
thyroid dysfunction.
20. Difference in outcomes
๏ต More depression after PCI in young women and elderly men may be
associated with more mortality.
๏ต Feeling diverse and being minority increases the post PCI mortality
according to PLATINUM-DIVERSITY trial.
๏ต Independent of sex of the doctors, women are managed less
frequently.
๏ต In PCI RCTs women fare more poorly than men.
21. Take home messages
๏ต Menopause is an ACS risk factor without similar male equivalent.
๏ต Complete revascularization after STEMI is important for women.
๏ต Variety of vascular dysfunction and psychosocial aspect are to be
understood in a better way to give greater benefit.
๏ต Older age, disproportionate burden of comorbidities and delay in
seeking care are of utmost importance.
22.
23. Thank you
๏ต Special thanks to Professor Julinda Mehilli for her wonderful lecture
in ESC 2018.
๏ต Few informations are taken from UPTODATE and Braunwaldโs Heart
Disease text book.
๏ต Special thanks to Catherine Gebhard for an excellent article in EHJ
2017.
