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A Closer Look at MI Among Younger Women

A Closer Look at MI Among Younger Women

Over time, the frequency of myocardial infarction (MI) in the United States has been declining overall as improvements have been made with regard to medical therapy for coronary artery disease. Although there has been a decline in the rate of ST-elevation MI (STEMI) in those aged 55 and older, the rate has remained steady in patients younger than 55 and among younger women. “Studies have shown that it’s harder to recognize the signs of MI in women,” says Luke Kim, MD, FACC, FSCAI. “Previous analyses indicate that women tend to receive less aggressive treatment than men.” Analyzing Disparities In a study presented at the Society for Cardiovascular Angiography and Interventions 2014 Scientific Sessions, Dr. Kim and colleagues analyzed data on about 13,000 women and more than 42,000 men aged 55 and younger who were hospitalized with an acute MI from 2007 to 2011 using the Nationwide Inpatient Sample database. The authors looked at temporal trends in MI as well as adverse in-hospital outcomes to compare findings by gender. The researchers observed a slight decline in the number of MIs among younger women between 2007 and 2009 but little change after that. Women had more preexisting health problems than men, including diabetes, hypertension, kidney disease, peripheral vascular disease, congestive heart failure, and obesity. Women were also more likely than men to have non-STEMIs. The study by Dr. Kim and colleagues also revealed that there were disparities in the treatment of MI. “Women who suffered an MI were far less likely than men to be treated with PCI or CABG surgery,” explains Dr. Kim. “They were also more likely to face...
UA/NSTEMI: A Guideline Update

UA/NSTEMI: A Guideline Update

Following the recent FDA approval of new medications to reduce cardiovascular death and heart attack in patients with acute coronary syndromes (ACS) and developments in the literature, the American College of Cardiology (ACC) and American Heart Association (AHA) released a focused update to 2007 guidelines on the management of patients with unstable angina (UA)/NSTEMI. The update, published in Circulation, focuses on how antiplatelets and anticoagulants fit into management algorithms for ACS. Key Updates to UA/NSTEMI Guidelines An important change in the ACC/AHA guideline update is that ticagrelor is now considered a treatment option for UA/NSTEMI patients, joining clopidogrel and prasugrel. “We recommend that when aspirin is given with ticagrelor for maintenance therapy, a low dose of aspirin (81 mg) should be used after the initial loading dose,” says Jeffrey L. Anderson, MD, FACC, FAHA, co-author of the guidelines. “Research shows that a high dose of aspirin appears to reduce the benefits of ticagrelor.” Aspirin remains a first-line therapy for managing patients with UA/NSTEMI. “When these patients arrive at the hospital, they should receive aspirin and an anticoagulant,” says Dr. Anderson. “Clinicians should then decide upon a second antiplatelet agent before angiography to define coronary anatomy. Clopidogrel, ticagrelor, or an intravenous glyco­protein IIb/IIIa agent are acceptable options. At or after coronary stenting, prasugrel becomes an additional option.” For patients receiving medical therapy only, the ACC/AHA guidelines recommend antiplatelet therapy with ticagrelor or clopidogrel, in addition to aspirin. Several changes were made in the guideline update regarding patients with renal insufficiency. “It’s important to assure that these patients are well hydrated if they’re going to the cath lab and that they...
Interpreting Troponin Tests: Coming to a New Consensus

Interpreting Troponin Tests: Coming to a New Consensus

Since its introduction in the early 1990s, cardiac troponin testing has been predominantly used to diagnose or rule out myocardial infarction (MI) in patients with possible symptoms of MI. However, it has become clear that a positive troponin indicates that cardiac injury has occurred, but it is not specific for the etiology of the injury. “Experience with troponin testing has also showed that higher levels identify patients at greater risk for adverse events, regardless of the clinical setting (eg, MI, heart failure, or non-cardiac etiologies),” explains L. Kristin Newby, MD, MHS, FACC, FAHA. “However, more recent studies have raised questions about cardiac troponin cutoffs that should be used for diagnostic and prognostic interpretations and the particular importance of the clinical context in making those interpretations.” In the Journal of the American College of Cardiology, Dr. Newby and colleagues from seven professional societies, led by the American College of Cardiology, released a consensus statement to help clinicians determine when to order troponin testing and how to interpret results. The document provides a framework for clinicians to interpret results of troponin testing in a useful mechanism-based construct. Key Recommendations on Troponin Testing According to the consensus statement, physicians should adopt the definition of MI that was recently updated in order to fully understand the implications of elevated troponin levels. “The universal definition of MI, which was updated in 2012, is important because it provides a standard framework in which to apply troponin testing for a diagnosis of MI and emphasizes not only troponin levels, but also the importance of clinical symptoms of MI,” Dr. Newby says. In addition, the consensus statement...

Heart Attack Patients Not Receiving Evidence-Based Treatment

Among patients with acute myocardial infarction, a large analysis has found that four variables appear to be significantly associated with greater adherence in at least four of six treatment adherence measures. These variables include: Hypertension. Hyperlipidemia. Treatment in a hospital with full interventional capabilities. Calendar year. Age, female sex, congestive heart failure, chronic renal insufficiency, atrial fibrillation, and chronic dialysis were associated with worse adherence. Abstract: American Journal of Medicine, January...

Optimizing Chest Pain Diagnoses in the ED

An estimated 8 million people present to EDs in the United States with chest pain each year, 15% to 25% of whom receive a diagnosis of acute coronary syndrome (ACS). Of this group, between 2% and 5% are discharged home without an ACS diagnosis but receive one within 30 days. Due to a fear of missing this subset of patients, many people presenting to the ED with chest pain are unnecessarily admitted to the hospital for observation and further investi­gation. These cases can clog EDs, increase the likelihood of unneeded testing, and increase healthcare costs (see also, A New Look at Leaving Without Being Seen in EDs). Algorithm to Manage Chest Pain Put to the Test My colleagues and I in the department of emergency medi­cine collaborated with the cardiology and nuclear medicine departments at our hospital. We developed an algorithm designed to streamline approaches for managing patients with potential cardiac chest pain. Our algorithm was evaluated in a study published in the April 2012 Annals of Emergency Medicine. With the algorithm, patients who presented to the ED with chest pain underwent a full history and physical examina­tion, along with EKG and biomarker testing. Patients with high-risk clinical features (eg, worsening angina or an EKG suspicious for ischemia or positive troponins) were referred to the cardiology department immediately. The remainder of patients had tests repeated at both 2 and 6 hours. Those who developed new pain, had ongoing pain, had changes on EKG, or had subsequent positive troponin levels were referred to the cardiology department as well. If patients did not have high-risk clinical features, had a normal EKG,...
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