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Gender differences in patients presenting with non-ST segment elevation myocardial infarction in the STAR registry
The Egyptian Heart Journal volume 73, Article number: 54 (2021)
In most acute coronary artery (ACS) related literature, the female gender constitutes a smaller proportion. This study is based on gender-specific data in the Saudi Acute Myocardial Infarction Registry Program (STARS-1 Program). A prospective multicenter study, conducted with patients diagnosed with ACS in 50 participating hospitals.
In total, 762 (34.12%) patients were diagnosed with non-ST segment elevation myocardial infarction. Of this group, only 164 (21.52%) were women. The mean age (64.52 ± 12.56 years) was older and the mean body mass index (BMI) was higher (30.58 ± 6.23). A significantly proportion was diabetic or hypertensive; however, a smaller proportion was smoking. Hyperlipidemia was present in 48%. The history of angina/MI/stroke and revascularization was similar, except for renal impairment. The presentation was atypical as only 70% presented with chest pain, and the rest with shortness of breath or epigastric pain. At presentation, the female group were more tachycardiac, had higher blood pressure, and a higher incidence of being in class 11-111 Killip heart failure. Only 32% had a normal systolic function, and the majority had either mild or moderate systolic dysfunction.
In particular, the rate of percutaneous coronary intervention was similar. The in-hospital mortality was similar (5%), with more women diagnosed with atrial fibrillation and heart failure at follow-up.
Women had a higher prevalence of risk factors affecting the presentation and morbidity but not mortality. Improving these risk factors and the lifestyle is a priority to improve the outcome and decrease morbidity.
Gender differences in scientific publications have always been a concern. Such differences may adversely affect the clinical features, management, and most importantly, the outcome . Exploring gender-related data might positively affect the prognosis. A continuous focus on gender differences is important as it improves our understanding . Saudi Arabia, as a developing country, faced the same challenge and this work presents a detailed analysis of data from 50 centers across the country . The data was extracted from secondary and tertiary hospitals and from different healthcare sectors, including hospitals with and without a catheter laboratory.
The STAR is a prospective study of all patients presenting with acute coronary syndrome (ACS) to an emergency department at 50 hospitals across Saudi Arabia. The details of the study have been described previously .
The design was a prospective, multi-center, recruited all consecutive AMI (STEMI or NSTEMI) admissions. All relevant data were gathered at admission, 1-month and 1-year follow-up.
The recruiting hospitals were both the one who had catheterization laboratory or not and included various health sectors in Saudi Arabia.
This study aimed to see the difference in the management strategy and the outcome of treatment among male and female patients. This snap shot of two groups will assess if temporal changes in AMI care between genders that were noted among different societies in different studies.
In total, 762 (34.12%) patients were diagnosed with non-ST segment elevation myocardial infarction. Of this group, only 164 (22.52%) were women. The mean age of the group (64.52 ± 12.56 years) was older than the male group and the mean body mass index (BMI) was higher (30.58 ± 6.23). A significantly higher proportion of the female group was diabetic or hypertensive; however, a smaller proportion was smoking. Hyperlipidemia was not significant between the two groups, although present in almost half (48%) of the female group. The history of angina/MI/stroke and revascularization was similar, except for renal impairment. The presentation was atypical compared to the male group as only 70% presented with chest pain, and the rest with shortness of breath or epigastric pain. At presentation, the female group were more tachycardiac, had higher blood pressure, and a higher incidence of being in class 11-111 Killip heart failure. Only 32% had a normal systolic function, and the majority had either mild or moderate systolic dysfunction (Table 1).
Guideline-directed medical therapy was not different between the two groups, except for the initiation of a beta-blocker on admission. In particular, the rate of percutaneous coronary intervention (PCI) was similar (Tables 2 and 3).
Overall, the in-hospital mortality was similar (5%), and more women were diagnosed with atrial fibrillation and heart failure at follow-up (Table 4). No difference were noted between the groups in recurrent ischemia, recurrent MI, cardiogenic shock, VTVF arrest, stroke, or major bleeding.
Women are still underrepresented in ACS-related literature. Based on the gender distribution in the country, we expected a larger proportion, not only 22% as reported in the current study. Because the data were extracted from the registry, collection bias played no role in the study. Possible explanations could be that the women had ACS but did not reach medical attention or they were incorrectly diagnosed due to their atypical symptoms. Both are major concerns that require further investigation and governmental attention, as previously reported [3, 4].
We also noted the high incidence of diabetes and hypertension in the female group. Both are modifiable risk factors that reflect the need to modify the lifestyle. The medical staff, especially at emergency rooms and paramedics, should be aware of the atypical presentation. The Red Crescent was under-utilized and a mass educational intervention is urgent.
Women are underrepresented, frequently had an atypical presentation and presented late. Risk factors are highly prevalent and need immediate attention. It should be stated that when they did present for medical attention, they received appropriate guideline-directed medical therapy and PCI.
Availability of data and materials
Via IRB office
Acute coronary artery
- STARS-1 Program:
Saudi Acute Myocardial Infarction Registry Program
Non-ST segment elevation myocardial infarction
Body mass index
Percutaneous coronary intervention
Wang Y, Zhu S, Du R, Zhou J, Chen Y, Zhang Q (2018) Impact of gender on short-term and long-term all-cause mortality in patients with non-ST-segment elevation acute coronary syndromes: a meta-analysis. Intern Emerg Med 13(2):273–285. https://doi.org/10.1007/s11739-017-1684-y Epub 2017 May 24.PMID: 28540660 Review
Alhabib KF, Kinsara AJ, Alghamdi S, Al-Murayeh M, Hussein GA, AlSaif S, Khalaf H, Alfaleh H, Hersi A, Kashour T, Al-Saleh A, Ali M, Ullah A, Mhish H, Abdo AN, Almutairi F, Arafah MR, AlKutshan R, Aldosari M, AlSabatien BY, Alrazzaz M, Maria AM, Aref AH, Selim MM, Morsy AM, AlTohari FA, Alrifai AA, Awaad AA, El-Sayed H, Mansour S, Atwa AA, Abdelkader S, Altamimi N, Saleh E, Alhaidari W, ElShihawy EHA, Busaleh AH, Abdalmoutaleb M, Fawzy EM, Mokhtar Z, Saleh AM, Ahmad MA, Almasswary A, Alshehri M, Abohatab KM, AlGarni T, Butt M, Altaj I, Abdullah F, Alhosni Y, Osman HB, Bugti N, Aziz AA, Alarabi A, AlHarbi IA (2019) The first survey of the Saudi Acute Myocardial Infarction Registry Program: main results and long-term outcomes (STARS-1 Program). PLoS One 14(5):e0216551. https://doi.org/10.1371/journal.pone.0216551 eCollection 2019
Hersi A, Al-Habib K, Al-Faleh H, Al-Nemer K, Alsaif S, Taraben A et al (2013) Gender inequality in the clinical outcomes of equally treated acute coronary syndrome patients in Saudi Arabia. Ann Saudi Med 33(4):339–346 https://doi.org/10.5144/0256-4947.2013.339. PMID: 24060711
Kalaf H, AlMesned A, Soomro T, Lasheen W, Ewid M, Al-Mohaimeed AA (2016) Cardiovascular disease risk profile among young Saudi women of Al-Qassim, Saudi Arabia: a cross-sectional study. Int J Health Sci (Qassim) 10(1):29–37. https://doi.org/10.12816/0031214 PMID: 27004055
Varghese T, Wenger NK (2018) Non-ST elevation acute coronary syndrome in women and the elderly: recent updates and stones still left unturned. F1000Res 7:F1000 Faculty Rev-1865. https://doi.org/10.12688/f1000research.16492.1
Eindhoven DC, Hilt AD, Zwaan TC, Schalij MJ, Borleffs CJW (2018) Age and gender differences in medical adherence after myocardial infarction: women do not receive optimal treatment - the Netherlands claims database. Eur J Prev Cardiol 25(2):181–189. https://doi.org/10.1177/2047487317744363
Sobers N, Rose AMC, Samuels TA, Critchley J, Abed M, Hambleton I, Harvey A, Unwin N (2019) Are there gender differences in acute management and secondary prevention of acute coronary syndromes in Barbados? A cohort study. BMJ Open 9(1):e025977. https://doi.org/10.1136/bmjopen-2018-025977
Zamzamy R, Kinsara AJ (2018) Gender inequity in cardiovascular care - global perspective. JAPI 66(7):80-82.
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The study was approved by IRB office, King Abdullah International Medical Research Center, number RJ15/008. Informed written consent was obtained anonymously from all participants before they were interviewed.
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Kinsara, A.J., Ismail, Y.M. Gender differences in patients presenting with non-ST segment elevation myocardial infarction in the STAR registry. Egypt Heart J 73, 54 (2021). https://doi.org/10.1186/s43044-021-00181-6
- STAR registry