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Sex Differences in Heart Failure Following Acute Coronary Syndromes
Quick Takes
- In a large study enrolling ACS patients from 11 European countries, female sex was independently associated with a higher risk for 30-day mortality and acute HF.
- These risks were higher among women presenting with STEMI compared with NSTEMI.
- In ACS patients with HF, women with STEMI were more likely to have HFrEF but women with NSTEMI were less likely to have HFrEF than men.
Study Questions:
Are there sex differences in presentation and outcomes in patients with acute heart failure (HF) with acute coronary syndrome (ACS)?
Methods:
This study used the ISACS (International Survey of Acute Coronary Syndromes) registry, which enrolled ACS patients from 11 European registries. The primary outcome was 30-day all-cause mortality from hospital admission. The secondary outcome was risk of acute HF on admission. Propensity-matched analyses were conducted to examine sex differences in presentations and outcomes.
Results:
Among 87,812 ACS patients, 25,187 (29%) had acute HF on admission, of which 35.2% were women. This included 56,038 ST-segment elevation myocardial infarction (STEMI) with 34% women and 31,774 NSTEMI patients with 38% women. Women were older, more likely to have diabetes and hypertension, and less likely to be current smokers with no difference in time from symptom onset to presentation.
Women with ACS had a higher risk for 30-day mortality than men (absolute difference, 3.5%; risk ratio [RR], 1.43; 95% confidence interval [CI], 1.37-1.50). This elevated 30-day mortality risk was higher for STEMI than NSTEMI. Women also had a higher risk for presenting with acute HF (absolute difference, 2.6%; RR, 1.13; 95% CI, 1.10-1.17). Acute HF risk was higher with STEMI than NSTEMI. Women with acute HF on presentation had a higher 30-day mortality risk (RR, 1.24; 95% CI, 1.17-1.31). In patients with STEMI and acute HF, women were more likely to have HF with reduced ejection fraction (HFrEF) compared with men. In patients with acute HF and NSTEMI, women were less likely to have HFrEF than men. In multivariable models, female sex was independently associated with acute HF and 30-day mortality.
Conclusions:
In a large study enrolling ACS patients from 11 European countries, female sex was independently associated with a higher risk for 30-day mortality and acute HF. These risks were higher among STEMI patients. In ACS patients with HF, women with STEMI were more likely to have HFrEF but women with NSTEMI were less likely to have HFrEF than men.
Perspective:
Although sex differences and outcomes in ACS have been extensively studied, studies have yielded mixed results. This study provides results of sex disparities and outcomes after ACS from one of the largest ACS cohorts enrolling over 80,000 ACS patients. Results highlight several differences between men and women presenting with ACS. Women remained at a higher risk for 30-day mortality post-ACS and risk for acute HF presentation that persisted despite propensity-score matching. Differences in revascularization strategy and time to presentation did not explain these differences. In addition, these higher risks for mortality and acute HF presentation were higher for women with STEMI than NSTEMI. There were biological differences in type of HF as well with women with STEMI presenting more frequently with HFrEF than men. However, women with NSTEMI presented more frequently with HFpEF than men. While mechanisms behind these differences cannot be assessed in this study, these findings certainly support the need to evaluate sex differences in response to treatment for ACS and HF.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Acute Heart Failure, Hypertension, Smoking, Chronic Angina
Keywords: Acute Coronary Syndrome, Anterior Wall Myocardial Infarction, Diabetes Mellitus, Heart Failure, Hypertension, Myocardial Infarction, Non-ST Elevated Myocardial Infarction, Secondary Prevention, Sex Characteristics, Smoking, ST Elevation Myocardial Infarction, Stroke Volume, Ventricular Dysfunction, Left
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