Myocardial Infarction and Atrial Fibrillation: Are there Differences between Men and Women?

    Authors

    Abstract

    Today, women with ST-elevation myocardial infarction receive suboptimal management and have worse outcomes than men, with higher rates of in-hospital adverse events and higher mortality. In 2017, the American Heart Association identified "closing knowledge gaps on acute myocardial infarction and treatments for women" as a public health priority. There are sex-specific differences in the management of atrial fibrillation (AF). Women with AF receive suboptimal management and are significantly less likely to receive therapeutic anticoagulation, attempt rhythm control, or undergo invasive cardiovascular procedures. Stroke prevention still remains central to the management of AF.

    Keywords

    women, myocardial infarction, atrial fibrillation

    DOI

    https://doi.org/10.15836/ccar2018.234

    Full Text

    ## Atrial fibrillation in women It is estimated that in 2010 20.9 million men and 12.6 million women suffered from atrial fibrillation (AF) globally (14). It is believed that by 2030 the European Union will have 14 to 17 million patients with AF, i.e. that approximately 120,000 to 250,000 new patients are diagnosed every year. The prevalence of AF in men is 596 per 100,000 persons and is lower in women: 373 per 100,000 persons. As the overall population ages, the prevalence and financial burden associated with AF management are constantly increasing. The risk factors for AF are usually diabetes, arterial hypertension, increased body-mass index (BMI), advanced age, smoking, and CAD (14). Over the past decades, these factors have changed both in women and in men: the first places were taken by increased BMI, unregulated arterial hypertension, and metabolic syndrome, which also represent some of the risk factors for the development of chronic renal disease (15). Current studies have not found an influence of hormone therapy on the manifestation of AF, especially not for postmenopausal hormone supplementation. However, the most significant differences were observed in the treatment of women with AF and increased risk of stroke (16). Most of the data comes from anticoagulant medication studies, although they also include women in smaller numbers (35-40% of total participants). All studies to date found increased risk of suffering stroke in women with AF, especially with women who had heart failure with preserved ejection fraction (HFpEF). Female sex is an independent risk factor for stroke caused by AF and for systemic thromboembolism. It was included in the CHA2DS2-VASc scoring system (congestive heart failure/systolic dysfunction/hypertension/age>65, diabetes, stroke/TIA/thromboembolism, vascular disease, female sex). All of the parameters contribute to the final score (0-9) that indicates the risk level for stroke (17). Female sex has also been included in the risk assessment in the HAS-BLED scoring system (hypertension, functional disorder of the liver or kidneys, history of stroke, and history of bleeding). Each of the parameters contributes to the final score (0-9) that indicates the risk of major bleeding within a year (18). Bleeding from anticoagulation medication for AF is more common in the older population (and in women) as well as in patients with chronic diseases. It is also more common in persons with chronic renal disease and due to medication interactions (substances that induce the P-gp system in the liver (for instance rifampicin and St John’s wort) or inhibit it (statins, antiarrhythmics, antifungal and antiviral medication)) (19). Many studies have found a difference in the use of anticoagulation medication between men and women (20). Differences has also been found among populations and different age groups. In long-term follow-up (2-5.3 years), men with AF had a higher risk of death compared with women. According to study results, the differences in the treatment of women are crucial: in the elevated prothrombine state in women, different cerebral blood flow, genetic predisposition, and sociocultural causes (later seeking of medical aid, application of warfarin). In the treatment of AF in women, it has been noted that they are more often subjected to frequency control and more rarely to rhythm control (21). As far as catheter ablation for AF is concerned, women who underwent it were of a more advanced age, whereas the outcomes and complications were similar as in the male group. Regarding differences in bleeding propensity, post hoc analyses performed in all larger studies of new anticoagulation medication did not find significant differences in major bleeding between the sexes. The ARISTOTLE and ROCKET AF analyses demonstrated that the risk of bleeding is lower in women than in men. ## Conclusion The clinical picture of CAD can present differently in women younger than 65 in comparison with men and older women: atypical symptoms are more common, as well as sweating, fatigue, shortness of breath, dyspnea, and atypical pain. Therefore, a systemic approach to STEMI management contributes to a reduction in the differences in management and outcomes among the sexes. In comparison with other fields in modern cardiology, there are still unclarified questions regarding everyday practice related to the differences among the sexes and AF management. It is these differences that could (especially at a young age due to hormonal differences) contribute to treatment options (controlling rhythm, not just frequency) and prognosis (primarily stroke prevention).

    Cardiologia Croatica
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    Myocardial Infarction and Atrial Fibrillation: Are there Differences between Men and Women?

    Professional Article
    Issue7-8
    Published
    Pages234-238
    PDF via DOIhttps://doi.org/10.15836/ccar2018.234
    women
    myocardial infarction
    atrial fibrillation

    Authors

    Martina Lovrić BenčićORCID
    Ingrid Prkačin*ORCID

    Abstract

    Today, women with ST-elevation myocardial infarction receive suboptimal management and have worse outcomes than men, with higher rates of in-hospital adverse events and higher mortality. In 2017, the American Heart Association identified "closing knowledge gaps on acute myocardial infarction and treatments for women" as a public health priority. There are sex-specific differences in the management of atrial fibrillation (AF). Women with AF receive suboptimal management and are significantly less likely to receive therapeutic anticoagulation, attempt rhythm control, or undergo invasive cardiovascular procedures. Stroke prevention still remains central to the management of AF.

    Full Text

    ## Atrial fibrillation in women It is estimated that in 2010 20.9 million men and 12.6 million women suffered from atrial fibrillation (AF) globally (14). It is believed that by 2030 the European Union will have 14 to 17 million patients with AF, i.e. that approximately 120,000 to 250,000 new patients are diagnosed every year. The prevalence of AF in men is 596 per 100,000 persons and is lower in women: 373 per 100,000 persons. As the overall population ages, the prevalence and financial burden associated with AF management are constantly increasing. The risk factors for AF are usually diabetes, arterial hypertension, increased body-mass index (BMI), advanced age, smoking, and CAD (14). Over the past decades, these factors have changed both in women and in men: the first places were taken by increased BMI, unregulated arterial hypertension, and metabolic syndrome, which also represent some of the risk factors for the development of chronic renal disease (15). Current studies have not found an influence of hormone therapy on the manifestation of AF, especially not for postmenopausal hormone supplementation. However, the most significant differences were observed in the treatment of women with AF and increased risk of stroke (16). Most of the data comes from anticoagulant medication studies, although they also include women in smaller numbers (35-40% of total participants). All studies to date found increased risk of suffering stroke in women with AF, especially with women who had heart failure with preserved ejection fraction (HFpEF). Female sex is an independent risk factor for stroke caused by AF and for systemic thromboembolism. It was included in the CHA2DS2-VASc scoring system (congestive heart failure/systolic dysfunction/hypertension/age>65, diabetes, stroke/TIA/thromboembolism, vascular disease, female sex). All of the parameters contribute to the final score (0-9) that indicates the risk level for stroke (17). Female sex has also been included in the risk assessment in the HAS-BLED scoring system (hypertension, functional disorder of the liver or kidneys, history of stroke, and history of bleeding). Each of the parameters contributes to the final score (0-9) that indicates the risk of major bleeding within a year (18). Bleeding from anticoagulation medication for AF is more common in the older population (and in women) as well as in patients with chronic diseases. It is also more common in persons with chronic renal disease and due to medication interactions (substances that induce the P-gp system in the liver (for instance rifampicin and St John’s wort) or inhibit it (statins, antiarrhythmics, antifungal and antiviral medication)) (19). Many studies have found a difference in the use of anticoagulation medication between men and women (20). Differences has also been found among populations and different age groups. In long-term follow-up (2-5.3 years), men with AF had a higher risk of death compared with women. According to study results, the differences in the treatment of women are crucial: in the elevated prothrombine state in women, different cerebral blood flow, genetic predisposition, and sociocultural causes (later seeking of medical aid, application of warfarin). In the treatment of AF in women, it has been noted that they are more often subjected to frequency control and more rarely to rhythm control (21). As far as catheter ablation for AF is concerned, women who underwent it were of a more advanced age, whereas the outcomes and complications were similar as in the male group. Regarding differences in bleeding propensity, post hoc analyses performed in all larger studies of new anticoagulation medication did not find significant differences in major bleeding between the sexes. The ARISTOTLE and ROCKET AF analyses demonstrated that the risk of bleeding is lower in women than in men. ## Conclusion The clinical picture of CAD can present differently in women younger than 65 in comparison with men and older women: atypical symptoms are more common, as well as sweating, fatigue, shortness of breath, dyspnea, and atypical pain. Therefore, a systemic approach to STEMI management contributes to a reduction in the differences in management and outcomes among the sexes. In comparison with other fields in modern cardiology, there are still unclarified questions regarding everyday practice related to the differences among the sexes and AF management. It is these differences that could (especially at a young age due to hormonal differences) contribute to treatment options (controlling rhythm, not just frequency) and prognosis (primarily stroke prevention).