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...

Background: High-sensitivity troponin assays are increasingly being adopted to expedite evaluation of patients with suspected acute coronary syndromes. Few direct comparisons have examined whether the enhanced performance of these assays at low concentrations leads to changes in care that improves longer-term outcomes. This study evaluated late outcomes of participants managed under an unmasked 0/1-hour high-sensitivity cardiac troponin T (hs-cTnT) protocol compared with a 0/3-hour masked hs-cTnT protocol. Methods: We conducted a multicenter prospective patient-level randomized comparison of care informed by unmasked 0/1-hour hs-cTnT protocol (reported to <5 ng/L) versus standard practice masked hs-cTnT testing (reported to ≤29 ng/L) assessed at 0/3 hours and followed participants for 12 months. Participants included were those presenting to metropolitan emergency departments with suspected acute coronary syndromes, without ECG evidence of coronary ischemia. The primary end point was time to all-cause death or myocardial infarction using Cox proportional hazards models adjusted for clustering within hospitals. Results: Between August 2015 and April 2019, we randomized 3378 participants, of whom 108 withdrew, resulting in 12-month follow-up for 3270 participants (masked: 1632; unmasked: 1638). Among these, 2993 (91.5%) had an initial troponin concentration of ≤29 ng/L. Deployment of the 0/1-hour hs-cTnT protocol was associated with reductions in functional testing. Over 12-month follow-up, there was no difference in invasive coronary angiography (0/1-hour unmasked: 232/1638 [14.2%]; 0/3-hour masked: 202/1632 [12.4%]; P =0.13), although an increase was seen among patients with hs-cTnT levels within the masked range (0/1-hour unmasked arm: 168/1507 [11.2%]; 0/3-hour masked arm: 124/1486 [8.3%]; P =0.010). By 12 months, all-cause death and myocardial infarction did not differ between study arms overall (0/1-hour: 82/1638 [5.0%] versus 0/3-hour: 62/1632 [3.8%]; hazard ratio, 1.32 [95% CI, 0.95–1.83]; P =0.10). Among participants with initial troponin T concentrations ≤29 ng/L, unmasked hs-cTnT reporting was associated with an increase in death or myocardial infarction (0/1-hour: 55/1507 [3.7%] versus 0/3-hour: 34/1486 [2.3%]; hazard ratio, 1.60 [95% CI, 1.05–2.46]; P =0.030). Conclusions: Unmasked hs-cTnT reporting deployed within a 0/1-hour protocol did not reduce ischemic events over 12-month follow-up. Changes in practice associated with the implementation of this protocol may be associated with an increase in death and myocardial infarction among those with newly identified troponin elevations. Registration: URL: https://www.anzctr.org.au ; Unique identifier: ACTRN12615001379505.

Aims High-sensitivity cardiac troponin strategies can provide risk stratification in patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). This study evaluated whether clinical risk scoring improves the classification performance of a rule-out profile in suspected ACS. Methods and results Patients presenting to ED with suspected ACS as part of the RAPID-TnT trial randomized to the intervention arm were included. Results ≥5 ng/L were available for all participants in this analysis. We evaluated the Thrombolysis In Myocardial Infarction (TIMI) risk score, History ECG Age Risk factors Troponin (HEART) score, and Emergency Department Assessment of Chest pain Score (EDACS) in addition to a rule-out profile based on the 0/1-h high-sensitivity cardiac troponin T protocol (&lt;5 ng/L or ≤12 ng/L and a change of &lt;3 ng/L at 1-h) using test performance parameters focusing on low-risk groups to identify the primary endpoint (TIMI ≤ 1, HEART ≤ 3, EDACS &lt; 16). Primary endpoint was a composite of type 1/2 myocardial infarction (MI) at index presentation and all-cause mortality or type 1/2 MI at 30 days. A total of 3378 participants were enrolled between August 2015 and April 2019 of which 108 were ineligible/withdrew consent (intervention arm: n = 1638). Sensitivity, specificity, negative predictive value (NPV), and area under the curve (AUC) of the rule-out profile was 94.4%, 76.8%, 99.6%, and 0.86, respectively with 72.9% identified as ‘low-risk’. Adding the clinical risk scores did not improve the sensitivity, NPV, or AUC with significantly lower specificity and ‘low-risk’ classified participants. Conclusions Addition of clinical risk scores to rule-out profile did not demonstrate improved classification performance for identifying the composite of type 1/2 MI at index presentation and all-cause mortality or type 1/2 MI at 30 days. Clinical trials registration URL: https://www.anzctr.org.au. Reg. No. ACTRN12615001379505.