Faculty of Medicine

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Sex Differences in Heart Failure Following Acute Coronary Syndromes
(Elsevier BV, 2023-05)
Cenko, Edina
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Manfrini, Olivia
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Yoon, Jinsung
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van der Schaar, Mihaela
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Bergami, Maria
BACKGROUND There have been conflicting reports regarding outcomes in women presenting with acute coronary syndrome (ACS).OBJECTIVES The objective of the study was to examine sex-specific differences in 30-day mortality in patients with ACS and acute heart failure (HF) at the time of presentation.METHODS This was a retrospective study of patients included in the International Survey of Acute Coronary Syndromes (ISACS Archives-NCT04008173). Acute HF was defined as Killip classes $2. Participants were stratified according to ACSpresentation: ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS). Differences in 30-day mortality and acute HF presentation at admission between sexes were examined using inverse propensity weighting based on the propensity score. Estimates were compared by test of interaction on the log scale. RESULTS A total of 87,812 patients were included, of whom 30,922 (35.2%) were women. Mortality was higher in women compared with men in those presenting with STEMI (risk ratio (RR): 1.65; 95% CI: 1.56-1.73) and NSTE-ACS (RR:1.18; 95% CI: 1.09-1.28; P interaction < 0.001). Acute HF was more common in women when compared to men with STEMI(RR: 1.24; 95% CI: 1.20-1.29) but not in those with NSTE-ACS (RR: 1.02; 95% CI: 0.97-1.08) (P interaction < 0.001). The presence of acute HF increased the risk of mortality for both sexes (odds ratio: 6.60; 95% CI: 6.25-6.98).CONCLUSIONS In patients presenting with ACS, mortality is higher in women. The presence of acute HF at hospital presentation increases the risk of mortality in both sexes. Women with STEMI are more likely to present with acute HFand this may, in part, explain sex differences in mortality. These findings may be helpful to improve sex-specific personalized risk stratification. (JACC Adv 2023;-:100294) © 2023 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open-access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/) (14) (PDF) Sex Differences in Heart Failure Following Acute Coronary Syndromes. Available from: https://www.researchgate.net/publication/370306869_Sex_Differences_in_Heart_Failure_Following_Acute_Coronary_Syndromes [accessed Jun 23, 2023].
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Sex differences and disparities in cardiovascular outcomes of COVID-19
(Oxford University Press (OUP), 2023-01-18)
Bugiardini, Raffaele
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Nava, Stefano
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Caramori, Gaetano
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Yoon, Jinsung
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Badimon, Lina
Background Previous analyses on sex differences in case fatality rates at population-level data had limited adjustment for key patient clinical characteristics thought to be associated with COVID-19 outcomes. We aimed to estimate the risk of specific organ dysfunctions and mortality in women and men. Methods and Results This retrospective cross-sectional study included 17 hospitals within 5 European countries participating in the International Survey of Acute Coronavirus Syndromes (ISACS) COVID-19(NCT05188612). Participants were individuals hospitalized with positive SARS-CoV-2 from March 2020 to February 2022. Risk-adjusted ratios(RR) of in-hospital mortality, acute respiratory failure(ARF), acute heart failure(AHF), and acute kidney injury(AKI) were calculated for women versus men. Estimates were evaluated by inverse probability of weighting and logistic regression models. The overall care cohort included 4,499 patients with COVID-19 associated hospitalizations. Of these, 1,524(33.9%) were admitted to ICU, and 1,117(24.8%) died during hospitalization. Compared with men, women were less likely to be admitted to ICU (RR:0.80; 95%CI: 0.71–0.91). In general wards (GW) and ICU cohorts, the adjusted women-to-men RRs for in-hospital mortality were of 1.13(95%CI: 0.90–1.42) and 0.86(95%CI: 0.70–1.05; pinteraction=0.04). Development of AHF, AKI and ARF was associated with increased mortality risk (ORs: 2.27; 95%CI; 1.73–2.98,3.85; 95%CI:3.21–4.63 and 3.95; 95%CI:3.04–5.14, respectively). The adjusted RRs for AKI and ARF were comparable among women and men regardless of intensity of care. By contrast, female sex was associated with higher odds for AHF in GW, but not in ICU (RRs:1.25; 95%CI0.94–1.67 versus 0.83; 95%CI:0.59–1.16, pinteraction=0.04). Conclusions Women in GW were at increased risk of AHF and in-hospital mortality for COVID-19 compared with men. For patients receiving ICU care, fatal complications including AHF and mortality appeared to be independent of sex. Equitable access to COVID-19 ICU care is needed to minimize the unfavourable outcome of women presenting with COVID-19 related complications.
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COVID-19 and acute heart failure among patients with cancer
(Oxford University Press (OUP), 2022-10-01)
Bergami, M
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Fabin, N
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Mjehovic, P
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Pasalic, M
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Scarpone, M
Background: Patients with cancer represent a uniquely vulnerable population not only with higher susceptibility to COVID-19 but also at increased risk for death. However, detailed information on causes of death and the contribution of pre-existing health conditions to death yet is missing. Purpose: This study focuses on the implications of COVID-19 in the cardiovascular health of patients with cancer by assessing the relation between cancer and de novo acute heart failure (AHF) with in-hospital mortality. Methods: The initial population consisted of 3968 patients included in the ISACS COVID-19 registry between March 2020 and February 2022. Of these, 546 patients with chronic HF were excluded, leaving a final population of 3422. Patients were divided in two groups according to the presence or absence of a cancer diagnosis at the time of hospitalization for COVID- 19. Primary outcomes were incidence of in-hospital mortality or AHF during hospitalization. Association between cancer and outcomes was estimated using multivariable logistic regression analyses. Subsidiary analysis was conducted to evaluate differences between patients with prior vs active cancer. Results: Of the 3422 patients included in the study, 468 patients had cancer (8.2% active, 5.5% past cancer). Cancer patients were older (68.9±13.4 vs 63.3±15.6, p-value <0.001) and more likely to be female (50.4% vs 39.1%, p-value <0.001). They presented more frequently with a history of chronic obstructive pulmonary disease (12.3% vs 7.6%, p-value = 0.001). When considering outcomes, cancer patients had a significantly higher incidence of in-hospital mortality (27.7% vs 19.2%; p-value <0.001). This despite the presence of a numerically higher mean PiO2/FiO2 (281±108.8 vs 267.05±122.5, p-value = 0.11) on admission and a lower rate of X-ray findings of interstitial pneumonia (60% vs 70.5%, p-value <0.001) than their non-oncological counterparts, as well as similar use of mechanical ventilation (30.6% vs 35.0%, p value=0.14). The association between cancer and death persisted when adjusting for demographic, laboratory findings and in-hospital treatment (OR: 1.46; 95% CI: 1.11–1.94; p value=0.01). Cancer patients also had higher rates of AHF (9.6% vs 4.7%, p-value <0.001) during hospitalization. This association was independent from presence of cardiovascular risk factors or comorbidities (OR: 1.61; 95% CI: 1.07–2.43; p value=0.02). When restricting the analysis to the cancer population, AHF appeared to be significantly associated with death (OR: 2.41; 95% CI 1.18– 4.95; p-value = 0.01), but this correlation persisted only in patients affected by active cancer in age and sex adjusted analyses (OR: 4.27; 95% CI: 1.51–12.07; p value=0.01 vs 1.20; 95% CI: 0.38–3.76; p-value = 0.75). Conclusions: The incidence of AHF in cancer patients with COVID-19 is high. Patients with active cancer are also at high risk for mortality. This has implications for cardiac monitoring and chemotherapy administration during COVID-19.
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Prognostic value of brain natriuretic peptide in COVID-19 with or without acute heart failure
(Oxford University Press (OUP), 2022-10-01)
Bergami, M
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Manfrini, O
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Cenko, E
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Dorobantu, M
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Background: Although Brain Natriuretic Peptide (BNP) provides strong prognostic information of an unfavorable outcome in patients with acute heart failure (AHF), there is little information of its relevance as a biomarker for outcomes in COVID-19 and its complications Purpose: To evaluate the association of increased BNP levels with complications and in-hospital mortality in a cohort of hospitalized COVID-19 patients. Methods: The study included COVID-19 patients with data on BNP levels included in the ISACS COVID-19 registry. The population was categorized according to the presence of peak BNP levels ≥100 pg/mL during hospitalization. Primary outcomes included in-hospital mortality, AHF or acute respiratory failure (ARF, defined as PiO2/FiO2<300 mmHg or need for mechanical ventilation). Calculations were conducted using age and sex-adjusted multivariable logistic regression analyses. Results were also stratified according to presence or absence of cardiovascular disease (CVD) history. Differences between subgroups were verified for statistical significance using test for interaction. Results: Of the 1152 patients included in the study, 615 (53.4%) had elevated BNP levels. These subjects were older (69.9±13.8 vs 59.1±16.8, p-value<0.001), had higher rates of cardiovascular risk factors (82.9% vs 57.7%, p-value<0.001) and presented more frequently with a prior history of CVD (either ischemic heart disease, cerebrovascular disease, venous thromboembolism, atrial fibrillation or a history of revascularization) (50.1% vs 27.5%, p-value<0.001). No sex differences were observed. When considering outcomes, BNP levels ≥100 pg/mL were associated with increased rates of in-hospital mortality (32.9% vs 4.9%, p-value<0.001), even after adjustment for demographic characteristics (OR: 7.35; 95% CI: 4.75–11.40; p-value<0.001). High BNP levels were also strongly associated with an increased risk of AHF (OR 19.9; 95% CI 8.6–45.9; pvalue< 0.001), a correlation that persisted both in patients with and without a prior CVD history (p for interaction=0.29). Of note, patients with elevated BNP also had a higher likelihood of developing ARF (OR 2.7; 95% CI 2.1– 3.6; p-value<0.001), even in absence of AHF (OR 3.00; 95% CI 2.20–4.1; p-value<0.001). Conclusions: In COVID-19, blood BNP level not only appears to be a predictor of in-hospital mortality and AHF but was also independently associated with an increased risk of ARF. This finding supports the routine use of BNP in all patients admitted to the hospital for COVID-19, regardless of a prior history of CVD.

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