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Sex is an important factor associated with pulmonary embolism (PE) disease presentation and outcomes, which may be related to pathobiological, social, and treatment-based differences. We are seeking to illuminate sex differences in pulmonary embolism presentation, care, and outcomes using an international registry and a national US database of people 65 years and older, the age group in which the majority of these events occur.The Sex Differences in PrEsentation, Risk Factors, Drug and Interventional Therapies, and OUtcomes of Elderly PatientS with Pulmonary Embolism (SERIOUS-PE) study has been designed to address knowledge gaps in this area. This study will use data from the Registro Informatizado Enfermedad TromboEmbolica (RIETE) registry and the US Medicare Fee-For-Service beneficiaries. RIETE is a large international registry of patients with venous thromboembolism with data collected on PE presentation, risk factors, co-morbidities, drug and interventional therapies, as well as 30-day and 1-year outcomes (including recurrent VTE, major bleeding, and mortality). Data from US Medicare Fee-For-Service beneficiaries will be used to understand the sex differences in PE hospitalizations, advanced therapies, and outcomes at 30-day and 1-year follow-up. Assessment of outcomes in both databases will be performed in unadjusted models, as well as those adjusted for demographics, co-morbidities, and treatments, to understand whether the potential sex differences in outcomes are related to differences in risk factors and co-morbidities, potential disparities in treatment, or a plausible biological difference in women versus men. Linear trends will be assessed over time.RIETE data from March 2001 through March 2021 include 33,462 elderly patients with PE, of whom 19,294 (57.7%) were women and 14,168 (42.3%) were men. In the Medicare Fee-For-Service database, between January 2001 and December 31, 2019, 1,030,247 patients were hospitalized with a principal discharge diagnosis of PE, of whom 599,816 (58.2%) were women and 430,431 (41.8%) were men.Findings from the SERIOUS-PE study will help address important knowledge gaps related to sex differences in presentation and risk factors, treatment patterns, and outcomes of older adults with PE. The results may guide changes in prognostic prediction rules based on sex-specific findings, identify sex-based disparities in care delivery that should be addressed by quality improvement, or uncover potential differences in response to available therapies that warrant testing in dedicated randomized trials.

Data on depression and stress among patients with spontaneous coronary artery dissection (SCAD) are limited. Using data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study, which prospectively enrolled 3,572 acute myocardial infarction (AMI) patients between 18 and 55 years of age, we identified 67 SCAD cases. We compared Patient Health Questionnaire-9 (PHQ-9) and 14-item Perceived Stress Scale (PSS-14) scores obtained at baseline, 1 month, and 12 months between SCAD and AMI of all other causes. Using longitudinal linear mixed-effects analysis, we compared depression and stress scores between SCAD and other AMI, adjusting for time and selected covariates. Patients with SCAD had lower baseline PHQ-9 scores (6.1 ± 6.0 vs 7.7 ± 6.4 for other patients with AMI, p = 0.03), similar 1-month scores, and lower 12-month scores (3.2 ± 4.3 vs 4.9 ± 5.5, p = 0.004). At baseline and 1 month, patients with SCAD had similar PSS-14 scores to those of other patients with AMI. At 12 months, patients with SCAD had lower scores (18.4 ± 8.8 vs 21.5 ± 9.3 for other patients with AMI, p = 0.009). After adjustment for cardiovascular risk factors, co-morbidities, and clinical acuity, no differences in PHQ-9 or PSS-14 scores remained between SCAD and other AMI. Similar results were obtained in a subgroup analysis of only women with SCAD and other AMI. In conclusion, patients with SCAD had a relatively lower burden of depression and perceived stress than other patients with AMI, potentially because of fewer co-morbidities and favorable socioeconomic factors. However, given high depression and stress burden in both SCAD and other patients with AMI, routine screening can help identify and treat these patients.

PURPOSE: Physical inactivity, a modifiable risk factor for cardiovascular disease, is independently associated with stroke. Though some prior data have suggested sex differences in levels of physical activity, whether there are sex differences in the role of physical activity in primary stroke prevention is largely unknown. Our objective was to conduct a systematic review to identify and describe recent findings on sex differences in the association between physical activity and incident (first-ever) stroke. We also aimed to describe current evidence for the strength of association between physical activity and reduced stroke risk in women in particular. METHODS: Using a pre-specified search strategy, we searched PubMed/MEDLINE and Cochrane Central to identify observational studies or trials from 2000 to 2020 reporting sex differences in physical activity and incident stroke. To be included, among other criteria, studies had to include sex-specific effect estimates for women, men, or both. Authors screened titles, abstracts, and full-text articles to identify papers meeting criteria, and study authors abstracted adjusted sex-specific estimates of the association between physical activity and incident stroke for total stroke (ischemic plus hemorrhagic) or ischemic stroke. FINDINGS: Thirty-seven studies met inclusion criteria. For total incident stroke (ischemic and hemorrhagic combined), 17 of those included both women and men. Among these 17 papers, 7 (41%) showed similar associations between physical activity and incident stroke between women and men, 6 (35%) of studies suggested a significant effect in women but not in men, and 3 (18%) of studies showed a significant effect in men but not in women. For ischemic stroke, of 10 papers including women and men, 5(50%) suggested similar effects in women and men, 4(40%) suggested a significant effect in women but not in men, and 1(10%) showed an effect in men but not women. For women specifically, the majority of included studies demonstrated a reduced risk of incident stroke with physical activity with relative risk reductions ranging from 11% to 72%, though most estimates fell between 20% and 40%. IMPLICATIONS: The majority of studies indicated a clear association between physical activity and reduction of stroke risk. Studies were split as to the potential for sex differences in this association. This should be further investigated prospectively to identify strategies for the use of increased physical activity for the primary stroke prevention, with sex-specific considerations as warranted. The sex-specific dose response relationship between physical activity and stroke risk is inconclusive and warrants more research.

BACKGROUND: Clinicians make a medical diagnosis by recognizing diagnostic possibilities, often using memories of prior examples. These memories, called exemplars, reflect specific symptom combinations in individual patients, yet most clinical studies report how symptoms aggregate in populations. We studied how symptoms of acute myocardial infarction combine in individuals as symptom phenotypes and how symptom phenotypes are distributed in women and men. METHODS: In this analysis of the SILVER-AMI Study, we studied 3041 patients (1346 women and 1645 men) ≥75 years old with acute myocardial infarction. Each patient had a standardized in-person interview during the acute myocardial infarction admission to document the presenting symptoms, which enabled a thorough examination of symptom combinations in individuals. Specific symptom combinations defined symptom phenotypes and distributions of symptom phenotypes were compared in women and men using Monte Carlo permutation testing and repeated subsampling. RESULTS: There were 1469 unique symptom phenotypes in the entire SILVER-AMI cohort of acute myocardial infarction patients. There were 831 unique symptom phenotypes in women, as compared with 819 in men, which was highly significant, given the larger number of men than women in the study (p

AimsLittle is known about the relationship between marital/partner status and patient-reported outcome measures (PROMs) following myocardial infarction (MI). We conducted a systematic review/meta-analysis and explored potential sex differences.Methods and resultsWe searched five databases (Medline, Web of Science, Scopus, EMBASE, and PsycINFO) from inception to 27 July 2022. Peer-reviewed studies of MI patients that evaluated marital/partner status as an independent variable and reported its associations with defined PROMs were eligible for inclusion. Results for eligible studies were classified into four pre-specified outcome domains [health-related quality of life (HRQoL), functional status, symptoms, and personal recovery (i.e. self-efficacy, adherence, and purpose/hope)]. Study quality was appraised using Newcastle–Ottawa Scale, and data were synthesized by outcome domains. We conducted subgroup analysis by sex. We included 34 studies (n = 16 712), of which 11 were included in meta-analyses. Being married/partnered was significantly associated with higher HRQoL {six studies [n = 2734]; pooled standardized mean difference, 0.37 [95% confidence interval (CI), 0.12–0.63], I2 = 51%} but not depression [three studies (n = 2005); pooled odds ratio, 0.72 (95% CI, 0.32–1.64); I2 = 65%] or self-efficacy [two studies (n = 356); pooled β, 0.03 (95% CI, −0.09 to 0.14); I2 = 0%]. The associations of marital/partner status with functional status, personal recovery outcomes, and symptoms of anxiety and fatigue were mixed. Sex differences were not evident due to mixed results from the available studies.ConclusionsMarried/partnered MI patients had higher HRQoL than unpartnered patients, but the associations with functional, symptom, and personal recovery outcomes and sex differences were less clear. Our findings inform better methodological approaches and standardized reporting to facilitate future research on these relationships.

Background: Marital stress is associated with worse cardiac outcomes in young adults (≤55 years) with acute myocardial infarction (AMI), but whether psychosocial factors mediate this association remains largely unknown. We conducted a mediation analysis to investigate whether marital stress worsened quality of life (QoL) after AMI by increasing the likelihood of depression or low social support. Methods: There were 1,037 married/partnered AMI survivors aged 18-55 years enrolled in the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study (2008-2012) (67% women, mean age 47 years). Marital stress was measured by the Stockholm Marital Stress Scale at 1 month post-AMI; categorized as absent/moderate or severe. Depression (Patient Health Questionnaire-9 score ≥10), low social support (ENRICHD Social Support Instrument score ≤3 on ≥2 items and total score ≤18), and cardiac-specific QoL (Seattle Angina Questionnaire) were assessed at 1 year post-AMI. Natural direct and indirect effects of marital stress, depression, and low social support on QoL were estimated by causal mediation analysis with bias-corrected bootstrapped confidence intervals. Baseline QoL, sex, age, race, and socioeconomic factors (education, income, employment, and insurance status) were entered as covariates in all models. Results: There was a statistically significant direct effect from severe marital stress to lower 1-year cardiac-specific QoL after adjusting for covariates ( Figure ). Low social support and depression mediated 14.7% and 11.1% of the total relationship between marital stress and QoL, respectively; however, only the mediating effect through low social support was statistically significant. Conclusion: Marital stress was significantly associated with worse 1-year cardiac-specific QoL, and this effect was partially mediated by low social support. Interventions to decrease marital stress that also screen and provide resources for social support may help to improve AMI outcomes.

Background Recovery from acute myocardial infarction (AMI) has been primarily understood in a narrow medical sense. For patients who survive, secondary prevention focuses largely on enhancing clinical outcomes. As a result, there is a lack of descriptive accounts of patients' experiences after AMI and little is known about how people go about the challenge of recovering from such an event. Objective We conducted a meta-synthesis of the available literature on qualitative accounts of patients' experiences after AMI. Methods We searched for relevant papers that were descriptive, qualitative accounts of participants' experiences after AMI across 4 electronic databases (April 2016). Using an adapted meta-ethnography approach, we analyzed the findings by translating studies into one another and synthesizing the findings from the studies. Results After a review of titles/abstracts, reading each article twice in full, and cross-referencing articles, this process resulted in 17 studies with 224 participants (48% women) aged 23 to 90 years. All participants provided a first-person account of an AMI within the 3-day to 25-year time frame. Two major themes emerged that characterized patients' experiences: navigating lifestyle changes and navigating the emotional reaction to the event-consisting of various subthemes. Conclusion Although AMI tends to be seen as a discrete event, participants are left with little professional guidance as to how to negotiate significant, and often discordant, psychosocial changes that have long-lasting effects on their lives, similar to persons with chronic illnesses but without research in place to figure out how to best support them.

Cognitive behavioural therapy for insomnia (CBT-I) is effective at treating chronic insomnia, yet in-person CBT-I can often be challenging to access. Prior studies have used technology to bridge barriers but have been unable to extensively assess the impact of the digital therapeutic on real-world patient experience and multidimensional outcomes. Among patients with insomnia, our aim is to determine the impact of a prescription digital therapeutic (PDT) (PEAR-003b, FDA-authorised as Somryst; herein called PDT) that provides mobile-delivered CBT-I on patient-reported outcomes (PROs) and healthcare utilisation.We are conducting a pragmatically designed, prospective, multicentre randomised controlled trial that leverages Hugo, a unique patient-centred health data-aggregating platform for data collection and patient follow-up from Hugo Health. A total of 100 participants with insomnia from two health centres will be enrolled onto the Hugo Health platform, provided with a linked Fitbit (Inspire 2) to track activity and then randomised 1:1 to receive (or not) the PDT for mobile-delivered CBT-I (Somryst). The primary outcome is a change in the insomnia severity index score from baseline to 9-week postrandomisation. Secondary outcomes include healthcare utilisation, health utility scores and clinical outcomes; change in sleep outcomes as measured with sleep diaries and a change in individual PROs including depressive symptoms, daytime sleepiness, health status, stress and anxiety. For those allocated to the PDT, we will also assess engagement with the PDT.The Institutional Review Boards at Yale University and the Mayo Clinic have approved the trial protocol. This trial will provide important data to patients, clinicians and policymakers about the impact of the PDT device delivering CBT-I on PROs, clinical outcomes and healthcare utilisation. Findings will be disseminated to participants, presented at professional meetings and published in peer-reviewed journals.NCT04909229.

IntroductionCognitive behavioral therapy for insomnia (CBT-I) is effective at treating chronic insomnia, yet in-person CBT-I can often be challenging to access. Prior studies have used technology to bridge barriers but have been unable to extensively assess the impact of the digital therapeutic on real-world patient experience and multi-dimensional outcomes. Among patients with insomnia, our aim is to determine the impact of a Prescription Digital Therapeutic (PDT) (PEAR-003b, FDA-authorized as Somryst; herein called PDT) that provides mobile-delivered CBT-I on patient-reported outcomes (PROs) and healthcare utilization.Methods and AnalysisWe are conducting a pragmatically designed, prospective, multi-center randomized controlled trial that leverages Hugo, a unique patient-centered health data-aggregating platform for data collection and patient follow-up from Hugo Health. A total of 100 participants with insomnia from two health centers will be enrolled onto the Hugo Health platform, provided with a linked Fitbit (Inspire 2) to track activity, and then randomized 1:1 to receive (or not) the PDT for mobile-delivered CBT-I (Somryst). The primary outcome is a change in the insomnia severity index score (ISI) score from baseline to 9-weeks post-randomization. Secondary outcomes include healthcare utilization, health utility scores, and clinical outcomes; change in sleep outcomes as measured with sleep diaries; and a change in individual PROs including depressive symptoms, daytime sleepiness, health status, stress, and anxiety. For those allocated to the PDT, we will also assess engagement with the PDT.Ethics and DisseminationThe Institutional Review Boards at Yale University and the Mayo Clinic have approved the trial protocol. This trial will provide important data to patients, clinicians, and policymakers about the impact of the PDT device delivering CBT-I on PROs, clinical outcomes, and healthcare utilization. Findings will be disseminated to participants, presented at professional meetings, and published in peer-reviewed journals.Trial Registration NumberNCT04909229Strengths and limitations of this studyThis is the first controlled study to examine the impact of a mobile-delivered, prescription digital therapeutic (PDT) delivering Cognitive Behavioral Therapy for Chronic Insomnia (i.e., PEAR-003b, FDA-authorized as Somryst) on real-world patients outcomes of care that includes a multi-dimensional analysis of patient benefit across guideline-recommended health domains (e.g., insomnia severity index) and healthcare utilization (e.g., emergency department visits).This randomized clinical trial will use Hugo, a novel patient-centered health data-aggregating platform for data collection and patient follow-up, which gathers and collates patient-reported outcomes, clinical outcomes, and healthcare utilization metrics for real-world patients with chronic insomnia. The participant has ownership over their data and contributes it to research.Future studies should focus on patients with chronic insomnia as well as co-morbid conditions such as major depression and whether sleep improvements can be sustained, particularly in the long-term.

Poorer health outcomes experienced by young women with acute coronary syndrome may be related to sex differences in the safety and efficacy of antiplatelet agents, such as clopidogrel. Polymorphisms in drug metabolism enzyme (cytochrome P450 [We used data from a combined cohort of 2272 patients (median age 49 years; 56% female) hospitalized for acute coronary syndrome. We examined interactions between sex andThe case-only analysis of 177 participants on clopidogrel at the time of presentation showed that the risk of an atherothrombotic event was greater in female carriers of theThis study highlights the need for an improved understanding of the role of sex-by-gene interactions in causing sex differences in drug metabolism.Les piètres résultats cliniques observés chez les jeunes femmes atteintes d’un syndrome coronarien aigu pourraient être liés à des différences entre les sexes en ce qui concerne l’innocuité et l’efficacité des antiplaquettaires, comme le clopidogrel. Le polymorphisme génétique des enzymes intervenant dans le métabolisme des médicaments (famille des cytochromes P450 [Nous avons utilisé les données d’une cohorte combinée de 2 272 patients (âge médian : 49 ans; 56 % de femmes) hospitalisés en raison d’un syndrome coronarien aigu. Nous avons examiné les interactions entre le sexe et les variants duL’analyse de cas de 177 participants prenant du clopidogrel au moment de leur admission à l’hôpital a montré que le risque d’événement athérothrombotique était plus élevé chez les femmes porteuses de l’allèle non fonctionnelCette étude fait ressortir la nécessité de mieux comprendre le rôle de l’interaction sexe-gène dans les différences entre les sexes relativement au métabolisme des médicaments.

Background: Sex differences in clinical characteristics and in-hospital outcomes among patients with non–ST-segment–elevation myocardial infarction have been described in Western countries, but whether these differences exist in China is unknown. Methods: We used a 2-stage random sampling design to create a nationally representative sample of patients admitted to 151 Chinese hospitals for non–ST-segment–elevation myocardial infarction in 2006, 2011, and 2015 and examined sex differences in clinical profiles, treatments, and in-hospital outcomes over this time. Multivariable logistic regression models adjusting for age or other potentially confounding clinical covariates were used to estimate these sex-specific differences. Results: Among 4611 patients, the proportion of women (39.8%) was unchanged between 2006 and 2015. Women were older with higher rates of hypertension, diabetes, and dyslipidemia. Among patients without contraindications, women were less likely to receive treatments than men, with significant differences for aspirin in 2015 (90.3% versus 93.9%) and for invasive strategy in 2011 (28.7% versus 45.7%) and 2015 (34.0% versus 48.4%). After adjusting for age, such differences in aspirin and invasive strategy in 2015 were not significant, but the difference in invasive strategy in 2011 persisted. The sex gaps in the use of invasive strategy did not narrow. From 2006 to 2015, a significant decrease in in-hospital mortality was observed in men (from 16.9% to 8.7%), but not in women (from 11.8% to 12.0%), with significant interaction between sex and study year ( P =0.023). After adjustment, in-hospital mortality in women was significantly lower than men in 2006, but not in 2011 or 2015. Conclusions: Sex differences in cardiovascular risk factors and invasive strategy after non–ST-segment–elevation myocardial infarction were observed between 2011 and 2015 in China. Although sex gaps in in-hospital mortality were largely explained by age differences, efforts to narrow sex-related disparities in quality of care should remain a focus. Registration: URL: http://www.clinicaltrials.gov ; Unique identifier: NCT01624883.

Background There has been a focus on alternative cardiac rehabilitation (CR) delivery models aimed at improving CR adherence and completion. We examined pre‐ and post‐CR health outcomes, reasons for discharge, and predictors of completion using a patient‐driven appointment‐based CR approach that uses center‐scheduled class start times. Methods and Results Data were used from an urban single‐center CR program at Yale New Haven Health (2012–2017) that enrolled 2135 patients. We evaluated pre‐ and post‐CR outcomes (12 weeks) using paired t tests and used a multivariable logistic regression model to examine predictors of CR completion (≥36 sessions) for the overall cardiovascular disease population. The mean age of participants was 65±12 years, 27.9% were women, and 5.1% were Black patients, and patients completed a median of 30 of 36 sessions. Patients achieved significant improvements in health outcomes, including across age and sex subgroups. The primary reason for discharge was completion of all 36 sessions of CR (46.4%). The final logistic regression model contained 12 predictors: age, sex, Black race, marital status, employment, number of physician‐reported risk factors, dietary fat intake >30%, obesity, lack of exercise, benign prostatic hyperplasia, and self‐reported stress and physical activity. Conclusions We demonstrated that patients participating in an appointment‐based CR program achieved significant improvements in health outcomes and across sex/age subgroups. In addition, older individuals were more likely to complete CR. An appointment‐based approach could be a viable alternative CR method to aid in optimizing the dose‐response benefit of CR for patients with cardiovascular disease.

The burden of ischemic heart disease (IHD) is a major health problem worldwide. The detrimental effect of gendered (ie, unevenly distributed between female and male) socioeconomic determinants of health (SDOH) on outcomes has been demonstrated, more so in female individuals. Therefore, addressing SDOH is a priority for the care implementation of patients with IHD. We conducted a scoping review to identify the types of SDOH-tailored interventions tested in randomised controlled trials (RCTs) among IHD patients, and whether the reporting of findings was sex-unbiased. We identified 8 SDOH domains: education, physical environment, health care system, economic stability, social support, sexual orientation, culture/language, and systemic racism. A total of 28 RCTs (2 ongoing) were evaluated. Since the 1990s, 26 RCTs have been conducted, mainly in the Middle East and Asia, and addressed only education, physical environment, health care system, and social support. The 77% of studies focused on patient-education interventions, and around 80% on SDOH-based interventions achieved positive effects on a variety of primary outcome(s). Among the limitations of the conducted RCTs, the most relevant were an overall low participation of female and racial/ethnical minority participants, a lack of sex-stratified analyses, and a missing opportunity of tailoring some SDOH interventions relevant for health. The SDOH-tailored interventions tested so far in RCTs, enrolling predominantly male patients and mainly targeting education and health literacy, were effective in improving outcomes among patients with IHD. Future studies should focus on a wider range of SDOH with an adequate representation of female and minority patients who would most benefit from such interventions.

Despite evidence-based guidelines, 1 stroke rehabilitation remains underutilized, particularly among women and minorities. 2 Telerehabilitation is a promising alternative to traditional in-person rehabilitation and offers a novel strategy to overcome access barriers, 3 which intensified during the COVID-19 pandemic. 4 A broadband connection is a prerequisite for its wide adoption but its availability varies across the United States ( https://broadbandnow.com/national-broadband-map ). Little is known about demographic and geographic variation in internet use among stroke survivors. In this study, we sought to compare internet use in a nationally representative sample of individuals with and without stroke.

Background: Stroke rehabilitation (SR) has been outlined in ASA/AHA guidelines as a critical component of post-acute care. US studies from the 2000s have found associations between rural residence and lower SR attendance, but contemporary information about SR attendance across geographic areas and patient subgroups is limited. Methods: Using the most recent 2011, 2013, 2015, and 2017 self-reported Behavioral Risk Factor Surveillance System (BRFSS) Surveys with SR data, we identified US adult stroke patients in 20 states. Rural/urban residence was classified by the Metropolitan Statistical Area codes. We compared SR attendance (Yes/No) among rural and urban stroke patients by sex and age groups (18-44y, 45-64y, 65+y). Logistic regression was used to examine the association between rural/urban residence and SR while controlling for key sociodemographic factors. Survey weighting was applied to all analyses. Results: Among 7878 stroke patients (40.8% rural, 62.2% women), slightly less rural residents attended SR compared to urban ones (30.8% vs 32.6%, p=0.357) ( Figure ). Rural/urban residence was not associated with SR prior to and after adjustment for sex, age, race, education, income, insurance status, and having a personal doctor (OR: 0.96, 95% CI: 0.80-1.15). In stratified analyses, women, patients 18-44y, and 45-64y who live in rural areas were less likely to attend SR than their urban counterparts. Women also had lower SR than men, irrespective of rural/urban residence. Conclusions: On average, a third of US stroke patients went to SR with no association found between rural/urban residence and SR attendance. However, a pattern of lower SR rates was observed across some sex and age subgroups in rural areas and in women regardless of residence status. Targeted interventions are needed to address rural/urban disparities and optimize secondary stroke prevention utilization, especially among women and young to middle aged patients in US rural areas.

Background: Prior studies have identified sex, age, and geographic differences in post-stroke rehabilitation use in certain US areas. Internet use is an important prerequisite to the adoption of telerehabilitation, which has shown promise in equalizing access to follow-up care among stroke patients. We aimed to assess 30-day internet use disparities between male and female stroke patients by age and within each US state. Methods: We identified US adults 18y and older with a self-reported history of stroke from the Behavioral Risk Factor Surveillance System surveys, a nationally representative dataset (2015-2017). Internet users were identified as those who responded “Yes” to the question, “Have you used the internet in the past 30 days?” Prevalence of internet use was compared between sex and age groups and by state. Survey weights were applied in all analyses. Results: Among 55260 individuals with stroke (57.5% women), 57.8% reported using the internet in the preceding 30 days. The overall prevalence of internet use was similar between women (58.2%, 95% CI: 57.0-59.4%) and men (57.4%, 95% CI: 56.1-58.8%). Female stroke patients had higher internet use than their male counterparts until age 65+y (all pFigure 1a ). Substantial differences in internet use by state were found for women and men with stroke, with stroke survivors in Louisiana reporting the greatest difference (women 51% vs. men 36%) ( Figure 1b ). Conclusions: Overall, less than 60% of US stroke survivors reported recent internet use, with marked variation by sex, age, and across states. Study findings may inform individual state’s actions to improve internet use among women 65+y who bear a greater stroke burden yet have lower internet use than men. Efforts to increase internet use in specific stroke patient subgroups may facilitate future telerehabilitation expansion and help to reduce sex- and age-based disparities currently present in post-stroke care.

ImportanceAmong younger adults, the association between Black race and postdischarge readmission after hospitalization for acute myocardial infarction (AMI) is insufficiently described.ObjectivesTo examine whether racial differences exist in all-cause 1-year hospital readmission among younger adults hospitalized for AMI and whether that difference retains significance after adjustment for cardiac factors and social determinants of health (SDOHs).Design, Setting, and ParticipantsThe VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study was an observational cohort study of younger adults (aged 18-55 years) hospitalized for AMI with a 2:1 female-to-male ratio across 103 US hospitals from January 1, 2008, to December 31, 2012. Data analysis was performed from August 1 to December 31, 2021.Main Outcomes and MeasuresThe primary outcome was all-cause readmission, defined as any hospital or observation stay greater than 24 hours within 1 year of discharge, identified through medical record abstraction and clinician adjudication. Logistic regression with sequential adjustment evaluated racial differences and potential moderation by sex and SDOHs. The Blinder-Oaxaca decomposition quantified how much of any racial difference was explained and not explained by covariates.ResultsThis study included 2822 participants (median [IQR] age, 48 [44-52] years; 1910 [67.7%] female; 2289 [81.1%] White and 533 [18.9%] Black; 868 [30.8%] readmitted). Black individuals had a higher rate of readmission than White individuals (210 [39.4%] vs 658 [28.8%], P P for interaction = .02) and fewer number of working hours per week (OR, 1.01; 95% CI, 1.00-1.02; P for interaction = .01) but not by sex. Decomposition indicates that 79% of the racial difference in risk of readmission went unexplained by the included covariates.Conclusions and RelevanceIn this multicenter study of younger adults hospitalized for AMI, Black individuals were more often readmitted in the year following discharge than White individuals. Although interventions to address SDOHs and employment may help decrease racial differences in 1-year readmission, more study is needed on the 79% of the racial difference not explained by the included covariates.

Background: Younger women (≤55 years) are at higher risk for readmission within one-year of hospitalization following acute myocardial infarction (AMI) compared to similarly aged men, yet there are no gender-specific risk prediction models for this population. Prior research suggests that gender-related factors more comprehensively explain sex-based differences in readmission risk. The objective was to develop and validate a risk prediction model of 1-year post-AMI readmission in young women considering demographic, clinical, and gender-related factors. Methods: We used data from women enrolled in the VIRGO study (n =2,007), a prospective observational study of young patients aged ≤55 years hospitalized with AMI in the US. Data were obtained from patient interviews, medical record abstraction, and adjudicated hospitalization records. Bayesian Model Averaging was used for model selection in a derivation cohort of 1338 women and subsequently validated in the remaining 669 women. Results: Within 1-year post-AMI, 684 (34.1%) women were readmitted at least once with a majority of readmissions due to cardiac causes (57.5%). The final model contained 9 predictors: experiencing any in-hospital complications, physical health at baseline (SF-12), disease-specific quality of life (Seattle Angina Questionnaire), diabetes, history of congestive heart failure, low income (≤30,000 USD), depression, length of hospital stay, and employment status (Figure) . Of the 9 predictors, 5 were gender-related. The model was well calibrated (calibration plots) and exhibited modest discrimination (C statistic=0.66 in development and validation cohorts). Conclusions: Younger women with diabetes, depression, history of congestive heart failure, and longer hospital stays were more likely to be readmitted. While clinical factors were the strongest predictors of readmission within 1-year among younger women with AMI, gender-related variables were important complements.

Background: Cardiac rehabilitation (CR) is a core component of secondary prevention shown to improve quality of life and reduce all-cause mortality after myocardial infarction (MI). Depression is twice as prevalent among young women (18-44y) versus men with MI and is linked with worse post-MI outcomes, yet information on sex-specific associations of depression and CR attendance is limited, particularly among younger MI patients. Methods: Using data from the 2011, 2013, 2015, and 2017 self-reported US Behavioral Risk Factor Surveillance System (BRFSS) surveys, we assessed the association between depression and CR attendance in adults with MI using logistic regression adjusting for sociodemographic factors. We calculated CR rates by sex and age subgroups for MI patients with and without depression. BRFSS survey weighting was applied to all analyses. Results: The study included 12,252 MI patients (44.2% women). CR attendance was comparable between MI patients with and without depression (36.1% vs 37.4%, p=0.440) ( Figure 1a ), and the association between depression and CR remained nonsignificant after adjusting for age, sex, race, education, and household income (OR=1.16, 95% CI: 1.00-1.35). CR attendance ranged from 19.0% to 51.0% across age and sex subgroups, with the lowest rate seen among women 18-44y with depression ( Figure 1b ). Women who were 45-64y and 65+y were less likely to attend CR than similarly aged men, regardless of depression status. Conclusions: Overall, just over one-third of patients with MI participated in CR, and depression was not associated with CR attendance. We found marked heterogeneity by subgroups, with lower CR rates observed for women across age groups, potentially putting them at higher risk for subsequent adverse cardiac events. Further research is needed to identify barriers leading to sex- and age-specific CR disparities to optimize attendance of post-acute care among subgroups, especially among younger women with depression.

Background Although there has been movement in cardiology to advance patient‐centered approaches to postacute myocardial infarction (AMI) care, work remains to be done in aligning patient preferences with clinical care. Our objective was to characterize patients’ experience of AMI and treatment to develop a new conceptual framework of patient‐centered recovery in cardiology. Methods and Results We conducted in‐depth interviews with people who previously experienced an AMI (2016–2019). The interview focused on participants’ experiences of their recovery, which were audio‐recorded, transcribed verbatim, and analyzed using a phenomenological framework. The overarching theme described by the 42 participants was feeling like a “different person” after the AMI. This shift manifested itself in both losses and gains, each of which posed new challenges to everyday life. The experience appeared to be an active process requiring people to take responsibility for their health. In terms of loss, participants describe how the AMI threatened their sense of safety and security and led to social isolation, fragility, uncertainty about the future, and difficulty expressing emotions accompanied this new fear. A conceptual framework describing the relationship between AMI, identity change, and functioning was developed. Conclusions Participants experienced the AMI as an unexpected disruption in their lives that had far‐reaching effects on their daily functioning, and were resolved in numerous ways. The conceptual framework may assist in providing a theoretical basis for future interventions in cardiology that not only engage and retain patients in care but also improve long‐term adherence to secondary prevention and other aspects of self‐care.

Background The extent to which race influences in‐hospital quality of care for young adults (≤55 years) with acute myocardial infarction (AMI) is largely unknown. We examined racial disparities in in‐hospital quality of AMI care and their impact on 1‐year cardiac readmission. Methods and Results We used data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study enrolling young Black and White US adults with AMI (2008–2012). An in‐hospital quality of care score (QCS) was computed (standard AMI quality indicators divided by the total a patient is eligible for). Multivariable logistic regression was performed to identify factors associated with the lowest QCS tertile, including interactions between race and social determinants of health. Among 2846 young adults with AMI (median 48 years [interquartile range 44–52], 67.4% women, 18.8% Black race), Black individuals, especially women, exhibited a higher prevalence of cardiac risk factors and social determinants of health and were more likely to experience a non–ST‐segment–elevation myocardial infarction than White individuals. Black individuals were more likely in the lowest QCS tertile than White individuals (40.8% versus 34.7%; P =0.003). The association between Black race and low QCS (odds ratio [OR], 1.25; 95% CI, 1.02–1.54) was attenuated by adjustment for confounders. Employment was independently associated with better QCS, especially among Black participants (OR, 0.76; 95% CI, 0.62–0.92; P‐ interaction =0.02). Black individuals experienced a higher rate of 1‐year cardiac readmission (29.9% versus 20.0%; P Conclusions Black individuals with AMI received lower in‐hospital quality of care and exhibited a higher rate of cardiac readmissions than White individuals. Black individuals had a lower quality of care if unemployed, highlighting the intersection of race and social determinants of health.

Background Harnessing health-related data posted on social media in real time can offer insights into how the pandemic impacts the mental health and general well-being of individuals and populations over time. Objective This study aimed to obtain information on symptoms and medical conditions self-reported by non-Twitter social media users during the COVID-19 pandemic, to determine how discussion of these symptoms and medical conditions changed over time, and to identify correlations between frequency of the top 5 commonly mentioned symptoms post and daily COVID-19 statistics (new cases, new deaths, new active cases, and new recovered cases) in the United States. Methods We used natural language processing (NLP) algorithms to identify symptom- and medical condition–related topics being discussed on social media between June 14 and December 13, 2020. The sample posts were geotagged by NetBase, a third-party data provider. We calculated the positive predictive value and sensitivity to validate the classification of posts. We also assessed the frequency of health-related discussions on social media over time during the study period, and used Pearson correlation coefficients to identify statistically significant correlations between the frequency of the 5 most commonly mentioned symptoms and fluctuation of daily US COVID-19 statistics. Results Within a total of 9,807,813 posts (nearly 70% were sourced from the United States), we identified a discussion of 120 symptom-related topics and 1542 medical condition–related topics. Our classification of the health-related posts had a positive predictive value of over 80% and an average classification rate of 92% sensitivity. The 5 most commonly mentioned symptoms on social media during the study period were anxiety (in 201,303 posts or 12.2% of the total posts mentioning symptoms), generalized pain (189,673, 11.5%), weight loss (95,793, 5.8%), fatigue (91,252, 5.5%), and coughing (86,235, 5.2%). The 5 most discussed medical conditions were COVID-19 (in 5,420,276 posts or 66.4% of the total posts mentioning medical conditions), unspecified infectious disease (469,356, 5.8%), influenza (270,166, 3.3%), unspecified disorders of the central nervous system (253,407, 3.1%), and depression (151,752, 1.9%). Changes in posts in the frequency of anxiety, generalized pain, and weight loss were significant but negatively correlated with daily new COVID-19 cases in the United States (r=-0.49, r=-0.46, and r=-0.39, respectively; P Conclusions COVID-19 and symptoms of anxiety were the 2 most commonly discussed health-related topics on social media from June 14 to December 13, 2020. Real-time monitoring of social media posts on symptoms and medical conditions may help assess the population’s mental health status and enhance public health surveillance for infectious disease.

Background Readmission over the first year following hospitalization for acute myocardial infarction (AMI) is common among younger adults (≤55 years). Our aim was to develop/validate a risk prediction model that considered a broad range of factors for readmission within 1 year. Methods and Results We used data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study, which enrolled young adults aged 18 to 55 years hospitalized with AMI across 103 US hospitals (N=2979). The primary outcome was ≥1 all‐cause readmissions within 1 year of hospital discharge. Bayesian model averaging was used to select the risk model. The mean age of participants was 47.1 years, 67.4% were women, and 23.2% were Black. Within 1 year of discharge for AMI, 905 (30.4%) of participants were readmitted and were more likely to be female, Black, and nonmarried. The final risk model consisted of 10 predictors: depressive symptoms (odds ratio [OR], 1.03; 95% CI, 1.01–1.05), better physical health (OR, 0.98; 95% CI, 0.97–0.99), in‐hospital complication of heart failure (OR, 1.44; 95% CI, 0.99–2.08), chronic obstructive pulmomary disease (OR, 1.29; 95% CI, 0.96–1.74), diabetes mellitus (OR, 1.23; 95% CI, 1.00–1.52), female sex (OR, 1.31; 95% CI, 1.05–1.65), low income (OR, 1.13; 95% CI, 0.89–1.42), prior AMI (OR, 1.47; 95% CI, 1.15–1.87), in‐hospital length of stay (OR, 1.13; 95% CI, 1.04–1.23), and being employed (OR, 0.88; 95% CI, 0.69–1.12). The model had excellent calibration and modest discrimination (C statistic=0.67 in development/validation cohorts). Conclusions Women and those with a prior AMI, increased depressive symptoms, longer inpatient length of stay and diabetes may be more likely to be readmitted. Notably, several predictors of readmission were psychosocial characteristics rather than markers of AMI severity. This finding may inform the development of interventions to reduce readmissions in young patients with AMI.

Background: The relative prevalence and clinical importance of monogenic mutations related to familial hypercholesterolemia and of high polygenic score (cumulative impact of many common variants) pathways for early-onset myocardial infarction remain uncertain. Whole-genome sequencing enables simultaneous ascertainment of both monogenic mutations and polygenic score for each individual. Methods: We performed deep-coverage whole-genome sequencing of 2081 patients from 4 racial subgroups hospitalized in the United States with early-onset myocardial infarction (age ≤55 years) recruited with a 2:1 female-to-male enrollment design. We compared these genomes with those of 3761 population-based control subjects. We first identified individuals with a rare, monogenic mutation related to familial hypercholesterolemia. Second, we calculated a recently developed polygenic score of 6.6 million common DNA variants to quantify the cumulative susceptibility conferred by common variants. We defined high polygenic score as the top 5% of the control distribution because this cutoff has previously been shown to confer similar risk to that of familial hypercholesterolemia mutations. Results: The mean age of the 2081 patients presenting with early-onset myocardial infarction was 48 years, and 66% were female. A familial hypercholesterolemia mutation was present in 36 of these patients (1.7%) and was associated with a 3.8-fold (95% CI, 2.1-6.8; P3-fold increased odds of early-onset myocardial infarction. However, high polygenic score has a 10-fold higher prevalence among patients presents with early-onset myocardial infarction. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00597922. ©2019, National Institutes of Health (no. TR001100), American Heart Association (no. 17SDG33680041), National Human Genome Research Institute (no. 5UM1HG008895)

IntroductionCognitive behavioural therapy for insomnia (CBT-I) is effective at treating chronic insomnia, yet in-person CBT-I can often be challenging to access. Prior studies have used technology to bridge barriers but have been unable to extensively assess the impact of the digital therapeutic on real-world patient experience and multidimensional outcomes. Among patients with insomnia, our aim is to determine the impact of a prescription digital therapeutic (PDT) (PEAR-003b, FDA-authorised as Somryst; herein called PDT) that provides mobile-delivered CBT-I on patient-reported outcomes (PROs) and healthcare utilisation.Methods and analysisWe are conducting a pragmatically designed, prospective, multicentre randomised controlled trial that leverages Hugo, a unique patient-centred health data-aggregating platform for data collection and patient follow-up from Hugo Health. A total of 100 participants with insomnia from two health centres will be enrolled onto the Hugo Health platform, provided with a linked Fitbit (Inspire 2) to track activity and then randomised 1:1 to receive (or not) the PDT for mobile-delivered CBT-I (Somryst). The primary outcome is a change in the insomnia severity index score from baseline to 9-week postrandomisation. Secondary outcomes include healthcare utilisation, health utility scores and clinical outcomes; change in sleep outcomes as measured with sleep diaries and a change in individual PROs including depressive symptoms, daytime sleepiness, health status, stress and anxiety. For those allocated to the PDT, we will also assess engagement with the PDT.Ethics and disseminationThe Institutional Review Boards at Yale University and the Mayo Clinic have approved the trial protocol. This trial will provide important data to patients, clinicians and policymakers about the impact of the PDT device delivering CBT-I on PROs, clinical outcomes and healthcare utilisation. Findings will be disseminated to participants, presented at professional meetings and published in peer-reviewed journals.Trial registration numberNCT04909229.

Background Whether there are sex differences in hemodynamic profiles among people with elevated blood pressure is not well understood and could guide personalization of treatment. Methods and results We described the clinical and hemodynamic characteristics of adults with elevated blood pressure in China using impedance cardiography. We included 45,082 individuals with elevated blood pressure (defined as systolic blood pressure of ≥130 mmHg or a diastolic blood pressure of ≥80 mmHg), of which 35.2% were women. Overall, women had a higher mean systolic blood pressure than men (139.0 [±15.7] mmHg vs 136.8 [±13.8] mmHg, P Conclusions Our findings indicate that there are sex differences in hypertension phenotype, but that sex alone is insufficient to infer an individual’s profile.

BackgroundWhether there are sex differences in hemodynamic profiles among people with elevated blood pressure is not well understood and could guide personalization of treatment.Methods and resultsWe described the clinical and hemodynamic characteristics of adults with elevated blood pressure in China using impedance cardiography. We included 45,082 individuals with elevated blood pressure (defined as systolic blood pressure of ≥130 mmHg or a diastolic blood pressure of ≥80 mmHg), of which 35.2% were women. Overall, women had a higher mean systolic blood pressure than men (139.0 [±15.7] mmHg vs 136.8 [±13.8] mmHg, PConclusionsOur findings indicate that there are sex differences in hypertension phenotype, but that sex alone is insufficient to infer an individual’s profile.

ObjectiveTo examine prevalence and characteristics of newly diagnosed diabetes (NDD) in younger adults hospitalised with acute myocardial infarction (AMI) and investigate whether NDD is associated with health status and clinical outcomes over 12-month post-AMI.MethodsIn individuals (18–55 years) admitted with AMI, without established diabetes, we defined NDD as (1) baseline or 1-month HbA1c≥6.5%; (2) discharge diabetes diagnosis or (3) diabetes medication initiation within 1 month. We compared baseline characteristics of NDD, established diabetes and no diabetes, and their associations with baseline, 1-month and 12-month health status (angina-specific and non-disease specific), mortality and in-hospital complications.ResultsAmong 3501 patients in Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients study, 14.5% met NDD criteria. Among 508 patients with NDD, 35 (6.9%) received discharge diagnosis, 91 (17.9%) received discharge diabetes education and 14 (2.8%) initiated pharmacological treatment within 1 month. NDD was more common in non-White (OR 1.58, 95% CI 1.23 to 2.03), obese (OR 1.72, 95% CI 1.39 to 2.12), financially stressed patients (OR 1.27, 95% CI 1.02 to 1.58). Compared with established diabetes, NDD was independently associated with better disease-specific health status and quality of life (p≤0.04). No significant differences were found in unadjusted in-hospital mortality and complications between NDD and established or no diabetes.ConclusionsNDD was common among adults≤55 years admitted with AMI and was more frequent in non-White, obese, financially stressed individuals. Under 20% of patients with NDD received discharge diagnosis or initiated discharge diabetes education or pharmacological treatment within 1 month post-AMI. NDD was not associated with increased risk of worse short-term health status compared with risk noted for established diabetes.Trial registration numberNCT00597922.

An increasing proportion of people in the US hospitalized for acute myocardial infarction (AMI) are younger than 55 years, with the largest increase in young women. Effective prevention requires an understanding of risk factors associated with risk of AMI in young women compared with men.To assess the sex-specific associations of demographic, clinical, and psychosocial risk factors with first AMI among adults younger than 55 years, overall, and by AMI subtype.This study used a case-control design with 2264 patients with AMI, aged 18 to 55 years, from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study and 2264 population-based controls matched for age, sex, and race and ethnicity from the National Health and Nutrition Examination Survey from 2008 to 2012. Data were analyzed from April 2020 to November 2021.A wide range of demographic, clinical, and psychosocial risk factors.Odds ratios (ORs) and population attributable fractions (PAF) for first AMI associated with demographic, clinical, and psychosocial risk factors.Of the 4528 case patients and matched controls, 3122 (68.9%) were women, and the median (IQR) age was 48 (44-52) years. Seven risk factors (diabetes [OR, 3.59 (95% CI, 2.72-4.74) in women vs 1.76 (1.19-2.60) in men], depression [OR, 3.09 (95% CI, 2.37-4.04) in women vs 1.77 (1.15-2.73) in men], hypertension [OR, 2.87 (95% CI, 2.31-3.57) in women vs 2.19 (1.65-2.90) in men], current smoking [OR, 3.28 (95% CI, 2.65-4.07) in women vs 3.28 (2.65-4.07) in men], family history of premature myocardial infarction [OR, 1.48 (95% CI, 1.17-1.88) in women vs 2.42 (1.71-3.41) in men], low household income [OR, 1.79 (95% CI, 1.28-2.50) in women vs 1.35 (0.82-2.23) in men], hypercholesterolemia [OR, 1.02 (95% CI, 0.81-1.29) in women vs 2.16 (1.49-3.15) in men]) collectively accounted for the majority of the total risk of AMI in women (83.9%) and men (85.1%). There were significant sex differences in risk factor associations: hypertension, depression, diabetes, current smoking, and family history of diabetes had stronger associations with AMI in young women, whereas hypercholesterolemia had a stronger association in young men. Risk factor profiles varied by AMI subtype, and traditional cardiovascular risk factors had higher prevalence and stronger ORs for type 1 AMI compared with other AMI subtypes.In this case-control study, 7 risk factors, many potentially modifiable, accounted for 85% of the risk of first AMI in young women and men. Significant differences in risk factor profiles and risk factor associations existed by sex and by AMI subtype. These findings suggest the need for sex-specific strategies in risk factor modification and prevention of AMI in young adults. Further research is needed to improve risk assessment of AMI subtypes.

Introduction: Although readmission over the first year following hospitalization for acute myocardial infarction (AMI) is common among younger adults (18-55 yrs), there is no available risk prediction model for this age group. Existing risk models have been developed in older populations, have modest predictive ability, and exhibit methodological drawbacks. We developed a risk prediction model that considered a broad range of demographic, clinical, and psychosocial factors for readmission within 1-year of hospitalization for AMI among young adults. Methods: Young AMI adults (18-55 yrs) were enrolled from the prospective observational VIRGO study (2008-2012) of 3,572 patients. Data were obtained from medical record abstraction, interviews, and adjudicated hospitalization records. The outcome was all-cause readmission within 1-year. We used a two-stage selection process (LASSO followed by Bayesian Model Averaging) to develop a risk model. Results: The median age was 48 years (IQR: 44,52), 67.1% were women, and 20.1% were Non-white or Hispanic. Within 1-year, 906 patients (25.3%) were readmitted. Patients who were readmitted were more likely to be female, black, and had a clustering of adverse risk factors and co-morbidities. From 61 original variables considered, the final multivariable model of readmission within 1-year of discharge consisted of 14 predictors (Figure) . The model was well calibrated (Hosmer-Lemeshow P >0.05) with moderate discrimination (C statistic over 33 imputations: 0.69 development cohort). Conclusion: Adverse clinical risk factors such as diabetes, hypertension and prior AMI, but also female sex, access to specialist care, and major depression were associated with a higher risk of readmission at 1-year post AMI. This information is important to inform the development of interventions to reduce readmissions in young patients with AMI.

Introduction: Cardiac rehabilitation (CR) is an evidence-based program to improve secondary prevention outcomes for patients with cardiovascular disease (CVD). Lower health-related quality of life is a known risk factor for worse CVD outcomes. We examined the effects of a patient-driven appointment-based CR program on health-related quality of life. Methods: We utilized data from the Yale New-Haven Health (YNHH) CR program over a 6-year period (2012-2017). Data was collected on patient demographics, clinical characteristics and socioeconomic status. The Medical Outcome Short-Form General Health Survey (SF-36) was used to measure general health status. We evaluated SF-36 score changes pre and post CR with paired T-tests and conducted logistic regression analysis to examine predictors of improvements in health-related quality of life. Results: Over the 6-year study period, a total of 2,135 patients (27.9% women, mean age 65±12 years) were enrolled in the CR program. Patients demonstrated significant improvements in both the SF-36 physical, mental and health transition components (P(Table) . In particular, patients had significant improvement in the social functioning domain (measures limitations patients see in their ability to participate in social activities due to physical/emotional issues), with an increase of 23.3 points out of 100. Physician-reported patient stress and/or depression on intake medical exam were significant negative predictors for improvement in the total SF-36 score (OR 0.23, 95% CI 0.08-0.80, P=0.021), with the effect driven largely by its impact on the physical component of SF-36 (OR 0.27, 95% CI 0.09-0.83, P=0.022). Conclusion: We demonstrated that a novel appointment-based CR program produced improvements in patient-reported health-related quality of life. Appointment-based CR could be a viable alternative for patients who prefer more scheduling flexibility, to optimize health status improvement and CVD outcomes.

Introduction: Cardiac rehabilitation (CR) is the pillar of secondary prevention for patients with cardiovascular disease (CVD). Despite its effectiveness, there remain systemic issues with adherence to in-clinic CR sessions, with the median number of CR sessions completed nationwide being 26 (out of a total of 36 sessions). We evaluated pre-post health outcomes for patients participating in a patient-driven appointment-based CR program, reasons for discharge, as well as predictors of total CR sessions attended. Methods: We utilized data from the Yale New-Haven Health (YNHH) CR program over a 6-year period (2012-2017). Data was collected on patient demographics, socio-economic status, and clinical characteristics. We evaluated CR outcomes with paired T-tests and conducted logistic regression analysis to determine predictors of CR adherence and completion. Results: A total of 2,135 patients were enrolled in CR from 2012 to 2017 (27.9% women, mean age 65±12 years). Patients completed a median of 30 sessions out of a total of 36. The primary reason for discharge was completion of all 36 sessions of CR (46.4%). The appointment-based CR program resulted in significant improvements in physical health outcomes (Table) , with matched-subject improvements of 1.42 METs increase, 0.32 kg/m 2 decrease in BMI and a 1.88% decrease in body fat percentage (P Conclusion: We demonstrated that an appointment-based CR program led to an increase in the median number of CR sessions completed versus the nationwide average, and produced significant improvements in health outcomes. Appointment-based CR could aid in optimizing the dose-response benefit of CR for patients with CVD.

Background The quality of care among young adults with acute myocardial infarction (AMI) may be related to biological sex, psycho-socio-cultural (gender) determinants or healthcare system-level factors. Purpose To examine whether sex, gender, and the type of healthcare system influence the quality of AMI care among young adults. Methods A total of 4,564 AMI young adults ( Results Women in the multipayer system had the highest risk factor burden. Across the phases of care for AMI, 20% of quality indicators were missed in both sexes. High stress, earner status, and social support were associated with a higher QCS in the pre-AMI phase, whereas only employment and earner status were associated with QCS in all other phases. In the pre-AMI phase, women had higher QCS than men, mainly in the single-payer system (adjusted-OR=1.85, 95% CI 1.46,2.35 vs. 1.07, 95% CI 0.84,1.36, P-interaction= 0.002). Regardless of sex, only employment status had a greater effect in the multipayer system (adjusted-OR=0.59, 95% CI 0.44,0.78 vs 1.13, 95% CI 0.89,1.44, P-interaction 0.05). Finally, in the post-AMI phase, men and women had a lower QCS, predominantly in the multipayer system. However, primary earners had higher QCS regardless of system. Conclusion Sex, gender, and healthcare system affected the quality of care after AMI. Women had a poorer in-hospital than men and both women and men had suboptimal post-discharge care. Being unemployed lowered the quality of care, more so in the multipayer system. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health and Research (CIHR)

Background Despite investments to improve quality of emergency care for patients with acute myocardial infarction (AMI), few studies have described national, real‐world trends in AMI care in the emergency department (ED). We aimed to describe trends in the epidemiology and quality of AMI care in US EDs over a recent 11‐year period, from 2005 to 2015. Methods and Results We conducted an observational study of ED visits for AMI using the National Hospital Ambulatory Medical Care Survey, a nationally representative probability sample of US EDs. AMI visits were classified as ST‐segment–elevation myocardial infarction (STEMI) and non‐STEMI. Outcomes included annual incidence of AMI, median ED length of stay, ED disposition type, and ED administration of evidence‐based medications. Annual ED visits for AMI decreased from 1 493 145 in 2005 to 581 924 in 2015. Estimated yearly incidence of ED visits for STEMI decreased from 1 402 768 to 315 813. The proportion of STEMI sent for immediate, same‐hospital catheterization increased from 12% to 37%. Among patients with STEMI sent directly for catheterization, median ED length of stay decreased from 62 to 37 minutes. ED administration of antithrombotic and nonaspirin antiplatelet agents rose for STEMI (23%–31% and 10%–27%, respectively). Conclusions National, real‐world trends in the epidemiology of AMI in the ED parallel those of clinical registries, with decreases in AMI incidence and STEMI proportion. ED care processes for STEMI mirror evolving guidelines that favor high‐intensity antiplatelet therapy, early invasive strategies, and regionalization of care.

Background: The quality of care among young adults with acute myocardial infarction (AMI) may be related to biological (sex) or psycho-socio-cultural (gender) determinants or healthcare system-level factors. Objectives: To examine whether sex, gender, and the type of healthcare system influence the quality of AMI care among young adults. Methods: A total of 4,564 AMI young adults ( Results: Women in the multipayer system had the highest risk factor burden. Across the phases of care for AMI, 20% of quality indicators were missed in both sexes. High stress, earner status, and social support were associated with a higher QCS in the pre-AMI phase, whereas only employment and earner status were associated with QCS in all other phases. In the pre-AMI phase, women had higher QCS than men, mainly in the single-payer system (adjusted-OR=1.85, 95%CI 1.46,2.35 vs. 1.07, 95%CI 0.84,1.36, P-interaction=0.002). Regardless of sex, only employment status had a greater effect in the multipayer system (adjusted-OR=0.59, 95%CI 0.44,0.78 vs 1.13, 95%CI 0.89,1.44, P-interaction0.05). Finally, in the post-AMI phase, men and women had a lower QCS, predominantly in the multipayer system. However, primary earners had higher QCS regardless of the healthcare system. Conclusion: Sex, gender, and the healthcare system affected the quality of care after AMI. Women had a poorer in-hospital than men and young adults had suboptimal post-discharge care. Being unemployed lowered the quality of care, more so in the multipayer healthcare system.

Background Sex differences in health status outcomes after percutaneous coronary intervention among patients without acute myocardial infarction are not well described. Methods and Results A total of 2237 patients (33.4% women) without acute myocardial infarction undergoing percutaneous coronary intervention were enrolled from 39 Chinese tertiary hospitals in the PEACE (China Patient‐centered Evaluative Assessment of Cardiac Events) prospective percutaneous coronary intervention study. Data were collected immediately before and 1 year following percutaneous coronary intervention. Health status was measured using the disease‐specific Seattle Angina Questionnaire (SAQ) Angina Frequency and Quality of Life domains, as well as the SAQ Summary Score. Among the study population, women were older, more often single, had lower levels of education, and had a higher prevalence of cardiac risk factors such as hypertension and diabetes mellitus. Women had lower mean 1‐year SAQ Angina Frequency scores (mean±SD, 91.0±17.3 versus 93.9±13.3; P P P P =0.007) in unadjusted analysis. However, women were less likely to achieve clinically significant improvement in SAQ Angina Frequency (adjusted odds ratio, 0.67; 95% CI, 0.45–1.00) and SAQ Quality of Life (adjusted odds ratio, 0.73; 95% CI, 0.56–0.96) after adjustment. Conclusions There were no clinically significant differences in 1‐year health status outcomes and improvement in health status by sex among patients without acute myocardial infarction following percutaneous coronary intervention. However, female sex was associated with poorer 1‐year health status and a lower likelihood of experiencing clinically improvement in health status. Clinical Trial Registration URL: https://www.clinicaltrials.gov/ . Unique identifier: NCT01624922.

Background: The diagnosis of acute myocardial infarction (AMI) is missed more frequently in young women than men, which may be related to the cognitive psychology of the diagnostic process. Physicians start the diagnostic process by intuitively recognizing familiar symptom phenotypes, but little is known about how symptoms combine in individuals as unique symptom phenotypes. We examined how symptoms of AMI combine as unique symptom phenotypes in individual patients to compare the distribution of symptom phenotypes in women versus men. Methods and Results: The VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) was a multicenter, observational cohort study of 3501 young adults hospitalized with AMI. Data were collected on presenting symptoms with standardized interviews and from medical record abstraction. The number and distribution of unique symptom phenotypes were compared between women and men. Because of the 2:1 female-to-male enrollment ratio, women and men were compared with permutation testing and repeated subsampling. There were 426 interview-symptom phenotypes in women and 280 in men. The observed difference between women and men of 146 phenotypes was significant, even allowing for the greater enrollment of women (permutation P =0.004, median difference 110 under the null hypothesis of no association between sex and phenotype). The repeated subsample analysis also showed significantly more interview-symptom phenotypes in women than men (206.8±7.3 versus 188.6±6.0, P P Conclusions: Women exhibited substantially more variation in unique symptom phenotypes than men, regardless of whether the symptoms were derived from structured interviews or abstracted from the medical record. These findings may provide an explanation for the higher missed diagnosis rate in young women with AMI and may have important implications for teaching and improving clinicians’ ability to recognize the diagnosis of AMI in women.

Key Points Question Among young adults with acute myocardial infarction (AMI) in the US and Canada, is quality of care associated with sex, social determinants of health (SDOH), and health care systems? Findings In this cohort study of 4048 adults 55 years or younger with AMI, being treated in the US (multipayer system) relative to Canada (single-payer system) was associated with a lower in-hospital and post-AMI quality-of-care score, regardless of all SDOH factors except unemployment. Lower in-hospital quality of care was associated with 1-year readmission rates in the US only. Meaning These findings suggest that health care systems and unemployment are associated with quality of AMI care., This cohort study of young adults aged 55 years or younger with acute myocardial infarction (AMI) in the US and Canada examines whether quality of care for AMI is associated with sex, social determinants of health, and health care systems., Importance Quality of care of young adults with acute myocardial infarction (AMI) may depend on health care systems in addition to individual-level factors such as biological sex and social determinants of health (SDOH). Objective To examine whether the quality of in-hospital and postacute care among young adults with AMI differs between the US and Canada and whether female sex and adverse SDOH are associated with a low quality of care. Design, Setting, and Participants This retrospective cohort analysis used data from 2 large cohorts of young adults (aged ≤55 years) receiving in-hospital and outpatient care for AMI at 127 centers in the US and Canada. Data were collected from August 21, 2008, to April 30, 2013, and analyzed from July 12, 2019, to March 10, 2021. Exposures Sex, SDOH, and health care system. Main Outcomes and Measures Opportunity-based quality-of-care score (QCS), determined by dividing the total number of quality indicators of care received by the total number for which the patient was eligible, with low quality of care defined as the lowest tertile of the QCS. Results A total of 4048 adults with AMI (2345 women [57.9%]; median age, 49 [interquartile range, 44-52] years; 3004 [74.2%] in the US) were included in the analysis. Of 3416 patients with in-hospital QCS available, 1061 (31.1%) received a low QCS, including more women compared with men (725 of 2007 [36.1%] vs 336 of 1409 [23.8%]; P

Young women with acute myocardial infarction (AMI) have a worse prognosis than their male counterparts. We searched for differences in the electrocardiographic presentation of men and women in a large, contemporary registry of young adults with AMI that could help explain gender differences in outcomes. The qualifying electrocardiogram was blindly assessed by a central core lab in 3,354 patients (67% women) aged 18 to 55 years included in the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients study. Compared with men, women did not have a different frequency of sinus rhythm, and they had shorter PR and QRS intervals and longer QTc intervals. Intraventricular conduction disturbances were not different among genders. Notably, women were more likely than men to have abnormal Q waves in anterior leads and a lower frequency of Q waves in other territories. ST-segment elevation myocardial infarction (STEMI) diagnosis was less frequent in women than in men (44.6% vs 55.1%, p 0.001). Among patients with STEMI, women had less magnitude and extent of ST-segment elevation than men. In patients with non-STEMI, the frequency, magnitude, and extent of ST-segment depression were not different among genders, but women had anterior ST-segment depression less frequently and anterior negative T waves more frequently compared with men. These differences remained statistically significant after adjusting for baseline characteristics. In conclusion, there are significant gender differences in the electrocardiographic presentation of AMI among young patients. Further studies are warranted to evaluate their impact on gender-related differences in the management and outcomes of AMI.

While high-sensitivity C-reactive protein (hs-CRP) is a marker of inflammation and higher cardiovascular risk, its association with health status (symptoms, function and quality of life) after acute myocardial infarction (AMI) is unknown.Among 3410 patients with AMI from the TRIUMPH (N = 1301) and VIRGO (N = 2109) studies, we compared 1-year generic (Medical Outcome Study Short Form-12 and Euro Quality of Life Visual Analog Scale) and disease-specific (Seattle Angina Questionnaire) health status outcomes in those with hs-CRP ≥2 mg/L vs.2 mg/L. In hierarchical linear regression models, we examined the association of 30-day hs-CRP levels with 1-year health status without adjustment, after adjusting for 30-day health status, and after adjusting for demographic, socioeconomic, disease severity/comorbidities and treatment characteristics.The median (25th, 75th percentiles) 30-day hs-CRP was 2.6 (1.1, 6.1) mg/L and 59% had hs-CRP ≥2 mg/L. Statin therapy was used in 92% of patients at hospital discharge. Thirty-day hs-CRP ≥2 mg/L was inversely associated with all 1-year health status measures in unadjusted and partially adjusted models, but not in fully-adjusted models. Results were similar when hs-CRP was analyzed as a continuous variable.While elevated hs-CRP 30 days after AMI was associated with worse health status in unadjusted analyses, this was not significant after adjusting for comorbidities, suggesting that hs-CRP may be a marker of comorbidities associated with worse health status. Whether reducing inflammation in AMI patients will improve health status should be tested in ongoing trials.