Re
Po
Ca diol.
2015;34(1):43---50
Re is a
Po uguesa
de
Ca diologia
Po uguese
Jou nal
o
Ca diology
www. e po ca diol.o g
ORIGINAL
ARTICLE
Influence
o
gende
on
p ognosis
o
acu e
co ona y
synd omes
José
Luis
Cab e izo-Ga cíaa,
Juan
I.
Pé ez-Cal ob,
Bego˜
na
Zalba-E ayoc,∗
aDepa men
o
In e nal
Medicine,
Gene al
Hospi al
o
De ense,
Za agoza,
Spain
bHead
o
Depa men
o
In e nal
Medicine,
‘‘Lozano
Blesa’’
Uni e si a y
Hospi al,
Za agoza,
Spain
cIn ensi e
Ca e
Uni ,
‘‘Lozano
Blesa’’
Uni e si a y
Hospi al,
Za agoza,
Spain
Recei ed
24
Decembe
2012;
accep ed
16
Augus
2014
A ailable
online
8
Janua y
2015
KEYWORDS
Acu e
co ona y
synd ome;
Risk
ac o ;
Age;
Gende ;
Su i al;
P ognosis
Abs ac
In oduc ion:
Ischemic
hea
disease
p esen s
di e en
ea u es
in
men
and
women.
We
ana-
lyzed
he
ela ion
be ween
gende
and
p ognosis
in
pa ien s
who
had
su e ed
a
high- isk
acu e
co ona y
synd ome
(ACS).
Me hods:
This
was
a
p ospec i e
analy ical
coho
s udy
pe o med
a
Lozano
Blesa
Uni e si y
Hospi al,
Za agoza,
Spain,
o
559
pa ien s
diagnosed
wi h
high- isk
ACS
wi h
and
wi hou
ST-
segmen
ele a ion
acco ding
o
he
Ame ican
College
o
Ca diology/Ame ican
Hea
Associa ion
guidelines.
The
sample
was
di ided
in o
wo
g oups
by
gende
and
di e ences
in
epidemio-
logic,
labo a o y,
elec oca diog aphic
and
echoca diog aphic
a iables
and
ea men
we e
eco ded.
A
Cox’s
p opo ional
haza d
model
was
applied
and
6-mon h
mo ali y
was
analyzed
as
he
main
a iable.
Resul s:
The
median
age
was
65.2±12.7
yea s,
and
21.8%
we e
women.
Baseline
cha ac e is ics
in
women
we e
mo e
un a o able,
wi h
highe
GRACE
sco es,
olde
age,
highe
p e alence
o
hype ension,
diabe es
and
hea
ailu e,
lowe
ejec ion
ac ion
and
mo e
enal
dys unc ion
a
admission.
Women
su e ed
mo e
ad e se
ca dio ascula
e en s
(27.9%
s.
15.8%,
p=0.002).
Six y- ou
pa ien s
died,
18.9%
o
he
women
s.
9.4%
o
he
men
(p=0.004).
A e
mul i a ia e
analysis,
emale
gende
did
no
p esen
an
independen
ela ion
wi h
mo ali y.
Hemoglobin
le el,
enal
unc ion,
ejec ion
ac ion
and
Killip
class
>1
p esen ed
significan
di e ences.
Conclusions:
Acu e
synd ome
co ona y
in
women
has
a
wo se
p ognosis
han
in
men.
Thei
ad e se
cou se
is
due
o
hei
baseline
cha ac e is ics
and
no
o
hei
gende .
©
2012
Sociedade
Po uguesa
de
Ca diologia.
Published
by
Else ie
España,
S.L.U.
All
igh s
ese ed.
∗Co esponding
au ho .
E-mail
add ess:
[email p o ec ed]
(B.
Zalba-E ayo).
h p://dx.doi.o g/10.1016/j. epc.2014.07.008
0870-2551/©
2012
Sociedade
Po uguesa
de
Ca diologia.
Published
by
Else ie
España,
S.L.U.
All
igh s
ese ed.
44
J.L.
Cab e izo-Ga cía
e
al.
PALAVRAS
CHAVE
Sínd ome
co oná ia
aguda;
Fa o
de
isco;
Idade;
Sexo;
Sob e i ência;
P ognós ico
Influência
do
géne o
no
p ognós ico
das
sínd omes
co oná ias
agudas
Resumo
In oduc¸ão:
A
doenc¸a
ca díaca
isquémica
ap esen a
ca ac e ís icas
di e en es
em
homens
e
mulhe es.
Foi
analisada
a
elac¸ão
en e
o
sexo
e
o
p ognós ico,
em
pacien es
í imas
de
sínd ome
co oná ia
aguda
(SCA)
de
al o
isco.
Mé odos:
Es udo
analí ico
p ospe i o,
de
coo e,
ealizado
no
Hospi al
Uni e si á io
Lozano
Blesa,
Za agoza,
Espanha.
A
populac¸ão
em
es udo
é
cons i uída
po
559
pacien es
com
SCA,
com
e
sem
ele ac¸ão
do
segmen o
ST,
de
aco do
com
a
Ame ican
College
o
Ca diology/Ame ican
Hea
Associa ion.
Es a
populac¸ão
oi
dico omizada
pelo
sexo
e
ealizado
um
es udo
compa a-
i o
analisando
a iá eis
epidemiológicas,
labo a o iais,
ele oca diog áficas,
ecoca diog áficas
e
de
p ocedimen o
de
a amen o.
Aplicou-se
o
mé odo
de
Cox
pa a
cálculo
do
isco
p o-
po cional
e
analisou-se
a
axa
de
mo alidade
como
a iá el
p incipal
nos
seis
meses
após
o
e en o.
Resul ados:
A
idade
média
oi
de
65,2±12,7
anos.
21,8%
dos
doen es
e am
do
sexo
eminino.
Quando
compa adas
com
o
sexo
masculino,
as
ca ac e ís icas
da
populac¸ão
eminina
e am
mais
des a o á eis,
ap esen ando
um
sco e
GRACE
mais
ele ado,
uma
idade
supe io
e
uma
maio
p e alência
de
hipe ensão
a e ial,
diabe es
melli us
e
de
insuficiência
ca díaca.
A
ac¸ão
de
ejec¸ão
e a
in e io
e
ap esen a am
g au
maio
de
insuficiência
ca díaca
e
de
dis unc¸ão
enal
na
admissão.
As
mulhe es
so e am
mais
e en os
ca dio ascula es
ad e sos
(27,9%
e sus
15,8%,
p=0,002).
Sessen a
e
qua o
pacien es
mo e am,
sendo
a
mo alidade
no
g upo
das
mulhe es
quando
compa ada
com
o
g upo
dos
homens
significa i amen e
supe io
(18,9%
e sus
9,4%,
p=
0,004).
Na
análise
mul i a iada,
o
sexo
eminino
não
ap esen a
elac¸ão
independen e
com
a
mo alidade.
Po
ou o
lado
o
alo
sé ico
de
hemoglobina,
a
unc¸ão
enal,
a
ac¸ão
de
ejec¸ão
e
Killip
>1
o am
a iá eis
iden ificadas
como
p edi o as
de
mo alidade.
Conclusões:
A
sínd ome
co oná ia
agudo
no
g upo
das
mulhe es
em
pio
p ognós ico
em
elac¸ão
ao
dos
homens.
A
e oluc¸ão
ad e sa
de e-se
às
ca ac e ís icas
iniciais
e
não
ao
ac o
de
se
do
sexo
eminino.
©
2012
Sociedade
Po uguesa
de
Ca diologia.
Publicado
po
Else ie
España,
S.L.U.
Todos
os
di ei os
ese ados.
In oduc ion
Ca dio ascula
disease
(CVD)
is
he
mos
common
cause
o
dea h
in
women
in
de eloped
coun ies
and
is
esponsible
o
mo e
han
he
combined
numbe
o
dea hs
due
o
he
nex
se en
causes
and
mo e
han
all
ypes
o
cance s
combined.
In
he
Uni ed
S a es,
CVD
mo ali y
in
women
exceeds
ha
o
men.
Co ona y
hea
disease
is
mainly
esponsible
wi h
24%,1 --- 4 and
al hough
dea h
om
ischemic
hea
disease
(IHD)
has
declined
in
men,
i s
incidence
is
s able
in
women.5,6
Despi e
he
bu den
o
co ona y
disease
in
women,
CVD
is
s ill
conside ed
a
disease
o
men
and
he e
is
a
alse
pe cep-
ion
ha
women
a e
in
some
way
p o ec ed.
IHD
in
women
appea s
o
ha e
i s
own
cha ac e is ics,
al hough
women
a e
ela i ely
unde - ep esen ed
in
s udies
and
egis ies.1,7
This
lack
o
ep esen a ion
in
andomized
clinical
i-
als
has
delayed
ecogni ion
o
specific
ca dio ascula
isk
ac o s
by
ex apola ing
esul s
om
s udies
o
he
male
popula ion.
The e
a e
significan
gaps
in
knowledge
o
CVD
in
women.
In
an
analysis
o
gende -specific
di e ences
in
he
cha ac e is ics,
de elopmen ,
managemen ,
and
p og-
nosis
o
acu e
co ona y
synd ome
(ACS)
be ween
1994
and
2002
in
he
RISCI,
PRIAMHO
I
and
II,
Desca es
and
TRI-
ANA
ials
conduc ed
by
he
Wo king
G oup
on
Ischemic
Hea
Disease
and
Co ona y
Ca e
Uni s
o
he
Spanish
Socie y
o
Ca diology,
only
24.3%
o
48
369
pa ien s
we e
women.8
On
a e age,
women
su e
myoca dial
in a c ion
(MI)
7---10
yea s
la e
han
men,
and
show
a
poo e
p ognosis
and
20%
highe
sho - e m
mo ali y
han
men,
independen ly
o
age.9
The
p ecise
easons
o
his
gende
di e ence
in
he
p ognosis
o
acu e
IHD
a e
unknown.
Howe e ,
epidemio-
logical
s udies
sugges
ha
di e ences
in
mo ali y
canno
be
explained
by
possible
p o ec i e
e ec s
o
ho mones.
They
gi e
mo e
weigh
o
elemen s
o
he
me abolic
syn-
d ome,
such
as
hype lipidemia
o
diabe es,
which
appea
o
be
mo e
p e alen
in
women,
and
o
di e ences
in
clin-
ical
p esen a ion
o
dispa i ies
in
he
use
o
diagnos ic
and
he apeu ic
esou ces.
Fu he mo e,
gende -linked
gene ic
ac o s,
which
may
be
c i ical
o
he
de elopmen
o
he
disease,
a e
e en
less
well
unde s ood.10
I
is
impo an
o
p omo e
educa ion
and
discussion
on
he
di e ences
in
p esen a ion,
de elopmen ,
and
ea -
men
o
ACS
in
bo h
sexes
and
o
ob ain
new
indica ions
o
IHD
in
women.
Edi o s
o
medical
jou nals
ha e
high-
ligh ed
he
need
o
s udies
specifically
on
women
ha
will
indica e
whe he
gende
influences
p ognosis,
includ-
ing
complica ions
and
ad e se
e ec s,
in
emale
pa ien s
who
ha e
su e ed
a
high- isk
ACS.11
Objec i e
We
se
ou
o
de e mine
he
di e ences
in
epidemiology,
p esen a ion
and
e olu ion
o
high- isk
ACS
in
men
and
Influence
o
gende
on
p ognosis
o
acu e
co ona y
synd omes
45
women,
analyzing
he
possible
e ec
o
gende
on
mo al-
i y
in-hospi al
and
du ing
a
6-mon h
ollow-up
pe iod
a e
he
acu e
co ona y
e en .
We
also
s udied
he
associa ion
be ween
gende
and
ad e se
ca dio ascula
e en s
includ-
ing
pos -in a c ion
angina,
ein a c ion,
and
hea
ailu e
in
he
same
ollow-up
pe iod.
Me hods
This
was
a
p ospec i e
analy ical
coho
s udy
o
pa ien s
admi ed
consecu i ely
o
ou
hospi al
be ween
Janua y
2006
and
Decembe
2007
wi h
a
diagnosis
o
high- isk
ACS
wi h
and
wi hou
ST-segmen
ele a ion
acco ding
o
he
c i e ia
o
he
ACC/AHA
(Ame ican
College
o
Ca diol-
ogy/Ame ican
Hea
Associa ion).12,13 Pa ien s
we e
ea ed
acco ding
o
he
ACC/AHA
guidelines.
Exclusion
c i e ia
we e
he
p esence
o
solid
o gan
o
hema ological
malignancy,
e e
o
sepsis
a
he
ime
o
he
s udy,
au oimmune
and
inflamma o y
diseases,
s age
5
ch onic
enal
ailu e
acco ding
o
he
2002
Na ional
Kidney
Founda ion
guidelines,14 and
he
absence
o
eliable
eco ds.
O
he
590
pa ien s
ini ially
selec ed,
31
we e
excluded,
and
he
final
sample
analyzed
was
hus
559
pa ien s.
S udy
a iables
Clinical
a iables
analyzed
we e
age,
gende ,
isk
ac-
o s
(hype ension,
diabe es,
dyslipidemia,
smoking,
hea
ailu e,
p e ious
MI),
physical
examina ion
a
admission
(hea
a e,
sys olic
blood
p essu e
[BP],
dias olic
BP,
and
pulse
p essu e).
Risk
s a ifica ion
was
pe o med
using
he
GRACE
sco e,
di iding
he
sample
in o
h ee
g oups:
low
(≤88
poin s),
medium
(89---118
poin s),
and
high
isk
(>118
poin s).
Labo a o y
a iables
eco ded
wi hin
wo
hou s
o
admis-
sion
included
hemoglobin,
leukocy e
coun ,
blood
glucose,
fib inogen,
u ic
acid,
glome ula
fil a ion
a e
es ima ed
by
he
4- a iable
Modifica ion
o
Die
in
Renal
Disease
equa ion,14 c ea ine
kinase
(CK)
and/o
c ea ine
kinase-MB
ac ion
(CK-MB)
and
oponin
I.
The
biochemical
a iables
we e
ob ained
using
he
Synch on
LX20
P o
analyze .
Pa ien s
we e
classified
on
he
basis
o
ST-segmen
cha -
ac e is ics
on
he
elec oca diog am
in o
h ee
g oups:
ele a ed,
no mal,
o
dep essed.
The
occu ence
o
ca diac
a hy hmias
du ing
hospi aliza ion
was
documen ed.
Le
en icula
ejec ion
ac ion
(EF)
was
de e mined
by
echoca diog aphy
a
admission
and
was
classified
as
no mal
i
>50%
o
educed
i
≤50%.
Pa ien s
wi h
Killip
class
>1
a
admission
we e
conside ed
o
ha e
acu e
hea
ailu e.
Repe usion
he apy
o
pa ien s
wi h
ST-segmen
ele-
a ion
ACS
was
di ided
in o
fib inolysis
and
pe cu aneous
co ona y
in e en ion.
The
endpoin s
eco ded
we e
all-cause
mo ali y
(in-
hospi al
o
wi hin
six
mon hs)
and
ad e se
ca dio ascula
e en s
(pos -in a c ion
angina,
e-in a c ion,
and
hea
ail-
u e).
Da a
we e
collec ed
by
clinical
and/o
elephone
con ac
wi h
pa ien s
o
hei
amilies.
S a is ical
analysis
Con inuous
a iables
we e
exp essed
as
mean
±
s anda d
de ia ion
and
quali a i e
a iables
as
equency
and
pe cen age.
Di e ences
in
quan i a i e
a iables
be ween
g oups
wi h
a
no mal
dis ibu ion
we e
compa ed
wi h
he
S uden ’s
es
o
independen
samples;
in
cases
o
non-
no mal
dis ibu ion,
a
nonpa ame ic
Mann-Whi ney
es
was
used.
Disc e e
a iables
we e
compa ed
using
he
chi-
squa e
es
o
Fishe ’s
exac
es .
The
independen
a iable
o
he
s udy
was
ca ego ized
acco ding
o
gende .
Cumu-
la i e
su i al
o
each
ca ego y
o
he
main
a iable
was
modeled
using
Kaplan-Meie
cu es,
and
hese
ca ego ies
we e
compa ed
wi h
he
log- ank
s a is ic.
To
de e mine
he
independen
ole
o
he
a iables
in
p edic ing
mo ali y,
a
Cox
p opo ional
haza ds
analysis
was
pe o med.
The
es i-
ma ed
coe ficien s
we e
exp essed
as
haza d
a io
(HR)
wi h
95%
confidence
in e als
(95%
CI).
The
final
de e mina ion
o
independen
p edic o s
o
6-mon h
mo ali y
was
pe o med
in
mul i a ia e
analysis
including
a iables
wi h
p<0.05
in
he
uni a ia e
analysis.
Values
we e
conside ed
significan
a
p<0.05.
The
s a is ics
so wa e
used
was
SPSS
15.0.
Resul s
Sample
cha ac e is ics
The
baseline
cha ac e is ics
o
he
559
pa ien s
wi h
ACS
en olled
in
he
s udy
a e
shown
in
Table
1.
The
mean
age
was
65.2±12.7
yea s
(33---93
yea s),
and
21.8%
we e
women.
Females
had
lowe
dias olic
BP
and
inc eased
leuko-
cy e
coun
on
admission,
lowe
p e alence
o
dyslipidemia,
inc eased
equency
o
no mal
o
dep essed
ST
segmen
on
he
elec oca diog am,
and
a
g ea e
endency
o
a hy h-
mias.
Female
gende
was
also
associa ed
wi h
olde
mean
age,
highe
hea
a e
and
pulse
p essu e
on
admission,
inc eased
p e alence
o
hype ension
and
diabe es
bu
lowe
p e alence
o
smoking,
mo e
equen
his o y
o
hea
ailu e
bu
a
lowe
incidence
o
p e ious
s oke,
lowe
EF,
inc eased
isk
acco ding
o
he
GRACE
sco e,
and
a
highe
equency
o
hea
ailu e
(Killip
>1)
du ing
hospi-
aliza ion.
Labo a o y
pa ame e s
a
admission
significan ly
associa ed
wi h
emale
gende
we e
lowe
hemoglobin
and
u ic
acid
le els
and
wo se
enal
unc ion,
and
highe
blood
glucose
and
fib inogen
concen a ions.
Women
mo e
o en
unde wen
p ima y
angioplas y.
Women
clea ly
had
a
wo se
p ognosis,
wi h
a
highe
a e
o
ad e se
ca diac
e en s
and
highe
mo ali y,
bo h
in-hospi al
and
du ing
ollow-up
(Table
2).
Gende
as
a
p ognos ic
ac o
The e
we e
64
dea hs
(11.4%),
44
in-hospi al,
he
mos
equen
causes
o
which
we e
ca diogenic
shock
(61.4%),
hea
ailu e
(13.6%),
and
en icula
fib illa ion
(9.1%).
The
a iables
associa ed
wi h
mo ali y
a e
shown
in
Table
3.
In
he
deceased
g oup
35.9%
we e
women
s.
20%
o
he
no-dea h
g oup
(p=0.004).
O he
p edic o s
o
mo ali y
we e
age,
hemodynamic
measu es
a
admission
(dec eased
hea
a e,
sys olic
BP,
dias olic
BP,
and
pulse),
labo a o y
es s
a
admission
(lowe
hemoglobin
concen a ion
and
46
J.L.
Cab e izo-Ga cía
e
al.
Table
1
Demog aphic
and
clinical
cha ac e is ics
o
he
s udy
popula ion
a
admission
by
gende .
Men
(n=437)
Women
(n=122)
p
Age
(yea s) 63.1±12.5 72.7±10.6 <0.001
Examina ion
a
admission
Hea
a e
(bpm)
76.1±20.1
81.7±22
0.009
Sys olic
BP
(mmHg)
135±27.1
135.1±30
0.961
Dias olic
BP
(mmHg)
79.3±17.5
76.3±18.7
0.105
Pulse
p essu e
(mmHg)
55.2±18.2
59.2±21.6
0.045
Ca dio ascula
isk
ac o s
(%)
Hype ension
53.3%
63.1%
0.034
Diabe es
19%
32%
0.002
Dyslipidemia
46.5% 43.4% 0.314
Smoking
51% 16.4% <0.001
Ca diac
his o y
(%)
His o y
o
hea
ailu e
2.7%
9.8%
0.002
His o y
o
MI
16.9%
8.2%
0.010
No mal
o
dep essed
ST
segmen
35.9%
41.8%
0.140
Dep essed
EF
(<50%)
33.7%
44.1%
0.034
Low
isk
(GRACE
sco e
≤88)a53.4%
29.4%
<0.001
A hy hmias
22.7%
27.9%
0.141
Labo a o y
abno mali ies
a
admission
Ele a ed
ca diac
enzymes
(%)b82.1%
81.8%
0.522
Ele a ed
oponin
I
(%)c98.2%
99.2%
0.381
Hemoglobin
(g/dl)
14.5±1.8
13±1.7
<0.001
Leukocy e
coun
(cell/mm3)
11
201.7±3943.9
11
524.8±4840.5
0.449
Blood
glucose
(mg/dl)
159.8±82.4
184.7±84.8
0.004
Fib inogen
(mg/dl)
415.6±136.5
454.2±161.6
0.010
U ic
acid
(mg/dl)
6.2±1.6
5.7±1.8
0.023
GFR
(ml/min/1.73
m2)
80±26
64.5±21.6
<0.001
Killip
class
>1
18.5%
36.1%
<0.001
Repe usion
he apy
in
STEMI
Fib inolysis
61.8%
52.1%
0.089
PCI
12.2%
28.3%
0.025
BP:
blood
p essu e;
EF:
ejec ion
ac ion;
GFR:
glome ula
fil a ion
a e
by
he
4- a iable
Modifica ion
o
Die
in
Renal
Disease
equa ion;
MI:
myoca dial
in a c ion;
PCI:
pe cu aneous
co ona y
in e en ion
(wi h
o
wi hou
s en ing);
STEMI:
ST-segmen
ele a ion
myoca dial
in a c ion.
aP obabili y
o
dea h
a
six
mon hs
a e
discha ge:
<3%.
bCK:
>300
U/l,
CK-MB:
CK-MB
>25
U/l).
c>0.04
ng/dl.
glome ula
fil a ion
a e,
inc eased
blood
glucose,
fib-
inogen
and
leukocy e
coun ),
his o y
o
MI
and
absence
o
smoking,
low
EF,
Killip
class
>1,
a hy hmias,
and
no
being
in
he
low- isk
GRACE
sco e
g oup.
The
Kaplan-Meie
cu e
shows
poo e
su i al
o
women
(Figu e
1).
Women
had
significan ly
highe
mo ali y
han
men
(18.9
s.
9.4%,
haza d
a io
[HR]
0.468,
95%
CI:
0.281---0.781,
p=0.004).
On
mul i a ia e
analysis
(adjus ed
o
age,
hea
a e,
Table
2
Ad e se
ca dio ascula
e en s
and
all-cause
mo ali y
a
six
mon hs
by
gende .
Men
(n=437)
Women
(n=122)
p
Ad e se
ca dio ascula
e en s
a
six
mon hs
(%)
15.8%
27.9%
0.002
Pos -in a c ion
angina
12%
22.8%
0.004
Rein a c ion
4.9%
4.4%
0.518
Hea
ailu e
4%
7.9%
0.075
To al
mo ali y
a
six
mon hs
(%) 9.4%
18.9%
0.004
In-hospi al
mo ali y
5.9%
14.8%
0.002
Mo ali y
a e
discha ge
3.6%
4.8%
0.378
Influence
o
gende
on
p ognosis
o
acu e
co ona y
synd omes
47
Table
3
Indi idual
a iables
associa ed
wi h
mo ali y
a
six
mon hs
a e
acu e
co ona y
synd ome.
Dea h
(n=64)
No
dea h
(n=495)
p
HR
(95%
CI)
Female
gende 35.9% 20%
0.004
0.468
(0.28---0.78)
Age
(yea s)
74.9±8.5
63.9±12.6
<0.001
1.091
(1.06---1.12)
Examina ion
a
admission
Hea
a e
(bpm)
84.3±22.1
76.5±20.2
0.005
1.014(1.00---1.02)
Sys olic
BP
(mmHg)
121.4±27.1
136.7±27.3
<0.001
0.979
(0.97---0.99)
Dias olic
BP
(mmHg)
70.3±15.8
79.7±17.8
<0.001
0.971
(0.96---0.99)
Pulse
p essu e
(mmHg)
51.3±17.5
56.7±19.1
0.031
0.984
(0.97---1.00)
Smoking
17.2% 46.9% <0.001
0.254
(0.13---0.49)
His o y
o
MI 28.1% 13.3% 0.002 2.322
(1.35---4.00)
Dep essed
EF
(<50%) 68.2% 32.7% <0.001 4.088
(2.17---7.71)
Low
isk
(GRACE
sco e
≤88)a7.9%
53.4%
0.002
4.979
(1.82---13.6)
A hy hmias
39.1%
21.8%
0.003
2.139
(1.29---3.53)
Labo a o y
abno mali ies
a
admission
Hemoglobin
(g/dl)
12.9±2.2
14.3±1.8
<0.001
0.746
(0.67---0.83)
Leucocy e
coun
(cell/mm3)12
412.5±5089
11
124
±3997.3
0.014
1.000
(1.00---1.00)
Blood
glucose
(mg/dl) 194.8±110.9 161.4±78.6
0.002
1.003
(1.00---1.01)
Fib inogen
(mg/dl)
GFR
(ml/min/1.73
m2) 486.5±202.3 416.3±132.3 <0.001
1.003
(1.00---1.00)
GFR
(ml/min/1.73
m2) 56.6±24.6 79.2±24.9
<0.001
0.963
(0.95---0.97)
Killip
class
>1
(%) 62.5 17.2 <0.001
6.616
(3.99---10.98)
BP:
blood
p essu e;
CI:
confidence
in e al;
EF:
ejec ion
ac ion;
GFR:
glome ula
fil a ion
a e
by
he
4- a iable
Modifica ion
o
Die
in
Renal
Disease
equa ion;
HR:
haza d
a io;
MI:
myoca dial
in a c ion.
aP obabili y
o
dea h
a
six
mon hs
a e
discha ge:
<3%.
sys olic
BP,
dias olic
BP,
and
pulse
p essu e
a
admission;
his o y
o
smoking
and
p e ious
in a c ion,
EF,
p esence
o
a hy hmias,
se e i y
on
GRACE
sco e,
hemoglobin,
leukocy es,
blood
glucose,
fib inogen,
and
GFR
a
admis-
sion;
and
Killip
class
>1),
gende
as
a
a iable
was
no
a
significan
p edic o
o
mo ali y.
Independen
p edic o s
o
1.00
0.95
0.90
0.85
0.80
050
100
p=0.0027
Su i al (days)
Cumula i e su i al
Women Men
150 200
Figu e
1
Su i al
unc ion.
mo ali y
we e
hemoglobin
le el
a
admission
(HR:
0.085;
95%
CI:
0.725---0.996,
p=0.044),
enal
unc ion
a
admission
(HR:
0.983,
95%
CI:
0.968---0.999,
p=0.037),
dep essed
EF
(HR:
2.074,
95%
CI:
1.030---4.176;
p=0.041),
and
hea
ailu e
du ing
hospi aliza ion
as
measu ed
by
Killip
class
>1
(HR:
3.487,
95%
CI:
1.526---7.969,
p=0.003),
he
la e
being
he
main
p edic o
ac o
o
mo ali y
(Table
4).
Discussion
The
s udy
collec ed
da a
p ospec i ely
on
a
consecu i e
se ies
o
pa ien s
who
su e ed
high- isk
ACS
ea ed
wi h
an
up- o-da e
he apeu ic
p o ocol
o
uns able
IHD.
The
women
in
he
s udy
popula ion
we e
olde
and
had
a
mo e
un a o able
clinical
p ofile,
wi h
poo e
ini ial
p ognosis
acco ding
o
he
GRACE
isk
sco e,
and
su e ed
a
g ea e
numbe
o
ad e se
ca dio ascula
e en s
including
pos -
in a c ion
angina,
ein a c ion
and
hea
ailu e,
as
well
as
inc eased
in-hospi al
and
all-cause
mo ali y,
in
compa ison
o
men.
Howe e ,
on
mul i a ia e
analysis,
hese
gende
di e ences
disappea ed,
which
sugges s
ha
mo e
o
less
a o able
e olu ion
depends
o
a
la ge
ex en
on
he
base-
line
cha ac e is ics
o
he
g oups.
Women
had
olde
mean
age
han
men
(63.1
s.
72.7
yea s)
and
began
o
su e
co ona y
acu e
e en s
a
decade
la e ,
which
is
a ibu able,
in
pa ,
o
he
p o ec i e
e ec
o
es ogens,
acco ding
o
some
s udies.15
Ele a ed
o al
choles e ol,
LDL
choles e ol,
and
iglyce ide
le els,
and
lowe
HDL-C
le els
du ing
menopause
may
con ibu e
o
he
inc eased
isk,
especially
om
he
six h
decade
o
li e.16 In
addi ion,
es ogens,
h ough
he
ni ic
oxide
pa hway,
induce
smoo h
muscle
cell
dila ion
and
48
J.L.
Cab e izo-Ga cía
e
al.
Table
4
Fac o s
p edic ing
all-cause
mo ali y
a
six
mon hs
a e
acu e
co ona y
synd ome
by
Cox
eg ession
analysis.
p
HR
95%
CI
Lowe
Uppe
Hemoglobin
a
admission
(g/dl)
0.044
0.085
0.725
0.996
GFR
(ml/min/1.73
m2)
a
admission
0.037
0.983
0.968
0.999
Dep essed
EF
(<50%)
0.041
2.074
1.030
4.176
Killip
class
>1
0.003
3.487
1.526
7.969
CI:
confidence
in e al;
EF:
ejec ion
ac ion;
GFR:
glome ula
fil a ion
a e
by
he
4- a iable
Modifica ion
o
Die
in
Renal
Disease
equa ion;
HR:
haza d
a io.
inhibi
ascula
p oli e a ion.17,18 Fo
yea s,
hese
da a
we e
conside ed
o
sugges
ha
exogenously
adminis e ed
es ogen
could
ha e
a
ca diop o ec i e
e ec .
Howe e ,
he
esul s
o
clinical
ials
on
bo h
p ima y
(WHI
and
WISDOM)
and
seconda y
p e en ion
(HERS
and
ESPRIT),
and
in
angiog aphic
endpoin s
(WAS,
WELL-HART
and
WAVE),
ad ised
agains
he
use
o
ho mone
eplacemen
he apy,
showing
nega i e
esul s
and
e en
g ea e
p og ession
o
a he oscle osis
and
inc eased
ad e se
e ec s
such
as
CVD,
deep
ein
h ombosis,
pulmona y
embolism
and
s oke,
no
o
men ion
he
po en ial
ca cinogenic
e ec
on
he
b eas ,
o a ies,
and
endome ium.19,20 Fu he mo e,
s udies
ocused
on
elde ly
pa ien s
wi h
MI
and
a
di e ence
in
age
o
less
han
one
yea
be ween
women
and
men
ha e
shown
ha
hospi al
mo ali y
in
women
is
highe
han
in
men
(40%
and
25%,
espec i ely),
which
leads
us
o
conclude
ha
he
age
ac o
alone
does
no
explain
a
wo se
p ognosis.
Also,
i
age
is
associa ed
wi h
a
highe
p e alence
o
isk
ac o s
o
ca dio ascula
and
o he
disease,
hen
his
con e s
a
g ea e
ea ly
mo ali y
in
women
wi h
MI.21
Ca dio ascula
disease
is
cha ac e ized
by
mul i ac o ial
e iology.
The
inc eased
co ona y
isk
is
mainly
ela ed
o
isk
ac o s
ha
inc ease
wi h
age.
Aging,
hype ension,
dyslipidemia,
diabe es,
smoking,
physical
inac i i y,
obesi y,
and
amily
his o y
a e
impo an
and
ein o ce
each
o he .
In
ou
esul s,
a
his o y
o
hype ension
and
diabe es
was
associa ed
significan ly
wi h
emale
gende .
The
p e alence
o
hype ension
in
he
adul
popula ion
is
28%
and
mo e
women
a e
a ec ed
om
he
fi h
o
six h
decades
o
li e
(52%
s.
48%
in
men).22 I s
impac
in
he
o m
o
le
en icula
hype ophy
is
associa ed
wi h
an
inc eased
isk
o
ca dio ascula
e en s,
con e ing
a
wo se
p ognosis
in
women
han
in
men.16 Diabe es,
especially
ype
2,
is
mo e
p e alen
in
women
han
in
men,
pa icula ly
a e
65
yea s
o
age,
and
is
he
single
mos
po en
ca dio ascula
isk
ac o
o
co ona y
hea
disease.
I s
impac
appea s
o
be
e en
highe
han
in
men.23
We
obse ed
highe
mo ali y
associa ed
wi h
g ea e
enal
dys unc ion
and
his
associa ion
was
significan
on
admission
in
women.
Renal
ailu e
is
a
poo
p ognos ic
ac-
o
in
pa ien s
su e ing
om
an
acu e
co ona y
e en ;
i
is
es ima ed
ha
one
hi d
o
hese
pa ien s
p esen
enal
dys unc ion
on
admission.24 The
abo e
ac o s
p oba-
bly
con ibu ed
o
he
inc eased
enal
dys unc ion
in
women
in
ou
s udy
and
he
ac
ha
women
had
mo e
p io
hea
ailu e,
highe
Killip
class
on
admission
and
mo e
episodes
o
ca diac
decompensa ion
a e
discha ge.
We
also
obse ed
lowe
EF
alues
in
women
and
an
inc eased
equency
o
a hy hmias
du ing
hospi aliza ion.
Al hough
women
had
ewe
p e ious
episodes
o
IHD
han
males,
hei
p ognosis
was
less
a o able,
as
also
seen
in
he
BADAPIC
egis y.25
Wi h
ega d
o
labo a o y
es s
on
admission,
anemia,
hype glycemia,
and
ele a ed
fib inogen
le els
we e
asso-
cia ed
wi h
inc eased
mo ali y
in
women;
in
he
case
o
anemia,
e en
a e
mul i a ia e
analysis.
The
inflamma o y
mechanism
unde lying
ascula
s ess
in
acu e
co ona y
e en s
appea s
o
con ibu e
o
hese
labo a o y
abno mal-
i ies.
Ele a ed
inflamma o y
ma ke s
p edic
ca dio ascula
isk
and
inflamma ion
may
ac
no
only
by
p omo ing
a he ogenesis
bu
also
by
des abilizing
ulne able
plaque.
In
a
s udy
by
A an
e
al.,26 anemia,
defined
as
a
hemoglobin
le el
o
less
han
12
g/dl,
was
a
p edic o
o
ca dio ascula
e en s
ollowing
an
ACS
du ing
a
ollow-up
o
3.3
yea s.
In
addi ion,
a ious
s udies
ha e
no ed
a
ela ionship
be ween
he
occu ence
and
se e i y
o
hype glycemia
and
inc eased
mo bidi y
and
mo ali y
in
ACS,
independen ly
o
p e iously
diagnosed
diabe es.27
Some
s udies
ha e
ound
an
associa ion,
a
leas
in
pa ,
be ween
he
poo e
p ognosis
in
women
and
gende
bias
obse ed
in
he
he apeu ic
measu es
applied,
especially
in
epe usion
he apy,
whose
benefi
would
be
e en
highe
because
women
a e
highe - isk
pa ien s.28 The
CRUSADE
s udy
da a
demons a e
ha
al hough
IHD
in
women
con in-
ues
o
be
associa ed
wi h
olde
age,
as
well
as
wi h
a
highe
p e alence
o
diabe es
and
hype ension,
he
he apeu ic
app oach
con inues
o
be
less
agg essi e,
wi h
ewe
co o-
na y
angiog ams
and
hepa in
ea men s.29 We
did
no
find
hese
di e ences
in
he
g oup
o
pa ien s
wi h
ST-segmen
ele a ion
(62.8%
o
he
sample),
and
he e
we e
no
signifi-
can
di e ences
in
fib inoly ic
he apy
and
epe usion
wi h
p ima y
angioplas y,
e en
in
women
who
we e
mo e
likely
o
benefi
om
hese
ea men s.
Conclusions
We
belie e
ha
all
he
isk
ac o s
known
o
be
associ-
a ed
mo e
closely
wi h
emale
gende
may
be
esponsible
o
hei
wo se
ou come.
The
significance
o
gende
as
such
is
dilu ed
in
mul i a ia e
analysis.
The
impo ance
o
classical
a iables
as
p ognos ic
ma ke s,
which
a e
indepen-
den ly
associa ed
wi h
highe
mo ali y
(EF
<50%,
Killip
class
>1,
enal
dys unc ion
and
anemia
on
admission)
is
inc eas-
ing.
Women
ha e
a
high- isk
s a ifica ion
acco ding
o
he
GRACE
sco e,
su e
mo e
ad e se
ca dio ascula
e en s,
Influence
o
gende
on
p ognosis
o
acu e
co ona y
synd omes
49
and
ha e
highe
mo ali y,
especially
in
he
sho
e m.
We
a e
awa e
ha
IHD
in
women
is
a
majo
p oblem
whose
impo ance
is
g ea e
han
o he
condi ions
al eady
known
o
be
leading
causes
o
mo ali y
in
women,
such
as
b eas
cance .
Howe e ,
we
belie e
ha
be o e
conside ing
emale
gende
pe
se
an
independen
p edic o
o
mo ali y
and
esigning
ou sel es
o
he
exis ence
o
gene ic
di e ences
ha
a e
no
ye
well
known,
we
should
fi s
inc ease
ou
e o s
o
include
women
in
scien ific
s udies
and
discus-
sion
o ums
a he
han
me ely
ex apola e
esea ch
findings
ocused
mos ly
on
men.
We
should
also
p omo e
he
imple-
men a ion
o
p e en ion
campaigns
because,
al hough
we
deal
wi h
he
isk
ac o s
o
men,
he
p e alence
o
dia-
be es,
hype ension,
dyslipidemia,
obesi y,
and
smoking
is
s ill
inc easing
in
women.
Ou
wo k
has
se e al
limi a ions:
he
sample
size
is
small
and
he e o e
so
is
he
numbe
o
dea hs.
A
longe
ollow-
up
pe iod
would
ha e
p o ided
mo e
in o ma ion,
and
i
would
also
ha e
been
in e es ing
o
in es iga e
he
causes
o
mo ali y
du ing
ollow-up.
E hical
disclosu es
P o ec ion
o
human
and
animal
subjec s.
The
au ho s
decla e
ha
no
expe imen s
we e
pe o med
on
humans
o
animals
o
his
s udy.
Confiden iali y
o
da a.
The
au ho s
decla e
ha
hey
ha e
ollowed
he
p o ocols
o
hei
wo k
cen e
on
he
publica-
ion
o
pa ien
da a.
Righ
o
p i acy
and
in o med
consen .
The
au ho s
ha e
ob ained
he
w i en
in o med
consen
o
he
pa ien s
o
subjec s
men ioned
in
he
a icle.
The
co esponding
au ho
is
in
possession
o
his
documen .
Conflic s
o
in e es
The
au ho s
ha e
no
conflic s
o
in e es
o
decla e.
Re e ences
1.
Ma uga
J,
Sala
J,
Aboal
J.
Epidemiology
o
ca dio ascula
dis-
ease
in
women.
Re
Esp
Ca diol.
2006;59:264---74.
2.
Ame ican
Hea
Associa ion.
Women
and
ca dio ascula
disease:
s a is ics.
S a is ical
ac
shee -popula ions.
A ail-
able
om:
www.ame icanhea .o g/downloadable/hea /
1109000876764FS10WM05REV.DOC
[accessed
Decembe
2005].
3.
Pe e sen
S,
Pe o
V,
Scabo ough
P,
e
al.
B i ish
Hea
Founda-
ion
Heal h
P omo ion
Resea ch
G oup.
Co ona y
Hea
Disease
S a is ics
2005.
London:
B i ish
Hea
Founda ion;
2005.
4.
Al onso
F,
Be mejo
J,
Sego ia
J.
Ca dio ascula
disease
in
women.
Why
now?
Re
Esp
Ca diol.
2006;59:259---63.
5.
Mosca
L,
Appel
LJ,
Benjamin
EJ,
e
al.
E idence-based
guidelines
o
ca dio ascula
disease
p e en ion
in
women.
Ci -
cula ion.
2004;109:672---93.
6.
Mosca
L,
Fe is
A,
Fabunmi
R,
e
al.
T acking
women’s
awa eness
o
hea
disease.
An
Ame ican
Hea
Associa ion
Na ional
S udy.
Ci cula ion.
2004;109:573---9.
7.
He as
M.
Ischemic
hea
disease
in
women:
clinical
p esen a-
ion,
non-in asi e
es ing
and
managemen
o
acu e
co ona y
synd omes.
Re
Esp
Ca diol.
2006;59:371---81.
8.
Alonso
J,
Bueno
H,
Ba dají
A,
e
al.
Influence
o
sex
on
acu e
co ona y
synd ome
mo ali y
and
ea men
in
Spain.
Re
Esp
Ca diol
Supl.
2008;8:8D---22D.
9.
Si uación
de
la
ca diopa ía
isquémica
en
Espa˜
na.
En:
Es a e-
gia
en
ca diopa ía
isquémica
del
Sis ema
Nacional
de
Salud.
Mad id:
Minis e io
de
Sanidad
y
Consumo,
Cen o
de
Publica-
ciones;
2006.
p.
25---31.
10.
Tomás
Abadal
L.
Ca dio ascula
isk
in
menopause:
my h,
pa a-
dox
o
eali y.
The
impo ance
o
clinical
obse a ions
s
s a is ical
da a
in e p e a ion.
Re
Esp
Ca diol.
1999;52:463---6.
11.
Al onso
F,
Be mejo
J,
Sego ia
J.
Re is a
Espa˜
nola
de
ca di-
ología
2005:
ac i i y
and
scien ific
ecogni ion.
Re
Esp
Ca diol.
2005;58:1482---7.
12.
Ande son
JL,
Adams
CD,
An man
EM,
e
al.
ACC/AHA
2007
guidelines
o
he
managemen
o
pa ien s
wi h
uns able
angina/non
ST-ele a ion
myoca dial
in a c ion:
a
epo
o
he
Ame ican
College
o
Ca diology/Ame ican
Hea
Associa-
ion
Task
Fo ce
on
P ac ice
Guidelines
(W i ing
Commi ee
o
Re ise
he
2002
Guidelines
o
he
Managemen
o
Pa ien s
Wi h
Uns able
Angina/Non
ST-Ele a ion
Myoca dial
In a c ion):
de eloped
in
collabo a ion
wi h
he
Ame ican
College
o
Eme -
gency
Physicians,
he
Socie y
o
Ca dio ascula
Angiog aphy
and
In e en ions,
and
he
Socie y
o
Tho acic
Su geons:
endo sed
by
he
Ame ican
Associa ion
o
Ca dio ascula
and
Pulmona y
Rehabili a ion
and
he
Socie y
o
Academic
Eme -
gency
Medicine.
Ci cula ion.
2007;116:e148---304.
13.
An man
EM,
Anbe
DT,
A ms ong
PW,
e
al.
ACC/AHA
guide-
lines
o
he
managemen
o
pa ien s
wi h
ST-ele a ion
myoca dial
in a c ion:
a
epo
o
he
Ame ican
College
o
Ca diology/Ame ican
Hea
Associa ion
Task
Fo ce
on
P ac ice
Guidelines
(Commi ee
o
Re ise
he
1999
Guidelines
o
he
Managemen
o
Pa ien s
wi h
Acu e
Myoca dial
In a c ion).
Ci -
cula ion.
2004;110:e82---292.
14.
K/DOQI
clinical
p ac ice
guidelines
o
ch onic
kidney
disease:
e alua ion,
classifica ion,
and
s a ifica ion.
Kidney
Disease
Ou come
Quali y
Ini ia i e.
Am
J
Kidney
Dis.
2002;39:S1---266.
15.
Jneid
H,
Thacke
HL.
Co ona y
a e y
disease
in
women:
di e -
en ,
o en
unde ea ed.
Cle e
Clin
J
Med.
2001;68:441---8.
16.
Coca
A,
Cea-Cal o
L,
Lozano
JV,
e
al.
High-densi y
lipop o ein
choles e ol
and
ca dio ascula
disease
in
Spanish
hype ensi e
women.
The
RIMHA
s udy.
Re
Esp
Ca diol.
2009;62:1022---31.
17.
Mendelsohn
ME,
Ka as
RH.
The
p o ec i e
e ec s
o
es o-
gen
on
he
ca dio ascula
sys em.
N
Engl
J
Med.
1999;340:
1801---11.
18.
Mendelsohn
ME,
Ka as
RH.
Molecula
and
cellula
basis
o
ca -
dio ascula
gende
di e ences.
Science.
2005;308:1583---7.
19.
G upo
de
abajo
de
menopausia
y
pos menopausia.
Guía
de
p ác ica
clínica
sob e
la
menopausia
y
pos menopausia.
Ba celona:
Sociedad
Espa˜
nola
de
Ginecología
y
Obs e icia,
Aso-
ciación
Espa˜
nola
pa a
el
Es udio
de
la
Menopausia,
Sociedad
Espa˜
nola
de
Medicina
de
Familia
y
Comuni a ia
y
Cen o
Coch ane
Ibe oame icano;
2004.
20.
G aham
I,
A a
D,
Bo ch-Johsen
K,
e
al.
Eu opean
guide-
lines
on
ca dio ascula
disease
p e en ion
in
clinical
p ac ice:
execu i e
summa y:
Fou h
Join
Task
Fo ce
o
he
Eu opean
Socie y
o
Ca diology
and
O he
Socie ies
on
Ca dio ascula
Disease
P e en ion
in
Clinical
P ac ice
(cons i u ed
by
ep e-
sen a i es
o
nine
socie ies
and
by
in i ed
expe s).
Eu
Hea
J.
2007;28:2375---414.
21.
Alcone o
Cama e o
AR,
San
José
Ga aga za
JM,
Mu˜
noz
Cacho
P,
e
al.
Gende
di e ences
in
he
hospi aliza ion
and
epe -
usion
delays
in
he
acu e
co ona y
synd ome.
En e m
In ensi a.
2009;20:44---9.
22.
Bell
TJ,
Tang
S,
Cand illi
S,
e
al.
E alua ion
o
hype en-
sion
p e alence
and
blood
p essu e
goal
a ainmen
using
da a
om
he
1999---2000
Na ional
Heal h
and
Nu i ion
Examina-
ion
Su ey
(NHANES
1999---2000).
Am
J
Hype ens.
2004;17(Pa
2):193A.
50
J.L.
Cab e izo-Ga cía
e
al.
23.
Sánchez
C,
Suá ez
C.
Ca dio ascula
pa hology
in
women.
Hipe ensión.
2003;20:171---82.
24.
Dumaine
R,
Colle
JP,
Tanguy
ML,
e
al.
P ognos ic
significance
o
enal
insu ficiency
in
pa ien s
p esen ing
wi h
acu e
co ona y
synd ome
( he
P ospec i e
Mul icen e
SYCOMORE
s udy).
Am
J
Ca diol.
2004;94:1543---7.
25.
Angui a
Sánchez
M,
In es igado es
egis o
BADAPIC.
Clini-
cal
cha ac e is ics,
ea men
and
sho - e m
mo bidi y
and
mo ali y
o
pa ien s
wi h
hea
ailu e
ollowed
in
hea
ail-
u e
clinics.
Resul s
o
he
BADAPIC
Regis y.
Re
Esp
Ca diol.
2004;57:1159---69.
26.
A an
CB,
Wessel
TR,
Olson
MB,
e
al.,
Na ional
Hea ,
Lung,
and
Blood
Ins i u e
Women’s
Ischemia
Synd ome
E alua ion
S udy.
Hemoglobin
le el
is
an
independen
p edic o
o
ad e se
ca -
dio ascula
ou comes
in
women
unde going
e alua ion
o
ches
pain:
esul s
om
he
Na ional
Hea ,
Lung,
and
Blood
Ins i-
u e
Women’s
Ischemia
Synd ome
E alua ion
S udy.
J
Am
Coll
Ca diol.
2004;43:2009---14.
27.
S ande s
I,
Diaman
M,
an
Gelde
RE,
e
al.
Admission
blood
glucose
le el
as
isk
indica o
o
dea h
a e
myoca dial
in a c-
ion
in
pa ien s
wi h
and
wi hou
diabe es
melli us.
A ch
In e n
Med.
2004;164:982---8.
28.
He nández
RA,
Rod íguez
JE.
E ec
o
sex
on
e as-
cula iza ion
s a egy.
Re
Esp
Ca diol.
2006;59:
487---501.
29.
Blomkalns
AL,
Chen
AY,
Hochman
JS,
e
al.,
CRUSADE
In es iga o s.
Gende
dispa i ies
in
he
diagnosis
and
ea -
men
o
non-ST-segmen
ele a ion
acu e
co ona y
synd omes:
la ge-scale
obse a ions
om
he
CRUSADE
(Can
Rapid
Risk
S a ifica ion
o
Uns able
Angina
Pa ien s
Supp ess
Ad e se
Ou comes
Wi h
Ea ly
Implemen a ion
o
he
Ame ican
Col-
lege
o
Ca diology/Ame ican
Hea
Associa ion
Guidelines)
Na ional
Quali y
Imp o emen
Ini ia i e.
J
Am
Coll
Ca diol.
2005;45:832---7.
