Relations of Sex to Diagnosis and Outcomes in Acute Coronary Syndrome

Nils Arne Sörensen, Johannes Tobias Neumann, Francisco Ojeda, Sarina Schäfer, Christina Magnussen, Till Keller, Karl J Lackner, Tanja Zeller, Mahir Karakas, Thomas Münzel, Stefan Blankenberg, Dirk Westermann, Renate B Schnabel, Nils Arne Sörensen, Johannes Tobias Neumann, Francisco Ojeda, Sarina Schäfer, Christina Magnussen, Till Keller, Karl J Lackner, Tanja Zeller, Mahir Karakas, Thomas Münzel, Stefan Blankenberg, Dirk Westermann, Renate B Schnabel

Abstract

Background: The atypical presentation of women with acute coronary syndrome (ACS) has been related to delayed diagnosis and treatment, which may explain worse outcome compared with men.

Methods and results: We analyzed pooled data of 2520 patients of 2 prospective cohorts in terms of differences in presentation and management of women and men suggestive of ACS. Using logistic regression, we established 2 diagnostic models and tested their diagnostic performance in both sexes separately. Sex-specific differences in management of patients with ACS were ascertained and a 2-year follow-up was performed. Women were older than men (median 67 versus 61 years, P=0.001), had more often dyspnea (22% versus 18%, P=0.024), nausea or vomiting (26% versus 16%, P=0.001) and radiating chest pain (47% versus 40%, P=0.001). Classical risk factors (smoking, diabetes mellitus, dyslipidemia or known coronary artery disease) were less frequent in women. Diagnostic models showed no significant sex-related differences in diagnostic performance in a "first contact" setting (medical history and symptoms) or after "complete triage" (including ECG and biomarkers). Women with ACS underwent coronary angiography (73.8% versus 84.3%, P<0.001) and revascularization (53.8% versus 70.1%, P<0.001) less frequently. Two-year incidence of myocardial infarction and death was similar in both sexes, but revascularization and cardiac rehospitalization were more frequent in men.

Conclusions: In a large cohort of patients with suspected ACS, sex differences in clinical presentation did not impair diagnostic accuracy. Two-year outcomes were comparable. Our findings suggest a benefit of chest pain units to minimize sex differences in ACS management and prognosis.

Clinical trial registration: URL: https://www.clinicaltrials.gov. Unique identifiers: NCT02355457 (BACC), NCT03227159 (stenoCardia).

Keywords: diagnosis; outcome; sex‐specific; troponin.

© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Figures

Figure 1
Figure 1
ROC curves for LASSO‐generated diagnostic models and hs‐TnI. Results are shown for women (A) and men (B). The LASSO (logistic regression) was performed on the two different groups of variables considered. We present results for the parameter 1 standard error of the minimum. ROC (receiver operating characteristic) curves and AUC (area under the curve) estimates were corrected for over optimism using bootstrap (with 500 iterations). The ROC curve and AUC for hs‐TnI uses the on‐admission value.
Figure 2
Figure 2
Kaplan–Meier curves for event‐free survival stratified by sex. Kaplan–Meier curves for the endpoints death (A), myocardial infarction (B), revascularization (C) and cardiovascular rehospitalization (D) are presented. The given P‐values were calculated using the log‐rank test.

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