SciELO - Scientific Electronic Library Online

 
vol.63 issue2Infant mortality due to congenital defects in Costa Rica: 2010-2018 updatePrevalence of vitamin D deficiency in Costa Rican children author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

  • Have no similar articlesSimilars in SciELO

Share


Acta Médica Costarricense

On-line version ISSN 0001-6002Print version ISSN 0001-6012

Acta méd. costarric vol.63 n.2 San José Apr./Jun. 2021

 

Original

Clinical and angiographic profile of women with acute myocardial infarction in a national hospital

Andrés Acuña-Román1 

Manuel Antonio Vindas-Villarreal2 

Donato A. Salas-Segura3 

1Hospital San Rafael de Alajuela, Servicio de CardiologíaCosta Rica

2Hospital Rafael Ángel Calderón Guardia, Unidad de Cuidados Intensivos, Costa Rica

3Hospital Rafael Ángel Calderón Guardia, San José. Costa Rica

Ischemic heart disease is the leading cause of death in women in Costa Rica and in the so-called western world. Although mortality has gradually decreased in recent years, its incidence tends to increase,1-3 among other reasons due to the aging of the population, the decrease in infectiouscontagious diseases, the increase in sedentary lifestyles, and chronic nondegenerative diseases such as arterial hypertension and diabetes mellitus.

Ischemic heart disease behaves differently in women than in men. In women, symptoms tend to be different in intensity and location and sometimes more subtle; the rate of obstructive lesions in the coronary vessels is lower and there is greater morbidity and less recovery after infarction.4-6

The present study shows the main epidemiological and health characteristics of patients admitted with acute myocardial infarction (AMI), from a sample of patients obtained over 5 years. Its objective is to provide a demographic and clinical description (including evolution and outcome) of this population that can also be compared with similar data from their male counterparts in subsequent studies or with what has already been recorded.2,5

To the best of our knowledge, this is the first investigation of its kind in Costa Rica.

Method

This was an observational, descriptive, retrospective study, covering a total period of 5 years (2011 to 2015), in which all patients with the diagnosis of AMI admitted during that time period were selected from the Intensive Care Unit (ICU) database. The database contains clinical and epidemiological information on the patients, including their evolution, complications, outcome, and procedures performed. The rest of the information required was obtained by consulting the patients’ clinical records.

Of the 190 patients diagnosed with AMI during this five-year period, we were able to collect complete information on 54 of them. This was an observational, descriptive, retrospective study, covering a total period of 5 years (2011 to 2015), in which all patients with the diagnosis of AMI admitted during that time period were selected from the Intensive Care Unit (ICU) database.

The database contains clinical and epidemiological information on the patients, including their evolution, complications, outcome, and procedures performed. The rest of the information required was obtained by consulting the patients’ clinical records.

Of the 190 patients diagnosed with AMI during this five-year period, we were able to collect complete information on 54 of them.

The information collected included demographic data, personal pathological history, symptoms, and signs of infarction, electrocardiographic, echocardiographic, and coronary angiographic findings, hospital stay, and mortality.

The statistical analysis was quantitative and descriptive and was performed with the SPSS v.21 software (IBM Corp., USA) and consisted of calculating frequency values, central tendency (mean, mode and median), measures of variability of range, percentiles, and chi-square as the main inferential statistical test.

Results

Of the 190 patients with a diagnosis of AMI admitted to the hospital during the study period, 34 died before hospital discharge and were therefore excluded from the analysis, and of the remaining 56, it was only possible to recover complete clinical information for 54 of them, who were finally included in the study.

The average age of the patients was 60 years with a range from 30 to 87 years and a mortality of 17.9%. Table 1 summarizes the main characteristics of the population.

Table No 1. General characteristics of the population of women with AMI, Intensive Care Unit, 2011-2015. n=54 patients 

Table 2 summarizes the main symptomatic manifestations and physical signs that were considered most relevant at the time of admission for the diagnosis of infarction in the case of patients already hospitalized for another cause. Chest pain was the most common symptom and was present in 89% of the patients likewise, half of the patients presented with arterial hypertension while 37% presented with hypotension (systolic arterial pressure < 90 mmHg) or circulatory collapse.

Table No 2. Symptoms and clinical signs of presenting infarction, 2011-2015. n=54 patients 

Regarding electrocardiographic findings, 34 patients (63%) of the patients presented with STsegment elevation infarction, but another 5 (9%) of them presented with ventricular fibrillation. Twelve patients (22%) presented with ST-segment elevation and 3 patients (5.5%) had bradyarrhythmias or atrioventricular block. From the point of view of electrical localization, 23 patients (42%) had anterior infarction, 19 (35%) inferior infarction, 11 (20%) lateral infarction, and only one right ventricular infarction.

Regarding the results of the use of thrombolytic therapy (specifical streptokinase) and its clinical efficacy in resolving myocardial ischemia, 37 patients (69%) were not thrombolysis versus 17 (31%) who were. Thrombolysis was effective in 3 patients. When the door-to-needle time (i.e., the time elapsed between the patient’s admission to the emergency department and the start of thrombolytic infusion) was considered, 9 patients were thrombolysis between the first 61 minutes to 60 hours, 4 of them were thrombolysis between the first 6 to 12 hours, 3 others between 12 to 24 hours and only one after 24 hours of symptom onset. All thrombolysis patients underwent angioplasty.

Table 3 shows the data collected through coronary angiography regarding the location of the culprit lesion, and the presence and location of other clinically important vascular lesions. It also shows the result of the angiography, i.e., how many were only diagnostic without intervention, how many were accompanied by balloon angioplasty, and how many intracoronary stents were placed. As in the previous table, we included information on the time elapsed since the patient was admitted to the emergency department or diagnosed with in-hospital AMI and taken to the catheterization laboratory. This time is known as door-to-balloon time.

Table No.3 Patients undergoing angioplasty with and without intravascular stenting, 2011-2015. n=54 patients 

In addition, the coronary vessel considered to be the culprit of the infarction, the total number of vessels in which obstructive and luminographically significant atherosclerotic lesions were found (lesions that obstruct the coronary lumen by more than 50%) and the number of vessels intervened (some patients had 2 or more stents placed) during the same angiographic intervention are detailed.

Multivessel disease was found to be present in most patients, with an average of 2 lesions per patient,with 30% of patients having 2-vessel disease and 18% having 3-vessel disease or involvement of the left main coronary artery.

A total of 37 stents were placed and only one of them was unmedicated (“bare metal”). Table 4 summarizes the main mechanical and non-mechanical complications of infarction in patients.

Table No.4 Main mechanical and non-mechanical complications of AMI in women, 2011-2015 n=54 patients 

Two of the patients were rushed to cardiac surgery because of the severity of the lesions.

At discharge, transthoracic echocardiography was performed in 32 of the patients and showed that 16 (50%) of them had an ejection fraction (EF) of 40-59%, 10 (31%) had an EF between 21-39%, 3 patients had an EF greater than 60% and 3 patients had an EF of 20% or less.

Discussion

As reported in the world literature,3,7 the patients who are infarcted are relatively young -practically – of them are under 70 years of ageand although most of them certainly had a good inhospital evolution judging by the length of stay, need for surgery, and mechanical and non-mechanical complications. However, according to our ICU database, their mortality rate was 6 points higher than that of men admitted with the same diagnosis and in the same period (17.9% in women vs. 12% in men) and nearly 1 in 6 did not survive the infarction.

Comparatively speaking, only 1 in 8 men died of AMI during the same study period. Conspicuously similar findings have been described in the international literature, for example, Wells3 explains that from 1979 to 2011 infarct mortality in men decreased by 17%, whereas in women it decreased by only 2.5%.

The specific reasons for the higher mortality in women merit a new study aimed at investigating this issue.

On the other hand, it should be noted, as always, that smoking is, after arterial hypertension, the main risk factor for ischemic heart disease. With these data, it is feasible to repeat this observation in the future in the hope that the new anti-smoking measures will improve these numbers (Law 9028, General Law for the Control of Tobacco and its Harmful Effects on Health, of 2012).8

In this study, there was no record of a true atypical presentation of infarction in women, although the correct term instead of atypical is different from that expected in men. Typical” chest pain was the cardinal manifestation in almost 90% of the patients, whereas, despite the high rate of diabetic patients, there was only one case of silent infarction. It has been described that one of the causes of increased mortality of AMI in women is the delay in treatment due to the different presentation of symptoms,3,4,7,9 here this does not seem to have greater weight because the clinical presentation turned out to be quite like the classic description of the manifestations of myocardial ischemia.

Electrocardiographic findings showed that, as in men, anterior infarction was the most frequent but closely followed by inferior infarction. Coronary angiography found obstructive findings compatible with the electrical localization of the area of ischemia in most cases, demonstrating that electrocardiographic topography is precise, although not always accurate.

Both pharmacological and mechanical coronary reperfusion strategies were applied late.10-12 Streptokinase was administered to a few patients and to almost half of them after 6 hours of symptom onset; this is one of the reasons why its success rate was so low. Although most patients were taken for angioplasty, only 35% were taken before 12 hours, thus missing the best window of opportunity. There was no statistically significant relationship between door-to-balloon time and mortality, but these late openings could explain why 41% of patients were discharged with an ejection fraction of less than 40% (“time is muscle”).

Women with ST-elevation AMI have a higher short- and long-term mortality than men but seem to do better, at least in the short term, with thrombolytic therapy11, with the caveat that there are no studies with streptokinase. Perhaps it would be better to favor the use of direct-acting thrombolytics over angioplasty in women, to improve mortality and reduce morbidity.

It has been described that the distribution and effect of coronary plaques differs according to sex, with about 60% of symptomatic women having no obstructive lesions found on angiography. 4,12-15 In our case, the presence of significant lesions was much higher due to the use of a small sample affected by detection bias and is not a true statistical finding.

On the other hand, Smilowitz et al.14 in a study of autopsies, found 16% of patients who died of AMI to have significant lesions in 2 vessels and 20% of patients with significant lesions in 3 vessels (for this study, 75% of coronary artery obstruction was considered severe). When comparing these findings with the results of this sample, the incidence of obstructive lesions in 2 vessels is very high and reflects a more severe degree of ischemic heart disease.

In conclusion, female patients with AMI not only have a higher mortality than their male counterparts, but also have severe coronary artery disease. And although their ischemic symptoms were very clear and patent, they received reperfusion treatment, both pharmacological and mechanical, late according to ischemic disease management guidelines, which probably contributed to higher mortality and greater loss of viable myocardial tissue.

Abbreviations: AMI: Acute myocardial infarction. ICU: Intensive Care Unit Sources of support: No sources to declare.

Conflicts of interest: There are no conflicts of interest to declare. dasscom@gmail.com

Referencias

1. Ministerio de Salud. Análisis de Situación de Salud Costa Rica 2014. Dirección de Vigilancia en Salud, editor. Ministerio de Salud de Costa Rica. San José: Ministerio de Salud de Costa Rica; 2014. 1-193 p. [ Links ]

2. Rojas, M., Castellanos, F., Marín, C., Bustamante, X., Montiel, H. F. Salud de las mujeres en Costa Rica, un análisis desde la perspectiva de género. San José: OPS MINSA; 2005. [ Links ]

3. Wells M, Kalman M. Women & heart disease: Symptoms and treatment guidelines. Nurse Pract. 2011;36(9):22-7. [ Links ]

4. Aggarwal NR, Patel HN, Mehta LS, Sanghani RM, Lundberg GP, Lewis SJ, et al. Sex Differences in Ischemic Heart Disease: Advances, Obstacles, and Next Steps. Circ Cardiovasc Qual Outcomes. 2018;11(2):1-14. [ Links ]

5. Brewer LPC, Svatikova A, Mulvagh SL. The challenges of prevention, diagnosis and treatment of ischemic heart disease in women. Cardiovasc Drugs Ther. 2015;29(4):355-68. [ Links ]

6. Garcia M, Mulvagh SL, Merz CNB, Buring JE, Manson JAE. Cardiovascular disease in women: Clinical perspectives. Circ Res. 2016;118(8):1273-93. [ Links ]

7. George J, Rapsomaniki E, Pujades-Rodriguez M, Shah AD, Denaxas S, Herrett E, et al. How does cardiovascular disease first present in women and men? Circulation. 2015;132(14):1320-8. [ Links ]

8. Burke GM, Genuardi M, Shappell H, D’Agostino RB, Magnani JW. Temporal Associations Between Smoking and Cardiovascular Disease, 1971 to 2006 (from the Framingham Heart Study). Am J Cardiol (Internet). 2017;120(10):1787-91. Available from: https:// doi.org/10.1016/j.amjcard.2017.07.087 [ Links ]

9. Gehrie ER, Reynolds HR, Chen AY, Neelon BH, Roe MT, Gibler WB, et al. Characterization and outcomes of women and men with non- ST-segment elevation myocardial infarction and nonobstructive coronary artery disease: Results from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early . Am Heart J (Internet). 2009;158(4):688-94. Available from: http:// dx.doi.org/10.1016/j.ahj.2009.08.004 [ Links ]

10. McSweeney JC, Rosenfeld AG, Abel WM, Braun LT, Burke LE, Daugherty SL, et al. Preventing and experiencing ischemic heart disease as a woman: State of the science: A scientific statement from the American Heart Association. Circulation. 2016;133(13):1302-31. [ Links ]

11. Ashley KE, Geraci SA. Ischemic heart disease in women. South Med J. 2013;106(7):427-33. [ Links ]

12. Sharaf B, Wood T, Shaw L, Johnson BD, Kelsey S, Anderson RD, et al. Adverse outcomes among women presenting with signs and symptoms of ischemia and no obstructive coronary artery disease: Findings from the National Heart, Lung, and Blood Institute-sponsored Women’s Ischemia Syndrome Evaluation (WISE) angiographic core lab. Am Heart J (Internet). 2013;166(1):134-41. Available from: http:// dx.doi.org/10.1016/j.ahj.2013.04.002 [ Links ]

13. Quyyumi AA. Women and ischemic heart disease: Pathophysiologic implications from the Women’s Ischemia Syndrome Evaluation (WISE) study and future research steps. J Am Coll Cardiol (Internet). 2006;47(3 SUPPL.):S66-71. Available from: http://dx.doi.org/10.1016/j.jacc.2004.11.075 [ Links ]

14. Smilowitz NR, Sampson BA, Abrecht CR, Siegfried JS, Hochman JS, Reynolds HR. Women have less severe and extensive coronary atherosclerosis in fatal cases of ischemic heart disease: An autopsy study. Am Heart J (Internet). 2011;161(4):681-8. Available from: http://dx.doi.org/10.1016/j.ahj.2010.12.022 [ Links ]

15. Pepine CJ, Ferdinand KC, Shaw LJ, Light- McGroary KA, Shah RU, Gulati M, et al. Emergence of Nonobstructive Coronary Artery Disease: A Woman’s Problem and Need for Change in Definition on Angiography. J Am Coll Cardiol. 2015;66(17):1918-33. [ Links ]

Received: January 13, 2021; Accepted: August 09, 2021

Creative Commons License Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons