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AHA releases scientific statement on acute myocardial infarction in women

Cardiovascular disease is an “equal-opportunity killer” of men and women, but physicians should be particularly aware of how acute myocardial infarction (MI) affects women differently, according to the first scientific statement on the topic from the American Heart Association (AHA).

The paper reviews the current evidence on the epidemiology, clinical presentation, pathophysiology, treatment, and outcomes of women with acute MI, as well as racial and ethnic differences. The paper was published in the March 1 Circulation.

Cardiovascular disease (CVD) mortality has been higher in women than in men since 1984, although the rate in women has declined since 2000, which may be the result of increased education and awareness, as well as application of evidence-based therapies, according to the paper. “This is encouraging, but there remains an excess in mortality in women that is multifactorial,” the authors wrote.

The differences in women stem from both biological and gender-based factors. Certain risk factors for coronary heart disease are more potent in women than in men, such as tobacco use, type 2 diabetes, and depression. Although sex-specific CVD research has improved over the past 2 decades, women are still underrepresented in CVD clinical trials, making up roughly 20% of enrolled patients, according to the paper.

Although chest pain or discomfort affects most patients with acute MI, women often present with atypical chest pain and angina-equivalent symptoms, such as dyspnea, weakness, fatigue, and indigestion. These differences in clinical presentation affect the timely identification, testing, and management of ischemic symptoms, leading to misdiagnosis, delayed revascularization, and higher acute MI mortality rates. Studies also show that women present later to treatment for acute MI than men.

Women have more favorable outcomes with percutaneous coronary interventions compared with thrombolytic therapy in the setting of ST-segment-elevation MI (STEMI) and benefit from an early invasive strategy for non-ST-segment-elevation MI (NSTEMI). Although recommended perfusion therapies for acute MI are similar for women and men, bleeding risks and other complications are greater in women, and cardiac rehabilitation is “underused and underprescribed for women,” according to the paper.

American College of Cardiology/AHA guidelines for NSTEMI acute coronary syndrome recommend that women receive pharmacotherapy similar to that given to men in acute NSTEMI and for secondary prevention, but clinicians should pay careful attention to weight and renal function when dosing antiplatelet and anticoagulant agents to reduce bleeding risk in women, according to the paper.

To improve outcomes in women with acute MI, the AHA calls for increased awareness of sex-specific differences in presentation, the inclusion of women of all ages in cardiovascular clinical research, the development of primary and secondary prevention strategies for women, and other measures. “The first step to personalized medicine is attention to sex-specific characteristics, and attention to sex disparities likely will improve the awareness, prevention, recognition, treatment, and outcomes of CHD in women,” the authors wrote.