Sex-based associations with microvascular injury and outcomes after ST-segment elevation myocardial infarction

Annette Marie Maznyczka, David Carrick, Jaclyn Carberry, Kenneth Mangion, Margaret McEntegart, Mark C Petrie, Hany Eteiba, Mitchell Lindsay, Stuart Hood, Stuart Watkins, Andrew Davie, Ahmed Mahrous, Ian Ford, Paul Welsh, Naveed Sattar, Keith G Oldroyd, Colin Berry, Annette Marie Maznyczka, David Carrick, Jaclyn Carberry, Kenneth Mangion, Margaret McEntegart, Mark C Petrie, Hany Eteiba, Mitchell Lindsay, Stuart Hood, Stuart Watkins, Andrew Davie, Ahmed Mahrous, Ian Ford, Paul Welsh, Naveed Sattar, Keith G Oldroyd, Colin Berry

Abstract

Objectives: We aimed to assess for sex differences in invasive parameters of acute microvascular reperfusion injury and infarct characteristics on cardiac MRI after ST-segment elevation myocardial infarction (STEMI).

Methods: Patients with STEMI undergoing emergency percutaneous coronary intervention (PCI) were prospectively enrolled. Index of microcirculatory resistance (IMR) and coronary flow reserve (CFR) were measured in the culprit artery post-PCI. Contrast-enhanced MRI was used to assess infarct characteristics, microvascular obstruction and myocardial haemorrhage, 2 days and 6 months post-STEMI. Prespecified outcomes were as follows: (i) all-cause death/first heart failure hospitalisation and (ii) cardiac death/non-fatal myocardial infarction/urgent coronary revascularisation (major adverse cardiovascular event, MACE) during 5- year median follow-up.

Results: In 324 patients with STEMI (87 women, mean age: 61 ± 12.19 years; 237 men, mean age: 59 ± 11.17 years), women had anterior STEMI less often, fewer prescriptions of beta-blockers at discharge and higher baseline N-terminal pro-B-type natriuretic peptide levels (all p < 0.05). Following emergency PCI, fewer women than men had Thrombolysis in Myocardial Infarction (TIMI) myocardial perfusion grades ≤ 1 (20% vs 32%, p = 0.027) and women had lower corrected TIMI frame counts (12.94 vs 17.65, p = 0.003). However, IMR, CFR, microvascular obstruction, myocardial haemorrhage, infarct size, myocardial salvage index, left ventricular remodelling and ejection fraction did not differ significantly between sexes. Female sex was not associated with MACE or all-cause death/first heart failure hospitalisation.

Conclusion: There were no sex differences in microvascular pathology in patients with acute STEMI. Women had less anterior infarcts than men, and beta-blocker therapy at discharge was prescribed less often in women.

Trial registration number: NCT02072850.

Keywords: MRI; clinical outcomes; index of microcirculatory resistance; microvascular obstruction; myocardial infarction; sex.

Conflict of interest statement

Competing interests: CB: Research Grant—Significant; Based on an institutional agreement with the University of Glasgow, CB has acted as a consultant to Abbott, a manufacturer of diagnostic coronary guidewires. The company has offered a significant research grant in relation to a research project led by CB. The University of Glasgow holds a research agreement with Siemens Healthcare, which manufactured the MRI scanner used in this study. KO: Honoraria—Modest. KO has acted as consultant to Abbott.

Figures

Figure 1
Figure 1
Consort flow diagram of the study. STEMI, ST-segment elevation myocardial infarction.
Figure 2
Figure 2
(A) Kaplan-Meier curve for MACE-free survival, after initial hospitalisation to 5-year follow-up. (B) Kaplan-Meier curve for survival free from all-cause death or the first heart failure hospitalisation to 5-year follow-up. MACE, major adverse cardiovascular event.

References

    1. Townsend N, Wilson L, Bhatnagar P, et al. . Cardiovascular disease in Europe: epidemiological update 2016. Eur Heart J 2016;37:3232–45. 10.1093/eurheartj/ehw334
    1. Mehta LS, Beckie TM, DeVon HA, et al. . American Heart Association cardiovascular disease in women and special populations Committee of the Council on clinical Cardiology, Council on epidemiology and prevention, Council on cardiovascular and stroke Nursing, and Council on quality of care and outcomes research. acute myocardial infarction in women: a scientific statement from the American Heart Association. Circulation 2016;133:916–47.
    1. Alabas OA, Gale CP, Hall M, et al. . Sex differences in treatments, relative survival, and excess mortality following acute myocardial infarction: national cohort study using the SWEDEHEART registry. J Am Heart Assoc 2017;6:e007123 10.1161/JAHA.117.007123
    1. Canali E, Masci P, Bogaert J, et al. . Impact of gender differences on myocardial salvage and post-ischaemic left ventricular remodelling after primary coronary angioplasty: new insights from cardiovascular magnetic resonance. Eur Heart J Cardiovasc Imaging 2012;13:948–53. 10.1093/ehjci/jes087
    1. Mehilli J, Ndrepepa G, Kastrati A, et al. . Gender and myocardial salvage after reperfusion treatment in acute myocardial infarction. J Am Coll Cardiol 2005;45:828–31. 10.1016/j.jacc.2004.11.054
    1. Tomey MI, Mehran R, Brener SJ, et al. . Sex, adverse cardiac events, and infarct size in anterior myocardial infarction: an analysis of intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction (INFUSE-AMI). Am Heart J 2015;169:86–93. 10.1016/j.ahj.2014.06.019
    1. Eitel I, Desch S, de Waha S, et al. . Sex differences in myocardial salvage and clinical outcome in patients with acute reperfused ST-elevation myocardial infarction: advances in cardiovascular imaging. Circ Cardiovasc Imaging 2012;5:119–26. 10.1161/CIRCIMAGING.111.965467
    1. Kosmidou I, Redfors B, Selker HP, et al. . Infarct size, left ventricular function, and prognosis in women compared to men after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: results from an individual patient-level pooled analysis of 10 randomized trials. Eur Heart J 2017;38:1656–63. 10.1093/eurheartj/ehx159
    1. Bugiardini R, Ricci B, Cenko E, et al. . Delayed care and mortality among women and men with myocardial infarction. J Am Heart Assoc 2017;6:e005968 10.1161/JAHA.117.005968
    1. D'Onofrio G, Safdar B, Lichtman JH, et al. . Sex differences in reperfusion in young patients with ST-segment-elevation myocardial infarction: results from the VIRGO study. Circulation 2015;131:1324–32. 10.1161/CIRCULATIONAHA.114.012293
    1. Lichtman JH, Leifheit EC, Safdar B, et al. . Sex differences in the presentation and perception of symptoms among young patients with myocardial infarction: evidence from the VIRGO study (variation in recovery: role of gender on outcomes of young AMI patients). Circulation 2018;137:781–90. 10.1161/CIRCULATIONAHA.117.031650
    1. Khera S, Kolte D, Gupta T, et al. . Temporal Trends and Sex Differences in Revascularization and Outcomes of ST-Segment Elevation Myocardial Infarction in Younger Adults in the United States. J Am Coll Cardiol 2015;66:1961–72. 10.1016/j.jacc.2015.08.865
    1. Ibanez B, James S, Agewall S, et al. . 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of cardiology (ESC). Eur Heart J 2018;39:119–77. 10.1093/eurheartj/ehx393
    1. Eitel I, Desch S, Fuernau G, et al. . Prognostic significance and determinants of myocardial salvage assessed by cardiovascular magnetic resonance in acute reperfused myocardial infarction. J Am Coll Cardiol 2010;55:2470–9. 10.1016/j.jacc.2010.01.049
    1. Carrick D, Haig C, Ahmed N, et al. . Comparative prognostic utility of indexes of microvascular function alone or in combination in patients with an acute ST-segment-elevation myocardial infarction. Circulation 2016;134:1833–47. 10.1161/CIRCULATIONAHA.116.022603
    1. Keeley EC, Mehran R, Brener SJ, et al. . Impact of multiple complex plaques on short- and long-term clinical outcomes in patients presenting with ST-segment elevation myocardial infarction (from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Trial). Am J Cardiol 2014;113:1621–7. 10.1016/j.amjcard.2014.02.016
    1. Schoos MM, Mehran R, Dangas GD, et al. . Gender differences in associations between intraprocedural thrombotic events during percutaneous coronary intervention and adverse outcomes. Am J Cardiol 2016;118:1661–8. 10.1016/j.amjcard.2016.08.046
    1. Verhaert D, Thavendiranathan P, Giri S, et al. . Direct T2 quantification of myocardial edema in acute ischemic injury. JACC Cardiovasc Imaging 2011;4:269–78. 10.1016/j.jcmg.2010.09.023
    1. Carrick D, Haig C, Rauhalammi S, et al. . Pathophysiology of LV Remodeling in Survivors of STEMI: Inflammation, Remote Myocardium, and Prognosis. JACC Cardiovasc Imaging 2015;8:779–89. 10.1016/j.jcmg.2015.03.007
    1. Kellman P, Arai AE, McVeigh ER, et al. . Phase-sensitive inversion recovery for detecting myocardial infarction using gadolinium-delayed hyperenhancement. Magn Reson Med 2002;47:372–83. 10.1002/mrm.10051
    1. Ann SH, De Jin C, Singh GB, et al. . Gender differences in plaque characteristics of culprit lesions in patients with ST elevation myocardial infarction. Heart Vessels 2016;31:1767–75. 10.1007/s00380-016-0806-1
    1. Bolognese L, Carrabba N, Parodi G, et al. . Impact of microvascular dysfunction on left ventricular remodeling and long-term clinical outcome after primary coronary angioplasty for acute myocardial infarction. Circulation 2004;109:1121–6. 10.1161/01.CIR.0000118496.44135.A7
    1. Dargie HJ. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the Capricorn randomised trial. Lancet 2001;357:1385–90. 10.1016/S0140-6736(00)04560-8
    1. Biondi-Zoccai GGL, Abate A, Bussani R, et al. . Reduced post-infarction myocardial apoptosis in women: a clue to their different clinical course? Heart 2005;91:99–101. 10.1136/hrt.2003.018754
    1. Rosmini S, Bulluck H, Captur G, et al. . Myocardial native T1 and extracellular volume with healthy ageing and gender. Eur Heart J Cardiovascular Imaging 2018;19:615–21. 10.1093/ehjci/jey034
    1. Carrick D, Haig C, Carberry J, et al. . Microvascular resistance of the culprit coronary artery in acute ST-elevation myocardial infarction. JCI Insight 2016;1:e85768 10.1172/jci.insight.85768
    1. O'Gara PT, Kushner FG, Ascheim DD, et al. . 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: Executive summary: a report of the American College of cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013;127:529–55. 10.1161/CIR.0b013e3182742c84
    1. Eindhoven DC, Hilt AD, Zwaan TC, et al. . Age and gender differences in medical adherence after myocardial infarction: Women do not receive optimal treatment - The Netherlands claims database. Eur J Prev Cardiol 2018;25:181–9. 10.1177/2047487317744363
    1. Ottani F, Galvani M, Ferrini D, et al. . Prodromal angina limits infarct size. A role for ischemic preconditioning. Circulation 1995;91:291–7.

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