The known Sex differences in the management and outcomes of patients with acute coronary syndromes have been reported, but many reported analyses were not adjusted for confounding covariates.The new Despite broader awareness of STEMI protocols, revascularisation rates for women with STEMI are lower than for men. In hospital, rates of major adverse cardiovascular events and mortality were similar, but at 6 months were significantly higher for women. Women were less frequently referred for cardiac rehabilitation or prescribed preventive medications on discharge.The implications Clinicians should consider potential barriers to equity for women in the management of STEMI. C ardiovascular disease is the leading cause of morbidity and mortality in both sexes, but an extensive literature has described differences between men and women in clinical presentation and pathophysiology that may influence management and outcomes.1,2 Observational studies have found that women with acute coronary syndromes (ACS) more frequently present with atypical symptoms, 3 with more comorbidities, 4 and at an older age, and that plaque rupture 5 and high risk features 3,6,7 are less likely to be identified during angiography than in men.Large hospital registry studies have found that women with ACS are less likely to receive evidence-based management, including coronary angiography and appropriate medications in hospital and at discharge. 4,6,[8][9][10] Australian data similarly indicate that women with ACS are underinvestigated and that evidence-based therapies are less often prescribed than for male patients. [10][11][12] Some studies have found that the higher mortality rates for women than for men with ACS in hospital, 4,6,9,10,13 at 30 days, 7,14 and at 6 months 3,13 are attenuated after adjusting for age and comorbid conditions, but others have found that differences persist despite adjustment. 8 In our investigation, we wanted to avoid confounding by the significant interactions between sex and type of ACS identified in earlier studies. 7,14 We therefore focused on patients with STEMI, as the clinical presentation and diagnosis of this condition is relatively consistent and the patients receive a largely standardised management plan. We hypothesised that management and outcomes for men and women with STEMI should be similar after adjusting for risk level.Our specific aims were to identify sex differences in the characteristics and outcomes of patients presenting with STEMI; to examine associations between sex and outcomes (morbidity and mortality) after adjusting for relevant covariates; and to explore whether there with differences in the prescribing of preventive medications for men and women after STEMI. MethodsWe analysed data from the CONCORDANCE (Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events) registry, an ongoing prospective ACS registry Main outcome measures: Rates of revascularisation (percutaneous coronary intervention [PCI], thrombolysis, coronary artery bypass grafting [CAB...

clinicaltrials.gov Identifier: NCT00091637.

BackgroundCardiovascular disease is a major cause of death in patients with stage 4–5 Chronic Kidney disease (CKD, eGFR < 30). There are only limited data on the risk factors predicting these complications in CKD patients. Our aim was to determine the role of clinical and echocardiographic parameters in predicting mortality and cardiovascular complications in CKD patients.MethodsWe conducted a prospective observational cohort study of 153 CKD patients between 2007 and 2009. All patients underwent echocardiography at baseline and were followed for a mean of 2.6 years using regular clinic visits and review of files and hospital presentations to record the incidence of cardiovascular events and death.ResultsOf 153 patients enrolled, 57 (37%) were on dialysis and 45 (78%) of these patients were on haemodialysis. An enlarged LV was present in 32% of patients and in 22% the LVEF was below 55%. LV mass index was increased in 75% of patients. Some degree of diastolic dysfunction was present in 85% of patients and 35% had grade 2 or higher diastolic dysfunction. During follow up 41 patients (27%) died, 15 (39%) from cardiovascular causes. Mortality was 24.0% in the non-dialysis patients versus 31.6% in patients on dialysis (p=ns). On multivariate analysis age >75 years, previous history of MI, diastolic dysfunction and detectable serum troponin T were significant independent predictor of mortality (P < 0.01).ConclusionPatients with stage 4–5 CKD had a mortality rate of 27% over a mean follow up of 2.6 years. Age >75 years, history of MI, diastolic dysfunction and troponin T were independent predictors of mortality.

ObjectiveWe aimed to assess the pattern of mortality and cause of death in a cohort of patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).MethodsConsecutive patients with STEMI treated with primary PCI during 2006–2013 were evaluated with a mean follow-up of 3.5 years (1–8.4 years). We used hospital and general practice records and mortality data from The Australian National Death Index.ResultsAmong 1313 patients (22.5% female) with mean age of 62.3±13.1 years, 181 patients (13.7%) died during long-term follow-up. In the first 7 days, 45 patients (3.4%) died, 76% of these due to cardiogenic shock. Between 7 days and 1 year, another 50 patients died (3.9%), 58% from cardiovascular causes and 22% from cancer. Beyond 1 year, there were 86 deaths with an estimated mean mortality rate of 2.05% per year, 36% of deaths were cardiovascular and 52% non-cardiovascular, including 29% cancer-related deaths. On multivariate analysis, age ≥75 years, history of diabetes, prior PCI, cardiogenic shock, estimated glomerular filtration rate (eGFR) <60 and symptom-to-balloon time >360 min were independent predictors of long-term mortality. In 16 patients who died of sudden cardiac death postdischarge, only 4 (25%) had ejection fraction ≤35% and would have been eligible for an implantable cardioverter defibrillator.ConclusionsIn the era of routine primary PCI, we found a mortality rate of 7.3% at 1 year, and 2.05% per year thereafter. Cause of death was predominantly cardiovascular in the first year and mainly non-cardiovascular after 1 year. Age, diabetes, prior PCI, cardiogenic shock, eGFR <60 and delayed treatment were independent predictors of mortality.