Factors Affecting Early Mortality and 1-Year Outcomes in Young Women With ST-Segment-Elevation Myocardial Infarction Aged Less Than or Equal to 45 Years

https://doi.org/10.1016/j.cpcardiol.2019.03.008Get rights and content

Abstract

Given that up to 2% of patients with myocardial infarction (MI) are young women, the purpose of this study was to evaluate factors affecting outcomes in young women with ST-segment-elevation myocardial infarction (STEMI) aged less than or equal to 45 years. We evaluated 796 women with STEMI aged less than or equal to 45 years between 2007 and 2014, and mortality was 4.0%. Death occurred more often in women with prehospital sudden cardiac arrest, and severe symptoms of heart failure; less commonly, the women were subjected to percutaneous coronary intervention (PCI), with a higher rate of incomplete revascularization. Beta blockers (BB) and angiotensin converting enzyme inhibitors were frequently used in the survivor group. The independent predictor of 30-day mortality was as follows: inability to undergo PCI (odds ratio [OR] 4.6, 95% confidence interval [CI] 1.45-14.76, P = 0.009), sudden cardiac arrest (OR 4.5, 95% CI 1.5-18.3, P = 0.04). An increase in systolic blood pressure for every 5 mm Hg was associated with lower mortality, OR 0.90, 95% CI 0.76-0.97 in patients without cardiogenic shock (CS) and OR 0.69, 95% CI 0.61-0.78, P < 0.0001 in the group with CS. Predictors for 1-year mortality were the inability to undergo PCI (hazard ratio [HR] 84, 95% CI 1.6-43.1, P = 0.01) and CS (HR 6.97, 95% CI 1.39-34.7, P = 0.01). An increase of 5% in left ventricular ejection fraction reduced the mortality rate for 60% (HR 0.40, 95% CI 0.26-0.63, P < 0.0001) and an increase in systolic blood pressure for every 5 mm Hg reduced mortality for 34% (HR 0.66, 95% CI 0.52-0.84, P = 0.02). Both short- and long-term outcomes in young women aged less than or equal to 45 years with STEMI are good. The strongest predictor for both 30-day and 1-year mortality was the inability to undergo PCI. Suboptimal use of beta blockers and angiotensin converting enzyme inhibitors affect the outcomes in young women. Hypotension in the acute phase of MI increased mortality in young women, independent of coexisting CS.

Introduction

In the era of interventional cardiology development, the prognosis of patients with ST-elevation acute myocardial infarction (STEMI) has significantly improved. In developed countries, in-hospital mortality does not usually exceed 5% and 1-year mortality ranges between 7% and 13% of the patient population and is related to age and gender.1, 2, 3 A particular group of patients are young people with myocardial infarction (MI) in whom often atypical symptomatology and nonatheromatous etiology of myocardial ischemia may have an impact on prognosis.

About 0.1%-2% of the MI population are young women.4 Recent population data from the nationwide database showed that women and men with STEMI under 45 years of age accounted for 3.9% of all patients with STEMI with a predominance of men (84.7% vs 15.3%), which means that 0.6% of all STEMI patients are young women.5 According to existing data, both short- and long-term outcomes in young STEMI patients seem to be favorable.6, 7, 8

Unfortunately, the literature on this subject is scarce. There are only a few published studies that pertain to young women. This may be due to: (1) the difficulty in gathering the right number from the population; and (2) an unspecified, often controversial definition of “youth.” In the available literature regarding young women with STEMI, the ages range from 35 to 60 years, which can generate significant discrepancies in results.

The purpose of this study was to evaluate the possible factors influencing 30-day and 1-year mortality in young women with STEMI aged less than or equal to 45 years.

Section snippets

Patients and Methods

We analyzed data from the period 2007-2014 of young women hospitalized with STEMI who were aged less than or equal to 45 years. The data came from the Polish Registry of Acute Coronary Syndromes,9 an ongoing, nationwide, multicenter, prospective, observational, and mandatory registry of all consecutive acute coronary syndrome (ACS) cases in Poland. From among all Polish hospitals, a total of 535 centers were selected to be invited to enter the registry, based on the following conditions: (1)

Results

Analyses were performed on the data of the 796 women with STEMI. The median age in the study group was 42.0 years (interquartile range: 38.0-44.0). Group characteristics are shown in Table 1.

Early 30-day mortality was 3.0%. The women who died had a higher prevalence of prehospital sudden cardiac arrest (SCA), 20.8% vs 2.7%. They were in worse overall condition at admission with a higher prevalence of the following: pulmonary edema, 8.3% vs 0.39%; CS, 29.2% vs 0.52%; higher heart rate; and more

Discussion

In recent years, a declining trend in ACS incidence and mortality rate in women has been observed.11,12 However, many authors believe that this phenomenon occurs mainly in the population of older women, with a steady rate of morbidity and mortality among younger women. Female gender is an independent adverse prognostic factor in ACS, but the data regarding diversity and differences in the course of the ACS in young women are scarce.13 Our analysis included only women with STEMI aged less than

Limitations

The main limitation of the study is its retrospective design: the questionnaire was completed over 3 stages, which may affect its accuracy. The analysis does not include patients who died during a prehospital period. Due to design of the study, the authors did not have data on the pharmacologic treatment used in the posthospital period, which could have an influence on long-term observation. Study analyzed only all-cause mortality. A matter of discussion was the age limit of patients. The study

Conclusions

Both the 30-day and 1-year prognosis in young women with STEMI aged less than or equal to 45 years were favorable and did not exceeded 4%. The strongest predictors of 30-day and 1-year mortality were the inability to undergo PCI. Suboptimal pharmacotherapy, that is, the lower use of BB and ACE-I, worsened the prognosis in young women. Hypotension in the acute phase of MI increased mortality in young women, independent of co-existing CS.

Contribution Statement

All authors contributed to: (1) conceiving and designing the study, or acquiring the data, or analyzing and interpreting the data; (2) drafting the article or revising it critically for important intellectual content; and (3) giving final approval of the version to be submitted.

Competing Interests

All authors declare they have no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years and no other relationships or activities that could appear to have influenced the submitted work.

Funding

The project was carried out under an internal grant from the Institute of Cardiology, Warsaw, no. (2.7/III/14).

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    Conflicts of interest: The authors have no conflicts of interest to disclose.

    All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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