Mohamed O Mohamed1, Muhammad Rashid2, Adam Timmis3, Sarah Clarke4, Claire Lawson5, Erin D Michos6, Chun Shing Kwok2, Mark De Belder7, Marco Valgimigli8, Mamas A Mamas1. 1. Keele Cardiovascular Research Group, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, United Kingdom. 2. Keele Cardiovascular Research Group, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom. 3. Department of Cardiology, Barts Heart Centre, Queen Mary University London, United Kingdom. 4. Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom. 5. Real World Evidence Unit, Diabetes Research Centre, University of Leicester, UK. 6. Division of Cardiology, Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, MD, United States. 7. National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, United Kingdom. 8. Department of Cardiology, Inselspital, Universitätsspital Bern, Bern, Switzerland.
Abstract
BACKGROUND: Risk factors for further bleeding and ischemic events after acute coronary syndrome (ACS) often overlap. Little is known about sex-based differences in the management and outcomes of ACS patients according to their combined bleeding-ischemic risk. METHODS: All ACS hospitalizations in the United Kingdom (2010-2017) were retrospectively analyzed, stratified by sex and bleeding-ischemic risk combination (using CRUSADE and GRACE scores). Multivariable logistic regression was performed to examine association between risk-groups and 1) receipt of guideline-recommended management and 2) in-hospital outcomes. RESULTS: Of 584,360 patients, a third of males (32.3%) and females (32.6%) were in the dual high-risk group (High CRUSADE- High GRACE). In comparison to the dual low-risk group (Low CRUSADE-Low GRACE), the dual high-risk patients of both sexes were 59-83% less likely to receive inpatient revascularisation (PCI or CABG) and 50% less likely to receive dual antiplatelet therapy (DAPT) on discharge, with a significant increase in odds of MACE (~8 to 9-fold), all-cause and cardiac mortality (25 to 35-fold), and bleeding (78-91%). The greatest difference in management and clinical outcomes between sexes was found in the dual-high risk group where females were less likely to receive guideline-recommended therapy (revascularisation and DAPT), compared to males, and were more likely to experience MACE, all-cause and cardiac mortality. CONCLUSION: ACS patients with dual high-risk for bleeding and recurrent ischemia, especially females, are less likely to receive guideline-recommended therapy and experience significantly worse outcomes. Novel strategies are needed to effectively manage this highly prevalent, complex patient group and address the under-treatment of females.
BACKGROUND: Risk factors for further bleeding and ischemic events after acute coronary syndrome (ACS) often overlap. Little is known about sex-based differences in the management and outcomes of ACS patients according to their combined bleeding-ischemic risk. METHODS: All ACS hospitalizations in the United Kingdom (2010-2017) were retrospectively analyzed, stratified by sex and bleeding-ischemic risk combination (using CRUSADE and GRACE scores). Multivariable logistic regression was performed to examine association between risk-groups and 1) receipt of guideline-recommended management and 2) in-hospital outcomes. RESULTS: Of 584,360 patients, a third of males (32.3%) and females (32.6%) were in the dual high-risk group (High CRUSADE- High GRACE). In comparison to the dual low-risk group (Low CRUSADE-Low GRACE), the dual high-risk patients of both sexes were 59-83% less likely to receive inpatient revascularisation (PCI or CABG) and 50% less likely to receive dual antiplatelet therapy (DAPT) on discharge, with a significant increase in odds of MACE (~8 to 9-fold), all-cause and cardiac mortality (25 to 35-fold), and bleeding (78-91%). The greatest difference in management and clinical outcomes between sexes was found in the dual-high risk group where females were less likely to receive guideline-recommended therapy (revascularisation and DAPT), compared to males, and were more likely to experience MACE, all-cause and cardiac mortality. CONCLUSION: ACS patients with dual high-risk for bleeding and recurrent ischemia, especially females, are less likely to receive guideline-recommended therapy and experience significantly worse outcomes. Novel strategies are needed to effectively manage this highly prevalent, complex patient group and address the under-treatment of females.
Authors: Saadiq M Moledina; Ahmad Shoaib; Louise Y Sun; Phyo K Myint; Rafail A Kotronias; Benoy N Shah; Chris P Gale; Hude Quan; Rodrigo Bagur; Mamas A Mamas Journal: Eur Heart J Qual Care Clin Outcomes Date: 2022-09-05