Coronary artery disease
Cardiac Hemodynamics in Men Versus Women During Acute ST-Segment Elevation Myocardial Infarction

https://doi.org/10.1016/j.amjcard.2013.03.007Get rights and content

Several biologic and clinical factors contribute to the increased 30-day mortality and re-infarction rate in women with ST-segment elevation myocardial infarction (STEMI). Sex differences in cardiac hemodynamic parameters such as pulmonary capillary wedge pressure (PCWP) have not been examined and might play an important role. The objectives of the present study were to examine whether female sex is an independent determinant of PCWP during acute STEMI and whether an elevated PCWP contributes to all-cause 30-day mortality and re-infarction in women. The clinical, angiographic, and hemodynamic features of 470 consecutive patients with STEMI (n = 135 women) undergoing emergency coronary angiography with right-side heart catheterization were evaluated with respect to sex. Women had an elevated PCWP (20 ± 8 vs 16 ± 7 mm Hg, p <0.001) and reduced mixed venous oxygen saturation (67 ± 11% vs 71 ± 9%, p = 0.004). On multivariate analysis, female sex (β = 4.04, 95% confidence interval [CI] 2.04 to 6.04, p <0.001), hypertension (β = 2.07, 95% CI 0.31 to 3.83, p = 0.021), and creatine kinase-estimated infarct size (β = 0.001, 95% CI 0.001 to 0.002, p ≤0.001) were independent predictors of an elevated PCWP. Female sex exerted a minor independent effect on 30-day mortality and re-infarction (odds ratio 2.36, 95% CI 1.25 to 4.46, p = 0.008). However, once PCWP was entered into the mediation model, sex was no longer significant, suggesting that the effect of sex on the post-STEMI outcomes is potentially mediated through PCWP (odds ratio 1.07, 95% CI 1.02 to 1.12, p = 0.011). In conclusion, during acute STEMI, women have greater left ventricular filling pressures compared with men, independent of age, hypertension, and infarct size. The biologic explanation for this difference requires additional investigation, although it does not appear to contribute to the increased 30-day mortality and re-infarction rate observed in women.

Section snippets

Methods

The present observational cohort study used data from a STEMI clinical registry that were collected from two South Australian teaching hospitals (the Queen Elizabeth and Lyell McEwin hospitals). These university teaching hospitals service the northwestern suburbs of Adelaide. From October 2005 to October 2010, 912 consecutive STEMI patients (n = 234 women, 26%) presented to the two hospitals and had extensive clinical data collected, including cardiovascular risk factors, medications, and STEMI

Results

From the 912 consecutive cases in the STEMI registry, hemodynamic data were available for 470 patients (n = 135 women, 15%). More than half of the hospital interventional cardiologists routinely performed RHC (68%) in the patients with acute STEMI they attended but only on selected patients by other cardiologists (32% RHC). Thus, the study cohort essentially represented consecutive patients treated by these interventional cardiologists. Moreover, compared with the overall cohort (n = 912), the

Discussion

The present study has provided important insights into the sex differences in clinical outcomes after acute STEMI, demonstrating that women have a greater PCWP than men. This was evident despite a similar infarct site and size, extent of coronary artery disease, and hospital-arrival clinical hemodynamic status. Although women with acute STEMI were more likely to be older and have hypertension, multivariate regression analysis confirmed that female sex was an independent predictor of PCWP, along

Disclosures

The authors have no conflicts of interest to disclose.

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