Advertisement

Sex-related differences in clinical outcomes among patients with myocardial infarction with nonobstructive coronary artery disease: A systematic review and meta-analysis

  • Rahul Chaudhary
    Correspondence
    Corresponding author at: Department of Cardiology, UPMC Heart and Vascular Institute, Scaife Tower 5th floor, 200 Lothrop St, Pittsburgh, PA 15213, United States of America.
    Affiliations
    Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
    Search for articles by this author
  • Michael Bashline
    Affiliations
    Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
    Search for articles by this author
  • Enrico M. Novelli
    Affiliations
    University of Pittsburgh Medical Center Vascular Medicine Institute, Pittsburgh, PA, United States of America

    Department of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
    Search for articles by this author
  • Kevin P. Bliden
    Affiliations
    Sinai Center of Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
    Search for articles by this author
  • Udaya S. Tantry
    Affiliations
    Sinai Center of Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
    Search for articles by this author
  • Oladipupo Olafiranye
    Affiliations
    University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Veterans Affairs Pittsburgh Health System, Pittsburgh, PA, USA
    Search for articles by this author
  • Aref Rahman
    Affiliations
    University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Veterans Affairs Pittsburgh Health System, Pittsburgh, PA, USA
    Search for articles by this author
  • Author Footnotes
    1 Combined last authors
    Paul A. Gurbel
    Footnotes
    1 Combined last authors
    Affiliations
    Sinai Center of Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
    Search for articles by this author
  • Author Footnotes
    1 Combined last authors
    John J. Pacella
    Footnotes
    1 Combined last authors
    Affiliations
    Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Department of Bioengineering, Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
    Search for articles by this author
  • Author Footnotes
    1 Combined last authors

      Highlights

      • The influence of sex on adverse events in MINOCA remains unclear.
      • Our meta-analysis of >28,000 MINOCA patients showed women had more MACE than men (10.1% vs. 9.1%).
      • The adverse events in women were driven only by higher incidence of stroke in women (3.5% vs. 2.2%, p < 0.05).
      • Diminishing influence of estrogen, hypercoagulability, and underprescribing in women are likely contributors to MACE.

      Abstract

      Background

      Among patients who present with acute myocardial infarction (MI), 2–6% are found to have non-obstructive coronary arteries (NOCA). Patients with MINOCA are more commonly women and present at a younger age (51–59 years). The influence of sex on adverse event rates remains unclear.

      Methods

      PubMed, MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), EMBASE, EBSCO, Web of Science and CINAHL databases were searched for trials comparing gender differences in clinical outcomes among patients with MINOCA from inception through April 10, 2022. The primary endpoint of the study was composite major adverse clinical events (MACE) including all-cause mortality, non-fatal MI, stroke, and cardiovascular readmissions, and secondary endpoints were the individual components of the MACE.

      Results

      Seven studies with a total of 28,671 MINOCA patients were included (n = 11,249 men and n = 17,422 women) over a mean follow-up of 2 years. Women had more MACE than men (10.1% vs. 9.1%, OR 1.15, 1.04–1.23, I2 = 44.7%). Among secondary endpoints, only the incidence of stroke was higher in women (3.5% vs. 2.2%, OR 1.3, 1.01–1.68, I2 = 0%). All-cause mortality, non-fatal MI, and cardiovascular readmissions were not significantly different between the two groups.

      Conclusions

      We hypothesize that small vessel disease associated with MINOCA drives MACE in women and the diminishing influence of estrogen, hypercoagulability and underprescribing could contribute to the differences sex-related outcomes.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to International Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Smilowitz N.R.
        • Mahajan A.M.
        • Roe M.T.
        • et al.
        Mortality of myocardial infarction by sex, age, and obstructive coronary artery disease status in the ACTION registry-GWTG (acute coronary treatment and intervention outcomes network registry-get with the guidelines).
        Circ. Cardiovasc. Qual. Outcomes. 2017; 10e003443
        • Eggers K.M.
        • Hjort M.
        • Baron T.
        • et al.
        Morbidity and cause-specific mortality in first-time myocardial infarction with nonobstructive coronary arteries.
        J. Intern. Med. 2019; 285: 419-428
        • Safdar B.
        • Spatz E.S.
        • Dreyer R.P.
        • et al.
        Presentation, clinical profile, and prognosis of young patients with myocardial infarction with nonobstructive coronary arteries (MINOCA): results from the VIRGO study.
        J. Am. Heart Assoc. 2018; 7
        • Jedrychowska M.
        • Januszek R.
        • Plens K.
        • Surdacki A.
        • Bartus S.
        • Dudek D.
        Impact of sex on the follow-up course and predictors of clinical outcomes in patients hospitalised due to myocardial infarction with non-obstructive coronary arteries: a single-centre experience.
        Kardiol. Pol. 2019; 77: 198-206
        • Jung R.G.
        • Parlow S.
        • Simard T.
        • et al.
        Clinical features, sex differences and outcomes of myocardial infarction with nonobstructive coronary arteries: a registry analysis.
        Coron. Artery Dis. 2021; 32: 10-16
        • Mohammed A.Q.
        • Abdu F.A.
        • Liu L.
        • et al.
        Does sex influence outcomes in myocardial infarction with nonobstructive coronary arteries?.
        Angiology. 2022; 73: 275-280
        • Gao S.
        • Ma W.
        • Huang S.
        • Lin X.
        • Yu M.
        Sex-specific clinical characteristics and long-term outcomes in patients with myocardial infarction with non-obstructive coronary arteries.
        Front Cardiovasc Med. 2021; 8670401
        • Sickinghe A.A.
        • Korporaal S.J.A.
        • den Ruijter H.M.
        • Kessler E.L.
        Estrogen contributions to microvascular dysfunction evolving to heart failure with preserved ejection fraction.
        Front. Endocrinol. (Lausanne). 2019; 10: 442
        • Chaudhary R.
        • Sukhi A.
        • Chaudhary R.
        • et al.
        Gender differences in thrombogenicity among patients with angina and non-obstructive coronary artery disease.
        J. Thromb. Thrombolysis. 2019; 48: 373-381
        • Ciliberti G.
        • Verdoia M.
        • Merlo M.
        • et al.
        Pharmacological therapy for the prevention of cardiovascular events in patients with myocardial infarction with non-obstructed coronary arteries (MINOCA): insights from a multicentre national registry.
        Int. J. Cardiol. 2021; 327: 9-14
        • Group ASC
        • Bowman L.
        • Mafham M.
        • et al.
        Effects of aspirin for primary prevention in persons with diabetes mellitus.
        N. Engl. J. Med. 2018; 379: 1529-1539
        • McNeil J.J.
        • Nelson M.R.
        • Woods R.L.
        • et al.
        Effect of aspirin on all-cause mortality in the healthy elderly.
        N. Engl. J. Med. 2018; 379: 1519-1528
        • Williams M.J.A.
        • Barr P.R.
        • Lee M.
        • Poppe K.K.
        • Kerr A.J.
        Outcome after myocardial infarction without obstructive coronary artery disease.
        Heart. 2019; 105: 524-530
        • Agewall S.
        • Beltrame J.F.
        • Reynolds H.R.
        • et al.
        ESC working group position paper on myocardial infarction with non-obstructive coronary arteries.
        Eur. Heart J. 2017; 38: 143-153